Every finding on record at Crown Rehab and Healthcare Center

Based on interview and record review, the facility failed to notify the resident or the resident's representative of meetings for care plan development, review, and revision, for three sampled residents (Resident #13, #32 and #40) out of 20 sampled residents. The facility census was 99 residents. Review of the facility policy titled Care Planning dated 10/24/22 showed: -The facility would develop a baseline and/or a comprehensive care plan for the residents. -The facility would provide a written summary of the baseline and/or comprehensive care plan to the resident and/or the resident's representative when the care plan was completed. -The medical record must contain evidence that the summary was given to the resident and/or the resident's representative. -The facility would invite the resident, if capable, and their family to the care plan meetings and use the best efforts to schedule the care plan meetings at times convenient for the resident and family. 1. Review of Resident #13's annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 1/1/25, showed the resident was cognitively intact. Review of the resident's electronic health record (EHR) progress notes dated January 2025 to March 2025 showed no notes that indicated the resident received notification of his/her care plan meeting. During an interview on 3/17/25 at 11:11 A.M., the resident said: -He/She was unsure of when his/her last care plan meeting was. --The last one may have been six months ago. -He/She did not have care plan meetings quarterly. 2. Review of Resident #32's annual MDS, dated [DATE], showed the resident was severely cognitively impaired. Review of the resident's EHR progress notes dated January 2025 to March 2025 showed: -No notes that indicated the resident received notification of his/her care plan meeting. -No noted that indicated the resident's representative received notification of the resident's care plan meeting. During an interview on 3/17/25 at 12:38 P. M, the resident's family member said: -He/She was unsure when the last care plan meeting was. -He/She was unsure how often and when care plan meeting notification should be made. 3. Review of Resident #40's annual MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's EHR progress notes dated January 2025 to March 2025 showed no notes that indicated the resident received notification of his/her care plan meeting. During an interview on 3/17/25 at 12:01 P.M., the resident said: -He/She had not been invited to a care plan meeting. -He/She did not attend any care plan meetings. -He/She wanted to know what his/her care plan said. 4. During an interview on 3/19/25 at 8:49 A.M., Certified Nursing Assistant (CNA) C said: -Resident's received invites to care plan meetings. -He/She thought they came from the Social Services Designee (SSD). During an interview on 3/19/25 at 9:26 A.M., CNA D said: -Residents were invited to care plan meetings by the SSD. -The team came and talked to the residents and let them know when the meeting was. During an interview on 3/19/25 at 9:57 A.M., Certified Medication Technician (CMT) A said: -Residents were invited by the SSD to care plan meetings. -The SSD talked to the residents, and they were very much included to make sure their needs were met. During an interview on 3/20/25 at 9:59 A.M., the SSD said: -He/She gave letters to residents and left them at bedside. -He/She called resident representatives/family to notify them of the care plan meetings. -He/She did not make a progress note when the resident and/or the resident's representative/family was invited to the resident's care plan meeting. During an interview on 3/21/25 at 9:27 A.M., the Administrator said: -The SSD gave letters to residents and left them at beside. -The SSD was making phone calls to resident families and not making progress notes. -The SSD did not have access to the electronic information notification system that sent out reminders to residents and family members through text and email. -There was no documentation that the care plan invites were being done.

Based on observation and interview, the facility failed to maintain the cleanliness in the kitchen by not removing rust and grime from one shelf in the walk-in cooler; failed to clean and maintain four ceiling vent covers over the hot drink preparation area and the hand washing sink dish washing areas. This practice potentially affected all residents who ate food from the kitchen. The facility census was 99 residents. Review of the facility's Cleaning Schedule policy, dated 10/24/22, showed: -The dietary staff maintained a sanitary environment by complying with routine cleaning schedules developed by the Dietary Manager. 1. Observation on 3/18/25 from 9:26 A.M. to 11:14 A.M. of the kitchen showed: -Two ceiling vent covers over the hot beverage preparation area were discolored with dark brown or black grime, dust or debris. -Two ceiling vent covers over the handwashing sink and dishwashing areas were discolored with dark brown or black grime, dust or debris. -One shelf inside the reach-in doors of the walk-in cooler was covered in a dark sticky substance and had rusted areas. During an interview on 3/19/25 at 10:33 A.M., the Dietary Manager said: -The kitchen staff were responsible for wiping shelves down. -He/She was unaware of how or who was responsible for removing rust from the shelves. -Maintenance was responsible for cleaning the ceiling vents. During an interview on 3/19/25 at 10:39 A.M., the Maintenance Director said: -The kitchen staff were responsible for cleaning the kitchen shelves. -If shelves were rusted then maintenance made arrangements to take the shelves out back and power wash them then repaint them if necessary. -He/She was not aware of the vent cover condition in the kitchen. -The vent covers were supposed to be cleaned quarterly. -There was a computer system that tracked when work orders were submitted and completed. -NOTE: He/She was going to provide a printout of the last time the vents were cleaned but did not provide it. During an interview on 3/19/25 at 10:50 A.M. the Regional Dietary Manager said the vent covers were rusted and had previously been painted. During an interview on 3/19/25 at 1:07 P.M., the Administrator said the vents were dirty and needed to cleaned and repainted.

Based on observation, interview, and record review, the facility failed to ensure accurate and timely tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing was completed for three sampled residents (Residents #79, #246, and #196) out of five residents sampled for tuberculosis screening/testing; and failed to ensure appropriate hand hygiene and infection control practices during incontinence care for three sampled residents (Resident #73, #246, and #21) out of 20 sampled residents. The facility census was 99 residents. Review of the facility Tuberculosis - Screening policy dated 10/24/22 showed: -Residents are to be screened for tuberculosis upon admission, readmission, and as indicated. -Any resident without a documented negative tuberculosis skin test (TST) within the previous 12 months receives a two-step TST upon admission. -When the first TST is negative, a follow-up TST is administered one to three weeks after the first test is read. -The policy did not give direction on when to read to skin test or how to document the findings. Review of the facility's Personal Protective Equipment-Using Gloves policy dated revised September 2010 showed: -Objectives: --To prevent the spread of infection. --To protect wounds from contamination. --To protect hands from potentially infectious material. -Miscellaneous: --Use disposable single-use gloves. --Discard used gloves into the waste receptacle inside the room. --Use non-sterile gloves primarily to prevent contamination when providing treatment or services to the patient. --Wash hands after removing gloves (Note: gloves do not replace handwashing). --Remove gloves before removing the mask and gown and discard them into the designated waste receptacle inside room. -When to use gloves: --When touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin. --When cleaning potentially contaminated items. --When in doubt. 1. Review of Resident #79's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's TB skin test records showed: -A TB skin test was administered on 9/4/24 and documented as negative. The results did not include the date the test was read. -A TB skin test was administered on 9/19/24 and documented as negative. The results did not include the date the test was read. 2. Review of Resident #246's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's TB skin test records showed: -A TB skin test was administered on 1/18/25 and documented as negative. The results did not include the date the test was read. -A second TB skin test was not administered until 3/19/25. 3. Review of Resident #196's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's TB skin test records showed a TB skin test was administered on 3/19/25, five days after the resident was admitted to the facility. 4. During an interview on 3/24/25 at 2:00 P.M., the Infection Preventionist said: -He/She administered the first step TB skin test to the resident upon admission to the facility. -If he/she was not there the floor nurse could administer the TB skin test. -He/She documented the results of the skin test in the electronic medical record 48-72 hours after the test was administered. -The electronic medical record did not give a space to document the date the test was read. -A second test was given a couple weeks after the first test was read. 5. Review of Resident #73's Face Sheet showed he/she was admitted on [DATE] with diagnoses of Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception) and dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/21/25 showed the resident: -Was severely cognitively impaired. -Relied on staff for total toileting cares. -Was always incontinent of bladder. Observation on 3/19/25 at 9:26 A.M. showed: -Certified Nursing Assistant (CNA) E and CNA C were already in the resident's room with gloved hands to transfer the resident from his/her wheelchair to the bed with a mechanical lift. -CNA E and CNA C transferred the resident to his/her bed, and with the same gloved hands, assisted the resident with turning in bed while pulling down his/her pants. -With the same gloved hands, CNA E unfastened the resident's brief, pulled wipes out of the container, and cleansed the resident's front genital area. -Without removing his/her gloves or asking CNA C to assist, CNA E put his/her gloved hands in the wipes container to remove more wipes to clean the resident's front genital area. -With the same gloved hands, CNA E touched the resident's skin to assist him/her turn in the bed, then reached in the wipes container, removed more wipes and cleansed the resident's buttocks, then finished removing the soiled brief from under the resident. -With the same gloved hands, CNA E placed a clean brief under the resident, touched the resident's skin and clothing to assist the resident turn in bed while CNA C finished fastening the clean brief. -With the same gloved hands CNA E and CNA C pulled the resident's pants up, and adjusted his/her shirt. -With the same gloved hands, CNA E touched the mechanical lift sling, then picked up the resident's shoes to place them on his/her feet, then picked up the resident's protective boots and placed them on the resident. -With the same gloved hands CNA E touched the mechanical lift, moved it closer to the bed, attached the sling to the lift while CNA C moved the resident's wheelchair closer to the bed. -With the same gloved hands CNA E and CNA C transferred the resident to the wheelchair, adjusted the resident in the wheelchair, and removed the sling from the lift. -With the same gloved hands, CNA E adjusted the resident's pillow on his/her bed, placed the package of wipes on the resident's bedside table next to his/her beverage container, and made the resident's bed. -With the same gloved hands, CNA E picked up the resident's beverage container and offered the resident a drink while CNA C wiped off the resident's bedside table with a wipe removed from the same package that was used during incontinence care. -CNA E removed one glove, and with the gloved hand removed the trash liner from the trash can. With his/her ungloved, unwashed/sanitized hand, he/she opened the door to the resident's room. -CNA C removed both gloves and without washing or sanitizing his/her hands, pushed the resident in his/her wheelchair out the door and down the hall. -CNA E exited the resident's room without washing or sanitizing his/her hands, with unsanitized/unwashed hands, he/she opened the soiled utility room door to dispose of the trash, then continued down the hall without washing or sanitizing his/her hands. During an interview on 3/19/25 at 9:38 A.M., CNA E and CNA C said they would not have changed anything that they did during the incontinence care provided to the resident at that time. During an interview on 3/24/25 at 1:33 P.M., Regional Nurse Consultant A and Regional Nurse Consultant B said: -Staff should wash or sanitize their hands prior to entering a room and putting on gloves. -Staff should remove their gloves, wash or sanitize their hands, then put on new gloves after transferring a resident, after removing a dirty brief, after cleaning the resident's genital area or buttocks. -CNA E should have had CNA C remove any additional wipes that were needed. Staff should not reach into the wipes container with contaminated gloves. -Staff should remove their gloves and wash or sanitize their hands after completing incontinence care and should not touch the resident's skin, clothing, bedding, any equipment, or the resident's beverage container with contaminated gloves. -Staff should have removed both gloves, washed or sanitized their hands before leaving the resident's room. 37576 6. Review of Resident #246's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of end stage renal disease (ESRD-The kidneys have stopped working well enough to survive without dialysis or a kidney transplant) 1/17/25. Observation on 3/21/25/at 9:47 A.M., of perineal care showed CNA G: -Sanitized his/her hands, put on a protective gown and put gloves on. -Picked up the resident's indwelling catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) drainage bag. -Handed the drainage bag to the Regional Wound Nurse Consultant. -Without removing the gloves, unfastened the resident's brief. -With the same contaminated gloves, turned the resident to his/her right side with a draw sheet. -With the same contaminated gloves cleaned the resident's buttocks around a wound dressing. -Then removed the gloves, sanitized his/her hands, put on new gloves,and finished perineal care. 7. Review of Resident #21's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -End stage renal disease 3/9/23. -Colostomy status (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen) 3/9/23. Observation on 3/18/25 at 10:49 A.M., of perineal care showed CNA J and CNA K: -Both washed his/her hands and put gloves on. -With gloved hands CNA K closed the room door and pulled the room dividing curtain around resident's bed. -With gloved hands CNA J moved the resident's wheelchair. -With contaminated gloves, both CNA J and CNA K repositioned the resident up in bed and removed his/her brief. -With the same contaminated gloves, CNA J picked up the graduate container, a package of wipes and a clean brief and placed them on the resident's bed. -With the same contaminated gloves, CNA K cleaned the resident's peri area. -With the same contaminated gloves, both CNA J and CNA K rolled the resident to his/her left side. -With the same contaminated gloves, CNA K cleaned the resident's buttocks. -With the same contaminated gloves, both CNA J and CNA K rolled the resident to his/her back and put a clean brief on him/her. -At the end of the procedure, CNA J and CNA K removed their gloves and washed their hands. 8. During an interview on 3/20/25 at 2:58 P.M., CNA K said: -Staff were to close the resident's door and curtains before starting cares. -Staff were to get all the supplies ready and place them on a clean area. -Staff were to wash their hands and put gloves on. -Gloves were to be changed when dirty. -Hands were to be washed/sanitized if gloves were dirty. -Staff should change gloves and wash/sanitize their hands if touching other items or objects during cares. -Gloves should be removed, hands should be washed/sanitized, and new gloves put on before putting a clean brief on the resident. During an interview on 3/24/25 at 10:01 A.M., Licensed Practical Nurse (LPN) D said: -Staff should wash/sanitize their hands and put on gloves when doing perineal or catheter cares. -Staff should not be touching other items with gloved hands during cares. -If staff touched other items during cares, staff needed to change gloves and wash/sanitize their hands and re-glove. -Staff should remove gloves and wash/sanitize their hands when finished with cares. During an interview on 3/24/25 at 11:28 A.M., CNA H said: -Get supplies ready and place on a clean area. -Wash hands, gown up, if doing catheter care, and put gloves on. -Don't touch other objects in room during cares. -If other objects were touched, change gloves and wash/sanitize hands, and re-glove. -Remove gloves and wash/sanitize hands when finished with cares. During an interview on 3/24/25 at 1:22 P.M., the Administrator, Regional Nurse consultants A & B said: -Hand hygiene should be performed before, in-between and after resident cares. -Staff should wash/sanitize hands and put on gloves when doing any type of resident cares such as perineal, colostomy and indwelling catheter cares. -Staff should set up needed supplies before starting cares. -Staff should not touch other items during care with gloves on. -If staff needed to touch other items during cares they should remove the gloves and wash/sanitize hands and put on clean gloves before returning to the care being done. -The staff should remove the amount of cleaning wipes needed before cares or have a second staff member handing the wipes as needed. -Gloves should be removed and hands washed/sanitized and re-glove when going from a dirty area to clean area during cares and after removing a dirty brief. -Staff should not be carrying items out of a resident's room with dirty gloves on.

Based on observation and interview, the facility failed to ensure residents were provided food that was at a safe and appetizing temperature for three sampled residents (Resident #14, #25, and #34) out of 20 sampled residents. The facility census was 99 residents. Review of the facility policy titled food temperatures dated 10/24/22 showed: -Insert the thermometer into the center of the product. -Wait until there is no movement for 15 seconds. Several readings may be needed to determine hot and cold spots. -Take the temperature of each pan of product before serving. -Acceptable serving temperatures were: --Hot cereal and gravy should be 135 degrees Fahrenheit (F). --Casseroles, Meat entrees, potatoes, pasta, soup, pureed food, vegetables, coffee, and eggs should be greater than 135 degrees F. --Hazardous salads, desserts, milk, and juice should be less than 41 degrees F. --Pastries, cakes should be less than 60 degrees F. -If temperatures did not meet the required serving temperatures, reheat the product or chill the product to the proper temperature. -If temperatures were not at acceptable levels and could not be corrected in time for meal service, an appropriate menu substitution should be implemented. 1. Review of the resident council minutes dated 11/26/24 showed: -There were 15 residents present. -Old business talked about included complaints of cold food. -New business discussed included complaints of cold food. Review of the resident council minutes dated 1/28/25 showed: -There were 19 residents present. -Old business talked about included cold food. -New business had dietary issues but cold food was not documented. Review of the resident council minutes dated 2/25/25 showed: -There were 14 residents present. -Old business talked about included dietary issues, cold food was not documented. -New business discussed included cold food. 2. Observation on 3/18/25 at 12:20 P.M. of a regular texture test tray showed: -The hot turkey slice was 117.5 degrees F. -The steamed spinach was 128.4 degrees F. -The sweet potato casserole was 131.1 degrees F. -The apple cobbler was 120.7 degrees F. Observation on 3/20/25 at 12:27 P.M. of a pureed test tray showed: -The pureed meat was 118 degrees F. -The pureed potatoes were 125 degrees F. -The pureed green beans were 116 degrees F. -The pureed pineapple upside down cake was 81 degrees F. 3. Review of Resident #14's annual Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) date 1/1/25 showed the resident:-Was cognitively intact. -Required set up/clean up assistance only. -Was able to feed himself/herself. During an interview on 3/17/25 at 2:26 P.M. the resident said the food was cold when he/she ate in his/her room. During an interview on 3/19/25 at 8:49 A.M. Certified Nursing Assistant (CNA) C said: -The resident had complained of cold food when he/she ate in his/her room. -He/She would heat up the resident's food in the microwave. During an interview on 3/19/25 at 9:57 A.M. Certified Medication Technician (CMT) A said: -The resident complained of being served cold food. -He/She would warm up the tray or get the resident a new tray, which ever the resident decided. 22727 4. During an interview on 3/17/25 at 10:44 A.M., Resident #25 said he/she ate in the Main Dining Room in the assisted section and the food was frequently cold. 5. During an interview on 3/17/25 at 9:40 A.M., Resident #34 said he/she ate in his/her room and the food temperatures were luke warm. 6. During an interview on 3/18/25 at 2:07 P.M. the Dietary Manager said: -Residents had complained of cold food. -Temperatures were taken while food was in the steam table and recorded on the log. -It took thirty minutes from when the first tray was plated to the last resident being served. -Foods temperatures were not taken again once they were plated. -Residents looked for him/her daily to tell him/her the food was cold. During an interview on 3/19/25 at 9:26 A.M. CNA D said a lot of residents had complained about cold food.

Based on interview and record review, the facility failed to complete annual evaluations for two sampled Certified Nursing Assistants (CNA),(CNA N and CNA P); and failed to provide the annual twelve hours of annual education to nursing assistants, based on their performance review for four sampled CNAs (CNA L, CNA N, CNA O, CNA P) out of five CNA's reviewed for annual evaluations and training's. The facility census was 99 residents. A policy for CNA Evaluations was requested and not provided by the date of exit. Review of the facility's undated policy titled Regular In-service Education showed: -All certified nursing personnel was required to complete at least 12 hours of in-service education annually from their date of hire. -Certified staff members who do not meet this requirement will be removed from the schedule. 1. Review of the education documentation showed: -CNA L had 3 hours of in-service training and lacked 9 hours of training. -CNA N had 3 hours of in-service training and lacked 9 hours of training. -CNA O had 3 hours of in-service training and lacked 9 hours of training. -CNA P had 3 hours of in-service training and lacked 9 hours of training. 2. Review of the annual evaluations showed: -CNA N was hired on 8/30/23. --He/She had no annual evaluation dated 2024. -CNA P was hired on 5/16/22. -He/She had no annual evaluation dated 2023 and 2024. 3. During an interview on 3/20/25 at 2:50 P.M. the Administrator said: -CNA L, CNA N, CNA O, and CNA P did not have all the required in-services. -CNA N and CNA O did not have an annual evaluation. During an interview on 3/21/25 at 9:44 A.M. the Director of Nursing (DON) said: -He/She expected CNAs to have annual evaluations. -He/She expected CNAs to have twelve hours of education annually. -He/She prepared the evaluations. -The evaluation addressed knowledge, reliability, goals, and weaknesses. -He/She did not know who audited to ensure annual evaluations were completed. During an interview on 3/21/25 at 10:36 A.M. the Payroll/Human Resources said: -CNAs would usually ask for the evaluation to be completed. -Annual evaluations were tracked between Payroll/Human Resources and the Administrator. -He/She was expected to audit evaluations were completed.

Based on observation, interview and record review, the facility failed to ensure bathing/showers were completed twice weekly and with the resident's preference considered for two sampled residents (Resident #4 and #79) out of 20 sampled residents. The facility census was 99 residents. A policy for showers/bathing was requested and was not received at the time of exit. 1. Review of Resident #4's Admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body) affecting left non-dominant side 3/4/20. -Traumatic brain compression without herniation (TBI-a condition where a head injury causes the brain to be compressed, but the brain tissue does not shift or herniate [an abnormal condition in which an organ or other tissue protrudes through an opening or narrow space] through the openings in the skull, subsequent encounter 10/05/2021. -Cognitive (involving conscious intellectual activity) communication deficit (problems with communication that have an underlying cause in a cognitive deficit such as: attention, memory, organization, problem solving/reasoning, rather than a primary language or speech deficit) 4/7/2020. -Morbid (severe) obesity (a disorder involving excessive body fat that increases the risk of health problems) due to excess calories 11/21/23. -Need for assistance with personal care 6/8/22. Review of the resident's undated Care Plan showed: -An Activities of Daily Living (ADL) self-care performance deficit related to TBI, and obesity Date Initiated: 1/24/2024 and Revision on: 10/29/2024. --Intervention: The resident was totally dependent on two staff to provide showers. Review of the resident's Annual Minimum Data set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 1/2/25 showed: -He/She was cognitively intact. -He/She required substantial/maximal (a helper provides more than half of the effort required to complete an activity) assistance with showering/bathing. Review of the resident's shower/skin condition reports dated February 2025 to March 15, 2025, showed he/she received: -One shower the week of 2/2/25 to 2/8/25. -One shower the week of 2/9/25 to 2/15/25. -No showers the week of 2/16/25 to 2/22/25. -One shower the week of 2/23/25 to 3/1/25. -One shower the week of 3/2/25 to 3/8/25. -One shower the week of 3/9/25 to 3/15/25. During an interview on 3/18/25 at 10:02 A.M., the resident said: -He/She didn't know when the last time he/she had a shower. -Would like a shower at least two times a week. 2. Review of Resident #79's Admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Cognitive communication deficit 9/4/24. -Muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use) and atrophy (The wasting away or decrease in size of a body part) 9/4/24. -Muscle weakness (when full effort doesn't produce a normal muscle contraction or movement, or a decrease in muscle strength) 9/4/24. Review of the resident's undated Care Plan showed: -He/She had an ADL self-care performance deficit related to arthritis to knees, Date Initiated: 9/6/2024 Revision on: 10/10/2024. --Intervention: The resident was totally dependent on two staff to provide showers. Review of the resident's Quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She required substantial/maximal assistance with showering/bathing. Review of the resident's shower/skin condition reports from February 2025 to March 15, 2025, showed he/she received: -One shower the week of 2/2/25 to 2/8/25. -One shower the week of 2/9/25 to 2/15/25. -One shower the week of 2/16/25 to 2/22/25. -One shower the week of 2/23/25 to 3/1/25. -No showers the week of 3/2/25 to 3/8/25 -One shower the week of 3/9/25 to 3/15/25. During an interview on 3/18/25 at 10:16 A.M., the resident said: -Sometimes he/she went weeks without a shower. -He/She did not get complete peri care (Perineal care to the area between the anus and the exterior genitalia) daily maybe once a week. -He/She would like a shower at least two times a week. 3. During an interview on 3/24/25 at 10:00 A.M., Certified Nursing Assistant (CNA) H said: -Residents should get showers at least two times a week when there was a shower aide. -The shower aide was off today. -The CNAs didn't give the showers unless the resident was incontinent, and needed cleaned up more than just using the wipes. -If a resident refused a shower the shower aide would try to encourage them and try at a different time. During an interview on 3/24/25 at 10:06 A.M., Licensed Practical Nurse (LPN) D said: -The residents should be offered a shower twice a week. -If a resident refused a shower CNAs should try again at a different time or ask the resident what time they wanted to take a shower. -If a resident continued to refuse a shower the CNA should notify the nurse. -The nurse would let the Director of Nursing (DON) know. During an interview on 3/24/25 at 1:22 P.M., the Administrator, and Regional Nurse Consultants A & B said: -All nursing staff, CNAs and nurses, were responsible for giving residents showers. -The facility had a shower aide. -If the shower aide was not available then the CNA should do the resident's scheduled shower. -The residents should be offered at least two showers a week or more often if the resident preferred more than twice a week. -If the shower aide was pulled to work the floor, then the showers should be divided out among the CNAs. -If a resident refused a shower the CNA should offer it at a different time. -The CNA giving the shower should notify the charge nurse and the DON if a resident refused a shower and chart it on the shower sheet. -Shower sheets were reviewed by management, and they would re-offer or find out what the resident preferred.

Based on interview and record review, the facility failed to ensure completion, submission and retention of a Level I Nursing Facility Pre-Admission Screening for Mental Illness, Intellectual Disability or Related Condition (PASRR-a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid (program that helps with medical costs for some people with limited income and resources) certified beds in a nursing facility regardless of the source of payment. The screening assures appropriate placement of persons known or suspected of having a mental impairment(s) and that the individual needs of mentally impaired persons can be and are being met in the appropriate placement environment) for one sampled resident (Resident #4) out of 20 sampled residents. The facility census was 99 residents. 1. Review of Resident # 4's Admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) 3/4/2020. -Cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit such as: attention, memory, organization, problem solving/reasoning, rather than a primary language or speech deficit) 4/7/2020. -Bipolar disorder (a form of mental illness associated with episodes of mood swings ranging from depressive lows to manic highs) 3/5/20. -Traumatic brain compression without herniation (TBI-a condition where a head injury causes the brain to be compressed, but the brain tissue does not shift or herniate [an abnormal condition in which an organ or other tissue protrudes through an opening or narrow space] through the openings in the skull, subsequent encounter 10/05/2021. Review of the resident's electronic health record showed no PASRR record. Review of the resident's undated Care Plan showed the resident: -Had impaired cognitive function/dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning) or impaired thought processes related to diagnosis of TBI Date Initiated: 4/1/2020 Revision on 3/5/2024. -Behavioral symptoms: Risk for harm to self or others due to medical condition of a TBI. Date Initiated: 10/6/2021 Revision on 3/12/2025. -Had a communication problem related to TBI Date Initiated: 4/1/2020 Revision on: 3/5/2024. During an interview on 3/19/25 at 1:50 P.M., the Social Service Designee (SSD) and the Administrator said: -The resident had a PASRR in 2004. -He/She came to the facility in 2020 from another closed facility. -This facility did not get a copy of the PASRR at the time of admission. -The facility contacted Central Office Medical Review Unit (COMRU). -COMRU was not able to provide a copy because of the original date of 2004. -COMRU advised the facility to do an updated form, there were no changes since admission, no psychiatric stays they were aware of since the resident's admitted to this facility. -A PASRR should have been completed before admission to the facility. -The facility should have completed a PASRR at the time of admission. -He/She should have a level two based on his/her diagnoses.

Based on observation, interview and record review, the facility failed to ensure communication and coordination of care with a resident's hospice (end of life care) provider for one sampled resident (Resident #73) out of 20 sampled residents. The facility census was 99 residents. Review of the facility's End of Life Care policy dated 10/24/22 showed no instructions on how the hospice provider and the facility will communicate with one another to ensure coordination of care. 1. Review of Resident #73's Face Sheet showed he/she was admitted on [DATE] and was receiving hospice services. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/21/25 showed the resident: -Was severely cognitively impaired. -Was receiving hospice services. Review of the facility's hospice provider communication book showed: -The front of the binder included written instructions for the facility to access the residents' who received hospice services from that provider's electronic records. -The binder included a tabbed section with admission information for each resident receiving hospice services on the unit from that hospice provider with a section for Resident #73. -No additional documentation related to the hospice provider's visits were included in the binder. During an interview on 3/19/25 at 11:22 A.M., Licensed Practical Nurse (LPN) E said: -The hospice communication book on the unit was the complete communication book. -Hospice staff provided verbal communication with facility staff of the visit with the resident. -No visits were documented in the facility's electronic medical records. -He/She was not aware of any way facility staff could access information related to hospice visits with the facility. During an interview on 3/24/25 at 9:21 A.M., Certified Medication Technician (CMT) B said: -He/She did not know how the hospice provider communicated with the facility regarding visits with the resident. -He/She knew there was a hospice book at the nurse's station, but did not know if it contained written documentation or how to access the hospice records. During an interview on 3/24/25 at 9:19 A.M., LPN A said: -Hospice communication was documented in the hospice book. -Facility staff got verbal communication from the hospice provider after each visit. -He/She did not get written communication from the hospice provider. -He/She did not know about the written instructions in the hospice binder instructing staff how to access the reports to verify or confirm visits and/or changes in orders. -If he/she had any questions regarding the resident's hospice orders, he/she would call the hospice provider to speak to the hospice staff working that day. -He/She had never accessed the hospice provider electronic records as instructed in the hospice book. During an interview on 3/24/25 at 9:39 A.M., the Administrator said: -Staff got verbal reports from the hospice provider. -Staff should document in the resident's progress notes or on the Physician's Order Sheet any changes in orders. -Staff were able to access the hospice provider's electronic portal to obtain the hospice providers documentation. -Staff should know the hospice provider's electronic portal information was in the hospice binder and should know that was how the facility was able to access the resident's hospice communication to ensure coordination of care.

Based on interview and record review, the facility failed to maintain audiological (science and medicine concerned with the sense of hearing) health by not following up with the audiologist recommendations for one sampled resident (Resident #28) out of 20 sampled residents. The facility census was 99 residents. 1. Review of Resident #28's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 8/24/24, showed: -The resident was cognitively intact. -The resident's hearing was adequate. Review of the resident's audiology report, dated 9/20/24, showed: -Ear exam results were abnormal in the resident's right ear. -The resident had impacted cerumen (ear wax) in both ears. -Removal of ear wax was attempted via suction. -Due to depth of the cerumen, it was not completely removed. -Refer for Debrox drops (a medicine for ear wax removal) and to follow facility protocol for cerumen management. Review of the resident's Physician Order Summary (POS) dated September 2024 showed no order for Debrox drops. Review of the residents Medication Administration Record (MAR)/Treatment Administration Record (TAR) dated September 2024 showed no treatment of cerumen or administration of Debrox drops. Review of the resident's POS October 2024 showed no order for Debrox drops. Review of the residents MAR/TAR dated October 2024 showed no treatment of cerumen or administration of Debrox drops. Review of the residents quarterly MDS, dated [DATE], showed the resident's hearing was adequate. Review of the resident's care plan dated 2/22/25, showed no information regarding hearing issues was noted. Review of the residents quarterly MDS, dated [DATE], showed the resident's hearing was adequate. During an interview on 3/17/25 at 1:33 P.M. the resident said: -He/She would like to be able hear better. -He/She would like to go back to the audiologist. During an interview on 3/19/25 at 8:49 A.M., Certified Nursing Assistant (CNA) C said: -The resident was hard of hearing. -He/She was unaware if the resident had seen the audiologist. During an interview on 3/19/25 at 9:26 A.M., CNA D said: -The resident was a little hard of hearing. -He/She was unaware if the resident needed hearing aids. -The resident had not asked him/her to see the audiologist. During an interview on 3/19/25 at 9:57 A.M., Certified Medication Technician (CMT) A said: -He/She had not noticed the resident being hard of hearing. -He/She had not given the resident ear drops, there was no order them. During an interview on 3/19/25 at 10:30 A.M. the resident said he/she had not received any ear drops. During an interview on 3/20/25 at 9:24 A.M., Licensed Practical Nurse (LPN) B said: -He/She was unaware if the resident required ear drops. -The resident had some hearing issues. During an interview on 3/20/25 at 9:59 A.M., the Social Services Designee (SSD) said: -He/She received a list of residents from the audiologist of which residents needed to be seen. -When he/she got the list he/she put a copy at all nurse stations and the nurses added any additional residents who requested to be seen. -The resident had to tell the nurse to be put on the list. -After the appointment the nurses received a report from the audiologist and updated any orders given by the audiologist. During an interview on 3/21/25 at 2:28 P.M., the Director of Nursing (DON) said: -He/She was unaware the resident had follow-up instructions from the audiologist. -He/She looked up the report from 9/10/24 and saw the audiologist recommended ear wax removal drops. -It was not on the physicians order sheet. -The ear drops should have been added to the physician order sheet, MAR/TAR and given. -He/She expected the nurses to follow up with the physician to add the orders to the order summary.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and foot care for one sampled resident (Resident #25) out of 20 sampled residents. The facility census was 99 residents. Review of the facility's policy titled Grooming Care of the fingernails and toenails dated as revised 10/24/22 showed: -Toenails were to be trimmed by Certified Nursing Assistants (CNA)s except for residents with the following conditions: --Diabetes or circulatory impairment. --Ingrown, infected, or painful nails. --Nails that are too hard, thick, or difficult to cut easily. -High risk residents and residents with hypertrophic (thickened and deformed nails that can be caused by fungal infections, older age, psoriasis (a skin disease that causes red, itchy scaly patches), and other factors), mycotic (a fungal infection causes the nail to separate from the nail bed, making it thick and fragile) and keratotic (characterized by thickened, rough, and often chalky-white or yellow-brown patches that can be caused by various factors, including dehydration, fungal infections, psoriasis, or other underlying conditions) toenails would be referred to the podiatrist. -Any changes in the color of the skin around the nail or nail bed were to be reported to the attending physician. 1. Review of Resident #25's profile and census tabs in the electronic health record (EHR) showed the resident admitted to the facility on [DATE], the resident was his/her own responsible party and the resident was receiving Medicaid funding (program that helps with medical costs for some people with limited income and resources) since 8/25/23. Review of the resident's EHR showed no documents regarding podiatry under the documents tab. Review of the resident's weekly skin observations dated 2/6/25 to 3/20/25 at 10:42 A.M. showed no documentation regarding the resident's toes or toenails. Review of the resident's shower sheet dated 2/6/25 showed: -The resident's feet were swollen and dry. -The resident had a scab/cut on his/her right great-toe. -The form was signed by a CNA and a nurse. Review of the resident's nurse's note dated 2/6/25 showed: -The resident was in the shower and had dried blood on his/her big toe of his/her left foot. -The resident's toe was assessed after his/her shower. -The resident's toe was swollen and dark in color, with a small open area next to the cuticle. -The Nurse Practitioner (NP) assessed the resident's toe and ordered Doxycycline (an antibiotic) 100 milligrams (mg) twice daily for seven days for an infected toe. Review of the resident's NP note dated 2/6/25 showed: -The resident was seen for his/her left great toe infection. -Nursing staff reported the resident had an infected toe. -On assessment, the resident's left great toe was noted to be red, inflamed, and swollen. -The resident said it hurt and was irritating. -Doxycycline 100 mg twice daily for seven days was ordered for a left great toe infection. Review of the resident's nurse's note dated 2/8/25 showed: -The resident received antibiotics for a sore big toe. -No signs or symptoms of infection were observed. -The resident's toenail was noted to be loose. Review of the resident's physician's progress note dated 2/18/25 showed the resident recently received oral antibiotics for a toe infection and it improved. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 2/12/25 showed the following staff assessment of the resident: -Cognitively intact. -Was usually understood by others. -Always understood others. -Required substantial/maximum assistance with lower body dressing and putting on and taking off footwear. -Did not walk. -One of his/her diagnoses included peripheral vascular disease (PVD-the build-up of fatty material inside the blood vessels reducing blood flow). Review of the resident's shower sheet dated 2/20/25 showed: -The resident's feet were dry, cracked, and swollen. -The form was signed by a CNA and a nurse. Review of the resident's Physician's Order Sheet (POS) dated March 2025 showed no orders for the resident's feet, toes, or toenails. Review of the resident's shower sheet dated 3/4/25 showed: -The resident's feet were dry, his/her toenails were overgrown and both of his/her lower legs were swollen. -The form was signed by a CNA. -A nurse had not signed the form. Review of the resident's care plan dated 3/7/25 showed it did not include anything about his/her feet, toes or toenails other than to tell the podiatrist the resident was receiving aspirin. Review of the resident's consent for podiatry was obtained on 3/10/25. Review of the resident's shower sheet dated 3/12/25 showed: -The resident's feet were dry and he/she had over-grown toenails. -The form was signed by a CNA and a nurse. Observation on 3/17/25 at 10:44 A.M. showed: -The resident was in bed, had compression socks on that were open at the foot-end so the resident's toes could be seen. -The resident's toenails were severely thickened, yellowed, and overgrown. -The skin on the resident's foot and toes was scaly and flaking all over. -The lower-left edge of the resident's left great toe cuticle had either dried up blood or a black substance. During an interview on 3/17/25 at 10:44 A.M. the resident said: -One of his/her toenails was sore. -He/She didn't think he/she had ever seen the podiatrist at the facility. During an interview on 3/20/25 at 9:36 A.M. the Social Services Designee (SSD) said: -He/She was responsible for scheduling podiatry appointments. -He/She thought the resident's Medicaid was pending and they had to wait for it to go through. -He/She sent his/her consent for podiatry on 3/10/25. -The resident had not been seen by the podiatrist yet. -The resident's sibling was his/her contact. Observation on 3/20/25 at 1:58 P.M. showed: -The resident was in bed and had compression socks on that were open at the foot-end so the resident's toes could be seen. -The resident's toenails were severely thickened, yellowed, and overgrown. -The skin on the resident's foot and toes was scaly and flaking all over. -The lower-left edge of the resident's left great-toe was either dried up blood or a black substance. During an interview on 3/20/25 at 1:58 P.M. the resident said: -He/She did not know anything about his/her Medicaid being pending. -The facility staff said when he/she first moved in that he/she was on the list for the podiatrist. -His/her toes and toenails were not this bad when he/she came to the facility in August 2023. During an interview on 3/24/25 at 8:37 A.M., Licensed Practical Nurse (LPN) C said: -The bath aide should put lotion on the resident's feet after showers. -The resident did not have an order for Eucerin (a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) but he/she could call and get an order for it. -He/She thought the SSD tried to get the resident to get into the podiatrist. During an interview on 3/24/25 at 8:59 A.M., CNA F said: -He/She put lotion on the resident's dry feet when he/she was working but he/she only worked as needed. -They had tried to do something for his/her toenails in the shower but were not able to do anything. -The resident's toenails were thick. Review of the SSD's email dated 3/24/25 at 10:42 A.M. showed the podiatry provider received the resident's paperwork and the next time they would be in the facility would be 4/24/25. During an interview on 3/24/25 at 1:24 P.M., -Registered Nurse (RN) Consultant A said: --CNAs should report toe and toenail conditions to the nurse. --The nurses were supposed to report any conditions that required the podiatrist to the SSD. -RN Consultant B said they should get some lotion for the resident's feet.

Based on interview and record review, the facility failed to ensure two sampled Nurse Assistants (NAs) (NA A and NA B) completed the Certified Nurse Assistant (CNA) training program within four months of his/her employment in the facility. The facility census was 99 residents. A policy was requested and was not received by the exit date. 1. Review of the facility spreadsheet for NA training on 3/19/24 showed: -NA A's date of hire was 7/28/24 with a completion deadline of the CNA training by 11/25/24. -He/She had worked on the following days: --3/3/25 on the day shift. --3/4/25 on the day shift. --3/10/25 on the day shift. --3/11/25 on the day shift. --3/12/25 on the day shift. --3/17/25 on the day shift. --3/18/25 on the day shift. -NA B's date of hire was 9/9/24 with a completion deadline of the CNA training by 1/7/25. -He/She had worked on the following days: --3/3/25 on the day shift. --3/4/25 on the day shift. --3/10/25 on the day shift. --3/11/25 on the day shift. --3/17/25 on the day shift. --3/18/25 on the day shift. During an interview on 3/19/25 at 1:44 P.M. NA A said: -He/She started direct hands on care in September 2024. -He/She worked direct hands on care until 3/18/25. -He/She was aware of the need to be completed with the CNA training within four months. -He/She had not completed the CNA training program and was not certified. During an interview on 3/20/25 at 12:05 P.M. NA B said: -He/She started direct hands on care around August 2024. -He/She was still working direct hands on care. -He/She was aware of the need to be completed with the CNA training within four months. -He/She had not completed the CNA training program and was not certified. During an interview on 3/21/25 at 9:44 A.M. the Director of Nursing (DON) said: -He/She expected NAs to complete the CNA training program and be certified within four months. -Payroll/Human Resource was responsible to audit the hire dates and training. -Payroll/Human Resource was responsible to ensure NAs were certified within the four months. During an interview on 3/21/25 at 10:36 A.M. the Payroll/Human Resources said: -He/She was responsible for monitoring the CNA training program. -He/She was responsible to ensure NAs were certified within four months. -NA A had not completed the CNA training program and was not certified within four months. -NA B had not completed the CNA training program and was not certified within four months.

Based on observation, interview, and record review, the facility failed to follow pre-prepared menus to ensure they met the nutritional adequacy needs of residents, in accordance with established national guidelines and professional standards for food service. This deficient practice potentially affected all residents who ate food from the kitchen. The facility's census was 88 residents with a licensed capacity for 118 residents at the time of the survey. 1. Review of the pre-prepared menus for the current month provided by the Dietary Manager (DM) showed the following: -The menus had the facility's food vendor name at the top left. -The lunch for Monday the 17th was listed as bacon wrapped beef, country mashed potatoes, and mixed vegetables. -The lunch for Tuesday the 18th was listed as a hot dog on a bun, crispy French fries, cucumber salad, and a cottage cheese/pineapple salad. -The lunch for Wednesday the 19th was listed as Frito chili pie, buttered corn, and jello salad. During an interview on 7/17/23 at 9:08 A.M. the DM said the following: -Their food vendor delivered every Wednesday. -Just because he/she ordered foods to match the menus did not mean they got them. -He/she tried to follow the menus, but occasionally had to make substitutions. -Most of the dietary staff were new hires. Observation on 7/17/23 at 11:47 A.M. showed the lunch served was beef goulash, mashed potatoes, and a vegetable blend. Review of the menu board posted in the hall outside the Main Dining room on 7/18/23 at 9:57 A.M. showed the lunch was going to be a hamburger patty, mashed potatoes, and mixed vegetables. During an interview on 7/18/23 at 10:03 A.M. the DM said he/she made up a week at a glance for meals ahead of time going by what foodstuffs were on hand and then seeing what the cook was able to make out of that. Review of the week at a glance menus for the current week provided by the DM showed the lunch for Wednesday the 19th was listed as chicken cordon bleu casserole, tossed salad, and honey glazed carrots. During an interview on 7/19/23 at 1:58 P.M. the DM said the following: -Menus were not followed and other foods were substituted because they had issues with their food vendor providing certain items for dishes. -Some recipes were also too difficult for the current cooks.

Based on observation, interview, and record review, the facility failed to keep the Dry Storage (DS) room, walk-in refrigerator, and walk-in freezer floors clean; to maintain sanitary beverage dispensers; to maintain plastic plate covers and utensils in good condition to avoid food safety hazards (cross-contamination); and failed to separate damaged foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 88 residents with a licensed capacity for 118 residents at the time of the survey. 1. Observation on 7/17/23 between 8:29 A.M. and 9:26 A.M. during the initial kitchen inspection showed the following: -There was a 6 pound (lb.) 12 ounce (oz.) can of chili with beans on a can dispenser rack in the DS area that was dented on one side toward the top rim. -There were several crumbs and two strips of plastic under the racks in the DS area. -There was plastic, paper, an onion skin, and a butter pod under the racks in the walk-in refrigerator. -There was plastic, two unwrapped frozen beef patties, and a piece of garlic bread under the racks in the walk-in freezer, and a bottom rack had a Ziploc bag of garlic sticks ripped open at the bottom which allowed them to spill out. -There was a scoop in the sugar bin under a food preparation table in the kitchen. -In an upright plastic utensil container on a food preparation table there were two white plastic scoop spatulas that were chipped on their edges. -The two coffee dispenser nozzles were crusty around the inner edges and the multi-juice soda gun (a soda gun system allows you to stream multiple beverage types through a single hose) dispenser had dried liquid streaks. -On a shelf under the steam table there were two teal and four maroon plate warmer covers that were chipped around their edges. During an interview on 7/17/23 at 9:08 A.M. the Dietary Manager (DM) said the staff was usually pretty good about not putting the scoop in the sugar bin, but they were mostly all newly hired. During an interview on 7/19/23 at 1:58 P.M. the DM said the following: -The dishwasher was responsible for cleaning the floors at night. -Damaged food stuff items were tossed out when found. -Dietary staff knew they could dispose of damaged food preparation items. -The soda gun was cleaned nightly and the coffee nozzles soaked; if the nozzles were too stained they were replaced.

Based on observation, interview, and record review, the facility failed to ensure medications were stored securely; failed to ensure other objects were not in with the residents' prescribed medications; failed to ensure refrigerators that store residents' prescribed medications and supplements were kept within the required temperatures; failed to ensure the sink in the medication room was kept clean and hand soap and towels were available to wash hands, and failed to ensure medication carts were not left unlocked while nursing staff was not in attendance of the medication cart. The facility census was 88 residents. Review of the facility's policy, Storage of Medication, dated 1/2021 showed: -Medications and biologicals were to have been stored properly, following the manufacturer's recommendation, to maintain their integrity and to support safe effective drug administration. -The medication supply was to have been accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Medication rooms, cabinets and medication supplies should have remained locked when not in use or attended by persons with authorized access. -Medications that required refrigeration or temperature between 36 degrees Fahrenheit (F) and 46 degrees F were kept in a refrigerator with a thermometer to allow temperature monitoring. -A temperature log or tracking mechanism was maintained to verify that the temperature had remained within accepted limits. -The temperature of any refrigerator that stored vaccines should have been monitored and recorded twice daily. -Medication storage should have been kept clean, well lit, organized and free of clutter. -Medication storage conditions were to have been monitored on a regular basis as a random quality assurance check. -As problems were identified, recommendations would have been made for corrective action to have been take. 1. Continuous observation on 7/17/23 from 6:00 A.M. to 6:15 A.M. of the medication room located behind the Central Nurses' station showed: -The medication room door was propped open with a trash can. -There were no nursing staff in the medication room. -Three male residents passed by the open medication room door within two feet of the door and looked inside the medication room as they passed by it. During an interview on 7/17/23 at 6:20 A.M. Licensed Practical Nurse (LPN) E said: -The medication room door should never have been propped open. -It would get hot in there but the door should have been closed and locked if a nurse was not in the medication room. 2. Observation on 7/17/23 at 6:30 A.M. of the Nurse's cart on 300/400 hall with LPN E showed: -Three loose AA batteries were in with a resident's prescribed medication, Acetycsteine (medication used to treat thick mucus in individuals with chronic lung disorders) two 30 milliliters (ml) vials. 3. Observation and review on 7/17/23 at 6:30 A.M. of the Medication Refrigerator Temperature Log with LPN E in the central medication room for July 2023 showed: -The log was taped to the front of the refrigerator. -The refrigerator temperature was checked four out of 17 opportunities. -Once the temperature was 35 degrees F. --There was no documentation staff did anything to correct the temperature in the refrigerator. -Once the temperature was 33 degrees F. --There was no documentation staff did anything to correct the temperature in the refrigerator. -The nurse verified there was no documentation staff had taken any steps to correct the temperature of the refrigerator when it was less than 36 degree F. Observation and review of the South Medication Refrigerator and Temperature Log on 7/17/23 at 6:40 A.M. with LPN E in the south medication room for July 2023 showed: -The temperature of the refrigerator for health shakes and supplements was 32 degrees F. -The temperature was verified by the nurse. -The log was taped to the front of the refrigerator. -The following residents' physician's prescribed supplements were in the refrigerator; -A box of Acidophilus (a supplement used to promote the growth of good bacteria in the stomach) 200 milligram (mg) capsules, the box showed refrigeration was recommended. -A box of Acidophilus 100 mg capsules, the box showed to refrigerate after opening. -The refrigerator temperature was checked twice out of 17 opportunities. -The temperature both times was 35 degrees F. -There was no documentation the staff did anything to correct the temperature in the refrigerator. -The nurse verified there was no documentation staff had taken any steps to correct the temperature of the refrigerator when it was less than 36 degree F. During an interview on 7/17/23 at 6:40 A.M. LPN E said: -Medication vaccines, and other biological product that must be refrigerated require a constant temperature, usually in the range of 36 degrees F to 46 degrees F. -If the medication refrigerator's temperature was lower than 36 degrees F or higher than 46 degrees F, the effectiveness of a drug or biological may have been damaged, became ineffective or possibly even toxic and harmful to the resident. -Daily as assigned by the Director of Nursing (DON), staff would check the medication refrigerator temperature to verify the proper range. -The temperature was to have been recorded on the temperature log. -If the medication refrigerator was below or above the accepted range of 36 degrees F to 46 degrees F, designated staff would have taken the following steps; -Remove all medicines and biological's from the refrigerator and inspect them for change in consistency, clarity or color. -Check the manufacturer's storage recommendation on the package, label or drug insert. -Separate those medications and biological's in question from the other items pulled from the medication refrigerator. -Readjust the medication refrigerator temperature to reset it to the 36 degrees F to 46 degrees F range. -Recheck the temperature in 30 minutes. -If there was still a problem check with the Maintenance staff. -Document the steps you took to resolve the problem. 4. Observation of the South Medication room on 7/17/23 at 6:45 A.M. with LPN E showed: -The only sink in the medication room was rusty. -There was no soap in the soap dispenser to wash hands with. 5. Observation on 7/17/23 at 7:20 A.M. of the Nurses' medication cart with LPN E showed: -He/she had left the medication cart unlocked for three minutes while he/she went inside a resident's room to obtain a blood sugar level. -The medication cart was pointing outward in the hallway. -No nursing staff was in attendance of the cart. -A male resident walked by the cart within two feet. 6. During an interview on 7/19/23 at 9:30 A.M. LPN E said: -You should never leave the medication cart opened unless you were getting medications out of it. -The door to the medication room should not have been propped open. -The night nurse should have checked the temperature on the refrigerators. -They should have signed that they checked the refrigerator temperatures. -He/she did not know what the correct temperature for the medication refrigerators was supposed to have been. -If the temperature of the medication or supplement refrigerator was out of range the nursing supervisor should have been informed. -There was only one sink in the medication room to wash your hands and it was rusty. -Housekeeping should have ensured the sink was clean and there was hand soap and towels available. -There should not have been batteries in the residents' medications. -He/she did not know who was ultimately responsible for ensuring the refrigerator temperatures were kept within range, the medication carts were locked when not in use, the medication room was kept clean, and ensuring there were no objects such as the batteries in the medication carts, maybe the DON. During an interview on 7/19/23 at 9:35 LPN C said: -Medication rooms and medications carts should always have been locked unless you were in front of the cart using it. -The medication and supplement refrigerator's temperature should have been checked at night by the night nurse. -If the refrigerator was out of range he/she would have told the nursing supervisor. -There should not have been any batteries in the cart with the residents' prescribed medications. -Whoever used the cart should have ensured it was clean. -Housekeeping was responsible to go into the medication room to clean it and ensure there was hand soap and towels so you could wash your hands. -Housekeeping should have had the nurse let them into the medication room to clean the sink, while the nurse watched them. During an interview on 7/21/23 at 8:40 A.M. LPN B said: -The medication cart and medication room should never have been left unlocked while unattended. -The night nurse was responsible for checking the temperature of the medication refrigerators. -He/she was not sure what the temperature of the medication/supplement refrigerators should have been. -The temperature of the medication/supplement refrigerators should have been checked daily. -If the temperature was out of range he/she would have adjusted the temperature and rechecked it again later. -There should not have been any blanks on the refrigerator log. -He/she was not sure who was responsible for ensuring the medication/supplement refrigerators were kept within an acceptable range. During an interview on 7/21/23 at 12:25 P.M. the DON said: -The temperature of the medication refrigerators should have been checked every shift. -The temperature should have been documented on the sheet that was on the refrigerator. -The temperature should have been within the perimeters that was on the temperature log sheet. -If the temperature was outside of the perimeters staff should have notified the maintenance department. -It was the responsibility of the night nurse to have been checking the temperatures of the medication refrigerators. -The nurse manager was responsible for ensuring the temperatures of the refrigerator had been checked. -It was not critical if the temperature of the medication refrigerator was up or down a few degrees. -The sink in the medication room should not have been rusty. -Any nurse could have cleaned the sink. -The nurse should have let housekeeping in the medication room to clean the floors and sink daily. -The medication cart should not have been left unlocked while unattended. -The door to the medication room should not have been propped open. -Any nurse who saw the medication room door opened should have closed it.

Based on observation, interview and record review, the facility failed to follow their policy to complete testing to screen residents upon admission for tuberculosis (TB- a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for two sampled residents (Resident #83, and #75) out of five sampled residents; the facility failed to follow infection control protocols during wound care for three sampled residents (Residents #23, #25 and #35), and to clean/sanitize scissors properly before and after use between residents for two sampled residents (Residents #25 and #35) out of 18 sampled residents. The facility census was 88 residents. Review of the facility's Tuberculosis Screening policy dated 10/24/22 showed: -All residents were to be screened upon admission to the facility. -Any resident without documented negative TB skin tests (TST) or chest x-ray within the previous 12 months would receive a baseline TST. -When the first TST was negative, a follow-up TST would be administered one to three weeks after the initial TST was read. Review of the Long Term Care Infection Prevention and Control Manual, Chapter 5, Vaccinations and TB testing, created by the Quality Improvement Program for Missouri (QIPMO), dated February 2022 and the Missouri Department of Health rule 19 CSR 20-20.100 dated 2/28/22 showed: -Paragraph two: --Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a Mantoux (a test for immunity to tuberculosis using intradermal injection of tuberculin) purified protein derivative (PPD) two-step TSTs. ---The results of the TSTs should be read within 48-72 hours from administration. --If the initial test is negative, zero to nine millimeters (mm), the second test, which can be given after admission, should be given one to three weeks later. --Documentation of chest X-ray evidence ruling out TB disease within one month prior to admission, along with an evaluation to rule out signs and symptoms compatible with infectious TB, may be accepted by the facility on an interim basis until the Mantoux PPD two-step TST is completed. Review of the facility's Hand Hygiene policy, dated 10/24/2022, showed: -The facility considered hand hygiene the primary means to prevent the spread of infections. -Facility staff are trained and in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. -Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents and visitors. -Facility staff perform hand hygiene procedures in the following circumstances: --When hands are soiled with visible dirt or debris. --After contact with intact or non-intact skin, clothing and environmental surfaces of residents even if gloves were worn. --In between gloves changes. -Alcohol based hand hygiene products can and should be used to decontaminate hands: --Before putting on sterile gloves for the purpose of performing aseptic procedures. -The use of gloves does not replace hand hygiene procedures. Review of the facility's Clean and Disinfection of Resident Care Equipment dated 10/24/2022 showed: -Resident-care equipment, including reusable items are cleaned and disinfected per current CDC (Center for Disease Control) recommendations for disinfection. -Reusable items (equipment that is designated reusable by more than on resident) are cleaned and disinfected or sterilized between residents. 1. Review of Resident #83's entry tracking form showed he/she was admitted to the facility on [DATE]. Review of the resident's immunization tab showed: -No documentation of any TSTs prior to May 2023. -A TST was documented as administered and read on 5/2/23 and the results were 0 mm/negative. -A TST was documented as administered and read on 5/12/23 and the results were 0 mm/negative. 2. Review of Resident # 75's entry tracking form showed he/she admitted to the facility on [DATE]. Review of the resident's immunization tab showed: -No documentation of any TSTs prior to May 2023. -A TST was documented as administered and read on 5/2/23 and the results were 0 mm/negative. -A TST was documented as administered and read on 5/10/23 and the results were 0 mm/negative. During an interview on 7/21/23 at 8:56 A.M., Graduate Practical Nurse (GPN) said the Infection Preventionist usually put in the orders for the TSTs and did them. During an interview on 7/21/23 at 12:25 P.M., the Director of Nursing (DON) said: -The admitting nurse should administer the TST for a newly admitted resident. -They reviewed new admissions daily and if the admitting nurse did not administer the first TST for a new resident, the Infection Preventionist or the Assistant Director of Nursing (ADON) did it. -The charge nurses read the TSTs. -The infection Preventionist put in the orders so the second TST was scheduled. 37576 3. Review of Resident #25's admission record showed he/she admitted on [DATE] with the following diagnoses: -Fracture of the right femur (thigh bone). -Sepsis (a bacterial infection in the blood), unspecified organism. -Local infection of the skin and subcutaneous tissue (the layer of tissue that underlies the skin), unspecified. Observation of wound care on 7/19/23 at 12:27 P.M., showed Licensed Practical Nurse (LPN) A: -Put supplies on the resident's table without cleaning it or placing a barrier down first. -Did not sanitize scissors before use. -The wound care company's Nurse Practitioner (NP) and LPN A washed their hands and donned (put on) gloves. -He/she handed the NP the items he/she needed. -He/she removed gloves, did not wash/sanitize his/her hands and re-gloved. -He/she applied Santyl (ointment that helps remove dead skin tissue and aid in wound healing) to the bed of the wound. -He/she then applied Gentamicin (antibiotic used to treat infection) on top. -He/she did not change gloves and wash/sanitize hands and re-glove. -He/she cut Hydrofera (an antimicrobial foam dressing) with the scissors to fit the wound bed and placed on the wound. -He/she did not change gloves and wash/sanitize hands and re-glove. -He/she placed a boarder dressing over wound. -He/she placed scissors on treatment cart. -He/she did not clean/sanitize scissors. -He/she removed gloves and sanitized hands. -He/she went to another resident's room. 4. Review of Resident #35's Admission record showed he/she admitted on [DATE] with the following diagnoses: -Cellulitis (a common and potentially serious bacterial skin infection) of right lower limb. -Diabetes Mellitus II [condition that affects the way the body processes blood sugar (glucose)] with Diabetic Nephropathy (affects the kidneys' ability of removing waste products and extra fluid from the body). -Sepsis (a bacterial infection in the blood), unspecified organism. Observation of wound care on 7/17/23 at 11:04 A.M., showed LPN A: -He/she put supplies on the resident's table without cleaning it or placing a barrier down first. -He/she sanitized hands and donned gloves. -He/she did not clean/sanitize scissors. -He/she cut gauze dressing from right leg with scissors, resident's right leg had two open blisters, one medial (middle) and one posterior (back). -He/she cleaned areas with wound cleaner. -He/she did not change gloves, wash/sanitize hands and re-glove. -He/she applied Santyl to both areas with an applicator. -He/she did not change gloves, wash/sanitize hands and re-glove. -He/she did not clean scissors. -He/she cut calcium alginate (CaAlg-a type of dressing that can absorb 20 times its weight in exudate and soak up loose debris from a wound bed) to fit areas and placed over the two spots. -He/she wrapped with bulky gauze wrap. -He/she removed gloves did not wash/sanitize hands. -He/she re-gloved to do left leg. -He/she cut gauze dressing off left leg with same scissors without cleaning from the right leg. -He/she cleaned leg with wound cleanser, posterior open blister and opened blister on anterior (front) near ankle area. -He/she applied Santyl to areas. -He/she cut the alginate without cleaning scissors. -He/she wrapped leg with the bulky gauze. -He/she removed gloves and washed hands. -He/she removed unused supplies from room to nurse's treatment/medication cart. -He/she placed scissors on top of treatment cart without sanitizing/cleaning scissors. -He/she took cart back to nurses station. -His/her scissors still laying on top of the treatment cart. -He/she went to pass meds to other residents. During an interview on 7/19/23 at 1:45 P.M., LPN A said: -He/she should have cleaned the bedside tray table or placed a barrier before laying the wound care supplies on it. -He/she should have changed his/her gloves and washed/sanitized hands: --After cleansing the wound and before applying the medication. --After applying the medication. -He/she should have cleaned/sanitized the scissors before and after each use and between residents. -He/she should not have left uncleaned scissors on top of the treatment cart. 42955 5. Review of Resident #23's face sheet, undated, showed: -The resident had the following diagnoses: --Senile degeneration of the brain (a decrease in the ability to think, concentrate, or remember). --Cognitive communication deficit (an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 7/1/23, showed: -The resident scored a 00 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 and 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items were crucial factors in care planning decisions). --This showed the resident was severely cognitively impaired. -The resident had a stage I (Intact skin with non-blanchable redness of a localized area usually over a bony prominence) or greater pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure) on his/her coccyx (tail bone). Observation on 7/20/23 at 11:00 A.M., of wound care showed LPN A: -He/she put the supplies on a bedside tray table without cleaning the table or providing a clean barrier. -He/she had donned gloves to remove the resident's clothes and disposable brief. -He/she cleansed the wound with wound cleanser. -He/she did not cleanse his/her hands or change gloves before applying Calmoseptine (a multipurpose moisture barrier that protects and helps heal skin irritations). -He/she reapplied the resident's clothes. -He/she remembered that he/she was to apply an abdominal pad (extra thick dressing to care for wounds that were draining). -With the same gloves on he/she removed the resident's clothes. -With the same gloves on he/she smeared the Calmoseptine around the wound. -He/she then placed the abdominal pad over the wound. During an interview on 7/20/23 at 11:20 P.M., LPN A said: -He/she should have changed his/her gloves and washed hands after cleansing the wound and before applying the medication. -He/she should have changed his/her gloves and washed hands after removing the resident's clothes before smearing the medication and applying the abdominal pad. -He/she should have cleaned the bedside tray table or placed a barrier before laying the wound care supplies on it. 6. During an interview on 7/21/23 at 12:25 P.M., the DON said: -While wound care was performed the nurse should remove gloves and wash/sanitize hands after touching or removing soiled dressing. -There should be a barrier on the bedside tray table if used for wound care. -The bedside tray table should be cleaned or have a barrier prior to putting anything on it for wound care. -The bedside tray table should have been cleaned following the procedure. -Gloves should be removed anytime they were soiled. -Hands should have been washed anytime the gloves were removed. -Gloves should be changed and hands washed/sanitized and new gloves put on when more than one wound treatment product is being applied. -Scissors should be cleaned: --Before and after use. --Between treatments on different areas of same resident. --Between each resident wound cares.

Based on interview and record review, the facility failed to ensure the narcotic count sheet was signed by both the on-coming and the off-going nurses to verify the correct count of narcotics. The facility census was 88 residents. Review of the facility's policy, Controlled Medication Storage, dated 11/2017 showed: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances were subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations. -The Director of Nursing (DON) and the consultant pharmacist monitor for compliance with federal and state laws and regulations in the handling of controlled medications. -The medication nurse on duty maintains possession of the key to the controlled medication storage areas. -At each shift change or when keys were surrendered, a physical inventory of all Scheduled II, including refrigerated items, was to have been conducted by two licensed nurses and was to have been documented on the controlled substances accountability record for verification of controlled substances count report. -The nursing care center may elect to have counted all controlled medication at shift change. -Current controlled medication accountability records were to have been kept in the Medication Administration Record (MAR) or narcotic book. -When completed, accountability records were to have been submitted to the DON and maintained on file at the nursing center. -The consultant pharmacist, or pharmacy designee was to have routinely reviewed a sampling audit of the controlled medication storage, records, and expiration dates during the medication storage inspections. 1. Review of the North side Certified Medication Technician's (CMT) medication cart narcotic count sheet on 7/17/23 at 6:07 A.M., showed the off going Licensed Practical Nurse (LPN) pre-signed the narcotic count sheet before the day shift CMT came on and counted. Review of the North side CMT medication cart narcotic count sheet dated 6/1/23 at 6:00 A.M., through 7/20/23 at 6:00 A.M., showed the following number of missing signatures out of the required four signatures a day: -On 6/4/23 there was one missing signature. -On 6/5/23 there was one missing signature. -On 6/6/23 there was one missing signature. -On 6/7/23 there was one missing signature. -On 6/9/23 there was one missing signature. -On 6/30/23 there was one missing signature. -On 7/2/23 there was one missing signature. 2. Review of the North side Nurses medication cart narcotic count sheet on 7/17/23 at 6:51 A.M., showed the off going LPN pre-signed the narcotic count sheet before the day shift nurse came on and counted. Review of the North side Nurses medication cart narcotic count sheet dated 5/31/23 at 6:00 A.M., through 7/19/23 at 6:00 A.M., showed the following number of missing signatures out of the required four signatures a day: -On 5/31/23 there was one missing signature. -On 6/1/23 there was one missing signature. -On 6/6/23 there was one missing signature. -On 6/7/23 there were three missing signatures. -On 6/9/23 there were two missing signatures. -On 6/10/23 there was one missing signature. -On 6/14/23 there was one missing signature. -On 6/23/23 there was one missing signature. -On 7/13/23 there was one missing signature. Review of the North side Nurses medication cart narcotic count sheet on 7/19/23 at 9:00 A.M., showed the on-coming LPN pre-signed the narcotic count sheet when he/she came on for the off going shift. 39469 3. Review of the CMT medication cart (100/200 hallway) narcotic count sheet on 7/17/23 at 6:07 A.M., showed: -The off going LPN pre-signed the narcotic count sheet before the day shift CMT or LPN came on and counted with him/her to verify the count was correct. -Signing signified all doses were recorded on the MAR, count sheets matched inventory on hand, and package log matched actual package count. -There were to have been two nurses' signatures per shift, one on coming and one off going. -There were two shifts per day. -July 1st to July 17th 2023 the narcotic count log showed. -12 out of 33 shifts had only one signature. -One shift out of 33 shifts did not have any signatures. -Seven out of 33 shifts the number of narcotic packages were blank. 4. Review of the North side Nurses' medication cart, (100/200) narcotic count sheet on 7/17/23 at 6:08 A.M. showed: -The off going LPN pre-signed the narcotic count sheet before the day shift nurse came on and counted with him/her to verify the count was correct. -Signing signified all doses were recorded on the MAR, count sheets matched inventory on hand, and package log matched actual package count. -There were to have been two nurses' signatures per shift, one on coming and one off going. -There were two shifts per day. -July 1st to July 17th 2023 the narcotic count log showed. -15 out of 33 shifts had only one signature. -Five out of 33 shifts did not have any signatures. -10 out of 33 shifts the number of narcotic packages were blank. 5. Review of the 300/400 hallway CMT cart narcotic count sheet on 7/17/23 at 6:10 A.M. showed: -The off going LPN pre-signed the narcotic count sheet before the day shift nurse came on and counted with him/her to verify the count was correct. -Signing signified all doses were recorded on the MAR, count sheets matched inventory on hand, and package log matched actual package count. -There were to have been two nurses' signatures per shift, one on coming and one off going. -There were two shifts per day. -July 1st to July 17th 2023 the narcotic count log showed. --Four out of 33 shifts had only one signature. 6. During an interview on 7/17/23 at 6:20 A.M. LPN E said: -No one should have pre signed the narcotic count sheet. -Two nurses were to have counted the narcotics together and signed when they were done counting confirming the count was correct. -There should not have been any blank spaces for the signatures or the count of medications. -The DON was ultimately responsible for ensuring the narcotic count was done correctly. During an interview on 7/21/23 at 8:49 A.M., LPN A said: -When he/she comes on shift, he/she would go through report with the off going nurse on residents and what needed to be done. -Signed the narcotic count sheet coming on. -Counted how many narcotic cards were in drawers of both medication carts and any refrigerated meds with off going nurse. -Made sure the total number of narcotic cards were accurate and correct on count sheet. -Would put total amount of narcotic cards on the count sheet add or subtract amount as medication cards are gone or new added from pharmacy. -The night shift added amount to count sheet when meds came in at night. -Signed that the count was correct. -Night nurse signed off when leaving shift that the count was correct. -Night shift and day shift nurses shouldn't sign before counting they needed to be sure amount of narcotics were correct. -Anytime exchanging keys with another nurse both should count and sign narcotic count sheet for accuracy then sign the sheet. -Let the DON and the Assistant Director of Nursing (ADON) know what meds needed to be destroyed and subtract those when meds were gone from cart or refrigerator. During an interview on 7/21/23 at 12:55 P.M. the DON said: -Narcotics should have been counted by both the on coming and off going nurses at the same time. -Both nurses should have signed the narcotic count sheet at the same time. -The nurses count the number of cards and the number of pills on each card. -The nurses sign the count sheet verifying the count was correct. -The nurses should not have signed the sheet before the other shift was there to count with them. -If the count was not correct or done correctly the staff would have been expected to notify the DON. -The charge nurse was responsible for ensuring the count was done correctly.

Based on interview and record review, the facility failed to reassess the effectiveness of individualized resident care and interventions by not reviewing and revising resident care plans (a document that specified health care and supported needs and outlined how the facility met resident requirements) for one sampled resident (Resident #23) out of 18 sampled residents. The facility census was 88 residents. Review of the facility's Care Planning policy, dated 10/24/22, showed: -The purpose of the policy was to ensure a comprehensive person-centered care plan was developed for each resident based on their individual needs. -The care plan served to help the resident move toward resident-specific goals which addressed the resident's medical, nursing, mental and psychosocial needs. -The care plan was updated as indicated for changes in condition, onset of new problems, and resolution of current problems and as deemed appropriate. -Changes may be made to the care plan on an ongoing basis for the duration of the resident's stay. 1. Review of Resident #23's face sheet, undated, showed the resident had the following diagnoses: -Senile degeneration of the brain (a decrease in the ability to think, concentrate, or remember), cognitive communication deficit (an impairment in thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and anxiety (mental condition characterized by excessive fear or apprehension about real or perceived threats, leading to altered behavior). Review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 1/10/23 showed: -The resident scored a zero on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 0 and 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items were crucial factors in care planning decisions). -This indicated the resident was severely cognitively impaired. Review of the resident's care plan, most recently dated 2/28/23, showed: -The resident had a history of low back pain with potential for increase. --The goal: The resident verbalized relief from pain. -The resident was admitted to the facility for specialized care. --The goal: The resident participated in care and decision making. -The resident had an activities of daily living (ADL) self-care performance deficit. --The goal: The resident improved current level of functioning. -The resident had suicidal ideations. --The goal: The resident identified ways of increasing meaningful relationships by the review date. Review of the resident's quarterly MDS, dated [DATE], showed: -The resident was totally dependent on staff for bed mobility, transfers, dressing, eating and personal hygiene. -The resident did not walk. -The resident was in a Broda chair (a specialized wheel chair that allowed immobile residents the ability to be reclined or tilted). -The resident was unable to speak. During an interview on 7/19/23 at 10:29 A.M., Certified Nurse Assistant (CNA) C said: -He/she checked on the resident every two hours for position and continence. -The resident was very contracted (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity). -The resident was non-verbal. -The resident did groan on occasion. During an interview on 7/19/23 at 12:04 P.M., CNA A said: -He/she got the resident up and put him/her to bed and provided cares to the resident. -The resident was on Hospice (end of life care) -He/she checked for incontinence and positioning between times of getting the resident up and laying him/her down. -The resident did not do any activities. -The resident required total care. During an interview on 7/19/23 at 2:46 P.M., Licensed Practical Nurse (LPN) B said: -The resident had incontinence brief changes as needed and checked every two hours for positioning. -The resident had no way to communicate. During an interview on 7/21/23 at 8:47 A.M., the MDS coordinator said: -The computer program provided pop-up messages when a care plan was due. -The resident's care plan was last updated on 7/3/23. -He/she had not revised the section regarding the resident's contractures. -Last time he/she went through the assessment the resident was more mobile. -ADL's were updated 7/20/23 -He/she had not removed the section regarding the resident was combative. -He/she was aware the resident was full assist on all ADL's. During an interview on 7/21/23 at 12:25 P.M., the Director of Nursing (DON) said: -The charge nurse was responsible for updating care plans. -The resident's decline was gradual but had started a faster decline about six months ago. -It was at that time the resident was moved to the Broda chair. -The resident had contractures since February of 2022. -He/she expected the care plan focus areas, goals and interventions to be updated to reflect decline. -He/she expected to see dates of the updates on the care plan. -There should be dates on all relevant areas of the care plan.

Based on interview and record review, the facility failed to complete labs as ordered for one sampled resident (Resident #31) out of five residents sampled for unnecessary medications. The facility census was 88 residents. Review of the facility's laboratory, diagnostic and radiology services policy dated 10/24/22 showed: -The facility was to ensure they provided laboratory services to meet the residents' needs. -The facility would coordinate lab services based on orders from an appropriate practitioner. -The facility was responsible for the timeliness of the lab services. 1. Review of Resident #31's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 5/15/23 showed the following staff assessment of the resident: -Moderately cognitively impaired. -Some of his/her diagnoses included anemia (when the red blood cell or hemoglobin is below normal so there aren't enough healthy red blood cells to carry adequate oxygen to the body's tissues), heart failure (condition in which the heart cannot pump enough blood to all parts of the body) , hyperlipidemia (high cholesterol), Alzheimer's disease (a progressive loss of brain cells that leads to memory loss and the decline of other thinking skills), dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes) and depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life). Review of the resident's medical records showed the following most recent lab results: -Vitamin D (contributes to healthy bones, has a role in nerves, muscles, immune system and mental health) dated 11/9/22. -Comprehensive Metabolic Panel (CMP-a panel of labs that give information regarding the functioning of one's kidney, liver, electrolytes, acid/base balance and blood sugar and blood protein levels) dated 2/8/23. -Complete Blood Count (CBC-a test that gives information about blood cells) with differential (CBCD-gives the percentages of the types of blood cells) dated 2/8/23. -There were no additional Vitamin D, CMP or CBCD labs completed after the above lab results. Review of the resident's July 2023 Physician's Order Sheet (POS) showed the following lab orders: -5/28/23: Vitamin D every six months (should have been done in May 2023). -5/28/23: CMP (should have been done in June 2023) and CBCD (should have been done in June 2023) every four months. During an interview on 7/21/23 at 12:25 P.M. the Director of Nursing (DON) said: -The resident's recurring labs were not done. -They switched labs on 6/7/23. -He/she called the lab within two weeks of switching to check to make sure re-occurring labs were still entered. -He/she was doing an audit to see if all lab orders were in correctly.

Based on observation, interview and record review, the facility failed to provide nail care for one sampled resident (Resident #83) and failed to respond promptly to one supplemental resident's (Resident #27) call bell/light out of 18 sampled residents. The facility census was 88 residents. Review of the facility's policy titled Communication - Call System dated 10/24/22 showed: -The call system was used to provide a mechanism for residents to promptly communicate with nursing staff. -The facility would provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities. -Nursing staff should answer call bells promptly. -When answering a request, nursing staff will return with the item or reply promptly. Review of the facility's Care and Services policy dated 10/24/22 showed residents were to receive the necessary care and services based on an individualized comprehensive assessment process. 1. Review of Resident #27's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 5/3/23 showed the following staff assessment of the resident: -Moderately impaired cognitive skills. -Totally dependent upon one staff for toileting. Review of the resident's care plan updated 5/4/23 showed: -The resident had an activities of daily living (ADLs-dressing, grooming, bathing, eating, and toileting) self-care performance deficit related to a fracture. -The resident was totally dependent on two staff for repositioning and turning in bed as necessary. -The resident was totally dependent on one to two staff for dressing. -The resident was on diuretic therapy (any medication that elevates the rate of urination) related to edema (swelling). Review of the resident's July 2023 Physician's Order Sheet (POS) showed a physician's order for Furosemide (a diuretic) 40 milligrams (mg), one tablet by mouth one time a day. Continuous observation on 7/17/23 beginning at 9:24 A.M. showed: -The resident's call light was on. -At 9:54 A.M., the resident said he/she had his/her call light on because he/she needed to use the bed pan and he/she was waiting a long time for it. -At 9:54 A.M., staff entered the resident's room. Continuous observation on 7/17/23 beginning at 11:48 A.M. showed: -At 11:48 A.M., the resident's call light was on. -At 12:15 P.M., the resident's call light was still on and staff entered the resident's room. Observation on 7/17/23 at 12:25 P.M. showed: -Staff were not in the resident's room and the resident said he/she still needed the bed pan, they never brought it to him/her and he/she was going to turn his/her call light back on. -The resident pressed his/her call light pad and it turned on. -At 12:26 P.M., two staff went into the resident's room. During an interview on 7/21/23 at 8:56 A.M., Graduate Practical Nurse (GPN) A said: -The call bells have a station at the nurses' station that light and beep to alert them a call bell is on. -He/she was not aware of any issues with time of response to call lights. -They worked together to get the call lights answered. -They were not given guidance on how soon they should respond to a call light but he/she preferred they were respond to within 10 minutes or less. During an interview on 7/21/23 at 9:10 A.M., Certified Nursing Assistant (CNA) D said: -They tried to respond to the call light as soon as they came on. -The resident stays in bed. -They kept the resident's bed pan in his/her bathroom. -The resident used the call light when he/she needed to use the bed pan. During an interview on 7/21/23 at 12:25 P.M., the Director of Nursing (DON) said: -Call light response should be as timely as possible. -The resident's call light should have been answered in less than 30 minutes. -He/She would expect staff to return as soon as possible or leave the call light on if the staff were unable to provide what the resident needed. 2. Review of Resident #83's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Moderately cognitively impaired. -Had clear speech. -Usually understood others and was usually understood by others. -Had no behaviors. -Did not refuse cares. -Required extensive assistance with personal hygiene. -Did not walk. -Had impaired range of motion in arms and legs on one side. -Used a wheelchair. -Did not have a diagnosis of diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Observation and interview on 7/20/23 at 11:20 A.M. showed: -The resident's toe nails were long. -Licensed Practical Nurse (LPN) D said if the resident doesn't see the podiatrist, he/she should. Observation and interview on 7/20/23 at 2:33 P.M. showed: -The resident's toe nails were long, thick and yellow. -The resident's first through fourth toe nails on his/her right foot were approximately 1/2 long from the top of his/her toe. -The resident's first toe nail on his/her left foot was about 1/2 long from the top of his/her toe. -The resident's second toe nail on his/her left foot was about 3/4 long from the top of his/her toe and curved over the top of his/her toe and went down the bottom side of his/her toe. -The resident said yes when asked if he/she thought his/her toenails were long and needed to be cut. Review of the resident's medical records showed no podiatry notes for 2023. Review of the resident's care plan revised 6/11/23 showed: -The resident had an ADL self-care performance deficit limited mobility. -Instructions to nursing staff to check the resident's nail length and trim and clean on bath day and as necessary and to report any changes to the nurse. During an interview on 7/21/23 at 8:56 A.M., GPN A said: -CNAs normally did nail care. -CNAs would be responsible for nail care since the resident was not diabetic. During an interview on 7/21/23 at 9:10 A.M., CNA A said: -He/she was not sure who was responsible for trimming the resident's toe nails. -He/she thought whoever did the resident's bath would do them at that time. During an interview on 7/20/23 at 1:09 P.M., the Social Services Director said: -He/she had worked at the facility for two months. -The podiatrist had their own list of residents who they were going to see. During an interview on 7/21/23 at 12:25 P.M., the DON said: -Social Services was responsible for podiatry. -They made a list from who Social Services said needed to see the podiatrist as well as the podiatrist maintained a list. -Whenever it was identified that a resident needed to see the podiatrist, they should notify Social Services. -The resident was on hospice (end of life care) so hospice staff could take care of the resident's toe nails as well.

Based on interview, and record review, the facility failed to ensure one sampled resident (Resident #64) had a code status upon admission out of 18 sampled residents. The facility census was 88 residents. Review of the facility's policy, Advance Directives, dated October 24, 2022 showed: -The Facility would respect a resident's advance directive and would comply with the resident's wishes expressed in an advance directive. -Upon admission, the Admission Staff or designee would obtain a copy of a resident's advance directive. -A copy of the resident's advance directive would have been included in the resident's medical record. -If the resident did not have an Advance Directive, the Facility would have provided the resident and/or resident's next of kin with information about advance directives upon request. -An Advance Directive was defined as a resident's written preference regarding treatment options. -Upon admission, the Admission Staff or designee would have provided written information to the resident concerning his or her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. -During the Social Services Assessment process, the Director of Social Services or designee would have also asked the resident whether he or she had a written advance directive, including whether the resident had requested or was in possession of an aid-in-dying drug. -If the resident had an Advance Directive, the Facility would obtain a copy of the document and place it in the resident's medical record. -If the resident did not wish to complete the Missouri Advance Directive, the Admissions Staff or designee would have notified the Administrator for further review. -If the resident did not have an Advance Directive, the Admissions Staff or designee would have informed the resident that the Facility could have provided the resident with a copy of the Advance Directive form. 1. Review of Resident #64's face sheet showed he/she had been readmitted to the facility on [DATE] with the following diagnoses: -Cognitive communication deficit (when a person has difficulty communicating because of injury to the brain that controls the ability to think). -Acute respiratory failure (an impairment of the gas exchange between the lungs and blood). -Acute pulmonary edema (a condition caused by excess fluid in the lungs). -Cardiomegaly (a medical condition in which the heart becomes enlarged that make it work harder). -Acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility staff for care planning) dated 5/29/23 showed his/her Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating he/she was cognitively intact. Review of the resident's medical record on 7/18/23 at 1:00 P.M. showed: -The face sheet did not show a code status. -The Physician's Order Sheet (POS) did not show a code status. -The care plan did not show a code status. -The Admission assessment showed the resident was a full code, dated 7/11/23. During an interview on 7/19/23 at 9:40 A.M. Licensed Practical Nurse (LPN) C said: -A resident's code status should have been in the electronic chart. -The code status should have been on the face sheet. -The code status should have been on the POS. -The code status should have been on the resident's care plan. -The resident did not have a code status on the face sheet, POS, or the care plan. -The nurse who admitted the resident was responsible for ensuring the code status was done on admission. -Medical Records checked that the resident's code status was obtained before scanning it into the resident's chart. -The resident's code status should have been on the face sheet, POS, and care plan the same day the resident had been admitted . During an interview on 7/19/23 at 10:00 A.M. the Medical Records Director said: -The code status should be on the resident's chart within 24 hours of admission, ideally the same day they had been admitted . -Upon admission the nurse who admitted the resident should obtain the code status. -The code status should have been on the face sheet, care plan, or POS. -It was not done. -The resident was a full code (initiate life saving maneuvers if his/her heart stopped). -If there was no Do Not Resuscitate (DNR - do not start life saving maneuvers if the heart stopped) papers signed so the resident was a full code. -The code status for this resident fell through the crack. -The paperwork from the hospital that the resident came from showed he/she was a full code. -The code status should be verified upon admission with the resident if they were their own person or verified with the resident's guardian. -The resident was his/her own person and should have been asked what they wished to do for a code status. -It was his/her responsibility to ensure it was in the resident's medical record. During an interview on 7/21/23 at 12:25 P.M. the Director of Nursing (DON) said: -A resident's Advanced Directives should have been obtained upon admission. -The admission nurse or the charge nurse were responsible for obtaining the code status for new admissions. -They go over new admissions in the morning Department Head meetings and it should have been caught there if it was missed. -The resident should have had a physician's order for advanced directives on the resident's face sheet, POS and care plan.

Based on observation, interview, and record review, the facility failed to ensure staff accurately documented a resident's wounds, including description, pain, odor, and measurements, weekly; to provide accurate wound description and documentation to the resident's physician; to have the resident's outside wound care provider medical records readily accessible; and to administer wound treatments per the resident's physician's orders for two sampled residents (Resident #1 and #3). Resident #1's right lower leg dressing became saturated, foul smelling, and full of maggots (the larva of a fly) in his/her wound. The resident was sent to the hospital and was found to have a wound infection and had a consultation for possible amputation. Nine residents were sampled. The facility census was 95 residents. Record review of the facility policy Resident Examination and Assessment revised February 2014, showed: -The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. -Check skin for intactness, moisture, color, texture and for presence of bruises, pressure ulcers, redness, [MEDICAL CONDITION] and rashes. -Document in the resident's medical record: --The date and time the procedure was performed. --The name and title of the individual(s) who performed the procedure. --All assessment data obtained during the procedure. --If the resident refused the procedure, the reason(s) why and the intervention taken. --The signature and title of the person recording the data. -Notify the supervisor if the resident refuses the examination. -Notify the physician of any abnormalities such as, but not limited to: --Wounds or rashes on the resident's skin. -Report other information in accordance with facility policy and professional standards of practice. Record review of the facility Physician Orders dated revised April 2012, showed: -Orders for medication and treatments will be consistent with principles of safe and effective order writing. -Specify what is to be done, location and frequency, and duration of the treatment. Record review of the facility Pressure Ulcer/Skin Breakdown Clinical Protocol dated revised March 2014, showed: -The nursing staff and attending physician will assess and document an individual's significant risk factors for developing skin breakdown. -In addition, the nurse shall describe and document/report the following: --Full assessment including location, type of impairment, length, width and depth and presence of exudate or necrotic tissue. --Pain assessment. -The physician will assist the staff to determine etiology (for example, arterial of stasis) and characteristics (necrotic tissue, status of wound bed, etc.) of the skin alteration. -The physician will help identify medical interventions related to wound management. -The physician will authorize pertinent orders related to wound treatments, including wound cleansing, debridement approaches, dressings and application of topical agents if indicated for type of skin alteration. -During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds. -The following information should be recorded in the resident's medical record: --The type of wound care given. --The date and time the wound care was given. --The position in which the resident was placed. --The name and title of the individual performing the wound care. --Any change in the resident's condition. --All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. --How the resident tolerated the procedure. --Any problems of complaints made by the resident related to the procedure. --If the resident refused the treatment and the reason(s) why. --The signature and title of the person recording the data. -Notify the supervisor if the resident refuses the wound care. -Report other information in accordance with the facility policy and professional standards of practice. Record review of the facility Guidelines for Charting and Documentation dated revised April 2012, showed: -The purpose of charting and documentation is to provide: --A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., and the progress of the resident's care. --Guidance to the physician in prescribing appropriate medications and treatments. --The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. --Nursing service personal with a record of the physical and mental status of the resident. --Assistance in development of a Plan of Care for each resident. --A legal record that protects the resident, care providers and the facility. -Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well as routine observations. -Be concise, accurate, complete, and use objective terms. -Document assessments, interventions, treatments and outcomes. -Documentation pertaining to a resident's refusal of treatment should include: --Date and time treatment attempted. --Treatment attempted. --Resident's response and reason(s) for refusal. --Name of person attempting to administer the treatment. --Document that the resident was informed of the purpose of the treatment and the consequences of not receiving the care. --Document each time the resident refuses his/her treatment, the resident's condition and any adverse effects due to such refusal. --Date and time the physician was notified of the resident's refusal of treatment in addition to the physician's response. --All pertinent observations. -Anytime the physician or family is called about the resident and their response. -When charting nursing summaries and/or assessments for skin include the following. --dry, moist, scaly, etc --Be descriptive of [MEDICAL CONDITIONS] etc --Include locations, size, depth, color, amount, consistency, odor of drainage, and status of tissue and surrounding area. --Indicate type of treatment and how often treatment is administered. -All entries must reflect the date, the time and the signature and title of the person recording the data. 1. Record review of Resident #1's Face Sheet showed he/she was admitted into the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. -[MEDICAL CONDITION] (plaque build-up it the artery wall) of native arteries of right leg. Record review of the resident's Physician's Order Sheet (POS) dated April 2020 showed: -an order for [REDACTED]. -an order for [REDACTED]. -Resident is only to be up 30 minutes in the A.M. and 30 minutes in the evening, every day and evening shift for wound healing start 5/12/20. Record review of the resident's Care Plan dated 2/26/18 revised on 5/07/19 showed: -He/she had moisture/incontinence associated skin damage to bilateral gluteal folds. -This skin damage will continue to show signs of improvement. -Assess/record/monitor wound healing. -Measure length, width and depth where possible. -Assess and document status of wound perimeter, wound bed and healing progress. -Report improvements and declines to the physician. -Staff will administer treatments as ordered and monitor for effectiveness. -Outside wound care provider to evaluate on a weekly basis initiated 3/8/20. -Update 4/23/20, the resident had wounds on his/her right lower extremity anterior, right lower extremity medial, right lateral foot, gluteal folds/posterior thighs/buttocks, coccyx, right ankle medial, see wound assessments for updated information. -Discontinued order on 6/25/20 for the resident to be up 30 minutes in the A.M. and 30 minutes in the P.M. due to non-compliance. The resident states he/she does not care and wants to go outside when he/she wants. -He/she is dependent on staff for all activities of daily living due to immobility with upper and lower extremity weakness. -He/she requires total assist time one or two staff for bath/shower/bed bath. -Bed mobility he/she requires assist of two staff for repositioning, he/she does not like to lay down during the day unless he/she has to. -Assist time three staff with Hoyer lift. -He/she has a communication problem related to [MEDICAL CONDITION] (partial loss of the ability to produce language (spoken, manual or written) comprehension generally remains intact). -He/she has difficulty with forming words and making myself known at times. -Keep explanations simple, ask yes or no questions. -He/she also has the following chronic arterial injuries to his/her right lower extremity anterior, right foot lateral, right lower extremity medial, right ankle inner, right foot mid, right distal, right heel, left foot lateral and left great toe. -The skin tear to the left great toe will be healed by review date 8/20/20. -He/she will have no complications related to any of his/her chronic arterial injuries through the review date of 8/20/20. -See wound records for additional with a total of 15 open areas. Record review of the resident's POS and Treatment Administration Record (TAR) dated April 2020 showed: -Treatment: Cleanse right medial ankle with wound cleaner (WC) and pat dry, apply Xeroform gauze (a wound dressing) to wound bed, cover with Super Absorbent Pad Non-Bordered (ABD) pad and wrap with Kerlix (woven gauze that is non-adhesive used to wrap wounds and burns) to secure, change every day shift and as needed (PRN) for wound healing start date 4/6/20. -No documentation the treatment was completed by staff two out of 23 opportunities. Record review of the facility's weekly Skin Impairment Report (non-pressure) dated 4/1/20 showed the resident had the following facility acquired non-pressure wounds managed by an outside wound care company: -Left lower extremity medial arterial wound measured 1.0 centimeters (cm) in length X 1.0 cm in width X 0.1 cm in depth acquired on 9/21/18. -Left foot lateral (position away from the midline of the body) vascular wound measured 2.5 cm in length X 2.0 cm in width X 0.1 cm in depth acquired on 3/5/19. -Right foot lateral vascular wound measured 1.0 cm in length X 0.5 cm in width X 0.1 cm in depth acquired on 10/29/19. -Left buttock Moisture Associated Skin Damage (MASD -inflammation or erosion of the skin caused by prolonged exposure to a source of moisture) wound measured 0.5 cm in length X 0.5 cm in width X 0.1 cm in depth acquired on 2/18/20. -Right ankle inner arterial wound measured 7.0 cm in length X 1.5 cm in width X 0.1 cm in depth acquired on 3/5/20. Record review of the resident's medical record showed no record of a Wound Management Report dated 4/1/20 from the resident's outside wound care provider. Record review of the resident's Long Term Care Assessment Note dated 4/3/20 showed: -The resident was readmitted to the facility on [DATE] at 12:10 P.M., from a wound care hospital. -The resident had a wound to his/her right medial ankle that measured 4.5 cm in length X 4.5 cm in width X 0.2 cm in depth, with moderate serosanguinous (containing blood and watery drainage) drainage, wound bed was 50% slough (nonviable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) otherwise granulation (new connective tissue and microscopic blood vessels that form on the surface of a wound during the healing process) noted. -Redness noted throughout buttock and upper thighs. --NOTE: No documentation by staff of the resident's left lower extremity medial wound, left lateral foot wound, or his/her right lateral foot wound. The facility wound report showed the resident's right medial ankle wound was 7.0 cm in length by 1.5 cm in width by 0.1 cm in width. Record review of the facility's weekly Skin Impairment Report (non-pressure) dated 4/9/20 showed the resident had the following facility acquired non-pressure wounds managed by an outside wound care company: -Left lower extremity medial arterial wound measured 1.0 cm in length X 1.0 cm in width X 0.1 cm in depth. -Left foot lateral vascular wound measured 2.5 cm in length X 2.0 cm in width X 0.1 cm in depth. -Right foot lateral vascular wound measured 1.0 cm in length X 0.5 cm in width X 0.1 cm in depth. -Left buttock MASD wound measured 0.5 cm in length X 0.5 cm in width X 0.1 cm in depth. -Right ankle inner arterial wound measured 7.0 cm in length X 1.5 cm in width X 0.1 cm in depth. Record review of the resident's facility weekly computerized Wound Record dated 4/9/20 showed: -First observed 4/9/20, right lateral calf vascular wound measured 2.5 cm in length X 1.5 cm in width X 0.1 cm in depth, large amount of serous (watery, clear, or slightly yellow/tan/pink drainage) drainage, no odor, no slough or eschar (a dry scab), physician notified 4/9/20. --Note: This wound was not listed on the resident's weekly Skin Impairment Report. Record review of the resident's medical record showed no record of a Wound Management Report dated 4/9/20 from the resident's outside wound care provider. Record review of the facility weekly Skin Impairment Report (non-pressure) dated 4/16/20 showed no weekly report. Record review of the resident's facility weekly computerized Wound Record dated 4/16/20 showed no weekly wound record was found in the resident's chart. Record review of the resident's medical record showed no record of a Wound Management Report dated 4/16/20 from the resident's outside wound care provider. Record review of the facility's weekly Skin Impairment Report (non-pressure) dated 4/23/20 showed the resident had the following facility acquired non-pressure wounds managed by an outside wound care company: -Right lower extremity medial arterial wound measured 9.3 cm in length X 4.0 cm in width X 0.5 cm in depth. -Right lower extremity anterior (front of the body) arterial wound measured 4.7 cm in length x 6.7 cm in width X 0.1 cm in depth. -Right foot lateral arterial wound measured 0.5 cm in length X 0.5 cm in width X 0.1 cm in depth. -Right ankle inner arterial wound measured 4.5 cm in length X 5.0 cm in width X 0.4 cm in depth. --Note: No documentation by the facility staff of the status of the resident's left lower extremity medial arterial wound, left lateral foot vascular wound or left buttock wound. Record review of the resident's outside wound care provider's Wound Management Report dated 4/23/20 showed the following additional information: -Right lower extremity, scant amount of serosanguinous drainage, he/she reported a wound pain of four out of ten (zero being no pain and ten being extreme pain) and the wound bed had 76-100% granulation. -Right foot lateral measured 0.5 cm in length X 0.5 cm in width X 0.5 in depth, with no drainage. The wound bed had 76-100% [MEDICATION NAME] (process of epidermis regenerating over a partial-thickness wound surface or in scar tissue forming on a full thickness wound bed). ---Note: The facility documented the measurements as 0.5 cm in length X 0.5 cm in width X .01 cm in depth. -Right medial ankle had a wound bed of 1-25% slough and 76-100% granulation. -Right lower extremity medial arterial wound had a wound bed of 1-25% slough and 26-50% granulation. Record review of the resident's facility weekly computerized Wound Record dated 4/23/20 showed: -Right lower extremity anterior arterial wound had foul odor, no percentage of wound bed and had deteriorated. -Right foot lateral arterial wound had no drainage or odor, no percentage of wound bed and had improved. -Right ankle inner arterial wound had moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed and had deteriorated. -Right lower extremity arterial wound had moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed and had deteriorated. Record review of the resident's POS and TAR dated May 2020 showed: -Treatment clarification effective 5/15/20: Right posterior thigh, Right medial lower leg, Right medial ankle, Right lateral foot, Right foot mid, Right heel, Right foot other distal, Left lateral foot, Left great toe, Right great toe: Cleanse the following areas with wound cleaner, pat dry, apply Xeroform gauze to wound beds that do not have eschar, cover areas with individual border pads, on bilateral lower extremities adhere with Kerlix and apply ace wrap, change daily and as needed for wound healing, ordered on [DATE] and started on 5/19/20. --NOTE: The order was documented on the POS for all ten areas as one order and staff documented the treatment for [REDACTED]. The order does not identify which wounds has eschar and which wounds do not have eschar. The TAR does not have a space for the staff to document the completion of treatment for [REDACTED]. -Treatment cleanse the following areas with wound cleaner: Right posterior thigh, Right medial lower leg, Right medial ankle, Right lateral foot, Right foot mid, Right heel, Right foot other distal, Left lateral foot, Left great toe, Right great toe, pat dry and apply Collagen pad, cut to fit wound bed, cover with island dressing, may secure with Kerlix, every day shift for wound healing start 5/23/20. --NOTE: The order was documented on the POS for all ten areas as one order and staff documented the treatment for [REDACTED]. The TAR does not have a space for the staff to document the completion of treatment for [REDACTED]. -Clean outer side of the Left great toe with wound cleaner, apply A & D Ointment to affected area and cover with a dressing in the morning for skin tear for 10 days started 5/10/20. --NOTE: No documentation by facility staff the treatment was provided three out of ten opportunities. -Treatment: Ace wrap to Right lower Extremity after placing clean dressing. --Right lower extremity Ace wrap, 6 of 62 opportunities were left blank. --Tubi grip to Left lower extremity. --Tubi grip to Left lower extremity, 6 of 62 opportunities were left blank. --Every day and evening shift for [MEDICAL CONDITION] on in the A.M. off at hour of sleep, start 4/24/20. -Treatment [MEDICATION NAME] Ointment 0.44-20.6% (Menthol-Zinc Oxide), apply to sacrum, buttocks topically every day and evening shift related to irritant contact [MEDICAL CONDITION], unspecified cause. --[MEDICATION NAME] Ointment, 5 of 62 opportunities were left blank. -Treatment cleanse Right medial ankle with wound cleaner, pat dry, apply Xeroform gauze to wound bed, cover with ABD pad, Kerlix to secure, change daily and PRN ordered on [DATE] discontinued on 5/18/20. -Noted: No documentation by facility staff the treatment was provided five of 18 opportunities. Record review of the facility's weekly Skin Impairment Report (non-pressure) dated 5/1/20 showed the resident had the following facility acquired non-pressure wounds managed by an outside wound care company: -Right lower extremity medial arterial wound measuring 10.0 cm in length X 4.0 cm in width X 0.5 cm in depth. -Right lower extremity anterior arterial wound measuring 1.8 cm in length x 1.0 cm in width X 0.1 cm in depth. -Right foot lateral arterial wound measuring 0.5 cm in length X 0.5 cm in width X 0.2 cm in depth. -Right ankle inner arterial wound measuring 4.5 cm in length X 5.0 cm in width X 0.3 cm in depth. Record review of the resident's outside wound care provider's Wound Management Report dated 5/1/20 showed the following additional information: -Right lower extremity, scant amount of serosanguinous drainage, wound pain of four out of ten, wound bed had 76-100% [MEDICATION NAME]. -Right foot lateral measured 0.5 cm in length X .05 cm in width X 0.5 in depth, no drainage, wound bed had 76-100% granulation, no [MEDICATION NAME], improved. -Right medial ankle had a wound bed had 1-25% slough and 76-100% granulation, improved. -Right lower extremity medial arterial wound had a wound bed of 1-25% slough and 26-50% granulation, improved. -Right foot mid arterial ulcer measured 2.2 cm in length X 1.2 cm in width X 0.2 cm in depth, moderate amount of serosanguinous drainage, wound bed had 76-100% Granulation. --NOTE: This wound was not documented on the facility's weekly Skin Impairment Report or the resident's weekly computerized Wound Report. Record review of the resident's facility weekly computerized Wound Record dated 5/1/20 showed: -The wounds listed below show the difference what is different between the Skin Impairment Report, Wound Record and the Wound Management Report: --Right lower extremity anterior arterial wound had foul odor, no percentage of wound bed. --Right foot lateral arterial wound had no drainage or odor, no percentage of wound bed and deteriorated. --Right ankle inner arterial wound had moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed and deteriorated. --Right lower extremity arterial wound moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed and deteriorated. Record review of the resident's weekly Skin Impairment Report (non-pressure) dated 5/7/20 showed the resident had the following facility acquired non-pressure wounds managed by an outside wound care company: -Right lower extremity medial arterial wound measuring 12.0 cm in length X 3.0 cm in width X 0.5 cm in depth. -Right lower extremity anterior arterial wound healed times one week. -Right foot lateral arterial wound measuring 1.5 cm in length X 1.2 cm in width X 0.2 cm in depth. -Right ankle inner arterial wound measuring 4.5 cm in length X 5.7 cm in width X 0.3 cm in depth. -Right foot mid arterial wound measuring 1.0 cm in length X 1.5 cm in width X 0.2 cm in depth acquired on 5/7/20. -Right heel fluid filled arterial wound measuring 4.0 cm in length X 3.5 cm in width X 0.1 cm in depth acquired on 5/7/20. -Right foot distal arterial wound measuring 1.0 cm in length X 1.5 cm in width X 0.1 cm in depth acquired on 5/7/20. -Left foot lateral arterial wound measuring 2.0 cm in length X 2.3 cm in width X 0.1 cm in depth acquired on 5/7/20. -Left great toe arterial wound measuring 0.5 cm in length X 0.5 cm in width X 0.1 cm in depth acquired on 5/7/20. Record review of the resident's outside wound care provider's Wound Management Report dated 5/7/20 showed the following additional information: -Right foot lateral wound bed had 76-100% Granulation, no change. -Right medial ankle had a wound bed of 26-50% eschar and 26-50% slough, no granulation, deteriorated. -Right lower extremity medial arterial wound had a wound bed 26-50% slough, no granulation, deteriorated. -Right foot mid had a wound bed of 76-100% granulation, no change. -Right heel was a fluid filled blister. -Right foot distal had a wound bed of 76-100% eschar, new. -Left lateral foot had a wound bed of 76-100% eschar, new. -Left great toe had a wound bed of 76-100% eschar, new Record review of the resident's facility weekly computerized Wound Record dated 5/7/20 showed: -The wounds listed below show the difference what is different between the Skin Impairment Report, Wound Record and the Wound Management Report: --Right foot lateral arterial wound had moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed and deteriorated. --Right ankle inner arterial wound had moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed and not changed. --Right lower extremity arterial wound moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed and deteriorated. --Right foot mid arterial wound moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed, new. --Right heel arterial wound moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed, new. --Right foot distal arterial wound moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed, new. --Left foot lateral arterial wound moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed, new. --Left great toe arterial wound moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed, new. Record review of the facility's weekly Skin Impairment Report (non-pressure) dated 5/15/20 showed the resident had the following facility acquired non-pressure wounds managed by an outside wound care company: -Right lower extremity medial arterial wound measuring 12.5 cm in length X 3.0 cm in width X 0.5 cm in depth. -Right lower extremity anterior arterial wound healed times two weeks. -Right foot lateral arterial wound measuring 1.8 cm in length X 1.5 cm in width X 0.2 cm in depth. -Right ankle inner arterial wound measuring 4.0 cm in length X 5.5 cm in width X 0.3 cm in depth. -Right foot mid arterial wound measuring 1.0 cm in length X 1.0 cm in width X 0.2 cm in depth. -Right heel fluid filled arterial wound measuring 7.0 cm in length X 4.5 cm in width X 0.2 cm in depth. -Right foot distal arterial wound measuring 2.5 cm in length X 2.2 cm in width X 0.2 cm in depth. -Left foot lateral arterial wound measuring 2.0 cm in length X 2.4 cm in width X 0.2 cm in depth. -Left great toe arterial wound measuring 2.0 cm in length X 1.5 cm in width X 0.2 cm in depth. Record review of the resident's outside wound care provider's Wound Management Report dated 5/15/20 showed the following additional information: -Right foot lateral wound bed had 1-25 % slough and 76-100% granulation, no change. -Right medial ankle had a wound bed of 26-50% eschar and 26-50% slough, no granulation, deteriorated. -Right lower extremity medial arterial wound had a wound bed 26-50% slough and 25-50% eschar, no granulation, deteriorated. -Right foot mid had a wound bed of 76-100% granulation. -Right heel had a wound bed of 76-100% granulation, deteriorated. -Right foot distal arterial wound had moderate amount of serosanguinous drainage with a foul odor, had a wound bed of 76% eschar, with wound pain rated a one out of ten, deteriorated. -Left lateral foot had a wound bed of 26-50% eschar and 26-50% slough, deteriorated. -Left great toe had a wound bed of 76-100% eschar. -Right great toe measured 2 cm in length x 2 cm in width x 0.1 cm in depth, wound bed was 76-100% eschar, new. --NOTE: This wound is not listed on the facility Skin Impairment Report dated 5/15/20. Record review of the resident's facility weekly computerized Wound Record dated 5/15/20 showed: -The wounds listed below show the difference what is different between the facility Skin Impairment Report, Wound Record and the outside wound care provider Wound Management Report: --Right foot lateral arterial wound had moderate amount of serosanguinous drainage with a foul odor, percentage of wound bed was 25% slough and no change. --Right ankle inner arterial wound had moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed and deteriorated. --Right lower extremity arterial wound moderate amount of serosanguinous drainage with a foul odor, percentage of wound bed was 50% slough and 50% eschar and deteriorated. --Right foot mid arterial wound moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed, no change. --Right heel arterial wound moderate amount of serosanguinous drainage with a foul odor, no percentage of wound bed, deteriorated. --Right foot distal arterial had wound pain rated 5-7 out of 10. --Left foot lateral arterial wound moderate amount of serosanguinous drainage with a foul odor, percentage of wound bed was 50% slough an 50% eschar, deteriorated. --Left great toe arterial wound moderate amount of serosanguinous drainage no odor, percentage of wound bed had 50% slough, deteriorated. --Right great toe first observed 5/15/20, measured 2.0 cm in length X 2.0 cm in width X 0.1 in depth, no drainage or odor, wound bed was 100% eschar. ---Noted: The right great toe was not listed on the facility weekly Skin Impairment Report for 5/15/20. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning) dated 5/18/20 showed he/she: -Was moderately cognitively impaired. -Had nine venous and arterial ulcers (open lesion caused by poor circulation). -Had open lesion(s) on the foot. -No behaviors of rejecting care. -Turning program. -Nutrition and hydration. Record review of the facility's weekly Skin Impairment Report (non-pressure) dated 5/21/20 showed the resident had the following facility acquired non-pressure wounds managed by an outside wound care company: -Right lower extremity medial arterial wound measuring 10.0 cm in length X 3.0 cm in width X 0.5 cm in depth, improved. -Right lower extremity anterior arterial wound healed times three weeks. -Right foot lateral arterial wound measured 1.8 cm in length X 1.0 cm in width X 0.2 cm in depth, no change. -Right ankle inner arterial wound measured 4.6 cm in length X 5.4 cm in width X 0.3 cm in depth, deteriorated. -Right foot mid arterial wound measured 1.0 cm in length X 1.5 cm in width X 0.2 cm in depth, deteriorated. -Right heel fluid filled arterial wound measured 2.5 cm in length X 3.0 cm in width X 0.1 cm in depth. -Right foot distal arterial wound measured 2.5 cm in length X 2.2 cm in width X 0.2 cm in depth, no change. -Left foot lateral arterial wound measured 2.0 cm in length X 2.5 cm in width X 0.2 cm in depth, improving. -Left great toe arterial wound measured 2.0 cm in length X 1.0 cm in width X 0.2 cm in depth, improving. -Right great toe arterial wound measured 1.5 cm in length X 1.0 cm in width X 0.1 cm in depth, improving. Record review of the resident's outside wound care provider's Wound Management Report dated 5/21/20 showed the following additional information: -Right lower extremity medial arterial wound, moderate amount of serosanguinous drainage, wound bed 26-50% slough and 25-50% eschar, no granulation, improving. -Right foot lateral arterial wound, no drainage, wound bed had 1-25 % slough and 76-100% granulation, no change. -Right medial ankle arterial ulcer, moderate amount of serosanguinous drainage, wound bed of 26-50% eschar and 26-50% slough, no granulation, deteriorated. -Right foot mid arterial wound, moderate amount of serosanguinous drainage, wound bed of 26-50% slough and 26-50% granulation. -Right heel arterial wound, no drainage, had a wound bed of 76-100% [MEDICATION NAME] and no granulation, improved. --Note: The right heel on the weekly Skin Impairment Report showed the right heel is fluid filled on 5/21/20. -Right foot distal arterial wound, moderate amount of serosanguinous drainage, wound bed of 26-50% slough and 51-75% granulation, no change. -Left lateral foot arterial wound, moderate amount of serosanguinous drainage, wound bed of 26-50% slough and 26-50% granulation, improving. -Left great toe arterial wound, moderate amount of drainage noted, no odor, wound bed of 76-100% granulation, improving. -Right great toe arterial wound, no drainage, wound bed was 76-100% eschar, improving. Record review of the facility's weekly Skin Impairment Report (no

Based on observation, interview and record review, the facility failed to identify a pressure ulcer, to report the pressure ulcer to the charge nurses before applying any treatment, to ensure the resident's low air mattress was not deflated in the middle of the mattress to prevent pressure ulcers, to accurately monitor and provide interventions to prevent further decline of a wound that deteriorated from a Stage II wound to a Stage IV wound with undermining (penetrating into tissue), and prevent the deterioration of his/her Stage II wound to a Stage III wound, failed to ensure the low air loss mattress was set at the appropriate setting of 240 for one sampled resident (Resident #1), to follow the physician's orders [REDACTED].#1 and #2) out of 17 sampled residents. The facility census was 101 residents. Record review of the facility's undated policy titled, Identification, Prevention and treatment of [REDACTED]. -Identification of at risk residents; -Promote the prevention of pressure ulcer development; -Promote the healing of pressure ulcers that are present while preventing complications to the extent possible; -Provide medical, nutritional and environmental interventions to protect against adverse effects of pressure, friction, shearing, nutritional deficits, acute illness and/or chronic disease processes; -Provide appropriate and accurate documentation; -Ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident's right to refuse treatment, and within the limits of recognized pathology and normal aging process; -Providing appropriate pressure reduction equipment as deemed necessary by the multidisciplinary team; -Weekly skin progress note and wound record will be utilized by the weight and wound committee; -Facility provides all nursing staff with computer software for documentation of alerts and skin condition; -Facility provides the nurses with the weekly wound sheet to document wound progression for easy tracking and compliance if resident is not seen by wound care physician and -Facility provides the nurses with charting guidelines on wounds to ensure accurate documentation. Record review of the facility's policy titled Reporting Alterations in Skin Integrity showed: -Preventative measures are to be implemented as soon as the resident's need is identified; -Prevention Interventions are to include proper turning and repositioning at least every two hours and as needed or requested by the resident; -Using positioning devices in the bed and/or the chair as needed; -Providing appropriate pressure reduction equipment deemed necessary by the team; -If a resident is admitted to the facility with a wound or acquires a wound while in the facility, the facility will provide the resident with the appropriate nutrition as tolerated and allowed by the resident, appropriate treatment of [REDACTED]. -The facility will continue to follow the prevention interventions as appropriate for the resident; -The facility will follow the treatment set in our protocols or an alternate prescribed treatment based on current standards of practice under the direction of the primary care physician and -The facility will provide nursing staff with the appropriate tools to obtain and document accurate information regarding a resident's risk factors and current skin condition. 1. Record review of Resident #2's clinical record showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Heart failure unspecified (the heart muscle slowly weakens and loses its ability to pump blood); -Contracture of right knee, left knee and left ankle (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints); -[MEDICAL CONDITION] (paralysis of one side of the body); -Morbid (severe) obesity (a disorder involving excessive body fat that increases health problems); -Pain; -Dysphagia (difficulty swallowing foods or liquids); -Atrioventricular block (a type of heart block in which the conduction between the atria and ventricles of the heart are impaired); -Muscle weakness; -[MEDICAL CONDITIONS] of coronary artery (disease in the hearts major blood vessels); -Stroke and -Resident was on hospice for end stage [MEDICAL CONDITION] (progression of heart failing to pump efficiently). Record review of the resident's wound report dated 11/7/16 showed: -A pressure ulcer on the resident's coccyx (commonly referred to as the tailbone, is the final segment of the vertebral column) measuring 1.5 cm (centimeters) in length by 1.0 cm in width by 0.1 cm in depth; -Had no exudate (drainage of fluid that filters from the circulatory system into [MEDICAL CONDITION] or areas of inflammation); -The resident's physician was notified on 11/14/16 and -Had treatment orders to cleanse the wound with a wound cleanser, pat dry and apply Calazine (helps treat and prevent diaper rash, protects from minor skin irritation) every shift for 14 days. Record review of the resident's Braden Scale Assessment (a tool used by health care professionals to measure a patients risk for developing pressure ulcers) dated 11/8/16 showed a score of 12 which indicates that the resident is a high risk for developing pressure ulcers. Record review of the resident's nursing progress notes dated 11/21/16 showed a Stage II coccyx pressure ulcer (partial thickness skin loss involving epidermis, dermis, or both, superficial and presents clinically as an abrasion, blister or shallow crater) was resolved. Record review of the resident's quarterly Minimum Data Set (MDS -federally mandated assessment tool required to be completed by facility staff for care planning) dated 11/8/16, showed he/she: -Was moderately cognitively impaired; -Was at risk for developing pressure ulcers; -Needed extensive assistance for bed mobility and transfers, and was wheelchair bound and -Was dependent upon staff for all Activities of Daily Living (ADL's - are routine activities that people do every day without needing assistance - eating, bathing, dressing, toileting, transferring, walking). Record review of resident's nursing progress notes showed: -On 12/26/16, had multiple open areas, see wound records, the staff did not document the location of the multiple open areas; -Had a rash that was resolving on his/her abdomen; -Apply [MEDICATION NAME] (a cream to treat fungal infections) to the resident's buttocks; -Apply Santyl (prescription ointment that debrides wounds by enzymatic action) to open areas (the staff did not document the location of the open areas) and -Apply skin prep (a liquid film forming dressing that upon application to intact skin forms a protective film to help reduce friction) to both extremities (the staff did not document where to apply the skin prep). Record review of the resident's nursing progress notes on 1/2/17 at 12:39 P.M., showed the resident had multiple open areas on all his/her extremities, his/her peri area was gaulded (chafed, rubbing skin against skin to the point of rawness), had an open area on his/her buttock. Record review of the resident's Hospice (end of life) nursing update visit report dated 1/4/17 showed the resident had a scar and the resident's skin was cool, dry, fragile and pale. Observation on 1/4/17 at 11:30 A.M., showed the resident: -Had a low air loss mattress (a mattress designed to be used in the prevention, treatment and management of pressure ulcers by using tiny laser made air holes in the mattress top surface continually blowing air causing the patient to float); -Low air loss mattress settings was at 180 per the resident's physician's orders [REDACTED].>-Low air loss mattress was slightly depressed in the middle of the mattress and -When the low air mattress was further depressed in the middle of the mattress, cells remain depressed for over 30 seconds (deflated state of the mattress provides no therapeutic action to help prevent and/or heal pressure ulcers). Observation on 1/6/17 at 8:30 A.M., showed resident's low air loss mattress continued to depress in the middle of the mattress. when pressure was applied to the top of the mattress it deflated the mattress so that the bed frame can be felt when pressure was applied. During an observation and interview on 1/6/17 at 11:45 A.M., Licensed Practical Nurse (LPN) G performed wound treatments for the resident: -Had an open wound to his/her coccyx; -The wound bed was dark red with light pink peri wound (area surrounding wound); -The wound to the his/her coccyx was approximately the size of a nickel with defined wound borders and -LPN G said he/she didn't know the resident had an open area on his/her coccyx. During an interview on 1/6/17 at 12:35 P.M., the Director of Nursing (DON) and Corporate Nurse Educator, the DON said: -The nurse told the DON that he/she did the wound treatments; -The treatments had been completed to the resident's lower extremities, not the coccyx, -The resident did not have a coccyx wound; -Did not know why it was documented in the resident's nurses notes that the resident had a coccyx wound; -Would find out why it was documented when the resident did not have a wound and -The multidisciplinary team meets every morning and they review any wounds at the meeting. Record review of the resident's Wound Record showed: -The wound was first observed on 1/7/17; -The wound was staged at a Stage II pressure ulcer and the measurements were 2.0 cm in length by 2.0 cm in width by 0.1 cm in depth; -Had a small amount of serous exudate (pale yellow or transparent body fluid); -Wound had no odor; -The wound bed color was pink, the surrounding tissue was pink, deteriorated and the resident complained of mild pain; -The peri wound (skin surrounding wound) was pink and intact; -There was no tunneling (channels that extend from a wound into and through subcutaneous tissue or muscle); -There was no undermining (less extensive, while tunneling penetrates more deeply into tissue); -The resident's rated the wound pain at a 4 ( using a scale of 1-10 which indicates that 1 was mild pain and 10 was excruciating pain) when wound was first being cleaned; -The wound was gently cleansed and current treatment applied and the resident said pain was no longer present; -Continue with the current plan of care; -No pain medications were given; -The resident's physician was notified on 1/7/17; -The resident's legal surrogate was contacted on 1/7/17 and -The current treatment order was apply Calazine skin protectant to buttocks every shift. Record review of the resident's Care Plan dated and revised on 1/8/17, showed: -To encourage good nutrition and hydration in order to promote healthier skin; -To follow the facility protocols for treatment of [REDACTED].>-To obtain blood work such as CBC (complete blood count) with diff (differential), blood cultures (used to detect the presence of bacteria or fungi in the blood), C&S (culture and sensitivity) of any open wounds as ordered by the resident's physician and -Use treatment as ordered by the resident's physician. Observation on 1/9/17 at 9:10 A.M., showed the resident's low air loss mattress to be further depressed in the middle of the mattress. Pressure applied to the middle of the mattress results in the depressed area remaining deflated for over one minute. The DON and Corporate Nurse Educator were notified of the mattress malfunction on 1/9/17 at 9:20 A.M. During an interview on 1/9/17 at 9:30 A.M. with the representative from the Durable Medical Equipment company regarding the low air loss mattress, he/she said that the setting of the mattress at 180 with the resident weight 169 pounds, should not affect the performance of the mattress and that he/she thought that there must be a leak in one of the cells of the mattress. During an interview on 1/9/17 at 11:00 A.M., Certified Nursing Assistant (CNA) G, said that if an open area is found on a resident that he/she would apply ointment and notify the nurse. During an interview on 1/9/17 at 11:15 A.M., CNA E said that if an open area was found on a resident he/she would apply barrier cream and tell the nurse. During an interview on 1/9/17 at 11:30 A.M., CNA C, said that if an open area was found on a resident he/she would tell the charge nurse and chart it, and does not put cream on unless the nurse tell him/her to do so. During an interview on 1/9/17 at 11:45 A.M., LPN E said that he/she becomes aware of an open area on a resident during shift to shift report, when the resident has a new written treatment order, or sometimes it shows up on the computer. Sometimes the CNA's just tell you and then you would make a treatment order. We usually just use our standing orders instead of calling the physician for an order. During an interview on 1/9/17 at 12:10 P.M., MDS Coordinator #A said he/she would expect to see the care plan updated in the event a new wound developed on a resident. During an interview on 1/9/17, at 1:00 P.M., the facility's wound physician said that it is unusual that they wouldn't identify a wound. On a day to day basis the expectation is that the nurses would call him/her with any issue and use the wound protocol. Then, when he/she comes in usually on Mondays, he/she may change the order. He/she take wound measurements weekly. He/she do not do any type of formal education with the staff, however, he/she does educate while doing his/her rounds. He/she will see the resident today,since he/she was informed he/she has a new wound. During a telephone interview on 1/9/17, at 2:15 P.M., the resident's physician said that the expectation is that the facility calls him/her with all new wounds. He/she then would utilize the wound protocol that facility has in place. He/she would expect the CNA's and/or the bath aides to identify any new wounds. He/she would expect them to tell the nurse and the nurse then should call him/her. During an interview on 1/10/17, at 2:00 P.M., the DON said the expectation is that the staff would report any open area on a resident to the charge nurse. 2. Record Review of Resident #1's face sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Dementia (decline in thinking that reduces a person ' s ability to perform everyday activities); -[MEDICAL CONDITION] (Inflammation of the joints, causing pain and stiffness); -Contracture of the resident's right and left knee; -[MEDICAL CONDITION] (hindrance of normal urine flow) and Retention of urine (inability to completely empty the bladder); -Gout (a form of arthritis characterized by severe pain, redness and tenderness in joints).;-Cognitive communication deficit (problems with communication related to impaired function of cognitive processes, i.e.: memory); -[MEDICAL CONDITION] and -Heart Failure. Record review of the resident's annual, MDS dated [DATE], showed he/she: -Required extensive assistance of two people for turning and repositioning in bed and for dressing, bathing, and transfers in and out of bed; -Is at risk of developing pressure ulcers; -Does not have any unhealed pressure ulcers; -Needed a pressure reducing device for his/her chair and bed; -Had the ability to express ideas and wants and make his/her needs known and -Understands verbal content with clear comprehension. Record Review of the resident's Care Plan showed the resident: -Was at risk for pressure ulcers related to limited mobility and dependence on staff for transfers, toileting, bed mobility and repositioning, [MEDICAL CONDITION], and history of skin breakdown; -Had a Stage II pressure ulcer to his/her coccyx on 10/10/16; -Required a low air loss (pressure reducing) mattress with setting of 240; -Required a modified heel elevator positioning device while in bed to decrease left hip rotation and contracture risk; -Treatments to pressure ulcers were to be administered as ordered and monitored for effectiveness; -Facility policies and protocols were to be followed for the prevention and treatment of [REDACTED].>-Was to be kept turned off of his/her coccyx and keep ankles and heels off the bed with heel riser (used to keep pressure off the heels of the feet) and bunny boots (foam boots that are used to reduce pressure and aid in the prevention of wounds) and -Required a pressure reducing cushion for his/her wheelchair. Record review of the resident's DON Weekly Wound Log dated 11/07/16 showed the resident: - Had a Stage II coccyx wound that measured 1.0 cm in length by 10 cm in width by 0.1 cm in depth that was facility acquired on 10/10/16; -The wound was being treated with Calazine daily and as needed and -The resident was to have a pad for his/her wheelchair and low air loss mattress for pressure reduction. Record review of the resident's DON Weekly Wound Log dated 11/14/16 showed the resident: - Had a Stage II coccyx wound had increased to 2.5 cm in length and decreased from 10 cm to 1.0 cm in width and the depth remained the same 0.1 cm; -The wound was being treated with Calazine every shift and -The resident was to have a pad for his/her wheelchair and a low air loss mattress for pressure reduction. Record review of the resident's DON Weekly Wound Log dated 11/21/16 showed the resident: - Had a Stage II coccyx wound size had increased in size to 3.0 cm in length by 1.5 cm in width by 0.1 cm in depth; -The wound was being treated with Calazine daily and as needed and -The resident was to have a pad for his/her wheelchair and a low air loss mattress for pressure reduction. Record review of the resident's wound care plan showed the resident: -Had a Stage II pressure ulcer to his/her coccyx; -Had a Stage II pressure ulcer on his/her right ankle on 11/28/16; -Required a low air loss (pressure reducing) mattress with setting of 240; -Required a modified heel elevator positioning device while in bed to decrease left hip rotation and contracture risk; -Treatments to pressure ulcers were to be administered as ordered and monitored for effectiveness; -Facility policies and protocols were to be followed for the prevention and treatment of [REDACTED].>-Was to be kept turned off of his/her coccyx and keep ankles and heels off the bed with heel riser (used to keep pressure off the heels of the feet) and bunny boots (foam boots that are used to reduce pressure and aid in the prevention of wounds) and -Required a pressure reducing cushion for his/her wheelchair. Record review of the resident's DON Weekly Wound Log dated 11/28/16 showed the resident: - Had aStage II coccyx wound that worsened and increased in size to measure 7.0 cm in length by 5.0 cm in width by 0.1 cm in depth; -A new physician's orders [REDACTED]. -The resident required a pad for the wheelchair/ and a low air loss mattress for pressure reduction and -The resident now had a blister to his/her right ankle, acquired on 11/21/16 and measured 2.0 cm in length by 2.0 cm in width by 0.1 cm in depth. Record review of the resident's DON Weekly Wound Log dated 12/05/16 showed the resident: - Had a Stage III coccyx wound measurements were 6.0 cm in length by 3.0 cm in width by 0.1 cm in depth; -Cleanse coccyx wound and apply Santyl and cover with foam daily and as needed; -The resident's left inner ankle and right ankle wound was healed and -The resident required a pad for his/her wheelchair and had a low air loss mattress for pressure reduction. Record review of the Wound Physician Report dated 12/05/16 showed the resident: - Had a Stage III coccyx wound measurements were 6.0 cm in length by 3.0 cm in width by 0.1 cm in depth; -Coccyx wound condition is acute, not healed; -No undermining was present.; -The residents right medial ankle blister, did not have any measurements and the DON Weekly Wound Log dated 12/5/16 showed the resident's right ankle wound was healed and -The resident's ankle blister wound condition was acute, not healed. Record review of the DON Weekly Wound Log dated 12/12/16 showed the resident: - Had a Stage III coccyx wound measurements were 4.0 cm in length by 4.0 cm in width by 1.5 cm in depth and had increased in depth from 0.1 cm on 12/05/16 to 1.5 cm; -Cleanse the wound then apply Santyl to the wound bed then cover with ABD and change the dressing daily and as needed; -The resident required a pad for the wheelchair and a low air loss mattress for pressure reduction and -No notation on this log pertaining the blister on the resident's right medial ankle as noted by the wound care physician progress report on 12/5/16. Record review of the Wound Physician Progress Report dated 12/12/16 showed the resident: - Had a Stage III coccyx wound measurements were 4.0 cm in length by 4.0 cm in width by 1.5 cm in depth; -Coccyx wound condition was acute and not healed; -No undermining or tunneling was present; -Right medical ankle blister, no measurements provided and -Right ankle blister condition was acute and was healed. Record review of the resident's wound care plan showed the resident had a Stage II pressure ulcer to his/her coccyx that progressed to a Stage III pressure ulcer on 12/12/16. Record review of the DON Weekly Wound Log dated 12/19/16 showed the resident: - Had a Stage III coccyx wound measurements were 3.5 cm in length by 4.5 cm in width by 1.5 cm in depth. The wound was wider than last measured on 12/12/16. -No change in the wound treatment and -The resident required a pad for the wheelchair and a low air loss mattress for pressure reduction. Record review of the Wound Physician Progress Report dated 12/19/16 showed the resident: - Had a Stage III coccyx wound measurements were 3.5 cm in length by 4.5 cm in width by 1.5 cm in depth; -Wound condition was acute and not healed; -No undermining or tunneling and -physician's orders [REDACTED]. Record review of the resident's December 2016 physician's orders [REDACTED].>-Cleanse wound on coccyx with normal saline then apply Santyl nickel thick, cover with a 4x4 (gauze pad) and ABD (absorbent gauze dressing) pad secure with [MEDICATION NAME] (foam wound dressing) daily on the day shift(6:00 A.M.-2:00P.M.) for wound healing for 14 days (started on 12/20/16) and -Cleanse wound on right inner ankle with normal saline then apply Santyl nickel thick cover with Allevyn (foam wound dressing) daily on the day shift for wound healing for 14 days (started on 12/20/16). Record Review of the residents Braden Scale dated 12/26/16 showed the resident: -Had a limited ability to communicate discomfort related to the need to be turned/repositioned in bed; -Was at a high risk for developing pressure ulcers with a Braden scale of 12; -Was essentially bedfast, which increases risk of developing pressure ulcers; -Was only able to make very limited, slight movements in his/her body position; -Was unable to make frequent or significant changes in body position independently; -Had poor nutritional intake due to poor appetite and -Required maximum assistance from facility staff in moving and required frequent repositioning. Record Review of the DON Weekly Wound Log dated 12/26/16 showed the resident: - Had a Stage III coccyx wound measurements were 3.5 cm in length by 4.5 cm in width by 1.5 cm in depth; -No change in the wound treatment and -The resident required a pad for the wheelchair and a low air loss mattress for pressure reduction. No Wound Physician Progress Report for 12/26/16 was available for review as the wound care physician did not visit that week. Record review of the resident's significant change MDS dated [DATE] showed he/she -Required extensive assistance of two staff members for turning and repositioning in bed, transfers, and dressing; -Had impairment in functional range of motion of both lower extremities and contractures to both left and right knees; -Was at risk of developing pressure ulcers; -Acquired a Stage II pressure ulcer identified on 11/21/16; -Has a Stage III pressure ulcer (full thickness tissue loss. Bone, tendon and muscle are not exposed); -The Stage III pressure ulcer measures 3.5 cm in length by 4.5 cm in width by 1.5 cm in depth; -The pressure ulcers were not present on admission; -Needed a pressure reducing device for his/her bed and chair; -Was on a turning and repositioning program; -Had nutrition and hydration intervention to manage skin problems; -Was receiving pressure ulcer care; -Was receiving application of ointments and medications to areas other than his/her feet and -Was receiving Hospice care (care for the terminally ill to aid in symptom and pain management and to attend to spiritual and emotional needs). No wound Physician Progress Report for 01/02/17 was available for review due to the wound care physician did not visit that week and no DON Weekly wound report was available for 01/02/17. Record review of the resident's POS dated January 2017 showed: -The resident's functional level is now bedrest due to decline, wounds, and pain; -Low air loss mattress at a setting of 240 for pressure relief; -Bunny boots on when in bed; -Vitamin C 500 mg give one tablet two times a day for wound healing; -Protein powder give one scoop by mouth three times a day for wound healing; -2 cal supplement give 120 cc by mouth four times a day for weight loss; -Multivitamin give one tablet by mouth daily for supplement; -Cleanse wound on coccyx with normal saline then apply Santyl nickel thick, cover with a 4x4 (gauze pad) and ABD (absorbent gauze dressing) pad secure with [MEDICATION NAME] (foam wound dressing) daily on the day shift(6:00 A.M.-2:00P.M.) for wound healing for 14 days and -Cleanse wound on right inner ankle with normal saline then apply Santyl nickel thick cover with Allevyn (foam wound dressing) daily on the day shift for wound healing for 14 days. During an interview on 01/03/17 at 2:50 P.M., LPN B said: -He/she was not sure what stage the resident's wounds are as he/she was not allowed to stage wounds; -He/she thinks it is a Stage II or a Stage III, but is not really sure; -He/she just started doing the wound rounds a couple of weeks ago but has not really been trained by the facility on wound care; -The wound care physician comes every week and see's all the residents with wounds and he/she does all the wound measurements; -The wound care physician comes every Monday but has not been here the last two Mondays due to the holidays; -He/she believes the wound care physician will resume regularly scheduled visits next week; -There is no one else that comes in place of the wound care physician or to do measurements if the wound care physician is not available; -The resident's wound is looking better and getting smaller each week; -Prior to him/her taking over wounds, all the Charge Nurses were expected to do the wound rounds with the wound care physician and do the wound documentation; -He/she has not had any formal education related to wounds, staging or measurements except what she received in nursing school and -He/she is scheduled to attend a webinar (video training) on wound care in the next couple of weeks. Record review of the resident's January 2017 POS showed a new physician's orders [REDACTED].M. per the resident's request. Observations on 1/4/17 at 5:10 A.M., 6:03 A.M., 11:12 A.M. and 12:00 P.M., showed the resident's LAL mattress setting was at 150, instead of 240, and the heel elevator was leaning against the wall in the resident's room. Observations on 1/6/17 at 8:30 A.M. and 9:12 A.M., showed the resident's LAL mattress setting was at 150 instead of 240 and the heel elevator leaning against the wall in the resident's room. During an interview on 1/6/17 at 9:15 A.M., LPN D said: -He/She would not be doing wound care to the resident's coccyx and ankle on his/her shift today; -The wound care orders were changed the other day and the resident's wound care was now being done on the night shift and -The resident was the one who requested the change in wound care from the day shift to the night shift. During an interview on 1/6/17 at 9:57 A.M. the resident said: -He/she does not know why the wound care is now being done at night; -He/she did not request a change in the time of the wound care and -It does not matter to him/her what time of day the wound care is done. During an interview on 1/6/17 at 11:00 A.M. the Central Supply Clerk said: -LPN B is now the wound nurse; -Prior to LPN B doing the wounds all the Charge Nurses were responsible for doing the wound documentation; -He/she only orders the low air loss mattresses from the company that supplies them and he/she makes sure they get on the right bed; -He/she was not responsible for anything to do with the low air loss mattresses other than ordering them and making sure they get to the facility; -He/she did not know who is supposed to check the settings on the low air loss mattresses but she knows it was not him/her and -The company that delivers the mattress usually puts it on the correct setting but she was not aware of the process for ensuring the mattress remains at the ordered setting. Observation on 1/6/17 at 11:17 A.M. showed: -The heel elevator was in place on the residents bed positioned under the resident's knees and calves with his/her heels were resting directly on the low air loss mattress and -The low air loss mattress setting was at 150. During an interview on 1/6/17 at 3:03 P.M. CNA O said: -CNAs were supposed to report any skin issue to the charge nurse as soon as he/she sees it; -If a new skin issue was identified then he/she puts it in the computer and the computer sends an alert to the charge nurse but she also tells the charge nurse in person; -He/she was not aware of who is supposed to check the settings on the low air loss mattresses but he/she thinks it's the charge nurse; -He/she has not received any direction nor education that the CNAs are responsible for checking the settings on the LAL mattress and -He/she lets the charge nurse know right away if the mattress seems low or looks like something is wrong with it. During an interview on 1/6/17 at 3:20 P.M. LPN F said: -He/she does not do weekly measurements of the residents wounds; -The charge nurses do weekly skin assessments on the residents and the computer tells them which residents are due for a skin assessment that day; -If he/she identified a new wound or skin issue then he/she assesses and measures the area and does appropriate alert/report and notify the appropriate nurse manager and family member/DPOA; -He/she did not always have to call the physician because the facility has standi

Based on observation, interview, and record review, the facility failed to ensure the placement of the [MEDICATION NAME] at all times and as ordered, to have the [MEDICATION NAME] available for two days in December and the staff did not notify the resident's physician that [MEDICATION NAME] was not available, to apply the [MEDICATION NAME] appropriately so it does not come off, to provide adequate pain management interventions and accurately assess the effectiveness of ordered pain management interventions and medications, to respond to the resident's cries for help related to pain for one sampled resident (Resident #1) and to coordinate services with Hospice (end of life care) for coordination of care for two sampled residents (Resident #1 and #2) out of 17 sampled residents. The facility census was 101 residents. Record Review of the facility's revised Pain Management Policy dated March 2011 showed: -Each resident who experiences pain will have a comprehensive pain assessment and an individualized care and treatment plan developed in collaboration with the physician, resident, family and interdisciplinary team to manage the pain; -The assessment and management of physical, psychological, emotional and spiritual pain of residents will be a team effort between resident, family, and staff in order to maximize the resident's quality of life; -All pain is real regardless of its cause, even when the cause remains unknown; -Pain is a subjective experience. The resident's behavioral response to pain is influenced by culture, religion and past experiences with pain; -Pain has physical as well as psychological consequences; -Residents who cannot fully participate in an assessment may manifest pain by alteration in mood, behavior, function and socialization; -Pain management is essential to promote resident's well being and quality of life; -It is the policy of this facility to provide staff with guidelines for the individualized management of pain in an effort to meet the needs of residents and family; -Residents of this facility can expect reports of pain to be believed; -Health professionals will respond quickly to reports of pain; -Effective pain management to the extent possible; -Dosages will be increased, pain monitored and assessed per physician's orders [REDACTED]. -With changes in dosage or new medications, pain or control of pain will be assessed every shift and documented in the medical record. This will happen until the pain medication is stabilized and pain is controlled by a regular scheduled dosage of medication combined with other modalities without the need of breakthrough medication for one full week. 1a. Record Review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record Review of the resident's Physician order [REDACTED].>-From 10/14/2016-12/09/16 for the resident to have [MEDICATION NAME] (skin patch containing narcotic pain medication used to treat severe pain, delivers dose to resident over a 72 hour period) [MEDICATION NAME] (apply to skin) patch 12 micrograms (mcg)/hour(hr), apply and replace the patch every three days, for pain related to [MEDICAL CONDITION], pain in bones and joints and foot; -On 12/10/2016, a new physician's orders [REDACTED]. -[MEDICATION NAME] 10-325 mg one-half a tablet every eight hours PRN (as needed) for pain and -[MEDICATION NAME] 500 mg two tablets by mouth every six hours as needed for pain. Record Review of the resident's nurses notes showed the following: -On 12/3/16 and 12/4/16, the resident requested and received PRN pain medication and -On 12/07/16, when the Charge Nurse went to remove the [MEDICATION NAME] and place a new one but was unable to locate the patch on the resident's body and the [MEDICATION NAME] was found on the floor of the resident's room. Record Review of the resident's December 2016 Medication Administration Record [REDACTED]. Record review of the resident's nurses notes showed the following: -On 12/09/16, the resident was yelling out in pain and was given a PRN [MEDICATION NAME] 10-325 mg one tablet at 9:32 A.M.; -On 12/09/16 at 11:25 A.M., the Charge Nurse documented the PRN medication was ineffective at relieving the resident's pain but no other interventions were documented as being implemented to relieve the resident's pain until 5:39 P.M. when the resident was given another [MEDICATION NAME] 10-325 mg for complaints of pain all over; -On 12/10/16 at 5:38 A.M. the night nurse was unable to locate the [MEDICATION NAME] on the resident's body when he/she went to replace it with a new pain patch; -On 12/11, 12/12, and 12/13/16 the resident requested, and received PRN pain medication for his/her reports of pain; -On 12/13/16 at 5:08 A.M. the night nurse was unable to locate the [MEDICATION NAME] on the resident's body and he/she was unable to apply a new patch as there were none available and he/she was waiting on a new prescription from the residents physician; -On 12/13/16 at 3:24 P.M., the nurse was unable to apply the [MEDICATION NAME] as he/she was still waiting on a prescription from the residents physician and -On 12/13/16 at 10:28 P.M. the nurse was unable to apply a [MEDICATION NAME] for pain as he/she was waiting on a new prescription from the residents physician. Record review of the resident's December 2016 MAR indicated [REDACTED]. Record review of the resident's nurses notes showed the following: -On 12/14/16 at 5:55 A.M., the nurse noted the resident did not have a [MEDICATION NAME] on his/her body; -On 12/15/16 at 5:23 P.M. the resident stated he/she had pain everywhere and was unable to rate the pain, the resident asked for and received a PRN pain medication and -The resident received PRN pain medication on 12/16, 12/17, 12/18, 12/19, 12/24, 12/25, 12/26 and 12/27/16. Record Review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 12/26/16 showed he/she: -Had the ability to express his/her needs and wants and was usually understood and was able to comprehend most conversations; -Received a scheduled pain medication regimen; -Received PRN pain medications; -Experiences pain frequently and -Rated his/her pain as six out of ten which indicated the resident had moderate to severe pain. Record Review of the resident's undated Hospice A Hospice/LTC Coordinated Task Plan of Care did not specify a visit frequency or associated tasks for the Hospice Licensed Nurse or the Hospice Aide. No pain care plan was present in the Hospice binder where the care plans were kept. Record Review of Hospice A's Registered Nurse (RN) A visit note for 12/28/16 showed: -The resident had a scheduled and PRN pain medication ordered; -The resident was in extreme pain during movement; -Any movement seemed to hurt the resident; -He/She discussed the resident's pain control with the facility Charge Nurse; -He/She discussed the resident's [DIAGNOSES REDACTED]. -The resident displayed loud moaning, groaning, crying, and facial grimacing; -The resident's pain level was rated at a six on a scale from 0-10; -The resident's pain is constant and stabbing and worsened by any movement and -The resident's pain is affecting his/her function and quality of life. Record review of the resident's nurses notes date 12/29/16, showed the resident received PRN pain medication. Record Review of the resident's Hospice RN note dated 12/30/16 showed: -The resident had PRN [MEDICATION NAME] ordered for pain if needed and -He/she completed a comprehensive pain assessment on the resident and the resident had mild to moderate discomfort with movement. Record Review of the resident's Hospice Aide Notes dated 12/30/16 showed: -The resident yelled and said he/she was in pain anytime he/she was touched and -The Hospice Aide reported the resident's pain to the facility Charge Nurse and the Hospice RN. Record Review of the resident's POS dated December 2016 showed physician's orders [REDACTED]. Record Review of the resident's nurses notes dated 12/30/16 showed the resident received his/her PRN pain medication. Record review of the resident's nurses notes dated 1/1/17. showed the nurse found the [MEDICATION NAME] on the resident's bed instead of on the resident's body. A new [MEDICATION NAME] was applied to the resident's body as ordered by the resident's physician. Observation on 1/3/17 at 11:30 A.M., showed the resident: -Was lying in bed on his/her left side; -Was alert, oriented to person and was able to speak; -Hospice RN A was at the resident's bedside; -Was reporting that his/her pain was all over and -Was moaning and was grimacing. During an interview on 1/3/17 at 11:30 A.M. the resident said: -He/se was hurting all over; -He/she was not sure if he/she has had any pain medication recently and -He/se hurts so badly all the time and sometimes the pain medication helps and sometimes it doesn't. During an interview on 1/3/17 at 11:30 A.M. Hospice RN A said: -He/se was the resident's Case Manager; -The resident's pain was well-controlled; -The resident does not have a need for comfort medications at this time; -He/she was going to ask the Charge Nurse to give the resident some pain medicine; -He/she was unaware that another Hospice Nurse visited the resident last week and changed the resident's [MEDICATION NAME] to be given twice a day and PRN due to resident's severe pain and -He/she usually visits the resident one to two times a week. Observation and interview on 1/3/17 from 11:30 A.M.-12:18 P.M. showed: -The resident was continually crying out and moaning loudly; -Licensed Practical Nurse (LPN) B was in the hallway alternating between being at the treatment cart and in and out of various resident rooms; -Certified Nurse Assistant (CNA) G entered the resident's room at 11:38 A.M. and set the resident's lunch tray on the bedside table stating, I'll be back in a bit to feed you and exited the room; -LPN B walked directly past the resident's room at 12:06 P.M., when the resident was yelling out loudly that his/her knees hurt, LPN B did not stop to check on the resident; -CNA G did not speak with the resident regarding his/her pain, offer to reposition or other nonpharmacological interventions; -During this observation time LPN B, CNA G, and various other staff members walked directly past the resident's room, while he/she was continually crying out in pain, and did not enter the resident's room or assist the resident in any way; -CNA G re-entered the resident's room at 12:18 P.M. and repositioned the resident in order to feed him/her lunch; -Following repositioning the resident stated he/she was a lot more comfortable and was no longer moaning or crying out; -LPN B said he/she was familiar with the resident. The resident climbed out of bed a while back and had just declined ever since. The resident had scheduled [MEDICATION NAME] twice daily and had already been medicated for pain this morning. The resident was usually only in pain when he/she gets her wound care done. He/she did not give any additional pain medication prior to the wound treatment because the resident had scheduled pain medicine. Observation on 1/3/17 at 2:23 P.M. showed: -LPN B and CNA G turned the resident on his/her right side in order for LPN B to perform wound care to the residents wound on the resident's coccyx (tailbone) and right inner ankle; -The resident was moaning, yelling and crying out during repositioning and while LPN B performed the wound care to his/her coccyx; -LPN B said that the resident had scheduled pain medication this A.M. and this medication was now scheduled twice daily; -LPN B said that the resident also had a [MEDICATION NAME] in place for pain control; -LPN B was unable to locate the [MEDICATION NAME] on the resident's back (common area for placement) or his/her chest; -LPN B then stated that he/she had located the patch on the resident's right chest and -LPN B was unable to verify where the patch was on the resident's chest, stating the skin folds sometimes hide the pain patch. Observation on 1/4/17 at 5:35 A.M. showed the resident: -Was lying in bed on his/her right side moaning and -Was grimacing and the resident replied that his/her knees and back were hurting. Observation on 1/4/17 at 6:30 A.M. showed the resident: -Remained in bed on his/her right side; -Was moaning and calling out loudly and -He/she said he/she hurt all over. Observation on 1/4/17 from 10:25-11:15 A.M., showed the resident: -Was lying in bed on his/her back moaning and crying out in pain; -At 11:00 A.M., was resting quietly in bed with his/her eyes closed and -At 11:15 A.M., was moaning and crying out loudly that he/she was hurting all over. During an interview on 1/4/17 at 12:00 P.M. LPN E said: -He/she was the assigned Charge Nurse for the resident on this date; -He/she was not that familiar with this resident as he/she does not normally work this hall; -He/she was aware that the resident had a [MEDICATION NAME] on for pain control in addition to other scheduled and PRN pain medication; -He/she had not given the resident any PRN medication today; -He/she had not been notified by the CNA that the resident had been crying out in pain; -He/she had not verified placement of the resident's [MEDICATION NAME] yet today but knows it was to be verified every shift; -He/she checked placement of the [MEDICATION NAME] and was unable to find the patch on the resident; -He/she immediately checked the order and replaced the [MEDICATION NAME] on the resident and -He/She notified the resident's physician that the [MEDICATION NAME] was not on the resident as ordered. During an interview on 1/4/17 at 12:10 P.M., the resident's physician said he/she expects the staff to immediately put the [MEDICATION NAME] back on if not found on the resident. Record review of the resident's nurses notes dated 1/4/17 at 12:14 P.M. the charge nurse could not locate the [MEDICATION NAME] on the resident's body so a new one was applied following notification of the resident's physician. Record review of the resident's January 2017 MAR indicated [REDACTED]. Record review of the resident's care plan, last updated on 1/5/17 showed he/she: -Had a communication problem related to pain; -The facility staff was to anticipate and meet the resident's needs; -Was admitted to Hospice on 12/20/16; -Will be kept comfortable through facility staff and Hospice; -Was to receive pain medications as ordered by the resident's physician; -Had the potential for pain related to [MEDICAL CONDITION] and chronic pain in back and joints; -Was to be monitored for the effectiveness of pain medication/pain interventions and he/she was to receive PRN pain medications as ordered; -Will be kept comfortable with the use of routine [MEDICATION NAME] (pain relieving medications) and nonpharmacological interventions and PRN [MEDICATION NAME]; -Hospice is to assist with managing the resident's pain; -The physician was to be contacted if current pain medications were not controlling signs and symptoms of pain; -Moaning, restless, grimacing, and/or crying was to be reported to the Charge Nurse for interventions and -Supportive devices, pillows, elevate head of bed, foot of bed, or recliner were to be utilized for pain relief. During an interview on 1/6/17 at 8:50 A.M. the resident said: -He/she was not having in pain; -He/she thought the patch they put on was helping and -He/she does not feel like he/she needs any additional pain medication at this time. Observation on 1/9/17 at 8:30 A.M. showed the resident: -Resting quietly in bed with his/her eyes closed; -Arouses easily when name was spoken; -Denied any pain and -Had no signs/symptoms of pain displayed. Observation on 1/10/17 at 8:10 A.M. showed the resident: -Was up in his/her Broda chair (wheelchair that tilts and reclines, promoting comfort) preparing to go to breakfast; -Did not display any signs/symptoms of pain; -Facial expression was relaxed and he/she was smiling and visiting with various staff members and -The [MEDICATION NAME] was in place on the resident's left upper chest. During an interview on 1/10/17 at 2:00 P.M. the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said: -He/she would expect the facility staff to acknowledge a resident's crying and attempt to console; -He/she would expect the facility Charge Nurse to perform a pain assessment and assess the effectiveness of interventions currently in place; -He/she would expect that the Charge Nurse would ensure that all ordered pain medications were given as scheduled; -He/she would expect the charge nurse to check and ensure that a [MEDICATION NAME] was appropriately in place as ordered by the physician; -The Charge Nurses were responsible for checking placement of the [MEDICATION NAME]es every shift to ensure the patch remains in place; -He/she agrees that if the patch does not remain on the resident's skin then no pain relief is provided; -He/she did not know what else to do but check placement every shift to ensure the patch remains on; -He/she expects the nurse to replace the patch immediately if the patch is not on the resident; -It would not be appropriate for the nurse not to replace the [MEDICATION NAME] as soon as he/she identifies that the patch is not in place and -He/she would expect a resident to be medicated prior to providing care or a wound treatment that would cause the resident pain. 1b. Record Review of Resident #1' s Face Sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED].>-End Stage [MEDICAL CONDITIONS] (a lung disease that makes it difficult to breath); -[MEDICAL CONDITION]; -Low back pain and -Pain in knees, bones, and joints. Record Review of the resident's Hospice care plan showed: -No date of initiation for care plan; -The resident name, room number and Hospice [DIAGNOSES REDACTED].>-The name and phone number of the Hospice provided and RN Case Manager and phone number were listed, as well as the names of the Home Health Aide, Chaplain and Social Worker assigned to the resident; -The Home Health Aide and RN visit schedule was blank; -There were no tasks listed showing duties/plan required of the Home Health Aide during the visit to the resident; -There were no tasks listed showing the duties/plan for the RN to perform during their visits to the resident and -The Hospice Social Worker and Chaplain would visit one time monthly and two additional visits during each 30 day period if needed. Record Review of the resident's January 2017 POS showed the resident: -Was admitted to Hospice services on 12/20/16 with a [DIAGNOSES REDACTED]. -Was to have a [MEDICATION NAME] Patch 12 (mcg/hr) applied to his/her skin and replaced every three days and -Received [MEDICATION NAME] 5/325 mg one tablet by mouth three times daily and as needed for pain. During an interview on 1/3/17 at 11:10 A.M. Hospice RN A said: -The resident was admitted to Hospice on 12/20/2016; -He/she will visit one to two times per week to check on resident and assist facility with caring for resident; -He/she is going to discuss with the Charge Nurse and increase in the resident's pain medication as the resident is so uncomfortable today; -He/she was unaware that additional pain medication had been scheduled last week; -He/she had been off for the holiday and he/she had not had a chance to catch up on computer stuff to see that medications had been changed; -He/she coordinates the care between the facility and the Hospice caregivers; -The Hospice staff will check in with the Charge Nurse, and sometimes the DON when they arrive at facility and -There is a written plan of care in the hospice book that outlines what each discipline is going to do. Record Review of the resident's significant change MDS dated [DATE], showed he/she: -Had experienced a significant change in his/her condition; -Was receiving Hospice services and -Experiences pain frequently. Record review of the resident's care plans, revised last on 1/5/17, showed the resident: -Was admitted to Hospice services on 12/20/16 for End Stage [MEDICAL CONDITION]; -Was to be kept comfortable through facility staff and Hospice; -Was to be monitored for unmet needs; -Was to receive scheduled and PRN pain medications; -Was to receive coordination of care services between the facility and Hospice; -Was to receive Hospice services per the Hospice care plan; -Was to be kept comfortable with the use of routine and PRN [MEDICATION NAME] and non-pharmacological interventions and -Was to receive pain management services through Hospice in coordination with the facility. During an interview on 1/9/17 at 9:45 A.M., CNA G said: -He/she does not know what days the Hospice CNA comes to provide care; -He/she does not know what duties the Hospice CNA performs and -He/she thinks there is a book at the desk that tells when they come and what they are supposed to do. During an interview on 1/9/17 at 9:50 A.M., CNA F said: -He/she does not know what days the Hospice CNA comes to the facility and -The Hospice people check in with the Charge Nurse and we see them when they are here but he/she does not know their schedule. During an interview on 1/9/17 at 11:55 A.M., LPN E said: -He/she does not normally work the floor so he/she is not sure when the Hospice nurse and aide visit; -The Hospice staff usually check in with the Charge Nurse to let them know when they are at the facility and -There is a book at the nurses station that tells what the Hospice is going to do when they are at the facility. During an interview on 1/10/17 at 10:53 A.M.,. LPN D said: -He/she does not know what the schedule is for the Hospice Nurse or Aide; -He/She thinks the Hospice Aide was at the facility yesterday; -Each Hospice keeps a book at the nurse's station with their notes in it; -The Hospice staff always checks in with the Charge Nurse when they come to the building to see if they need anything and -If facility staff has to call the resident's physician for anything they will usually call the Hospice and let them know. During an interview on 01/10/17 at 10:30 A.M. the Director of Clinical Services for Hospice said: -All Hospice staff is to check in with the facility's DON, the facility Social Worker, and the Charge Nurse when they arrive at the facility; -The Care Plan lists the specific tasks/duties the Home Health Aide is to perform during his/her visit; -A copy of the Care Plan is left in a notebook at the facility; -The Hospice Case Manager is to coordinate care with the facility staff and attend care plan meetings; -Every Friday the Hospice prints the visit notes for the week and the notes are delivered to the facility the following Monday; -He/she printed all of the notes from the previous week visit last Friday and they were delivered and placed in the book on 1/9/17; -He/she did not know why the resident's Hospice care plan was not in the Hospice book for facility and Hospice staff to reference; -He/she did not know why there were no Hospice notes in the book since 12/30/16 and -He/she will have to follow up with the Hospice Case Manager. During an interview on 1/10/17 at 2:00 P.M. the DON and ADON said: -He/she does not know the process for ensuring coordination of care is occurring between the facility and the Hospice provider; -The Hospice case manager does not check in with him/her when he/she makes a visit to the facility; -The Hospice case manager is to check in with the charge nurse when he/she arrives at the facility; -The Hospice book at the nurse's station should contain a care plan that also lists the tasks/duties the Hospice aide and nurse are going to perform; -The hospice book at the nurse's station should have copies of the visit notes; -He/she thinks the Hospice nurse comes to the care plan meetings for the resident and -He/she expects for coordination of care between the facility and hospice to be occurring. 2. Record review of Resident #2's facility care plan revised on 3/11/16 showed: -Bathing with the assistance of one staff member to shower the resident two times a week; -Coordinate all cares with Hospice and notify them of need for personal care items, oxygen supplies and medications and -Hospice care per Hospice care plan. Record review of the resident's Hospice care plan showed the nursing home staff and Hospice staff will coordinate care, supplies, and equipment to meet the resident's needs. Record review of the Hospice visit notes and care plan showed no coordination of care regarding which days of the week bathing would be provided for the resident as coordinated with the facility. Record review of the facility's care plan for the resident showed no coordination of care regarding which days of the week bathing would be provided for the resident as coordinated with Hospice. During an interview on 1/6/17 at 2:00 P.M., the DON said that the expectation was the coordination of care between the facility and Hospice would occur and it is the responsibility of the charge nurse for coordinating the care and that this would be on the resident's care plan.