Every finding on record at Glenwood Rehabilitation & Health Care Center

Based on observation, record review, and interviews, the facility failed to ensure food was protected from possible contamination at all times when staff failed to properly store and label food and when the stacked dishes while still wet. The facility had a census of 54.1. Review of the facility policy titled Food Storage (Dry, Refrigerated, and Frozen), undated, showed the following:-Foods shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety;-All food items will be labeled, that must include the name of the food and the date by which it should be sold, consumed or discarded;-Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration;-Leftover contents of cans and prepared food will be stored in covered, labeled, and dated containers in refrigerators and /or freezers;-When freezing food that has been prepared on-site, ensure there is clear labeling of the item. Observation on 04/27/26, at 9:00 A.M., of the refrigerator showed the following:-Seven pieces of cake on small white foam plates uncovered;-Meat mixture in a large, zipped bag not labeled;-Small red plastic bowl, with an unidentifiable orange item in it. Observation on 04/27/26, at 9:00 A.M., of the freezer showed the following:-Six hamburger patties with packages opened and exposed to air with no date or label;-Six chicken patties with packages opened and exposed to air with no date or label. Observation and interview on 04/27/26, at 9:20 A.M., showed the following:-Dietary Aide (DA) C could not identify an unable bag; -HE/She thought it may be chicken alfredo or tune noodle casserole but was unsure. During an interview on 04/30/26, at approximately 1:42 P.M., [NAME] E said the following:-Any opened items should be placed in a plastic container and labeled and dated, so anyone can tell what the item is;-This is the same for the refrigerator, freezer, or pantry. During an interview on 04/30/26, at approximately 1:56 P.M., DA C said staff are not supposed to put anything away without writing the date on the front of it. During an interview on 04/30/26, at approximately 2:17 P.M., the Dietary Manager (DM) said the following:-Every opened item must have a written date and be clearly labeled, before being stored;-This included dry storage, the refrigerator, or the freezer; -Proper storage policy states any unused product would go into container or bag and be labeled and dated. During an interview on 04/30/26, at approximately 3:00 P.M., the DON said the following:-All items should have a label and date written on the outside;-All items should be identifiable. During an interview on 04/30/26, at approximately 3:20 P.M., the Administrator said the following:-Everything should be clearly labeled and dated so staff are aware of what it is and when it must be used by;-Anything that has been opened must be labeled and dated. 2. Review showed the facility did not provide a policy regarding dish washing and drying. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the following:-Items must be allowed to drain and to air-dry before being stacked or stored;-Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Observation on 04/27/26, at 9:25 A.M., showed the following:-Forty-four clear drinking cups stacked wet with no air flow;-Thirty-nine plastic trays stacked wet with no air flow;-Two, medium-sized steam table metal pans, stacked wet with no air flow. Observation on 04/29/26, at approximately 2:40 P.M., showed the following:-Fifty-three plastic trays stacked and wet with no air flow;-Fifty-four plastic drinking cups stacked and wet with no air flow; During an interview on 04/29/26, at 2:45 P.M., [NAME] D said he/she did not realize that the dishes had to be air dried. During an interview on 04/30/26, at 1:42 P.M., [NAME] E said the following:-To dry the dishes, they are placed in front of the fan and they wait for them to dry air completely;-The dishes are not allowed to be put away until they are totally dry;-He/she always tried to make sure dishes were completely dry before putting them away. During an interview on 04/30/26, at approximately 1:56 P.M., DA C said the following:-Dishes were to be air dried once taken from the dishwasher;-It takes a while to dry all the dishes in this way;-He/she knew there could not be standing water on the dishes when put away;-Dished must be completely dried and thought they just got in a hurry or did not notice the water. During an interview on 04/30/26, at approximately 2:15 P.M., the Dietary Manager said staff should air dry all dishes before putting them away. During an interview on 04/30/26, at approximately 3:00 P.M., the DON said the following:-The dishes should be air dried;-He/she expected that all dishes were being done properly. During an interview on 04/30/26, at approximately 3:20 P.M., the Administrator said dishes should not be stacked wet.

Based on observation, interview and record review, the facility failed to maintain a complete infection prevention and control program when staff failed to follow Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO - microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents. Although the names of certain MDROs describe resistance to only one agent, these pathogens are frequently resistant to most available antimicrobial agents) that employs targeted gown and glove use during high contact resident care activities)) when providing wound and incontinent care to one resident (Resident #3) with a wound. Staff failed to completed proper hand hygiene while providing incontinent cares for two residents (Resident #3 and #47). Staff failed to ensure Tuberculin Skin Tests (TST) were completed in accordance with the requirements for tuberculosis (TB - an infectious disease that primarily affects the lungs, characterized by fever, cough, and difficulty breathing) testing for long-term care employees and per facility policy for one staff member (Registered Nurse (RN) A. The facility census was 54. 1. Review of the facility's policy titled, Standard Precautions - Hand Hygiene, dated 2019, showed the following:-Purpose to cleanse hands to prevent the spread of potentially deadly infections; to provide a clean and healthy environment for residents, staff and visitors; and to reduce the risk to the healthcare provider of colonization or infections acquired from a resident;-Hand hygiene (hand washing and/or alcohol-based hand rub - ABHR) continues to be the primary means of preventing the transmission of infection. Accepted standards of practice such as the use of ABHR instead of soap and water in all clinical situations except when hands are visibly soiled; after caring for a resident with known or suspected Clostridium difficile ( C-diff - a bacterium that causes severe diarrhea and harmful inflammation of the large intestine) or norovirus (a highly contagious virus that causes severe, sudden vomiting and diarrhea) infection during an outbreak; before eating; and after using the restroom;-Staff must perform hand hygiene even if gloves are utilized;-Gloves or the use of baby wipes are not a substitute for hand hygiene. Review of the facility's policy titled, Standard Precautions - Gloves, dated 2019, showed the following:-Purpose to reduce the possibility that healthcare workers will become infected with microorganisms (tiny living things that are too small to be seen without a microscope) that are infecting residents and to prevent healthcare worker exposure to blood and other potentially infectious materials from the resident, equipment, and the environment; and to reduce the likelihood that healthcare workers will transmit their endogenous microbial flora (everyone has their own home-grown germs) to residents. To lessen the possibility that personnel will become transiently colonized with microorganisms that can be transmitted to other residents;-Disposable single-use examination gloves are worn when hand contact with blood, other potentially infectious materials, mucous membranes and non-intact skin is anticipated; when performing vascular access procedures; when handling or touching contaminated items or surfaces; if hand of healthcare provider has cuts, abrasions or other open areas healthcare worker; and when caring for a resident with uncontained body fluids or known or suspected drug-resistant organism colonization or infection;-Examination gloves are removed as soon as practical when contaminated; as soon as practical when torn, punctured or when the ability to function as a barrier is compromised; between resident contacts; and before touching uncontaminated surfaces or other areas of the same resident's body that may be uncontaminated. 2. Review of Centers for Disease Control and Prevention' (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs, dated 04/02/24, showed the following:-MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs;-EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities;-EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO;-Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens,changing briefs or assisting with toileting, device care or use of central line (a long, flexible tube inserted into a large vein in the chest, neck, or arm, with the tip ending close to the heart), urinary catheter (a thin, flexible, indwelling urinary tube inserted through the urethra into the bladder to drain urine continuously), feeding tube (a medical device used to deliver liquid food, fluids, and medications directly to the stomach or small intestine), tracheostomy (a surgical procedure that creates an opening, called a stoma, through the neck directly into the windpipe (trachea) /ventilator (a medical machine that helps a patient breathe or fully breathes for them)and wound care of any skin opening requiring a dressing. Review of the facility's policy titled, Infection Prevention and Control Manual-Enhanced Barrier Precautions, undated, showed the following:-EBP is an infection control intervention designed to reduce transmission of MDROs in nursing homes. EBP involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (such as residents that have wounds or indwelling medical devices). This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized;-EBP expanded the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. EBP is recommended for residents known to be colonized or infected with a MDRO, as well as those at increased risk of MDRO acquisition. Standard Precautions still apply while using EBP;-EBP is recommended for residents with infection or colonization with a MDRO or a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO or indwelling medical devices such as central venous catheters, urinary catheters, feeding tubes, and tracheostomies/ventilators;-High-contact resident care activities where a gown and gloves should be used include bathing/showing, transferring residents from one position to another, providing hygiene, changing bed linens, changing briefs or assisting with toileting, caring for or using an indwelling medical device, or performing wound care. Review of Resident #3's face sheet (brief resident profile sheet) showed the following:-admission date of 03/20/26;-Diagnoses included vascular dementia (decline in thinking, memory, and behavior caused by conditions that block or reduce blood flow to the brain) with agitation, delusional disorders (a mental health condition where a person holds strong, irrational beliefs that are untrue), chronic atrial fibrillation (a continuous heart condition where the top chambers of the heart quiver instead of beating effectively causing an irregular and fast, pounding heartbeat), and depression. Review of the resident's care plan, dated 04/27/26, showed the following:-At risk for skin breakdown related to incontinence and dependent on staff to provide substantial positioning changes;-Resident had skin breakdown to coccyx (tailbone) and heel;-The resident had an activities of daily living (ADL) deficient and was dependent on staff for toilet use and required one staff for transfers.(Staff did not address the need for EBP.) Observation on 04/29/26, at 3:57 P.M., showed the following:-The resident had an EBP sign on the door to his/her room;-Certified Nurse Aide (CNA) J and CNA L entered the resident's room. The CNAs did not complete hand hygiene and put on gloves. The CNAs did not don a gown;-The CNAs positioned the resident for incontinent care and CNA J wiped the front genital area with a clean wipe;-The CNAs repositioned the resident to his/her left side. CNA J pulled out the dirty brief, used a clean wipe to wash between the buttocks from front to back, changed wipes, and wiped entire buttock area;-CNA J placed a clean brief on the resident without changing glove or performing hand hygiene; -CNA L placed pillows behind the resident's back, while CNA J turned the resident on his/her right side, covered with sheet and blanket, and placed the call light on his/her lap. The CNAs did not change gloves or perform hand hygiene;-CNA J took off his/her dirty gloves, washed his/her hands, put new gloves on, and wiped the resident's face with a clean washcloth;-CNA J took off his/her gloves, placed them in the trash can, exited the resident's room, and did not perform hand hygiene;-CNA L took off his/her gloves, placed them in the trash, exited the room with the trash, and did perform hand hygiene. 3. Review of Resident #47's face sheet showed the following: -admission date of 02/04/25;-Diagnoses included hemiplegia and hemiparesis affecting left non-dominant side (the right side of the brain is damaged, causing weakness or paralysis on the left side of the body), cerebral infarction (a blockage in the brain when a blood clot or narrowing artery blocks blood flow to part of the brain, causing brain cells to die from lack of oxygen), major depressive disorder, convulsions (uncontrollable shaking or jerking of the body caused by involuntary muscle contractions and relaxation), and generalized muscle weakness. Review of the resident's care plan, dated 02/18/26, showed the following:-The resident had an ADL deficit and required two staff participation to reposition, turn, and dressing;-Required total assistance with personal hygiene care;-Dependent on staff to change and cleanse skin related to incontinence of bowel and bladder;-The resident required a Hoyer lift (a mechanical lift for resident who cannot bear weight) for transfers with two staff assistance. Observation on 04/29/26, at 3:34 P.M., showed the following:-CNA J entered the resident's room and put on gloves without performing hand hygiene;-Nurse Aide (NA) K entered the resident's room with the Hoyer lift, did not perform hand hygiene, and donned gloves;-Both aides positioned the resident to provide incontinent care;-NA K washed the resident's front genital area with a clean wipe, then the aides turned the resident on his/her left side;-NA K pulled out the dirty brief, used a clean wipe to wash between the buttocks and entire buttock area, wiped from front to back, and used clean wipes with each pass; -NA K placed clean brief on the resident and covered the resident with a sheet without performing hand hygiene or changing his/her gloves;-Both aides washed their hands and transferred the resident. 4. During an interview on 04/29/26, at 5:05 P.M., CNA L said the following:-Staff should perform hand hygiene when entering and exiting a resident's room, before feeding residents, and after any resident care;-Staff should wear gloves with incontinent care and any direct resident care;-Staff should change gloves after providing care when dirty and before touching a clean area;-Staff should wear EBP for residents with an open wound or Foley catheter (a device that drains urine from the bladder into an external collection bag);-Staff should wear gloves and a gown when providing direct care for residents on EBP. During an interview on 04/29/26, at 5:10 P.M., CNA J said the following:-Staff should perform hand hygiene before going into a resident's room, before and after feeding residents, between passing dinner trays, after incontinent care, and after leaving a resident's room;-Staff should put on gloves before providing incontinent care, bath care, shaving, and any cares with body fluids;-Staff should perform hand hygiene before putting on gloves and after taking off gloves; -Staff should change gloves after providing care when dirty and before touching a clean area; -Staff should follow EBP for residents with a catheter, feeding tube, open wound or a colostomy (an opening created on the belly for the colon and waste collects to a pouch outside the body);-Staff should wear gloves and a gown when providing direct care for residents on EBP;-Staff should wear gloves and a gown when providing care for Resident #3. During an interview on 04/30/26, at 3:18 P.M., Licensed Practical Nurse (LPN) I said the following:-Staff should perform hand hygiene before entering and after leaving each resident's room, before and after meals, before and after feeding, before and after changing gloves, and in between each resident care;-Staff should wear EBP for residents with a catheter, open wound, and colostomy;-Staff should wear gloves and a gown when providing direct care such as catheter care, wound care, incontinent care, and showers; -An EBP sign on the resident's door tells staff to wear gloves and a gown for direct patient care;-Resident #3 has a EBP sign outside of his/her room. Staff should wear gloves and a gown for the resident's direct care. During an interview on 04/30/26, at 3:39 P.M., the Social Services Director (SSD)/Infection Control Preventionist (IP) said the following:-Expected staff to perform hand hygiene when entering and leaving a resident's room, before and after eating, after using the bathroom, after smoking, and between clean and dirty treatments;-Expected staff to change gloves between clean and dirty treatments and between each resident;-Staff should perform hand hygiene before putting on gloves and after taking gloves off;-Expected staff to wear gloves and a gown for residents on EBP;-Expected staff to wear EBP when providing wound care, catheter care, changing a catheter, tube feeding, showers, incontinent care, and any other type of direct resident care;-Expected a resident on EBP to be included in the care plan. During an interview on 04/30/26 at 4:02 P.M., the Director of Nursing (DON) said the following:-Expected staff to perform hand hygiene before entering and after leaving a resident's room, before and after all cares;-Expected staff to perform hand hygiene before and after changing gloves;-Expected staff to change gloves after touching anything dirty and before touching a clean area;-Expected staff to use EBP on residents with an open wound or with any indwelling device; -Expected a resident on EBP to be included in the care plan;-Expected staff to wear EBP when providing care for Resident #3. During an interview on 04/30/26, at 4:19 P.M., the Administrator said the following:-Expected staff to use proper hand hygiene, wear and change gloves according to policy and professional standards for all resident care; -Expected staff to wear EBP for all designated residents direct care. 5. Review of the facility's policy titled Tuberculosis Screening - Employees, dated 2019, showed the following:-It is the policy of this facility to assess risks for tuberculosis based on region/community data and screen staff according to State law. For example, all healthcare workers are to be tested for tuberculosis upon hire and yearly thereafter unless contraindicated or in accordance with State requirements;-Initial testing will be a two-step procedure with the first dose given before beginning work and the second booster dose given sever to 21 days after the first if the first dose is negative along with an employee risk screening tool;-New employees will not be allowed to work until the TST, or chest x-ray results are known;-Employees who will be receiving the two-step TST may begin work after the first step results are negative;-TST results will be documented in the employee's medical record;-TST is read between 48 and 72 hours after administration by someone trained in reading and interpretation. Review of the general requirements of 19 CSR 20.20.100 (3), TB testing for employees in Long Term Care Facilities, showed the following:-Long-term care facilities shall screen their employees for TB using the Mantoux method (tool for screening for tuberculosis and for tuberculosis diagnosis) PPD two-step tuberculin test within one month prior to starting employment; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status;-If the initial test is negative, the second test should be given as soon as possible within three weeks after employment begins unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. Review of the Employee TB Screening Tool for Registered Nurse (RN) A showed the following information:-Date of hire of 04/25/25;-Step one administered on 04/25/25;-The test was required as a condition of employment;-Employee must report back within 48 to 72 hours to be examined;-Step one results read on 04/30/25 (five days after administration). During an interview on 04/30/26, at 3:43 P.M., the IP/SSD said the following:-Newly hired employees must be TB tested with negative results prior to starting to work in the facility;-The test should be read in 48 to 72 hours;-Step #2 of the process should be done in approximately seven to ten days. If it was more than 21 days they would need to start the 2-step process over;-The TB tests are documented on the Employee TB Screening Tool form; -The employee answers the questions and either the SSD or another nurse should document the administration and result reading of each test;-RN A would need to start a new 2-step TB testing process because the first test was not read timely;-The forms are kept in a binder and reviewed at morning meetings to monitor for required completion dates. During an interview on 04/30/26, at 4:02 P.M., the Director of Nursing (DON) said the following: -The IP/SSD was responsible for initiating and monitoring completion of staff TB tests;-If SSD was not present, any other nurse could administer the TB test and initiate the documentation;- Any nurse could read the test result;-The testing was tracked on the form that is filled out for that employee;-TB tests should be read within 48 to 72 hours. During an interview on 04/30/26, at 4:19 P.M., the Administrator said the following: -TB testing was monitored by the SSD;-If the SSD was not there when the test should be done, another nurse would do the test at the nurses' station where the documentation binder was kept;-SSD audits the binder at every morning meeting;-TB tests should be read within 48-72 hours.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment was free of accident hazards when the resident accessible hot water temperatures in rooms of eight residents' (Resident #41, #27, #31, #42, #3, #7, #34, and #51) measured greater than 120 degrees Fahrenheit (F). The facility census was 54. Review showed the facility did not provide a policy regarding hot water temperature monitoring. Review of the American Burn Association website, updated 2002, showed the following:-Hot water caused third degree burns (full thickness burns which go through the skin and affect deeper tissue resulting in white or blackened, charred skin) at the following temperatures and time parameters:-In 1 second at 155 degrees F;-In 2 seconds at 148 degrees F;-In 5 seconds at 140 degrees F;-In 15 seconds at 133 degrees F;-In 1 minute at 127 degrees F;-In 3 minutes at 124 degrees F.-Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. 1. Review of Resident #41's face sheet (brief resident profile sheet) showed the following:-admission date of 11/26/24;-Diagnoses included Parkinson's disease (a progressive brain disorder that causes problems with movement, balance, and muscle control), need for assistance with personal care, and altered mental status (change in a person's awareness, alertness, or mental sharpness). Review of the resident's care plan, reviewed 03/09/26, showed the following:-Resident required one staff assistance with activities of daily living;-Resident was alert and oriented, but unable to talk. Review of resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/29/26, showed the following:-Unable to speak clearly, but can understand others;-Required staff assistance for bathing, toileting, personal hygiene and transferring. 2. Review of Resident #27's face sheet showed the following:-admission date of 02/14/22;-Diagnoses included Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple daily tasks), generalized epilepsy (a brain condition characterized by recurring, unprovoked seizures that start on both sides of the brain simultaneously), altered mental status, depression, and anxiety. Review of resident's care plan, dated 02/03/26, showed the following:-Resident was alert and oriented but may be forgetful due to the dementia disease process;-Required staff assistance with toileting, transferring, bathing and personal hygiene. Review of resident's MDS, dated [DATE], showed the following:-Cognitively intact;-Dependent on staff for bathing, toileting, and personal hygiene. 3. Review of Resident #31's face sheet showed the following:-admission date of 05/01/25;-Diagnoses included type two diabetes with neuropathy (the body doesn't produce enough insulin which can cause nerve damage with long-term high blood glucose levels), and need for assistance with personal care. Review of resident's care plan, dated 02/05/26, showed dependent on staff for transferring, toileting, bathing, and dressing. Review of resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Dependent on staff for bathing, toileting, transfers, and personal hygiene. 4. Review of Resident #42's face sheet showed the following:-admission date of 09/28/15;-Diagnoses included dementia with other behavioral disturbance (a decline in mental ability such as memory, thinking, or reasoning, that is severe enough to interfere with daily life), type two diabetes, and chronic pain syndrome (a condition where pain lasts for more than 3 to 6 months). Review of resident's MDS, dated [DATE], showed the following:-Cognitively intact;-Independent for toileting, bathing, dressing and personal hygiene. Review of resident's care plan, dated 04/18/26, showed the following:-Resident had history of traumatic brain injury and could affect decision making;-Independent for all activities of daily living. 5. Observation on 04/29/26, of the bathroom sink water temperature for Resident #41, # 27, #31, and #42 showed the following: -At 6:18 P.M., the hot water measured 124.1 degrees F;-At 7:23 P.M., the hot water measured 124.7 degrees F. 6. Review of Resident #3's face sheet showed the following:-admission date of 03/20/26;-Diagnoses included vascular dementia (decline in thinking, memory, and behavior caused by conditions that block or reduce blood flow to the brain) with agitation, delusional disorders (a mental health condition where a person holds strong, irrational beliefs that are untrue), and depression. Review of the resident's comprehensive MDS, dated [DATE], showed the following:-Cognitively intact;-Dependent on staff for repositioning, transferring and bathing. Review of resident's care plan, dated 04/27/26, showed resident was dependent on staff for toileting, bathing, dressing, eating, personal hygiene, and transferring. 7. Review of Resident #7's face sheet showed the following:-admission date of 01/24/25;-Diagnoses included Parkinson's disease, dementia, obsessive-compulsive disorder (a mental health condition causing uncontrollable thoughts and repeated behaviors), and anxiety.Review of resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Dependent on staff for transfers, toileting, bathing and personal hygiene. 8. Review of Resident #34's face sheet showed the following:-admission date of 04/01/25;-Diagnoses included Huntington's disease (a rare, inherited, and progressive brain disorder that causes nerve cells to break down over time), depression, and insomnia. Review of resident's MDS ,dated 04/15/2026, showed the following:-Cognitively intact;-Independent with toileting, transfers and dressing;-Substantial assistance from staff with personal hygiene. Review of resident's care plan, dated 04/28/26, showed the following:-Alert and oriented with some short-term memory deficit;-Independent with most activities of daily living but may need one staff assistance for personal hygiene. 9. Review of Resident #51's face sheet showed the following:-admission date of 03/04/24;-Diagnoses included cerebrovascular disease (a condition that affects blood flow to the brain), dementia, reduced mobility, and generalized muscle weakness. Review of the resident's MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Dependent on staff for transfers, bathing and personal hygiene. Review of resident's care plan, dated 04/22/26, showed resident dependent on staff for all activities of daily living. 10. Observation on 04/29/26, at 7:20 P.M., showed the bathroom sink water temperature for Resident #3, #7, #34, and #51 measured 122.8 degrees F. 11. During an interview on 04/30/26, at 2:07 P.M., the Maintenance Director said he/she expected water temperatures in the resident rooms to be between 105 degrees and 120 degrees F. During an interview on 04/30/26, at 2:10 P.M., the Dietary Manager said the following:-He/she was the prior maintenance director;-He/she conducted all weekly water temperature monitoring during the day shift when most resident showers given;-He/she would expect water temperatures in the resident room to be between 105 degrees and 120 degrees F; -He/she would test water temperatures in two different resident rooms in each hallway. During an interview on 04/30/26 at 4:02 P.M., the Director of Nursing (DON) said the following:-He/She expected staff to check the resident water temperatures and ensure temperatures were in a safe range;-He/She expected staff to conduct water temperatures monitoring at different times and shifts. During an interview on 04/30/26, at 4:19 P.M., the Administrator said the following:-He/She expected staff to notify maintenance and administration if water temperatures were too hot;-He/She expected staff to conduct weekly water temperature monitoring and ensure temperatures were in a safe range

Based on observation, interview, and record review the facility failed to ensure residents were free from significant medication errors when the facility failed to administer noon insulin on dialysis (a life- sustaining treatment for kidney failure, filtering waste and excess fluid from the blood when the kidneys have less than 10-15 % function) days and failed to prime the insulin pen before administration for one resident (Resident #2). The facility census was 54.Review of the facility procedure titled Medication Pass Tips, dated 05/2019, showed administer each medication as instructed on the electronic Medication Administration Record (eMAR) and within the timeframe established by the facility. 1. Review of Resident #2's face sheet (brief look at resident information) showed the following:-admission date of 11/05/25;-Diagnoses include chronic kidney disease, diabetes, and dependence on renal (kidney) dialysis. Review of the resident's comprehensive Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 04/01/26, showed the following:-Cognitively impaired;-Received dialysis;-Receives hypoglycemics (medications used to lower blood sugar/glucose levels in patients with diabetes). Review of the resident's care plan, dated 06/05/25, showed the following:-Monitor blood glucose levels as ordered and provide insulin as ordered;-Encourage the resident to attend dialysis appointments on Mondays, Wednesdays, and Fridays. Review of the resident's April 2026 Physician Order Sheet (POS) showed the following:-An order, dated 03/20/26, for dialysis every Monday, Wednesday, and Friday with pick up time of 7:00 A.M.- 7:30 A.M.;-An order, dated 04/01/26, for insulin lispro (a rapid acting man-made insulin used to treat high blood sugar/glucose) subcutaneous (the layer of fatty tissue located directly beneath the dermis and epidermis of the skin) solution pen injector 200 u/ milliliter (ml), inject per sliding scale;-If the blood glucose level is 181 milligrams/deciliter (mg/dL) to 200 mg/dL, administer 2 units of insulin;-If the blood glucose level is 201 mg/dL to 250 mg/dL, administer 4 units of insulin;-If the blood glucose level is 251 mg/dL to 300 mg/dL, administer 6 units of insulin;-If the blood glucose level is 301 mg/dL to 350 mg/dL, administer 8 units of insulin;-If the blood glucose level is 351 mg/dL to 400 mg/dL, administer 10 units of insulin;-If the blood glucose level is 401 mg/dL to 450 mg/dL, administer 12 units of insulin;-If the blood glucose level is greater than 450 mg/dL, call the physician. Review of the resident's medication administration record (MAR), dated 04/01/26, showed the resident's noon blood sugar check and dose of sliding scale insulin were not administered. Review of the resident's progress note dated 04/01/26, at 9:47 A.M., showed the resident's noon medications were held due to the resident attending dialysis. Review of the resident's MAR, dated 04/03/26, showed the resident's noon blood sugar check and dose of sliding scale insulin were not administered. Review of the resident's progress note dated 04/03/26, at 7:08 A.M., showed the resident's noon insulin was held due to the resident attending dialysis. Review of the resident's MAR, dated 04/06/26, showed the resident's noon blood sugar check and dose of sliding scale insulin were not administered. Review of the resident's progress note dated 04/06/26, at 5:35 A.M., showed the resident's A.M. medications and noon insulin were held due to the resident attending dialysis. Review of the resident's MAR, dated 04/08/26, showed the resident's noon blood sugar check and dose of sliding scale insulin were not administered. Review of the resident's progress note dated 04/08/26, at 5:36 A.M., showed the resident's noon insulin was held due to the resident attending dialysis. Review of the resident's MAR, dated 04/10/26, showed the resident's noon blood sugar check was administered and sliding scale insulin was not required. Review of the resident's MAR, dated 04/13/26, showed the resident's noon blood sugar check and dose of sliding scale insulin were not administered. Review of the resident's progress note dated 04/13/26, at 7:08 A.M., showed the noon insulin medications was held due to the resident attending dialysis. Review of the resident's MAR, dated 04/15/26, showed the resident's noon blood sugar check and dose of sliding scale insulin weas not administered. Review of the resident's progress note dated 04/15/26, at 5:58 A.M., showed the noon insulin medications was held due to the resident attending dialysis. Review of the resident's MAR, dated 04/17/26, showed the resident's noon blood sugar check and dose of sliding scale insulin was not administered. Review of the resident's progress note dated 04/17/26, at 5:34 A.M., showed the noon insulin medications were held due to the resident attending dialysis. Review of the resident's MAR, dated 04/20/26, showed the resident's noon blood sugar check and dose of sliding scale insulin were not administered. Review of the resident's progress note dated 04/20/26, at 5:24 A.M., showed the noon insulin medications were held due to the resident attending dialysis. Review of the resident's MAR, dated 04/22/26, showed the resident's noon blood sugar check and dose of sliding scale insulin were not administered. Review of the resident's progress note dated 04/22/26, at 4:15 A.M., showed the resident's noon insulin medications were held due to the resident attending dialysis. Review of the resident's MAR, dated 04/24/26, showed the resident's noon blood sugar check and dose of sliding scale insulin were not administered. Review of the resident's progress note dated 04/24/26, at 8:50 A.M., showed the resident's noon insulin medications were held due to the resident attending dialysis. Review of the resident's progress note dated 04/24/26, at 10:23 A.M., showed the following:-Staff spoke to the Nurse Practitioner (NP) about whether the resident's medications were to be held prior to dialysis treatments;-The NP advised to administer the medications as prescribed. Review of the resident's MAR, dated 04/27/26, showed the resident's noon blood sugar check and dose of sliding scale insulin were not administered. Review of the resident's progress note, dated 04/27/26, showed no documentation regarding the administration or withholding of the resident's medications. During an interview on 04/30/26, at 11:15 A.M., Registered Nurse (RN) A said the following:-Physician orders should be followed. If an order is not clear, he/she will call the physician for clarification;-The resident goes to dialysis three times a week;-The Infection Preventionist(IP)/Social Services Director (SSD) spoke with a pharmacist, who conferred with the NP, and it was determined that the resident should be receiving his/her medications;-Orders for a resident's medication to be held (not administered) are documented on the POS;-Staff notified the NP that the resident missed several medication administrations;-Missed medication administrations should be documented on the MAR and in the resident's progress notes. The physician should be notified. During an interview on 04/30/26, at 2:12 P.M., Certified Medication Technician (CMT) M said the following:-Physician orders should be followed;-All medications should be given unless there is a specific hold order documented in the POS. During an interview on 04/30/26, at 2:15 P.M., CMT N said the following:-Physician orders should be followed;-All medications should be given unless there is a specific hold order documented in the POS. During an interview on 04/30/26 ,at 2:20 P.M., the IP/SSD said the following:-Physician orders should be followed;-In March 2026, the IP/SSD verified with the pharmacist and the NP that the resident should be receiving his/her medications on dialysis days;-The IP/SSD documented the information in the resident's progress notes and verbally notified all nurses. During an interview on 04/30/26 at 4:00 P.M., the Director of Nursing (DON) said the following:-Physician orders should be followed;-All medications should be given unless there is a specific hold order documented in the POS;-The resident previously missed medication administrations because the NP was unsure if the medications would be dialyzed or not and wanted clarification from the pharmacist;-The pharmacist clarified that the resident's medications should be administered as ordered. Nursing staff were notified;-If a medication is not administered, she expects staff to document in the MAR and progress notes. Staff should also notify the NP. During an interview on 04/30/26 at 4:19 P.M., the Administrator said the following:-Physician orders should be followed;-All medications should be given unless there is a specific hold order documented in the POS;-The resident missed medication administrations because the NP was unsure if the medications would be dialyzed or not and wanted clarification from the pharmacist;-The pharmacist clarified that the resident's medications should be administered as ordered. Nursing staff were notified;-If a medication is not administered, she expects staff to document in the MAR and progress notes. Staff should also notify the NP.-The NP is changing the resident's orders to better accommodate the dialysis schedule. 2. Review of the Food and Drug Administration (FDA) package insert and patient information for insulin lispro, dated 03/2013, showed the following: -Prime before each injection. Priming ensures the pen is ready to dose and removes air that may collect in the cartridge during normal use. If you do not prime before each injection, you may get too much or too little insulin;-Turn the dose knob to select two units;-Hold your pen with the needle pointing up;-Tap the cartridge holder gently to collect air bubbles at the top;-Hold your pen with needle pointing up; -Push the dose knob in until it stops, and 0 is seen in the Dose window.;-Hold the dose knob in and count to five slowly. A stream of insulin should be seen from the needle. If you do not see a stream of insulin, repeat the priming steps no more than four times;-If you still do not see a stream of insulin, change the needle and repeat the priming steps. Observation on 04/30/26 at 11:15 A.M., showed the following:-RN A obtain the resident's blood glucose level. The residents' blood glucose level was 371 mg/dL and per order required 10 units (u) of insulin;-The RN obtained the insulin pen, attached the needle, and dialed up to 10 units;-RN A administered the insulin without priming the needle. During an interview on 04/30/26, at 1:02 P.M., RN A said the following:-Insulin pens should be primed with two units prior to each administration;-The purpose of priming is to get the air out of the needle, to ensure the resident receives the full dose of medication;-Physician orders should be followed. During an interview on 04/30/26, at 2:18 P.M., the MDS Nurse said insulin pens should be primed with two units with every administration to ensure residents receive the correct dosage. During an interview on 04/30/26, at 2:25 P.M., the Social Services Director/Infection Preventionist said the following:-Physician orders should be followed;-Insulin pens should be primed with two units with every administration to ensure residents receive the correct dosage. During an interview on 04/30/26, at 4:02 P.M., the DON said the following:-Physician orders should be followed;-Insulin pens should be primed with two units with every administration to ensure residents receive the correct dosage. During an interview on 04/30/26, at 4:19 P.M., the Administrator said the following;-Physician orders should be followed;-Insulin pens should be primed with two units with every administration to ensure residents receive the correct dosage.

Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) received the necessary services to maintain good personal hygiene when the facility failed to document reapproaches after bathing refusals for two residents (Residents #28 and #50) of 19 residents reviewed. The facility census was 54.Review of the facility policy titled Activities of Daily Living, dated 09/24/25, showed the following information:-The facility provides each resident with care, treatment, and services according to the resident's individualized care plan;-Based on the comprehensive assessment of each resident, facility staff will ensure that the resident's ability to perform activities of daily living does not decline unless the resident's medical condition circumstances make the decline unavoidable. Review showed the facility did not provide a policy related to showers. 1. Review of Resident #28's face sheet (brief look at resident information) showed the following:-admission date of 07/11/25;-Diagnoses included dementia with behavioral disturbances, Alzheimer's disease, high blood pressure, high blood pressure, and dizziness. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 04/22/26, showed the following:-Severe cognitive impairment;-Dependent on assistance from staff for bathing;-Required supervision from staff for dressing. Review of the resident's care plan, dated 07/21/25, showed the following:-Dependent on staff for bathing;-The resident often refused bathing and required staff to reapproach as needed;-The resident able to dress his/herself;-The resident can perform his/her own personal hygiene of brushing his/her hair. Review of the resident's Electronic Medical Record (EMR), under ADL-bathing assessments, dated April 2026, showed the following:-On 04/03/26, the resident received a shower;-On 04/07/26, the resident was offered a shower once and refused;-On 04/09/26, the resident was offered a shower once and refused;-On 04/14/26, the resident was offered a shower once and refused;-On 04/17/26, the resident was offered a shower once and refused;-On 04/21/26, the resident was offered a shower once and refused;-On 04/22/26, the resident was offered a shower once and refused. Review of the resident's progress notes, dated 04/07/26, 04/09/26, 04/14/26, 04/17/26, 04/21/26, and 04/22/26, showed staff did not document regarding resident bathing refusals or attempts to reapproach. Review of the resident's progress note, dated 04/24/26, showed the following information:-Staff assisted the resident to the shower room without issue;-Once in the shower room, the resident kept trying to leave the room;-Both staff members talked with the resident in a soothing reassuring tone;-The resident sat on the shower chair, but staff were unable to undress the resident;-Staff were unable to bathe the resident. Staff escorted the resident back to the unit;-No new interventions, second attempt or reschedule documented. Review of the resident's EMR, under ADL-bathing assessments, dated April 2026, showed on 04/28/26, the resident was offered a shower twice and refused. Review of the resident's progress note, dated 04/28/26 showed staff did not document regarding the bathing refusals. Observation on 04/27/26, at 11:00 A.M., showed the following:-Resident #38 wandering about the halls of the unit;-The resident wore Aztec printed leggings;-The resident's hair appeared disheveled and unwashed as evidenced by uncombed hair appearing with an oily substance throughout the root to the ends of his/her hair. Observation on 04/28/26 at 6:16 A.M., showed the following:-The resident sat on the couch in the main living room area of the unit;-The resident's hair appeared disheveled and unwashed. His/her hair was uncombed with an oily substance throughout the root to the ends of his/her hair. Observation on 04/29/26, at 12:09 P.M., showed the following:-The resident sat in the dining area;-The resident's hair appeared disheveled and unwashed. His/her hair was uncombed with an oily substance throughout the root to the ends of his/her hair. During an interview on 04/29/26, at 4:08 P.M., Licensed Practical Nurse (LPN) F said the following:-The resident was non-compliant with cares;-He/she was unsure what the proper procedure would be to get the resident to bathe;-He/she assumed staff would just need to reapproach the resident at different times of the day to be successful. During an interview on 04/30/26, at 1:02 P.M., Registered Nurse (RN) A said the following:-The resident's shower days were Tuesday and Friday;-The resident was very confused and is difficult to assist with bathing;-Staff tried to reapproach the resident at other times of the day and talk in a calm reassuring voice;-If the current interventions of reapproaching and redirecting were not working, he/she was unsure of what else can be implemented to get the resident to bathe. 2. Review of Resident #50's face sheet showed the following information:-admission date of 11/01/25;-Diagnoses included stroke, changes to the brain, right/dominant sided weakness/immobility, difficulty with speech following stroke, arthritis, muscle wasting, difficulty swallowing, difficulty in walking/lack of coordination, cognitive communication deficit, pain, and history of falling. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Functional limitation in range of motion upper and lower extremities impaired, one side;-Dependent on staff for oral, toileting, and personal hygiene, showers/bathing, dressing, bed mobility, and transfers. Review of the resident's care plan, updated 11/13/25, showed self care performance deficit related to right side paralysis; totally dependent on staff to provide a bath as necessary. Staff to provide with a sponge bath when a full bath or shower cannot be tolerated. Review of the resident's EMR, under ADL-bathing assessments, dated April 2026, showed the following:-On 04/03/26, the resident received a shower with the assistance of two staff;-On 04/14/26, the resident refused a shower. Review of a nurse practitioner's progress note, dated 04/20/26, showed the following:-Recommend good hygiene and skin care to prevent skin breakdown;-Continue with moderate assistance with ADLs as needed. Review of the resident's EMR, under ADL-bathing assessments, dated April 2026, showed the following:-On 04/21/26, the resident refused a shower;-On 04/22/26, the resident refused a shower;-On 04/24/26, the resident refused a shower. Review of the resident's care plan, updated 4/28/26, showed the resident preferred to only have one bath per week on Fridays and refused showers often. Review of the resident's EMR, under ADL-bathing assessments, dated April 2026, showed on 04/29/26, the resident refused a shower. Review of the resident's April 2026 progress notes showed staff did not document regarding resident bathing refusals or staff reapproaching the resident. Observation on 04/27/26, at 11:47 A.M., showed the resident sat in a wheelchair in the front lobby of the facility. The resident's hair appeared to be uncombed and dirty. During an interview on 04/30/26, at 4:30 P.M., Certified Medication Technician (CMT) B said the following:-The resident resisted cares at times, but staff can sometimes explain the care enough for the resident to accept assistance;-He/she believed the resident received showers or was bathed but did not have direct knowledge of the method or frequency. 3. During an interview on 04/30/26 at 1:02 P.M., Registered Nurse (RN) A said the following:-Staff are expected to offer each resident two showers a week;-When a resident refuses showers for almost a month, it would be appropriate to notify the resident's family. He/she has attempted to make contact with the resident's family and has been unsuccessful;-All attempts at bathing and/or any refusals should be documented in the nurse's notes. 4. During an interview on 04/30/2, at 2:18 P.M., the MDS Nurse said the following:-Any aspects of a resident's care should be found on the care plan;-Staff nurses have not brought any new bathing interventions to her to add to the resident care plans;-A resident should be reapproached later in the day if the resident initially refuses bathing. If the resident continued to refuse, the staff should notify the charge nurse and the charge nurse should document the attempt, intervention, and refusal;-If a resident refused to bathe one day, the staff should try again the following day;-Sometimes different staff approaches can make all the difference. During an interview on 04/30/26, at 2:25 P.M., the Social Services Director (SSD) said the following:-Any aspects of a resident's care should be found on the care plan;-The resident should be reapproached later in the day if the resident initially refuses bathing. If the resident continued to refuse, the staff should notify the charge nurse and the charge nurse should document the attempt, intervention, and refusal;-If a resident refused to bathe one day, the staff should try again the following day;-Sometimes different staff approaches can make all the difference. During an interview on 04/30/26, at 4:02 P.M., the Director of Nursing (DON) said the following:-She expected all residents to be offered at least two bathing opportunities a week;-Showers were documented in the resident's EMR under ADL-bathing;-If the resident frequently refused, the resident should be asked again at a later time with a different approach. If the resident continues to refuse, the charge nurse should document the refusal in the progress notes;-If a resident refused bathing for an extended period of time, she expected staff to notify the resident's family. During an interview on 04/30/26, at 4:02 P.M., the Administrator said the following:-She expected all residents to be offered at least two bathing opportunities a week;-Showers were documented in the resident's EMR under ADL-bathing;-For residents that have frequent refusals, she expected staff to offer again with a different approach and document refusals in the progress notes;-Frequent refusals and/or new interventions should be documented in the care plan;-She expected the resident's family to be notified if the resident frequently refuses bathing.

Based on observation, interview, and record review, the facility failed to ensure medication error rates did not exceed five percent when the facility completed two medication errors out of an 25 opportunities (an 8% error rate) affecting two residents (Resident #53 and #2). The facility census was 54.Review of the facility procedure titled Medication Pass Tips, dated 05/2019, showed the following:-Prior to preparing medication verify the resident's identity, verify each drug against the electronic medical record (eMAR); and if the resident requires the medication is to be crushed; check to see if the drug can be crushed;-Verify the route against the eMAR;-Administer each medication as instructed on the eMAR and within the timeframe established by the facility;-For insulin; prime insulin pens with two units (u) before each use. 1. Review of Resident #53's face sheet (brief look at resident information) showed the following:-admission date of 03/08/24;-Diagnoses included hypokalemia (low potassium). Review of the resident's care plan, dated 06/05/25, showed staff to administer medications as ordered. Review of the resident's April 2026 Physician Order Sheet (POS) showed an order, dated 05/21/25, for potassium chloride 20 milliequivalents (meq) ER (extended release). Staff to give one tablet by mouth two times a day and do not crush. May dissolve in 120 milliliters (ml) of water. Observation on 04/29/26, at 4:05 P.M., showed the following: -Licensed Practical Nurse (LPN) F prepared the resident's evening medications;-LPN F obtained and placed all evening medications, including one tablet of potassium chloride) into a plastic sleeve and crushed the medications prior to adding them to applesauce and administering them to the resident. During an interview on 04/30/26, at 11:15 A.M., Registered Nurse (RN) A said the following:-Medications in capsule, delayed release, or extended-release form should not be crushed;-Potassium chloride should not be crushed. The medication can be dissolved in water if the resident has trouble swallowing. During an interview on 04/30/26, at 2:12 P.M., Certified Medication Technician (CMT) M said the following:-Medications in capsule, delayed release, extended release, or enteric coated should not be crushed;-Potassium chloride should not be crushed. The medication can be dissolved in water if the resident has trouble swallowing. During an interview on 04/30/26, at 2:15 P.M., CMT N said the following:-Medications in capsule, delayed release, extended release, or enteric coated should not be crushed;-Potassium chloride should not be crushed. The medication can be dissolved in water if the resident has trouble swallowing. During an interview on 04/30/26, at 4:00 P.M., the Director of Nursing (DON) said the following:-Medications in capsule, delayed release, extended release, or enteric coated should not be crushed;-Potassium chloride should not be crushed. The medication can be dissolved in water if the resident has trouble swallowing. During an interview on 04/30/26, at 4:19 P.M., the Administrator said the following:-Medications in capsule, delayed release, extended release, or enteric coated should not be crushed;-Potassium chloride should not be crushed. The medication can be dissolved in water if the resident has trouble swallowing. 2. Review of resident #2's face sheet showed the following:-admission date of 11/05/25;-Diagnoses included diabetes. Review of the Food and Drug Administration (FDA) package insert and patient information for insulin lispro, dated 03/2013, showed the following: -Prime before each injection. Priming ensures the pen is ready to dose and removes air that may collect in the cartridge during normal use. If you do not prime before each injection, you may get too much or too little insulin;-Turn the dose knob to select two units;-Hold your pen with the needle pointing up;-Tap the cartridge holder gently to collect air bubbles at the top;-Hold your pen with needle pointing up; -Push the dose knob in until it stops, and 0 is seen in the Dose window.;-Hold the dose knob in and count to five slowly. A stream of insulin should be seen from the needle. If you do not see a stream of insulin, repeat the priming steps no more than four times;-If you still do not see a stream of insulin, change the needle and repeat the priming steps. Review of the resident's comprehensive MDS, dated [DATE], showed the resident received insulin injections seven days out of the week. Review of the resident's April 2026 POS showed the following information:-An order, dated 04/01/26, for insulin lispro (a rapid acting man-made insulin used to treat high blood sugar/glucose) subcutaneous (the layer of fatty tissue located directly beneath the dermis and epidermis of the skin) solution pen injector 200 u/ milliliter (ml), inject per sliding scale;-If the blood glucose level is 181 milligrams/deciliter (mg/dL) to 200 mg/dL, administer 2 units of insulin;-If the blood glucose level is 201 mg/dL to 250 mg/dL, administer 4 units of insulin;-If the blood glucose level is 251 mg/dL to 300 mg/dL, administer 6 units of insulin;-If the blood glucose level is 301 mg/dL to 350 mg/dL, administer 8 units of insulin;-If the blood glucose level is 351 mg/dL to 400 mg/dL, administer 10 units of insulin;-If the blood glucose level is 401 mg/dL to 450 mg/dL, administer 12 units of insulin;-If the blood glucose level is greater than 450 mg/dL, call the physician. Observation on 04/30/26 at 11:15 A.M., showed the following:-RN A obtain the resident's blood glucose level. The residents' blood glucose level was 371 mg/dL and per order required 10 units (u) of insulin;-The RN obtained the insulin pen, attached the needle, and dialed up to 10 units;-RN A administered the insulin without priming the needle. During an interview on 04/30/26, at 1:02 P.M., RN A said the following:-Insulin pens should be primed with two units prior to each administration;-The purpose of priming is to get the air out of the needle, to ensure the resident receives the full dose of medication;-Physician orders should be followed. During an interview on 04/30/26, at 2:18 P.M., the MDS Nurse said insulin pens should be primed with two units with every administration to ensure residents receive the correct dosage. During an interview on 04/30/26, at 2:25 P.M., the Social Services Director/Infection Preventionist said the following:-Physician orders should be followed;-Insulin pens should be primed with two units with every administration to ensure residents receive the correct dosage. During an interview on 04/30/26, at 4:02 P.M., the DON said the following:-Physician orders should be followed;-Insulin pens should be primed with two units with every administration to ensure residents receive the correct dosage. During an interview on 04/30/26, at 4:19 P.M., the Administrator said the following;-Physician orders should be followed;-Insulin pens should be primed with two units with every administration to ensure residents receive the correct dosage.

Based on record review and interview, the facility failed to ensure all residents were free from significant medication errors when one staff member (Certified Medication Tech (CMT) D) administered another resident's medication to one resident (Resident #1) resulting in a drop in blood pressure and the resident being sent to the hospital. A sampled of seven residents were reviewed in a facility with a census of 50.Review of the facility policy titled Medication Monitoring and Management, revised January 2019, showed the following:-Medications are administered at the frequency and times indicated in the prescriber orders;-The consultant pharmacist, or designated pharmacy personnel, at the request of the facility observes the medication administration techniques of staff and assists and advises the facility in conducting routine medication administration observations, including identifying the drug given, identification of the resident, prep for administration, time of administration, technique, and documentation. Review of the facility policy titled Medical. Errors, and Events, dated 12/2024, showed when medical errors or adverse resident events are identified, the facility will analyze the cause, implement corrective actions to prevent future events, and conduct monitoring to ensure desired outcome are achieved and sustained. Review of the facility policy titled Medication Pass Tips, updated May 2019, showed the following:-Prior to preparing medication, verify the resident's identify. A photo is available on the electronic Medication Administration Record (eMAR). Another staff member who is familiar with the resident may be consulted to verify the identity. Also call the resident by name;-Verify the drug against the eMAR. Ensure the label matches the eMAR exactly;-Verify the dose in each blister against the eMAR;-Verify the route against the eMAR;-Administer each medication as instructed on the eMAR and within the time frames established by the facility. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following:-admission date of 12/18/24;-Diagnoses included parkinsonism (involuntary shaking movements), neurocognitive disorder with lewy bodies (progressive brain disorder that affects thinking, movement, behavior and sleep), anxiety (feelings of nervousness), and dementia (decline in mental ability, severe enough to interfere with daily life);-Picture of the resident was present;-Allergies to lorazepam (an anti-anxiety medication) list. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/27/25, showed severe cognitive impairment. Review of the resident's care plan, last updated 07/02/25, showed the following:-Allergies to lorazepam;-Resident was on hospice;-Resident had hearing deficit and difficulty understanding;-Staff should administer medications as ordered. Review of the resident's July 2025 Physician's Order Sheet showed the following:-Resident had allergies to lorazepam;-An order, dated 02/10/25, for levothyroxine (treats hypothyroidism (condition where the thyroid gland doesn't produce enough hormone)), 50 micro grams (mcg), give 50mcg one time per day related to hypothyroidism. Staff to administer at 5:00 A.M.;-An order, dated 02/10/25, for vitamin D3, 25 mcg, give one tablet three times per day for vitamin D deficiency;-An order, dated 02/10/25, for memantine HCL (treats moderate to severe dementia), 10 milligrams (mg) two times per day related to dementia. Staff to administer during A.M., liberal medication pass;-An order, dated 02/10/25, for carb/levo (treats Parkinson's disease), 25-100 mg, two tablets three times per day related to parkinsonism. Administer during the liberal medication passes on the A.M., noon, and evening;-An order, dated 03/20/25, for multivitamin, give one tablet daily for vitamin deficiency. Staff to administer on liberal A.M., medication pass;-An order, dated 04/03/25, for acetaminophen (treats pain), 325 mg, give two tablets two times per day for pain.Review of the resident's July 2025 MAR showed the following:-A picture of the resident;-Resident had allergies to lorazepam;-Staff documented administering the resident's multi vitamin, vitamin D, acetaminophen 650 mg, memantine 10 mg, and carb/levo 35-100 mg on the morning on 07/28/25;-Staff also documented administering another resident's medications to Resident #1, including lamotrigine (used to treat certain types of seizures or as a mood stabilizer) 100 mg, sertraline (class of antidepressants used to treat mental health conditions)100 mg, diltiazem (used primarily to lower blood pressure), 360 mg, olanzapine (atypical antipsychotic medication primarily used to treat various mental health conditions) 2.5 mg, losartan (used to treat high blood pressure) 50 mg, and Ativan (lorazepam) 1 mg;-Staff did not administer the resident's noon medications on 07/28/25 due to the resident being hospitalized .Review of the resident's vital signs, dated 07/28/25, showed the following:-At 7:15 A.M., the resident's blood pressure was 102/58 millimeter of Mercury (mm/Hg) (first number represents the systolic (pressure when the heart rests between beats), second number represents the diastolic pressure (when the heart rests between beats). Healthy blood pressure range is 120/80 mm/Hg);-At 8:15 A.M., the resident's blood pressure measured 90/50 mm/Hg.-At 9:15 A.M., the resident's blood pressure measured 72/40 mm/Hg. Review of the resident's SBAR (situation, background, assessment and recommendation) Communication Form and Progress Note, dated 07/28/25, at 9:41 A.M., showed the following:-Resident was becoming hypotensive (low blood pressure). It started on 07/28/25 and has gotten worse;-Resident was not drinking,-Resident was given the wrong medications including losartan 50 mg, metoprolol (used to treat high blood pressure) 50 mg, diltiazem 360 mg, olanzapine 2.5 mg, sertraline 100 mg, lamotrigine 100 mg, and Ativan 1 mg;-Allergies include lorazepam (Ativan);- Resident's blood pressure on 07/28/25 at 9:15 A.M. in lying position was 72/40 mm/Hg;-Resident has decreased consciousness, decreased mobility, more tired, and hypotensive;-Monitoring vital signs and sending to hospital. Review of the resident's medical record showed a hospital transfer form completed on 07/28/25, at 10:25 A.M., by Registered Nurse (RN) F showed the following:-Resident sent to hospital on [DATE] at 9:50 A.M.;-Reason for transfer was abnormal vital signs;-Resident allergies include lorazepam;-Resident had dementia;-Resident's blood pressure on 07/28/25 at 9:15 A.M. in lying position was 72/40 mm/Hg;-Resident was alert, disoriented, but can follow simple instructions. Review of the facility's Med Error Report, dated 7/28/25, completed by RN F, showed the following:-Resident was trying to get up out of the wheelchair and CMT D was distracted because another resident was trying to take things off from the medication cart;-CMT D accidently gave Resident #1 medication belonging to another resident;-Resident #1 was administered Ativan 1 mg, losartan 50 mg, diltiazem 360 mg, olanzapine 2.5 mg, sertraline 100 mg, and lamotrigine 100mg;-Incident occurred at the nursing station;-On 07/28/25, at 6:40 A.M., staff called the on-call nurse practitioner (NP) and notified him/her of the incident. He/she requested the resident's vital signs be taken every hour for the first twelve hours, and then every two hours for the next 12 hours (staff did not document notifying the nurse practitioner of the medication error or of the resident's allergy to one of the medications received).-Resident is oriented to person only;-On 07/28/25, at 9:20 A.M., staff notified the facility's Medical Director of the resident's low blood pressure reading (staff did not document notifying the Medical Director of the medication error or of the resident's allergy to one of the medications received). During an interview on 07/31/25, at 11:31 A.M., CMT D said the following:-When administering medications to residents, he/she looked at the MAR for the orders and looked for the resident's medications with their name on the label. He/she popped out the medication and put the cards back in the cart. He/she didn't sign off the meds until they were administered;-He/she didn't know the five rights of medications administration;-He/she knows the residents well. If he/she didn't know a resident, he/she would ask the nurse for a second opinion;-If he/she administered the incorrect medications to a resident, he/she would tell the nurse;-On 07/28/25, he/she popped out another resident's medications. He/she was in the television room where several other residents were located, including Resident #1;-There was one resident in the facility that walks around screaming and grabs stuff from the medication cart. Staff have to constantly redirect him/her;-The resident was trying to get out of his/her chair and the aide askes him/her to watch the resident and he/she was busy;-He/she was distracted and before he/she knew it, he/she had given Resident #1 the other resident's medications;-He/she told RN F that he/she messed up. RN F looked up the medications that had been given to the resident and he/she called the doctor. The doctor told them to keep an eye on the resident's blood pressure. The resident's blood pressure kept getting lower, so they sent the resident to the hospital. During an interview on 08/04/25, at 9:30 A.M., RN F said the following:-He/she has one CMT on 100 and 200 halls and one in the unit;-Staff know the residents as they have pictures on the face sheet and the MAR;-He/she expected the staff to use the five rights of right resident, right pill, right form, right dosage, and right time;-If there was a medication error, he/she wanted staff to notify him/her of the incident;-On 07/28/25, around 6:30 A.M., CMT D said he/she had some distractions. One resident was trying to take things off his/her cart and another resident was trying to stand up. The CMT had just poured another resident's medications and accidently gave them to Resident #1. As soon as the CMT administered them to the incorrect resident, he/she said, oh crap and reported what he/she had done;-The MDS Coordinator took the resident's vitals, and he/she called the on-call;-He/she spoke to an NP that told him/she to take the resident's vitals every hour for the first 12 hours and every two hours for 12 hours. He/she discussed with the on-call if that was frequent enough, but he/she did what he/she was told to do;-He/she noticed the resident's blood pressure dropping so he/she called the doctor and got an order to send the resident out;-The resident was a bit drowsier but didn't have any other behavior;-He/she did not know at the time the resident had an allergy to Ativan and he/she did not tell the on call about the allergy. During an interview on 07/31/25, at 12:40 P.M., Certified Nurse's Aide (CNA) E said the following:-If he/she saw a change in a resident's behavior, he/she would tell the nurse what they resident is doing;-He/she was not in the tv room when the incident with the resident took place, but he/she heard about the incident;-It was a chaotic morning on 07/28/25;-He/she knows the nurse called the doctor after the resident was given the incorrect meds;-The resident seemed to be sedated after the incident. During an interview on 07/31/25, at 9:00 A.M., CMT A said the following:-He/she goes down the MAR and the medications that have the yellow banner are the ones that are due to be administered. The green banner means they've been administered;-He/she marks the medications off as he/she places them in the medication cups;-He/she also initials the backs of the bubble packs;-When he/she first started administering medications at the facility, he/she would ask the resident for their name. If the resident didn't know their name, he/she would ask other nursing staff for the resident's verification. The resident's eMAR has their picture, but they don't' always look like the resident;-When he/she is administering meds, he/she looks at the name of the medication and checks that against the MAR;-If he/she administers the wrong medication to a resident, he/she would go straight to the nurse;-He/she would do 15-minute checks or maybe constant. During an interview on 07/31/25, at 10:55 A.M., Licensed Practical Nurse (LPN) B said the following:-One CMT covers the 100 and 200 halls and there is a CMT on 300 hall during the days;-He/she does not administer many medications, except narcotics;-He/she looks at the MAR, which lists the medications prescribed. He/she verifies the medication is correct by looking at the label against the MAR and signs the medication out of the narcotic book;-The residents have pictures on their face sheet;-He/she tells the resident what the medication is for;-The five rights of medication administration are the right dose, right medication, right time, right resident and right documentation;-After the medication is administered to the resident, he/she signs it off in the MAR;-If a resident is administered the incorrect medications, he/she would contact the doctor immediately and contact the family, Director of Nursing (DON) and Administrator;-He/she was not in the facility when Resident #1 was administered the incorrect medications;-He/she was told the resident was given the roommate's medications and CMT D realized it after he/she done it. During an interview on 07/31/25, at 11:05 A.M., RN C said the following:-He/she looks at the MAR to see what's ordered, if it's an as needed medication he/she would check with other staff to see when it was last administered;-He/she looks at the pictures as each resident has a picture on their MAR. If they didn't have a picture, he/she would ask another staff for their name;-The five rights of medication administration are right order, right time, right patient, right site, and right route;-If a resident is administered the wrong medication, he/she would call the Administrator, physician, and family;-He/she would complete an incident report and do as the doctor orders. During an interview on 07/31/25, at 3:00 P.M., the Medical Director said the following:-He/she would expect the nursing home to call him/her with a med error;-He/she did not recall the incident with the resident, but may have heard about it;-If an emergency comes during the weekend or before/after business hours the staff will call the on-call and they give direction;-Since this incident happened around 6:30 A.M., the on-call would have handled it. He/she said the on-call does not follow up with him/her after they take a call from a facility. He/she expected the facility staff to update him/her with any continued problems with a resident. During interviews on 07/31/25, at 11:13 A.M. and 12:50 P.M., the Administrator said the following:-On the 7/28/25, during the morning pass, CMT D popped out another resident's medications between 6:30 A.M. and 7:00 A.M. He/she looked at the MAR and said the medications were signed off at 7:30 A.M. and administered shortly after that time;-CMT D said there were several residents around when the CMT prepared the other resident's medications, and he/she got distracted and administered the medication to Resident #1;-CMT D realized right after he/she administered them, what had happened. He/she went to RN F and told him/her what happened;-RN F got on the computer to determine what medications were administered to Resident #1 and called the on-call. He/she spoke to the NP on call and told him/her what medications had been administered to Resident #1;-The NP ordered the facility to complete vitals every hour for the first 12 hours and every two hours until 24 hours were completed;-The resident's blood pressure dropped so they called the Medical Director, and he told them to send the resident to the hospital;-He/she would expect staff to follow the policy when administering medications. They should be looking at the MAR to see what's ordered, pull out the cards or bottles of meds, ensure they match the orders, and there are not allergies to the medication, and administer the meds;-Each resident has a picture in the eMAR within 24 hours of admission;-He/she would expect the staff to call the resident by name and have the resident repeat their name back. If staff question who the resident is, and the resident is unable to tell them, he/she would expect the staff to ask another staff member the resident's name;-Five rights are right medication, right resident, right route, right frequency and right documentation;-If staff administer the incorrect medication, they should notify the charge nurse. The nurse will assess and notify the doctor, representative, DON, and him/her;-He/she would expect the staff to follow the doctor's direction;-In the situation with the resident, he/she was administered another resident's medications. CMT D realized this immediately and told RN F. RN F then gathered the necessary information and called the on-call to relay the medications that were administered. They may not always agree on the direction given, but they are to follow it;-On-call went ahead and told the staff to administer the resident's medications, with the exception of the acetaminophen;-The resident was monitored and as soon as his/her blood pressure got too low, they called the doctor and were told to send the resident out;-He/she believed the on call was told about the allergy Resident #1 has to Ativan. 2573755, 2574061, 2575228

Based on observation and record review, the facility failed to maintain a complete infection prevention and control program when staff failed to ensure Tuberculin Skin Tests (TST) were completed in accordance with the requirements for tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) testing for long-term care employees and per facility policy for three staff members (Director of Nursing (DON), Activity Director (AD), and Laundry E) of ten sampled staff members. The facility census was 36. Review of the facility's policy, titled Tuberculosis Control, undated, showed the following: -All employees will be screened for TB; -Once the decision has been made to employ an individual, the individual will be asked for documentation of a prior Purified Protein Derivative (PPD - a skin test to determine if someone has tuberculosis); -If the employee does not have documentation of a prior PPD, the first step PPD will be administered by the nursing department, documented on the Employee Immunization Record, and must be read prior to or no later than the start date; -If the employee has documented evidence of prior two-step PPD, the decision tree for employee accepts position will be followed; -Documented evidence of prior PPD will be maintained with the facility Employee Immunization Records; -If there is no documentation of prior two-step test, administer first step prior to employment; read results of first step two to three days after administration; -If negative results, administer second step within one to three weeks of employment; -If documentation of first step with negative results within past three weeks prior to employment, administer the second-step within one to three weeks; -Read results of second step test in two to three days after administration; -Negative results, do a one step test by anniversary date of last test and then annually. Review of the general requirements of 19 CSR 20.20.100 (3), TB testing for employees in Long Term Care Facilities, showed the following information: -Long-term care facilities shall screen their employees for TB using the Mantoux method (tool for screening for tuberculosis and for tuberculosis diagnosis) PPD two step tuberculin test within one month prior to starting employment; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status; -If the initial test is negative, the second test should be given as soon as possible within three weeks after employment begins unless documentation is provided indicating a Mantoux PPD test in the past and at least one (1) subsequent annual test within the past two years. 1. Review of the DON's personnel record showed the following information: -Hire/start date of 09/06/22; -An annual TB test from another facility, dated 08/10/22, showed a result of negative; -The facility did not have documentation of a second step test administered/read or documentation indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years 2. Review of the AD's personnel record showed the following information: -Hire/start dated of 02/06/23; -The facility did not have documentation of a step 1 or step 2 TB test administered. During an interview on 04/25/24, at 10:01 A.M., the Business Office Manager (BOM) said staff administered an annual TB test on the AD on 04/24/24, but was unable to locate any testing from his/her previous employer. 3. Review of Laundry E's personnel record showed the following information: -Hire/start date of 10/12/23; -The facility did not have documentation of step 1 or step 2 TB test administered. During an interview on 04/25/24, at 10:01 A.M., the BOM said there was not a test result located for Laundry E. 4. During an interview on 04/25/24, at 10:01 A.M., the BOM said when an employee is hired, any nurse can administer and read the TB testing required. The social worker is also the infection control nurse and she tracks the staff TB testing. The social worker was out of the office. 5. During an interview on 04/25/24, at 10:40 A.M., the DON said once an employee had been interviewed and hired, a TB skin test was administered. The TB test is read 48 to 72 hours after administered. The new staff is then told to report to a nurse in 10 days to receive the second step TB test. The social worker also tracked staff TB testing. 6. During an interview on 04/25/24, at 11:30 A.M., the Administrator said the TB test is done on hire and read on the day of orientation. The second step completed within a couple weeks. This should always be done with all new employees.

Based on observation, interview, and record review, the facility failed to document an assessment of risk versus benefits of side rail use for one resident (Resident #1) and failed to obtain informed consent for the use of side rails prior to installation; failed to address the use of side rails in the care plan; failed to obtain physician orders for the use of side rails; failed to obtain gap measurement for the risk of entrapment; and failed to complete ongoing assessments to ensure the side rails were secure and appropriate for the use of two residents (Resident #1 and #20). The facility census was 36. Review of the facility's policy titled Side Rail/Positioning Bar Protocol, undated, showed the following; -Before placing a Side Rail/Positioning Bar, read the following process to ensure the appropriateness and safety for the resident; -Physician/Director of Nursing/Therapy Department make side rail/positioning bar request to be placed on a specific resident bed. Since the side rail/positioning bar that is typically used for positioning, make sure to ask if the side rail/positioning bar being placed is left, right, or both; -Begin the Side Rail Assessment in the electronic medical record (EMR) and discuss the risks/benefits with the resident (if responsible party) or family/friend (if responsible party) and receive consent. If family/friend is the responsible party, then you may take a verbal consent over the phone, but the verbal must be noted within the additional information section of the observation; -Request for the Maintenance Director to place the side rail/positioning bar on the bed and maintenance will then measure to ensure the safety of the rail. If the measurements pass the safety requirements, the side rail will stay in place. If the side rail/positioning bar do not pass (fail) the safety requirements, then maintenance will remove the side rail. Maintenance Director will not place a side rail/positioning bar without consent being in place. If the measurements fail, then the nurse will need to notify the resident/family that the side rail/positioning bar cannot remain due to the measurements not meeting the safety requirements; -Once the observation is completed, the observation should be printed, and the resident/family will sign the consent line. Please give completed signature form to Medical Records to be uploaded into the resident's EMR; -A final nursing progress note summarizing the side rail observation, measurement, and consent was completed upon placing the left, right, or both side rail/positioning bar; -The side rail/positioning bar should never be placed except by the designee who is measuring for safety requirements. Side rails are never to be placed without measurements and consent. 1. Review of Resident # 1's face sheet (a document that gives a patient's information at a quick glance) showed the following; -admitted [DATE]; -Diagnoses included major depressive disorder, malignant neoplasm of esophagus (cancer of the esophagus), type two diabetes, and chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe). Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 02/09/24, showed the following; -The resident had moderate cognitive impairment; -The resident required substantial/maximal assistance from staff to roll left to right in the bed; -The resident required staff to do all of the effort for chair/bed-to chair transfer. Observations on 04/23/24, at 2:42 P.M., and on 04/24/24, at 8:45 A.M., 1:31 P.M., and 1:35 P.M., showed the resident laid in bed with half side rails on both sides of the bed in the upright position. Review of the resident's care plan, revised 02/14/24, showed the following: -Required extensive staff assist with activities of daily living (ADL - activities related to personal care) as he/she is not able to use his/her arms well with abnormality of left elbow; -He/She required two staff assist with Hoyer lift (mechanical lift used to transfer resident) transfers related to weakness and pain; -He/she needed two staff assist with dressing and bed mobility; -He/She needed one staff assist with personal hygiene and bathing. (Staff did not care plan related to the use of side rails.) Review of the resident's April 2024 Physician's Order Sheer (POS) showed staff did not obtained a physician's order for the use of side rails. Review of the resident's medical record showed staff did not document a side rail assessment, gap measurements, or informed consent for the resident's side rails. During an interview on 04/24/24, at 2:09 P.M., Certified Nursing Assistant (CNA) D said the resident had side rails because he/she used the bedside table drawers for positioning assist in the past, which was a risk for the resident. During an interview on 04/24/24, at 2:19 P.M., Licensed Practical Nurse (LPN) B said the resident had side rails because he/she requested them. The nurse did not know of any other reason for the side rails. The nurse looked in the resident's medical record and could not find the side rails addressed in the care plan and could not locate a bed rail assessment/consent for the resident. During an interview on 04/25/24, at 9:02 A.M., the Director of Nursing (DON) said the resident used side rails because the DON requested a u-shaped bar for mobility, however hospice ended up bringing and installing half side rails instead. The facility staff have not completed any follow up on the side rails. Upon review of the care plan, she did not find where staff addressed the use of side rails in the care plan. She could not locate a bed rail assessment/consent, or a physician's order for the side rails in the resident's medical record. He/she had spoken with the resident's family, but did not have any documentation of that. She did not know for sure when hospice installed the side rails. She requested the grab bars (u-shaped bar) because the resident had been reaching over and opening the drawer and grabbing the drawer to pull his/her self over in bed and it was not safe. The DON looked at communication to hospice and said she requested the grab bars on 02/16/24. 2. Review of Resident # 20's face sheet showed the following; -admitted [DATE]; -Diagnoses include malignant neoplasm of rectosigmoid junction (a cancerous tumor involving the rectum and colon), chronic kidney disease (disease of the kidneys leading to kidney failure), type two diabetes, and high blood pressure. Review of the resident's bed rail assessment, dated 02/08/24, showed staff started the assessment and completed the portion of the assessment that addressed the risks/benefits of the side rails. Staff did not document gap measurements of the side rails or informed consent for the side rails. The assessment status showed in progress. Review of the resident's annual MDS, dated [DATE], showed the following; -The resident had severe cognitive impairment; -The resident required substantial/maximal assistance from staff to roll left and right; -Total dependence on staff to move from sitting to lying, and for transfers. Observations showed the following: -On 04/22/24, at 3:23 P.M., the resident laid in the bed with half side rails on both sides of the bed, in an upright position; -On 04/23/24, at 9:38 A.M. and 2:44 P.M., the resident laid in the bed with half side rails on both sides of the bed, in an upright position; -On 04/24/24, at 8:46 A.M., 9:17 A.M., 9:27 A.M., 11:07 A.M., and 1:32 P.M., showed the resident laid in the bed with half side rails on both sides of the bed, in an upright position. Review of the resident's care plan, revised 02/21/24, showed the following; -The resident required extensive staff assist of two with ADL cares; -Required two staff assist with dressing and personal hygiene; -Required two-person transfer with the use of a sit to stand lift (a mechanical device with an upper body sling used for lifting the resident to a standing position). (Staff did not address the use of side rails in the care plan.) Review of the resident's April 2024 POS showed staff did not obtain an order for the use of side rails. Review of the resident's medical record showed staff did not document gap measurements for the side rails or informed consent for the resident's side rails. During an interview on 04/24/24, at 2:09 P.M., CNA D said the resident used to be a bad fall risk, sometimes he/she would sit on the edge of the bed. He/she no longer does that, since installing the side rails on the bed. During an interview on 04/24/24, at 2:19 P.M., LPN B said the resident has side rails because he/she requested them, and he/she tends to fall out of bed. During an interview on 04/25/24, at 9:02 A.M., the DON said the resident uses side rails because hospice sent them and set them up. By the time they were on the bed; family requested the side rails to stay in place. She could not find anything side rail related in the care plan. The resident also does not have a physician's order for the side rails. She completed some of the bed rail assessment. She did not include the type of rail, measurements, or consent. He/she has spoken with the resident's family, but does not have any documentation of that. 3. During an interview on 04/24/24, at 1:56 P.M., CNA C said some residents have side rails. To have side rails they must have a physician's order and it is to help the resident with mobility. Residents are not allowed to have full or half side rails without the physician's order. He/She knows if a resident has side rails by looking in the care plan that's found within their charting system on the computer. If side rails are not shown in the care plan, he/she would ask the nurse to update it. If he/she came across a resident he/she thought would benefit from side rails, he/she would address it with the charge nurse and therapy department to see if they could further evaluate the need for them. The charge nurse would then go to the DON to get the physician's order. He/She is unsure if they are supposed to complete an assessment. 4. During an interview on 04/24/24, at 2:09 P.M., CNA D said residents require a physician's order for side rails. If he/she saw a resident that could benefit from side rails, the aide would tell his/her charge nurse. The charge nurse would then tell the DON and they go from there but it's up to the physician at the end of the day. He/She could find out if a resident has side rails by looking in the care plan or the resident's medical record. If he/she could not find the side rail information, he/she would go to the Assistant Director of Nursing (ADON) for direction. 5. During an interview on 04/24/24, at 2:19 P.M., LPN B said if a resident required side rails the charge nurse would fill out a bed rail assessment and consent form within the observations tab on the facility computer charting system. This should be completed on admission. He/She would also fill out this assessment any given time, if he/she saw a resident that would benefit, or the resident requested side rails. The assessment includes a measurements section that the Maintenance Director is supposed to complete while placing the side rails. The Maintenance Director makes sure the side rails are safe, then nursing staff inspects them. The assessment also includes the informed consent for the side rails. The assessment is usually filled out on admission, when the need arises, and is reviewed quarterly. When a staff member suggests a resident may benefit, the facility touches base with the physician through their physician book (a book that the physician checks when onsite). The side rails must be for positioning and not for restraint use. The facility would not necessarily need to obtain a physician order, but the facility would confer with the physician. Once a resident has side rails, that information can be found/heard in report, the care plan, and should be documented within the weekly and monthly assessment notes. 6. During interviews on 04/25/24, at 8:51 A.M. and 11:21 A.M., the Maintenance Supervisor said the staff report to him that a resident needs side rails. He obtains the side rails from the shed and installs them. Sometimes the DON will give him a paper form and he will do the measurements on that form. If he doesn't do the measurements, the DON does it. The form he fills out is kept and stored by the DON. He follows up on the side rail installation the next day, as well as obtains weekly measurements. If the measurements differ from the original ones, he will again document on that same form the current measurements. The DON has the original form that he fills out for the side rail measurements. He said that form should include the installation measurements as well has the weekly measurements. When he does the weekly checks, he makes sure the side rails are tight enough, the rails are spaced safely, and any gaps are appropriate. He said he used to do the measurements all the time, but within the last six months, the DON has taken over. Any side rails gap measurements from the last six months would be from the DON. During that time, he has just performed safety checks, such as making sure they aren't loose and work properly. 7. During an interview on 04/25/24, at 9:02 A.M., the DON said gap measurements for side rails are documented under observations in the facility computer charting system. She does not keep a paper record, It's all electronic. The form is called a Bed Rail Assessment and Consent. If a resident needs side rails, it's typically for mobility issues. Facility staff first would complete the Bed Rail Assessment and Consent Form/Contact Family. Staff would let the family and the resident know the risks/benefits for the side rails, obtain consent for the side rails, and then contact the physician for an order. Measurements are requested from maintenance, as he is the one who installs the side rails. Hospice companies may also install bed rails using their equipment company. The maintenance supervisor does the measurements regardless of who installs the side rails. If the maintenance supervisor was not able to complete the measurements, the DON would. Observations, measurements, and consent are all located within the bed rail assessment form. She is unsure if there is follow up or timely reviews after the installation of the side rails. She assumes there would need to be a review if the mattress changed. If remeasurements were needed, there is no additional space on the assessment form to enter those, she would probably document that in a nurses note. Staff is aware of side rail use by looking in the care plan. 8. During an interview on 04/25/24, at 11:46 A.M., the Administrator said that if a resident needed side rails, the facility would first need to make sure they are going to use it for mobility. They cannot use them as a restraint. Families of the residents often requests side rails to prevent falls, but the facility is aware they cannot do that. She expects staff to get measurements, informed consent, and a physician's order for the side rails. She also expects side rail use to be addressed in the care plan. The maintenance supervisor and/or DON obtain the gap measurements. He/she expects side rails to be reviewed quarterly and as needed.

Based on observation, record review, and interview, the facility failed to provide respiratory care consistent with standards of practice when staff failed to obtain physician orders for and care plan the use of a continuous positive airway pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open while a person sleeps) machine for one resident (Resident #140). Two residents were reviewed for use of oxygen in a facility with a census of 36. Review of a facility policy titled Continuous Pressure Airway Pressure (CPAP) Administration, undated, showed the following: -Purpose to administer continuous positive airway pressure to maintain open airway to the resident with obstructive sleep apnea (breathing repeatedly stops and starts) or respiratory problems breathing when sleeping. -Contact quality assurance (QA) nurse prior to placement for clarification of orders and support; -Check physician's order for pressure setting and method of administration; -CPAP machine should be placed on table near bed; -Fill humidifier with distilled (may use tap) water to appropriate level; -Assist resident as needed with applying and adjusting CPAP mask and head strap. 1. Review of Resident #140's face sheet (give basic profile information) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with acute exacerbation, heart failure, shortness of breath, obstructive sleep apnea, and hypoxemia (abnormally low concentration of oxygen in the blood). Review of the resident's nurse's note, dated 04/11/24, showed the following: -Oxygen worn at all times at two liter per nasal cannula; -CPAP at night. Review of the resident's entry tracking Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 04/11/24, showed no indication of CPAP usage. Review of the resident's physician order sheet (POS), current as of 04/24/24, showed no order for the use of a CPAP machine. Review of the resident's care plan, last updated 04/24/24, showed staff did not document information pertaining to the use of a CPAP machine. Observation on 04/24/24, at 9:20 A.M., showed a CPAP machine on the resident's night stand. During an interview on 04/24/24, at 9:25 A.M., the resident said he/she was supposed to use the CPAP machine at night while sleeping. The resident said sometimes he/she intends to use the machine, but he/she falls asleep before donning the mask and turning on the machine. During an interview on 04/24/24, at 9:45 A.M., Certified Nurse Aide (CNA) A said he/she knew the resident used the CPAP at least sometimes at night. The CNA has turned off the machine in the morning and switched the tubing back over to the oxygen concentrator. During an interview on 04/25/24, at 12:44 P.M., Licensed Practical Nurse (LPN) B said physician orders should be entered per hospital discharge orders or the nurse should call the physician to clarify or get orders. Admission order entry is done by either social services or the admitting nurse. The use of a CPAP machine should have a physician order. The nurse should call to get the physician order if it is not on the hospital discharge orders or in the narrative. LPN B said the resident did have a CPAP, but could not locate an order for its use. The CPAP should also be included on the care plan and information given to the aides during shift report for a new resident or to a new staff person. During an interview on 04/25/24, at 12:52 P.M., the Director of Nursing (DON) said the admitting nurse/staff should get CPAP orders from the physician when they call with admit orders for approval. The DON could not locate an order for the resident's CPAP. The DON said the CPAP use should also be on the care plan. During an interview with the Administrator, DON, and QA Nurse on 04/25/24, at 3:15 P.M., the QA Nurse said a CPAP should have a physician order, be listed on MDS, and be included in the care plan.

Based on observation, interview, and record review, the facility failed to provide pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care consistent with professional standards of practice when staff failed to document a complete assessment of a new pressure ulcer and failed to update the care plan timely regarding the skin breakdown and intervention changes for one resident (Resident #20). The facility census was 36. Review of the facility policy, Wound Champion Program, undated, showed the following: -All residents will have a head-to-toe skin assessment completed by the licensed nurse every seven days. The weekly skin assessment should be documented via the electronic medical record's weekly skin assessment. If wounds are identified during the assessment, the nurse must obtain an order for treatment and notify the wound champion; -Always complete weekly skin assessments as scheduled and always report any new skin concerns to the wound champion. Notify the family and the physician of any new wounds, obtain treatment orders, and document accordingly; -When wounds are identified, each wound assessment (location, measurements, odor, exudate, etc.) should be documented in the electronic medical record by wound management. By using this feature, staff can monitor and track healing over time; -Each community is to have a wound champion who will collaborate with the licensed nurses and the Director of Nursing (DON). The wound champion will monitor the progress of each wound weekly and recommend treatment and treatment changes when applicable; -The care plan should reflect the current status of the wound with appropriate goals and approaches. 1. Review of Resident #20's face sheet (document that gives resident information at a glance) showed the following information: -admitted [DATE]; -Diagnoses included malignant neoplasm of rectosigmoid junction (a cancerous tumor of the rectum and colon), chronic kidney disease (a disease of the kidneys leading to kidney failure), type two diabetes, pressure ulcer of sacral (located below the lumbar spine and above the tailbone) region, unspecified stage, and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in the body's composition and function). Review of the resident's Braden Sale Assessment (tool completed by facility staff to identify patients at risk for pressure ulcers), last revised on 02/07/24, showed the following information: -Resident assessed as mild risk for pressure ulcer development; -Staff did not indicate any interventions and indicated continue current plan of care. Review of the resident's care plan, revised on 02/19/24, showed the following information; -Previous history of skin breakdown to his/her bottom; -Remains at risk for breakdown related to poor nutrition and spending a lot of time in bed/wheelchair; -Ensure he/she has pressure relieving devices to his/her bed and wheelchair; -Monitor skin during activities of daily living cares and baths for signs and symptoms of skin breakdown such as redness, open areas, or blisters; -Assist to the restroom before and after meals, every two hours at night, and as needed. Assist with changing and peri-care after each incontinent episode. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/26/24, showed the following information: -At risk for developing pressure ulcers; -No unhealed pressure ulcers; -Had pressure reducing devices for bed and chair; -Turning and repositioning program; -Applications of ointments/medications other than to feet. Review of the resident's weekly skin assessment, dated 04/20/24, showed the following information; -Existing non-foot skin issue; -Soft heels; -Resident has pressure reducing devices for bed and chair; -Treatment in place, effective. Review of the resident's progress note, dated 04/20/24, showed redness and open area noted to the resident's bottom with calazime (skin protectant ointment used for temporary relief from skin irritations) applied with rounding. (Staff did not document the exact location of the wound, measurements, an assessment of the wound bed, peri-wound (area around the wound bed), exudate (drainage), pain, or approximation of the wound (how well the edges of the wound are closed). Staff did not document notification of the family, physician, or DON of the wound.) Review of the resident's current Physician Order Sheet (POS), showed the following; -An order, dated 04/21/24, for staff to cleanse gluteal fold (horizontal crease that forms below the buttocks, separating the upper thigh from the buttocks)/coccyx (tailbone) with wound cleanser, apply skin prep (wipe that forms barrier between the resident's skin and adhesives to help preserve skin integrity) to peri wound, and cover with calazime (skin protectant with zinc oxide that helps to treat and prevent diaper rash and minor skin irritations) two times a day and as needed. Review of the resident's Wound Management tab, located within the facility's electronic charting system, showed staff did not enter documentation of the resident having a current pressure ulcer. Observation and interview on 04/24/24, 11:07 A.M., showed Certified Nursing Assistant (CNA) D and CNA A entered Resident #20's room to perform incontinence care and get the resident up for lunch. CNA A said there is a current open area to the resident's buttocks. The resident had a superficial, crater-like open area on the resident's coccyx (tailbone) with a beefy red wound bed with additional pencil tip openings observed on both sides of the resident's buttocks, CNA A said the resident has diarrhea a lot and the wound information should be in the chart. Review of the resident's care plan, on 04/25/24, showed staff did not update the care plan with the open area documented in the 04/20/24 weekly progress note. Staff did not document new interventions related to the open area. During an interview on 04/25/24, at 10:57 A.M., Certified Nurse Aide (CNA) A said the resident had an open area on his/her coccyx. The area had been there within this past month. Initially, the resident's skin wasn't this bad, but he/she has problems with his/her bowels, and it has affected his/her skin more this month. Staff would report any new open areas to their charge nurse, the charge nurse would then come and assess the area and give the aides direction from there. During an interview on 04/25/24, at 11:05 A.M., Licensed Practical Nurse (LPN) B said the resident does have an open area that is raw and excoriated. The current treatment is calazime every shift. He/she thought the wound had been there about a week. If an open area was reported to him/her, he/she would go assess the wound and then let the DON know. From there, the two of them would come up with a treatment plan, call the physician and report the wound measurements, assessment of the wound such as if the area is blanchable, bleeding, pain, exudate, and discuss interventions for pressure reduction. The nurse would then document all of that in a progress note, as well as the wound management tab in the electronic medical record. The DON completes the weekly skin assessments. During an interview on 04/25/24, at 9:02 A.M., the DON said the resident has a small shearing open area on his/her bottom that opened at the end of last week. The facility initially does calamine cream treatment. If within a week, the area does not looking better; then, he/she will start measurements, and upgrade treatment. He/she does not have any measurements of the resident's open area documented. The DON said she should probably measure at that moment of an area opening up, but if it's superficial, the facility staff provide treatment of calazime cream for a week then upgrade treatment and measure it at that time. Staff found the open area on the resident's gluteal fold/coccyx, on 04/21/24. He/she likes to see the wounds once a week, and said they get a wound management company on board for pressure related wounds. Assessment of a new open area should be documented in the progress notes. The note should include an initial measurement, and describe the wound with things like; color of the wound bed, exudate, peri wound area, documentation of notification to physician, family, and DON, wound edges, treatment put into place etc. Facility staff do not document the stage of the wound, that is up to the physician or the wound management company. During an interview on 04/25/24, at 11:57 A.M., the Administrator said if staff found an open area on skin, they cannot stage it. They should make the physician aware and get an order to treat. They should document an assessment that includes the size, category, and anything they can describe about it. They also should be measuring/tracking the pressure ulcers weekly. Staff should document in the progress notes and should also make others aware at a weekly resident assessment review meeting. Skin assessments and shower sheets should be looked at during those times as well. The DON completes the weekly wound assessments. The nurses measure the wounds. The physician or wound management company documents the stages of the wounds.

Based on record review and interview, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) level one was retained in the resident's medical record and accessible for one resident (Resident #26) of three residents reviewed for PASARR. The facility census was 36. Review showed the facility did not provide a policy regarding PASARR requirements. 1. Review of Resident #26's face sheet (provides basic profile information) showed the following: -admitted [DATE]; -Diagnoses included schizophrenia (mental disorder affecting ability to think, feel, and behave clearly), anxiety disorder, psychotic disorder with delusions (firmly held false beliefs) due to known physiological condition, and encephalopathy (brain disease that alters brain function or structure). Review of the resident's care plan, last updated 04/15/24, showed the following information: -On 09/07/22, staff care planned a history of hollering out and cursing and talking to the voices in his/her head. Resident often speaks of being raped and fighting the demons; -On 01/19/23, staff care planned the resident had experienced trauma and may need assistance to address the physical, behavioral, and or social impacts of the trauma. The resident had developed fear, terror, dread or helplessness following exposure to a traumatic event (sexual assault, war, natural disaster, abuse or violence). Review of a print out of the resident's electronic submission entitled Level One Nursing Facility Pre-Admission Screening for Mental Illness (MI), Intellectual Disability (ID), or Related Condition, dated 12/31/22, showed the following: -Signs or symptoms of a major mental illness: Yes. Resident will yell at evil Spirits who are raping him/her. Psychotic disorder, anxiety disorder, and delusional disorder; -Area of impairment due to serious mental illness: Yes. Serious difficulty interacting appropriately and communicating effectively with other persons, has a possible history of altercations, evictions, unstable employment, fear of strangers, and avoidance of interpersonal relationship and social isolation; -Individual has experienced one psychiatric treatment episode that was more intensive than routine follow-up care and/or due to mental illness, experienced at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning: Yes (option not designated/unchecked); -Suspected diagnosis or history of Intellectual Disability/Related Condition: Head Injury/Traumatic Brain Injury (TBI); likely to continue indefinitely; -Results in substantial functional limitation in three or more major life activities: capacity for independent living, self-care,and mobility; -Physician's Authorization and Signature: (left blank); -Diagnoses relevant to Applicant's Functional and/or Skilled Nursing needs: anxiety disorder, psychotic disorder with delusions, psychosis, traumatic subdural (brain injury) with loss of consciousness, hyperglycemia (high blood sugar), osteomyelitis (inflammation or swelling of bone tissue usually the result of an infection), encephalopathy (brain disease), and chronic obstructive pulmonary disease (COPD - breathing disorder); -Behavioral: 6 points = Unstable mental condition monitored by a physician or licensed mental health professional at least monthly or behavior symptoms are currently exhibited OR psychiatric conditions are recently exhibited; -Level of Care Determination by DRL (Division of Regulation and Licensure) Central Office Medical Review Unit (COMRU): Submission incomplete (no determination on level of care by COMRU). Review of the resident's record showed no additional DA-124 (screening form) or Level 1 forms. Review of an email between the facility and Missouri COMRU showed the following: -The Administrator made inquiry on 04/25/24 regarding whether or not there was an approved DA-124 for the resident; -COMRU responded the resident had a Level 2 on record; however, it was more than a year old so a new application would need to be submitted if the facility did not have copies from 2023. During an interview on 04/25/24, at 10:01 A.M., the Business Office Manager (BOM) said he/she had been the previous social worker and the process at that time for DA-124 was that he/she would start the form with the resident identifying information and then give the form to the Director of Nursing (DON) to complete the medical information. The form was then sent into the state's COMRU. He/she did not know the current process for the DA-124's. During an interview on 04/25/24, at 10:40 A.M., the DON said he/she did not have any knowledge of DA-124's or Level 2's. She said the current social worker was responsible for the process. The social worker was out the facility and unavailable for interview. During an interview on 04/25/24, at 11:00 A.M., Licensed Practical Nurse (LPN) B said that the social worker was responsible for the PASARR process. During an interview on 04/25/24, at 1:30 P.M., the Administrator said the social worker was responsible for submitting the DA-124. The facility did not have an available record showing submission, completion, and level of care determination for the resident.

Based on interview and record review, the facility failed to notify and coordinate with the State-designated authority following newly evident or possible serious mental illness for one resident (Resident #7) who had a temporary approved level two Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long-term care. The PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability and be offered the most appropriate integrated setting for their needs (in the community, a nursing facility, or acute care setting) and receive the services they need in those settings). The facility census was 36. Review showed the facility did not provide a policy regarding PASARR requirements. 1. Review of Resident #7's face sheet (a brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), intellectual disabilities ( limits to a person's ability to learn at an expected level and function in daily life), and anxiety disorder. Review of the resident's Level 1 PASARR, dated 12/15/20, showed the following information: -Does not show any signs of symptoms of major mental disorder; -Had not been diagnosed as having a major mental disorder; -Primary reason for nursing facility placement not due to dementia; -Had a serious problem in levels of functioning in the last six months; -Severe developmental disorder with cognitive delay; -Suspected to have a related condition; -Rule out autism; -Did not qualify for a special admission category. Review of the resident's PASARR evaluation report, dated 12/23/20, showed the following: -The individual's needs could be met in a nursing facility at this time; -Short term nursing facility level of service with transition to community, consider group home; -Resident had been placed at the nursing facility due to the urgency of his/her condition and living situation. Resident required 24-hour per day supervision due to apparent developmental disability and reported IQ of 50 (moderate range). Resident was unable to make decisions for self, due to intellectual disability. He/she required 24 hours supervision to assure basic needs were met and that he/she was safe. He/she required meal preparation and set up to promote adequate nutrition. He/she required nursing staff to daily evaluate stoma status, to reapply stoma bags several times per day. He/she would benefit from ongoing education regarding the need for stoma bag to remain in place and the benefits of doing so, such as increased activity options. Resident would benefit from nursing facility placement to allow for social interaction to develop friendships; -Guardian had indicated plan to initiate referral for disability services to enable to him/her to live in less restricted level of care in the future, if possible. Nursing facility social services to coordinate the discharge plan with the individual's targeted case manager and regional office community living coordinator to facility the individual's return to the community living situation (with the necessary community supports); -Date processed 12/31/20; -Determination: Yes, resident had Intellectual Disability (ID); -Resident did not need specialty developmental disability services; -The resident did need nursing facility level services; -Recommend for short term nursing facility stay; -Review date 04/30/21; -New DA-124 needed (screening form). Review of resident's Conditional Temporary Approval letter, dated 01/04/21, from Department of Health and Senior Services (DHSS), addressed to the facility administrator, noted the following: -Resident had been referred for a Level II screening for admission into long-term care facility; -After review, the Department of Mental Health (DMH) had determined that the applicant had met the federal definition of Intellectual Disability/Related Condition (ID/RC), but does not require specialized services. Please incorporate the lesser intensity services into the resident's care plan; -Temporarily approved for skilled nursing facility placement from 12/09/20 to 04/30/21 only; -admitted nursing facility must submit new DA-124 forms on 04/15/21. Review of the resident's record showed no additional DA-124 or level 1 forms. During an interview on 04/25/24, at 10:01 A.M., the Business Office Manager (BOM) said he/she had been the previous social worker and the process at that time for DA-124 was that he/she would start the form with the resident identifying information and then give the form to the Director of Nursing (DON) to complete the medical information. The form was then sent in to the states Central Office Medical Review Unit (COMRU). He/she did not know the current process for the DA-124's. During an interview on 04/25/24, at 10:40 A.M., the DON said he/she did not have any knowledge of DA-124 or Level 2. The current social worker was responsible for the process. The social worker was out the facility. During an interview on 04/25/24, at 11:00 A.M., Licensed Practical Nurse (LPN) B said that the social worker was responsible for the PASARR process. During an interview on 04/25/24, at 11:30 A.M., the Administrator said that the DA-124 should be done by the social worker, he/she was also a nurse, and it should be started within 24 to 48 hours. The form was then sent to the Medical Director for signature, if it had not previously been signed by a doctor from the hospital. It was then sent to COMRU. Staff should monitor for return of the level 1 and/or level 2. The Administrator was not at the facility when the resident was admitted . He/she was unsure if the person reading form just did not read that it was only a temporary approval. He/she talked to COMRU on 04/24/24 and the DA-124 would be completed as a new admission.

Based on record review and interview, the facility failed to ensure Minimum Data Sets (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) were accurate when staff failed to address one resident's (Resident #7) ostomy (a surgical opening through the abdomen to form an artificial anal opening) on the resident's MDS. The facility census was 36. Review showed the facility did not provide a policy regarding MDS documentation. 1. Review of Resident #7's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included colostomy status (surgery to create an opening for the colon (large intestine) through the belly). Review of the resident's physician order sheet (POS), current as of 04/25/24, showed an order, dated 04/17/22, for colostomy care every shift. Review of the resident's quarterly MDS, dated [DATE], showed staff documented ostomy under the bladder and bowel appliance care area. Review of the resident's quarterly MDS, dated [DATE], showed staff documented none of the above under the bladder and bowel appliance care area. Review of the resident's annual MDS, dated [DATE], showed staff documented none of the above under the bladder and bowel appliance care area. Review of the resident's quarterly MDS, dated [DATE], showed staff documented none of the above under the bladder and bowel appliance care area. Review of the resident's care plan, last reviewed on 03/25/24, showed the following: -Resident had a colostomy that he/she will remove at times; -Staff should monitor frequently to ensure colostomy was intact and empty as needed; -Resident will turn on call light at times and ask for his/her colostomy to be emptied; -Staff should monitor frequently. Observation on 04/24/24, at 10:00 A.M., showed the resident resting in bed with an ostomy visible on the right side of abdomen. During an interview on 04/25/24, at 10:40 A.M., the Director of Nursing (DON) said an ostomy appliance should be on the MDS for the resident. The MDS Coordinator was currently unavailable. During an interview on 04/25/24, at 11:00 A.M., Licensed Practical Nurse (LPN) B said that nursing staff notify the MDS coordinator and the DON of care plan and MDS input. Staff should work as a team. Ostomy appliance should be marked on the MDS for the resident. During an interview on 04/25/24, at 11:30 A.M., the Administrator said an ostomy should be on MDS. Any appliance or care area applicable to any resident should be on the MDS. The MDS should be accurate. The MDS Coordinator completed MDS assessments from nurse charting, as well as worked with the residents and interviewed staff. The MDS Coordinator was unavailable.

Based on interview and record review, the facility failed to maintain proof of the completed Nurse Aide (NA) Registry check for one newly hired staff to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility. The facility census was 48. Record review of the facility's protocol titled How to Hire an Employee, undated, showed the following: -The NA Registry is to be run and printed on all employees, before orientation; -This needs ran prior to the employees start (hire) date and a hard copy of the results put in the employee file. 1. Record review of the Director of Nursing (DON)'s personnel file showed the following: -Date of hire of 4/4/22; -The facility did not maintain a copy of DON's NA registry check. During an interview on 6/03/22, at 1:42 P.M., the Business Office Manager (BOM) said the following: -He/she completed NA registry checks on all newly hired employees; -He/she completed a NA registry check on the DON, but could not find the document confirming the check. During an interview of on 6/3/22, at 2:59 P.M., the Administrator said the following: -He/she expected the BOM to complete NA registry checks on all newly hired staff; -The BOM should maintain proof of the NA registry checks in the employee file.

Based on observation, interview, and record review the facility failed to provide the correct amount of an entrée to six residents on a puree or liquid puree diet. The facility census was 48. Record review of the facility's policy titled Menu's, dated 05/15, showed menus shall meet the nutritional needs of the resident in accordance with the attending physician's orders and the Recommended Dietary Allowances. 1. Record review of a board in the kitchen showed five residents on puree diets and one resident on liquid puree diet. Record review of the facility's Diet Spreadsheet for Spring/Summer 2022 showed the following: -Cheese ravioli and marinara, two #8 scoops (3.7 ounces (oz.)) for puree diet. Observation on 6/2/22, beginning at at 10:25 A.M., showed the following: -Cook A placed a #12 scoop (2.3 oz.) by the puree cheese ravioli and marinara on the steam table; -The Registered Dietician (RD) pointed out the wrong scoop size and the cook said nursing told the kitchen staff the amount of puree was overwhelming so they used a #12 scoop. The RD informed the cook they did not have a physician's order for smaller portions and to use the #8 scoop that the recipe called for; -The cook used a #10 scoop (2.75 oz. or .4 cup) to serve cheese ravioli and marinara for the five puree and one liquid puree scoop during the noon meal service. During an interview on 6/2/22, at 12:23 P.M., Cook A said the following: -He/she knew the scoop size to use by looking at the recipe or diet spreadsheet; -He/she should use the scoop size the recipe or diet spreadsheet called for; -He/she used the #10 scoop on the cheese ravioli and marinara, but should have used the #8. He/she did not give the correct serving size for the puree diets. During an interview on 6/2/22, at 1:42 P.M., the RD said the following: -The cooks found the correct scoop size in the recipe or the diet spreadsheet; -The cooks should use the correct scoop size during meal service; -If the recipe called for a #8 scoop, the cook should not use a #10 scoop; -The scoop size in the recipe provided adequate nutrition. During an interview on 6/3/22, at 10:04 P.M., Cook B said the following: -He/she knew the scoop size to use by looking at the diet spreadsheet. It told the scoop size used for each diet; -He/she followed the diet spreadsheet for scoop size during meal service; -It was important to follow the spreadsheet for scoop size to give the resident's the correct portions and nutrition. During an interview on 6/3/22, at 1:10 P.M., the Dietary Manager said the following: -The cooks found the scoop size to use in the diet spreadsheet and they should follow this; -They needed an order to give smaller portions; -If the diet spreadsheet called for a #8 scoop, the cook should not use a #10 scoop because would be a smaller portion and could cause weight loss; -Nursing staff told him/her the amount of puree served was overwhelming so he/she told the cooks to use a smaller scoop size; -He/she did not know at the time they needed a physician's order for smaller portions. During an interview on 6/3/21, at 2:41 P.M., the Administrator said the following: -The cooks should follow the portion size the menus dictate; -If a resident did not want a big portion, they should accommodate this; -Nursing should not tell the kitchen to use a smaller portion unless they obtained a physician's order; -It was important for the cooks to follow the correct portion size for adequate nutrition; -If the RD pointed out the cook had the wrong scoop size, the cook should use the scoop size they told the cook to use.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a manner to protect it from potential contamination when staff failed to have a light fixture repaired that contained insects in it above a food preparation area and when staff failed to properly wash hands before and after gloving and touching food. The facility's census was 48. 1. Record review of the facility's policy titled Cleaning Schedules, dated 05/2015, showed the following: -It is the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; -Daily, weekly, and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning tasks listed will be posted in the Dietary Department: Specify the day(s) the cleaning schedule will be done; specify who is responsible to do the cleaning by shift and position; post the schedule prior to the beginning of each week; and the employee will initial in the column under the day the task is completed. Record review of the facility's policy titled Developing Cleaning Schedules, dated 05/2015, showed the following: -Purpose to develop detailed cleaning schedules to ensure sanitation is at acceptable standards; -Follow the steps below when creating cleaning schedules. Cleaning schedule forms on the next pages may be used, or standardized schedules may be used or adapted if desired; -Divide department into areas: prep area, dish room area, storage area, etc.; -List all equipment (small and large) within each area; -List all items to be cleaned within each area: walls, floors, vents, etc.; -Determine how frequently each area or item will need to be cleaned: after each use, per shift, daily, weekly or monthly; -Determine time frames needed for different cleaning assignments; -Specify who is to complete the cleaning task by listing the position next to each item or area to be cleaned; -The employee responsible for performing the task is responsible for initialing the cleaning schedule on the day the task is completed; -Cleaning schedules should be kept on file for one year. Record review of the facility's Daily Cleaning Schedule showed it did not address light fixtures. Observations on 6/2/22, at 10:19 A.M., showed the cover to a light fixture over a food prep area hung down approximately one inch on one corner and contained approximately 15 small, dark colored insects that appeared to be dead. During an interview on 6/2/22, at 1:42 P.M., the Registered Dietician said the following: -Light fixtures in the kitchen should be intact and clean; -If the dietary staff saw a broken fixture, they told maintenance; -A cover to a light fixture in a food prep area should not be broken and should not contain small black bugs. Observation on 6/3/22, at 10:12 A.M., showed the cover to a light fixture over a food prep area with black tape connected to the cover but not to the fixture, hung down approximately one inch. During an interview on 6/3/22, at 1:10 P.M., the Dietary Manager said the following: -If a light fixture in the kitchen broken, he/she told maintenance; -If a cover to a light fixture contained bugs, kitchen staff cleaned it. He/she took the covers off the light fixtures and cleaned them from time to time. He/she cleaned the bugs out of the light fixture this morning and taped the cover shut and told maintenance it needed repaired; -He/she should not have taped the cover to the light fixture because the tape could come off and fall in the food. During an interview on 6/3/22, at 2:41 P.M., the Administrator said the following: -The cover to the light fixture in the kitchen over a food prep area should not be broken or contain small black bugs and kitchen staff should not attempt to repair the cover with tape. If a light fixture contained bugs in the food prep area, they could get in the food. If the cover to the light fixture broke, pieces of it could get in the food and if repaired with tape, the tape could come loose and get in the food. 2. Record review of the facility's policy titled Handwashing, dated 05/15, showed the following: -If using gloves, remove gloves; -Roll down paper towels (some facilities may have self-dispensing paper towels); -Turn on water and run until warm; -Wet hands and forearms with warm water; -Lather hands with antiseptic soap; -Wash hands, giving particular attention to there areas between fingers, around cuticles, and under fingernails; -Wash forearms as well; -Rinse thoroughly with warm water, beginning at the top of the forearm; -Wipe hands dry with paper towel and dispose of paper towel. Record review of the Missouri Food code for the Food Establishments of the State of Missouri, dated 6/3/13, showed the following: -Food employees shall clean their hands and exposed portions of their arms as specified immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; when switching between working with raw food and working with ready-to-eat food; before donning gloves for working with food; and after engaging in other activities that contaminate the hands. Observations on 6/2/22, beginning at 10:25 A.M., showed the following: -Cook A donned gloves and obtained two frozen hamburger patties and placed them in a frying pan. He/she then doffed the gloves. He/she did not perform hand hygiene prior to donning or after doffing the gloves; -The cook donned gloves and obtained two frozen chicken strips and placed them in a pan of oil. He/she doffed the gloves. He/she did not perform hand hygiene prior to donning or after doffing the gloves; -The cook donned gloves and obtained a hot dog and placed it in a pan of water. He/she doffed the gloves. He/she did not perform hand hygiene prior to donning or after doffing the gloves; -The cook donned gloves and obtained frozen French fries and placed them in the pan of oil and then doffed the gloves. He/she did not perform hand hygiene before or after gloving; -The cook donned gloves and obtained a hamburger bun and a slice of cheese. He/she placed the hamburger bun on a plate and the slice of cheese on the hamburger then doffed the gloves. He/she did not perform hand hygiene before or after gloving. During an interview on 6/2/22, at 12:23 P.M., Cook A said the following: -He/she washed his/her hands anytime he/she put gloves on and took gloves off, between tasks and if they become soiled. During an interview on 6/2/22, at 1:42 P.M., the Registered Dietician said the following: -Kitchen staff should wash hands when contaminated, after touching their face, after eating, after smoking, after unloading dirty end of the dish machine and before and after gloving. During an interview on 6/3/22, at 1:10 P.M., the Dietary Manager said the following: -Kitchen staff washed their hands anytime they touched self, picked something off the floor, after served a tray and before and after gloving; -He/she expected the kitchen staff to wash hands before and after gloving to prevent cross contamination. During an interview on 6/3/22, at 2:41 P.M., the Administrator said the following: -Staff should wash hands anytime they handled food, opened a refrigerator, anytime soiled and after they took of their gloves. They should wash in between changing gloves to prevent cross contamination. The kitchen staff should not be wearing gloves.

Based on record review and interview, the facility failed to maintain documentation of maintaining a functioned Quality Assessment and Assurance (QAA) Committee that met at least quarterly with the required members. The facility census was 48. 1. Record review of the facility's QAA/QAPI (Quality Assurance/Performance Improvement) Manual, showed the following: -Staff did not document the dates the QAA/QAPI committee met; -Staff did not document how many members attended the meetings; -Staff documented monthly concerns discussed, but did not document discussion plans to address the concerns discussed. During an interview on 06/03/22, at 1:54 P.M., the Administrator said the following: -She does not have a sign in sheet to show of who attended the QAA meetings; -She said she, the Director or Nursing (DON) and the Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) Coordinator always attend the monthly meetings; -The Medical Director has attended twice, but she did not know when and had no documentation to show who attended the meetings; -The maintenance department, the Social Worker, the Dietary Manager, activities, and the pharmacist, gives the committee their concerns; -The QAA committee does go over concerns every month.

Based on interview and record review, the facility failed to protect residents from misappropriation of property when staff discovered missing doses of controlled medications that were in possession of the facility for three residents (Resident #8, #97 and #98). The facility census was 48. Record review of the facility's Abuse Prohibition Protocol Manual, dated [DATE], showed misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent. Record review of the facility's undated policy for the Narcotic Count, showed the following: -Purpose to complete a physical inventory of narcotics at each shift change to identify discrepancies; -Controlled substances are available only to licensed nurse, pharmacists, and certified medical technicians; -The narcotics supply is to be kept under two locks at all times. -One RN (registered nurse), LPN (licensed practical nurse), or CMT (certified medication technician) going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of narcotics supply for each individual resident at the change of each shift; -After the supply is counted and justified, the nurse/CMT records the date and his/her signature, verifying that the count is correct; -If the count is not accurate, the nurse going off duty is to remain on duty until the count is reconciled and the DON must be notified for further instruction; -Discrepancies found at any time are to be immediately reported to the Director of Nursing (DON). The DON will initiate an investigation to determine the cause of the discrepancy; -The nurse going off duty surrenders the narcotics key to the nurse coming on duty after the narcotics count is reconciled. 1. Record review of the facility's investigation for missing narcotics, dated [DATE], showed the following: -On [DATE], at 9:28 A.M., RN E notified the administrator that at the morning shift count, they were unable to locate Resident #8's [MEDICATION(S)] (antianxiety medication) 0.5 milligram (mg) tablet times one and [MEDICATION(S)] (treats moderate to severe pain, chronic pain) 50 mg tablets times two. Staff reviewed the narcotic records and checked the medication drawers on the medication cart; -CMT F worked on [DATE] from 7:00 A.M. to 8:00 P.M.; -CMT F counted the medication cart with LPN C at approximately 8:00 P.M. on [DATE], and the narcotic count was correct; -CMT F handed the narcotic keys over to LPN C after reconciling the narcotics on the medication cart; -LPN C was the only staff who had the narcotic keys to the medication cart from [DATE] at 8:00 P.M. to approximately 6:00 A.M. on [DATE]; -LPN C told the administrator that he/she did not know what happened to Resident #8's missing [MEDICATION(S)] and [MEDICATION(S)]; -The administrator asked LPN C if he/she had a prescription for opiates and LPN C said no but had prescription for antidepressant and then said, Okay, I will tell you what happened; -LPN C said to the administrator that it was a rough last night and he/she took a dose of Resident #97's (who had passed away that evening of [DATE]) liquid [MEDICATION(S)] (treats moderate to severe pain) 0.5 milliliters (ml); -Administrator had LPN C write a statement, then notified LPN C that he/she was terminated and that law enforcement would be notified and then escorted LPN C out of the facility; -The Director of Nursing (DON) arrived at 10:45 A.M. to assist with the investigation; -The DON and RN E, LPN D, and CMT G completed a recount of all drug count and found no additional discrepancies with the narcotic medications; -The DON began an immediate audit of all controlled substances to look for patterns or concerns with administrations; -The DON began interviewing residents to check and assess residents for any pain concerns; -The named Resident #8 whose [MEDICATION(S)] and [MEDICATION(S)] were missing did not appear to have any outcome and his/her records showed that he/she received the [MEDICATION(S)] and [MEDICATION(S)] as ordered. The DON assessed the resident and did not feel the resident exhibited any abnormal signs of pain or anxiety; -The DON began with staff education regarding Narcotic Drug Count and Misappropriation; -On [DATE], at 3:45 P.M., the local police notified the administrator that they went to LPN C's house to conduct their investigation and LPN C admitted to the police that he/she diverted medications; -On [DATE],at 8:40 A.M. and 9:15 A.M , the Administrator called DHSS the state agency and left a message to report the misappropriation. The state agency returned the call at 9:33 A.M. Record review of LPN D's written statement, dated [DATE], showed LPN D came in to work the 6:00 A.M. to 6:00 P.M. shift at 5:45 A.M. LPN C, the night nurse, told LPN D that he/she had a busy night and gave LPN a quick report of activity that happened in the Alzheimer unit since that was where LPN D was to work that day. LPN D took the key for the medication cart stating that before LPN C left to go home, to come back to the Alzheimer's unit to count with him/her. LPN C said he/she would come back to the unit to count after he/she gave report to RN E. LPN D went ahead and began passing medications to residents and when he/she got to Resident #8's medications, the count was off with the resident's [MEDICATION(S)] 50 mg and [MEDICATION(S)] 0.5 mg. LPN D went and got LPN C and said LPN C needed to count with him/her and that the count was off. LPN C stated, I'm glad you reminded me. I was getting ready to leave. LPN D and LPN C counted together and still had the same problem. LPN C said the count was right last night with the medication technician who worked. LPN D said they needed to go talk to RN E. During interview on [DATE], at 11:38 A.M., LPN D said he/she had come in to work on the day shift on [DATE]. He/she took the medication cart from LPN C. LPN D said, I was stupid to go ahead and get the keys to the medication cart in the Alzheimer's unit, since LPN C was giving report to RN E who was at the main nurses' desk up front. LPN D was in a hurry to get back to the Alzheimer's unit to get started on the medication pass administration since there were several medications to administer. LPN D said he/she should not have said to LPN C, Go ahead and give me the keys to the medication cart so I can go back and start passing medications on the unit. When you are done with report with RN E, come back and we will count the medication cart. While administering medications, LPN D was to administer Resident #8's scheduled narcotics [MEDICATION(S)] 50 mg and [MEDICATION(S)] 0.5 mg. LPN D noticed two [MEDICATION(S)] 50 mg tablets and and one [MEDICATION(S)] 0.5 mg tablet was missing and not in the medication card. The narcotic sheet and the bubble pack medication card did not match amount. LPN D had not and did not pop any of the medications from their bubble pack cards, but went up right away to the locked Alzheimer's unit door and opened it and noticed LPN C was preparing to leave the facility. LPN D had told LPN C to come back after doing report with RN E and when he/she caught LPN C, LPN C said, Oh yeah and came back to the unit to count the narcotic medications. The narcotic medications were still off of the right count. LPN C said he/she was trying to get his/her brain in order to tell LPN D what happened to Resident #8's medications. Record review of LPN C's written statement, dated [DATE], showed LPN C said when the CMT was ready to leave (the evening of [DATE]), it was routine to go and count the narcotics. They first count the amount of the medications then they count the actual pills in the cards. It was the oncoming nurse and the medication technician who counted and the count was perfect. The CMT left for the night, and LPN C continued working the shift. Around 4:00 A.M., on [DATE], LPN C found him/herself very exhausted and went into the medication room. A resident (Resident #97) had passed away that evening (on [DATE]) and had medications left over. LPN C took 0.5 ml of [MEDICATION(S)] sulfate from the expired resident's medications. When the day shift came in, as the charge nurse, LPN C had to count with the CMT or the nurse to reconcile the medications. The (unnamed) nurse discovered some medications were missing. The (unnamed) nurse and LPN C looked everywhere, but none were found. The charge nurse then called the administrator about the missing [MEDICATION(S)] and [MEDICATION(S)] medications. The administrator came in to complete the investigation and give a drug test to those involved LPN C failed the drug test and told the administrator what happened with taking Resident #97's [MEDICATION(S)] 0.5 ml medication for him/herself's use. Record review of CMT F's written statement, dated [DATE], showed last night ([DATE]), the narcotic count was correct. This morning ([DATE]), CMT F received a call from the nurse saying the narcotic count was off. CMT F came back into work and they all tried to figure out where the error occurred, but was unable to find the error. During interview on [DATE], at 3:25 P.M., CMT F said they were to safeguard the narcotic medications and triple check everything to make sure the count matches. CMT F does the medication pass on the Alzheimer's unit and did work on that Saturday [DATE]. On Sunday, [DATE], the nurse called and said the narcotic count was off and CMT F went in to the facility. There were scheduled narcotic medications all day to administer and CMT F said he/she counted off with LPN C the evening before ([DATE]) and the narcotic count matched. LPN C, the night charge nurse took the narcotic keys from him/her. When CMT F came to the facility, CMT G and RN E were counting to locate the two missing [MEDICATION(S)]. They did not find the missing medications. Record review of CMT G's written statement, dated [DATE], showed CMT G heard LPN D ask where LPN C was at approximately 8:15 A.M. LPN D asked CMT G if LPN C had left the facility because LPN C had not counted the narcotics with LPN D. CMT G said he/she didn't think LPN C had left yet and LPN D said they had a problem with the narcotic count. CMT G told RN E about 8:20 A.M. and saw LPN D and LPN C go to the Alzheimer's unit to count the narcotics. LPN C came out of the unit and called CMT F to come in to the facility since the narcotic count was wrong and they couldn't figure out why. CMT G asked LPN C if he/she counted narcotics with CMT F last evening and LPN C said, yes and the count was right last night. CMT G asked if LPN D had counted with LPN C this morning ([DATE]) and LPN D said no. CMT G went to the unit with RN E and CMT F to see if maybe there was a PRN (as needed) medication that was not signed out and they checked the count and could not find the issue. RN E called the DON and the administrator. During an interview on [DATE], at 3:10 P.M., CMT G said staff were to keep the medication cart locked and keep narcotics behind two locked doors. When they do the narcotic count, CMT G was to count off with the overnight nurse. They count the number of cards and then the number of pills and sign together as a double check system. LPN C worked that night ([DATE]) and had charting to catch up on and stayed over. The CMT was on the Alzheimer's unit. Around 8:15 A.M. to 9:00 A.M., was when the day nurse (LPN D) came out of the unit and asked where LPN C was. LPN C was at the front nurses' desk and charting on the computer. CMT G was in the dining room and heard LPN D, the day nurse say, The narcotic count was off and had issues with the medication cart. LPN D was already passing medications on the unit. LPN C, the night nurse said the narcotic count was fine when he/she counted with the CMT that night before ([DATE]). CMT G went back to the unit to count with the day charge nurse LPN D. The evening CMT G came in and couldn't figure it out. LPN C tested positive for opioids. The administrator called the police. The missing medications were Resident #8's [MEDICATION(S)] and [MEDICATION(S)]. The nurses had liquid [MEDICATION(S)] missing on a resident. During interview on [DATE], at 2:50 P.M., RN E said the following: -Staff were to count the narcotics every shift to make sure the count was right before they accept the narcotic keys from the night charge nurse: -During the narcotic count, the oncoming nurse counts the actual medication cards with the off going nurse and the off going nurse does the book and verifies this and reads the numbers off to the other nurse. They both look at the card and the number in the book and both sign off; -They were to count at the beginning of the shift or before the shift begins. This is usually at 6:00 A.M. to 6:15 A.M. and same in the evening; -LPN D on the unit and the CMT out in the main area notified RN E there may be a problem with the count; -They searched the drawers on the medication cart and did not find the missing two [MEDICATION(S)] and the one [MEDICATION(S)]; -If the staff waste a medication, or if the resident spits out the medication, they need a witness to sign this on the narcotic sheet; - RN E did give report to and counted the narcotics with LPN C the night before (on [DATE]). On Sunday (which was [DATE]) about 6:00 A.M., RN E did report with LPN C at the main nurse's desk; -On [DATE], RN E was at the main nurse's station checking blood sugars when LPN D called him/her to the unit since LPN D could not find Resident #8's two [MEDICATION(S)] and one [MEDICATION(S)] medications; -LPN C had not charted the medication as given and could not tell him/her what happened to the medications; -RN E asked LPN C if he/she administered the medications to Resident #8, but all these medications were scheduled medications; -They were popped out of the medication card. RN E searched the medication cart and the [MEDICATION(S)] and [MEDICATION(S)] were not there. 2. Record review of Resident #8's face sheet (admission data) showed the following: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Medications Flowsheet, dated ,d+[DATE], showed the following: -An order, dated [DATE], for [MEDICATION(S)] (generic for [MEDICATION(S)])) 0.5 mg tablet, one tablet three times a day (scheduled at 8:00 A.M., 2:00 P.M. and 6:00 P.M.); -An order, dated [DATE], for [MEDICATION(S)] 50 mg, one tablet three times a day (scheduled at 8:00 A.M., 2:00 P.M., and 7:00 P.M.). Record review of the resident's narcotic sheet showed the following: -A page for the resident's [MEDICATION(S)] 50 mg with directions to administer one tablet three times daily; -The final entry on the narcotic count sheet showed on [DATE], at 8:00 A.M., a nurse signed administration of the medication, leaving a remaining balance of 12 tablets. Record review of the resident's narcotic sheet showed the following: -A page for the resident's [MEDICATION(S)] 0.5 mg, with directions to administer one tablet by mouth three times daily; -The final entry on the narcotic count sheet showed on [DATE], a nurse signed administration of the medication, leaving a remaining balance of 15 tablets on the count sheet. 3. Record review of Resident #97's face sheet showed the following: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -admitted to hospice (end of life care) services [DATE]. Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, [DATE]. for [MEDICATION(S)] solution 20 mg/5 ml (4 mg/ml) 0.5 milliliters (ml) by mouth for pain every 30 minutes PRN (as needed). Record review of the resident's narcotic sheet showed the following: -A page for the resident's [MEDICATION(S)] sulfate solution 100 mg/5 ml with directions to administer 0.5 ml (10 mg) sublingually (under the tongue) every 30 minutes as needed for pain or air hunger; -The final entry on the narcotic count sheet showed on [DATE], a nurse signed administration of the medication, leaving a remaining balance of 25.5 ml on the count sheet. -Disposition of remaining doses with quantity destroyed 25.5 ml on [DATE] with two RN signatures. 4. Record review of Resident #98's face sheet showed the following: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -discharged to home on [DATE]. Record review of the resident's Medications Flowsheet, dated ,d+[DATE], showed the following: -An order, dated [DATE], for [MEDICATION(S)]-acetaminophen (combination medication used to relieve moderate to severe pain. It contains an opiod narcotic [MEDICATION(S)] and non-opiod narcotic acetaminophen that works in the brain to change how your body feels and responds to pain) tablet 7.5 mg-325 mg, may take every six hours PRN for pain (not to exceed three grams of acetaminophen of all sources in a 24 hour period). Record review of the resident's narcotic sheet showed the following: -A page for the resident's [MEDICATION(S)]/acetaminophen 7.5 mg-325 mg with directions to administer by mouth; -Amount received 13.5 tablets; -The final entry on the narcotic count sheet showed on [DATE], initialed (not a full signature) by unidentified staff, administration of the medication, leaving a remaining balance of 8.5 tablets on the count sheet. Record review of the facility investigation report, dated [DATE], showed the following: -LPN C was the admitting nurse for the resident; -LPN C admitted verbally and in writing to the police that he/she took five pills from the resident's [MEDICATION(S)] ([MEDICATION(S)]-acetaminophen 7.5 mg-325 mg) bottle that the resident brought from home before LPN C completed a drug count with the additional (unnamed nurse). During interview on [DATE], at 10:30 A.M., the DON said the following: -The resident was admitted on [DATE], at 5:15 P.M., and was only to be here a short time like two to three days to recover after having surgery; -The resident brought his/her own medications in on admission when LPN C and RN E were here working; -The resident came around shift change and LPN C took five of the resident's [MEDICATION(S)]-acetaminophen 7.5 mg-325 mg medication before adding the number of [MEDICATION(S)] tablets to the count; -LPN C took the resident's personal medications into the medication room and the other nurse was assessing the resident; -He/she nor any staff at the facility were aware that this had happened with the resident's [MEDICATION(S)]-acetaminophen 7.5 mg-325 mg medication. 5. Record review of the police report, dated [DATE], showed the following: -On [DATE], an RN told the administrator that narcotics were missing when counted; -The administrator said when he/she spoke to LPN C, LPN C said that around 4:00 A.M. the morning of [DATE], he/she felt very exhausted, went into the medication room, at that time a resident had passed away and there were medications left over. LPN C took 0.5ml of [MEDICATION(S)] sulfate from the expired resident; -On [DATE],2 at 2:28 P.M., the police officer went to LPN C's residence to question him/her; -LPN C said that since working at the facility, he/she had been taking patients' medications every day, sometimes several times a day and consuming them him/herself; -LPN C said when he/she had to count the narcotic medications at the end of shift, he/she would write down on the medical chart that the patient would be given the medications but in reality, he/she would be giving a Tylenol to the patient; -LPN C said he/she would take several small amounts of liquid [MEDICATION(S)] throughout his/her shift as well; -LPN C stated that about a week before, he/she got a new admission to the facility and took several [MEDICATION(S)] medications out of the bottle before the patient's medications were counted. 6. During interview on [DATE], at 9:53 A.M., the DON said the following: -Before taking the medication cart, staff were to count narcotics with the oncoming nurse and/or CMT, and the off going nurse and/or CMT; -On the resident's Medications Flowsheet, the nurses should sign their full name when they administer medications; -Two nurses were to sign in a resident's personal medications (like from a medication bottle) and a pharmacist or physician was to identify the medication; -They should encourage family to take the resident's personal medications home. 7. During interview on [DATE], at 12:30 P.M., the Administrator said the following: -Resident #8's had two [MEDICATION(S)] (for medium to severe pain) tablets and one [MEDICATION(S)] (for anxiety) tablet was missing on the morning of [DATE]; -LPN C, night charge nurse, had control of the medication cart with Resident #8's narcotic medications. LPN D was the oncoming nurse who took over the cart; -LPN C told the administrator that he/she had a bad night and took [MEDICATION(S)] solution 20 mg/5 ml (4 mg/ml) 0.5ml liquid from Resident # 97 who had already passed away earlier that evening on [DATE] and took Res #98, a new admission, [MEDICATION(S)] medication (for moderate to severe pain); -LPN C denied taking Resident #8's [MEDICATION(S)] and [MEDICATION(S)]. MO 289

Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS- ) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for one resident (Residents #6) who remained in the facility after discharge from Medicare Part A services. The facility census was 48. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/09/09, and showed the following: -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of either the SNFABN (form CMS- ) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them his/herself or through other insurance they may have; -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Record review showed the facility did not provide a policy regarding Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS- ). 1. Record review of Resident #6's Skilled Nursing Facility Beneficiary Protection Notification Review showed the following: -Medicare Part A skilled services episode start date 2/11/22; -Services ended on 3/09/22; -Last covered day of Medicare Part A service as 3/09/22; -Facility staff did not provide the resident or his/her legal representative the SNFABN form CMS- or alternative denial letter. During an interview on 6/02/22, at 9:05 A.M., the Administrator said she overlooked completing the ABN notice to the resident. She said the resident was appealing the ABN and the family was looking to move the resident to a independent living facility. The ABN notice should have been provided to the resident as required.

Based on record review, observation and interview the facility failed to identify, assess and treat a newly identified Stage II (thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer, failed to identify, assess and monitor three unstageable (a pressure ulcer is considered unstageable when one cannot visualize the wound bed due to the presence of slough or eschar) pressure ulcers, and failed to perform wound care using infection control practices to prevent possible infection for one resident (Resident #11) and failed to identify, assess and monitor a Stage II pressure ulcer and an area of suspected deep tissue injury (DTI) for one resident (Resident #7) in a selected sample of 11 residents. The facility identified one resident (Resident #11) with pressure ulcers. The facility's census was 47. According to the National Pressure Ulcer Advisory Panel (NPUAP) http://www.npuap.org, deep tissue injury (DTI) is a term to describe a unique form of pressure ulcers. These ulcers have been described by clinicians for many years with terms such as purple pressure ulcers, ulcers that are likely to deteriorate and bruises on bony prominences (Ankrom, 2005). Although it looks like a deep bruise, deep tissue injury is sometimes mistaken for a category I pressure ulcer. This can happen if only the color and fact that the skin is intact are noted. NPAUP's proposed definition, is "a pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) to Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer even with optimal treatment." (NPAUP, 2002). Deep tissue injury represents a dangerous lesion due to its potential for rapid deterioration. 1. Record review of Resident #11's admission orders [REDACTED] -Apply skin protectant cream, topically, every morning; -[DIAGNOSES REDACTED]. -Insert indwelling catheter (a sterile tube inserted into the bladder to drain urine) on arrival to the facility. Record review of the data collection form, completed by facility staff on admission, dated 08/13/13, showed the following information: -Staff admitted the resident to the facility with a [DIAGNOSES REDACTED]. -The resident had a pressure ulcer to his right heel, a pressure ulcer to his left hip; -Scrotum excoriated (to damage or remove a superficial area of skin, as by scratching, or the application of chemicals); -See nursing note, dated 08/15/13, for clarification of the resident's skin condition; -Left [MEDICAL CONDITION]; -Required total assist for transfers; -Used a wheelchair; -Dependent with grooming and hygiene; -Catheter. Record review of a nurses' note, dated 08/15/13, showed the following information: -Pressure area on inner aspect of right ankle that measured 2.5 centimeter (cm) x 3 cm; -Pressure area on the outer aspect of the right ankle that measured 2.2 cm x 1.6 cm; -Staff applied Skin Prep to these areas; -Abraded (scrape or wear away by friction) area on the right hip with [MEDICATION NAME] (a skin protectant combination that also temporarily relieves itching and pain. It also decreases moisture in the affected area) applied. Record review of the initial wound assessment, undated, showed the following information: -Stage I pressure ulcer (a persistent area of skin redness without a break in the skin, that is nonblanchable (reddened area that does not temporarily turn white or pale when pressure is applied; usually a result of impaired circulation)) to the coccyx (tailbone); -Heel blisters; -Penis reddened with an approximately 0.5 cm x 0.2 cm open area with yellow slough (dead tissue that is white or yellow and clings to the wound bed in strings or clumps); -First observed on admission; -Staff did document an assessment of the Stage I pressure ulcer, to include size and surrounding tissue. Record review of the weekly wound report, dated 08/19/13, showed the following information: -DTI, 3.5 cm x 3.2 cm purple fluid-filled blister to the right inner heel. Treatment: Skin Prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) every shift; -DTI, 1 cm x 1.4 cm light red resolving blister to the outer right heel. Treatment: Skin Prep every shift; -DTI, 3.5 cm x 6.5 cm, bruise-colored area to the coccyx; -Special device: Low air loss mattress (an air-filled pressure relieving mattress that can reduce the negative effects of heat and moisture buildup on the skin); -Staff did not document an assessment of the penile wound to include size, color wound bed, surrounding skin, drainage and odor. Record review of the admission Minimum Data Set (MDS) assessment, a federally mandated comprehensive assessment tool, completed by facility staff, dated 08/22/13, showed the following information: -Short and long term memory problems; -Moderately impaired daily decision making skills; -Dependent on staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing; -Indwelling catheter (a sterile tube inserted into the bladder to drain urine); -Occasionally incontinent of urine; -Frequently incontinent of bowel; -Two Stage II pressure ulcers (present on admit); -Moisture associated skin damage; -One unstageable pressure ulcer with suspected deep tissue injury, not present on admit; -Pressure reducing device for bed and chair; -Turning/repositioning program; -Nutrition or hydration intervention to manage skin problems; -Ulcer care; -Applications of ointments/medications other than to feet. Record review of a physician's orders [REDACTED]. Record review of nurses' notes, dated 08/22/13-08/25/13, showed the following information: -On 08/22/13, at 2:40 P.M., a nurse documented open wound to the resident's right great toe, blisters to heel are intact, Skin Prep applied, as ordered. Coccyx had an intact 6.5 cm x 3.5 cm dark purple area, [MEDICATION NAME] applied; positioned off coccyx and heel floated. The resident is on a low air loss mattress. Instructed staff to position the resident, on non-[MEDICAL TREATMENT] days, in bed except for meals; -On 08/25/13, at 12:15 A.M., a nurse documented the resident had multiple skin issues. Circular red areas to the right heel and outer ankle, excoriation to the scrotum with small sores to the head of the penis, creams applied. Crease of buttocks reddened, dark circular area to coccyx which did not blanch well. Left note for the wound nurse to reevaluate. Record review of a physician's orders [REDACTED]. Record review of a nurses' note, dated 08/26/13, at 12:18 A.M., a nurse documented the physician examined wounds to the resident's scrotum and penis. The physician instructed staff to continue the [MEDICATION NAME] and keep skin off skin with use of pillows between the resident's legs. The resident chooses not to keep the pillows between his legs, at times, and staff replaces. Record review of a physician's orders [REDACTED]. New order for staff to clean the coccyx with wound cleanser and apply wound gel with [MEDICATION NAME] mix (a cream or ointment with antibiotic properties that helps to heal skin wound) to the wound bed and cover with a Optilock (a super absorbent polymer core dressing) and secure with [MEDICATION NAME] (fabric tape), change every two to three days and as needed. Record review of the weekly wound report, dated 08/26/13, showed the following information: -DTI, 4 cm x 3 cm purple fluid-filled blister to the right inner heel. Treatment: Skin Prep every shift; -DTI, 1.5 cm x 1.5 cm light red resolving blister to the outer right heel. Treatment: Skin Prep every shift; -DTI, 6 cm x 7 cm, red wound bed with 3 cm x 3.5 cm area of black eschar (dead tissue) to the coccyx. Treatment: [MEDICATION NAME] wound gel; -Special device: Low air loss mattress; -Staff did not document an assessment of the wounds to the penis, scrotum and great toe to include size, color wound bed, surrounding skin, drainage and odor. Record review of a physician's orders [REDACTED]., three times a day. Record review of a nurses' note, dated 08/28/13, at 10:45 P.M., showed a nurse documented he/she called the physician regarding the resident's sacral wound and received new orders for wet to dressings every shift. Record review of a physician's orders [REDACTED]. -Apply a damp to dry dressing to the sacral (sacrum, the triangular-shaped bone at the base of the spine wound) after thoroughly cleansing, every shift; -Check the dressing to the coccyx, for placement, every shift. Record review of the care plan, dated 08/29/13, showed the following information: -Problem: admitted with pressure ulcers to the heel and coccyx and multiple abrasions and [MEDICAL CONDITION]; -Pressure relieving device to bed and chair; -Low air loss mattress; -Float the resident's heel and ensure pressure is off the heel; -Turn and position before meals, after meals, every two hours at night and as needed to promote comfort; -Provide positioning devices to maintain positioning; -Provide treatment as ordered; -Notify the physician, as needed, when wounds decline; -Encourage good nutrition to aid in wound healing. Record review of the nurses' notes, dated 09/01/13-09/02/13, showed the following information: -On 09/01/13, at 10:19 A.M., a nurse documented wet to dry dressing to sacral area, open area on the penis, treated with [MEDICATION NAME] and zinc; -09/02/13, at 10:09 A.M., a nurse documented dressings changed, as ordered, without difficulty. Wound to coccyx appeared to be worsening, macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) with slough present. Record review of a physician's orders [REDACTED]. Record review of a nurses' note, dated 09/03/13, at 6:54 A.M., showed a nurse documented the physician was at the facility and reevaluated wound progress. The left buttock had white adhering slough tissue, the right buttock had cleared up with one slight open area, area to the scrotum had white loose slough tissue, dry purple blister to the outer heel, inner heel purple with fluid-filled blister in the center, out edges of the area were dry; new treatment started today. End of penis with necrotic (dead tissue) and wet to dry dressing started to wound, today. Record review of physician's orders [REDACTED]. -Wet to dry dressing to the penis wound, every shift; -Change treatment to both buttocks: Cleanse with wound cleaner and apply Enluxtra (a self-adaptive wound dressing) to buttocks and inner heel, change every two to three days and as needed. Record review of the weekly wound report, dated 09/04/13, showed the following information: -DTI that measured1.8 cm x 2 cm to right inner heel. Resolving outer edge, blister with fluid-filled center. Treatment: Enluxtra, change every two to three days; -DTI, 1.25 cm x 1.5 cm, light red resolving blister to the outer right heel. Treatment: Skin Prep every shift; -DTI, 7.5 cm x 2.5 cm unstageable pressure ulcer with white adhering slough to the coccyx. Treatment: Enluxtra, change every two to three days; -Special device: Low air loss mattress; -Staff did not document an assessment of the wounds to the penis, scrotum and great toe to include size, color wound bed, surrounding skin, drainage and odor. Record review of a physician's orders [REDACTED]. -On 09/04/13 the physician instructed staff to administer, to the resident, Prosource (a protein supplement) 30 milliliters (ml) two times a day, for wound healing; house shakes (a protein supplement) two times a day, for wound healing; Vitamin C (a supplement) 500 milligrams (mg) every day, for wound healing; Zinc (a supplement) 50 mg every day, for wound healing. An observation on 09/06/13, at 9:25 A.M., showed Licensed Practical Nurse (LPN) I and Certified Nurse Assistant (CNA) J entered the resident's room and provided wound care as follows: -The LPN sanitized his/her hands and gloved then removed the protective bootie and sock from the resident's right foot and showed dark brown/purple pea-sized eschar on the resident's great toe; -He/she removed the dressing on the resident's right inner heel and showed a purple half-dollar sized area with a quarter-sized fluid filled blister in the center of the wound with black eschar on the upper left edge of from 12:00 o'clock to 2:00 o'clock. LPN I said there was not as much fluid inside the blister; the wound had improved, The LPN cleaned the area with normal saline, changed his/her gloves, then placed a small piece of Enluxtra over the wound and covered it with a transparent dressing. The LPN did not change gloves or sanitize his/her hands after he/she removed the dressing, possibly contaminating the wound; -The LPN sanitized his/her hands and gloved. He/she turned the resident's foot to the left (outer heel) and showed a pea-sized fluid filled blister surrounded by nickel-sized light purple tissue. The LPN applied Skin Prep to the area then applied a sock and protective bootie to the resident's foot; -The LPN sanitized his/her hands and gloved. He/she removed the dressing on the resident's scrotum and showed a nickel-sized open area covered with yellow slough with pink wound edges connected to dime-sized open area with a pink wound bed. A small amount yellow-green drainage was visable on the removed dressing. The LPN cleaned the area with normal saline, changed his/her gloves, then placed a small piece of Enluxtra over the wound and covered it with a transparent dressing. The LPN did not change gloves or sanitize his/her hands after he/she removed the dressing, possibly contaminating the wound; -The LPN sanitized his/her hands, gloved and turned the resident onto his/her left side showing a pea-sized open wound with a pink wound bed on the resident's right gluteal fold. The LPN did not perform a treatment to the new pea-sized wound; -He/she removed the dressing on the resident's sacrum and showed a half orange-sized open wound, covered with white slough. The surrounding skin was purple with black eschar from 12:00 o'clock to 2:00 o'clock. The outer edge of the surrounding skin was pink. The entire wound, including the open area and surrounding tissue was approximately orange-sized. LPN I said the resident's wound looked better since the treatment was changed to Enluxtra. The LPN cleaned the area with normal saline, changed his/her gloves, then placed a piece of Enluxtra over the wound and covered it with a transparent dressing. The LPN did not change gloves or sanitize his/her hands after he/she removed the dressing, possibly contaminating the wound; -The LPN sanitized his/her hands and gloved. He/she removed the dressing on the resident's penis and showed a quarter-sized open area covered with loose, stringy black eschar. A moderate amount yellow drainage was visable on the removed dressing. The wound had an odor. The LPN cleaned the area with normal saline, changed his/her gloves, placed a gauze, moistened with normal saline, over the wound then wrapped gauze around the wound and catheter tubing, securing it with tape. The LPN did not change gloves or sanitize his/her hands after he/she removed the dressing, possibly contaminating the wound. During an interview conducted on 09/06/13, at 2:00 P.M., the DON said staff should change gloves and wash or sanitize their hands after removing a dressing, before cleaning the wound. During an interview conducted on 09/06/13, at 10:55 A.M., the resident's physician said on 09/03/13 he assessed the wound on the resident's penis. He thought the catheter created pressure causing the resident's penis to become necrotic. The resident goes to [MEDICAL TREATMENT] three times a week and due to the type of chair the resident sits in, staff (at the [MEDICAL TREATMENT] center) are unable to change his position frequently. The physician was not as concerned about the wounds on the resident's sacrum and heel as he was about the wounds on the resident's scrotum and penis. The physician said he instructed staff to obtain a wound consult, but until the wound clinic's physician sees the resident, we (the physician and facility staff) will continue to treat the wounds. The physician thought the resident admitted to the facility with all of the wounds. Record review of the resident's current medical record on 09/06/13, showed staff did not document assessments of the resident's wounds located on his scrotum, penis, great toe and right gluteal fold to include size, color wound bed, surrounding skin, drainage and odor. During an interview conducted on 09/06/13, at 12:30 P.M., the corporate nurse said the facility had no other documented wound assessments for Resident #11. Record review of a written communication, provided to survey staff by facility staff, on 09/06/13, at approximately 1:00 P.M., showed staff inserted the indwelling catheter, after the resident arrived to the facility, for [MEDICAL CONDITION]. Staff contacted the physician on 09/06/13 and received an order to discontinue the indwelling catheter. 2. Record review of Resident #7's significant change in status MDS, dated [DATE], showed the following information: -Cognitively intact as indicated by a total BIM (a brief screener that aids in detecting cognitive impairment) of a 13; -Required extensive assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Occasionally incontinent of urine; -Frequently incontinent of bowel; -At risk for developing pressure ulcers; -No pressure ulcers; -Pressure reducing device for bed and chair; -Applications of ointments/medications other than to feet. Record review of the care plan, dated 07/18/13, showed the following information: -At risk for skin breakdown due to the resident requires staff assist with transfers, wheelchair dependent and frequent episodes of bowel and bladder incontinence; -Monitor skin during activities of daily living (adl) cares and baths for skin breakdown such as redness, blisters, open areas. Notify the charge nurse as needed; -Assist the resident with toileting, cleansing of skin and repositioning, as needed, to maintain good skin integrity; -Apply skin barrier creams, as needed, to maintain good skin integrity. Record review of the 30-day MDS assessment, dated 08/03/13, showed the following changes from the previous assessment (07/14/13): -Frequently incontinent of urine; -Always continent of bowel; -Turning/repositioning program. Record review of a physician's orders [REDACTED]. Record review of the nurses' notes, dated 08/06/13-08/13/13, showed the following information: -On 08/06/13, at 11:21 P.M., a nurse documented the resident's perineal area had some redness. Powder applied, as ordered (the nurse did not specify what "powder" he/she applied. The resident did not have an order for [REDACTED]. -On 08/07/13, at 7:20 P.M., a nurse documented the resident had episodes of incontinent stool this afternoon due to increased doses of [MEDICATION NAME] for increased ammonia levels; -On 08/09/13, at 7:34 P.M., a nurse documented the resident's perineal area was not as red as before, continue current treatment; -On 08/12/13, at 10:02 P.M., a nurse documented the resident continued with very loose diarrhea and was incontinent of bowel and bladder; -On 08/13/13, at 1:56 P.M., a nurse documented the resident's perineal area reddened and excoriated. New orders received from the physician. The nurse also observed a "bruise" on the resident's buttocks, purple in color, blanches and measured 10 cm x 12 cm. Educated the resident regarding lying in bed throughout the day without an incontinent brief, good perineal care and treatment as ordered, to relieve tenderness to perineal area and decrease bruising from possibly being up in chair on buttocks for multiple hours at a time. The resident verbalized understanding. Record review of a physician's orders [REDACTED]. Record review of nurses' notes, dated 08/19/13-08/23/13, showed the following information: -On 08/19/13, at 1:24 P.M., a nurse documented the resident had excoriation to his/her perineal area. Staff positioned him/her in bed without bottoms and applied [MEDICATION NAME]; -On 08/20/13, at 9:01 A.M., (weekly summary) a nurse documented the resident was alert and oriented with some confusion. He/she had redness to his/her perineal and rectal areas, treatment completed by staff. The resident was incontinent of bowel and bladder more often and wore incontinent briefs while up and none at bedtime; -On 08/23/13, at 3:13 P.M., a nurse documented hospice staff admitted the resident to their services. The nurse assisted hospice staff with the resident's perineal care. The resident had three open sores located on his/her genitalia and excoriation to his/her rectal folds. Treatment completed as ordered, new orders received. Staff will monitor for changes. Staff did not document an assessment of the open areas to include size, color, surrounding tissue, drainage or odor. Record review of the initial nursing assessment, completed by hospice staff, dated 08/23/13, showed the following information: -The resident admitted to hospice services for [MEDICAL CONDITION] of the liver (scarring of the liver caused by many forms of liver diseases and conditions). Ammonia levels are elevated and he/she receives [MEDICATION NAME] three times a day; -The resident complained of pain to his/her buttocks and perineal areas, rated an 8 out of 10. The hospice nurse requested staff to administer pain medication to the resident to decrease pain as areas are soiled with loose stool; -The resident had multiple Stage II areas to his/her buttocks: Right buttock wounds measured 0.75 cm x 0.5 cm and 1 cm x 0.25 cm; right posterior (back) thigh areas measured 1.2 cm x 0.5 cm and 0.5 cm x 0.5 cm; gluteal cleft (the groove between the buttocks that runs from just below the sacrum to the perineum (the region of the body between the anus and the genital organs)) wounds measured 6 cm x 0.7 cm 0.7 cm x 0.5 cm, 1.5 cm x 1.5 cm and 1 cm x 0.7 cm; genitalia had a 4 cm x 1.1 cm wound with a 1 cm x 0.75 cm area of eschar in the center. Just below this large area the resident had a 1 cm x 1 cm ulceration with greenish-yellow drainage; -The nurse cleansed the area with warm soapy water, patted dry and applied Micatin powder to the areas and educated provided to staff on the need to check the resident for bowel incontinence frequently as he/she will have frequent loose stools from the [MEDICATION NAME]; -Low air loss mattress ordered for prevention of further wound development. Record review of the resident current medical record showed staff did not document identification or assessment of the Stage II pressure ulcers and did not update the care plan after identification of the pressure ulcers to reflect current interventions and treatments. Record review of a physician's orders [REDACTED]. -Open to air when in bed, no brief; -Only up for meals then immediately back down in bed; -Low air loss mattress. Record review of the August 2013 treatment administration record (TAR) showed the following information: -On 08/23/13, no brief while in bed, up for meals only; -On 08/23/13, anti-fungal powder with perineal care; -[MEDICATION NAME] to buttock crease; -The TAR did not include the 08/13/13 Micatin powder order. Staff did not document administering the Micatin (anti-fungal) powder from 08/13/13-08/23/13 (10 days). Record review of a nurses' note, dated 09/04/13, at 2:17 A.M., showed the following information: -A nurse documented the resident received treatment every shift to his/her the Stage II ulceration located on his/her genitalia. The resident was up for meals but staff lay him/her down directly after meals due to his/her genitalia; -Staff did not document an assessment of the open areas to include size, color, surrounding tissue, drainage or odor and did not document any further assessments of the perineal wounds or "bruise" on the resident's buttocks. An observation on 09/05/13, at 11:40 A.M., showed the resident laid on his/her back, with his/her eyes closed. CNA H and CNA G entered the room and removed the blanket covering the resident's perineal area. The resident had a pea-sized open wound with a pink wound bed to his/her genitalia. The surrounding skin was swollen and red. As staff performed perineal care, the resident told staff to "be careful" referring to the open area on his/her genitalia. The CNAs rolled the resident onto his/her side and showed a baseball-sized purple area to the resident's coccyx. CNAH said the resident's skin looked a lot better. He/she had three open areas to his/her genitalia; two have healed and now he/she only has one. During an interview conducted on 09/05/13, at 11:40 A.M., the hospice nurse said the resident's genitalia was excoriated and swollen. The open area was caused from pressure when he/she sits in his/her wheelchair. During an interview conducted on 09/06/13, at 12:30 P.M., the corporate nurse said the facility had no other documented wound assessments for Resident #7. During an interview conducted on 09/06/13, at 2:40 P.M., Registered Nurse (RN) A said the resident had three open areas on his/her frontal perineal area. One had yellow slough. Hospice staff called the RN into the resident's room to assist with perineal care. The RN did not know the wounds on the resident's genitalia were that bad. The hospice nurses measured each of the wounds and told the RN he/she did not need to measure them. The resident has a purple area on his/her bottom. The resident used to sit a lot but now is more compliant with lying down. The resident received a new wheelchair cushion and an air mattress for pressure relief and staff lay down the resident right after meals. The purple area on the resident's buttocks looks like a bruise but does not change colors. It has been there at least since March 2013. The RN did not think the purple area was a deep tissue injury or related to pressure. 3. During an interview conducted on 09/06/13, at 2:00 P.M., the DON said the following: -The MDS coordinator is responsible for documenting wound assessments weekly. She performs wound assessments on all wounds including pressure ulcers, vascular ulcers, major skin tears and deep tissue injuries. The assessment should include measurements, drainage, odor, if the wound is healing or deteriorating, treatments and current interventions; -A deep tissue injury looks like a blood blister when it is located on a heel and a bruise when it is located on the buttocks; -Staff should change gloves and wash or sanitize their hands after removing a dressing, before cleaning the wound.