Every finding on record at Golden Age Living Center

Based on interview and record review, facility staff failed to provide protective oversight for one resident (Resident #1) when staff failed to supervise the resident, including checking on them and offering hydration to the resident, while he/she sat outside from 9:23 A.M. until 11:52 A.M on 7/18/26. Outside temperatures ranged from 84 F to 88 F and the heat index ranged from the mid-90's to low 100's F. The resident had severe cognitive impairment, required substantial/maximum assistance with mobility, and utilized a wheelchair for mobility. The failure resulted in the resident becoming unresponsive, vomiting, and having a temperature of 101. 7 degrees Fahrenheit (F). The resident was admitted to the local hospital with diagnoses of dehydration from environmental heat exposure and pneumonia. The facility census was 57.The administrator was notified on 07/22/26 at 11:50 A.M. of an Immediate Jeopardy (IJ) which began on 07/18/26. The IJ was removed on 07/22/26, as confirmed by surveyor onsite verification. Review of the facility's policy titled Emergency Procedure- Extreme High Temperatures Policy, effective 11/01/2017, showed the policy did not contain information related to outdoor temperatures. Review of the facility's policy titled Hydration, revised 03/08/19, showed the policy did not contain information related to the hydration of residents while outside. Review of the facility provided policies showed it did not contain a policy to direct staff on how to provide protective oversight of residents who are outside unattended. Review of the www.wunderground.com/history/daily/us/mo (weather website) showed the outside temperature on 07/18/26 from 9:15 A.M., to 11:55 A.M., ranged from 84 F to 88 F and the heat index ranged from the mid-90's to low 100's F. 1. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff documented the resident as:-Severely cognitively impaired;-Required substantial/maximum assist with mobility;-Used a wheelchair;-Diagnoses of non-traumatic brain injury, hypertension (high blood pressure), anxiety, and depression. Review of the resident's care plan, dated 06/18/26, showed staff documented the resident may sit outside by the nurse's station door or the front porch to be supervised. The resident refuses sunscreen and a sun hat. Review showed the care plan did not contain documentation on how the resident should be supervised or provided hydration while outside. During an interview on 07 /21/26 at 11:30 A.M., the Administrator said when they reviewed the video it showed Licensed Practical Nurse (LPN) A took Resident #2 outside at 8:55 A.M. (07/18/26) and then the LPN brought Resident #1 inside at 8:56 A.M. The administrator said the video showed Certified Nurse Aide (CNA) B took Resident #1 back outside at 9:23 A.M. and then Housekeeper C brought Resident #2 inside at 9:43 A.M. The Administrator said Resident #1 remained outside until 11:52 A.M. and it is unknown if anyone offered the resident water while he/she was outside. Review of the resident's nurse's note, dated 07/18/26, showed Registered Nurse (RN) E documented when he/she went to get the resident for lunch, the resident was outside. The RN documented the resident was unresponsive, had a red face, was hot to touch, with a temperature of 101.7 F (normal body temperature 97.8 F to 99.1 F), pulse of 108 beats per minute (normal pulse 60 to 100 beats per minute), a blood pressure of 159/84 (normal blood pressure 90/60 to 120/80 mm Hg), and an oxygen saturation (the percentage of hemoglobin in your red blood cells carrying oxygen) of 91 percent. The RN documented the resident was leaning to the right side and the resident began vomiting food particles and fluids. The RN documented the resident's clothes were removed and obtained cool clothing for the resident. The resident was still not responsive. The RN documented he/she called 911 at 12:00 P.M. Review of the resident's hospital records, dated 07/18/26 through 07/20/26, showed the resident admitted to the local hospital for dehydration from environmental heat exposure and acute pneumonia. During an interview on 07/21/26 at 8:47 A.M., the Administrator said they have a system to set timers for 15 minutes when residents are outside. He/She said the resident was checked on, but not as often as he/she should have been. Staff would look out the window to check on him/her, but the resident was sitting at an angle. During an interview on 07/21/26 at 10:54 A.M., LPN A said he/she took Resident #2 outside and brought Resident #1 inside early in morning before breakfast. The LPN said staff usually set a timer for 15 minutes to ensure residents outside are checked on or they tell the nurses or aides on that hall to watch because a resident is outside. During an interview on 7/21/26 at 10:30 A.M., CNA B said he/she took the resident outside and did not set a timer, because he/she did not know to do that and he/she did not offer the resident water because the resident declines water. During an interview on 7/21/26 at 10:34 A.M., Housekeeper C said he/she brought Resident #2 back into the building, because he/she was knocking at the door to be let in. The housekeeper said he/she saw Resident #1 sitting outside, but it looked like he/she was sleeping because he/she did that regularly. The housekeeper said he/she did not offer the resident water when he/she saw the resident outside because the resident appeared to be sleeping. During an interview on 07/21/26 at 9:41 A.M., RN E said he/she went to get the resident ready for lunch and the resident was still outside. The resident would not respond to him/her, so he/she brought the resident inside and yelled for help. The resident began vomiting and staff helped get the resident into bed. The resident had a temperature of 101.7 F and was hot to the touch. Staff redressed the resident in cooler clothes because he/she was fully dressed outside and added cool towels to the resident's face. The RN said he/she could not get the resident to wake up and called 911. During interviews on 07/21/26 at 11:42 A.M. and 1:19 P.M., the administrator said he/she expected staffto set a timer to check on the residents every 15 minutes and offer water to the residents when they check on them. The Administrator said the facility did not have a policy for the timer use; it is just a standard operating procedure, and he/she expected the timer to be set no matter the temperature. The facility did not have a policy for the hydration of residents while outside and could not provide documentation to show staff were trained on his/her expectations to set a timer and offer water when residents are outside. The Administrator said the facility did not have a policy for extreme heat temperatures and the residents sitting outside. The Administrator said he/she felt anything under 90 F was not an extreme temperature. During an interview on 07/21/26 at 2:18 P.M., the resident's physician, who is also the facility's medical director, said timeframes for checking on a resident outdoors would vary by each resident. The physician said the resident should have been checked on more frequently and, while he/she did not have a set time, every thirty minutes seems fair. The physician said he/she would expect staff to offer hydration to the residents when they are outside. The physician said different homes have different policies of when the residents can go outside, but it was the residents' right and this resident wanted to go outside. During an interview on 07/22/26 at 10:08 A.M., the hospital physician said the resident's fever could be caused by both environmental heat exposure and pneumonia, however, the resident was without a fever for his/her stay at the hospital so it was probably the outcome of prolonged heat exposure. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy (IJ) level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). 3103756

Based on observation, interview and record review, facility staff failed to complete an investigation related to missing controlled narcotic medication for one resident (Resident #1) when staff identified three missing controlled narcotics. The facility census was 53.1. Review of the facility's Abuse and Neglect, Prevention, Investigation and Reporting policy, revised 06/23/2022, showed all items of concern related to misappropriation shall be investigated urgently with swift correction which shall include education to staff members on prevention of such. All collected information and documents shall be maintained in the administrator's office.Review of the facility's Guideline for Discrepancy in Count of Controlled Medication, undated, showed the purpose of the guidelines are to assure controlled medications were accounted for at least three times daily. All controlled medications are to be counted by the Certified Medication Technician (CMT) and/or licensed nurse at each shift change. Any discrepancy is to be reported immediately to the charge nurse/Director of Nursing (DON) Parties involved are to stay in the medication room until the issue can be resolved. Medications are to be recounted by licensed staff and all attempts made to determine where and when the error occurred. If the error/medication cannot be located the administrator is to be notified and all involved parties interviewed. The incident is to be reported to the Division of Health and Senior Services hotline. The pharmacist is to be notified of the discrepancy.2. Review of Resident #1's face sheet, dated 11/10/25, showed the resident admitted to the facility on [DATE] with diagnoses of generalized weakness, and a right femur fracture.Review of the resident's Physician Order Sheet (POS), dated 10/30/25 through 11/10/25, showed an order for Clonazepam 0.5 milligrams (mg) give one tablet by mouth at bedtime and Clonazepam 0.5 mg one tablet twice per day as needed.Review of the residents Controlled Drug Records, dated 10/30/25 through 11/10/25, showed facility staff documented they received Clonazepam 0.5 mg 155 tablets in one bottle on 10/30/25. Review showed staff documented they received 79 tablets on one record and 76 tablets on a separate record to allow for ease of counting on the controlled narcotic count sheet. Review showed staff documented three missing doses on the 76-tablet controlled narcotic count sheet as indicated by circling doses 68, 69, and 70. Review of the resident's Medication Administration Record (MAR), dated 10/30/25 through 11/10/25, showed staff documented Clonazepam 0.5 mg one tablet administered on 10/30/25, 10/31/25, 11/01/25, 11/02/25, 11/03/25, 11/04/25, 11/05/25, 11/06/25, 11/07/25, 11/07/25, 11/08/25, and 11/09/25. Review of the resident's Individual Narcotic Count Sheet, dated 11/11/25, did not contain documentation two nurses reconciled the Clonazepam 0.5 mg from 10/30/25 through 11/10/25. Review of the resident's Nurses Progress Notes, dated 10/30/25 through 11/09/25, did not contain documentation related to missing controlled narcotic medications.Review of the facility's medication records showed the records did not contain documentation of an investigation related to the missing controlled narcotic medications.Observation on 11/10/25 at 10:05 A.M., showed the resident's bottle of clonazepam contained 141 tablets.During an interview on 11/10/2025 at 9:59 A.M., CMT B said he/she was aware the resident's medication count was incorrect. CMT B said an unidentified CMT had recognized a medication count error the weekend prior. CMT B said he/she did not know who investigated the count error or what documentation was completed other than the three circled doses on the controlled drug record sheet. CMT B said the nurses are responsible for investigating and documenting medication count issues.During an interview on 11/10/2025 at 11:41 A.M., Licensed Practical Nurse (LPN) A said a CMT or nurse taking over the medication cart is responsible for ensuring medication counts are correct. LPN A said CMT's would be expected to notify a nurse of incorrect medication counts and the nurse would review the records and investigate. LPN A said the nurse would inform the DON if the discrepancy could not be resolved. LPN A said he/she did not know how or where count errors were documented, but he/she thought the DON would document the issue. LPN A said he/she was not aware of residents' medication counts needing review or investigation.During an interview on 11/10/2025 at 11:48 A.M., the DON said when a resident brings controlled medications from home two nurses count the medications to verify counts. The DON said staff should count pills at every shift change and if medication counts did not match, he/she would interview staff to identify the problem. The DON said he/she thought one of the night nurses noticed the incorrect pill count on 11/03/25. The DON said he/she spoke with the two nurses who counted the resident's medication on admission, and he/she determined the nurses counted incorrectly but he/she could not say if the pills were counted incorrectly or taken. The DON said he/she never asked staff why the medication discrepancy was not identified until 11/03/25 after he/she determined a counting error took place on 10/30/25. The DON said he/she notified the administrator but did not receive any further instruction from the administrator. The DON said he/she did not know the facility's policy related to count discrepancies in controlled medications. The DON said he/she did not document his/her investigation and did not document the discrepancy on the controlled medication sheet or in the resident's chart.During an interview on 11/10/2025 at 12:03 P.M., the administrator said CMTs, and nurses should catch incorrect medication counts at shift change when they count the controlled medications. The administrator said he/she expects all controlled medications to be counted accurately at every shift change. The administrator said the charge nurse or DON should be notified of any discrepancies in the medication counts. The administrator said the DON is responsible for investigating medication discrepancies and documenting his/her findings on the medication sheet and in the resident's progress notes. The administrator said he/she was not aware the DON did not document the resident's medication count discrepancy or the result of his/her investigation. The administrator said he/she was aware of an issue with one resident's medication count, but he/she did not recall which resident. The administrator said the DON assured him/her the resident's medications were counted incorrectly when the resident was admitted . The administrator said he/she was aware staff did not follow facility policy. Complaint 2664063

Based on interview and record review, facility staff failed to consistently document the code status as Do Not Resuscitate (DNR) or Full Code (Cardiopulmonary resuscitation (CPR)) in the comprehensive care plan for nine residents (Resident #10, #18, #19, #21, #40, #41, #42, #8, and #32), and failed to transcribe or correct code status orders for two residents (Resident #8, and #32) out of 14 sampled residents. The facility census was 45. 1. Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR/DNR) Policy, dated [DATE], showed when a resident chooses to be a Full Code or a DNR, the order should be approved by the physician and entered into the electronic medical record as such. A DNR paper or Transportable Physician Order for Patient Preferences (TPOPP) must be signed by a physician. Review of the facility's policy titled, Physician Orders per e-Charting, dated [DATE], showed: -Any new order is to be transcribed to the paper physician order form by the physician or the nurse taking the verbal order; -The order is to immediately be entered into the electric chart by the nurse taking off the order; -24 hour chart audits are to be completed daily to ensure that all new orders have been addressed. Review of the facility's policy titled, Care Plan Completion Policy, dated [DATE], showed: -The facility shall use a care plan to provide daily care and treatment to the resident; -The care plan shall be completed and updated according to regulatory requirements; -Care plans shall be reviewed and updated at least upon admission, and quarterly and/or significant change; -For items that need addressed or revised prior to the next care plan meeting, a Care Plan Addendum shall be completed, and copy given to all departments; -The resident has a right to refuse any or all portions of the plan of care; the refusal shall be noted in a progress note by the Minimum Data Set (MDS), a federally mandated assessment tool completed by staff, Coordinator or Social Service Designee (SSD) at the completion of the care plan meeting and/or as needed; -The MDS Coordinator shall initiate care plan addendums at any time an individual presents a need that requires a change or addition to the care plan; -The Director of Nursing (DON) shall ensure that the care plan is completed according to the resident's individual and unique needs and that measurable goals with timeframes are continued throughout the resident's stay. 2. Review of Resident #10's Quarterly MDS, dated [DATE], showed staff documented the resident cognitively intact. Review of the resident's face sheet, undated, showed staff documented the resident's code status as DNR. Review of the Physician Order Sheet (POS), dated [DATE], showed an order for a code statusas DNR. Review of the medical record showed a TPOPP and Out of Hospital DNR (OHDNR) dated [DATE]. Review of the care plan, dated [DATE], showed staff did not document the resident's code status. During an interview on [DATE] at 2:53 P.M., the MDS coordinator said he/she did not know the code status is not listed in the resident's care plan, but saidit should be. 3. Review of Resident #18's Significant Change MDS, dated [DATE], showed staff assessed the resident as significantly cognitively impaired. Review of the resident's Face Sheet, undated, showed staff documented the resident's code status as DNR. Review of the POS, dated [DATE], showed an order for DNR code status dated [DATE]. Review of the care plan, dated [DATE], showed staff did not document the resident's code status. 4. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident with moderate cognitive impairment. Review of the resident's Face Sheet, undated, showed staff documented the resident's code status as DNR. Review of the POS, dated [DATE], showed an order for DNR code status dated [DATE]. Review of the care plan, dated [DATE], showed staff did not document the resident's code status. During an interview on [DATE] at 2:59 P.M., the MDS Coordinator said he/she does not know the resident's code status and the code status should be on the resident's care plan. He/She said he/she does not know why it is not in the care plan. During an interview on [DATE] at 3:38 P.M., the SSD said the resident should have his/her code status on his/her care plan. The SSD said he/she can't remember if he/she told the MDS Coordinator the resident's code status. During an interview on [DATE] at 11:17 A.M., the DON said the resident should have a code status on his/her care plan. 5. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's Face Sheet, undated, showed staff documented the resident's code status as DNR. Review of the POS, dated [DATE], showed an order for DNR code status dated [DATE]. Review of the care plan, dated [DATE], showed staff documented the resident's code status as full code. During an interview on [DATE] at 2:54 P.M., the MDS Coordinator said he/she thinks the resident's code status should be on the care plan. The MDS Coordinator said he/she should update the resident's care plan immediately if the resident's code status changes. The MDS Coordinator said he/she knows the resident had a code status change and to be honest he/she forgot to update the resident's care plan, it should have been updated. During an interview on [DATE] at 3:38 P.M., the SSD said during the resident's care plan meeting, the resident said he/she wanted to be a DNR and signed the forms. The SSD said he/she did not check the resident's care plan. The SSD said the resident's care plan should have been updated. During an interview on [DATE] at 11:17 A.M., the DON said he/she knows the resident switched to a DNR code status. The DON said he/she did not know the resident's care plan had him/her listed as a Full code. The DON said the resident's care plan should be updated immediately with code status change. 6. Review of resident #40's Quarterly MDS, dated [DATE], showed staff assessed the resident with mild cognitive impairment. Review of the resident's face sheet, undated, showed staff documented the resident's code status as full code. Review of the POS, dated [DATE], showed an order for full code status. Review of the TPOPP, undated, showed staff documented the resident's code status as full code. Review of the care plan, dated [DATE], showed staff did not document the resident's code status. 7. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the resident as rarely/never understood, and with short and long term memory problems. Review of the resident's face sheet, undated, showed staff documented the resident's code status as DNR. Review of the POS, dated [DATE], showed an order for DNR code status dated [DATE]. Review of the resident's care plan, dated [DATE], showed staff did not document the resident's code status. 8. Review of Resident #42's Quarterly MDS, dated [DATE], showed staff assessed the resident as rarely/never understood, and with short and long term memory problems. Review of the resident's face sheet, undated, showed staff documented the resident's code status as DNR. Review of the resident's POS, dated [DATE], showed an order for DNR code status dated [DATE]. Review of the resident's care plan, dated [DATE], showed staff did not document the resident's code status. 9. Review of Resident #8's Significant Change MDS, dated [DATE], showed staff documented the resident had short and long term memory problems. Review of the resident's face sheet, undated, showed staff documented the resident's code status as DNR. Review of the POS, dated [DATE], showed an order for Full Code status dated [DATE]. Review of the resident's TPOPP, dated [DATE] showed to attempt CPR, full code, uploaded to the electronic health record (EHR) on [DATE]. Review of the resident's TPOPP, undated, showed resident to be DNR, uploaded to the EHR on [DATE]. Review of the resident's care plan, dated [DATE], showed staff did not document the resident's code status. During an interview on [DATE] at 9:15 A.M., LPN A said he/she did not know the resident did not have a code status on the care plan, he/she said I guess I didn't pay attention and did not know the code status did not match on the face sheet and POS. During an interview on [DATE] at 11:52 A.M., the administrator said the resident had changed back and forth regarding his/her code status and it should have been changed on the POS to DNR. The administrator said he/she did not know why it had not been updated. 10. Review of Resident #32's Admission MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired. Review of the resident's face sheet, undated, showed staff documented the resident's code status as DNR. Review of the POS, dated [DATE], showed it did not contain an order for code status. Review of the resident's care plan, dated [DATE], showed staff did not document the resident's code status. 11. During an interview on [DATE] at 9:00 A.M., LPN K said he/she reviewed the two full code sheets that were posted on the hallway. The LPN said he/she is unable to determine which full code list is accurate. The LPN said if there are two lists there is a possibility to grab the wrong one and potentially not carry out a resident's code status wishes. During an interview on [DATE] at 2:54 P.M., the MDS Coordinator said he/she thinks code status should go on care plan. The MDS Coordinator said the SSD gives him/her the residents code status, and there should be an order for it. During an interview on [DATE] at 3:38 P.M., the SSD said if the facility does not get anything from the hospital, he/she starts the resident as a full code, until the resident gets to the facility and signs sign the document for the code status wishes. The SSD said nursing will notify him/her, or hospitals will notify him/her, if a resident's code status changes and he/she notifies the MDS Coordinator. The SSD said when he/she gets the code status, he/she takes the TPOPP to the nurses at the nurse's station. If the nurse is not at the nurse's station, he/she will lay it on the nurse's computer keyboard. The SSD said he/she does not follow up after that. The SSD said the resident's care plan should be changed as soon as staff can do it. The SSD said if the code status is wrong on the care plan, there is a risk staff would provide CPR to a resident that is a DNR. There is also a risk staff would not resuscitate a resident that is a full code. During an interview on [DATE] at 8:48 A.M., Licensed Practical Nurse (LPN) K said residents code status should be on the care plan. The LPN said the MDS coordinator is responsible for reviewing code status information and updating the care plan. During an interview on [DATE] at 9:11 A.M., CNA G said he/she would look in the care plan to see the resident's code status. CNA G said it absolutely should be in the care plan, and he/she did not know it was not in the care plan for Residents #8, #18, #32, #41, and #42. CNA G said he/she thinks the office takes care of the code status when they are admitted . During an interview on [DATE] at 9:15 A.M., LPN A said the code status is on the computer on the face sheet. LPN A said usually the nurses put the orders in on admission on the POS and it is based on the baseline care plan and TPOPP or OHDNR sheets. LPN A said the SSD will change the code status on the face sheet, and he/she is supposed to notify the nurses and then the nurses change the order in the computer. LPN A said code status is usually on the care plan, and when he/she has care plan meetings the resident is asked if they want to continue with the same code status. He/she did not know residents #18, #41, and #42 did not have their code status on the care plan. LPN A said the risk of not having an order is doing CPR on someone who is a DNR or not doing anything for someone that is a full code. During an interview on [DATE] at 11:17 A.M., the DON said they would not necessarily expect a code status to be on the care plan. He/she said the code status orders the nurses initially receive for the residents are from the hospital. The DON said if the code status changes, the SSD lets the nursing staff know. The DON said he/she expects the POS to contain a code status order and it should match the residents wishes. The DON said the MDS Coordinator looks at orders that come from the hospital and if there is a change in code status, the SSD should verbally communicate it with the nursing staff and MDS Coordinator. The DON said the MDS coordinator is responsible for updating the care plans, and he/she gets the code status information as it is updated from the SSD. The DON said having the wrong code status could cause confusion a resident may receive care they do not want. The DON said the nurse that the SSD hands the updated code status to, is responsible for getting the updated order. The DON said she is not sure why the resident's code status is not on the care plan. During an interview on [DATE] at 11:52 A.M., the administrator said the SSD is responsible for getting the code status for residents, and once the SSD has it he/she is to take it to the nurse's station and give it to the nurse. The SSD puts the code status on the resident's face sheet. The nurse is responsible for putting the order on the POS when completing the admission paperwork. The administrator said the MDS coordinator is responsible for updating the care plan. The administrator said he/she did not think code status needed to be on the care plan. 45489 48982 50361

Based on interview and record review, facility staff failed to perform a pre-dialysis (procedure to remove waste products from the blood when the kidneys stop functioning properly) assessment and to have a system in place for ongoing communication with the dialysis clinic for one (Resident #25) of one sampled resident. Facility census was 45. 1. Review of the facility's dialysis services policy and procedure, dated 04/05/23, showed staff are directed to obtain communication with the dialysis clinic. Review of the facility's memorandum of agreement with the dialysis clinic, undated, showed the facilities responsibilities are: -If the long term care facility is a skilled nursing facility appropriate long term care facility healthcare staff will make an assessment of each patient's physical condition and determine whether the patient is stable enough to be dialyzed; -If it is determined that a patient is sufficiently stable, this assessment will be communicated to the dialysis facility's nurse manager or designee; -This assessment and communication will occur prior to each and every transfer of a patient to the dialysis facility regardless of the number of times any particular patient may be transferred and dialyzed. 2. Review of Resident #25's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/04/25, showed staff documented the resident did not receive dialysis services, and diagnoses of renal insufficiency, renal failure, or end stage renal disease. Review of the Physician Order Sheet (POS), dated January 2025, showed an order for dialysis on Monday, Wednesday and Friday. Review of the care plan, dated 01/22/25, showed staff documented the resident attends dialysis every Monday, Wednesday, and Friday. Obtain weight, blood pressure, and pulse prior to leaving for and when returned from dialysis. Review of the medical record showed facility staff did not document they assessed the resident prior to dialysis and did not contain the pre and post dialysis vital sign communication form with required weight, blood pressure, pulse or assessment required from 11/04/24-11/11/24 and from 11/12/24-01/28/25. During an interview on 01/28/25 at 8:48 A.M., the resident said staff do not check his/her vital signs before he/she leaves for dialysis or when he/she returns from dialysis. He/She said the dialysis clinic staff send him/her back to the facility with a piece of paper that has information on it. During an interview on 01/29/2025 at 9:13 A.M., Licensed Practical Nurse (LPN) K said there is no formal continuous communication between the dialysis clinic and the facility. The nurse said he/she can call the clinic if he/she needs to talk to them. The night shift staff check the residents weight before dialysis but do not communicate this with the clinic. The LPN said staff do not complete an assessment before the resident goes to dialysis. During an interview on 01/29/2025 at 9:23 A.M., the Director of Nursing (DON) said the dialysis clinic sends the facility blood work results once a week and the resident sometimes returns from dialysis with a form that lets staff know how much fluid had been removed and what the resident's vital signs were while at the dialysis clinic. Staff check the resident's vital signs after dialysis and document it in the resident treatment record. The staff check the resident's weight prior to dialysis and the resident is responsible for telling the dialysis clinic his/her weight. The facility does not have ongoing communication with the dialysis clinic. The DON said he/she did not know staff were not following the facility policy, and the staff does not have a good system in place. During an interview on 01/30/2025 at 9:36 A.M., the administrator said the resident is alert and oriented and can make decisions and communicate with the dialysis clinic. The administrator said if there are concerns at the facility or the dialysis clinic they would call or send paperwork to communicate the concern. The administrator said he/she is not aware of any regular ongoing communication between the facility and the dialysis clinic. The administrator said he/she did not know if vital signs were communicated between the facilities and did not know the form was not being used.

Based on observation, interview and record review, facility staff failed to post the telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to report allegations of abuse and neglect), the name, address, and phone number for the Long-Term Care Ombudsman (a program serving residents of nursing homes and residential care facilities to provide support and assistance with their problems or complaints), and resident rights in a form and manner accessible to residents and visitors on the secured memory care unit (MCU). The facility census was 46. 1. Review of facility policy titled, Golden Age Living Center Postings, dated August 12, 2018 showed: -Purpose is to provide notices and postings to residents, families, and staff that are required by law; -Postings that should be provided as required: Medicaid posting, Resident Right Postings, Ombudsman posting, Hotline Posting, Grievance Posting, Current Menus, and Smoking Requirements; -The administrator and/or designee shall be responsible for keeping postings current. 2. Observation on 11/28/23 at 11:26 A.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse Hotline or the name, the address and phone number for the Long-Term Care Ombudsman, and the residents rights in the secured MCU. Observation on 11/29/23 at 3:37 P.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse Hotline or the name, the address and phone number for the Long-Term Care Ombudsman, and the residents rights in the secured MCU. Observation on 11/30/23 at 8:22 A.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse Hotline or the name, the address and phone number for the Long-Term Care Ombudsman, and the residents rights in the secured MCU. Observation on 12/01/23 at 10:45 A.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse Hotline or the name, the address and phone number for the Long-Term Care Ombudsman, and the residents rights in the secured MCU. During an interview on 12/01/23 at 11:08 A.M., Resident #8 said he/she has not heard of an ombudsman, but it would nice to know that information. The resident said he/she does not know where to find the hotline number, but he/she should and would like to. During an interview on 12/01/23 at 11:09 A.M., Certified Nursing Aide (CNA) J said the required postings are on the main hall outside the MCU and thinks it is in a book at the nurses' desk. CNA J said the information should be posted on the MCU, it is currently not accessible to residents on the MCU but it should be. During an interview on 12/01/23 at 11:15 A.M., Licensed Practical Nurse (LPN) K said the required postings are in a book at the nurses' desk in the MCU, and in the locked break room, but it is not accessible to residents or visitors. The LPN said residents and visitors should have access to all of that information. During an interview on 12/01/23 at 11:18 A.M., the Director of Nursing (DON) said the required postings are in a case near the front of the building, and he/she did not know the information was not posted on the MCU. The DON said all required postings should be posted on the MCU, and a lot of family who visit do not pass by the locations where they are posted in the main facility. The DON said residents and family members should have access to the ombudsman, resident rights and Abuse and Neglect hotline information. During an interview on 12/01/23 at 11:32 A.M., the Administrator said the required postings are in the glass cased bulletin board near the front entrance of the building. The administrator did not know the required postings were not posted on the MCU, and it should be.

Based on record review and interview, facility staff failed to document the date and location of the documentation used to complete the Care Area Assessment (CAA) section (section V0200) of the Minimum Data Set (MDS), a federally mandated resident assessment tool, for 12 sampled residents (Residents #1, #13, #17, #21, #24, #25, #28, #37, #44, #46, #49, and #56). The facility census was 83. 1. Review of the CAA summary section of the Resident Assessment Instrument (RAI) Manual showed the following: -Check section A (Care Area Triggered) if Care Area is triggered; -For each triggered care area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Care Plan Decision column must be completed within seven days of completing the RAI (MDS and CAAs). Check column B (Care Planning Decision) if the triggered area is addressed in the care plan; -Indicate in the location and date of CAA Documentation column where information related to the CAA can be found. CAA documentation should include information on the complicating factors, risks, and any referrals for this resident for this care area. 2. Review of Resident #1's MDS CAA Summary, completed by facility staff and dated 6/3/22, showed the CAA summary did not contain the location and date of supportive CAA documentation as directed in Section V. 3. Review of Resident #13's MDS CAA Summary, completed by facility staff and dated 7/3/22, showed the CAA summary did not contain the location and date of supportive CAA documentation as directed in Section V. 4. Review of Resident #17's MDS CAA Summary, completed by facility staff and dated 7/4/22, showed the CAA summary did not contain the location and date of supportive CAA documentation as directed in Section V. 5. Review of Resident #21's MDS CAA Summary, completed by facility staff and dated 7/3/22, showed the CAA summary did not contain the location and date of supportive CAA documentation as directed in Section V. 6. Review of Resident #24's MDS CAA Summary, completed by facility staff and dated 7/17/22, showed the CAA summary did not contain the location and date of supportive CAA documentation as directed in Section V. 7. Review of Resident #25's MDS CAA Summary, completed by facility staff and dated 9/16/22, showed the CAA summary did not contain the location and date of supportive CAA documentation as directed in Section V. 8. Review of Resident #28's MDS CAA Summary, completed by facility staff and dated 7/21/22, showed the CAA summary did not contain the location and date of supportive CAA documentation as directed in Section V. 9. Review of Resident #37's MDS CAA Summary, completed by facility staff and dated 8/10/22, showed the CAA summary did not contain the location and date of supportive CAA documentation as directed in Section V. 10. Review of Resident #44's MDS CAA Summary, completed by facility staff and dated 8/3/22, showed the CAA summary did not contain the location and date of supportive CAA documentation as directed in Section V. 11. Review of Resident #46's MDS CAA Summary, completed by facility staff and dated 7/21/22, showed the CAA summary did not contain the location and date of supportive CAA documentation as directed in Section V. 12. Review of Resident #49's MDS CAA Summary, completed by facility staff and dated 8/27/22, showed the CAA summary did not contain the location and date of supportive CAA documentation as directed in Section V. 13. Review of Resident #56's MDS CAA Summary, completed by facility staff and dated 7/24/22, showed the CAA summary did not contain the location and date of supportive CAA documentation as directed in Section V. 14. During an interview on 10/14/22 at 2:07 P.M., the MDS Coordinator said he/she does not use the CAA's for anything. He/She said if something triggered, staff investigates to assure make sure the triggered item is a true problem the resident needs addressed. During an interview on 10/14/22 at 2:18 P.M., the administrator said the MDS Coordinator and the DON are responsible for the MDS information. During an interview on 10/14/22 2:42 P.M., Director of Nursing (DON) said she is in charge of the MDSs triggered CAA. He/She takes information from what LPN C and the MDS coordinator, gives him/her and resident's needs to create care plans. He/She said he/she never uses dates or times in the in the CAAs, and only addresses which document areas the information could be found.

Based on interview and record review, facility staff failed to address the triggered care areas of the Care Area Assessment (CAA) for 11 residents (Resident #1, #13, #17, #21, #23, #24, #28, #36, #37, #46, and #49) and failed to provide person-centered care plans with measurable time frames, and goals for four residents (Resident #23, #36, #44, and #56), in order to meet the residents' individual, medical and nursing needs. The facility census was 53. 1. Review of the CAA summary section of the Resident Assessment Instrument (RAI) Manual showed the following: -Check section A (Care Area Triggered) if Care Area is triggered; -For each triggered care area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Care Plan Decision column must be completed within seven days of completing the RAI (MDS and CAA's). Check column B (Care Planning Decision) if the triggered area is addressed in the care plan; -Indicate in the location and date of CAA Documentation column where information related to the CAA can be found. CAA documentation should include information on the complicating factors, risks, and any referrals for this resident for this care area. In addition, review showed the facility did not have a Care Plan Policy with directions for comprehensive, measurable goals, time frames, or interventions. 2. Review of Resident #1's CAA worksheet, dated 6/3/22 showed the following triggered areas: -Cognitive loss/Dementia; -Visual function; -Communication; -ADL Functional/Rehabilitation Potential; -Urinary incontinence and indwelling catheter; -Falls; -Nutritional Status; -Dehydration/Fluid Maintenance; -Dental Care; -Pressure ulcers; -[CONDITION(S)] Drug use. Review of the resident's care plan, dated 10/12/22 showed staff did not document that they addressed the following triggered care areas: -Visual function; -Communication; -Urinary incontinence and indwelling catheter; -Falls; -Nutritional Status; -Pressure ulcers; -[CONDITION(S)] Drug use. Further review showed staff did not document a rationale for the decision not to proceed with a care plan for all the areas triggered. 3. Review of Resident #13's CAA worksheet, dated 7/3/22 showed the following triggered areas: -Delirium; -Cognitive loss/Dementia; -Communication; -Urinary incontinence and indwelling catheter; -Mood State; -Behavioral Symptoms; -Falls; -Nutritional Status; -Dental Care; -Pressure ulcers; -[CONDITION(S)] Drug use. Review of the resident's care plan, dated 9/27/22 showed staff did not document that they addressed the following triggered care areas: -Delirium; -Cognitive loss/Dementia; -Urinary incontinence and indwelling catheter; -Behavioral Symptoms; -Falls; -Nutritional Status; -Pressure ulcers; -[CONDITION(S)] Drug use. Further review showed staff did not document a rationale for the decision not to proceed with a care plan for all the areas triggered. 4. Review of Resident #17's CAA worksheet, dated 7/4/22, showed the following triggered areas: -Delirium; -Cognitive loss/Dementia; -Visual function; -ADL Functional/Rehabilitation Potential; -Urinary incontinence and indwelling catheter; -Psychosocial well-being; -Falls; -Nutritional status; -Dehydration/Fluid Maintenance; -Dental Care; -Pressure Ulcers. Review of the resident's care plan, dated 9/19/22 showed staff did not document that they addressed the following triggered care areas: -Urinary incontinence and indwelling catheter; -Psychosocial well-being; -Dehydration/Fluid Maintenance. Further review showed staff did not document a rationale for the decision not to proceed with a care plan for all the areas triggered. 5. Review of Resident #21's CAA worksheet, dated 7/3/22 showed the following triggered areas: -ADL Functional/Rehabilitation Potential; -Urinary incontinence and indwelling catheter; -Falls; -Nutritional Status; -Dehydration/Fluid Maintenance; -Dental Care; -Pressure ulcers; -[CONDITION(S)] Drug use. Review of the resident's care plan, dated 8/16/22 showed staff did not document that they addressed the following triggered care areas: -Dehydration/Fluid Maintenance; -Dental Care. Further review showed staff did not document a rationale for the decision not to proceed with a care plan for all the areas triggered. 6. Review of Resident #23's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Dependent with bed mobility, transfers, dressing, eating, and personal hygiene, dressing, and toilet use; -Required extensive assistance of two staff members for toileting; -Impaired with both lower extremities; -diagnosed with [CONDITION(S)] (the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem), diabetes, [CONDITION(S)] (a condition in which there are high levels of fat particles in the blood), and [CONDITION(S)] (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth). Review of the resident's care plan, updated on 9/27/22, showed the care plan did not address prevention of increased contractures of the resident's legs. In addition, the care plan did not contain measurable goals and time frames. During an interview on 10/12/22 at 11:55 A.M., Certified Nursing Aide (CNA) B said the resident had contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in both legs. He/She said the resident was not receiving formal treatment or positioning to prevent the contractures from getting worse. CNA B said the resident screams in pain and becomes combative if staff attempts to stretch the resident's legs, but does allow the staff to stretch and move the resident's legs gently while getting dressed and other daily care. He/She said this is how staff maintains the movement of the resident's legs. 7. Review of Resident #24's CAA worksheet, dated 7/17/2022 showed the following triggered areas: -Cognitive Loss/Dementia; -Visual Function; -Communication; -Urinary Incontinence and Indwelling Catheter; -Falls; -Nutritional Status; -Dehydration/Fluid Maintenance; -Dental Care; -Pressure Ulcer; -[CONDITION(S)] Drug Use. Review of the resident's care plan, dated 10/11/22 showed staff did not document that they addressed the following triggered care areas: -Cognitive Loss/Dementia; -Communication; -Dehydration/Fluid Maintenance; -Dental Care; -Pressure Ulcer; -[CONDITION(S)] Drug Use. Further review showed staff did not document a rationale for the decision not to proceed with a care plan for all the areas triggered. 8. Review of Resident 28's CAA worksheet, dated 7/21/22 showed the following triggered areas: -Cognitive loss/Dementia; -Communication; -Falls; -Nutritional Status; -Dental Care; -Pressure ulcers. Review of the resident's care plan, dated 1/17/22 showed staff did not document that they addressed the following triggered care areas: -Communication; -Falls; -Nutritional Status; -Pressure ulcers. Further review showed staff did not document a rationale for the decision not to proceed with a care plan for all the areas triggered. 9. Review of Resident #36's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderately cognitively impaired; -Required extensive assistance of two staff members for bed mobility, transfers, dressing, and toileting; -Required extensive assistance of one staff member for personal hygiene; -Impaired with one lower extremity; -diagnosed with [CONDITION(S)], high blood pressure, disease of the bowels, [CONDITION(S)], a fracture, dementia, [CONDITION(S)], anxiety, and depression. During an interview on 10/11/22 at 1:33 P.M., the resident's spouse said that rehabilitation and walking were very important for his/her spouse in order to maintain or gain independence. Review of the resident's physician orders, dated 4/29/20, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, updated on 6/21/22, showed the care plan did not address restorative therapy or rehab nursing assistant services. In addition, the care plan did not contain measurable goals and time frames. 10. Review of Resident #37's CAA worksheet, dated 5/10/22, showed the following triggered areas: -Cognitive loss/Dementia; -ADL Functional/Rehabilitation Potential; -Urinary incontinence and indwelling catheter; -Falls; -Nutritional status; -Dehydration/Fluid Maintenance; -Dental Care; -Pressure Ulcer; -[CONDITION(S)] Drug Use. Review of the resident's care plan, dated 8/10/22 showed staff did not document that they addressed the following triggered care areas: -Urinary incontinence and indwelling catheter; -Psychosocial well-being; -Dehydration/Fluid Maintenance. Further review showed staff did not document a rationale for the decision not to proceed with a care plan for all the areas triggered. 11. Review of Resident #44's comprehensive care plan, last updated 10/11/22, showed the record did not contain measurable time frames to address the resident's care area problems. 12. Review of Resident 46's CAA worksheet, dated 7/21/22 showed the following triggered areas: -Delirium; -Cognitive loss/Dementia; -Communication; -Urinary incontinence and indwelling catheter; -Falls; -Nutritional Status; -Dehydration/Fluid Maintenance; -Dental Care; -Pressure ulcers; -[CONDITION(S)] Drug use. Review of the resident's care plan, dated 8/18/22 showed staff did not document that they addressed the following triggered care areas: -Delirium; -Cognitive loss/Dementia; -Communication; -Urinary incontinence and indwelling catheter; -Nutritional Status; -Dehydration/Fluid Maintenance; -Dental Care; -Pressure ulcers; -[CONDITION(S)] Drug use. Further review showed staff did not document a rationale for the decision not to proceed with a care plan for all the areas triggered. 13. Review of Resident #49's CAA worksheet dated 8/27/22, showed the following triggered areas: -Cognitive loss/Dementia; -ADL Functional/Rehabilitation Potential; -Urinary incontinence and indwelling catheter; -Pressure Ulcer. Review of the resident's care plan, dated 8/29/22 showed staff did not document that they addressed the following triggered care areas: -Cognitive loss/Dementia; -Urinary incontinence and indwelling catheter; -Pressure Ulcer. Further review showed staff did not document a rationale for the decision not to proceed with a care plan for all the areas triggered. 14. Review of Resident #56's comprehensive care plan, last updated 10/12/22, showed the record did not contain measurable time frames to address the resident's care area problems. 15. During an interview on 10/14/22 at 1:40 P.M., Certified Nurses Aid (CNA) D said care plans should be up to date, complete, and accurate. He/She said he/she relies on the care plans to tell him/her how to care for each resident and it is especially important when there are changes or updates that have been made to the residents' care. Not only is it important for staff to know how to take care of the residents, but it is also important when residents are being evaluated for significant changes in health. During an interview on 10/14/22 at 2:07 P.M., Licensed Practical Nurse (LPN) C, the MDS Coordinator said care plans are developed using the hospital discharge papers and after talking with the resident and/or the resident's family about their goals. He/She said the CAAs are not used for the care plans. He/She said if updates are needed, they are added to the Care Plan and staff receive in-services regarding the changes. He/She said the care plan should include all aspects of the residents' care. During an interview on 10/14/22 at 2:18 P.M., the administrator said he/she was involved writing the baseline care plan based on the information from the hospital so all care staff have access to the information before the resident arrives. He/She said further work on the MDS and care plan is the responsibility of the Director of Nursing (DON) and MDS coordinator. During an interview on 10/14/22 02:42 P.M., DON said the MDS Coordinator takes care of the care plans and the care plan reviews, and the team meets about them every quarter. During an interview on 10/20/22 at 11:57 A.M., the administrator said the care plan policy needed updated as it did not address many aspects of care plans.

Based on interview and record review facility staff failed to ensure residents remained free of significant medication errors for one resident (Resident #1) who was given [MEDICATION(S)] (a medication that lowers blood sugar) when it was not prescribed which caused the resident's blood sugar to drop to 36 and require two injections followed by one dose of [MEDICATION(S)] (medication used to raise blood sugar) gel to stabalize it. The facility census was 44. 1. Review of the facility's Administering Medications policy, dated 04/08/20, showed medications must be administered per orders, Medication should be checked three times to assure right resident and medications ordered for a particular resident should not be administered to another resident. 2. Review of the facility's Adverse Consequences and Medication Errors policy, dated 07/26/18, showed the facility defined a medication error as the preparation or administration of drugs or biological which is not in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of Resident #1's discharge Minimum Data Set (MDS), (a federally mandated tool used to assess residents), dated 12/13/21, showed staff assessed the resident as follows: -Did not have diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Did not receive insulin injections; -Did not receive orders for insulin. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's electronic physician sheet order history showed an order was entered on 1/7/20 for [MEDICATION(S)] 25 units subcutaneous at bedtime with a discontinuation date of 1/10/20. Review of the resident's electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and again on 1/9/22 at 8:00 P.M. Review of the resident's progress notes, late entry dated 3/31/22 for 1/10/22, showed staff documented on arrival to unit where the resident resides he/she was found in bed which was normal for the resident he/she did not like to get up for the day until later in the morning. During morning medication pass noticed an insulin vial in the top of the medication cart to be given at hs. Review showed staff documented he/she planned to check the order for this after the pass was complete. Review showed around 9 A.M. resident was assisted into a wheelchair by staff. Review showed the resident sat at a table in the dining room and appeared very sleepy. Review showed the resident's blood sugar was checked and results were 36. Physician notified and new order received for [MEDICATION(S)] (medication used to raise blood sugar) Intramuscular (IM) and repeat a second dose if needed. [MEDICATION(S)] IM administered. Review showed staff documented they administered a second dose of [MEDICATION(S)] after 15 minutes, blood sugar remained low, resident still appears very sleepy. Review showed resident able to take sips of juice, oral gel was given. Resident then able to eat breakfast with assist per his/her normal. Blood sugars monitored every hour throughout the shift. Family notified. During an interview on 3/30/22 at 1:55 P.M., the Director of Nursing said the resident had received the insulin in error and they had reviewed it but he/she could not find the documentation of the incident in the resident's medical record either. He/She said staff are expected to transcribe medications for the correct residents and they should also document medication errors and details in the residents medical record. During an interview on 3/30/22 at 2:06 P.M., Licensed Practical Nurse (LPN) A said that he/she did not document the medication error in the resident's medical record when it occurred because he/she was under the impression that was for internal use only and was not supposed to be documented in the resident's medical record. LPN A said the medication error had occurred because the nurse who obtained the order initially put it on the wrong resident's chart and when he/she saw the insulin bottle on his/her cart he/he had planned to investigate it because the resident had not received insulin injections before. During an interview on 3/31/22 at 2:20 P.M., LPN B said they had worked with the physician to get all insulin pens converted to vials and he/she received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN B said the software program they used would glitch and he/she thinks that is what happened. During an interview on 3/31/22 at 10:00 A.M., the Administrator said he/she would expect staff to transcribe physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MO 479

Based on observation, interview, and record review facility staff failed to follow the facility policy for disposing of medication when Certified Medication Technician (CMT ) A dropped the medication for three residents (Resident #1, #2, and #3) picked the medication up with an ungloved hand and placed the medication in the residents' medication cups. The facility census was 43. 1. Review of the Facility's Medications Guideline for Oral Medication Pass Policy, undated, showed if a medication is dropped or touched, the medication is to be discarded and a new one obtained from the medication card. Additonal review showed staff are instructed to wash their hands after administration, and procede to the next resident. 2. Observation on 05/13/21 at 9:03 A.M., showed CMT A prepared Resident #1's medication. Observation showed the CMT dropped the resident's potassium tablet on top of the medication cart. Observation showed the CMT picked up medication tablet with his/her unsanitized bare hand and placed it in the resident's medication cup and then administered the medication to the resident. The CMA did not dispose of the medication as directed in the facility policy. 3. Observation on 05/13/21 at 9:06 A.M., showed CMT A prepared Resident #2's medication. Observation showed the CMT dropped the resident's medication on top of the medication cart. Observation showed the CMT picked up the medication tablet with his/her unsanitized bare hand and placed it in the resident's medication cup and then administered the medication to the resident. The CMA did not dispose of the medication as directed in the facility policy. 4. Observation on 05/13/21 at 9:17 A.M., showed CMT A prepared Resident #3's medication. Further observation showed CMT A poured two pills into the cap of a stock medication and when he/she went to pour one into the medication cup he/she used an ungloved hand to hold one pill down. Observation showed the CMT placed the touched pill back into the stock bottle. Additional observation showed CMT A dropped one of the resident's medications on top of the medication cart, put the cup to the edge of the cart and used the bubble card to sweep the pill into the resident's cup and then administered the medication to the resident. The CMA did not dispose of the medication as directed in the facility policy. 5. Observation on 05/13/21 at 9:19 A.M., showed CMT A with an unsanitized bare hand replaced five pills into a loose medication bubble pack and taped it back. The CMA did not dispose of the medication as directed in the facility policy. 6. During an interview on 05/13/21 at 9:24 A.M., CMT A said he/she should have thrown away any of the medications that dropped on the medication cart and replaced them. He/She said, I don't know why I didn't. During an interview on 05/13/21 at 12:01 P.M., the administrator said, We will have to retrain our staff on medication pass and what to do when medication is dropped. MO 590

Based on interview and record review, facility staff failed to develop and implement policies and procedures for the inspection, testing and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility staff also failed to administer the purified protein derivative (PPD) two-step skin test for one resident (Resident #20) and failed to provide the annually screen for signs and symptoms of [MEDICAL CONDITION] (TB) (a skin test that determines if you have TB) for seven resident's (Resident #7, #8, #19, #20, #22, and #42) out of a sample of 12 resident's. The facility census was 46. 1. Review of the facility's building maintenance, inspection and testing records, showed the records did not contain documentation of a water management program to monitor the facility's water systems for the growth of waterborne pathogens and prevent LD. During an interview on 06/06/18 at 8:00 A.M., the Maintenance Director said did not have policies and procedures for the inspection, testing and maintenance of the facility water systems and he/she did not know of the requirement to develop a water management program to prevent the growth of waterborne pathogens. During an interview on 06/06/18 at 1:15 P.M., the administrator said he/she did not have policies and procedures for the inspection, testing and maintenance of the facility water systems and he/she did not know of the requirement to develop a water management program to prevent the growth of waterborne pathogens. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as [MEDICAL CONDITION] or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of [DIAGNOSES REDACTED] was published in (YEAR) by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In (YEAR), the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard(https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. 2. Review of Missouri state regulations 19 CSR 20-20.100 ([MEDICAL CONDITION] (TB) testing for residents and workers in long-term care facilities) showed: -Long-term care facilities shall screen their residents and staff for [MEDICAL CONDITION] using the Mantoux method PPD five [MEDICATION NAME] unit test (TST). Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of TB disease; -All positive findings shall require a chest X-ray to rule out active [MEDICAL CONDITION] disease; -Individuals with a positive finding need not have repeat annual chest X-rays. They shall have a documented annual evaluation to rule out signs and symptoms of [MEDICAL CONDITION] disease. 3. Review of the facility's TB testing policy , undated, shows staff are to directed to: -Administer the PPD skin test within the first week of admission to the facility; -Read the test within 48-72 hours and if negative the test is to be repeated in one to three weeks and read in 48-72 hours; -A routine yearly test is not recommended unless there are signs and symptoms of TB or a known exposure; -The resident is to be assessed for signs and symptoms of TB yearly and documented on. 4. Review of Resident #7's, medical record showed the resident admitted to the facility on [DATE]. Additional review of the resident medical record showed records did not contain documentation staff completed the annual TB screening assessment for signs and symptoms. 5. Review of Resident #8's medical record, showed the resident admitted to the facility on [DATE]. Additional review of the resident medical record showed records did not contain documentation staff completed the annual TB screening assessment for signs and symptoms. 6. Review of Resident #19's medical record showed the resident was admitted to on 08/13/12. Additional review of the resident medical record showed records did not contain documentation staff completed the annual TB screening assessment for signs and symptoms. 7. Review of Resident #20's medical record showed the resident admitted to the facility on [DATE]. Additional review of the resident medical record showed records did not contain documentation staff completed the annual TB screening assessment for signs and symptoms. 8. Review of Resident #22's medical record showed the resident admitted to the facility on [DATE]. Additional review of the resident medical record showed records did not contain documentation staff completed the annual TB screening assessment for signs and symptoms. 9. Review of Resident #42's medical record showed the resident admitted to the facility on [DATE]. Additional review of the resident medical record showed records did not contain documentation staff completed the annual TB screening assessment for signs and symptoms. 10. During an interview on 6/08/18, at 2:06 P.M., LPN A said the charge nurses are expected to complete a two-step PPD test on admission. He/She said the first step is done the first week of admission, and the second step is completed two weeks after the first step. He/She said he/she should make sure the two step is completed on admission and must have missed the ones not done. He/She said the facility does not complete annual TB screens because they did not know they had too. LPN A said he/she could not find any documentation to show the residents received the annual [MEDICAL CONDITION] screen in (YEAR).

Based on staff interviews and record review, facility staff failed to keep resident petty cash separated from facility petty cash. This had the potential to affect all residents. The census was 46. Review of the facility's admission packet, showed under Money and Property: Resident funds will not be commingled with facility funds or the funds of any other person, other than another resident. Review on 6/7/18 showed staff did not have a ledger for the residents' petty cash. In addition, the monthly reconciled bank statements did not show petty cash for the residents. During an interview on 6/7/18 at 10:20 A.M., the bookkeeper in charge of resident trust funds said the facility does not have petty cash for the residents. He/She said if the residents want cash, he/she gives it to them from the facility's petty cash. He/She fills out a form which lists the resident's name and the amount requested and reimburses the facility's petty cash from the resident's trust. The monthly resident petty cash totals appear on the facility's Petty Cash Reimbursement Report under reimbursable resident purchases. Individual petty cash reimbursements are combined with other costs under room and board on each residents' quarterly statement. He/She did not know residents' petty cash had to be separate from the facility's petty cash and did not know if the facility has a policy regarding petty cash. During an interview on 6/8/18 at 12:05 P.M., the administrator said the facility has a policy regarding resident funds and she expects the bookkeeper to be familiar with the policy and the regulations regarding resident funds. She said resident petty cash should be kept separate from the facility's petty cash.

Based on staff interview and record review, facility staff failed to ensure timely notification of balance letters to residents when the balance of the Medicaid residents' trust fund accounts exceeded $1,799.99, $200.00 less than the SSI resource limit. This deficient practice had the potential to affect all residents that received Medicaid services. The census was 46. 1. Review of the Department of Social Services memo dated 7/1/17, showed the following: -The Department of Social Services has increased the resident resource limit to $2,000.00 for an individual; -Previous notification to the resident at $799.99 and above is now notification to be given at $1,799.99 and above or the resident may lose eligibility for Medicaid or Supplemental Security Income (SSI). 2. Review of the facility's Resident Admission Packet showed facility staff will notify each Medicaid resident when his/her balance of personal funds comes within $200 of the Medicaid limit and the effect of this on eligibility. 3. Review of Resident #7's balance reports showed the following: -As of 7/31/17, the resident had $2161.01 in his/her account; -As of 8/31/17, the resident had $2700.00 in his/her account; -As of 10/1/17, the resident had $2274.67 in his/her account. 4. Review of Resident #12's balance reports showed the following: -As of 8/31/17, the resident had $2259.10 in his/her account; -As of 2/22/18, the resident had $1925.11 in his/her account; -As of 3/26/18, the resident had $1949.07 in his/her account. 5. Review of Resident #30's balance reports showed the following: -As of 10/26/17, the resident had $1832.45 in his/her account; -As of 11/27/17, the resident had $1832.62 in his/her account. 6. During an interview on 6/7/18 at 7:50 A.M., the bookkeeper/accountant in charge of resident funds said he/she does not send out spend down letters. The bookkeeper said he/she calls the residents' responsible party regarding balances, but he/she does not follow up with a letter. He/She did not have documentation of the phone calls regarding balances. He/She said he/she thinks there is a policy regarding resident fund balances, but is not sure. He/she did not know to send a letter regarding balances over $1799. During an interview on 6/8/18 at 12:05 P.M., the administrator said there is a policy regarding resident account balances. She said she expects the bookkeeper to be familiar with the regulations regarding resident funds and to follow them. She said the bookkeeper is responsible to review accounts and send out the letters and follow up with a phone call, as needed. The administrator said phone calls cannot substitute for the letters, but could be used to supplement.

Based on staff interview and record review, facility staff failed to provide a free basic haircut for Medicaid residents. This had the potential to affect all Medicaid residents. The census was 46. Review of the facility's current admission packet, showed the following information: -The barber and beautician are not covered by insurances and will be an out-of-pocket expense. The barber charges $10 per cut. The beautician charges $15 for cut/shampoo/set and $45 for a perm. You may ask someone else to perform these services, if desired. A check list was attached to the letter with the following options: -The barber/beautician is to perform hair maintenance; -If no, list who will be cutting the resident's hair. During an interview on 6/8/18 at 11:42 A.M., the social worker (SW) said she reviews the admission packet with new residents and family. She said the information about beautician/barber charges is part of the current admission packet and the prices may vary depending on who cuts the hair. The SW said the facility does not offer free haircuts to the residents. She said they offered free haircuts in the past, but it was an administrative decision to no longer offer them. She said she is not aware Medicaid residents should be offered a free basic haircut. During an interview on 6/8/18 at 12:05 P.M., the administrator said residents are charged for barber/beautician services and they do not offer a free basic haircut for Medicaid residents. She said residents' family members would never agree to have just anyone cut the resident's hair and she doesn't think anyone would want a haircut by staff, even if it was free. She said the residents have the option of going out for a haircut and they do not offer a free basic haircut.

Based on observation, interview and record review the facility staff failed to provide restorative nursing services to maintain or improve range of motion (ROM) two resident's (Resident #19 and #43) out of four sampled residents. The facility census was 46. 1. Review of the facility's policy Range of Motion Exercised, undated, directs staff to: -Provide ROM exercises to prevent loss of (ROM; specific exercises include -Shoulders-flexion/extension, abduction/adduction, internal/external rotation; -Elbow-flexion/extension, supination/pronation; -Wrist-flexion/extension/hyperextension, abduction/adduction; -Fingers-flexion/extension, abduction/adduction, thumb rotation, thumb opposition; -Hip and knee-flexion/extension, abduction/adduction, internal/external rotation; -Ankle-inversion/eversion, dorsiflexion/plantarlexion; -Toes-flexion/extension, abduction/adduction; -Document task. 2. Review of Resident #19's significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, dated 3/29/18, showed the staff assessed the resident as: -Cognitively intact; -[DIAGNOSES REDACTED]. -Limited range of motion in both upper and both lower extremities (arms and legs); -One Stage 3 and One Stage 4 pressure ulcer 3.9 length, 8.2 cm width, and 0.3 cm depth, most severe tissue type-slough; -Pressure reducing device for chair and bed. Additional review showed the record did not contain Restorative Nursing Program documentation. Review of the resident's Restorative Nursing Program, dated 6/20/16, shows staff are directed as follows: -The resident has a left hand contracture; -Apply splint daily, to be worn from 7:00 A.M. to 1:00 P.M.; -Left hand Passive ROM to increase extension (in the muscles) prior to placement of the splint; -ROM to left and right shoulders and elbows. Review of the resident's care plan, last updated 5/23/18, showed it did not contain information about the resident's contracture, limited ROM, or his/her splint for his/her left hand. Review of the resident's Daily Care Guide, dated 6/8/18, showed staff are directed to: -Passive ROM to upper extremities daily and stretched and rotation; -Splint/Brace assistance: apply brace to left hand after washing and range of motion. Review of the resident's Restorative Minutes, dated 12/1/17-6/8/18, showed the staff documented the resident received a splint or brace assistance on one day 3/3/18. The minutes did not contain documentation of passive or active range of motion during that time. Observation on 6/6/18 at 11:19 A.M., showed the resident in bed, his/her left hand contractured. Further observation showed the resident did not have a splint or roll in the resident's left hand. During an interview on 6/6/18, at 1:56 P.M., the resident said he/she is paralyzed from the chest down. He/She said he/she does not get assistance with stretching or moving his/her extremities and he/she cannot open his/her left hand. The resident said staff used to use a splint for his/her left hand and he/she doesn't even know where it is. He/She said he/she is starting to lose movement in his/her left shoulder too, It is starting to feel stiff. Observation on 6/7/18, at 6:30 A.M., showed the resident in bed with his/her left hand contractured. Further observation showed the resident did not have a splint or roll in his/her left hand. During an interview on 6/7/18, at 6:42 A.M., certified nurse assistant/restorative nurse assistant (CNA/RNA) F said he/she is trained to do restorative, but does not work as a restorative aide at this time. He/She said he/she does not know why the resident did not have a splint, or if the resident receives restorative nursing. Observation on 6/7/18, at 1:15 P.M., showed the resident in bed with his/her left hand contractured. Further observation showed the resident did not have a splint or roll in the resident's left hand. During an interview on 6/8/18, at 10:38 A.M., certified nurse assistant/restorative nurse assistant (CNA/RNA) E said that he/she is trained to do restorative but does not work as a restorative aide at this time. He/She said he/she did not know why the resident did not have a splint, or if the resident receives restoritive nursing. 3. Review of Resident #43's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -Did not display behaviors or reject care during the look back period; -Dependent on two or more staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Dependent on one staff for eating and bathing; -Functional limitation of range of motion in both upper and both lower extremities; -Uses a wheelchair for mobility; -[DIAGNOSES REDACTED]. -Did not receive restorative nursing care during the look back period. Review of the resident's care plan, updated 5/26/18, showed staff documented: -Family would like the resident to do exercise activities (has not moved extremities without assistance at present); -Family would like the resident to go home; -Uses a wheelchair for mobility and is totally dependent on staff for mobility; -Requires a mechanical lift for transfers. Additional review showed the care plan does not provide direction to staff regarding how to care for the resident's contractures of both hands. Review of the resident's physician order [REDACTED]. Additional review showed staff did not document any orders for a restorative program or therapy evaluations. Observation on 6/5/18 at 11:40 A.M., showed the resident in his/her wheelchair in the dining room. Additional observation showed contractures to both of the resident's hands, with a soft cone in the palm of the right hand. Observation and interview on 6/7/18 at 1:30 P.M., showed the resident in bed. CNA C and CNA D provided care to the resident. CNA C placed the resident's left hand on a pillow. Additional observation showed a soft cone in the palm of his/her right hand. The CNAs did not provide range of motion or exercises to the resident's contracted hands. CNA C said staff do not provide any care to the resident's hands other than to place the left hand on a pillow and remove the cone from the right hand daily to wash the hand. The CNA said staff do not place a cone or roll in the left hand because his/her hand won't hold onto anything anymore. Observation on 6/8/18 at 10:16 A.M., showed the resident in his/her wheelchair in the dining room. Additional observation showed contractures to both of the resident's hands, with a soft cone in the palm of the right hand. During an interview on 6/8/18 at 11:26 A.M., CNA E said staff do not provide restorative care for the resident. The CNA said he/she thinks the resident would benefit from restorative care and said he/she did not know why the resident does not receive restorative care. During an interview on 6/8/18 at 3:02 P.M., the administrator (ADM) said he/she thought staff requested a therapy evaluation for the resident but was not sure. The administrator said nursing staff and therapy staff are responsible to request therapy evaluations. During an interview on 6/8/18 at 3:30 P.M., LPN D said he/she did not know why staff did not provide therapy or a restorative program to the resident. During an interview on 6/8/18 at 4:00 P.M., the ADM said therapy staff are waiting for insurance approval before they provide therapy services to the resident. 4. During an interview on 6/08/18, at 3:18 P.M., the ADM said some of the CNA's are trained in restorative nursing, and staff are expected to complete the restorative task and document them. He/She said there is not a designated restorative aide at this time.

Based on interview and record review the facility staff failed to offer or administer the recommended Pneumococcal vaccination for four resident's (Resident #19, #20, #38, and #40) out of 12 sampled residents. The facility census was 46. 1. Review of the Center for Disease Control (CDC) website, last updated 12/6/17, showed there are two types of Pneumococcal vaccines available in the United States, Pneumococcal conjugate vaccine (PCV13 or Prevnar13®) and Pneumococcal [MEDICATION NAME] vaccine (PPSV23 or [MEDICATION NAME]®). The CDC recommends Pneumococcal vaccination for all adults [AGE] years or older. Additional review shows the CDC recommends the following: In certain situations, other children and adults should also receive Pneumococcal vaccines. Below is more information about which Pneumococcal vaccines CDC recommends by age group and medical condition (where applicable). For Adults 19 through [AGE] years: -CDC recommends Pneumococcal vaccination for adults 19 through [AGE] years old who have certain medical conditions or who smoke. *For anyone with any of the conditions listed below who has not previously received the recommended Pneumococcal vaccines: -[DIAGNOSES REDACTED]s -Cochlear implant(s) *CDC recommends you: -Give 1 dose of PCV13 and 1 dose of PPSV23. Administer PCV13 first, then give the PPSV23 dose at least 8 weeks later. *For anyone with any of the conditions listed below who has not previously received the recommended Pneumococcal vaccines: -[MEDICAL CONDITION] cell disease or other hemoglobinopathies; -Congenital or acquired asplenia; -Congenital or acquired immunodeficiency; -HIV infection; -[MEDICAL CONDITION] or nephroti[DIAGNOSES REDACTED]; -[MEDICAL CONDITION] or [MEDICAL CONDITION]; -Hodgkin's disease; -Generalized malignancy; -Iatrogenic immunosuppression (diseases requiring treatment with immunosuppressive drugs, including long-term systemic corticosteroids and [MEDICAL CONDITION] therapy); -Solid organ transplantation; -[DIAGNOSES REDACTED]; CDC recommends you: Give 1 dose of PCV13 and 2 doses of PPSV23. Administer PCV13 first, then give the first PPSV23 dose at least 8 weeks later. Give the second dose of PPSV23 at least 5 years after the first. *For anyone who smokes and has not previously received the recommended Pneumococcal vaccine CDC recommends you: Give 1 dose of PPSV23. *For anyone with any of the conditions listed below who has not previously received the recommended Pneumococcal vaccine: Alcoholism Chronic [MEDICAL CONDITION] Chronic liver disease [MEDICAL CONDITION] Diabetes mellitus CDC recommends you: Give 1 dose of PPSV23. *Adults [AGE] years or Older CDC recommends Pneumococcal vaccination for all adults [AGE] years or older: -Give 1 dose of PCV13 to all adults [AGE] years or older who have not previously received a dose; -Give 1 dose of PPSV23 to all adults [AGE] years or older at least 1 year after any prior PCV13 dose and at least 5 years after any prior PPSV23 dose; -Adults who received one or two doses of PPSV23 before age 65 should receive one final dose of the vaccine at age 65 or older. 2. Review of the facility's Influenza and Pneumonia Vaccination Guidelines, dated 3/13/18, showed every resident should be up to date on their vaccines or offered vaccines and if not then Pneumonia vaccine is to be administered per CDC guidelines and Pneumonia vaccine is to be offered on admit and reviewed yearly. 3. Review of Resident #19's significant change in status assessment (SCSA) MDS, dated [DATE], showed the staff assessed the resident as: -admitted [DATE]; -Cognitively intact; -[DIAGNOSES REDACTED]. -One Stage 3 and One Stage 4 pressure ulcer 3.9 length, 8.2 cm width, and 0.3 cm depth, most severe tissue type-slough; -Oxygen therapy; -Influenza vaccine 10/30/17; -Pneumococcal vaccination up to date. Review of the resident's medical record showed the resident is [AGE] years or older. Review of the resident's Immunization record showed the resident received the PCV13 (not dated). The record did not contain information the facility offered or administered the PPSV23. 4. Review of Resident #20's SCSA MDS, dated [DATE], showed the staff assessed the resident as: -admitted [DATE]; -Cognitively intact; -[DIAGNOSES REDACTED]. -Mild depression; -Pneumococcal up to date. Review of the resident's medical record showed the resident is [AGE] years or older. Review of the resident's Immunization record showed the resident received the PCV13 on 7/16/17. The record did not contain information the facility offered or administered the PPSV23. 5. Review of Resident's #38 admission MDS, date 4/30/18, showed the resident's Pneumococcal vaccination was up to date. Review of the resident's medical record, showed the admitted [DIAGNOSES REDACTED]. During an interview on 6/8/18 at 2:00 P.M., the MDS Coordinator said he/she could not find any documentation to show the resident received the Pneumococcal vaccination. He/She said it was marked to the best of his/her, when completing the MDS, it could have been on a hospital record but he/she cannot locate the information at this time and the staff did not document a pneumococcal vaccination on the resident's immunization record. 6. Review of Resident #43's MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -[DIAGNOSES REDACTED]. -Did not receive Pneumococcal vaccine due to ineligible or medical contraindication. Review of the resident's plan of care, last updated 5/26/18, showed staff documented the resident does not meet the pneumonia injection criteria due to age. Review of the resident's Immunizations Administered Upon Admission form, undated, showed staff did not document they administered a Pneumococcal vaccine. During an interview on 6/8/18 at 2:00 P.M., Licensed Practical Nurse (LPN) D and the MDS Coordinator said staff did not administer Pneumococcal vaccines to the resident due to his/her age. LPN D and the MDS Coordinator said the only criteria staff use to determine eligibility for Pneumococcal vaccination is age. Staff do not consider [DIAGNOSES REDACTED]. 7. During an interview on 6/08/18, at 2:06 P.M., LPN A said the facility licensed staff review the resident's immunization history. He/She said the Pneumococcal vaccines are offered to residents over [AGE] years of age. LPN A said the facility staff first offer the PCV13 if the resident wants it, and then offer the PPSV23 a year later. He/She said he/she is not aware resident's with certain [DIAGNOSES REDACTED]. LPN A said the consents are in the resident's medical record and staff are expected to document all vaccinations and history of previous vaccinations on the resident's vaccination record. He/She is not sure why the immunizations with consents are not completed.

Based on staff interview and record review, facility staff failed to ensure resident's with a mental disorder and individuals with intellectual disability had a DA-124 level I screen (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASARR) level II screen is required) as required, for two of three sampled residents (Resident #8 and #43). The census was 46. 1. Review of Resident #8's quarterly MDS, dated [DATE], showed: -admission date of [DATE]; -[DIAGNOSES REDACTED]. -No information for Preadmission Screening and Resident Review (PASARR); Review of the resident's medical record showed it did not contain a DA-124 C, level 1 screen or a PASARR level 2 screen. During an interview on 6/8/18 at 2:00 P.M., the Director of Nursing (DON) said she could not find any documentation which showed staff completed a DA-124 C or PASARR for the resident. 2. Review of Resident #43's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -Did not display behaviors or reject care during the look back period; -[DIAGNOSES REDACTED]. -Received an antidepressant seven days of seven during the look back period. Review of the resident's Level One screening form, dated 5/10/18, showed staff documented the the resident did not have a [DIAGNOSES REDACTED]. Staff did not ensure the resident had an accurate Level One screening. Review of the resident's medical record showed staff did not obtain a Level Two screening as required due to the resident's [DIAGNOSES REDACTED]. During an interview on 6/8/18 at 3:30 P.M., the MDS Coordinator said he/she did not know if the resident had a Level Two screening, and did not know why the Level One screening is incorrect.

Based on interview and record review, the facility staff failed to ensure one resident (Resident #20) remained free from misappropriation of property, when the resident's ring and watch went missing. The facility census was 46. 1. Review of the facility's policy Resident Abuse Prevention, dated 1/1/02, directs the staff: -Prevent mistreatment, neglect, abuse, misappropriation of funds, prohibition of verbal, sexual, mental, physical, corporal punishments and involuntary seclusion; -To ensure follow-up and full investigation of such occurrences, with necessary reporting actions to regulatory agencies and responsible parties/guardians and physicians; -Definitions: a. Abuse: The infliction of physical, sexual, emotional, and/or verbal injury or harm on a resident; to include mistreatment, corporal punishment and involuntary seclusion; b. Neglect: The failure of those responsible for the care of an individual to provide reasonable and necessary services to maintain the physical and mental health of that individual; when that results in imminent danger to the health, safety and welfare of the individual; c. Exploitation: Illegal or improper use of a resident's property or funds. -Staff shall know to report actions that are of a concern to them so that proper follow-up can be conducted; -Investigation process: -- Charge nurse should remove alleged perpetrator away from all residents; - Interview the resident; - Notify the resident's responsible party of the alleged situation; - Notify the medical director and/or the resident's physician - All staff on the shift must remain at the facility until dismissed by department head or administrator; - All staff from the shift during the time of the allegation and the oncoming shift must be interviewed; - All staff from the shift during the time of the allegation must write a statement; - A department head and/or administrator shall keep a running commentary of events/statements/interviews, etc., that will be helpful in resolution of this issue; - Department head or administrator will send alleged perpetrator out of the facility, on suspension until the matter is resolved; - The department head and the administrator shall make a decision to notify the regulatory agencies if any concern or question that abuse or neglect did occur or serious bodily injury; even if all facts have not been obtained. If the event that caused the reasonable suspicion results in serious bodily injury, the report must be made immediately after forming the suspicion (no later that two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming the suspicion. - After a full complete review to the best of the facilities ability a decision shall be made about the employee. -A full report and copies of the investigation will be submitted to DHSS within 5 days from the initial report of incident. -All collected information shall be maintained in an allegations file in the administrators office. 2. Review of Resident #20's significant change Minimum Data Set (MDS), a federally mandated assessment, dated 3/30/18, showed staff assessed the resident as: -admitted [DATE]; -Cognitively intact; -[DIAGNOSES REDACTED]. -Mild depression; -No behaviors. 3. During an interview on 6/06/18, at 10:51 A.M., the resident said someone stole his/her ring 4 or 5 months ago. He/She said it had a pink flower on a gold band. He/She said he/she had hygiene stuff go missing too, but the facility usually replaces it. The resident said facility staff told him/her they could not do anything unless he/she knows who took the ring. He/She said the ring is worth $75-$100, but had sentimental value to him/her. During an interview on 6/07/18, at 2:00 P.M., the social services director (SSD) said the resident reported a missing ring. He/She said facility staff looked everywhere and did not find it. He/She said staff could not verify the resident brought the ring to the facility because staff did not document the ring on the resident's inventory list. He/She said he/she did not document the concern, did not offer to call the police or report to DHSS because they could not verify the resident brought in the ring. During an interview on 6/08/18, at 3:02 P.M., the administrator (ADM) said the resident reported a missing ring. He/She said they interviewed staff and they said they had not seen the ring, and staff did not list it on the resident's inventory. He/She said staff looked for it. The ADM said the resident's spouse said he/she did not know about the ring and was not concerned about it. He/She said the resident constantly says something is gone or stolen, and staff did not report it to the police or DHSS because they didn't have anything to go by. The ADM said the resident cried wolf so many times the facility did not know if it was true. He/She said he/she didn't consider reporting it because he/she did not know how reliable the resident is. The ADM said if a resident reports an item missing and facility staff can not find it, and the value is over $50, the facility staff report it to the police and DHSS, and if the item is worth less than $50, the facility does not report it, just replaces it. During an interview on 6/18/18, at 10:30 A.M., the resident's spouse said the resident had a ring that is missing. He/She said the resident was very upset so he/she found the ring in a catalog and brought it in to show the facility staff so they could find it. He/She said the resident had a gold watch that went missing about the same time. He/She said the facility took a picture of the catalog and said they looked for it. He/She said the facility did not offer to call the police or replace the items. He/She said he/she already bought the resident a new watch. He/She said facility staff probably didn't do anything because they owe money and are currently making payments. He/She said the resident said from the beginning that a staff member saw the ring and said, I wish I had a ring like that.

Based on interview and record review, the facility staff failed to develop and implement written policies and procedures for the investigation of allegations of neglect and exploitation of residents and misappropriation of resident property and includes the staff identification of abuse, neglect, exploitation, and misappropriation of resident property, and the required reporting of allegations and investigative findings and taking corrective actions. The facility census was 46. 1. Review of the facility's policy Resident Abuse Prevention, dated 1/1/02, directs the staff: -Prevent mistreatment, neglect, abuse, misappropriation of funds, prohibition of verbal, sexual, mental, physical, corporal punishments and involuntary seclusion; -To ensure follow-up and full investigation of such occurrences, with necessary reporting actions to regulatory agencies and responsible parties/guardians and physicians; -Definitions: a. Abuse: The infliction of physical, sexual, emotional, and/or verbal injury or harm on a resident; to include mistreatment, corporal punishment and involuntary seclusion; b. Neglect: The failure of those responsible for the care of an individual to provide reasonable and necessary services to maintain the physical and mental health of that individual; when that results in imminent danger to the health, safety and welfare of the individual; c. Exploitation: Illegal or improper use of a resident's property or funds. -Staff shall know to report actions that are of a concern to them so that proper follow-up can be conducted, by reviewing the above definitions and the facilities compliance with those statements at the time of orientation, yearly or more frequently in in-services and by written materials such as this policy and procedure; -Investigation process: -- Charge nurse should remove alleged perpetrator away from all residents; - Interview the resident; - Notify the resident's responsible party of the alleged situation; - Notify the medical director and/or the resident's physician - All staff on the shift must remain at the facility until dismissed by department head or administrator; - All staff from the shift during the time of the allegation and the oncoming shift must be interviewed; - All staff from the shift during the time of the allegation must write a statement; - A department head and/or administrator shall keep a running commentary of events/statements/interviews, etc., that will be helpful in resolution of this issue; - Department head or administrator will send alleged perpetrator out of the facility, on suspension until the matter is resolved; - The department head and the administrator shall make a decision to notify the regulatory agencies if any concern or question that abuse or neglect did occur or serious bodily injury; even if all facts have not been obtained. If the event that caused the reasonable suspicion results in serious bodily injury, the report must be made immediately after forming the suspicion (no later that two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming the suspicion. - After a full complete review to the best of the facilities ability a decision shall be made about the employee. -A full report and copies of the investigation will be submitted to DHSS within 5 days from the initial report of incident. -All collected information shall be maintained in an allegations file in the administrators office. The policy did not contain direction to the staff for the investigation of allegations of neglect and exploitation of residents and misappropriation of resident property and includes the staff identification of abuse, neglect, exploitation, and misappropriation of resident property, and the required reporting of allegations and investigative findings and taking corrective actions. Further review of the policy showed the policy did not contain direction to the staff on prevention of abuse and neglect to include care planning and guidance on how to address resident's with a history of behaviors. The policy also did not contain direction to staff to report incidents within 2 hours of the allegation Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. During an interview on 6/08/18, at 3:02 P.M., the administrator (ADM) said the policy contained all the required information and direction to staff. He/She said he/she did not know the reporting guidelines had changed.

Based on resident and staff interview and record review, facility staff failed to report misappropriation of one resident's (Resident #20) property, to Department of Health and Senior Services (DHSS), or law enforcement. The facility census was 46. 1. Review of the facility's policy Resident Abuse Prevention, dated 1/1/02, directs the staff: -Prevent mistreatment, neglect, abuse, misappropriation of funds, prohibition of verbal, sexual, mental, physical, corporal punishments and involuntary seclusion; -To ensure follow-up and full investigation of such occurrences, with necessary reporting actions to regulatory agencies and responsible parties/guardians and physicians; -Definitions: a. Abuse: The infliction of physical, sexual, emotional, and/or verbal injury or harm on a resident; to include mistreatment, corporal punishment and involuntary seclusion; b. Neglect: The failure of those responsible for the care of an individual to provide reasonable and necessary services to maintain the physical and mental health of that individual; when that results in imminent danger to the health, safety and welfare of the individual; c. Exploitation: Illegal or improper use of a resident's property or funds. -Staff shall know to report actions that are of a concern to them so that proper follow-up can be conducted; -Investigation process: -- Charge nurse should remove alleged perpetrator away from all residents; - Interview the resident; - Notify the resident's responsible party of the alleged situation; - Notify the medical director and/or the resident's physician - All staff on the shift must remain at the facility until dismissed by department head or administrator; - All staff from the shift during the time of the allegation and the oncoming shift must be interviewed; - All staff from the shift during the time of the allegation must write a statement; - A department head and/or administrator shall keep a running commentary of events/statements/interviews, etc., that will be helpful in resolution of this issue; - Department head or administrator will send alleged perpetrator out of the facility, on suspension until the matter is resolved; - The department head and the administrator shall make a decision to notify the regulatory agencies if any concern or question that abuse or neglect did occur or serious bodily injury; even if all facts have not been obtained. If the event that caused the reasonable suspicion results in serious bodily injury, the report must be made immediately after forming the suspicion (no later that two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming the suspicion. - After a full complete review to the best of the facilities ability a decision shall be made about the employee. -A full report and copies of the investigation will be submitted to DHSS within 5 days from the initial report of incident. -All collected information shall be maintained in an allegations file in the administrators office. 2. Review of Resident #20's significant change Minimum Data Set (MDS), a federally mandated assessment, dated 3/30/18, showed staff assessed the resident as: -admitted [DATE]; -Cognitively intact; -[DIAGNOSES REDACTED]. -Mild depression; -No behaviors. 3. During an interview on 6/06/18, at 10:51 A.M., the resident said someone stole his/her ring 4 or 5 months ago. He/She said it had a pink flower on a gold band. He/She said he/she had hygiene stuff go missing too, but the facility usually replaces it. The resident said facility staff told him/her they could not do anything unless he/she knows who took the ring. He/She said the ring is worth $75-$100, but had sentimental value to him/her. During an interview on 6/07/18, at 2:00 P.M., the social services director (SSD) said the resident reported a missing ring. He/She said facility staff looked everywhere and did not find it. He/She said staff could not verify the resident brought the ring to the facility because staff did not document the ring on the resident's inventory list. He/She said he/she did not document the concern, did not offer to call the police or report to DHSS because they could not verify the resident brought in the ring. During an interview on 6/08/18, at 3:02 P.M., the administrator (ADM) said the resident reported a missing ring. He/She said they interviewed staff and they said they had not seen the ring, and staff did not list it on the resident's inventory. He/She said staff looked for it. The ADM said the resident's spouse said he/she did not know about the ring and was not concerned about it. He/She said the resident constantly says something is gone or stolen, and staff did not report it to the police or DHSS because they didn't have anything to go by. The ADM said the resident cried wolf so many times the facility did not know if it was true. He/She said he/she didn't consider reporting it because he/she did not know how reliable the resident is. The ADM said if a resident reports an item missing and facility staff can not find it, and the value is over $50, the facility staff report it to the police and DHSS, and if the item is worth less than $50, the facility does not report it, just replaces it. During an interview on 6/18/18, at 10:30 A.M., the resident's spouse said the resident had a ring that is missing. He/She said the resident was very upset so he/she found the ring in a catalog and brought it in to show the facility staff so they could find it. He/She said the resident had a gold watch that went missing about the same time. He/She said the facility took a picture of the catalog and said they looked for it. He/She said the facility did not offer to call the police or replace the items. He/She said he/she already bought the resident a new watch. He/She said facility staff probably didn't do anything because they owe money and are currently making payments. He/She said the resident said from the beginning that a staff member saw the ring and said, I wish I had a ring like that.

Based on staff interview and record review, facility staff failed to ensure the admission policy did not require the resident to waive potential facility liability for loss of personal property for two out of 12 sampled residents (Residents #38 and #42). In addition, the facility's admission procedure required a $500 deposit by the admitted for residents who were considered Medicaid pending for two out of 12 sampled residents (Residents #22 and #38). The census was 46. 1. Review of Resident #22's medical record, showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Medicaid recipient. Review of the resident's Resident or Responsible Payables form, showed the following: -Requirement for deposit of $500 is expected by the admitted ; -The resident is expected to meet medical necessity for Medicaid services and may be considered as Medicaid pending; -Signed by the resident's Responsible Party; -Dated 8/1/13. 2. Review of Resident #38's medical record, showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED].>Review of the resident's Resident or Responsible Payables form, showed the following: -Requirement for deposit of $500 is expected by the admitted ; -The resident is expected to meet medical necessity for Medicaid services and may be considered as Medicaid pending; -Signed by the resident's Responsible Party; -Dated 1/29/18. Review of the resident's Personal Items and Valuables Accountability form, showed the following: -The facility is not liable for missing or damaged items that the resident's family, representative, or the residents have chosen to keep in the resident's possession; -Signed by the resident's Responsible Party; -Dated 1/29/18. 3. Review of Resident #42's medical record, showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Medicaid recipient. Review of the resident's Personal Items and Valuables Accountability form, showed the following: -The facility is not liable for missing or damaged items that the resident's family, representative, or the residents have chosen to keep in the resident's possession; -Signed by the resident's Responsible Party; -Dated 1/30/17. 4. During an interview on 6/8/18 at 11:42 A.M., the social worker (SW) said one of her duties is going over the admission packets with the residents or their responsible parties. She tells them to read it thoroughly and ask her any questions they have. She said the Personal Items and Valuables Accountability form is part of the admission packet and the form asks the resident or responsible party to waive the facility's responsibility for personal items left in the possession of the resident. The SW said they do not replace or reimburse residents for lost, stolen, or damaged personal items. She said Resident #20 misplaced his/her ring and staff looked for the ring, but they have not replaced or reimbursed the resident. The exception is if staff break an item, such as dentures. She said the Resident or Responsible Payables form requires a $500 deposit from all residents. The form does not say Medicaid residents do not have to pay the deposit. The form does not explain what the $500 pays or how to get the deposit back after Medicaid payments begin. 5. During an interview on 6/8/18 at 12:05 P.M., the administrator said she wanted to go through the admission packet and review the forms but has not had time. The Resident or Responsible Payables form says a $500 deposit is required at admission. The form has an area where the residents or responsible party check the payment source. One of the options is Medicaid. The form also has an area where the resident or responsible party can check that Medicaid is pending. The form does not clarify that Medicaid residents are not required to pay the $500 deposit. In regards to missing items, the facility will look for the missing item, but the facility's policy is not to replace anything in the resident's possession. The facility cannot be responsible for items that the resident forgets to remove from their pockets and sends through the washing machine. The facility cannot afford to replace an $800 phone or other expensive items. 6. During an interview on 6/8/18 at 5:30 P.M., the bookkeeper said he/she does not have any receipts from the $500 deposits which are required at admission. The families usually do not ask for a receipt. The deposit is documented on the resident's quarterly statement, but it is not clearly stated that it is a deposit. He/She said often times the $500 is combined with other monies and appears as a deposit larger than $500. The requirement for a $500 deposit upon admission began several administrators ago. Since a couple can do a division of assets, often times the spouse in the facility is left without a way to pay their costs or even without the $50 monthly allowance. Also, Medicaid only pays up to three months retroactive. If it takes longer than three months to get approved for Medicaid, then the resident has a bill that often times does not get paid.

Based on observation, interview, and record review, facility staff failed to develop and update a plan of care for pressure ulcer prevention/treatment to communicate interventions to facility staff, failed to prevent the development of two residents at risk for pressure ulcers to develop two unstageable pressure ulcers (full thickness skin and tissue loss which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured), and a stage three pressure ulcer (full thickness loss of skin) for one resident (Resident #9) and one stage three pressure ulcer for one resident (Resident #10). Facility staff failed to accurately assess and stage two resident's pressure ulcers (Resident #9 and Resident #10). Facility staff additionally failed to develop new interventions and treatments in a timely manner for two residents (Resident #9 and #10) to prevent deterioration of the wound. 1. Review of the Resident Assessment Instrument (RAI) Manual showed: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. 2. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated September 2016, showed the following definitions: -Stage 1 pressure injury is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) [DIAGNOSES REDACTED] (redness). Presence of blanchable [DIAGNOSES REDACTED] changes in sensation, temperature, or firmness may precede visual changes; -Stage 2 pressure injury is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (the new connective tissue), slough (dead tissue in the process of separating form the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off form the healthy skin usually black or brown) are not present; -Stage 3 pressure injury is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed; -Stage 4 pressure injury is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location; -Unstageable pressure injury is a full thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot by confirmed because it is obscured by slough or eschar; -Deep Tissue pressure injury is an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstagable, stage 3 or stage 4 pressure injury). 3. Review of the facility's policy titled Wounds: Guidelines for Assessment/Reassessment of Existing Wounds/Pressure Ulcers, dated August 2016, showed staff are directed to do the following: -Assessment of skin and all wounds on admission/readmission to the facility per the admission assessment form and the Braden scale (a tool used to determine the resident's risk of skin breakdown); -Weekly skin assessments will be done by the charge nurse; -Charge nurse will assess the wound and/or dressing daily. The wound will be measured weekly and documented by the wound team with length, width, depth; -The wound nurse will meet with the wound clinic team weekly to assess the wound status and to evaluate if the treatment is effective or if changes need to be implemented; -Wounds will be staged per protocol by wound clinic team. Further review showed the policy defines the pressure ulcer stages as follows: -Stage one pressure ulcer is a change in skin temperature, change in tissue consistency, pain, itching; -Stage two pressure ulcer is superficial, involving the epidermis/dermis; -Stage three pressure ulcer is a full thickness, necrosis, deep crater, undermining; -Stage four pressure ulcer has muscle, bone, tendon involvement. Review showed the policy did not provide direction for staff related to granulation tissue, unstageable pressure ulcers and suspected deep tissue injuries. 4. Review of the facility's Braden Scale: Guideline for Assessing the Resident for High Risk Skin Condition Policy, undated, showed staff are directed to do the following: -The charge nurse is responsible; -The Braden will be used to assess all new admissions; -If the resident rates 12 or less they will be deemed high risk for developing skin issues; -The high risk resident will be assessed monthly per the Braden Scale as long as they continue to rate 12 or less on the scale; -The resident that scores above a 12 on the Braden Scale will be assessed annually and as needed, which may coincide with their Minimum Data Set (MDS), a federally mandated assessment tool. 5. Review of Resident #9's admission Minimum Data Set (MDS), a federally mandated assessment, dated 5/1/17, showed facility staff assessed the resident as the following: -Did not reject care; -Extensive assistance of two staff members for bed mobility and transfers; -Extensive assistance of two staff members for dressing and toileting; -Frequently incontinent of bowel; -At risk to develop pressure ulcers; -No pressure ulcers. Review of the resident's 30 day MDS, dated [DATE], showed the facility staff assessed the resident as the following: -Did not reject care; -Extensive assistance of two staff members for bed mobility and transfers; -Extensive assistance of two staff members for dressing and toileting; -Occasionally incontinent of bowel and bladder; -At risk to develop pressure ulcers; -Stage 3 pressure ulcer; 2.5 centimeter (cm) long, 2 cm wide, 0.1 cm depth; most severe tissue type-slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. Review of the resident's Braden Scale, dated 4/24/17, showed facility staff assessed the resident as: -Friction and Shear a potential problem; -Score of 18, at risk of skin breakdown. Review of the documentation showed it did not contain reassessment of risk for skin breakdown after staff identified the resident's pressure wound. Review of the resident's plan of care, updated 5/12/17, showed staff documented pressure ulcer risk initiated on 5/5/17, related to decreased mobility, and poor nutrition with the following addendums: -5/17/17 Right heel, new treatment on physician's orders [REDACTED]. -5/31/17 Right heel pressure ulcer, new treatment order for unna boot (medicated compression dressing) on POS, goal to heal wound and provide comfort. -6/7/17 Left heel new treatment order on POS, provide comfort and heal wound. Additional review of the plan of care showed it did not contain interventions to prevent further breakdown on the resident's left heel, left inner thigh, or to prevent further breakdown on other areas of the resident's body, after staff identified a pressure wound on the resident's right heel. The plan of care did not contain direction to staff to move the resident's pressure relief cushion from the wheelchair to recliner when staff transferred the resident. Review of the resident's Physician Orders, dated May 2017, showed the physician ordered: -6/2/17: Weekly skin assessment on Mondays; -6/7/17: Left heel apply skin prep Monday, Wednesday, and Friday before applying unna boot; -6/7/17: Right thigh clean with saline, apply vaseline gauze cut to fit wound, apply tape bordered gauze, change daily and as needed (PRN). Review of the resident's weekly skin assessments, dated May 2017 through June 2017,showed facility staff documented the following: -5/3/17- no issues; -5/10/17- no issues; -5/18/17- right heel area noted, did not contain description or details; -5/25/17- right heel area noted, did not contain description or details. The documentation did not contain a weekly skin assessment after 5/25/17, as directed by facility policy. Review of the resident's Wound Assessment Report, from 5/17/17 through 6/8/17, showed staff documented the following: -5/31/2017- Pressure ulcer bottom of right heel identified 5/17/17, deteriorated, Stage 3, measures 2.4 cm length, 1.9 cm width, and 0.1 cm depth. Pressure ulcer wound bed with 50% granulation tissue, 50% slough, surrounding skin macerated with scant (little) serous (clear) drainage. -6/7/2017- Pressure ulcer bottom of right heel identified 5/17/17, deteriorated, Stage 3, measures 3.5 cm length, 4.1 cm width, and 0.1 cm depth. Pressure ulcer wound bed with 30% slough, 70% eschar, surrounding skin macerated with scant (little) serous (clear) drainage. New left heel deep suspected tissue injury and new right thigh trauma area. Review of the documentation showed it did not contain wound measurements, wound bed, surrounding skin, drainage or descriptions of the new wounds. Review of the documentation showed staff did not document wound assessments, including measurements, wound bed, surrounding skin, or drainage from 5/17/17-5/31/17. Review of the resident's nurse's notes, dated 5/17/17 at 4:25 P.M., showed staff documented the resident with increased [MEDICAL CONDITION] (swelling) at times, new area of concern, pressure ulcer stage 3 to right heel, new order noted on POS. Review of the resident's nurse's notes, dated 5/18/17 at 3:11 P.M., showed staff documented the resident continued with bilateral lower extremity [MEDICAL CONDITION]. Review of the resident's nurse's notes, dated 5/24/17 at 1:32 P.M., showed staff documented the resident continued with [MEDICAL CONDITION] weeping from bilateral lower legs. Review of the resident's nurse's notes, dated 5/24/17 at 3:44 P.M., showed staff documented the resident continued to have 4+ (1-4 scale healthcare uses to determine amount of swelling, 4+ is the most swelling) [MEDICAL CONDITION] to bilateral lower extremities. Review of the resident's nurse's notes, dated 6/7/17 at 12:58 P.M., showed staff documented the resident continued with [MEDICAL CONDITION] weeping from bilateral lower legs. Staff documented the resident's right heel tissue quality deteriorated, identified a new left heel suspected deep tissue injury (an open or unopened area of discoloration on the skin as a result from prolonged pressure), and a new trauma area to upper right thigh. Observation on 6/6/17 at 10:05 A.M., during the initial tour, showed staff propelled the resident in his/her wheelchair, the resident's pants were wet on both upper thighs, and his/her heels rested directly on the foot pedals. The director of nursing (DON) said the resident had weeping legs, and a pressure ulcer on his/her heel. Observation on 6/6/17 at 12:52 P.M., showed the resident propelled himself/herself from the dining room table, and his/her heels rested directly on the foot pedals. Observation on 6/7/17 at 9:46 A.M., showed the wound nurse entered the resident's room. Observation showed the resident in bed with his/her heels directly on the pillow. Observation showed staff transferred the resident to a bath chair. Observation showed the wound nurse measured the resident's right heel wound as 4 cm length, 2.5 cm width, and 0 cm depth. The wound nurse said the wound is 100 percent necrotic black tissue and is unstageable and started a couple of weeks ago. Observation showed the wound nurse measured the resident's left heel wound as 4 cm length, 3 cm width, and 0 cm depth. The wound nurse said the wound is 100 percent necrotic black tissue and is unstageable. The wound nurse said wound clinic staff identified the resident's left heel wound on 6/7/17. Observation on 6/7/17 at 12:32 P.M., showed the resident in his/her wheelchair with his/her heels directly on the foot pedals. Observation on 6/8/17 at 6:10 A.M., showed the resident in his/her recliner without a pressure relief cushion. During an interview on 6/8/17 at 9:30 A.M., the resident said he/she slept in his/her bed until a couple of nights ago, because the pain is so much worse when he/she elevates his/her legs in bed, [MEDICAL CONDITION] hurts. The resident said he/she cannot get comfortable in bed so now he/she sleeps in his/her recliner. The resident said he/she has a special cushion in his/her wheelchair, but not in his/her recliner. Observation and interview with the wound nurse on 6/8/17 at 9:32 A.M., showed the resident with a dark purple, soft area on 100% of the wound bed on his/her left heel. The wound nurse said it measured 3.1cm length, 4.2 cm width, and 0.1 cm depth, with 100% eschar. Additional observation showed the right heel with a dark purple, soft area on 90 % of the wound bed on the right heel with the inside edge of the wound coming apart from the skin with a yellow area on 5% of the wound bed, and red bumpy tissue on 5% of the wound bed. The wound nurse said it measured 3.5cm length, 4.1 cm width, and 0.1 cm depth, had 90% eschar, and 10% slough. Observation showed a red open area to the resident's right inner thigh and the wound nurse said it measured 7 cm length, 0.6 cm width, 0.1 cm depth, and described the wound bed as 100% granulation. The wound nurse said staff did not consider it a pressure ulcer because it was from friction/shear. (According to the RAI manual, friction and/or shear in combination with pressure causes pressure ulcers.) The wound nurse said staff can use pressure relieving boots for residents with heel ulcers, he/she did not know why staff did not use them. During an interview on 6/8/17 at 1:16 P.M., Certified Nursing Assistant (CNA) E said staff are expected to transfer the resident from the bed to the recliner, use cream, and float the resident's heels to prevent breakdown. CNA E said these interventions should be on the resident's care plan, but he/she is not sure if they are. CNA E said when staff float the resident's heels on pillows the heels should not touch the bed or pillows directly. During an interview on 6/8/17 at 1:22 P.M., Licensed Practical Nurse (LPN) D said staff are expected to turn the resident from side to side, float his/her heels, and provide pressure ulcer treatments. LPN D said when staff float the resident's heels the heels should not be directly on the bed or pillow. LPN D said these interventions should be on the resident's care plan and he/she does not know if they are. LPN D said the MDS coordinator or wound nurse complete the Braden assessments and if a resident scores at risk therapy recommends interventions to prevent skin breakdown and those interventions should be on the care plan. LPN D said the wound nurse does the weekly skin assessments on days and the charge nurse does the weekly skin assessments for residents on weekends and evenings. LPN D said staff are expected to document areas of concern on the skin assessments. During an interview on 6/8/17 at 1:37 P.M., CNA G said staff float the resident's heels and turn and reposition the resident as the resident allows. CNA G said when staff float the resident's heels they should place the resident's heels off the bed and pillow. CNA G said the resident's interventions should be on his/her care plan, but he/she is not sure if they are on the care plan. During an interview on 6/8/17 at 2:01 P.M., the wound nurse said staff are expected to offload the resident's heels on pillows, encourage protein and nutrition, and monitor labs. The wound nurse said the interventions should be on the resident's care plan but he/she is not sure if they are. 6. Review of Resident #10's MDS, dated [DATE], showed facility staff assessed the resident as follows: -Moderate cognitive impairment; -Did not reject care; -Limited assistance of one staff member for bed mobility and transfers; -Extensive assistance of one staff member for dressing and toileting; -Risk of developing pressure ulcers; -No pressure ulcers. Review of the resident's Braden Scale, a tool used to determine the resident's risk of skin breakdown, dated 12/11/16, showed the facility staff assessed the resident with a score of 16, at risk of skin breakdown. Review of the resident's plan of care, dated 01/20/17, showed staff did not document pressure ulcer risk on the resident's plan of care with interventions to prevent pressure ulcers. Review of the resident's care plan addendum, dated 5/31/17, showed staff documented the resident with a left buttock pressure ulcer, stage II. Staff documented the treatment order, but did not document interventions to prevent further skin breakdown. Review of the resident's POS, dated June 2017, showed a physician order [REDACTED]. Review of the resident's nurses' notes, dated May 2017 through June 2017, showed staff did not document any information related to the resident's pressure ulcer. Review of the resident's Admission Skin Assessments, dated May 2017 through June 2017, showed staff assessed the resident's skin as the following: -5/21/17 - nothing documented; -6/1/17 - staff noted the resident's bottom as an area of concern, but did not document any additional information. Review of the resident's Wound Assessment Report, from May 2017 through June 2017, showed facility staff documented the following: -5/31/2017 wound identified on 5/31/17 left buttock pressure ulcer stage two with measurements of 1.4 cm by 1.5 cm by 0.1 cm with 100 percent granulation tissue; -6/7/17; left buttock pressure ulcer stage two with measurements of 2.7 cm by 1 cm by 0.1 cm with 100 percent granulation tissue. Further review of the Wound Assessment Report, From May 2017 through June 2017, showed staff did not stage the pressure ulcers accurately. (According to NPUAP guidelines, granulation tissue is not present in Stage II pressure ulcers). Observation on 6/8/17 at 7:53 A.M., showed CNA E and CNA F assisted the resident to stand up from his/her wheelchair. Observation showed the wound nurse measured the left buttock wound as 2.2 cm by 1.5 cm by 0.1 cm. The wound nurse said the wound bed contained 100 percent granulation tissue and was beefy red. Observation showed CNA E and CNA F assisted the resident into his/her recliner. The CNAs did not place a pressure relief cushion in the resident's recliner before they transferred the resident to the recliner. Observation and interview on 6/8/17 at 11:10 A.M., showed the resident in a recliner in his/her room. Observation showed the recliner did not contain a pressure relief cushion. The resident said staff removed his/her cushion for the recliner a few days ago to clean, and have not brought it back. He/She said his/her bottom is really sore, and the cushion helped it to not hurt so bad. The resident said he/she hopes they bring it back soon. Observation on 6/8/17 at 1:00 P.M., showed the resident in his/her recliner in the same position without a pressure reducing cushion. Observation on 6/8/17 at 2:04 P.M., showed the resident's in his/her recliner in the same position without a cushion in his/her recliner. During an interview on 6/8/17 at 1:16 P.M., CNA E said staff are expected to turn and reposition the resident, and use barrier cream to prevent breakdown in resident's skin. CNA E said he/she is not sure if those interventions are on the resident's care plan. During an interview on 6/8/17 at 1:22 P.M., LPN D said if staff identify a pressure ulcer or determine a resident is at risk for pressure ulcers it should be on the resident's care plan. LPN D said staff turn the resident side to side and provide a pressure reducing cushion in his/her wheelchair. LPN D said he/she is not aware of a cushion in the resident's recliner. LPN D said staff are expected to include these interventions on the resident's care plan and he/she does not know if the interventions are on his/her care plan. LPN D said the MDS coordinator and the Director of Nursing (DON) update the care plans. LPN D said the MDS coordinator or wound nurse complete the Braden assessments and if a resident scores at risk, therapy recommends interventions to prevent skin breakdown and that should be on the care plan. LPN D said the wound nurse completes the weekly skin assessments on days and the charge nurse completes the weekly skin assessments for residents on weekends and evenings. During an interview on 6/8/17 at 1:37 P.M., CNA G said staff use the resident's care plan to know what interventions to prevent pressure ulcers or prevent pressure ulcers from worsening. CNA G said staff provide a cushion for the resident's wheelchair. CNA G said he/she is not aware of a cushion in the resident's recliner. CNA G said he/she is not sure if the pressure ulcer interventions are on the resident's care plan. During an interview on 6/8/17 at 2:01 P.M., The wound nurse said staff are expected to monitor the resident's labs, turn and reposition him/her, encourage protein and fluid intake, and provide a pressure reducing cushion in his/her wheelchair. The wound nurse said these interventions should be on the resident's care plan and he/she is not sure why they are not. The wound nurse said the resident did have a cushion in his/her recliner, but staff took it to laundry and did not return it. 7. During an interview on 6/8/17 at 1:15 P.M., the DON said if staff identify a resident is at risk for skin breakdown, they are expected to use a barrier cream if the resident is incontinent, contact the wound care nurse, request a wound service consult, and turn and reposition the resident frequently. The DON said he/she did not know if the standard facility mattresses are appropriate for the residents with pressure ulcers, and did not know if staff could implement pressure relief cushions and mattresses without a physician's orders [REDACTED]. He/She did not know why staff did not document all the skin assessments. The DON said the wound clinic physician directed facility staff the nurses cannot measure or stage wounds. The wound nurse completes the weekly wound assessments. The DON said he/she expects staff to document wound assessments including stage and interventions, according to current clinical standards. He/She said if a new wound is found or has deteriorated he/she expects staff to implement new treatments, interventions, and update the care plan with an addendum. He/She said Resident #9's wheelchair cushion should move with him/her when staff transfer him/her to the recliner, and staff should have replaced Resident #10's pressure relief cushion immediately. The DON said staff are expected to float heels correctly and he/she did not know why staff did not ensure the heels did not rest directly on any surface. 8. During an interview on 6/8/17 at 2:01 P.M., the wound nurse said he/she assesses wounds with the wound clinic staff weekly. The wound nurse said he/she documents the wound assessment including appearance, drainage, odor, and measurements. The wound nurse said wound clinic staff stages the wound and tells him/her the wound type and what type and percentage of tissue is in the wound. The wound nurse said he/she expects the wound clinic to stage according to NPUAP guidelines and the RAI guidelines. The wound nurse said he/she had not asked why wound clinic staff do not stage wounds according to those guidelines. The wound nurse said he/she completes the Braden assessments on admission. If the resident's score indicates the resident is at risk to develop pressure ulcers, staff should implement preventative interventions. The wound nurse said he/she completes skin assessments on weekday days and the charge nurses complete skin assessments weekly on weekends and evenings. The wound nurse said staff just circle the problem areas on the skin assessments and do not document the specific skin issue.