Every finding on record at Good Shepherd Community Care and Rehabilitation

Based on interview, and record review, the facility failed to notify the resident's responsible party timely of changes in condition, when one resident (Resident #1) developed a worsening pressure ulcer and when the resident's condition declined. The facility census was 57.Review of the facility policy titled, Change in a Resident's Condition or Status, revised November 2015, showed:-The facility shall promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical condition and/or status;-Unless otherwise instructed by the resident, the nurse supervisor/charge nurse will notify the resident's family or representative when there is a significant change in the resident's physical status;-Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical condition or status;-The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status. 1.Review of Resident #1's Face Sheet showed:-admitted to the facility on [DATE] from the hospital;-The facility listed two family members as emergency contacts. Review of the resident's Care Plan, dated 06/23/26, showed the following:Problem: pressure ulcer.-Resident at risk for pressure ulcers related to decreased mobility, weakness, and pain to the right foot/ankle;-Cast/splint on the resident's right ankle/foot per orthopedics;-The splint is to remain in place, keep clean and dry until orthopedic follow up appointment;-Staples will be removed by the physician or nurse practitioner at that time also;-The resident has a pressure-relieving mattress and a pressure relieving device to his/her wheelchair;-The resident can make his/her needs known;Interventions:-Avoid shearing of the resident's skin during positioning, transferring, and turning;-Encourage the resident to make frequent changes in position;-Keep the resident as clean and dry as possible. Minimize skin exposure to moisture;-Report any signs of skin breakdown (sore, tender, red, or broken skin areas);-Turn and reposition every 2 hours while awake;-Use lifting device, lift sheet, while the resident is in bed.-Update 07/07/26, left heel skin prep (a protective medical barrier). Review of the resident's Daily Skilled Nurse's Note, dated 07/07/26, showed a nurse documented:-Pressure ulcer to left heel;-The nurse did not document notification of the resident's family of the pressure ulcer. Review of the resident's Nurse's Notes, dated 07/07/26, showed:-Resident has a new order for skin prep to the left heel;-The nurse did not document notification of the resident's family of the new order. Review of the resident's Daily Skilled Nurse's Note, dated 07/08/26, showed a nurse documented:-Black area to left heel 2.0 centimeters (cm) long by 2.0 cm wide, area closed, tender to touch;-The nurse did not document notification of the resident's family of the pressure ulcer. Review of the resident's Daily Skilled Nurse's Note, dated 07/09/26, showed a nurse documented:-Pressure ulcer to left heel;-Today, the black pressure ulcer on the resident's left heel is twice the size of 07/08/26;-Skin prep to the site;-The nurse did not document notification of the resident's family of the worsening pressure ulcer. Review of the resident's Care Plan, updated on 07/09/26, showed:-Admit to Healing Partners (a visiting wound care company);-Refer to the Treatment Administration Record (TAR) for current treatment. Review of the Healing Partners Skin and Wound Note, dated 07/09/26, showed:-First evaluation of existing wound resident by new wound care team;The resident has a pre-existing deep tissue injury (DTI) of the left heel and has been present for less than 30 days;-Previous treatment includes offloading;-Previous care for the wound was provided by the primary care physician (PCP);-Plan weekly and as needed wound evaluations;-Physical examination: Resident has limited ambulation, out of bed mobility with a wheelchair. Lower extremity edema to the left lower leg, has cast on the right lower leg;Assessment of wound :-Location: Left heel;-Primary etiology (cause): Pressure ulcer;Stage: DTI;Wound status: First evaluation of existing wound be new provider;Odor: None;Size 3.0 centimeters (cm) long by 6.0 cm wide with no depth;Wound base: 100% eschar (black dead tissue);Periwound: Intact;Exudate (drainage): NonePain: None;Treatment recommendations: Cleanse with wound cleanser, apply skin prep to the base of the wound, leave open to air, apply daily;-Follow up in 1 week for wound evaluation;-The wound team did not document notification of the resident's family. Review of the resident's July 2026 Nurse's Notes did not show notification of the resident's family of the pressure ulcer, of the order for visiting wound care, or of the pressure ulcer treatment orders.Review of the resident's Order Recap Report for August 2026, showed an order, with a start date of 07/30/26 and an end date of 08/18/26 to cleanse the left heel with wound cleanser, apply skin protectant daily and as needed. Review of the Healing Partners Skin and Wound Note, dated 08/17/26, showed:-Subsequent encounter for skin and wound care;The resident has a pre-existing deep tissue injury (DTI) of the left heel and has been present for less than 30 days;-Previous treatment includes offloading;-Previous care for the wound was provided by the primary care physician (PCP);-Plan weekly and as needed wound evaluations;-Physical examination: Ambulation: Out of bed mobility with a wheelchair. Lower extremity edema to the left lower leg;Assessment of wound :-Location: Left heel;-Primary etiology (cause): Pressure ulcer;Stage: Stage 3 (a full layer skin loss where the subcutaneous fat may be visible);Wound status: Stable;Odor: None;Size 2.5 centimeters (cm) long by 5.6 cm by 0.2 cm depth;Wound base: 90% eschar and 10% granulation (red healthy tissue);Peri-wound: Dryness;Exudate (drainage): Light amount of sanguineousPain: 2 (0-10 scale);Treatment recommendations: Cleanse with wound cleanser/normal saline, apply skin prep to the surrounding tissue or peri-wound, Hydrogel (an absorbent material) gauze to base of the wound, secure with silicone bordered gauze, change three times per week, and as needed;-The wound team did not document notification of the resident's family. Review of the resident's Order Recap Report for August 2026 showed the following order, dated 08/18/26:-Left heel: Cleanse with wound cleanser, protect peri-wound with skin prep;-Apply hydrogel gauze to wound bed;-Cover with silicone bordered foam, three times per week and as needed for soiling, saturation, or early removal. Review of the resident's Progress Note, dated 08/23/26 at 11:22 A.M., showed a nurse documented the following:-Skilled Evaluation: Resident having disorganized thinking. Resident lethargic and confused. Resident experiencing signs of short-term memory loss. Oriented to place and person;Confused: New;Disorganized thinking: New.Lethargic: New.Short-term memory loss: New.Level of cognitive impairment: Alert with some forgetfulness. Resident was coherent. Speech was unclear. No language barrier. Resident usually made self understood. Resident usually understood others;Mental Status Note: Resident was not him/herself today. Resident was too weak to transfer self, usually staff could transfer the resident with one person assistance, but today needed two-person maximum assistance;-Called the resident's physician and reported resident's condition and received a new order for a urinalysis and complete blood count (CBC).-Nurse did not document notification of the resident's family of the resident's change in condition or of the new orders. Review of the resident's Progress Note, dated 08/23/2026 at 2:55 P.M., showed a nurse documented the following:-Background: Resident assessed throughout the day, but condition worsened;-Communication with the resident's physician;-Situation: Assumed role as nurse at 2:00 P.M. Upon assessment, the resident did not respond much at all. He/she was in his/her chair. Blood pressure = 74/71 millimeters of mercury (mm/Hg) (normal range =90-120/60-80 mm/Hg) , Heart rate = 100 beats/per minute (BPM) (normal range = 60-100 BPM), oxygen saturation =75% on room air (normal 90-100%), oral temperature is 104 degrees Fahrenheit (F) (normal 98.6 degrees F). His/her left leg appeared red and hot throughout most of his/her leg. Staff applied oxygen at 5 liters/minute/nasal canula (NC); Oxygen saturation rose to 95% on 5 liters of oxygen;-Recommendations: The nurse called the resident's physician, and the physician gave an order to send the resident to the hospital. Review of the resident's Progress Note, dated 08/23/26 at 2:59 P.M., showed the following communication with family:-The nurse called and spoke to one of the resident's emergency contacts and the family member agreed with sending the resident to the emergency room. Review of the resident's Progress Note, dated 08/23/36 at 3:00 P.M., showed:-The resident was currently on 5 liters/minute/nasal cannula of oxygen and emergency medical services (EMS) were on the way. The resident's left leg was red and purple. Review of the resident's Progress Note, dated 08/23/26 at 3:30 P.M. showed:-The nurse called the hospital and gave report on the resident's condition. During an interview on 08/27/26 at 12:04 P.M. and 3:19 P.M., Licensed Practical Nurse (LPN) A said the following:-He/she had cared for Resident #1 a few times in the past, the last time he/she saw the resident's left heel pressure ulcer, the heel was black eschar, and the edges of the wound were intact, no redness or drainage and the treatment ordered was to apply skin prep;-The facility staff should have notified the resident's family/responsible party about the development of the pressure ulcer;-He/she did not notify the resident's family about the resident's pressure ulcer;-He/she did not know if staff notified Resident #1's family about the resident's pressure ulcer;-The Director of Nursing (DON) was responsible for completing resident weekly wound assessments;-The nurse should notify the family if a resident has a change in condition and/or if the physician gave new orders. During an interview on 08/27/26 at 12:45 P.M., Registered Nurse (RN) B said the following:-He/she discovered the resident's left heel pressure ulcer when it looked like a small red blister, the area eventually turned black in color;-He/she last observed and treated the resident's left heel pressure ulcer one week prior (on Thursday, 08/20/26);-At that time, the resident's heel appeared as a black cap, with no drainage, and no redness to the surrounding area;-When a resident developed a pressure ulcer, the nurse usually notified the Assistant Director of Nursing (ADON) and the DON and the ADON or DON notified the physician and obtained treatment orders, and the ADON or DON notified the resident's family with the new treatment orders;-Nurses should notify the resident's physician and family of a change in condition, such as development of a pressure ulcer or change in the resident's level of consciousness. During an interview on 08/27/26 at 1:26 P.M. and 3:02 P.M., RN C said the following:-He/she worked on the afternoon of 08/23/26 and sent Resident #1 out to the hospital;-The day nurse passed on to RN C in report that the resident was not acting him/herself and was sleepy and did not want to get up out of bed during the day;-The day nurse reported the resident's vital signs were stable and he/she contacted the resident's physician about the resident's condition, and he/she ordered some labs;-RN C went to assess the resident around 2:30 P.M. and found the resident to be lethargic with abnormal vital signs and the resident's left leg was red swollen and warm to touch;-The nurse notified the resident's physician about the resident's condition and obtained orders to send the resident out to the hospital for evaluation and notified the resident's family;-The nurse who initially discovered the resident's pressure ulcer should have notified the resident's family;-The nurse should have notified the resident's family of any treatment orders and when the pressure ulcer worsened;-On 08/23/26, the day shift nurse should have contacted the resident's family of the resident's change in condition and of the physician's orders for lab tests. During an interview on 08/27/26 at 2:20 P.M., the DON said the following:-He/she was responsible for weekly wound assessments, and he/she made weekly rounds with Healing Partners (wound care company);-On 08/17/26, he/she observed the resident's left heel pressure ulcer. At that time the area was a black eschar cap with loose edges with some bloody drainage noted. The wound was the approximate size of an elongated golf ball. The wound care staff tried to debride (cut away) some of the dead tissue around the edge of the wound and changed the treatment to a topical dressing to help loosen some of the dead tissue;-He/she should have notified the resident's family of the existence of the resident's pressure ulcer and of the declining status of the wound;-When the resident condition changed on 08/23/26, the day nurse that contacted the resident's physician should have also notified the resident's family of the resident's change in condition and of the physician orders for lab tests and documented the notification in the nurse notes. During an interview on 8/27/26 at 2:50 P.M., the Administrator said the following:-The facility nursing staff should have contacted the resident's family of the pressure ulcer onset and of any new treatment orders. During an interview on 8/27/26 at 3:29 P.M., LPN D said the following:-The nurse who discovered the resident's pressure ulcer should have notified the resident's family and document the notification in the resident's progress notes;-The nurse should notify the resident's family with any change in condition and if the physician orders lab tests and document in the resident's nurse notes. 3174822

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner to protect the food from possible contamination when staff failed to keep all storage and food preparation services clean and free of debris, and staff failed to complete proper hand hygiene when touching nonfood contact surfaces. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 61.Review showed the facility did not provide policies related to the cleaning of kitchen surfaces, use of hair nets, or hand-washing procedures for kitchen staff. Review of the Missouri Food Code, published 2013, regarding glove use, food storage, and equipment showed the following:-If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation;-Food shall be protected from contamination by storing the food in a clean, dry location,Where it is not exposed to splash, dust, or other contamination;-Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 1. Observation on 03/03/26, at 10:48 A.M., in the kitchen showed the following:-Three-door stainless steel refrigerator with visible debris on the handles and around the handle area. The handles were slightly tacky to the touch;-A second three-door stainless steel refrigerator with visible debris on the handles and around the handle area. The handles were slightly tacky to the touch;-Four-door freezer with slight debris on the handles and around the handles;-A griddle (a flat-top grill) with extensive, heavy grease buildup on the surface, and heavy buildup along the sides;-Six-burner stovetop with extensive grease and food buildup around the burner and support elements. Observations on 03/03/26, at 11:00 A.M., during lunch serve-out showed the following:-Dietary aide (DA) Z with a pair of gloves on, working in the kitchen and dining room;-DA Z touched refrigerator handles and removed items;-He/She exited the kitchen by using the handle to open the kitchen door;-DA Z touched resident plates and cups in the dining room;-He/She pushed on the kitchen door with their gloved hands and touched the area in front of the steam table;-DA Z touched his/her face and hair (in a hairnet) and then proceeded to pass more plates and cups to residents;-DA Z did not change gloves or perform hand hygiene (such as washing hands or using hand sanitizer) between changing tasks. Observations on 03/05/26 at 9:52A.M., in the kitchen, showed the following:-Three-door, stainless steel refrigerator with visible debris on the handles and around the handle area. The handles were slightly tacky to the touch;-A second three-door stainless steel refrigerator with visible debris on the handles and around the handle area. The handles were slightly tacky to the touch;-Four-door freezer with slight debris on the handles and around the handles;-A griddle with extensive, heavy buildup of grease on the griddle surface, and especially heavy buildup along its sides;-Six-burner stovetop with extensive grease and food buildup around the burner and support elements. Observations on 03/05/26, at 10:53 A.M., in the kitchen and dining room during lunch serve-out, showed the following:-DA AA with a pair of gloves on, adjusted his/her hairnet, and the waist of their pants;-DA AA opened the kitchen door, and delivered a plate of food, a cup, and utensils to a resident, then re-entered the kitchen;-DA AA opened a refrigerator, removed food, and took a plate, cup, and utensils to another resident in the dining room;-DA AA did not change gloves or perform hand hygiene between changing tasks. Observation on 03/05/26, at 11:07 A.M., in the kitchen showed the following:-Signage posted by the dishwasher, Food service deep cleaning schedule;-Staff are scheduled to clean the stove burners, front, sides, back, and top on Wednesdays;-Staff are scheduled to clean all three refrigerators, including doors, top, bottom, and sides on Thursdays;-Staff sign off when the task is complete;-The Dietary Manager (DM) last signed the list on 02/23/26. During an interview on 03/06/26 at 1:50 P.M., the DM said the following: -Cleaning schedules are posted in the kitchen;-Kitchen staff are assigned weekly and month cleaning tasks;-The cleaning schedule includes exterior of equipment, the stovetop, and griddle area;-The griddle and stove are difficult to clean because they are used frequently;-Staff should use gloves when handling food. Gloves are not necessary when handling plates or cups;-Gloves should be changed after touching hair, face, or door handles. During an interview on 03/09/26 at 2:20 P.M., the Administrator said the following:-Cleaning schedules are posted in the kitchen, and staff are expected to complete required tasks;-The DM should ensure all cleaning tasks have been completed and signed off on;-The Administrator is unaware of any debris buildup on kitchen surfaces;-Staff are expected to perform hand hygiene when touch nonfood contact surfaces and items.

Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to handwashing, personal protective equipment, utilizing the resident's neighbor's bedside table during a dressing change, and not appropriately cleaning shared wound care supplies after changing pressure wound dressings on two residents (Resident #19 and #60).The facility census was 61. Record review of the manufacturer guidelines provided by the facility for CaviWipes, (the disinfectant wipes) used by the facility to clean shared wound supplies between residents, showed the following:-CaviWipes are environmental protection agency (EPA) registered, non-woven, intermediate-level disinfectant wipes designed for hard, non-porous surfaces;-Use gloves to clean, then disinfect surfaces by keeping them wet for the required time;-For application, use one or more wipes to remove visible debris (pre-clean). Use another wipe to thoroughly wet the surface for disinfection;-For contact time, surfaces must remain visibly wet for three minutes to ensure effectiveness against tuberculosis (infectious disease primarily affecting the lungs), bacteria, and viruses. Record review of the policy titled, Infection Control Guidelines revised in August 2012, showed the following:-The purpose is for general infection control while caring for residents;-Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues, including: the facility protocols for isolation (standard and transmission based) precautions and the location of all personal protective gear;-Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with residents, when hands are visibly dirty or soiled with blood or other body fluids, after contact with blood, body fluids, secretions, mucus membranes, or non-intact skin, after removing gloves, and after handling items potentially contaminated with blood, body fluids, or secretions;-Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature;-Rinse hands thoroughly under running water;-Dry hands thoroughly with paper towels;-When using alcohol-based hand rubs, apply generous amount of product to palm of hand and rub hands together;-Cover all surfaces of hands and fingers until hands are dry;-When applying and removing gloves, perform hand hygiene before applying non-sterile gloves. Record review of the policy titled, Enhanced Barrier Precautions revised in May 2024, showed the following:-Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents;-EBPs are used as an infection prevention and control intervention to reduce the spread of MDROs to residents;-EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply;-Gloves and gown are applied prior to performing high contact resident care activity (as opposed to before entering the room);-Personal protective equipment (PPE) is changed before caring for another resident;-Face protection may be used if there is also a risk of splash or spray;-Examples of high contact resident care activities requiring the use of gown and gloves for EBP includes wound care (any skin opening requiring a dressing);-EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization;-EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk;-Staff are trained prior to caring for residents on EBPs;-Signs are posted in the door or wall outside the resident room indication the type of precautions and PPE required;-PPE is available outside the resident's room;-For environmental control, ensure that environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces are appropriately cleaned. Record review of the policy titled, Personal Protective Equipment-Using Gloves, Revised September 2010, showed the following:-The purpose is to guide the use of gloves;-The objectives are to prevent the spread of infections, to protect wounds from contamination, and to protect hands from potentially infectious material;-When gloves are indicated, use disposable single-use gloves;-Discard use gloves into the waste receptacle inside the examination or treatment rooms;-Use non-sterile gloves primarily to prevent contamination of the employee's hands when providing treatment or services to the patient and when cleaning contaminated surfaces;-Wash hands after removing gloves. (Note: Gloves do not replace handwashing).-Remove gloves before removing the mask and gown and discard them into the designated waste receptacle inside the room. 1. Review of the Resident #19's face sheet (brief look at resident information) showed the following information:-admission date of 11/01/25;-Diagnoses included fracture (a partial or complete break in a bone) of lower end of right femur (bone that goes from the hip to the knee), pressure ulcer (bedsore) of sacral region (tailbone), stage 2 (partial-thickness skin loss of a wound), arthritis, hypertension, depression, and anxiety. Review of the resident's care plan, initiated on 11/01/25, showed the following information:-admitted with a stage 2 pressure ulcer of sacrum and is being treated with off loading and skin barrier cream;-Requires two staff members to assist with bed mobility and transfers;-On enhanced barrier precautions (EBP-infection control measures requiring staff to wear gowns and gloves during high-contact care for residents);-On a turning and repositioning schedule. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 02/02/26, showed the following information:-Cognitively intact;-Dependent for toileting, lower body dressing, putting on and taking off footwear, chair/bed-to-chair transfer, and toilet transfer;-Substantial/Maximal assistance for shower/bathing, upper body dressing, rolling left to right, sit to lying, and lying to sitting on side of bed;-Occasional urinary incontinence;-Has one or more unhealed pressure ulcers. Observation of Resident #19 on 03/04/26, at 1:29 P.M., showed the following:-Registered Nurse (RN) E and Certified Medication Technician (CMT) W entered the resident's room, washed his/her hands, and put on gloves;-RN E brought a resident shared wound cleanser and wound adhesive bottle into the room along with the resident's ordered dressing supplies;-CMT W prompted RN E to put a gown and mask on, so RN E applied a gown, but no face masks were available in the resident's room;-The housekeeping staff knocked on the door, and RN E asked the housekeeper to bring him/her a face mask, which RN E received and put on;-RN E borrowed the bedside table from the resident's neighbor in bed two to put the wound care supplies on. The bedside table was not cleaned and the table contained personal items for the resident in bed two;-RN E removed the residents soiled dressing and took his/her gloves off and placed them on the resident's neighbor's bedside table;-The nurse put new gloves on and sprayed a 4x4 gauze pad with the wound cleanser and used the 4x4 gauze pad to soak the sacral region wound. This process was repeated four times;-Without changing his/her gloves or washing his/her hands or using hand sanitizer, he/she applied Zinc oxide (topical skin protectant used to treat and prevent minor skin irritations) to the sacral region wound;-RN X removed his/her gloves and reapplied the dirty gloves that were previously placed on the resident's neighbor's bedside table. No handwashing or hand hygiene was observed;-The nurse sprayed wound prep on the skin surrounding the wound and placed a dressing between the buttocks. A [NAME] silicone super absorbent bandage with no border was placed over the wound dressing. The bandage was secured with tape and initialed and dated by the RN;-The RN removed his/her gloves and then removed the trash bag from the trash can that the soiled wound care supplies and gloves were placed it and tied the bag up; -CMT W removed his/her gown and gloves and washed his/her hands in the resident's sink in the room;-RN E removed his/her gown and then removed his/her mask and washed his/her hands in the resident's sink in the room;-The nurse removed the resident contaminated wound supply bottles from the neighbor's bedside table and returned the bedside table to the neighbor without cleaning it;-RN E took the two resident contaminated wound supply bottles to the nurses station and put gloves on to clean the bottles with CaviWipes. The bottles were wiped down for less than a minute. He/She removed his/her gloves and placed the bottles back in the nurse's cart located in the hall. No handwashing or hand sanitizing was observed. During an interview on 03/05/26, at 12:00 P.M., RN E said Resident #19 is on EBP's. During an interview on 03/06/26, at 10:38 A.M., CAN B said Resident #19 is on EBP. During an interview on 03/06/26, at 10:40 A.M., RN Y said Resident #19 is on EBP because of open wounds. 2. Review of the Resident #60's face sheet (brief look at resident information) showed the following information:-admission date of 02/02/26;-Diagnoses included stage 2 (open wound with partial thickness skin loss) pressure ulcer of sacral region (large bone at the bottom of the spine). Review of the resident's comprehensive admission Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 02/12/26, showed the following information:-Cognitively intact;-Uses a walker and wheelchair;-Partial to moderate assistance for toileting hygiene;-Dependent with shower/bathing, lower body dressing, putting on or taking off footwear, chair/bed-to-chair transfers, toilet transfer, and tub/shower transfer;-Substantial/Maximal assistance for upper body dressing, rolling left and right, sit to lying, lying to sitting on side of bed, and sit to stand;-Has one or more unhealed pressure ulcers/injuries;-Pressure ulcer/injury care. Observation of Resident #60 on 03/04/26, at 1:47 P.M., showed the following:-RN E did not wash his/her hands following the cleaning of shared wound care supplies that were previously used for another dressing change with resident #19;-Without applying gloves, he/she opened and removed Resident #60's wound dressing in the hall while standing at the nurse's cart, obtain scissors from the cart, did not clean the scissors and then cut the 4 x 4 dressing into a smaller piece;-The scissors were placed back into the nurse's cart without being cleaned;-RN E entered Resident #60's room with the wound care supplies and laid the supplies directly on the resident's cluttered bedside table after moving things around on the table to find room for the supplies;-He/She closed the resident's door and proceeded to put gloves on without washing his/her hands or using hand sanitizer;-RN E failed to don a gown for the wound care procedure per enhanced barrier precaution guidelines;-One glove fell on the floor, so RN E picked it up off the floor and then got a new glove and put it on without completing handwashing or using hand sanitizer;-With the gloves on, RN E removed the Jello, water, and a bowl with left over food from the bedside table and put them on the sink counter in the room;-The hospice nurse entered the room and offered to help turn the resident on his/her side for the coccyx wound dressing change. Gloves were applied, but no handwashing or hand sanitizer was used;-The hospice nurse also failed to don a gown for the pressure wound dressing change;-After the resident was rolled to his/her side, RN E noticed that Resident #60 had a bowel movement and needed to be cleaned up;-RN E informed the resident that the nurse on the next shift would return to complete the dressing change after the nurse aides cleaned him/her up;-RN E and the hospice nurse removed their gloves, washed their hands in the sink, and RN E left the room to give report to the oncoming nurse;-The opened dressing supplies were left on the bedside table for the oncoming nurse to use. Observation of Resident #60 on 03/04/26, at 2:32 P.M., showed the following:-RN X put on gloves and entered Resident #60's room. He/She failed to wash his/her hands and did not put a gown on per enhanced barrier precaution guidelines for the resident;-Nurse aide I entered the room and put on gloves without washing his/her hands or putting a gown on;-The resident was rolled on his/her side and the dressing on the sacrum wound was loose and the wound was exposed;-RN X removed the wound dressing, wiped the bowel off the resident's bottom, and then removed his/her gloves and put on new gloves without washing his/her hands or using hand sanitizer;-RN X applied wound cleanser to the two 4x4 dressings that the RN E left in the room on the bedside table and cleaned the wound one time with each 4x4;-He/She sprayed wound prep around the wound edges;-RN X removed his/her gloves and reached in his/her pocket to find a pair of scissors to cut the Mepilex dressing because he/she stated the dressing was too big, but he/she did not have any scissor;-RN X removed his/her gloves and washed his/her hands in the resident's room;-RN X exited the room to obtain scissors and more gloves;-RN X returned to the room with a pair of scissors and gloves, but he/she did not wash his/her hands, use hand sanitizer or don a gown;-He/She put new gloves on and used an alcohol wipe to clean the scissors;-The Mepilex dressing was cut into a smaller piece and applied over the sacral wound. A self-adhesive tan bandage was applied over the Mepilex dressing and tape was placed over the bandage and labeled with the date and RN's initials;-RN X removed his/her gloves and put new gloves on to place a new depends on the resident. No handwashing or hand sanitizer was used;-NA I removed his/her gloves and left the resident's room without washing his/her hands or using hand sanitizer.-NA I returned to the room and put new gloves on without washing his/her hands or using hand sanitizer. He/She replaced the soiled bed pad that had fecal matter on it with a new bed pad;-NA I removed his/her gloves and applied new gloves without washing his/her hands or using hand sanitizer. New gloves were applied and NA I assisted RN X with repositioning the residents depend;-RN X removed his/her gloves and washed his/her hands in the sink in the resident's room before exiting;-NA I removed his/her gloves and left the resident's room with the soiled content in a bag. He/She did not wash his/her hands or use hand sanitizer before exiting the room;-RN X took the resident contaminated wound cleanser bottle and wound prep bottles to the nurse's desk, obtained a paper towel, and placed the scissors, and the two wound supply bottles on the nurse's desk;-RN X stated that he/she did not know where RN E found the CaviWipes to clean the shared wound care supplies, so a CNA that was at the nurse's station showed him/her where they were stored; -RN X put gloves on and used one wipe to wipe down the scissors, and the two wound supply bottles in less than a minute;-RN X removed his/her gloves and returned the shared wound care supplies to the nurse's cart in the hallway. No handwashing or hand sanitizing was observed. RN X returned to the nurse's station; 3. During an interview on 03/04/26, at 3:03 P.M., RN X said he/she was taught to use a gown if a wound is contagious. During an interview on 03/05/26, at 12:00 P.M., Registered Nurse (RN) E said the following:-Enhanced barrier precautions (EBP) include wearing a mask, gown, and gloves during resident care;-The residents medication administration record (MAR) should show documentation that a resident is on EBP;-Staff are expected to wear gowns and gloves while completing peri care on a resident and with any resident that has an incision. If they are going to be close up with the resident during care, they are expected to wear a mask;-Handwashing should be completed during a dressing change if your hands become contaminated;-Handwashing should be completed before and after resident care;-Staff have access to hand sanitizer in the hallways outside of resident rooms;-After removing a dressing, nurses should wash their hands and change their gloves;-When cleaning the resident shared wound care supplies, such as wound cleanser and wound adhesive bottles, staff should clean the bottles with CaviWipes for 20 seconds. During an interview on 03/05/26, at 3:40 P.M., Certified Nurse Assistant (CNA) F said the following:-EBP means that staff should put barrier cream on a resident's bottom to help keep their skin from getting red and sore;-He/She wears a gown and gloves to complete catheter care and if a resident is diagnosed with C. diff (bacteria that causes severe, watery diarrhea); No gown or gloves were indicated for wound care;-He/She washes his/her hands before he/she puts gloves on and after he/she removes his/her gloves. During an interview on 03/06/26, at 10:38 A.M., Certified Nurse Aide (CNA) B said the following:-EBP is a cream such as [NAME] oxide or A & D ointment used for redness on a resident's bottom to help keep moisture off the skin;-He/She always wears gloves in a resident's room and if he/she is doing anything with a residents wound or catheter or if a resident has C-diff (a bacterium that causes severe diarrhea), he/she wears a gown too;-He/She washes his/her hands after changing a resident. During an interview on 03/06/26, at 10:40 A.M., RN Y said the following:-Staff should wear a gown, mask, and gloves with catheter care, wound treatments, and any open source of infection;-He/She would not reuse gloves during a dressing change. He/she uses as many gloves as needed to complete the dressing change;-He/She uses sanitation wipes to clean resident contaminated wound care supplies such as the wound cleanser bottle, wound adhesive spray bottle, and scissors. He/She would wipe the supplies down, but he/she is not aware of there being a specific amount of time the wound supplies need to be cleaned for to kill bacteria. He/She wipes the supplies down, lets them dry, and replaces the supplies back in the nurse's cart;-Nursing staff should wear a mask, gown, gloves, and wash their hands before and after wound care, and then discard all the soiled content into the trash before leaving the resident's room;-If his/her gloves become soiled during a dressing change or if the wound has a lot of drainage, he/she would remove his/her gloves and put new gloves on;-He/She would change his/her gloves after applying Zinc oxide to a wound, prior to applying a new dressing over the wound;-He/She would use hand sanitizer between glove changes while changing a wound dressing. During an interview on 03/06/26, at 12:10 P.M., the Director of Nursing (DON) said the following:-He/She would expect staff to know what enhanced barrier precautions (EBP) mean;-He/She would not expect staff to say that EBP means they should apply a barrier cream to a residence peri area or buttocks to help prevent redness and moisture;-EBP should be used for residents that have chronic wounds;-Staff should use gloves and gowns for EBP and if there is a risk for body fluids to be splashed on staff they should also wear a mask;-Nursing staff should not be borrowing the resident's neighbors bedside table to put wound care supplies on during a dressing change on a wound and then return the bedside table to the resident's neighbor without sanitizing the bedside table;-Staff are trained on EBP but he/she is not sure how often and he/she does not know the date that the last training was provided;-Nursing staff should not be reusing dirty gloves during a resident's wound care dressing change;-Nursing staff are expected to change their gloves and wash their hands or use hand sanitizer when they go from a dirty process to a clean process during wound care;-The resident shared wound care supplies such as wound cleanser and wound adhesive spray bottles should be cleaned with CaviWipes for one to three minutes. During an interview on 03/06/26, at 12:55 P.M., the Administrator said the following:-He/She would expect staff to know what enhanced barrier precautions (EBP) mean and to follow enhanced barrier precautions with the residents that have it ordered;-Staff should know that EBP does not mean applying barrier cream to a resident's buttocks;-Staff are trained on EBP upon hire, quarterly, and with any audits;-EBP should be used on residents who have chronic wounds;-EBP involves wearing gowns and gloves to provide resident care;-In addition, staff should wear a mask as part of EBP if there is a chance for body fluids to be splashed or if a resident has a respiratory diagnosis;-He/She would expect nursing staff and other staff that are assisting the nurse to wear a gown and gloves while providing wound care to a resident;-He/She would not expect a nurse to be told by a certified nurse aide (CNA) that he/she needed to wear a gown and/or mask during wound care;-Staff should not be reusing gloves during the wound care for a resident;-Staff should be washing their hands prior to contact with a resident and after contact with a resident;-Staff should be changing their gloves and washing their hands when providing wound care to a resident and they are going from a dirty process to a clean process;--Nursing staff should not be borrowing the resident's neighbors bedside table to use for wound care supplies during a dressing change and then return the bedside table to the resident's neighbor without being sanitized.

Based on observation, interview, and record review, the facility failed to have a system in place to ensure nurse aides (NA) completed their training, competencies, and testing in a timely manner when eight NAs (NA G, NA H, NA I, NA J, NA K, NA L, NA M, and NA N) failed to complete a state approved certified nursing assistant (CNA) training program, competency evaluation, and certification test within four months of beginning work as an NA. The facility census was 61.Review of the facility policy titled, Nurse Aide Qualifications and Training Requirements, revised September 2011, showed the following:-Nurse aides must undergo a state-approved training program;-Nurse Aide is defined as any individual providing nursing or nursing-related services to residents in our facility who are not a licensed health professional, a registered dietitian, or someone who volunteers to provide such services without pay;-In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA), our facility will only employ those nurse aides who meet the requirements set forth in the federal and state statutes concerning the staffing of long-term care facilities;-Our facility will not use any individual as a nurse aide for more than four months full-time, temporary, per diem, or other basis unless that individual is competent to provide nursing and nursing related services and that individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state, or that individual has been deemed competent as provided in 483.150 (a) and (b) of the Requirements of Participation;-Our facility will not use any individual as a nurse aide who has worked less than four months unless the individual is a full-time employee and participating in a state-approved training and competence evaluation program; has demonstrated competence through satisfactory participation in a state-approved nurse aide training and competency evaluation program; or has been determined competent as provided in 483.150 (a) and (b) of the Requirements of Participation;-Nursing assistants failing to successfully complete the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services.1.Review of the facility's Job description report, dated 03/03/26, showed NA G's original hire date was 09/03/25, with a current hire date of 01/03/26.Review of NA G's personnel record showed the facility did not have documentation of completion of a state approved CNA testing program within four months of hire.Observation on 03/03/26, at 3:05 P.M., showed NA G used a Hoyer lift (a mechanical device with a sling attached to lift and transfer a non ambulatory resident) to transfer a resident from his/her bed to his/her wheelchair.During an interview on 03/03/26, at 3:05 P.M., NA G said he/she worked as an NA at the facility since September of 2025.During an interview on 03/06/26, at 4:45 P.M., the Director of Nursing (DON) said NA G had worked at the facility as a NA for six months. He/She completed the CNA training on 12/19/25, but he/she had not completed the CNA test.During an interview on 03/06/26, at 4:53 P.M., the Office Manager (OM) said NA G was initially hired as a NA on 09/03/25, terminated 01/02/26, and rehired on 01/03/26.2. Review of the facility's Job description report, dated 03/03/26, showed NA H's original hire date was 12/14/23, with a current hire date of 01/28/26.Review of NA H's personnel record showed the facility did not have documentation of completion of a state approved CNA testing program within four months of hire.Observation on 03/03/26, at 3:05 P.M., showed NA G used a Hoyer lift (a mechanical device with a sling attached to lift and transfer a non ambulatory resident) to transfer a resident from his/her bed to his/her wheelchair.During an interview on 03/03/26, at 3:05 P.M., NA H said he/she worked as an NA at the facility for over a year.During an interview on 03/06/26, at 4:53 P.M., the OM said the following: -NA H was initially hired as a NA two years ago and he/she has been terminated in the facility computer system numerous times;-He/She was initially hired on 12/14/23, terminated on 05/20/24;-NA H was rehired on 05/22/24, terminated on 09/22/24, rehired on 09/23/24, terminated on 01/21/25, rehired on 01/22/25, terminated on 05/27/25, rehired on 05/28/25, terminated 09/27/25, rehired on 09/28/25, terminated on 01/27/26, and rehired on 01/28/26.During an interview on 03/06/26, at 4:45 P.M., the DON said NA H had worked as an NA at the facility since 12/14/23. He/She was scheduled to retake the CNA class next week. He/She had not completed the CNA test. 3. Review of the facility's Job description report, dated 03/03/26, showed NA I's original hire date was 02/07/24, with a current hire date of 01/28/26.Review of NA I's personnel record showed the facility did not have documentation of completion of a state approved CNA testing program within four months of hire.During an interview on 03/04/26, at 2:37 P.M., NA I said he/she worked as a NA at the facility for two years.Observation on 03/04/26, at 2:37 P.M., showed NA I assisted RN X with providing resident incontinent care after a bowel movement and a wound dressing change.During an interview on 03/06/26, at 4:45 P.M., the DON said NA I had worked as an NA at the facility since 02/07/24. He/She was scheduled to retake the CNA class next week. NA, I finished the CNA course in November of 2025, attempted the CNA test one time and failed.During an interview on 03/06/26, at 4:53 P.M., the OM said NA I was initially hired as a NA on 02/07/24, terminated on 09/21/25, rehired on 09/22/25, terminated on 01/21/25, rehired on 01/22/25, terminated on 05/27/25, rehired on 05/28/25, terminated on 09/27/25, rehired on 09/28/25, terminated on 01/27/26, and rehired on 01/28/26.4. Review of the facility's Job description report, dated 03/03/26, showed NA J's original hire date was 08/13/24, with a current hire date of 01/28/26.During an interview on 03/06/26, at 4:45 P.M., the DON said NA J was scheduled to restart the CNA class next week. The NA worked an NA on the floor.5. Review of the facility's Job description report, dated 03/03/26, showed NA K's original hire date was 09/12/24, with a current hire date of 01/28/26.During an interview on 03/06/26, at 4:45 P.M., the DON said NA K was scheduled to restart the CNA class next week. The NA worked an NA on the floor.6. Review of the facility's Job description report, dated 03/03/26, showed NA L's original hire date was 08/25/23, with a current hire date of 01/28/26.During an interview on 03/06/26, at 4:45 P.M., the DON said NA L was scheduled to restart the CNA class next week. The NA worked an NA on the floor.7. Review of the facility's Job description report, dated 03/03/26, showed NA M's original hire date was 07/21/25, with a current hire date of 11/21/25.During an interview on 03/06/26, at 4:45 P.M., the DON said NA M had completed the CNA course but was not scheduled to take the test. The NA was working as an NA on the floor.8. Review of the facility's Job description report, dated 03/03/26, showed NA N's original hire date was 09/24/25, with a current hire date of 01/24/26.During an interview on 03/06/26, at 4:45 P.M., the DON said NA N had completed the CNA course but was not scheduled to take the test. The NA was working as an NA on the floor. 9. Review of an email from the Administrator dated 03/09/26, at 2:48 P.M., showed the following:-The email identified NA G, NA H, NA I, NA J, NA K, NA L, NA M, and NA N as employed longer than four months;-The email noted the NA's that finished their NA training within the four months but did not test within the four months and were terminated in the computer and re-started to stay within the four-month timeframe that NA's can be employed for and work with residents.10. During an interview on 03/06/26, at 4:45 P.M., the DON said the following:-The NA's have close to one year to complete their CNA test after they complete the CNA course;-NA's are required to complete their CNA course and pass the CNA test within four months of being hired or they need to be terminated and rehired. During an interview on 03/06/26, at 4:53 P.M., the Office Manager (OM) said the following:-The NA's have close to a year from the start of their CNA training to take the CNA exam, and they get three tries to pass the test;-If the NA's do not pass the CNA course or test, they have to start the CNA training again;-The NA's that do not pass the CNA course or CNA test are fired after their four months with the facility is up and they are hired back the next day;-The OM was responsible for assigning a termination date and a new hire date in the facility computer system.During an interview on 03/09/26, at 12:15 P.M., the Administrator said the following:-He/She did not know the exact number of NA's working in the facility that have worked on the floor with residents for over four months;-NA's have four months to complete their CNA training once they start working;-The facility has been having a problem with getting the NA's tested for CNA certification;-NA's have one year to take their CNA test after they finish the course;-If the NA's fail the CNA test, they get a second attempt;-The NAs cannot be employed beyond four months if they do not complete the course or pass the CNA test, so the facility is terminating the NA's that have not finished the course or passed their test in the four-month timeframe and re-hiring them;-For the NA's that do not complete their course or pass their CNA test in the four-month timeframe that is required, the OM notifies the DON and CNA instructor that he/she terminated the NA in the facility computer system and provided them with a new hire date; -The NA was allowed to continue working on the floor with residents since they have a new hire date in the facility computer system;-This cycle is repeated every four months if the NA has not completed their CNA class or passed their CNA test;-He/She is aware that some of the NA's working the floor and caring for residents have been employed with the facility as an NA for over two years;-The Administrator is aware that NAs cannot work on the floor providing care to residents if they do not complete the CNA course and pass their CNA test within four months. After four months the NA would have to work in housekeeping or dietary if they were not terminated and rehired.

Based on interview and record review, the facility failed to ensure resident received wound care consistent with standards of practice when staff failed to arrange a physician ordered wound care consult for one resident (Resident #60) and failed to document why it was not completed in the resident's record. The facility census was 61.Review of the facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised in March 2014, showed the following:-The physician will authorize orders related to wound treatments, including wound cleansing, and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents if indicated for type of skin alteration;-During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds;-The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions.1. Review of the Resident #60's face sheet (brief look at resident information) showed the following information:-admission date of 02/02/26;-Diagnoses included stage 2 (open wound with partial thickness skin loss) pressure ulcer of sacral region (large bone at the base of the spine). Review of the resident's comprehensive admission skin assessment, dated 02/02/26, showed an open area on the coccyx (tailbone) that measured 3 centimeters (cm) x 1 1/2 cm.Review of the resident's care plan, updated 03/04/26, showed the following information:-At risk for pressure ulcers related to weakness;-Had a pressure relieving mattress and a pressure relieving device for wheelchair/chair;-Resident's skin will remain intact;-Stage 2 pressure ulcer of coccyx (tailbone) present on admission;-Goal is to resolve pressure ulcer;-Encourage resident to make frequent changes in body position;-Provide incontinence care after each incontinent episode;-Report any signs of skin breakdown;-Turn and reposition every two hours when awake.-Pressure relieving device to chair and to turn and reposition every 1-2 hours to offload sacrum;-Air mattress put on bed this week and Pro-Stat (supplement) added daily;-Further decline of pressure ulcer on coccyx related to decreasing nutrition/hydration and declined mobility. Wound care dressing changes per physician's orders.Review of the resident's comprehensive admission Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 02/12/26, showed the following information:-Cognitively intact;-Had one or more unhealed pressure ulcers/injuries;-One stage 2 pressure ulcer present on admission;-Pressure ulcer/injury care.Review of the resident's current Physician Order Sheets (POS) showed an order, dated 02/23/26, for wound care consultation today if possible and for Pro-Stat daily as tolerated.Review of the resident's record showed staff did not document a wound care consult requested or why one was not completed. During an interview on 03/06/26, at 10:40 A.M., Registered Nurse (RN) Y said the following:-Nursing staff should follow physician orders and schedule a wound consult if a wound consult was ordered by the physician;-The Director of Nursing (DON) was responsible for setting up the wound consultants.During an interview on 03/06/26, at 12:10 P.M., the Director of Nursing (DON) said the following:-The DON verbally informed the physician the facility contracted wound consultant group, was no longer seeing residents at the facility for wound consultants, but he/she failed to document the conversation or further orders from the physician in the resident's medical record;-He/She did not try to schedule a wound consult for the resident outside of the facility after he/she was informed by the contractor company was no longer accepting wound consults from the facility;-He/She spoke with the wound contractor nurse the same day (02/23/26) the physician wrote the order for a wound consult to be completed as soon as possible and it was their last day in the facility, so they would not be able to accept the physician ordered wound consult and would probably not be able to accept wound consults at the facility for several months. During an interview on 03/06/26, at 12:55 P.M., the Administrator said the following:-Staff are expected to follow through on wound consult orders;-If a wound care consulting service is no longer available at the facility, staff are expected to talk with the physician and ask if he/she would like the order discontinued or if he/she would like the resident sent outside the facility to a wound consultant clinic.

Based on interview and record review, the facility failed to ensure a system in place that clearly and consistently represented each resident's choice of code status (if they wished to receive cardiopulmonary resuscitation (CPR-lifesaving technique that's useful in many emergencies in which someone's breathing or heartbeat has stopped) if their heart and/or breathing stopped) when staff failed to ensure one resident's (Resident #59) code status was consistent throughout the medical record. The facility census was 61.Review showed the facility did not provide a policy related to resident code status.1. Record review of resident #59's face sheet (a general information sheet) showed the following:-admission date to the facility of [DATE];-Diagnoses of chronic obstructive pulmonary disease (lung disease), high blood pressure, heart disease;-Full code (CPR, and other life-saving techniques, should be administered if resident heart and/or breathing stopped).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated [DATE], shows the resident to be cognitively intact.Record review of the resident's physician order sheet (POS) for [DATE] showed resident code status as full code.Review of the resident's paper medical chart showed the following:-The front page with the resident's preferred code status to be full code;-Outside the Hospital Do Not Resuscitate (OH-DNR) legal document (indicates trained staff or medical personnel should not complete CPR or other life-saving techniques, should the resident's heart and/or breathing stop);-The OH-DNR was signed by the resident's physician and the resident himself/herself.Observation on [DATE], at 9:45 A.M., showed the nameplate by the resident's door with a green sticker beside his/her name.During an interview on [DATE] at 9:50 A.M., Licensed Practicing Nurse (LPN) D said the following:-A green sticker beside the resident's nameplate indicates the resident is full code;-LPN D said the first sheet of the paper chart shows a resident's code status. During an interview on [DATE] with Resident #59, he/she said he/she would like to be full code. He/She would like staff to perform CPR on him/her should his/her heart or breathing stop. The resident said he/she does not know what an OH-DNR form is. During an interview on [DATE], Registered Nurse (RN) E said the following:-A resident's code status should clearly be in the front of the resident's chart, and on the face sheet;-Resident #59 has both full code paperwork and an OH-DNR in their file;-The resident should not have both full code paperwork and an OH-DNR in their file.During an interview on [DATE] at 2:20 P.M., the Administrator said the following:-The resident's code status should be on the first page of the resident chart;-Resident's code status is also on their face sheet, and located outside their room by their nameplate (indicated by a sticker-green for full code, red for DNR);-If a resident is DNR, a completed OH-DNR page signed by the resident (or representative) and physician, is located in their paper medical chart;-There should not be conflicting code status information in a resident's chart.

Based on observation, interview and record review, the facility failed to monitor, provide treatment, and evaluate results for one resident (Resident #57) with constipation in a timely manner. The facility census was 61.Review of the facility's policy, revised September 2012, titled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol showed the following:-As part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. This should include a review of gastrointestinal problems during any recent hospitalizations, results of previous barium studies, endoscopies, etc.;-In addition, the nurse shall assess and document/report the following: -Vital signs; -Presence of fecal impaction; -Signs of dehydration (altered level of consciousness, lethargy, dizziness, recent change in mental status, dry mucous membranes, decreased urine output); -Abdominal assessment; -Digital rectal examination; -Onset, duration, frequence, severity of signs and symptoms; -All current medications; -All active diagnoses, and; -Recent labs;-The staff and physician will identify risk factors related to bowel dysfunction, for example, severe anxiety disorder, recent antibiotic use, or taking medications that are used to treat, or that may cause or contribute to, gastrointestinal erosion (a raw area, shallow break, or small, superficial sore in the lining of the stomach or intestine), bleeding, diarrhea, dysmotility (condition in which muscles and/or nerves of the digestive system do not work as they should), etc.;-The staff and physician will characterize symptoms related to bowel function; for example, location and radiation of abdominal pain, time relationship to meals, presence of cramps or bloating, etc.;-Check for diffuse or localized tenderness and listen for bowel sounds in area of suspected ileus (a temporary condition where your intestine can't push food and waste out of your body) or obstruction;-Consistent terminology and documentation over time enable comparison of symptoms and evaluation of the effectiveness of specific interventions;-Treatment/Management: -The physician will identify and order pertinent cause-specific and symptomatic interventions; for example, institute a regimen to prevent constipation;-Monitoring and Follow-Up: -The staff and physician will monitor the individual's response to interventions and overall progress; for example, overall degree of comfort or distress, frequency and consistency of bowel movements, and the frequency, severity, and duration of abdominal pain, etc.; -The physician will adjust interventions based on identification of causes, resident responses to treatment, and other relevant factors. 1. Review of Resident #57's face sheet (brief resident profile sheet) showed the following information:-admitted to the facility on [DATE];-Received hospice services;-Diagnoses included chronic kidney disease-hospice primary (end-of-life care provided during the final stages of a terminal illness); morbid obesity (a significant amount of excess weight); spinal stenosis, lumbar region (narrowing of the spinal canal in the lower part of your back); vascular dementia without behavioral disturbance (decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain); congestive heart failure (the heart is weakened which leads to poor circulation and fluid buildup); depression. Review of the resident's physician orders, dated 02/05/26, showed the following:-Furosemide (Lasix) (a diuretic that increases urine output, which can lead to dehydration, reduced water content in the stool, may slow digestion and contribute to constipation.) 40 milligram (mg) tablet, one tablet, one time daily for edema;-Senna-time (an over-the-counter natural vegetable stimulant laxative used to relieve occasional constipation) 8.6 mg, one tablet, one time daily as needed for constipation;-Ondansetron (Zofran) 4 mg, one tablet, every eight hours as needed for nausea and vomiting;-The orders did not include any daily medication order to prevent constipation. Review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/11/26, showed the following information:-Moderate cognitive impairment;-Occasionally incontinent of bowel;-Constipation not present. Review of the resident's care plan, reviewed/revised on 02/13/26, showed the following:-At risk for adverse consequences to receiving the diuretic medication Lasix for treatment of edema/high blood pressure. Nursing approach: report signs and symptoms of dehydration including constipation;-Required assistance for activities of daily living (ADL) completion related to declined mobility and declined mental status;-Required assistance of one staff member for bed mobility, transfers, and ambulation with a rolling walker;-Able to make needs known but does not always remember to use the call light to ask for assistance;-Impaired decision making related to declined mental status;-Chronic pain of shoulders and lower back. Nursing to assess for pain, effectiveness of pain medication and for adverse reactions to medication;-Occasional bladder incontinence related to declined mental status and declined mobility/function. Review of the resident's physician orders, dated 02/27/26, showed the following:-Levofloxacin (Levaquin) (an antibiotic used to treat bacterial infections in many different parts of the body) 750 mg, one tablet, one time daily for seven days;-Acidophilus (a probiotic supplement that may reduce antibiotic-associated diarrhea), one capsule, two times daily for 14 days. Review of the resident's nurse's notes showed the following:-On 02/27/26, new order for Levaquin 750 mg, daily for seven days, resident had no signs or symptoms of adverse reactions, first dose given. Review of the February 2026 Certified Nurse's Assistant-Activities of Daily living (CNA-ADL) tracking forms showed the following:-On 02/27/26, the aides documented the resident had two bowel movements. Review of the resident's nurse's notes showed the following:-On 02/28/26, at 4:00 A.M., the resident continued on Levaquin for upper respiratory infection (URI), no adverse reactions noted, has rested well tonight, no coughing noted;-On 02/28/26, at 1:00 P.M., the resident continued on Levaquin for URI, no adverse reactions, he/she ate better today than previous days, no coughing noted;-On 02/28/26, at 4:00 P.M., the resident continued on Levaquin for URI with no signs or symptoms of adverse reactions noted;-On 02/28/26, at 12:10 A.M., Levaquin treatment for URI continued, resting quietly, both eyes closed. Review of the February 2026 and March 2026 Certified Nurse's Assistant-Activities of Daily living (CNA-ADL) tracking forms showed the following:-Staff did not document the resident had any bowel movements on 02/28/26 and 03/01/26. Review of the resident's March 2026 medication administration record (MAR) showed the following:-Ondansetron 4 mg, one tablet, administered on 03/01/26, at 11:40 A.M., reason given nausea/vomiting, noted nurse aware of vomiting, results effective. Review of the resident's nurse's notes showed the following:-On 03/01/26 (no time entered), the resident continued Levaquin for URI, had nausea/vomiting at lunch time, did not eat any lunch, no side effects noted;-On 03/01/26 (no time entered), the resident continued Levaquin for URI, with no signs or symptoms of adverse reactions noted;-On 03/01/26 (no time entered), the resident continued on antibiotic therapy for URI, no signs or symptoms of adverse reactions noted. Review of the bowel movement documentation and intervention list form, dated 03/01/26, showed:-Staff did not add the resident to the intervention list. Review of the resident's nurse's notes showed the following:-On 03/02/26, at 9:40 A.M., the resident continued on antibiotic therapy for URI, no reported or observed side effects;-On 03/02/26, at 4:30 P.M., the resident continued on antibiotic therapy for URI with no signs or symptoms of adverse reactions;-On 03/02/26, at 8:06 P.M., the resident continued on antibiotic therapy for URI, no signs or symptoms of adverse reactions noted. Review of the resident's March 2026 CNA-ADL tracking form showed the following:-On 03/02/26 and 03/03/26, staff did not document any bowel movements for the resident. The staff did not provide the bowel movement documentation and intervention list form for 03/02/26 and 03/03/26. Review of the resident's nurse's notes showed the following:-On 03/03/26, at 10:24 A.M., the resident continued on antibiotic treatment for URI without adverse reactions. Review of the resident's March 2026 MAR showed the following:-On 03/03/26, at 2:32 P.M., staff administered ondansetron 4 mg, one tablet for complaint of nausea, results acceptable. Review of the resident's nurse's notes showed the following:-On 03/03/26, at 4:08 P.M, the resident continued on antibiotic therapy for URI with no signs or symptoms of adverse reactions;-On 03/03/26, at 11:30 P.M., the resident continued on antibiotic therapy for URI, no signs or symptoms of adverse reactions to antibiotic, no cough, congestion or shortness of breath. During an observation and interview on 03/04/26, at 11:04 A.M., the resident said the following:-He/she did not feel good;-He/she had been on antibiotics since he/she came to the facility;-He/she did not eat breakfast that morning;-The resident told staff and they gave him/her a medication for nausea that morning. The resident said it helped;-It had been several days since his/her last bowel movement. He/she did not remember the exact date, but thought staff knew and did not know if any interventions had been done;-The resident had a vomit bag at the resident's side on the bed and call light within reach. During an observation and interview on 03/04/26, at 11:31 A.M., Registered Nurse (RN) E came into Resident #57's room and said the following:-The resident was on an antibiotic for an upper respiratory infection;-The nurse listened to the resident's lungs and said the resident's lungs were clear;-The nurse asked the resident if he/she had a cough and the resident said he/she had a dry cough;-The nurse did not ask the resident if he/she had any adverse reactions to the antibiotic, nausea/vomiting, constipation or about his/her general well-being;-The resident did not tell the nurse about symptoms of nausea or constipation. Review of the resident's March 2026 MAR showed the following:-On 03/04/26, at 12:03 P.M., staff administered Senna 8.6 mg, one tablet for complaint of constipation, results ineffective. During an observation and interview on 03/04/26, at 1:52 P.M., the resident said:-He/she was still slightly nauseated;-The resident drank warm prune juice and ate spinach. Review of the bowel movement documentation and intervention list form dated 03/04/26 showed:-Staff documented the resident's last bowel movement occurred on 03/01/26;-Staff documented the intervention given as prune juice;-No results. Review of the March 2026 CNA-ADL tracking forms showed the following:-On 03/04/26, staff did not document any bowel movement for the resident. Review of the resident's March MAR showed the following:-On 03/05/26, at 8:47 A.M., staff administered ondansetron 4 mg, one tablet for complaint of nausea/vomiting, results acceptable; During an observation and interview on 03/05/26, the resident said the following:-At 9:45 A.M., the resident said he/she woke up this morning nauseated and threw up yesterday afternoon;-Staff knew of his/her symptoms and gave the resident an anti-nausea medication and medication for constipation that morning.-He/she did not know the exact time staff administered the medications. The resident said he/she did not have any results yet. -At 11:53 A.M., he/she was still nauseated and had not had a bowel movement, can't get anything out either way;-The resident had a vomit pan beside him/her in the bed;-He/she pressed the call light to request an alternative for lunch;-At 12:24 P.M., the resident said he/she had eaten a little bit of rice and jello;-Staff had not administered any medication for nausea to him/her;-Staff administered a medication to help the resident have a bowel movement, but did not know the name of the medication. -At 2:07 P.M., the resident said he/she ate some saltine crackers;-The resident was not as nauseated as he/she was earlier in the day;-The resident still had not had a bowel movement;-Before the resident came to the facility, he/she would usually have a bowel movement daily;-Staff usually ask the resident if he/she has had a bowel movement and he/she tells staff. During an interview on 03/05/26, at 2:19 P.M., Nurse's Assistant (NA) A said the following:-The aides document resident bowel movements in the ADL notebook on the CNA-ADL tracking form;-The aides document all resident bowel movements every shift;-The CNA-ADL tracking form was the only place that resident bowel movements were documented;-NA A asks the independent residents if they had a bowel movement every shift;-He/she would tell the Certified Medication Technician (CMT) or nurse if a resident had gone without a bowel movement for three days or more;-He/she would tell the nurse if a resident said he/she was constipated;-The aides would need to look at past documentation on the CNA-ADL tracking form to count days a resident had gone without a bowel movement;-Resident #57 can tell staff if he/she had a bowel movement;-If Resident #57 is continent, he/she will use the call light for assistance in wiping after a bowel movement;-Occasionally, Resident #57 was incontinent.-NA A reviewed the CNA-ADL tracking form for Resident #57, he/she verified the resident's last bowel movement was on 02/27/26 (six days prior). During an interview on 03/05/26, at 2:26 P.M., CMT C said the following:-It was CMT C's first day back to work after three days off;-CMT C reviews the CNA-ADL tracking form for all of the residents throughout his/her shift;-He/she did not know of any other place that staff document resident bowel movements;-He/she usually does not ask the residents if they have had a bowel movement, he/she only looks on the tracking form;-Residents sometimes let CMT C know if it has been a while since they had their last bowel movement;-There is no set bowel protocol in the facility, it is dependent on each specific resident's physician's orders;-If it was three days or more since a resident's last bowel movement, CMT C would look at the resident's orders, give the as-needed laxative or stool softener and notify the nurse;-If the resident did not have an as-needed laxative or stool softener order, CMT C would give prune juice or butter, and tell the nurse;-CMT C reviewed the CNA-ADL tracking form for Resident #57. He/she verified staff documented the resident's last bowel movement as 02/27/26 (six days prior);-He/she would look at Resident #57's orders and give the ordered medication for constipation.-On 03/06/26, at 10:04 A.M., CMT C said he/she remembered there was another form completed daily by each day shift's CMT;-The form is titled bowel movement documentation and intervention list. It showed the resident name, date of last bowel movement, intervention and results;-CMT C looks over CNA-ADL tracking form for each resident and then adds the resident to the bowel movement documentation and intervention list;-At the end of the shift, CMT C gives the form to the nurse to review and sign. Review of the resident's March 2026 MAR showed the following:-On 03/05/26, at 2:36 P.M., staff administered senna 8.6 mg, one tablet for complaint of constipation, results showed no bowel movement yet. During an interview on 03/05/26, at 2:41 P.M., Licensed Practical Nurse (LPN) D said the following:-Staff documented all resident bowel movements in the CNA notebook on the CNA-ADL tracking forms, that is the only place staff document bowel movements;-LPN D does not look at the CNA documentation. The CMTs review the CNA documentation.-When residents have gone three days since their last bowel movement, the CMT would check as needed medications on the physician's orders;-The CMT would then notify the nurse of the action taken;-LPN D reviewed the CNA-ADL tracking form for Resident #57, he/she verified staff documented the resident's last bowel movement on 02/27/26 (six days prior);-LPN D would make sure the CMT gave Resident #57 an ordered medication for constipation, prune juice and he/she would contact the physician to let him/her know action taken so far and if a new order was needed. Review of the resident's bowel movement documentation and intervention list form, dated 03/05/26, showed:-The resident's last bowel movement on 02/27/26;-Staff documented intervention of prune juice and senna, 1 tablet administered;-Staff documented the resident had two bowel movements at 7:40 P.M. Review of the resident's physician/nurse correspondence form, dated 03/05/26, showed:-Staff faxed the form to the physician at 3:42 P.M.;-The physician reply fax was received at 7:33 P.M., and showed the physician's response as Miralax 17 grams (gm), dissolve one scoop powder in eight ounces (oz) of water/juice, one time daily until large bowel movement, then as needed. Review of the resident's nurse's notes showed the following:-On 03/05/26 (no time entered), the nurse documented the new order received for Miralax daily until large bowel movement, then as needed and faxed the order to the pharmacy. Review of the resident's March 2026 MAR showed the following:-On 03/05/26, at 11:30 P.M., staff administered ondansetron 4 mg, one tablet for complaint of nausea/vomiting, results ineffective. Review of the resident's March 2026 CNA-ADL Tracking Form showed the following:-Staff documented the resident had two bowel movements on 03/05/26, evening shift;-Staff documented the resident had three bowel movements on 03/05/26, night shift. Review of the resident's March 2026 MAR showed the following:-Staff did not administer the Miralax medication. Observation on 03/06/26, at 9:54 A.M., showed the following:-The resident lay in the bed, resting with eyes closed, breathing evenly, unresponsive to greeting;-Assistant Director of Nursing (ADON), came to the resident's bedside, gently rubbed the resident's left arm, the resident slowly responded, spoke slowly, acted lethargic, and unable to keep eyes open;-The ADON asked the resident if he/she remembered the CMT giving a medication for constipation on 03/01/26, the resident could not answer and closed his/her eyes;-The ADON said she would come back later. During an interview on 03/06/26, at 10:04 A.M., CMT C said he/she was told Resident #57 had several bowel movements last night. Review of the resident's nurse's notes showed the following:-On 03/06/26, at 10:13 A.M., late entry, per speaking with CMT W, resident had bowel movement on 03/01/26, CMT W forgot to document. During an interview on 03/06/26, at 2:02 P.M., the administrator said she called CMT W on 03/06/26 to clarify the bowel monitoring documentation and intervention list form, dated 03/04/26, that showed the resident had a bowel movement on 03/01/26, and wrote a late entry nurses note to explain. During an interview on 03/06/26, at 10:23 A.M., CNA B said the following:-CNA B documents resident bowel movements in the CNA notebook on the CNA-ADL tracking form immediately so he/she does not forget;-CNA B looks at the last several days of bowel movement documentation and reports to the CMT and nurse if the resident did not have a bowel movement in the last three days or more;-CNA B had been told Resident #57 had several bowel movements on the previous shift. During an observation and interview on 03/06/26, at 11:22 A.M., the resident said the following:-He/she had several bowel movements last night, had not eaten yet today, still nauseated, been sleeping all morning, and his/her mouth was dry;-The resident took several sips of water and acted drowsy;-The resident did not remember if he/she had taken any nausea medicine;-At 11:25 A.M., Hospice RN V entered the resident's room;-Hospice RN V said the resident had a 100.1 degree temperature;-The resident thought he/she was in the hospital, repeated twice to call his/her family about not feeling well, and was just tired;-Hospice RN V told the resident he/she would contact the hospice physician and the family member, and return that afternoon to reassess;-The resident started to act more awake.-At 2:00 P.M., Hospice RN V said the following:-The resident had new orders from the hospice physician for the following: -One time dose of fosfomycin (a powerful, single-dose powder antibiotic used to treat uncomplicated bladder infections) 3 grams; -As-needed hospice nurse visit for the weekend; -To encourage the resident to drink lots of water;-The resident's temperature was down to 99.4 degrees; During an observation and interview on 03/06/26, at 12:33 P.M., the resident said:-He/she was just a little nauseated and generally just not feeling good;-The resident was more alert and oriented to place, person and day;-The resident had told Hospice RN V about not feeling well, but did not remember if he/she had told the facility nurse. During an interview on 03/06/26, at 1:39 P.M., Director of Nursing (DON) said the following:-Resident bowel movements are documented by the CNAs in the CNA notebook on the CNA-ADL tracking form daily and on every shift;-The DON would expect the CNAs and CMTs to be responsible for counting the days since a resident's last bowel movement;-The DON would expect the CMT to add a resident's bowel movements to the CNA-ADL tracking form if not on the form;-The DON would expect the CMT to review the bowel movement documentation daily and add the residents that have not had a bowel movement in three days or more to the bowel movement documentation and intervention list form;-The DON would expect the CMT to review the resident's physician orders for each resident's medication interventions if constipated and inform the nurse;-The DON would expect the CMT to document all interventions on the bowel movement documentation and intervention list form, sign, and give the form to the nurse at the end of the shift to review and sign;-The nurse should put the signed bowel movement documentation and intervention list form in the DON's mailbox every day for review;-The DON reviews the CMT bowel movement documentation and intervention list form daily;-The DON would not expect the nurse to document the as-needed medications given for constipation for the residents, that would be the CMT's responsibility;-A follow-up reminder automatically comes up on the computer MAR for the CMT to document the results of the as-needed medication for constipation. If there are no results, the CMT should not complete it and the follow-up reminder would continue;-The DON would expect the nurse to assess a resident with constipation by listening to bowel sounds, abdominal palpation, and complaints of pain or nausea. If the resident did not have results, then the nurse should contact the physician for new orders;-The DON would not expect bowel movement monitoring and treatment to be delayed because the CNAs, CMTs, nurses and herself are all reviewing the documentation daily;-Resident #57 was admitted to the facility in February 2026 and staff did not know his/her bowel habits yet;-The DON did not think the resident had constipation marked as a risk factor in the care plan;-The DON said the resident was probably not as comfortable talking with the facility staff like he/she was with the hospice staff he/she had while at home;-The DON could only locate the CMT bowel movement documentation and intervention list forms for 03/01/26, 03/04/26, 03/05/26, 03/06/26 and could not locate the forms for 03/02/26 and 03/03/26. During an interview on 03/06/26, at 2:02 P.M., the administrator said the following:-The DON had told the administrator about the bowel monitoring issue with the resident;-The administrator would expect the CNAs and CMTs to document and review all the resident's bowel movements daily;-The administrator would expect the CMTs to inform the nurse of any interventions and results;-She would expect the nurse to communicate with the physician for orders to treat the resident's constipation;-The administrator would expect the nurses to assess residents for signs and symptoms of constipation and document the assessment and interventions in the nurse's notes;-She would expect the nurses to document the results of interventions and any communication with the physician if new orders were needed;-The administrator agreed the nurses' notes for the resident said there were no adverse reactions to the antibiotic ordered on 02/27/26, but the MAR showed the resident had received several doses of ondansetron;-The administrator said the only documentation bedside staff had about Resident #57's bowel movements was the CNA-ADL tracking form that showed the last bowel movement was on 02/27/26.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals are stored and kept in a locked locations only available to staff designated to administer medication. This deficient practice effected one resident (Resident #2) when staff failed to removed inhaled medications (inhalers) at the resident's bedside. The facility census was 61. 1.Review of the facility policy titled Storage of Medications revised April 2007, showed the following information:-Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers;-The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner;-drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems;-Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys. 2.Review of Resident #2's face sheet (brief look at resident information) showed the following:-admitted to the facility on [DATE];-Diagnoses include schizophrenia (a chronic, severe brain disorder characterized by hallucinations, delusions, and disorganized thinking), diabetes, heart failure, and high blood pressure.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff) dated 12/13/25, showed the following:-Cognitively intact;-Requires partial to moderate assistance for personal hygiene and dressing, is independent for mobility;-Diagnoses include high blood pressure, heart failure, and chronic obstructive pulmonary disorder (COPD-inflammatory lung disease causing obstructed air flow resulting in breathing difficulties).Review of the resident's care plan, dated 07/17/24, showed the resident did not keep medications at bedside.Observation on 03/03/26 at 10:00 A.M., showed the resident had a red inhaler labeled Ventolin (albuterol sulfate, is a quick relief (rescue) inhaler used to treat or prevent bronchospasm such as wheezing and shortness of breath (SOB)) on his/her bedside table. The resident was not in his/her room at the time.Observation on 03/03/26 at 2:00 P.M., showed the resident had a red inhaler labeled Ventolin on his/her bedside table. The resident was not in his/her room at this time.Observation and interview with the resident on 03/04/26 at 9:36 A.M., showed the resident had a red inhaler labeled Ventolin on his/her bedside table. The resident said that he/she only uses the inhaler as needed for rescue breathing.Review of the resident's March 2026 Physician Order Sheet (POS) showed the following:-An order dated 07/18/23 for Albuterol AER HFA (Albuterol sulfate/Ventolin); inhale one to two puffs via inhalation every 6 hours as needed for COPD;-The POS does not show an order for keeping medications at bedside.Review of the resident's March 2026 Medication Administration Record (MAR) showed the resident had not received any administrations of Ventolin this month.During an interview on 03/05/26 at 10:09 A.M., Nurses Assistant (NA) G said the following:-Some residents at the facility do keep medications at bedside, such as non-prescriptions like eye drops;-No medications that a resident could potentially take too much of should be at the bedside;-He/she has not seen any residents have inhalers at the bedside; that would not be allowed without a physician's order.During an interview on 03/05/26 at 10:25 A.M., Registered Nurse (RN) P said the following:-There are times when a physician would write orders for residents to keep inhalers at bedside, but he/she currently does not have any residents that have that order;-No residents should keep any medications at bedside without a physician order;-He/she was not aware the resident had an inhaler at bedside. During an interview on 03/05/26 at 2:00 P.M., The Director of Nursing (DON) said the following:-No residents are allowed to keep any medications at bedside without a physician order;-She was not aware the resident had an inhaler at bedside.During an interview on 03/05/26 at 2:20 P.M., Certified Mediation Technician (CMT) O said the following:-Some residents keep medications such as inhalers, at bedside. A physician order is required to keep an inhaler at the resident's bedside;-The resident does keep an inhaler at bedside, he/she was not sure if the resident had an order for this.During an interview on 03/09/26 at 12:15 P.M., The Administrator said the following:-Residents are not allowed to keep medications at bedside, at this facility;-She was not aware of any residents having inhalers at bedside.

Based on observation, interview, and record review, the facility failed to ensure all residents received dental services as needed when staff failed to address one resident's (Resident #29) reports of pain resulting in refusal of oral hygiene. The facility had a census of 61.Review of a facility policy titled, Teeth, Brushing, revised October 2010, showed the following information:-Residents should be assisted with brushing his/her teeth based on their individual needs;-Residents should be encouraged to participate in their own dental care as much as possible;-Staff are to document in the resident's medical record the date and time the resident's teeth were brushed and who completed the ADL activity;-The Certified Nurse Assistants (CNA) should report to the nurse assessments obtained concerning the resident's mouth and complaints of pain or discomfort of the mouth;-The nurse is to document information reported by the CNA in the resident's medical record;-Staff are to document refusal of treatment, reason why and interventions taken to address refusals;-Staff are to notify a supervisor of refusal of dental hygiene.1. Review of Resident #29's face sheet (basic information sheet) showed the following:-admission date of 12/30/24;-Diagnoses included Alzheimer's disease (a progressive disease impacting memory, thinking, and behavior) and dementia (progressive or persistent loss of cognitive function impacting the memory, language, problem-solving, and other thinking abilities of daily life);-He/She had an enacted Durable Power of Attorney for health decisions.Review of the resident's Minimum Data Set (MDS- a federally mandated, standardized clinical assessment tool used to evaluate resident functional capabilities, health needs, and cognition), dated 12/31/25, showed the following:-Severe cognitive impairment;-Partial to moderate assistance required for oral hygiene;-A mechanically altered diet;-Teeth indicated with obvious or likely broken or with cavities.Review of the resident's January 2026 monthly summary showed the following:-He/She had cavity/broken teeth indicated;-He/She required staff assistance for oral hygiene.Review of the resident's January 2026 nurses' notes showed staff did not document related to dental care or need for dental services.Review of the resident's February 2026 monthly summary showed the following:-He/She had cavity/broken teeth indicated;-The oral status section for assistance level needed was blank.Review of the resident's February 2026 nurses' notes showed staff did not document related to dental care or need for dental services. Review of the resident's current care plan, as of 03/06/26, showed the following:-He/She has broken/few teeth;-He/She required assistance with daily oral care;-Staff to encourage use of a soft toothbrush and report any signs of bleeding of the gums.(Staff did not care plan regarding the resident's dental service needs.)Observation on 03/03/26, at 10:48 A.M., of the resident showed the following:-The resident had multiple upper and lower teeth missing;-His/Her teeth had heavy accumulation of green, yellowed, and blackened build-up or decay to multiple teeth around his/her gumline;-His/Her breath had a strong unpleasant odor.Observation on 03/04/26, at 11:12 A.M., of the resident showed the resident's teeth and mouth odor in the same condition as previously observed. Observation on 03/06/26, at 8:47 A.M., of the resident showed the resident's teeth in the same condition as previously observed.During an interview on 03/06/26, at 8:30 A.M., CNA Q said the following:-Staff provided the resident set-up assistance for teeth brushing;-He/She stood near the resident and provided verbal encouragement;-The resident brushed his/her teeth most of the time but had periods of refusal;-When he/she refused oral care, the CNA reapproached the resident later in the day;-He/She had not reported refusals to nursing;-The resident had bad teeth with significant decay;-He/She did not know if the resident's dental care was being addressed;-He/She would report concerns with ongoing refusals and issues with oral care to the nurse.During an interview on 03/06/06, at 12:55 P.M., the resident's responsible party said the following:-The resident had a long history of dental issues dating prior to admission;-The resident said he/she was hesitant to brush his/her teeth as he/she believed brushing would cause discomfort and his/her gums to bleed;-Staff could be better with brushing the resident's teeth and he/she did not know if they assisted the resident. During an interview on 03/06/26, at 2:03 P.M., Nurses Assistant (NA) R said the following:-CNAs and NAs provide daily assistance to residents including brushing teeth when needed;-The assistance level needed is documented in the care plan;-Refusals should be reported to the nurse immediately and reapproach later to attempt;-Concerns with a resident's oral care or condition should be immediately reported to the nurse.During an interview on 03/06/26, at 2:12 P.M., CNA S said the following:-The resident is somewhat compliant with brushing his/her teeth, but needs staff assistance and encouragement;-He/She will refuse at times stating he/she has sensitive gums, and it causes discomfort;-He/She is unaware of any facility measures being taken to address discomfort prior to brushing his/her teeth;-Refusals of oral care should be reported immediately to nursing;-Concerns of oral condition or teeth of a resident should be reported to the nurse.During an interview on 03/06/26, at 3:36 P.M., CNA T said the following:-The resident admitted with dental issues including tooth decay and lack of oral hygiene;-The resident is compliant most of the time with brushing his/her teeth, but he/she states it causes discomfort;-He/She did not know of any interventions being taken to address the resident's discomfort prior to brushing;-He/She would report refusals to the nurse immediately and attempt again later;-Concerns with oral hygiene or condition should be reported immediately to the nurse.During an interview on 03/06/26, at 3:43 P.M., Licensed Practical Nurse (LPN) D said the following:-The aides are responsible for providing care daily including brushing teeth of residents;-Refusals should be documented and reported to the charge nurse immediately;-Staff should make additional attempts and pass along at shift change any issues.During an interview on 03/06/26, at 3:48 P.M., Registered Nurse (RN) U said the following:-The resident refused daily oral hygiene due to discomfort;-He/She was unaware of any interventions to address the resident's discomfort prior to oral hygiene being attempted;-The aides are responsible for daily oral hygiene of residents;-The aides should report any refusals or concerns with dental condition to the nurse immediately.During an interview on 03/06/26, at 4:24 P.M., the Assistant Director of Nursing (ADON) said the following:-The resident will not allow staff to brush his/her teeth and has the right to refuse;-The resident has not seen a dentist in years;-Residents should have their teeth brushed twice daily;-Refusals of oral care should be reported immediately to the charge nurse;-Refusals should be documented in the nurse's notes;-The aides are responsible for completing daily oral care.During an interview on 03/06/26, at 4:32 P.M., the Director of Nursing (DON) said the following:-The Social Services Director (SSD) handled dental concerns and issues with resident teeth;-The dentist comes to the facility quarterly to see residents, but he/she did not know if the dentist had seen the resident;-He/She was unaware of the resident refusing dental care or oral hygiene;-He/She said he/she would not be surprised if the resident refused dental care or oral hygiene;-He/She would expect to be notified by staff of refusals of dental care;-Refusals should be documented in the care plan and have proper interventions in place.During an interview on 03/06/26, at 4:36 P.M., the SSD said the following:-He/She was unaware of any dental concerns for the resident;-He/She should have been informed of concerns with his dental condition;-All staff are responsible for reporting dental concerns.During an interview on 03/09/26, at 8:37 A.M., the Administrator said the following:-Aides are responsible for providing daily oral care assistance;-Refusals should be reported to the nurse and additional attempts to provide care with alternative staff;-The resident admitted with poor dental condition and refusals of dental hygiene;-Staff monitor for pain and signs of infection but allow him/her to continue his/her normal routine as not to upset the resident;-The resident may have a modified diet related to his dental health.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner to protect the food from possible contamination when staff failed to store food in sealed containers; failed to discard expired and freezer burnt food; failed to ensure vents, windows, and fans were free of dirt and lint; failed to ensure the dishwasher washed and rinsed the dishes at the recommended temperature; and failed to ensure the dishwasher chemicals tested at recommended level. This had the potential to affect all residents who consumed food from the facility kitchen. The facility had a census of 62 residents. 1. Review of the 2013 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination. Review of the facility policy titled, Food Receiving and Storage, revised [DATE], showed the following: -Food services, or other designated staff, will maintain clean food storage areas at all times; -Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in and first out system; -All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Observations on [DATE], beginning at 10:14 A.M., showed the standing refrigerator in the kitchen area contained the following: -An opened container of Greek yogurt with an expiration date of [DATE] with a hand written date of ,d+[DATE]; -An unopened container of sauce with a best buy date of [DATE]; -A bag of opened whipped topping in sealed bag with no label/date; -An unsealed bag flour tortillas with the package opened to air with no label/date; -A plastic container with aluminum foil cover with a four to five inch slit, open to air, with potato salad written in marker with no date; -Sealed bag of romaine lettuce sealed no label/date; -Large rectangular plastic container with lettuce and onion and no label/date. Observations on [DATE], beginning at 10:14 A.M., of the food storage area showed he following: -Two 57 ounce open containers of instant mashed potatoes with no label/date. The containers were unsealed and open to air. Observations on [DATE], beginning at 10:14 A.M., of the standing freezers showed the following: -A bag of tater tots sealed with no label/date. There were visible ice crystals on the tater tots; -A bag of sliced peaches inside sealed bag with no label/date; -Sealed bag with label pumpkin ,d+[DATE] written in marker with visible ice crystals on the pumpkin; -One bag of opened self-rising flour inside an unsealed plastic grocery bag; -One bag of opened bread flour inside an unsealed plastic grocery bag. During an interview on [DATE], at 2:20 P.M., Dietary Cook A said the following: -Staff should put open food products in a sealed plastic container or sealed plastic bag and label with the date opened and three days after that date; -Expired foods should be immediately discarded; -The facility does not have a schedule for performing spot checks for expired foods; -He/she does not know of steps staff should take to avoid foods becoming freezer burnt and assumed freezer burnt food should be immediately thrown out. During an interview on [DATE], at 3:19 P.M., the Dietary Manager (DM) said the following: -Staff should store opened food in a sealed plastic container or plastic bag with a label including name of the product, date opened and three days after the open date (throw away date); -Expired food should be discarded immediately; -The facility does not have a system in place for checking for expired foods; -Staff should double wrap food and put in plastic bags to avoid freezer burn; -Staff should dispose of any freezer burnt foods immediately. During an interview on [DATE], at 3:19 P.M., the Administrator said staff should store opened food in a sealed container with a date, and stored food should not be expired. 2. Review of the 2013 Missouri Food Code showed the following: -Food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination; -Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues; -The physical facilities shall be cleaned as often as necessary to keep them clean. Observation on [DATE], at 10:14 A.M., showed the ceiling vent near food preparation table contained visible dirt and lint that could fall into food being prepared. Observation on [DATE], at 11:16 A.M., showed the following: -Large long vents above the window in dishwashing preparation area contained visible dirt and lint which could fall and contaminate clean dishes; -The screen windows and window cranks in the dishwasher and microwave area were visibly dirty with lint particles, dirt and grime; -The windowsill had a large number of pieces of dirt and lint. The window sill was located directly over the area where the clean dishes come out of the dishwasher and are stored for drying; -A fan attached to the wall directly facing the area where dishes come out of the dishwasher had dangling lint particles and was running; -A metal box unit and metal spindles on top of the range hood had visible dirt, grime, and lint and located in the area where food is prepared and served; -Ceiling vent near food preparation table contained visible dirt and lint. During an interview on [DATE], at 2:20 P.M., Dietary Cook A said the following: -The facility has a cleaning schedule including the day of the week and what tasks should be completed; -Maintenance staff are responsible for cleaning the vents and windows, and he/she is unsure of the schedule. During an interview on [DATE], at 2:32 P.M., Dishwasher B said the following: -He/she has performed some of the cleaning tasks, but is not sure if there is a cleaning list; -He/she only cleans what he/she has been told to clean. During an interview on [DATE], at 3:05 P.M., Dietary Aide C said the following: -The facility has a weekly cleaning schedule; -He/she looks at the schedule on a daily basis and checks off tasks as completed; - Maintenance is responsible for cleaning vents requiring a ladder and any other tasks requiring use of a ladder. During an interview on [DATE], at 3:19 P.M., the DM said the following: -There is a weekly cleaning check list; -Staff use a pole to clean the vents above once a month; -The screen window is not on the cleaning list, and she cleaned it the last time it was cleaned; -Dishwashing staff should wipe down the fan above the dishwasher daily; -The cleaning list does not specify wiping down the fan, but does specify the dishwasher should clean the dishwasher area daily. -Maintenance cleans the range hood and anything above it, including the spindles and the box on top of the hood. During an interview on [DATE], at 11:01 A.M., the Maintenance Supervisor said the following; -Maintenance has a monthly checklist for kitchen duties such as inspecting the filters and drip pans in the fridges and freezers, inspect the sprinklers, and clean the entire range hood; -The spindles on top of the range hood and the box on top are not on the monthly checklist to clean, and staff complete visual spot checks; -He is not sure when it was last cleaned and will add it as a duty on the monthly checklist; -There should not be visible dust and grime on the box or the spindles. During an interview on [DATE], at 3:19 P.M., the Administrator said there should be a monthly cleaning schedule for the entire kitchen. The dietician also inspects the monthly cleaning schedule. The dietary supervisor is in charge of making sure it is completed. Dietary aides are assigned to monthly cleaning. There is an extra aide who just cleans some items such as surfaces and areas behind the refrigerator. 3. Review of the facility policy titled, Good [NAME] Nursing Home Protocol Dish Washing, undated, showed the following: -The dishes shall be cleaned, dry, and sanitary for next use; -The dishwasher shall visually inspect chemicals of the dish machine and replace any that are empty; -The chemical tests should be completed after the first two racks of dishes to ensure sanitation; -The results of the chemical tests shall be recorded on the sanitation log. Observation on [DATE], at 11:46 A.M. showed the following: -The dishwasher had displayed the manufacturer recommendations for the wash and rinse cycles at a minimum of 120 degrees Fahrenheit (F), and the sanitizer should test at a minimum of 50 parts per million (pmm) chlorine sanitizer. Review of the facility's Low Temperature Chemical Sanitation Log, for March of 2024, showed 54 out of 82 temperature were documented to be below 120 degrees F for the wash cycle in the month of [DATE]. Observation on [DATE], beginning at 11:46 A.M. showed the following: -Dishwasher temperatures during three cycles were 105.5 degrees F, 115.6 degrees F, and 116.8 degrees F; -The sanitizer test strip did not read 50 pmm or above during two separate tests. During an interview on [DATE], at 2:20 P.M., Dietary Cook A said the following: -He/she runs the dishwasher on a rare occasion, and it should run at 120 degrees F, but he/she is not sure if that is for the wash and rinse cycle; -He/she is aware of the sanitizer test strips, but not sure of details; -There is a log for staff to keep track of the temperatures and test strips results. During an interview on [DATE], at 2:32 P.M., Dishwasher B said the following: -He/she thinks the dishwasher should run at 185 degrees at wash and 200 degrees at rinse; -He/she documents the dishwasher temperatures and sanitizer test strip per meal service on the log; -He/she believes the sanitizer test strip should show 200 pmm; -Dishwasher temperatures have not been running hot enough, and he/she has notified the DM; -He/she notified the DM when the sanitizer test strip did not test where they should. During an interview on [DATE], at 3:05 P.M., Dietary Aide (DA) C said the following: -Dishwasher temperatures should not run below 100 degrees F for the wash or rinse cycle; -Staff should notify the cook, DM, or maintenance if the dishwasher temperatures fall below 100 degrees F; -Staff should take dishwasher cycle temperatures at the beginning of every shift and document; -The sanitizer test strips should be testing at 200 pmm; -He/she had documented temperatures lower than 120 degrees F during the month of [DATE], but did not notify management because they were not below 100 degrees F. During an interview on [DATE], at 3:19 P.M., the DM said the following: -Dishwasher washer and rinse cycles should be over 120 degrees F; -Sanitizer test strips should show 200 pmm per the dietician; -Staff should obtain and document the temperatures and sanitation testing at the beginning of every shift; -Staff should contact the DM or maintenance if the temperatures are not high enough or sanitizer is not testing out appropriately. During an interview on [DATE], at 3:19 P.M., the Administrator said dishwasher temperatures should be 120 degrees F or above. Staff document every shift (twice daily) for temperatures and test strips. If the test-strip levels is out of range the staff should stop using the dishwasher, notify the supervisor, then go to procedure of three-compartment sink.

Based on interview, and record review, the facility failed to ensure the revision of comprehensive care plans to include measurable objectives and timeframes to meet the medical and nursing needs for two residents (Resident #11, and Resident #313) who sustained falls with injuries, for one resident (Resident #10) who declined requiring the use of a wheelchair, and for one resident (Resident #14) who required significant additional nutritional assistance out of 19 sampled residents. The facility census was 62. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, showed the following: -The comprehensive person-centered care plan will incorporate identified problem areas; incorporate risk factors associated with identified problems; and reflect currently recognized standards of practice for problem areas and conditions; -Assessment of residents is ongoing and care plans are revised as resident information or condition changes; -The Interdisciplinary Team (IDT) must update the care plan when there is a significant change, the desired outcome is not met, after a hospital stay, and quarterly. 1. Review of the facility policy titled, Falls and Fall Risk, Managing, revised December 2007, showed the following: -Based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -The staff will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions; -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicated why the current approach remains relevant; -If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until calling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable; -Falls committee will review all falls to identify and implement relevant interventions to try to minimize serious consequences of falling. 2. Review of Resident #11 's face sheet showed the following: -admitted [DATE]; -Diagnoses of dementia, heart failure, chronic kidney disease, and low back pain. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 02/21/24, showed the following: -Severe cognitive impairment; -Functional limitation in range of motion to both lower extremities; -Dependent on staff (staff does all effort) wheelchair mobility, transfers, toileting, and personal hygiene; -One (non-injury) fall since admission. Review of the resident's care plan, updated 02/27/24, showed the following: -Resident will require assistance for activities of daily living (ADL) completion related to weakness and diagnosis of dementia and history of fracture of lower extremity; -Resident is alert and able to communicate her needs. He/she is non-weight bearing on lower extremity. And uses a Hoyer (mechanical lift) for transfers. He/she requires assistance for toileting, transfers, feeding, dressing, grooming, and ambulation. His/her ability to assist will decrease throughout the day as he/she fatigues; -Keep area free of clutter/obstacles; -Resident will require one to two assist for bed mobility, toileting, and hygiene needs; -Resident is a risk for falls related to weakness, impulsivity due to dementia, history of falling, and history of leg fracture that did not heal properly; -Resident uses a Hoyer lift for transfers and resident is dependent for ambulation. Review of the resident's fall risk evaluation, dated 02/28/24, completed by facility staff, showed staff assessed the resident as a fall risk. Review of the facility's fall scene investigation report, dated 03/10/24, showed the following: -At 8:10 A.M., the resident slipped out of the wheelchair in the activity room; -A drawn picture showed a wheelchair and a ramp with a stick figure lying at the end of the ramp; -Aide started coming up the ramp after breakfast; -Re-creation of events before fall: The resident was gotten up and taken down for breakfast. After breakfast geri-chair (a reclining wheelchair with a foot rest that can be elevated by staff), not in reclined mode, was pushed by staff. When staff started to go up ramp, they push the chair forward and the resident fell out; -What appears to be the initial root cause of the fall: Not understanding how geri-chairs work and need to be reclined to push resident around; -Describe initial interventions to prevent future falls: More education to staff on geri-chair and why need to be reclined to push up ramp; -Falls team meeting notes conclusion: Resident leaned forward and fell out chair was at normal height for feeding; -Additional care plan/nurse aide assignment updates: Fall education provided to all nursing staff. Review of the resident's nurse's note, dated 03/11/24, showed at 5:15 A.M., the resident returned from the hospital emergency room in an ambulance with a knee immobilizer in place. Social services to contact an orthopedic surgeon for a follow up appointment due to fracture. Review of the resident's care plan showed staff did not update the care plan with the most recent fall, the fracture, or new interventions following the resident's fall/fracture on 03/10/24. During an interview on 03/29/24, at 9:39 A.M., Registered Nurse (RN) L said the following: -He/she worked as the MDS and Care Plan Coordinator for the entire facility since August 2022; -If the resident had a fall, the care plan should be updated to reflect the new fall intervention; -He/she recently became aware that he/she had missed some of the care plans; -The resident should have had a fall care plan update after his/her fall on 03/10/24 with new intervention. 49585 2. Review of Resident #313's face sheet showed the following: -admitted [DATE]; -Diagnoses included inflammatory polyarthropathy (arthritis affecting multiple joints), muscle weakness, and repeated falls. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Impairment in range of motion to upper and lower extremities; -Partial to moderate assistance with bed mobility, walking, and transfers; -Uses walker for mobility. Review of the resident's care plan, dated 01/15/24, showed the following: -Resident required assistance of one staff for transfers, ambulation, toileting, dressing, and hygiene; -Alert with confusion at times; -At risk for falls related to weakness and a history of falling; -Resident had a fall on 01/27/24, 03/20/24, and 03/26/24. (Staff did not care plan implementation new interventions after the resident's falls on 01/27/24, 03/20/24, or 03/26/24.) 3. Review of Resident #10's face showed the following: -admitted [DATE]; -Diagnoses included dementia (impaired ability to remember, think, or make decisions), repeated falls, muscle weakness, abnormalities of gait and mobility, and osteoarthritis. Review of the resident's Physical Therapy Discharge Summary, dated 08/10/23, showed resident upon discharge was substantial to maximal assistance for transfers. Resident can stand without gait tolerance and required partial to moderate assistance with wheelchair mobility. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Impairment in range of motion to lower extremities; -Requires substantial to maximal assistance with transfers; -Dependent for wheelchair for mobility. Review of the resident's care plan, dated 01/31/24, showed the following: -Requires assistance of one staff for activities of daily living (ADL); -Uses a roller walker; -Requires supervision for transfers and ambulation; -Alert with confusion at times; -Risk for falls related to weakness. (Staff did not update the care plan to show the resident's need to use a wheelchair.) During an interview on 03/29/24, at 9:57 A.M., RN O said the resident used a wheelchair for ambulation. During an interview on 03/29/24, at 11:01 A.M., Nurse Assistant (NA) F said he/she used the care plan or will ask the nurse to find resident information. During an interview on 03/29/24, at 12:19 P.M., Certified Nurse Assistant (CNA) P said the following: -The care plan gives information regarding resident care; -Nurse assistants also give report to each other at shift changes. During an interview on 03/29/24, at 1:20 P.M., RN L (Care Plan Coordinator) said the following: -Care plan information is obtained using information found in chart, MDS, staff interviews and observations; -Nurses leave a note in his/her box for resident changes or declines; -Care plan is updated quarterly or for any changes; -Fall interventions should be updated after a resident fall; -Changes in mobility or a change in mobility device should be updated in care plan; -All updates should occur when change happens or as soon as possible; 36974 4. Review of Resident #14's face sheet showed the following: -admitted [DATE]; -Diagnoses included Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), history of stroke, right-side paralysis following a stroke, and heart failure. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had severe cognitive impairment; -He/she resident had severe impairment on one side of his/her body; -He/she required oversight or instruction while eating; -He/she required some staff assistance to sit up in bed from a lying position; -He/she had complaints of difficulty swallowing. Review of the resident's March 2024 physician's orders showed the following: -An order, dated 01/31/24, to offer the resident a protein shake twice a day; -An order, dated 02/01/24, to weigh the resident once a week; -An order, dated 02/16/24, for staff to measure fluid intake once a week and for staff assist resident to sit up in bed or chair due to concerns of aspiration pneumonia (when food or liquid is breathed into the airways or lungs, instead of being swallowed). Review of the resident's current care plan, last updated 01/24/24, showed the following: -The resident has a pureed diet with thickened liquids; -Resident had difficulty swallowing following a stroke; -Resident able to communicate preferences most of the time; -Resident required assistance with feeding; (Staff did not address the nutritional needs of giving the resident a nutritional shake, to weigh the resident once a week, to measure fluid intake once a week, or for staff to assist resident to sit up in bed or chair due to concerns or aspiration pneumonia on the care plan.) 5. During an interview on 04/01/24, at 3:10 P.M., CNA AA said he/she would look at care plans for information on resident care . The care plans are available at nurses' stations and are updated on regular basis. If staff have are concerns for care plans, he/she would go to nurse. 6. During an interview on 03/29/24, at 11:01 A.M., NA F said he/she used the care plan or will ask the nurse to find resident information. 7. During an interview on 03/29/24, at 12:19 P.M., CNA P said the following: -The care plan gives information regarding resident care; -Nurse assistants also give report to each other at shift changes. 8. During an interview on 04/01/24, at 3:27 P.M., RN T said the following: -Any nurse can update a resident care plan with changes, but typically RN L (Care Plan Coordinator) updated the residents' care plans with changes/new interventions; -After a resident fell , staff try a new intervention and that interventions should end up on the care plan; -The nurse aides could look in the resident's care plan or ask a nurse to find out how much staff assistance a resident required for transfers, if the resident required a wheelchair for mobility, or if the resident had specific fall interventions. 9. During an interview on 03/29/24, at 1:20 P.M., RN L (the Care Plan Coordinator) said the following: -Care plan information is obtained using information found in chart, MDS, staff interviews and observations; -Nurses leave a note in his/her box for resident changes or declines; -Care plan is updated quarterly or for any changes; -Fall interventions should be updated after a resident fall; -Changes in mobility or a change in mobility device should be updated in care plan; -All updates should occur when change happens or as soon as possible. 10. During an interview on 04/01/24, at 12:11 P.M., the Administrator said the following: -The nurses or the Care Plan Coordinator should update the care plan with changes in the resident's status: -Nursing should update the resident's care plan after each fall with a new interventions and date the intervention; -If a resident previously used a walker, but later required a wheelchair for mobility, nursing should ensure the care plan was up to date with that information.

Based on observation, interview, and record review, the facility failed to ensure an environment as free of accident hazards as possible when staff failed to use equipment improperly resulting a fall with injury, when staff did not update the care plan with new interventions after the fall, and when staff did not document a timely and complete assessment of the resident after the fall for one resident (Resident #11). The facility failed to ensure residents were transferred safely when staff failed to transfer one resident properly with a Hoyer lift (mechanical devised used for lifting residents) resulting in bruising to the resident's face and failed to document a full and timely assessment of the bruise received for one resident (Resident #21). The facility failed to ensure an effective system was in place to monitor all residents ability to smoke and monitor smoking supplies when staff were unclear if one resident (Resident #32) could smoke independently safely and could keep his/her smoking supplies on his/her person. A sample of 19 residents was reviewed in the a home with a census of 62. 1. Review of the facility policy titled, Falls and Fall Risk, Managing, revised December 2007, showed the following: -Based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -The staff will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions; -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicated why the current approach remains relevant; -If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until calling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable; -Falls committee will review all falls to identify and implement relevant interventions to try to minimize serious consequences of falling. Review of Resident #11's face sheet showed the following: -admitted [DATE]; -Resident on hospice services; -Diagnoses included of dementia, heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs), chronic kidney disease (characterized by progressive damage and loss of function in the kidneys), and low back pain. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 02/21/24, showed the following: -Severe cognitive impairment; -Functional limitation in range of motion to both lower extremities; -Used a wheelchair for mobility device; -Dependent on staff (staff does all effort) for wheelchair mobility, transfers, toileting, and personal hygiene; -Required partial/moderate assistance of staff with eating; -One (non-injury) fall since admission. Review of the resident's care plan, dated 02/27/24, showed the following: -Resident will require assistance for activities of daily living (ADL) completion related to weakness and diagnosis of dementia and history of fracture of lower extremity; -Resident is alert and able to communicate her needs; -Resident is non-weight bearing on lower extremity and uses a Hoyer (mechanical lift) for transfers; -Resident requires assistance for toileting, transfers, feeding, dressing, grooming, and ambulation; -Resident's ability to assist will decrease throughout the day as he/she fatigues; -Keep area free of clutter/obstacles; -Resident will require one to two assist for bed mobility, toileting, and hygiene needs; -Resident will require set up assistance for meals; -Resident is a risk for falls related to weakness, impulsivity due to dementia, history of falling, and history of leg fracture that did not heal properly; -Resident uses a Hoyer lift for transfers and resident is dependent for ambulation. Review of the resident's Fall Risk Evaluation, completed by facility staff, dated 02/28/24, showed a total score of 14 (a resident who scores a 10 or higher is at risk for falls). Review of the facility's Fall Scene Investigation Report, dated 03/10/24, showed the following: -At 8:10 A.M., the resident slipped out of his/her wheelchair in the activity room; -A drawn picture showed a wheelchair and a ramp with a stick figure lying at the end of the ramp; -Re-creation of events before fall: Staff had gotten the resident up and taken him/her down for breakfast. After breakfast, the resident's geri-chair (a high back cushioned wheel that reclines preventing rising) was not in reclined mode. Staff was pushing and started to go up the ramp and pushed chair forward. The resident fell out; -What appears to be the initial root cause of the fall: Not understanding how geri-chairs work and need to be reclined to push resident around; -Describe initial interventions to prevent future falls: More education to staff on geri-chair and why need to be reclined to push up ramp; -Falls team meeting notes conclusion: When speaking with nurse aide immediately after resident leaning forward. When resident leaned forward and fell out chair was at normal height for meal assistance; -Additional care plan/nurse aide assignment updates: Fall education provided to all nursing staff. Review of the resident's nurses' notes, dated 03/10/24, showed the following: -Staff did not document regarding the resident's fall on the day of the fall; -At 10:00 A.M., a nurse called the resident's physician to report a deformity of the resident's right knee and leg. New physician's order received for an X-ray of the resident's knee and tibia (shin bone)/fibula (calf bone). The nurse contacted the mobile X-ray company and scheduled the X-ray STAT (immediately); -An untimed note, nurse received results from X-ray. The nurse notified the physician and received an order to send the resident to the emergency room for evaluation. The resident's next of kin notified and requested a particular hospital. The nurse notified the paramedics and sent the resident out via ambulance at 6:10 P.M.; -An untimed note, the nurse placed a call to the physician regarding deformity of the resident's knee. The physician ordered an x-ray and then sent the resident to the emergency room . The resident returned to the facility with a knee immobilizer. Review of the resident's March 2024 physician orders showed an order, dated 03/10/24, for an X-ray of the resident's right knee. Review of the resident's nurse's note dated 03/11/24, at 5:15 A.M., showed the resident returned from the hospital emergency room in an ambulance with a knee immobilizer in place. Social services to contact an orthopedic surgeon for a follow up appointment. Review of the resident's care plan showed staff did not update the care plan with the most recent fall, the fracture, or new interventions following the resident's fall/fracture on 03/10/24. Review of the resident's March 2024 physician orders showed an order, dated 03/20/24, for staff to send the resident to the emergency room for evaluation of his/her right leg. Review of the resident's physician progress note, dated 03/20/24, showed the following: -Resident admitted to the facility due to distal tibia/fibula (lower leg bones) fractures that required an open reduction-internal fixation (ORIF - a surgery used to stabilize and heal broken bones). A few weeks later, the resident fell and broke his/her distal femur just proximal to (above) the knee. The resident is now wearing a knee immobilizer. During an interview on 03/29/24, at 9:39 A.M., Registered Nurse (RN) L said the following: -He/she worked as the MDS and Care Plan Coordinator for the entire facility since August 2022; -If the resident had a fall, the care plan should be updated to reflect the new fall intervention; -He/she recently became aware that he/she had missed some of the care plans; -The resident should have had a fall care plan update after his/her fall on 03/10/24 with new intervention. During an interview on 03/27/24, at 1:57 P.M., Nurse Assistant (NA) V said the following: -On the day of the resident's fall, he/she propelled the resident out of the dining room after the meal; -He/she planned to recline the resident's back in his/her wheelchair and raise the resident's legs while in the dining room, but there were other residents close by and the NA was afraid of bumping into another resident; He/she decided to recline the resident back in his/her wheelchair approximately two inches from the beginning of the ramp while propelling the resident forward. The resident leaned forward and fell out of the chair onto the ramp; -The resident landed on the carpet on his/her right side and his/her right leg was twisted; -He/she left the resident and went and found Registered Nurse (RN) O and told the nurse about the fall; -The nurse came and assessed the resident; -The NA then said he/she did not notice the resident was leaning forward, because the aide was trying to elevate the resident's feet and recline the chair using hand controls at the back of the chair, but he/she did not get the footrest up and the front of the resident's wheelchair footrest ran into the ramp and the resident fell forward and out of the wheelchair. -Sometimes, other NAs or nurses helped the NA to lean the resident's chair back, when he/she had difficulties reclining the chair. During an interview on 03/27/24, at 2:17 P.M., NA U said the following: -On the day of the resident's fall on the ramp, RN O said NA V were pushing the resident up the ramp, but forgot to lean him/her chair back and the resident fell ; -The nurse asked NA U for help getting the resident up out of the floor. During an interview on 03/27/24, at 2:25 P.M., NA G said the following: -Staff asked him/her to assist getting the resident up out of the floor; -When he/she arrived on the ramp, the resident lay on his/her side on the ramp in front of the reclining wheelchair; -The wheelchair was the type that reclines and tilts with a footrest. The chair had two handles at the back, staff can squeeze one to tilt the chair and one to recline and elevate the footrest; -He/she helped the nurse assess the resident, the resident's legs were bent, but the resident did not complain of pain; -Staff assisted the resident up and back to his/her room and onto the bed; -An hour or two later, he/she noticed the resident's inner leg below the knee looked swollen and the resident complained of a little pain; -He/she reported the change to the nurse, RN O, who then assessed the resident's leg; -The physician ordered an X-Ray. During an interview on 03/27/24, at 2:50 P.M., the Director of Nursing (DON) said he/she could not locate a nurse's note related to the resident's fall on 03/10/24, but the nurse did complete a fall investigative report. During an interview on 03/28/24, at 10:26 A.M., Certified Nurse Assistant (CNA) S said the following: -The resident was a high fall risk; -He/she leaned the resident back in the reclining wheelchair anytime the resident was not eating or drinking, due the resident being a high fall risk. During an interview on 03/28/24, at 10:48 A.M., RN M said the following: -The resident fell out of his/her wheelchair onto the ramp and fractured his/her leg because a nurse aide (NA V) forgot to elevate the resident's wheelchair footrest and he/she ran the footrest into the ramp floor (carpeted). The resident sustained a fracture to his/her femur; -He/she had an issue, prior to the resident's fall with the resident's reclining wheelchair catching on the ramp carpet; -He/she tried to educate staff to elevate the resident's leg rest on the reclining wheelchair before staff attempted to propel the resident's chair up the ramp, but NA V was not working the day the nurse provided the education; -After the resident's fall on the ramp, the facility moved the resident to another part of the facility where staff did not have to push the resident up the ramp; -Staff should have leaned the resident back in a reclined position, if the resident was not eating or drinking; -The nurse said he/she did not think that any of the residents had specific orders or were care planned to be leaned back, but the nurse said he/she thought it was more of a common sense/nursing judgement to lean the residents back, because they sit up very straight in that style of chair and can topple over easily. During an interview on 03/28/24, at 11:45 A.M., NA H said during meals, staff sat the resident up straight in his/her reclining wheelchair, but any other time, staff should lay the resident back, so the resident's footrest did not bump into the ramp and the resident did not fall out of his/her chair. During an interview on 04/01/24, at 3:27 P.M., Registered Nurse (RN) T said the following: -Staff needed to ensure the resident was positioned safely and reclined back in the chair when going up the ramp, so the resident did not lean forward and fall out of the chair. During an interview on 03/28/24, at 2:38 P.M., the Director of Nursing (DON) said the following: -The resident admitted to the facility with a leg fracture, so the facility placed the resident in a reclining wheelchair for comfort; -While eating, staff placed the resident straight up in his/her wheelchair, but if not eating or drinking staff positioned the resident back for comfort, and decreased fall risk. The resident was at a high risk for falls; -He/she expected staff to assist the residents with mobility while on the ramp and staff should position the residents for safety in the wheelchairs; -From what he/she understood, NA V had to get enough momentum going to get up the ramp when propelling a resident up; -On the day of the resident's fall on the ramp, the resident leaned forward, just as the NA got to the ramp and he/she fell forward; -The DON said he/she was not aware the resident's reclining wheelchair footrest hit the ramp; -The DON said the NA should have had the resident positioned properly in his/her wheelchair. During an interview on 04/01/24, at 2:34 P.M., the resident's physician, Physician Y, said the following: -Nurses should assess residents with a change in condition and document the assessments in the resident's medical record; -The facility staff should properly operate a reclining wheelchair ensuring the resident's safety; -The facility staff should have elevated the resident's footrest prior to going up the ramp high enough that the resident's footrest did not hit the ramp; -Improper use of the wheelchair could increase the risk of accidents occurring. 2. Review of the facility policy titled, Using a Mechanical Lifting Machine, revised July 2017, showed, the following: -The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device; -At least two nursing assistants are needed to safely move a resident with a mechanical lift; -When the transfer destination is reached, slowly lower the resident to the receiving surface; -Once the resident's weight is released, stop the lowering, and ensure that the sling bar does not hit the resident; -Detach the sling from the lift; -Carefully remove the sling from under the resident. Be mindful of the resident's position and balance, and skin. Review of Resident #21's face sheet showed the following: -Readmitted [DATE]; -Diagnoses of osteoarthritis (a common form of arthritis) of both hands, dependence on wheelchair, congestive heart failure (heart failure), and muscle weakness. Review of the resident's care plan, revised on 07/05/23, showed the following: -Resident required assistance for ADL completion related to weakness; -Resident used a wheelchair for mobility; -Resident will require assistance of one to two staff for transfers. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognitive ability; -Dependent (helper does all the effort) on staff for mobility, transfers; -Used wheelchair for mobility device. Review of a note, hand-written by Certified Nurse Assistant (CNA) P showed on 3/22/24, he/she accidentally hit the resident with the Hoyer lift above the resident's eye and informed the nurse. Observation of the resident on 03/25/24, at 10:41 A.M., showed the following: -The resident sat up in a wheelchair in his/her room; -The resident sat on a Hoyer lift pad; -The resident had a dark, purplish-red, skin discoloration, approximately two centimeters (cm) in diameter, to his/her right, outer eye brow area. Review of the resident's nurse notes showed staff did not document in the nurses' notes from 03/22/24 to 03/25/24. Review of the resident's Skin Monitoring: Comprehensive CNA Shower review form, dated 03/26/24, showed resident had bruising to his/her right eye area. Review of the resident's nurse's note, dated 03/26/24 (untimed), showed the following: -Per CNA report, a bruise to the resident's right eye was from a Hoyer hook when moving the Hoyer lift out of the way on 03/22/24. The DON and the MDS Coordinator were made aware. Review of an accident report, dated 03/27/24, showed a nurse documented the following: -On 03/22/24, while transferring a resident with a Hoyer lift, resident sustained a bruise to his/her eye; -Staff education provided on proper Hoyer lift use and keeping hand on the bar for resident protection. During an interview on 03/28/24, at 10:26 A.M., CNA S said the following: -He/she worked as the shower aide; -On Monday, 03/25/24, he/she noticed a bruise by the resident's right eye; -He/she filled out a shower skin sheet (a form with a body diagram and list of skin issues, indicating the resident's bruise and location) and told the nurse about the bruise by the resident's s right eyebrow; -He/she was unsure what happened to the resident's eye, and he/she did not ask resident what cause the bruise because the resident did not talk much. During an interview on 03/28/24, at 10:48 A.M., RN M said the following: -On 03/25/24, he/she observed the resident's facial bruise and asked other staff what caused the bruise, but no one knew; -On 03/26/24, CNA P told RN M, he/she accidentally hit the resident's face with the Hoyer lift bar on 03/22/24, and CNA P reported the incident to RN X and RN L on 03/22/24; -RN M could not find any documentation about the incident in the resident's medical record; -On 03/26/24, RN M made a nurse's note entry and spoke to the DON about the incident; -RN M did not notify the resident's family or physician about the incident or injury and did not know if another nurse notified them. During an interview on 03/28/24, at 11:37 A.M., CNA P said the following: -He/she and NA W were assisting the resident into his/her wheelchair using a Hoyer lift; -After lowering the resident into the chair, he/she unhooked the Hoyer sling straps from the lift bar, but as he/she rolled the lift away from the resident, the bar swung around and bumped the resident's head; -He/she notified one of the nurses, RN X ,of the incident; -A couple hours later, the CNA observed a bruise to the resident's right outer eyebrow area and notified the nurses, RN X and RN L, of the bruise; -The nurse, RN X, went to the resident's room to check on the resident; -The CNA said he/she normally holds onto the bar, so that it does not swing and hit the resident, but he/she looked away for a second and then he/she felt the bar bump into the resident's head; -The CNA said the resident did not complain of pain or yell out when the injury occurred. During an interview on 03/28/24, at 11:41 A.M., NA W said the following: -Last Friday, 03/22/24, he/she assisted CNA P with transferring the resident into a wheelchair from bed. Staff unhooked the lift sling from the Hoyer lift and as staff were moving the lift away from the resident, the sling bar hit the resident on his/her eye. At first the resident did not have a mark, but the resident's eye bruised a couple of hours later and he/she reported to the nurse, RN L; -A staff member usually holds onto the bar when moving the lift, but staff did not hold onto the bar this time. He/she was unsure why. During an interview on 03/28/24, at 11:55 A.M., RN L said the following: -On Friday 03/22/24, he/she worked as the charge nurse for a couple of hours and then RN X came in and took over as the charge nurse; -Sometime on Friday, 03/22/24, CNA P informed RN L he/she bumped the resident with a Hoyer lift bar during a transfer, but said there were no apparent injuries to the resident. RN L instructed CNA P to notify RN X because he/she needed to complete an incident report. Later that same day, CNA P said the resident's right outer brow was starting to bruise. At that time, RN L assessed the resident and he/she had light bruising to the right outer brow. The bruise was approximately 1.5 centimeters (cm) in size, with a reddish-purple color. -The resident denied pain to the area, denied a headache. -The nurse said he/she did not document incident/ injury, did not notify the resident's physician or next of kin, and did not follow up with the charge nurse, RN X, but he/she should have done so; -Staff should keep one hand on the lift bar, at all times, to avoid hitting a resident with the swinging bar; -CNA P said he/she knew to hold onto the bar, but CNA P was not mindful of how close the bar was to the resident's head. During a phone interview on 03/28/24, at 1:37 P.M., RN X said the following: -On Friday, 03/22/24, he/she arrived at the facility at 10:00 A.M., and received report from RN L; -RN L relayed that CNA P reported, he/she accidentally bumped the resident on the head with a Hoyer sling bar, but no apparent injuries; -Later in the shift, (unsure of time) CNA P came to RN X and said the resident had developed a bruise; -RN X went to the resident and observed the resident had an approximate half-dime size bruise to his/her right outer eyebrow area; -The resident did not answer when the nurse asked the resident if he/she was in pain; -The nurse said she checked the resident's pupils and they looked normal and equal; -The nurse did not chart anything about the incident or injury; -The nurse should have documented an assessment, neurological checks, and VS in the nurse's notes, but he/she failed to do so; -The nurse said he/she did not notify the resident's physician or responsible party because he/she assumed RN L had made the notifications. During an interview on 03/28/24, at 2:38 P.M., the DON said the following: -Staff should stabilize the Hoyer bar to keep the bar from swinging into a resident; -The nurses should have assessed the resident and documented the assessment in the resident's nurse notes; -The nurses should have notified the resident's physician and responsible party and documented the notifications in the nurse notes; -If the nurse did not document, then it was not done. 3. Review of the facility policy titled, Smoking Policy and Procedure, undated, showed the following: -This facility shall establish and maintain safe resident smoking practices; -To identify factors that may put resident at risk for smoking independently and so provide appropriate supervision/approaches for safety; -Prior to, or upon admission, resident shall be informed about any limitation on smoking, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences; for example, in making room assignments; -All residents who smoke tobacco products shall have a Smoking Assessment completed upon admission, quarterly, and as needed; -Risk factors identified through the assessment process shall be used in the development of the plan of care; -Each individual facility shall develop a Smoking Policy based on the facility environment and staffing capabilities; -All residents/responsible party shall receive a copy of the facility Smoking Policy; -All residents, visitors, and associated shall smoke in designated smoking areas only; -Smoking restrictions shall be strictly enforced in all non-smoking areas. Smoking is prohibited inside the facility; -The facility shall establish designated times to provide smoking opportunities to residents requiring assistance and/or supervision; -The smoking assessment shall be filed in the assessment portion of the medical record; -All smoking products (cigarettes, lighters, etc.) in the locked medication room; -Residents who smoke independently, will not be assigned a smoking schedule; -Independent smokers will be allowed to smoke without associate supervision. Residents will notify the charge nurse when they would like to smoke and their whereabouts while smoking (designated smoking area). Residents will be responsible to return all smoking products/materials back to the charge nurse after smoking. Review of Resident # 32's face sheet showed the following: -Readmitted [DATE]; -Diagnoses of need for continuous supervision, stroke, hemiplegia (paralysis of one side of the body) and hemiparesis (loss of motor skills of one side of the body) affecting non-dominant side, chronic kidney disease, peripheral vascular disease (a circulatory condition is which narrowed blood vessels reduce blood flow to the limbs), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), dementia, generalized anxiety disorder, and major depression. Review of the resident's care plan, revised on 05/26/23, showed the resident enjoyed smoking and has supervised cigarette breaks. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Used wheelchair independently for mobility device; -Functional limitation in range of motion (ROM) lower extremity impairment on one side; -Independent with eating, oral hygiene, toileting hygiene, upper body dressing, and personal hygiene; -Required substantial/maximum assistance (helper does greater than half of the effort) with showering, sitting to standing and chair/bed transfers; -Required partial/moderate assistance (helper does less than half of the effort) with lower body dressing. Review of the resident's smoking safety evaluation, completed on 02/21/24, showed the resident had demonstrated ability to safely smoke without supervision. Review of the resident's care plan showed staff did not update the care plan regarding the resident's need to be supervised or not for smoking. Review of the resident's March 2024 physician orders showed activity level as up ad lib (as often as desired/necessary). Observation and interview of the resident on 03/25/24, at 10:52 A.M., showed the following: -The resident sat in a wheelchair in his/her room; -The resident said he/she was preparing to go outside to smoke and had misplaced his/her cigarettes; -The resident began looking through clothing located in a laundry basket for cigarettes and a lighter; -The resident said he/she kept a lighter and cigarettes in his/her room and could go outside to smoke any time. Observation on 03/26/24, at 2:50 P.M., showed the following: -The resident sat in his/her wheelchair, in the outside courtyard, smoking a cigarette; -The resident was completely alone, with no other residents or staff visible outside. During an interview on 03/26/24, at 3:07 P.M., RN M said the following: -At the time of hire, other staff members told the nurse which residents were independent with smoking; -Three residents were independent with smoking, including the resident; -The resident was allowed to keep his/her cigarettes and lighter in his/her room. During an interview on 03/27/24, at 10:19 A.M., CNA R said the following: -The resident smokes outside by him/herself. The CNA said when the resident starts sleeping a lot, the CNA stayed outside with the resident; -The resident keeps cigarettes and possibly a lighter in his/her room; -Some of the residents kept their cigarettes and lighters at the nurse's desk; -He/she assumed the resident was supposed to leave his/her cigarettes and lighter at the desk. During an interview on 03/28/24, at 10:26 A.M., CNA S said the following: -The resident fell asleep frequently while smoking; -Staff allow the resident to go outside by him/herself, but he/she was not supposed to be allowed to smoke without supervision; -He/she was not aware of the resident ever burning him/herself, but the resident does not have burn holes in his/her clothing. During an interview on 03/28/24, at 10:48 A.M., RN M said the following: -Prior to this week, the resident was going outside and smoking independently; -In the early part of January 2024, the resident would get drowsy and fall asleep in the hallway, more recently he/she usually makes it to his/her room before falling asleep; -The nurse said he/she was unsure if the resident fell asleep outside while smoking; -The nurse he/she did not think any of the residents should go outside and smoke by themselves because it was not safe; -When he/she first started working at the facility, he/she asked other nurses about the resident smoking by him/herself, and other staff told the nurse the resident was independent with smoking and the resident had always been allowed to keep his/her own cigarettes and lighter in his/her room or on his/her person. During an interview on 03/28/24, at 11:45 A.M., NA H said the following: -Prior to this week, the resident went outside independently to smoke anytime, but the facility now had scheduled resident smoke times, and someone had to be with the resident outside, beginning this week; -Prior to this week, the resident was allowed to keep his/her cigarettes and lighter in his/her room, now he/she was supposed to keep those at the nurses' desk. During an interview on 03/28/24, at 2:38 P.M., the DON said the following: -The DON was unsure who was responsible for completing the resident smoking assessments, but the nurses should complete the assessments; -Social services kept the resident smoking assessments in their office; -The facility's smoking policy prohibits residents from keeping cigarettes or lighters in their rooms; -The DON and staff encouraged the resident to leave his/her lighter and cigarettes at the desk, but the resident did not always comply; -A staff member should be outside with the resident when he/she smoked and normally there was someone outside with the resident; -Several of the staff members smoke and can take the resident outside with them; -The resident frequently falls asleep, which is why he/she should not be alone outside while smoking. During an interview on 03/28/24, at 3:57 P.M., the Admission Coordinator said the following: -Social Services (SS) completed all the resident smoking safety assessments on a quarterly basis (every 3 months) and kept the assessments in a folder in the SS office; -The resident was pretty safe with smoking, but he/she did have a habit of falling asleep; -Staff did not allow the resident to keep his/her lighter or cigarettes in his/her room, but staff had an issue at times, with the resident not turning in his/her lighter and cigarettes at the nurses' desk; -Prior to this week, facility staff allowed the resident to go outside by him/herself to smoke. During an interview on 03/29/24, at 9:39 A.M., RN L said the following: -He/she was responsib [TRUNCATED]

Based on interview and record review, the facility failed to have a system in placed to ensure nurse aides (NA) completed their training, competencies, and testing in a timely manner when seven NAs (NA D, NA E, NA F, NA G, NA H, NA I, and NA J) failed to complete a state approved certified nursing assistant (CNA) training program, competency evaluation, and certification test timely and continued to work providing direct care to residents. The facility's census was 62. Review of the facility policy titled, Nurse Aide Qualifications & Training Requirements, revised October 2017, the facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem or otherwise unless: -That individual is competent to provide nursing care and nursing related services, and -That the individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state, or; -That individual has been deemed competent as provided in 483.150 (a) and (b) of the requirements of participation. 1. Review of the facility's Staff Position Report, dated 03/27/24, showed the following: -NA I was hired as an NA on 11/16/22; -NA E was hired as an NA on 05/30/23; -NA J was hired as an NA on 06/14/23; -NA F was hired as an NA on 07/18/23; -NA D was hired as an NA on 08/17/23; -NA H was hired as an NA on 08/25/23; -NA G was hired as an NA on 10/13/23. Review of facility and personnel records for NA I, NA E, NA J, NA F, NA D, NA H, and NA G showed the facility did not have documentation of the NA's completing a state approved CNA testing program within four months of hire. During an interview on 03/27/24, at 1:57 P.M., NA V said the following: -He/she worked at the facility as an NA for approximately 2 years; -He/she completed the NA training class, but still needed to take the test to become certified; -The facility had not told NA V when he/she would be taking the CNA test. During an interview on 04/01/24, at 11:00 A.M., NA G said the following: -He/she had been employed at the facility as an NA since October of 2023; -He/she completed the NA classes the end of January 2024, but he cannot afford to take the test yet due to the testing site being three hours away. The facility has not indicated they will pay for testing cost upon inquiry; -Has not taken his NA competency test; -Received a emailed letter from the facility indicating he/she had until February 2025 to test; -Worked his/her entire time at the facility as a NA. During an interview on 04/01/24, at 11:45 A.M., NA H said the following: -He/she has worked at the facility since August of 2023 as an NA. -Completed the classes to become a CNA by the end of December 2023; -He/she waited to schedule for his/her test in February 2024; -He/she just completed his/her competency evaluation on 03/29/24 at a testing site three hours away and was awaiting test results; -Worked his/her entire time at the facility as a NA. During an interview on 03/29/24, at 12:15 P.M., Registered Nurse (RN) K said the following: -He/she teaches the NA classes at the facility; -Students complete the free course work and skills training at the facility; -Class hours are usually around 100 hours and the course will take longer with absences; -The students complete training within four months of hire, but they take the course test elsewhere; -The NA students must register online for an outside testing site once the class is completed at the facility; -He/she was not aware of the length of time they can continue employment as a NA after they complete the classroom portion of the course; -Aware that students have to wait a long period of time before they test and has brought these concerns to administration; -NA's are allowed to work the floor after they complete the program and wait for testing to be finished. During an interview on 04/01/24, at 12:15 P.M., RN L said the following: -Notified this week during the current inspection process of NA's not completing their CNA classes in four months; -Previous testing practices allowed the staff to test at the facility increasing compliance with completing the course; -Since using the online testing service the students are not testing or scheduling for their test less than four months; -Students are allowed to take up to a year to complete the course. During an interview on 04/01/24, at 1:55 P.M. the Director of Nursing (DON) said the following; -NA's should complete 16 hours of basic skills training and then complete 75 hours of additional competency training before they can test for their certified nurse aide test; -NA's should complete the training within 4 months or be allowed to work in a non-nursing care area if they have not completed the training within 4 months; -Students schedule their own test online, but have difficulties with getting this done; -Recently asked to pay for a NA's test, but is hesitant to do this due to fear of the staff member not completing the testing or leaving employment after completion; -He/She is aware of NA's not completing their CNA classes and testing within the required four months; -Not aware of how many NA's they have working past four months. During an interview on 04/01/24, at 3:25 P.M., the Administrator said the following: -The facility uses an online testing company for their certified nurse aide program. He/she is aware of current NA staff taking longer than four months to complete the course. An NA should be terminated, restart the program or be reassigned as a non-nurse domestic aide or a dietary aide until they are fully certified. The facility will help the NA pay for the testing if needed and was not made aware this was a reason staff were not scheduling their testing until the current inspection inquiry. The NA should be reassigned to a non-nursing related service until they complete the program. 34906 50155

Based on observation, interview, and record review, the facility failed to establish a system of records to ensure all controlled drugs were routinely and consistently reconciled and that discontinued or expired controlled medications and disposed of in a timely manner. The facility's census was 62. Review of the facility's Storage of Medications Policy, dated April 2007, showed the following: -The facility shall store all drugs and biological's in a safe, secure and orderly manner; -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biological's shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others; -Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems; -Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of missing medications of several residents; -Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location; -Medications must be stored separately and labeled accordingly. Review of the facility's Discarding and Destroying Medications Policy, dated October 2014, showed the following: -Medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances; -All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of; -Schedule II, III and IV (non-hazardous controlled substances) will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non hazardous controlled medications; -Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident; -For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substance with other solid waste following the steps below: removal of the medication from its original containers and mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include, sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage; -Dispose with the solid waste in the presence of two witnesses; -Document the disposal of the medication disposition record and keep on file for at least two years; -For emergency kit controlled substances disposal, complete the appropriate portions of the controlled medication accountability form. Review of the facility's Controlled Substances Policy, dated December 2012, showed the following: -Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises; -The Director of Nursing (DON) will identify staff members who are authorized to handle controlled substances; -Controlled substances must be counted upon delivery by the nurse receiving the medication, along with the person delivering the medication together. Both individuals must sign the designated controlled substance record; -Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medication. This container must remain locked at all times, except when it is accessed to obtain medications for residents; -The charge nurse on duty will maintain the keys to controlled substance containers. The DON will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers; -Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the DON; -The DON shall investigate any discrepancies in narcotic reconciliation to determine the cause and identify any reasonable parties, and shall give the Administrator a written report of such findings. 1. Review of the facility's Narcotic Overflow Log, dated 03/13/24, for the facility's emergency kit (E-Kit) showed the red tag (lockout tag - 02426005) was placed on the counted locked cabinet. The staff did not document that a count was performed, only with the change of a red tag. Review of the facility's Current Narcotic Overflow Medication Count Inventory Sheet, showed the following: -On 12/08/23, staff added two cards of thirty tablets (total of 60 tablets) of tramadol (a controlled pain medication) to the cabinet; -On 12/08/23, staff added one bottle of ninety tablets of Ativan (a controlled antianxiety medication) 0.5 milligram (mg) to the cabinet; -Staff did not document medication counts for overflow narcotics from 12/09/23 to 03/07/24; -On 03/07/24, staff added a medication card containing three tablets of Fentanyl (a controlled pain medication), a medication card containing twelve tablets of morphine (a controlled pain medication), a medication card containing six tablets of Lyrica 50 mg (a controlled anticonvulsant medication), and two vials of Narcan (a medication to reverse narcotic overdose) 0.4 mg/ml to the cabinet. Two nurses signed off on the current count; -Staff did not document medication counts for overflow narcotics from 03/08/24 to 03/12/24; -On 3/13/24, staff removed three tablets of Fentanyl, a medication card containing twelve tablets of morphine, a medication card containing six tablets of Lyrica 50 mg, and two vials of Narcan 0.4 mg/ml from the cabinet. Two nurses signed off on the current cabinet count; -Staff did not document medication counts for overflow narcotics from 03/14/24 to 03/27/24. Observation on 03/29/24, at 11:40 A.M., of the current narcotic inventory count with Registered Nurse (RN) L and RN Z of the facility's lower medication room's current narcotic overflow medication count Inventory showed the following: -Two cards of thirty tablets (total of 60 tablets) of tramadol; -One bottle of ninety tablets of Ativan 0.5 mg. Review of the facility's Current Discontinued Narcotic Log, last dated 03/21/24, showed the red tag (02725976) was placed on the locked medication discontinued narcotic overflow cabinet. The staff made no documentation that a count was performed, only with the change of a red tag. Review of the facility's Current Discontinued Narcotic Log Sheet showed the following: -On 11/16/23, staff documented the cabinet was empty and did not have any discontinued narcotics; -On 11/16/23, untimed, staff added a bottle of 25.25 ml of Roxanol (narcotic pain medication) 20 mg/ml, three unopened 30 ml bottle of Roxanol 20 mg/ml, twenty-eight tablets of Ativan 0.5 mg, twenty-nine tablets of Norco (a narcotic pain medication) 7.5 mg/325 mg, twenty tablets of oxycodone (a narcotic pain medication) 5 mg, twelve tablets of clonazepam (a controlled anticonvulsant medication) 0.5 mg, eighteen tablets of pregabalin (Lyrica) 50 mg, and thirty tablets of pregabalin 50 mg to the cabinet. Two nurses signed off on the current cabinet count; -Staff did not document medication counts for discontinued narcotics from 11/17/23 to 11/21/23; -On 11/22/23, untimed, staff added a bottle of 20.75 ml of morphine sulfate 20 mg/ml, twenty-six tablets of lorazepam (Ativan) 0.5 mg, twenty-one tablets of lorazepam 0.5 mg, and thirteen tablets of hydrocodone 5 mg/325 mg to the cabinet. Two nurses signed off on the current cabinet count; -Staff did not document medication counts for the discontinued narcotics from 11/23/23 to 11/25/23; -On 11/26/23, untimed, staff added thirty tablets of tramadol (an controlled pain medication) 50 mg to the cabinet. Two nurses signed off on the current cabinet count; -Staff did not document medication counts for discontinued narcotics from 11/27/23 to 12/05/23; -On 12/06/23, untimed, staff added 14 tablets of phenobarbital (an anitseizure medication) 30 mg to the cabinet. Two nurses signed off on the current cabinet count; -Staff did not document medication counts for discontinued narcotics during from 12/07/23 to 12/29/23; -On 12/30/23, untimed, staff added a bottle of 29.5 ml of morphine sulfate 20 mg/ml and a 29.5 ml bottle of lorazepam 2 mg/ml to the cabinet. Two nurses signed off on the current cabinet count; -Staff did not document medication counts for discontinued narcotics from 01/31/23 to 01/25/24; -On 01/26/24, untimed, staff added thirty tablets of tramadol 50 mg, six tablets of tramadol 50 mg, nineteen tablets of alprazolam (a controlled antianxiety medication) 0.25 mg, and thirty tablets of alprazolam 0.25 mg to the cabinet. Two staff signed off on the current cabinet count; -Staff did not document medication counts for discontinued narcotics on 01/27/24; -On 01/28/24, untimed, staff added ten tablets of hydrocodone 5 mg/325 mg, eight tables of lorazepam 1 mg, one 60 ml bottle of lorazepam 2 mg/ml, one 27.5 ml bottle of morphine sulfate 20 mg/ml, and twenty-eight tablets of phenobarbital 32.4 mg to the cabinet. Two nurses signed off on the current cabinet count; -Staff did not document medication counts for discontinued narcotics from 01/29/24 to 02/04/24; -On 02/05/24, untimed, staff added ten tablets of tramadol 50 mg, one 29.5 ml bottle of lorazepam intensol 2 mg/ml, and one 28.25 ml bottle of lorazepam intensol 2 mg/ml to the cabinet. Two nurses signed off on the current cabinet count; -Staff did not document medication counts for discontinued narcotics from 02/06/24 to 02/07/24; -On 02/08/24, untimed, staff added thirty tablets of oxycodone 7.5 mg/325 mg and ten tablets of hydrocodone 7.5 mg/325 mg to the cabinet. Two nurses signed off on the current cabinet count; -Staff did not document medication counts for discontinued narcotics from 02/09/24 to 02/22/24; -On 02/23/24, untimed, staff added one 28.35 ml bottle of lorazepam 2 mg/ml and one 29.5 ml bottle of morphine sulfate 20 mg/ml to the cabinet. Two nurses signed off on the current cabinet count; -On 02/24/24, untimed, staff added twenty-one tablets of Ativan 0.5 mg, and eight tablets of Norco 7.5 mg/325 mg to the cabinet. Two nurses signed off on the current cabinet count; -Staff did not document medication counts for discontinued narcotics 02/25/24 to 02/29/24; -On 03/01/24, untimed, staff added one 27.5 milliliters (ml) bottle of lorazepam 2 mg/ml, fifteen tablets of lorazepam 0.5 mg, a 19 ml bottle of morphine sulfate 20 mg/ml, and sixteen tablets of lorazepam 0.5 mg to the cabinet. Two nurses signed off on the current cabinet count; -Staff did not document medication counts for discontinued narcotics during from 03/02/24 to 03/14/24; -On 03/15/24, untimed, staff added twenty six tablets of tramadol, eight tablets of tramadol, and twenty-eight tablets of Xanax (a controlled antianxiety medication) to the cabinet. Two nurses signed off on the current cabinet count; -Staff did not document medication counts for discontinued narcotics from 03/16/24 to 03/20/24; -On 3/21/24 untimed, staff added twenty tablets of tramadol, twenty-four ml of liquid Ativan 2 mg/ml, and seven ml of Roxanol 20 mg/ml to the cabinet. Two nurses signed off on the current cabinet count; -Staff did not document medication counts for discontinued narcotics from 03/21/24 to 03/27/24. During an observation 03/27/24, at 10:40 A.M. of the lower medication room on showed the following: -A red tag (02725976) on a locked cabinet labeled, Medication Discontinued Narcotic Overflow Cabinet; -A red tag (02426005) on a locked cabinet labeled, Active Overflow Narcotic Substances. During an observation and interview on 03/27/24, at 11:00 A.M., RN L accessed the facility's medication dispensing system. Observations were made of RN L performing a count on a current supply of medication kept in the facility E-kit. RN L said the count has to be correct or the dispensing machine will not allow the staff to continue with withdraw from the machine. The staff are not provided a number of the medication on hand prior to the staff entering the count. Staff only count the controlled medication if they accessed a locked supply of controlled medications with a red tag. The RN was aware staff are expected to count controlled medication per shift with the oncoming nurse. The RN was not aware of anyone checking the red tags routinely to see if they are broken. During an observation on 03/29/24, at 11:04 A.M., of the narcotic inventory count with RN L and RN Z, of the facility's lower medication room's discontinued narcotic storage cabinet showed the following: -A bottle of 25.25 ml of Roxanol 20 mg/ml; -Three unopened, 30 ml bottle of Roxanol 20 mg/ml; -Twenty-eight tablets of Ativan 0.5 mg; -Twenty-nine tablets of Norco 7.5 mg/325 mg; -Twenty tablets of oxycodone 5 mg; -Twelve tablets of clonazepam 0.5 mg; -Eighteen tablets of Pregabalin 50 mg; -Thirty tablets of Pregabalin 50 mg; -A bottle of 20.75 ml of morphine sulfate 20 mg/ml; -Twenty-six tablets of lorazepam 0.5 mg; -Twenty-one tablets of lorazepam 0.5 mg; -Thirteen tablets of hydrocodone 5 mg/325 mg; -Thirty tablets of tramadol 50 mg; -Fourteen tablets of phenobarbital 30 mg; -A bottle of 29.5 ml of morphine sulfate 20 mg/ml; -A 29.5 ml bottle of lorazepam 2/g/ml; -Thirty tablets of tramadol 50 mg; -Six tablets of tramadol 50 mg; -Nineteen tablets of alprazolam 0.25 mg; -Thirty tablets of alprazolam 0.25 mg; -Ten tablets of hydrocodone 5 mg/325 mg; -Eight tables of lorazepam 1 mg; -One, 60 ml bottle of lorazepam 2 mg/ml; -One, 27.5 ml bottle of morphine sulfate 20 mg/ml; -Twenty-eight tablets of phenobarbital 32.4 mg; -Ten tablets of tramadol 50 mg (a pain medication); -One, 29.5 ml bottle of lorazepam intensol 2 mg/ml; -One, 28.25 ml bottle of lorazepam Intensol 2 mg/ml; -Thirty tablets of oxycodone 7.5 mg/325 mg; -Ten tablets of hydrocodone 7.5 mg/325 mg; -One, 28.35 ml bottle of lorazepam 2 mg/ml; -One, 29.5 ml bottle of morphine sulfate 20 mg/ml; -Twenty-one tablets of Ativan 0.5 mg; -Eight tablets of Norco 7.5 mg/325 mg; -One, 27.5 milliliters (ml) bottle of lorazepam 2 mg/ml; -Fifteen tablets of lorazepam 0.5 mg; -A 19 ml bottle of morphine sulfate 20 mg/ml; -Sixteen tablets of lorazepam 0.5 mg; -Twenty six tablets of tramadol; -Eight tablets of tramadol; Twenty-eight tablets of Xanax; -Twenty tablets of tramadol; -Twenty-four ml of liquid Ativan 2 mg/ml; -Seven ml of Roxanol 20 mg/ml. During an interview on 03/27/24, at 1:13 P.M., the Director of Nursing (DON) said the staff are required to do a reconciliation of medications on the facility's automatic dispensing system when the medication box is counted. The staff only do counts if the red tag is broken or if a medication is used. She tries to destroy medication when she has time. She has not had time to destroy any medications recently, but did not realize it has been five months since any expired medication destruction has occurred. During an interview on 03/28/24, at 10:48 A.M., RN M said the following: -He/she worked as a charge nurse on the day shift; -Nurses locked the overflow or discontinued controlled medications in a locked cabinet in the medication room; -Nurses have not been checking the red plastic tag locks on medication room controlled medication cabinet at the beginning and end of each shift. During an interview on 03/28/24 at 1:37 P.M., RN X said the following: -He/she worked as a charge nurse on the night shift; -He/she counted the controlled medications stored in the medication and treatment carts at the beginning an end of each shift with the oncoming and off going nurse or CMT; -He/she did not count the controlled medications stored in the medication cabinet at the beginning and end of each shift; -The nurses counted the controlled medications stored in the medication room cabinet when accessing the cabinet to remove or add a medication, but otherwise did not count these medications. During an interview on 04/01/24, at 11:30 A.M., RN Q said the oncoming nurses should count with the previous shift for any controlled substances. He/she has not recently signed out any overflow narcotics or destroyed any discontinued medications recently. The staff count only when the red tag is removed or changed on the locked narcotics. During an interview on 04/01/24, at 12:50 P.M. RN N said staff are expected to count every shift the narcotic count tag and check the storage cabinets are locked. This is a new practice discovered this week and staff have not started implementing it. The staff realized the this was not being done and should have been checked every shift. During an interview on 04/01/24, at 2:30 P.M. the DON said all expired medications showed be destroyed timely. He/she is working on establishing a set time to destroy medications at least quarterly. He/she is encouraging certified medication technicians (CMT's) to destroy medications with the charge nurse to keep from large amounts of medications to accumulate. The red tags were being checked at least weekly before, but the nurses should check them at least every shift. During an interview on 04/01/24, at 3:25 P.M., the Administrator said the nursing staff should count narcotics at the beginning of their shift. The staff should utilize counts and a tag system to assist with securing medication every shift. 34906

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for all residents that included measurable objectives and timeframes to meet a resident's medical and nursing needs as identified in the comprehensive assessment when staff did not care plan one resident's (Resident #11) use of an anticoagulant medication and did not care plan one resident's (Resident #46) oxygen usage. A sample of 19 residents was reviewed in a facility with a census of 62. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, showed the comprehensive person-centered care plan will incorporate identified problem areas; incorporate risk factors associated with identified problems; and reflect currently recognized standards of practice for problem areas and conditions. 1. Review of the facility policy titled, Anticoagulant-Clinical Protocol, revised September 2012, showed the following: -The staff will identify and address potential complications in individuals receiving anticoagulation; -The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems; -If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in the urine), hemoptysis (blood in the sputum), or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. Review of Resident #11 's face sheet showed: -admitted [DATE]; -Diagnoses included dementia, heart failure, chronic kidney disease, and low back pain. Review of the resident's March 2023 Physician Order Sheet (POS) showed the following: -A current order for Eliquis (blood thinner/anticoagulant) 2.50 milligrams (mg), staff to administer one tablet by mouth two times daily for a diagnosis of atrial fibrillation (an abnormal heart rhythm). Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 02/21/24, showed resident taking anticoagulants. Review of the resident's current care plan showed staff did not care plan related to the resident's use of an anticoagulant medications. During an interview on 03/28/24, at 10:12 A.M., Certified Nurse Assistant (CNA) R said the following: -He/she does restorative therapy with the residents; -The CNA was not aware which residents were taking blood thinners, unless the resident told the CNA about the blood thinner; -The CNA said it was important to know who was on blood thinners, so that he/she could watch for any signs of bruising or bleeding and notify the nurse. During an interview on 03/28/24, at 10:26 A.M., CNA S said the following: -The CNA currently worked as the shower aide; -The CNA did not know which residents were taking blood thinners; -The CNA should know which residents were on blood thinners, in case they sustained a cut or skin tear; -The CNA said the nurse would have to tell him/her which residents were on blood thinner or he/she could look in the resident care plans. During an interview on 03/28/24, at 10:48 A.M., Registered Nurse (RN) M said the following: -He/she was unsure if the aides were informed of which residents were on blood thinners, but they could ask the nurse; -In a way, it would be important for staff to know in case the resident started bleeding, but anytime a resident started bleeding the aide should tell the nurse anyway. During an interview on 04/01/24, at 3:27 P.M., RN T said staff could look at the care plan to find out if a resident took blood thinners. During an interview on 03/29/24, at 9:39 A.M., RN L said the following: -He/she worked as the MDS and Care Plan Coordinator for the entire facility since August 2022; -If a resident was on an anticoagulant, that information should be on the resident's care plan; -He/she recently became aware that he/she had missed some of the care plans. During an interview on 03/28/24, at 2:38 P.M., the Director of Nursing (DON) said the following: -Resident care plans should include information about blood thinners and precautions; -The nurse aides should know which residents are on blood thinners so they can watch for potential for more injury or bruising/bleeding. During an interview on 04/01/24, at 12:11 P.M., the Administrator said nursing should include a resident's use of anticoagulants on the care plan. 49585 2. Review of the Resident #46's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included congestive heart failure (a long-term condition in which the heart can't pump blood well enough to meet the body's needs), dependence on supplemental oxygen, dyspnea (difficult or labored breathing), and severe persistent asthma. Review of the resident's physician order, dated 12/26/23, showed an order for oxygen at two to three liters/minute/nasal cannula (NC). Review of the resident's admission MDS, dated [DATE], showed the resident had continuous oxygen therapy. Review of the resident's care plan, revised on 01/15/24, showed resident had oxygen tubing that he/she does not keep off the floor. (Staff did not address when and how much oxygen was used or what to monitor related to the use of oxygen.) Observation on 03/26/24, at 11:07 A.M., showed the resident in his/her room sitting in wheelchair with oxygen in place via nasal cannula putting a puzzle together. Observation on 03/27/24, at 1:27 P.M., showed resident in room with oxygen in place via nasal cannula. Observation on 03/28/24, at 3:02 P.M., showed resident sitting in recliner in room with oxygen in place via nasal cannula. During an interview on 03/29/24, at 10:49 A.M., RN O said he/she communicates with aides about resident changes. The MDS Coordinator completes care plans. During an interview on 03/29/24, at 11:01 A.M., Nurse Assistant (NA) F said he/she uses the care plan or will ask the nurse to find resident information on resident oxygen use. During an interview on 03/29/24, at 12:19 P.M., CNA P said the care plan gives information regarding resident care. Nurse assistants also give report to each other at shift changes. During an interview on 04/01/24, at 3:27 P.M., RN T said staff could look at the care plan to determine if a resident required oxygen therapy. During an interview on 03/29/24, at 1:20 P.M., the MDS Coordinator said oxygen use should be updated in the care plan. No specific information regarding oxygen use was included in the resident's care plan. During an interview on 04/01/24, at 12:11 P.M., the Administrator said nursing should include a resident's use of oxygen on the care plan. 3. During an interview on 04/01/24, at 3:27 P.M., RN T said any nurse can update a resident care plan with changes, but typically RN L (the Care Plan Coordinator) updated the resident care plans with changes/new interventions. 4. During an interview on 03/29/24, at 1:20 P.M., the MDS Coordinator said the following: -Care plan information is obtained using information found in chart, MDS, staff interviews and observations; -Nurses leave a note in his/her box for resident changes or declines; -Care plan is updated quarterly or for any changes; -All updates should occur when change happens or as soon as possible. 5. During an interview on 04/01/24, at 12:11 P.M. the Administrator said the nurses or the Care Plan Coordinator should update the care plan with changes in the resident's status. 36974

Based on interview and record review, the facility failed to ensure a system in place that clearly and consistently represented each resident's choice of code status (if they wished to receive cardiopulmonary resuscitation (CPR - lifesaving technique that's useful in many emergencies in which someone's breathing or heartbeat has stopped) if their heart and/or breathing stopped) when staff failed to have the physician sign one resident's (Resident #46) Outside the Hospital Do Not Resuscitate Form (DNR - do not attempt CPR) and when staff failed to ensure one resident's (Resident #20) code status was consistent throughout the medical record. The facility census was 62. Review of the facility's policy titled, Advanced Directive, revised [DATE], showed the following: -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive; -The interdisciplinary team will review annually with the resident his or her advanced directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument; -Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment and care plan; -The Director of Nursing (DON) or designee will notify the Attending Physician of advanced directives so that appropriate orders can be documented in the resident's medical record and plan of care. 1. Review of the Resident #46's face sheet (a document that gives a resident's information at a quick glance) showed the following: -An admitted [DATE]; -Diagnoses included congestive heart failure (a long-term condition in which the heart can't pump blood well enough to meet the body's needs), dyspnea (difficult or labored breathing), and severe persistent asthma; -Code status of DNR. Review of resident's Outside the Hospital Do Not Resuscitate Order (OHDNR), dated [DATE], showed the form signed by the resident. A physician had not signed the form. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated [DATE], showed the resident had moderate cognitive impairment. Review of the resident's care plan, revised on [DATE], showed a code status of DNR. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed code status as DNR. During an interview on [DATE], at 3:02 P.M., the resident said he/she spoke with a social worker and physician about a DNR order this week and confirmed he/she does not want chest compressions. 50155 2. Review of Resident #20's face sheet, undated, showed the following -admitted [DATE]; -Diagnoses included depression (a common mental disorder causing depressed mood or loss of pleasure or interest in activities); -Full code status (wished to receive CPR). Review of the resident's POS, dated [DATE], showed the resident as a DNR code status. Review of the resident's Annual Social Service Care Plan Note, dated [DATE], showed resident wished to remain full code status. Review of the resident's Annual Review Code Status Form, dated [DATE], showed a code status of full code. Review of the resident's care plan, revised [DATE], showed a resident as a DNR code status. Review of the resident's POS, dated February 2024 and [DATE], showed the resident as a DNR code status. During an interview on [DATE], at 3:15 P.M., the resident said the staff have asked many times about what he/she wants his/her code status to be. He/she just recently changed it to full code. 3. During an interview on [DATE], at 1:40 P.M., Licensed Practical Nurse (LPN) BB said if the resident's code status changes the social worker will change the dots by the resident's names outside their door. A red dot for DNR and green for CPR. He/She said if the information was different on the POS for that resident it should be caught by the DON who is responsible for doing the change out/monthly medication administration record (MAR) review. 4. During an interview on [DATE], at 2:30 P.M., LPN CC said if the code status changes the social worker will change the dots by the resident's names outside their door. Red for DNR and green for CPR. He/She said if the information was different on the POS for that resident, it would be by the DON who is responsible for change out/monthly MAR review to catch the error. 5. During an interview on [DATE], at 12:15 P.M., the MDS Nurse said if the code status changes that Social Services notifies him/her and that it won't take long to change the status on the MDS/Care Plan. If one had not been changed, he/she would go in and change it as soon as it was brought to his/her attention. 6. During an interview on [DATE], at 12:35 P.M., the Social Services Coordinator said if the code status changes, he/she would change the paper in front of chart the dot outside the resident's door. He/she would also change it in the electronic medical record. He/she would also notify the family/guardian to get them to sign if resident was not the responsible party and then send the new form to physician for signature. 7. During an interview on [DATE], at 1:55 A.M., the DON said social workers are directed to have the resident and/or representative to complete a form with the resident's code status wishes and it would be signed off by the physician. She said the information should be the same in each area of the resident's medical records. She checks the Physician Order Summary monthly to verify orders are correct in the resident's medical chart. The MDS Coordinator was responsible to verify the care plan reflected the information in the resident's medical chart. 8. During an interview on [DATE], at 3:25 P.M., the Administrator said she would expect the resident's code status to be documented in the resident's charts as soon as the order changes. The information should be the same and if not, it would be caught in monthly change over the next month. 33187

Based on observation, interview, and record review, the facility failed to ensure all controlled medications were stored per standards of practice when a controlled substance was not stored in a locked box. The facility's census was 62. Review of the facility's Storage of Medications Policy, dated April 2007, showed the following: -The facility shall store all drugs and biological's in a safe, secure, and orderly manner; -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biological's shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others; -Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems; -Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately and labeled accordingly. Review of 19 Code of State Regulation (CSR) 30-1.034 showed controlled substances shall be stored in a securely locked, substantially constructed cabinet. 1. Observation on 03/27/24, at 10:35 A.M., of the facility's lower nurse medication room showed the following; -The medication room refrigerator emergency kit (E-Kit) storage box was unlocked. The box contained six vials of Ativan Intensol (antianxiety medication/controlled substance) 2 milligram/milliliter (mg/ml). -Registered Nurse (RN M) immediately locked the cabinet and returned the box to the refrigerator. During an interview on 03/27/24, at 10:37 A.M., RN M said the controlled substances kept in the facility's locked refrigerator for the emergency kit should be double locked at all times. The Ativan vials were unopened and the count was correct at the beginning of the shift. During an interview on 04/01/24, at 2:30 P.M. the Director of Nursing (DON) said staff are expected to secure all medication. During an interview on 04/01/24, at 3:25 P.M., the Administrator said staff are expected to store controlled medication in a double locked cabinet or refrigerator.

49585 Based on interview, and record review, the facility failed ensure medical records were maintained and accurate in accordance of standards of practice when staff failed to timely document an assessment and notification of the physician for one resident (Resident #313), who fell and sustained a foot fracture. A sample of 19 residents was reviewed in a facility with a census of 62. Review of the facility policy titled, Changes in a Resident's Condition or Status, revised December 2016, showed the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition change or status. Review of the facility policy titled, Charting and Documentation, revised July 2017, showed the following: -All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. -The following information is to be documented in the resident's medical record: objective observations; medications administered; treatments or services performed; changes in the resident's condition; events, incidents, or accidents involving the resident; and progress toward or changes in the care plan goals and objectives. 1. Review of Resident #313's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included of inflammatory polyarthropathy (painful inflammation and stiffness of multiple joints), muscle weakness, repeated falls, and lack of coordination. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/10/23, showed the following: -Severe cognitive impairment; -Impairment in range of motion to upper and lower extremities; -Partial to moderate assistance with bed mobility, walking, and transfers; -Uses walker for mobility. Review of the resident's Fall Risk Evaluation, dated 12/29/23, showed staff assessed the resident as a fall risk. Review of the resident's care plan, revised on 01/15/24, showed the following: -Required assistance of one staff for transfers, ambulation, toileting, dressing, and hygiene; -Resident was occasionally incontinent of urine and continent of bowel; -Resident was alert with confusion at times; -At risk for falls related to weakness and a history of falling; -Resident had falls on 01/27/24, 03/20/24, and 03/26/24; -Controlled Ankle Movement (CAM) boot; -Check skin every shift. Review of facility Fall Scene Investigation Report, dated 03/20/24, showed the following: -Staff found the resident on the floor near his/her bed after staff heard a crash coming from the room; -Contributing factors leading to fall noted as medical status, physical condition, diagnosis, and mood or mental status. Review of the resident's nursing progress note dated 03/20/24, at 6:30 A.M., showed the following: -The resident stated he/she poured buckets of pee on the floor, but floor appeared dry; -The resident ambulated to restroom with two staff after fall; -The resident was unsteady and crying with no tears; -Resident went to dining room for breakfast. Review of transfer record dated 03/20/24, at 12:00 P.M., showed the following: -The resident transferred to an acute care hospital due to a possible fracture of his/her left foot; -The resident was able to ambulate short distance, then complained of pain with weight bearing; -Staff noted a knot to the resident's left lateral foot. Review of hospital after visit summary dated 03/20/24, at 2:49 P.M. showed the following: -The resident had a fracture at the base of the fifth metatarsal (bone in the foot); -The resident should wear walking boot and may bear weight as tolerated. Review of the resident's nursing progress note dated 03/20/24, at 3:40 P.M., showed the following: -The resident returned to the facility from the emergency room with family; -The resident reported to staff he/she has a fracture of foot and was wearing a walking boot; -No orders or instructions were given to facility. Review of nursing notes showed staff did not document an assessment, assessment findings, or notification to physician after the fall. During an interview on 03/28/24, at 2:03 P.M., Registered Nurse (RN) N said the following: -He/she conducted a head-to-toe assessment of resident after fall and found no abnormal findings; -He/she would not document range of motion or skin assessment after a fall unless abnormal findings noted; -Resident had a flesh colored almond sized bump on outside of foot noted on the way to dining room for lunch; -Nurse contacted physician after resident complaint of pain and a bump discovered; -Resident sent out to hospital around lunch time; -He/she forgot to document physician order for transfer and assessment in chart. During an interview on 03/29/24, at 11:08 A.M., RN O said the following: -If a resident has a fall, he/she would document an assessment, obtain vital signs, complete fall paperwork, and notify the physician. During an interview on 04/01/24, at 3:27 P.M., RN T said the following: -The nurse should document the fall assessment and notifications in the nurse notes and complete an incident report and conduct neurological checks per the facility policy, if the resident sustained a head injury of the fall was not witnessed; -The nurse should assess the resident for any injuries for three days following the fall, and document in the resident's nurse notes. During an interview on 03/28/24, at 3:18 P.M., the Medical Director said he/she would expect nurses to document an assessment after a resident fall. During an interview on 03/28/24, at 2:38 P.M., the Director of Nursing (DON) said the nurse should document the fall, assessment, and notifications in the nurses' notes. During an interview on 04/01/24, at 12:11 P.M., the Administrator said the following: -Nurses should chart when a resident has an accident or injury at the time of the occurrence in the nurse notes; -The nurse should assess a resident for injury and notify the resident's physician, next of kin, and document in the resident's nurse notes; -The nurse should assess the resident again later if the resident develops latent signs/symptoms of injury; -Nurses should chart for 72 hours on any resident fall on the fall monitoring sheet and daily for three days in the nurse notes

Based on interview and record review, the facility staff failed to ensure the safety of all residents when staff failed to ensure they followed proper standards of practice, facility policy, and the resident's care plan when one aide attempted to transfer one resident (Resident #1) in the Hoyer lift (a mechanical device with a sling attached to lift and transfer a non-ambulatory resident) with no assistance. This resulted in the resident suffering a fall causing a right femur (the large bone in the leg) fracture. The facility census was 66. The Administrator and Director of Nursing (DON) were notified on 7/22/2022, at 12:40 P.M., of the Past Non-Compliance which occurred on 7/18/2022. Facility staff notified Department of Health and Senior Services (DHSS) of the noncompliance, started an investigation, suspended the employee involved, in-serviced the facility staff involved in transferring residents, and started doing daily random observations of staff performing transfers on all shifts. The checks will be done daily for a month, then three times weekly indefinitely. The noncompliance was corrected on 7/19/2022. Record review of the facility's policy Lifting Machine, Using a Mechanical, dated July 2017, showed the following: -At least two nursing assistants are needed to safely move a resident with a mechanical lift; -Place the sling under the resident; -Lower the sling bar closer to the resident; -Attach the sling straps to the sling bar, according to the manufacturer's directions; -Make sure the sling is securely attached to the clips and that it is perfectly balanced; -Before the resident is lifted, double check the security of the sling attachment; -Examine all hooks, clips, or fasteners; -Lift the resident two inches from the surface to check the stability of the attachment; -Gently support the resident as he/she is moved. 1. Record review of Resident #1's face sheet (a brief resident summary sheet) showed the following: -admitted [DATE]; -Diagnoses included a prior fracture of the right femur, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), impulse disorder (a condition where people have impulses that are difficult or impossible to resist), [CONDITION(S)] (cancer of the tube that runs from the throat to the stomach), and muscle weakness. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 4/20/2022, showed the following: -Severely cognitively impaired; -Dependent on staff for transfers. Record review of the resident's care plan, updated 7/18/2022, showed the following: -On 8/2/2021, staff care planned the resident required a Hoyer lift for transfers; -On 8/2/2021, staff care planned the resident required the assist of two staff with Hoyer lift transfers. Record review of the resident's nursing note dated 7/18/2022, at 5:45 A.M., showed the following: -Resident being transferred from bed to the wheelchair and slid out of the sling at least three feet to the floor. The aide was able to keep him/her from hitting his/her head. The resident's right hip appeared to be deformed. Staff called the Medical Director and an order was given to send to the emergency room for evaluation. Record review of the facility's investigation, dated 7/19/2022, showed the following: -CNA A had dressed and placed the resident in the Hoyer pad and was in the process of getting the resident transferred to the chair when the sling slid out of the Hoyer; -The CNA was able to catch the upper body/head area of the resident; -The lower half of the resident hit the floor; -The Hoyer sling was still attached to the Hoyer lift after the resident was on the floor; -Interviewed all witnesses, inspection of the Hoyer pad was performed. Record review of Certified Nurse Aide (CNA) A's written statement, dated 7/18/2022, showed the following: -The aide dressed the resident and put the lift pad under the resident; -He/she raised the resident out of the bed with the lift and opened both Hoyer legs; -The aide pulled the Hoyer the rest of the way out to the doorway, and walked to the side of the lift with the controller in his/her hand; -The Hoyer made a popping noise and the resident started to roll out in an outward and downward motion, landing on his/her left side; -The aide grabbed a hold of the resident's head area when he/she was going down; -Two of the pad straps were still attached to the Hoyer lift; -The aide went to the doorway to get the nurse then went back to sit with the resident while waiting for the ambulance; -The nurse had the aide put the Hoyer pad under the resident while he/she was on the floor to get him/her up when the ambulance arrived. Record review of the CNA A's Disciplinary Warning Notice, dated 7/18/2022, showed the following: -The CNA received a Disciplinary Warning for using a Hoyer lift with only one person and another aide in the room, resulting in a resident falling on the floor; -He/she should always use two staff members when using a Hoyer lift. During an interview on 7/29/2022, at 12:35 P.M., CNA A said on 7/18/2022 he/she clipped the resident in the Hoyer lift to perform at transfer. He/she moved the lift, stopped, backed the lift out, stopped again, heard a popping sound, and the resident fell out of the lift onto the floor. The aide said he/she was operating the lift by him/herself and Nursing Assistant (NA) B was assisting the resident's roommate. He/she had been trained to always use two people to operate the lift and facility policy says for two people to operate the lift. Two people should always operate the Hoyer lift. Record review of NA B's written statement, dated 07/18/2022, showed the following: -NA B was changing the resident's roommate as directed by CNA A; -As CNA A lifted the resident into the Hoyer lift, the sling slipped through the loops and the resident fell to the floor; -CNA A rushed to the resident's side as quickly as he/she could to aid the resident. During an interview on 8/3/2022, at 6:45 P.M., NA B said he/she was in the room during the transfer, but was assisting the resident's roommate with dressing. CNA was doing the transfer alone and had transferred several residents alone that morning. NA B said when he/she was hired he/she had no training on how to operate the Hoyer lift, but had watched some videos. He/she said the Hoyer should always be operated with two staff members and in the CNA training he/she was receiving, it was taught to always perform the lift transfers with two people. During an interview on 7/22/2022, at 10:45 A.M., Registered Nurse (RN) C said the Hoyer lift should always be operated by two staff members. It is never acceptable for the lift to be operated by one staff member. During an interview on 7/22/2022, at 10:55 A.M., RN D said two people are always to operate the Hoyer lift. It is never acceptable for one person to operate it by themselves. During an interview on 7/22/2022, at 11:00 A.M., RN E said the Hoyer lift should always have two people operating it. It is never acceptable to use one person. During an interview on 7/22/2022, at 11:10 A.M., CNA F said there should always be two people operating the Hoyer lift. It is never appropriate to use one person. During an interview on 7/22/2022, at 12:20 P.M., the Assistant Director of Nursing (ADON) said she expects staff to always use two people when transferring residents with the Hoyer lift. The day the resident fell , there were two staff in the room, but only one operating the lift. The aide was immediately suspended. It is never acceptable for staff to perform Hoyer transfers with one staff member. During an interview on 7/22/2022, at 12:30 P.M., the Administrator said she expects staff to use two persons to transfer with the Hoyer. It is never acceptable to use one staff member to transfer with the Hoyer. During an interview on 7/22/2022, at 2:42 P.M., the Medical Director said she expects staff to use two persons to operate the Hoyer lift if the facility policy calls for two persons. The resident's fall resulted in a right femur fracture. MO 334

Based on interview, observation, and record review, the facility failed to keep food safe from potential contamination when surfaces had a build up grease, lint, and hair on food contact areas or areas that directly affected food contact areas. The facility census was 62. Record review of the facility's policy titled Sanitation, revised October 2008, showed the following information: -The food service area shall be maintained in a clean and sanitary manner; -All kitchen areas and dining areas shall be kept clean, free from litter and rubbish; -All utensils, counters, shelves and equipment shall be kept clean and maintained in good repair; -All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions; -Between uses, cloths and towels used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution; -The food service manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas; -Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks; and, -Food service staff will clean after each task before proceeding to the next assignment. 1. Observation on 03/22/2022, at 10:00 A.M. showed no cleaning schedule posted in the kitchen directing staff on what duties to complete. Observation of the kitchen on 3/22/2022, at 10:00 A.M., showed the following areas covered in a substance of a lint/grease/grime mixture: -The metal slider coverings above the stove (directly above the plastic plates covers); -A fan secured to the wall that hung over the dishwasher and would blow over the metal countertop where staff place dishes to dry. When staff turned on the fan, a substance hung from the fan and moved around from the force of the air. Observation on 3/22/2022, at 10:00 A.M., showed some hairs stuck to and hanging on the edge of the tray carrier full of clean stacked dishes and the top of the dishwasher with grime and food particles laying upon it. Observation of the kitchen on 3/24/2022, at 11:34 A.M., showed the following: -Overhead fan secured to the wall, above the dishwashing area on and blowing; -Long strings of hair and grime connected in different areas on the fan and blowing around the front of the fan, while still connected; -The steam table that held the food ran perpendicular to the dishwashing station, with approximately six to seven feet between the two work stations; -The steam table was approximately five to six feet from the fan; -In between the stations was a 3-shelf rolling cart, where the fresh plates of food were being placed. The fan blew on the resident's plates being prepared by staff; -A second fan ran near the three-bin metal sink. The black, tall, standing fan that had a grime substance on the front and back of the fan's shield, blowing onto a prep table that had pumpkin pie on it. During an interview on 3/25/2022, at 1:38 P.M., Dietary Aide (DA) D said the following: -He/she does not have any cleaning schedule or jobs to do, as far as he/she is aware of; -He/she did not know who cleaned or who should do the regular cleaning; -He/she is only required to clean the dishwasher and surrounding area. During an interview on 3/25/2022, at 1:56 P.M., Dietary Cook E said the following: -He/she thinks there is a cleaning schedule posted somewhere, but could not show where it is; -He/she said it has been posted in the past; -He/she stated that cleaning is to whoever gets to the job first; -No one is assigned certain days of when they are to clean certain areas. During an interview on 3/25/2022, at 2:08 P.M., Dietary Cook F said the following: -There is a cleaning schedule that is put into a book that sits on the counter, but it's not there at this time; -Anyone who has time should start cleaning, but no one has actual duties assigned to them. During an interview on 3/24/2022, at 11:59 AM, the Dietary Supervisor said the following: -The staff know to clean up after they are done working in an area, but have not been assigned to clean any certain area. During an interview on 3/25/2022, at 4:08 P.M., the Administrator said the following: -The condition of the kitchen was not acceptable.

Based on observation, interview, and record review the facility failed to assess, monitor, implement interventions, and appropriately treat one resident's (Resident #1) diabetic ulcer; failed to notify the physician, in a timely manner, to obtain orders for treatment and failed to notify the physician when the ulcer showed signs of deterioration and infection resulting in an admission to the hospital for intravenous antibiotics and surgical debridement of the ulcer. The facility identified Resident #1 as the only resident in the facility with an open diabetic ulcer. The facility failed to prevent and/or manage pain for one resident (Resident #1) of 12 sampled residents and two additionally selected residents (Residents #19 and #20). The facility failed to assess, monitor, and adequately treat an increase in pain, the decrease in the current pain management interventions effectiveness, and notify the physician of an increase in the resident's reported pain. The facility failed to assess and adequately treat the physical signs/symptoms of pain displayed by one cognitively impaired resident, (Resident #19) who was unable to definitively communicate a level or location of pain and failed to assess, treat and consistently monitor pain and failed to identify and implement interventions for signs and symptoms of possible depression for one resident (Resident #20) who had a history of [REDACTED]. sensitivity test for a new onset of yellow wound drainage to the resident's right "pinky" toe for one resident (Resident #10) out of 12 sampled residents. The facility census was 56. The Merck Manual of Geriatrics, third edition, 2000, defines diabetes mellitus as "...a syndrome characterized by [MEDICAL CONDITION] (high blood sugar)...Infection risk from fungi and bacteria is increased because of decreased cellular immunity caused by acute [MEDICAL CONDITION] and circulatory deficits caused by chronic [MEDICAL CONDITION]. The American Academy of Family Physicians, 1998, states, "Diabetic foot complications are the most common cause of nontraumatic lower extremity amputations in the industrialized world. The risk of lower extremity amputation is 15 to 46 times higher in diabetics than in persons who do not have diabetes mellitus....The vast majority of diabetic foot complications resulting in amputation begin with the formation of skin ulcers. Early detection and appropriate treatment of [REDACTED]." Record review of the facility's Pressure Ulcer/Skin Breakdown Clinical Protocol, dated October 2010, showed the following information: -The nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores; -The nurse will assess vital signs, full assessment of the pressure sore including, location, stage, length, depth, presence of exudates or necrotic tissue; -The physician and staff will examine the skin of a new admission for ulcerations or indications of an ulcer that has not yet ulcerated at the skin surface; -The physician will help identify medical interventions, for example, treating a soft tissue infection, removing necrotic tissue, managing pain related to the wound or to wound treatments. 1. Record review of Resident #1's medical record showed that staff admitted the resident to the facility on [DATE], following a hospitalization on [DATE]. Record review of the hospital's history and physical (H&P) showed the hospital admitted the resident on 5/22/13, for observation. Once admitted to the hospital, the resident developed an upper GI (gastrointestinal) bleed and went into the ICU (intensive care unit). Hospital assessment showed a blistering formation on the skin with discoloration under the skin and foot pain. On 5/23/13, staff assessed the resident for [MEDICAL CONDITION] (inflammation of connective tissue with severe inflammation of skin) and abscess (a collection of pus that has accumulated within a tissue because of an [MEDICAL CONDITION] process in response to either an infectious process or other foreign materials) of the foot with no acute pathology. The hospital discharge record showed the hospital physician documented the resident had an open sore to his/her left heel. Staff documented the wound measurements as 4 centimeter (cm) of necrotic (form of cell injury that results in the premature death of cells in living tissue) tissue, and a 1 cm black area. The hospital physician diagnosed the resident with dry gangrene (a necrosis or death, of tissue, usually due to deficient or absent blood supply. It may be dark or black in color). The hospital discharge instruction did not order a treatment for [REDACTED]. Record review of the facility's admission nursing evaluation, dated 5/25/13, showed facility staff documented the resident had pale, cold, dry skin with swelling present on both lower extremities. Staff documented "treatment to the left heel.". Record review of the facility's admission nurse's note, dated 5/25/13, at 2:35 P.M., showed staff documented the resident admitted to the facility with a pressure ulcer to the left heel. Record review of the facility's daily skilled nurse's note, dated 5/25/13, showed staff documented the resident had a [MEDICAL CONDITION]. Staff documented that the diabetic ulcer was "quarter sized" with pink drainage. Staff cleaned the area with wound cleanser and applied dressing, without a physician's orders [REDACTED]. During an interview on 8/08/13, at 12:56 P.M., the Staff Development Coordinator said staff perform a skin assessment on new residents and fax the physician to obtain wound/ulcer orders. Record review of the facility's social service note, dated 5/25/13, showed the resident had an issue with his/her heel and was not walking at the time of admission without the assistance of a wheelchair. The resident required some staff assistance for his/her ADLs (Activities of daily living: toileting, grooming, bathing, etc). Record review of the facility's physician fax sheet, dated 5/26/13, showed the following information: -Staff notified the physician the resident had a diabetic ulcer to his/her left heel. Staff asked the physician if he would like to continue to current treatment of [REDACTED]. -On 5/28/13 the physician responded to the facility's fax. (two days after staff originally faxed the request); -From 5/25/13-5/28/13 staff performed the treatment without a physician's orders [REDACTED]. -Staff did not document additional attempts to reach the physician for a treatment order and did not document they discussed of the severity of the ulcer's decline with the physician at that time. Record review of the daily skilled nurses' notes, dated 5/26/13, showed the following: -Wound/diabetic ulcer on the left heel; -Moderate amount of yellow drainage; -Staff did not document notifying the physician of the change in wound status. Interviews conducted on 8/13/13, with the physician, showed the following: -At 8:32 A.M., the physician did not remember what the facility reported to him regarding the resident's wound/ulcer. The physician did not assess the wound/ulcer and was unaware of when the facility first alerted him to the yellow drainage of the wound; -At 5:00 P.M., the physician said on 05/26/13 staff notified him, by fax, of the resident's ulcer. He did not review the fax until 5/28/13 and he did not remember if he and staff discussed the wound. The physician reviewed the resident's orders on 05/29/13 when he was at the facility. Pressure sore staging, according to the U.S. Dept. of Health and Human Services Clinical Practice Guidelines, are as follows: -Stage I - a persistent area of skin redness without a break in the skin, that is non-blanchable (Redness of skin surface that persists when pressure is applied); -Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister; -Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling; -Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Record review of the daily skilled nurses' notes, dated 5/27/13, showed the following: -Stage II; -Moderate amount of yellow drainage with a pink wound bed; - Evening shift staff documented the resident received skilled services for a pressure ulcer to the left foot; -Staff did not document notifying the physician of the ulcer assessment. Record review of the May 2013 physician's orders [REDACTED]. Record review of the daily skilled nurses' notes, dated 5/28/13, showed the following: -Left interior (inner) ankle (ulcer located on left heel) dressing with yellow drainage; -Resident said tenderness on touch; -Staff did not document of physician notification of the ulcer assessment. Record review of the daily skilled nurses' notes dated, 5/30/13, showed the following: -Stage II pressure ulcer to the left interior ankle with yellow drainage; -Tenderness reported by the resident; -Staff did not document of physician notification of the ulcer assessment. Record review of the facility's physician fax sheet, dated 5/30/13, showed the facility contacted the physician regarding the resident's insulin and sliding scale. The facility staff did not alert the physician to any wound changes. Record review of the daily skilled nurses' notes, dated 5/31/13, showed day shift staff documented the resident's skin was warm, dry and pale with a large ulcer to the medial (middle) left heel. All three shifts documented the wound was a pressure ulcer and a diabetic ulcer. Record review of the resident's admission Minimum Data Set (MDS) a federally mandated comprehensive assessment, completed by facility staff, dated 05/31/2013, showed the following information: -Brief Interview for Mental Status (BIMS) score of 15 (no cognitive impairment status); -Required staff supervision and set up help with toileting: -Required staff assistance of one for bed mobility; -Continent of bladder and bowel; -Not steady with balance with transitions and walking, requiring staff assistance; -Impaired range of motion (ROM) to both lower extremities; -Diabetes mellitus; -Difficulty in walking; -Muscle weakness; -Lack of coordination; -One unstageable pressure ulcer with slough; -[MEDICAL CONDITION] with pressure ulcer care; -No suspected deep tissue injury. Record review of the resident's care plan, dated 5/31/13, showed the following information: -Increased weakness; -Pressure ulcer to left heel; -Allow and encourage the resident to do as much as possible; -Assist as needed; -Assist of one for hygiene; -Change bed linens daily; -Examine skin per facility protocol to assess for reddened areas; -Report any redness or skin breakdown to charge nurse or treatment nurse; -Staff did not develop interventions related to the ulcer. Record review of the daily skilled nurses' notes, dated 6/01/13, showed the following: -Moderate amount of yellow drainage; -All three shifts documented a pressure ulcer and a diabetic ulcer; -Staff did not document of physician notification of the wound assessment. Record review of a nurse's note, dated 6/01/13, at 7:30 A.M, showed staff documented the heel dressing was off. The wound was "very" red and had a moderate amount of yellowish drainage; -The ulcer bed was red and inflamed (swollen) and measured approximately 5 cm in diameter and 0.3 cm deep (this is the first time staff documented wound measurements); -Staff notified the physician of the wound's decline and received new treatment orders; -[MEDICATION NAME] (antibiotic) 100 milligrams (mg) by mouth, twice a day, for 10 days; -Change dressing to left heel ulcer daily; -Change dressing treatment to calcium alginate (combine with wound/ulcer drainage to form a gel in the moist wound bed. This process helps the wound heal by limiting secretions in the wound and minimizing bacterial contamination) gauze and kling wrap (self-adhering gauze roll). Record review of the daily skilled nurses' notes, dated 6/02/13, showed yellow drainage from the wound. All three shifts documented the ulcer as a pressure ulcer. Record review of the daily skilled nurses' notes, dated 6/03/13, showed the following: -No odor to ulcer but blood tinged drainage assessed by staff with tenderness; -The resident complained ulce tender to touch. Record review of the daily skilled nurses' notes, dated 6/04/13, showed the resident complained the ulcer was tender to touch. Record review of the facility's wound report, dated 6/04/13, showed the following: -Stage III wound (Staff marked through Stage III and wrote "unstageable" (a term used when the wound bed is not visible due to a non-removable dressing/device, coverage of the wound bed by slough and/or eschar) on form in different handwriting)); -Wound measured 5 cm in diameter; -[MEDICATION NAME] tissue ([MEDICATION NAME] occurs when the epidermis (outermost layers of cells in the skin) grows over a wound surface)); -Moderate drainage; -No odor; -Current treatment of [REDACTED]. -Treatment effective. Record review of the daily skilled nurses' notes, dated 6/05/13, showed yellow drainage to left heel ulcer with a dry dressing. Record review of the daily skilled nurses' notes, dated 6/06/13 showed the following: -Ulcer measurement 4.5 cm x 3.8 cm with surrounding loose dry skin; -Inner measurement of 2.0 cm x 1.5 cm dark center; -Moderate amount of brown drainage; -Redness to left foot peri-wound (surrounding the ulcer); -All three shifts documented the area as a diabetic ulcer; -Staff did not document physician notification of the change in color of the drainage, the dark center of the ulcer, or the redness to the peri-wound on assessment. During an interview on 8/08/13, at 12:45 P.M., Licensed Practical Nurse (LPN) M said staff would notify the physician if the treatment was not working and would document the notification in the nurse notes. During an interview on 8/08/13, at 12:56 P.M., the Staff Development Coordinator said new residents get a skin assessment and staff fax the physician and request wound/ulcer orders. He/she said the other residents receive a weekly skin assessment and staff faxes those assessments to the physician weekly. He/she said if the staff observes a significant change that the staff call the physician and request new orders. He/she said staff would call the physician on an increase in exudates, odor, or a significant change. Record review of the daily skilled nurses' notes, dated 6/07/13, showed the following: -Moderate amount of greenish-brown drainage (Purulent refers to yellow, gray or green drainage that comes out of a wound when infection invades the area. The volume of the exudates increases when an infection occurs);-Staff did not document notifying the physician of the change in the wound's status. Record review of the daily skilled nurses' notes, dated 6/08/13, showed the following: -Ulcer area dark red; -Black ulcer wound bed with scant slough (necrotic tissue in the process of separating from viable portions of the body); -All three shifts documented the area as a pressure ulcer; -Staff did not document physician notification of the change in the color of the ulcer area to dark red, the newly assessed black wound bed, or the newly assessed slough to the ulcer on assessment. Record review of the daily skilled nurses' notes, dated 6/09/13, showed the following: -Ulcer with dark brown to black base; -Yellow and white slough to outer perimeter of the ulcer; -All three shifts documented the area as a pressure ulcer; -Staff did not document physician notification of the brown to black wound bed or the newly assessed yellow and white slough to the outer perimeter of the ulcer on assessment. Record review of the facility's physician fax sheet, dated 6/11/13, showed staff notified the physician of hard stools. The facility staff did not document they notified the physician of the ulcer's decline. Record review of the daily skilled nurses' notes, dated 6/12/13, showed the following: -Left heel draining serosanguinous (consisting of both blood and serous fluid) fluid; -Eschar (dead tissue) observed; -Staff changed the dressing and applied a calcium alginate strip only to the eschar; -All three shifts documented the area as a [MEDICAL CONDITION]; -Staff did not document physician notification of the assessed eschar. Record review of the facility's physician fax sheet, dated 6/13/13, showed the facility staff notified the physician of the resident's need for side rails. The facility staff did not document physician notification of the ulcer's decline. Record review of the daily skilled nurse's note, dated 6/13/13, showed staff documented the resident's left heel had a moderate amount of yellow drainage. All three shifts documented the area as a diabetic ulcer. Record review of facility's physician fax sheet, dated 6/14/13, showed the following information: -Diabetic ulcer, Stage III, on the left heel had an odor; -Copy of physician's orders [REDACTED]. -No necrosis; -Wound shows improvement; -Complete [MEDICATION NAME] on 06/11/13; -Current trearment of calcium alginate, started on 06/01/13; -The physician instructed staff to continue the current treatment. Record review of the daily skilled nurses' notes, dated 6/14/13, showed the following: -Odor to the wound; -No necrosis noted; -Wound showed improvement; -Physician notified; -No new orders received; -All three shifts documented the area as a diabetic ulcer; -Staff did not notify the physician of the odor. Record of the medical record from 06/06/13-06/14/13 (eight days) showed staff did not notify the physician of the change in wound appearance and wound drainage, although staff notified him two separate occasions regarding other medical issues related to the resident. Record review of the daily skilled nurses' notes, dated 6/15/13, showed the staff documented the left foot ulcer had moderate drainage and odor. Staff documented the area as a pressure ulcer on day and evening shift, and night shift documented the area as a diabetic ulcer. From 06/09/13-06/15/13 the medical record showed staff did not document measurements of the wound. During an interview on 8/09/13, at 9:30 A.M., the DON said she expected the staff to notify the physician with significant changes. She said she expected staff to notify the physician by phone with a wound decline if the staff could not wait for a fax response. The DON said a significant change in a wound included signs and symptoms of an infection, and increase in the measurement, an increase in the depth, a change in the look of the tissue, new necrotic tissue or slough, or an increase of the drainage/exudates or odor to the ulcer. The DON said she expected staff to measure the depth an ulcer and expected staff to measure the peri-wound separately from the open ulcer. Staff should document the measurements on a new weekly sheet. Record review of the daily skilled nurses' notes, dated 6/16/13, showed the following: -Ulcer had necrosis and odor; -Staff documented the area as a pressure ulcer on day shift, and evening and night shift documented the area as a diabetic ulcer; -Staff did not document physician notification of the necrosis or continuing odor to the ulcer. Record review of the daily skilled nurse's note, dated 6/17/13, showed the following: -No odor noted to ulcer; -Necrotic tissue to the center of the ulcer with pink edges; -Physician notified by fax. Record review of the facility's physician fax sheet, dated 6/17/13, showed the following: -Necrotic area in the center of the ulcer; -Pink edges and good blood flow; -Small amount of yellowish/red drainage; -Tenderness to the area; -No odor which is a change from last week; -Staff requested a treatment order change to [MEDICATION NAME] hydroactive gel, (designed for the hydration and management of partial- and full-thickness wounds such as pressure sores, leg ulcers, and diabetic ulcers) cover with transparent (clear) dressing, change every three days and as needed until resolved; -Staff notified the physician the gel is designed for hydration and management of partial full thickness wounds and aids in autolytic debridement (the use of synthetic dressings to cover a wound and allow dead tissue to self-digest from enzymes present in wound fluids); -On 06/19/13 (two days after the facility sent the fax), the physician responded; -Staff did not document additional attempts to contact the physician by phone or fax from 06/17/13-06/19/13. Record review of the facility's wound report, dated 6/17/13, showed the following information: -Stage III wound (with Stage III marked through and "unstageable" wrote on form in different handwriting); -Wound measured 3 cm x 3 cm and had a depth of 1/4 cm; -[MEDICATION NAME] tissue (staff placed a line through "[MEDICATION NAME] tissue" and handwrote "necrotic [MEDICATION NAME] unmeasurable"); -Moderate drainage; -No odor; -Current treatment of [REDACTED]. -Treatment effective (marked out and non-effective marked); -Staff documented "faxed out" under the new orders section of the form Record review of the daily skilled nurses' notes, dated 06/18/2013, showed the following: -Slight odor with a greenish-yellow ulcer center; -White outer skin debrided (removal of dead, damaged, or infected tissue. Debridement is achieved by surgical intervention, mechanical through friction and/or chemical through enzyme medication) with red blood noted (the note does not describe how and who debrided the wound); -All three shifts documented the area as a diabetic ulcer; -Staff did not document notifying the physician of the wound's slight odor. Record review of the daily skilled nurses' notes, dated 6/19/13, showed the following: -Odor noted; -Ulcer blanchable (a reddened area that turns white when pressure is applied); -New treatment order received for cleanse with normal saline, cover wound with [MEDICATION NAME] hydroactive gel, cover with transparent dressing until resolved, change every three days and as needed; -Ulcer draining brownish-yellow bloody drainage in a moderate amount; -All three shifts documented the area as a diabetic ulcer; -Staff did not document physician notification of the change in drainage color or the amount of drainage of the ulcer on assessment; -The facility staff did not document any additional attempts to contact the physician by phone or fax for notification of the ulcer from 6/17/13 to 6/19/13. Record review of the facility's physician fax sheet, dated 6/19/13, showed the facility staff notified the physician of mild pain. The facility staff did not document physician notification of the ulcer decline since last communication on 6/17/13. Record review of the daily skilled nurses' notes, dated 6/20/13, showed the following: -Large amount of green drainage; -Slight odor; -Physician notified on day shift with no new orders; -The dressing was changed on night shift due to the dressing coming loose and a strong odor was noted; -Staff did not document physician notification of the newly assessed strong odor. Record review of the daily skilled nurses' notes, dated 6/21/13, showed the following: -Dressing changed with a moderate amount of green drainage; -No odor noted; -All three shifts documented the area as a diabetic ulcer. Record review of the facility's physician notification fax sheet, dated 6/21/13, showed the following: -Left heel, Stage III ulcer; -Large amount of greenish drainage; -Foul odor; -One day it looks better the next day it does not; -The entire heel was mushy; -Staff wondered if there could be tunnelling (channels that extend from a wound into and through subcutaneous tissue or muscle) underneath; -The facility requested orders for a culture of the wound, an antibiotic and to send the resident to the wound clinic; -On 06/25/13 (four days after staff sent the fax) the physician responded with new orders; -The facility staff did not document any additional attempts to contact the physician by phone or fax from 06/21/13-06/25/13. Record review of the daily skilled nurses' notes, dated 6/22/13, showed staff assessed a small odor. Record review of the facility's monthly summary, dated 6/22/13, showed that staff documented no ulcers. Record review of the daily skilled nurses' notes, dated 6/23/13, showed the following: -Odor noted; -Outer edges of the ulcer, pink; -Center of ulcer green; -Physician is aware of ulcer conditions. Record review of the daily skilled nurses' notes, dated 6/24/13, showed the following: -Large amount of green drainage assessed on day shift; -Slight odor; -Applied the [MEDICATION NAME] gel to the ulcer; -Moderate amount of yellow drainage assessed on night shift; -All three shifts documented the area as a diabetic ulcer; -Staff did not document physician notification of the ulcer assessment. Record review of the daily skilled nurses' notes, dated 6/25/13, showed the following: -Received new orders for a C&S (culture and sensitivity) of the ulcer; -Refer to the wound clinic; -Keflex 500 mg, two times a day for10 days; -Left heel ulcer with slough; -All three shifts documented the area as a diabetic ulcer; -Staff did not document physician notification of slough to ulcer. Record review of the daily skilled nurse's note, dated 6/26/13, showed the following: -Moderate amount of yellow-green drainage; -Center of ulcer is yellow; -Surrounding skin is pink; -Wound culture pending; -All three shifts documented the area as a diabetic ulcer. Record review of the facility's physician notification fax sheet, dated 6/26/13, showed the facility notified the physician via fax and requested the order for the wound clinic consult be placed "on hold" due to the resident's insurance (HMO) and asked if they could wait and see how the resident reacted to the antibiotic.The physician agreed with the facility's request. During an interview on 8/13/13, at 5:00 P.M., the physician said he thought the wound/ulcer required debridement on 6/25/13. On 06/25/13, the facility informaed the physician the resident's insurance would not pay for him/her to be seen at the wound clinic. The physician was going to make an appointment for the resident to see him in his office for debridement of the wound but on 07/03/13, the facility made an appointment for the resident to go to the wound clinic on 07/12/13. Record review of the daily skilled nurse's note, dated 6/27/13, showed the following: -Moderate amount of yellow drainage; -Foul odor; -Center of ulcer is yellow; -Surrounding skin is pink; -Stage of ulcer is unknown due to slough. Record review of the facility's physician fax sheet, dated 6/27/13, showed the facility staff notified the physician of two newly identified Stage II pressure ulcers to the resident's left buttock and a red area to the resident's right buttock. The facility staff did not document physician notification of the color change to the diabetic ulcer on the heel assessed on 6/26/13. Record review of the facility's wound report, dated 6/27/13 (ten days after last wound measurement), showed the following information: -Stage III wound (with Stage III marked through and unstageable wrote on form in different handwriting); -Inner area 2.5 cm x 1.8 cm; -Outer area 3.0 cm x 2.3 cm [DIAGNOSES REDACTED] (redness); -[MEDICATION NAME] tissue; -Moderate drainage; -Moderate odor; -Rated pain a six (6) out of a ten (10) scale; -Current treatment of [REDACTED]. -Treatment effective. Record review of the facility's wound/skin healing record, dated 6/27/13, showed the following information: -Stage III ulcer; -Wound bed measured 2.5 cm x 1.8cm; -[DIAGNOSES REDACTED] measured 3 cm x 2.3 cm; -Slough to the wound bed; -Bright red peri-wound; -Moderate amount of purulent drainage; -Moderate amount of odor; -Resident reported his/her present level of pain at 3 out of 10 on the pain scale; -Response to treament: No change. Record review of the preliminary C&S results, reported by the laboratory, on 6/28/13, showed the following: -Moderate Escherichia coli (bacteria that is normally found in the lower intestine); -Moderate Pseudomonas aeruginosa (bacteria found in dirt, water and skin). Record review of the daily skilled nurses' notes, dated 6/28/13, showed the following: -Improvement noted; -Continues with yellow drainage assessed by day shift; -Continues with odor assessed by day shift; -Culture received and physician notified by phone with no new orders; -Moderate amount of brown drainage with foul smelling odor; -Staff documented on the area as a diabetic ulcer on day shift and night shift; -Staff did not document physician notification of the change of odor from slight to foul or the change in drainage from green to brown. Record review of the daily skilled nurses' notes, dated 6/29/13, showed the following: -Left heel ulcer draining brown colored foul smelling drainage; -Wound unstageable due to slough; -All three shifts documented the area as a diabetic ulcer; -Staff did not document physician notification of the newly assessed slough to the ulcer. Record review of the daily skilled nurses' notes, dated 6/30/13, showed the following: -Moderate amount of brown colored foul smelling drainage; -Staff documented the area as a diabetic ulcer on day and night shift; -Unstageable ulcer due to slough. Record review of the facility's physician fax sheet, dated 6/30/13, showed the facility staff notified the physician of the resident's lower extremities. Staff assessed the lower extremities as extremely swollen. The lower extremities had blisters and wept (natural bodily fluid that is escaping out of the unprotected area of her skin). Record review of the laboratory's C&S of the left heel final culture report, dated 6/30/13, showed the following: -Moderate Escherichia coli; -Moderate Pseudomonas aeruginosa; -Moderate [MEDICAL CONDITION] (MRSA, a resistant bacterial infection difficult to treat). Record review of the nurses' notes, dated 6/30/13, showed staff failed to notify the physician of the final C&S report, and the newly [MEDICAL CONDITION] infection. During an interview on 8/13/13, at 5:00 P.M., the physician said he thought the wound/ulcer required debridement on 6/25/13, and ordered a C&S of the wound/ulcer. The resident's antibiotic was changed and the resident was scheduled to be seen on 7/01/13, or prior. The facility printed the C&S on 6/30/13, but he did not see it until 7/02/13. Record review of the daily skilled nurses' notes, dated 7/01/13, showed staff assessed a strong odor from the dressing. Staff documented that the consulting nurse practitioner (NP) was in the building to assess the resident, and that the she said she would discuss the situation with the attending physician and fax over any new orders. All three shifts documented the area as a diabetic ulcer. Record review of the consulting NP progress note, dated 7/01/13, showed the following: -Wound measurement of 5 cm to 6 cm diameter with dark center (the physician ordered Keflex on 6/25/13 for 10 days); -Tenderness with [DIAGNOSES REDACTED]; -Continue dressing changes daily; -Elevate legs to reduce swelling; -Possible debridement at the wound clinic. Record review of the facility's physician fax sheet, dated 7/01/13, showed the facility staff notified the physician that the resident had been out of a [MEDICATION NAME](used treat injuries and other painful muscle conditions) for a week and has had increase

Based on observation, interview and record review, the facility failed to implement interventions to reduce the risk of falls for one of the 17 sampled residents (Residents #4). Resident #4 fell four times with some minor injuries between 3/9/13 through 6/16/13 and the facility failed to implement interventions after each fall specific to the resident's active decline in physical and mental status or place interventions to lessen the risk of injury from sustained falls. The resident then fell twice on 6/16/13 and the second fall resulted in a right hip fracture with a hospital stay of nine days. Upon return to the facility, staff failed to provide supervision and interventions for the resident who continued to fall six more times between 6/28/13 through 8/5/13. The census was 56. Record review of the facility's "Accidents and Incidents" policy, dated 12/2007, showed the following information shall be included on the "Report of Incident/Accident" form: -The date and time the accident or incident took place; -The nature of the injury/illness (example bruise, fall, nausea, etc.); -The circumstances surrounding the accident or incident; -Where the accident or incident took place; -The names of witnesses and their accounts of the accident or incident; -The injured resident's account of the accident or incident; -The time the physician was notified, as well as the time the physician responded and any instructions; -The date and time the family was notified and by whom; -The condition of the resident, including vital signs; -The disposition of the injured; -Any corrective action taken; -Follow-up information; -Other pertinent data as necessary or required, and; -The signature and title of the person completing the report. Record review of the facility's "Charting and Documentation" policy, dated 4/2008, showed the following information: -The staff would document all services provided to the resident, or any changes in the resident's medical or mental condition, in the resident's medical records; -The staff must document all observations, medications administered, services performed, etc., in the resident's clinical records; -The staff must record all incidents, accidents, or changes in the resident's condition; -Documentation of procedures and treatments would include care-specific details and include: date and time the care was provided, the name and title of the staff who provided the care, the assessment data and any unusual findings obtained during the care, how the resident tolerated the care, whether the resident refused the care, notification of family, physician or other staff and the signature and title of the individual documenting. Record review of the facility's "Change in a Resident's Condition or Status" policy, dated 4/2011, showed the following information: -The facility would promptly notify the resident, the physician and responsible party of changes in the resident's medical or mental condition or status; -The staff would notify the physician for an accident or incident involving the resident and for a discovery of injuries of an unknown source. 1. Record review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment, completed by facility staff, dated 2/11/13 showed the following information: -[DIAGNOSES REDACTED]. -Brief Interview for Mental Status (BIMS) (brief test to score a resident's comprehension status) of 9 (8-12: moderately cognitively impaired); -The resident was not steady with walking, turning around in a standing position or moving from a seated to standing position, but able to stabilize without staff assistance; -Used a walker for ambulation; -No range of motion impairments; -No falls since last quarterly MDS assessment on 11/14/12; -Always continent of bowel and bladder. Record review of the fall risk evaluation, dated 2/19/13, showed a score of 12. A score of 10 or higher resulted in a risk for a fall. The staff were to consider environmental risk factors in the resident's interventions. The staff failed to show interventions were in place to reduce the risk of a fall. Record review of the nurses' notes showed the following information: -On 3/6/13 at 3:00 P.M., the resident wandered, was confused, and was looking for a ride home. The staff observed the resident pushing buttons on the door panel but staff redirected the resident easily; -On 3/9/13 at 4:15 P.M., staff found the resident on the floor on his/her right side. The resident's feet were at the doorway and the walker was at the door entry with a blanket wrapped on the cross brace. The resident was wearing the appropriate shoes and clothing. The resident complained of left hip pain. The staff rolled the resident onto his/her back. The assessment showed the pelvic girdle intact. After the assessment, the resident denied pain. The resident's lower legs moved with a full range of motion (ROM) and no rotation or shortening. The staff transferred the resident to a chair and the resident denied pain or discomfort while sitting in the chair. Staff observed a pink discoloration to the resident's left upper back. Staff notified the physician by fax. Staff received no answer with attempted family notification. Staff notified the Director of Nurses (DON). On 3/11/13 at 4:00 P.M., staff received a fax back from the physician regarding the fall (on 3/9/13) with no new orders. Staff failed to show interventions were in place to reduce the risk of another fall on the care plan or in the resident's medical records. Record review of the fall risk re-evaluation, dated 3/13/13, showed a score of 14. The staff failed to show interventions were in place to reduce the risk of a fall after the re-evaluation which resulted in a higher risk than the previous evaluation on 2/19/13. Record review of the nurses' notes showed the following information: -On 3/20/13 at 8:50 P.M., staff found the resident sitting on the floor, the bed mattress (flipped off the bed frame and was on the floor) in the upright position against the bed frame. The resident leaned against the mattress with no injury. Staff started neuro checks. The resident denied pain. Staff faxed the physician. Staff notified the family, Assistant Director of Nursing (ADON), social services and the administrator. Staff failed to show interventions were in place to reduce the risk of another fall on the care plan or in the resident's medical records; -On 3/25/13 at 3:00 P.M., the physician ordered a urine analysis for complaints of increased confusion and agitation with attempts to redirect. Staff notified the family; -On 4/14/13 at 1:30 P.M., staff notified the physician of an increase in right shoulder pain. The as needed (PRN) order of Tylenol given only had an effect of 2-3 hours. No new orders. Staff made no notes regarding the onset of the right shoulder pain or whether the shoulder pain was acute or chronic; -On 4/17/13 at 1:25 P.M., the physician placed new orders, by fax, for Ultram (treats pain) 50 milligrams (mg) one tablet by mouth every six hours, PRN for pain and Aspercreme (treats pain) topical cream to right shoulder for complaint of pain three times a day, PRN. Record review of the resident's quarterly MDS, dated [DATE], showed the following changes since the last MDS assessment: -A decline in BIMS of 7 (0-7 = severe cognitive impairment); -Occasionally incontinent of bladder; -One fall with no injury and one fall with minor injury since the last quarterly MDS assessment on 2/11/13. Record review of the fall risk evaluation, dated 5/6/13, showed a score of 12. The staff failed to show interventions were in place to reduce the risk of a fall after re-evaluation showed the resident was at high risk for a fall. Record review of the resident's care plan, reviewed on 5/6/13, showed staff did not add new interventions to prevent the resident from falling or interventions to reduce the risk of injury with a sustained fall. The DON identified the plan of care, dated 8/27/12, as the care plan currently used by staff for 08/27/12 through 07/09/13. The care plan included the following information with regard to fall prevention: -Fall: The resident was at risk for falls due to displaying slight unsteadiness with gait and transfers. The resident would forget to use his/her walker at times; -Supervise the transfers, ambulation and assist PRN to ensure safety; -Assess environment carefully for fall risks and make needed corrections or modifications; -Be certain the footwear was non-skid; -Create and maintain a clear path to the bathroom; -Educate the resident PRN in safety awareness; -Encourage and remind the resident to use the call light for needs; -Maintain room and pathways free of clutter; -Make sure all staff members were aware the resident was at risk for falls; -Ensure the resident always used his/her walker for ambulation; -Staff did not include individualized interventions related to the resident's physical and mental decline. Record review of the nurse's notes showed the following information: -On 5/8/13 at 1:23 A.M., the aide reported the resident sat on the floor. Upon observation, the resident sat on the floor beside the bed holding his/her left knee. The nurse asked the resident to move his/her leg. The resident held up his/her leg up and bent the knee with no apparent difficulty. The resident was alert and oriented and had full ROM. The staff asked the resident to move into his/her chair in order for the resident to reach the call light. The resident stood and favored his/her left knee a little, but was able to bear full weight when taking a step to the left. The resident had a 1 centimeter (cm) by 2 cm abrasion to the left knee that was pink with no drainage or swelling. The nurse applied triple antibiotic (TAO) and a bandage. The resident complained of knee pain but nothing else was wrong. When asked, the resident said he/she tried to get out of bed and fell on his/her knee. The staff faxed the physician. At 3:15 P.M., the physician faxed an order for [REDACTED]. The staff failed to show interventions were in place to reduce the risk of another fall on the care plan or in the resident's medical records. Record review of the nurses' notes, events regarding the right hip fracture, showed the following information: -On 6/16/13 at 3:35 A.M., an aide found the resident sitting on the floor next to his/her bed on top of a blanket. When asked, the resident said he/she tried to reach his/her walker and then fell . The nurse observed swelling in the left foot and ankle. The resident said, "ouch" when the ankle was moved. The nurse offered an ice pack, but the resident refused. The nurse offered prescribed pain medications, but the resident spit them out and said, "It tastes bad". The resident walked around the room with a walker. At 5:00 A.M., the staff notified the DON of the fall. At 8:00 A.M., the nurse called the physician regarding the fall and received an order for [REDACTED]. The staff failed to show interventions were in place to reduce the risk of another fall or interventions to reduce the risk of injury with a sustained fall on the care plan or in the resident's medical records. At 12:35 P.M., the x-ray report showed no acute fracture or dislocation of the left foot and ankle. At 12:40 P.M., the staff faxed the results to the physician; -On 6/16/13 at 11:05 P.M., an aide called the nurse into the resident's room. The staff found the resident on the floor next to the bed. The resident complained of soreness on both lower legs. The nurse and two aides assisted the resident into bed. The nurse assessed the resident. The resident complained of right hip pain. The ROM showed no apparent injuries. The staff administered PRN pain medication. The staff failed to show interventions were in place to reduce the risk of another fall or interventions to reduce the risk of injury with a sustained fall on the care plan or in the resident's medical records; -On 6/17/13 at 2:40 A.M., the resident sat on the side of the bed and complained of right femur pain. The nurse observed mild swelling to the upper leg (thigh area). The nurse called the physician and received an order for [REDACTED].M., the staff received an order to transfer the resident to the hospital due to a right hip fracture. At 9:40 A.M., the resident transferred to the hospital. Record review of the discharge MDS, dated [DATE], showed the following changes since the last MDS assessment: -No BIMS score given; -Frequently incontinent of both bowel and bladder; -One fall with major injury and one fall with minor injury since last quarterly MDS assessment on 5/6/13. Record review of the daily skilled nurse's notes showed the following information: -On 6/26/13 at 5:00 P.M., the resident readmitted to the facility following hospitalization due to surgery from a right hip fracture nine days prior. The resident's skin assessment showed a right mid-thigh five inch incision with five intact sutures. The incision had no redness or drainage noted. Record review of the fall risk evaluation, dated 6/26/13, showed a score of 13. The staff failed to show interventions were in place to reduce the risk of a fall after re-evaluation showed the resident was at high risk for a fall. Record review of the medical record, dated 6/28/13, showed the following information: -Physical therapy ordered for four weeks, five sessions a week for gait and transfer training with [DIAGNOSES REDACTED]. Record review of the nurses' notes showed the following information: -On 6/28/13 at 6:30 A.M., staff called the nurse into the resident's room. The resident was on the floor with his/her head propped up by the resident's hands. The resident asked the staff to help him/her off of the floor. The resident complained his/her neck hurt while on the floor in this position. The nurse assessed ROM in all extremities. The nurse and two aides helped the resident into his/her wheelchair. Once in his/her wheelchair, the resident denied pain. The resident was alert with confusion. The confusion was normal to the resident and his/her disease process. The right hip incision was dry with no signs or symptoms of infection. The incision edges were well proximate and healing well. The resident went to the dining room for breakfast. The staff would continue to monitor. At 4:00 P.M., the staff faxed the physician for clarification on medication orders, but did not notify the physician of the fall on 6/28/13. The staff failed to show interventions were in place to reduce the risk of another fall, or reduce the risk of injury, in the resident's medical records; -On 7/1/13 at 8:45 P.M., the staff notified the physician of the fall (on 6/28/13); -On 7/2/13 at 5:30 P.M., the physician's Nurse Practitioner (NP) faxed an order for [REDACTED]. -On 7/3/13 at 10:45 A.M., the resident progressed with therapy. The resident walked with his/her rolling walker from his/her room to the therapy room. Therapy would continue to work with the resident to increase his/her independence. Record review of the resident's significant change MDS, dated [DATE], showed the following changes since the last MDS assessment: -A decline in BIMS of 5 (0-7 = severe cognitive impairment); -The resident was not steady with walking, turning around in a standing position or moving from a seated to standing position, no longer able to stabilize without staff assistance; -Used a walker and a wheelchair for ambulation; -One fall without injury since last assessment on 6/17/13; -Frequently incontinent of bladder and always continent of bowel. Record review of the nurses' notes showed the following: -On 7/5/13 at 3:00 P.M., an aide found the resident on his/her left side in a fetal position between the bed and his/her wheelchair. The wheelchair brakes were unlocked. The call light was in reach from the wheelchair. The resident was up in his/her wheelchair and attempted to self transfer then fell . The resident was unsure what he/she tried to do. With the questioning, the resident became irritated with the staff. The fall was unwitnessed. There were two, 1 cm in diameter, pink areas on the skin to the right shoulder. The resident denied pain. The hip was symmetrical. At 3:40 P.M., the staff faxed the physician and notified the family, the DON, the administrator and social services. The neuro checks were within normal limits (WNL). The staff failed to show interventions were in place to reduce the risk of another fall, or interventions to reduce the risk of injury with a sustained fall, on the care plan or in the resident's medical records; -On 7/8/13 at 9:00 P.M., staff notified the physician of the fall on 7/5/13. No new orders. Record review of the resident's care plan, dated 07/9/2013, showed staff updated the plan and added following interventions to the original care plan, dated 8/27/12, specific to the resident: -Fall: The resident was now at increased fall risk due to the recent hip fracture; -Assist of one staff member for transfers and ambulation to ensure safety; -The resident rarely used the call light and would require frequent checks; -Anticipate the resident's needs and ensure to meet all physical needs; -Resident did well with the walker for short distance but would require a wheelchair for distance locomotion. Record review of the care plan, dated 7/9/13, showed, on 7/12/13, physical therapy included the following update: -The resident would no longer receive physical therapy and would work with restorative therapy to increase Activities of Daily Living (ADL) performance. Record review of the resident's therapy discharge notes, dated 7/18/13, showed the following: -Nursing staff educated on proper transfer techniques; -Clinical impression: improved transfers; -Complicating factors included: confusion prevented the resident from achieving all established goals; -Weight bearing as tolerated with a device and assist at all times; -The resident required a lower level of assistance. Record review of the nurses' notes showed the following: -On 7/16/13 at 2:20 P.M., the staff found the resident on the floor. The ROM assessment was completed. The resident denied pain. The resident tried to stand-up to go to the restroom. The fall was unwitnessed. The nurse completed a full assessment and found no apparent injury. The nurse and two aides assisted the resident to his/her feet with a gait belt with no complaints of pain. Staff re-educated the resident (with a BIMS of 5) to ask or use the call light for help. The staff will continue to monitor. The staff failed to show interventions were in place to reduce the risk of another fall, or interventions to reduce the risk of injury with a sustained fall, on the care plan or in the resident's medical records; -On 7/17/13 at 5:00 P.M., the physician signed acknowledgement of the resident's fall on 7/16/13. Record review showed after eight falls, on 7/25/13, staff implemented a ten minute monitoring sheet for the resident. The monitoring sheet did not show interventions used to prevent a fall from reoccurring or interventions to reduce the risk of injury with a sustained fall. Record review of the nurses' notes showed the following: -On 7/26/13 at 5:05 A.M., the nurse found the resident on the floor while walking by the resident's room. The nurse assisted the resident with changing his/her clothes and cleaning him/her up. No apparent injuries. The neuro checks were completed. The staff notified the DON, administrator and the family. The staff faxed the physician regarding the fall. The nurse continued to monitor. The staff failed to show interventions were in place to reduce the risk of another fall, or interventions to reduce the risk of injury with a sustained fall, on the care plan or in the resident's medical records. Record review of the facility's ten minute monitoring sheet, dated 7/26/13 through 7/29/13, showed where the resident was every ten minutes. The monitoring sheet did not show interventions used to prevent a fall from reoccurring or interventions to reduce the risk of injury with a sustained fall. Record review of the nurses' notes showed the following: -On 7/29/13 at 12:30 P.M., the physician faxed back regarding fall and no new orders given. Record review of the facility's ten minute monitoring sheet, dated 7/30/13, showed where the resident was every ten minutes. The monitoring sheet did not show interventions used to prevent a fall from reoccurring or interventions to reduce the risk of injury with a sustained fall. Record review of the nurses' notes showed the following: -On 8/3/13 at 11:10 A.M., when the resident propelled himself/herself down the hall, he/she slid out of the wheelchair onto the floor. The nurse completed the neuro checks and vital signs. The nurse noted no injuries. The nurse and two staff members assisted the resident back into the wheelchair. The nurse gave the PRN Ultram for joint discomfort. The nurse notified the DON, the administrator, the physician and the family. The nurse spoke with the restorative aide (RNA) to walk with the resident to build strength. The staff failed to show interventions were in place to reduce the risk of another fall, or interventions to reduce the risk of injury with a sustained fall, on the care plan or in the resident's medical records; -On 8/5/13 at 3:00 A.M., the aide heard the resident yelling for help as the aide walked by the resident's room from the hall. The aide found the resident on the floor beside his/her bed with the covers wrapped around him/her. The resident said his/her left, back lower ribs hurt a little. The nurse found no marks or swelling. The resident was in a pleasant mood at that time. The resident did not request for pain medication. The nurse did not note an injury when he/she completed a full ROM to all extremities of the resident. The nurse notified the administrator, the DON, the physician and the oncoming staff. The staff failed to show interventions were in place to reduce the risk of another fall, or interventions to reduce the risk of injury with a sustained fall, on the care plan or in the resident's medical records; -On 8/5/13 at 8:50 A.M., the resident complained of right rib pain since the fall in the morning. The nurse listened to the resident's lungs. The resident said it was painful to take in a deep breath. The nurse notified the physician and he gave an order for [REDACTED].M., the staff faxed the results of the x-ray to the physician with no evidence of a fracture. Record review of the resident's care plan, dated 8/5/13, showed staff added the following information: -Fall: The resident fell twice over the weekend. Once he/she slid out of the wheelchair with no injury noted. Then the staff found the resident on the floor in front of his/her bed. Apparently the resident attempted to get out of bed and fell . The resident complained of rib pain to his/her right side. The physician ordered x-rays; -Approaches: The resident would require frequent checks and assessment for pain. Reorient the resident with the use of the call light due to the recent falls. Observation on 8/5/13 at 2:45 P.M., showed the resident was in bed. Staff had not implemented a floor pad or low bed to prevent injury if the resident sustained [REDACTED]. The pulled privacy curtain was against the full length of the bed on the left side of the resident and the wall with the window was on the resident's right side. The blankets wrapped around the resident. His/her shoes were on the floor beside the bed and the socks the resident was wearing were not skid resistance. The call light attached to the bed, near the resident's head. Record review of the nurses' notes showed the following: -On 8/6/13 at 4:45 A.M., a small bruise to the top of the left hand noted at that time. The resident denied pain. The resident was in bed on his/her left side. The staff would continue to monitor. Observation on 8/6/13 at 9:13 A.M., showed the resident was in bed. The head of the resident was at the foot of the bed and his/her feet were at the head of the bed (HOB). The call light attached to the sheet of the bed at the HOB in between where the resident's legs were and his/her exit off the bed. The blankets wrapped around the resident and over the resident's head. The bed side table was against the resident's bed at the HOB. During an interview on 8/6/13 at 12:00, the resident sat at the dining room table and fed himself/herself. His/her plate was clean except to empty bags of potato chips. The resident said he/she didn't remember what he/she had for lunch. The resident picked up one of the bags of chips and said he/she guessed he/she had some chips for lunch. Record review of the facility's ten minute monitoring sheet, dated 8/6/13, showed where the resident was every ten minutes. The documentation did not show interventions used to prevent a fall from reoccurring. During an interview on 8/9/13 at 9:31 A.M. and at 9:51 A.M., the DON expected to notify the physician of an injury, a fall, out of the norm vital signs, medication errors, wound decline and change in mental status which cannot wait for a fax. After a fall, the DON expected the staff to document interventions on the care plan. If the fall happened on a weekend, the staff would put interventions into place but not document the interventions. The MDS coordinator was responsible for putting the interventions on the care plan. Some of the interventions would include: increased resident checks by the Certified Nursing Aide (CNA) and, or implement a low bed. The DON expected the staff to call her and verify the interventions. The DON expected the CNAs to look in the care plan of each resident who fell regarding interventions. The CNAs would know to look because of the shift to shift verbal communication. The facility was small and everyone knew if a resident fell but there would not be any other documentation for the aides to know except for the 72 hour neuro check list. The neuro check form did not include intervention and did not include description of how the fall occurred. The DON showed incident forms of the resident's falls. The forms did not include interventions to reduce the risk of reoccurring falls. For Resident #4, a low bed would increase his/her chance of a fall when he/she got out or into bed. The floor mat would also cause a problem for him/her to become more unsteady and could cause him/her to fall. If an aide went into the room, saw the resident wrapped up in his/her own blanket then woke the resident to unwrap him/her, the resident would become angry. The DON expected the aides to complete ten minute checks on the resident. The staff did not try a low bed because it would cause more problems. If the aides find the resident wrapped in his/her own blankets, the DON expected the aides to carefully unwrap the resident to try and not wake the resident.

Based on interview and record review, the facility failed to adequately assess, monitor, report to the physician, and treat one resident's (Resident #1) increase in pain, change in skin color and skin condition, and ongoing low-grade fever in a timely manner in a facility with a census of 58. 1. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 10/3/12, showed the following information: -Short and long term memory problem; -Severely impaired decision-making skills; -Unclear speech (slurred or mumbled words); -Total dependence on staff for bed mobility, transfers, toilet use, and personal hygiene; -Functional limitation in range of motion of upper and lower extremities on both sides; -Always incontinent of bowel and bladder; -Received a scheduled pain medication regimen in the previous five days of the assessment; -Did not receive any as needed pain medication in the previous five days of the assessment. Record review of the care plan, dated 7/16/12, and reviewed on 10/3/12, showed the following information: -History of stroke with [MEDICAL CONDITION] (loss of voluntary movement on one side of the body) and total dependence on staff for all activities of daily living (ADLs). Staff uses a mechanical lift for transfers. Resident does not ambulate; -Incontinent of bladder and bowel. Resident wore adult briefs. Check frequently and change as needed; -Tube feeding only. Nothing by mouth; -Resident will require frequent checks as he/she does not use his/her call light; -Ask questions in a way that require only a yes or no response or head nod; -Observe for nonverbal cues and anticipate his/her needs; -At risk for dehydration due to enteral feeding tube; -Measure intake and output every shift; -Monitor for signs and symptoms of dehydration such as dry mucous membranes, poor urine output, concentrated urine, and poor skin turgor; -Notify physician of any signs or symptoms of dehydration; -Monitor for signs and symptoms of urinary tract infections such as pain or burning, redness or pus-like drainage; urine with cloudy appearance, foul odor, or mucous or blood present; -Resident takes routine Tylenol and also gets [MEDICATION NAME] as needed for pain management. Resident has frequent leg pain. Resident is at risk for undiagnosed pain due to poor communication; -Assess frequently for occurrence of pain; -Notify physician if pain is not controlled; -Monitor for nonverbal signs of pain: grimacing or pained facial expressions, rubbing or guarding a particular area, or physical behaviors such as hitting or kicking when area is touched. Resident may also grunt or groan when he/she is in pain. Record review of the December 2012 physician order [REDACTED]. -It carried over a previous order dated 9/9/12 for Tylenol 500 mg twice a day routinely at 8:00 A.M. and 8:00 P.M. -It carried over a previous order dated 9/9/12 for [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) narcotic pain medication every six hours as needed for pain. Record review of the October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of the November 2012 MAR indicated [REDACTED]. Staff administered the pain medication on 11/1/12, 11/9/12, 11/13/12, and 11/27/12. Record review of the December 2012 MAR indicated [REDACTED]. The pain medication was effective. During interview on 1/10/13, at 12:39 P.M., certified nursing assistant (CNA) A said on 12/22/12, the resident seemed his/her normal self. There did not seem to be anything out of the ordinary with the resident that shift. During interview on 1/10/13, at 1:43 P.M., registered nurse (RN) B said the resident seemed okay on 12/22/12. During interview on 1/10/13, at 2:07 P.M., RN C said on 12/22/12 (evening shift), the resident had emesis (vomiting) that day, which was not unusual for the resident. The resident did that periodically. The resident did not have any signs or symptoms of pain that day. The resident's skin was normal and the resident was laughing and in good spirits. Record review of the vital sign flow sheet, showed on 12/22/12, night shift nurse licensed practical nurse (LPN) D documented the resident had a temperature of 99.5 degrees. Record review of a nurse's note, dated 12/23/12, at 1:30 A.M., showed LPN D documented the resident had emesis two times that shift. The nurse turned off the tube feeding to allow the resident's stomach to settle. At 4:30 A.M., the nurse documented the resident had no further emesis and restarted the tube feeding. During interview on 1/10/13, at 9:59 P.M., LPN D (night shift) said on 12/23/12, the only thing he/she noticed going on with the resident was the emesis. The resident had emesis two times that shift. The nurse stopped the tube feeding for a few hours and then restarted it that morning. The resident did not have a fever. The nurse put the resident on the vital sign list for the next day. Residents on that list have vital signs checked every shift. The resident's skin was normal and the resident did not show any signs or symptoms of pain. During interview on 1/10/13, at 10:20 P.M., CNA E said on Saturday 12/22/12, staff said the resident was not feeling well on their shift. The aide said on night shift, the resident had emesis. The resident was really warm and had a fever. If the resident is uncomfortable, the resident taps his/her heel against the rail. The aide asked the resident if he/she was hurting and he/she said "yes". But, the resident did not want any pain medicine. The resident was not totally cheerful. Usually, he/she could get the resident to laugh. The resident seemed more serious and was not his/her normal "jovial" self. The resident's skin was clammy from head to chest. The resident was sweaty. The resident only voided twice. That was decreased output for him/her. During interview on 1/10/13, at 10:29 P.M., CNA F said on the weekend of 12/22/12 and 12/23/12 (night shift), the resident starting vomiting a little bit. The resident's skin was clammy. The resident did not seem to be in particular pain, just not feeling well. Record review of a nurse's note, dated 12/23/12, at 8:15 A.M., RN B documented the resident had no emesis so far that shift. At 1:05 P.M., RN B documented the resident had been up in the wheelchair that shift and had no further emesis. Record review of the vital sign flow sheet, showed on 12/23/12, the day shift nurse RN B documented the resident had a temperature of 99.5 degrees. At 11:30 A.M., the nurse rechecked the resident's temperature and it was 97.4 degrees axillary. Record review of the December 2012 MAR indicated [REDACTED].M., for complaints of right leg pain. The nurse documented the resident had a face scale score of 6. Record review of the National Institutes of Health regarding the 1-10 numeric pain rating scale showed a score of 1-3 indicated mild pain, a score of 4-6 indicated moderate pain, a score of 7-10 indicated severe pain. Record review of the Wong-Baker FACES Pain Rating Scale, indicated zero indicated no pain, with a highest rating possible of 5, which indicated it hurts as much as you can imagine. During interview on 1/10/13, at 1:43 P.M., RN B said on 12/23/12 (day shift), the resident did not have vomiting that shift. The resident had a 99.5 degree axillary temperature. The nurse re-checked it and it went down. The resident had a routine Tylenol order. The nurse questioned if the resident had a urinary tract infection. In the past, when the resident had a temperature, it was a urinary tract infection. During interview on 1/10/13, at 2:07 P.M., RN C said on 12/23/12 (evening shift), the resident had emesis on day shift and had a slight temperature on his/her shift. The resident's lungs were slightly diminished. The nurse said he/she was watching for aspiration pneumonia because the resident had a history of [REDACTED]. Record review of a nurse's note, dated 12/24/12, at 2:30 A.M., showed LPN D documented the resident as afebrile with no emesis that shift. During interview on 1/10/13, at 10:20 P.M., CNA E said on 12/24/12 (night shift), the resident seemed in a better mood, but seemed uncomfortable. During interview on 1/10/13, at 9:59 P.M., LPN D said nothing was going on with the resident on 12/24/12 night shift. The resident did not have any emesis or signs and symptoms of pain. The resident's behavior and urine output were normal. During interview on 1/10/13, at 10:29 P.M., CNA F said on 12/24/12 night shift, the resident was laughing and in good mood. The resident did not have any pain that night. The resident's skin was warm. The resident's skin was usually warm though. The resident's skin was not clammy and the skin color was okay. The aide said he/she did not think the resident had any fever, just clammy. They had to cool the resident off, so they opened the window in his/her room. Record review of a nurse's note, dated 12/24/12, at 9:58 A.M., showed RN B faxed the physician for the first time regarding changes in the resident's condition (first noted on 12/22/12). In the fax, the nurse documented the resident had a temperature of 99.2 degrees axillary. The nurse documented the resident's "blood sugars" had been up. The resident had a temperature of 99 degrees the day before on day shift. The nurse asked for an order to check a urinalysis (UA, test to check for urinary tract infection) and culture and sensitivity (test to determine what bacteria is causing the infection and what antibiotics are sensitive to the bacteria) if needed. At 11:30 A.M., the physician faxed back orders for a UA, and culture and sensitivity if needed. The physician also ordered a complete blood count (CBC) blood test. At 12:50 P.M., the nurse documented the staff obtained the UA specimen. During interview on 1/10/13, at 12:32 P.M., restorative nursing assistant (RNA) G said on 12/24/12 (day shift) he/she worked the floor. He/she tried to joke with the resident, but he/she was not the same. The resident was hot, sweaty, and clammy. At about noon of that shift, the resident had no output and the aide notified RN B. The nurse faxed the physician and he ordered a UA. The staff used a urinal to collect the urine. The aide said the resident did not have any emesis on that shift. During interview on 1/10/13, at 1:32 P.M., CNA H said he/she took care of the resident on 12/24/12 (day shift). The aide said he/she did not notice anything different with the resident that shift. The resident seemed his/her usual self. The resident did not grimace when they rolled him/her to provide care. The resident's behavior was normal. The resident gets clammy sometimes, so the resident probably was clammy that day. The resident's skin color was okay. Staff did not get the resident up that day, but the aide did not remember the reason. The resident had been incontinent of urine during the shift. The resident did not have any emesis that day. During interview on 1/10/13, at 1:43 P.M., RN B said on 12/24/12, at 9:58 A.M., the nurse faxed the physician regarding the temperature of 99.2 degrees, blood glucose elevation, and requested a urinalysis. The nurse did not remember any facial grimacing. The nurse said he/she did not remember the resident's skin color not being okay. The resident was sweaty, but the nurse thought that was due to the temperature. The resident's behavior seemed normal. The resident would acknowledge him/her as normal. The resident had not voided that shift when he/she faxed the physician at 9:58 A.M. At 11:30 A.M., the physician faxed orders for a UA, culture and sensitivity, and complete blood count (CBC). The nurse told the staff to use a urinal to collect the UA. Staff was able to do that. Record review of a nurse's note, dated 12/24/12, at 3:35 P.M., showed LPN I documented the resident was clammy and had a temperature of 98.9 degrees axillary. The resident was moaning. The nurse administered a [MEDICATION NAME] pain medication. The resident had no emesis. The nurse documented lab came and drew the blood tests and picked up the UA specimen. The resident's blood glucose was 272. During interview on 1/10/13, at 12:55 P.M., LPN I said when he/she came in to work on 12/24/12 (evening shift), he/she got report and the resident had a fever. The facility had completed some lab work on the resident at 3:00 P.M. The lab picked up the UA at 3:00 P.M. At 3:30 P.M., the nurse noticed the resident had facial grimacing and was clammy, hot, and sweaty. The resident is hot-blooded, but this was different for him/her. The nurse could tell the resident did not feel well overall. The nurse thought he/she had emesis on day shift and thought maybe the resident was coming down with the flu. The nurse administered a pain pill to the resident. At approximately 6:00 P.M., the treatment nurse went in and he/she said the resident was laughing for him/her. At approximately 8:00 P.M., the nurse entered the room for medication administration and blood glucose check. Nothing seemed out of the ordinary for the resident. The resident looked fine just seemed a little sleepy, drowsy. The resident did not look extra-clammy. It seemed to be resolving. The nurse said the resident did not have any emesis that shift, but staff did not get the resident up because he/she was not feeling well. The resident's skin color was normal. During interview on 1/10/13, at 1:24 P.M., RN J said he/she worked 11:00 A.M. to 7:00 P.M. on 12/24/12. He/she was covering the shift. The nurse completed treatments that shift. Around 6:00 P.M., the nurse asked the resident where his/her smile was and the resident smiled at the nurse. The resident was laughing at the nurse and did not show any signs of pain. The resident's skin appeared normal, not clammy. The resident's skin color was normal. The resident was not sweaty. During interview on 1/10/13, at 2:30 P.M., CNA K said he/she worked evening shift on 12/24/12. The aide said nothing seemed unusual for the resident. The aide asked the resident if he/she hurt and the resident shook his/her head "no". The aide said he/she asked every time when entered room. The resident seemed to be his/her "normal chipper self". Record review of the December 2012 MAR indicated [REDACTED].M., the nurse administered the as needed [MEDICATION NAME] pain medication due to the resident showing signs and symptoms of pain. The resident was moaning and the nurse documented the resident's face pain score was 6. Record review of the urinalysis (UA), collected date 12/24/12, at 2:50 P.M., showed the following information: -Protein 30 mg (normal would be negative); -No bacteria seen. -Hyaline casts 6-10 (normal would be 0-2); -Staff stamped it with a fax stamp and dated it 12/27/12. Record review of another copy of the lab showed the physician signed and dated it 12/26/12. Record review of Mosby's diagnostic and laboratory test reference, second edition, showed the following information: -Increased levels of hyaline casts may indicate proteinuria (the abnormal presence of protein in the urine), fever, [MEDICAL CONDITIONS], or [MEDICAL CONDITION] (kidney disease); -Increased levels of protein in the urine may indicate nephroti[DIAGNOSES REDACTED] (kidney disease), diabetes, [MEDICAL CONDITION], or [MEDICAL CONDITION]. Record review of the complete blood count (CBC), collected date 12/24/12, at 2:50 P.M., showed the following information: -Elevated white blood cell count of 11.3 (normal would be 4.8-10.8); -Low red blood cell count of 3.42 (normal would be 4.6-6.2); -Low hemoglobin of 9.5 (normal would be 14-18); -Low hematocrit of 32.2 (normal would be 41-53); -Low platelet count of 121 (normal would be 140-440); -Low lymphocytes of 19 (normal would be 24-44); -Elevated monocytes of 14 (normal would be 4-10); -Decreased platelet estimate; -Abnormal red blood cell morphology; -1+ anisocytosis (normal would be none seen); -1+ polychromasia (normal would be none seen). -Staff stamped it with a fax stamp on 12/27/12. Record review of another copy of the lab showed the physician signed and dated it 12/26/12. Record review of Mosby's diagnostic and laboratory reference, second edition, showed the following information: -Increased white blood cell count may indicate infection, trauma, or inflammation; -Decreased lymphocytes may [MEDICAL CONDITION] (blood infection); -Elevated monocytes may indicate chronic [MEDICAL CONDITION] disorders or [MEDICAL CONDITION] infections; -Anisocytosis indicates increased red blood cell size and may indicate liver disorder. Record review of the vital sign sheet, showed on 12/24/12, the night shift nurse RN L documented the resident's temperature was 96.5 degrees. During interview on 1/10/13, at 9:52 P.M., RN L said he/she worked night shift. On 12/24/12, the resident did not act like he/she felt good. The resident's color was off. The nurse passed the information on to the next shift. The resident was not his/her normal self. Usually, the resident smiled and laughed. The resident normally responded with a yes/no. The resident seemed kind of out of it. The resident had a yellow tint overall to his/her skin. The resident did not show any signs or symptoms of pain or emesis. The facility had the stomach flu going around. The nurse said he/she did not fax or call the physician. The nurse did not think he/she gave any pain medicine. The nurse said nothing unusual was reported during report. The nurse thought the resident's output was okay on that shift. The resident just did not act like his/her cheerful self. The resident seemed kind of out of it. The nurse was worried the resident was coming down with something. Record review of the December 2012 MAR indicated [REDACTED].M., LPN M documented he/she administered one [MEDICATION NAME] for complaints of back pain with a pain level of 8 out of 10. Record review of the next entry, dated 12/25/12, at 12:30 P.M., showed LPN M documented the resident's color was noted to be jaundiced (yellow discoloration of the skin, mucous membranes, and sclerae of the eyes, caused by greater than normal amounts of bilirubin in the blood). The resident was absent of void until this time. Once staff got the resident up in the chair, the resident did void. The resident had a temperature of 99.4 degrees. At 1:00 P.M., the nurse faxed the lab results to the physician's office. Record review of the nurses' notes did not show the straight cath procedure that was completed on the resident. The nurse did not document the results, amount, character of the urine, or notification of the physician to obtain an order to complete the straight cath or notification of the physician regarding the results of the straight cath procedure. Record review of the Mosby's Medical, Nursing, and Allied Health Dictionary, 4th edition, showed the following information regarding jaundice. Persons with jaundice may also experience nausea, vomiting, and abdominal pain and may pass dark urine. Jaundice is a symptom of many disorders, including liver diseases, biliary (gallbladder) obstruction, and [DIAGNOSES REDACTED] (a group of blood disorders). During interview on 1/10/13, at 9:47 A.M., LPN M said he/she worked 12/25/12 (day shift) with the resident. The resident was his/her normal self. The resident shook his/her leg that day which was a cue that he/she was hurting somewhere. When questioned the resident regarding different body parts, the resident indicated his/her back hurt. Most of the morning, the resident sat in the room with his/her family member. The resident was sweating, but he/she is always warm. Staff normally kept a fan pointed at the resident. The nurse said nothing was out of the normal for the resident. The nurse said he/she did note that day the resident looked jaundiced and he/she passed that on to the oncoming nurse. The nurse said he/she had noticed it the day before. The nurse thought that was one of the reasons the staff got the UA. Regarding the change of color, the nurse did not fax the physician because the staff just got the labs and UA ordered. The nurse had not seen the results because it was Christmas day. During interview on 1/10/13, at 12:39 P.M., CNA A said he/she worked with the resident on 12/25/12 (day shift). The aide said the first time he/she checked the resident, he/she was not feeling well. The resident was sweaty and kind of clammy. The aide asked the resident if he/she was not feeling well and the resident shook his/her head "no". The aide told the nurse and the nurse said to go ahead and get the resident up. The staff transferred the resident to the chair. The resident was sweaty and kind of feverish. The resident did not smile as normal. Usually, when staff goes in, the resident will grin and perk up. The resident did not do that on that day. The resident's skin seemed "puffy" all over. The resident's right side hand and leg seemed puffier than the other side. The aide thought maybe the resident was coming down with something. The resident did not indicate pain to the aide. The resident did not void during that shift. The aide let the nurse, LPN M, know that the resident was not feeling well. The biggest concern the aide had was the resident's skin was not hot, just kind of clammy. The nurse obtained a straight cath on the resident after they transferred the resident to the chair. The nurse drained the urine into a trash can. The aide said from when he/she saw the resident on Saturday 12/22/12 to Christmas day 12/25/12, he/she could really see a change. Record review of the December 2012 physician order [REDACTED]. Record review of the December 2012 MAR indicated [REDACTED].M., the nurse administered one as needed [MEDICATION NAME] pain medication for complaints of right leg pain. The resident's face pain scale score was 6. Record review of a nurse's note, dated 12/25/12, at 8:00 P.M., showed RN C faxed the physician regarding the resident's increase in pain over the last several days. The resident's blood glucose was elevated at 329 at 4:30 P.M. that day. The resident had a jaundiced skin color and sclera. The resident generally indicated he/she did not feel well. During interview on 1/10/13, at 2:35 P.M., CNA N said he/she worked on 12/25/12 evening shift. When the aide began the shift, the resident was up in the chair. The aide and another aide transferred the resident to bed. The resident did not void on that evening shift. That is unusual for the resident. The resident was in a little pain after the transfer. The resident was not him/her self. The aide could tell by the "look on face". After the aides got the resident to bed, the resident's face changed to normal. Before they transferred the resident, the resident usually joked with the staff. The resident did not joke that day. The aides noticed the pain and asked the resident if he/she was hurting. The resident said "yes". The charge nurse RN C was in the room also. The nurse also asked the resident about the pain. The nurse looked at the resident's eyes and said they were jaundiced. The resident's skin might have been a little clammy after the aides laid him/her down in bed. The resident went back to his/her normal self. Record review of the vital sign flow sheet, showed on 12/25/12, the evening shift nurse, RN C documented the resident's temperature was 99.4 degrees axillary. The nurse also documented a second temperature of 97.7 degrees axillary. During interview on 1/10/13, at 2:07 P.M., RN C said on 12/25/12 (evening shift), the resident had a jaundice color. Day shift reported the resident was not urinating well. The resident had a wet brief in the middle of evening shift, but it was not as wet as normal. The resident had a slight temperature. The resident complained of increased pain and the nurse had to give the resident [MEDICATION NAME], which was unusual for the resident. When the nurse gave it, he/she saw the resident had been taking it more often. The resident's blood glucose was elevated in the 300's, which was unusual for the resident. The resident's blood glucose usually ran from 160-180 on the evening shift. The nurse sent a fax to the physician so he would have it on 12/26/12 morning. The nurse said he/she was hoping he would be in the office. The nurse said the fax contained information regarding the resident having the jaundiced color, emesis for several days, increased pain, although the location of the pain could not be determined and that the resident generally did not look good. The fax also included the blood glucose elevation. The resident did not smile and his/her color was off. The resident usually jokes, but was not doing that. The resident was not his/her normal self. The pain medication seemed to help the pain. The resident did not seem to get better or worse throughout the shift. The resident's output was decreased that shift. The nurse said he/she was hoping the physician would come in that shift. The resident was not critical and so he/she felt the fax was sufficient. The nurse was hoping to hear something by the next day. The nurse did not have any further contact or call to the physician. Record review of the December 2012 MAR indicated [REDACTED].M., LPN D administered one as needed [MEDICATION NAME] pain medication for complaints of leg pain. The nurse documented the resident's face pain scale score was 8 out of 10. Record review of a nurse's note, dated 12/26/12, at 1:30 A.M., showed LPN D documented the resident complained of pain earlier in the shift and he/she administered the as needed [MEDICATION NAME] at 10:45 P.M. (on 12/25/12). The resident did not have any emesis. The resident had a temperature of 99.5 degrees. At 2:00 A.M., the nurse documented the resident continued with low-grade temperature of 99 degrees. At 4:00 A.M., the nurse documented a late entry, showing the resident had not voided all of second shift (evening shift) or night shift at that time in the shift. The nurse straight cathed the resident and received 350 cc of dark yellow urine with a foul smell. The nurse and aide completed a head to toe assessment to attempt to see where the fluid was going. The resident did not have any [MEDICAL CONDITION] in either lower extremity or upper extremity. The resident grimaced in pain when the nurse moved the resident's right leg to check for swelling. The nurse documented he/she knew a fax was out to the physician regarding this pain; the nurse reported it to the oncoming nurse. The nurse did not document administration of any additional pain medication for the resident's pain and grimacing. The nurse did not notify the physician regarding the need or results of the straight cath that was completed. The resident did not have any physician's orders [REDACTED]. During interview on 1/10/13, at 9:59 P.M., LPN D said on 12/26/12, the resident complained of pain at 1:30 A.M. The aides told the nurse the resident had pain in his/her legs, especially in the right leg. The nurse administered pain medication and notified the physician. The facility had done some labs the day before. They had contacted the physician on 12/25/12 morning. Once in awhile, the resident would have pain. The resident complained of pain twice during the shift. The resident had a low-grade temperature. At 4:00 A.M., the nurse entered the room to attend to the resident's tube feeding. The aides reported the resident had not voided that shift and that was unusual for the resident. The nurse completed a full body assessment looking for [MEDICAL CONDITION]. The resident did not have any swelling. The nurse listened to the resident's lungs, which were diminished. After the 4:00 A.M. assessment, the nurse wrote out everything to the physician and faxed it to the physician. The nurse reported it to the nurse coming on next shift. The oncoming nurse was going to call and talk to the physician. The nurse said he/she documented the 12/26/12 4:00 A.M. late entry that night when he/she came back in to work on 12/26/12. The resident's skin was okay. The resident just had the pain and they knew the pain was in the resident's leg. The resident's behavior was okay except when they moved the resident. The resident showed pain on movement. When staff turned the resident, the resident would grimace. The nurse thought the resident had a low-grade temperature that shift. The nurse said the resident had ran a low-grade temperature since 12/23/12 when the emesis occurred. That is when they noticed something going on and began monitoring the resident. The nurse said the only contact he/she had with the physician that shift was the fax sent out around 4:00 A.M. During interview on 1/10/13, at 10:20 P.M., CNA E took care of the resident on the night shift 12/25/12 going into 12/26/12. The charge nurse said the resident's right leg was swollen from knee to hip and to be "extra-extra careful" with the resident. The resident was in a better mood, but did seem in pain. The aide thought the pain did not seem as bad as on the weekend. The resident did not void until 4:30 A.M. to 5:00 A.M., when the resident had a large amount of urine. The resident's skin felt normal, not clammy. Record review of a nurse's note, dated 12/26/12, at 7:30 A.M., showed RN B faxed the physician regarding the resident's right knee was [MEDICAL CONDITION] and noted [MEDICAL CONDITION] to his/her upper thigh. When the nurse asked the resident if his/her knee hurt, the resident shook his/her head "yes". The nurse described how the resident's legs were positioned differently than normal. If moved leg, the resident shook his/her head that it hurt. The nurse documented he/she would give routine Tylenol for the resident's temperature of 100 degrees axillary. The nurse did not administer any as needed [MEDICATION NAME] pain medication for the resident's pain. The nurse did not document any additional assessment or follow-up of the resident's pain. During interview on 1/10/13, at 12:39 P.M., CNA A said he/she took care of the resident on 12/26/12 (day shift). The resident was still not feeling well so the staff just let him/her be. The resident did not void that shift and they did not transfer the resident that shift. The resident's skin appeared the same, sweaty and clammy. The resident was not his/her normal self. During interview on 1/10/13, at 1:15 P.M., CNA O said he/she took care of the resident on 12/26/12 (day shift). When the aide checked the resident, his/her skin was cold and clammy to the aide. The aide had several other staff also check the resident's skin and they agreed about the condition of the resident's skin. The aide told the nurse RN B. The resident's vital signs were normal and the resident did not have a fever that shift. The only other thing that appeared abnormal was the resident did not void at all that shift. The resident did not seem to be in pain, but acted different. The resident kept shaking his/her head "no" regarding pain, but did not feel good. The resident was not as cheerful as usual. That is why the staff asked the resident about pain and if he/she felt okay. During interview on 1/10/13, at 1:43 P.M., RN B said on 12/26/12 (day shift), the resident had a temperature. The resident's knee and upper thigh was [MEDICAL CONDITION]. The resident's right leg did not have any redness. The nurse asked the resident if his/her knee hurt and the resident shook his/her head "yes". Normally, the resident crossed one leg over the other, but this time, the right leg was bent, but not crossed over the other leg. The nurse said he/she administered the resident routine medications, which included Tylenol. The nurse did not remember the resident having clammy skin. The nurse did not remember any other details about the resident's skin. At 7:30 A.M., the nurse faxed the physician about the leg being [MEDICAL CONDITION]. The resident said it hurt and the nurse described the positioning of the resident's leg to the physician in the fax. If the nurse moved th