Every finding on record at Heritage Wellness & Rehabilitation

Based on interview and record review, the facility failed to prevent psychosocial abuse for two sampled residents (Residents #2 and #3) out of 12 sampled residents. On 4/15/16 Resident #1 was rubbing his/her hands on Resident #2's arm, shoulder and knee. On 5/5/26 Resident #1 touched Resident 2 on the breast and inner thigh. On 5/11/26 Resident #1 kissed Resident #3, resulting in Resident #3 crying. The facility census was 63 residents.Review of the facility's Abuse Prevention policy, dated 7/1/25, showed:-Abuse is willful infliction of injury, confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress and may be resident to resident, staff to resident, family to resident, or visitor to resident.-Sexual abuse is any touching of a resident directly or through clothing for sexual purpose or in a sexual manner, including but not limited to kissing, touching of genitals, buttocks, or breasts, or causing a resident to touch someone for sexual purposes.-Mental abuse was the use of verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, fear, shame, agitation, or degradation. 1. Review of Resident #1's admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses:-Major depressive disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).-Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety).-Mild cognitive impairment (a stage of memory and thinking decline that is more pronounced than normal aging but not severe enough to disrupt daily life). Review of Resident #1's Pre-admission Screening and Resident Review, Level I (PASRR - Level I, a preliminary identification process used to determine if an individual has or is suspected of having a qualifying mental illness or intellectual/developmental disability (ID/DD). If the screening is negative the process is complete. If positive it flags for a Level II, an in-depth evaluation by the state's mental health or ID/DD authority to determine if nursing care and/or specialized services are needed.), dated 7/29/20, showed the resident had no diagnosis or signs or symptoms of a serious mental disorder, ID/DD, and had not required intensive psychiatric treatment within the past two years. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 4/15/26, showed the resident was severely cognitively impaired (a significant deterioration in mental capacity, such as short or long-term memory loss and impaired reasoning that prevents an individual from living independently). Review of Resident #2's admission Record showed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). Review of Resident #2's annual MDS, dated [DATE], showed he/she was severely cognitively impaired.Review of Resident #1's nursing Behavior note, dated 4/15/26 at 6:12 P.M. showed:-At supper time Resident #1 was rubbing his/her hands on a resident (Resident #2 according to interviews) from the A unit. -The resident was asked to stop and staff removed Resident #2 from the situation.-Resident #1 then started cussing at staff and Resident #6 stepped up to intervene. -Then Resident #1 started cussing at Resident #6 and flipped him/her off. During an interview on 5/13/26 at 10:20 A.M., Licensed Practical Nurse (LPN) A said:-Certified Nursing Assistant (CNA) A reported to him/her that Resident #1 was touching Resident #2 on the arm, shoulder and knee in the dining room on 4/15/26. -When CNA A told Resident #1 to leave Resident #2 alone the resident started cussing at CNA A. Resident #6 got in the middle of it and told Resident #1 to leave CNA A alone. -Resident #1 then started cussing at Resident #6 and flipped him/her off. -He/She thought the incident happened around supper time at Resident #1's table.-He/She wrote a behavioral note on 4/15/26 and slid a note under the Assistant Director of Nursing (ADON) and Director of Nursing (DON)'s office door. -He/She was told by management there had been a past incident between Resident #1 and #2 and that Resident #1 wasn't supposed to be around Resident #2. -In a monthly meeting they talked about reportable incidents, but he/she couldn't recall if it was before or after the 4/15/26 incident. Review of Resident #6's quarterly MDS dated [DATE] showed he/she was cognitively intact. During an interview on 5/13/26 at 1:21 P.M., Resident #6 said:-About a month ago Resident #2 came over to the table where he/she and Resident #1 were sitting. -He/She saw Resident #1 touch Resident #2's breast(s). -Staff told Resident #1 to stop, but he/she couldn't say who the staff was.-Resident #1 yelled to the staff he/she wasn't bothering Resident #2 and had some loud, aggressive words to say to the staff.-He/She told Resident #1 to get away from Resident #2 and Resident #1 yelled he/she wasn't doing anything and told Resident #6 to shut up. -Staff told Resident #2 to get to his/her own table. During an interview on 5/13/26 at 1:35 P.M., Resident #2 said about a month ago Resident #1 touched him/her on the shoulder and might have touched him/her on the knee, but he/she wasn't sure. During an interview on 5/13/26 at 2:21 P.M. CNA A said:-He/She was told several months ago by the charge nurse that Resident #1 had touched Resident #2 or did something inappropriate. -Resident #2 wouldn't have been able to remember it by the next day.-When he/she walked into the dining room on 4/15/26 to bring a resident to a table he/she saw Residents #1 and #2 were close together near the back of the dining room and Resident #1 was holding Resident #2's hand on top of Resident #2's crotch. -He/She felt that Resident #1 knew he/she had his/her hand on Resident #2's crotch and was aware that no staff was in the dining room. -When Resident #1 was asked to let go of Resident #2's hand, he/she did, but then started cussing him/her out and grabbed the armrest of Resident #2's wheelchair. -Resident #6 was at the table and told Resident #1 he/she would fight him/her if Resident #1 kept trying to swing at him/her and didn't leave him/her alone. -Resident #1 flipped Resident #6 off, giving him/her the finger and called Resident #6 the b word.-He/She got between Residents #1 and #6 and told Resident #6 to just relax because he/she had the situation under control. Resident #1 left the area. During an interview on 5/14/26 at 11:42 A.M. Certified Medication Technician (CMT) A said:-A month ago, in the dining room before lunch was served Resident #1 had his/her hand on the inside of Resident #2's lower thigh. -He/She told the resident to keep his/her hands to himself/herself. During an interview on 5/14/26 at 5:00 P.M. the Administrator said:-Resident #6 reported that Resident #1 touched Resident #2's shoulder and inside of the resident's left knee on 4/15/26. -He/She didn't think the touching was of a sexual nature because Resident #1 had a history of grabbing and touching people to get their attention. -He/She also touched people when talking to them. -He/She knew the 5/5/26 was inappropriate touch but thought it was an impulsive behavior and didn't see it as abuse because they both actively seek each other out.-Resident #1 had no further behaviors after the 72 hours of 15-minute checks and he/she didn't see any reason to continue increased monitoring. Review of the facility's internal investigation, dated 5/5/26 showed:-On 5/5/26 at approximately 11:50 A.M., Resident #5 reported to the Activities Director that Resident #1 touched Resident #2 on the breast and inner thigh.-Findings: It was determined Residents #1 and #2 were actively seek one another. -Facility staff instructed to monitor and redirect as needed. Review of Resident #5's quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of Resident #5's undated statement showed he/she saw Resident #1 touch Resident #2 down below and on Resident #2's breast. During an interview on 5/14/26 at 1:15 P.M. Resident #5 said:-About a month ago he/she saw Residents #1 and #2 in the dining room. Resident #1 was feeling Resident #2 all over near the dining room doors and weren't at a table. -He/She saw Resident #1's hand all over both Resident #2's breasts, rubbing them and putting his/her hand on Resident #2's crotch and moving his/her hand around.-Resident #2 was kind of crying so he/she thought he/she was upset and Resident #2 also looked scared. Resident #2 was saying it hurts, it hurts.-He/She told the Activities Director and Social Services Director that the resident said it hurts thinking the resident meant it hurt when he/she was touched by Resident #1.-He/She was scared Resident #1 would do something like try to touch him/her or another resident. Review of the Activity Director's statement, dated 5/5/26, showed:-He/She was in the Activities office on 5/5/26 when Resident #5 came in and said Resident #1 was touching Resident #2 between his/her legs and breast in the cafeteria.-He/She went to the dining room and found Resident #1's hand was on the inside of Resident #2's leg.-He/She told Resident #1 to stop, and Resident #1 put his/her hand on Resident #2's knee.-He/She again told Resident #1 to stop, and Resident #1 said to mind his/her own business. During an interview on 5/12/26 at 12:55 P.M., the Activities Director said:-Resident #5 reported to him/her that someone was in the dining room touching someone else. The resident didn't mention names or body parts at the time.-He/She left his/her office and went immediately to the dining room. -When he/she got there Residents #1 and #2 were in the back of the dining room. -Resident #1 had his/her hand on the inside of Resident #2's thigh close to his/her knee. Resident #2 was wearing pants. During an interview on 5/12/26 at 3:16 P.M., the DON said:-When he/she first came to the facility he/she was told Resident #1 and #2 were to be kept separated as much as possible due to an incident of inappropriate sexual behavior in September of 2025 where Resident #1 touched Resident #2.-He/She thought the 4/27/26 incident was with Resident #2. -He/She read that on 5/9/26 Resident #1 tried to touch another resident, but he she didn't know who that resident was (Note: interview revealed it was Resident #3) and spat at and kicked a staff member. -On 5/5/26 Residents #1 and #2 both managed to wander down to the dining room a little before lunch was served where it was reported Resident #1 touched Resident #2 inappropriately. During an interview on 5/13/26 at 4:41 P.M. Resident #2's responsible party said:-He/She first became concerned about Resident #1 in Sept of 2025. -The facility had called and told him/her an incident happened. -They said Resident #1 either grabbed or attempted to grab Resident #2's breasts. -He/She was told Resident #1 tried to grab Resident #2 between his/her legs.-He/She filed a police report.-The facility had also called him/her about what happened 5/5/26. -For some reason Resident #1 would always come to Resident #2's table. -He/She could see on Resident #2's room monitor that Resident #1 went into Resident #2's room on 5/11/26. -He/She had started taking Resident #2 out of the facility after lunch and brought him/her back to the facility in the evening after supper and put him/her to bed to make sure Resident #2 was safe. -Resident #2 was a social bug and liked to roam, but because of Resident #1 staff often had Resident #2 behind the nurses' desk. -It felt like Resident #2 was being punished while Resident #1 roamed the hallways and did what he/she wanted. Review of Resident #7's annual MDS dated [DATE] showed he/she was cognitively intact. During an interview on 5/14/26 at 1:54 P.M. Resident #7 said:-A couple of weeks ago Resident #2 was looking out the dining room window and Resident #1's wheelchair was next to his/hers.-Resident #1 was touching Resident #2 at the crotch and at Resident #2's chest.-The residents in the dining room told Resident #1 to stop. During an interview on 5/12/26 at 2:14 P.M. the ADON said on 5/5/26 the Activity Director came to his/her office and said a resident notified him/her that Resident #1 touched Resident #2 on his/her upper arm and knee. No staff were in the dining room at the time. During an interview on 5/13/26 at 2:21 P.M. CNA A said:-When he/she walked into the dining room on 4/15/26 to bring a resident to a table he/she saw Residents #1 and #2 were close together near the back of the dining room and Resident #1 was holding Resident #2's hand on top of Resident #2's crotch. -He/She felt that Resident #1 knew he/she had his/her hand on Resident #2's crotch and knew no staff was in the dining room. -When Resident #1 was asked to let go of Resident #2's hand, he/she did, but then started cussing CNA A out and grabbed the armrest of Resident #2's wheelchair when he/she started to move Resident #2's wheelchair. During an interview on 5/14/26 at 11:42 A.M. CMT A said:-A month ago, in the dining room before lunch was served Resident #1 had his/her hand on the inside of Resident #2's lower thigh. -Resident #2 liked to look out the window and can wheel himself/herself there and that is where the incident happened. 2. Review of Resident #3's admission Record showed the resident was admitted to the facility on [DATE] with diagnoses that include dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Review of Resident #3's annual MDS, dated [DATE], showed he/she:-Was sometimes understood simple, direct communication.-Was severely cognitively impaired.-Had no behaviors and did not wander.-Had upper body extremity impairments on both sides. Review of Resident #1's nursing progress note dated 5/9/26 at 12:31 P.M., showed Resident #1 tried to touch another resident. During an interview on 5/14/26 at 11:42 A.M. CMT A said:-He/She had seen Resident #1 try to go towards Residents #2 and #3 in the past. -Over the past weekend or two he/she saw Resident #1's hand on Resident #3's upper chest when they were in the dining room and told the resident he/she couldn't do that. The resident said, make me. It was the same incident where he/she got kicked. Resident #1 was at Resident #3's table. -He/She told Resident #1 he/she needed to move away from Resident #3's table. Again he said, make me and wasn't moving.-He/She told Resident #1 he/she needed to push him/her away from Resident #3. Review of the facility's internal investigation dated 5/11/26 showed:-On 5/11/26 at 1:40 P.M., Resident #1 approached Resident #3 in the hallway and kissed Resident #3. -After reviewing witness statements and residents' medical records it has been determined that Resident #1 should not be allowed to return to the facility for the safety of others. Review of CNA A's statement, dated 5/11/26, showed he/she observed Resident #1 kissing Resident #3 on the mouth. During an interview on 5/13/26 at 2:21 P.M. CNA A said:-He/she saw Resident #1 press his/her lips to Resident #3's. -He/She heard a smack and saw their lips together. Then he/she saw Resident #1 open his/her mouth and his/her tongue was a little out as if Resident #1 was going to put it in Resident #3's mouth. -He/She said something to the effect of what you are doing. -Resident #1 said Resident #3 asked him/her for a kiss. Review of the Maintenance Director's statement, dated 5/11/26, showed:-He/She was coming down the 50 hall to the corner of 80 hall across from the nurses station and saw Resident #3 sitting in his/her wheelchair crying near the linen closet door. -Resident #1 was beside Resident #3 in his/her wheelchair.-He/She asked the two CNAs what was going on and they said Resident #1 was trying to kiss Resident #3.-Resident #1 was calling Resident #3 a crybaby and telling Resident #3 to shut up. During an interview on 5/12/26 at 1:32 P.M., the Maintenance Director said:-He/She was coming down the 50 hall and heard Resident #1 using profanity at Resident #3. -Resident #1 told Resident #3 to shut the [expletive] up and kept calling him/her a crybaby. -Resident #3 was near the linen closet across from the nurses' station. -He/She could see immediately Resident #3 was crying. -Resident #1 was three feet or so away and was backing up away from Resident #3 when he/she came around the corner. -The CNAs said Resident #1 had kissed Resident #3. They didn't say where on the body Resident #3 was kissed. They never said if Resident #1 touched Resident #3 inappropriately in any other way. During an interview on 5/14/26 at 11:42 A.M. CMT A said:-Over the past weekend or two he/she saw Resident #1's hand on Resident #3's upper chest when they were in the dining room and told the resident he/she couldn't do that. The resident said, make me. -He/She told Resident #1 he/she needed to move away from Resident #3's table. Again he said, make me and wasn't moving.-He/She told Resident #1 he/she needed to push him/her away from Resident #3. During an interview on 5/14/26 at 12:16 P.M. CNA B said:-On 5/11/26 Resident was facing the nurses' station.-He/She and CNA A were walking toward the nurses' station, and he/she noticed Resident #1 was holding Resident #3's hands and then kissed Resident #3 on the lips.-Resident #3 started crying right after that happened and looked upset.-He/She told Resident #1 to let go of Resident #3's hands which he/she wouldn't do, and he/she had to physically separate Resident #1's hands from Resident #3. During an interview on 5/14/26 at 12:30 P.M. Resident #3's legal representative said:-The facility called him/her on 5/11/26 and said a resident kissed Resident #3 and the resident was pretty upset about it, but they didn't go into any details.-Resident #3 was an emotional person and the experience likely startled him/her at the time. -Once the resident becomes upset it can take a half hour for him/her to calm down although Resident #3 wouldn't be able to remember why he/she was upset. 3. During an interview on 5/14/26 at 5:00 P.M. the Administrator said:-Resident #1 inappropriately touched Resident #2 on 5/5/26.-With the 5/5/26 incident Resident #1's behaviors became more aggressive and hypersexual.-He/She thought the kissing incident on 5/11/26 was inappropriate.-The resident was given an immediate discharge because he/she had become so restless and impulsive, and it was determined he/she was no longer safe to be around other residents.

Based on interview and record review, the facility failed to self-report two instances of possible abuse of two sampled residents (Residents #2 and #3) out of 12 sampled residents. On 4/15/16 Resident #1 was rubbing his/her hands on Resident #2's arm, shoulder and knee. On 5/9/26 Resident #1 touched Resident #3's on the breast/upper chest area. The facility census was 63 residents.Review of the facility's Abuse Prevention policy, dated 7/1/25, showed:-Abuse is willful infliction of injury, confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress and may be resident to resident, staff to resident, family to resident, or visitor to resident.-Sexual abuse is any touching of a resident directly or through clothing for sexual purpose or in a sexual manner, including but not limited to kissing, touching of genitals, buttocks, or breasts, or causing a resident to touch someone for sexual purposes.-Mental abuse was the use of verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, fear, shame, agitation, or degradation.-The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. 1. Review of Resident #1's admission Record showed the resident was admitted to the facility 9/5/25 with the following diagnoses:-Major depressive disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).-Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety).-Mild cognitive impairment (a stage of memory and thinking decline that is more pronounced than normal aging but not severe enough to disrupt daily life). Review of Resident #1's Pre-admission Screening and Resident Review, Level I (PASRR - Level I, a preliminary identification process used to determine if an individual has or is suspected of having a qualifying mental illness or intellectual/developmental disability (ID/DD). If the screening is negative the process is complete. If positive it flags for a Level II, an in-depth evaluation by the state's mental health or ID/DD authority to determine if nursing care and/or specialized services are needed.), dated 7/29/20, showed the resident had no diagnosis or signs or symptoms of a serious mental disorder, ID/DD, and had not required intensive psychiatric treatment within the past two years. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 4/15/26, showed the resident:-Was severely cognitively impaired (a significant deterioration in mental capacity, such as short or long-term memory loss and impaired reasoning that prevents an individual from living independently).-Had continuous inattention and disorganized thinking.-Had no verbal or physical behaviors that affected others during the review period.-Wandered daily. Review of Resident #2's admission Record showed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). Review of Resident #2's annual MDS, dated [DATE] showed he/she:-Was admitted to the facility on [DATE].-Sometimes understood simple, direct communication.-Was severely cognitively impaired.-Had no behaviors and did not wander-Was diagnosed with Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). Review of Resident #1's nursing Behavior note, dated 4/15/26 at 6:12 P.M. showed:-At supper time Resident #1 was rubbing his/her hands on another resident (Resident #2 according to staff and resident interviews) from the unit. -The resident was asked to stop and staff removed Resident #2 from the situation.-Resident #1 then started cussing at staff and a third resident (Resident #6 according to staff and resident interviews) stepped up to intervene. -Then Resident #1 started cussing at Resident #6 and flipped him/her off.-Staff intervened, Resident #1 then turned around and went to his/her table to eat. During an interview on 5/12/26 at 3:16 P.M., the Director of Nursing (DON) said:-When he/she first came to the facility he/she was told Resident #1 and #2 were to be kept separated as much as possible due to an incident of inappropriate sexual behavior in September of 2025 where Resident #1inappropiately touched Resident #2.-He/She thought the 4/15/26 incident might have involved Resident #2, but he/she wasn't at the facility that day and wasn't sure. -He/She read that on 5/9/26 Resident #1 tried to touch another resident and spat at and kicked a staff member. -Staff have all been educated by the Administrator when to report incidents and the type of incidents to report, which include reporting any possible abuse or neglect.-The facility policy shows that all incidents with the potential for abuse should be reported.-Staff have all been educated so they can report directly to the Administrator. During an interview on 5/13/26 at 10:20 A.M., Licensed Practical Nurse (LPN) A said:-Certified Nursing Assistant (CNA) A reported to him/her that Resident #1 was touching Resident #2 on the arm, shoulder and knee in the dining room on 4/15/26. -When CNA A told Resident #1 to leave Resident #2 alone the resident started cussing at CNA A. -Resident #6 got in the middle of it and told Resident #1 to leave CNA A alone. -Resident #1 then started cussing at Resident #6 and flipped him/her off. -He/She thought the incident happened around supper time at Resident #1's table.-He/She wrote a behavioral note on 4/15/26 and slid a note under the ADON and DON's office door. -He/She did not immediately report the incident to anyone in management and hadn't asked CNA A, Resident #1, or Resident #6 for their statements to start an investigation because he/she had never been told there had been any inappropriate behaviors from Resident #1 in the past and thought it was just a behavior and didn't realize he/she needed to do an incident report at the time. -In a monthly meeting they talked about reportable incidents, but he/she couldn't recall if it was before or after the 4/15/26 incident. -About a week after the 4/15/26 incident he/she received education from the Administrator, DON, and ADON to report any incident whatsoever that was out of the ordinary and also was educated on Resident #1's behavioral history. They discussed the types of incidents that needed to be reported, such as anything that could rise to the level of abuse as well as any significant behaviors. The 4/15/26 incident should have been reported immediately to the Administrator and DON. Review of Resident #6's quarterly MDS dated [DATE] showed he/she:-Was admitted to the facility 7/9/24.-Clearly understood others.-Was cognitively intact.-Had no behaviors.-Was diagnosed with a stroke. During an interview on 5/13/26 at 1:21 P.M., Resident #6 said:-About a month ago Resident #2 came over to the table where he/she and Resident #1 were sitting. -He/She saw Resident #1 touch Resident #2's breast(s). -Staff was in the dining room when it happened and told Resident #1 to stop, but he/she couldn't say who the staff was. -Resident #1 yelled to the staff he/she wasn't bothering Resident #2 and had some loud, aggressive words to say to the staff.-He/She also told Resident #1 to get away from Resident #2 and Resident #1 yelled he/she wasn't doing anything and told him/her (Resident #6) to shut up. -Staff told Resident #2 to get to his/her own table. During an interview on 5/13/26 at 2:21 P.M. CNA A said:-He/She was told several months ago by the charge nurse that Resident #1 had touched Resident #2 or did something inappropriate. -Resident #2 wouldn't have been able to remember it by the next day.-When he/she walked into the dining room on 4/15/26 to bring a resident to a table he/she saw Residents #1 and #2 were close together near the back of the dining room and Resident #1 was holding Resident #2's hand on top of Resident #2's crotch. He/She didn't see Resident #1 touch Resident #2's breast(s).-When he/she asked Resident #1 to let go of Resident #2's hand, the resident did, but then Resident #1 started cussing CNA A out and grabbed the armrest of Resident #2's wheelchair and swung out at him/her. During an interview on 5/14/26 at 11:42 A.M. Certified Medication Technician (CMT) A said:-A month ago in the dining room before lunch was served Resident #1 had his/her hand on the inside of Resident #2's lower thigh. -He/She told the resident to keep his/her hands to himself/herself. -He/She reported it to the charge nurse and the other CNA who were working at the time, but he/she was not asked to write a statement and didn't know if any administrative staff had been informed. -He/She received education that all incidents that could be considered abuse or are out of the ordinary were to be reported to the charge nurse. During an interview on 5/14/26 at 5:00 P.M. the Administrator said:-Resident #6 reported that Resident #1 touched Resident #2's shoulder and inside of the resident's left knee on 4/15/26. -He/She didn't report the incident to the state authority because he/she didn't think the touching was of a sexual nature. Resident #1 had a history of grabbing and touching people to get their attention and he/she thought that was what the resident was doing. -Staff have all been educated to report all incidents that are out of the ordinary immediately to their supervisor and any suspicion of possible abuse must be reported immediately to their supervisor, Administrator and DON. 2. Review of Resident #3's annual MDS, dated [DATE] showed he/she-Was admitted to the facility on [DATE].-Sometimes understood simple, direct communication.-Was severely cognitively impaired.-Had no behaviors and did not wander.-Had upper body extremity impairments on both sides.-Was diagnosed with dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Review of a nursing progress note dated 5/9/26 at 12:31 P.M., showed:-Resident #1 tried to touch another resident (Resident #3, according to staff interviews). -When staff intervened Resident #1 spat at him/her and kicked the staff.-Resident #1 was redirected to his/her room. No injury to Resident #3. During an interview on 5/14/26 at 11:12 A.M., LPN B said:-After lunch on 5/9/26 Certified Medication Technician (CMT) A reported to him/her that Resident #1 was touching another resident but didn't say what part of the body was touched or mention who was touched. -He/She instructed CMT A to report it to the Administrator and CMT A said he/she would write a statement. During an interview on 5/14/26 at 11:42 A.M., CMT A said:-He/She had seen Resident #1 try to go towards Residents #2 and #3 in the past. -Over the past weekend or two he/she saw Resident #1's hand on Resident #3's upper chest when they were in the dining room and told the resident he/she couldn't do that. The resident said make me. It was the same incident where he/she got kicked. Resident #1 was at Resident #3's table. -He/She told Resident #1 he/she needed to move away from Resident #3's table. Again he said make me and wasn't moving.-He/She reported the incident to the charge nurse. -Staff have been educated to report all incidents that could be abuse or major behaviors to their supervisors. During an interview on 5/14/26 at 2:43 P.M., the Regional Nurse Consultant (RNC) said the Administrator was responsible for reporting all incidents of potential abuse to the State agency. Any incidents of crimes should also be reported to the police. During an interview on 5/14/26 at 5:00 P.M., the Administrator said:-He/She did not know about the 5/9/26 incident until 5/11/26 when he/she reviewed the resident's chart. Staff were educated at the time about reporting. -He/She reported the 5/11/26 incident because he/she knew that was inappropriate but didn't know that the touching on 5/9/26 was inappropriate.-He/She was responsible for reporting all incidents he/she thought were potentially abusive.

Based on interview and record review, the facility failed to investigate two instances of possible abuse for two residents (Residents #2 and #3) out of 12 sampled residents. On 4/15/16 Resident #1 was rubbing his/her hands on Resident #2 arm, shoulder and knee. On 5/9/26 Resident #1 touched Resident #3's on the breast/upper chest area. The facility census was 63 residents.Review of the facility's Abuse Prevention policy, dated 7/1/25, showed:-Abuse is willful infliction of injury, confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress and may be resident to resident, staff to resident, family to resident, or visitor to resident.-Sexual abuse is any touching of a resident directly or through clothing for sexual purpose or in a sexual manner, including but not limited to kissing, touching of genitals, buttocks, or breasts, or causing a resident to touch someone for sexual purposes.-Mental abuse was the use of verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, fear, shame, agitation, or degradation.-The facility will initiate at the time of any findings of potential abuse or neglect an investigation to determine cause and effect and provide protection to any alleged victims to prevent harm during the continuance of the investigation.-Suspected or substantiated cases of resident abuse, neglect, misappropriation, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative, and as required by state guidelines. 1. Review of Resident #1's admission Record showed the resident was admitted to the facility 9/5/25 with the following diagnoses:-Major depressive disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).-Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety).-Mild cognitive impairment (a stage of memory and thinking decline that is more pronounced than normal aging but not severe enough to disrupt daily life). Review of Resident #1's Pre-admission Screening and Resident Review, Level I (PASRR - Level I, a preliminary identification process used to determine if an individual has or is suspected of having a qualifying mental illness or intellectual/developmental disability (ID/DD). If the screening is negative the process is complete. If positive it flags for a Level II, an in-depth evaluation by the state's mental health or ID/DD authority to determine if nursing care and/or specialized services are needed.), dated 7/29/20, showed the resident had no diagnosis or signs or symptoms of a serious mental disorder, ID/DD, and had not required intensive psychiatric treatment within the past two years Review of Resident #2's annual Minimum Data Set (MDS-xx , dated 4/15/26 showed he/she:-Was admitted to the facility on [DATE].-Sometimes understood simple, direct communication.-Was severely cognitively impaired.-Had no behaviors and did not wander-Was diagnosed with Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). Review of Resident #1's nursing Behavior note, dated 4/15/26 at 6:12 P.M. showed:-At supper time Resident #1 was rubbing his/her hands on another resident (Resident #2 according to staff and resident interviews) from the unit. -The resident was asked to stop and staff removed Resident #2 from the situation.-Resident #1 then started cussing at staff and a third resident (Resident #6 according to staff and resident interviews) stepped up to intervene. -Then Resident #1 started cussing at Resident #6 and flipped him/her off.-Staff intervened, Resident #1 then turned around and went to his/her table to eat. During an interview on 5/12/26 at 3:16 P.M., the Director of Nursing (DON) said:-When he/she first came to the facility he/she was told Resident #1 and #2 were to be kept separated as much as possible due to an incident of inappropriate sexual behavior in September of 2025 where Resident #1 touched Resident #2.-He/She thought the 4/15/26 incident might have involved Resident #2, but he/she wasn't at the facility that day and wasn't sure. -He/She wasn't sure if the Administrator investigated it or put any new interventions in place or if Resident #1 was placed on any increased monitoring. -There was staff training by the Administrator related to reporting incidents and to watch Residents #1 and #2 closely. -He/She read that on 5/9/26 Resident #1 tried to touch another resident and spat at and kicked a staff member, but he/she didn't know details about the incident. -The Administrator was responsible for investigating incidents of potential abuse. During an interview on 5/13/26 at 10:20 A.M., Licensed Practical Nurse (LPN) A said:-Certified Nursing Assistant (CNA) A reported to him/her that Resident #1 was touching Resident #2 on the arm, shoulder and knee in the dining room on 4/15/26. -When CNA A told Resident #1 to leave Resident #2 alone the resident started cussing at CNA A. -Resident #6 got in the middle of it and told Resident #1 to leave CNA A alone. -Resident #1 then started cussing at Resident #6 and flipped him/her off. -He/She thought the incident happened around supper time at Resident #1's table.-He/She wrote a behavioral note on 4/15/26 and slid a note under the Assistant Director of Nursing (ADON) and DON's office door. -He/She was educated after 4/15/26 that any behavioral or other incidents should be recorded by the charge nurse on an incident report and witness statements should be obtained.-Resident #1 was put on 15-min checks after the 4/15/26 incident. Review of Resident #6's quarterly MDS dated [DATE] showed he/she:-Was admitted to the facility 7/9/24.-Clearly understood others.-Was cognitively intact.-Had no behaviors.-Was diagnosed with a stroke. During an interview on 5/13/26 at 1:21 P.M., Resident #6 said:-About a month ago Resident #2 came over to the table he/she and Resident #1 were sitting. -He/She saw Resident #1 touch Resident #2's breast(s). -Staff told Resident #1 to stop, but he/she couldn't say who the staff was.-Resident #1 yelled to the staff he/she wasn't bothering Resident #2 and had some loud, aggressive words to say to the staff.-He/She also told Resident #1 to get away from Resident #2 and Resident #1 yelled he/she wasn't doing anything and told him/her (Resident #6) to shut up. -Staff told Resident #2 to get to his/her own table. During an interview on 5/13/26 at 1:35 P.M., Resident #2 said:-About a month ago Resident #1 touched him/her on the shoulder and might have touched him/her on the knee, but he/she wasn't sure. -He/She couldn't remember Resident #1 touching him/her inappropriately and thought of Resident #1 as a friend and never remembered feeling uncomfortable around him/her. During an interview on 5/13/26 at 2:21 P.M. CNA A said:-He/She was told several months ago by the charge nurse that Resident #1 had touched Resident #2 or did something inappropriate. -Resident #2 wouldn't have been able to remember it by the next day.-When he/she walked into the dining room on 4/15/26 to bring a resident to a table he/she saw Residents #1 and #2 were close together near the back of the dining room and Resident #1 was holding Resident #2's hand on top of Resident #2's crotch. -He/She felt that Resident #1 knew he/she had his/her hand on Resident #2's crotch and knew no staff was in the dining room. -When Resident #1 was asked to let go of Resident #2's hand, he/she did, but then started cussing CNA A out and grabbed the armrest of Resident #2's wheelchair. -Resident #1 was calling him/her the b word and saying the f word. Resident #1 was yelling and showing his/her fist and punching as if trying to hit CNA A, but he/she backed up out of Resident #1's way. -Resident #1 told CNA A to mind his/her own business and said Resident #2 didn't have to leave or do what CNA A said. -Resident #6 was at the table and told Resident #1 he/she would fight him/her if Resident #1 kept trying to swing at CNA A and didn't leave him/her alone. -Resident #1 flipped Resident #6 off, giving him/her the finger and called Resident #6 the b word. -He/She got between Residents #1 and #6 and told Resident #6 to just relax because he/she had the situation under control. Resident #1 left the area. -Resident #2 liked to look out the windows at the back of the dining room which was close to where Resident #1 sat for his/her meals. During an interview on 5/14/26 at 5:00 P.M. the Administrator said:-Resident #6 reported that Resident #1 touched Resident #2's shoulder and inside of the resident's left knee on 4/15/26. -He/She was responsible for investigating all incidents of possible abuse.-He/She didn't think the touching was of a sexual nature because Resident #1 had a history of grabbing and touching people to get their attention and when talking to them so he/she didn't investigate the incident as possible abuse. 2. Review of Resident #3's admission Record showed the resident was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Review of the resident's annual MDS, dated [DATE] showed he/she-Was admitted to the facility on [DATE].-Sometimes understood simple, direct communication.-Was severely cognitively impaired.-Had no behaviors and did not wander.-Had upper body extremity impairments on both sides.-Was diagnosed with dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Review of a nursing progress note dated 5/9/26 at 12:31 P.M., showed:-Resident #1 tried to touch another resident (Resident #3, according to staff interviews). -When staff intervened Resident #1 spat at him/her and kicked the staff. During an interview on 5/14/26 at 11:12 A.M., LPN B said:-After lunch on 5/9/26 Certified Medication Technician (CMT) A reported to him/her that Resident #1 was touching another resident but didn't say what part of the body was touched or mention who was touched. -He/She instructed CMT A to report it to the Administrator and CMT A said he/she would write a statement. -CMT A said he/she tried to intervene by separating Resident #1 from the other resident. -He/She could tell by CMT A's affect and tone of voice he/she was upset, probably because Resident #1 kicked CMT A in the leg, cussed at him/her, and called him/her names. CMT A said the resident also spat at him/her. -Immediately after separating the two residents Resident #1 went to the A unit and then came back to the B unit after about a half hour. -In April, 2026 he/she overheard other staff saying Resident #1 inappropriately touched another resident from the A unit. During an interview on 5/14/26 at 11:42 A.M., CMT A said:-He/She had seen Resident #1 try to go towards Residents #2 and #3 in the past. -Over the past weekend or two he/she saw Resident #1's hand on Resident #3's upper chest when they were in the dining room and told the resident he/she couldn't do that. The resident said make me. It was the same incident where he/she got kicked. Resident #1 was at Resident #3's table. -He/She told Resident #1 he/she needed to move away from Resident #3's table. Again he said make me and wasn't moving.-He/She told Resident #1 he/she needed to push him/her away from Resident #3. During an interview on 5/14/26 at 2:43 P.M., the Regional Nurse Consultant (RNC) said the Administrator was responsible for investigating any potential incidents of abuse. During an interview on 5/14/26 at 5:00 P.M., the Administrator said:-He/She did not know about the 5/9/26 incident until 5/11/26 when he/she reviewed the resident's chart. -He/She was responsible for reporting any potential instances of abuse. -The resident typically touched other residents to get their attention and often touched them when speaking to them. -He/She was not informed that anyone had been touched by Resident #1 in an inappropriate manner on 5/9/26 so he/she did not investigate the incident.

Based on record review and interview, the facility failed to provide a final accounting of resident fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate for four of four sampled expired residents (Resident #2, #3, #4 and #5). The facility continued to receive Social Security money and withdraw room and board for two residents (Resident #3 and #5) after they expired. The facility failed to provide a final accounting of resident fund balances or refund Social Security money. The facility census was 50.1. Review of the facility maintained discharged and expired report titled Action Summary for the period [DATE] through [DATE], showed Resident #3 expired on [DATE].Review of Resident #3's Ledger for the period [DATE] through [DATE], showed $133.40 held in the Resident Trust Account on [DATE] was not reported to the Department of Social Services Third Party Liability Unit (TPL) as of [DATE], 143 days after he/she expired. Review showed the facility continued to receive and hold Social Security money and withdraw room and board after he/she expired. The facility received and withdrew the following amounts:Date Amount Description[DATE] +$960.00 Social Security-(Deposit)[DATE] -$910.00 July Surplus (Room and Board)-(Withdrawal)[DATE] +$0.01 Interest-(Deposit)[DATE] +$960.00 Social Security-(Deposit)[DATE] -$910.00 July Surplus-(Withdrawal)[DATE] -$910.00 Room and Board-(Withdrawal)[DATE] +$0.05 Interest-(Deposit)Review of Resident #3's Resident Trust Ledger showed room and board previously withdrawn in the amount of $910.00 for the following months:-07/2025 withdrawn on [DATE];-08/2025 withdrawn on [DATE]; and-09/2025 withdrawn on [DATE].The Social Security deposit on Resident #3's resident trust ledger dated [DATE], in the amount of $960.00 was not returned to Social Security as of [DATE], 141 days after the deposit date.The Social Security deposit on Resident #3's resident trust ledger dated [DATE], in the amount of $960.00 was not returned to Social Security as of [DATE], 111 days after the deposit date.2. Review of the facility maintained discharged and expired report titled Action Summary for the period [DATE] through [DATE], showed Resident #5 expired on [DATE].Review of Resident #5's Ledger for the period [DATE] through [DATE], showed $2,731.79 held in the Resident Trust Account on [DATE], was not reported to the Department of Social Services Third Party Liability Unit as of [DATE], 91 days after he/she expired. Review showed the facility continued to receive and hold Social Security money and withdraw room and board after he/she expired. The facility received and withdrew the following amounts:Date Amount Description[DATE] -$1,479.00 July Surplus -(Withdrawal)[DATE] +$0.20 Interest-(Deposit)[DATE] +$0.14 Interest-(Deposit)[DATE] +$1,529.00 Social Security-(Deposit)[DATE] +$0.15 Interest-(Deposit)Review of Resident #5's Resident Trust Ledger showed the incorrect surplus amounts withdrawn for the following months:Date Amount Description[DATE] $1,190.00 July Surplus[DATE] $1,190.00 July Surplus (08/2025)[DATE] $1,479.00 July Surplus (09/2025)[DATE] $1,479.00 July Surplus (10/2025) Review of e-mail correspondence dated [DATE] at 12:10 P.M., showed the Department of Social Services Family Support Division Constituent Services Program Coordinator, said Resident #5's monthly vendor surplus was listed as:Month Correct Surplus07/2025 $1,152.0008/2025 $1,151.0009/2025 $1,151.0010/2025 $1,151.00Review showed Resident #5 should have had an additional $2,212.49, from incorrect surplus and duplicated room and board withdrawals, held in the resident trust account that was not reported to the Department of Social Services Third Party Liability Unit as of [DATE], 91 days after he/she expired.The Social Security deposit labeled as Room and Board on Resident #5's resident trust ledger, dated [DATE], in the amount of $1,529.00 was not refunded or returned to Social Security as of [DATE], 50 days after the deposit date. 3. Review of the facility maintained discharged and expired report titled Action Summary for the period [DATE] through [DATE], showed Resident #2 expired on [DATE].Review of Resident #2's Ledger for the period [DATE] through [DATE], showed Resident #2's funds held in the resident trust account, in the amount of $55.14 were not reported to the Department of Social Services Third Party Liability Unit as of [DATE], 146 days after he/she expired.4. Review of the facility maintained discharged and expired report titled Action Summary for the period [DATE] through [DATE], showed Resident #4 expired on [DATE].Review of Resident #4's Ledger for the period [DATE] through [DATE], showed Resident #4's funds held in the resident trust account, in the amount of $50.21 were not reported to the Department of Social Services Third Party Liability Unit as of [DATE], 106 days after he/she expired.5. Email correspondence dated [DATE] at 2:00 P.M., showed the Regional Business Office Manager said the following:-A TPL was submitted for Residents #2, #3, #4 and #5, (but did not provide a submitted date nor a copy to DHSS);-Did not provide a response as to why additional room and board was withdrawn after Residents #3 and #5 expired; and-The facility was waiting for Social Security to request or recoup the funds for Resident #5.

Based on interview and record review, the facility failed to protect three sampled residents (Resident #1, #6, and #9) from misappropriation of property out of nine sampled residents. The facility census was 48 residents.A facility policy for Theft and Misappropriation of Resident Property was requested and not provided. A facility policy for Controlled Substances was requested and not provided. A facility policy for Discarding and Destroying Medication was requested and not provided. A facility policy for Medication Administration and Documentation was requested and not provided. 1.Review of Resident #1's admission Record showed the resident admitted to the facility on [DATE] and was re admitted to the facility on [DATE] with a diagnosis of chronic pain. Review of the resident's Brief Interview for Mental Status (BIMS) dated 7/15/25 showed the resident was moderately impaired. Review of the resident's care plan revised 7/16/25, showed:-The resident was on pain medication related to chronic pain.--Staff was to administer analgesic medications as ordered by physician.--Staff was to monitor and document side effects and effectiveness every shift. Review of the resident's Physicians Order Sheet (POS) dated 7/1/25-12/19/25 showed:-Percocet (Oxycodone w/Acetaminophen- Opioid, narcotic analgesic) Oral Tablet 5-325 milligram (mg). Give 1 tablet by mouth every 6 hours as needed for pain was started on 7/31/25 and discontinued on 8/19/25.-Percocet Oral Tablet 5-325 mg. Give 2 tablet by mouth every 6 hours as needed for pain was started on 7/31/25 and discontinued on 8/19/25.- Percocet Oral Tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for pain was started on 8/19/25 and discontinued on 9/24/25.-Percocet Oral Tablet 5-325 mg. Give 2 tablet by mouth every 4 hours as needed for pain was started on 8/19/25 and discontinued on 9/24/25.-Hydrocodone-Acetaminophen Tablet 5-325 mg (Norco - Opioid, analgesic narcotic). Give 1 tablet by mouth three times a day for pain was started on 9/24/25. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 8/26/25 showed one 30 count pack of Percocet Oral Tablet 5-325 mg was delivered to the facility. Review of the resident's Controlled Substance Accountability Sheet 1 of 1 dated 8/26/25 showed Licensed Practical Nurse (LPN) A removed 22 Percocet 5-325 mg tablets for the resident from 9/1/25 to 9/5/25.Note: On 9/2/25 at 11:15 A.M., LPN A signed out 4 Percocet 5-325 mg tablets and documented on the accountability form that 2 of the 4 tablets dropped on the floor. There is no documentation the tablets were wasted by a second staff member. Review of the resident's MAR dated 9/1/25-9/30/25 showed he/she was administered 4 tablets Percocet 5-325 mg tablets 9/1/25 to 9/5/25.Note: From 9/1/25 to 9/5/25 there were 18 unaccounted for oxycodone/acetaminophen 5-325 mg tablets signed out of the accountability sheet by LPN A that were not documented as being given to the resident on the resident's MAR. Review of the POS dated 7/1/25-12/19/25 showed:- Percocet Oral Tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for pain was discontinued on 9/24/25. -Percocet Oral Tablet 5-325 mg. Give 2 tablet by mouth every 4 hours as needed for pain was discontinued on 9/24/25. -Norco Tablet 5-325 mg. Give 1 tablet by mouth three times a day for pain was started on 9/24/25. Review of the pharmacy's Controlled Substance Dispense log printed on 12/19/25 at 9:00 A.M., showed LPN A removed 25 Norco 5-325 mg tablets between 10/27/25 - 11/30/25. Review of the resident's Controlled Substance Accountability Sheet dated 10/27/25 showed LPN A documented the removal of 13 Norco between 10/27/25-11/23/25. Note: The facility only provided the accountability sheet up to 11/26/25. 12 Norco 5-325 mg tablets were unaccounted for. Review of the resident's MAR dated 11/1/25-11/30/25 showed he/she was administered 11 tablets of Norco 5-325 mg between 10/27/25 to 11/30/25.-NOTE: 14 Norco 5-325 mg tablets were unaccounted for. Review of the pharmacy's Controlled Substance Dispense log printed on 12/19/25 at 9:00 A.M., showed LPN A removed 15 Norco 5-325 mg tablets between 12/2/25 - 12/14/25. Review of the resident's MAR dated 12/1/25-12/31/25 showed:-He/She was administered 7 tablets of Norco 5-325 mg between 12/2/25 to 12/7/25.-Note: The provided the resident's MAR documentation up to 12/7/25 with no documentation of Norco administration after that date. -NOTE: 14 Norco 5-325 mg tablets were unaccounted for. During an interview on 12/19/25 at 10:00 A.M., Pharmacist and Operational Manager said:-2 packs of 30 (60 total) Percocet pills were delivered to the facility on 7/31/25.-1 pack of 30 Percocet pills were delivered to the facility on 8/26/25.-1 pack of 30 Percocet pills were delivered to the facility on 9/5/25.-1 pack of 30 Percocet pills were delivered to the facility on 9/11/25.-1 pack of 30 Percocet pills were delivered to the facility on 9/19/25.-1 pack of 30 Percocet pills were delivered to the facility on 9/23/25.-3 packs of 30 (90 total) Norco 5-325 mg pills were delivered to the facility on 9/26/25.-Each 30 pack would have had its own accountability sheet.-If an accountability sheet can't be accounted for, then neither can the narcotic pills that the sheet was holding accountable. -If the only accountability sheet that the facility could provide for Percocet that was delivered on 7/31/25 was 2 of 2, that meant sheet 1 of 2 (30 pills) were unaccounted for. -If the facility could not provide the accountability sheet for the Percocet (30 pills) delivered on 9/5/25, the pills were unaccounted for.-If the facility could not provide the accountability sheet for the Percocet 30 pills) delivered on 9/11/25, the pills were unaccounted for.-If the only accountability sheet that the facility could provide for Norco that was delivered on 9/26/25 was 2 of 3, that meant sheet 1 of 3 (30 pills) and sheet 3 of 3 (30 pills) were unaccounted for, for a total of 60 pills. -The resident's narcotic medication began to get dispensed from the medication dispensary (pyxis) on 10/27/25, due to the physician changing the medication order from as needed to schedule and no further narcotic packs were delivered to the facility. During an interview on 12/19/25 at 2:44 P.M. LPN B said on 8/10/25, a urine sample was taken for the resident and tested for opioids at the lab and the resident's urine test came back negative for opioids, despite LPN A consistently signing the opioids out on the resident's narcotic accountability log. 2. Review of Resident #6's admission Record showed the resident admitted to the facility on [DATE] and was re admitted to the facility on [DATE], with a diagnosis of pain in the right knee. Review of the resident's BIMS dated 12/17/25 showed the resident was cognitively intact. Review of the resident's POS dated 7/1/25-10/31/25 showed:-Percocet Oral Tablet 5-325 mg. Give one tablet by mouth every 6 hours as needed for pain was started on 8/19/25 and discontinued on 9/12/25.-Percocet Oral Tablet 5-325 mg. Give one tablet by mouth at bedtime started on 9/12/25 and discontinued on 10/15/25. Review of the residents MAR dated 10/1/25 -10/31/25 showed from 10/1/25-10/11/25 there was 1 unaccounted for Percocet 5-325 mg tablets. Review of the pharmacy's Controlled Substance Dispense log on 12/19/25 at 9:00 A.M., showed LPN A removed 2 Percocet on 11/30/25. Review of the resident's MAR dated 11/1/25-11/31/25 showed, 1 Percocet was administered by LPN A.NOTE: 1 Percocet tablet was unaccounted for. Review of the pharmacy's Controlled Substance Dispense log on 12/19/25 at 9:00 A.M., showed LPN A removed 10 Percocet between 12/2/25- 12/14/25. Review of the resident's MAR dated 12/1/25-12/31/25 showed he/she was administered 5 tablets of hydrocodone 12/2/25 to 12/14/25.NOTE: 5 Percocet tablet was unaccounted for. During an interview on 12/19/25 at 11:54 A.M. the resident said:-He/She only received pain medication at night.-He/She never asked for pain medication during the day when the medication was ordered as needed. -He/She did not receive the signed-out pain medication that was on the accountability logs unless they were given at night.-He/She did not receive pain medication from LPN A on 8/29/25 at 7:25 A.M, 9/1/25 at 6:40 A.M., or 9/5/25 at 7:20 A.M. because he/she was never awake that early.-The physician recently changed his/her medication order to get it scheduled.-He/She heard it was changed because some of his/her pain medication was missing. 3. Review of Resident #9's admission Record showed the resident admitted to the facility on [DATE] and was re admitted to the facility on [DATE], with a diagnosis of chronic pain. Review of the resident's BIMS dated 12/10/25 showed the resident was cognitively intact. Review of the resident's POS dated 7/1/25-12/19/25 showed:-Oxycodone tablet 5 mg. Give one tablet by mouth every 6 hours as needed for pain was started on 7/18/25 and discontinued on 9/10/25.-Oxycodone tablet 5 mg. Give one tablet by mouth every 4 hours as needed for pain was started on 9/10/25 and discontinued on 10/1/25.-Norco Tablet 5-325 mg. Give 1 tablet by mouth two times a day for pain was started on 10/1/25. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 7/12/25 showed one 28 count pack of Oxycodone was delivered to the facility. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 9/10/25 showed one 30 count pack of Oxycodone was delivered to the facility. Review of the resident's Controlled Substance Accountability Sheet 1 of 1 dated 9/10/25 showed: -LPN A removed 30 oxycodone tablets. -LPN A was the only staff member who signed out on the accountability log. Review of the resident's MAR dated 9/1/25-9/31/25 showed:-He/She was administered 5 tablets of oxycodone 9/18/25 to 9/30/25.-Note: From 9/18/25-9/30/25 there were 24 unaccounted for oxycodone signed out of the accountability sheet by LPN A that were not documented as being given to the resident on the resident's MAR.-Note: LPN A was the only nurse who signed out any of the oxycodone on this narcotic accountability log. Review of the pharmacy's Controlled Substance Dispense log printed on 12/19/25 at 9:00 A.M., showed LPN A removed 2 Norco on 10/27/25 from the automatic dispenser. Review of the resident's Controlled Substance Accountability Sheet dated 10/1/25 showed LPN A removed 1 Norco tablet from the medication cart supply on 10/27/25. Review of the resident's MAR dated 10/1/25-10/31/25 showed 1 Norco was documented as administered to the resident. -NOTE: 2 Norco tablets were unaccounted for. Review of the resident's Controlled Substance Accountability Sheet dated 10/20/25 showed the accountability sheet provided by the facility only went to 11/15/25. Review of the pharmacy's Controlled Substance Dispense log printed on 12/19/25 at 9:00 A.M., showed LPN A removed 14 Norco tablets between 11/9/25 - 11/30/25. Review of the resident's MAR dated 11/1/25-11/30/25 showed: he/she was administered 8 hydrocodone tablets 11/8/25 to 11/30/25. -Note: 6 Norco were unaccounted for. Review of the pharmacy's Controlled Substance Dispense log printed on 12/19/25 at 9:00 A.M., showed LPN A removed 10 Norco tablets between 12/2/25 - 12/14/25. Review of the resident's MAR dated 12/1/25-12/31/25 showed he/she was administered 5 hydrocodone tablets 12/2/25 -12/7/25. -Note: 5 Norco were unaccounted for. During an interview on 12/19/25 at 12:15 P.M. the resident said:-He/She did not ask for pain medication much when it was ordered as needed.-He/She was unsure why the physician changed the order to get pain medication twice a day. -He/She did not receive all of the oxycodone that was signed out for him/her on the narcotic countability logs. 4. During an interview on 12/19/25 at 10:20 A.M., Registered Nurse (RN) A said:-He/She was the Director of Nursing (DON) in training. -The as needed pain medications was administered from the medication cart, from a bubble pack.-The scheduled pain medication was administered from the pixus style dispense machine in the medication room. -When a nurse or Certified Medication Technician (CMT) gave a resident a pain medication, the order should have been looked up in the resident's MAR to ensure accuracy and documented in the resident's MAR that the medication was administered. -If a nurse or CMT gave a resident a pain medication that was a narcotic, in addition to signing the resident's MAR, the nurse or CMT should have signed the narcotic out on the resident's narcotic accountability sheet. -The Assistant Director of Nursing (ADON) was LPN A.-LPN A was the one who was responsible for monitoring the facility's narcotic logs. -When a label on a narcotic accountability sheet stated, 1 of 2, this meant that 2, 30 count packs of that narcotic and 2 narcotic accountability sheets were delivered from the pharmacy to the facility. During an interview on 12/19/25 at 12:28 P.M., the Physician said:-He/She changed the resident's as needed oxycodone orders to scheduled hydrocodone orders because he/she knew that oxycodone was not being administered to the resident's as they were being signed out.-He/She suspected narcotic diversion at the facility.-Changing the pain medication orders to scheduled forced more accountability with the pain medication as scheduled pain medication was dispensed from the machine and not from the medication cart. -He/She was upset because the narcotics unaccounted for at the facility fell under his/her medical license.-All pain medication should be documented by staff per the professional standards and guidelines. -If a resident's medication was not documented on the residents MAR, then it could not be proven that a medication was given to the resident. During an interview on 12/19/25 2:13 P.M., CMT A said:-The CMT's administered the scheduled pain medication to the residents.-The nurses administered the as needed pain medications to the residents.-All administered pain medication was supposed to be documented as given in the resident's MAR and on the resident's narcotic accountability sheets.-If a resident's medication was not documented on the residents MAR, then the medication was not given to the resident. -There was missing narcotics in the facility.-The missing narcotics were reported to the previous Administrator and the regional nurse consultant.-He/She was one of the staff members who reported the missing narcotic to the Administrator and regional nurse back in September. -He/She was unsure of the exact date that he/she reported the missing narcotics to the Administrator and the regional nurse. -Other staff members have also reported missing narcotic to the Administrator and the regional nurse, which included, LPN B and CMT B. During an interview on 12/19/25 at 2:44 P.M., LPN B said:-He/She noticed that LPN A was the only staff member to consistently give as needed pain medication to the residents. -LPN A signed out narcotics on accountability sheets but was not documenting that he/she administered them to the residents.-He/She knew that to be true because he/she would ask the residents if they received their pain medication right after LPN A signed them out and the residents would say no and he/she reported to prior ownership. -He/She reported missing narcotics in March to the previous administration under the previous owners. -He/She reported that there were narcotics missing in September again to the current regional nurse who was the interim Administrator at the time for the new company. -He/She reported the missing narcotics to the regional nurse who was acting as the Administrator at that time. -LPN A was not signing the residents MARs after he/she signed narcotics out on the accountability logs.-LPN A was suspended in September 2025 under the previous ownership for drug diversion. - September is when the missing narcotics were reported again due to them continuing to be unaccounted for.-The reporting in September was to the regional nurse who was the interim Administrator at the time of reporting. -LPN A was allowed to come back with the rule that he/she could no longer work the medication carts or have access to the narcotics.-When the new company bought the old company out, the new company was not made aware of the agreement and the drug diversion investigation involving LPN A, and gave LPN A the narcotic keys back. -LPN A was pulled from the floor from the previous company and since the new company has allowed him/her back on the floor, narcotics started disappearing again. -He/She witnessed entire cards of narcotics disappear after LPN A worked. During an interview on 12/19/25 at 3:23 P.M., CMT B said:-He/She has worked at the facility for 3 years.-He/She believed that drug diversion has been occurring at the facility.-Drug diversion occurred with the previous owners that involved LPN A and has been occurring again since LPN A started working back on the floor. -He/She asked Resident #1 why the resident started asking for an increased amount of pain medication a few months back and Resident #1 informed him/her that LPN A instructed the resident to do so. -He/She reported the missing narcotics to the previous administration under the previous ownership in March. -He/She asked Resident #6 and Resident #9 on several occasions if they received pain medication after LPN A signed the medications out on the narcotic accountability log, and both residents have denied receiving the medication that was signed out by LPN A on numerous occasions. -He/She worked on a weekend with LPN A when he/she witnessed an entire pill card full of oxycodone disappear. -At the time of the missing narcotics being gone, him/her and LPN A were the only staff members with access to the medication cart. -The missing medication card and accountability sheet belonged to Resident #1 and was delivered on 7/31/25.-He/She reported the missing medication to the previous interim Administrator. During an interview on 12/19/25 at 3:44 P.M. LPN A said: -He/She was the Assistant Director of Nurses (ADON). -When someone is giving a narcotic, it should be charted in the MAR and charted on the narcotic accountability log. -He/She would have expected nurses and CMT's to chart narcotic administration in the MAR under all circumstances.-When narcotic accountability logs are completed, staff placed the logs in his/her box to file.-He/She was unsure why there were missing narcotic logs and unaccounted for narcotics.-He/She was unsure who was responsible for auditing narcotic logs and narcotic administration. -There has been issues in the past with possible narcotic diversion at the facility and he/she was investigated for diversion. -He/She knew there were narcotics reported missing from the facility in July and August.-There was another narcotic diversion in the facility when the previous owners owned the facility back in March 2025.-All staff members in the facility back in March had to give a urine sample.-He/She did divert narcotics from Resident #6 to Resident #1 on 9/10/25. -He/She was written up for the diversion.-He/She had his/her family member sign as the second nurse on the accountability log when the diversion occurred.-His/Her family member was not on the clock or working at the facility when he/she had him/her sign on the accountability log.-He/She has made some mistakes when it came to narcotic accountability.-He/She understood that when a medication was not documented as being administered, it could not be proven that it was administered to the resident.-He/She understood that professional standards of practice required nurses to document in a resident's medical record and MAR when a nurse administered a narcotic or any other medication to the resident. -He/She refused to answer when asked why he/she was documenting the administration of non-narcotic medications but did not document the administration of the narcotics. During an interview on 12/19/25 at 4:40 P.M., Administrator and Regional Nurse Consultant said:-They would expect narcotic to be documented in the resident's MAR any time a narcotic is signed out on the resident's narcotic accountability log.-They would have expected a residents narcotic accountability log and a resident's MAR to reflect the same administration patterns. - The pharmacy was responsible for the pixus narcotic auditing.-The ADON was responsible for the narcotic accountability logs and as needed narcotics in the medication cart. -LPN A was under investigation in 9/2025 for drug diversion and it was reported to the state agency at that time.-LPN A was also under investigation from the previous company for drug diversion.-The previous company failed to divulge the diversion investigation results to the new owners and LPN A was placed back on the floor and given access to narcotics. -Only assigned nursers and CMT's should be administering medications to the resident's-There were occasions where LPN A accessed the narcotics and signed narcotics out on the accountability logs when he/she was not the assigned nurse for the residents.-LPN A got upset with the Administrator when he/she pulled LPN A from the floor as a nurse and instructed LPN A to only perform ADON duties.-LPN A was written up in 09/25 for diverting narcotics from Resident #6 to Resident #1. -The Pharmacy reported that they suspected a pattern of diversion due to LPN A being the nurse that always called to get the residents narcotics refilled and delivered to the facility. Complaint # 2679032

Based on interview and record review, the facility failed to accurately account for narcotic medication reconciliation for three sampled residents (Resident #1. #6 and #9) out of nine sampled residents. The facility census was 48 residents.A facility policy for Medication Administration and Documentation was requested and not provided. 1.Review of Resident #1's admission Record showed the resident admitted to the facility on [DATE] and was re admitted to the facility on [DATE], with a diagnosis of chronic pain. Review of the resident's Brief Interview for Mental Status (BIMS) dated 7/15/25 showed the resident was moderately impaired. Review of the resident's Physicians Order Sheet (POS) dated 7/1/25-12/19/25 showed:-Percocet (Oxycodone w/Acetaminophen- Opioid, narcotic analgesic) Oral Tablet 5-325 Milligram (MG). Give 1 tablet by mouth every 6 hours as needed for pain was started on 7/31/25 and discontinued on 8/19/25.-Percocet Oral Tablet 5-325 mg (Oxycodone w/ Acetaminophen). Give 2 tablet by mouth every 6 hours as needed for pain was started on 7/31/25 and discontinued on 8/19/25.- Percocet Oral Tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for pain was started on 8/19/25 and discontinued on 9/24/25.-Percocet Oral Tablet 5-325 mg. Give 2 tablet by mouth every 4 hours as needed for pain was started on 8/19/25 and discontinued on 9/24/25.-Hydrocodone-Acetaminophen Tablet 5-325 MG (Norco - Opioid, analgesic narcotic). Give 1 tablet by mouth three times a day for pain was started on 9/24/25. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 7/31/25 showed two 30 count packs of Percocet Oral Tablet 5-325 mg were delivered to the facility for a total of 60 tablets.Note: Accountability sheet 1 of 2 for 30 Percocet Oral Tablets 5-325 mg was unaccounted for and could not be provided by the facility. Review of the resident's Controlled Substance Accountability Sheet 2 of 2 dated 7/31/25 showed 26 Percocet 5-325 mg tablets were removed for the resident from 8/8/25 to 8/25/25.Note: There was no documentation 8/26/25 to 8/29/25. Review of the resident's Medication Administration Record (MAR) dated 8/1/25-8/31/25 showed he/she was administered 6 tablets of Percocet 5-325 mg tablets between 8/8/25 to 8/25/25.NOTE: 20 tablets of Percocet 5-325 mg tablets were unaccounted for. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 8/26/25 showed one 30 count pack of Percocet Oral Tablet 5-325 mg was delivered to the facility. Review of the resident's Controlled Substance Accountability Sheet 1 of 1 dated 8/26/25 showed 22 Percocet 5-325 mg tablets were removed for the resident from 9/1/25 to 9/5/25.Note: On 9/2/25 at 11:15 A.M., Licensed Practical Nurse (LPN) A signed out 4 oxycodone/acetaminophen 5-325 mg tablets and documented on the accountability form that 2 of the 4 tablets dropped on the floor. There is no documentation the tablets were wasted by a second staff member. Review of the resident's MAR dated 9/1/25-9/30/25 showed he/she was administered 4 tablets of Percocet 5-325 mg tablets 9/1,25 to 9/5/25.Note: From 9/1/25 to 9/5/25 there were 18 unaccounted for Percocet 5-325 mg tablets. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 9/5/25 showed one 30 count pack of Percocet Oral Tablet 5-325 mg was delivered to the facility.-Note: The accountability sheet for 30 Percocet Oral Tablets 5-325 mg was unaccounted for and could not be provided by the facility. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 9/11/25 showed one 30 count pack of Percocet Oral Tablet 5-325 mg was delivered to the facility.-Note: The accountability sheet for 30 Percocet Oral Tablets 5-325 mg was unaccounted for and could not be provided by the facility. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 9/19/25 showed one 30 count pack of Percocet Oral Tablet 5-325 mg was delivered to the facility. Review of the resident's Controlled Substance Accountability Sheet 1 of 1 dated 9/19/25 showed 19 Percocet 5-325 mg tablets were removed for the resident from 9/21/25 to 9/23/25. Review of the resident's MAR dated 9/1/25-9/30/25 showed he/she was administered 10 tablets of oxycodone/acetaminophen 5-325 mg tablets 9/21/25 to 9/23/25.-Note: From 9/21/25-9/23/25 there were 10 unaccounted for Percocet 5-325 mg tablets. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 9/26/25 showed:-Three 30 count packs (90 total) of Norco Tablet 5-325 mg were delivered to the facility.-Note: Accountability sheet 1 of 3 and 3 of 3 for 30 Norco Tablet 5-325 mg was unaccounted for and could not be provided by the facility. 60 total hydrocodone delivered were unaccounted for. Review of the pharmacy's Controlled Substance Dispense log printed on 12/19/25 at 9:00 A.M., showed 25 Norco 5-325 mg tablets were removed from the medication dispensing machine. Review of the resident's Controlled Substance Accountability Sheet dated 10/27/25 showed nine Norco 5-325 mg tablets removed from the medication dispense machine were not logged as available on the accounting sheet.Note: The facility only provided the accountability sheet up to 11/26/25. Review of the resident's MAR dated 11/1/25-11/30/25 showed:-He/she was administered 7 tablets of hydrocodone 10/27/25 to 11/30/25.-14 Norco 5-325 mg tablets were unaccounted for. Review of the pharmacy's Controlled Substance Dispense log printed on 12/19/25 at 9:00 A.M., showed 15 Norco 5-325 mg tablets were removed from the medication dispensing machine. Review of the resident's MAR dated 12/1/25-12/31/25 showed:-He/she was administered 7 tablets of hydrocodone 12/2/25 to 12/7/25.-Note: Was provided MAR documentation up to 12/7/25.-Eight Norco 5-325 mg tablets were unaccounted for. During an interview on 12/19/25 at 10:00 A.M., Pharmacist and Operational Manager said:-2 packs of 30 (60 total) Percocet pills were delivered to the facility on 7/31/25.-1 pack of 30 Percocet pills were delivered to the facility on 8/26/25., 9/5/25, 9/11/25, 9/19/25, and 9/23/25.-3 packs of 30 (90 total) Norco Tablet 5-325 mg pills were delivered to the facility on 9/26/25.-Each 30 pack would have had its own accountability sheet.-If an accountability sheet can't be accounted for, then neither can the narcotic pills that the sheet was holding accountable.-The resident's narcotic medication began to get dispensed from the medication dispensary on 10/27/25, due to the physician changing the medication order from as needed to schedule and no further narcotic packs were delivered to the facility. 2. Review of Resident #6's admission Record showed the resident admitted to the facility on [DATE] and was re admitted to the facility on [DATE], with a diagnosis of pain in the right knee. Review of the resident's BIMS dated 12/17/25 showed the resident was cognitively intact. Review of the resident's POS dated 7/1/25-10/31/25 showed:-Percocet Oral Tablet 5-325 mg. Give one tablet by mouth every 6 hours as needed for pain was started on 8/19/25 and discontinued on 9/12/25.-Percocet Oral Tablet 5-325 mg. Give one tablet by mouth at bedtime started on 9/12/25 and discontinued on 10/15/25. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 8/23/25 showed two 30 count packs of Percocet Oral Tablet 5-325 mg was delivered to the facility.-Note: The accountability sheet for 30 Percocet Oral Tablets 5-325 mg was unaccounted for and could not be provided by the facility. Review of the resident's Controlled Substance Accountability Sheet 2 of 2 dated 8/23/25 showed:-Two Percocet 5-325 mg tablets were removed from 8/29/25 - 8/31/25.-LPN A documented that 1 of the 2 medications pulled was dropped with no destruction log to support. Review of the resident's MAR dated 8/1/25-8/31/25 showed no documentation of administration.-NOTE: Two Percocet 5-325 mg tablets were unaccounted for. Review of the resident's Controlled Substance Accountability Sheet 2 of 2 dated 8/23/25 showed:-11 Percocet 5-325 mg tablets were removed from 9/1/25 to 9/30/25. -Two tablets were documented as being removed from this resident's supply to administer to another resident. Review of the resident's MAR dated 9/1/25-9/30/25 showed he/she was administered two tablets of Percocet 9/1/25 to 9/30/25.-NOTE: Nine Percocet 5-325 mg tablets were unaccounted for. Review of the resident's Controlled Substance Accountability Sheet 2 of 2 dated 8/23/25 showed two Percocet 5-325 mg tablets were removed from 10/1/25 to 10/11/25.Note: On 10/11/25 at 8:00 P.M. LPN A documented a remaining quantity of 1 oxycodone on the accountability sheet. There was no further documentation of where that 1 oxycodone went. Review of the resident's MAR dated 10/1/25- 10/11/25 showed he/she was administered two tablets of Percocet 9/1/25 to 9/30/25.-NOTE: One Percocet 5-325 mg tablets were unaccounted for. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 9/11/25 showed two 30 count packs of Percocet Oral Tablet 5-325 mg were delivered to the facility.-Note: The 2 of 2 accountability sheet for 30 Percocet Oral Tablets 5-325 mg was unaccounted for and could not be provided by the facility. Review of the pharmacy's Controlled Substance Dispense log on 12/19/25 at 9:00 A.M., showed two Percocet tablets were removed on 11/30/25. Review of the resident's MAR dated 11/1/25-11/31/25 showed one Percocet 5-325 mg tablet was administered. -NOTE: One Percocet 5-325 mg tablet was unaccounted for. Review of the pharmacy's Controlled Substance Dispense log on 12/19/25 at 9:00 A.M., showed 10 Percocet tablets were removed from 12/2/25 - 12/14/25. Review of the resident's MAR dated 12/1/25-12/31/25 showed he/she was administered 5 tablets of Percocet 12/2/25 to 12/14/25.-NOTE: Five Percocet 5-325 mg tablets were unaccounted for. During an interview on 12/19/25 at 11:54 A.M. the resident said:-He/She only received pain medication at night.-He/She never asked for pain medication during the day when the medication was ordered as needed.-He/She did not receive the signed-out pain medication that was on the accountability logs unless they were given at night.-He/She did not receive pain medication from LPN A on 8/29/25 at 7:25 A.M, 9/1/25 at 6:40 A.M., or 9/5/25 at 7:20 A.M. because he/she was never awake that early. 3. Review of Resident #9's admission Record showed the resident admitted to the facility on [DATE] and was re admitted to the facility on [DATE], with the diagnoses of congestive heart failure and chronic pain. Review of the resident's BIMS dated 12/10/25 showed the resident was cognitively intact. Review of the resident's POS dated 7/1/25-12/19/25 showed:-Oxycodone tablet 5 mg. Give one tablet by mouth every 6 hours as needed for pain was started on 7/18/25 and discontinued on 9/10/25.-Oxycodone tablet 5 mg. Give one tablet by mouth every 4 hours as needed for pain was started on 9/10/25 and discontinued on 10/1/25.-Norco Tablet 5-325 mg. Give 1 tablet by mouth two times a day for pain was started on 10/1/25. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 7/12/25 showed one 28 count pack of Oxycodone was delivered to the facility. Review of the resident's Controlled Substance Accountability Sheet 1 of 1 dated 7/12/25 showed five tablets of oxycodone were removed for the resident from 7/20/25 to 7/31/25. Review of the resident's MAR dated 7/1/25-7/31/25 showed he/she was administered one oxycodone tablet.-NOTE: Four Oxycodone 5 mg tablets were unaccounted for. Review of the resident's Controlled Substance Accountability Sheet 1 of 1 dated 7/12/25 showed 15 tablets of oxycodone were removed for the resident from 8/8/25 to 8/29/25. Review of the resident's MAR dated 8/1/25-8/31/25 showed he/she was administered five tablets of oxycodone 8/8/25 to 8/29/25.-NOTE: 10 Oxycodone 5 mg tablets were unaccounted for. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 8/30/25 showed one 28 count pack of Oxycodone was delivered to the facility.Note: Accountability sheet 1 of 1 for Oxycodone 5 mg was unaccounted for and could not be provided by the facility. 28 total oxycodone delivered were unaccounted for. Review of the pharmacy's-controlled substance delivery confirmation packing slip dated 9/10/25 showed one 30 count pack of Oxycodone was delivered to the facility. Review of the resident's Controlled Substance Accountability Sheet 1 of 1 dated 9/10/25 showed 29 oxycodone tablets were removed for the resident from 9/10/25 - 9/30/25. Review of the resident's MAR dated 9/1/25-9/31/25 showed he/she was administered 5 tablets of oxycodone 9/18/25 to 9/30/25.-NOTE: 24 Oxycodone 5 mg tablets were unaccounted for. Review of the pharmacy's Controlled Substance Dispense log printed on 12/19/25 at 9:00 A.M., showed two Norco 5-325 tablets were removed from the medication dispensing machine on 10/27/25. Review of the resident's Controlled Substance Accountability Sheet dated 10/1/25 showed LPN A removed one Norco 5-325 mg tablet. Review of the resident's MAR dated 10/1/25-10/31/25 showed one Norco 5-325 mg tablet was administered.-NOTE: Two Norco 5-325 mg tablets were unaccounted for. Review of the pharmacy's Controlled Substance Dispense log printed on 12/19/25 at 9:00 A.M., showed 14 Norco 5-325 mg tablets were removed from the medication dispensing machine between 11/8/25 - 11/30/25. Review of the resident's Controlled Substance Accountability Sheet dated 10/20/25 showed:-Note: The accountability sheet provided by the facility only went to 11/15/25.-Note: 14 Norco tablets were unaccounted for. Review of the resident's MAR dated 11/1/25-11/30/25 showed he/she was administered 8 hydrocodone tablets 11/8/25 to 11/30/25.-Note: Six Norco tablets were unaccounted for. Review of the pharmacy's Controlled Substance Dispense log printed on 12/19/25 at 9:00 A.M., showed 10 Norco tablets were removed from 12/2/25 - 12/14/25.-2 hydrocodone on 12/2/25 at 1:24 P.M.-2 hydrocodone on 12/3/25 at 11:02 A.M.-2 hydrocodone on 12/6/25 at 12:38 P.M.-2 hydrocodone on 12/7/25 at 7:21 P.M.-2 hydrocodone on 12/14/25 at 11:30 A.M. Review of the resident's MAR dated 12/1/25-12/31/25 showed he/she was administered 5 hydrocodone tablets 12/2/25 -12/7/25.-Note: Five Norco tablets were unaccounted for. During an interview on 12/19/25 at 12:15 P.M. the resident said:-He/She did not ask for pain medication very much when it was ordered as needed.-He/She was unsure why the physician changed the order to get pain medication twice a day.-He/She did not receive all of the oxycodone that was signed out for him/her on the narcotic countability logs. 4. During an interview on 12/19/25 at 10:20 A.M., Registered Nurse (RN) A said:-He/She was the Director of Nursing (DON) in training.-The nurses were responsible for administering the as needed pain medication to the residents.-The Certified Medication Technicians (CMT's) were responsible for administering the scheduled pain medication to the residents.-The as needed pain medications was administered from the medication cart and from a bubble pack.-The scheduled pain medication was administered from the pixus style dispense machine in the medication room. -When a nurse or CMT gave a resident a pain medication, the order should have been looked up in the resident's MAR to ensure accuracy and documented in the resident's MAR that the medication was administered.-If a nurse or CMT gave a resident a pain medication that was a narcotic, in addition to signing the resident's MAR, the nurse or CMT should have signed the narcotic out on the resident's narcotic accountability sheet.-The Assistant Director of Nursing (ADON) was LPN A.-LPN A was the one who was responsible for monitoring the facility's narcotic logs.-When a label on a narcotic accountability sheet stated, 1 of 2, this meant that 2, 30 count packs of that narcotic and 2 narcotic accountability sheets were delivered from the pharmacy to the facility. During an interview on 12/19/25 at, the Physician said:-All pain medication should be documented by staff per the professional standards and guidelines.-If a resident's medication was not documented on the residents MAR, then it could not be proven that a medication was given to the resident. During an interview on 12/19/25 2:13 P.M., CMT A said:-The CMT's administered the scheduled pain medication to the residents.-The nurses administered the as needed pain medications to the residents.-All administered pain medication was supposed to be documented as given in the resident's MAR and on the resident's narcotic accountability sheets.-If a resident's medication was not documented on the residents MAR, then the medication was not given to the resident. During an interview on 12/19/25 at 3:44 P.M., ADON/ LPN A said:-When someone is giving a narcotic, it should be charted in the MAR and charted on the narcotic accountability log.-He/She would have expected nurses and CMT's to chart narcotic administration in the MAR under all circumstances.-When narcotic accountability logs are completed, staff placed the logs in his/her box to file.-He/She was unsure why there were missing narcotic logs and unaccounted for narcotics.-He/She was unsure who was responsible for auditing narcotic logs and narcotic administration.-He/She understood that when a medication was not documented as being administered, it could not be proven that it was administered to the resident.-He/She understood that professional standards of practice required nurses to document in a resident's medical record and MAR when a nurse administered a narcotic or any other medication to the resident. During an interview on 12/19/25 at 4:40 P.M., Administrator and Regional Nurse Consultant said:-They would expect narcotic to be documented in the resident's MAR any time a narcotic is signed out on the resident's narcotic accountability log.-They would have expected a residents narcotic accountability log and a resident's MAR to reflect the same administration patterns.- The pharmacy was responsible for the pixus narcotic auditing.-The ADON was responsible for the narcotic accountability logs and as needed narcotics in the medication cart. Complaint # 2679032

Based on interview and record review, facility staff failed to follow facility policy for using mechanical lifts for one sampled resident, (Resident #24) out of five sampled residents. Facility staff failed to inspect the lift sling for safety on 5/10/25. During a transfer, the sling strap broke and the resident fell to the floor. The resident hit his/her head on his/her recliner causing two bumps on the back of his/her head. The facility census was 55 residents. Review of the facility's Safety Precautions, Lifting Policy dated 2001, revised on 12/2009 showed: -All personal shall follow safety precautions established by the facility when lifting of handling heavy objects. -When lifting or moving residents, makes sure that equipment is secure (wheelchair, beds, stretcher, etc.) -If there are mechanical devices available to assist in moving residents more safely, use them. -Tell the resident what you are doing. -Report any defective equipment to the supervisor as soon as practical. Review of the facility's undated Sling/Harness Check showed: -To properly inspect a Proactive Medical sling, staff should check for signs of damage like frayed seams, loops, or tears. -Ensure the sling is free from wear, fading, or any holes. -The label should also be intact and clearly visible, providing information about the sling's capacity. -Additionally, verify that the wear sleeves on the ends of the sling are intact and that all stitching is secure. -Replace if staff notice any damage or wear. -Follow the washing instructions on the sling label, ensuring temperatures do not exceed 185 degrees Fahrenheit and air-drying or low-temperature drying. 1. Review of Resident#24's admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Osteoporosis (a condition where bones become thin and weakened, increasing the risk of fracture). -Primary Osteoarthritis (a joint disease that causes pain, stiffness and loss of movement), right hip. -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Pain. -Muscle Weakness -Cognitive Communication Deficit (a communication difficulty caused by a cognitive impairment, can include language comprehension, language expression, pragmatics, reasoning, attention, memory, organization/planning, or insight/awareness). Review of the resident's undated Order Summary Report showed: -He/She will utilize sit to stand (a mechanical lift) for transfers when he/she is fatigued or in pain and as needed. -Eliquis (a medication which thins the blood) 2.5 milligrams(mg) tablet by mouth two times a day for heart disease. Review of the resident's undated Care Plan showed: -He/She utilizes a hand-held communication board that allows staff/family/ medical professionals to write out information for him/her to read and answer. -He/she had impaired functional status regarding bed mobility, transfers, walking, toileting, and locomotion. --Interventions were that he/she requires mechanical lift sit to stand with one staff assistance for transfers, start date of 9/20/23. -He/She was at risk for falling related to deconditioning, gait/balance problems, incontinence, and vision/hearing problems. --Interventions were to anticipate and meet resident's needs, call light was within reach, encourage resident to use it for assistance as needed, and prompt response to all requests for assistance. -He/She was on anticoagulant therapy (medications that prevent blood clots) for Atrial fibrillation (is an irregular and often very rapid heart rhythm). --Interventions were to monitor/document/report as needed (PRN) adverse reactions of blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting. Diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of the Hoyer (a mechanical lift using a sling to transfer a resident from one place to another) Sling Care Label on 5/13/25 showed: -Hand wash only water temperature no more than 120 degrees Fahrenheit (F). -Do not bleach will damage integrity of sling and strap materials which may result in failure causing injury or death to the resident and/or care giver. -Air dry only. -Inspect sling for wear prior to each use. -If signs of tearing, fraying, or wear are found discard the sling immediately. -Worn out slings are not safe for use and may result in injury or death. -Useful life of the sling is six months from the date of purchase under normal use. -However heavy use or excessive washing may reduce the useful life of the sling. NOTE: Observation of the sling showed no date on the sling when put in service. Review of resident's fall during staff assistance dated 5/10/25 at 11:00 A.M. showed: -The resident was being assisted by Certified Nursing Assistant (CNA) A using a Hoyer Lift to transfer the resident from bed to wheelchair. -The strap on the sling broke causing him/her to fall out of the sling. -He/She hit his/her head on a chair causing two raised bumps on the back of his/her head. -He/She was unable to give description. -No injuries observed at the time of incident. -He/She was sent to the hospital for evaluation and treatment. -Level of Pain: --Breathing score was zero, detail normal breathing. --Negative Vocalization score was one, detail occasional moan or groan, low level of speech with a negative quality. --Facial Expression score of one, detail sad, frightened, or frown. --Body Language score was one, detail tense. --Consolability score was zero, detail no need to console. -Alert to person, place, and situation. -No injuries observed post incident. Review of the resident's Incident Note dated 5/10/25 showed: -He/She was in the Hoyer Lift sling being transferred. -The strap broke causing him/her to fall to the ground. -He/She landed on his/her buttock but hit his/her head on his/her recliner chair. -Emergency Medical Services (EMS) was called and he/she was taken to the hospital for evaluation. -The physician, family, hospice and DON were informed of the incident. -All slings were inspected on 5/12/25 for wear and fray by the Maintenance Director. -All slings were in good condition and good for use. Review of the facility Statement of Inservice Training for Employees dated 5/10/25 showed: -Employee in-service started on 5/10/25 covered the use of lifts, safety measures regarding policy of two staff requirement for safety, and proper use of lifts. NOTE: Showed no training on inspecting Hoyer slings before using to transferring a resident. During an interview on 5/13/25 at 1:46 P.M. CNA B said: -He/She had Hoyer lift training during orientation and have had in-service training on the Hoyer lift and sling inspection as recent as 5/10/25. -Uses two staff to transfer residents with the sit to stand and Hoyer lifts. -He/She gets all of his/her residents that use a lift to transfer dressed and ready for breakfast, then he/she gets another nursing staff member to help him/her use the lift to transfer the resident. -He/She checks the sling for any damage before putting the sling under the residents. During an interview on 5/10/25 at 2:14 P.M. Maintenance Director said: -He/She does the checks on the Hoyer lifts and the slings at the same time. -The slings were just something he/she has always did once a month. -Laundry should also be checking the slings for wear and tear when washing and drying them. -The slings are to be hung to dry and not put in a dryer per manufacture of the slings. -The facility had been drying the slings in the dryer to dry. -The strap should not have just broke. -The strap had to be frayed or cut for it to break. -Looking at the strap he/she can tell it had a cut in it and where the strap ripped the rest of the way. -The sling should have never been used for any resident and been taken out of service. -Review of the written statement from CNA A dated 5/10/25 showed: -He/She and Registered Nurse (RN) A changed the resident before lunch and as he/she was getting the resident up from the bed to the chair the strap broke on the Hoyer sling. -The resident fell on his/her butt in a sitting position first, then hit his/her head on the chair. -The resident was completely alert during this time. During an interview on 5/13/25 at 2:47 P.M. CNA A said: -The resident needed changed and RN A assisted him/her in changing the resident. -He/She examined the sling and its straps before placing the sling under the resident. -He/She would look for holes, rips and/or tears in the sling and straps prior to using it. The sling was in good condition prior to using it. -He/She hooked up the black straps and RN A was spotter for the resident's head (positioned by the resident's head to help guide the resident during the mechanical lift transfer) during the transfer. -He/she was operating the Hoyer lift when the strap broke and the resident fell to the floor hitting his/her head on the chair. -He/She always checks the Hoyer slings before using them to transfer a resident. -He/She never transfers a resident with out a second staff member. -He/She was inserviced on 5/10/25 after the incident on Hoyer transfers and sling inspection before use. During an interview on 5/13/25 at 3:38 P.M. Laundry Aide A said: -When he/she started at the facility he/she was told to dry the Hoyer slings in the dryer. -He/She questioned it because at his/her last job he/she was told the slings were to hang dry. -Was told it was policy to dry in the dryer. -He/She puts the washer on the personals setting, no bleach. -When done in the washer he/she places the slings in the dryer to dry. -Not sure what the temperature is when drying but it gets really hot. -He/She was told on 5/12/25 to hang dry the slings. -The slings could need washed and dried daily if soiled. Review of the written statement from RN A supervisor dated 5/10/25: -He/She and CNA A were in the room changing the resident. -Resident was laid on the bed due to being a Hoyer Lift. -When done changing the resident he/she and CNA A were getting the resident up from the bed to the chair. -The strap on the Hoyer sling broke and the resident fell on his/her bottom and landed in a sitting position. -The resident did hit his/her head on the recliner and trash can. -Assessment was completed on the resident and observed two bumps on back of his/her head. -The resident was on blood thinner medications. -Neuro checks were started. ---The resident was sent to the hospital for evaluation and treatment due to hitting head and on blood thinners. ---The resident showed no signs or symptoms of distress. ---The resident was alert and oriented at time of transfer to hospital. During an interview on 5/13/25 at 3:47 P.M. RN A said: -He/She was in the resident's room helping CNA A change the resident before getting him/her up for lunch. -He/She did not see if CNA A checked the sling for wear and tear before putting the sling under the resident as he/she was up by the resident's head to spot during the transfer. -The nursing staff usually check the slings before using them. -He/She did not know what color of loops were to be used on the resident for positioning in a sitting position. -The sling was hooked up on the black straps when the strap broke. -He/She did not check the sling prior to use. During an interview on 5/13/25 at 4:26 P.M. the DON said: -He/She would expect all nursing staff to check the slings for wear and tear before using to transfer a resident with the Hoyer lift. -If there were signs of wear and tear the sling should be taken out of service and another sling should be used to transfer the resident. -The charge nurse should be notified of the damaged sling and given the sling to him/her. -Two nursing staff are to transfer residents with the Hoyer lift. -Nursing staff have hands on training during orientation and during in-services throughout the year as needed. -He/She was notified of the incident at 11:08 A.M. and reported to the facility on 5/10/25. -He/She started an investigation and nursing staff on shift were in-serviced on proper inspection of Hoyer slings and proper use of the Hoyer lift. -He/She forgot to put the sling inspection training on the in-service sheet and did not feel right adding it after staff members had already signed the sheet. -He/She is continuing education for nursing staff before working a shift. -All slings have been checked for wear and tear; no other slings showed any damage. -RN A was in the resident's room helping CNA A change and transfer the resident with the Hoyer lift from the bed to the wheelchair when the strap broke. During an interview on 5/14/25 at 3:01 P.M. the Physician said: -He/She would expect the nursing staff to examine the Hoyer sling for any damage before using the sling to transfer any resident. -If any damage the sling should not be used and taken out of service. MO00254063

Based on observation, interview and record review, the facility failed to provide care and services to meet the needs of a resident on hospice (end of life care) for one sampled resident (Resident #29) out of five sampled residents. The facility census was 55 residents. Review of the facility's Hospice Program Policy dated 2001, revised 7/2017 showed: -Hospice services are available to residents at the end of life. -It was the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: --Determining the appropriate plan of care. --Changing the level of services provided when it was deemed appropriate. --Providing medical direction, nursing and clinical management of the terminal illness. --Providing medications necessary for the palliation of pain and symptoms. -It was the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided in appropriately based on the individual resident's needs. --Administering prescribed therapies, including those therapies determined appropriate by hospice and delineated in the hospice plan of care. -Communicating with the hospice provider and documenting such communications to ensure that the needs of the resident are addressed and met 24 hours per day. -The coordinated care plan will reflect the resident's goals and wishes, as stated in his/her advance directives and during on going communication with the resident or representative, including: --Palliative goals and objectives. --Palliative interventions, medical treatment and diagnostic test. -The coordination care plan shall be revised and updated as necessary to reflect the resident's status including, but not limited to: --Diagnosis. --Problem list. --Symptom management (pain, nausea, vomiting etc.). Review of the facility's Medication Therapy Policy dated 2001, revised 4/07 showed: -Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. -The physician will identify situations where medications should be tapered, discontinued, or changed to another medication. Review of the facility's Administer Medications Policy dated 1/1/24 showed: -To ensure safe and effective administration of medication in accordance with physician orders. 1. Review of Resident #29's admission Record showed he/she was admitted to the facility on [DATE], readmitted on [DATE] with the following diagnosis: -Hypertensive Heart Disease (prolonged high blood pressure) with Heart Failure (a chronic condition in which the heart does not pump blood as well as it should). -Chronic Diastolic (Congestive) Heart Failure (a condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly). -Rheumatoid Arthritis (is an ongoing chronic condition that causes pain, swelling and irritation, called inflammation, in the joints). Review of the resident's Pain Assessment on 4/19/25 showed he/she: -Had pain in the last five days. -Frequently experienced pain in the last five days. -Pain effect on sleep rarely or not at all. -Interferes with therapy and day to day activities frequently. -Pain intensity on a score of zero being no pain to 10 being high pain score of six. -Verbal descriptor scale was moderate. -Staff should assess for pain. -Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw). -Frequency he/she complains of pain every one to two days. -Pain management with scheduled pain medications. -No as needed pain medication offered. -No non-medication interventions for pain. Review of the resident's Care Plan last reviewed on 4/29/25 showed: -He/She has chronic pain related to rheumatoid arthritis, left hip fracture and artificial left and right knee joints. --He/She will not have an interruption in normal activities due to pain. --Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. --Monitor/record/report to nurse any signs/symptoms of non-verbal pain (changes in breathing, vocalizations, mood/behavior changes, facial expressions, and body actions. --Monitor/document for side effects of pain medications. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 5/12/25 showed the resident: -Was severely cognitively impaired. -Was receiving hospice services. Review of the resident's Order Summary Report dated 5/14/25 showed: -Admit to hospice, order date 5/12/25. --NOTE: Resident was admitted on hospice on 5/9/25 when the contract was signed. -May crush medications as needed (PRN), order date 5/14/25 at 11:00 A.M., no start date. -Hyoscyamine Sulfate Oral Tablet Disintegrating 0.125 milligrams (mg), give one tablet by mouth every four hours PRN for increased secretions, order and start date of 5/14/25 at 7:00 A.M. -Lorazepam Oral Tablet 0.5 mg, give one tablet by mouth every four hours PRN for anxiety, order and start date of 5/14/25 at 10:54 A.M. -Morphine Sulfate Oral Tablet 15 mg, give one tablet by mouth every six hours PRN for pain/shortness of air (SOA), order and start date of 5/14/25 at 10:58 A.M. --NOTE: The hospice physician's order on 5/10/25 for liquid Lorazepam and liquid Morphine was not located in the resident's hospice orders. -Zofran Oral Tablet 4 mg, give one tablet by mouth every eight hours PRN for nausea, order and start date of 5/9/25. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 5/1/25 to 5/31/25 showed: -Lorazepam Oral Tablet 0.5 mg, give one tablet by mouth every four hours PRN for anxiety, first dose given on 5/14/25 at 11:18 A.M. -Morphine Sulfate Oral Tablet 15 mg, give one tablet by mouth every six hours PRN for pain/shortness of air (SOA), first dose given on 5/14/25 at 11:18 A.M. --NOTE: The hospice physician's order on 5/10/25 for liquid Lorazepam and liquid Morphine was not located in the resident's hospice orders. -Tramadol-Acetaminophen Tablet 37.5-325 mg, give one tablet by mouth every six hours for pain, last dose given on 5/13/25 at 11:07 P.M. Review of the facility's hospice provider communication book on 5/14/25 showed: -Hospice start of care date was 5/9/25. -Patient consent form. -Election of hospice benefits. -Hospice election statement. -Visit Notes. -Medicine list printed on 5/12/25. During an interview on 5/14/25 at 12:21 P.M. the Hospice Physician said: -He/She gave verbal orders for the resident's medications on 5/10/25 for liquid sublingual (under the tongue) morphine (pain), lorazepam (anxiety) and hyoscyamine sulfate (increased secretions). He/She gave the orders verbally to the hospice nurse to be written in the hospice book for the facility to enter into the computer. -On 5/12/25 he/she was informed the medication orders disappeared from the facility between 5/10/25 and 5/12/25. -The orders were never entered into the resident's MAR or TAR and never given to the resident. -He/She gave the same orders again on 5/12/25 to the nurse to be filled for the resident's comfort. -He/She was told the facility requested no liquid medications and would like the medication orders to be given in tablet form due to drug diversion per the Director of Nursing (DON). -He/She always orders liquid in these medications due to the liquid form works better and faster than the tablet form. -The tablets could be crushed and mixed with something for the resident to swallow easier. -This resident was having difficulty swallowing before being admitted to hospice. -The medication orders were not put into the resident's MAR until 5/14/25. -The facility physician prefers the hospice physician to take care of the residents' medications once admitted to hospice. During an interview on 5/14/25 at 12:40 P.M., Family Member #1 said: -The resident just received some medications finally. -Hospice wrote out all the medication orders on 5/10/25 and gave the medication orders to the nurse. -The facility was not able to find the medication orders and all orders were rewritten on 5/13/25 by hospice. During an observation on 5/14/25 at 12:40 P.M. showed: -The resident was sitting up straight in bed. -Family member #1 was at the bed side trying to get the resident to drink some juice. -The resident was not responding to any verbal commands. -Resident had his/her eyes closed, with his/her mouth open, nasal cannula on for oxygen due to shortness of air. During an interview on 5/14/25 at 3:01 P.M. the facility Physician said: -Generally, he/she does not override a hospice physician. -He/She was not contacted by the facility to change the resident's liquid medications order by hospice to pills to be crushed. -He/She would expect the facility to follow the hospice physician's orders as prescribed. -Hospice takes over the medications once the resident was admitted to hospice. -The resident was not able to swallow medication whole. -The medications need to be crushed and put in applesauce or pudding to give to the resident. During an interview on 5/14/25 at 3:34 P.M. the DON said: -He/She was at the facility on 5/10/25, when hospice put the resident's orders in the communication book. -The resident's hospice physician had ordered liquid morphine, lorazepam, and hycosamine. He/She does not know what happened to those orders. -He/She asked the nurse that was on duty when the hospice physician gave the orders for liquid morphine, lorazepam, and hycosamine, however he/she could not remember what his/she did with the orders. -He/She want the resident's hospice physician to order tablets instead of liquid medications. -Does not know why the orders were not put into the computer for approval by the facility physician. -The nurse on duty or him/her self should have entered the orders in the computer received by the hospice physician at the time the hospice orders were received. -He/She expected staff to enter physician orders at the time they are received and to follow the physician orders. -Hospice takes over the resident's medications. -He/She had asked hospice to not use liquid medications due to possible drug diversion. -He/She called all contracted hospices and asked them to either discontinue the liquid medications for nonuse or write the order in tablet form. -The hospice orders were confusing for the facility nurse. -He/She went through the orders with the night nurse and hospice on 5/13/25. -The night nurse contacted the hospice physician to discontinue some medications and to enter new medication orders on 5/13/25. -He/She continued putting in the new orders for the morphine, lorazepam and hyoscyamine Sulfate on 5/14/25. -Hospice did tell him/her the resident needed his/her medications in liquid but did order tablet form. -Family member #2 wanted to start the comfort medications right away. -The resident could still talk on 5/13/25 and said he/she was not in pain. -He/She asked the resident if he/she could swallow his/her medications. -Resident said he/she would try. -He/She gave the resident his/her lorazepam tablet with some water. -The resident had a very hard time swallowing the pill. -He/She crushed up the resident's morphine and gave it in applesauce a little bite at a time. -He/She informed the resident that the medications could make him/her sleepy. -Medications were give at 11:18 A.M. on 5/14/25. -The facility does have liquid morphine and lorazepam in the E-Kit if needed. During an interview on 5/14/25 at 4:30 P.M. Family member #2 said: -The resident was admitted to hospice on 5/9/25. -On 5/12/25, hospice re-ordered comfort medications for the resident. -He/She sits with the resident during the evening and part of the night. -He/She asked the DON on 5/10/25 about the comfort medications due to the resident being restless and the DON said he/she was going to hold off on the medications because the resident was not in any pain. -He/She continued to ask the DON about comfort medications from 5/11/25 - 5/14/25. -He/She talked to the hospice nurse about the comfort medications being held. The hospice nurse did not understand why they were held. -On 5/13/25, the resident was very restless and cried out during the night. -The night nurse gave the resident some medication and the resident calmed down. -He/She was upset the resident had not received any comfort medications. MO00254214

Based on interview and record review, the facility failed to follow the facility policy and procedure and investigate an injury of unknown origin of a fractured (broken) arm for one sampled resident (Resident #35); and failed to investigate the cause of skin tears and bruises for one sampled resident (Resident #30) out of 14 sampled residents. The facility census was 55 residents. The Administrator was notified on 2/14/25 at 9:00 P.M. of the Immediate Jeopardy (IJ) which began on 1/3/25. The IJ was removed on 2/18/25, as confirmed by surveyor onsite verification. Review of the facility policy titled: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, showed: -Residents had the right to be free from abuse, neglect, misappropriation of property and exploitation. -Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. -Investigate and report any allegations within time frames required by federal requirements. -Establish and implement a Quality Assurance and Performance Improvement (QAPI) review and analysis of reports, allegations or findings of abuse, neglect, mistreatment or misappropriation of property. Review of the facility policy titled: Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating, dated September 2022, showed: -If resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. -All allegations are thoroughly investigated. The Administrator initiates investigations. -Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. -The Administrator is responsible for keeping the resident and his/her representative informed of the progress of the investigation. -The investigator consults daily with the Administrator concerning the progress/findings of the investigation. -Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the Administrator. -Within five business days of the incident, the Administrator will provide a follow-up investigation report. -The follow up investigation report will provide sufficient information to describe the results of the investigation and indicate any corrective actions taken if the allegation was verified. -The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. 1. Review of the Resident #35's Admission Record showed he/she admitted on [DATE] with a diagnosis of Dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning). Review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning), dated 10/20/24, showed: -He/She was severely cognitively impaired. -Had a diagnosis of Dementia. -Required maximum assistance to total dependence with all aspects of activities of daily living. Review of the resident's Health Status Note, dated 1/3/25 at 1:26 P.M., showed: -The resident complained of pain to his/her left forearm when day shift arrived. -Deformity noted to his/her left forearm. -A message was left with the resident's Physician's answering service. -A left forearm x-ray was ordered. -The Administrator was notified. Review of the resident's X-ray Results Report, dated 1/3/25 at 4:03 P.M., showed: -There was an acute (sudden onset) spiral fracture (occurs when a rotating force was applied along the axis [imaginary line running through the center of a bone] of a bone, often occurred when the body was in motion while one extremity was planted) of the distal (away from the point of attachment) diaphysis (the long tubular shaft of a bone) of the Ulnar bone (the longer bone in the forearm located on the side of the little finger and extends from the elbow to wrist). Review of the resident's progress note, dated 1/8/25 at 4:39 P.M., showed: -The MDS Coordinator rounded with the Physician who was seeing the resident for a fractured arm. -The MDS Coordinator asked for results from the X-ray which had been sent to nurses on 1/3/25. -The X-ray results showed a spiral fracture of the resident's left arm. -The MDS Coordinator looked for a report of the fracture and none was noted. -The MDS Coordinator reported to the Executive Director and the Director of Nursing (DON) the family had not been notified and the resident's arm was broken. Review of the resident's progress note, dated 1/10/25 at 1:23 P.M., showed: -The MDS Coordinator spoke with the resident's family member concerning the resident's left arm fracture. -The family member was very upset the resident had a fracture of the left arm and was not notified until six days later. -The MDS Coordinator had not been notified of a fall or an injury until 1/8/25 when rounding with the Physician for a follow-up for a fracture. -The MDS Coordinator looked for additional progress notes and there were no reports of the injury or that the family had been informed of the X-ray and break of the left arm. Review of the resident's Quarterly MDS, dated [DATE], showed his/her cognition was severely impaired. During an interview on 1/22/25 12:35 P.M., the resident's family member said: -The resident had a spiral arm fracture and the facility did not know when or how it happened. -The facility found out the resident was having pain on 1/3/25 and did an X-ray on 1/3/25. -The family found out about the X-ray and the fracture on 1/8/25 from the Executive Director. -The DON called the family member to see if the family wanted the resident to see the doctor or be sent to the emergency room (ER). -The family member said to make a doctor's appointment by Friday 1/10/25. -The family member talked to the MDS Coordinator on Friday 1/10/25 and found out the resident could not get a doctor appointment and to send the resident to the ER. -While in the ER the resident had a splint put on his/her left arm and was to see an Orthopedic doctor on Friday 1/24/25. -The family member wanted to know what happened. Review of the resident's Electronic Health Record (EHR) showed: -No nursing documentation of the resident complaining of pain. -No incident report for an injury of unknown origin for a spiral fracture of the left forearm. -No documentation of an investigation of the cause of an injury of unknown origin. During an interview on 1/28/25 at 12:28 P.M., the DON said: -There was no incident report written regarding the resident's pain, X-ray, and X-ray results. -There was no investigation done to determine the cause of the resident's injury of unknown origin that resulted in a fractured arm. During an interview on 1/31/25 at 3:25 P.M., the DON, Assistant Director and the Executive Director said: -The Assistant Director was not aware an incident report needed to be made with an injury of unknown origin. -The Assistant Director did not investigate the cause of the resident's injury of unknown origin. -The DON was not aware an incident report needed to be made with an injury of unknown origin. -The DON did not investigate the cause of the resident's injury of unknown origin. During an interview on 2/14/25 at 6:30 P.M., Certified Nurse Aide (CNA) T said: -The resident had not complained of pain in his/her arm or anywhere else on the night shift 1/2/25 into 1/3/25. During an interview on 2/14/25 at 6:48 P.M., CNA S said: -While he/she was putting the resident to bed on 1/2/25 the resident complained of pain in his/her left arm. -The resident was still swinging both arms at the CNA as he/she always did. -He/She told Licensed Practical Nurse (LPN) G about the resident complaining of pain. -No one thought anything about it, as the resident was still swinging his/her arms at anyone who did anything to help him/her. -When he/she got the resident up on the morning of 1/3/25 for breakfast the resident said his/her arm still hurt, but he/she was still swinging both arms around. -He/She again told LPN G the the resident was complaining of pain. -LPN G went to the dining room to look at the resident's arm. -LPN G touched the resident's arm and the resident said ouch, but was swinging his/her arms at LPN G. -He/She and LPN G both thought if the resident's arm was hurt, the resident wouldn't be swinging/swatting at the staff with his/her arms. During an interview on 2/14/25 at 7:19 P.M., LPN G said: -CNA S did report the resident was complaining of pain, but did not remember what day or time it was. -CNA S told him/her the resident was in the dining room and was complaining of pain in the right arm. -He/She looked at the resident's right arm and did not see any swelling or discoloration. -He/She did not look at the resident's left arm at that time. -The resident was swinging both arms and swatting at him/her. -The resident did not complain of pain at that time. During an interview on 2/14/25 at 7:06 P.M., CNA C said: -The resident did not complaint of pain during day shift on 1/2/24 or day shift 1/3/25 to him/her. -The licensed nurse gave residents pain medication. -He/She did not help get the resident up on 1/2/25 or 1/3/25. During an interview on 2/14/25 at 7:57 P.M. CNA D said: -He/she worked day shift on 1/3/25. -He/she went to the resident's room to provide care for the resident and the resident said don't touch my arm, it's broken and then pointed to his/her left arm. -The resident did not complain of pain in his/her left arm at that time. -The resident had a long sleeve shirt on, and when the sleeve was moved the resident winced, but did not say it hurt. -The resident's upper left forearm looked swollen and appeared light reddish in color. -He/She went to tell the nurse, but could not find the nurse so he/she told the Assistant Director. -The Assistant Director looked at the resident's arm and told CNA D to find the nurse and have an x-ray ordered. During an interview on 2/14/25 at 7:04 P.M. the Assistant Director said: -When he/she arrived to work on 1/3/25 a day shift employee informed him/her of the resident complaining of left arm pain. -He/She went to look at the resident's left arm. -He/She could see something wasn't right with the resident's left arm, but did not have clinical experience and told staff to notify the DON when he/she arrived. -He/She did not start a risk management form. -A risk management form should have been started. -He/She did not start an incident report. -An incident report should have been done. -He/She did not start an investigation. -An investigation should have been done. -As of February 14, 2025 no incident report or investigation had been done. During an interview on 2/14/25 at 7:04 P.M., the DON said: -He/She did not start a risk management form. -He/She asked the 1/2/25 night shift staff if they knew what happened to the resident's arm. -There was no documentation of the staff interviews. -He/She asked the 1/3/25 day shift staff if they knew what happened to the resident's arm. -There was no documentation of the staff interviews. -He/She did not start an incident report. -He/She did not know an incident report needed to be done. -He/She did not start an investigation. -He/She did not know an investigation needed to be done. During a phone interview on 2/14/25 at 7:34 P.M., Physician A said: -The staff should have called and discussed possible causes of the fracture during the investigation of the injury. -The staff should have followed their policy and procedures following an incident. -If the policy and procedures said to complete a risk management report, an incident report and/or an investigation, the reports should have been done. -There should be some written record of an incident report and investigation. 22727 2. Review of Resident #30's Admission MDS dated [DATE] showed: -He/She was severely cognitively impaired. -Was dependent on staff for most of cares. -Had a diagnosis of Cancer. Review of the resident's health status note, dated 5/23/24 at 5:19 P.M., showed: -A small, open area was noted to the resident's right shin. -The area appeared to be the result of ruptured bruise. Review of the resident's electronic health record, health status notes dates 5/24/24 to 8/14/24 showed: -The resident had no skin issues documented. -The resident had no bruises documented. -The resident had not skin tears documented. Review of the resident's most recent skin assessment, dated 8/14/24, showed: -The resident had no skin issues. -The resident had no bruises. Review of the resident's quarterly MDS, dated [DATE], showed the following staff assessment of the resident: -Moderately cognitively impaired. -Had no functional limitation in range of motion in any extremities. -Required maximum assistance with toileting hygiene, dressing, and personal hygiene. -Required moderate assistance with bathing and going from sitting to standing. -Used a manual wheelchair. -Did not stand. -Was always incontinent of bowel and bladder. -Some of his/her diagnoses included cancer and high blood pressure. -Had a skin tear. Review of the resident's care plan, dated 11/18/24 (the last time the resident's care plan was updated), showed it did not include anything about skin injuries including skin tears or bruises. Review of the resident's nurse's note, dated 1/26/25 at 4:31 A.M. showed: -The resident was noted to have a small skin tear to his/her right ankle approximately 0.2 centimeters (cm) round with a small amount of red drainage. -No information regarding how the skin tear happened. During an interview on 1/30/25 at 9:08 A.M., the MDS Coordinator said: -He/She had not noticed the resident having any wounds, bruises, skin tears or scratches. -The resident usually turned on his/her call light and didn't usually try to get up on his/her own. -The resident would yell out for help if his/her call light wasn't in reach. During an interview on 1/30/25 at 11:26 A.M., the DON said: -He/She didn't know any cause of the resident's bruise or skin tears. -He/She did not know an investigation was required when a resident had a skin injury, or bruise to determine the root cause or contributing factors of the injury. During an interview on 1/30/25 11:50 A.M., the DON said: -There was a risk management form they could enter, but he/she could not open it. -There were no incident reports or investigations on the any of the resident's bruises or skin tears. Observation on 1/30/25 at 2:09 P.M., showed the resident was in his/her room in his/her wheelchair asleep and had a large bruise that was dark purple, yellow, and green on the right side of his/her face that covered his/her forehead, was around the resident's right eye and down to his/her cheek. During an interview on 1/31/25 at 3:25 P.M., the DON said: -The nurses should have documented and started a risk management form after finding the skin tears and/or bruises. -He/She did not know he/she was responsible to investigate skin tears and/or bruises for a reason or contributing factor of the injury. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00247918 MO00248157 MO00249755

Based on interview and record review, the facility failed to address areas of needed improvement by not developing and implementing Performance Improvement Plans (PIP - a process designed to help facilities address and fix deficiencies) which could affect all facility areas including residents quality of life. The facility census was 55 residents. Review of the facility's Quality Assurance and Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) Program - Governance and Leadership Policy, dated March 2020, showed: -The QAPI program was overseen and implemented by the QAPI committee and reported findings, actions and results to the administrator and governing body. -The Administrator was ultimately responsible for the QAPI program and for interpreting results, and findings to the governing body. -The QAPI committee was responsible for: --Coordinating, developing, implementing, monitoring and evaluation of performance improvement projects to achieve specific goals. --Establishing performance outcome indicators for quality of care and services delivered in the facility. --Choosing and implementing tools that best captured and measured dated about chose indicators. 1. During an interview on 1/31/25 at 9:18 A.M., the Assistant Director said: -There were no current PIPs the facility was working on. -The survey process identified several areas needing improvement: --Showers for residents. --Wound care. --General documentation. --Investigations in all areas. -He/She did not know what a PIP was until about two weeks ago. During an interview on 1/31/25 at 4:55 P.M. the Executive Director said: -He/She would have expected to see PIPs in place. -He/She expected areas of improvement to be identified in stand-up meetings (a daily meeting that involved the core team) every morning with department heads. -These areas of improvement would be carried over into a PIP.

Based on interview and record review, the facility failed to ensure the services of a Registered Nurse (RN) were utilized eight hours per day, seven days per week. This had the potential to affect all residents of the facility. The facility census was 55 residents. Review of the facility's Staffing, Sufficient and Competent Nursing policy, dated as revised August 2022, showed: -Licensed nurses and Certified Nursing Assistants (CNA) were available 24 hours a day, seven days a week to provide competent resident care services. -A RN provides services at least eight consecutive hours every 24 hours, seven days a week. -RNs may be scheduled more than eight hours depending on the acuity needs of the resident. 1. Review of the Facility Assessment, dated 1/16/25, showed: -The facility was licensed for 118 residents. -Current full-time staff was 41. -Part-time staff was 3. -As needed (PRN) staff was 4. Hours per resident days (HPRD) showed: -Day shift: --Two RNs. --Two Licensed Practical Nurses (LPNs). --Four CNA/Nurse Assistants (NA). -Night shift: --No RN. --Two LPNs. --Four CNA/NAs. Review of the facility staffing sheet, dated 1/4/25, showed: -RN A was scheduled to work the day shift on 1/4/25. Review of the facility staffing sheet, dated 1/5/25, showed: -RN A was not scheduled to work on 1/5/25. -There was no other RN scheduled to work. -The Director of Nursing (DON) did not come in to the building and work as the RN coverage. Review of the facility staffing sheet, dated 1/6/25, showed: -The DON was scheduled to be the RN in the building on 1/6/25. -There was no other RN scheduled to work. -The DON did not work on 1/6/25. Review of the facility's current staff list, dated 1/17/25, showed: -The DON as a RN. -RN A as the weekend and part time RN. -RN B as a full-time RN. During an interview on 1/28/25 at 12:39 P.M., the DON said: -He/She was a RN. -He/She had started on December 31, 2024, as the Interim DON. -The staffing coordinator was responsible to make sure there was enough staff for each position. -He/She didn't know anything about the staffing at that time and still was not sure how the staffing was done. -Was not aware the RN scheduled for 1/5/25 or 1/6/25 did not show. -He/She sometimes filled in as the RN and would work the floor if there was no other RN scheduled. -He/She was scheduled to work as the DON on 1/6/25, but was unable to come in. -He/She did not know there was no other RN working on 1/6/25. During an interview on 1/28/25 at 1:12 P.M., the Assistant Director said: -He/She did the staffing. -Staffing sheets were done in advance and if there were empty positions he/she tried to see if the full-time staff would pick up the shift. -If full time staff didn't pick up a shift then he/she called the staffing agency the facility contracts with. -If the staffing agency couldn't fill the position, the facility offered incentives to staff such as a bonus for working an extra shift. -The facility had a scheduled RN to work the weekends. -That RN worked Saturday 1/4/25. -Sunday 1/5/25 there was no RN scheduled to work. -The DON did not work on 1/5/25. -The DON was scheduled to work Monday 1/6/25 and would have been the RN, but he/she was unable to make it in. -There was no RN on duty on 1/5/25 and 1/6/25. During an interview on 1/31/25 at 3:25 P.M., the DON, Assistant Director, and the Executive Director said: -There should be RN coverage for at least eight hours in a 24-hour period. -There should have been a RN working on 1/5/25 and 1/6/25. -When a RN was not scheduled or if the RN called off, the DON was expected to cover the position. -Staffing sheets were done in advance and if a RN was needed, the Assistant Director would call the staffing agency to see if they could fill the spot. -The DON was not aware he/she was expected to cover shifts that did not have RN coverage.

Based on interview and record review, the facility failed to develop and implement written procedures for its Quality Assurance and Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) Program which led to the inability to gather feedback for quality improvement. This practice had the ability to affect all residents. The facility census was 55 residents. Review of the facility's QAPI Program - Governance and Leadership policy, dated March 2020, showed: -The Administrator was ultimately responsible for the QAPI program. -The QAPI program was based on data, resident and staff input, and other information that measured performance. -The QAPI program focused on problems and opportunities that reflected processes, functions, and services provided by the residents. -The responsibilities of the QAPI committee were to: --Collect and analyze performance indicator data. --Identify, evaluate, monitor, and improve facility systems and processes. --Identify and resolve negative outcomes. --Establish benchmarks and goals. --Utilize root cause analysis to help identify problems. 1. Review of the facility's Quality Assurance (QA) Meetings agenda, dated 11/19/24, showed: -Number of staff breakdown by position, call-ins, and terminations. -Staff attended: --Medical Director. --Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) Coordinator. --Activities Director. --Human Resources Director. -NOTE: No other notes were available. Review of the facility's QA Meetings agenda, dated December 2024, showed: -Staff attended: --Medical Director. --MDS Coordinator. --Bookkeeper. --Dietary Manager. -COVID-19 status for residents was reviewed showing five residents. -NOTE: No other notes were available. Records for a January 2025 QA Meeting were requested and not provided. During an interview on 1/31/25 at 9:18 A.M., the Assistant Director said: -The QAPI committee met once a month, depending on the physicians schedule. -The Administrator, Director of Nursing (DON), MDS coordinator, Business Office Director (BOD), Maintenance Director, Dietary Manager, Activities Coordinator, Social Services Designee (SSD), Therapy and Human Resources (HR) attended the meetings. -The QAPI Committee only had a policy to go by. -There were no procedures or guidelines. -The committee did not meet in January 2025. -The committee had no current improvement projects. -During monthly QAPI meetings, all staff brought in packets with their concerns and information to report to the committee. -Those concerns were not tracked for improvement. During an interview on 1/31/25 at 4:55 P.M., the Executive Director said: -He/She requested copies of QAPI policies and procedures from the corporate office and was only provided the policy. -He/She expected staff to follow committee policies and procedures. -He/She was unaware the QAPI committee did not have procedures or guidelines to follow.

Based on interview and record review, the facility failed to have anyone in the position, or performing the tasks and responsibilities of the Infection Preventionist. The facility census was 55 residents. Review of the facility's policy ,Infection Preventionist, dated September 2022 showed: -The Infection Preventionist was responsible for coordinating the implementation and updating of the infection prevention and control program. -The Infection Preventionist collects, analyzes and provides infection and antibiotic usage data and trends to nursing staff and health care practitioners. -The Infection Preventionist has obtained specialized training beyond initial professional training or education prior to assuming the role including antibiotic stewardship. -The Infection Preventionist was employed on site and at least part time. 1. During an interview on 1/31/25 at 10:00 AM the Administrator said: -There was currently no one in the role of the Infection Preventionist. -They have not had an Infection Preventionist at the facility for years. -The Infection Preventionist would be responsible for monitoring, tracking infections, antibiotic usage, monitoring Transmission Based Precautions, and Enhanced Barrier Protection (a set of infection control measures that use personal protective equipment (PPE- specialized clothing or gear worn to protect the wearer from injury, infection, or illness) to reduce the spread of multidrug-resistant organism (MDRO - bacteria or microorganisms that have become resistant to multiple antibiotics) for residents who had wounds or indwelling medical devices) and education of staff and resident regarding infections, antibiotic usage, and the use of Transmission Based Precautions and Enhanced Barrier Protection. During an interview on 1/31/25 at 3:30 P.M. the Director of Nursing (DON) said: -There should have been an Infection Preventionist at the facility. -There was not anyone in the role of Infection Preventionist at this time. -No one was performing the tasks or responsibilities of the Infection Preventionist.

Based on observation, interview, and record review, the facility failed to ensure five sampled residents (Resident #3, #9, #30, #39, and #37) who should have been on Enhanced Barrier Precautions (EBP), a set of infection control measures that used personal protective equipment (PPE- specialized clothing or gear worn to protect the wearer from injury, infection, or illness) to reduce the spread of multidrug-resistant organism (MDRO - bacteria or microorganisms that have become resistant to multiple antibiotics) for residents who had wounds or indwelling medical devices. The facility also failed to educate staff about EBP, failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide Tuberculosis (TB-a communicable disease that affects the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for three sampled residents (Residents #2, #9, and #109); failed to ensure staff used hand hygiene during wound care for two sampled residents, (Resident #3 and #39); and failed to wear gloves when administering eye drops to one sampled resident (Resident #39) out of 14 sampled residents. The facility identified three residents as having pressure ulcers (any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s)) not present upon admission, one resident with tube feeding (a medical device used to provide nutrition to patients who cannot obtain nutrition by swallowing), one resident with a colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen), and three residents with a catheter (a tube passed through the urethra into the bladder to drain urine) who should have had EBP in place. The facility census was 55 residents. Review of the facility's Tuberculosis, Screening Residents policy, dated August 2019, showed: -The facility screened all residents for TB. -Individuals identified with active TB would be isolated form other residents and staff. -The admitting nurse screened new residents prior to admission and readmission for information regarding exposure to the symptoms to TB, including: --Coughing for more than three weeks. --Loss of appetite. --Fatigue. --Weight loss. --Night sweats. --Bloody sputum (a blood-tinged thick mucus from the lung). --Hoarseness. --Fever and or chest pain. -If a potential resident was exposed to active TB or at increased risk of TB infection, he/she was screened for Latent Tuberculosis Infection (LTBI) using the TB skin tests (TST- a test to detect TB completed by injecting a small amount of TB protein under the top layer of skin on your inner forearm). -The facility conducted an annual risk assessment to determine risk of exposure. 1. Review of Resident #2's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's medical record showed there was no documentation of the resident's TB testing or screening. 2. Review of Resident #9's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's medical record showed there was no documentation of the resident's TB testing or screening. 3. Review of Resident #109's entry tracking from showed the resident admitted to the facility on [DATE]. Review of the resident's medical record showed there was no documentation of the resident's TB testing or screening. During an interview on 1/29/25 at 8:54 A.M., Resident #109 said he/she did not remember if he/she received a TST when he/she was admitted to the facility. 4. During an interview on 1/29/25 at 10:15 A.M., Licensed Practical Nurse (LPN) A said: -New residents were supposed to get the two step TST; -The nurse on duty completed the new admissions assessments, including administering the TST; -He/She had not completed any recent TST on the residents; -The DON reviewed the new admission chart within 72 hours of admission and should have seen if the TST was completed; -If the TST was completed it would be in the residents medical file. During an interview on 1/31/25 at 4:55 P.M., the Director Of Nursing (DON) said: -The facility did the TST on each resident within 24 hours of admission; -Each test was read in 48-72 hours; -The second step of the TST was done about two weeks later; -The admitting nurse was responsible for completing the TST; -There was a form the resident completed and signed giving permission or if the resident refused; -He/She was unsure what the protocol was if the resident refused; -The administering of the TST and results should be uploaded to the resident's medical file; -He/She was unaware if anyone was tracking them. During an interview on 1/31/25 at 4:55 P.M., the Executive Director said: -Nurses knew there was a physician's order for the TST and they were supposed to administer them; -TST's and results should be documented on the MAR/TAR, as well as on a progress note; -The Electronic Health Record system generated tasks when the tests were to be completed; -If there was no documentation of the TST being administered then it was not done. During an interview on 1/28/25 at 8:42 A.M., the DON said he/she was still looking into who was responsible for doing resident TB testing/screening. 5. Review of the facility's policy, Enhanced Barrier Precautions, dated August 2022 showed: -EBPs would be 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 would be applied prior to performing the high contact resident care activity. -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: --Providing hygiene. --Changing briefs or assisting with toileting. --Device care or use (urinary catheter, feeding tube. --Wound care (any skin opening requiring a dressing). -Staff would be trained prior to caring for residents on EBPs. -Signs would be posted on the door or wall outside the resident's room indicating the type of precautions and PPE required. -PPE would be available outside the resident's room. Review of Resident #9's Physician's Order Sheet (POS), dated January 2025, showed: -Treatment orders for the resident's coccyx wound were to be completed daily; -Treatment orders for the resident's right cheek wound were to be completed every Monday, Wednesday and Friday and as needed for soiling. Observation on 1/22/25 at 10:15 A.M. showed: -Staff were inside the resident's room and responded doing cares when the door was knocked on; -There were no signs on the resident's door indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares. Observation on 1/22/25 at 11:10 A.M. showed: -An unidentified staff brought a mechanical lift into the resident's room and said he/she would be right back to get the resident up; -The unidentified staff went and got another unidentified staff person, they went into the resident's room and closed the door behind them, not wearing any PPE; -There were no signs on the resident's door indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares. Observation on 1/22/25 at 11:59 A.M. showed: -There were no signs on the resident's door indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares. Review of the resident's care plan showed: -The printed care plan dated 1/24/25 provided by the facility did not include any wounds; -The care plan in the EHR showed: --No care plan for the resident's wound on his/her cheek; --The problem identified updated on 1/24/25 was the resident had a venous/stasis ulcer (open lesion caused by poor blood flow) of the coccyx. Observation on 1/24/25 at 9:25 A.M. showed: -There were no signs on the resident's door indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares. Observation on 1/27/25 at 10:08 A.M. showed: -There were no signs on the resident's door indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares. Observation on 1/27/25 at 3:06 P.M. showed: -Agency Licensed Practical Nurse (LPN) E did not wear a gown during the resident's wound treatments; -There were no signs on the resident's door indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares. During an interview on 1/28/25 at 10:40 A.M., LPN B said he/she did not know anything about EBP, and the facility had not provided any education on EBP. During an interview on 1/28/25 at 10:45 A.M. Certified Nursing Assistant (CNA) E and CNA F said: -They had never heard of EBP; -They were not doing EBP at the facility; -There had been no education on EBP at the facility. During an interview on 1/30/25 at 9:30 A.M. Certified Medication Technician (CMT) C said: -They were not doing EBP at the facility before this week; -Staff had not had education on EBP; -He/She did not know which residents should have been on EBP or what was expected of staff other than what was now on the signs. During an interview on 1/30/25 at 9:40 A.M. LPN C said: -He/She had not known what EBP was before this week; -They had not had education on EBP as to what was expected or who should have been on it. During an interview on 1/31/25 at 3:30 P.M. the DON said: -He/She had not heard of EBP before and were not following it; -There should have been an EBP sign on the resident's door and an isolation cart with PPE also at the door. 42955 6. Review of Resident #37's face sheet, undated, showed the resident had the following diagnoses: -Quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs and the torso) -The resident had a colostomy and a suprapubic catheter; -The resident had cystostomy (an opening into the urinary bladder by surgical incision). Review of the resident's TAR dated November 2024 showed: -The resident received colostomy care as ordered; -The resident received urinary catheter care as ordered. Review of the resident's December 2024 TAR, showed: -The resident received colostomy care as ordered; -The resident received urinary catheter care as ordered. Review of the resident's care plan dated 12/17/24, showed: -The resident had Clostridium Difficile (C-diff -a bacterium that caused an infection of the colon); --The resident was on contact isolation (gowns and masks should be worn when changing contaminated linens); --The resident remained free from discomfort, complications or signs and symptoms of gastro-intestinal alterations; -The resident had an indwelling suprapubic catheter; -The resident had a colostomy. Review of the resident's POS for all orders until 1/28/25, showed the resident had orders for: -Change colostomy bag every three days as needed; -Urinary catheter care every shift; -Change the urinary drainage bag every night shift on Sundays. During an interview on 1/27/25 at 12:54 P.M., CNA A said: -The resident had catheter care; -He/She used gloves when catheter care was provided; -No other PPE was used; -He/She did not remember a PPE cart being outside of the resident's door; -He/She was unaware of EBP. During an interview on 1/27/25 at 1:12 P.M., CNA B said: -He/She provided catheter care to the resident; -He/She was unaware of any issues with the residents catheter care; -He/She wore gloves as part of the residents catheter care; -He/She did not wear other PPE; -He/She was unaware that he/she was supposed to. During an interview on 1/28/25 at 9:30 A.M., LPN A said: -The resident had a catheter; -The resident received catheter and colostomy care from the CNA's; -He/She was familiar with and implemented EBP practices; -The other staff should have used EBP during catheter and colostomy cares, but he/she was unaware if other staff were; -There were no PPE carts outside of the resident's room; -He/She had PPE in the medication cart, in the clean utility closet and sometimes behind the nurses station desk. During an interview on 1/31/25 at 4:55 P.M. the Assistant Director said: -There were no EBPs put into place for this resident; -The resident should have been on EBP; -He/She received EBP training on 1/28/25; -The new DON was not aware of the EBP protocols; -The nurses were responsible for providing the care to the resident and should have used EBP; -They were not practicing EBP; -He/She was unaware if appropriate PPE was available for EBP; -He/She was unaware of the location of the PPE. 39469 7. Observation on 1/22/25 at 2:00 P.M. showed: -There were no signs on Resident #3, #9, #30, #39, and #37's doors indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares on residents who should have been on EBP. Observation on 1/23/25 at 10:00 A.M. showed: -There were no signs on Resident #3, #9, #30, #39, and #37's doors indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares on residents who should have been on EBP. Observation on 1/24/25 at 9:36 A.M. showed: -There were no signs on Resident #3, #9, #30, #39, and #37's doors indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares on residents who should have been on EBP. Observation on 1/27/25 at 9:00 A.M. showed: -There were no signs on Resident #3, #9, #30, #39, and #37's doors indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares on residents who should have been on EBP. 8. Review of Resident #30's quarterly MDS dated [DATE] showed: -He/She was moderately cognitively impaired; -He/She was at risk for pressure sores; -He/She had an application of non surgical dressings to a place other than feet, dated 8/15/24; -He/She had an application of dressings to feet. Observation on 1/24/25 at 10:15 A.M. showed: -Two Certified Nursing Assistants (CNA)s entered the resident's room to do incontinent cares; -The two CNA's were not wearing PPE; -There was no sign on his/her door indicating he/she should have been on EBP; -There was no isolation cart with PPE in or by the room. Observation on 1/24/25 at 1:00 P.M. showed: -There were no signs on Resident #3, #9, #30, #39, and #37's doors indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares on residents who should have been on EBP. 9. Review of the facility's policy, Handwashing/Hand Hygiene, dated August 2019 showed: -All personnel should have been trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. -All personnel should have followed the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Use an alcohol-based hand rub or soap and water for the following situations: -Before and after direct contact with residents. -Before and after handling an invasive devise. -Before donning sterile gloves. -Before handling clean or soiled dressing. -Before moving from a contaminated body site to a clean body site during resident care. -After contact with a resident's intact skin. -After handling used dressings or contaminated equipment. -Before and after entering isolation precaution settings. -Hand hygiene was the final step after removing and disposing of PPE. Review of Resident 39's quarterly MDS dated [DATE] showed: -He/She was cognitively intact; -He/She was always incontinent of bowel and bladder; -He/She was at risk of developing skin ulcers; -He/She did not have an unhealed pressure ulcers. Review of the resident's skin monitoring/shower sheets dated December 2024 showed on 12/12/24 he/she had a spot on his/her buttock. Review of the resident's skin monitoring/shower sheets dated January 2025 showed: -On 1/13/25 he/she had an open sore on his/her buttock; -His/her peri area was very red; -On 1/20/25 he/she had a sore on his/her bottom; -His/her peri area was irritated. Review of the resident's Medication Administration Record (MAR) dated January 2025 showed: -Predisone Acetate Ophthalmic (medication used for inflammation or injury to the eyes) Suspension 1% to instill one drop in left eye one time a day dated 8/27/24; -Xalatan Ophthalmic solution (used to treat high pressure in the eye) 0.005% to instill one drop in each eye at bedtime for eye drops; -Cyclosporine emulsion (to treat dry eye) 0.005% to instill one drop in both eyes two times a day for dry eye; -Dorzolamide Hydrochloride solution 2% to instill one drop in let eye two times a day for dry eye; -Cleanse the buttocks wound with wound cleanser, gently pat dry, and cover with dressing daily and as needed, dated 12/27/24. The resident's care plan was requested and not provided by time of exit. Observation on 1/28/25 at 10:16 A.M. of wound care with Licensed Practical Nurse (LPN) B showed: -There was no EBP sign on the resident's door; -There was no isolation cart with PPE outside the resident's door; -CNA's E and F had moved the resident from his/her wheelchair to the bed; -CNA's E and F had assisted the nurse to reposition the resident in the bed and took off his/her pants to do wound care; -LPN B and CNA E and F had gloves on but no gown; -CNA's E and F removed the resident's paper brief; -LPN B wiped off the old cream on the resident's coccyx area; -The resident then urinated; -LPN B cleaned the urine off of the resident; -LPN B did not change gloves or wash hands before applying the cream.; -LPN B and CNA E and F took off their gloves but did not wash their hands when they left the room. During an interview on 1/28/25 at 10:40 A.M. LPN B said: -They should have washed their hands before they left the resident's room; -He/She did not know anything about EBP, the facility had not provided any education on EBP. During an interview on 1/28/25 at 10:45 A.M. CNA E and CNA F said: -They had never heard of EBP; -There had been no education on EBP at the facility; -They should have washed their hands after they took their gloves off before they left the room. Observation on 1/28/25 at 3:40 P.M. of pictures of the resident's buttock wounds showed: -There were three quarter sized stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) wounds on the residents coccyx area three weeks ago; -An area around the wounds that measured 10 centimeters (cm) by 6 cm was extremely reddened. During an interview on 1/30/25 at 4:00 P.M. the resident's family member said: -He/She came to to see the resident every night when he/she got off of work; -In the evening, staff were not wearing a gown or gloves when doing cares on the resident even though there has been a sign on the door and an isolation cart by the resident's door; -The Certified Medication Technician (CMT) C never wore gloves when he/she administered eye drops to the resident. 10. Review of Resident #3's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Gastrostomy status (a thin, flexible tube inserted through the abdominal wall and into the stomach to provide nutrition for those who can not eat); -Bladder neck obstruction (a condition in which the opening of the bladder is narrowed or blocked preventing urine from flowing freely); -Retention of urine (difficulty urinating and completely emptying the bladder). -Diarrhea (loose watery stools that occur frequently). Review of the resident's quarterly MDS dated [DATE] showed: -He/She was cognitively intact; -Having a catheter was not checked; -He/She was incontinent of bowel and bladder; -Had a feeding tube; -He/She did not have a pressure ulcer. Review of the resident's Skin monitoring/Shower sheet dated December 2024 showed on 12/18/24 the resident had a red area on his/her buttock and abdomen. Review of the resident's Skin monitoring/Shower sheet dated January 2025 showed on 1/27/25 his/her peri area and buttock were red. Review of the resident's POS dated January 2025 showed: -Give one and one half cartons of Jevity (a calorie dense therapeutic nutrition) 1.2 calorie three times a day; -Urinary catheter (a tube placed in the body to drain the urine) care every shift related to bladder-neck obstruction; -Nothing by mouth (NPO); -Apply protective house stock barrier cream/boarder foam to Stage I (skin that appears red but does not have a break in it) buttock area every morning and night for wound healing/infection prevention; -Cleanse lower abdominal rash/abrasion with wound cleanser cover with boarder gauze (a absorptive dressing that consists of three layers) one time a day for wound care relate to cellulitis (a potentially serious bacterial skin infection) of abdominal wall; -Cleanse coccyx wound area with wound cleanser, pat dry, apply Xeroform (a non adherent dressing that maintains a moist wound) or calcium alginate (absorbs wound fluid) and cover with wound dressing. Review of the resident's care plan dated 1/27/25 showed: -He/She had a peg tube for feeding daily; -He/She had an indwelling suprapubic catheter; -NOTE: The resident did not have a suprapubic catheter, the resident had an indwelling catheter; --Staff was to change indwelling catheter as indicated; -He/She had potential impairment to skin integrity related to decreased bed mobility. Lower abdominal rash/abrasion; --Staff was to cleanse wound with wound cleanser, barrier cream, foam dressing, border gauze; -He/She had a urinary tract infection on 8/25/24; --Staff should follow good hygiene practices; -He/She had a nutritional problem or potential nutritional problem related to being NPO and having a feeding tube for feeding; -Staff was to provide and serve diet as ordered; --NOTE: The resident was NPO and was not have anything by mouth; -Staff was to have snacks available between meals; --NOTE: The resident was NPO and was not have anything by mouth. Observation on 1/30/25 at 9:10 A.M. of the resident's wound care with LPN C and LPN C showed: -The resident's anal area was reddened and had stool on it; -LPN C cleaned the stool off the resident and then changed gloves without washing his/her hands; -LPN C wiped off the old ointment; -LPN C helped to change the residents position; -LPN C did not change gloves or wash his/her hands before applying the boarder gauze; -LPN C applied zinc oxide then took off gloves and washed his/her hands. During an interview on 1/30/25 at 9:30 A.M. CMT C said: -They were not doing EBP at the facility before this week; -Staff had not had education on EBP; -He/She did not know which residents should have been on EBP; -He/She did not know what was expected of staff other than what was now on the signs; -Staff should wash their hands every time gloves were changed; -When staff do resident cares hands should be washed before and after cares. During an interview on 1/30/25 at 9:40 A.M. LPN C said: -He/She should have washed his/her hands every time he/she changed gloves. -He/She forgot to do that. -He/She had not known what EBP was before this week. -They have not had education on EBP or told what was expected or who should have been on EBP. -The resident had an indwelling catheter, a feeding tube, and open areas on his/her skin. 11. During an interview on 1/31/25 at 3:30 P.M. the DON said: -No one was responsible to ensure staff were performing appropriate hand hygiene; -He/She had not heard of EBP and was not following it; -When doing wound care staff should have washed their hands before and after cares; -Staff were expected to wash hands and change gloves when going from dirty to clean during wound care; -Staff were expected to use gloves when administering eye drops; -He/She recently learned that any resident who had a catheter, feeding tube, or open areas should have been on EBP; -There should have been a sign on the door and an isolation cart also at the door; -Residents who were on EBP was something that should have been passed on during report. MO00247709

Based on observation and interview, the facility failed to maintain the ceiling vent in the dining room free of a heavy buildup of dust; failed to maintain the 80 Hall free of a persistent urine odor; failed to ensure the hot water in resident rooms 86, 84, 82 was at or above 105 F (degrees Fahrenheit); failed to ensure there was not a buildup of dust and debris on the floor in resident rooms [ROOM NUMBERS]; failed to prevent a heavy buildup of dust in the ceiling vents in 50 Hall Shower Room A, 20 Hall Shower Room A, and in the restroom of resident room [ROOM NUMBER]. This practice potentially affected at least 40 residents who resided in, or used those areas in the facility. The facility census was 55 residents. 1. Observation on 1/28/25 at 11:45 A.M., with the Maintenance Director showed a heavy buildup of dust in the ceiling vent in the dining room. During an interview on 1/28/25 at 11:46 A. M, the Maintenance Director said the ceiling vent looked like it had not been cleaned in a while. 2. Observations on 1/28/25 with the Maintenance Director showed the following rooms on the 80 Hall: -At 11:51 A.M. there was a strong urine odor in the hall in general. -At 11:53 A.M. there was a strong urine odor in resident room [ROOM NUMBER]. -At 11:58 A.M. there was a strong urine odor in resident room [ROOM NUMBER] -At 11:59 A.M., there was a strong urine odor in resident room [ROOM NUMBER]. -At 12:07 P.M., there was a string urine odor in resident room [ROOM NUMBER]. Observation on 1/28/25 from 12:15 P.M. to 3:00 P.M., showed: -The 80 Hall in general had a strong urine odor. -room [ROOM NUMBER] had a strong urine odor. -room [ROOM NUMBER] had a strong urine odor. -room [ROOM NUMBER] had a strong urine odor. -room [ROOM NUMBER] had a strong urine odor. During an interview on 1/29/25 at 2:24 P.M., Housekeeper A said the following regarding the urine smell in the 80 Hall: -He/she did not think the cleaning agents were strong enough to get the smell out. -He/she sprayed the cleaning agent on the floor and mopped the floors in the restroom of those rooms where most of the urine odor originated. -He/she sprayed the cleaning agent on the toilets and wiped the toilets down. -Some of the residents have problems and urinate on the floor and the urine may soak into the floor. -The smell did not go away even after cleaning. Observation on 1/29/25 at 2:31 P.M., showed: -The floor of the shared restroom between resident rooms [ROOM NUMBERS] was very sticky. -Shoes stuck to the floor while walking in that restroom. -There was a urine odor in the shared restroom. Observation on 1/30/25 at 10:00 A.M., showed there was a urine odor in the 80 hall in general. During an interview on 1/30/25 at 12:04 P.M., the Executive Director said he/she smelled the urine odor in the 80 Hall. During an interview on 1/31/25 at 9:09 A.M., the Executive Director said: -He/she had smelled the persistent urine odor in the 80 Hall. -He/she spoke with the Maintenance Supervisor about creating a Lead Housekeeper and trying to deep clean all the rooms on the 80 Hall. 3. Observation on 1/28/25 with the Maintenance Supervisor showed: -At 11:55 A.M., the hot water in resident room [ROOM NUMBER], was 81.3 F after the water was allowed to run for 2 or more minutes. -At 11:59 A.M., the hot water temperature in resident room [ROOM NUMBER], was 101.3 F -At 12:09 P.M., the hot water temperature in resident room [ROOM NUMBER] was 100 F. During an interview on 1/28/25 at 12:01 P.M., the Maintenance Director said: -He/she had only been working at the facility for a few weeks -He/she was not sure which hot water heater provided hot water to the resident rooms on the 80 Hall. 4. Observations on 1/28/25 with the Maintenance Director, showed a buildup of dust and debris in the following rooms: -At 12:24 P.M., there was a buildup of debris on the floor at the corner of the bed and the wall in resident room [ROOM NUMBER]. -At 2:16 P.M., there was a heavy buildup of dust on the floor in Shower Room A on the 50 Hall. -At 2:26 P.M., there was a heavy buildup of dust in the restroom ceiling vent in resident room [ROOM NUMBER]. -At 3:15 P.M., there was a buildup of cobwebs in the corner next to the bed on the floor in resident room [ROOM NUMBER]. Observations on 1/29/25 with the Maintenance Director, showed a buildup of dust and debris in the following rooms: -At 11:24 A.M., there was a heavy buildup of cobwebs behind the bed on the floor in resident room [ROOM NUMBER]. -At 11:31 A.M., there was a buildup of dust in the ceiling vent in Shower Room A of 20 Hall. During an interview on 1/29/25 at 11:35 A.M., the Maintenance Director said he/she expected housekeeping staff to clean the areas with the cobwebs and clean the areas behind the beds. During an interview on 1/29/25 at 2:32 P.M., Housekeeper B said: -His/her supervisors want the housekeepers to deep clean a couple rooms per day. -During a deep clean the housekeepers pull everything into the middle of the room. -During a regular clean, they dust the areas in the room they may spot clean. MO00247567

Based on interview and record review, the facility failed to ensure a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) (SNF/ABN-form Centers for Medicare and Medicaid Services (CMS)-10055) was provided to the resident or their representative for three sampled residents (Residents #41, #43, and #56) out of three sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled). The facility census was 55 residents. Review of the facility's Medicare Advance Beneficiary and Medicare Non-Coverage Notices policy, dated as revised September 2022, showed when Medicare A stops coverage of the resident's extended care items or services, the facility should issue a SNF/ABN before the extended care items or services are terminated. Review of the CMS memo (S&C-09-20), dated 1/9/09, showed: -If the SNF believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled using the SNF/ABN (form CMS-10055). -The SNF/ABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have. Review of the CMS website, updated 8/28/24, showed SNFs use the SNF/ABN as the liability notice for Medicare Part A items and services. 1. Review of the facility's Beneficiary Notice worksheet of residents discharged from Medicare Part A within the last six months form showed: -Resident #56 was discharged from Medicare A on 12/8/24. -Resident #41 was discharged from Medicare A on 11/13/24. -Resident #43 was discharged from Medicare A on 8/31/24. Review of Resident #56, #41, and #43's beneficiary notices showed none of the residents were provided with an SNF/ABN. During an interview on 1/27/25 at 1:44 P.M., the Social Services Director said he/she was told not to do the SNF/ABN on residents discharged off Medicare A services and to only provide the SNF/ABN when the resident was on Medicare B benefits that were ending. During an interview on 1/31/25 at 3:25 P.M., the Contract Administrator said the SNF/ABN should have been completed for Resident #56, #41, and #43.

Based on interview and record review, the facility failed to maintain records of reconciled (a process that takes place when the deposits, credits and interest that are on record but were not accounted for on the final bank statement; are added to the final amount on the bank statement, then checks and charges that are on record, but were not listed on the bank account statement, are subtracted from the adjusted final amount) banks statements dated January 2024 to September 2024; failed to maintain the monthly ending petty cash (small amount of discretionary funds in the form of cash used for small cash disbursements) amounts from January 2024 to December 2024; failed to maintain signatures or receipts of withdrawals from one sampled resident's (Resident #5's) account; failed to post (make a record of ) deposits into the resident trust fund accounts in a timely manner for two sampled residents (Resident#5 and #2) of four residents selected for resident trust fund review. This practice potentially affected 44 residents who allowed the facility to manage their resident trust funds. The facility census was 55 residents. Review of the facility's policy entitled Resident Trust Policy and Procedures, dated March 2023, showed: -Purpose: Baptist Homes and Healthcare Ministries need to be good stewards of the money entrusted to us by our residents and their families. This policy and procedures document outlines a general guide and specific steps on how to handle resident trust funds across the organization. -General Information regarding responsibilities off holding Resident Funds: --The facility shall keep an accurate, maintained accounting system for the residents that choose to have their personal funds managed. These funds shall be safeguarded by the facility, using complete and separate accounting principles, which precludes any commingling of resident funds with facility funds. --Personal Funds of the resident shall be used exclusively for the resident, which must be authorized in writing. The individuals who can authorize such transactions may be the resident, his/her legal guardian, or a legal representative (who may not be an employee at the facility, including the Administrator). The facility is allowed to purchase a burial plan for the resident when written authorization is obtained. --Records related to the resident funds shall be maintained in the facility or shall be made available for review and copying, in their entirety, within 24 hours of a request for access by the Social Security Administration, Missouri Department of Health and Senior Services or other Federal and State Agencies. --Social Security checks (SSA) that include both room and board and the monthly personal allowance should be deposited in the resident trust account and then the room and board amount is transferred to the site account. 1. Review of the Reconciled Bank statements, dated January 2024 to December 2024, showed: -The absence of the bank statements from January 2024 to September 2024. -The absence of the monthly ending balances of petty cash dated January 2024 to December 2024. During an interview on 1/23/25 at 11:40 A.M., the Assistant Director said the reconciled bank statements should be uploaded to a file at the corporate level. During an interview on 1/23/25 at 11:44 A.M., the Business Office Manager (BOM) said there was no documentation of reconciled bank statements from January 2024 to September 2024. During an interview on 1/23/25 at 11:58 A.M., the BOM said the previous BOM has been gone since 11/5/24, and that BOM did not do reconciliations of the bank statements. During an interview on 1/23/25 at 3:17 P.M., the BOM said: -He/she was trying to figure out the record keeping processes of the facility. -The reconciliations from January 2024 to September 2024 should have been uploaded to the corporate file for the facility. 2. Review of the Petty Cash Count Sheet (a one day accounting of how much money was actually in the petty cash box and added to the amount of money that had already been withdrawn over a certain time period) showed a difference of $19.00 between the amount in the petty cash box and added to the amount that was already spent. -The beginning amount of the petty cash was $500.00 on 12/18/24. -The amount in the petty cash box was $180.00 -The amount of money that was already spent, was $301.00. -There was a difference of $19.00 between what the amount should have been $500.00 and the amount that was totaled on the Petty Cash Count sheet, which was $481.00. During an interview on 1/23/25 at 12:07 P.M., the BOM said the facility had not tracked any petty cash in October 2024, November 2024, and December 2024. During an interview on 1/23/25 at 1:37 P.M., the BOM said: -He/she started on 12/17/24 and he/she may have missed recording cash withdrawals on 12/18/24 and 12/19/24 just a few days after he/she started. 3. Review of Resident #5's Trust Statement showed: -A deposit of $1,493.00 which was transferred into the resident's account in October 2024. -The absence of the amount being posted (properly accounted for) in that month. -The amount of $1,493.00 was posted on 12/31/24, which caused the resident trust account to increase to $6,789.79, which was above the Missouri (MO) Health Net limit of $5,909.25. During an interview on 1/23/25 at 12:46 P.M., the BOM said: -There was a deposit for $1,493.00 that originally came in October 2024, but was not posted by the previous BOM. -That amount did not get posted until 12/31/24 by the current BOM, which caused the resident's account balance to exceed the MO Healthnet limit. 4. Review of Resident #2's Trust Statement showed: -A deposit of $1,395.00 which was transferred into that resident's account in October 2024. -The absence of the amount being posted in that month. -The amount of $1,395.00 was finally posted on 12/31/24 which caused the resident trust account to increase to $5,921.88, which is above the MO Health Net limit of $5,909.25. During an interview on 1/23/25 at 12:58 P.M., the BOM said: -There was a deposit of $1,395.00 that came in October 2024, but was not posted in October 2024 by the previous BOM. -That amount did not get posted until 12/31/24 by the current BOM which caused the resident's account balance to exceed the MO Healthnet limit. 5. Review of Resident #5's trust statement showed a withdrawal of $100.00 on 9/10/24 and a withdrawal of $50.00 on 10/10/24 with no receipt or signature for the withdrawals. During an interview on 1/23/25 at 12:51 P.M., the BOM said: -He/she started the position at the facility on 12/17/24. -There were no receipts or signatures for the withdrawals completed in September 2024 and October 2024.

Based on interview and record review, the facility failed to maintain authorization forms for three sampled residents (Residents #5, #2, and #39) out of four residents sampled for the resident trust review. The facility census was 55 residents. Review of the facility's policy entitled Resident Trust Policy and Procedures, dated March 2023, showed: -Purpose: Baptist Homes and Healthcare Ministries need to be good stewards of the money entrusted to us by our residents and their families. -This policy and procedures document outlines a general guide and specific steps on how to handle resident trust funds across the organization. -General Information regarding responsibilities of holding Resident Funds: --Personal Funds of the resident shall be used exclusively for the resident, which must be authorized in writing. The individuals who can authorize such transactions may be the resident, his/her legal guardian, or a legal representative (who may not be an employee at the facility, including the Administrator). The facility is allowed to purchase a burial plan for the resident when written authorization is obtained. 1. Review of the Resident Fund records for Resident #5 showed the absence of signed authorization forms which allowed the facility to manage funds on behalf of the residents. 2. Review of the Resident Fund records for Resident#2 showed the absence of signed authorization forms which allowed the facility to manage funds on behalf of the residents. 3. Review of the Resident Fund records for Resident #39 showed the absence of signed authorization forms which allowed the facility to manage funds on behalf of the residents. During an interview on 1/23/25 at 3:31 P.M., the Business Office Manager (BOM) said: -The previous BOM did not keep track of the authorization forms, which were signed by the residents. -He/she had only been in the position since December 17, 2024.

Based on observation, interview, and record review, the facility failed to accurately reflect the resident's status on Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) assessments for three sampled residents (Resident #9, #40, and #3) out of 14 sampled residents. The facility census was 55 residents. Review of the facility MDS 3.0 Process policy, dated 1/1/24, showed: -The facility should complete an accurate MDS. -The MDS should be signed by everyone completing any portions of the assessment to certify the accuracy of the portion of the assessment he/she completed. 1. Review of Resident #9's care plan, dated 7/25/23, showed the resident had a pressure ulcer (any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s)) that was a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) to his/her right face cheek related to heart disease, right sided weakness, chronic pain, incontinence, and weight loss. Review of the resident's Treatment Administration Record (TAR), dated November 2024, showed: -Treatment orders for the resident's coccyx wound dated 2/9/24. -Treatment orders for the resident's face cheek wound dated 7/3/24. Review of the resident's Physician's Order Sheet (POS), dated January 2025, showed: -A physician's order for hospice dated 7/28/23. -A physician's order for a wound treatment for the resident's coccyx dated 2/9/24 . -A physician's order for a wound treatment for the resident's right cheek dated 12/23/24. Review of the resident's quarterly MDS dated [DATE] showed: -The resident was not on hospice (end of life care). -The skin section was marked as not assessed. -Section GG (functional abilities): The resident was dependent on staff for all cares. Review of the resident's care plan, dated January 2025, showed the resident had a Stage IV pressure ulcer on his/her right cheek. Review of the resident's hospice nurse's note, dated 1/15/25, showed the hospice nurse documented that he/she completed the treatments on the resident's coccyx and cheek wounds. Review of the resident's care plan, updated 1/24/25, showed: -The resident had a venous/stasis ulcer (open lesion caused by poor circulation) of the coccyx treatment in place. -No care plan for the resident's cheek wound. Observation on 1/27/25 at 3:06 P.M. with Licensed Practical Nurse (LPN) E showed: -The resident had a wound on his/her coccyx and a wound on his/her face on the right cheek. -LPN completed the wound treatments on both wounds. During an interview on 1/30/25 at 9:08 A.M., the MDS Coordinator said: -Not marking the resident for hospice was a mistake. -The resident had been on hospice for a long time. -He/She started doing wound rounds with the wound doctor two weeks ago since no one else was doing it. -He/She rounded with the wound doctor, entered in wound treatment orders, and did not have time to do care plans or MDSs. -He/She was also assigned additional duties at times such as working as a floor nurse and giving showers so he/she was not able to update the MDS. -The MDS should be accurate. During an interview on 1/31/25 at 3:25 P.M., with the Director of Nursing (DON) present, the Executive Director said: -Hospice should have been marked yes. -The MDS Coordinator and the DON were supposed to complete the wounds section. -The MDS Coordinator had been pulled to other duties so he/she didn't have time to update the MDS. -The MDS should be complete and accurate. 2. Review of Resident #40's quarterly MDS dated [DATE] showed the resident was on an anticoagulant medication. Review of the resident's Medication Administration Record (MAR), dated November 2024, showed: -No orders for an anticoagulant (medication used to slow down the process of making blood clots) medication. -A physician's order, dated 9/27/24, for aspirin which was an antiplatelet (prevent blood cells called platelets from clumping together to form a clot) medication. During an interview on 1/30/25 at 9:08 A.M., the MDS Coordinator said he/she accidentally marked anticoagulant medication when antiplatelet medication should have been marked. During an interview on 1/31/25 at 3:25 P.M., with the DON present, the Executive Director said: -The charge nurse and the DON were responsible for completing the medication section. -The MDS should have reflected the correct medication classification. -The MDS should be complete and accurate. 39469 3. Review of Resident #3's face sheet, undated, showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD-a condition causing constriction of the airways and difficulty or discomfort in breathing). -Bipolar disorder (mental health condition that caused extreme mood swings). -Vascular dementia (impaired supply of blood to the brain). Review of the resident's quarterly MDS, dated [DATE], showed the cognitive status section of the MDS was not completed. Review of the resident's care plan, dated 11/5/24, showed: -The resident had potential impairment to skin integrity and received wound management. -The resident had a peg tube (a thin, flexible tube inserted through the skin of the abdomen directly into the stomach) in place. -The resident had a suprapubic catheter (a medical device that drained urine from the bladder through a small incision in the abdomen). Review of the resident's Physician Order Summary, dated January 2025, showed: -The resident had a peg tube. -The resident had a urinary catheter (a tube placed in the body to drain and collect urine from the bladder). -The resident had a pressure ulcer on his/her coccyx (small bone at the end of the spine). Review of the resident's quarterly MDS, dated [DATE], showed: -The resident's cognitive status section of the MDS was not completed. -The resident showed no skin conditions present at time of assessment. --The resident had a pressure ulcer at the time of the assessment. -NOTE: The resident had a peg tube and a urinary catheter in place at the time of the assessment that were not identified on the assessment. Observation on 1/22/25 at 10:44 A.M., showed: -The resident had a wound on his/her coccyx. 4. During an interview on 1/23/25 at 10:09 A.M., the MDS Coordinator said: -He/She was called in to work the floor a lot and his/her MDS updates didn't always get done. -He/She had not been able to complete care plans. -Residents were assessed when they were admitted and again quarterly, or as needed with changes in the resident's condition. -Resident #3's peg tube should have been identified on the MDS. -Resident #3's urinary catheter should have been identified on the MDS. During an interview on 1/29/25 at 10:32 P.M., LPN A, said: -The MDS Coordinator completed the resident's MDSs. -Nurses did not complete the resident MDSs. -Nurses told the MDS Coordinator when something changed with the resident. During an interview on 1/31/25 at 4:44 P.M., the DON said: -Residents with pressure ulcer should have those reflected in the MDS. -He/She would expect to see peg tube and urinary catheter on the MDS. -He/She expected the MDS to reflect current and up to date resident information.

Based on observation, interview, and record review, the facility failed to provide continuity of resident care by not reviewing and revising resident comprehensive care plans for four sampled residents (Resident #15, #28, #39, and #9) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated March 2022, showed: -A comprehensive care plan was developed for each resident. -The care plan was developed within seven days of the completion of the resident's required Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) and no more than 21 days after admission. -Assessments of residents were ongoing and care plans were reviewed and revised as information about the resident and resident's conditions change. -The interdisciplinary team (facility staff and health care professionals who work together to manage the physical, psychological, and spiritual needs of the resident) reviewed and updated care plans at least quarterly. Review of the facility's MDS Coordinator Job Description, dated March 2023, showed: -To ensure timely, accurate, and complete assessment of the resident's health and functional status during the entire assessment period. -Participate in the interdisciplinary team process to communicate opportunities, facilitate efficient and effective care plan development and management. -Communicate with care team regarding practitioner orders, care plans, and changes in condition. 1. Review of Resident #15's face sheet, undated, showed the resident admitted to the facility on [DATE] with the following diagnoses: -Otalgia (a condition which caused discomfort, aching, or sharp pain in one or both ears). -Unspecified hearing loss. -Anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress). Review of the resident's Hearing Aid Purchase Agreement, dated 7/3/24, showed the resident received a new hearing aid for his/her left ear. Review of the resident's quarterly MDS, dated [DATE], showed: -The resident had minimal difficulty hearing. -The resident did not have hearing aids. During an interview on 1/24/25 at 8:57 A.M., the resident said: -He/She needed batteries for his/her hearing aid. -He/She asked staff to replace them. Observation on 1/24/25 at 8:57 A.M., showed: -The resident was speaking to the surveyor. -The surveyor had to speak loudly for the resident to understand what was being said. -The resident was fidgeting with his/her hearing aid and a pack of unused hearing aid batteries. During an interview on 1/27/25 at 12:54 P.M., Certified Nursing Assistant (CNA) A said: -He/She did not remember the resident having a hearing aid. -The resident had not asked him/her for batteries. During an interview on 1/27/25 at 1:12 P.M., CNA B said he/she was unaware if the resident had hearing aids. During an interview on 1/28/25 at 9:30 A.M., Licensed Practical Nurse (LPN) A said: -He/She had never seen the resident with hearing aids. -If a resident did wear hearing aids it should be on the resident's care plan so staff were aware of the use of hearing aids. During an interview on 1/30/25 at 10:44 A.M., LPN C said: -Resident care plans should have current information. -Hearing aids should be in the care plan. -Resident #15 had a hearing aid in his/her left ear. -He/She checked the EHR and did not see hearing aids on the care plan. During an interview on 1/31/25 at 3:25 P.M., with the Director of Nursing (DON) present, the Executive Director said: -Resident #15 had a hearing aid. -The hearing aid should have been addressed in the resident's care plan. 2. Review of Resident #28's face sheet, undated, showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Alzheimer's Disease (a brain disorder that included loss of memory, confusion, difficulty thinking, and changes in language, behavior, and personality). -Age related physical debility. -Anxiety. Review of the resident's Hospice (end of life care) contract, dated 8/27/24, showed the resident entered Hospice care on 8/27/24. Review of the resident's care plan, dated 11/13/24, showed no documentation of the resident receiving Hospice care. Review of the resident's quarterly MDS, dated [DATE], showed: -The resident was severely cognitively impaired. -The resident was on Hospice. Review of the resident's Hospice Book, undated showed the resident had received visits from Hospice personnel throughout the months of December 2024 and January 2025. During an interview on 1/22/25 at 9:37 A.M., the resident's family member said the resident was on Hospice. During an interview on 1/30/25 at 10:44 A.M., LPN C said: -The resident care plans should have current information. -Hospice care should be in the care plan. -Resident #28 was on Hospice. -He/She checked the EHR and did not see Hospice on the care plan. During an interview on 1/31/25 at 3:25 P.M., with the Director of Nursing (DON) present, the Executive Director said: -Resident #28 was receiving Hospice services. -Hospice should have been addressed in the resident's care plan. 3. Review of Resident #39's Admission MDS dated [DATE] showed: -He/She was cognitively intact. -The resident was dependent on staff for feeding assistance. Review of the resident's electronic care plan, dated 11/15/24, showed: -No goals or interventions regarding feeding assistance was addressed. -NOTE: a paper copy of the care plan was requested and not received Review of the resident's quarterly MDS, dated [DATE], showed: -The resident was cognitively intact. -The resident was at risk for malnutrition. -The resident was dependent on staff for feeding assistance. -He/She was diagnosed with muscle weakness. During an interview on 1/22/25 at 8:30 A.M. the resident's family member said: -The resident needed feeding assistance. -The staff were not feeding the resident. During an interview on 1/29/25 at 10:32 A.M., LPN A said: -The resident required total assistance from staff with feeding. During an interview on 1/30/25 at 10:44 A.M., LPN C said: -The resident was totally dependant on staff for feeding. During an interview on 1/31/25 at 3:25 P.M., with the Director of Nursing (DON) present, the Executive Director said: -The resident was dependent on staff for feeding assistance. -The resident's care plan should have reflected the total dependence on staff for feeding assistance. 22727 4. Review of Resident #9's significant change MDS, dated [DATE], showed the resident had no wounds. Review of the resident's care plan, dated 7/25/23, showed: -The resident had a stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear) to his/her face on the right cheek. -The resident had a venous/stasis ulcer (open lesion caused by poor circulation) of the coccyx with a treatment in place. Review of the resident's quarterly MDS, dated [DATE], showed the resident had one stage III (full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon or muscle is not exposed) pressure ulcer. Review of the resident's quarterly MDS, dated [DATE], showed the resident had four stage IV pressure ulcers. Review of the resident's care plan, updated 1/24/25, (third day of the survey) showed: -The resident had a venous/stasis ulcer of the coccyx with treatment in place. -The care plan did not include the resident's facial wound on his/her cheek. Review of the resident's Physician's Order Sheet (POS) dated January 2025 showed: -Physician's orders for a treatment to the resident's coccyx dated 2/7/24. -Physician's orders for a treatment to the resident's face on the right cheek dated 12/23/24. Observation on 1/27/25 at 3:06 P.M., with LPN E showed: -The resident had a wound on his/her coccyx and a wound on his/her face on the right cheek. -LPN E completed the wound treatments on both wounds. During an interview on 1/29/25 at 10:32 A.M., LPN A said: -The MDS Coordinator developed the care plans. -The nurses told the MDS Coordinator of any changes with the residents and then the MDS Coordinator was responsible for updating the care plan. During an interview on 1/30/25 at 9:08 A.M., the MDS Coordinator said: -The family told him/her they weren't aware of the wound on the resident's cheek. -He/She read somewhere that the resident had the cheek wound when he/she admitted to the facility. -He/She was told the resident's cheek wound was cut off. -He/She was responsible for developing the care plans. -He/She was assigned other duties such as working as a floor nurse and doing baths so sometimes he/she didn't have time to do care plans. 5. During an interview on 1/23/25 at 10:09 A.M., the MDS Coordinator said: -He/She was called to work the floor a lot. -He/She had not completed or updated all the care plans. -He/She had been in the position for two weeks and the MDS Coordinator before him/her was not doing the care plans correctly. -Care plan changes need to be updated quarterly and with any changes in resident's condition. During an interview on 1/27/25 at 12:54 P.M., CNA A said: -He/She found information about residents on their care plan. -He/She was unaware of when care plan updates were completed. During an interview on 1/27/25 at 1:12 P.M., CNA B said: -Care plans could be seen on the resident's medical record. -Care plans should be up to date. During an interview on 1/29/25 at 10:32 A.M., LPN A said: -Nurses do not update care plans. -Nurses told the MDS Coordinator when something needed updated. -The MDS Coordinator then updated the care plans. During an interview on 1/31/25 at 3:25 P.M., with the Director of Nursing (DON) present, the Executive Director said: -Any wounds that were present upon admission should be in the care plan. -Updates to care plans should stem from communication between the DON and the MDS Coordinator. MO00247435

Based on observation, interview, and record review, facility staff failed to assess, monitor, and implement and document interventions and treatments in order to prevent new pressure ulcers and/or prevent current pressure ulcers from worsening for one sampled resident (Resident #5) out of 17 sampled residents. Facility staff failed to follow physician's orders [REDACTED]. or black) in the wound bed), and failed to identify and treat a pressure ulcer on the left buttock, which resulted in an unstageable pressure ulcer, for one resident (Resident #5). Facility staff failed to notify a resident's physician in a timely manner and failed to provide an accurate description of the resident's pressure ulcer for one resident (Resident #5). Additionally, facility staff failed to accurately identify a pressure ulcer on a resident's right foot, which resulted in an unstageable pressure ulcer, for one resident (Resident #19). The facility census was 64 residents. Record review of the facility's Care and Prevention of Pressure Ulcer policy, dated March 2015, showed staff were directed to: -Observe skin, any persistent reddened area that remains after pressure is relieved is a high risk area for a pressure ulcer to begin; -Use pressure-reducing devices to relieve pressure; -Turn the resident every two hours and position with pads or pillows to protect bony prominences; -Use elbow and heel protectors if needed. Record review of the facility's Wound and Skin Care Program policy, dated October 2011, showed staff were directed to: -Nurse Aides should complete a Comprehensive Certified Nursing Assistant (CNA) Shower Review on all residents when they are bathed or showered and give to the charge nurse; -CNAs should observe skin integrity during the daily provision of routine care and report any impairments to the charge nurse for appropriate and timely follow-up; -The charge nurse should review, sign, and address any conditions noted; -The Comprehensive CNA Shower Review should be reviewed by the Director of Nursing (DON) at least weekly; -Residents should be examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers; -Findings from the weekly skin assessment should be documented by the licensed nurse on a Weekly Skin Assessment form or on a Licensed Nurse Weekly Skin Assessment form; -When a pressure ulcer is present, daily monitoring (with accompanying documentation when a complication or change is identified) should include: --An evaluation of the pressure ulcer, if no dressing is present; --An evaluation of the status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking); --The status of the area surrounding the ulcer (that can be observed without removing the dressing); --The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example, increased redness or swelling around the wound or increased drainage from the wound), and whether pain, if present, is being adequately controlled; -When assessing an ulcer, it is important to differentiate between pressure-related versus non-pressure-related ulcers, determine the ulcer's stage, and describe and monitor the ulcer's characteristics; -The Wound Nurse, or designee, should maintain and update a list of resident's who have been identified to be at high risk, and an assessment and documentation schedule. Record review of the facility's Skin Monitoring: Comprehensive CNA Shower Review form showed staff were directed to: -Perform a visual assessment of a resident's skin when giving the resident a shower and to report any abnormal skin to the charge nurse immediately; -Forward any problems to the DON for review; -Use the form to show the exact location and description of the abnormality. -Sign and date the form when completed by the CNA; -Sign and date the form when reviewed by the charge nurse and complete an assessment with interventions; -A box was provided to indicate if the form was forwarded to the DON; -The DON was to sign and date the form. 1. Record review of Resident #5's Face Sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Dementia. Record review of the resident's Braden Scale for Predicting Pressure Ulcer Risk, dated 3/17/17, showed the resident's score was 15, which indicated he/she was at risk for the development of pressure ulcers. Record review of the resident's Admission Clinical Assessment, dated 3/17/17, showed: -The resident was admitted to the facility on [DATE]; -The resident's skin was warm, dry, and intact; -The resident had a patch over his/her coccyx (tailbone) to prevent skin breakdown. Record review of the resident's Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff for care planning, dated 3/23/17, showed the resident: -Was moderately cognitively impaired; -Required total staff assistance for bed mobility, transfers, locomotion, dressing, toileting, personal hygiene, and bathing; -Required extensive staff assistance for eating; -Always incontinent of stool; -At risk for developing pressure ulcers; -Did not have a pressure ulcer. Record review of the resident's care plan, dated 3/25/17, showed the resident was at risk for the development of pressure ulcers related to urinary incontinence and the need for assistance with bed mobility. The care plan instructed staff to: -Assist the resident with turning and repositioning every two hours and as needed; -Complete weekly skin assessments and as needed; -Report any signs of skin breakdown. Record review of the resident's Comprehensive CNA Shower Review, dated 3/28/17, showed: -The resident had a blister on the bottom of his/her left foot; -The form was undated and signed by a CNA and by a charge nurse; -Put [MEDICATION NAME] (a clear dressing) and boot was handwritten at the top of the form with no signature or date; -An assessment and intervention was not completed by the charge nurse; -The box was not checked to indicate the assessment was forwarded to the DON; -The form was not signed by the DON. Record review of the resident's Occupational Therapy Progress Notes, dated 3/30/17, showed staff documented: -Educated staff and family on positioning techniques in order to prevent pressure ulcers; -The remaining functional deficits include decreased strength, cognition, endurance, and new sore on the resident's left foot; -The resident is unable to maintain adequate and safe position in a wheelchair to prevent deformity and/or skin breakdown. Record review of the resident's Comprehensive CNA Shower Review dated 3/30/17 showed: -The resident has an intact blister on his/her left heel. (The previous bath sheet showed the blister was on the bottom of the resident's left foot, not on his/her left heel). -The form was signed and dated by the CNA and a charge nurse on 3/30/17. -The form did not have documentation by the charge nurse that an assessment was completed by the charge nurse and did not include interventions. -The box was not checked to indicate the assessment was forwarded to the DON. -The form was not signed by the DON. Record review of the resident's Treatment Administration Record (TAR), dated March 2017, showed the licensed nursed completed a weekly skin assessment on 3/30/17 with no documentation of any skin abnormalities. Record review of the resident's physician's orders [REDACTED]. -Have an outside wound care company assess and treat the resident as needed. Further review of the resident's medical record showed the outside wound care company identified to assess and treat the resident did not have a contract to provide services to the resident according to the resident's payer source. Record review of the resident's Comprehensive CNA Shower Review, dated 4/4/17, showed: -The resident had a blister on the bottom of his/her left foot (the previous bath sheet showed the blister was on the resident's left heel, not on the bottom of his/her left foot); -The form was undated and signed by a CNA and by a charge nurse; -An assessment and intervention was not completed by the charge nurse; -The box was not checked to indicate the assessment was forwarded to the DON; -The form was not signed by the DON. Record review of the resident's podiatrist provider notes, dated 4/6/17, showed: -The resident went to the podiatrist for a routine appointment for toenail trimming; -The resident had a 7 centimeter (cm) bullous (fluid-filled blister) lesion on the plantar (bottom) left foot without [DIAGNOSES REDACTED] (redness) or drainage; -The blister was present for one week resulting from pressure on the resident's bed; -Leave the blister intact. Record review of the resident's Nurse's Progress Notes, dated 4/6/17, showed staff documented: -The resident returned to the facility from an outside podiatrist appointment; -The podiatrist wants to leave the blister intact on the bottom of the resident's left foot and to off-load the resident's feet to avoid further skin breakdown; -If the resident's blister on his/her left foot pops/drains, apply [MEDICATION NAME] (a topical antibiotic cream) to the area twice daily. Record review of the resident's Telephone Order Sheet, dated 4/6/17, showed staff documented: -Left foot blister: off-load feet to avoid further skin breakdown, if the blister pops/drains, cut excess skin off and apply [MEDICATION NAME] cream 1% to area twice daily; -Keep boot on the resident's left foot to avoid breakdown. Record review of the resident's April 2017 TAR showed: -A weekly skin assessment was completed by a licensed nurse on 4/6/17 with no documentation of any skin abnormalities, including the blister on the resident's left foot which was identified on the resident's bath sheets on 3/28/17, 3/30/17, and 4/4/17; -Keep boot on the resident's left foot to avoid breakdown, check each shift, was charted as completed each shift from 4/6/17 day shift through 4/10/17 evening shift. Observations on 4/7/17 at 6:30 A.M., 6:45 A.M., 7:25 A.M., and 7:50 A.M. , showed the resident sat in a reclined position in his/her Broda chair (a chair that provides seating and positioning options that enable individuals to find a comfortable way to sit) without a boot on his/her left foot. During an interview on 4/10/17 at 8:10 A.M., the resident's family member said: -The resident was in bed most of the time when he/she was first admitted to the facility; -The resident would be so far down in his/her bed that his/her feet would be pressed up against the foot rest of the bed each time he/she saw the resident; -He/she thought the resident received therapy in his/her room during the first couple of weeks he/she was at the facility; -He/she noticed the blister on the bottom of the resident's left foot near the end of March; -When the resident went to a podiatry appointment, he/she brought the blister to the attention of the podiatrist. Observation and interview on 4/10/17 at 8:35 A.M., showed the resident: -Sat in his/her Broda chair wearing non-skid slipper socks without a boot on his/her left foot; -Staff transferred the resident to his/her bed to perform incontinence care; -The state surveyor identified two Stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. It may also present as an intact or open/ruptured blister) on the resident's buttocks and coccyx area. One Stage II pressure ulcer was on the resident's coccyx and measured approximately 1 1/2 centimeters (cm) in length by 1 1/2 cm in width with a scant amount of clear drainage noted. One Stage II pressure ulcer was on the resident's left buttock and measured approximately 1 cm in length by 1 1/2 cm in width with a scant amount of clear drainage noted; -CNA B and CNA C said they did not notice the opened areas until the state surveyor asked about them; -CNA C removed the resident's non-skid slipper socks and a large blister, approximately 7 cm in length by 7 cm in width was observed on the bottom of the resident's left foot. The blister was covered by an undated, transparent [MEDICATION NAME] dressing (a clear dressing); -CNA B and CNA C said the blister had been there for a few days. Observation on 4/10/17 at 10:30 A.M. and 2:15 P.M. showed the resident sat in his/her Broda chair without a boot on his/her left foot. Observation on 4/11/17 at 3:10 A.M., showed the resident in bed on his/her back, without a boot on his/her left foot and without his/her feet off-loaded. His/her feet rested directly on the mattress. During an interview on 4/11/17 at 3:20 A.M., Licensed Practical Nurse (LPN) D said the resident did not have any open areas or skin issues he/she was aware of. He/she had just assisted the CNA with incontinence care and did not observe any open areas on the resident's buttocks or coccyx. He/she was not aware of any blisters on the resident, including the resident's foot. During an interview on 4/11/17 at 4:55 A.M., the DON said the resident did not have any wounds. Observation on 4/11/17 at 5:15 A.M., showed the resident was in bed on his/her back, without a boot on his/her left foot and without his/her feet off-loaded. His/her feet rested directly on the mattress. Observation and interview on 4/11/17 at 6:30 A.M. showed: -The resident was in bed on his/her back without a boot on his/her left foot and without his/her feet off-loaded when CNA F entered the room; -CNA F provided incontinence care for the resident; -CNA F said the resident did not have any open areas on his/her buttocks or coccyx and he/she was unaware of a blister on the resident's foot; -CNA F elevated the resident's buttocks slightly from the bed and reached under the resident to cleanse his/her buttocks during incontinence care; -CNA F was unable to see the resident's coccyx from that position; -After the surveyor asked CNA F to turn the resident more to his/her right side to enable CNA F to see the resident's buttocks and coccyx, CNA F cleansed the resident's buttocks again; -After the surveyor asked CNA F about the open areas on the resident's buttocks and coccyx, CNA F said he/she had not noticed the open areas before; -A clear, undated [MEDICATION NAME] dressing was on the bottom of the resident's left foot covering the 7 cm by 7 cm blister; -CNA F said he/she was not aware of the blister on the resident's left foot until just then; -The resident was on his/her back without a boot on his/her left foot and without his/her feet off-loaded when CNA F exited the room. During an interview on 4/11/17 at 6:40 A.M., the DON said: -He/she was not aware an open area was discovered on the resident's coccyx and on his/her buttocks the previous day; -He/she forgot the resident had a blister on the bottom of his/her left foot; -An outside wound care company was treating the resident for the blister on the bottom of his/her left foot. During an interview on 4/11/17 at 6:45 A.M., LPN A said: -Nurses should document the resident's skin assessment in the computer; -If a resident has a skin abnormality, including open areas and blisters, the nurse should document it in the computer; -The outside wound care company has its own documentation when they evaluate and treat a resident, but the facility should have copies of the documentation; -The MDS Coordinator changed the dressing on the resident's blister the previous night (4/10/17). During an interview on 4/11/17 at 6:50 A.M., the MDS Coordinator said: -He/she did not change the dressing on the resident's foot because the resident did not have treatment orders for his/her foot blister; -He/she noticed the blister on the bottom of the resident's foot on 4/4/17 and put the [MEDICATION NAME] on the blister at that time; -an order for [REDACTED]. During an interview on 4/11/17 at 6:53 A.M., the DON said: -an order for [REDACTED].>-an order for [REDACTED].>-He/she thought the therapy department may have discovered the blister on the bottom of the resident's foot; -The skin assessments completed by the nursing staff on 3/30/17 and 4/6/17 showed no documentation of skin abnormalities and that the resident's skin was intact on those dates; -The order for the wound care company was obtained as a preventative measure since the resident had some pink skin on his/her buttocks, not due to the blister on his/her foot or for open areas. During an interview on 4/11/17 at 6:55 A.M., LPN A said: -The outside wound care company comes to the facility on Tuesdays; -The outside wound care company was at the facility on 4/4/17, but they did not see the resident at that time; -He/she was not sure if the resident's physician was notified of the resident's blister on his/her foot; -He/she did not see any documentation a skin assessment was completed on the resident since the resident was admitted on [DATE]; -All nurses were responsible for assessing the skin of their assigned residents and for providing wound care for their assigned residents; -The nurses were responsible for documenting the skin assessments and to notify the DON of any skin abnormalities; -The DON was supposed to follow-up on the reported skin abnormalities; -Sometimes he/she did not have time to do the skin assessments, so the next shift should have completed it; -He/she did not know who was responsible to ensure the skin assessments were completed. During an interview on 4/11/17 at 8:15 A.M., Physician A said: -He/she was told the resident had a small blister on his/her heel sometime last week; -He/she was not informed by the staff the resident had a blister on the bottom of his/her foot or that the blister measured approximately 7 cm in length by 7 cm in width; -He/she would not have given the staff an order to cut the edges off of the blister that measured that large; -He/she was not informed by the staff the blister had been discovered by the therapy department on 3/28/17; -He/she would have expected staff to report the blister on the bottom of the resident's foot and the open areas on his/her buttocks and coccyx immediately after it was discovered; -He/she would have expected staff to accurately describe the size and location of any wounds or blisters found on a resident for accurate treatment orders; -He/she was not informed of any open areas on the resident's buttocks or coccyx. During an interview on 4/11/17 at 8:30 A.M., the Outside Wound Care Nurse said: -The resident was not being seen by the outside wound care company because of the resident's payer source; -The resident would have to see a provider for his/her wound care that accepted his/her payer source due to payment contracts. During an interview on 4/11/17 at 8:35 A.M., LPN B said: -He/she was not sure if the resident's physician was notified of the resident's foot blister or the open areas on the resident's buttocks and coccyx; -The resident's podiatrist had initially given orders for the resident's foot blister to remain intact and cut the edges if it popped; -No one reported to him/her the resident had open areas on his/her buttocks yesterday; -The resident had an order when he/she was discharged from the hospital and admitted to the facility to have a pink pad on his/her coccyx for prevention. He/she was not sure why the pink pad was discontinued and not carried over upon admission. He/she could not find an order to discontinue the pink pad; -Staff should document in the computer any skin abnormalities, but sometimes they did not always do it. During an interview on 4/11/17 at 11:00 A.M., LPN C said: -All nurses are able to do skin assessments on their assigned residents; -The facility does not have a designated wound care nurse to do skin assessments and provide wound care treatments; -Nurses should do the skin assessments weekly and document in the computer; -If the weekly skin assessment is initialed by the staff, it means it was completed by that nurse on that date; -If there are any skin abnormalities, the staff should then chart the abnormality either on the TAR or in the Nurses Notes; -He/she could not find any documentation on the resident on the resident's TAR or the resident's Nurses Notes about the resident's blister on his/her foot nor about the open areas on his/her buttocks and coccyx; -He/she could not find where he/she documented any skin assessments for the resident since 3/4/17 even though it was ordered weekly. He/she probably just forgot to do them since he/she was busy doing other things; -The DON was responsible for following-up to ensure all skin assessments were completed and to follow-up on identified skin abnormalities; -The DON would report to the resident's physician any skin abnormalities. During an interview on 4/11/17 at 2:35 P.M., the MDS Coordinator said: -After reviewing the bath sheet dated 3/28/17, he/she remembered he/she actually placed the clean [MEDICATION NAME] on the resident's blister on the bottom of his/her left foot on 3/28/17 not on 4/4/17; -On 3/28/17 he/she obtained a blue boot to put on the resident's left foot to prevent any further breakdown and notified the charge nurse of the blister; -The charge nurse should have notified the DON and the physician; -He/she did not notify the DON or the physician because he/she was not the charge nurse; -He/she signed the bath sheet dated 3/28/17 as the charge nurse; -He/she also signed the bath sheet dated 4/4/17 as the charge nurse. The resident had the same clear [MEDICATION NAME] on the blister on the bottom of his/her left foot as the one he/she had placed on 3/28/17 at that time. He/she did not report the blister on the bottom of the resident's left foot to the DON or the resident's physician at that time; -The DON did not sign the bath sheets dated 3/28/17, 3/30/17, or 4/4/17. During an interview on 4/11/17 at 3:09 P.M., CNA A said: -He/she signed the bath sheets dated 3/28/17 and 4/4/17; -He/she believes the charge nurse was notified of the blister on the resident's left foot documented on the bath sheets; -He/she had the MDS Coordinator come with him/her to the resident's room to show him/her the blister on the bottom of the resident's left foot; -The MDS Coordinator signed the bath sheets dated 3/28/17 and 4/4/17 as the charge nurse who was informed of the blister; -The resident usually had a patch on his/her bottom, but he/she did not document it on the resident's bath sheet. Record review of the resident's podiatry provider notes, dated 4/13/17, showed: -Deroof (remove the top of) left foot plantar blister; -Copious (large) amounts of serosanguineous drainage (blood and watery drainage) noted. Record review of the resident's hospital admission records, dated 4/18/17, showed the resident: -Had an unstageable pressure ulcer on his/her left heel measuring 2.5 cm length by 7.7 cm width covered in black/brown eschar; -Had an unstageable pressure ulcer on his/her left buttock extending to his/her coccyx measuring 3 cm length by 7 cm width; -Had a Stage II pressure ulcer on his/her coccyx measuring 1.5 cm length by 1.5 cm width by 0.1 cm depth; -Had a stage I pressure ulcer on his/her right iliac crest (hip bone) measuring 1 cm length by 5 cm width. 2. Record review of Resident #19's Face Sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Slough or eschar may be present on some parts of the wound bed. It often includes undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface) and tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) on his/her sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity); -An open wound on his/her right foot; -An open wound on his/her buttocks. Record review of the resident's admission MDS, dated [DATE], showed the resident: -Was moderately cognitively impaired; -Required total staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; -Incontinent of stool; -At risk for pressure ulcers; -Had one Stage IV pressure ulcer upon admission which measured 1.5 cm in length by 1 cm in width by 0.1 cm in depth. Record review of the resident's Skin Monitoring: Comprehensive CNA Shower Review, dated 1/1/17, showed the document was signed by the charge nurse but not signed by the DON. Record review of the resident's outside wound care company wound assessment, dated 1/10/17, showed the resident had: -A new unstageable pressure ulcer on the resident's left hip measuring 1.5 cm in length by 1 cm in width by 0.1 cm in depth; -A new Stage II pressure ulcer on the resident's coccyx in the sacral region measuring 2.5 cm in length by 0.3 cm in width. Record review of the resident's Skin Monitoring: Comprehensive CNA Shower Review, dated 1/11/17, showed no documentation of any skin abnormalities. The document was signed by the charge nurse but not by the DON. Record review of the resident's Facility Weekly Skin Assessment, dated 1/16/17, showed the resident's sacral ulcer was improving, the rest of the resident's skin was intact. Record review of the resident's outside wound care company wound assessment, dated 1/17/17, showed: -An unstageable pressure ulcer on the resident's left hip had healed; -A Stage II pressure ulcer on the resident's coccyx in the sacral region had improved, measuring 2.8 cm length by 0.9 cm width by 0.3 cm depth. Record review of the resident's care plan, dated 1/24/17, showed: -The resident was at risk for the development of pressure ulcers due to incontinence of bowels, and need for assistance with bed mobility. He/she currently had a pressure ulcer on his/her left hip and on his/her coccyx; -He/she was to wear bunny boots (soft, quilted cotton boots designed to minimize friction and reduce pressure to heels) to relieve pressure on his/her heels; -Staff were to turn and reposition the resident every two hours and as needed; -Staff were to conduct a systematic skin inspection weekly and as needed, paying close attention to bony prominences; -Keep bony prominences from direct contact with one another using pillows, foam wedges, etc. Foam cushions should be positioned between his/her legs; -Keep the resident off current pressure wounds; -Report any signs of skin breakdown. Record review of the resident's outside wound care company wound assessment; dated 1/24/17; showed: -A Stage II pressure ulcer on the resident's coccyx in the sacral region had improved, measuring 1 cm length by 0.5 cm width by 0.2 cm depth. Record review of the resident's Skin Monitoring: Comprehensive CNA Shower Review, dated 1/25/17,showed the document was not signed by the charge nurse or by the DON. Record review of the resident's Skin Monitoring: Comprehensive CNA Shower Review, dated 1/29/17, showed the document was signed by the charge nurse but not by the DON. Record review of the resident's facility Weekly Skin Assessment, dated 1/30/17, showed the resident had an existing sacral ulcer. Record review of the resident's outside wound care company's wound assessment, dated 1/31/17, showed: -A Stage II pressure ulcer on the resident's coccyx in the sacral region had deteriorated measuring 2.5 cm length by 0.5 cm width by 0.4 cm depth. Record review of the resident's outside wound care company's wound assessment, dated 2/21/17, showed: -A stage III pressure ulcer (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; it may include undermining or tunneling) on the resident's coccyx in the sacral region had improved measuring 2.3 cm length by 1 cm width by 0.5 cm depth. The wound had increased from a stage II to a stage III pressure ulcer; -A new unstageable pressure ulcer on the resident's right ankle measuring 1.2 cm length by 1.8 cm width by 0.1 cm depth. Record review of the resident's outside wound care company's wound assessment, dated 2/28/17, showed: -A stage III pressure ulcer on the resident's coccyx in the sacral region had deteriorated measuring 2.5 cm length by 0.5 cm width by 0.5 cm depth; -An unstageable pressure ulcer on the resident's right ankle had improved measuring 1 cm length by 0.9 cm width by 0.2 cm depth. Record review of the resident's Skin Monitoring: Comprehensive CNA Shower Review, dated 2/28/17, showed the resident had a wound on his/her buttocks area, and a wound on his/her right outer ankle. The form was signed by the charge nurse but not by the DON. Record review of the resident's outside wound care company's wound assessment dated [DATE] showed: -A stage III pressure ulcer on the resident's coccyx in the sacral region was unchanged measuring 2.4 cm length by 0.5 cm width by 0.6 cm depth; -An unstageable pressure ulcer on the resident's right ankle had improved measuring 1.3 cm length by 1.7 cm width by 0.2 cm depth. Record review of the resident's facility Weekly Skin Assessment, dated 3/13/17, showed the resident had an existing wound to his/her sacral area and to his/her right ankle. Record review of the resident's outside wound care company's wound assessment, dated 3/14/17, showed: -A stage III pressure ulcer on the resident's coccyx in the sacral region had improved measuring 2.4 cm length by 0.4 cm width by 0.6 cm depth; -An unstageable pressure ulcer on the resident's right ankle had deteriorated measuring 3 cm length by 2 cm width by 0.4 cm depth. Record review of the resident's facility Weekly Skin Assessment, dated 3/20/17, showed the resident had swelling to his/her right foot, and existing areas to his/her right ankle and sacral areas. Record review of the resident's facility Weekly Skin Assessment, dated 3/27/17, showed the resident had swelling to his/her right foot, and open areas to his/her right ankle and coccyx areas. Record review of the resident's outside wound care company's wound assessment, dated 3/28/17, showed: -A stage III pressure ulcer on the resident's coccyx in the sacral region had deteriorated measuring 2 cm length by 0.4 cm width by 0.5 cm depth; -An unstageable pressure ulcer on the resident's right ankle had deteriorated measuring 2 cm length by 2.7 cm width by 0.8 cm depth after debridement with tendon exposure, strong odor, and moderate amount of serosanguineous drainage. Record review of the resident's April 2017 MAR indicated [REDACTED] -Administer Bactrim DS (an antibiotic) 800-160 milligrams (mg) twice daily for seven days for an open wound on his/her right foot beginning 3/28/17. This was discontinued on 4/3/17; -Administer [MEDICATION NAME] (an antibiotic) 875-125 mg twice daily for 14 days for an open wound on his/her right foot beginning 4/3/17; -Have an o

Based on interview and record review, the facility failed to ensure the resident environment remained as free from accident hazards as possible, when facility staff failed to provide a safe transfer for one sampled resident (Resident #3), which resulted in an avoidable fall with injuries,out of 17 sampled residents. The facility census was 64 residents. 1. Record review of Resident #3's Face Sheet showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident's Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff for care planning, dated 2/1/17, showed he/she: -Had short and long-term memory problem; -Needed extensive assistance to transfer and with bed mobility; -Did not ambulate and was only able to transfer surface to surface with the assistance of staff; and -Did not have a history of falls. Record review of the resident's care plan updated 2/1/17, showed he/she had a vascular wound on his/her right foot, had impaired vision and hearing, needed moderate to extensive assistance with mobility, two person assistance with bed mobility and needed two persons to transfer him/her with a full body lift from surface to surface. It also showed the resident was at risk for falls due to muscle weakness, unsteady balance, and decreased cognition. The care plan interventions instructed staff to: -Give the resident verbal reminders not to try to transfer himself/herself without assistance; -Keep the resident's bed in the lowest, locked position; -Provide the assistance of two persons using a full body lift for transfers; and -Use a wheelchair for locomotion which is to be propelled by staff in his/her room and in hallways. Record review of the resident's undated MDS Kardex Report (a simplified care plan sheet for quick reference) showed a brief description of the resident's care and special needs. It showed the resident was not steady during surface to surface transfers, had functional limitations on his/her upper and lower extremities, and used a hoyer (a mechanical lift). Record review of the resident's undated Lift Mobility Status form showed the form was not completely filled out, but a handwritten notation at the bottom of the form showed requires max assist and a hoyer lift. Record review of the resident's Nursing Notes showed on 3/11/17 at 3:28 P.M., the resident complained of his/her arm hurting when trying to move it. After undressing the resident, the nurse found a large hematoma (a localized collection of blood outside the blood vessels, due to either disease or trauma including injury or surgery) to his/her right shoulder area. The nurse notified the resident's physician and x-rays were ordered. The resident's responsible party was at his/her bedside and said the resident previously had pins placed in his/her shoulder due to a prior injury. Record review of the resident's Skin Monitoring Shower Review sheet dated 3/11/17, showed the nurse completed a full body assessment and documented the resident: -Had abrasions to his/her left cheek, chin and forehead, and redness to his/her right cheek; -Bruising to both knees and his/her right hand; and -A large bruise to his/her right arm and possible dislocation of his/her right shoulder. Record review of the resident's Nursing Notes showed on 3/11/17 at 7:45 P.M., the facility received the x-ray results and showed a right proximal humerus fracture to the resident's right shoulder. The resident's responsible party wanted the resident sent to the hospital and the nurse attempted to notify the resident's physician and called emergency services to take the resident to the hospital. Record review of the resident's radiology results dated 3/11/17, showed there was a proximal humerus fracture. Record review of the resident's Investigation Report dated 3/16/17 showed: -The incident occurred on 3/11/17, between 10:15 A.M. and 10:59 A.M., in the shower room; -The circumstances surrounding the incident showed a nursing staff was giving the resident a shower and the resident was transferred from the shower chair to his/her wheelchair; -The resident was injured due to neglect and sustained a hematoma to his/her forehead, right forefinger, right shoulder, and right knee; -The resident's injuries did not require medical attention; -Certified Nursing Assistant (CNA) L informed the charge nurse that the resident had contusions on his/her forehead and jaw and the resident had pain. The charge nurse assessed the resident and discovered a contusion on the resident's armpit and shoulder area. The Administrator and Director of Nursing (DON) were also informed; -Corrective action taken: CNA L was placed on suspension and all nursing staff was in-serviced on proper transfer methods of each resident and how to find out the resident's transfer status; -Witness statement of CNA L showed on 3/11/17, he/she used a sit to stand lift to transfer the resident by himself/herself from his/her wheelchair to the shower chair (and back) and failed to properly connect and fasten all of the supportive straps and torso holster to more safely transfer the resident. In the process of transferring the resident from the shower chair to his/her wheelchair, the resident began slipping out of the holder and to the floor. CNA L documented he/she was not aware of the extent of the resident's injuries initially, but saw the abrasions on his/her face. CNA L documented he/she did not explain to the facility staff exactly what happened until 3/15/17 four days after the resident complained of pain. During an interview on 4/6/17 at 3:45 P.M.,the resident's Responsible Party said: -On 3/11/17, they visited the resident around 12:45 P.M. and upon arrival, noticed he/she had a bruised area on his/her left cheek and under his/her jawline; -He/she also saw bruising on the resident's right knee and right finger; -When he/she asked nursing staff about the bruises, Licensed Practical Nurse (LPN) C told him/her that he/she was aware of the resident's bruises, but did not know how they occurred; -He/she spoke with CNA G and asked if he/she was aware of the resident's bruises and how they occurred. CNA G said he/she was unaware, but went to the resident's room to look at the resident and as he/she was looking at the bruised areas he/she noticed the resident complaining of pain when his/her right shoulder was touched. When they looked at it, they observed a very large blue and purple bruise and his/her shoulder bone was swollen and looked to be dislocated; -He/she and CNA G immediately went to get LPN C to look at the resident's shoulder and LPN X came and completed a full body assessment and contacted the resident's physician to have an x-ray ordered; -The x-ray was completed and the technician told him/her the resident's right arm was not moveable and his/her shoulder was possibly fractured or dislocated; -Two additional nurses at the facility came to look at the resident's shoulder also and interviewed CNA L, who was assigned to the resident to provide care that day; -They received the x-ray results which showed the resident's shoulder was fractured. He/she asked LPN C to send the resident to the hospital, which they did; -When he/she asked the resident what happened, the resident said the incident occurred while he/she was in the shower room; and -CNA L, who gave the resident's shower that morning, had not informed them of how the injuries occurred, but he/she later found out CNA L had not transferred the resident correctly and had not used a full body lift with two persons to transfer him/her as he/she should have. During an interview on 4/6/17 at 2:38 P.M., LPN C said: -On 3/11/17, CNA G came to him/her and said the resident was complaining of pain and had bruising on his/her face and shoulder; -When he/she went to assess the resident, he/she saw the resident's bruising on his/her face and his/her right shoulder looked bruised and dislocated; -The resident had a shower that morning and CNA L had been assigned to the resident, so when he/she asked CNA L if he/she was aware of the resident's bruises, CNA L told him/her that he/she was not aware of any bruising and had not documented any bruises on the resident's shower sheet; -He/she notified the Administrator, DON, and physician and when the x-ray was completed, it showed the resident had a fractured shoulder and they sent the resident out to the hospital; -He/she completed the incident report and later found out from the DON, that CNA L had used improper equipment to transfer the resident in the shower room and did not have any assistance when he/she was transferring the resident and the resident fell from the lift, sustaining injury; -The resident's responsible party was in the facility after the resident's shower and noticed the bruising on the resident; and -The resident was sent back from the hospital with an immobilizer to his/her right arm and shoulder because he/she was not a candidate for surgery. During an interview on 4/10/17 at 2:00 P.M., CNA G said he/she was working on 3/11/17 on the morning the incident occurred and saw the resident sitting outside of the shower room in his/her wheelchair as he/she was going into the dining room to assist residents to eat that morning. CNA G said: -CNA L was with the resident and was preparing to give the resident a shower; -He/she did not notice any bruising on the resident at that time and the resident did not seem to be in pain; -All of the nursing staff except CNA L were in the dining room so there were no nursing staff assisting CNA L and he/she did not ask for any assistance (to his/her knowledge); -Not long after they were in the dining room, CNA L came into the dining room and said the resident was complaining about pain in his/her arm/shoulder hurting to LPN C; -CNA L did not say the resident had fallen or was injured in the shower room and LPN C said he/she would see the resident once he/she finished feeding a resident; -After breakfast was over and they were back on the unit, he/she finished assisting the residents he/she was assigned to and did not see the resident again until the resident's responsible party came in to visit and asked him/her how the resident obtained the bruising; -He/she went with the resident's responsible party to look at the resident and he/she saw bruising on the resident's face. When he/she touched the resident's right shoulder, the resident gave a painful response and he/she asked the resident what happened, but when he/she pulled the resident's shirt down he/she saw that the resident's shoulder was swollen and badly bruised (blue and purple). He/she went to LPN C and told him/her he/she needed to look at the resident; -Once LPN C went to assess the resident and notified the resident's physician to obtain an x-ray, he/she went back to attending to his/her assigned residents; and -The resident had always been transferred with two persons using a full body lift and all of the nursing staff was aware of that because the resident was not weight bearing. During an interview on 4/13/17 at 1:50 P.M., the Interim DON said: -He/she expected residents to be transferred according to the resident's need and safest method; -If the resident's intervention showed the resident was to be transferred with two persons using a mechanical lift then the nursing staff should follow the intervention; and -There may not be an order for [REDACTED].

Based on observation, interview, and record review, the facility staff failed to provide adequate supervision and protective oversight for one severely cognitively impaired sampled resident (Resident #1), who was at risk for elopement, out of four sampled residents. Resident #1 left the facility unattended by facility staff and was found in the rear facility parking lot outside of the dining room doors by a facility cook. The resident was dressed in a long sleeved shirt, pants, socks, and shoes. The temperature at the time of the elopement was 18 degrees with a wind chill of seven degrees Fahrenheit. The facility census was 58 residents. 1. Record review of Resident #1's undated Resident Face Sheet showed the resident was admitted on [DATE] with the following Diagnosis: [REDACTED].>-Dementia with behaviors (a chronic persistent disorder of mental processes usually caused by a brain disease or injury marked by confusion with periods of lashing out, hitting, kicking, yelling, or resisting help). Record review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff and used for care planning, dated 4/29/16 showed: -The resident exhibited wandering behaviors one to three days in the past seven days. Record review of the resident's medical record showed no Elopement Risk Forms. Record review of the resident's physician's orders [REDACTED]. -Received Seroquel 25 milligrams (mg) (a medication used to treat dementia) every morning for dementia and behavioral disturbances; -Received Seroquel 50 mg every night; -Was admitted due to the inability to live alone and the need for 24 hour assistance, observation, and planning. Record review of the resident's quarterly MDS, dated [DATE], showed: -The resident was not cognitively intact; -He/she was able to self-propel his/her wheelchair and required staff supervision. Record review of the resident's Care Plan, dated 10/25/16, showed he/she had a care plan for behaviors and falls, which directed staff to observe the resident frequently and place the resident in a supervised area when he/she was out of bed. Further review showed staff did not develop interventions for the resident's wandering or elopement risk. Record review of the resident's Resident Progress Notes, dated 12/12/16 at 5:41 A.M., showed staff documented: -The dietary aide came to the nurse's station and said that there was a resident outside and the alarm was going off; -The nursing staff was not able to hear the alarm because the dining room double doors were closed; -The resident was outside by the posts on the side of the rear parking lot; -The resident attempted to resist going back inside by putting his/her feet down on the ground making maneuvering the wheelchair difficult; -The resident's skin was cold to touch; -The resident was combative while staff attempted to place blankets around him/her; -The resident's temperature once he/she was brought inside was 87.6 degrees Fahrenheit; -A message was left for the attending physician, and emergency medical response was called. Record review of the resident's Resident Progress Notes, dated 12/12/16 at 5:51 A.M., showed staff documented: -Emergency medical response arrived at the facility; -The resident was lethargic, but was able to stand with staff assistance to get onto the stretcher. Record review of the resident's Resident Progress Notes, dated 12/12/16 at 6:00 A.M., showed staff documented: -Another nurse assisted with the resident's assessment; -The resident was cold to touch, was shivering, lips and nail beds were blue and the resident was combative; -The resident was wrapped in blankets and another nurse took the resident's temperature both under his/her arm and orally; -The resident's temperature ranged from 85 degrees Fahrenheit to 92 degrees Fahrenheit; -The nurse witnessed the resident's eyes roll back in his/her head and start whole body tremors, which lasted approximately five to seven seconds. -After the tremoring, the resident became less combative and less responsive; -The resident was not talking or following instructions; -Staff notified the physician and family. Record review of the resident's Resident Progress Notes, dated 12/12/16 at 9:50 A.M., showed staff documented: -The resident's physician returned the call and was informed of the incident and the resident's transfer to the hospital. Record review of the resident's hospital records, dated 12/12/16, showed: -The resident was admitted into the Emergency Department after having been found outside in the cold at his/her nursing home; -The resident was found to be unresponsive to verbal stimulation by Emergency Medical Response staff; -The resident was responsive to pain and was cold to the touch; -His/her temperature was 91.0 degrees Fahrenheit; -The resident was diagnosed with [REDACTED]. During an interview on 12/12/16 at 12:45 P.M., the Administrator said: -The resident slept most of the day on 12/11/16; -He/she refused to go to bed during the night and was combative with staff when they tried to assist him/her to go to bed; -He/she wandered in his/her wheelchair all night long making loops around the nursing home; -Early the morning of 12/12/16, staff found the resident outside the dining room door in his/her wheelchair; -The resident was only outside for approximately five minutes; -There was no policy regarding the alarm systems and the maintenance staff was not doing the monthly checks on the system like they were doing on the wander guard system; -He/she was not aware of an Elopement Policy on file for the facility; -The facility used to have a wander guard system and this resident had a wander guard bracelet, however, when the new company took over in September of 2016, they removed the wander guard system and placed key pads on the dining room and front doors; -In April 2016, the resident made an attempt to exit the front door; -The resident wore a wander guard bracelet at that time (Note: No documentation of the April incident was found in the medical record). During an interview on 12/12/16 at 1:00 P.M., Licensed Practical Nurse (LPN) A said: -He/she received information from the night nurse saying that the alarm sounded, but the staff was not able to hear the alarm from the nurse's station; -There was no alarm system or any indicators at the nurse's station to alert the nurses if a resident went out the back dining room door or the front door; -He/she did not know how the resident got out; -The resident frequently did not sleep well during the night; -The resident also had a history of [REDACTED]. -During the spring of 2016 the resident tried to get out the front doors, but was stopped before going out. During an interview on 12/12/16 at 1:05 P.M., the resident's family member and Durable Power of Attorney (DPOA) said: -He/she received a message from the facility stating that the resident got out of the building, was outside for a few minutes, and was being transferred to the hospital for evaluation; -He/she went to the hospital and was told by a hospital staff member that the resident got out of the building, was out for an hour and was found on the ground, so the physician was doing a Computerized Tomography (CT) scan (x-ray images from several angles using computer processing to create cross-sectional images of the body) of his/her head; -The resident had a history of [REDACTED]. During an interview on 12/12/16 at 1:15 P.M., LPN B said: -He/she received report from the off-going night shift nurse; -The night shift nurse who cared for the resident that night was very upset; -The night shift nurse told LPN B that he/she did not hear the alarm and did not know the resident was outside; -The night shift nurse reported that he/she did not know how long the resident was outside; -LPN B received report from the hospital stating that they warmed the resident and he/she would be sent back to the facility. Observation on 12/12/16 at 2:25 P.M., showed: -The dining room door alarm sounded while standing in the hallway near the dining room with the dining room double doors (that separate the dining room and the hallway) open; -The alarm was audible near the nurse's station; -The alarm was not audible after walking into a hallway alcove; -The alarm was not audible in residents' rooms half way down the hall away from the dining room. During an interview on 12/12/16 at 3:10 P.M., the emergency room Physician said: -He/she was told the resident was found outside of the facility; -He/she was not told whether or not the resident had fallen while outside; -He/she ordered a CT scan which was normal; -The resident's temperature was approximately 92 degrees Fahrenheit in the Emergency Department; -The physician did not believe the resident was outside for more than eight to ten minutes. During an interview on 12/12/16 at 3:15 P.M., LPN C said: -He/she was working at the nurse's station down the hall from the dining room; -He/she did not hear the alarm go off; -During the night, the alarms rarely go off, so when they do, the nurses are always attentive to them due to the rarity of it happening; -The nurse assigned to the resident came and got LPN C to help with the assessment after the resident was back inside the facility; -This was the second time that LPN C was aware of the resident attempting to get outside; -The resident is supposed to ask for help to get into the wheelchair, however, he/she frequently gets himself/herself into the wheelchair without asking for help; -LPN C thought that the resident still had a wander guard bracelet on to prevent him/her from leaving the building unattended; -He/she did not realize the facility no longer had a wander guard system in place. During an interview on 12/12/16 at 3:35 P.M., LPN D said: -He/she was nurse for the resident on the morning he/she got outside; -He/she was getting a treatment ready for another resident when the cook hollered at him/her that a resident was outside the dining room in a wheelchair; -The double fire doors leading into the dining room were closed at the time, and he/she never heard the alarm sounding; -The resident wandered around in his/her wheelchair all night long; -He/she did not know what time it was when he/she last saw the resident before staff found him/her outside. During an interview on 12/13/16 at 10:00 A.M., the resident's attending physician said: -The resident did not have frost bite (injury to body tissue caused from prolonged exposure to extreme cold usually affecting the fingers, toes and nose); -The physician did not feel that the resident could have been outside for an hour; -If the resident had been out for an hour, he/she would have had frost bite. Observation on 12/13/16 at 10:05 A.M., showed: -An alarm test was performed with the double fire doors to the dining room closed; -Less than half way down the hall, the alarm was not audible; -The alarm was not audible at both nurse's stations; -The alarm was not audible in resident rooms. During an interview on 12/13/16 at 10:15 A.M., the Administrator and Maintenance Director said: -They did an alarm test during the night shift at 2:00 A.M. on 12/14/16, and after seven minutes of the alarm sounding with the double fire doors to the dining room closed, there was no staff response; -After seven minutes, the Maintenance Director opened the double fire doors and the staff responded within 23 seconds. During an interview on 12/13/16 at 10:20 A.M., Cook A said: -He/she came in to work through the back side doors and went into the kitchen to start breakfast; -He/she immediately heard the dining room back door alarm sounding; -He/she went to the doors and saw the resident outside in his/her wheelchair; -He/she tried to get the resident back inside, but he/she put his/her feet down and would not allow the cook to wheel him/her back inside; -Cook A ran to get the nurse in charge of the resident to help get the resident inside; -The resident moved all his/her extremities; -Cook A was not sure if one double door was closed or if both double doors were closed at the time he/she went to get the nurse; -There were no other residents in the dining room at the time of the incident. During an interview on 12/13/16 at 10:15 A.M., the Emergency Medical Technician (EMT) said: -When he/she arrived at the facility to transport the resident to the hospital, he/she found the resident in his/her wheelchair, wrapped up in blankets, and a warm wash cloth on his/her head with facility staff present; -The resident was unresponsive until the EMT performed a sternal rub (a practice used in emergencies where one rubs vigorously and with pressure onto the patient's sternum in order to try and get a response from an unresponsive patient), and he/she aroused slightly; -The resident's body and lower back were ice cold; -The EMT stated that he/she was able to feel how cold the resident was through his/her gloves; -During the report that he/she received from the nursing staff, he/she was told they were not sure how long the resident was outside, that it could have been up to an hour, but the nurses were not sure; -The nurses told the EMT that they do rounds every hour and were not sure the last time they saw the resident; -The EMT was told the resident's temperature ranged from 87 degrees to 91.2 degrees Fahrenheit; -The resident was given warm intravenous (into the vein) fluids in the ambulance; During an interview on 12/13/16 at 12:10 P.M., Certified Nursing Assistant (CNA) A said: -He/she worked both the evening and night shift on the date of the incident; -The resident slept all evening and refused to get up for dinner; -The resident did not get up until around 10:30 P.M. on 12/11/16; -He/she wandered around the facility all night long in his/her wheelchair; -This was normal behavior for the resident as he/she frequently slept during the day and evening, would refuse dinner, would dress himself/herself and stay up all night long wandering in his/her wheelchair around the facility; -The CNA was not sure of the last time he/she saw the resident make a round of the facility, because he/she was getting other residents up for the day; -The CNA never heard the alarm going off and had no idea the resident went outside; -He/she had no idea how long the resident was outside; -He/she had never had anything like this happen before. During an interview on 12/13/16 at 1:45 P.M., the Director of Nursing (DON) said: -The staff nurses should have done Elopement Risk Forms on all of the residents; -He/she expects staff to assess all residents for elopement upon admission and quarterly; -He/she expects staff to check on all residents every one to two hours during the night, and to check on residents at risk for elopement every hour; -He/she was not sure if staff assessed the resident for elopement in the past. During an interview on 12/16/16 at 10:30 A.M., the Maintenance Director said: -He/she had been performed monthly alarm checks of both the front and back dining room door alarms; -He/she, however, only tested to see that the alarm sounded after the 15 second delay in opening the door; -He/she never listened to see if the alarms were audible both with the dining room double fire doors open and with them shut; -There was nothing in place at the nurse's station to indicate to the nursing staff that the front or back dining room door alarms were sounding. MO 004 Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility began immediately training the staff on elopement monitoring and documentation, identifying and reporting residents at risk of behaviors and began completing facility elopement risk assessments on all the residents. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with the state law (Section 198.026.1RSMo) requiring that prompt remedial action be taken to address class I violations.

Based on observation, interview and record review, the facility staff failed to ensure appropriate interventions were put into place after falls, failed to ensure the fall interventions were implemented, and failed to monitor the effectiveness of the interventions placed for falls which resulted in one cognitively impaired sampled resident (Resident #5) having a total of nine falls including suffering a left hip fracture on 8/25/15 and a humerus fracture (broken shoulder) on 11/11/15; failed to identify the cause of each fall for three sampled residents (Resident #3, #7, and #8), update the care plan, and put appropriate fall interventions in place; failed to ensure the medication cart remained locked when unattended during medication pass and Accu checks; and failed to perform a transfer for three sampled residents (Resident #2, #6, and #7) in a safe manner. The total sample was 13 residents. The facility census was 77 residents. Record review of the facility's Falls Management Guidelines policy dated 10/21/15 showed: -During pre-admission, determine if the resident had a history of [REDACTED]. -Following a resident's fall the licensed nurse: --Should assess the resident. --Contact the resident's physician and family. --Implement appropriate interventions. --Update the care plan. --The interdisciplinary team should review the fall within 72 hours and make additional interventions. Record review of the facility's Post Fall Analysis Summary and Guidelines for Completion policy dated 11/23/15 showed: -The licensed nurse was responsible for completing the Post Fall Analysis Summary. --The licensed nurse reviewed all interventions used prior to the resident's fall and identify any new interventions that will be immediately placed to reduce the potential for falls to reoccur. -The interdisciplinary team will review the Post Fall Analysis report within 72 hours and recommendations shall be recorded on the report and the care plan revised as necessary. Record review of the facility's Transfer Activities policy dated 1/26/15 showed: -Equipment needed: transfer belt (gaitbelt-(a belt, usually made of heavy canvas with a sturdy buckle, used to help residents move). -Apply the gaitbelt to the resident. -Do not support the resident underneath the arms. -Do not allow the resident to hold on around your neck. 1. Record review of Resident #5's Admission Record showed the resident had been admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Dementia with behavioral disturbance (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses with behaviors). -End stage renal disease (kidney failure). -Dialysis (process of cleansing the blood by passing it through a special machine-necessary when the kidneys are not able to filter the blood). -Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Depressive disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable). -Altered mental status. Record review of the resident's General Notes on 7/11/15 showed: -The resident was admitted to the facility for skilled services after a total right hip surgery. -The resident was alert and oriented times two (alert to person, place, but not alert to time), was forgetful, and had short term memory issues. Record review of the resident's Immediate Plan of Care: At Risk For Falls dated 7/11/15 showed the resident: -fell in the last 30 days (prior to admission). -Had a hip fracture upon admission. -Needed to have a bed and wheelchair alarm. -Needed to have his/her call light available. -Needed to be assisted by one staff member with transfers. Record review of the resident's Verification of Investigation report dated 7/16/15 at 11:00 A.M., showed: -Description of event: The resident was heard yelling help. When several staff members entered the room the resident was observed lying on his/her left side and his/her head towards the foot of his/her bed. No alarm was sounding. -Assessment of resident: The resident was crying on in excruciating pain. The resident was unable to move his/her hip without yelling out in pain. The resident had no bruising, swelling, or redness. The resident was assisted back to bed with the assistance of physical therapy staff. -Resident interview: The resident stated he/she was looking for his/her telephone to call his/her family member to ask her why he/she was put here. -Immediate resident protection initiated: A bed alarm was placed under the resident at this time. -Causes and contributing factors: The resident had generalized weakness related to a new right hip surgery. The resident had confusion. -Recommendations/interventions to provide reoccurrence: Better pain management and check the resident for a possible Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system). Record review of the resident's Change of Condition note dated 7/16/15 showed: -The event information described in the above Verification of Investigation report dated 7/16/15 at 11:00 A.M. -The resident had a prior history of falls. -The resident's physician and Durable Power of Attorney (DPOA-a person previously identified to make decisions for an individual in the event of inability to make wishes known) were notified. -The resident's DPOA was not very happy and the nurse promised an alarm would be put into place. -The resident was sent to the hospital for evaluation and treatment and returned to the facility with no new orders. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated tool required to be completed by the facility staff for care planning) dated 7/17/15 showed the resident: -Was moderately cognitively impaired. -Had inattention and disorganized thinking. -Required the extensive assistance of staff for transfers, dressing, hygiene and bathing. -Was frequently incontinent of bladder and occasionally incontinent of bowel. -Had been admitted with a (left) hip fracture. -Had one non-injury fall. Record review of the resident's General Note dated 7/17/15 showed the resident: -Was alert and oriented times two and very confused at times. Record review of the resident's Verification of Investigation report dated 7/19/15 at 10:30 P.M., showed: -Description of event: The resident slid off to the floor beside his/her bed after attempting to transfer himself/herself to his/her wheelchair. The resident did not call for assistance. -Assessment of resident: The resident was assessed with [REDACTED]. -Resident interview: He/she stated he/she was sitting on the side of the bed and slid to the floor. -Immediate resident protection initiated: The physician and family were notified. Neurochecks (neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs). -Causes and contributing factors: The resident attempted to transfer himself/herself and did not call for assistance. -Recommendations/interventions to provide reoccurrence: Bed alarms were placed to alert the staff the resident was attempting to transfer and not call for assistance. Record review of the Change of Condition note dated 7/20/15 showed: -The event information described in the above Verification of Investigation report dated 7/19/15 at 10:30 P.M. -The resident's physician and family were notified. Record review of the resident's General Notes dated 7/29/15 showed the resident: -Was alert and oriented, forgetful at times, and was able to make his/her needs known. Record review of the resident's Verification of Investigation report dated 8/3/15 at 8:00 P.M., showed: -Description of event: The resident was observed to be on the floor. The resident yelled out and the staff heard the bedside table move and hit the wall. -Assessment of resident: The resident was assessed with [REDACTED]. -Resident interview: The resident was very confused and said his/her family member was moving out of state. The resident was attempting to get a hold of his/her family member before he/she left so he/she could ask the family member why he/she was moving. The staff tried to re-orientate the resident but were unsuccessful. -Immediate resident protection initiated: The resident was placed in his/her recliner. -Causes and contributing factors: The resident had bare feet, confusion, and the bedside table was in the middle of the room. -Recommendations/interventions to provide reoccurrence: The resident needed non-skid socks, needed to be reoriented to his/her surroundings, and his/her room needed to be better organized to accommodate the resident. Record review of the Change of Condition note dated 8/3/15 showed: -The event information described in the above Verification of Investigation report dated 8/3/15 at 8:00 P.M. -The resident had a history of [REDACTED]. -The resident's confusion increased at night. -The resident's family and physician had been notified. Record review of the resident's Verification of Investigation report dated 8/18/15 at 6:57 A.M., showed: -Description of event: The staff heard the resident make a strange noise and found him/her lying on the floor beside the bed. -Assessment of resident: The resident had a skin tear to his/her left elbow. -Resident interview: The resident stated he/she was getting out of bed to go to the bathroom and slid out of bed onto the floor. He/she did not hit his/her head and was not hurting anywhere. -Immediate resident protection initiated: The resident was reminded to use his/her call light and wait for assistance before getting up. -Causes and contributing factors: The resident had a history of [REDACTED]. -Recommendations/interventions to provide reoccurrence: Keep the resident's bed in a low position and place mats on the floor. Remind the resident to use his/her call light and wait for assistance before getting up. -The resident's physician was notified. Record review of the Change of Condition note dated 8/18/15 showed: -The event information described in the above Verification of Investigation report dated 8/18/15 at 6:57 A.M. -The resident had a recent hip replacement and multiple falls. Record review of the resident's Verification of Investigation report dated 8/25/15 at 11:00 A.M., showed: -Description of event: The resident was observed to be on the floor sitting on his/her buttocks by the sink. -Assessment of resident: The resident was assessed, had no swelling to the coccyx area and denied pain. The resident was angry at himself/herself and calling himself/herself stupid and an idiot for being so confused. -Resident interview: The resident said he/she was reaching for something, but he/she was lost and did not remember what it was, then he/she slipped and fell . -Immediate resident protection initiated: The resident was transferred to his/her wheelchair, was brought to the dining room, and began eating his/her lunch. -Causes and contributing factors: The resident's disease process was worsening. The resident became aggravated about being confused/lost about his/her family not being around him/her. -Recommendations/interventions to provide reoccurrence: Provide the resident with activities and attempt to keep the resident from being alone in his/her room. Redirect/attempt to re-orientate the resident to his/her surroundings. Record review of the Change of Condition note dated 8/25/15 showed: -The event information described in the above Verification of Investigation report dated 8/25/15 at 11:00 A.M. -The physician and family were notified. Record review of the resident's General Note dated 8/26/15 showed: -The resident had been in extreme pain since his/her fall on 8/25/15. -The resident had an x-ray of the left hip and had a left hip fracture. -The resident's physician sent the resident to the hospital. -The resident's family was notified. Record review of the resident's hospital History and Physical dated 8/27/15 showed the resident: -fell at the nursing home and was in pain. -Suffered a left femoral neck fracture (hip fracture). Record review of the resident's hospital Operative Report dated 8/27/15 showed the resident: -Had an open reduction and internal fixation of the subcapital fracture with multiple pinning (surgical repair) of the left hip. Record review of the resident's General Note dated 8/29/15 showed: -The resident was readmitted to the facility after a hospital stay. -The resident had a left hip fracture surgical repair and had a 1.4 inch long incision to the left hip with two staples. -The resident had bed alarms in place which were on and functioning and his/her call light within reach. Record review of the resident's General Note dated 9/2/16 showed: -The resident was on skilled services related to a left hip fracture repair. -The resident was alert and oriented to one (himself/herself) and had increased confusion since his/her surgery. Record review of the resident's general Notes dated 9/8/15 and 9/11/15 showed the resident: -Was alert and oriented to himself/herself and had increased confusion at night. Record review of the resident's general Notes dated 10/2/15 showed the resident: -Was alert and oriented to himself/herself and was able to make his/her needs known. Record review of the resident's Verification of Investigation report dated 10/12/15 at 10:45 P.M., showed: -Description of event: The staff heard a loud crash and went to investigate. The resident was found lying on the floor of his/her room. -Assessment of resident: The resident had a small abrasion to his/her right ear. -Resident interview: The resident stated he/she needed to have a bowel movement, was going to the restroom and fell . -Immediate resident protection initiated: The resident was assisted back to bed and the bed was placed in the lowest position so the resident would not fall again. -Causes and contributing factors: The resident had increased confusion with periods of agitation and aggression. The resident's bed was not in the lowest position and the call light was right beside him/her. -Recommendations/interventions to provide reoccurrence: The staff was asked to remind the resident to always use his/her call light. The resident was assisted back to bed and the bed was placed in the lowest position with mats at the bedside. Record review of the Change of Condition note dated 10/2/15 showed: -The event information described in the above Verification of Investigation report dated 10/12/15 at 10:45 P.M. -The resident wanted to go back to bed after the fall. Record review of the resident's Determination of Decision Making Capacity dated 11/4/15 showed: -Two physician's had signed the document stating the resident was incapacitated and could no longer make informed decisions because of cognitive impairment. Record review of the resident's Verification of Investigation report dated 11/04/15 at 9:40 A.M., showed: -Description of event: The resident stood up and tried to take a step. -Assessment of resident: The resident had no injuries. -Resident interview: Guess I can't walk. -Immediate resident protection initiated: The resident was assisted to his/her wheelchair. -Causes and contributing factors: The resident had impaired cognition, impaired mobility, confusion, and thought he/she was capable of independent transfers. -Recommendations/interventions to provide reoccurrence: The staff would park the resident next to the receptionist while waiting for the driver to take him/her out to the van for transport. Record review of the Change of Condition note dated 11/4/15 showed: -The event information described in the above Verification of Investigation report dated 11/04/15 at 9:40 A.M. -The resident was sitting up front waiting to go to dialysis when he/she stood up to try to take a step and sat on the floor. -The resident was very forgetful and confused at times. -The resident had no safety thought. -The physician and family were notified. Record review of the resident's Verification of Investigation report dated 11/11/15 at 3:10 P.M., showed: -Description of event: The resident was found on the floor by a Certified Nurses Aide (CNA). -Assessment of resident: The resident had full range of motion in all extremities except for his/her left shoulder. The resident could squeeze the staffs hand but would scream with pain with range of motion of his/her left arm. The resident's physician ordered and x-ray of the resident's shoulder. -Resident interview: The resident stated he/she was trying to go to the bathroom. The resident's bed was in the lower position and his/her call light was within reach. The resident decided he/she could go to the bathroom by himself/herself. -Immediate resident protection initiated: The resident was put in his/her wheelchair at his/her request while waiting for an x-ray. -Causes and contributing factors: The resident needed assistance with ambulation from his/her bed. -Recommendations/interventions to provide reoccurrence: Keep the resident's call light within reach and his/her bed low to the floor. Record review of the Change of Condition note dated 11/11/15 showed: -The event information described in the above Verification of Investigation report dated 11/11/15 at 3:10 P.M. -The resident's family and physician were notified. -The physician ordered an x-ray of the resident's left shoulder. -The x-ray showed a non-displaced fracture of the surgical neck humerus (shoulder fracture). -The resident's physician was notified and gave orders to send the resident to the hospital. Record review of the resident's General Note dated 11/11/15 showed: -The resident returned from the hospital at 5:30 P.M. with a shoulder immobilizer on and physician orders [REDACTED]. -The resident was alert, confused and was trying to pull the immobilizer off. Record review of the resident's hospital Patient Visit Information form dated 11/11/15 showed the resident: -Had a fracture of the surgical neck of the left humerus. -Had a shoulder immobilizer placed until orthopedics could be contacted. Record review of the resident's Verification of Investigation report dated 11/12/15 at 4:50 P.M., showed: -Description of event: The nurse was called to the resident's room by a CNA. The resident was sitting on the floor in front of his/her wheelchair leaning to his/her left side. The left arm immobilizer was on the bathroom floor. The resident left arm was above his/her head and his/her left hand was holding on to the wheelchair arm. -Assessment of resident: The resident had a history of [REDACTED]. The resident was alert, confused, and complained of pain in his/her left arm. The resident's physician was notified and the resident was sent to the emergency room for evaluation and treatment. -Resident interview: The resident was alert, confused and complained of left arm pain. -Immediate resident protection initiated: The resident's physician was notified and the resident was sent to the emergency room for the evaluation on his/her right humerus fracture. -Causes and contributing factors: The CNA had assisted the resident to the bathroom and instructed the resident to put call light on when he/she was finished. -Recommendations/interventions to provide reoccurrence: Never leave the resident alone in the bathroom. Record review of the Change of Condition note dated 11/12/15 showed: -The event information described in the above Verification of Investigation report dated 11/12/15 at 4:50 P.M. -The resident's physician was notified and gave orders to sent the resident to the emergency room . Record review of the resident's General Note dated 11/12/15 showed: -The resident returned from the emergency room with physician's orders [REDACTED]. -The resident was to continue to use the shoulder immobilizer until he/she saw an orthopedic physician. Record review of the resident's fall Care Plan last updated on 11/12/15 showed: -On 9/2/15, keep the resident's room well lit free of clutter. Assess the resident's wheelchair for the appropriate size, assess for foot rests and anti-tip bars and the need to have the wheelchair locked/unlocked for safety. Keep the resident's call light and personal items within reach. Provide proper footwear to keep the resident from slipping. The nurse was to assure the resident would get out of bed and into his/her wheelchair when he/she was restless and could not sleep. -On 9/19/15, put wheelchair and bed alarms in place and ensure functioning to alert the staff if the resident attempts to transfer himself/herself unassisted by the staff. -On 10/26/15, the resident was moved to room 23-2 to be closer to the staff. -On 10/28/15, the staff were to attempt to keep the resident in view at all times. -On 11/4/15, the resident would be placed by the receptionist while waiting for transportation to dialysis or other appointments. -On 11/11/15, medicate the resident for anxiety, agitation, and restlessness as needed. -On 11/12/15, if the resident was agitated, the staff were to get the resident out of bed and engage him/her in activities. The resident enjoyed being up at night. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Sometimes understood others. -Required the total assistance of staff for transfers and bathing. -Required the extensive assistance of staff for dressing, and personal hygiene. -Was frequently incontinent of bladder and always incontinent of bowel. -Had two non-injury falls and one major injury fall. Record review of the resident's General Note dated 11/30/15 showed: -The resident was being followed by an orthopedic physician. -An x-ray was ordered to send with the resident for his/her orthopedic follow up. Record review of the resident's physical function Care Plan dated 11/30/15 showed the resident: -Needed to keep his/her immobilizer on his/her left shoulder until further follow up with the orthopedic physician to rest his/her left arm and shoulder. Record review of the resident's General Note dated 12/11/15 showed: -The resident was being followed by an orthopedic physician. -An x-ray was ordered to send with the resident for his/her orthopedic follow up. Record review of the resident's General Note dated 12/25/15 showed: -The resident was being followed by an orthopedic physician. -The resident needed to continue to wear the left shoulder immobilizer until his/her next follow up appointment. Observation on 1/28/16 at 2:40 P.M., showed: -The resident was in a low bed lying on his/her back. -A mat was on the left side of the resident's bed. -A bed alarm was hanging on the right side of the bed. -The right side of the bed did not have a mat placed on the floor. -A tray table was wedged between the upper part of the right side of the resident's bed between the bed and the wall. -The resident's wheelchair was wedged up against the lower/middle part of the left side of the resident's bed. -The resident's room was at the end of the opposite hall from the nurses station. -There was no alarm on the resident's wheelchair. Observation on 1/29/16 at 7:45 A.M., showed: -The resident was in the dining room in his/her high back wheelchair. -The resident had foot pedals on his/her wheelchair and had slipper socks on his/her feet. -There was no alarm on the resident's wheelchair. Observation on 2/1/16 at at 5:13 A.M., showed: -The resident's room door was closed. -The resident was in a low bed lying on his/her right side. -A mat was on both sides of the resident's bed. -A bed alarm was hanging on the right side of the bed. -A tray table was wedged between the upper part of the right side of the resident's bed between the bed and the wall. -A half side rail was up on the right side of the bed. -The resident's room was at the end of the opposite hall from the nurses station. During an interview on 2/1/16 at 5:15 A.M., CNA A said: -The resident was a fall risk and used mats beside his/her bed, a low bed, and a bed alarm. -The resident was more agitated in the evening hours and needed to be watched closely. -The resident did not have any major injury falls, the resident would roll out of bed sometimes. -He/she would complete rounds at night every two hours on the resident. During an interview on 2/1/16 at 10:40 A.M., Certified Medication Technician (CMT) A said: -The resident was a fall risk and used mats beside his/her bed and a bed alarm. -The resident would try to get up out of bed. -The resident should have a chair alarm on his/her wheelchair. -The resident had a fall which resulted in a shoulder injury. -The resident's bed area should be free of clutter and his/her tray table should not be wedged between the bed and the wall. During an interview on 2/1/16 at 11:18 A.M., the Medical Director (also the resident's physician) said: -The resident had falls and was very disoriented and had been confused since admission to the facility. -The resident could not be re-educated to use his/her call light because he/she was not able to understand due to cognitive impairment. -The resident should not be left alone in the bathroom and needed frequent monitoring. -The interventions used by the staff were not correct interventions for a cognitively impaired resident. -The resident was a hard case due to his/her confusion and falls. During an interview on 2/1/16 at 11:34 A.M., CNA C said: -The resident was a fall risk and had mats beside his/her bed and a bed alarm. -The resident could not understand to use his/her call light and could not be redirected to use the call light due to confusion. -The resident would get agitated when he/she wanted to get up. During an interview on 2/4/16 at 10:35 A.M., Licensed Practical Nurse (LPN) A said: -The resident was a fall risk. -The resident would holler out instead of using the call light. -The resident could not understand to use the call light. -The resident was not alert and was very confused. -The resident did have fall mats, a low bed, alarms on his/her wheelchair and bed, gripper socks, and needed to be toileted after breakfast. -He/she expected the CNAs to ensure all interventions were in place for fall prevention and not leave the resident alone. -He/she expected the CNAs to keep the resident's bed area free of clutter. -The resident's room was at the end of the hall from the nurses station and the staff could not hear the bed alarms at the nurses station. -There were four residents down the hall with alarms so the staff would have to check the four rooms to find out which alarm was going off. During an interview on 2/8/16 at 11:30 A.M., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) said: -After a fall the nursing staff complete a note and then complete a Verification of Investigation report. -A new intervention should be placed after each fall and updated on the care plan. -The nurses should not re-educate the resident to use his/her call light. -The resident was cognitively impaired and could not remember to use his/her call light. -The charge nurses were responsible for ensuring the CNAs knew the resident was a fall risk and had major injury falls. -He/she expected the staff to ensure the interventions were in place for falls and keep the resident's bed surrounding free of clutter. -The resident was moved to a room on the main hallway since the staff frequent the hallway. -He/she was unaware the resident's alarms could not be heard at the nurses station. -He/she reviews all of the Verification of Investigation reports in a weekly fall meeting which included the DON, ADON, Social Services, and Activities. -The team reviewed the falls, looked at tracking and trending, and reviewed the interventions. 2. Record review of Resident #6's Admission Record showed the resident had been admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). Record review of the resident's Care Plan dated 3/2/15 showed the resident: -Was cognitively impaired with advanced Alzheimers disease. -Needed the assistance of two staff members with toileting, dressing, and bed mobility. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Needed the extensive assistance of two staff members with transfers. Record review of the resident's Lift Mobility Status Form dated 11/20/15 showed the resident needed the assistance of two staff members with transfers and did not need a specialized lift for transfers. Observation on 1/29/16 at 12:29 P.M., showed: -CNA C and CNA E prepared to transfer the resident from his/her wheelchair to the bed. -CNA C and CNA E secured a gaitbelt around the resident's waist. -CNA C and CNA E stood on each side of the resident. -CNA C and CNA E had one hand on the gaitbelt and one hand hooked under the resident's shoulders. -The resident was lifted up underneath his/her shoulders and his/her shoulders lifted upward. -The resident's legs were bent upwards, did not put any weight on his/her feet, and his/her feet did not touch the floor during the transfer. During an interview on 1/29/16 at 12:31 P.M., CNA C and CNA E said: -This was the normal method of tranfer for the resident. -They usually lift the resident up underneath his/her shoulders. -The resident had not been putting his/her feet on the floor during transfers for a long time. -CNA C had told a charge nurse a while back the resident was not bearing weight during transfers but the charge nurse he/she reported it to was no longer employed at the facility. During an interview on 2/4/16 at 10:35 A.M., LPN A said: -During a gaitbelt assisted transfer, the resident should be able to bear weight on his/her feet and pivot on his/her feet. -The resident should not have been lifted up underneath his/her shoulders. During an interview on 2/4/16 at 1:08 A.M., the Therapy Director said: -If a resident could not bear weight during a transfer, they would need to be transfered with a mechanical lift. -The resident should not have been lifted up underneath his/her shoulders. -This could cause an injury to the resident's shoulders. During an interview on 2/8/16 at 11:30 A.M., the DON and ADON said: -During a gaitbelt transfer, the resident should have been able to put weight on his/her feet during the transfer. -The staff should not lift the resident underneath his/her shoulders. 3. Observation of the medication pass and Accu checks on 2/1/16 beginning at 5:15 A.M. showed LPN D walked away from the medication cart at 5:20 A.M., 5:35 A.M., 5:40 P.M., 5:45 A.M., 5:50 A.M., 5:55 A.M., 6:08 A.M., 6:11 A.M., 6:16 A.M., 6:19 A.M. and 6:29 A.M., failing to l

Based on observation, interview, and record review, facility staff failed to provide protective oversight and supervision for one confused resident (Resident #2), of three sampled residents, with a history of elopement attempts. The resident left the faciity on [DATE] without staff knowledge and was found on the facility parking lot after he/she fell out of his/her wheelchair, which resulted in injuries to his/her head and multiple bruises and skin tears. Additionally, staff failed to ensure the system designed to alert staff of resident elopements properly functioned. The facility census was 71 residents. Record review of the facility's undated Elopement Guideline policy showed: - Elopement, for purposes of this policy and procedure, is defined as a situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety, needs and therefore at risk for injury outside the confines of the living center, has left the living center without knowledge of staff; - Upon admission, each resident is reviewed to establish elopement risk using the Clinical Health status form. The family may be interviewed for resident's previous history of elopement and responses recorded in the medical record. Residents on the secured unit will be deemed at risk for elopement; - All residents at risk of elopement are assessed quarterly and as needed; - Staff will observe that each resident's bracelet alarm/device is in place each shift; - Staff will establish a process to check bracelet alarm/device batteries according to the manufacture's directions; - Staff will document the findings on the Treatment Administration Record (TAR) or other form of documentation; - A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents; - Door alarms are tested daily, and the results of the tests are then recorded on a designated log; - Only the Executive Director/or designee may authorize disabling the alarm system and is responsible for the method of monitoring for the resident's safety and resetting the alarm; - The Living Center will identify such environmental hazards such as entrances, stairwells or exits that pose a foreseeable danger to residents who wander or have an exit seeking behavior. The Living Center will implement interventions to minimize these risks and hazards as appropriate; - Documentation should include: -- The admission assessment, which may indicate potential to wander or exit living center; -- A care plan that addresses the potential to wander or exit the living center and the measures taken to prevent wandering/elopement; -- All attempts to elope, efforts to locate, notification and results of efforts; -- Full observation/visualization after an elopement for any injuries or new symptoms or conditions which may have developed; -- Entries that are time specific to reflect the responsiveness and timeliness of actions taken to locate and asses the resident; and -- To ensure a bracelet alarm/device is in place and functioning (per TAR or other form of documentation). - All new employees are inserviced on the elopement policy during orientation. All employees will be in-serviced on elopement procedures annually and as needed in response to attempted elopements. - After the resident is located and returned to the unit, assess for changes identifying the following items: -- Observed behaviors or resident statements; -- Objective data, underlying illnesses or diagnoses; -- Physical assessment; -- General appearance; and -- Document the above findings in an Interdisciplinary Team Progress Note (IPN). - All elopement events will be reviewed, analyzed and summarized by the Quality Assurance (QA) Committee to ensure the appropriate process improvement actions have been taken; - An elopement care plan is to be in place and the interventions individualized and implemented per physical observation; - The door alarms are checked and documented in Building Engines; and - The alarm bracelet function is checked daily and documented. Record review of the Stanley Healthcare Solutions website, www.stanleyhealthcare.com, showed all WanderGuard Departure Alert System devices should be placed on the resident's dominant wrist or ankle. A WanderGuard Departure Alert System is a door monitor designed to monitor cognitively impaired individuals, residents that wander and residents considered a flight-risk, that alarms when a resident with a monitoring device passes through the doorway and will engage the delayed egress (a way to exit a building) magnetic exit door lock preventing the resident from exiting the building. 1. Record review of Resident #2's facility face sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. - Anxiety; - Osteoporosis; - Depressive disorder; - Persistent mental disorder (mental illnesses with complex symptoms that require ongoing treatment and management, most often varying types and dosages of medication and therapy); and - Muscle weakness. Record review of the resident's at risk for elopement care plan, dated 4/8/14, showed he/she said I am leaving, going home, had his/her purse, looked for exits and asked about leaving. Staff were instructed to: - Assess the resident for risk of elopement per living center policy; - Encourage the family to bring in personal possessions; - Evaluate the affect of cognitive impairment upon the resident's ability to understand changes in his/her surroundings; - Introduce the resident to others living in the facility (the resident had been residing at this facility since 5/16/11); - Involve the resident in preferred activities, and the care plan did not identify what the resident's preferred activities were; - Redirect the resident from the door; and - Take a picture of the resident upon admission for identification for updating elopement book. Further review of the care plan showed it was not individualized to instruct staff on resident specific interventions to distract or redirect him/her when exit seeking. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's Clinical Health Status Annual Assessment, dated 11/13/14, showed he/she: - Had short-term and long-term memory problems; - Required assistance with decision making; - Could not ambulate independently, transfer independently, ambulate with limited assistance or pivot transfer with limited assistance; and - Was not physically able to leave the building on his/her own. Record review of the resident's quarterly Interdisciplinary Resident Review Assessment, dated 2/11/15, showed he/she: - Had short-term and long-term memory problems; - Required assistance with decision making; - Required the use of a wheelchair; - had a history of [REDACTED].>- Was not physically able to leave the building on his/her own. Record review of the resident's Situation Background Assessment Recommendation (SBAR) note, dated 3/16/15 at 3:45 P.M., showed: - Situation: The resident sat in his/her wheelchair in the front lobby, and as two residents re-entered the building, he/she managed to maneuver his/her wheelchair out the front door onto the porch and headed down the sidewalk; - Background: The resident was alert, confused and wore a Wanderguard, received hospice services (end of life care) and had a Do Not Resuscitate order; - Assessment: The resident's Wanderguard sounded the door alarm. A Certified Nursing Assistant (CNA) responded. He/she brought the resident back inside. The resident was easily redirected and there were no further attempts to exit the building; - Response: Reported to the resident's physician and left a message on the responsible party's voicemail. The Director of Nursing (DON) was aware. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 5/13/15, showed staff assessed the resident as: - Had a Brief Interview for Mental Status (BIMS - an assessment to determine cognitive impairment) score of 2 showing he/she displayed severe cognitive impairment; - Displayed inattention and disorganized thinking; - Displayed wandering behavior; - Required extensive assistance for transfers; - Did not walk; - Required limited assistance with locomotion on and off the unit; - Used a wheelchair; - Had [DIAGNOSES REDACTED]. - He/she received antianxiety and antidepressant medication. Record review of the resident's quarterly Interdisciplinary Resident Review Assessment, dated 5/13/15, showed staff assessed the resident as: - Had short-term and long-term memory problems; - Required assistance with decision making; - Did not have a history of wandering; - Required the use of a wheelchair; - Was not physically able to leave the building on his/her own; - Was cognitively impaired; and - Had impaired decision-making skills. Record review of the resident's General Note, dated 6/6/15 at 2:14 P.M., showed: - He/she tried to get out the front door, but the Wanderguard alerted the staff. The resident was brought back to the floor. The resident stayed around others and did not try to go outside. Record review of the resident's SBAR - Change of Condition, dated 6/29/15 at 10:59 P.M., showed: - Situation: A witness saw the resident in a wheelchair roll down the parking lot, fall over in his/her wheelchair with the chair landing on top of him/her. The witness stated the resident had no loss of consciousness; - Background: The resident had confusion with a history of wandering; - Assessment: The resident lay on his/her left side. The resident was alert but confused and unable to explain what happened. Range of motion (ROM) was performed to all extremities without complaints of discomfort from the resident. A visual examination was performed with discoloration noted to both knees, a lump on the left side of his/her head, a skin tear to the top of his/her right hand and skin tears to the resident's left shoulder, left wrist and left upper outer arm. Redness was noted on his/her left hip. Neurological checks (an assessment of reflexes to determine if the nervous system is impaired) were within normal limits for this resident. - Response: Three staff members assisted the resident back into his/her wheelchair. Staff notified the resident's physician. The resident's physician gave an order to transfer the resident to the hospital for evaluation. Staff notified the resident's responsible party at approximately 7:55 P.M. Record review of the resident's at risk for elopement care plan, dated 6/30/15, showed staff were instructed to: - Assess the resident for risk of elopement per living center policy; - Check the placement and function of the Wanderguard every shift; - Evaluate the affect of cognitive impairment upon the resident's ability to understand changes in his/her surroundings; - Involve the resident in preferred activities; - Involve the resident in decision making regarding daily choices; - Redirect the resident from the door; and - Take a picture of the resident upon admission for identification for updating the elopement book. Further review showed the care plan was not individualized to instruct staff on resident-specific interventions to distract or redirect him/her when he/she was exit seeking. Record review of the resident's TAR, dated June 2015, showed: - A physician's orders [REDACTED]. - No documentation of the Wanderguard checked on 6/11/15 on the evening shift (3:00 P.M. - 11:00 P.M.); - Documentation showed the resident's Wanderguard was checked for placement and functioning status on the day shift (7:00 A.M. - 3:00 P.M.) on 6/30/15. Record review of the facility's Verification of Investigation, dated 7/2/15 at 1:06 P.M., showed: - Description of event/allegation: Witnesses (names not provided in the investigation) state they saw the resident in his/her wheelchair rolling fast and out of control down the parking lot from the direction of the facility's front door. The resident's wheelchair fell over and the resident fell out with his/her wheelchair landing on top of him/her. The witness came into the facility for help. Licensed Practical Nurse (LPN) A was the first nurse to respond. The witnesses said the resident did not lose consciousness. - Assessment of resident/describe injury: The resident was laying on his/her left side. The resident was alert but confused and unable to explain what happened. Range of motion to extremities was done without complaint of discomfort from the resident. A visual exam showed discoloration to both knees, a lump on the left side of his/her head, a skin tear to the top of his/her right hand and skin tears to the resident's left shoulder, left wrist and left upper outer arm. Redness was noted to the resident's left hip. Neurological checks were within normal limits for this resident. - Resident interview summary: The resident was alert but very confused and unable to explain what happened or why he/she went out of the building. - Contributing factors: It is possible the resident left the building because his/her family member recently left the facility and he/she might have tried to go after his/her family member. - Interventions taken to prevent reoccurrence: Louder alarm on the Wanderguard system if possible. Record review of the resident's hospital's medical record, dated 6/29/15, showed: - The Physician's Assistant (PA) stated he/she was informed the resident had a witnessed slip out of the wheelchair. - The resident's family member informed the PA that the resident had gone down a hill in the wheelchair, in which the wheelchair tipped over and the resident tumbled out of the wheelchair. - The resident was admitted with the following Diagnoses: [REDACTED].) -- Skin tears and -- Multiple contusions. During an interview on 6/30/15 at 8:55 A.M., the Director of Nursing (DON) said: - The incident was documented as a fall from the wheelchair, not as an elopement. - The front door has a Wanderguard system and the doors will automatically lock when a resident with a Wanderguard device attached approaches the door. The system will also alarm which can be heard at both nurses' stations. - At 9:00 P.M., the front doors are locked and require the use of a code to enter or exit the building. - Maintenance checks the Wanderguard system to ensure it is functioning properly. - The nurses are responsible to check the Wanderguard devices every shift to make sure the device is in place and in working order. Observation and interview with Maintenance Staff A on 6/30/15 at 2:25 P.M., showed: - The front doors can be opened by pressing the automatic door opening button on the wall. This will open both sets of doors. - If a resident wearing a Wanderguard device presses this button, both doors will open and the alarm will not sound until the resident is approximately 6 from the front door. - Using a hand held device, he/she checked the Wanderguard system and the device indicated the system was in working order. - A staff member brought Resident #1 to the front doors and the Wanderguard system alarmed but allowed the resident to go through the doors to the outside. - Resident #1 was brought back inside and once again the staff approached the system with the resident and the system alarmed but again the doors did not automatically lock. - The DON retrieved Resident #2's wheelchair with the Wanderguard device still on the frame of the wheelchair and propelled the wheelchair to the front door. The Wanderguard system did alarm, but the magnetic locks did not engage. - Maintenance Staff A had the DON remove the chair from the area and instructed the DON to bring the wheelchair back towards the Wanderguard system. Once again, the alarm sounded but the door did not lock. - This step was repeated after the Wanderguard device was removed from the wheelchair and the Wanderguard system alarmed and the magnetic locks engaged preventing the front door from being opened. - Maintenance Staff A called a local door company to come to the facility and check the doors to see what was causing the problem. During an interview on 7/2/15 at 2:20 P.M., the resident's family member said: - He/she was gone from the facility an hour when he/she received a telephone call from LPN A stating the resident had been badly injured and was being transferred to the Emergency Department of a local hospital. - LPN A told the family member the resident was observed by visitors to be flying down the parking lot in his/her wheelchair and tumbled out of the wheelchair onto the pavement with the wheelchair landing on top of the resident. - LPN A also said he/she had prevented the resident from going out of the doors earlier in evening. - Upon arrival at the hospital's Emergency Department, Resident #2 had skin tears on both of his/her hands, the crease of the left elbow, the right arm, and the left shoulder. - Both knees were bruised and swollen. - The resident's right eye was swollen shut and bruised. - The PA stated the x-rays showed no broken bones and the hospital was getting ready to send to the resident back to the facility. - The resident's family member informed the PA the resident was not going back to the facility since he/she made it out of the facility's building and went flying down the driveway in his/her wheelchair and then fell out of his/her wheelchair with the wheelchair landing on top of the resident. - The PA stated this was not the information facility staff relayed to them. - The PA stated they were only told the resident had a witnessed fall from his/her wheelchair. - CT scans were then performed which indicated no broken bones, however, a wrist fracture could not be ruled out. - The resident was admitted to the hospital for further testing and observation. - The resident will not be returning to the facility. - Upon further discussion with facility staff, he/she was informed the resident left the building on a couple of other occasions and he/she was not notified and was not aware of these occurrences. During an interview on 7/2/15 at 3:00 P.M., LPN B said: - The resident's family member visited with the resident at the facility. - LPN B came back from dinner around 7:15 P.M. and did not see anyone outside. - He/she did not witness anything outside of the facility as he/she passed medications to the residents. - He/she heard the charge nurse say I need help around 7:35 P.M. or 7:40 P.M. - He/she assisted LPN C in transferring the resident from the wheelchair onto his/her bed. - The resident had abrasions and/or skins tears to his/her left arm above the crease of the elbow, and on top of his/her right hand. - Both of the resident's knees were black and blue. - He/she did not see any open areas or redness on the resident's hips. - The resident had a hematoma (a solid swelling of clotted blood within the tissues) on the left side of his/her forehead. - After the examination, LPN C said he/she was sending the resident to the hospital. During an interview on 7/6/15 at 2:28 P.M., LPN C said: - He/she was working on 40 hall when he/she heard an overhead page for a nurse to immediately go the facility's parking lot. - He/she looked out the door and saw someone on the pavement of the driveway with the wheelchair on its side next to him/her. - He/she saw people in the parking lot around someone on the ground. - He/she did not know it was a resident until he/she got to the resident. - LPN A was the first nurse to report to the scene. - LPN C checked the resident over and performed range of motion on the resident's extremities and nothing appeared to be broken. - He/she noted skin tears on the resident's left arm, bruising to both of the resident's knees and a bump on the resident's forehead. - The resident cried as they lifted him/her from the ground into the wheelchair. - LPN C, LPN A, and a male visitor lifted the resident from the ground and placed him/her into the wheelchair. - LPN A and LPN B assisted LPN C with transferring the resident from the wheelchair onto his/her bed. - He/she had a CNA obtain the resident's vital signs. - He/she called the resident's physician's and received an order to transport the resident to the local Emergency Department. - He/she called the resident's responsible party but does not remember the time or what he/she said to the resident's responsible party. - LPN C did not hear the Wanderguard alarms sound prior to the resident leaving the facility, but that is not unusual with the televisions and the noise. - The Wanderguard system started alarming like crazy when they brought the resident back into the facility. - He/she did not call a report into the Emergency Department. - He/she described the incident to the paramedics as the resident went down the driveway in his/her wheelchair and fell out. During an interview on 7/6/15 at 2:50 P.M., CNA A said: - He/she did not hear the Wanderguard alarm sound, but usually cannot if in another resident's room providing care. - Every once in a while, the resident tried to go out the front doors, especially if he/she attended a function. When the resident saw everyone else leave, he/she thought he/she needed to leave as well. CNA A could usually redirect the resident. - The resident's family members came to the facility earlier in the day to celebrate the resident's birthday. - The family members were gone maybe an hour or an hour and a half before the resident left the building. - If he/she hears the alarm, he/she goes to the front door to see if someone came in or went out. - The facility receptionist is supposed to code lock the front doors. - A code is required to enter or leave the building once the doors are locked. - If the automatic door opening button is pushed after the front door is locked, neither of the two sets of doors will open. - If the Wanderguard system is tripped, it will continue to sound until the code has been entered into the device on the door. - Nothing unusual occurred prior to the resident leaving the building. - Staff cannot always hear the alarm on A-wing especially if it is noisy. - He/she was in another resident's room performing cares when the resident went out the front doors. - He/she saw three decent sized skin tears and a lump and a bruise on the resident's forehead. - The resident was already in the bed when he/she saw him/her. - He/she noted scrapes and bruises to both of the resident's knees. - LPN C was in the room with the resident. - If a resident attempts to go out the front doors and another staff member intervenes, that staff member will bring the resident back to the appropriate wing and let the staff know the resident tried to go out the doors. - He/she was not told the resident tried to go out the doors earlier in his/her shift. During an interview on 7/6/15 at 1:10 P.M., the DON said: - When a resident falls, he/she expects the nurse to assess the resident by performing range of motion to ensure nothing was broken and use the assistance of two staff members to transfer the resident to his/her wheelchair; - The investigation on this incident is not finished; - The nurses are responsible for checking all Wanderguard devices each shift using a hand held unit that is held up to the Wanderguard device and the unit will indicate if the Wanderguard device is in working order; and - The nurses document this on the resident's TAR. During an interview on 7/6/15 at 1:40 P.M., Maintenance Staff A said: - The facility has a Wanderguard system installed at the front door; - If the system is approached by a resident wearing a Wanderguard device, the system will chirp/alarm and the doors will automatically lock; - The Wanderguard system is installed on the outside set of the double doors. - The inside set of double doors does not have an alarm; - If a resident wearing a Wanderguard device hits the automatic door opening button, both doors will automatically open and the resident will be able to leave the building but the alarm will chirp/sound; - He/she monitors and checks the system daily by using a hand held device which indicates if the system is working properly; - He/she does not take a Wanderguard bracelet with him/her to check the system at the front door; - It is the nursing staff's responsibility to check the functioning of the Wanderguard device when it is on a resident; - The alarm sounds at both nurse's stations; and - The lamp post in the parking lot, which is located where the resident was found, is approximately 150 - 200 feet from the facility's front door. Observation on 7/6/15 at 1:48 P.M., showed the Wanderguard system alarm was heard in the family room on B-wing near the nurse's station. Observation on 7/6/15 at 1:54 P.M., the Wanderguard system alarm could not be heard at the A-wing nurse's station. During an interview on 7/6/15 at 2:10 P.M., Witness A said: - He/she pulled into the facility's parking lot and saw a resident in a wheelchair flying down the driveway. - The resident put both arms out as if to grab the light pole as he/she approached it. - The resident was not able to grab onto the light pole and fell out of the wheelchair onto the pavement on his/her knees, hands and elbows, and then landed on his/her face on the pavement with the wheelchair landing on top of the resident. - He/she immediately put his/her vehicle into park and ran to the person on the ground. - He/she removed the wheelchair from on top of the resident. - He/she did not move the resident. - He/she asked another visitor to go inside and get some help. - A male visitor arrived at the resident's side and asked Witness A if he/she wanted help getting the resident back into the wheelchair and he/she replied no. - Nurses from the facility arrived and turned the resident onto his/her back. - One of the nurses performed range of motion. - Witness A asked the nurse if he/she wanted him/her to call for an ambulance and the nurse replied no, just help me get him/her back into the wheelchair. - Witness A refused to assist in transferring the resident. - The two nurses and the male visitor assisted the resident back into the wheelchair and propelled the wheelchair and the resident back into the facility. During an interview on 7/6/15 at 6:40 P.M., LPN A said: - On the evening of 6/29/15, unsure of the time, he/she was on the main hallway of B-wing. - He/she saw someone come down the hall (he/she is unsure of whom this person was). - The person informed him/her that a resident was in the parking lot. - He/she summoned the other nurse. - He/she performed an assessment on the resident, range of motion, looked at his/her skin, and made sure all of the resident's extremities moved. - He/she stated LPN C did most of the assessment. - The wheelchair was on the ground next to the resident. - The resident was found on the ground approximately ten feet past the light pole in the facility driveway. - He/she noted a skin tear on the resident's left arm. - He/she does not remember the resident's face having bruising or redness. - After coming back into the building, he/she went back to his/her unit. - He/she does not remember the Wanderguard alarm sounding prior to the resident leaving. - He/she does not remember who else was there except LPN C. - He/she is unsure of how the resident got out the front door. - Earlier in the shift, he/she heard the alarm and saw Resident #2 going out the doors and he/she ran to retrieve him/her and took the resident back to A-wing. - He/she told another staff member the resident tried to go out the front door, he/she does not remember who he/she told. - He/she checked the Wanderguard devices with a hand held unit. The unit beeps letting him/her know the device worked. - Residents are put on 15 minute checks if they attempt to elope. During an interview on 7/16/15 at 1:10 P.M., the resident's physician stated: - He/she did not know how the resident got out of the facility. - He/she expected the Wanderguard system to alarm when the resident approached the front doors of the facility. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility began immediately training the staff on prevention of elopement, identifying and reporting residents at risk of elopement, and began completing facility elopement risk assessments on all residents. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address class I violations. MO 119

Based on observation, interview and record review, the facility staff failed follow their wound care policy by not monitoring and documenting the assessment, description, and measurements of a pressure ulcer (open wounds that form whenever prolonged pressure is applied to skin covering bony outcrops of the body) on re-admission to the facility for two sampled residents (Resident #3 and #16); failed to accurately perform wound care using Dakin's solution (bleach) according to standards of practice; failed to document their assessment of the pressure ulcer after each dressing change for continuity of care and for changes in the condition of a pressure ulcer; failed to notify the resident's physician when the change in the condition of resident's pressure ulcer showed deterioration for one sampled resident (Resident #3); failed to ensure a resident who entered the facility without a pressure ulcer didn't develop a pressure ulcer; failed to effectively monitor this resident's skin for changes, including deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.) after he/she experienced several falls; failed to document on-going assessments when a resident developed a deep tissue injury which developed into a full thickness wound (tissue destruction extending though the skin to involved subcutaneous tissue and possibly bone and muscle); and failed to assess this resident's skin to prevent the development of a pressure sore during the use of a splint following a fracture; failed to ensure the resident's and Certified Nursing Assistant (CNA) Care Plans were updated to reflect changes in the resident's care for one sampled resident (Resident #1); and failed to follow the physician's treatment orders by failing to document the treatments were provided as ordered to the resident's pressure sore for one sampled resident (Resident #16) of 16 sampled residents. The facility census was 79 residents. Record review of the 2009 National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [REDACTED]. -Risk factors identified in a risk assessment should lead to an individualized Plan of Care to minimize the impact of those variables. NPUAP Recommended Skin Assessment: Ensure that a complete skin assessment is part of the risk assessment screening policy in place in all health care settings. Each health care setting should have a policy in place that includes recommendations for a structured approach to skin assessment relevant to the setting, as well as for clinical areas to be targeted and the timing of assessment/reassessment. It should make clear recommendations for documenting skin assessment and communicating information to the wider health care team; - Educate professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [MEDICAL CONDITION], and induration (hardness). These additional assessment techniques can be used in caring for all individuals. However, there is evidence that Stage I pressure ulcers are under-detected in individuals with darkly pigmented skin because areas of redness are not as easily seen. - Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition. Ongoing assessment of the skin is necessary to detect early signs of pressure damage. - Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness), especially in individuals with darkly pigmented skin. Localized heat, [MEDICAL CONDITION], and induration have all been identified as warning signs for pressure ulcer development. As it is not always possible to see signs of redness on darkly pigmented skin, these additional signs should be considered in assessment. - Observe the skin for pressure damage caused by medical devices. Many different types of medical devices have been reported as having caused pressure damage (e.g., catheters, oxygen tubing, neck collars, casts, splints, etc.). - Document all skin assessments, noting details of any pain possibly related to pressure damage. Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals. - Whenever possible, do not turn the individual onto a body surface that is still reddened from a previous episode of pressure loading. Redness indicates that the body has not recovered from the previous loading and requires further rest from repeated pressure. -Stage II: Partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed, without slough, which may also present as an intact or open/ruptured fluid-filled blister without slough or bruising; bruising indicates deep tissue injury. -Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough (yellow, tan, gray, green or brown tissue) may be present but does not obscure (hide) the depth of tissue loss, and may include undermining and tunneling. -Category/Stage IV: Full thickness skin loss Full thickness skin tissue loss with exposed bone, tendon or muscle. -Unstageable/ Unclassified: Full thickness skin loss with unknown depth in which the actual depth of the ulcer is completely covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed; and until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; But, it will be either a Stage III or IV. -Suspected Deep Tissue Injury - depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to surrounding tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution (progression of the wound) may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Record review of the facility policy titled "Skin Integrity Guideline", dated January 2011, showed: -It was to provide guidelines for optimal care to promote healing to residents with all identified alteration in skin integrity i.e. surgical incisions. General Guidelines: -Assessment/observation to be completed within the first twenty four hours of admission/quarterly/significant change of condition using the Clinical Health Status Tool. -If identified risk present for the interventions will be documented in the Immediate Plan of Care or Comprehensive Care Plan. -Residents utilizing a wheelchair as a primary mode of transportation will have a pressure reducing cushion. -Pressure redistribution mattresses are in place. -If there is decline in skin integrity pressure redistribution surfaces will be reviewed for appropriateness. -Residents will be observed by the CNA daily for reddened/open areas, [MEDICAL CONDITION] of feet or sacrum. Changes will be reported to the licensed nurse and documented. -Initiate positioning schedule to meet individual resident needs and minimize concentrated pressure to skin. -If identified at risk or with actual alterations in skin integrity of feet, footwear will be addressed for appropriateness. -Positioning devices such as pillows or foam wedges are recommended to keep bony prominences from direct contact with one another. -Minimal linen under prone skin areas, i.e., only one incontinent pad or draw sheet should be used. -Use lifting devices such as mechanical lift, Maxi-slide, trapeze or bed linen to move residents who cannot assist during transfers and position changes. -Moisture skin. -Cleansing/Incontinent Care-rinse with warm water or follow center incontinence protocol. Pat dry-do not massage bony prominences. May apply moisture barrier cream or follow center incontinence protocol. Promote activity level, mobility and Range of Motion (ROM) as appropriate. -Documentation of Weekly Skin Assessments/Observations: -Licensed Nurse will be responsible for performing this skin assessment/observation. -The nursing order for weekly skin observations on all residents will be entered and print out on the Treatment Administration Record. -Licensed nurse to document weekly on all wounds using the "Wound Evaluation Flow Sheet." -Determine care plans consistently implemented, evaluated and revised based on the needs of the resident. If resident is refusing treatment, review risks, benefits and alternatives. Re-evaluate and attempting other interventions. -Resident will be assessed/observed for risk of skin breakdown within 24 hours of admission-quarterly and with decline in condition. -Individualized plan of care (IPOC) or care plan is in place and reflects current interventions including devices, support services and nutrition. -Would Evaluation Flow Sheet is accurately and thoroughly completed for all wounds. (one form per wound) -Physical observation reflects care plan interventions (including preventative measures) are in place. -Weekly skin checks are in place. -Director of Nursing Services or designee evaluates/observes wounds on a weekly basis. Treatment Protocol for a Stage IV wound to include any of the following based on licensed nurse skin and wound assessment done weekly: -A wound cleanser product for cleansing and irrigation of a superficial and chronic wounds. -A transparent dressing (for coverage only) for partial thickness wounds, maintaining clean moist surface and provides some mechanical protection against friction. Do not use on infected wounds or wounds with moderate to heavy drainage or exudates. -Non-adherent composite dressing for light to heavy exudating wounds, healthy granulation tissues, necrotic tissue (slough or moist eschar) or a combination of granulation and necrotic tissue. Secondary dressing for deep full thickness wounds. -A [MEDICATION NAME] dressing to absorb minimal to moderate amounts of drainage. Use of these dressings for acute and chronic wounds that are partial or full thickness. Granular or partially necrotic wounds. -A gel or hydrogel for light to moderate absorption. Partial thickness (especially good for residents with skin breakdown and very friable skin on extremities.) May be used on full thickness wounds and to keep surface clean and moist in conjunction with other dressings. Use for Autolysis. -Hydrogel sheet for partial or full thickness wounds. Non-draining to moderate draining wounds. -Alginates for moderate to heavy exudating wounds, partial thickness wounds and for Autolysis. -Impregnated gauze for wound coverage, protection as a primary dressing and exudates absorption. -Foam Dressings for partial to full thickness wounds with small to moderate amounts of exudates and for Autolysis. Not indicated for wounds with dry eschar. Record review of International Association for Continuing Education and Training and endorsed by the NPUAP dated July 2012, showed the following: Chemical Debridement: -Chemical debridement utilizes solutions to breakdown necrotic (dead) tissue in wounds. The most widely used chemical debridement is Dakin's solution. -Dakin's solution at the strength of 0.25% is nontoxic to healthy tissue, and gauze dressings soaked in Dakin's solution help to dissolve necrotic tissue and decrease the bacterial burden in the wound, -The dressings must be changed every 12 hours, -The periwound area should be protected from contact with the dressing, either with petroleum ointment or strips of solid skin barrier around the edges of the wound. -Dakin's solution loses its potency in 24 to 48 hours and must be replaced every other day. -When first opened the container should be labeled with the date and time, -After the wound is free from necrotic tissue, the use of Dakin's solution should be discontinued. 1. Record review of Resident #1's admission Nursing Assessment (Clinical Health Status) dated 2/24/12, showed the resident:-Was admitted to the facility for aftercare following the surgical repair of his/her fractured left hip; -Had [MEDICAL CONDITION] (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception); -Was alert, had short and long-term memory problems, and needed assistance with decision-making;-Had high impairment of his/her hearing;-Was sometimes understood others and was sometimes understood;-Had the following skin issues identified on the body diagrams that were included on the assessment form:--A surgical incision along his/her left hip;--A bruise in the bend of his/her right arm or slightly above;--A bruise on the back of his/her right hand.Note: There was no documentation by the facility staff showing the resident had any skin issues at his/her sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) or coccyx area(tailbone) at the time of his/her admission to the facility, and the areas on the body diagram were left blank by the facility staff; -Was evaluated and found to be at risk for pressure sore development, with a Braden Scale (a standardized assessment tool that measures a person's risk for skin breakdown/wound development) score of 16 (at risk for pressure sores);-Had limited ability to respond to pressure-related discomfort, i.e., shifting his/her position in response to discomfort from sitting in the same place too long;-His/her skin was occasionally moist, requiring an extra linen change approximately once a day;-He/she was slightly limited in his/her mobility; the ability to change and control his/her body position;-Had adequate nutritional intake eating over half of his/her meals, consumed adequate protein, and/or usually took a supplement if he/she refused a meal;-Had a potential problem with friction (a force that acts against motion) and shearing (the interaction of both gravity and friction against the surface of the skin which occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches or tears the underlying capillaries and blood vessels causing tissue damage);-Regarding his/her activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting), including his/her ability to ambulate and transfer was left blank; with no assessment of the resident's ability to participate in his/her dressing, grooming, bathing, eating, and/or how he/she managed his/her toileting needs when he/she wasn't incontinent nor were there any assistive devices identified as being used for this resident;-Was occasionally incontinent (loss of voluntary control) of urine;Note: The resident's bowel function/control was not identified;-Had weakness on his/her left side, and was non-weight-bearing on his/her left lower extremity;-Used devices and restraints;Note: The type of devices/restraints being used was not identified on the assessment form by the facility staff;-Had a Fall Risk score of 15 which showed he/she was at risk for experiencing falls;-Was disoriented times three at all times;-Had fallen one to two times in the past six months;-Was ambulatory. Note: The assessment showed this resident was non-weight-bearing on his/her left lower extremity;-Had balance problems while standing and walking, had lower extremity weakness, and had a change in his/her gait pattern when walking through a doorway and required the use of assistive devices;-Had a pain level of four (0 = no pain; 10 = excruciating pain) in his/her left hip at the time of admission that was intermittent, and the resident said an acceptable level of pain for him/her was at a three level;-Was identified as having the following immediate care plan needs: pain, urinary incontinence, falls, and anticoagulation (blood thinning) therapy;Note: The resident was assessed to be at risk for skin breakdown, but this concern (pressure ulcer) was not identified as a care plan need. Record review of the resident's Physician's Order Sheet (POS) showed he/she was admitted on [DATE], was to have weekly skin assessments, and had [DIAGNOSES REDACTED].; and -A history of peripheral autonomic [MEDICAL CONDITION] (a condition that results when nerves that connect to the brain and the spinal cord from the rest of the body are damaged or diseased). Record review of the resident's Nurse's Progress Notes dated 2/24/12, showed the resident:-Had fallen at home and fractured his/her hip, and he/she was being admitted for aftercare following surgery to repair the [MEDICAL CONDITION];-Was alert and very confused, oriented to self only, and he/she was hard of hearing;-Had a surgical incision with staples without redness, swelling or drainage, covered with a clean, dry, intact dressing;-Needed the assistance of two staff for ambulation and transfers;-Was non-weight-bearing on his/her left leg and used a wheelchair for ambulation;-Was usually continent of his/her bowel and bladder functions, but wore briefs due to occasional stress incontinence (inability to hold one's urine when the bladder is pressured, such as during coughing, sneezing, lifting objects).Note: The staff did not document that the resident had any wounds or skin concerns to his/her coccyx or sacrum. Record review of the resident's Nurse's Progress Notes dated 2/24/12 through 2/26/12, showed no documentation related to any changes in the resident's skin condition. The resident remained confused, required extensive assist for his/her ADLs, was incontinent and received cares for this, and was turned every two hours. Record review of the resident's Nurse's Progress Notes dated 2/27/12, showed the resident:-Was drowsy and withdrawn when he/she was awakened. His/her mentation (mental processes) was delayed and hazy;-Resisted his/her therapy and was not easily redirected;-Required the extensive assistance of one staff person for bed mobility, transfers, eating, and elimination needs; and was dependent on staff when in his/her wheelchair;-Had barrier cream applied after episodes of incontinence and was checked frequently;-Showed no signs or symptoms of infection at his/her incision site, the area remained secured with staples and the dressing was clean, dry and intact. Otherwise, the resident's skin was noted to be clean, dry and intact, and documentation showed staff would continue to monitor the resident. Record review of the resident's Nurse's Progress Notes dated 2/28/12, showed the resident:-Was oriented to himself/herself, was withdrawn and had a flat affect (no expression on his/her face);-Had delayed thought processes and provided vague responses;-Remained incontinent;-His/her incision remained intact without signs or symptoms of infection. The dressing was clean, dry and intact, and the resident's skin was warm, dry and intact, and staff was going to continue to monitor the resident. Record review of the resident's Nurse's Progress Notes dated 2/29/12, showed the resident's skin assessment was unchanged from the previous day. Record review of the resident's POS showed a physician's order, dated 3/1/12, for the resident to have a low-air loss mattress (a special mattress used to relieve pressure over all areas of the body, used to prevent or alleviate pressure ulcers in people who are unable to move on their own) with bolsters (cushions used for positioning; placed along the edges of a mattress to help define its edges). Record review of the facility's Fall Investigation Report, for the event dated 3/10/12 at 10:00 A.M., showed the staff found the resident sitting on the edge of his/her bed, and he/she scooted himself/herself to the floor as the staff entered the room. No injuries were observed. Record review of the resident's POS showed on 3/21/12, he/she had a new [DIAGNOSES REDACTED]. Record review of the resident's Orthopedic Notes dated 3/22/12, showed no evidence of displacement or hardware failure related to the resident's repaired [MEDICAL CONDITION]. Record review of the resident's Nurse's Progress Notes dated 3/23/12, showed:-At 1:18 P.M., the resident has a Stage II wound at his/her coccyx. There was a foam dressing, and it was clean, dry and intact. The wound was being managed by the Wound Care Nurse; otherwise, the resident's skin was warm, dry and intact. Record review of the resident's Wound Evaluation Flow Sheet dated 3/23/12, showed:-The resident had developed a pressure ulcer on his/her coccyx which measured 0.6 centimeters (cm) x 0.6 cm x 0.1 cm;-The wound had scant amount of serous (watery, clear, or slightly yellow/tan/pink drainage) drainage;-There was no pain at the site;-The wound bed showed 90% granulation tissue (any soft pink fleshy projections that form during the healing process in a wound) and 10% slough (necrotic (dead) tissue in the process of separating from the viable portions of the body);-The surrounding tissue was clean, dry, and intact;-The resident was receiving wound treatments daily and had been using a pressure redistribution mattress;Note: The stage/type of wound was not documented on this sheet, and the section related to the review and updating of the resident's care plan was been left blank by the facility staff. Record review of the resident's Nurse's Progress Notes dated 3/26/12 at 12:06 P.M., showed no documentation about the resident's Stage II pressure ulcer in the resident's Nurse's Progress Notes from 3/24/12 until this entry. Record review of the resident's Nurse's Progress Notes dated 3/28/12, showed:-The resident was using a low-air loss mattress;-The resident's wound was without signs or symptoms of infection;-The wound care treatment was changed and the Wound Care Nurse saw the resident four times a week for the wound on the resident's coccyx;-The resident wasn't always compliant with turning every two hours, and favored his/her left leg a lot;-The resident required total care. Record review of the resident's Nurse's Progress Notes dated 3/29/12, showed staff must anticipate all of the resident's needs as the resident required total care by the staff. He/she was fed his/her meals, if the resident wouldn't do so. The resident was incontinent of bowel and bladder and was checked every two hours for any incontinence. Care was given after each episode. He/she received wound care by the Wound Care Nurse four times a week. Record review of the resident's Wound Evaluation Flow Sheets dated 3/29/12 through 4/4/12, showed the resident's coccyx wound was identified as a Stage II, and was getting smaller with no drainage present. Record review of the resident's Up/Down Schedule dated April 2012, showed the resident was to be up in his/her wheelchair for all meals plus and hour afterwards, and included the following guidelines:-7:30 A.M.: Up for breakfast;-10:00 A.M.: Bed to rest;-11:30 A.M.: Up for lunch;-2:00 P.M.: Bed to rest;-4:30 P.M.: Up for supper;-7:00 P.M.: Bed for the evening.Note: Documentation did not show this resident was to be the last up and the first down prior to and after meals. Record review of the resident's Wound Evaluation Flow Sheet dated 4/10/12, showed the resident's coccyx wound had healed. Note: The resident's Nurse's Progress Notes dated 4/11/12, continued to show the resident had a Stage II ulceration to his/her coccyx and it was without signs and symptoms of infection. The Wound Care Nurse and staff would continue to monitor the wound. There was no documentation related to the continued monitoring of the condition of the resident's coccyx in the Nurse's Progress Notes from 4/12/12 through 4/13/12. On 4/14/12, staff noted that the resident's wound had resolved. Staff again documented "will continue to monitor." The care plan was not updated to show any further prevention interventions. Record review of the resident's Nurse's Progress Notes, dated 4/15/12, showed the resident needed the assistance of one staff member when using his/her wheelchair, for transfers, dining, toileting and bed mobility. The resident was incontinent of bowel and bladder and was provided cares after each episode. Documentation showed the resident was being repositioned every two hours and that his/her skin was warm and dry.Note: There was no documentation related to the condition of the resident's skin at his/her coccyx. Record review of the resident's Nurse's Progress Notes, dated 4/17/12 at 5:29 A.M., showed there was no documentation related to the condition of the skin at the resident's coccyx. Documentation showed the resident's skin was warm and dry and he/she was being repositioned for comfort every two hours. Record review of the resident's Bath Sheet dated 4/17/12, showed:-There were no reddened areas, open [MEDICAL CONDITION], abrasions or skin tears. bruises or blisters, or other skin problems reported to the charge nurse;-The signature line for the charge nurse was completed with no date. Note: There was no documentation related to the condition of the resident's skin at the recently healed wound at the resident's coccyx. Record review of the resident's Nurse's Progress Notes dated 4/18/12, showed:-The resident had a fracture of his/her right radius (one of the bones in the forearm);-He/she returned from the hospital with his/her arm wrapped in an Ace wrap and in a sling;-The resident was to leave the sling on and get a follow-up appointment with an orthopedic (related to the bone/skeleton) doctor. Note: There was no documentation showing there was any problem with the resident's skin at his/her coccyx from the fall, and no documentation related to the condition of the resident's skin on the resident's upper right arm. Record review of the resident's Nurse's Progress Notes dated 4/19/12, showed the resident was to have surgery on 4/25/12. He/she had a soft splint from the resident's fingers to his/her elbow. The resident's fingers on his/her right hand were swollen; and circulation checks were within normal limits. Note: There was no documentation related to the condition of the resident's skin at his/her upper right arm. Record review of the resident's Bath Sheet dated 4/20/12, showed:-No reddened areas, open [MEDICAL CONDITION], abrasions, or skin tears, no bruises or blisters;-The resident received a bed bath that day as he/she refused his/her bath due to pain and feeling cold;-There were no other skin problems reported to the charge nurse.Note: Documentation on the body diagram (front view) showed the right arm was circled and showed the resident was having pain in his/her fingers and there was bruising present. Record review of the resident's Bath Sheet dated 4/24/12, showed:-No reddened areas, no open [MEDICAL CONDITION], abrasions, or skin tears, no bruises or blisters;-The resident received a bed bath that day as he/she refused his/her bath due to pain and feeling cold;-The line identifying other skin problems that were reported to the charge nurse was left blank by the facility staff. Note: The front and back view of the human body diagrams present on the bath sheet showed no marks or documentation, yet the resident's right arm remained in a splint. Record review of the resident's Nurse's Progress Notes, dated 4/26/12, showed the resident's right wrist fracture was set by the physician without the need for surgery. The resident's right arm was in a soft splint, wrapped with an Ace wrap and in a sling. The fingers of the resident's right hand were swollen, but circulation remained intact.Note: There was no documentation related to the condition of the resident's skin at either end of the soft splint since its initial application on 4/18/12. Note: The facility did not provide the resident's Bath Sheet for 4/27/12 and 5/1/12. Review of the resident's Nurse's Progress Notes did not show he/she had refused his/her bath on those dates nor was there any documentation related to the condition of the resident's skin. Record review of the resident's Nurse's Progress Notes from 4/18/12 through 5/1/12, showed no documentation that the licensed nursing staff had monitored the resident's skin weekly or that they had assessed the resident's coccyx for signs and symptoms of breakdown at the previous wound site. Record review of the resident's Nurse's Progress Notes dated 4/30/12, showed the resident had swelling in his/her fingers on his/her right hand and it was elevated on pillow. The resident was repositioned every two hours for comfort.Note: There was no documentation related to the condition of the rest of the resident's skin, such as discolorations/bruises at any bony prominences and/or that anything had surfaced since the resident's fall on 4/18/12. Record review of the resident's Physician's Progress Notes dated 5/1/12, showed the resident had confusion. The resident had a recent right wrist fracture and was complaining of pain, but could not elaborate on it. The resident's skin condition was documented as "fair." Note: There was no documentation by the staff showing the resident had any specific skin issues/concerns, and the section identifying "open areas" was left blank by the resident's physician. Record review of the resident's Nurse's Progress Notes dated 5/2/12, showed the Wound Nurse was called into the resident's room that morning due to an "area on (his/her) coccyx" due to a DTI (deep tissue injury) on the coccyx from a previous fall.Note: The resident's medical record documentation had shown there was "no deep tissue injury" at the time of the resident's fall on 4/18/12, and there was no documentation in the resident's Nurse's Notes related to any skin issues at the resident's coccyx, until this entry on 5/2/12. The resident's previous pressure ulcer at his/her coccyx was documented as healed as of 4/10/12. Record review of the resident's Wound Evaluation Flow Sheet dated 5/2/12, showed:-The resident's coccyx wound measured 5.2 cm x 6.6 cm x "U" (the "U" was not defined by the facility staff);-There was no tunneling or sinus tracts (a cavity or channel underlying a wound that involves an area larger than the visible surface of the wound)/undermining present;-The wound had 80% brown eschar (scab) and 20% yellow slough. The surrounding skin was fragile;-There was no drainage from the wound;-Documentation showed current preventative interventions included the use of a pressure redistribution mattress;-Wound care was to be completed daily. Note: The facility did not provide the resident's Bath Sheet for 5/4/12. Review of the resident's Nurse's Notes showed no documentation related to the resident's skin condition on 5/4/12. Record review of the resident's Wound Evaluation Flow Sheet dated 5/8/12, showed:-The wound measurements were unchanged at 5.2 cm x 6.6 cm x "U" (the "U" was not defined by the facility staff); -The wound was 80% covered with a soft, brown eschar, and 20% covered with adhesive yellow slough. The tissue surrounding the wound was red and fragile;-The resident had been started on Keflex (a medication used to treat infection) 500 milligrams (mg) every six hours for ten days (5/4/12 through 5/14/12) due to the condition of the wound bed;-There was no drainage, tunneling, sinus tracts, or undermining of the wound. Record review of the resident's Nurse's Progress Notes dated 5/8/12, showed:-A review of the Wound Report (see above) and showed there had been a mild odor present at the coccyx wound. The resident was being turned side-to-side while he/she was in bed. His/her appetite was poor and he/she was being assisted with eating;-The splint to the resident's right arm was clean, dry, and intact;-The resident's fingers were pink in color;Note: There was no documentation that showed the facility staff was monitoring the resident's skin at either end of the splint on the resident's right arm. The facility had not provided the resident's Bath Sheet (5/8/12) for review. Record review of the resident's Nurse's Progress Notes dated 5/10/12, showed:-The family reported to the staff that the resident's p

Based on observation, interview, and record review, the facility staff failed to assess resident's severe pain and administer pain medications prior to providing wound care for one sampled resident (Resident #2) out of 13 sampled residents. The facility census was 79 residents. Record review of the facility's pain management guidelines dated January 2011, showed it's purpose was to provide guidelines for the consistent assessment, management and documentation of pain in order to provide maximum comfort and enhanced quality of life. Under the policy guidelines, the functions of appropriate pain management include, but are not limited to: -Recognizing and reporting pain as a fifth vital sign, -Assessing pain and evaluating response to pain management interventions using a pain management scale based on resident self-report or objective assessment for the cognitively impaired, -Recognizing that pain medications may be given around- the-clock, -Intervening to treat pain before the pain becomes severe, -Using knowledge of dosages to maintain both resident safety and pain relief as routes and types of ordered drug change, -Documenting pain assessment, intervention, and evaluation activities in a clean and concise manner per the plan of care, -Intervening to minimize side effects. Record review of the facility's pain management guidelines dated January 2011, showed the pain assessment tool instructed staff to: -Use the PAINAD (pain in advanced dementia) scale to assess the resident's pain, -Recognizing behavioral indicators such as frowns, grimacing, fearfulness, fidgety, guarding, groaning and moaning. -Documentation: -Clinical assessment-clinical health status tool, -Pain evaluation. -Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -Pain monitoring tool, -Interdisciplinary/nursing progress note, -Minimum Data Set (MDS)(a federally mandated assessment tool required to be completed by the facility staff), -Care plan/immediate plan of care. -The licensed nurse updates the plan of care to reflect interventions for ongoing pain management. 1. Record review of Resident's #2 face sheet showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. -Adult failure to thrive, -Urinary tract infection (infection of the urinary system), [MEDICAL CONDITION] (a decrease in bone mass), -Generalized pain, -Anorexia (loss of appetite), -Diabetes (a deficiency or complete lack of insulin secretion), -[MEDICAL CONDITION] (a mental disorder characterized by a feeling of profound sadness), -[MEDICAL CONDITION] (a slowly progressive disease of the brain that is characterized by impairment of memory), and -Dementia (loss of thinking, remembering, and reasoning). Record review of the resident's care plan dated 6/11/12, showed a problem of potential for alteration in comfort due to [DIAGNOSES REDACTED]. Interventions directed staff to: -Administer pain medications as ordered, -Evaluate and establish level of pain on numeric scale/evaluation tool (0-10), -Evaluate characteristics and frequency/pattern of pain, -Observe the resident for facial grimacing and body language for non-verbal signs of discomfort, and -Utilize a pain monitoring tool to evaluate the effectiveness of interventions. Record review of the resident's care plan dated 6/11/12, showed a problem of a potential for alteration in skin integrity with an open area identified on 7/15/12 of the left metatarsal (the bones of the foot present between the heel (tarsus of the foot) and the toes. These are a group of five long cylindrical bones that are collectively called metatarsus. These bones do not have individual names, rather these are numbered from inside to outside. The first one being the inner most one, related to the big toe of the foot. Rest are known as second, third, fourth and fifth metatarsal; each joins with the respective small toe in the front of the foot) arterial ulcer, with a goal for the resident not to have signs of tissue impairment, with interventions taken to reduce risk for skin breakdown daily. Interventions directed staff to: -Assist with turning and repositioning when in bed, -Complete the Braden Scale (a tool used to assess a resident for the risk of developing pressure ulcers)per facility policy, -Conduct diabetic foot monitoring, -Do not massage above bony prominence, -Provide his/her left foot treatment as ordered, -Apply Prevalon boots (a protector that minimizes pressure, friction and shearing on the resident's feet and heels) bilaterally (on both feet), -Provide a pressure reducing wheelchair cushion and pressure reduction mattress, -Complete his/her skin assessment per facility policy. Record review of wound care company's progress notes dated 8/14/12, showed: -Wound debridement (the removal of dead tissue) of the subcutaneous tissue (beneath the skin) was completed, -The tendon (tissues that connect muscles to the bone) was exposed after debridement. Record review of the wound company's progress note dated 8/28/12, showed: -To apply 6% [MEDICATION NAME] spray (a medication that numbs the nerves and reduces pain) to his/her left first metatarsal head wound three to five minutes prior to dressing changes. Record review of the resident's MDS dated [DATE], showed the following: -He/she was cognitive impaired for daily decision making, -He/she required total care for bathing, transferring, dressing and toileting. -Was not on a scheduled pain regimen, -Did not receive any prn (when needed) medications, -Did not have any pain. Note: The MDS stated the resident did not have any pain, but on 8/28/12 the wound company progress notes said to premedicate the resident for pain three to five minutes prior to the wound dressing change. Record review of the wound company's progress note dated 9/6/12, showed the resident's plan of care was to: -Continue with Prevalon heel boots to the resident's left lower extremities as written, -Continue premedication for the resident as written with 6% [MEDICATION NAME] spray three to five minutes prior to dressing changes. Record review of the resident's physician's orders [REDACTED]. -Admit the resident to Hospice (end of life palliative care) with the [DIAGNOSES REDACTED]. -For the wound company's nurse to perform the resident's wound care procedures and other related treatments, -For the staff to check the resident for pain every shift using the facility's pain scale, -To administer [MEDICATION NAME] sulfate (concentrate) 20 milligram (mg) solution by mouth as needed (prn) every six hours for pain, -For the staff to do weekly skin assessment, -Wear Prevalon boots at all times, and staff was to check this on every shift every day, -To cleanse the resident's left first metatarsal wound with normal saline; apply Santyl (an ointment used to remove dying tissue from wounds allowing healthy tissue to grow) to the wound bed, cover with moist gauze, and secure with Mepore (a self-adherent, absorbent, and breathable dressing with an outer film layer that protects the wound from water and contamination), and to change the resident's dressing daily until healed. Record review of the resident's pain monitoring tool that was in the resident's medical record from 10/9/12-10/16/12 showed the following: -There were boxes for staff to fill in regarding the resident's pain, -The boxes for the date and time the resident had pain was left blank -The box for staff to rate the resident's pain was left blank, -The box for the staff to put the location of the resident's pain was left blank, -The box for the staff to document the non-pharmaceutical interventions and the pharmaceutical interventions were left blank, -The box where the staff to document their initials was left blank, -The boxes for staff to put in the time of the follow-up pain rating from the interventions used was left blank. Observation on 10/9/12 at 2:45 P.M., showed: -Licensed Practical Nurse (LPN) E removed the resident's Prevalon boot from the resident's left foot, -LPN E put on gloves, -LPN E removed the resident's soiled dressing from the resident's left foot; and the old dressing had a moderate amount of brown serous-sanguineous (containing blood and water) drainage, -LPN E sprayed safe cleanse wound cleanser onto a 4x4 gauze and wiped the resident's wound on his/her left first metatarsal, -The resident said "Oooh, Oooh, Oooh," and turned his/her head from side to side, and was groaning and moaning during the wound treatment, -The resident attempted to pull his/her foot away when LPN E was cleaning the resident's wound, -The resident said "Oooh, Oooh, Oooh" with facial grimacing, -The resident again attempted to move his/her foot away from the nurse providing the wound care, -LPN E did not stop the wound care and continued to wipe the wound with the gauze, -The resident continued to grimace and moan, -LPN E put the Santyl ointment on a cotton swab and applied it to the wound, -The resident said"Oooh, Oooh" again with facial grimacing, and tried to move her foot away from LPN E, -LPN E applied Mepro dressing to the wound and put on the resident's Prevalon boot, -LPN E gathered the supplies and left the resident room. During an interview on 10/9/12 at 12:30 P.M., LPN A said: -The wound care company nurse does not come here anymore (the facility took over the resident's wound care on 9/11/12), -The Director of Nursing (DON) has taken over the resident's wound care because he/she is wound certified, -He/she would medicate any resident that was having pain during wound care, -He/she will contact the resident's physician and get an order to medicate the resident 30 minutes before providing wound care. During an interview on 10/9/12 at 1:40 P.M., the DON said the following: -She would expect the staff to medicate the resident if he/she is in pain, -This resident is a hospice resident, -The resident is not cognitive, and does not always answer questions appropriately, -The resident does not know if he/she is in pain, it depends on the the day you ask him/her, -If a resident shows some pain while treatment is being done he/she would expect the nurse to stop the dressing change and to medicate the resident. During an interview on 10/10/12 at 10:00 A.M., LPN E said: -The resident experiences pain when doing the wound care treatment, -It is "awful painful" for the resident, -He/she was grimacing and he/she tried to pull her foot away; you could tell he/she was in pain when he/she was doing her wound treatment, -The resident did not have an order to medicate before the wound treatment, -The order was obtained yesterday from the resident's physician to medicate the resident thirty minutes before performing wound care. During an interview on 10/12/12 at 10:31 A.M., the Medical Director said: -He/she has pain medication on order, -He/she would expect the staff to medicate the resident prior to any dressing changes.