Every finding on record at Hidden Lake Health Care Center

Based on observation, interview and record review, the facility failed to ensure appropriate perineal care (cleansing the genitals, between the legs and buttocks of the groin) was provided for two out of three perineal care observations (Residents #19 and #53). In addition, the facility failed to ensure showers were provided per shower schedule for one sample resident (Resident #30). The sample was 19. The census was 63. Review of the facility's Peri-Care policy, revised 06/29/26, showed:-Purpose: to ensure that the genital area is kept clean and proper techniques are used to prevent skin breakdown, infections or any other impairments that can be caused from not using proper aseptic technique (a set of practices used to stop the spread of germs);-Perineal care is called peri care. It is defined as washing the genitals and anal area. Peri care prevents skin breakdown, odors, and infection. Perineal care is very important in maintaining the residents' comfort. More frequent care is required for residents who are incontinent;-Other than soap and water, different products may be used when providing care. Non-rinse pre-moistened wipes are acceptable. 1. Review of Resident #19's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 050/7/26, showed:-Cognitively intact;-Diagnoses included falls and macular degeneration (impaired vision);-Supervision or touch assistance (requires staff assistance to monitor and assist when needed) for hygiene. Review of the resident's care plan, last updated 07/29/26, did not address the incontinent care needs of the resident. Observation on 07/27/26 at approximately 11:00 A.M., showed Certified Nurse Assistant (CNA) C performed peri care for the resident. The resident lay on his/her back, wet with urine. CNA C did not cleanse all areas of the genitals. CNA C rolled the resident to the side to clean the buttocks. The resident started to urinate again. CNA C left the room to find a new brief. CNA C returned, applied the new brief and failed to cleanse the genitals after the resident had urinated. During an interview on 07/31/26 at approximately 4:30 P.M., the Director of Nursing (DON) said she would expect all residents to be clean. She expected all areas of the genitals to be cleaned and the resident to be cleaned after each episode of incontinent care. 2. Review of Resident #53's medical record, showed diagnoses included dementia, lung disease, contractures, stroke, paralysis, liver disease, and chronic pain. Review of the resident's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Total staff assistance for eating, wheelchair mobility, bed mobility and hygiene;-Incontinent of bowel and bladder. Review of the resident's care plan, in use during the survey, showed it did not address the incontinent care needs of the resident. During an observation on 07/28/26 at 7:26 A.M., CNA A and CNA B entered the resident's room. The resident lay in bed. CNA A, without washing his/her hands, applied gloves, unfastened the brief and tucked the urine saturated brief under the resident's buttocks. The brief contained dark colored urine. CNA B, without washing his/her hands, applied gloves and obtained two wipes. CNA B wiped the resident. CNA B did not cleanse all areas of the genitals. CNA A turned the resident onto his/her side and exposed the buttocks. The resident's buttocks noted to be wet with urine. CNA A obtained a wipe and wiped once between the buttocks and disposed of the wipe. He/She did not cleanse the resident's buttocks and/or hip areas in contact with the brief, potentially soiled by urine. CNA B did not wash his/her hands and placed a clean brief under the resident and both aides secured the brief into place. During an interview following the perineal care observation, CNA A and CNA B said the resident had not been changed for several hours and the resident had been wearing the same urine saturated brief. CNA A and CNA B said they were rushed to get additional residents up for breakfast and did not perform thorough cleansing. The entire perineal area and buttocks should have been cleansed prior to applying the clean brief and dressing the resident. The CNAs did not perform hand hygiene prior or during peri care. 3. Review of the facility's Shower policy, revised 06/24/24, showed:-Purpose: assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues per current standards of practice;-Residents will be provided showers as per request or as per facility schedule protocols and based on resident safety;-Assist the resident with the shower. Review of Resident #30's medical record, showed:-Diagnoses included diabetes, quadriplegia (paralysis in all limbs), osteomyelitis (bone infection) depression, vascular disease, chronic wounds, anxiety, seizures and bladder dysfunction;-Used an indwelling urinary catheter;-Used electric scooter for mobility;-Received treatment for chronic wounds. Review of the resident's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Required full staff assistance for bed mobility, transfers, incontinence care and bathing. Review of the resident's care plan, in use during the survey, showed:-Focus: the resident has a self-care deficit related to paralysis;-Goal: to maintain current level of function;-Interventions: avoid scrubbing and pat dry, check nail length, staff provide sponge bath if shower is not tolerated, and staff provide total assistance with bathing or showers. During an interview on 07/28/26 at 9:20 A.M., the resident said he/she transferred to the facility in January 2026 and is paralyzed from the waist down. He/She is scheduled to receive showers in the evening and had not received a shower for the last two weeks. Staff have offered to wipe him/her down but he/she enjoyed a shower. During an observation and interview on 07/28/26 at 10:52 A.M., CNA A said the resident required staff to assist him/her with bed mobility, transfers and showers. The resident received showers in the evening twice a week. The aides fill out a shower sheet if the resident received a shower or if the shower is refused. Resident #30 does not usually refuse showers. The nurses fill out the scheduled showers based upon the shower schedule binder. CNA A opened the shower binder. The resident's shower schedule is every Wednesday and Saturday during the evening shift. Review of the resident's CNA shower sheet review forms for July 2026, reviewed on 7/28/26, showed:-On 07/01/26: received a bed bath-On0 7/15/26: received a shower;-On 07/18/26: received a shower;-No further shower documentation provided. During an interview on 07/30/26 at 11:33 A.M., the resident said he/she did not receive a shower last night. He/She wanted a shower and the staff said they would come to bathe him/her. The staff did not return to provide the shower. He/She had not had a shower in several weeks, and he/she would have to wait until Saturday evening. He/She rarely refused showers. 4. During an interview on 07/29/26 at 4:13 P.M., the DON said the aides are to document showers and baths on the shower sheets. If the resident does not have a shower sheet completed, the shower/bath was not provided. She expected the nurse to document if a shower is refused in the progress notes. Shower preference should be included in the care plan. Resident #30 received showers during the evening shift. Perineal care should be completed front to back and all areas of the groin. Incorrect perineal care could contribute to infection, odors and skin irritation. The facility charge nurse should verify the shower sheets were completed prior to the end of the aides shift. 31192903097737

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #18) received adequate supervision and care to prevent accidents when one Certified Nurse Aide (CNA) failed to ensure two staff were present to assist during personal care, in accordance with the resident's care plan. While providing care, the CNA rolled the resident off the bed and onto the floor, resulting in the resident sustaining a fractured arm. The sample was 11. The census was 63. The Administrator was notified on 5/21/26 of the past non-compliance, which occurred on 5/8/26. The facility provided in-service training for all staff regarding the facility's resident bed mobility, transfer, and care policies. The deficiency was corrected on 5/8/26. Review of the facility's Fall Risk Assessment policy, revised 4/30/24, showed:-Purpose: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provide supervision and assistive devices to each resident to prevent avoidable accidents. -Policy:--The care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident; --Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice. Review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/9/26, showed the following:-Moderate cognitive impairment;-No moods or behaviors exhibited;-Dependent with activities of daily living (ADLs);-Diagnoses included anxiety disorder. Review of the resident's care plan, in use at the time of survey, showed the following:-Focus: Resident has an ADL self-care performance deficit with regards to pain due to degenerative joint disease and lumbar spinal stenosis (a common condition where the spinal canal, which contains the nerve roots and spinal cord, becomes compressed);-Interventions included resident requires assistance of two staff to turn and reposition in bed as necessary. Review of the resident's nurse's note, dated 5/8/26 at 10:21 A.M., showed Licensed Practical Nurse (LPN) A documented the CNA notified this nurse the resident was on the floor. Upon entering the room, the resident was lying face down with both of his/her arms flexed under his/her body. A puddle of blood was noted under the resident's face. The resident's physician was made aware of the incident and received an order to send resident to hospital for further evaluation. The resident's nose was noted to have a pinpoint opening and a drop of blood coming out once cleaned. The resident's nose was noted to be swollen, but the resident denied any pain. The resident moved his/her legs and allowed this nurse to move both arms. The resident said he/she was in a little pain but he/she was alright. The resident showed slight usual discomfort to his/her right upper extremity. The resident was lifted on Hoyer (mechanical lift) device and showed no signs of pain or discomfort. The resident was put in bed and CNA turned the resident to the right to put his/her diaper on and the resident screamed. When asked where it hurt, the resident pointed to his/her right arm. Emergency Medical Services (EMS) arrived and made aware of all of the above. EMS left with resident at 10:05 A.M. Review of the resident's hospital record, dated 5/8/26, showed the resident was sent to the emergency room due to right arm pain and bloody nose. Of note, the resident resides at a nursing facility. The resident said the nurse was telling him/her to roll over and he/she rolled over and fell out of bed, landing on his/her right side, hitting his/her face and head. An x-ray to the right elbow showed mildly displaced communicated fracture (bone fractured into two more pieces) of the right distal (situated farthest form the center or point of attachment) humerus (long bone in the upper arm). A computed tomography (CT) scan showed comminuted fracture of the right distal humerus with extensive soft tissue swelling/ill-defined hematoma surrounding the elbow and extending into the forearm. Observation on 5/21/26 at 9:48 A.M., showed the resident in bed with a sling on his/her right arm, working with a Physical Therapist (PT). During an interview on 5/21/26 at 10:53 A.M., LPN A said CNA B notified him/her of the incident with the resident. CNA B said when he/she was changing the resident in bed, he/she rolled the resident over and the resident fell out of the bed. The resident was supposed to be a two-person assist in bed. CNA B could have reviewed the nurses reference book to see the resident's care needs. Review of the facility's nurse reference book, located at the second floor nursing station, reviewed on 5/21/26, showed the resident was a two-person assist with care. During an interview on 5/21/26 at 10:59 A.M., CNA B said he/she provided care to the resident alone. He/She rolled the resident onto his/her right side and the resident rolled out of the bed and onto the floor. CNA B did not know the resident was a two-person assist with care. The residents used to have a note about their care needs on the inside of their closet, but those are no longer there. During an interview on 5/21/26 at 11:05 A.M., the Director of Nursing (DON) said the CNA should have reviewed the nursing reference book to review the resident's care needs. After the incident, she in-serviced all staff on using a two-person assist and bed mobility. During an interview on 5/21/26 at 12:25 P.M., the Administrator said he was aware the DON in-serviced all staff on using a two-person assist and bed mobility on 5/8/26. He expected staff to follow the resident's care plan and to have used two-person assist. 3020430

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when staff failed to transcribe physician orders resulting in missed medication changes and/or missed completion of labs for two residents (Residents #5 and #1). The sample was 8. The census was 63. Review of the facility's Transcription of Orders/Following Physician's Orders policy, dated 5/18/24, showed the following:-Purpose: The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physician's orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders;-Policy:--Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in residents' electronic medical records (EMR) in orders section;--After laboratory testing, diagnostic testing or other services are ordered, the nurse will document orders in residents' EMR and fill out the corresponding requisition for the specific services to be obtained;--Clarification of physician's orders will be obtained if the order is either unclear or the nurse is uncomfortable in implementation of the physician's orders. 1. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/8/26, showed the following:-No cognitive impairment;-Diagnoses included anemia (decrease in the number of red blood cells), high blood pressure, seizure disorder, anxiety, depression, and bipolar disorder (a chronic mental health condition characterized by extreme mood swings). Review of the resident's physician progress note, dated 4/9/26, showed plan/treatment included:-Routine labs including autoimmune profile (detects autoantibodies that cause the immune system to attack healthy tissue);-Start doxycycline (antibiotic) 100 milligrams (mg) twice daily for 10 days;-Discontinue the lithium (mood stabilizer) medication and check the resident's lithium level. Review of the resident's EMR, showed:-An active order, dated 4/2/26, for lithium carbonate (mood stabilizer) oral tablet extended release 450 mg, give one tablet by mouth two times a day;-No physician order for doxycycline or documentation of the medication being started, as directed by the physician progress note from 4/9/26;-No documentation of completion of routine labs or lithium level, as directed by the physician progress note from 4/9/26. During an interview on 4/20/26 at 1:10 P.M., the resident said he/she wanted to stop taking his/her lithium medication because it made him/her feel funny. During an interview on 4/22/26 at 8:40 A.M., Licensed Practical Nurse (LPN) A said he/she was not aware of the resident's physician orders from 4/9/26. He/She would review the resident's physician progress notes and would add the physician orders from the notes, which would include any medication orders changes and/or laboratory orders. During an interview on 4/22/26 at 9:20 A.M., LPN B said the Medical Director came in on 4/9/26 and all the physician's new orders were sent to the Director of Nursing (DON). To LPN B's knowledge, the DON deals with all the new physician orders and inputs them into the resident's electronic medical records. 2. Review of Resident #1's admission MDS, dated [DATE], showed the following:-No cognitive impairment;-Diagnoses included diabetes and depression. Review of the resident's physician's progress note, dated 3/19/26, showed plan/treatment included order routine laboratory studies for further evaluation. Review of the resident's EMR, showed:-No physician order for routine laboratory studies, as documented in the physician progress note from 3/19/26;-No completion of laboratory studies, as indicated by the physician progress note from 3/19/26. During an interview on 4/20/26 at 11:27 A.M., the resident said his/her physician ordered lab work but no one has come to do any type of blood draw. 3. During an interview on 4/21/26 at 9:00 A.M, the DON said she would review the physician progress notes for Residents #5 and #1 and would give the physician orders to the charge nurse to put into effect. She did not know what happened with the physician orders from the physician notes being missed and she did not know the orders were not followed. The routine labs mentioned in the physician progress notes meant full sets of labs, including complete blood count (CBC, determines general health status and screens for and monitors for a variety of disorders, including anemia) and comprehensive metabolic panel (measurement of blood sugar, electrolytes, fluid balance, kidney and liver function). 4. During an interview on 4/21/26 at 9:05 A.M., the Administrator said he expected the facility's policy to be followed. He did not know why the policy was not followed regarding physician orders. Today was the first time of him hearing about these issues with orders not followed. 29833612980383

Based on observation, interview and record review, the facility failed to ensure staff provided adequate supervision and assistance to prevent accidents for one of three sampled residents (Resident #1) when one staff member used a gait belt (also known as a transfer belt, a safety device used to assist individuals with mobility issues during transfers and ambulation) instead of a Hoyer lift (allow a person to be lifted and transferred with a minimum of physical effort), and another staff member used a Hoyer lift alone to transfer the resident at a later time. The resident was sent to the hospital after the inappropriate transfers with a hematoma on the back of his/her head and a swollen leg. The x-ray from the hospital showed the resident's tibia (shin bone) was fractured. The census was 49. The Administrator was notified on 6/30/25 of the past non-compliance. The facility immediately began an investigation of the incident, suspended the staff involved in the improper transfers and in-serviced all staff on safe lift and transfer procedures. The noncompliance was corrected on 5/8/25. Review of the Safe Lifting and Movement of Residents policy, revised 8/08, showed: -Policy statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses mechanical lifting devices for the lifting and movement of residents; -Policy Interpretation and Implementation: Mechanical lifting devices shall be used for any resident needing a two person assist. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted; -Staff responsible for direct resident care will be trained in the use of mechanical lifting devices. The manufacturer of purchased equipment shall provide initial staff training on the use of mechanical lifts, as well as on the routine checks and long term maintenance of equipment. Subsequent training and retraining of staff on the use of mechanical lifting devices shall be conducted by designated team leaders; -Staffing for all shifts will include sufficient numbers of staff members who have been trained in the use of mechanical lifting devices; -The transferring needs of residents shall be assessed on an ongoing basis. Resident transferring and lifting needs shall be documented in the care plan. Review of the Using a Portable Lifting Machine policy, revised 8/08, showed: -Purpose: The purpose of this procedure is to help lift residents using a mechanical lifting device; -Preparation: Review the resident's care plan to assess for any special needs of the resident; -General guidelines: The portable lift should be used by two staff members. Review of Resident #1's annual Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 2/12/25, showed: -Adequate vision and hearing; -Clear speech; -Understands others and is understood; -Severely cognitively impaired; -Upper extremity: Impairment on one side; -Lower extremity (hip, knee, ankle, foot): Impairment on one side; -Functional abilities and goals: --Resident dependent (helper does all of the effort. Resident does none of the effort to complete the activity) for toileting, --Resident required substantial/maximal assistance (helper does more than half the effort) to shower/bathe self, upper body dressing and lower body dressing; --Resident required substantial/maximal assistance to roll from left to right; --Chair to bed to chair transfers and sit to stand required substantial/maximal staff assistance; --Sit to stand required substantial/maximal staff assistance; -Diagnoses included unspecified dementia, unspecified osteoarthritis (a degenerative joint disease characterized by the breakdown of cartilage and the underlying bone), repeated falls, chronic kidney disease and adult failure to thrive. Review of the resident's skin assessment dated [DATE], showed no new skin issues. Review of the resident's progress notes, showed: -On 5/6/25 at 11:59 A.M., the nurse was called down to the resident's room to observe a hematoma on the back of the resident's head. The Certified Nurse's Aide (CNA) told the nurse he/she had no knowledge of the hemotoma. Staff placed a call to the resident's physician and were awaiting a call back. At 12:55 P.M., the physician's office called back with no new orders. Staff would follow up with hospice. At 2:53 P.M., nursing staff notified the Director of Nursing (DON), the resident had a bump on the back of his/her head. The resident told staff he/she did not remember if he/she had a fall or bumped his/her head. The bump measured 4.0 centimeters (cm) by 3.5 cm to the back of his/her head in the occipital region (the back of the skull). The resident complained of pain. Staff called 911. Emergency Medical Services (EMS) arrived and escorted the resident to the emergency room. Staff notified the resident's physician. At 3:32 P.M., the nurse noted after reading statements obtained from staff, there was a statement which said the resident was sliding out of his/her chair, and the resident could have hit his/her head on the arm of the Broda chair(specialized reclining chair propelled by staff). At 7:06 P.M., the nurse informed the resident's responsible party the hospital reported the CT (a computerized tomography scan is a type of imaging that uses X-ray techniques to create detailed images of the body) scan was unremarkable, but the resident had a left knee fracture. The hospital was placing a left knee immobilizer on and sending the resident back to the facility. Review of the resident's hospital paperwork, showed: -Encounter start date and time: 5/6/25 at 2:52 P.M., -Reason for visit: --Nonintractable headache (headaches that are generally manageable with over-the-counter or prescription medication); --Closed fracture of proximal end of left tibia (the shinbone is broken just below the knee, and the skin around the break is not broken). Review of the resident's care plan dated 5/7/25, showed: -Focus: Resident at high risk for falls related to limited mobility, requires assistance with activities of daily living (ADL) tasks, impaired gait/balance, Medication side effects, generalized weakness and impaired cognition; -Interventions/Tasks: Broda chair for mobility. Requires assist of two staff with transfers and bed mobility; -All transfers via Hoyer lift times two staff. Observation and interview on 6/30/25 at 12:30 P.M., showed the resident lay in bed with his/her left leg immobilized in a brace. He/She said he/she hurt his/her leg when he/she fell but did not remember any details of when or how he/she fell. During an interview on 6/30/25 at 2:35 P.M., CNA H said he/she worked with the resident the night before he/she was sent to the hospital and got him/her up that morning (5/6/25). The resident was not complaining of pain at that time and did not have a knot on his/her head. The CNA knew this because he/she brushed the resident's hair. He/She did not know the resident required a Hoyer lift. The CNA used a gait belt to lift the resident up and transfer him/her into his/her wheelchair. Prior to the resident's 5/6/25 injury, this is how he/she usually transferred the resident from the bed to the chair and the chair to the bed. Review of a written statement by CNA G dated 5/6/25, showed: -The CNA noticed the resident sliding out of his/her chair on 5/6/25 around 11:00 A.M.; -The CNA took the resident to his/her room to put him/her to bed; -He/She went to go get the nurse to help him/her assist with getting the resident to bed; -The nurse exited the room once the resident was in bed, and the CNA continued to do his/her care. When he/she turned the resident over, he/she noticed a knot on the back of the resident's head. He/She got the nurse to come back and look at the resident. During an interview on 6/30/25 at 11:00 A.M., CNA G said he/she did not get the resident out of bed that morning. The resident was already up, dressed and in the dining room in his/her wheelchair. Right after breakfast around 9:00 A.M., the CNA noticed the resident was moving his/her legs off the Broda chair, and there was a puddle underneath him/her. The CNA took the resident back to his/her room, so he/she could put him/her to bed and change him/her. Once they got back to the resident's room, the resident started sliding down in his/her wheelchair so the CNA went to get the Hoyer lift, to transfer the resident out of his/her chair into his/her bed. He/She knew there were supposed to be two staff when the Hoyer lift was used, but he/she could not locate another staff member and was afraid the resident would slide out of his/her chair. The resident did not complain of pain at all during this transfer. Once the CNA got the resident into bed, he/she noticed the knot on the back of his/her head. He/She went and got the nurse who came in and assessed the resident. Review of a written statement by Licensed Practical Nurse (LPN) D, dated 5/6/25, showed: -The LPN assisted CNA G with the Hoyer lift to lay the resident down, then went to the next resident; -LPN D was called back to the resident's room by CNA G to observe a knot on the back of the resident's head at the occipital ridge. LPN D called the resident's physician to notify him and obtain orders. The physician said to notify hospice. The hospice nurse entered the building at the same time LPN D was hanging up the phone. During an interview on 6/30/25 at 11:25 A.M., LPN D said he/she remembered CNA G calling him/her to the resident's room because the resident had a bump on his/her head. He/She remembered calling the resident's physician and sending him/her to the hospital. He/She thought he/she watched the CNA transfer the resident but could not remember for sure. He/She noticed a slight swelling on the resident's left leg after he/she assessed the resident. The LPN thought he/she charted this but could not remember if he/she did. There was a lot going on with the hospice people there and trying to get hold of the resident's physician. Review of a written statement by Hospice LPN J, dated 5/6/25, showed: -When LPN J arrived to the facility on 5/6/25, he/she was informed by LPN D the resident had a hemotoma to the back of his/her head; - LPN D had applied ice compression and notified the resident's physician who said to notify hospice; -The DON was present during this conversation and went with the hospice nurse to assess the resident; -LPN J and the DON turned the resident to measure the hematoma; -After this assessment, LPN J and CNA G provided incontinence care; -Hospice Aide M noticed a hematoma area to the left lower leg; -LPN J notified the DON about the leg hematoma; -The DON informed LPN J, they were sending the resident to the hospital. During an interview on 6/30/25 at 10:30 A.M., LPN J said when he/she arrived at the facility on 5/6/25, LPN D told him/her the resident had a laceration on the back of his/her head. A hospice aide started to give the resident a bed bath and noticed the bruising on the his/her left leg. LPN J told LPN D about the bruising. The resident did not complain about the bruising on his/her leg but did grimace when they were looking at the knot on the back of his/her head. LPN J did not know if staff noticed the bruising on the leg earlier. LPN D told him/her they were sending the resident to the hospital. Review of a written statement by Hospice Aide M dated 5/6/25, showed upon arrival to the facility, LPN J gave him/her a report the resident was going to the hospital because he/she had a knot on his/her head. Hospice Aide M washed the resident's face and applied cream on both arms and legs. At this point, Hospice Aide M saw a large knot on the resident's left leg and notified LPN D. The leg looked like it was hard to the touch. During an interview on 6/30/25 at 11:10 A.M., CNA K said the staff were supposed to use a Hoyer lift to transfer the resident. There needed to be at least two staff when using the Hoyer lift to prevent injuries to the resident. If they could not find a second person, they were supposed to wait or ask the nurse to help. During an interview on 6/30/25 at 11:15 A.M., CNA L said he/she did not work on the resident's floor. If a resident required a Hoyer lift for a transfer they were supposed to use two people. If you could not find a second person, you were supposed to wait until you could find one. This was a safety precaution to protect the residents. During an interview on 6/30/35 at 11:20 A.M., LPN F said staff always needed to use two people when using the Hoyer lift to transfer residents. The staff should always wait until two people were there because trying to transfer with one person could accidentally cause an injury to the resident. During an interview on 6/30/25 at 12:35 P.M., Registered Nurse E said there is a list of residents at the nurse's desk which alert staff about residents who needed assistance with transferring, including Hoyer lifts. If a resident needed a Hoyer lift for a transfer, they were always supposed to use two staff. If they could not find another staff member, they should wait. They should never try to transfer a resident using a Hoyer lift alone. During an interview on 6/30/25 at 2:15 P.M., the DON said the resident needed a Hoyer lift to transfer since 7/24. All the staff know they were supposed to use two people with a Hoyer lift because she trains them. The staff should not have transferred the resident alone and should not have used a gait belt instead of the Hoyer lift. If staff cannot find a second person to assist, they should wait until one is available. If staff use the Hoyer lift alone the resident could get injured. The residents who need transfer assistance are listed in the communication book at the nurse's station. If there are any questions about a resident's transfer status, staff should look in the book. During interviews on 6/30/35 at 8:30 A.M. and at 3:00 P.M., the Administrator said she originally thought the resident was sent to the hospital for the bump on his/her head. They interviewed staff and got statements showing the resident was transferred appropriately, so they did not know how the fracture occurred. The Administrator then viewed the camera footage and saw CNA G enter the room with the Hoyer lift alone and then leave with the Hoyer lift alone. The camera footage showed the resident moving his/her leg at the foot of the chair in the dining room prior to the transfer, so she thought the leg injury came from getting his/her leg caught on the chair. The CNA should not have transferred the resident by him/herself. The Administrator would have expected the CNA to wait until help was available. CNA G was suspended for transferring the resident by him/herself. All staff were in-serviced about the proper use of lifts. MO00253848 MO00253863

Based on observation, interview and record review, the facility failed to meet professional service standards when staff did not investigate the case of an injury after the discovery for one resident (Resident #1) after the resident had a right foot fracture. Facility staff did not notify the family of the resident change in condition. In addition, the facility did not completely transcribe or clarify orders from hospital emergency room . The sample was four. The census was 53. Review of the facility's Accident and Incident Investigation Guidelines policy, undated, showed: -An accident/incident investigation is not designed to find fault or blame, it is an analysis to determine causative factors that can be controlled or eliminated to prevent future occurrences, potential injuries, or abuse; -Investigation Process: As soon as an incident is known a licensed nurse, or other department director(s) will investigate causative factors and, as soon as possible, remove any person or item which would cause further harm or injury; -A nurse should begin the initial investigation of the incident, as soon as possible, by: -Determining if an injury occurred, performing appropriate assessments, and providing emergency care and seeking medical intervention when necessary; -Determining the extent of the injury and the medical intervention necessary to prevent further physical injury or mental pain; -Securing the names of all individuals present at the time of the occurrence - or description of individuals un-named; -Requesting a written statement of what occurred from the nurse and Certified Nurse Assistant (CNA) assigned to the resident's care; -Interviewing individuals present at the time of the incident or similar incidents: other residents, other employees, visitors, others in the building at the time of the occurrence; -Determining the location, date, and time of the occurrence; -Determining how the incident could have occurred; -Obtain written statements from other individual(s) present before they leave the building, look for differences between what witnesses say occurred; -Inspection of the environment for causative factors; -Reviewing the actual use of assistive devices per care plan and physician order; -Reviewing staff adherence to care plan in transferring residents from one location to another or other mobility issues; -Reviewing staff adherence to CNA assignment for Activities of Daily Living (ADL) assistance; -Determine caregiver knowledge of how to identify an accident/incident; -If an injury occurred, the resident must be assessed promptly; -Appropriate emergency care provided; -Notification made to physician, administrator, Director of Nursing (DON), police, ambulance, family/sponsor, other caregivers; -Ensure resident is properly protected during investigation; -Place information on the 24-hour report; -Scheduling appropriate timely assessments; -Follow up on effectiveness of interventions. Review of the facility's Notification of Change Guideline, dated 10/01/2021, showed: -Purpose: It is the practice of this facility that changes in a resident condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and are reported to and consulted with the attending physician. The resident and/or the resident representative will be educated about treatment options and supported to make an informed decision; -Objective of the notification of change guideline is to ensure facility staff make appropriate notification to the physician or delegated Non-Physician Practitioner and immediate notification to the resident and/or the resident representative when there is a change in condition; -Requirements for notification of resident, the resident representative, and their physician include: -A significant change in the resident's physical, mental, or psychosocial status; -An accident involving the resident, which results in injury and has the potential for requiring physician intervention; -Procedure: The facility shall promptly notify the resident and/or the resident representative and consult with the physician with changes in the resident's condition or status by: -Obtain orders for appropriate treatment and monitoring and promote the resident's right to make choices about treatment and care preferences; -Document the notification and record any new orders in the resident's medical record; -Educate the resident and/or representative about the proposed plan to treat, manage or monitor the resident's change in condition; -Educate the resident and/or resident representative about the risks and benefits of the proposed treatment change and provide an opportunity for the resident to make an informed choice of treatment; -Update the resident's care plan, transcribe, and implement the provider's orders; -Communicate the changes to the care team and pharmacy. Review of Resident #1's medical record, showed: -Diagnoses included stroke, dementia, unspecified psychosis, and high blood pressure; -Brief Interview for Mental Status (BIMS), dated 12/30/24, showed severe cognitive impairment; -A diagnostic x-ray dated 2/1/25 at 2:37 P.M., showed right foot two view results. The bones appear diffusely demineralized (widespread loss of minerals from bones resulting in fragile bones). Acute non-displaced fifth metatarsal (foot bone) base fracture. Review of the resident's hospital after visit summary note, dated 2/1/25, showed: -Diagnoses: acute bilateral (both side) ankle pain, closed nondisplaced fracture of fifth metatarsal bone of the right foot; -Schedule an appointment as soon as possible in one week with the follow-up physician; -Schedule an appointment for follow-up in three weeks with an orthopedic specialty; -Medium Boot applied; -Home Care: -You may be given a splint, cast, shoe, or boot to keep the injured area from moving. Unless you were told otherwise, use crutches or a walker. Don't put weight on the injured foot until your healthcare provider says you can do so; -Keep your leg elevated to reduce pain and swelling. When sleeping, put a pillow under the injured leg. When sitting, support the injured leg so it is above your heart; -Put an ice pack on the injured area. Do this for 20 minutes every one to two hours the first day for pain relief. Continue using the ice pack three to four times a day for the next two days. Then use the ice pack as needed to ease pain and swelling; -Keep the splint, cast boot, or shoe dry; -You may use acetaminophen (Tylenol) or ibuprofen to control pain unless another pain medicine was prescribed. Review of the resident's physician order sheet, showed: -An order dated 2/1/24, cast care boot to right foot on while up for pain, watch for skin breakdown; -An order dated 2/11/24, tape great right toe to second toe for alternative healing measures two times a day; -No order for ice pack to injured foot; -No order for elevation with pillow to injured foot. Review of the resident's Treatment Administration Record (TAR), dated February 2025, showed: -Treatment scheduled to tape great right toe to second toe for alternative healing measures two times a day, dated 2/11/25, and marked as completed two times a day from start date; -Scheduled cast care boot to right foot while up for pain, watch for skin breakdown scheduled seven times a day from start date 2/3/25; -No schedule for ice pack or elevation to injured foot. Review of the resident's care plan, initiated 2/4/25, showed: -Focus: Resident has a bone fracture to his/her right foot. He/She is at risk for slow, delayed healing to the foot related to removal of boot cast. Removal of tape from toes; -Goal: The resident will not develop complications or permanent loss of mobility related to fracture through review date; -Interventions included: -Apply cast boot to right lower extremity and remind resident to leave the cast boot on especially if ambulation; -Encouragement and/or reminders to leave tape in place to the toes; -Give pain, anti-inflammatory medications as ordered. Monitor/document side effects and effectiveness; -Monitor/document/report as needed for edema (swelling), bruising/discoloration of skin, skin temperature changes, loss of sensation distal to fracture, presence/absence of pulses distal to fracture. If cast is present, skin breakdown or trauma at cast edges; -Support injured area with pillows and immobilize part as appropriate. Review of the resident's progress notes, showed: -On 1/31/25 at 6:37 P.M., resident complains of pain to top of right foot. Call placed to physician's exchange. Awaiting a call back for possible new orders; -On 1/31/25 at 10:32 P.M., received return call from Medical Doctor (MD) new order for two view STAT (right now/immediate) x-ray of right foot and ankle; -On 2/1/25 at 6:12 A.M., contacted x-ray for estimated time of arrival. Stated exam scheduled for today. Will put a call out to technician to contact facility with a time. Resident lying in bed resting at this time. Shows no signs or symptoms of pain or discomfort. No redness or swelling observed; -On 2/1/25 at 1:15 P.M., x-ray technician here at this time, all x-rays of right foot and ankle completed. Resident tolerate x-ray without difficulty; -On 2/1/25 at 2:00 P.M., grandchild here at this time to take resident out on leave of absent (LOA) requesting wheelchair related to resident complaint of right foot pain. Explained that we are waiting on x-ray results. Resident currently LOA; -On 2/1/25 at 3:09 P.M., received call from the resident's family, related to resident having to have x-rays taken of right foot. Informed that this writer would notify him/her once x-ray results were obtained. Family also states that he/she will call on 2/3/25 related to not being notified that resident needed x-rays to be obtained; -On 2/1/25 at 5:33 P.M., resident remains LOA currently; -On 2/1/25 at 7:35 P.M., call received from family, informed this writer that grandchild has taken resident to the emergency room (ER) for evaluation and that resident does have fracture to right foot and they are not sure if resident is going to be admitted . Will call facility with further information and update if resident is to be admitted . Family would like to be notified if x-ray results are sent to facility; -Administrator's note on 2/1/25 at 8:08 P.M., spoke with family about the resident's ER visit and he/she is updating other family, of our conversation. He/She informed the administrator that the resident's grandchild came to get the resident for their routine LOA visit but noted the resident in the wheelchair and the staff informed him/her of the pain and x-ray. The grandchild ended up taking the resident to the ER because he/she was concerned about the resident having difficulty walking. He/She verbally reported that the resident has a fracture of a toe which one he/she is not certain. The administrator informed him/her staff noticed he/she had no signs of injury like bruising or swelling. Records and staff communication revealed no fall, and nothing was in his/her room that could be considered heavy and would have fallen on his/her foot; -On 2/1/25 at 10:08 P.M., resident transported to facility from Hospital in a car accompanied by family. Wheelchair used to transport resident to room and place in bed. Resident is alert to self, skin warm and dry, respiration even and unlabored, right foot fracture, cast boot for comfort; -On 2/11/25 at 12:30 P.M., call placed to physician to request orders related to resident continuously removing boot from right foot. New order to tape great right toe (large toe) to second toe right toe for alternative healing measures two times a day. Updated in electronic medical record; -No note the care instructions from the ER visit for ice and elevation was reviewed with the physician; -No clarification regarding the residents 5th toe being broken and why the order specified taping the big toe to the second toe and not the 4th toes to the 5th toe. Observation on 2/24/25 at 8:55 A.M., showed the resident walked around in his/her room and was unable to say his/her name or answer questions. He/She wore a nightgown with no socks or shoes on, no boot on and no tape on the resident's toes. A black walking boot was present in the room next to nightstand under the window. At 9:50 A.M., the resident sat in the dining room eating breakfast, dressed in clothes with sock and boot on the right foot and a sock and shoe on the left foot. Observation on 2/25/25 at 10:03 A.M., showed the resident sat in the common area next to the dining room with a boot on his/her right foot. Licensed Practical Nurse (LPN) A walked the resident down to his/her room and removed the boot. Observation showed all toes taped together and the LPN said the orders are confusing because he/she thought the injury was to the little toe not the big toe, which is what the order has, big toe tape to second toe, so he/she tapped them all together. During an interview on 2/24/25 at 10:05 A.M., LPN E said the staff must tape the resident's toe for support because he/she will not leave his/her boot on. During an interview on 2/24/25 at 12:50 P.M., the Administrator said if a resident is having pain or a change in condition, the physician and family should be notified immediately and orders from physician obtained if necessary. They cannot order STAT x-rays or labs because they do not have access to these services immediately. If the physician requires STAT to an order the resident should be sent to the ER for evaluation. The facility does not have a policy and procedure for STAT orders and they need to call the medical director for clarification and understanding of time frame for STAT orders. During an interview on 2/24/25 at 6:40 A.M., LPN B said he/she worked 1/31/25 at 7:00 P.M. to 2/1/25 at 7:00 A.M. and when he/she arrived to work the resident was in bed. LPN A reported to him/her that the resident had been complaining of right foot pain and to call the physician for an x-ray order. He/She called the physician for a STAT x-ray order of the resident's right foot. He/She checked on the resident several times through the night and the resident slept all night in bed and when he/she palpitated the resident's foot, the resident did not grimace or move his/her foot. There were no signs or symptoms of swelling or bruising. The Administrator calls in every morning around 4:00 A.M. to check on the facility, staff, and residents. When she called, LPN B informed her about the resident's foot and the STAT x-ray order. That is when he/she found out the facility does not have a STAT order for labs and x-rays and if a STAT order is needed then the resident needs to be sent to the ER. The Administrator said the day shift will follow up with x-ray for the resident. He/She never called the family because he/she assumed LPN A had done that. The resident remained in bed all night on his/her shift. When the next shift came in, he/she told them to check on the status of the x-ray. During an interview on 2/24/25 at 7:00 A.M., RN C said he/she did not get a report on the resident from the off going shift and was not aware the resident had an issue with his/her foot until staff got the resident up for breakfast and told him/her they had to use a wheelchair because he/she could not walk to the dining room. He/She looked in the computer and saw an x-ray had been ordered. He/She followed up on x-ray to see when they would arrive. The x-ray happened after lunch. The grandchild came in after the x-ray to pick the resident up for a LOA, this is routine for this grandchild, and asked why the resident was in a wheelchair and he/she said he/she is complaining of foot pain and an x-ray has just been done and we are waiting on the results. He/She did not know he/she was taking the resident to the ER until the family called and said the resident has a toe fracture. He/She never heard what caused the fracture, but assumed the resident walks around all the time, and hit his/her toe on something. A STAT order means as soon as possible, about two to three hours. How long it took for the resident to receive the x-ray was not a STAT order. He/She did not know the family had not been notified but they should have been notified immediately that the resident was having foot pain. During an interview on 2/25/25 at 7:26 A.M., LPN A said it was at the end of his/her shift and he/she had already reported off to the nurse coming on when he/she was told by staff the resident was limping and complaining of pain. He/She went to the resident's room and assessed the foot, and resident had no signs or symptoms of pain upon palpitation, swelling, redness, or bruising. Only when he/she got up to walk did he/she limp and grimace in pain. He/She told the oncoming nurse that he/she had not done anything because he/she was just told by the aide that the resident was having issues. During an interview on 2/25/25 at 11:25 A.M., the Administrator said the family should be notified as soon as possible if a resident has a change in condition, including limping or pain in the foot. She would expect an investigation following an injury of unknown origin to be completed when a resident has a fractured toe so staff can determine what may have caused the fracture to make sure an avoidable issue does not exist. The outcome of the investigation should be followed up with the family. She expected all staff to follow physician orders, make sure they are correct before they give medication or complete treatment and if orders are unclear, she expects them to call for clarification. Nursing staff should never document an order as completed if it was not completed as written. All dressings should be initialed, dated, and timed with completion of treatment. STAT orders mean as soon as possible. She has discussed with facility staff the need for clarification from physicians as to orders that can be completed STAT at the facility and orders that if a STAT reading is needed the resident will need to be sent to the ER. STAT orders need parameters clarification and education completed with physician and staff. The order for STAT x-ray should have been clarified with the physician to see if the resident needed to be sent to ER, or a time frame for completion. The resident's family should have been notified as soon as the resident started limping and complaining of pain. MO00248941

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction) receives necessary treatment and service to promote healing when staff did not provide wound care to one resident (Resident #4) according to physician orders and facility policy and procedures. Four residents were sampled. The census was 53. Review of the facility's policy and procedure for Dressing Non-Sterile Aseptic Technique, undated, showed: -The purpose of this procedure is to provide guidelines for the application of non-sterile dressings: -Preparation: -Verify that there is a physician's order for this procedure; -Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs; -Check the treatment record; -Procedure: -Bring supplies into resident's room. Cut strips of tape adequate for securing dressing and add date and initials or if adhesive dressing used, label dressing at this time; -Documentation: The following information should be recorded in the resident's medical record or Treatment Administration Record (TAR): -The date and shift the dressing was changed; -The initials of the individual changing the dressing; -The type of dressing used, and wound care given. Review of Resident #4's medical record, showed: -Hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (stroke) affecting right dominant side of body, acute upper respiratory infections, aphasia (difficulty speaking), high blood pressure, epilepsy (seizure disorder), dysphagia (swallowing difficulty), diabetes, and unhealed pressure ulcers; -Brief Interview for Mental Status (BIMS) assessment dated [DATE], showed severe cognitive impairment. Review of the resident's physician orders, showed: -An order, dated 12/11/23, for Prevalon boots (cushion boot designed to help reduce the risk of heel pressure injury), on at all times while in bed for offloading every shift for pressure injury; -An order dated 1/23/24, for Skintegrity 2 (foam dressing with border tape) apply to left heel topically every day shift for skin protection, apply border foam dressing and heel protectors; -An order dated 2/24/25, for Cavilon (skin prep, protective barrier wipe). Apply to affected area (area not specified) topically every eight hours as needed for skin protection; -No orders to cleanse left heel wound with cleanser. Review of the Wound Company progress visit report, dated 1/8/25 at 5:45 A.M., completed by the wound company Nurse Practitioner (NP), showed: -Patient presents with suspected deep tissue injury (DTI, a type of pressure injury that occurs when prolonged pressure or shear forces damage the underlying soft tissues, such as muscles, tendons, and bones) to left heel; -The wound is a 2 by 3 (no unit of measurement) area of deep purple. The skin is currently intact; -Wound Care Orders: -Cleanse wound with cleanser, protect peri-wound (skin surrounding wound) with skin prep, cover wound with bordered foam dressing, change daily and as needed for soiling or saturation; -Pressure Relief/Offloading: -Resident on low air loss mattress, offload heels with Prevalon boots. Patient should always have on heel protectors when in bed. Review of the resident's wound weekly observation tool, dated 1/8/25 at 10:37 A.M., showed wound to left heel, DTI, unstageable, measured 2 centimeters (cm) long by 3 cm wide. Continue skin prep with border foam dressing. Review of the resident's progress note, dated 1/8/25 at 10:31 A.M., written by Registered Nurse (RN) C, showed wound care completed per wound company NP. The residents physician/medical director and resident family notified of resident being seen and evaluated by wound NP with orders to continue with skin prep and border foam dressing to left heel. DTI measures 2 by 3 (no unit of measurement), resident to have protective boots on at all times. Observation and interview on 2/24/25 at 10:29 A.M., showed the resident lay in bed awake with both heels flat on the bed, no pillow support to off load heels and no heel protector boots on the resident's heels. The resident said he/she is doing fine and denied having a dressing to his/her heel. At 10:32 A.M. Certified Nursing Assistant (CNA) H entered the resident's room to check on the resident. CNA H asked the resident if he/she is ready to get up and the resident replied yes. Observation showed no dressing to left heel, and a quarter size black and deep purple spot on his/her left heel. CNA H said the resident does not have a dressing to the heel and is supposed to wear heel protecting boots all the time to help protect his/her heels. He/She does not know why the boots were not on the resident's feet. During an interview on 2/24/25 at 1:55 P.M., Licensed Practical Nurse (LPN) G said the resident's order for the left heel is to apply skin prep and he/she completed the task earlier in the day. When asked if the heel receives any kind of dressing, he/she replied the resident has heel boots to help protect the heel and skin prep, no dressing. During an interview on 2/24/25 at 2:20 P.M., LPN G said he/she checked the resident's orders prior to completing the task. After checking the order, LPN G said he/she did not know the order had changed to apply a dressing. He/She has only been using skin prep to the heel and has never applied a dressing. He/She said all orders should be verified prior to completing the treatment. He/She looked up the order and said the order changed on 1/23/25. He/She was not aware of the change and has not completed the order correctly since 1/23/25. Observation on 2/25/25 at 12:26 P.M., showed RN C removed the resident's left heel boot and pulled back the intact foam dressing with border from the heel. The dressing was dated 2/25/25 with nursing initials present. RN C measured the wound at 2 cm long by 1.5 cm wide. He/She reapplied the dressing. During an interview on 2/25/25 at 12:45 P.M., the Administrator said all nursing staff should review all orders prior to administering medications and treatments. She expected nursing staff to check the order prior to completing the treatment or administering the medications. She also expected all nurses to check the orders and if they need clarification to call the physician for clarification. Nursing staff should check progress notes daily to review continuity of care. Progress notes are a form of communication between the resident's medical providers and nursing staff. On 3/3/25 at 10:33 A.M., the Administrator said all wounds are measured and recorded in centimeters. MO00249248

U4413 Based on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for 26 residents (Resident #1, #2, #3, #4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27 and #28). The facility census was 50. 1. Record review of the facility maintained Accounts Receivable (A/R) Aging Report, dated 11/22/24, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in Operating Account #1 $8,139.85 #2 $5,896.30 #3 $1,200.00 #4 $6,559.70 #5 $3,439.81 #7 $148.90 #8 $381.49 #9 $6,362.00 #10 $2,625.00 #11 $34,606.68 #12 $3,354.86 #13 $4.37 #14 $75.00 #16 $59,357.03 #17 $4,260.00 #18 $631.67 #19 $3,035.54 #20 $4,696.00 #21 $2,338.06 #22 $4,829.96 #23 $641.89 #24 $3,508.81 #25 $1,459.04 #26 $4,846.00 #27 $2,363.48 #28 $1.90 Total $164,763.34 During email correspondence on 11/26/24 at 2:13 P.M., 2:52 P.M., 3:41 P.M. and 4:24 P.M., the Business Office Manager (BOM) said Residents #3, #8, #9, #10, #13, #14, #19, #23, #25 and #28 are valid credits and should be refunded. The BOM said more research would need to be completed for Residents #1, #2, #4, #5, #7, #11, #16, #17, #18, #20, #21, #22, #26 and #27 to verify if they are valid credits. Resident #12 owes a private co-insurance balance and the BOM is checking to see if the credit can be applied. Resident #24 has a valid credit and the money should be refunded to the resident trust account. During an interview on 12/11/24 at 4:24 P.M., the Administrator said the facility was not aware of the credit balances in the Accounts Receivable Account. MO00245395

U4413 Based on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 50. Review of the facility maintained Resident Trust Bank Statements for the period 06/2024 through 11/2024, showed an average monthly balance of $19,158.19. Review of the facility maintained Accounts Receivable (A/R) Aging Report, dated 11/22/24, showed the facility held a balance of resident funds in the amount of $164,763.34. Review on 12/11/24 of the Department of Health and Senior Services approved bond list showed the facility had a $30,000 approved bond, making the bond insufficient by $246,000.00. During an interview on 12/11/24 at 4:24 P.M., the Administrator said the facility was not aware of the credit balances in the Accounts Receivable Account and the credits will be corrected, or the bond will be increased. MO00245395

Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistance to prevent accidents for two residents. Staff failed to follow safe practices, respond to request for additional assistance and be aware of the resident's surroundings for one resident (Resident #1) when moving the resident in the bed. The resident fell off the raised bed, onto the floor, sustaining three spinal compression fractures (break in a vertebra (spinal bone) that then collapses), a tooth avulsion (complete displacement of a tooth from its socket due to trauma) and a contusion (bruise) of the face. Staff also failed to complete a safe gait belt (assistive device used to help prevent falls during transfers) transfer for one resident (Resident #2). The sample size was three. The census was 53. Review of the facility's Safety and Supervision of Residents policy, dated July 2017, showed: -Policy Statement: The facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities; -Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; -Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents; -The individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents; -The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents; -The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices; -Implementing interventions to reduce accident risks and hazards shall include the following: -Communicating specific interventions to all relevant staff; -Assigning responsibility for carrying out interventions; -Providing training, as necessary; -Ensuring that interventions are implemented; -Documenting interventions. -Monitoring the effectiveness of interventions shall include the following: -Ensuring that interventions are implemented correctly and consistently; -Evaluating the effectiveness of interventions; -Modifying or replacing interventions as needed; -Evaluating the effectiveness of new or revised interventions; -The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly; -Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Review of the facility's Gait Belt Use Guideline, dated February 2023, showed: -Purpose: A gait belt is a safety device made of cloth that buckles securely around a resident's waist. The device provides a secure grasping surface to aid during transfer and ambulation. Commonly used for residents who are at risk for falls and those who require assistance during transfer; -If the resident has one-sided weakness, position the destination surface (wheelchair, commode, or chair) on the resident's unaffected side; -Position yourself close to the resident to face each other; -Grasp both sides of the gait belt using an underhand grip; -While firmly gripping the gait belt, keep your back straight, bend your knees slightly, position your feet in a wide stance to maintain proper body mechanics and begin rocking back and forth to overcome forces resisting transfer. Instruct the resident on a count of three to push off of the surface to encourage independence; -Allow the resident to stand for a moment to ensure balance; -Instruct the resident to pivot and to bear as much weight as possible on the unaffected side. Support the affected side because the resident will tend to lean to this side; -Pivot on your back foot, guiding the resident to the destination surface. Maintain contact between the destination surface and the resident's legs to ensure proper positioning prior to the resident sitting; -Flex your knees and hips while assisting the patient onto the destination surface. Using good body mechanics prevents back injury by supporting weight with large muscle groups; -After reaching the destination surface, keep a firm grip on the gait belt and gently lower the patient onto the surface. Tell the patient to reach and grasp the arm resets using them to bear some weight if possible; -If the resident loses weight bearing ability during ambulation or transfer, maintain your grip on the gait belt, pull the resident as close to your body as possible and gently slide them to the floor using the large muscles in your upper leg; -Alert the nurse immediately. 1. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/27/24, showed: -Cognitively intact; -Impairment on both sides of upper and lower body; -Dependent for toileting and bed mobility; -Always incontinent of bowel and bladder; -Diagnoses included debility (physical weakness), dementia, diabetes mellitus, atrial fibrillation (a-fib, irregular heart rhythm), depression and psychotic disorder; -Used a pressure reducing device for bed. Review of the resident's physical therapy discharge summary, dated 8/12/24, showed: -Dependent for all mobility; -Dependent for all bed mobility, including rolling left to right; -There was no documentation showing if bed mobility required a one or two person assist. Review of the Primary Care Provider's (PCP) progress note, dated 8/13/24, showed: -Chief complaint was skilled therapy evaluation; -The resident was overweight; -The resident reported limited range of motion, muscle stiffness and stiffness localized to one or more joints; -The resident reported confusion, gait abnormality, difficulty with balance and poor coordination; -The resident's motor strength of his/her arms was normal; -The resident had lower body weakness, lack of coordination and impaired balance; -There was no documentation showing the resident's bed mobility status and/or an order for therapy to evaluate the resident. Review of the resident's progress notes, showed: -8/19/24 at 9:30 P.M., the nurse was alerted to come to the resident's room. Upon arrival the nurse saw the resident was on the floor, on the side of his/her bed lying close to the wall on his/her stomach. The resident's arms were straight at his/her sides and his/her legs were stretched out straight. The resident was rolled over to his/her back by multiple staff members. The resident had a small amount of blood on his/her lips and on the side of his/her face, and a hematoma (collection of blood that pools under the skin) on the right side of his/her forehead. The PCP, resident's responsible party (RRP), Nursing Supervisor and Director of Nursing (DON) were notified. The resident was ordered to go out to the emergency room for evaluation. Review of the hospital discharge documents, dated 8/19/24, showed: -The resident was seen for a fall and head injury; -Diagnoses included fall, compression fracture of T7 vertebra, compression fracture of T10 vertebra, compression fracture of T12 vertebra, tooth avulsion and contusion of face. Review of Certified Nurse Assistant (CNA) D's written statement, dated 8/19/23, showed: -He/She was providing perineal care (peri-care, washing the front and back of the hips, genitals, anal area and buttocks) for the resident; -He/She rolled the resident to the left side of the bed, reached for wipes with one hand and held the resident in place with his/her other hand; -The resident rolled closer to the edge of the bed and CNA D was not able to catch the resident or bring the resident back towards him/her; -The resident rolled out of the bed, face down on the floor; -He/She called out for help and the nurse came to assess the resident; -The resident was sent out to the hospital. Review of CNA D's written statement, dated 8/21/24, showed: -He/She was cleaning the resident and the resident was actively incontinent of bowel, so the CNA went to get more wipes; -The bed started moving and the resident fell over so fast the CNA was unable to catch him/her; -He/She did not remember the resident calling out he/she was falling; -It all happened so fast; -He/She did not get assistance because the resident had always been a one person assist. Review of the resident's progress notes, dated 8/20/24 at 4:10 A.M., showed the resident returned from the hospital to the facility. The resident had new diagnosis of fall, compression fractures of thoracic vertebrae (located on the spine at mid-back) at T7, T10 and T12, a tooth avulsion and a contusion of the face. Review of the resident's care plan, dated 8/23/24, showed: -Problem: Activities of Daily Living (ADLs) self-care performance deficit related to activity intolerance, fatigue and impaired balance; -Interventions included the resident requires max assist of two staff for repositioning and turning in the bed frequently and as necessary -There was no documentation showing bed mobility transfer status prior to the updated care plan on 8/23/24. Review of the resident's Kardex (summary of resident's information, such as medications, care instructions, and follow ups), dated 8/27/24, showed no documentation regarding one or two person assist for bed mobility. Observation of the resident on 8/27/24 at 8:15 A.M., showed: -The resident lay on a low air loss mattress (LALM), breathing in short, shallow breaths, with his/her eyes closed and grimacing in pain; -The resident had a raised lump located above his/her bruised right eye and a brown dried substance trailed out of the right side of his/her mouth; -The resident's left arm had a dark, raised bruise located above the elbow and a dark bruise located on his/her lower forearm. During an interview on 8/27/24 at 8:16 A.M., the resident said: -He/She was in a lot of pain; -His/Her right eye was painful and felt heavy; -His/Her back and left shoulder really hurt; -He/She sometimes felt like he/she wanted it all to end; -Sometimes two people moved him/her in the bed, sometimes it was only one; -He/She remembered telling CNA D to get help to move him/her in the bed because he/she did not feel safe with the CNA doing it by him/herself; -CNA D did not listen to the resident's request and replied he/she could do it by him/herself; -The resident asked CNA D again to get a second person to help move him/her in the bed, as it would make the resident feel more comfortable, safer; -CNA D proceeded to roll the resident over towards the wall and then all hell broke loose; -The resident could not remember if the CNA was holding him/her; -The resident called out that the bed was moving and he/she was sliding; -CNA D replied Hold on, hold on but there was nothing for the resident to hold on to; -The resident fell partly off the bed to the floor hitting his/her left shoulder and head on the floor; -The resident thinks his/her lower body was still on the bed and must have slid off after his/her upper body hit the floor; -The resident couldn't remember anything else but excruciating pain; -Staff did not always listen to the resident when he/she asked for a second staff member to help with transfers. Sometimes staff got a second person to help but most of the time they did not. During an interview on 8/27/24 at 10:32 A.M., Licensed Practical Nurse (LPN) C said: -He/She was just coming on assignment on 8/19/24 when he/she was called to the room to assist the resident off the floor; -The bed was up pretty high, as CNA D was rather tall, and the resident was lying face down on the floor between the bed and the wall; -He/She helped roll the resident over and saw the resident had a bruise in the middle of his/her forehead, a little blood on his/her lips and the resident's face looked pale and swollen; -He/She was not sure what the resident's bed mobility transfer status was before the incident on 8/19/24; -He/She expected CNA D to get a second person to help move the resident in his/her bed for safety as the resident was weak and on a LALM which was slick and increased the risk of the resident falling off the bed. During an interview on 8/28/24 at 12:39 P.M. and at 1:48 P.M., the Director of Therapy said: -When a resident rolls to one side on a LALM, the mattress would deflate underneath the body pressure which would increase the risk of falling off the bed, especially if there was not another person on the side of the resident to support them; -It was not safe practice to roll a resident on a LALM unassisted; -He expected two nursing staff to assist the resident with bed mobility before the incident on 8/19/24; -He was not sure if that was ever told to nursing staff; -The therapy documentation only specifies maximum assist or moderate assist which did not specify if one or two staff members were required. During an interview on 8/30/24 at 11:45 P.M., the Administrator said: -She did not know what the resident's transfer status for bed mobility was prior to the accident that occurred on 8/19/24; -Therapy verbally told her the resident was a one person transfer for bed mobility and the nursing staff agreed; -She expected the resident's transfer status for bed mobility to show if it was one or two person assist and be documented in the resident's care plan, Kardex and therapy screen so all staff knew how to safely transfer the resident; -CNA D did not make the correct decision to move the resident by him/herself. It was not a safe or good decision, and regardless if the CNA thought he/she could move the resident independently, the resident asked for a second person; -She expected CNA D to stop his/her care, put the resident in a safe position on the bed and to go get a second person to assist for safety. Review of the facility's final summary, dated 8/23/24, showed: -The employee failed to obtain assistance even after the resident requested and failed to ensure bed wheels were in locked position; -The resident did fall out of the bed; -The incident occurred but it was an accident; -The employee failed to follow safe practices, respond to request for additional assistance and be aware of the resident's surroundings. 2. Review of Resident's #2's hospice (specialized care for those with anticipated life expectancy of six months or less) documents, showed: -admitted to hospice on 2/8/24; -Long-term Care/Hospice Coordination of Care Form, dated 2/8/24, showed medical equipment required by the patient included a Broda chair (a specialized reclining chair propelled by staff). Review of the resident's physician orders, showed an order, dated 3/22/24, for Occupational Therapy (OT, treatment to improve ability to perform daily tasks) evaluation and treatment as indicated for transfer status and positioning. Review of the resident's electronic medical record (EMR), showed there was no documentation showing OT evaluated the resident following the 3/22/24 order. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive deficit; -Impairment on one side of upper body; -Required maximal assistance for bed mobility and transfers; -Diagnoses included kidney failure and dementia; -Received hospice services. Review of the resident's care plan, dated 6/3/24, showed: -Problem: activities of daily living (ADL) self-care performance deficit related to cognitive impairment, gait and balance impairment, generalized weakness and decreased mobility; -Interventions included monitor resident/document/report any changes, reasons for self-care deficit, declines in function; Pad sit to stand lift (mechanical lift used to transfer resident from one seated surface to another) with soft pad to prevent skin issues. Review of the Morse Fall scale (fall risk assessment tool), dated 7/29/24, showed the resident had a high risk of falling. Review of the resident's hospice documents, showed: -A nursing recertification assessment, dated 7/30/24, showed the resident required two assist for all transfers; -A nursing visit, dated 8/8/24, showed the resident required maximal assistance with transfers and care; -There was no documentation of a therapy evaluation found. Review of the resident's Kardex, dated 8/27/24, showed the resident was able to transfer with a gait belt and one staff assist. Observation on 8/27/24 at 8:23 A.M., showed the resident lay in his/her bed while CNA A dressed the resident in clean clothes. The resident did not respond to any directions, did not speak, open his/her eyes or move his/her body independently during CNA A's care. Observation on 8/27/24 at 8:55 A.M., showed: -CNA A and CNA B provided care to the resident while he/she lay in his/her bed; -CNA A placed his/her hands under the resident's shoulders and pulled the resident up from a lying position to a seated position, then swung the resident's legs from on top of the bed, to the side of the bed; -CNA A held the resident upright with his/her left arm encircling around the resident's back while trying to put the gait belt in place around the resident's waist with his/her right hand; -CNA B helped secure the resident's gait belt around his/her waist while CNA A held onto the resident's left shoulder to keep the resident upright; -The resident did not support his/her own body in an upright position and did not respond to directions or open his/her eyes while the CNAs put the gait belt in place; -The gait belt was very loose, hanging off the resident's waist to his/her lap; -CNA A positioned him/herself on the resident's left side, looped his/her right arm under the resident's left underarm and reached behind the resident to grab on to the resident's gait belt and the back of the resident's pants with his/her left hand; -CNA B positioned him/herself on the resident's right side, looped his/her left arm under the resident's right underarm and reached behind the resident to grab on to the back of the resident's pants with his/her right hand; -Both CNAs lifted the resident up from his/her seated position on the bed and, without the resident's feet touching flat on the floor, put the resident into his/her Broda chair; -The resident did not support his/her own weight when standing, did not pivot, speak or open his/her eyes during the transfer. During an interview on 8/27/24 at 11:18 A.M. and at 12:27 P.M., CNA A said: -He/She knew a resident's transfer status from the EMR under task charting for ADLs; -The resident was a two person gait belt transfer; -Gait belts were placed around a resident's waist with a two finger gap between the gait belt and the resident's body to avoid the resident slipping out of the gait belt during transfer; -When two staff members transfer a resident with a gait belt, one staff member should be on each side of the resident, hook one arm under the resident's underarms while using their opposite hands to grasp the side of the resident's gait belt to assist the resident to a standing position; -Residents are expected to support their own weight during a gait belt transfer; -Pulling a resident up by their shoulders, a loose gait belt and/or the back of the resident's pants increases the risk of a resident falling to the ground, injury to their body or trauma to their skin; -He/she did not know why he/she did not use safe gait belt technique for the resident. During an interview on 8/27/24 at 12:48 P.M., CNA B said: -Gait belts were used to transfer a resident safely; -Gait belts were placed around the resident's chest with a gap large enough to put a hand between the gait belt and the resident's body; -Nursing staff were expected to hook their hands under the gait belt at the back of the resident and in the front of the resident when pulling them up to a standing position; -Pulling a resident up by their shoulders, a loose gait belt and/or the back of the resident's pants increases the risk of a resident falling to the ground, injury to their body or trauma to their skin; -He/she did not know why he/she did not use safe gait belt technique for the resident; -He/She found out transfer status from the nurse at the beginning of his/her assignment and did not know where else to find the information; -He/She was asked by CNA A to assist in the resident's transfer; -He/She did not know if the resident was safe to transfer with a gait belt with two staff member assist. During an interview on 8/27/24 at 12:56 P.M., LPN C said: -He/She expected nursing staff to follow the gait belt policy to ensure resident's safety; -Pulling a resident up by the back of their pants or holding them up by their shoulders puts the resident at risk of injury and did not respect a resident's dignity; -The resident was a two person assist with gait belt according to the resident's chart. During an interview on 8/27/24 at 1:31 P.M., the Administrator said: -She expected nursing staff to place a gait belt at the resident's chest, with a two finger gap, put one hand under the gait belt at the back of the resident and one hand under the gait belt at the side of the resident to assist the resident to a standing position; -Residents were at risk of falling if a gait belt was too loose or not used appropriately; -Residents were at risk of injury to their joints and/or trauma to their skin if nursing staff pulled residents up by their limbs or the back of their pants; -Residents were expected to stand, supporting their own weight, and pivot to transfer from one surface to another with a gait belt; -She expected nursing staff to alert the nurse if a resident was not able to support their own weight and then use a mechanical lift to transfer the resident for safety; -She expected nursing staff to know resident's transfer status and to inquire of their supervisors or the therapy department if there were any questions. During an interview on 8/28/24 at 12:39 P.M. and at 1:48 P.M., the Director of Therapy said: -He expected nursing staff to place a gait belt between a resident's waist and chest and the best practice was placement under the belly button; secured with a couple of fingers' gap between the belt and the resident's body; -He expected during a two person gait belt assist for staff members to stand one on each side of the resident, hook their arms under the resident's arm and then grab the back of the gait belt to assist the resident to a standing position; -Residents needed to be able support their own weight and pivot during a gait belt transfer; -It was not appropriate for nursing staff to lift and move a resident from one surface to another. It increased the risk of injury to the resident, increased fall risk and increased risk of injury to staff; -The nursing staff increased the risk of the resident falling off the bed when the resident had no trunk control, and was not able to support him/herself in an upright seated position; -He expected nursing staff to report any declines or changes in mobility to their nurses in charge, the supervisors or the therapy department; -When the resident went on hospice, his department was told to defer to the hospice team and their evaluations of the resident's ADL capabilities; -He believed the last time the resident was evaluated by his department was in April or March and the resident was appropriate for a gait belt transfer. He could not recall if the resident was appropriate for a one or two person gait belt transfer at that time. 3. During an interview on 8/27/24 at 10:10 A.M., LPN C said: -Nursing staff was informed of residents' transfer status by the therapy department, either verbally or by putting transfer status in the residents' EMR; -Nurses relay residents' transfer status at the beginning of the shift and CNAs could also access residents' transfer status by looking at the Kardex; -Two staff members were sometimes needed for bed mobility or transfers if the resident was immobile, especially if the CNA was not able to move/support the resident's weight on their own; -He/She expected therapy to designate if a resident was a one or two person assist when a resident was dependent with any ADLs; -He/She expected CNAs to ask for help during any type of care, including moving residents in bed or during transfers, in order to keep residents safe. During an interview on 8/30/24 at 11:39 A.M., the Administrator said: -She expected nursing staff to have knowledge of and to follow facility policies; -The therapy department evaluated new admissions and readmits, and after a new event. They screen to determine if further therapy was needed and made the determination how the resident would transfer; -Therapy educated clinical staff on residents' transfer status; -She expected nurses to report transfer status of residents to other staff and update the care plan if needed; -She expected MDS staff to include residents' transfer status in their care plan and on their Kardex; -She expected therapy to notify nursing staff of specific directions for transfers, bed mobility and to signify if a one person or two person assist was necessary for safety. MO00240878

Based on observation, interview and record review, the facility failed to grant access to the facility's electronic medical records (EMR) in a timely manner (i.e. before the end of the first day of the survey) to the Surveyor during an on-site investigation. The facility also failed to provide hospice (specialized care for those with anticipated life expectancy of six months or less) providers access to a resident's EMR for one resident (Resident #2). The sample size was three. The census was 53. Review of the facility's hospice skilled nursing and respite facility agreement, dated 9/11/23, showed: -Hospice administers a program of palliative and supportive services, including interdisciplinary care services to meet the physical, psychological, social and spiritual needs of terminally ill persons and their families; and -Hospice is duly licensed hospice care provider in the State of MO and duly certified by the federal government to provide comprehensive hospice services to Medicare and Medicaid eligible person as delineated under applicable law; -Hospice and the facilities are duly licensed, long-term care facilities providing nursing Facility Services to its residents, and desires to make Hospice Services available to such residents; -Hospice and the facilities desire to provide the highest quality and level of services to Hospice Patients and residents of the facilities with respect to the care and management of their terminal illness; -The facilities and Hospice, in consideration of the mutual advantages occurring to each, and to eligible residents and their families, do hereby agree with each with the others as follows: -Attending Physician: a doctor of medicine or osteopathy (treats musculoskeletal framework) who is identified by the individual, at the time he or she elects to receive Hospice Care, as having the most significant role in determination and delivery of the individual's medical care; -Interdisciplinary Team: a team at a minimum of duly licensed doctor of medicine or osteopathy, a registered nurse, a social worker and a counselor, and such other personnel as Hospice deems necessary, who provide or supervise the care and services offered by Hospice; -The Medical Director: a doctor of medicine or osteopathy who assumes overall responsibility for the medical component of the Hospice's Patient Care Program. -The Case Manager: a registered nurse designated by the HOSPICE to coordinate the implementation of the Plan of Care for each patient. 1. Observations on 8/27/24, showed: -The Surveyor entered the facility at approximately 8:00 A.M.; -The receptionist informed the Surveyor that the Director of Nursing (DON) and the Administrator were not in building; receptionist called them to make them aware of Surveyor's arrival; -At 8:41 A.M., the DON arrived to facility and the Surveyor gave her entrance papers with the request for EMR access; -At 11:09 A.M., the DON gave the Surveyor passwords to log in to the EMR system. The Surveyor was not able to log in using the passwords and informed the DON; -At 12:05 P.M., the DON gave the Surveyor another password to log in to the EMR. The Surveyor was locked out of all resident records and only able to read resident progress notes and physician orders. The DON was informed; -The facility disabled that password, saying they would get the Surveyor a new password that would allow access to residents' full EMR; -At 1:15 P.M., the DON said she was unable to get the Surveyor a new password to access EMR and their Information Technology (IT) representative was coming to the building at 2:00 P.M. to address the issue. During an interview on 8/27/24 at 1:45 P.M., the Administrator was informed the Surveyor entered the facility at approximately 8:00 A.M. that morning and had not had access to residents' EMR for the entirety of the Surveyor's work day, as the Surveyor had to leave the facility at 2:00 P.M. in order to stay within her scheduled work day hours. The Administrator apologized, stating there was nothing else they can do. 2. Review of Resident's #2's election of Hospice Medicare benefit and patient authorization documents, showed: -admitted to hospice on 2/8/24; -The resident chose the Hospice Physician as their attending physician to oversee his/her care. The attending physician would work in collaboration with Hospice to provided care related to his/her terminal illness and related conditions; -The resident gave the hospice company consent to treat and authorized the agency to carry out procedures as order by physician on the plan of treatment; -The resident consented to the use and disclosure of his/her personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. Review of the resident's hospice election statement, dated 2/8/24, showed the resident requested services from the Hospice company and authorized release of all medical records and/or information to or from Hospice as required to act on the request. Review of the resident's Long-Term Care/Hospice Coordination of Care form, dated 2/8/24, showed: -The name of the Hospice Registered Nurse Manager, the name of the primary Hospice Nurse and the name of the primary Hospice Aide; -A schedule of hospice nurse visits to take place on Mondays and Wednesdays; -A schedule of the hospice aide to provide baths/showers to take place on Tuesdays and Thursdays Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/14/24, showed: -Severe cognitive deficit; -Diagnoses included kidney failure and dementia; -Received hospice services. Review of the resident's hospice documents, showed: -On 7/17/24 at 3:05 P.M., the Hospice Nurse Care Coordination note: the facility nurse printed out a copy of the resident's current weights and medication orders. The facility nurse went to retrieve the printed medical records and was told by the Administrator that the Hospice Nurse was not allowed to have the printed copies of the resident's medical record. The Hospice Nurse called the Hospice Director and informed her of the situation; -On 8/16/24 at 12:05 P.M., the Hospice Nurse Care Coordination note: the DON told the Hospice Nurse she was not able to give the resident's current physician orders or recent weights upon request. The DON asked for a copy of the contract between the facility and hospice. The Hospice Nurse gave the information to send the facility/hospice agreement contract to the Hospice Director and Hospice Office Manager. The contract was sent to the facility via fax; -On 8/19/24 at 11:04 A.M., a Care Coordination note: a request was sent to the facility for the resident's current medication list and they were waiting to receive records via fax; -On 8/21/24 at 2:40 P.M., the Hospice Nurse Care Coordination note: the DON told the Hospice Nurse she was not able to give the Hospice Nurse the resident's medical records until after a care plan meeting was set up with the facility. The Hospice Nurse informed the Hospice Director; -On 8/23/24, no time annotated, the Hospice Nurse set up a care plan meeting with the facility staff for 8/27/24 at 10:30 A.M. During an interview on 8/30/24 at 10:41 A.M., the Hospice Nurse said: -He/She was refused access to the resident's EMR sometime in July; -He/She was told by the Administrator they would not release the resident's medical record until they had a care meeting with the Hospice team, including the Hospice Nurse, Hospice Director and Hospice Social Worker; -The Hospice care team arrived for their scheduled care plan meeting with the facility on 8/27/24 at 10:00 A.M. but was told it was canceled. During a interview on 8/30/24 at 11:00 A.M., the Director of Hospice said: -She was informed by the Hospice Nurse the facility Administrator refused to give him/her copies of the resident's EMR upon request; -She was not sure why the Administrator was blocking access to the resident's EMR; -The Hospice Physician needed the resident's medical record in order to coordinate care with the facility; -Lack of access to the resident's EMR affected the plan of care because the hospice staff could not tell if there were missing orders, if the resident was receiving medications/treatments as ordered, if the plan of care was appropriate or needed changed; -The Hospice company had a contract with the facility before they even accepted the resident into their care. During an interview on 8/30/24 at 11:39 A.M., the Administrator said: -The facility coordinated resident care with the hospice team by setting up care plan meetings to discuss care needs, any new interventions needed and to make sure they were providing continuity of care. The facility and hospice team would meet at a minimum quarterly; -A facility and hospice company contract was put in place at start of hospice care. There was a blanket contract for whenever a resident was referred to the hospice company. The Social Services Designee (SSD) was responsible for keeping the contracts/agreement in his/her office; -The resident's hospice team had access to his/her EMR both onsite and offsite; -He/She was not able to provide dates when the hospice team was given access to the facility's EMR and did not send proof of the hospice team logging into the resident's EMR; -She required the hospice team to send an email request for a copy of the resident's EMR; -She refused to allow the facility nurses to give the Hospice Nurse copies of the resident's EMR; -She asked the Hospice Nurse for an email address to send the resident's EMR to him/her. The Hospice Nurse gave the Administrator an email address that was not specific to the company so she refused to send the resident's EMR; -The SSD had an email address in which he/she was communicating to the hospice team to set up a care plan meeting; -She required the hospice team to come in for a care plan meeting because she did not know how the hospice team was caring for the resident, why the resident was on hospice, who was working with the resident or when they were coming in to care for the resident; -The hospice team communicated with the staff by documenting their visits in a binder specific to the hospice company and the residents they cared for. During an interview on 9/9/24 at 11:09 A.M., the Director of Hospice said: -Hospice staff could only get information about the resident's electronic medical records by asking the nurse or administrative staff to print off the medical records; -The hospice staff did not have access to the resident's EMR while onsite or offsite; -She was not sure the last time the Hospice Nurse was able to obtain the resident's medical records from the facility. During an interview on 8/30/24 at 10:41 A.M. and on 9/9/24 11:47 A.M., the Hospice Nurse said: -He/She was not able to access the EMR while onsite or off site; -He/She only received printed records upon request from the nurse; -He/She would ask the nurse if there were any new orders or changes of condition and the facility nurse would answer. He/She had a good working relationship with the nursing staff; -He/She was told by the nursing staff they were not allowed to give him/her the resident's printed medical record due to the Administrator's instructions; -He/She could not remember the last time the facility gave him/her the resident's printed physician order sheets or weights; -The Hospice Physician asks for the resident's medical records and he/she was not able to provide them due to the facility refusing access; -He/She was never given access, tutorials or instructions on how to access resident's EMR while onsite or offsite; -He/She still does not have access to the resident's EMR and it affected coordination of care.

Based on interview and record review, the facility failed to thoroughly and accurately assess, document, and notify the physician of a change in condition sustained by two of 14 sampled residents (Residents #44 and #36) and one closed record (Resident #306). Resident #44 had a diagnosis of congestive heart failure and history of fluid retention. The facility failed to monitor and report the resident's weight gain and respiratory changes. Resident #44 was transported to the hospital and administered intravenous Lasix (diuretic). Resident #306 experienced symptoms of confusion and inability to use a motorized wheelchair. The facility received orders for lab work on 6/6/24 and critical lab results were sent to the facility on [DATE]. Resident #306 continued to experience a change in condition that included inability to use utensils and increased confusion. Between 6/7 and 6/9/24, nursing staff failed to notify the physician of the critical labs and the resident's worsening status until 6/10/24. The resident was transported to the hospital with diagnoses of acute kidney failure and urinary tract infection. The facility also failed to order a urinalysis for Resident #36, who went to the hospital one week later with a diagnosis of kidney infection. The census was 53. Review of the facility's Change in Resident's Condition or Status policy, revised August 2008, showed: -The Director of Nursing (DON) or designee will notify the resident's Attending Physician or On-Call Physician when there has been: -An accident, incident, unusual occurrences, abuse situation, or allegation of abuse involving the resident (ex: choking episodes and etc.); -A discovery of any injury - with cause known or unknown; -A reaction to medication/medication error; -A significant change in the resident's physical/emotional/mental condition; -A need to alter the resident's medical treatment significantly; -Refusal of treatment or medications as clinically appropriate; -A need to transfer the resident to a hospital/treatment center; -A discharge without proper medical authority (Against Medical Advice); and/or -Instructions to notify the physician of changes in the resident's condition; -A significant change of condition is a decline or improvement in the resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self limiting); -Impacts more than one area of the resident's health status; -Requires interdisciplinary review and/or revision to the care plan; -The final decision regarding what constitutes a significant change in status is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument; -DON or designee will notify the resident/ legal representative when: -The resident is involved in any accident, incident or unusual occurrence with or without injury including injuries of an unknown source; -Abuse situations, or allegations of abuse; -There is a significant change in the resident's physical. mental. or psychosocial status; -There is a need to change the resident's room assignment; -A decision has been made to discharge the resident from the facility; -It is necessary to transfer the resident to a hospital/treatment center; -Notification will be made as soon as possible (within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.). In medical emergencies notification should be made as soon as possible after occurrence of the event; -The DON or designee will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status; -If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current Omnibus Budget Reconciliation Act (OBRA) regulations governing resident assessments and as outlined in the Minimum Data Set (MDS) 2.0 RAI Instruction Manual; -A representative of business office/ social service will verify the address and telephone number of the resident's family or legal representative on a quarterly basis. Any noted changes will be reported to the Director of Nursing Services to ensure that such information is changed in the resident's medical record; -A representative of the business office will notify the resident, his/her family, or legal representative when there is a change in resident's billing status. 1. Review of Resident #306's medical record, showed: -admitted on [DATE]; -Diagnoses of hypertension (HTN, high blood pressure), chronic kidney disease, constipation, gastroenteritis and colitis (a digestive disease that causes inflammation of the colon's mucosal lining). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/10/24, showed: -No cognitive impairment; -Diagnoses included hypertension, renal failure, depression, anemia, and asthma; -Always incontinent of bowel and bladder; -Independent with eating at admission; -Uses motorized wheelchair. Review of the resident's care plan, dated 2/2/24, showed: -Focus: Has an Activity of Daily Living (ADL) self-care performance deficit related to weakness and limited mobility. He/She is non-ambulatory and uses a motorized wheelchair for mobility; -Goal: The resident will improve current level of function in transfers; -Interventions: Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Review of the resident's progress notes, showed: -On 6/6/24 at 2:50 P.M., Resident exhibiting increased confusion and inability to bear weight. Resident displays difficulty navigating in his/her motorized wheelchair due to gross bilateral lower extremity (BLE), edema and weakness. Informed DON, Physical therapy (PT) assessed and provided regular wheelchair. Resident's transfer status changed to Hoyer lift (mechanical lift) at this time. Call placed to physician's office to report and request order for lab work. Call placed to power of attorney (POA), message left; -On 6/6/24 at 3:44 P.M., Call back from physician's office. Order obtained for complete blood count (CBC, determines general health status and screens for and monitors for a variety of disorders) and basic metabolic panel (BMP, measures several important aspects of your blood). Call placed to lab and informed of need for draw. Phlebotomist will be out on next business day. Requisition completed. Call placed to responsible party (RP), message left; -On 6/7/24 at 11:21 A.M., late entry: lab here for blood draw. Results pending. Review of the resident's vital signs, showed no documentation of the resident's temperature on 6/6 through 6/9/24. No documentation of the resident's respirations on 6/6 through 6/9/24. Review of the resident's critical lab results, showed: -Collection date: 6/7/24 at 10:40 A.M.; -Received date: 6/7/24 at 4:00 P.M.; -Glucose showed 48, critical low (reference range/cut off 82-115); -BUN showed 59, critical high (reference range/cut off 8-23); -Bicarbonate (CO2) showed 13, critical low (reference range/cut off 22-29); -Originally reported on 6/7/24 at 5:25 P.M. Review of the resident's progress notes, showed: -On 6/8/24 at 7:28 P.M., resident requires assists with feeding. He/She not able to use utensils. Resident has increased confusion, able to answer simple yes or no answers. RP informed of changes. Continue on antibiotic therapy for cellulitis (a bacterial infection that affects the deeper layers of the skin and the tissue underneath). Encourage fluids; -No documentation of acknowledgement of critical lab results or notification of change in condition to physician between 6/7 through 6/9/24; -No documentation of an assessment or monitoring the resident's change in condition on 6/9/24; -On 6/10/24 at 7:00 A.M., patient remains on close observation for antibiotic related to cellulitis. Zero complaints of pain or discomfort. Patient was resting in bed all night with eyes closed. Patient appeared to be asleep but easily awaken with call light in reach; -On 6/10/24 at 4:06 P.M., resident exhibits listlessness (a state of having little to no interest in anything, or a lack of energy), malaise (a general feeling of discomfort, uneasiness, or lack of well-being), and disorientation. Final lab results received. Many high and low values as well as critical results. Labs faxed and called to physician's office. Call back received from Physician L. Telephone orders received to send to emergency room for evaluation and treatment for abnormal labs. Call placed to daughter and informed. DON made aware. Call placed to local 911 for transport. Ambulance service had no available units; -On 6/10/24 at 5:02 P.M., Emergency Medical Service (EMS) in facility. Assumed care of resident. Report given. Exited facility in route to emergency room . Report called to nurse. Review of the resident's vital signs, showed: -On 6/10/24 at 4:44 P.M., the resident's temperature was 97.3 degrees Fahrenheit (F). -On 6/10/24 at 4:44 P.M., the resident's respirations were 20 breaths per minute. -No documentation of the resident's blood sugar on 6/6 through 6/10/24; -No documentation of the resident's oxygen saturation on 6/6/ through 6/10/24. Review of the resident's Physician Order Sheets (POS), showed an order, dated 6/10/24, to send to the hospital for evaluation and treatment for abnormal lab values. During an interview on 8/15/24 at 11:48 A.M., the Administrator said they were looking into the resident's labs from 6/6/24, to see when it was reported. They had notes during their clinical meeting about the resident's change in condition. They ordered the labs and they were the ones who sent the resident out as well. They noticed the change in condition. During an interview on 8/15/24 at 1:17 P.M., Licensed Practical Nurse (LPN) M said the results were faxed from the lab and he/she had access to look at the labs as well. The lab company would call the facility and fax any critical labs. If there was a critical lab, he/she would call the physician immediately and give the results. Physician L wanted the resident sent out. LPN M received a verbal order to send the resident out and he/she faxed the lab results. During an interview on 8/15/24 at 1:26 P.M., Receptionist O from the lab company said there was a phone call to the facility attempted on 6/7/24 between 5:30 P.M. and 5:45 P.M. with no answer. The facility has three fax numbers on file, and the lab faxed the lab results to all three fax numbers between 5:26 P.M. and 5:27 P.M. The lab results were uploaded to the online portal as soon as the results were completed. It was instant. There was also an email on file and the lab results were also emailed. He/She read the email address that belonged to RN B. The only confirmation he/she was able to see was the system showed a status of completed. During an interview on 8/16/24 at 8:40 A.M., the DON said if there were critical labs, the lab would call the facility. Critical labs were also faxed and emailed. When she spoke to the lab company, they said they would call and send results to the three fax numbers they had. Nursing was expected to call the physician and fax the lab results to the physician. If they did not get the physician right away, she expected nursing to call back and relay a message. The DON did not have any knowledge of what happened with the lab results for the resident. She expected nursing to contact the physician if a resident had a change in condition. She expected nursing to contact the physician if the resident had a change in condition during the weekend. The resident's oxygen saturation should have been checked and blood sugar as well, regardless if diabetic or not. The DON said the resident's glucose on the lab result would be considered low. The resident's lab results should have been addressed immediately. If staff could not reach the physician, they could call the family and send the resident out to the emergency room for evaluation. During an interview on 8/16/24 at 10:14 A.M., the Social Worker for Physician L said on 6/6/24, the Nurse Practitioner ordered a BMP/comprehensive metabolic panel (CMP, measurement of blood sugar, electrolyte, fluid balance, kidney and liver function). The nurse reported the resident had increased confusion, safety concerns using a manual wheelchair and would be transferred in a Hoyer lift. On 6/10/24, it was reported to the physician there were critical labs. They received labs at 3:15 P.M. Physician L ordered to send the resident to hospital due to critical labs. Staff were expected to call the physician for critical labs. There was no documentation the facility contacted Physician L between 6/7 and 6/9/24, but he/she could not say the facility did not call or if they tried to contact the physician. But they could call the exchange on the weekends. Sometimes there was not a quick turn around with labs, they were seeing a trend. Labs results were not coming in from the lab like they used to. The facility should follow their policy in regards to monitoring and assessment for a change in condition, but the facility had a plan in place and notified the office. They had a safety plan for the resident and the labs were reported to them. If staff continued to have concerns regarding the resident's symptoms, staff could call the exchange on the weekend. During an interview on 8/16/24 at 9:41 A.M., medical assistant for Physician K said the resident had diagnoses of colitis, chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lung), and a skin ulcer on the right heel. The resident was last seen by Physician K on 5/23/24. There was documentation positive for leg swelling, but no chest pain or palpitations. There was no documentation the facility contacted the physician between 6/7 through 6/10/24. The medical assistant read the documentation from the emergency roiagnom on [DATE]. The resident was admitted for acute renal failure and urinary tract infection (UTI). It was documented the resident was discharged back to the facility and eventually went home for hospice care. During an interview on 8/18/24 at 9:36 A.M., LPN T vaguely remembered the weekend of 6/7 through 6/9/24. He/She remembered the resident started to decline. He/She could not recall anything about 6/7/24, but in general, the resident's condition declined more. He/She had more confusion, and already had weakness on one side. He/She did get to a point he/she could not hold utensils. LPN T did not recall receiving any critical labs that weekend or the resident's labs in general. LPN T was not aware of any labs. The resident was definitely slowly declining and had wounds on his/her lower leg. At baseline, the resident was alert, he/she was up, and used a mobilized wheelchair. His/Her left side was weaker than the other side. He/She went to the hospital and was not really the same when he/she came back. He/She had a lot of incontinent episodes of stool and constant bowel movement. LPN T spoke with the resident's POA about the decline. The POA noticed a decline as well and wanted another opinion from Physician K. He/She had started to decline at that point. They had to feed the resident when he/she declined. When he/she had loose stools, the resident stayed in bed. They put the resident in the regular wheelchair. LPN T did not remember notifying anyone at that point during that weekend. They continued to monitor his/her blood pressure and temperature. During an interview on 8/18/24 at 4:32 P.M., LPN U said he/she remembered the resident. In general, he/she remembered working the weekend of 6/7 through 6/9/24. The resident was in the hospital at one point prior to that weekend. The resident was not herself when he/she came back. LPN U remembered that the resident was unsafe in the mobile chair, so they suggested a Hoyer for his/her safety and staff safety. LPN U remembered the resident had labs done, but it was toward the end, right before the resident was sent to the hospital. He/She remembered they were monitoring the resident closely, as they would with a change in condition. They were doing full assessments, mental and physical, and vitals. The resident was alert and oriented and could have a conversation. The nurse did not remember what happened in specifics of assessments on the weekend of 6/7, but they were monitoring the resident every hour. He/She did not have his/her light on, but the rounds were done hourly. He/She could not recall if anyone was notified. If he/she called, it would have been documented. During an interview on 8/16/24 at 12:29 P.M., the Administrator said she expected staff to contact the physician if the resident had a change in condition on 6/8 that showed he/she could not use utensils or required assistance with feeding. Staff should have called the exchange. The change in condition policy was referring to the condition, but a baseline was needed. Staff should get vitals and any assessments that were appropriate for the change that resident was having. Staff should always have baseline vitals so they can compare previous to current. Blood sugar should be checked if they were on dialysis or diabetic, but she would have to see new protocols on that. Oxygen saturation, blood pressure, respirations, and temperature should be obtained. She expected nursing to notify the physician timely for the labs. The Administrator said the resident's critical labs should have been addressed immediately. The only thing that was mentioned to her was the resident had frequent stools. They were discussing the resident having a private room, but it was related to frequent stools. It was the last month before he/she went out. She expected staff to routinely check labs because the resident could become dehydrated due to the loose stools. She expected the resident to be hydrated and receive fluids. They had a plan in place for the frequent stools, as it was discussed in the clinical meeting. The Administrator was not aware of the resident being sent to the hospital prior to 6/10/24. From 6/7 through 6/11/24, the Administrator did not receive any information on the resident. 2. Review of Resident #44's admission MDS dated [DATE], showed: -Severe cognitive impairment; -Required set-up for eating and oral hygiene; -Required supervision for showering and personal hygiene; -Mobility: independent; -Diagnoses included heart failure, high blood pressure, dementia and COPD. Review of the resident's care plan, last revised on 6/5/24 and in use during the survey, showed: -Focus: Resident has congestive heart failure (CHF, a chronic condition that occurs when the heart can't pump blood efficiently enough to meet the body's needs and can cause fluid build up in the body's organs); -Goal: The resident will have clear lung sounds, hear rate and rhythm within normal limits; -Interventions included: -Monitor lab work: Potassium (K+, measures amount of potassium in the blood), Sodium (NA, measures amount of sodium in the blood), blood urea nitrogen (BUN, measures amount of urea nitrogen in the blood), creatinine (measures how well the kidneys are filtering waste form the blood); -Monitor/document PRN any signs/symptoms of CHF: weight gain unrelated to intake, shortness of breath (SOB) upon exertion, dependent edema (swelling that occurs in areas of the body affected by gravity, happens when extra fluid gets trapped in the body's tissues) of legs and feet, perioribital edema (swelling around the eyes due to fluid buildup and inflammation), weakness and/or fatigue. Review of the resident's Physician Orders, showed: -An order, dated 5/3/24, Albuterol Sulfate Inhalation Nebulization Solution (treats sudden episodes of difficulty breathing) (2.5 milligrams (mg)/3 milliliter (mL)), 3 mL inhale orally via nebulizer PRN for SOB/wheezing. Administer one vial four times a day PRN for wheezing/SOB; -An order, dated 5/3/24, apply oxygen (O2) per nasal canula (a device that delivers extra oxygen through a tube into the nose) PRN and check O2 (saturation (sat, amount of oxygen in the blood) every shift PRN for SOB. Notify physician if below 90%; -The order did not specify the flow rate of oxygen; -An order, dated 6/14/24, Advair Diskus Inhalation Aerosol Powder Breath Activated (medication used to prevent SOB and wheezing) 250-50 microgram (mcg)/act, two puff inhale orally, every 12 hours related to other emphysema (COPD); -An order, dated 6/13/24, Albuterol-Budesonide Inhalation Aerosol (used as needed to treat and help prevent asthma (inflammation and narrowing of the small airways in the lungs) symptoms, 90-80 mcg/act, two inhalations inhale orally every four hours as needed for shortness of breath; Dyspnea (feeling like you cannot get enough air, air hunger). Review of the resident's weights, showed: -5/3/24, 127.6 pounds (lbs); -5/16/24, 130.2 lbs; -5/21/24, 128.8 lbs; -5/31/24, 128.5 lbs. Review of the resident's progress notes, showed: -A Nutrition/Dietary note dated 5/31/24 at 11:59 A.M., New Admit Note; Resident able to make needs known. Resident on a low-calorie sweeteners (LCS, sugar substitutes used), no added salt (NAS) diet. Regular texture. Thin consistency. Resident is particular about diet and practices a vegetarian lifestyle. Resident has no concerns of chewing or swallowing. Resident has a moderate appetite--consumes 75-100% of meals. Resident is independent with meals. 5/31: 128.5 lbs. Will continue to follow and intervene as needed. Review of the resident's weights, showed: -6/12/24, 134.8 lbs. Review of the resident's progress notes, showed: -A Weight Change note, dated 6/21/24 at 4:38 P.M., Weight Change Warning: Value: 134.8 lbs. Vital Date: 6/12/24 3:38 P.M., +5.0% change. Registered Dietician (RD) recommends notifying the physician of weight gains with history of fluid retention. Follow as needed; -No documentation staff contacted the resident's physician regarding the increase in weight; -A Nurses note, dated 6/26/24 at 2:21 A.M., Weekly weight obtained, 138.8 lbs standing; -No documentation staff contacted the resident's physician regarding the increase in weight. Review of the resident's weights, showed: -6/26/24, 138.8 lbs; -7/3/24, 138.8 lbs. Review of the resident's progress notes, showed: -A Weight Change note, dated 7/10/24 at 11:54 A.M., Weight Warning: Value: 138.8. Triggered for previous weight gain trends, remains stable with no new recommendations, follow as needed; -No documentation staff contacted the resident's physician regarding the increase in weight; -An Order note, dated 7/22/24 at 2:26 P.M., Nurse Practitioner (NP) in to see patient. New orders received for labs: CMP, CBC, thyroid stimulating hormone (TSH, indicates how the thyroid gland is functioning), hemoglobin A1C (HgBA1c, measures the average amount of blood sugar), lipid panel (measures for cardiovascular disease), Vitamin D and B12; -An Order note, dated 7/22/24 at 2:28 P.M., Lab tech in to draw labs today; -A Nurses note, dated 7/24/24 at 11:38 A.M., Labs faxed to resident's physician's office with the following abnormals noted: mean corpuscular hemoglobin concentration 31.9 low (MCHC, blood test that measures average concentration of hemoglobin red blood cells. Normal range is 32-36), HgBA1c 6.0 high (normal range is below 5.7%), Creatinine 1.35 high (normal range is 0.6-1.1) and eGFR 39 low (a test that measures how well the kidneys filter waste and toxins in the blood, normal range is 90 or higher). Review of the resident's vital signs for August 2024, showed: -On 8/6/24, respiration 18 breaths per minute; -On 8/6/24, O2 saturation of 96% at room air. Review of the resident's weights, showed: -8/7/24, 143.8 lbs; -The resident had an 11.9% weight gain in three months. Observation and interview on 8/12/24 at 11:50 A.M., showed the resident sat on his/her rollator in the hallway. He/She said he/she was resting. The resident said he/she just finished a breathing treatment. A nebulizer mask (a device that allows a person to inhale liquid medicine in the form of a mist that goes directly into their lungs) was observed on the resident's bed. The resident said he/she received treatments when out of breath. An O2 concentrator (a medical device that takes in air from the room and filters out nitrogen to provide higher concentrations of oxygen for breathing) sat next to the resident's bed. The resident said he/she used it at night and whenever he/she was out of breath. He/She said it should be set on two liters (L, flow rate). Observation showed the concentrator was set at 2 L. Observation and interview on 8/13/24 at 8:55 A.M., showed the resident lay in bed on his/her side and wore a nebulizer mask. He/She said he/she felt weak today. The nurse was aware and that's why he/she was doing a breathing treatment. Observation on 8/13/24 at 2:08 P.M., showed the resident lay in bed on his/her side. He/She wore the nasal canula to receive oxygen. The concentrator was set at 2 L. Review of the resident's progress notes, dated 8/13/24 at 2:31 P.M., showed the resident was complaining of weakness and SOB when walking. Vital signs (VS) are 127/82 (blood pressure, normal range is 90/60 - 120/80), 78 (pulse, normal ranges is 60-100 beats per minute), 20 (breathing, normal range is 12-18 breaths per minute), 98.6% (oxygen saturation, normal range is 95% -100% while resting) on room air, lung sounds. Medical doctor (MD) made aware and verbal order given for chest x-ray. X-ray, vendor called and scheduled. Observation on 8/14/24 at 9:18 A.M., showed the resident lay in bed on his/her side. The resident's nasal canula was next to him/her on the bed. Review of the resident's August 2024 Medication Administration Record (MAR), showed staff did not document administering the PRN nebulizer treatments, PRN oxygen or PRN O2 saturation. Review of the resident's vital signs for August 2024, showed: -No other documentation regarding the resident's respiratory status. Review of the resident's progress notes, showed: -On 8/14/24 at 2:32 P.M., a Weight Change note, Weight Warning: Value 143.8 lbs. +7.5% change, +10.0% change. Resident reviewed by RD for weight gain trends., recommend contacting the physician to notify of gains with history fluid retention and cardiac concerns; -On 8/14/24 at 5:39 P.M., a Nurses note, Skilled received orders to send patient to emergency room for evaluation and treatment related to SOB, increased activity intolerance and decreased endurance, productive cough green and brown sputum (phlegm), noted and reported signs and symptoms; -On 8/15/24 at 6:30 A.M., Nurses note, Patient was admitted to hospital with diagnosis of CHF exacerbation. During an interview on 8/15/24 at 9:04 A.M. and 1:05 P.M., Registered Nurse (RN) B said the resident went out to the hospital at 6:06 P.M. on 6/14/24. There was a chest x-ray ordered, but the results hadn't been received. Yesterday the resident had increased SOB when walking and green/brown sputum. The MD saw the resident the day before. The resident did not have a lot of edema, it was more SOB. The resident's condition was getting progressively worse. If a resident felt lethargic or had SOB, RN B would check the resident's O2 saturation. He/She was not sure what the facility's standard was for checking O2, but he/she would check it to make sure it was within range. RN B was not sure how dietician recommendations were processed or who put them in place. RN B saw nutritional notes in the resident's record. If he/she received an order for labs, he/she would make a progress note and put the order in and then fax it to the lab. Once the lab results were received, if they were critical, the doctor should be called. If they were not critical, then they would be faxed. There should be a follow up note on the lab results to say if the doctor gave new orders or not. During an interview on 8/15/24 at 9:51 A.M., the RD said she had concerns about the resident's elevated weight caused by fluid retention. She provided her feedback within 48 hours of reviewing a resident. She did not receive any response from facility staff regarding her June recommendation to notify the doctor of the resident's significant weight increase. RD recommendations were sent to the Administrator and DON, who then contact the physician. Usually nursing would follow through if there's an order. During an interview with the Administrator and DON on 8/16/24 at 9:37 A.M., the Administrator said the nurse should have contacted the doctor regarding the resident's increased weight especially since he/she had CHF. If the resident became more labored with breathing, staff should have monitored him/her more frequently. If the resident used continuous O2, it should have been documented somewhere. Staff should have documented their monitoring and observations of the resident. The resident's vitals should have been documented. There could have been additional monitoring and interventions with the resident's change in condition. 3. Review of Resident #36's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Moderate to total staff assistance needed for hygiene, toileting, mobility and transfers; -Always incontinent of bowel and bladder; -Had a urinary tract infection (UTI) in the last 30 days; -Diagnoses included diabetes, stroke, paralysis, heart failure and Alzheimer's disease. Review of the care plan, in use during the survey, showed: -Focus: Bladder incontinence; -Goal: the resident will remain free of UTI's; -Interventions: encourage fluid throughout the day, keep skin clean and dry, labs/diagnostics as ordered and report to the physician, monitor and document for a UTI such as pain, burning, blood tinged urine, foul smelling urine, fever and change in mental status. Review of the progress notes, dated 7/14/24 at 2: 50 P.M., showed the resident complained of burning upon urination. Upon assessment, hematuria (blood in the urine) noted. Physician notified and new order given to obtain a urinalysis (UA) and culture. Staff may straight catheterize (a procedure that involves inserting a hollow, soft-tipped urinary catheter into the urethra and into the bladder to drain urine) if needed. Review of the POS, showed no documented orders for the urinalysis and culture. Review of the progress notes from 7/14/24 through 7/22/24, showed no documentation regarding the ordered UA testing or resident urinary status. Review of the progress notes, showed: -On 7/23/24 at 10:12 A.M., the resident placed into the bed to obtain the UA sample. Staff attempted twice. No UA sample obtained; -On 7/23/24 at 12:35 P.M., NP notified the resident had a mental status change. Staff attempted twice to obtain UA sample with no results. New order received to send to the emergency room (ER) for evaluation and treatment; -On 7/23/24 at 2:47 P.M., emergency services notified, the resident had an acute mental status (AMS)change and low blood pressure. Current vital signs: blood pressure 130/47 (normal 120/80), pulse 82 (normal 60-80), respirations 16 (normal 12-18) and temperature 97.4 degrees (normal 97.1-99.1 degrees); Review of the hospital admission history and physical, dated 7/23/24 at 11:45 P.M., showed: -History of present illness: the patient is alert to self and place. He/She was sent to the ER for AMS and hematuria. The obtained UA sample is red and cloudy. Urine culture is pending. The patient administered intravenous (IV) ceftriaxone (antibiotic); -Assessment and plan: acute encephalopathy (rapid brain dysfunction and mental status change), acute cystitis (bladder infection) with hematuria; -Acute encephalopathy due to UTI: Administer ordered cefepime (antibiotic). Review of the

37672 Based on observation, interview and record review, the facility failed to ensure one resident who readmitted to the facility with an identified Stage II pressure wound (a partial thickness loss of the skin epidermis and dermis that appears as an open wound or blister) to the coccyx (tailbone) did not develop worsening or additional skin wounds. The facility failed to conduct re-admission wound measurements, transcribe hospice wound care orders, and notify the physician of the wound. As a result, the wound the resident had on admission got larger and appeared to have slough (moist dead tissue) that developed which is consistent with a Stage III pressure injury (full tissue loss) (Resident #9). The sample size was 14. The census was 53. Review of the state operations manual, showed the following definitions for staging pressure ulcers: -Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present; -Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. Review of the facility's undated pressure/skin breakdown protocol, showed: -Policy specifications: -Document the significant risk factors for developing pressure sores, such as immobility, weight loss and history of pressure wounds; -The nurse shall assess and document/report the following: -Full assessment of the skin condition including but not limited to the location, stage, partial (extends partially into the muscle) or full (extends through all muscle tissue) thickness, length, width, depth and presence of exudate (drainage) or necrotic (black, dead) tissue; -Pain assessment; -The resident mobility status; -Current treatments, including supportive devices; -All active diagnoses; -Examine the skin of any new admission for any alterations of skin integrity; -The physician will assist staff define the type of ulceration; -Identify the factors contributing or predisposing residents to skin breakdown, such as medical comorbidities and macerated (breakdown caused by frequent wetness) or friable (thin, delicate) skin; -Document any signs/symptoms of infection, skin condition assessment, the impact of other diagnoses on wound healing; -The physician will give orders related to wound treatments, including pressure redistribution surfaces, wound cleansing and debridement (surgical removal of dead tissues) approaches, dressing and application of topical agents; -The physician will help identify medical interventions related to the wound management; -The physician will help staff characterize the likelihood of wound healing; -As needed, the physician will help identify medical and ethical issues influencing wound healing. Review of Resident #9's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 5/4/24, showed: -Moderate cognitive impairment; -Does not resist care; -Physical impairment one side upper extremity; -Staff provided substantial to maximum assistance: toileting, bathing, dressing, repositioning, and bed mobility; -Diagnoses included: heart failure, diabetes, stroke, paralysis, depression and malnutrition; -At risk to develop pressure injury; -Had moisture associate skin damage (MASD, inflammation or skin erosion caused by prolonged exposure to moisture); -No pressure injury; -Used a pressure reducing device on the bed; -Application of ointments other than to feet. Review of the resident's care plan, in use during the survey, showed: -Focus: potential for impaired skin integrity and pressure ulcer development related to bowel and bladder incontinence, and requiring assistance for daily care; -Goal: The resident will have intact skin, and be free of redness; -Interventions: Staff administer treatments as ordered, assist with repositioning, follow facility protocol for prevention of skin breakdown, monitor skin with routine care and immediately notify the nurse of changes, and weekly skin assessments. Review of the facility wound report, dated 6/7/24 through 8/7/24, showed the resident not listed. Review of the progress notes, showed on 8/9/24 at 9:49 A.M., a nurse note: the resident readmitted to the facility from. He/She had a Stage II to the sacrum (tailbone) and a dressing in place. He/She is awaiting hospice evaluation. Review of the resident's re-admission Braden scale (assessment tool commonly used in health care to assess and document a client's risk for developing pressure ulcer) risk assessment, dated 8/9/24, showed a score of 9 or very high risk to develop pressure injury Review of the resident's progress notes, showed on 8/9/24 at 10:40 A.M., a nurse documented the resident was assessed and admitted into hospice services. Currently awaiting orders. Review of the resident's hospice admission assessment, dated 8/9/24, showed: -Wound protocol: -Wound #1: Pressure injury, lower back-tailbone; -Skin prep (protective barrier wipe); -Cover with foam border dressing; -Change every day and as needed (PRN). Review of the resident's electronic Physician Order Sheet (ePOS), reviewed on 8/12/24 at 4:17 P.M., showed no orders for wound care or wound treatments. During observation and interview on 8/14/24 at 7:42 A.M., Certified Nurse Aide (CNA) J entered the resident's room and assisted the resident to stand at the bathroom grab bars and removed the resident's pants and brief. CNA J said the resident had an open wound on the left buttock and added the resident recently returned from the hospital. CNA J said the wound had a treatment yesterday morning, and the dressing fell off yesterday afternoon, he/she told the nurse yesterday. He/She started the shift today at 6:30 A.M. and he/she did not see a treatment in place at morning care. Observation of the resident's left upper buttock and the left mid-buttock showed two open, uncovered wounds. The wounds appeared red and approximately nickel sized. CNA J cleaned and dried the wounds. CNA J applied skin barrier ointment to the wounds and buttock area. CNA J reapplied the brief, and pulled up the resident's pants. CNA J assisted the resident into the main dining room and did not notify the nurse of the open areas. Review of the resident's medical record, reviewed on 8/14/24 at 11:53 A.M., showed no documentation of wound care orders, wound assessment, or wound measurements. During an observation and interview on 8/14/24 at 1:09 P.M., Licensed Practical Nurse (LPN) C said he/she readmitted the resident to the facility on [DATE]. The resident was admitted to the facility with a small open area close to his/her coccyx area. The resident was admitted to hospice services on 8/9/24. He/She was the nurse on duty and he/she spoke to the hospice nurse after the admission. He/She last worked at the facility on 8/9/24. LPN C said he/she was not notified of any additional wounds by any nurse or aide and added the resident did not have current wound care orders in the medical records. LPN C entered the resident's room [ROOM NUMBER]/14/24 and removed the sheet and exposed the resident's buttocks. LPN C said there were multiple open wounds to the resident's left inner upper and midline buttock. The two wound measurements noted: -Left upper, inner buttock: Stage II pressure ulcer (PU): 2.0 centimeter (cm) x 0.8 cm x 0 cm. Skin gray and slough noted, surrounding tissue red and inflamed; -Left midline buttock: Stage II PU: Measured 0.5 cm x 0.4 cm x 0.0 cm. Surrounding tissue red, inflamed. When LPN C cleaned the area, the resident said Ouch, stop, it hurts. -In addition, there were approximately 6 additional open wounds scattered across the left buttocks, LPN C said the wounds appeared from shearing. LPN C said the resident had more wounds since he/she returned to the facility. The wound near the tailbone, that he/she had assessed upon re-admission, had gotten larger and appeared to have slough. LPN C said he/she did not notify the physician of the wound near the tailbone when the resident readmitted to the facility. The resident was admitted to hospice services, and LPN C assumed the hospice provider would obtain wound care orders. The hospice provider did not notify LPN C of any wound care orders after admission into hospice. On 8/14/24 at 2:21 P.M., LPN C reviewed the hospice plan of care binder. He/She noted the wound care orders and said the wound care orders did not get entered into the medical records. The aides should have reported the changes in the skin since the resident's re-admission. If aides notice a change in the skin or no treatments, they should notify the nurse immediately so an assessment and treatment can be applied. The resident should have an air mattress, the resident currently had a standard mattress. LPN C would notify the hospice provider of the skin condition and obtain orders. Review of the resident's medical record, reviewed on 8/15/24 at 6:50 A.M., showed no wound measurements from 8/14/24 and no physician or hospice notifications. Observation on 8/15/24 at 7:48 A.M., showed the resident asleep in bed, on his/her back on a standard mattress, with a brief noted in place. During an interview on 8/15/24 at 7:49 A.M., LPN C said he/she had forgotten to document the wound assessment from 8/14/24. He/She called the hospice provider on 8/14/23 and requested wound care orders. The hospice provider had not responded before he/she left work after 7:00 P.M., on 8/14/24. LPN C did not call the physician to obtain wound care orders and continued to wait for the hospice provider to respond with orders as of the time of the interview. LPN C said hospice should obtain orders for the wound care. During an interview on 8/15/24 at 7:55 A.M., the Director of Nursing (DON) said she had been employed at the facility since July 2024. the facility did not have a wound care nurse, and the DON was recently notified by the Administrator that she was responsible for tracking wounds. She expected aides to immediately notify the nurse of any skin changes. The nurse should immediately assess the resident's skin, obtain measurements, and notify the physician for orders. The nurses should notify the DON of any wounds and she would add the resident to the wound report. The facility wound report is two weeks behind, and she used the wound reports for wound identification. The wound report is based off staff reporting skin issues to her. If a resident is admitted with a wound, the admitting nurse should measure and document the wound. The physician should be notified and orders given. If the resident received hospice services, the same procedure should apply. Wounds need an initial measurement at the time of discovery, and then measured weekly after to monitor changes. The resident should get a weekly skin assessment by the charge nurses and this should be documented in the medical record. She was not notified of the resident's original wound on 8/9/24. LPN C notified her of the skin assessment from 8/14/24 on the morning of 8/15/24. LPN C should have documented measurements, started a wound event in the medical record, and contacted the physician. Nurses should not rely on hospice to obtain orders, that is the responsibility of the facility. The resident should have had wound care orders since the time of re-admission since a wound was noted at that time. It is the nurse's responsibility to ensure all hospice orders are documented in the medical record. During an interview on 8/15/24 at 1:35 P.M., the hospice director said the resident admitted on hospice services on 8/9/24. The admitting Registered Nurse (RN) documented a wound to the upper left buttock and documented wound care orders onto the start of care. Wound orders were obtained and verbally given to the facility charge nurse, LPN C. LPN C called the hospice provider on 8/15/24 and requested additional wound care orders and notified the hospice provider of additional wounds. The hospice director instructed LPN C to begin the treatments and the orders would be faxed over once the physician signed them. She expected facility staff to implement hospice orders when given, orders should be started when given to prevent a delay in care and treatment. The hospice nurses provide orders both verbally and written to the facility staff. Hospice staff also write orders in the hospice binder for additional information. During an interview on 8/16/24 at 8:45 A.M., the Administrator said all wounds should be measured, physician orders obtained, wound measurements and the type documented. If the resident received hospice care, the hospice nurse should give an oral report to the facility nurse. Hospice orders should be immediately transcribed into the medical record. If aides notice a change in skin condition, they should report it to the charge nurse or nurse supervisor immediately. MO00239868 50366

Based on observation, interview and record review, the facility failed to follow the menu for lunch on two of two days by not serving the correct meal according to the menu for that day. This practice potentially affected all residents who received food from the kitchen. The facility census was 51. Review of the facility's undated Dietary Services Policy, showed: -Policy: It is the policy of this facility to provide a quality dietetic service using high standards of sanitation that meet the daily nutritional needs of the residents; -All menus for regular or modified diets shall be: Approved by the dietitian; -Prepared in writing in advance; -Clean and legible; -Developed variety of, prepared by diverse methods; -Dated for the current week on the face of the menu; -Posted, to be visually accessible in the preparation area and posted or made available to residents; -Specific as to each kind of food, method of preparation, and amount to be individually served -Followed in the preparation of residents' meals; -Food variances from planned menu shall be of similar nutritive value; -Substitutions shall be noted on the face of the posted copy of the menu and maintained as a permanent record of substitutions including reason for the menu change; -Kept on file for six months. 1. Review of the facility's monthly menu, dated October 2024, showed the following: -On 10/7/24, the lunch menu showed country veal steak and gravy, homemade mashed potatoes, and sauteed zucchini. Observation on 10/7/24 at 12:26 P.M. and 12:35 P.M., showed a daily menu posted on the first and second floor dining room. The monthly menu was posted directly above the daily menu. The daily menu showed lemon and thyme roast chicken, garlic mashed potatoes, steamed mixed vegetables, and fresh baked roll. The residents on the first and second floor were served baked lemon and thyme roast chicken, mashed potatoes and mixed vegetables. During an interview on 10/7/24 at 12:35 P.M., the Dietary Manager (DM) confirmed that lunch was switched with what the residents were supposed to receive for dinner on Saturday. The cook did not show up on Saturday, so the DM came in. The residents were supposed to receive baked chicken on Saturday, but they were served chicken fingers and salad. The baked chicken that was supposed to be served for dinner on Saturday was served for lunch today. 2. Review of the facility's monthly menu, dated October 2024, showed the following: -On 10/8/24, the lunch menu showed ham steak and peach glaze, rice and smoked beans, glazed carrots, and fresh baked roll. Observation on 10/8/24 at 12:45 P.M., showed a daily menu posted on the first and second floor dining room. The monthly menu was posted directly above the daily menu. The daily menu showed country veal steak, rice and beans, and glazed carrots. At 12:50 P.M., the residents on the second floor were served country veal steak, rice and beans, and glazed carrots. 3. During an interview on 10/7/24 at 2:45 P.M., the DM said the previous DM just quit. The previous DM did not order food according to what was on the menu. The DM said he/she was not sure if they would have had the baked lemon and thyme chicken to serve on Saturday evening. The DM will follow the menu and order food according to the menu.

Based on observation, interview and record review, the facility failed to follow the menu for lunch on two of two days by not serving the correct meal according to the menu for that day. This practice potentially affected all residents who received food from the kitchen. The facility census was 51. Review of the facility's undated Dietary Services Policy, showed: -Policy: It is the policy of this facility to provide a quality dietetic service using high standards of sanitation that meet the daily nutritional needs of the residents; -All menus for regular or modified diets shall be: Approved by the dietitian; -Prepared in writing in advance; -Clean and legible; -Developed variety of, prepared by diverse methods; -Dated for the current week on the face of the menu; -Posted, to be visually accessible in the preparation area and posted or made available to residents; -Specific as to each kind of food, method of preparation, and amount to be individually served -Followed in the preparation of residents' meals; -Food variances from planned menu shall be of similar nutritive value; -Substitutions shall be noted on the face of the posted copy of the menu and maintained as a permanent record of substitutions including reason for the menu change; -Kept on file for six months. 1. Review of the facility's monthly menu, dated October 2024, showed the following: -On 10/7/24, the lunch menu showed country veal steak and gravy, homemade mashed potatoes, and sauteed zucchini. Observation on 10/7/24 at 12:26 P.M. and 12:35 P.M., showed a daily menu posted on the first and second floor dining room. The monthly menu was posted directly above the daily menu. The daily menu showed lemon and thyme roast chicken, garlic mashed potatoes, steamed mixed vegetables, and fresh baked roll. The residents on the first and second floor were served baked lemon and thyme roast chicken, mashed potatoes and mixed vegetables. During an interview on 10/7/24 at 12:35 P.M., the Dietary Manager (DM) confirmed that lunch was switched with what the residents were supposed to receive for dinner on Saturday. The cook did not show up on Saturday, so the DM came in. The residents were supposed to receive baked chicken on Saturday, but they were served chicken fingers and salad. The baked chicken that was supposed to be served for dinner on Saturday was served for lunch today. 2. Review of the facility's monthly menu, dated October 2024, showed the following: -On 10/8/24, the lunch menu showed ham steak and peach glaze, rice and smoked beans, glazed carrots, and fresh baked roll. Observation on 10/8/24 at 12:45 P.M., showed a daily menu posted on the first and second floor dining room. The monthly menu was posted directly above the daily menu. The daily menu showed country veal steak, rice and beans, and glazed carrots. At 12:50 P.M., the residents on the second floor were served country veal steak, rice and beans, and glazed carrots. 3. During an interview on 10/7/24 at 2:45 P.M., the DM said the previous DM just quit. The previous DM did not order food according to what was on the menu. The DM said he/she was not sure if they would have had the baked lemon and thyme chicken to serve on Saturday evening. The DM will follow the menu and order food according to the menu.

Based on observation and interview, the facility failed to ensure time/temperature controls for safety food (food that requires time/temperature control for safety to limit the growth of pathogens) were maintained at or below 41 degrees Fahrenheit (F) and freezer temperatures were maintained at a temperature to keep food frozen solid to prevent the potential for foodborne illnesses, failed to ensure the dishwasher in the main kitchen and in the dishwash room of the skilled nursing facility (SNF) were in working order, failed to ensure the sanitizer sink for the three compartment sink in the main kitchen was in working order to allow staff to properly sanitize dishes, and failed to ensure the handwash sinks in the first floor kitchenette and SNF dish room were in working order to allow staff to wash their hands to prevent cross-contamination. In addition, the facility failed to have thermometers available for staff to test the temperature of prepared foods. The facility also failed to maintain the overall cleanliness of the main kitchen and first and second floor kitchenette floors, walls, ceilings and equipment. Staff failed to keep open food items labeled, dated and sealed. Furthermore, the facility also failed to prevent the potential for cross contamination when staff left the flour scoop in the container in the main kitchen and stored the ice scoop on top the top shelf of steamtable in the first floor kitchenette. These deficient practices had the potential to affect all residents who ate at the facility. The census was 53. 1. Observation of the main kitchen on 8/13/24, showed: -At 9:55 A.M., the walk-in cooler door was propped open with an orange bucket. The temperature on the external thermometer read 50 F; -At 10:00 A.M., the walk-in cooler door remained open; -At 10:02 A.M., the Assistant Dietary Manager (ADM) and the Sous Chef (SC) were observed in the walk-in cooler unloading boxes. The door remained propped open. The external thermometer read 52 F; -The walk-in freezer within the walk-in cooler external thermometer read 10 F. Foods inside the walk-in freezer remained frozen solid. During an interview on 8/13/24 at 10:06 A.M., the ADM said it was her second day on the job. She was unsure why the door was propped open, but thought it had not been longer than 10-15 minutes. Observation on 8/13/24 at 10:07 A.M., showed the surveyor requested to take the temperature of an opened gallon of milk located on the bottom shelf, near the door of the walk-in cooler. Staff were unable to locate a thermometer to take the temperature. The ADM poured milk into a cup. The temperature was taken using the surveyor's thermometer and read 41.5 F. The ADM said the temperature should be less than 41 F. The ADM said she would throw out the milk and close the door to the walk-in cooler. Observation of the main kitchen on 8/13/24, showed: -At 10:51 A.M., the door to the walk-in cooler was propped open with an orange bucket; -The SC was inside the cooler with a laundry cart and was putting boxes of food into it; -The SC said they were expecting a food shipment today and needed to move frozen food the secondary freezer to make room. Observation on 8/13/24 at 10:58 A.M., showed the surveyor requested to take temperatures of food items stored in the walk-in cooler. The ADM gathered a small pan of pureed meat, an opened package of ham, and an opened container of cottage cheese. Using the surveyor's thermometer, the food temperatures, showed: -Pureed meat, 42.3 F; -Ham, 42 F; -Cottage cheese, 43.3 F; -During an interview, the ADM said any food items above the threshold of 41 F needed to be tossed out. She would begin temping the foods. Observation of the SNF kitchen on 8/13/24 from 11:11 A.M. to 11:30 A.M., showed: -The door of the walk-in cooler propped open with the laundry cart; -The SC unloaded boxes of frozen food into the cooler; -A reach-in freezer near the stove had a digital thermometer on the outside, which was blank and had no thermometer inside; -Two boxes of bacon. The boxes showed, keep refrigerated; -A box of turkey breakfast patties. The box showed, Keep frozen; -An open box of turkey sausage links. The box showed, Keep frozen. During an interview on 8/13/24 at 11:14 A.M., the SC said he assumed their should be a working thermometer for the reach-in freezer. He opened the door, touched one of the boxes of meat and said they felt cool. He said the Dietary Manager quit three weeks ago and he was in charge until the new Dietary Manager started. He did not know when that would be. He said he unloaded the boxes of food in the walk-in cooler because he did not know where another walk-in freezer was located. He needed to find it. Observation of the SNF walk-in cooler on 8/13/24 at 11:30 A.M., showed: -Two boxes of pasteurized whole eggs. The outside of the box showed Do not freeze; -Four boxes of fully baked yeast rolls. The outside of the box, showed Keep refrigerated' -A box of chocolate chip cookie dough; -Two boxes of hard shell eggs; -A box of white bread. The outside of the box said Never refrigerate. Keep frozen; -Two opened boxes of frozen chicken wings. The box showed, Keep refrigerated or frozen; -Seven boxes of turkey sausage breakfast patties. The box showed, Keep frozen; -Four boxes of beef patties. The box showed, Keep frozen; -A box labeled pork loin. The box showed, Keep refrigerated or frozen; -A box of scrambled egg mix; -The external thermometer read 40 F. There was not an internal thermometer. Observation of the SNF kitchen on 8/13/24 at 1:37 P.M., showed: -The external thermometer on the walk-in cooler read 38 F; -The internal temperature of the walk-in cooler, taken with the surveyor's air thermometer, read 36 F; -The internal temperature of the reach-in cooler, taken with the surveyor's air thermometer, read 43.9 F. During an interview on 8/13/24 at 2:29 P.M. with the Administrator and ADM, the Administrator said she expected food to be stored at the proper temperature. The ADM said the food in the SNF walk-in cooler would be there temporarily. She took temperatures and it was ok. She did not know how long the food would be stored in the SNF. The Administrator said she expected staff to have and use thermometers. If they don't have thermometers, then they wouldn't be able to take food temps. The main kitchen should definitely have thermometers because that's where the residents' food was coming from. During an interview on 8/14/24 at 3:16 P.M., the Administrator said the ADM completed in-services with staff on keeping the cooler doors closed and maintaining proper food temperatures. She purchased thermometers for staff. Observation of the SNF kitchen on 8/15/24 at 10:46 A.M., showed: -The external thermometer of the walk-in cooler read 46 F; -An internal thermometer in the walk-in cooler, placed by the facility, read of 44 F; -An internal temperature in the walk in cooler, taken with the surveyor's air thermometer, read 43 F; -In addition to the food observed in the walk-in cooler on 8/13/24, five boxes of Mighty Shakes (nutritional supplement, which should remain frozen until ready to use) were in the walk-in cooler; -An opened box of turkey sausage breakfast patties were soft to the touch; -An opened box of chicken wings were no longer frozen solid. Observation of the SNF reach-in freezer on 8/15/24 at 10:52 A.M., showed: -The exterior thermometer was blank; -An internal temperature, taken with the surveyor's air thermometer, read 39.6 F; -The boxes of bacon and sausages remained inside. Observation of the main kitchen on 8/15/24 at 10:57 A.M., showed: -Four dietary staff standing by the work table across from the walk-in cooler; -The walk-in cooler propped open with an orange bucket; -Food items on shelves had visible condensation; -Bags of shredded cheese and cartons of liquid eggs appeared to be bulging; -An internal temperature, taken with the surveyor's air thermometer, read 51 F. During an interview on 8/15/24 at 10:59 A.M., the ADM said she was not sure how long the door was propped open, but it shouldn't be. The door should remain closed so that the food coming out of it would not be harmful to anyone. If food was stored above 41 F it would be in the danger zone and not safe for consumption. It was everyone's responsibility to keep the door closed. Observation on 8/15/24 at 11:02 A.M., showed the surveyor requested to take temperatures of food items stored in the walk-in cooler. The ADM gathered a carton of yogurt on a shelf closest to the cooler door and a gallon of milk stored on a shelf approximately 2/3 of the way into the cooler. Using the ADM's thermometer, the food temperatures, showed: -Yogurt: 51.4 F; -Milk: 42.6 F. During an interview on 8/15/24 at 11:16 A.M., the ADM said she spoke with staff who were in the kitchen and no one knew who propped open the walk-in cooler door. During an interview on 8/15/24 at 11:58 A.M., the Administrator said she did two in-services with staff on the door being propped open. The outcome could be the potential to make someone sick. She would throw out the food in the SNF walk-in cooler and reach-in freezer. She would have the ADM throw out any food that exceeded 41 F in the main kitchen's walk-in cooler. 2. Observation of the main kitchen on all days of the survey from 8/12/24 through 8/16/24, showed the dishwash machine with a sign taped to the outside which read Out of Order 5/13/24. During an interview on 8/12/24 at 11:10 A.M., Dietary Aide (DA) V said he/she was responsible for washing the dishes. The dishwash machine had been broken for a while. He/She had to wash everything by hand in the three compartment sink. Observation of the main kitchen on 8/13/24 at 1:50 P.M., showed two DAs at the three compartment sink, washing dishes. DA X stood at the wash sink and after washing dishes, dunked the dishes in the rinse sink then handed to DA W. DA W then took the dishes and ran them under the faucet and a hose which was attached to the sanitizer container mounted on the wall. DA W then placed the dishes on the rack to dry. Review of the container of sanitizer on 8/13/24 at approximately 1:52 P.M., showed: Sanitizer one ounce to 16 gallons. Immerse all utensils for at least two minutes. During an interview on 8/13/24 at approximately 1:55 P.M., DA W said he/she was new and had been trained on how to wash dishes. DA W said the first step was to spray the dishes to remove any debris, then put in soapy water and wash. He/She would then rinse the dishes by running under the faucet and sanitizer hose. He/She would then put the dish on the rack to dry then put away. There was not a way to plug the sanitizer sink, so it could not be filled with sanitizer. Observation of the SNF dish room on 8/13/24 at 2:01 P.M., showed the right side of the dishwash machine with a heavy white and yellow build-up on the exterior. Standing water which was gray with white debris floating on top was inside the machine. There was an approximately half inch wide rust colored ring around the inside of the machine at the surface of the standing water. During an interview on 8/13/24 at 2:29 P.M., the Administrator said she was not aware the dish machine in the main kitchen did not work at all. She only knew staff were having challenges with it. She had asked the former Dietary Manager to obtain bids for repairs. She instructed staff to only wash pots and pans in the three-compartment sink. All other dishes were to be washed in the Assisted Living kitchenette. Staff should wash, rinse then sanitize when using the three-compartment sink. She was not sure how long dishes should be submerged in the sanitizer, but dishes should be submerged. She was not aware there was not a way to plug the sanitizer sink. It was important to sanitize dishes to prevent cross contamination. She was not aware of the condition of the dishwash machine in the SNF. During an interview on 8/14/24 at 3:16 P.M., the Administrator said the ADM completed in-services with staff on the proper way to use the three-compartment sink. The lever on the sanitize sink was repaired, so it could now be filled. A plug was also purchased as a back-up. The dishwash machine in the SNF was emptied and delimed. Observation and interview on 8/15/24 at 11:10 A.M., showed the three compartment- sink in the main kitchen had signs posted: wash, rinse, sanitize. DA V washed dishes. All three compartments were filled with soapy water. DA V said he/she was educated on the three-sink method. He/She said there should be soapy water in the wash first sink and bubbly water in the second and third sinks. 3. Observation of the first-floor kitchenette and dishwash room on 8/13/24, showed: -The kitchenette sink had no running water or soap; -At 7:44 A.M., DA Y entered the kitchenette and donned gloves. He/She then removed pans of food from the hot box and placed them onto the steam table. He/She grabbed a thermometer and then left the kitchenette. At 7:47 A.M., DA Y returned with alcohol wipes. He/She had on gloves. At 7:50 A.M., DA Y again left the kitchenette and returned with gloved hands. He/She then grabbed serving utensils and placed on the steam table. DA Y did not wash his/her hands upon entering the kitchenette; -The dishwash room sink was missing the faucet handle on the right side. The left side handle did not turn on the water. During an interview on 8/13/24 at 2:29 P.M., the Administrator said she expected staff to wash their hands when going from dirty to clean. She was not aware the water was not running in the handwash sinks. It was important for staff to wash their hands to prevent cross contamination and for infection control. Staff should have at least used hand sanitizer. She also expected staff do complete work orders for maintenance so things could be fixed. 4. Observation of the main kitchen on 8/12 through 8/15/24, showed: -Scraps of food, crumbs and debris on the floors; -The floors were slick with grease; -Food scraps ground into the rubber mats in the dish wash area; -Dust on and around seven out of nine ceiling vents; -The ceiling over the steam table had water stains and exposed dry wall that was cracked and chips were in the well of the steam table; -Splatter and dried spills on the walls by the work tables; -Heavy white build up on the floor around the ice-machine; -A thick build up of grease, dust and food particles were visible on the tops, fronts, sides and handles of the warmer, convection oven, stove and flat top; -The interior underneath the well of the deep fat fryer where the grease drain was located, had a brownish sticky build up on the inside of the door and all over the drain; -The table the stand up mixer was on had a reddish spill that was dried and covered with dust; -The floor of the walk in cooler had pieces of lettuce leaves and dried white spills; -The floor of the walk-in freezer had pieces of paper, a piece of cardboard and bits of ice; -The lids to the bulk food containers were sticky and covered in dust. The sides had dried splatter; -The base of the commercial food processor that attached to the bowl had caked on food particles and the sides were grimy; -The floors under the dish machine and the three-compartment sinks had whitish build-up and bits of trash; -Crumbs on the floor in the dry storage room. Observations of the first-floor kitchenette on 8/13 through 8/15/24, showed: -Heavy white and yellow build up around and under the ice machine; -Splatter on the walls; -Dust on the ceiling and around the vents; -Dust and food particles on the shelves under the steam table and work table; -Dried spills on the bottom of the reach-in refrigerator and freezer. Observations of the second-floor kitchenette on 8/14 through 8/16/24, showed a heavy white and yellow build up around and under the ice machine. During an interview on 8/15/24 at 11:20 A.M., the ADM said the floors should be clean. There should not be dust on the vents, but this should be done routinely by maintenance. The commercial food processor should not have food particles caked on it, to prevent cross contamination. The bulk bins should be clean. The large equipment and tables should be cleaned and sanitized. The deep fat fryer should not have a build up of grease because it was a potential fire hazard. The inside of refrigerators and freezers should be clean. The floors in the walk-in cooler and freezer should be clean. 5. Observations of the main kitchen on 8/12 through 8/15/24, showed: -In the dry storage room: -An open bag of muffin mix was not sealed or dated; -An opened bag of chocolate cake mix, wrapped in cling wrap, was not dated; -An opened bag of shredded coconut and an opened bag of powdered sugar, wrapped in cling wrap, were not dated; -An opened bag of yellow cake mix and an opened box of parboiled rice, wrapped in cling wrap, were not dated; -Three opened packages of pasta, wrapped in cling wrap, and undated; -Four wrapped sandwiches in the reach in cooler were undated; -Approximately 20 cups of various condiments in the reach in cooler were undated; -Five opened one gallon containers of various condiments in the walk-in cooler were undated; -A tray with six cups of chocolate ice cream were covered with plastic wrap and undated in the walk in freezer; -A pan with unidentifiable contents was covered in plastic wrap and did not have a label or date. Observations of the SNF kitchenettes, showed: -On 8/13/24 at 7:30 A.M., in the refrigerator, were an opened box with approximately 20 thawed Mighty shakes with a use by date of 8/15/24 and instructions to thaw and use within 14 days were undated and an opened box of thawed Ready Care shakes (nutritional supplement) with instructions to thaw and use in seven days, were undated; -On 8/14/24 at 8:44 A.M., in the reach-in was an undated, opened box of thawed Ready Care shakes. During an interview on 8/15/14 at 11:20 A.M., the ADM said opened food items should be labeled, dated and sealed, preferably in a zip lock bag, to ensure food was safe for consumption. 6. Observation of the main kitchen on 8/12/24 at 10:48 A.M., 8/13/24 at 10:18 A.M., showed a scoop inside the bulk flour container. Observation of the second-floor kitchenette on 8/14/24 at 8:44 A.M., showed the ice scoop on top of the steam table next to a bag of hot dog buns. During an interview on 8/15/24 at 11:20 A.M., the ADM said the scoops should be stored in holders to prevent cross contamination. 7. During an interview on 8/15/24 at 2:25 P.M., the Administrator said the floors, walls, ceilings and vents in all the dietary areas should be clean. All large equipment should be clean. Food should be labeled, dated and sealed.

Based on interview and record review, the facility failed to develop and implement the Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all residents in the facility. The census was 53. Review of QAPI at a glance: A step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home, created by the Centers for Medicare and Medicaid Services (CMS), showed: -The Affordable Care Act of 2010 requires nursing homes to have an acceptable QAPI plan within a year of the promulgation (declaration of new law) of a QAPI regulation. However, a more basic reason to build care systems based on a QAPI philosophy is to ensure a systematic, comprehensive, data-driven approach to care. During an interview on 8/16/24 at 8:35 AM, the Administrator said the facility has the CMS QAPI at a glance step by step guide to implementing a QAPI plan but has not added any addendums nor has she initiated a facility specific QAPI plan. She started as administrator March 2024 and is unaware of a plan prior to her start date. The facility has had several emergency issues that have come up since she started and she has not had a chance to implement a corrective plan. The QAPI committee should meet quarterly and she had planned on a meeting in July 2024 but unfortunately was unable to organize it.

37672 50366 Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. The facility had two floors in which residents resided. Lighting issues were identified in the first-floor spa room and men's restroom. The dining room on the first floor had chipped paint and duck-tape on the floor. One resident (Resident #23) had torn drywall and an unfinished ceiling in the bathroom. In addition, 12 additional resident rooms had a variety of environmental concerns. The sample was 14. The census was 53. Review of the facility's Nursing Home Residents' Rights, provided to residents upon admission to the facility, showed: -No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the Constitution of the United States solely on account of his or her status as a resident of the Community; -The right to live in an environment that promotes and supports each resident's dignity, individuality, independence, self-determination, privacy, and choice and to be treated with consideration and respect. 1. Observations on 8/14/24 at 8:30 AM and 8/16/24 at 7:33 AM, showed: The spa room, located on Spring Garden Hall, had two out of the three sets of lights, with double fluorescent light bulbs going out and not bright and only gave off a dim pink color. Observations on 8/14/24 at 8:36 AM and 8/16/24 at 8:05 AM, showed: The men's restroom, located on the first floor off the dining room, was dark and had no working light fixtures. During an interview on 8/16/24 at 7:45 AM, Certified Nursing Assistant (CNA) G said the lights in the spa room and men's restroom have been out for a while. It was reported to maintenance. During an interview on 8/15/24 at 7:00 AM, Licensed Practical Nurse (LPN) I said he/she was not aware the men's restroom light does not work 2. Observation on 8/16/24 at 7:33 AM, showed: The dining area and halls on the first floor had numerous areas in need of paint touch up. The area around a door that goes outside off the dining room has paint that buckled and chipped off. In the combined dining and activity area there was baseboard trim missing and an area of grey duct-tape, peeled up from the dining room floor that lead to the halls and resident activity area. 3. Observation on 8/13/24 at 7:26 A.M., of Resident #23's bathroom, showed the bathroom drywall torn, ripped and unfinished at the ceiling. LPN I said the bathroom wall had been in disrepair for months. He/She did not know if the maintenance staff were aware of the issue. He/She was not aware who to report maintenance issues or repair needs to. He/She would report issues to the Director of Nursing (DON). 4. Observations on 8/12/24 at 1:50 PM, 8/14/24 at 8:51 AM, and 8/16/24 8:04 at AM, showed: Resident room [ROOM NUMBER], double occupancy room, had a very strong odor of urine and was in need of paint touch up. 5. Observation and interview on 8/13/24 at 7:26 AM, showed: Resident room [ROOM NUMBER] restroom had drywall torn, ripped and unfinished at the ceiling. Licensed Practical Nurse (LPN) I said the restroom wall had been in disrepair for months. He/She did not know if the maintenance staff were aware of the issue. He/She was not aware who to report maintenance issues or repair needs to. He/She would report issues to the DON. Observations on 8/14/24 at 8:41 AM and 8/16/24 at 8:03 AM, showed: Resident double occupancy room [ROOM NUMBER], with a very strong odor of urine. The resident's area on the right side of room was missing the privacy curtain. In the resident's restroom, the light cover over the vanity fixture was missing and exposed two fluorescent light bulbs. 6. Observation on 8/14/24 at 8:40 AM, showed: Resident room [ROOM NUMBER], had no light cover over the vanity fixture that exposed two fluorescent light bulbs with one bulb not working. The paint on the wall around the air-conditioner chipped off with white patches of drywall exposed. Drywall torn, ripped, and unfinished at the ceiling with an opening approximately 3 feet in length and a half an inch wide, where the wall and the ceiling meet. 7. Observation on 8/14/24 at 8:46 AM, showed: Resident double occupancy room [ROOM NUMBER], with the light cover over the vanity fixture missing and exposed two fluorescent light bulbs with one light bulb not working. The brown wall on the left side of the room around the call light connection had patches of white in was need of paint. 8. Observation on 8/14/24 at 8:51 AM, showed: Resident double occupancy room [ROOM NUMBER], the restroom had a dirty laundry container that overflowed with dirty clothes onto the floor next to the commode. In front of the commode was a black, anti-slip coating peeled off with ragged edges. 9. Observation on 8/16/24 at 7:34 AM, showed: Resident room [ROOM NUMBER], the right side of room with white marks in need of paint touch up. 10. Observation on 8/16/24 at 7:36 AM, showed: Resident double occupancy room [ROOM NUMBER], with areas on the wall around the corners and scattered around the room in need of paint touch up. 11. Observation on 8/16/24 at 7:39 AM, showed: Resident double occupancy room [ROOM NUMBER], did not have individual privacy curtains for the beds in the room. 12. Observation and interview on 8/16/24 at 7:40 AM, showed: Resident double occupancy room [ROOM NUMBER], had multiple scattered areas on the wall in need of paint touch up and the light in the restroom not working. LPN G said the light has been out for at least two weeks and he/she has told maintenance about it a couple times. The residents in the room are confused. 13. Observation on 8/16/24 at 7:41 AM, showed: Resident double occupancy room [ROOM NUMBER], restroom fluorescent light was very dim. The residents in the room were unable to be interviewed. 14. During an observation on 8/16/24 at 7:42 AM, showed: Resident double occupancy room [ROOM NUMBER], had wall repairs completed around the air conditioner in need of touch up paint. 15. During an interview on 8/12/24 at 11:56 A.M., Resident #304 said the carpet is an issue for him/her. The carpets in the hallway and outside the nurse's station and dining room are dirty and stained. 16. During an interview with the resident council, on 8/14/24 at 1:48 P.M., Resident #5, said his/her blinds were worn. Maintenance said he/she was not able to receive new blinds. He/She could not remember the reason. 17. During an interview on 8/16/24 at 12:56 PM, the DON said all rooms should have privacy curtains in them. She was not aware of all the lights being out, strong urine odor in rooms #121 and #124, privacy curtains missing in rooms #124 and #122, duct tape on floor in dining and activity area, and walls needing repairs and painting. Staff are responsibility to fill out a maintenance form, available at all nursing stations, when repairs are needed and give it to the maintenance department or to her so she can give it to them during the morning meeting. All fluorescent light fixtures should have covers over them and the carpets in the rooms with strong urine odor need to be shampooed. 18. During an interview on 8/16/24 at 1:10 PM, the Administrator said all rooms should have privacy curtains. She was not aware of all the lights being out, strong urine odor in rooms, privacy curtains missing in rooms #124 and 122, duct tape on the floor in dining and activity area, and walls needing repairs and painting. All the resident's equipment, clothes and the room's carpet needs to be checked and cleaned to see where the urine odor is coming from. She will check with housekeeping. 19. During an interview on 8/16/24 at 11:32 AM, the Housekeeping Supervisor (HKS) said she has only been in the position for three weeks but has been working at the facility for [AGE] years in various jobs. She is aware of the strong urine odor in rooms #121 and #124 and said it is down deep in the carpet. She has started a deep cleaning program, and these rooms are on the list. NOTE TO REVIEWER - No resident interviews about the resident room examples or common area examples except for the one about the carpets. MP

35394 37672 Based on interview and record review, the facility failed to encode and transmit resident assessment data within 7 days after a facility completes a resident's assessment for seven of seven residents investigated for Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) assessments for encoding and transmission, as indicated by the MDS showing in progress or ready to export (Residents #10, #28, #16, #23, #30, #45 and #12). The census was 53. Review of the MDS, version 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-Admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the Admission assessment, the MDS Completion Date must be no later than 13 days after the entry date; -Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software); -Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. 1. Review of the facility's Electronic Submission of the MDS policy, revised December 2006, showed: -Policy: All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's computer MDS informational system and transmitted to the State database in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations governing the transmission of MDS data; -MDS electronic submissions shall be conducted in accordance with current OBRA regulations governing the transmission of such data; -The MDS Coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that initial feedback and validation reports from each transmission are maintained for historical purposes and for tracking; -All MDS assessment data will be backed up daily. 2. Review of Resident #10's medical record, showed: -admitted [DATE]; -A Discharge assessment, dated 10/15/23, ready to export as of 8/14/24; -An Entry assessment, dated 10/20/23, ready to export as of 8/14/24; -A Quarterly assessment, dated 11/10/23, ready to export as of 8/14/24; -An Annual assessment, dated 2/8/24, ready to export as of 8/14/24. 2. Review of Resident #28's medical record, showed: -Admission 3/21/24; -An Admission MDS assessment, dated 3/28/24, ready to export as of 8/14/24. 3. Review of Resident #16's medical record, showed: -readmitted [DATE]; -Enrolled into hospice services: 2/8/24 -A Significant Change MDS assessment, with an ARD date 2/12/24, ready to export as of 8/15/24. 4. Resident #23's medical record, showed: -admitted on [DATE]; -A Quarterly assessment, dated 4/3/24, ready to export as of 8/13/24. 5. Resident #30's medical record, showed: -admitted on [DATE]; -A Quarterly assessment, dated 4/3/24, ready to export as of 8/13/24. 6. Resident #45's medical record, showed: -admitted on [DATE]; -A Quarterly assessment, dated 3/30/24, ready to export as of 8/13/24; -An Annual assessment, dated 6/24/24, ready to export as of 8/13/24. 7. Resident #12's medical record, showed: -admitted on [DATE]; -A Quarterly assessment, dated 2/28/24, ready to export as of 8/13/24. 8. During an interview on 8/15/24 at 9:31 A.M., MDS Coordinator said she has been doing MDS since April. There is an alert in the electronic medical record that notifies nursing when an MDS is due. They are done within two weeks of the time of admission. A significant change MDS would be completed if something had been identified that would not improve in two weeks or an admission into hospice services. In the electronic medical record, export ready means it is ready to be transmitted. She is learning more about transmitting in the electronic medical record and it was a different system than what she was used to. There were glitches in the system. The residents who did not have transmitted MDS were prior to her starting. She had to individually find each resident to transmit the MDS, so it is taking her time. She was able to print a list, but it did not appear to be accurate to her. She did not remember what was inaccurate about it; however, she could not use the report and had went to each resident's MDS for transmission. She was not aware if there were issues with transmitting the MDS when she started, but there was a lot to catch up on. The discharge MDS is expected to be completed 14 days after the resident's discharge. 9. During an interview on 8/16/24 at 8:40 A.M., the Director of Nursing (DON) said she would expect the MDS to be accurate and submitted timely. She was not aware MDS's were not transmitted. 10. During an interview on 8/16/24 at 1:01 P.M., the Administrator said the DON oversees the MDS, but there had been changes in that position and issues with the MDS' in the past. The MDS Coordinator could pull up the validation report since the electronic medical record is not always accurate. The report from the electronic medical record may have been the report the MDS Coordinator was not able to use. 11. During an interview on 8/16/24 at 3:11 P.M., the MDS Coordinator pulled up the validation reports and said if the assessment was submitted, the validation report would tell them if it was rejected or accepted. Most of the MDS assessments were submitted and it said it was rejected. In the facility's electronic medical record, it would say exported or export ready. She goes back to each individual resident in the electronic medical record and will try to correlate both. The MDS Coordinator was asked to look into Resident #45 who did not have a Quarterly assessment transmitted. At 4:04 P.M., the MDS Coordinator said the resident's MDS was updated. Resident #45's quarterly assessment, showed the batch was accepted on 6/4/24 and the Quarterly assessment, dated 6/24/24, showed accepted in the electronic medical record.

Based on observation, interview and record review, the facility failed to ensure residents who required dialysis (the process of filtering toxins from the blood in individuals with kidney failure), received services consistent with professional standards of practice for two of two residents investigated for dialysis services (Residents #107 and #106). In addition, the facility failed to have a policy to address the assessments, monitoring, and communication with dialysis centers for their dialysis residents. The facility identified two residents as receiving dialysis and concerns were identified for both residents. The census was 53. 1. Review of Resident #107's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/4/24, showed: -No cognitive impairment; -Diagnoses included stroke, end stage renal disease and diabetes; -Special treatments: dialysis. Review of the resident's care plan, in use during the survey, showed: Resident needs dialysis secondary to end stage renal disease. He/She goes to the dialysis center on Mondays, Wednesdays and Fridays to receive his/her treatments. Review of the resident's August 2024 physician orders, showed: -An order dated 7/4/24, with the name, address, phone number and chair time for dialysis; -No order to assess or monitor the resident pre or post dialysis treatments. Review of the resident's medical record, showed no communication sheets documented between staff and the dialysis center. During an interview on 8/15/24 at 1:37 P.M., Licensed Practical Nurse C said the resident goes to dialysis on Mondays, Wednesdays and Fridays from 8:15 A.M. and returns between 3:00 P.M. and 5 P.M. Observation on 8/16/24 at 8:04 A.M., showed the resident up in his/her wheelchair in the lobby. He/she confirmed he/she was waiting to go to dialysis. 2. Review of Resident #106's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included: Heart failure, diabetes, cerebral palsy (a group of neurological disorders that affect a person's ability to move, maintain balance, and posture) and end stage renal disease; -Special treatments: dialysis. Review of the resident's care plan, in use during the survey, showed: Resident receives hemodialysis three times a week for ESRD related to diabetes; Review of the resident's August 2024 physician orders, showed: -An order dated 12/11/23, Check site of dialysis catheter (a flexible tube that's used to access a patient's bloodstream during dialysis treatment) every shift for drainage and condition of dressing; -No order for dialysis, what days the resident received dialysis or where the resident went for dialysis. Observations of the resident on 8/13/24 at 8:50 A.M. and 8/15/24 at 9:00 A.M., showed the resident up in his/her wheelchair in the lobby. The resident confirmed he/she was waiting to go to dialysis. 3. During an interview 8/16/24 at 9:37 A.M., the Administrator said there did not have to be an order for specific days or places. She thought there never had to be an order for dialysis treatment. There should be an order for the access site. There should be a policy. There should be documentation for communication between the dialysis center and the facility.

50366 Based on observation, interview and record review, the facility failed to ensure that seven out of seven residents (Residents #43, #20, #22, #5, #254, #10, and #106) reviewed for siderail use, had a comprehensive risk-benefit assessment completed. This failure had the potential for residents at risk for entrapment to become entrapped in the siderail with a risk of severe injury and/or death with bedrail use. The census was 53. Review of the facility's Side Rail Policy, undated, showed: -Regardless of the purpose for which bed rails are being used or considered, a decision to utilize or remove those in current use should occur within the framework of an individual patient assessment; -Use of bed rails should be based on patient's assessed medical needs and should be documented clearly and approved by the interdisciplinary team; -The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted and determined not to be the treatment of choice for the patient; -The decision to use bedrails should be based on a comprehensive assessment and identification of the patient's needs, which include comparing the potential for injury or death associated with use or non-use of bed rails to the benefits for an individual patient. 1. Review of Resident #43's medical record, showed: -Diagnosis of dementia and a history of falls; -An order, dated 6/6/24, for a 48 inch bariatric bed with bariatric transfer bar; -No comprehensive risk-benefit assessment completed for the resident's use of siderails; -No care plan completed for resident's use of siderails. Observations and interviews, showed: -On 8/12/24 at 1:16 PM, the resident not present in room. The resident had a quarter length siderail attached to the left side of the bed. The resident's roommate said Resident #43 has fallen out of bed and so the facility staff attached the siderails to the resident's bed so he/she will not fall out of the bed; -On 8/14/24 at 2:55 PM, the Resident sat in his/her wheelchair with a family member present in the resident's room. The resident's bed had a quarter rail on the left side of the bed. The resident was unable to answer questions due to confusion. The resident's family member said he/she requested the siderails to help keep the resident from falling out of the bed. 2. Review of Resident #20's medical recorded, showed: -Diagnoses of dementia, history of falling, hemiplegia and hemiparesis (paralysis and/or weakness) affecting the right dominant side, stroke, and brain hemorrhage (bleed); -No orders for the resident's use of siderails; -No comprehensive risk-benefit assessment completed for the resident's use of siderails; -Plan of care revised 12/20/22, showed; -Focus; activities of daily living (ADL) self-care performance deficit related to dementia, stroke and brain hemorrhage; -Goal; The Resident will be encouraged to improve current level of function in activities of daily living through the review date; -Interventions to be completed by nursing staff: -For bed mobility, the Resident requires assistance of one staff to turn and reposition in bed; -For transfer, the Resident requires assistance of one staff to move between surfaces with assistance of bilateral U-rails (a type of siderail shaped like a U, commonly used for mobility). Observations and interviews, showed: -On 8/12/24 at 1:50 PM, the resident sat in a wheelchair in his/her room, and had bilateral U-rails on the bed with controls for the bed attached inside the U- rail. The Resident said he/she does not use the U-rails on the bed; -On 8/14/24 at 1:50 PM, the resident sat in a wheelchair in the resident's room getting ready to go outside for an activity. Activity Aide D said the resident's U-rails are used to hold the resident's bed controls and the resident does not use them to move in bed because the resident requires total assistance to move in bed; -On 8/15/24 at 8:11 AM, the resident not in his/her room. Bilateral U-rails present on the sides of the resident's bed. 3. Review of Resident #22's medical recorded, showed: -Diagnoses of dementia, hemiplegia, and confusion; -No orders for the resident's use of siderails; -No comprehensive risk-benefit assessment completed for the resident' use of siderails; -No care plan completed for resident's use of siderails. Observations and interviews, showed: -On 8/12/24 at 2:37 PM, the resident sat on the side of his/her bed with bilateral U-rails present on sides of the bed. Certified Nurse Assistant (CNA) G and Restorative Aide (RA) E assisted the resident to a standing positioning. CNA G held the resident's hands as RA E stood by for assistance and both staff walked the resident to the resident's restroom. The resident did not use the siderails on the bed to stand; -On 8/14/24 at 2:42 PM, the resident not in his/her room. Bilateral U-rails present on the sides of the resident's bed. 4. Review of Resident #5's medical record, showed: -Diagnosis of history of falling, confusion, and mood disorder; -An order dated 12/12/22 for bilateral U-rails when in bed for use in transfer from bed and self-positioning; -No comprehensive risk-benefit assessment completed for the resident' use of siderails; -Plan of care revised 12/11/22, showed; -Focus: ADL self-care performance deficit; -Goal: The Resident will improve current level of function in ADLs; -Interventions to be completed by nursing staff: -For bed mobility, the resident requires assistance of one staff to turn and reposition in bed as necessary with the assistance of U-rails; -For transfer, the resident is able to self-transfer in and out of bed with the assistance of bilateral U-rails. Observations and interviews, showed: -On 8/12/24 at 2:07 PM, the resident sat in his/her room in a wheelchair. Bilateral U-rails were attached to the sides of the resident's bed. The resident said staff help him/her get up out of bed and to also to move around in bed; -On 8/12/24 at 5:07 PM, the resident not in his/her room. Bilateral U-rails present on sides of the resident's bed. 5. Review of Resident #254's medical records, showed: -Diagnosis of end stage heart failure, repeated falls, urine retention, and anxiety disorder; -No orders for the resident's use of siderails; -No comprehensive risk-benefit assessment completed for the resident' use of siderails; -No care plan completed for resident's use of siderails. Observations and interviews, showed: -On 8/12/24 at 1:50 PM, the resident sat in his/her wheelchair next to his/her bed. The bed had a quarter size bedrail on the left side of the bed; -On 8/14/24 at 1:50 PM, the resident sat in his/her wheelchair in his/her room getting ready to go outside for an activity. The resident said he/she uses the siderail to help him/her change positions in bed; -On 8/15/24 at 8:11 AM, the resident not in his/her room. Quarter sized siderail was present on left side of the resident's bed. 6. Review of Resident #10's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) dated 5/10/24, showed: -Severe cognitive impairment; -Lying to sitting on side of bed, sit to stand, chair to bed transfer: Helper does more than half the effort; -Diagnoses included heart failure, dementia and hemiplegia. Review of the resident's physician's orders, showed an order, dated 10/23/23 for: Side Rails: Two U Rails up for safety during care provision, transfers from bed to wheelchair and to assist with bed mobility. Observe for injury or entrapment related to side rail use. Review of the resident's care plan, last revised on 3/19/24 and in use during the survey, showed: -Focus: Resident has an ADL self-care performance deficit related to impaired mobility, hemiplegia; -Goal: Resident will maintain current level of function through the review date; -Interventions included: Siderails: two U RAILS up for safety during care provision, transfers from bed to wheelchair per self and to assist with bed mobility and transfer. Observe for injury or entrapment related to siderail use. Review of the resident's medical record, showed no comprehensive risk-benefit assessment completed for the resident' use of siderails. Observations on 8/13/24 at 2:05 P.M. and 8/15/24, showed the resident's bed with bilateral quarter rails in the upright position. 7. Review of Resident #106's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Roll left and right: Partial/moderate assistance; -Lying to sitting on side of bed: Helper does less than half; -Diagnoses included: Heart failure, diabetes, cerebral palsy (a group of neurological disorders that affect a person's ability to move, maintain balance, and posture) and seizure disorder. Review of the resident's physician's orders, showed an order dated 12/11/23 for bilateral U Rails when in bed for repositioning. Review of the resident's care plan, last revised on 2/9/24 and in use during the survey, showed: -Focus: Resident has an ADL self-care performance deficit related to impaired balance; -Interventions included reposition in bed with use of bilateral U Rail. Review of the resident's medical record, showed no comprehensive risk-benefit assessment completed for the resident' use of siderails. Observations of the resident, showed: -On 8/14/24 at 8:38 A.M., the resident dressed and lay in bed. Both U Rails in the upright position; -On 8/14/24 at 2:56 P.M., both U rails in the upright position. 8. During an interview on 8/14/24 at 12:11 P.M., the Administrator said they do not use siderails. They use positioning mobility devices, which included quarter and U rails. 9. During an interview on 8/16/24 at 10:00 AM, the Director of Therapy Services said he has not completed a specific siderail assessment for current residents. Siderails should only be used to assist with the resident's movement in bed and transitioning in and out of bed. Staff should report a resident who is unsafe for siderails to the therapy department so the resident can be assessed for safety. Therapy should assist with assessing residents for safe bedrail use prior to the resident having siderails and reassessed with each resident's change in condition. He is not familiar with the facility policy for siderail usage. Siderails should never be used to keep a resident in bed. 10. During an interview on 8/16/24 at 12:46 PM, the Director of Nursing (DON) said she is aware that some residents have siderails and they are used for positioning. She is not aware of any systems in place to assess and maintain siderails. Siderails should be assessed quarterly and with resident change in condition. The DON also said she is new to this position and is not up to date on the facility's policy and procedures for siderails. 11. During an interview on 8/16/24 at 1:15 PM, the Administrator said she is not aware of current facility residents using or having siderails. The facility does not have a system in place to monitor and assess for resident siderails. All residents should have an assessment prior to the application and use of siderails to keep resident's safe and free from harm and entrapment. Nursing and therapy should be responsible for this assessment. The assessment should be completed quarterly and upon the resident's change in condition. It is the responsibility of maintenance to supply and attached side rails. The facility does not have a policy and procedure for maintenance to check siderails for safety once installed. She said it a challenging question about whether or not U-rails are considered siderails but regardless, the same assessment should be completed for any type of rail attached to resident side of bed.

Based on interview and record review, the facility failed to ensure one resident (Resident #3) was free from abuse when staff failed to appropriately intervene and separate Residents #1 and #3 upon observation of the residents engaging in an increasingly agitated argument over Resident #3's walker. Resident #1 grabbed Resident #3's walker and pushed him/her to the ground, resulting in a fractured femur to Resident #3. The sample was four. The census was 51. Review of the facility's Abuse Prevention policy, undated, showed: -This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: -Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation, and misappropriation of property; -Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; -Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; -This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; -Orientation and Training of Employees: --During orientation of new employees, the facility will cover at least the following topics: -What constitutes abuse, neglect, exploitation, and misappropriation of resident property; -Dementia management and resident abuse prevention; -How to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff; -The policy failed to provide written guidance for staff on how to correct and intervene in situations in which abuse is more likely to occur. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/26/24, showed: -Moderate cognitive impairment; -Behaviors not exhibited; -Diagnoses included Alzheimer's disease, dementia, and anxiety. Review of the resident's care plan, revised 5/24/24, showed: -Focus: Behavior: The resident is an elopement risk/wanderer related to history of attempts to leave facility unattended and impaired safety awareness; -Interventions include distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Distract resident by talking about his/her minister days and how God saved him/her. Talk about his/her boxing days and who he/she fought. -Focus: Resident has a behavior problem of verbal aggression; -Goal: Resident will not have a decline due to aggression until next review date; -Interventions included: Anticipate and meet the resident's needs. Caregivers to provide opportunity for positive interaction, attention. If reasonable, discuss the resident's behavior and explain/reinforce why behaviors are inappropriate and/or unacceptable to the resident. Monitor behavior episodes and attempt to determine underlying cause. Praise any indication of the resident's progress/improvement in behavior; -Focus: Resident is/has potential to be verbally aggressive related to dementia, ineffective coping skills, and poor impulse control; -Goal: Resident will have less than three episodes per day of verbal aggression through the review date; -Interventions included: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess resident's understanding of the situation and allow time for the resident to express self and feelings toward the situation. Monitor behaviors (specify frequency) and document observed behavior and attempted interventions. When the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, and if response is aggressive, staff to walk calmly away and approach later. Review of the resident's nurse's note, dated 5/24/24 at 5:09 P.M., showed the resident was witnessed attempting to remove front-wheeled walker (FWW) from another resident. Resident then pushed the other resident before staff was able to intervene. Assessed at the time. Alert and oriented times one (to person). Increased aggression and agitation noted at the time. Non-compliant with redirection at the time, triggers unknown. Resident to be transported to hospital related to safety towards self and others, psychiatric evaluation, and treatment. Review of Resident #3's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Use of walker; -Diagnoses included arthritis. Review of the resident's care plan, revised 5/24/24, showed the resident at risk for falls related to gait/balance problems, incontinence, wandering, and history of falls. Review of the resident's nurse's note, dated 5/24/24 at 5:00 P.M., showed the nurse documented he/she was made aware another resident was attempting to claim the resident's FWW. When he/she attempted to remove his/her FWW, the resident was pushed onto the floor before staff was able to intervene. Resident assessed at the time. Resident lying on left side, alert and oriented times one to two (to person and place) at times with periods of pleasant confusion noted. Complained of pain, voiced 10 out of 10 to left hip, left side of head noted. Call placed to emergency services related to transport to hospital. Review of the resident's hospital record, dated 5/28/24, showed the resident diagnosed with closed fracture (fracture with the skin intact) of neck of left femur (thighbone). Surgery performed on 5/26/24. During an interview on 6/4/24 at 11:24 A.M., Resident #3 said his/her hip was broken by Resident #1. The residents were in the dining room and when Resident #3 was standing up, Resident #1 snapped. He/She picked up Resident #3 and threw him/her down on the floor. Resident #3 was not sure why this happened. He/She went to the hospital and had surgery. He/She cannot walk right now and uses a wheelchair. During an interview on 6/4/24 at 1:28 P.M., Resident #1 said he/she did not have any issues with other residents. He/She denied hitting or pushing anyone. During an interview on 6/4/24 at 12:42 P.M., Certified Nurse Aide (CNA) I said Resident #1 has a history of verbal and physical aggression toward other residents and staff. On the day of the incident involving Residents #1 and #3, both residents were sitting on the couch in the sitting area next to the dining room. CNA I was walking other residents to the dining room for dinner and heard Residents #1 and #3 talking about Resident #3's walker. Resident #1 started getting angry, raising his/her voice and getting mad. As CNA I continued to walk residents to the dining room, he/she told Resident #1 the walker was not his/hers and told Resident #3 to move away from Resident #1. While Resident #3 tried to move away, Resident #1 stood up and tried to grab Resident #3's walker. CNA I saw this as he/she was walking with another resident, and again told Resident #1 the walker was not his/hers. Resident #1 hopped up in Resident #3's face and pushed Resident #3 hard, using both hands. Resident #3 fell on to the floor and started crying. The Certified Medication Technician (CMT) was also in the area passing medications at the time of the incident. Neither CNA I nor the CMT physically approached Residents #1 and #3 to intervene during the disagreement before Resident #1 pushed Resident #3. During an interview on 6/4/24 at 1:02 P.M., CMT E said on the day of the incident involving Residents #1 and #3, the residents were sitting on the couch in the sitting area next to the dining room. CMT E was passing medications at the cart in the dining room. He/She heard the residents getting agitated. Resident #1 was very, very agitated. He/She is a former boxer, so when he/she gets agitated, people can't get too close to him/her. The CNA who was walking by tried saying something to Resident #1. Resident #3 stood up and Resident #1 kept saying Resident #3's walker belonged to Resident #1. Resident #3 kept saying no, the walker belonged to him/her. Resident #1 grabbed the walker and Resident #3 pulled it back. CMT E turned his/her head toward the resident standing next to him/her at the medication cart, and when he/she turned back around, Resident #3 was on the ground with his/her head against the coffee table. Neither CMT E nor the CNA physically approached the residents to intervene during the disagreement, before Resident #3 was observed on the ground. Looking back at the incident, CMT E does not believe he/she could or should have done anything differently. Review of the facility's list of active employees and in-service trainings on resident to resident interactions, resident behavior, and cognitive impaired behaviors, provided on 5/30/24 and 6/4/24, showed: -74 staff employed by facility; -30 facility staff not documented as in attendance of in-service trainings; -CMT E not documented as in attendance of in-service trainings. During an interview on 6/4/24 at 4:31 P.M., Licensed Practical Nurse (LPN) C said he/she was working on the day of the incident involving Resident #1 and Resident #3, but he/she was in another resident's room and did not witness the altercation. The CNA informed LPN C of what occurred, and LPN C went to the sitting area and found Resident #3 on the floor, crying and hysterical. Staff said Resident #1 pushed Resident #3 after arguing over a walker. Resident #1 has dementia and can be aggressive toward other residents and staff. It is unknown what triggers him/her. He/She has dementia and likes to help with laundry and housekeeping tasks. Staff need to keep him/her busy with something before he/she gets triggered. Staff should redirect him/her as soon as he/she starts getting agitated. During an interview on 6/6/24 at 2:31 P.M., LPN J said Resident #1 likes to help staff and is easily redirected when given tasks he/she enjoys, like folding towels, sweeping, and wiping tables. Staff were expected to anticipate the resident's needs and observe his/her behavior. If they notice the resident is becoming anxious or agitated, they should intervene and redirect the resident. Staff should not wait for the resident to exhibit a behavior before they approach and redirect the resident. During an interview on 6/4/24 at 2:29 P.M., the Director of Nurses (DON) said Resident #1 is cognitively impaired and requires reality orientation. The DON has not seen the resident demonstrate the aggressive behaviors reported by staff. The resident sundowns (demonstrates increased confusion, restlessness, agitation, or irritability as night approaches) and the DON has observed at around 2:00 P.M., he/she jumps up and says he/she has to go to work. The DON is able to redirect him/her and finds the resident is easily redirectable. The resident likes to help clean things and likes working with his/her hands. He/She likes to sing, dance, and watch television, and he/she has preferred television shows. If staff are observing the resident being aggressive, they need to document their observations in the resident's record so she can try to look for what staff are seeing. She needs to see if the resident really has aggressive behaviors, or if staff are afraid of him/her because he/she was a boxer in the past. The resident feeds off staff's energy. Staff should respond to the resident in a calm manner. Administration has been doing in-service training with staff on resident behaviors and communication with residents who are cognitively impaired. During an interview on 6/4/24 at approximately 2:45 P.M., the Administrator said the facility is still relatively new for Resident #1. Prior to moving to the facility, the resident had a routine. Staff are still learning his/her patterns and behaviors, and trying to see what works and what doesn't when addressing him/her. They identified that the resident likes snacks and likes to help staff clean. He/She seemed more relaxed when sitting in one of the chairs in the sitting area, rather than on the couch. He/She did not respond well to overstimulation or people talking to him/her aggressively. Staff seem like they are afraid of the resident. It could be that his/her behavior was exacerbated by staff's response to him/her. During her investigation, the Administrator found that when Residents #1 and #3 started arguing, there was an opportunity where staff should have physically intervened and immediately separated the residents when they started getting agitated. When a resident becomes agitated or exhibits behaviors, the Administrator expected staff to redirect the resident using the identified interventions. MO00236799

Based on observation, interview, and record review, the facility failed to follow proper infection control practice when they failed to implement their water management program to prevent the spread of waterborne pathogens, such as Legionella. The facility failed to sanitize shared medical equipment between resident use, follow proper infection control practices when handling resident laundry, and offer residents hand hygiene prior to meal service. This deficient practice has the potential to affect all residents who reside in the facility. The census was 51. 1. Review of the facility's Water Management Program, dated 10/1/17, showed: -Policy explanation and compliance guidelines: -The maintenance director will maintain documentation that describes the facility's water system; -A risk assessment of water system components will be conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system; -The risk assessment will be completed by the facility leadership and the infection preventionist with collaboration from other facility team members, such as maintenance employees, safety officers, risk and quality management staff and the director of nursing (DON); -Based on the risk assessment, control measures will be established to address potential hazards. A variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens; -Testing protocols and acceptable ranges will be established for each control measure; -The facility will conduct an annual review of the water management program as part of the annual review of the infection prevention and control program, and as needed; -The infection preventionist will maintain documentation of all the activities related to the water management program. 1. During an interview on 10/25/22 at 8:56 A.M., the administrator said the facility had a water management policy, but the program had not been implemented. The maintenance director had only been at the facility for two months and had not done anything with this program. The water management team had not been selected. He will double check for any facility flow diagrams or any other parts of the program and provide what he finds. He would expect the water management program to have been implemented. During an interview on 10/25/22 at 4:36 P.M., the DON verified she was the infection preventionist and said she is not involved in the water management program. During an interview on 10/26/22 at 8:54 A.M., the Plant Operations Director said he had no responsibilities as it relates to the water management program. Review of all documents provided by the facility as of survey exit on 10/28/22 showed no further information or documents provided for the facility's water management program. 2. Review of the facility's Hand-Washing/Handy Hygiene policy, dated March 2020, showed: -It is the policy of the facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel and visitors. Alcohol based hand rug (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or body fluids; -Facility staff should perform handwashing using antimicrobial or non-antimicrobial soap under the following conditions: -When hands are visibly soiled; -Blowing your nose, coughing or sneezing; -Before eating; -After using the restroom; -When hands are no visibly soiled employees may use an ABHR containing at least 60% alcohol in all of the following situations: -Before direct contact with residents; -After direct contact with a resident but before direct contact with another resident; -Before donning (applying) gloves; -Before and after putting on and upon removal of personal protective equipment, including gloves; -After contact with a resident's intact skin; -After contact with objects such as medical devices or equipment in the immediate vicinity of a resident that may be potentially contaminated; -During resident meal service: In-between tray pass if contact with resident is made hand hygiene should be used; when removing trays hand hygiene should be used before contact with a residents tray or with a resident. 3. Review of the facility's undated Multi-Use Equipment Cleaning Policy/Procedure showed: -Individual equipment will be provided for each resident on the Renewal Hall (used as the isolation unit) to keep in their rooms, which include: -Blood pressure cuff/Stethoscope; -Thermometer; -Gait belt; -The policy did not address the process to sanitize shared medical equipment between resident use if they do not reside on the Renewal Hall. Observation on 10/26/22 at 8:14 A.M., showed Certified Medication Technician (CMT) D took the blood pressure of residents in the second floor dining room. He/she set the blood pressure machine on the table in front of a resident, applied the cuff to the left arm, and measured the resident's blood pressure. He/she then documented the results on a piece of paper, picked up the blood pressure cuff, went to another resident, set the machine on the table, and applied the cuff to the resident's left arm. When done, he/she documented the results on his/her piece of paper, removed the blood pressure cuff, picked up the machine and went to another resident at the table. He/she set the machine on the table in front of the resident and applied the blood pressure cuff to the resident's left arm. When done, he/she documented the results on his/her paper, removed the cuff and picked up the machine from the table. He/she then went to a different resident, set the machine on the table, and applied the cuff to the resident's right arm. He/she documented the results on his/her paper, removed the cuff and picked up the machine. CMT D went to a different table, set the machine on the table, applied the cuff and measured the resident's blood pressure in the right arm. When done, he/she documented the results on his/her paper and went to another resident at the same table, applied the cuff to the left arm. When done, he/she document the results on his/her paper, removed the cuff, and returned to the medication cart. CMT D never sanitized or washed his/her hands. He/she set the cuff and machine on the cart, logged into the computer and began to document. CMT D never cleaned the blood pressure cuff or his/her hands between residents. Observation showed ABHR available on the wall in the dining room. During an interview on 10/28/22 at 7:52 A.M., CMT D said he/she had never been trained on the requirement to cleanse the blood pressure cuff between residents. He/she does have access to alcohol wipes and Sani-wipes with the purple lid that is kept at the nurse's station, medication room and on the halls. During an interview on 10/27/22 at 8:27 A.M., the Director of Nursing (DON) said shared medical equipment should be cleaned with alcohol or disinfectant wipes with the purple lid. Staff should clean the blood pressure cuff between each resident. The disinfectant wipes are kept in all medication carts, medication room and nurses station. If the machine was set on the table, it should be cleaned after each use. During an interview on 10/28/22 at 7:42 A.M., Licensed Practical Nurse (LPN) F said he/she has his/her own blood pressure wrist cuff he/she uses to get blood pressures. Staff are expected to clean shared medical equipment between resident use. He/she uses the Sani-wipes with the purple lid. 4. Observation on 10/25/22 at 2:14 P.M., of the basement level laundry room, showed an entrance that lead to a wash machine and a soiled linen laundry chute with a linen cart positioned under, approximately half full with soiled linen. Through a doorway, a dryer positioned against the wall. On top of the dryer a stack wet resident clothing placed on the dryer lid. Three bags of wet linen sat on the floor in the clean/sort area, each with appeared to contain rags and each with at least one rag that lay on the top of the bag, not inside the bag. Two racks with clean folded facility linen next to where the bags lay. During an interview at this time Housekeeper V said housekeeping staff are responsible for washing their own rags. They bring it to the laundry room, and put them in the wash themselves. He/she was not sure what the resident linen was doing there. It should not be there. During an interview on 10/25/22 at 2:21 P.M., the Director of Nursing (DON) said resident clothes should not to be done downstairs because of the contaminated machines. The downstairs machine is not for resident use, only for housekeeping. Resident linen is outsourced to a company and is stored in the clean area of the housekeeping laundry room. She was not sure if the bags of wet linen on the floor in the clean storage area and clothes on top of the dryer were clean or dirty. There are wash machines on each floor for resident clothes. Observation showed the DON picked through the stack of wet clothes on top of the dryer lid and said this should not be there. During an interview on 10/25/22 at 2:57 P.M., the DON said the facility does not have a policy specific to resident laundry. 5. Observation of the first floor dining room on 10/24/22 at 7:14 A.M., showed residents sat in the dining room and waited for meal service. A resident was observed to self-propel his/her wheelchair around other residents and to a seat on the far side of the dining room. At 8:02 A.M., staff began to serve residents breakfast. No staff offered residents hand hygiene. Observation on the first floor dining room on 10/24/22 at 11:57 A.M., showed residents sat in the dining room as staff played music and engaged with the residents. At 12: 23 P.M., staff began to pass drinks to the residents. At 12:27 P.M., staff began to serve resident their lunch trays. No staff offered residents hand hygiene. Observation of the second floor dining room on 10/26/22 at 6:37 A.M., showed three residents up and sat in the dining room. One of the residents sat in a wheelchair and propelled the wheelchair closer to the table by grabbing the handles adjacent to the wheels. The palm of his/her hands rested directly on the wheels when moving the wheelchair. At 6:40 A.M., staff started to assist residents to the dining room. At 6:52 A.M., a staff person began to pass coffee to residents in the dining room. No hand hygiene was offered to the residents. The resident who had repositioned his/her wheelchair at the table held a cup of coffee and drank it. At 7:20 A.M., a staff person walked around the dining room and offered clothing protectors to the residents. No hand hygiene offered. A resident self-propelled down the hall, into the dining room, and asked for coffee. Staff informed the resident more coffee was brewing. At 7:30 A.M., the resident was provided a cup of coffee. No hand hygiene was offered. At 8:14 A.M., showed several residents sat in the dining room. Some resident were assisted by staff, other resident self-propelled up to the tables at 8:29 A.M., 14 residents sat in the dining room as meal service started. Staff passed trays to residents and no hand hygiene offered. Observation of the first floor lunch service on 10/26/22 at 11:35 A.M., showed nursing staff helped residents to the dining room for lunch and some residents arrived independently in their wheelchair or ambulating. Lunch service started at 12:00 P.M. and staff did not offer residents hand sanitizer prior to delivering their meals to their tables. During an interview on 10/28/22 at 11:46 A.M., with the administrator, DON, and Dietary Manager, they said residents should be offered hand sanitizer before they eat, or wipes so they can wash their hands. Staff serving the residents are responsible to do this. There is no policy to address this process. During an interview on 10/28/22 at 7:42 A.M., Licensed Practical Nurse (LPN) F said the certified nursing assistants (CNAs) should offer residents hand hygiene before meals. During an interview on 10/28/22 at 7:52 A.M., Certified Medication Technician (CMT) D said when CNAs do morning care and bring the resident to the table, they should be washing their hands in their rooms. If the resident self-propels to the dining room, staff should be offering hand hygiene after they arrive. During an interview on 10/28/22 at 8:02 A.M., CNA G said when serving meals, residents should be offered hand gel to sanitize their hands before meal service.

Based on observation, interview and record review, the facility failed to prevent one resident (Resident #42) from developing an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue, separating from living tissue) and/or eschar (dry, dark scab or falling away of dead skin) in the wound bed) by failing to monitor the resident's skin, failing to report new wounds, failing to obtain treatment orders in a timely manner and failing to follow the facility's wound policy. The sample size was 13. The facility census was 49. Review of the facility's Pressure Injury and Skin Condition Assessment Policy, dated 11/28/12 and last updated 1/17/18, showed the following: -Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. Pressure (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) and other ulcers (diabetic, arterial, venous) will be assessed and measured at least every seven days by a licensed nurse and documented in the resident's record; -A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at time of admission/readmission. The pressure ulcer risk will be updated quarterly and as necessary; -Residents identified will have a weekly skin assessment by a licensed nurse; -A wound assessment will be initiated and documented in the resident chart when pressure or other ulcers are identified by a licensed nurse; -Each resident will be observed for skin breakdown daily during care and on the Certified Nurses Assistant (CNA's) assignment. Changes shall be promptly reported to the charge nurse who will perform a skin assessment; -If the resident receives a shower, it will be necessary to have the resident stand or be returned to bed to visualize the buttocks and groin; -At the earliest sign of a pressure injury or other skin problem, the resident, legal representative and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing notes; -Prior to performing the skin assessment, the nurse is to have a sufficient supply of clean disposable gloves, a disposable measuring device and a clean cotton tipped applicator to measure wound tunneling (channels that extend from a wound into and through subcutaneous (SQ, beneath the skin) tissue or muscle, usually extends in just one direction)/undermining (occurs in all directions beneath the wound opening, affecting a larger area of SQ tissue); -Pressure injuries and other ulcers (arterial, venous, diabetic) will be measured at least weekly and recorded in the resident's medical record; -The wound assessment should include the location, size, stage, odor, drainage, description and date and initials of the person performing the assessment; -Measure the length vertically in relation to head to toe and the width horizontally from hip to hip. Measure straight down into the deepest part of the wound for the depth. *If the wound is necrotic and the base of the wound bed is not visible or tunneling, the stage cannot be determined and must be recorded as an non-stageable with an undetermined depth; -When there are weekly changes which require physician and responsible party notification, documentation of findings will be made in the clinical record. These changes include, but are not limited to: a) New onset of purulent drainage; b) New onset of odor; c) [MEDICAL CONDITION] (deep inflammation of the tissues just under the skin, caused by infection); d) Increased pain related to the wound; e) Significant increase in the wound size; f) New onset of ulcers; -Update the care plan accordingly; -Record the treatment on the treatment administration record; -The attending physician will be notified within seven to 14 days of the lack of response to the treatment. 1. Review of Resident #42's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/4/19, showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Unable to ambulate; -Dependent on staff for bed mobility and transfers; -Extensive assistance required for personal hygiene, dressing and toileting; -Frequently incontinent of bowel and bladder; -No skin issues; -No risk of developing pressure ulcers; -No special treatments or programs; -Height 65 inches and weight 117 pounds; -[DIAGNOSES REDACTED]. Review of the resident's electronic (e) chart, showed additional [DIAGNOSES REDACTED]. Review of the admission progress note, dated 7/28/19 at 1:14 P.M., showed the following: -[DIAGNOSES REDACTED]. -Receives [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday; Review of the care plan, dated 7/28 and last updated 8/6/19 and in use during the survey, showed the following: -Problem: Potential for impairment to skin integrity related to weakness; -Goal: Resident will not develop further alteration in skin integrity; -Interventions: Avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, avoid shearing, use a lift sheet for positioning, avoid skin to skin contact, ensure linens are wrinkle free, minimize pressure over bony prominences and use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Review of the Registered Dietician's (RD's) nutrition assessment, dated 8/7/19, showed the resident had a [DIAGNOSES REDACTED]. Diet appropriate at that time for nutritional needs but would follow if nutritional supplements were needed. Review of the resident's weekly skin observations, showed the following: -8/4 and 8/11/19, showed resident's skin intact-no concerns; -No other weekly skin assessments found. Review of the facility's wound reports, dated 8/2, 8/9, 8/16 and 8/23/19, showed the resident's name not listed. Observation on 8/23/19 at 7:50 [NAME]M., showed the resident in bed on his/her right side. CNA A present at the bedside and had just provided incontinence care. Resident had an open area to his/her coccyx (tailbone) approximately 2 centimeters (cm) long by 0.1 cm wide, open and deep pink in color. CNA A applied moisturizing cream and said to his/her knowledge, the nurse didn't use any other treatment on the area. He/she said the moisturizing ointment was what he/she used because the open area on the resident's coccyx had been there for a couple of days. During an interview and observation on 8/26/19 at 11:24 [NAME]M., Licensed Practical Nurse (LPN) B said she was not aware of any skin breakdown on the resident. LPN B entered the resident's room and removed the resident's brief. LPN B turned the resident to his/her left side, exposed a triangle shaped area, with a black area in the center, on the resident's coccyx . The area measured approximately 1.5 cm by 1.5 cm, enclosed on all three sides by a yellowish colored substance that measured approximately 0.2 cm in width. LPN B initially said the area was not a wound, then said it was actually an unstageable pressure ulcer. He/she then dressed the resident in a clean brief and said he/she would call the physician. LPN B said he/she was not informed by the CNAs of any skin breakdown. During an interview and observation on 8/26/19 at 11:45 P.M. the Director of Nursing (DON) evaluated the resident's skin. She removed the resident's brief and said Where did this come from? She initially said the wound was a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured blister) pressure ulcer. After further assessment, the DON said the wound bed was covered with 100% eschar tissue, and the wound was an unstageable pressure ulcer to the coccyx. She measured the pressure ulcer as 4 cm by 4 cm with 2.5 cm depth and said she was not informed by the charge nurse or CNAs of the skin breakdown. She said licensed nurses do weekly skin assessments and document in the chart and on shower days, the CNAs observe the skin and notify the charge nurse of any skin issues. CNAs should have notified the charge nurse when they initially saw the open area, and an order should have been obtained at that time. Moisturizing lotion was not effective, and they should have used an ointment with zinc oxide because that is a barrier ointment. She said the pressure ulcer should have been covered, and the nurse needed to contact the wound team. Review of the physician's orders [REDACTED]. Further review of the care plan, last updated on 8/26/19, showed the following: -Problem: Resident has an ulcer, unstageable to the coccyx related to immobility; -Goal: Pressure ulcer will show signs of healing and remain free from infection through the review date; -Interventions: Follow facility policies/protocols for prevention/treatment of [REDACTED]. Review of the skin assessment, completed by the DON on 8/26/19 and recorded at 11:05 P.M., showed the following: -Unstageable pressure ulcer to the coccyx; -Wound acquired in-house; -Type of wound is pressure and unstageable; -No tunneling or undermining present; -Odor present; -No pain. Observation and interview on 8/27/19 at 9:35 [NAME]M., showed CNA A and LPN C placed a gait belt around the resident's waist and assisted him/her to bed. LPN C cleansed the bedside table with a bleach wipe, lay a barrier on the table, and opened and prepared dressing supplies. He/she removed the dressing from the resident's coccyx and said It has a little odor and then said I don't know how that got so bad so fast. The wound, completely covered in black eschar, showed an open area below the wound and an open area to the left of the wound. LPN B said the large wound was an unstageable pressure ulcer and the other two wounds were Stage II pressure ulcers. He/she measured the unstageable pressure ulcer as 4 cm in length by 3 cm in width. He/she said the wound has some depth, but he/she did not measure the depth. He/she measured the Stage II pressure ulcer below the unstageable pressure ulcer as 2 cm in length and 1 cm in width and the Stage II pressure ulcer to the left measured 1 cm long by 1.5 cm in width. He/she cleansed the unstageable pressure ulcer with normal saline (NS, sterile solution used to clean wounds) then wet gauze with NS and placed it in the wound bed, covered it with a [MEDICATION NAME] pad (non-adherent and sterile dressing, which is good for direct wound contact for small to medium sized wounds to help absorb light wound fluid) and applied tape. He/she said he/she would have to contact the physician to get a new order for the Stage II pressure ulcers. Review of LPN C's progress note, dated 8/27/19 at 10:28 [NAME]M., showed a dressing change completed. Removal of wet to dry dressing and serous fluid (typically pale yellow and transparent) found on packing to coccyx wound. Scant amount of serosanguineous fluid (yellow with small amounts of blood) found on dressing from stage 2, measuring 2 cm in length by 1 cm in width just below coccyx wound. Stage 2 wound to left medial buttock measuring 1 cm by 0.5. DON, physician and power of attorney (POA) made aware. Physician notified for new treatment order for stage 2 wound. Review of POS on 8/27/19 at 11:00 [NAME]M., showed no new orders. During an interview on 8/27/19 at 1:00 P.M., the DON said she would expect the CNA to let the charge nurse know of any open areas. The nurse should then do a skin assessment and place a note in the progress notes. She said the charge nurse did tell her of the resident's wound, but not before the survey team did. She said the nurse was supposed to do a skin assessment weekly and as needed. A nurse did apparently do a skin assessment on 8/18/19, but scratched it out, and the DON did not know why that was done. She said the nurse informed her that the resident refused a shower on 8/25/19, so she was unable to do a skin assessment, and the DON told her that was not a legitimate reason to not perform a skin assessment. She said had the skin assessments been performed per policy and had the CNA informed the nurse of the initial skin issue, this whole situation may well have been prevented. She said she recently provided in-services to the staff regarding several different areas of care. Skin care and the prevention and treatment of [REDACTED]. She said the resident will now be on an air mattress, have a cushion in his/her wheelchair and be turned and repositioned at least every two hours. When asked, the DON said the staff had not provided adequate and effective care to this resident. During an interview on 8/28/19 at 12:29 P.M., the resident's primary physician said first of all, a CNA should never decide what treatment to use, and the nurse should be instruct the CNAs to always report any kind of skin issue. The physician said the resident's condition was very poor and given his/her condition, wounds were almost unavoidable, but they could not be ignored either. If the skin breakdown had been reported to the nurse when first noticed, the wound may not have progressed to the point it had.

Based on interview and record review, the facility failed to provide treatment, consistent with professional standards of practice, for one of five sampled residents with an existing pressure injury (Resident #1). The facility failed to monitor the effectiveness of the physician ordered treatment in place, document assessments, take measurements and update physicians when a resident's pressure ulcer deteriorated. This resulted in hospitalization for one resident due to a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough (dead tissue, usually cream or yellow in color) or eschar (dead cells) may be present on some parts of the wound bed. Often includes undermining (wound open underneath the border of the wound) or tunneling (extend from the initial injury deeper into the surrounding tissues). The facility also failed to follow their change in condition policy for the resident. The census was 58. Review of Resident #1's face sheet, showed a readmitted from an acute care hospital on [DATE]. Review of the nurses notes, showed no entries for 3/25/19. Review of the resident's care plan, dated 3/25/19, showed the following: -Focus: pressure ulcer on coccyx (tailbone); -Goal: show signs of pressure ulcer healing and remain free of infection; -Interventions: monitor the resident for side effects and effectiveness of orders, administer treatments as ordered, turned/repositioned every 2 hours or as needed. Review of the resident's skin assessment, dated 3/27/19, showed the following: -Pressure wound on coccyx; -9.6 centimeters (cm) length; -4.3 cm width; -0.8 cm depth; -Stage IV. Further review of the resident's nurses notes, showed the following: -3/26/19, no nursing entry; -3/27/19 at 11:30 A.M., (Late entry, reason for charting: readmission) wounds/skin concerns present with no changes in skin integrity. Dressing changed per treatment orders; -3/27/19 at 7:30 P.M., wounds/skin concerns present with no changes in skin integrity. Dressing changed per treatment orders. Pressure reducing device for chair. Pressure reducing device for bed. Nutrition or hydration intervention to manage skin problems; -3/30/19 at 3:45 P.M., wounds/skin concerns present with no changes in skin integrity. Dressing changed per treatment orders; -3/30/19 at 8:02 P.M., wounds/skin concerns present with no changes in skin integrity. Resident has treatable wounds; -3/31/19 at 3:27 A.M., wounds/skin concerns present with no changes in skin integrity. Resident has treatable wounds; -3/31/19 at 4:55 P.M., wounds/skin concerns present with no changes in skin integrity. Dressing changed per treatment orders. Review of the resident's wound physician assessment, dated 4/1/19, and showed the following: -A coccyx wound present on admission of 3/25/19; -Wound is a Stage IV pressure ulcer; -12.5 cm in length; -4.5 cm in width; -2 cm in depth; -Undermining, 4 cm; -A large amount of serous drainage (one common type of wound drainage containing blood); -A mild foul odor after cleansing; -1 to 33% granulation tissue in wound bed (the healing surface of a wound); -67% to 100% necrotic tissue with adherent slough; -The periwound (tissue surrounding the wound itself. This tissue ideally provides a barrier to the wound, which protects it) no abnormalities noted; -Comorbidities include mixed incontinence, diabetes, heart failure, history of stroke; -Wound culture taken. Review of the resident's treatment administration record (TAR), showed the following: -Treatment order, dated 4/1/2019; -Cleanse wound with Dakin's solution (a strong antiseptic that kills most forms of bacteria [MEDICAL CONDITION]) and soak gauze with Dakin's. Apply Santyl (sterile enzymatic [MEDICATION NAME] ointment) to wound bed, pack wound with soaked gauze, cover wound with abdominal (ABD) gauze pads and kerlix (woven gauze). Twice a day and as needed.; -4/2/19 day treatment blank, with no sign off as completed; -4/6/19 day and evening treatment blank, with no sign off as completed; -4/7/19 evening treatment blank, with no sign off as completed. Review of the resident's wound physician assessment, dated 4/8/19, and showed the following: -Coccyx ulcer worsening; -Resident appears sickly not in acute distress; -13 cm in length; -10 cm in width; -2 cm in depth; -No granulation within bed of wound; -Periwound maceration (occurs when skin is in contact with moisture for too long) and [DIAGNOSES REDACTED] (redness of the skin); -Periwound tenderness with palpitation; -A strong odor; -Wound culture report not available; -Referred to emergency room . Review of the resident's lab report, dated 4/8/19, showed the following: -Collection date of 4/4/19; -Heavy growth of Pseudomonas aeruginosa (a common encapsulated, gram-negative, rod-shaped bacterium that causes bone and joint infections. The bacteria are found widely in the environment). During an interview on 4/30/19 at 9:18 A.M., Licensed Practical Nurse (LPN) A said he/she was not the wound nurse in March. His/her last day of being a wound nurse was in (MONTH) 2019. On 3/27/19, he/she went to do the treatment on the resident and noticed there were no measurements or pictures of the wound in the resident's chart. At that time, she took a picture and documented the wound measurements. He/she said it is the wound nurse's responsibility to assess and measure the wounds weekly. The floor nurse would also do a weekly skin assessment and document findings, but not measurements. During an interview on 4/30/19 at 3:00 P.M., LPN B said he/she has been employed with the facility since (MONTH) (YEAR). In the beginning of (MONTH) 2019, (unsure of the exact date), he/she became the facility wound nurse. A wound nurse's job is to evaluate wounds and pressure ulcers once a week, assess, measure and document characteristics of findings. He/she did not assess the resident and never did the resident's treatment to his/her pressure ulcer. LPN B did not believe the facility had a wound nurse in (MONTH) 2019. Further review of the resident's nursing notes, showed: -No measurements of the pressure wound after 3/27/19; -No wound nurse assessment; -No documentation of a change in condition; -No documentation of increased odor of wound; -No documentation of pain assessment; -No documentation of wound size increasing; -No notification to the doctor of wound's decline. Review of the resident's hospital admission assessment, dated 4/8/19, showed on exam a Stage IV, grossly infected pressure ulcer. The ulcer is very advanced with visible bone and tissue breakdown. There is a necrotic area that when palpated, produces foul smelling discharge that goes into the wound. The resident would need surgery to debride (remove all the devitalized tissue from the wound bed to promote wound healing) and possibly pack the wound. The family will be educated on the patient's profoundly poor prognosis of his/her baseline debility and his/her infections which are going to make his/her recovery very limited if any. During an interview on 4/25/19 at 10:25 A.M., the interim Director of Nursing (DON) said she expected the wound nurse to assess and document the findings weekly of all wounds and pressure ulcers. She expected a photo to be taken weekly of the resident's wounds to document measurements. She expected the floor nurse to do a weekly skin assessment and document abnormal findings. If a resident had a change in condition or worsening of a wound, she expected the nurse to document findings and notify the physician. During an interview on 4/25/19 at 3:46 P.M., the resident's wound physician said between his visit on 4/1/19 and 4/8/19, the resident's wound size increased, the odor was stronger and there was a loss in granulated tissue. In this case, he expected the nursing staff to notice the change in condition and document the findings. The resident could have been sent to the hospital sooner. Review of the facility's pressure ulcer prevention policy, revised on 1/15/18 showed the resident's skin should be inspected several times a day during bathing, hygiene and repositioning measures. Review of facility's change in condition policy, revised on 11/17/17, showed the facility will inform the resident and consult with the resident's physician when there is a significant change in the resident's physical status. MO 195

Based on observation, interview, and record review the facility failed to thoroughly investigate five of eight sampled residents' falls in a manner which would enable staff to effectively plan interventions to prevent possible injury from falls, failed to carry out planned interventions to prevent accidental injury for one sampled resident and failed to ensure the residents environment remained as free of accident hazards as possible by ensuring chemicals were not accessible to residents. (Residents #6, #1, #9, #11, #13 and #7) The census was 61 with 50 in certified beds. 1. Review of Resident #6's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Tramadol (medication for moderate pain) 50 milligrams (mg) three times a day, ordered [DATE]; -Tylenol extra strength 500 mg tablet once a day, at 8:00 P.M., ordered [DATE]; -Up in wheelchair with standby assist, dated [DATE]; -Vicodin (medication used for moderate pain) ,[DATE] mg, one tablet four times per day as needed for pain, ordered [DATE]; -X-ray of right elbow, for right elbow pain, ordered [DATE]. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -No short/long term memory loss; -Required moderate assistance of staff for bed mobility, transfer, toileting and bathing; -Required extensive assistance of staff for personal hygiene; -Incontinent of bowel and bladder. Review of the resident's care plan, updated [DATE], showed the following: -Falls: -Problem: Having more difficulty with transfers; -Goal: Will be free from injury through the next review; -Approach: Non-skid footwear, make sure glasses are on and clean. Remind him/her to call for assistance with toileting and activities of daily living. Check on more frequently since move to new room. Observe for blurred vision and vertigo. Remind to lock wheelchair before transferring. Fall assessment to include therapy, charge nurse and care plan nurse after three falls within 30 days. Therapy evaluation and treatment as needed for strengthening and transfers. Review of the resident's nurse's notes, showed the following: -[DATE] at 1:27 P.M.: Pain; pain unrelieved by medication; -[DATE] at 6:44 P.M.: Right shoulder pain, throbbing. Verbalizing helplessness. Having difficulty raising right arm to feed himself/herself during meals. No swelling or redness noted. Will continue to monitor; -[DATE] at 8:58 P.M.: Shoulder pain, ache; -[DATE] at 8:21 A.M.: Pain left arm; -[DATE] at 3:28 P.M.: Pain unrelieved by medication, anxiety, grimacing. Right elbow swelling that appears like a dislocation and is painful with range of motion. Physician notified; -[DATE] at 6:13 P.M.: X-ray of right elbow. Review of the resident's X-ray report, dated [DATE], showed a fracture of the right elbow, with soft swelling present. Further review of the resident's nurse's notes, showed the following: -[DATE] at 12:33 A.M.: X-ray results: fracture of the right elbow, soft tissue swelling present. New order for sling to right arm; -[DATE] at 1:10 P.M.: Resident said he/she feels he/she could have hurt the arm by pulling himself/herself up with the pull bar in the bathroom. Resident states his/her arm has always hurt but just in the last couple of days that the pain has been worse. Will be wearing a sling for the next two weeks. Review of the resident's POS, dated [DATE], showed the following: -Hoyer lift for transfers, ordered [DATE]. Review of the resident's nurse's notes, showed the following: -[DATE] at 4:37 P.M.: Transfer with two person assist, resident requires Hoyer lift with all transfers; -[DATE] at 10:57 P.M.: Resident in room trying to transfer self or adjust self in wheelchair when he/she fell to the floor. Found laying on right side, abrasion to right side forehead, skin tear to right elbow and abrasion to right knee. New order for X-ray of right elbow. Review of the resident's Incident Details, dated [DATE] at 9:20 P.M., showed the following: -Type of Injury: Fall from chair; -Type of Injury: Skin tear, abrasion, minor injury; -Incident location: Resident's room; -Incident not witnessed; -Details of the Incident: Resident trying to transfer/get situated in wheelchair when he/she fell to the floor, found on the right side, skin tear right elbow, abrasion to right knee and right side of forehead; -Medications administered within 24 hours of the incident: Hydrocodone Bitartrate and acetaminophen (narcotic pain medication used for moderate to severe pain) 7XXX,[DATE] mg by mouth daily every four hours, received at 8:33 P.M. Review of the resident's nurse's notes, showed the following: -[DATE] at 12:22 A.M.: Results of X-ray show a complete separation/dislocation of the elbow, resident complaining of severe pain to right arm, call to physician, pain medication administered; -[DATE] at 1:34 A.M.: Sent to hospital for evaluation; -[DATE] at 12:17 P.M.: admitted to hospital with [DIAGNOSES REDACTED]. Review of the resident's POS, dated [DATE], showed the following: -Vicodin (hydrocodone bitartrate and acetaminophen) ,[DATE] mg every six hours for pain, ordered [DATE]; -Up in wheelchair-standby assist discontinued on [DATE]. Review of the resident's medical record did not show any interventions put into place after the resident fractured his/her elbow ([DATE]). In additon, no further updates to the care plan were made. During an interview on [DATE] at 1:30 P.M., the Director of Nurses (DON) said the resident informed staff he/she hurt his/her arm by pulling himself/herself up in the bathroom using the grab bar (for the ,[DATE] fracture). Since the resident knew what had happened, the facility did not investigate any other potential causes of the injury. During an interview, on [DATE] at 12:43 P.M., the resident's physician said the facility notified him of the resident's complaint of right arm pain on [DATE], and he ordered pain medication and a X-ray of the elbow. The first injury could have been caused by the resident pulling up by the pull bar in the bathroom because of severe osteoporosis (brittle bones). The resident has dementia and because he/she didn't follow directions not to transfer, fell causing a more severe injury to his/her right elbow requiring surgery to repair it. 2. Review of Resident #1's face sheet, showed the following: -admitted d of [DATE]; -Admitting [DIAGNOSES REDACTED]. Review of the resident's admitting fall risk assessment, dated [DATE], showed a score of 28 (a score of 10 or higher indicates a risk for falls). Review of the resident's POS, dated [DATE], showed an order dated [DATE], for skilled therapy three times a week for 90 days to increase gait strengthening and ambulation. Review of the resident's initial MDS, dated [DATE], showed the following: -Short/long term memory loss; -Cognitive/decisional impairment; -Required extensive assistance of staff for all personal hygiene; -Incontinent of bowel and bladder; -No falls prior to admission. Review of the resident's care plan, last updated on [DATE], showed the following: -Falls: [DATE], [DATE], [DATE], [DATE] and [DATE]; -Problems: I'm at risk for falling again: -Goals: I want to be safe from injuries; -Approaches: Make sure my chair and bed alarms are on since I have a history of falls. I like books, magazines, papers to keep me busy. Take me to religious services. Keep me at the nurse's station so I can be seen. Check on me frequently throughout the night and if I'm awake offer to take me to the toilet. Check alarms per protocol and walk me frequently during the day and evening to keep me active. Review of the resident's nurse's notes, showed the following: -[DATE] at 7:57 P.M., resident was found on floor in the dining room, had fallen out of wheelchair. Resident had skin tears noted to back of left hand 1 centimeter (cm) x 5 cm and the back of the left arm 3 cm x 15 cm. Resident assessment noted a hematoma to the back of head. Ice pack held on back of head and neuro checks done with no abnormalities noted. Resident's skin tears were cleaned and triple antibiotic ointment (TAO) and dry dressings applied. Family and physician made aware. -[DATE] at 3:35 A.M., found resident sitting on floor on buttocks on cushion from recliner chair. Resident was attempting to slide across floor on the cushion. Range of motion done to all four extremities without any noted discomfort. He/She was not incontinent. -[DATE] at 4:02 P.M., resident up in wheelchair for meals, family notified about head hematoma and skin tear to right shoulder. Physician notified of negative X-ray result; no dislocation. X-ray results faxed to physician office. Pain medication given as resident verbalized pain to right shoulder during AM assessment/care, pain rated a 3 on a scale of 0 to 10. At noon resident verbalized no pain and was moving around. He/She socializes with others. No sign of discomfort noted; family visited. -[DATE] at 9:42 P.M., nurse saw the resident out of his/her wheelchair, reaching over and losing his/her balance. Resident hit his/her forehead on the hardwood floor in the dining area. Incident happened at 8:45 P.M. Family notified and request resident be sent to the hospital. Ambulance arrived and left with resident at 9:05 P.M. Physician notified. -[DATE] at 3:42 A.M., resident returned from the hospital with a bandage on his/her head. Forehead laceration closed with dermabond (a skin glue used to close open wounds). Red bruising to right elbow. X-ray done at the hospital was negative. Review of facility's incident log, showed the following for the resident: -[DATE] at 6:40 P.M., fell from chair in the dining area. Skin tears to the left forearm and the back of the left hand; -[DATE] at 3:35 A.M., found on the floor in his/her room. No apparent injury; -[DATE] at 6:10 A.M., unknown type of occurrence in an unknown location. Abrasion to right forehead. (The facility could not produce a completed investigation regarding the incident or show if any new interventions were put into place); -[DATE] at 5:40 A.M., found on the floor in the corridor. Skin tear to right middle calf. (The facility could not produce a completed investigation regarding the incident or show if any new interventions were put into place); -[DATE] at 8:45 P.M., fall from wheelchair in the dining room with abrasion to forehead. (The facility could not produce an investigation regarding the incident or show if any new interventions were put into place). Review of the resident's Incident Details, showed the following additional information not found on the incident log: -[DATE] at 6:40 P.M., no additional information or interventions. -[DATE] at 3:35 A.M., the resident was not incontinent and was unable to tell the nurse what he/she was attempting to do. Resident bumped his/her head. Range of motion to all extremities. No signs of redness, skin tears or open areas. Resident alert to person only. Bed and chair alarm in place (not indicated if the alarms were on and sounding at the time of the fall). [DATE] at 6:10 A.M., the resident found with injury to head and arm. Resident unable to say what happened. (No mention of bed or chair alarm and if they were in use or sounding). [DATE] at 5:40 A.M., alarm and mat continue to be in place as ordered. (No mention if the alarms were sounding at the time of the fall). [DATE], No Incident Details sheet provided. Observations throughout the survey, [DATE] through [DATE], showed the following: -[DATE] at 1:43 P.M., the resident sat in his/her wheelchair in the corridor, then self propelled in a slow rocking motion back to his/her room. A wheelchair alarm was applied however, no staff were present; -[DATE] at 5:25 A.M., the resident sat in his/her wheelchair in the dining room and self propelled in a slow rocking motion back. A wheelchair alarm was applied however, no staff were present. Another resident yelled out for help because he/she was afraid Resident #1 would fall. During an interview on [DATE] at 11:10 A.M., a family member of the resident said he/she informed the facility the resident had fallen at a previous nursing home. The family member said after the second fall in early March the family requested and got interventions put into place to help prevent the resident from falling again. The interventions were to lower the resident's bed, place alarms on the resident's bed and wheelchair and put a floor mat next to the bed when the resident was in bed. Review of the care cards used by the certified nurse aides (CNA), on [DATE], showed no interventions or preventative care/action for falls and safety for the resident. During an interview on [DATE] at 10:50 A.M., the physical therapist (PT) said the resident was referred to the therapy department in February 2011, after the first fall. The resident had continued to decline because his/her calf muscles continue to tighten up. The resident does not extent his/her legs outward enough but now scoots himself/herself in a rocking motion. The resident has enough upper body strength to lift himself/herself out of wheelchair. PT staff are aware of falls as they are discussed in daily staff meetings. The facility does not have an official fall committee to put changes in place. During an interview on [DATE] at 2:30 P.M., the DON said the nurse's notes lacked documentation whether the wheelchair and/or bed alarms were sounding and the resident's care plan failed to show all of the interventions the facility put into place. 3. Review of Resident #9's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -No acute cognitive changes; -Felt tired; -No behavior problems; -Limited assistance for bed mobility, transfer, walking, dressing and toileting; -Extensive assistance for personal hygiene; -Not steady during sit to stand movement, walking, reversing directions while walking and surface to surface transfers; -Walker or wheelchair used for movement; -Occasionally incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -History of falls since admission. Review of the resident's care plan, dated [DATE], and updated on [DATE] and [DATE], showed a risk of falls and the interventions included the following: -Call the resident's doctor and family if he/she falls; -Be sure the area around the resident and his/her room was free of clutter; -Ensure the resident's bed was in the low position; -Lock the resident's wheelchair during transfers; -Assist the resident with transfers; -Assist the resident to the bathroom frequently during the day and night; -Check on the resident frequently at night; -Ensure the resident's call light was in easy reach at all times; -Monitor the resident carefully to ensure he/she does not injure him/herself; -Remind the resident to use his/her walker, or call for assistance if he/she was tired or anxious (added on [DATE]). Review of the resident's nurse's notes, showed the following: -[DATE], at 1:50 P.M., found on the floor of his/her bedroom with his/her head near the heater. The resident tried to arise from his/her chair to go to the bathroom, fell and sustained a 1 cm open area to the back of the right forearm. Staff toileted the resident, assisted him/her back into the chair, and instructed the resident to use the call system when he/she needed help. -[DATE], at 1:55 P.M., found on the floor of his/her bathroom. Staff heard the resident call for help and found the resident lying in the doorway to the bathroom. The resident sustained [REDACTED]. Staff toileted the resident and instructed the resident to use the call system when he/she needed help. -[DATE] at 4:55 P.M., found on the floor of his/her bathroom. Staff documented nothing further regarding the fall in the resident's medical record or fall log. During observation and interview, on [DATE] at 12:57 P.M., the resident rested in bed with the head of the bed up 30 degrees. He/She had returned, the day before, from the hospital (due to a fall earlier in the week). He/She felt nervous all the time and used a walker due to unsteadiness on his/her feet. At 1:20 P.M., a CNA brought the resident's food tray and placed it on the over the bed table. The resident said he/she wanted to sit up in the recliner chair to eat, so the CNA assisted the resident. Observation on [DATE] at 8:14 A.M., showed the resident sat at a table in the main dining room to eat breakfast. At 10:13 A.M., the resident sat asleep in the recliner chair in his/her bedroom with the footrest up. During an interview, on [DATE] at 3:30 P.M., the administrator said the resident was often anxious but seemed more anxious since his/her roommate died a couple of months ago. He/She had a new roommate, but they had not bonded yet. The resident had a history of [REDACTED]. The only thing which distracted the resident from his/her anxiety was the soft, stuffed animal (a seal) brought around by the activity staff. The administrator said the stuffed animal had a calming effect on the resident, who enjoyed petting it. He/She was too weak to hold the seal for long periods, but the administrator realized as she talked the activity worker could place the stuffed seal on the resident's over the bed table in front of him/her. During an interview, on [DATE] at 10:50 A.M., the PT said he evaluated the resident and began skilled therapy with him/her on [DATE]. The resident was anxious and afraid of falling after the fall in February 2011, but he/she had been anxious prior to the fall. During an interview, on [DATE] at 1:30 P.M., the DON said the resident always appeared anxious and this increased the likelihood the resident would fall. Staff had not developed any interventions to address the resident's anxiety as a part of fall prevention. He/She could provide no documentation of fall investigations related to the resident's February or [DATE], falls. The DON could provide no documentation of fall assessments completed prior to or as a result of the resident's February or [DATE], falls. The DON could not say why the resident was not picked up for physical therapy prior to [DATE]. The only change made to the resident's comprehensive plan of care as a result of the resident's February or [DATE], falls directed staff to remind the resident to use his/her walker or to call for assistance if the resident was tired or anxious. The DON said it could be difficult for the resident to remember to ask for assistance when he/she felt anxious. She said staff might interpret the care plan subjectively when instructed to assist the resident to the bathroom frequently or to check on the resident frequently. 4. Review of Resident #11's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -No acute cognitive changes; -Felt tired; -No behavior problems; -Limited assistance for bed mobility, transfer, walking and toileting; -Extensive assistance for dressing and personal hygiene; -Wheelchair used for movement; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -No history of falls since admission. Review of the resident's care plan, dated [DATE], and updated on [DATE], showed at risk of falls when trying to get to the bathroom and the interventions included the following: -Remind the resident to call for assistance; -Suggest going to the bathroom when making rounds; -Therapy should screen the resident as needed; -Check on the resident a little more frequently. Review of the resident's POS, dated [DATE] through [DATE], showed the following: -An order dated [DATE] for a bed alarm; -An order dated [DATE] for a wheelchair alarm; -An order dated [DATE] for physical therapy. Review of facility's Incident Log, showed the following: -[DATE] at 12:30 P.M., the resident fell in his/her bedroom without apparent injury; -[DATE] at 5:45 A.M., the resident fell getting in or our of bed and sustained a skin tear to the right upper shin; -[DATE] at 5:05 A.M., the resident's leg got caught under his/her wheelchair and sustained a minor laceration to the right knee. Review of the resident's nurse's notes, showed the following: -[DATE] at 3:53 P.M., no mention of any fall or injury. New order for an X-ray of the resident's lumbar back and left hip; -[DATE] at 6:44 A.M., found on the floor after he/she fell getting out of the wheelchair into bed unassisted. Sustained a 0.3 cm by 0.2 cm skin tear to the right shin. Staff assisted the resident back into the chair, dressed and brought him/her to the nurse's station for observation. -[DATE] at 8:21 A.M., no mention of any fall or injury. The resident refused to allow the nurse to assess the affected area. During observation on [DATE], from at least 12:50 P.M. until 3:10 P.M., the resident sat in his/her wheelchair in the dining room, his/her bedroom, or moved up and down the hallway. After the resident ate lunch, he/she sat with eyes closed as though he/she might be asleep at the dining room table. At 1:35 P.M., the resident verbally harassed another resident in the main dining room about the other resident's ability to stand independently. During observation, on [DATE] from 8:05 A.M. until 11:18 A.M., the resident sat in his/her wheelchair in the main dining room, his/her bedroom or moved up and down the hallway. After the resident ate breakfast, he/she sat with eyes closed as though he/she might be asleep at the dining room table. During an interview, on [DATE] at 10:50 A.M., the PT said he evaluated the resident for physical therapy after the [DATE], fall and began skilled physical therapy on [DATE]. The resident did not seem to understand the usefulness of doing any physical therapy, but seldom refused to participate. During an interview, on [DATE] at 1:30 P.M., the DON said the chair alarm added to the resident's wheelchair, on [DATE], was probably in response to the resident's fall on [DATE], but she was not sure why the nurse got the order for the alarm. She could provide no documentation of fall investigations related to the resident's [DATE], or [DATE] falls. The DON could provide no documentation of fall assessments completed prior to or as a result of the resident's [DATE], or [DATE] falls. The DON could not say why the resident was not picked up for physical therapy prior to [DATE]. The only change made to the resident's comprehensive plan of care as a result of the resident's [DATE], or [DATE], falls directed staff to check on the resident more frequently. The DON agreed it could be difficult for staff to determine what what was meant by checking on the resident more frequently. During an interview, on [DATE] at 1:30 P.M., the administrator said staff did not implement a chair alarm faster after the [DATE] fall, because it might have prevented them from considering other more appropriate interventions. They should have obtained a chair alarm earlier if the only other intervention was going to be for staff to check on the resident more often. 5. Review of Resident #13's POS, dated [DATE], showed the following: -Hip fracture; -Chronic pain. Review of the resident's nurses' notes, showed the following: -[DATE] at 2:27 A.M., resident yelled for help. Found in room sitting on the floor in front of the bed with wheelchair across the room. Said he/she slipped while trying to transfer himself/herself to bed. Denies pain, but said he/she hit the left side of his/her face on the carpet. -[DATE], no entry regarding a fall. -[DATE] at 2:27 A.M., found sitting on the floor in his/her room by the bed. Denies hitting head. Staff had just toileted 5 minutes earlier. -[DATE] at 3:00 A.M., sitting on the floor in his/her room in front of his/her wheelchair. Neuro checks within normal limits. Denies pain. -[DATE] at 11:50 P.M., found on the bathroom floor after a loud noise. On left side bleeding from an approximate 3 cm skin tear with bruising. Large hematoma to the forehead, ice applied. Neuro checks within normal limits. Transported to the hospital and admitted . Review of the facility's Incident Log, showed the following: -[DATE] at 4:30 A.M., fell from bed, no apparent injury; -[DATE] at 2:27 A.M., found on floor, no apparent injury; -[DATE] at 3:00 A.M., found on floor, no apparent injury; -[DATE] at 11:55 A.M., found on bathroom floor, left forehead hematoma. Skin tear to back of left hand. Requested Information regarding the facility's investigation into the resident's falls, physician's orders [REDACTED].M., [DATE] at 3:30 P.M. and on [DATE] at 3:30 P.M. No information was provided. 6. Review of Resident #7's significant change in status MDS, dated [DATE], showed the following: -Signs and symptoms of delirium: behavior present, fluctuates (sluggishness, staring into space, staying in one position, moving very slowly); -Over the past two weeks: felt down, depressed or hopeless (2 - 6 days), trouble falling or staying asleep (2 - 6 days), felt tired or had little energy (12 - 14 days); -Extensive assistance of two staff for bed mobility; -Extensive assistance of one staff for walking in room/corridor and eating; -Activity did not occur: moving from a seated to standing position, walking, turning around, moving on/off the toilet and surface to surface transfers; -[DIAGNOSES REDACTED]. Review of the resident's POS, dated ,[DATE], showed an order for [REDACTED]. Observation on [DATE] from 5:15 A.M. until 6:25 A.M., showed the resident lay in bed without a bed alarm. At 6:25 A.M., Nurse F and CNA G entered the room to complete the resident's skin assessment. Both Nurse F and CNA G failed to notice the resident had no bed alarm and left the resident's room after completing the skin assessment. The resident remained in bed until 10:30 A.M., when staff transferred the resident from the bed to a wheelchair. During an interview, on [DATE] at 1:30 P.M., the administrator said all nursing staff were responsible for ensuring residents have their alarms on as ordered. 7. During an interview, on [DATE] at 10:50 A.M., the PT said falls were reviewed every weekday during morning interdisciplinary meetings. Staff discuss possible interventions and determine if they require any physician's orders [REDACTED]. 8. Review of the facility's Fall Prevention and Management Program, dated [DATE], showed the following: -Each resident will be assessed for risk factors related to falling upon admission, quarterly, with any change in condition, upon return from a hospitalization , and after any fall; -Furniture in the resident's room will allow for direct access to their bathroom; -Each resident's bed will be positioned to allow the resident to place his/her feet flat on the floor when sitting on the side of the bed; -Each resident will be offered the use of a transfer assistance device for the bed as appropriate; -Each resident and family will be educated about tripping hazards; -Residents who use wheelchairs will have the wheelchair brakes tested upon admission, if they don't work a different wheelchair will be provided; -Residents who use canes or walkers will have them checked for condition/wear upon admission, they will be replaced as necessary; -Residents will be oriented to their rooms, and the operation of all lights, furniture, equipment, and call lights upon admission; -Toilet seat risers will be provided to all residents who need them upon admission; -Each resident and family will be educated about issues related to fall prevention; -Upon admission each resident will be assessed for falls using a fall risk assessment tool; -An interdisciplinary team will develop a plan for services to improve or maintain the resident's standing and sitting balance and other interventions to reduce the resident's risk for falls; -All team members are responsible for reporting changes in a resident's gait, ability to rise and sit down, and balance to the resident's nurse; -Residents should wear non-slip shoes or slippers when ambulating; -Discourage walking barefoot or in stocking feet, and discourage full length robes or dresses; -Ensure the resident's eyeglasses are clean, and encourage their use; -Place any resident with a medication or dosage change on a fall watch list for three days, and monitor and document the resident's lying and standing blood pressure when specific medications (listed in the policy) are prescribed, monitor for any side effects of medications, keep the resident's physician informed of any concerns with blood pressure or side effects; -Residents at risk for falls will have interdisciplinary care plan interventions developed to address such; -Residents with a new fall or change in risk level will have their care plans reevaluated; -Each time a staff member leaves the room of a resident at high risk for falls ask the resident if he/she needs assistance to the bathroom, a drink of water, or any other need, remind the resident to use his/her call light if they need assistance. If the resident expressed a need, attend to it promptly or find a team member who can; -All team members are responsible to take action if they see a resident at risk for falls trying to get out of their bed or chair; -Restorative services will be provided to any resident at risk for decline; -Residents at risk for falls will have a plan of care which includes specific behavior(s) that may precede a fall. 9. During an interview, on [DATE] at 1:30 P.M., the administrator and DON said all resident incidents were documented on a written report and witnessed falls/injuries were further documented with statements obtained from the resident (if possible) and any staff who may have any pertinent information at the time of the incident. Staff statements were required on any residents who have an unwitnessed fall/injury. Staff members write synopses of any events preceding an unwitnessed incident including the resident's demeanor and activities for one to two hours prior to any unwitnessed injury/incident. The DON analyzes the staff incident reports and brings information concerning them to a daily interdisciplinary meeting where they are discussed and options to prevent further incidents planned. If solutions are easy, they are implemented immediately. After a resident's first fall the DON has staff obtain an order from the resident's physician for blood work and a urinary analysis, a physical therapy screening may also be warranted. After a resident's second fall the DON insists on an automatic physical therapy screening. Fall risk assessments are completed routinely as a part of the initial and quarterly resident care planning and assessment process, fall risk assessments are also completed after each resident fall. All falls are addressed through both the daily interdisciplinary meeting process and the quarterly care plan process. All new interventions determined through either process are implemented immediately when possible. The resident assessment coordinator who attends both the daily interdisciplinary meetings and the care plan meetings is responsible to write any change to the resident's care into their comprehensive plan of care (immediately after each meeting in which changes to the care are decided). Facility nurses and aides learn of any changes to a resident's plan of care through the written 24 hour report sheet used to make daily report on all residents at shift change. 10. Observations on [DATE] at 2:00 P.M. and on [DATE] at 9:50 A.M., showed the following chemicals left unlocked and unattended in the beauty shop: -The beauty shop hours of operation were Fridays and Saturdays from 9:00 A.M. until 1:00 P.M. -A 16 ounce (oz.) bottle of Hydrocide labeled "Danger Harmful or Fatal if Swallowed"; -A 16 oz. can of Non-Acetone Vital Hair Spray labeled "Danger Avoid eye contact, can cause eye irritation". 11. During an interview on [DATE] at 2:50

Based on observation, interview and record review, the facility failed to ensure adequate hydration for one of two residents, out of the 12 sampled, that received all nutrition and fluids through a gastrostomy tube. The facility failed to contact the resident's physician regarding the registered dietician's recommendations to increase the amount of water the resident received during gastrostomy tube flushes and failed to obtain an ordered laboratory test, used to determine hydration status. (Resident #7) The census was 61 with 50 in certified beds. 1. Review of Resident #7's quarterly Minimum Data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/12/10, showed the following: -Admission 5/25/10; -Usually understood/understands; -Independent with eating, set-up assistance only; -[DIAGNOSES REDACTED]. -Gastrostomy tube ([DEVICE], tube inserted into the stomach through the abdominal wall to provide fluids, nutrition and medication) feeding; -Mechanically altered diet; -Average fluid intake per day: received 501 or more cubic centimeters (ccs) of fluid. Review of a nurse's note, dated 2/14/11 at 2:23 P.M., showed the resident complained of nausea earlier in the shift. An emesis (vomit) of a coffee brown substance was noted. Staff notified the resident's physician who gave orders for [MEDICATION NAME] (medication to stop nausea and vomiting) and to monitor the resident. Review of a nurse's note, dated 2/14/11 at 5:11 P.M., showed the resident passed a large amount of loose stool, had an oxygen saturation level of 89% (normal range 90% - 100%), decreased breath sounds in both lungs and was slow to respond to verbal stimuli. Staff notified the resident's physician and received an order to transport the resident to a local hospital. Review of the resident's nurse's note, dated 2/15/11 at 6:24 P.M., showed an admission to a local hospital with [DIAGNOSES REDACTED]. Review of the results of the resident's blood urea nitrogen (BUN, blood test used to determine kidney function. An elevated level can indicate dehydration), taken at the hospital upon admission on 2/14/11, showed a value of 55 (normal range 7 - 27). On 2/15/11, the resident's BUN result dropped to 49 and on 2/16/11, to 37. Review of the resident's hospital discharge orders, dated 2/17/11, no time indicated, showed an order for [REDACTED]. Review of a nurse's note, dated 2/18/11 at 2:29 A.M., showed the resident returned to the facility on [DATE] at 4:45 P.M. Review of the resident's physician's orders [REDACTED]. -an order for [REDACTED]. -[MEDICATION NAME] 1.2 tube feeding at 65 ccs an hour, continuous; -Flush the [DEVICE] every six hours with 150 ccs of water. Review of the registered dietician's (RD) progress note, dated 2/24/11 at 10:49 A.M., showed a recommendation to increase the resident's [DEVICE] flush to 200 ccs of water every six hours (800 ccs daily). Review of the resident's medical record, showed no documentation by staff, to indicate the resident's physician had been contacted regarding the RD's recommendation. Review of the resident's electronic treatment administration record (ETAR, where nurses document the [DEVICE] flushes), dated 2/24/11, showed staff flushed the resident's [DEVICE] with 150 ccs of water every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Signs and symptoms of [MEDICAL CONDITION]: behavior present, fluctuated (sluggishness, staring into space, staying in one position, moving very slowly); -Over the past two weeks: felt down, depressed or hopeless (2 - 6 days), trouble falling or staying asleep (2 - 6 days), felt tired or had little energy (12 - 14 days); -Extensive assistance of two staff for bed mobility; -Extensive assistance of one staff for walking in room/corridor and eating; -Activity did not occur: moving from a seated to standing position, walking, turning around, moving on/off the toilet and surface to surface transfers; -[DIAGNOSES REDACTED]. -[DEVICE] feeding; -Total calories: received 51% or more of total daily caloric intake through the [DEVICE]; -Average fluid intake per day: received 501 or more ccs of fluid; -Staff failed to indicate dehydration as a recent diagnosis. Review of the resident's ETAR, dated 2/25/11, showed staff flushed the resident's [DEVICE] with 150 ccs of water every six hours. Review of the physician's progress note, dated 2/26/11, showed the resident had been admitted to a local hospital on [DATE], for nausea/vomiting, diarrhea, dehydration and altered mental status. He/She had been hospitalized for [REDACTED]. Continue present treatment and obtain a basic metabolic profile (BMP, blood test which includes a BUN and BUN/Creatinine Ratio (test used to check for dehydration), on Monday, 2/28/11. Review of the facility ETAR from 2/26/11 through 2/28/11, showed staff flushed the resident's [DEVICE] with 150 ccs of water every six hours. Review of the results of the resident's BMP, on 2/28/11, showed the following: -BUN: 43; -BUN/creatinine ratio: 72 (normal range 6 - 34). Review of a copy of the BMP, obtained on 2/28/11, and faxed to the resident's physician on 3/1/11, showed a hand written note by a facility staff person indicating the resident's most recent BUN (date not noted) had a value of 27. The physician responded on 3/2/11, by fax, requesting staff obtain another BMP in one week. Review of the resident's medical record, showed staff failed to obtain the BMP as ordered. Review of the ETAR, from 3/1/11 through 3/7/11, showed staff flushed the resident's [DEVICE] with 150 ccs of water every six hours. Review of the resident's care plan, last updated on 3/7/11, showed the following: -Risk for dehydration; -Ensure resident received all ordered free water (water flushes) per [DEVICE]; -Monitor for signs and symptoms of dehydration; -Problems with short term memory and some confusion since his/her stroke. Review of the resident's ETAR, from 3/7/11 through 3/15/11, showed staff flushed the resident's [DEVICE] with 150 ccs of water every six hours. Review of the RD's progress note, dated 3/15/11 at 12:30 P.M., showed the RD noted the results of the resident's BUN and BUN/Creatinine Ratio tests completed on 2/28/1. The RD recommended the resident's [DEVICE] flushes be increased to 175 ccs of water every four hours (1050 ccs daily), with a goal that the resident would show no signs or symptoms of dehydration. Review of the resident's ETAR, dated 3/15/11 through 3/18/11, showed staff flushed the resident's [DEVICE] with 150 ccs of water every six hours. Review of a nurse's note dated, Friday 3/18/11, (three days after the RD wrote her recommendations), showed staff faxed the resident's physician the RD's recommendations and documented they would continue to monitor the resident's progress daily. Review of the resident's ETAR, dated 3/19/11 through 3/23/11, showed staff flushed the resident's [DEVICE] with 150 ccs of water every six hours. Review of the resident's medical record, on 3/23/11, showed staff failed to follow up with the resident's physician to see if he received the 3/18/11, fax regarding the RD's recommendation to increase the resident's [DEVICE] flush. Observation on 3/24/11 at 5:00 A.M., showed the resident lay in bed with a [DEVICE] pole next to his/her bed. Nurse B, the midnight nurse, had hung a sealed and unopened [DEVICE] flush syringe, dated 3/24/11, on the [DEVICE] pole next to a bag of [MEDICATION NAME] 1.2 that had been dated and timed, 3/24/11 at 2:00 A.M. At 6:20 A.M., Nurse B finished his/her medication pass. At 7:00 A.M., the [DEVICE] flush syringe remained sealed and unopened. Review of a physician's orders [REDACTED].M., showed the resident's physician gave a telephone order to increase the resident's [DEVICE] flushes to 175 cc every four hours. Observation on 3/25/11 at 5:15 A.M., showed the resident lay in bed with a [DEVICE] pole next to his/her bed. Nurse B had hung a sealed and unopened [DEVICE] flush syringe dated 3/25/11, on the [DEVICE] pole next to a bag of [MEDICATION NAME] 1.2 that had been dated and timed, 3/25/11 at 12:45 A.M. At 6:35 A.M., Nurse B finished passing his/her medications. Observation at this time showed the resident's [DEVICE] flush syringe remained sealed and unopened. During an interview on 3/25/11 at 7:20 A.M., Nurse B said he/she worked the midnight shift, which ended at 7:30 A.M. He/She hung the resident's new [DEVICE] syringe and bag of feeding and discarded the old [DEVICE] syringe and bag of feeding at around 12:00 A.M., every night. At around 6:00 A.M., he/she gave the resident his/her medications and flushed the [DEVICE] again. When asked why the resident's [DEVICE] syringe on 3/24/11 and 3/25/11, had not been opened until after he/she left for the day, Nurse B said the surveyor misunderstood him/her. He/She did not discard the old [DEVICE] syringe at 12:00 A.M., only the tube feeding bag. He/She hung the new [DEVICE] syringe at 12:00 A.M., with the new tube feeding bag, but kept the old [DEVICE] syringe and used it for the 12:00 A.M. and 6:00 A.M., [DEVICE] flushes before discarding it. He/She wanted the day shift to have a fresh [DEVICE] syringe when they started their shift. During an interview, on 3/25/11 at 10:10 A.M., the RD said she came to the facility on ce a week. After making recommendations, she leaves a form listing those recommendations with the administrator, Director of Nurses (DON), Assistant Director of Nurses and the dietary manager. She would expect the facility to contact the physicians within five to seven days after she leaves her recommendations. She did not feel Resident #7 was currently receiving an adequate amount of fluids. She did not know why the facility failed to contact the physician about her recommendations to increase the resident's [DEVICE] flushes. During an interview, on 3/25/11 at 10:10 A.M., the DON said the RD gives her the recommendations and she gives them to the nurses. The nurses are supposed to contact the physicians with the RD's recommendations. She did not know why the nurses failed to contact the resident's physician on 2/24/11. The nurses faxed the physician the RD's recommendations on 3/18/11, but the physician did not respond to the fax. She thought the nurses called the physician after sending the fax, but could not find supporting documentation. If the nurses called the physician it should have been documented. The facility started a new policy a couple of weeks ago. If a physician did not respond to a fax or phone call within 24 hours, the nurse should contact the facility medical director. The DON could not find documentation to show whether the nurses called the facility medical director. The resident was still receiving a 150 cc [DEVICE] flush every six hours and the nurses failed to obtain the BMP one week after receiving the physician's orders [REDACTED]. She did not know why the nurse failed to process the order. During an interview, on 3/25/11 at 11:00 A.M., the resident's physician said he did not remember being contacted by the facility about the RD's recommendation, on 2/24/11, to increase the [DEVICE] flush to 200 ccs of water every six hours. He did receive a fax from the facility, about the resident's BMP, on 3/1/11. The resident had an elevated BUN and BUN/Creatinine Ratio level which indicated the resident could be "dry", or dehydrated. He did not know the facility failed to obtain the follow up BMP he ordered, on 3/2/11. He reviewed the faxes he had received from the facility regarding the resident at this time. He did not receive a fax dated 3/18/11, with the RD's recommendation to increase the resident's [DEVICE] flush to 175 ccs of water every four hours. He would have increased the resident's [DEVICE] flush if the facility had contacted him. His office turns the fax machine off on Fridays because he does not want potentially important faxes to sit on the fax machine all weekend long without being addressed. If his fax machine is off, the facility could and should call him. Review of the results of the resident's BMP, obtained on 3/29/11, showed the following: -BUN: 42; -BUN/Creatinine Ratio: 60. Review of the facility "Preventing Dehydration" policy dated 4/1/08, showed the following: -It is the policy of the community to ensure that residents receive sufficient fluid to maintain proper hydration and health. When a resident develops a clinical condition that places them at risk for dehydration, interventions acceptable and appropriate for the resident will be implemented; -The neighborhood nurse leader or designee will assess all residents for the risk of dehydration at move in and periodically during the resident's stay. The dietician and/or certified dietary manager in collaboration with the resident or the resident's legal representative and interdisciplinary care team will develop an individualized care plan to ensure that the resident's hydration needs are met; -Since most older adults are at risk for dehydration, team members who work in the neighborhoods will be provided education about the signs and symptoms of dehydration during orientation and through the community's in-service education program. Offering fluids to residents who are at risk for dehydration will be the responsibility of all neighborhood team members that are qualified to assist a resident with fluid intake.