Every finding on record at Hill Crest Manor

Based on observations, interviews and record review, the facility failed to follow standards of practice when they failed to ensure one of the 14 sampled residents, (Resident #28) had a physician's order to have medication at bedside and failed to have a physician's order to self - administer medications. The facility census was 56.Review of the facility policy titled, Self-Administering Medications, dated February 2021 showed the resident was supposed to administer their own medications when the resident's physician and the Interdisciplinary Team (IDT) determined it was safe for the resident. 1. Review of Resident #28's self - administration of medication assessment dated [DATE] showed the resident was capable of self-administering medication. Review of the resident's Quarterly MDS, dated [DATE] showed:- Cognitive skills intact.- Required supervision/touch assistance with eating.- Required set up/clean up with oral care and personal hygiene.- Diagnoses included anxiety, depression, high blood pressure, atrial fibrillation (A-fib, an irregular and often fast heartbeat caused by chaotic electrical signals in the heart's upper chambers), and Chronic Obstructive Pulmonary Disease (COPD, obstruction of air flow that interferes with normal breathing). Observation and interview on [DATE] at 8:26 A.M., showed:- The resident sat in his/her chair and had oxygen on at 2 liters per nasal cannula (2L/NC).- The resident had an opened and undated bottle of generic eye drops (used for dry eyes), an opened and undated Albuterol inhaler (used for COPD) and an opened and undated bottle of Flonase nasal spray (used for seasonal allergies) which expired 2/26 on the bedside table. - The resident said he/she had trouble breathing and needed the inhaler and used the eye drops and Flonase when needed. Observation on [DATE] at 9:19 A.M., showed the resident still had the bottle of generic eye drops, the Albuterol inhaler, and the expired bottle of Flonase nasal spray plus an unopened bottle of Systane eye drops (used for dry eyes) and opened bottle of vaporizing rub (used for nasal congestion and minor aches and pains). Review of the resident's Physician Order Sheet (POS) dated [DATE], showed:- Start date: [DATE] - Oxygen at 2L/NC for shortness of breath.- Start date: [DATE] - Flonase nasal suspension, one spray each nostril two times daily for allergies. Unsupervised self - administration. May keep at bedside and self-administer. Resident to blow nose prior to administering. - Start date: [DATE] - Pro Air HFA Inhalation Aerosol Solution 108 (90 base) mcg/act, inhale two puffs orally every four hours as needed for shortness of air. Unsupervised self - administration. Rinse mouth after use. - Did not have an order for the generic eye drops, the Systane eye drops or the vaporizing rub. Did not have an order to keep the eye drops or the vaporizing rub at bedside. Review of the resident's Medication Administration Record (MAR) dated, [DATE] showed:- Oxygen at 2L/NC for shortness of breath.- Flonase nasal suspension, one spray each nostril two times daily for allergies. Unsupervised self - administration. May keep at bedside and self-administer. Resident to blow nose prior to administering.- Pro Air HFA Inhalation Aerosol Solution 108 (90 base) mcg/act, inhale two puffs orally every four hours as needed for shortness of air. Unsupervised self - administration. Rinse mouth after use. During an interview on [DATE] at 7:04 A.M., Registered Nurse (RN) A said:- There should be an order to leave medications at bedside.- There should be an order for the resident to self - administer the medication.- Self - administration assessments of medications used to be done by the MDS quarterly, but he/she was not for sure who did them now or how often. During an interview on [DATE] at 9:21 A.M., Certified Medication Technician (CMT) said:- Medications should not be left at bedside. - There should be a physician's order to leave medications at bedside.- He/She was not aware of any residents who had orders to leave medications at bedside.- He/She did not know if a resident was supposed to have an assessment completed to self - administer medications.- He/She would assume if a resident did have medications at bedside, someone would check the medication at bedside to see if they were expired and if the resident had used them, but he/she was not for sure. During an interview on [DATE] at 9:29 A.M., Licensed Practical Nurse (LPN) A said:- The residents should have a physician's order to leave medications at bedside.- He/She was not for sure if any of the residents had an order to leave medications at bedside. - There should be an order for the resident to self - administer the medication.- There should be an assessment completed to see if the resident was able to safely self - administer medications.- The nurse or CMT should check with the resident to see if they have taken the medication and should check to make sure the medications were not expired. During an interview on [DATE] at 11:51 A.M., the Director of Nursing (DON) said:- If a resident had any medication at bedside, there should be an order for it and an order to self-administer the medication.- Staff should check to make sure the medication is not expired and see if the resident has administered the medication.- There should be an order for each medication at bedside.- Assessments for self - administering of medications should be completed quarterly.

Based on record review and interview, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect), failed to check the Family Care Safety Registry (FCSR) to ensure that persons caring for children, seniors, or physically or mentally disabled individuals can be screened for employment purposes. The law requires that every child care and elder care worker hired on or after January 1, 2001, and every personal care worker hired on or after January 1, 2002. This affected five of 10 sampled staff. The facility census was 56.Review of the facility policy titled, New Hire Checklist Policy, dated February 2022 showed all newly hired staff will have a criminal background check, employee disqualification list check, certified nursing registry federal indicator check, and family care registry indicator check prior to employment start date.1. Employee A- New hire record review showed:Hired on 10/05/25- No FCSR, or CNA registry was checked.2. Employee B-New hire record review showed:Hired on 02/13/26-No criminal background check, or NA registry was checked.3. Employee C -New hire record review showed:Hired on 02/06/25- No criminal background check, no employee disqualification check, or NA registry was checked.4. Employee D- New hire record review showed:Hired on 08/11/25- No NA registry was checked.5. Employee E-New hire record review showed:Hired on 12/13/25- No NA registry was checked. No employee disqualification check, and no family care registry was checked.During an interview on 05/06/26 at 12:20 P.M. the Director of Nursing said there had been some checks not completed and was not sure why. She said that all staff should be checked through all the Federal Indicators prior to start of employment.During an interview on 05/06/26 at 2:22 P.M., the Administrator said all new employees should have a background check completed and documented prior to start of employment.

Based on observation, interview, and record review the facility failed to ensure that a resident's who required respiratory care, were provided such care consistent with professional standards of practice when the facility failed to ensure oxygen tubing was changed on a regular basis for four resident's (Resident's #8, #10, #49, and #28) of 14 sampled resident's. And when the facility failed to ensure oxygen concentrator filters were cleaned for two resident's (Residents #8 and #49). The facility census was 56.The facility did not provide a policy for respiratory care. 1. Review of Resident #8's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 03/30/26, showed: -The resident was cognitively intact; -The resident required assistance from staff to carry out activities of daily living; -The resident had diagnoses of shortness of breath, asthma (a chronic respiratory disease that causes the airway to narrow), and obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep). Review of the resident's care plan, dated 05/04/26, showed: -The resident was at risk for shortness of breath and required oxygen use related to asthma; -The resident wore oxygen at three (3) liters continuously per nasal cannula (a thin plastic tube with two small prongs that rest just inside the nostrils to deliver supplemental oxygen). Observation on 05/05/2026 at 10:52 A.M. showed: -The resident had a nasal cannula on that was connected to an oxygen concentrator in the resident's room; -The nasal cannula was not labeled with a date indicating the day the nasal cannula tubing was changed; -The filter (foam on the back on the oxygen concentrator that ensures clean oxygen) on the oxygen concentrator had [NAME] up dust covering the filter. 2.Review of Resident #10's Comprehensive MDS dated [DATE], showed: -The resident was cognitively intact; -The resident received hospice (end of life care for individuals with terminal illness) care; -The resident requiring supplemental oxygen was not addressed; -The resident had diagnoses of dysphagia (difficulty swallowing often causing coughing, choking, or pain), generalized edema (sever widespread excess fluid buildup throughout the body's tissues), and hypertension (high blood pressure). Review of the resident's care plan, dated 03/25/26, showed: The resident requiring supplemental oxygen was not addressed. Observation on 05/05/2026 11:17 at A.M. showed: -The resident had a nasal cannula on that was connected to an oxygen concentrator in the resident's room; -The nasal cannula was not labeled with a date indicating when the nasal cannula tubing was changed. During an Interview on 05/07/2026 at 8:34 A.M. Licensed Practical Nurse (LPN) A said: -Oxygen tubing should be changed every Sunday and a label placed on the tubing indicating when it was changed; -Oxygen concentrator filters should not have dust built up on them. During an Interview on 05/07/2026 at 8:52 A.M. the MDS Coordinator said: -Oxygen tubing was changed every Sunday; -Oxygen tubing should be labeled with the date that it was changed; -Oxygen concentrator filters should not have dust built up on them. During an Interview on 05/07/2026 at 11:52 A.M. the Director of Nursing (DON) said: -Oxygen tubing should be changed weekly and labeled indicating the date it was changed; -Oxygen concentrator filters should be cleaned weekly. 3. Review of Resident #49's care plan, revised 02/16/26 showed: - The resident had shortness of air related to decreased energy and fatigue secondary to dysphasia (difficulty with language or communication). - Elevate the head of the bed due to shortness of air. Encourage sustained deep breathing. Maintain a clear airway. Monitor/document changes in orientation, increased restlessness, anxiety and air hunger. Report breathing abnormalities to the physician. Use pain management as appropriate. - The care plan did not address the use of oxygen or the use of nebulizer treatments. Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact. - Upper and lower extremities impaired on one side. - Dependent on the assistance of staff for transfers. - Diagnoses included high blood pressure, diabetes mellitus, depression, hemiplegia (paralysis affecting one side of the body), hemiparesis (muscular weakness on one side of the body). Observation and interview on 05/05/26 at 9:18 A.M., showed: - The resident had an oxygen concentrator in his/her room. The oxygen tubing was not dated. The filter on the oxygen concentrator was covered in gray lint. The humidified water bottle was dated 04/05/26. - The nebulizer tubing was dated 04/26 and was placed inside a plastic bag dated 05/03. - The resident said he/she used the nebulizer and oxygen when he/she was short of air. Review of the resident's POS, dated May 2026 showed: - Start date: 01/30/26 - Ipratropium-albuterol solution 0.5-2.5 (3) mg/ml. Inhale every four hours as needed for shortness of air or wheezing. - Did not have an order to specify how often to change the nebulizer tubing. - The resident did not have an order for oxygen use. Review of the resident's MAR dated May 2026 showed: - Ipratropium-albuterol solution 0.5-2.5 (3) mg/ml. Inhale every four hours as needed for shortness of air or wheezing. - Staff documented it was administered on 05/05/26. - Did not have any documentation to indicate when the tubing should be changed or when it was changed. 4. Review of Resident #28's Quarterly MDS, dated [DATE] showed:- Cognitive skills intact.- Required set up/clean up with personal hygiene.- Diagnoses included anxiety, depression, high blood pressure, atrial fibrillation (A-fib, an irregular and often fast heartbeat caused by chaotic electrical signals in the heart's upper chambers), and Chronic Obstructive Pulmonary Disease (COPD, obstruction of air flow that interferes with normal breathing). Observation on 05/04/26 at 8:26 A.M., showed:- The resident sat in his/her chair and had oxygen on at 3.5 liters per nasal cannula (3.5L/NC).- The oxygen tubing was dated 04/19/26. The humidified water bottle was dated 04/05/26. -The portable oxygen tubing was dated 04/26. Review of the resident's Physician Order Sheet (POS) dated May 2026, showed, Start date: 01/14/25 - Oxygen at 2L/NC for shortness of breath. Review of the resident's Medication Administration Record (MAR) dated, May 2026 showed, Oxygen at 2L/NC for shortness of breath. During an interview on 05/07/26 at 7:04 A.M., RN A said:-The oxygen tubing should be changed weekly and dated. -The filters should be cleaned weekly. -The humidified water bottle should be changed and dated monthly. -The nebulizer tubing should be changed weekly and dated. During an interview on 05/07/26 at 9:21 A.M., CMT A said:-The oxygen tubing should be changed out weekly and dated on the night shift. -The nebulizer tubing should also be changed out weekly and dated. -He/She was not for sure how often the filters should be cleaned on the oxygen concentrators. -The residents should have an order for oxygen and how often to change the oxygen and nebulizer tubing. 5. During an interview on 05/07/26 at 9:29 A.M., LPN A said:-The residents should have an order for oxygen. -The oxygen tubing should be changed weekly on Sunday night by the night shift, and it should be dated when changed. -He/She thought the oxygen filters should be cleaned twice monthly. -The humidified water bottle should be changed twice monthly. -The nebulizer tubing should be changed every Sunday by the night shift and dated. 6. During an interview on 5/7/26 at 11:51 A.M., the Director of Nursing (DON) said:-There should be an order for oxygen. -The oxygen and nebulizer tubing should be changed and dated weekly. -The oxygen filters should be cleaned weekly.

Based on observations, interviews and record review, the facility failed to post the daily staffing sheets to include the amount of hours scheduled to work for both licensed and non-licensed nursing staff and failed to have it in an area unobstructed from the public view. The facility census was 56.The facility did not have a policy regarding the position of daily census and staffing sheets. 1. Observation and interview on 05/05/26 at 11:22 A.M., showed:- Staffing sheets were only available from 04/28/26 to 05/04/26, - The Regional Nurse Consultant (RNC) said he/she discovered on 04/28/26 the staff had not been filling out the daily staffing sheets. He/She had been unable to locate any staffing sheets for the last year. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) planned to in-service the night shift charge nurses, then the charge nurses would be responsible to fill them out. Currently, the DON and ADON were filling out the daily staffing sheets. During an interview on 05/07/26 at 7:04 A.M., Registered Nurse (RN) A said the daily staffing sheets should be filled out daily and posted in plain view of staff, residents and visitors. During an interview on 05/07/26 at 11:51 A.M., the DON said the daily staffing sheet should be filled out on each shift and posted in plain view daily. The night shift charge nurse would make any changes if there were call ins.

Based on observation and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when facility staff failed to properly store, label and monitor food items for expiration dates, failed to properly temperature check cooked food items, failed to use gloves while handling ready-to-eat food items, and failed to properly sanitize between kitchen tasks. This affected all residents in the facility. The facility census was 56. Review of facility policy titled, Food Preparation and Service, dated November 2022, showed:- Cross-contamination can occur when harmful substances, chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, or utensils that are not adequately cleaned.- Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.- Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese.- Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single use items and are discarded after each use. Review of facility policy titled, Food Receiving and Storage, dated November 2022, showed:- Food shall be received and stored in a manner that complies with safe food handling practices;- Food in designated dry storage areas are kept at least six inches off the floor;- All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).- Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded;Review of facility policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated November 2022, showed:- Employees must wash their hands after handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food;- Contact between food and bare (ungloved) hands is prohibited;Observation of the kitchen on 05/04/26 at 7:52 A.M. showed:Stand-up Refrigerator:- Lettuce had rotten leaves on the outside of four heads of lettuce;- Lemonade in a one-gallon plastic pitcher dated 04/27, use by 04/30 (expired);- Fruit punch in a one-gallon plastic pitcher dated 04/27, use by 04/30 (expired);- 9 unlabeled individual sized portions of unknown food in plastic serving cups with no dates;- Tomatoes, fresh, in container with no dates;- Cottage Cheese, 5-pound container, opened 05/03/26, expired 05/03/26;- Leftover pickles stored in a plastic container dated 04/22 (expired);- Plastic container of two pounds of leftover bologna opened 04/27 with use by date of 04/30 (expired);- Six pounds of country sausage with no dates in resealed package;- Gravy stored on 04/28 (expired);Dry Storeroom:- Two personal bags stored on top of raw onions in an open box;- Empty plastic container stored on top of raw potatoes in an open box;- Bag of granulated sugar, 50 pounds, stored on the floor;- Two #10 cans of baked beans stored on the floor propping the storeroom door open;- Five pounds of graham cracker crumbs, resealed in bag with no dates;Review of Food Temperature Log for recording final cooking temperatures, dated May 2026, showed:- No entries for lunch and dinner on 05/02/26;- No entries for breakfast, lunch, and dinner on 05/03/26;During an interview on 05/05/26 at 9:25 A.M., the Dietary Manager (DM) said that the temperature log should have been filled out but her staff did not do it due to training shortfalls with their performance.Observation of the kitchen on 05/05/26 at 9:30 A.M., showed:Walk-In Refrigerator:- 18 plastic containers of an unknown food labeled incorrectly with the date of 05/06/26;- Plastic container of expired bologna from 04/30 now has one-quarter of a pound of meat in the container;- Four uncovered drinks in plastic cups with no labels or dates;Kitchen Area:- 7 individual packages of Peanut Butter and Jelly sandwiches dated 05/06 in error with a use by date of 05/09;During an interview on 05/05/26 at 9:40 A.M., the DM said:- She got her dates mixed up and was writing 05/06 on containers instead of the correct date of today which is 05/05.- She is not positive on the leftover timeframe for meats such as bologna but the standard is three days.Observation in the kitchen on 05/05/26 at 9:42 A.M., showed:- The DM opening the container of bologna, smelling it and then determining it was not suitable for residents and discarded the remainder of the meat;- 10:50 A.M. Dietary Aide (A) was removing brownies from the cooking tray and placing them into serving dishes with his/her bare hands;- 10:54 A.M. Dietary [NAME] (A) wearing gloves finished working with sliced ham, disposed of gloves, and then started packaging food items in bags without washing hands;During an interview on 05/05/26 at 2:45 P.M., the Administrator said:- When working with ready to eat food items staff should use gloves and not touch food with their bare hands;- Leftovers should have a label that identifies the food item with open date and use by date;- Food items should not be stored on the floor, they should be six inches off the ground;- Expired items should be disposed of immediately;- Leftovers should be discarded per facility policy and within state and federal regulations;

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical needs and the services that were to be furnished to attain or maintain the resident's highest practicable wellbeing when the facility failed to include how to care for a catheter as well as supplemental oxygen for Resident #10. This affected one of 14 sampled residents. The facility census was 56.Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, showed:-The comprehensive person-centered care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;-Assessment of resident's were ongoing and care plans were revised as information about the resident's and the resident's conditions changed. 1.Review of Resident #10's Comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff) dated 03/27/26, showed:-The resident was cognitively intact;-The resident was receiving hospice (end of life care for individuals with terminal illness) care;-The resident requiring supplemental oxygen was not addressed;-The resident had diagnoses of dysphagia (difficulty swallowing often causing coughing, choking, or pain), generalized edema (sever widespread excess fluid buildup throughout the body's tissues), and hypertension (high blood pressure). Review of the resident's care plan, dated 03/25/26, showed: The resident requiring supplemental oxygen was not addressed. Review of the resident's physician's order sheet, dated 05/06/26, showed:-The resident had an order for urinary catheter care each shift beginning on 04/01/26;-The resident's physician's order sheet did not show an order for supplemental oxygen. Observation on 05/05/2026 at 11:08 A.M. showed:-The resident had an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine). Observation on 05/05/2026 11:17 at A.M. showed: -The resident had a nasal cannula (a thin plastic tube with two small prongs that rest just inside the nostrils to deliver supplemental oxygen) on that was connected to an oxygen concentrator in the resident's room; -The supplemental oxygen was being administered at three liters per minute;-The nasal cannula was not labeled with a date indicating the day the nasal cannula tubing was changed. During an Interview on 05/07/2026 at 8:34 A.M. Licensed Practical Nurse (LPN) A said: -A resident requiring oxygen should be addressed in the care plan;-A resident requiring an indwelling urinary catheter should be addressed in the care plan;-The MDS Coordinator updates the care plans; During an Interview on 05/07/2026 at 8:52 A.M. the MDS Coordinator said:-A resident requiring an indwelling urinary catheter should be addressed in the care plan;-A resident requiring supplemental oxygen should be addressed in the care plan;-If a resident required a new treatment plan or medical equipment the nurse could leave her a note for he to update the care plan or the nurse could update it themselves. During an Interview on 05/07/2026 at 10:15 A.M. Certified Nursing Assistant (CNA) A said:-He/she looked at resident's care plans to determine what type of care the resident would need;-If a resident had a catheter or needed oxygen it would be addressed in the resident's care plan. During an Interview on 05/07/2026 at 10:21 A.M. Nursing Assistant (NA) A said:-He/she looked at the resident's care plan to determine what type of care the resident would need;-If a resident had a catheter or needed oxygen it would be addressed in the resident's care plan. During an Interview on 05/07/2026 at 11:52 A.M. the Director of Nursing (DON) said:-The need for supplemental oxygen should be addressed in the resident's care plan;-The need for an indwelling urinary catheter should be addressed in the resident's care plan.

Based on interviews and facility job description review, the facility failed to employ either a full time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to carry out the functions of the food and nutrition services. This failure had the potential to affect all residents who received food from the kitchen. The facility census was 56.Review of the facility job description, Director of Food Services, undated, showed:- The primary purpose of the job position is to assist the Dietitian in planning, organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal and state regulations. - Assist in planning, developing, organizing, implementing, evaluating, and directing the Food Services Department, programs and activities.- Involve the resident/family in planning objectives and goals for the resident.- Review and check competence of food services personnel and make necessary adjustments/corrections as required or that may become necessary.- Monitor food services service personnel to assure that they are following established safety regulations in the use of equipment supplies.- Education requirements: Must possess at minimum a high school diploma and be a graduate of an accredited course in dietetic training approved by the American Dietetic Association.- Experience: Must have as a minimum five years experience in a supervisory capacity in a hospital, nursing care facility, or other related medical facility. - Must have training in cost control, food management, and diet therapy.- Must be registered as a Food Service Director in this state.Request for Human Resources hiring documentation for the DM was not provided. During an interview on 05/05/26 at 9:30 A.M., the DM said:- She had prior experience as a Dietary Aide and then moved up to the cook position for three to four years. She has been the DM for the last three years. She is not certified as a Dietary Manager and is not enrolled in any programs to obtain that certification. - The RD comes to the facility monthly and as needed will do some on hands training with her on various subject areas. - Was not positive about the leftover policy and how it applied to all of the various foods she works with. Her standard is three days but she doesn't have the actual policy that covers leftovers. During an interview on 05/05/26 at 2:15 P.M., the Administrator said:- The DM was fully qualified as a Certified Dietary Manager and he would provide the documentation.

Based on interview and record review, the facility failed to ensure residents remained free from accident hazards when one resident (Resident #1) eloped from the facility through an unsecured and unalarmed exit door. This affected one of four residents sampled. The facility census was 54. On 6/27/25 the Administrator was notified of the past noncompliance situation which occurred on 6/7/25. On 6/7/25 an investigation immediately began and corrective actions were implemented. The noncompliance was corrected on 6/10/25. Review of the facility policy, Wandering and Elopements, revised March 2019, showed: - The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; - The residents' care plan will include strategies and interventions to maintain the resident's safety; - If a resident is missing, initiate the elopement/missing resident emergency procedure; - If the resident was not authorized to leave, initiate a search of the building and premises; Review of the facility policy, Resident Rights, undated, showed: - Resident has right to a safe, clean, comfortable and homelike environment and supports for daily living safely; - The facility maximizes resident independence and does not pose a safety risk; 1. Review of Resident #1's admission Record, dated 6/8/25, showed: - Diagnosis: dementia, depression, Alzheimer's disease, and stage 3 chronic kidney disease; Review of Resident's progress notes, showed: - Note dated 6/7/25 at 7:30 P.M. showed the resident eloped from facility; - Note dated 6/7/25 at 11:36 P.M. showed an elopement evaluation was completed and the resident is at risk for elopement; - Note dated 6/7/25 at 11:40 P.M. showed the resident a mental status screening completed that indicates resident has severe cognitive impairment; - Note dated 6/8/25 at 2:46 P.M. showed the physician gave an order to transfer the reisdent to another facility; Review of Resident's Care Plan, revised 6/8/25, showed: - Resident is an elopement risk/wanderer with impaired safety awareness; - Relocation to a more appropriate placement with assessment; - Distract resident from wandering by offering pleasant diversions structured activities; - Monitor location frequently and document wandering behavior and attempted diversional interventions; - Resident placed on 1:1 monitoring 6/7/25; Review of facility elopement investigation, dated 6/8/25, showed: - Resident eloped from the facility on 6/7/25; - Resident has a guardian; - Resident exited the south exit door without staff observance at 7:25 P.M. The door was unlocked and the alarm which initially sounded once the door was opened reset once the door closed; - A resident who witnessed the elopement contacted CNA (A) who then contacted LPN (A) to initiate a complete building search for the resident; - At 7:35 P.M. a former employee in town saw the resident, called the facility to let them know the were bringing the resident back to the facility. At 7:45 P.M. the resident returned to the facility; - Weather was clear, it was 70 degrees Fahrenheit outside, and the resident was fully clothed with shoes on when they departed and returned to the facility; - A full physical and psychosocial assessment was done on the resident with no concerns noted; - It was determined that the resident traveled one third of a mile on foot from the facility before he/she was returned; - Root cause of the incident as determined by the investigation: Resident was able to exit the facility without staff in pursuit, the door alarm ceased to sound once the door closed following the resident's exit, the door/alarm system had been disengaged; Observation on 6/27/25 at 9:20 A.M., showed the south side exit doors opened by a staff member, the alarm sounded and is audible at the charge nurses station and in the the hallway. The alarm would not silence until a staff member entered a keycode into the keypad; During an interview on 6/27/25 at 9:38 A.M., the Maintenance Director said: - The former system was old and for some reason was disengaged which allowed the alarm to reset as soon as the door was closed which was not how the system was intended to work; - Elopement drills have been conducted with staff for training; - He does approximately 10 daily door checks to ensure the system is working properly which entails making sure the alarm system is engaged properly and the doors lock function as intended; - On 6/10/25 a new keypad and locking mechanism was installed. The new system was tested by the installation team and the Maintenance Director to make sure the locking system engages properly and the alarm system does not reset unless a staff member enters a key code into the door keypad; During an interview on 6/27/25 at 10:14 A.M, LPN (B) said: - He/she is the charge nurse on morning shift and checks to make sure the doors are locked; - If the alarm goes off he/she will check the doors to investigate; During an interview on 6/27/25 at 10:30 A.M. the Social Services Director (SSD) said: - She has been here for three years and elopements are very uncommon; - She verified that the resident did elope on 6/7/25 and was gone for about 20 minutes before a former staff member returned him/her to the facility. Staff were unaware initially that the resident had eloped until a resident alerted them and an immediate search was conducted; - The facility did an elopement drill earlier this month and they are conducted quarterly; - The alarm is now more audible for the staff to hear; - The doors have been improved to be more reliable; - When a door is opened the alarm will keep sounding until a staff member enters a code into the keypad; - They have done recent in-services on keeping doors locked, abuse and neglect, and elopement; During an interview on 6/27/25 at 11:45 A.M., the Administrator said: - A resident should not be able to exit the building without staff knowledge if they are not their own person; - Doors with the exception of egress doors, should be locked at all times; - Resident #1 did not sustain any injuries or harm during the incident; - Interventions that have been put in place since the incident: every resident had an elopement assessment completed and updated in their care plans, education on the elopement binder and policies, education on abuse and neglect, education on interventions for elopement, review of staff break policy, new keypad and door system installed for the facility, alarm volume adjusted for easier staff identification, daily door checks instituted for staff, resident transferred after approval received from Public Administrator (guardian) and physician to another facility that better matched the resident's needs and population, ADHOC Quality Assurance Committee Meeting conducted to review the issue and provide solutions, and monthly monitoring by QA; - All inserving and corrective actions were completed as of 6/10/25. MO255491

Based on interviews and record review, the facility failed to ensure 11 of 11 residents who participated in a group meeting, knew how to file a grievance in writing, file anonymously, and obtain a written decision regarding a grievance. The facility census was 58. Review of the facility's policy titled, Grievances/Complaints, Recording and Investigating, revised April 2017, showed: - All grievances and complaints filed with the facility will be investigated and corrective action will be taken to resolve the grievances; - The Administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer; - Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations; - The investigation and report will include, as applicable: the date and time of the alleged incident; the circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts of the alleged incident; the resident's account of the alleged incident; accounts of any other individuals involved and recommendations for corrective action; - The grievance officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The following information will be recorded and maintained in the log: the date the grievance /complaint was received; the name and room number of the resident filing the grievance/complaint (if available); the name and relationship of the person filing the grievance/complaint on behalf of the resident (if available); the date the alleged incident took place; the name of name of the person investigation the incident; the date the resident or interested party, was informed of the findings and the disposition of the grievance; - Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. 1. Review of the resident's council meeting minutes, dated 11/16/24 showed the minutes did not indicate if the residents knew how to file a grievance. 2. Review of the resident's resident council minutes, dated 12/14/24 showed the minutes did not indicate if the residents knew how to file a grievance. 3. Review of the resident's resident council minutes, dated 1/18/25 showed the minutes did not indicate if the residents knew how to file a grievance. 4. During an group meeting on 1/27/25 at 1:07 P.M., 11 of the 11 residents said they were not for sure how to file a grievance. During an interview on 1/27/25 at 4:37 P.M., the Activity Director said he/she had not gone over how to file a grievance, where the paperwork is located or who the residents should talk to. During an interview on 1/19/25 at 4:16 P.M., the Administrator said the grievance would go to the interdisciplinary team (IDT) and they would work on it and let the residents know how it was resolved.

Based on observation, interview, and record review the facility failed to honor the resident's right to a dignified existence (Resident #11), and additionally when staff failed to assure residents rights to privacy was maintained for five (Resident # 8, #11, #12, #19, #21) of the 15 sampled residents. The facility census was 58. Review of the facility's policy titled, Resident Rights, revised February, showed: - Employees shall treat all residents with kindness, respect, and dignity; -Staff will maintain a residents right to privacy; -Federal and state laws guarantee certain basic rights to all residents of this facility. 1. Review of the Resident #12's Face Sheet., showed: - Diagnoses included: Stroke and muscle weakness; - Do not resuscitate (No chest compressions for life saving). Review of Resident #12's, undated care plan., showed; - Resident was alert and oriented; - Required assistance of 1 person for showers and transfers; - Independent with mobility while in wheelchair; - The care plan did not address how many showers a week the resident prefers; - Resident requires 1 person assist for personal hygiene and grooming; - Staff are to anticipate and meet the needs of the residents; - The right to privacy and knocking prior to entry of room was not care planned. Observation of CNA A on 1/26/25 at 10:05 A.M., entered the residents room without knocking or announcing self. Observation of CNA D on 1/27/25 at 2:15 P.M.,entered the resident's room without knocking or announcing self. During at interview on 1/28/25 at 1:01 P.M., the resident said, staff never knock, they just walk in like the own the place. 2. Review of Resident #19's Face Sheet showed: - Responsible for self; -Diagnoses: Pneumonia (infection of the lungs that impacts breathing), Diabetes, (a condition in which the body does not process blood sugar properly, depression, and restless leg syndrome (twitching of the legs). During an Interview on 1/26/25 at 1:32 P.M. the resident said nursing staff did not knock on his/her door before entering his/her room and staff talk about him/her in the hall way. Observation 01/27/25 at 08:38 A.M. showed: Nursing staff came out of the resident's room in the hallway and yelled out to the DON (Director of Nursing) that Resident #19 was getting sick, and throwing up, then the DON yelled to to then Nurse, the resident was getting sick. All in view of other staff and residents in the hallway. Observation on 01/28/25 at 07:08 A.M. showed: CNA's walking out of Resident #19's room discussing the current condition of the resident to other staff in front of other resident's. 47195 Review of facility policy titled, Dignity, revised February 2021, showed: -Residents are treated with dignity and respect at all times; -Individuals needs and preferences of the resident are identified through the assessment process; -Staff are expected to knock and request permission before entering residents' rooms; -Staff inform and orient residents to their environment; -Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of the facilty policy titled, Personal Conduct, undated, showed employees are expected to be courteous and to treat everyone with dignity and respect. 3. Review of Resident #8's quarterly MDS (Minimum Data Set), a federally mandated assessment tool completed by facility staff, dated 11/15/24, showed: -They had moderate impaired cognition; -They had impairment to one side of upper and lower extremity; -They were dependent on a wheelchair; -They were dependent for transfers from sitting to lying, lying to sitting on side of bed, chair to bed transfers, and shower transfers; -He/She required substantial/maximal assistance rolling left and right; -Diagnoses included stroke (condition that occurred when blood flow to part of the brain was disrupted causing damage to brain tissue due to blocked blood vessel), hip fracture, anxiety, depression (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities that previously enjoyed), schizophrenia (a mental health condition that affects a persons thoughts, perceptions, and behaviors), acute pain (a sudden pain that is short-lived and caused by an injury, illness, or medical procedure), restless leg syndrome, and generalized weakness (decreased muscle strength or lack of physical energy in most parts of the body). Review of care plan, revised 12/19/24, showed: -They will be treated with dignity and respect; -Communication: Use my preferred name. Identify yourself at each interaction. Face them when speaking and make eye contact. Reduce any distractions by turning off television, radio, close door, etc. They understood consistent, simple, directive sentences. Provide them with necessary cues and stop and return if agitated. Review of physicians orders, dated 1/27/25, showed an order dated 1/1/25 to readmit to hospice. Observation on 1/26/25 9:36 A.M., showed CMT A and CNA B burst into resident's room and did not knock or announce self prior to entering resident's room. Observation on 1/27/25 at 7:49 A.M. showed resident was laying in their bed with a gown half on and their chest exposed. Resident's room door was open and resident was visible from the hallway. During an interview on 1/29/24 at 2:04 P.M., CNA C said staff should knock and announce themselves prior to entering a resident room. During an interview on 1/29/24 at 2:22 P.M., CNA D said staff should always knock and announce themselves when entering a residents room. During an interview on 1/29/25 at 2:34 P.M., CMT A said staff should knock prior to entering resident room and announce themselves. During an interview on 1/29/24 at 4:16 P.M., Director of Nursing said she expected staff to knock and announce themselves prior to entering a resident room. During an interview on 1/29/24 at 4:16 P.M., Administrator said she expected staff to knock and announce themselves prior to entering a resident room. 4. Review of Resident #16's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Required substantial to maximum assistance with toilet use, showers, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included high blood pressure, stroke, anxiety, depression, and atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow). Observation and interview on 1/26/25 at 12:26 P.M., showed: - CNA B opened the resident's door and did not knock or announce him/herself first; - The resident said he/she would prefer the staff knock and announce themselves before they enter his/her room. During an interview on 1/29/25 at 10:27 A.M., CNA B said: - He/She should have knocked and announced him/herself before entering the resident's room; - He/She was not aware of any staff being rude, yelling or rough with residents and has not had any residents complain about it to him/her. 5. Review of Resident #21's Annual MDS, dated [DATE] showed: - Cognitive skills moderately impaired; - Required substantial to maximum assistance with toilet use and showers; - Frequently incontinent of urine; - Occasionally incontinent of bowel; - Diagnoses included diabetes mellitus, high blood pressure, anxiety, depression, high blood pressure, and schizophrenia ( a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). During an interview on 1/26/25 at 2:33 P.M., the resident said staff do not knock and announce themselves before they enter the room and the resident would prefer they knock announce themselves before entering the room. During an interview on 1/26/25 at 2:33 P.M., Resident #21 said: - He/She had reported staff being rough with him/her. He/She had reported it to the previous Administrator and the previous DON but they did not do anything about it; - CNA A has yelled at him/her before during one of his/her spells. He/She reported it to the previous Administrator and the previous DON and they said it was natural and not to worry about it and they did not do anything about it. 6. Review of Resident #11's quarterly MDS, dated [DATE], showed: -They were moderately cognitively impaired; -He/She had clear speech; -He/She was able to make self-understood and usually understood -missing some or part/intent of message but comprehends most of conversation; -They had severely impaired vision; -They were dependent on a wheelchair; -They had no impairment to upper or lower extremities; -They were independent with mobility-rolling left and right, sit to lying, lying to sitting; -They required supervision or touching assistance with chair to bed transfers, toilet transfers, tub/shower transfers; -Diagnoses included: glaucoma (condition affecting the eye that can lead to vision loss if left untreated), high blood pressure, dementia (group of brain disorders that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and judgement), anxiety, depression, psychotic disorder (a disconnection from reality), polyarthritis (condition affecting multiple joints without specifying location of inflammation), idiopathic neuropathies (nerve damage that can cause pain, numbness, tingling, or weakness in the body), and muscle spasms. Review of care plan, revised 11/21/24, showed: -They will be treated with dignity and respect; -They can verbally express their wants and needs. Educate staff to provide resident with opportunities to do so; -They required assistance with activities and meals related to decreased visual function secondary to diagnosis of glaucoma; -They had visual impairment, place their meal plate in reach and letting her know what is on plate. -Approach them from the front speak before touching or providing care etc for resident; -Tell them where you are placing items, be consistent; -They liked to call for help on a regular basis. Assist them with their needs and reassure them. Review of physician's orders, dated 1/27/25, showed an order dated 1/17/25 for occupational therapy to evaluate for activities of daily living, cognitive skills, functional mobility and safety awareness, low vision, and compensatory techniques. Observation on 1/26/24 at 12:50 P.M. showed resident was at lunch sitting with two aids and had received no assistance from CNA A who was sitting beside resident. Resident had food all over their left hand. CNA A did not provide verbal prompts or cues to resident. Observation on 1/27/25 at 10:08 A.M., showed CNA A entered resident's room without knocking on door. CNA A did not introduce self to resident and did not say anything to resident. CNA A did not tell resident what they were doing with resident prior to moving resident out of their room at 10:11 A.M. in their wheelchair. During an interview on 1/29/24 at 2:04 P.M., CNA C said: -Resident #11 was independent with meals but required verbal cues; -Staff provided resident with verbal cues by telling resident where their food was located by using the orientation of the clock method; -Resident #11 got scared a lot so staff have to provide a lot of verbal reassurances. During an interview on 1/29/24 at 2:22 P.M., CNA D said: -Resident #11 staff tell residents what food was in front of them and take their hand to guide them and showing them where there meat is, vegetable, dessert, and so on; -For resident #11, you have to verbally talk through everything with them due to their visual impairments. During an interview on 1/29/25 at 2:34 P.M., CMT A said: -Resident #11 required explanation of every step due to their visual impairments; -Staff should explain location of Resident #11's wheelchair prior to assisting in a transfer and orient to items around room such as when assisting in bathroom describing location of grab bar, or call light, or bedside table; -Staff would explain meals to resident #11 by describing where food is located in front of them on their plate and the location of their drink cup items; During an interview on 1/29/24 at 4:16 P.M., Director of Nursing said she expected staff to explain what they were doing with visually impaired residents prior to providing cares and assisting with meals. During an interview on 1/29/24 at 4:16 P.M., Administrator said she expected staff to announce themselves to visually impaired residents, and provide activity of daily living cares and meal service according to their care plan. 51166 7. Review of Resident #32's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -They had no impairment in upper or lower extremities; -Diagnoses included: heart disease, Alzheimer's Disease (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Review of care plan, dated 12/19/24, showed the resident requires staff assistance with ADL's (activities of daily living). Observation on 1/27/25 at 4:39 P.M. showed the resident's hair was frizzy, uncombed and was longer than resident traditionally wears their hair. Their hair was standing straight out and unmanaged. During an interview on 1/27/25 at 12:41 P.M., Resident's Responsible Party said the staff had not brushed the reisdent's hair on 1/10/25 and it looked like the resident stuck their finger in a light socket. During an interview on 1/28/25 at 3:26 P.M., Resident #32's family member said: -The resident had not had a hair cut or perm in months; -The resident was to have a haircut on 1/24/25 but did not receive a haircut. During an interview on 1/29/25 at 11:48 A.M., Activities Director said: -The facility had been without a beautician for a couple of months; -The resident had hair set by the beautician on 1/24/25, but did not receive a haircut or perm; -There were no set timelines for when residents haircuts were scheduled; -The staff would set up a haircut appointment for residents when they requested a cut or when residents hair looked shaggy. During an interview on 1/29/25 at 4:16 P.M., Administrator said: -Residents should receive haircuts regularly; -Residents hair should be clean and combed. MO248475 31102

Based on interview and record review the facility failed to assure that three residents (Resident #12, #25, and #42) had the right to self-determination through support of resident choice, when staff did not honor one resident's request for specific menu food items that had been encouraged by the facility's dietician (Resident # 42) but not not provided to the resident, and additionally failed to honor resident choice for showers for two residents (Resident #12, #25) out of the sampled 15 residents. The facility census was 58. Review of the facility's policy titled, Resident Rights, revised February, showed: - All residents have the right to choice, and self determination, respect, and dignity; - Federal and state laws guarantee certain basic rights to all residents of this facility. 1. Review of the Resident #12's Face Sheet., showed diagnoses included a stroke and muscle weakness. Review of Resident #12's, undated care plan., showed; - Resident was alert and oriented; - Required assistance of 1 person for showers and transfers; - Independent with mobility while in wheelchair; - The care plan does not address how many showers a week the resident prefers. Review of the Resident's shower sheets provided, showed: - The week of 11/4/24, the resident received only 1 shower; - The week of 11/24/24, the resident received only 1 shower; - The week of 1/3/25, the resident received only 1 shower. During an interview at 12:46 P.M. on 01/28/25 the resident said he/she doesn't feel that he/she has a say about when he/she receives a shower and would like a shower at least twice a week. He/She does not feel clean, and it upsets him/her. 2. Review of Resident #25's face sheet., showed diagnoses included Diabetes (a condition in which the body does not process blood sugar properly), obesity, depression, swelling in the legs and feet. Review of Care Plan, dated 11/19/24., showed: -Resident prefers showers in the day time; -The care plan does not address how many showers a week the resident prefers; -Resident has depression and staff should encourage resident to maintain independence. Review of the Residents Shower Sheets., showed; - Week of 12/20/24- One shower was documented; - Week of 12/26/24-One shower was documented; - Week of 1/11/25- One shower was documented. During an interview on 01/26/25 10:39 AM., the resident said he/she did not get a shower this week, or last week. He/she would like a shower twice a week. I feel dirty when I don't get a shower. During an interview on 1/26/25 at 2:15 P.M., Certified Nurses Aide (CNA) A said staff complete the showers when we can. Resident's should have a shower at least twice a week. During an interview with the Administrator and Director of Nursing (DON) on 1/25/25 at 4:05 P.M., stated: -Resident's who wish to have a shower twice a week, should be able to; -Resident's are allowed choice in their daily care; -Showers are to be documented on the shower sheets and signed by the nurse they are completed when the CNA/Bath CNA completes them. 51166 3. Review of Resident #42's Annual MDS assessment, (A mandatory assessment completed by facility staff).,dated 12/21/24 showed: -Cognitive skills were intact; -Diagnoses included: Heart disease, pneumonia (infection of the lungs), diabetes, thyroid disorder, arthritis, anxiety, depression, and asthma (chronic lung disease). Review of physician's orders showed on 7/30/24 orders were entered for regular diet, texture and consistency. Review of care plan, dated 10/14/24, showed: -Resident had a potential for weight loss; -If resident consumed less than 50% of their meal, an alternative should have been offered; -Snacks or supplements should have been offered when resident asked for or needed them. During an interview on 1/27/25 at 9:59 A.M., Resident #42 said: -They did not get enough fresh fruit; -Meals were repetitive (always the same foods); -When they were admitted to the facility, they told the dietician about their food preferences such as yogurt, fresh fruit, or cheese but they have not been offered these items. During an interview on 1/29/25 at 8:58 A.M., Resident #42 said: -They felt defeated because there were no healthy food options; -They did not like that they had to ask their family for fresh fruit and other preferred food items; -They had given up on getting to eat the food they enjoyed. During an interview on 2/4/24 at 4:33 P.M., the Dietician said: -They entered resident food preferences in their system and Dietary Manager should have followed up on resident preferences; -Residents could have obtained their desired food items if the facility had the budget to provide those foods. During an interview on 2/5/25 at 8:34 A.M., Dietary Manager said residents needed to ask kitchen staff for specific foods so they could put in an order. During an interview on 2/5/25 at 10:56 A.M., Administrator said: -Residents should have been able to get their preferred food within reason; -Facility should have had fruit, yogurt and cheese on hand; -They have not always had fresh fruit available.

Based on interview and record review, the facility failed to act promptly and resolve resident grievances voiced during the resident council meetings concerning issues of resident care and life in the facility and failed to communicate how the issues were resolved. The facility census was 58. Review of the facility's policy titled, Grievances/Complaints, Recording and Investigating, revised April 2017, showed: - All grievances and complaints filed with the facility will be investigated and corrective action will be taken to resolve the grievances; - The Administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer; - Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations; - The investigation and report will include, as applicable: the date and time of the alleged incident; the circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts of the alleged incident; the resident's account of the alleged incident; accounts of any other individuals involved and recommendations for corrective action; - The grievance officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The following information will be recorded and maintained in the log: the date the grievance /complaint was received; the name and room number of the resident filing the grievance/complaint (if available); the name and relationship of the person filing the grievance/complaint on behalf of the resident (if available); the date the alleged incident took place; the name of name of the person investigation the incident; the date the resident or interested party, was informed of the findings and the disposition of the grievance; - Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. 1. Review of the resident council minutes, dated 11/16/24 showed: - New Business: Issues: Dietary - could residents be offered seconds on both sides? Nursing- staff is rude to residents that can't feed themselves; aides are loud at night; not answering call lights very promptly; beds not made. Laundry - missing blankets and clothes. The area for action taken and who the person responsible was left blank. 2. Review of the resident council minutes, dated 1/18/25 showed: New Business: Issues: Can residents get Internet in their rooms? Need more sheets, bigger bed; Laundry - missing clothes. Housekeeping - not always cleaning rooms. The area for action taken and who the person responsible was left blank. 3. During a group meeting with the residents on 1/27/25 at 1:07 P.M., the residents said: - When concerns are brought up at their resident council meetings, the staff do not tell them what has been done to correct the issues brought up from the previous meeting. - During the resident council meeting on 1/27/25 at 1:07 P.M., nine out of the 11 residents at the meeting said CNA A is rude, and rough with them. They have reported it to the previous Administrator and DON and nothing was ever done. During an interview on 1/27/25 at 4:37 P.M., the Activity Director said: - When a resident brings up a concern at the resident council meeting, he/she made copies and passed them out to all the department heads and also gave one to he previous Administrator and Director of Nursing (DON); - He/she is unable to discuss the results with the residents because he/she did not get any feedback from the department heads to know how the issues were handled. During an interview on 1/29/25 at 8:56 A.M., the Administrator and the DON said she was not aware of any issues being reported by the resident council about a specific aide. During an interview on 1/29/25 at 4:16 P.M., the Administrator said: - Staff yelling at residents, residents being rough with cares or cursing should be reported to administration for action. - She would expect the manager to work the process, then discuss it with administration. - The manager should go back to the resident council and notify the residents how issues were to be resolved.

Based on record review and interviews, the facility failed to maintain a surety bond that was equal or greater than one and one-half times the average monthly balance for the residents trust fund (RTF) account for the last 12 consecutive months from January 2024-December 2024. This had the potential to affect all residents who had funds held in the RTF account. The facility census was 58. Review of facility policy, resident trust fund management, revised June 2022, showed: -Transactions are to be handled and records are to be kept in accordance with established directives and in conformance with state and federal requirements. -Facility will have a bond that equals at least one and one-half times the annual average of the fund account. This bond amount must also cover any credit balances on the facility accounts receivable (credit balances in PVT, PVA, and PVB accounts should be transferred to the RTF promptly). -The bookkeeper will keep a copy of the bond with the resident trust fund records. The bookkeeper will perform quarterly reviews and increase or decrease the bond as necessary. Record review on 1/27/25 of the RTF account for the last 12 consecutive months from January 2024 to December 2024 showed: -The facility's current approved bond amount equaled $58,000; -The average monthly balance for the RTF account equaled $39,259.28 (which was determined using the total of each ending balance for the last 12 months bank statements plus the petty cash ending balances and divided by 12 months); -An average monthly balance of $39,000 required a bond of at least $58,500; -Surety Bond #LSF032677 dated December 15, 2009 bond amount was changed from $65,000 to $58,000 on 12/15/2024; -Department of Health & Senior Services approved the surety bond adjustment #LSF032677 to $58,000 on December 17, 2024. During an interview on 1/27/25 at 3:57 P.M., Business Office Manager said: -Surety bond should be sufficient to cover 1.5x the average amount held in accounts; -Facility had a larger surety bond but had decreased the bond amount in December from $65,000 to $58,000. During an interview on 1/29/25 at 4:16 P.M., Administrator said: -He/She expected the surety bond held by the facility to be sufficient by equaling 1.5x times the average monthly account total held in the resident trust accounts.

Based on interviews and record review, the facility failed to annually inform the resident's of their rights. This affected 11 of the 11 residents in the group interview. The facility census was 58. Review of the facility's policy titled, Resident Rights, revised February, showed: - Employees shall treat all residents with kindness, respect, and dignity; - Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be informed about his/her rights and responsibilities. 1. Review of the resident council minutes, dated 11/16/24 showed the section for resident rights reviewed was left blank. 2. Review of the resident council minutes, dated 12/4/24 showed the section for resident rights reviewed was left blank. 3. Review of the resident council minutes, dated 1/8/25 showed the section for resident rights reviewed was left blank. 4. During a group meeting on 1/27/25 at 1:07 P.M., 11 of the 11 residents who attended the meeting said they did not discuss their rights during their monthly resident council meeting. During an interview on 1/27/25 at 4:37 P.M., the Activity Director said: - He/she helped the residents set up for their meetings; - He/she was not aware how often the facility must provide a notice of rights and services to the resident. During an interview on 1/29/25 at 4:16 P.M., the Administrator said the resident's rights should be discussed at their resident council meetings.

Based on interview and record review, the facility failed to provide accessible information on the location of the State Long-Term Care Ombudsman program that was readily available and could be read by all residents in the facility without assistance. The census was 58. Review of the facility's policy titled, Resident Rights, revised February 2024, showed: - Employees shall treat all residents with kindness, respect, and dignity; - Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to communicate with outside agencies regarding any matter. 1. During a resident group meeting on 1/27/25 at 1:07 P.M., 11 of the 11 residents who attended the meeting did not know what the Ombudsman was, what they did or where to find information about the Ombudsman program in the facility. Observation on 1/27/25 at 4:50 P.M., showed the Ombudsman information was located in the hall by living room area. During an interview on 1/27/25 at 4:37 P.M., the Activity Director said: - He/she helps the residents set up their resident council meetings; - He/she has gone over the Ombudsman information in the past, but has not recently discussed the information with the residents or the Ombudsman's contact information. During an interview on 1/29/25 at 4:16 P.M., the Administrator said staff should inform residents of who the Ombudsman is, what the role of the Ombudsman is and contact information.

Based on interviews, the facility failed to deliver Saturday mail to facility residents. The facility census was 58. Review of the facility's policy titled, Resident Rights, revised February 2024, showed: - Employees shall treat all residents with kindness, respect, and dignity; - Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to access to a telephone, mail and electronic mail (e-mail). 1. During the resident group meeting on 1/27/25 at 1:07 P.M., 11 of the 11 residents who attended the meeting said the mail is not passed out to the residents on Saturdays. During an interview on 1/27/25 at 4:37 P.M., the Activity Director said:- In the past, a resident used to go out and get the mail out of the mailbox and put it in the office but that has stopped; - The mail is delivered to the facility on Saturdays, but it does not get passed out to the residents until on Mondays. During an interview on 1/29/25 at 4:16 P.M., the Administrator said the on call managers should pass the mail out to the residents on Saturdays.

Based on record review and interview, the facility failed to implement their own Abuse and Neglect policy, when they did not verify through the employee disqualification list (EDL) verification checks prior to the hire dates of five out of eight employees (Dietary Aide A, Nurse Aide (NA) A, NA B, [NAME] A, Maintenance Director) and additionally failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator ( a marker given by the Federal government to individuals who have committed abuse/neglect) for one of the eight sampled staff (Registered Nurse (RN) A). The facility census was 58. Review of facility policy, Employee Disqualification List (EDL), revised 2/2022, showed: -The employee designated by the administrator to complete the EDL background check will access the EDL website and complete the access to automatic system. -At the time of consideration of employment, the designated employee shall access the EDL website indicated and check EDL. Any candidate for employment whose name is on the list is not eligible for hire; -Print off the notice returned by email to indicate that the EDL had been checked. Make sure it included the date and the initial of the person making the request. Review of facility policy, Abuse Prevention Program, Revised [DATE], showed: Background checks will be done at the time of hire in accordance with the facility background check policy. staff will not be hired who have been found guilty, or plead no contendere, of abuse, neglect, mistreatment of resident or misappropriation of resident property by a court of law. -The nurse aide registry will be checked prior to employment for each state where a nurse aide has shown to have worked, or has listed certification. Nurse aides will not be hired who name is on any state abuse registry. -Verification of background checks, nurse aide registry checks and reference checks will be maintained in the personnel file of each employee. A notation by facility staff member of telephone contacts for registry check and previous employer checks would constitute verification. Review of the six sampled employee files showed: 1. Dietary Aide A, Date of Hire (DOH) 8/1/24, had no EDL check; 2. Nurse Aide (NA), DOH 6/25/24, had no EDL check; 3. NA B, DOH 9/30/24, had no EDL check; 4. [NAME] A, DOH 12/16/23, had an EDL check completed on 1/29/25 (1 year, 1 month, and 13 days from their initial DOH); 5. Maintenance Director, DOH 1/16/25, had an EDL check completed 1/29/25 (13 days after their DOH). 6. Registered Nurse A, DOH 12/6/23, had no nurse aide registry check. During an interview on 1/29/25 at 1:25 P.M., Business Office Manager said: -They just checked EDL for employees upon hire and not on a routine basis; -They were to check nurse aide registry for all employees; -Dietary Aide A's first day of work was 8/4/24; -They did not locate an EDL on [NAME] A so they completed a new one on 1/29/25; -Maintenance Director was just hired 1/16/25, so they just completed an EDL check on 1/29/25. During an interview on 1/29/25, the Regional Accounting person said EDL checks were to be completed quarterly on all employees. During an interview on 1/29/25 at 4:16 P.M., the Administrator said she expected EDL and CNA registry checks to be completed per facility policy and upon hire.

Based on interviews, and record review, the facility failed to hold care plan meetings on a quarterly basis or when a resident's significant change in condition occurred. The facility additionally failed to involve residents and/or their representatives in the care planning process for five residents (#24, #32, #42, #16, #21) of the 15 residents sampled. The facility census was 58. Review of the facility's Care Planning Policy, dated 3/2022, showed: -The interdisciplinary team (IDT), in conjunction with the resident and their family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident; -Each resident's comprehensive person-centered care plan was consistent with the resident's rights to participate in the development and implementation of their plan of care, including the right to: - Participate in the planning process; -Identify individuals or roles to be included; -Request meetings; -Request revisions to the plan of care; -See the care plan and sign it after significant changes were made. Review of facility's Resident Rights policy, undated showed the Resident had the right to be informed of and participate in their care plan and treatment. 1. Review of Resident #24's Significant Change MDS (Minimum Data Set), a federally mandated assessment tool completed by the facility staff for care planning), dated 10/18/24, showed: -Cognitive skills were intact; -Diagnoses included: kidney disease, diabetes (a condition resulting in too much sugar in the blood), arthritis (joint pain and swelling), depression, anxiety (feeling of dread and fear), fractures, and thyroid disorder (condition that effects the thyroid gland). During an interview on 1/28/25 at 3:15 P.M., Resident #24 said he/she was upset he/she was not involved in their own care planning because they did not know what was going on or what they needed to do in regards to their care. 2. Review of Resident #32's Significant Change MDS, dated [DATE], showed: -Severe cognitive impairment; -They had no impairment in upper or lower extremities; -Diagnoses included: heart disease, Alzheimer's disease (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). During an interview on 1/28/25 at 3:33 P.M., Resident #32's DPOA (durable power of attorney) said that the facility staff told them the resident can no longer use a walker, because staff was afraid the resident would fall, however there was no care plan meeting held to address the change in the resident's mobility. During an interview on 1/29/25 at 8:40 A.M., Certified Medication Technician (CMT) A said: -Resident #32 was ambulatory but was not feeling well a few weeks ago; -Resident #32 became weaker after being sick so the resident was transitioned to a wheelchair. During an interview on 1/29/25 at 9:30 A.M., Physical Therapy Assistant (PTA) A said: -Resident #32 had been in therapy three times a week since 1/9/25; -At the end of December, 2024, nursing staff asked PTA A if Resident #32 could switch from using a walker to a wheelchair because the resident was now unsafe when they used a walker; - PTA A told staff to transition Resident #32 to a wheelchair; -MDS Coordinator was responsible for updating the care plan. 3. Review of Resident #42's Annual MDS assessment, dated 12/21/24., showed: -Cognitive skills were intact; -Diagnoses included: heart disease, pneumonia (infection of the lungs), diabetes, thyroid disorder, arthritis, anxiety, depression, and asthma (chronic lung disease). During an interview on 1/27/25 at 9:49 A.M., Resident #42 said they were frustrated that they have only been invited to one care plan meeting and had not been kept up-to-date with changes in their plan of care. Review of Resident #42's face sheet and record review showed admitted [DATE]. No documentation regarding scheduling or having care plan meetings since admission to the current date. During an interview on 1/29/25 at 10:16 A.M., Registered Nurse (RN) A said: -Care plan meetings should be conducted every 90 days and when there was a significant change in a resident's condition; -Resident #32's care plan should have been updated when their status changed from ambulating with a walker to only using a wheelchair. 31102 4. Review of Resident #16's face sheet showed: - admitted - 3/20/24; - The resident was his/her own responsible party. Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Diagnoses included stroke, anxiety, high blood pressure and depression. Review of the resident's care plan, revised 12/26/24 showed it did not address if the resident was invited or attended his/her care plan meeting. During an interview on 1/26/25 at 12:15 P.M., the resident said he/she has not been invited to his/her care plan meeting and has not attended a care plan meeting and would like to. 5. Review of Resident #21's face sheet showed: - admitted - 1/20/20; - The resident was his/her own responsible party. Review of the resident's Annual MDS, dated [DATE] showed: - Cognitive skills moderately impaired; - Diagnoses included diabetes mellitus, anxiety, depression, high blood pressure, schizophrenia ( a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). Review of the resident's care plan, revised 12/27/24 showed it did not address if the resident was invited or attended his/her care plan meeting. During an interview on 1/26/25 at 2:41 P.M., the resident said he/she has not been invited to his/her care plan meeting and has not attended a care plan meeting. During an interview on 1/29/25 at 1:37 P.M., the MDS Coordinator said: -Care plan meetings were held at a minimum on a quarterly basis; -Socials Services Director made appointments for care plan meetings with the residents and the family; -Social services, MDS Coordinator, DON, charge nurse, CNA, activities, dietary, family, or resident were invited to care plan meetings; -MDS Coordinator, Social Services Director, DON (director of nursing), and the Administrator had the ability to update care plans; -Care plan updates were triggered when a resident had significant changes, hospitalization s, an update from CNA's or nurses, or quarterly due dates or annual assessment occurred; -Social Services Director was responsible for keeping records of the invitees and attendees of care plan meetings. During an interview on 1/29/25 at 3:05 P.M., the Social Services Director said: -They were responsible for coordinating care plan meetings; -They talked to residents to notify them of their care plan meetings; -Care plan meetings were expected to be held quarterly or if there was a significant change; -They did not have any record of care plan meeting invitations or attendance. During an interview on 1/29/25 at 4:16 P.M., the Administrator said: -Care plans should be completed upon admission, updated quarterly, and when a resident had a significant change; -A significant change would be when a resident transitioned from a walker to a wheelchair and should have been care planned.

Based on observation, interview, and record review, the facility staff failed to ensure residents remained free from accident hazards when staff did not follow the manufacturer's guidelines when transferring one (Resident # 8) in a mechanical lift and while pushing residents in their wheelchairs without foot pedals for two (Resident #11 and #30) residents. This affected three (Resident #8, #11, and #30) of the fifteen sampled residents. The facility census was 58. Review of facility policy, Resident Rights, undated, showed: -Safe Environment: Resident have the right to a safe, clean, comfortable, and homelike environment, including while receiving treatment and supports for daily services. Review of facility policy, Resident Handling Policy, Revised in 2000, showed: -Resident handling policy exists to ensure a safe working environment for resident handlers; -Resident transfer status will be reviewed via care-plan time frame and on an as needed basis; -Resident transfer status will be documented in the resident's chart and care plan. Review of facility policy, wheelchair policy, undated, showed: -Facility allows the resident the use of wheelchairs for mobility under their own propulsion or with assistance of staff. Residents may utilize wheelchairs without leg rests under their choice to allow for greater independence; -Movement within the chair may be under the residents' own means or with staff assistance at the resident's decision; -Residents may choose not to utilize leg rests on wheelchairs to improve their freedom to peddle chairs to and from, rest feet on the floor, increase ability to get closer to items such as meals, or other deemed appropriate reasons; -Wheelchair use and resident choices will be care planned as needed. Review of manufacturer guidelines for use dated 2018, showed: -When transferring a resident/lifting the patient: -Warning: The legs of the patient lift must be in the maximum open position for optimum stability and safety. 1. Review of Resident #8's Quarterly MDS (Minimum Data Set), A federally mandated assessment tool completed by facility staff, dated 11/15/24, showed: -They had moderate impaired cognition; -They had impairment to one side of upper and lower extremity; -They were dependent on a wheelchair; -He/She was dependent for transfers from sitting to lying, lying to sitting on side of bed, chair to bed transfers, and shower transfers; -He/She required substantial/maximal assistance rolling left and right; -Diagnoses included: Stroke (condition that occurred when blood flow to part of the brain was disrupted causing damage to brain tissue due to blocked blood vessel), hip fracture, anxiety, depression (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities that previously enjoyed), schizophrenia (a mental health condition that affects a persons thoughts, perceptions, and behaviors), acute pain (a sudden pain that is short-lived and caused by an injury, illness, or medical procedure), restless leg syndrome, and generalized weakness (decreased muscle strength or lack of physical energy in most parts of the body). Review of care plan, revised 11/13/24 showed the resident required assist of two staff for transfers with a mechanical lift. Review of physician's orders, dated 1/28/24, showed and order revised 1/26/24 may use mechanical lift for transfers. During an observation on 1/27/25 at 10:26 A.M. resident was transferred from their chair to their bed in resident room by Certified Nurse Aide (CNA) A and CNA B . Observation showed CNA B raised Resident #8 from their chair and CNA B assisted from behind chair stabilizing the patient. As Resident #8 was being transferred from the chair to the bed the mechanical lift legs remained closed and were not spread as CNA B mobilized resident in the lift from their chair to their bed. During an interview on 1/29/25 at 2:04 P.M., CNA C said when using a mechanical lift the legs should be spread while transferring a resident. During an interview on 1/29/25 at 2:22 P.M., CNA D said when transferring a resident they should move residents with the mechanical lift legs closed. During an interview on 1/29/25 at 2:34 P.M., CMT A said: -While transferring a resident with the mechanical lift the legs should be open; -The legs of the mechanical lift should never be closed when somebody is in the lift because the lift could topple over. During an interview on 1/29/25 at 4:16 P.M., Director of Nursing said she expected the mechanical lift to be used according to manufacturers guidelines. During an interview on 1/29/25 at 4:16 P.M., Administrator said she expected the mechanical lift to be used according to manufacturers guidelines. 2. Review of Resident #11's Quarterly MDS, dated [DATE], showed: -They were moderately cognitively impaired; -They had severely impaired vision; -They were dependent on a wheelchair; -They had no impairment to upper or lower extremities; -They were independent with mobility-rolling left and right, sit to lying, lying to sitting, ; -They required supervision or touching assistance with chair to bed transfers, toilet transfers, tub/shower transfers; -Diagnoses included: Glaucoma (condition affecting the eye that can lead to vision loss if left untreated), high blood pressure, dementia (group of brain disorders that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and judgement), anxiety, depression, psychotic disorder (a disconnection from reality), polyarthritis (condition affecting multiple joints without specifying location of inflammation), idiopathic neuropathies (nerve damage that can cause pain, numbness, tingling, or weakness in the body), and muscle spasms. Review of care plan, revised 11/21/24, showed the reisdent used a wheelchair for mobility and could propel self and may need assistance with the task at time due to visual impairments. Review of physician's orders, dated 1/27/25, showed: -Start 1/17/25, occupational therapy to evaluate for activities of daily living, cognitive skills, functional mobility and safety awareness, low vision, and compensatory techniques Observation on 1/26/25 at 10:11 A.M. showed CNA A wheeled resident out of his/her room without any foot pedals on resident's chair. CNA A was stopped by DON at common area of 300 halls. CNA A then applied a blanket to resident's legs and wheeled resident down to administrative office by front entry of building where CNA A was observed applying foot pedals to resident's wheelchair. Observation on 1/27/25 at 10:32 A.M. showed Resident had a wheelchair foot pedal sitting on floor at foot of their bed in their room. 3. Review of Resident #30's Quarterly MDS, dated [DATE], showed: -They were cognitively intact; -They had impairment on one side of upper and lower extremities; -They were dependent on a wheelchair; -They were independent with wheeling self 50-150 feet in a manual wheelchair; -Diagnoses included: aftercare following joint replacement surgery, muscle weakness, muscle spasms, hemiplegia and hemiparesis following stroke affecting left non-dominant sides (condition that causes weakness or paralysis on one side of the body), cognitive communication deficit (condition affecting a person's ability to speak, listen, read, write, and interact socially). Review of care plan revised 1/27/25, showed: -They used wheelchair for mobility and could propel self short distances. They relied on staff and family to propel them at times. They would propel themselves backwards in their wheelchair, ensure theirs and other residents safety is monitored. Observation on 1/28/25 at 9:59 A.M. showed CNA D pushed resident #30 with no right side foot pedal on his/her wheelchair when pushing out of bathroom back to their room. Resident had a foot pedal on left side foot rest of wheelchair with foot on pedal but right foot was observed on the floor on right side of chair. 4. During an interview on 1/29/25 at 2:04 P.M., CNA C said he/she was not allowed to push residents in wheelchairs without foot pedals because it could result in injury. During an interview on 1/29/25 at 2:22 P.M., CNA D said residents should not be pushed without foot pedals on their wheelchairs. During an interview on 1/29/25 at 2:34 P.M., CMT A said residents being pushed in wheelchairs should have foot pedals on their wheelchairs. During an interview on 1/29/25 at 2:44 P.M., Social Service Designee said: -Residents in wheelchairs could not be pushed without foot pedals; -It would be residents preference if they were able to hold their feet up during a transfer it would be okay to push them without pedals; -Therapy had been working on adjust foot pedals for wheelchairs. During an interview on 1/29/25 at 4:16 P.M., Director of Nursing said she expected dependent residents who were pushed through the facility to have foot pedals on their wheelchairs. During an interview on 1/29/25 at 4:16 P.M., Administrator said she expected dependent residents pushed through the facility to have foot pedals on their wheelchairs.

Based on interview and record review, the facility failed to ensure nurse aides (NA's) met the minimum qualifications which included satisfactory participation in a State-approved nurse aide training and competency evaluation program within four months of hire. The facility census was 58. The facility did not provide a policy regarding hiring and training nurse aides. 1. Review of the facility employee list showed: - NA A was hired on 6/5/24; - NA D was hired on 12/19/22; - NA E was hired on 5/19/23. Record review of personnel files showed no documentation that NA A, NA D and NA E had been certified. During an interview on 1/29/24 at 4:16 P.M., the Administrator said they are no longer hiring NA's, but NAs should have their certification within four months of their hire date.

Please refer to Event ID: Y8C912 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 1/31/23. Based on interview and record review, the facility failed to keep two residents (Resident #1 and #2) free from abuse when Certified Medication Technician (CMT) A grabbed Resident #1's arm during a struggle over a magazine. CMT A caused a bruise and swelling to the resident's right arm. CMT A called Resident #2 a Needy little bitch when he/she activated his/her call light, because he/she had spilled his/her medications on his/her chest. The Director of Nursing (DON) was aware of both allegations and did not follow facility policy to protect residents pending the investigation findings. CMT A was allowed to continue to provide care to residents. This affected two of six residents sampled. The facility census was 49. Review of the undated Abuse and Neglect Policy showed: - The resident has the right to be free from abuse. - The facility will protect the residents from abuse by facility staff. - The facility administration will identify, assess and investigate all possible incidents of abuse. - Employees accused of abuse will immediately be reassigned to do duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the administrator. - Signs of physical abuse are bruises. - The resident's have the right to be free from physical, verbal, mental, and sexual abuse. Review of the Resident Rights policy, dated February 2021, showed: - All employees shall treat all resident with kindness, respect and dignity. - The resident has the right to have a dignified existence. - The resident has the right to be free from abuse. 1. Review of the facility investigation, dated 2/5/23, showed: - The investigation was completed and documented by the DON. - 2/5/23 Resident #1 told the DON he/she was in a verbal argument with Resident #3 over a magazine the day prior. He/she had possession of the magazine. - CMT A entered his/her room, tried to take the magazine from him/her. He/she hid the magazine behind his/her back as CMT A reached for it, and he/she hit Resident #1's arm and left a large purple bruise. - The DON identified a large purple bruise with a hematoma (swollen area caused by collected blood) to the resident's right forearm. - Resident #3 told the DON Resident #1 said he/she had his/her magazine. The two resident's argued and Resident #3 gave the magazine to Resident #1. - CMT A entered the room to settle things. - The DON documented CMT A entered Resident #1's room after he/she heard Resident #1 and #3 arguing. He/she asked for the magazine, Resident #1 would not give it to him/her. - He/she squatted in front of the resident, the resident raised his/her fist and put his/her foot at CMT A's groin. - CMT A said he/she did grab Resident #1's arm and pushed the wheelchair away. - The bruise to the resident's arm did not show a handprint and had a hematoma, indicating a bump into something. - CMT A apologized to the resident. - There was no evidence of willful abuse. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by the facility staff) dated 12/30/22 showed: - He/she had a Brief Interview for Mental Status (BIMS) score of 7, indicating moderate cognitive impairment. - Diagnoses included anxiety, depression, schizophrenia (a mental disorder that can affect thinking and behaviors) - He/she had a history of verbal outburst and behaviors. - He/she required the assistance of one staff member to get dressed and use the toilet. - He/she was wheelchair bound. Review of the resident's undated behavior care plan showed: - The resident had a history of verbally aggressive behaviors towards other residents. - The staff were not supposed to argue with the resident. - The staff were supposed to talk with him/her in a calm voice when he/she was disruptive. During an interview on 3/23/23 at 11:04 A.M., Resident #2 said: - He/she was in the shower, that was across the hall from Resident #1's room, with Nurse Aide (NA) A on 2/4/23 and heard the resident yelling. - CMT A entered the shower room and asked him/her what was going on, CMT A thought the noise came from the shower room. - CMT A discovered the shouting came from across the hall. - A few minutes later CMT A entered the shower room again and reported he/she took care of the situation. - The morning of 2/5/23, Resident #1 pulled up her shirt sleeve and showed Resident #2 a large purple bruise to his/her forearm. Resident #1 reported to him/her that CMT A grabbed his/her arm to take a magazine away from him/her. - Resident #2 reported the incident to the DON on 2/5/23. Observation of a photo obtained on 2/5/23 by Resident #2 showed Resident #1's right forearm with an orange size dark purple bruise above the wrist on top of the arm. A second lighter purple bruise, the size of an orange can be seen directly above the first bruise. Redness to the area can be seen connecting the two bruises. Review of the skin assessment, dated 2/5/23, showed the DON documented the resident had a dark purple bruise to his/her right forearm that measured 4.3 centimeters (CM) long and 2.1 CM wide. Review of Resident #3's Quarterly MDS, dated [DATE], showed: - He/she had a BIMS score of 15, indicating no cognitive impairment. - Diagnoses included: Seizure disorder and anxiety. - He/she required the assistance of one staff member to transfer, reposition in bed, get dressed, and use the toilet. During an interview on 3/23/23 at 3:24 P.M., Resident #3 said: - He/she and Resident #1 were in the door way of Resident #1's room, Resident #1 was in his/her room and Resident #3 was in the hallway. Both residents were in their wheelchairs. - The resident's argued over a magazine Resident #3 had possession of. He/she then gave the magazine to Resident #1 to stop the argument. - CMT A stepped in between the residents, Resident #1 held the magazine behind his/her back. - CMT grabbed Resident #1's arm, took the magazine away from him/her. CMT A bruised the resident's arm real bad. - He/she did not see the resident make a fist or lift his/her feet from the ground. During an interview on 3/29/23 at 9:32 A.M., CMT A said: - He/she was standing at the medication cart at the south nurse's desk and heard Resident #1 and Resident #3 arguing. - He/she separated the residents and discovered they were arguing over a magazine Resident #1 had possession of. - He/she squatted in front of Resident #1, who then balled his/her fist at CMT A. - CMT A raised his/her left arm to block the resident. He/she did not recall if he/she made contact with the resident. - Resident #1 said he/she would not give the magazine to CMT A. CMT A grabbed the magazine form the resident. - He/she should not have taken the magazine from the resident. - He/she should have walked away and reproached the resident later in the day. During an interview on 3/29/23 at 12:09 P.M., the DON said: - She conducted the abuse investigation as she always had by speaking to the two residents involved and CMT A. - She felt like Resident #1's bruise occurred during the incident, but did not look like a hand print. - CMT A denied touching the resident. - CMT a should not have reached for the resident's magazine. He/she should have ensured the residents were safe and walked away and reproached Resident #1 later in the day. - He/she felt like the bruise occurred during the incident, but did not feel it was abuse. - She allowed CMT A to continue to perform his/her duties because there was not enough staff to replace him/her. During an interview on 3/23/23 at 4:00 P.M., the Corporate nurse said: - He/she expected CMT A to walk away from the situation once he/she determined the residents were safe and reproach Resident #1 later in the day. - He/she expected all resident's to be treated with dignity and respect at all times. - CMT A should not have grabbed the resident's arm. During an interview on 3/29/23 at 9:15 A.M., Primary Care Physician (PCP) A said: - He had not received notification from the facility staff about Resident #1's bruise or regarding an allegation of abuse made by Resident #1 about CMT A. Review of CMT A's time card showed the following: -2/4/23, clocked in at 8:00 A.M. and out at 10:15 P.M. -2/5/23, clocked in at 9:00 A.M. and out on 2/6/23 at 2:45 A.M. -2/7/23, clocked in at 8:00 A.M. and out at 9:15 P.M. -2/8/23, clocked in at 9:00 A.M. and out at 12:30 A.M. -2/9/23, clocked in at 10:45 A.M. and out at 10:45 P.M. -2/10/23, clocked in at 9:00 A.M. and out at 9:15 P.M. -2/13/23, clocked in at 2:00 P.M. and out at 9:45 P.M. -2/14/23, clocked in at 9:15 A.M. and out at 10:15 P.M. -2/15/23, clocked in at 9:45 A.M. and out at 9:30 P.M. -2/17/23, clocked in at 8:45 A.M. and out at 8:45 P.M. -2/18/23, clocked in at 10:30 A.M. and out at 9:30 P.M. -2/19/23, clocked in at 9:30 A.M. and out at on 2/20/23 at 2:45 A.M. -2/22/23, clocked in at 9:30 A.M. and out at 9:00 P.M. -2/23/23, clocked in at 8:45 A.M. and out at 9:15 P.M. -2/24/23, clocked in at 9:30 A.M. and out at 2:15 A.M. -2/27/23, clocked in at 9:45 A.M. and out at 9:30 P.M. -2/28/23, clocked in at 10:00 A.M. and out at 8:45 P.M. -3/1/23, clocked in at 8:45 A.M. and out at 9:45 P.M. -3/3/23, clocked in at 9:00 A.M. and out at 6:30 P.M. -3/4/23, clocked in at 9:15 A.M. and out at 8:00 P.M. -3/5/23, clocked in at 9:45 A.M. and out at 9:00 P.M. -3/6/23, clocked in at 10:30 A.M. and out at 9:30 P.M. -3/8/23, clocked in at 7:15 A.M. and out at 2:30 P.M. -3/9/23, clocked in at 8:45 A.M. and out at 8:45 P.M. 2. Review of Resident #2's Admission MDS, dated [DATE], showed: - He/she had a BIMS score of 15, indicating no cognitive impairment. - Diagnoses included: Heart Failure and anxiety. - He/she required the assistance of one staff to transfer, get dressed and use the toilet. Review of the undated behavior care plan showed: - He/she displayed verbally aggressive behavior with bad language at times. - The staff were not supposed to argue with the resident. During an interview on 3/23/23 at 11:04 A.M., the resident said: - One evening in early February 2023, CMT A placed his/her evening medications on the night stand. The resident was asleep and when she awakened later, the resident found pills lying on his/her chest. - The resident turned his/her light on, CMT A entered his/her room. - CMT A told the resident you know, you are a needy little bitch. - This comment made the resident feel angry and he/she felt abused. During an interview on 3/28/23 at 4:28 P.M., a former resident said: - He/she was Resident #2's roommate in February 2023. - Resident #2 woke up one evening and had spilled pills on his/her chest. - Resident #2 rang his/her call light, CMT A entered the room and told Resident #2 he/she was a needy little bitch. During an interview on 3/23/23 at 3:49 P.M., Family Member A said: - The resident called him/her during one evening the last week of January 2023. The resident was upset and frustrated and in disbelief. He/she reported CMT A called him/her a needy little bitch. - He/she called the facility nurse and reported what the resident reported to him/her. - The DON called him/her about 9:00 P.M. the same night to discuss the allegation. - The DON told him/her CMT A would be sent home while they investigated. The next day he/she found out CMT A was not sent home and was allowed to continue to work. During an interview on 3/29/23 at 9:32 A.M. CMT A said: - He/she called Resident # 2 a needy little bitch after he/she had turned the call light on during the evening, but could not recall the date. - He/she was joking with the resident when he/she called the resident a needy little bitch and did not realize there was a problem until the next morning when the DON talked with him/her and stated the resident made a complaint about him/her calling the resident a needy little bitch. - The DON verbally told him/her that was an inappropriate thing to say and not to do it again. - He/she did not receive a written warning and was not suspended pending the investigation. During an interview on 3/29/23 at 12:09 P.M., the DON said: - CMT A admitted he/she called the resident a needy little bitch as he/she was exiting the resident's room in a joking manner. - She told CMT A he/she was not allowed to call residents names. During an interview on 3/28/23 at 12:47 P.M. the Administrator said: - She denied knowledge of the allegation that CMT A called Resident #2 a needy little bitch. - She was not aware the resident reported CMT A for calling him/her a needy little bitch and considered the comment made to the resident as verbal abuse. During an interview on 3/29/23 at 2:00 P.M. PCP B said: - The facility staff did not tell him CMT A called the resident a needy little bitch. - He considered the comment to be verbal abuse. MO213606

Based on record review and interview, the facility staff failed to keep one resident (Resident #1) free from abuse when Nurse Aide (NA) A provided the resident with a green leafy plant material that appeared to be marijuana/cannabis (a psychoactive drug from the cannabis plant) on 1/12/23 and the resident ingested it on 1/12/23 and 1/13/23. The resident was prescribed medications noted to have both major and moderate interactions with cannabis. The resident experienced a change in condition that included, vomiting, decreased oxygen saturation (measurement of the amount of oxygen in the blood with a normal reading of 100%) of 65% requiring use of oxygen, gray skin tone, an increased heart rate of 115, and decreased cognition. Certified Medication Technician (CMT) A, discovered some remaining marijuana in the resident's room and flushed it down the toilet. NA A was not suspended as per the facility's abuse and neglect policy and was allowed to work in the facility 1/13/23 to 1/15/23. On 1/14/23, NA A gave NA D a narcotic pain pill from his/her pocket. NA D did not report this illegal act to administration. On 1/15/23, NA D witnessed NA A cut Resident #2's prescribed narcotic pain medication in half, place half in a baggie, and place it in his/her pocket. The facility census was 47. The administrator was notified on 1/27/23 at 1:11 P.M. of an Immediate Jeopardy (IJ) which began on 1/12/23. The IJ was removed on 1/29/23 as confirmed by surveyor on-site. Review of the undated Abuse and Neglect policy showed: - Drugs that are given to residents is considered to be abuse. - The Administrator will ensure that any further potential abuse was prevented. - The Administrator will immediately suspend the employee that participated in the alleged abuse pending the investigation findings. Review of the Resident's Rights policy, dated February 2021, showed: - The resident had the right to be free from abuse. 1. Review of Resident #1's annual Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 11/14/22, showed: - He/she had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. - Diagnoses included: depression, heart disease, anxiety, and diabetes mellitus type two (a disease in which the body does not process blood sugar properly). - He/she depended on two staff members to transfer, reposition while in bed, use the toilet, and to get dressed. Review of Resident #1's physician orders for January, 2023 showed the following: -Hydrocodone Bitartrate/APAP 5/325mg- 1 tab by mouth twice a day for pain- 12:00-noon and 5:00 P.M. -Lisinopril 10mg- 1 tab by mouth at 12 noon. Hold if blood pressure is less than 110/60 (for treatment of hypertension-high blood pressure). -Abilify(ARIPiprazole) 10 mg- 1 tab by mouth daily (administer in A.M.). -Lasix 40 mg- 1 tab by mouth daily (administer in A.M.) for treatment of Congestive Heart Failure. -Imdur/Isosorbide mononitrate 30 mg- 1 tab by mouth daily. Hold for blood pressure less than 110/60 (for treatment of angina which is chest discomfort or shortness of breath caused when heart muscles receive insufficient oxygen rich blood). -Xanax 0.5mg- 1 tab by mouth at noon and hour of sleep for anxiety. -Baclofen 10 mg- 1 tab by mouth daily at hour of sleep for treatment of spasms. Review of Drug.com's drug interactions for cannabis (a Schedule 1 substance) with medications prescribed to Resident #1 showed the following: *Major interaction with Hydrocodone Bitartrate: -Using narcotic pain or cough medications together with other medications that also cause central nervous system depression can lead to serious side effects including respiratory distress, coma, and even death. -Talk to your doctor if you have any questions or concerns. Your doctor may be able to prescribe alternatives that do not interact, or you may need a dose adjustment or more frequent monitoring to safely use both medications. -Do not drink alcohol or self-medicate with these medications without your doctor's approval, and do not exceed the doses or frequency and duration of use prescribed by your doctor. -Medications may cause dizziness, drowsiness, difficulty concentrating, and impairment in judgment, reaction speed and motor coordination. -It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor. *Moderate interaction with Lisinopril -Lisinopril and cannabis may have additive effects in lowering your blood pressure. You may experience headache, dizziness, lightheadedness, fainting, and/or changes in pulse or heart rate. *Moderate interaction with Abilify (ARIPiprazole) -Using cannabis together with ARIPiprazole may increase side effects such as dizziness, drowsiness, confusion, and difficulty concentrating. Some people, especially the elderly, may also experience impairment in thinking, judgment, and motor coordination. *Moderate interaction with Lasix -Furosemide/Lasix and cannabis may have additive effects in lowering blood pressure. You may experience headache, dizziness, lightheadedness, fainting, and/or changes in pulse or heart rate. *Moderate interaction with Imdur -Isosorbide mononitrate/Imdur and cannabis may have additive effects in lowering your blood pressure. You may experience headache, dizziness, lightheadedness, fainting, and/or changes in pulse or heart rate. *Moderate interaction with Xanax -Using ALPRAZolam/Xanax together with cannabis may increase side effects such as dizziness, drowsiness, confusion, and difficulty concentrating. Some people, especially the elderly, may also experience impairment in thinking, judgment, and motor coordination. Moderate interaction with Baclofen -Using Baclofen together with cannabis may increase side effects such as dizziness, drowsiness, confusion, and difficulty concentrating. Some people, especially the elderly, may also experience impairment in thinking, judgment, and motor coordination. Review of the resident's Physician Order Sheet (POS) and Medication Administration Record (MAR), dated January 2023, showed: - 5/16/22 Hydrocodone 5 mg- acetaminophen 325 mg (pain medication), give one tablet by mouth two times daily at noon and 7:00 P.M. Signed on the MAR and narcotic count sheet as given at noon and 7:00 P.M. on 1/13/23. - 7/9/22 Xanax (a medication to treat anxiety), 0.5 mg per tablet, give one tablet by mouth two times daily at noon and 8:00 P.M. Signed on the MAR and narcotic count sheet as given at noon and 7:00 P.M. on 1/13/23. During an interview on 1/18/23 at 3:44 P.M., the resident said: - NA A gave him/her a cellophane cigarette wrapper that contained green leafy marijuana on 1/12/23. - The marijuana was about three inches long. - The resident ate a small amount the evening he/she received it and then placed it in his/her glasses case on his/her bedside table. - He/she ate more of the marijuana at lunch time on 1/13/23. - He/she placed the remaining marijuana back in the cellophane cigarette wrapper and back in his/her glasses case. - He/she became very ill, vomiting and did not remember anything further. During an interview on 1/18/23 at 4:33 P.M., NA B said: - He/she entered the resident's room with Licensed Practical Nurse (LPN) A on 1/13/23 at 11:00 A.M. and the resident had vomited everywhere. - He/she had to change the resident's clothes and bedding. - The resident just looked at the staff, was not able to talk, and was not able to say his/her name. - The resident told him/her NA A gave the marijuana to the resident at 4:00 P.M. - He/she reported to the DON the resident identified NA A as the person who gave him/her the marijuana. - The resident vomited several more times during his/her shift that ended at 6:00 P.M. - The nurse had to put oxygen on the resident because his/her oxygen was so low and the resident's skin was gray in color. - The resident was not able to eat lunch or supper on 1/13/23 because he/she was vomiting so much. - He/she told the DON about the resident's condition, but the DON did not go to the resident's room. During an interview on 1/19/23 at 5:32 P.M., LPN A said: - At 11:00 A.M. he/she and NA B entered the resident's room to provide wound care. - The resident had vomited a large amount of greenish- yellow bile colored vomit that covered the resident's clothing and bedding. The resident required a complete bed change. - He/she and NA B completed the wound care, the resident vomited again. - The resident appeared gray in color and his/her vital signs were: respirations of 36, rapid and shallow, heart rate irregular and 50-115 was their heart rate ranging between throughout the shift, blood sugar 106, and oxygen saturation of 65%, indicating the resident did not have the normal range of 90 to 100% of oxygen in his/her blood stream. - LPN A put oxygen on the resident at five liters (the maximum amount the machine would provide) and the resident's oxygen saturation came up to 88% within five minutes. - The resident was very slow to respond verbally and was confused. - The resident would not answer questions, but instead repeated the question that was asked of him/her. - The residents words were very slow and drawn out. - CMT A entered the room around 11:30 to give the resident his/her medications. - CMT A found a bag that contained a green leafy plant that appeared to be marijuana. - He/she did not notify the physician of the resident's changes. During an interview on 1/24/23 at 12:43 P.M., CMT A said: - The resident took his/her medications during the A.M. medication pass on 1/13/23 without difficulty and the resident appeared at his/her baseline at that time. - He/she entered the resident's room to give him/her scheduled medications at 11:45 A.M. on 1/13/23. - The resident was very calm and was not making eye contact. The resident had green vomit all over his/her clothing face, side of neck, and pillow. - The resident's skin was gray in color. - The resident was not able to take his/her medications at that time, but did an hour later with a protein drink. - LPN A and NA B was already in the resident's room, the resident was very slow to talk and repeated the questions that were asked of him/her. - He/she found marijuana in the resident's glasses case that was on his/her over the bed table. - The DON entered the resident's room and asked the resident who gave him/her the marijuana; the resident was not able to answer the question. - He/she told the Administrator he/she found marijuana in the resident's room. - The administrator told CMT A to flush the marijuana down the toilet. - He/she flushed the remaining marijuana down the employee toilet. During an interview on 1/24/23 at 2:16 P.M., NA C said: - He/she helped NA B clean the resident after he/she had vomited on him/herself and the bedding. - The resident said he/she was not feeling well and vomiting. - The resident looked very pale and gray. - The resident was able to talk very little and was very slow to say words. - LPN A was assessing the resident, the resident's oxygen saturation was low and LPN A placed oxygen on the resident. - The resident's skin color improved after he/she had oxygen on. - CMT A looked through the resident's room and found a small bag with what appeared to be marijuana in it. Review of the resident's nurse's note, dated 1/13/23 at 1:30 P.M., documented by the administrator showed: - She was called to the resident's room by a Certified Nurse Aide (CNA) because the resident was not acting right. - The resident had green vomit to the right side of his/her face and neck. - The resident was alert, but slow to respond. - The resident was found with a small amount of green leafy plant material that appeared to be marijuana; the resident said he/she consumed some of it by eating it. - The physician was notified with an order to continue to monitor the resident and report concerns to him. (Note: This contradicts interviews with administrator, nursing staff and the resident's physician.) During an interview on 1/26/23 at 4:15 P.M., the DON said: - The resident told her NA A gave the resident marijuana on 1/13/23. - She called NA A prior to his/her shift on 1/13/23, who denied the allegation. - She allowed NA A to work his/her scheduled night shifts on 1/13/23, 1/14/23, and 1/15/23. - She did not begin educating the staff about the facility abuse and neglect policy. - She assessed the resident, the resident was not able to answer her questions and was slow to speech. - She did not call the resident's physician until 9:00 P.M. on 1/13/23. - The physician should have been notified when the resident's change in condition was assessed earlier in the day. - She should have called the resident's physician earlier in the day when she found out the resident had eaten marijuana and was sick with vomiting and abnormal vital signs. During an interview on 1/26/23 at 4:10 P.M., the Administrator said: - She overheard that the resident said NA A gave him/her marijuana. - She made a comment in the hallway that the remaining marijuana needed to be flushed down the toilet. - She was unaware who flushed the marijuana down the toilet. - She did not educate the staff about the facility abuse and neglect policy. - She did not ensure NA A had not given other resident's marijuana throughout the facility. - She did not call the physician, police or the state agency. During an interview on 1/26/23 at 8:04 A.M. NA A said he/she did not give marijuana to the resident. During an interview on 1/31/23 at 1:00 P.M., LPN B said: - He/she had received in nurses report at 6:00 P.M. on 1/13/23 the resident had consumed marijuana earlier in the day and became ill with vomiting, he/she was lethargic, not able to answer questions clearly. - He/she assessed the resident between 6:30 and 7:00 P.M. and the resident was still lethargic, but able to answer him/her when a question was asked. - He/she checked the resident's blood sugar at 8:00 P.M., the resident was more alert and able to answer questions. - The resident was not able to hold his/her glass for a drink of water; this was abnormal behavior for the resident who normally was able to feed him/herself and hold his/her own glass for drinks. During an interview on 1/25/23 at 9:01 A.M., Primary Care Physician (PCP) A said: - He received a call from the DON on 1/13/22 at 9:00 P.M. reporting the resident had ingested marijuana earlier in the day, had vomited but had returned to baseline. - He instructed the DON to continue to monitor the resident and notify him of any changes. - The combination of ingesting marijuana and the resident's scheduled Xanax and Hydrocodone medications were a bad combination and could have been harmful to the resident. 2. During an interview on 1/18/23 at 4:59 P.M., NA D said: - LPN B often told NA A to give medications to residents. - LPN B placed residents medication in medication cups and sat the cups on top of the cart. - During the night on 1/14/23 he/she had a headache and was unable to find LPN B to ask for Tylenol from the medication cart. - He/she and NA A were outside smoking. NA D asked NA A if he/she had a Tylenol for a head ache. - NA A told NA D he/she had something better and handed him/her a pill from his/her pocket. - NA D said the pill did not look right, it was white, oblong shaped with the numbers M367 imprinted on the pill. - He/she searched the numbers on the pill online and discovered the pill was hydrocodone. - NA D did not consume the pill, but hid the pill in the supply room, because he/she did not want to have the pill on him/herself. - He/she did not tell anyone about the pill until the next evening, because he/she did not know what to do. Review of Resident #2's quarterly MDS, dated [DATE], showed: - He/she had a BIMS score of 15, indicating no cognitive impairment. - His/her diagnoses included depression, psychosis (severe mental condition in which thought and emotions are affected resulting in loss of reality), and chronic pain. Review of the resident's care plan for pain dated 9/23/22, showed: - The staff were to observe the resident for effectiveness of the pain medication. - The facility staff will provide pain medications as the physician prescribed. Review of the resident's POS, dated January 2023, showed: - 10/29/22 Oxycodone/ acetaminophen (a highly addictive pain medication) 10/325 mg, give one tablet by mouth every eight hours. Observation of a Oxycodone/acetaminophen 10/325 mg tab showed the medication was white, oblong and had M367 imprinted on the pill. During an interview on 1/18/23 at 4:59 P.M., NA D said: - On 1/15/23, NA A was in the cart looking at the cards of pills and placed pills in medication cups. - NA A took the medication to Resident #2. - NA A entered Resident #2's room and asked NA D to enter the room with him/her. - NA A pulled a pill cutter from the resident's closet and cut a round pill in half with it. - NA A told NA D, Resident #2 gets half and he/she got half. - NA A told NA D he/she took the medication from residents often. - NA A then placed the half pill in a clear sandwich bag with other half pills and gave the resident half a pill. During an interview on 1/18/23 at 4:59 P.M., NA D said: - NA D confided to NA B during supper on 1/15/23 that NA A had given him/her a narcotic pain pill the night prior. - NA D later during the night of 1/15/23 called the police to report the pill. - NA D gave the police the pill as evidence. At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. MO212731

Based on interview and record review, the facility failed to notify Resident #1's physician in a timely manner when staff discovered the resident ingested a green leafy plant material that appeared to be marijuana/cannabis (a psychoactive drug from the cannabis plant) and experienced a change in condition that included, vomiting, decreased oxygen saturation (measurement of the amount of oxygen in the blood with a normal reading of 100%) of 65% requiring use of oxygen, gray skin tone, an increased heart rate of 115, and decreased cognition at 11:00 A.M. on 1/13/23. Licensed Practical Nurse (LPN) A placed the resident on five liters of oxygen, but did not call the physician. The facility Administrator and Director of Nursing (DON) assessed the resident at 1:30 P.M. The facility DON notified the resident's physician at 9:00 P.M. on 1/13/23. The facility census was 47. Review of the Change of Resident Condition policy, dated February 2021, included: - A significant change was defined as a change that will not resolve itself without intervention by staff and/or impacts more than one area of the resident's health status. - The nurse will notify the resident's physician when there was a significant change in physical condition in the resident. - The nurse will notify the physician when there was a need to transfer the resident to the hospital. 1. Review of Resident #1's annual Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 11/14/22, showed: - He/she had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. - Diagnoses included: depression, heart disease, anxiety, and diabetes mellitus type two (a disease in which the body does not process blood sugar properly). - He/she depended on two staff members to transfer, reposition while in bed, use the toilet and to get dressed. Review of Resident #1's physician orders for January, 2023 showed the following: -Hydrocodone Bitartrate/APAP 5/325mg- 1 tab by mouth twice a day for pain- 12:00-noon and 5:00 P.M. -Lisinopril 10mg- 1 tab by mouth at 12 noon. Hold if blood pressure is less than 110/60 (for treatment of hypertension-high blood pressure). -Abilify(ARIPiprazole) 10 mg- 1 tab by mouth daily (administer in A.M.). -Lasix 40 mg- 1 tab by mouth daily (administer in A.M.) for treatment of Congestive Heart Failure. -Imdur/Isosorbide mononitrate 30 mg- 1 tab by mouth daily. Hold for blood pressure less than 110/60 (for treatment of angina which is chest discomfort or shortness of breath caused when heart muscles receive insufficient oxygen rich blood). -Xanax 0.5mg- 1 tab by mouth at noon and hour of sleep for anxiety. -Baclofen 10 mg- 1 tab by mouth daily at hour of sleep for treatment of spasms. Review of Drug.com's drug interactions for cannabis (a Schedule 1 substance) with medications prescribed to Resident #1 showed the following: *Major interaction with Hydrocodone Bitartrate: -Using narcotic pain or cough medications together with other medications that also cause central nervous system depression can lead to serious side effects including respiratory distress, coma, and even death. -Talk to your doctor if you have any questions or concerns. Your doctor may be able to prescribe alternatives that do not interact, or you may need a dose adjustment or more frequent monitoring to safely use both medications. -Do not drink alcohol or self-medicate with these medications without your doctor's approval, and do not exceed the doses or frequency and duration of use prescribed by your doctor. -Medications may cause dizziness, drowsiness, difficulty concentrating, and impairment in judgment, reaction speed and motor coordination. -It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor. *Moderate interaction with Lisinopril -Lisinopril and cannabis may have additive effects in lowering your blood pressure. You may experience headache, dizziness, lightheadedness, fainting, and/or changes in pulse or heart rate. *Moderate interaction with Abilify (ARIPiprazole) -Using cannabis together with ARIPiprazole may increase side effects such as dizziness, drowsiness, confusion, and difficulty concentrating. Some people, especially the elderly, may also experience impairment in thinking, judgment, and motor coordination. *Moderate interaction with Lasix -Furosemide/Lasix and cannabis may have additive effects in lowering blood pressure. You may experience headache, dizziness, lightheadedness, fainting, and/or changes in pulse or heart rate. *Moderate interaction with Imdur -Isosorbide mononitrate/Imdur and cannabis may have additive effects in lowering your blood pressure. You may experience headache, dizziness, lightheadedness, fainting, and/or changes in pulse or heart rate. *Moderate interaction with Xanax -Using ALPRAZolam/Xanax together with cannabis may increase side effects such as dizziness, drowsiness, confusion, and difficulty concentrating. Some people, especially the elderly, may also experience impairment in thinking, judgment, and motor coordination. Moderate interaction with Baclofen -Using Baclofen together with cannabis may increase side effects such as dizziness, drowsiness, confusion, and difficulty concentrating. Some people, especially the elderly, may also experience impairment in thinking, judgment, and motor coordination. During an interview on 1/18/23 at 4:33 P.M., Nurse Aide (NA) B said: - The resident was his/her normal self the morning of 01/13/23 and ate breakfast prior to 11:00 A.M. - He/she entered the resident's room with LPN A at 11:00 A.M. and the resident had vomited everywhere. - He/she had to change the resident's clothes and bedding. - The resident just looked at the staff, was not able to talk, and was not able to say his/her name. - The resident vomited several more times during his/her shift that ended at 6:00 P.M. - The nurse had to put oxygen on the resident, because his/her oxygen was so low and the resident's skin was gray in color. - The resident was not able to eat lunch or supper on 1/13/23, because he/she was vomiting so much. - He/she told the DON about the resident's condition, but the DON did not go to the resident's room. During an interview on 1/19/23 at 5:32 P.M., LPN A said: - On 1/13/23 at approximately 11:00 A.M., he/she and NA B entered the resident's room to provide wound care. - The resident had vomited a large amount of greenish-yellow bile colored vomit that covered the resident's clothing and bedding. The resident required a complete bed change. - He/she and NA B completed the wound care, the resident vomited again. - The resident appeared gray in color and his/her vital signs were: respirations of 36, rapid and shallow, heart rate irregular and a range of 50-115 through out the shift, blood sugar 106, and oxygen saturation of 65%, indicating the resident did not have normal oxygen in his/her blood stream. - LPN A put oxygen on the resident at five liters (the maximum amount the machine would do) and the resident's oxygen saturation came up to 88% within five minutes. - The resident was very slow to respond verbally and confused. - The resident would not answer questions, but instead repeated the question that was asked of him/her back. - Certified Medication Technician (CMT) A entered the room around 11:30 A. M. to give the resident his/her medications. - CMT A found a bag that contained a green leafy plant that appeared to be marijuana. - He/she did not notify the physician of the resident's change of condition. - He/she told the DON of the resident's change in condition and expected the DON to call the physician. During an interview on 1/24/23 at 12:43 P.M., CMT A said: - He/she entered the resident's room to give him/her scheduled medications at 11:45 A.M. on 1/13/23. - The resident was very calm and not making eye contact and the resident had been vomiting. - The resident's skin was gray in color. - The resident was not able to take his/her medications at that time, but did an hour later with a protein drink. - LPN A and NA B was already in the resident's room, the resident was very slow to talk and repeated the questions that were asked of him/her. - He/she found marijuana in the resident's room. - The DON entered the resident's room and asked the resident who gave him/her the marijuana; the resident was not able to answer the question. Review of the January 2023 Medication Administration Record (MAR) showed: - 1/13/23 The resident was given Zoloft at 8:00 A.M. - MAR was hand written changed from A.M. to noon for the following medications: Plavix, Abilify and Lasix. - 1/13/23 The resident was given Plavix, Abilify, Lasix, Imdur, Lisinopril, Xanax, and Hydrocodone Bitartrate/Acetaminophen at 12:30 P.M. - 1/13/23 He/she was given Hydrocodone Bitartrate/Acetaminophen, Xanax, and Baclofen at 7:00 P.M. Review of the resident's record showed the administrator documented on 1/13/23 at 1:30 P.M.: - She was called to the resident's room by a Certified Nurse Aide (CNA) because the resident was not acting right. - The resident had green vomit to the right side of his/her face and neck. - The resident was alert, but slow to respond. - The resident was found with a small amount of green leafy plant material that appeared to be marijuana; the resident said he/she consumed some of it by eating it. - The physician was notified with an order to continue to monitor the resident and report concerns to him. (Note: This contradicts interviews with administrator, nursing staff and the resident's physician.) During an interview on 1/26/23 at 4:15 P.M., the DON said: - The resident told her NA A gave the resident marijuana on 1/13/23. - She assessed the resident and he/she was not able to answer her questions and was slow to speak. - She did not call the resident's physician right away, because she thought LPN A did. - She expected LPN A to call the physician when the resident's change in condition was assessed earlier in the day. - She should have called the resident's physician earlier in the day when she found out the resident had eaten marijuana and was sick with vomiting and abnormal vital signs. During an interview on 1/31/23 at 1:00 P.M., LPN B said: - He/she had received in nurses report at 6:00 P.M. on 1/13/23 the resident had consumed marijuana earlier in the day and became ill with vomiting, he/she was lethargic, not able to answer questions clearly. - He/she assessed the resident between 6:30 and 7:00 P.M. and the resident was still lethargic, but able to answer him/her when a question was asked. - He/she checked the resident's blood sugar at 8:00 P.M., the resident was more alert and able to answer questions. - The resident was not able to hold his/her glass for a drink of water; this was abnormal behavior for the resident who normally was able to feed him/herself and hold his/her own glass for drinks. - He/she did not notify the physician because he/she thought the previous nurse had. During an interview on 1/26/23 at 4:10 P.M., the Administrator said: - She expected the nurse who assessed the resident to notify the physician when the resident was found to have a change in condition. -She did not notify the physician, but documented she did. The DON notified the physician. During an interview on 1/25/23 at 9:01 A.M., Physician A said: - He received a call from the DON on 1/13/22 at 9:00 P.M. reporting the resident had ingested marijuana earlier in the day, had vomited but had returned to baseline. - He instructed the DON to continue to monitor the resident and notify him of any changes. - The DON did not tell him the resident had a low oxygen saturation of 65% and was placed on oxygen. - If he had been told the resident's had a low oxygen saturation, he would have directed the facility nurse to send the resident to the Emergency Department (ED) for further evaluation. - The DON did not tell him the resident had decreased cognition and increased confusion. - He would have expected the facility staff to call him immediately about the residents change in condition. - The combination of ingesting marijuana and the resident's scheduled Xanax and Hydrocodone medications were a bad combination and could have been harmful to the resident. - He would have expected the facility staff to call emergency services and send the resident to the ED for further evaluation. MO212731

Based on observation, interviews and record reviews, the facility failed to provide the necessary care and services for two of two sampled residents (Residents #1 and #2) to attain their highest practicable mental and physical well-being when staff failed to do the following: - To develop and implement a [DEVICE] policy and procedure; - To obtain complete dressing change orders; - To obtain a [DEVICE] (a device which uses a controlled amount of negative pressure to promote wound healing) to provide the amount of physician-ordered negative pressure; - To apply wound dressings properly; - And to timely schedule a physician-ordered appointment and then postponed the appointment. The facility census was 44. Review of Venturi [DEVICE] user manual at <http://www.talleygroup.com> showed: - Vacuum level can be adjusted when in stand-by mode and for up to one minute after last button operation when power unit is running using the UP and DOWN arrow buttons. Pressure can be adjusted in 5 mmHg increments between 10 mmHg and 120 mmHg according to treatment requirements, the most widely used being between 60-80 mmHg. The power unit will begin operation at the default pressure of 80 mmHg. The selected vacuum level is shown on the display screen. - Warning and Fault Alarms Low Vacuum - will alert if vacuum pressure falls below minimum allowable levels. Power unit will continue to run whilst this warning is displayed. Check that wound dressing is completely sealed and that all tubing connections are secure. Press the MUTE button to silence/clear alarm. Note that alarm will reoccur if fault persists. If fault re-occurs, contact Talley Medical. - Tube [MEDICATION NAME] - this warning activates when pump demand abruptly ceases. Note that a certain level of flow in the drain is required for the alarm to be active. The warning will occur, for example, in the case of a blocked tube, kinked tube or if the dressing is obstructed. Note that the tube [MEDICATION NAME] alarm can be selected on or off as required. Default is on. 1. During an interview on 2/27/13, at 12:15 P.M., the Director of Nursing(DON) said the facility did not have a policy and procedure to direct staff how to care for a [DEVICE]. Review of Resident #1's hospital's post-operative orders, dated 1/17/13, provided by the facility's DON, showed: - Admit to medical surgical (unit) under Physician E for 23 hours; - [DIAGNOSES REDACTED]. - Keep dressing intact and [DEVICE] on 175 millimeter of mercury (mm/Hg) continuous; - Okay to discharge in the morning with home health (HH); - Follow up appointment needed with Physician A on Monday, 1/21/13, in specialty clinic. - Physician A, the resident's surgeon, signed the orders. Review of Physician A's hospital telephone order, provided by the facility's DON, dated 1/18/13, at 8:20 A.M., showed: - Place hospital [DEVICE] on 175 mm/Hg, continuous suction, moderate intensity; - Apply new dressing per protocol; - Antibiotic beads in place, do not remove; - Upon discharge, clamp tubing and leave dressing in place; - Notify HH of discharge and to present to patient's home for placement of home vacuum unit. Review of the hospital's discharge instructions, dated 1/18/13, showed: - Discharge to home; - Dressing change and wound care, per home health; - Notified home health Staff A on 1/18/13; - Equipment upon discharge - [DEVICE]; - The listed medications included [MEDICATION NAME] / [MEDICATION NAME] 325 milligrams (mg) / 5 mg every four to six hours as needed (PRN) for pain and [MEDICATION NAME] 1 gram (gm) intravenous (IV - given through a vein). - Follow up appointment with Physician A at 10:30 A.M., on 1/23/13; - Did not show dressing change instructions nor [DEVICE] settings. During an interview on 2/27/13, at 12:15 P.M., the DON said: - She did not know anything about a follow up appointment scheduled on 1/21/13, with Physician A. - The resident had an appointment with Physician A for 1/23/13. The facility had a scheduling conflict so we tried to reschedule that appointment. The physician said he/she had to see the resident so we rearranged things and took him/her to the appointment. During an interview on 2/27/13, at 3:00 P.M., Registered Nurse (RN) K, specialty clinic nurse, said Physician A expected facility staff to call the hospital or the specialty clinic for orders if the hospital did not send any wound orders. During an interview on 2/28/13, at 2:05 P.M., the administrator (Adm) said: - Staff could contact the admitting physician for orders. - She expected staff to contact the hospital for specific dressing orders, if the admitting physician did not give those orders. Review of the nurses' notes, dated 1/18/13, through 1/23/13, (date of the specialty clinic appointment) showed no staff documented they called the hospital or the specialty clinic for dressing change orders or [DEVICE] negative pressure settings. During an interview on 2/28/13, at 10:25 A.M., Social Service Designee (SSD) said: - About 4:00 P.M. on 1/18/13, the hospital social worker (SW) called the facility. - The SW said the resident was supposed to be discharged to home with home health, but the hospital did not feel comfortable sending him/her home. The SW asked if the facility would admit the resident that evening. - The SSD called the administrator and she agreed to admit the resident that evening. - The only thing the SW told him/her was that the resident needed a [DEVICE]. - The hospital faxed information to the facility nurses. - The SSD called RN A and asked him/her to order a [DEVICE]. During interviews on 2/25/13, at 2:00 P.M., and 2/28/13, at 12:40 P.M., RN C said: - On 1/18/13, he/she worked as the charge nurse from 6:00 A.M. to 6:00 P.M. - He/she received a report from the hospital staff about the admission. - The hospital staff told him/her the resident had a [DEVICE]. - He/she did not remember them saying anything about what dressing to use, how often to change the dressing, or the [DEVICE] settings. - He/she had not worked with a [DEVICE] "for some time" so RN A showed him/her how to change the dressing. During interviews on 2/25/13, at 9:40 A.M., 2/27/13, at 12:30 P.M. and 1:50 P.M., and 2/28/13, at 11:50 A.M., RN A said: - He/she had already left the facility when the SSD called and told him/her about the new admission and asked him/her to order a [DEVICE]. - He/she called the facility's durable medical equipment (DME) supplier and "just told then I needed a [DEVICE]." - The DME always brought the same brand and model of [DEVICE] and supplied the dressing materials. He/she was familiar with the [DEVICE] and the dressings. - He/she returned to the facility that evening to admit the resident. - The DME driver arrived, looked at the resident's dressing with him/her, and brought in the necessary dressing supplies. - The DME driver told him/her to remember to border the wound (cover the good tissue surrounding the wound with a protective dressing to prevent breakdown) and to put the LipoGel (a hydrogel wound dressing) on the black foam dressing before inserting the foam into the wound. - RN A changed the resident's [DEVICE] dressing that evening because it leaked (he/she defined a leak as a broken seal which would prevent the necessary negative pressure). RN A said he/she applied the LipoGel to the black foam as the DME driver instructed and set the [DEVICE] at 175 mm/Hg. - RN A said he/she did not remember how he/she knew to set the [DEVICE] at 175 mm/Hg. - The hospital discharge orders did not contain dressing orders and the hospital did not send a written prescription for the pain medication. - RN A called Physician F, a facility physician, told him/her about the admission and that he/she had just changed the resident's dressing. RN A asked Physician F when staff should change the dressing and he/she said changing it on Tuesdays and Fridays was fine. RN A asked Physician F for a pain medication order and told the physician the resident had an appointment at the specialty clinic on 1/23/13. - RN A did not ask for orders for setting the amount of [DEVICE] negative pressure. During an interview on 2/28/13, at 1:30 P.M., the DON and RN A said: - RN A said he/she set the [DEVICE] at 175 mm/Hg. - RN A said he/she thought the display panel showed he/she set the [DEVICE] at 175 mm/Hg negative pressure. Review of RN A's admission note, dated 1/18/13, at 6:50 P.M., showed: - Resident arrived by ambulance; - Alert and oriented times three (person, place, and time); - Complaining of left heel pain, changed left heel [DEVICE] as dressing "leaking." - Called Physician F at 9:00 P.M., notified him/her of new admit, asked for pain medication order as the resident rated pain at a nine (on one to ten scale), and received a [MEDICATION NAME] (narcotic pain medication) order. - No documentation about the [DEVICE] negative pressure setting. Review of Physician F's telephone order, dated 1/18/13, showed: - [MEDICATION NAME] 5/500 milligrams (mg) two tablets every 4-6 hours as needed (PRN); - [DEVICE] to left heel change Tuesday and Friday. Review of the nurses' notes, dated 1/18/13 through 2/11/13, showed no staff documented the [DEVICE] negative pressure settings. Review of RN B's nurse's note, dated 1/19/13, at 10:00 A.M., showed Physician F made the initial visit and new orders noted. Review of Physician F's orders, dated 1/19/13, showed: - Medication orders; - Orders for flushing the resident's IV line; - Appointment on Wednesday with Physician A; - No dressing change orders; - No orders for setting the [DEVICE] negative pressure. Review of RN C's nurse's notes, showed: - 1/21/13, at 10:00 A.M. - [DEVICE] continues to left heel with continuous pressure. - 1/22/13, at 1:00 P.M. - [DEVICE] changed and pain medication given after change due to discomfort while doing dressing. - Neither nurse's note showed the [DEVICE] negative pressure setting. During an interview on 2/25/13, at 10:30 A.M., the SSD said: - She scheduled residents' appointments and arranged the transportation. - On 1/23/13, RN A and a certified nurse aide (CNA) took the resident to the appointment. During interviews on 2/25/13, at 11:35 A.M. and 2/28/13, at 11:50 A.M. the DON and RN A said: - The DON said she worked as a charge nurse until she became the DON on 1/24/13. She changed the resident's [DEVICE] dressing on 1/22/13, and did not use the LipoGel. She said RN A called her on 1/22/13, and said to border the wound to the edge and to not apply the LipoGel to the black foam. - RN A said he/she knew to border a wound when applying a [DEVICE]; but did not know to border a wound "to the edge" until the resident's 1/23/12, appointment with Physician A. - RN A said, during the appointment on 1/23/13, Physician A told him/her to not use the LipoGel. He/she did not know to tell the DON to not use the LipoGel on 1/22/13. - The DON said she thought RN A told her to border the wound to the edge and to not use the LipoGel on 1/22/13. - RN A said when the clinic staff removed the resident's dressing the border did not cover the good skin to the edge of the wound. - RN A said on 1/23/13, the only reason he/she went with the resident was because the activity director and he/she were the only staff that could drive the van. RN A said he/she worked as the MDS coordinator, but drove the van if the activity director was not available. - RN A said the clinic nurses instructed him/her on how to border the wound to the edge and bridge the [DEVICE]. He/she then told the facility nurses. - RN A said he/she told Physician A the facility staff changed the dressing on Tuesdays and Fridays; and Physician A said to continue changing the dressing on Mondays, Wednesdays, and Fridays. - The DON and RN A said they had several residents with a [DEVICE], in the past, but none within for at least the last six to eight months. They said the DME supplier provided training on the [DEVICE] and dressings, but they had not had any training for at least a year. - The DON said even if they provided training every January, if they did not have a resident with a [DEVICE] until September, staff would not remember how to apply the dressings and [DEVICE]. She said a [DEVICE] dressing is a specialty and not common knowledge. - RN A said the facility had several new nurses and he/she educated them before they did the dressings. During a telephone interview on 2/25/13, at 8:20 A.M., and 2/27/13, at 3:00 P.M., RN K said: - The specialty clinic looked for facilities with [DEVICE] knowledge. - They said they knew how to do [DEVICE] dressings. - On the first office visit, the foam was in contact with good skin which made the wound larger. - It is basic to all [DEVICE] dressings to drape the good skin and any nurse that did [DEVICE] dressings would know that. - We educated the two staff with the resident and told them they had to drape the wound. Review of Physician A's clinic note, dated 1/23/13, showed: - The resident presents for a follow up after having a partial calcanectomy (surgical removal of a part of the heel bone), ulcer debridement (removal of dead tissue) and [DEVICE] application on 1/17/13. - The facility nurses have been changing the [DEVICE] every other day. - When the resident arrived for the appointment, the [DEVICE] was in place but "improperly applied." The black foam sponge was overlying the skin and had damaged some otherwise healthy surrounding skin and soft tissue. -Upon removing the [DEVICE], the surrounding tissue that was healthy upon leaving the operating room was again necrotic and unhealthy in appearance. This was likely contributed to by improperly placed [DEVICE]. "After debridement, however, I was able to get back down to what appeared to be healthy bleeding granular tissue surrounding the ulceration." - Plan - From soft tissue infection standpoint, his/her foot overall looks much improved. Continue with the intravenous [MEDICATION NAME] until 2/22/13, for a total of six weeks. Continue with [DEVICE] changes Monday, Wednesday and Friday, which will be key to attempting to close such a large deficit. I ordered a Dermagraft (a skin substitute made from human cells placed on a dissolvable mesh material and used to help in wound closure) which we will start applying in two weeks if the wound bed continues to look uninfected. - "I spent a long time with the staff today. The nurses here at (hospital name) spent time educating the nurse who is doing the [DEVICE] change at the facility on proper technique for applying the [DEVICE]." Review of Physician A's progress note, dated 1/23/13, provided by the DON, showed: - Acute osteo[DIAGNOSES REDACTED] left calcaneous status [REDACTED]. - Continue IV [MEDICATION NAME] until 2/22/13; - Chronic diabetic ulcer left heel; - Continue [DEVICE] changes Monday, Wednesday, and Friday at 175 mm/Hg continuous setting; - Follow up in specialty clinic in two week for wound care and possible graft; - Call with questions. Review of Licensed Practical Nurse (LPN) C nurse's note, dated 1/23/13, at 6:00 P.M., showed: - Had appointment with Physician A today; - Continue [MEDICATION NAME] until 2/22/13; - Change [DEVICE] Monday, Wednesday, and Friday; - Follow up with Physician A in two weeks. Review of nurse's note, dated 1/24/13, showed staff documented they reinforced left foot dressing due to [DEVICE] alarming. Staff did not document why the alarm sounded or the [DEVICE] negative pressure setting. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/28/13, showed: - admitted [DATE], from the hospital; - Brief interview for mental status (BIMS) of 15 (a score of 13-15 signified cognitively intact); - Did not reject care; - One Stage IV pressure ulcer (full thickness skin loss with extensive destruction, tissue necrosis (death), or damage to muscle, bone, or supporting structures. Undermining and sinus tracts also may be associated with Stage IV pressure ulcers) present on admission; - [DIAGNOSES REDACTED]. During an interview on 2/28/13, at 11:50 A.M., RN A said: - He/she changed the [DEVICE] dressing on 1/30/13, because the facility had several new nurses who did not know about [DEVICE]. - He/she set the [DEVICE] pressure at 175 mm/Hg. - He/she did not initial the treatment administration record (TAR) on 1/30/13, to show he/she changed the [DEVICE] dressing. Review of the TAR, dated January 2013, showed no staff initialed on Wednesday, 1/30/13, to signify they changed the [DEVICE] dressing. During an interview on 2/25/13, at 11:35 A.M., the DON said she expected staff to sign the TAR when they changed the dressing. Review of RN C's nurse's note, dated 2/4/13, at 10:00 A.M., showed: - He/she documented he/she changed the dressing at this time with resident tolerating well. Wound bed has good tissue as well as 50% slough (dead tissue). Small amount of maceration (soft, white, deteriorating skin around the edges of the wound from soaking in a liquid) around the wound bed. Treatment done as ordered. - RN C did not document the [DEVICE] setting. During an interview on 2/25/13, at 10:30 A.M., the SSD said: - She arranged for the OATS bus to transport the resident to the 2/6/13, physician appointment. - She said no staff accompanied the resident and he/she returned with appointments for 2/8/13, and 2/11/13. During an interview on 2/25/13, at 8:20 A.M., and 2/27/13, at 3:00 P.M., RN K said: - Initially, the facility staff changed the dressings; but when it got so bad, we decided to change the dressings in the specialty clinic. - Facility staff should know how to do [DEVICE] dressings; but if they did not know, they should call. - The facility did not send any staff with the resident for the second appointment (2/6/13). Review of Physician A's progress note, dated 2/6/13, provided by the DON, showed the physician wrote nursing visit orders for Friday, 2/8/13, and Monday, 2/11/13. Review of LPN's A nurse's note, dated 2/6/13, at 9:00 P.M., showed he/she wrote [DEVICE] to stay in place until appointment on Friday (2/8/13). During an interview on 2/28/13, at 11:50 A.M., RN A said: - He/she and the activity director took the resident to the appointment on 2/8/13. - They stayed in the waiting room while the nurses changed the dressing. During an interview on 2/25/13, at 2:00 P.M., RN C said: - He/she had not done [DEVICE] dressings for some time, not since the last facility where he/she worked. - RN A showed him/her how to do the dressing. - When the [DEVICE] showed low pressure, he/she checked the dressing and reinforced it with Opsite (occlusive dressing). Review of RN C's nurse's note, dated 2/10/13, at 10:00 A.M., showed: - Reinforced wound dressing with Opsite due to [DEVICE] "sounding and saying low suction to drsg (dressing)." - He/she did not document the [DEVICE] negative pressure setting. Review of RN C's nurse's note, dated 2/11/13, at 12:00 A.M., showed: - [DEVICE] alarm sounding with printout that suction was low. - Reinforced wound dressing with Opsite until alarm stopped sounding and vacuum was working properly. - He/she did not document the [DEVICE] negative pressure setting. Review of Physician A's clinic note, dated 2/11/13, showed: - The resident came in for a nurse's visit today to have the [DEVICE] changed on the left heel wound. - The nurses became very concerned about the appearance of the wound and asked me to see him/her. - The [DEVICE] was in place incorrectly and it appears not to have been cared for since its last application here at the hospital. - The drainage tube was full and clogged, so there was no active suction. As a result, the fluid buildup around the wound has rendered the graft I put on last week nonviable (dead or dying tissue). - The increased exudates, which was not being suctioned off, also caused the black foam to migrate proximally and injure skin, making the wound larger. - There is now exposed Achilles tendon (connects the heel bone to the calf muscle). - There continues to be no sign of soft tissue infection fortunately; however, the Achilles tendon that is exposed does not look healthy or viable. - Unfortunately, the facility where he/she has been receiving care has not been attending to the wound or [DEVICE] as instructed and further damage has been cause to the soft tissues. - The wound needs to go back to the operating room for aggressive debridement of the Achilles tendon and the further exposed bone. - I am also going to send him/her for x-rays to make sure there are not early signs of gas gangrene going up the calf, as it continues to be tender. During a joint interview on 2/28/13, at 3:00 P.M., RN C and LPN A said: - RN C said when the resident's [DEVICE] alarmed he/she reinforced the dressing. - Both said they never saw anything other than liquid in the [DEVICE] drainage tubing. - Both said the [DEVICE] displayed the pressure setting, but they did not remember the amount of pressure it displayed. Review of the nurses' notes from 1/18/13, through 2/11/13, showed no staff documented the [DEVICE] pressure setting. During an interview on 2/27/13, at 4:30 P.M., DME Office Manager (OM) A said: - He/she previously delivered the [DEVICE] and educated facilities on how to use them. - The DME only supplied Talley Venturi [DEVICE]. - On an initial visit, a salesperson educated facility staff on the [DEVICE]. - The drivers re-educated staff on the functions of the equipment. - The DME provided a wound nurse for education on dressings. - The driver explained the vacuum alarms to facility staff and provided a toll-free number which is answered 24 hours a day, seven days a week. - The [DEVICE]'s liquid crystal display (LCD) display panel showed negative pressure settings and if the unit alarmed it showed the problem. - If the LCD showed "no suction," that meant either no suction or low suction, and staff needed to "trouble shoot" to identify the reason for the alarm. Staff should check for a small hole in the dressing, a tubing issue or canister issue. - The DME attached a placard to each [DEVICE] and provided a user manual in the carry bag. - Instructions for applying the dressings are on the placard. - The DME records did not show any calls from the facility between 1/18/13, and 2/11/13, to report any equipment problems. During an interview on 2/28/13, at 8:25 A.M., DME OM B said: - The [DEVICE] pressure ranged from 10 mm/Hg to 120 mm/Hg before the manufacturer updated the software. - The software update increased the [DEVICE] maximum pressure to 160 mm/Hg. - The vacuum would not supply negative pressure greater than 160 mm/Hg. During an interview on 2/28/13, at 8:25 A.M., DME OM B said: - The DME only carried the Talley Venturi Avanti [DEVICE]. - The [DEVICE] pressure ranged from 10 mm/hg to 120 mm/Hg before the software update. - The software update increased the [DEVICE] maximum pressure to 160 mm/Hg. During an interview on 2/28/13, at 11:50 A.M., the DON and RN A said: - The DON said facility's corporation had a contract with the DME to provide any needed medical equipment. To her knowledge, staff cannot contact other DME suppliers. She said staff must contact the contracted DME for supplies. - Both said they did not attempt to get a different [DEVICE] because they did not know that [DEVICE] supplied a maximum pressure of 160 mm/Hg. - RN A said the nurses at the specialty clinic were not familiar with that brand of [DEVICE]. 2. During an interview on 2/28/13, at 1:40 P.M., the DON said: - Resident #2 had a [DIAGNOSES REDACTED]. - The resident went into the hospital in June or July of 2012, for a second opinion on [MEDICAL CONDITION] and pain control. The physicians could not stent the right leg. - The resident was admitted to hospice in the fall of 2012, for pain control. Review of the resident's quarterly MDS, dated [DATE], showed: - Short-term memory problems; - Moderately impaired cognitive skills for daily decision-making; - One Stage II (Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) pressure ulcer; - One Stage III (Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue) pressure ulcer; - Hospice services; - [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. - 1/6/13, a wound care team order to cleanse the right heel with wound cleanser, apply a nickel size thickness of Santyl (an active enzymatic therapy that removes necrotic tissue from wounds) mixed with [MEDICATION NAME] (antibiotic), cover with alginate (used to absorb drainage), and a bordered dressing. Review of the TAR, dated January 2013, showed staff initialed they applied the wound care team's dressing order dated 1/6/13, to the right heel from 1/7/13, through 1/18/13. Review of the wound care team's consultation form, dated 1/9/13, showed: - A Wagner Grade 2 (deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation) diabetic right heel ulcer measured 3.3 centimeters (cm) by 5.8 cm by 0.8 cm deep. - Slough (dead tissue) covered 100% of the ulcer. - Periwound - red and odorous; - Surgical debridement of tissue down to, and including subcutaneous tissue, extending to viable tissue. - 100% debrided; - Description -improved; - Consulted with facility nurse regarding resident status and plan of care. - Reviewed right heel wound culture as positive for Proteus mirabilis (a gram-negative bacteria) and Kocuria kristinae (gram positive bacteria) resistant [MEDICATION NAME]/sulfamethox, sensitive to [MEDICATION NAME]. During an interview on 2/28/13, at 11:50 A.M., the DON said she called Physician B, the resident's primary physician, on 1/11/13, and he/she ordered Keflex to treat the right heel infection. She said staff started the Keflex that evening (1/11/13). Review of the wound care team's consultation form, dated 1/16/13, showed: - Wagner Grade 2 diabetic right heel ulcer measured 3.2 cm by 6.0 cm by 1.3 cm deep. - Slough covered 75% of the ulcer. - Periwound - red and odorous; - Surgical debridement of tissue down to, and including subcutaneous, extending to viable tissue; - 100% debrided; - Description -worsening. During an interview on 2/28/13, at 1:30 P.M., RN C said: - On 1/18/13, he/she made rounds with Physician B. - Physician B looked at the resident's right heel and said to discontinue the wound care team, get an appointment with Physician C, a podiatrist, and continue the same dressing until the appointment. - He/she did not call Physician B about the resident's 1/31/13, appointment because he/she did not make the appointment. Review of Physician B's progress note, dated 1/18/13, showed: - Remains on Keflex for right heel wound; - Stage II pressure heel (at least). Review of Physician B's handwritten order, dated 1/18/13, showed: - Appointment with Physician C; - Discontinue wound care team. During an interview on 2/25/13, at 9:15 A.M., the DON said staff continued to use the wound care team's 1/6/13, dressing orders from 1/18/13, to 2/4/13, because they did not have any other orders. Review of the TAR, dated January 2013, showed staff initialed they continued to apply the 1/6/13, wound care team's dressing order to the right heel from 1/19/13, through 1/31/13. During an interview on 1/28/13, at 2:05 P.M., the Adm said she expected staff to either write a physician's orders [REDACTED]. Review of the 24 hour report, dated 1/18/13, showed: - Discontinue wound team and wants appointment with Physician C; - Did not show any orders to continue the same dressing orders. Review of RN C's nurse's note, dated 1/18/13, at 4:00 P.M., showed: - Remains on antibiotics for right heel wound; - Physician here and gave orders to discontinue wound care team and for Physician C to see the resident. - Did not show any reference to continuing current wound orders. During an interview on 2/28/13, at 11:50 A.M., the DON said: - She was not in the facility on 1/18/13; - She did the resident's right heel dressing on 1/19/13, and 1/20/13. The ulcer did not necessarily look worse, but the odor was bad. - She worked as a charge nurse until 1/24/13, when she started as DON. During an interview on 2/25/13, at 9:15 A.M., the DON said the SSD made residents' appointments and scheduled transportation. During an interview on 2/25/13, at 9:30 A.M., the SSD said: - Physician B was sure Physician C would come to the facility to see the resident. - She called Physician C's office and the staff said the physician was not there but they would ask him/her. She did not know when she called Physician C's office because she did not make any note about the calls. - Physician C's staff called and said he/she was not able to come to the facility. - She originally made the appointment for 1/31/13. She did not remember why the appointment was so far off. She marked appointments on a monthly calendar, but did not make any other notes. - Staff did not take residents to appointments when the weather was bad or cold. - She marked the appointment on the calendar as rescheduled due to cold and rescheduled the appointment for 2/4/13. She said, "Oh, that's right, she (DON) thought it needed to be sooner, was for the 8th (2/8/13) and changed to the 4th (2/4/13)." During a telephone interview, on 2/22/13, at 9:30 A.M. Physician C's medical assistant said: - Their office routinely scheduled appointments within a day or two of when patients called for an appointment. The only exception was if Physician C was taking continuing education classes; but that was not the case in January 2013. - He/she did not know why the facility made the appointment for 1/31/13. - They would have noted the reason in the resident's chart, but he/she did not have a chart yet. - On 1/31/13, the facility staff called and re-scheduled the appointment for 2/8/13, because of the weather. - The appointment was then moved to 2/4/13. - He/she could not understand why they canceled the 1/31/13, appointment when the resident's heel looked so bad. During an observation and interview on 2/25/13, at 9:15 A.M., the DON did and said: - Pointed to the nurses' station calendar used for residents' appointments. - She said originally, the appointment was for 1/31/13, then rescheduled to 2/8/13. - If the weather is bad, staff did not take residents to appointments. The Adm decided when not to take residents to appointments. - "I was upset, it was too far out and the odor from the heel was bad; and I wanted the appointment earlier." She called and moved the appointment to 2/4/13. - Staff took the resident to Physician C's office on 2/4/13, and the physician admitted the resident directly to the hospital. During an interview on 2/28/13, at 11:50 A.M., RN A said to his/her knowledge, no staff contacted Physician B for dressing change orders nor informed the physician about the 1/31/13, appointment and rescheduling the appointment. During an interview on 2/25/13, at 10:05 A.M., the Adm said: - Staff did not take residents out for routine appointments if the weather was too cold or icy. - Staff told her if residents had scheduled appointments, and she decided if the weather was too bad to take them out. - Staff never told her which residents had appointments. - No staff told her the appointment was for the resident's heel. - Staff did not tell her the resident's heel was bad. - No staff told her that it was not a routine appointment. - She expected staff to tell her if it was not a routine appointment. - She did

This deficiency is uncorrected. For additional information see statement of deficiencies, dated September 11, 2012. Based on observation, interview and record review, the facility failed to assure staff provided necessary treatment and services for one of two sampled residents (Resident #2) with pressure ulcers. Staff failed to provide a pressure relieving cushion in the resident's chair and failed to apply the physician ordered treatment per manufacturer's directions. The facility identified two residents with pressure ulcers. The facility census was 50. 1. Review of the facility's undated policy, entitled "Wound Protocol," showed: - Staff were directed to identify and measure the wound and notify the (attending) physician for treatment orders (including lab work and dietary supplements) and an order for [REDACTED]. - Staff were directed to update the care plan and communicate all information by report sheet and were to communicate all information to aides. - The Wound Protocol did not give staff specific directions related to pressure relief or wound treatments. Review of the manufacturer's prescribing information for Santyl (wound treatment ointment used to debride or remove slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous) from the wound bed) showed directions to apply the ointment at two millimeter thickness (approximately nickel thickness). 2. During an interview on 11/13/12 at 3:00 P.M., the Minimum Data Set (MDS) coordinator said the facility did not have a Wound Policy. Staff followed the wound team's (Physician B and associated staff's) directions. During an interview on 11/15/12 at 9:16 A.M. the Director of Nurses (DON) said : - Physician's B and associated staff made weekly visits to assess (ordered) resident's wounds and provides direction for wound care. - Registered Nurse (RN) A accompanied Physician B's staff on weekly rounds to see ordered residents, but there was no one staff person responsible for monitoring residents with pressure ulcers. 3. Review of Resident #2's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/24/12, showed: - Short- and long-term memory problems. - Moderately impaired cognitive skills for daily decision making. - Total dependence on staff for bed mobility and transfers. - [DIAGNOSES REDACTED]. - Resident at risk for pressure ulcers. - Resident had one unhealed stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough). - Resident had one unhealed stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at it's base than at the skin surface) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound)) . - Resident had one unstageable pressure ulcer (wound bed covered by slough or eschar (necrotic or dead tissue, black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin)). During an interview on 11/14/12, at 3:05 P.M., the MDS coordinator said hospice provided the resident's geri chair (padded wheelchair that reclines) when he/she went on hospice in the middle of September 2012. Hospice was responsible for the equipment provided. Review of the resident's care plan, dated 10/2/12, showed: - Problem "I have an unstageable wound to my coccyx "(tailbone). - Approaches included treatment as ordered by physician, reposition me every two hours and prn (as necessary), "I have a pressure relieving cushion in my wheelchair" and (Physician B) will be managing my wound care. Review of the resident's Consultation Form - Preliminary Report, completed by Physician B's staff, dated 10/10/12, showed: - The facility asked Physician B's group to see the resident for their opinon on how to manage the resident's wounds. - The resident had a chronic (duration of greater than four weeks) pressure ulcer on his/her pelvis/coccyx. The ulcer was unstageable, with a large amount of purulent (drainage resulting from an infection) and measured 8.0 centimeters (cm) in length, by 4.0 cm in width and 2.5 cm in depth. - The resident had a chronic pressure ulcer on his/her right heel. The ulcer was unstageable with a moderate amount of serous (watery)- sanguineous (bloody) drainage and measured 1.8 cm in length by 3.0 cm in width by 0.1 cm in depth. - Physician B's staff described both wounds as worsening. Review of the resident's coccyx ulcer culture (test which shows the presence of infection in the ulcer) final results, dated 10/24/12 showed the presence of many [MEDICATION NAME] faecalis (bacteria normally found in the intestines, can cause infection in other areas of the body) and many Diptheroids (type of bacteria that resembles the microorganism that causes [MEDICATION NAME]) in the ulcer. Review of the resident's current physician's orders [REDACTED]. - On 10/11/12, orders to cleanse the coccyx wound with wound cleanser (of facility's choice) and apply a mixture of Santyl and [MEDICATION NAME] (antibiotic) cream, then Algisite (wound dressing that forms a gel when in contact with exudate (drainage) and helps create and maintain a moist wound environment and promotes healing) and cover with a dry dressing daily. - On 11/7/12, orders to apply Skin Prep (a liquid film-forming dressing used to prepare the skin so tape will adhere and also used for the skin protective film it produces) to the periwound (around the wound) area of the coccyx. - On 11/13/12, the order to use [MEDICATION NAME] alginated dressing (dressing that maintains a moist wound healing environment and helps protect from bacterial contamination) to coccyx until Algisite is available. Review of the resident's current physician's orders [REDACTED]. - On 10/11/12, the order to cleanse the right heel with wound cleanser (of facility's choice), apply Santyl, Vaseline gauze and cover with dry dressing daily. Review of the resident's current physician's orders [REDACTED]. - On 11/7/12, the physician ordered staff to apply Santyl to the resident's right lateral leg and cover with Vaseline gauze (gauze soaked with Vaseline) and a dry dressing. Review of the resident's current physician's orders [REDACTED]. - On 11/7/12, the physician ordered staff to cleanse the right medial ankle and apply Skin Prep. Observation on 11/13/12, at 8:25 A.M., showed the resident seated in his/her geri chair in the dining room. Observation on 11/13/12, at 9:00 A.M., showed Certified Nurse Aides (CNAs) L and M transferred the resident from his/her geri chair to bed. A vinyl upholstery covered the resident's geri chair and felt firm to touch. The chair contained no pressure relieving cushion. Observation on 11/13/12, at 10:00 A.M., showed Registered Nurse (RN) B provided wound care as follows: - Cleansed the resident's coccyx pressure ulcers. - Mixed approximately five cubic centimeters (cc) of 0.1% [MEDICATION NAME] sulfate cream (an antibiotic) with approximately five cc of Santyl. - Applied the mixture of [MEDICATION NAME] and Santyl to the inside of an open pressure ulcer over the resident's coccyx. Tan slough was visible in the base of the ulcer. Packed the ulcer with [MEDICATION NAME]. Applied skin prep around the wound and covered the wound with gauze dressings. - Cleansed, and applied a thin layer (less than the thickness of a nickel) of Santyl to pressure ulcer's on the resident's right heel and right inner lower leg. Covered both areas with Vaseline gauze and then dry gauze dressings. - Provided treatment to right medial ankle as ordered. During an interview on 11/13/12, at 2:05 P.M., RN B said he/she applied Santyl in a thin layer to the three pressure ulcer sites. "I just used what was left in the tube - there was not a lot." He/she did not know Santyl needed to be applied to the thickness of a nickel. Observation on 11/13/12, at 12:45 P.M., showed the resident seated in his/her geri chair (with no additional pressure relieving cushion) in a slightly tilted back position. This position put the resident's coccyx in contact with the back of the geri chair. Observation and interview on 11/13/12, at 1:47 P.M., showed the resident sat in his/her geri chair. The resident said he/she was waiting to lie down. He/she said his/her bottom hurt when he/she sat in the chair. The chair contained no pressure relieving cushion. Observation on 11/14/12, at 8:38 A.M., showed CNA N and Certified Medication Technician (CMT) A transferred the resident into his/her geri chair. The geri chair was unchanged from 11/13/12; the seat and back cushions were firm and covered with a heavy vinyl material. The chair contained no pressure relieving cushion. During an interview on 11/14/12 at 10:10 A.M., Resident #2 said staff just put him/her to bed. The resident said his/her bottom hurt really bad after he/she sat up very long. The resident said his/her bottom hurt a lot. The resident's wheelchair was beside his/her bed and there was no pressure relieving device in the chair. During an interview on 11/14/12, at 2:50 P.M., following his/her assessment of the resident's pressure ulcers, Advanced Registered Nurse Practitioner (ARNP) A (who worked with Physician B) said: - The resident's geri chair was not appropriate for pressure relief and there should be a pressure relieving cushion in the seat of the chair. - Staff should apply Santyl to the resident's pressure ulcers in a thickness equal to the thickness of a nickel for the treatment to be effective. Review of the resident's Consultation Form, written by ARNP A on 11/14/12, showed: - He/she measured the resident's coccyx pressure ulcer as 4.0 cm in length by 4.0 cm in width by 3.4 cm in depth, with undermining of 1.1 cm. There was a large amount of purulent drainage. - ARNP A now classified the resident's right heel ulcer as due to diabetes. He/she measured the ulcer as 4.5 cm in length by 8.0 cm in width by 0.1 cm in depth. There was a moderate amount of serous-sanguineous drainage. - ARNP A documented two additional ulcers, one on the right medial (inside) ankle and right lateral (outside) leg. He/she described both of these ulcers as caused by diabetes. During an interview on 11/15/12 at 9:16 A.M., the DON said: - Hospice provided the geri chair for the resident's use in September 2012. They provided that chair because of it's ability to allow repositioning of the resident (can be upright or tilted back with a footrest elevated). - Some staff had told her there was a cushion in the chair at one time, other staff are not sure if there is a cushion. The chair itself does not provide pressure relief. - The resident should have a pressure relieving cushion in his/her geri chair. - She would have expected all staff who care for the resident to have noted the chair had no pressure relieving cushion. - Physician B and his/her staff directed wound treatment, but did not direct pressure relief. - She knew Santyl had to be moist or wet to be effective, but did not know the ointment had to be applied at a minimum of nickel thickness to be effective. - The physician did not specify any amount of Santyl to apply. - The facility had recently provided staff training related to pressure ulcer care. The presenter did not cover how to apply Santyl. - Staff should read manufacturer's directions for information related to how to apply a treatment. During an interview on 11/14/12 at 10:10 A.M., Resident #2 said staff just put him/her to bed. He/she got up before breakfast. The resident said his/her bottom hurt really bad after he/she sat up very long. The resident said his/her bottom hurt a lot. The resident's wheelchair was beside his/her bed and there was no pressure relieving device in the chair.

Based on observations, interviews and record review, the facility failed to follow their protocol to prevent the development and progression of pressure ulcers, and provide appropriate treatment, and pressure relief to promote healing. This affected two of 12 sampled residents (Resident #2 and #4). The facility census was 49. Review of the facility's Protocols for "At Risk" Residents, revised [DATE], showed: - Definition: Those residents who score 12 or less on the Braden Risk Assessment; - Care interventions included: Observe the skin at least daily. Assess for reddened areas, [MEDICAL CONDITION], spongy or blistered areas; - Support surfaces: Overlays of foam, gel, air, water can be used, and residents should be evaluated to see if they "bottom out" on that surface; - Friction/Shear: Minimize shear forces by lifting resident during transfer and turning, do not slide. Utilize a draw sheet or transfer board; - Moisture: Incontinence care-Check resident for incontinence at least every two hours; - Nutrition: Lab values will be reviewed by the dietitian. Specific labs to monitor; [MEDICATION NAME], pre-[MEDICATION NAME] and Complete Blood Count (CBC), as ordered by the physician; - Documentation: Ongoing documentation by the charge/treatment nurses in the medical record to describe the effectiveness of interventions and resident's response to therapy. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: - A Brief Interview for Mental Status (BIMS) score of 15, which indicated he/she was cognitively intact; - Independent with bed mobility, dressing, eating and personal hygiene; - Independent with ambulation in his/her room, hallways, and locomotion on and off the unit; - Limited assist of one staff for transfers, toilet use, and bathing; - Continent of urine; - Required scheduled and as needed (PRN) pain medication; - Used non-medication interventions; - Occasionally had pain; - Rated a "2" on ,[DATE] pain scale; - [DIAGNOSES REDACTED]. - No pressure ulcers. Review of the resident's Braden Scale for Predicting Pressure Sore Risk, last updated [DATE], showed a score of 21, or low risk. Review of Magnetic Resonance Imaging (MRI) of the resident's right knee, without contrast, dated [DATE], showed the anterior cruciate ligament is torn. There is severe degeneration of the posterior cruciate ligament with a few intact fibers. Review of Daily Skilled Nurse's Note, dated [DATE], showed the resident had a 3.5 centimeter (cm) x 5 cm. blister on his/her right heel. Review of the resident's significant change MDS, dated [DATE], showed: - A BIMS score of 15, which indicated he/she was cognitively intact; - Required extensive assist of two staff for bed mobility, dressing, toilet use and bathing; - Dependent on two staff for transfers; - Unable to ambulate in room or hallways; - Dependent on one staff for locomotion on and off the unit; - Extensive assist of one staff for personal hygiene; - Required scheduled and as needed (PRN) pain medication; - Used non medical interventions; - Almost constant pain; - Rated a 10 on ,[DATE] pain scale; - [DIAGNOSES REDACTED]. - Stage II pressure ulcer (heel). Review of the resident's Braden Scale for Predicting Pressure Sore Risk, showed staff did not update to reflect the new open areas or significant change in status. Review of Orthopedic Consult, dated [DATE], showed: - Severe [MEDICAL CONDITION] Joint Disease in right knee; - Steroid injection to knee. Review of the Nurse Aide Daily Report Sheet, dated [DATE], showed: - The resident had a shower; - Bottom was red and cream applied. Review of Nursing Shift Report sheet, dated [DATE], showed: - Bottom is open; - Three areas: 0.5 cm. by 0.5 cm.; Review of Fax sent to Physician A on [DATE], showed: - Signs and Symptoms: Three open areas to coccyx; - Request: [MEDICATION NAME] Gel to open areas; - Physician A agreed with the suggestion. Review of Resident #2's Care Plan for Pressure Ulcers (PU's), revised on [DATE], showed: - Problem: A stage II (a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater) to right heel. He/she has a stage III (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling), to his/her coccyx; - Goal: He/she will not have any other skin concerns; - Interventions: Assess for any skin breakdown or reddened areas while providing care; - Report any red areas to the nurse, he/she will report to the physician; - Treatment as ordered by physician; - Heel protectors on when in bed; - Keep his/her heels off the bed when able; - Turn side to side; - Zinc, Vitamin C and protein powder as ordered; - Low air loss mattress on bed; - Labs as ordered; - Weekly skin assessment with measurements; - Report any changes to the physician. Review of the resident's physician's orders [REDACTED]. - No order for [MEDICATION NAME] Gel; - No order for Zinc, Vitamin C or protein powder; - On [DATE]- an order for [REDACTED]. - On [DATE]- an order for [REDACTED]. - [DIAGNOSES REDACTED]. Review of the resident's Treatment Administration Record (TAR), dated [DATE], showed: - treatment for [REDACTED]. - Staff did not initial the treatment to the right heel as done on 16 out of 52 opportunities; - [MEDICATION NAME] Gel to open areas on coccyx not written on the TAR; - treatment for [REDACTED]. Review of the resident's Skin Care Alert sheets, dated [DATE], [DATE], [DATE], and [DATE], showed no skin issues noted during showers. Review of the resident's POS, dated [DATE], showed: - On [DATE], an order for [REDACTED]. - On [DATE], an order for [REDACTED]. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - Vitamin C not initialed as given until [DATE], two days after the order; - Zinc not initialed as given until [DATE]. Review of the resident's TAR, dated [DATE], showed treatment to coccyx and buttock initialed as done two out of five opportunities. Observation on [DATE], at 12:19 P.M., showed the resident in his/her wheelchair in the dining room eating lunch. Observation and interview on [DATE], at 2:05 P.M., showed: - CNA A had resident turned onto his/her left side; - The surveyor asked CNA A what the area was on his/her right hip; - CNA A said there was a mark on it, it looked like an abrasion. - White dressing on coccyx; - Blue and grey Velcro boots on both feet. Review of order form for Low Air Loss (LAL) mattress showed; - It was delivered on [DATE], at 4:40 P.M.; - Comments included: DON and CN will install on [DATE], because the resident was already in bed. Observation on [DATE], at 6:00 P.M., showed the resident in bed on his/her back. Observation on [DATE], at 8:37 A.M., showed the resident in bed on his/her back. Observation on [DATE], at 9:10 A.M., showed the resident in bed on his/her back with his/her eyes closed. Observation on [DATE], at 9:37 A.M., showed the resident awake with the head of the bed elevated eating breakfast. Observation on [DATE], at 1:10 P.M., showed MDS Coordinator changing the resident's pressure mattress to a LAL mattress. Observation on [DATE], at 5:30 A.M., showed the resident in bed on his/her back. The LAL mattress did not look inflated. The mattress did not contain air and was flat against the bed springs. During an interview on [DATE], at 11:50 A.M., the resident told the surveyor that his/her bed was not very comfortable. Observation and interview on [DATE], at 11:50 A.M., showed RN A did the treatments to the coccyx and buttocks; - LAL mattress did not look inflated; - NA B moved the bed away from the wall and turned the resident onto his/her left side; - RN A said the coccyx was a stage IV and the left buttock was unstageable; - PU to coccyx and buttocks acquired in-house; - Two open areas on the right buttock, one on the coccyx and one on the left buttock; - Area on the right hip is new and measured 4 cm. x 0.5 cm.; - RN A said he/she thought the area on the right hip was caused from the lift pad, the long area appeared to be a blister; - The right heel measured 4.5 cm. x 2.9 cm.; - RN A said the loose, dry stuff is coming off, it's a blister; - RN A adjusted the controls on the bed and set it on 285 from 240. During an observation and interview on [DATE], at 12:40, the DON said: - Surveyor asked the DON to check the bed to see if it was properly inflated; - RN A may have increased the number to make it firmer so he/she could do the resident's treatment; - The DON turned the bed down from 285 to 185; - The DON discovered that the Cardiopulmonary Resuscitation (CPR) plug had been pulled and the bed was not inflated. The LAL mattress did not contain air and was flat against the bed springs. During an interview on [DATE], at 1:10 P.M., CNA G said: - He/she marks any new areas on the skin care sheets; - The resident gets his/her showers on Monday and Thursdays; - The resident had his /her shower on [DATE], and area on right hip was reported to the Charge Nurse (CN), and the Director of Nursing (DON). During an interview on [DATE], at 2:45 P.M., the resident said his/her bed was a lot more comfortable, felt so much better. During an interview on [DATE], at 3:35 P.M., the DON said: - The immobility of the resident's right leg caused the blister on his/her heel; - We use the Braden Scale to determine if a resident is at risk for skin breakdown. During an interview on [DATE], at 3:40 P.M., the DON said the shower aide uses the skin care sheets and only marks new areas. Review of the Weekly Skin Report, dated [DATE], showed; - PU on coccyx measured 3.5 cm. x 2 cm.; - PU on right buttock measured 2 cm. x 2 cm.; - PU on left buttock measured 0.5 cm. x 0.8 cm.; - Treatment included: debrided by Physical Therapy, Iodosorb, Algisite and dry dressing; - Blister reabsorb on right heel and measured 3.5 cm. x 4 cm. - Treatment to right heel included skip prep and pressure relief. Observation on [DATE], at 8:20 A.M., showed the resident sitting up in bed and attempted to eat her breakfast but required assistance from staff. Observation and interview on [DATE], at 10:27 A.M., showed: - The DON pulled back the resident's covers and said he/she was wet; - The resident said he/she asked the staff for the bedpan, but no one came; - The dressing on the coccyx was wet; - RN A said Physical Therapy debrided the coccyx on [DATE]; - RN A measured and described the PU's as follows: Left upper buttocks measured 2 cm. x 2.5 cm with black/brown eschar (dead or devitalized tissue that has lost its usual physical properties and biological activity),on the far right (laterally and medially), and yellow slough (avascular tissue in the process of separating from the viable portions of the body and is usually light colored) on the bottom and medially. The coccyx measured 3.7 cm. x 1.5 cm., the top with dark brown eschar and yellow slough at the bottom. The right buttock measured 1.2 cm. x 1.2 cm. at the bottom and the top measured 1 cm. x 0.6 cm. Both had yellow slough with no odor noted. The lower right buttock measured 3.5 cm. x 2 cm. with redness. The peri wound area measured 9.5 cm. x 11.5 cm. RN A said the two wounds with eschar are not stageable and the two with slough are Stage III. During an interview on [DATE], at 11:25 A.M., RN A said: - The resident went to an area hospital on [DATE], for three days and then transferred to a city hospital; - Returned on [DATE]; - The resident has not ambulated since [DATE]; - On [DATE], had three open areas on coccyx; - Did not measure the three open areas on the coccyx until [DATE]. The coccyx measured 3 cm. x 1 cm., the right buttock measured 2 cm. x 1 cm., the bottom right buttock measured 0.7 cm. x 1 cm., and the left buttock measured 1 cm. x 1.5 cm.; - Normally the nurses document the findings in the nurses notes, but no one did; - Physician A made rounds this month, but don't believe that he/she assessed the resident's wounds; - If a treatment is not working, will usually change it within a week or so; - The staff are supposed to notify nursing about any skin issues. During an interview on [DATE], at 11:25 A.M., the DON said: - Would expect the nurses to document an assessment in the nurse's notes and notify the physician if they note changes or discover new areas; - Had an order for [REDACTED]. - Therapy found the blister on the resident's right heel; - If a resident has a wound and there is no slough, we use [MEDICATION NAME]; - The physician is notified by phone, usually, and we tell him/her the measurements and get our orders; - We do not document what we tell the Physician. During an interview on [DATE] at 12:55 P.M., Physician A said: - He/she feels like the facility does have a wound care protocol; - He/she believes the nurses do a good job; the facility has not had any significant wounds; - He/she is not surprised that the resident has had a decline in his/her condition. During an interview on [DATE] at 12:55 P.M., the DON said: - The staff should be monitoring the LAL mattresses when they are performing cares; - If the staff notice any problems with the LAL mattresses, they should report it to the CN or to me; - We do not have any forms in place to monitor the LAL mattresses. During an interview on [DATE] at 1:50 P.M., the Physical Therapy Aide (PTA) A said: - Physical Therapy (PT) is currently doing E-Stim to promote circulation around the wound; - Registered Physical Therapist (RPT) did an evaluation on [DATE] and did not debride the wound because the resident is diabetic and if we removed the eschar, it could make the wound worse; - The resident was on therapy, but we discharged him/her because the pain was intolerable; - His/her last therapy treatment was on [DATE]; - The resident is on the Restorative program now. 2. Review of Resident #4's Admission MDS, dated [DATE] showed: -A [DIAGNOSES REDACTED]. -A Brief Interview of Mental Status (BIMS), showed the resident was cognitively intact. -The resident had no pressure ulcers upon admission. Review of the resident's Braden scale for predicting pressure sore risk dated [DATE] showed a score of 19 which showed the resident at low risk. Review of the resident's nursing notes documented by the Director of Nursing (DON) dated [DATE] showed: -Intact blisters on bilateral heels, left 4.5 centimeters x 8.5 centimeters, right back 3 centimeters x 2.5 centimeters, and right lateral 2 centimeters x 3.5 centimeters. Faxed physician and notified resident ' s daughter by phone. Daughter states the resident ' s shoes had insoles removed as resident didn ' t like them, she stated they might have rubbed on heels. These shoes were not put back on the resident and gripper socks were used instead. Skin prep applied to area per protocol. Resident denied pain to area. Staff was instructed to float heels in recliner and bed. Review of the resident's pressure ulcer care plan dated [DATE] showed: - Stage II blisters on both heels. -Free float heels. -No shoes, only gripper socks. -Turn and reposition every two hours as needed. The resident was able to turn him/herself in bed with minimal difficulty. Review of the resident ' s weekly skin report dated [DATE] showed: -Stage II blister left heel 4.5 centimeters x 8.5 centimeters. -Stage II blister right heel 3 centimeters x 2.5 centimeters. -Stage II blister right heel 2 centimeters x 3.5 centimeters. -Treatments- skin prep and pressure relief. Review of the resident's monthly nurse's summary dated [DATE] showed no skin conditions. Review of the resident's August and September physician's orders [REDACTED]. Review of resident's nursing notes dated [DATE], late entry for [DATE] showed: -New orders to treat bilateral heels with Iodesorb/Algisite and cover with dry dressing. Staff continue to float heels on pillow in bed and chair, resident to wear only gripper socks. Observation on [DATE] at 2:00 P.M., showed that the resident sat in his/her recliner with foot rest out. Both heels rested on the foot rest. During an interview on [DATE] at 3:50 P.M., the DON said we are keeping the resident ' s heels pressure free, giving the resident a protein powder supplement and a multi-vitamin supplement. During an interview on [DATE] at 4:05 P.M., the resident said there was some pain when the nurses change the bandage but there was more pain when his/her heels touched the pillow. Observation on [DATE] at 5:30 A.M., showed the resident sat in his/her recliner with a pillow positioned under his/her calves but heels still touched the recliner foot rest. During an interview on [DATE] at 5:35 A.M., Certified Nurse's Aide (CNA) J said the resident wanted to get out of bed around 3:00 A.M. Sometimes the resident wants to get up in the night. He/she made sure his/her heels were floated. During an interview on [DATE] at 3:15 P.M., the DON said we treat each resident with wounds specific to their needs. Observation on [DATE] at 10:00 A.M., showed the resident sat in his/her recliner and both heels rested on the extended foot rest. During an interview on [DATE] at 10:15 A.M., CNA A said he/she floated the resident's heels. It looks like his/her pillow slid down. During an interview on [DATE] at 1:30 P.M., the DON said our CNA's were suppose to float the resident's heels and check every two hours to check to make sure the heels were still floated. They should reposition the resident every two hours. During an interview on [DATE] at 1:30 P.M., RN A said he/she usually did rounds and monitored to make sure heels were floated and the resident was repositioned as best as he/she could. During an interview on [DATE] at 1:30 P.M., the DON said the resident's care plan should be followed on repositioning to prevent pressure ulcers. The CNA's have access to the care plans. Observation on [DATE] at 2:15 P.M., showed the resident sat in his/her recliner in the upright position. His/her heels touched the extended foot rest.