Every finding on record at Jefferson City Manor Care Center

Based on interview and record review, facility staff failed to conduct and document an annual facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies as required. The facility census was 70.1. Review of the facility's Facility Assessment policy, revised October 2018, showed the facility assessment is conducted annually to determine and update the capacity to meet the need of and competently care for the residents during day-to-day operations. Determining our capacity to meet the needs of and care for the residents during emergencies is included in this assessment. Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific need of the residents. The team responsible for conducting, reviewing and updating the facility assessment includes the administrator, a representative for the governing body, the medical director, the director of nursing services, the infection preventionist, and the director from the following departments: environmental services, physical operation, dietary services, social services, activity service and rehabilitative services.Review of the facility assessment, updated 4/7/26, showed the facility assessment had not been reviewed by the QAA and Quality Assurance and Performance Improvement (QUAPI) team since February 2025.During an interview on 4/7/26 at 11:18 A.M., the administrator said he/she did not update the facility assessment today and has not had a full annual facility assessment since he/she took over in September 2025. He/She said he/she does not know when the annual is due but probably February 2026 and it was not completed.Complaint #2973700

Based on observation, interview, and record review, facility staff failed to prevent the spread of bacteria and other infection causing contaminants during the provision of care and treatments for three residents when staff failed to remove soiled gloves and/or properly wash their hands, failed to place blood sugar testing supplies and the glucometer ( a device for monitoring blood sugars) on a protective barrier and failed to for clean and sanitize the multiple use resident glucometer before and after each use for three residents (Resident #1, Resident #2 and Resident #3) out of three. Facility census was 71.1. Review of the facility's Handwashing/Hand Hygiene policy, dated 2001, showed facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel and residents;-Wash hands with soap (antimicrobial or non-antimicrobial) and water when hands are visibly soiled;-Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before and after direct contact with resident, before performing any non-surgical invasive procedures, before donning sterile gloves, after contact with a resident' intact skin, and after contact with blood or bodily fluids. 2. Review of the manufacturer's instructions, Cleaning and Disinfecting the Meter, undated, showed to minimize the risk of transmission of blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below. The meter should be cleaned and disinfected after use on each patient. The Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed;-Wipe the entire surface of the meter three times horizontally and three times vertically using one towelette to clean blood and other body fluids;-Pull out one new towelette and wipe the entire surface of the meter three times horizontally and three time vertically using a new towelette to remove blood-borne pathogens;-Allow exterior to remain wet for one minute, then wipe the meter using a dry cloth. Review of the facility's Obtaining a Fingerstick Glucose Level policy, dated 10/2011, showed the purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. Disinfected glucometer with sterile lancet; or single-resident use spring-loaded or automatic or safety type lancet. Always ensure blood glucose meters intended for reuse are cleaned and disinfected between resident use;-Wear clean gloves;-Clean and disinfect reusable equipment between uses according on the manufacturer's instructions and current infection control standards of practice;-Remove gloves and discard into designated container;-Wash hands;-The policy did not contain direction for staff regarding placing the glucometer and testing supplies on a protective barrier. 3. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as moderately cognitively impairment with a diagnosis of Diabetes Mellitus.Observation on 04/02/26 at 9:12 A.M., showed Licensed Practical Nurse (LPN) A removed the glucometer from the medication cart and placed it directly on the cart without a protect barrier. He/She entered resident's room to give the resident his/her medication and to check his/her blood sugar. LPN A did not wash his/her hands and applied gloves. LPN A checked the resident's blood sugar, placed the glucometer on the cart without a protective barrier, and did not sanitize the glucometer, he/she placed the glucometer in the basket with other blood sugar supplies. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed staff assessed the resident with a severe cognitive impairment and a diagnosis of Diabetes Mellitus. Observation on 04/02/26 at 9:51 A.M., showed LPN A enter resident's room to check his/her blood sugar. He/She put on gloves, placed the glucometer, alcohol pad, and lancet needle directly on the bedside table without a protective barrier. He/She attempted to take the resident's blood sugar but was unable to get a sample. He/She removed his/her gloves, gathered a new lancet needle and alcohol pad, and put on new gloves without performing hand hygiene. He/She laid the alcohol pad and lancet needle on the resident's bed. He/She used the lancet needle to obtain blood for the test and used his/her finger to remove the excess blood from the resident's finger. LPN A removed one of his/her gloves that he/she used to wipe the excess blood from the resident's finger, and placed the glucometer on the resident's bed, then picked up the glucometer with his/her ungloved hand. LPN A left the resident's room and placed the glucometer directly on the medication cart without a barrier. He/She pulled medication out of the medication cart for the resident, without performing hand hygiene, and gave the resident his/her medication. He/She used an alcohol pad to clean the glucometer and place it back in the medication cart. During an interview on 04/02/26 at 10:07 A.M., LPN A said he/she wiped the glucometer with an alcohol pad between uses on each resident. He/She said he/she believed the facility wanted him/her to use the purple disinfectant wipes to clean the glucometer, but there were no gloves available on the medication cart, and he/she was scared to use the wipes without gloves. LPN A said he/she did not know the disinfectant instructions from the manufacturer. He/She said the concern with not properly sanitizing the glucometer was the potential to spread blood borne illness from resident to resident. LPN A said he/she knew he/she should use a protective barrier for the glucometer and supplies due to the potential to spread disease and illness. He/She said he/she did not use hand hygiene after touching the resident's blood and between glove changes. LPN A said he/she realized he/she missed hand hygiene opportunities and there was the potential to transfer disease and illness by not performing hand hygiene between tasks. He/She said he/she was stressed and filling in for the Certified Medication Technician (CMT), in addition to doing his/her nursing responsibilities, so he/she knew he/she made errors. 4. Review of Resident #4's quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and had a diagnosis of Diabetes Mellitus. Observation on 04/02/26 at 11:26 A.M., CMT B exited a resident's room with the glucometer and laid the glucometer directly on the medication cart. He/She put a new strip in the glucometer, gathered the alcohol and lancet needle, then laid them on the medication cart without a protective barrier. He/She entered the resident's room to obtain the resident's blood sugar, exited the resident's room and placed the glucometer on the medication cart without a protective barrier. He/She used an alcohol pad to wipe down the glucometer and placed it in the medication cart. During an interview on 04/02/26 at 11:30 A.M., CMT B said the glucometer was used for more than one resident and staff are directed to sanitize the glucometer between residents. He/She said he/she mostly used alcohol wipes, but they did have sanitizing wipes available. He/She said he/she did not know the manufacturer instructions for sanitizing the glucometer. CMT B said he/she never used a protective barrier for the glucometer or supplies, and he/she was never trained to use a protective barrier. He/She said the concern about not following the sanitation instructions is the equipment could be considered unsanitary. 5. During an interview on 04/02/26 at 3:12 P.M., the administrator said the blood sugar testing supplies should be placed on a clean surface or protective barrier to avoid an infection control issue. He/She said staff are educated to perform hand hygiene before starting a blood sugar check and change gloves and perform hand hygiene during the process, and once done, remove his/her gloves and complete hand hygiene to prevent a possible infection control issue. He/She said staff are directed to follow manufacturer directions for disinfecting a glucometer if used on more than one resident. He/She said staff are to use the wipes in the purple tub to clean the glucometer. He/She said alcohol wipes are not sufficient to disinfect a glucometer and was a possible infection control issue.During an interview on 04/02/26 at 3:13 P.M. the Director of Nursing (DON) said blood sugar testing equipment should be placed on a clean surface or protective barrier to prevent infection control issues. He/She said staff are directed to use hand hygiene before doing using the lancet, change gloves and perform hand hygiene during the process and once done with the process, staff should remove gloves and perform hand hygiene to prevent possible infection control issues. He/She said staff if staff used a glucometer for more than one resident, he/she expected staff to follow manufacturer directions for sanitizing. He/She said staff are required to use the wipes in a purple tub. He/She said using an alcohol wipe would not disinfect the glucometer, which is an infection control issue. Complaint #2798647

Based on interview and record review, facility staff failed to complete a baseline care plan assessment within 48 hours for one resident (Resident #1) out of three sampled residents. The facility census was 70.1.Review of facility's Baseline Care plan policy, revised December 2016, showed a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. To assure the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission.2. Review of Resident #4's facility face sheet showed the resident admitted to the facility on [DATE].Review of the resident's base line care plan showed the resident admitted to the facility on [DATE] and staff submitted the baseline care plan on 3/15/26.During an interview on 4/7/26 at 11:18 A.M., the Administrator said he/she did not realize the resident's baseline care plan was late, he/she said the baseline care plan should be completed within forty-eight hours. He/She said there was a full-time MDS and care plan staff but he/she has been pulled to be a floor nurse because of short staffing.During an interview on 4/20/26 at 4:07 P.M., the MDS Coordinator said he/she has been pulled to the floor to work as a registered nurse (RN) and it has caused her to fall behind on care plans. He/She said there was also an influx in admits around this time that caused an overload of work. Complaint # 2973819

Based on interviews and record review, facility staff failed to develop an individualized comprehensive care plan for one resident (Resident #4's) out of 3 sampled residents. The facility census was 70.1. Review of the facility's Care Plan Comprehensive Person-Centered Policy, revised December 2016, showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: Include measurable objectives and timeframes, Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment, Include the resident's stated goals upon admission and desired outcomes. Reflect the resident's expressed wishes regarding care and treatment goals, Reflect treatment goals, timetables and objectives in measurable outcomes. 2. Review of Resident #4's Comprehensive Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/30/26, showed staff assessed the resident as cognitively intact with a diagnosis of anxiety, cardiac arrythmia, vitamin deficiency and pain. Review of the resident's face sheet showed the resident admitted to the facility on [DATE].Review of the resident's Care plan, reviewed 4/7/26, showed staff documented the resident is a smoker. The resident will not suffer injury from unsafe smoking practices through the review date. The resident is able to smoke unsupervised. The resident's care plan did not contain documentation in any other care areas to include Activities of Daily Living (ADL's), behaviors, and diagnoses.During an interview on 4/7/26 at 11:18 A.M., the administrator said the resident should have a much more comprehensive care plan than just his/her smoking instructions. He/She said there was a full-time MDS and care plan staff but he/she has been pulled to be a floor nurse because of short staffing.During an interview on 4/20/26 at 4:07 P.M., the MDS Coordinator said he/she has been pulled to the floor to work as a registered nurse (RN) and it has caused her to fall behind on care plans. He/She said there was also an influx in admits around this time that caused an overload of work. He/She said the care plan is person centered but a few of the things she documents on most residents care plans are code status, activities, diagnoses, behaviors, BIMS (brief interview mental status, braden assessment (for pressure ulcer risk), activities of daily living (ADLS) and then they are updated quarterly or as needed.Complaint #2973819

Based on interview and record review, facility staff failed to notify the physician and resident's responsible party after allegations of abuse for one resident (Resident #1) out of one sampled resident. The facility census was 62.1. Review of the facility's Change in a Resident's Condition or Status policy, revised February 2021, showed facility staff will promptly notify the physician and resident representative of changes in the resident's medical/mental condition and/or status.2. Review of Resident #1's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/09/25, showed staff assessed the resident:-Severe cognitive impairment, -Daily rejection of care;-Always incontinent of bowel and bladder;-Diagnosed with non-Alzheimer's dementia, depression.Review of the resident's progress notes, dated 1/27/26 to 2/4/26, did not contain documentation the physician or family had been notified CNA A slapped the resident on the leg while he/she provide his/her care. During an interview on 2/4/26 at 10:59 A.M., the resident's family member said he/she was not notified by facility staff related to the allegation of employee to resident abuse until he/she visited the resident the following day and the administrator asked him/her if he/she knew about the abuse.During an interview on 2/4/26 3:35 pm, the administrator said he/she expected the physician and family to be notified if there are allegations of employee to resident abuse, but he/she could not locate a progress report showing the physician or resident representative had been notified. The administrator reviewed the incident report that surveyor did not have access to, and it also did not contain documentation that the physician or family were notified. During an interview on 2/26/26 at 1:30 P.M., the Nurse Practitioner (NP) said he/she had no record and did not receive a call from the facility related to a CNA who slapped the resident while the resident received care. Complaint # 2727980

Based on observation, interview, and record review, facility staff failed to prevent physical abuse to one resident (Resident #1) out of four sampled residents, when Certified Nursing Assistant (CNA) A slapped Resident #1 on the leg while he/she provided care. The facility census was 62.The administrator was notified on 2/11/26 of past Non-Compliance which occurred on 0/27/26 when the administrator began in-servicing all staff 1/28/26 on abuse and neglect after he/she substantiated a report of abuse that CNA A slapped the resident on the leg while he/she provided care.1. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program and Clinical Protocol policy, revised April 2021, showed the facility will develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents.Review of the facility's investigation, 1/28/26, showed staff notified the administrator Nurse Assistant (NA) B witnessed CNA A hit the resident on the leg five times. Witness statements were collected, and resident interviews obtained. Based on the investigation it was found substantiated, and CNA A was terminated on 1/28/26. Administrator completed in-services with staff on abuse neglect 1/28/26. 2. Review of Resident #1's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/09/25, showed staff assessed the resident as:-Severely cognitively impaired;-Daily rejection of care;-Always incontinent of bowel and bladder;-Diagnosed with non-Alzheimer's dementia, and depression.Review of the resident's Care Plan, dated 04/08/24, showed staff assessed the resident as: -Impaired cognitive function/dementia or impaired thought process;-Activities of Daily Living (ADL) self-care performance deficit, -Physically aggressive; -Bowel and bladder incontinence.Review of the resident's progress notes, dated 1/24/26 to 1/28/26, did not contain documentation that CNA A slapped the resident on his/her leg while he/she performed care. 3. Review of CNA A personnel records showed he/she completed and signed new hire orientation on 5/19/25 which included Abuse and Neglect training. Review of the training log showed the CNA attended an additional Abuse and Neglect in-service on 10/16/25.During an interview on 2/4/26 at 12:15 P.M., Resident #4 said he/she is Resident #1's roommate. He/She said he/she has not seen anything because the curtain is closed but he/she could hear it. During an interview on 2/4/26 at 12:46 P.M., CNA A. said he/she has been employed at facility since June, 2025. CNA A said on 1/27/26 at 10:45 P.M., he/ she was helping Resident #1 to bed. He/Said the resident always resists. The resident's brief was soaked with urine. CNA A said he/she had to work alone because there was no one to help him/her. He/She struggled to remove the wet brief and wipe the resident clean. CNA A said he/she instructed the resident to open her legs, but he/she would tighten them. CNA A said he/she pushed the brief through her legs. The resident was in bed and he/she was washing cups at the sink in the room when the charge nurse, Registered Nurse (RN) C, from the other hall came into the room and told him/her it had been reported he/she hit the resident five times. He/She told RN C he/she has never hit or slapped anyone. He/She said he/she was surprised by the accusation. CNA A said he/she was embarrassed when told he/she could no longer work at the facility because he/she had abused a resident. During an interview on 2/4/26 3:35 pm, the administrator said he/she received a call around 11:00 P.M. on 1/27/26 from RN C that NA B witnessed CNA A strike Resident #1 five times on the leg while performing pedicare. The Administrator said CNA A was immediately suspended pending investigation. The Administrator said based on the investigation, he/she believed CNA A did not have an intent to harm, but that CNA A did not show a sufficient understanding of the difference between the potential harmful act and a physical prompt to gain cooperation from a resident. CNA A was terminated on 1/28/26. The Administrator said all staff receive Abuse and Neglect training upon hire, and an inservice was given on 10/16/25. The Administrator said though he/she has a reasonable doubt the circumstances around the incident met the facility policy's definition of abuse, he/she stands by the decision to terminate the employee to prevent future occurrences. The Administrator said he/she can't say it was deliberate, given the employee's apparent lack of understanding of inappropriate action, there was a risk to residents. During an interview on 2/5/26 at 3:30 P.M. NA B said he/she has been employed at the facility since 12/17/25. NA B said he/she received Abuse/Neglect training during orientation. NA B said he/she learned if you see something, say something. NA B said on 1/27/26 at 10:30 P.M., he/she was walking down the 300 Hall on the way to the laundry room, and as he/she was passing room [ROOM NUMBER], he/she heard a smacking noise. He/She said the sound was clear because the hall was very quiet at that time of night. The NA said the slaps sounded forceful since he/she could hear them in the hall. He/She looked into the room without entering and saw the resident hit CNA A, then CNA A hit the resident on the outer part of her left thigh with an open hand. The resident was on his/her right side at the time wearing a brief. The resident hit CNA A again, and CNA A hit the resident again. He/She believed, between what he/she heard and saw, the resident was hit or slapped a total of five times. NA B said he/she has worked with this resident before and knows he/she is a fighter when care is being performed, but you are not supposed to hit them back. NA B said when CNA A saw NA B looking into the room, CNA A's eyes got big. NA B immediately went to tell his/her charge nurse, RN C. NA B said RN C said let's go see what is going on. When NA B and RN C returned to room [ROOM NUMBER], CNA A was still in the room, and the resident was lying quietly in bed. NA B said RN C asked CNA A what was happening and was told he/she was trying to lay the resident down, but the resident was fighting him/her. Complaint #2727980

Based on interview and record review, facility staff failed to replace the resident's wanderguard (a device used to protect at-risk-residents from wandering outside a facility without staff's awareness) after staff identified the resident did not have a wanderguard in place as ordered by the physician, which resulted in the resident leaving the facility without staff's knowledge before he/she was taken back to the facility by a member of the community. The facility census was 68.The administrator was notified on 12/12/25 of past Non-Compliance, which occurred on 12/05/25 when staff reported the resident had left the facility without staff knowledge. Staff immediately assessed the resident for physical injuries and presence of the wanderguard, replaced the wanderguard, initiated new orders from the physician to increase the wanderguard checks from two to six times daily, in-serviced staff on wanderguard placement checks and to replace if a resident's wanderguard is missing, and updated the resident's care plan. 1. Review of the facility's Wandering and Elopements policy, revised 03/2019, showed the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 2. Review of the facility's Staff Quick Guide to the Resident Guard System, undated, showed staff are directed: -Residents will be evaluated for their elopement risk on admission and periodically;-Any resident that is determined to be an elopement risk will have a resident tag placed on them;-The device must be activated by the charge nurse prior to placing it on the resident;-If a resident attempts to elope from the building, the charge nurse will contact the physician, Director of Nursing (DON), and administrator, and a resident tag will be placed on the resident immediately. 3. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 09/26/25, showed staff assessed the resident as moderate cognitive impairment, independent with ambulation, and no wandering behaviors in the seven-day review period. Review of resident's face sheet, dated 12/11/25, showed the resident admitted to the facility on [DATE] with primary diagnosis of Alzheimer's Disease, and is his/her own responsible party. Review of the resident's care plan, revised 06/14/25, showed staff assessed the resident requires a wanderguard to his/her left ankle related to resident wanders aimlessly. Review of the resident's quarterly elopement/wandering assessment form, dated 06/15/25, showed staff assessed the resident wanders, and with a history of or attempted elopements. Review of the resident's quarterly elopement/wandering assessment form, dated 09/24/25, showed staff assessed the resident wanders, and with a history of or attempted elopements. Review of the resident's physician order sheet (POS), dated 10/01/25 through 10/31/25, showed an order for wanderguard bracelet to left ankle, check placement every shift and as needed, start date of 06/15/25. Review of the resident's progress notes, dated 10/01/25 through 10/31/25, showed staff documented the resident did not have a wanderguard on 10/04/25, 10/05/25, 10/06/25, 10/08/25, 10/09/25, 10/10/25, 10/14/25, 10/18/25, 10/19/25, 10/22/25, 10/23/25, 10/27/25, and 10/28/25. The record did not contain documentation staff replaced the wanderguard, or reason the resident did not have a wanderguard on. Review of the resident's POS, dated 11/01/25 through 11/30/25, showed an order for wanderguard bracelet to left ankle, check placement every shift and as needed, start date 06/15/25. Review of the resident's progress notes, dated 11/01/25 through 11/30/25, showed staff documented the resident did not have a wanderguard on 11/01/25, 11/02/25, 11/05/25, 11/06/25, 11/07/25, 11/10/25, 11/11/25, 11/12/25, 11/13/25, 11/14/25, 11/15/25, 11/16/25, 11/18/25, 11/19/25, 11/20/25, 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/25/25, 11/26/25, 11/29/25, and 11/30/25. The record did not contain documentation staff replaced the wanderguard, or reason the resident did not have a wanderguard on. Review of the resident's POS, dated 12/01/25 through 12/04/25, showed an order for wanderguard bracelet to left ankle, check placement every shift and as needed, start date 06/15/25. Review of the resident's progress notes, dated 12/01/25 through 12/04/25, showed staff documented the resident did not have a wanderguard on 12/01/25, 12/02/25, 12/03/25, and 12/04/25. The record did not contain documentation staff replaced the wanderguard, or reason the resident did not have a wanderguard on. Review of the facility's investigation, dated 12/05/25, showed staff documented a member of the community saw the resident sitting on a curb on a residential street close to the facility and transported the resident back to the facility. The resident had been outside the facility for approximately one hour, was dressed appropriately for the weather, assessed with an abrasion to his/her buttock, and did not have a wanderguard in place when he/she returned to the facility. During an interview on 12/11/25 at 12:30 P.M., the DON said he/she was not aware the resident did not have a wanderguard prior to 12/05/25. The DON if a nurse identified and documented the resident did not have a wanderguard in place, he/she would expect the nurse to replace the wanderguard. During an interview on 12/11/25 at 2:12 P.M., Registered Nurse (RN) A said he/she was the DON until 11/26/25 and was never notified the resident did not have a wanderguard in place. RN A said the nurses are responsible to check wanderguard placement and document on the TAR, so if a nurse identified the resident did not have his/her wanderguard in place, he/she would expect the nurse to replace the wanderguard. During an interview on 12/11/25 at 3:24 P.M., the administrator said shortly after he/she came to the facility, someone had mentioned the resident's wanderguard was missing, he/she suggested the nurse notify the DON to reassess the resident, contact the physician to replace the wanderguard if needed, but he/she did not follow up and was not aware the resident did not have a wanderguard in place prior to leaving the facility on 12/05/25. The administrator said the nurses are responsible to check wanderguard placement on residents as ordered by the physician, and if a nurse identified a resident did not have his/her wanderguard, he/she expects the nurse to get with the maintenance director or the administrator for a replacement wanderguard. During an interview on 12/12/25 at 7:47 A.M., RN B said the resident had a wanderguard at one point, but he/she was not sure when or how the wanderguard was removed. RN B said he/she has documented the resident did not have a wanderguard in place but had not attempted to replace the wanderguard because the resident had not been displaying any exit-seeking behaviors, and he/she was told by someone, the resident was no longer considered a safety risk for elopement. During an interview on 12/12/25 at 8:22 A.M., Licensed Practical Nurse (LPN) C said the resident did not have a wanderguard for a while, he/she attempted once to replace the wanderguard but did not document his/her attempt to do so. LPN C said he/she documented several times the resident did not have a wanderguard, but he/she did not notify the DON or the administrator about replacing it since the resident had not been displaying any exit-seeking behaviors, and staff would visually monitor the resident during his/her shift. During an interview on 12/12/25 at 9:40 A.M., the Maintenance Director said he/she recalls the resident having a wanderguard at one point then he/she no longer had one, but the nurses are responsible to assess and place wanderguard on any resident who needs one. He/She said he/she did not recall any request from staff for a replacement wanderguard for the resident before 12/05/25. Intake# 2686022

Based on observation, interview, and record review, facility staff failed to maintain professional standards of care, when staff failed to document they administered wound treatments as directed by the physician for two residents (Resident #1 and #2) out of three sampled residents. The facility census was 64.1. Review of the facility's Charting and Documentation policy, revised July 2017, showed documentation of procedures and treatments will include care-specific details, included: -The date and time the procedure/treatment was provided;-The name and title of the individual(s) who provided the care;-Whether the resident refused the procedure/treatment;-The signature and title of the individual documenting. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/10/25, showed staff assessed the resident as cognitively intact, one venous and arterial ulcer (wound in the skin of the lower leg or foot), and rejected care one to three days in the seven-day review period. Review of the resident's Physician Order Sheet (POS), dated 10/01/25 through 10/31/25, showed staff were directed to cleanse the right lower leg with wound cleanser, pat dry, apply skin prep (a protective skin-protectant film) to entire area daily every day shift; and cleanse the left lower leg with wound cleanser, apply betadine paint (to prevent and treat skin infections) to peri-wound/intact skin, apply calcium alginate (to absorb moisture and minimize infection) to open wound bed, apply extra-large ABD pad (to absorb drainage and protect wounds), wrap with elastic bandage, change daily every day shift and as needed if heavily soiled/saturated. Review of the resident's Treatment Administration Record (TAR), dated 10/01/25 through 10/31/25, showed the record did not contain documentation staff provided wound treatment as directed by the physician or that the resident refused his/her treatment on 10/06/25, 10/11/25, 10/15/25, 10/16/25, and 10/29/25. During an interview on 11/17/25 at 2:56 P.M., the Director of Nursing (DON) said the resident sometimes refuses his/her treatments and he/she expects the nurse to document any refusal on the TAR. 3. Review of Resident #2's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact, received surgical wound care, and did not reject care. Review of the resident's POS, dated 10/01/25 through 10/31/25, showed a physician order directed staff to provide pin-site care: cleanse with warm soapy water, pat dry, massage around pin sites, non-woven sponge 2x2 secure with paper tape, foam dressing to medial ankle, every shift for treatment. Review of the resident's TAR, dated 10/01/25 through 10/31/25, showed the record did not contain documentation staff provided wound treatment as directed by the physician on 10/06/25, 10/08/25, 10/09/25, 10/10/25, 10/13/25, 10/17/25, 10/18/25, 10/22/25, 10/23/25, 10/24/25, 10/26/25, and 10/30/25. Review of the resident's POS, dated 11/01/25 through 11/17/25, showed staff were directed to provide pin-site care: cleanse with warm soapy water, pat dry, massage around pin sites, non-woven sponge 2x2 secure with paper tape, foam dressing to medial ankle, every shift for treatment. Review of the resident's TAR, dated 11/01/25 through 11/17/25, showed the record did not contain documentation staff provided wound treatment as directed by the physician on 11/06/25, 11/14/25, and 11/16/25. During an interview on 11/17/25 at 1:15 P.M., the resident said staff have not been doing his/her treatments every shift (twice daily) like his/her physician has ordered. During an interview on 11/17/25 at 2:56 P.M., the DON said he/she was not aware of the resident refusing his/her treatments and he/she expects the nurses to administer the treatments twice daily as directed by the physician to reduce the risk of infection. 4. During an interview on 11/17/25 at 2:20 P.M., Licensed Practical Nurse (LPN) B said the charge nurse is responsible to provide treatments as directed by the POS and document on the TAR once completed. LPN B said if there are missing documentation/signatures on a resident's TAR it is uncertain if the treatments were completed. The LPN said he/she thinks the DON audits for missing documentation on residents' TAR. During an interview on 11/17/25 at2:38 P.M., the administrator said the nurses are expected to administer treatments as ordered by the physician and document on the TAR when completed. He/She said if there are missing documentation/signatures on the TAR, then the treatment probably wasn't administered. He/She said the DON is responsible to conduct weekly audits for missing treatments and address any concerns with the nurses. Complaint #2649088

Based on observation, interview and record review, facility staff failed to meet professional standards of practice when they failed follow a treatment order for one resident (Resident #2) out of three sampled residents, notify the physician or follow up with the pharmacy when a medication was unavailable for one resident (Resident #4) out of one sampled residents, failed to ensure one resident (Resident #17) out of five sampled residents oxygen was in place, and one resident (Resident #25) out of five sampled residents oxygen delivery was at the prescribed flow rate. Staff failed to follow physician orders when they failed to document one resident's weight (Resident #51) out of two sampled residents daily, and perform a urinalysis test for one resident (#55) out of one sampled residents. The facility census was 55. 1. Review of facility's Medication and Treatment Orders policy, dated July 2016, showed staff were directed as follows: -Medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in this state; -Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/18/25 showed the staff assessed the resident as cognitively intact. Review of the resident's Physician Order Sheet (POS), dated April 2025, showed the following orders: -Apply Hydrocortisone 2.5% cream (a topical steroid medication used to treat skin conditions that cause inflammation, itching, and redness) mixed with Ketoconazole (to treat skin infections caused by fungi) to under arms, chest, and groin area one time a day; -Clobetasol Propionate external cream 0.05% (reduces swelling, redness, itching and rashes) apply to skin folds topically every shift. Review of the resident's Treatment Administration Record (TAR), dated April 2025, showed staff documented the Hydrocortisone 2.5% Cream as not administered due to doing different treatment on the following dates: -April 11; -April 15; -April 16; -April 19; -April 20; -April 24; -April 30. Review of the resident's TAR, dated May 2025, showed staff documented the Hydrocortisone 2.5% Cream as not administered due to doing different treatment on the following dates: -May 3; -May 5. During an interview on 05/05/25 at 11:14 A.M., the resident said he/she has treatment orders for his/her sores and he/she is supposed to have a treatment twice a day, but it maybe only gets done once a day. During an interview on 05/08/25 at 3:45 P.M., the Director of Nursing (DON) said he/she is not 100% sure why the resident has two different cream orders. He/She said he/she saw the two orders this morning and agrees it needs to be clarified on which order should be done. He/She said the nurse doing the treatment should clarify with physician which treatment should be done instead of putting using different treatment. He/She said he/she is responsible for ensuring that all orders are correct. During an interview on 05/08/25 at 4:25 P.M., the administrator said if there are conflicting treatment orders the charge nurse should clarify the order with the physician on which treatment should be done. He/She said the Assistant Director of Nursing (ADON) and DON should be doing chart checks and audits on all the charts when a resident goes out to the hopsital and comes back, with significant changes, and quarterly. 3. Review of Resident #4's Annual MDS, dated [DATE], showed the staff assessed the resident as cognitively intact. Review of the resident's POS, dated April 2025, showed the physician directed staff to administer: -Norco (to relieve moderate to severe pain) oral tablet 10-325 milligram (mg), give one tablet by mouth every four hours for pain; -Norco oral tablet 5-325mg, give two tablets by mouth six times a day for pain. May use two 5/325mg Norco from Omnicell (automated dispensing cabinets are used to store and dispense medications) until residents Norco 10/325 tabs arrive, then discontinue 5/325mg order. Review of the resident's Medication Administration Record (MAR), dated April 2025, showed staff documented: -Norco 10-325mg unavailable on 04/19/25 at 4:00 A.M. through 04/23/25 at 4:00 P.M.; -Norco 5-325mg unavailable from Omnicell from 04/22/25 at 12:00 P.M. through 04/23/25 at 4:00 P.M. Review of the residents nurse notes, dated 04/19/25 through 04/21/25, showed staff did not document contact with the physician or the pharmacy until 4/21/25 at 9:10 P.M. when the resident did not receive his/her Norco 10-325mg. Review of the nurses notes, dated 4/22/25 through 4/23/25 showed staff did not document contact with the physician or the pharmacy when the resident did not receive his/her Norco 5-325mg 2 tablets due to medication unavailable from Omnicell. During an interview on 05/06/25 at 09:32 A.M., the resident said in April the facility was out of his/her medication for about six days before they finally received it from the pharmacy. During an interview on 05/08/25 at 3:45 P.M., the Director of Nursing (DON) said he/she was aware of resident pain medication not being available in April. He/She said they were waiting on the script from pharmacy. He/She said he/she was not aware that the substitution order of Norco 5/325mg two tablets were unavailable from the Omnicell for any period of time nor that the resident missed more doses of pain medication. He/She said it is the charge nurse's responsibility to call the pharmacy and see about the medication when it is not available. He/She said the charge nurse should contact the physician to get another order and to ensure the pharmacy received the script. During an interview on 05/08/25 at 4:25 P.M., the administrator said the Charge nurse should notify the pharmacy of a needed refill five days before the script runs out. He/She said the charge nurse should notify the physician if a medication is not available to get a new order. 4. Review of Resident #17's Quarterly MDS, dated [DATE] showed the staff assessed the resident as severely cognitive impairment. Review of the resident's POS, dated April 2025, showed: -Oxygen at two Liter (L) per nasal cannula, every shift; -Oxygen Tubing and humidifier change, clean concentrator filter every Wednesday night. Observation on 05/05/25 at 1:18 P.M., showed the resident in the lounge area without oxygen in place. The wheelchair did not have an oxygen tank or tubing on the back. Observation on 05/06/25 at 9:15 A.M., showed the resident in the lounge area without oxygen in place. The wheelchair did not have an oxygen tank or tubing on the back. Observation on 05/07/25 at 10:10 A.M., showed the resident in the bed without oxygen in place and no oxygen concentrator in room. Observation on 05/08/25 at 11:05 A.M., showed the resident in the lounge area without oxygen in place. The wheelchair did not have an oxygen tank or tubing on the back. During an interview on 05/08/25 at 3:20 P.M., LPN E said residents' oxygen saturation is checked every shift. He/She said he/she believes the resident has an oxygen order as needed if oxygen gets below a certain level. During an interview on 05/08/25 at 3:45 P.M., the DON said resident does not use oxygen. He/She said he/she was aware of the oxygen order but thought it was as needed. During an interview on 05/08/25 at 4:35 P.M., the administrator said he/she would expect oxygen to be on resident if it is ordered. He/She said the ADON and DON should be doing chart checks and audits on all the charts when a resident goes out to hopsital and comes back, with significant changes, and quarterly. 5. Review of Resident #25's Annual MDS, dated [DATE] showed the staff assessed the resident as cognitively intact. Review of the resident's POS, dated April 2025, showed continuous oxygen at two liters per nasal cannula. Observation on 05/05/25 at 10:22 A.M., showed resident in bed with oxygen via nasal cannula at 3.5 liters. Observation on 05/07/25 at 1:30 P.M., showed resident in bed with oxygen via nasal cannula at 3.5 liters. Observation on 05/08/25 at 11:18 A.M., showed resident in bed with oxygen via nasal cannula at 3.5 liters. During an interview on 05/07/25 at 1:30 P.M. the resident said his/her oxygen should be on two liters. During an interview on 05/08/25 at 3:20 P.M., LPN E said he/she is agency and only works about once a month. He/She said he/she knows they checked the resident oxygen every shift. He/She said he/she is unsure of what liter of oxygen without looking in chart, but he/she believes the resident told her five liters last time he/she worked. During an interview on 05/08/25 at 3:45 P.M., the DON said it is not okay for oxygen to be on a different liter then what is ordered. He/She said the charge nurse is responsible for checking every shift to ensure oxygen is on the correct liter as ordered. During an interview on 05/08/25 at 4:25 P.M., the administrator said he/she expects oxygen to be on same liter that is ordered. He/She said the charge nurse is responsible for checking oxygen every shift and correct the oxygen liter if it is wrong. He/She said the DON oversees that the orders are being followed. 6. Review of facility's policy's, Weight Assessment and Intervention, revised March 2022, showed: -Resident weights are monitored for undesirable or unintended weight loss or gain; -Residents are weighed upon admission and at intervals established by the interdisciplinary team; -Weights are recorded in the individual's medical record. 7.Review of Resident #51's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Dependent on staff for mobility, and transfers; -Diagnosis of Congestive Heart Failure. Review of the resident's POS, dated 03/29/25, showed an order for daily weights, notify physician if weight increases or decreases by three pounds in one day or three pounds in one week. Every day shift. Review of the resident's medical record, dated 03/29/25 through 05/08/25, showed the following dates and weights for the resident: -03/29/25- 229.3 Lbs; -03/30/25- did not contain a weight; -03/31/25- 209.1 Lbs. -04/01/25- 212.8 Lbs; -04/02/25- 213.2 Lbs; -04/03/25- did not contain a weight; -04/04/25- 213.0 Lbs; -04/05/25- did not contain a weight; -The record did not contain a daily weight, or documentation of physician notification with a increase or decrease in weight by three pounds daily or for the week -04/06/25- did not contain a weight; -04/07/25- 215.0 Lbs; -04/08/25- 214.6 Lbs; -04/09/25- did not contain a weight; -04/10/25- did not contain a weight; -04/11/25- did not contain a weight; -04/12/25- 215.2 Lbs; -The record did not contain a daily weight for this week. -04/13/25 - 214.4 Lbs; -04/14/25- did not contain a weight; -04/15/25- 213.9 Lbs; -04/16/25 - did not contain a weight; -04/17/25- 207.0 Lbs; -04/18/25- 206.0 Lbs; -04/19/25- 206.8 Lbs; -The record did not contain a daily weight, or documentation of physician notification with a increase or decrease in weight for the week. -04/20/25- 205.0 Lbs; -04/21/25- did not contain a weight; -04/22/25- did not contain a weight; -04/23/25- did not contain a weight; -04/24/25- 203.8 Lbs; -04/25/25- did not contain a weight; -04/26/25- did not contain a weight; -The record did not contain a daily weight for this week. -04/27/25- 215.4 Lbs; -04/28/25- 218.4 Lbs; -04/29/25- 217.2 Lbs; -04/30/25- did not contain a weight; -05/01/25- did not contain a weight; -05/02/25- 222.4 Lbs; -05/03/25- did not contain a weight; -The record did not contain a daily weight, or documentation of physician notification with a increase or decrease in weight by three pounds daily or for the week. -05/04/25- 219.6 Lbs; -05/05/25- did not contain a weight; -05/05/25- did not contain a weight; -05/06/25- 216.2 Lbs; -05/07/25- did not contain a weight; -05/08/25- did not contain a weight; -The record did not contain a daily weight, or documentation of physician notification with a increase or decrease in weight by three pounds daily or for the week. During an interview on 05/07/25 at 1:50 P.M., the resident said he/she is not weighed every day and said he/she does not refuse to be weighed. During an interview on 05/08/25 at 1:10 P.M., LPN A said it is the responsibility of the charge nurse to make sure weights are done. LPN A said the resident is in and out of the facility often with his/her family member that maybe why some weights are missing. The LPN said staff should still try to get a weight when the resident is back in the facility. LPN A said he/she does not know if the doctor has been contacted about fluctuation of weights on this resident, but if it was done it would be documented in the resident's medical record. During an interview on 05/08/25 at 3:35 P.M., the DON said the resident has congestive heart failure and possible swelling which is more then likely why he/she has weights ordered daily. The DON said the resident can be noncompliant but will usually do the weights. The DON said she did not know the order said to notify the weight change to the doctor, therefore does not is unsure of it being done. During an interview on 05/08/25 at 4:25 P.M., the administrator said he is unsure about weights being done, but would expect staff to follow physician orders. 8. Review of the facility's policies showed staff did not provide a policy for physicians orders. 9. Review of Resident #55's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Indwelling catheter. Review of the residents progress note, dated 05/05/25, showed the facility Nurse Practitioner (NP) documented the resident continued to have foul urine, previous urine test was not sent off to lab, new orders given to repeat. Review of the resident's POS, dated 05/08/25, showed the record did not contain an order for urine test. During an interview on 05/05/25 at 10:45 A.M., the resident said he/she has had some symptoms of a possible Urinary Tract Infection (UTI), and had spoken with the NP several days ago and a urine test should have been ordered, but he/she has not heard anything. During an interview on 05/08/25 at 1:12 P.M., LPN A said new orders are put into the residents chart as they are given, the charge nurse will confirm orders at the start of shift. The LPN said not all nurses have access to the doctors or nurse practitioner's notes. LPN A was not aware of a urinalysis test ordered for the resident. During an interview on 05/08/25 at 3:39 P.M., the DON said they will obtain the urine test today, he/she said the NP sits down with her and goes over any new orders after his/her rounds. The DON said he/she is responsible to transcribe the orders given to him/her by the NP. The DON said the order must have been missed being put onto the residents POS. During an interview on 05/08/25 at 4:27 P.M., the Administrator said he is unsure why the order was not put on the residents POS, the DON is responsible to put the order in as she sits down with the NP and goes over this after he/she sees the residents. MO00253550

Based on interview and record review, facility staff failed to ensure continuing competence of nurse aides of no less than 12 hours in-service education per year and address areas of weakness as determined in nurse aides' performance reviews and the facility assessment. The facility census was 55. 1. Review of the facility's policies showed staff did not provide a policy for staff training. Review of the Facility Assessment, dated 02/13/25, showed the following new hire training for nursing staff: -Advanced directives; -Effective communication; -Preventing, recognizing and reporting abuse; -Workplace safety; -Hand hygiene; -Health Insurance Portability and Accountability (HIPPAA), a law that protects the privacy of medical information, overview; -Infection prevention and control; -Protecting Resident rights in nursing facilities; -Safe transfers; -Perineal Care check list; -Dementia care: managing challenging behaviors; -Emergency Disaster Preparedness; -Electronic Medical Record charting; -Annual education includes all the new hire training plus the topics of corporate compliance, overview of the aging process and pressure ulcer prevention; -Training is provided through direct 1:1 education, group in-servicing, return demonstration and online web-based curriculum. -Additional education and training resources are available as needed through contracted companies/vendors. Review of the facility's web-based curriculum training plan, undated showed the plan did not contain pressure ulcer prevention education. Review of the group based in-service training showed the following: -July 2024, training included oxygen safety, emergency preparedness and medication storage; -October 2024, training included Hippa/Privacy, abuse reporting and investigating, medication and treatment orders, medication administration, medication storage, and needle handling; -December 2024, training included showers, timely call lights, wheelchair cleansing, dependent care for residents, passing ice water, and Enhanced Barrier Precautions (EBP); -March 2025, training included activities of daily living, care of nails, and advanced directives; -The group-based in-services did not contain documentation of length of training, pressure ulcer prevention or any training for the months of March, April, May, June, August, September, October or November of 2024 or January and February of 2025. 2. Review of Certified Nurse Aide (CNA) H's employee file showed a hire date of 06/21/23. Review of the CNA's web-based training record showed he/she did not complete the assigned fire safety, flooding, corporate compliance essentials of quality improvement, hazardous chemicals, minimizing slips, trips and falls, preventing/recognizing/reporting of abuse, sharps injury, transferring safely, essentials of HIPPA, and dementia care module 1, 2, and 3 training. The training did not contain the number of hours of completed courses. 3. Review of Certified Medication Technician (CMT) B's employee file showed a hire date of 11/20/23. Review of the CMT's web-based training record showed he/she did not complete the assigned advanced directives, infection prevention and control, communication, preventing/recognizing/reporting abuse, essentials of resident rights, or dementia care modules 1-5. The training did not contain the number of hours of completed courses. 4. Review of CMT I's employee file showed a hire date of 06/24/24. Review of the CMT's web-based training record showed he/she did not complete any assigned web-based training. 5. Review of CMT J's employee file showed a hire date of 03/18/24. Review of the CMT's web-based training record showed he/she did not complete the assigned active shooter, equipment failure, emergency preparedness, earthquake preparedness, flooding, fire safety, advanced directives, quality improvement, hazardous chemicals, minimizing slips/trips/falls, oxygen safety, essentials of HIPPA, and tornado watch training. The training did not contain the number of hours of completed courses. 6. During an interview on 05/07/25 at 10:39 A.M., the Administrator said that the required training is posted in the employee breakroom with a list of topics and a list of staff who are behind. Staff are expected to get them done. During an interview on 05/08/25 at 10:18 A.M., CNA D said there is in-house group training once a month that goes over facility concerns. He/She said he/she is not sure how long they are and has not received an evaluation or review. The CNA said he/she will be employed one year next month. During an interview on 05/08/25 at 03:35 P.M., the Director of Nursing (DON) said staff training is completed and monitored by the DON and the Administrator using a web-based training program. He/She said he/she does not know how the 12-hour required training is tracked or who is responsible to track it. Education is determined by what is going on in the facility at the time of the training and said annual reviews are completed by the DON and Administrator and reviewed with the staff member. During an interview on 05/08/25 at 04:24 P.M., the Administrator said the web based program tracks the hours of completion and should be monitored by the DON. The DON and Administrator are responsible to ensure nursing staff receive all the required training to include topics in the facility assessment and based on resident needs. Yearly performance reviews are completed at the administrator level and staff are given wage increases based off of them, but do not determine education. Education is determined at a corporate level using best practice and Centers for Medicare and Medicaid Services (CMS) guidelines. He/She was unaware staff did not have the required education completed.

Based on observation, interview and record review, the facility staff failed to maintain and serve food items at temperatures adequate to prevent food borne illness. This failure has the potential to affect all residents. The facility census was 55. 1. Review of the facility's Serving Temperatures for Hot and Cold Foods policy, dated 2020, showed the cook will take temperatures of hot and cold food items using approved food thermometers prior to each meal service. Hot foods will be served at 135 to 170 degrees Fahrenheit (F). Each facility should check state specific regulations for minimum temperatures. Review showed cold foods will be served at 41 degrees F or below. Review showed the policy did not contain guidance related to cold food storage between meals. Observation on 05/05/25 at 11:27 A.M., showed the area below the kitchen service window contained a four-drawer refrigerator, which contained a cold table on top. Observation showed the cold table contained ham, sliced cheese, shredded cheese, lettuce, sliced tomatoes, jalapeno peppers and boiled eggs. Observation showed the food temperatures on the cold table: -Shredded cheese, 46 degrees F; -Ham, 47 degrees F; -Sliced cheese, 48 degrees F; -Boiled eggs in the table well, 49 degrees. Observation showed a second metal bin of boiled eggs set on top of the bin, which set in the table. The temperature of the top boiled eggs was 71 degrees F. Observation showed kitchen staff used items from the cold table during lunch service. Observation on 05/05/25 at 11:48 A.M., showed the Dietary Manager (DM) served the residents the lunch meal. Observation showed the temperature of the pureed chicken and pureed vegetables, which were being held in steam table pans, were both 122 degrees F. Observation showed the DM served the pureed items to two residents. Observation showed the temperature of the chicken, which was served to residents who received regular diets was 131 degrees F. Observation on 05/06/25 at 12:05 P.M. showed the cold table contained ham, cheese, lettuce, sliced tomatoes, jalapeno peppers and boiled eggs. Observation showed the temperature of the ham and boiled eggs were 46 degrees F when checked using a calibrated digital thermometer. Observation on 05/07/25 at 11:46 A.M., showed the temperature of the ham on the cold table was 45 degrees F when checked with a calibrated digital thermometer. During an interview on 05/06/25 at 12:05 P.M. the DM said cold table food should be held at 40 degrees or below. The DM said the cook was responsible for checking food temperatures. The DM said he/she checked the thermometer in the four-drawer refrigerator below the cold table, but he/she never checked the food temperatures on the cold table. The DM said the cold table was covered with a metal lid at the end of the day so the food items remained in the cold table between meals. The DM said he/she ran out of alcohol wipes the day prior, so he/she did not check food temperatures. The DM said hot foods should be held at 135 degrees F or higher. During an interview on 05/06/25 at 12:10 P.M., [NAME] C said food on the cold table should be held at 30 to 35 degrees, but not frozen. [NAME] C said he/she checked meat and egg temperatures but did not check the temperature of other food items which were held on the cold table. [NAME] C said he/she did not document cold table food temperatures. During an interview on 05/06/25 at 1:30 P.M., the administrator said the DM and cooks were responsible for ensuring all cold foods were held below 40 degrees and hot foods were held at greater than 140 degrees. The administrator said he/she was not aware of any issues with food holding temperatures.

Based on observation, interview, and record review, facility staff failed to thoroughly investigate and document bruises of unknown origin for one resident (Resident #15) out of one sampled residents as directed by the facility policy. The facility census was 55. 1. Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, showed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, states, and federal agencies and thoroughly investigated by facility management. Review showed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review showed: -The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: -The state licensing/certification agency responsible for surveying/licensing the facility; -The local/state ombudsman; -The residents representative; -Law enforcement officials; -The resident attending physician; -The facility medical director; -Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions are needed for the protection of residents. 2. Review of Resident #15's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used by staff, dated 02/10/25, showed staff assessed the resident as follows: -Severe Cognitive impairment; -Substantial/maximal assist from staff for toileting or shower/bathe; -Partial/moderate assist from staff for transfers, sitting to lying, and lying to sitting on bed; -Diagnoses of Non-Traumatic Brain Dysfunction, Aphasia, and Dementia; -Used wheelchair and walker. Review of the resident's plan of care, dated 03/25/25, showed staff assessed the resident impaired cognitive function/dementia or impaired thought processes, at moderate risk for falls and an alternation in musculoskeletal status with an ataxic gait, difficulty walking, and reduced mobility. The resident's care plan did not contain documentation of a fall or bruise. Observation on 05/06/25 at 10:36 A.M., showed the resident in his/her wheelchair with a bruise on his/her left forehead and lateral left eye area. Observation on 05/07/25 at 10:07 A.M., showed the resident in his/her wheelchair with a bruise on his/her left forehead, lateral left eye area, and underneath left eye. Review of the resident's electronic medical record, showed the record did not contain documentation of the resident's bruises, or a facility investigation of the injury of unknown origin. During an interview on 05/06/25 at 2:12 P.M., Licensed Practical nurse (LPN) F said he/she was unsure where the bruise came from on the resident's face. He/She said resident may have fallen. He/She reviewed residents' electronic chart and could not find anything about the bruise or where it came from. During an interview on 05/07/25 at 10: 41 A.M., Certified Nurses Aide (CNA) G said he/she is unsure what happened to the resident's face. He/She said he/she last worked on Sunday 05/04/25 from 7 A.M. to 7 P.M. and the bruise was not on his/her face at that time. During an interview on 05/07/25 at 11:22 A.M., the Director of Nursing (DON) said he/she was informed about the bruise on Monday 05/05/25 in the afternoon. He/She said he/she is unsure how the resident got the bruise on face. He/She said he/she has not started an investigation at this time or has not notified the doctor or family regarding the bruise because, I just haven't had a chance. He/She said he/she is unsure of what the policy says regarding injury of unknown origin. During an interview on 05/08/25 at 8:41 A.M., the administrator said the resident can get his/herself back up after a fall. He/She said the bruise was discovered Monday morning, but nothing was put into the chart, and it should have been. He/She said the facility is now investigating the bruise. He/She said the injury of unknown origin should have been reported to state when it was discovered Monday morning.

Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs for four residents (Resident #18, #29, #40 and #47) out of five sampled residents. The facility's census was 55. 1. Review of the facility's Care Plans Goals and Objectives policy, dated April 2009, showed: -Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and are resident oriented, behaviorally stated, are measurable and contain timeframes to meet the resident's needs in accordance with the comprehensive assessment; -Goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition, when the desired outcome has not been achieved, when the resident has been readmitted to the facility from a hospital/rehabilitation stay and at least quarterly. 2. Review of Resident #18's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/04/25, showed staff assessed the resident as: -Cognitively impaired; -Limited range of motion to both upper extremities; -Dependent on staff for all care; -Diagnosis of Multiple Sclerosis (a disease that damages the nerves) and Alzheimer Dementia. Review of the resident's care plan, dated 02/13/25, showed the care plan did not contain direction or guidance for contracture management. Observation on 05/05/25 at 1:17 P.M., showed the resident hands contracted. 3. Review of Resident #29's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Impaired range of motion to one upper and one lower extremity; -Diagnosis of dementia and hemiplegia (weakness or paralysis of one side of the body). Review of the resident's care plan, dated 05/05/25, showed the care plan did not contain direction or guidance for contracture management. Observation on 05/06/25 at 3:13 P.M., showed the resident left hand contracted. 4. Review of Resident #40's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -No smoking; -Diagnosis of depression. Review of the resident's care plan, dated 01/24/25, showed the care plan did not contain guidance or preference related to smoking. During an interview on 05/05/25 at 09:57 A.M., the resident said he/she smokes and keeps his/her smoking materials with him/her. He/She does not have staff supervision and goes out whenever he/she wants to the smoking area. 5. Review of Resident #47's Medicare 5-day MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Wears corrective lenses for vision; -Requires set up/clean up assistance for eating; -Required partial to moderate assistance for oral hygiene; -Required substantial to maximum assistance for rolling from left to right, sitting to lying, showers and upper body dressing; -Dependent on staff for lying to sitting, transfers, toilet hygiene, lower body dressing and putting on and taking off footwear; -Incontinent of bowel and bladder; -Presence of pain; -Prescribed a mechanically altered diet; -Presence of a stage one or higher pressure wound; -Risk for pressure wound; -Received an antipsychotic medication, antidepressant medication and an antibiotic medication; -No restraints; -Goal to remain in the facility -Diagnosis of stroke. Review of the resident's medical record, showed the record did not contain a comprehensive care plan. 6. During an interview on 05/08/25 at 3:35 P.M., the Director of Nursing (DON) said care plans should include code status, discharge planning, activities of daily living, weight/nutrition, pressure wounds, skin integrity, behaviors, tobacco use, contracture managment, use of bars on the beds, or rails. He/She said the MDS Coordinator is responsible to ensure the care plans are kept up to date, but the facility has been without a care plan coordinator and the corporate nurse is helping out. During an interview on 05/08/25 at 4:11 P.M., the Corporate Nurse said care plans should include code status, activities of daily living, discharge planning, high risk medication use, bed rails, contracture managment, pain managment, urinary status, falls and pressure risks, and use of psychotropic medications. He/She said the MDS nurse is responsible to update the care plans, but the facility has been without one. He/She is trying to keep them updated along with his/her other responsibilities. During an interview on 05/08/25 at 04:24 P.M., the Administrator said the MDS nurse updates the care plans but the facility is currently without a full time MDS Coordinator. He/She said the corporate nurse is trying to help keep them updated but has other responsibilities as well.

Based on interview and record review, facility staff failed to complete a Significant Change Minimum Data Set (MDS), a federally mandated resident assessment tool, for three residents (Resident #18, #44, and #47) out of 14 sampled residents who had either improvements and/or declines in condition. The facility census was 55. 1. Review of the facility's policies showed staff did not provide a policy for completion of a Significant Change of Status Assessment. Review of the Resident Assessment Instrument (RAI) manual version 3.0, dated October 2024, Omnibus Budget Reconciliation Act (OBRA)-required Assessment Summary showed assessment time frames as follows: -A significant change in status assessment (SCSA) is appropriate when there is a determination that significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent quarterly assessments and the resident's condition is not expected to return to baseline in two weeks; -A significant change is any decline in two or more of the following: decision making has changed; presence of a resident mood item no previously reported by the resident or staff and /or an increase in symptom frequency in Section E; changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since last assessment; any decline in an Activities of Daily Living (ADL) physical functioning area where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual functioning; residents incontinence patters changes or placement of indwelling catheter; emergence of unplanned weight loss, emergence of a new pressure ulcer at stage II (partial-thickness skin loss) or higher, a new unstageable pressure ulcer/injury (depth and extent of the tissue damage cannot be determined ), a new deep tissue injury or worsening in pressure ulcer status (where the skin remains intact, but the underlying tissues are damaged); -A significant change is any improvement in two or more of the following: any improvement in ADL physical functioning area where a resident is newly coded independent, set up or clean-up assistance, or supervision or touching assistance since last assessment and dates does not reflect normal fluctuations in that individuals functioning; a decrease in areas where behavioral symptoms are coded as being present and/or the frequency of a symptom decreases; resident's decision making improves; and the resident's incontinence pattern improves; -A significant change assessment must be completed within 14 days after a determination has been made that a significant change in status has occurred and submitted within 14 days of the care plan completion date. 2. Review of Resident #18's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Not feeling down, depressed or hopeless, or rejection of care; -Did not have poor appetite or overeating; -Mood severity the potential for depression symptoms; -Functional limitation of range of motion to both lower extremities; -Dependent on staff for eating, oral hygiene, upper body dressing, personal hygiene and rolling left to right; -Had pain; -No weight gain; -No presence of a stage one or greater pressure wound or Moisture Associated Skin Damage (MASD). Review of the residents quarterly MDS, dated [DATE], showed staff assessed the resident as: -Felt down, depressed or hopeless 7-11 days; -Had a poor appetite or overeating 2-6 days; -Mood severity score potential for depression symptoms; -Rejected care one to three days; -No functional limitation of range of motion to lower extremities; -Required substantial to maximum assistance for eating, oral hygiene, upper body dressing, personal hygiene and rolling left to right; -No pain; -Gained weight; -Had a stage one or greater pressure wound and MASD. Review of the resident's medical record showed facility staff did not complete a significant change in status assessment when the resident had a decline in feeling down, depressed or hopeless, poor appetite or overeating, new rejection of care behavior, gained weight and developed a stage one or greater pressure wound and MASD and had an improvement in pain, range of motion, eating, oral hygiene, upper body dressing, personal hygiene and rolling left to right. During an interview on 05/08/25 at 4:24 P.M., the Corporate MDS nurse said he/she does not believe staff were coding activities of daily living correctly and a correction should have been completed but missed. 3. Review of Resident #44's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Moderate cognitive impairment; -Did not reject care; -No oxygen therapy; -Required partial to moderate assistance with toileting, and shower/bathing. Review of the Resident's Annual MDS, dated [DATE] showed staff assessed the resident as: -Severe cognitive impairment; -Rejection of care four to six days; -Required oxygen therapy; -Required substantial to maximal assistance for shower/bathing; -Dependent for toileting. Review of the resident's medical record showed facility staff did not complete a significant change in status assessment when the resident had a decine in cognition, new rejection of care behavior, required oxygen therapy, and required more assistance for toileting and bathing. 4. Review of Resident #47's admission MDS, dated [DATE], showed staff assessed the resident as: -Mood severity score of one; -Required set up assistance from staff for oral hygiene; -Dependent on staff for showers and sit to lying; -Frequently incontinent of bowel and bladder; -No pain; -No stage one or greater pressure wound. Review of the resident's 5-day Medicare Assessment, dated 04/13/25, showed staff assessed the resident as: -Mood severity score of zero; -Required partial to moderate assistance for oral hygiene; -Required substantial to maximum assistance for showers and sit to lying; -Always incontinent of bowel and bladder; -Had pain; -Presence of a stage one or greater pressure wound. Review of the resident's medical record showed facility staff did not complete a significant change in status assessment when the resident declined in mood, oral hygiene assistance, showers and sit to lying, bowel and bladder function, pain and presence of new stage one or greater pressure wound. During an interview on 05/08/25 at 4:11 P.M., the Corporate MDS nurse said a significant change should have been completed on the resident but missed it. 5. During an interview on 05/08/25 at 3:35 P.M., the Director of Nursing (DON) said staff use the RAI manual to determine a significant change of status and would include things like new referral to hospice, decline in activities or daily living, weight loss and new pressure wounds. He/She is not sure why the assessments were not completed but should have been. He/She said the MDS Coordinator is currently a corporate nurse who is filling in until a full time staff member can be hired and trained and is responsible to ensure the MDS assessments are completed timely. During an interview on 05/08/25 at 4:11 P.M., the Corporate Nurse said he/she is currently trying to keep up with the MDS assessments along with her other responsibilities. He/She said a significant change of status is completed when there has been a significant change in the resident that would not correct itself within 14 days. He/She said if there is a determination made that a significant change of status assessment will not be completed, then a note should be put into the medical record. During an interview on 05/08/25 at 4:24 P.M., the administrator said he/she is trying to hire a full time MDS Coordinator and is using the corporate nurse for assistance to complete the MDS assessments with the help of the DON.

Based on interview and record review, facility staff failed to hold care plan meeting with the resident and/or the resident's representative, and failed to ensure the Interdisciplinary Team (IDT) participated in care conferences for four residents (Resident #29, #31, #40, and #51) of 14 sampled residents reviewed for care planning. The facility census was 55. 1. Review of the facility's Care Plans Goals and Objectives policy, dated April 2009, showed the policy did not contain direction on contacting or inviting the resident and/or resident representative to the care planning conferences. 2. Review of Resident #29's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/12/25, showed the staff assessed the resident as cognitively impaired. During an interview on 05/06/25 at 3:15 P.M., the resident said he/she has not been invited to a meeting to discuss his/her care plan. During an interview on 05/08/25 at 11:29 A.M., the resident's family member said he/she had not been invited to a care plan meeting. Review of the resident's medical record showed the record did not contain documentation of a care plan meeting or the IDT team attended a care plan conference. 3. Review of Resident #31's Quarterly MDS, dated [DATE], showed the staff assessed the resident as cognitively intact. During an interview on 05/05/25 at 2:30 P.M., the resident said he/she has never attended care plan meeting. Review of the resident's medical record showed the record did not contain documentation of a care plan meeting or the IDT team attended a care plan conference. 4. Review of Resident #40's Annual MDS, dated [DATE], showed the staff assessed the resident as cognitively intact. During an interview on 05/05/25 at 9:57 A.M., the resident said he/she had not been invited to a care plan meeting since September. Review of the resident's medical record showed the record did not contain documentation of a care plan meeting or the IDT team attended a care plan conference. 5. Review of Resident #51's dated 02/07/25, showed the staff assessed the resident as cognitively impaired. During an interview on 05/06/25 at 2:15 P.M., the resident said he/she has never attended care plan meeting. During an interview on 05/06/25 at 2:16 P.M., the resident family member said he/she had not been invited to a care plan meeting. 6. During an interview on 05/07/25, at 2:07 P.M., the Care Plan Coordinator/Corporate nurse said he/she has not been doing care plan meetings, he/she has just not had time. During an interview on 05/07/25 at 2:08 P.M., the Director of Nursing (DON) said he/she has not done care plan meetings, and there is no documentation to provide. During an interview on 05/07/25 at 02:09 P.M., the administrator said the MDS Coordinator/Corporate nurse/Care Plan Coordinator, with the help of the DON is responsible for care plan meetings. The facility is currently without a full time MDS Coordinator/Care Plan coordinator so the corporate nurse is trying to help keep up with all these responsibilities.

Based on interview and record review, facility staff failed to provide a sufficient number of staff members to ensure call lights were answered in timely manner. The facility census was 55 . 1. Review of the facility assessment tool, dated 02/13/25, showed: -Average census of 63 residents; -Direct care staff needed for a 24-hour period of time: -Licensed Nurses: two for each shift; -Certified Medication Technicians (CMT's): two on dayshift; -Certified Nurse Aides (CNA's): One to 15 residents on dayshift and one to 19 residents on nightshift. Review of the facility's Call Lights Policy, dated March 2021, showed the procedure is to ensure timely responses to resident's requests and needs. The policy did not contain direction for who may answer the call light. 2. Review of the Nursing staff time clock report, dated 05/02/25, showed: -Dayshift: One Registered Nurse (RN), Three Licensed Practical Nurse (LPN), three CMT, three CNA, and three Nurse Aides (NA); -Nightshift: two LPN, one CMT and two CNA. Review of the facility's wireless call light report, dated 05/02/25 showed: -At 1:07 A.M., room [ROOM NUMBER] with call light response time of 31 minutes; -At 3:35 A.M., room [ROOM NUMBER] with call light response time of 50 minutes; -At 4:33 A.M., room [ROOM NUMBER] with call light response time of 49 minutes; -At 5:02 A.M., room [ROOM NUMBER] with call light response time of 36 minutes; -At 6:20 A.M., room [ROOM NUMBER] with call light response time of 30 minutes; -At 6:20 A.M., room [ROOM NUMBER] with call light response time of 34 minutes; -At 6:21 A.M., room [ROOM NUMBER] with call light response time of 1 hour and 4 minutes; -At 8:09 A.M., room [ROOM NUMBER] with call light response time of 31 minutes; -At 9:35 A.M., room [ROOM NUMBER] with call light response time of 46 minutes; -At 9:41 A.M., room [ROOM NUMBER] with call light response time of 39 minutes; -At 10:35 A.M., room [ROOM NUMBER] with call light response time of 42 minutes; -At 11:19 A.M., room [ROOM NUMBER] with call light response time of 1 hour and 6 minutes; -At 11:31 A.M., room [ROOM NUMBER] with call light response time of 41 minutes; -At 12:23 P.M., room [ROOM NUMBER] with call light response time of 42 minutes; -At 12:43 P.M., room [ROOM NUMBER] with call light response time of 40 minutes; -At 12:48 P.M., room [ROOM NUMBER] with call light response time of 30 minutes; -At 1:29 P.M., room [ROOM NUMBER] with call light response time of 30 minutes; -At 3:37 P.M., room [ROOM NUMBER] with call light response time of 39 minutes; -At 3:49 P.M., room [ROOM NUMBER] with call light response time of 30 minutes; -At 4:22 P.M., room [ROOM NUMBER] with call light response time of 1 hour and 41 minutes; -At 4:38 P.M., room [ROOM NUMBER] with call light response time of 47 minutes; -At 4:44 P.M., room [ROOM NUMBER] with call light response time of 38 minutes; -At 5:32 P.M., room [ROOM NUMBER] with call light response time of 55 minutes; -At 5:32 P.M., room [ROOM NUMBER] with call light response time of 35 minutes; -At 5:44 P.M., room [ROOM NUMBER] with call light response time of 35 minutes; -At 6:19 P.M., room [ROOM NUMBER] with call light response time of 38 minutes; -At 6:58 P.M., room [ROOM NUMBER] with call light response time of 1 hour and 33 minutes; -At 7:17 P.M., room [ROOM NUMBER] with call light response time of 43 minutes; -At 7:48 P.M., room [ROOM NUMBER] with call light response time of 1 hour; -At 8:09 P.M., room [ROOM NUMBER] with call light response time of 1 hour and 14 minutes; -At 8:44 P.M., room [ROOM NUMBER] with call light response time of 54 minutes; -At 9:05 P.M., room [ROOM NUMBER] with call light response time of 32 minutes; -At 11:06 P.M., room [ROOM NUMBER] with call light response time of 47 minutes; -At 11:54 P.M., room [ROOM NUMBER] with call light response time of 34 minutes. 3. Review of the Nursing staff time clock report, dated 05/03/25, showed: -Dayshift: one RN, one LPN, two CMT, five CNA, and one NA; -Nightshift: two LPN, three CNA, and two NA. Review of the facility's wireless call light report, dated 05/03/25 showed: -At 6:27 A.M., room [ROOM NUMBER] with call light response time of 35 minutes; -At 6:31 A.M., room [ROOM NUMBER] with call light response time of 36 minutes; -At 9:42 A.M., room [ROOM NUMBER] with call light response time of 35 minutes; -At 12:15 P.M., room [ROOM NUMBER] with call light response time of 36 minutes; -At 3:18 P.M., room [ROOM NUMBER] with call light response time of 56 minutes; -At 3:26 P.M., room [ROOM NUMBER] with call light response time of 30 minutes. 4. Review of the Nursing staff time clock report, dated 05/04/25, showed: -Dayshift: two LPN, three CMT, four CNA and one NA; -Nightshift: two LPN, three CNA, and two NA. Review of the facility's wireless call light report, dated 05/04/25 showed: -At 10:06 A.M., room [ROOM NUMBER] with call light response time of 42 minutes; -At 10:40 A.M., room [ROOM NUMBER] with call light response time of 1 hour and 52 minutes; -At 12:44 P.M., room [ROOM NUMBER] with call light response time of 34 minutes; -At 2:58 P.M., room [ROOM NUMBER] with call light response time of 31 minutes; -At 10:46 P.M., room [ROOM NUMBER] with call light response time of 33 minutes; -At 10:48 P.M., room [ROOM NUMBER] with call light response time of 32 minutes; -At 11:10 P.M., room [ROOM NUMBER] with call light response time of 33 minutes. 5. Review of the Nursing staff time clock report, dated, 05/05/25, showed: -Dayshift: two LPN, three CMT, three CNA and two NA; -Nightshift: one RN, one LPN, one CMT, five CNA and one NA. Review of the facility's wireless call light report, dated 05/05/25 showed: -At 3:19 A.M., room [ROOM NUMBER] with call light response time of 39 minutes; -At 4:31 A.M., room [ROOM NUMBER] with call light response time of 37 minutes; -At 5:35 A.M., room [ROOM NUMBER] with call light response time of 1 hour and 16 minutes; -At 6:21 A.M., room [ROOM NUMBER] with call light response time of 31 minutes; -At 7:04 A.M., room [ROOM NUMBER] with call light response time of 1 hour; -At 7:59 A.M., room [ROOM NUMBER] with call light response time of 33 minutes; -At 12:01 P.M., room [ROOM NUMBER] with call light response time of 37 minutes; -At 12:03 P.M., room [ROOM NUMBER] with call light response time of 35 minutes; -At 1:26 P.M., room [ROOM NUMBER] with call light response time of 31 minutes; -At 3:08 P.M., room [ROOM NUMBER] with call light response time of 52 minutes; -At 3:52 P.M., room [ROOM NUMBER] with call light response time of 1 hour and 17 minutes; -At 4:01 P.M., room [ROOM NUMBER] with call light response time of 1 hour and 21 minutes; -At 4:40 P.M., room [ROOM NUMBER] with call light response time of 1 hour and 5 minutes; -At 5:05 P.M., room [ROOM NUMBER] with call light response time of 36 minutes; -At 5:15 P.M., room [ROOM NUMBER] with call light response time of 36 minutes; -At 5:18 P.M., room [ROOM NUMBER] with call light response time of 36 minutes; -At 5:24 P.M., room [ROOM NUMBER] with call light response time of 32 minutes; -At 6:21 P.M., room [ROOM NUMBER] with call light response time of 38 minutes; -At 6:54 P.M., room [ROOM NUMBER] with call light response time of 31 minutes; -At 11:37 P.M., room [ROOM NUMBER] with call light response time of 33 minutes; -At 11:52 P.M., room [ROOM NUMBER] with call light response time of 38 minutes. 6. During an interview on 05/05/25 at 9:39 A.M., Resident #24 said call lights sometimes go unanswered for over 15-20 minutes and gets tired of waiting. He/She said he/she is supposed to wait for staff to help him/her transfer and walk. Sometimes there is two aides on each hall, but my hall is the one that gets hit with only one. He/She said staff is shorter mostly on the day hours but does happen on the nights too. During an interview on 05/05/25 at 9:57 A.M., Resident #39 said staffing is a huge issue. Staff take a really long time to answer call lights and makes him/her feel like they don't matter. He/She said sometimes he/she scoots down in the bed and it hurts his/her bottom when staff cannot come in a decent timeframe. During an interview on 05/05/25 at 9:57 A.M., Resident #29 said often call lights take over 30 to 40 minutes to be answered and is unacceptable. He/She said he/she has anxiety and one time it was elevated and it took over an hour to get a staff member to get his/her something for his/her anxiety. He/She said the aides are notified when the light is sounded, then if not answered, goes to the nurse, then the management. He/She said he/she has expressed his/her concern with management but has not heard back. The resident said he/she is not a high call bell user, but when pressing it, there is a need. He/She believes staff should answer the lights within 15 minutes or less. During an interview on 05/05/25 at 10:27 A.M., Resident #26 said there isn't enough staff to ensure he/she is out of bed for activities. The resident said he/she requires a mechanical lift to get into and out of bed and requires an extra staff member. Often times, he/she puts on the call light and staff push it off, leave to get help and either do not return or its 30 minutes to an hour later. He/She said one night he/she pushed the call light and requested to go to bed. He/She said it took over three hours to get put to bed. The resident said he/she brought the concern to the management but is told they are doing the best they can and/or they cannot find good people to work. He/She feels like since he/she takes a little bit longer for care, he/she is put on the bottom of the aides list. During an interview on 05/05/25 at 11:17 A.M., Resident #35 said staff do not get him/her up when he/she wants to get up, and is often told it's because they dont have enough help, he/she is a mechanical lift transfer. The resident said staff will often come into their room, shut the call light off, and say they will come back but don't. During an interview on 05/05/25 at 2:53 P.M., Resident #21 said there isn't enough staff. He/She said it takes over 40 minutes to answer his/her light he/she hates to sit in bowel movement. He/She gets tired of the staff that are just working for a paycheck. The resident said he/she is at the facility because he/she needs care and expects staff to provide it, timely. During an interview on 05/06/25 at 9:23 A.M., Resident #4 said call light times are long on days and evenings. The resident said, I've waited over two hours quite often. During an interview on 05/08/25 at 10:18 A.M., Certified Nurse Aide (CNA) D said call lights could take a little longer when the facility is short staffed but most of the time the average time to answer call lights is around five to eight minutes and does not know of any resident complaints of long call light times. He/She said 10 minutes or longer to let a call light to go unanswered is unacceptable because to a resident, it may feel a lot longer or the resident may have fell or some other accident may have happened. He/She said when there are times when there isn't enough staff, the current staff will team up and work together to get things done. During an interview on 5/8/25 at 11:15 A.M., Licensed Practical Nurse (LPN) E said the average call light wait time is around 20-30 minutes but should be less than 15. He/She said the time of day plays a part in long call lights such as around meals and right after supper, which is when staff are assisting a lot of residents, treatments are being completed, and that some of the residents can be demanding. He/She said having to wait that long can increase the risk of resident harm, depending on their critical care needs. The nurse said that he/she believes that only nursing staff have access to the nurse call system and are the only ones who can access the call lights. Residents do complain about having to wait, but staff do the best they can. During an interview on 05/08/25 at 12:58 P.M, LPN A said the average call light response time is between eight and 10 minutes but during meals may go up to 15 minutes. He/She said the staff do the best they can for what they have. Some days more help is needed but the management is good about getting agency staff to help out. If call lights go beyond 15 minutes or longer, the resident could be in distress or there might be an emergency. During an interview on 05/08/25 at 03:35 P.M., the Director of Nursing (DON) said the average call light response time is around 11 minutes and would be considered unacceptable to go beyond 15 minutes. He/She said staff don't know if there is an emergency or not or life and death. He/She said just nursing has access to the call light system and is set up to go through an application on either the facility provided device or the staff's personal cell phone. He/She said he/she reviews the call light log but was not aware of the call lights going beyond 30 minutes as presented in the call light report. During an interview on 5/8/25 at 4:24 P.M., the Administrator said staff call light response time for the past month and half has been 10-15 minutes. He/She said going over 15 minutes to respond to a residents call light is unacceptable. The Administrator said that sometimes the staff will answer the call light and if unable to meet the needs will leave the light on so that they don't forget. The call light logs are discussed in the facility Interdisciplinary Team meetings and notifications come up on his/her phone all the time. He/She said he/she calls the facility weekly to discuss with staff how to improve time management and is aware call lights are an issue. There is enough staff but the current staff need better training in time management.

Based on interview and record review, facility staff failed to obtain a timely advanced directive who received Cardiopulmonary Resuscitation (CPR) when he/she elected to be a Do Not Resuscitate (DNR - indicates that, in case of respiratory or cardiac failure, the resident has directed that no cardiopulmonary resuscitation or other life-sustaining treatments or methods are to be used) and failed to document residents' code status consistently as a DNR for one resident (Resident #1). The facility census was 62. 1. Review of the facility's Advance Directives policy, revised [DATE], showed advanced directives will be respected in accordance with state law and facility policy. The resident has the right to refuse treatment. A resident will not be treated against his/her wishes. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The plan of care for each resident will be consistent with his/her documented treatment preferences. 2. Review of Resident #1's medical record showed: -admitted to facility on [DATE]; -Expired at facility on [DATE]; -A signed DNR form dated [DATE]. Review of the resident's Physician Order Sheet (POS), dated February 2025, showed the record did not contain an order for his/her code status or advanced directive. Review of the resident's care plan, dated [DATE], showed staff documented the resident code status as DNR. Review of the resident's nurses notes, dated [DATE] at 5:49 A.M., showed staff documented staff found the resident with no pulse, no respirations and cyanotic (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood). Uncertain of code status CPR s started until discovered the resident code status of DNR on his/her facesheet. During an interview on [DATE] at 9:59 A.M., the Diretor of Nursing (DON) said all residents code statuses are kept at the nurses station in a binder and on outside of their doors with a green sticker indicating full code and a red sticker indicating DNR. He/She does not know why staff did not follow the residents wishes. During an interview on [DATE] at 10:00 A.M., the administrator said code statuses are displayed next to the resident's name on the outside of their door and there is a book with the residents DNR forms at the nurses stations. The administrator said he/she does not know why the staff did not look before performing CPR and the expectation is the code statuses are able to be identified quickly for staff to make the right medical decision. During a phone interview on [DATE] at 11:19 A.M., Licensed practical nurse (LPN) A said he/she did not know the residents code status and he/she erred on the side of caution and started to perform CPR. He/She said an aide called emergency medical services and they took over CPR upon arrival. He/She said he/she found the residents advanced directive and they stopped life saving measures. He/She said he/she was not aware there was a book at the nurses station with code statuses and does not remember if the resident had a green sticker on his/her name plate outside his/her room but his/her room mate did and was a full code. He/She said he/she thought he/she was doing the right thing. MO00251388

Based on observation, interview, and record review, facility staff failed to provide care to meet the hygiene needs for four residents (Resident #1, #2, #3 and #4) out of five sampled residents when staff did not provide nail care and assist with facial hair. The facility census was 64. 1. Review of the facility's Activities of Daily Living (ADLs), Supporting policy, dated March, 2018, showed staff were directed as follows: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to care out ADL; -Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. -Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable; -Appropriate care and services will be provided for resident who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care); -If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 12/26/24, showed staff assessed the resident as follow: -Severe cognitive impairment; -Did not reject of care; -Resident completed personal hygiene by himself/herself. Review of the residents care plan, dated 01/09/25, showed the resident mostly independent with activities of daily living (ADL), but required some cues and reminders. The plan showed staff were directed to check the resident's nail length, trim and clean on bath days and as necessary. Review of the resident's shower sheets, dated 01/24/25, 01/28-25, 01/31/25, 02/07/25, 02/11/25, 02/14/25, 02/18/25, 02/20/25, and 02/21/25, showed it did not contain documentation staff provided nail care or assistance with facial hair. Observation on 02/21/25 at 8:45 A.M., showed the resident nails long with debris under the nail and with facial hair. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Exhibited rejection of care one to three days during the seven day look back period; -Required substantial to maximal assistance from staff with personal hygiene. Review of the resident's care plan, dated 12/31/24, showed the resident has an ADL self-care performance deficit and required extensive assistance from one staff for personal hygiene. Review of the resident's shower sheets, dated 01/24/25, 01/28/25, 01/31/25, 02/07/25, 02/18/25, and 02/21/25, showed it did not contain documentation staff provided nail care or assistance with facial hair. Observation on 02/21/25 at 12:02 P.M., showed the resident had long, uneven nails. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not reject care; -Required set up or clean up assistance only with personal hygiene. Review of the resident's care plan, dated 01/02/25, showed the resident has an ADL self-care performance deficit and required minimum assistance to stand by assistance only of one for personal hygiene. Review of the resident's shower sheets, dated 01/22/25, 01/25/25, 01/29/25, 02/04/25, 02/05/25, 02/08/25, 02/12/25, 02/19/25, 02/20/25, and 02/21/25, showed it did not contain documentation staff provided nail care. Observation on 02/21/25 at 9:26 A.M., showed the resident nails long with debris and with facial hair. During an interview on 02/21/25 at 9:26 A.M., the resident said staff would trim his/her nails, but he had to ask them to provide care. He/She said his/her left hand was contracted and required assistance from staff for care. He/She said sometimes his/her nails dug into his/her skin, causing pain, and the length of his/her nails, bothered him/her. 5. Review of Resident #4's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not reject of care; -Required partial to moderate assistance from staff with personal hygiene. Review of the resident's care plan, dated 12/31/24, showed the resident has an ADL self-care performance deficit related to confusion and required moderate to maximum assistance from one staff with personal hygiene. Review of the resident's shower sheets, dated 01/21/25, 01/28/25, 01/31/25, 02/04/25, 02/07/25, 02/11/25, and 02/18/25, showed it did not contain documentation staff provided nail care or assistance with facial hair. Observation on 02/21/25 at 11:40 A.M., showed the resident's hair was unkempt, he/she had long nails with debris and un-groomed facial hair. During an interview on 02/21/25 at 11:43 A.M., Certified Nurse Aide (CNA) A said staff should have brushed the resident's hair after getting the resident out of bed, but did not think about it. He/She said he/she normally checked resident's nails daily, but did not have a chance to look at the resident's nails yet. During an interview on 02/21/25 at 11:52 A.M., the resident said sometimes the staff would trim his/her nails and brush his/her hair. He/She said the long nails do bother him/her. 6. During an interview on 02/21/25 at 11:43 A.M., CNA A said resident's are provided nail care and assistance with facial hair on shower days and as needed. He/She said staff are directed to brush residents hair when assisted out of bed. He/She said if the resident's nails have debris under them, there is an infection control concern. During an interview on 02/21/25 at 12:13 P.M., Licensed Practical Nurse (LPN) B said staff provided nail care and assist with facial hair on shower days by the aides and resident's hair should be brushed in the morning and as needed. He/She said the concern with a resident with debris under the nails is the potential for infection. He/She said it was not dignified for the resident to not be well-groomed. During an interview on 02/21/25 at 3:42 P.M., Assistant Director of Nursing (ADON) said resident are provided nail care and assistance with facial hair on shower days and when needed. He/She said staff are directed to brush resident's hair in the mornings and when needed. He/She said if a resident refused care, staff are directed to offer care more often. He/She said if a resident had long nails with debris under the nails and spread bacteria to other parts of the body. During an interview on 02/21/25 at 3:43 P.M., the administrator said resident are provided nail care and assistance with facial hair on shower days and when needed. He/She said staff are directed to brush resident's hair in the mornings and when needed. He/She said if a resident refused care, staff are directed to offer care more often. He/She said if a resident had long nails with debris under the nails, it could be an infection control issue. He/She said the resident's have a right to be clean and would be considered a dignity issue if the resident was not well-groomed. MO00249746

Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for one resident (Resident# 2), and failed to update care plans at least quarterly in conjunction with the required Minimum Data Set ((MDS) a federally mandated assessment instrument), to provide interventions to meet individual needs for two residents (Resident #1 and #3) out of three sampled residents. The facility census was 68. 1. Review of the facility's Goals, Objectives, and Care Plans policy, revised April 2000, showed staff are directed as follows: -Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence; -Goals and objectives are entered onto the resident's so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved; -Goals and objectives are reviewed and/or revised at least quarterly. 2. Review of Resident #1's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Used a diuretic, opioid and hypoglycemic (medication for low blood sugar); -Used a wheelchair; -Dependent on staff for transferring in and out of tub/shower, toilet and to and from a bed to a chair or wheelchair; -Required setup or cleanup assistance from staff with eating and oral and personal hygiene; -Dependent on staff for toileting assistance; -Required substantial to maximal assistance from staff with showering and lower body dressing; -Required partial to moderate assistance from staff with upper body dressing; -Uses oxygen therapy. Review of the resident's care plan, dated 06/27/24, showed the care plan had not been updated with the 10/02/24 MDS assessment. 3. Review of Resident #2's entry MDS, dated [DATE], showed it did not contain documentation of a completed MDS Assessment. Review of the resident's care plan, dated 10/31/24, showed the care plan had not been updated with the resident's activities of daily living (ADL) or the specific anticoagulant medication with the 10/31/24 assessment. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Used an opioid, hypoglycemic and anticoagulant (medication used to prevent blood clots from forming or growing); -Independent for eating and oral hygiene; -Dependent on staff for toileting and lower body dressing; -Required substantial to maximal assistance from staff for bathing; -Required supervision from staff for upper body dressing; -Required setup assistance from staff for personal hygiene; -Used a wheelchair. Review of the resident's care plan, dated 05/01/24, showed the care plan had not been updated with the 10/26/24 MDS assessment. 5. During an interview on 12/23/24 at 1:31 P.M., the MDS Coordinator said he/she was responsible to update and/or revise the care plans on an quarterly and annual basis. He/She said the comprehensive care plan should be completed within twenty one days of admission. The MDS Coordinator said he/she started his/her position in June and had been working on fixing the care plans. During an interview on 12/23/24 at 2:24 P.M., the administrator said the MDS Coordinator was responsible to update and/or revise the care plans quarterly and annually. He/She said the comprehensive care plan should be completed within twenty one days of admission to the facility. He/She said the MDS Coordinator should be checking the care plans on a weekly basis to ensure the plans are completed according to guidelines. He/She said there was a form listing the residents scheduled care plan meetings as a resource for the MDS Coordinator. He/She said the facility hired a second person to assist with updating the care plans. During an interview on 12/23/24 at 2:25 P.M., the Director of Nursing (DON) said the MDS Coordinator was responsible to update and/or revise the care plans quarterly and annually. He/She said the comprehensive care plan should be completed by the MDS Coordinator within twenty one days from the date of admission. He/She said the MDS Coordinator should be checking the care plans on a weekly basis to ensure the plans are completed according to guidelines. He/She said there was a form listing the residents scheduled care plan meetings as a resource for the MDS Coordinator. He/She said the facility hired a second person to assist with updating the care plans. He/She said he/she just started his/her position and was working on getting the issue with the care plans resolved. MO00246774

Based on observation and interview, facility staff failed to ensure residents' privacy were protected, when six resident's (Resident's #2, #3, #7, #8, #9 and #16) out of 16 sampled residents, medical information were face up on the nurse station desks, in a public area visible by other residents and visitors to the facility. Facility census was 71. 1. Review of the facility's policy titled Confidentiality of Information and Personal Privacy, dated October 2017, showed the facility will strive to protect the resident's privacy in regards to his/her: accommodations; medical treatment; and personal care. Access to resident personal and medical records will be limited to authorized staff and business associates. 2. Observation on 09/25/24 at 10:27 A.M. and 10:31 A.M., showed the nurses station desk unattended with the resident report sheet face up, and contained Resident #2, #3, #7, #8, #9 and #16 code status, date of birth, allergies, and diagnoses. Observation showed multiple resident near the nurses station. 3. Observation on 09/25/24 at 10:33 A.M., showed Licensed Practical Nurse (LPN) E at the nurses station desk with the resident report face up. Observaton showed a visitor approached the desk. During an interview on 09/25/24 at 10:39 A.M., LPN E said the visitor is a friend of Residentwho had been discharged from the facility yesterday. During an interview on 09/25/24 at 1:19 P.M., LPN E said the paper on the desk is a report sheet and should not be face up on the desk. LPN said staff should flip the report sheet over on the desk when the staff leave the desk, where the resident's information is not visible. LPN E said that is LPN G's nurse report. During an interview on 09/26/24 at 3:00 P.M., LPN G said the nurse's report is supposed to be face down, if it's not, it could be a violation of the resident's privacy. The LPN G said he/she did not turn it upside down. During an interview on 09/26/24 at 11:39 A.M., the Director of Nursing (DON) said staff are supposed to keep papers turned over and covered at the Nurse's desk. The DON said the Nurse's report sheet has resident's private information and needs to be protected. The DON said he/she would expect staff to keep it covered, or turned over. 5. Observation on 09/25/24 at 1:50 P.M., showed the nurses desk with a physician visit note for Resident #16 face up with the residents medical information visible to the public and other residents. During an interview on 09/25/24 at 1:56 P.M., LPN A said he/she had been at the nurse's station and got up for a call light. The LPN said the physician note should not be face up for the resident's privacy. During an interview on 09/26/24 at 11:39 A.M., the Director of Nursing (DON) said progress notes have protected information on it and he/she would expect staff to keep it covered, or turned over. During an interview on 09/26/24 at 1:42 P.M., the administrator said staff should make sure resident's medical information is not available to public and he/she would expect staff to put it in a folder, flip over, or put in chair under desk. The administrator identified the two documents as a Nurse's report and a physician note. The administrator said the two documents should not be face up on the nurse's desk. MO00242199

Based on observation, interview, and record review, facility staff failed to ensure the residnet was free from a significant medication error when staff failed to administer of one resident's (Resident #1) Metolazone (a diuretic medication used to treat high blood pressure and edema) and Torsemide (a diuretic medication used to treat edema due to congestive heart failure (CHF), kidney disease, or liver disease) as directed by the physician and failed to notify the resident's physician the medication was not available to be administer which resulted in the resident being admitted to the hospital with acute chronic hypoxic respiratory failure (not enough oxygen in the blood), mild pulmonary edema with pleural effusion (fluid collected inside and outside of the lungs), and chronic kidney disease Stage IV. The facility census was 69. 1. Review showed the facility did not have a policy instructing staff what to do when a medication was not able to be started when ordered. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/20/23, showed staff assessed the resident as: -Cognitively intact; -Diagnosis of chronic kidney disease (CKD) (kidneys filter waste and excess fluid from the blood, as kidneys fail waste builds up), atrial fibrillation (irregular rapid heart rate that commonly causes poor blood flow), hypertension, (higher than normal blood pressure), and diabetes mellitus type II (the body is unable to produce enough insulin). Review of the resident's care plan, dated September 2023, showed staff documented the resident diagnoses of CHF. Interventions showed staff are directed to give cardiac medications as ordered and monitor/document/report any signs of congestive heart failure such as dependent edema (swelling to parts of the body influenced by gravity) of legs and feet, shortness of breath upon exertion, and crackles and wheezes upon auscultation (listening with stethoscope). Review of the resident's Physician Order Sheets (POS), dated November 2023, showed the physician ordered: -Lasix 40 mg give one tablet by mouth one time a day related to CKD in the morning, discontinue 11/2/23; -Lasix 40 mg give one tablet by mouth in the afternoon for edema, discontinue 11/2/23; -Metolazone 5 mg give one tablet by mouth one time only related to essential hypertension for one day, give 30 minutes prior to morning (A.M.) Torsemide, start 11/3/23; -Torsemide 40 mg give one table by mouth two times a day related to essential hypertension, start 11/3/23. Review of the resident's Medication Administration Record (MAR), dated November 2023, showed staff were directed to administer Metolazone 5 mg give one tablet by mouth one time only related to essential hypertension for one day, give 30 minutes prior to A.M. Torsemide, start 11/3/23 and Torsemide 40 mg give one table by mouth two times a day related to essential hypertension, start 11/3/23. Review showed the MAR did not contain documentation of the administration of Metolazone or Torsemide on 11/3/23 or 11/4/23. Review of the facility's order delivery report, dated 11/1/23 to 11/4/23, showed the residents Metolazone delivered on 11/3/23 and the Torsemide on delivered 11/4/23. Review of the nurses notes, dated 11/5/23 at 6:00 P.M., showed Licensed Practical Nurse (LPN) A documented the resident's family member asked if the resident had received his/her one time dose of Metolazone and started the Tosemide, because he/she had labored breathing. Upon assessment the resident had shortness of breath with oxygen on at 2 Liters/minute via nasal cannula (NC), inspiratory wheezing (a wheeze on inhale), a non productive cough, edema to both lower extremities, and a change in mental status. LPN A documented he/she reviewed the MAR and noted the resident's one time dose of Metolzaone and scheduled Torsemide had not been given as ordered. Review showed the resident's respirtory rate 24 and his/her blood pressure 154/66. Review of the nurses notes, dated 11/5/23 at 6:18 P.M., showed staff documented they notified the physician's office and received orders for an immediate x-ray, Guaifensin (medication for congestion), and breathing treatments every four hours for five days. Review showed staff documented the resident's family request he/she be sent to the hospital. Review of the nurses notes, dated 11/5/23 at 7:15 P.M., showed staff documented Emergency Medical Services (EMS) arried at the facility to transport the residnet to the hospital and staff notified the emergency room the resident was sent out. Review of the resident's hospital records, dated 11/5/23, showed the resident admitted with acute chronic hypoxic respiratory failure, COVID-19 pneumonia, mild pulmonary edema with pleural effusion, chronic kidney disease Stage IV, and urinary tract infection. During an interview on 11/9/23 at 11:10 A.M., Certified Medication Technician (CMT) D said nurses are responsible for entering orders in to the system. He/She said if he/she has any questions he/she asks the nurse. He/She said he/she saw the Metolazone and Torsemide on the MAR and had been ordered, but not delivered. He/She did not tell the nurse because the medications were ordered, but gave all other scheduled medications available to the resident for his/her shift. CMT D said he/she did not remember if he/she checked the back up medications, to see if the medication was available. He/She said he/she was not sure who was responsible for making sure medications are put in as delivered when they arrive from the pharmacy. During an interview on 11/9/23 at 11:28 A.M., LPN A said he/she was asked by the resident's family if he/she had received the new ordered medication from his/her cardiac appointment on 11/1/23. He/She said he/she checked the system to find the Metolazone had not been given and the resident had started the Torsemide on 11/4/23. The resident had been at his/her baseline on 11/5 and he/she was not told in report the resident was waiting on the medications. He/She said nurses are responsible for putting in the orders and the pharmacy receives them and fills them. He/She said staff are expected to check the Omnicell (backup medication location) to see if they have an initial dose before the pharmacy delivered the resident's medication. If they do not have the medication, staff are expected to notify the charge nurse. The nurse calls the pharmacy to see when the medication is expected to be delivered and to notify the physician to see if something different needs to be given until the medication arrives. He/She was not made aware by the CMT the medications were not available. He/She said the nurse would be responsible for changing the start and stop date on the one time dose medication. He/She said the Director of Nurses (DON) had been responsible for making sure this was completed, but was not sure who was responsible at this time. During an interview on 11/9/23 at 3:00 P.M., the Clinical Director said the charge nurse is responsible for putting in orders from the doctor. He/She said the pharmacy automatically fills the prescription when entered, because their system is synced with the pharmacy. He/She said pharmacy deliveries are normally delivered at the front nurse's station. The nurses or CMT's are expected to reconcile the medications delivered, marked as delivered in the system, and put the medications away in the medication carts. The Clinical Director said he/she put the new order in on 11/2/23 for the metolazone and torsemide and discontinued the resident's Lasix as ordered, and the new medications were ordered to start on 11/3/23. He/She said staff are expected to check the Omnicell to see if the medication is available if it is not on the medication cart. If the medication is not available, the CMT is expected to notify the charge nurse and the charge nurse is expected to contact the pharmacy and the physician. The nurse should also change the start date when the medication is delivered so the order is updated in their system. He/She said the nurses are responsible for checking the start and stop dates. He/She said the CMT should have reported to the charge nurse when the medication was unavailable so the pharmacy and doctor could be notified and see what, if anything should be done. The Clinical Director said he/she has been responsible for making sure orders have been put in correctly and followed, but it is typically the DON or Assistant Director of Nurses (ADON). During an interview on 11/22/23 at 10:13 A.M., CMT E said he/she does not remember what medications he/she checked in but knows he/she put all medications delivered on 11/3/23 in the appropriate medication carts. He/She did not tell the nurse the resident's medication had been delivered, because he/she did not know the resident was waiting on it. He/She said he/she did not know there was an area to mark the medications as received in point click care. If a medication is not available to give, staff are to check the omnicell and report to the charge nurse so they can call the doctor. He/She said the nurse would be responsible for changing the start and stop date of medications. He/She does not know who is responsible for checking to make sure orders are put in and filled. During an interview on 11/22/23 at 1:49 P.M., CMT F said the nurses are responsible for putting in orders. He/She said if a medication is not available staff are to check to the Omnicell and notify the charge nurse. He/She said he/she was not made aware by the night nurse the medication had been delivered. He/She said he/she did not see the resident's Metolazone on the cart or on the MAR but could have overlooked it if it was a single dose medication, because the resident's medication come in a rollpack with contains all the medications the resident takes during a specific time period. He/She said if there were any medications on the MAR not available he/she would have checked the Omnicell and notified the nurse. He/She said the ADON would be responsible for checking to make sure orders are put in and followed. During an interview on 11/22/23 at 3:03 P.M., CMT H said nurses are responsible for entering orders. He/She said he/she believes the DON and ADON would be responsible for making sure the orders are put in and followed. He/She said if a medication is unavailable, staff are expected to check the omnicell and report to the charge nurse if it is not available. He/She said he/she told the nurse the medications were not available, but does not remember the nurse he/she told. He/She said there is an option to mark if the medication has been received but he/she does not know if staff are supposed to mark it or not. He/She was not made aware the resident was waiting on medications at shift change. During an interview on 11/22/23 at 3:20 P.M., LPN C said nurses are responsible for putting in orders and he/she is not sure who is responsible for making sure they are put in and followed. He/She said staff are the check the omnicell and tell the charge nurse if the medication is not available. He/She was not made aware the resident's medication was not available and was not made aware the resident was waiting on medications when he/she received report. He/She said the pharmacy and doctor should have been notified and the start and stop date adjusted at the doctors discretion. LPN C said he/she has reconciled medications before, but the CMT's are responsible for putting them away in the medication cart. During an interview on 11/30/23 at 1:35 P.M., the physician said he/she would expect staff to notify his/her office or the on call staff if a medication was not available to start as ordered. He/She said the resident needed to be on a diuretic (medication used for edema and fluid retension) due to his/her diagnoses. He/She said it is a possible cause of the resident's change in condition. MO00227070

Based on observation, interview, and record review, facility staff failed to provide care consistent with professional standards of practice to promote the prevention of pressure ulcer (PU) development for one resident (Resident #52) after staff identified the resident was at risk for PUs. Additionally, staff failed to obtain a physician ordered treatment for an unstageable wound to the resident's coccyx, from 11/16/22 to 12/22/22, more than 30 days after the start of the PU, failed to obtain a physician ordered treatment for an unstageable PU to the resident's left hip discovered on 12/31/22, failed to follow the resident's plan of care to prevent additional pressure injuries (PI)s and promote the healing of PUs. Additionally, staff failed to document assessments, and failed to identify a new PI. The facility census was 80. Review of the National Pressure Injury Advisory Panels (NPIAP) definitions of staging showed: -Pressure Injury: localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear; -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum (liquid)-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue (pink/red tissues, bumpy in appearance), slough (liquefied or wet dead tissue, can be yellow or white in color) and eschar (dried dead tissue, can be tan, black, or brown in color) are not present; -Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury; -Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury; -Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. 1. Review of the facility's Prevention of Pressure Injuries Policy, dated April 2020, showed: -Inspect the skin on a daily basis when performing or assisting with personal care or Activities of Daily Living (ADLs); -Identify any signs of developing pressure injuries (i.e., non-blanchable erythema (redness); -Inspect skin pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); -Reposition the resident as indicated on the care plan; -Keep the skin clean and hydrated; -Clean promptly after episodes of incontinence; -Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team (IDT); -Provide support devices and assistance as needed (PRN). Remind and encourage residents to change positions; -Select appropriate support surfaces based on the resident's risk factors, in accordance with clinical practice; -Evaluate, report and document potential changes in skin; -Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's Wound Care Policy, dated October 2010, showed: -Verify there is a physician's order for this procedure; -Notify the supervisor if the resident refuses the wound care. 2. Review of Resident #52's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 10/18/22, showed staff assessed the resident as: -Severe Cognitive Impairment; -Did not have behaviors; -Did not reject care; -Totally dependent on two staff members for bed mobility, transfers, and dressing; -Did not have a Stage I PU or greater; -Clinical assessment and formal assessment completed to determine PU risk; -At risk for PUs; -No applications of ointments/medications other than to feet; -Diagnoses of displaced intertrochanteric fracture of right femur, initial encounter (hip fracture), peripheral vascular disease (a slow and progressive circulation disorder), stroke, Hemiplegia/Hemiparesis (severe and complete loss of strength/mild loss of strength); Cognitive communication Deficit (Difficulty with thinking and speaking). Review showed staff documented the resident was at risk for the development of PUs and did not document the use of pressure relief devices. Review of the resident's care plan, revised 1/25/23, showed: -Activity of Daily Living (ADL) self-care performance deficit related to activity tolerance, confusion, hemiplegia, impaired balance; -Totally dependent on one staff for repositioning and turning in bed every shift and as necessary; -Skin inspections weekly; -Turn and reposition every two hours and as needed. Keep body in good alignment; -Actual impairment to skin integrity of the right groin and coccyx; -Follow facility protocols for treatment of injury; -Follow treatment orders for dressing changes; -Heel protector to right foot while in bed; -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate, include any other notable changes or observations. Review of the resident's Skin Only Evaluation, dated 10/18/22, 10/25/22, and 11/8/22 showed staff documented the resident did not have a PU. Further review, showed it did not contain documentation in regard interventions used for PU prevention. Review of the resident's Skin Only Evaluations, dated November 2022, showed staff documented: -11/13/22: -New Left Inguinal Region, Pressure Ulcer/Injury; -3 centimeters (cm) in Length (L) by 2 cm in Width (W) by 0.2 cm in Depth (D); -Wound Odor: Yes; -Wound bed: Slough; -Wound exudate: Purulent: (thin, thick, opaque, tan/yellow drainage); -Dressing saturation: Moderate: 26-75 percent (%); -11/16/22: -Left Inguinal Region, Pressure Ulcer/Injury: No change from previous assessment; -New Issue: Coccyx: Deep tissue injury, Stage 2; -3 cm in L by 2.5 cm in W by 0.2 cm in D; -Wound Bed: Granulation tissue; -Wound exudate: Serosanguineous: thin, watery, pale red/pink drainage; -11/23/22: -Left Inguinal Region Pressure Ulcer/Injury; -3 cm in L by 2 cm in W by 0.2 cm in D; -Wound Odor: Yes; -Wound Exudate: Purulent -Dressing saturation: Moderate 26-75%; -Coccyx Deep Tissue Injury, Stage 2; -3 cm in L by 2.5 cm in W by 0.2 cm D; -Wound Bed: Granulation -Wound Exudate: Serosanguineous. Review of the resident's wound consult, dated 11/15/22, showed: -Contractures (lower extremities), other (left above knee Amputation (AKA), open sore; -Wound Left Groin is an unstageable PI obscured full-thickness skin and tissue loss; -3 cm in L by 1 cm in W with no measurable depth; -Moderate amount of serous (thin and watery and will usually have a clear to yellowish or brownish appearance) drainage with mild odor; -Wound bed is 76% to 100% slough; -The peri-wound skin exhibits erythema; -Temperature of peri-wound skin is warm with signs and symptoms of infection; -Wound Culture & Sensitivity (C&S), laboratory test used to determine type of bacteria present, and antibiotics the bacteria is sensitive to, pending; -New problem; -Wound Orders: Cleanse wound with Hypochlorous Acid (wound care agent with powerful microbicidal, antibiofilm, and wound healing potency). No need to rinse from wound or skin. Use to irrigate or scrub the wound bed. Protect peri-wound with skin protectant, apply a nickel thick amount of Santyl (gel used remove dead tissue from wounds) to wound bed, cover with gauze pad, change dressing daily, and PRN for soiling saturation, or unscheduled removal; -Advanced wound specialist to follow up in one week to reassess progress of wound/skin issue; -Plan of care discussed with facility staff; -Laboratory: Bacteria and Fungus identified. Review of the resident's progress notes, dated November 2022, showed staff documented: -11/19/22 at 6:44 P.M., the resident requested to go to the hospital. Stated the pain from the groin wound is worse. Rated pain a 10 out of 10 on a scale of 1-10 (one being minimal pain and 10 being excruciating pain). Wound appears worse, and has a foul odor. It is deeper and wider than previously noted. 3.5 cm in L by 1.8 cm in W, approximately 0.5 cm D. Message sent to physician to approve transfer; -11/22/22 at 4:15 P.M., resident readmitted from hospital. Review of the resident's wound consult note, dated 11/22/22 showed: -Contractures (hips); -Wound to Left groin is an Unstageable PI; -Measurements are 3 cm in L by 4.2 cm in W with no measurable depth; -Moderate amount of serous drainage with mild odor; -Wound bed is 76% to 100% slough; -The peri-wound skin exhibits erythema with warmth and signs and symptoms of infection; -11/15/22 culture positive for multiple organisms. Antibiotics started 11/18/22; -Quality of tissue compared to previous visit: No change; -Wound drainage compared to previous visit: No change; -Peri-Wound tissue compared to previous visit: No change; -Length and Width compared to previous visit: Deteriorated; -Cleanse wound with Hypochlorous Acid, use to irrigate or scrub the wound bed, protect peri-wound with skin protectant, apply Santyl nickel thick to wound bed, cover with gauze pad, change daily and PRN for soiling, saturation, or unscheduled removal; -Medications prescribed: Doxycycline hyclate (antibiotic) 100 milligrams (mg) twice daily (BID) for seven days with start date of 11/18/22 and Ciprofloxacin (antibiotic) 500 mg BID for seven days with start date of 11/18/22; -Report obtained from staff nurse regarding patient. Sent to hospital 11/19/22 due to severe pain; -High risk: Wounds could potentially worsen putting client at high risk of sepsis, infection or death. Review of the wound consult note, showed it did not contain documentation in regard to the resident's coccyx wound. Review of the Physician Order Summary (POS), dated November 2022 showed: -8/16/22: Heel protector to right foot while in bed; -11/13/22: Wound culture to Left Inguinal wound infection, Stat for infection to wound; -11/13/22: Wound care to evaluate and treat; -11/13/22: Apply Santyl to groin BID for wound to Left groin; -11/22/22: House supplement (health shake) two times a day (BID) for weight loss; -11/22/22: Apply Santyl to Left Groin BID; Review showed it did not contain a treatment order for the resident's coccyx wound, identified on 11/16/22. Review of the Administration Record, dated November 2022, showed: -11/13/22: Left Groin wound: Cleanse with normal saline (NS), pat dry, apply Santyl, and cover with dry dressing BID until healed; Review showed it did not contain documentation in regard to the resident's coccyx wound, identified on 11/16/22 or the heel protector to the right foot. Review of the resident's Significant Change in Status Assessment (SCSA) MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive Impairment; -Did not have physical or verbal behaviors directed towards others; -Did not reject care; -Required extensive assistance from two staff members for bed mobility and toileting; -Totally dependent on two staff members for transfers; -Had a lower extremity impairment to one side; -Uses a wheelchair; -One Stage 3 PU; -No Arterial/Venous Ulcers (ulcers that develop from lack of blood flow); -Pressure reducing device to bed; -No pressure reducing device to chair; -Receives Hospice Care; -Has diagnoses of hip fracture, PVD, stroke, Hemiplegia/Hemiparesis, and Cognitive communication deficit, does not have malnutrition. Review of the MDS showed it did not contain documentation of more than one pressure ulcer. Review of the resident's Skin Only Evaluations, dated December 2022, showed staff documented: -12/6/22: -Left Inguinal Region Pressure Ulcer/Injury; -4.5 cm L by 3.2 cm W by 0.2 cm D; -Wound Odor: Yes; -Treatment: Santyl; -Wound Bed: Slough; -Wound Exudate: Purulent; -Dressing Saturation: Moderate 26-75%; -Coccyx Deep Tissues Injury, Stage 2; -3 cm in L by 2.5 cm in W by 0.2 cm in D; -Wound Bed: Granulation tissue; -Wound Exudate: Serosanguineous. -12/8/22: -Left Inguinal Region Pressure Ulcer/Injury -No change since previous assessment; -Coccyx Deep Tissue Injury, Unstageable; -5 cm in L by 3.5 cm in W by 0.2 cm D; -Wound Bed: Necrotic (dead tissue). Review showed it did not contain a treatment for the resident's coccyx wound. Review of the Skin Only Evaluations, dated 12/13/22, 12/20/22, and 12/27/22 showed staff documented the resident's left inguinal wound and coccyx wound had no changes in size, odor, or appearance. Review of the Registered Dietician (RD)'S Progress Note, dated 12/13/22 at 8:46 A.M., showed the RD documented, Skin: Stage 3 pressure wound to left groin. Hospice care noted. Resident receives a regular diet with house supplement BID to aid in wound healing and help maximize nutritional intake. Review showed it did not contain documentation of the resident's coccyx wound. Review of the progress notes, dated December 2022, showed staff documented: -12/2/22 at 1:34 P.M., wound to coccyx 10 cm by 2 cm Deep Tissue injury (DTI). Hospice notified of wound and need for dressing order change; -12/2/22 at 6:38 P.M., Mood is pleasant, no unwanted behaviors witnessed; -12/5/22 at 12:22 P.M., Mood pleasant, no unwanted behaviors witnessed; -12/13/22 at 3:00 A.M., Mood pleasant, no unwanted behaviors witnessed; -12/14/22 at 3:32 P.M., This resident has a wound that was reviewed in IDT; -12/31/22 at 6:49 P.M., Incident Note: Resident has a new stage 2 pressure injury on the left hip. There are two spots. One measuring 2.5 cm by 2.5 cm the other 3.5 cm by 2.5 cm. Hydro-colloid dressing (wound dressing) applied. Review of the resident's POS, dated December 2022, showed: -12/2/22: Hospice Evaluation & Treatment; -12/6/22: Admit to Hospice Services; -12/17/22: Left Groin Wound: Cleanse with normal saline, pat dry, apply MediHoney (wound gel used for antibacterial properties), cover with dry dressing BID until healed; -12/22/22: Apply MediHoney and bordered gauze to coccyx wound daily, start date 12/23/22; Review showed the POS did not contain a treatment for the resident's coccyx wound from 11/16/22 until 12/22/23, and did not contain a treatment order for the pressure wound to the resident's left hip identified on 12/31/22. Review of the resident's Administration Record, dated December 2022, showed: -12/18/22: Left Groin Wound: Cleanse with NS, pat dry, apply MediHoney, and cover with dry dressing BID until healed; -12/23/22: MediHoney and bordered gauze to coccyx wound daily. Review of the administration record showed it did not contain a treatment for the resident's left hip pressure ulcer. Review of the resident's Skin Only Evaluations, dated January 2023, showed: -1/3/23: -Left inguinal Region Pressure Ulcer Injury; -4.6 cm in L by 3.2 cm in W by 0.6 cm in D; -Wound Odor: Yes; -Treatment: Santyl and gauze; -Wound Bed: Slough; -Exudate: Purulent; -Coccyx, Deep Tissue Injury, Unstageable; -6 cm in L by 2.6 cm in W by 0.5 cm in D; -Wound Odor: Yes; -Treatment Schedule: Daily; -Wound Bed: Necrotic; -New Issue: -Left Hip, Pressure Ulcer Injury, Stage 2; -6 cm in L by 0.5 cm in W by 0.1 cm in D; -Wound Odor: No; Review of the Skin Only Evaluations, dated 1/11, 1/17, and 1/24 showed: -Left Inguinal Region Pressure Ulcer/Injury; -Wound Odor: Yes; -Left Hip Pressure Ulcer/Injury; -Coccyx, Pressure Ulcer Injury; -Dressing Saturation: Moderate. Review showed evaluations did not contain documentation of each area of skin breakdown's width, length, depth, type of tissue, and exudate, Review of the resident's POS, dated January 2023, showed it did not contain a treatment order for the resident's left hip pressure ulcer. Review of the resident's Administration record, dated January 2023, showed it did not contain a treatment order for the resident's let hip pressure ulcer. Observation on 1/24/23 at 2:43 P.M., showed the resident lay on his/her left side in bed. Further observation, showed a blue heel boot on the floor at the head of the bed. Observation on 1/24/23 at 4:56 P.M., showed the resident lay on his/her left side in bed. Further observation, showed a blue heel boot on the floor at the head of the bed. Observation on 1/25/23 at 9:14 A.M., showed the resident lay on his/her left side in bed. Observation on 1/25/23 at 10:06 A.M., showed the resident lay on his/her left side in bed. Observation on 1/25/23 at 2:10 P.M., showed the resident lay on his/her left side in bed. During an interview on 1/25/23 at 2:15 P.M., Certified Nurse Aide (CNA) G said he/she thought a wound company comes in and sees the resident, but he/she did not know the last time they had been to the facility. The CNA said the resident always lays on his/her left side. He/She said the resident is not turned and repositioned, because he/she has a contracted left hip. He/She said he/she always lays the resident on his/her left side in bed, and has never been told to position the resident any other way. Additionally, the CNA said the resident is only gotten up for meals. The CNA said he/she works with the resident often. Observation on 1/26/23 at 9:03 A.M., showed the resident lay in bed on his/her left side. Observation on 1/26/23 at 9:11 A.M., showed Hospice Registered Nurse (RN) U entered the resident's room to provide wound care. During an interview on 1/26/23 at 9:15 P.M., Hospice RN U said he/she is at the facility two times week to see the resident but will now be there three times a week, to provide wound care. Additionally, RN U said the resident does not have pain with wound care, which is good and bad. Observation on 1/25/23 at 9:19 A.M., showed Hospice RN U removed gauze from the resident's left groin, measured an odorous wound, with a light pink wound bed covered with small raised bumps and white edges, cleansed the wound, as the resident cried out, and applied MediHoney and gauze. RN U said the wound measured 2.1 cm, and is hard to measure because the resident's hips are contracted. Further observation, showed a wound to the resident's coccyx, 50% of the wound bed had raised bumps and was pink in color, the wound tunneled (a passageway between the skin surface and organ spaces, caused by infection, sheer force of pressure, past surgical procedures at area of wound) at 12 O'clock (top of wound) and had yellow adherent slough near a small area of white tissue in the wound bed. A white shiny linear striation could be seen in the middle of the wound. The RN said the wound measured 10 cm x 8 cm and had a 5 cm x 4 cm area of granulation tissue, he/she said the yellow tissue was slough, and the wound had started tunneling prior to his/her current assessment. The RN did not measure the wounds depth. The resident cried out, and the RN applied MediHoney and bordered gauze to the wound. Additional observation, showed a wound to the resident's left hip, which the RN measured at 5.5 cm x 4 cm with a 2.2 cm necrotic (black) area. The wound had adherent yellow slough that pulled away from the edges of the wound, and had eschar. During an interview on 1/26/23 at 10:03 A.M., Hospice RN U said the resident's Left hip wound looked worse. He/She said sometimes the facility staff tell him/her the resident refuses care. He/She said he/she has tried to educate them on how to reapproach the resident, and other things to try. He/She said the resident has orders for pain medications and received the medication before wound care. He/She said the resident yells out that his/her bottom hurts when he/she's in the wheelchair. The RN said staff should turn and reposition the resident. He/She said the resident's wounds would get worse if the resident was not turned and repositioned regularly. RN U said the resident's PU to his/her coccyx was a Stage 3. He/She said the resident is so thin, you could palpate bone, but he/she does not have any meat on his/her bones. He/She said the resident's left hip, and left groin PUs were unstageable. Observation on 1/26/23 at 2:16 P.M., showed the resident lay on his/her left side in bed. Observation on 1/26/23 at 2:43 P.M., showed the resident lay on his/her left side in bed. Further observation, showed a blue heel boot on the floor at the head of his/her bed. Observation on 1/26/23 at 5:55 P.M., showed the resident lay on his/her left side in bed. Observation on 1/27/23 at 10:06 A.M., showed the resident lay on his/her left side in bed. Observation on 1/27/23 at 10:58 A.M., showed LPN I and NA N entered the resident's room to provide wound care. NA N pulled back the blankets on the bed and showed the resident's bottom. A urine saturated dressing peeled away from the resident's skin on his/her sacrum/coccyx. The resident's mattress was saturated with urine through the wet sheets. During an interview on 1/27/23 at 1:33 P.M., Certified Medication Technician (CMT) K said the resident has wounds to his/her bottom and groin. He/She said the resident is supposed to wear to boot to his/her right foot. He/She said the CNAs are responsible for ensuring the boot is on and the resident is turned and repositioned. He/She said staff should turn and reposition the resident. He/She said staff has access to care plans, but he/she could not figure out how to get to it. During an interview on 1/27/23 at 1:34 P.M., CNA G said staff should turn and reposition residents every two hours. He/She said the resident has a wound to his/her bottom and groin. He/she said the smell of the wound to the resident's groin has improved, but you can still smell it. He/She said the wound to the resident's left hip is new. He/She said the resident does not have any skin issues to his/her right foot. The CNA said the resident does not wear a heel boot to the right foot. He/She said if the resident refuses care, staff are supposed to document the refusal, and tell the charge nurse. CNA G said the resident does not refuse to be turned and repositioned, and he/she is always positioned on his/her left side because of the wound to his/her bottom. He/She said he/she thought the resident should always be positioned on his/her left side because of his/her wounds. He/She said he/she has not been directed to position the resident any other way. Observation on 1/27/23 at 1:40 P.M., showed CNA G entered the resident's room, pulled back the blankets, and removed the resident's sock to his/her right foot. Further observation, showed a an approximate 1 cm x 1 cm pink and purple area to the resident's medial malleolus (bony prominence on inner side of the ankle). When asked the CNA said the resident has had the area for a while. He/she said he/she could not remember if it was reported to the charge nurse. The CNA touched the area and it did not change color (unblanchable). He/She said he/she does not know what caused the area. During an interview on 1/27/23 at 1:52 P.M., LPN I said he/she is an agency nurse and works at the facility from time to time. He/She said he/she is familiar with the resident. He/She said the resident did not have any skin issues to his/her right foot that he/she was aware of. He/She said he/she does not know if the resident should have a heel boot on when in bed. He/She said there is not a treatment order for the heel boot. He/She said he/she would expect a heel boot to have a physician's order, be on the care plan, and be on the treatment record. The LPN said if staff found a new skin issue, they should report it the charge nurse. He/She said no one has reported a new skin issue for the resident to him/her. He/she said if an area was reported, he/she would assess the area, and obtain a treatment order. He/She did not know the resident did not have a treatment order for the left hip wound. He/She said the charge nurses are responsible for obtaining orders from the physicians. He/She said the resident does not refuse any care or treatment, but he/she said he/she is patient with the resident, and some of the staff is not. The LPN said if the resident did refuse care, he/she would stop, wait, and reapproach the resident at a later time. If that did not work, he/she said he/she would ask for help, and let the Director of Nursing (DON) know. LPN I said the resident has a Stage 3 or Stage 4 PU to the coccyx, a Stage 2 PU to the left hip, and another Stage 2 PU to the left groin. He/She said the resident has contractures to his/her left hip, and he/she assumes that is what caused the left groin pressure ulcer. He/She said he/she does not know if staff had anything in place to try and prevent the left groin PU. He/She said all residents should be turned and repositioned every two hours. He/She said staff should turn and reposition the resident because the resident is not able to do it himself/herself. He/She said staff is probably not turning and repositioning the resident because it's not in the charting. He/She said when he/she was in the resident's room earlier today he/she did notice the resident did not have a wedge or other positioning devices in the room. He/She said since the resident receives hospice care, he/she would think hospice would provide positioning wedges, or an air mattress. He/She said the resident should have something, and he/she does not. He/She said if staff are not turning and repositioning the resident, and not putting a heel boot on him/her, it can lead to further skin breakdown. He/She said the resident's hip wound could be from staff not turning and repositioning him/her. Additionally, he/she said the resident's wounds are worse than they were the last time he/she was at the facility, which could also be a result of the resident not being turned and repositioned. He/She said the resident eats, and staff have to feed him/her because he/she can't feed himself/herself. During an interview on 1/27/23 at 2:29 P.M., the DON said said hospice care was considered because the resident was not doing well, and family approved it. He/She said the resident was not eating and was refusing wound care. He/She said staff completed wound treatments and assessments until January, and since then hospice has completed them. He/She said the last wound documentation in the computer system is from 1/3/23 because hospice completes all the wound assessments. He/She said facility staff does not complete the wound assessments. He/She said the facility does not have a dedicated wound nurse, and wound assessments are the responsibility of the charge nurse. He/She said the hospice nurse will be coming to the facility daily now. He/She said the resident was seeing a wound consultant but that was discontinued in December due to the resident qualifying for hospice services. The DON said he/she expects staff to turn and reposition residents every two hours, and if the resident refuses it should be charted. He/She said due to the resident's wounds to his/her hip, groin, and bottom he/she should be kept off of his/her hip as much as possible. He/She said he/she expects staff to use pillows, wedges or anything to position the resident. He/She said he/she did not know staff were not turning and repositioning the resident. He/She said no one has told the staff not to turn and reposition him/her due to his/her contractures. He/She said he/she assumes the resident does not have an air mattress because he/she rolled out of bed. During the interview, the Assistant Director of Nursing (ADON) came in the room and said a Nurse Practitioner was in the facility, and suggested the facility contact hospice because the resident's wounds are not healing, and he/she suspected the resident had osteomyelitis to the left groin and left hip. The DON said if the resident has an order for ankle boot staff should ensure the ankle boot is in place. He/She said the resident had blue ankle boots at one time, but he/she did not know what happened to them. He/She said the order should be on the POS, Administration Record, and in the care plan. He/She said he/she does not know why it is not on the administration record. He/She said he/she has not seen the resident with an ankle boot on. The DON said if staff is not turning and repositioning the resident, and not ensuring he/she has an ankle boot on, if it's ordered, it could cause further skin breakdown, and for his/her existing wounds to become worse. He/She said if a CNA notices any skin changes, it should be reported to the charge nurse. He/She said he/she would expect staff to assess and document the area. He/She said he/she did not know the resident has has an unblanchable area to his/her inner ankle. The DON said he/she saw the resident's coccyx and groin wound in December, but has not seen them since. He/She said he/she has not see the wound to the resident's left hip. He/She said the facility is in the middle of switching wound consultants, he/she said he/she did not know the wound contsultant did not see the resident's coccyx wound. During an interview on 1/27/23 at 3:32 P.M., LPN I said it is the responsibility of the charge nurse to obtain treatment orders. He/she said if the resident is a hospice resident it is still the charge nurses responsibility to ensure care is completed, and obtain orders. Additionally, LPN I said he/she was informed the NP who was in the facility earlier was not allowed to give orders for the resident, because the resident receives hospice services. He/She said the NP said he/she wanted additional imaging completed because he/she felt the resident's coccyx wound could be causing the wound to the resident's left hip and felt it was due to osteomyelitis. He/She said he/she would also be notifying hospice the resident does not have a treatment order for the PU to the left hip, and in regard to new suspected deep tissue injury (SDTI) to the resident's right inner ankle. During an interview on 1/27/23 at 4:10 P.M., the DON said he/she was aware the resident did not have a treatment order for the PU to his/her left hip, and did not have one for a period of time for the coccyx wound. He/She said the facility is ultimately responsible for completing wound assessments and obtaining treatment orders. He/She said the physician has been notified in regard to a treatment for the left hip PU. He/She said Physician T resigned on 12/31/22, and the new Medical Director will not give any new orders without first seeing the residents, and he/she will not give any orders for residents who receive hospice services. He/She said staff could obtain orders from the Hospice Medical Director, and he/she did not say if staff has contacted them. <b[TRUNCATED]

Based on observation, interview and record review the facility failed to accurately assess one resident's (Resident #1) right heel blister as pressure related and failed to consistently provide appropriate interventions for a resident identified by the facility as being at risk for pressure ulcers. The facility census was 75. 1. Review of the Resident Assessment Instrument (RAI) manual dated July, 2010, which is utilized by facility staff in developing individualized care plans, showed the following documentation: "A Stage II pressure ulcer is a partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red-pink wound bed. May also present as an intact or open/ruptured blister." Review of the facility's undated Wound Care and Procedure policy for a Stage II pressure ulcer showed it directed licensed facility staff to complete the following: - Complete a Wound Tracking Form; - The doctor is to be notified; - Initiate treatment as recommended by the doctor; - The nurse must complete the assessment of the wound on the Wound Tracking Form every Tuesday. Record review of the resident's comprehensive Minimum Data Set, a federally mandated assessment instrument, dated 06/05/13 showed staff assessed the resident as follows: - Alert and oriented; - Dependent on staff for bed mobility and transfers; - Frequently incontinent of feces and bladder; - At risk for developing pressure ulcers; - No pressure or veinous ulcers on admission; - Turning and repositioning program; - Pressure relieving device in bed; - [DIAGNOSES REDACTED]. Review of the resident's comprehensive plan of care dated 06/13/12, showed staff recorded the resident as being at risk for possible skin breakdown due to his/her mobility, poor oral intake, incontinence, [MEDICAL CONDITION] and his/her recent history of gangrene with amputation of his/her left great toe. The facility staff were directed to provide the following interventions for the resident: - Administer treatments as ordered and update the doctor of progress; - Assist of two staff for bed mobility as needed such as pulling up in bed; - Monitor for signs or symptoms of pain; - Administer medications as ordered; - Monitor surgical site for signs or symptoms of infection; - Apply surgical boot for his/her left foot. Further review showed the resident's care plan did not contain interventions for the prevention of pressure ulcers even though staff assessed the resident at risk for developing pressure ulcers. Review of the facility's Wound Tracking Form dated July, 2013 showed the staff did not record weekly assessments of the resident's right heel blister to include stage, wound appearance, presence or absence of drainage, measurements, presence or absence of odor or color of the surrounding tissue. Review of the resident's nurses notes dated 07/09/13 on the 7:00 A.M. to 3:00 P.M. shift showed staff documented the following: New order from Physician A to start physical therapy. Physician A notified regarding intact blister on "left" heel area greenish gray with odor. During an interview on 08/02/13 at 9:00 A.M. Registered Nurse (RN) B said the resident did not have a blister on his/her left heel; it was on his/her right heel. Review of Physician A's progress notes dated 07/09/13 showed he/she documented an assessment of the resident's left great toe amputation. Further review showed Physician A documented the resident did not have any new complaints. Physician A documented the resident had a [DIAGNOSES REDACTED]. Review of the resident's nurses notes showed staff recorded the following: - 07/10/13 (7:00 A.M. to 3:00 P.M. shift), staff recorded the resident's right heel blister dry with heel protector in place; - 07/11/13 (7:00 A.M. to 3:00 P.M. shift), staff recorded the resident's right heel blister dry with right heel in bootee; - 07/12/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded the resident's right heel blister dry; - 07/13/13 showed licensed staff did not record an assessment of the resident's right heel blister; - 07/14/13 (7:00 A.M. to 3:00 P.M. shift) licensed staff recorded the resident's blister to his/her right medial heel noted. Staff documented the blister was covered with [MEDICATION NAME] to protect from opening. Staff documented a posey boot secured to right foot and elevated. Review of the resident's plan of care, showed staff added the following on 07/14/13: Blister intact on right heel. Staff did not document any interventions regarding the right heel blister. Review of Physician A's progress notes dated 07/15/13 showed he/she documented an assessment of the resident's "new" right heel blister and included a [DIAGNOSES REDACTED]. Review of the resident's plan of care, showed on 07/15/13, staff added the following: The resident's podiatrist documented new orders in his/her progress note and orders received. Treatments as ordered. Review of the resident's nurses' notes, showed staff documented the following: - 07/15/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded the resident's right heel blister intact; - 07/16/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded the resident's right heel intact; - 07/16/13 (3:00 P.M. to 11:00 P.M. shift) staff recorded the resident's blister intact to his/her right heel; - 07/17/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded the resident's right heel blister intact; - 07/18/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded the resident's right heel blister open and received a treatment order to apply triple antibiotic ointment to the blister and cover with gauze 4 x 4 and Kerlix (gauze bandage roll) daily until healed; - 07/19/13 showed licensed staff did not record an assessment of the resident's right heel blister; - 07/20/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded the resident's blister to his/her right heel was dry; - 07/21/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded the resident's blister to his/her right heel with slight serosanguineous (watery bloody drainage). Staff did not record they notified the resident's physician of the change in the resident's right heel blister; - 07/22/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded the resident's right heel with some serosanguineous drainage; - 07/23/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded the resident's right heel blister without drainage; - 07/24/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded the resident's right heel with small amount of serosanguineous drainage; - 07/25/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded a new order to paint (apply) [MEDICATION NAME] (substance applied to skin to reduce the chances of infection) to the resident's right heel daily; - 07/26/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded they completed the resident's right heel treatment as ordered with [MEDICATION NAME] and cover with 4 x 4 gauze and Kerlix; - 07/27/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded they administered treatment to his/her right heel blister as ordered; - 07/28/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded the resident's right medial (middle) heel was necrotic (dead skin tissue) and appeared to have a pocket of loose skin to posterior region. Staff recorded they administered the resident's treatment as ordered. Staff did not record they notified the resident's physician of the change in the resident's right heel blister; - 07/29/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded they completed the treatment to the resident's right heel blister and painted it with [MEDICATION NAME] and covered with 4 x 4 gauze and Kerlix. Staff recorded they noted a small amount of yellowish drainage on the old dressing. Staff did not record they notified the resident's physician of the change in the resident's right heel blister; - 07/30/13 the staff did not record an assessment of the resident's right heel wound; - 07/31/13 (7:00 A.M. to 3:00 P.M. shift) staff recorded the resident's right heel had eschar (dead leathery skin tissue). Staff recorded the right heel wound did not have any drainage. Observation on 08/02/13 at 8:35 A.M., showed the resident lay in bed with loosely fitting blue foam boots on his/her feet. Observation on 08/02/13 at 9:45 A.M. showed the resident sat in his/her recliner in his/her room. Further observation showed his/her right foot in a blue foam boot. Registered Nurse (RN) B removed the resident's blue foam boot and old dressing from his/her right foot. Observation showed an area to the inner aspect of his/her right heel which measured approximately 3.0 centimeters x 2.0 centimeters. The wound bed was covered with eschar and no odor or drainage was apparent. During an interview on 08/02/13 at 10:35 A.M. the resident said he/she did not believe he/she wore a heel protector on his/her right foot prior to the blister developing. During an interview on 08/02/13 at 10:40 A.M. the Assistant Director of Nursing (ADON) said the facility did not track vascular ulcers as they did pressure ulcers. The ADON said for non-pressure wounds the nurses document the wound appearance in the nurses notes. During an interview on 08/02/13 at 11:50 A.M. the ADON said due to the resident's vascular diagnosis, they assessed the heel blister as a vascular ulcer versus a pressure ulcer. During an interview on 08/06/13 at 10:00 A.M. Physician A said the resident's right heel blister was due to "pressure" from rubbing his/her heel on the mattress. Physician A said the resident did not have good circulation, and if there was a lot of pressure on one area it could lead to a pressure ulcer forming. Physician A said even after he/she ordered the resident to have foam boots on in bed, there was "many a time" he/she would visit the resident and find he/she would not have foam boots on in bed. Physician A said there were also times when the resident did have the foam boots on but "loosely" so they would fall away from "not" fitting securely around the resident's feet. Physician A said he/she felt the blister "was avoidable" because if the resident would have had heel protectors on to begin with, he/she doubted if the blister would have developed. Physician A said he/she would expect the nurses to document on the wound during dressing changes to include any change in the appearance of the wound. Physician A said he/she would expect to see, at least, "weekly" measurements to monitor for changes in the size. During an interview on 08/12/13 at 10:45 A.M., Licensed Practical Nurse (LPN) C said he/she was approached by the resident's family member on 07/14/13 and was asked by the family member if the resident had a treatment for [REDACTED]. LPN C said he/she was not informed of it during the morning report with the 11:00 P.M. to 7:00 A.M. shift. LPN C said he/she reviewed the resident's treatment record, did not see a treatment for [REDACTED]. LPN C said he/she wrote a nursing order to monitor the blister for intactness each shift, cover the resident's right heel blister with [MEDICATION NAME] (padded foam dressing) and for the resident to wear a posey boot (heel protector) to his/her right foot at all times until the resident's primary care physician could assess his/her right heel blister. LPN C said there were already heel protectors in the resident's room, but "none" on his/her right foot, at that time, so he/she placed one on his/her right foot. LPN C said he/she sent a facsimile (fax) on 07/14/13 to the resident's primary care physician concerning the resident's right heel blister. During an interview on 08/13/13 at 8:25 A.M., Physician A said he/she was first made aware of the resident's right heel blister through a fax he/she received on 07/15/13 from someone at the facility who asked if he/she was aware of the resident's right heel blister, and he/she responded, no, but he/she would see the resident that day. Physician A said the fax also included the measurement of the blister which was 1.0 centimeter in size. Physician A said he/she checked the resident's records he/she had in his/her office and could not find any documentation concerning the resident's right heel blister prior to 07/15/13. Physician A said for a wound to be greenish-gray with an odor might indicate an infection or gangrene but it would also depend on additional assessment of the surrounding tissue. Physician A said typically an intact blister would not have an odor. During an interview on 08/13/13 at 12:50 P.M. the Director of Nurses (DON) said the decision to assess the resident's right heel blister as vascular instead of pressure was based on his/her vascular diagnosis. The DON said she expected staff to keep heel protectors on the resident as the physician ordered and especially after he/she developed the blister. During an interview on 08/19/13 at 7:05 A.M. Physician A said the resident's right heel blister was due to "pressure." Physician A said the resident has a [DIAGNOSES REDACTED]. Physician A said if the resident had developed a blood clot in his/her ankle, then he/she could safely say it was caused by his/her [MEDICAL CONDITION]; however the chance he/she had developed a blood clot in his/her heel was very doubtful. Physician A said the cause was from the resident rubbing his/her heel on the mattress which could have been avoided by him/her wearing heel protectors. MO 808