Every finding on record at Joplin Gardens

Based on record review and interviews, the facility failed to ensure all residents were kept free from possible accident hazards when staff failed to follow the care plan regarding the use of a mechanical lift for a transfer resulting in one resident (Resident #1) suffering a fracture to the upper arm. A sample of six residents was reviewed for transfer safety. The facility census was 76.On 02/17/26, the Administrator and Director of Nursing (DON) were notified of the Past Non-Compliance that occurred on 02/16/26, at 10:30 A.M., which resulted in injury to Resident #1. On 02/17/26, the Administrator completed a root cause analysis and investigation into the incident and educated employees involved. The Administrator and DON in-serviced all employees regarding company expectations and policies for resident transfers, including following care plans pertaining to the use of mechanical lifts or gait belt assist for transfers. The noncompliance was corrected on 3/10/26. Review of the facility's policy entitled Hydraulic Lift (Hoyer Lift), undated showed the following:-Follow the manufacturer's instructions when using any type of hydraulic lift;-The purpose of the use of a hydraulic lift was to enable one individual to lift and move a resident safely.Review showed the facility did not provide a policy related to care plans.1. Review of Resident #1's face sheet (gives basic profile information at a glance) showed the following:-admission date of 07/08/24;-Diagnoses included stroke, right/dominant side weakness/paralysis and speech difficulty following stroke, obesity, cognitive communication deficit, arthritis pain in right knee, left arm pain, generalized muscle weakness, difficulty in walking, and restlessness and agitation. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 01/30/26, showed the following:-Moderately impaired cognition;-Functional limitation on range of motion of one-sided upper extremity, bilateral lower extremities;-Dependent on assistance for transfer to/from chair/bed.Review of the resident's care plan, last reviewed 01/21/26, showed the following:-Staff to assist with a Hoyer lift and two staff assist out of bed each day;-Needs the use of a Hoyer lift and two persons to safely transfer resident in and out of bed and wheelchair; -Follow protocol and policy when using the Hoyer lift to assist with transfers;-Two person assist with repositioning to avoid skin friction/shearing.Review of the resident's nurses' notes showed the following information:-On 02/16/26, at 10:30 A.M., a certified nurse aide (CNA) called out for the nurse from resident's room. Upon entering the room nurse found CNA holding resident on side of bed, bottom not touching ground and back against the bed. Nurse assisted CNA with getting the resident back into bed. No head injury noted. Resident noted to have a little redness to mid-back area with no skin tears or bruising noted at this time. CNA stated he/she was transferring the resident into bed and resident's feet slipped from underneath him/her. CNA stated he/she lowered the resident down and resident did not hit his/her head. The resident complained of generalized pan and staff administered as needed Tramadol (pain medication) given. Staff notified hospice, physician, on call management, and emergency contact;-On 02/17/26, at 2:50 P.M., resident complained of pain and decreased mobility to left shoulder. Hospice gave order for x-ray. Staff notified resident who was agreeable;-On 02/17/26, at 2:18 P.M., resident had an x-ray of the left humerus (upper arm bone). Imaging showed a possible fracture. Staff called hospice, physician, and family and they wanted him/her sent out to the hospital for an evaluation. Resident was given a dose of Tramadol, morphine (used to treat moderate to severe pain) and lorazepam (sedative) for the pain. Staff called emergency medical services (EMS) was called at 1:55 P.M. EMS arrived at 2:08 P.M. and left facility at 2:15 P.M. Resident assisted to stretcher with no incident. Family at bedside at time of transfer. Nurse notified Administrator and Director of Nursing (DON) notified;-On 02/17/26, at 5:58 P.M., resident returned to facility from hospital emergency department with no new orders except to follow up with physician's office on 02/18/26;-On 02/18/26, at 10:52 P.M., Resident continued on fall follow-up with left arm in sling and signs/symptoms of pain during incontinence care. Staff administered pain medication given.During an interview on 03/17/26, at 3:25 P.M., CNA C said the following: -He/she came to work at 6:00 A.M. on 02/16/26, and the resident was sitting in his/her wheelchair;-Later that morning as the resident's family member was leaving and asked CNA C to put the resident back in bed;-There was no Hoyer sling under the resident, so he/she thought maybe the resident was now a one-person assist for transfers;-The CNA did not look at the resident's care plan or ask anyone else how the resident transferred-CNA C placed a gait belt on the resident and assisted him/her from the wheelchair to the bed;-As the resident sat on the bed, he/she started to slide down the edge of the bed;-CNA C grabbed the resident from the front, under the arms, and heard a crack as the CNA held onto the resident to keep him/her from sliding to the floor;-The CNA called out to the nurse for assistance to get the resident into bed;-Two staff were required to transfer a resident via Hoyer lift or sit-to-stand lift. During an interview on 03/17/26, at 3:12 P.M., CNA D said staff should follow the care plan pertaining to the resident's transfer status. Staff should ask the nurse if they aren't sure.During an interview on 03/17/26, at 3:18 P.M., CNA E said staff should check a resident's care plan, which would show the transfer requirements. Staff should follow the care plan or ask the nurse if they are not sure.During an interview on 03/17/26, at 12:53 P.M., Certified Medication Technician (CMT) A said the following: -Nurses should inform the nursing staff of a resident's transfer needs/status upon their admit;-The transfer status is entered into the care plan;-If the resident's care plan states that the resident is a Hoyer lift or two-person gait belt assist to transfer, staff should follow those instructions and guidelines;-If in doubt the staff should ask the nurse.During an interview on 03/17/26, at 1:01 P.M., CMT B said the following:-The therapy department assesses residents on admission and tells the nursing staff how they transfer;-The facility policy required two staff to assist with a Hoyer transfer or sit-to-stand lift transfer;-Staff transfer status information in report from the previous shift for a new resident or if there has been a change in status;-Staff should follow the directions given in report or listed on the care plan. If it stated the resident required two-person assist or Hoyer transfer.During an interview on 03/17/26, at 2:35 P.M., the Administrator said the following: -The resident should be transferred using a Hoyer lift;-During the night shift on 02/15/26, the staff found the resident partway out of his/her bed; -Two staff quickly lifted the resident over into the wheelchair without using the Hoyer lift; -There was no Hoyer sling left under the resident;-After breakfast on 02/16/26, CNA C was going to put the resident back in bed;-The CNA said he/she wasn't sure of the resident's ability to transfer, but sized him/her up and decided he/she could transfer the resident without another staff to assist;-As the CNA was moving the resident to the bed, the resident began sliding off of the bed;-The CNA grabbed the resident from the front to keep him/her from sliding to the floor and called out to the nurse for assistance;-Staff must use a gait belt to assist any resident needing transfer assist and to follow the care plan or information given by the nurse regarding a resident's transfer status. Complaint #2787938

This citation is uncorrected. For prior example please see Event ID 1D8649-H1, exit date 12/12/25.1.Please refer to event 1D8649-H2, exit date 01/23/26, for details. Complaint #2718425

Based on interview and record review, the facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day seven days per week. The facility census was 79.Review showed the facility did not provide a policy related to nursing schedules.1. Review of the Monthly Work Schedule, dated August 2025, showed no RN scheduled to work.Review of the Monthly Work Schedule, dated September 2025, showed no RN scheduled to work.Review of the facility provided time sheets showed no RN clocked in or out on 09/13/25, 09/20/25, 09/21/25, and 09/28/25. Review of the facility provided time sheets showed on 09/14/25 an RN clocked in at 7:00 A.M. and clocked out at 11:00 A.M. (4 hours).Review the facility provided time sheets showed on 09/27/25 the Director of Nursing (DON) clocked in at 10:00 A.M., clocked out at 2:00 P.M., and clocked in at 4:00 P.M. and clocked out at 8:00 P.M. (8 non-consecutive hours).During an interview on 10/02/25, at 12:45 P.M., Licensed Practical Nurse (LPN) D said he/she worked a rotating scheduled and there was not an RN that worked on duty most of the weekends he/she worked. There was an RN that worked part time but during the school year he/she did not work very often. There is an on-call nurse but he/she is not always an RN.During an interview on 10/02/25, at 1:30 P.M., Certified Medication Tech (CMT) B said generally he/she worked Monday through Thursday and sometimes pick up on weekends. He/she was unsure if there was an RN normally working.During an interview on 10/02/25, at 3:00 P.M., LPN A said he/she did not work weekends and was not aware of how many RNs were employed. The DON was available during the week.During an interview on 10/02/25, at 4:10 P.M., the DON there were four RNs currently employed. The Administrator, the DON, the MDS Coordinator, and one part time RN that worked when he/she was available. He/she was aware there was not always an RN on shift.During an interview on 10/02/25, at 5:10 P.M., the Administrator there were lapses in RN coverage. The facility had tried to fill those holes in the RN coverage and know that the state requires 8 hours per day of RN coverage. Currently, the MDS Coordinator would occasionally work complete MDS duties on the weekend. The Administrator, DON, and one part time RN were the only RNs at the time.

Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for four residents (Resident #1, #2, #3, #4, #5, #6) . The facility census was 79.Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for six residents (Resident #1, #2, #3, #4, #5, and #6) . The facility census was 79. Review showed the facility did not provide a shower policy. 1. Review of the facility current Shower Schedules showed the following:-room [ROOM NUMBER] to 108 scheduled for Monday and Thursdays;-room [ROOM NUMBER] to 118 scheduled for Tuesday and Fridays;-room [ROOM NUMBER] to 118 make up days on Wednesday, Saturday, Sundays;-room [ROOM NUMBER] to 210 scheduled for Monday and Thursday;-room [ROOM NUMBER] to 218 scheduled for Tuesday and Friday;-room [ROOM NUMBER] to 218 make up days on Wednesday, Saturday, Sunday;-room [ROOM NUMBER] to 308 scheduled for Monday and Thursday;-room [ROOM NUMBER] to 318 scheduled for Tuesday and Friday;-room [ROOM NUMBER] to 318 make up days Wednesday, Saturday, Sunday. 2. Review of Resident #1's face sheet (a brief information sheet about the resident) showed the following:-admission date of 05/25/16;-Diagnoses included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), cauda equina syndrome (serious neurological condition that occurs when the bundle of nerves (cauda equina) at the lower end of the spinal cord becomes compressed or damaged), generalized anxiety disorder, and neuromuscular dysfunction of the bladder (loss of bladder control, inability to empty bladder). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 07/25/25, showed the following:-Cognitively intact;-Use of wheelchair for mobility;-Required partial to moderate assistance of staff for toileting hygiene, showering, and transfers. Review of the resident's care plan, updated 08/05/25, showed the following:-Resident required moderate staff assistance for bathing;-Resident performed own personal hygiene and grooming with staff set up due to weakness;-Resident required staff assist with shower to include hair;(Staff did not care plan related to resident's shower schedule or preferences.) Review of the facility CNA Shower forms showed the following:-No shower sheets available for August 2025 in the shower sheet book;-On 09/10/25, resident wanted to wait until the following day;-On 09/11/25, resident received a shower;-On 09/17/25, resident wanted to wait until the following day;-On 09/18/25, resident said it was too late for a shower;-On 09/23/25, resident received a shower;-On 09/26/25, resident refused a shower. Review of the resident's medical record showed staff did not document regarding resident showers, additional refusals, or attempts to reapproach regarding shower. During an interview on 10/02/25, at 9:45 A.M, the resident said that he/she thought the showers were scheduled for Monday and Thursday. He/she did not know when his/her last shower was. He/she was not receiving two showers per week and would prefer two per week. 3. Review of Resident #2's face sheet showed the following:-admission date of 11/02/21;-Diagnoses included paroxysmal atrial fibrillation (an irregular and often very rapid heart rate that can lead to blood clots in the heart), heart failure (chronic condition in which the heart doesn't pump blood as well as it should), polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body), chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should) Stage 3 (mild to moderate damage). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Required partial to moderate assistance for showering;-Independent for personal hygiene. Review of the resident's care plan, updated 02/09/25, showed the following:-Resident chooses to shower on Sundays only;-Staff should offer resident a shower on Sundays;-Staff should offer shower and assist resident with anything needed. Review of the facility CNA Shower forms showed the following:-No shower sheets available for August 2025 in the shower sheet book;-On 09/10/25, resident received a shower;-On 09/17/25, resident received a shower;-On 09/24/25, resident received a shower.-No other shower sheets noted. During an interview on 10/02/25, at 10:30 A.M, the resident said that he/she did not know when his/her last shower was. He/she would prefer to receive a shower at least once per week. 4. Review of Resident 3's face sheet showed the following:-admission date of 02/11/25;-Most recent re-admission on [DATE];-Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), pressure ulcer of sacral region stage 4 (area at the base of the spine with severe, full-thickness wound that extends beyond the skin and into the muscle, tendon, or bone, characterized by exposed tissue and potential signs of infection like pus, odor, and discolored drainage), and vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain). Review of the resident's care plan, updated 07/17/25, showed staff did not care plan related to the shower needs and preferences of the resident. Review of the facility CNA Shower forms showed the following:-On 08/06/25, resident received a shower;-On 08/08/25, resident received a shower;-On 08/12/25, resident received a shower;-On 08/17/25, resident received a shower;-On 08/28/25, resident received a shower;-On 09/03/25, resident received a shower;-On 09/05/25, resident received a shower;-On 09/16/25, resident received a shower;-On 09/23/25, resident received a shower. During an interview on 10/02/25, at 10:30 A.M, the resident said that he/she thought the showers were scheduled for every Sunday. He/she did not know when his/her last shower was. He/she would prefer to receive at least twice per week. 5. Review of Resident #4's face sheet showed the following information:-admission date of 10/30/24;-Diagnoses included paraplegia (loss of motor and sensory functions in both lower limbs), diabetes, heart failure, bipolar disorder (chronic mental health condition characterized by extreme mood swings between highs and lows), high blood pressure, chronic kidney disease, presence of suprapubic catheter (surgically placed tubing through the abdomen to drain the bladder), urinary tract infection (UTI), major depressive disorder (severe with psychotic symptoms), fibromyalgia (widespread pain, fatigue), neuromuscular dysfunction of bladder, severe obesity, and open wound right thigh. Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Cognitively intact;-Functional limitation in range of motion (ROM) with impairment to both lower extremities;-Use of wheelchair;-Dependent on others for showers/bathing. Review of the resident's care plan, updated 07/31/25, showed resident chooses to receive his/her showers once a week on Wednesday because he/she prefers certain staff members. Review of the facility CNA Showers forms showed the following:-On 08/10/25, received a bed bath;-On 08/24/25, refused a shower;-On 08/26/25, received a shower;-On 08/31/25, refused a shower with two CNAs offering;-On 09/10/25, received a shower;-On 09/17/25, refused a shower (wasn't feeling well);-On 09/22/25, refused a shower (felt dizzy);-On 09/25/25, refused a shower. During an interview on 10/02/25, at 10:09 A.M., the resident said there were not enough staff to accommodate his/her preference for showers once or twice weekly. There was no longer a designated bath aide on the hall. The resident said his/her last shower was about three weeks prior and he/she didn't get full bed baths. The only cleaning was done with brief changes which was not enough. 6. Review of Resident #5's face sheet showed the following information:-admission date of 05/15/25;-Diagnoses included type 2 diabetes with nerve damage and joint breakdown, atrial fibrillation (a-fib - irregular heart function), left below knee amputation, high blood pressure, obesity, depression, insomnia, repeated falls, pain, open wound to the foot, and acute upper respiratory infection. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Functional limitation in ROM with impairment to one side, lower extremity;-Use of wheelchair;-Limb prosthesis;-Required set up or clean up assistance for showers/bathing. Review of the resident's care plan, reviewed 08/21/25, showed the following:-Resident requests only showers done by male staff. If not available, set up a time when a male is on the staffing schedule;-At risk for pressure ulcers related to decreased mobility and poor skin turgor; needs a full skin evaluation weekly with bath/shower;-Requires limited to no assistance with grooming/hygiene; shower/bath with staff assist, include hair care. Review of the facility CNA Showers forms showed the following:-On 08/07/25, received a shower;-On 08/17/25 (ten days later), refused a shower;-On 08/20/25, received a shower (13 days after previous shower);-On 08/23/25, received a shower;-On 08/26/25, refused a shower;-On 08/27/25, received a shower;-On 08/29/25, received a shower;-On 09/03/25, received a shower;-On 09/09/25, refused a shower;-On 09/14/25, received a shower (11 days after previous shower);-On 09/19/25, received a shower;-On 09/23/25, refused a shower by a female staff.(Staff did not document any showers offered since 09/23/25; 13 days since previous shower.) During an interview on 10/02/25, at 12:43 P.M., the resident said he/she was lucky if he/she got one shower a week. He/she wanted two showers weekly. The resident said he/she felt dirty and needed a shower today, but so far nobody had offered to give him/her one. He/she said there were no scheduled days for his/her showers. 7. Review of Resident #6's face sheet showed the following information:-admission date of 03/20/25;-Diagnoses included cerebral palsy, post-polio syndrome (nerve and muscle disorder), lymphedema (swelling caused by buildup of fluid in the body's tissues), fungal infection of the skin and nails, poor vision, chronic pain, muscle spasm, and anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Functional limitation in ROM with impairment to both lower extremities;-Use of wheelchair;-Required substantial/maximal assistance for showers/bathing. Review of the resident's care plan, updated 09/30/25, showed resident at risk for infection. Staff to ensure additional precautions are taken for hygiene and sanitation practices. Shower/bath with staff assist to include hair care. Review of the facility CNA Showers forms showed the following:-On 07/27/25, received a shower;-On 08/06/25, refused a shower;-On 08/19/25, received a shower (23 days since previous shower);-On 09/02/25, refused a shower (resident said it was too late);-On 09/09/25, refused a shower;-On 09/10/25, received a bed bath (22 days since previous shower);-On 09/14/25, received a shower;-On 09/17/25, refused a shower;-On 09/19/25, refused a shower;-On 09/23/25, refused a shower.(Staff did not document any showers offered since 09/23/25; 18 days since previous shower.) During an interview on 10/02/25, at 3:30 P.M., the resident said regarding showers, It's bad! Haven't had one for a while. The resident said he/she wanted at least two showers weekly. 8. During an interview on 10/02/25, at 1:15 P.M., Certified Medication Tech (CM) B said there was one CNA for 30 residents on the hall. There was a shower aide that came in once per week from 2:00 P.M. to 8:00 P.M., otherwise the aides and the CMTs tried to get showers completed daily. Some residents did not receive showers twice per week. During an interview on 10/02/25, at 12:41 P.M., CMT G said they no longer had a separate assigned bath aide. The residents should all get two showers per week. The CNA on each hall/unit was assigned showers to complete on a daily basis, based on room numbers. The CMTs and the nurses were also assigned certain showers, but CMT G said he/she did not usually have time to give all the showers assigned to him/her. He/she was assigned four showers for that day. He/she would probably only get to two of them. He/she was expected to work the floor and help the aide in between medication passes, as well as assist with all meals on their shift. While a CNA was giving a shower, the CMT and nurse had to cover all other resident care needs. Staff should document showers or refusals on a shower sheet and give the sheets to the charge nurse. They tried to reattempt refused showers; either that day or the next. Sometimes he/she would tell the next shift if a resident had requested a shower in the evening or early the next morning. During an interview on 10/02/25, at 3:00 P.M., Licensed Practical Nurse (LPN) A said staff were assigned showers to be completed each day from management. The shower sheet was turned into the nurse and signed and then given to the Director of Nursing (DON). He/she had not typically seen a resident only receive one or two showers per month but was not sure if they received two showers per week. During an interview on 10/02/25, at 9:56 A.M., LPN F and LPN D both said showers were probably not getting done because they only had one aide on each hall/unit. LPN F said residents should get two showers per week, but that was not getting done. During an interview on 10/02/25, at 4:10 P.M., the DON said Hospice provides showers twice a week to their residents and if they don't give a shower the staff will offer that shower again. The residents should be getting twice a week showers. The schedule is on Monday the low number room of the halls should be showered, Tuesdays the high numbers of the halls. Wednesday is a make-up day, then Thursday is the low numbers and Friday is the high numbers again. For the most part she believed residents were getting two showers per week. If a resident refused, staff should go over and offer three times during their shift and notify the nurse who should document the refusal in the medical record. Facility was almost to the point that a full-time shower aide could be hired. There was one aide that worked from 2:00 P.M. to 8:00 P.M. on Wednesday and Thursdays. That staff generally provided showers on those days from 2:00 P.M. to 6:00 P.M., and then assisted with laying down residents after supper and might provide another shower or two before leaving at 8:00 P.M. During an interview on 10/02/25, at 5:10 P.M., the Administrator said showers were offered two times a week. The low room numbers were Monday and Thursdays, the high room numbers were Tuesday and Fridays. Wednesday, Saturday, and Sunday were makeup days. The resident can request different days. The nursing staff gave showers, all CNA's, CMT's, and nurses. They are assigned showers on a daily basis. When they receive complaints about showers, they look into who was working and assigned that tasks. Some residents refused unless a specific staff was available. As much as they can they try to assign that preferred staff but cannot always do so. If a resident refused, they should be offered on the make-up days. They collect the Monday and Tuesday shower sheets and then complete the make-up schedule for Wednesday, then collect the Thursday and Friday shower sheets and schedule the make-up schedules for Saturday and Sunday. Complaints 2594960, 2607877, 2617974

Based on observation, record review and interview, the facility failed to have sufficient nursing staff to meet the needs of the residents. The facility failed to provide showers per the preferences of three residents (Residents #1, #2, and #3), answer call lights in a timely manner for one resident (Resident #4) who experienced a fall, and repositioning and meal assistance/cueing for one resident (Resident #6). A sample of 12 residents was reviewed for staffing. The facility census was 84. Review showed the facility did not provide a shower policy.1. Review of the resident's census, dated 01/22/26, showed a total of 84 residents with 22 residents on 100-hall. Review of a listing provided by the Administrator and Director of Nursing (DON), on 01/22/26, showed eight of the 22 residents on the 100-hall required two-person assist. Review of the facility's Daily Staffing Breakdown Sheets showed nursing staff scheduled on 100-hall as follows: -On 01/19/26, day shift had two nurses, one CMT, and one CNA;-On 01/19/26, night shift had two nurses and one CNA;-On 01/20/26, day shift had two nurses, one CMT, and one CNA;-On 01/20/26, night shift had one nurse, one CMT, and one CNA;-On 01/21/26, day shift had two nurses, one CMT, one CNA, and one NA (6:00 A.M.-10:00 A.M. only)-On 01/21/26, night shift had two nurses and one CNA;-On 01/22/26, day shift had one nurse, one CMT, and one CNA; -On 01/22/26, night shift had two nurses (one resigned and one worked), and one CNA.Review of the facility current shower logs showed the following:-Rooms 101 to 108 scheduled for Mondays and Thursdays;-Rooms 109 to 118 scheduled for Tuesdays and Fridays;-Rooms 101 to 118 make up days on Wednesdays, Saturdays, and Sundays.2. Review of the resident's census, dated 01/22/26, showed a total of 84 residents with 31 residents on 200-hall.Review of a listing provided by the Administrator and DON, on 01/22/26, showed 12 of the 31 residents on 200 hall required two-person assist for transfers. Review of the facility's Daily Staffing Breakdown Sheets showed nursing staff scheduled on 200-hall as follows: -On 01/19/26, day shift had one nurse, one CMT, and one CAN;-On 01/19/26, night shift had one nurse and one CNA; -On 01/20/26, day shift had two nurses, one CMT, and one CNA; -On 01/20/26, night shift had one nurse and one CNA; -On 01/21/26, day shift had one nurse, one CMT, and one CNA;-On 01/21/26, night shift had one nurse and one CNA;-On 01/22/26, day shift had one nurse, one CMT, and one CNA; -On 01/22/26, night shift had one nurse and one CNA.Review of the facility current shower logs showed the following:-Rooms 201 to 210 scheduled for Mondays and Thursdays;-Rooms 211 to 218 scheduled for Tuesday and Fridays;-Rooms 201 to 218 make up days on Wednesdays, Saturdays, and Sundays.3. Review of the resident's census, dated 01/22/26, showed a total of 84 residents with 31 residents on 300-hall. Review of a listing provided by the Administrator and DON, on 01/22/26, showed 11 of the 31 residents on the 300-hall required two-person assist.Review of the facility's Daily Staffing Breakdown Sheets showed nursing staff scheduled on 300-hall as follows:-On 01/19/26, day shift had one nurse, one CMT, and one CNA;-On 01/19/26, night shift had one nurse and one CNA;-On 01/20/26, day shift had one nurse, one CMT, one CNA, and one float CNA (2:00 P.M. to 6:00 P.M.);-On 01/20/26, night shift had one nurse, one CMT, one CNA and one float CNA (6:00 P.M. - 12:00 A.M.);-On 01/21/26, day shift had one nurse, one CMT, and one CNA;-On 01/21/26, night shift had one nurse, one1 CNA, and one float CNA;-On 01/22/26, day shift had one nurse, one CMT, one CNA, and one float CNA (12:00 P.M.-12:00 A.M.). A showed aide was also scheduled, but but called in and did not work;-On 01/22/26, night shift had one nurse and one CNA.Review of the facility current shower logs showed the following:-Rooms 301 to 308 scheduled for Mondays and Thursdays;-Rooms 309 to 318 scheduled for Tuesdays and Fridays;-Rooms 301 to 318 make up days on Wednesdays, Saturdays, and Sunday.4. Review of Resident #1's face sheet (gives brief profile information about the resident) showed the following:-admission date of 11/18/25;-Diagnoses included stroke, left-side/non-dominant side weakness and paralysis following stroke, glaucoma (eye disease leading to vision loss), major depressive disorder, and difficulty with speech and swallowing following stroke. Review of the resident's entry comprehensive Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/24/25, showed the following information:-Cognitively intact;-Very important to choose between tub bath, shower, bed bath, or sponge bath;-Impairment to upper and lower extremity - one side;-Required the use of cane or wheelchair for mobility;-Required substantial/maximal assistance for bathing and toileting hygiene. Review of the resident's care plan, last updated 01/13/26, showed the following:-Preferred showers in the mornings. Nursing staff will provide shower as requested;-At risk for urinary incontinence due to requiring increased assist with daily cares/mobility;-Required extensive assistance for dressing, bathing, toileting, hygiene, transfers, and mobility;-Assist with activities of daily living (ADLs - dressing, grooming, eating, etc.) as needed; -Shower/bath with staff assistance to include hair care. Review of the resident's Skin Monitoring: Comprehensive CNA (Certified Nurse Aide) Shower Review sheets showed the following:-Staff documented completion of a shower on 12/19/25;-Staff documented completion of a shower on 12/24/25 (five days since the previous shower);-Staff documented completion of a shower on 12/30/25 (six days since the previous shower);-Staff documented completion of a shower on 01/09/26 (ten days since the previous shower);-Staff documented completion of a shower on 01/16/26 (seven days since the previous shower);-Staff documented completion of a shower on 01/20/26 (four days since the previous shower).-Staff did not document any refusal of showers by the resident. During an interview on 01/21/26, at 10:54 A.M., a family member of the resident said he/she had to monitor the resident's shower status. There were not enough staff to accommodate the residents' shower schedule. During an interview on 01/21/26, at 4:10 P.M., the resident said he/she was scheduled for showers twice weekly, but that was not being done. The resident wanted at least two showers per week, more if possible. He/she was used to taking a shower almost every day at home. The facility did not have an assigned shower aides and the aides had to give all the showers. There wasn't usually enough staff or time to get to him/her on the shower schedule. His/her room was at the end of the hall and therefore toward the end of the schedule. 5. Review of Resident #2's face sheet showed the following;-admission date of 05/15/25;-Diagnoses included type 2 diabetes with severe nerve damage and joint disease, left below the knee amputation, obesity, depression, insomnia, and open foot wound. Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Cognitively intact;-Impairment to lower extremity - one side;-Required the use of wheelchair and/or limb prosthesis for mobility;-Required partial/moderate assistance for bathing. Review of the resident's care plan, last updated 01/12/26, showed the following:-Preferred a shower between 10:00 P.M. and 11:00 P.M. Nursing staff will offer shower per resident's request;-Requests showers done only by male staff. Make certain a male staff showers the resident, if not available, set up a time when a male is on the staffing schedule;-Assist with ADLs as needed;-Shower/bath with staff assist to include hair care. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review sheets for showed the following:-Staff documented completion of a shower on 12/03/25;-Staff documented completion of a shower on 12/12/25 (nine days since the previous shower);-The resident signed refusal of a shower until off COVID on 12/22/25;-Staff documented the resident refused a shower on 12/30/25 (27 days since the previous shower);-Staff documented completion of a shower on 01/04/26 (32 days since the previous shower);-Staff documented the resident refused a shower on 01/06/26;-Staff documented completion of a shower on 01/09/26 (five days since the previous shower);-Staff documented the resident refused a shower on 01/13/26;-Staff documented completion of a shower on 01/20/26 (11 days since the previous shower).Review of the resident's nurses' notes showed staff did not document any additional offers for a shower. During an interview on 01/21/26, at 11:12 A.M., the resident said he/she had only been getting a shower every week to week and a half. He/she wanted one to two showers per week. The resident said there wasn't enough staff to accommodate all the scheduled showers and other resident needs on the hall. During an interview on 01/22/26, at 9:55 A.M., the resident said he/she was scheduled for two showers per week. He/she would prefer that frequency because otherwise he/she starts to feel like he/she really needs one. The resident said he/she understood that did not have enough staff or time to do two showers weekly, so he/she tried not to complain. He/she woke at 4:00 A.M. that day and the night shift agreed to give him/her a shower. 6. Review of Resident #3's face sheet showed the following:-admission date of 03/20/25;-Diagnoses included cerebral palsy (movement, muscle tone, or posture disorders caused by damage that occurs to the developing brain, usually before or during birth), post-polio (virus that can affect the brain and spinal cord) syndrome (occurs later in life; causes progressive muscle weakness, fatigue, joint pain and sometimes breathing or swallowing difficulties), poor vision, chronic pain, anxiety disorder, and insomnia. Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Cognitively intact;-Impairment to lower extremities - both sides;-Required the use of wheelchair for mobility;-Dependent on assistance for toileting hygiene, sitting/lying down, sit to stand, chair/bed-to-chair transfer, tub/shower transfer, and bathing;-Required substantial/maximal assistance for personal hygiene. Review of the resident's care plan, last updated 01/12/26, showed the following:-Preferred a night shower if preferred aide was working but will take a shower if that aide was not working. Nursing staff will offer shower per resident's request;-Frequent refusals to cares depending on who the provider is and/or mood state. Communicate in advance of options for cares and timing, and staff to work with resident to agree to a time when care can be performed;-Needed extensive assistance for bathing/hygiene, transfers and mobility due to weakness;-Shower/bath with staff assist to include hair care. Review of the resident's Skin Monitoring: Comprehensive CNA (Certified Nurse Aide) Shower Review sheets showed the following:-The resident signed refusal of a shower on 12/30/25;-Staff documented the resident's verbal refusal of a shower (refused to sign due to couldn't see the paper) on 01/02/26;-Staff documented the resident refused a shower twice when offered on 01/06/26;-The resident signed refusal of a shower on 01/07/26.Review of the resident's nurse progress notes, dated 12/16/25 through 01/22/26, showed staff did not document information pertaining to offer or refusals of showers. Review of a listing provided by the Administrator and DON showed the resident required the use of a mechanical lift transfers. During an interview on 01/21/26, at 11:48 A.M., the resident said the following: -The staff were trying to accommodate the residents' preferences for getting showers, but there were not enough of them to give all the showers and respond to other resident needs;-The hall only had one nurse, one med tech, and one aide during the day and only two people on the night shift. Those staff were expected to give the showers, give the medications, do treatments, and respond to the call lights. The residents couldn't expect them to do that much and keep up;-He/she required two staff to assist with transfers using a mechanical lift. They used the lift to place him/her on the shower chair/bed;-There weren't always two staff available for the transfers. During an interview on 01/22/26, at 9:57 A.M., the resident said the following: -He/she was only offered showers every week or so, sometimes longer between offers;-He/she wanted at least one per week;-He/she preferred to have a shower given by the same person but would accept one rather than go without;-There just aren't enough staff to accommodate the residents' showers and needs. 7. During an interview on 01/21/26, at 11:00 A.M., CMT A said the following: -Residents' showers were scheduled for twice weekly;-A shower missed on Monday or Tuesday should be added to the make-up list for Wednesday;-The CMT and nurses on each hall were supposed to help give showers;-The 100-hall usually had four staff assigned; -Three staff were assigned on the 200 and 300 halls;-The CMT was not sure how many showers were being completed as scheduled or were missed/skipped. During an interview on 01/21/26, at 2:25 P.M., CMT C said the following: -The CMTs and nurses were supposed to help the CNAs complete all the residents' showers;-For that day the CNA had seven or eight scheduled showers, the CMT had four, and the nurse had one or two others;-They do not usually get the scheduled showers done because there are too many other duties to complete and unexpected resident needs;-On the previous day the CNA had not been able to give any showers;-The night shift was also assigned some showers to give after dinner;-Residents have refused his/her offer of a shower, saying there are too many showers scheduled for the CNA, and the CMT shouldn't do them. During an interview on 01/22/26, at 3:03 P.M., CMT G said the following: -Staff can't get the scheduled showers done every day; -There are only limited staff scheduled and too much to do;-Sometimes they can add a resident to the evening shower schedule or to the next day, but that may not be possible either;-If a shower is missed, the resident is supposed to be added to the make-up day.During an interview on 01/21/26, at 2:40 P.M., CNA D said staff do the best they can, but they can't get the scheduled showers done every day with the limited number of staff working each hall. During an interview on 01/21/26, at 3:55 P.M., CNA E said the following:-Once in a while there are two aides working (one CNA and one nurse aide (NA));-If there was only one aide, it was too hard to get to all the showers scheduled;-He/she wasn't able to get any of his/her assigned showers completed the day before, the hospice aide gave one, and the nurse wasn't able to give any;-He/she might not get to any showers that day, due to too many other resident needs and requests, and it was already almost time to get residents up, changed/cleaned, and to the dining room for dinner;-So far that day two showers had been given; one by the CMT and one by the nurse;-If the CNA was giving a shower, the CMT and the nurse would need to watch the halls and answer call lights;-The night shift is assigned several showers, plus any missed during the day;-If showers are missed, the Assistant Director of Nursing (ADON) should add the residents to the make-up schedule. During an interview on 01/22/26, at 10:18 A.M., CNA I said the following: -They were supposed to document completed showers; -The nurse was supposed to add any missed showers to the list for the next make-up day on Wednesday or Saturday/Sunday;-He/she asked the ADON how he/she was supposed to make sure people get changed, turned, fed, transferred, and showered when there were 31 residents and only one aide. He/she was told to ask the med tech or nurse for help;-The med tech and nurse were busy with their own duties to do.During an interview on 01/22/26, at 2:55 P.M., Licensed Practical Nurse (LPN) F said the following: -They try to get all showers done, but there are too many to complete two per week based on the limited number of staff working each hall;-Missed showers are supposed to be moved to the make-up day on Wednesday. They aren't usually moved to the night shift, although they do have some scheduled for evenings, or to the weekends;-The staff giving or offering the shower should document completion or refusal;-They try to re-offer the shower twice on the same day.During an interview on 01/22/26, at 10:42 P.M., LPN H said the following: -There was a list of scheduled showers for each hall;-They don't always get done, depending on what else happens with the residents that day;-On the night shift there aren't always three staff per hall and some residents required the assist of two staff. If both staff are in a resident room, there might not be anyone available to watch the floor and answer call lights;-Only one staff working night shift can be off the floor;-The staff on other halls are alerted to breaks so that they could respond to an assist request by the remaining staff on a hall if necessary.During an interview on 01/22/26, at 3:20 P.M., the ADON said the following:-Residents' showers were scheduled for twice weekly for Monday/Thursday or Tuesday/Friday; -The halls were split in half by room number and scheduled accordingly;-Shower make-up days were Wednesdays and Saturday/Sunday;-The ADON recently did an audit of all residents' shower preferences. He/she tried to include that information on the shower assignment sheets;-The scheduled showers did not always get done, depending on other activities going on;-It was a team effort and scheduled staff knew they were expected to complete their assigned showers as well as their designated duties such as nursing or medication pass;-The facility did have one CNA that occasionally came in to give showers;-The residents should get showers at their preferred time and frequency.During an interview on 01/22/26, at 3:45 P.M., the Director of Nursing (DON) said the following: -An audit was done of residents' shower preferences, and they try to accommodate those preferences;-The CNA, CMT, and nurses were each assigned residents for showers;-The staff were to document showers or refusals on a shower sheet, which was then turned in to the ADON or DON;-Staff should offer a shower at least twice on the scheduled day and document if refused both times. During an interview on 01/21/26, at 10:35 A.M., the Administrator said the following: -They had implemented a revised shower schedule overseen by the ADON;-The ADON conducted an audit to determine the shower preferences for all residents;-The ADON made the daily schedule for each hall and assigned staff to the residents;-The CNA, the CMT, and the nurses were responsible for completing their assigned showers and documenting the completion or refusal;-The charge nurse would sign off on the schedule sheet at the end of the day and give it to the ADON for review;-The ADON would then add missed showers to the make-up days on Wednesdays or Saturdays/Sundays-If a resident required a two person assist for any care, the other staff was responsible for watching the floor and answering the call lights;-The Administrator thought the residents' showers were being completed per their preferences. 8. Review of Resident #4's face sheet showed the following:-admission date of 10/09/25;-Diagnoses included type 2 diabetes with blood vessel damage and foot ulcer, amputation of right leg above the knee, severe obesity, major depressive disorder, anxiety disorder, nerve damage resulting in loss of bladder control/urinary incontinence/retention, and history of urinary tract infection (UTI). Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Cognition mildly impaired;-Impairment to lower extremity, one side;-Utilized a walker and/or wheelchair;-Required substantial/maximal assistance for toileting, shower/bathing, bed mobility, and transfers;-Walking not attempted during the seven-day look-back period due to medical condition or safety. Review of the resident's care plan, last updated 01/20/26, showed the following:-Assist with ADLs as appropriate;-At risk for urinary incontinence due to requiring increased assistance with daily care/mobility; -Encourage resident to use the bathroom routinely and assist as needed;-Keep call light in reach at all times in room and bathroom and instruct resident to use and reinforce the need for use;-At risk for falls related to needing total assist for mobility, unsteady gait, and cognitive deficit; -Assist to the bathroom before and after meals, at bedtimes, and as needed;-Extensive assistance needed for toileting, transfers and mobility due to weakness, post amputation and disease process. Review of a listing provided by the Administrator and DON showed the resident required the assistance of two staff for transfers/mobility. Review of the resident's progress note dated 01/06/26, at 2:41 P.M., showed staff documented the resident was heard yelling. Staff went to his/her room and noted the resident sitting on the floor in his/her bathroom in front of his/her wheelchair and toilet. Staff had put him/her on the toilet and asked him/her to pull call light when done. The resident did pull call light, but did not wait for staff to come help him/her. During an interview on 01/21/26, at 11:20 A.M., Resident #5 (Resident #4's roommate) said he/she didn't need to use the call light, but his/her roommate (Resident #4) did. Resident #4 sometimes waits, and waits, and waits so Resident #5 has to go out of the room and get somebody to help him/her. Resident #5 said his/her roommate has fallen a couple of times waiting for assistance to/from the bathroom. During an observation and interview on 01/21/26, at 3:51 P.M., Resident #4 said the following: -His/her (right leg) above the knee amputation was done in October due to diabetes;-He/she experienced a fall on 01/06/26, while getting him/herself off the toilet. He/she was supposed to have assistance for transfers but said, They are very short-handed. He/she had turned on the call light, waited quite a while - about ten minutes, but didn't want to wait any longer. The resident attempted to transfer him/herself back to the wheelchair;-The resident still had bruising and swelling to the left knee from that fall;-The resident said he/she had transferred him/herself other times because of urgency and not wanting to wait so long he/she might make a mess;-Sometimes his/her roommate had to go out to the hall to try to find somebody to help.During an interview on 01/21/26, at 10:54 A.M., a family member of Resident #1 said there were not enough staff to respond quickly enough to the resident's call lights. The resident had incontinent episodes due to waiting too long for assistance. During an interview on 01/21/26, at 11:12 A.M., Resident #2 said he/she didn't bother to use his/her call light very often, because staff took 30 minutes to one hour to respond. During an interview on 01/21/26, at 11:48 A.M., Resident #3 said he/she had previously had to use his/her cell phone to call the facility, because the staff had taken a very long time to respond to his/her call light.During an interview on 01/21/26, at 10:52 A.M., Resident #7 said it could take a half-hour for a call light response. He/she said if staff don't respond by then, he/she goes out to the hallway and hollers for them. The resident said there is only one CNA on the wing, and they might be across the building. During an interview on 01/21/26, at 2:01 P.M., the Resident #8 said he/she sometimes waited up to one hour for call light response at night. He/she usually just proceeded to do everything for him/herself. 9. Review of the facility's policy entitled Feeding the Resident (Dependent Eating), undated, showed the purpose was to assist the resident with feeding and to provide adequate nutrition. The policy was not specific as to when or under what circumstances to assist the resident with eating. Review of Resident #6's face sheet showed the following:-admission date of 02/23/24 and re-admission date of 06/04/24;-Diagnoses included dementia, depression, protein-calorie malnutrition, osteoarthritis, history of urinary tract infections (UTIs), chronic pain syndrome, depressive disorder, and pressure ulcers of left ankle and right and left heels. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderately impaired cognition;-Required set up assistance for eating.Review of the resident's care plan, updated on 01/12/26, showed the following:-Able to feed self with finger foods, but needs assistance eating from staff overall; -Resident had recent weight loss and orders for ice cream twice daily and protein supplement;-Nursing staff will monitor nutritional intake.Review of the resident's current Physician's Order Sheet (POS) showed an order, dated 10/06/24, for staff to assist the resident to eat. Resident was able to feed him/herself with finger foods and larger items like sandwiches. Review of the resident's progress notes showed the following:-On 12/19/25, the Registered Dietician (RD) documented the resident remained on hospice care and received a regular diet with protein supplements and ice cream daily. Resident's appetite was fair and intake was about 50% on average. Resident received assistance and encouragement/cues at mealtimes but could feed himself finger foods. Resident had some weight loss. Current nutrition regimen appropriate with no changes recommended. Staff to continue to encourage intake, assist, and honor preferences as able;-On 01/21/26, the RD documented the resident remained on hospice care and received a regular diet with protein supplements and ice cream twice daily. Resident's appetite was fair with intake about 50% on average. Resident received assistance and encouragement/cues at mealtimes but can feed self finger foods. Resident continued with weight loss. Current nutrition regimen appropriate with no changes recommended. Staff to continue to encourage intake, assist, and honor preferences as able.Observations on 01/22/26 showed the following:-At 1:08 P.M., the resident rested in bed on his/her back. The head of the bed was raised to a 45 degree angle. The bedside table was positioned over the resident's lap. The lunch tray was set up on and contained two opened cartons of milk with straws inserted, a bowl of chicken and dumplings, a plate of fried okra, cornbread, and a bowl of apricot halves. There was no adaptive equipment present. The resident's right hand held a spoon and rested on the tray. The food appeared to be untouched;-At 1:12 P.M., LPN J entered the room and asked the resident if he/she wanted some apricots. The resident asked the LPN what he/she was doing and the LPN replied, I'm helping you eat lunch. LPN J fed the resident three spoonfuls of apricots, said I'll check on you in a few minutes, and left the room at 1:15 P.M.;-At 1:17 P.M., Dietary Aide (DA) K entered the resident's room to pick up the lunch tray but told the resident he/she'd come back later and check. DA K left the room to attend to other residents' trays;-At 1:18 P.M., the surveyor entered the resident's room and asked if he/she needed help to eat. The resident's spoon contained dumplings, but appeared as though a bite had not been taken. DA K was outside the door and said, I think he/she needs help. I've told them, but nobody listens to me. I would love to help, but I'm not allowed; the CNA is too busy. DA K asked Resident #6 if he/she could take a bite of food by him/herself. The resident placed the spoon into the dumplings, but was only able to scoop a small amount; he/she slowly raised the spoon and took the bite. DA K said, I'll help you and fed the resident a spoonful of dumplings. The resident smiled widely. DA K exited the room and said there was only one CNA for 30 people, and they just couldn't get everything done;-At 1:35 P.M., continued observation showed the resident was asleep, still holding the spoon. No other food appeared to have been touched;-At 1:40 P.M., LPN L stood at the treatment cart down the hall, charting on the computer;-At 1:46 P.M., CNA I entered the resident room across the hall to answer the call light and exited after one minute. CNA I did not enter the resident's room;-At 1:52 P.M., LPN L moved the treatment cart to another resident's room and entered;-At 1:57 P.M., LPN L moved the treatment cart to the resident's room, exiting the room at 2:01 P.M.;-At 2:03 P.M., the resident remained in the same position, asleep with the spoon in his/her right hand, and a cup of dumplings in his/her lap.During an interview on 01/21/26, at 2:18 P.M., CNA I said he/she did not assist the resident with eating lunch that day and did not know how much he/she ate due to not picking up the tray him/herself. During an interview on 01/22/26, at 3:43 P.M., LPN L said he/she had fed the resident few bites of food while in the room. The resident use to eat much better. 10. During an interview on 01/21/26, at 2:18 P.M., CNA I said the following: -The 200-hall census was usually in the high 20's to 30 or so;-He/she completed incontinent care and repositioning for the residents every two hours;-The CMT and nurse would help if needed;-When asked if he/she was able to complete his/her tasks during the shift, he/she hesitated and then said, I try. During an interview on 01/22/26, at 3:43 P.M., LPN L said the staff struggled to get everything done. The residents should be checked on, changed, and repositioned at least every two hours. During an interview on 01/22/26, at 3:20 P.M., the ADON said the facility was staffed appropriately. The nurses, CMTs, and aides were expected to work together to complete all resident care. During an interview on 01/22/26, at 3:45 P.M., the DON said the following: -The higher acuity hall (100) had four staff scheduled on day shift (two nurses, CMT, and CNA) and two to three staff on night shift;-Each of the other two halls (200 and 300) had three staff scheduled on day shift (nurse, CMT, and CNA) and two at night (nurse and CNA);-The DON said they scheduled an appropriate number of staff for each hall, and the staff were expected to help each other as needed to provide the necessary care for the residents. Complaint #2718425

Based on observation, interview, and record review, the facility failed to ensure all dependent residents received services necessary to maintain good grooming and personal hygiene when the staff failed to provide assistance with bathing to three residents (Resident #1, #2, and #3) out of a sample of thirteen residents. The facility's census was 71. Review of the facility's policy titled Daily Care Needs, dated March 2015, showed the following: -The purpose of daily care needs is to refresh the resident and provide cleanliness, comfort, and neatness; -Before beginning care, staff should check the bathing schedule. Review of the facility's policy titled Bath (Shower), dated March 2015, showed the following: -It is the policy of the facility to provide a shower to maintain skin integrity, comfort, and cleanliness; -Staff should encourage the resident to do as much of his/her own care as possible; -Supervise and assist as necessary. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/06/24, showed the following: -Resident was cognitively intact; -Resident required supervision for oral and personal hygiene and substantial assistance from staff for toilet hygiene and showering; -Resident used a wheelchair for mobility. Review of the resident's care plan, revised 01/22/25, showed the following: -Resident required staff assistance with showering; -Resident required limited staff assistance with grooming and hygiene; -Resident required two staff assistance with mobility and transfers. Review of the resident's November 2025 Shower Sheets showed the resident received a shower on 11/21/24. Review of the resident's December shower sheets showed the resident received a shower on the following dates: -On 12/04/24, resident offered shower but refused; -On 12/16/24; -On 12/28/24. Review of the resident's January 2025 shower sheets showed the resident received a shower on 01/22/24. During interviews on 01/21/25, at 11:39 A.M., and on 01/23/25, at 9:40 A.M., the resident said the following: -The resident reported he/she had been at facility for three months and only had two showers; -The resident asked the Administrator about showers and was informed corporate would not allow the hiring of a shower aide; -Resident reported he/she liked to get two showers weekly and felt crappy not getting one; -Resident received a third shower since admission last night. 2. Review of Resident #2's face sheet showed the following information: -admitted [DATE]; -Diagnoses included congestive heart failure (a long-term condition in which the heart can't pump blood well enough to meet the body's needs). Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Used wheelchair for mobility; -Dependent for transfers, showers, and lower body dressing; -Substantial staff assistance with upper body dressing; -Partial to moderate staff assistance with personal hygiene; -Set up and clean up assistance with oral hygiene. Review of the resident's care plan, dated 10/17/24, showed the resident required assistance with activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting). Staff assistance needed with showers including hair care. Review of the resident's shower sheets showed staff did not document a shower offered or provided in October 2024. Review of the resident's November 2024 Shower Sheets showed resident received a shower on the following dates: -On 11/01/24; -On 11/10/24; -On 11/15/24; -On 11/19/24, resident refused shower; -On 11/20/24. Review of the resident's December 2024 Shower Sheets showed resident one sheet, dated 12/05/24, which indicated resident in the hospital and no shower given. 3. Review of Resident #3's face sheet showed the following information: -admitted [DATE]; -Diagnoses included hemiplegia and hemiparesis affecting right dominate side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and obesity. Review of the resident's annual MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Used wheelchair or cane for mobility; -Independent with oral hygiene, dressing, personal hygiene, and toileting; -Moderate staff assistance with showers. Review of the resident's care plan, revised 12/13/24, showed the resident was mostly independent with ADL's, but required one staff assistance with showers and hair brushing. Review of the resident's October 2024 and November 2024 Shower Sheets showed staff did not document offering or completion of a shower for the month. Review of the resident's December 2024 Shower Sheets showed the resident received a shower on 12/15/24 and on 12/28/24. Review of the resident's January 2025 shower sheets showed resident received a shower on 01/14/25 and on 01/22/25. During an interview on 01/21/25, at 11:00 A.M., the resident said he/she had a shower once every two weeks. He/she was supposed to have one shower per week, but would like more. 4. During an interview on 01/23/25, at 2:20 P.M., Nurse Assistant (NA) A said residents should receive two showers per week. Staff should complete shower sheets upon completion of resident shower. During an interview on 01/23/25, at 2:40 P.M., Certified Medication Technician (CMT) B said he/she did not provide resident showers, but residents should be receiving two showers weekly. During an interview on 01/23/25, at 2:45 P.M., Licensed Practical Nurse (LPN) C said the following: -Residents should receive showers two to three times per week; -Staff do not get a chance to shower residents twice weekly sometimes; -Residents receive at least one shower per week; -Shower sheets should be completed after the shower and given to the Director of Nursing (DON). During an interview on 01/23/25, at 3:25 P.M., Licensed Practical Nurse (LPN) C said residents should receive showers twice per week. During an interview on 01/23/25, at 11:35 A.M., the Director of Nursing (DON) said that he/she had recently been working on a new process to improve resident showers. Staff should provide him/her with a completed shower sheet. He/she has requested staff sign shower sheets even if the resident refused. During an interview on 01/23/25, at 5:00 P.M., the Administrator said the following: -Residents should have a shower at least one time per week; -He/she would prefer residents to have showers based on preference or at least two showers per week. MO00246671, MO00246674, MO00246824

Based upon record review and interviews, the facility failed to perform a complete admission assessment, including a skin assessment, and did not identify and provide timely treatment for a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one resident (Resident #1). The facility census was 71. Review of a facility policy titled Admission Nurse's Note, dated March 2015, showed the following: -The purpose of the policy is to ensure information is documented for the resident upon admission; -Upon admission of a resident, the nurse will document a body audit which includes site and size of the scars, rashes, bruises or abrasions, pressure sores (injury to skin and underlying tissue resulting from prolonged pressure on the skin) or stasis ulcer (wound to the leg or ankle caused by abnormal or damaged veins), and general overall appearance and cleanliness. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), diabetes mellitus (disease that results in too much sugar in the blood), and pressure ulcer of the sacral (area located above the tailbone) region, stage 3 (wound that extends through the entire thickness of skin and damages the underlying tissue). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/06/24, showed the following: -Resident was cognitively intact; -Resident required supervision for oral and personal hygiene and substantial assistance from staff for toilet hygiene and showering; -Resident had a stage 3 pressure ulcer; -Resident used a wheelchair for mobility. Review of the resident's care plan, revised 01/22/25, showed the following: -Required two staff assistance with mobility and transfers; -Nursing should check skin routinely, treat and perform all preventative cares (turning, propping, repositioning) to prevent pressure injury; -Had skin breakdown to coccyx (tailbone) that the wound nurse and wound care provider will monitor and treat. Review of the resident's admission clinical assessment, dated 10/30/24, showed the resident had the following risk factors for skin breakdown: a history of pressure sores, poor skin turgor, and predisposing diseases. The nurse documented he/she was unable to do a skin assessment as the resident was up in a power chair and arranging new room. Review of the resident's progress notes, dated 10/31/24 to 11/01/24, showed staff did not document regarding skin, or attempts to assess skin. Review of the resident's progress note, dated 11/02/24, showed staff notified the nurse that the resident had a brown adhesive foam dressing on. The nurse observed a brown adhesive dressing to the coccyx upon assessment. Resident noted to have open area to coccyx and a piece of calcium alginate (highly absorptive dressing) to area beneath dressing. Area cleansed and new dressing applied. Air mattress ordered and wound care nurse notified. Review of the resident's physician order report showed an order, dated 11/02/24, to cleanse area to coccyx with hypochlorous acid (fights bacteria), apply sure prep (skin protectant) to peri wound area, apply calcium alginate to wound bed, and cover with adhesive foam border gauze as needed for loose or soiled dressing (three days after the resident admitted to the facility with the wound). Review of the resident;s progress notes, dated 11/03/24, showed staff did not document regarding the resident's coccyx wound. Review of the resident's progress note, dated 11/04/24, showed the Wound Care Nurse assessed wound to coccyx and noted wound bed was pink with small amount of bloody drainage noted with firm scar tissue noted to peri wound. Order updated and outside wound provider notified (five days after the resident admitted to the facility with the wound). Review of the resident's weekly skin assessment, dated 11/04/24, showed the resident had an open area to the coccyx and resident had effective treatment in place. During an interview on 01/23/25, at 1:31 P.M., Licensed Practical Nurse (LPN) E said the following: -He/she was the facility wound care nurse; -The admission nurse was responsible for skin assessments, but if he/she was at the facility during admission they will assist; -The initial skin assessment should not be completed after resident has been in facility two or three days; -Admission skin assessment should occur within two hours of admission to the facility. During an interview on 01/23/25, at 2:45 P.M. LPN C said the following: -Skin assessments should be completed within two hours of admission; -The nurse should try again if the resident refuses first attempt at skin assessment and it should be completed within the first 24 hours. During an interview on 01/23/25, at 3:25 P.M. LPN D said the following: -The nurse on duty when the resident was admitted was responsible for the admission assessment; -He/she would document any refusal of assessment and notify the oncoming shift to have it completed; -A skin assessment should be completed with two hours of admission so the facility can assume responsibility for any wounds. During an interview on 01/23/25, at 5:00 P.M. the Director of Nursing (DON) said the following: -The nurse should complete a skin assessment within two hours of admission; -The nurse should notify the wound care nurse if a resident refuses a skin assessment so he/she can follow up the next day;d-The nurse should notify physician and family if resident continues to refuse a skin assessment. During an interview on 01/23/25, at 5:00 P.M. the Administrator said a resident should not go three days without a skin assessment. The nurse should notify the Administrator, the physician, and the resident's family of refusals. MO00246671

Based on observation and interview, the facility failed to maintain ceiling vents to ensure condensation and/or peeling paint did not drop from the vent onto the food preparation area. This had the potential to affect all 65 residents of the facility who received their meals from the facility kitchen. 1. During the initial tour of the kitchen on 08/20/24, at 9:00 A.M., with the Dietary Manager (DM), three ceiling vents were observed to have rust, dust, and peeling paint on and around the vents. One vent, located in front of the freezer, was observed to be falling from the ceiling. Another vent, located above the edge of the food preparation table, had condensation dripping from the edges of the vent, landing in front of the food preparation table. The drips were confirmed by the DM and [NAME] #1. They both confirmed there was a potential for the condensation and/or peeling paint to fall into food being moved from the stove to the preparation table and vice versa. During an interview on 08/23/24, at 1:20 P.M., the Maintenance Director (MD) said that he was responsible for the maintenance of the ceiling vents and that he was aware of their condition, but had not fixed the concerns. During an interview on 08/23/24, at 2:02 P.M., the Administrator said they did not have a policy for monitoring the ceiling vents in the kitchen.

Based on observation, interview, and record review, the facility failed to maintain food at a palatable temperature on one of three halls (300 hall) when six on the hall (Residents #17, #18, #21, #29, #33, and #38) complained of cold food on the hall of 27 residents. Review of the facility's policy titled Food Temperatures, dated May 2015, showed the following guidance: -Temperatures of hot foods should be maintained at no less than 140.0 degrees Fahrenheit (F) during meal service; -Hot food should be at least 120 degrees F when served to the resident. 1. Review of Resident #21's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 05/07/24, showed the resident was moderately cognitively impaired. During an interview on 08/20/24, at 11:41 A.M., the resident said most times the food is adequate, but it can be cold. He/she ate his/her meals in the dining room. 2. Review of Resident #18's quarterly MDS, with an ARD of 06/12/24, showed the resident was moderately cognitively impaired. During an interview on 08/20/24, at 1:40 P.M., the resident said the food is often cold which doesn't make sense since the kitchen is right there. The resident said he/she ate his/her meals in the dining room. 3. Review of Resident #29's re-entry MDS, with an ARD of 07/08/24, showed the resident was severely cognitively impaired. During an interview on 08/20/24, at 4:06 P.M., the resident, along with his/her family member said the food was cold. The resident received meals in his/her room and was often assisted by family member. 4. Review of Resident #38's quarterly MDS, with an ARD of 04/04/24, showed the resident was cognitively intact. During an interview on 08/20/24, at 4:19 P.M., the resident said the food is cold and he/she ate meals both in the dining room and in his/her room. 5. Review of Resident #33's quarterly MDS, with an ARD of 05/16/24, showed the resident was cognitively intact. During an interview on 08/20/24, at 4:25 P.M., the resident said the food can be cold sometimes and he/she ate his/her meals in the dining room at the table right next to the serving window. 6. Review of Resident #17's quarterly MDS, with an ARD of 06/20/24, showed the resident was cognitively intact. During an interview on 08/20/24, at 5:03 P.M., the resident said he/she did not understand how the food could get cold from the kitchen directly to the table. The resident said he/she ate his/her meals in the dining room and in his/her room. 8. During a group interview on 08/22/24, at 9:00 A.M., with six residents (Resident #1, #18, #19, #21, #34, and #50), chosen by the facility as alert and oriented and regularly attended the monthly Resident Council meetings, the residents said the food was served cold on the 100 and 300 halls. 9. During an interview and record review on 08/23/24, at 11:10 A.M., the Dietary Manager (DM) said three insulated carts leave the kitchen at the same time for the 100, 200, and 300 hall kitchenettes. The dietary staff member who was to serve the meal transports the cart. The food temperatures are taken prior to placing the food in the food carts and on the steam table prior to meal service on each unit. Review of the food temperature logs showed appropriate temperatures from the kitchen. 10. During observation and test tray of the 300 hall meal service on 08/23/24, at 11:50 A.M., showed 13 residents seated in the dining room. The steam table was observed on and lids covered two steam table wells (one contained fish fillets and one contained onion rings). A container of coleslaw was observed on an ice bath. Food temperatures of the hot food were taken by the dietary staff member and measured 135.0 degrees F. After all the resident meals had been served in the dining room and resident rooms, a test tray was obtained and the DM took the food temperatures at 12:30 P.M. The fried fish fillet with cream sauce was 103.0 degrees F. The fish was cold and unpalatable when tasted. The onion rings were 127.0 degrees F. The onion rings were soft, marginally warm, and difficult to chew. 11. During an interview and observation on 08/23/24, at 12:45 P.M., the DM said it must be the steamer bay. It had been fixed within the past two months. The DM took the temperature of the steamer bay which held the fish fillets and it registered 117.0 degrees F. The DM said that's too low. The DM said he had not looked at the temperature log prior to the meal service on the 300 hall and was unaware the steamer bay was not functioning properly. He/she had no additional monitoring system beyond taking food temperatures prior to service from the kitchenette.

Based on observation, interview, and record review, the facility failed to ensure insulin pens were dated when opened for seven of 13 residents (Residents #8, #53, #49, #33, #55, #34, and #11) who were administered insulin in the facility. The facility failed also failed to ensure five vials of influenza vaccines were not expired in two of two medication rooms. Review of an undated facility policy titled, Labeling Drugs and Medications, showed all drugs and biologicals must be properly labeled and legible at all times. Review of an undated facility policy titled, Medications, Storage of, showed no discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. 1. Observation and interview on 08/21/24, at 1:36 P.M., of the Magnolia medication room with Licensed Practical Nurse (LPN) #6 showed two boxes containing vials of influenza vaccine that were noted to have an expiration date of 06/30/24. LPN #6 confirmed that the vials were expired and should have been removed from the refrigerator. Observation and interview on 08/22/24, at 4:50 A.M., of the Dogwood/Willow medication room with LPN #5 showed three boxes containing vials of influenza vaccine that were noted to have an expiration date of 06/30/24 on the box. LPN #5 confirmed that the vials were expired and should have been removed from the refrigerator. On 08/21/24, at 1:53 P.M., the Administrator said the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the unit nurses were responsible for ensuring expired medications were properly disposed of. 2. Observation and interview of the Dogwood medication cart on 08/22/24, at 4:43 A.M., with LPN #5 showed the following: -An opened and undated Novolin R Flex Pen for Resident #8; -An opened and undated Degludec insulin pen and Ozempic flex pen for Resident #53; -An opened and undated Novolog insulin pen and Tresiba insulin pen for Resident #49. -LPN #5 confirmed all the insulin pens and the Ozempic were open and undated. The LPN said the pens should have been dated with an open date. Observation and interview of the [NAME] medication cart on 08/22/24, at 4:57 A.M., with LPN #1 showed the following: -An opened and undated Humalog insulin pen for Resident #33; -An opened and undated Degludec insulin pen for Resident #55; -An opened and undated Novolog insulin pen for Resident #34; -An opened and undated Novolog insulin pen for Resident #11; -LPN #1 confirmed that the insulin pens had been opened and should have been dated when opened on the label. During an interview on 08/22/24, at 7:53 A.M., the Director of Nursing (DON) said the nurses were responsible for ensuring insulin pens were dated with open dates.

Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) for one resident of one resident (Resident #216) reviewed for EBP, out of a total sample of 22, who had had a peripherally inserted central catheter (PICC line - a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) and received antibiotics. Review of the facility's policy titled, Enhanced Barrier Precautions, dated March 2024, showed the following: -The purpose of the policy is to prevent broader transmission of MDRO (multi-drug resistant organisms) and to help protect patients with chronic wounds and indwelling devices; -EBP (enhanced barrier precautions) should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed. Review of the EBP-Enhanced Barrier Precautions in-service, dated April 2024, provided by the Administrator showed the following: -Staff will notice a new dot on the name tags by residents' doors; -EBP is indicated for residents with infection or colonization with a CDC (Centers for Disease Control) targeted MDRO when contact precautions do not otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. (The inservice did not address EBP for high-contact care such as showering/bathing and toileting, use of gown and gloves for high contact cares, or where the PPE was located.) 1. Review of Resident #216's Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included bacteremia (the presence of bacteria in the blood stream). Review of the resident's admission Minimum Data Set (MDS - federally mandated assessment instrument completed by facility staff), located in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 08/23/24, showed the resident was cognitively intact. Observation on 08/20/24, at 2:58 P.M., showed the resident showed the resident had a PICC line in her right arm. Licensed Practical Nurse (LPN) #1 washed his/her hands and disconnected the intravenous (IV) antibiotic from the resident's PICC line. LPN #1 did not wear a gown or gloves during the high-contact care. During an interview on 08/02/24, at 3:00 P.M., LPN #1 said he/she had not received any training or in-services on EBP when administering or removing IV antibiotics from a PICC line. LPN #1 said there was no readily accessible PPE (personal protective equipment) to use when administering IV antibiotics to the resident. During an interview on 08/21/24, at 2:20 P.M., the resident said nursing staff had not been using gowns or gloves when administering his/her IV antibiotics since admission to the facility and the Certified Nurse Aides (CNAs) had been not been utilizing protective equipment when assisting his/her with showers or high-contact cares. During an interview on 08/21/24, at 2:30 P.M., CNA #1 said he/she had not received any training or in-services on EBP. During an interview on 08/21/24, at 3:00 P.M., the Infection Preventionist (IP) said he/she had talked to the charge nurses and administration about EBP. There was a dot next to a resident's name on the name plate if staff needed to use EBP. The PPE was in a three-drawer dresser located in the lounge area on the unit. During an interview on 08/21/24, at 3:05 P.M., the Director of Nursing (DON) and the Regional Quality Assurance (QA) nurse were informed of the lack of EBP during the resident's IV care and the staff's lack of knowledge on EBP requirements. The DON said they had training for all staff twice. During an interview on 08/22/24, at 3:50 P.M., LPN #1 said he/she did not think he/she needed to wear precautions for IV administration, but was aware of it for indwelling urinary catheters.

Based on record review and interview, the facility failed to ensure an environment as free of hazards of possible when staff failed to transfer one resident (Resident #38), of 22 sample residents, with two staff members as care planned when using the mechanical lift (Hoyer Lift). 1. Review of Resident #38's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, showed the following: -admitted [DATE]; -Diagnoses included of type II diabetes mellitus with diabetic neuropathy (causes weakness, numbness and pain, usually in the hands and feet), cerebral infarction (stroke), and acquired absence of left leg below the knee (BKA). Review of the resident's comprehensive care plan, initiated 07/14/21, located under the RAI tab in the EMR, showed an identified problem as required assistance of 2+ people for mobility and transfers/Hoyer lift to wheelchair and toilet. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), with an assessment reference date (ARD) of 04/04/24, showed the resident was cognitively intact. Review of the Incident Report provided by the Administrator showed the following: -On 08/09/24, at 12:52 A.M., called to resident room by Certified Nurse Aide (CNA). The resident's right great toenail was bleeding and slightly pulled back from nail bed. The CNA reported it happened during transfer via Hoyer lift. It was hit and then started bleeding. -Resident is diabetic and will need close monitoring for the wound. Area cleaned with pure and clean, wrapped with gauze, and taped. New order placed. Wound nurse will assess and adjust treatment as necessary. Resident denied pain. Review of the resident's Progress Notes, located in the EMR under the Resident tab, showed the following: -On 08/09/24, 12:52 A.M., called to resident room by CNA. The resident's right great toenail bleeding and slightly pulled back from nailbed. CNA reported it happened during transfer via Hoyer lift. It was hit and then started bleeding. The resident is diabetic and will need close monitoring for the wound. Staff cleaned the area with pure and clean, wrapped with gauze, and taped. New order placed. Wound will nurse assess and adjust treatment, as necessary. Resident denied pain. -On 08/09/24, 10:40 A.M., nurse notified that resident toenail had been bumped and was bleeding. Upon assessment the bottom of the toenail has a small open area between toenail and cuticle, the toenail is intact at this time. No sign/symptom of infection noted. Orders placed. Staff will monitor daily and discontinue when healed. -On 08/11/24, at 9:24 P.M., reassessed resident's great toe for signs and symptoms of infection. No signs noted with no increased warmth, no redness, and no pain noted. Resident requested prophylactic antibiotic due to previous difficulties with wounds to his left foot and is requested an urgent podiatry appointment; -On 08/10/24, at 9:21 P.M., recorded as late entry on 08/11/24, at 9:24 P.M., resident requested that this nurse look under bandage to right great toe while administering bedtime insulin. When removing bandage, noted toenail to be disconnected from nail bed except small amount of tissue in inner aspect of nail bed. No new bleeding, no signs/symptoms of infection noted, and no redness or pain noted. Staff reapplied bandage. -On 08/12/24, 5:50 P.M., Nurse Practitioner (NP) rounded on resident and gave new orders for Keflex (antibiotic) 500 mg (milligrams) PO (by mouth) BID (twice a day) for five days for pulled away toenail. Staff entered orders entered in the electronic medical record. Staff updated resident on treatment plan during rounds. During an interview on 08/20/24, at 4:15 P.M., the resident said CNA #2 bumped his/her foot into the wall and he/she is now losing the nail. The CNA had the resident on the crane (mechanical lift) by him/herself. During an interview on 08/22/24, at 4:20 A.M., CNA 5 said there are five mechanical lifts on the resident's. The CNAs we always help each other with the lifts. If the float CNA isn't available, the nurse will help. Staff safely transfer the resident with only one person. During an interview with CNA #2, on 08/23/24 at 8:48 A.M., the CNA confirmed that he/she was the CNA transferring the resident with the Hoyer lift at the time of the incident. The resident hit his/her toe on the doorframe. The CNA #2 declined to respond when asked if he/she was transferred the resident by him/herself, or if a Hoyer lift required two staff members to use. During an interview on 08/23/24, at 8:58 A.M., the Director of Nurses (DON) said the Hoyer lift has to be two people. CNA #2 did not have another staff with him/her during the transfer. The DON confirmed there was no identification of a second staff person noted on the incident report, nor was there an identification of a second staff person noted in the progress notes.

Based on interview and record review, the facility failed to provide care per standards of practice when staff failed to document and follow physician's orders related to blood sugar tests for one of one resident (Resident #23) reviewed for insulin use out of a total sample of 22. 1. Review of Resident #23's Face Sheet,' located in the 'Face Sheet tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses included diabetes and bilateral (both sides) shoulder fractures. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), located in the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 07/11/24, showed the following: -Cognitively intact for daily decision-making' -Administered insulin on six out seven days during the observation period. Review of the resident's Physician Orders, located under the Orders tab of the EMR, showed an order for the resident's blood sugar level to be checked before meals. Review of the resident's nursing Progress Notes, dated 08/01/24 at 12:46 P.M., and located in the 'Progress Notes tab of the EMR, showed the following: -Licensed Practical Nurse (LPN) #2 documented blood sugar at approximately 12:40 P.M. read 468 milligrams/deciliter (mg/dL). Nurse retook blood sugar on opposite hand with a reading 449 mg/dL. -LPN contacted the physician and received orders to administer 7 units of insulin and recheck blood sugar level in three three hours at 4:00 P.M. Staff to call if the resident's blood glucose level measured over 300 mg/dL. Review of the resident's Progress Notes and Orders tab of the EMR showed no documentation LPN #2 obtained the resident's blood sugar level at 4:00 PM. There was no documentation that the physician was notified of any results. There was no documentation the resident received any insulin. There was no documentation LPN #2 communicated with other nursing staff responsible for the resident's care. Review of the resident's nursing Progress Notes, located in the Progress Notes tab of the EMR and dated 08/01/24 at 10:19 PM, showed LPN #4 documented recheck resident blood sugar this time measured 371 mg/dL. The LPN notified the physician and received orders to administer 4 units of Humalog (short-acting insulin) per resident sliding scale. The nurse administered insulin. The LPN did not document why the resident's blood sugar was checked at this time. During an interview on 08/20/24, at 9:32 A.M., the resident said his/her sugars have been over 200 mg/dL since he/she has been at the facility. There was one time it was over 400 mg/dL. During an interview on 08/23/24, at 8:13 A.M., LPN #8 said there was no documention of the resident's blood sugaring being obtained on 08/01/23, at 4:00 P.M. The LPN said if it was not documented, then the blood sugar was not done as ordered. During an interview on 08/23/24, at 9:38 A.M., LPN #2 said at 4:17 P.M., the resident's blood sugar level was 330 mg/dL and he/she notified the physician. The physician gave an order to administer five units of insulin plus the resident's sliding scale insulin to equal eight units of insulin. He/she was supposed to recheck the resident's blood sugar in one hour and call the physician if it was over 300. Dinner had been served late, so she gave the resident the insulin at 5:30 P.M. He/she should have documented the physician order, but forgot to. He/she remembered at 8:30 P.M., called LPN #4, and told him/her to get the blood sugar and call the physician if it was over 300. LPN #2 said he/she failed to document the blood sugar and write a nursing Progress Note regarding the phone call with the physician and write the order. During an interview on 08/23/24, at 12:25 P.M., the Director of Nursing (DON) said physician orders, blood sugar checks, and communication between staff in regard to the resident's blood sugar levels should have been documented in the EMR as an order, a progress note written, and it should be reported to the next nurse at shift change.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - mandated federal assessment completed by facility staff) assessment was accurate and complete for one resident (Resident #24) of 22 residents whose MDS were reviewed. Review of the Resident Assessment Instrument manual, version 1.19.1, dated October 2023, showed the following: -The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status; -In addition, an accurate assessment required collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, and/or other legally authorized representative, or significant other as appropriate or acceptable. 1. Review of Resident #24's Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included heart failure, kidney disease, and a stroke. Review of the resident's quarterly MDS, located in the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 05/21/24, showed staff did not assess the resident in the following care areas: -Section C: Cognitive Patterns; -Section D: Mood; -Section E: Behaviors. During an interview on 08/22/24, at 10:36 A.M., the Social Services Director (SSD) said he/she was responsible for coding Sections C, D, and E on the MDS assessments. The SSD said she was unsure why those areas were no coded and thought maybe he/she had been out that week. During an interview on 08/23/24, at 10:26 A.M., the MDS Coordinator (MDSC) said he/she did not know why he/she did not code the missing sections. He/she did sign off on the assessment as complete.

Based on interview and record review, the facility failed follow standards of practice when the staff failed to monitor and follow-up on STAT (immediate) lab results resulting in treatment for one resident (Resident #1) infection. The facility census was 57. Record review of the Cleveland Clinics Website (myclevelandclinic.org), dated 11/05/21, showed the following: -A urinalysis (UA - is a quicker test that screens urine for the presence of red and white blood cells and bacteria that can indicate an infection); -A urinalysis can't identify the specific bacteria causing a urinary tract infection (UTI). A urine culture is completed for that. If bacteria grow in the urine culture test; -After the lab receives the urine sample, they grow the culture in an incubator for 24 to 48 hours; -The lab conducts an antibiotic sensitivity test on the bacteria in the cultured sample. Also called an antibiotic susceptibility test, this test identifies the type of bacteria causing the infection and which antibiotics the bacteria is sensitive to, meaning which antibiotics will kill the bacteria. This information helps the healthcare provider select the most effective antibiotic medicine. Record review of the facility's policy, Lab Reporting Guidelines, undated, showed the following: -The following guidelines will be followed to ensure that lab recommendations are completed timely; -The nurse will receive the order for the lab draw, enter the order in the orders, and document the telephone order, verbal order, or written order; -The lab order will be transcribed in the lab computer system for processing by the lab; -If the lab is STAT, call the lab to report the new order; -Once routine lab results are returned to the facility, the nurse will notify the physician via fax and follow up call in 12 hours if no return documentation. If there is a critical result, follow STAT protocol; -Once STAT lab results are returned to the facility, the physician will be notified via fax and phone call within one hour; -The nurse will document in nurses' notes that the lab results were received and sent to the physician for review. Any new orders will be documented in the nurses' notes and entered into the orders. 1. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admitted [DATE]; -Diagnoses included fracture of UTI, retention of urine, and cognitive communication deficit. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/8/22, showed the following: -Cognitively intact; -Required extensive assistance with transfers and toileting. Record review of the facility's, STAT Same Day Requisition, dated 12/10/22, showed the following: -Ordered tests: UA with culture if indicated. Record review of the resident's physician's order sheet, dated December 2022, showed no order for a UA or culture. Record review of the resident's nurses' notes showed the following: -On 12/10/22, at 11:15 A.M., Licensed Practical Nurse (LPN) A said the resident notified him/her of concerns of urinary frequency/urgency following scant output and burning upon voiding. On-call nurse was notified of resident's symptoms of possible UTI. The nurse notified the on-call nurse practitioner (NP) and awaiting new orders; -On 12/10/22, at 11:43 A.M., LPN A received STAT orders from on-call NP for a STAT UA with culture if indicated. Orders placed in medication administration record (MAR) and online. Staff called the lab for confirmation. Lab technician informed him/her that STAT labs are completed anywhere from two to four hours. Will continue to observe; -On 12/10/22, at 2:10 P.M., LPN A said at 1:00 P.M., 18 cc (cubic centimeter) of urine collected with hat/clean catch. The lab verified they must have at least 20 cc of urine for UA with culture if indicted. Small, frequent voids about one hour with approximately 15 to 60 cc of urine. Resident said burning feels like it's internal. Specimen left in sterile cup in the refrigerator with requisition. Awaiting Lab tech estimated time of arrival to facility; -On 12/10/22, at 9:58 A.M., LPN A said lab technician in facility to pick-up stat UA sample and drew stat labs per nurse practitioner. Lab departed facility with urine cup and vials of blood; -On 12/11/22, at 9:50 P.M., LPN A said STAT UA/lab result: Results pending for UA. The lab is aware of the STAT urgency; -On 12/12/22, at 11:35 A.M.,LPN B said UA results faxed from the lab. Lab faxed to the physician. UA was positive and are awaiting culture results. Record review of resident's medical records showed the following: -Urinalysis results from collection 12/10/22 at 1:00 P.M.; -Appearance was turbid (cloudy, opaque, or thick with suspended matter), showing an abnormal result. -Color:dark yellow, -Positive for nitrates (a sign of a possible urinary tract infection (UTI)), indicating an abnormal result ; -Leuko esterase UA (a screening test used to detect a substance that suggests there are white blood cells in the urine.), 3+ indicating an abnormal result -White blood cells, 11-20/hpf (high power field), indicating an abnormal result; -Bacteria 4+, indicating an abnormal result; -Crystals, triple phosphate present (neutral and alkaline urine and are associated with upper urinary tract infections with urease-producing organisms), indicating an abnormal result. Record review of resident's records showed the following: -A lab report inquiry showed the resident's lab was reported on 12/12/2022; -A urine culture final report dated 12/13/22; -Positive for entercoccus faecalis (a gram-positive bacterium that can cause a variety of infections of which urinary tract infections are the most common); -Susceptibility testing on entercocci isolated from lower urinary tract or minor infections is not routinely performed. These infections generally response to treatment with high doses of ampicillin (antibiotic) or penicillin (antibiotic). Alternates include erythromycin (antibiotic), ciprofloxacin (antibiotic), nitrofurantoin (antibiotic) or tetracycline. Record review of the resident's physician progress notes, dated 12/20/22, showed the following: -The resident's family present and reported that a UA was collected and was positive for a UTI. The culture results are available and shows sensitivity to Cipro. Will start on Cipro today as well a probiotic and order labs; -Plan: Cipro 500 mg daily for 5 days and probiotics 1 capsule daily. Record review of the resident's medical record showed staff did not document regarding the resident's culture results 12/20/22 (seven days later after the culture results were finalized). Record review of the resident's nurses' notes showed the following: -On 12/20/22, at 3:36 P.M., LPN C said NP saw the resident. New orders Cipro 500 milligram (mg) one time daily for 5 days due to results from culture and previous U/A obtained. Record review of the resident's December 2022 MAR, showed an order for Cipro 500 mg, 1 tablet, once a day, with a start date 12/20/22, for urinary tract infection. Record review of the resident's plan of care, dated 12/20/22, showed the following: -Received antibiotics for a urinary tract infection. He/she took Cipro (antibiotic) from 12/20/22 to 12/25/22; -Resident will be on the most appropriate antibiotic During an interview on 1/23/23, at 12:51 P.M., LPN B said the following: -He/she was aware that the UA was positive and the facility had been waiting to get back the urine culture for the resident to see what type of bacteria he/she had. The physician will not prescribe an antibiotic based on a UA being positive. The physician wants a culture completed first to make sure the correct antibiotic is prescribed; -He/she only worked the first few days after the resident had the culture. He/she checked and the results had not come in yet. He/she is not sure what happened after that; -The expectation is that results of a culture will come back within five days. He/she is not sure why they did not have the results until ten days after sending it to the lab; -Staff should follow up on the culture by contacting the lab if they have not received results from a culture within three to five days. During an interview on 1/23/23, at 2:15 P.M., Certified Nurse Aide (CNA) D said the following: -He/she lets the nurse know if he/she notices any residents having symptoms of a UTI such as pain/burning, increased frequency/urgency or odor/color change; -The nurse notifies the physician and gets orders for a UA. During an interview on 1/24/23, at 11:02 A.M., LPN E said the following: -If a resident is have symptoms of a UTI, such as, pain/burning, increased frequency/urgency or odor, he/she will notify the physician to get an order for a UA. He/she faxes the order to the lab. He/she will also follow up with a phone call it is a STAT lab; -When they receive results of the UA they let the physician know. If it is positive he/she generally will want a culture done which is usually put in the original order; -It can take around three to five days to get a culture back; -The physician will not order antibiotics until the culture results are reviewed; -He/she will follow up with the lab if the results are not showing up in the computer within three days; -He/she was not aware of the resident having a UA or culture ordered. If he/she would have known he/she would have followed up on it. During an interview on 1/24/22, at 11:15 A.M., Registered Nurse (RN) G said the following: - If a resident is having symptoms of a UTI, he/she will notify the physician to get an order for a UA/urine culture. He/she faxes the order to the lab; -When they receive results of the UA they let the physician know and they wait for the culture results; -He/she checks after three days if there are not results in the computer. The nurse should pass the information onto the next nurse in report so they can also be looking for results; -He/she as not aware of the resident having a UA/urine culture. During an interview on 1/24/22, at 12:07 P.M., RN F said the following: -He/she was made aware by the resident's family on 12/20/22 that the resident had a pending urine culture. They were upset because it had been 10 days and he/she had not been started on an antibiotic when the resident had a positive UA; -The resident was having a little increased confusion, but no other symptoms at that time; -The Administrator usually follows up on labs. He/she asked LPN B and he/she said the culture results had not come back yet; -The lab was contacted and the culture had been completed. He/she was not sure when it was completed. The NP reviewed the culture and put in orders to start an antibiotic on 12/20/22; -He/she is not sure why nobody followed up on the culture. He/she follows up on cultures if the results are not in the computer after three days and then sends it to the physician. During an interview on 1/24/22, at 11:28 A.M., the Director of Nursing (DON) said the following: -If a resident is having symptoms of a UTI, the expectation, is the nurse will contact the physician to get orders for a UA/culture. That information should be passed on to the next nurse and should be followed up on; -A different lab completed the culture and it was not obvious that the culture results were available; -It usually takes about five days for the lab they normally use to complete a culture, but the lab used for the resident completed it in three days. The staff was just not aware; -The nurse should have followed up on the resident's urine culture after five days to see why they didn't have results if they weren't seeing it in the computer. He/she is not sure why that didn't happen. During interviews on 1/23/23, at 2:42 P.M., and on 1/24/22, at 12:45 P.M., the Administrator said the following: -The physician will not order an antibiotic until he/she reviews the results from the culture; -The lab that normally does their cultures did not complete it this time and the results were put in the computer in a way that made it difficult for staff to notice the results were completed and put into the computer; -He/she would expect staff to follow up on cultures if results are not received after three days; -The resident's culture should have been followed up on sooner; -Staff had to call the lab on the 12/20/23 to get the results. MO00211766

Based on observations, interviews, and record reviews, the facility failed to document a thorough investigation completed regarding grievances; failed to document an explanation of the findings and proposed remedies related to grievances, family, and/or staff; failed to identify the current grievance officer; failed to ensure the residents had the right to file a grievance anonymously; and failed to educate and review guidelines on how to file a grievance with the residents and staff. The facility census was 57. Record Review of the facility's policy, Grievance Protocol, undated, showed the following: -The purpose of the grievance/complaint report and Grievance Log is to provide a written record of each resident and family concern and to insure proper follow-up through the appropriate discipline; -The Social Service Director (SSD) is responsible for the program, although the Administrator is ultimately responsible for the proper implementation of the program. The SSD informs the Administrator of each incident; -Any member of the social services staff can complete the Grievance Complaint Report. The appropriate situations for use of the Grievance Complaint Report are resident articles that are lost of cannot be located and continual concern of lost resident items (including laundry concerns); resident care or personal hygiene issues that cannot be immediately resolved; resident or family concerns with dietary issues; diet or temperature of meals; any resident or family concerns with a staff member; and any resident or family issue that would require a resolution; -The SSD will obtain the original Grievance Complaint Report, record the grievances on the Monthly Grievance Log, inform the Administrator of the grievance, and forward a copy of the grievance to the appropriate discipline; -The Administrator and SSD evaluate the Monthly Grievance Log for trends or patterns and devise and action plan to correct issues. A new Grievance Log should be completed each month. Record review of the facility's policy, Your Rights, as a Resident in a Long-Term Care Facility , undated, showed the following: -Residents may voice grievances and recommend changes to facility staff or to outside representatives. Owners and staff of long term care facilities are prohibited by law from retaliating in the case of complaints; -Residents should speak with the Director if Nursing (DON) or Administrator of the home if they encounter problems requiring immediate action. For non-emergencies, residents should speak to the resident council or the Ombudsman. 1. Record review of the facility's Grievance Log showed the following: -On 9/27/22, a grievance was logged for a resident; -Staff did not log any grievances for October 2022, November 2022, or December 2022. 2. During an interview on 12/14/22, at 10:50 A.M., Resident #1 said the following: -On Monday (12/14/22) evening, Certified Nurse Aide (CNA) A yelled at him/her. Resident #2 was taking ornaments off the Christmas Tree and CNA A was not being very nice; -He/she was trying to get CNA A to do something about it and CNA A said if you don't like it you can leave; -He/she reported it to the Administrator yesterday. During an interview on 12/15/22, at 11:24 A.M., CNA A said the following: -On 12/12/22, Resident #1 became upset and started yelling at him/her because he/she was upset about Resident #2 taking ornaments off the Christmas tree and wanted CNA A to do something about it; -He/she is not sure who to direct residents to if they have a grievance. He/she is not aware of who the Grievance Officer is. He/she would probably direct the resident to his/her charge nurse. During an interview on 12/15/22, at 4:29 P.M., Licensed Practical Nurse (LPN) D said the following: -Earlier this week he/she overheard a disagreement between Resident #1 and CNA A. Resident #1 was upset and yelling and CNA raised her voice when speaking to him. LPN D intervened at that time by saying enough due to it sounding like CNA was frustrated and the situation escalating; -He/she did not report the incident because he/she did not feel it was abuse. During an interview on 12/14/22, at 12:15 P.M., the Administrator said the following: -Resident #1 came to him/her yesterday morning and said he/she was upset because he/she had decorated the Christmas tree and Resident #2 was taking the ornaments off the tree; -He told CNA A and did not feel like he/she handled the situation appropriately and did not stop the resident from taking the ornaments; -He/she has not investigated the incident further or started a grievance. 3. During an interview on 12/14/22, at 3:17 P.M., Resident #3 said the following: -He/she recently reported that a roll of five dollars' worth of dimes had gone missing; -He/she told Receptionist E about it and the Administrator overheard and said it had been reported; -He/she has not heard anything more about it since then. The facility did not replace the dimes or inform him/her of the outcome. During an interview on 12/15/22, at 1:02 P.M., Receptionist E said the following: -Resident #3 told him/her that she was missing a roll of dimes (five dollars); -He/she was not sure exactly when it was, but thought it was last week sometime; -The Administrator overheard them talking about it and said it had already been addressed so he/she didn't think she needed to do anything more. During an interview on 12/15/22, at 5:18 P.M., the Administrator said the following: -He/she overheard Resident #3 and Receptionist E talking about something going missing, but he/she thought they were referring to a previous allegation of misappropriation that had been addressed; -The Administrator was not aware of Resident #3's roll of dimes going missing. There was a miscommunication and it was not addressed, but it should have been. The resident should have been grievance/investigation should have been documented. 4. During an interview on 12/15/22, at 2:15 P.M., the SSD said the following: -The facility hasn't really had any grievances recently. He/she had been keeping a binder with concerns/complaints, but he/she was told by the previous Administrator to stop doing that; -He/she does not document any concerns/complaints/grievances if he/she is able to resolve them in 24 to 48 hours; -He/she is not sure what the policy says about addressing grievances; -He/she is not sure if the instructions for filing a grievance is posted for the residents; -During the admission process residents are informed they can file a grievance; -He/she is not sure who the Grievance Officer is; -He/she is not sure how a resident would file a grievance anonymously. The nurses station has forms, but the nurse would have to get it for the resident. 5. During an interview on 12/15/22, at 2:30 P.M., the Social Services Assistant (SSA) said the following: -He/she considers concerns that can't be resolved within 24 to 48 hours to be grievances. He/she has not been filling out a grievance form or putting concern/complaints on the grievance log if it is resolved within 24 hours; -He/she is not sure who the Grievance Officer was. 6. During an interview on 12/15/22, at 2:51 P.M., Certified Medication Tech (CMT) B said he/she would report resident grievances/complaints to his/her charge nurse. 7. During an interview on 12/15/22, at 2:56 P.M., LPN C said the following: -If resident's have a grievance there is a form they can fill out for them. The residents have to ask for the form; -He/she is not sure how to fill out the form; -He/she is not sure there is a way for them to file a grievance with the facility anonymously or instructions on how to file the grievance; -He/she is not sure there is a way -He/she would most likely report grievances to the Director of Nursing (DON). 8. During an interview on 12/15/22, at 5:18 P.M., the Administrator and DON said the following: -Grievances are concerns that the facility cannot solve within 24 hours and concern/complaint form should be completed. A complaint/concern form is not completed if is solved within 24 hours; -There are concern/complaint forms on each unit, but the resident would have to ask the nurse to get them; -The concern/complaint forms have gone by the way side and the staff need to be re-educated about them; -The Grievance Officer would be the SSD; -The facility does not have information about the Grievance Officer posted for the residents in the facility; -Concerns and complaints from residents should be addressed and documented. MO00210652

Based on observation, interview, and record review, the facility failed to ensure a resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record for three residents (Resident #8, Resident #47 and Resident #104). The facility census was 60. Record review of the facility's policy titled Do Not Resuscitate (DNR- do not attempt cardiopulmonary resuscitation (CPR-an emergency procedure that is performed when a person's heartbeat or breathing has stopped)) Guidelines, undated, showed the following: -The facility recognizes the right of any competent resident or person responsible for making health care decisions for the resident to request the cardiopulmonary resuscitation (CPR) be withheld in the event of cardiac or respiratory arrest; -Upon admission, the social services designee will provide information on CPR to the resident and/or resident's legal representative and will review the Outside of the Hospital Do-Not Resuscitate (OHDNR) order form. The OHDNR can only be signed by the resident or legal representative; -After review of the OHDNR form, the resident or legal representative will make their decision known by signing the form; -It will be explained to the resident or legal representative that at any time the resident or legal representative may revoke the OHDNR order; -Once the OHDNR form has been signed it will be placed in the medical record under the advanced directive tab (in the computer system); -The resident's face sheet, door dot, care plan, physician orders, and 'computer banner' shall be up to date with the current status. Record review of the OHDNR form showed the following: -Area for patient's name and patient's signature or patient representative's signature; -Area for attending physician's signature with date, physician' license number, telephone number physician printed or typed name and address, and facility or agency name. 1. Record review of Resident #8's face sheet (admission data) showed the following: -admitted [DATE] and readmitted [DATE]; -Code status of DNR. Record review of the resident's OHDNR form showed the following: -The resident signed the form on [DATE]; -The physician signed the form on [DATE]. Record review of the resident's care plan, revised [DATE], showed a code status of DNR. Record review of the resident's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on [DATE], at 2:00 P.M. of the resident's door showed the resident had a green dot (full code) on his/her door name plate During an observation and interview on [DATE], at 10:33 A.M., Certified Nurse Aide (CNA) A opened the resident's electronic medical record (EMR) which showed the resident's code status of DNR. During an interview and record review on [DATE], at 12:46 P.M., Licensed Practical Nurse (LPN) B said the following: -The resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident and physician signed the uploaded DNR form in the computer on [DATE]; -The resident had a green folder (located in the nurses' station) which showed a face sheet, dated [DATE], with a full code status at the top of the sheet; -The resident's code status is not up to date and should be consistent in the medical record. During an interview on [DATE], at 1:15 P.M., the Minimum Data Set (MDS)/Care Plan Coordinator said the resident was admitted to hospice. The resident's POS showed a code status of full code and the care plan showed a code status of DNR. During an interview on [DATE], at 1:21 P.M., the Director of Nursing (DON) said the following: -The resident's code status in the resident's EMR showed DNR code status; -The resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -The DNR form uploaded in the computer dated [DATE] is signed by the physician and resident; -The resident's code status should be clear and consistent throughout the medical record. 2. Record review of Resident #47's face sheet showed the following: -admitted [DATE] and readmitted [DATE]. Record review of the resident's OHDNR form showed the following: -The resident signed the form on [DATE]; -The resident's physician signed the form on [DATE]. Record review of the resident's care plan, revised [DATE], showed code status of a full code. Record review of the resident's current POS, dated [DATE], showed the resident code status as a DNR. During an observation on [DATE] at 2:00 P.M. of the resident's door showed the resident had a red dot (indicated DNR) on his/her door name plate. During an interview on [DATE], at 10:33 A.M., CNA A said the resident's EMR showed the resident's code status of DNR. During an observation and interview on [DATE], at 12:46 P.M., LPN B said the following: -The EMR showed a code status of DNR; -The POS, dated [DATE], showed a code status of DNR; -The resident's red folder showed a DNR form dated [DATE] that was signed by the resident and physician; -The face sheet (printed [DATE]) in the resident's red folder showed a full code status. During an interview on [DATE], at 1:15 P.M., the MDS/Care Plan Coordinator said the following: -The EMR showed the resident's code status of DNR; -The resident's care plan showed a code status of full code; -The resident's code status should be consistent throughout the medical record. During an interview on [DATE], at 1:21 P.M., the DON said the following: -The resident's EMR showed code status of DNR; -The resident's POS, dated [DATE], showed a code status of DNR; -The resident's care plan showed a code status of full code; -The resident's DNR form was signed by the resident [DATE] and the physician signed the order on [DATE]; -The physician may not have signed the DNR form until the resident was readmitted on [DATE] from the hospital. 3. Record review of Resident #104's face sheet showed the following: -admitted [DATE]; -Code status of DNR. Record review of the resident's OHDNR form showed the following: -The resident signed the form on [DATE]; -The resident's physician signed the form on [DATE]. Record review of the resident's care plan, dated [DATE], showed code status of full code. Record review on [DATE], at 9:10 A.M., of the resident's POS, dated [DATE], showed the resident's code status as a full code. Record review on [DATE], at 3:52 P.M., showed the DNR form, dated [DATE], in a red folder inside of the nurses station. During an observation on [DATE], at 2:00 P.M., of the resident's door showed the resident had no name or dot on his/her nametag to indicated code status. During an interview on [DATE], at 10:33 A.M., CNA A said the resident's code status showed full code in the resident's EMR. During an interview on [DATE], at 12:46 P.M., LPN B said the following: -The resident's EMR showed a code status of full code; -The POS showed an order, dated [DATE], of full code status; -The DNR uploaded in the computer showed the DNR form signed on [DATE]; -The red folder has the DNR form; -Staff did not update the resident's code status in the EMR. During an interview on [DATE], at 1:15 P.M., the MDS/Care Plan Coordinator said the following: -The resident's EMR showed a code status of full code; -The resident's care plan showed a code status of full code; -The DNR form is uploaded in the computer with the resident signature on [DATE] and physician signature on [DATE]; -Staff must have missed the resident's change of code status and medical records have been piled up. During an interview on [DATE], at 1:21 P.M., the DON said the following: -The resident's EMR showed code status of full code; -The DNR signed form was uploaded in the computer; -The POS showed a code status of full code dated [DATE]. 4. During an interview on [DATE], at 10:33 A.M., CNA A said the following: -CNA's find the code status in the activities of daily living (ADL's) on the computer; -Staff also find the code status on the care plans located in the nurses' station; -He/she would get the nurse if he/she finds a resident unresponsive. 5. During an interview on [DATE], at 11:21 A.M., Certified Medication Technician (CMT) C said the following: -Staff find a resident's code status in the chart; -Staff click on the resident's name in the computer to find a resident's code status; -Staff alert the charge nurse if a resident is found unresponsive and look for the resident's code status; -The green color is for full code and red color is for DNR; -Full code means not breathing and to start CPR; -DNR means do not resuscitate; -The code status should be on the resident's care plan. 6. During an interview on [DATE], at 11:34 A.M., CNA D said the following: -Staff find a resident's code status on every resident's door; -The resident's door tag has their name and a red or green sticker; -The red sticker is DNR and the green sticker is full code; -The nurses' station has folders which have the resident room numbers and are color coded, red for DNR and green for full code; -Staff should inform the charge nurse of any updates to a resident's care plan; -The resident's code status should be consistent throughout the medical record. 7. During an interview on [DATE], at 12:46 P.M., LPN B said the following: -Staff find a resident's code status with the dot system on the resident's names on the doors. The red dot means DNR and the green dot means full code; -DNR means do not resuscitate and full code means to start CPR; -Staff find the resident's code status in the chart; -The CNA's find the code status on the computer at a kiosk; -Staff check a resident for a heart beat if found unresponsive; -Staff check a resident's code status on the computer (the chart) if no heartbeat; -He/she thinks the social service staff review a resident's code status upon admission with the resident and family; -Medical record staff upload the DNR form into the computer; -He/she did not know what staff upload the information in the computer if there is a change in code status; -There is a cubby system in the nurses station with green folders which mean full code and the red folders mean DNR; -The green folder has the emergency transfer form and face sheet with full code on the face sheet; -The red folder should have the OHDNR form and the face sheet should have DNR on it; -The code status should be consistent throughout the medical record. 8. During an interview on [DATE], at 1:15 P.M., the MDS/Care Plan Coordinator said the following: -She finds the resident's code status in the EMR when she completes the five day and admission entries; -Staff discuss updates to resident care plans in the morning meetings; -Nurses enter the code status in the computer; -A resident's code status should be consistent throughout the medical record. 9. During an interview on [DATE], at 1:21 P.M., the DON said the following: -Staff find a resident's code status in the computer system; -Nurses enter a resident's name in the computer and find the resident's current code status under the resident's name; -Social service staff assist the nursing staff to get the resident's code status paperwork signed; -There are folders at the nurses' station. The red folder for DNR and a green folder for full code; -The computer is the most updated code status for a resident; -Staff should grab the resident's folder in the cubby inside of the nurses' station if they send a resident to the hospital; -Medical record staff upload the DNR forms into the computer; -Staff should document in the progress notes and inform nursing staff a resident has a change in code status; -Staff find a resident's code status on the resident's name plate on their doors with red or green stickers; -Administration staff review resident's progress notes every morning. Staff report any updates or changes to staff; -Care plans should have resident's updated code status; -A resident's code status should be clear and consistent throughout medical record. 10. During an interview on [DATE], at 1:38 P.M., the Administrator said a resident's code status should be consistent throughout medical record. 11. During an interview on [DATE], at 3:23 P.M., the Medical Record Staff said the following: -The hospital sends a resident's code status upon admission; -Social service staff explain the code status upon admission to the resident or representative; -Social service staff get the signed DNR form to the physician to sign; -Social Service staff scan the signed DNR form and gives him/her a copy of the DNR form; -He/she uploads the signed DNR form into the advance directive section in the computer; -He/she places a signed DNR form to the folder in the nurses' station. Green folder means full code and the red folder means DNR; -The MDS/Care Plan Coordinator reviews physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Social service staff get the appropriate forms signed if a change in code status, gives to the physician and scans the documents in the computer and gives him/her a copy; -The business office manager sets up the chart in the electronic health record and enters the resident's name, race, address and code status; -The resident's code status should be consistent throughout the medical record. 12. During an interview on [DATE], at 3:33 P.M., the Social Service Designee said the following: -She reviews code status with the resident or representative upon admission; -She faxes the physician the DNR form once the resident or representative signs it. She makes a copy of the completed DNR form for medical record staff and gives one to the nursing staff; -The DNR form should be in the red folder in the cubby located in the nurses's station; -The green folder in the cubby located in the nurses' station means full code; -Medical record staff upload the DNR form into the computer; -Medical record staff and/or the DON place the dots on the resident's door; -Medical record staff give the code status to the Care Plan Coordinator who updates the care plan. 13. During an interview on [DATE], at 10:49 A.M., the Business Office Manager said she did not do anything with the code status. The nursing staff enters the resident's code status in the computer. 14. During an interview on [DATE], at 11:01 A.M., the Social Service Director said the following: -Social service staff complete the code status with the resident/representative upon admission; -Social services fax the DNR form to the physician to sign, scans the signed form to medical record staff, make a purple copy and white copy and gives to medical record staff to file.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate below five percent when staff made three errors out of 27 opportunities, resulting in an error rate of 11.11 percent, affecting three residents (Resident #6, #24, and #37). The facility census was 60. Record review of the facility provided information titled, Insulin By Kwikpen (or similar pen type device) showed the following: -Staff need to prime the pen before each use to assure the unit accuracy. Turn the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue to hold the pen with the needle pointed up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose in and count to five slowly. Staff should see insulin at the tip of the needle, if not re-prime. Record review of the [MEDICATION(S)] [MEDICATION(S)] (a fast-acting insulin) manufacturer's guidance, dated 3/2021, showed the following: -Before each injection small amounts of air may collect in the cartridge during normal use; -To avoid injecting air and to ensure proper dosing, -Prime (referred to as an air shot) the flex pen before each injection; -Turn the dose selector to select two units; -Hold the flex pen with the needle pointing up. Tap the cartridge gently to make any air bubbles collect at the top of the cartridge -Keep the needle pointing upward, and press the push button all the way in. The dose selector returns all the way to 0; -Make sure a drop appears; -If a drop of insulin does not appear, change the needle and repeat the procedure, no more than six times. Record review of the [MEDICATION(S)] (name brand of [MEDICATION(S)]-a fast acting insulin) [MEDICATION(S)] (device used to administer the insulin) manufacturer's insert, dated November 2019, showed the following information: -[MEDICATION(S)] insulin should be administered 15 minutes before a meal or immediately after a meal; -[CONDITION(S)] (low blood sugar) is the most common adverse reaction to insulin therapy and may be life-threatening. Symptoms may be different for each person and may change from time to time. Severe [CONDITION(S)] can cause seizures and may be life threatening or cause death. -Prime the pen before each injection: Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly; If you do not prime before each injection, you may give too much or too little insulin; -To prime the pen, turn the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top, continue holding the pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly; -You should see insulin at the tip of the needle; -If you do not see insulin, repeat priming steps six to eight, no more than four times; -If you still do not see insulin, change the needle and repeat priming steps six to eight; -Small air bubbles will not affect the dose; -Turn the dose knob to select the number of units you need to inject. The dose indicator should line up with the dose. 1. Record review of Resident #6's face sheet showed an admitted [DATE]. Record review of the resident's September 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 8/22/20, for [MEDICATION(S)] R [MEDICATION(S)] insulin, administer subcutaneously (SQ - to inject between the skin and the muscle) per sliding scale before meals and at bedtime, as follows: -Blood sugar level of less than 70 milligrams/deciliter (mg/dL), call physician; -Blood sugar level of 70 mg/dL to 130 mg/dL, administer 0 units of insulin; -Blood sugar level of 131 mg/dL to 180 mg/dL, administer 2 units of insulin; -Blood sugar level of 181 mg/dL to 240 mg/dL, administer 4 units of insulin; -Blood sugar level of 241 mg/dL to 300 mg/dL, administer 6 units of insulin; -Blood sugar level of 301 mg/dL to 350 mg/dL, administer 8 units of insulin; -Blood sugar level of 351 mg/dL to 400 mg/dL, administer 10 units of insulin; -Blood sugar level of greater than 400 mg/dL, administer 12 units of insulin and notify the physician. Observation on 9/09/22, at 11:05 A.M., of Licensed Practical Nurse (LPN) I showed the following: -The nurse entered the resident's room and performed a blood glucose test via finger stick (Accucheck) with a result of 159 mg/dL; -The nurse then reviewed the resident's order on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -The nurse removed the cap from the resident's [MEDICATION(S)] [MEDICATION(S)], cleansed the rubber stopper with alcohol, inserted a disposable needle, and dialed to two units; -The nurse then entered the resident's room cleansed the resident's right upper arm with an alcohol wipe and administered the two units of insulin via the [MEDICATION(S)] [MEDICATION(S)]. (The nurse did not prime the insulin pen prior to the SQ administration.) 2. Record review of Resident #37's face sheet the resident admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the resident's September 2022 POS and MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 2/10/21, for [MEDICATION(S)] Kwikpen, administer SQ per sliding scale before meals and at bedtime, as follows: -Blood sugar level of less than 60 milligrams/deciliter (mg/dL), call the physician; -Blood sugar level of 150 mg/dL to 200 mg/dL, administer 3 units of insulin; -Blood sugar level of 201 mg/dL to 250 mg/dL, administer 6 units of insulin; -Blood sugar level of 251 mg/dL to 300 mg/dL, administer 9 units of insulin; -Blood sugar level of 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -Blood sugar level of 351 mg/dL to 400 mg/dL, administer 15 units of insulin; -Blood sugar level of greater than 400 mg/dL, administer 18 units of insulin; -If the blood sugar is greater than 401 mg/dl, notify the physician. Observation on 9/09/22, at 11:16 A.M., of LPN I showed the following: -The nurse entered the resident's room and performed a blood glucose test via finger stick (Accucheck), with a result of 183 mg/dL; -The nurse then reviewed the resident's order on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -The nurse removed the cap from the resident's insulin [MEDICATION(S)] (generic for [MEDICATION(S)] Kwikpen), cleansed the rubber stopper with alcohol, inserted a disposable needle, and dialed to three units; -The nurse then entered the resident's room cleansed the resident's left upper arm with an alcohol wipe and administered the three units of insulin via the Insulin [MEDICATION(S)] pen. (The nurse did not prime the insulin pen prior to the SQ administration.) 3. Record review of Resident #24's face sheet showed the resident admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the resident's September 2022 POS and MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 2/10/21, for [MEDICATION(S)] [MEDICATION(S)], administer SQ per sliding scale before meals and at bedtime, as follows: -Blood sugar level of 0 milligrams/deciliter (mg/dl) to 149 mg/dl, administer 0 units of insulin; -Blood sugar level of 150 mg/dL to 200 mg/dL, administer 3 units of insulin; -Blood sugar level of 201 mg/dL to 250 mg/dL, administer 6 units of insulin; -Blood sugar level of 251 mg/dL to 300 mg/dL, administer 9 units of insulin; -Blood sugar level of 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -Blood sugar level of 351 mg/dL to 400 mg/dL, administer 15 units of insulin; -Blood sugar level of 401 mg/dL to 450 mg/dL, administer 18 units of insulin; -If the blood sugar is greater than 450 mg/dL, notify the physician. Observation on 9/09/22, at 11:35 A.M., of Assistant Director of Nursing (ADON) showed the following: -The nurse entered the resident's room and performed a blood glucose test via finger stick (Accucheck), with a result of 326 mg/dL; -The nurse then reviewed the resident's order on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -The nurse removed the cap from the resident's [MEDICATION(S)] [MEDICATION(S)], cleansed the rubber stopper with alcohol, inserted a disposable needle, and dialed to two units; -The nurse then entered the resident's room cleansed the resident's left lower abdomen with an alcohol wipe and administered the twelve units of insulin via the [MEDICATION(S)] [MEDICATION(S)]. (The nurse did not prime the insulin pen prior to the SQ administration.) 4. During an interview on 9/9/22, at 11:40 A.M., the ADON said the following: -He/she was not aware of the need to prime the resident insulin pens before each use. 5. During an interview on 9/12/22, at 3:18 P.M., the Director of Nursing (DON) said the following: -She expected all facility nurses to prime insulin pens with two units of insulin before each dose; -She had not provided any recent training to nurses about this because she was not aware there was an issue with insulin administration. 6. During an interview on 9/13/22, at 12:17 P.M., the Administrator said: -She expected all facility nurses to prime insulin pens with two units of insulin before administering each insulin dose.

Based on interview and record review, the facility failed to ensure all controlled drugs were reconciled periodically per standards of practice when off going and on coming nurses/certified medication technicians (CMTs) failed to count narcotics/controlled medications and failed to sign the controlled substance shift change record during shift change for two of two medication carts, two of two nurse treatment carts, and one of two refrigerator lock boxes located in the facility. The facility census was 60. Record review of the facility policy titled, Narcotic Count, undated, showed the following: -Purpose is to complete a physical inventory of narcotics at each shift change to identify discrepancies; -One registered nurse (RN), licensed practical nurse (LPN), or certified medication technician (CMT) going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of narcotics supply for each individual resident at the change of each shift.; -Narcotic records are reconciled by a physical count of the remaining narcotic supply at each shift change by the incoming and outgoing licensed nurse. Records are to be retained for at least one year. Emergency kits containing narcotics will be checked at the same time to be sure seal has not been broken or will be reconciled if seal is broken; -After the supply is counted and justified, the nurse/CMT records the date and his/her signature, verifying that the count is correct; -The nurse going off duty surrenders the narcotic key to the nurse coming on duty after the narcotic count is reconciled. 1. Record review of the facility's September 2022 Controlled Substance Shift Change Record for the Dogwood Unit medication cart locked narcotic drawer showed the following: -On 9/1/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/1/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/4/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/4/22, at 6:00 P.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/6/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/6/22, at 6:00 P.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/7/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/7/22, at 6:00 P.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/8/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/9/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/9/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/11/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count. Record review of the facility's September 2022 Controlled Substance Shift Change Record 2022, for the Dogwood Unit nurse treatment cart locked narcotic drawer showed: -On 9/1/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/4/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count;; -On 9/7/22, at 6:00 P.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/8/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/11/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count. Record review of the facility's September 2022 Controlled Substance Shift Change Record for the Dogwood Unit medication refrigerator locked narcotic box showed: -On 9/1/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/4/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/5/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/6/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/6/22, at 6:00 P.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/7/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/7/22, at 6:00 P.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/8/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/11/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count. Record review of the facility's September 2022 Controlled Substance Shift Change Record for the Willow Unit medication cart locked narcotic drawer showed: -On 9/1/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/6/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/9/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/9/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/11/22. at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count. Record review of the facility's September 2022 Controlled Substance Shift Change Record for the Willow Unit nurse treatment cart locked narcotic drawer showed: -On 9/1/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/1/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/4/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/4/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/5/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/5/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/6/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/8/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/9/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/9/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/11/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count. During an interview on 9/13/22, at 10:01 A.M., Licensed Practical Nurse (LPN) J said the following: -At the beginning of each day shift, the off going night nurse handed the narcotic keys to LPN J, but did not count the narcotics with LPN J; -At the end of each day shift, LPN J handed the narcotic keys to the oncoming night nurse, but LPN J did not count narcotics with the night nurse. During an interview on 9/13/22, at 10:55 A.M., the Director of Nursing said the following: -She expected the off going and oncoming nurse or CMT to count all narcotics at the change of shift and sign/initial the narcotic count records; -The night shift nurse/CMT should count the medication cart narcotics with the day shift CMT/nurse; -The night shift nurse should count the nurse cart narcotics and the refrigerated narcotics with the day shift nurse; -Two staff should be present during the narcotic count and both should sign the narcotic shift change record each shift. During an interview on 9/13/22, at 11:28 A.M., CMT F said the following: -He/she noticed gaps in the signatures on the narcotic book/record; -Occasionally, some of the nurses forgot to sign, but he/she always counted the narcotics at the beginning and end of his/her shift with a nurse or CMT. During an interview on 9/13/22, at 11:44 A.M., CMT K said the following: -Some of the night shift nurses failed to sign the narcotic record at shift change; -He/she always counted narcotics and signed the narcotic shift change record at the beginning and end of each shift. During an interview on 9/13/22, at 12:17 P.M., the Administrator said the following: -He/she expected the off going nurse/CMT and the oncoming nurse/CMT to count narcotics and sign the narcotic count record each time the narcotic keys changed hands.

Based on observation, interview, and record review, the facility failed to document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation; failed to obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #50). Staff failed to complete ongoing assessments to ensure the side rails are appropriate for use, failed to include the side rail on the care plan for four residents, and failed to obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's census was 60. Record review of the facility's policy titled Side Rail Protocol, undated, showed the following: -Before placing a side rail read the following process to ensure the appropriateness and safety for the resident; -Physician/Director of Nursing (DON)/therapy department make side rail requests for side rails to be placed on a specific resident bed; -Since the side rail that is typically used for positioning, make sure to ask if the side being placed is left, right or both; -Begin the side rail assessment in electronic medical record (EMR) and discuss the risks/benefits with the resident (if responsible party) or family/friend (responsible party) and receive consent; -If a family/friend is the responsible party then you may take a verbal consent over the phone, but the verbal must be noted within the additional information section of the observation; -Request for the maintenance director to place the side rail on the bed and maintenance will then measure to ensure the safety of the rail. As long as the measurements pass the safety requirements the side rail will stay in place. If the side rail do not pass (fail) the safety requirements then maintenance will remove the side rail; -Maintenance director will not place a side rail without consent being in place; -If the measurements fail then the nurse will need to notify the resident/family that the side rail cannot remain due to the measurements not meeting the safety requirements; -Once the observation is completed, the observation should be printed and the resident/family will sign the consent line; -Please give completed signature form to medical records to be uploaded into resident's EMR; -A final nursing progress note summarizing the side rail observation, measurement and consent was completed upon placing the left, right or both side rail. 1. Record review of Resident #7's face sheet (admission data) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 8/25/22, showed the following information: -Severely impaired cognition; -Extensive assistance required with bed mobility, transfer, dressing and toilet use Record review of the resident's care plan, revised on 9/12/22, showed the following: -Required total care for dressing, bathing, toileting, hygiene, transfers and mobility. (Staff did not care plan the use of an enabler or side rail.) Record review of the resident's September 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 9/13/22, at 10:23 A.M., showed an enabler ('U' shaped 'bar') attached to the left side of the bed up by the head of the bed. During an interview on 9/13/22, at 10:26 A.M., CNA D said the resident uses the enabler on his/her bed. The resident holds the rail when staff roll him/her in bed for assistance with care. The resident has days when more confused. During an interview on 9/13/22, at 11:15 A.M., the Director of Nursing (DON) said the resident uses the enabler. The resident is confused and tries to get out of his/her bed at times. During an interview on 9/13/22, at 2:17 P.M., the Care Plan Coordinator said the resident's side rail is not on his/her care plan. Record review of the resident's current medical record showed staff did not document identification and use of possible alternatives prior to use of side rails, assessing risk versus benefits of side rail use, obtaining informed consent for the use of side rails prior to installation, measurements, or ongoing assessments to ensure the side rails were appropriate for use. 2. Record review of the Resident #12's face sheet showed the following: -admitted on [DATE], readmission on 9/28/21; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's side rail assessment and consent, dated 6/2/21, showed the following: -The resident used side rails for positioning or support; -The resident expressed a desire to have side rails raised in his/her bed for safety and/or comfort; -The resident has a quarter rail used to assist in positioning and transfers; -Assessment of potential entrapment zones completed on 5/5/21; -Risks and benefits explained to resident/family on 6/2/21. Record review of the resident's care plan, revised on 6/12/22, showed the following: -The resident is at risk for falls due to his/her limited mobility, weakness, pain and use of assistive devices; (Staff did not care plan the use of an enabler or side rail.) Record review of the resident's September 2022 POS showed no order for use of a bed rail. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderately impaired cognitive skills; -Independent with bed mobility and dressing; -Limited assistance required with transfer and toilet use. Observations on 9/8/22, at 10:54 A.M., and on 9/12/22, at 3:28 P.M., showed the resident's bed had a quarter size rail in the up position on the left side of the bed. During an interview on 9/13/22, at 11:15 A.M., the DON said the resident requested the quarter size side rail. During an interview on 9/13/22 at 2:17 P.M., the Care Plan Coordinator said the resident's side rail is not on his/her care plan. Record review of the resident's current medical record showed staff did not document ongoing assessments to ensure the side rails were appropriate for use. 3. Record review of Resident #43's face sheet showed the following: -admitted on [DATE] with readmission on 7/18/22; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderately impaired cognitive skills; -Extensive assistance required with bed mobility, transfer and dressing. Record review of the resident's care plan, revised on 8/2/22, showed the following: -The resident is at risk for falls due to generalized weakness and balance problems. (Staff did not care plan the use of an enabler or side rail.) Record review of the resident's September 2022 POS showed no order for an enabler/side rail. Observation on 9/8/22, at 9:57 A.M., showed the resident on his/her bed with the head of the bed elevated with the inverted U-shaped bars on each side of his/her bed. These bars extended up from the bed frame to a height of approximately one foot above mattress level and were located approximately 1/3 of the way down from the head of the bed and were approximately 6 inches wide. During an interview on 9/13/22, at 11:15 A.M., the DON said the resident is alert and follows directions. The resident holds the rail when staff assist with care and rolling in bed. During an interview on 9/13/22, at 2:17 P.M., the Care Plan Coordinator said resident's enabler is not on his/her care plan. Record review of the resident's current medical record showed staff did not document identification and use of possible alternatives prior to use of side rails, assessing risk versus benefits of side rail use, obtaining informed consent for the use of side rails prior to installation, measurements or ongoing assessments to ensure the side rails were appropriate for use. 4. Record review of Resident #50's face sheet showed the following: -Admission on 8/3/22; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following information: -Moderately impaired cognitive skills; -Extensive assistance required with bed mobility, transfer, and dressing. Record review of the resident's care plan, dated 8/11/22, showed the following: -The resident is at risk for falls due to his/her cognitive deficits, need for assistance for bed mobility and for transfers; -Staff should observe the resident for behaviors and lack of safety awareness that would place him/her at increased risk for falls. (Staff did not care plan the use of an enabler or side rail.) Record review of the resident's September POS showed no order for an enabler/side rail. Observation on 9/12/22, at 3:38 P.M., showed the resident rested quietly on his/her low bed with inverted U-shaped bars on each side of his/her bed. These bars extended up from the bed frame to a height of approximately one foot above mattress level and were located approximately 1/3 of the way down from the head of the bed and were approximately 6 inches wide. During an interview on 9/13/22, at 11:15 A.M., the DON said the resident is very confused and uses the enabler to reposition. The resident tries to get out of his/her bed and has had falls. During an interview on 9/13/22, at 2:17 P.M., the Care Plan Coordinator said the resident's enabler is not on his/her care plan. Record review of the resident's current medical record showed staff did not document identification and use of possible alternatives prior to use of side rails, assessing risk versus benefits of side rail use, obtaining informed consent for the use of side rails prior to installation, measurements or ongoing assessments to ensure the side rails were appropriate for use. 5. During an interview on 9/13/22, at 10:26 A.M., Certified Nurse Aide (CNA) D said the following: -All the residents have the 'U' shaped bars on their beds; -Staff request therapy staff for an evaluation if a resident needs a side rail; -Maintenance staff installs the rails on the resident's bed. 6. During an interview on 9/13/22, at 10:33 A.M., Certified Medication Technician (CMT) F said the following: -Maintenance staff installs the bed rails; -Nurses and therapy staff complete the side rail assessment. 7. During an interview on 9/13/22, at 10:39 A.M., Licensed Practical Nurse (LPN) E said the following: -Staff look at the computer or on the care plan to see if a resident has a side rail, enabler, or grab bar; -The Care Plan Coordinator updates the care plans. Staff inform the DON of any updates to care plans; -The DON or nurses complete the side rail assessments; -He/she did not not of measurements for the side rails; -He/she did not know if reassessments or reevaluations were completed after the first assessment of a side rail; -He/she did not know if staff get a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 8. During an interview on 9/13/22, at 11:07 A.M., the Maintenance Supervisor said the following: -Nurses inform him if a resident needs a bar or side rail on a bed; -He contacts the manufacturer and orders the rails; -He installs the bed rails; -He informs the manufacturer of the model of bed. There are two different styles of beds in the facility; -The manufacturer has the appropriate rail or grab bar of exact fit and does the measurements when sends the rail to the facility; -He did not know of measurements or zones to inspect for bed rails on the beds; -He checks one or two rooms every month and checks the rails to see if tight; -Nursing documents in the maintenance log book at the nursing station if any rails are loose. 9. During an interview on 9/13/22, at 11:15 A.M., the DON said the following: -Enabler bars are to help a resident roll or position in bed; -The enablers are the 'U' shaped bars; -Maintenance staff install the enabler bars; -Facility protocol did not require any observations to measure the enabler; -The enabler bars are smaller than the quarter size side rail and not in the EMR system for documentation. The EMR just has observations for quarter size, half size and full rails. The nurse completes the assessments that 'pops' up once a year; -The facility staff did not complete any assessments, observations or measuring for gaps or zones for the enabler bars. 10. During an interview on 9/13/22, at 11:55 A.M., Director of Rehabilitation said the following: -The therapy staff did not complete assessments for side rails or enablers; -Therapy staff make suggestions for a side rail if a residents needs one for turning or bed mobility and inform maintenance staff. 11. During an interview on 9/13/22, at 1:50 P.M., the Administrator said the following: -Maintenance staff install the 'U' shaped rail on the beds; -The facility did not consider the enabler ('U shaped bar) a side rail; -The facility did not conduct measurements on the enablers; -The enabler bars are for residents to hold self over for incontinent, care and changing the bed; -Side rails are the quarter size, half size and full size rails; -There is no written assessment for an enabler bar and is based on if the resident is able to assist in positioning; -The enabler or side rail should be on the resident's care plan. 12. During an interview on 9/13/22 at 2:17 P.M., the care plan coordinator said the following: -She is not involved in the process of residents getting side rails or enablers; -She did not know if the enabler is suppose to be on the care plan.

Based on observation, interview and record review, the facility failed to consistently implement interventions, monitor and perform timely and complete assessments for one resident (Resident #7) who developed an unstageable (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is covered by dead tissue) pressure ulcer to the right heel, a stage II (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater) pressure ulcer to the buttocks, and a Stage III (a full thickness of skin is lost, exposing the subcutaneous tissues-presents as a deep crater with or without undermining adjacent tissue) pressure ulcer to the left heel out of five residents the facility identified with pressure ulcers. The facility census was 72. Record review of the facility's policy titled, Pressure Ulcer, Care and Prevention of dated March 2015, showed the following information: -The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers; -Use pressure-reducing devices to relieve pressure; -Turn the resident every two hours and position with pads or pillows to protect bony prominences; -Use elbow and heel protectors if needed. Record review of the facility's policy titled, Bath (Shower) dated March 2015, showed the following information: -Purpose: to maintain skin integrity, comfort and cleanliness; -Report any reddened areas, skin discolorations or skin breaks to the charge nurse. 1. Record review of Resident #7's face sheet showed an admission date of [DATE]. His/her [DIAGNOSES REDACTED]. Record review of the resident's admission clinical assessment dated [DATE], showed staff did not identify any skin issues or pressure ulcers on the resident upon admission. Record review of the Braden Scale for predicting the resident's pressure ulcer risk dated 03/23/17, showed staff assessed the resident's total score as 21 indicating the resident was not at risk for developing pressure ulcers. Record review of the resident's medical record showed staff did not document a weekly skin assessment for 03/30/17. Record review of the resident's bath sheets titled, Skin Monitoring: Comprehensive CNA (Certified Nurse Assistant) shower review dated 03/31/17, showed staff circled the buttocks area of a body diagram on the form and documented redness. Record review of the resident's care plan dated 04/03/17, showed the following information: -Potential for skin breakdown/impairment related to impaired mobility and incontinence; -During staff assisted showers, note and report any areas of redness/breakdown to the charge nurse; -Inspect skin daily for changes; -Weekly skin checks per licensed staff; -Weekly and as needed skin checks; -Report any concerns to the Director of Nursing (DON) and physician for treatment orders; -Pressure relieving mattress to bed to minimize pressure points and promote skin integrity; -Assist to turn and reposition; -Foot care and circulation/skin integrity assessments to include pedal pulse (an arterial pulse which can be felt on top of the foot in front of the ankle) checks per policy per licensed nursing staff. Report any abnormal findings to the physician including any open areas for treatment orders; -Observe for changes in skin condition during daily care and bath days. Record review of the resident's 14 day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/06/17, showed the following information: -Cognition moderately impaired; -Required extensive assistance for bed mobility and transfers; -Frequently incontinent of bowel; -[DIAGNOSES REDACTED]. -No ulcers, wounds or skin problems; -No moisture associated skin damage (MASD-caused by prolonged exposure to various sources of moisture, including urine or stool). Record review of the facility's Weekly Skin assessment dated [DATE], showed the following information: -Dryness on both of the resident's legs and swelling to his/her right foot and ankle; -Skin breakdown beginning on the buttocks. Staff did not document an assessment of the skin breakdown on the resident's buttocks to include size, color and surrounding tissue. Record review of a nurses' note dated 04/08/17, at 2:27 P.M., showed a nurse documented the following information: -The resident had a large area close to stageable pressure ulcer on his/her heel (did not indicate the left or right heel). Skin was eroding (gradually wear away), there was a large amount of blood under his/her heel. Staff did not document a full assessment of the heel wound to include size, color, and surrounding tissue; -Obtained wound care orders from the physician for dressing changes to the resident's right heel; -Repositioned resident every two hours to prevent further skin break down; -Staff did not document an assessment of the resident's buttocks. Record review of a physician's orders [REDACTED]. Record review of a nurses' note dated 04/09/17, at 11:58 P.M., showed a nurse documented the following information: -Dressing to right heel changed. Blister now open and draining with a moderate amount of serosanguinous (relating to both blood and the liquid part of blood (serum)) drainage. Staff did not document a complete assessment of the heel wound to include size, color, and surrounding tissue; -Left upper inner buttocks Stage II pressure ulcer. Staff did not document a full assessment of the wound to include size, color, and surrounding tissue. -Right upper buttocks Stage II pressure ulcer. Staff did not document a full assessment of the wound to include size, color, and surrounding tissue. -The DON notified the physician and left a message. Record review of physician's orders [REDACTED]. -Schedule an appointment with the wound clinic due to a left heel pressure ulcer and to debride an unstageable right heel pressure ulcer; -Podus Boot to the right heel (boot made of plastic and lined with soft material to protect the skin and relieve heel pressure). To be worn day/night until ulcer resolved. Record review of a nurses' note dated 04/10/17, at 6:26 P.M. and 10:11 P.M., showed the following information: -Right heel dressing changed per orders, no worsening of condition; -New order for a Podus Boot to the right heel; -Physician was aware the blister on the resident's right heel was open. -New order for wound clinic for possible debridement (removal of dead tissue). Record review of the facility's Weekly Wound Documentation dated 04/10/17, showed the following information: -Large unstageable pressure ulcer presented as a blister on the resident's right heel that measured 6.5 centimeters (cm) x 5.4 cm. Staff did not document the color of the wound; -Acquired at the facility and discovered on 04/07/17; -Surrounding tissue dry/flaky; -No documentation of an assessment of the left heel; -No documentation of an assessment of the resident's buttocks. Record review of the resident's bath sheets titled, Skin Monitoring: Comprehensive CNA shower review dated 04/11/17, showed staff documented the following: -Soft heels; -Staff circled the bottom of the right foot and documented, skin coming off. Record review of the facility's Weekly Skin assessment dated [DATE], at 3:27 P.M., showed the charge nurse documented documented the following: -Existing skin issue-described below; -Resident had redness on buttocks; -Both legs were dry; -No swelling; -No documentation or assessment regarding the resident's right or left heel. Record review of the nurses' notes dated 04/14/17, showed the following information: -Wound dressings to right heel changed this morning. Heel did not appear to be healing; -Podus boot not on. DON/ADON notified; -Heel protected with heel cushion. Record review of the facility's Weekly Wound Documentation dated 04/17/17, showed the following information: -Right heel Stage II pressure ulcer measured 5.5 cm x 4.0 cm x 0.1 cm. [MEDICATION NAME] tissue (new skin) growing in superficial ulcer with a scant amount of serosanguinous drainage; -No documentation of an assessment of the left heel; -No documentation of an assessment of the resident's buttocks. Record review of the resident's bath sheets titled, Skin Monitoring: Comprehensive CNA shower review dated 04/18/17, showed staff documented, No New skin issues. Staff did not circle or document on the body graph. Record review of the nurses' notes dated 04/20/17, showed the following information: -Resident's legs/feet elevated and on pillows with both heels floated on pillows; -No documentation of Podus boot in place. Record review of the Treatment Administration Record (TAR) dated 03/23/17 to 04/22/17, showed staff documented observing the Podus Boot on the resident's right foot as follows: -04/11/17, between 7:00 A.M. to 11:00 A.M.; -04/12/17, at 11:23 A.M.; -04/14/17, at 2:08 P.M.; -04/15/17, at 12:03 P.M.; -04/18/17, at 11:55 A.M.; -04/21/17, at 11:40 A.M.; -04/22/17, at 11:25 A.M.; -Physician order [REDACTED]. Record review of the resident's medical record showed on 04/23/17, staff transferred the resident to the hospital for a medical issue not related to his/her pressure sores. Record review of the hospital's History and Physical assessment dated [DATE], showed the resident admitted to the hospital with [REDACTED]. Record review of the hospital's Advanced Wound Care Protocol dated 04/24/17, showed a Certified Wound Care Nurse initiated wound care on the following areas: -Stage II pressure ulcer on the resident's coccyx (tailbone); -Unstageable pressure ulcer on the resident's right heel; -Stage III pressure ulcer on the resident's left heel. Record review of the hospital transfer report dated 04/28/17, at 3:40 P.M., showed the resident had open pressure ulcers to both of his/her heels; right heel unstageable and the left heel Stage III, and a Stage II pressure ulcer on the Coccyx. During an interview on 04/28/17, at 4:07 P.M., CNA K said he/she was familiar with the resident. The resident did not have any precautions other than staff applying cream on the resident's red bottom. The nurse also applied a patch (dressing) on the resident's bottom. Staff used heel protectors and floated the resident's heels. The CNA remembered the resident had a bandage on his/her right heel. An observation on 04/28/17, at approximately 4:15 P.M., showed the resident returned to the facility from the hospital. Staff wheeled the resident, on a gurney, to his/her room at the facility. During an interview on 04/28/17, at 4:58 P.M., the Assistant Director of Nursing (ADON) said the following: -He/she had been the wound nurse for two to three weeks; -On 04/06/17 or 04/07/17 staff notified him/her of a blister on the resident's heel; -The ADON covered the blister with a foam protecting dressing; -Staff used pillows and heel protectors; -If a bath aide finds any skin issue on a resident they document it on the skin monitoring shower sheet and she assesses the areas of concern; -The resident was a high risk for pressure ulcers due to an admission [DIAGNOSES REDACTED]. -Resident was able to move his/her legs around in bed but not certain how much feeling he/she had in his/her feet and legs; -The resident did not have any pressure ulcers upon admission; -She completed the resident's treatment on 04/20/17 and at that time, the resident did not have pressure ulcers on his/her bottom or left heel; -The nurses' should have completed a skin assessment on 03/30/17 but this was not done until 04/06/17 (two weeks later). Observation and interview on 04/28/17, at 6:45 P.M. (approximately 2 hours and 30 minutes after arriving at the facility), showed the following: -The resident laid in bed, uncovered, positioned on his/her back, wearing a hospital gown. -The resident's heels rested/touched the bed. The pressure ulcers to the resident's right and left heels did not have wound dressings covering protecting them. -The DON entered the resident's room and placed pillows beneath the resident's legs raising his/her heels off the mattress. -The resident's right heel had a large pressure ulcer which contained dry black eschar (dead tissue) located at 12 o'clock in the upper portion with adjoining open and moist red tissue located at six o'clock in the lower portion of the ulcer. The DON said the overall area measured approximately 6.5 cm x 5.0 cm; -The resident's left heel had an unopened brown colored pressure ulcer approximately the size of a nickel. During an observation and interview on 04/28/17, at 6:58 P.M., showed a Registered Nurse (RN) F seated at the nurses station. RN F said he/she had not yet assessed the resident because he/she was busy trying to get report from the out-going nurse. Observation on 04/28/17, at 7:00 P.M., showed the following: -CNA G and the DON entered the resident's room to provide care. CNA G removed the pillows beneath the resident's legs causing the heels and open ulcer to have contact with the bedding, unprotected. -After the CNA rolled the resident on his/her side, the DON removed a foam dressing covering the resident's coccyx area. The dressing containing fecal matter which was visible in an open area on the resident's red and excoriated (damage or remove part of the surface of the skin), bottom and coccyx. -The open area was approximately dime size with pink watery drainage. -The DON placed her gloved finger in the stool stained area then touched and pressed on and around the reddened coccyx area, possibly introducing bacteria into the open wound; -The DON said the coccyx was moisture associated skin damage with fungal infection. During an interview on 04/28/17, beginning at 7:30 P.M., the DON said the following: -The charge nurse should perform a full skin assessment on a resident within one hour upon admission; -If a resident is a high risk for developing a pressure ulcer, staff should complete a skin assessment upon admission and weekly thereafter; -The Braden Scale is not a guide to end all for assessing a pressure ulcer. Comorbidities and nurse assessments are also valuable for determining care interventions; -Open wounds should not touch the bedding; -The resident's Podus boot was on order; -Nursing should change gloves and wash hands and reapply gloves before touching and assessing a wound after contacting fecal material due to the risk of infection. MO 120