Every finding on record at Kingswood Senior Living

Based on interview and record review, the facility failed to meet the medical needs of one sampled resident (Resident #1) out of four sampled residents, who admitted to the facility on [DATE] from the hospital with an indwelling foley catheter (a tube placed to drain the bladder). On 07/09/26, the resident's Urologist (medical doctor and surgeon specializing in diagnosing and treating conditions of the urinary tract) removed the indwelling foley catheter and ordered the resident to be monitored for urinary retention. The facility failed to document any monitoring for post void retention (PVR - urinary output) per policy and as ordered. The facility failed to timely assess the resident's change of condition when the resident had increased confusion, diarrhea with no evidence of urinary output and consult, or collaborate with the resident's medical durable power of attorney (DPOA). The failure resulted in the resident's hospitalization and admittance to the intensive care unit (ICU) for severe sepsis, fever, urinary retention, acute kidney injury, acute lower urinary tract infection, atrial fibrillation, cognitive decline and generalized weakness. The facility census was 65 residents. The Administrator was notified on 07/21/26 at 12:57 P.M. of an Immediate Jeopardy (IJ) which began on 07/09/26. The IJ was removed on 07/23/26 as confirmed by surveyor onsite verification. Review of the facility Urinary Continence and Incontinence Assessment and Management policy, dated 08/2022, showed:-As a part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence.-Relevant information related to urinary continence includes a history of urinary incontinence, observation of use of urinary catheter, and information such as type and frequency of physical assistance necessary for the resident to access bathroom privileges.-Periodically staff will define each individual's level of continence.-As part of its assessment, nursing staff will seek and document details related to continence such as voiding patterns.-If a resident was admitted from the hospital with a newly placed indwelling catheter, the attending physician and staff will evaluate the potential for removing it, depending on the current condition and the rationale for its original placement.-The staff will document the results of the toileting trial in the resident's medical record.-A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments.-For individuals with persistent or recurrent urinary retention despite interventions, the staff and physician will seek treatable causes and consider intermittent catheterization, if feasible, before placing and indwelling catheter.-The physician will identify situation in which an indwelling urethral or suprapubic catheter are indicated and will document why other alternative are not feasible. -Assess the resident for appropriateness for behavioral techniques or toileting plans being considered.-Record the resident's current voiding pattern, including voiding times and amount.-If a post void residual test is ordered it should be performed within a few minutes after continent or incontinent void (urination).-Preferably, the volume of the void should be measured, but if it is an incontinent void, the amount of incontinence (small, moderate, large) should be recorded, along with the PVR volume.-Normal PVR is less than 50 milliliters (ML) remaining in the bladder.-Where available, bladder ultrasound (scan performed by trained personnel) may be a less invasive alternative to urinary catheterization for determining PVR. Review of Nursing Skills National Institute Health Chapter 21 Facilitation for Elimination Guidelines, dated 2023, showed:-Standard nursing protocol dictates that after a Foley catheter is removed nurses must closely monitor the patient's output and bladder function.-The patient should be back to normal urination in six to eight hours post removal of Foley catheter.-The nurse would be expected to document the exact time of the first urination and measure the volume with the expectation that a resident would urinate at least 300 ml and if not notify the provider for reinsertion of the catheter. -Inability to urinate after Foley catheter removal is classified as acute urinary retention which is considered a urological emergency and requires prompt assessment and bladder decompression (removal urine from bladder). 1.Review of Resident #1s admission orders, dated 07/03/26, showed the resident's indwelling Foley catheter to be monitored every shift. Review of the resident's electronic medical record (EMR) showed no care plan for Foley catheter care, urinary retention, or voiding assistance. Review of the resident's Urologist medical record, dated 07/09/26, showed:-Resident's indwelling catheter removed.-Resident to be monitored for urinary retention. May re-insert 16 French Foley if PVR >400ml.-Follow up appointment 08/04/26.The order did not document how often or how long to monitor for urinary retention. Review of the resident's July 2026 Physician Order Sheet showed an order transcribed by Registered Nurse (RN) A, stating the resident to be monitored for urinary retention as needed. May re-insert 16 French Foley if PVR >400ml as needed for urinary retention, dated 07/09/26. Review of the resident's Treatment Administration Record (TAR), dated 07/01/26 through 07/30/26, showed an order for the resident to be monitored for urinary retention as needed. May re-insert 16 French Foley if PVR >400ml as needed for urinary retention, dated 07/09/26. Review showed staff did not document the resident's output or urinary output or retention on the TAR as ordered from 07/9/26 - 07/11/26. Review of the resident's medical record showed no documentation of monitoring the resident's output or urinary retention from 07/09/26 through 07/11/26. During an interview on 07/17/26 at 1:00 P.M., RN A said:-the paperwork received from the urology clinic was not the same paperwork he/she had received to put the new order in regarding monitoring for urinary retention;-The paperwork used to put the order in the system was from the clinic, but that paperwork was then placed in the Director of Nursing's (DON's) box;-He/She had not contacted the urology clinic when putting the order in to determine the monitoring needs.-It was the Urologist's responsibility to call report to him/her. During an interview on 07/16/26 at 9:48 P.M., Certified Nurse Aide (CNA) B said:-He/She worked night shift 7:00 P.M. to 7:00 A.M. 07/09/26 to 7/10/26 and 07/10/26 to 07/11/26.-During change of shift on both 07/10/26 and 07/11/26, he/she told Licensed Practical Nurse (LPN) D the resident was not urinating.-He/She also reported the resident was up multiple times trying to urinate and had diarrhea. During an interview on 07/20/26 at 7:00 A.M CNA E said:-He/She told LPN D on 07/12/26 the resident had no urinary output on 07/11/26 and 07/12/26.-On 07/12/26 LPN D wanted a urine specimen from the resident.-He/She took the resident to the bathroom several times in an attempt to obtain a urine specimen.-He/She advised LPN D the resident had not voided and was acting weird.-He/She was to give clarity on how the resident was acting weird.-He/She recalled the resident had not voided the day before 07/11/26 either and reported to LPN D at shift change. Review of the resident's Progress Note, dated 07/12/26 at 11:26 A.M., showed:-LPN D notified by CNA E the resident was unable to urinate, need to collect UA due to increased confusion, the resident did not have a wet brief when changed.-Bladder scan done showing 891ml urine retained in the bladder.-LPN D unable to insert catheter in the resident's bladder, will contact the doctor. During an interview on 07/17/26 at 10:35 A.M., LPN D said:-He/She was the resident's nurse for the day shift 7:00 A.M. to 7:00 P.M. on 07/10/26, 07/11/26, and 07/12/26.-He/She recalled the resident having had diarrhea.-He/She had not observed the resident urinating.-He/She had documented the resident's urine was clear and no concerns with the resident's bowels because he/she was in a hurry on 07/10/26 and 07/11/26.-On 07/11/26 he/she was concerned, because the resident had increased diarrhea and increased confusion. He/She then obtained orders from the Medical Director for labs and put them on the POS.-He/She had not contacted the medical Durable Power Of Attorney (DPOA).-On 07/12/26, CNA E told him/her the resident had not urinated during the day shift on 07/12/26.-He/She then did a bladder scan which showed 891ml of urine retained in the resident's bladder.-He/She attempted to insert a Foley catheter in the resident unsuccessfully.-He/She contacted the Medical Director and the resident was sent to the hospital. Review of the National Institute for Health's website showed normal functional bladder capacity in adults ranges from approximately 300 to 400 ml. Further review of the resident's July 2026 POS showed no orders for labs dated 07/11/26. Review of the resident's medical record showed no documentation in the progress notes of facility staff notifying the physician of concerns on 07/11/26 or any lab orders obtained. Review of the resident's Progress Note, 07/12/2026 at 5:32 P.M., showed:-The resident admitted to hospital with diagnosis of severe sepsis.-The Medical Director and the DON were notified. Review of the resident's hospital emergency room (ER) note, dated 07/12/26, showed: -Chief complaint of urinary retention.-Presented to the ER due to fever and decreased urine output.-The resident had a Foley catheter placed during his/her last visit.-Reportedly had the Foley catheter removed several days ago and had decreased urine output over the last two to three days.-The resident had a fever of 103.2 Fahrenheit (normal between 97 F to 99 F).-The resident stated he/she did not feel very good, but was unable to expand on that. Bladder scan revealed a full bladder with greater than 1000 milliliters (ml) of urine.-The resident had significant urinary retention and a Foley catheter could not be placed by the ER staff prompting stat urology consult.-The resident was intravenous (IV) fluid hydrated aggressively due to sepsis and IV antibiotics due to the fever.-The resident was observed to have a high heart rate of 112 beats per minute and low blood pressure.-Diagnoses included fever, urinary retention, urinary tract infection (UTI), and sepsis. Review of the resident's hospital Urology consult note, dated 07/12/26, showed:-Need for Foley for retention, UTI, and difficult placement.-The resident presented because he/she did not feel good, facility mentioned decreasing urine output after Foley removed a few days ago for voiding trial, ER was unable to place Foley.-The resident had a history of gross hematuria (blood in the urine).-Cat scan (CT) showed enlargement of prostate with mass effect on the bladder on 07/01/26.-No intake or output date in the 24 hours ended 07/12/26 at 2:53 P.M.-Foley was placed with return of brown urine.-Assessment and Plan:--Urinary retention, difficult Foley placement, bladder neck contracture possible, and UTI suspected.--As he/she failed this voiding trial, would recommend Foley until further urologic evaluation. Review of the resident's hospital note, dated 07/12/26, showed:-The resident presented to the ER via Emergency Medical Services (EMS) from the skilled nursing facility due to lack of urination for the last three days.-Per report the indwelling catheter was removed three days ago, and the resident had little to no output since then.-The resident had greater than 1400 ml brown urine in catheter bag.-Sepsis protocol activated on arrival.-Initially IV fluids were held due to severe urinary retention but was receiving two liter fluid bolus.-The resident had no history of renal disease.-Urine very clearly indicative of infection, cultures pending.-The resident was ill-appearing and lethargic.-Assessment and Plan:--Severe sepsis, fever, urinary retention, and acute UTI.---Do not remove Foley catheter placed with guidewire by urology.---Catheter recently removed at facility and did not urinate for three days.---At least 1400 ml retained in the bladder.---The resident received sepsis fluid bolus with ICU admission.--Acute kidney injury likely due to obstructive uropathy/urinary retention. Review of the resident's hospital Pulmonology consult note, dated 07/12/26, showed:-Impressions included septic shock from urinary tract infection and acute kidney injury.-The resident to keep Foley catheter.-Broad-spectrum antibiotics and follow-up on blood and urine cultures. Review of the resident's hospital documentation, dated 07/15/26, showed:--Urine and blood cultures grew ESBL Klebsiella (a strain of bacteria that makes an enzyme that breaks down and destroys many common antibiotics like penicillin and cephalosporins). During an interview on 07/16/26 at 11:06 A.M., Hospital Intensive Care Unit (ICU) RN said:-The resident was sent to the hospital and admitted for severe sepsis, fever, urinary retention, acute kidney injury, acute lower urinary tract infection, atrial fibrillation, cognitive decline and generalized weakness.-Upon admission the resident's temperature was 103 degrees Fahrenheit, blood pressure was 90/80 (normal should be less than 120/80 or more than 90/60), and heart rate was 104 (normal 60 to 100 beats per minute), Creatinine was 4 (normal 0.7 to 1.3), [NAME] blood cell count spiked over 37,000 (normal 4000 to 10000). -In the ER he/she had greater than 1400 ml of brown urine drained from his/her bladder. During an interview on 7/20/26 at 6:30 A.M., RN B said:-He/She was the night nurse (7:00 P.M. to 7:00 A.M.) on 07/11/26 to 07/12/26.-On 07/11/26 he/she did not receive report from LPN D and was not aware the resident no longer had the indwelling catheter in place until he/she had assisted CNA D to put the resident to bed.-On 07/12/26 CNA D reported the resident was a little bit wet.-He/She did not see the resident void or witness any incontinence.-The expectations after a catheter removal was to monitor for 48 hours using the bladder scanner.-Typically, this meant to scan the resident every four hours to ensure urination.-Had he/she known the Foley catheter had been removed he/she would have used the bladder scanner to check for PVR during the night medication pass, the middle of the night and again in the morning. During an interview on 07/16/26 at 2:35 P.M., the Urology Nurse said:-He/She expected the facility staff to ensure the resident was taken to the bathroom at least three to four times in a 24-hour period to ensure the resident was voiding. -Normal urine production is 30ml per hour, meaning it would take approximately 47 hours to produce 1400ml of urine.-He/She expected the staff to monitor the resident for PVR at least two times per shift.-He/She had not talked with the facility staff after the office appointment. During an interview on 07/17/26 at 11:43 A.M., the Medical Director said:-He/She expected the facility staff to monitor the resident voiding and to use the bladder scanner to verify PVR as per the order of the specialist physician.-Had the facility staff monitored, assessed and reported according to expectation the resident would have been sent to the hospital sooner, the outcome may not have changed but could have been less severe. During an interview on 07/17/26 at 8:16 A.M., the DPOA said:-He/She did not get any notifications about the resident having diarrhea or voiding issues until 07/12/26 when the resident was being sent to the hospital.-He/She was upset with the lack of communication and the level of care his/her family member received. During an interview on 07/20/26 at 12:00 P.M., the DON said:-Written orders were expected to be transcribed then sent to medical records to upload into the resident's electronic medical record.-He/She expected staff to monitor the resident for voiding per facility policy and to use the bladder scanner if needed.-There was no place for CNAs to record monitoring the resident urinary retention, CNAs were to report to their nurse.-The facility had begun using a new electronic health record (EMR) just before the resident was admitted .-This resident should have been monitored for output and the bladder scanner used to measure retention once his/her indwelling catheter was removed.-Care plans were lacking due to the recent transition to a new EMR system. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). 3061822

Based on observation, interview and record review, the facility failed to maintain the cleanliness of the floors around and under equipment in the main kitchen and around the counters in Satellite Kitchen #3; failed to ensure in the main kitchen the bins that contained dried items (sugar, flour, and cereal) did not have grime and debris on them; failed to ensure in Satellite Kitchen #3 there was not a black substance potentially mold in the juice machine around the tops of the juice nozzles, coffee debris around the coffee nozzles, and dried spills on both sides of the serving station walls. This practice potentially affected all residents. The facility census was 56 residents. The facility did not provide a sanitation policy. 1. Observation on 6/16/25 at 2:41 P.M., of the initial main kitchen showed the following: -Bins that contained dried items (sugar, flour, cereal) had grime and debris on them. -Dirt and food debris on the floor, under, around, behind and in front of the equipment, some exampled areas were the oven, three compartment sink, preparation table with preparation sinks, and the Centerline miniature freezer over in the serving area Observation on 6/18/25 from 9:00 A.M. to 11:30 A.M. during the lunch meal preparation in the main kitchen showed the following: -Bins that contained dried items (sugar, flour, cereal) had grime and debris on them. -Dirt and food debris on the floor, under, around, behind and in front of the equipment some exampled areas were the oven, three compartment sink, preparation table with preparation sinks, and the Centerline miniature freezer over in the serving area Observation on 6/18/25 at 11:40 A.M., during the lunch service in Satellite Kitchen #3 showed the following: -A black substance potentially mold around the top of the nozzles of the juice machine. -Food debris splashes around the nozzles of the coffee dispenser. -Dirt and debris on the floors in the kitchen. -Dried spills on both sides of the serving station walls. Review of the main facility kitchen undated cleaning schedule showed each day of the week and time that an item and area were to be cleaned. Review of the Satellite kitchen cleaning procedure revised dated 1/22/2019 showed: -Staff should have followed the cleaning schedule. -Staff should have followed the after-meal checklist for sanitation. During an interview on 6/18/25 at 3:22 P.M., the Director of Dining Services said: -The kitchen staff were to maintain the cleanliness of the main kitchen. -Sundays were the deep cleaning day and staff would clean behind equipment on that day. During an interview on 6/18/25 at 3:22 P.M., the Dietary Manager said he/she was responsible for maintaining the cleanliness of Satellite Kitchen #3.

3. Review of Resident #5's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Moderate cognition impairment. -Required assistance from staff with his/her activities of daily living (ADL bathing, transfers, toileting, mobility). -No pain indicated. -Application of medications other than to feet. -Application of dressings to feet. Review of the resident's POS dated June 2025 showed: -Enhanced Barrier Precautions. -Wound treatment three times a week and as needed if dressing becomes soiled or if the dressing comes off. --Open area to mid back. Review of the resident's Medication Administration Record (MAR) dated June 2025 showed: -Calcium Alginate (brown seaweed and used in various applications due to its unique properties. It is particularly known for its use in wound care dressings due to its high absorbency and ability to form a gel-like substance) three times a week and as needed if dressing becomes soiled or if the dressing comes off to mid back. Review of the resident's current undated care plan showed he/she was at risk for pressure ulcers related to impaired mobility and history of skin issues and had the following interventions: -Pressure injury to thoracic spine (mid back) had reopened. -Treatments as ordered. -Enhanced barrier Precautions related to wounds. -Ensure enhanced barrier precautions signage on resident door. -Start to use PPE per enhanced barrier precautions. Observation on 6/16/25 at 3:24 P.M. showed the resident: -Had a low air loss mattress in place. -Had an EBP sign on his/her door. --The EBP sign indicated for resident who had wounds gloves and gown were to be worn. Observation on 6/17/25 at 10:17 A.M. showed: -LPN C washed his/her hands and put on gloves. -Two CNA's washed their hands and put on gloves. -Gowns were not worn during the wound treatment by LPN C, or either CNA's who were in the room assisting with wound care. During an interview on 6/17/25 at 10:25 A.M. LPN C said: -Enhanced barrier precautions were in place for open wounds. -He/She did not put on a gown when performing wound care. -There were gowns and gloves available in the resident's bathroom. -He/She should have put on a gown when performing wound care. During an interview on 6/17/25 at 10:26 A.M. the Infection Preventionist (IP) said: -There was PPE available in the resident's bathroom. -Gowns and gloves were available. -All staff should wear gowns and gloves when performing or assisting with wound care. Observation on 6/17/25 at 11:30 A.M. showed a cart with PPE was in the resident's room inside the door that had gowns and gloves available. During an interview on 6/18/25 at 9:27 A.M. the Infection Preventionist said: -Staff should be using EBP during wound care. -Staff received training in orientation regarding EBP and the PPE and also there was a sign on each resident's door that indicated EBP was in place with instructions of what PPE was to be used. -The EBP PPE was in a storage cart in the resident's room and was readily available. -All staff should be wearing PPE if working with a rsident who required EBP. -All staff participating in wound care should be wearing the appropriate PPE. -Gloves and gowns should be worn by all staff who are participating or performing wound care on a resident. -There is a list of resident's who are currently on EBP posted at the nurses stations on both floors. -The list of resident's who are currently on EBP is also sent to department heads. -All staff who participated in wound care should have had on gloves and gowns. Observation on 6/18/25 at 11:00 A.M. showed a cart with gowns and gloves was inside the resident's room to the right of the door. During an interview on 6/18/25 at 11:15 A.M. RN A said: -When a resident had a wound, gown and gloves should be worn during wound care. -All staff involved with the procedure would be expected to wear the appropriate PPE of gown and gloves. During an interview on 6/18/25 at 12:06 P.M. LPN C said: -He/She should have had a gown and gloves on while performing wound care. -All staff who were in the room and participating in wound care should have had a gown and gloves on while wound care was being provided. Based on observation, interview and record review, the facility failed to ensure Enhanced Barrier Precaution (EBP-an infection control strategy used in nursing homes to reduce the spread of multidrug-resistant organisms (MDRO) signs were posted and Personal Protective Equipment (PPE- protective clothing, gowns, gloves, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) was available and used when providing cares to three sampled residents (Resident #162, #163 and #5) and failed to ensure hand hygiene was used to prevent cross contamination during care for one sampled resident (Resident #163) out of 14 sampled residents. The facility census was 56 residents. Review of the facility's Enhanced Barrier Precautions policy and procedure dated August 2022, showed EBP were used as an infection prevention and control intervention to reduce the spread of MRDO's to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. It showed: -Gowns and gloves were applied before performing high contact resident care activities. PPE was changed before caring for another resident. -Examples of high contact resident care activities requiring gowns and gloves included dressing, bathing, transferring, performing hygiene, toileting/changing briefs, changing linens, device use/care and wound care. -Signs were posted on the door or wall outside of the room indicating the type of precautions and PPE required. -PPE was available outside of the resident rooms. -Staff were trained to care for residents on EBPs. Review of the facility's Handwashing policy and procedure dated October 2023, showed all personnel were trained on the importance of hand hygiene in preventing the transmission of healthcare associated infections. All personnel were expected to adhere to hand hygiene practices to help prevent the spread of infections to other personnel, residents and visitors. Hand hygiene was indicated: -Immediately before touching a resident. -Before performing aseptic tasks (placing an indwelling device or handling an invasive medical device). -After contact with blood, bodily fluid, or contaminated surfaces. -After touching a resident or touching the resident's environment. -Before moving from work on a soiled body site to a clean body site on the same resident. -Immediately after glove removal. 1. Review of Resident #163's Face Sheet showed the resident was admitted on [DATE], with diagnoses including hip fracture (with surgical hip repair), bladder cancer, kidney failure, kidney disease and pain due to trauma. Review of the resident's Nursing assessment dated [DATE], showed: -The resident had excoriation (abrasion) to his/her buttocks/coccyx (the last bone at the bottom of the spine, also called the tailbone), that was identified as moisture associated skin damage (MASD-skin inflammation and erosion caused by prolonged exposure to excessive moisture) and had potential breakdown. -The resident had a surgical wound to his/her left lower back. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 6/12/25, showed the resident: -Was alert and oriented, without delusions, hallucinations or behaviors. -Had lower extremity impairment on one side that affected his/her range of motion. -Needed maximum assistance with bathing and needed moderate assistance with dressing, transferring and mobility and used a walker and wheelchair for ambulation. Observation on 6/16/25 at 11:26 A.M., showed there was a stop sign on the resident's door showing the resident was on Enhanced Barrier Precautions and instructing staff to wear a gown and gloves when providing resident care. The resident was sitting in his/her wheelchair in his/her room at a table with his/her spouse present. Registered Nurse (RN) C came into the resident's room and stated he/she was going to give the resident's medication. RN C did the following: -Without washing or sanitizing his/her hands, RN C put on gloves, prepared the resident's Heparin (an anticoagulant used to decrease the clotting ability of the blood) medication and gave it to him/her. -Afterward RN C collected the medication supplies and walked out of the resident's room without degloving, washing or sanitizing his/her hands. Observation and interview on 6/17/25 at 11:38 A.M., showed the resident's call light was on. The resident was in his/her room sitting in his/her recliner. Certified Nursing Assistant (CNA) B, without donning a gown, washing or sanitizing his/her hands went into the resident's room and asked him/her what he/she needed. The resident said he/she was in pain and wanted to transfer to his/her bed. CNA B: -Put on gloves, put a gait belt around the resident and assisted the resident up to his/her wheelchair and then from his/her wheelchair to his/her bed. CNA B removed the gait belt. -CNA B without removing his/her gloves, washing or sanitizing his/her hands or re-gloving, he/she obtained a urine measurement cup and drained fluid from the resident's urine bag. He/She wiped the tip of the tubing with a sanitary wipe, took the container to the bathroom, emptied it and then removed his/her gloves and washed his/her hands, turning off the water with his/her hand, then dried his/her hands. -CNA B re-gloved, removed the resident's pants and pulled his/her brief down. The resident was not soiled so CNA put cream on the resident's bottom and pulled his/her brief back up. -CNA B then removed his/her gloves and washed his/her hands, turning off the water with his/her hand, then dried his/her hands. He/She raised the resident's bed before leaving the room. -CNA B said the resident was on EBP for his/her ostomy. He/She said when they enter the resident's room, they usually put on gloves to perform cares and that was it. He/She said he/she did not know if they were supposed to wear gowns when providing care to residents on EBP. He/She said the resident did have a PPE box in his/her room and pointed to a box that was located behind the bathroom door. Inside the box drawers showed alcohol prep pads, a box of latex gloves and trash bags. there were no gowns, masks or sanitizer inside. During an interview on 6/18/25 at 12:00 P.M. RN C said: -Staff were expected to wash or sanitize their hands whenever they go in to provide resident cares. -She would expect staff to wash their hands or sanitize them whenever their hands were soiled, when completing dirty to clean tasks, when going between resident rooms and before leaving a resident's room. -He/She did not quite know what residents were qualified to be on Enhanced Barrier Precautions, but he/she would ask the other nurses if he/she was not sure. -The stop sign was placed on the resident's door and there was a cart containing gowns, gloves and whatever other protective equipment was on the sign (it tells them what personal protective equipment should be in the cart). -The nursing staff were supposed to follow the instructions that were on the sign and the personal protective equipment should be in the resident's cart. -the resident was on EBP for wounds and he/she had a colostomy bag. -He/She was unaware there were no gowns in his/her PPE cart. During an interview on 6/18/25 at 4:40 P.M., the Director of Nursing (DON) said: -Upon entering the resident's room, staff should wash their hands. They should wash or sanitize their hands between dirty and clean tasks and before leaving the resident's room. -Nursing staff who gave the resident medication should have washed or sanitized his/her hands upon entering the resident's room, before gloving and should have removed his/her gloves and washed/sanitized his/her hands after giving the resident's medication, before leaving the resident's room. -He/She had informed staff they were to wash their hands upon entering the resident's room before performing cares and before leaving the room. -The nursing staff would not have to glove when transferring a resident, but they should have washed their hands before and after performing cares. 2. Review of Resident #162's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including left hip fracture, pain due to trauma, heart disease, high blood pressure, anemia (low iron), urine retention (the inability to completely empty the bladder of urine) and protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Review of the resident's Physician's Order Sheet (POS) dated June 2025, showed physician's orders for: -Apply Skin prep to right heel every shift daily, monitor for infection (6/15/25). -Cleanse right heel with normal saline every shift (6/17/25). -Monitor left hip incision for signs and symptoms of infection until healed (6/11/25). Review of the resident's Nursing Notes dated 6/15/25, showed when nursing staff was completing incontinence care, on the resident's right heel was necrotic (dead) tissue that was red and painful to touch. The resident was left in bed with both heels elevated, call light and fluids within reach, and bed in its lowest position. Review of the resident's MDS documentation showed the resident's MDS had not been completed to date. Observation on 6/16/25 at 11:03 A.M., showed the resident did not have an Enhanced Barrier Precaution stop sign on his/her door and there was no personal protective equipment container/box in the hall, outside the resident's door or upon entry. There was a container in the resident's room beside his/her dresser by the television. The resident was laying in his/her bed with glasses on and oxygen on at 3 liters per minute. He/She was in a hospital gown and was wearing a soft boot on his/her right foot. Both legs were elevated on a pillow. He/She was alert and said he/she fell at home and broke his/her hip and a rib. He/She said he/she also had a wound on his/her heel that the nurse treated daily. Observation on 6/17/25 at 9:50 A.M., showed the resident did not have an Enhanced Barrier Precaution stop sign on his/her door. The resident was laying on his/her bed on his/her left side with both feet on a pillow and his/her right foot was in a soft boot. At 10:17 A.M. Licensed Practical Nurse (LPN) A put on gloves and cleaned the top of his/her treatment cart with bleach wipes then took the cart into the resident's room without putting on a gown. He/She placed a barrier on top of the cart and put wound care supplies on it. He/She removed his/her gloves and discarded them. He/She then washed his/her hands removed the resident's soft boot and completed the resident's wound care treatment. When completed, LPN A washed his/her hands before exiting the resident's room with the treatment cart. LPN A said: -They were treating the resident's wound and the wound care team was also following the resident's wound. -He/She was unaware that he/she needed to wear a gown when completing the resident's wound treatment. -He/She was unsure if the resident was on Enhanced Barrier Precautions. -There should be an Enhanced Barrier Precaution sign on the resident's door.

2. Review of Resident #28's quarterly MDS dated [DATE], section N0415 showed: -The resident was taking an anticoagulant (medication that prevents the blood from clotting). -The resident was taking an antiplatelet (medication that prevents the platelets in blood from collecting and forming clots). Review of the resident's Medication Administration Record (MAR) dated 6/18/25, showed: -There were no orders for anticoagulant medications. -There were no orders for antiplatelet medications. - A physician's order, for Aspirin (nonsteroidal anti-inflammatory drug NSAID) 81 milligram (mg) tablet, delayed release enteric coated (EC a barrier to prevent the gastric acids in the stomach from dissolving or degrading drugs after you swallow them) once daily by mouth (po) for prophylaxis (as a preventative measure) dated 3/7/25. --This drug is an NSAID by class. ---This drug is not classified as an anticoagulant or antiplatelet. During an interview on 6/18/25 at 12:17 P.M., the MDS Coordinator said: -The MDS should be accurate. -He/she considered Plavix (antiplatelet), Eliquis (anticoagulant), Warfarin (generic anticoagulant) and Coumadin (name brand anticoagulant) to be classified as either an anticoagulant or antiplatelet. --The resident was not taking Plavix, Eliquis, Coumadin, or Warfarin. -The resident was taking Aspirin 81 mg EC. --Aspirin 81 mg EC is not an anticoagulant. During an interview on 6/18/25 at 1:20 P.M., the DON said he/she expected the MDS to be accurate and complete. Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) was accurate for two sampled residents (Resident #15, and #28) out of 14 sampled residents. The facility census was 56 residents. Review of the facility's policy titled Certifying the Accuracy of the Resident Assessment, dated November 2019, showed: -Any person completing a portion of the MDS, must sign and certify the accuracy of that portion of the assessment. -Any healthcare professional who participates in the assessment process is qualified to assess the medical, functional, and/or psychosocial status of the resident that is relevant to the professional's qualifications and knowledge. Review of the current Long Term Care (LTC) MDS manual (v)1.19.1 effective October 1, 2024 showed: -Section P0100, physical restraints, are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Section N0415, high-risk drug class medications, were to be coded according to their pharmacological classification, not how they were being used. 1. Review of Resident #15's annual MDS dated [DATE] showed: -He/She was cognitively intact. -He/She used restraints. --The restraint was a bed rail used less than daily. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She used restraints. --The restraint was a bed rail used less than daily. Review of the resident's Physician's Orders dated June 2025 showed there was no order for restraints. Review of the resident's progress notes dated June 2025 showed there were no notes regarding side rails being used as a restraint. Review of the resident's current Activities of Daily Living (ADL) care plan showed: -Impaired functional status, bed mobility. -Side rail to the left side of the bed for bed mobility. -Positioning rail to the right side of the bed for bed mobility. -NOTE: There was no care plan that addressed the use of a restraint. Observation on 6/16/25 at 10:57 A.M. showed the resident had one cane side rail and one quarter side rail on bed. During an interview on 6/16/25 at 10:57 A.M. the resident said: -He/She wanted to have the side rails in place to assist with bed mobility and border definition. -He/She was able to get in and out of bed without difficulty with the side rails in place. -He/She wanted the side rails up. Observation on 6/17/25 at 11:45 A.M. showed the resident's bed had one cane side rail and one quarter side rail up. During an interview on 6/17/25 at 11:45 A.M. the resident said he/she wanted both of the side rails up on his/her bed. Observation on 6/18/25 at 11:10 A.M. showed the resident's bed had one cane side rail and one quarter side rails up. During an interview on 6/18/25 at 11:10 A.M. the resident said he/she wanted both of the side rails up on his/her bed. During an interview on 6/18/25 11:07 A.M. Registered Nurse (RN) A and RN B said: -U bars (cane side rails) were attached to the bed and could not be moved and were used for mobility. -The quarter side rail was attached to the bed and could not be lowered and was used for mobility. -The resident was able to get in and out of bed independently without difficulty. -The side rails did not interfere with his/her ability to get in and out of bed independently. -Neither the U bar/cane or the quarter side rail would be considered a restraint for the resident. During an interview on 6/18/25 11:35 A.M. the MDS Coordinator said: -The MDS should be accurate. -The resident did not use restraints. -The resident wanted both the side rails up for bed mobility. -The resident had the ability to get in and out of bed independently. -The side rails were not restraints. -Restraint should not have been marked on any of the MDS's. During an interview on 6/18/25 at 12:54 P.M. the Director of Nursing (DON) said: -The MDS should be accurate for the resident. -The side rails were used for mobility and did not restrict the resident from getting in and out of bed independently. -The resident did not use restraints. -Restraint should not have been marked on any of the resident's MDS's.

Based on observation, interview, and record review, the facility failed to ensure weekly skin checks were completed and documented; failed to communicate new pressure injury to physician and dietician; failed to ensure that wound care treatments were in place, completed and documented, for one sampled resident (Resident #28) out of 14 sampled residents. The facility census was 56 residents. A review of the facility's policy titled Pressure Ulcer/Skin Breakdown Clinical Protocol dated April 2018 showed: -The nurse shall describe, document, and report the following: --Full assessment of pressure sore including location, stage, length, width, depth, presence of exudates or necrotic tissue. --Pain assessment. --Resident's mobility status. --Current treatments including support surfaces. --All active diagnoses -The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. -During resident visits, the physician will evaluate and document the progress of wound healing. 1. Review of Resident #28's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 5/14/25 showed: -The resident was at risk for developing pressure injuries. -Staff was to administer application of ointment/medications other than to feet for skin and ulcer treatments. -The resident was dependent on staff for toilet hygiene. -The resident was frequently incontinent of bowel and bladder. Review of the resident's weekly skin assessment forms dated May 2025 and June 2025 showed: -There was no skin assessment completed on 5/10/25. -There was no skin assessment completed on 5/24/25. -There was no skin assessment completed on 6/7/25. - On 6/13/25 at 3:08 P.M. the resident had a left buttock Stage II pressure injury (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) which measured 0.5 centimeters (cm) in length, 0.3 cm in width, and 0.1 cm in depth. Treatment of Baza antifungal cream (a type of skin care product used to protect and soothe the skin, often as a moisture barrier). -On 6/13/25 at 10:00 P.M. another skin assessment was completed and showed no new issues. --NOTE: open area was identified earlier that day. Review of the resident's care plan updated on 6/13/25 showed: -The resident had impaired skin integrity (a state where the skin's protective barrier is compromised, making it vulnerable to damage, infection, and other complications) on 6/13/2025. --There was no description or location documented. -Staff were to complete a weekly skin assessment. -Staff were to administer treatments as ordered. -Staff were to notify the Dietician for evaluation and treatment as necessary. -Resident was a check and change as needed, for incontinence. -Skin risk assessment was to be done quarterly. Review of the resident's Interdisciplinary Note dated 6/13/25 showed: -Wound rounds were completed with a local wound care group. -The resident had a new pressure injury (localized area of damage to the skin and underlying tissue) to left inner buttock, wound bed (the open area of a wound, specifically the base or surface where the injury occurred) present with granulation tissue (a type of new, pink or red tissue that forms in the healing process of wounds). -No documentation that indicated there was communication with the resident's physician or Nurse Practitioner (NP an advanced practice registered nurse (APRN) who provides comprehensive patient care, including diagnosing and treating illnesses, managing chronic conditions, and prescribing medication) related to the development of the new pressure injury. -The resident denied pain or distress when asked. -No drainage or odor was observed. -Treatments and interventions were in place. -Staff was to continue plan of care. Review of the resident's Physician Order Sheet (POS) dated June 2025 showed no treatment orders for the resident's pressure injury. Review of the resident's Medication Administration Record (MAR) dated June 2025 showed no treatment orders for the resident's pressure injury. Observation on 6/17/25 at 11:57 A.M. with Certified Nursing Assistant (CNA) C showed: -Toileting cares were provided to the resident. -An open area to the resident's left buttock was noted. -NOTE: CNA C did not apply barrier cream. During an interview on 6/18/25 at 11:03 A.M., Registered Nurse (RN) A said: -Skin assessments could be found under the skin conditions section of Matrix (an electronic health record (EHR) system designed for Long Term Care (LTC) facilities, including skilled nursing facilities and assisted living communities). -Skin assessments were done on shower days, twice per week. -The procedure for a new wound was to do a new skin assessment, notify the physician, notify the family, and notify administrative personnel. During an interview on 6/18/25 at 11:58 A.M., CNA A said: -The resident required assistance with toileting. -The resident was not toileted on a schedule, he/she called when he/she needed assistance. -Barrier cream was applied as needed. During an interview on 6/18/25 at 12:04 P.M., the Wound Care Nurse said: -Skin assessments should be done at least weekly and with a new pressure injury or a significant change. -Skin assessments were found under the skin conditions section of Matrix and bath sheets. -The procedure for staff to address a new open area was to let the wound care nurse know, identify on a bath sheet, notify the Director of Nursing (DON) and any other managers. -It was his/her responsibility to assess a new open area location, characteristics, and measurements, get a physician's order for treatment, fill out a skin assessment, and put the resident on the list for the wound doctor to round on. -He/She expected to be notified of all new open areas. -The facility had a standing order for Baza cream 2% for intact skin as a preventative measure. -Baza cream 2% could be used for Stage II pressure injuries. -CNA's could apply barrier creams to intact skin only. -The CNA's had received in-service training on applying barrier cream to intact skin. During an interview on 6/18/25 at 1:20 P.M., the DON said: -He/She expected a weekly skin assessment to be done if there was an order to do so. -Skin assessments could be found under skin conditions in the Matrix.

Based on observation, interview and record review, the facility failed to adequately treat pain for one sampled resident (Resident #163) who expressed pain out of 14 sampled residents. The facility census was 56 residents. Review of the facility's Pain policy and procedure dated October 2022, showed the physician and staff will identify individuals who have pain or who are at risk for having pain. Policy and procedures showed: -The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, when there is an onset of new pain or worsening of existing pain. -The staff will identify the characteristics of pain such as location, intensity, frequency, pattern and severity. -The nursing staff will identify any situations where an increase in pain may be anticipated; for example, wound care, ambulation or repositioning. -With input from the resident to the extent possible, the physician and staff will establish goals of pain management and treatment. -The staff will reassess the individual's pain at regular intervals; at least every shift for acute pain or significant changes in chronic pain and at least weekly in stable chronic pain. -The staff will evaluate and report the resident's use of standing and as needed (PRN) pain medications. -Depending on the characteristics of pain; the physician may start with PRN doses or supplement standing doses with PRN doses for breakthrough pain. 1. Review of Resident #163's Face Sheet showed the resident was admitted on [DATE], with diagnoses including hip fracture (with surgical hip repair), bladder cancer, kidney failure, kidney disease and acute (a sudden, sharp, and short-lived pain that typically lasts for less than 6 months) pain due to trauma. Review of the resident's Nursing assessment dated [DATE], showed: -The resident had excoriation to his/her buttocks/coccyx (the last bone at the bottom of the spine, also called the tailbone), that was identified as moisture associated skin damage (MASD-skin inflammation and erosion caused by prolonged exposure to excessive moisture) and had potential breakdown. -The resident had a surgical wound to his/her left lower back. -The resident had pain that was acute. -The resident's pain severity (on a pain scale of zero to 10, zero is no pain) was 3. -Pain location, type, onset, duration, relief from pain, current treatment for pain were not documented on the assessment. -The resident received pain relief with current prescribed orders. Review of the resident's admission Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated 6/12/25 showed the resident: -Was alert and oriented, without delusions, hallucinations or behaviors. -Had lower extremity impairment on one side that affected his/her range of motion. -Needed maximum assistance with bathing and needed moderate assistance with dressing, transferring and mobility and used a walker and wheelchair for ambulation. -Had moderate pain that was consistent, received scheduled pain medication and non-pharmacological pain interventions and did not receive PRN pain medication. Review of the resident's Physician's Order Sheet (POS) dated June 2025, showed physician's orders for: -Physical Therapy 5 times weekly for 60 days for skilled services (ordered 6/9/25). -Pain Assessment every shift (ordered 6/6/25). -Tramadol (an opioid medicine used for the short-term relief of moderate to severe pain) 50 milligram (mg) three times a day (TID) for acute pain (order dated 6/13/25, last dose 6/17/25). -There was no documentation or physician's orders for pain medication to be administered as needed (PRN) or for breakthrough pain that occurred between scheduled pain administration times. Review of the resident's Care Plan dated 6/6/25, showed the resident had complaints of acute pain. Interventions showed nursing staff was to: -Assess pain of the resident. -Administer pain medications. -Evaluate effectiveness of pain management. -NOTE: The Care Plan did not show the resident's pain location (s) or non-pharmacological interventions for pain for each pain area. Review of the resident's Medication Administration Record (MAR) dated June 2025 showed physician's orders for Tramadol 50 mg TID for chronic pain (start date 6/6/25 to 6/13/25), and Tramadol 50 mg TID for acute pain due to trauma (start date 6/13/25). The MAR showed: -Documentation showed Tramadol was not available on 6/6/25. -Tramadol 50 mg TID for chronic pain was administered to the resident daily from 6/7/25 to 6/13/25 at 8:00 A.M., 2:00 P.M. and 8:00 P.M. as ordered except on 6/12/25 at 8:00 P.M (showed the resident refused the medication). -Tramadol 50 mg daily for acute pain was administered to the resident daily from 6/13/25 to 6/17/25 at 5:00 A.M., 12:00 P.M., and 6:00 P.M., except on 6/13/25 at 5:00 A.M. (no documentation of rationale). -Documentation showed the resident daily pain assessments from 6/7/25 to 6/17/25 (on the 7:00 A.M. to 7:00 P.M. shift) showed the resident had general pain on 6/9/25, 6/10/25, 6/13/25, 6/14/25 and back pain on 6/12/25. On the 7:00 P.M. to 7:00 A.M. shift documentation showed the resident had pain on 6/9/25 and 6/10/25. All other dates showed the resident did not have any pain when he/she was assessed (the specific time of each assessment was not documented on the provided record). -Documentation on the MAR did not show the effectiveness of pain management interventions after medication was provided to the resident. Review of the resident's Skilled Nursing Notes showed: -On 6/9/25 the nurse documented the resident continued on daily skilled charting with diagnoses including a closed left hip fracture with routine healing, history of bladder cancer, acute pain due to trauma. The nurse documented the resident had raw skin and redness on his/her coccyx, used a wheelchair for mobility and was still working with physical and occupational therapy. The resident needed assistance of two persons with transfers. It showed the nurse gave the resident Tramadol as needed (PRN). --Documentation did not show where the resident's pain was located or pain severity level at that time. -On 6/13/25 the nurse documented the resident continued on daily skilled charting with diagnoses including a closed left hip fracture with routine healing, history of bladder cancer, acute pain due to trauma. The nurse documented the resident was pleasant and able to make his/her needs known and was able to roll himself/herself from side to side (in bed). The nurse documented Tramadol was given to the resident once he/she arrived from dialysis (a medical procedure that filters and cleanses the blood of patients whose kidneys are not functioning properly) due to pain. --Documentation did not show where the resident's pain was located or pain severity level at that time. Review of the resident's Physician's Assistant Notes dated 6/13/25, showed Physician Assistant A documented he/she completed a physical medical and rehabilitation evaluation (his/her family was at bedside). The resident's primary concern was related to mobility and activities of daily living (bathing, dressing, mobility, transfers, eating) dysfunction. The physician assistant documented: -The resident was admitted for skilled nursing and rehabilitation and was seen to optimize therapy, pain control and discharge planning. -The physician assistant examined the resident and reviewed his/her medical record and medications. -The resident's family was very upset today - reports the resident wasn't given his/her pain medication prior to dialysis. -Currently the resident presented with increased pain, otherwise, pain had been controlled. -Assessment showed the resident would continue with rehabilitation. Deconditioning/Gait instability - the resident was a high risk for functional impairment without therapy and adequate pain control. The resident had high risk for developing contractures, pressure ulcers, poor healing or fall if not receiving adequate therapy and pain control. The resident would continue all of his/her medications per primary care physician. The resident's rehabilitation and medical needs were discussed with nursing staff and therapy. -Regarding acute pain the physician showed orders to continue Tramadol 50 mg TID and to continue to titrate his/her pain regimen here to optimize therapy performance and functional gains. -Plan: Discussed the plan today with nursing and therapy. Continue therapy orders above. Continue to titrate medical regimen here to optimize pain, therapy performance, decrease the risk of falls and decrease the risk of complications and comorbidities that place patient at high risk of readmission to acute care hospital. Review of the resident's Physician's Assistant Notes dated 6/16/25, showed Physician Assistant A documented he/she completed a physical medical and rehabilitation evaluation (his/her family was at bedside). The resident's primary concern was related to mobility and activities of daily living (bathing, dressing, mobility, transfers, eating) dysfunction. The Physician Assistant documented: -The resident reported going to and from dialysis went much smoother today. Noted the resident had an appointment with his/her surgeon this afternoon. Pain under controlled. The resident denied other complaints at this time. -Physician Assistant A completed a physical examination of the resident and reviewed his/her medical record and medications. -Assessment showed the resident would continue with rehabilitation. Deconditioning/Gait instability - the resident was a high risk for functional impairment without therapy and adequate pain control. The resident had a high risk for developing contractures, pressure ulcers, poor healing or fall if not receiving adequate therapy and pain control. The resident would continue all of his/her medications per primary care physician. The resident's rehabilitation and medical needs were discussed with nursing staff and therapy. -Regarding acute pain the Physician Assistant showed orders to continue Tramadol 50 mg TID and to continue to titrate his/her pain regimen here to optimize therapy performance and functional gains. - Plan: Discussed the plan today with nursing and therapy. Continue therapy orders above. Continue to titrate medical regimen here to optimize pain, therapy performance, decrease the risk of falls and decrease the risk of complications and comorbidities that place patient at high risk of readmission to acute care hospital. -NOTE: There was no change in the resident's pain regimen. There was no documentation identifying the location of the resident's pain or if the location had changed. There was no documentation showing whether the pain to the resident's back or coccyx were addressed or were a factor in the resident's pain management regimen. There was no documentation showing the effectiveness of the resident's current pain regimen. There was no documentation or orders that addressed breakthrough pain for the resident. Review of the resident's Medical Record did not show documentation that additional sources of the resident's pain other than his/her hip (example: back and coccyx pain) were also being addressed in his/her pain management program. Observation on 6/16/25 at 11:19 A.M., showed the resident was sitting in his/her wheelchair wearing oxygen. His/her spouse was visiting and both said: -One day last week, he/she didn't get his/her pain medication before going to dialysis and he/she was very uncomfortable while at dialysis. -The resident said he/she received his/her scheduled pain medication today and received it daily. -He/She primarily had back pain, but at this time he/she was not currently in pain. -He/She did not know for sure if he/she had any pain medication for breakthrough pain ordered. -He/She did have pain at times between the times he/she received his/her scheduled pain medication. -He/She had not received any pain medication when he/she had pain between the times he/she received his/her scheduled medication. Review of the resident's Nursing Notes showed: -On 6/17/25 the nurse documented the resident continued on daily skilled charting with diagnoses including a closed left hip fracture with routine healing, history of bladder cancer, acute pain due to trauma. The nurse documented the resident had pain and discomfort in his/her back/coccyx area and was given scheduled Tramadol. --The nurse did not document where the resident said his/her pain was located or what level of pain severity at that time. Review of the resident's Nurse Practitioner Notes (NP) showed: -On 6/17/25 the NP documented he/she examined the resident reviewed his/her medical record and medications. The NP documented: -The resident complained of some pain to his/her coccyx due to a wound there. -The resident denied pain in his/her hip and had still been participating in rehabilitative therapy. -His/Her assessment regarding the resident's left hip fracture with surgical repair showed his/her pain was controlled. Regarding his/her coccyx wound, the wound doctor was following it and staff was to continue topical treatment as ordered and offload pressure as much as possible. -The Nurse Practitioner did not address the resident's additional areas of known pain (back and coccyx) and did not document any additional pain medication for breakthrough pain or a pain regimen that also addressed the resident's back and coccyx pain. Review of the resident's Care Plan updated 6/17/25 showed the resident required follow up care for a left hip fracture and took narcotic medication. It also showed the resident was admitted with moisture associated skin damage to his/her buttocks/coccyx and had a surgical incision to his/her left hip. Pain interventions included: -Note the side effects such as lethargy, sedation and low blood pressure. -Document the side effects noticed and relief for each. -Notify the physician of non-manageable side effects or the resident desiring changes in medication due to side effects that were intolerable. -NOTE: The care plan did not identify how the facility was addressing pain for the resident (pharmacological and non-pharmacological interventions) for each pain source and the effectiveness of the pain medication. Observation and interview on 6/17/25 at 10:07 A.M., showed the resident was sitting in his/her recliner, reclined with his/her feet outstretched. The resident said: -He/She was having some pain and though he/she took a scheduled pain medication earlier this morning, it was not helping much with his/her current pain. -Currently the pain was on his/her bottom and he/she had a wound there on his/her coccyx. -The nursing staff put cream on the wound but it hurt. -He/She did not know if she had any pain medication ordered in addition to his/her scheduled pain medication. -He/She would ask for pain medication. Observation and interview on 6/17/25 at 11:38 A.M., showed the resident's call light was turned on. Certified Nursing Assistant (CNA) B went into the resident's room and the resident was sitting in his/her recliner. The resident had a grimace/frown on his/her face and was moaning. The resident said he/she was in pain and needed help transferring to his/her bed because his/her bottom was hurting. CNA B moved the recliner into an upright position, put on gait belt and assisted the resident up to his/her walker and pivot to his/her wheelchair. He/She took the resident to his/her bed and assisted him/her into bed. CNA B put on gloves and checked the resident's brief for incontinence and then put cream on the resident's bottom (the resident's bottom showed a deep red area with sheared shin that was the size of a nickel. The resident winced when the cream was administered. The resident said that he/she was in pain from the sore on his/her bottom. CNA B told the resident he/she would inform the nurse of the resident's pain. CNA B said: -When he/she answered the call light the resident said he/she wanted to get into bed, his/her bottom hurt and he/she was in pain. -Earlier today, he/she was in the resident's room while the NP was visiting the resident and the resident asked the NP to look at her bottom and informed him/her of his/her pain, but he/she left the room at that time. -He/She asked the resident if the NP looked at his/her bottom and the resident said the NP did not. -The resident told them whenever he/she was in pain and they informed the nurse. -He/She did not know if the resident had scheduled and PRN pain medication, but he/she knew the resident took pain medication. Observation and interview on 6/17/25 at 11:59 A.M., showed CNA B told Licensed Practical Nurse (LPN) A that the resident was in pain. LPN A said: -The resident only had Tramadol for pain and it was given on a scheduled basis three times daily. -The resident did not have any additional pain medication but they had Tylenol they could give to him/her. -It was time for the resident to receive his/her pain medication and he/she was getting ready to give it to the resident. -LPN A prepared the resident's medications and went to the resident's room. He/She asked if the resident was in pain and provided a pain pill to him/her. -LPN A said the resident normally had pain in his/her back. Currently the resident said his/her pain level was at 6-7 (on a scale of zero to 10, 10 is severe pain) and he/she gave him/her pain medication due to pain on his/her bottom. -He/She saw the resident's bottom last week and it was red and raw but after seeing it again later that week, there was an open area that they began treating and the wound care doctor was following. During an interview on 6/18/25 at 10:49 A.M. LPN A said: -The resident complained of pain to his/her back and bottom frequently and received Tramadol three times daily. -The resident did not have any pain mediation ordered for breakthrough pain. -It did not seem that the resident's pain was controlled because the resident had pain between the scheduled time to receive his/her pain medication. -When a resident complained of pain, they would try to provide non-medication interventions in addition to physician ordered medication to treat pain. -If the interventions did not work, they would notify the physician to try to get additional pain medication or change in dosage in order to manage pain. -He/She had not notified the resident's physician of the additional pain the resident had. -Physician Assistant A visited weekly, was here today and he/she was responsible for the resident's pain management. -Both the NP and Physician Assistant A were aware of the resident's pain and were managing it. -He/She did not know why there had been no changes in the resident's pain regimen or medication because the resident had complained of pain since he/she was admitted to the facility. During an interview on 6/18/25 10:59 with the Physical Therapist A and Physician Assistant A: -Physical Therapist A said the resident had therapy for his/her hip repair and he/she had pain, but he/she had not been complaining recently of hip pain during therapy. He/She said yesterday he/she noticed the resident was wincing when he/she sat down because he/she had an open area on his/her coccyx. He/She said other than that, the resident had not complained of pain during therapy. -Physician Assistant A said the resident was receiving scheduled Tramadol for pain three times daily and he/she went to see the resident and the resident said that he/she was not in any pain and was satisfied with the current pain regimen. He/She said the resident and his/her spouse did not want an increase in pain medication. Observation and interview on 6/18/25 at 11:05 A.M. the resident was sitting in his/her wheelchair in his/her room. He/She said: -Though he/she had Tramadol for pain, it helped, but it didn't always manage his/her pain all of the time. -He/She used to have more hip pain, but he/she did not have hip pain anymore. -He/She had back pain but now most of his/her pain came from the wound on his/her bottom. -He/She currently did not have anything for breakthrough pain, so when he/she had pain (outside of the scheduled pain medication times) the staff were unable to give him/her anything for it. -He/She would like to receive pain medication for when he/she had pain that occurred between his/her scheduled pain medication times, or when his/her pain was more severe and the Tramadol did not help to relive it. -He/She did not recall speaking to Physician A today about his/her pain because he/she had just returned from a doctor appointment. -Currently his/her pain was at a 5 out of 10. -He/She had received his/her pain medication this morning before going to dialysis and received a pain pill a few minutes ago. During an interview on 6/18/25 at 11:34 A.M., the Director of Nursing (DON) said: -When the resident was admitted from the hospital, he/she only had scheduled Tramadol prescribed for him/her. -Usually they would have a PRN to assist with managing pain in addition to the scheduled pain medication for someone with similar health issues. -He/She looked in the resident's medical record and did not see documentation showing the resident had been complaining of pain until recently. -He/She saw Physician Assistant A's note dated 6/16/25 that showed the resident's pain was undercontrolled, but when he/she asked Physician A about it, Physician A said it was a typo and should have read under control. -Typically, if a resident was having additional pain that was not managed with the scheduled pain medication, they would have an order for Tylenol or something they could give to help relieve the resident's pain. -It may have been the resident had not been informing the staff that he/she was having additional pain. -The nursing staff was really good at addressing pain and he/she would ensure this was addressed for the resident.

Based on observation, interview and record review, the facility failed to ensure complete orders for dialysis (a medical procedure that filters and cleanses the blood of patients whose kidneys are not functioning properly), were on the Physician Order Sheet (POS) and documented in the care plan for one sampled resident (Resident #163) out of 14 sampled residents. The facility census was 56 residents. Review of the facility Dialysis policy and procedure dated February 2023, showed there was no documentation or procedure regarding physician's orders for residents who receive dialysis and what the physician's order should include. 1. Review of Resident #163's Face Sheet showed the resident was admitted on [DATE], with diagnoses including hip fracture, bladder cancer, kidney disease, acute kidney failure, and acute pain due to trauma. Review of the resident's POS dated June 2025, showed physician's orders for: -Renvela 800 milligrams (mg) three times daily for kidney disease (start date 6/6/25). -Complete pre and post dialysis communication form twice daily (start date 6/9/25). -The POS (to include ancillary orders) did not show where the resident received dialysis to include site location and contact information, what days the resident went to dialysis, where the resident's dialysis port (a surgically created connection that allows blood to be accessed for dialysis. There are several types of dialysis ports) was located and how the resident's port was to be cared for. Review of the resident's Care Plan dated 6/9/25, showed there was no care plan for dialysis that showed the name and location of the dialysis provider, how many times per week and time, what type of dialysis access site the resident had and where it was located, how the facility staff cared for and monitored the resident's dialysis access site and how the facility coordinated care with the dialysis provider. Review of the resident's Nursing Notes showed on 6/9/25 the resident continued on daily skilled charting. Notes showed the resident attended dialysis three days weekly on Monday, Wednesday and Friday. The nurse documented the resident's port was assessed and intact. Review of the resident's admission Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated 6/12/25 showed the resident: -Was alert and oriented, without delusions, hallucinations or behaviors. -Had lower extremity impairment on one side that affected his/her range of motion. -Needed maximum assistance with bathing, needed moderate assistance with dressing, transferring and mobility and used a walker and wheelchair for ambulation. -Had kidney disease and received dialysis. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated June 2025 showed physician's orders to: -Monitor the resident's dialysis port to his/her chest every shift for signs and symptoms of infection. -Monitor the thrill (a palpable vibration felt over the access site),and bruit (a whooshing sound heard with a stethoscope or by ear) every shift. -Complete pre/post dialysis communication form. Review of the resident's POS dated June 2025 showed an updated physician's order to monitor the resident's dialysis port every shift for signs and symptoms of infection (start date 6/16/25). Observation and interview on 6/16/25 at 11:19 A.M., showed the resident was sitting in his/her wheelchair in his/her room with his/her spouse. There was a clean bandage on the resident's right clavicle/neck area that was clean without signs of drainage. The resident said: -He/She had just returned from dialysis and his/her dialysis days were on Monday, Wednesday and Friday. -He/She left for dialysis around 5:00 A.M. and returned around 10:30 A.M. Review of the resident's Care Plan updated on 6/17/25, showed the resident had altered renal function that required dialysis therapy. Interventions showed staff would: -Arrange transportation to dialysis (location identified) three times a week. -Assess the resident's general condition and notify the physician of any changes. -Complete pre and post dialysis communication. -Assess the resident after each treatment including vital signs, port site, and signs and symptoms of infection, redness, pain or bleeding. -Assessment to be completed by the dietician routinely to determine nutritional needs. -Administer pain medication prior to dialysis. During an interview on 6/18/25 at 2:15 P.M., Registered Nurse (RN) C said: -He/She was not sure if there should be physician's orders that showed the resident was on dialysis. -There were orders for dialysis but he/she did not know if they included the location, days the resident attended dialysis, where the dialysis access site was or how they were to monitor the access site. -He/She would have to ask another charge nurse or the Director of Nursing (DON). During an interview on 6/18/25 at 2:20 P.M., Licensed Practical Nurse (LPN) B said: -They normally do not have physician's orders stating where the resident attends dialysis and on what days or time on the POS. -They have physician's orders that instruct them to monitor the resident's access site and they document this on the resident's MAR. They also document pre and post assessments on the dialysis communication forms. -They should have orders for the dialysis site and how to monitor it, documentation for providing snacks to the resident and orders for the pre and post dialysis monitoring. -Information regarding the resident's dialysis site location, information regarding where the resident attended dialysis and days and how they monitor the access site should be on the resident's care plan. -He/She then called the DON on the telephone and confirmed this information again. During an interview on 6/18/25 at 4:30 P.M., the DON said: -They would look for the MAR and TAR to find where the port was. -They document monitoring of the resident's dialysis port on the resident's MAR/TAR. -They do not have physician's orders that show the location of the resident's dialysis, days he/she attended dialysis or location of the resident's access site on the POS. -The nursing report, calendar and the resident's MAR/TAR have documentation showing this information. -The nurse would have to look through the resident's medical record for this information. -I did not think I needed an ancillary order for dialysis because it's on the chart flag that shows the resident was on dialysis. -Regarding nursing staff who were new to the facility or agency staff, they would receive information regarding the resident's dialysis in report and in the resident's medical record, not necessarily on the physician's order sheet.

Based on observation and interview, the facility failed to maintain the large fan in the laundry room free of a heavy buildup of dust which caused the fan to blow dust towards the laundry staff and the folding area of the laundry. The facility census was 56 residents. 1. Observation on 6/17/25 at 2:23 P.M., showed a heavy buildup of dust on the blades of the fan in the laundry. During an interview on 6/17/25 at 2:24 P.M., Maintenance Assistant B said he/she did not know the last time the fan was cleaned.

Based on observation and interview, the facility failed to ensure there was negative air flow in the 1st floor soiled utility room. The facility census was 56 residents. 1. Observation on 6/17/25 at 2:05 showed the absence of negative air flow from the 1st floor as required in a soiled utility room as evidenced by using two different tissue papers to check if the vent was drawing the paper up. During an interview on 6/17/25 at 2:07 P.M., the Director of Facility Operations said he/she was not sure how long that soiled utility room was without negative air flow.

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1) was treated with dignity and respect when on 5/14/25 Registered Nurse (RN) A grabbed the resident's arm, held it in place while the resident was resisting care resulting in a moon shaped skin tear out of three sampled residents. The facility census was 55 residents. The Administrator was notified on 5/22/25 at 5:12 P.M. of the past noncompliance which began on 5/14/25. The facility in-serviced all staff on the facility's resident rights, abuse and neglect policies. RN A was terminated on 5/16/25. The deficiency was corrected on 5/14/25. Review of the facility Resident Rights Policy dated 2001, revised in 2/2021 showed: -Employees shall treat all residents with kindness, respect, and dignity. -These rights include but not limited to: --A dignified existence. --Self-determination. --Exercise his/her rights as a resident as a resident of the facility and as a resident or citizen of the United States. --Exercise his/her rights without interference, coercion, discrimination or reprisal from the facility. 1. Record review of Resident #1's Profile Face Sheet showed he/she had the following diagnoses: -Hemiplegia (a condition characterized by paralysis affecting one side of the body, typically the face, arm, and leg) following a stroke affecting his/her right dominant side. -Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to a individual's social functioning and/or activities of daily living). -Reduced mobility. -Aphasic (is an impairment in a person's ability to comprehend or formulate language because of damage to specific brain regions). Review of the resident's undated Care Plan showed: -He/She had impaired decision making related to hemiplga following a stroke and major depressive disorder. --Provide cues and supervision for safety awareness. --Avoid use of restraints. --Respect resident's rights to make decisions. -He/She is aphasic related to history of a stroke. --Allow to lip read. --Staff to speak slowly and calmly. --Offer a quite environment to allow for effective communication. --He/She was able to communicate needs through gestures and can effectively wave and use his/her left arm as needed to shoo you away. -He/She was max assist for all transfers and cares. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 5/8/25 showed he/she: -Was severely cognitively impaired. -Was rarely/never understood by others. -Was able to understand others. -Had no behaviors. -Did not reject cares. Review of the facility's Suspected Abuse Investigation dated 5/14/25 showed: -On 5/14/25, at approximately 11:00 A.M., agency Certified Nurses Aide (CNA) A went and got RN A to assist him/her with attempting to get the resident out of bed as the resident had previously refused. -Policy was to get the nurse and if the resident refuses after multiple attempts allow the resident to refuse and document the refusal and notify the physician. -CNA A and RN A went into the resident's room to attempt to get him/her out of bed. -The resident refused to get out of bed and began to swing his/her left arm wildly towards both staff members. -RN A grabbed the resident's left arm to stop him/her from flailing his/her arm. -When RN A grabbed the resident's left arm he/she caused a small moon shaped skin tear by the resident's elbow. -The resident calmed down and eventually agreed to get out of bed. -CNA A notified the Director of Nursing (DON) of the incident around 1:30 P.M. -RN A indicated he/she put a note into the resident's medical record stating what had happened. -A skin assessment was completed on the resident and showed a small moon shaped skin tear on his/her left arm by the elbow. -The resident was interviewed by social services. -When asked what happened the resident pointed to his/her left arm. -Resident shook his/her head back and forth when asked if it hurt. -When asked if the encounter with staff was aggressive or rough the resident stated yes, did this staff member hurt you he/she stated yes. -The resident was asked if he/she was upset over the incident, and he/she stated no. -The resident was asked if he/she understood what he/she was being asked and he/she stated yes and pointed at an open area on his/her arm and stated 1 - 2 at the two red marks on his/her left arm. -When asked if he/she wanted RN A to stay out of his/her room he/she stated yes. -Resident appeared to be very irritated with each question. Review of the resident's Interdisciplinary Note dated 5/14/25 at 11:3 A.M. by RN A showed: -Resident resistant to care this morning. -Resistant to incontinent care and Activities of Daily Living management. -Resident verbally and physically aggressive to him/her. -Resident attempted to hit him/her with closed hand. -Resident deflected from action. -Resident said he/she was sorry and caressed the RN A's arms. -Two open areas were noted by CNA A on resident's left arm. -Covered with dressing. -Assistant Director of Nursing (ADON) aware of sites. -Resident compliant with completing care and placed in mobile wheelchair. During an interview on 5/28/25 at 1:05 P.M., RN A said: -He/she had told CNA A several times that morning the resident needed to be up and out of bed. -He/She and CNA A went into the resident's room to change the resident and get the resident up for lunch. -The resident can not stay in bed all day. -The resident did not want to get up and kept saying no, no, no. -The resident hit him/her in the face and hit the side rail on the bed. -He/She held the resident's arms to keep the resident from hurting his/herself. -The resident had two small skin tears on his/her left arm. -He/she should have walked away. Review of CNA A's written statement dated 5/14/25 showed: -About 10:30 A.M. or 11:00 A.M., RN A told him/her to get the resident up. -He/she went into the resident's room and asked the resident if he/she wanted to get up, the resident told him/her no. -He/she then went to RN A to explain the resident told him/her no on getting up. -RN A told him/her the resident needed to get up for lunch. -He/she said he/she would get another aide to help, and RN A said no he/she would help him/her with the resident. -In the resident's room RN A told the resident that he/she needed to get up and the resident said no. -The resident grabbed the turning hoop (rail). -RN A grabbed the resident's arm off the turning hoop (rail) and then held both arms on the bed resulting in two small skin tears. -The resident then said he/she was sorry and RN A stated he/she should be sorry, that was ridiculous. -RN A asked the resident if he/she wanted to give RN A some sugar. -The resident said no. -RN A said then he/she would get the resident a coke. -The resident did get up in the wheelchair after he/she was changed. During an interview on 5/22/25 at 2:00 P.M., agency CNA A said: -He/She went into the resident's room to get the resident up before lunch. -The resident said no. -He/She went and told RN A the resident did not want to get up before lunch. -RN A said the resident needed to get up and went into the resident's room with him/her. -He/She went to change the resident, and the resident grabbed the half rail. -RN A pulled the resident's hands off the half rail and held down the resident's arms. -The resident was trying to get his/her arm loose from the hold. -The resident never swung his/her arms at RN A. -RN A never gave the resident an option to get changed and stay in bed. -RN A told the resident he/she was getting up for lunch. -RN A then asked the resident if the resident wanted him/her to give a kiss (some sugar), the resident said no. -RN A then offered to buy the resident a coke. During an interview on 5/22/25 at 2:23 P.M., the resident said: - I have no words to say, over and over. -Observation showed a moon shaped scab area on the resident's left arm by his/her elbow. During an interview on 5/22/25 at 3:16 P.M., the Administrator said: -He/She was notified of the incident on 5/22/25 around 1:30 P.M. -The resident has the right to stay in bed if he/she wanted to. -RN A should have just walked away from the resident because the resident was safe in bed. -The resident received a skin tear on his/her left arm by the elbow. -He/she educated for both abuse and resident rights, dignity to all staff but felt this instance with RN A was a customer service dignity issue. MO00254273 MO00254294

Based on interview and record review, facility staff failed to follow facility policy for using mechanical lifts for one sampled resident, (Resident #1) out of five sampled residents. Facility staff failed to use two staff to transfer the resident using a Hoyer lift (a medical device used to assist lifting and transferring individuals with limited mobility) and failed to inspect the lift sling for safety on 2/26/25. During the transfer, the sling strap broke and the resident fell to the floor. The resident sustained a subdural hematoma (a type of bleeding that occurs inside the skull in the outermost membrane surrounding the brain) and a fractured right hip and was admitted to the hospital intensive care unit (ICU). The facility census was 59 residents. The Director of Nursing (DON) was notified on 3/4/25 at 5:12 P.M. of the past noncompliance Immediate Jeopardy (IJ) which began on 2/26/25. The administrator and DON inspected all lift slings being used by residents. The administrator and maintenance director inspected all lifts to ensure they were working properly. The facility in-serviced all staff on the facility's mechanical lift policy. Certified Nurse Aide (CNA) A received one-on-one training regarding the facility's mechanical lift policy. The facility policy of inspecting lift slings was changed from quarterly to monthly. The IJ was corrected 2/27/25. Review of the facility's undated Using a Mechanical Lifting Machine policy showed: -A general guideline that at least two nursing assistants were needed to safely move a resident with a mechanical lift. -Staff should make sure all necessary equipment, (slings, hooks, chains, straps and supports) were on hand and in good condition. -Any worn, frayed or ripped slings should be discarded. Review of CNA A's facility Orientation Check list, dated 8/21/23, showed the initialed check list did not include the use of lift devices. 1. Review of Resident #1's Profile Face Sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Cerebral palsy, unspecified, (a group of disorders which affect movement, posture and balance). -Spinal Stenosis, unspecified, (a condition where spaces between the spine narrow and put pressure on the nerves that travel through it). -History of falling. -Primary osteoarthritis, (a joint disease that causes pain, stiffness and loss of movement), both hands. Review of the resident's undated Physician's Orders showed an order for Eliquis (a medication which thins the blood) 5 milligrams (mg) tablet by mouth twice a day for cerebral palsy with a start date of 12/31/24. Review of the resident's undated Care Plan showed: -The resident had impaired functional status regarding bed mobility, transfers, walking, toileting, and locomotion. Interventions were that he/she was a two-person transfer using a Hoyer lift with two assists. The start date was 1/4/23. -The resident was at risk for falling related to the extensive need for assistance with activities of daily living and transfers. The resident had fall on 6/12/24 during a transfer using a sit-to-stand device, per his/her request, with two staff members present. Interventions were that the resident and staff were educated to use a Hoyer lift as he/she was unable to stand or assist with transfers. The start date was 6/20/24. -The resident was on anticoagulant therapy (medications that prevent blood clots) for deep vein thrombosis (a condition in which a blood clot forms in a deep blood vessel). Interventions were to assess and monitor for signs and symptoms of bleeding, abnormal bruising, blood in urine, blood in stools, bloody vomit, and nose bleeds. The start date was 12/30/24. Review of the resident's Incident Report, dated 2/26/25, showed: -The incident happened on 2/26/25 at 9:15 A.M. -The resident fell out of a Hoyer lift. -The Hoyer sling broke. -He/She was safely assisted up in his/her chair. -He/She was noted with a hematoma on the back left side of his/her head after assessment. -He/She had a suspected closed head injury. -He/She was supervised by staff. Review of the resident's Interdisciplinary Notes, dated 2/26/25 at 10:55 A.M., showed: -The resident fell out of the Hoyer lift that morning. -The Hoyer strap broke. -The resident hit his/her head; hematoma noted of the left side back of the resident's head. -Orders received to send the resident out to the emergency room (ER) to be further evaluated. -The resident was taking Eliquis, twice a day, 5 mg orally. -The resident's family emergency contact was contacted and the doctor noted. -The resident went to the hospital. Review of the facility undated Suspected Abuse Investigation showed: -The occurrence type was a mechanical lift error. -The occurrence was first known on 2/26/25 at approximately 10:00 A.M. -On Wednesday, 2/26/25 CNA A attempted to transfer the resident with a mechanical lift. -CNA A admitted to not having a second person for assistance, knowing that was the facility policy. -During the transfer, a strap on the mechanical lift sling broke causing the resident to bump the back of his/her head. -CNA A immediately notified his/her nurse, Licensed Practical Nurse (LPN) A and the Director of Nursing (DON) who assessed the resident for injury and pain. -The resident complained of no pain after the initial fall and only had a small bump on the back of his/her head. Review of the resident's Interdisciplinary Note, dated 2/27/25 at 7:14 A.M., showed. -The resident arrived back at the facility on 2/26/25 after lunch. -He/She was transferred back to his/her bed by paramedics and two staff. -He/She did not want to be bothered. -He/She appeared to be in no apparent distress or discomfort. -At the hospital several tests were done, however the resident returned from the hospital with only the finding of constipation. -He/She was treated for constipation and returned to the facility. Review of the resident's Interdisciplinary Note, dated 2/27/25 at 12:54 A.M., showed: -The resident was sent back to the hospital on 2/26/25 due to altered level of consciousness at approximately 7:45 P.M. He/She was not able to keep his/her eyes open and was non-verbal. -He/She was admitted to the ICU with a left hip fracture and brain bleed per the ER charge nurse. -6:00 A.M. follow up on resident in neuro department; his/her vital signs were stable, repeat computerized tomography (CT) scan (a medical imaging technique that uses x-rays to create detailed images of inside the body) was done; results were pending. Review of the resident's hospital CT abdomen and pelvis scan report, dated 2/26/25 at 9:30 P.M., showed a left femoral neck fracture with severe varus angulation (a condition in which a limb angles inward at the joint). Review of the resident's hospital radiology report, dated 2/26/25 at 11:15 P.M., showed a left femoral subcapital fracture (a type of hip fracture that occurs just below the head of the thigh bone), with severe varus angulation with no dislocation. Review of the resident's hospital orthopedic (a branch of medicine that focuses on the musculoskeletal system) consult note, dated 2/27/25, showed: -The resident was returned to the hospital ED on the evening of 2/26/25 due to altered mental status. -He/She initially presented to the ED that morning after a fall from a Hoyer lift at his/her facility. -Per chart review at that time showed he/she was evaluated and returned to the facility. -Repeated imaging showed he/she had a left hip fracture as well as a subdural hematoma. -Orthopedics was consulted for evaluation of his/her fracture. -On exam, the patient was non-responsive to questioning/commands. -Per nursing staff, the patient had been non-verbal since admission. Review of the resident's hospital diagnosis assessment plan, dated 2/26/25 at 10:33 P.M., showed: -The resident had a history of cerebral palsy and was not able to walk at baseline. -He/She presented in the morning as a trauma activation due to a fall from a Hoyer lift, on Eliquis. -He/She was subsequently discharged back to his/her nursing facility. -He/She presented this evening secondary to continued lethargy (state of mental or physical fatigue, lack of energy or sluggishness) throughout the day. -ED evaluation demonstrated a new moderate to large left sided subdural hematoma without midline shift. -On exam the patient occasionally responded to questioning and localized stimuli, but was not following commands. During an interview on 3/4/25 at 10:50 A.M., CNA A said: -He/She got the resident up and put the sling under him/her. -He/She lifted the resident up a few inches and one of the lift straps broke. -The resident was still over the bed when the strap broke, but he/she fell and went down on the floor. -He/She went to go get the nurse and they got the resident up in his/her wheelchair. -He/She decided to lift the resident by him/herself, because the other staff were busy. -There were enough staff, but they were all getting the other residents up. -He/She was getting the resident up for breakfast and was not in a hurry for any reason. -The resident was not hitting or combative. -He/She probably should have waited until other staff were available, but he/she had other residents he/she also had to get up. -This was the only time he/she used the Hoyer with just one person. -The resident did not say anything while he/she and the nurse were getting him/her into the wheelchair. -When the resident was in the wheelchair, they could feel a bump on his/her head. -They brought the resident up to the front area to wait for the paramedics to arrive. -He/She did not notice the sling was not in good condition; it did not seem like anything was wrong with it or anything that might break. He/She did not really look at it. -The sling was the right size for the resident. He/she did not need a special size; the one he/she had was adequate. -It would be the responsibility of the person using the sling to inspect it before using it. -He/She had previously been educated to use two people when using the Hoyer lift. -It had probably been a year since he/she had any training about lifts. During an interview on 3/4/25 at 10:40 A.M., LPN A said: -It was the day shift when the resident fell. -CNA A came and got him/her and told him/her the resident fell. -He/She went into the room and the resident was laying on the floor. -He/She assessed the resident and LPN A and CNA A began to get him/her up into his/her wheelchair. That is when when they noticed a bump on his/her head. -The bump was about the size of a half dollar, but was not red or bleeding. -He/She called the Nurse Practitioner and told him/her the resident fell. He/She was told to send the resident to the hospital. -The resident was on a blood thinner. -The resident was in his/her wheelchair and placed in the hallway. -The resident was taken to the hospital due to the bump on his/her head. -The hospital sent the resident back within a few hours and said he/she was fine, except for being constipated and he/she had been given an enema. -The hospital ran a lot of tests on the resident, including a CT of the head and concluded everything was normal. -Later, the night nurse noticed a change in the resident's condition and had him/her sent back to to the hospital. -CNA A said he/she put the resident on the lift without assistance, but did not say why. -It was not common for only one person to use the lift and it was against policy. -There was always someone to help. He/She would have gotten another staff person before he/she went into the resident's room. If another staff person was not available at the time, other cares could be done until they were. -The staff had been trained to inspect the slings before using them. It was the staff person's responsibility who was using the sling to check and see if it was in good condition. -Staff were educated there were supposed to be two staff when using a mechanical lift; they received education every year. During an interview on 3/4/25 at 11:50 A.M., Maintenance Staff A said: -Prior to the resident's fall, the maintenance staff had not been involved in checking the slings to make sure they were in good condition. -He/She did not know who would have been responsible for that. Observation on 3/4/25 at 1:30 P.M., showed the resident was observed in the hospital ICU lying on his/her back. He/She had some purple blotches visible on both arms. He/She appeared partially conscious and would slightly open his/her eyes at times. He/She could not speak. During an interview on 3/4/25 at 4:40 P.M., LPN B said: -He/She worked on 2/26/25 and was a nurse on the facility's east hall. -There probably would have been someone to help CNA A with the transfer if they were not busy. -CNA A should have waited for help. -While waiting, he/she could have put the Hoyer sling under the resident or gotten him/her dressed until help was available. -He/She had training that there should be two people to use a Hoyer, at orientation and possibly one other time. -Staff were also trained prior to this event to inspect the Hoyer sling and if a problem was seen to report it to the charge nurse, DON or Administrator. During an interview on 3/4/25 at 5:00 P.M., CNA B said: -He/She was working on 2/26/25. -All of the staff were busy, but there were people around if someone needed assistance. -He/She usually helped CNA A, but they were really busy that day. -If there was not someone available to assist at the moment, a staff person could get the resident dressed, place the Hoyer sling under the resident and hook it to the lift, but wait to lift until assistance was available. -He/She had been taught that there should always be two people using the lifts. -He/She had not previously checked the integrity of the slings prior to the accident, but would be doing so now. -He/She was trained on using the lifts when he/she started his/her employment at the facility, but did not remember if he/she had additional training prior to the incident. During an interview on 3/5/25 at 9:00 A.M., LPN C said: -He/She worked from 7:00 P.M. on 2/26/25 to 7:00 A.M. on 2/27/25. -He/She thought the resident was sleeping, but he/she would open his/her eyes and close them. -The resident's blood pressure was low and pulse was high, and in his/her judgment that could indicate a bleed. -The resident was usually responsive and took medications well. -He/She called the nurse practitioner and got an order to send the resident out to the hospital. -Some of the paramedics who had taken the resident out earlier in the day came and they stated he/she seemed different. -He/She checked on the residents at the beginning of the shift, between 7:00 P.M. and 7:30 P.M. The resident was sent out by 7:45 P.M. -He/She had previously been trained to use two people when using the Hoyer lift. -He/She told the CNAs if they needed help to come and get him/her. During an interview on 3/4/25 at 1:30 P.M., the resident's Family Member A said: -First the family was informed the resident fell and then the Hoyer lift broke. -The resident was not weight bearing, due to cerebral palsy. -The resident had been able to make his/her wishes known. -If he/she was unable to get his/her hip stabilized, he/she would have to go on hospice (end of life care). -The resident was receiving tube feedings now. -He/She had total cognitive ability prior to the fall. -The hip repair became secondary to the head trauma. During an interview on 3/4/25 at 3:20 P.M., the DON said: -CNA A was oriented to his/her position at the facility in 8/23. -He/She did not have the information on CNA A's last training on the use of mechanical lifts and Human Resources could not provide it either. -If there were other staff in the room they would be witnesses if he/she was not performing a duty correctly and be able to assist the CNA. -CNA was getting the resident up for breakfast. -There was no reason for him/her not to wait for assistance; there was no emergency. -His/Her expectation was that staff would always utilize two people for a mechanical transfer of a resident and to follow the facility policy, and that was what he/she told them. -Staff had been told if a sling was not looking good to bring it to his/her attention or the charge nurse or the Administrator. -The lift slings came in small, medium, large and extra-large sizes; use was determined by how tall or short the resident was. The facility used medium and large sizes. -The resident's sling was the appropriate size. -He/She thought the fraying on the sling's straps would have been noticeable, because it was pretty visible. -CNA A should have brought the condition of the sling to someone's attention. -All staff knew transfers were to be done with two people. -He/She could not say whether it would have made a difference if another staff person would have made a difference in preventing the fall. During an interview on 3/13/25 at 2:10 P.M., Nurse Practitioner A said: -The facility staff called on 2/26/25 to let him/her know the resident had fallen from a Hoyer lift. He/She did not know the circumstances of that. -It was reported to him/her the resident had hit his/her head and had a bump, so he/she ordered the resident to be sent to the ED to be evaluated. -The resident was released back to the facility the same day. -Later that evening, the nurse called and let him/her know the resident was lethargic and had a change of condition to get an order to send the resident back to the hospital, which he/she gave. -That was all he/she knew about it except he/she found out later the resident had a broken hip and a brain bleed. -He/She would expect the facility staff would follow their policy for safety using mechanical lifts. MO00250373 MO00250214

Based on interview and record review, the facility failed to notify the physician, Administrator, Director of Nursing (DON) and/or the resident representative of one resident's (Resident #1) changes in skin condition resulting in a delay in treatment out of four sampled residents. The facility census was 67 residents. Review of the facility Change in a Resident's Condition or Status dated 2/2021 showed: -Our facility promptly notifies the resident, his/her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. -The nurse will notify the resident's attending physician or physician on call when there has been a(n) significant change in the resident's physical, emotional, or mental condition and the need to alter the resident's medical treatment significantly. -Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. -Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical or mental condition or status. 1. Review of Resident #1's Face Sheet showed the resident was admitted on [DATE] with diagnoses including altered mental status, acute kidney failure, cellulitis of the lower limbs, and abnormalities of gait and mobility. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/8/24 showed the resident was severely cognitively impaired. Review of the resident's Interdisciplinary Notes dated: -10/13/24, 10/16/24, 10/17/24, 10/19/24, 10/24/24 and 10/25/24 Licensed Practical Nurse (LPN) A documented wounds were found. -No documentation was found of notification to the resident's physician and or family from 10/13/24 through 10/25/24 in the interdisciplinary notes. **NOTE**The medical record showed no notification to the physician until 10/28/24 and showed no notification to the family until 11/7/24. During an interview on 12/19/24 at 9:21 A.M. Family Member #3 said: -Upon admission on [DATE], to the facility the resident did not have any open wound on his/her body. -On 11/18/24, the resident's spouse received notification the resident was being sent to the hospital due to coughing up blood. -Upon arrival at the hospital the resident was assessed to have many open wounds to his/her body. -He/she was not told of the resident having any wounds. During an interview on 1/13/25 at 2:31 P.M. LPN A said: -He/She documented new pressure injuries to heels and left ankle, which were not present the day of admission. -He/She reported to someone, but unable to state who he/she reported the pressure injury to or when, and did not document in the nursing notes. -Confirmed documenting the pressure injury to heels and left ankle on 10/13/24, 10/16/24, 10/17/24, and 10/21/24. -He/She did not notify the physician of the pressure injuries observed and documented. -He/She did not notify the family of the pressure injuries observed and documented. -He/She did not notify the nurse accepting the resident on the second floor for LTC on 10/21/24 of the pressure injuries. -When identifying a new wound, it should be documented, notify the wound nurse and put something protective in place. -Wounds should be measured, the physician should be notified, and family notified if they are not aware. -He/She did not know why he/she did not notify the physician or the family of the resident's wounds. -The physician would be notified by nursing when in the facility, including him/herself. During an interview on 1/14/25 at 12:13 P.M. the Nurse Practitioner (NP) said: -There was no notification on 10/13/24 of wounds from the nursing staff. -Confirmed there was no notification of the documented wounds from 10/13/24 through 10/21/24 while on the first floor for skilled services. -Confirmed there was no notification of any skin conditions or concerns from 10/21/24 through 10/28/24 after moving to the second floor for LTC. -He/She expects to be notified when wounds are discovered to put treatments as well as preventative measures in place. During an interview on 1/14/25 at 1:28 P.M. Assistant Director of Nursing (ADON) B said: -If any changes were noted the nurses were to notify the ADONs. -The nurses should have called the doctor or NP and the family. -On 10/28/24 he/she was notified by Certified Nurses Aide (CNA) A of the resident having wounds. -He/She believed the resident had six to eight wounds on 10/28/24. -He/She did not notify the family of the wounds or new orders at any time. During an interview on 1/14/25 at 3:08 P.M. LPN D said when identifying new wounds the nurses were expected to document, give the information to wound nurse, contact the doctor and contact the family after talking to the doctor. During an interview on 1/15/25 at 5:15 P.M. LPN E said: -He/She thought the resident had a coccyx wound while on the skilled unit. -For new wounds he/she would use standing orders, measure the wound and document, contact the doctor and notify the DON. -He/She has never been told to notify the family unless sending the resident out of the facility. During an interview on 1/16/25 at 11:25 A.M. LPN B said: -He/She cared for the resident was on the first floor for skilled services. -He/She documented pressure injury to the ankle on 10/19/24. -He/She notified the Director of Nursing (DON) and wound nurse/ADON, although it was not documented. -He/She felt the family probably already knew, so he/she did not contact the family. During an interview on 1/16/24 at 12:48 P.M. the DON said: -He/She was first notified of the resident's wounds to the inside of his/her knee by ADON B on 10/28/24. -When a new wound is discovered the nurses were to report to DON, ADON A or ADON B and let them decide the next steps. -His/Her expectation was the nurses notify him/her by phone, text, something and then he/she will decide the process. -Nurses may contact the doctor without DON direction, he/she just wanted notified. -As a nurse they should be notifying the physician with any change. -The delayed notification and treatment of the resident's wounds was one that got missed as a result of bad decisions and poor choices by the staff. During an interview on 1/16/25 at 1:39 P.M. ADON A said: -On 10/21/24 when the resident was transferred to the second floor LTC, information related to the wounds and any other relevant information should have been given in a report from LPN A to the LPN D. -He/She expected staff to notify someone when a new wound is discovered, DON, ADON, Administrator, or physician, and put a treatment in place. -He/She still expected the provider to be called. During an interview on 1/16/24 at 4:30 P.M. the Administrator said: -He/She expected CNAs to notify the charge nurse when new wounds are discovered. -He/She expected the nurses to notify the doctor and get orders for treatment or interventions and to notify the family. -After the doctor and family were notified the nurse should notify the ADON, DON and administrator. -Braden assessments are to be done according to policy and quarterly. -He/She was aware the resident's wounds were not reported. -He/She expected family to be notified of any changes before the end of shift. During an interview on 1/21/25 at 10:44 A.M. Family Member #1 said: -The resident was transferred from the hospital to the facility on [DATE] with no skin issues. -He/She was not aware of any wounds until after the resident was sent to the hospital on [DATE]. During an interview on 1/21/25 at 10:51 A.M. Family Member #2 said at no time prior to the resident being sent to the hospital on [DATE] was the family made aware of the resident's wounds or any changes in the resident's care. MO00246983

Based on observation, interview and record review, the facility failed to ensure weekly skin/wound assessments, wound assessments included a detailed description and measurements of the pressure ulcer/injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), and to notify the resident's physician of a new pressure ulcer to obtain treatment orders in a timely manner for one sampled resident (Resident #1) out of four sampled residents. The facility census was 67 residents. Review of the facility Pressure Injury Risk assessment dated 3/2020 showed: -The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. -Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure injuries. -Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. -When conducting a risk assessment, if a new skin alteration is noted, initiate a pressure or non-pressure form related to the type of alteration in skin. -The following should be recorded in the resident's medical record utilizing facility forms: --The type of assessment conducted. --Date, time, and type of skin care provided, if appropriate. --Condition of the resident's skin, if identified. --Initiation of a pressure form if new skin alteration noted. --Documentation in medical record addressing physician notification if new skin alteration noted with change of plan of care, if indicated. --Documentation in medical record addressing family, guardian or resident notification if new skin alteration noted with change of plan of care, if indicated. Review of the facility Prevention of Pressure Injuries dated 4/2020 showed: -Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. -Assess the resident on admission (within eight hours) for existing pressure injury risk factors. -Repeat the risk assessment weekly and upon any changes in condition. -Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. -Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADL's). -Skin Care includes: --Keep the skin clean and hydrated. --Use a barrier product to protect skin from moisture. --Use facility-approved protective dressings for at risk individuals. -Mobility/Repositioning: --Reposition all resident with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. -Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. -Evaluate, report and document potential change in the skin. Review of the facility Pressure Ulcers/Skin Breakdown Clinical Protocol dated 4/2020 showed: -The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers, for example immobility, recent wight loss, and history of pressure ulcers. -In addition, the nurse shall describe and document/report the following: --Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudate (drainage) or necrotic (dead) tissue. --Pain assessment. --Resident's mobility status. --Current treatments, including support surfaces. --All active diagnoses. -The staff and practitioner will examine the skin of newly admitted resident for evidence of existing pressure ulcers or other skin conditions. -The physician will assist the staff to identify the type and characteristics of an ulcer. -The physician will help identify factors contributing or predisposing resident to skin breakdown, for example medical comorbidities, and macerated or friable skin. -The physician will clarify the status of relevant medical issues. -The physician will order pertinent wound treatment, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. -The physician will help identify medical interventions related to wound management. -The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors. -As needed the physician will help identify medical and ethical issues influencing would healing. -During resident visits, the physician will evaluate and document the progress of wound healing, especially for those with complicated, extensive, or poorly-healing wounds. -The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. 1. Review of Resident #1's Face Sheet showed the resident was admitted on [DATE] with diagnoses including altered mental status, acute kidney failure, cellulitis of the lower limbs, and abnormalities of gait and mobility. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/8/24 showed the resident: -Was severely cognitively impaired. -Impaired functional mobility to one upper extremity. -Impaired functional mobility to both lower extremities. -Used a wheelchair for mobility. -Required substantial to maximum assistance with shower/bath and personal hygiene. -Was dependent for toileting. -Was dependent for all mobility. -Was incontinent with bowel and bladder. -At risk for pressure ulcers. -MASD (moisture associated skin damage) identified. -Pressure reducing device for chair and bed. -Turn and repositioning program. -Application of ointment and medications other than to feet. Review of the resident's undated Care Plan showed the resident: -Impaired functional status: bed mobility, transfers, toileting, eating, personal hygiene and bathing, 10/2/24. --One to two person assist will all ADL's. -Had incontinence issues, 10/2/24. --Required assistance with staff to manage bowel and bladder incontinence. --Used incontinence briefs. -At risk for pressure ulcers related to decrease in function mobility and incontinence, 10/2/24. --Skin would remain intact with no new open areas by pressure or friction for the following 90 days. ---Skin assessment Braden Scale weekly for four weeks upon admission/readmission then quarterly, 10/2/24. ---Use pressure reducing mattress, cushion when in bed, wheelchair and float heels when in bed as needed, 10/2/24. ---Low air loss mattress to be in place, 10/14/24. ---MASD to buttock, barrier cream after each incontinent episode and as needed, 10/14/24. ---Treatments as ordered,11/4/24. ---Turn and position as needed, 11/4/24. ---Dietician to evaluate and treat as needed, 11/4/24. ---Pillow between knees while in bed, 11/4/24. -Resident is dependent for all cares, staff to anticipate needs, 11/4/24. -Had alteration in circulation resulting in edema, related to congestive heart failure. --Keep limb elevated as necessary to minimize edema, reduction in edema or not increased. ---Monitor skin condition daily to ensure no pressure or vascular wound present. Review of Interdisciplinary Note dated 10/2/24 at 2:59 P.M. showed Licensed Practical Nurse (LPN) A documented the resident was admitted to the facility and no skin assessment documented at that time. Review of the resident's Braden Scale (a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers) Assessment on 10/2/24 showed a score of 10, indicating the resident was at risk for pressure injury development. Review of the resident's Physician's Orders dated 10/3/24 showed Low Air Loss (LAL) mattress to bed for wound prevention. Review of Interdisciplinary Note dated 10/3/24 at 10:43 A.M. showed the resident was assessed by the physician with no noted skin conditions. Review of the resident's shower sheet dated 10/5/24 showed no concerns. Review of Interdisciplinary Note dated 10/8/24 at 11:01 A.M. showed the resident was assessed by the Nurse Practitioner (NP) with no noted skin conditions. Review of the resident's Certified Nursing Assistant (CNA) shower sheet dated 10/9/24 showed pressure area to left buttock, skin evaluation form showed MASD to right buttock and barrier cream treatment. No documentation of a detailed description of the left buttock, no documentation the resident's family or physician was notified. Review of the resident's Braden Scale Assessment on 10/9/24 showed a score of 11, indicating the resident was at risk for pressure injury development. Review of the resident's Interdisciplinary Note dated 10/10/24 at 10:41 A.M. showed the resident was assessed by the physician with no noted skin conditions. Review of the resident's Interdisciplinary Note dated 10/13/24 at 3:47 P.M. showed LPN A documented: -Pressure areas to bilateral heels and left inner ankle. No documentation of measurements, staging, or detailed descriptions for the identified Pressure Injuries on the resident's right heel, left heel, and left ankle. No documentation the resident's physician or family were notified. Review of the resident's Interdisciplinary Note dated 10/15/24 at 10:20 A.M. showed the resident was assessed by NP with no noted skin conditions. Review of the resident's Interdisciplinary Note dated 10/16/24 at 2:55 P.M. showed LPN A documented: -Pressure areas to bilateral heels and left inner ankle. No documentation of measurements, staging, or detailed descriptions for the identified Pressure Injuries on the resident's right heel, left heel, and left ankle. No documentation the resident's physician or family were notified. Review of the resident's Interdisciplinary Note dated 10/17/24 at 11:43 A.M. showed the resident was assessed by NP with no noted skin conditions. Review of the resident's Interdisciplinary Note dated 10/17/24 at 1:07 P.M. showed LPN A documented: -Pressure areas to bilateral heels and left inner ankle. No documentation of measurements, staging, or detailed descriptions for the identified Pressure Injuries on the resident's right heel, left heel, and left ankle. No documentation the resident's physician or family were notified. -Low Air Loss (LAL) bed with proper settings and pillows in place to offload pressure areas. Review of the resident's Interdisciplinary Note dated 10/19/24 at 11:19 A.M. showed LPN B documented resident's pressure areas noted. No documentation where these pressure areas were located on the resident's skin. No documentation of measurements, staging, or detailed descriptions for the identified Pressure Injuries on the resident's right heel, left heel, and left ankle. No documentation the resident's physician or family were notified. Review of the resident's Interdisciplinary Note dated 10/21/24 at 2:15 P.M. showed LPN A documented: -Pressure areas to bilateral heels and left inner ankle. No documentation of measurements, staging, or detailed descriptions for the identified Pressure Injuries on the resident's right heel, left heel, and left ankle. No documentation the resident's physician or family were notified. -LAL mattress will be taken upstairs and placed on resident's bed with proper settings. Review of the resident's Physician's Orders dated 10/25/24 showed Silvadene (a topical, antibacterial cream) Twice daily apply to sacrum and coccyx and as needed (PRN) incontinence for wound care. No documentation of treatment orders for the resident's right and left heel wounds and left ankle wound. Review of the resident's Interdisciplinary Note dated 10/25/24 AT 5:33 A.M. showed LPN C documented: -No documentation of the previously identified pressure injuries to the resident's right and left heel and left ankle, identified on 10/13/24. Review of the resident's Physician's Orders dated 10/28/24 showed: -Arginaid 4.5 gram/156 milligram/9.2 gram oral powder packet by mouth twice daily for wound healing. -Pro-stat Renal Care 15 gram-100 kilocalorie/30 milliliters oral liquid by mouth twice daily for wound healing. Review of the resident's skin evaluation form dated 10/28/24 showed: . -Sacrum pressure injury, 1 cm x 0.5 cm x 0.3 cm, Stage III (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; it may include undermining or tunneling) type 2 granulation, light serous drainage, treatment of Silvadene. -No documentation of the previously identified pressure injuries to the resident's right and left heel and left ankle, identified on 10/13/24. Review of the resident's Interdisciplinary Note dated 10/28/24 at 6:52 P.M. showed Registered Nurse (RN) A documented: -Wound care nurse (Assistant Director of Nursing (ADON) B) assessed today for new wounds note to inner bilateral knees and buttock. No documentation of measurements, staging, or detailed descriptions for the identified Pressure Injuries on the resident's right knee, left knee, and buttock. No documentation the resident's physician or family were notified. -No documentation of the previously identified pressure injuries to the resident's right and left heel and left ankle, identified on 10/13/24. Review of the resident's Physician's Orders dated 10/29/24 showed: -Aquacel Ag (a dressing that is indicated for moderate to high exuding wounds which are infected or at risk of infection) Extra, 4 inch x 5 inch bandage (Hydrocolloid dressing) 4 inch x 5 inch topical, Once daily cleanse inner knees with wound cleanser, apply Aquacel to wound bed, cover with border foam, change daily and as needed (PRN). -No documentation of treatment orders for the resident's pressure injuries to his/her right and left heel and left ankle discovered on 10/13/24. Review of the resident's skin evaluation form dated 10/29/24: -Right knee pressure injury, 3 cm x 2 cm x 0 cm, healing Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. It may also present as an intact or open/ruptured blister) with light serous (watery, clear, or slightly yellow/tan/pink drainage) drainage, treatment of Aquacel Ag. -Left knee pressure injury, 3 cm x 1.5 cm x 0.1 cm, healing Stage II with light serous drainage, treatment of Aquacel Ag. -No documentation of the previously identified pressure injuries to the resident's right and left heel and left ankle, identified on 10/13/24. Review of the resident's wound assessment document dated 10/29/24 showed: -Right inner knee, eschar, 4.5 cm x 2.0 cm x 0.1 cm. -Left inner knee, eschar, 3.5 cm x 1.5 cm, x 0.1 cm. -No documentation of staging, or detailed descriptions for the identified Pressure Injuries on the resident's right and left knees. No documentation of the previously identified pressure injuries to the resident's right heel, left heel, and left ankle. Review of the resident's Interdisciplinary Note dated 11/1/24 at 9:36 P.M. showed LPN C documented: -Resident had wounds in the knee area and around the coccyx. No documentation of measurements, staging, or detailed descriptions for the identified wounds. -No documentation of the Pressure Injuries on the resident's right heel, left heel, and left ankle identified on 10/13/24. Review of the resident's Physician's Orders dated 11/3/24 showed: -Paint area to left medial foot with betadine and cover with abdominal pad, wrap with kerlix and secure with tape every other day. -Paint area to right medial heel with betadine and cover with abdominal pad, wrap with kerlix and secure with tape every other day. -Heel protectors on bilateral feet at all times except for personal cares. --NOTE: the resident's right and left heels/ankles were identified to have pressure injuries on 10/13/24. These treatment orders were obtained 21 days after the wounds were initially identified. Review of the resident's skin evaluation form dated 11/3/24: -Right inner heel 6 cm x 8 cm x 0 cm, betadine and cover with abdominal pad, wrap with kerlix and secure with tape every other day. -Pressure reducing mattress and chair documented. -No documentation of staging, or detailed descriptions for the right heel. Review of the resident's Interdisciplinary Note dated 11/3/24 at 11:12 A.M. showed RN A documented: -Noted to have dark purple blisters to left medial foot 3.0 centimeters (cm) X 3.0 cm with no drainage. -Noted new area to right medial heel with purple blister measuring 6.0 cm x 8.0 cm. -Both periwound areas noted to have dark purple discoloration. -Center of both wounds are soft and boggy. -Treatment done: --Pain both areas with betadine, cover with abdominal pads and wrap with kerlix and secure with tape every other day. -All other treatments done as ordered. Review of the resident's wound assessment document dated 11/7/24 showed: -Right heel, Deep Tissue Injury (DTI - Deep tissue injury may be characterized by a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Presentation may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared to adjacent tissue), bruise. -Right outer foot, 2.0 cm x 1.0, bruise. -Right fifth digit, 1.5 cm x 1.5 cm, maceration. -Left lateral foot, 1.5 cm x 1.3, bruise. -Left ankle, 2 cm x 2 cm, bruised. -Left inner heel, 2.5 cm x 3.5 cm, bruised. Review of the resident's Physician's Orders dated 11/7/24 showed: -Consult wound team. -CBC (complete blood count) and CMP (comprehensive metabolic panel) next lab day. -House supplement 240 cubic centimeter (cc) by mouth three times a day for wound healing. Review of the resident's Interdisciplinary Note dated 11/7/24 at 11:15 A.M. showed NP documented: -Resident seen for general decline. -Developed pressure wound to bilateral heels, bilateral inner knees, bilateral hips and sacrum. -Start Remeron for appetite. -Continue topical wound care. -Offload pressure as much as possible and turn frequently. -LAL mattress. -Repeat labs and push fluids. --NOTE: No documentation by facility staff of a pressure injury to the resident's right hip. No documentation of treatment orders for the resident's right hip. Review of the resident's Interdisciplinary Note dated 11/7/24 at 1:36 P.M. showed Director of Nursing (DON) documented: -Continues to have skin issues. -Waiting for therapy orders to manage contracture issues. -New abductor wedge ordered for management of wounds on inside of knees. -LAL mattress and will get a roho cushion (an air-filled cushion that's designed to distribute pressure and support the body while sitting) for the resident. -Will be getting wound consult. Review of the resident's Interdisciplinary Note dated 11/7/24 at 2:25 P.M. showed ADON B documented: -Resident continues with multiple wounds to sacrum, coccyx, buttocks, bilateral inner knees, and area to lateral left and right feet. -NP here to see resident and new orders. -Wounds: right and left heels, right and left inner knees, right and left lateral feet, left foot 5th digit, left and right hips, left lower buttocks, left buttocks, left upper buttocks, sacrum, left upper buttocks, left lower buttocks, please see wound reporting log. No documentation a skin/wound assessment was completed on 11/14/24. The resident was discharged to the hospital on [DATE]. During an interview on 12/19/24 at 9:21 A.M. Family Member #3 said: -Upon admission on [DATE], to the facility the resident did not have any open wound on his/her body. -On 11/18/24, the resident's spouse received notification the resident was being sent to the hospital. -Upon arrival at the hospital the resident was assessed to have many open wounds to his/her body. -The infection from the wounds spread to the bone. -On 11/22/24 the resident was admitted to hospice (end of life). -On 11/27/24 the resident succumbed to the infection. During an interview on 1/13/25 at 11:46 A.M. the Assistant Director of Nursing (ADON) B said: -He/She is the ADON for the second floor and wound care nurse for the facility. -He/She was not tracking wounds until the end of October 2024. -There was no wound clinic or third party wound care providers. -He/She does weekly wound care assessments and charts those assessments on the following Monday. -He/She saw the resident for the first time on 10/28/24 when CNA A informed him/her of the resident having wounds. -The resident was on skilled services on the first floor from 10/2/24 through 10/21/24, when he/she was moved to the second floor for long-term care (LTC). -He/She felt the resident should have had skin assessments documented in the skilled nursing documentation while on skilled services. -He/She was concerned the floor nurses were not doing thorough assessments, specifically skin assessments. -When he/she noted the wounds on the resident, the NP was in the facility and assessed the wounds the same day. -He/She discussed his/her concerns about the resident's wounds with the DON. -He/She asked the physician for a diagnosis of unavoidable wounds due to the rate of wound development. -He/She was not aware of the resident having wounds prior to 10/28/24, although the resident's electronic medical record (EMR) Pressure Injury on 10/13/24. During an interview on 1/13/25 at 2:04 P.M. the DON said: -Confirmed the resident was on the first floor for skilled services from 10/2/24 through 10/21/24, then moved to the second floor for LTC. -Confirmed there was Pressure Injury documented by LPN A on 10/13/24, while the first measurement and initiation of treatment was documented on 10/28/24 by ADON B. -Expects the nurse to assess the resident when transferred from one floor to another floor and report to be given. During an interview on 1/13/25 at 2:31 P.M. LPN A said: -He/She was the admitting nurse for the resident on 10/2/24. -Due to the resident's contractures upon admission, he/she recommended a LAL mattress. -Confirmed he/she did the admission assessment on 10/3/24 and there no skin concerns at that time. -He/She documented new PI to heels and left ankle, which were not present the day of admission. -He/She reported to someone, but unable to state who he/she reported the PI's to or when, and did not document in the nursing notes. -Confirmed documenting the PI's to heels and left ankle on 10/13/24, 10/16/24, 10/17/24, and 10/21/24. -He/She did not notify the physician of the PI's observed and documented. -He/She did not notify the family of the PI's observed and documented. -He/She did not notify the nurse accepting the resident on the second floor for LTC on 10/21/24 of the PI's. -There were no treatment orders in place for PI or other skin concerns while the resident was on the first floor for skilled services from 10/13/24 through 10/21/24. -He/She was doing treatments consisting of wound cleanser and border foam, although there was no orders in place. He/She did not document these treatments. -The resident went without appropriate treatment for 15 days to open wounds. -When identifying a new wound, it should be documented, notify the wound nurse and put something protective in place. -Wounds should be measured, the physician should be notified, and family notified if they are not aware. -He/She did not know why he/she did not notify the physician or the family of the resident's wounds. -The physician would be notified by nursing when in the facility, including him/herself. During an interview on 1/14/25 at 12:13 P.M. the NP said: -He/She recalls seeing the resident on the second floor LTC for wounds. -When the resident was on the first floor skilled, he/she does not recall the resident having any wounds. -Recalled the resident having diagnoses including failure to thrive and congestive heart failure (CHF). -Recalled seeing the resident wearing booties while on the skilled unit. -There was no notification on 10/13/24 of wounds from the nursing staff. -Did not recall any wounds until after the resident was moved to the second floor LTC. -No documentation from the physician related to skin concerns or wounds while the resident was on skilled services on the first floor. -Expects nurses to document wounds, use standing orders when appropriate or call the provider if the standing orders do not meet the criteria. -Standing orders were available to al the nurses for skin tears, wounds or development of wounds, and other minor concerns, so it is not necessary to call. -If standing orders are used, the nurse should put the order on the Physician's Orders in the EMR and print for signature, which also serves as notification. -From the initial noted PI's on 10/13/24 through 10/28/24 there was no documentation of notification or treatment in the interdisciplinary notes in which timeframe he/she expected the wounds to monitored daily and not have been without treatment or interventions. -Review of the POS showed a treatment order on 10/25/24 for Silvadene, which was from the list of approved standing orders. -Review of the POS showed treatment orders from 11/3/24 were from the approved standing orders. -He/She did not recall the standing orders from 10/25/24 and 11/3/24 being printed to be signed. -When he/she saw the resident on 11/7/24 he/she ordered lab and appetite stimulant due to not eating likely contributing to wounds. -Confirmed there was no notification of the documented wounds from 10/13/24 through 10/21/24 while on the first floor for skilled services. -Confirmed there was no notification of any skin conditions or concerns from 10/21/24 through 10/28/24 after moving to the second floor for LTC. -The resident had documented open wounds from 10/13/24 until sent out of the facility on 11/18/24 and no antibiotics were initiated. -There was an increased risk for infection due to no treatment for open PI's from 10/13/24 through 10/28/24. -He/She expects to be notified when wounds are discovered to put treatments as well as preventative measures in place. -If he/she would have been notified sooner and interventions could be put in place sooner, however, the resident was prone to wounds due to comorbidities and overall decline. During an interview on 1/14/25 at 1:28 P.M. ADON B said: -He/She was doing wound care once weekly and the floor nurses were expected to do wound care the other six days per week. -If any changes noted, the nurses were to notify the ADONs. -He/She was not aware of standing orders. -The nurses should have called the doctor or NP. -On 10/28/24 he/she was notified by CNA A of the resident having wounds. -He/She believes the resident had six to eight wounds on 10/28/24. -On 10/28/24 he/she did not see any wounds to the heels, but did recall the resident had wounds to his/her knees and sacrum. -No treatment to open PI's for 15 days could have led to the resident's deterioration. During an interview on 1/14/25 at 2:02 P.M. CNA A said: -He/She took care of the resident at times throughout the resident's stay. -He/She notified ADON B about the resident's skin condition concerns on 10/28/24. -If new wounds are noticed during care he/she will report to the charge nurse, then the nurse will address the wound and tell the CNAs what to do. During an interview on 1/14/25 at 2:49 P.M. CNA B said: -He/She works on the second floor LTC. -Recalls the resident moving to the second floor LTC and was in bed most of the time. -He/She noticed wounds to the resident's knees, hip, buttocks and heels. -The resident came from the first floor with the wounds. -When he/she noticed the dressings to the buttocks and hip wounds, he/she thought the nurses were aware due to dressings in place. -When he/she observed new wounds to the toe and heel, he/she reported to his/her charge nurse, but could not recall what day it was. -When he/she finds new wounds, the first step is to notify the charge nurse, then the nurse will let him/her know what to do. -Every shower the residents should have a skin check, but at least once a week the nurse is supposed to come to the shower room and assess the resident's skin per the shower/skin check schedule. During an interview on 1/14/25 at 3:08 P.M. LPN D said: -He/She did not recall being the nurse who accepted the resident to the second floor LTC. -Review of the interdisciplinary notes showed he/she was the nurse on 10/21/24. -He/She could not recall when he/she assessed the resident after moving to the second floor LTC. -The resident had skin prep to the toes and boots on from day one of transferring to LTC. -He/She did not assess the resident, just followed the orders from being on skilled services. -Nobody particular said the resident had wounds. -Wounds were already known when the resident came to LTC and if the bandages came off he/she would replace them. -Could not recall how long the resident was on the LTC before orders for wound care were obtained. -When identifying new wounds the nurses are expected to document, give the information to wound nurse, contact the doctor and contact the family after talking to the doctor. During an interview on 1/15/25 at 5:15 P.M. LPN E said: -He/She took care of the resident while the resident was on the first floor for skilled services. -He/She recalled the resident was contracted but did not recall doing any kind of skin assessment during that time. -He/She thought the resident had a coccyx wound while on the skilled unit. -For new wounds he/she would use standing orders, measure the wound and document, contact the doctor and notify the DON. -He/She has never been told to notify the family unless sending the resident out of the facility. During an interview on 1/15/25 at 5:29 P.M. LPN F said: -He/She recalled taking care of the resident while on the skilled unit. -Did recall the resident developing wounds, but unable to recall any other details related to the wounds. -He/She did not know if anything was done for the wounds from 10/13/24 through 10/21/24. -For new wounds he/she would notify the wound nurse/ADON and also notify the doctor and family. -He/She would follow up on new wounds and check for wound care orders. -The nurses on night shift fill out a sheet and chart in the EMR for skin integrity assessments. During an interview on 1/15/25 at 5:40 P.M. Registered Nurse (RN) B said: -When new wounds are discovered the nurse was expected to call the doctor, family and DON and document in the EMR. -Treatment orders are to be put in the EMR to be performed as ordered. During an interview on 1/16/25 at 8:06 A.M. LPN C said: -He/She recalls taking care of the resident on the first floor for skilled care. -He/She did not recall the resident having wounds. -While on skilled services residents are to have a head to toe assessment to include a skin assessment. -He/She moved to the second floor LTC before the resident moved from the first floor. -He/She only saw the resident around three times while passing medications. -He/She thought the resident had been on the second floor for some time bef

Based on interview and record review, the facility failed to ensure care plans were reviewed, updated and/or revised for two sampled residents (Residents #1 and #3) out of four sampled residents. The facility census was 67 residents. Review of the facility Care Plans, Comprehensive Person-Centered dated 03/2022 showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident physical, psychosocial and functional needs is developed and implemented for each resident. -The comprehensive, person-centered care plan: --Includes measurable objectives and timeframe's. --Describes the services that to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. --Reflects currently recognized standards of practice for problem areas and conditions. -Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. Review of the facility Pressure Injury Risk assessment dated 3/2020 showed: -The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PI). -The purpose of injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed, and which will take time to modify. -Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be crated to address the modifiable risks for pressure injuries. Review of the facility Prevention of Pressure Injuries dated 4/2020 showed: -The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and intervention for specific risk factors. -Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. 1. Review of Resident #1's Face Sheet showed the resident was admitted on [DATE] with diagnoses including altered mental status, acute kidney failure, cellulitis of the lower limbs, and abnormalities of gait and mobility. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/8/24 showed the resident: -At risk for pressure ulcers. -Moisture Associated Skin Damage (MASD) identified. -Pressure reducing device for chair and bed. -Turn and repositioning program. -Nutrition and hydration intervention to manage skin problems. -Application of ointment and medications other than to feet. Review of the resident's undated Care Plan showed the resident: -Dietary needs are risk for weight loss, risk for swallowing problems related to oral status of edentulous (no teeth) as well as mechanical soft no added salt diet with thin liquids and two liter fluid restriction, 10/2/24. -At risk for pressure ulcers related to decrease in function mobility and incontinence, 10/2/24. --Skin would remain intact with no new open areas by pressure or friction for the following 90 days. ---Skin assessment Braden Scale weekly for four weeks upon admission/readmission then quarterly, 10/2/24. ---Use pressure reducing mattress, cushion when in bed, wheelchair and float heels when in bed as needed, 10/2/24. ---Low air loss mattress to be in place, 10/14/24. ---MASD to buttock, barrier cream after each incontinent episode and as needed, 10/14/24. ---Treatments as ordered,11/4/24. ---Turn and position as needed, 11/4/24. ---Dietician to evaluate and treat as needed, 11/4/24. ---Pillow between knees while in bed, 11/4/24. ---Staff to monitor for changes in mental status and functional abilities and report concerns to physician, 11/4/24. ---Resident is dependent for all cares, staff to anticipate needs, 11/4/24. -Had alteration in circulation resulting in edema, related to congestive heart failure. --Keep limb elevated as necessary to minimize edema, reduction in edema or not increased. ---Monitor skin condition daily to ensure no pressure or vascular wound present. *NOTE: the care plan did not directly address any current acquired pressure injuries. 2. Review of Resident #3's Face Sheet showed the resident was admitted on [DATE] with diagnoses including wedge compression fractures to the second and fifth lumbar, age related osteoporosis, and muscle weakness. Review of the resident's undated Care Plan showed it did not reflect the resident's facility acquired deep tissue injury (DTI) to his/her right heel. During an interview on 1/13/25 at 11:46 A.M. the Assistant Director of Nursing (ADON) B said he/she was responsible for ensuring care plans are in place for all residents on the second floor. 3. During an interview on 1/14/25 at 12:13 P.M. the Nurse Practitioner (NP) said he/she expected care plans to be updated to reflect the current pressure injuries to Resident #1 and Resident #3. During an interview on 1/14/25 at 1:28 P.M. ADON B said: -The ADONs were responsible for updating care plans. -Resident #1's care plan was not updated to reflect the pressure injuries, treatments and other interventions. -Resident #3's care plan was not updated to reflect the DTI to his/her right heel and should have been updated on 11/20/24. During an interview on 1/16/25 at 1:39 P.M. ADON A said: -He/She was responsible for ensuring care plans are in place for all residents on the first floor. -He/She would have updated the Resident #1's care plan if the wounds had been addressed before the resident was moved to the second floor for long-term care (LTC). During an interview on 1/22/25 at 11:25 A.M. the Director of Nursing (DON) said: -The ADONs were responsible for updating care plans for the residents. -He/She expected care plans for all residents to be updated with one week of any noted changes. During an interview on 1/22/25 at 11:45 A.M. the Administrator said he/she expected all care plans to be updated as needed, quarterly and per regulatory standard. MO00246983

Based on interview and record review, the facility failed to ensure a Registered Dietitian (RD) was in the facility to perform dietary assessments and to consult with dietary staff in the kitchen. This practice affected two sampled residents (Residents #1 and #2) who needed dietary assessments during the time span when there was no RD coming to the facility out of four sampled residents. The facility census was 67 residents. Review of the facility Dietitian policy dated 11/2022 showed: -A qualified dietitian or other clinically qualified nutrition professional will help oversee food and nutrition services provided to the residents. -The dietitian or nutrition professional may be a full time or part time consultant or an employee depending on the current requirements of the facility. --The requirements are based on: ---Assessments and care plans of resident nutritional needs. ---The over all facility assessment of the number, acuity and diagnoses of the resident population. -Our facility's dietitian is responsible for, but not necessarily limited to: --Assessing nutritional needs of residents. --Developing and evaluating regular and therapeutic diets. 1. Review of Resident #1's Face Sheet showed the resident was admitted on [DATE] with diagnoses including altered mental status, acute kidney failure, cellulitis of the lower limbs, and abnormalities of gait and mobility. Review of the resident's undated Care Plan showed the resident: -Dietary needs are risk for weight loss, risk for swallowing problems related to oral status of edentulous (no teeth) as well as mechanical soft no added salt diet with thin liquids and two liter fluid restriction, 10/2/24. ---Dietician to evaluate and treat as needed, 11/4/24. Review of Interdisciplinary Note dated 11/7/24 at 11:15 A.M. showed Nurse Practitioner (NP) documented: -Resident seen for general decline. -Weight loss of 21 pounds since admission at the beginning of October. -Developed pressure wound to his/her bilateral heels, bilateral inner knees, bilateral hips and sacrum. -Start Remeron (appetite stimulate) for appetite. Review of Interdisciplinary Note dated 11/7/24 at 1:36 P.M. showed Director of Nursing (DON) documented the resident triggered for weight loss in 30 days. **NOTE**The resident medical record showed no RD note and/or assessments. During an interview on 1/14/25 at 12:13 P.M. the NP said there should have been a Dietitian consult for failure to thrive, abnormal labs and newly acquired wounds, but there were issues with having a RD in facility. 2. Review of Resident #3's Face Sheet showed the resident was admitted on [DATE] with diagnoses including Type II Diabetes, hypomagnesemia, hyperkalemia and anemia. Review of the resident's undated Care Plan showed: -Resident was edentulous (had no teeth). -Resident will be provided diet per physician's order, regular NAS (no added salt), thin liquid diet with a two liter fluid restriction in place. -Educate on diet allowances and restrictions, need for compliance and ill effect of non-compliance, encourage and praise compliance. -Liberalized diet and mealtimes as possible for acceptance and blood glucose stabilization with safe parameters. -Offer bedtime nourishment per recommendations of RD or physician. **NOTE**The resident medical record showed no RD note and/or assessment. 3. During an interview on 1/22/25 at 10:17 A.M. the Director of Nursing (DON) said: -They had not had a RD for a while, although there was one onsite on 1/13/25. -Prior to the recent RD, there had been several weeks where there was not a RD consistently. -He/She was unable to provide any RD notes/consultations for Resident #1 and Resident #3. -He/She expected a RD consult any time something occurs then to follow RD recommendations for the resident. During an interview on 1/22/25 at 11:01 A.M. the Administrator said: -There had been issues with the company in keeping a RD in the facility. -Confirmed with invoices there had been no RD in the facility from 11/3/24 through 12/6/24. -Upon his/her hire in 10/24 there were challenges with having a RD in the facility consistently. MO00246983

Based on observation and interview, the facility failed to maintain the ceiling tiles, light fixtures, and sprinkler heads, which were over the food preparation table and the dishwasher area, free of a dust buildup. This practice potentially affected all residents who ate food prepared in the kitchen. The facility census was 58 residents. 1. Observation on 9/25/23 at 9:42 A.M., showed a buildup of dust on the sprinkler head on the ceiling close to the food preparation area. Observation on 9/25/23 at 9:43 A.M., showed a dust buildup on the ceiling tiles and on the light fixtures over the food preparation table. Observation on 9/25/23 at 9:47 A.M., showed a buildup on the ceiling tiles and on the light fixtures over the dishwasher area. During an interview on 9/25/23 at 1:01 P.M., the Director of Dining Services said there was a utility person that cleaned the ceiling tiles and light fixtures every month. During an interview on 9/25/23 at 1:03 P.M. the Dietary Utility Person said he/she had not yet cleaned the ceiling tiles and light fixtures over the dishwasher area.

Based on observation, interview, and record review, the facility failed to ensure they followed infection control practices by performing hand hygiene between glove changes for three sampled residents (Residents #13, #44, and #19) out of 15 sampled residents. The facility census was 58 residents. Review of the facility's policy, titled Hand washing/Hand Hygiene dated August 2019, showed: -Staff were to perform hand hygiene with soap and water or an alcohol-based hand rub before and after coming on duty, before and after direct contact with residents, after contact with a resident's intact skin, and after removing gloves. 1. Review of Resident #13's Admission Face Sheet showed he/she had the following diagnoses: -Kidney failure (one or both of your kidneys no longer function well on their own.). -Neuromuscular dysfunction of bladder (or neurogenic bladder, is a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). Review of the resident's Care Plan dated 5/1/23 showed: -The resident required assistance of one staff member for toileting. -The resident frequently refused to let staff assist him/her in the bathroom. -The resident was readmitted with an indwelling catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) related to urine retention, neurogenic bladder and infection in urine. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 8/13/23, showed he/she: -Was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. -He/she was able to understand others and make his/her needs known. -Required limited assistance of one staff member with personal cares. -Had an indwelling catheter. During an interview on 9/25/23 at 9:54 A.M., the resident said he/she was picky on who he/she would let assist with his/her personal cares. Observation on 9/25/23 at 9:54 A.M. showed there were no lingering odors noted in the resident's room. During an interview on 9/28/23 at 9:13 A.M., the resident said: -The day shift staff did not normally provide care to his/her private areas. -The resident did most of his/her own care. During an interview on 9/28/23 at 9:17 A.M., Certified Nursing Assistant (CNA) F said the resident did most of his/her own front private area care, but if he/she had a bowel movement then staff would assist the resident. Observation on 9/28/23 at 10:10 A.M., of the resident's peri care showed: -Registered Nurse (RN) D, CNA E and CNA F provided the care. -Staff washed their hands when they entered the resident's room and applied gloves to their hands. -The resident was able to transfer himself/herself to bed with stand by assist by the CNA's. -The resident required assistance with his/her legs being swung onto the bed to lay down. -RN D provided the resident's front genitalia care with gloved hands, used one wipe at a time for perineal peri care. -RN D, then prepared to remove the indwelling catheter by deflating the catheter balloon. -He/she withdrew 12 cubic centimeters (cc) of normal saline from catheter balloon (is inflated to hold indwelling catheter in place) with a clean empty syringe. -The indwelling catheter was removed and was intact. -RN D removed his/her gloves and sanitized his/her hands. -CNA F and CNA E assisted the resident to his/her right side to continue to provide personal peri care. -CNA F and CNA E had finished the resident's care, then removed their gloves and placed new gloves on their hands without sanitizing their hands. -RN D prepped the resident for a new indwelling catheter. -He/she had opened up the sterile catheter supplies and laid them on a clean barrier. -He/she sanitized his/her hands and placed new gloves on his/her hands. -RN D applied the lubricant to the tip of the new catheter and placed back in clean field container. He/she did not touch tip of the catheter. -RN D then removed his/her gloves, sanitized his/her hands and obtained sterile gloves from the package and betadine swabs. -RN D opened the sterile glove package and placed the sterile gloves on his/her hands, no issue noted. -RN D used his/her left hand as his/her dirty hand, held the genital area open and the right hand was his/her clean hand and proceeded to insert the new 16 French (FR a measure of the outer diameter of a catheter) indwelling catheter. -He/she inserted the indwelling catheter into the bladder and inflated the balloon with 5 cc of normal saline. -Clear yellow urine returned with a chunk of reddish brown sediment floating in the tubing. -RN D completed care then removed his/her gloves and washed his/her hands. -CNA's assisted the resident to his/her wheelchair and placed a new brief on the resident. -CNA F and CNA E removed their gloves and washed their hands before leaving room. During an interview on 9/29/23 at 11:36 A.M., CNA F said: -Should wash hands upon entering and exiting the residents room. -Wash or sanitize hands when moving from a dirty to a clean process and between each glove change. -He/she could not remember if he/she had sanitized his/her hands after he/she removed his/her gloves on 9/28/23. During an interview on 9/29/23 at 10:43 A.M., CNA E said: -Should wash hands before and after resident care. -He/she would sanitize his/her hands between each glove change. During interview on 9/29/23 at 1:00 P.M., RN C said: -Would expect staff to wash hands upon entering and exiting room. -Would expect staff to wash or sanitize hands when moving from a dirty to a clean process. -Should sanitize or wash hand between glove changes. During an interview on 9/29/231:58 P.M., Director of Nursing (DON) said: -He/she would expect hand hygiene when entering and exiting a resident room, before and after resident care, and when going from a dirty to a clean task. -He/she would expect hand hygiene to be performed in between each glove change. -During staff orientation they discussed handwashing. 21003 2. Review of Resident #44's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including shortness of breath, respiratory failure, chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure, kidney disease, fluid overload and cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). Review of the resident's annual MDS dated [DATE], showed the resident: -Was alert and oriented. -Needed extensive assistance with bathing and hygiene, limited assistance with dressing and toileting. -Needed supervision with ambulation and was able to mobilize in a wheelchair. -Had no skin problems or other wounds. -Received ointment treatments and application of dressings to his/her feet and other areas (other than feet). Observation on 9/25/23 at 9:45 A.M., showed the resident was sitting in his/her wheelchair with oxygen on. He/she had a wound on his/her right lower leg (shin area) that looked like a macerated (when the skin is exposed to moisture for extended periods) and excoriated (wearing off of the skin) skin area that was 5 inches long by 4 inches wide with redness. There was no dressing on his/her right or left leg at this time. The resident's left shin and calf looked like intact skin that was red, dry and flaky. During an interview on 9/25/23 at 9:45 A.M., the resident said: -He/she had edema on both of his/her legs that began to leak. -The nursing staff were able to heal his/her left leg, but were still working on the right leg. -He/she was waiting for the nurse to come in to complete his/her treatments and to put the dressings on. -After his/her legs were treated they re-wrap it. Observation on 9/27/23 at 10:40 A.M., showed the resident was sitting in his/her recliner with his/her legs elevated. Licensed Practical Nurse (LPN) C/Wound Care Nurse entered the resident's room and brought a container with wound supplies inside and placed it on the seat of the resident's wheelchair. LPN C washed his/her hands, turning off the faucet with his/her elbow. LPN C did the following: -He/She applied gloves then removed the tubigrip stocking from both of the resident's legs. -He/She discarded his/her gloves and then placed a barrier under both of the resident's legs. -He/She then, without using an alcohol wipe to clean the scissors, used a pair of scissors to cut the dressing off of the resident's left leg, then right leg. -He/She discarded the barrier, soiled dressings and gloves. -He/She re-gloved and using normal saline and a 4x4 gauze, cleaned the resident's left leg. There was a small red area to the side of the resident's upper calf. -He/She then discarded his/her gloves and the 4x4 gauze, and without washing or sanitizing his/her hands, he/she re-gloved, opened a package containing xerofoam and a new package of gauze wrap, placed the xerofoam on the resident's calf and wrapped it with gauze. -He/She then discarded his/her gloves and washed his/her hands. -He/She gloved then placed a clean barrier under the resident's right leg, removed and discarded the xerofoam dressing from the resident's right leg. -The resident's right leg was red and macerated on the middle front femur and his/her skin was shedding with beefy red underlying skin. -LPN C removed his/her gloves and discarded them. -After applying new gloves he/she then used normal saline and 4x4 gauze, cleaned the resident's skin. -He/She discarded the gauze and his/her gloves, and without washing or sanitizing his/her hands, he/she re-gloved, opened three packages of xerofoam, placed them on the residents wound, then removed and discarded his/her gloves. -He/She then discarded his/her gloves and washed his/her hands. -He/She gloved, opened a new gauze and wrapped the resident's right leg, discarded his/her gloves. -Without wiping the scissors with an alcohol wipe, he/she cut two tubigrip stockings then gloved, taped the gauze on both of the resident's legs and put the tubigrips on both legs. -He/She pulled the trash, de-gloved and discarded them then washed his/her hands. During an interview on 9/27/23 at 11:09 A.M., LPN C said: -He/She wiped down the scissors after every use. -He/She should have used an alcohol wipe to wipe the scissors after he/she used them to cut off the resident's dressing. -He/she would normally have hand sanitizer with him/her but forgot to get it during this treatment. -He/She knew he/she forgot to wash his/her hands after cleaning the resident's wound because he/she was nervous. -He/She was supposed to wash or sanitize his/her hands with every glove change and after every dirty task. 45623 3. Review of Resident #19's face sheet showed he/she was admitted with a diagnosis of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Review of the resident's Quarterly MDS dated [DATE], showed: -The resident had a severe cognitive deficiency. -The resident was totally dependent on staff for personal hygiene. -The resident had one Stage III Pressure Ulcer (a full thickness wound with tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) Review of the resident's undated care plan showed staff documented the resident had a Stage III Pressure Ulcer on his/her coccyx (a small triangular bone at the base of the spinal column). Review of the resident's Physician's Orders, dated September 2023, showed the physician ordered staff to clean the wound daily with wound cleaner, apply medihoney (medical honey), cover wound bed with calcium alginate (a type of dressing to promote tissue rebuilding), and to apply a bordered foam dressing daily. During an interview on 9/27/23 at 11:09 A.M., LPN C said he/she wiped down the scissors after every use. Observation on 9/27/23 at 12:59 P.M. showed: -CNA C and LPN C entered the resident's room to perform wound care. -CNA C and LPN C washed their hands, put on gloves, and got supplies ready. -LPN C removed the resident's wound dressing. -LPN C, without removing soiled gloves, sprayed wound cleanser on the wound and used gauze to clean away debris. -LPN C then removed his/her gloves, washed his/her hands, and put on new gloves. -LPN C opened the rest of the supplies and applied the medihoney and calcium alginate to the resident's wound. -LPN C removed his/her gloves, and without hand hygiene, put on new gloves. -LPN C then placed the bordered foam dressing to the resident. -LPN C removed his/her gloves and placed the used, but not cleaned, scissors in his/her pocket. 4. During an interview on 9/27/23 at 12:59 P.M., LPN C said staff were to perform hand hygiene after every glove change. During an interview on 9/28/23 at 1:22 P.M., LPN A said staff were to perform hand hygiene after every glove removal. During an interview on 9/28/23 at 2:16 P.M., RN A said staff were to perform hand hygiene after every glove removal. During an interview on 9/29/23 at 1:57 P.M., the DON said: -Staff were to perform hand hygiene upon entering a room, leaving a room, between glove changes, and when going from a dirty to clean task. -He/she expected staff to perform hand hygiene when gloves were removed even if they had just put them on and hadn't touched anything. -The scissors should be cleansed before and after each use.

Based on observation and interview, the facility failed to do or maintain the beauty shop ceiling vent free from a dust buildup; to maintain the floor in the 1st floor east kitchenette free from a buildup of rust and water; maintain the restroom ceiling vent in resident room [ROOM NUMBER] free from a buildup of dust; to maintain resident rooms [ROOM NUMBERS] free from a buildup of cobwebs; to maintain the floor in the 2nd floor west kitchenette free from a a buildup of debris; failed to maintain hot water temperatures at or close to 105 F (degrees Fahrenheit) in resident rooms 123, 114, 212, 223 and 216 for two days of the survey. This practice potentially affected at least 35 residents who resided in or used those areas. The facility census was 58 residents. 1. Observation on 9/26/23 with the Director of Facility Operations showed: -At 1:55 P.M., there was a buildup of dust inside the ceiling vent in the beauty shop. -At 2:16 P.M., there was a buildup of water and rust behind the ice machine in the 1st floor East kitchenette. 2. Observation on 9/27/23 with the Director of Facility Operations showed: -At 8:40 A.M., there was a buildup of cobwebs between the bed and the wall in resident room [ROOM NUMBER]. -At 9:15 A.M., there was a buildup of dust on the table top fan in resident room [ROOM NUMBER]. -At 10:00 A.M., there was a buildup of dust inside the vent in resident room [ROOM NUMBER]. -At 10:27 A.M., there was a buildup of cobwebs in the corner between the bed and the wall in resident room [ROOM NUMBER]. -At 10:33 A.M., there was a buildup of cobwebs in the corner between the bed and the wall in resident room [ROOM NUMBER]. -At 11:06 A.M., there was a buildup of debris behind the refrigerator in the 2nd floor west kitchenette. During an interview on 9/27/23 at 10:00 A.M., the Director of Facility Operations said he/she did not know the last time the ceiling vent in resident room [ROOM NUMBER] was cleaned. During an interview on 9/28/23 at 1:05 P.M. the Assistant Housekeeping Supervisor said the following: -The housekeepers clean the kitchenettes after breakfast and the dietary staff were to clean the kitchenettes after the lunch and dinner meals. -A final decision had not been made as to which department, whether housekeeping or the dietary department was to clean the serving area of the kitchenettes. -Those duties needed to be discussed between the Assistant Dining Service Director and the Housekeeping Supervisor. -The cobwebs were something the housekeepers should look for. -The bed in resident room [ROOM NUMBER], needed to be pulled out to get at the cobwebs from a better angle. -The fan in resident room [ROOM NUMBER] should have been dusted because he/she saw the dust and expected the housekeepers to clean the fan once they saw the dust on the fan. During an interview on 9/29/23 at 2:42 P.M. the Administrator said he/she would expect the housekeeping staff to maintain the rooms free of cobwebs. 3. Observation on 9/28/23, of the resident room hot water temperatures showed the following temperatures. **Note: water temperatures were taken after letting the faucet run for two minutes or more. -At 8:38 A.M., the hot water temperature in resident room [ROOM NUMBER], was 89.4 F. -At 8:41 A.M., the hot water temperature in resident room [ROOM NUMBER], was 99.0 F. -At 9:14 A.M., the hot water temperature in resident room [ROOM NUMBER], was 92.8 F. -At 9:35 A.M., the hot water temperature in resident room [ROOM NUMBER], was 89.7 F. -At 9:39 A.M., the hot water temperature in resident room [ROOM NUMBER], was 94.4 F. 4. Observation on 9/29/23 of the resident room hot water temperatures , showed the following temperatures. -At 8:43 A.M., the hot water temperature in resident room [ROOM NUMBER], was 96.6 F. -At 8:44 A.M., the hot water temperature in resident room [ROOM NUMBER], was 90.5 F. -At 8:47 A.M., the hot water temperature in resident room [ROOM NUMBER], was 94.0 F. -At 8:54 A.M., the hot water temperature in resident room [ROOM NUMBER], was 96.4 F. -At 9:14 A.M., the hot water temperature in resident room [ROOM NUMBER], was 100.0 F. Observation on 9/29/23 at 8:59 A.M., with the Director of Facility Operations showed the following: -The hot water storage tank in the mechanical room was set at a temperature of 133.5 F. -The hot water heater was set to send out the water at 131 F. During an interview on 9/29/23 at 9:07 A.M., the Director of Facility Operations said: -The current mixing valve (a device that combines two or more fluid streams at different temperatures to produce a mixed stream at a desired temperature. Mixing valves are commonly used in plumbing systems to regulate water temperature for showers, baths) was preventing the water temperatures in some rooms from getting to at least 105 F. - Each faucet in each room had a mixing valve and some of those faucets needed to be changed.

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was properly stored for four sampled residents (Resident #44, #10, #35, and #20), and failed to care plan the use of respiratory equipment for three sampled residents (Resident #44, #35, and #20) out of 15 sampled residents. The facility census was 58 residents. Review of the facility's policy, titled Continuous Positive Airway Pressure (CPAP-a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing)/Bilevel Positive Airway Pressure (BiPap-a type of device that helps with breathing) Support dated March 2015, showed: -Staff were to clean Cpap and BiPap masks with warm, soapy water for five minutes, rinse with warm water, and allow it to air dry. A copy of the facility's respiratory equipment storage policy was not received at time of exit. Review of the facility's policy, titled Goals and Objectives, Care Plans dated April 2009, showed: -Staff were to enter goals and objectives on each resident's care plan so that all disciplines had access to such information and were able to report whether or not the desired outcomes were achieved. 1. Review of Resident #44's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including shortness of breath, respiratory failure, chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure. Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 9/21/23, showed the resident: -Was alert and oriented. -Needed extensive assistance with bathing and hygiene, limited assistance with dressing and toileting. -Needed supervision with ambulation and was able to mobilize in a wheelchair. -Used oxygen. Review of the resident's Physician's Order Sheet (POS) dated 9/2023, showed physician's orders for: -Oxygen at 2 liters per minute to keep oxygen saturation levels between 90 and 93 percent due to hypoxia (a deficiency of oxygen reaching the tissues). -Ipratropium 3 milligrams (mg), inhalation every 4 hours as needed for wheezing. Observation on 9/27/23 at 9:00 A.M., showed the resident was sitting in his/her recliner, dressed for the weather. He/She was wearing his/her oxygen nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). There was a breathing treatment machine sitting next to his/her bed on the dresser. The face mask was uncovered and there was no bag beside it on the dresser. During an interview on 9/27/23 at 9:00 A.M. the resident said he/she was having a good day. Observation and interview on 9/27/23 at 1:22 P.M., showed the resident had just come from the bathroom. He/she was not wearing his/her oxygen. He/she transferred himself/herself into his/her recliner. The resident's nasal cannula and tubing were coiled on top of his/her tray table along with other personal belongings. The resident's breathing treatment machine was sitting on the dresser next to his/her bed and the face mask was still sitting beside the machine uncovered. There were no bags observed to store the face mask or cannula. The resident said: -The nurse came in to check his/her oxygen level earlier today and told him/her that since his/her oxygen level was at 100, he/she did not need to wear oxygen and the nurse told him/her to remove the nasal cannula. -He/she did not receive a bag or anything to place the nasal cannula and tubing in to prevent contamination. -He/she only used his/her breathing treatment machine when he/she had shortness of breath or as needed. -His/her breathing treatment face mask was always stored on top of his/her dresser. -He/she had never placed the face mask in a bag or storage container to prevent contamination. -Facility staff had not given him/her anything to store his/her face mask or oxygen tubing in. Observation on 9/28/23 at 9:35 A.M., the resident was in his/her wheelchair dressed for the weather, mobilizing down the hallway. In his/her room showed the resident's oxygen concentrator was on and running. There was a plastic bag attached to the concentrator (a medical device that gives you extra oxygen). His/her nasal cannula and tubing were laying on the floor beside his/her recliner, uncovered. On the dresser was his/her breathing treatment machine and beside it was the face mask that was uncovered. During an interview on 9/28/23 at 9:45 A.M., Certified Nursing Assistant (CNA) D said: -Nasal cannulas, face masks and other oxygen equipment was supposed to be stored in plastic bags when not in use. -They could obtain the plastic bags if there were none in the resident's room. -The nursing aides were supposed to check to ensure the bags were available and the nasal cannulas and face masks were stored properly every time they went to the resident's room to provide care. -If they saw a nasal cannula, face mask or oxygen tubing on the floor, they would have to notify the nurse who would give them new ones to replace the contaminated ones with. During an interview on 9/28/23 at 10:00 A.M., Licensed Practical Nurse (LPN) F said: -All face masks, nasal cannulas and oxygen tubing were supposed to be stored in a plastic bag when not in use and they are changed out every week on Sunday. -All nursing staff was responsible for making rounds and checking to see that the oxygen equipment was stored properly. -If a resident did not have storage bags, the nursing staff could provide it and were responsible for ensuring the bags were available for the resident to put their oxygen equipment in. During an interview on 9/29/23 at 1:57 P.M., the Director of Nursing (DON) said: -Oxygen nasal cannulas and facemasks should be in a bag hanging on the oxygen concentrator. -Face masks should be rinsed out and left on a towel to dry. -They should educate residents who are able to remove their own oxygen masks, nasal cannulas on storage and they do try to educate the residents on oxygen storage. -The storage bag should be labeled and dated and the date should also be on the nasal cannula. -The nursing staff should change oxygen nasal cannulas and face masks it if they go into the room and see it on the floor-they should get another one and put it in a bag. -All nursing staff have access to the plastic bags to provide for storage of the nasal cannulas and oxygen equipment. -Resident #44 removed his/her nasal cannula and would drop it on the floor regularly. 33409 2. Review of Resident #10 Admission Face Sheet showed he/she had diagnosis of COPD. Review of the resident's Medication Administration Record (MAR) dated 8/2023 showed: -Nursing staff were to cleanse oxygen (O2) concentrator filter and change O2 tubing every week. --By nursing initials O2 tubing had been changed 4 out 4 weeks. Review of the resident's POS dated 9/2023 showed: -He/she had a physician order for oxygen to be on at a rate for 4 liters per nasal cannula to keep oxygen saturation (the fraction of the hemoglobin molecules in a blood sample that are saturated with oxygen at a given partial pressure of oxygen) above 90%, monitor every shift as needed for chronic respiratory failure with hypoxia. (Ordered on 6/12/23). -Cleanse oxygen concentrator filter and change tubing every week. Review of the resident's MAR dated 9/2023 showed: -Nursing staff were to cleanse oxygen concentrator filter and change O2 tubing every week. --By nursing initials O2 tubing had been changed 3 out 4 weeks. Last dated changed was on 9/24/23. Observation on 9/25/23 at 10:57 A.M., of the resident's room showed: -Oxygen nasal cannula and tubing laid on top of his/her O2 concentrator. -Had a plastic bag on concentrator with room number and no date. Observation on 9/25/23 at 12:43 P.M., showed the resident's O2 tubing remained uncovered on top of the O2 concentrator. During an interview on 9/26/23 at 7:53 A.M., CNA F said: -The resident did most of his/her own cares and he/she was able to remove his/her nasal cannula. -The resident did not normally use the O2 during the day time. Observation on 9/27/23 at 9:25 A.M., showed: -His/her O2 tubing was placed in the plastic bag taped to concentrator. -The plastic bag was labeled with resident's room number. -Did not have a date on the bag or the tubing. During an interview on 9/27/23 at 9:25 A.M. the resident said he/she did not use oxygen very often, only as needed. Observation on 9/28/23 at 9:31 A.M. showed: -The resident's O2 tubing was placed in an undated plastic bag. -The bag had the resident room number on the bag. During an interview on 9/29/23 at 10:43 A.M., CNA D said: -The resident O2 tubing should be stored in plastic bag when not in use. -The bag should be dated with the date when tubing was changed. During an interview on 9/29/23 at 1:57 P.M., the DON said: -Nursing staff were responsible for changing the O2 tubing, the bag and water weekly. -The resident removed his/her own O2 nasal cannula and he/she mainly used oxygen at night. -All staff should be checking to make sure the O2 tubing was stored in plastic bags when not in use. 45623 3. Review of Resident #20's face sheet showed he/she was admitted with Obstructive Sleep Apnea (while sleeping, the muscles in the back of the throat relax too much to allow for proper breathing). Review of the resident's Admission MDS dated [DATE], showed: -The resident was cognitively intact. -The resident used a Continuous Positive Airway Pressure (Cpap-a machine that is used to deliver a set pressure to the airways that is maintained throughout the respiratory cycle, both breathing in and out). -The resident required extensive assistance with bed mobility, dressing, and personal hygiene. Review of the resident's undated care plan showed staff had not entered any goals or interventions related to the use of a cpap machine. Observation on 9/25/23 at 11:57 A.M. showed: -The resident's cpap mask was lying on the cpap machine, uncovered and undated. -No bag was present for storage of the cpap mask. Observation on 9/26/23 at 9:16 A.M. showed: -Registered Nurse (RN) A and CNA C entered the resident's room and assisted the resident to get dressed. -The resident's cpap mask was lying on the resident's bedside table uncovered and undated. -After dressing the resident, CNA C made the resident's bed and placed the cpap mask on the bedding uncovered. During an interview on 9/26/23 at 10:11 A.M., the resident said: -He/she put on and took off his/her own cpap mask. -Staff had never told him/her that the cpap mask was to be covered when stored. Observation on 9/27/23 at 8:59 A.M. showed the resident's cpap mask was lying on the resident's bedside table, uncovered and undated. 4. Review of Resident #35's face sheet showed he/she was admitted with COPD. Review of the resident's undated care plan showed staff addressed the resident's oxygen use. Review of the resident's Admission MDS, dated [DATE], showed: -The resident was cognitively intact. -The resident used oxygen. -The resident required extensive assistance for transferring and dressing. Observation on 9/26/23 at 8:33 A.M. showed the nasal cannula attached to the oxygen concentrator was lying on the floor. Observation on 9/27/23 at 9:13 A.M. showed: -CNA E was in the resident's room making the bed. -The nasal cannula, attached to the oxygen concentrator, was lying on the floor. -CNA E left the resident's room while the nasal cannula remained on the floor. Observation on 9/29/23 at 9:32 A.M. showed the nasal cannula, attached to the oxygen concentrator, was lying on the floor. 5. During an interview on 9/28/23 at 11:54 A.M., CNA A said: -Nasal cannulas and cpap masks were to be stored in a plastic bag on the corresponding machine. -Staff were to educate residents that removed their own nasal cannula and/or cpap mask on proper storage. -If he/she found a cpap mask that was not covered, he/she would get a bag and place it in the bag. -If he/she found a nasal cannula not covered, he/she would throw it away and get a new one. -Oxygen and cpap use were to be care planned. During an interview on 9/28/23 at 1:06 P.M., CNA B said: -Staff were to store all cpap masks and nasal cannulas in a plastic bag when not in use. -If he/she saw a nasal cannula or cpap mask not stored properly, he/she would replace it. -Staff were not to reuse the nasal cannula or cpap mask if found stored improperly because staff would not know if it had been contaminated. -Staff educated residents on storage of nasal cannulas and cpap masks if they were able to remove them themselves. -Oxygen and cpap use were to be care planned. During an interview on 9/28/23 at 1:22 p.m., LPN A said: -Staff were to store cpap masks and nasal cannulas in a plastic bag when not in use. -Staff educated residents on storage of nasal cannulas and cpap masks if they were able to remove them themselves. -He/she would replace any nasal cannula or cpap mask that he/she found stored improperly. -Oxygen and cpap use were to be care planned. During an interview on 9/28/23 at 1:26 P.M., RN A said: -Staff could lay nasal cannulas and cpap masks on the resident's bedside table when not in use as long as it wasn't on the floor. -He/she did not expect oxygen and cpap use to be care planned. During an interview on 9/28/23 at 2:39 P.M., LPN B said: -Nasal cannulas and cpap masks were to be stored in a bag when not in use. -He/she would replace a nasal cannula or cpap mask found stored improperly. -Oxygen and cpap use were to be care planned. During an interview on 9/29/23 at 1:57 P.M., the DON said: -Staff were to place nasal cannulas and cpap masks in a plastic bag when not in use. -Staff educated residents who removed their own cpap mask and/or nasal cannula on proper storage of the equipment. -All nasal cannulas and cpap masks were to be dated, as well as the bag they were stored in. -All staff were responsible for ensuring supplies were stored properly. -Staff were to replace any nasal cannula or cpap mask that was found on the floor. -He/she did not expect oxygen or cpap use to be included in the care plan.

Based on observation, interview and record review, the facility failed to document a comprehensive assessment for a suprapubic (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) stoma (surgical opening) site weekly for two sampled residents (Resident #23 and #35); to document a suprapubic catheter change on 8/1/23 and on 9/1/23 for one sample resident (Resident #23); to ensure a dignity bag (a bag that the drainage bag is placed into to prevent contamination and other people seeing the urine) was placed for three sampled residents (Resident #19, #4, and #35); to complete physician's ordered cares to the catheter for three sampled residents (Resident #19, #4, and #35); to ensure the drainage bag was managed appropriately to prevent infection for two sampled residents (Resident #35 and #4); to ensure a comprehensive care plan included the type of catheter, location for one sampled resident (Resident #23); and to follow physician's orders regarding catheter size for three sampled residents (Resident #35, #19, and #4) out of 15 sampled residents. The facility census of 58 residents. Review of the facility suprapubic catheter policy revised on 10/2010 showed: -The purpose of this procedure was to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. -Review the resident care plan to assess for any special need for the resident. -The urinary drainage bag must be held or positioned lower than the bladder at all times in the tubing and drainage bag from flowing back into the urinary bladder. -Wash around the catheter site with soap and water. (Note: if the resident drainage sponge around the stoma site, remove the sponge before washing with soap and water.) Wash outer part of the catheter tube with soap and water. -Empty wash basin and then remove gloves and wash and dry hands thoroughly. -Staff should document the following into the resident's medical record: --The date and time the procedure was performed. --The name and title of the individual(s) who performed the procedure. --All assessment data obtained during the procedure. --How the resident tolerated the procedure. --If the resident refused the procedure, the reason(s) why and the interventions taken. --Results of skin assessment around the stoma site. --Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. --Any problems or complaints made by the resident during the procedure. --The signature and title of the person recording the data. -Notify the nurse supervisor if resident refused the procedure. -Notify the residents physician with any skin abnormalities in the skin assessment or characters in urine. -To change or remove supra pubic catheter verify physicians orders -Following information should be recorded in the resident's medical record for changing of supra pubic catheter: --The date and time the procedure was performed. --The name and title of the individual(s) who performed the procedure. --All assessment data obtained during the procedure. --How the resident tolerated the procedure. --If the resident refused the procedure, the reason(s) why and the intervention taken. --The type of tube removed. --The balloon size, the catheter size, and composition of replacement tube. --Method of stabilization. --Return of urine flow. --The signature and title of the person recording the data. -Notify the supervisor if the resident refused the procedure. -Notify the physician if resistance was met while replacing tube or if urine was cloudy, bloody, had a foul odor, etc. -Report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #23's Face Sheet showed he/she was admitted with following diagnoses: -Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system). -Neurogenic Bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). Review of the resident's Urinary/Indwelling/Foley Catheter (a hollow tube that was inserted into the bladder to drain urine) care plan dated 5/17/23 showed: -The resident required indwelling urinary catheter care related to a neurogenic bladder. -The resident would have catheter care managed appropriately as evidenced by not exhibiting signs of infection or trauma. -Provide catheter care every shift and as needed to be completed by licensed nursing staff and Certified Nursing Assistants (CNA's). -Use a 16 French (FR a measure of the outer diameter of a catheter), Foley catheter per physician order. -His/her catheter drainage bag should be changed per physician order. -Do not allow the resident's catheter drainage tubing or any part of the drainage system to touch the floor. -Position the resident's catheter drainage bag below his/her bladder. -NOTE: No indication of the location and type of indwelling catheter (the resident had a suprapubic catheter). -NOTE: No specific intervention to monitor the suprapubic site for infections. -NOTE: No detailed instructions on how to care for and clean the suprapubic stoma site. Review of the resident's Medication Administration Record (MAR) dated 8/23 showed: -A Physician order for the resident's monthly suprapubic catheter change: 16 FR/10 cubic centimeter (cc) balloon catheter, to be changed on first of each month. --On 8/1/23 there was no documentation that indicated the suprapubic catheter had been changed during night shift. Review of the resident's medical record dated 8/1/23 showed there was no documentation in a nursing note related to changing the resident's suprapubic catheter or assessment of the stoma site on that date. Review of the resident's nursing note dated 8/14/23 at 3:51 P.M. as a late entry showed: -The Registered Nurse (RN) went to provide suprapubic catheter care and noted brown drainage around suprapubic insertion site. -The RN cleansed the site with normal saline and a gauze pad (open weave of gauze helps absorb fluid). -The RN noted reddened skin from where the drainage was and skin around catheter was bleeding. -There was an odor to the site. -The RN applied a new drain sponge. -The resident denied pain or discomfort. Able to make his/her need known. Review of the resident's nurse's note dated 8/15/23 at 1:16 P.M. showed the resident was seen by the Nurse Practitioner (NP) and the following orders were obtained: -Fluid culture from the suprapubic catheter site. -Mupirocin 2% topical ointment (an antibiotic. It works by stopping the growth of certain bacteria) was started to suprapubic site daily. -NOTE: There was no further documentation related to the treatment of potential infection at suprapubic site and progress or if healed. Review of the resident's MAR dated 8/16/23 showed: -New physician order for Mupirocin 2% topical ointment apply daily to suprapubic site for seven days prophylactic treatment to suprapubic site (ordered on 8/15/23) --Treatment was not documented as completed one out seven days ordered. Review of the resident's monthly Nursing Summary form dated 8/17/23 showed: -Check box under skin condition fair. -Check box under bladder had Foley catheter size 16 FR, urine color yellow and the resident was treated for UTI within the last 30 days. -Had no documentation or place to document the monitoring the resident suprapubic site. Review of the resident's weekly Skin assessment dated [DATE] showed: -No documentation related to the assessment of the suprapubic site. -The suprapubic stoma site location was not indicated on the body demographic. -No documentation under the nursing note section. Review of the resident's Physician Order Sheet (POS) dated 9/2023 showed: -The resident had a physician's order for a 16 FR Foley catheter, was to have Foley catheter care every shift and to empty catheter drainage bag every shift for urinary tract infection, (last dose 9/27/23) initial order dated 5/12/23. -Had a physician's order for weekly catheter drainage bag changes as needed every week. -Had a physician order for the resident's monthly suprapubic catheter change: 16 FR/10 cc balloon catheter, to be changed on first of each month on the night shift, related to infection control/to maintain patency of the catheter. -NOTE: Did not have specific order for the suprapubic catheter site care and monitoring. Review of the resident's MAR dated 9/2023 showed: -A physician's order for the monthly suprapubic catheter change: 16 FR/10 cc balloon catheter, to be changed on first of each month. --Nursing initials signed as catheter changed on 9/1/23 during night shift. -The resident had a physician's order for Foley catheter 16 FR, Foley catheter care every shift and to empty catheter drainage bag every shift for urinary tract infection, initial order dated 5/12/23. -Nine out 28 days had no documentation of amount of urine emptied from the catheter drainage bag. -Four out 28 days had no documentation indicating the catheter care was completed. Review of the resident's medical record dated 9/1/23 showed there was no nursing note related to changing the resident's suprapubic catheter or assessment of the stoma site on that date. Review of the resident's weekly skin evaluation forms dated 9/3/23, 9/9/23, 9/21/23 and 9/23/23 showed: -No documentation related to the assessment of the resident suprapubic site. -No nursing note documented on the form. -the location of the suprapubic stoma site was not indicated on the body demographic. Observation on 9/25/23 at 9:15 A.M. of the resident showed: -He/she was sitting in the television area. -His/her catheter drainage bag was under his/her wheelchair in a privacy bag. -The privacy bag was dragging on the ground. -At 9:28 A.M., the resident was still in the television area with the catheter bag under the wheelchair touching the ground with staff members in the area. Observation on 9/26/23 at 12:00 P.M., of the resident showed: -He/she was wheeled to the dining area. -The resident's catheter bag was under his/her wheelchair with catheter drainage tube dragging on the ground. -There was a thick creamy yellow substance in the catheter tube. Observation on 9/27/23 at 8:53 A.M., of the resident showed: -He/she was in the television area with the catheter tubing touching the floor under the wheelchair. -There was a cloudy thick substance in the catheter tube. -The catheter bag was in privacy bag between the wheel and a metal bar. During an interview on 9/27/23 at 9:12 A.M., the resident said: -The nursing staff and CNA's clean and monitor the resident's suprapubic site. -That morning, the CNA completed catheter care during peri care and said the doctor should look at the resident catheter site. The CNA was supposed to let the nurse know. -No nursing staff had assessed his/her suprapubic site yet. -He/she had a history of chronic UTI's. Observation on 9/27/23 at 1:47 P.M., of the resident's supra pubic site showed: -Licensed Practical Nurse (LPN) G removed the old dressing, there was a slight odor noted and had a brownish red drainage noted on the dressing and catheter tubing. -Suprapubic was located in lower middle abdominal fold, the skin area was a brownish color. -LPN G cleaned the site with wound cleanser and attempted to clean the tubing of the brownish drainage. -The resident said he/she was not sure when the last time the suprapubic catheter had been changed. -The catheter drainage tubing had a cloudy creamy yellow drainage in it. -The resident denied any pain at the suprapubic site. -LPN G had to check when last time the suprapubic catheter had been changed. -LPN G decided best to go ahead and change the catheter since so soiled. -LPN G removed his/her gloves and made the resident comfortable, washed his/her hands. -Left to check the physician's orders. -LPN G was going to get another nurse to complete the task. Review of the resident's nursing note dated 9/27/23 at 19:41 P.M. showed: -The resident's suprapubic catheter was changed that day along with his/her stat-lock and catheter bag. -The site had moderate bloody drainage and appeared to possibly have yeast in the folds of his/her [NAME] (lower skin fold of abdomen) along the catheter site. -The area was cleansed with wound cleanser and dried, a split sponge was applied to the finished area and [NAME] yeast was treated per resident's treatment orders. -Documented on TAR as changed. During an interview on 9/28/23 9:10 A.M., LPN F said: -The resident's suprapubic catheter site should be cleansed and the dressing changed every shift. -Should be documented on the resident's MAR. -The resident suprapubic catheter site was looking better. During an interview 9/29/23 at 9:04 A.M., RN C said: -He/she would expect the resident to have a physician's order for care and monitoring of the suprapubic site. -He/she would document suprapubic catheter care and monitoring of the site on the residents TAR and in the nursing notes. During an interview on 9/29/23 at 9:12 A.M., of the resident's Treatment Administration Record (TAR), MAR and POS dated 9/2023 with LPN F said: -He/she was not able to find a specific physician's order for monitoring and care of the resident's suprapubic site. -No detailed documentation found on the care of the site. -The facility electric medical record sometimes deleted or lost documentation, such as nursing notes. -He/she had been completing care on the resident's suprapubic site but had not been documenting in the resident's medical record any findings. During an interview on 9/29/23 at 10:43 A.M., CNA D and CNA E said: -He/she checked the resident's catheter bag every hour for placement of drainage bag and tubing, and if needed emptied. -He/she would empty the drainage bag before end each shift. -The catheter drainage bag and tubing should not be touching the floor. -CNA D said he/she had provided care for the resident and had cleaned from the navel area down around the suprapubic catheter site and down the catheter tube. On 9/27/23 was the first day he/she had noticed a drainage and odor from the suprapubic catheter site. -He/she had notified nursing staff that morning. During interview on 9/29/23 at 1:00 P.M., RN C said: -He/she would expect to find documentation on the resident's TAR or MAR for the catheter change and care of the suprapubic catheter. -He/she would have made a detailed note to include the how the resident tolerated the process, amount of urine, color, and type of catheter. -The Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) Coordinator would be responsible for updating the resident's care plan. During an interview on 9/29/23 at 1:58 P.M., the Director of Nursing (DON) said: -Suprapubic catheter site should be cleaned daily by the nursing staff and documented on the resident's MAR. -He/she would expect to have a physician's order for the care of the resident's suprapubic catheter site. -Which would not be a specific order for just suprapubic, but a basic order for Foley catheter care every shift. -Which would mean clean any catheter site with soap and water every shift. -Nurses should document the care of suprapubic catheters on the MAR, if there's something abnormal he/she would expect nursing staff to document in the progress notes. -For suprapubic catheters, the facility documents by exception. -The weekly skin assessments would not include those residents with healed surgical sites, because it's just a part of them. -The facility did not really document a healed stoma upon admission, they would just document that they had it. -When staff were cleaning the stoma site and noticed changes to the site, he/she would expect staff to document those changes. Again, charting done by exception only. -When nursing staff were changing the catheter, he/she would expect document when finding anything abnormal, but otherwise would be fine if nursing do not have detailed documentation of the changing of the catheter. 45623 2. Review of Resident #35's face sheet showed he/she was admitted with retention of urine (when you are unable to fully empty your bladder). Review of the resident's undated care plan showed: -Staff documented the resident required a suprapubic catheter due to retention of urine. -Staff were to maintain the position of the drainage bag below the level of the bladder. -Staff were to store the drainage bag inside a protective dignity bag. Review of the resident's Physician's Orders dated September 2023 showed the physician entered an order for a suprapubic catheter, size 18-20 French with a 30 cc balloon (the balloon was inflated with saline or sterile water after insertion to keep the catheter in place). Review of the resident's Medication Record dated September 2023 showed: -Staff were to complete catheter care every shift. -Staff signed catheter care was completed every shift. Review of the resident's bath sheet, dated 9/9/23, showed staff documented the resident had no wounds or open areas to the skin. Review of the resident's bath sheet, dated 9/13/23, showed staff documented the resident had one surgical wound on his/her right hip. Review of the resident's Skin Evaluation Form, dated 9/13/23, showed LPN C documented the resident had no surgical wounds. Review of the resident's Admission MDS, dated [DATE], showed: -The resident was cognitively intact. -The resident had an in-dwelling (remains inside the body) catheter. -The resident required supervision for personal hygiene. -The resident required extensive assistance for transferring and dressing. Review of the resident's Skin Evaluation Form, dated 9/20/23, showed LPN C documented the resident had no surgical wounds. Review of the resident's bath sheet, dated 9/23/23, showed staff documented the resident had no wounds or open areas to the skin. Review of the resident's Skin Evaluation Form, dated 9/23/23, showed LPN B documented the resident did not have a surgical wound. Observation on 9/25/23 at 1:24 P.M. showed the urine drainage bag was not in a dignity bag. During an interview on 9/27/23 at 9:29 A.M., the resident said: -Staff cleaned his/her stoma but not every day. -Staff cleaned his/her stoma when he/she mentioned it. -He/she cleaned the stoma twice a day when he/she lived independently, but staff at the facility had only cleaned it once since his/her admission. Observation on 9/27/23 at 9:29 A.M. showed the resident's stoma had a small amount of bloody drainage, blood crusting around the outer edge, and no gauze present. During an interview on 9/27/23 at 10:18 A.M., LPN D said staff did not clean the stoma for this resident as the resident had hospice services. Review of the resident's Medication Report, received from the DON on 9/27/23 at 11:04 A.M. showed staff had documented catheter care had been completed that day for the resident. During an interview on 9/27/23 at 1:19 P.M., LPN D said: -He/she was responsible for the resident that day. -He/she refused to answer if the resident's stoma had been cleaned. During an interview on 9/27/23 at 2:12 P.M., the resident said staff had not cleaned his/her stoma that day. Observation on 9/27/23 at 2:12 P.M. showed: -Crusted blood around the resident's stoma. -The top of the resident's brief had fresh blood where it had rubbed against the stoma. -The catheter in the resident was a 22 French with a 10 cc balloon. Observation on 9/27/23 at 2:39 P.M. showed: -LPN E and LPN C transferred the resident to his/her bed. -Once the resident was sat on the bed, LPN C, while standing over the resident, picked up the urine drainage bag and held it at his/her eye level, which was at the level of the resident's collar bone. -LPN C was asked by the resident if someone would clean his/her catheter stoma as blood was leaking onto his/her brief. -LPN C responded to the resident's request by saying he/she would ask LPN D to clean it as soon as he/she left the room. -LPN C left the resident's room, walked past LPN D, and did not relay the resident's request. 3. Review of Resident #19's face sheet showed he/she was admitted with a diagnosis of Overactive Bladder (a frequent and sudden urge to urinate that is difficult to control). Review of the resident's Annual MDS, dated [DATE], showed: -The resident had a severe cognitive deficiency. -The resident was totally dependent on staff for personal hygiene. -The resident had an in-dwelling catheter. Review of the resident's undated care plan showed staff had inserted an 18 French catheter with a 5 cc balloon to promote wound healing. Review of the resident's Physician's Orders, dated September 2023, showed the physician ordered the resident to have an 18 French catheter with a 5 cc balloon inserted through the urethra (a duct that allows urine to flow from the bladder out of the body) on 8/16/23. Review of the resident's Medication Record, dated September 2023, showed staff did not provide catheter care 9/11/23 and 9/14/23. Observation on 9/26/23 at 11:19 A.M. showed: -Staff had hung the drainage bag from the resident's bed without a dignity bag. -The drainage bag and urine was visible from the hallway. Observation on 9/27/23 at 9:41 A.M. showed: -Staff had hung the drainage bag from the resident's bed without a dignity bag. -The drainage bag and urine was visible from the hallway. -A note on a communication board in the resident's room read catheter leaks. Observation on 9/27/23 at 12:59 P.M. showed: -The drainage bag was not in a dignity bag and was still visible from the hallway. -The resident had a 16 French catheter with a 30 cc balloon inserted through the urethra. During an interview on 9/27/23 at 12:59 P.M., LPN C said the drainage bag should have been in a dignity bag. Observation on 9/28/23 at 9:25 A.M. showed the resident's drainage bag, not in a dignity bag, was visible from the hallway. 4. Review of Resident #4's face sheet showed he/she was admitted with: -Retention of urine. -UTI. Review of the resident's Quarterly MDS, dated [DATE], showed: -The resident was unable to make himself/herself understood. -The resident had an in-dwelling catheter. -The resident required extensive staff assistance for transferring and dressing. -The resident required supervision for personal hygiene. Review of the resident's undated care plan showed staff documented: -The resident was to have a 16 French suprapubic catheter with a 10 cc balloon. -The resident had frequent UTIs. -The resident was to have catheter care performed every shift. Review of the resident's Physician's Orders, dated September 2023, showed: -The resident was to have a suprapubic catheter, size 16 French with a 10 cc balloon. -Staff were to perform catheter care for the resident every shift. Review of the resident's Medication Record, dated September 2023, showed staff did not document cleaning the resident's catheter on the following dates: -9/8/23 during night shift. -9/10/23 during day shift. -9/11/23 during night shift. -9/12/23 during night shift. During an interview on 9/25/23 at 2:29 P.M., the resident's family member said: -The resident had a lot of UTIs. -The resident had previously had a catheter inserted through the urethra, but due to frequent UTIs, a suprapubic stoma had been created and the resident's catheter was now inserted through the stoma. Observation on 9/26/23 at 8:02 A.M. showed the resident was in the dining room with the drainage bag hanging from the seat of the wheelchair, without a dignity bag. Observation on 9/26/23 at 8:09 A.M. showed RN B told the resident that his/her drainage bag had to be in a dignity bag and moved the resident to a private room. Observation on 9/26/23 at 1:19 P.M. showed: -Staff had placed the resident's drainage bag in a dignity bag but the drainage bag was falling out and dragging on the floor. -The resident was attempting to wheel himself/herself in the wheelchair but kept getting stuck on the drainage tubing. Observation on 9/28/23 at 10:34 A.M. showed the resident had a 16 French suprapubic catheter with a 5 cc balloon inserted into his/her stoma. 5. During an interview on 9/28/23 at 11:54 A.M., CNA A said: -The catheter in the resident was to match the French size and balloon size on the physician's order and care plan. -A catheter that was a smaller French size than ordered could cause leaking. -Drainage bags could not be held above the level of the bladder because it could cause urine to flow back into the resident and possibly cause an UTI. -Drainage bags were always to be in a dignity bag. -The drainage bag and tubing were never to drag on the ground as it could cause an infection. -A blank on the Medication Record indicated the task was not done. During an interview on 9/28/23 at 1:22 P.M., LPN A said: -The catheter in the resident was to match the French size and balloon size on the physician's order and care plan. -A smaller catheter than ordered could cause leaking. -Staff were to complete catheter care per the physician's order. -A suprapubic site with drainage was to have gauze placed around it. -Drainage bags were never to be held above the resident's bladder because it could cause urine to flow back into the resident which could cause an infection. -Drainage bags were to be in a privacy bag any time the resident was in a public area or if it was visible from the hallway. -The drainage bag and tubing was not to drag on the ground. -Blanks on the Medication Record indicated the task was not done. During an interview on 9/28/23 at 2:16 P.M., RN A said: -The catheter in the resident was to match the French size and balloon size on the physician's order and care plan. -A smaller catheter than ordered could cause leaking. -Nurses were responsible for cleaning suprapubic catheters, all nursing staff could clean a catheter inserted through the urethra. -Drainage bags were never to be held above the resident's bladder because it could cause urine to flow back into the resident which could cause an infection. -Drainage bags were always to be in a dignity bag. -The drainage bag and tubing was never to drag on the ground as it may lead to an infection. -Blanks on the Medication Record indicated the task was not completed. During an interview on 9/29/23 at 1:57 P.M., the DON said: -The catheter in the resident was to match the French size and balloon size on the physician's order and care plan. -A smaller catheter than ordered could cause leaking; that included the catheter French size and the balloon size. -A suprapubic site with drainage was to have gauze placed around it. -Drainage bags were never to be held above the resident's bladder because it could cause urine to flow back into the resident which could cause an infection. -Drainage bags were always to be in a dignity bag. -The drainage bag and tubing was never to drag on the ground. -Blanks on the Medication Record did not mean the task wasn't done, and signatures did not mean the task was done; he/she could not say any task had been completed unless he/she had witnessed it. -Resident #35 had a history of UTIs. -Staff were only to chart an assessment of the stoma if there was an abnormality. -Staff were not to include healed stomas on the skin assessments because it's just part of them. -Staff were not expected to document the stomas appearance at admission if it was healed.

Based on observation, interview and record review, the facility failed to ensure the staff were educated on pressure ulcer prevention and treatment; to assess, document, and monitor pressure ulcers, to complete weekly pressure ulcer tracking and follow the pressure ulcer tracking protocol, and to assess the residents risk of developing pressure ulcers for three sampled residents (Resident #1, #4 and #5), to ensure a low air loss mattress was set to the appropriate setting to aid in the prevention and healing of pressure ulcers, to perform peri care during the night shift and left the resident soaked in urine for an extended period causing the wounds to his/her buttock, coccyx and ishium that had antimicrobial dressings on the wounds to treat and prevent wound infections to be saturated with urine, to update and/or implement pressure ulcer care plan and to prevent the further development of a pressure ulcer for one resident who had existing pressure ulcers which one pressure ulcer had declined into an unstageable pressure ulcer and had a Stage III pressure ulcer to his/her buttock and the resident's coccyx wound had worsen with tunneling for one sampled resident (Resident #4); to ensure the resident was kept clean and dry from urine to promote wound healing, and to ensure the resident had pressure ulcer prevention in his/her wheelchair to prevent the pressure ulcer from declining; to provide proper wound care for a resident who was admitted to the facility with a Stage I pressure ulcer to the coccyx which declined to an unstageable coccyx pressure ulcer for one sampled resident (Resident #5); and to treat the resident's pressure ulcer timely; to follow physician's wound care orders for the staff to apply a corn pad to the resident's left second toe that was facility acquired and had declined to an unstageable pressure ulcer for one sampled resident (Resident #1) out of nine sampled residents. The facility census was 26 residents. Record review of the National Pressure Ulcer Advisory Panel (NPUAP) showed: Pressure Injury: -A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. -Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin:Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis:Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue (good viable tissue), slough (yellow or tan dead tissue) and eschar (dark hard black dead tissue) are not present. -Stage 3 Pressure Injury: Full-thickness skin loss:Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (is deep tissue damage around the margins) and tunneling (are channels that extend from a wound into and through subcutaneous tissue or muscle) may occur. Fascia (a thin sheath of fibrous tissue enclosing a muscle or other organs), muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Record review of the facility's undated policy titled, Pressure Ulcer (PU-localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction) Prevention and Management, showed: -At the time of admission all residents would: --Be assessed for all PU risk factors using the standardized Braden or Norton scale; --Have a complete head to toe evaluation of skin condition and tissue tolerance, with all efforts to complete the assessment within two hours of admission; --Have an Initial Care Plan developed based on the resident's risk factors and risk score; -- be on a wound preventative protocol if the resident is incontinent; -Ongoing assessment and monitoring for skin ulcer prevention would include: --Identification of at risk residents using a standardized Norton or Braden PU risk assessment tool on a quarterly basis and at the time of significant change; --Documentation on the resident's Minimum Data Set (a federally mandated assessment instrument completed by facility staff) of PU risks and Pressure Ulcers; --Care Plan (written out plan for the care of the resident) for PU prevention or intervention; --Weekly skin checks for all residents completed by a nurse as part of the resident's clinical record, as well as skin checks completed by personal care assistants at the time of the resident's bath or shower; -Initial and weekly assessment of an actual Pressure Ulcer would include: --The PU location, stage, size, shape, depth of sinus track (also referred to as a tunnel, a passageway underneath the skin that extends in any one direction through soft tissue and results in dead space with potential for abscess formation), surrounding tissue, and drainage (type, color, odor, and amount), wound bed, wound edges, and related pain. A pressure ulcer healing sheet would be initiated following assessment. --PUSH (Pressure Ulcer Scale for Healing, developed by the National Pressure Ulcer Advisory Panel, NPUAP), could be used as a quick, reliable tool to monitor the PU status over time; --All PU assessments for all residents would be performed by one nurse whenever possible; --When there was no progress within three weeks or when deterioration was present, the Physician should be notified for treatment order review; --Referral to a Wound Specialist should be considered for Stage III or IV pressure ulcers; -Care plan protocols would include: --Interventions based on the resident's risk factors, pressure ulcer stage, and standards of practice; --Treatments consistent with NPUAP guidelines; --Review, input and approval of all wound care protocol by the Medical Director; -Quality Assurance (QA-maintenance of a desired level of quality in service delivery) would ensure: --All pressure ulcers were added to the PU tracking form/log; --The Interdisciplinary Team (IDT-professional clinical staff from various disciplines working together to provide coordinated care) Risk Team representative reviewed all new pressure ulcers and monitored weekly progress; --PU were reported at least quarterly to the QA Committee/meeting; --Quality Indicators (QI-Measures that reflect a health care or clinical outcome) for pressure ulcers were printed and reviewed monthly; --PU were investigated for standards and implementation of care; --PU trends were reported quarterly to the QA and Improvement Committee and shared with staff through meetings, in-services and communication boards; -Staff Development was responsible for educating direct care staff on standards of practice to: --Prevent and manage PU; --Recognize skin issues and pressure points; and --Review pressure reduction and relief measures; -Staff Development was responsible for educating licensed nurses on: --Staging of PU by depth and description; --Recognition of early tissue damage signs, including Stage 1 pressure ulcers; --Development of a care plan based on risk factors; --The facility's pressure ulcer documentation system; and --Treatment protocols and competency of sterile dressing application. Document review of the facility's undated Setting the Air Mattress instructions showed: -For pumps set according to the resident's weight staff were to get an accurate weight; -For pumps set from soft to firm staff were to: --Inflate the mattress at the softest comfort level for the resident; --Check that the mattress wasn't bottoming out by placing a hand palm up under the mattress and pushing up. Staff should not be able to touch the resident and the resident should not touch the bed frame. --Tests for bottoming out were to be completed as follows: with the resident lying on his/her back push up from under the buttocks; with the resident lying on his/her side push up from under his/her shoulder and hip; with the resident lying on his/her stomach push up from under his/her stomach. -Once the mattress was set at the desired level mark the air pump to the appropriate setting by affixing a piece of tape on the air pump indicating the appropriate setting. (The instructions didn't specify who would determine the settings); and -Monitor the mattresses to validate the settings. (The instructions did not specify the monitoring schedule or who should monitor the settings). 1a. Record review of Resident #4's Face sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Had a Stage II pressure ulcer to the resident's left buttock; -Colonoscopy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen); -[MEDICAL CONDITION]/[MEDICAL CONDITION] (total or [DIAGNOSES REDACTED] of one side of the body that results from disease of or injury to the motor centers of the brain), -Cerebral arterial occlusion with infarction (Restricted blood supply resulting in death to brain tissue, a stroke); -Muscle weakness and -Diabetes Mellitus type 2 (DM-a chronic condition that affects the way the body processes blood sugar/glucose). Record review of the resident's Care Plan, dated 9/8/15 to present, and reviewed on 10/24/17, showed: -The resident had self-care deficits requiring total staff assistance related to bed mobility, dressing, grooming, toileting, and transfers; -The resident had impaired skin integrity with a Stage III pressure ulcer to the coccyx and an open area to the left upper thigh. Interventions included: --Daily wound care as ordered; --Weekly documentation of wound site, size, drainage, healing, and treatment. Notification to physician if no healing occurred within three weeks or in the event of wound deterioration; --Keeping the skin clean and dry, and providing perineal care (care to the area between the anus and the exterior genitalia) after each incontinent episode and --Placement of a urinary chuck (disposable pad) on the resident's bed for protection and chuck changes for incontinent episodes. Record review of the resident's October, 2017 physician's orders [REDACTED]. -The resident was prescribed the following supplements, beginning on 1/4/16, for PU of sacral region, unstageable: --Multivitamin with minerals, daily; --Oyster shell calcium with Vitamin D, 500 milligrams (mg) (1,250 mg) - 200 unit, twice daily (BID); --Vitamin C 500 mg, daily; --Vitamin D2 400 unit daily; -Encourage resident to lie down in between meals on side for pressure relief of coccyx (near the small triangular bone at the base of the spinal column, commonly referred to as the tailbone) wound, twice daily beginning on 6/29/16 and -Apply ointment to the resident's chronic coccyx wound daily, starting 6/10/17. Record review of the resident's pressure ulcer tracking by an outside wound care company showed: -The resident received care for a Stage III coccyx pressure ulcer and a Stage II left ischial tuberosity (IT- sit-bone area) wound from 5/15/17 through 7/2017; -At the time of discharge from the contracted wound care service the sacrum (coccyx area) wound was 0.2 (greatest length, head to toe) x 0.2 (greatest width, side to side) x 0.2 depth (deepest part of the wound bed) centimeters (cm) with 100 percent (%) granulation (new connective tissue and microscopic blood vessels that typically form from the base of the wound during the healing process). Documentation showed the PU was considered to be stable and small with no concerns. Recommendations were to continue with Triad cream for protection and -Documentation showed the left IT area was considered healed. Record review of the resident's pressure ulcer prevention and management documentation from 8/01/17 through 9/5/17, showed: -A weekly wound report, dated 8/4/17, documenting a Stage III coccyx wound 0.1 x 0.2 x 0.3 cm with 100% granulation and scant serous (transparent to pale yellow bodily fluid of a benign, or harmless, nature), being treated with Triad [MEDICATION NAME] Wound Dressing (zinc oxide). The nurse completing the form was not noted; -A weekly wound report, dated 8/7/17, documenting a Stage III coccyx wound 0.1 x 0.2 x 0.3 cm with 100% granulation and scant serous being treated with zinc oxide. There was no signature or notation of the nurse completing the form; and -The resident's Norton Plus Skin Risk Evaluation, dated 8/11/17, showed a pressure ulcer risk score of eight (a score of 10 or less indicates the resident is at high risk for pressure ulcer development) and the presence of a Stage I or higher PU. There was no documentation of the PU's location, appearance, drainage, odor, or measurements. Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 9/5/17, showed: -A Brief Interview for Mental Status (BIMS - A screening tool used in nursing homes to assess cognition) score of six. (A BIMS score of zero to seven indicates severe cognitive impairment); -Total dependence on staff for bed mobility, toileting, and personal hygiene, as well as other activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -The resident had functional limitations in range of motion (ROM - the range on which a joint can move) on one side of the upper extremity (shoulder, elbow, wrist, hand) and bilaterally (both sides) on the lower extremities (hips, knees, ankles, feet); -The resident was at risk for developing pressure ulcers and had a Stage II PU acquired on 2/8/17; -The resident had an ostomy (surgically created opening in the abdominal wall where the bowel protrudes for the discharge of waste) and -The resident was always incontinent of urine. Record review of the resident's pressure ulcer prevention and management documentation from 9/6/17 through 9/29/17, showed: -There was no documentation of visual skin evaluations or wound assessments between 8/7/17 and 9/14/17; -The resident's Norton Plus Skin Risk Evaluation, dated 9/15/17, documented a total skin risk assessment score of 11 (a score of 11 to 15 indicates the resident was at moderate risk for pressure ulcer development), and the presence of a Stage I or greater PU on the coccyx. The PU was described as being located on the coccyx, healing with no odor or drainage. The space on the form to document the wound's length, width and depth measurements were left blank; -A weekly wound report, dated 9/26/17, documented a Stage II PU on the coccyx, measuring 0.1 x 0.2 x 0.3 cm, with scant serous being treated with zinc oxide. There was no signature or notation of the nurse completing the form and -The resident's Norton Plus Skin Risk Evaluation, dated 9/29/17, documented there was no Stage I or greater PU and did not show a pressure ulcer risk score. Documentation showed the resident had a reddened groin/pubic area on the resident's back which was healing with no odor or drainage and a reddened area on the resident's lateral (side furthest from the middle or center of the body) breast (left or right is not specified) which had a healing appearance with no odor or drainage. The was no documentation of the reddened area measurements. Record review of the resident's Norton Skin Risk Evaluation, dated 10/6/17, showed a total skin risk assessment score of two and no Stage I or greater PU. Record review of the resident's POS, dated October, 2017, showed treatment orders to cleanse area to upper left thigh with normal saline and pat dry. Apply [MEDICATION NAME] (a dressing to treat wounds with drainage) and cover with Allevyn foam (absorbent dressing) dressing every other day and PRN (pro re nata-as needed) starting 10/7/17. Record review of the resident's pressure ulcer prevention and management documentation from 10/07/17 through 10/23/17, showed: -An incident report, dated 10/8/17 documenting an open area to the gluteal fold (area where the thigh meets the buttock). The wound was measured at 4 x 1.5 x 0.5 cm by Licensed Practical Nurse (LPN) C and was described as a sheered, open area. The intervention to prevent a future similar occurrence was to check to see if the resident needed a different size brief; -The resident's Norton Plus Skin Risk Evaluation, dated 10/9/17, documenting a Stage I or higher PU. There was no documentation of the resident's skin risk assessment score. The areas on the form to document the wound's location, appearance, odor, drainage, and measurements were left blank and -The resident's Norton Plus Skin Risk Evaluation, dated 10/13/17, showed a total skin risk assessment score of four and the presence of a Stage I or higher PU. A coccyx PU, measuring 0.1 x 0.1 x 0.2 cm, was described as healing with no odor or drainage. A second wound, measuring 1.5 x 0.5 x 0.0 cm, was described as an open lesion (abnormal tissue change) and healing with no odor or drainage. The wounds were measured by LPN C; and -There was no documentation between 10/13/17 and 10/23/17 of visual skin evaluations or wound assessments. Record review of the resident's pressure ulcer prevention and management documentation on 10/24/17 showed: -A Visual Skin Evaluation, dated 10/24/17 at 3:36 P.M., documenting a non-blanchable (when pressed, the skin tissue does not briefly turn white or a lighter color) PU on the left side of the coccyx measuring 6.5 x 5.8 x 0.1 cm, with a small amount of clear drainage; -A second wound described as a small, reddened, blanchable (when pressed, the skin briefly turns white or light colored and quickly returns to its original color) abrasion to the left buttock with a small amount of serosanguinous (yellowish fluid with small amounts of blood) drainage measuring 2.1 x 2.5 x 0.1 cm and -The wounds were measured by the Director of Nurses (DON). Record review of the resident's progress note, dated 10/24/17, written by the Advanced Practice Registered Nurse (APRN), showed the resident complained of pain to his/her bottom and had a Stage III wound to his/her left buttock and tunneling of the sacral wound; Record review of the resident's telephone orders, dated 10/24/17, showed treatment orders to the buttock and sacral wounds with normal saline, pat dry and apply [MEDICATION NAME], (contains [MEDICATION NAME], which offers antibacterial protection and is used in the management of hard to heal wounds) to wound beds and cover with [MEDICATION NAME] Ag Foam dressing daily and PRN. Observation and interview on 10/25/17 at 9:13 A.M. showed: -Licensed Practical Nurse (LPN) C removed the dressings from the resident's gluteal fold and coccyx. Both dressings had a small amount of serosanguineous drainage and there was no odor; -The resident's gluteal pressure ulcer was unstageable and measured 2.5 cm long, 1.7 cm wide and 1.4 cm deep, the wound bed was about 75 percent covered with tan slough, had a small area of pink granulation tissue and a dark red center at the lower right side of the wound and the skin surrounding the wound was red. LPN C said he/she could not see the wound bed; - The resident's coccyx wound was unstageable and measured 4.0 cm long, 2.4 cm wide and 0 .7 cm deep, with about 30 percent slough and eschar at the top left area of the wound bed and a dark area at the right lower portion of the wound bed that obscured the wound bed, there was a small area on the left center edge of the wound with bright red blood, the skin surrounding the wound extending out about 0.5 cm was red and non-blanchable (had redness that did not become pale under applied light pressure) LPN C said he/she could not see the wound bed and -LPN C cleansed the areas, applied [MEDICATION NAME] and a bordered gauze dressing using correct technique, hand hygiene and needed infection control measures. During an interview on 10/25/17 at 10:30 A.M., the DON said: -Charge nurses were not consistently documenting wound measurements; -He/she started educating staff on measuring wounds on 10/18/17 and -He/she saw the resident's coccyx wound on 10/18/17 and described it as having redness the size of his/her fist with an open area the size of a golf ball. Record review of the resident's wound tracking forms and clinical notes showed there was no documentation of the coccyx wound description or measurements on 10/18/17. Multiple requests were made for this documentation. During an interview on 10/26/17 at 10:00 A.M. the Medical Director said: -Skin assessments for residents with pressure ulcers should be completed on a daily basis to assess effectiveness of treatments. Once the resident is responding to treatment documentation can be weekly; -Wounds should be tracked according to facility policy; -Staff assessing wounds should know how to measure. Whenever possible, wounds should be measured by the same facility nurse; -He/she expected to be notified immediately if the resident had worsening wounds; -He/she had seen the resident's coccyx PU that morning and the PU was unstageable in the middle; -He/she was checking the resident's Erythrocyte Sedimentation Rate (ESR, often referred to as Sed Rate - indicates the presence of inflammation which could be associated with infection and/or other diseases) for the gluteal fold wound and -He/she didn't think the gluteal fold wound was a pressure ulcer and said it could be associated with osteo[DIAGNOSES REDACTED] (inflammation of bone caused by infection). During an interview on 10/27/17 at 10:15 A.M., the Physician Assistant from the contracted wound care agency said: -The resident's wound care treatment had been discontinued towards the end of summer. At the time the coccyx PU was approximately 0.2 x 0.2 x 0.2 cm in size and the consulting team thought the facility could manage the wound from that point forward and -The DON reported to him/her the resident had two new wounds and the coccyx wound had tunneling. During an interview on 10/27/17 at 11:10 A.M., LPN B said: -On 10/18/17 when he/she worked the resident had only one wound, the coccyx PU. It wasn't even pink and looked like a small piece of peeling skin; -On 10/20/17 at 6:30 A.M. CNA E reported the resident was left wet by the night shift CNA; -LPN B observed the resident lying in urine. The resident's chuck and sheet were soaked and there was a dried urine ring surrounding the wet urine and -On 10/20/17 the coccyx PU was no longer superficial. The site was angry red in color. Record review of the resident's wound tracking forms and clinical notes showed there was no documentation of the coccyx wound description or measurements on 10/20/17. Multiple requests were made for this documentation. During an interview on 10/27/17 at 12:10 P.M., Certified Nurses Aide (CNA) E said: -On the morning of either 10/19/17 or 10/20/17: --The night shift CNA reported the residents on the hall were all changed and dry; --CNA E entered the resident's room a few minutes past 6:30 A.M. and found the resident soaked in urine. The resident was wearing a disposable brief and the brief, bed chuck, and sheet under the chuck were saturated with urine; --There was a dark yellow stain which had dried surrounding the wet urine on the sheet; --There was a very strong odor in the room which smelled like both fresh and old urine and --He/she reported the issue to the charge nurse after finding the resident had been left lying in urine. During an interview on 10/27/17 at 1:15 P.M. a family member of the resident said: -Approximately four to five years ago the resident had his/her colon removed as well as surrounding tissue. Because of this the resident was very susceptible to developing pressure ulcers and almost always had a PU on the coccyx area, and often on other areas as well and -It was essential that staff caring for the resident be vigilant about monitoring and assessing the resident's skin condition and wounds as well as consistently follow all the resident's PU prevention and wound care protocol. During an interview on 10/27/17 at 1:30 P.M., the DON said: -He/she hadn't been notified when weekly skin evaluations and wound assessments were not being done; -He/she expected visual skin assessments to be completed by charge nurses on a weekly and PRN basis for all residents; -Wounds were to be assessed and documented initially and on a weekly and PRN basis; -Nursing staff were not trained by the facility in tracking and staging wounds and -If there was slough to the wound bed and the nurse could not see the wound bed the wound was considered unstageable. 1b. Record review of Resident #4's Care Plan, dated 9/8/15 to present, and reviewed on 10/24/17, showed: -The resident had impaired skin integrity with a Stage III pressure ulcer to the coccyx and an open area to the left upper thigh and -- To use of a Low Air Loss (LAL) mattress for pressure relief for wound healing, and nursing to check settings and functioning on every shift. Record review of the resident's October, 2017 POS showed a physician order [REDACTED]. Record review of the resident's weight history showed the resident's weight fluctuated between 138.9 pounds and 146.2 pounds between 1/1/17 and 10/4/17. Documentation showed the resident weighed 144.2 pounds on 10/4/17. Observation on 10/23/17 at 1:25 P.M. of the resident's LAL mattress setting showed the mattress was set at 310. Observation on 10/24/17 at 1:15 P.M. of the resident's LAL mattress setting showed the mattress was set to 320. During an interview on 10/24/17 at 1:20 P.M., CNA B said: -The mattresses were set by someone other than the CNAs; -If the mattress wasn't inflated he/she would report it to the charge nurse and -He/she was not trained on the setting of air mattresses. During an interview on 10/25/17 at 8:30 A.M., LPN C said: -An outside company installed and set the resident's air mattress; -Charge nurses check daily to make sure residents' mattresses are inflated; -He/she didn't know at what level the resident's air mattresses was to be set and -He/she could call the mattress company if he/she had questions about the mattress setting. During an interview on 10/26/17 at 10:00 A.M. the Medical Director said: -Residents with a PU should have an air mattress to minimize pressure and a cushion in the resident's chair at all times and -Mattresses designed to go by the resident's weight should be set according to the resident's weight. Observation on 10/27/17 at 11:05 A.M. showed the resident's LAL mattress was set at 350. During an interview on 10/27/17 at 11:10 A.M., LPN B said: -The contracting air mattress company sets the residents' beds; -The resident's orders say to check the functioning of the mattress. When he/she checked the mattress each shift he/she checked to ensure the pump was on and the mattress was inflated; -The resident weighed 146.4 pounds as of 10/24/17 so the bed should be set at 150. The resident's orders didn't specify to set the mattress according to the resident's weight. During an interview on 10/27/17 at 1:30 P.M., the DON said: -The charge nurse was responsible for the LAL mattress settings. A book was located at both of the facility's nurse's stations with a number to call regarding the air mattress equipment. If the charge nurses had questions regarding the LAL mattress settings they should call the company; -Some air mattresses are designed to be set according to a person's weight and should be set according to the resident's weight and -The DON did not check on the air mattress settings. 2. Record review of Resident #5's Face Sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Difficulty walking and -Weakness. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was severely cognitively impaired; -Required extensive assistance of staff members for transfers; -Required the total assistance of staff members for personal hygiene and dressing; -Did not have any pressure ulcers; -Was continent of bowel and bladder; -Was at risk for pressure ulcers and -Required a pressure relieving device in his/her bed and wheelchair. Record review of the resident's Clinical Notes dated 9/13/17 at 11:31 A.M. showed he/she had a change of condition and was sent to the hospital. Record review of the resident's Clinic Notes dated 9/18/17 at 8:15 P.M. showed: -The resident was readmitted to the facility and -The resident had an open area to his/her coccyx and his/her bilateral heels were soft. Record review of the resident's Bath Sheet dated 9/19/17 showed: -The resident received a bath; -The resident did not have a red areas to his/her skin and -The resident did not have a open areas to his/her skin. Record review of the resident's Clinical Notes dated 9/19/17 at 6:34 P.M. showed the resident had returned from the hospital with a pressure ulcer to his/her coccyx (tailbone) with treatment orders. Record review of the resident's Clinical Notes-addendum dated 9/20/17 at 10:37 A.M. showed: -The resident returned from the hospital with a pressure ulcer to his/her coccyx with treatment orders; and -The resident had a stage IV pressure ulcer to the coccyx and a treatment was in place. Record review of the resident's pressure ulcer Care Plan dated 9/20/17 showed the resident: -Was readmitted to the facility with a Stage IV pressure ulcer; -Needed the staff to assess and record the size (length, width, and depth), amount and characteristics of exudates (fluids from the pressure ulcer) and pain status; -Needed the staff to check for incontinence and keep him/her dry and clean when wet or soiled; -Needed pillows, pads or wedges to reduce pressure on heels and pressure points; -Needed to be turned and repositioned and -Needed a a pressure reducing mattress and pressure reducing pads while sitting. Record review of the resident's Clinical Notes-addendum

Based on observation, interview, and record review, facility staff failed to identify the resident's left sided upper extremity weakness upon admission and provide staff instruction for safe service of hot beverages; when a resident was served hot coffee in a Styrofoam cup with no lid on his/her left (weak) side resulting in a hot coffee spill, which caused a second degree burn (a burn that often looks wet or moist, affecting the first and second layers of skin (epidermis and dermis); and failed to put interventions in place to prevent further burn injuries from occurring for one sampled resident (Resident #4) out of nine sampled residents. The facility census was 25 residents. Record review of the website www.mayoclinic.com showed the following regarding burns: -Burns are injuries to tissue that can be caused by fire, the sun, chemicals, heated objects or fluids, electricity, or other means. Burns can be minor medical problems or life-threatening emergencies. -Burn treatment depends on the severity and size of the burn. You can treat most minor burns at home using first-aid measures, such as cooling the skin and applying an anesthetic cream or aloe gel to the burn. Deep or widespread burns need immediate medical attention. -Burns occur when the skin is exposed to high temperatures greater than 140 degrees Fahrenheit (? F). Many substances can cause burns, including fire, hot liquid or steam, hot metal, glass or other objects, electrical currents, radiation such as from X-rays or radiation therapy to treat cancer, sunlight or ultraviolet (UV) light from a sunlamp or tanning bed, chemicals such as strong acids, alkalis (such as lye or cement), paint thinner or gasoline, and friction. -A second-degree burn, which often looks wet or moist, affects the first and second layers of skin (epidermis and dermis). Blisters may develop and pain can be severe. -For treatment, cool the burn. Put burned areas in room-temperature water between 50 ? F to 77? F for 15 to 30 minutes. Don't use ice or ice water. Putting ice directly on a burn can cause the body to become too cold and cause further damage to the wound. Record review of the American Burn Association website Scald Injury Prevention Educator's Guide showed: -Older adults, persons with disabilities and children are most likely to incur scald burns, -The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed, -Exposure to water 120? F requires an average of five minutes of exposure for a full thickness burn to occur, -When the temperature of a hot liquid is increased to 140? F it takes only five seconds or less for a serious burn to occur, -Coffee and other hot beverages are usually served at 160? F to 180? F, resulting in almost instantaneous burns that will require surgery, -Older adults have thinner skin so hot liquids cause deeper burns with even brief exposure, -Older adults ability to feel heat may be decreased due to certain medical conditions or medications, -Because they have poor microcirculation (blood flow through the smallest vessels), heat is removed from burned tissue rather slowly compared to younger adults, -Mobility impairments, slow or awkward movements, muscle weakness or fatigue, or slower reflexes increase the risk of spills while moving hot liquids, -A Time and Temperature Relationship to Severe Burns graph showed: --Water temperatures of 155? F take one second for a third degree burn to occur, --Water temperatures of 148? F take two seconds for a third degree burn to occur, --Water temperatures of 140? F take five seconds for a third degree burn to occur, --Water temperatures of 133? F take 15 seconds for a third degree burn to occur, --Water temperatures of 127? F take one minute for a third degree burn to occur, --Water temperatures of 124? F take three minutes for a third degree burn to occur, --Water temperatures of 120? F take five minutes for a third degree burn to occur. 1. Record review of the Resident #4's Face Sheet showed the resident was admitted to the facility on [DATE] for Medicare skilled services and was his/her own responsible party. Record review of the resident's Nurse's Note dated 1/4/12, showed the resident had no open sores or wounds upon admission. Record review of the resident's Medicare Nursing Documentation form dated 1/4/12, showed the resident: -Was alert and oriented to person, place, and time. -Had an intact short and long-term memory. Record review of the resident's physician's orders [REDACTED]. -Hypertension (HTN - high blood pressure). -[DIAGNOSES REDACTED] (below normal function of the thyroid gland which regulated metabolism). -Urinary tract infection (UTI - an infection of one or more structures in the urinary system). -Dyslipidemia (any of several lipid (fat) abnormalities in the blood stream). -Anemia (a decrease in hemoglobin in the blood to levels below the normal range). -Hypokalemia (an abnormally low concentration of potassium ions in the blood).-[DIAGNOSES REDACTED] of the left hip (deposition of calcium salts in the cartilage of joints). -[DIAGNOSES REDACTED] (cancer of the female organs). Record review of the resident's admission Nurse's Note dated 1/4/12, showed. -The resident had been assessed by the nurse. -There was no documentation to show the resident had left sided weakness. Record review of the resident's initial Care Plan dated 1/4/12, showed: -No information regarding the resident's left sided weakness or coffee burn incident. -No direction to staff regarding the resident's Activities of Daily Living (ADL - how a resident self-performs eating, dressing, grooming). -There was no information regarding the resident's level of assistance needed with eating or drinking. -There was no information regarding any specialized cups the resident may have needed or placement of the cups. Note: Staff did not add any new interventions to the resident's initial care plan after the coffee burn occurred. Record review of the resident's Medicare Nursing Documentation form dated 1/5/12, showed a Progress Note on the back of the form dated 1/6/12 at 8:30 A.M., and written by Licensed Practical Nurse (LPN) A (a charge nurse), which stated: -The resident obtained a burn to his/her left thigh. The resident spilled hot coffee accidentally which was offered by a Certified Nursing Assistant (CNA) in a Styrofoam cup and lid. The day unit coordinator Registered Nurse witnessed (the incident) and the report was also passed to the nurse on the next shift. An incident report was completed. Nurse Practitioner (NP) A was notified of the hot coffee burn incident. There were no new orders at this time, and the staff will monitor the site for blistering. Record review of the resident's untitled Nurse Practitioner Notes written by Nurse Practitioner A and dated 1/6/12, showed the resident was alert and oriented with mild to moderate short-term memory impairment. Observation on 1/11/12 at 8:50 A.M., in the east hall dining room (the resident's dining room) showed: -The temperature of the coffee from the coffee maker was 159? F. -The temperature of the coffee from the carafe was 158? F degrees F. Observation on 1/11/12 at 12:17 P.M., showed: -The resident was in the east dining room. -The resident was served hot coffee from the carafe. -The temperature of the coffee from the carafe was 169.7? F. During an interview on 1/11/12 at 12:45 P.M., the resident said: -He/she was given a hot cup of coffee in a Styrofoam cup without a lid on the first day he/she had come to the facility. -An unknown staff member put the hot coffee on his/her overbed table in his/her room. -When he/she picked up the hot cup of coffee, it fell on his/her lap. -He/she did not know why the staff put the coffee on his/her left side when he/she could not use his/her left arm very well. -He/she lifted his/her left arm and said it does not work well. -The burn wound hurt when the staff pulled his/her pants up and down over the wound. Note: The resident's overbed table during the observation was on the left side of his/her bed, and the resident had left sided weakness. Observation and interview on 1/11/12 at 1:35 P.M., showed: -LPN D assisted the resident with removing his/her pants. -The resident had a large area of reddened skin that had multiple open areas on the resident's left thigh. -The burned left thigh area did not have a treatment or dressing on the area. -The left anterior thigh had the following wounds: --Wound 1 had an irregular shape 2.5 centimeter (cm) in length by 1.5 cm in width wound. The center of the wound appeared waxy and the edges were red crusty. --Wound 2 had a 0.25 cm round open area with a pink wound bed. -The left lateral thigh had the following wounds: --Wound 3 had an irregular shape 1.5 cm in length by 1.0 cm in width wound. The center of the wound appeared waxy and the edges were red crusty. --Wound 4 had a linear, flat 0.25 cm in length by 1.0 cm in width wound that was dry and crusted. -The surrounding skin area around the wounds was bright red in an area 8 cm by 10 cm in size. -The resident said the wounds were very painful when he/she spilled the cup of hot coffee on his/her leg, and was only painful now when the staff pulled his/her pants up and down and the pants would rub on the wounds. During an interview on 1/11/12 at 2:05 P.M., LPN B said: -He/she was working the day shift on 1/6/12. -He/she was given report from LPN A. -The resident was given coffee on 1/6/12 around 6:00 A.M. -The resident spilled the hot coffee on himself/herself. -He/she had been told the resident's thigh area was red. -He/she looked at the left thigh and it was barely red in a 6 inch by 5 inch area. -LPN A had contacted the physician and completed an incident report. -He/she knew the resident had left sided weakness. -No new interventions were put into place to prevent this from occurring again. During an interview on 1/11/12 at 2:10 P.M., CNA A said: -He/she was unaware that the resident had suffered a coffee burn to his/her left thigh. -He/she knew the resident had left sided weakness. -He/she had not been told of any interventions to prevent a coffee burn from occurring again. During an interview on 1/11/12 at 2:20 P.M., the Director of Nursing (DON) said LPN A filled out an incident report and he/she was trying to locate it now. During an interview in 1/11/12 at 2:35 P.M., the DON said: -He/she had been unaware of the resident's coffee burn to his/her left thigh. -He/she expected the staff to give the incident report to him/her. -He/she had not received the incident report from LPN A. -He/she discovered the resident had a coffee burn when he/she reviewed the resident's medical record during a care plan meeting on 1/10/12. During a telephone interview on 1/11/12 at 2:45 P.M., LPN A said: -He/she had worked the night shift on 1/5/12. -A staff member gave the resident hot coffee in the morning on 1/6/12. -The resident spilled it on his/her left leg. -The left thigh was red and he/she put ice on it. -He/she did not see any blisters at that time. -He/she filled out an incident report. -He/she passed the information regarding the incident to LPN B in report. -LPN B notified NP A. -He/she did not give a copy of the incident report to the DON. -He/she left the incident report on the desk at the nurses' station. -He/she normally would put the incident report on the DON's desk but he/she was getting off work at that time. -He/she thought the next shift would update the care plan with the occurrence and add any new interventions. -He/she had not updated the resident's care plan. -He/she told the staff to only give the resident hot coffee when the resident was supervised. Observation on 11/11/12 at 4:15 P.M., in the east hall dining room showed: -Coffee had just finished brewing in the coffee pot. -The temperature of a cup of coffee poured into a plastic coffee cup was 168.9? F. During an interview on 1/12/12 at 9:05 A.M., the DON said: -An incident report had been completed by LPN A. -LPN A located the incident report on 1/11/12 in the evening. -The incident report had been found in a pile of papers at the nurses' station in the unit clerk's bin. -Attached with the incident report is an interventions form that detaches and becomes a part of the care plan. -The nurse was suppose to take this off and put it in the chart when the incident report was completed. -No new interventions were placed in the resident's medical record on the date of the hot coffee burn incident. -The DON provided a copy of the form "Interventions for safety to prevent further incidences of falls." Record review of the resident's Incident Report received on 1/12/12 at 9:05 A.M., and originally dated 1/6/12, showed: -It had been completed by LPN A. -The resident was given a cup of hot coffee by a CNA. -LPN A later heard the resident saying, "Please help me, I spilled coffee on my clothes." -The resident's pant's were removed. -The site (thigh) was red on two quarter sized areas and cold water was applied. -Ice was put in a ziplock bag and applied to the area (this is not a standard of practice for burn care). -The NP A was notified at 8:00 A.M. Record review of the form "Interventions for Safety to prevent further incidences of falls" received on 1/12/12 at 9:05 A.M. and originally dated 1/6/12, showed: -It had been completed by LPN A. -The on-coming staff had been instructed to monitor the resident closer when he/she had hot liquids. -The physician had been contacted and he/she had been given a physician's orders [REDACTED]. Note: There was nothing noted about the left sided weakness of the resident or specific individualized interventions that were put into place. Observation of the resident's wound and interviews with LPN C and the DON on 1/12/12 at 12:10 P.M., showed: -LPN C and the DON in the room with the resident. -LPN C assisted the resident with removing his/her pants. -The resident had a large area of reddened skin that had multiple open areas on the resident's left thigh. -The burned left thigh area did not have a treatment or dressing on the area. -The left anterior thigh had the following wounds: --Wound 1 had an irregular shape 2.5 cm in length by 1.5 cm in width wound. The center of the wound appeared waxy and the edges were red crusty. --Wound 2 had a 0.25 cm round open area with a pink wound bed. -The left lateral thigh had the following wounds: --Wound 3 had an irregular shape 1.5 cm in length by 1.0 cm in width wound. The center of the wound appeared waxy and the edges were red crusty. --Wound 4 had a linear, flat 0.25 cm in length by 1.0 cm in width wound that was dry and crusted. -The surrounding skin area around the wounds was bright red in an 8 cm by 10 cm area. -The DON said it was a second degree burn. -The resident stated he/she had no pain from the wounds. During a telephone interview on 1/12/12 at 2:40 P.M., Physician A (the resident's physician) said: -The resident had second degree burns on his/her left thigh. -The epithelium (skin) was gone. -He/she expected the DON to be notified of the coffee burn incident when it occurred. -He/she expected interventions to be put into place when the burn incident occurred. -There was a systemic problem with notifying the DON and putting interventions in place. Record review of the resident's Corrective Action form for LPN A dated 1/13/12, showed: -The form was a written warning due to a lack of following facility policies, procedures, and industry standards of care. -This employee did not follow procedure by not writing in the medical record or notifying the appropriate staff of a resident who sustained an incident that resulted in an injury. -Failure to follow procedure led to multiple miscommunications with the entire nursing staff when the focus of care is to remain on the resident at all times. -Multiple disciplines had to be called and verify events in order to see that resident needs were addressed. -Although the resident's needs did and always come first; the tremendous amount of hours that were lost in trying to identify the event itself and impact on the resident have been enormous.

Based on observation, interview, and record review, facility staff failed to treat a second degree burn (a burn that often looks wet or moist, affects the first and second layers of skin; the epidermis and dermis) to the resident's left thigh area caused by a hot coffee spill, to monitor the burned area, to obtain the physician's ordered treatment from the pharmacy to treat the burned area resulting in four wound treatments not being administered to the burned area, and to provide appropriate wound care using acceptable standards of practice for one sampled resident (Resident #4); and failed to provide non-pharmacological interventions to relieve resident pain or discomfort prior to the administration of pain medications, and complete a pain scale rating before and after the pain medication was administered for four sampled resident (Resident #1, #2, #3 and #6) out of nine sampled residents. The facility census was 25 residents. Record review of the facility's undated policy titled "Condition Change, of the Resident-Observing, Recording, and Monitoring," showed it's purpose was to observe, record, and report any condition change to the attending physician so proper treatment would be implemented. The procedure directed staff after all injuries or changes to: -Observe for swelling and discoloration, and note the areas size, depth, site and color. -Observe for pain. -Contact the resident's physician. -Complete an incident report. -Monitor the resident's condition frequently until stable. -Document the date and time the condition change was identified, the emergency care provided, the notification of the physician, and observation of the resident at least every shift until the resident's condition was stable. -General resident care plan documentation guidelines included to: --Identify the underlying problem that caused the change of condition. --Establish a measurable goal for resolution of the condition. --Develop a plan to treat the condition; and observe and monitor the resident's response to treatment. --Develop a plan that included preventative safety measures, safety measures, and resident education. --Develop a plan for observation and reporting of complications. Record review of the website www.mayoclinic.com showed the following regarding burns: -A second-degree burn, which often looks wet or moist, affects the first and second layers of skin (epidermis and dermis). Blisters may develop and pain can be severe. -For treatment, cool the burn. Put burned areas in room-temperature water between 50 degrees Fahrenheit (? F) to 77? F for 15 to 30 minutes. Don't use ice or ice water. Putting ice directly on a burn can cause the body to become too cold and cause further damage to the wound. 1. Record review of the Resident #4's Face Sheet showed the resident was admitted to the facility on [DATE] for Medicare skilled services, and was his/her own responsible party. Record review of the resident's Nurse's Note dated 1/4/12, showed the resident had no open sores or wounds upon admission. Record review of the resident's Medicare Nursing Documentation form dated 1/4/12, showed the resident: -Was alert and oriented to person, place, and time, and -Had intact short and long-term memory. Record review of the resident's Physician's Orders Sheet (POS) dated 1/4/12, showed the resident had the following Diagnoses: [REDACTED]. -Hypertension (HTN - high blood pressure). -[MEDICAL CONDITION] (below normal function of the [MEDICAL CONDITION] which regulated metabolism). -Urinary tract infection (UTI - an infection of one or more structures in the urinary system). -[MEDICAL CONDITION] (any of several lipid (fat) abnormalities in the blood stream). -[MEDICAL CONDITION] (a decrease in hemoglobin in the blood to levels below the normal range). -Hypokalemia (an abnormally low concentration of potassium ions in the blood).-[DIAGNOSES REDACTED] of the left hip (deposition of calcium salts in the cartilage of joints). -[MEDICAL CONDITION] (cancer of the female organs). Record review of the resident's Medicare Nursing Documentation form dated 1/5/12, showed a Progress Note on the back of the form dated 1/6/12 at 8:30 A.M., and written by Licensed Practical Nurse (LPN) A, which stated: -The resident obtained a burn to his/her left thigh. The resident spilled hot coffee accidentally which was offered by a Certified Nursing Assistant (CNA) in a Styrofoam cup and lid. The day unit coordinator Registered Nurse witnessed (the incident) and the report was also passed to the nurse on the next shift. An incident report was completed. Nurse Practitioner (NP) A was notified of the hot coffee burn incident. There were no new orders at this time, and the staff will monitor the site for blistering. Record review of the resident's untitled nurse practitioner notes dated 1/6/12, showed the resident: -Was seen by NP A. -Had been assessed by cardiology (a medical speciality addressing [MEDICAL CONDITION]) at the hospital related to a second [MEDICAL CONDITION] ([MEDICAL CONDITION]-stroke) that left the resident with left sided weakness. -Had a stenting (a cylindrical structure placed in an artery to open the blockage) of the bilateral carotid artery (an artery that supplies the head and neck with [MEDICATION NAME] blood). -Was doing well today and was gaining strength back in his/her left extremities. -Had been ambulating with his/her walker in therapy. -Was alert and oriented to person, place and time. -Was alert and oriented with mild to moderate short-term memory impairment. -Had fairly good insight and judgment. -Had the following Diagnoses: [REDACTED]. --GI Bleed (bleeding of the gastrointestinal (stomach) tract). --[MEDICAL CONDITION]. --[MEDICAL CONDITION]. --[MEDICAL CONDITION]. --[MEDICAL CONDITION]. --[DIAGNOSES REDACTED] (insufficiency of a heart valve). -Note: NP A did not document that the resident had a coffee burn to his/her left thigh area. Record review of the resident's Medicare Nursing Documentation form dated 1/6/12, showed a Progress Note on the back of the form dated 1/6/12 on the 3:00 P.M.-11:00 P.M. shift, that stated: -The resident's leg was starting to blister from the coffee burn yesterday, and the resident adamantly denied any pain. Note: The staff did not document that they had notified the resident's physician of the blister to the resident's left thigh area, did not document that they provided any treatment to the resident's burned area on his/her left thigh, and did not document that they assessed the resident's burned area on his/her left thigh on each shift as per the facility policy. Record review of the resident's Medicare Nursing Documentation form dated 1/7/12, showed the staff did not document that they assessed the resident's burned area on his/her left thigh on each shift as per the facility policy. Record review of the resident's Medicare Nursing Documentation form dated 1/8/12, showed the staff did not document that they assessed the resident's burned area on his/her left thigh on each shift as per the facility policy. Record review of the resident's Medicare Nursing Documentation form dated 1/9/12, showed a Progress Note on the back of the form dated 1/9/12 on the 11:00 P.M.-7:00 A.M. shift, that stated: -The resident denied pain and discomfort of the left leg mid-thigh area. The area was blistered from a hot coffee spill. [MEDICATION NAME] (an antibiotic cream used on the skin for second or third [MEDICAL CONDITION] helps to prevent or treat serious infection) was applied to the resident's left thigh. Note: The staff did not document that they notified the resident's physician of the blistered area to the resident's left thigh area, did not document that they obtained a physician's order for a [MEDICATION NAME] cream to treat the resident's burned left thigh, and did not document that they assessed the resident's burned area on his/her left thigh on each shift as per the facility policy. Record review of the resident's Physician's Telephone Orders Sheet dated 1/9/12, showed no physician's order for a [MEDICATION NAME] treatment to treat the resident's burned left thigh area. Record review of the resident's Physician's Progress Note dated 1/10/12, showed: -The resident was seen by Physician A (the resident's physician). -A particular concern was the second [MEDICAL CONDITION] the resident's left thigh. -The incident occurred on 1/5/12. Note: The nurse's notes showed the hot coffee spill and burn to the resident's leg occurred the morning of 1/6/12. -NP A was notified that morning of the burn. -The burn had [DIAGNOSES REDACTED] (redness of the skin) only at the time. -The new blister involving the dermal (skin) required [MEDICATION NAME] Cream. -He/she expected a full healing of the resident's burned area on his/her left thigh. Record review of the resident's late entry Nurse's Note dated 1/10/12 at 1:00 P.M., showed: -Upon the investigation of this resident's left thigh blister this alert and oriented resident requested a cup of coffee on 1/5/12 at 6:00 A.M. (the prior nurse's notes showed it was on 1/6/12 at 6:00 A.M.) and the coffee was provided. -The resident later told the nurse he/she had spilled some hot coffee on himself/herself. -The nurse's assessment revealed a red area on the resident's left thigh and the resident did not complain of any pain. -The Nurse Practitioner was notified on 1/5/12 in the morning and agreed with the nursing assessment to continue to monitor and call if there were any changes to the burn area. -The nurse assessed the area and discovered a nickel sized area on the resident's left thigh that had an open area. -The resident's physician stated he/she would review it today and make changes as needed. Record review of the resident's Physician's Telephone Orders Sheet dated 1/10/12 at 5:00 P.M., showed a physician's order for [MEDICATION NAME] cream to be applied to the resident's left thigh twice a day and to cover with [MEDICATION NAME] (a non-adherent dressing). During an interview on 1/11/12 at 12:45 P.M., the resident said: -He/she was given a hot cup of coffee in a Styrofoam cup without a lid. -An unknown staff member put the hot coffee on his/her overbed table in his/her room. -When he/she picked up the hot cup of coffee, it fell on his/her lap. -He/she did not know why the staff put the coffee on his/her left side when he/she could not use his/her left arm very well. -He/she attempted to lift his/her left arm and said it does not work well. -The staff had not provided any treatment or dressing to the burned area on his/her left thigh. -The burned area hurt when the staff pulled his/her pants up and down over the wound. Observation and interview on 1/11/12 at 1:35 P.M., showed: -LPN D assisted the resident with removing his/her pants. -The resident had a large area of reddened skin that had multiple open areas on the resident's left thigh. -The burned left thigh area did not have a treatment or dressing on the area. -The left anterior thigh had the following wounds: --Wound 1 had an irregular shape 2.5 centimeter (cm) in length by 1.5 cm in width wound. The center of the wound appeared waxy and the edges were red crusty. --Wound 2 had a 0.25 cm round open area with a pink wound bed. -The left lateral thigh had the following wounds: --Wound 3 had an irregular shape 1.5 cm in length by 1.0 cm in width wound. The center of the wound appeared waxy and the edges were red crusty. --Wound 4 had a linear, flat 0.25 cm in length by 1.0 cm in width wound that was dry and crusted. -The surrounding skin area around the wounds was bright red in an area 8 cm by 10 cm in size. -The resident said the wounds were very painful when he/she spilled the cup of hot coffee on his/her leg, and was only painful now when the staff pulled his/her pants up and down and the pants would rub on the wounds. During an interview on 1/11/12 at 1:40 P.M., the Director of Nursing (DON) said: -NP A was notified when the hot coffee burn happened. -NP A looked at the area and told the staff to keep an eye on the burned area. -No treatment orders had been given to the staff from NP A. During an interview on 1/11/12 at 2:05 P.M., LPN B said: -He/she was working the day shift on 1/6/12. -He/she was given the daily report from LPN A. -The resident was given hot coffee on 1/6/12 around 6:00 A.M. -The resident spilled the hot coffee on himself/herself. -He/she had been told the resident's thigh area was red. -He/she looked at the left thigh and it was barely red in a 6 inch by 5 inch area. -LPN A contacted the physician and completed an incident report. -He/she knew the resident had left sided weakness. -No new interventions were put into place to prevent a coffee burn from from occurring again. During an interview on 1/11/12 at 2:15 P.M., LPN C (the day charge nurse) said: -The resident had a wound on his/her left thigh due to a hot coffee spill. -The documentation for monitoring the wound should be listed in the daily Medicare nurse's notes. During a telephone interview on 1/11/12 at 2:45 P.M., LPN A said: -He/she had worked the night shift on 1/5/12. -A staff member gave the resident hot coffee in the morning on 1/6/12. -The resident spilled it on his/her left leg. -The left thigh was red and he/she put ice on the burned area. (Note: This is not a standard of practice for burns). -He/she did not see any blisters at that time. -He/she filled out an incident report. -He/she passed the information regarding the incident to LPN B in report. -LPN B notified NP A. -The wound had started to blister over the weekend. -He/she had not called the resident's physician when the blisters appeared. -On 1/8/12, the resident's left thigh was barely red, probably from the resident's clothes rubbing on the area. -He/she had seen the wound on 1/10/12 at night and the resident's left thigh area had blisters. Record review of the resident's Incident Report received on 1/12/12 at 9:05 A.M., and originally dated 1/6/12, showed: -It was completed by LPN A. -The resident was given a cup of hot coffee by a CNA. -LPN A later heard the resident saying, "Please help me, I spilled coffee on my clothes." -The resident's pants were removed. -The site (thigh) had two quarter sized reddened areas and cold water was applied. -Ice was put in a ziplock bag and applied to the area. During a telephone interview on 1/11/12 at 3:16 P.M., NP A said: -He/she had been notified of the coffee burn by a nurse. -The nurse did not ask for a treatment order. -He/she went by the description of the area that the nurse gave him/her. -He/she was not a burn expert but thought blisters would normally appear sooner on a burn. -He/she expected the [MEDICATION NAME] treatment to have started at least by the next day after the treatment had been ordered. -He/she expected the staff to be monitoring the burned area at least every shift (three times per day). -He/she had not specified to the nurse how often the burned area needed to be monitored. Record review of the resident's Weekly Wound Record dated 1/12/12, showed: -The resident had a burn on his/her left lateral (the side) thigh. -The wound measured 1.5 cm in length by 1.0 cm in width. -The burned area was pink. -The wound was a fluid filled blister. -There was no drainage present and the scab was intact. -The treatment was to apply [MEDICATION NAME] cream and cover the burned area with [MEDICATION NAME]. -The physician had been notified about the burn on 1/10/12. Record review of the resident's Weekly Wound Record dated 1/12/12, showed: -The resident had a burn on his/her left anterior (the top) thigh. -The wound measured 2.8 cm in length by 1.5 cm in width. -The burned area was pink. -The wound was a fluid filled blister. -There was no drainage present and the scab was intact. -The treatment was to apply [MEDICATION NAME] cream and cover the burned area with [MEDICATION NAME]. -The physician had been notified about the burn on 1/10/12. -The wound was stable. Record review of the resident's Treatment Administration Record (TAR) received on 1/12/12 at 9:20 A.M., and originally dated 12/20/11, showed a physician ordered treatment dated 1/10/12 to apply [MEDICATION NAME] cream to the resident's left thigh twice a day and cover with [MEDICATION NAME], and: -There was no staff documentation to show the treatment was administered on 1/10/12, 1/11/12, or on 1/12/12 in the morning. -The treatment had not been completed on 1/10/12 in the evening. -The treatment had not been completed on 1/11/12 in the morning or in the evening. -The treatment had not been completed on 1/12/12 in the morning. Note: According to documentation from the TAR a total of four treatments for the resident's left thigh burned area were not completed. During a telephone interview on 1/12/12 at 10:40 A.M., Pharmacy Representative A said: -The physician's order for [MEDICATION NAME] cream dated 1/10/12 had not been received until 1/12/12 at 7:48 A.M. -The facility had sent a request for a refill of the [MEDICATION NAME] on 1/11/12 at 8:48 A.M. -He/she immediately faxed back through his/her computer a response to the facility on [DATE] at 8:49 A.M., requesting a copy of the physician's telephone order so the [MEDICATION NAME] treatment could be filled. -The physician's telephone order had not been received from the facility until 1/12/12 at 7:48 A.M. Record review of a fax received on 1/12/12 at 10:55 A.M., from the facility pharmacy showed the following documents: -A refill order form from the facility to the pharmacy requesting [MEDICATION NAME] Cream. The document had a stamped code from the fax machine as being received by the pharmacy on 1/11/12 at 8:48 A.M. -A request fax message request from the pharmacy to the facility on [DATE] requesting the physician's order for the [MEDICATION NAME] cream in order to complete the order. -A copy of the resident's Telephone Orders Sheet dated 1/10/12 at 5:00 P.M., showed the physician's order for [MEDICATION NAME] to the left thigh twice a day and to cover with [MEDICATION NAME]. The document had a stamped code from the fax machine as being received by the pharmacy on 1/12/12 at 7:48 A.M. Note: There was no record of the original physician's order for [MEDICATION NAME] being received by the pharmacy on 1/10/12. During an interview on 1/12/12 at 11:16 A.M., the DON said: -He/she expected the pharmacy to have a treatment delivered within four hours after the pharmacy received the physician's order. -He/she was unaware that the resident's treatment order for [MEDICATION NAME] had not been received from the pharmacy. -The first treatment should have been done on 1/10/12 in the evening but it was not done. -He/she was unaware that the treatment order of [MEDICATION NAME] had not been applied to the resident's burn as ordered by the physician. Observation of the resident's wound treatment and interviews with LPN C and the DON on 1/12/12 at 12:10 P.M., showed: -LPN C and the DON in the room with the resident. -LPN C placed a small container of normal saline, a package of 4x4 gauze (a type of wound dressing), paper tape, scissors, a tube of [MEDICATION NAME] cream and a box of gloves directly on the resident's overbed table without first placing a barrier on the overbed table to maintain a clean field (a technique used during wound care to help prevent infection of the wound). -LPN C assisted the resident with removing his/her pants. -The resident had a large area of reddened skin that had multiple open areas on the resident's left thigh. -The burned left thigh area did not have a treatment or dressing on the area. -The left anterior thigh had the following wounds: --Wound 1 had an irregular shape 2.5 cm in length by 1.5 cm in width wound. The center of the wound appeared waxy and the edges were red crusty. --Wound 2 had a 0.25 cm round open area with a pink wound bed. -The left lateral thigh had the following wounds: --Wound 3 had an irregular shape 1.5 cm in length by 1.0 cm in width wound. The center of the wound appeared waxy and the edges were red crusty. --Wound 4 had a linear, flat 0.25 cm in length by 1.0 cm in width wound that was dry and crusted. -The surrounding skin area around the wounds was bright red in an 8 cm by 10 cm area. -The DON said it was a second degree burn. -LPN C cleansed the wounds area with normal saline and 4x4 gauze. -The resident stated he/she had no pain from the wounds. -LPN C had the [MEDICATION NAME] tube from the overbed table. -The DON said to LPN C that he/she would get something to apply the [MEDICATION NAME] with. -The DON returned to the room with cotton swabs. -LPN C applied [MEDICATION NAME] to the resident's anterior thigh wound by rubbing the cotton swab in a back and forth motion (instead of circular motion starting in the center and moving outward). LPN C did not cover the smaller area with the [MEDICATION NAME]. -LPN C applied [MEDICATION NAME] with a new cotton swab to the resident's lateral thigh wound by rubbing the cotton swab in a back and forth motion (instead of circular motion starting in the center and moving outward). -LPN C cut the [MEDICATION NAME] dressing with the scissors that were directly placed on the overbed table. -LPN C started to place the [MEDICATION NAME] dressing over the wound when the surveyor intervened and inquired about the smaller wound on the anterior thigh that had not been covered with [MEDICATION NAME] cream. -The DON left the room and returned with additional cotton swabs. -LPN C said he/she should have covered all of the open areas with [MEDICATION NAME] cream. -LPN C applied additional [MEDICATION NAME] cream in a back and forth motion over the wounds including the smaller wound. -LPN C applied the [MEDICATION NAME] pad to the wound areas leaving a small portion of the 0.5 cm open area uncovered by the [MEDICATION NAME] dressing. -LPN C secured the [MEDICATION NAME] dressing with paper tape. -The paper tape was in direct contact with the red skin and a small portion of the 0.5 cm wound. -LPN C said this was the first treatment that had been applied to the resident's burned left thigh area. During an interview on 1/12/12 at 12:40, LPN C said: -He/she could have used a clean towel as a barrier for the wound care supplies he/she had placed on the resident's overbed table. -The treatment was a clean procedure and it did not have to be sterile, and the supplies needed to set on a clean field. -The scissors he/she used were brand new but he/she placed the scissors directly on the overbed table without a barrier. -He/she wiped the [MEDICATION NAME] cream on the resident's wounds in a back and forth motion. -He/she had missed putting [MEDICATION NAME] cream on the small open area on the anterior thigh. During an interview on 1/12/12 at 12:45, the DON said: -LPN C could have put a barrier down before placing the wound care supplies on the over bed table. -He/she acknowledged that LPN C put his/her scissors directly on the over bed table. -He/she should have used a barrier for all of the wound care supplies. -He/she would prefer that LPN C had used one cotton swab for each open area. During a telephone interview on 1/12/12 at 2:40 P.M., Physician A said: -The resident had second [MEDICAL CONDITION] his/her left thigh. -The epithelium (skin) was gone. -He/she had been notified of the blistered area on 1/10/12 but not before. -NP A had originally been notified of the burn incident right after it occurred when the area was only red. -He/she had been told by the DON that the treatment of [REDACTED]. -He/she expected the facility to notify him/her and the DON as soon as the blisters appeared over the area. -The DON stated the facility was using [MEDICATION NAME] (an antibiotic cream) on the burn wounds and covering it with a non-stick pad until the [MEDICATION NAME] order was received by the pharmacy, and [MEDICATION NAME] would have been fine to use on the wounds. -If the wounds had not been treated until today that was a concern to him/her. -The wounds should have been treated with [MEDICATION NAME] when he/she gave the order. -He/she had not given an order for [REDACTED]. -He/she expected all of the open areas to be covered by [MEDICATION NAME] when the wounds were treated. -It was a problem if the staff member did not cover all of the open areas with [MEDICATION NAME] during wound treatment. -The wounds were stable at this point. -There was a systemic failure at the facility. During an interview on 1/12/12 at 3:00 P.M., LPN C said: -He/she had been doing the wound treatments for the past few days on the resident's hall. -He/she had not applied [MEDICATION NAME] to the resident's wounds. -He/she would have obtained a physician's order for the [MEDICATION NAME] before using it on the resident's wounds. -The facility did not keep [MEDICATION NAME] in stock. -The wounds had remained uncovered and not treated until today. -There had been no other treatment applied to the wounds. -He/she had applied the first treatment of [REDACTED]. Note: The facility wound care policy was requested but not received by the end of the survey. 2. Record review of the facility's undated Pain Management Program policy showed each resident will be assessed using our interdisciplinary approach with regard to the level of pain or discomfort experienced, and reviewing both medical and social histories and all other [DIAGNOSES REDACTED]. The policy objective was to promote prompt and effective assessment, [DIAGNOSES REDACTED]. The assessment procedures stated the nurse will perform a pain assessment including: -The current pain management regimen. -The history of pain. -The resident's cognitive status. -What relieved the pain in the past including pharmacological and non-pharmacological interventions. -What level of pain was acceptable to the resident. -The description of the pain. -The location of the pain. -The current level of pain using a 1-10 pain scale rating. (A rating of 1 is the lowest level of pain while a rating of 10 is the highest level of pain). -Medical factors and [DIAGNOSES REDACTED]. The policy's intervention protocols if pharmacological intervention was initiated included the following. -The least evasive route should be used first. -The wishes of the resident for level of sedation must be considered. -The realistic outcome should be communicated to the resident, as it is always not realistic to relieve all of the resident's pain. -For residents with constant moderate pain, a long acting medication for breakthrough pain is usually desired. -For intermittent pain, a short acting medication should be ordered as needed. -Pain management is best achieved with scheduled pain medications and should include an as needed pain medication for breakthrough management. -Documentation of pain and effect of intervention is to be documented on the flow sheet or nurses notes. -The flow sheet called Pain Assessment Treatment Administration record showed pain was documented on an hourly basis each shift. Note: The flow sheet did not have an area to list when a breakthrough medication was given. 3. Record review of Resident #6's Face Sheet showed the resident was admitted to the facility on [DATE] for Medicare skilled services. Record review of the resident's POS dated 12/19/11 showed he/she had [DIAGNOSES REDACTED]. -[MEDICATION NAME] 5/325 (a narcotic pain reliever that consists of 5 milligrams (mg) of the [MEDICATION NAME] narcotic, and 325 mg of [MEDICATION NAME]; also known as Tylenol), take one tablet every four hours as needed for breakthrough pain. -[MEDICATION NAME] (also known as [MEDICATION NAME], a narcotic pain medication) 10/325, take two tablets every three hours as needed for pain. Record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -On 12/20/11, two tablets of [MEDICATION NAME] 10/325 mg were administered to the resident for a pain scale rating of eight and a complaint of pain in the left hip. Note: The staff did not document if any non-pharmacological interventions were tried before administering the pain medication, and did not document if they assessed the resident's pain using the pain scale rating 30 minutes to one hour after the pain medication was administered to show if the pain medication had been effective. -On 12/25/11, two tablets of [MEDICATION NAME] 10/325 mg were administered to the resident for pain. Note: The staff did not document if any non-pharmacological interventions were tried before administering the pain medication, did not document if they assessed the resident's pain using the pain scale rating prior to the administration of the pain medication, and did not document if they assessed the resident's pain using the pain scale rating 30 minutes to one hour after the pain medication was administered to show if the pain medication had been effective. -On 12/31/11, two tablets of [MEDICATION NAME] 10/325 mg were administered to the resident for pain. Note: The staff did not document if any non-pharmacological interventions were tried before administering the pain medication, did not document if they assessed the resident's pain using the pain scale rating prior to the administration of the pain medication, and did not document if they assessed the resident's pain using the pain scale rating 30 minutes to one hour after the pain medication was administered to show if the pain medication had been effective. -On 1/1/12, two tablets of [MEDICATION NAME] 10/325 mg were administered to the resident for pain. Note: The staff did not document if any non-pharmacological interventions were tried before administering the pain medication, did not document if they assessed the resident's pain using the pain scale prior to the administration of the pain medication, and did not document if they assessed the resident's pain using the pain scale rating 30 minutes to one hour after the pain medication was administered to show if the pain medication had been effective. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff) dated 12/26/11 showed the resident: -Had moderately impaired cognition. -Needed extensive assistance of two staff members for transfers, bed mobility and toilet use. -Needed the extensive assistance of one staff member for walking, dressing, personal hygiene and bathing. -Had a recent hip replacement. -Had severe pain in the last five days. Record review of the resident's medical record on 1/11/12 showed no comprehensive care plan, and no care plan addressing the resident's pain. 4. Record review of Resident #3's face sheet showed the resident was admitted on [DATE] with no specified admitting diagnoses. Record review of the resident's January 2012 POS showed the following [DIAGNOSES REDACTED]. -Bilateral (both sides) swelling and ulcers on the lower extremities; -UTI; and -Right-sided inguinal pain (groin pain). Record review of the resident's Initial Pain Care Plan dated 1/3/12, showed in the area of pain management the goal was for the resident to experience less pain, and directed staff to: -Provide non-drug Interventions; -Monitor his/her pain every shift; and -Assess his/her pain tolerance. Record review of the resident's January 2012 as needed (PRN) MAR indicated [REDACTED]. Results were to be documented with an appropriate code, and to initial if a person was an observer other than the nurse administering. If a reason for administration was not clearly indicated in the order block, document a reason on the back. The MAR indicated [REDACTED] -[MEDICATION NAME] ([MEDICATION NAME] - a narcotic-like pain reliever used to treat moderate to severe pain.) 50 mg, take one tablet every four hours PRN for pain. Record review of the back of the resident's January 2012 PRN MAR indicated [REDACTED]'s pain duration and location, and medication's effectiveness each time the [MEDICATION NAME] was administered as follows: - On 12/31/11 at 6:00 P.M., and - On 1/5/12 at a time that was documented, bu