Every finding on record at Kirksville Manor Care Center

Based on observation and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff failed to ensure food items were sealed, labeled, dated, and stored in sanitary conditions. Staff did not practice proper hand hygiene when handling residents' drinks. The ice machine did not contain an air gap at the drain or backflow prevention device to prevent potential backflow from the drain back into the ice machine. The facility census was 56.1. Review of the facility policy, Food Receiving and Storage, dated 2001, showed the following: -Non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity control, free of insects rodents and kept clean; -Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use; -All foods starting refrigerated or freezer are covered, labeled and dated (use by date). Review of the facility policy, Sanitization, dated 2001, showed the following: -The food service area is maintained in a clean and sanitary manner; -All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. Observation on 03/16/26 from 8:48 A.M. to 9:33 A.M., during the initial kitchen and dietary storage tour of the facility, showed the following:-Under the food preparation counter in the kitchen, the exterior surfaces of the bulk flour, sugar, and salt containers were splattered with food debris and sticky residue;-In the reach-in coolers in the kitchen, a clear container of a tomato-based liquid and a clear container of shredded meat were not labeled or dated. Several unlabeled, undated bowls of frosted cake were uncovered. A package of butter was not securely sealed. A box of sausage patties was unsealed;-In the dry storage room, a large bag of dry noodles sat on the shelf and was not sealed. A soiled apron sat on top of an open box that contained packets of gravy mix. Several stacks of uncovered coffee filters sat on a shelf next to an air conditioner that had a moderate accumulation of dust and debris across the surface of the unit. There was food debris, trash, and dirt on the floor, including under the food storage shelves. A large oil-saturated cardboard box that contained a jug of canola oil sat on the floor;-In the reach-in freezer in the service hall outside the kitchen, the inner bags in boxes of breaded [NAME], cookie dough, and broccoli were not sealed. Observation on 03/17/26 at 10:09 A.M., in the dietary storage room, located across the hall from the staff breakroom, showed the following:-A large bag of navy beans sat on the shelf and was not sealed;-A moderate accumulation of food debris and trash was scattered across the floor, including under the food storage shelves. Observation on 03/16/26 at 9:26 A.M. and on 03/17/26 at 10:36 A.M., of four upright freezers in the vacant dining room (across from room [ROOM NUMBER]), showed the following:-One unlabeled freezer, which contained loaves of bread and packages of frozen raw meat, was rusted across the exterior surface of the door and the inner metal shelves were rusted across 50% of the shelf surfaces;-A second freezer, labeled 'Proteins,' contained various boxes and bags of frozen meat. The bottom shelf was rust-colored and had multiple chipped and broken areas across the surface of the shelf;-A third freezer, labeled 'Vegetables,' contained an unsealed box of corn and other boxes and bags of vegetables. The bottom shelf had reddish-brown residue and bits of food debris across the surface of the shelf;-A fourth freezer, labeled 'Starches,' contained boxes and bags of food items. The bottom shelf had scratches and areas of rust across the surface of the shelf. During an interview on 03/18/26 at 11:52 A.M., the Dietary Manager said he expected food to be stored under sanitary conditions, labeled, dated, and sealed. He had a deep clean schedule for the kitchen, but there had been a lot of new dietary staff and it was difficult to implement the schedule with the new staff. During an interview on 03/18/26 at 1:22 P.M., the Administrator said he expected staff to store, prepare, and serve food in a safe and sanitary manner. 2. Observation on 03/16/26, from 11:45 P.M. to 12:05 P.M., showed the following:-Certified Medication Technician O (CMT) served drinks to residents in the dining room;-He/She did not perform hand hygiene;-With bare hands, CMT O picked up two empty coffee cups, set them on the counter in front of the coffee pot and placed her bare hand on top of the drinking surfaces;-He/She filled the cups with coffee and carried the cups across the dining room by the drinking surface (rim) of the cup instead of by the cup handle and served the beverages to Resident #37 and Resident #60;-He/She did not perform hand hygiene;-With his/her bare hands, he/she picked up two stacked, empty Styrofoam cups, separated them, touched the drinking surface, set them on the counter in front of the tea pitcher, and again, touched the drinking surface with his/her bare hand; -He/She filled the cups with tea and carried the cups across the dining room and served the beverages to Resident #2 and Resident #23. During an interview on 03/17/26 at 9:59 A.M., CMT O said the following:-He/She served several resident's drinks during lunch;-He/She touched the drinking surface with his/her bare hands;-He/She did not wash his/her hands with soap and water or use hand sanitizer when serving drinks to the residents;-He/She should not touch the drinking surface with his/her bare hands. During an interview on 03/17/26 at 8:00 A.M., the Dietary Manager said the following:-Staff should not touch drinking surfaces with their bare hands when serving drinks;-Staff should wash their hands with soap and water or use hand sanitizer before serving a drink to a resident. During an interview on 03/17/26 at 10:21 A.M., the Director of Nursing (DON) said when serving drinks to residents staff should not touch the drinking surface with their hands. Staff should wash their hands with soap and water or use hand sanitizer between every four drinks served. Staff should hold a cup from the bottom to ensure their fingers do not touch the drinking surface. 3. Observation on 03/16/26 at 9:20 A.M., of the facility's ice machine, showed the following:-At the back of the machine, an approximately 3-foot vertical pipe attached to an approximately 1-foot long horizontal pipe connected the ice machine drain directly to the floor drain with no air gap present between the pipe and the floor drain;-At the bottom of the machine, an approximately 2-foot horizontal pipe connected the ice machine drain directly to the floor drain with no air gap present between the pipe and the floor drain. During an interview on 03/16/26 at 4:16 P.M., the Maintenance Supervisor said he expected the ice machine to have an air gap at the drain to prevent potential backflow into the unit. The machine was leased and the company that owned it was responsible for management of the machine, including the connection to the drain. During an interview on 03/18/26 at 11:52 A.M., the Dietary Manager said the facility leased the ice machine, and he was unaware there was no air gap at the drain to prevent backflow of liquid back into the machine.

Based on observation, interview, and record review, the facility failed to implement policies and procedures to ensure resident trust accounts were not allowed to go into a negative balance for one resident (Resident #53) and failed to deposit residents' personal funds in excess of $50.00 into an interest-bearing account for two residents (Residents #15 and #2). The facility reported holding funds for nine residents. The facility census was 56. Review of the facility's undated policy, Accounting and Records of Resident Funds, showed the following:-The business office maintains a record of all financial transactions involving the resident's personal funds on deposit with the facility;-Individual accounting ledgers are maintained in accordance with generally accepted accounting principles; -The policy did not address negative balance in the resident trust fund account. Review of the facility's undated Resident Trust Account for Personal Funds Agreement showed the following:-Resident may keep up to $50.00 in a petty cash fund at the facility in the Social Services Department;-Resident personal funds over $50.00 will be placed in an interest-bearing bank account. 1. Review of the facility provided ledgers of residents who held money in the resident trust showed the following:-Nine residents held money in the resident trust fund account;-The list did not include Resident #15 and #2. 2. Review of Resident #53's resident fund ledger, dated 12/28/25 through 03/02/26, showed the following:-On 01/06/26, the resident's account balance was $10.11;-On 01/16/26, the resident signed a store receipt in the amount of $43.36;-On 01/16/26, $43.96 was withdrawn from the resident's account. The resident's account balance was -$33.85;-On 01/20/26, $40.00 was deposited into the resident's account;-On 2/16/26, the resident's account balance was $2.82;-On 2/17/26, the resident signed a store receipt in the amount of $13.64;-On 2/17/26, $13.64 was withdrawn from the resident's account. The resident's account balance was -$10.82;-On 03/02/26, $30.00 was deposited into the resident's account. During an interview on 03/17/26 at 12:27 P.M., the resident's guardian said the following:-He/She sent the resident $30.00 per month for his/her spending;-Resident #53 was having a hard time managing his/her money;-He/She had to send extra money after one of the resident's purchases. 3. Observation on 03/18/26 at 12:30 P.M. showed an envelope, labeled with Resident #15's name, was held in a safe in the Social Services Director's office. The envelope contained $66.00 in cash. 4. Observation on 03/18/26 at 12:30 P.M. showed an envelope, labeled with Resident #2's name, was held in a safe in the Social Services Director's office. The envelope contained $72.68 in cash. 5. During an interview on 03/18/26 at 12:30 P.M., the Social Services Director said the following:-She was responsible for the safe keeping and maintenance of the residents' money in the envelopes;-She was unaware there was a $50.00 limit (in the petty cash). During interviews on 03/18/26 at 10:47 A.M. and 5:15 P.M., the Administrator said the following:-He took over maintenance of the resident trust fund account in July 2025;-He authorized Resident #53's purchase in January. He was out of the building a lot and did not know if he knew the resident's balance;-He was the only one with access to the resident trust fund balances;-There should be no negative balances in the resident trust fund;-Staff kept residents' money in envelopes in a safe at the facility for residents who asked the facility to put their money away for safe keeping;-The money in the envelopes was accounted for on the front of the envelopes with entries showing the disbursement and the SSD's signature;-The SSD was responsible for maintaining the money in the envelopes in the safe in her office; -Not all the residents who asked him to safeguard their money was in the resident trust fund account;-He was unsure if the residents could have more than $50.00 in the envelope.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #26) in a review of 18 sampled and three additional residents (Resident #32, #12 and #8), received the prescribed insulin (a hormone used to treat diabetes by controlling blood sugar levels) dosage when staff failed to prime the insulin pen prior to administration per the manufacturer's guidelines. The facility census was 56. Review of the facility's policy, Insulin Pen, revised 08/15/25, showed the following:-Policy: It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge; -Procedure: -Attach pen needle: -Prime the insulin pen: Dial 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears; -Set the insulin dose:-Injecting the insulin: -Inject the needle straight at a 90-degree angle to the skin; -Fully depress plunger until the dosing numbers count back to zero; -While still pressing the plunger, keep the needle in the skin for up to six to ten (6-10) seconds and then remove the needle from the skin; Review of the Lantus Solostar (a prefilled insulin pen) manufacturer's administration guidelines, revised 11/2018, showed the following:-Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: -Ensuring the pen and needle work properly; -Removing air bubbles; -Select a dose of two (2) units by turning the dosage selector; -Hold the pen with the needle pointing upwards; -Tap the insulin reservoir so that any air bubbles rise up towards the needle; -Press the injection button all the way in. Check if insulin comes out of the needle tip. -You may have to perform the safety test several times before insulin is seen;-If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them;-If still no insulin comes out, the needle may be blocked. Change the needle and try again;-Inject the dose: -Insert the needle into the skin; -Deliver the dose by pressing the injection button in all the way; -Keep the injection button pressed all the way in. Slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose will be delivered. Review of the Novolog Flex Pen (a prefilled insulin pen) manufacturer's administration guidelines, dated September 2025, showed the following:-Apply the needle and take off the cap;-The air shot: -To avoid injecting air and to ensure proper dosing, perform an air shot; -Turn the dose selector to select two units; -Hold the Novolog flex pen with the needle pointing up; -Tap the cartridge gently with your finger a few times to get rid of any air bubbles that have collected at the end of the cartridge; -Keep the needle pointed upwards and push the dose selector until it returns to zero; -A drop of insulin should appear at the end of the needle; -With the dose selector at zero, dial up the correct dose of insulin units. Review of the Lispro Kwik Pen (a prefilled insulin pen) package insert showed the following: -Prime- If you do not prime before each injection, you may get too much or too little insulin. Turn the dose knob to select two units, hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. Repeat the priming procedure if you did not see insulin at the tip of the needle;-Turn the dose knob and select the number of units you need to inject and administer the medication. 1. Review of Resident #26's physician order summary, dated March 2026, showed the following:-Blood glucose finger sticks: fasting in the morning. Obtain one time a day;-Lantus (insulin) subcutaneous solution 100 units/milliliter (mL), inject 10 units subcutaneously (beneath the skin) in the morning. Observation on 03/17/26 at 7:07 A.M. showed the following:-Certified Medication Aide (CMT) M applied a needle to the end of the Lantus insulin pen;-CMT M did not prime the needle;-CMT M dialed up 10 units of Lantus;-He/She administered the Lantus into the resident's left upper arm;-He/She held the needle on the resident's arm for six seconds;-He/She did not hold the needle in the resident's arm for 10 seconds as directed by the manufacturer guidelines to ensure the full dose was delivered. 2. Review of Resident #32's physician order summary, dated March 2026, showed the following:-Insulin aspart (Novolog) flex pen subcutaneous solution pen injector 100 units/ml;-Inject as per sliding scale: if 0-150 =0; 151-200 = 1; 201-250 = 2; 251-300 = 3; 301-350 = 3; 351-400 = 5; 401-450 = 5;-Give subcutaneously before meals and at bedtime. Review of the resident's medication administration record (MAR), dated 03/16/26 at 11:00 A.M., showed the resident's blood sugar was 163. Observation on 03/16/26 at 11:12 A.M., showed the following:-CMT M applied a needle to the end of the insulin aspart pen;-CMT M did not prime the needle;-CMT M dialed up one unit of insulin aspart;-He/She administered the insulin aspart into the resident's left arm. 3. Review of Resident #12's physician order summary, dated March 2026, showed the following:-Novolog Flex Pen 100 units/mL;-Inject as per sliding scale if 151-199 = 2; if 200-249 = 4; if 250-299 = 6; if 300-349 = 8; if [PHONE NUMBER] = 10 subcutaneously before meals and at bedtime. Review of the residents' MAR, dated 03/16/26 at 11:00 A.M., showed the resident's blood sugar was 210. Observation on 03/16/26 at 11:20 A.M. showed the following:-CMT M applied a needle to the end of the Novolog flex pen;-CMT M did not prime the needle;-CMT M dialed up four unit of Novolog;-He/She administered the Novolog into the resident's right lower abdomen. Review of the resident's MAR, dated 03/17/26 at 7:30 A.M., showed the resident's blood sugar was 193 (blood sugar reading for insulin administration at 6:50 A.M.) Observation on 03/17/26 at 6:50 A.M., showed the following:-CMT M applied a needle to the end of the insulin Novolog flex pen;-CMT M did not prime the needle;-CMT M dialed up two units of Novolog;-He/She administered the Novolog into the resident's left lower abdomen. During an interview on 03/17/26 at 7:22 A.M., CMT M said the following:-He/She did not prime the needle before administering insulin to Residents #32, #12 or #26;-He/She thought the only time he/she had to prime an insulin pen was when it was initially opened and before the first use;-He/She was not aware he/she needed to prime insulin pens before administering the medication;-When he/she administered insulin from a pen, he/she held the needle to the resident's skin for five to six seconds. 4. Review of Resident #8's March 2026 physician orders showed the following:-Diagnosis of type I diabetes;-Lispro Kwik Pen Insulin 100 units/mL, inject per sliding scale: if 1-39 = give 1 vial of D50; 40-60 = give 1/2 vial of D50 or a snack; 180-200 = 2 units; 201-250 = 4 units ; 251-300 = 6 units; 301-350 = 8 units; 351-500 = 10; above 450, give 10 units and call physician, subcutaneously before meals and at bedtime. Observation on 03/16/26 at 5:04 P.M., showed the following:-CMT D attached a needle to the resident's Lispro Kwik Pen; -CMT D did not prime the insulin pen;-CMT D dialed up two units of Lispro insulin per the sliding scale insulin instructions, and administered the medication in the resident's left upper arm. During an interview on 03/17/26 at 7:45 A.M., CMT D said the following:-When using an insulin pen, he/she was to prime the needle with two units, then dial up the dose and inject the insulin; -He/She thought he/she primed the insulin pen prior to administering the resident's insulin on 03/16/26 at 5:04 P.M. 5. During interviews on 03/17/26 at 7:39 A.M. and 03/18/26 at 6:00 P.M., the Director of Nursing (DON) said the following:-During insulin administration using an insulin pen, staff needed to prime the needle with two units, administer the insulin and hold the pen on the resident's skin for 6 to 10 seconds;-Staff should follow manufacturer guidelines when administering medications.

Based on observation, interview, and record review, the facility failed to maintain a system to ensure residents' money was managed in accordance with proper accounting principles when the facility did not reconcile the residents' petty cash each month. The facility also failed to reconcile the resident trust fund bank account monthly to ensure accurate accounting of funds. The facility census was 59. Review of the undated facility policy, Accounting and Records of Resident Funds, showed the following:-The business office maintains a record of all financial transactions involving the residents' personal funds on deposit with the facility;-Individual accounting ledgers are maintained in accordance with generally accepted accounting principles. 1. Review of the facility provided ledgers of residents who held money in the resident trust showed the following:-Nine residents held money in the resident trust fund account;-The list did not include Resident #15;-The list did not include Resident #2;-The list did not include Resident #3;-The list did not include Resident #12;-The list did not include Resident #31;-The list did not include Resident #38. 2. Observation on 03/18/26 at 12:30 P.M. of an envelope, labeled with Resident #15's name, held in the Social Services Department office, showed the following:-The envelope contained $66.00 in cash;-On 10/08/25, the contents of the envelope were verified with staff initials;-There was no monthly reconciliation of the petty cash held in the envelope or documentation of a monthly verification of contents after 10/08/25. 3. Observation on 03/18/26 at 12:30 P.M. of an envelope, labeled with Resident #2's name, held in the Social Services Department office, showed the following:-The envelope contained $72.68 in cash;-On 10/08/25, the contents were verified with staff initials;-There was no monthly reconciliation of the petty cash held in the envelope or documentation of a monthly verification of contents after 10/08/25. 4. Observation on 03/18/26 at 12:30 P.M. of an envelope, labeled with Resident #3's name, held in the Social Services Department office, showed the following:-The envelope contained $16.00 in cash;-On 10/07/25, the contents were verified with staff initials;-There was no monthly reconciliation of the petty cash held in the envelope or documentation of a monthly verification of contents after 10/07/25. 5. Observation on 03/18/26 at 12:30 P.M. of an envelope, labeled with Resident #12's name, held in the Social Services Department office, showed the following:-The envelope contained $50.00 in cash;-On 10/17/25, the contents were verified with staff initials;-There was no monthly reconciliation of the petty cash held in the envelope or documentation of a monthly verification of contents after 10/17/25. 6. Observation on 03/18/26 at 12:30 P.M. of an envelope, labeled with Resident #31's name, held in the Social Services Department office, showed the following:-The envelope contained $30.00 in cash;-On 10/09/25, contents were verified with staff initials;-There was no monthly reconciliation of the petty cash held in the envelope or documentation of a monthly verification of contents after 10/09/25. 7. Observation on 03/18/26 at 12:30 P.M. of an envelope, labeled with Resident #38's name, held in the Social Services Department office, showed the following:-The envelope contained $50.00 in cash;-On 01/19/26, the contents were verified with staff initials;-There was no monthly reconciliation of the petty cash held in the envelope or documentation of a monthly verification of contents after 01/19/26. 8. Observation on 03/18/26 at 12:30 P.M. of an envelope, labeled with Resident #13's name, held in the Social Services Department office, showed the following:-The envelope contained $50.00 in cash;-On 05/05/25, the contents were verified with staff initials;-There was no monthly reconciliation of the petty cash held in the envelope or documentation of a monthly verification of contents after 05/05/25. 9. Observation on 03/18/26 at 12:30 P.M. of an envelope, labeled with Resident #44's name, held in the Social Services Department office, showed the following:-The envelope contained $15.00 in cash;-On 10/08/25, the contents were verified with staff initials;-There was no monthly reconciliation of the petty cash held in the envelope or documentation of a monthly verification of contents after 10/08/25. 10. Observation on 03/18/26 at 12:30 P.M. of an envelope, labeled with Resident #48's name, held in the Social Services Department office, showed the following:-The envelope contained $0.67 in change;-On 10/08/25, the contents were verified with staff initials;-There was no monthly reconciliation of the petty cash held in the envelope or documentation of a monthly verification of contents after 10/08/25. 11. During an interview on 03/18/26 at 12:30 P.M., the Social Services Director (SSD) said the following:-She was responsible for the safe keeping and maintenance of the resident's money in the envelopes;-She was unaware the money in the envelopes was considered petty cash and needed to be reconciled each month. 12.Review of the Resident Trust Fund ledgers, Resident Trust Fund bank statements and reconciliation form, dated 12/31/25 through 02/28/26, showed the following:-The total amount of the Resident Trust Fund ledgers on 12/31/25 was $7,004.24. The total amount in the Resident Trust Fund bank account was $12,662.58. The facility's reconciliation for the bank account showed the reconciled balance was $12,662.58. The difference between the Resident Trust ledgers and the Resident Trust Fund bank account was $7,004.24-The total amount of the Resident Trust Fund ledgers on 01/31/26 was $4,270.64. The total amount in the Resident Trust Fund bank account was $9,694.12. The facility's reconciliation for the bank account showed the reconciled balance was $9,694.12. The difference between the Resident Trust ledgers and the Resident Trust Fund bank account was $5,423.48;-The total amount of the Resident Trust Fund ledgers on 02/28/26 was $5,129.14. The total amount in the Resident Trust Fund bank account was $10,478.95. The facility's reconciliation for the bank account showed the reconciled balance was $10,478.95. The difference between the Resident Trust ledgers and the Resident Trust Fund bank account was $5,349.81.(The facility did not properly reconcile the resident trust fund bank account monthly to ensure accurate accounting of funds.) 13.During an interview on 03/18/26 at 10:47 A.M. and 5:15 P.M., the Administrator said the following:-He took over maintenance of the resident trust fund account in July 2025;-He was responsible for reconciling the resident trust fund account each month; -There was an approximately $2,000.00 extra in the Resident Trust Fund account. The $2,000.00 had been in the account since before 2022. He tried to find out where the money came from, but he was unable to make that determination; -If the account would have been reconciled properly, he/she would have been able to identify who the $2000.00 belonged to; -He did not have any resident trust fund petty cash in the building;-There was money in envelopes in a safe at the facility was for residents who asked the facility to put their money away for safe keeping;-He did not consider the money in the envelopes to be petty cash;-The money in the envelopes was accounted for on the front of the envelopes with entries showing the disbursement and the SSD's signature;-The SSD was responsible for maintaining the money in the envelopes in the safe in her office;-The resident cash was not reconciled monthly, just when a resident withdrew or deposited money from the envelope.

Based on observation and interview, the facility failed to maintain walls, flooring, resident sleeping rooms, resident restrooms, and shower and toilet rooms to be clean and good repair. The facility census was 56.Observations on 03/16/26 from 10:18 A.M. to 4:23 P.M. and on 03/17/26 from 10:13 A.M. to 3:24 P.M., during the Life Safety Code tour of the facility, showed the following: -In occupied resident room [ROOM NUMBER], ten wooden slats were missing from the closet door; -In occupied resident room [ROOM NUMBER], eight wooden slats were missing from the closet door. The edge of the room door was chipped and a 2-inch piece of plastic was missing from the door covering; -In the bathroom to occupied resident room [ROOM NUMBER], the floor was discolored yellow, and there was brown and black residue around the toilet which had areas of missing caulk; -In occupied resident room [ROOM NUMBER], there were two unfilled holes in the wall above the towel rack by the sink; -In unoccupied resident room [ROOM NUMBER], the sink pulled away from the wall and the cove base along the wall under the sink was off the wall. There was a 2-inch by 4-inch circular area of textured paint that was missing from the ceiling. There were two 1-inch by 2-inch pieces of tile missing from the floor; -In occupied resident room [ROOM NUMBER], one wooden slat was missing from the closet door; -In occupied resident room [ROOM NUMBER], five wooden slats were missing from the closet door; -In the bathroom to occupied resident room [ROOM NUMBER], the floor was discolored yellow and gray in several areas; -In occupied resident room [ROOM NUMBER], a 2-inch by 2-inch section of floor tile was missing; -In the bathroom to occupied resident rooms [ROOM NUMBERS], the floor was discolored brown around the base of the toilet; -In the bathroom to unoccupied resident room [ROOM NUMBER], the floor was discolored gray in several areas. Around the base of the toilet, the caulking was missing and there was a brown residue. A 3-inch section of flooring was missing; -In occupied resident room [ROOM NUMBER], a 2-inch section of cove base was coming loose from the wall; -In the bathroom to occupied resident room [ROOM NUMBER], the floor was discolored with a yellow residue; -In occupied resident room [ROOM NUMBER], there were four 1-inch sections of tile and a 2-inch by 2-inch section of tile missing from the floor. Above the sink, the wall was bulging outward and there was a 6-inch crack in the wall paint; -In the bathroom to occupied resident room [ROOM NUMBER], there was brown residue on the floor and the caulk was missing around the base of the toilet; -In occupied resident room [ROOM NUMBER], the edge of the room door was chipped and there were 2-inch pieces missing from the plastic door covering; -In the bathroom for occupied resident rooms [ROOM NUMBERS], the floor was discolored with a dark brown residue around the base of the toilet which had areas of missing caulk; -In occupied resident room [ROOM NUMBER], a 2-inch by 6-inch section of the protective plastic cover on the room door was missing; -In occupied resident room [ROOM NUMBER], a 4-inch by 12-inch section of floor tile was missing and a 3-inch by 6-inch piece of cove base trim by the closet door was missing; -In the main entryway, the baseboard heater had spots areas of rust; -In the main dining room, a 6-inch by 4-inch area of the ceiling had loose flaking paint. Two areas of the ceiling, measuring 2-foot by 12-foot and 2-foot by 3-foot, were discolored brown. A 2-foot by 2-foot ceiling vent had a moderate accumulation of dust; -In the staff restroom by the Victorian [NAME] nurses' station, there was a heavy accumulation of dust on the 8-inch by 8-inch ceiling vent; -In the women's restroom by the kitchen, there was no tile on the floor which was discolored gray around the edges of the room. There was a dark brown discoloration by the base of the toilet; -In the janitor closet, a heavy accumulation of dust was visible on a 6-inch by 6-inch ceiling vent; -In the beauty shop, a 2-inch by 6-inch section of floor tile was missing; -In the Victorian [NAME] dining room, a 4-foot by 5-foot section of ceiling was not flush with the rest of the ceiling and drooped down. Two 2-foot circular areas of the ceiling were discolored brown and had cracked and flaking areas of paint; -In the north shower room (Victorian Rose), the floor was discolored with a gray residue and there were yellow dried drips on the floor under the sink. The wall by the sink had various scuffs and marks on the painted surface. Around the toilet, the floor was discolored brown, there was missing caulk around the base of the toilet, and there were gray streaks across the front surface of the toilet. An 8-inch by 8-inch ceiling vent had rusted areas across its surface. The ceiling had an approximately 8-foot long cracked area where the textured ceiling paint was coming loose; -In the south shower room (Victorian Rose), there was a very heavy accumulation of cobwebs and dust on the 6-inch by 6-inch ceiling vent. Observation in the bathroom for occupied resident room [ROOM NUMBER]'s on 03/15/26 at 9:30 A.M. showed the following:-The caulking around the bathroom toilet was missing and/or cracked in areas; -The bathroom floor appeared dirty with a brown and grayish discoloration. Observation in occupied resident room [ROOM NUMBER] on 03/15/26 at 9:45 A.M. showed a large hole in the wall behind the head of the bed. Observation in occupied resident room [ROOM NUMBER] on 03/15/26 at 9:45 A.M. showed the following:-The wall behind the bed was marred;-The bathroom floor had black discoloration behind the toilet;-The floor at the entrance to the room had a brown discoloration. Observation in occupied resident room [ROOM NUMBER] on 03/15/26 at 10:00 A.M. showed the following:-The floor appeared dirty with a brown/black discoloration;-The paint on the wall beside the air conditioning unit had peeled away from the wall; -There was no mattress on the bed next to the window;-The bathroom floor appeared dirty with brown/black discoloration. Observation in the bathroom for occupied resident room [ROOM NUMBER] on 03/15/26 at 10:15 A.M. showed the bathroom floor appeared dirty with black discoloration. Observation in the bathroom for occupied resident room [ROOM NUMBER] on 03/15/26 at 10:15 A.M. showed the floor appeared dirty and the bathroom door was marred. Observation of the bath/shower room on Hummingbird Lane on 03/15/26 at 11:56 A.M. showed the following:-The door was marred;-The door casing to the room was cracked and dirty;-The floor behind the toilet and under the sink appeared dirty with brown/grayish discoloration; -The caulking around the toilet and the wall beside the toilet was missing and/or cracked. Observation on 03/15/26 at 1:25 P.M. in occupied resident room [ROOM NUMBER] showed the following:-A large hole in the wall behind the bed;-The walls beside the bed were marred;-The flooring in the room had a black discoloration. During an interview on 03/18/26 at 10:15 A.M., Housekeeper P said the facility did not have someone who specifically cleaned floors. Housekeeping staff mopped the floors daily, but did not strip the floors. During interviews on 03/16/26 at 11:00 A.M., on 03/17/26 at 10:13 A.M., and on 03/18/26 at 1:22 P.M., the Maintenance Supervisor said the following: -He was the only maintenance staff for the building, and there was no housekeeping supervisor; -He cleaned the main dining room ceiling vent twice per year in the Spring and Fall; -The floors in the facility had not been stripped in about three years; -Staff told him verbally when repairs were needed. During an interview on 03/18/26 at 1:22 P.M., the Administrator said he expected the residents to have a safe and homelike environment. The facility had been without a housekeeping supervisor for approximately one and one-half to two years.

Based on observation, interview, and record review, the facility failed to update care plans to reflect current care needs for six residents (Residents #1, #34, #22, #45, #6, and #42), in a review of 18 sampled residents. The facility census was 56. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed the following:-The RAI and Care Planning as required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool;-It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;-The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. 1. Review of Resident #1's care plan, dated 11/12/25, showed the following:-The resident had hemodialysis (process for removal of waste and excess water from the blood due to kidney failure) related to acute kidney failure;-He/She had a fistula (connection between an artery and a vein, surgically created for dialysis treatments) located in his/her left arm;-Check and change dressing daily at left arm access site and document. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool to be completed by the facility, dated 01/05/26 showed the following:-His/Her diagnosis included renal insufficiency (partial kidney function failure characterized by less than normal urine excretion);-Required dialysis (process for removal of waste and excess water from the blood due to kidney failure).Review of the resident's physician's orders, dated March 2026, showed the following:-No blood pressure, intravenous access (IV, technique for administering fluids, medications or nutrients directly into a vein) or labs in the right arm;-No lifting over 15 pounds or putting stress on the arm with the access. Observation on 03/16/26 at 1:10 P.M., showed the resident sat in his/her wheelchair. The resident had a Permacath (a flexible tube inserted into a vein) in his/her right upper chest covered with Tegaderm (a transparent dressing). Review of the resident's care plan showed no documentation the care plan was updated to include the resident's Permacath, no lifting over 15 pounds, and no blood pressure, intravenous access or labs in the right arm. During an interview on 03/25/26 at 11:35 A.M., the Care Plan Coordinator said the resident's care plan should reflect he/she had a Permacath for dialysis and not the fistula in the left arm, and added do not take blood pressure, IV's or labs in the right arm, and no lifting over 15 pounds. 2. Review of Resident #34's care plan, dated 10/09/25, showed he/she required assistance from one staff and a wheeled walker for transfers, ambulation, toileting and dressing. Review of the resident's quarterly MDS, dated [DATE], showed he/she required substantial/maximum assistance from staff for sit-to-stand, chair/bed transfers, toilet transfers, and shower transfers. Review of the resident's physicians orders, dated March 2026, showed the following:-Right knee immobilizer (ordered 01/13/26);-Non-weight bearing bilateral lower extremities (ordered 01/13/26);-May transition weight bearing as tolerated to right lower extremity while in knee immobilizer (ordered 01/28/26);-Do not use knee immobilizer when ambulating (ordered 01/28/26). Observation on 03/16/26 at 2:50 P.M., showed Certified Nurse Assistant (CNA) K and CNA C transferred the resident with a mechanical lift from the wheelchair to bed. The resident had a knee immobilizer on his/her right knee. Review of the resident's care plan showed no documentation the care plan was updated to include the right knee immobilizer, non-weight bearing status, transition to weight bearing as tolerated with knee immobilizer, and not to use the knee immobilizer with ambulation. During an interview on 03/16/26 at 2:50 P.M., CNA K said the resident had a fracture in his/her upper leg and was non-weight bearing. The resident wore a knee immobilizer on his/her right knee and transferred with a mechanical lift. A charge nurse communicated these things to him/her a couple of months ago. During an interview on 03/25/26 at 11:35 A.M., the Care Plan Coordinator said the resident's care plan should reflect the use of a mechanical lift, the use of a knee immobilizer, non-weight bearing status, transition to weight bearing as tolerated with knee immobilizer, and do not use knee immobilizer when ambulating. 3. Review of Resident #22's admission MDS, dated [DATE], showed the following:-The resident had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device;-He/She had one or more unhealed pressure ulcer injuries;-He/She had one stage 3 pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling)-One unstageable pressure ulcer (slough and/or eschar known but not stageable due to coverage of wound bed by slough and/or eschar); -He/She had an infection of the foot;-He/She had diabetic foot ulcers (an open wound on the foot);-He/She had an ostomy (a surgically created opening in the abdomen that allows waste or urine to exit the body). Review of the resident's hospital medical records, dated 02/20/26, showed the following:-He/She was admitted to hospital on [DATE] with severe peripheral vascular disease (a circulation disorder) and diabetes with neuropathy (nerve damage caused by long-term high blood sugar);-He/She was seen by wound clinic for progression of his/her chronic ischemic wounds (slow-healing wound caused by reduced blood flow to tissues). Review of the resident's physician's order report, dated March 2026, showed the following:-Cleanse wound to right lateral foot with wound cleanser, pat dry. Apply skin prep to peri wound. Apply Silver sorb (a antimicrobial wound gel) and Silver Alginate (a highly absorbent, antimicrobial wound dressing) to wound bed and cover with foam border gauze dressing every three days (original order dated 02/25/26);-Cleanse wound to genitalia with wound cleanser, pat dry, apply skin prep to peri wound, and apply duoderm (a hydrocolloid dressing) to wound every three days (original order dated 02/25/26);-Urostomy (a surgical procedure creating an opening on the abdomen to divert urine outside the body) to right abdomen (original order dated 02/25/26);-Check and drain urostomy drainage bag every shift (original order dated 02/25/26);-May have diabetic shoes. Review of the resident's smoking assessment, dated 02/25/26, showed the resident smoked tobacco. Review of the resident's care plan, last revised on 03/16/26, showed the following:-No documentation the resident had wounds; -No documentation the resident had a urostomy; -No documentation the resident used diabetic shoes;-No documentation the resident enhanced barrier precautions (EBP) due to presence of a urostomy and wounds;-No documentation the resident smoked tobacco. 4. Review of Resident #45's care plan, last revised on 08/08/24, showed the following: -He/She required assistance of two staff and a wheeled walker for all transfers and toileting (updated 01/19/26);-He/She had a pressure wound on the left heel with a wound vac (updated 08/08/25). Review of the resident's quarterly MDS, dated [DATE], showed the following:-He/She had a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling);-He/She had a stage 4 pressure ulcer present upon admission/reentry (previous assessment showed no stage four pressure ulcers were documented);-He/She had an infection of the foot;-He/She had required application of nonsurgical dressings (with or without topical medications) other than to feet;-He/She required application of dressings to feet (with or without topical medications);-He/She was dependent on staff with transfers; Review of the resident's wound clinic report, dated 03/06/26, showed the following:-Healed stage 4 pressure ulcer (onset 10/24/25) of the right lateral malleolus (bony prominence on either side of the ankle);-Healed stage 4 pressure ulcer of the lateral right malleolus (onset 10/24/25);-Orders included Cavilon (used to protect intact or damaged skin from moisture, body fluids, adhesives, and friction) to area then place a border foam dressing every two to three days or as needed. Continue to offload to avoid pressure, float heels at all times, and monitor for signs and symptoms of infection. Observation on 03/15/26 at 10:16 A.M. showed a sign on the resident's door showed he/she was on EBP and directed staff to apply PPE (gown and gloves). A storage device hung from the resident's door and contained gowns and gloves. Review of the resident's physician's orders, dated March 2026, showed no orders for a wound vac. Review of the resident's skilled evaluation, dated 03/16/26, showed the following:-He/She had an in-house acquired osteomyelitis to his/her left heel;-He/She had an in-house acquired chronic medical device related pressure ulcer/injury to the right ankle. Observation on 03/16/26 at 3:30 P.M. showed the following:-The resident had dressings on his/her left heel and right ankle;-He/She required use of a Hoyer lift for transfers;-There was not a wound vac attached to the resident's wounds. Review of the resident's care plan on 3/16/26 showed the following: -The care plan did not correctly identify the resident's transfer status. The resident required a Hoyer lift to transfer;-The care plan was not updated to not include the wound vac;-No documentation the resident had a wound on his/her right ankle; -No documentation the resident's required EBP due to presence of wounds. 5. Review of Resident #6's care plan, revised on 02/26/25, showed the following:-Diagnosis of urine retention (when the bladder does not release urine and it builds up);-The resident had a suprapubic catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine). Review of the resident's MDS, dated [DATE], showed the resident had a urinary catheter (sterile tube inserted into the bladder to drain urine). Review of the resident's physicians' orders, dated March 2026, showed staff was to utilize Enhanced barrier precautions (EBP) every shift for suprapubic catheter. Observation on 03/15/26 at 12:47 P.M., showed the resident sat in his/her wheelchair. A urinary catheter bag hung from the resident's wheelchair. Observation on 03/17/26 at 6:22 A.M. showed the following:-CNA O entered the resident's room and did not put on a gown or face shield;-CNA O obtained a urine collection canister from the resident's bathroom and took it to the resident's bedside;-CNA O emptied the urine of the resident's urinary catheter bag into a urine collection canister and emptied the urine into the resident's toilet;-CNA O did not wear a gown or face shield while emptying the resident's catheter bag. Review of the resident's care plan showed no documentation the care plan was updated to include the resident was on EBP for a urinary catheter. 6. Review of Resident #42's care plan, initiated on 04/17/24, showed the resident had dialysis on Tuesday, Thursday, and Saturday. Review of the resident's quarterly MDS, dated [DATE], showed he/she required dialysis treatments. Review of the resident's physician's orders, dated 03/16/26, showed the following:-He/She required dialysis on Monday, Wednesday, and Fridays (original order dated 02/20/26); -He/She had a Permacath to the right chest for dialysis. Review of the resident's care plan on 03/16/26 showed no documentation staff revised the care plan to reflect the resident had dialysis on Monday, Wednesday and Friday and no documentation to show the resident required enhanced barrier precautions due to having a Permacath. 7. During an interview on 03/18/26 at 9:00 A.M., the Care Plan Coordinator said the following:-Wounds should be part of the resident's care plan;-Care plans should be accurate and reflect the resident's direct care needs;-She was behind on updating care plans because of working patient care. Care plans had not been updated as they should have;-Staff should be able to go to the care plan and know exactly what care needs the resident required and the current care plans are not like that at this time.

Based on observation, interview, and record review, the facility failed to follow current infection control standards for seven residents (Residents #3, #1, #6, #26, #42, #4 and #45), in a review of 18 sampled and three additional residents (Residents #8, #12, and #32). Staff failed to follow enhanced barrier precautions (EBP) by not wearing personal protective equipment (PPE) to prevent infection while providing personal care for Residents #4, #45, #42, #1 and #6, failed to clean a multi-resident use glucometer (machine used to measure blood glucose levels in the blood) and use a barrier during blood glucose finger sticks for Residents #3, #8, #12 and #26, failed to clean insulin pen hubs before attaching a needle for administration of the medication for Residents #12, #26, and #32, and failed to develop a Legionella water management team and conduct meetings to review the monitoring of the facility water system for Legionella. The facility census was 56. Review of the facility's policy for Enhanced Barrier Precautions (EBP), updated on 03/23/24, showed the following:-Enhanced barrier precautions referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities;-All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions;-All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions;-The facility will have the discretion on how to communicate to staff which residents require the use of EBP, if staff are aware of which residents require the use of EBP prior to providing high-contact care activities;-An order for enhanced barrier precautions will be obtained for residents with any of the following 1)Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) 2) indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) 3) even if the resident is not known to be infected or colonized with a MDRO. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply;-Implementation of Enhanced Barrier Precautions: -Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). -PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room;-High-contact resident care activities include: -Dressing; -Bathing; -Transferring; -Providing hygiene; -Changing linens: -Changing briefs or assisting with toileting; -Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes; -Wound care: any skin opening requiring a dressing;-Enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting with bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility;-Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by facility staff, dated 12/22/25, showed the following:-The resident had a feeding tube (a tube surgically inserted into the stomach to provide hydration, nutrition, and medications);-He/She was always incontinent of bowel and bladder;-Dependent on staff with transfers, bathing, and personal hygiene. Review of the resident's care plan, last revised 10/03/25, showed the following:-He/She had a percutaneous endoscopic gastrostomy (PEG tube, surgical insertion of a tube through the abdominal wall into the stomach); -He/She was incontinent of bowel and bladder-Staff was to assist him/her with perineal cleansing as needed and follow standards of practices of care for peri care and infection control protocols;-He/She required two persons assist with Hoyer lift (mechanical lift) for all transfers;-He/She required two persons assist for all activities of daily living (ADL). Observation of the resident's room door on 03/15/26 at 9:45 A.M. showed a sign directing staff to use personal protective equipment (PPE) when providing care for the resident as he/she was on EBP. A storage device containing PPE (gowns and gloves) hung from the resident's door. Observation on 03/15/26 at 9:48 A.M. showed the following:-The resident lay in his/her bed;-He/She was incontinent of bowel and bladder.-Certified Nursing Assistant (CNA) E and CNA F entered the resident's room and did not put on gowns;-CNA E and CNA F provided incontinence care then transferred the resident from his/her bed to the wheelchair. Neither staff wore a gown when they provided care for the resident. Observation on 03/16/26 at 3:12 P.M. showed CNA C and CNA K did not wear gowns and transferred the resident with the Hoyer lift from his/her wheelchair to the bed and provided incontinence care. Observations on 03/17/26 at 7:00 A.M. showed the following:-CNA J entered the resident's room to prepare the resident for a shower;-Without wearing a gown, CNA J put an incontinence brief on the resident and put the shower Hoyer lift pad under the resident;-CNA I entered the room, did not put on a gown, and assisted CNA J transfer the resident from the bed to the wheelchair with the Hoyer lift. Observation on 03/17/26 at 7:47 A.M. showed CNA I and CNA J did wear gowns and transferred the resident to his/her bed, assisted the resident to dress, combed the resident's hair, and put dentures in the resident's mouth. During interview on 03/17/26 at 8:05 A.M., CNA J and CNA I said they did not know they needed to wear a gown when providing personal care for the resident. They did not wear a gown when providing care because they had not been instructed to do so. They thought the signs on the doors were for staff who provided direct care to the resident's PEG tube. 2. Review of Resident #45's undated list of diagnoses list showed the following:-Acute osteomyelitis (infection of the bone) left ankle and foot;-Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) of the left heel;-Unstageable pressure ulcer (slough and/or eschar known but not stageable due to coverage of wound bed by slough and/or eschar) of the right ankle. Review of the resident's quarterly MDS, dated [DATE], showed the following:-He/She was dependent on staff with toileting, showering, and transfers;-He/She had a stage 4 pressure ulcer;-He/She had an infection of the foot;-He/She was always incontinent of bowel and bladder. Review of the resident's care plan, last revised/reviewed on 11/24/25, showed the following:-He/She had a pressure ulcer on the left heel;-He/She required two staff assist with Hoyer lift for all transfers;-He/She required assist of one with bathing;-He/She was incontinent of bowel and bladder;-He/She required assistance with perineal cleansing when he/she asked for assistance.(There was no documentation to address the resident's need for EBP.) Review of the resident's physician's orders, dated March 2026, showed the following:-He/She had wounds to the left heel which required dressing changes three times a week;-He/She had a wound to the right ankle that required a dressing change every two to three days and as needed. Observation on 03/15/26 at 10:16 A.M. showed a sign on the resident's room door showed the resident was on EBP and directed staff to apply PPE (gown and gloves). A storage device, containing gowns and gloves, hung from the resident's door. Observation on 03/16/26 at 3:30 P.M., showed the following:-CNA G and CNA H entered the resident's room;-Neither CNA G nor CNA H put on a gown;-CNA G and CNA H transferred the resident to bed, put a Hoyer lift sling under the resident, provided incontinence care, and transferred the resident to the shower chair. 3. Review of Resident #42's care plan, last revised on 11/21/25, showed the following:-He/She had end stage renal disease (chronic irreversible kidney failure) and required dialysis three times a week;-He/She required two staff and the Hoyer lift for all transfers;-He/She required extensive assistance of two staff with all ADLs. Review of the resident's quarterly MDS, dated [DATE], showed the following:-His/Her cognition was moderately impaired;-He/She was dependent on staff for showers, toilet hygiene, dressing, oral hygiene, showers, and transfers;-He/She was always incontinent of bowel and bladder;-He/She required dialysis (a treatment that filters waste and excess fluid from the blood). Review of the resident's physician's orders, dated March 2026, showed the following:-He/She required dialysis three times a week;-Permacath (a flexible tube inserted into a large vein for dialysis access) to the right chest for dialysis. During an on 3/16/26 at 2:55 P.M., the resident's representative said staff did not always wear gowns when they provided care. Staff wore gowns when the resident had an infection, but the resident did not currently have an infection. Observation on 03/16/26 at 3:15 P.M., showed a sign for EBP and contact precautions was posted on the resident's room door. PPE (gloves, gowns, and masks) hung on the outside of the door. During an interview on 03/17/26 at 8:10 A.M., CNA C and CNA K said the following:-Staff only wore PPE if they provided care to the area that required PPE/EBP, such as providing direct care to the catheter, wounds, or PEG tube;-Only the nurses wore the PPE because they cared for residents' wounds and PEG tubes; -He/She did not wear PPE a gown or a mask when he/she provided care for residents with wounds or a PEG tube. 4. Review of Resident #1's Care Plan, dated 11/12/25, showed the following:-The resident had hemodialysis (process for removal of waste and excess water from the blood due to kidney failure) related to acute kidney failure (loss of kidney's ability to remove waste);-The resident required assist of one staff and wheeled walker for all transfers;-The resident used a bedside commode for toileting with assist of one staff and wheeled walker;(There was no documentation to address the resident's need for EBP.) Review of the resident's physicians orders, dated March 2026, showed the following:-Diagnoses included dependence on renal dialysis;-Dialysis site- Permacath to right chest. Review of the resident's quarterly MDS, dated [DATE], showed the following:-He/She required substantial help from staff for transfers and dressing;-He/She was dependent on staff for toileting hygiene;-He/She received dialysis. Observation on 03/15/26 at 10:10 A.M., showed an EBP sign on the door directed staff to apply gown and gloves. A storage device containing gowns and gloves hung from the resident's door. Observation on 03/16/26 at 2:13 P.M., showed the following:-CNA K entered the resident's room;-CNA K did not put on a gown, washed his/her hands, put on gloves and applied lotion to the resident's feet;-CNA K did not wear a gown when providing care to the resident. Observation on 03/17/26 at 6:25 A.M., showed the following:-CNA K entered the resident's room; -CNA K did not put on a gown, washed his/her hands, put on gloves, and assisted the resident to sit on the edge of bed, stand with a walker and pivot to sit on the commode;-CNA K assisted the resident with dressing;-CNA K provided the resident with incontinence care;-CNA K assisted the resident to transfer from the commode to the wheelchair;-CNA K did not wear a gown while providing care to the resident. During an interview on 03/17/26 at 5:20 A.M., Nursing Assistant (NA) L said the following:-Staff do not use EBP with the resident;-The resident required assistance with getting in bed, getting to the commode, and with perineal care. 5. Review of Resident #6's quarterly MDS, dated [DATE], showed the following:-He/She was cognitively intact;-He/She had a urinary catheter (a sterile tube inserted into the bladder to drain urine);-He/She was dependent on staff for personal hygiene. Review of the resident's care plan, revised on 02/26/25, showed the following: -The resident has a suprapubic urinary catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine);-He/She needs staff assistance with one for toileting and personal hygiene;(There was no documentation to address the resident's need for EBP.) Review of the resident's physician orders, dated March 2026, showed the following:-Enhanced Barrier Precautions every shift for suprapubic catheter; -Suprapubic urinary catheter. Observation on 03/17/26 at 6:22 A.M. showed no EBP signage or supplies were on the resident's room door. Observation on 03/17/26 at 6:22 A.M. showed the following:-CNA O entered the resident's room and did not put on a gown; -CNA O rinsed and dried the resident's dentures, applied denture adhesive to the dentures, and handed them to the resident to put in his/her mouth;-CNA O placed a urine collection canister near the resident's catheter bag (a medical device that collects urine draining from the bladder through a catheter). He/She drained the resident's urine from the catheter bag into the empty urine collection canister;-CNA O emptied the canister into the resident's toilet; -CNA O put a hearing aide in the resident's left ear and put slippers on the resident's feet;-CNA O assisted the resident to transfer to the wheelchair;-CNA O did not wear a gown during the residents' personal cares and did not wear a gown and face shield when emptying the resident's catheter bag. During interviews on 03/15/26 at 12:38 P.M. and 1:57 P.M., the resident said the following:-He/She had a catheter;-Staff had to help him/her get dressed, put on his/her shoes and help transfer him/her to the toilet;-Staff never wore a gown when performing his/her personal cares or catheter care. During an interview on 03/17/26 at 9:43 A.M., CNA O said the following:-He/She needed to wear a gown when providing peri care or catheter care for the resident; -He/She did not have to wear a gown during personal cares, only catheter care;-He/She did not perform catheter care (on 03/17/26 at 6:22 A.M.), so he/she did not have to wear a gown. During interviews on 03/17/26 at 9:52 A.M. and 10:36 A.M., Licensed Practical Nurse (LPN) N said the following:-Staff were to wear a gown when they performed catheter care;-Staff should wear a gown when emptying the resident's catheter bag. 6. During an interview on 03/17/26 at 10:09 A.M., the Infection Preventionist (IP) said the following:-Any resident with an indwelling medical device, including a Permacath, PEG tube, supra pubic catheter, chronic wounds, or any other indwelling medical device, required staff to wear PPE during all personal cares;-Staff should wear a gown and eye protection while performing any personal cares;-She was responsible for ensuring EBP signage and EBP supplies were hung on the residents' doors;-The nurses notified her if a resident required EBP signage and supplies on their door;-She was unaware Resident #6 did not have EBP signage or supplies on his/her door.During an interview on 03/17/26 at 10:21 A.M., the Director of Nursing (DON) said the following:-Staff should wear PPE when providing personal cares for any resident with wounds or a medical device; -Medical devices included catheters, feeding tubes, PICC lines, and Permacaths;-The IP was responsible for ensuring EBP signage and supplies were on the residents' doors 7. Review of the facility's undated policy for cleaning of the glucometer, showed to clean the machine by using a soft cloth or tissue to wipe the meter's exterior. If necessary, dip the soft cloth or tissue in a small amount of alcohol. (The policy did not instruct staff to clean the glucometer with an antimicrobial agent after use to prevent the spread of communicable diseases.) Review of the Centers for Disease Control and Prevention website, showed the following:-Proper Protocol: For cleaning blood or other potentially infectious materials, the CDC recommend using an EPA-registered tuberculocidal disinfectant or a 1:10 to 1:100 dilution of bleach and water;-If you are dealing with blood in a professional or healthcare setting, it is recommended to use specialized germicidal wipes (such as Sani-Cloth) or a bleach solution rather than standard consumer disinfecting wipes. Review of the Microdot Minute Wipe manufacturer's instructions for use showed the following:-Disinfecting: To disinfect hard, non-porous surfaces, use one or more wipes, as necessary, to thoroughly wet the surface to be treated. Treated surface must remain visibly wet for one minute to achieve complete disinfection of all pathogens listed on this label;-Allow surfaces to air dry;-Kills Human Immunodeficiency Virus Type 1 (HIV-1, a retrovirus that attacks the human immune system), Hepatitis B Virus (HBV, a contagious virus that causes liver inflammation, and Hepatitis C Virus (HCV, a contagious, bloodborne viral infection that causes liver inflammation). Review of the undated American Health Care Association, Tips for Meeting the Cleaning and Disinfection of Blood Glucose Meter Requirements in Skilled Nursing Facilities, showed the following: -Place barrier under blood glucose meter when in a resident's room or placed on top of medication cart to avoid spread of microorganisms and contamination of surfaces and other equipment or supplies;-Tip: Place clean and dry paper towel(s) under blood glucose meter before placing on resident table or on top of medication cart. Review of the facility's policy, Insulin Pen (a pre-filled pen containing insulin), revised 08/15/25, showed the following procedure for attaching the pen needle:-Remove the pen cap from the insulin pen;-Wipe the rubber seal with an alcohol pad;-Screw the pen needle onto the insulin pen. Review of the Novolog Flex Pen (prefilled insulin pen) manufacturer's administration guidelines, dated September 2025, showed the following: -Pull off the pen cap;-Wipe the rubber stopper with an alcohol swab;-Screw the needle tightly onto your FlexPen. Review of the Lantus Solostar (prefilled insulin pen) manufacturer's administration guidelines, revised 11/2018, showed the following procedure to attach the needle:-Wipe the rubber seal with alcohol;-Remove the protective seal from a new needle;-Line up the needle with the pen and keep it straight as you attach it (screw or push on, depending on the needle type). 8. Review of Resident #3's physician orders, dated March 2026, showed the following:-The resident had a diagnosis of Type 2 diabetes mellitus (metabolic disease);-Monitor blood glucose (measurement of the amount of glucose or sugar in the blood) four times daily. Observation on 03/16/26 at 5:00 P.M., showed the following:-Certified Medication Technician (CMT) D gathered supplies from the medication cart for blood glucose monitoring, entered the resident's room and sat the multi-resident use glucometer on top of the resident's sheet without a barrier;-CMT D put on gloves without first performing hand hygiene;-CMT D obtained the blood sample from the resident's finger, picked up the glucometer, performed the blood sugar finger stick by placing a blood-filled test strip in the glucometer, then removed the blood-filled test strip from the glucometer and discarded the used test strip in the trash;-CMT D sat the glucometer directly on the resident's bedside table without a barrier; -CMT D checked the resident's blood pressure;-CMT D removed his/her gloves and used hand sanitizer; -CMT D returned the glucometer to the top of the medication cart without a barrier; -CMT D did not clean or sanitize the glucometer and went to Resident #8's room; -A container of Micro Minute Wipes (disinfectant wipes) sat on top of the medication cart. 9. Review of Resident #8's physician orders, dated March 2026, showed the following:-The resident had a diagnosis of Type 1 diabetes mellitus;-Monitor blood glucose four times daily. Observation on 03/16/26 at 5:04 P.M., showed the following:-CMT D gathered supplies from the medication cart for blood glucose monitoring, including the uncleaned multi-resident used glucometer from on top of the medication cart, entered the resident's room and sat the glucometer on top of the resident's blanket without a barrier;-CMT D checked the resident's blood pressure;-CMT D put on gloves without performing hand hygiene;-CMT D obtained the blood sample from the resident's finger and performed the blood sugar finger stick by placing a blood-filled test strip in the glucometer;-CMT D sat the glucometer on the resident's bedside table without a barrier, obtained the result and then removed the blood-filled test strip from the glucometer and discarded the used test strip in the trash;-CMT D removed his/her gloves and did not perform hand hygiene; -CMT D removed an insulin pen from the medication cart drawer and prepared the ordered dose;-Without performing hand hygiene, CMT D put on gloves, administered the insulin, discarded the needle and put the insulin pen back in the medication cart drawer;-CMT D removed his/her gloves, did not perform hand hygiene and charted the blood glucose results in the resident's electronic health record (EHR). During an interview on 03/17/26 at 7:45 A.M., CMT D said the following: -He/She should clean the glucometer after each use; -He/She should place the glucometer and blood glucose testing supplies on a barrier; -He/She sometimes forgot to clean the glucometer each time it was used; -He/She sometimes forgot to put down a barrier;-He/She should use hand sanitizer after removing his/her gloves and before putting on new gloves; -He/She thought he/she used hand sanitizer after removing his/her gloves. 10. Review of Resident #12's undated diagnoses sheet showed the resident's diagnoses includedType 2 diabetes mellitus. Review of the resident's physician order summary, dated March 2026, showed an order for Novolog (rapid acting injectable medication used to treat diabetes) Flex Pen Subcutaneous Solution Pen Injector 100 units/mL, inject per sliding scale. Observation on 03/16/26 at 11:16 A.M. and 11:20 A,M. showed the following:-CMT M removed the glucometer out of his/her cart and sat it directly on top of the medication cart, without a barrier;-CMT M entered the resident's room and placed the glucometer and the testing strip directly on the resident's bed side table with no barrier;-CMT M obtained a blood sample from the resident's finger performed the blood sugar finger stick by placing a blood-filled test strip in the glucometer;-CMT M left the resident's room with the glucometer, removed the blood-filled test strip from the glucometer and placed the blood-filled test strip directly on top of the medication cart;-CMT M placed the glucometer directly on the mouse pad on top of the medication cart; -CMT M removed the resident's Novolog insulin pen from the medication cart, removed the cap from the insulin pen and without cleaning the hub of the insulin pen with an alcohol pad, applied the needle to the hub, prepared and administered the resident his/her insulin;-CMT M did not clean the top of the medication cart. Observation on 03/17/26 at 6:50 A.M., showed CMT M removed the resident's Novolog insulin pen from the medication cart, removed the cap from the insulin pen and without cleaning the hub of the insulin pen with an alcohol pad, applied the needle to the hub, prepared and administered the resident his/her insulin. 11. Review of Resident #26's undated diagnoses sheet showed his/her diagnoses included Type 2 diabetes mellitus with other diabetic neurological complications. Review of the resident's physician order summary, dated March 2026, showed the following:-Blood sugar finger stick: Fasting (restriction of food and beverage other than water) in the morning; obtain one time a day;-Lantus (injectable long-acting medication used to treat diabetes) Subcutaneous Solution 100 Units/mL, Inject 10 units subcutaneously in the morning. Observation on 03/17/26 at 7:07 A.M., showed the following:-The glucometer set directly on top of the medication cart without a barrier;-CMT M put on gloves and placed a lancet (a puncturing device) and 2x2 gauze directly on top of the medication cart, without a barrier;-CMT M put a test strip into the glucometer, gathered the supplies for the ordered blood sugar finger stick and entered the resident's room;-CMT M cleaned the resident's finger with an alcohol pad and used the lancet to obtain a droplet of blood from the resident for testing;-CMT M left the resident's room with the glucometer and placed it directly on top of the medication cart, without a barrier;-CMT M removed the resident's Lantus insulin pen from the medication cart, removed the cap from the insulin pen and without cleaning the hub of the insulin pen with an alcohol pad, applied the needle to the hub, prepared and administered the resident his/her insulin. 12. Review of Resident #32's physician order summary, dated March 2026, showed an order for insulin aspart (Novolog) flex pen subcutaneous solution pen injector 100 units/ml, inject per sliding scale before meals and at bedtime. Observation on 03/16/26 at 11:12 A.M., showed CMT M removed the resident's insulin aspart insulin pen from the medication cart, removed the cap from the insulin pen and without cleaning the hub of the insulin pen with an alcohol pad, applied the needle to the hub, prepared and administered the resident his/her insulin. During an interview on 03/17/26 at 7:22 A.M., CMT M said the following:-Staff should clean the glucometer after every use with a Microdot Minute Wipe;-No one had ever told him/her there needed to be a barrier between the glucometer and another surface like the medication cart or a resident's bedside table;-He/She did not clean the hub of the insulin pens before administering Resident #32, #12 or #26 their ordered insulin;-He/She should have cleaned the hub of the insulin pens before administering the medication. During interviews on 03/17/26 at 7:39 A.M., and 03/18/26 at 6:00 P.M., the Director of Nursing (DON) said the following:-Staff should clean the glucometer after each use;-Staff should place the glucometer on a clean surface (barrier) when in use at the medication cart or in the resident's room;-Staff needed to clean the hub of an insulin pen before applying the needle tip. 13. Review of the facility Policy and Procedure for Monitoring Water Supply to minimize outbreaks of Legionella Bacteria Contamination, revised 11/26/18, showed it is the policy of the facility to maintain water management controls through the use of risk assessments, water management program team meetings and through a water management program so as to minimize the possibility of a Legionella outbreak in residents through contamination of the facility water system. (The policy did not address a water management team, team members or how often the water management meetings should be conducted.) Review of the Centers for Disease Control Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings: A Practical Guide to Implementing Industry Standards, dated 09/30/25, showed the following:-Make sure the program is running as designed and is effective;-Healthcare facilities water management program teams include infection control staff may also choose to use their facility's routine surveillance for health care associated legionnaires' disease to supplement validation efforts for their program;-Healthcare facilities water management program teams that include infection control staff may also choose to use their facility's routine surveillance for health care associated Legionnaires' diseaseto supplement validation efforts for their program.;-Now that you have a water management program, you need to be sure that it is effective. Your program team should establish procedures to confirm, both initially and on an ongoing basis, that the water management program effectively controls the hazardous conditions throughout the building water systems. This step is called validation.;-Document and communicate all the activities of your Water Management Program;-Your written program should include at least the following: -Program team, including names, titles, contact information, and roles on the team -Confirmatory procedures, including verification steps to show that the program is being followed aswritten and validation to show that the program is effective;-Communication: Be sure to communicate with your employees and colleagues about your program on a regular basis and train those responsible for implementing and monitoring the program.-Use this communication as an opportunity to identify strategies for improving the management andefficiency of your water systems. During an interview on 03/16/26 at 5:00 P.M., the Maintenance Director said currently there was no water management team and no water management meetings. During an interview on 03/16/26 at 5:10 P.M., the Infection Preventionist (IP) said she was not part of the water management team and there were no water management meetings. During an interview on 03/16/26 at 5:30 P.M. and 03/25/26 at 12:11 P.M., the Administrator said there was no water management team and there were no water management meetings. He had informal meetings which included the Medical Director and IP but he was not having any formal meetings on a regular basis. He did not share any meeting information at the QAPI meeting.

Based on interview, observation, and record review, the facility failed to notify the physician for one resident (Resident #4), in a review of 18 sampled residents, when the resident had a change in condition and abnormal lab results. The facility census was 56. Review of the facility's policy for lab and diagnostic test results, last revised November 2018, showed the following:-When test results are reported to the facility, a nurse will first review the results.-A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition.-The reason for getting a test often affects the urgency of acting upon the result;-Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: -Whether the physician has requested to be notified as soon as a result is received. -Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). -Whether the resident/patient's clinical status is unclear, or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison.-If the resident has signs and symptoms of acute illness or condition change and he/she is not stable or improving, or there are no previous results for comparison, then the nurse will notify the physician promptly to discuss the situation, including a description of relevant clinical findings as well as the test results.-Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable, or current treatment needs review or clarification. 1. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 12/22/25, showed the following:-His/Her cognition was severely impaired;-He/She had difficulty swallowing;-He/She had a feeding tube (a tube surgically inserted into the stomach to provide hydration, nutrition, and medications). Review of resident's progress notes, dated 02/25/26 at 8:44 P.M., showed the following: -The resident had not been very alert during the shift;-Staff notified the resident's representative and he/she requested labs be obtained on the resident;-Lab orders were obtained from the resident's physician and collected. Review of the resident's vital signs, dated 02/27/26 at 7:17 A.M., showed the resident's oxygen saturation was 87% (normal range between 95-100%) on oxygen delivered via nasal canula. Review of the resident's progress notes, dated 02/27/26, showed no documentation of the resident's condition and no documentation staff notified the resident's physician of the resident's low oxygen saturations when on oxygen at 7:17 A.M. Review of the resident's lab results, collected on 02/26/26, showed the following:-Lab results were reported to the facility on [DATE] at 8:00 A.M.;-Blood urea nitrogen (BUN, a waste product filtered out of the blood by the kidneys. Increased concentrations in the blood may indicate a temporary or chronic decrease in kidney function.) was 38 (normal range 5-23).-Sodium level was 159 (normal range 134-145);-Chloride level was 121 (normal range 98-107);-BUN/Creatinine ratio (indicates urea nitrogen is elevated relative to creatinine, commonly signaling pre-renal issues like dehydration) was 47.5 (normal range 10-20). -White blood cell (WBC) count was 15.7 (normal range 4.8-10.8);-There was a handwritten note on the lab results noting nursing staff faxed the results to the resident's physician on 02/27/26 at 9:00 A.M. Review of the resident's progress notes, dated 02/27/26, showed no documentation related to the resident's condition. Review of the resident's progress note, dated 02/27/26 at 5:00 P.M., showed the following:-The resident's representative arrived at the facility to visit the resident and requested to view the resident's labs;-The resident's representative contacted the resident's physician regarding the lab results and his/her concerns the resident was dehydrated, rapid weight loss, and increased fatigue;-The resident's physician gave orders to send the resident to the hospital for evaluation and treatment due to recent lab results, dehydration, and recent rapid weight loss. During an interview on 03/15/2026 at 12:45 P.M., the resident's representative said he/she was not notified of the resident's decreased oxygen saturation levels. He/She visited the resident on 02/27/26 (after the labs were obtained). He/She noted the resident had decreased level of consciousness and was extremely thirsty. He/She notified the physician of the resident's status and abnormal lab results. The on-call physician said the resident needed sent to the hospital for evaluation and treatment. The resident's primary care physician reached out to him/her and said he/she was made aware of the resident's labs (unaware of when he/she was notified), and the resident needed to go to the hospital. The resident's representative had already had the resident sent to the hospital. Review of the resident's hospital medical records, dated 02/28/26, showed the resident was admitted to the hospital on [DATE] with acute hypoxic respiratory failure (not enough oxygen in the blood) secondary to pneumonia (lung infection), sepsis secondary to multifocal pneumonia, pneumonia, hypernatremia (low sodium levels) secondary to dehydration, metabolic encephalopathy (a serious brain dysfunction caused by systemic illness, organ failure, or chemical imbalances) secondary to sepsis, and electrolyte derangements (occurs when the concentration of essential minerals-like sodium, potassium, and calcium is too high or low in the body, disrupting nerve, muscle, and heart function), moderate to severe dehydration with hypernatremia (elevated sodium level), dry mucous membranes, tachyarrhythmia (an abnormally fast heart rate) likely secondary to sepsis and dehydration. During an interview on 03/18/26 at 4:40 P.M., the Director of Nursing (DON) said staff was to call the resident's physicians with abnormal lab results an hour after faxing the results to ensure the physician was aware of the abnormal lab results that need to be addressed. The nurse should have contacted the resident's physician for orders when he/she noted the abnormal lab results because the resident's condition could change and deteriorate quickly if abnormal labs were not addressed. Complaint 2792589

Based on interview and record review, the facility failed to provide a copy of bed hold policy and written notice of transfer to the resident and/or the resident's representative when three residents (Residents #2, #4, and #56), in a review of 18 sampled residents, were transferred to the hospital. The facility census was 56. Review of the facility's Bed Hold Policy, last revised October 2022, showed the following:-All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice, notice well in advance of any transfer (e.g., in the admission packet) and at the time of transfer (or, if the transfer was an emergency, within 24 hours);-The written bed-hold notices provided to the residents/representatives explain in detail the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility, the reserve bed payment policy as indicated by the state plan (for Medicaid residents), the facility policy regarding bed-hold periods, the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents), and the facility return policy. 1. Review of the Resident #2's face sheet showed the resident had a responsible party. Review of the resident's progress note, dated 03/06/26 at 9:45 A.M., showed the following:-The resident's oxygen saturation (percent of oxygen in the blood) was 87 percent (%) (normal levels 95%-100%);-The resident's respiratory rate (number of breaths per minute) was in the high 20's (normal 12-20); -The facility contacted emergency medical services, and the resident was sent to the emergency room. Review of the resident's medical record showed no documentation the facility provided the resident's representative with the facility's bed hold policy and a written notice of transfer when the resident was transferred to the hospital on [DATE]. Review of the resident's medical record showed the resident returned to the facility from the hospital on [DATE]. During an interview on 03/17/26 at 12:45 P.M., the resident's representative said he/she did not receive a copy of the bed hold policy or a notice of transfer with the resident went to the hospital on [DATE]. 2. Review of the Resident #4's face sheet showed the resident had a responsible party. Review of the resident's hospital records, dated 02/28/26, showed the resident was transferred and admitted to the hospital for dehydration, sepsis (serious condition in which the body responds improperly to an infection.), and failure to thrive (weight or rate of weight gain is significantly lower than expected) on 02/27/26. Review of the resident's progress note, dated 03/03/26 at 3:10 P.M., showed the resident returned to the facility. Review of the resident's medical record showed no documentation the facility provided the resident's representative with the facility's bed hold policy and a written notice of transfer discharge when the resident was transferred to the hospital on [DATE]. During an interview on 03/17/26 at 9:46 A.M., the resident's representative said he/she did not receive a copy of the bed hold policy or a notice of transfer with the resident went to the hospital on [DATE]. 3. Review of the Resident #56's face sheet showed the resident had a responsible party. Review of the resident's progress note, dated 02/25/26 at 10:23 A.M., showed the following:-The wound care nurse thought the resident had an infection and needed to be sent to the hospital; -The facility contacted emergency medical services, and the resident was sent to the emergency room. Review of the resident's medical record showed no documentation the facility provided the resident's representative with the facility's bed hold policy and a written notice of transfer discharge when the resident was transferred to the hospital on [DATE]. Review of the resident's progress note, dated 03/03/26 at 2:15 P.M., showed the resident was readmitted to the facility from the hospital. During an interview on 03/24/26 at 7:38 A.M., the resident's representative said he/she did not receive a copy of the bed hold policy or a notice of transfer with the resident went to the hospital on [DATE]. 4. During an interview on 03/17/26 at 10:47 A.M., Licensed Practical Nurse (LPN) N said the nursing staff were to send a transfer packet with a resident upon transfer to the hospital. He/She did not send a transfer/discharge notice or bed hold policy to a guardian/responsible party. He/She did not know who was responsible for ensuring the resident and/or responsible party received the information. During an interview on 03/17/26 at 3:00 P.M., LPN B said the charge nurse was to complete the transfer/discharge packet which included the bed hold policy and transfer/discharge notices, and place them on the Director of Nursing's (DON) desk when completed, but they didn't always get completed. During an interview on 03/17/26 at 3:14 P.M., the DON said the nurse who initiated a resident transfer was responsible for issuing the transfer/discharge notice and bed hold policy to the resident and/or responsible party.

Based on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for two residents (Residents #45 and #34), in a review of 18 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the residents' health status and required interdisciplinary review and/or revision of the care plan. The facility census was 56. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0, showed a significant change is a decline or improvement in a resident's status that:-Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and is not self-limiting;-Impacts more than one area of the resident's health status;-Requires interdisciplinary review and/or revision to the care plan.-The manual also showed a SCSA was appropriate if there was a consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of activities of daily living (ADL) decline or improvement);-Decline in two or more of the following: -Resident's decision-making ability has changed; -Presence of a resident mood item not previously reported by the resident or staff and/or an increase in the symptom frequency (PHQ-2 to 9(C)), e.g., increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for items in Section E (Behavior); -Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment; -Any decline in an ADL physical functioning area (e.g., self-care or mobility) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning; -Resident's incontinence pattern changes or there was placement of an indwelling catheter; -Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days); -Emergence of a new pressure ulcer at Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) or higher, a new unstageable pressure ulcer/injury (dead tissue is present, the actual base and condition of the ulcer cannot be determined), a new deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) or worsening in pressure ulcer status; -Resident begins to use a restraint of any type when it was not used before; and/or -Emergence of a condition/disease in which a resident is judged to be unstable. Review of the facility's policy for Comprehensive Assessments, last revised March 2022, showed the following: -Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual;-Significant Change in Status Assessment - The SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an admission assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT's determination was made that the resident had a significant change;-A significant change is a major decline or improvement in a resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting, impacts more than one area of the resident's health status, and requires interdisciplinary review and/or revision of the care plan. 1. Review of Resident #45's annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 04/04/25, showed the following:-He/She required partial/moderate assistance with showering, upper/lower body dressing, transitioning from sitting to standing positions, toilet transfers, and walking 10 and 50 feet;-He/She did not have any falls;-He/She did not have any wounds;-He/She was frequently incontinent of bladder. Review of resident's fall assessment, dated 06/04/25, showed he/she fell and fractured his/her right hip. Review of the resident's quarterly MDS, dated [DATE], showed the following:-He/She required substantial/maximum assistance with showering, upper/lower body dressing, transitioning from sitting to standing positions, toilet transfers (previous assessment showed he/she required partial/moderate assessment);-Walking did not occur (previous assessment showed he/she required partial/moderate assistance with walking);-He/She was always incontinent of bladder (previous assessment showed he/she was frequently incontinent of bladder);-He/She had a joint replacement (previous assessment showed he/she had not had a joint replacement);-He/She had a surgical wound (previous assessment showed he/she did not have any surgical wounds);-There were no falls documented (the resident fell with major injury (hip fracture) on 06/04/26).(Staff did not complete a comprehensive assessment for a significant change in status when the resident showed a decline in three or more areas since the previous assessment, completed on 04/04/25.) Review of the resident's care plan showed the following:-On 08/02/25, the resident fell;-On 08/08/26, the resident's transfer status changed to a two person assist with Hoyer lift (mechanical lift);-On 08/08/26, update showed the resident had a pressure ulcer on the left heal requiring use of a wound vac (vacuum-assisted closure used to conduct negative pressure wound therapy to promote healing). Review of resident's MDS record showed he/she was discharged to an outside facility on 08/02/25 and returned on 08/08/25. Review of the resident's quarterly MDS, dated [DATE], showed the following:-He/She was dependent on staff assistance with showering, upper/lower body dressing, transitioning from sitting to standing positions, chair to bed, bed to chair, and toilet transfers (previous assessment showed he/she required substantial/maximum assistance);-He/She was always incontinent of bowel and bladder;-He/She had one unstageable pressure ulcer (previous assessment showed the resident did not have any pressure ulcers);-He/She had an infection of the foot (previous assessment showed the resident did not have any infections);-He/She required pressure ulcer injury care (previous assessment showed the resident did not have any pressure ulcer injuries);-He/She used antibiotics in the previous seven-day look back period (previous assessment showed the resident did not require use of antibiotic therapy).(Staff did not complete a comprehensive assessment for a significant change in status when the resident showed a decline in three or more areas since the previous assessment, completed on 07/05/25.) Observation on 03/16/26 at 3:30 P.M. showed the following:-The resident had dressings to left heal and right ankle;-He/She required use of a Hoyer lift for transfers;-He/She was incontinent of bowel and bladder. During an interview on 03/18/26 at 9:00 A.M., the MDS Coordinator said the following:-The resident declined after he/she fell and fractured his/her hip (on 06/04/25). Before the fall, resident could walk but still required assistance. Now the resident was dependent on staff;-After the second fall, the resident returned from the hospital with wounds;-She did not think to do a significant change for the falls, development of wounds and the resident's transfer status requiring a Hoyer lift because they always had to do things for the resident, but she should have completed a significant change for resident's decline in August;-She followed the RAI process when completing significant change assessments. 2. Review of Resident #34's annual MDS, dated [DATE], showed the following:-Occasionally incontinent of bladder; -Partial/moderate assistance with personal hygiene, sit to stand, chair to bed transfers, toilet and shower transfers, and walking 10 feet; Review of the resident's quarterly MDS, dated [DATE], showed the following:-Dependent for toileting hygiene;-Substantial/maximum assistance with sit-to-stand, chair/bed transfers, toilet transfers, shower transfers, and walk 10 feet;-Substantial/maximum assistance with personal hygiene, upper and lower body dressing, roll left and right, sit to lying, lying to sitting on the side of the bed; -Always incontinent of bladder;(The facility did not complete a SCSA when the resident had a decline in his/her continence status and a decline in his/her ability to perform toileting hygiene, transfers, and ambulation.) Review of the resident's quarterly MDS, dated [DATE], showed the following:-Dependent for upper and lower body dressing, personal hygiene, roll left and right, sit to lying, lying to sitting on the side of the bed(worsened); -Walk 10 feet not attempted due to medical condition (worsened);-Physical and occupational therapy (new).(The facility did not complete a SCSA when the resident required more for upper and lower body dressing, personal hygiene, rolling left and right, sit to lying, lying to sitting on the edge of the bed, and ambulation.) During an interview on 03/25/26 at 11:35 A.M., the MDS Coordinator said the resident would not have needed a significant change MDS with the quarterly MDS completed on 10/10/25, since she recalled the resident only had a change in transfer status. 3. During an interview on 03/18/26 at 5:30 P.M., the Director of Nursing said staff were to follow the RAI process when assessing if a resident required a significant change assessment.

Based on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen and ensure all areas of the kitchen were clean. The census was 48. Review of the facility's Sanitation policy, revised November 2022, showed the following:-All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects;-All utensils, counters, shelves and equipment are kept clean;-Service area wiping cloths are cleaned and dried or placed in a chemical sanitizing solution of appropriate concentration;-Kitchen wastes that are not disposed of by mechanical means are kept in clean, leakproof, nonabsorbent, tightly closed containers and disposed of daily. Review of the facility's Food Preparation and Service policy, revised November 2022, showed the following:-Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands, food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned;-Appropriate measures are used to prevent cross-contamination; such as, sanitizing towels and cloths used for wiping surfaces in containers filled with appropriate sanitizing solution (at concentrations specified by the manufacturer of the solution used). 1. Observation of the kitchen on 12/23/25 from 8:15 A.M. through 10:10 A.M., showed the following:-The wall to the left of the sanitation sinks had splashes of a liquid substance that ran down the wall and had dried;-The floor under the third sanitation sink from the left had a buildup of brown colored debris approximately 36 inches by 24 inches;-Rags used to wipe off the dining room tables were stored in a plastic can, without soaking in any solution;-The baseboard behind sanitation sinks had buildup of thick, black debris;-The first sink of the sanitation sinks to the far left was stained brown;-There were food particles and liquid splatter on the bottom shelf of the table to the left of the stove;-The back splash behind the table on the left side of the stove had liquid substances that had splashed, run down the back splash and dried;-Face plates of the outlet and switches above and behind the table to the left of the stove had dried substances present;-The plug end and cord going to an appliance had dried substance on both;-A white, dry, substance on the metal, wire shelves where clean utensils, pitchers, coffee cups and meal trays were stored and rust present on the sides of the cart. During an interview on 12/23/25 at 9:45 A.M., [NAME] A said the following:-The night shift was responsible for sweeping and mopping the kitchen and dining room every night;-The dietary staff used a cleaning solution with the rags to clean off dining room tables after the residents finished their meals, the solution and rags were changed out every evening;-Cook A took the plates, glasses, and utensils off the table, then wiped it down with the rags that were soaked in the solution;-The night shift was responsible for cleaning out the dishwasher food strainer every night. During an interview on 12/23/25 at 10:10 A.M., the Dietary Manager said the following:-It was everyone's job to keep the kitchen clean;-The cook maintained the cleaning of the kitchen;-The dietary aide was responsible for the dish room and dining room;-The cook mopped the kitchen floor at the end of each day;-The dietary aides wiped and sanitized the dining room tables after each meal;-The cook was responsible for dumping the rags used to clean the tables every night;-The dietary aides were responsible for cleaning the dishwasher food strainer at least daily, however, he preferred after every meal. During an interview on 12/23/25 at 11:50 A.M., the Administrator said the following:-His expectation was the kitchen and dishwashing rooms followed sanitation guidelines;-Each shift was expected to complete the cleaning tasks assigned to them. 2668865

Based on interview and record review, the facility failed to protect one resident (Resident #1) from physical and verbal abuse. Certified Nurse Assistant (CNA) A slapped the resident with an open hand and referred to the resident as a pedophile in the presence of the resident. The facility census was 48.On 06/30/25, the administrator was notified of the past noncompliance which occurred on 6/13/25. On 6/21/25, the administrator became aware of the staff to resident abuse allegation involving Certified Nurse Assistant (CNA) A and Resident #1. Upon discovery, the facility suspended CNA A, conducted an investigation, and notified the appropriate parties. All facility staff were educated on the facility abuse policy related to physical and verbal abuse and on the expectations for monitoring for abuse and reporting abuse. The deficiency was corrected on 6/21/25. Review of the facility's abuse policy, last reviewed on 01/31/24, showed the following:-It was the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse;-Abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse. It includes verbal abuse and physical abuse;-Physical abuse included but not limited to hitting, slapping, punching, biting, and kicking;-Verbal abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging the derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 06/12/25, showed the following:-His/Her cognition was moderately impaired;-He/She was dependent on staff for assistance with all activities of daily living (ADL);-He/She was always incontinent of bowel and bladder;-He/She had physical behaviors directed toward others one to three days out of the previous seven day look back period. Review of the resident's face sheet, dated 06/24/25, showed the resident's diagnoses included anxiety disorder, hemiplegia/hemiparesis (paralysis of one side of the body), and nontraumatic intracerebral hemorrhage (bleeding in the brain). Review of the resident's care plan, last reviewed on 06/24/25, showed the following:-He/She required extensive assistance from two staff for all activities of daily living (ADL) tasks;-He/She had a feeding tube in his/her abdomen;-He/She had the potential for increased behavioral symptoms due to diagnoses of dementia, stroke, depression, and history of sexual verbal/physical behaviors with staff;-He/She made staff uncomfortable with sexual and verbal behaviors. Staff were to remind and educate the resident this was inappropriate;-He/She required cues, reminders, and education to not touch staff in a sexual or physical way or ask for sexual favors. Review of facility's online report, dated 06/21/25, showed an allegation of abuse that occurred on 6/13/25 as Certified Nursing Assistant (CNA) B assisted CNA A change the resident. After the staff cleaned the resident, the resident's feeding tube opened. CNA A smacked the resident on the thigh below his/her buttock because CNA A thought the resident opened the feeding tube on purpose and soiled himself/herself and the bed again. Review of the facility's investigation report, dated 06/21/25, showed the following:-Nurse Aide (NA) F reported to Licensed Practical Nurse (LPN) C that CNA B told NA F that CNA B and CNA A went into the resident's room to get up the resident. The resident had soiled himself/herself and the bed. Once staff (CNA A and CNA B) changed the bed, they rolled the resident, and the resident's feeding tube opened and spilled the contents out onto the resident and the bed, which required another bed/clothing change. At that time, CNA A smacked the resident on the thigh below the buttock because he/she (CNA A) thought the resident disconnected the feeding tube on purpose;-The resident was unable to answer questions due to his/her cognitive impairment;-Staff interviews showed CNA A was more agitated with the resident due to the resident's increased sexual behaviors;-CNA B reported that CNA A referred to the resident as a pedophile;-CNA E said CNA A referred to the resident as a pedophile while rounding on the hall;-CNA A was suspended until further notice.-In conclusion, per interviews with the resident and other residents and staff, there was no evidence to substantiate the allegation of abuse. Review of a CNA B's written statement/interview, provided by the facility, dated 06/25/25 at 11:10 A.M., showed CNA B witnessed CNA A smack the resident's posterior left thigh because the resident's feeding tube top kept popping open. During an interview on 06/30/25 at 12:00 P.M., NA F said CNA B reported to him/her he/she witnessed CNA A smack the resident on the leg when CNA A and CNA B provided care on 06/13/25. Review of LPN C's written statement/interview, provided by the facility, dated 06/21/25 at 3:15 P.M., showed the following:-NA F reported to him/her CNA B witnessed CNA A strike the resident with an open hand on 06/13/25;-He/She contacted CNA B on 06/21/25, who confirmed he/she witnessed CNA A strike the resident with an open hand. During an interview on 06/30/25 at 11:39 A.M., LPN C said the following:-On 06/21/25, NA F reported to him/her CNA B told NA F that CNA A struck the resident;-He/She contacted CNA B who said he/she witnessed CNA A strike the resident;-CNA A had become more irritated with the resident. During an interview on 06/30/25 at 2:30 P.M., CNA E said the following:-CNA B told him/her the resident's feeding tube kept disconnecting while CNA B and CNA A assisted the resident with dressing. CNA A thought the resident was doing this on purpose and smacked the resident on the bottom;-In the last couple of weeks, he/she assisted CNA A get the resident ready for bed and witnessed the resident grab CNA A's breasts. CNA A removed the resident's hands from his/her breasts and called the resident a pedophile. CNA A asked the resident if he/she would like someone to grab his/her family member's breasts. During an interview on 06/30/25 at 2:25 P.M., CNA H said the following:-CNA A talked mean, was hostile, and aggressive with the resident;-CNA A had referred to the resident as a pedophile to the resident's face. During an interview on 06/30/25 at 9:30 A.M., the resident's next of kin said the following:-The facility reported on 06/21/25 that a CNA smacked the resident.-During the investigation, allegations were made that CNA A referred to the resident as a pedophile;-The resident had a history of sexual behaviors, but was pretty good about being redirected;-The resident's cognition varied from day to day;-The resident nodded his/her head yes when he/she asked the resident if anyone had hit him/her. During an interview on 06/30/25 at 3:39 P.M., the Director of Nursing said the abuse allegation was in-conclusive due to the witness (CNA B) did not follow through with the investigation process (CNA B did continue his/her employment after the facility began their investigation). Staff calling a resident names was considered a form of verbal abuse. During an interview on 06/30/25 at 3:15 P.M., the Administrator said the following:-Based on the information obtained, they did not know if CNA A smacked the resident; -The facility found out about CNA A referring to the resident as a pedophile during the facility's abuse investigation;-Referring to the resident as a pedophile could be categorized as abuse due to the humiliation that it could cause the resident. Complaint 1716802

Refer to Event ID M9W912 Based on interview and record review, the facility failed to provide care and treatment following a fall with injury for one resident (Resident #9) with a personal history of a stroke and who was on Xarelto (anticoagulant or blood thinning medication) of nine sampled residents. The resident complained of right sided rib pain at the time of the fall and continued to complain of pain 9 out of 10 (on a scale from 0 to 10 with ten being the worst pain) to the right side. Approximately 2-1/2 hours after the resident was found, the resident's family member arrived at the facility to check on the resident and requested the resident be re-evaluated by staff due to the resident's severe pain, along with shortness of breath. Approximately 10-3/4 hours after the resident was found, the resident continued to complain of pain of 7 out of 10. Staff described the resident as very tearful and in a lot of pain when repositioned, and the physician was not notified. On 10/22/24, the resident's physician gave orders to send the resident to the emergency room (ER) for evaluation, nonemergent, due to a high blood potassium level. In the emergency department the resident was found to have a large right sided hemothorax (when a collection of blood accumulates in the chest cavity, often caused by trauma or injury, symptoms can include difficulty breathing and pain) with multiple displaced rib fractures and a right scapular fracture (a rare injury that occurs when the shoulder blade is directly or indirectly impacted by a significant amount of force such as a fall or blow to the shoulder). At the time of the fall, the on-call physician, who was not the resident's primary care physician, was notified that the resident had slipped from the wheelchair and there was no injury and the notification was facility procedure. The physician was not notified the resident was in pain after the fall and continued to have pain throughout the night, the use of an anticoagulant medication, the resident's shortness of breath or that the fall was unwitnessed. The facility census was 51.

Refer to Event ID M9W912 Based on interview and record, review the facility failed to develop a care plan with interventions to prevent falls for one resident (Resident #9) of nine sampled residents, who was at risk for falls and was admitted to the facility after having falls at home. The resident sustained a fall while at the facility on 10/21/22. Staff failed to complete a thorough post fall assessment or notify the Director of Nursing (DON), as directed by facility policy, at the time of the fall. The facility failed to communicate the resident's fall to the oncoming shift at shift change. The facility failed to communicate pertinent information regarding the fall to the on-call physician, who was not familiar with the resident which delayed evaluation and treatment. As a result of the fall, the resident sustained a large right sided hemothorax (when a collection of blood accumulates in the chest cavity, often caused by trauma or injury, symptoms can include difficulty breathing and pain) with multiple displaced rib fractures (broken ribs where the pieces of bone have moved so that a gap has formed around the fracture, complications can include punctured lungs and damage to other organs) and a right scapular fracture (a rare injury that occurs when the shoulder blade is directly or indirectly impacted by a significant amount of force such as a fall or blow to the shoulder). The facility census was 51.

Refer to Event ID M9W912 Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for five sampled residents (Resident #7, #8, #2, #6, and #1). The facility failed to have adequate staffing to check and provide incontinence care to residents in a timely manner, to provide routine showers to ensure good personal hygiene, to answer call lights in a timely manner and to assist residents out of bed for meals, and ensure all residents were served meals. The facility census was 51.

Refer to Event ID M9W912 Based on observation and interview, the facility failed to maintain resident dignity and self determination for four residents (Resident #1, #8, #2, and #7) when staff failed to provide grooming assistance to include basic haircuts. The facility census was 51.

Refer to Event ID M9W912 Based on observation, interview, and record review, the facility failed to provide three residents (Resident #7, #8 and #2 ), of nine sampled residents, with assistance with activities of daily living (ADL) when staff failed to check for incontinence. The facility failed to ensure Resident #7's hair was groomed and pulled back out of the resident's face during meals and throughout the day. The facility also failed to ensure Resident #2 received routine showers. The facility census was 51.

Based on interview and record review, the facility failed to provide care and treatment following a fall with injury for one resident (Resident #9) with a personal history of a stroke and who was on Xarelto (anticoagulant or blood thinning medication) of nine sampled residents. The resident complained of right sided rib pain at the time of the fall and continued to complain of pain 9 out of 10 (on a scale from 0 to 10 with ten being the worst pain) to the right side. Approximately 2-1/2 hours after the resident was found, the resident's family member arrived at the facility to check on the resident and requested the resident be re-evaluated by staff due to the resident's severe pain, along with shortness of breath. Approximately 10-3/4 hours after the resident was found, the resident continued to complain of pain of 7 out of 10. Staff described the resident as very tearful and in a lot of pain when repositioned, and the physician was not notified. On 10/22/24, the resident's physician gave orders to send the resident to the emergency room (ER) for evaluation, nonemergent, due to a high blood potassium level. In the emergency department the resident was found to have a large right sided hemothorax (when a collection of blood accumulates in the chest cavity, often caused by trauma or injury, symptoms can include difficulty breathing and pain) with multiple displaced rib fractures and a right scapular fracture (a rare injury that occurs when the shoulder blade is directly or indirectly impacted by a significant amount of force such as a fall or blow to the shoulder). At the time of the fall, the on-call physician, who was not the resident's primary care physician, was notified that the resident had slipped from the wheelchair and there was no injury and the notification was facility procedure. The physician was not notified the resident was in pain after the fall and continued to have pain throughout the night, the use of an anticoagulant medication, the resident's shortness of breath or that the fall was unwitnessed. The facility census was 51. The administrator was notified on 11/21/24 at 12:30 P.M of the Immediate Jeopardy (IJ) which began on 10/21/24. The IJ was removed on 11/21/24, per onsite verification. Review of the facility's policy, Acute Condition Changes, dated March 2018, showed the following: -The physician will help identify individuals with a significant risk for having acute changes of condition during their stay; -The nurse shall assess and document/report baseline information to include current level of pain and recent changes in pain level, onset, duration and the severity, all active diagnoses, and current medications; -Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the nurse; -Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness. Phone calls should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status. Review of the facility's policy, Pain Assessment and Management, dated March 2022, showed the following: -The purpose of this procedure is to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; -The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan and the resident's choice related to pain management; -Pain management is a multidisciplinary care process that includes assessing the potential for pain, recognizing the presence of pain, addressing the underlying causes of the pain; -Report to the physician significant changes in the resident's level of pain. 1. Review of Resident #9's care plan dated 10/17/24 showed the following: -The resident required assistance of two staff for bed mobility, for pulling up in bed, repositioning in bed, dressing, toileting, and transfers (Date initiated, 10/17/24); -The resident will attempt to do things without assistance, staff to anticipate needs during routine rounds, as needed and per request (Date initiated, 10/17/24); -The resident was up in the wheelchair, leaned forward, and fell to the floor. Experienced right rib pain. Interventions for staff to continue to educate about not leaning forward in wheelchair, keep call light within reach at all times. (Date initiated, 10/21/24 and revised on 11/6/24). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/21/24, showed the following: -Moderate cognitive impairment; -The resident had pain occasionally and received as needed (PRN) pain medications; -Pain rarely affected sleep; -Pain occasionally affected day to day activities; -No range of motion impairment to upper extremities; -Range of motion impairment in both lower extremities; -Wheelchair used for mobility; -Substantial to maximum assistance required from a staff member to move from sitting to lying position, and for chair/bed to chair transfer; -The resident had one fall since admission with no evidence of injury. Review of the resident's physician order sheet (POS) dated October 2024 showed the following: -Diagnoses included acquired absence of left leg above knee, acquired absence of right leg above the knee, malignant neoplasm of the frontal lobe (a cancerous tumor in the frontal lobe of the brain), muscle wasting and atrophy (decrease in muscle mass and strength) and diabetes; -An order for Xarelto 20 milligram (mg) daily. Review of the resident's Nursing Note dated 10/21/24 at 5:25 P.M. showed the following: -Registered Nurse (RN) A was called to the resident's room by Certified Nurse Assistant (CNA) E. The resident was found lying on the floor on his/her back in front of his/her wheelchair. The resident said he/she was up in his/her wheelchair, leaned forward and fell out of the wheelchair. This fall was not witnessed; -The resident complained of right-side rib pain, but no apparent injury was noted. Staff transferred the resident from the floor to the wheelchair with the assist of two staff members and a mechanical lift. Staff assisted the resident to the dining room. Neurology checks (quick assessment that evaluates the health of someone's nervous system through a series of tests) started, and vital signs (measurements of the body's basic function including temperature, pulse rate, respiration rate and blood pressure) obtained; -On call physician notified of the fall at 5:40 P.M. and no new orders received. Family notified of the fall. Review of the resident's Medication Administration Record (MAR), dated 10/21/24 at 8:30 P.M.,. showed the resident complained of pain in his/her right rib area and rated it a 9 on a scale from 0 to 10 with ten being the worst pain. Staff administered Tramadol (medication used to treat moderate to severe pain) 50 mg and the medication was noted as effective. Review of the resident's Nursing Note, dated 10/21/24 at 9:17 P.M., showed the resident was tearful and said he/she wanted to go home at times. The resident complained of right sided rib pain. Upon palpation resident was tender to touch on the right side and 3 to 4 inches below the axilla (armpit). There was no documentation of the physician being notified. Review of the resident's Nursing Note, dated 10/22/24 at 4:12 A.M., showed the resident complained of pain in his/her right side and rated it a 7 on a 0 to 10 scale with ten being the worst. Staff administered two Tylenol Extra Strength 500 mg tablets (analgesic used to treat mild to moderate pain) and it was noted to be effective. Review of the resident's MAR, dated 10/22/24 at 7:12 A.M., showed the resident complained of right-side rib pain and rated it a 6 on a scale from 0 to 10. Staff administered Tramadol 50 mg one tablet for right sided rib pain, and it was ineffective. No further treatment for pain was initiated when the Tramadol did not effectively relieve the pain. Review of the resident's Nursing Note, dated 10/22/24 at 8:21 A.M., completed by Licensed Practical Nurse (LPN) C, showed the on-call physician's office called and gave an order to send the resident to the emergency department for evaluation due to a critical potassium level and to send the resident nonemergent. Notified the resident's family member of the order. At that time the family member voiced concerns about the fall from the night before and said the resident was still in a lot of pain. LPN C was unaware of the fall. The family member reported the resident was complaining of arm, shoulder, side, and back pain. The resident rated his/her pain a 10. Message sent to the physician to see if he/she wanted any x-rays while at the hospital. After receiving an order from the physician on 10/22/24 at 8:21 A.M. to send the resident to the hospital, Emergency Medical Services (EMS) was contacted to transport the resident. Review of the resident's Nursing Note dated 10/22/24 at 9:15 A.M., showed staff spoke with the ER nurse regarding the fall and complaint of pain, along with high potassium level. The ER nurse said they were in the process of doing x-rays for the resident. Review of the resident's Hospital Discharge Summary, dated 10/25/24 at 1:30 P.M., showed the following: -The resident presented through the emergency room department with complaints related to a fall out of his/her wheelchair. The resident was found to have a large right sided traumatic hemothorax with multiple displaced rib fractures and a right scapula fracture. Evacuation hemothorax was achieved through tube thoracotomy (a surgical procedure that involves making an incision in the chest wall and inserting a tube to drain fluid or air from the pleural space); -It was easy to identify that this injury pattern would be quite disruptive to the resident's quality of life and there would be a long road to any meaningful recovery if meaningful recovery was achievable. Aggressive pain control measures were taken; -The resident will discharge back to the facility with hospice arrangements. During an interview on 11/19/24 at 3:00 P.M., Certified Nurse Assistant (CNA) E said the following: -He/She found the resident on the floor on his/her back. The resident had fallen out of his/her wheelchair and CNA E notified RN A. During an interview on 11/21/24 at 5:15 P.M., CNA F said the following: -On 10/21/24 he/she worked 11:00 P.M. to 7:00 A.M.; -He/She was notified of the resident having a fall in report; -At 4:00 A.M., the resident was tearful and complained of right rib pain. The resident had a lot of pain when staff turned him/her, it was not normal for the resident to have rib pain. CNA F reported that to the charge nurse. During an interview on 11/19/24 at 12:50 P.M., RN A said the following: -On the evening of 10/21/24, CNA E found the resident on the floor. The resident complained of right sided rib pain after the fall. He/She touched the resident's side and the resident had discomfort; -He/She notified the physician on call (not the resident's primary physician) the resident had a fall and had some rib soreness. He/She did not receive any orders. He/She did not communicate to the physician the resident was on a blood thinning medication; -The resident had increased pain at bedtime, but RN A didn't feel it required urgent care or the physician being notified. If the resident had a rib fracture nothing really could be done for it; -RN A scheduled a mobile x-ray for the following day. During an interview on 11/20/24 at 7:54 A.M., LPN C said the following: -He/She worked the 7:00 A.M. to 3:00 P.M. shift on 10/22/24; -He/She received no information during shift change report regarding the resident or a fall from the staff on the previous shift; -The resident's family member reported the morning of 10/22/24 the resident was crying out in pain and hurt all over since the fall; -The resident had been sent out for a critical potassium level. LPN C called the hospital and requested the resident have x-xays due to pain from the fall. During an interview on 11/20/24 at 5:30 P.M., the resident's family member said the following: -On the evening of 10/21/24, RN A called him/her and said the resident fell out of his/her wheelchair onto the floor. RN A said he/she had checked the resident over and didn't have any concerns; -On 10/21/24 approximately 8:00 P.M., the resident's family member arrived at the facility to check on the resident. The resident complained of right sided rib pain and had concerns his/her ribs were broken. He/She questioned RN A about the resident's increased pain. RN A said he/she would schedule a mobile x-Ray for the next day; - On 10/22/2024 when the resident's family member arrived at the facility, the resident was crying out in pain, hurting all over and having some difficulty breathing. The family member reported the pain to LPN C and LPN C was not aware the resident had fallen the evening before; -The resident was diagnosed with multiple rib fractures and a right shoulder fracture. He/she felt the resident should have been evaluated in the emergency room the night of the fall. The resident was in a lot of pain throughout the night; -Due to the extent of the injuries after the fall, the resident elected to go on hospice and return to the facility with no surgical intervention. During an interview on 11/19/24 at 2:15 P.M., the Director of Nursing (DON) said the following: -She would expect any resident who sustained a fall and was on a blood thinning medication be sent out for evaluation due to a risk of bleeding; -She would expect all staff to notify the administrative staff member on call of a resident fall. RN A did not notify the administrative staff on call of the fall; -RN A did not provide the physician on call with enough information regarding the resident and the fall or make the physician aware the resident was on blood thinning medication; -The post fall assessment was not thorough and there was no evidence the night charge nurse evaluated the resident following the fall for any increased pain or change in status; -The resident had increased pain and should have been sent out for evaluation at the time of the fall. During an interview on 11/26/24 at 11:02 A.M., the Administrator said the following: -He would expect staff to follow the facility policy regarding a change in condition and pain assessment; -He would expect staff to assess a resident for pain following a fall and relay any concerns or an increase in pain to the physician. During an interview on 11/20/24 at 11:10 A.M., the Physician Q (on call physician) said the following: -He was the physician on call on 10/21/24, but had not seen or evaluated the resident in the past; -He was notified the resident slipped from the wheelchair and it was procedure to notify the physician on call, but was told no injury had occurred; -The nurse described the resident as having some tenderness, but nothing more; -He would expect staff to notify him that the fall was unwitnessed, the resident was on a blood thinning medication or any continued or an increase in pain; -Communication played a role and if he had received all the details regarding the fall and the resident's history and use of a blood thinner, he would have sent the resident out for evaluation at the time of the fall. 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 G level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO244074

Based on interview and record review, the facility failed to provide care and treatment following a fall with injury for one resident (Resident #9) with a personal history of a stroke and who was on Xarelto (anticoagulant or blood thinning medication) of nine sampled residents. The resident complained of right sided rib pain at the time of the fall and continued to complain of pain 9 out of 10 (on a scale from 0 to 10 with ten being the worst pain) to the right side. Approximately 2-1/2 hours after the resident was found, the resident's family member arrived at the facility to check on the resident and requested the resident be re-evaluated by staff due to the resident's severe pain, along with shortness of breath. Approximately 10-3/4 hours after the resident was found, the resident continued to complain of pain of 7 out of 10. Staff described the resident as very tearful and in a lot of pain when repositioned, and the physician was not notified. On 10/22/24, the resident's physician gave orders to send the resident to the emergency room (ER) for evaluation, nonemergent, due to a high blood potassium level. In the emergency department the resident was found to have a large right sided hemothorax (when a collection of blood accumulates in the chest cavity, often caused by trauma or injury, symptoms can include difficulty breathing and pain) with multiple displaced rib fractures and a right scapular fracture (a rare injury that occurs when the shoulder blade is directly or indirectly impacted by a significant amount of force such as a fall or blow to the shoulder). At the time of the fall, the on-call physician, who was not the resident's primary care physician, was notified that the resident had slipped from the wheelchair and there was no injury and the notification was facility procedure. The physician was not notified the resident was in pain after the fall and continued to have pain throughout the night, the use of an anticoagulant medication, the resident's shortness of breath or that the fall was unwitnessed. The facility census was 51. The administrator was notified on 11/21/24 at 12:30 P.M of the Immediate Jeopardy (IJ) which began on 10/21/24. The IJ was removed on 11/21/24, per onsite verification. Review of the facility's policy, Acute Condition Changes, dated March 2018, showed the following: -The physician will help identify individuals with a significant risk for having acute changes of condition during their stay; -The nurse shall assess and document/report baseline information to include current level of pain and recent changes in pain level, onset, duration and the severity, all active diagnoses, and current medications; -Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the nurse; -Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness. Phone calls should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status. Review of the facility's policy, Pain Assessment and Management, dated March 2022, showed the following: -The purpose of this procedure is to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; -The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan and the resident's choice related to pain management; -Pain management is a multidisciplinary care process that includes assessing the potential for pain, recognizing the presence of pain, addressing the underlying causes of the pain; -Report to the physician significant changes in the resident's level of pain. 1. Review of Resident #9's care plan dated 10/17/24 showed the following: -The resident required assistance of two staff for bed mobility, for pulling up in bed, repositioning in bed, dressing, toileting, and transfers (Date initiated, 10/17/24); -The resident will attempt to do things without assistance, staff to anticipate needs during routine rounds, as needed and per request (Date initiated, 10/17/24); -The resident was up in the wheelchair, leaned forward, and fell to the floor. Experienced right rib pain. Interventions for staff to continue to educate about not leaning forward in wheelchair, keep call light within reach at all times. (Date initiated, 10/21/24 and revised on 11/6/24). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/21/24, showed the following: -Moderate cognitive impairment; -The resident had pain occasionally and received as needed (PRN) pain medications; -Pain rarely affected sleep; -Pain occasionally affected day to day activities; -No range of motion impairment to upper extremities; -Range of motion impairment in both lower extremities; -Wheelchair used for mobility; -Substantial to maximum assistance required from a staff member to move from sitting to lying position, and for chair/bed to chair transfer; -The resident had one fall since admission with no evidence of injury. Review of the resident's physician order sheet (POS) dated October 2024 showed the following: -Diagnoses included acquired absence of left leg above knee, acquired absence of right leg above the knee, malignant neoplasm of the frontal lobe (a cancerous tumor in the frontal lobe of the brain), muscle wasting and atrophy (decrease in muscle mass and strength) and diabetes; -An order for Xarelto 20 milligram (mg) daily. Review of the resident's Nursing Note dated 10/21/24 at 5:25 P.M. showed the following: -Registered Nurse (RN) A was called to the resident's room by Certified Nurse Assistant (CNA) E. The resident was found lying on the floor on his/her back in front of his/her wheelchair. The resident said he/she was up in his/her wheelchair, leaned forward and fell out of the wheelchair. This fall was not witnessed; -The resident complained of right-side rib pain, but no apparent injury was noted. Staff transferred the resident from the floor to the wheelchair with the assist of two staff members and a mechanical lift. Staff assisted the resident to the dining room. Neurology checks (quick assessment that evaluates the health of someone's nervous system through a series of tests) started, and vital signs (measurements of the body's basic function including temperature, pulse rate, respiration rate and blood pressure) obtained; -On call physician notified of the fall at 5:40 P.M. and no new orders received. Family notified of the fall. Review of the resident's Medication Administration Record (MAR), dated 10/21/24 at 8:30 P.M.,. showed the resident complained of pain in his/her right rib area and rated it a 9 on a scale from 0 to 10 with ten being the worst pain. Staff administered Tramadol (medication used to treat moderate to severe pain) 50 mg and the medication was noted as effective. Review of the resident's Nursing Note, dated 10/21/24 at 9:17 P.M., showed the resident was tearful and said he/she wanted to go home at times. The resident complained of right sided rib pain. Upon palpation resident was tender to touch on the right side and 3 to 4 inches below the axilla (armpit). There was no documentation of the physician being notified. Review of the resident's Nursing Note, dated 10/22/24 at 4:12 A.M., showed the resident complained of pain in his/her right side and rated it a 7 on a 0 to 10 scale with ten being the worst. Staff administered two Tylenol Extra Strength 500 mg tablets (analgesic used to treat mild to moderate pain) and it was noted to be effective. Review of the resident's MAR, dated 10/22/24 at 7:12 A.M., showed the resident complained of right-side rib pain and rated it a 6 on a scale from 0 to 10. Staff administered Tramadol 50 mg one tablet for right sided rib pain, and it was ineffective. No further treatment for pain was initiated when the Tramadol did not effectively relieve the pain. Review of the resident's Nursing Note, dated 10/22/24 at 8:21 A.M., completed by Licensed Practical Nurse (LPN) C, showed the on-call physician's office called and gave an order to send the resident to the emergency department for evaluation due to a critical potassium level and to send the resident nonemergent. Notified the resident's family member of the order. At that time the family member voiced concerns about the fall from the night before and said the resident was still in a lot of pain. LPN C was unaware of the fall. The family member reported the resident was complaining of arm, shoulder, side, and back pain. The resident rated his/her pain a 10. Message sent to the physician to see if he/she wanted any x-rays while at the hospital. After receiving an order from the physician on 10/22/24 at 8:21 A.M. to send the resident to the hospital, Emergency Medical Services (EMS) was contacted to transport the resident. Review of the resident's Nursing Note dated 10/22/24 at 9:15 A.M., showed staff spoke with the ER nurse regarding the fall and complaint of pain, along with high potassium level. The ER nurse said they were in the process of doing x-rays for the resident. Review of the resident's Hospital Discharge summary, dated [DATE] at 1:30 P.M., showed the following: -The resident presented through the emergency room department with complaints related to a fall out of his/her wheelchair. The resident was found to have a large right sided traumatic hemothorax with multiple displaced rib fractures and a right scapula fracture. Evacuation hemothorax was achieved through tube thoracotomy (a surgical procedure that involves making an incision in the chest wall and inserting a tube to drain fluid or air from the pleural space); -It was easy to identify that this injury pattern would be quite disruptive to the resident's quality of life and there would be a long road to any meaningful recovery if meaningful recovery was achievable. Aggressive pain control measures were taken; -The resident will discharge back to the facility with hospice arrangements. During an interview on 11/19/24 at 3:00 P.M., Certified Nurse Assistant (CNA) E said the following: -He/She found the resident on the floor on his/her back. The resident had fallen out of his/her wheelchair and CNA E notified RN A. During an interview on 11/21/24 at 5:15 P.M., CNA F said the following: -On 10/21/24 he/she worked 11:00 P.M. to 7:00 A.M.; -He/She was notified of the resident having a fall in report; -At 4:00 A.M., the resident was tearful and complained of right rib pain. The resident had a lot of pain when staff turned him/her, it was not normal for the resident to have rib pain. CNA F reported that to the charge nurse. During an interview on 11/19/24 at 12:50 P.M., RN A said the following: -On the evening of 10/21/24, CNA E found the resident on the floor. The resident complained of right sided rib pain after the fall. He/She touched the resident's side and the resident had discomfort; -He/She notified the physician on call (not the resident's primary physician) the resident had a fall and had some rib soreness. He/She did not receive any orders. He/She did not communicate to the physician the resident was on a blood thinning medication; -The resident had increased pain at bedtime, but RN A didn't feel it required urgent care or the physician being notified. If the resident had a rib fracture nothing really could be done for it; -RN A scheduled a mobile x-ray for the following day. During an interview on 11/20/24 at 7:54 A.M., LPN C said the following: -He/She worked the 7:00 A.M. to 3:00 P.M. shift on 10/22/24; -He/She received no information during shift change report regarding the resident or a fall from the staff on the previous shift; -The resident's family member reported the morning of 10/22/24 the resident was crying out in pain and hurt all over since the fall; -The resident had been sent out for a critical potassium level. LPN C called the hospital and requested the resident have x-xays due to pain from the fall. During an interview on 11/20/24 at 5:30 P.M., the resident's family member said the following: -On the evening of 10/21/24, RN A called him/her and said the resident fell out of his/her wheelchair onto the floor. RN A said he/she had checked the resident over and didn't have any concerns; -On 10/21/24 approximately 8:00 P.M., the resident's family member arrived at the facility to check on the resident. The resident complained of right sided rib pain and had concerns his/her ribs were broken. He/She questioned RN A about the resident's increased pain. RN A said he/she would schedule a mobile x-Ray for the next day; - On 10/22/2024 when the resident's family member arrived at the facility, the resident was crying out in pain, hurting all over and having some difficulty breathing. The family member reported the pain to LPN C and LPN C was not aware the resident had fallen the evening before; -The resident was diagnosed with multiple rib fractures and a right shoulder fracture. He/she felt the resident should have been evaluated in the emergency room the night of the fall. The resident was in a lot of pain throughout the night; -Due to the extent of the injuries after the fall, the resident elected to go on hospice and return to the facility with no surgical intervention. During an interview on 11/19/24 at 2:15 P.M., the Director of Nursing (DON) said the following: -She would expect any resident who sustained a fall and was on a blood thinning medication be sent out for evaluation due to a risk of bleeding; -She would expect all staff to notify the administrative staff member on call of a resident fall. RN A did not notify the administrative staff on call of the fall; -RN A did not provide the physician on call with enough information regarding the resident and the fall or make the physician aware the resident was on blood thinning medication; -The post fall assessment was not thorough and there was no evidence the night charge nurse evaluated the resident following the fall for any increased pain or change in status; -The resident had increased pain and should have been sent out for evaluation at the time of the fall. During an interview on 11/26/24 at 11:02 A.M., the Administrator said the following: -He would expect staff to follow the facility policy regarding a change in condition and pain assessment; -He would expect staff to assess a resident for pain following a fall and relay any concerns or an increase in pain to the physician. During an interview on 11/20/24 at 11:10 A.M., the Physician Q (on call physician) said the following: -He was the physician on call on 10/21/24, but had not seen or evaluated the resident in the past; -He was notified the resident slipped from the wheelchair and it was procedure to notify the physician on call, but was told no injury had occurred; -The nurse described the resident as having some tenderness, but nothing more; -He would expect staff to notify him that the fall was unwitnessed, the resident was on a blood thinning medication or any continued or an increase in pain; -Communication played a role and if he had received all the details regarding the fall and the resident's history and use of a blood thinner, he would have sent the resident out for evaluation at the time of the fall. 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 G level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO244074

Based on interview and record, review the facility failed to develop a care plan with interventions to prevent falls for one resident (Resident #9) of nine sampled residents, who was at risk for falls and was admitted to the facility after having falls at home. The resident sustained a fall while at the facility on 10/21/22. Staff failed to complete a thorough post fall assessment or notify the Director of Nursing (DON), as directed by facility policy, at the time of the fall. The facility failed to communicate the resident's fall to the oncoming shift at shift change. The facility failed to communicate pertinent information regarding the fall to the on-call physician, who was not familiar with the resident which delayed evaluation and treatment. As a result of the fall, the resident sustained a large right sided hemothorax (when a collection of blood accumulates in the chest cavity, often caused by trauma or injury, symptoms can include difficulty breathing and pain) with multiple displaced rib fractures (broken ribs where the pieces of bone have moved so that a gap has formed around the fracture, complications can include punctured lungs and damage to other organs) and a right scapular fracture (a rare injury that occurs when the shoulder blade is directly or indirectly impacted by a significant amount of force such as a fall or blow to the shoulder). The facility census was 51. Review of the facility's policy titled, Care Plans-Baseline, December 2016 showed the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission; -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; -The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including, but limited to initial goals based on admission orders, physician orders, dietary orders, therapy services and social services. Review of the facility's policy titled, Assessing Falls and Their Causes, dated March 2018, showed the following: -The purposes of this procedure was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall; -Review the resident's care plan to assess for any special needs of the resident, identify current medications and active medical conditions; -Falls are the leading cause of morbidity and mortality among the elderly in nursing homes, falling maybe related to underlying clinical or medical conditions, overall functional decline, medication side effects or environmental risk factors; -If a resident has just fallen, or is found in the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities; -If an assessment rules out significant injury or condition change, notify the practitioner routinely by fax, or phone the next day; -Observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and document findings in the medical record; -Document any observed signs or symptoms of pain, swelling, bruising or deformity, and/or decreased mobility, and any changes in level of responsiveness/consciousness or overall function. Note the presence or absence of significant findings; -After an observed or probable fall, clarify details of the fall, such as when fall occurred and what the individual was trying to do at the time if the fall; -Distinguish falls as rolling, sliding, or dropping from bed or chair to floor; -Within 24 hours of the fall, begin to try to identify the likely cause of the incident; -When a resident falls, record in the medical record the condition in which the resident was found, assessment data, including vital signs and any obvious injuries. Interventions or treatment administered, notification to the physician and family, as indicated, completion of falls risk assessment, appropriate interventions to prevent future falls; -Report to the attending physician (timing of notification may vary, depending on whether injury was involved), the DON and the nursing supervisor on duty 1. Review of Resident #9's Nursing Note, dated 10/14/24 at 9:13 P.M., showed the following: -The resident was admitted from the hospital emergency room ; -The resident transfers with assist of two staff and slides from wheelchair to bed and has bilateral amputation of lower extremities. History of falls which was the reason the resident was in the emergency room today. Review of the resident's Care Plan, dated 10/17/24, showed the following: Diagnoses included acquired absence of left leg above knee, acquired absence of right leg above the knee, malignant neoplasm of the frontal lobe (a cancerous tumor in the frontal lobe of the brain), muscle wasting and atrophy (decrease in muscle mass and strength) and diabetes; -The resident required assist of two for bed mobility, for pulling up in bed, repositioning in bed, dressing, toileting, and transfers (Date initiated, 10/17/24); -The resident will attempt to do things without assistance, staff to anticipate my needs during routine rounds, as needed and per request (Date initiated, 10/17/24) -The care plan did not address the resident's risk for falls or include interventions to prevent falls. Review of the resident's Fall Risk Evaluation, dated 10/20/24, showed the following: -Upon admission and quarterly, at a minimum, thereafter, observe the resident status in the 11 clinical condition parameters listed below by assigning the corresponding score which best describes the resident. If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan; -Staff documented the resident had no falls in the past three months, was bedbound/continent, had a change of condition in the last 14 days, had a recent hospitalization , took one to two medications that increased the likelihood for falls, and had multiple predisposing diseases that increased the likelihood for falls; -The resident's score was 17 showing the resident was at high risk for falls, the section of the evaluation Risk for Falls including options for interventions, was not completed by staff. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/21/24, showed the following: -Moderate cognitive impairment; -The resident had pain occasionally and received as needed (PRN) pain medications; -Pain rarely affected sleep; -Pain occasionally affected day to day activities; -No range of motion impairment to upper extremities; -Range of motion impairment in lower extremities; -Wheelchair used for mobility; -Substantial to maximum assistance required from a staff member to move from sitting to lying position, rolling left to right, and for chair/bed to chair transfer; -The resident had one fall since admission with no evidence of injury. Review of the resident's Occupational Therapy Evaluation, dated 10/17/24, showed the following: -The resident will increase sitting balance during Activities of Living (ADL) to fair and using righting reactions 75% of the time to reduce the risk of falls, facilitate upright posture and increase participation with functional tasks; -Sitting during meals percentage baseline was less than 25% and was poor (sits unsupported with minimal assist and unable to weight shift). Review of the resident's Nursing Note, dated 10/21/24 at 5:25 P.M., showed the following: -Registered Nurse (RN) A was called to the resident's room by Certified Nurse Assistant (CNA) E. The resident was found on the floor on his/her back in front of his/her wheelchair. The resident said he/she was up in his/her wheelchair, leaned forward and fell out of the wheelchair; -The resident complained of right-side rib pain, but no apparent injury was noted. Staff transferred the resident from the floor to the wheelchair with the assist of two staff members and a mechanical lift. The resident was assisted to the dining room; -Staff notified the call physician at 5:40 P.M. and no new orders were received. Review of the resident's Unwitnessed Fall Report dated 10/21/24 at 6:07 P.M., showed the following: -RN A was called to the resident's room, the resident was on the floor on his/her back in front of the wheelchair. The resident said he/she leaned forward in the wheelchair and fell out; -The resident was assisted to the wheelchair by two staff members and use of a mechanical lift and brought to the dining room. No apparent injury noted. The resident complained of right-sided rib tenderness; -Level of pain was a 5 on a 0 to 10 scale with 10 being the worse; -The section for environmental factors and situational factors was not completed; -Predisposing factors: weakness/fainted and trunk control and balance issue. Review of the resident's medical record showed staff did not document on 10/21/24 (11:00 P.M. to 7:00 A.M.) that the 11-7 shift charge nurse assessed the resident post fall for any delayed complications, pain or injury. Review of the resident's hospital Discharge Summary, dated 10/25/24 at 1:30 P.M., showed the following: -The resident presented through the emergency room department with complaints related to a fall out of his/her wheelchair. The resident was found to have a large right sided traumatic hemothorax with multiple displaced rib fractures and a right scapula fracture. Evacuation hemothorax was achieved through tube thoracostomy. -It was easy to identify that this injury pattern would be quite disruptive to the resident's quality of life and there would a long road to any meaningful recovery if meaningful recovery was achievable. Aggressive pain control measures were taken. -The resident will discharge back to the facility with hospice arrangements. Review of the resident's care plan, revised 11/6/24, showed fall on 10/21/24, right rib pain. Up in wheelchair and leaned forward and fell to floor. Interventions for staff to continue to educate about not leaning forward in wheelchair. During an interview on 11/20/24 at 5:30 P.M., the resident's family member said the following: -The resident was admitted directly to the facility from the emergency room after a fall at home. The resident had fallen multiple times at home trying to transfer; -On the evening of 10/21/24, RN A called him/her and said the resident fell out of his/her wheelchair onto the floor. RN A said he/she had checked the resident over and didn't have any concerns; -On 10/21/24 approximately 8:00 P.M. the family member arrived at the facility to check on the resident. The resident complained of right sided rib pain and had concerns his/her ribs were broken. He/She questioned RN A about the resident's increased pain. RN A said he/she would schedule a mobile x-ray for the next day; -The following day (10/22/24) when the family member arrived at the facility the resident was crying out in pain, hurting all over and having some difficulty breathing. The family member reported the pain to Licensed Practical Nurse (LPN) C and he/she was not aware the resident had fallen the evening before; -The resident ended up with multiple rib fractures and a right shoulder fracture. He/she felt the resident should have been evaluated in the emergency room the night of the fall. The resident was in a lot of pain throughout the night; -Due to the extent of the injuries after the fall, the resident elected to go on hospice and return to the facility with no surgical intervention. During an interview on 11/19/24 at 3:00 P.M., CNA E said the following: -He/She was not aware the resident had a history of falls. He/She didn't know of any fall interventions that were in place to prevent falls for the resident; -He/She found the resident on the floor on his/her back. The resident fell out of his/her wheelchair and CNA E notified RN A. During an interview on 11/20/24 at 1:36 P.M., CNA P said the following: -The resident was typically in bed, the resident was so weak he/she wasn't sure the resident could hold himself/herself up if in the wheelchair for very long. CNA P was afraid to even leave the resident in the wheelchair while he/she changed the bed linens on shower day; -CNA P made a comment to one of the charges nurse that he/she was concerned with leaving the resident in his/her wheelchair unsupervised because the resident was so weak; -CNA P wasn't sure if the resident had a history of falls. During an interview on 11/20/24 at 7:54 A.M., LPN C said the following: -He/She was not aware the resident had a fall in the past or prior to admission. He/She could not recall any fall prevention interventions that were in place for the resident prior to his/her fall on 10/21/24; -He/She worked the 7:00 A.M. to 3:00 P.M. shift on 10/22/24; -The off-going nurse provided no information at shift change to LPN C regarding the resident or a fall. If any resident had a recent fall, he/she evaluated the resident at the start of his/her shift to assure there was no post fall concerns. This was not done as LPN C was not aware of the resident's fall; -The resident's family member reported that morning the resident was crying out in pain and hurt all over since the fall; -The resident had been sent out for a critical potassium level, LPN C called the hospital and requested the resident have x-rays due to pain from the fall. During an interview on 11/20/24 at 9:00 A.M., LPN B said on 10/21/24 he/she worked the 11:00 P.M. to 7:00 A.M. shift. LPN B did not recall if the resident had a fall prior to his/her shift. He/She could not recall if the resident had any pain throughout his/her shift. During an interview on 11/20/24 at 10:00 A.M. with Physical Therapy Assistant (PTA) O said the following: -The resident was very weak and required a mechanical lift for transfers; -The resident's core strength was very poor. The resident was often slumped over in bed and required assistance to sit up in bed due to his/her weakness; -The resident was not safe to sit in his/her wheelchair unsupervised due being visibly weaker prior to the fall. PTA O thought the nursing staff were aware of this, but was not sure if it was communicated to them. During an interview on 11/19/24 at 2:15 P.M., the DON said the following: -The resident was admitted to the facility from the emergency room following a fall at home. A fall care plan and interventions should have been put in place upon admission; -She would expect the Fall Risk Evaluation be completed accurately. The fall incident report should be thorough and attempt to find the root cause of the fall; -She was not aware that therapy staff had concerns with the resident being up in the wheelchair unsupervised. That information was not relayed to her, she would expect for therapy to relay that information to the nursing staff; -The facility also had a weekly meeting with therapy to discuss the residents and any concerns or recommendations; -She would expect staff to report any falls to the oncoming shift at change of shift and documentation of the resident's status following the fall; -She would expect all staff notify the administrative staff member on call of a resident fall. RN A didn't notify the administrative staff on call of the fall; -The post fall assessment was not thorough and there was no evidence the night charge nurse evaluated the resident following the fall for any increased pain or changes in status; -The resident had an increase of pain and should have been sent out for evaluation at the time of the fall; -She would expect for the baseline care plan be completed at admission by the admitting nurse. During an interview on 11/26/24 at 11:02 A.M. the Administrator said the following: -He would expect staff to follow the facility policy regarding falls; -He would expect staff to assess a resident for pain following a fall and relay any concerns or an increase in pain to the physician. During an interview on 11/20/24 at 11:10 A.M. the Physician Q (on call physician on) said the following: -He was the physician on call on 10/21/24, but had not seen or evaluated the resident in the past; -He was notified the resident slipped from the wheelchair and it was procedure to notify the physician on call, but was told no injury had occurred; -The nurse described the resident as having some tenderness, but nothing more. MO244074

Based on interview and record, review the facility failed to develop a care plan with interventions to prevent falls for one resident (Resident #9) of nine sampled residents, who was at risk for falls and was admitted to the facility after having falls at home. The resident sustained a fall while at the facility on 10/21/22. Staff failed to complete a thorough post fall assessment or notify the Director of Nursing (DON), as directed by facility policy, at the time of the fall. The facility failed to communicate the resident's fall to the oncoming shift at shift change. The facility failed to communicate pertinent information regarding the fall to the on-call physician, who was not familiar with the resident which delayed evaluation and treatment. As a result of the fall, the resident sustained a large right sided hemothorax (when a collection of blood accumulates in the chest cavity, often caused by trauma or injury, symptoms can include difficulty breathing and pain) with multiple displaced rib fractures (broken ribs where the pieces of bone have moved so that a gap has formed around the fracture, complications can include punctured lungs and damage to other organs) and a right scapular fracture (a rare injury that occurs when the shoulder blade is directly or indirectly impacted by a significant amount of force such as a fall or blow to the shoulder). The facility census was 51. Review of the facility's policy titled, Care Plans-Baseline, December 2016 showed the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission; -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; -The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including, but limited to initial goals based on admission orders, physician orders, dietary orders, therapy services and social services. Review of the facility's policy titled, Assessing Falls and Their Causes, dated March 2018, showed the following: -The purposes of this procedure was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall; -Review the resident's care plan to assess for any special needs of the resident, identify current medications and active medical conditions; -Falls are the leading cause of morbidity and mortality among the elderly in nursing homes, falling maybe related to underlying clinical or medical conditions, overall functional decline, medication side effects or environmental risk factors; -If a resident has just fallen, or is found in the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities; -If an assessment rules out significant injury or condition change, notify the practitioner routinely by fax, or phone the next day; -Observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and document findings in the medical record; -Document any observed signs or symptoms of pain, swelling, bruising or deformity, and/or decreased mobility, and any changes in level of responsiveness/consciousness or overall function. Note the presence or absence of significant findings; -After an observed or probable fall, clarify details of the fall, such as when fall occurred and what the individual was trying to do at the time if the fall; -Distinguish falls as rolling, sliding, or dropping from bed or chair to floor; -Within 24 hours of the fall, begin to try to identify the likely cause of the incident; -When a resident falls, record in the medical record the condition in which the resident was found, assessment data, including vital signs and any obvious injuries. Interventions or treatment administered, notification to the physician and family, as indicated, completion of falls risk assessment, appropriate interventions to prevent future falls; -Report to the attending physician (timing of notification may vary, depending on whether injury was involved), the DON and the nursing supervisor on duty 1. Review of Resident #9's Nursing Note, dated 10/14/24 at 9:13 P.M., showed the following: -The resident was admitted from the hospital emergency room; -The resident transfers with assist of two staff and slides from wheelchair to bed and has bilateral amputation of lower extremities. History of falls which was the reason the resident was in the emergency room today. Review of the resident's Care Plan, dated 10/17/24, showed the following: Diagnoses included acquired absence of left leg above knee, acquired absence of right leg above the knee, malignant neoplasm of the frontal lobe (a cancerous tumor in the frontal lobe of the brain), muscle wasting and atrophy (decrease in muscle mass and strength) and diabetes; -The resident required assist of two for bed mobility, for pulling up in bed, repositioning in bed, dressing, toileting, and transfers (Date initiated, 10/17/24); -The resident will attempt to do things without assistance, staff to anticipate my needs during routine rounds, as needed and per request (Date initiated, 10/17/24) -The care plan did not address the resident's risk for falls or include interventions to prevent falls. Review of the resident's Fall Risk Evaluation, dated 10/20/24, showed the following: -Upon admission and quarterly, at a minimum, thereafter, observe the resident status in the 11 clinical condition parameters listed below by assigning the corresponding score which best describes the resident. If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan; -Staff documented the resident had no falls in the past three months, was bedbound/continent, had a change of condition in the last 14 days, had a recent hospitalization, took one to two medications that increased the likelihood for falls, and had multiple predisposing diseases that increased the likelihood for falls; -The resident's score was 17 showing the resident was at high risk for falls, the section of the evaluation Risk for Falls including options for interventions, was not completed by staff. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/21/24, showed the following: -Moderate cognitive impairment; -The resident had pain occasionally and received as needed (PRN) pain medications; -Pain rarely affected sleep; -Pain occasionally affected day to day activities; -No range of motion impairment to upper extremities; -Range of motion impairment in lower extremities; -Wheelchair used for mobility; -Substantial to maximum assistance required from a staff member to move from sitting to lying position, rolling left to right, and for chair/bed to chair transfer; -The resident had one fall since admission with no evidence of injury. Review of the resident's Occupational Therapy Evaluation, dated 10/17/24, showed the following: -The resident will increase sitting balance during Activities of Living (ADL) to fair and using righting reactions 75% of the time to reduce the risk of falls, facilitate upright posture and increase participation with functional tasks; -Sitting during meals percentage baseline was less than 25% and was poor (sits unsupported with minimal assist and unable to weight shift). Review of the resident's Nursing Note, dated 10/21/24 at 5:25 P.M., showed the following: -Registered Nurse (RN) A was called to the resident's room by Certified Nurse Assistant (CNA) E. The resident was found on the floor on his/her back in front of his/her wheelchair. The resident said he/she was up in his/her wheelchair, leaned forward and fell out of the wheelchair; -The resident complained of right-side rib pain, but no apparent injury was noted. Staff transferred the resident from the floor to the wheelchair with the assist of two staff members and a mechanical lift. The resident was assisted to the dining room; -Staff notified the call physician at 5:40 P.M. and no new orders were received. Review of the resident's Unwitnessed Fall Report dated 10/21/24 at 6:07 P.M., showed the following: -RN A was called to the resident's room, the resident was on the floor on his/her back in front of the wheelchair. The resident said he/she leaned forward in the wheelchair and fell out; -The resident was assisted to the wheelchair by two staff members and use of a mechanical lift and brought to the dining room. No apparent injury noted. The resident complained of right-sided rib tenderness; -Level of pain was a 5 on a 0 to 10 scale with 10 being the worse; -The section for environmental factors and situational factors was not completed; -Predisposing factors: weakness/fainted and trunk control and balance issue. Review of the resident's medical record showed staff did not document on 10/21/24 (11:00 P.M. to 7:00 A.M.) that the 11-7 shift charge nurse assessed the resident post fall for any delayed complications, pain or injury. Review of the resident's hospital Discharge summary, dated [DATE] at 1:30 P.M., showed the following: -The resident presented through the emergency room department with complaints related to a fall out of his/her wheelchair. The resident was found to have a large right sided traumatic hemothorax with multiple displaced rib fractures and a right scapula fracture. Evacuation hemothorax was achieved through tube thoracostomy. -It was easy to identify that this injury pattern would be quite disruptive to the resident's quality of life and there would a long road to any meaningful recovery if meaningful recovery was achievable. Aggressive pain control measures were taken. -The resident will discharge back to the facility with hospice arrangements. Review of the resident's care plan, revised 11/6/24, showed fall on 10/21/24, right rib pain. Up in wheelchair and leaned forward and fell to floor. Interventions for staff to continue to educate about not leaning forward in wheelchair. During an interview on 11/20/24 at 5:30 P.M., the resident's family member said the following: -The resident was admitted directly to the facility from the emergency room after a fall at home. The resident had fallen multiple times at home trying to transfer; -On the evening of 10/21/24, RN A called him/her and said the resident fell out of his/her wheelchair onto the floor. RN A said he/she had checked the resident over and didn't have any concerns; -On 10/21/24 approximately 8:00 P.M. the family member arrived at the facility to check on the resident. The resident complained of right sided rib pain and had concerns his/her ribs were broken. He/She questioned RN A about the resident's increased pain. RN A said he/she would schedule a mobile x-ray for the next day; -The following day (10/22/24) when the family member arrived at the facility the resident was crying out in pain, hurting all over and having some difficulty breathing. The family member reported the pain to Licensed Practical Nurse (LPN) C and he/she was not aware the resident had fallen the evening before; -The resident ended up with multiple rib fractures and a right shoulder fracture. He/she felt the resident should have been evaluated in the emergency room the night of the fall. The resident was in a lot of pain throughout the night; -Due to the extent of the injuries after the fall, the resident elected to go on hospice and return to the facility with no surgical intervention. During an interview on 11/19/24 at 3:00 P.M., CNA E said the following: -He/She was not aware the resident had a history of falls. He/She didn't know of any fall interventions that were in place to prevent falls for the resident; -He/She found the resident on the floor on his/her back. The resident fell out of his/her wheelchair and CNA E notified RN A. During an interview on 11/20/24 at 1:36 P.M., CNA P said the following: -The resident was typically in bed, the resident was so weak he/she wasn't sure the resident could hold himself/herself up if in the wheelchair for very long. CNA P was afraid to even leave the resident in the wheelchair while he/she changed the bed linens on shower day; -CNA P made a comment to one of the charges nurse that he/she was concerned with leaving the resident in his/her wheelchair unsupervised because the resident was so weak; -CNA P wasn't sure if the resident had a history of falls. During an interview on 11/20/24 at 7:54 A.M., LPN C said the following: -He/She was not aware the resident had a fall in the past or prior to admission. He/She could not recall any fall prevention interventions that were in place for the resident prior to his/her fall on 10/21/24; -He/She worked the 7:00 A.M. to 3:00 P.M. shift on 10/22/24; -The off-going nurse provided no information at shift change to LPN C regarding the resident or a fall. If any resident had a recent fall, he/she evaluated the resident at the start of his/her shift to assure there was no post fall concerns. This was not done as LPN C was not aware of the resident's fall; -The resident's family member reported that morning the resident was crying out in pain and hurt all over since the fall; -The resident had been sent out for a critical potassium level, LPN C called the hospital and requested the resident have x-rays due to pain from the fall. During an interview on 11/20/24 at 9:00 A.M., LPN B said on 10/21/24 he/she worked the 11:00 P.M. to 7:00 A.M. shift. LPN B did not recall if the resident had a fall prior to his/her shift. He/She could not recall if the resident had any pain throughout his/her shift. During an interview on 11/20/24 at 10:00 A.M. with Physical Therapy Assistant (PTA) O said the following: -The resident was very weak and required a mechanical lift for transfers; -The resident's core strength was very poor. The resident was often slumped over in bed and required assistance to sit up in bed due to his/her weakness; -The resident was not safe to sit in his/her wheelchair unsupervised due being visibly weaker prior to the fall. PTA O thought the nursing staff were aware of this, but was not sure if it was communicated to them. During an interview on 11/19/24 at 2:15 P.M., the DON said the following: -The resident was admitted to the facility from the emergency room following a fall at home. A fall care plan and interventions should have been put in place upon admission; -She would expect the Fall Risk Evaluation be completed accurately. The fall incident report should be thorough and attempt to find the root cause of the fall; -She was not aware that therapy staff had concerns with the resident being up in the wheelchair unsupervised. That information was not relayed to her, she would expect for therapy to relay that information to the nursing staff; -The facility also had a weekly meeting with therapy to discuss the residents and any concerns or recommendations; -She would expect staff to report any falls to the oncoming shift at change of shift and documentation of the resident's status following the fall; -She would expect all staff notify the administrative staff member on call of a resident fall. RN A didn't notify the administrative staff on call of the fall; -The post fall assessment was not thorough and there was no evidence the night charge nurse evaluated the resident following the fall for any increased pain or changes in status; -The resident had an increase of pain and should have been sent out for evaluation at the time of the fall; -She would expect for the baseline care plan be completed at admission by the admitting nurse. During an interview on 11/26/24 at 11:02 A.M. the Administrator said the following: -He would expect staff to follow the facility policy regarding falls; -He would expect staff to assess a resident for pain following a fall and relay any concerns or an increase in pain to the physician. During an interview on 11/20/24 at 11:10 A.M. the Physician Q (on call physician on) said the following: -He was the physician on call on 10/21/24, but had not seen or evaluated the resident in the past; -He was notified the resident slipped from the wheelchair and it was procedure to notify the physician on call, but was told no injury had occurred; -The nurse described the resident as having some tenderness, but nothing more. MO244074

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #53), in a sample of three residents, who presented with diagnoses of major depressive disorder, anxiety and dementia related psychosis, received the necessary behavioral health care services to maintain the highest practicable physical, mental and psychosocial well-being. The facility failed to report the resident's statements related to direct self harm and suicidal ideation to the resident's physician to further evaluate the resident and ensure the resident's safety. The facility also failed to provide any psychiatric services to the resident after his/her admission from an acute psychiatric hospital unit for geriatric patients. The facility failed to identify the resident's worsening depression and to investigate the root cause of the resident's behaviors, including suicidal thoughts, and to address these appropriately. There was no care plan to direct staff in appropriate interaction and care of this resident with behavioral health care needs. The facility census was 56. Review of the facility's policy Suicide Threats, revised December 2007, showed the following: -Resident suicide threats shall be taken seriously and addressed appropriately; -Staff shall report any resident threats of suicide immediately to the nurse supervisor/charge nurse; -The nurse supervisor/charge nurse shall immediately assess the situation and shall notify the charge nurse/ supervisor and/or director of nursing services of such threats; -A staff member shall remain with the resident until the nurse supervisor/charge nurse arrives to evaluate the resident; -After assessing the resident in more detail, the nurse supervisor/charge nurse shall notify the resident's attending physician and responsible party, and shall seek further direction from the physician; -All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately; -As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated; -If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present; -Staff shall document details of the situation objectively in the resident's medical record. Review of the facility's policy Behavioral Health Services, revised February 2019, showed the following: -The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care; -Behavioral health services are provided to residents as needed as part of the interdisciplinary, person centered approach to care; -Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care; -Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse or post-traumatic stress disorder(s) will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavoidable; -Staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress; -Staff training regarding behavioral health services includes, but is not limited to: a. Recognizing changes in behavior that indicate psychological distress; b. Implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs; c. Monitoring care plan interventions and reporting changes in condition; and d. Protocols and guidelines related to the treatment of mental disorders, psychosocial adjustment difficulties, history of trauma and post-traumatic stress disorder; -Behavioral health services are provided by staff who are qualified and competent in behavioral health and trauma-informed care; -Staff are scheduled in sufficient numbers to manage resident needs throughout the day, evening and night. Review of drugs.com showed the following: -Abilify is a medication for depression. It is not approved for use in older adults with dementia-related psychosis. People with depression or mental illness may have thoughts about suicide. Tell your doctor right away if you have any sudden changes in mood or behavior, or thoughts about suicide. Stop using Abilify and call your doctor at once if you have the following symptoms: fever with stiff muscles and rapid heart rate; uncontrolled muscle movements; symptoms that come on suddenly such as numbness or weakness, severe headache, and problems with vision, speech, or balance.; -Sertraline is an antidepressant medication that is used to treat major depressive disorder. Tell your doctor right away if you have any sudden changes in mood or behavior, or thoughts about suicide. -Mirtazepine is an antidepressant medication. Some people have thoughts about suicide when first taking an antidepressant. Your doctor will need to check your progress at regular visits while you are using mirtazapine. Your family or other caregivers should also be alert to changes in your mood or symptoms; -Klonopin is used to treat panic disorders. Some people have thoughts about suicide while taking Klonopin. Tell your doctor right away if you have any sudden changes in mood or behavior, or thoughts about suicide. Get medical help right away if you stop using Klonopin and have symptoms such as: unusual muscle movements, being more active or talkative, sudden and severe changes in mood or behavior, confusion, hallucinations, seizures, or thoughts about suicide; -Seroquel is an antipsychotic medication used to treat schizophrenia and bipolar disease. People with depression or mental illness may have thoughts about suicide. Some young people may have increased suicidal thoughts when first starting Seroquel. Tell your doctor right away if you have any sudden changes in mood or behavior, or thoughts about suicide. Seroquel may increase the risk of death in older adults with mental health problems related to dementia. Seek medical attention right away if you have symptoms of serotonin syndrome, such as: agitation, hallucinations, fever, sweating, shivering, fast heart rate, muscle stiffness, twitching, loss of coordination, nausea, vomiting, or diarrhea; -Phenytoin (a medication for seizures) contains a warning to report any new or worsening symptoms to your doctor, such as: mood or behavior changes, depression, anxiety, or if you feel agitated, hostile, restless, hyperactive (mentally or physically), or have thoughts about suicide or hurting yourself. 1. Review of Resident #53's face sheet showed the resident entered the facility from an acute inpatient geropsychiatric unit on 10/17/23. Review of the resident's psychiatric evaluation from his/her hospital referral paperwork, dated 9/21/23, showed the following: -admitted from outside hospital secondary to worsening anxiety and panic; -Physical aggression present; -Irritable, Anxious; -Negative for suicide ideation, suicide plan, ability to carry out plan, self-injurious behavior; -Admit patient inpatient psychiatric unit; -Monitor for safety and symptoms; -Provide group and individual therapy; -Adjust psychotropics (antipsychotic, antianxiety, antidepressant, and hypnotic medications); -Estimated length of stay 10-12 days. Review of the resident's physician orders, dated 10/17/23, showed the following: -Phenytoin 200 milligrams (mg) two times a day; -Klonopin 1 mg two times a day; -Abilify 15 mg daily. Review of the resident's physician orders, dated 10/24/23, showed Sertraline 50 mg daily. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment, completed by facility staff and dated 10/24/23, showed the following: -Severe cognitive impairment; -Diagnosis include chronic respiratory failure with hypoxia (low levels of oxygen in your tissues), dementia related psychosis, seizure disorder, anxiety and depression, psychosis; -Vision adequate; -Understands and is understood; -No signs or symptoms of depression; -No hallucination or delusions; -No behaviors directed at self or others; -The resident is taking antipsychotic, antidepressant and antianxiety medications. Review of the resident's care plan, dated 10/24/23, showed the resident needs assist with all activities of daily living (ADL) functions. The care plan was not complete and did not include the resident's cognitive impairment, anxiety, depression, dementia with psychosis or the resident's use of psychotropic medications. Review of the resident's history and physical, dated 10/31/23, showed the following: -Resident is thin, sitting in his/her wheelchair very anxious, shaking a lot, mild respiratory distress; -Very anxious says he/she is depressed, no issues with suicidal ideations or intentions; -Chronic obstructive pulmonary disease (COPD)/emphysema (diseases that cause airflow blockage and breathing-related problems); -Transcatheter aortic valve replacement (TAVR)(heart surgery replacing a valve in the heart), long-term anticoagulation (medication to thin the blood); -Oxygen dependent; -Seizure disorder; -Anxiety; -Depression; -Protein calorie malnutrition. Review of the resident's physician orders, dated 11/5/23, showed Seroquel 25 mg two times daily (the resident did not have an appropriate diagnoses for this medication), and increased the resident's phenytoin to 300 mg two times a day. Review of the resident's physician orders, dated 11/8/23, showed an addition of Klonopin 1 mg three times a day and mirtazapine 7.5 mg daily. Review of the resident's nurses notes, dated 11/21/2023 at 6:43 A.M., showed staff faxed the resident's physician in regards to the resident's low blood pressures and increased anxiety. The resident is ringing his/her call light multiple times, stating he/she is afraid to die, awaiting response. Review of the resident's physician orders, dated 11/22/23, showed to increase sertraline to 100 mg daily. Review of the resident's nurses notes, dated 11/23/2023 at 4:36 A.M., showed the resident is exhibiting a doom and gloom mentality. Said, I am going to die. States that he/she has always suffered from anxiety. Medication therapy is somewhat effective, but wears off before next scheduled dose. (The resident's medical record did not include documentation of physician notification, or nursing administration notification.) Review of the resident's nurses notes, dated 11/25/2023 at 9:40 P.M., showed Certified Nurse Assistant (CNA) reported to writer that resident said he/she was suicidal and that resident said he/she was going to pull on this catheter tubing and pull it out so it would cut him/herself in half. At 9:45 P.M. writer was called to resident's room. Resident is on the floor on his/her hands and knees. No injuries noted at this time. Denies hitting head. Resident on the floor said he/she fell out of bed and was on hands and knees. Resident told writer that he/she wanted to commit suicide and he/she threw himself/herself onto the floor and was hoping the tubes would rip in half so he/she would have to go to the hospital. Resident said it didn't work and he/she wasn't going to kill himself/herself because there was nothing in his/her room to do it with. Resident was brought to the nurse's station for one-on-one care. New order for Seroquel 12.5 mg given. (No documentation was provided to show the facility followed their suicide threat policy, specifically staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present; staff shall document details of the situation objectively in the resident's medical record.) Review of the resident's nurses notes, dated 11/27/2023 at 3:48 A.M., showed the resident asked staff to take him/her to the nurses station to watch him/her. This was unusual for this resident. Resident sat in front of nurse at nurses station, with an anxiety attack saying he/she is going to die and he/she needs help because he/she is a fall risk. This nurse reassured him/her. Attempted to call physician with critical blood pressure (b/p) 70/40 (Normal range blood pressure systolic (top number) 90-120, diastolic (bottom number) 60-80), heart rate 101 (Normal range heart rate 60-80), oxygen saturation (O2 sat) 83% (88% and 92% oxygen level is considered safe for someone with moderate to severe COPD). Resident complaining of dizziness. The resident got up from his/her wheelchair and fell . The resident said it was not on purpose. The resident was sent to the emergency room at 2:10 A.M. Review of the resident's nurses notes, dated 11/27/23, at 7:51 A.M., showed the resident returned from the emergency room at 6:30 A.M. with respiratory difficulty and a urinary tract infection. Review of the resident's nurses notes, dated 12/2/23 at 9:45 A.M., showed the resident sat across from the nursing station in a wheelchair, panicking about going to the hospital due to previous fall. Resident was observed falling to left side from wheelchair to floor. Complained of left hip pain. Resident holding left side and nurse noted no rotation or shortening of left lower limb. Requested to go to the hospital. Resident then complained of head pain. Resident then complained of right hip pain. No injury to right hip noted at this time. On call physician notified and requested nurse to call resident's family. Resident's family declined hospitalization . Primary care physician notified again and ordered Seroquel to increase to 50 mg at bedtime (HS). Resident to be monitored through the night every 2 hours and as needed. (No change to diagnoses.) Review of the resident's physician progress note, dated 12/14/23, showed the resident had several episodes of anxiety attacks between 11/24/23 and 12/3/23. Resident is better after increasing seroquel dosage. Continue to monitor his/her anxiety and mood and notify physician if resident becomes suicidal or anxiety attack becomes uncontrollable. Review of the resident's physician orders, dated 12/23/23, showed increase Seroquel to 50 mg two times a day. (No documented reason as to why this increase was made and no changes to resident's diagnoses). Review of the resident's physician orders, dated 1/15/24, showed the following: -Observe closely for side effects of antipsychotic medications every shift; -Observe closely for side effects of anti-depressant medications every shift; -Document in a progress note every shift if the resident displayed depressive behaviors such as crying; -Document in a progress note every shift if the resident displayed psychotic behaviors such as delusions. Review of the resident's Medication Administration Record (MAR), dated 1/15/24, showed the following additions: -Observe closely for significant side effects of anti-depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior; staff was to document a yes or no response every day, evening and night shift if side effects were noted; -Resident did not display depressive behaviors such as crying; staff was to document a yes or no response every day, evening and night shift if the behavior was noted; if targeted behavior is observed, document in a progress note every shift. -Resident did not display psychotic behaviors such as delusions; staff was to document a yes or no response every day, evening and night shift if the behavior was noted; if targeted behavior is observed, document in a progress note every shift. Review of the resident's nurses notes, dated 1/16/24 at 6:15 A.M., showed resident slept well most of this shift. Upon awaking, resident immediately started to make himself/herself shake throughout his/her arms and hands. He/She asked for his/her anxiety medication and this nurse administered it to him/her. Within two minutes of taking the medication the resident put on his/her call light wanting to know when he could have another anxiety pill. This nurse educated the resident that this medication was scheduled and it would be a while before he/she could be given another, to which he/she replied, I'm never going to make it. This nurse assured him/her that he/she would be alright and told him/her to breathe and calm down. Review of the resident's MAR dated 1/16/24, showed the staff documented Yes on night shift to the resident did not display depressive behaviors such as crying (indicating the resident displayed crying behaviors); if targeted behavior is observed, document in a progress note every shift. Review of the resident's nurses notes for night shift (10:00 P.M. to 6:00 A.M.) on 1/16/24 showed no documentation about behaviors. Review of the resident's physician orders, dated 1/17/24, to decrease Abilify to 10 mg daily and increase seroquel to 50 mg in A.M. and 75 mg in P.M. for generalized anxiety (No documentation about communication with the physician that lead to this order). No change to the resident's diagnoses. Review of the resident's physician orders, dated 1/18/24, showed to increase Klonopin to 1 mg at 6:00 A.M., 12:00 noon, and Klonopin 2 mg at HS (No documentation about communication with the physician that lead to this order). Review of the resident's pre-admission screening/resident review (PASRR) Level II Evaluation, dated 1/19/24, showed the following: -Moderate dementia with conflicting scores on dementia testing completed; -Major depressive disorder, recurrent, severe with psychotic symptoms; -PHQ-9 ((Patient Health Questionnaire-9) objectifies and assesses degree of depression severity via questionnaire) score 12 (score of 1-4 minimal depression, 5-9 mild depression, 10-14 moderate depression, 15-19 moderately severe depression, and 20-27 severe depression); -Generalized anxiety disorder; -Anxiety and panic related to breathing difficulties; -Major neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness); -Treated as an inpatient at an acute geropsychiatric facility in September for anxiety and panic; -History of physical aggression, irritable and anxious mood; -Constant anxiety related to his/her breathing difficulties; -Requires assistance with activities of daily living and believes he/she is going blind; -Exhibits hopelessness, helplessness, and anxiety due to chronic breathing problems; -No history or current thoughts/plans/acts/ideation or intention of suicide or self injury; -Dementia is moderate with behavioral difficulties, fluctuating orientation; -Geri Psych is recommended. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -PHQ-9 result is 00; -Two or more falls since last MDS. Review of the resident's MAR, dated 2/4/24, showed the staff documented Yes on day shift to: observe closely for significant side effects of anti-depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior (indicating staff observed significant side effects of anti-depressant medication). Review of the resident's nurses notes, dated 2/4/24 at 2:01 P.M., showed the resident said he/she just wanted to take a big cup full of pills and just swallow them all. The electronic health record did not include physician notification, family notification, or nursing administration notification of the resident's statement of suicidal ideation (There was no documentation to show staff stayed with the resident or followed the suicide threat policy). Review of the resident's care plan, revised 2/7/24, showed the following: -Behavior Management; -Encourage participation in self-calming behaviors such as breathing exercises, meditation, or guided imagery; -Ensure the safety of resident and others; -Evaluate medication schedule and possible pharmacological causes of disruptive behavior; -Evaluate medication schedule and possible pharmacological causes of repetitive behavior; -Monitor for signs/symptoms of infection; -Provide verbal feedback to resident regarding behavior; -Utilize diversion techniques as needed; The care plan did not include specific behaviors, anxiety, depression, suicidal ideation, or specific information regarding the resident's psychoactive medications. Review of the resident's MAR dated 2/20/24, showed staff documented Yes on the MAR for all three of the following items on evening shift (2:00 P.M. to 10:00 P.M.) Documentation of Yes indicated the target behavior was observed and should be documented in a progress note: -Observe closely for significant side effects of anti-depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior; -Resident did not display depressive behaviors such as crying. If targeted behavior is observed, document in a progress note every shift; -Resident did not display psychotic behaviors such as delusions. If targeted behavior is observed, document in a progress note every shift. Review of the resident's nurses notes for evening shift on 2/20/24 showed no documentation about behaviors or side effects. Review of the resident's MAR, dated 2/23/24, showed the staff documented Yes on the MAR for all three of the following items n evening shift: Documentation of Yes indicated the target behavior was observed and should be documented in a progress note: -Observe closely for significant side effects of anti-depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior; -Resident did not display depressive behaviors such as crying. If targeted behavior is observed, document in a progress note every shift; -Resident did not display psychotic behaviors such as delusions. If targeted behavior is observed, document in a progress note every shift. Review of the resident's nurses notes for evening shift on 2/23/24 showed no documentation about behaviors or side effects. Review of the resident's MAR dated 2/26/24, showed the staff documented Yes on the MAR for all three of the following items on evening shift. Documentation of Yes indicated the target behavior was observed and should be documented in a progress note:: -Observe closely for significant side effects of anti-depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior; -Resident did not display depressive behaviors such as crying. If targeted behavior is observed, document in a progress note every shift; -Resident did not display psychotic behaviors such as delusions. If targeted behavior is observed, document in a progress note every shift. Review of the resident's nurses notes for evening shift on 2/26/24 showed no documentation about behaviors or side effects. During an interview on 3/12/24, at 1:25 P.M., Licensed Practical Nurse (LPN) #2 said the following: -He/She is the resident's charge nurse; -He/She knows the resident has threatened suicide, that is why the resident was at the facility; -The resident's spouse called the facility one day and he/she answered the phone. The resident's spouse was upset because the resident threatened to kill himself/herself while they were talking on the phone; -He/She was not the resident's nurse that day, he/she was working on the other unit, so he/she transferred the call to the other unit; -If staff do not directly hear the threat, then they cannot do anything about what the resident tells his/her spouse; -The resident was not seeing a psychiatrist or receiving any counseling that he/she knew of; -If there is suicidal ideation, or a direct threat of self-harm, staff usually just monitor a resident with 15 minute checks; -Staff are expected to notify the physician and family if there is suicidal ideation or a direct threat of self-harm; -Staff are expected to write a nurses note if they say yes to behavior monitoring on the Medication Administration Record. During observation and interview on 3/12/24, at 1:40 P.M.,the resident sat at the nurses station in his/her wheelchair with oxygen on via nasal cannula and a urinary catheter present. The resident was slumped over to his/her right side with his/her head on his/her shoulder. The resident said he/she did not want to be alone and did not want to talk about his/her prior suicidal statements. During an interview on 3/12/24, at 3:51 P.M., the Director of Nursing (DON )said the following: -Resident #53 has high anxiety; he/she makes a lot of comments and hates to be alone; -The resident's behaviors and interventions are expected to be on the care plan; -Changes in behaviors and increase in severity of behaviors, like suicidal ideation and or threats of self-harm, are expected to be reported to the resident's physician; -Increased or new behaviors are expected to be reported to nursing administration; she did not know of the resident voicing wanting to harm himself/herself; -Staff would be expected to follow up on the threats of self-harm or suicidal ideation; -Threats of self-harm or suicidal ideation would trigger a change of condition PASRR; -Staff did not report to her the resident made remarks with direct threats of self harm or suicidal ideations; -The charge nurse would have been expected to follow up on the resident's presentation on 2/4/24 of suicidal ideation; -The charge nurse would be expected to notify the Social Services Director (SSD) of new behaviors. During an interview on 3/12/24, at 4:05 P.M., the SSD said the following: -She had the resident's Level I screening; -There was a meeting about his/her Level II but she did not think one was completed because the resident has dementia; -No one told her the resident made remarks with direct threats of self harm or suicidal ideations; -No one asked for her to find psychiatric services for the resident or send a referral out for the resident. During an interview on 3/13/24 at 8:15 A.M., the Administrator said the following: -The facility brought a chaplain in with Resident #53 initially because of his/her fear of dying; -She expected staff to report suicidal ideations to the physician and nursing administration to ensure the resident is safe and treated for their condition; -Staff are expected to call their department head or the administrator if there is a situation they are not sure how to handle; -She expected the staff to notify a physician of a change in condition; -If a change of condition is urgent or emergent, she expected staff to alert the attending physician; if no answer, then the medical director and the director of nursing until they get a response or call 911. During an interview on 3/13/24 at 11:15 A.M., the resident's physician said the following: -The resident often threatens to throw himself/herself on the floor; -She was not notified of the resident making a direct threat to harm himself/herself; -If a resident makes a direct threat of self-harm, she expects staff to notify her; -She would have had the facility send a referral to the inpatient geriatric psychiatric unit with the intention of readmission to the gero-psychiatric unit, if she had known of the resident voiced intentions of harming himself/herself; -Sometimes the staff gets complacent with behaviors and doesn't know when the behaviors have escalated to a point the physician needs to be notified; -The resident does not have counseling, or any psychiatric services following him/her because the facility does not have the services available; -She assumed care of the resident from another physician after admission to the facility; -She was trying to slowly adjust the resident's psychiatric medications because the resident was on so many.

Based on interview and record review, the facility failed to accurately assess and timely report changes in condition to the resident's physician for one resident (Resident #2), who was admitted to the facility following a fall, in a review of six sampled residents. The day following his/her admission, the resident developed blisters, edema, pain and bruising to his/her left knee. Staff did not consistently assess the resident's skin and his/her condition as the resident continued to have pain requiring a narcotic pain medication and received antibiotic therapy, and did not timely notify the physician of the changes in the resident's condition. The resident requested to see his/her physician (11 days after admission) and was admitted to the hospital with significant swelling from his/her knee to his/her toes, severe pain, and a wound on his/her knee. The facility census was 63. Review of the facility's policy, Resident Examination and Assessment, revised February 2014, showed the following: -The purpose of this procedure is to examine and assess the resident for any abnormalities in health status; -Skin: intactness, moisture, color, texture, presence of bruises, pressure sores, redness, edema and rashes; -All assessment data obtained during the procedure should be recorded in the resident's medical record; -Notify the physician of any abnormalities such as, but not limited to: -Wounds or rashes on the resident's skin; -Worsening pain, as reported by the resident; -Report other information in accordance with facility policy and professional standards of practice. Review of the facility's policy, Change in Resident's Condition or Status, revised May 2017, showed the following: -Our facility shall promptly notify the resident, his/her attending physician, and 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(an): -Discovery of injuries of an unknown source; -Significant change in the resident's physical/emotional/mental condition; -Need to alter the resident's medical treatment significantly; -Need to transfer the resident to a hospital/treatment center; -Specific instruction to notify the physician of changes in the resident's condition; -Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider; -Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status; -The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 1. Review of Resident #2's Physician Order Sheet (POS), dated November 2023, showed the resident's diagnoses included Alzheimer's disease and history of falls. Review of the resident's face sheet showed he/she was his/her own responsible party and was admitted to the facility on [DATE]. Review of the resident's nurses' notes dated 11/17/23, showed the resident was admitted to the facility from home after a fall on 11/16/23. The resident complained of left knee pain. Physician C was here this evening and reviewed orders. Review of the resident's medical record showed no documentation staff completed a skin assessment of the resident's left knee upon his/her admission to the facility on [DATE]. Review of the resident's nurses notes showed the following: -On 11/18/23 at 6:39 A.M., skin warm to touch, bruises noted to left side of left knee. diagnosed with contusion (bruise) to left knee due to fall; -On 11/18/23 at 9:42 P.M., Licensed Practical Nurse (LPN) F documented he/she faxed Physician C about the resident's knee. Fluid filled blisters, edema, heat, pain and bruising; -On 11/19/23 at 12:07 P.M., LPN I documented the resident's left knee was swollen, bruised and had several pus pockets surrounding the knee. Physician was notified 11/17/23 via email per charting (previous note showed physician was notified by fax on 11/18/23). Review of the resident's Medication Administration Record (MAR), dated November 2023, showed the following: -On 11/19/23 at 12:34 P.M., the resident rated his/her pain a five (on a scale of one to 10 with 10 being the most pain). Staff administered hydrocodone-acetaminophen (a narcotic pain medication) 5-325 milligrams (mg) as needed (PRN) for pain related to contusion of left knee; -On 11/20/23 at 12:31 A.M., the resident rated his/her pain a six (on a scale of one to 10). Staff administered hydrocodone-acetaminophen 5-325 mg PRN for pain related to contusion of left knee. Review of the resident's baseline care plan, dated 11/20/23, showed the following: -Partial/moderate assistance for toileting, dressing, transfers, bed mobility; -Used walker and wheelchair for mobility; -The resident had a fall in the last month prior to admission; -Current skin integrity issues left blank; -Baseline care plan did not address swelling or bruising of the resident's left knee. Review of the resident's nurses notes, dated 11/20/23 at 1:32 P.M., showed LPN A documented the resident's skin was warm and dry, skin color within normal limits (WNL) and turgor is normal. No skin issues. (Review showed no evidence LPN A documented an assessment of the condition of the resident's knee.) Review of the resident's medical record showed no evidence the facility received a response or followed up with the resident's physician on 11/19/23 or 11/20/23 regarding the swelling, fluid filled blisters, heat and pain identified on 11/18/23. The resident continued to have pain in his/her left knee which required administration of PRN narcotic pain medication. Review of email correspondence between LPN A and Physician C, dated 11/21/23, showed Physician C noted per discussion with staff, we are going to start Bactrim DS (an antibiotic) twice daily for seven days. If knee gets worse by tomorrow, resident to go to hospital for evaluation by orthopedics urgently. Review of the resident's POS, dated November 2023, showed no documentation of the order to give Bactrim DS twice daily for seven days or if the knee gets worse by tomorrow to go to the hospital for evaluation by orthopedics urgently (as documented on the email correspondence received from the physician on 11/21/23). Review of the resident's nurses' notes showed the following: -On 11/21/23 at 2:01 P.M., LPN A documented he/she received call from Physician C to start resident on Bactrim DS one tablet by mouth twice daily for seven days for possible infection to left knee. Further instructed to monitor, and if fever or signs/symptoms of sepsis (blood infection), to call the office; -On 11/21/23 at 2:27 P.M., LPN A documented the resident's skin warm and dry, skin color WNL and turgor is normal. No skin issues. (Review showed no evidence LPN A documented an assessment of the condition of the resident's knee.) Review of the resident's MAR, dated 11/21/23, showed the resident rated his/her pain a nine (on a scale of one to 10) on the evening and night shifts. (Review of the resident's nurses notes showed no documentation related to the resident's pain on these shifts.) Review of the resident's MAR, dated 11/22/23 at 1:00 A.M., showed the resident rated his/her pain a nine (on a scale of one to 10). Staff administered hydrocodone-acetaminophen 5-325 mg PRN for pain related to contusion of left knee. Review of the resident's nurses note, dated 11/22/23 at 1:37 P.M., showed LPN B documented the resident continues on Bactrim DS for left knee infection. Review of the resident's wound evaluation completed by LPN D/wound nurse, dated 11/22/23, showed the following: -Blister left front knee measured 12 centimeters (cm) by 11.2 cm; -Suspected infection; -Wound presents with multiple blisters that are rupturing. Peri-wound has edema and color is black and blue. Warm to the touch. The physician has been notified. Will continue current medications and treatment. During interviews on 12/13/23 at 11:50 A.M., Physician C said he/she received a fax from the facility on 11/22/23 stating the resident's blisters were the same. He/She sent a fax back to the facility asking if there was any improvement and did not receive a reply back from the facility. Review of the resident's medical record showed no documentation of the fax the facility sent to the physician on 11/22/23 and no documentation to show the facility notified the physician of the resident's pain, swelling, and bruising. Review of the resident's MAR, dated 11/22/23 at 4:41 P.M., showed the resident rated his/her pain a nine. Staff administered hydrocodone-acetaminophen 5-325 mg PRN for pain related to contusion of left knee. (Review of the resident's nurses notes showed no documentation related to the resident's pain on this shift.) Review of the resident's nurses' notes showed the following: -On 11/23/23 at 2:19 P.M., the Director of Nurses (DON) documented the resident continues on Bactrim DS for infection to the left knee. Site is noted to be warm to touch, with fluid filled blisters, redness and edema. The resident complains of pain to touch but refuses pain medication. (Reviewed showed no documentation the facility staff notified the resident's physician of the condition of the resident's knee on 11/23/23); -On 11/24/23 at 1:13 P.M., skin warm and dry, skin color WNL and turgor is normal. Currently taking Bactrim DS until 11/28/23. Infection noted to left knee. The resident had pain in his/her left knee; pain rated at a 3. The pain was aching, dull, cramping, non-radiating and worse with movement. Review of the resident's MAR, dated 11/24/23, showed the resident rated his/her pain a 10 (on a scale of one to 10) on the evening shift. Staff administered hydrocodone-acetaminophen 5-325 mg PRN for pain related to contusion of left knee at 7:01 P.M. (Review of the resident's nurses notes showed no documentation related to the resident's pain on this shift.) Review of the resident's medical record showed no evidence staff assessed the resident's skin on 11/25/23. Review of the resident's MAR, dated 11/25/23 at 12:15 P.M., showed the resident rated his/her pain a 10 (on a scale of one to 10). Staff administered Tylenol (pain reliever) 325 mg, two tabs PRN for pain related to contusion of the left knee. (Review of the resident's nurses notes showed no documentation related to the resident's pain on this shift.) Review of the resident's nurses' notes showed the following: -On 11/26/23 at 3:53 P.M., LPN G documented the resident continues on antibiotic for left knee wound infection. (No documentation staff completed a skin assessment of the resident's knee); -On 11/27/23 at 7:55 A.M., LPN H documented the resident continues on antibiotic due to blisters left knee. Voices no complaints of pain or discomfort. Wound open to air. (No documentation staff completed a skin assessment of the resident's knee). Review of the resident's MAR, dated 11/27/23 at 8:54 A.M., showed the resident rated his/her pain a 10. Staff administered hydrocodone-acetaminophen 5-325 mg PRN for pain related to contusion of the left knee. Review of the resident's medical record showed no evidence the facility assessed the resident's knee on 11/24/23 through 11/27/23 to identify an improvement or decline in the resident's condition. The resident continued to have pain in his/her left knee which required administration of PRN narcotic pain medication. During interview on 12/12/23 at 12:01 P.M., LPN D/wound nurse said the resident wanted to see his/her original primary care physician (PCP D) so that appointment was made (for 11/28/23). Review of the resident's nurses notes showed the following: -On 11/28/23 at 1:21 P.M., LPN B documented the resident's skin warm and dry, skin color WNL and turgor is normal. Currently taking skin antibiotics. Skin infection noted to left knee. (No documentation staff completed a skin assessment of the resident's knee); -On 11/28/23 at 10:35 P.M., the resident had an appointment with his/her primary care physician (PCP) D outside the facility and was referred to the emergency room for urgent evaluation of the left knee swelling and hematoma. The resident was admitted to the hospital. Review of the resident's emergency department physician documentation, dated 11/28/23, showed the following: -The resident presented to the emergency department for left leg swelling and tenderness. He/She was seen in this hospital on 11/16 after a fall at home. The resident said he/he was unable to bear weight on his/her left knee and family had him/her placed in the nursing facility on 11/17/23 for assistance with activities of daily living while he/she recovered. Since then, the resident's knee has continued to swell and has developed a large open area with granulation tissue (connective tissue in a wound). At this time, the resident has significant swelling from the proximal knee all the way down to his/her toes on his/her left foot. The resident endorses significant pain upon standing and also significant pain to light palpitation. He/She went to the physician today to be evaluated and the physician sent him/her to the emergency department for further evaluation; -Exam: The resident reports decreased sensation in the affective extremity. The resident experiences severe pain on palpitation or the affected extremity. Swelling and tenderness in left leg. Large wound on medial left knee with swelling going all the way to to the left foot. 2+ pitting edema (swelling) that is extremely painful to light palpitation. -Possible compartment syndrome (an increase in pressure inside a muscle, which restricts blood flow and causes pain). Surgical consult suspects a closed degloving injury (closed degloving soft tissue injury, caused by abrupt separation of skin and subcutaneous tissue from the underlying fascia). Review of the resident's computed tomography (CT) scan angiogram (efficient and accurate in the evaluation of lower extremity arterial injuries after trauma. Specific CTA signs of vascular injury can be readily detected, and additional information regarding osseous and soft-tissue injuries can also be routinely obtained), dated 11/28/23, showed the following: -Large medial (midline) and anterior (front) superficial (on the surface) fascia (a thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber and muscle in place) thigh hematoma (happens when an injury causes blood to collect and pool under the skin) measuring 12.3 centimeters (cm) by 4.9 cm by 17.3 cm; -Extensive cutaneous (relating to the skin) and subcutaneous (under the skin) superficial fascia cellulitis (a deep bacterial infection of the skin). Review of the hospital general surgery procedure notes, dated 12/1/23, showed the following: -Pre-operative diagnosis: infected hematoma left lower extremity; -Procedure: Excisional debridement (surgical removal of tissue) of left lower extremity hematoma; -Swelling and eschar (dead tissue) was located to the left knee. The 4 cm by 5 cm eschar over the region of swelling was removed which exposed a large amount of old blood clot and fluid. The clot was debrided and the wound found to undermine approximately 11 cm at 7:00 position, 3 cm at 9:00 position, and 9 cm at 11:00 position. The wound extended to the muscle. A wound vac (a mechanical device used to gently pull fluid from a wound over time) was placed. During interview on 12/12/23 at 11:44 A.M., 12/13/23 at 11:39 A.M., and 12/19/23 at 11:04 A.M., LPN B (who documented in the resident's nurses notes on 11/22 and 11/28) said the following: -He/She saw the resident's knee on 11/22/23 (the day after the resident started on antibiotics) but he/she did not remember being told to send the resident to the emergency room if the knee was worse. This was the first time he/she saw the resident's knee and thought the knee was getting better; -The resident had cellulitis of the left knee. It was red and had a few blisters; -Staff should document when the resident had blisters; -The resident went out for an appointment (on 11/28/23) and was sent to the hospital. During interview on 12/12/23 at 12:01 P.M., LPN D/wound nurse said the following: -The admitting nurse was responsible for the initial skin assessment. -The resident did not have any open wounds when he/she was admitted (on Saturday, 11/17/23); -The next week the resident's friend alerted him/her that the resident had blisters on his/her left knee. The physician was notified and LPN A sent a picture of the knee to the physician. The physician ordered an antibiotic for cellulitis (on 11/21/23); -He/She completed the resident's skin assessment on 11/22/23. During interviews on 12/12/23 at 1:09 P.M.,12/13/23 at 11:48 A.M., and 12/19/23 at 11:00 A.M., LPN A said the following: -The resident's left knee was swollen, red and blistered. He/She sent a fax and called Physician C. He/She also sent Physician C a picture of the resident's knee and received orders for an antibiotic (on 11/21/23); -He/She remembered the order to send the resident to the emergency room if the resident's knee was worse. He/She thought he/she verbally told the next shift nurse about this order. If he/she didn't pass it on verbally, then he/she would have written it in the report book; -He/She couldn't remember seeing the resident's knee on 11/23/23, the next time he/she worked, to know if the knee was the same or worse; -If there was a change in the wounds, then staff should notify the physician; -He/She supposed staff should have documented daily on the blisters and bruising on the resident's knee; -He/She usually faxed the physician with any concerns; -He/She would follow-up on faxed concerns in a couple days. During interviews on 12/12/23 at 2:10 P.M.,on 12/13/23 at 11:27 A.M., and 12/19/23 at 10:56 A.M., the Director of Nursing (DON) said the following: -The wound nurse completed weekly skin assessments (for residents with wounds), and the charge nurses completed weekly skin assessments on the residents' shower days; -If staff see anything new or a decline in an area, they were to let the wound nurse know so he/she would get orders; -The resident had some skin changes including swelling and blisters. One blister popped and scabbed over. She passed it on in report on 11/20/23 or 11/21/23 (she couldn't remember which day for sure) that the physician needed to be notified of the swelling and blisters; -She expected staff to follow-up on a fax to the physician with a phone call within 24 hours to see if the physician's office received the fax and for any new orders; -She was not aware of the order to send the resident to the emergency room for evaluation if the resident's knee worsened (order received on 11/21/23); -She would have expected staff to respond to the physician's fax (sent 11/22/23 per the physician interview) asking if there were any improvements in the blisters; -She would expect staff to document on bruising and blisters in the resident's daily assessment, and to assess and document accurate descriptions of wounds. During interviews on 12/13/23 at 11:50 A.M. and on 12/19/23 at 4:42 P.M., Physician C said the following: -He/She saw the resident in the facility on admission. The resident's left knee was swollen and had bruising around the thigh on the anterior aspect (front part). There were no blisters at that time; -He/She would have expected the facility to notify/follow-up with him/her regarding the fax they sent on 11/18/23 before staff sent him/her the pictures of the resident's knee on 11/21/23; -A little while after admission, staff sent a picture of the resident's left knee in an email. He/She called the facility and ordered Bactrim DS for seven days for suspected cellulitis, and if the knee worsened, to send the resident to the emergency room for urgent orthopedic evaluation (ordered received 11/21/23); -He/She received a fax from the facility on 11/22/23 stating the blisters were the same. He/She sent back a fax asking if there was any improvement and did not receive a reply back from the facility; -He/She would have expected staff to notify him/her after 11/21/23 when the resident continued to have pain, swelling and blisters. During interview on 12/20/23 at 9:25 A.M., the administrator said he expected staff to follow-up on a fax to the resident's physician by the end of the staff's shift. If that staff did not get a response from the physician, then he would expect staff to pass this information along in report so the next shift could follow-up. He expected staff to document skin assessments accurately on initial assessment and when there was a change in the skin condition. He expected staff to pass along information to the next shift if a resident had an order to send to the hospital if not improved and he would expect staff to follow physician orders.

Based on observation, interview, and record review, the facility failed to consistently evaluate, implement, and modify interventions, in accordance with current standards of practice and as necessary to reduce the risk of falls, for one resident (Resident #20), in a review of three sampled residents. The facility also failed to safely secure the resident (Resident #20) in the facility van during a transport from the hospital where the resident was evaluated for injuries from a fall. The resident slid out of his/her wheelchair and onto the floor of the facility van. The facility staff did not report, evaluate, or modify interventions to prevent further falls during transportation in the facility van. The resident sustained multiple bruises over his/her face and arms in addition to skin tears with reported pain from his/her falls. The facility census was 63. Review of the facility policy, Falls Clinical Protocol, last revised March 2018, showed the following: -The physician will help identify individuals with a history of falls and risk factors for falling. -The nurse shall assess and document/report the following: vital signs, recent injury, musculoskeletal function, observing for change in normal range of motion, weight bearing, change in cognition or level of consciousness, neurological status, pain, frequency and number of falls since last physician visit, precipitating factors, details on how fall occurred, current medications, especially those associated with dizziness or lethargy, and active diagnoses. -The staff and practitioner will review each resident's risk factors for falling and document in the medical record; -The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls. -Falls often have medical causes; they are not just a nursing issue. -The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc.; -Falls should also be identified a witnessed or unwitnessed events. -For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. -Often, multiple factors contribute to a falling problem. -lf the cause of a fall is unclear, or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. -The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. -Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. -If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). -The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. -The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. -Frail elderly individuals are often at greater risk for serious adverse consequences of falls. -Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. -If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has resolved by addressing the underlying cause. -If the individual continues to fall. the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. Review of the facility's policy, Falls Risk Assessment, revised March 2018, showed the following: -The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. -Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. -The nursing staff will ask the resident and/or his/her family about any history of the resident falling. -The nursing staff, attending physician, and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension (low blood pressure); -The staff will look for evidence of a possible link between the onset of falling (or an increase in falling episodes) and recent changes in the current medication regimen. -The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as decreased vision and peripheral neuropathy) that may predispose to falls. -Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis). -The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition. -The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. -The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. During an interview on 2/8/24, at 1:45 P.M., the Director of Nursing (DON) said the facility did not have a policy for securing a resident for transport in the facility vehicle. 1. Review of Resident #20's undated face showed his/her diagnoses included altered mental status, muscle weakness, unsteadiness on feet, need for assistance with personal care, lack of coordination, reduced mobility, dizziness, restlessness and agitation, abnormal gait and mobility, and a history of falls. Review of the resident's care plan, dated 5/17/23, showed it did not contain information regarding the resident's fall risk, or interventions to prevent falls. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 5/24/23, showed the following: -admitted to the facility on [DATE]; -Moderate cognitive impairment; -Diagnosis include metabolic encephalopathy (problem in the brain caused by chemistry issues in the blood), non-traumatic brain dysfunction, altered mental state, history of falling, unsteady on feet, abnormal gait, and restlessness and agitation. -Moderate hearing difficulty; -Usually understands and is usually understood; -Verbal behaviors directed towards others; -Uses wheelchair and dependent on staff for transfers; -Requires staff to provide more than half of the effort for wheelchair mobility/locomotion; -Fall in the month prior to admission to the facility and two to six months prior to admission; -One fall with no injury since admission to the facility -Section V: fall care area triggered for falls and staff documented falls will be addressed in the resident's care plan. Review of the resident's quarterly MDS, dated [DATE], showed the resident had two or more falls with no injury since last assessment. Review of the resident's care plan did not address fall risk or history of falls. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors or rejection of care. Review of the resident's care plan, updated 11/21/23, showed it did not contain information regarding the resident's fall risk, or interventions to prevent falls. Review of the resident's care plan, updated 1/3/24, showed it did not contain information regarding the resident's fall risk, or interventions to prevent falls. Review of the resident's nurse's notes, dated 1/19/24, at 2:27 A.M., showed the following: -Entry for fall on 1/18/2024 at 7:15 P.M.; -Resident found on floor sitting cross legged when staff entered room; -Resident stated he/she was going to climb the wall and take a shower; -Alert and oriented to person, facility and year; -At approximately 9:30 P.M. staff witnessed resident sliding from wheelchair to floor, no injuries noted. Review of the resident's nurses notes dated 1/23/24, at 8:50 P.M., showed the following: -Certified Nurse Assistant (CNA) was called to resident room by another resident across the hall; -Resident was lying on his/her back on the floor mat by his/her bed; -Neurological checks initiated; -Resident alert and oriented times one and mumbling at times, which was the same as prior to fall. Review of the resident's post fall evaluation, dated 1/23/24, 9:01 P.M. showed the following: -Fall occurred in the resident's room and was not witnessed; -Resident was lying on floor mat by bed; -Wearing glasses, socks on his/her feet; -Resident was not wearing oxygen as prescribed at time of fall; -Incontinent at time of fall; -Contributing factors include confusion, delusions, restlessness, and incontinence;. -Skin note: older bruises noted to left posterior hand and open scratches to left lower extremity that are not new; -Resident has had a change in mental status, behaviors and hospitalization in last six months. Review of the resident's nurse's notes, dated 1/30/24, at 8:24 A.M., showed the following: -Resident on the floor in dining room; -Witness to the fall said the resident was attempting to stand up, and went face first onto the floor; -Bridge of nose cut open and swollen; -Left pinky finger with skin tear approximately 4 centimeter (cm) in length; -Resident complained of right shoulder/rib pain; -911 called and family notified; -Resident transported by emergency services to the hospital; -The resident returned to the facility Review of the resident's record showed no documentation staff completed any root cause analysis of the falls, initiation of fall interventions, a post fall evaluation after the fall on 1/30/24, or evidence of neurological checks. The resident's care plan did not show the resident as a fall risk or any evidence or reevaluation of the resident's care plan to address falls. Review of the resident's nurse's notes, dated 2/5/24, at 1:21 A.M., showed the following: -Resident observed sitting up with legs crossed on bedside mat, bed in low position; -Residents pants were wet with urine. Review of the resident's record showed no documentation the resident's physician or family were notified of the fall, a fall evaluation was completed, reevaluation of any interventions to prevent falls was completed after the fall on 2/5/24 1:21 A.M. fall. The resident's medical record did not contain a post fall evaluation. The resident's care plan did not contain fall risk or any evidence or reevaluation of the resident's care plan for falls. Review of the resident's nurse's notes, dated 2/5/24, at 3:39 A.M., showed the resident was found lying across his/her floor mat sideways, with his/her head off on the floor. The staff did not document evidence of physician notification, family notification, evaluation of fall, or re-evaluation of fall interventions after the 2/5/24 3:39 A.M. fall. The resident's care plan did not contain fall risk or any evidence or reevaluation of interventions to prevent future falls. Review of the resident's nurse's notes, dated 2/5/24, at 9:35 A.M., showed the following: -Witnessed as resident went headfirst out of his/her wheelchair onto his/her knees on the floor in dining room; -Resident did not hit his/her head; -Resident did bump his/her elbow and reopened an old skin tear to right elbow. The staff did not document evidence of physician notification, family notification, evaluation of fall, or re-evaluation of fall interventions after the 2/5/24 9:35 A.M. fall. The resident's care plan did not contain fall risk or any evidence or reevaluation of interventions to prevent future falls. Review of the resident's nurse's notes, dated 2/5/24, at 10:13 P.M., showed the following: -At 5:45 P.M. another resident informed writer that resident was on the floor; -Resident was lying on the floor mat by his/her bed; -Resident was trying to sit up but had poor trunk control; -Resident had a 2 cm x 0.1 cm skin tear superior to right antecubital (elbow) area; -Resident continues to hallucinate; -The resident speaks, he/she has word salad (mixture of words that do not make sense) and garbled speech noted which is not new; -Resident admits to hitting his/her head; -Neurological checks initiated; -Physician notified and orders received to transport the resident to the emergency room for evaluation and treatment. The staff did not document evidence of continued neurological checks, evaluation of the fall, or re-evaluation of fall interventions after the 2/5/24 10:13 P.M. fall. The resident's care plan did not contain fall risk or any evidence or reevaluation of interventions to prevent future falls. Review of the resident's nurse's notes, dated 2/6/24, at 4:33 A.M., showed the following: -Transport driver called at 3:55 AM and asked for someone to meet the facility vehicle outside when they arrived at the building; -The resident was on the floor of the bus, he/she slid out of his/her wheelchair; -The resident did not have injuries; -Resident returned to his/her room and in bed; -Bandage on right upper arm with red drainage, bandage on left lower arm, bruise's on both right and left arms; -Pupils slow to react; -Blood pressure 95/44, heart rate 58 (normal ranges for heart rate is 60-80 beats per minute, blood pressure: 90-120/60-80); -Resident returned from the emergency room with a diagnosis of vascular dementia, unspecified severity, with other behavioral disturbance. During an interview on 2/8/24, at 1:42 PM., Transportation Staff #34 said the following: -He/She and staff member Certified Medication Technician (CMT) #35 went to the hospital to pick the resident up and transport him/her back to the facility on 2/6/24; -When the staff arrived at the emergency room the hospital staff brought the resident out to the facility vehicle; -The resident was flipping and flopping, and carrying on; -CMT #35 didn't know what to do; -He/She told the CMT, we will just have to strap him/her the best we can and go; -The resident slid out of the chair while they were driving to the facility; -He/She called the facility when they were 2 minutes away while he/she was driving, so staff would meet them outside to get the resident off the floor of the vehicle. During an interview on 2/8/24, at 3:18 P.M., Licensed Practical Nurse (LPN) #14 said the following: -Transportation aide called and said he/she was two minutes out and the resident was on the floor of the vehicle; -He/She met the vehicle outside the facility; -The resident had his/her buttocks on the floor of the van and his/her back was against the seat of the wheelchair; -He/She assessed the resident and documented the fall in his/her chart; -He/She did not evaluate the resident's care plan, notify the physician, notify the family, or notify nurse management because he/she is a new nurse and did not know what all had to be done. Review of the resident's skin evaluation, dated 2/6/24, at 2:03 P.M., showed the following: -Bruising right eye, measures length 2.5 cm, width 1 cm; -Bruising left eye, measures length 2.5 cm, width 1 cm; -Bruising nasal area; -Skin tear, nasal area, measures length 1.5 cm, width 0.3 cm; -Skin tear, left finger, measures length 1.5 cm, width 0.3 cm, some pain; -Bruising left forearm; -Bruising left upper arm; -Bruising right finger(s); -Bruising right forearm; -Bruising right anterior elbow; -Bruising right upper arm; -Skin tear right elbow measures length 2 cm width 1 cm, area painful. The staff did not document evidence of physician notification, family notification, evaluation of fall, or re-evaluation of fall interventions after the 2/6/24 4:33 A.M. fall. The resident's medical record did not contain a post fall evaluation. The resident's care plan did not contain fall risk or any evidence or reevaluation of the resident's care plan for falls. Observation on 2/8/24, at 1:15 P.M., showed the resident in his/her room. The resident had dark purple bruising around both eyes and on the right cheek. Both of the resident's arms were covered in bruises with the majority of his/her forearms dark purple. The resident has a large uncovered scabbed area approximately 2.5 cm long on his/her right arm above the elbow. During an interview on 2/8/24, at 1:28 P.M., Nurse Aide (NA) #11 said the resident falls a lot. He/She is not sure what was in place to prevent the resident from falling. The resident has a lot of bruises from the falls. The resident has slept the last two days. During an interview on 2/8/24, at 1:20 P.M., the resident's family member said the resident has fallen a lot. This week he/she has fallen, some of the staff say 2 falls and some say 3. Staff said the resident's blood pressure has been low. During an interview on 2/8/24, at 1:42 PM., the DON said the following: -Staff are expected to assess a resident for injuries after a fall, if a resident hit their head or if the fall was unwitnessed staff do neurological checks for 72 hours; -Staff are expected to report the fall to nursing management, the physician, and the resident's family; -The staff are expected to do a post fall evaluation, and the MDS coordinator is expected to update the care plan after re-evaluating the interventions; -Staff should have taken the resident back into the hospital if he/she could not be secured safely in the facility vehicle; -It is not a safe transport if the resident slid out of the wheelchair to the floor of the vehicle, the resident could have had worse injuries. During an interview on 3/13/24, at 8:15 A.M., the Administration said the following: She expected staff to follow up with falls to put measures in place to prevent future falls; -Staff are expected to only transport residents that are safe to transport; combative residents are not safe to transport; -Staff should not accepted the resident from the emergency room if he/she was combative because they could not safely transport a combative resident; -Staff are expected to call their department head or the administrator if there is something they are not sure how to handle a situation.

Based on observation, interview, and record review, the facility failed to consistently evaluate, implement, and modify interventions, in accordance with current standards of practice and as necessary to reduce the risk of falls, for one resident (Resident #20), in a review of three sampled residents. The facility also failed to safely secure the resident (Resident #20) in the facility van during a transport from the hospital where the resident was evaluated for injuries from a fall. The resident slid out of his/her wheelchair and onto the floor of the facility van. The facility staff did not report, evaluate, or modify interventions to prevent further falls during transportation in the facility van. The resident sustained multiple bruises over his/her face and arms in addition to skin tears with reported pain from his/her falls. The facility census was 63. Review of the facility policy, Falls Clinical Protocol, last revised March 2018, showed the following: -The physician will help identify individuals with a history of falls and risk factors for falling. -The nurse shall assess and document/report the following: vital signs, recent injury, musculoskeletal function, observing for change in normal range of motion, weight bearing, change in cognition or level of consciousness, neurological status, pain, frequency and number of falls since last physician visit, precipitating factors, details on how fall occurred, current medications, especially those associated with dizziness or lethargy, and active diagnoses. -The staff and practitioner will review each resident's risk factors for falling and document in the medical record; -The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls. -Falls often have medical causes; they are not just a nursing issue. -The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc.; -Falls should also be identified a witnessed or unwitnessed events. -For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. -Often, multiple factors contribute to a falling problem. -lf the cause of a fall is unclear, or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. -The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. -Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. -If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). -The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. -The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. -Frail elderly individuals are often at greater risk for serious adverse consequences of falls. -Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. -If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has resolved by addressing the underlying cause. -If the individual continues to fall. the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. Review of the facility's policy, Falls Risk Assessment, revised March 2018, showed the following: -The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. -Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. -The nursing staff will ask the resident and/or his/her family about any history of the resident falling. -The nursing staff, attending physician, and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension (low blood pressure); -The staff will look for evidence of a possible link between the onset of falling (or an increase in falling episodes) and recent changes in the current medication regimen. -The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as decreased vision and peripheral neuropathy) that may predispose to falls. -Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis). -The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition. -The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. -The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. During an interview on 2/8/24, at 1:45 P.M., the Director of Nursing (DON) said the facility did not have a policy for securing a resident for transport in the facility vehicle. 1. Review of Resident #20's undated face showed his/her diagnoses included altered mental status, muscle weakness, unsteadiness on feet, need for assistance with personal care, lack of coordination, reduced mobility, dizziness, restlessness and agitation, abnormal gait and mobility, and a history of falls. Review of the resident's care plan, dated 5/17/23, showed it did not contain information regarding the resident's fall risk, or interventions to prevent falls. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 5/24/23, showed the following: -admitted to the facility on [DATE]; -Moderate cognitive impairment; -Diagnosis include metabolic encephalopathy (problem in the brain caused by chemistry issues in the blood), non-traumatic brain dysfunction, altered mental state, history of falling, unsteady on feet, abnormal gait, and restlessness and agitation. -Moderate hearing difficulty; -Usually understands and is usually understood; -Verbal behaviors directed towards others; -Uses wheelchair and dependent on staff for transfers; -Requires staff to provide more than half of the effort for wheelchair mobility/locomotion; -Fall in the month prior to admission to the facility and two to six months prior to admission; -One fall with no injury since admission to the facility -Section V: fall care area triggered for falls and staff documented falls will be addressed in the resident's care plan. Review of the resident's quarterly MDS, dated [DATE], showed the resident had two or more falls with no injury since last assessment. Review of the resident's care plan did not address fall risk or history of falls. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors or rejection of care. Review of the resident's care plan, updated 11/21/23, showed it did not contain information regarding the resident's fall risk, or interventions to prevent falls. Review of the resident's care plan, updated 1/3/24, showed it did not contain information regarding the resident's fall risk, or interventions to prevent falls. Review of the resident's nurse's notes, dated 1/19/24, at 2:27 A.M., showed the following: -Entry for fall on 1/18/2024 at 7:15 P.M.; -Resident found on floor sitting cross legged when staff entered room; -Resident stated he/she was going to climb the wall and take a shower; -Alert and oriented to person, facility and year; -At approximately 9:30 P.M. staff witnessed resident sliding from wheelchair to floor, no injuries noted. Review of the resident's nurses notes dated 1/23/24, at 8:50 P.M., showed the following: -Certified Nurse Assistant (CNA) was called to resident room by another resident across the hall; -Resident was lying on his/her back on the floor mat by his/her bed; -Neurological checks initiated; -Resident alert and oriented times one and mumbling at times, which was the same as prior to fall. Review of the resident's post fall evaluation, dated 1/23/24, 9:01 P.M. showed the following: -Fall occurred in the resident's room and was not witnessed; -Resident was lying on floor mat by bed; -Wearing glasses, socks on his/her feet; -Resident was not wearing oxygen as prescribed at time of fall; -Incontinent at time of fall; -Contributing factors include confusion, delusions, restlessness, and incontinence;. -Skin note: older bruises noted to left posterior hand and open scratches to left lower extremity that are not new; -Resident has had a change in mental status, behaviors and hospitalization in last six months. Review of the resident's nurse's notes, dated 1/30/24, at 8:24 A.M., showed the following: -Resident on the floor in dining room; -Witness to the fall said the resident was attempting to stand up, and went face first onto the floor; -Bridge of nose cut open and swollen; -Left pinky finger with skin tear approximately 4 centimeter (cm) in length; -Resident complained of right shoulder/rib pain; -911 called and family notified; -Resident transported by emergency services to the hospital; -The resident returned to the facility Review of the resident's record showed no documentation staff completed any root cause analysis of the falls, initiation of fall interventions, a post fall evaluation after the fall on 1/30/24, or evidence of neurological checks. The resident's care plan did not show the resident as a fall risk or any evidence or reevaluation of the resident's care plan to address falls. Review of the resident's nurse's notes, dated 2/5/24, at 1:21 A.M., showed the following: -Resident observed sitting up with legs crossed on bedside mat, bed in low position; -Residents pants were wet with urine. Review of the resident's record showed no documentation the resident's physician or family were notified of the fall, a fall evaluation was completed, reevaluation of any interventions to prevent falls was completed after the fall on 2/5/24 1:21 A.M. fall. The resident's medical record did not contain a post fall evaluation. The resident's care plan did not contain fall risk or any evidence or reevaluation of the resident's care plan for falls. Review of the resident's nurse's notes, dated 2/5/24, at 3:39 A.M., showed the resident was found lying across his/her floor mat sideways, with his/her head off on the floor. The staff did not document evidence of physician notification, family notification, evaluation of fall, or re-evaluation of fall interventions after the 2/5/24 3:39 A.M. fall. The resident's care plan did not contain fall risk or any evidence or reevaluation of interventions to prevent future falls. Review of the resident's nurse's notes, dated 2/5/24, at 9:35 A.M., showed the following: -Witnessed as resident went headfirst out of his/her wheelchair onto his/her knees on the floor in dining room; -Resident did not hit his/her head; -Resident did bump his/her elbow and reopened an old skin tear to right elbow. The staff did not document evidence of physician notification, family notification, evaluation of fall, or re-evaluation of fall interventions after the 2/5/24 9:35 A.M. fall. The resident's care plan did not contain fall risk or any evidence or reevaluation of interventions to prevent future falls. Review of the resident's nurse's notes, dated 2/5/24, at 10:13 P.M., showed the following: -At 5:45 P.M. another resident informed writer that resident was on the floor; -Resident was lying on the floor mat by his/her bed; -Resident was trying to sit up but had poor trunk control; -Resident had a 2 cm x 0.1 cm skin tear superior to right antecubital (elbow) area; -Resident continues to hallucinate; -The resident speaks, he/she has word salad (mixture of words that do not make sense) and garbled speech noted which is not new; -Resident admits to hitting his/her head; -Neurological checks initiated; -Physician notified and orders received to transport the resident to the emergency room for evaluation and treatment. The staff did not document evidence of continued neurological checks, evaluation of the fall, or re-evaluation of fall interventions after the 2/5/24 10:13 P.M. fall. The resident's care plan did not contain fall risk or any evidence or reevaluation of interventions to prevent future falls. Review of the resident's nurse's notes, dated 2/6/24, at 4:33 A.M., showed the following: -Transport driver called at 3:55 AM and asked for someone to meet the facility vehicle outside when they arrived at the building; -The resident was on the floor of the bus, he/she slid out of his/her wheelchair; -The resident did not have injuries; -Resident returned to his/her room and in bed; -Bandage on right upper arm with red drainage, bandage on left lower arm, bruise's on both right and left arms; -Pupils slow to react; -Blood pressure 95/44, heart rate 58 (normal ranges for heart rate is 60-80 beats per minute, blood pressure: 90-120/60-80); -Resident returned from the emergency room with a diagnosis of vascular dementia, unspecified severity, with other behavioral disturbance. During an interview on 2/8/24, at 1:42 PM., Transportation Staff #34 said the following: -He/She and staff member Certified Medication Technician (CMT) #35 went to the hospital to pick the resident up and transport him/her back to the facility on [DATE]; -When the staff arrived at the emergency room the hospital staff brought the resident out to the facility vehicle; -The resident was flipping and flopping, and carrying on; -CMT #35 didn't know what to do; -He/She told the CMT, we will just have to strap him/her the best we can and go; -The resident slid out of the chair while they were driving to the facility; -He/She called the facility when they were 2 minutes away while he/she was driving, so staff would meet them outside to get the resident off the floor of the vehicle. During an interview on 2/8/24, at 3:18 P.M., Licensed Practical Nurse (LPN) #14 said the following: -Transportation aide called and said he/she was two minutes out and the resident was on the floor of the vehicle; -He/She met the vehicle outside the facility; -The resident had his/her buttocks on the floor of the van and his/her back was against the seat of the wheelchair; -He/She assessed the resident and documented the fall in his/her chart; -He/She did not evaluate the resident's care plan, notify the physician, notify the family, or notify nurse management because he/she is a new nurse and did not know what all had to be done. Review of the resident's skin evaluation, dated 2/6/24, at 2:03 P.M., showed the following: -Bruising right eye, measures length 2.5 cm, width 1 cm; -Bruising left eye, measures length 2.5 cm, width 1 cm; -Bruising nasal area; -Skin tear, nasal area, measures length 1.5 cm, width 0.3 cm; -Skin tear, left finger, measures length 1.5 cm, width 0.3 cm, some pain; -Bruising left forearm; -Bruising left upper arm; -Bruising right finger(s); -Bruising right forearm; -Bruising right anterior elbow; -Bruising right upper arm; -Skin tear right elbow measures length 2 cm width 1 cm, area painful. The staff did not document evidence of physician notification, family notification, evaluation of fall, or re-evaluation of fall interventions after the 2/6/24 4:33 A.M. fall. The resident's medical record did not contain a post fall evaluation. The resident's care plan did not contain fall risk or any evidence or reevaluation of the resident's care plan for falls. Observation on 2/8/24, at 1:15 P.M., showed the resident in his/her room. The resident had dark purple bruising around both eyes and on the right cheek. Both of the resident's arms were covered in bruises with the majority of his/her forearms dark purple. The resident has a large uncovered scabbed area approximately 2.5 cm long on his/her right arm above the elbow. During an interview on 2/8/24, at 1:28 P.M., Nurse Aide (NA) #11 said the resident falls a lot. He/She is not sure what was in place to prevent the resident from falling. The resident has a lot of bruises from the falls. The resident has slept the last two days. During an interview on 2/8/24, at 1:20 P.M., the resident's family member said the resident has fallen a lot. This week he/she has fallen, some of the staff say 2 falls and some say 3. Staff said the resident's blood pressure has been low. During an interview on 2/8/24, at 1:42 PM., the DON said the following: -Staff are expected to assess a resident for injuries after a fall, if a resident hit their head or if the fall was unwitnessed staff do neurological checks for 72 hours; -Staff are expected to report the fall to nursing management, the physician, and the resident's family; -The staff are expected to do a post fall evaluation, and the MDS coordinator is expected to update the care plan after re-evaluating the interventions; -Staff should have taken the resident back into the hospital if he/she could not be secured safely in the facility vehicle; -It is not a safe transport if the resident slid out of the wheelchair to the floor of the vehicle, the resident could have had worse injuries. During an interview on 3/13/24, at 8:15 A.M., the Administration said the following: She expected staff to follow up with falls to put measures in place to prevent future falls; -Staff are expected to only transport residents that are safe to transport; combative residents are not safe to transport; -Staff should not accepted the resident from the emergency room if he/she was combative because they could not safely transport a combative resident; -Staff are expected to call their department head or the administrator if there is something they are not sure how to handle a situation.

Based on interview and record review the facility failed to ensure one resident (Resident #1), a resident dependent on staff for eating and at risk for choking and aspiration, did not receive foods, including rice and peas, that were contraindicated for his/her condition. The resident presented with coughing and gurgling following a meal which included rice and peas. The resident required transfer to the hospital as a result and later expired. The facility census was 64 certified and nine licensed only for a total of 73 residents. 1. Review of the facility's policy Diet Guidelines, from https://essentialpuree.com/national-dysphagia/-diet-puree-guidelines/, undated, showed the following: -Mechanical Soft - Foods of nearly regular textures with the exception of very hard, sticky or crunchy foods. This texture requires chewing and tongue control. Foods should be tender and easy to break into pieces with a fork; -Altered Mechanical Soft - Foods with a moist, soft texture. Meats need to be chopped or ground and served with a binder. Vegetables need to be well cooked and easily chewed (fork tender). No hard, chewy, fibrous, crisp or crumbly bits. Patients usually struggle with scrambled eggs on this diet. No husk, seed, skins, gristle or crusts. This includes peas, corn, tomatoes, berries, lima beans, etc. No floppy textures such as lettuce and raw spinach. No foods where the juice separates from the solid upon chewing, like watermelon. Individuals on this diet generally cannot tolerate mixed consistencies. Think of this diet as a stepping stone up to regular mechanical soft. 2. Review of the Wonderful World of Swallowing, undated, provided by the facility, showed the following: -Dysphagia: Difficulties with swallowing. Includes the mouth (tongue, teeth, lips), the throat, and the esophagus (tube that goes to the stomach); -Evaluations: Bedside evaluation: Speech Therapist determines swallow abilities of the resident in their current environment (bed, dining room, etc) and decides if other measures are needed (therapy, video swallow study (VSS), diet adjustments); -Follow eating precautions and dietary orders exactly; -Communicate with charge nurse and Speech Therapy about a resident's eating/drinking; -Ask questions if there is something that you wonder about or are unsure about. 3. Review of the facility ALTERED MECHANICAL SOFT DIET GUIDELINES, dated [DATE], showed the following: -ANY RESIDENT ON AN ALTERED MECHANICAL SOFT DIET WILL HAVE THESE RESTRICTIONS: -ALL MEATS MUST HAVE BINDER, I.E., GRAVY, SAUCE, ETC; -NO FOODS WITH BREADING; -NO FOODS WITH SEEDS, SKINS, OR HULLS; -NO BREAD EXCEPT MOIST AND SOFT; -NO COARSE CEREALS; -NO NUTS; -NO RICE/RICE DISHES; -ANY EXCEPTIONS TO THIS DIET WILL BE DETERMINED BY SPEECH LANGUAGE PATHOLOGIST (SLP) AND BE RECORDED ON RESIDENT MEAL CARD; -PLEASE WATCH YOUR CARDS AND DIETS CAREFULLY. 4. Review of the policy, Resident Nutrition Services, revised (MONTH) (YEAR), showed the following: -Nursing personnel will ensure that residents are served the correct food tray; -If an incorrect meal has been delivered, nursing staff will report it to the Dietary Manager so that a new food tray can be issued; 5. Review of the policy, Therapeutic Diets, revised (MONTH) (YEAR), showed the following: -Policy Interpretation and Implementation - Mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets. Examples of therapeutic diets include: Diabetic/calorie controlled diet, Low sodium diet, Cardiac diet and Altered consistency diet; -Routine menus are planned by the Food Services Manager, and approved by a Registered Dietitian for nutritional adequacy. The Food Services Manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered. 6. Review of Resident # 1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Severely impaired cognition; -Required supervision and setup help of one staff for eating; -[DIAGNOSES REDACTED]. -Mechanically altered diet. Review of the resident's (MONTH) 2019 physician orders [REDACTED]. -[DIAGNOSES REDACTED]. -Assess lung sounds with any episode of choking, excessive coughing or signs and symptoms of aspiration due to aspiration precautions. Notify physician with any concerns; -Speech therapy (ST) to evaluate and treat ordered [DATE]; -Speech language pathologist (SLP) recommends altered mechanical soft diet. No bread. Resident needs one on one assist at all meals, continue nectar thickened liquids. Review of the resident's care plan dated [DATE] showed the following: -FYI - ASPIRATION PRECAUTIONS; -No documentation regarding the resident's diet consistency. Review of the resident's dietary note, dated [DATE] at 1:07 P.M., showed the resident was re-admitted to the facility on [DATE]. The resident was to be evaluated by physical therapy, occupational therapy and speech therapy. Diet: Altered mechanical soft. No rolls, breadsticks, or toast. (MONTH) have slice of bread with butter, nectar thick liquids. Dietary communication slip given to kitchen staff with diet order and instructed to continue diet until speech language pathologist recommendation received. Monitor and follow up as indicated. Review of the nurse's note dated [DATE] at 8:02 P.M., showed ST evaluated and recommended to start the resident on a mechanical soft diet with nectar thick fluids and no bread. Up to supper with assist of two to wheelchair and one assist to dining room in wheelchair. Review of the resident's nurse's note dated [DATE] at 10:51 [NAME]M., showed the resident was on a mechanical soft diet with no rolls/toast/breadsticks, may have a slice of bread with butter and nectar thick liquids and a magic cup (supplement) with lunch/supper. Review of a nurse's note dated [DATE] at 11:13 [NAME]M., showed a late entry for [DATE] at 8:30 [NAME]M. The resident in bed this morning resting with eyes closed. Declines getting up for breakfast. Lung sounds diminished throughout (but he/she does not take breaths even on request). He/she denies any pain or discomfort at this time as well. He/she is on an altered mechanical soft diet, no rolls/toast/breadsticks, may have slice of bread with butter, nectar thick liquids and does require assist times one with feeding when he/she does not feed him/herself but requires supervision due to aspiration risk. ST treatment not recommended at this time due to limited potential for progress and they gave above mentioned diet order. Review of nurse's notes dated [DATE] at 11:27 [NAME]M., showed late entry from [DATE] at 12:45 P.M. Writer was called to dining room due to report the resident is gurgling. This writer and the Assistant Director of Nurses (ADON) went to the dining room and the resident had stopped the gurgling sound and he/she was coughing. Writer encouraged coughing and letting the resident rest (stop feeding) and to bring to the desk when done so he/she could monitor the resident more closely. The resident was being assisted with his/her meal by a Certified Nurse Aide (CNA). The resident is at the desk and appears to be in no distress at this time. The resident's diet order on the 30th was for pureed diet but was changed by ST on the 31st to an altered mechanical soft with no rolls/toast/breadsticks but may have slice of bread with butter, nectar thick liquids and this is the diet order that was served on the 31st. Review of the nurse's notes dated [DATE] at 5:19 P.M., showed the nurse was called to the resident's room to check on the resident's condition. The resident was sitting up leaning on staff sitting beside him/her. Resident pale breathing with intercostal muscles (several groups of muscles that run between the ribs and help form and move the chest wall) gasping for air. Resident on 2.5 liters of oxygen per nasal cannula. Lungs with wheezing in the upper right lung with wet lung sounds throughout, diminished in the lower lobes. Resident able to slightly nod his/her head when asked questions. Called physician's office and talked to staff about health status change. Received orders to give one dose of [MEDICATION NAME] per nebulizer (medication that relaxes muscles in the airways given through a machine that turns the liquid into a mist for inhalation) and transfer to the emergency room to evaluate and treat. Review of the resident's emergency room department report, dated [DATE] at 3:25 P.M. showed the resident presented to the emergency department with complaints of shortness of breath and was pronounced deceased on [DATE] at 3:45 P.M. with [MEDICAL CONDITION] and [MEDICAL CONDITION] (absence of enough oxygen in the tissues to sustain bodily functions). Review of the resident's Certification of Death, showed the following: -date of death - [DATE]; -Underlying cause of death: -Cerebral vascular incident - 5 years; -Aspiration airway obstruction - 1 day. During interview on [DATE] at 1:27 P.M. Dietary Aide K said the following: -The noon meal on [DATE] included peas and rice; -The resident was on an altered mechanical soft diet and was to have no seeds, no husks, and no rice; -Cook H overlooked the altered mechanical soft part of the resident's diet and served the resident peas and rice. During interview on [DATE] at 1:46 P.M. Cook H said the resident was on a mechanical soft diet. This included ground meat and soft foods. During interview on [DATE] at 1:28 P.M., CNA I said he/she served the resident's lunch tray on [DATE] and there was no diet card on the tray to verify the diet. There was rice on the resident's tray. During interview on [DATE], at 11:18 [NAME]M., CNA A said the following: -The resident was a choking risk; -The serving slip showed the diet a resident required and staff verify the tray to the slip when serving the tray; -The resident did not have a serving slip that day. Review of written statement, dated [DATE], showed CNA A wrote the following: -He/She was feeding the resident lunch. The resident did not have a dietary card with his/her meal. He/She fed the resident two or three bites of fish mixed with tartar sauce, one bite of peas and one bite of rice. The resident ate about 75 percent of his/her yogurt. CNA/Restorative aide (RA) B and CNA C were also in the dining room. The resident started coughing. It sounded like the resident was also gurgling. CNA C got the Assistant Director of Nurses (ADON) and Licensed Practical Nurse (LPN) D. LPN D said to let him/her know if the resident does it again. The resident continued to do this and was also coughing up a lot of what looked like mucous; he/she reported this to LPN D. After people were out of the dining room, CNA A said he/she sat the resident up by the nurse's station so LPN D could hear the resident. Staff laid the resident down in bed. During interview on [DATE] at 12:49 P.M., CNA C said CNA A was feeding the resident lunch consisting of fish, rice and peas and he/she heard the resident gurgle. He/She told the charge nurse the resident was gurgling and the charge nurse didn't understand what he/she meant by gurgling. The charge nurse went to the dining room to see the resident and listened to the resident's chest and back with his/her stethoscope. The resident did not eat anything else and was taken out of the dining room to sit at the nurse's station. The charge nurse told staff to put the resident to bed. They put oxygen on the resident. The resident seemed to be scared and did not act like him/herself. The resident wasn't talking like he/she usually did. There was no diet card on the tray that day. During interview on [DATE] at 11:55 [NAME]M., LPN D said he/she was called into the dining room and the ADON went with him/her. The resident was not actively choking when he/she was in the dining room. He/She told the staff not to feed the resident for a minute and then the resident coughed. LPN D said he/she asked staff to bring the resident to the nurse's desk so he/she could watch the resident. He/She could tell the resident wasn't feeling well. He/She went to the office for approximately 45 minutes and when he/she came out of the office the resident was being sent to the emergency room . During interview on [DATE] at 2:13 P.M., the Director of Nurses (DON) said she was in her office when the CNA said the resident was gurgling. The ADON and charge nurse went to assess the resident and the ADON returned and said all was okay. Later she was in the hall and an activity assistant was standing in the doorway waiting for an aide due to the resident was trying to get out of bed. She then looked in on the resident and he/she did not look good. She went to her office to get a stethoscope to assess the resident and she asked the charge nurse from the oncoming shift to assess the resident. The resident's oxygen saturations were 71% (normal saturations are ,[DATE]%), on 2 liters oxygen, the oxygen was increased to 5 liters and the physician was called for an inhaler and nebulizer treatment. The resident was short of breath but was not wheezing or gurgling. The resident was having a hard time breathing and had emesis (vomiting) with a scant amount of pink tinged mucous. The resident had a mortified look like he/she was scared and couldn't catch his/her breath. LPN J listened to the resident and said sounds like she's breathing through water. During interview on [DATE] at 1:54 P.M., the dietary manager said she was responsible for printing the diet slips that go on the trays. The slip had been pulled off the hot cart and she found the resident's serving slip the following week after learning it was missing. It was located under the stainless steel work table against the wall with other papers. She expected the staff to contact her or the charge nurse when there was no diet card. She was told the charge nurse was notified and the charge nurse said the resident's diet had not changed from his/her prior stay. The prior diet was altered mechanical. She does not know why the staff served the resident rice and peas. During interview on [DATE] at 10:40 [NAME]M. and 2:21 P.M. and [DATE] at 1:35 P.M., the administrator said the following: -Dietary staff served the resident the incorrect diet; -The cook should serve according to the diet card; -The resident did not have a diet card that day. During interview on [DATE] at 10:41 [NAME]M., the resident's physician said the following: -The resident saw the speech therapist consistently who made changes to his/her diet; -He would expect diet orders to be followed; -Speech therapy recommended an altered mechanical diet and the facility needed to figure out how to do it. MO 0

Based on observation, interview and record review, the facility failed to monitor pressure relief when seated for one resident (Resident #3) identified as at risk for pressure ulcers of four sampled residents prior to the resident developing a pressure ulcer and did not follow-up on dietary recommendations when the resident developed a pressure ulcer. The facility census was 94. 1. Review of an undated facility policy, titled "Prevention of Pressure Ulcers" showed pressure ulcers were usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident and often times become infected. Pressure ulcers are often made worse by continual pressure, heat, moisture and irritating substances on the resident's skin. Once a pressure ulcer develops, it can be extremely difficult to heal. Encourage the resident to participate in active and passive range of motion exercises to improve circulation. Ensure the resident drinks plenty of fluids and eats a well-balanced diet. Identification of residents at risk: A pressure ulcer risk assessment (Braden Scale) will be completed on each resident upon admission/readmission to the facility and at least quarterly thereafter. Interventions linked to the Braden scores. (Further preventive action may be taken at this time). A score of 15 to 18 indicated the resident at risk. Interventions included frequent turning, at least every two hours scheduled. Staff may use a written schedule. Maximize the resident's mobility. Use a pressure-reducing support surface if the resident is bedfast or chairfast. For a score of 13 to 14, it indicated a moderate risk. The interventions were the same, but also included the use of positioning devices for 30 degree lateral positioning. A score of 10 to 12, indicated a high risk. The interventions were the same as the above, but also included increasing the turning frequency and doing small shifts in position. Additional clinical conditions, treatments and abnormal laboratory values that indicated a resident was a risk were listed in the survey tag, F314 and included continuous urinary incontinence or chronic voiding dysfunction,[MEDICAL CONDITION], chronic or [MEDICAL CONDITION] and significant changes in weight (greater than or equal to five percent in 30 days or 10% in 180 days. Specific preventative measures for bedfast/chairfast residents were for a resident in bed, change positions at least every two hours, raise the head of the bed as little and for a short a time as possible. For a resident in a chair, change position every two hours and use foam, gel or air cushion to relieve/reduce pressure. Reduce friction by lifting rather than dragging when repositioning. Use a draw sheet or lift pad for repositioning. Participate in a rehabilitation program with restorative and/or skilled therapy. Specific preventative measures for residents with poor nutrition, included staff should encourage the resident to eat a balanced diet. If a normal diet is not possible, staff should talk to the physician about supplements and/or snacks, repeat labs as necessary and refer to the Registered Dietician (RD) for assessment and recommendations. 2. Review of an undated facility policy, titled "Pressure Ulcer Treatment" showed the pressure ulcer treatment program should focus on the following strategies: -Assessing the resident and the pressure ulcers; -Managing tissue loads; -Pressure ulcer care; -Managing bacterial colonization and infection; -Operative repair of the pressure ulcers; -Education and quality improvement. When eschar (dead tissue) is present, a pressure ulcer cannot be accurately staged until the eschar is removed. The facility protocol for Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer showed: Clean shallow, minimal drainage: -Protect; -Manage drainage; -Promote moist wound healing; -Treatment included: Cleanse with normal saline or other skin cleanser in accordance with physician orders [REDACTED]. For medium drainage, follow the same procedure, but consider the need for alginate or foam. The facility policy for treatment of [REDACTED]. 3. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/15/14 showed he/she: -Was understood by others; -Understood others; -Did not receive an interview for mental status because he/she was rarely/never understood; -Had long-term and short-term memory problems; -Had moderately impaired cognitive skills for daily decision making; -Was totally dependent upon two or more people's physical assistance for bed mobility, transfers and bathing; -Did not ambulate in his/her room or in the corridor; -Was totally dependent upon one person's physical assistance for personal hygiene; -Required limited assistance of one person for eating; -Used a wheelchair for mobility; -Was always incontinent of bowel and bladder; -Had active [DIAGNOSES REDACTED]. -Was 56 inches long and weighed 187 pounds; -Had no weight loss and was on a therapeutic diet; -Was at risk of developing pressure ulcers (open wounds that form whenever prolonged pressure is applied to skin covering bony outcrops of the body. Residents who are bedridden are at risk of developing pressure ulcers; -Had no pressure ulcers or other skin problems; -Had no pressure ulcers present on the previous assessment; -Had no skin and ulcer treatment, and did not have a pressure relieving device in the wheelchair and was not on a turning/repositioning program. (The MDS identified the resident at risk for pressure ulcers. The facility did not include utilizing a pressure relieving device in the chair or turn and reposition as per the facility's policy). Review of the resident's Braden Scale (scale for predicting pressure ulcer risk), dated 12/22/14 showed a score of 17. A score of 15-18 indicated a mild risk for the development of pressure ulcers. The score was based upon the facility assessment the resident including: -The resident had no sensory perception impairment (the resident responded to verbal commands and had no sensory impairment which would limit ability to feel or voice pain or discomfort); -Was occasionally moist (skin is occasionally moist, requiring an extra linen change approximately once a day); -Was chairfast (ability to walk was severely limited or nonexistent. He/she could not bear his/her own weight and/or he/she must be assisted into chair or bed); -Had slightly limited mobility (made frequent though slight changes in body or extremity position independently); -Had adequate nutrition (Ate over half of most meals. Ate a total of four servings of protein (meat, dairy products) each day. Occasionally would refuse a meal, but would usually take a supplement if offered); -Had a potential problem with friction or shear (Moved feebly or required minimum assistance. During a move, skin probably slid to some extent against sheets, chair, restraints or other devices. Maintained relatively good position in chair or bed most of the time, but occasionally slid down). Review of the resident's care plan, last updated 12/22/14 showed: -The resident had altered thought processes and may miss some part/intent of conversation. He/she may have difficulty making a decision in new situations. Interventions for this problem showed the resident would shake his/her bedside rails when he/she needed assistance instead of using his/her call light. Staff should educate the resident on the call light. At times, the resident hit his/her arms on the railing to make noise to get staff's attention; -He/she was at risk for skin breakdown due to episodes of incontinence and decreased mobility. Interventions included the request to leave the Hoyer sling under him/her in the wheelchair, keep his/her skin clean and dry, perform pericare as needed after each incontinence episode, keep his/her bed linens clean, dry and wrinkle free; position him/her in good body alignment and support with pillows as the resident will allow, notify charge nurse and wound nurse of any red or open areas and notify the physician as needed. Review showed no documentation the resident's care plan included interventions, as identified in the facility's policy, for a resident at risk for pressure ulcers, including to reposition the resident at least every two hours and to provide a pressure reducing support surface for a resident who is bedfast or chairfast. Staff assessed the resident as chairfast on the Braden Scale, completed on 12/22/14. Review of the resident's Dietician's Progress Record showed an entry, dated 2/13/15, the dietician evaluated the resident for weight loss. The resident's February, 2015 weight was 165 pounds, which was a 13 pound loss in one month, or 7.3%, a decrease of 25 pounds in three months, or 13.2% and a decrease of 22 pounds in six months. The resident had experienced a decline. He/she was on a pureed (foods with a smooth, pudding-like consistency), no added salt diet with nectar thickened liquids (easily pourable and are comparable to apricot nectar or thicker cream soups). The resident received Med Pass (a supplement of calories and protein) 60 milliliters (mL) three times a day (started 2/3/15). The dietician recommended continuing obtaining weekly weights for monitoring. The resident also moved to another nursing unit due to increase in care needed. The note did not mention or address any skin breakdown. Review of the resident's Skin Alteration Record, dated 2/18/15 showed the resident with a new pressure ulcer on the left ischial tuberosity (the rough bony projection at the junction of the lower end of the body of the ischium and its ramus; this is a weight-bearing point in the sitting position). It was not present upon admission. The wound had the following characteristics: -Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous)); -Measurement at onset was 3.6 cm length by 4.0 cm width and 0 cm depth; -Moderate exudate (fluid emitted by an organism through pores or a wound) which was serous (fluid); -No odor; -Wound bed was pink/red; -The wound edges were well-defined; -No signs of infection; -Treatment/Plan: wheelchair cushion, turn and reposition every one to two hours. There were no dietary interventions at this time; -Current treatment was absorbent silver dressing secured with [MEDICATION NAME] (a dressing); -Nursing notified the resident's physician and family; -Outpatient wound clinic referral was not indicated. During an interview on 4/1/15 at 2:10 P.M., Licensed Practical Nurse (LPN)/Wound Nurse A said one of the nurse aides came and got him/her and reported the wound on the resident they found while putting him/her to bed on 2/18/15. They found the wound while doing pericare. It was a Stage II pressure ulcer with no appreciable depth. Review of the resident's care plan showed no documentation staff updated the resident's care plan to address the resident's newly developed pressure ulcer and the treatment interventions identified on the Skin Alteration Record, dated 2/18/15. The interventions included wheelchair cushion, and to turn and reposition every one to two hours. Review of the facility's undated summary entitled root cause analysis of the resident's wound on the ischium, showed staff transferred the resident from the special care unit to the general population on 2/11/15. Staff fitted the resident for a new wheelchair on 2/12/15 and 2/13/15. On 2/18/15, staff noted the resident with a Stage II pressure ulcer. During investigative discussions with the Certified Nurse Aide (CNA) staff, who provided care to the resident, the facility determined the resident was always on either side while in bed and did not like to be positioned on his/her back. The only surface with which the area of breakdown came in contact was his/her wheelchair seat. At the time, LPN/Wound Nurse A examined the wheelchair seat and the cushion without any concerns. Staff removed the cushion and sat in the wheelchair. Staff were able to palpate (feel) the crossbars of the sling seat with their hands and while sitting in the wheelchair. Staff discussed the resident's wheelchair had been changed twice in seven to ten days. Facility staff concluded at some point during the wheelchair trials and prior to the discovery of the pressure ulcer, staff did not put the wheelchair cushion in place. During an interview on 3/12/15 at 12:25 P.M., LPN/Wound Nurse A said the resident's wheelchair change happened three or four days after staff moved him/her to the current unit (resident moved from SCU on 2/11/15). Staff thought the resident looked uncomfortable in his/her old wheelchair and they were not positive the resident actually went without a cushion in the wheelchair. The facility issued the resident a new cushion which was secured to the wheelchair. During an interview on 3/12/15 at 12:25 P.M., the facility administrator said the facility staff changed the resident's wheelchair and he/she suspected the resident's wheelchair cushion did not go with him/her, so he/she may have gone a couple days without the cushion. The resident sat for some time in the chair at some point. Review of the resident's Braden Scale, dated 2/19/15 showed a score of 10. A score of 12 or less represented high risk. The score was based upon staff assessment the resident: -Had slightly impaired sensory perception (the resident responded to verbal commands but could not always communicate discomfort or need to be turned or had some sensory impairment which limited ability to feel pain or discomfort in one or two extremities); -Was constantly moist (skin is kept moist almost constantly by perspiration, urine, etc. Dampness was detected every time resident was moved or turned); -Was chairfast (ability to walk was severely limited or nonexistent. He/she could not bear his/her own weight and/or he/she must be assisted into chair or bed); -Had very limited mobility (made occasional slight changes in body or extremity position, but was unable to make frequent, significant changes independently); -Had very poor nutrition (Never ate a complete meal. Rarely ate more than a third of any food offered. Ate two servings or less of protein (meat, dairy products) per day; -Had a problem with friction or shear (Required moderate to maximum assistance in moving or complete lifting without sliding against sheets was impossible. Frequently slid down in bed or chair and required repositioning with maximum assistance). Review of the resident's nurse's note, dated 2/22/15 at 7:25 A.M. showed the resident's wound with a foul odor. Nursing received a telephone order for culture of the wound at the left ischial tuberosity. Review of the resident's untimed nurses' note, dated 2/25/15 showed nursing received a new order for [MEDICATION NAME] (an antibiotic) 500 milligrams (mg) one capsule by mouth four times a day for ten days for wound infection. Record review showed no further documentation of the condition of the wound between 2/12/15 and 2/27/15. Review the resident's Skin Alteration Record, dated 2/27/15 showed the resident with a pressure ulcer on the left ischial tuberosity. It was not present upon admission. Nursing obtained an order for [REDACTED]. -Unstageable; -Measurement at onset was 3.6 cm length by 4.0 cm width and depth was unable to be determined; -The current measurements were 5.8 cm length by 5.0 cm width and depth was unable to be determined because of 100% necrosis (cell injury that results in the premature death of cells in living tissue); -Slough and eschar present; -Heavy/copious exudate (fluid emitted by an organism through pores or a wound) which was serous (fluid) and purulent (with pus); -Strong/foul odor; -Wound bed was 100% necrotic with gray slough; -The wound edges were well-defined; -Treatment/Plan: air bed, wheelchair gel cushion, turn and reposition every one to two hours. There were no dietary interventions at this time; -Current treatment was therahoney, gauze with 4X4 (a four inch by four inch piece of gauze) and [MEDICATION NAME] tape (a non-woven, polyester, soft, cloth surgical tape). Review of faxed communication from LPN/Wound Nurse A to the physician, dated 2/27/15 showed the resident's wound on the left ischium had changed significantly since 2/24/15. The area was now 100% gray to black necrotic (dead tissue), copious malodorous drainage which made it difficult to maintain the outer dressing. The periwound (skin bordering the wound) was without redness, but with slight induration. The current treatment of [REDACTED]. The staff was adjusting and trying different outer dressings to find one that will be effective stay in place. The resident continued [MEDICATION NAME] also. The facility requested an order for [REDACTED]. Review of the resident's Dietician's Progress Record showed an entry, dated 2/28/15 the dietician evaluated the resident regarding a new wound. The resident's wound status as of 2/27/15 was an area on his/her left ischium measuring 5.8 cm by 5.0 cm and it was unstageable. The resident was to be seen in the wound clinic for debridement of the wound. The dietician recommended adding multivitamin with minerals (a supplement) and [MEDICATION NAME] (an [MEDICATION NAME]-intensive drink for patients recovering from burns, surgery or wounds which may help promote wound healing) one packet twice a day for wound healing. Review of a physician's progress note, dated 3/3/15 showed the resident's wound changed and the resident was with minimum verbal response. He/she was cooperative and in no acute distress. He/she had a left ischial ulcer, progressive dementia, [MEDICAL CONDITION] and high blood pressure. The plan was to refer the resident to the wound clinic for evaluation and possible debridement and culture and sensitivity. Record review showed no further documentation of the condition of the wound between 2/27/15 and 3/5/15. Review of the resident's Skin Alteration Record, dated 3/5/15 showed the resident with a pressure ulcer on the left ischial tuberosity. It was not present upon admission. The resident had a wound clinic appointment on 3/17/15. The wound had the following characteristics: -Unstageable; -Measurement at onset was of 3.6 cm length by 4.0 cm width and depth was unable to be determined; -Current measurement was 5.4 cm length by 5.0 cm width and depth was unable to be determined; -Slough and eschar present; -Moderate exudate (fluid emitted by an organism through pores or a wound) which was serous (fluid) and purulent (with pus); -Strong/foul odor; -Wound bed was 100% necrotic with white, yellow and gray slough; -The wound edges were well-defined; -Treatment/Plan: air bed, wheelchair cushion, turn and reposition every two hours, dietician to see him/her on 3/6/15; -Current treatment was therahoney, gauze and [MEDICATION NAME] tape. Review of the resident's Dietician's Progress Record showed an entry, dated 3/6/15 showed the dietician evaluated the resident for quarterly review and weight loss evaluation. The resident's March, 2015 weight was 167, which was a two pound increase for one month, a 20 pound weight loss for three months, or 10.7%. The resident took a pureed, no added salt diet with nectar thickened liquids. He/she received Med Pass 60 mL supplement three times a day. Medications and laboratory results were reviewed. Wound status as of 3/5/15 was an area on his/her left ischium measuring 5.4 cm by 5.0 cm and it was unstageable. A recommendation was made 2/28/15 and was still pending. Review of the resident's significant change in status MDS, dated [DATE] showed he/she: -Exhibited a loss of liquids or solids from his/her mouth when eating or drinking; -Lost 5% or more weight in the last month or 10% or more in the last six months and was on a physician-prescribed weight-loss regimen and on a mechanically altered diet and therapeutic diet; -Had a Stage I pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence) or greater, scar over a bony prominence or a non-removable dressing or device; -Was at risk of developing pressure ulcers; -Had one unstageable pressure ulcer (known, but not stageable due to non-removable dressing/device or slough (soft, moist avascular (devitalized) tissue; may be white, yellow, tan or gray, may be loose or firmly adherent) and/or eschar (an area of dead tissue) and it measured 7 centimeters (cm) in length by 4 cm in width and depth was unable to determine; -The most severe tissue type was slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous; -Had no pressure ulcers present on the previous assessment; -Had skin and ulcer treatments which included pressure relieving devices on the bed and in the chair, nutrition/hydration intervention to manage skin problems and pressure ulcer care. Review of the resident's nurses' note, dated 3/10/15 at 6:30 A.M. showed the resident's wound was extremely malodorous (smelling very unpleasant) with copious amounts of drainage. Nursing received a new order to culture the wound and collected a specimen. Review of a physician's progress note, dated 3/10/15 showed the resident with increased foul drainage. The last culture grew aerococcus (a bacteria), but the resident appeared worse with the wound. He/she was placed on [MEDICATION NAME] (an antibiotic). Assessment showed wound infection, [MEDICAL CONDITION] and dementia. The plan was to repeat a culture and sensitivity (which was sent on this morning and would probably change the antibiotic, but would await the culture report), start [MEDICATION NAME] for anaerobic (organism that does not require oxygen for growth) bacteria. Review of the resident's Skin Alteration Record, dated 3/11/15 showed the resident's wound showed necrosis was thinning around the wound edges and walls. The wound had depth, but staff was unable to measure due to necrosis. The wound measurements increased this week. The physician's office was notified and gave no new orders at this time. The wound showed the following characteristics: -Exudate was heavy/copious with a serous consistency; -Odor was improving; -It was 100% necrotic (staff noted improvement around the edges and noted it to be thinning); -Grey eschar was present; -The resident had no pain during the assessment; -Wound edges were attached to the base and well-defined. They were slightly [DIAGNOSES REDACTED]tic and indurated one centimeter; -Measurement at onset was of 3.6 cm length by 4.0 cm width and depth was unable to be determined; -Current measurements were length 6.8 cm by 4.4 cm with depth unable to be determined due to 100% necrosis; -The wound increased in size in one week; -It showed signs of odor; -A culture, dated 3/10/15 showed proteus mirabilis and the resident was on [MEDICATION NAME] 300 mg one by mouth four times a day for 10 days; -Pressure redistribution interventions were an airbed and wheelchair cushion and turning and repositioning every one to two hours; -Dietary interventions were [MEDICATION NAME] twice a day and multivitamin with mineral daily (started 3/12/15). (The RD recommended these interventions on 2/28/15); -Current treatment was therahoney, gauze with 4X4 and [MEDICATION NAME] tape. Change every 72 hours and as needed. Review of the resident's nurses' note, dated 3/11/15 at 3:00 A.M. showed the resident was agitated, moaning out with movement noted. An increase in pain was not covered with as needed Tylenol ([MEDICATION NAME]). Nursing received a new telephone order for [MEDICATION NAME] 5 mg/325 mg (a combination of [MEDICATION NAME] and [MEDICATION NAME] used for pain), take one by mouth every four hours as needed for pain. Observation of the resident on 3/12/15 at 5:34 A.M. showed the resident lay in bed on his/her right side shaking the half-side rail on the bed. The bed was against the wall on the left side. Observation on 3/12/15 at 11:10 A.M. with LPN C showed the resident's wound undressed and ready for treatment. The wound showed a foul odor with 50% slough and 50% eschar. The wound was full thickness. The wound bed showed slough and eschar. During an interview on 3/12/15 at 11:26 A.M. and 12:25 P.M., LPN A/Wound Nurse said he/she performed weekly wound assessments. The current measurements of the resident's wound were 6.8 cm length by 4.4 cm width. He/she did not measure depth due to the wound bed being all slough. This was at the end of one week. At the beginning of the next week on Tuesday, staff reported the wound had a significant change. It was 100% adhered slough. He/she had not identified any undermining or tunneling at this time. Review of the resident's nurse' note, dated 3/12/15 during the 7:00 A.M. to 3:00 P.M. shift showed nursing obtained a new order per the RD's recommendation. Multivitamin with minerals daily and [MEDICATION NAME] one packet twice a day for wound healing. Review of the physician's orders [REDACTED]. -Multivitamin with mineral, one tablet by mouth daily (supplement); -[MEDICATION NAME], one packet by mouth twice a day (wound healing). Review of the resident's March, 2015 Medication Administration Record [REDACTED]. (The Registered Dietician made the initial recommendation for the daily multivitamin and [MEDICATION NAME] to promote wound healing on 2/28/15. The resident began the supplements 12 days after the recommendation was made.) During an interview on 3/26/15 at 11:59 A.M., LPN/Wound Nurse A said the dietician came on a Saturday and emailed recommendations to the Director of Nursing (DON) who would then send the recommendations to the physician. He/she did not know why the dietician's recommendations were not started until 3/12/15; it was not normal for that much time to lapse. Review of the resident's Wound Clinic Progress Note, dated 3/17/15 showed the resident had poor intake recently. Per staff, the wound started one month ago. The resident had a large, deep penetrating ischial ulcer. The wound clinic consulted with a surgeon for formal debridement. Review an undated facility summary entitled root cause analysis of the resident's wound on the ischium showed on 3/17/15, the wound clinic physician debrided the wound and admitted the resident to the hospital with osteo[DIAGNOSES REDACTED] (an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue). Review of the resident's operative report, dated 3/17/15 showed initially there was an unstageable wound because of the amount of eschar present. Once the eschar was removed, a full-thickness wound which was very extensive and extended down along the rectum and levator ani (a broad, thin muscle, situated on the side of the pelvis) and also continued to tunnel forwardly, down along the sides of the vagina. The tunnel measured 12.1 cm. The surgeon performed surgical debridement which included removing gangrenous, nonviable skin, subcutaneous tissue, muscle and fascia. The surgeon noted the wound would absolutely need further surgery to expose the tunnel to ensure maximum wound healing and ensure all necrotic tissue was removed. This would require a [MEDICAL CONDITION] (a [MEDICAL CONDITION] is when the colon is cut in half and the end leading to the stomach is brought through the wall of the abdomen and attached to the skin) to divert bowel movements and probably a feeding tube for nutrition. The resident has extensive age and contractures in his/her legs and was basically bedridden. The surgeon did not feel the team should probably be so aggressive and should be looking at palliative care for the resident. During an interview on 4/1/15 at 2:52 P.M., RD E said: -He/she visited the facility twice a month and received updated wound reports and asked if there were any new wounds. If there was a new wound, he/she would chart on it and make appropriate recommendations. The resident was having unplanned weight loss. -When he/she made recommendations, he/she expected the facility to follow up on those recommendations. He/she spoke to the DON regarding the need to follow up on his/her recommendations for the resident since they had not. He/she did not know what happened to cause the delay; -The delay had the potential to impact the deterioration of the wound. The dietician felt the resident would benefit from his/her recommendations when he/she made them. During an interview on 4/1/15 at 2:00 P.M., the Director of Nurses (DON) said: -She had not done any assessment on the resident's wound; the wound nurse and the charge nurses assessed it. The wound nurse attended several seminars related to wounds and shadowed at the wound clinic and consulted with the wound nurses there. -His/her expectation regarding the RD's recommendations would be that the order would be be obtained by the physician and put in place. During an interview on 3/26/15 at 1:39 P.M., Physician B said the resident was on a weight-loss regimen and he thought the nutritional supplement was for increased protein needed for wound healing. Protein and reducing pressure off the bony prominence were what was important for this resident. He did not see the resident's wound initially, but saw it after it had broken open, become malodorous and had increased drainage. He did not know what caused the wound for the resident, but said it would have been due to pressure over the bony prominence. MO 8 and MO 6