Every finding on record at Lakeview Post Acute

Based on interview and record review, the facility failed to ensure ongoing skin monitoring, physician notification, and timely treatment for one resident (Resident #1) who developed skin shearing (mechanical injury caused by the combination of friction and gravity, where the skin sticks to a surface, like bedding, causing deep tissue damage and blood vessel damage) and an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage could not be determined due to slough (dead tissue) or eschar (necrotic tissue)) pressure ulcer (localized damage to the skin that usually occur over a bony prominence as a result of pressure). In addition, facility staff failed to complete a skin assessment and provide wound care for one resident (Resident #2) who was admitted to the facility with a pressure ulcer. Four residents were sampled for wounds, and problems were identified with two. The census was 103.Review of the facility's Wound Care policy, revised October 2010, showed:-Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing;-Preparation:-Verify that there is a physician's order for this procedure;-Review the resident's care plan to assess for any special needs of the resident;-Documentation: The following information should be recorded in the resident's medical record;--The type of wound care given;--The date and time the wound care was given;--The position in which the resident was placed;--The name and title of the individual performing wound care;--Any changes in the resident's condition;--All assessment data obtained when inspecting the wound;--How the resident tolerated the procedure;--Any problems or complaints made by the resident related to the procedure;--If the resident refused the treatment and why;--The signature and title of the person recording the data;-Reporting;--Notify the supervisor if the resident refuses the wound care;--Report other information in accordance with facility policy and professional standards of practice. Review of the facility's Medication and Treatment Orders policy, dated July 2016, showed:-Policy statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing;-Drug and biological orders must be recorded on the physician's order sheet in the resident's chart;-The signing of orders shall be by signature or a personal computer key;-Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date, and the time of the order. Review of the facility's Charting and Documentation policy, dated July 2017, showed:-Documentation in the medical record may be electronic, manual or a combination;-The following information is to be documented in the resident medical record;--Treatments or services performed;-To ensure consistency in charting and documentation of the resident's clinical record, documentation of procedures and treatments will include care-specific details, including:--The date and time the procedure/treatment was provided;--The name and title of the individual(s) who provided the care;--The assessment data and/or any unusual findings obtained during the procedure/treatment;--How the resident tolerated the procedure/treatment;--Whether the resident refused the procedure/treatment;--Notification of family, physician, or other staff, if indicated, and;--The signature and title of the individual documenting. 1. Review of Resident #1's Comprehensive Skin Evaluation/Assessment, dated 2/3/26, showed:-admission date 2/2/26;-Skin: Dry, intact, and warm;-No presence of wounds. Review of the resident's Braden Scale (tool used to assess a resident's risk of developing pressure ulcers) assessment, dated 2/3/26, showed a score of 15 (a score of 15 to 18 means at risk for pressure ulcers). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/7/26, showed:-Resident high risk for developing a pressure ulcer and/or pressure injury;-Resident admitted with no pressure ulcers and/or pressure injuries. Review of the resident's weekly skin assessments showed:-On 2/10/26, skin dry, intact, warm and no presence of skin breakdown;-On 2/17/26, no skin assessment documented. Review of the resident's progress notes, dated 2/18/26, showed:-At 6:57 P.M., staff documented the resident presented with a skin shear to left buttock measuring 2.0 centimeters (cm) by (x) 2.0 cm. Nurse applied foam dressing and sent message to Nurse Practitioner (NP) for treatment order;-No additional nursing documentation showing the NP returned the call and/or any new treatment orders;-No documentation the resident's responsible party was notified of the resident's change in condition. Review of the resident's physician order sheet (POS), dated 2/18/26, showed no new treatment orders for the wound identified on 2/18/26. Review of the resident's progress notes, dated 2/19/26, showed:-Staff documented the resident remained on antibiotic therapy related to an upper respiratory infection and incident follow up related to a new wound. No changes noted;-No documentation of wound size, notification of family and/or physician, or any new physician orders obtained for wound care. Review of the resident's progress notes, dated 2/20/26 through 2/24/26, showed no documentation of the resident's wound identified on 2/18/26. Review of the resident's Comprehensive Skin Evaluation/Assessment, dated 2/23/26, showed:-Staff documented the resident's skin was dry, warm, and had the presence of wounds. Staff identified a new wound on the resident's sacrum (area at base of the spine);-No wound description including size or stage (way of defining tissue damage severity) of the wound noted. In the space designated for notifications, staff documented no notifications were required. Review of the resident's POS, showed:-An order, dated 2/23/26 at 3:10 P.M., for the resident to be followed by wound care;-No wound care orders noted. Review of the resident's Wound Care Management note, dated 2/24/26, showed:-Resident was seen for wound evaluation and treatment;-Resident's wound on the sacral region measured 3.0 cm x 5.0 cm x unable to determine (UTD) cm. 60% necrotic and 40% granulation (healing tissue);-Treatment plan: Cleanse area with normal saline (NS) pat dry, apply Santyl (medication which removes dead skin tissue from wounds), dress with calcium alginate (highly absorbent gel forming dressing), cover with a foam bordered dressing, change daily and as needed (PRN). Review of the resident's POS, dated 2/24/26, showed no treatment orders for wound care related to the wound identified on 2/23/26. Review of the resident's POS and treatment administration record (TAR), showed:-An order, dated 2/25/26, at 9:24 P.M., for wound care to sacrum. Cleanse with wound cleanser, pat dry, apply Santyl to wound bed followed by calcium alginate, cover with dry protective dressing. Change daily and PRN if soiled or dislodged, every day shift for wound care. Low air loss mattress (mattress with alternating pressure with a steady flow of air to prevent and treat pressure ulcers);--The TAR showed staff documented the first treatment applied on 2/26/26. Review of the resident's Wound Care Management note, dated 3/3/26, showed:-Resident re-evaluated for pressure wound;-Wound measured 5.0 cm x 3.0 cm x UTD cm. Wound bed: 15% slough, 80% necrotic, and 5% granulation;-Treatment plan: Cleanse with NS, pat dry, apply Santyl, and cover with bordered gauze dressing daily and PRN. Review of the resident's POS and TAR, showed:-An order, dated 3/3/26, at 9:28 A.M., for wound care to unstageable sacrum, cleanse with wound cleanser, pat dry, apply Santyl to wound bed followed by calcium alginate, cover with dry protective dressing. Change daily every 12 hours and PRN;--The TAR showed the treatment not documented as administered on 3/3/26. Review of the resident's care plan, in use during the time of the investigation, initiated and revised 3/9/26, showed:-Focus: The resident has an unstageable pressure ulcer to sacrum and is at risk for further breakdown;-Goal: Will have intact skin, free of redness, blisters or discoloration by/through next review;-Interventions: Administer medication as ordered. Administer treatment as ordered, monitor dressing every shift to ensure it is intact and adhering, report lose dressing to treatment nurse, monitor nutritional status, monitor/document/report to physician PRN changes in skin status. Review of the resident's Wound Care Management note, dated 3/10/26, showed:-Resident re-evaluated for chronic pressure wound;-Wound measured 4.5 cm x 4.5 cm x UTD cm. 60% slough, 20% necrotic and 20% granulation;-Treatment plan: Cleanse with NS, pat dry, apply Santyl to wound bed, cover with bordered gauze dressing, change daily and PRN. Further review of the resident's TAR, showed staff failed to document the treatment as completed for wound care to the unstageable sacrum on 3/12/26 and 3/16/26. Review of the resident's progress note, dated 3/17/26 at 7:00 A.M., showed the resident sent to the hospital for respiratory distress. During an interview on 3/2/26 at 9:49 A.M., Family Member (FM) F said he/she provided the resident a bath on 2/23/26 and noticed the resident had an open area on his/her buttocks, at the crack between his/her buttocks. The area was about the size of a dime. FM F told Assistant Director of Nursing (ADON) B about the resident's skin breakdown. The nurse checked the resident's medical record and said the resident's medical record did not show any documentation the resident had any skin breakdown. On 2/27/26, the resident had a dressing over the area that was dated 2/25/26. FM F removed the dressing and the resident's wound was brown and black and was emanating a horrible odor. During an interview on 3/26/26 at 1:10 P.M., ADON B said FM F did approach him/her and reported the resident had a new wound on his/her buttocks. ADON B referred FM F to the Wound Nurse. He/She looked in the resident's record and found no documentation of a wound. He/She did not go assess the resident and/or document the family member's observation and/or concerns in the resident's medical record. He/She is the ADON for the 200, 300 and 400 halls. He/She did not know which residents had pressure ulcers and/or wounds on his/her units because the wound reports go to the Director of Nursing (DON). He/She was not the charge nurse on the day FM F approached him/her. He/She was just doing rounds on that day. Both nurses that documented the initial observations of the resident's skin breakdown work for a staffing agency. He/She didn't know why the resident's physician was not notified of the wound noted on 2/18/26, when the resident's skin breakdown was first identified. He/She is not responsible for updating resident care plans. He/She did not document FM F's concerns or observations because he/she referred FM F to the Wound Nurse. The Wound Nurse is responsible for documenting anything dealing with wounds. During an interview on 3/26/26 at 1:55 P.M., Wound Nurse C said he/she is the only Wound Nurse at the facility. He/She remembered FM F telling him/her about the resident's skin breakdown. He/She did assess the resident or fill out a Comprehensive Skin Evaluation/Assessment. He/She did not measure or stage the area. He/She wrote an order for the resident to be seen by the specialized wound care management team. He/She did not call the resident's physician or obtain treatment orders. He/She was responsible for weekly wound assessments and daily wound care, Monday through Friday. Weekend nurses were responsible for doing daily treatments and should be assessing all new residents and re-admitted residents. He/She did not do a weekly skin assessment on the resident on 2/17/26. He/She could not remember why the skin assessment was not done. The facility used to have two wound care nurses. It was overwhelming to be the only nurse responsible for wound care and wound documentation. The resident did go from 3/10/26 to 3/24/26 without having a formal skin assessment preformed and documented. The resident did develop the wounds at the facility. Wound Nurse C didn't know why it took two days to initiate the resident's treatment after the order was written. 2. Review of Resident #2's admission MDS, dated [DATE], showed:-Diagnoses included quadriplegia (paralysis affecting all four limbs);-Always incontinent of bowel;-At risk for pressure ulcers;-No pressure ulcers at the time of assessment. Review of the resident's care plan, in use during the time of the investigation, showed:-Focus: Resident is at risk for skin breakdown related to being bedbound and Braden Risk score;-Goal: Will maintain adequate nutrition/hydration to prevent skin breakdown. Will prevent or delay skin breakdown to the extent possible given risk factors;-Interventions: Administer treatment as ordered, apply barrier cream as indicated, check skin during daily care provisions. Review of the resident's hospital Discharge summary, dated [DATE], showed a Registered Dietician assessment, dated 3/9/26, referenced skin/wound, pressure injury to sacrum. Review of the resident's Braden Scale Observation/Assessment, dated 3/10/26, showed a score of 8 (a score of 9 or below means very high risk for pressure ulcers). Review of the resident's medical record, showed no skin assessments documented as completed from 3/9/26 through 3/14/26. Review of the resident's progress note, dated 3/14/26, showed he/she was discharged to the hospital for respiratory distress. No skin evaluation/assessment noted. During an interview on 3/15/26 at 8:45 A.M., Hospital Nurse G said the resident returned to the same hospital from where he/she had been discharged to the facility 3/9/26. He/She returned to the hospital from the facility with a deep tissue injury (a serious form of pressure injury where intense, prolonged pressure damages soft tissue under the skin) to his/her coccyx. Upon admission to the hospital on 3/14/26, the resident was noted to still be wearing the same protective skin dressing the hospital staff had applied prior to the resident's discharge to the facility on 3/9/26. 3. During an interview on 3/26/26 at 3:33 P.M., the Director of Nursing (DON) and Administrator-in-Training said, both Wound Nurse C and ADON B were terminated effective 3/25/26 for poor work performance related to wound care and wound care management. 4. During an interview on 3/26/26 at 2:28 P.M., the facility's Medical Director and primary care physician for both residents said he was not informed of Resident #1's wounds when they were first identified by nursing staff. He was not informed Resident #2 had a dressing on his/her coccyx when he/she was re-admitted to the facility on [DATE]. Nursing staff should absolutely assess every resident from head to toe on admission and/or re-admission. Skin assessments should be completed on a weekly basis, at minimum. The facility has had problems with communication regarding pressure ulcers and wound care. 27912022804303

Based on observation, interview, and record review, the facility failed to ensure proper foot/wound care was performed for one resident (Resident #3) who had a wound to the great toe and a blister to the second toe. The resident's great toe wound became infected. The facility also failed to ensure the resident's second toe blister was documented on the resident's skin assessments. The sample was 10. The census was 95. Review of the facility's foot care policy, dated 10/2022, showed: -Policy statement: Residents receive appropriate care and treatment in order to maintain mobility and foot health; -Policy implementation: Residents are provided with foot care and treatment in accordance with professional standards of practice. Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/31/25, showed: -Diagnoses included: Epilepsy (seizure disorder), history of stroke, cognitive communication deficit, and muscle weakness; -Severe cognitive impairment. Review of the resident's care plan, in use at the time of the investigation, showed: -Focus: Resident is at risk for skin breakdown; -Goal: Resident will be compliant with treatments and intervention measures to prevent skin breakdown; -Interventions: Administer medication as ordered. Administer treatments as ordered, assist to turn and reposition as indicated/tolerated. Review of the resident's comprehensive skin assessments, showed: -Skin assessment, dated 5/23/25, an open area noted on great toe, left foot. Resident denies pain. Wound team notified and they will assess. Second toe blister was not noted on the skin assessment; -Skin assessment, dated 5/30/25, an open area noted on great toe, left foot. Resident denies pain. Wound team notified and they will assess. Second toe blister was not noted on the skin assessment; -No comprehensive skin assessment completed on 5/22/25. Review on 6/3/25, of the resident's Physician's Orders Summary (POS), showed no treatment orders for the resident's left great toe wound or the second toe blister. Review on 6/3/25, of the resident's progress notes, showed: -A late entry note for 5/22/25, created on 6/3/25 by the Director of Nursing (DON), showed upon assessment of patient, it was noted that patient had an area to the top of his/her left great toe. The area was open 0.2 cm (centimeters) by .1 cm without drainage. Physician made aware and gave orders to leave wound open to air and patient not to wear his/her shoes at this time because shoes are too tight. Patient's sister made aware of wound and that shoes need to be replaced. She stated she would work on getting him/her new shoes. Physician wishes for the contracted wound care company to see patient. Wound team updated and to notify the contracted wound care company and get approval for patient to see them; -A note, dated 6/3/25, written by the DON, wound culture (laboratory test to determine if wound is infected) obtained of the resident's left great toe, placed for laboratory to pick up. Review of the resident's skin monitoring shower sheets, showed: -On 5/22/25 the resident received a shower. The resident's great toe wound was noted on the sheet to notify the nurse. The wound on the second toe was not noted; -On 5/26/25 the resident received a bed bath. The resident's great toe wound was noted on the sheet. The wound on the second toe was not noted; -On 5/29/25 the resident received a shower. The resident's great toe wound was noted on the sheet. The wound on the second toe was not noted. Review of the facility's most recent resident wound report, dated 5/27/25, showed the resident and his/her big toe wound and second toe blister were not listed. Observation and interview on 6/3/25 at 10:46 A.M., showed the resident lying in bed awake. The resident's left foot was wrapped with gauze. The wrap was dated 6/3/25. The resident said he/she did not remember what happened to his/her toe. Observation on 6/4/25 at 8:18 A.M., of the resident's left foot, showed: -The great toe had an open wound on the lower left portion of the resident's toenail. The toenail, where the wound was located, was absent. The skin surrounding the wound was reddened. The area surrounding the lower left nail had maroon drainage; -The second toe had an intact blister on the underside of the toe. During observation and interview on 6/3/25 at 11:18 A.M., the resident's sister said she was informed on 5/22/25 that the resident had a new wound on his/her great toe. The DON told her the wound was caused by the resident wearing shoes that were too small. The resident's sister felt that the wound was not caused by the shoe but something else. She was also concerned that the resident's wound was not covered with a treatment once it was discovered on 5/22/25. A picture on the sister's phone, timestamped 5/22/25, of the resident's left foot, showed the resident's great toe had an open wound. The lower left portion of the resident's toenail was absent, and the skin underneath was reddened. The area surrounding the lower left nail had maroon drainage. The resident's second toe had an unopened blister on the bottom side of the toe. She took the picture of the resident's foot after being notified of his/her wound. The DON did not mention the blister on the resident's second toe. During an interview on 6/4/25 at 10:41 A.M., Licensed Practical Nurse (LPN) A said that 5/22/25 was the day where the resident's great toe wound was first noted during the resident's shower. He/She did not know how the wound occurred. He/She was unaware until 6/3/25 that the resident had a blister on his/her second toe. A thorough skin assessment should have been done on 5/22/25 after the resident's great toe injury was observed. During an interview on 6/4/25 at 10:30 A.M., the resident's Physician said he/she was not aware of the resident's great toe wound or the blister on the resident's second toe. The Physician spoke with the nurse practitioner, who was also unaware of the resident's wounds. The Physician was on vacation on and around 5/22/25 and did not give the DON any orders or instructions for the resident's toe wounds. The Physician would have wanted to be made aware of the wounds and would have expected the great toe wound to be covered to prevent infection. During an interview on 6/4/25 at 10:47 A.M., the DON said that the resident's Physician gave an order for the resident's great toe wound on 5/22/25 for the wound to be left uncovered until the wound management company could assess the resident's left great toe. She said the resident's toe wound happened due to the resident's shoes being too tight. She called the physician's exchange and spoke with someone she thought was the resident's Physician, but she couldn't be sure. The resident does not propel himself/herself in his/her wheelchair and requires assistance. The wound on the resident's great toe is infected and the resident is now on antibiotics as of 6/4/25. The resident's great toe wound was not covered but was left open to air. The first day the resident's toe wound was covered/treated was 6/3/25. During an interview on 6/4/25 at 11:26 A.M., the wound management company's wound nurse said 6/3/25 was his/her first appointment with the resident. The resident's left great toe has an infected wound. He/She had to perform debridement (the removal of dead skin and foreign material from a wound) under the toenail where the wound was located. He/She would have expected the wound to be covered to prevent infection. During an interview on 6/4/25 at 1:36 P.M., the DON said she would expect for skin assessments to be complete and accurate. She would have expected staff to do a complete skin assessment of the resident once the resident's great toe wound was noted. The DON expected the resident's second toe blister to be found on the skin assessment completed on 5/23/25. She would have expected the nurse to obtain a treatment order once the resident's great toe wound was discovered. MO00254686

Based on observation, interview and record review, the facility failed to provide a homelike environment when staff failed to provide hot water for bathing and personal care for residents. This affected six out of nine sampled residents (Residents #3, #5, #6, #7, #8 and #9), five of six additional sampled resident rooms, and two of two shower rooms. The census was 92. Review of the facility's Water Temperatures Policy and Procedure, revised 12/2009, showed: -Policy Interpretation and Implementation; -Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of 98 degrees Fahrenheit (F) - 120 degrees F, or the minimum and maximum allowable temperature per state regulations; -Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log; -Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. 1. Observations and measurements of resident room hot water faucet temperatures, after the hot water faucet ran for two minutes, showed the following hot water faucet temperature measurements were recorded: -On 3/5/25 at 9:52 A.M., room [ROOM NUMBER], the hot water faucet temperature measured at 88.9 degrees Fahrenheit (F); -On 3/5/25 at 9:55 A.M., room [ROOM NUMBER], the hot water faucet temperature measured at 92.4 degrees F; -On 3/5/25 at 10:05 A.M., room [ROOM NUMBER] the hot water faucet temperature measured at 92.2 degrees F; -On 3/5/25 at 10:25 A.M., room [ROOM NUMBER] the hot water faucet temperature measured at 84.5 degrees F; -On 3/5/25 at 10:45 A.M., room [ROOM NUMBER] the hot water faucet temperature measured at 95.5 degrees F; -On 3/5/25 at 11:15 A.M., room [ROOM NUMBER] the hot water faucet temperature measured at 84.0 degrees F; -On 3/5/25 at 11:20 A.M., room [ROOM NUMBER] the hot water faucet temperature measured at 85.5 degrees F; -On 3/5/25 at 11:25 A.M., room [ROOM NUMBER] the hot water faucet temperature measured at 77.0 degrees F; -On 3/5/25 at 11:30 A.M., room [ROOM NUMBER] the hot water faucet temperature measured at 86.6 degrees F. 2. Review of Resident #6's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/16/24, showed: -Moderately impaired cognition; -Supervision and set up help required for dressing and personal hygiene; -Diagnoses included bilateral hips osteoarthritis (joint tissue breakdown), right below the knee amputation, transient ischemic attack (TIA, mini stroke), chronic obstruction pulmonary disease (COPD, airflow and lung disease causing restrictive airflow and breathing problems), diabetes and acute kidney failure. During an interview and hot water faucet temperature measurement on 3/6/25 at 8:45 A.M., the water temperature measured at 88.1 degrees F, after the hot water faucet ran for two minutes. The resident said the water in his/her room is too cold. He/She told staff about it two weeks ago and they said they would get back with him/her. He/She hadn't heard anything yet. The resident didn't remember who the staff person was. He/She would like his/her water to be hot all the time. 3. Review of Resident #5's annual MDS, dated [DATE], showed: -Moderately impaired cognition; -Required partial/moderate assistance with activities of daily living (ADLs); -Diagnoses included respiratory failure, right breast cancer, adult failure to thrive, pressure ulcer (area of skin damage that develops when prolonged pressure is applied to a specific part of the body) to sacral area (area at base of spine and above tailbone). During an interview and hot water faucet temperature measurement on 3/6/25 at 8:55 A.M., the water temperature measured at 104.5 degrees F., after the hot water faucet ran for two minutes. The resident said he/she receives bed baths, and the water is too cold. It also takes forever to warm up and at times it doesn't warm up at all. He/She said he/she would like hot water all the time. 4. Review of Resident #7's medical records, showed: -Moderately impaired cognition; -Required moderate to maximum assistance with ADLs; -Diagnoses included osteoarthritis (joint tissue breakdown) of the right knee, diabetes, respiratory failure with hypoxia (lungs do not have enough oxygen), kidney disease, neuropathy (damage nerves causing tingling and numbness, or loss of sensation in the hands, feet, legs or back. During an interview and hot water faucet temperature measurement on 3/6/25 at 9:10 A.M., the water temperature measured at 94.6-degree F., after the hot water faucet ran for two minutes. The resident said he/she moved from a different unit to this room about 5 months ago. The water is always cold in this room and he/she would like it to get hot. 5. Review of Resident #3's annual MDS, dated [DATE] showed: -Cognitively intact; -Required partial/moderate assistance with ADLs; -Diagnoses included muscular dystrophy (genetic disorder that causes weakness and decreased skeletal muscles), right tibia (shin bone) fracture, right ankle fracture, pressure ulcer to sacral area. During an interview and hot water faucet temperature measurement on 3/6/25 at 9:12 A.M., the water temperature measured at 94.6-degree F., after the hot water faucet ran for two minutes. The resident said the water does not warm up. He/She would like the water to be warm and not cold. 6. Review of Resident #8's annual MDS, dated [DATE], showed: -Cognitively intact; -Required partial/moderate assistance with ADLs; -Diagnoses included peripheral vascular disease (PVD, narrowing of veins and arteries decreasing blood flow in the legs), hemiplegia and hemiparesis (paralysis and weakness) following a cerebral infarction (stroke) affecting the right dominant side. Observation and interview on 3/6/25 at 9:16 A.M., showed Certified Nurse Assistant (CNA) A turned the water on hot and left the room. The resident said he/she would like hot water and for it not to take so long to heat up. At 9:19 A.M., CNA A said it takes the water about three minutes to warm up. The hot water measured 82.7 degrees F. CNA A said the water was cold to touch. CNA A said he/she always checks the water temperature by using the back of his/her hand to make sure it was warm enough but not too hot. 7. Review of Resident #9's annual MDS, dated [DATE], showed: -Cognitively intact; -Required set up and clean up assistance with ADLs; -Diagnoses included osteoarthritis (joint tissue breakdown), respiratory failure with hypoxia (difficulty breathing due to lack of oxygen), kidney disease, lymphedema (swelling, stiffness, and pain in the arms and legs), pressure ulcer to right buttock. Observation and interview on 3/6/25 at 9:25 A.M., showed the water temperature measured at 103.8-degree F, after the hot water faucet ran for two minutes. The resident said the water temperature is too cold at times. He/She wanted it to be warm and not take so long to warm up. When he/she gets in the shower in the shower room on unit 200, it runs out of hot water and so he/she had to rinse off with cold water. Observation on 3/6/25 at 10:35 A.M., showed the resident was getting ready to take a shower on unit 200's shower room and said he/she would not get under the water because it is always too cold. 8. Observation on 3/6/25, showed: -9:30 A.M. room [ROOM NUMBER], hot water faucet temperature measured at 94.4 degrees F; -9:50 A.M. shower room on unit 300, hot water faucet in the shower measured at 91.2 degrees F. and the shower tub hot water faucet measured at 84.0 degrees F; -10:27 A.M. shower room on unit 200, hot water faucet in the shower measured at 87.2 degrees F. 9. During an interview on 3/5/25 at 1:46 P.M., Housekeeper B said he/she worked at the facility for about a year and sometimes water takes a bit of time to heat up. Maintenance has been working on it. Housekeeper B had been told to make sure the hot water faucet that is connected to the soap system is turned off after he/she filled the mop buckets, so the hot water doesn't run out. 10. During an interview on 3/6/25 at 10:02 A.M., the Administrator, Housekeeping Supervisor, and Maintenance Supervisor said the hot water faucet temperatures are measured and recorded once a week and they are picked at random, three resident rooms and one shower room. They follow the state guidelines for the hot water temperatures to maintain 105-120-degree F. and they expected this temperature to be reached within two minutes. They said they are aware of hot water issues and have been working on it. A plumber is scheduled to evaluate the hot water issues. They were not aware of how many rooms had low temperatures, including the showers. They agreed the temperatures measured in the resident rooms and shower rooms are not within their policy and procedures guidelines and the low temperatures do not provide a homelike environment to the residents. The Maintenance Director said the last time a plumber came out, he/she was told the issue is coming from the soap dispensing system. The soap system holds constant hot and cold water pressure to the faucet. It is turned on and off at the hose but if housekeeping does not turn the hot water off, it continues to use the hot water to maintain a hot temperature. 11. Review of the Test and Log Hot Water Temperatures, dated 2/28/25, completed by the Maintenance Director, showed four out of 10 hot water temperature measured below 105-degrees F. During an interview on 3/6/25 at 12:10 P.M., the Maintenance Supervisor said when he/she reviews and records the hot water temperatures, he/she only makes sure the hot water is not running too hot. They have had to replace eight water heaters and three mixing valves on the hot water connection in the past year. 12. During an interview on 3/6/25 at 9:40 A.M., the Administrator said he/she does not review the water temperature logs. MO00249964

jw Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards by failing to obtain and administer a resident's medication for rheumatoid arthritis (RA, a chronic autoimmune disease that causes the body's immune system to attack its own tissue resulting in joint inflammation, pain and stiffness), who was on Medicare Part A (While a resident is on Medicare part A, the facility is required to cover the cost of room and board, nursing care, therapy, medical supplies and equipment, medications, transportation and social services at 100 % for the first 20 days, after that there is a co-pay) and failed to follow physician ordered wound treatments for a wound vac (A medical device that uses suction to help wounds heal), and failed to obtain orders for a wet to dry dressing (a type of wound dressing that involves applying a moist gauze to a wound and allowing it to dry) when staff were unable to obtain supplies for the wound vac for one resident (Resident #24). The facility also failed to follow physician's orders for daily wound care treatments for one resident's bilateral (both) lower extremities and left buttock (Resident #87). The sample was five. The census was 77. Review of the facility's Wound Care policy revised October 2010, showed: -Purpose: To provide guidelines for the care of wounds to promote healing; -Preparation: -Verify there is a physician's order for this procedure; -The following information should be recorded in the resident's medical record: -The type of wound care given; -The date and time the wound care was given; -The name and title of the individual performing the wound care; -Any change in the resident's condition; -All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; -Any problems or complaints made by the resident related to the procedure; -If the resident refused the treatment and the reason(s) why; -The signature and title of the person recording the data; -Reporting: -Notify the supervisor if the resident refuses the wound care; -Report other information in accordance with facility policy and professional standards of practice. Review of the facility's Change in a Resident's Condition or Status, revised November 2015, showed: -Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. -Policy Interpretation and Implementation: -The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On -Call Physician when there has been: -A need to alter the resident's medical treatment significantly; -Refusal of treatment or medications (i.e., two (2) or more consecutive times); -Regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident of any changes in his/her medical care or nursing treatments. Review of the facility's policy for Charting and Documentation, revised July 2017, showed: -All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record; -The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care; -Policy Interpretation and Implementation: -The following information is to be documented in the resident medical record: -Medications administered; -Treatments or services performed; -Changes in the resident's condition; -Documentation of procedures and treatments will include care-specific details, including: -The date and time the procedure/treatment was provided; -The name and title of the individual(s) who provided the care; -The assessment data and/or any unusual findings obtained during the procedure/treatment; -How the resident tolerated the procedure/treatment; -Whether the resident refused the procedure/treatment; -Notification of family, physician or other staff, if indicated; and -The signature and title of the individual documenting. Review of the facility's Admissions Policies, revised December 2006, included: -The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility; -Our admission policy applies to all residents admitted to the facility without regard to payment source; -The objective of our admission policies are to: -Admit residents who can be adequately care for by the facility; -Assure that appropriate medical and financial records are provided to the facility prior to or upon the resident's admission; -It shall be the responsibility of the Administrator, through the Admissions Department, to assure that the established admissions policies, as they may apply, are followed by the facility and the resident. 1. Review of Resident #24's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/25/24, showed: -Cognitively intact; -Independent with skills of decision making; -No rejection of care -Range of Motion (ROM) impairment on one side for upper and lower extremity; -Dependent on staff for toileting hygiene, transfers, baths and showers; -Pain present; -No pressure ulcers (injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure or friction); -No venous/arterial ulcers (ulcers caused by decreased blood circulation); -No foot problems; -No other skin problems; -The resident's admission assessment showed wound measurements. So, the MDS is not accurate when it says no other skin problems. -11/24/24, discharge with return anticipated; -12/3/24. Re-entry; -12/9/24, discharge with return anticipated; -12/13/24, re-entry to the facility. Review of the resident's Physician Order Sheets (POS), dated December 13, 2024, showed: -An order dated 12/13/24, for a wound vac to the resident's left lower leg at 125 millimeter (mm) of mercury Hg (a unit of pressure used to measure the suction force applied by the wound vac device) to be changed every Monday, Wednesday and Friday; -No orders for a wet to dry dressing; -An order dated 12/16/24, for Xeljanz ER (used to treat moderate to severe forms of RA when other medications have not worked well. It helps reduce inflammation in the body); 11 milligrams (mg) once daily in the morning; -An order dated 12/17/24, to hold the Xeljanz ER 11 mg. Review of the resident's progress notes, showed: -On 12/13/24 at 3:09 (P.M.), the resident arrived back to the facility. Staff noted a wound to left lower extremity, waiting for wound vac to arrive. No new orders; -On 12/14/24 at 7:17 A.M., wound vac applied to left lower wound. Wound measures 18.5 centimeters (cm) by 9 cm by 0.3 cm; -On 12/17/24 at 3:24 P.M., the Nurse Practitioner, (NP) okayed a hold for Xeljanz; -Staff did not document the wound vac was not available from 12/22/24 through 12/29/24 or that staff applied a wet to dry dressing; -Staff did not document why the resident's Xeljanz was on hold; -Staff did not document any additional wound measurements. Review of the resident's care plan, dated 12/13/24, showed: -The care plan did not address the wound on the resident's left lower leg; -The care plan did not address the use of the wound vac; -The care plan did not address the use of a wet to dry dressing; -The care plan did not address the resident's pain related to RA. Review of the resident's Treatment Administration Record (TAR), for December 2024, showed staff documented the resident's wound vac treatment completed as ordered on 12/16/24, 12/18/24, 12/20/24, 12/23/24, 12/25/24, 12/27/24 and 12/30/24. There was no documentation of a wet to dry dressing. Review of the resident's TAR for January 2025, showed staff documented they provided the wound vac treatment as completed on 1/1/25. During an interview on 1/3/25, at 7:18 A.M., the resident said: -He/She was admitted to the facility on [DATE], for skilled therapy services including wound care; -It took three days before staff applied the wound vac; -The floor nurses did not know how to apply the wound vac and/or where to get the wound vac supplies; -The wound vac was not changed on 12/18/24 12/20/24 or 12/23/24; -On 12/24/24, the alarm on the wound vac pump kept alarming because the collection canister was full; -Staff did not have access to additional collection canisters; -The Nurse working on 12/24/24, took the wound vac dressing off and silenced the alarm; -The Nurse applied a wet to dry dressing to the wound; -The resident's family member came to the facility and did a wet to dry dressing on 12/25-31/24; -On 1/3/25, the Wound Nurse applied a new wound vac. There are no measurements documented so it is unknown if the wound condition deteriorated due to the treatment not being provided as ordered; -Prior to coming to the facility, he/she was taking RA medication, Xeljanz XR, 11 mg once a day; -The facility had the Nurse Practitioner put the medication on hold because it was too expensive; -He/She was having increased pain in his/her hands and knees; -On a scale of 1 to 10, his/her pain level was an 11; -The longer he/she did not get his/her RA medications, the worse the symptoms were becoming and soon the damage would be irreversible; -As far as he/she knew the facility did not substitute any other medication for his/her Xeljanz XR. During a telephone interview on 1/3/25 at 9:33 A.M., the NP said the resident's Xeljanz XR was put on hold due to the cost of the medication. He/She put the resident on Prednisone (short term anti-inflammatory drug) yesterday for increased inflammation and pain. During a telephone interview on 1/3/25 at 10:20 A.M., the resident's Primary Care Physician said the resident's RA medication was on hold due to the cost. It would cost approximately $6,000.00 per month and the facility would be financially responsible for the cost. A resident should not be taken off a long term medication just because they were in a Medicare Part A bed. He would expect the facility to follow physician's orders. Medications and treatments should not be documented as provided if they had not been provided. During an interview on 1/3/25 at 11:43 A.M., Central Supply (CS) I, said he/she ordered general medical supplies. Wound care products were ordered by the Wound Care Nurse and/or the Director of Nursing (DON). He/she did not know anything about who ordered wound vac supplies and/or if enough wound care products were ordered. During a telephone interview on 1/3/25, at 12:17 P.M., Licensed Practical Nurse (LPN) B said on or around 12/23/24, during the day shift, the resident's family member reported the wound vac was alarming. The collection canister was full of bloody drainage. LPN B turned off the wound vac. He/She was unable to find the equipment to replace the collection canister. He/She removed the wound vac dressing and applied a wet to dry dressing. He/She did not contact the resident's physician because he/she thought the resident already had an order for the dressing. He/She thought he/she documented the dressing on the resident's TAR. If the TAR showed he/she documented the wound vac dressing was changed, that documentation was in error. He/She administered a wet to dry dressing. During a telephone interview on 1/3/25 at 1:50 P.M., a representative from the wound vac company said wound vac supplies should be ordered two weeks in advance. The company sent the wound vac supplies out for the resident on 12/12/24. The shipment contained a pump and two dressing change kits. No collection canisters were ordered. On 12/23/24, two dressing kits were ordered, but no collection canisters. On 12/26/24, the facility ordered six dressing kits and three canisters. During a telephone interview on 1/6/25 a 2:02 P.M., the resident's Responsible Party (RP) said the resident was not admitted with the wound vac. He/She had a wound vac on while he/she was in the hospital. When the resident was discharged from the hospital the hospital staff removed the wound vac because the wound vac pump belonged to the hospital. The resident was admitted to the facility with orders for a wound vac. The facility assured the hospital staff they would able to provide a wound vac for the resident when he/she arrived at the facility. The resident was in the facility for three days prior to getting the wound vac applied to his/her wound. On or around 12/23/24, the wound vac stopped working. Staff did not have the skills or equipment to replace the wound vac. The resident went more than a full week without the wound vac. LPN B applied a wet to dry dressing to the resident's lower leg on 12/24/24. When the RP came to visit the resident on 12/25/24, the resident's wound was draining so much bloody fluid, he/she changed the dressing. He/She brought the supplies for a wet to dry dressing and did the dressing change. The RP applied the resident's wet to dry dressing changes until 1/3/25, when staff put another wound vac on the resident. The resident was supposed to be seen at the wound clinic on 12/30/24, but the appointment was canceled. The facility said the resident canceled the appointment, but the resident said he/she did not cancel the appointment. The facility also had the house Physician discontinue the resident's RA medications because it cost too much. The resident kept telling the RP that he/she was in pain and was having decreased function of his/her hands due to not getting the medication. During an interview on 1/3/25 at 2:00 P.M., the administrator and DON did not deny the resident's RA medication was on hold because it was very expensive. The DON said she was not aware, the resident did not have his/her wound vac applied because the wound vac supplies had not been ordered. She was not told the resident was getting a wet to dry dressing applied to his/her would by his/her family member. 2. Review of Resident #87's medical record showed: -Original admitted [DATE]; -A readmitted [DATE]; -Diagnoses included chronic venous hypertension (improper functioning of the vein valves of the leg causing swelling and skin changes), with ulcer and inflammation (swelling) of both lower extremities, non-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecified severity. Review of the resident's admission MDS, dated [DATE], showed: -No cognitive impairment; -No Rejection of care; -Required partial assistance with sit to stand, toileting hygiene, showers, lower body dressing; -No diagnosis of peripheral/arterial vascular disease (narrow blood vessels reduce blood flow to the limbs); -No pressure ulcers. Review of the resident's physician orders dated 12/16/24, showed: -An order, for left lateral foot: Apply betadine (an antiseptic product to treat infections) daily; -An order for posterior (back of) thigh (does not specify which thigh): clean, apply collagen (protein used to treat wounds) and calcium alginate (dressing that promotes wound healing) and cover with a boarder dressing (self-adherent a sterile, foam dressing), once a day and as needed (PRN); -An order for right posterior leg: Foam cleanser, triad cream (a zinc-based wound dressing paste that aids with healing); -An order for left posterior leg: Foam cleaner, Ca-alginate, wrap with rolled gauze (stretchy gauze like material that clings to itself use to wrap around a wound or injury) and Ace wraps (brand of elastic bandage that is used to provide support and compression) once daily and PRN; -An order for left medial (facing towards the body) leg: Foam cleanser, triad cream, collagen, gauze wrap and Ace wraps once daily and PRN. Review of the resident's care plan, revised on 12/17/24, showed: -Focus: Resident has impaired skin, present on admission as evidenced by bilateral lower extremity lymphedema (condition that causes swelling in both legs); -Goal: Integrity will be managed daily until resolution without evidence of severe complications; -Interventions: Check skin daily, educate on avoiding skin injuries, handle gently during activities of daily living (ADLs), keep skin dry to the extent possible, resident is only allowing Wound Care Nurse to complete treatments and is taking off Coban dressing (A self-adhering bandage or wrap that sticks to itself but does not adhere well to other surfaces) at his/her own will; -Focus: Resident has bilateral lower extremity lymphedema wounds that are being followed by the Wound Physician; -Goal: Resident will be without complications related to wounds; -Interventions: If complications arise, report to physician for new orders if applicable. Review of the resident's TAR dated 12/31/24 and 1/1/25, showed staff documented the resident's treatments completed as ordered. Observation and interview on 1/2/25, at 11:46 A.M., showed the resident sat on the edge of his/her bed. A dressing on his/her left outer foot was dated 12/30/24. The resident said staff had not changed any of his/her wound dressings since 12/30/24. The Wound Physician quit and no longer worked for the facility. The Wound Nurse had been off sick. Staff had not changed the dressing as of 1/2/24 at 11:46 A.M., because the facility did not have the needed wound supplies. Review of the resident's TAR on 1/3/24, at 12:00 P.M., showed staff documented the resident refused his/her treatment. Observation and interview on 1/3/24 at 1:30 P.M., showed the resident sat on the edge of his/her bed. The resident said he/she refused to have his/her dressings changed this morning. The dressing on his/her left lower leg was dated 1/3/24. During an interview on 1/3/25 at 2:00 P.M., the Administrator and DON said it was not acceptable to document a treatment was provided when it had not. All wound treatments should have orders. They would expect the Nurse on duty to notify the Physician if a treatment or medication was not available. MO00247046 MO00247270 MO00247391 34477

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure resident rooms (Resident #87, #25 and #64) were free from gnats (small, two winged fly that resembles a mosquito). This failure had the potential to affect all residents. The sample was five. The census was 77. Review of the facility's pest control policy dated May 2008, showed: Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: -The facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents; -Pest control services are provided by the facility's vendor; -Windows are screened at all times; -Maintenance services assist when appropriate and necessary in providing pest control services. 1. Review of Resident #87's, admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/25/24, showed: -Cognitively intact; -Independent with skills of decision making; -No rejection of care. Observations and interview on 1/2/25, at 11:15 A.M., and 1:40 P.M., showed the resident sat on the bed in his/her room. The resident had food and drinks on his/her over the bed table. His/Her trash can was full of trash, old food and cups of juice. The room was swarming with gnats. 20-30 gnats were noted in the resident's trash can and flying throughout the room. Gnats were landing on the resident's over the bed table landing on the resident's meal tray and in the resident's glass of juice. The resident had removed his/her wound dressings from his/her lower legs and gnats were landing on the resident's open wounds. The resident said the gnats have been an ongoing problem for some time. He/she has to cover everything to prevent gnat from landing and dying on his/her food. During an interview on 1/2/25 at 1:40 P.M., the Director of Nursing said she was unaware of the gnats in the resident's room. Observations and interview on 1/3/25 at 6:38 A.M., 7:13 A.M., 12:48 P.M., and 2:20 P.M., showed the resident's room still had a swarm of gnats flying around her table, trash can and his/her face and body. The resident said, staff had put a cup of vinegar in her room this morning, but nursing staff threw it away. 2. Review of Resident #25's quarterly MDS, dated [DATE], showed: -Cognition not assessed; -Self-care not assessed; -Diagnoses included cancer and palliative care (a medical approach that focuses on improving the quality of life for people with serious illnesses). Observation and interview on 1/2/25 at 11:28 A.M. and 1:19 P.M., and 1/3/25 at 8:15 A.M., showed the resident lay in bed with gnats flying all over his/her room. The resident said the gnats have been in his/her room for a long time. The resident said he/she has to cover all his/her food and drinks because of the gnats. No one had been in the resident's room to treat for gnats. 3. Review of Resident # 64's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Required substantial/maximum assistance with toileting and showering; -Diagnoses included high blood pressure, diabetes and dementia. Observation of the resident's room on 1/3/25 at 8:09 A.M., showed several gnats flying near the door to the bathroom. The floor was sticky. 4. During an interview on 1/3/25 at 6:44 A.M., the Maintenance Director said he was aware some rooms had gnats. The residents in those rooms had food and juice in their rooms. If a problem was reported to him, he would contact the pest control company and have them come address the issue. He had treated the drains for gnats, but they were still around. 5. During an interview on 1/3/25 at 9:56 A.M., a representative with the pest control vendor said they were last in the facility on 12/11/24. At that time, the kitchen was treated for gnats. The drains needed to be cleaned in order to alleviate the issue. They were contacted today to come out to the facility to treat for gnats in specific resident rooms. 6. During an interview on 1/3/25 at 2:00 P.M., the Administrator said he was not aware of the gnats in the residents' rooms. The Director of Nursing said she only became aware of the gnats when she was assisting with skin assessments and wound care yesterday. 34477 -

Based on observation, interview and record review, the facility failed to ensure resident records were complete and accurately documented when staff documented treatments were provided when they were not (Residents #24, #87 and #13). The sample was 5. The census was 77. Review of the facility's Wound Care policy revised October 2010, showed: -Purpose: To provide guidelines for the care of wounds to promote healing; -Preparation: -Verify there is a physician's order for this procedure; -Any problems or complaints made by the resident related to the procedure; -If the resident refused the treatment and the reason(s) why; -The signature and title of the person recording the data; -Reporting: -Notify the supervisor if the resident refuses the wound care; -Report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #24's, quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/25/24, showed: -Cognitively intact; -Independent with skills of decision making; -No rejection of care. Review of the resident's Physician Order Sheets (POS), dated December 13, 2024, showed: -An order dated, 12/13/24 for a wound vac (A medical device that uses suction to help wounds heal) to the resident's left lower leg at 125 millimeter (mm) of mercury Hg (a unit of pressure used to measure the suction force applied by the wound vac device) to be changed every Monday, Wednesday and Friday; -No orders for a wet to dry dressing. Review of the resident's progress notes, showed: -On 12/13/24 at 3:09 P.M., the resident arrived back to the facility. Staff noted a wound to left lower extremity, waiting for wound vac to arrive. No new orders; -On 12/14/24 at 7:17 A.M., wound vac applied to left lower wound. Wound measures 18.5 centimeters (cm) by 9 cm by 0.3 cm.; -No documentation the wound vac was not available on 12/20/24, 12/23/24, 12/25/24, 12/27/24, 12/30/24 or 1/1/25; -Staff did not document the application of a wet to dry dressing (a type of wound dressing that involves applying a moist gauze to a wound and allowing it to dry). Review of the resident's Treatment Administration Record (TAR), for December 2024, showed staff documented the resident's wound vac treatment completed as ordered on 12/20/24, 12/23/24, 12/25/24, 12/27/24 and 12/30/24. There was no documentation of a wet to dry dressing. Review of the resident's TAR for January 2025, showed staff documented they provided the wound vac treatment on 1/1/25. During an interview on 1/3/25, at 7:18 A.M., the resident said: -He/She was admitted to the facility on [DATE], for skilled therapy services including wound care; -The wound vac was applied to the wound by the treatment Nurse on 12/16/24. It took three days before staff applied the wound vac; -The floor Nurses did not know how to apply the wound vac and/or where to get the wound vac supplies; -The wound vac was not changed on 12/20/24 or 12/23/24; -On 12/24/24, the alarm on the wound vac pump kept alarming because the collection canister was full; -Staff did not have access to additional collection canisters; -The Nurse working on 12/24/24, took the wound vac dressing off and silenced the alarm; -The Nurse applied a wet to dry dressing to the wound; -The resident's family member came to the facility and did a wet to dry dressing on 12/25-31/24; -On 1/3/25, the wound Nurse applied a new wound vac; During a telephone interview on 1/3/25 at 10:20 A.M., the resident's Primary Care Physician said he would expect the facility to follow physician's orders. Medications and treatments should not be documented as provided if they had not been provided. During an interview on 1/3/25 at 11:43 A.M., Central Supply (CS) I, said he/she orders general medical supplies. Wound care products are ordered by the wound care Nurse and/or the Director of Nursing (DON). During a telephone interview on 1/3/25, at 12:17 P.M., Licensed Practical Nurse (LPN) B said, on or around 12/23/24, during the day shift, the resident's family member reported the wound vac was alarming. The collection canister was full of bloody drainage. LPN B turned off the wound vac. He/She was unable to find the equipment to replace the collection canister. He/She removed the wound vac dressing and applied a wet to dry dressing. He/She did not contact the resident's physician because he/she thought the resident already had and order for a wet to dry dressing. He/She thought she documented the wet to dry dressing in on the resident's TAR. If the TAR showed he/she documented the wound vac dressing was changed, that documentation was in error. He/she administered a wet to dry dressing. During a telephone interview on 1/3/25 at 1:50 P.M., a representative from the wound vac company said, wound vac supplies should be ordered two weeks in advance. Wound vac supplies were sent out for Resident #24 on 12/12/24. The shipment contained a pump and two dressing change kits. No collection canisters were ordered. On 12/23/24, two dressing kits were ordered, but no collection canisters. On 12/26/24, the facility ordered six dressing kits and three canisters. During a telephone interview on 1/6/25, the resident's Responsible Party (RP) said, the resident was not admitted with the wound vac. He/She had the wound vac on while he/she was in the hospital. When the resident was discharged from the hospital, hospital staff removed the wound vac because the wound vac pump belonged to the hospital. The resident was admitted to the facility with orders for a wound vac. The facility had assured the hospital staff they would be able to provide a wound vac for the resident when she/she arrived at the facility. The resident was in the facility for three days prior to getting the wound vac applied to his/her wound. On or around 12/23/24, the wound vac stopped working. Staff did not have the skills or equipment to replace the wound vac. The resident had gone more than a full week without the wound vac. LPN B, did apply a wet to dry dressing on 12/24/24, to the resident's lower leg. When the RP came to visit the resident on 12/25/24, the resident's wound was draining so much bloody fluid, he/she changed the dressing. He/she brought the supplies for a wet to dry dressing and did the dressing change. The RP did the resident's wet to dry dressing change until 1/3/25, when staff put another wound vac on the resident. 2. Review of Resident #87's medical record showed: -Original admitted [DATE]; -A readmitted [DATE]; -Diagnoses included chronic venous hypertension (improper functioning of the vein valves of the leg causing swelling and skin changes), with ulcer and inflammation (swelling) of both lower extremities, non-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecified severity. Review of the resident's admission MDS, dated [DATE], showed: -No cognitive impairment; -No Rejection of care: No behaviors exhibited. Review of the resident's POS, showed on 12/16/24: -A order, for left lateral foot: Apply betadine (An antiseptic product to treat infections) daily; -A order for, posterior (back of) thigh (does not specify which thigh): clean, apply collagen (protein used to treat wounds) and calcium alginate (dressing that promotes wound healing) and cover with a boarder dressing (self-adherent a sterile, foam dressing), once a day and as needed (PRN); -An order for right posterior leg: Foam cleanser, triad cream (a zinc-based wound dressing paste) to aid with healing; -An order for, left posterior leg. Foam cleaner, Ca-alginate, wrap with rolled gauze (stretchy gauze like material that clings to itself use to wrap around a wound or injury) and Ace wraps (brand of elastic bandage that is used to provide support and compression) once daily and PRN; -An order for left medial (facing towards the body) leg. Foam cleanser, triad cream, collagen, gauze wrap and ace wraps once daily and PRN. Review of the resident's TAR dated 12/31/24 and 1/1/25, showed staff documented the resident's treatments completed as ordered. During observation and interview on 1/2/24, at 11:46 A.M., the resident sat on the edge of his/her bed. A dressing on his/her left outer foot, dated 12/30/24. The resident said staff had not changed any of his/her wound dressings since 12/30/24. The Wound Physician had quit and no longer worked for the facility. The wound Nurse had been off sick. Staff had not changed the dressing as of 1/2/24 at 11:46 A.M., because the facility did not have the needed wound supplies. Review of the resident's TAR on 1/3/24, at 12:00 P.M., showed staff documented the resident refused his/her treatment. Observation on 1/3/24 at 1:30 P.M., showed the resident sat on the edge of his/her bed. The dressing on his/her left lower leg was dated 1/3/24. 3. Review of Resident #13's admission MDS, dated [DATE], showed: -No cognitive impairment; -No rejection of care: No behaviors exhibited. Review of the resident's physician orders, showed an order, dated 12/17/24 to wrap leg daily with tubigrip (A tubular bandage that provides and compression) or ace wrap in the morning for swelling. Review of the resident's 1/25 TAR showed staff initialed the resident's wraps had been applied as ordered on 1/2/25. Observations of the resident on 1/2/25 from 11:59 A.M. to 2:45 P.M., showed the resident in his/her room. The resident's legs were not wrapped. The resident's legs appeared to be swollen. The resident's socks appeared to be too tight around the resident's ankles due to the swelling. During an interview on 1/3/25 at 9:20 A.M., Certified Medication Technician (CMT) A said Nurses or therapy applied wraps to residents' legs. During an interview on 1/3/25 at 12:51 P.M. the resident's Nurse Practitioner (NP) said the resident was not always compliant with wearing wraps. He/She would be compliant for days and then refuse. The NP did not know why the resident would sometimes refuse. She was not sure the resident was always alert and oriented, especially if the resident did not have on oxygen. Due to this, the NP was not sure the resident always understood the potential consequences of refusing to wear the leg wraps. It was very important for the resident to wear the wraps due to having CHF. The resident had been hospitalized a few times recently due to exacerbation of CHF. It could be very bad if the resident's legs became really swollen and began leaking fluid. It could be difficult to heal. During an interview on 1/3/25 at 2:00 P.M., the Administrator and DON said it is not acceptable to document a treatment as provided when it was not provided. All wound treatments should have orders. They would expect the Nurse on duty to notify the physician if a treatment or medication was not available. 34477

TN: See edit below in red Based on observation, interview and record review, the facility failed to ensure two residents, who were incontinent of bladder, received the necessary services to maintain good personal hygiene when staff failed to check or clean one resident who was bed bound (Resident #25) and left one resident in his/her wheelchair surrounded by a large puddle of urine (Resident #64). In addition, staff failed to provide showers at least twice weekly for both residents. Review of the facility's Activities of Daily Living (ADL), Supporting policy, last revised in March 2018, showed: -Resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: -Hygiene (bathing, dressing, grooming and oral care) -Elimination (toileting); -If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching in a different way or at a different time, or having another staff member speak with the resident may be appropriate. Review of the facility's Bath, Shower/Tub policy, revised 2/2018, included: -The purpose of this procedure are to promote cleanliness, provide comfort to the resident and observed the condition of the resident's skin; -Documentation: -The date and time the shower/tub bath was performed; -If the resident refused the shower/tub bath, the reason(s); -Reporting: Notify the supervisor if the resident refuses the shower/tub bath. 1. Review of Resident #25's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/20/24, showed: -Cognition not assessed; -Rejection of care: Behavior not exhibited; -Self-care not assessed; -Frequently incontinent of urine; -Occasionally incontinent of bowel; -Diagnoses included cancer and palliative care (a medical approach that focuses on improving the quality of life for people with serious illnesses); -Resident has a condition or chronic disease that may result in a life expectancy of less than six months: Yes. Review of the resident's physician order sheet, showed an order dated 8/20/24 to admit to hospice care. Review of the resident's care plan, last revised on 12/16/24, showed: -Focus: Resident often refuses medications, ADLs and other cares; -Goal: Resident will be without complications related to refusal of medications and cares; -Interventions included: Continue to offer cares and medications; -Staff did not address the resident's refusal to take showers or baths or any preferences related to bathing; -Staff did not address the resident's incontinence and amount of assistance needed or related interventions. Observation on 1/2/25 at 1:19 P.M., showed the Director of Nursing (DON) rolled the resident onto his/her left side for a skin assessment. The resident's brief was saturated with urine and the pad under the resident was saturated with urine and feces. The DON provided peri-care. During an interview on 1/2/25 at 1:19 P.M., the resident said the last time someone changed him/her was around 7:30 A.M. Staff changed him/her one time a day. The resident would get soaked and the pad underneath him/her would also get soaked. Observations and interviews on 1/3/25, showed: -At 6:30 A.M., the resident lay in bed. The resident said he/she was changed a couple of hours ago. The pad under the resident was dry; -At 10:18 A.M. and 10:25 A.M., the resident lay in bed. The resident said he/she was not comfortable. He/She said he/she smelled and was having a bowel movement now. No one had cleaned the resident since early that morning. The pad under the resident was the same one observed at 6:30 A.M. The resident wanted to be changed and turned. Review of the 100 Hall's shower book, showed: -The resident was scheduled to receive showers on Wednesday and Saturday evenings; -One shower sheet for December 2024, dated 12/18/24, was completed by hospice; -No other documentation to show the resident was offered or refused any other showers for the month of December 2024 or January 2025; Review of the resident's hospice binder, showed: -Hospice/Long Term Care Coordinated task plan of care; -Health Aide visits: Wednesdays and Saturdays; -12/18/24, bath given; -No other documentation to show if the resident was offered or refused a shower or bath for December 2024; -1/2/25, refused bath from Aide. Review of the resident's progress notes, from October 2024 through January 2025, showed: -On 1/2/25 at 7:30 P.M., Hospice Aide was here today to give resident a shower and resident refused the shower. Hospice Nurse made aware; -No other documentation the resident refused showers. During an interview on 1/2/25 at 11:28 A.M. and 1:19 P.M., the resident said he/she wanted a shower, but only by female staff. The resident had not had a bath or shower for over a week. During interviews on 1/3/25, at 10:18 A.M. and 10:25 A.M., the resident said he/she had just called the hospice company to ask about getting a bath. He/She hadn't had one in two weeks. He/She smelled and the room smelled. It was disgusting. During an interview on 1/3/25 at 10:37 A.M., Certified Nurse Aide (CNA) H said the resident refused to take a shower yesterday. Staff had to do care in pairs because the resident had accused them of stealing and touching him/her inappropriately in the past. There are usually three CNAs assigned to the hall who do their own showers. Or, the shower aide, who worked Monday through Friday, did all of the resident showers. TN: delete red, please. During an interview on 1/3/25 at 11:17 A.M., the DON said the resident was a heavy wetter. The resident had been checked on prior to the DON completing the skin assessment on 1/2/25. While the she was trying to clean the resident, the resident was actively urinating. If a resident was wet, staff should provide care and clean them. Residents should receive showers at least twice weekly. If a resident refused showers, it should be documented on the resident's care plan. The DON said her guess was that facility staff were offering the resident showers on the same days hospice was supposed to provide showers. However, the showers provided by hospice should be in addition to the showers being provided by staff. Failure to provide incontinence care or showers could be a dignity issue. 2. Review of Resident # 64's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Rejection of care: Behavior not exhibited; -Required substantial/maximum assistance with toileting and showering; -Always incontinent of bowel and bladder; -Diagnoses included high blood pressure, diabetes and dementia. Review of the resident's care plan, in use during the survey, showed: -Focus: Resident has history of resisting care related to adjustment to nursing home (last revised 8/6/23); -Goal: Resident will cooperate with care and adjust to new environment; -Interventions included: Allow resident to make decisions about treatment regime, to provide sense of control, provide care based on resident preferences; -Focus: Resident is at risk for injury related to fall as he/she is on psychotropic medications (A class of drugs that treat mental illnesses by altering the chemical makeup of the brain and nervous system), history of falls prior to admission and poor safety awareness (last revised on 6/8/23); -Goal: Resident will not have any major injuries with falls; -Interventions included: Call light within reach and answered promptly, environmental evaluation to assess for safety, keep environment/room tidy and keep pathways clear, up ad lib without assistive device; -Focus: Resident is incontinent of bowel and bladder (date initiated 1/17/24); -Goal: Resident to remain free of skin breakdown related to incontinence; -Interventions included: Alert medical doctor of ongoing issues related to incontinence, encourage resident to use the restroom/call for help to use the restroom every four hours and as needed. Resident often refuses help to use the restroom and declines to be taken when he/she is visibly soiled. Continue to educate the resident on the importance of incontinence management; -The care plan did not address the resident's shower/bathing preferences. Review of the 100 Hall shower book, showed: -The resident was scheduled to for showers on Tuesday and Friday evenings; -For the month of December 2024, the resident had completed shower sheets for 12/6, 12/19 and 12/27/24; -No documentation to show the resident refused any showers/baths. During an interview on 1/3/25 at 10:37 A.M., CNA H said the resident did not refuse showers. Observation on 1/2/25, showed: -At 11:44 A.M. Physical Therapist (PT) L entered the resident's room. The resident sat in his/her wheelchair next to his/her bed. The resident had his/her legs propped up on the bed to the left of the wheelchair. The PT asked the resident if he/she had had an accident because the floor behind the resident looked wet. PT L told the resident he/she needed to be cleaned up and asked the resident to put on his/her call light. The resident said the call light did not work. PT L said he/she would tell staff and come back later. PT L then left the room; -At 2:09 P.M., the resident remained in his/her room in his/her wheelchair in the same location. A large wet puddle was observed behind the resident's wheelchair and underneath his/her wheelchair. The floor was sticky and there were visible dried yellow areas at the edges of the puddle. The resident said there was not much he/she could do due to being diabetic and in a wheelchair; -During an interview at 2:25 P.M., Registered Nurse (RN) M said the resident was able to voice his/her needs. The resident needed assistance to use the bathroom. Staff should check on the resident at least every two hours; -At 2:30 P.M., RN M went with the surveyor into the resident's room. RN M turned the light on and saw the puddle under and behind the resident. The resident confirmed the puddle was urine and said no one had been in to assist him/her with going to the bathroom. The resident said this happened all the time and he/she was not happy about it. RN M said he/she would have staff help clean up the resident and left the room. RN M returned moments later with two CNAs who said they would clean up the resident. RN M said he/she would have housekeeping clean the resident's floor. During an interview on 1/2/25 at 2:38 P.M., PT L said he/she told someone in housekeeping or maintenance about the puddle under the resident. He/She could not remember exactly who was told. PT L said he/she went back to the resident's room later and the puddle was cleaned up. A coworker had spoken with the resident about the appropriate places to go to the bathroom. This type of incident had been happening more frequently. He/She was not sure if this was a behavior or if the resident had a cognitive decline. During an interview on 1/2/25 at 2:40 P.M., CNA H said he/she was assigned to the resident and just helped clean up the resident. CNA H said the resident's brief was dry. The resident had a tendency to pull down his/her pants and urinate. This had been happening for at least a year. Staff are supposed to check on residents at least every two hours. Review of the resident's medical record showed no documentation regarding the resident urinating on the floor. During an interview on 1/3/25 at 11:17 A.M., the DON said residents should receive showers at least twice a week. If they frequently refused, it should be documented and included on their care plan. She was not aware staff said the resident would urinate on the floor. This should have been documented in the resident's medical record. If staff were made aware a resident was wet or there was urine on the floor, she would expect them to address it immediately. -

Based on observation, interview and record review, the facility failed to ensure services were provided to meet professional standards of practice and per the resident's plan of care when staff failed to apply wraps to Resident #13's legs, per physician orders. The sample was size was five. The census was 77. Review of the facility's Wound Care policy revised October 2010, showed: -Purpose: To provide guidelines for the care of wounds to promote healing; -Preparation: -Verify there is a physician's order for this procedure; -Any problems or complaints made by the resident related to the procedure; -If the resident refused the treatment and the reason(s) why; -The signature and title of the person recording the data; -Reporting: -Notify the supervisor if the resident refuses the wound care; -Report other information in accordance with facility policy and professional standards of practice. Review of Resident #13's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 12/17/24, showed: -No cognitive impairment; -Rejection of care: No behaviors exhibited; -Required partial assistance with lying to sitting and sitting to standing; -Required maximal assistance with putting on and taking off footwear and dressing his/her lower body; -Diagnoses included congestive heart failure (CHF, a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs. Symptoms include swelling in the legs), diabetes, high blood pressure and chronic obstructive pulmonary disease (COPD, a lung disease that damages the airways and makes it hard to breathe). Review of the resident's physician orders, showed an order, dated 12/17/24 to wrap leg daily with tubigrip or ace wrap in the morning for swelling. Review of the resident's care plan, in use during the survey, showed: -Staff did not address the resident's need for leg wraps; -Staff did not address any behaviors related to the resident's plan of care. Review of the resident's January 2025 medication administration record (MAR), showed staff initialed the resident's wraps had been applied as ordered on 1/2/25. Observations of the resident on 1/2/25 from 11:59 A.M. to 2:45 P.M., showed the resident in his/her room. The resident's legs were not wrapped. The resident's legs appeared to be swollen. The resident's socks appeared to be too tight around the resident's ankles due to the swelling. During an interview on 1/3/25 at 9:20 A.M., Certified Medication Technician (CMT) A said nurses or therapy applied wraps to residents' legs. During an interview on 1/3/25 at 12:51 P.M. the resident's Nurse Practitioner (NP) said the resident was not always compliant with wearing wraps. He/She would be compliant for days and then refuse. The NP did not know why the resident would sometimes refuse. She was not sure the resident was always alert and oriented, especially if the resident did not have on oxygen. Due to this, the NP was not sure the resident always understood the potential consequences of refusing to wear the leg wraps. It was very important for the resident to wear the wraps due to having CHF. The resident had been hospitalized a few times recently due to exacerbation of CHF. It could be very bad if the resident's legs became really swollen and began leaking fluid. It could be difficult to heal. During an interview on 1/3/25 at 2:00 P.M., the Director of Nursing (DON) said staff should not document a treatment was done if it had not been done. Staff should document if and when a resident refused their treatment. MO00247391 -

See deficiency cited at event id #ISJ412 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 10/21/24. Based on observation, interview and record review, the facility failed to ensure call lights were in working order, including visible notification at the nurses station for four of 23 sampled residents (Residents #32, #46, #64, and #60). The census was 89. Review of the facility's Call System, Residents policy, revised September 2022, showed: -Policy Statement: Residents are provided with a means to call staff for assistance through communication systems that directly calls a staff member or a centralized work station; -Policy Interpretation and Implementation; -Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor; -The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional; -The resident call system is routinely maintained and tested by the maintenance department. 1. Review of Resident #32's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/7/24, showed: -Cognitively intact; -No behaviors. During an interview on 12/11/24 at 1:08 A.M., the resident said he/she had not had a functional call light for a month. The facility staff were aware and it had not been fixed. The facility provided a bell, but staff would not answer the bell. Observation and interview on 12/11/24 at 1:43 P.M., showed the resident's call light did not stay on when pressed. The lights from the wall and from the hall turned on for approximately two seconds. There was no audible sound. The resident said the facility wanted to move him/her to a different room, but he/she refused due to being in the same room for six years. He/She did not want to move or change anything in his/her home. 2. Review of Resident #46's quarterly MDS, dated [DATE], showed: -Mild cognitive impairment; -Rejection of care occurred four to six out of seven days. Observation and interview on 12/9/24 at 9:00 A.M., showed the resident lay in bed. He/She said when the call light was pressed the light would not stay on. The resident pressed the call light. The light in the room lit up red and stayed on for a few seconds then the light went off. The light did not light up in the hallway. Observation and interview on 12/9/24 at 11:45 A.M., showed the resident lay in bed. Certified Nurse Aide (CNA) E was in the room, trying to turn the resident's television on. The resident pressed the call light inside the room, which turned red then went off. CNA E said he/she was not aware the call light was not working. During an interview on 12/9/24 at approximately 1:00 P.M., the Director of Nursing (DON) said Resident #46 and Resident #64 were being moved to another room. Observation and interview on 12/11/24 at 12:20 P.M., showed the resident lay in bed in the same room. The resident said the facility said they would move him/her today, but he/she did not know if he/she was going to move or not. Maintenance Worker D was in the room working on the call lights. He/She said the call lights were not working. The problem was the call light cords were pulled out of the wall and they needed to be rewired. Observation on 12/12/24 at 2:56 P.M., showed the resident pushed his/her call light, which did not light up. 3. Review of Resident #64's quarterly MDS, dated [DATE], showed: -Mild cognitive impairment; -No behaviors; -Required maximal assistance for toileting; -Required supervision for personal hygiene. Observation and interview on 12/9/24 at 11:45 A.M., showed CNA E pressed the resident's call light and it did not light up inside the room. Then he/she checked the call light in the hall and said the light did not light up. CNA E said if the resident needed anything, he/she would have to catch staff as they walked by the room. They needed maintenance to fix it. During an interview on 12/12/24 at 2:56 P.M., the resident sat in his/her chair in his/her room. The resident said maintenance was working on the call light the day before yesterday, but he/she did not know if the call light was working or not. 4. Review of Resident #60's care plan, revised 10/15/24 and in use during the time of the survey, showed: -Focus: The resident is at risk for fall with or without injury related to altered balance while standing and/or walking and altered mental status; -Goal: Will minimize risk for falls to extent possible; -Interventions: Provide verbal reminders/cues to ask for assistance as needed. Observation on 12/12/24 at 3:00 P.M., showed the resident was in his/her room with a bell within reach. The call light was plugged into the wall, but the cord was cut just before where the cord was inserted into the wall. The resident said his/her call light had not worked for a little while. If he/she needed something he/she would use his/her roommate's call light. Or he/she would walk out into the hall and tell staff himself/herself. 5. During an interview on 12/12/24 at 11:20 A.M., Licensed Practical Nurse (LPN) F said he/she was aware of only one resident's room with a call light which was not working. The resident was given a bell. During an interview on 12/12/24 at 3:05 P.M., Certified Medication Technician (CMT) G said he/she was not aware of any rooms where the call lights were not working. If he/she saw a room where the call light did not work, he/she would tell the supervisor. During an interview on 12/12/24 at 3:10 P.M., CNA H, said he/she just saw Resident #46's and Resident # 32's call lights were not working. He/She was aware that some of the rooms' call lights were not working, and those residents were given a bell. During an interview on 12/12/24 at 10:10 A.M., the Maintenance Director said currently there were 10 call lights that did not work. The call lights were wrapped around the bed rail and when the beds were moved, the cords were getting ripped out of the wall. This resulted in the call lights needing to be rewired and replaced. A bell was the only alternative the facility had for rooms where the call lights were not working. The facility ordered 20 call lights a couple of months ago, but they have not come in yet. During an interview on 12/12/24 at 3:15 P.M., the DON said Resident #32 was offered to move to another room, but he/she refused. Maintenance had been working on the call lights in Resident #46's and Resident #64's room. The residents were moved earlier this week, but they wanted to move back. The DON would expect all call lights to be working. MO00245656 MO00244495 MO00246314

See the SOD cited at F602, Event ID# ISJ412 Based on observation, interview and record review, the facility failed to prevent the diversion (the unauthorized removal) of Schedule II controlled medications (medication with higher potential of dependency and abuse) for one resident (Resident #194). The census was 89. The Director of Nursing (DON) was notified on 12/13/24, of the past non-compliance which began and ended on 11/12/24. The facility began an investigation, interviewed staff and the pharmacy delivery person, performed medication carts review on each hall, notified the police, in-serviced staff on abuse and misappropriation of resident property (including drug diversion), and terminated Licensed Practical Nurse (LPN) A. Review of the facility's Identifying Exploitation, Theft and Misappropriation of Resident Property Policy, revised April 2021, showed: -Policy Statement: As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to recognize exploitation of residents and misappropriation of resident property; -Policy Interpretation and Implementation: -Exploitation, theft and misappropriation of resident property are strictly prohibited; -It is understood by the leadership in this facility that preventing these occurrences requires staff education and training; -Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent; -Examples of misappropriation of resident property include: -Identity theft; -Theft of money from bank accounts; -Unauthorized or coerced purchases on the resident's credit card; -Coercion to provide gifts in exchange for ongoing care; -Manipulating the resident into providing monetary support or assistance; -Drug diversion (taking the resident's medication); and -Theft of personal belongings; -Staff and providers are expected to report suspected exploitation, theft or misappropriation of resident property; -The QAPI committee reviews and creates plans of action to address quality deficiencies that may lead to exploitation, theft or misappropriation of resident property. Review of the facility's investigation, showed: -Date and Time of Alleged Incident: 11/12/24 at 7:30 A.M.; -Summary of Alleged Incident, showed drug diversion identified on the morning of 11/12/24 on 200 hall unit, and was committed by night shift LPN A. He/She was terminated. Review of the Police Department report, dated 11/12/24 at 5:16 P.M., showed: -Reporter: Former Administrator; -Incident Code: Felsteal: Felony Stealing -Offense: Stealing - controlled substance from building; -LPN A was identified in the report; -Resident #194 was identified as the victim; -Witness: LPN B and Former Administrator. Review of the video footage sent by the facility, showed a staff, LPN A, retrieved a medication card from a medication cart. He/She appeared to be taking some medication and placed the medication card in a backpack which was on the desk at the nurse station. Review of Resident #194's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/9/24, showed: -Cognitively intact; -No impairment to upper and lower extremities; -Diagnoses included heart disease, kidney disease, septicemia (blood poisoning), and COPD (chronic obstructive pulmonary disease, a group of lung diseases that block airflow and make it difficult to breathe); -Takes opioid medication. Review of the resident's electronic health record showed: -An order of Hydrocodone-Acetaminophen oral tablet 5-325 milligrams (mg) (Norco, contains opioid used to relieve moderate to severe pain), give 1 tablet every 8 hours for pain, start date of 11/4/24; -The Medication Administration Record showed LPN A administered the medication to the resident on 11/11/24 at 10:00 P.M. and on 11/12/24 at 6:00 A.M During an interview on 12/12/24 at 10:59 A.M., LPN A said he/she worked the 3:00 P.M.-11:00 P.M. shift, but was unable to recall the exact date. He/She was a new staff and only worked for three days before he/she was terminated. The facility terminated him/her because he/she looked very tired and looked under the influence. The DON notified him/her over the phone about the termination. LPN A said he/she did not take any of the residents' medications. He/She was taking prescription medications for high blood pressure and Xanax (used to treat anxiety). He/She had prescriptions for those medications. LPN A said he/she had no issues or history of controlled substance use. LPN A took his/her own Tylenol (used to treat minor pain and fever) that night, but did not take his/her Xanax. He/She took Xanax before bedtime. LPN A added that he/she was asked to come to the medication room by another nurse and was told he/she looked tired, fumbled the keys, and was told to go home. He/She then received a call from the DON the next morning and was told he/she was terminated. The DON did not mention any missing medications. During an interview on 12/12/24 at 12:23 P.M., LPN B said he/she worked on the 200 hall on the 11/12/24 day shift to relieve LPN A from working the night shift, 7:00 P.M. to 7:00 A.M He/She clocked-in around 7:15 A.M. LPN B said LPN A told him/her that he/she was going to be orientating LPN A. LPN B observed LPN A to be confused and somewhat disoriented. He/She told LPN A they were going to wait for the night shift nurse. After a few minutes, LPN A told LPN B he/she was the night shift nurse and was just confused. Both LPNs proceeded with providing change-of-shift report and LPN B continued to observe LPN A to look very tired and had slow speech. LPN B said when they counted the narcotic medications, there were a couple of medication counts that were off. LPN A then said he/she administered those medications during his/her shift, then signed out the medications to correct the count. After LPN A left, LPN B checked and cleaned the medication cart and observed a narcotic count sheet that was stuck in one of the drawers of the cart. The sheet contained Resident #194's information. LPN B looked for the medication card that matched with the count sheet, but was unable to find the medication. He/She contacted the pharmacy who verified the medication for the resident was delivered and was received by LPN A. LPN B reported the missing medication to the former Administrator. They found the medication label, the top part of the medication card that was torn, in the shred box. During an interview on 12/18/24 at 9:20 A.M., the resident said he/she received Norco medication, while at the facility. He/She did not recall the specific time and date of receiving the medication, including 11/11/24 and 11/12/24. But, there were a few times he/she did not receive it at the requested time. During an interview on 12/12/24 on 11:37 A.M., the Administrator said he was not at the facility when the drug diversion incident occurred. The former Administrator provided the investigation information and all the in-services provided to the staff regarding receiving narcotic medications. The Administrator said the facility did not offer drug-testing. During an interview on 12/18/24 at 9:33 A.M., a Florissant Police Department dispatch receptionist said LPN A was issued a warrant for questioning and was arrested on 12/5/24. The case was sent for prosecution. MO00245100

Based on observation, interview and record review, facility staff failed to ensure physician orders for tracheostomy and ventilation machines (a machine that provides positive pressure ventilation) were compete with all pertinent information to care for residents and failed to have orders for continuous oxygen monitoring for residents with a tracheostomy (Residents #13, #25, and #245). Additionally, the facility failed to have staff trained on how to set and monitor the functioning of ventilation machines and continuous oxygen monitoring devices. Review of the facility's Oxygen Administration policy, revised October 2010, showed: -Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration; -Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol; Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: -Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes); -Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion); -Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); -Vital signs; -Lung sounds; -Arterial blood gases and oxygen saturation. During an interview on 10/16/24 at 12:55 P.M., Registered Respiratory Therapist (RRT) Z said the facility utilized a [NAME] closed suction system on the 200, 300, and 400 halls. Review of the facility's Suction Policy, revised August 2014, showed: -The policy did not address the facility's use of a [NAME] Closed Suction System (a closed-circuit method for tracheal suctioning that uses a catheter (tube) that can be reused) for residents with a tracheotomy and did not provide manufacturers guidelines for any of the suction equipment used in the facility. During an interview on 10/1/24 at 8:18 A.M., the Director of Nursing (DON) said the facility used a continuous oxygen monitoring system on the 300 and 400 hall for residents that have a tracheostomy and require continuous oxygen. The device was attached to a resident by way of a sensor attached to the resident's fingernail or toenail. The machine monitored the resident's oxygen saturation levels and heart rate. The monitors would alarm if a residents' oxygen saturation was too low, the resident's heart rate was too high or too low and/or if the sensor was dislodged. The continuous oxygen monitoring machine would alarm in the resident's room with sound and flash in red the room number. 1. Review of Resident #13's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/25/24, showed: -Adequate hearing; -Speech Clarity: Unclear speech, slurred or mumbled words; -Makes Self Understood: Usually understood, difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability To Understand Others: Usually understands, misses some part/intent of message but comprehends most conversation; -Cognitively intact; -Rejection of Care: Behavior not exhibited; -Diagnoses of heart failure (e.g., congestive heart failure (CHF, a long term condition that occurs when the heart cannot pump blood well enough to provide the body with a normal supply) and pulmonary edema (excessive fluid accumulation in the tissue or air spaces of the lungs), pneumonia (an inflammatory condition of the lungs), anxiety, depression, schizophrenia (a mental disorder characterized by recurring episodes of psychosis (a mental state marked by loss of contact with reality)), asthma (long-term inflammatory disease of the airways/lungs), and respiratory failure; -Respiratory Treatments: Oxygen therapy, suctioning, tracheostomy care and non-invasive mechanical ventilator. Review of the resident's care plan, located in the electronic health record (EHR), showed: -Date Initiated 6/9/23, revised on 3/8/24 : -Focus: Diagnosis of CHF. At risk for respiratory complication as evidenced by shortness of breath (SOB), tachypnea (rapid breathing), and dyspnea (difficult breathing).; -Goal: Will not have complications related to CHF which requires outside interventions; -Interventions/Tasks: Administer medication as ordered. Monitor for signs of respiratory distress. Monitor oxygen saturation; -Date Initiated 6/9/23, revised on 3/8/24: -Focus: Uses oxygen continuously; -Goal: Will not have complications requiring outside interventions related to tracheostomy/ventilator; -Interventions/Tasks: Change oxygen tubing as ordered. Change suction system as ordered. Monitor and respond to ventilator alarms as ordered; -Date Initiated 2/24/24 and Revised On 3/8/24: -Focus: Requires an invasive mechanical ventilator and is at risk for respiratory distress; -Goal (revised on 10/1/24): Secretions are mobilized and airway remains patent; -Interventions/Tasks: Assess tracheal tube, checking whether it is secure. Assess rate and quality of respiratory pattern. Assess vital signs. Call light in reach and answered promptly. Resident has a chronic ventilator (vent) and likes to hook himself/herself up to the ventilator nightly. It has been determined that the resident is not safe for himself/herself off of the vent although he/she continues to take his/her vent off at his/her own will. Resident has been educated that doing this puts him/her at harm for respiratory failure. Monitor oxygen saturation through pulse oximetry and atrial blood gases as appropriate and notify physician if below 92% (normal 95-100%). Review of the resident's physician's orders (POS) on 10/16/24 showed: -An order dated 10/10/24 for High Humidity Trach Collar (HHTC) @28% for Sats (saturations) greater than 90% oxygen (O2). No directions specified for order; -An order dated 10/14/24 for Tracheostomy showed: Trach care, cleanse site with ( ) sterile water or normal saline (H202/NS) and change trach dressing. Type: _______, Size:__________, Cuffed:__________, Uncuffed:_________, Fenestrated (A fenestrated tube is a tracheostomy tube with a hole or holes in the outer cannula that allow air to pass through the patient's upper airway and mouth):__yes__no , Disposable Inner Cannula:__yes__no, Passy-Muir Valve:__yes, # of hours use__, __no___. Cuff must be deflated while a Passy Muir speaking valve is in place (a medical device that allows patients with tracheotomies or ventilators to speak and communicate) every 8 hours; -The tracheostomy order did not include the specific information staff needed to care for the resident's tracheostomy. -It did not contain orders for the resident's ventilator or ventilator settings; -It did not contain an order for continuous oxygen monitoring. Observation on 10/16/24 at 6:38 A.M., showed unknown certified nursing assistant (CNA) alerted Licensed Practical Nurse (LPN) BB the resident needed to be suctioned. The oxygen monitoring screen at the nurse's station and on the resident hallways were not sounding to indicate if the resident was having trouble with his/her oxygen levels. LPN BB entered the resident's room and attempted to suction the resident and RR Z came in and took over. Observation at that time showed, the resident's continuous oxygen monitor had been turned off. RRT Z looked at the resident's continuous oxygen monitoring machine and turned it on. The screen showed a malfunction error. RRT Z left the room and brought in a replacement machine. During interviews on 10/15/24 at 7:15 A.M., and on 10/16/24 at 7:08 A.M., 8:15 A.M. and 11:15 A.M., RRT Z said the facility used a continuous oxygen monitoring system for residents with a tracheotomy. The monitoring system alerted with an alarm if something was wrong. He/She did not know who was responsible for maintaining the equipment and making sure it was in working order. Staff that were working should assess the equipment daily. Staff should ensure equipment was plugged in and working, sensors were intact and in place on the residents. During an interview on 10/2/24 at 12:25 P.M., Registered Nurse (RN) W said the continuous oxygen monitoring system malfunctioned all the time. At times the machine would alarm in a resident's room, but not at the nurse's station and/or on the monitoring screens in the hallways. Only the respiratory therapy department knew how to set and maintain the ventilators on the hallways. 2. Review of Resident #25's medical record showed: -Diagnosis included Chronic Obstructive Pulmonary Disease (COPD, lung disease), dysphagia (difficulty swallowing), and unspecified intracranial injury (brain injury). Review of the resident's quarterly MDS, dated [DATE], showed: -Speech Clarity: Unclear speech, slurred or mumbled words; -Makes Self Understood: Usually understood, difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability To Understand Others: Usually understands - misses some part/intent of message but comprehends most conversation; -Moderately cognitively impaired; -Rejection of Care: Behavior not exhibited; -Respiratory Treatments: Oxygen therapy, suctioning, and tracheostomy care. Review of the resident's care plan, revised on 10/16/24, showed: -Focus: Tracheostomy. Resident requires a tracheostomy; -Goal: Will have no signs of complications with tracheostomy to the extent possible; -Interventions: Auscultate lung sounds (listen to) lung sounds, assessing for decreased or adventitious lung sounds (refer to sounds that are heard in addition to the expected breath sounds mentioned above. The most commonly heard adventitious sounds include crackles, rhonchi, and wheezes), change suction system as ordered/indicated, change trach ties (helps stabilize and keep the tracheal cannula (a tube within the outer tube which can be removed) in place) as ordered and as needed, provide means of communication, reassure help is available immediately; -Focus: Requires the use of oxygen continuous related to acute respiratory failure; -Goal: Will be complaint with oxygen therapy. Will be maintained at their respiratory baseline with a patent (open) airway and unlabored respirations; -Interventions: Maintain head of bed elevated to level of comfort to promote oxygenation. Provide calm environment free of stimuli to reduce/prevent anxiety, respiratory therapy as indicated, monitor for signs and symptoms of respiratory distress and report to physician, pulse oximetry. Review of the resident's POS, dated 10/16/24, showed the following: -Oxygen at 6 liters/minute continuously per trach collar; -Suction tracheostomy tube as needed to clear airway; -The orders did not include: -Type or size of tracheostomy; -Use of continuous oxygen monitoring. Observation on 10/16/24 at 7:04 A.M., showed the resident lay in bed. His/Her HHTC was not attached to any oxygen source and the mask was lying on the foot of the bed. There was no continuous oxygen monitoring machine in his/her room to alert staff the resident was not receiving oxygen. During an interview on 10/16/24 at 7:43 A.M., the DON said he did not know why Resident #25 did not have a continuous oxygen monitoring machine in his/her room. 3. Review of Resident #245's medical record physicians order sheet showed: -An order dated 7/26/24, to suction secretions as needed orally (by mouth) using a catheter; -An order dated 7/26/24, for continuous oxygen saturation monitoring; -An order dated 7/26/24, for oxygen at 5 L /minute continuous per nasal cannula; -It did not contain orders for HHTC; -It did not contain orders for tracheostomy cannula, including brand or size. Review of the resident's care plan, revised on 10/1/24, showed: -Focus: Resident requires a tracheostomy and is at risk for complications; -Goal: Will have no signs or symptoms of complications with tracheostomy tube to the extent possible; -Interventions: Administer humidified oxygen as ordered, administer medications as ordered, encourage to cough out secretions, monitor and report signs of respiratory distress or hypoxia (body not getting enough oxygen), provide trach care as indicated, resident has a #6 [NAME] trach (a tube used to bypass upper airway obstructions) and make sure the resident is in a comfortable position; -Focus: Resident requires the use of oxygen continuous 5L/min per nasal cannula related to respiratory failure; -Goal: Will be compliant with oxygen therapy; -Interventions: Change humidification and oxygen tubing as indicated, educate the resident on the importance of keeping the oxygen on and at the prescribed setting, and monitor and report signs of hypoxia to physician. -The care plan did not address the resident used a HHTC and utilized a continuous oxygen monitoring system. Review of the resident's progress note, dated 10/8/24, showed: -Trach care done; -Patient remains on 28% (nothing noted); -5L trach collar set up (no mention of oxygen). Observation on 10/16/24 at 7:04 A.M., showed the resident lay in bed. His/Her HHTC mask was at the nape (back) of his/her neck and not over his/her tracheostomy stoma (surgically created opening in the neck that leads to the windpipe). 4. During interviews on 10/15/24 at 7:15 A.M., and on 10/16/24 at 7:08 A.M., 8:15 A.M. and 11:15 A.M., RRT Z said the respiratory therapist was responsible for setting the ventilators. There should be orders in the resident's medical records to include settings of the ventilators, brand and size of tracheostomy equipment, levels of high humidity and oxygen flow rates. The respiratory therapy staff had not inserviced the nurses at the facility on the use of the facility's specific equipment and policies. During an interview on 10/17/24 at 11:13 A.M., LPN FF said he/she had not been provided any additional training by the facility for using their specific equipment and or policies and procedures regarding caring for residents with a tracheostomy. During an interview on 10/1/24 at 7:58 A.M., RRT EE said the facility had approximately 12 to 15 residents with a tracheostomy. All of the residents with a tracheostomy used the piped in wall oxygen and suctioning equipment. All residents with a tracheostomy should have continuous oxygen monitoring equipment. During an interview on 10/16/24 at 7:43 A.M., the DON said all residents with orders for oxygen and HHTC should have their equipment placed correctly and monitored by staff. During an interview on 10/21/24 at 2:00 P.M., the Administrator said he would expect residents' medical records to contain complete and accurate orders. During a telephone interview on 10/16/24 at 3:40 P.M., the facility's medical director said all residents' physician's orders should address the residents' tracheostomy care, including the brand name and size of the equipment. Ventilator orders should be on the physician's order sheets. All residents with a tracheotomy should be on continuous oxygen monitoring.

46970 Based on interview and record review, the facility failed to notify the Department of Health and Senior Services (DHSS) as required by state and federal regulations when one resident eloped from the facility and was found by police (Resident #38). In addition the facility failed to notify DHSS when allegations of abuse were made by two residents (Residents #52 and #48). The sample size was 33. The census was 99. Review of the facility's Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating Policy, dated revised September 2022, showed: - Reporting Allegations to the Administrator and Authorities: - If resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish), neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.), exploitation (taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion), misappropriation of resident property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law; - The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: -The state licensing/certification agency responsible for surveying/licensing the facility; -The local/state ombudsman; -The resident's representative; -Adult protective services (where state law provides jurisdiction in long-term care); -Law enforcement officials; -The resident's attending physician; and -The facility medical director. -Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury; -Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone; -Notices include, as appropriate: -the resident's name; -the resident's room number; -the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.); -the date and time the alleged incident occurred; -the name(s) of all persons involved in the alleged incident; and -what immediate action was taken by the facility; -Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents; -Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 1. Review of Resident #38's care plan, in use during the time of the investigation, revised 7/16/24, showed: -Focus: Initiated 3/24/24. The resident has been identified as an elopement risk; -Goal: Assist resident with redirection if found wandering to keep him/her aware of his/her surroundings through the next review date; -Interventions: Assess resident risk factors that may trigger wandering behavior. Educate staff where they can find elopement binders. The resident has been placed in the at risk for elopement binder. Music helps the resident relax. Play music for the resident if he/she is actively anxious. Re-orientate resident to his/her room or familiar place as needed; -No information regarding the elopement on 9/14/24. Review of the Fire Protection District report, dated 9/14/24, showed: -Transportation Date: 9/14/24; -Onset Time: 5:00 A.M.; -Emergency Medical Services (EMS) dispatched to a residence with a chief complaint of a confused person. EMS responded with lights and sirens. EMS arrived on scene to find the police standing on the side of the road. Per police, a passerby called 911 of an old man/woman wandering around with no shoes on. Per police, the patient is confused and can't answer questions correctly. Patient is a [AGE] year-old man/woman with a chief complaint of altered mental status. Patient is alert and oriented to self. Patient states he/she was from East St. Louis and did not know how he/she got to the area. Patient sat and secured to stretcher for safety. Patient loaded into hospital and taken to the hospital. Review of the hospital's Health Facility Transfer Chart, showed: -admitted [DATE]; -Expected discharge date of [DATE]; -Oriented to person, disoriented to place, disoriented to situation, disoriented to time; -Final Diagnosis: Altered mental status; -Presenting History: Patient presented to the emergency room from street via police with concern for altered mental status. Patient is resting in bed. He/she says he/she is feeling better. No further history from patient. Per the hospital social worker, patient has a piece of paper with him/her stating the resident's name, identification number, room number, diet order: mechanical soft, regular double portions, thin liquids; -Per the resident's family member, the facility called him/her on 9/14/24 to inform him/her the patient was missing. However, when the Social Worker called the facility on 9/14/24 at 9:59 A.M., the receptionist said the patient was not from their facility. The family member states the facility is working to get the patient transferred to another facility. The family member is aware patient will need to return back to the facility while waiting for the facility to coordinate the transfer if patient is medically ready for discharge; -Per Fire House staff, the patient was picked up 0.2 miles away from the facility; -Social worker called the facility at the listed phone number. The receptionist said the patient was not from their facility; -Social Worker called the assisted living facility associated with the nursing home. The receptionist said the patient is not from their facility. Review of the resident's progress notes, showed no information regarding the resident's elopement on 9/14/24. Review of the resident's progress note, dated 9/18/24 at 3:31 P.M., showed at 1:50 P.M., the resident arrived from the hospital to the facility. No complaints and no respiratory distress noted. Resident was able to make some needs known, and oriented to room, call light, television, bed remote and staff. No edema (swelling) noted and continues to ambulate with slow and steady gait and no use of assist devices. Call placed to the Nurse Practitioner and made her aware the resident has returned to the facility. Review of the resident's physician's progress note, dated 9/20/24 at 7:51 A.M., showed a late entry: Return from hospital. Patient being seen today after being admitted to the hospital with altered mental status. Patient was found on the street by police and was taken to the hospital. Patient improved and was discharged back to the facility with recommendations for patient to be transferred to a memory care accessible facility. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/30/24, showed: -Cognitively impaired; -Wandered four to six days out of seven; -Diagnoses included Alzheimer's Disease and dementia. During an interview on 10/11/24 at 2:52 P.M., Certified Nurse Aide (CNA) B said he/she worked the night shift on 9/13/24 and 9/14/24. He/She was on the hall but not assigned to the resident. He/She thought they did rounds on all residents during the night shift on 9/14/24. He/She saw the resident around 8:00 P.M. on 9/13/24. The resident wandered and was in the dining room and tended to wander throughout the facility. That night, the front doors were broken, and the alarms were not sounding. Apparently, the resident left the facility during the night and was found outside on the facility property and taken to the hospital. He/She did not know the resident was missing until he/she returned on 9/15/24. Licensed Practical Nurse (LPN) R was the nurse on duty and likely did not report the incident. LPN R told CNA B, You didn't see or hear anything regarding the resident's elopement. During an interview on 10/30/24 at 9:13 A.M., LPN UU said he/she worked through an agency and worked during the night shift on 9/14/24 and was assigned to a different hall. He/She did not recall a resident eloping and did not receive any information regarding an elopement. He/She could not recall receiving or providing a report to the on-coming nurse and could not recall who it was. During an interview on 10/11/24 at 2:12 P.M., the Administrator said he was out of town when the incident occurred. The Director of Nursing (DON) received a call and found out the resident was picked up by the police in front of the facility. The police did not come into the facility to find out if the resident belonged at the facility. The resident was a wanderer but not exit-seeking. The resident must have eloped from the facility around 5:00 A.M. Staff discovered he/she was missing around 9:00 A.M. when staff were passing medication. The incident was not reported or investigated thoroughly because the Administrator found out about the incident outside of the time frame and did not have any information. 2. Review of Resident #52's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included: diabetes, high blood pressure, stroke, and hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) or hemiparesis (weakness in a leg, arm, or face) and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 10/16/24 at 7:35 A.M., the resident said a few weeks ago on the night shift, Certified Nurse Aide (CNA) B hit him/her in the head with a closed fist. He/She had provided care, but the resident said he/she did not feel like this was an accident. He/She did not know why the CNA would hit him/her. The CNA was being ignorant. The resident said the incident made him/her feel like he/she was abused, and the facility did not care. The resident said he/she saw the CNA after the incident and he/she felt scared. He/She reported the allegation to the nurse and the Social Worker (SW), and the SW interviewed him/her. During an interview on 10/14/24 at approximately 5:00 P.M. and on 10/16/24 at 3:35 P.M., LPN R said the allegation happened on 9/9/24 around 5:30 A.M. to 6:00 A.M., the nurse was in the resident's bathroom getting warm water to flush the residents feeding tube (a medical device used to provide nutrition). When he/she walked around the curtain and saw the resident and CNA B, both were quiet and just looking. The nurse asked them what was going on. The resident said CNA B slapped him/her in the face. The CNA denied the allegation and left out of the room. The nurse assessed the resident and did not see any redness, bruising or scars on his/her face. The nurse called the on-call phone and spoke with Registered Nurse (RN) W who told him/her to send CNA B home. LPN R sent CNA B home at the same time he/she texted the Director of Nursing (DON) to report the allegation. LPN R said he/she did not document the incident because he/she did not know what the protocol was. When he/she asked what needed to be documented and where to document the allegation, nobody said anything. The next day, the resident told the nurse the facility let the CNA come back to work. The resident never denied the allegation occurred. Review of text messages dated 9/9/24 at 6:18 A.M. and 7:20 A.M., showed: -LPN R: I have a resident who is saying a CNA smacked him/her in the face. The CNA is saying he/she won't get the resident up anymore; -DON: dear lord, what is the name of the CNA; -LPN: CNA B; -DON: ok thank you. During an interview on 10/17/24 at 5:03 P.M., RN W said he/she got a call from LPN R who reported the resident told him/her CNA B had struck him/her. RN W instructed LPN R to immediately send CNA B home and to assess the resident for injuries. RN W reported the allegation to the DON and the Administrator. He/She did not know if the allegation was called in or not. During an interview on 10/16/24 at 11:25 A.M., LPN NN said LPN R reported to him/her CNA B slapped the resident in the face and he/she reported the incident to management. The SW and the Administrator talked with the resident. If an allegation of abuse was made management would tell the nurse what to do and where to document, it. During an interview on 10/16/24 at 12:10 P.M., the SW said if a resident had an altercation with an employee, she would redirect to the Administrator. The SW said the incident with the resident happened a little bit ago on the night shift. Nursing reported the incident to the Administrator and the Administrator asked her to talk with the resident. The resident said the young staff member who got him/her up was ugly and when he/she told the staff member, they got mad and was rough with him/her. The CNA denied hitting the resident. The SW reported her findings to the Administrator. The allegation should have been reported to DHSS. She did not know if the allegation was reported to DHSS. During an interview on 10/16/24 at 12:40 P.M., the DON said if something happened, he would expect for staff to document it. If the DON was not in the building when an allegation of abuse was made, he he would expect for staff to call or text to notify him. The resident was not always alert and oriented and had periods of confusion/delusions (a fixed, false belief resistant to change despite conflicting evidence). The resident reported an allegation to the nurse and the nurse notified the DON. The nurse said the resident said CNA B had slapped him/her in the face. The DON was told this was not the first time the resident alleged a staff member had hit him/her. The DON said he talked with the nurse and CNA B. CNA B denied the allegation. When the resident was interviewed, he/she said nothing happened. Once the resident denied the allegation, the CNA was able to come back to work. The DON did not recall seeing any documentation regarding the incident. Allegations of abuse should be reported to DHSS. This allegation was not reported because the resident said it did not happen. During an interview on 10/16/24 at 1:10 P.M., the Administrator said LPN R reported the resident said CNA B slapped him/her. The incident took place a few months ago towards the end of the shift. By the time the Administrator was notified of the incident, CNA B's shift was over. The resident was alert and oriented. When the resident was interviewed, the resident denied CNA B hit him/her. CNA B also denied the allegation. The resident could make things up, but he/she had never said anything like this in the past. The allegation was not reported to DHSS because the facility deemed no abuse, or anything had happened. 3. Review of Resident #48's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included depression and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's care plan, in use during the survey, showed: -Focus: Medication - Anti-Anxiety: Resident requires anti-anxiety medication related to anxiety disorder (Intense, excessive, and persistent worry and fear about everyday situations) date initiated 7/5/23; -Goal: Resident's medication use will result in the maintenance of the resident's functional status; -Interventions/Tasks: -Provide the resident with an activity calendar in room; -Remind the resident the importance of social interaction; -Room visits with the resident, 1:1 for socialization if needed. Review of the resident's progress notes, showed no documentation related to a resident-to-resident abuse allegation. During an interview on 10/15/24 at 9:41 A.M., the resident said he/she was attacked in his/her bed on 7/22/24 by Resident #75. He/She said the resident was no longer in the facility because his/her mental state was worse than other residents in the facility. The resident said Resident #75 was in his/her room when he/she came back from lunch going through his/her packed bags. He/She said Resident #75 took out his/her black dress and held it up. He/She told Resident #75 to put his/her clothes down. The resident said he/she thought Resident #75 wanted sex from him/her because Resident #75 took both his/her hands and grabbed him/her by the head and began pulling the resident towards his/her body. The resident said Resident #75 started to lay back on the bed. The resident's dress flew up, and Resident #75 opened the resident's legs. The resident said Resident #75's vagina was shaved. The resident said he/she didn't know how he/she ended up on top of Resident #75 because the resident was bigger and stronger than him/her. The resident said his/her back was hurting all of the time. He/She said the facility didn't protect him/her from Resident #75. The resident said he/she told Resident #75 not to come back to his/her room and said staff never told Resident #75 to leave his/her room. The resident said he/she had to leave his/her room and yell out for nursing staff to make Resident #75 to leave his/her room. He/She said Resident #75 always challenged him/her when walking down the hall. The resident said he/she told LPN NN and CNA A. The resident said once they came into his/her room, Resident #75 let him/her go. The resident said he/she spoke to the head man, the Administrator. He/She said the Administrator asked him/her a few questions. The Social Worker came and was upset about what happened to him/her. He/She said the Social Worker was beet red and felt bad for him/her. He/She said the Social Worker was tearful, same as him/her. During an interview on 10/16/24 at 11:23 A.M., LPN NN said the resident told him/her about the incident between him/her and the other resident. LPN NN said the other resident was a wander and he/she went into the resident's room. LPN NN said the wandering resident went through Resident #48's things and he/she was trying to get the wandering resident out of his/her room. LPN NN said the resident came out of his/her room into the hallway and told LPN NN the other resident was in his/her room and going through his/her stuff. LPN NN said he/she went into the resident's room and re-directed the wandering resident out of the room. He/She said there was no altercation between the two residents but Resident #48 was really upset with the other resident for being in his/her room. LPN NN said the resident never told him/her he/she had been attacked by the other resident. During an interview on 10/16/24 at 2:16 P.M., CNA A said he/she knew both residents. He/She said the other resident was no longer in the facility but did wander. CNA A said the other resident went into Resident #48's room and went through his/her things. He/She said someone had a bell and asked where it was coming from. He/She said the resident just wanted CNA A to get the other resident from his/her room. CNA A said there was no physical altercation. During an interview on 10/17/24 at 2:19 P.M., the Social Worker said the resident made it up and had a history of making up things. He/She was bipolar, schizophrenic (a disorder that affects a person's ability to think, feel, and behave clearly), and had anxiety. She said the resident had a history of having sex with people to get money. She said the resident had not had any trauma since coming to the facility that she knew of, and no one reported any abuse allegation to her regarding the resident. She had spoken with the resident about the alleged altercation between the two residents and told the Administrator. She said as far as she knew, there was no physical altercations between the two residents. During an interview on 10/21/24 at 3:08 P.M., the Administrator said he spoke with the resident when the incident had been brought to his attention. He didn't think to document it in that moment. The resident told him what happened with the other resident. He said as far as he could tell, there was no physical altercation, so he dismissed it. He expected allegations of abuse to be reported and investigated. 3. During an interview on 10/21/24 at 3:08 P.M., the Administrator said allegations of abuse and neglect should be investigated and reported to DHSS. MO00243149

45083 Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address the specific needs of the residents. (Residents #38, #47, #344, #67, and #48). The sample was 33. The census was 99. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated 2001, showed: -Policy Statement: A comprehensive, person-centered plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; Policy Interpretation and Implementation: -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her pain of care, including the right to: -Receive the services and/or items included in the plan of care; The comprehensive, person-centered care plan: -Includes measurable objectives and timeframes; -Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: -Professional services that are responsible for each element of care; -Builds on the resident's strengths; and -Reflects currently recognized standards of practice for problem areas and conditions. 1. Review of Resident #38's care plan, in use during the time of the investigation, revised 7/16/24, showed: -Focus: Initiated 3/24/24. The resident has been identified as an elopement risk; -Goal: Assist resident with redirection if found wandering to keep him/her aware of his/her surroundings through the next review date; -Interventions: Assess resident risk factors that may trigger wandering behavior. Educate staff where they can find elopement binders. The resident has been placed in the at risk for elopement binder. Music helps the resident relax. Play music for the resident if he/she is actively anxious. Re-orientate resident to his/her room or familiar place as needed; Review of the resident's hospital's Health Facility Transfer Chart, showed: -admitted [DATE]; -Expected discharge date of [DATE]; -Oriented to person, disoriented to place, disoriented to situation, disoriented to time; -Final Diagnosis: Altered mental status; -Presenting History: Patient presented to the emergency room from street via police with concern for altered mental status. Patient is resting in bed. He/she says he/she is feeling better. No further history from patient. Per the hospital social worker, patient has a piece of paper with him/her stating the resident's name, identification number, room number, diet order. -Per the resident's family member, the facility called him/her on 9/14/24 to inform him/her the patient was missing. However, when the hospital social worker called the facility on 9/14/24 at 9:59 A.M., the receptionist said the patient was not from their facility. The family member states the facility is working to get the patient transferred to another facility. The family member is aware patient will need to return back to the facility while waiting for the facility to coordinate the transfer if patient is medically ready for discharge; -Per fire house staff, the patient was picked up 0.2 miles away from the facility. Review of the resident's Elopement and Wandering Risk Observation/Assessment, dated 9/18/24, showed: -Mobility Status: The resident ambulates independently with or without the use of assistive devices; -Cognitive Status: The resident is disoriented or has periods of confusion and/or impaired attention span but does not wander; -Disease Diagnosis: The resident has two or more diagnoses that may impact cognition; -Mood/Behavior Status: The resident has verbalized a desire to leave the facility, packed their belongings, stood by the exit door or attempted to open an exit door -History of Elopement Attempts: The resident has exhibited unsafe wandering or has made one or more attempts to elope prior to admission or in the last year -Behavior Modification: Exhibits unsafe wandering or elopement attempts but is easily redirected; -Intervention: The care plan has been initiated/updated to reflect interventions aimed at reducing the risk of unsafe wandering or an elopement. Review of the resident's progress note, dated 9/18/24 at 3:31 P.M., showed at 1:50 P.M., the resident arrived from the hospital to the facility. No complaints and no respiratory distress noted. Resident was able to make some needs known, and oriented to room, call light, television, bed remote and staff. No edema noted and continues to ambulate with slow and steady gait and no use of assist devices. Call placed to the nurse practitioner and made her aware the resident has returned to the facility. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/30/24, showed: -Cognitively impaired; -Wandered four to six days out of seven; -Diagnoses included Alzheimer's Disease and dementia. Review of the care plan, revised 7/16/24, viewed 10/10/24 at 10:51 A.M., showed no information or updated interventions regarding the resident's elopement on 9/14/24. 2. Review of Resident #47's quarterly MDS, dated [DATE], showed: -Mild cognitive impairment; -No behaviors; -Diagnoses included heart failure, diabetes and depression; -Bed rails used daily. Observation of the resident on 10/10/24 at approximately 8:03 A.M., 10/11/24 at 8:52 A.M., 10/15/24 at 9:25 A.M. and 10/16/24 at 7:22 A.M., showed the resident lay in bed, with quarter-length side rails raised and in use on both sides of the bed. Review of the resident's care plan, revised 5/16/24, viewed 10/11/24 at 12:56 P.M., in use during the time of the investigation, showed no information regarding the use of side rails. During an interview on 10/15/24 at 6:12 P.M., the resident said he/she used the side rails for repositioning in bed. 3. Review of Resident #344's entry MDS, dated [DATE], showed no information. Review of the resident's medical record, showed: -admitted [DATE]; -Diagnoses included hemiparesis (weakness to one side of the body) following a stroke, respiratory failure, cognitive communication deficit, epilepsy, traumatic brain injury, tracheostomy (a surgical procedure that creates an opening in the neck to provide an airway and help with breathing) status and gastrostomy (G-tube, creates an opening into the stomach through the abdomen, allowing a feeding tube to deliver nutrition directly) status. Review of the resident's care plan, revised 8/31/24, reviewed 10/11/24 at 12:59 P.M., showed no information regarding the resident's use of a tracheostomy, gastrostomy or side rail. Review of the resident's physician's orders, dated 10/8/24 through 11/6/24, showed: -An order, dated 8/24/24 for nothing by mouth (NPO) diet ; -An order, dated 9/12/24 for Jevity (provides complete balanced nutrition for tube feeding) at 60 milliliters per hour every shift; -No information regarding tracheostomy status; -No information regarding the use of side rails. Observation on 10/10/24 at approximately 8:03 A.M., showed the resident lay in bed with quarter length side rails raised and in use on both sides of the bed. The resident's G-tube infused at 60 milliliters per hour. The resident had a tracheostomy tube on his/her neck. The resident was non-verbal and nodded his/her head when asked if he/she was okay. Observations on 10/11/24 at 8:55 A.M. and 10/15/24 at 9:48 A.M., showed the resident lay in bed with quarter length side rails raised and in use on both sides of the bed. The resident's G-tube infused at 60 milliliters per hour. The resident had a tracheostomy tube on his/her neck. Observation on 10/16/24 at 7:26 A.M., showed the resident lay in bed on his/her back with quarter length side rails raised on both sides. 4. Review of Resident #67's Bed Rail Observation/Assessment, dated 4/6/24, showed bed rails were used for safety and positioning. Review of the resident's care plan, revised 4/16/24, in use during the time of the investigation and viewed on 10/11/24 at 1:03 P.M., showed no information regarding the use of side rails. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitive impairment; -No behaviors; -Diagnoses included cancer, stroke, seizures and depression; -Bed rails not used. Observations on 10/10/24 at approximately 8:03 A.M., 10/11/24 at 8:48 A.M., 10/15/24 at 6:10 P.M. and 10/16/24 at 7:17 A.M., showed the resident lay in bed on his/her back. with quarter-length bed rails in use and raised on both sides of the bed. 5. Review of Resident # 48's annual MDS, dated [DATE], showed, moderate cognitive impairment, depression, and bipolar disorder (a disorder associated with mood swings from depressive lows to manic highs). Review of the resident's progress notes, dated 8/14/24, showed: -On this date, 8/9/24 at 3:15 P.M., this writer observed the resident attempting to give another resident an oatmeal cream pie that he/she was not supposed to eat due to diet restriction. Director of Nurses (DON) and this writer continued to explain to the resident that it was not safe for him/her to give other residents snacks. He/She again insisted on feeding the resident. Social Services notified the resident was not being complainant when asked not to feed the resident. Review of the resident's physician orders, start date 10/7/24, showed, anti-depressant medication: Prozac; -Side effects: Common- sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia (rapid heart rate), muscle tremor, agitation, headache, skin rash, photosensitivity (skin), excessive weight gain. Special attention for heart disease, glaucoma (eye nerve disease), chronic constipation, seizure disorder, edema (swelling). Monitor; -Directions: Every shift document; -Antipsychotic medication: Haldol and Seroquel; -Side effects: Common- sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal (involuntary movements) reaction, weight gain, edema, postural hypotension (low blood pressure), sweating, loss of appetite, urinary retention. Nursing alert: Tardive dyskinesia (movement disorder that occurs as a result of certain medications), seizure disorder, chronic constipation, glaucoma, diabetes, skin pigmentation, jaundice (yellow skin caused by liver disorders). Monitor; -Directions: Every shift document. Review of the resident's care plan in use at the time of the investigation, showed: -No documentation of 8/9/24 behavior or intervention(s) care planned; -No documentation of behaviors or potential side effects related to antipsychotic or antidepressant medications; -No documentation of refusal of care behavior or interventions. During an interview on 10/17/24 at 2:18 P.M., the Social Worker said it was hard to re-direct the resident, so they needed to call the doctor to get instructions on what to do. The facility staff need more education on people with dementia. When the resident had stressful incidents, he/she would come to the Social Worker's office. The Social Worker said she would report whatever the resident's issues were to the nurse, call the physician, set up a care conference call with the resident's family, and if needed, one-on-one supervision. She calls psychiatry to come out as needed. The resident received psychiatric services once a month. The resident should go out to have his/her medications evaluated/adjusted, but when Emergency Medical Services (EMS) comes, he/she refuses to go. She expected the resident's behaviors, interventions, and services received to be on his/her care plan. 6. During an interview on 10/21/24 at 10:32 A.M., the Assistant Director of Nursing (ADON) said the residents' care plans should be completed and accurate specific to the residents' needs in a timely manner. 7. During an interview on 10/21/24 at 1:56 P.M., the MDS Coordinator said she was responsible for updating care plans, along with nurses and the Social Worker. Care plans were updated quarterly and as needed. Care plans should reflect the resident's specific needs. G-tubes, tracheostomies, side rails, elopements, falls and wounds should be included in a resident's care plan if it reflected the resident's specific need. 8. During an interview on 10/21/24 at 3:18 P.M., the Administrator said he expected the care plans to be accurate and complete, including residents' behaviors and interventions. 46970

Based on observation, interview and record review, the facility failed to provide services by sufficient numbers of nursing personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care needs. The facility did not have a system in place to ensure the required coverage was provided. As a result one resident, who experienced acute shortness of breath had to call 911 for intervention. (Resident #35). Another resident called 911 on one occasion because he/she could not get staff to answer his/her call light to help reposition a tube and on another occasion because he/she had a soiled brief and had waited 10 hours for staff to clean him/her. (Resident #46). In addition, one resident, who was dependent on staff for nutrition, went over 5 hours without receiving his/her physician ordered tube feeding (a method of providing nutrition, fluids, and medication to someone who is unable to eat or drink safely by mouth). (Resident #245). In addition, during the survey, one resident's light was observed to be on for almost two hours while staff walked past the resident's room. (Resident #20). The facility also failed to have adequate awake employees prepared to provide care and safely monitor residents on the night shift. The census was 99. Review of the facility's Facility Assessment Tool, not dated showed: -Number of residents licensed to provide care for: 120; -Average daily census: 90; -Number (enter average or range) of persons admitted : -Weekday: ,d+[DATE]; -Weekend: ,d+[DATE]; -Number (enter average or range) of persons discharged : -Weekday: ,d+[DATE]; -Weekend: ,d+[DATE]; -Acuity: -Special treatments and conditions: number/average or range of residents: -Oxygen therapy: ,d+[DATE] -Suctioning (a device used to extract fluids/secretions such as saliva and mucus from body cavities): ,d+[DATE]; -Tracheostomy care: ,d+[DATE]; -Ventilator or respirator: 1; -IV medications: ,d+[DATE]; -Dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly): ,d+[DATE]; -Advanced wound care needs: ,d+[DATE] -Assistance with activities of daily living (ADL): -Transfer: -Independent: 14; -Assist of ,d+[DATE] staff: 49; -Dependent: 19; -Toilet use: -Independent: 8; -Assist of ,d+[DATE] staff: 52; -Dependent: 22; -Eating -Independent: 62 -Assist of ,d+[DATE] staff: 11; -Dependent on staff: 9; -Respiratory/Ventilator : -Not addressed -Licensed Nurses Licensed Practical Nurse (LPN), Registered Nurse (RN), based on the facility's budgeted staffing plan. Staff will be adjusted based on resident needs and the skill levels of available staff. -Director of Nursing (DON) RN full-time; -Days (7:00 A.M. to 7:00 P.M.) -LPN (Licensed Practical Nurse) Assistant Director of Nursing (ADON) -4 LPN/RN Charge Nurses; -1 LPN Wound Care Nurse; -1 LPN MDS Nurse (Minimum Data Set, a federally mandated assessment completed by facility staff): -Nights (7:00 P.M. to 7:00 A.M.); Certified Nursing Assistant (CNA): -Days 1:15 residents; -Nights 1:18 residents; Other (e.g., Department Heads, Nurse Educator, Quality Assurance, Ancillary staff in maintenance, housekeeping, dietary and laundry); -Admissions Coordinator -Marketing Director -Social Services Director -Social Services Assistant - Medical Records Director -Activities Director -Director of Environmental Services -Business Office Manager -Dietary Supervisor -Director of Rehab -Central Supply -Housekeeping -Laundry -Dietary Aides -Cooks -Individual staff assignment: Facility determines, and reviews individual staff assignments based on the acuity of current resident needs. The nurses and CNAs are generally assigned to the same area to promote consistency and continuity of care. Information provided by the facility on [DATE], showed the following: -80 residents were designated as full code; -29 residents had pressure ulcers (injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure or friction); -19 residents received tube feedings through a gastrostomy tube (g-tube, a tube inserted through the abdomen that brings nutrition directly to the stomach); -15 residents had a tracheotomy (tube surgically inserted into the trachea for the purpose of breathing) and required oxygen by way of a high humidity trach collar, (HHTC-a soft plastic mask that provides extra humidity to a tracheostomy by delivering humidified air or oxygen directly to the trach); -10 residents received dialysis (helps filter waste, excess fluid and toxins from the blood); -Six residents required intravenous (IV) antibiotics; -Two residents used a ventilator (machine used to assist with breathing); -Two residents used continuous positive airway pressure machine (CPAP, a machine that uses mild air pressure to keep breathing airways open while you sleep). 1. Review of Resident #35's care plan, revised on [DATE], showed: -Focus: Uses nasal Bilevel Positive Airway Pressure machine (BiPAP, a noninvasive machine that helps people breathe by delivering pressurized air into the airways through a mask or nasal canula (a device that delivers extra oxygen through a tube and into the nose)) while in bed during the night and sometimes during the day; -Goal: Absence of complications from the noninvasive mechanical ventilation; -Interventions: Observe for changes in the level of consciousness, assess respiratory rate, depth and [NAME], assess heart rate, blood pressure and breath sounds. Review of the resident's quarterly MDS, dated [DATE], showed: -Clear speech, understood, understands, clear comprehension; -Cognitively intact; -Behavior: Rejection of care: Behavior not exhibited; -Prognosis: Does the resident have a condition or chronic disease that may result in a life expectancy of less than six months: no; -No dyspnea (shortness of breath); -No specialized treatments including oxygen therapy and/or use of BiPAP. Review of the resident's physician's order sheets (POS) dated [DATE], showed; -Full code; -Continuous BiPap every shift. Review of the facility's Daily Assignment Sheet, dated [DATE], showed: -One nurse, and three CNAs scheduled for the night shift 7:00 P.M. through 7:00 A.M., on the 100 hall. Review of the Florissant Valley Fire Protection District (FVFPD) EMS run sheet, dated [DATE] at 1:01 A.M., showed: -EMS responded to the facility for a resident with ineffective breathing; -Found the resident lying in bed, unresponsive; -Staff was performing CPR (Cardiopulmonary Resuscitation, an emergency lifesaving procedure performed when the heart stops beating); -The resident was nonverbal and was in respiratory arrest with a palatable pulse noted to his/her carotid (neck) and radial (wrist) region; -Staff was unable to report any notable history of the patient; -Implied consent was used to treat and transfer the resident. Review of the resident's progress notes showed: -On [DATE], at 1:40 A.M., this nurse responded to a phone call from 911 stating they were on their way to a resident calling and saying he/she can't breathe. The nurse immediately stopped what they were doing and found nursing personnel. The CNA from 200 hall went to check on the resident and the nurse went to find the resident's nurse which took about one minute. The nurse informed the 100 hall nurse, which was the resident's nurse, about the call. That nurse walked in the room while this nurse was walking back towards 200 hall getting coded status. This nurse was called to the resident's room by the other nurse, so he/she did not make it to check the code status. CNA noticed green dot near door which means full code. As he/she entered the room the resident was unresponsive and was pale/grey. The nurse checked carotid and radial pulse which was very faint. He/She did not start CPR. The nurse asked the CNAs to raise the bed and make it as flat as possible and he/she continued to assess the resident. He/She grabbed oxygen and placed it on the resident. As he/she was placing the oxygen EMS arrived and took over. This nurse provided EMS the face sheet and medication list; -On [DATE] at 3:29 A.M., writer made aware by staff that resident called 911 himself/herself due to difficulty breathing. The writer along with staff nurse entered the resident's room and found resident not responsive to verbal stimuli or sternal rub. Weak radial and carotid pulse were found. Staff applied oxygen from crash cart when paramedics arrived and transported resident to the emergency room (ER). Responsible party called, no answer, voice mail inbox full. Nurse Practitioner and nursing management made aware; -On [DATE] at 7:43 A.M., Late entry: Spoke with nurse, resident's vitals were not indicative of starting CPR. EMS arrived and did not see necessity to start CPR while in the building. EMS then transported the resident to the hospital. During an interview on [DATE] at 7:20 A.M., LPN X said, he/she was working the night the resident was sent to the hospital. EMS called the facility to report the resident had called 911 and they were in route to the facility. He/She was not working on the resident's hall. The agency nurse who was assigned to work the hall was outside in his/her car on break. The agency nurse came back inside after LPN X sent a CNA out to get him/her. LPN X was originally scheduled to work on the 100 hall, but the 200 hall nurse called in and he/she was pulled to the 100 hall. There was usually one nurse on each hall during the night shift. At times the 300 and 400 halls would have two nurses but that was rare. It was very difficult to care for ,d+[DATE] residents for 12 hours by yourself. The facility didn't have enough staff to adequately care for the number of residents they have. During an interview on [DATE] at 5:01 P.M. Paramedic I said the resident called 911 himself/herself. He/She reported his/her call light had been on an extended period of time and no staff would respond. He/She was having difficulty breathing. The resident sounded like he/she was in respiratory distress. An ambulance was immediately dispatched to the facility. In the meantime, EMS attempted to contact the facility and make them aware of what was going on. It took a long time for any staff to answer the phone and receive report. When EMS arrived at the facility the resident was lying in bed with his/her phone still on the bed. Staff were attempting CPR. The resident was transported to the nearest hospital. This particular facility did not have enough staff and not enough trained staff. EMS had been called to the facility 126 times in the past 90 days. Most of the time, staff were calling because they didn't know how to operate the equipment at the facility. Or, residents called because there was not enough staff to meet their basic care needs. During an interview on [DATE] at 7:42 A.M., CNA KK said, he/she was not working the night the resident was sent the hospital. He/She heard the resident called 911 himself/herself. That was not unusual for residents. The facility had a lot of residents that called 911 themselves when they couldn't get staff to help them. The call light system did not light up. The facility used a lot of agency staff because they could not keep staff. The facility was very short of staff. Two employees could not possibly care for ,d+[DATE] residents at a time. During an interview on [DATE] at 7:01 A.M., CNA DD said normally there were two CNAs on the night shift. They were responsible for showers, getting residents to bed and keeping residents clean and dry. Then, in the early morning they had to get residents back up for breakfast. It was too much for just two staff. There had been times when only one CNA was assigned to the hall. During an interview on [DATE] at 7:10 A.M., CNA JJ said he/she didn't think there was enough staff to meet the needs of the residents. Night shift had about ,d+[DATE] showers, there were a lot of residents that were two person assist. They usually had between ,d+[DATE] residents on the 100 hall. Two staff couldn't take care of that number of residents and do everything that was supposed to get done. 2. Review of Resident # 46's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -No refusal of care; -Always incontinent of bowel and balder; -At risk for pressure ulcers. Review of an EMS trip sheet, dated [DATE], at 2:26 P.M., showed an ambulance was dispatched to the facility for the resident. EMS crew documented: -Arrived to find male/female subject A&O x 4 (alert and oriented to person, place, time and event) in bed in no obvious distress with complaints that he/she cannot get any of the facility staff to answer his/her call light; -Resident states that his/her oxygen tubing came off his/her oxygen delivering unit, and he/she needed it placed back on, but no one was answering the call light, so he/she had to call 911; -Resident was attempting to get a hold of a facility worker, no one was answering his/her call light; EMS arrived on scene to find one facility worker sitting in a commons area with a blanket and cell phone in hand; -Facility employee was not aware of the call light; -When in the resident's room, the resident's roommate was also in need of assistance from the facility staff due to him/her dropping his phone on the ground when also attempting to call 911 for assistance of subject; -The resident was placed back onto his/her oxygen and was asked if he/she needed any medical attention; -He/She states he/she only called 911 because the staff was not answering his/her call light nor his/her verbal callings for help; -Resident was offered transportation to the hospital for further evaluation multiple times; -Resident refuses transportation multiple times under his/her own will, signature obtained; -At the time of obtaining signature facility staff had walked away and out of the wing of the nursing home with no line of site to any of the call lights; Review of an EMS report dated [DATE] at 6:00 P.M., showed EMS staff documented: -EMS called to the facility by the resident; -Staff was not aware; -Upon arrival to the nurse's station, EMS staff asked facility staff what room they were supposed to go to; -Staff made no effort to come to the room and see why the resident had called 911 or what was going on with the resident; -The resident was cognitively intact; -Resident reported he/she notified nursing staff at 8:00 A.M., he/she was soiled and needed to be cleaned up and changed; -The resident was lying on a bed with no sheet, just one disposable pad under him/her; -The pad was completely soiled and saturated with feces and urine; -The disposable pad was completely soaked through and when the resident was moved, a standing puddle of urine was noted on the mattress; -Staff made no effort to talk to EMS or ask any questions about the resident as EMS walked pass the desk. During an interview on [DATE] at 8:05 A.M., the resident said he/she has called 911 multiple times. The last time he/she called was because staff had not changed him/her all day and he/she was soaked with urine and feces. Staff said they were short of staff all the time and/or they ignored his/her light During an interview on [DATE] at 10:00 A.M., CNA C said call bells should be answered timely. If a call light went off and he/she was with a resident, he/she would finish with that resident then go to the resident who was ringing. 3. Review of Resident #245's medical record, showed: -admitted to the facility on [DATE]; -Diagnoses included cerebral infarction (stroke), hemiplegia (muscle weakness or partial paralysis on one side of the body), acute respiratory failure (enough oxygen in the tissues in your body or when you have too much carbon dioxide in your blood), and dysphagia (difficulty swallowing), unspecified protein-calorie malnutrition; -Physician's order for NPO (nothing by mouth) diet; -Physician's order of Jevity 1.5 Cal (high protein and fiber supplement) for enteral feed (tube feeding, method of providing nutrition to patients who are unable to eat or swallow safely), 70 milliliters per hour (ml/hr), with 150 ml/hour of water every 4 hours. Review of the resident's care plan, revised on [DATE], showed: -Focus: has a g-tube and is at risk for enteral nutrition complications; -Goal: Will be able to tolerate enteral support without pulling at tube and causing trauma to nares (openings of the nose) or stoma (a small opening in the abdomen that is used to remove body waste (feces and urine) into a collection bag), no gastric distress, diarrhea, abdominal distention; -Interventions: Check for tube placement as ordered, notify Physician if unable to tolerate tube feeding, observe for abdominal distention, regurgitation, nausea, abdominal pain, diarrhea, congestion, change in level of consciousness (LOC), fever, and notify Physician of occurrence, observe for signs and symptoms of infection and report any findings to Physician. Observations on [DATE] at 7:04 A.M. and 10:49 A.M., showed the resident lay in bed. His/Her tube feeding pump was off. An empty 1000 ml bottle hung on the pole. The bottle was dated [DATE], at 4:00 P.M. During an interview on [DATE] at 11:02 A.M., LPN D said he/she was assigned to Hall 400 and there was supposed to be another nurse on Hall 300 where the resident resided. LPN D said the resident had an order of Jevity 1.5 Cal and was supposed to be a continuous infusion. He/She was not notified there was not a nurse on Hall 300 and was not aware the resident's tube feeding was not infusing. LPN D hung and started the tube feeding infusion as ordered at 11:15 A.M. During an interview on [DATE] 3:13 P.M., LPN F said tube feeding should be administered per physician's order. The staff were supposed to check the residents throughout the day to know if a new bag needed to be hung. He/She said the tube feeding pump beeped when the bottle was empty. LPN F added that there should be more staff on Halls 300 and 400 for the safety of the residents. He/She said there would only be one nurse at times. He/She said there were a lot of oversight, and the residents' care should be taken seriously, and the facility should provide sufficient and competent staffing. During an interview on [DATE] at 2:49 P.M., CNA AA said Halls 300 and 400 were supposed to have two nurses on day shift but sometimes there was only one. He/She said it would be difficult for one nurse to work on those halls. 4. Review of Resident #20's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Always incontinent of bowel and bladder; -Diagnoses included: high blood pressure, diabetes, chronic lung disease, and hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) or hemiparesis (a slight weakness in a leg, arm, or face). Observations on [DATE] of the resident's call light, showed: -At 5:45 A.M. the call light was on; -At 5:58 A.M., the call light remained on. Staff walked down the same hall as the resident's room and went into another resident's room whose call light was not on; -At 6:13 A.M., the call remained on. During an interview at 6:15 A.M., the resident said he/she turned the call light on 30 minutes ago and no one had come to answer it. He/She put the call light on for staff to dry him/her. The resident said staff did not routinely come in and check on him/her during the night. The resident had to ring the call light if he/she needed anything. Observation on [DATE] of the resident's call light, showed: -At 6:25 A.M., the call light was on; -At 6:31 A.M., the call light was on; -At 6:42 A.M., the call light remained on, the nurse was at the nurse's station; -At 6:50 A.M., the call light was on; -At 6:55 A.M., call light remained on. During observation and interview on [DATE] at 7:03 A.M., LPN Q said he/she personally did not know why the light was on and said call lights should be answered expeditiously. Observation on [DATE] at 7:15 A.M., showed the resident's call light remained on. Observation and interview on [DATE] at 7:38 A.M., showed the call light remained on. The resident said staff had not come to check on him/her. During an interview on [DATE] at 9:45 A.M., the resident said when he/she put the call light on, he/she normally had to wait for over an hour for someone to answer it. The resident said this made him/her feel like they were not important and what he/she needed was not important. 5. Observation on [DATE] at 4:04 A.M., showed CNA J sitting on a chair, in a corner of a common seating area by the 300 hall's nurses' station. CNA J had a bedsheet in the chair he/she was sitting on, and a table in front of him/her. On the table was a laptop, and a backpack on the floor next to the table. He/She appeared to be sleeping and had woken up when approached. He/She was stretching, and his/her eyes were red. He/She was somewhat disoriented and unable to answer immediately when asked if he/she was a staff. CNA J then said, No, no and tried to avoid the interview. He/She stood up and said he/she was a CNA and worked for an agency. No name tag was observed. During an interview on [DATE] at 6:04 A.M., CNA HH assigned to Hall 300 said the evening or midnight shift started at 7:00 P.M. and ended at 7:00 A.M. The CNAs did patient rounds every two hours. He/She did not have time stop because there was so much to do. There were eight residents with tracheostomys on the 300 hall. CNA HH also assisted CNA J who was assigned to the 400 hall which had more patients with tracheostomys. CNA HH said he/she did not have training on tracheostomy care but had [AGE] years CNA experience. He/She notified the nurse if the residents required suctioning or any tracheostomy care. There was one nurse and two CNAs assigned to the 300 and 400 halls. 6. During interview on [DATE] at 10:32 P.M., the ADON said she expected the staff to not sleep or nap during their shift. Staff were expected to do patient rounds and make sure call lights were being answered. The staff could not leave the facility during their 30-minute breaks. The ADON agreed the 300 and 400 hall residents were of higher acuity and should have more staff. She said she would not do it if she would be assigned to these halls because it would not be safe. The ADON added that tube feedings should be administered as ordered by the physician. The midnight shift nurse was responsible for changing the tubing every 24 hours. 7. During an interview on [DATE] at 7:15 A.M., the Staffing Coordinator (SC) said the night shift worked 7:00 P.M. to 7:00 A.M. and should be staffed daily including weekends with three floor nurses and six CNAs. The facility should have one licensed nurse on each of the three units and two CNAs were scheduled each night for the three units. The facility utilized agency staff on a frequent basis. Day shift worked 7:00 A.M. to 7:00 P.M. and should be staffed daily including weekends with six nurses, one wound nurse and one Certified Medication Technician (CMT). Three CNAs were scheduled on each of the three units. Respiratory therapists worked Monday through Friday on the day shift. During an interview on [DATE] at approximately 5:00 P.M., LPN R said typically the facility had three nurses on the night shift, one nurse on each hall. But half of the time the facility had two nurses, one nurse for the 300 and 400 halls and one nurse for the 100 and 200 halls. In addition to the nurse, each hall typically had two CNAs but sometimes there were only two CNAs for the whole building. Sometimes a hall would start off with two CNAs, but one CNA may leave early or sometimes a CNA was sent home early. Review of text messages sent from LPN R to the DON, undated, showed: -LPN R: sorry to bother you; -DON: what's up; -LPN R: I'm at work, I keep going through the same things with the same aide, he/she left on break with multiple lights on and people needing to be changed; -DON: I hate you're (message cut off). Review of a text message sent from LPN R to the on-call phone, dated [DATE] at 2:03 A.M., showed: We have two aides that been gone and unable to be found since 12 tonight this is the second time this happened during a shift. During an interview on [DATE] at 3:09 P.M., the Administrator said he expected the facility to have sufficient staffing. The staff should not be sleeping during their shift. 8. During Resident Council interviews on [DATE] at 2:00 P.M., residents said the longest wait time for call lights was between four and six hours. One resident said he/she saw six staff walk past call lights. During an interview on [DATE] at 12:08 P.M., CNA L said he/she answered the call light within five to ten minutes. He/She said no one should pass a room with the call light on. All of the residents belong to all of the staff so anyone passing by can answer the call light. He/She turned the call light off in the resident's room while he/she was completing whatever the resident asked him/her to do. He/She said the call light should not be turned off before completing the task because staff may get distracted and forget what the resident wanted. During an interview on [DATE] at 12:13 P.M., CNA M said when the call lights go off, they are supposed to check the room to see what's going on. He/She said if a lot of call lights were going off, he/she worked them from most important, such as resident being wet, to getting water. Sometimes it could get hectic but he/she answered the call lights as fast as he/she could. He/She encouraged residents to use his/her call light instead of yelling out for help. He/She said the call light should not be turned off before the resident was helped and no one should tell a resident they would be back and not go back. CNA M said if he/she could help the resident right then, he/she would. During an interview on [DATE] at approximately 12:30 P.M., CMT N said the call lights should be answered within five minutes and all staff should make sure the resident had his/her call light in reach before leaving the room. CMT N said the call light should not be turned off before the resident's request had been completed because staff might forget what the resident needed. He/She said anyone could answer the call light and no one should walk past a room if the call light was on. 9. During interview on [DATE] at 10:32 P.M., the ADON said residents' call lights should be answered in timely manner. She said any staff can answer to call lights. Not answering a call lights for one to two hours was unacceptable. 10. During an interview on [DATE] 3:09 P.M., the Administrator said call he would expect for the facility to have sufficient staff and he would expect for call lights to be answered timely. MO00239413 MO00241263 MO00241307 MO00242176 MO00242993 MO00243224 MO00243620 MO00243010 MO00242979 MO00243149 42247 45083 46970

Based on interview and record review, the facility failed to establish a system of record for all controlled drugs (drug or chemical that is regulated by the government in terms of its manufacture, possession, and use) with sufficient detail to enable an accurate reconciliation for two out of three medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 99. Review of the facility's Controlled Substances Policy, dated November 2022, showed: -The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. Review of the facility's Controlled Substance Shift Change Count-Check Sheet, dated 10/1/24 through 10/14/24, showed: -On the 100 hall: Oncoming shift, six out of 28 opportunities were blank and off going shift, nine out of 28 opportunities were blank; -On the 300-400 hall: Oncoming shift, three out of 28 opportunities were blank and off going shift, five out of 28 opportunities were blank. During an interview on 10/14/24 at approximately 10:30 A.M., Licensed Practical Nurse (LPN) F said controlled substances should be counted every shift. The oncoming nurse counts with the off going nurse. The number of packages is counted along with the number of pills. If the count was correct, both staff members sign the controlled substance shift count sheet (log). If there was a blank on the log, it would mean someone forgot to sign because the nurses are counting controlled substances and doing report at the same time. During an interview on 10/14/24 at 11:00 A.M., LPN H said the number of packages and the number of pills is counted with the oncoming staff and the off going staff every shift. If the count was correct, both staff members sign the log. If there was a blank on the log, that would mean the nurse did not sign the log. He/She did not know why someone would not sign the log. During an interview on 10/17/24 at 10:10 A.M., LPN NN said the oncoming and off going nurse count the controlled substances. If the count was correct, they both would sign on the log. If the log was not signed, that would mean the nurse did not sign. If the log was not signed, you would not know if they did the count or not. During an interview on 10/16/24 at 2:33 P.M., the Director of Nursing said controlled substances should be counted with two nurses, the on coming and the off going, every shift and documented in the controlled substance binder. If there was a hole on the control log, that would mean the nurse was not doing their job. During an interview on 10/21/24 at 3:08 P.M., the Administrator said he expected staff to follow the facility's policies and procedures.

Based on observation, interview and record review, the facility failed to label and store medications according to acceptable standards of practice, when staff failed to lock the medication carts on one hall, date medications when opened, failed to store an unopened insulin pen in the refrigerator, and date an opened vial of a purified protein derivative (PPD, used to diagnose tuberculosis (TB) infection). For three of three medication carts reviewed and one of two medication storage rooms reviewed. The facility identified six medication/treatment carts and three medication rooms. The census was 99. Review of the facility's Medication Labeling and Storage Policy, dated 2001, showed: -Policy statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys; -Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location; -Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial, -The policy failed to show if and when medications should be dated. Review of the facility's Security of Medication Cart, dated April 2007, showed medication carts must be securely locked at all times when out of the nurse's view. 1. Observation on 10/10/24, of the 100 hall medication carts, showed: -At 5:45 A.M., one medication cart located across from the nurse's station, unlocked. There was no staff at the nurse's station or in view of the cart; -At 5:47 A.M., Licensed Practical Nurse (LPN) Q stood at the medication cart; -At 5:53 A.M., LPN Q walked away from the medication cart, leaving the cart unlocked. The second medication cart located in the hall in front of the common area, unlocked and not in view of staff; -At 5:55 A.M., LPN Q returned to second medication cart; -At 5:57 A.M., LPN Q walked away from the second medication cart, the lock on the medication cart partially pushed in; -At 5:58 A.M., LPN Q returned to the second medication cart and unlocked the cart by pulling the lock out (no key used), the first medication cart remains unlocked and unsupervised; -At 6:02 A.M., LPN Q returned to the second medication cart and unlocked it by pulling the lock out (no key used); -At 6:25 A.M., both medication carts were unlocked, no staff present at the nurse's station or in view of the carts; -At 6:31 A.M., staff locked the second medication cart, the first medication remained was unlocked. During an interview on 10/16/24 at 9:55 A.M., LPN H said when the medication cart was not in use the medication cart should be locked. During an interview on 10/17/24 at 10:10 A.M., LPN NN said the medication cart should be locked when it is not in use. 2. Review of the package insert for Novolog insulin (short acting) recommended storage, showed store unused Novolog in a refrigerator between 36 Fahrenheit (F) to 46 F. Review of the insulin lispro pen (short acting insulin) manufacturers instructions for use, showed: -In-use Pen: Store the Pen you are currently using at room temperature. Keep away from heat and light; -Throw away the Insulin Lispro Pen you are using after 28 days, even if it still has insulin left in it. Observation on 10/14/24 at 9:55 A.M., the 200 hall nurse's cart, showed: -One Novolog insulin pen stored on the medication cart that was unopened; -One insulin Lispro pen opened and undated. During an interview on 10/14/24 at 9:55 A.M., LPN E said unopened insulin pens should be stored in the refrigerator until they are opened. The insulin lispro was started the end of last month or it was started on the first of this month. 3. Review of the Food and Drug Administration (FDA) website, showed purified protein derivative (PPD) solution should be discarded 30 days after opening or if the solution becomes cloudy. Observation on 10/14/24 at approximately 10:30 A.M., of the 300-400 hall medication room, showed one vial of a PPD, opened and undated. During an interview on 10/14/24 at approximately 10:30 A.M., LPN F said the PPD was opened 10/5/24. Observation at this time showed LPN F wrote the date of 10/5/24 on the PPD solution at this time. 4. During an interview on 10/16/24 at 9:55 A.M., LPN H said injectable medications should be dated when they are opened. 5. During an interview on 10/16/24 at 2:33 P.M., the Director of Nursing (DON) said the medication cart should be locked when it is stored. Insulin and PPD solution should be dated when opened. Insulin should be discarded after 28 days for all insulins. Unopened insulin should be stored in the refrigerator. 6. During an interview on 10/21/24 at 3:09 P.M., the Administrator said the medication cart should be locked when not in use. Injectables should be dated when opened and unopened insulin should be stored in the refrigerator.

Based on interview and record review, the facility failed to have a complete and thorough facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. The facility assessment did not address complete staffing needs to include respiratory therapists, restorative therapy, social services, and dietary service staff. In addition, the facility assessment failed to address staff competencies to meet the needs of residents. The census was 99. Review of the facility's undated Facility Assessment, showed: -No names and/or titles of staff involved in completing assessment; -Average daily census: 90; -Special treatments and conditions: -Oxygen therapy: 14-20 on average; -Suctioning: 7-10 on average; -Tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) care: 7-10 on average; -Ventilator (provides mechanical ventilation/breathing) or respirator (an apparatus used to induce artificial respiration): 1; -Bilevel positive airway pressure (BIPAP, non-invasive breathing device that helps people breath)/continuous positive airway pressure(CPAP, a machine that delivers positive airway pressure to aide in breathing): 5-8 average; -Staff Type/Plan: The following contains the facility's budgeted staffing plan. Staff will be adjusted based on resident needs and the skill levels of available staff. CNAs (Certified Nurse's Aides) to residents: 1:15 ratio on days, and 1:18 on nights; -Residents independent for dressing 7, bathing: 5, transfers: 14, eating: 62, toileting: 8; -Residents requiring assist of 1-2 staff for dressing 52, bathing: 58, transfers: 49, eating:11, toileting: 52; -Residents dependent for: Dressing: 23, bathing: 19, transfers: 19, eating: 9, toileting: 15; -No documentation of ratios of direct care staff, for tracheostomy care, restorative therapy staff, Social Services staff, dietary staff, housekeeping and laundry staff necessary on each shift to ensure the needs of residents are met; -No documentation of the need for a Registered Respiratory Therapist, or the need for respiratory therapy 24 hours a day, seven days a week; -No information regarding staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population. During the course of the survey process, problems were identified which included: -Insufficient nursing staff available to meet the needs of residents, as evidenced by staff interviews, residents with missed treatments, and residents with inappropriate tracheostomy care; -Respiratory therapy was not scheduled 24 hours a day, seven days a week. During an interview on 10/21/24 at 2:27 P.M., the Administrator said the facility assessment is developed by the Administrator and reviewed by the facility's Regional office and facility's interdisciplinary team. The facility assessment is updated annually unless needed otherwise. He expects the facility assessment to accurately reflect the facility's general staffing needs, including staff ratios. The facility assessment should include all of the facility's resources as they pertain resident care needs.

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards when staff failed to perform hand hygiene between glove changes and failed to wear appropriate personnel protective equipment (PPE) for four residents (Residents #243, #82, #73 and #52) who required Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs, bacteria or fungi resistant to multiple antimicrobials (an agent that kills microorganisms or stops their growth)); that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS). In addition, the facility failed to assure a resident's Foley catheter (or indwelling catheter, a thin and hollow tube that's inserted into the bladder to drain urine) bag was off the floor for one resident (Resident #244). The sample was 33. The census was 99. Review of the facility's Enhanced Barrier Precautions Policy, dated 2001, showed: -Policy statement: enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents; -Gloves and gown are applied prior to performing the high contact resident care activity; -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: -Dressing; -Bathing/showering; -Transferring; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of [NAME] colonization; -Wounds generally include chronic wounds (wound that doesn't heal; heal slowly or heals but tends to recur); -Indwelling medical devices include urinary catheters (a sterile tube inserted into the bladder through the urinary tract to drain urine) and feeding tubes. Review of the EBP sign, undated, showed: -Everyone must: clean their hand including before entering and before leaving the room; -Providers and staff must wear gown and gloves for the following high contact resident care activities: -Dressing; -Transferring; -Changing linens; -Providing hygiene; -Changing brief; -Device care or use: urinary catheter. 1. Review of Resident #243's entry Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/30/24, showed he/she was admitted to the facility on [DATE]. Review of the resident's medical record, showed: -Diagnoses included malignant neoplasm (cancerous tumor) of mouth, tracheostomy (a surgical procedure that creates an opening in the neck to provide an airway and help with breathing), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) and high blood pressure. Review of the care plan, in use at the time of survey, showed: -Focus: The resident requires a tracheostomy and is at risk for complications related to accidental decannulation (removal of a tracheostomy tube); -Goal: Will have no signs or symptoms of complications with tracheostomy tube to the extent possible; -Interventions: Administer medications as ordered, change trach ties as ordered and as needed, ensure ties are secure, encourage to cough out secretions. Observation on 10/10/24 at 8:32 A.M., showed Registered Respiratory Therapist (RRT) CC entered the resident's room, applied gloves, gown, surgical mask and eye goggles. He/She placed a trash liner into a trash bin, then removed his/her gloves and replaced with clean ones, with no hand hygiene in between. He/She then removed the old tracheostomy dressing with light blood drainage stained on the dressing and placed it in the trash bin. He/She proceeded to clean the resident's tracheostomy area with cotton swabs, cleaning each side of the stoma (opening), wearing the same gloves. He/She removed the gloves after throwing the cotton swabs away and applied a pair of clean gloves. No hand hygiene was performed. He/She lowered the head of bed with a gloved hand, touching the bed controls. Using the same gloves, RRT CC applied a clean dressing to the tracheostomy site and adjusted it to fit. He/She removed the gloves and elevated the head of the bed. He/She applied clean gloves with no hand hygiene performed. He/She obtained a suction tool (Yankauer, suction tip is an oral suctioning tool used in medical procedures), and suctioned the resident's mouth, then placed the suction tool into its original packaging and in a plastic bag, then hung it unto the wall. 2. Review of Resident #82's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high blood pressure, anemia (decrease in number of red blood cells) and spinal stenosis (narrowing of the spinal canal); -Number of unstageable (unable to visualize wound bed) pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction) with suspected deep tissue injury (when a deep pressure injury is suspected but can't be confirmed) in evolution: eight. Observation on 10/10/24 at 4:30 A.M., showed an EBP sign outside the resident's room. The resident lay in bed. Certified Nurse Aide (CNA) V emptied 1200 milliliters (mL) of urine from the resident's catheter bag. The CNA did not wear a gown. The CNA unfastened the resident's brief and rolled the resident towards the door. The resident had a bowel movement. The CNA removed the dressing from the coccyx (a small triangular bone at the base of the spinal column) and said the Wound Nurse would do the dressing in the morning. He/She used a disposable wipe to clean the resident's back side and folded a clean pad and sheet halfway under the resident, applied an antifungal cream to his/her bottom, rolled the resident towards the window, positioned the sheet and brief under the resident and rolled the resident onto his/her back. CNA V used a disposable wipe to clean the resident from front to back, and fastened the brief. The CNA did not wear a gown or change his/her gloves when going from dirty to clean areas while providing care. 3. Review of Resident #73's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included cancer, anemia and high blood pressure; -Number of unstageable pressure ulcers with suspected deep tissue injury in evolution: one. Observation on 10/10/24 at 4:45 A.M., showed a sign for EBP on the wall outside the room. The resident lay in bed. CNA O performed hand hygiene and put on gloves, unfastened the resident's brief, used a disposable wipe, and performed peri care (cleansing between the legs and buttocks area). The resident rolled over and the CNA wiped the resident's back side. There was no dressing on the open wound on the resident's coccyx. CNA O rolled the resident onto his/her back and fastened the brief, put a gown on the resident, adjusted his/her socks and covered he resident up then he/she removed his/her gloves. The CNA did not wear a gown while providing personal care and did not change his/her gloves when going from dirty to clean areas while providing care. 4. Review of Resident #52's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included diabetes, high blood pressure, stroke and hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) or hemiparesis (slight weakness in a leg, arm, or face). Review of the care plan, in use at the time of survey, showed: -Focus: resident had a gastronomy tube (g-tube, feeding tube) and is to be flushed for patency; -Interventions: flush g-tube per doctor's orders. Observation on 10/10/24 at 7:15 A.M., showed no EBP sign outside the resident's door. The resident lay in bed. CNA C provided peri care and placed a clean brief on the resident. When the resident was rolled onto his/her side, a g-tube was observed. The mechanical lift pad was placed under the resident. CNA C and CNA A used the mechanical lift to transfer the resident into the chair. Neither CNA wore a gown while providing personal care or while transferring the resident. 5. During an interview on 10/21/24 at 9:25 A.M., the Infection Control Preventionist (ICP) Nurse said residents who have wounds, urinary catheters and g-tubes required EBP and staff should wear a gown and gloves while providing direct resident care. Staff know which residents require EBP because they have a sign outside their door. Staff should perform hand hygiene when they enter the resident's room and apply gloves, they should clean the peri area from front to back, remove the gloves and perform hand hygiene and apply new gloves when they go from a dirty to clean area. Hand hygiene should also be performed after they finish providing care. The packages of disposable wipes are for single resident use. 6. During an interview on 10/21/24 at 10:32 A.M., the Assistant Director of Nursing (ADON) said she expected staff to perform hand hygiene in between glove changes. Staff are expected to use hand sanitizers or wash with soap and water. She also expected staff to wear the required PPE for residents on EBP. 7. Review of Resident #244's admission MDS, dated [DATE], showed: -Adequate hearing, unclear speech, usually understood, usually understands; -Impairment of both sides of upper and lower extremities; -Dependent on self-care. Review of the resident's medical record, showed diagnoses included anoxic (deficient in oxygen) brain damage, chronic respiratory failure, tracheostomy, gastrostomy and cognitive communication deficit. Review of the care plan, in use at the time of survey, showed: -Focus: The resident was at risk for complications with urinary system related to indwelling catheter; -Goal: Will have no complications of infections related to the urinary device; -Interventions: Administer medications as ordered, notify physician of signs and symptoms of urinary tract infection (UTI) such as mental status changes, foul smelling urine, color change in urine, hematuria (blood in the urine), sedimentation, burning with urination, increased temperature, privacy cover to catheter bag as indicated to promote dignity. Review of the resident's physician's orders, started on 9/29/24, showed Meropenem Solution Reconstituted (used to treat infections caused by bacteria) 1 gram (GM), intravenously (IV, fluids or medications administered within the veins) every 12 hours for bacterial infection, for 7 days. Review of the resident's progress notes, showed documentation, dated on 9/24/24 at 6:41 P.M., 9/27/24 at 3:27 P.M., and 10/13/24 at 5:16 P.M., of abdominal distention and blockage in his/her Foley catheter. Observation on 10/10/24 at 8:13 A.M., showed the resident's Foley bag lay on the floor, on top of the floor mat. The bag was not placed in a privacy bag and was behind the privacy curtain. During an interview on 10/18/24 at 3:13 P.M., Licensed Practical Nurse (LPN) F said Foley bags should be off the floor at all times to prevent infection. 8. During an interview on 10/21/24 at 9:25 A.M., the ICP Nurse said the residents' Foley bags should be off the ground. The bag should be changed when observed contact to the ground. The staff were expected to apply PPE when providing care to residents with Foley catheter. 9. During an interview on 10/21/24 at 3:08 P.M., the Administrator said he expected staff to follow the facility's infection control policies and procedures. 45083

Based on observation, interview and record review, the facility failed to immediately notify a resident's responsible party (RP) after the resident eloped from the facility (Resident #38). The facility also failed to notify two residents' RPs after a change in condition (Resident #196 and #89). In addition, the facility failed to notify the RP after a transfer to the emergency room (Resident #243). The sample size was 33. The census was 99. Review of the facility's change in a resident's condition or status policy, revised November 2015, showed: -Policy statement: The facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, residents rights, etc.); -A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting); b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan; and d. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument; -Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. there is a significant change in the resident's physical, mental, or psychosocial status; c. there is a need to change the resident's room assignment; d. a decision has been made to discharge the resident from the facility; and/or e. it is necessary to transfer the resident to a hospital/treatment center. 1. Review of Resident #38's Fire Protection District report, dated 9/14/24, showed: -Transportation Date: 9/14/24; -Onset Time: 5:00 A.M.; -Emergency Medical Services (EMS) dispatched to a residence with a chief complaint of a confused person. EMS responded with lights and sirens. EMS arrived on scene to find the police standing on the side of the road. Per police, a passerby called 911 of an old man/woman wandering around with no shoes on. Per police, the patient is confused and can't answer questions correctly. Patient is a [AGE] year-old man/woman with a chief complaint of altered mental status. Patient is alert and oriented to self. Patient states he/she was from East St. Louis and did not know how he/she got to the area. Patient sat and secured to stretcher for safety. Patient loaded into hospital and taken to the hospital. Review of the hospital's Health Facility Transfer Chart, showed: -admitted [DATE]; -Expected discharge date of [DATE]; -Oriented to person, disoriented to place, disoriented to situation, disoriented to time; -Final Diagnosis: Altered mental status; -Presenting History: Patient presented to the emergency room from street via police with concern for altered mental status. Patient is resting in bed. He/she says he/she is feeling better. No further history from patient. Per the hospital social worker, patient has a piece of paper with him/her stating the resident's name, identification number, room number, diet order: mechanical soft, regular double portions, thin liquids. -Per fire house staff, the patient was picked up 0.2 miles away from the facility. Review of the resident's progress note, dated 9/18/24 at 3:31 P.M., showed at 1:50 P.M., the resident arrived from the hospital to the facility. Call placed to the nurse practitioner and made her aware the resident has returned to the facility. -No information regarding notification of the RP. During an interview on 10/11/24 at 1:33 P.M., the resident's family member said he/she received a call around 9:00 A.M. or 10:00 A.M. on 9/14/24 from the facility asking if he/she picked up the resident because they could not locate him/her. He/she immediately went to the facility. When he/she arrived, they told him/her the resident was in the hospital. During an interview on 10/11/24 at 2:12 P.M., the Administrator said he was out of town when the incident occurred. The Director of Nursing (DON) received a call and found out the resident was picked up by the police in front of the facility. The family was not notified immediately following the incident because they did not have all of the information. All staff denied knowing anything about the incident and the staff who initially contacted the RP was through a nursing agency and they could not get ahold of him/her to ask questions. The DON should have told the RP the resident was actually missing. 2. Review of Resident #196's medical record, showed: -admitted on [DATE]; -admitted to hospice services on 9/6/24; -Was a full code; -Diagnoses included chronic respiratory failure, anoxic brain injury (occurs when the brain is deprived of oxygen), tracheostomy (opening created in the front of neck to create an air passage), pressure ulcer ( injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure or friction to sacral region (tailbone), severe protein-calorie malnutrition and dysphagia (difficulty swallowing); -A family member was designated as a #1 emergency contact. Review of the resident's admission Minimum Data Set (MDS), dated a federally mandated assessment instrument completed by facility staff, dated 8/30/24, showed: -The resident was dependent on staff for all activities of daily living; -Had a swallowing disorder; -Had a Gastrostomy (g-tube, a tube surgically inserted through the abdomen into the stomach to provide hydration, nutrition and medications); -Received oxygen therapy; -Received suctioning; -Received tracheotomy (a surgical procedure that creates an opening in the neck to provide an airway and help with breathing) care. Review of a progress note dated 9/11/24, showed -At 7:19 A.M., Registered Nurse (RN) T documented, a change of condition noted during this shift with increased heart rate ranging from 146-165 (normal heart rate 6-100) and shallow breathing. Breathing treatment and comfort medication administered. Hospice notified and advised to keep monitoring and giving comfort medications. Incoming nurse notified and will notify the family. Nurse Practitioner (NP) notified; -At 8:25 A.M., the resident's responsible party was notified; -At 5:24 P.M., the nurse on duty was alerted by the aide to come to the resident's room due to a possible code. Upon arriving to the resident's room, the nurse observed two respiratory therapists (RT-a healthcare professional who treats patients with breathing difficulties) at the bedside with the resident's family member. One RT was checking for a pulse the other was preparing the Ambu bag (a medical tool used to force air into the lungs of patients who are not breathing; or are not breathing adequately so still need assistance) that was at the bedside. During an interview on 10/1/04 at 1:46 P.M. Licensed Practical Nurse (LPN) F said on 9/11/24, the day shift nurse did not show for the day shift. At about 7:15 or 7:30 A.M., he/she went over to get report from the night shift nurse. RN T told him/her the resident had a change in condition overnight. When he/she asked RN T if he/she had contacted the family, RN T said no. He/She was going to let the day shift nurse notify the family. LPN F instructed RN T to call the family. RN T called the family around 8:30 A.M. The family was upset and questioning why the resident had not been sent to the hospital for evaluation. During an interview on 10/2/24 at 3:32 P.M., RN T said: -The resident's heart rate kept going up and down all night; -Around midnight the resident's oxygen saturation monitor kept beeping; -The machine showed the resident's heart rate was elevated; -He/She suctioned the resident and provided the resident with a breathing treatment and the resident's heart rate dropped back to normal; -Around 4-4:30 A.M., the resident's oxygen monitor alarmed again, he/she suctioned the resident again and provided a breathing treatment and the resident's heart rate dropped back to normal; -The resident did have shallow breathing; -He/She notified hospice and the Nurse Practitioner (NP) about the resident's change in condition; -Both the hospice nurse and the NP told him/her to keep giving the resident his/her medications and to continue monitor the resident's condition; -When he/she gave report to the oncoming nurse, the oncoming nurse told him/her to notify the family; -Around 7:45 to 8:00 A.M., he/she called the resident's family member; -The resident's other family member called the facility back and wanted to know why the family had not been notified of the change in condition when it happened and why was the resident not sent to the hospital for a change in condition; -He/She should have called the resident's responsible party at the time the change in condition was noted. During an interview on 10/3/24 at 2:31 P.M., NP U said: -RN T did notify him/her about the resident's change in condition; -He/She expected the nurse to follow the facility policy and call the power of attorney and inform them of the resident's change in condition. During an interview on 10/1/24, at 3:00 P.M., the DON said he would expect nurses to notify the resident's responsible party after change of conditions or an incident and document in the progress notes. 3. Review of Resident #89's admission MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included: heart failure, end stage renal disease (ESRD, chronic irreversible kidney failure), and hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) or hemiparesis (a slight weakness in a leg, arm, or face); -Does this resident have one or more unhealed pressure ulcers at stage one (a reddened, painful area on the skin that does not turn white (blanch) when pressed) or higher? NO. Review of the resident's medication records, showed: -An admission/readmission evaluation assessment, dated 10/8/24, showed: -Skin evaluation, comments: resident noted with a 1 X 0.1 centimeter (cm) open area to right buttocks with 2 smaller area to right buttocks measuring 0.5 x 0.5, foam dressing applied; -No documentation the resident's representative (RR) had been notified. Observation on 10/16/24 at 9:15 A.M., showed the resident was lay in bed. The Wound Nurse assisted the resident onto his/her side. The resident had several open areas on his/her sacrum and right buttocks. The wound nurse described all the areas as stage 3 pressure ulcers (full thickness tissue loss, subcutaneous fat may be visible, but the bone, tendon or muscle is not exposed. Slough (yellow/white material in the wound bed) may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). Review of the progress notes dated 10/8/24 through 10/18/24, showed: -On 10/17/24 at 8:55 A.M., Skin assessment performed on resident 10/16/24. open areas found on sacrum and right buttock. Measurements obtained, Triad paste (barrier) and foam dressing applied. The wound doctor made aware and will see resident today 10/17/24. -There was no progress note showing the resident had wounds prior to 10/17/24 and there was no documentation showing the RP was made aware of the wounds. During an interview on 10/17/24 at 9:05 A.M., RR XX said on 10/12/24 the nurse was putting the resident into bed and the resident yelled out. The nurse assessed the resident, and the resident had a dressing on his/her buttocks. The RP said they were never notified the resident had wounds. 4. Review of Resident #243's medical record showed: -Initial admitted [DATE]; -Diagnoses included malignant neoplasm (cancerous tumor) of mouth, tracheostomy, gastrostomy, and high blood pressure; -Progress note dated 9/14/2024 7:43 A.M., showed the resident was sent to the hospital via ambulance due to respiratory distress; -Progress note dated 9/14/24 at 6:31 P.M., showed the resident returned to the facility -No documentation staff notified the family or responsible party of the resident's transfer to the hospitalization ; -Progress note dated 9/17 at 4:40 A.M., showed the resident was sent to the hospital due to change of condition; -Progress note dated 9/30/24 at 7:10 P.M., showed the resident was readmitted to the facility; -No documentation staff notified the family or responsible party of the resident's transfer to the hospitalization . During an interview on 10/10/24 at 11:55 A.M., the resident's emergency contact person said the facility did not notify the family of the resident's transfers to the hospital. They just found out when the hospital called. During an interview on 10/18/24 at 3:13 P.M., LPN F said the staff were expected to notify the family or responsible party for any changes of condition or hospitalization and should be documented in the electronic health records (EHR) 5. During an interview on 10/21/24 at 10:32 A.M., the Assistant Director of Nursing (ADON) said she expected the staff to notify the residents' physician and responsible party for any changes of condition and transfers. They should be documented in the EHR under progress notes. 6. During an interview on 10/21/24 at 3:09 P.M., the Administrator expected the staff to notify the family or responsible party to be notified for changes of condition and hospitalization s or transfers. MO00243620 MOO243224 42247 45083

42247 Based on interview and record review, the facility failed to ensure their licensed staff were competent in their knowledge of the facility policy and procedures for how to provide tracheostomy (tube surgically inserted into the trachea for the purpose of breathing) care and suctioning to residents. In addition, the facility failed to train their licensed nursing staff on the use of the facility's continuous oxygen monitoring system, piped in oxygen system, and the wall suctioning equipment. This had the potential to affect the 15 residents at the facility who had a tracheostomy and required frequent suctioning and oxygen saturation monitoring. The facility census was 99. Review of the facility's Suction Policy, revised [DATE], showed: Purpose: The purpose of this procedure is to help prevent nosocomial (facility acquired) infections associated with suctioning and to prevent transmission of such infections to residents and staff; General Guidelines: -Wash hands before and after suctioning and before and after manipulating any respiratory therapy equipment. -Wear sterile gloves on both hands when performing care of a tracheostomy and during endotracheal (in the trachea/windpipe) suctioning of residents, whether through the oropharynx (throat), endotracheal tube or tracheostomy; -Suction machines must be available at the bedside of residents who require suctioning because they cannot clear nasal, oral and/or respiratory secretions by themselves and also at the bedside of all tracheostomy and ventilator residents; -When disconnecting ventilator residents from ventilator breathing circuits to provide suctioning, direct the mist from the ventilator away from the resident's and the employee's faces, to prevent conjunctivitis. -A portable suction machine filter must be inspected weekly and changed as necessary. -The policy did not address the facility's use of a [NAME] Closed Suction System (a closed-circuit method for tracheal suctioning that uses a catheter (tube) that can be reused) for residents with a tracheotomy. The facility should have a policy for each specific type of suction machine used in the facility. The facility did not provide any manufactures guidelines to any of their equipment. The facility did not have a policy and or procedure guide for the use of their continuous oxygen monitoring system. The facility did not have a policy and or procedure guide for the use of piped in oxygen or suction system. During an interview on [DATE] at 12:55 P.M., Registered Respiratory Therapist (RRT) Z said the facility utilized a [NAME] closed suction system on the 200, 300, and 400 halls. Review of the [NAME] Closed Suction System for adults manufacturers guidelines, showed: The [NAME] Closed Suction System is a closed-circuit method for tracheal suctioning that uses a catheter that can be reused. Here are some steps for performing a [NAME] suction: -Prepare: Wash your hands, open the package, and remove all caps from the catheter. -Attach the catheter: Slide the catheter into the sleeve to the correct depth. -Suction: -Squeeze the thumb valve to create a vacuum; -Slowly remove the catheter while continuing to squeeze the thumb valve; -Do not leave the catheter in for more than 5 seconds; -Repeat until patient breathes easily or their lungs sound clear; -Slide the catheter in the sleeve to the color or number as you were told or measured. This is the suction depth. 1. Review of Resident #13's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Adequate hearing; -Speech Clarity: Unclear speech, slurred or mumbled words; -Makes Self Understood: Usually understood, difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability To Understand Others: Usually understands, misses some part/intent of message but comprehends most conversation; -Cognitively intact; -Diagnoses of heart failure (e.g., congestive heart failure (CHF, a long term condition that occurs when the heart cannot pump blood well enough to provide the body with a normal supply) and pulmonary edema (excessive fluid accumulation in the tissue or air spaces of the lungs), pneumonia (an inflammatory condition of the lungs), anxiety, depression, schizophrenia (a mental disorder characterized by recurring episodes of psychosis (a mental state marked by loss of contact with reality)), asthma (long-term inflammatory disease of the airways/lungs), and respiratory failure; -Respiratory Treatments: Oxygen therapy, suctioning, tracheostomy care, and non-invasive mechanical ventilator. Review of the resident's care plan, located in the electronic health record (EHR), showed: -Date Initiated [DATE] and Revised On [DATE]: -Focus: Requires an invasive mechanical ventilator and is at risk for respiratory distress; -Goal (revised on [DATE]): Secretions are mobilized and airway remains patent; -Interventions/Tasks: Assess tracheal tube, checking whether it is secure. Assess rate and quality of respiratory pattern. Assess vital signs. Call light in reach and answered promptly. Resident has a chronic ventilator and likes to hook himself/herself up to the ventilator (vent) nightly. It has been determined that the resident is not safe to take him/herself off of the vent although he/she continues to take his/her vent off at his/her own will. Resident has been educated that doing this puts him/her at harm for respiratory failure. Monitor oxygen saturation. Observation on [DATE] at 6:38 A.M., showed an unknown certified nursing assistant (CNA) alerted Licensed Practical Nurse (LPN) BB the resident needed to be suctioned. The LPN entered the resident's room and attempted to suction the resident. The resident told LPN BB he/she was not doing it correctly. LPN BB continued to attempt to suction the resident, but said he/she did not know what he/she was doing wrong. At 6:40 A.M. RRT Z entered the room and began to provide the needed suctioning. RRT Z said the resident's electronic oxygen saturation machine had been turned off when he/she entered the room with LPN BB. During an interview on [DATE] at 6:35 A.M., LPN BB said he/she learned tracheostomy care in nursing school, but did not have any experience at this facility. He/She was not provided any training or information specific to the facility's equipment and or policies and procedures. There were no training materials at the nurse's station. When he/she accepted the assignment to the facility he/she was not informed he/she would be responsible for ,d+[DATE] residents with a tracheostomy or residents on ventilators. He/She thought the monitoring board at the nurse's station and on the hallways was the facility's call light system. He/She was not given report about the residents when he/she arrived at the facility. During interviews on [DATE] at 7:15 A.M., and on [DATE] at 7:08 A.M., 8:15 A.M. and 11:15 A.M., RRT Z said he/she assisted to suction the resident (on [DATE]). The facility used a continuous oxygen monitoring system for residents with a tracheotomy. The monitoring system alerted with an alarm if something was wrong and it could not read a resident's oxygen level. He/She did not know who was responsible for maintaining the equipment and making sure it was in working order. Staff that were working should assess the equipment on a daily basis. Staff should ensure equipment was plugged in and working, sensors were intact and in place on the residents. The respiratory therapy staff had not inserviced the nurses at the facility on the use of the facility's specific equipment and policies. He/She was not aware of any competency training provided to nursing staff prior to working with residents who had a tracheostomy. During an interview on [DATE] at 11:20 A.M., the resident said he/she almost died this morning. The LPN did not know what he/she was doing. He/She was using the wrong tubing to try and suction the resident's trach. Residents called 911 themselves because staff were not trained how to deal with tracheostomy residents and ventilators. During an interview on [DATE] at 7:58 A.M., RRT EE said the facility had approximately 12 to 15 residents with a tracheostomy. All of the residents with a tracheostomy used the piped in wall oxygen and suctioning equipment. All RRT staff worked the day shift, (7:00 A.M. to 7:00 P.M.). The facility was in the process of training nursing staff on the facility's equipment and policies. During an interview on [DATE] at 12:25 P.M., Registered Nurse (RN) W said the facility staff were not trained on the facility's specific oxygen system, suctioning system or continuous oxygen monitoring system. The facility did not have enough trained staff to care for the amount of residents with a tracheostomy and or residents that require a ventilator. The facility did not have any respiratory therapists that worked on the evening/night shift and/or weekends and holidays. The continuous oxygen monitoring system malfunctioned all the time. At times the machine would alarm in a resident's room, but not at the nurse's station and/or on the monitoring screens in the hallways. Only the respiratory therapy department knew how to set and maintain the ventilators on the hallways. During interviews on [DATE] and [DATE] at 3:00 P.M. and 7:00 A.M., RN T said on the 7:00 P.M. to 7:00 A.M. shift, he/she is the only nurse working on the ,d+[DATE] hall. Respiratory therapists did not work after 5:00 P.M. He/she didn't know what the monitor screen at the nurses' station or on the hallways was used for. He/she knew how to do tracheostomy care. The facility did not provide any training regarding their policies on tracheostomy care or the how to use the equipment the facility utilizes. During an interview on [DATE] at 6:29 A.M., LPN GG said he/she had not been provided any additional training or inservicing on the specific equipment the facility used. When the facility asked agency staff to come to the facility, they asked if the nurse had any experience with tracheostomy care. During an interview on [DATE] at 11:10 A.M., the Administrator said the facility had hired some new respiratory therapists. He was hoping they could get them to stagger their shifts, so at least someone would be in the facility until 11:00 P.M. Facility nurses and agency nurses were not provided additional training for tracheostomy care. Staff were not provided competency education. Nurses should know how to provide tracheostomy care and ventilator care because, they are nurses. During an interview on [DATE] at 3:40 P.M., the facility's Medical Director said she thought the facility had a respiratory therapist on duty 24 hours a day, 7 days a week. She was unaware respiratory therapy staff were not in the facility on the evening/night shift. The facility should only put fully trained and competent nurses on the respiratory hall. Staff should be inserviced on the facility's policies and procedures prior to working. MO00241263 MO00242176 MO00242776 MO00242834 MO00242862 MO00242993 MO00242979 45083

Based on interview and record review, the facility failed to administer prescribed antibiotics, as prescribed by the physician, for a wound infection, and the wounds further deteriorated; failed to notify the Primary Care Physician of the resident's increased bruising; failed to promptly identify hemorrhaging following the debridement (removal of dead or infected tissue) procedure completed on two wounds; and failed to monitor for signs and symptoms of bleeding after wound debridement on a resident receiving an anticoagulant medication. On [DATE], the facility wound nurse accompanied the Wound Nurse Practitioner, who assessed the resident as needing a debridement procedure. The debridement was completed while the resident was receiving scheduled Xarelto (an anticoagulant medication which decreases the ability for blood to clot). The facility wound nurse failed to notify the Wound Nurse Practitioner of the dose of the Xarelto. No monitoring of the resident was implemented related to the increased risk for bleeding. At approximately 6:00 P.M., facility staff found the resident in his/her bed, bleeding from his/her wounds. Emergency services were called and the resident was sent to the hospital for evaluation and services. The resident's hospital admission diagnosis was hemorrhagic shock (caused by heavy bleeding, the heart can't get the body the blood and oxygen it needs to function), tachycardia (fast heart rate), and hypotensive (low blood pressure). The resident later died at the hospital (Resident #3). The facility also failed to complete treatment orders as prescribed and complete wound assessments for one resident who had a surgical wound (Resident #9). The sample was four. The census was 80. The administrator was informed on [DATE] at 4:59 P.M., of an Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor on-site verification. Review of the facility's wound care policy, undated, showed: -Purpose: To provide guidelines for the care of wounds to promote healing; -Verify that there is a physician's order for the procedure; -Review the resident's care plan to assess for any special needs of the resident; -The following information should be recorded in the resident's medical record; -a. Type of wound care given; -b. The date and time the wound care was give; -c. The position in which the resident was placed; -d. The name and the title of the individual performing the wound care; -e. Any change in the resident's condition; -f. All assessment data (i.e. wound bed color, size, drainage, etc.) obtained when inspecting the wound; -g. How the resident tolerated the procedure; -h. Any problems or complaints made by the resident related to the procedure; -i. If the resident refused the treatment and the reason(s) why; -j. The signature and the title of the person recoding the data; -Report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #3's medical record, showed: -admitted on [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease blocks air flow), respiratory failure (lungs can't get enough oxygen into the blood), hemiplegia and hemiparesis (muscle weakness or muscle paralysis) after stroke, affecting left side; atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), and cirrhosis of liver (liver damage). Review of the resident's hospital discharge documents, dated [DATE], showed: -Xareltro (anticoagulant) was ordered to address the resident's diagnosis of atrial fibrillation (irregular heart rate); -A computed tomography scan (CT, X-ray technology to produce images of the inside of the body) result on [DATE], showed there was no pulmonary embolism present, the resident had severe heart failure and probable underlying congestive hepatopathy (back up of blood in the liver, resulting from heart failure). Review of the resident's skin assessment, dated [DATE] at 7:49 A.M., showed: -A Stage II pressure ulcer (Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister) left elbow, measuring 4 centimeters (cm) by 2 cm. There was no further description documented; -A Stage II pressure ulcer, sacrum (triangular bone located above the coccyx (tailbone), measuring 5 cm by 3 cm. There was no further description documented; -The Nurse Practitioner was notified for treatment orders. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Severe cognitive impairment; -No rejection of care; -Dependent for toileting, hygiene, shower/bathing and rolling left to right; -At risk if developing pressure ulcers; -Presence of two unhealed Stage II pressure ulcers. Review of the resident's medical record showed: -No wound assessments found from [DATE] through [DATE]. Review of the resident's care plan, dated [DATE], showed the resident had a pressure ulcer. There were no goals or interventions listed. Review of the resident's physician order sheet (POS), showed an order, dated [DATE], for specialized wound management company to evaluate and treat with follow up as indicated; -An order, dated [DATE], for rivaroxaban (Xarelto, anti-coagulant) 20 milligrams (mg), give every evening. Review of the resident's Medication Administration Record (MAR), dated [DATE], showed the facility administered Xarelto 20 mg, every evening as ordered from [DATE] through [DATE]. Review of the resident's specialty wound management progress note, dated [DATE], showed: -Nursing expressed concerns of the resident's daily Xareltro dose as the resident was noted to have small bruising throughout his/her body; -Wound present at right ischium (forms the lower and back part of the hip bone), new on [DATE], Unstageable Pressure Ulcer, 100% Necrotic tissue in wound bed; measuring 4.2 centimeters (cm) by 6.2 cm; small amount of yellow, green/blue drainage present; -Right ischium is concerning for infections. New order for Ciprofloxacin (antibiotic) 500 mg daily and Doxycycline (antibiotic) 100 mg daily for ten days; -No culture done. Review of the resident's POS, dated [DATE] through [DATE], showed there were no orders documented for Ciprofloxacin or Doxycycline. During an interview on [DATE], at 10:59 A.M., Wound Nurse A, said: -She did rounds with the Wound Nurse Practitioner (NP) on a weekly basis; -The Wound Nurse wrote down the resident's wound assessments, measurements and any new orders in a wound log that was kept at the facility; -Wound Nurse A would use the wound log to update the resident's medical records, put in new orders for treatments and antibiotics; -She remembered on [DATE], the Wound NP ordered an antibiotic for the resident because she was concerned about the resident's wounds getting infected; -Wound Nurse A thought the Wound NP was going to call the resident's facility NP to discuss the order; -It was Wound Nurse A's responsibility to make sure the antibiotic order was put in and started; -Wound Nurse A does not know why she did not follow up to make sure the antibiotic order was placed and started; -She should have documented every time she saw bruises on the resident and she should have notified the PCP and the NP of her concerns; -If she had documented her observations of the bruises the PCP or NP could have seen it in the medical record and changed their plan of care; -She did not know why she did not tell the resident's PCP or NP of her concerns of the resident's increased bruising related to the Xarelto. Review of the resident's specialty wound management progress note, dated [DATE], showed: -Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling) present at his/her coccyx, with 10% granulated and 90% necrotic tissue in wound bed, bone in wound bed structure, measured 2.5 cm by 3.5 cm by 0.5 cm. Wound was debrided. Post Op measurements: 2.5 cm by 3.5 cm by 0.5 cm, 70% necrotic tissue present. Minimal blood loss, hemostasis (stopped blood loss) was achieved by pressure; -Stage IV pressure ulcer present at his/her left elbow with 40% granulated and 60% slough tissue present at wound base, tendon visible at wound bed structure, measured 2.5 cm by 3.0 cm by 0.2 cm; -Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) present at his/her left ischium 20% granulated and 80% necrotic tissue at wound bed, measured 4.0 cm by 4.8 cm by 0.8 cm. Wound was debrided. Post Op measurements: 4.0 cm by 4.8 cm by 0.8 cm 60% necrotic tissue present. Minimal blood loss, hemostasis (stopped blood loss) was achieved by pressure; -Unstageable pressure ulcer present at his/her right ischium, with 10% granulation and 90% necrotic tissue. Measured 5.1 cm by 6.7 cm by 0.4 cm. Review of the resident's medical record, showed: -A progress note, dated [DATE] at 11:00 A.M., the Wound NP debrided the resident's wound; a moderate amount of bleeding stopped after the treatment was done; -A progress note, dated [DATE] at 6:20 P.M., the resident was noted lying in large amounts of bright, red blood with clots. Dressings to both hips were leaking a constant flow of blood; large clots of blood were also noted attached to the bed pad and sheets. A pressure dressing was applied to all areas. Emergency Services were called and report was given; -A progress note, dated [DATE] at 6:45 P.M., pressure dressings were intact on the resident's right and left hip. The primary care physician was called and the resident went out to the hospital. During an interview on [DATE] at 7:22 A.M., Wound Nurse A said: -She was present on [DATE], when the Wound NP debrided the resident's left elbow, the coccyx wound, and one other wound that she could not remember; -The resident did not bleed much and they were able to stop the bleeding by applying pressure; -She applied pressure dressings to all three wound sites; -She told the Certified Nurse Aide (CNA) and the nurse on duty the resident had the procedure and to watch for bleeding. She could not remember who she told specifically; -She was aware the resident was on Xarelto and was at higher risk of bleeding; -She last saw the resident in his/her room eating dinner, at approximately 5:30 P.M., with staff. The resident did not have any signs or symptoms of bleeding. The resident was sitting up in his/her bed. During an interview on [DATE] at 9:10 A.M., the Wound NP, said: -She worked with an outside wound specialty company and came in weekly to evaluate and treat residents; -She saw the resident on [DATE], was concerned of infection because his/her wounds had declined so much from the prior visit, and ordered antibiotic therapy; -She expected nurses to put the order in the medical record and follow orders as written; -She expected nurses to call her if there were any issues with the order; -She saw the resident on [DATE], and debrided the resident's coccyx wound due to deteriorated state from the prior assessment; She was concerned the infection had spread; -There was minimal bleeding from the resident's coccyx which stopped after she applied pressure; -She put a foam bandage on the coccyx before leaving the room; -She knew the resident was on Xarelto on [DATE], because Wound Nurse A was concerned that the resident was bruising; -She was not aware of the dose of Xarelto. She did not look it up nor ask; -She had no expectations of staff that day to increase monitoring of the resident due to risk of bleeding related to the debridement; -She was aware the resident was sent out to the hospital later that same day due to excessive bleeding, but did not feel it was due to the debridement as that was done 10 to 12 hours earlier that day. During an interview on [DATE] at 12:10 P.M., CNA I said: -He/She was the CNA on the resident's hall on [DATE], from 7:00 A.M. through 7:00 P.M.; -Wound NP and Wound Nurse A were in the resident's room and told him/her the resident needed incontinence care around 12:00 P.M. that day; -While changing the resident's brief, he/she noticed the resident's bandages on his/her coccyx and one on his/her hip looked like they were full of blood, the blood was not leaking out of the bandage nor were the bandages wet with blood. If the bandages were dry they were white. If the bandages were wet, they were blue. Both bandages were blue; -The CNA did not report his/her findings to the nurse; -Around 3:00 P.M., He/She checked the resident again for incontinence and found the resident's brief was dry. The CNA only observed the front of the resident's brief. The CNA did not see any signs of blood and the resident was acting normally; -Around 5:30 P.M., CNA I assisted the resident with his/her dinner in his/her room. The resident was sitting up in his/her bed. The resident showed no signs or symptoms of distress or bleeding; -A little after 6:00 P.M., CNA I did rounds on the resident and checked to see if the resident needed incontinence care. CNA I pulled back the covers and saw the sheets and the bed pad were soaked in blood; -CNA I called Nurse F to the room and they turned the resident over to see where he/she was bleeding from. CNA I could not really tell the source of the bleeding; -Emergency Services then came and took the resident to the hospital; -CNA I was not told by the Wound NP or Wound Nurse A they had cut on the resident's wounds or that the resident needed special monitoring for bleeding. During an interview on [DATE] at 10:43 A.M., Nurse F said: -He/She was the nurse for the resident on [DATE] from 7:00 A.M. until 7:00 P.M.; -He/She was not aware the resident had any wound debridement procedures that day; -He/She had last seen the resident around 3:30 P.M. and the resident was acting as his/her usual self, asking for snacks, and had no signs or symptoms of bleeding; -He/She was notified by an agency CNA (name unknown) around 6:00 P.M. the resident was bleeding profusely while in his/her bed; -He/She went to assess the resident and found the resident lying in his/her bed with blood saturating the sheets, his/her gown, and the bed pad; -He/She turned the resident over to see where the resident was bleeding and saw the wounds at both hips were bleeding profusely, and the coccyx wound was bleeding slightly; -The resident had foam dressings on all three wounds, there were no pressure dressings present; -He/She applied pressure to try to stop the bleeding at the wounds, called Emergency Services and sent the resident out to the hospital; -He/She would have assessed the resident's wounds and dressings for signs of bleeding if he/she had been aware the resident had the debridement procedure earlier that morning; -He/She had not received any instruction to monitor the resident for signs of bleeding throughout his/her shift and did not look at the resident's wounds until there was a reported issue. Review of the hospital record, dated [DATE] at 11:23 P.M., showed: -The chief complaint was debridement of a sacral wound today, won't stop bleeding, on Xarelto; -Hemoglobin level low at 6.1 g/dl, (low hemoglobin level can cause trouble breathing, rapid heart rate, and as condition worsens, heart problems and even death if levels are below 6.5 g/dl) showing a change from 10.0 on [DATE]; -Four units of red blood cells (blood transfusion) were given; -Assessment and plan: Hemorrhagic shock, tachycardia, hypotensive (low blood pressure). Spoke with family regarding patient's status, required high-flow oxygen nasal cannula (device used to deliver oxygen with two small tubes that fit into the nostrils), respiratory status seems compromised. Explained the resident could go into worsening heart failure with blood transfusions, may ultimately go into respiratory failure (body can't get enough oxygen to sustain bodily functions); -On [DATE], started cefepime (antibiotic)1 gram intravenously (IV, through the vein), every 24 hours, for wound infection; -On [DATE], started Vancomycin (antibiotic) IV, 750 mg in 250 milliliters (ml) IV piggy back (IVPB), every 24 hours for wound infection; -A radiology assessment, dated [DATE], showed the resident had decubitus ulcers of right and ischial tuberosity with mild superficial infection and coccygeal decubitus ulcer with exposed bone, all with possible chronic osteomyelitis (infection of the bone); Possible right adductor muscle group (muscles of the hip) pyomyositis (purulent infection of skeletal muscle, often with abscess formation); -On [DATE], at 11:15 A.M., a clinical progress note said the patient with past medical history of chronic heart failure (CHF), diabetes, and AFib, admitted with profound anemia secondary to a sacral decubitus after debridement. His/Her hemoglobin was 6.1 and he/she received blood transfusions. He/She was noted to be in AFib with rapid ventricular response (RVR, rapid heard rate, disrupts blood supply to the body), slightly hypotensive (low blood pressure) and edematous (swelling in the tissues). He/She was chronically ill, debilitated with contractures and some degree of dementia; -On [DATE], the resident's hemoglobin level was still low at 8.0 g/dl; -The resident passed on [DATE] at 3:01 P.M.; -Final diagnosis, dated [DATE] at 1:33 A.M., showed deceased , Stage IV sacral decubitus ulcer present on admission (POA) status post debridement complicated by hemorrhage (sudden blood loss), Stage IV left ischial pressure ulcer POA, Stage IV right ischial pressure ulcer POA, Sepsis (infection of the blood) POA, Left elbow pressure ulcer POA, anti-coagulation therapy on Xarelto, anemia (iron poor blood) related to hemorrhage, pulmonary embolism (blood clot found in lungs) coagulopathy (body unable to clot blood leading to excessive bleeding) was present on admission; -Hospital course included: The resident was admitted for supra-therapeutic international normalized ratio (INR, blood clotting levels are too high, at risk for dangerous bleeding), bleeding from sacral ulcer; resident went into AFib after admission, surgeries to address pressure ulcers and pleural effusion (buildup of fluid in tissues around lungs) were canceled due to high INR, the resident became hypothermic (body temperature low) and hypoglycemic (low blood sugar), he/she likely went into liver failure leading to cardiac arrest (heart attack). The resident ultimately stopped breathing, and was pronounced deceased on [DATE] at 3:01 P.M. During an interview on [DATE] at 11:27 A.M., the Administrator and DON said: -They expected the Wound NP and the Wound Nurse to know the resident was on an anticoagulant and the dose of the anticoagulant before they started a debridement procedure due to a risk of hemorrhaging; -They expected Wound Nurse A and the Wound NP to check the dosage of Xarelto before performing the debridement procedure due to the risk of hemorrhaging; -It would have been safer to hold the Xarelto a couple of days before the debridement of the wounds -They expected the Wound NP to stop the anticoagulant a couple of days before the debridement procedure due the risk of hemorrhaging, difficulty clotting; -They expected Wound Nurse A to document the details of the wound debridement including the location of the wounds, the status after the procedure, what type of dressings were applied and who was informed of the debridement; -They expected the nurse to document the wounds that were debrided, the type of dressing that was put on the debridement cites, what time the debridement took place, how the resident tolerated the debridement process, and what the condition of the resident was upon completion; -They expected the Wound NP to document the procedure and have it uploaded into the resident's medical record; -They expected the Wound Nurse to tell the resident's assigned nurse that the debridement procedure was completed so the nurse and CNAs could monitor the resident for signs and symptoms of bleeding, checking the debridement sites at least every two hours and documenting the observations in the progress notes. -They expected the nursing staff assigned to the resident to monitor for signs and symptoms of bleeding after the procedure and to check on the resident at least every two hours. During an interview on [DATE], at 8:16 A.M., the Primary Care Physician (PCP) said: -The resident was on Xarelto due to his/her diagnosis of Afib; -He was not consulted by the Wound NP before she debrided the resident's wounds; -The debridement procedure could have waited, as it was not a life-saving procedure; -He would have preferred if the Xarelto was held for a couple of days before the procedure because of the risk of hemorrhaging; -He expected the facility to monitor the resident closely after the procedure and to apply pressure bandages over the areas that were debrided to lessen the risk of hemorrhaging; -The bleeding was caused by the debridement of the wound. During an interview on [DATE], at 3:45 P.M., the Specialty Wound Physician, said: -He was a vascular surgeon and mostly consulted with the specialty wound management company on vascular and arterial wounds; -The specialty wound management company serviced many patients that were outside of his practice as he focused on vascular and arterial wounds; -He expected the Wound NP to consult with the facility and the facility's PCP in regards to plan of care for residents with pressure ulcers; -The Wound NP did not consult with him regarding the resident or her plan of care of the resident's pressure ulcer; -He expected the Wound NP to consult with the resident's PCP in regards to the plan of care of the resident's pressure ulcer and the nursing staff to monitor the resident closely after the debridement. 2. Review of Resident #9's medical record, showed: -admitted [DATE]; -Diagnoses included right below the knee amputation, end stage kidney disease, and diabetes. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Cognitively intact; -Had a surgical wound; -Received surgical wound care. Review of the resident's assessments, showed no wound assessments completed from time of admission. Review of the resident's POS, dated [DATE], showed: -An order, dated [DATE] and discontinued on [DATE], to clean right below knee amputation with normal saline, pat dry, apply calcium alginate with silver (anti-microbial, used to absorb drainage) and cover with a dry dressing and wrap with kerlix (stretchy gauze roll) every day; -An order, dated [DATE], for Santyl (removes dead tissue), apply to right below knee amputation; -An order, dated [DATE], to clean right below knee amputation with normal saline, pat dry, apply calcium alginate (used to absorb drainage) and cover with a dry dressing and wrap with kerlix every day. Review of the resident's care plan, dated [DATE], showed the resident had a surgical incision with interventions of administer treatments as ordered. Review of the resident's Treatment Administration Record (TAR), dated [DATE], showed: -An order, dated [DATE] and discontinued on [DATE], to clean right below knee amputation with normal saline, pat dry, apply calcium alginate with silver and cover with a dry dressing and wrap with kerlix every day, was not administered on ,d+[DATE], ,d+[DATE], and [DATE]; -An order, dated [DATE], for Santyl to right below knee amputation, apply daily, was not administered on ,d+[DATE], ,d+[DATE], and [DATE]; -An order, dated [DATE], to clean right below knee amputation with normal saline, pat dry, apply calcium alginate and cover with a dry dressing and wrap with kerlix every day, was not administered on ,d+[DATE] or [DATE]. Observation on [DATE] at 9:11 A.M., showed Wound Nurse A provided wound care to the resident. The treatment on the resident's right below the knee amputation was not dated or initialed to show when and who administered the treatment. During an interview on [DATE], at 9:13 A.M., the resident said he/she did not receive any wound care over the weekend and it was very common for the staff to miss treatments. During an interview on [DATE] at 10:35 A.M., Wound Nurse A said: -She had been the Wound Nurse for the facility since early September and worked Monday through Friday; -She completed wound treatments on all residents during her shifts; -If she was not able to complete a wound treatment, she would alert the nurse and expected them to complete as ordered; -She was responsible for putting in wound assessments and completing the facility wound report. She was not able to complete those tasks because she was busy trying to set up a system and make sure she changed all the dressings while on shift; -She completed weekly rounds with the Wound Nurse Practitioner and would put in any new orders that she gave; -She was responsible for completing skin assessments on new residents; -She expected nurses to alert her of new or worsening wounds. During an interview on [DATE] at 9:42 A.M., the Wound NP said she saw the resident's wound last week and both have deteriorated, due to lack of following treatment orders. The resident's right below the knee amputation was wet, had increased slough, small areas of green which looked like infection, and there was a foul odor as well. During an interview on [DATE] at 12:40 P.M., the DON said: -The facility could not provide any wound reports for the prior three months; -She expected the Wound Nurse to complete wound reports weekly and submit them by Friday so the facility could track their wounds and determine if improvements were needed in their wound care program; -She was responsible to review the weekly wound reports from the Wound Nurse; -She expected the Wound Nurse to update the resident's weekly wound assessments and to complete them if they were not followed by the Wound NP; -She expected nurses to complete treatments if the Wound Nurse was not able to and on the weekends. During an interview on [DATE] at 9:10 A.M., the Wound NP said: -She often came into the building and upon assessing her residents, she would find dressings were not completed as ordered. She has seen bandages on residents' wounds that were a week old; -Not following treatment orders as written increases the risk of infection and further deterioration of the wound, which puts the resident's overall health at risk; -The nurses were not completing treatments and were not writing accurate progress notes which described the status of the wound, all of which affected the plan of care. During an interview on [DATE], at 2:21 P.M., Wound Nurse B said she expected each wound to have a separate wound treatment order. There was no way to know if each wound location was actually treated per the physician order if wound treatments were combined. During an interview on [DATE], at 4:31 P.M., the Administrator and DON said they expected each wound to have a separate wound order so they could track if treatments were followed as ordered. MO00225167 MO00225763 MO00225861 MO00227095 MO00226752 Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the on-site 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. Note: At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview and record review, the facility failed to turn and reposition a resident with existing pressure ulcers, failed to enter new orders, and failed to provide a pressure relieving mattress for one resident (Resident #4). The facility also failed to follow orders and complete wound assessments for one resident (Resident #13) and failed to complete skin assessments and document wound treatments for one resident (Resident #17). The sample size was three. The census was 80. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel 2014 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., Wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling; Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined; Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; Slough: necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy; Eschar: thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound. Review of the facility's prevention of pressure ulcers policy, undated, showed: -Reposition all residents with or at risk of pressure injuries on an individualized schedule as determined by the interdisciplinary care team; -Select appropriate support services based on the resident's risk factors, in accordance with current clinical practice; -Evaluate, report and document potential changes in the skin. Review of the facility's wound care policy, undated, showed: -Purpose: To provide guidelines for the care of wounds to promote healing; -Verify that there is a physician's order for the procedure; -Review the resident's care plan to assess for any special needs of the resident; -The following information should be recorded in the resident's medical record; -a. Type of wound care given; -b. The date and time the wound care was give; -c. The position in which the resident was placed; -d. The name and the title of the individual performing the wound care; -e. Any change in the resident's condition; -f. All assessment data (i.e. wound bed color, size, drainage, etc.) obtained when inspecting the wound; -g. How the resident tolerated the procedure; -h. Any problems or complaints made by the resident related to the procedure; -i. If the resident refused the treatment and the reason(s) why; -J. The signature and the title of the person recoding the data. -Report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #4's medical record on 10/27/23, showed: -Diagnoses included respiratory failure, stroke, hemiplegia and hemiparesis (weakness or paralysis) following stroke affecting left dominant side, cognitive communication deficient, speech and language deficits following stroke, dependence on supplemental oxygen, tracheostomy and a gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). Review of the resident's re-admission progress note, dated 10/20/23 at 6:06 P.M. showed the resident was in a coma/persistent vegetative state, had a colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall), an enteral feeding tube (liquid nutrition that enters the stomach or intestine through a tube), was non-ambulatory, and had a tracheostomy (tube surgically inserted into the trachea for the purpose of breathing). Review of the resident's brief interview of mental status (BIMS) score, dated 10/24/23, showed a score of 0 out of a possible score of 15, indicating severe cognitive impairment. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/27/23, showed: -Impairment on both sides of upper and lower body; -Dependent on assistance from staff for all activities of daily living (ADLs); -At risk for pressure ulcers; -Had four unhealed Stage IV pressure ulcers. Review of a skin and wound evaluation, dated 10/23/23 at 10:04 A.M. showed, the resident had a Stage IV pressure ulcer located at his/her left buttock, medial; measuring 13.0 cm by 6.9 cm, with 80% slough and 20% granulation tissue in wound bed, with heavy, purulent (containing pus) exudate present with a strong odor; -A skin and wound evaluation, dated 10/23/23 at 10:13 A.M., the resident had a Stage IV pressure ulcer present at his/her left, lateral buttocks; measuring 9.3 cm by 10.5 cm with 70% granulation and 30% slough tissue in wound bed, heavy, sero-sanguineous (contains blood and blood -serum) exudate present with a strong odor; -A skin and wound evaluation dated 10/23/23 at 10:16 A.M., the resident had a Stage IV Pressure Ulcer located on his/her sacrum, medial (towards middle of body); measuring 7.1 cm by 3.0 cm with 20% granulation and 80% slough tissue present in wound bed with heavy, sero-sanguineous exudate present, with a strong odor; -A skin and wound evaluation dated 10/23/23 at 10:27 A.M., the resident had a Stage IV pressure ulcer located at his/her right, lateral (away from midline of body) buttock; measuring 6.1 cm by 7.4 cm with 80% granulation and 20% slough tissue in wound bed. Review of the Physician's Order Sheet (POS) dated 11/14/23 showed an order, dated 10/23/23, for Stage IV pressure ulcers to right ischium (a paired bone of the pelvis. Together with the ilium and pubis, they form the hip bone), left ischium, left tronchanter (top of thigh bone, widest part of the hip), and sacrum utilizing negative pressure wound vacuum therapy with medihoney (ointment forms protective barrier) for debridement of slough, every three days during day shift. Review of the Registered Dietician's (RD) nutritional assessment, dated 10/24/23, showed the resident was 72 inches, or 6 feet tall and weighed 129.0 pounds (lbs). Review of the resident's Treatment Administration Record (TAR), dated October 2023, the treatment order, dated 10/23/23 for the Stage IV pressure ulcer to right ischium, left ischium, left tronchanter and sacrum was documented by Wound Nurse B as administered on 10/23. The resident's baseline care plan, dated 10/26/23, showed only goals for physical and occupational therapy. There was no other concerns or goals documented. Observation on 10/27/23 at 9:01 A.M. and at 10:27 A.M., showed the resident in his/her bed, covered in a blanket, positioned to the right side, with his/her legs bent at the knee, with his/her right foot pressed up against the foot board of the bed. During an interview on 10/27/23 at 10:32 A.M., the resident's family member said he/she visits the resident before work every day and the resident is in the same exact position that he/she was when the family member left the day before. The family member also stayed with the resident for 48 hours straight, which he/she does every week, and staff do not come and turn or reposition the resident. The family member was concerned the resident's pressure ulcers would not heal if they did not turn him/her on a regular schedule. He/She asked staff several times to make sure to reposition the resident but he/she felt the staff ignored his/her requests. Observation on 10/27/23 at 12:30 P.M , showed the resident in his/her bed, covered in a blanket, positioned to the right side, with his/her legs bent at the knee, with his/her right foot pressed up against the foot board of the bed. During an interview on 10/27/23 at 2:21 P.M., Wound Nurse B said: -Residents should get turned or repositioned on a regular schedule to help prevent pressure ulcers; -The resident was at higher risk of getting new or worsening pressure ulcers if he/she was not on a specialty mattress, in a bed that was too short for his/her needs, and was not getting turned to promote pressure relief; -He/She was not sure why there was an inappropriate order for a wound vacuum (vac) for the resident's wounds. The resident did not have a wound vac to treat the wounds. -He/She had changed the resident's treatments and had filled out the TAR. He/She was not aware the order was not written correctly; -Each wound should have a separate wound treatment order, as it helped keep track of whether or not the treatment was getting administered as intended; -He/She got new orders for wound treatments for the resident on 10/23/23, he/she did not know why he/she did not put it in the resident's medical record; -He/She knew the resident needed a specialty mattress, as well as a larger mattress; he/she did not know why it was not ordered by him/her or anyone else. During an interview on 11/3/23 at 12:27 P.M., the Nurse Practitioner (NP) said: -She expected residents at risk for or with existing pressure ulcers to get turned and repositioned every two hours; -She expected staff to follow physician orders as written and to put in orders as soon as possible, within the day the order was given; -She expected staff to write separate wound orders for each wound; -She expected residents at risk for, or with existing pressures ulcers, to receive specialty mattresses and/or longer beds within 48 hours of admit, or discovery of new wound. 2. Review of Resident #13's medical record, showed: -admitted on [DATE]; -Diagnoses included kidney disease, diabetes mellitus and heart failure; -Review of the care plan, dated 7/7/23, showed pressure ulcers were not addressed. Review of the specialty wound progress notes, showed: -On 9/8/23, the resident had a new pressure ulcer on his/her left medial ankle, measuring 0.3 cm by 0.4 cm by 01 cm with moderate, serosanguinous drainage; -On 10/6/23, the resident's left medial ankle, pressure ulcer had 100% granulation tissue at wound bed and measured 1.0 cm by 1.7 cm by 0.2 cm, with a small amount of serosanguinous exudate. Review of the resident's Physician Order Sheet (POS), showed: -An order, dated 9/29/23, and discontinued on 10/6/23, for Santyl (a debridement ointment) to right inner ankle, apply every other day, during day shift; -An order, dated 10/6/23, for Santyl to left inner ankle, apply every other day, during day shift. Review of the medical record showed there were no wound assessments found, from 9/8/23 through 10/10/23, for the resident's left medial ankle wound. Review of the resident's TAR, dated October 2023, showed the facility did not administer treatment to the resident's left medial ankle as ordered on 10/9 and 10/11/23. Observation on 10/11/23 at 10:25 A.M., showed Wound Nurse A provided wound care to the resident's left ankle. The resident had a treatment dated 10/6/23 on his/her left ankle. Wound Nurse A verified he/she was the one who dated and initiated that treatment on 10/6/23. The resident did not have a wound on his/her right ankle. During an interview on 10/12/23, at 9:46 A.M., the Wound NP said she saw the resident's wound last week and it was improving. Today the wound at the left ankle had declined, with 30% granulation and 70% slough tissue in the wound bed. She had to debride (remove the dead or infected tissue) the wound. She believes the deterioration of the wound was due to lack of following orders per review of the TAR and observation. The nurses aren't changing the treatments. The resident does not have a wound on his/her right inner ankle. 3. Review of Resident #17's medical record, showed: -admitted on [DATE], -Diagnoses included end stage kidney disease, malnutrition, adult failure to thrive, and diabetes mellitus; -On 9/16/23 at 6:01 P.M., an admission evaluation: the resident was alert to self, was non-ambulatory and non-ambulating, required assistance with activities of daily living, and had a pinpoint size open area to coccyx (tailbone), treatment order of collagen (encourages wound healing) and foam dressing every three days and as needed. All orders verified with Primary Care Physician (PCP); -Review of care plan, dated 9/22/23,showed no wounds addressed; -There were no skin assessments found from 9/16/23 through 10/11/23; -Review of physician orders, dated 9/16/23 through 10/11/23, showed no orders were found for wound care; -There were no progress notes found documenting care of the wound found at the resident's coccyx; -There were no orders found to complete a weekly skin assessment; -There were no TARs found for duration of stay; -The resident discharged on [DATE]. Review of the resident's hospital skin and wound assessment, dated 10/22/23 at 12:00 A.M., Stage II Pressure Ulcer located at middle of buttocks; present on admission; open, with red/pink wound bed; small amount of serosanguinous exudate present. During an interview on 10/26/23 at 12:56 P.M., Wound Nurse A said she did not remember treating the resident for any wounds and could not remember if she had completed a skin assessment on the resident during his/her stay. During an interview on 10/26/23 at 1:32 P.M., Nurse G said: -He/She completed the admission assessment on the resident and found the small wound at his/her coccyx; -He/She remembers getting a treatment order but could not remember what it was or if and when the wound was healed out; -He/She did not know if the resident had any wounds upon discharge; -He/She expected the Certified Nurse Aides (CNAs) to notify nurses if they saw any new wounds and to document wounds on the shower sheets; -The Wound Nurse was responsible for resident's wound care unless she was unable to complete it, then it was the nurse's responsibility; -The Wound Nurse was responsible for completing weekly skin assessments. Nurses were responsible for weekly skin assessment if the Wound Nurse was not able to complete them and the order came up on their shift. During an interview on 10/27/23 at 11:05 A.M., the Director of Nursing (DON) said they could not find any shower sheets for the resident that were completed during the time of his/her stay. 4. During an interview on 10/11/23 at 10:35 A.M., Wound Nurse A said: -He/She had been the Wound Nurse for the facility for since early September and worked Monday through Friday; -He/She completed wound treatments on all residents during her shifts; -If he/she was not able to complete a wound treatment, he/she would alert the nurse and expected them to complete as ordered; -He/She was responsible for putting in wound assessments and completing the facility wound report. He/She was not able to complete those tasks because she was busy trying to set up a system and make sure she changed all the dressings while on shift. She did not make the DON aware she was not able to complete the wound reports; -He/She was not sure who was responsible for skin assessments. He/She tried to do them when he/she could and he/she expected the nurses to do them when the order came up on their shift; -He/She completed weekly rounds with the Wound Nurse Practitioner and would put in any new orders that she gave; -He/She was responsible for completing skin assessments on new residents; -He/She expected nurses to alert him/her of new or worsening wounds. During an interview on 10/12/23, at 10:43 A.M. Nurse I, said he/she thought the wound nurse was responsible for completing residents' weekly skin assessments. If a CNA noticed a new skin issue, he/she expected the CNA to mark it on residents' shower sheet, or notify the nurse immediately. The nurse would then assess the new skin issue, notify the PCP, get new orders, notify the family and document all in a progress note. Nurses were also expected to complete a full skin assessment and a wound assessment as well, when they found a new skin issue. Nurses were also responsible to complete treatments if the wound nurse was not able to, if she was not on shift, and during the weekends. During an interview on 10/11/23 at 12:40 P.M., the DON said: -The facility could not provide any wound reports for the prior three months; -She expected the Wound Nurse to complete wound reports weekly and submit them by Friday so the facility could track their wounds and determine if improvements were needed in their wound care program; -She was responsible to review the weekly wound reports from the wound nurse; -She expected the Wound Nurse to update the residents' weekly wound assessments and to complete them if they were not followed by the Wound NP; -She expected residents to have an order for weekly skin assessments; -She expected nurses to complete treatments and weekly skin assessments if the wound nurse was not able to and on the weekends. During an interview on 10/12/23 at 9:10 A.M., the Wound NP said: -She often came into the building and upon assessing her residents, she would find dressings were not completed as ordered. She has seen bandages on residents' wounds that were a week old; -Not following treatment orders as written increases the risk of infection and further deterioration of the wound which puts the resident's overall health at risk; -The nurses were not completing treatments, completing skin assessments and were not writing accurate progress notes which described the status of the wound, all of which affected the plan of care. During an interview on 10/11/23 at 11:28 A.M., the DON said: -When a new wound was identified, she expected the wound nurse to notify the PCP to get an order to have the specialty wound management company evaluate and treat the wound; -The resident or the resident's responsible party has to consent to treatment. During an interview on 10/12/23 at 11:19 A.M., the Administrator and DON said: -They were both responsible for following up and holding staff accountable for their expectations; -They expected staff to follow facility policies; -They expected nurses to complete treatments as ordered; -They expected nurses to complete weekly skin assessments; -They expected the Wound Nurse to complete a weekly wound assessment or input the data from the specialty wound management progress note into the resident's medical record; -They expected the progress notes from the Wound NP to get up-loaded into resident's medical records on a weekly basis; -They expected nurses to put in orders when given; -They expected nurses to put in separate wound orders for each separate wound. MO00225167 MO00225763 MO00226176 MO00226430 MO00227279

This deficiency is uncorrected. For previous examples, see the statement of deficiencies dated 11/14/23. Based on observation, interview, and record review, the facility failed to ensure staff routinely placed heel protectors and/or Podus Boots (multi-purpose boots designed to relieve pressure on the heels) for one resident (Resident #2) who was admitted with no pressure ulcers on the heels, and required maximum assistance to turn and reposition. On 11/30/23, the resident's heels were boggy/red and warm to touch. Facility staff failed to assess the heels and notify the physician about those changes. On 12/5/23, the resident developed deep tissue injuries (DTI, a pressure related injury that damages underlying layers of skin that may be painful, mushy, boggy, firm, and warm to touch) on both heels, causing a physical decline in the resident's ability to participate in physical therapy due to pain. The facility also failed to ensure one resident's (Resident #10) treatment order for a Stage 3 pressure injury/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) on the right buttock was changed promptly. In addition, the facility failed to change one resident's treatment daily as ordered (Resident #4), and failed to ensure another resident's (Resident #23) treatment order had been added to the Physician's Order Sheet (POS) and Treatment Administration Record (TAR). Twelve residents with pressure ulcers were sampled and problems were identified with four. The census was 80. Review of the facility Prevention of Pressure Injuries policy, undated, included the following: -Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors; -Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable; -Risk Assessment: -Assess the resident on admission for existing pressure injury risk factors. Repeat the assessment weekly and upon changes in condition; -Use a standardized pressure injury screening tool to determine and document risk factors; -Supplement the use of a risk assessment tool with assessment of additional risk factors; -Skin Assessment: -Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge; -During the skin assessment inspect: Presence of erythema (redness), temperature of skin and soft tissue, and edema (swelling); -Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living. Identify any signs of developing pressure injuries. Inspect pressure points (sacrum (area between the lower back and upper buttocks), heels, buttocks, coccyx (tailbone) elbows, ischium (fold between the lower buttocks and upper posterior (back) of the thighs), and trochanter (hip); -Support Surfaces and Pressure Redistribution: -Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice; -Monitoring: -Evaluate, report and document potential changes in the skin; -Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility Medication and Treatment Orders policy, undated, showed: -Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing; -Policy Interpretation and Implementation: -Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and time of the order; -Licensed nursing staff is required to follow physician orders. Review of the Treatment Nurse job description, undated, included the following: -General Purpose: The primary function of the Treatment Nurse is to ensure effective and efficient care is provided as prescribed by the physician and as required by facility policies and procedures. The Treatment Nurse reports to and is directly responsible to the Director of Nursing (DON); -Essential Duties: -Excellent communication skills and strong customer service for residents; -Provide resident care including carrying out physician's orders for care, including providing medication and treatment; -Ensure appropriate wound care management services are included in the plan to promote healing which includes but not limited to special mattresses and nutritional supplements;; -Assist in preparing and updating care plans for treatment-related issues; -Assist physicians and other healthcare providers when making visits and conducting examinations; -Communicate with physicians and other health professionals regarding resident care, treatment and condition; -Report significant findings or changes in condition and potential concerns to Registered Nurse or DON. 1. Review of the resident's Resident #2's progress notes showed: -11/19/23 at 5:22 P.M.: The resident was admitted with a diagnosis of a left hip fracture. Skin assessment complete. Some bruising and swelling noted to right upper extremity, but resident states that is where hospital placed his/her IV (intravenous). No documentation regarding the resident's skin/heels. Review of the resident's Braden Scale for Predicting Pressure Sore Risk assessment, dated 11/19/23, showed a score of 16. (A score of 15-16 indicates the resident is at risk to develop a pressure sore.) Review of the resident's Physical Therapy Treatment Encounter Note(s), showed: Date of Service: 11/20/23 (first date of service): -Pain Assessment: Resident verbalized pain level; -Pain at Rest: 4/10, Location: Surgical site (left hip). Pain Description: Dull ache; -Pain With Movement: 8/10, Location: surgical site. Pain Description: Sharp, stabbing; -Bed Mobility: Maximum assistance; -Standing Balance: Static standing (the body remains stationary) = Poor. Dynamic -Standing (when the body is in motion) = Poor; Dates of Service: 11/21/23, 11/22/23, 11/23/23, 11/24/23, 11/27/23, 11/28/23: -Pain location is associated with left hip. No documentation regarding the resident's bilateral heels. Review of Resident #2's the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/26/23, showed: -Speech Clarity: Clear speech - distinct intelligible words; -Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Understanding verbal content, however able: Understands - clear comprehension; -Moderately impaired cognition; -Functional Limitation in Range of Motion: Impairment on one side; -Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity: Toileting hygiene; -Dependent: Lower body dressing; -Partial/moderate assistance: Roll left and right; -Substantial/maximal assistance - Helper does more than half the effort: Sit to lying; Lying to sitting on the side of the bed; -Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity: Sit to stand, chair/bed -to-chair transfer; -Diagnoses: Cancer (with or without metastasis), anemia (a lack of red blood cells to carry oxygen), heart failure, high blood pressure, renal (kidney) insufficiency, hip fracture, dementia and malnutrition; -Is the resident at risk of developing pressure ulcers: Yes; -Unhealed pressure ulcers: No. Review of the resident's current care plan located in the electronic healthcare record (EHR), showed: -Focus 11/23/23: admitted to the facility for short term stay. Goal: Will have positive and appropriate continuity of care continued post discharge; -No Focus/Goal/Intervention related to the resident's heels. Review of the facility weekly pressure ulcer tracking report showed: -11/24/23 and 12/1/23: No areas identified. Review of the resident's Physical Therapy Treatment Encounter Note(s), showed: Date of Service: 11/30/23: -Pain Assessment: Resident verbalized pain level; -Pain at Rest: 0/10; -Pain With Movement: 4/10, Location: Left hip/thigh and right heel. Pain Description: Dull ache; -Narrative: Resident laying in bed. Occupational Therapist (OT) asked PT (Physical Therapist) to assess bilateral lower extremities. Resident's bilateral lower extremities distal calves to feet present with increased edema, warmth and redness. Bilateral heels have deep tissue injury noted. This was reported to nursing; Date of Service: 12/1/23: -Pain Assessment: Pain level determined based on resident's behaviors. Behaviors Exhibited: Protective behaviors to area of pain. Reflexive responses (e.g., ouch, stop). When PT inquired about pain to left hip/thigh, resident states I don't have pain. I just make those sounds; Narrative: PT assessed bilateral lower extremities and heels again. Bilateral lower edema present with redness and warmth. Bilateral heels still have deep tissue injury present. PT donned (placed) bilateral heel protectors while in bed. Visual aide placed on resident's closet door for resident to wear heel protectors while in bed and up in wheelchair to reduce further risk of skin breakdown. Reported concern to nurse regarding bilateral edema/warmth/redness and bilateral heels still boggy/deep tissue injury; Date of Service: 12/4/23: -No documentation about the resident's heels; Date of Service: 12/5/23: -Narrative: Resident in bed. Bilateral heel protectors are not on. Resident education to ensure that the bilateral heel protectors are on in bed. PT wrote order in EHR for patient to wear bilateral heel protectors while in bed and up in wheelchair. PT assessed bilateral heels, both still present with deep tissue injury. Notified wound nurse (facility Treatment Nurse) about bilateral heels. Review of the resident's POS, located in the EHR, showed: -Start Date 12/5/23: Resident to wear bilateral heel protector boots while in bed, and while up in wheelchair to reduce the risk of skin breakdown; -Start Date 12/6/23: Left and right heel, DTI (deep tissue injury). Paint with Betadine (used to prevent or treat skin infection and promote healing) daily and PRN (as necessary). Review of the facility weekly pressure ulcer tracking report showed: -11/24/23 and 12/1/23: No areas identified; -12/8/23: -Right Heel: --Acquired (at facility); --Type of Wound: Pressure; --Stage: DTI; --Previous Measurements: Blank; --Current Measurements: 1.5 centimeters (cm) x 1.2 cm; --Current Treatment: Betadine, paint daily and PRN; --Change in Treatment: Not at this time; --Improved/Worsening: New; -Left Heel: --Acquired at facility; --Type of Wound: Pressure; --Stage: DTI; --Previous Measurements: Blank; --Current Measurements: 1.0 cm x 2.0 cm; --Current Treatment: Betadine, paint daily and PRN; --Change in Treatment: Not at this time; --Improved/Worsening: New. Review of the resident's Physical Therapy Treatment Encounter Note(s), showed: Date of Service: 12/8/23: -Resident Reports: Resident reported pain in bilateral heels and left proximal femur on this date. Resident asked several times during treatment session when treatment would be done and when he/she could return to his/her room; Date of Service: 12/13/23: -Pain Assessment: Resident verbalized pain level; -Pain at Rest: 3/10. Frequency: Constant. Location: Bilateral heels. Pain Description: Sharp, stabbing; -Pain With Movement: 6/10. Frequency: Constant. Location: Bilateral heels. Pain Description: Sharp, stabbing, throbbing; -What exacerbates pain? Standing; -Narrative: The therapist applied diathermy (therapeutic generation of local heat applied to body tissues by high energy electromagnetic currents) to bilateral heels for 30 minutes, each heel, to facilitate reduction in pain; -Narrative: PT assessed bilateral heel wounds. Bilateral heels are now painful to touch. Resident reports 6/10 bilateral heel pain with palpation. Bilateral heels appear to be black/boggy. Review of the resident's Braden Scale for Predicting Pressure Sore Risk assessment, dated 12/10/23, showed a score of 16. Observation on 12/13/23 at 6:30 A.M., showed the resident lay in bed with socks on both feet, but no podus boots. A sign on the closet door showed: please put heel protectors on when in bed and up in wheelchair. The DON removed the resident's socks, showing one circular area of eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin) on each heel. The DON said the resident's heels are identified as deep tissue injury and the resident should be wearing the heel protectors all the time. The resident said he/she did not wear the heel protectors last night. Sometimes staff put them on and sometimes they don't. He/She did not mind wearing the heel proctors, but he/she can't put them on by himself/herself. Review of the resident's Physical Therapy Treatment Encounter Note, showed: Date of Service: 12/14/23: -Pain at Rest: 0/10; -Pain With Movement: 4/10. Frequency: Constant. Location: Bilateral heels and left bridge of foot and ankle. Pain Description: Ache; -Narrative: Resident performed bed mobility for proper positioning with bilateral heel protectors to improve ability to perform self-pressure relief to avoid skin issues; -Narrative: Care plan meeting with Social Services, OT, and resident's Power of Attorney (POA) via phone to discuss progress with skilled PT services. PT reported to POA that limited standing due to bilateral heel skin breakdown to which POA was not aware of. Continue with skilled PT as tolerated. Review of the facility weekly pressure ulcer tracking report showed: -12/15/23: -Right Heel: --Type of Wound: Pressure; --Stage: DTI; --Previous Measurements: Blank; --Current Measurements: 1.5 cm x 1.2 cm; --Current Treatment: Betadine, paint daily and PRN; --Change in Treatment: Not at this time; --Improved/Worsening: New; -Left Heel: --Type of Wound: Pressure; --Stage: DTI; --Previous Measurements: Blank; --Current Measurements: 1.0 cm x 2.0 cm; --Current Treatment: Betadine, paint daily and PRN; --Change in Treatment: Not at this time; --Improved/Worsening: New. During an interview on 12/18/23 at 9:21 A.M., Physical Therapy (PT) N reviewed his/her therapy documentation and said the resident started physical therapy on 11/20/23, and he/she assessed the resident's heels every day he/she worked with the resident. On the first day, 11/20/23, the resident's heels were fine, but the resident required maximum assistance of one staff for turning and repositioning, and he/she told the nursing department the resident needed heel protectors as a preventative measure to prevent heel breakdown. On 11/30/23, the resident was not wearing heel protectors. The resident's heels were boggy and red. He/She showed the resident's heels to Nurse O and told the nurse the resident had not been wearing the heel protectors and the resident needed to wear them. On that same day, 11/30/23, the Occupational Therapist alerted facility management in a group chat (a tool the facility used for management to communicate) that the resident's heels were breaking down. On 12/1/23, he/she found the resident not wearing his/her heel protectors again. He/She reported it to nursing, he/she thinks it was Nurse O again, but was not certain. On 12/5/23, he/she noted the resident's heels were necrotic (eschar) and put an order in for the resident to wear podus boots continuously and diathermy. Since developing the eschar on the heels, the resident has had limited standing ability due to pain from the DTI on the heels. Review of the resident's progress notes showed: -11/20/23: No documentation regarding PT N requesting heel protectors for the resident to prevent skin breakdown; -11/30/23 and 12/1/23: No documentation regarding the resident's heels noted to be boggy and red, and no documentation about the resident needing heel protectors. During an interview on 12/19/23 at 11:12 A.M., Nurse O said he/she did not recall PT N informing him/her on 11/30/23 or 12/1/23, of any concerns about the resident's heels. Had he/she been made aware, he/she would have assessed the resident's heels, called the physician and documented it in the progress notes. During an interview on 12/19/23 at 12:45 P.M., the Administrator said group chat is a tool to keep management updated on daily changes. He checked the group chat for 11/30/23 and said there was a message showing the resident's heels were red, boggy and warm to touch. The DON said the Treatment Nurse said she was going to assess the resident's heels, but apparently she didn't. During an interview on 12/18/23 at 8:24 A.M., Certified Nursing Assistant (CNA) G said the nurses will let them know which residents need to wear heel protectors or specialized boots during the morning report. He/She said there is nothing in the computer system that he/she is aware of that will show the resident needs heel protectors or boots. During an interview on 12/18/23 at 12:14 P.M., Nurse K said the nurses are responsible to inform the CNAs if a resident has an order to wear heel protectors or specialized boots. During an interview on 12/18/23 at 12:20 P.M.,, CNA B said he/she is not familiar with the resident, but the nurses will let them know if a resident is required to wear heel protectors or specialized boots. There is not a list that he/she is aware of that informs them if residents need heel protectors or specialized boots. During an interview on 12/18/23 at 12:30 P.M., Nurse L said the nurses are responsible to let the CNAs know which residents need a heel protector or boot. There is nothing in the computer system for the CNAs to refer to about heel protectors or boots that he/she is aware of. Observation on 12/18/23 at 1:32 P.M., showed the resident sat in a wheelchair in his/her room, watching TV. He/She had socks on and his/her heels were resting on the wheelchair's metal foot rests. CNA P entered the room during the observation, asked the resident a question and began to leave the room. The surveyor asked the CNA if the resident was supposed to be wearing protective boots. The CNA said yes, the resident returned from an appointment a short while ago. The CNA put the resident's boots on at that time. During a telephone interview on 1/5/23 at 10:45 A.M., the Nurse Practitioner (NP), who is the NP for the resident's physician and who is also the facility Medical Director, said she would have expected staff to have written an order for the resident to wear heel protectors as a preventative measure if PT N had concerns about potential skin breakdown. She would have expected the heel protectors to have been worn while in bed and while up in the wheelchair. On 11/30/23, when PT N noticed the resident's heels being boggy and red, she would have expected the nurse PT N informed to have assessed the heels, and contacted either her or the physician. She would have ordered Skin Prep (a protective barrier) every shift and the podus boots at that time. She would have expected the nurse to have documented the red/boggy heels in the progress notes and added it to the TAR so the resident's heels could be routinely assessed and monitored. She is not surprised the heels are causing resident to have an increase in pain and a decline in standing during PT sessions. The resident may have avoided the skin breakdown to the heels had staff applied the heel protectors consistently. 2. Review of Resident #10's admission MDS, dated [DATE], showed: -Diagnoses: Paraplegia (complete paralysis of the lower half of the body) and malnutrition; -Risk of Pressure Ulcers? Yes; -Unhealed Pressure Ulcers: Yes; -Four Stage 2 pressure ulcers (Partial thickness loss of dermis (skin) 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); -One Stage 3 pressure ulcer; -One 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 or tunneling). Review of the resident's current care plan, showed: Focus: Impaired skin integrity as evidenced by multiple chronic wounds present on admission. Goal: Actual alteration in skin integrity will be managed daily until resolution without evidence of sever complications. - Interventions/Tasks: Administer treatments as ordered. Assess for ulcerated areas on the skin. Check skin during daily care provisions. Pressure relieving devices for heels. Review of the resident's Wound Management notes, showed: -Visit Date: 12/4/23: -Location: Right buttock (gluteal); -Type: Pressure ulcer/injury: Stage 3; -Wound Bed Description: 100% granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process); -Measurements: 3.7 cm x 1.7 cm x 0.3 cm; -Periwound: Scarring; -Exudate (fluid that made of cells, proteins and solid materials): Moderate; -Color: Serosanguineous (wound discharge that contains both blood and blood serum); -Wound Status: Improved; -Plan: Cleanse with wound cleanser (WC), apply collagen (a type of protein that aids in tissue repair) and calcium alginate (absorbent dressing), cover with dry bordered dressing and change daily and PRN; -Visit Date: 12/7/23: -Location: Right buttock (gluteal); -Type: Pressure ulcer/injury: Stage 3; -Wound Bed Description: 100% granulation tissue; -Measurements: 3.5 cm x 0.7 cm x 0.3 cm; -Periwound: Scarring; -Exudate: Moderate; -Color: Serosanguineous; -Wound Status: Improved; -Plan: Cleanse with WC, apply Drawtex (a dressing for wounds with moderate to high levels of exudate), cover with a dry bordered dressing and change every 3 days and PRN; -Visit Date: 12/11/23: -Location: Right buttock (gluteal); -Type: Pressure ulcer/injury: Stage 3; -Wound Bed Description: 100% granulation tissue; -Measurements: 3.5 cm x 1.0 cm x 0.3 cm; -Periwound: Scarring; -Exudate: Moderate; -Color: Serosanguineous; -Wound Status: Unchanged/stable; -Plan: Cleanse with WC, apply Drawtex, cover with a dry bordered dressing and change every 3 days and PRN. Review of the resident's TAR, showed: -Right Gluteal Stage 4: -Start Date 12/5/23 Discontinue Date: 12/12/23: Cleanse area with WC, pat dry, apply collagen, cover with calcium alginate, cover with foam and change daily and PRN; -Staff initiated the treatment was completed daily from 12/5/23 through 12/11/23. -The TAR did not include the updated plan/order from 12/7/23 and 12/11/23. Review of the resident's POS, showed: -Revision Date 12/12/23 Start Date 12/14/23: -Right gluteal, Stage 4. Cleanse with WC, pat dry, apply Drawtex to wound bed, cover with foam and change every 3 days and PRN. -The POS did not include the correct dressing ordered by wound management on 12/7/23 and 12/11/23. Review of the resident's Wound Management notes, showed: -Visit Date: 12/14/23: -Location: Right buttock (gluteal); -Type: Pressure ulcer/injury: Stage 3; -Wound Bed Description: 100% granulation tissue; -Measurements: 3.2 cm x 1.0 cm x 0.3 cm; -Periwound: Scarring; -Exudate: Moderate; -Color: Serosanguineous; -Wound Status: Unchanged/stable; -Plan: Cleanse with WC, apply Drawtex, cover with a dry bordered dressing and change every 3 days and PRN. Review of the resident's TAR, showed: -Right Gluteal Stage 4: -Start Date 12/14/23 (8 days after the order was written by Wound Management on 12/7/23) Discontinue Date 12/14/23: Cleanse area with WC, apply Drawtex to wound bed, cover with foam and change every 3 days; -Staff initialed the treatment was completed on 12/14/23. --The TAR did not include the correct dressing ordered by wound management on 12/7/23, 12/11/23 and 12/14/23. Review of the resident's Wound Management notes, showed: -Visit Date: 12/18/23: -Location: Right buttock (gluteal); -Type: Pressure ulcer/injury: Stage 3; -Wound Bed Description: 100% granulation tissue; -Measurements: 3.2 cm x 1.0 cm x 0.3 cm; -Periwound: Scarring; -Exudate: Moderate; -Color: Serosanguineous; -Wound Status: Unchanged/stable; -Plan: Cleanse with WC, apply Drawtex, cover with a dry bordered dressing and change every 3 days and PRN. Review of the resident's TAR, showed: -Right Gluteal Stage 4: -Start Date: 12/18/23 No Discontinue Date: Cleanse area with WC, apply Drawtex to wound bed, cover with foam and change every 3 days; -Staff initialed the treatment was completed on 12/18/23 as ordered. --The TAR did not include the correct dressing ordered by wound management on 12/7/23, 12/11/23 12/14/23, and 12/18/23. 3. Review of Resident #4's admission MDS, dated [DATE], showed: -Diagnoses: cancer (with or without metastasis) and malnutrition. -Risk of Pressure Ulcers: Yes; -Unhealed Pressure Ulcers: Yes; -One Stage 3 pressure ulcer. Review of the resident's current care plan, showed: Focus: At risk for impaired skin integrity related to impaired mobility and incontinence. Goal: Skin integrity will be maintained through next review. Interventions/Tasks: Apply barrier cream (a cream used to keep moisture off the skin), check and change as indicated, keep skin clean and dry, monitor skin daily with routine care; -The care plan did not identify the resident's pressure ulcers. Review of the resident's POS on 12/14/23 at 2:30 P.M., included the following treatment: -Start Date: 11/7/23, DC Date: 12/13/23: Right heel Stage 3. Cleanse with WC, pat dry and apply Santyl (ointment is used to remove damaged tissue from chronic skin ulcers) and calcium alginate, cover with foam and change daily and PRN. Observation on 12/13/23 at 6:42 A.M., showed the resident lay in bed as the DON assessed the resident's skin. The DON confirmed the dressing on the resident's right heel was dated 12/11/23. She was not certain how often the treatment/dressing should be completed. The resident said no one completed the treatment on his/her right heel yesterday (12/12/23). Observation on 12/13/23 at 8:13 A.M., showed the resident lay in bed as the facility's Treatment Nurse completed the resident's treatments/dressings which included the resident's right foot/heel. The Treatment Nurse confirmed the right foot/heel dressing was dated 12/11/23. She said the dressing was ordered to be completed daily. The floor nurse was responsible to complete the resident's treatment to the right heel yesterday, but since the dressing was dated 12/11/23, she would have to assume the treatment was not done on 12/12/23 as ordered. Review of the resident's TAR on 12/13/23 at 2:34 P.M., showed the treatment to the resident's right heel had been initialed as completed on 12/12/23, by the facility's Treatment Nurse. During an interview on 12/13/23 at 11:12 A.M., the facility's Treatment Nurse said she did not do the resident's right heel treatment on 12/12/23, and had no explanation as to why her initials were entered on the TAR. 4. Review of Resident #23's quarterly MDS, dated [DATE], showed: -Diagnoses of anemia, renal (kidney) insufficiency, diabetes mellitus (high blood sugar) and malnutrition; -Risk of Pressure Ulcers? Yes; -Unhealed Pressure Ulcers: Yes; -Two Stage 2 pressure ulcers. Review of the resident's current care plan, located in the EHR, showed: -Focus: Episodes of incontinence. Goal: Will have decreased frequency of incontinent episodes of with assist and support from staff. Interventions/Tasks: Apply barrier cream as ordered. Check and change as indicated. Keep skin clean and dry to the extent possible; -Focus: Requires assistance with activities of daily living. Goal: Resident will be at his/her highest functional level with assist from staff. Interventions/Tasks: Assistive devices as ordered. Requires extensive assistance with bed mobility, transfer, toileting, dressing and hygiene; -Focus: Diagnosis of malnutrition. Goal: Weight will remain stable and his/her nutritional needs will be met. Interventions/Tasks: Administer supplements as ordered. Monitor weights daily. Review of the resident's Braden Scale for Predicting Pressure Sore Risk, dated 10/30/23, showed a score of 15. (A score of 15-18 indicates At Risk.) Review of the resident's Wound Management notes, showed: -Visit Date: 12/1/23: -Location: Left medial (extending toward the middle) ankle (malleolus) pressure ulcer; -Type: Pressure injury related to medical device; -Wound Bed Description: 90% granulation tissue and 10% slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous); -Measurement: 2.0 cm x 2.0 cm x 0.3 cm; -Periwound: Normal; -Exudate: Moderate; -Color: Serosanguinous; -Wound Status: Improved; -Plan: Cleanse with WC, apply Santyl and calcium alginate, cover with a foam dressing and charge daily and PRN; -Visit Dates: 12/4/23, 12/7/23, 12/11/23, 12/14/23 and 12/18/23: -Plan: Cleanse with WC, apply Santyl and calcium alginate, wrap with Unna boot (a specialized compression gauze bandage), and change weekly and PRN. Review of the resident's POS, showed no treatment order dated 12/4/23, to Cleanse left medial ankle/malleolus with WC, apply Santyl and calcium alginate, wrap with Unna Boot, and change weekly and PRN. Review of the resident's TAR, dated 12/1/23 through 12/31/23, showed: -Start Date: 11/30/23 Discontinue Date: 12/1/23: Left medial malleolus. Cleanse area with WC, pat dry, apply nickel thick Santyl to wound bed, cover with calcium alginate and secure with foam dressing and change daily and PRN; -Start Date: 12/2/23 Discontinue Date: 12/4/23: Left medial malleolus. Cleanse area with WC, pat dry, apply collagen and Santyl to wound bed, cover with calcium alginate, secure with foam dressing and change daily and PRN; -No treatment order starting on 12/4/23, to cleanse the left medial ankle/malleolus with WC, apply Santyl and calcium alginate, wrap with Unna Boot, and change weekly and PRN. During an interview on 12/12/18/23 at 8:50 A.M., the Wound Management (WM) NP said she expected the facility to have added her 12/4/23 treatment order for Santyl, calcium alginate, wrap with Unna Boot w

This deficiency is uncorrected. For previous examples, see the statement of deficiencies dated 11/14/23. Based on observation, interview, and record review, the facility failed to ensure staff routinely placed heel protectors and/or Podus Boots (multi-purpose boots designed to relieve pressure on the heels) for one resident (Resident #2) who was admitted with no pressure ulcers on the heels, and required maximum assistance to turn and reposition. On 11/30/23, the resident's heels were boggy/red and warm to touch. Facility staff failed to assess the heels and notify the physician about those changes. On 12/5/23, the resident developed deep tissue injuries (DTI, a pressure related injury that damages underlying layers of skin that may be painful, mushy, boggy, firm, and warm to touch) on both heels, causing a physical decline in the resident's ability to participate in physical therapy due to pain. The facility also failed to ensure one resident's (Resident #10) treatment order for a Stage 3 pressure injury/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) on the right buttock was changed promptly. In addition, the facility failed to change one resident's treatment daily as ordered (Resident #4), and failed to ensure another resident's (Resident #23) treatment order had been added to the Physician's Order Sheet (POS) and Treatment Administration Record (TAR). Twelve residents with pressure ulcers were sampled and problems were identified with four. The census was 80. Review of the facility Prevention of Pressure Injuries policy, undated, included the following: -Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors; -Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable; -Risk Assessment: -Assess the resident on admission for existing pressure injury risk factors. Repeat the assessment weekly and upon changes in condition; -Use a standardized pressure injury screening tool to determine and document risk factors; -Supplement the use of a risk assessment tool with assessment of additional risk factors; -Skin Assessment: -Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge; -During the skin assessment inspect: Presence of erythema (redness), temperature of skin and soft tissue, and edema (swelling); -Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living. Identify any signs of developing pressure injuries. Inspect pressure points (sacrum (area between the lower back and upper buttocks), heels, buttocks, coccyx (tailbone) elbows, ischium (fold between the lower buttocks and upper posterior (back) of the thighs), and trochanter (hip); -Support Surfaces and Pressure Redistribution: -Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice; -Monitoring: -Evaluate, report and document potential changes in the skin; -Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility Medication and Treatment Orders policy, undated, showed: -Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing; -Policy Interpretation and Implementation: -Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and time of the order; -Licensed nursing staff is required to follow physician orders. Review of the Treatment Nurse job description, undated, included the following: -General Purpose: The primary function of the Treatment Nurse is to ensure effective and efficient care is provided as prescribed by the physician and as required by facility policies and procedures. The Treatment Nurse reports to and is directly responsible to the Director of Nursing (DON); -Essential Duties: -Excellent communication skills and strong customer service for residents; -Provide resident care including carrying out physician's orders for care, including providing medication and treatment; -Ensure appropriate wound care management services are included in the plan to promote healing which includes but not limited to special mattresses and nutritional supplements;; -Assist in preparing and updating care plans for treatment-related issues; -Assist physicians and other healthcare providers when making visits and conducting examinations; -Communicate with physicians and other health professionals regarding resident care, treatment and condition; -Report significant findings or changes in condition and potential concerns to Registered Nurse or DON. 1. Review of the resident's Resident #2's progress notes showed: -11/19/23 at 5:22 P.M.: The resident was admitted with a diagnosis of a left hip fracture. Skin assessment complete. Some bruising and swelling noted to right upper extremity, but resident states that is where hospital placed his/her IV (intravenous). No documentation regarding the resident's skin/heels. Review of the resident's Braden Scale for Predicting Pressure Sore Risk assessment, dated 11/19/23, showed a score of 16. (A score of 15-16 indicates the resident is at risk to develop a pressure sore.) Review of the resident's Physical Therapy Treatment Encounter Note(s), showed: Date of Service: 11/20/23 (first date of service): -Pain Assessment: Resident verbalized pain level; -Pain at Rest: 4/10, Location: Surgical site (left hip). Pain Description: Dull ache; -Pain With Movement: 8/10, Location: surgical site. Pain Description: Sharp, stabbing; -Bed Mobility: Maximum assistance; -Standing Balance: Static standing (the body remains stationary) = Poor. Dynamic -Standing (when the body is in motion) = Poor; Dates of Service: 11/21/23, 11/22/23, 11/23/23, 11/24/23, 11/27/23, 11/28/23: -Pain location is associated with left hip. No documentation regarding the resident's bilateral heels. Review of Resident #2's the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/26/23, showed: -Speech Clarity: Clear speech - distinct intelligible words; -Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Understanding verbal content, however able: Understands - clear comprehension; -Moderately impaired cognition; -Functional Limitation in Range of Motion: Impairment on one side; -Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity: Toileting hygiene; -Dependent: Lower body dressing; -Partial/moderate assistance: Roll left and right; -Substantial/maximal assistance - Helper does more than half the effort: Sit to lying; Lying to sitting on the side of the bed; -Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity: Sit to stand, chair/bed -to-chair transfer; -Diagnoses: Cancer (with or without metastasis), anemia (a lack of red blood cells to carry oxygen), heart failure, high blood pressure, renal (kidney) insufficiency, hip fracture, dementia and malnutrition; -Is the resident at risk of developing pressure ulcers: Yes; -Unhealed pressure ulcers: No. Review of the resident's current care plan located in the electronic healthcare record (EHR), showed: -Focus 11/23/23: admitted to the facility for short term stay. Goal: Will have positive and appropriate continuity of care continued post discharge; -No Focus/Goal/Intervention related to the resident's heels. Review of the facility weekly pressure ulcer tracking report showed: -11/24/23 and 12/1/23: No areas identified. Review of the resident's Physical Therapy Treatment Encounter Note(s), showed: Date of Service: 11/30/23: -Pain Assessment: Resident verbalized pain level; -Pain at Rest: 0/10; -Pain With Movement: 4/10, Location: Left hip/thigh and right heel. Pain Description: Dull ache; -Narrative: Resident laying in bed. Occupational Therapist (OT) asked PT (Physical Therapist) to assess bilateral lower extremities. Resident's bilateral lower extremities distal calves to feet present with increased edema, warmth and redness. Bilateral heels have deep tissue injury noted. This was reported to nursing; Date of Service: 12/1/23: -Pain Assessment: Pain level determined based on resident's behaviors. Behaviors Exhibited: Protective behaviors to area of pain. Reflexive responses (e.g., ouch, stop). When PT inquired about pain to left hip/thigh, resident states I don't have pain. I just make those sounds; Narrative: PT assessed bilateral lower extremities and heels again. Bilateral lower edema present with redness and warmth. Bilateral heels still have deep tissue injury present. PT donned (placed) bilateral heel protectors while in bed. Visual aide placed on resident's closet door for resident to wear heel protectors while in bed and up in wheelchair to reduce further risk of skin breakdown. Reported concern to nurse regarding bilateral edema/warmth/redness and bilateral heels still boggy/deep tissue injury; Date of Service: 12/4/23: -No documentation about the resident's heels; Date of Service: 12/5/23: -Narrative: Resident in bed. Bilateral heel protectors are not on. Resident education to ensure that the bilateral heel protectors are on in bed. PT wrote order in EHR for patient to wear bilateral heel protectors while in bed and up in wheelchair. PT assessed bilateral heels, both still present with deep tissue injury. Notified wound nurse (facility Treatment Nurse) about bilateral heels. Review of the resident's POS, located in the EHR, showed: -Start Date 12/5/23: Resident to wear bilateral heel protector boots while in bed, and while up in wheelchair to reduce the risk of skin breakdown; -Start Date 12/6/23: Left and right heel, DTI (deep tissue injury). Paint with Betadine (used to prevent or treat skin infection and promote healing) daily and PRN (as necessary). Review of the facility weekly pressure ulcer tracking report showed: -11/24/23 and 12/1/23: No areas identified; -12/8/23: -Right Heel: --Acquired (at facility); --Type of Wound: Pressure; --Stage: DTI; --Previous Measurements: Blank; --Current Measurements: 1.5 centimeters (cm) x 1.2 cm; --Current Treatment: Betadine, paint daily and PRN; --Change in Treatment: Not at this time; --Improved/Worsening: New; -Left Heel: --Acquired at facility; --Type of Wound: Pressure; --Stage: DTI; --Previous Measurements: Blank; --Current Measurements: 1.0 cm x 2.0 cm; --Current Treatment: Betadine, paint daily and PRN; --Change in Treatment: Not at this time; --Improved/Worsening: New. Review of the resident's Physical Therapy Treatment Encounter Note(s), showed: Date of Service: 12/8/23: -Resident Reports: Resident reported pain in bilateral heels and left proximal femur on this date. Resident asked several times during treatment session when treatment would be done and when he/she could return to his/her room; Date of Service: 12/13/23: -Pain Assessment: Resident verbalized pain level; -Pain at Rest: 3/10. Frequency: Constant. Location: Bilateral heels. Pain Description: Sharp, stabbing; -Pain With Movement: 6/10. Frequency: Constant. Location: Bilateral heels. Pain Description: Sharp, stabbing, throbbing; -What exacerbates pain? Standing; -Narrative: The therapist applied diathermy (therapeutic generation of local heat applied to body tissues by high energy electromagnetic currents) to bilateral heels for 30 minutes, each heel, to facilitate reduction in pain; -Narrative: PT assessed bilateral heel wounds. Bilateral heels are now painful to touch. Resident reports 6/10 bilateral heel pain with palpation. Bilateral heels appear to be black/boggy. Review of the resident's Braden Scale for Predicting Pressure Sore Risk assessment, dated 12/10/23, showed a score of 16. Observation on 12/13/23 at 6:30 A.M., showed the resident lay in bed with socks on both feet, but no podus boots. A sign on the closet door showed: please put heel protectors on when in bed and up in wheelchair. The DON removed the resident's socks, showing one circular area of eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin) on each heel. The DON said the resident's heels are identified as deep tissue injury and the resident should be wearing the heel protectors all the time. The resident said he/she did not wear the heel protectors last night. Sometimes staff put them on and sometimes they don't. He/She did not mind wearing the heel proctors, but he/she can't put them on by himself/herself. Review of the resident's Physical Therapy Treatment Encounter Note, showed: Date of Service: 12/14/23: -Pain at Rest: 0/10; -Pain With Movement: 4/10. Frequency: Constant. Location: Bilateral heels and left bridge of foot and ankle. Pain Description: Ache; -Narrative: Resident performed bed mobility for proper positioning with bilateral heel protectors to improve ability to perform self-pressure relief to avoid skin issues; -Narrative: Care plan meeting with Social Services, OT, and resident's Power of Attorney (POA) via phone to discuss progress with skilled PT services. PT reported to POA that limited standing due to bilateral heel skin breakdown to which POA was not aware of. Continue with skilled PT as tolerated. Review of the facility weekly pressure ulcer tracking report showed: -12/15/23: -Right Heel: --Type of Wound: Pressure; --Stage: DTI; --Previous Measurements: Blank; --Current Measurements: 1.5 cm x 1.2 cm; --Current Treatment: Betadine, paint daily and PRN; --Change in Treatment: Not at this time; --Improved/Worsening: New; -Left Heel: --Type of Wound: Pressure; --Stage: DTI; --Previous Measurements: Blank; --Current Measurements: 1.0 cm x 2.0 cm; --Current Treatment: Betadine, paint daily and PRN; --Change in Treatment: Not at this time; --Improved/Worsening: New. During an interview on 12/18/23 at 9:21 A.M., Physical Therapy (PT) N reviewed his/her therapy documentation and said the resident started physical therapy on 11/20/23, and he/she assessed the resident's heels every day he/she worked with the resident. On the first day, 11/20/23, the resident's heels were fine, but the resident required maximum assistance of one staff for turning and repositioning, and he/she told the nursing department the resident needed heel protectors as a preventative measure to prevent heel breakdown. On 11/30/23, the resident was not wearing heel protectors. The resident's heels were boggy and red. He/She showed the resident's heels to Nurse O and told the nurse the resident had not been wearing the heel protectors and the resident needed to wear them. On that same day, 11/30/23, the Occupational Therapist alerted facility management in a group chat (a tool the facility used for management to communicate) that the resident's heels were breaking down. On 12/1/23, he/she found the resident not wearing his/her heel protectors again. He/She reported it to nursing, he/she thinks it was Nurse O again, but was not certain. On 12/5/23, he/she noted the resident's heels were necrotic (eschar) and put an order in for the resident to wear podus boots continuously and diathermy. Since developing the eschar on the heels, the resident has had limited standing ability due to pain from the DTI on the heels. Review of the resident's progress notes showed: -11/20/23: No documentation regarding PT N requesting heel protectors for the resident to prevent skin breakdown; -11/30/23 and 12/1/23: No documentation regarding the resident's heels noted to be boggy and red, and no documentation about the resident needing heel protectors. During an interview on 12/19/23 at 11:12 A.M., Nurse O said he/she did not recall PT N informing him/her on 11/30/23 or 12/1/23, of any concerns about the resident's heels. Had he/she been made aware, he/she would have assessed the resident's heels, called the physician and documented it in the progress notes. During an interview on 12/19/23 at 12:45 P.M., the Administrator said group chat is a tool to keep management updated on daily changes. He checked the group chat for 11/30/23 and said there was a message showing the resident's heels were red, boggy and warm to touch. The DON said the Treatment Nurse said she was going to assess the resident's heels, but apparently she didn't. During an interview on 12/18/23 at 8:24 A.M., Certified Nursing Assistant (CNA) G said the nurses will let them know which residents need to wear heel protectors or specialized boots during the morning report. He/She said there is nothing in the computer system that he/she is aware of that will show the resident needs heel protectors or boots. During an interview on 12/18/23 at 12:14 P.M., Nurse K said the nurses are responsible to inform the CNAs if a resident has an order to wear heel protectors or specialized boots. During an interview on 12/18/23 at 12:20 P.M.,, CNA B said he/she is not familiar with the resident, but the nurses will let them know if a resident is required to wear heel protectors or specialized boots. There is not a list that he/she is aware of that informs them if residents need heel protectors or specialized boots. During an interview on 12/18/23 at 12:30 P.M., Nurse L said the nurses are responsible to let the CNAs know which residents need a heel protector or boot. There is nothing in the computer system for the CNAs to refer to about heel protectors or boots that he/she is aware of. Observation on 12/18/23 at 1:32 P.M., showed the resident sat in a wheelchair in his/her room, watching TV. He/She had socks on and his/her heels were resting on the wheelchair's metal foot rests. CNA P entered the room during the observation, asked the resident a question and began to leave the room. The surveyor asked the CNA if the resident was supposed to be wearing protective boots. The CNA said yes, the resident returned from an appointment a short while ago. The CNA put the resident's boots on at that time. During a telephone interview on 1/5/23 at 10:45 A.M., the Nurse Practitioner (NP), who is the NP for the resident's physician and who is also the facility Medical Director, said she would have expected staff to have written an order for the resident to wear heel protectors as a preventative measure if PT N had concerns about potential skin breakdown. She would have expected the heel protectors to have been worn while in bed and while up in the wheelchair. On 11/30/23, when PT N noticed the resident's heels being boggy and red, she would have expected the nurse PT N informed to have assessed the heels, and contacted either her or the physician. She would have ordered Skin Prep (a protective barrier) every shift and the podus boots at that time. She would have expected the nurse to have documented the red/boggy heels in the progress notes and added it to the TAR so the resident's heels could be routinely assessed and monitored. She is not surprised the heels are causing resident to have an increase in pain and a decline in standing during PT sessions. The resident may have avoided the skin breakdown to the heels had staff applied the heel protectors consistently. 2. Review of Resident #10's admission MDS, dated [DATE], showed: -Diagnoses: Paraplegia (complete paralysis of the lower half of the body) and malnutrition; -Risk of Pressure Ulcers? Yes; -Unhealed Pressure Ulcers: Yes; -Four Stage 2 pressure ulcers (Partial thickness loss of dermis (skin) 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); -One Stage 3 pressure ulcer; -One 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 or tunneling). Review of the resident's current care plan, showed: Focus: Impaired skin integrity as evidenced by multiple chronic wounds present on admission. Goal: Actual alteration in skin integrity will be managed daily until resolution without evidence of sever complications. - Interventions/Tasks: Administer treatments as ordered. Assess for ulcerated areas on the skin. Check skin during daily care provisions. Pressure relieving devices for heels. Review of the resident's Wound Management notes, showed: -Visit Date: 12/4/23: -Location: Right buttock (gluteal); -Type: Pressure ulcer/injury: Stage 3; -Wound Bed Description: 100% granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process); -Measurements: 3.7 cm x 1.7 cm x 0.3 cm; -Periwound: Scarring; -Exudate (fluid that made of cells, proteins and solid materials): Moderate; -Color: Serosanguineous (wound discharge that contains both blood and blood serum); -Wound Status: Improved; -Plan: Cleanse with wound cleanser (WC), apply collagen (a type of protein that aids in tissue repair) and calcium alginate (absorbent dressing), cover with dry bordered dressing and change daily and PRN; -Visit Date: 12/7/23: -Location: Right buttock (gluteal); -Type: Pressure ulcer/injury: Stage 3; -Wound Bed Description: 100% granulation tissue; -Measurements: 3.5 cm x 0.7 cm x 0.3 cm; -Periwound: Scarring; -Exudate: Moderate; -Color: Serosanguineous; -Wound Status: Improved; -Plan: Cleanse with WC, apply Drawtex (a dressing for wounds with moderate to high levels of exudate), cover with a dry bordered dressing and change every 3 days and PRN; -Visit Date: 12/11/23: -Location: Right buttock (gluteal); -Type: Pressure ulcer/injury: Stage 3; -Wound Bed Description: 100% granulation tissue; -Measurements: 3.5 cm x 1.0 cm x 0.3 cm; -Periwound: Scarring; -Exudate: Moderate; -Color: Serosanguineous; -Wound Status: Unchanged/stable; -Plan: Cleanse with WC, apply Drawtex, cover with a dry bordered dressing and change every 3 days and PRN. Review of the resident's TAR, showed: -Right Gluteal Stage 4: -Start Date 12/5/23 Discontinue Date: 12/12/23: Cleanse area with WC, pat dry, apply collagen, cover with calcium alginate, cover with foam and change daily and PRN; -Staff initiated the treatment was completed daily from 12/5/23 through 12/11/23. -The TAR did not include the updated plan/order from 12/7/23 and 12/11/23. Review of the resident's POS, showed: -Revision Date 12/12/23 Start Date 12/14/23: -Right gluteal, Stage 4. Cleanse with WC, pat dry, apply Drawtex to wound bed, cover with foam and change every 3 days and PRN. -The POS did not include the correct dressing ordered by wound management on 12/7/23 and 12/11/23. Review of the resident's Wound Management notes, showed: -Visit Date: 12/14/23: -Location: Right buttock (gluteal); -Type: Pressure ulcer/injury: Stage 3; -Wound Bed Description: 100% granulation tissue; -Measurements: 3.2 cm x 1.0 cm x 0.3 cm; -Periwound: Scarring; -Exudate: Moderate; -Color: Serosanguineous; -Wound Status: Unchanged/stable; -Plan: Cleanse with WC, apply Drawtex, cover with a dry bordered dressing and change every 3 days and PRN. Review of the resident's TAR, showed: -Right Gluteal Stage 4: -Start Date 12/14/23 (8 days after the order was written by Wound Management on 12/7/23) Discontinue Date 12/14/23: Cleanse area with WC, apply Drawtex to wound bed, cover with foam and change every 3 days; -Staff initialed the treatment was completed on 12/14/23. --The TAR did not include the correct dressing ordered by wound management on 12/7/23, 12/11/23 and 12/14/23. Review of the resident's Wound Management notes, showed: -Visit Date: 12/18/23: -Location: Right buttock (gluteal); -Type: Pressure ulcer/injury: Stage 3; -Wound Bed Description: 100% granulation tissue; -Measurements: 3.2 cm x 1.0 cm x 0.3 cm; -Periwound: Scarring; -Exudate: Moderate; -Color: Serosanguineous; -Wound Status: Unchanged/stable; -Plan: Cleanse with WC, apply Drawtex, cover with a dry bordered dressing and change every 3 days and PRN. Review of the resident's TAR, showed: -Right Gluteal Stage 4: -Start Date: 12/18/23 No Discontinue Date: Cleanse area with WC, apply Drawtex to wound bed, cover with foam and change every 3 days; -Staff initialed the treatment was completed on 12/18/23 as ordered. --The TAR did not include the correct dressing ordered by wound management on 12/7/23, 12/11/23 12/14/23, and 12/18/23. 3. Review of Resident #4's admission MDS, dated [DATE], showed: -Diagnoses: cancer (with or without metastasis) and malnutrition. -Risk of Pressure Ulcers: Yes; -Unhealed Pressure Ulcers: Yes; -One Stage 3 pressure ulcer. Review of the resident's current care plan, showed: Focus: At risk for impaired skin integrity related to impaired mobility and incontinence. Goal: Skin integrity will be maintained through next review. Interventions/Tasks: Apply barrier cream (a cream used to keep moisture off the skin), check and change as indicated, keep skin clean and dry, monitor skin daily with routine care; -The care plan did not identify the resident's pressure ulcers. Review of the resident's POS on 12/14/23 at 2:30 P.M., included the following treatment: -Start Date: 11/7/23, DC Date: 12/13/23: Right heel Stage 3. Cleanse with WC, pat dry and apply Santyl (ointment is used to remove damaged tissue from chronic skin ulcers) and calcium alginate, cover with foam and change daily and PRN. Observation on 12/13/23 at 6:42 A.M., showed the resident lay in bed as the DON assessed the resident's skin. The DON confirmed the dressing on the resident's right heel was dated 12/11/23. She was not certain how often the treatment/dressing should be completed. The resident said no one completed the treatment on his/her right heel yesterday (12/12/23). Observation on 12/13/23 at 8:13 A.M., showed the resident lay in bed as the facility's Treatment Nurse completed the resident's treatments/dressings which included the resident's right foot/heel. The Treatment Nurse confirmed the right foot/heel dressing was dated 12/11/23. She said the dressing was ordered to be completed daily. The floor nurse was responsible to complete the resident's treatment to the right heel yesterday, but since the dressing was dated 12/11/23, she would have to assume the treatment was not done on 12/12/23 as ordered. Review of the resident's TAR on 12/13/23 at 2:34 P.M., showed the treatment to the resident's right heel had been initialed as completed on 12/12/23, by the facility's Treatment Nurse. During an interview on 12/13/23 at 11:12 A.M., the facility's Treatment Nurse said she did not do the resident's right heel treatment on 12/12/23, and had no explanation as to why her initials were entered on the TAR. 4. Review of Resident #23's quarterly MDS, dated [DATE], showed: -Diagnoses of anemia, renal (kidney) insufficiency, diabetes mellitus (high blood sugar) and malnutrition; -Risk of Pressure Ulcers? Yes; -Unhealed Pressure Ulcers: Yes; -Two Stage 2 pressure ulcers. Review of the resident's current care plan, located in the EHR, showed: -Focus: Episodes of incontinence. Goal: Will have decreased frequency of incontinent episodes of with assist and support from staff. Interventions/Tasks: Apply barrier cream as ordered. Check and change as indicated. Keep skin clean and dry to the extent possible; -Focus: Requires assistance with activities of daily living. Goal: Resident will be at his/her highest functional level with assist from staff. Interventions/Tasks: Assistive devices as ordered. Requires extensive assistance with bed mobility, transfer, toileting, dressing and hygiene; -Focus: Diagnosis of malnutrition. Goal: Weight will remain stable and his/her nutritional needs will be met. Interventions/Tasks: Administer supplements as ordered. Monitor weights daily. Review of the resident's Braden Scale for Predicting Pressure Sore Risk, dated 10/30/23, showed a score of 15. (A score of 15-18 indicates At Risk.) Review of the resident's Wound Management notes, showed: -Visit Date: 12/1/23: -Location: Left medial (extending toward the middle) ankle (malleolus) pressure ulcer; -Type: Pressure injury related to medical device; -Wound Bed Description: 90% granulation tissue and 10% slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous); -Measurement: 2.0 cm x 2.0 cm x 0.3 cm; -Periwound: Normal; -Exudate: Moderate; -Color: Serosanguinous; -Wound Status: Improved; -Plan: Cleanse with WC, apply Santyl and calcium alginate, cover with a foam dressing and charge daily and PRN; -Visit Dates: 12/4/23, 12/7/23, 12/11/23, 12/14/23 and 12/18/23: -Plan: Cleanse with WC, apply Santyl and calcium alginate, wrap with Unna boot (a specialized compression gauze bandage), and change weekly and PRN. Review of the resident's POS, showed no treatment order dated 12/4/23, to Cleanse left medial ankle/malleolus with WC, apply Santyl and calcium alginate, wrap with Unna Boot, and change weekly and PRN. Review of the resident's TAR, dated 12/1/23 through 12/31/23, showed: -Start Date: 11/30/23 Discontinue Date: 12/1/23: Left medial malleolus. Cleanse area with WC, pat dry, apply nickel thick Santyl to wound bed, cover with calcium alginate and secure with foam dressing and change daily and PRN; -Start Date: 12/2/23 Discontinue Date: 12/4/23: Left medial malleolus. Cleanse area with WC, pat dry, apply collagen and Santyl to wound bed, cover with calcium alginate, secure with foam dressing and change daily and PRN; -No treatment order starting on 12/4/23, to cleanse the left medial ankle/malleolus with WC, apply Santyl and calcium alginate, wrap with Unna Boot, and change weekly and PRN. During an interview on 12/12/18/23 at 8:50 A.M., the Wound Management (WM) NP said she expected the facility to have added her 12/4/23 treatment order for Santyl, calcium alginate, wrap with Unna Boot weekly to the TAR, but she had been completing the treatment weekly during her visits to the facility. During an interview on 12/26/23 at 1:30 P.M., the DON said even though the Wound Company's NP had been completing the resident's weekly treatment, she expected the facility's Treatment Nurse to have added the NP's order to the POS and TAR on 12/4/23. 5. During an interview on 12/13/23 at 7:20 A.M., the DON said the facility's Treatment Nurse completes the complicated treatments Monday through Friday, and gives the floor nurses a list of the less complicated treatments to be completed. She expected all the treatments to be administered as ordered. During an interview on 12/14/23 at 12:20 P.M., the facility's Treatment Nurse said she works Monday through Friday. She is responsible to make rounds with the Wound Company's NP on Mondays and Thursdays. She does not have a password to obtain the WM NP's printed notes, but the NP does leave her handwritten assessments and orders before she leaves for the day. She is responsible to ensure any changed or new orders are entered accurately on the POS and TAR the day the NP leaves. She does the bigger treatments Monday through Friday

Based on observation, interview and record review, the facility failed to ensure staff treated a resident in a respectful and dignified manner after the resident informed nursing staff he/she did not want a staff person providing personal care to the resident (Resident #2). Staff failed to report or follow this request from the resident. As a result, the staff person returned the next day to care for the resident. During the second interaction, the same staff person left the resident on the toilet exposed in the bathroom after leaving the resident's room. This resulted in the resident reporting having nightmares and fear of retaliation from the facility. The sample was 14. The census was 60. Review of the facility's Resident Right's Policy, revised December, 2016, showed: -Policy Statement; -Employees shall treat all residents with kindness, respect, and dignity; -Policy Interpretation and Implementation; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to; -a dignified existence; -be treated with respect, kindness, and dignity; -be free from abuse, neglect, misappropriation of property, and exploitation; -be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; -self-determination; -voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; -have the facility respond to his or her grievances. Review of Resident #2's Care Plan, revised on 4/17/23, showed: -Focus: The resident is occasionally incontinent of urine and bowel. He/she fluctuates between being continent/incontinent of bowel. This is his/her normal pattern; -Goal: The resident will have reduced episodes of incontinence with assist and support from staff through next review; -Interventions: Assist with toileting. Check and change as indicated and incontinent care as indicated; -Focus: The resident requires assist with activities of daily living care. He/she has a diagnoses of osteoarthritis and fluctuates between limited and extensive assist required at all times; -Goal: The resident will participate in daily care to his/her highest ability with assist from staff through next review; -Interventions: Encourage resident to complete aspects of care he/she is able with set up from staff and provide assist with portions he/she is unable to complete. Requires assist times two at times with bed mobility, transfers and toileting. The resident at times requires a mechanical lift with two staff assistance for transfers. Toileting assist times one. Incontinent of bladder and bowel-assist with perineal care (cleansing between the hips, including the anal and genital areas) every shift and as needed. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/29/23, showed: -Moderate cognitive impairment; -Exhibited no behaviors; -Required one staff assist with transfers; -Toilet use, actively occurred once or twice and required set up only; -Not steady when moving from seated to standing position; -Only able to stabilize with human assistance when moving on and off the toilet and surface to surface transfers; -Diagnoses included heart disease, high blood pressure, dementia and anxiety. Review of the facility's incident investigation, dated 6/19/23, showed: -On 6/19/23, it was reported by the resident that he/she had a negative interaction with a staff member, Certified Nursing Assistant (CNA) A, in which the resident alleges that CNA A was rude and told the resident that he/she needed to stand in pivot, when the resident could not do so. CNA A asked the resident to stand from his/her bed and assist in his/her transfer, to which the resident states he/she told CNA A he/she was unable to stand and could only scoot. CNA A allegedly softly tapped the resident's leg while saying, We don't scoot, scoot, scoot, we stand, stand, stand. CNA A then transferred the resident to the wheelchair and then to the commode. While on the commode, the resident alleged that CNA A, after being told by the resident he/she could not stand and bear weight, removed the resident's wheelchair from reach, and leaving the door open, left the room while the resident used the commode. The resident states he/she reached and pulled his/her wheelchair, which had locked wheels, towards him/her. The allegation was said to have happened 6/15/23. The family of the resident approached the Social Services Director (SSD) and requested a follow-up. This being the first time the SSD had been notified of the situation, notified the administrator and an investigation was initiated immediately; -Upon completion of investigation the facility was unable to substantiate the allegation of willful abuse occurred. During interviews with the resident, it was found that CNA A was alleged to have made statements telling the resident that he/she could perform transfers at a higher level and ability than the resident felt he/she was able to do. CNA A vehemently denied any abuse occurred, stating he/she only wanted to help preserve the resident's ability to transfer as he/she was always trained to highly encourage residents to maintain their highest level of independence and did not intend to be disrespectful or argumentative. CNA A stated he/she had previously understood the resident's abilities regarding transfer status to be of stand and pivot, though the resident maintained that he/she could only scoot; -The resident alleged CNA A ripped his/her pull-up/brief off during an interaction in the restroom after telling CNA A he/she did not need any help. CNA A stated he/she did in fact rip the brief, as he/she had been trained to rip the brief on the side by the seams so as not to cause an unsteady resident to be pulled on when he/she was attempting to assist during incontinence care. The resident stated he/she told CNA A that he/she did not need help, and CNA A ignored him/her and removed his/her brief when in the restroom. CNA A stated the resident told him/her that he/she did not need help and was able to care for him/herself, though during observation of the resident on the commode, the CNA noted the resident to be sitting on the commode with a brief on and not able to remove it, thus prompting CNA A to rip the sides of the brief off so as to provide what he/she perceived as necessary care, as he/she interpreted the resident to be reluctant to care, as CNA A also was under the belief that the resident was not participating in transfers at the level CNA A previously understood the resident's ability to transfer to be. It was during this same interaction CNA A was reported to have moved the resident's wheelchair out of reach. The resident alleges the wheelchair was removed as an action of anger. Interviews with CNA A resulted in CNA A claiming that he/she moved the chair for safety, during the time he/she assisted with the resident's soiled brief, and then left it out of reach to prevent an unsafe transfer that could result in a fall and injury; -The resident states he/she has nightmares from the interactions that took place between he/she and CNA A. The CNA remains suspended from the facility. The resident alleges he/she reported CNA A's behavior to staff on 6/16/23. The resident told his/her family member he/she had to make two reports about the staff member prompting the resident's family member to inquire with the SSD on 6/19/23. During interviews, it was initially reported by the resident he/she only told the nurse he/she did not want CNA A as his/her aide due to the confusion of the transfer status. Later during interviews, the resident stated he/she reported to nursing staff a detailed account of the allegation, and staff said they would immediately notify the Administrator. During interviews with Nurse B, who reported to the administrator the initial concerns of the resident, it was affirmed the resident reported only the transfer concerns, not at any time was it brought to his/her attention there was any allegation of abuse or otherwise reportable item. During an interview on 7/11/23 at 8:57 A.M., the resident's family member said the resident was still upset about the incident and was afraid of retaliation from the facility. The resident reported the issue on 6/15/23 and 6/16/23 to the nurse, but the CNA continued to work with the resident. The family member approached the SSD on 6/19/23 to inquire about the outcome of his/her concerns. During an interview on 7/10/23 at 9:55 A.M. and 7/11/23 at 10:00 A.M., the resident said 6/15/23 was the first time she worked with CNA A. The incident occurred during the 7:00 P.M. to 7:00 A.M. shift. It was close to his/her bedtime, between 8:00 P.M. and 9:00 P.M. and he/she wanted to get to bed from his/her wheelchair. He/She asked CNA A to assist him/her in getting into bed. CNA A told the resident he/she could transfer him/herself. The resident told the CNA he/she could only scoot. The CNA was very persistent and told the resident not to scoot but to stand on his/her own. The resident did scoot and managed to get to the bed on his/her own. The next morning, the resident wanted to get up and the CNA told him/her to get in the wheelchair on his/her own. The resident tried to stand but was having a difficult time and told the CNA he/she could only scoot. The CNA tapped the resident's leg and said, Don't say you can't. The resident managed to get in the chair on his/her own because he/she was afraid of the CNA. The resident reported the incident to the nurse on duty who was about to leave for the day. He/She could not recall which nurse it was but the nurse said he/she would report the concerns to the administrator. The same CNA returned the evening of 6/17/23 and was assigned to the resident. The resident was afraid of the CNA and kept wetting him/herself. He/She pushed the call light because he/she was soiled. CNA A came into the room and asked the resident, why did he/she keep wetting him/herself and said he/she would place two briefs on the resident to hold him/her through the night. The following morning, it was time for the resident to get up. The CNA entered his/her room and told the resident he/she needed to get up. The CNA told the resident to move him/herself to the wheelchair. The resident told the CNA he/she could not do so. The CNA told the resident to lift his/her arm and the CNA grabbed the resident's arm and placed him/her into the wheelchair and rolled him/her to the bathroom. The CNA told the resident to stand up and hold onto the grab bar in the bathroom to use to transfer him/herself onto the commode. The resident managed to get on the toilet. The CNA then ripped the resident's two briefs off while he/she was seated on the toilet. He/She then took the resident's wheelchair and moved it so the resident could not access it, left the bathroom and room door open, and left the room. The resident could not reach the wheelchair and did not want to press the call light because he/she was afraid CNA A would return. The resident said it took about 25 minutes until he/she was able to scoot him/herself off the commode and was able to grab onto the wheelchair. The wheelchair was locked and he/she had a hard time getting the wheelchair close enough to transfer him/herself into. The resident was able to finally get to the wheelchair and transferred him/herself. He/She reported being extremely tired after getting him/herself into the wheelchair. The resident reported the incident to the nurse a second time. He/She could not recall who the nurse was but said it was a different nurse from the one he/she reported to before. The nurse told the resident he/she would report it to the Administrator. During an interview on 7/10/23 at 12:55 P.M., CNA A said he/she was not too familiar with the resident and had worked with him/her twice before. The first time he/she worked with the resident, the resident was able to transfer him/herself and assist with personal care. The second time CNA A worked with the resident, the resident said he/she could only scoot. CNA A assisted the resident into his/her wheelchair and wheeled him/her to the bathroom. CNA A assisted the resident to the toilet and ripped off his/her brief from the sides. He/She moved the resident's wheelchair out of the way so the resident could safely use the restroom, and left to care for other residents while the resident was left on the commode. While in another resident's room, CNA A was called by the nurse and told he/she left the resident on the toilet and the resident was not happy with the care he/she received. CNA A was told to write a statement and has been suspended since the incident. CNA A said he/she tends to talk loud and the resident may have thought he/she was being disrespectful. He/She was also trained to allow the residents to help out with their own care as much as they could. During an interview on 7/11/23 at 10:25 A.M., Nurse B said he/she was not on duty when the incident occurred. He/she was the day nurse. Nurse C was the nurse on duty during the night shift and gave Nurse B report and said the resident did not want CNA A working with him/her because he/she did not know the resident's transfer status. Nurse C did not tell Nurse B anything else about the resident. When the shift was about to change, the resident approached Nurse B and told him/her that he/she did not want CNA A working with him/her. The resident did not express why he/she did not want the CNA working with him/her. Nurse B did not see the CNA working and did not think much of it since the resident did not provide many details. He/She did not report this to management. Nurse C was the one who gave report and he/she was under the impression Nurse C would report the incident to management if there were concerns. During an interview on 7/11/23 at 1:20 P.M., Nurse C said he/she was working the overnight shift on 6/17/23 when he/she entered the resident's room because the resident was crying. The resident told Nurse C he/she did not want the CNA working with him/her. The aide made him/her stand when he/she couldn't and also placed two briefs on the resident. Nurse C approached CNA A and asked what happened. The CNA said he/she double briefed the resident to help him/her out. He/She also wanted the resident to stand and help with care as much as he/she could. Nurse C explained to CNA A double briefing a resident was not acceptable and they could not force a resident to participate in transfers if they were unable to do so. Nurse C did not report this to management but did enter the information on the 24 hour nursing report and reported to the on-coming nurse. During an interview on 7/11/23 at 12:40 P.M., the SSD said on 6/19/23, the resident's family member approached him/her and wanted to know the outcome of the incident the resident reported. The SSD was not sure what the family member was talking about and went to speak with the resident. The resident told her about the CNA and said he/she was afraid of the CNA. The resident told the SSD he/she reported the incident on 6/15/23 and again on 6/17/23 and had not heard anything. The SSD immediately contacted the Administrator to inform him of the resident's concerns. The incident should have been reported on 6/15/23, when the resident first expressed concerns. During an interview on 7/11/23 at 1:50 P.M., the Administrator, Administrator in Training and Director of Nursing (DON) said the resident first reported his/her concerns to the nurse but only said there was a disagreement regarding the resident's transfer status and wanted someone more familiar to work with him/her. On 6/19/23 was when the resident made the allegation of the CNA being rough and leaving the resident on the commode. When the resident made the first allegation, he/she did not appear to be in distress. Staff should have made management aware of the allegations when it was first reported. The CNA should not have placed two briefs on the resident and should not have made the resident participate in the transfer if he/she was not physically able to do so. The CNA was trying to help the resident maintain his/her independence. The CNA should not have left the resident on the commode. However, the resident was alert and oriented and could have pressed the call light if he/she needed assistance to get off the commode and into the wheelchair. MO00220257

Based on observation, interview and record review, the facility failed to ensure residents receive care for the prevention and treatment of pressures ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction) consistent with acceptable standards of practice for two of two residents investigated for pressure ulcers. One resident had a history of pressure ulcers upon admission. The facility failed to consistently assess his/her skin and when a pressure ulcer was observed, the treatment was not completed as ordered. The resident was later identified to have an unstageable (full thickness tissue loss in which actual depth of the ulcer is obscured by slough (yellow, tan, gray, green, or brown dead tissue) and/or eschar (tan, brown, or black dead tissue) in the wound bed) pressure ulcer and required wound debridement (removal of dead tissue from the wound bed) (Resident #4). One resident observed to receive pressure ulcer care was found with no treatment in place (Resident #8). The census was 60. 1. Review of the facility's Prevention of Pressure Injuries policy, dated April 2020, showed: -The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors; -Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable; -Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition; -Conduct a comprehensive skin assessment upon or soon after admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge; -During the skin assessment, inspect: presence of erythema (reddening of the skin), temperature of skin and soft tissue, and edema (swelling); -Inspect skin on a daily basis when performing or assisting with persona care or activates of daily living (ADLs): Identify any signs of developing pressure injuries. Inspect pressure points. Wash the skin after any episode for incontinence, moisturize dry skin daily, and reposition resident as indicated on the care plan; -Monitoring: Evaluate, report, and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's Pressure Ulcers/Skin Breakdown- Clinical Protocol, dated April 2018, showed: -The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and history of pressure ulcer(s); -In addition, the nurse shall describe and document/report the following: A full assessment of pressure sores including location, stage, length, width and depth, presence of exudate (drainage) or necrotic (dead) tissue; -The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions; -The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents; -They physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. During an interview on 7/10/23 at 6:40 A.M., the Wound Care Nurse said he worked the night shift as the floor nurse last night due to staffing and will be ending his shift soon. He usually works days. He is new to the facility within the past few weeks and accepted the role of the wound care nurse. When he is working the floor or off work, the floor nurse is responsible for wound care treatments. 2. Review of Resident #4's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 1/19/23, showed: -Cognitively intact; -Extensive assistance required for bed mobility, dressing, toilet use, and personal hygiene; -Diagnoses included diabetes and high cholesterol; -Is the resident at risk of developing pressure ulcers: Yes; -Does the resident have one or more unhealed pressure ulcer: Yes; -Number of unstageable pressure ulcers that were present upon admission: Three; -Skin ulcer treatments: Pressure reducing devices for the chair and bed, turning/repositioning program, pressure ulcer care, application of ointments/medications other than to feet. Review of the resident's care plan, in use during the time the resident resided at the facility, showed: -Focus: Date initiated 2/8/23: The resident has a pressure ulcer related to immobility; -Goal: Pressure ulcer will show signs of healing and remain free form infection; -Interventions included: Administer treatments as ordered and monitor for effectiveness. Follow facility policies for the prevention and treatment of skin breakdown. The resident needs reminders and at times assistance to turn/reposition at least every 2 hours, more often as needed or requested. The resident requires a low air loss mattress on the bed, a pressure reducing cushion in the chair, and heel pressure offloaded while in bed. Review of the resident's nursing admission assessment, dated 1/13/23, showed: -Skin evaluation- General appearance: Dry; -Note all skin issues: Issues identified to the feet. No issues identified to the buttocks area. Review of the resident's hand written admission nurses note, dated 1/13/23 at 4:30 P.M., showed: -Resident admitted to his/her room. Skin intact with pink excoriation to buttocks, left side of foot purple discolored area. All other skin intact. Review of the resident's admission Braden assessment (used to determine risk of pressure ulcers), dated 1/13/23, showed a score of 18 (at risk). Review of the resident's January 2023 treatment administration record (TAR), showed an order dated 1/14/23, for nystatin-triamcinolone external cream (used to treat or prevent fungal infection of the skin), apply to buttocks two times a day for anti-fungal. Documented as completed as ordered. Review of the resident's nursing daily skilled charting forms, showed: -On 1/20/23 at 3:00 P.M., integumentary (skin): No integumentary areas checked. Skilled nursing interventions to aide in wound healing: Turning/repositioning program; -On 1/21/23 at 6:08 A.M., integumentary: Skin color normal. Skilled nursing interventions to aide in wound healing: Elevate heels with pillow. Turning/repositioning program; -On 1/22/23 at 6:12 A.M., integumentary: Skin color normal. Skilled nursing interventions to aide in wound healing: Turning/repositioning program; -On 1/23/23 at 6:10 P.M., integumentary: Warm, dry. Skilled nursing interventions to aide in wound healing: Nutrition/hydration interventions. Review of the resident's nursing- body assessment/observation, dated 2/8/23 at 12:33 A.M., showed: -Coccyx (buttocks area) pressure wound. No documentation of measurements, appearance, or staging of the pressure wound. Review of the resident's February 2023 TAR, showed: -The order for Nystatin-triamcinolone external cream discontinued on 2/8/23. Documented as completed as ordered up and until the date discontinued; -An order dated 2/9/23, for medi-honey wound/bum dressing external paste (a cream used to treat wounds by decreasing inflammation and decreasing bacteria growth). Apply to buttocks topically every day shift for wound care. Cleanse with dermal wound cleanser, pat dry, apply medi-honey and dressing daily until healed. The treatment was not documented as completed any day in the month of February 2023. Review of the resident's nursing- body assessment/observation, dated 2/20/23 at 10:02 P.M., showed: -Coccyx pressure wound. No documentation of measurements, appearance, or staging of the pressure wound. Review of the resident's progress notes, showed: -No corresponding documentation regarding the resident's skin on 2/8/23 and 2/20/23; -On 2/22/23 at 5:17 P.M., skin/wound note: Measurement of right coccyx wound is 3 x 3.5 and measurement to left coccyx wound is 2 x 0.7. Treatment currently in place. No staging or descriptions of the wounds provided. Review of the resident's medical record, showed no further documentation of the resident's skin, treatments completed, or wound appearance, measurements, or staging in the months of January and February 2023. During an interview on 7/10/23 at 2:30 P.M., any skin assessments available for the resident was requested from the Director of Nursing (DON). On 7/11/23 at approximately 8:00 A.M., the DON provided documentation of wound and skin assessment for the resident and said prior to February 2023, the facility was under different ownership and there was no additional information she had to provide besides what was already provided. Review of the resident's progress note, dated 3/2/23 at 2:27 P.M., showed skin/wound note: Resident had initial assessment by wound physician. Unstageable pressure wound to sacrum (buttocks area) measures 2.8 centimeters (cm) x 2.2 cm. Wound bed contains yellow and white slough. Continue treatment of medi-honey and foam daily. Review of the resident's March 2023 TAR, showed: -An order dated 2/9/23 and discontinued on 3/27/23, for medi-honey wound/bum dressing external paste. Apply to buttocks topically every day shift for wound care. Cleanse with dermal wound cleanser, pat dry, apply medi-honey and dressing daily until healed. Not documented as completed on 3/2, 3/3, 3/ and, 3/24/23 with no reason documented why the treatment was not completed. Review of the resident's progress notes, showed no corresponding notes on the dates of 3/2, 3/3, 3/4 and 3/24/23 for the missed treatments. Review of the resident's skin and wound evaluation, dated 3/16/23 at 11:08 A.M., showed: -Pressure wound, unstageable- obscured full-thickens skin and tissue loss due to slough and/or eschar. Location: Coccyx. In-house acquired on 2/8/23; -Wound measurements: Area- 1.5 cm square, length- 1.6 cm, width- 1.3 cm, depth 0.1 cm; -Wound bed granulation (new tissue growth), 20%. Slough 60%. Eschar 20%; -Moderate drainage, serous (clear), no odor, wound edges attached: appear flush with wound bed or as a sloping edge. Surrounding tissue normal in color; -Dressing intact. Cleaning solution, normal saline, enzymatic debridement (removal of dead tissue by the use of a wound ointment). Primary dressing, calcium alginate (also referred to as Medi-honey). Review of the resident's March 2023 TAR, showed: -An order dated 3/27/23 and discontinued 3/31/23, for Santyl ointment (debridement ointment) apply to sacrum topically every day shift for pressure injury stage III or IV (stage III ulcer, full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed. Stage IV ulcer, full thickness tissue loss with exposed bone, tendon or muscle). Before applying Santyl, cleanse with normal saline or Vashe (wound cleanser). Protect the peri-wound (skin surrounding the wound) with skin prep (protective barrier wipe). After Santyl application, cover with gauze or ABD (absorbent dressing), secure with medi-hypafix tape. Monitor for signs and symptoms of infection. The treatment not documented as completed as ordered on 3/31/23; -No documented treatment applied to the sacrum or coccyx area on 3/31/23; -An order dated 3/29/23, for a low air loss mattress. No air loss mattress documented as provided prior to 3/29/23 at the 7:00 P.M. through 7:00 A.M. shift. Review of the resident's medical record, showed no further skin assessments or wound assessments completed in March 2023 or provided by the DON. Review of the resident's April 2023 TAR, showed: -An order dated 4/1/23 and discontinued on 4/24/23, for Santyl ointment. Apply to sacrum topically every day shift for pressure injury stage III or IV. Before applying Santyl, cleanse with normal saline or Vashe. Protect the peri-wound with Zinc cream (skin protectant ointment). After Santyl application cover with gauze of ABD. Secure dressing with medi-hypafix tape. Monitor for signs and symptoms of infection. The treatment document as completed with no reason for the treatment not being completed on 4/2, 4/8, 4/14, 4/17 and 4/20/23; -An order dated 4/24/23 for Santyl ointment. Apply to sacrum topically every dayshift for pressure injury stage III or IV. Before applying Santyl, cleanse with normal saline or Vashe. Protect the peri-wound with Zinc cream. After Santyl application, cover with dry dressing, secure dressing with medi-hypafix tape. Monitor for signs and symptoms of infection. Documented as completed as ordered. Review of the resident's progress notes, showed no documentation of wound treatment provided or reason for treatment not provided on 4/2, 4/8, 4/14, 4/17 and 4/20/23. Review of the resident's skin and wound evaluation, dated 4/6/23 at 11:02 A.M., showed: -Pressure wound, unstageable- obscured full-thickens skin and tissue loss due to slough and/or eschar. Location: Coccyx. In-house acquired on 2/8/23; -Wound measurements: Area- 18.6 cm square, length- 4.8 cm, width- 4.4 cm, depth not applicable; -Wound bed slough 50%. Eschar 50%; -Moderate drainage, serous, no odor, wound edges attached: appear flush with wound bed or as a sloping edge. Surrounding tissue erythema: Redness of the skin- may be intense bright red, dark red, or purple. Induration (thickening of the skin that can result from edema or inflammation) less than 2 cm around wound; -Dressing intact. Cleaning solution, normal saline, enzymatic debridement. Primary dressing, calcium alginate. Review of the resident's skin and wound evaluation, dated 4/13/23 at 9:21 P.M., showed: -Pressure wound, unstageable- obscured full-thickens skin and tissue loss due to slough and/or eschar. Location: Coccyx. In-house acquired on 2/8/23; -Wound measurements: Area- 2.9 cm square, length- 1.9 cm, width- 1.7 cm, depth not applicable; -Wound bed granulation 20%. Slough 60%. Eschar 20%; -Moderate drainage, sanguineous/bloody, no odor, wound edges attached: appear flush with wound bed or as a sloping edge. Surrounding tissue excoriated: superficial loss of tissue. Induration: none; -Dressing intact. Cleaning solution, normal saline, enzymatic debridement. Primary dressing, calcium alginate. Review of the resident's weekly nursing comprehensive skin evaluation/assessment, dated 4/14/23, showed: -Skin dry, warm; -Resident has one or more newly identified or existing wound or skin integrity concerns. See additional information below and may use skin and wound evaluation; -Coccyx pressure wound. No documentation of measurements, description of the wound bed or staging. Review of the resident's skin and wound evaluation, dated 4/20/23 at 3:59 P.M., showed: -Pressure wound, unstageable- obscured full-thickens skin and tissue loss due to slough and/or eschar. Location: Coccyx. In-house acquired (date blank); -Wound measurements: Area- 5.1 cm square, length- 3.3 cm, width- 2.1 cm, depth not applicable; -Wound bed, drainage, and peri-wound not assessed; -Type of dressing used not assessed. Review of the resident's skin and wound evaluation, dated 4/20/23 at 4:03 P.M., showed: -Pressure wound, unstageable- obscured full-thickens skin and tissue loss due to slough and/or eschar. Location: Coccyx. In-house acquired (date blank); -Wound measurements: Area- 5.8 cm square, length- 3.0 cm, width- 2.5 cm, depth not applicable; -Wound bed, drainage, and peri-wound not assessed; -Type of dressing used not assessed. Review of the resident's specialized wound management note, dated 4/20/23, showed: -Initial evaluation of a coccyx pressure ulcer; -Wound/ulcer #1: Location coccyx. Pressure unstageable; -Wound bed description: 10% granulation tissue and 90% slough tissue. Post-debridement: 30% granulation, 70% slough; -Measurements: Length 3.6 cm x width 2.8 cm x depth undetermined; -Peri-wound: Erythema- no signs or symptoms of infection; -Exudate: Moderate, yellow; -Plan: Cleanse with wound cleanser or normal saline, apply Santyl and calcium alginate, cover with a dry dressing. Change daily and as needed; -Additional notes: Wound was debrided. During an interview on 7/11/23 at 1:50 P.M., with the DON, Administrator, and Assistant Administrator, they said when the open area was first documented on February 8, 2023, a description of the wound should have been documented and the wound measured. Then the information passed on to the wound advisor. The ordered treatment obtained at that time should have been completed as ordered. For the measurements completed in the progress notes on February 22, 2023, there should be staging included. There should have been a skin assessment completed between February 8th and 22nd, 2023 and there should have been skin assessments done after February 22nd and prior to March 16th, 2023. Weekly skin assessment should have been done. 3. Review of Resident #8's admission MDS, dated [DATE], showed: -Cognitive status not assessed, blank; -Extensive assistance required for bed mobility, transfers, dressing, and toilet use; -Always incontinent of bowel and bladder; -Diagnoses included wound infection and anxiety; -Is the resident at risk for developing pressure ulcers: Yes; -Unhealed pressure ulcers: No. Review of the resident's progress note, dated 6/2/23 at 12:41 A.M., showed admission/readmission: Resident arrived to the facility per ambulance accompanied by a friend. Alert and oriented x4 (person, place, time, and situation), able to make needs known. Skin assessment completed. Stage IV to sacrum. Review of the resident's July 2023 TAR, reviewed for the dates of 7/1/23 through 7/9/23, showed an active order dated 6/28/23, for treatment to sacral pressure injury stage IV. Cleanse with dermal wound cleanser or normal saline, pat dry. Apply silver alginate (antimicrobial dressing) to wound bed and pack would with silver alginate. Cover with Optifoam dressing daily and as needed if saturated or stool is on the bandage: -On 7/1, 7/7, and 7/8/23, staff documented the treatment not done. See progress notes; -On 7/3/23, the treatment documentation blank. -On 7/4/23, staff documented treatment refused. Review of the resident's progress notes, showed: -On 7/1/23 at 6:40 P.M., sacral treatment administration note: Resident up in the chair. The progress notes did not document any resident education or further attempts to complete the treatment; -No documentation on 7/3/23 regarding the missed treatment; -On 7/4/23 at 7:44 P.M., sacral treatment administration note: Refused. No documentation staff educated the resident or made further attempts to complete the treatment; -On 7/5/23 at 9:04 A.M., resident seen today by the nurse and skin and wound management nurse practitioner. The resident has a stage IV pressure injury to the sacrum. Wound measures 4.0 x 4.3 x 2.0 cm. No undermining (when the wound depth extends under the skin around the wound edges) was noted upon treatment and assessment today. Wound has a faint odor noted by this nurse and wound nurse practitioner; -On 7/7/23 at 7:39 P.M., sacral treatment administration note: No documentation why the treatment was not completed, resident education, or further attempts to complete the treatment as ordered; -On 7/8/23 at 6:42 P.M., sacral treatment administration note: Resident up in chair and is not ready for dressing change. No documentation of resident education or further attempts to complete the dressing change. During an observation and interview on 7/10/23 at 10:42 A.M., showed the resident sat in his/her room in a wheelchair. The resident said no one had been in yet today to complete his/her wound care. The time they usually come in varies. During an interview on 7/10/23 at 10:45 A.M., Nurse F said he/she has not yet done the wound treatment for the resident. Since there is no wound nurse on duty at this time, she will be the person who does it. During an interview on 7/10/23 at 11:21 A.M., Clinical Nurse Manager G said he/she will be completing the wound care for the resident on behalf of the floor nurse. He/she entered the resident's room and the resident said he/she was headed to lunch and wanted to wait until after lunch. Observation on 7/10/23 at 2:11 P.M., showed Clinical Nurse Manager G entered the resident's room with wound care supplies. The resident sat in a wheelchair next to his/her bed. Clinical Nurse Manager G assisted the resident to bed and to his/her left side. Observation showed an open would to the resident's buttocks with reddened wound edges. The wound appeared deep. No dressing in place. The resident said he/she requires help from staff to either go to the bathroom or get cleaned up after going to the bathroom. He/she is not able to do this his/herself. He/she is not sure when the dressing came off, but does not remember it being applied yesterday. Clinical Nurse Manager G verified there was no dressing on the wound and no dressing inside the resident's brief. Clinical Nurse Manager G completed the wound care as ordered and said the dressing should be in place. During an interview on 7/10/23 at 2:45 P.M., Certified Nursing Assistant (CNA) D and CNA E said if they notice a wound without a treatment in place, they should tell the nurse. 4. During an interview on 7/11/23 at 1:50 P.M., with the DON, Administrator, and Assistant Administrator, they said skin should be assessed weekly and/or twice a week with showers. Documentation of wounds should include the presence of the wound, appearance, any additional care needed or notes regarding the wound. Treatments should be on and completed as ordered. MO00220435

Based on observation, interview and record review, the facility failed to ensure basic life support, including cardio-pulmonary resuscitation (CPR), would be provided if such care was needed per the resident's choice, and would only be provided to a resident subject to related physician orders and resident choice. The facility failed to have a system to ensure each resident's code status is obtained timely upon admission, ensure code status matched the resident's wishes, and ensure each resident's code status was accurately documented. Resident #41 had both a full code and a do not resuscitate (DNR) code status sheet signed and dated the same day, a physician order for DNR, and, during an interview, the resident said he/she wanted to be a full code. Resident #66 had no order for code status, a DNR signed in his/her admission paperwork, and when interviewed said he/she would not want CPR performed. Resident #48 had no order for code status and a DNR signed in his/her admission paperwork. The facility failed to obtain an ordered code status for an additional eight out of 26 residents investigated for advanced directives (Residents #123, #47, #46, #58, #122, #16, #55 and #63). In addition, Resident #59 had an ordered code status and no signed code status form. The census was 73. Of those 73 residents, 38 had orders for full code, 8 had orders for DNR and 27 had no ordered code status in the electronic physician order sheet. The administrator was notified on [DATE] at 10:20 A.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. 1. Review of the facility's Advanced Directives policy, dated [DATE], showed: -The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy; -DNR indicates that, in case of respirator or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no CPR or other life-sustaining treatment or methods are to be used; -Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives; -The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 2. Review of the facility's Do Not Resuscitate Order policy, dated [DATE], showed: -Our facility will not use CPR and related emergency measures to maintain life functions on a resident when there is a DNR order in effect; -A DNR order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record; -The interdisciplinary care planning team will review advanced directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. 3. Review of Resident #41's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included heart failure and kidney disease. Review of the resident's electronic medical record, showed: -A Patient/Resident Code Status sheet, dated [DATE], for Full Resuscitation (Full Code, lifesaving measures to include CPR desired) checked and signed by the resident on [DATE]; -An Outside The Hospital Do-Not-Resuscitate (OH-DNR) order signed by the resident and Nurse practitioner on [DATE]; -An order, dated [DATE] for DNR. During an interview on [DATE] at 6:30 P.M., Nurse Z checked the resident's electronic medical record and said the resident had an order for DNR and it was signed by the Nurse Practitioner. The physician's order and face sheet indicated the resident was a DNR. He/she was not sure why the full code status was checked on the code status sheet. The resident would not be resuscitated if the time came and he/she required it. During an interview on [DATE] at 8:08 A.M., the resident said he/she did not know what his/her code status was listed as at the facility, but he/she wanted to be saved, but just not put on machines. He/She had a care plan meeting about a week ago, but code status was not discussed. During an interview on [DATE] 8:59 A.M., the Administrator said it looks like the resident signed the wrong side of the code status form. Of the two, the one with the physician signature should be followed. He was not aware of the resident's wishes to be full code. He said this should be validated and he would clarify. 4. Review of Resident #66's admission MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included cancer, malnutrition, anxiety and depression. Review of the resident's electronic medical record, showed: -No ordered code status and no code status listed on the resident's profile; -Scanned in documents titled Admission Packet, contained an OH-DNR, dated [DATE], signed by the resident and physician; -The resident's care plan, last reviewed on [DATE], showed: -Focus: The resident has a physician order for life sustaining treatment; -Goal: Full code status will be followed; -Interventions included: Staff will recognize resident wishes and follow as indicated. During an interview on [DATE] at 5:30 P.M., the resident said no one asked him/her about code status. He/She, under no circumstances, wants CPR done. During an interview on [DATE] at 6:25 P.M., Licensed Practical Nurse (LPN) E looked at the resident's electronic medical record and said he/she did not know the resident's code status. It is not in the orders. If the resident was to be found with no signs of life, he/she would initiate CPR. 5. Review of Resident #48's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included diabetes, high blood pressure and paraplegia (paralysis of the legs and lower body). Review of the resident's electronic medical record, showed: -No ordered code status and no code status listed on the resident's profile; -Scanned in documents, showed a resident code status form with DNR selected and signed by the resident on [DATE] and an OH-DNR signed by the resident and physician, dated [DATE]; -A care plan, dated [DATE], showed: -Focus: The resident has a physician order for life sustaining treatment; -Goal: Full code status will be followed; -Interventions included: Full code physician order for life sustaining treatment will be in the medical record at all times. During an interview on [DATE] at 6:25 P.M., LPN E looked at the resident's electronic medical record and said he/she did not know the residents code status because there is no order. 6. Review of Resident #123's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included multiple sclerosis (a disease in which the immune system attacks the protective covering of the nerves, resulting in nerve damage), malnutrition, anxiety and depression. Review of the resident's electronic medical record, showed: -No ordered code status and no code status listed on the resident's profile; -No signed code status sheet; -A care plan, dated [DATE], showed code status not addressed. During an interview on [DATE] at 5:51 P.M., the resident said no one ever talked to him/her about code status. He/She would want to be a full code with everything done to save his/her life. During an interview on [DATE] at 6:25 P.M., LPN E looked at the resident's electronic medical record and said he/she did not see a code status for the resident. 7. Review of Resident #47's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart disease and kidney disease. Review of the resident's electronic medical record, showed: -No ordered code status and no code status listed on the resident's profile; -No signed code status sheet; -A care plan, dated [DATE], showed code status not addressed. During an interview on [DATE] at 5:55 P.M., the resident said no one talked to him/her about his/her code status. He/she would want CPR. During an interview on [DATE] at 6:25 P.M., LPN E looked at the resident's electronic medical record and said he/she did not see a code status for the resident. 8. Review of Resident #46's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high blood pressure, diabetes and stroke. Review of the resident's electronic medical record, showed: -No ordered code status and no code status listed on the resident's profile; -No signed code status sheet; -A care plan, dated [DATE], showed code status not addressed. During an interview on [DATE] at 6:25 P.M., LPN E looked at the resident's electronic medical record and said he/she did not see a code status for the resident. 9. Review of Resident #58's admission MDS, dated [DATE], showed: -Brief interview for mental status (used to determine cognitive status), not assessed; -Diagnoses included stroke, kidney disease and diabetes. Review of the resident's electronic medical record, showed: -No ordered code status and no code status listed on the resident's profile; -No signed code status sheet; -A care plan, dated [DATE], showed code status not addressed. During an interview on [DATE] at 6:25 P.M., LPN E looked at the resident's electronic medical record and said he/she did not see a code status for the resident. 10. Review of Resident #122's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included dementia. Review of the resident's electronic medical record, showed: -No ordered code status and no code status listed on the resident's profile; -No signed code status sheet; -A care plan, dated [DATE], showed code status not addressed. During an interview on [DATE] at 6:25 P.M., LPN E looked at the resident's electronic medical record and said he/she did not see a code status for the resident. 11. Review of Resident #16's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included heart disease and kidney disease. Review of the resident's electronic medical record, reviewed on [DATE], showed: -No physician's order for a code status; -No code status on top of the resident's profile; -No code status sheet in the records. During an interview on [DATE] at 6:30 P.M., Nurse Z checked the resident's code status and said the resident did not have a code status listed in his/her medical record. No code status meant the resident was a full code. 12. Review of Resident #55's quarterly MDS, dated [DATE], showed: -Rarely/never understood; -Diagnoses included stroke, respiratory failure, anxiety and depression. Review of the resident's electronic medical record, reviewed on [DATE], showed: -No physician's order for a code status; -No code status on the top of the resident's profile. During an interview on [DATE] at 6:30 P.M., Nurse Z checked the resident's code status and said the resident did not have a code status listed on the physician's orders or profile. Nurse Z checked the documents tab on the electronic medical record and saw a Patient/Resident Code Status sheet that indicated the resident was a full code. The code status information should be located in the physician's orders and resident profile. If the resident required resuscitation, staff would have to try to locate the code status sheet. 13. Review of Resident #63's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included diabetes, dementia and multiple sclerosis. Review of the resident's electronic medical record, showed: -No ordered code status and no code status listed on the resident's profile; -No signed code status sheet; -A care plan, dated [DATE], showed: -Focus: The resident has a physician order for life sustaining treatment; -Goal: Full code status will be followed; -Interventions included full code physician order for life sustaining treatment will be in the medical record at all times. During an interview on [DATE] at 6:25 P.M., LPN W checked the resident's medical record and said he/she did not see the code status on the resident's physician orders or on the resident's profile. During an interview on [DATE] at 6:30 P.M., the resident said when he/she was admitted to the facility, no one asked him/her about his/her code status. 14. Review of Resident #59's Admission MDS, dated [DATE], showed: -Mild cognitive impairment; -Diagnoses included end stage renal disease and diabetes. Review of the resident's electronic medical record, reviewed on [DATE], showed: -A physician's order, dated [DATE], for a full code; -Full code listed on the resident's profile; -No signed document indicating the resident was a full code. During an interview on [DATE] at 6:30 P.M., Nurse Z checked the resident's code status and said the resident was a full code. There was nothing signed by the resident indicating his/her wishes to be a full code. During an interview on [DATE] at 8:16 A.M., the resident said his/her wish was to be a full code, but no one had spoken to him/her about his/her wishes. 15. During an interview on [DATE] at 6:25 P.M., LPN W said when a resident is admitted to the facility, staff make sure a code status form is signed. Staff have the Power of Attorney (POA) sign the form and the doctor also has to sign it. He/She does not get a lot of admissions, so he/she would have to double check to see who was responsible for getting the code status form completed. LPN W knows a resident's code status by checking the resident's electronic medical record, the code status is listed on the physician orders and on the resident's profile. 16. During an interview on [DATE] at approximately 6:25 P.M., the Social Service Designee (SSD) said when a resident is admitted to the facility, the admissions director is responsible for going over the code status with the residents. Admissions asks the resident what their code status is and if a resident chose to be a full code; the form is signed by the resident, uploaded into the computer and the orders are entered into the computer. If the resident chose DNR, the resident would sign the form and the physician would also need to sign the form. Once the form was signed by the physician, the orders would be entered into the computer. The Admissions Director works Monday through Friday and when he/she is not at the facility, the code status form is left for the nurse to complete. At 6:38 P.M., the SSD said the resident's code status is in the electronic medical record, nowhere else. 17. During an interview on [DATE] at 6:25 P.M., LPN E said the residents' code status should be in the electronic medical record in the orders and on the profile. There are no paper charts on the floor. If a resident would be found with no heart beat and/or respirations, and no code status could be found, he/she would initiate CPR until someone could locate a valid DNR order. He/She was not sure where to locate signed code status sheets. He/She believes it is the nurse completing the admission who obtains the code status, but he/she is agency and does not work for the facility. 18. During an interview on [DATE] at 6:34 P.M., Certified Medication Technician (CMT) D said the resident's code status is in the electronic medical records and he/she believes there are also paper charts at the nurse's station. If he/she needed to know a resident's code status, he/she would ask the nurse. CMT D talked with the nurse and then said he/she checked and there are no paper charts on the floor, he/she thought there were. If he/she found a resident without signs of life, he/she would get the nurse. 19. During an interview on [DATE] at 6:30 P.M., Nurse Z said if there was no code status listed in the resident's medical record, the resident was an automatic full code. Code status should be listed in the physician's order, resident profile and signed by the resident. The only way to know a resident's code status was to check the medical record. Staff would benefit from a clipboard listing the residents code statuses. 20. During an interview on [DATE] at 6:35 P.M., Medical Records said there is no paper chart. All resident records are in the electronic medical record. 21. During an interview on [DATE] at 7:44 P.M., the Admissions/Marketing Director said when a new admission comes in, he/she takes the admission agreement to them for signature. He/She does not get the resident's code status. He/She is not sure who is responsible to do this. 22. During an interview on [DATE] at 8:51 A.M., the Administrator said it is the expectation that resident code status is obtained and put in the electronic medical record. That is where staff would look to validate a code status. This should be completed as soon as possible upon admission, but within the first 24 hours. At 8:59 A.M., the Administrator said it is the admitting nurse who is responsible to obtain the code status. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. 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 E 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). 37681 42247

Based on observation, interview and record review, the facility failed to ensure residents remained free of significant medication errors as evidenced by one resident receiving 10 times the ordered dose of [MEDICATION NAME] on two of two doses administered. The resident was sent to the hospital for evaluation after the second wrong dose, was observed and returned to the facility the same day (Resident #1). The sample size was five. The census was 80. Review of Resident #1's face sheet, showed he/she was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED].>-[MEDICAL CONDITION] ([MEDICAL CONDITION], blood clots that form within a vein in the lower leg or thigh); -[MEDICAL CONDITION] (bile [MEDICAL CONDITION]) with metastasis to the lung and right hip; -Cancer associated pain. Review of the resident's progress note, dated 3/19/19, showed the resident was admitted to the facility at 7:45 P.M. The resident was alert and orientated and made his/her needs known. All medications were verified with the resident's physician, documented on the medication administration record (MAR) and faxed to the pharmacy. Review of the resident's pain assessment, dated 3/19/19 at 9:00 P.M., showed staff documented: -Currently in pain: yes; -Resident stage [MEDICAL CONDITION] in bones and hip; -Chronic pain; -Past pain interventions: Prescribed medications effective, over the counter medications non-effective, no answer for non-medication interventions; -In the past 24 hours pain has completely interfered with: Ability to communicate, mood, ability to ambulate, eating, sleeping and enjoyment; -Staff did not document what makes the pain worse or in the last 24 hours, how much relief pain treatments/medications provided. Review of the resident's medical record, showed no interim care plan or comprehensive care plan documented. During an interview on 4/30/19 at 9:00 [NAME]M., the administrator said staff did not document an interim or comprehensive care plan for the resident. The interim care plan should be completed and in the resident's medical record with 48 hours of admission. The admitting nurse was responsible to ensure the care plan was completed. Review of the resident's physician's orders [REDACTED]. Review of the resident's MAR, dated (MONTH) 2019, showed staff initialed [MEDICATION NAME] 2 mg/1 ml, 15 mg/7.5 ml was administered on the following dates and times: -On 3/20/19, no time documented on the MAR; -On 3/21/19 at 9:50 [NAME]M. Review of the resident's controlled substance proof of use form from the pharmacy, dated 3/19/19, showed [MEDICATION NAME] sulfate 100 mg/5 ml, administer 15 mg/7.5 ml by mouth every three hours PRN. Three bottles sent, equals 90 ml (30 ml per bottle.) Staff documented [MEDICATION NAME] was administered to the resident on 3/20/19 at 1:20 P.M. and on 3/21/19 at 9:50 [NAME]M. Observation of the [MEDICATION NAME] label and box that was sent from the pharmacy, dated 3/19/19, showed [MEDICATION NAME] sulfate oral solution 100 mg/5 ml (20 mg/1 mg) 30 ml per bottle, three bottles sent. Administer 15 mg/7.5 ml by mouth every three hours PRN for pain. The side of the box, showed a bright orange sticker, [MEDICATION NAME] sulfate oral concentrate 20 mg/1 ml, 15 mg = 0.75 ml. Review of the resident's progress note, dated 3/21/19 at 12:23 [NAME]M., showed staff documented the resident was lethargic and did not request pain medication. No sign of acute distress. Vital signs: Blood pressure (B/P): 105/68 (normal 120/80), Pulse (P): 85 (normal 60 to 100), Respirations (R): 18 (normal 12 to 20), Temperature (T): 99.3 (normal 98.6). Review of the resident's progress note, dated 3/21/19 at 11:24 [NAME]M., showed Nurse A documented [MEDICATION NAME] was administered per physician's orders [REDACTED]. Nurse A checked the medication with the original prescription and noted the dosages were different. He/she contacted the pharmacy and the resident's physician. The resident was observed walking in the therapy gym at that time. The physician called back and gave orders to transfer the resident to the hospital for further evaluation and treatment. Vital signs documented: B/P: 139/90, P: 107, R: 18, T: 100.3. Review of the resident's progress note, dated 3/21/19 at 11:55 [NAME]M., showed Nurse A documented the ambulance was at the facility and transported the resident to the hospital. During an interview on 4/2/19 at 1:00 P.M., Nurse A said the [MEDICATION NAME] was a new physician's orders [REDACTED]. The nurse pulled up the 1 ml of liquid [MEDICATION NAME], in the syringe that came with the bottle, seven and a half times to equal 7.5 ml. The resident questioned the medication and he/she showed the resident the bottle and he/she checked the original prescription and verified the medication was correct. The resident drank the liquid [MEDICATION NAME] medication. Nurse A said he/she administered the liquid [MEDICATION NAME] 15 mg/7.5 ml on 3/20/19 and on 3/21/19. It was on 3/21/19, he/she noted it was not the correct concentration of [MEDICATION NAME], the order was for 10 mg/5 ml (2 mg/1 ml) but the [MEDICATION NAME] he/she administered was 100 mg/5 ml (20 mg/1 ml.) Nurse A assessed the resident at that time but did not document the assessment in the resident's medical record. He/she notified the resident's physician and family of the medication error and the resident was transferred to the hospital for evaluation. During an interview on 4/2/19 at 9:35 [NAME]M., the administrator said she was aware of the [MEDICATION NAME] medication issue but said it was not a medication error. She knew it was a high dose of [MEDICATION NAME] but it was a different concentration being 20 mg/1 ml, not 2 mg/1 ml. The resident propelled himself/herself to the administrator's office on 3/21/19 and said he/she thought there was a medication error regarding his/her [MEDICATION NAME]. The resident was alert at that time and said he/she was still in pain. The resident was not lethargic. Nurse A administered the resident's [MEDICATION NAME] that morning. The resident requested to be transferred to the hospital to be evaluated. No staff were inserviced on medication administration or medication errors because she did not know it was a medication error at that time. During an interview on 4/2/19 at 2:00 P.M., Pharmacist B said the wrong concentration of [MEDICATION NAME] was sent to the facility. The physician's orders [REDACTED]. The pharmacy sent three bottles of 30 ml that were 100 mg/5 ml. The resident was supposed to receive 15 mg/7.5 ml of 10 mg/5 ml (2 mg/1 ml) [MEDICATION NAME] concentrate. But since the wrong [MEDICATION NAME] concentrate was sent to the facility, the resident should have received 15 mg/0.75. If staff administered 150 mg/7.5 ml of 100 mg/5 ml (20 mg/1 ml) [MEDICATION NAME] the resident would have received 135 mg/6.75 ml over the amount that was prescribed with each dose administered. The pharmacist was not aware of this medication error, but did say facility staff should have checked the physician's orders [REDACTED]. During an interview on 5/6/19 at 1:30 P.M., the resident's physician said she was at the facility and was notified of the medication error on 3/21/19. He/she and Nurse A assessed the resident. Nurse A took the resident's vital signs at that time. The resident was lethargic and had [MEDICAL CONDITION] (low heart rate) at that time. This change in condition was due to the significant [MEDICATION NAME] error/overdose. She ordered the resident be sent to the emergency room due to the high dose of [MEDICATION NAME] administered on 3/20/19 and 3/21/19. She expected staff to read the physician's orders [REDACTED]. The resident could have went into respiratory distress due this significant medication error. Review of the facility's investigation summary, dated 4/2/19, showed on 3/21/19, the resident told the administrator he/she had a concern regarding the amount of pain medication he/she received. The resident was alert and orientated times three and able to propel himself/herself in his/her wheelchair. The resident did not appear lethargic, weak or confused. His/her speech was clear and he/she was able to verbalize his/her concerns clearly. The resident said he/she was not given the correct amount of [MEDICATION NAME]. The resident initially stated the nurse did not administer enough, then he/she stated the nurse administered too much. The administrator looked at the [MEDICATION NAME] orders and it did not appear there was a medication error but that she was getting a lot of [MEDICATION NAME] and that the resident was still in severe pain. The resident went to the emergency room for evaluation and returned with no new orders. This was not reported to state because it did not appear a medication error occurred. Review of the resident's hospital records, dated 3/21/19, showed: -The resident was assessed in the emergency room for an accidental overdose of [MEDICATION NAME]. He/she was supposed to receive 15 mg of oral immediate release [MEDICATION NAME] liquid, but instead he/she received 150 mg. The resident stated he/she felt groggy and spacey and complained of intermittent mild chest pain and anxiety. The resident was observed at the hospital and then sent back to the nursing home the same day; -Hospital staff documented the time of onset ([MEDICATION NAME] begins to take effect) of oral immediate release [MEDICATION NAME] is typically within about 30 minutes and time of peak plasma level (maximum effect of the [MEDICATION NAME]) is approximately 1 hour. It was suspected the resident had already passed peak effect time for this immediate release [MEDICATION NAME], and that he/she was unlikely to develop respiratory suppression at that time. They hesitated to administer any reversal agent, given the resident's [MEDICAL CONDITION] pain and heavy opioid dependence. Review of the facility's policies and procedures regarding medication administration received, were policies and procedures regarding: Times of medication administration revised on 2/21/19, psychopharmacological medication management revised on 8/23/17, identification of residents prior to administering medications and providing treatments or procedures, dated 11/27/18, self-administration of medication and a skills check list for respiratory medication administration, dated 9/6/17. None of these showed staff what to do to verify the correct concentration of a medication was received from the pharmacy and when actually administering a medication. During an interview on 4/2/19 at 2:00 P.M., the administrator said she did not realize it was a medication error. She did not realize the [MEDICATION NAME] concentrate was not the physician ordered concentrate. She expected staff to check the physician's orders [REDACTED]. MO 103

Based on interview and record review, the facility failed to thoroughly and accurately assess, document and notify the physician of a change in condition sustained by one newly admitted resident with a history of stroke. When staff reported the resident experienced a change in transfer status on the day shift, the day nurse did not assess the resident. When the evening shift staff notified the evening nurse of the resident's slurred speech and facial drooping, he/she assessed the resident and found left sided facial drooping and weakness in the hand grips and leg raises, and sent the resident to the hospital via regular transport and not 911. (Resident #2) The sample was five. The census was 80. Review of Resident #2's face sheet, showed an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Initial Data Collection Tool/Nursing Service, dated 3/14/19, showed staff documented: -Vital signs: Blood pressure (B/P): 150/76 (normal 120/80), Pulse (P): 72 (normal 60 to 100), Respirations (R): 20 (normal 12 to 20), Temperature (T): 97.3 (normal 98.6); -Cognitive status: Alert, oriented, short term memory loss, requires assistance to make daily decisions, mental function varies throughout the day; -Physical functioning: Able to reposition self in bed: Yes, required cueing assistance to reposition self, understands and able to recognize need to wait for assistance; -Transfers:1-2 person assistance; -Assistive device: Wheelchair; -Communication/hearing: Able to communicate needs, clear speech, hears adequately; -Psychosocial well-being: Quiet and passive; -Vision: Blind; -Neurological: Handgrips equal; -Respiratory: Regular; -Cardiovascular: Regular pulse; -Gastrointestinal: Abdomen soft, bowel sounds: Yes, continent of bowel; -Present urinary/toileting status: Continent of urine; -Describe the resident's voiding patterns: Alert and knows when needs to use the bathroom, needs assistance; -Risk factors/complications: Impaired cognition, visual deficits, stroke, impaired mobility. Review of the resident's progress note, dated 3/14/19 at 3:36 P.M., showed staff documented the resident arrived to the facility at 12:45 P.M. The resident was alert and oriented with clear speech. He/she was blind in both eyes. The resident had right side weakness and was a one person assist with activities of daily living (ADLs). Review of the nurse report sheet, dated 3/14/19, showed staff documented: -Day shift: New admit arrived at 12:45 P.M. Medications verified, visually challenged in both eyes; -Evening shift: No information documented; -Night shift: Stable. Assist x 1, Alert and oriented x 2-3, blind bilateral eyes. Review of the resident's progress note, dated 3/15/19 at 7:38 P.M., showed staff documented the resident was very quiet and friendly and he/she expressed no complaint of pain or discomfort. He/she enjoyed visitors at that time. Review of the resident's progress note, dated 3/15/19 at 10:09 P.M., showed staff documented the resident was alert and orientated with no complaint of pain or discomfort and was resting well at that time. The resident tolerates assist of one staff with his/her meals and ADLs due to being visually impaired. No apparent problems noted at that time. Vital signs: B/P: 145/71, P: 68, R: 16, T: 97.6. During an interview on 5/2/19, at 10:00 [NAME]M., the administrator said the nurse report sheet, dated 3/15/19, showed the resident was not listed. Review of the resident's progress notes, dated 3/16/19, showed no documentation of the resident's status. During an interview on 4/16/19 at 1:30 P.M., Certified Nurse Aide (CNA) [NAME] said he/she worked the day shift (7:00 [NAME]M. through 3:00 P.M.) on 3/16/19, and was assigned to the resident. The resident was alert and continent of bowel and bladder. His/her speech was clear and he/she talked to staff. The resident talked and was able to make his/her needs known. The resident was a one person transfer. He/she stood up and pivoted to the wheelchair and bed. The resident had left sided weakness on admission. During an interview on 4/16/19 at 10:30 [NAME]M., Nurse G said he/she worked the day shift on 3/16/19, and was assigned to the resident. The resident was alert, awake and had clear speech. He/she was visually impaired, so staff fed him/her meals. He/she was continent and was able to let staff know when he/she needed to use the bathroom. The resident was a one person stand pivot transfer that day. Nurse G recalled the resident had a fear of falling and would resist transfers. The resident had left sided weakness from a previous stroke. During an interview on 4/16/19 at 12:00 P.M., CNA F said he/she worked the evening shift (from 3:00 P.M. through 11:00 P.M.) on 3/16/19, and was assigned to the resident. The resident was at his/her baseline that day. The resident was a one person, stand, pivot transfer from wheelchair to bed. He/she was continent of urine and bowel. His/her speech was clear and he/she was alert and oriented and able to make his/her needs known. The resident enjoyed family visiting him/her and he/she communicated verbally. During an interview on 4/16/19 at 1:00 P.M., Nurse H said he/she worked the evening shift on 3/16/19, and was assigned to the resident. The resident was in the dining room for dinner. Staff fed the resident because he/she was visually impaired. He/she ate 100% of dinner. The resident was alert and able to make his/her needs known. The resident was continent and able to let staff know when he/she needed to go to the bathroom. The resident's speech was clear. During an interview on 4/17/19 at 7:00 [NAME]M., Nurse I said he/she worked the night shift starting on 3/16/19 at 11:00 P.M. through 7:00 [NAME]M. on 3/17/19. This was the first time he/she received report on the resident. Nurse H reported the resident was a new admit and was a two person transfer and should probably be a sit to stand lift because the resident was blind and scared of falling. That was the only shift Nurse I worked with the resident. He/she was in bed when Nurse I got to work and was still in bed when Nurse I left the facility. No staff reported any concerns regarding the resident. On the morning of 3/17/19, Nurse I gave nurse report to Nurse G, the resident was a two person sit to stand transfer. Review of the nurse report sheet, dated 3/16/19, showed staff documented: -Day shift: OK; -Evening shift: OK; -Night shift: stable. During an interview on 4/16/19 at 1:45 P.M., CNA C said he/she worked the day shift on 3/17/19. He/she was assigned to another area of the facility, but came over to assist with getting residents up. CNA C did not know the resident and that was the first time he/she transferred the resident. The nurse told him/her the resident was a one person assist to transfer. The resident was not helping to stand up and was total weight (unable to bear weight and staff had to support the resident's full weight to complete the transfer). CNA C and CNA D transferred the resident from his/her bed to a wheelchair. He/she did not take care of the resident after that. CNA C reported the resident was not a one person transfer and that he/she was total weight. He/she told the nurse the resident should be a sit to stand transfer. During an interview on 4/18/19 at 8:00 [NAME]M., CNA D said he/she worked the day shift on 3/17/19. He/she was assigned to another area of the facility, but came over to assist with getting residents up. He/she did not know the resident and that was the first time working with the resident. CNA D was in the resident's room with CNA C and assisted him/her with transferring the resident from his/her bed to his/her wheelchair. The resident did not stand at all during the transfer, he/she was total weight during the transfer. CNA D did not take care of the resident after that. During an interview on 4/16/19 at 10:30 [NAME]M., Nurse G said he/she worked the day shift on 3/17/19, and was assigned to the resident. The night shift nurse reported the resident was stable and had no change in condition. Nurse G said CNA C said he/she transferred the resident by himself/herself and reported the resident was pulling back during the transfer and asked Nurse G how the resident was a one person transfer. CNA C fed the resident breakfast and Nurse G said he/she was at baseline. Another staff fed him/her lunch and he/she remained at baseline. Staff laid the resident in bed after lunch and the resident rested. The CNAs reported the resident kept resisting and pulling back during transfers. Nurse G reported that to the evening shift nurse and CNAs. He/she documented the resident was now a sit to stand for transfers on the nurse report sheet. No staff reported the resident had a change in condition or that his/her speech was slurred, had facial drooping or was incontinent. After giving the evening shift nurse and CNAs report, he/she left the facility. The resident was resting in bed. Nurse G said the resident did not have a change in condition on the day shift. The resident was up in his/her wheelchair in the dining room and ate breakfast and lunch. The resident's transfer status was changed due to him/her resisting staff during transfers. Review of the nurse report sheet, dated 3/17/19, showed the day shift nurse documented the resident was OK and a note that he/she required more assistance with transfers was written off to the side of the page by the resident's name. During an interview on 4/16/19 at 1:30 P.M., CNA [NAME] said he/she worked the evening shift on 3/17/19, and was assigned to the resident. When he/she arrived to the facility, the resident lay in bed. When he/she went to get the resident up for dinner between 4:00 P.M. and 4:15 P.M., he/she noted the resident did not look right. The resident's speech was slurred and his/her face was droopy. CNA [NAME] recalled staff reported the resident was a stand up lift, and he/she wondered what was going on with the resident because he/she was able to stand and pivot the day before. He/she notified the charge nurse of the resident's change in condition. He/she obtained the residents vital signs and gave them to the nurse. CNA F entered the resident's room and said it looked like he/she had a stroke. During an interview on 4/16/19 at 12:00 P.M., CNA F said he/she worked the evening shift on 3/17/19, and was assigned to the resident. The resident was in bed when he/she got to the facility. CNA [NAME] was pushing a sit to stand lift into the resident's room. He/she knew something was not right because the resident was a one person stand pivot transfer the day before. CNA F went into the resident's room at approximately 4:45 P.M., and noted the resident did not look right. The resident's mouth was twisted, speech was slurred and the resident was not understanding what he/she was saying. CNA F reported the resident did not look right to Nurse H. Nurse H assessed the resident and called his/her physician and reported the resident had a change in condition. CNA F did not get the resident out of bed at that time. The resident was incontinent of urine and CNA F and CNA [NAME] provided incontinence care in bed. The resident's family came to the facility to visit and said the resident needed to go to the hospital. During an interview on 4/16/19 at 1:00 P.M., Nurse H said he/she worked the evening on 3/17/19, and was assigned to the resident. Between 4:30 P.M. and 5:00 P.M., CNA [NAME] asked him/her, The resident can't stand? Nurse H told CNA E, that Nurse G reported the resident was declining. CNA [NAME] told him/her the resident was a stand pivot transfer the day before. Nurse H said he/she was not very familiar with all the residents and this resident was a new admit, so he/she trusted what CNA [NAME] reported to him/her. CNA [NAME] reported the resident's speech was off, that it was garbled and something was wrong with the resident. Nurse H called the resident's physician and then went through his/her medical record. The nurse said the resident had a previous stroke and had left sided weakness prior to being admitted to the facility. Nurse H assessed the resident had bilateral weakness with hand grips and leg raises and a facial droop. The resident's family was visiting at that time and said the resident had a change in medical condition and wanted him/her to be assessed at the hospital. Nurse H said he/she did not call 911 for emergency medical services (EMS) because the resident's vital signs and respiratory status were stable. EMS got to the facility 45 to 60 minutes later. If the resident had a stroke, it was earlier in the day so the emergency room would not have administered a medication tissue plasiminogen activator (TPA, a medication administered via intravenous (IV) and works by dissolving a clot and improving blood flow to the part of the brain being deprived of blood) because it was not within the time frame to administer the medication anymore. He/she was not a physician so he/she could not determine if the resident had a stroke or not. He/she sent the resident to the hospital for further evaluation and treatment. Review of the resident's progress note, dated 3/17/19 at 10:16 P.M., showed staff documented at 6:30 P.M., a CNA reported the resident had a change in condition. The resident was able to stand before, but now he/she appeared to have left sided weakness and was unable to bear weight. This nurse assessed the resident and the resident had left facial droop, slurred speech and weakness to his/her left upper and left lower extremity. The resident's physician was notified of the change in condition. Family was at the resident's bedside. The resident's responsible party wanted the resident to be sent to the emergency room for further evaluation and treatment. Staff called 911. Emergency medical services (EMS) got to the facility at 6:45 P.M. and transported the resident to the hospital. Vital signs: B/P: 160/77, P: 78, R: 20, T: 97.1, oxygen saturation (O2 sat, oxygenation of the blood): 97% on room air (normal 95 to 100%). Review of the nurse report sheet, dated 3/17/19, showed the evening shift nurse documented the resident was sent to the hospital due to left sided weakness and facial droop. Review of the resident's hospital records, for 3/17/19 through 3/23/19, showed: -Speech is slurred. Left facial droop. Weakness to left upper and lower extremity, unable to grip with left hand, unable to lift left leg off the bed. -Principle Diagnoses: [REDACTED]. During an interview on 5/7/19 at 12:10 P.M., Nurse G clarified the resident had right sided weakness upon admission to the facility. During a prior interview, he/she had said it was left sided weakness. During interviews on 4/17/19 at 2:30 P.M. and 5/7/19 at 12:20 P.M., the therapy director said the resident was assessed by a physical therapist (PT) on 3/15/19. The resident communicated with clear speech, was alert and was moderate assist with transfers. The resident had left sided weakness at that time. He/she ambulated 10 feet with the PT assistance. The resident did not pull on or resist therapy staff. It was determined safe for the resident to be a stand, pivot, transfer with a gait belt. The resident was able to stand and pivot well during the assessment. During an interview on 4/16/19 at 2:30 P.M., the interim Director of Nurses (DON) said she expected the nurses to know the signs and symptoms of a stroke, which include slurred speech, facial drooping and right/left side weakness. She expected staff to call 911 immediately when a resident was assessed to have stroke symptoms. The medication TPA could be administered in the emergency room to break up the clot but it has to be administered with two to three hours of the onset of stroke symptoms. If a resident has a history of stroke, that was more reason to call 911 and send the resident to the hospital as soon as possible. The nurse documented 911 was called in the resident's progress note, but if he/she did not call 911, he/she should not have documented he/she did. During an interview on 5/7/19 at 1:30 P.M., the resident's physician said she did not assess the resident. When a resident was admitted to the facility, staff are expected to assess the resident and his/her medical record if applicable. The information staff document in the resident's medical record should be accurate. He/she did not know if the resident had left sided or right sided weakness on admission. When a resident's transfer status changes, she expected a nurse to assess the resident. She expected staff to know signs and symptoms of a stroke and to assess the resident. When a resident was assessed to have signs and symptoms of stroke, she expected the nurse to call her immediately and to transport the resident to the hospital via 911. There are specific time frames to treat a stroke at the hospital and it was imperative to get the resident to the hospital as soon as possible (STAT.) She was not aware the resident had signs of a stroke at the facility. Review of the facility's change in resident's condition policy, revised 3/10, showed the following: -All changes in the resident's condition will be recorded in the resident's medical record, such changes or conditions include, but are not limited to: -Any accident/incident involving the resident; -Any change in the resident's mental, physical or emotional status; -The attending physician will be notified of any incident, accident or change in the resident's medical condition; -The resident's next of kin or representative will be notified of all changes in the resident's condition or status; -Nursing will be responsible for notifying the resident and/or his/her legal representative of all changes in the resident's condition or status; -The interdisciplinary care plan team will meet to discuss the plan of care. MO 860

Based on interview and record review, the facility failed to protect a resident (Resident #1) from harm when transferring the resident with a mechanical lift (an assistive device used to move those who are unable to stand on their own whose weight makes it unsafe to move or lift them manually) by placing the resident on an improper sling prior to the transfer. The sling from the mechanical lift broke, causing the resident to fall and sustain fractures. This affected one of three sampled residents. The census was 79. Review of Resident #1's Fall Risk Evaluation, dated 4/26/18, showed he/she was at a high risk for falls. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/19/18, showed the following: -Brief interview of mental status (BIMS), a brief screener that aids in detecting cognitive impairment, score of 15 (cognitively intact); -Did not exhibit behaviors; -Required extensive assistance of two staff for bed mobility; -Required total dependence of two staff for transfers; -[DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. Review of the resident's nurse's note, dated 9/14/18 at 3:35 P.M., showed a Certified Medication Technician (CMT) was doing a transfer with another CMT with a mechanical lift and came to get two nurses when the sling from the lift slipped from under the resident. The resident did fall onto his/her left side onto the floor. The resident was assessed with [REDACTED]. The resident was assisted by four staff off of the floor to the bed. Pain medication was administered, but not effective. The Director of Nursing (DON), physician and family was notified of the incident. The physician ordered x-rays to the left hip and left rib cage. The resident continued to complain of pain to the head and left side. The physician assessed the resident and ordered the resident be sent to the hospital. Review of the resident's hospital records, dated 9/14/18, showed the following: -The patient presents to the emergency department from a facility after sustaining a fall while transferring from a mechanical lift. During the transfer, the straps broke and he/she fell out of the lift and landed on the ground. He/she reports sharp pain to his/her low back and left buttock. The patient typically ambulates per wheelchair. Left above the knee amputation and right [MEDICAL CONDITION]; -[DIAGNOSES REDACTED].>-Findings: The axial bone window (part of the skeleton that consists of the bones of the head and trunk of a vertebrate (backbone)) showed a hairline [MEDICAL CONDITION] sacral (a large shaped vertebra at the inferior end of the spine that forms the solid base of the spinal column where it intersects with the hip bones to form the pelvis. It supports the weight of the upper body as it is spread across the pelvis and into the legs), primarily in the anterior cortex (responsible for many psychological and physiological functions). Also, fractures were visible in the left superior pubic ramus (a part of the pelvis that is thin and flat) where it joins with the acetabulum (a concave surface of the pelvis. The head of the femur meets with the acetabulum, forming the hip joint) and in the left inferior pubic ramus (part of the pelvis that is thin and flat and passes laterally downward from the medial end of the superior ramus). During an interview on 10/16/18 at 10:45 A.M., CMT A said CMT B was assigned to the resident and asked him/her to spot the resident during the transfer. The resident was already dressed and ready. They placed the straps on the mechanical lift and placed the resident in the sling. They began to transfer the resident. CMT A did not notice anything wrong with the straps or the sling prior to transferring the resident. As they transferred the resident, the strap snapped and the resident fell to the floor and hit his/her side. The resident was about a foot from the wheelchair when he/she fell . He/she asked the resident if he/she was okay. CMT B ran to get the nurse. CMT A placed a pillow under the resident's head. Everything on the mechanical lift appeared to work fine. It did not beep and operated properly. The nurse assessed the resident and four staff transferred him/her back onto the bed. During an interview on 10/16/18 at 10:55 A.M., CMT B said he/she entered the resident's room to get him/her in the chair for a hair appointment. The resident was already dressed. CMT A spotted CMT B for the transfer. They hooked the resident up to the mechanical lift and placed the wheelchair at an angle. As they transferred the resident, the sling snapped and the resident fell to his/her side and hit his/her buttock. The resident said he/she was in pain. CMT B ran and notified the nurse. Three nurses came and one assessed the resident. They transferred the resident back onto the bed. CMT B said it turned out the straps connected to the body of the mechanical lift were defective. At the time, he/she was not aware of this. The strap could have been old or the resident was too heavy for the sling. The resident had a strap and sling specifically for his/her use. On the day of the fall, the sling he/she normally used was not in the resident's room. CMT B was not sure why they were not in the resident's room. The sling was thrown away after the fall. The resident continued to complain of pain and was sent to the hospital. During an interview on 10/16/18 at 12:15 P.M., Nurse D said he/she was the charge nurse on the day the resident fell from the mechanical lift. He/she passed medication when CMT B approached him/her and said the resident fell . He/she entered the resident's room and saw the resident on his/her left side while CMT A supported the resident's neck with a pillow. He/she assessed the resident and went to get another nurse to transfer the resident back onto the bed. After the fall, they did some troubleshooting to make sure the mechanical lift was not defective. They found the pad was too small, according to CMT A and CMT B. The resident had a pad specific to his/her size and weight. The pad used was not a proper fit after they discovered it wasn't for the resident. Staff tried to keep slings, straps and pads in the residents' rooms, but they could be removed if they were dirty, or another resident needed it. The pad broke from the straps during the transfer. From Nurse D's knowledge, he/she thought it was the same pad the resident used in the past, but was not sure. Physical therapy initially determined the size of the pad to be used. However, the Certified Nurse's Assistants (CNAs) and CMTs could determine if all equipment, including slings, pads and straps for the mechanical devices were the right fit before transferring a resident. The straps were not fitting properly. Nurse D gave the resident pain medication, but it did not help. The physician was at the facility and assessed the resident and decided to send him/her to the emergency room . During an interview on 10/16/18 at 12:00 P.M., Nurse C said Nurse D was the nurse on duty, but he/she charted the incident because he/she was new. All residents had personalized slings and straps in their rooms specific to body weight. Nurse C saw the sling after the resident fell . The strap was no longer attached to the belt and looked like it just snapped. He/she could not recall if the sling was too small, but said at all times, the slings had to be specific to body weight. During an interview on 10/16/18 at 11:45 A.M., Nurse E said he/she was not the nurse assigned to the resident, but assisted in placing him/her back to the bed. The residents had straps in their rooms unless it was in laundry. Straps and slings were specific to each resident's size. Staff were expected to place a resident in a sling specific to his/her size. The resident should fit comfortably in the sling. If a resident was not placed in the right size sling, or the straps were not the right fit, the resident could fall or have an accident. During an interview on 10/16/18 at 1:10 P.M., the DON said it was reported to her they were getting the resident ready for a shower when he/she fell . The nurse assessed the resident, obtained vitals and x-rays. They did a reenactment of the transfer and nothing seemed out of place. After further investigation, the safety officer found the sling to be defective. The pads are specific to the resident and should not be changed or given to other residents to use. If the pad or sling was too small, staff should not have transferred the resident using that particular sling. Staff could see if the resident was too big for the sling or if he/she did not fit properly prior to the transfer. During an interview on 10/16/18 at 2:20 P.M., the administrator said she expected staff to transfer the resident safely. She ordered more slings to make sure each resident had the correct one specific to their body weight and size. Review of the facility's Lifting Techniques-General Information policy and procedure, revised (MONTH) 2004, showed the following: -Policy: The purpose of this procedure is to provide general information concerning use of proper lifting techniques when lifting or moving a resident while preventing injury to the associate or resident; -Procedure: -Give the most support to the heaviest part of the resident's body; -Make sure you have a firm and secure grip before moving the resident; -Report any defective equipment to the staff/charge nurse as soon as practical. MO 917

Based on observation, interview and record review the facility failed to provide treatment to existing pressure ulcers (pressure injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) and failed to prevent the development of new pressure ulcers. The facility identified nine residents as having pressure ulcers, six were included in the sample and issues were identified with four (Resident #60, #48, #231 and #74). The census was 77. Review of the facility's Pressure Ulcer/Injury Prevention Policy, dated 11/2017, showed the following: -A comprehensive skin assessment on admission and re-admission to the center may identify pre-existing signs of possible deep tissue damage already present. These signs include purple or very dark areas surrounded by [MEDICAL CONDITION] (swelling), profound redness or induration (a hardened mass or formation), bogginess (an abnormal texture of tissues characterized by a feeling of sponginess, usually because of high fluid content) and/or drainage; -A risk assessment tool that determines the resident's risk for pressure ulcer development. The score is documented in the resident's chart; -A resident's risk may increase due to an acute illness or condition change and may require additional evaluation; -A skin assessment should be performed weekly; -Measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care and include: -Skin inspections with particular attention to bony prominences; -Skin cleansing with appropriate cleanser at the time of soiling and at routine intervals; -Treat skin with moisturizers; -Minimize skin exposure to incontinence using devices such as briefs and skin barriers; -Minimize injury due to shear (pressure against the skin) and friction (rubbing two surfaces against one another) through proper positioning, transfers and turning schedules; -Encourage fluid intake; -Improve resident's mobility and activity; -Measures to protect the resident against pressure friction and shear are implemented in the plan of care: -Reposition at least every two to four hours; -Utilize positioning devices to keep bony prominences from direct contact; -Heel protectors/suspension should be implemented when the resident is in bed; -Use lift devices to move residents in bed; -Use pressure reduction devices when the resident is in a wheelchair; -A pressure reduction mattress is placed under the resident; -Resident and significant others are educated regarding the preventative skin care plan; -When skin breakdown occurs, it requires attention and a change in the plan of care. Review of the facility's Wound Assessment policy, dated 2/25/15, showed: -Guidelines: -It is the responsibility of the licensed nurse to complete the wound assessment and to document the findings on the treatment record - wound assessment; -Assessment and documentation are completed at admission, re-admission, weekly and as needed (PRN); -The wound type is identified; -Pressure ulcers are staged based upon the Minimum Data Set (MDS) guidelines (a federally mandated assessment instrument completed by facility staff). All other wounds do not require staging; -Response to treatment based on the goal for the resident's wound is noted, additional documentation may be needed when a wound is not responding to treatment; -Documentation of the wound should include description including physical characteristics, in the medical record to avoid miscommunication or misinterpretation and should include wound location, stage, size, tissue type, exudate (drainage), undermining/tunneling (unidirectional depth of the wound into broader and deeper tissue areas), wound bed presentation, odor and any pain and wound type. 1. Review of Resident #60's significant change MDS, dated [DATE], showed: -Severely impaired cognition; -Required total assistance with bed mobility, transfers, hygiene, dressing and toileting; -Frequently incontinent; -At risk for pressure ulcers; -Number of unhealed pressure ulcers: Zero; -Number of pressure ulcers present at last assessment: Zero; -Skin and pressure ulcer treatments: Pressure reducing device for chair and bed, and ointments. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Total dependence on staff for hygiene, dressing, toileting and bed mobility; -Frequently incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -Number of pressure ulcers upon last assessment: Zero; -At risk for pressure ulcers; -Number of unstageable pressure ulcers (slough (moist dead tissue) or eschar (dry dead tissue) is present, the actual base and condition of the ulcer cannot be determined) developed since last assessment: 3; -Dimensions of unhealed stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling) or stage IV (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 or tunneling): 4.4 centimeters (cm) by 2.3 cm by 0.0 cm; -Skin and ulcer treatments: Pressure reducing devices for chair and bed, pressure ulcer care, nutrition/hydration and surgical wound care. Review of the resident's significant change MDS, dated [DATE], showed the following: -Required extensive assistance with mobility, transfers, toileting and hygiene; -Frequently incontinent of bladder and bowel; -At risk for pressure ulcers; -Current number of unhealed pressure ulcers at each stage: One at stage IV; -Dimensions of unhealed pressure ulcer: 5.5 cm by 11.0 cm by 7.0 cm; -Skin and ulcer treatments: Pressure reducing devices for chair and bed, turning/repositioning and pressure ulcer care. Review of the resident's care plan, last revised on 9/5/18, and in use during the survey, showed: Problem: Resident has a stage IV pressure ulcer on the coccyx (tailbone) and diabetic ulcers to bilateral (both) of the lower extremities. Resident has right lower leg immobility, incontinence and poor nutritional status; Goal: Resident will not develop any new areas of skin breakdown through next review; Approaches included: Staff will assist as needed to reposition/shift weight to relieve pressure. Avoid skin/skin contact. Assessment completed quarterly and as needed, weekly skin check, consult/make referral for screen as needed, encourage side rails and/or trapeze to assist in turning and float heels. Minimize pressure over bony prominences, notify nurse of any new areas of skin breakdown/redness/blisters/bruises/discoloration. Observe effectiveness/response to treatments as ordered. Low air loss mattress (LAL, special mattress used to relieve pressure) and cushion. Resident attends a hospital based wound care center. Resident has wound surgery scheduled for 9/20/18. Review of the facility's wound report, provided on 9/17/18, showed the following for the resident: -For the week of 5/21 through 5/25/18: Wound bed of all 5 open areas are stage III with red/pink and has excoriation (skin irritation) around coccyx. (Staff included indecipherable measurements); -No further wound reports provided for (MONTH) (YEAR); -No wound reports provided for (MONTH) (YEAR); -For the week of 7/8 through 7/13/18: -Left buttocks stage II, measured 1.6 cm by 2.3 cm by 0.2 cm with red excoriated areas, no defined edges with scant (small amount) drainage; -Right buttocks stage II, measured 1.9 cm by 2.8 cm with red excoriation and blanchable. Second right buttocks area healed; -Coccyx, not staged, measured 0.8 cm by 1.0 cm with red excoriation; -Second left buttocks area, not staged, measured 2.2 cm by 1.2 cm by 0.1 cm with red excoriation and scant drainage; -For the week of 7/16 through 7/20/18: -Left buttocks, stage II, measured 1.6 cm by 2.8 cm, pink and blanchable; -Right buttocks, stage II, measured 1.9 by 2.8 cm with pink, blanchable defined edges; -Left ankle, stage IV, measured 2.0 cm by 3.0 cm by 0.2 cm with 75% slough and red defined edges and scant drainage; -Right chin, stage IV, measured 3.2 cm by 1.9 cm by 0.1 cm with 50% slough and red defined edges and scant drainage; -Coccyx, not staged, measured 0.8 cm by 1.0 cm with 50% slough and red defined edges; -Second left buttocks, not staged, area measured 2.2 cm by 1.2 cm by 0.1 cm with 50% slough and red defined edges and scant drainage; -No further wound reports provided for (MONTH) (YEAR); -For the week of 8/13 through 8/17/18: -Right inner thigh, stage II, measured 10.0 by 2.6 with 10% slough and blanchable defined edges; -Left ankle, unstageable, measured 1.9 cm by 2.8 cm by 0.2 cm with 50% slough and red defined edges and scant drainage; -Right buttocks, not staged, measured 2.4 cm by 2.8 cm, pink and red with macerated edges (caused by excessive amounts of fluid remaining in contact with the skin or the surface of a wound for extended periods) and dark wound bed with defined edges; -Coccyx, not staged, measured 0.8 by 1.0 with excoriated, pink and non-defined edges; -No further wound reports provided for (MONTH) (YEAR); -For the week of 9/10 through 9/14/18: -Right inner thigh, stage II and stage IV, measured 9.0 cm by 0.2 cm with 10% slough and blanchable defined edges and moderate drainage; -Left ankle, unstageable, measured 2.0 cm by 3.0 cm by 0.2 cm with 75% slough, red defined edges and scant drainage; -Coccyx, not staged, measured 0.8 cm by 0.1 cm with excoriated pink area and non-defined edges with scant drainage; -Right chin, unstageable, measured 2.5 cm by 1.8 cm by 0.1 cm with 50% slough and red with defined edges and scant edges; -No further would reports provided for (MONTH) (YEAR). Review of the resident's (MONTH) (YEAR) electronic physician order [REDACTED]. -An order dated 6/18/18, to apply [MEDICATION NAME] (skin barrier ointment) to buttocks topically every shift and PRN for skin integrity; -An order dated 6/18/18, to cleanse open areas. Apply Allevyn foam (dressing specifically designed to manage chronic or acute draining wounds) every three days; -An order dated 7/22/18, to cleanse buttocks and coccyx with normal saline. Apply Duoderm (protective dressing). Change every three days; -An order dated 7/22/18, to cleanse right inner thigh with normal saline. Apply Santyl (ointment used to help break up and remove dead skin and tissue). Cover with Island dressing (an absorbent pad) daily; -An order dated 7/22/18, to cleanse left ankle with normal saline. Apply small Allevyn. Skin prep (protective wipe) to all affected areas daily; -An order dated 7/23/18, to cleanse chin with normal saline. Apply 4 by 4 gauze. Change daily and PRN. Review of the resident's (MONTH) (YEAR) telephone orders, showed the following: -An order dated 8/23/18, for Santyl ointment. Cleanse coccyx with normal saline. Pat dry. Apply nickel size Santyl to area on coccyx then cover with Allevyn foam every day and PRN; -An order dated 8/29/18, to send out to wound clinic. Review of the resident's (MONTH) (YEAR) treatment administration record (TAR), showed the following: -An order dated 6/18/18, to cleanse open areas. Apply Allevyn foam every three days. Staff documented a slash marks through the order and wrote d/c (discontinued). Staff did not document administering this treatment for [REDACTED]. -An order dated 7/22/18, to cleanse buttocks and coccyx with normal saline. Apply Duoderm. Change every three days. Staff did not document the application of this treatment on 8/4, 8/5, 8/7, 8/8, 8/10, 8/11, 8/13, 8/14 and 8/16 through 8/24, (YEAR). After the 8/25/18 application, staff wrote d/c and N.O. (new order) and did not document the application of any further treatments; -An order dated 7/22/18, to cleanse right inner thigh with normal saline. Apply Santyl. Cover with Island foam dressing daily. Staff documented applying the treatment 22 out of 28 opportunities. On 8/29/18, staff wrote healed; -An order dated 7/23/18, to cleanse chin with normal saline. Apply 4 by 4 gauze. Change daily and PRN. Staff documented applying the treatment 28 out of 31 opportunities; -An order dated 6/18/18, to apply [MEDICATION NAME] to buttocks topically every shift and as needed. Staff documented applying the treatment 20 times out of 31 opportunities for the A.M. treatment. Staff documented applying the treatment 27 times out 31 opportunities for the afternoon treatment. Staff documented applying the treatment 30 out of 31 times for the night treatment; -An undated, handwritten order to cleanse coccyx with normal saline. Apply Santyl to area. Apply Duoderm every 48 hours on the night shift. Staff did not document applying this treatment on the TAR; -An undated, handwritten order to cleanse coccyx with normal saline, pat dry. Apply Santyl, nickel thick to coccyx. Cover with Allevyn foam every day on the evening shift. Staff did not document applying this treatment on the TAR; -Review of the back of the TAR's, showed staff did not document why treatments were not completed as ordered. Review of the resident's (MONTH) progress notes, showed no documentation of wound assessments, measurements, descriptions or treatment of [REDACTED]. Review of the resident's (MONTH) (YEAR), electronic POS, showed the following orders: -An order dated 6/18/18, to apply [MEDICATION NAME] to buttocks topically every shift and PRN for skin integrity; -An order dated 6/18/18, to cleanse open areas. Apply Allevyn foam every three days; -An order dated 7/22/18, to cleanse right inner thigh with normal saline. Apply Santyl. Cover with Island dressing daily; -An order dated 7/22/18, to cleanse left ankle with normal saline. Apply small Allevyn. Skin prep to all affected areas daily; -An order dated 7/23/18, to cleanse chin with normal saline. Apply 4 by 4 gauze. Change daily and PRN; -An order dated 8/23/18, to cleanse coccyx with normal saline. Pat dry. Apply nickel size Santyl ointment to area on coccyx. Cover with Allevyn foam. Change daily and PRN. Review of the resident's (MONTH) (YEAR) telephone orders, showed the following: -An order dated 9/5/18, for [MEDICATION NAME] (antibiotic used to treat infections) 100 milligram (mg) to be given every 12 hours. Staff did not include a [DIAGNOSES REDACTED]. -An order dated 9/10/18, to cleanse the coccyx with mild soap and rinse thoroughly. Pat wound area dry using gauze sponges. Apply nickel thick Santyl to the wound bed and pack, with wet to dry dressing, cover with 4 by 4 gauze, Abdominal pad (ABD pad, used for large wounds or for wounds requiring high absorbency) and tape. Change twice a day every 12 hours. Review of the resident's (MONTH) (YEAR) TAR, showed: -An order dated 6/18/18, to cleanse open areas. Apply Allevyn foam every three days. Staff crossed off this order and did not document applying this treatment for [REDACTED]. -An order dated 7/22/18, to cleanse right inner thigh with normal saline. Apply Santyl. Cover with Island dressing every day. Staff crossed off this order and did not document applying this treatment for [REDACTED]. -An order dated 7/23/18, to cleanse chin with normal saline. Apply 4 by 4 gauze. Change daily and PRN. Staff crossed off this order and did not document applying this treatment for [REDACTED]. -an order for [REDACTED]. Apply nickel size Santyl ointment to area on coccyx. Cover with Allevyn foam. Change daily and PRN. Staff failed to document the application of the treatment on 9/1, 9/2, 9/7, 9/8 and 9/9/18. Staff then wrote changed 9/10/18. Staff crossed off this order and did not document applying this treatment for [REDACTED]. -An order dated 6/18/18, to apply [MEDICATION NAME] to buttocks topically every shift and as needed. Staff documented applying the morning treatment for 15 of 20 opportunities. Staff documented applying the afternoon treatment for 16 of 19 opportunities. Staff documented applying the night treatment 16 of 19 opportunities; -A handwritten order dated 9/10/18, to cleanse the coccyx with mild soap and rinse thoroughly. Pat wound area dry with gauze sponges. Apply nickel thick Santyl to wound bed and pack with wet to dry dressing. Cover with 4 by 4 gauze, ABD pad and tape. Change twice a day every 12 hours. Staff documented starting the morning treatment on 9/11/18 and provided the treatment 9 out of 10 opportunities. Staff documented starting the evening treatment on 9/11/18 and provided the treatment 7 out of 10 opportunities. Review of the resident's (MONTH) (YEAR) progress notes, showed the following: -A nurse's note, dated 9/5/18 at 3:46 P.M., Resident lying in bed, turned on right side facing window. Dressing on coccyx dry and intact. No signs or symptoms of distress noted. Educated staff of importance of resident staying dry and being rotated every two hours. New orders given from wound clinic; -A nurse's note, dated 9/6/18 at 2:25 P.M., Nurse made rounds to ensure resident was dry before shift change. Dressing on coccyx was changed by this nurse and Director of Nursing (DON). Call placed to wound clinic to set up closed pulse irrigation (CPI, hydro-wound debridement). Appointment for 9/10/18 is a follow up wound care appointment and to get a second opinion from the surgeon; -A nurse's note, dated 9/12/18 at 3:20 P.M., Resident has appointment scheduled for surgery to get a [DEVICE] (a device used to vacuum drainage from the wound); -A nurse's note, dated 9/20/18 at 6:20 A.M., Coccyx wound cleaned and dressing changed. At 4:45 A.M., resident was taken by ambulance to hospital for wound treatment; -The progress notes, showed no further documentation of wound assessments, measurements, descriptions or treatment of [REDACTED]. Observations of the resident during the survey process, showed the following: -On 9/17/18 at 2:18 P.M., resident rested on his/her back on a low air loss mattress with the head of bed raised. The resident asked to be turned; -On 9/18/18 at 10:46 A.M., the resident rested on his/her back, awake, with his/her head of bed raised; -On 9/18/18 at 12:45 P.M., the resident rested on his/her back, awake, with his/her head of bed raised; -On 9/18/18 at 2:28 P.M., the resident rested on his/her left side, awake, with his/her head of bed raised; -On 9/19/18 at 10:35 A.M., the resident rested on his/her right side, awake, with his/her head of bed raised; -On 9/19/18 at 1:41 P.M., the resident rested on his/her left side with his/her head of bed raised. The resident said his/her butt hurt earlier, but staff moved him/her and he/she is starting to feel better. During an interview on 9/21/18 at 10:20 A.M., with the DON and corporate nurse, the DON said the resident is being treated at a wound clinic for his/her coccyx. The area was debrided (surgical removal of tissue) so that a [DEVICE] could be applied. The charge nurse is responsible for providing the ordered treatments and should take measurements. The facility wound nurse was terminated in the middle of (MONTH) (YEAR). They suspect the disgruntled employee took wound reports. certified nurse aides (CNAs) also monitor the resident's skin before showers are given and are to make the nurse aware if any changes are noted. If an area on the TAR is blank, it means the treatment was not completed. An antibiotic should have a corresponding diagnosis. The corporate nurse said the resident has a history of infections in his/her wounds. During an interview on 9/26/18 at 12:45 P.M., the wound clinic nurse said the wound clinic had seen the resident for two visits. The first visit had been on 9/5/18 and the coccyx wound had been a stage IV at that time, had a foul odor and large amounts of drainage with dead tissue. The wound had so much slough that the only option was surgical debridement. The wound physician performed an in office debridement and placed the resident on [MEDICATION NAME] 100 mg twice a day for ten days for an obvious infection to the wound. The physician wanted to apply a [DEVICE] at the time; however, due to the extensiveness of the infection and tissue death, the physician scheduled a surgical wound debridement for 9/20/18 and for a [DEVICE] to be placed at the time of surgery. The wound increased in length and width between the first appointment on 9/5/18 and the second clinic appointment of 9/10/18. The wound physician completed a wound culture on 9/5/18 and the results showed positive for bacterial growth, the surgical debridement was scheduled. At the first appointment, the facility had told the clinic the resident had the coccyx wound since (MONTH) (YEAR). The resident had the scheduled wound debridement on 9/20/18 and remained at the hospital for a 23 hour post-surgical observation and discharged back to the facility with a [DEVICE] to the coccyx and a scheduled post-surgical follow up appointment for 9/24/18. The resident did not show up for the scheduled appointment on 9/24/18 because the facility failed to transport the resident, citing issues with transportation. The post-surgical visit was rescheduled to 10/1/18. He/she had concerns with the facility completing wound treatments as ordered because on the 9/10/18 appointment, the resident arrived to the appointment with no dressing or treatment to the stage IV coccyx wound. The facility does not send treatment records or nurse notes to the wound clinic appointments. It is vital that wound treatments are completed as ordered so the wounds heal correctly and the risk of infection is reduced. Review of the resident's wound clinic documentation, provided on 9/27/18, showed the following: -Resident's visits: -9/5/18, resident made appointment; -9/10/18, resident made appointment. Surgical consult; -9/24/18, resident missed appointment. No call, no show; -10/1/18, pending appointment. Review of resident's wound clinic 9/5/18 progress notes, showed the following: -Resident's history of present illness (HPI): 9/5/18: Resident comes to wound center due to having a large stage IV pressure ulcer involving the sacrum (triangular bone located above the coccyx). Examination showed an ulcer measured 5.5 cm by 11.0 cm by 7.0 cm. The ulcer showed a significant amount of tunneling and necrotic material. Resident was hosptalized on [DATE]. At the time of discharge from the hospital the resident was noted to have a pressure ulcer involving the back and buttocks noted to be a stage III; -Wound history: Resident presents with three open areas which have been present for approximately three months. Laboratory tests have not been completed in the last month. The resident had not tested positive for an antibiotic resistant organism. The resident has not tested positive for osteo[DIAGNOSES REDACTED] (inflammation of bone caused by infection); -Assessment: Large pressure ulcer of the buttocks. Wound #3 is open. Original cause of wound was it gradually appeared. The wound is currently classified as a stage IV wound with etiology of pressure ulcer and is located on the coccyx. The wound measures 5.5 cm by 11 cm by 7 cm. There is muscle and fat layer exposed and fascia (a thin sheath of fibrous tissue enclosing a muscle or other organ) exposed. There is no tunneling noted, however there is undermining. There is a medium amount of Serosanguineous (containing or relating to both blood and the liquid part of blood) drainage noted. Foul odor after cleansing noted. There is medium red granulation within the wound bed. There is a medium amount of necrotic tissue within the wound bed including adherent slough; -Wound treatment: Change two times a day with Santyl ointment. Apply nickel thick into wound then pack with wet to dry dressing over Santyl today only at wound center wet to dry dressing. Turn every 2 hours. Resident should be off his/her bottom as much as possible. Air loss mattress on bed, cushion when up in chair; -Procedure: Pre-procedure [DIAGNOSES REDACTED]. There was a skin/subcutaneous tissue/muscle debridement. Debridement with total area of 60.5 square cm performed. A minimal amount of bleeding was controlled with pressure. The procedure was tolerated well. Post debridement measurements: 5.5 cm by 11 cm by 7 cm. Post procedure [DIAGNOSES REDACTED]. -Laboratory test ordered: Tissue culture with sensitivity of the coccyx; -Medication ordered: [MEDICATION NAME] 100 mg to be given twice a day for 10 days starting on 9/5/18; -Return appointment in one week. Review of the resident's wound clinic progress notes on 9/10/18, showed the following: -Assessment: Wound #3 status is open. Original cause of wound was it gradually appeared. The wound is currently classified as a stage IV wound with etiology of pressure ulcer and is located on the coccyx. The wound measure 7 cm by 13 cm by 7 cm. There is muscle, fat layer exposed and fascia exposed. There is undermining starting at 12:00 (location representative of a clock face) and ending at 2:00 with a maximum distance of 3.5 cm. There is a medium amount of serosanguineous drainage noted. Foul odor noted after cleaning. There is a medium red granulation within the wound bed. There is a medium amount of necrotic tissue within the wound bed including adherent slough and necrosis of muscle; -Stage IV decubitus ulcer (pressure ulcer), would benefit from surgical debridement and negative pressure therapy; -Plan: -Follow up appointments: Return in one week, 9/17/18 to plan surgery in the next week with [DEVICE] application. Resident will need [DEVICE] at facility following surgery; -Dressing change frequency: Two times a day, every 12 hours; -Dressing/Treatment: cleanse the coccyx with mild soap and rinse thoroughly. Pat wound area dry with gauze sponges. Apply nickel thick Santyl to wound bed and pack with wet to dry dressing. Cover with 4 by 4 gauze, ABD pad and tape. Change twice a day every 12 hours; -Negative wound therapy: [DEVICE] to wound continuously at 125 pressure. Santyl to wound first, then start [DEVICE] with it after surgery is done; -Follow-up appointment: Will schedule for wound debridement, [DEVICE] will be placed as outpatient. 2. Review of Resident #48's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Extensive staff assistance needed for toileting, hygiene, bed mobility and dressing; -Frequently incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -admitted to facility with one stage IV pressure ulcer (wound extends to the bone, often exposed tendon and muscle present); -No other pressure ulcers present upon admission; -At risk to develop additional pressure ulcers; -Received wound care, pressure ulcer prevention and turning and repositioning services. Review of the resident's care plan, updated on 8/11/18 and in use at the time of the survey, showed: -Problem: Stage IV pressure ulcer to coccyx; -Goal: Pressure ulcer will show signs of healing by decrease in size, improved appearance and free from infection; -Approaches: Staff assist PRN to reposition and shift weight to relieve pressure, complete weekly skin checks, float heels in bed, minimize pressure over bony prominence, notify the nurse immediately of any new areas of skin breakdown, redness, blisters, bruises discoloration noted during bathing or daily care, notify resident and responsible party of any new areas of skin breakdown, observe effectiveness of response to treatment as ordered, observe for pain and medicate PRN, provide incontinence care after each episode and apply barrier cream, provide air mattress, report changes in skin to the physician and wound care as ordered. Review of the resident's weekly skin integrity data collection form, showed: -On 5/10/18 admission skin assessment: bruises and redness to the coccyx and both heels; -On 5/17/18: Necrotic (dead) coccyx ulcer and boggy areas to both heels; -On 5/24/18: Necrotic coccyx ulcer and open areas to both heels; -No additional skin assessments located from 5/24/18 to 6/5/18. Review of the resident's pressure ulcer status record, showed: -On 6/5/18: Coccyx wound unstageable. Measured 6.1 cm by 6.5 cm small amount of drainage, no odor and has white edges, eschar and slough; -On 6/11/18: Unidentified wound measured 7.8 cm x 6.6 cm copious (large amounts) of drainage, no odors, tissue is yellow, green and macerated (moist tissue damage), wound is improved. Physician notified on 6/11/18; -On 9/11/18: Coccyx wound unstageable, measured 2 cm x 3 cm x 1.5 cm deep, moderate drainage, no odor, wound is beefy red, no tunneling. -No documentation found for the scheduled assessment dates of 6/20, 6/25, 7/2, 7/18, 8/13 and 8/28/18 for the coccyx pressure wound. Review of the resident's wound clinic discharge note, showed: -On 8/27/18 the resident seen outpatient at the wound clinic and received the following orders for the coccyx wound: Apply Santly nickel thick to the wound bed, apply [DEVICE], pack tunneling area lightly at 7 o'clock, Duoderm around the wound for protection. [DEVICE] to wound continuously at 125 millimeters of mercury (mm/hg) pressure. Resident should be turned or repositioned every two hours, use pillows for positioning; -Wound clinic discharge note, showed follow up appointment scheduled for 9/10/18; -On 9/17/18 the resident seen at the wound care clinic and received the following orders for the coccyx wound: Clean area with normal saline, apply Santyl nickel thick to coccyx wound bed, apply [DEVICE]. Apply Duoderm around wound edges; -Apply moisturizing lotion to feet and legs daily; -Date acquired: 5/11/18; -Measurements: 1.9 cm long x 2 cm wide x 2.5 cm deep; -Ulcer type: Stage IV -Exudate type and color: Serosangeous and red, brown, small amount of necrotic tissue; -Exposed tissues: fat and muscle layers; -Peri-wound (wound edge): Excoriation and maceration present. Review of the resident's (MONTH) (YEAR), physician order [REDACTED].>-An order dated 8/11/18 to clean coccyx wound with normal saline, apply Santyl ointment to the wound bed, soak gauze with normal saline, squeeze out excess and pack into wound bed, pack with gauze and cover with Allevyn, change daily. The order had a hand drawn line through the order that showed the order changed, no date found when order changed and no new order documented; -No order located on the POS for the use of [DEVICE] and treatment to the coccyx wound. Review of the resident's (MONTH) (YEAR) TAR, showed: -An undated order for [DEVICE] 125 mm/hg pressure. Apply Santly first to coccyx, then wound vac. Change three times weekly: -The dressing scheduled to be completed on 9/19/18; -An order dated 9/17/18 to apply moisturizing lotion to feet and legs daily, scheduled for 11:00 P.M. to 7:00 A.M., showed no staff initials the treatment had been provided. Observation on 9/19/18 at 5:58 A.M., showed CNA F and G talked in the hallway. CNA G told CNA F that he/she had not been responsible to care for the resident during the night shift. CNA F threw both his/her hands in the air and said he/she thought the CNA G was responsible to care for the resident, so he/she guessed he/she will care for him/her now. He/she gathered supplies and entered the resident's room. He/she unfastened the urine saturated brief and provided personal care to

Based on observation, interview and record review, the facility failed to provide appropriate care and services to aide in the healing of pressure ulcers. Of the 10 residents the facility identified as having pressure ulcers, five were chosen for the sample and problems were found with two. Both residents had Stage III pressure ulcers. The sample was 13. (Residents #12 and #10) The census was 68. 1. Review of Resident #12's complete medical record, showed the following: -A face sheet, showed an admission date of [DATE]. [DIAGNOSES REDACTED]. -A nurse's note, dated 6/26/17 at 10:35 P.M., showed the resident had one friction (a wearing away of skin due to rubbing against another object) area at the coccyx (tailbone) and two friction areas to the inner right gluteal (buttock) with a superficial layer of skin removed. The resident refused to allow the nurse to remove the dressings and measure the wounds on his/her bilateral lower extremities; -A Braden Scale (used for predicting pressure ulcer risk), dated 6/26/17, showed a score of 13, indicated moderate risk; -A Braden Scale, dated 7/3/17, showed a score of 13, indicated moderate risk; -No other description of the resident's pressure ulcers. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/3/17, showed the following: -Understands/understood; -Brief interview of mental status (BIMS) score of 15 out of a possible score of 15, indicated intact cognition; -admitted with two Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured blister) pressure ulcer on 6/26/17. Review of the resident's July 2017 physician's orders [REDACTED]. -An order, dated 6/26/17, for zinc oxide (barrier cream) to coccyx and bilateral gluteal folds, every shift until healed; -An order dated 6/26/17, for weekly skin assessments; -An order, dated 7/14/17, to clean right/back inner thigh with wound cleanser (solution use to clean wounds) or normal saline and apply Duoderm (a moisture retaining occlusive dressing) every three days or PRN (as needed) until healed. Review of the resident's nurses notes, showed no notes between 6/28/17 through 7/14/17 and no charting on the right/back inner thigh areas. Review of the treatment administration record (TAR), showed the following: -On 7/5/17, staff did not document a weekly skin assessment; -On 7/12, 19 and 26/17, staff documented they completed a skin assessment. Staff did not document any skin issues; -On 7/14/17 staff documented they completed the treatment to the right/back inner thigh. The Duoderm treatment for [REDACTED]. Further review of the resident's medical record, showed the following: -Braden Scale, dated 7/14/17, showed a score of 13, indicated moderate risk; -A pressure ulcer status record, dated 7/14/17, indicated the resident had a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) right posterior thigh pressure ulcer, measured 1.7 centimeters (cm) in length by 0.6 cm in width by 0.1 cm in depth, with red beefy tissue; -A weekly pressure ulcer tracking report, dated 7/14/17, (the first time the resident appeared on the report since admission), showed the following: -One Stage II right inner thigh pressure ulcer with no measurements; -One Stage III right inner thigh pressure ulcer with a length of 4.0 cm; -One Stage III right inner thigh pressure ulcer with no measurements; -A pressure ulcer status record, dated 7/21/17, indicated the resident had a Stage III right inner thigh pressure ulcer, measured 1.7 cm by 0.6 cm by 0.1 cm with red tissue; -A weekly pressure ulcer tracking report, dated 7/21/17, showed the following: -One Stage II right inner thigh pressure ulcer with no measurements; -One Stage III right inner thigh pressure ulcer with a length of 4.0 cm; -One Stage III right inner thigh pressure ulcer with no measurements. Observation on 7/25/17 at 4:25 P.M., showed the resident sat in his/her recliner. Certified Nurse Aide (CNA) Y entered the resident's room. The CNA assisted the resident with removing his/her clothing and standing, then pulled down the resident's incontinence brief. The resident leaned forward and exposed three open areas on his/her right inner posterior (back) thigh. The open area on the resident's right upper inner thigh, measured approximately 0.1 cm in length by 0.5 cm in width with pink tissue covering the wound bed. The second and third open areas, located on the resident's right medial and distal (away from the body) inner thigh, measured approximately 2.5 cm in length by 3.0 cm in width, with pink to beefy red tissue covering the wound bed. The CNA assisted the resident into the bed. CNA Y verified no dressing inside the resident's incontinence brief. The resident said he/she did have a dressing on his/her right inner thigh, but when he/she was receiving therapy that day, at 4:00 P.M., the dressing was coming off so therapy staff removed it. The CNA said he/she told the charge nurse of the dressing not being on and the charge nurse said he/she was coming into the room to provide the treatment and dressing application. Nurse H and Nurse C entered the resident's room. Without washing his/her hands, Nurse H applied gloves and placed the resident's package of Duoderm, tube of zinc oxide and packages of gauze directly on the resident's bed without a barrier. Nurse C assisted the resident onto his/her left side. Nurse H picked up the bottle of wound cleanser and sprayed the solution back and forth over the resident's buttocks and three open areas on the right inner thigh. Without removing his/her gloves, Nurse H picked up multiple pieces of 4 by 4 gauze and wiped from the resident's perineal/vaginal area onto the open areas on the resident's right inner thigh. Nurse H placed the soiled gauze underneath the resident's buttocks. Without changing his/her gloves, Nurse H picked up several pieces of gauze dressings, continued to wipe and pat dry each open area wiping back and forth, then back and forth again from each open area. Nurse H removed his/her gloves and placed the soiled gauze and gloves directly on the resident's bed. Without washing his/her hands, Nurse H applied gloves, picked up a measuring tape and measured the first, open area on the resident's right inner thigh as 4.0 cm by 1.0 cm., with pink to beefy red tissue in the wound bed. Nurse C said the open area on the resident's right upper inner thigh was a Stage II pressure ulcer. Nurse H did not remove his/her gloves, and placed the same measuring device on the second open area that measured 3.5 cm by 0.4 cm, with approximately 20% yellow slough in the wound bed, and beefy red tissue surrounding the periwound edges. Nurse C said the second and third open areas on the resident's right inner thigh were Stage III pressure ulcers. Nurse C said the second open area contained approximately 20% slough. Without removing his/her gloves, Nurse H placed the same measuring device on the third, open area that measured 4.0 cm by 1.0 cm. Nurse H removed his/her gloves, did not wash his/her hands, applied gloves and applied a large Duoderm dressing over the open areas on the resident's right inner thigh. Nurse H removed his/her gloves, but did not wash his/her hands, applied gloves, removed the cap from the zinc oxide tube, placed the cap directly on the resident's bed and applied the ointment to the residents buttocks. Nurse H picked up the cap to the zinc oxide tube, wiped off the end of the cap with the soiled gauze used to cleanse the open areas on the resident's right inner thigh and placed the cap on the end of the zinc oxide tube. Nurse H removed his/her gloves and washed his/her hands. Further review of the resident's medical record, showed a weekly pressure ulcer status record, dated 7/27/17, indicated the resident had a 1.4 cm by 0.4 cm by 0.1 cm Stage III right inner thigh pressure ulcer, with red tissue. During an interview on 7/27/17 at 4:05 P.M., the Director of Nurses (DON) said nursing staff should clean each open area with a different gauze and should measure each open area with a different measuring device to aide in appropriate healing process. She said if nursing staff did not clean and/or measure the open areas using appropriate technique, it would impede the healing process. During an interview on 8/4/17 at 2:45 P.M., the facility's medical director said he expected nursing staff to change their gloves during treatments, when cleaning one wound bed then another and would expect nursing staff to use different gauze for each different wound bed. He would expect staff to use clean gauze when reapplying the cap to the zinc oxide tube, should not have cleaned from the perineal/vaginal area then into the wound all for infection control purpose. 2. Review of Resident #10's face sheet, showed the following: -readmitted to the facility from a local hospital on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's hospital wound assessment, showed the following: -7/8/17 at 1:32 A.M.: Left heel Stage III pressure ulcer. Wound bed fragile and painful. Measured 5 cm long by 4 cm wide by 0.5 cm deep. No tunneling. Full thickness. Moderate amount purulent (containing pus) exudate (drainage) with foul odor; -7/11/17 at 11:15 A.M.: Left heel wound bed fragile, pearly pink, full thickness with maceration (softening/breakdown of skin due to prolonged exposure to moisture) of the periwound skin. Small amount purulent exudate with mild odor. No measurements recorded. Review of the resident's POS, dated 7/11/17 through 7/31/17, showed the following: -An order dated 7/11/17, to apply Dakin's Solution (antimicrobial cleanser which eliminates bacteria and odor from an infected wound) 0.125% (1/4 strength) to affected area daily; -An order dated 7/13/17, for skilled physical therapy five times a week for six weeks for wound care to include closed pulsed irrigation (a wound flushing process to keep a wound clean and promote healing) to the left heel with 3000 cubic centimeters (cc) of normal saline. Review of the resident's treatment administration record (TAR), dated 7/11/1/7 through 7/31/17, showed the following: -An order dated 2/8/17, to cleanse the left heel wound with normal saline. Apply Poly Mem (a dressing that fills, absorbs and moistens wounds), cut to fit wound bed. Cover with 4 by 4 and Kerlix (gauze wrap) daily; -The resident was admitted to a local hospital on 7/8 through 7/11/17, with a [DIAGNOSES REDACTED]. -Staff documented they applied the treatment every day from 7/1 through 7/16 and from 7/19 through 7/26/17; -Staff did not document any treatment done on 7/17 and 7/18/17; -No treatment found to apply Dakin's Solution to the left heel wound as ordered on [DATE]. Observation on 7/26/17 at 10:30 A.M., showed the resident lay in bed on his/her right side. Physical Therapist (PT) Q, uncovered the resident's feet, removed the Prevalon (protective) boot from his/her left foot and exposed an undated dressing on the left foot. Nurse D put on gloves and removed the dressing. PT Q put on gloves and irrigated the resident's left heel wound with 3000 cc of normal saline. After PT Q finished irrigating the wound, Nurse D changed his/her gloves and measured the area as 6.0 cm long by 6.0 cm wide by 0.5 cm deep, with a thin sliver of yellow slough at the edge of the periwound. Nurse D said the area was a Stage III diabetic ulcer. Nurse D removed his/her soiled gloves, washed his/her hands, put on clean gloves, placed a piece of Poly Mem dressing over the left heel wound and wrapped the left heel and foot with Kerlix. He/she removed his/her soiled gloves, washed his/her hands and removed the plastic bag with the soiled equipment from the room. Neither Nurse D or PT Q applied any Dakin's Solution to the wound prior to dressing the wound and leaving the room. During an interview on 7/27/17 at 1:15 P.M., the DON looked at the resident's medical record and said there was no current treatment order for the resident's left heel wound, there had not been one since the resident returned from the hospital on [DATE], and the order for the Poly Mem was an old order in use prior to his/her hospitalization . She would have expected staff to clarify the order for the Dakin's Solution, as to where it was to be applied and obtain current orders for a treatment to the left heel wound.