Every finding on record at Lansdowne Village

Based on observation, interview and record review, the facility failed to store and prepare food in accordance with professional standards for food safety and facility policy on three of three days of observation. The facility failed to ensure the hot water in the hand washing sink was functional and failed to ensure staff washed their hands after touching their face mask, personal phone and other potentially unclean surfaces. Staff failed to clean food debris from the floors, dish washing 3-vat sink, equipment, and food preparation surfaces. Staff stored dried goods with no lids or the lids opened. In addition, drinks and other liquids were spilled in the dry storage room and not cleaned for all three days of observation. This had the potential to affect all residents who ate from the facility kitchen. The census was 121.1. Review of the Department of Health - City of [NAME] hand washing sign, posted at the handwashing sink, showed handwashing is done after handling garbage; before handling food; anytime you change tasks; after handling dirty dishes, utensils, or equipment; after taking off or putting on gloves; after touching your face, hair, or clothing; after using the bathroom; after eating or drinking; and, after coughing or sneezing. Review of the Hand Sink Proper Hand Washing Procedure sign, posed at the handwashing sink, showed:-Wet your hands with hot running water;-Apply soap;-Rub your hands together for at least 20 seconds;-Clean under fingernails and between fingers;-Rinse hands thoroughly under running water;-Dry hands. Observation of breakfast meal prep in the kitchen on 9/26/25 at 5:04 A.M., showed [NAME] J arrived through the back entrance and unlocked the kitchen door to allow the surveyor entrance. [NAME] J said he/she is the only dietary staff at this time and will begin breakfast meal prep. Observation showed the resident trays set out on the carts with utensils, napkins, and resident diet tickets. [NAME] J put on gloves and did not wash his/her hands. The surveyor washed his/her hands at the handwashing sink. The water ran for approximately 2 minutes and it did not get hot. [NAME] J said he/she had no idea if the water at the handwashing sink got hot. [NAME] J began meal preparation. He/She placed cooked eggs, some hardboiled and some scrambled eggs in a blender and made pureed eggs. He/She then covered the pureed eggs with plastic wrap. He/She changed his/her gloves and placed the dirty blender into the middle vat of the 3-vat sink and ran hot water over the dish. He/She then removed his/her gloves, and without washing his/her hands, walked into the walk-in cooler and came out with a box of individual serving sized butter. [NAME] J placed butter on each meal tray. He/She then picked up a butter container that had fallen on the floor and held it in his/her ungloved hand as he/she returned the box of butter to the walk-in cooler. He/She then exited the walk-in cooler with the butter that had fallen and bread. He/She placed the butter in the trash and placed gloves on. He/She did not wash his/her hands. He/She placed a toaster on the back wall preparation station, took two pieces of bread out of the bread bag and placed them in the toaster. [NAME] J got pre-cooked hardboiled eggs from the walk-in cooler, pleased them in a large pan on the stove, and added hot water from the coffee maker before turning on the oven. He/She removed his/her gloves and placed new gloves on. He/She then took the toasted bread from the toaster and placed it on a tray and put more bread in the toaster. [NAME] J continued to prepare the breakfast meal. Further on in the observation, [NAME] J removed his/her gloves, walked over to the mixer that sat in the 3-vat sink, placed gloves on and washed the blender with dish soap and hot water. He/She changed his/her gloves and did not wash his/her hands. He/She took the blender to the back food preparation area and made pureed sausage with pre-cooked sausage. Once done, he/she placed the blender in the middle vat of the 3-vat sink and ran hot water over it. He/She covered the pureed sausage with plastic wrap and placed in a warming cart. He/She continued with meal preparation. At 5:52 A.M., someone knocked at the kitchen door. [NAME] J answered the door, got a metal tub from the clean dish rack in the back and handed it to the person at the door. He/She removed his/her gloves and did not wash his/her hands, placed new gloves on and continued with meal preparation. At 6:11 A.M., Dietary Aide (DA) L arrived through the back door with his/her bag and phone in hand. He/She wore a face mask over his/her mouth. He/She placed his/her cell phone down on a serving cart and returned to the back area where the lockers are. He/She returned and washed his/her hands. After washing his/her hands, the temperature of the water was tested and felt cold to the touch. DA L picked up his/her cell phone and placed it on the back food preparation station. He/She then got a hair net and put it on. The kitchen phone rang. DA L pulled his/her facemask down to his/her chin and picked up the phone. After the call, he/she walked over and without washing his/her hands or placing gloves on, began to pull trays out of the carts and read the name cards. Once he/she found the intended tray, he/she grabbed it and placed it on the steam table. He/She grabbed an individual serving sized syrup, placed it on the tray, told [NAME] J that the resident needed their tray by 7:00 A.M. and walked into the walk-in cooler. He/She returned with a juice and placed it on the tray. He/She then pulled his/her mask up over his/her mouth and walked out of the kitchen. At 6:22 A.M, more staff began to arrive to help with meal service. At 6:24 A.M., DA L returned to the kitchen and washed his/her hands in the hand washing sink. Once done, the water was checked and felt cold to the touch. He/She placed gloves on and began helping with meal preparation. A little later in the observation, DA L, with no gloves on, placed syrup on the trays. He/She adjusted his/her facemask and then continued to place syrup on the trays. He/She then walked over to the dish drying racks, pulled his/her mask down under his/her chin and began to sort through the stacks of cups. He/She then placed gloves on without washing his/her hands and began to pass out bowls of cereal. Observation and interview on 9/29/25 at 7:23 A.M., showed meal service in progress in the kitchen. The surveyor allowed the handwashing sink to run for approximately 2 minutes. The water felt cold to the touch. [NAME] K said there was an issue with the hot water at the hand washing sink. The water heater clicks off at times. He/She thinks it is fixed now. During an interview on 9/29/25 at 7:28 A.M., the Administrator said no one had reported issues with the hand washing sink not getting warm. During an interview on 9/29/25 at 9:19 A.M., the DM said staff wash their hands when they first arrive at the kitchen and anytime hands get soiled. The issue with the hot water in the handwashing sink just started. Maintenance was just made aware of the issue today. During an interview on 9/29/25 at 10:11 A.M., the Maintenance Supervisor said he was told today about the water in the handwashing sink not getting hot. He had not investigated the cause yet. At 1:51 P.M., the Maintenance Supervisor said the water is fixed. Someone had turned the hot water valve handle, and it was not all the way on. During an interview on 9/30/25 at 11:30 A.M., with the DM and Administrator, the DM said staff should wash their hands when they first arrive to the kitchen, when they change their gloves, and after touching a mask or their phone. Staff should not put their phones on the food preparation stations. 2. Review of the facility's Nutritional Services Sanitation policy, dated 3/31/21, showed:-Nutritional services shall ensure a clean and sanitary work environment; to promote and protect food safety; and, to maintain compliance with Federal, State and local regulations governing food sanitation and safety;-Personnel shall be responsible for daily, weekly, and monthly cleaning assignments as determined by the dietary manger and/or his/her designee;-Cleaning assignments may include but not limited to equipment, storage areas, walls, and food service-related carts. 3. Review of the facility's Ware Washing policy, dated 3/31/21, showed:-Nutritional services employees shall ensure food is prepared and served in clean food-safe supplies and maintain compliance with Federal, State, and local regulations governing food safety;-Tableware and supplies shall be washed and sanitized according to food safety practices and regulatory guidelines as follows: All tableware, utensils, preparation, and service supplies shall be washed and sanitized in the pot sink and/or through use of a commercially approved dish machine;-The pot sink shall be a three sink unit with a detergent in the first sink, a clear rinse water in the second, and a sanitizer in the third and final sink. Pots and pans washed in the pot sink may be sanitized in the dish machine;-The dish machine shall be emptied and cleaned after each meal, then refilled, as appropriate. 4. Review of the facility's Daily Kitchen Checklist, dated 9/22/25 though 9/28/25 that hung on the pin board near the Dietary Manager's office, reviewed on 9/29/25 at 7:28 A.M., showed use N/A when the item is not applicable. Do not leave blank. Use W/O when work order is pending. Do not leave blank:-All dishes, pots, pans, and utensils are cleaned and stored properly after each meal and snack:--Initialed as completed on Mon 9/22, Sat 9/27, and Sun 9/28. All other dates blank;-All sinks are cleaned and sanitized after use:--Initialed as completed on Mon 9/22, Sat 9/27, and Sun 9/28. All other dates blank;-All work counters/tables are cleaned and sanitized after use:--Initialed as completed on Mon 9/22, Sat 9/27, and Sun 9/28. All other dates blank;-Steam table is cleaned and sanitized after each use:--Initialed as completed on Mon 9/22, Sat 9/27, and Sun 9/28. All other dates blank;-Floors swept and mopped daily:--Initialed as completed on Sat 9/27 and Sun 9/28. All other dates blank;-Store room floors, shelves, and area cleaned and tidied up daily;--Initialed as completed on Mon 9/22. All other dates blank;-Clean steamer and steam table after each use:--Initialed as completed on Sat 9/27 and Sun 9/28. All other dates blank. 5. Review of the facility's Weekly Kitchen Checklist, dated 9/22/25 though 9/28/25 that hung on the pin board near the Dietary Manager's office, reviewed on 9/29/25 at 7:28 A.M., showed:-Clean pantries, shelves, and food canisters: Documented as completed on 9/24/25;-Deep clean ovens weekly or as needed: Not documented as completed;-Polish all stainless-steel surfaces: Not documented as completed;-Deep fryer cleaned and oil changed weekly, or as needed: Not documented as completed. 6. Review of the facility's Monthly Kitchen Checklist, dated September, that hung on the pin board near the Dietary Manager's office, reviewed on 9/29/25 at 7:28 A.M., showed:-Underneath all prep stations deep cleaned: Not documented as completed;-Floors deep cleaned: Not documented as completed;-Underneath cook's area deep cleaned. Not documented as completed. 7. Observation during the initial brief kitchen tour on 9/25/25 at 8:30 A.M., showed meal service in progress:-The kitchen floor with dirt and debris;-The dry storage room with a single serving juice cup on the ground between two storage racks and a liquid spilled out from around it. The spill looked partially dried. Along the wall on the right side of the dry storage room, an oily spill under the dry storage rack. To the right of the door to the dry storge room, a dried and sticky spill on the ground. Review of the facility's menu showed:-Cheeseburger on a bun, lettuce, tomato and pickle served for the dinner meal on 9/24/25; -Tater tots served for the dinner meal on 9/25/25. Observation of breakfast meal service on 9/26/25 at 5:04 A.M., showed:-The kitchen floor with dirt and debris;-The dry storage room with a single serving juice cup on the ground between two storage racks and a dried liquid spilled out from around it. Along the wall on the right side of the dry storage room, an oily spill under the dry storage rack. To the right of the door to the dry storge room, a dried and sticky spill on the ground;-Behind the oven an opened individual serving jelly container lay on the ground;-A two-tier stainless-steel rolling cart near the dish washing sink with a tater tot on the bottom tier;-Dirty dishes sat in the dish washing station with food debris caked on. [NAME] J said the dishes were from the prior day;-Under the 3-vat sink, the floor sticky. A medium sized pieces of cardboard that appeared wet with an opened individual sized serving butter container and food debris on top;-A flour and sugar bin sat on the floor in the back food predation station. The binds covered on top and on the sides with drips and greasy smears. The sugar container with 4 large drips of what appeared to be dried puree food on the top;-A two-tier stainless-steel table in the back serving area with rusty spots on the bottom tier with the stainless steel finish missing. Dried on food drips and greasy spills cover the bottom tier and along the sides. Clean muffin pans and a cutting board stored on the bottom shelf;-Behind the ice machine, a large amount of debris and trash lay on the ground, with a build-up of a black, thick substance. A leak from the ice machine and a puddle on the ground. The wall behind the ice machine appeared to be swollen and wet, with a hole in the wall with a dark colored, fuzzy substance on the wall;-Under the dishwashing sink, an opened single serving peanut butter container lay on the ground next to some crinkled up plastic wrap;-The 3-vat sink against the wall near the dishwashing station. The basin to the right labeled wash, the middle basin labeled rinse, the basin to the left labeled sanitize. Inside the sanitize basin, a large amount of what appeared to be meat cuttings and other food debris dried to and caked onto the bottom and sides of the basin. The wash basin wet and appeared to be recently used. Soapy suds on the bottom of the basin. At 5:47 A.M., a baby roach crawled across the shelf above the 3-vat sink;-A food warmer, located near the deep [NAME], with a greasy build-up along the bottom lip and grease splashes across the front. The greasy build-up filled the bottom lip that appeared to be approximately a quarter inch deep and half inch wide on the side closest to the deep [NAME]. The side of the [NAME], near the deep [NAME], had a large amount of greasy splatters with food debris stuck to the splatters;-The deep [NAME] with food debris and crumbs along the edges, sides, and top. Food debris floated on the top of the grease;-The floor around the deep [NAME] with a thick greasy build-up with dirt and debris stuck to the grease;-The front of the steam table, with a dead roach that lay on the bottom shelf next to clean dishes. A second dead roach a few inches away. Under the steam table in front of the [NAME], a paper towel appeared greasy and stuck to the bottom shelf;-A build-up of debris under the serving station/steam table;-In the dish washing sink in the dish washing station, the sink with dried food, to include pickles, onions, strawberries, greens, and other food debris;-A square drain on the floor near the 3-vat sink with a metal cover with food debris caked around the edges. A roach crawled out of the drain and crawled to the back food preparation station;-Under the stove, napkins, plastic wrap, food debris and a build-up of dirt. A large roach crawled out from under the stove and crawled under the steam table. Observation on 9/29/25 at 7:16 A.M., showed:-The kitchen floor with dirt and debris;-The dry storage room with a single serving juice cup on the ground between two storage racks and a dried liquid spilled out from around it. Along the wall on the right side of the dry storage room, an oily spill under the dry storage rack. To the right of the door to the dry storge room, a dried and sticky spill on the ground;-The 3-vat sink against the wall near the dishwashing station. A dead roach lay inside the wash basin;-A two-tier stainless-steel table in the back serving area with rusty spots on the bottom tier with the stainless-steel finish missing;-Behind the ice machine, a large amount of debris and trash lay on the ground, with a build-up of a black, thick substance. A leak from the ice machine caused a puddle on the ground. The wall behind the ice machine appeared to be swollen and wet, with a hole in the wall with a dark colored, fuzzy substance on the wall;-A roach smashed on the ground in front of the steam table;-A food warmer, located near the deep [NAME], with a greasy build-up along the bottom lip and grease splashes across the front. The greasy build-up filled the bottom lip that appeared to be approximately a quarter inch deep and half inch wide on the side closest to the deep [NAME]. The side of the [NAME], near the deep [NAME], with a large amount of greasy splatters with food debris stuck to the splatters;-The deep [NAME] with food debris and crumbs along the edges, sides, and top. Food debris floated on the top of the grease;-The floor around the deep [NAME] with a thick greasy build-up with dirt and debris stuck to the grease;-The front of the steam table, with a dead roach that lay on the bottom shelf next to clean dishes. Under the steam table in front of the [NAME], a paper towel appeared greasy and stuck to the bottom shelf;-A build-up of debris under the serving station/steam table;-A square drain on the floor near the 3-vat sink with a metal cover with food debris caked around the edges. During an interview on 9/29/25 at 7:23 A.M., [NAME] K said he/she has seen some roaches but not too bad. There is a daily cleaning list. [NAME] K pointed to the pin board near the dietary manager's office and said staff sign off when a task is done. In the evening, after dinner, staff wash all the dishes. The cook does a walk around to ensure the dishes are done. During an interview on 9/29/25 at 7:31 A.M., the Administrator said there is a cleaning schedule hanging on the wall near the dietary manager's office that staff sign when a job is done. During an interview with the DM, completed during a walkthrough of the kitchen on 9/29/25 at 9:19 A.M., the DM said the deep [NAME] is cleaned once a week. The day of week this is done differs. Typically, it is cleaned on Thursday or Friday. [NAME] K said he/she changed the [NAME] oil two Fridays ago. The DM said the other cook should have changed it then on this last Friday. When cleaning the friers, they drain the oil and clean all the debris and run hot soapy water through it. The spatters and food debris on the heating tray is cleaned up after lunch, daily. They do wash dishes in the 3-vat sink. Food debris should be cleaned up immediately out of the sink. On Friday 9/26/25, the sink was dirty because staff left the food debris overnight and they should have cleaned it before they left. Kitchen closing duties include to clean up all the food debris before leaving for the day. The cardboard under the sink should be cleaned up. That was there when they replaced the tubing under the skin. It was done a while back, not sure when. Once a week the floor in the dry storage room should be cleaned. If there is a spill, it should be cleaned immediately. Observation showed the juice cup that was on the floor was now sitting on the food storage shelf. The three spills remained. The DM picked up the empty juice cup and said she would throw it away. Observation showed a dead roach on the steamtable shelf. The DM and she said this should be cleaned up. Observation showed debris and build-up behind the ice machine. The DM said the debris behind the ice machine should be cleaned up every day. It should be cleaned under and behind the equipment every day. 8. Observation on 9/25/25 at 8:30 A.M., in the back preparation station, showed:-A container of fajita seasoning, sat on a shelf opened;-A container of ground thyme leaves, sat on a shelf opened;-A large tub of parsley flakes with no lid. Observation on 9/26/25 at 5:04 A.M. and 5:20 A.M., in the back preparation station, showed:-A container of fajita seasoning, sat on a shelf opened;-A container of ground thyme leaves, sat on a shelf opened;-A large tub of parsley flakes with no lid;-A container of rotisserie seasoning, sat on a shelf opened;-A container of black pepper, sat on a shelf opened;-A container of salt, sat on the counter, with the lid propped opened;-The sugar bin that sat on the floor, with the lid propped opened. During an interview on 9/29/25 at 9:19 A.M., the DM said she is not sure where the lid to the parsley flakes is. Seasoning should be closed after use. During an interview on 9/30/25 at 11:30 A.M., with the DM and Administrator, the DM said the sugar and salt bin lids should be closed when not in use.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program in the facility kitchen. Staff failed to ensure food debris was cleaned up daily resulting in roaches being present in the kitchen. The census was 121.Review of the facility's Pest Control policy, dated 8/2/21, showed:-The facility maintains an effective pest control program to remain free of pests and rodents. Pest control strategies are developed emphasizing kitchens, cafeterias, laundries, central supply areas, loading docks, construction, activities, and other regions prone to pest infestations;-All food stored in the dietary area is kept in a designated area in securely covered containers and stored off of the floor and away from the walls. Review of 5 months of pest control visit documents, showed:-Technician visit on 5/9/25: Target issue- ants. No further notes of the areas treated, recommendations, or findings;-Technician visit on 6/26/25: Target issues- spiders and mice. No further notes of the areas treated, recommendations, or findings;-Technician visit on 7/17/25: Target issues- spiders, ants, and mice. Technician comments: Treated for roaches in kitchen and break room baited exterior rodent station for mice activity;-Technician visit on 8/18/25: Target issue- spiders and mice. Technician comments: Treated all areas as needed, replaced bait in rodent stations as needed;-Technician visit on 9/9/25: Target issue- ants and spiders. Technician comments: Treated 3 office, kitchen, nurses stations, dining room, and 3 bathrooms;-Technician visit on 9/26/25: Target issue- ants and spiders. Technician comments: Treated kitchen for roaches. Observation of breakfast meal prep in the kitchen on 9/26/25 at 5:04 A.M., showed [NAME] J arrived through the back entrance and unlocked the kitchen door to allow the surveyor entrance. [NAME] J said he/she is the only dietary staff at this time and will begin breakfast meal prep. Observation of the kitchen, showed trays already set up with utensils, resident diet tickets, and napkins. As [NAME] J placed breakfast meat in the oven, a roach crawled across the back food prep area along the floor. Observation in the back food prep area showed a bin of parsley flakes with no lid and several other seasoning containers with the lids opened sat on the prep station. A second roach crawled out from under the 3-vat sink. Observation under the sink showed trash and food debris on the floor. Observation behind the oven showed trash and food debris, to include an opened individual serving sized jelly container. A 2-tier rolling cart sat near the dish washing sink with a tater tot on the bottom tier. Dirty dishes sat in the dish machine area. Food debris sat in the 3-vat sink. As [NAME] J prepped for breakfast, at 5:47 A.M., a small baby roach crawled across the shelf above the 3-vat sink where clean serving dishes sat. [NAME] J walked over and placed the mixer in the middle rinse sink of the 3-vat sink and ran hot water over it. As [NAME] J stood at the stove, a roach crawled from under the back side of the steam table, closest to the oven and stove, up onto the second shelf of the steam table/prep station and crawled into a white storage bin. Serving utensils were kept in the white storage bin. After a few minutes, the roach crawled back out of the storage bin and around the edge of the bin and then crawled down onto the shelf. Observation of the front side of the steam table, near the ice maker, showed a dead roach lay on the bottom shelf. A second dead roach was also seen a few inches away. There was a buildup of food debris under the various serving stations and dish station. Dirt and debris build-up in the grout between the floor tiles. At 7:05 A.M., a roach crawled out of a drain on the floor near the 3-vat sink. It scurried towards the back food prep area and went under the back food prep station. Observation of the drain showed food debris caked around the edges in the crevices. At 7:07 A.M., [NAME] J reached into the white bin that the roach had crawled into, located on the shelf of the steam table and grabbed a servings scoop from the bin. He/She paced it in the scrambled eggs. [NAME] J said he/she needed a serving spoon for purees and then pulled out the white bin that had previously had the roach in it, yelled out oh gross, and pushed the container back under the shelf. He/She then shivered and said gross. Observation at 7:19 A.M., showed a roach crawled out of the bin that [NAME] J had just looked in and it crawled into the neighboring bin, that also contained serving spoons. The cook began cooking pancakes. At 7:28 A.M., a baby roach crawled down the wall near the 3-vat sink. At 7:38 A.M., a roach crawled along the back wall behind the oven, on the floor. It hid behind an electric cord. At 7:48 A.M., [NAME] J grabbed a spatula form the bin that the roach had most recently been seen crawling into and used it to flip pancakes. At 7:55 A.M., a very large, winged roach crawled out from under the stove and crawled to under the steam table. Observation under the stove showed trash, napkins, plastic wrap, along with food debris and a buildup of dirt. Observation of the kitchen on 9/29/25 at 7:16 A.M., showed debris on the kitchen floor. A dead roach in the wash bin of the 3-vat sink. A roach smashed on the ground in front of the steam table. At 7:23 A.M., [NAME] K said he/she had seen some roaches but not too bad. The facility is working on it. The pest control company comes, and staff clean daily. During an observation and interview on 9/29/25 at 9:19 A.M., the Dietary Manager (DM) said regarding pests, she had not seen any roaches. Food debris should not be left overnight. Staff should clean before they leave. Closing duties include clean up all the food debris before leaving for the day. The surveyor showed the DM a dead roach that lay on the bottom shelf of the steamtable. The DM said it should have been cleaned up. During an interview with the Administrator, Director of Nursing, and Corporate Administrator on 10/1/25 at 12:19 P.M., the Administrator said when the pest control company comes, they do not leave any recommendations of things to do to decrease the chance of getting pests with her. If they left recommendations, it would be with the maintenance supervisor. Part of an effective pest control program includes cleaning the kitchen of food debris and trash. 257375925821422584514

Based on observation, interview and record review, the facility failed to ensure menus and recipes were followed to ensure they maintain nutritional value. Staff served the wrong meal for breakfast for one of three breakfast meal observations. Staff failed to follow the recipe for two of three puree diets to ensure proper nutritional value and texture. In addition, staff failed to follow meal tickets to ensure preferences were reasonably accommodated for one resident (Resident #24). This had the potential to affect all residents at the facility. The census was 121.1. Review of the facility's menu for the date of 9/30/25, showed cereal of choice, breakfast sandwiches, bacon, and hashbrowns. Observation of the breakfast hall tray meal service on 9/30/25 from 8:30 A.M. thorough 10:00 A.M., showed no breakfast sandwiches observed to be provided. Residents got a variety of items, such as eggs, bacon, and oatmeal. During an interview on 9/30/25 at 1:22 P.M., Resident #4 said today for breakfast he/she got two fried eggs, oatmeal, and bacon. He/She did not get a sandwich for breakfast. Residents have discussed this during resident council meetings, yet nothing has changed. During an interview on 9/30/25 at 10:25 A.M., Resident #24 said for breakfast today he/she got two boiled eggs, one piece of bacon, and nothing else. During an interview on 9/30/25 at 1:49 P.M., Activity Aide M said during the resident council meetings, residents report that what is served for meals is not what is in the menu, which is a frequent concern. During an interview on 9/30/25 at 11:30 A.M., with the Dietary Manager (DM) and Administrator, the DM said today for breakfast, residents were served hashbrowns, bacon, eggs, and oatmeal. Residents should have been served breakfast sandwiches. Dietary staff did not make breakfast sandwiches because most people cannot use their hands, or they want something different. If they made breakfast sandwiches, it would be bacon on bread with cheese and an egg. During an interview on 9/30/25 at 11:52 A.M., the Dietician said staff should follow the menus. 2. During an interview on 9/25/25 at 8:30 A.M., [NAME] K said there are currently 10 residents on a puree diet. 3. Review of the facility's Puree Egg recipe, showed measure the desired number of servings into the food processor. Blend until smooth. Add milk if product needs thinning. Observation on 9/26/25 at 5:15 A.M., showed [NAME] J placed cooked scrambled eggs and a few hardboiled eggs into a blender. He/She then added hot water and blended the eggs. He/She added more hot water and blended. Observation showed the puree recipe book lay closed on the counter next to [NAME] J and was not used. [NAME] J said he/she was not sure how many eggs were used for the scrambled eggs because it was made the day prior. He/She poured the puree out in a steam table pan. It appeared thick and slightly chunky. A sample of the pureed eggs showed it tasted bland and watered down and had a gritty/[NAME] texture. [NAME] J covered the pan with plastic wrap and placed it on the steam table. During an interview on 9/30/25 at 11:30 A.M., with the DM and Administrator, the DM said recipes should be followed. 4. Review of the facility's Cereal Oatmeal Quick recipe, showed:-Water: 2 1/2 gallon;-Instant Oatmeal: 3 pounds (48 oz);-Stir Oats into briskly boiling water. [NAME] for 10 to 12 minutes;-Remove from heat and cover. Let stand for 5 minutes. If oatmeal thickens, add boiling water to obtain a thick pouring consistency; -Pureed: Measure desired number of servings into a food processor. Blend until smooth. Use the fork drip test and the spoon tilt to test to confirm texture. Observation on 9/26/25 at 6:41 A.M., showed [NAME] J opened two quick rolled oats tubs. The tubs appeared to be 42 ounces. He/She poured one full tub and part of the other tub into what appeared to be a 40-quart pot that sat on the stove with steaming hot water. He/She stirred the oats. At 6:51 A.M., [NAME] J added a small, unmeasured amount of melted butter into the pot. He/She stirred the oatmeal and carried the pot to the back food prep station. There, he/she poured the oatmeal into two different steamtable pans. The oatmeal appeared watery. A sample taste of the oatmeal showed it was thin and watery and the oats not fully cooked. There was no flavor. A greasy feel could be felt on the lips from the added butter, but no butter flavor tasted. [NAME] J said he/she would have preferred to cook it longer, but he/she was pressed for time. He/She covered both with plastic wrap and placed the pans onto the steam table. [NAME] J did not puree any of the oatmeal. At 7:18 A.M., [NAME] J stirred the oatmeal. It continued to appear thin and watery. At 7:28 A.M., [NAME] J began meal service. He/She served up one hall cart at a time. Other dietary staff read out the meal tickets as he/she served the trays. He/She placed the oatmeal on trays for regular diets and puree diets. During an interview on 9/30/25 at 11:30 A.M., with the DM and Administrator, the DM said for residents on a puree diet, the oatmeal should be pureed. Recipes should be followed. 5. Review of Resident #24's meal ticket, dated 10/1/25, showed regular diet:-Breakfast notes: Two fresh fruit;-Lunch note: Two fresh fruit;-Dinner note: Two fresh fruit and a small salad with one slice of tomato and one slice of onion. Observation and interview on 10/1/25 at 9:34 A.M., showed the resident in his/her room with his/her breakfast tray. The resident was served bacon and two eggs. He/She said the breakfast is the same every day. He/She is supposed to get fresh fruit, and he/she does not. It even shows it on the meal ticket. Most days he/she gets no fresh fruit. During an interview on 10/1/25 at 12:19 P.M., with the Administrator, Director of Nursing (DON) and Corporate Administrator, they said meal tickets preferences should be followed when able. There is always fresh fruit on hand. The resident wants a lot of fresh fruit. He/She will go down to the kitchen and get it when he/she wants it. 1598315

Based on observation, interview and record review, the facility failed to prepare foods by methods that conserve nutritive value, flavor, and appearance. In addition, the facility failed to ensure food was palatable for one of two sample trays tested. Residents interviewed reported concerns with the palatability and flavor of food (Residents #4, #61, #75, #118, and #6). The sample was 24. The census was 121.1. During an interview on 9/26/25 at 10:11 A.M., 10 residents who represent the resident council, said the food is terrible. Sometimes it is so bad you cannot eat it. The fried eggs are hard. The oatmeal is bad. They put dislikes on their meal tickets but are still served those items. During an interview on 9/30/25 at 1:49 P.M., Activity Aid M said the residents at the resident council meetings frequently complaint about the food taste and not being offered any condiments that would help with food taste. 2. Observation on 9/26/25 at 5:15 A.M., showed [NAME] J made pureed eggs. He/She placed cooked scrambled eggs and a few hardboiled eggs into a blender. He/She then added hot water and blended the eggs. He/She poured the puree out in a steam table pan. It appeared thick and slightly chunky. A tasted sample of the pureed eggs showed it tasted bland and watered down and had a gritty/[NAME] texture. Observation on 9/26/25 at 6:41 A.M., showed [NAME] J put quick rolled oats into a pot that sat on the stove with steaming hot water. He/She stirred the oats. At 6:51 A.M., [NAME] J added a small, unmeasured amount of melted butter into the pot. He/She stirred the oatmeal and carried the pot to the back food prep station. There, he/she poured the oatmeal into two different steamtable pans. The oatmeal appeared watery. A sample taste of the oatmeal showed it was thin and watery and the oats not fully cooked. There was no flavor. A greasy feel could be felt on the lips from the added butter, but no butter flavor tasted. [NAME] J said he/she would have preferred to cook it longer, but he/she was pressed for time. Observation on 9/26/25 at 9:22 A.M., showed breakfast meal service finished. No salt or sugar was provided on any of the trays sent out. A test tray sampled at that time included a fried egg, sausage, oatmeal, 2 pieces of bacon, French toast and a pancake. The oatmeal had no flavor. One of the pieces of bacon was cooked through but the second piece of bacon was flimsy and rubbery, no crunch, the fat not rendered. 3. Review of Resident #4's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/11/25, showed the resident cognitively intact. During an interview on 9/25/25 at 9:27 A.M., the resident said there are food issues at the facility, specifically taste. The food does not taste right. It is hit and miss. if you do not like what is served, they will offer things like hot dogs. 4. Review of Resident #61's quarterly MDS, dated [DATE], showed the resident cognitively intact. During an interview on 10/1/25 at 8:27 A.M., the resident said the resident council had been trying to get creamer, coffee, sugar, and condiments for their food sent with the trays, but dietary does not send it up with the trays and nursing staff said they do not have any on the floor, so residents are not given these with their meals. The food tastes bad. Some of the food that he/she is served is too hard to eat. Carrots are not cooked right. The scalloped potatoes are hard as a rock. Residents have so much trouble getting coffee and have to beg for sugar and creamer. The facility does keep coffee and creamer on the first floor, but it does not come up to the second floor. Staff should be offering condiments. At the resident council meetings residents complain but nothing changes. 5. Review of Resident #75's quarterly MDS, dated [DATE], showed the resident cognitively intact. During an interview on 9/29/25 at 9:10 A.M., the resident said he/she never finished his/her meal because the food was nasty at all meals. 6. Review of Resident #118's quarterly MDS, dated [DATE], showed the resident cognitively intact. During an interview on 9/25/25 at approximately 9:36 A.M., the resident said the food was gross. The facility will offer alternatives, but the alternatives were not good either. He/she has expressed his/her concerns about the food. 7. Review of Resident #6's quarterly MDS, dated [DATE], showed the resident cognitively intact. During an interview on 9/25/25 at approximately 9:40 A.M., the resident said the food was horrible. He/she received options and choices, but the taste was horrible. 8. During an interview on 9/30/25 at 11:30 A.M., with the DM and Administrator, the DM said food should food be flavorful and appetizing. Dietary staff should add butter, milk, and brown sugar to the oatmeal for the residents with fortified foods, this is also called super cereal. Regular oatmeal does not get anything in it. If a resident wants something for their oatmeal, dietary will send condiments to them. The Administrator said all the oatmeal should be super cereal. When cooking bacon, the bacon should be cooked through and fat rendered. 9. During an interview on 9/30/25 at 11:52 A.M., the Dietician said super cereal should get butter and brown sugar added. Other residents can add butter or sugar depending on what they request.

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards when staff failed to follow the facility's policy to use appropriate technique and hand hygiene during incontinence care (peri-care, cleansing the genitals and anal area) for 5 out of 5 residents observed (Residents #10, #59, #6, #117 and #69). The staff also failed to wear a gown when providing high contact care for residents on Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) 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) for 5 out of 6 residents observed (Residents #6, #117, #69, #75 and #57). The sample was 24. The census was 121.Review of the facility's Hand Hygiene policy, dated 4/28/22, showed:-The facility will provide guidelines to employees on proper handwashing and hand hygiene techniques that will aid in the prevention of the transmission of infections;-Handwashing: Employees will perform handwashing with soap and water when hands are visibly soiled;-Hand Sanitizer: Employees may use an alcohol-based hand rub when hands are not visibly soiled. Review of the facility's Incontinent Care policy, dated 7/21/22, showed:-The facility will provide incontinence care as directed in the plan of care;-Perform hand hygiene and apply gloves;-Remove soiled brief/under-pad;-Cleanse perineal area from front to back;-Use a clean surface area of the cloth for each wipe;-Remove gloves and perform handy hygiene and apply clean gloves;-If necessary, apply protective ointment;-Remove gloves and perform hand hygiene;-Reposition resident in a safe/comfortable position. Review of the facility's EBP, policy dated 5/15/24, showed:-Policy: the facility may expand the use of Personal Protective Equipment (PPE) & refer to the use of gowns & gloves during high-contact resident care activities that provide opportunities for transfer of MRDOs to hands/clothing. The use of gown & gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for facility residents with wounds and/or indwelling medical devices regardless of [NAME] colonization as well as for residents with [NAME] infection/colonization;-Examples of High-Contact Resident Care Activities requiring Gown & Glove Use for EBP: Dressing; Transferring; Providing Hygiene; Changing Briefs or Toileting; and, Wound Care: Skin Opening requiring a dressing;-Post signage on the door/wall outside of the resident's room indicating the use of EBP;-Post signage in the resident room with information on use of EBP & required PPE (e.g., gown & gloves). Enhanced Barrier Precautions signage should include information on high contact resident care activities that require the use of gown & gloves. 1. Review of Resident #10's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/8/25, showed:-Resident rarely/never understood;-Dependent on toilet hygiene;-Always incontinent of bowel and bladder;-Diagnoses included pneumonia, stroke, and hemiplegia or hemiparesis (paralysis or weakness on one side of the body). Review of the resident's care plan, in use at the time of the investigation, showed:-Focus: Activity of daily living (ADL) self-care performance deficit;-Goal: Maintain current level of function with ADLs;-Interventions included: Personal hygiene care: Dependent on staff. During an observation and interview on 9/26/25 at 10:11 A.M., the resident's spouse said the resident needs to be changed. Observation showed the resident lay in bed with his/her head elevated. At 10:20 A.M., Certified Nursing Assistant (CNA) N entered the room to provide care. He/She washed his/her hands and applied two pairs of gloves and proper personal protective equipment (PPE). CNA N said he/she likes to double glove because sometimes a glove will get a hole in it. The resident's spouse assisted CNA N to unsecure the residents brief and help to position the resident into the bed. CNA N pushed the resident's brief down between the resident's legs and assisted the resident to turn to his/her left side, to face away from him/her. The resident had soft bowel movement throughout the brief and on his/her skin. Barrier cream visible on the resident's skin. CNA N cleansed the stool from the resident's skin and then removed one pair of gloves, leaving the other on. He/She did not perform hand hygiene. He/She applied barrier cream to his/her left gloved hand and applied the cream to the resident's buttocks area. While wearing the same gloves used to apply barrier cream, CNA N then applied a clean brief and adjusted the resident's pillow while he/she wore the same soiled gloves. 2. Review of Resident #59's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment; -Dependent on toilet hygiene;-Frequently incontinent of urine and bowel;-Diagnoses included Parkinson's disease, heart failure, and history of hip fracture. Review of the resident's care plan, revised 6/5/25, in use at the time of the investigation, showed:-Focus: The resident has limited mobility and requires assistance with ADLs;-Goal: Will remain free of complications related to immobility, including contractures, thrombus formation (blood clot), skin breakdown, fall-related injury;-Interventions: Provide supportive care assistance with mobility as needed, document assistance as needed. Observation and interview on 9/26/25 at 5:57 A.M., showed the resident sat at the side of the bed with both feet on a puddle of urine on the floor. The resident said he/she was waiting for the staff who will bring clothes and help him/her change. The blanket and bed sheets were rolled by the foot of the bed. He/She said they were soaked. The incontinence pad and middle part of the fitted sheet were soaked with urine. The resident said he/she woke up cold and wet and had been waiting for someone to help him/her all night. Observation on 9/26/25 at 6:11 A.M., showed CNA P entered the room to provide care. The resident lay on the bed. The CNA brought the resident's clothes and a pack of wet disposable wipes. After applying gloves, he/she unfastened and placed the soiled brief under the resident. The resident then pulled the brief from under him/her and gave it to the CNA. He/She placed the brief in the trash bin. The CNA asked the resident to roll on the side, facing the wall. Without changing gloves, CNA P pulled 2 disposable wipes and wiped the resident's buttocks, once on each side. He/She then applied the clean brief on without cleaning the front genital area and the anal area. He/She put the resident's pants on, then assisted him/her to sit up on the side of bed. He/She then put the resident's top and shoes on and pivot-transferred him/her to the wheelchair. The CNA wore the same pair of gloves the whole time. 3. Review of Resident #6's quarterly MDS, dated [DATE], showed:-Cognitively intact;-No behaviors;-Dependent on toileting hygiene;-Always incontinent of bowel and bladder;-Diagnoses included hemiplegia and depression. Review of the care plan, in use during the time of the investigation, showed:-Focus: The resident has an ADL deficit related to hemiplegia following a stroke affecting left non-dominant side:--Goal: The resident will maintain current level of function with ADLs through the review date;--Interventions: Does not use bed pan, toilet or commode. Utilize check and change to manage incontinency;-Focus: EBP:--Goal: To reduce the opportunities for transfer of MDROs during high contact resident care activities when contact precautions do not otherwise apply;--Interventions: EBP precautions. During an interview on 9/25/25 at approximately 9:36 A.M., the resident said he/she relied on staff for everything, including toileting. Sometimes he/she was left wet after pressing the call light for assistance. It happens more during evening and night shifts. During an observation and interview on 9/26/25 at 5:30 A.M., the resident lay in bed on his/her back. The resident said he/she pressed the call light and no one answered. He/she said he/she was soiled. An odor of urine was present in the resident's room. At 5:39 A.M., CNA I responded to the resident's call light. Observation on 9/26/25 at 5:40 A.M., showed CNA I entered the resident's room with some washcloths and an incontinent brief. He/She soaked the washcloths under running water in the sink, then applied gloves, no gown was worn. CNA I lowered the resident's head of bed. He/She wrung the washcloths and placed them on the resident's foot of bed. He/She applied gloves, unfastened the brief, then rolled and pushed the brief under the resident. Without changing gloves or performing hand hygiene, he/she wiped the resident's groin area with one washcloth, twice on each groin, alternating left and right and using the same side of the washcloth. He/She did not wipe the genital area. He/She then rolled the resident to one side and wiped his/her buttocks with two swipes using one washcloth, then used another washcloth wiping the same area. The CNA did not wipe or clean the anal area. He/She then applied a clean brief, grabbed the sheet and blanket, and covered the resident while wearing the same gloves. He/She picked up the dirty washcloths, placed them in a bag and adjusted the resident's head of bed. He/She boosted the resident up in bed by pulling the incontinent pad. He/She then removed the gloves and left the room without performing hand hygiene. 4. Review of Resident #117's MDS, dated [DATE], showed:-Moderately impaired cognition;-Dependent on toilet hygiene, lower body dressing and chair/bed to chair transfer; -Partial/moderate assistance for upper body dressing;-Number of stage 3 pressure wounds (full thickness tissue loss, subcutaneous fat may be visible, but the bone, tendon or muscle is not exposed): one;-Diagnoses included: atrial fibrillation (a-fib, irregular heart rhythm), dementia, chronic kidney disease (CKD, impaired kidney function), pressure ulcer of unspecified heel, stage 3. Review of the resident's care plan, in use at the time of survey, showed:-Focus: ADL self-care performance deficit related to dementia:--Goal: resident requires assistance with ADL care and mobility; --Interventions included: Bed mobility: requires staff assistance to turn and reposition in bed; Dressing: requires staff assistance to dress; Personal hygiene-needed one assist;-Focus: EBP: wounds:--Goal: to reduce the opportunities for transfer of MRDO during high - contact resident care activities, when contact precautions do not otherwise apply;--Interventions: incorporate periodic monitoring/evaluation of adherence to infection prevention practices to determine the need for additional training/education. Review of the resident's order summary report, dated 9/25/25, showed a physician order for EBP (wounds) examples of high-contact resident care activities requiring gown and glove use for EBP. EBP Precautions: dressing, transferring, providing hygiene, changing briefs or toileting, and wound care: skin opening requiring a dressing. every shift. Observation on 9/26/25 at 5:40 A.M., showed a red EBP magnet on the door frame. The magnet did not show the type of PPE required or what type of high contact care activities required the use of gown and gloves. CNA E entered the resident's room, performed hand hygiene and put gloves on. Staff did not wear a gown. Then he/she pulled the covers back, unfastened the resident's brief and provided incontinence care and placed a new brief on the resident. While wearing the same gloves, CNA E went to the closet and removed a shirt and a pair of pants and dressed the resident. CNA E removed his/her gloves and left the room to get a gait belt. No hand hygiene was performed after removing his/her gloves. When CNA E returned to the room, he/she put gloves on, without performing hand hygiene, placed the gait belt around the resident 's waist and transferred the resident from the bed to the chair. Observation on 9/26/25 at 10:32 A.M., showed the resident sat in his/her wheelchair in his/her room. The Wound Practitioner and the wound nurse entered the resident's room, performed hand hygiene, and put gloves on. Staff did not wear a gown. The Wound Practitioner removed the dressings on the right heel and left foot. The Wound Practitioner said both wounds were 100% eschar (dead tissue). The Wound Practitioner instructed the wound nurse to paint the wounds with betadine and leave open to air (OTA). The wound nurse provided the treatment. 5. Review of Resident #69's quarterly MDS dated [DATE], showed:-Severe cognitive impairment;-Dependent on toilet hygiene, lower body dressing, rolling left to right and for chair/bed to chair transfers;-Partial/moderate assistance for upper body dressing;-Always incontinent of bowel and bladder;-Diagnoses included: heart failure, high blood pressure, renal insufficiency (partial kidney function failure characterized by less than normal urine excretion), diabetes, and Alzheimer's disease. Review of the resident's care plan, in use at the time of survey, showed:-Focus: ADL self-care performance deficit related to Alzheimer's disease and limited mobility:--Goal: will maintain current level of function with ADLs;--Interventions included: Toilet use: does not use bed pan, toilet or commode. Check and change to manage incontinency; Dressing: dependent on staff; Transfer: two person assist and mechanical lift;-Focus: EBP related to wounds:--Goal: to reduce the opportunities for transfer of MDRO during high contact resident care activities, when contact precautions do not otherwise apply;--Intervention included: Ensure access to alcohol-based hand rub; Examples of high-contact resident care activities requiring gown and glove use for all EBP precautions; transferring, providing hygiene, changing briefs; dressing, and wound care: skin opening requiring a dressing; Post signage on the door/wall outside of the resident's room; indicating the type of precautions & required PPE (e.g., gown and gloves). EBP signage should include high contact resident care activities that require the use of gown and gloves. Review of the resident's order summary report dated 9/30/25, showed a physician order for EBP (wounds) examples of high-contact resident care activities requiring gown and glove use for EBP. EBP Precautions: dressing, transferring, providing hygiene, changing briefs or toileting, and wound care: skin opening requiring a dressing. Every shift. Observation on 9/26/25 at 6:42 A.M., showed CNA E went to the linen cart in the hallway, gathered supplies, put his/her gloves on while in the hall, and entered the resident's room. There was a red EBP magnet on the door frame. The magnet did not show the type of PPE required or what type of high contact care activities required the use of gown and gloves. The resident lay in bed. CNA E pulled the covers back, unfastened the residents brief, provided incontinence care, rolled the resident towards the wall, provided incontinence care, removed the soiled brief and tucked a new brief halfway under the resident, rolled the resident towards the door, then onto his/her back, and adjusted and fastened the brief. He/She did not change gloves or perform hand hygiene during care. With the same gloves on, he/she went to the closet and removed a shirt and pair of pants. Then he/she rolled the resident side to side to put his/her pants on and placed the mechanical lift sling under the resident. CNA E removed his/her gloves and left the room without performing hand hygiene. A few minutes later CNA E returned with the Activities Director and the mechanical lift. Both staff performed hand hygiene and put gloves on, attached the lift sling to the lift and transferred the resident into his/her chair. The Activity Director unfastened the lift cloth from the lift, removed her gloves and performed hand hygiene, then removed the lift from the room. CNA E removed the resident's gown, put his/her shirt and heel protector boots on, removed his/her gloves and performed hand hygiene. Neither staff wore a gown while providing high contact, direct care. Observation on 9/26/25 at 12:25 P.M., showed the resident in bed. The Wound Practitioner and the wound nurse entered the resident's room, performed hand hygiene and put gloves on. Neither put a gown on. The resident was rolled towards the wall. The Wound Practitioner said the wound had a scant amount (small amount) of sero-sanguineous (clear and watery fluid seeping from a wound) drainage, the wound was a mixture of moisture associated skin damage (MASD, skin inflammation, erosion, or damage caused by prolonged exposure to moisture) and a pressure ulcer (injury to the skin and/or underlying tissue, as a result of pressure or friction). She instructed the wound nurse to apply triad (hydrophilic paste for light-to- moderate levels of wound exudate) cream and leave OTA. The wound nurse provided wound care. 6. Review of Resident #75's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included: heart failure, high blood pressure, renal insufficiency, diabetes and depression. Review of the resident's order summary, dated 9/25/25, showed a physician order for EBP (wounds) examples of high-contact resident care activities requiring gown and glove use for EBP. EBP Precautions: dressing, transferring, providing hygiene, changing briefs or toileting, and wound care: skin opening requiring a dressing. Every shift. Observation and interview on 9/25/25 at 10:33 A.M., showed a red EBP magnet on his/her door frame. The magnet did not show the type of PPE required or what type of high contact care activities required the use of gown and gloves. The resident said water gets under his/her skin then it weeps. The resident pulled up his/her pant leg, there was a small amount of yellowish drainage weeping from the right mid-shin area. There was no dressing over the wound. Observation on 9/26/25 at 12:29 P.M., showed the wound nurse entered the resident's room, and put gloves on, he did not put a gown on. The wound nurse said the wound was 2.3 centimeter (cm) X 3.5 cm X 0 and it had a small amount of weeping. He cleaned the wound with wound cleanser, applied triad cream and a dry dressing. 7. Review of Resident #57's quarterly MDS, dated [DATE], showed:-Serve cognitive impairment;-Diagnoses included: heart failure, high blood pressure, anxiety and non-Alzheimer's dementia;-Number of stage 3 pressure ulcers: one. Review of the resident's care plan in use at the time of survey, showed:-Focus: EBP: wounds;-Goal: to reduce the opportunities for transfer of MDRO during high - contact resident care activities, when contact precautions do not otherwise apply;-Interventions: incorporate periodic monitoring/evaluation of adherence to infection prevention practices to determine the need for additional training/education. Review of the order summary report, dated 9/25/25, showed a physician order for EBP (wounds) examples of high-contact resident care activities requiring gown and glove use for EBP. EBP Precautions: dressing, transferring, providing hygiene, changing briefs or toileting, and wound care: skin opening requiring a dressing. Every shift. Observation on 9/26/25 at 12:15 P.M., showed the resident lay in bed. There was an EBP magnet on the door frame. The Wound Practitioner and wound nurse entered the room, performed hand hygiene, and put gloves on. Neither wore a gown. The Wound Practitioner removed the dressing on the resident's buttocks area. The Wound Practitioner described the wound as a stage 2 pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, may also present as an intact or open/ruptured blister). The Wound Practitioner instructed the wound nurse to use triad cream and leave OTA. The wound nurse provided wound care. 9. During an interview on 9/30/25 at 8:40 A.M., CNA U said hand hygiene should be done when you enter the room, after you set up your supplies, between dirty and clean and after you finish providing care. Residents should be wiped from front to back and the washcloth turned after each wipe. If there was a red EBP magnet on the door frame that meant one person in the room was on oxygen. Currently there are no residents on the hall that required EBP. 10. During an interview on 9/30/25 at 9:00 A.M., Certified Medication Technician (CMT) T said when he/she provided incontinence care, he/she performed hand hygiene and put on/changed gloves when he/she entered the room, changed the water and after the task was completed. Residents should be wiped from front to back. If a resident was on EBP that meant staff should keep their hands washed and wear gloves while providing care to the resident. He/She knew which residents were on EBP because the nurse/nurse manager would tell them. Also, it would be on the Kardex (gives a brief overview of each resident). CMT T identified one resident who was on EBP. When asked about the red EBP magnet on the door frame of another resident, CMT T said, I'm confused, I will have to ask some questions. 11. During an interview on 9/30/25 at 9:30 A.M., CMT S said he/she performed hand hygiene and put on/changed gloves before and after providing care. When providing incontinence care, residents should be wiped from front to back. He/She knew which residents required EBP by the sign on the door. If a resident was on EBP, staff should wear mask, gown and gloves every time they go into the resident's room. 12. During an interview on 9/30/25 at 7:48 A.M., Licensed practical Nurse (LPN) O said staff provide universal precautions for all residents. If more precautions are required, a sign on the door will identify what type of precautions are required. For example, contact precautions would have a sign indicating the type of PPE required with the PPE kit set up outside the room. For EBP, there is a sign outside the door, and a PPE kit set up in the room. Staff were in-serviced on EBP and what PPE is required for these residents. If a resident is on EBP, staff are to wear gloves and gown when providing any hands-on care. Regarding incontinence care, staff were provided with in-service training a couple weeks ago. Staff had a skills day. Direct care staff were required to demonstrate providing care and they were quizzed. Any issues identified were corrected at that time. 13. During an interview on 9/30/25 at 8:40 A.M. Registered Nurse (RN) B said residents who have wounds required EBP. Staff should wear gown and gloves every time they go into the resident's room. Staff know which residents required EBP because by the signage on the door, or they can look in the computer and a red flag will pop up. 14. During an interview on 9/30/25 at 11:23 A.M., the Wound Nurse said if a resident was on EBP staff should wear gloves, gown, and perform hand hygiene when providing high contact care and when providing wound care. EBP should be used when the wound is open or weeping. If the wound was not open, there was no need for EBP. He knew which residents required EBP by the red magnet on the door, signs on the door and it pops up on the nurse Medication Administration record (MAR). He checked the chart and confirmed Residents #69, #57, #117 and #75 were on EBP. 15. During an interview on 9/30/25, the Assistant Director of Nursing (ADON) said she was also responsible for infection control. Staff should perform hand hygiene when they enter the room, after care is provided and/or before they leave the room. When staff provide peri care she would expect for staff to explain what they are going to do, perform hand hygiene, gather their supplies, perform hand hygiene, wipe the resident from front to back, and fold the towel after each wipe, perform hand hygiene and roll the resident to wash the back, cleaning front to back and turning the towel after each wipe. Once completed, staff should perform hand hygiene. Staff have recently been in-serviced on incontinent care. Residents who have wounds require EBP. Staff should wear gown and gloves and a face shield if needed while providing high contact care and wound care. Staff know which residents required EBP by the red magnet on the doorframe, the physician orders, care plan and recent in-services. She would expect for staff and all providers to use EBP during high contact care and when performing wound care. 16. During an interview on 9/30/25 at 12:24 P.M., the Director of Nursing (DON) said when providing incontinence care, gloves should be changed and hands sanitized after touching a soiled surface and before touching a clean surface. Hand hygiene should be performed with glove changes. Staff should not double glove in place of glove changes and hand hygiene. If a gloved hand is used to apply ointment to the buttocks, the same gloved hand should not be used to touch the resident, their pillow or other clean surfaces. When providing care, all areas potentially soiled should be cleaned, to include the genitals. Staff know which residents are on EBP by signs on the doors. Staff should wear PPE, gowns, gloves and shield if needed. Staff only need to wear PPE when providing care. 17. During an interview on 9/30/26 at 12:20 P.M., the Administrator said she would expect for staff to follow physician orders and the facility's policy and procedures.

Based on observation, interview and record review, the facility failed to serve residents a nourishing snack at bedtime when the time between meals was more than 14 hours. This had the potential to affect all residents (including Residents #61, #24, #36 and #4), who ate from the facility kitchen. The sample was 24. The census was 121.Review of the facility's Meals and Snacks policy, dated 3/31/21, showed:-Meal service shall be provided to residents on a regularly scheduled basis according to facility established times. Nutritional services shall be responsible for all food preparation including snacks and shall deliver meals to the residents or the nursing units. Snacks shall be delivered to the nursing units by nutritional services personnel. Nursing shall be responsible for distributing snacks to the residents;-Mealtimes shall be scheduled to ensure a maximum of 14 hours from dinner to breakfast on the following day;-The policy failed to address the requirement for a substantial snack delivered at bedtime when there are more than 14 hours between meals. 1. Review of the facility's mealtimes and location list, showed on Carondelet, [NAME], [NAME], Missouri, and Meramec:-Breakfast 8:00 A.M. to 9:30 A.M.;-Lunch 12:00 P.M. to 1:30 P.M.;-Dinner 5:00 P.M. to 6:30 P.M.;-Lafyette hall not listed;-15 hours between the dinner and breakfast meal service. Observation of meal service on 9/25/25, showed meals served during the scheduled mealtimes:-At 12:41 P.M., lunch trays arrived to [NAME];-At 5:45 P.M., dinner trays were already delivered, and residents ate dinner on the second floor ([NAME] and Lafyette). Observation of meal service on 9/26/25, showed meals served during the scheduled mealtimes. At 5:04 A.M., [NAME] J arrived for meal prep. At 7:28 A.M., [NAME] J began dishing food onto trays as dietary staff loaded them into carts. The first cart left the kitchen at 7:49 A.M. At 9:22 A.M., the last tray left the kitchen. Observation of meal service on 9/29/25, at 8:46 A.M., showed hall trays delivered to the Missouri hall, served during the scheduled mealtimes. Observation of meal service on 9/30/25, showed meals served:-At 8:59 A.M., breakfast trays arrived 2nd floor ([NAME] and Lafyette), served late;-At 1:20 P.M., lunch trays arrived at the Carondelet Hall during scheduled mealtimes. During an interview 9/25/25 at 12:45 P.M., the Dietary Manager said breakfast prep starts at 5:00 A.M. and served at 7:30 A.M. Right after breakfast the cook starts lunch prep, and lunch is served at 11:30 A.M. Evening dietary staff come in at 12:00 P.M. for dinner prep and dinner is served at 4:30 P.M. 2. Review of the Resident Counsel minutes, dated 7/9/25, showed snacks not being given out. Department responses: food is appropriate temp when leaving the line. Will make prompt change to get food to halls faster and get with nursing to serve faster. Review of the Resident Counsel minutes, dated 9/10/25, showed residents not receiving what they are ordering, no snacks, beverages not on trays. Department response: I will in-service staff on customer service, advise residents to call front desk in the event they do not get through to the kitchen, and will send a variety of snacks each night. During an interview on 9/26/25 at 10:11 A.M., 10 residents who represent the resident council said bedtime snacks are left at the nurse's station. Staff do not pass snacks, unless someone asks for snacks. One resident said he/she did not even know the facility had snacks. During an interview on 9/30/25 at 1:49 P.M., Activity Aide M said during the resident council meetings, residents frequently complain that breakfast is served late. They say they are not getting their eve snack. The snacks are not being offered and/or provided when requested. 3. Review of Resident #61's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/4/25, showed the resident cognitively intact. During an interview on 10/1/25 at 8:27 A.M., Resident #61 said dinner is usually served by 5:00 P.M., but sometimes as late as 5:20 P.M.; however, yesterday it was served at 6:30 P.M. He/She never gets snacks in the evening or at bedtime except for 3 nights ago, someone came around and offered snack cakes or chips. That was the first time in months he/she was offered a snack in the evening. He/She had been told in the past there are snacks on the nurse's desk and the residents have to get them ourselves. He/She had never been offered something like a sandwich. He/She would probably be interested in a sandwich at times, especially if dinner was early or if he/she did not eat a lot. 4. Review of Resident #24's quarterly MDS, dated [DATE], showed the resident cognitively intact. During an interview on 9/29/25 at 9:17 A.M., the resident said breakfast will sometimes come as late as 9:30 A.M. or 10:00 A.M. It is too long between meals. There are no stacks offered at night. There are stacks at the nurse's station if residents want to ask. They have cookies and other snacks like that, but nothing substantial. On 9/30/25 at 1:17 P.M., the resident said he/she was never told that he/she could have a sandwich at bedtime. That is something he/she would be interest in. Tonight, he/she will ask for one. During an interview on 10/1/25 at 8:22 A.M., the resident said he/she asked for a sandwich last night and staff said he/she already had dinner. He/She was not provided with a sandwich. 5. Review of Resident #36 quarterly MDS, dated [DATE], showed the resident cognitively intact. During an interview on 9/30/25 at 10:36 A.M., the resident said staff do not serve evening snacks. Sometimes they offer chips, just snacks, and nothing substantial. He/She will sometimes go up to 16 hours without food. Breakfast usually comes around 8:00 A.M. 6. Review of Resident #4's quarterly MDS, dated [DATE], showed the resident cognitively intact. During an interview on 9/29/25 at 9:38 A.M., the resident said dinner is served by 6:00 P.M. In the evenings, sometimes he/she gets a snack and sometimes not. Staff are given snacks from the kitchen before kitchen staff leave, but staff do not always pass it out to the residents. The snacks consist of cookies and snack cakes, nothing substantial or healthy. During an interview on 10/1/25 at 9:23 A.M., the resident said he/she asked staff for a sandwich last night and staff said now you know they didn't send any sandwiches up here, we are lucky if we get snacks sent. 7. During an interview on 9/30/25 at 11:30 A.M., with the Dietary Manager (DM) and Administrator, the DM said in the evenings, residents get sandwiches, chips, [NAME] butters bars, and honeybuns. Dietary will deliver it to the nurse's station. Nursing staff will be responsible for passing the food. Sandwiches are placed in the resident refrigerator on the first floor. Observation on 10/1/25 at 9:36 A.M., of the clean utility room that contained the resident refrigerator, showed a 3-shelf refrigerator. The entire top and middle shelf full of lunch bags, sodas, and grocery bags. The bottom shelf was half full with grocery bags and Tupperware containers. The available shelving was an area approximate 8 inches by 12 inches. No sandwiches were in the refrigerator. 8. During an interview on 10/1/25 at 11:38 A.M., the Dietician said if there are more than 14 hours between dinner and breakfast, she would expect a substantial snack to be offered at bedtime. A substantial snack could be something like a fruit cup, yogurt, cookies and a sandwich. He/She talked with the DM yesterday and was told that there are not more than 14 hours between meals, and that the mealtime list provided was not correct. The DM told her she provides the residents with things like [NAME] butter bars and chips. She did not mention sandwiches.

Based on observation, interview, and record review, the facility failed to ensure residents who required tube feeding for nutrition received the feedings as ordered and received the care to prevent complications. One resident did not receive tube feeding as ordered when the pump, which was set at the correct rate, did not deliver the feeding at the correct rate. In addition, as a result of the slow infusion of formula, staff did not change the tube feeding bottle as frequently as they otherwise would have. The tube feeding hung for over 24 hours, on two different days of the five days of observation, putting the resident at risk for receiving spoiled formula (Resident #44). In addition, one resident with a history of pneumonia was provided personal care with their head lowered as the tube feeding infused, increasing the risk for aspiration pneumonia. These deficient practices affected two of three residents investigated for tube feeding care. The sample was 24. The census was 121.Review of the facility's Tube Feeding policy, dated 8/21/24, showed:-Residents with an order for tube feeding will be assessed and monitored by a registered dietician to ensure nutritional needs are being met;-Nursing will receive tube feeding order written by a physician;-The policy did not address the care required for proper tube feeding maintenance. 1. Review of Resident #44's medical record, showed:-Diagnoses included dysphagia oropharyngeal phase (difficulty or inability to move food from the mouth through the throat);-An order dated 6/11/25, for Jevity 1.5 (liquid nutrition) at 65 milliliters (ml) per hour continuous. Observation on 9/25/25 at 10:10 A.M., showed the resident lay in bed. A factory sealed 1500 ml bottle of Jevity 1.5 infused at 65 ml per hour. The bottle dated as hung on 9/24 at 7:04 P.M. and appeared to have just under the1500 ml that remained in the bottle (approximately 975 ml of formula should have been infused since the bottle was hung). At 12:24 P.M., the same tube feeding bottle hung at a rate of 65 ml per hour with 1400 ml of the formula that remained in the bottle. At 3:53 P.M., the same formula bottle hung. The tube feeding pump alarmed inactive. 1400 ml of formula remained in the bottle (approximately 1,360 ml of formula should have infused since the bottle was hung). Observation on 9/26/25 at 10:36 A.M., showed the resident lay in bed. The same factory sealed 1500 ml bottle of Jevity 1.5 that hung the day prior remained on the pump and infused at 65 ml per hour. The bottle dated as hung on 9/24 at 7:04 P.M. (over 24 hours) and appeared to have 550 ml that remained in the bottle. Observation on 9/29/25 at 7:42 A.M., showed the resident lay in bed. A factory sealed 1500 ml bottle of Jevity 1.5 infused at 65 ml per hour. The bottle dated as hung 9/28 at 9:00 P.M., with just under 1200 ml of formula that remained in the bottle (approximately 680 ml of formula should have infused since the bottle was hung). At 1:21 P.M., the same tube feeding bottle infused at 65 ml per hour with approximately 750 ml of formula that remained. Observation on 9/30/25 at 7:44 A.M., showed the resident lay in bed. A factory sealed 1500 ml bottle of Jevity 1.5 infused at 65 ml per hour. The bottle dated as hung on 9/30 at 5:30 A.M. with just under 1500 ml of formula that remained. At 1:18 P.M., the same tube feeding bottle hung on the tube feeding machine. The machine alarmed cassette error and no tube feeding infused. Approximately 1400 ml of tube feeding remained in the bottle (approximately 490 ml of formula should have infused since the bottle was hung). Observation on 10/1/25 at 8:24 A.M., showed the resident lay in bed. The same factory sealed 1500 ml bottle of Jevity 1.5 that hung over 24 hours prior remained on the pump and infused at 65 ml per hour. The bottle dated as hung on 9/30 at 5:30 A.M. with 900 ml of formula that remained (the entire bottle plus an additional approximate 250 ml of another bottle should have infused in this timeframe). During an interview on 9/30/25 at 7:48 A.M., Licensed practical Nurse (LPN) O said the resident had an issue with his/her pump this morning with being clogged. It needed to be flushed. Tube feeding bottles and tubing are to be changed at a minimum of 24 hours, but if the bottle empties before that, staff will replace it at that time. During an interview with the Administrator, Director of Nursing (DON), and Corporate Administrator on 10/1/25 at 12:19 P.M., they said tube feeding formula should not be allowed to hang over 24 hours. Staff document on the bottle when the formula was hung. Staff should follow physician orders. 2. Review of Resident #10's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/8/25, showed:-Resident rarely/never understood;-Diagnoses included pneumonia, stroke, and hemiplegia or hemiparesis (paralysis or weakness on one side of the body);-An order dated 9/5/25 for Jevity 1.5 at 60 ml per hour via pump, may be disconnected for up to 2 hours for care. During an observation and interview on 9/26/25 at 10:11 A.M., showed the resident lay in bed. A bottle of Jevity 1.5 infused at 60 ml per hour per his/her feeding tube. At 10:20 A.M., Certified Nursing Assistant (CNA) N entered the room to provide care. CNA N placed gloves on and lowered the resident's head of bed. The tube feeding continued to infuse. CNA N provided personal care, assisted the resident to get in a comfortable position in bed and then elevated the head of bed. Observation on 9/29/25 at 8:13 A.M., showed CNA N entered the room to provide care. The Wound Nurse entered the room for a skin assessment. CNA N placed gloves on and lowered the resident's head of bed. The tube feeding continued to infuse. CNA N provided personal care, assisted the resident to get in a comfortable position in bed and then elevated the head of bed. The Wound Nurse did not pause the feeding or direct the CNA to not lower the resident's head of bed as the formula infused. During an interview on 9/30/25 at 7:48 A.M., LPN O said when direct care staff are providing care, staff should call the nurse so the tube feeding can be put on hold during care. If this is not done the resident would be at risk of aspiration. During an interview on 9/30/25 at 12:24 P.M., the DON said if a resident is on a continuous tube feeding, CNAs should tell the nurse so they can turn the pump off if they need to provide care. Allowing tube feeding to infuse with the head of bed low is increased risk of aspiration.

Based on interview and record review, the facility failed to ensure residents/and or responsible parties were notified in a timely manner when resident accounts were within $200.00 of the Medicaid limit or when the resident's account was over the Medicaid limit ($6068.80) (Residents #19, #6 and #35). The facility also failed to ensure third party liability (TPL) forms were completed for the final accounting for residents who expired, within 30 days. This affected two of three sampled residents who expired and had money in their accounts (Residents #131 and #129). The sample size was 24. The census was 121. Review of the facility's undated Business Office-Resident Trust Fund Policy and Procedure, showed:-Policy Statement: Residents of a skilled Nursing Center are to have their funds managed and personal spending money available to them. If the choice to open a trust account is made, the resident has the right to have their money safeguarded and accounted for by the Center. The Administrator ultimately will be responsible for the oversight and management of resident funds. 1. Review of Resident #19's Resident Statement Landscape, dated [DATE] at 1:12 P.M., showed a current balance of $12,161.13. Review of the resident's medical record, showed:-Payor Source-Medicaid;-No Resident Fund Balance Notification sent to the resident or resident representative as of [DATE]. 2. Review of Resident #6's Resident Statement Landscape, dated [DATE] at 1:12 P.M., showed a current balance of $8,496.39. Review of the resident's medical record, showed:-Payor Source-Medicaid;-No Resident Fund Balance Notification sent to the resident or resident representative as of [DATE]. 3. Review of Resident #35's Resident Statement Landscape, dated [DATE] at 1:12 P.M., showed a current balance of $7,460.29. Review of the resident's medical record, showed:-Payor Source-Medicaid;-No Resident Fund Balance Notification sent to the resident or resident representative as of [DATE]. 4. During an interview on [DATE] at 12:39 P.M., the Business Office Manager (BOM) said she had not sent any Resident Fund Balance Notifications when residents reached the $200.00 Medicaid limit. She is now aware the letters should have been sent and would send the letters going forward. 5. Review of Resident #131's resident fund account, showed:-Resident expired on [DATE];-A balance of $837.25 as of [DATE];-No TPL letter sent. 6. Review of Resident #129's resident fund account, showed:-Resident expired on [DATE];-A balance of $4,239.70 as of [DATE];-No TPL letter sent. 7. During an interview on [DATE] at 12:39 P.M., the BOM said TPL letters should be sent within 30 days of a resident's death. She was new to the position and would send them out within 30 days going forward. 8. During an interview on [DATE] at approximately 12:30 P.M., the Administrator said she expected Medicaid resource letters to be sent out when resident balances are within $200.00 of the resource limit. Residents are at risk of losing their benefits. She also expected TPL letters to be sent within 30 days of a resident's death.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored appropriately. The facility identified ten medication/treatment carts and four medication rooms. Six of the ten carts and two of the four medication rooms were checked for medication storage. Issues were found in four medication carts and one medication room. Staff failed to date an opened Lispro insulin pen (fast-acting insulin used to manage blood sugar levels), to label two opened bottles of Nitroglycerin (used to treat and prevent chest pain in people with coronary artery disease) tablets, to store an opened Ensure (nutritional shakes used as meal supplement) carton with ice or refrigerate, and to make sure an opened topical cream had a cap or cover. In addition, the facility failed to label an opened Breo Ellipta inhaler (used to treat asthma) that was placed on the countertop in the medication room. The census was 121.Review of the facility's Storage of Medication policy, dated revised 11/18, showed:-Policy: medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier;-All medications dispensed by the pharmacy are stored in the container with the pharmacy label;-Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal;-Certain medications, including some multi-dose preparations, may require different dating once opened per regulations/guidelines;-When the original seal of a manufacturer's container or vial is initially broken, it is recommended that a nurse write the date opened on the medication container or vial. Review of the Ensure Plus manufacturer's website, showed, once opened, it should be refrigerated. 1. Observation and interview on 9/29/25 at 9:32 A.M., showed an undated, opened Lispro insulin pen in the top drawer of the [NAME] Hall nurse medication cart. Registered Nurse (RN) B said the medication should be dated once opened. The medication was filled on 9/26/25. RN B did not know who opened and administered the medication. 2. Observation and interview on 9/29/25 at 9:30 A.M. in the top drawer of the treatment cart on [NAME] Hall, there was one open tube of triamcinolone cream 0.1% (topical cream that relieves redness, itching and swelling) with no cap on it. RN B said the medication should have a cap on it. The cap was lost, and he/she would discard the medication. 3. Observation on 9/29/25 at approximately 10:00 A.M., showed an opened Breo Ellipta 200 microgram (mcg)/25 mcg inhaler on the countertop in the Meramec Hall medication room, without a label showing who the medication belonged to. 4. Observation and interview on 9/29/25 at 10:10 A.M., the Missouri Hall treatment cart had one bottle of Nitroglycerin 0.4 milligram, without a label showing who the medication belonged to. Licensed Practical Nurse (LPN) C said he/she did not know who the medication belonged to, and all medications should have a label with the resident's name and expiration date on it. 5. Observation on 9/29/25 at 10:35 A.M., the [NAME] Certified Medication Technician (CMT) medication cart had one bottle of Nitroglycerin 0.4 milligram with no name on the medication, in the top drawer. There were several cartons of Ensure Plus in the drawer, one carton was open and was not on ice. CMT D said he/she did not know who the nitroglycerin belonged to. He/She opened the Ensure Plus today and he/she would dispose of it. 6. During an interview on 9/30/25 at 12:21 P.M., the Director of Nursing (DON) said the staff should label and date all opened medications. Opened topical creams should be capped and stored properly. The Ensure drinks should be refrigerated or placed in ice after opening.

Based on observation, interview and record review, the facility failed to adequately provide assistance to promote good nutrition. The facility identified 33 residents who received fortified foods. On one of one day of meal preparation observation, the facility failed to prepare and serve fortified food, super cereal. The facility failed to ensure one resident (Resident #11) with nutritional needs received fortified foods, health shakes and one on one meal assistance, as ordered. The sample size was 24. The census was 121.Review of the facility's Weight Variances policy, dated 3/31/21, showed:-Policy: All residents who experience significant, insidious and/or unintentional/unplanned weight loss or gain shall be assessed for nutritional status by the Registered Dietician (RD) to include but not limited to adding calorie rich/preferred snacks between meals, fortification, supplements, liberalizing diet and plan for expected weight changes. 1.Observation on 9/26/25 at 6:41 A.M., showed [NAME] J opened two quick rolled oats tubs. The tubs appeared to be 42 ounces. He/She poured one full tub and part of the other tub into what appeared to be a 40-quart pot that sat on the stove with steaming hot water. He/She stirred the oats. At 6:51 A.M., [NAME] J added a small, unmeasured amount of melted butter into the pot. He/She stirred the oatmeal and carried the pot to the back food prep station. There, he/she poured the oatmeal into two different steam table pans. The oatmeal appeared watery. A sample taste of the oatmeal showed it was thin and watery and the oats were not fully cooked. There was no flavor. A greasy feel could be detected from the added butter, but there was no butter flavor tasted. [NAME] J said he/she would have preferred to cook it longer, but he/she was pressed for time. He/She covered both pans with plastic wrap and placed them onto the steam table. [NAME] J did not prepare super cereal. At 7:18 A.M., [NAME] J stirred the oatmeal. It continued to appear thin and watery. At 7:28 A.M., [NAME] J began meal service. He/She served up one hall cart at a time. Other dietary staff read out the meal tickets as he/she served the trays. He/She placed the oatmeal on trays for regular and fortified diets. No health shakes were placed on the trays. Review of the facility's Cereal Oatmeal Quick recipe, showed:-Water: 2 1/2 gallon;-Instant Oatmeal: 3 pounds (48 oz);-Stir Oats into briskly boiling water. [NAME] for 10 to 12 minutes;-Remove from heat and cover. Let stand for 5 minutes. If oatmeal thickens, add boiling water to obtain a thick pouring consistency. Review of the facility's Fortified List, showed 33 residents who received fortified foods. 2. Review of Resident #11's current care plan, showed:-Focus: (Revised 11/6/24) The resident has nutritional problems related to impaired cognition;-Goal: The resident will maintain adequate nutritional status as evidenced by maintaining current weight with no signs and symptoms of malnutrition, and consuming meals as tolerated daily through review date;-Interventions: Administer medications as ordered. The resident needs a calm, quiet setting at meals with adequate eating time;-Focus: (Revised 1/15/25) The resident has unplanned/unexpected weight loss related to cognition;-Goal: The resident will consume 50%, two of three meals per day;-Interventions: Fortified (foods that have essential nutrients added to them to improve nutritional value of the food and help people meet their daily nutrient requirements) breakfast and provide assist with meals. Review of the monthly weight report, showed the resident's April 2025 weight was 167.8 pounds (lbs). Review of the resident's Nutritional Evaluation, dated 4/23/25, showed:-Assessment: Resident requires feeding assistance with meals;-Plan/Recommendations: Recommend fortified breakfast and double portions with meals. House shakes with meals. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/11/25, showed:-Cognitively impaired;-No rejection of care;-Required substantial/maximum assistance with eating;-Diagnoses included dementia, anxiety and Parkinson's disease (a progressive disorder that affects movement, balance and coordination). Review of the resident's physician's orders, dated 9/4/25, showed an order dated 4/29/25, Regular diet, regular texture, thin consistency. One on one feeding assist, double portions, divided plate and fortified foods with all meals. Review of the resident's Weights and Vitals summary, dated 9/4/25 at 9:46 A.M., showed a weight of 138.4 lbs. Observation and interview on 9/29/25 at 1:15 P.M., showed the resident sat in his/her chair attempting to eat lunch. The resident was alone in his/her room. The meal consisted of spaghetti, one piece of bread and what appeared to be a slice of cake, all on a regular plate. A cup of juice was also present on the resident's table. No health shake was on the tray. The resident held a regular fork and tried scooping a forkful of spaghetti but could not lift it towards his/her mouth. When asked if the resident needed assistance, he/she said, I think I'm done eating now as he/she tried to unsuccessfully grab another forkful of spaghetti. When asked if the resident received his/her shake, the resident said no. The resident could not say when he/she last received a house shake. The plate was nearly full at this time. Review of the resident's lunch meal ticket, dated 9/29/25, showed:-Standing orders: double portions, fortified foods and a four ounce house shake;-Alerts: Feeding assistance. Review of the resident's September 2025 Medication Administration Record, showed a house shake was administered on 9/29/25 at 12:00 P.M. Review of the resident's Nutrition, Amount Eaten report, dated 9/29/25 at 1:54 P.M., showed the resident consumed 76-100% of his/her meal. During an interview on 9/30/25 at 10:30 A.M., Certified Nurse Aide (CNA) D said he/she was not familiar with fortified foods or super cereal and could not say if residents received it with their breakfast. Observation and interview on 9/30/25 at 8:04 A.M., showed CNA Q passed fresh water and ice to residents. He/She said health shakes would arrive with breakfast. He/She was assigned to Resident #11. Observation and interview on 9/30/25 at 8:07 A.M., showed Certified Medication Technician (CMT) S administered the resident's medication. He/She said house shakes were different from the nutritional shakes and were included on the dietary trays. The house shake would arrive with the resident's breakfast. Observation on 9/30/25 at 8:33 A.M., showed no breakfast trays on the unit. Observation on 9/30/25 at 8:48 A.M., showed the resident lay in bed and yelled help. Observation on 9/30/25 at 8:59 A.M., showed the breakfast trays arrived on the unit. Staff began taking trays to resident rooms. Observation on 9/30/25 at 9:44 A.M., showed the resident lay in bed asleep. He/She had not received his/her breakfast tray. During an interview on 9/30/25 at 9:45 A.M., CNA Q said they were done passing trays to residents. At 9:48 A.M., he/she said the resident did not receive a tray. He/She would ask why. They were going to get the resident out of bed, but his/her chair broke the other day so he/she would remain in bed until the chair was repaired. CNA Q was not sure if the resident needed assistance with meals. CNA Q was just getting used to the residents. Observation on 9/30/25 at 10:00 A.M., showed the resident's call light went off at the nurse's station and the light flashed from outside of his/her door. An unknown staff member entered the room and turned the light off. At 10:01 A.M., the resident's call light went off again. Licensed Practical Nurse (LPN) A and the same unknown staff entered the room at 10:03 A.M. and turned the call light off. At 10:04 A.M., the resident lay in bed with his/her eyes closed. During an interview on 9/30/25 at 10:10 A.M., LPN A said the aide informed him/her the resident did not receive his/her breakfast tray, and they were going to get it. LPN A was not sure why the resident did not receive a tray. Observation on 9/30/25 at 10:36 A.M., showed the resident had not received his/her breakfast tray. CNA R said he/she was familiar with the resident and would weigh the resident. Observation and interview on 9/30/25 at 10:41 A.M., showed CMT S and CNA R attempted to weigh the resident, but he/she remained asleep, and the staff were not able to obtain a weight. CMT S said he/she was familiar with the resident. The resident tends to throw his/her food at times so he/she may not receive a tray. Staff will bring the residents donuts and other snacks. The resident was able to feed him/herself and does not require one on one feeding assistance. The resident had not received his/her breakfast tray as of 10:43 A.M. Review of the resident's Nutrition, Amount Eaten report, dated 9/30/25 at 9:00 A.M., showed the resident consumed 0-25% of his/her meal. Observation and interview on 9/30/25 at 12:04 P.M., showed CMT S and CNA R weighed the resident. The resident weighed 131.0 lbs. CNA R said the resident experienced weight loss within the last 30 days. Review of the resident's Nutrition, Amount Eaten report, for the month of September 2025, showed the resident consumed 76-100% of his/her meals 37 times and 51-75% of his/her meals 30 times. During an interview on 9/30/25 at 11:30 A.M., the Dietary Manager (DM) said fortified meals were foods with added nutritional value. Super cereal was oatmeal made with extra brown sugar, butter and milk. Super cereal was made daily, separate from regular oatmeal. When informed super cereal had not been made for breakfast on 9/26/25, she said it should have been made and served with breakfast. House shakes were in the kitchen and provided on the trays with resident meals. Dietary staff were responsible for ensuring health shakes were placed on the trays. When informed the health shakes were not passed out for residents until 9/30/25 during breakfast, she said she expected staff to pass them out, as ordered. During an interview on 9/30/25 at 11:52 A.M., the Registered Dietician (RD) said fortified foods should be made daily and served for residents with an order. Super cereal was considered a fortified food. It consisted of oatmeal with extra butter and sugar and should be made in addition to regular oatmeal. House shakes were in the kitchen and should be provided on the tray with meals. She was familiar with the resident and said he/she had an order for double portions, health shakes, a divided plate, fortified foods and assistance with all meals. Even if a resident was on hospice, the expectation was for the resident to receive the recommended diet, and for staff to feed the resident. Staff should have passed the resident a tray and assisted with feeding, or at least offered a tray to the resident. When told the resident did not receive any of the dietary recommendations, the RD said the resident had a significant weight loss and staff were expected to follow dietary recommendations. During an interview on 10/1/25 at approximately 12:30 P.M., the Administrator said she expected dietary orders to be followed. She also expected the resident to receive assistance with meals. The resident should have received a meal tray when staff passed out trays.

Based on observation, interview and record review, the facility failed to ensure residents who required assistance with personal care received the care timely for three residents who were left wet/soiled for extended periods (Residents #10, #59 and #6). Moreover, the facility failed to ensure staff cleansed all areas of the skin for these residents during incontinence care. The sample size was 24. The census was 121.Review of the facility's Incontinent Care policy, dated 7/21/22, showed:-The facility will provide incontinence care as directed in the plan of care;-Perform hand hygiene and apply gloves;-Remove soiled brief/under-pad;-Cleanse perineal area from front to back;-Cleanse the rectal area;-Use a clean surface area of the cloth for each wipe;-Remove gloves and perform handy hygiene and apply clean gloves;-If necessary, apply protective ointment;-Remove gloves and perform hand hygiene;-Reposition resident in a safe/comfortable position. 1. Review of Resident #10's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/8/25, showed:-Resident rarely/never understood;-Dependent on toilet hygiene;-Always incontinent of bowel and bladder;-Diagnoses included pneumonia, stroke and hemiplegia or hemiparesis (paralysis or weakness on one side of the body). Review of the resident's care plan, in use at the time of the investigation, showed:-Focus: Activities of daily living (ADL) self-care performance deficit;-Goal: Maintain current level of function with ADLs;-Interventions include: Personal hygiene care: Dependent on staff. During an interview on 9/25/25 at 9:53 A.M., the resident's spouse said he/she is at the facility at 8:00 A.M. every day to help his/her spouse because staff do not check on him/her for hours. The resident is always left wet. Staff just do not help. He/She talked to the Administrator, but nothing changes. He/She does not believe staff are providing the care the resident needs, either while he/she is at the facility or after he/she leaves. He/She is at the facility a lot. During an observation and interview on 9/26/25 at 10:11 A.M., the resident's spouse said the resident needed to be changed. Observation showed the resident lay in bed with his/her head elevated. At 10:20 A.M., Certified Nursing Assistant (CNA) N entered the room to provide care. He/She washed his/her hands and applied two pairs of gloves and proper personal protective equipment (PPE). The resident's spouse assisted CNA N to unsecure the resident's brief and help to position the resident in the bed. CNA N pushed the resident's brief down between the resident's legs and assisted the resident to turn to his/her left side, to face away from him/her. The resident had soft bowel movement throughout the brief and on his/her skin. Barrier cream was visible on the resident's skin. CNA N cleansed the stool from the resident's buttocks and then removed one pair of gloves, leaving the other on. He/She applied barrier cream to his/her left gloved hand and applied the cream to the resident's buttocks area. CNA N then applied a clean brief. CNA N failed to cleanse the resident's genitals or inner legs, that were potentially soiled. During observation and interview on 9/29/25 at 8:06 A.M., the resident's wife said the resident was wet. He/She unsecured the resident's brief and showed a saturated brief with urine soaked through the brief and saturated through two towels that lay under the resident. Loose stool was visible near the back of the brief. The resident's skin appeared reddened. The resident's spouse said he/she waved down staff when he/she arrived and saw how wet the resident was, but he/she thought they just thought he/she was waving and not requesting help. Observation on 9/29/25 at 8:13 A.M., showed CNA N entered the room to provide care. The resident had two towels under him/her which were visibly wet with urine. CNA N said he/she needed to get the wound nurse for a skin assessment. At 8:20 A.M., CNA N returned, followed shortly by the wound nurse. CNA N placed gloves on and unsecured the resident's brief. The brief appeared heavy and saturated with urine. Chunks of cotton from the brief stuck to the resident's genitals and buttocks. Liquid stool was between the resident's legs and on his/her buttocks. CNA N began to wipe off the stool to allow the wound nurse to visualize the buttocks. The buttocks were bright red and appeared excoriated. CNA N said this is the first time he/she provided care to the resident on his/her shift, but he/she only arrived about an hour ago. The resident is not typically this wet when he/she comes in. The night shift should not have allowed the resident to be this wet and should have changed the resident before he/she was wet enough to soak through the brief. The wound nurse said the resident needed to continue to receive the barrier cream during care to treat the excoriation. 2. Review of the Resident #59's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment; -Dependent on staff for toilet hygiene;-Frequently incontinent of urine and bowel;-Diagnoses included Parkinson's disease (a movement disorder that worsens over time), heart failure and history of hip fracture. Review of the resident's care plan, revised 6/5/25, in use at the time of the investigation, showed:-Focus: The resident has limited mobility and requires assistance with ADL;-Goal: Will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall-related injury;-Interventions: Provide supportive care assistance with mobility as needed, document assistance as needed. Observation and interview on 9/26/25 at 5:57 A.M., showed the resident sat at the side of the bed with both legs on a puddle of urine on the floor. The resident said he/she was waiting for the lady who will bring clothes and help him/her change. The blanket and bedsheets were rolled by the foot of the bed. He/She said they were soaked. The incontinence pad and middle part of the fitted sheet were soaked with urine. The resident said he/she woke up cold and wet and had been waiting for someone to help him/her all night. The call light was not within the resident's reach. He/She was confused when asked if he/she used the call light. He/She did not know what it was for. Observation on 9/26/25 at 6:06 A.M., showed CNA P entered the room and told the resident he/she was soaking wet. CNA P asked the resident to lay back down, then he/she left the room. At 6:11 A.M., CNA P returned with the resident's clothes and disposable wipes. He/She wiped the resident's buttocks and applied an incontinence brief. He/She sat the resident up on side of bed and applied a clean shirt and pants. During an interview on 9/26/25 at 6:22 A.M., CNA P said the resident was confused and does not remember using the call light. During the night shift, the residents were being checked every two hours. He/She said there were not enough staff on night shift, one CNA on one side/wing cannot do all the tasks. 3. Review of Resident #6's quarterly MDS, dated [DATE], showed:-Cognitively intact;-No behaviors;-Dependent on staff for toileting him/herself;-Always incontinent of bowel and bladder;-Diagnoses included hemiplegia and depression. Review of the resident's care plan, revised 6/5/25, in use at the time of the investigation, showed:-Focus: The resident has an ADL deficit related to hemiplegia;-Goal: The resident will maintain current level of function with ADLs through the review date;-Interventions: Does not use bed pan, toilet or commode. Utilize check and change to manage incontinency. During an interview on 9/25/25 at approximately 9:36 A.M., the resident said he/she relied on staff for everything, including toileting. Sometimes he/she was left wet after pressing the call light for assistance. It happens more during evening and night shifts. During an observation and interview on 9/26/25 at 5:30 A.M., the resident lay in bed on his/her back. The resident said he/she pressed the call light, and no one answered. He/She said he/she was soiled. An odor of urine was present in the resident's room. The resident said he/she had been waiting for an hour. The call light was not on upon arrival to the resident's room. The resident was asked to press his/her call light again at 5:31 A.M. The resident pushed the call light and said he/she was upset because this always happened at night. At 5:39 A.M., CNA I responded to the resident's call light. Observation and interview on 9/26/25 at 5:40 A.M., showed CNA I entered the resident's room with some washcloths and an incontinence brief. When CNA I removed the brief, it was soaked with urine. CNA I wiped the resident's groin areas and buttocks with wet washcloths and applied a clean brief. The resident said it felt better after being soaked wet for a while. During an interview on 9/26/25 at approximately 5:55 A.M., CNA I said he/she was responsible for about 20 residents during the night shift. He/She would answer call lights within five minutes. Twenty residents were manageable. The resident relied on staff for all toileting needs. 4. During an interview on 9/30/25 at 7:48 A.M., Licensed Practical Nurse (LPN) O said regarding incontinence care, staff were provided in-service training a couple weeks ago. Staff had a skills day. Direct care staff were required to demonstrate providing care and they were quizzed. 5. During an interview on 9/30/25 at 12:24 P.M., the Director of Nursing (DON) said residents who are incontinent of bowel and bladder should be checked every two hours. If residents are left wet for too long, there is an increased risk of skin breakdown. If a resident was left wet long enough for the cotton on the brief to stick to the skin and to saturate the brief and bedding, that is too long. 2595043

Based on interview and record review, the facility failed to ensure two residents received an accurate assessment, reflective of the residents' status at the time of assessment, when the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) was incorrectly coded that the residents received insulin. (Residents #4 and #74). The sample was 24. The census was 121. 1. Review of Resident #4's quarterly MDS, dated [DATE], showed:-Diagnoses included diabetes;-Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days: one. Review of the order summary report, dated 10/1/25, showed a physician order for Ozempic (glucagon-like peptide-1 (GLP-1) receptor agonist) subcutaneous (under the skin) solution pen injector 2 milligram (mg)/1.5 milliliter (mL), inject 2 mg subcutaneous every Saturday related to type 2 diabetes mellitus. 2. Review of Resident #75's quarterly MDS, dated [DATE], showed:-Diagnoses included diabetes;-Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days: one. Review of the order summary report, dated 9/25/25, showed a physician order for Mounjaro (GLP-1 receptor agonists) subcutaneous auto-injector pen 15 mg/0.5 mL, inject 1 application subcutaneous every Tuesday for baseline (no other information was noted). 3. During an interview on 10/1/25 at 9:25 A.M., the MDS Coordinator said Resident #4 started his/her Ozempic in August. Resident #75 was on insulin which was discontinued in March. Since then, the resident has been on Ozempic and currently has an order for Mounjaro. Ozempic and Mounjaro are not classified as insulin and should not be coded as insulin on the MDS. She expected the MDS to be coded accurately. 4. During an interview on 10/1/25 at 12:20 P.M., the Administrator said she expected insulin to be coded accurately on the MDS.

Based on observation, interview and record review, the facility failed to ensure a resident's right to self-administer medications is protected if the interdisciplinary team has determined the practice is clinically appropriate for one resident (Resident #97) who had a desire to self-administer a medication and had an order to self-administer, with no assessment to ensure safe administration. The sample was 24. The census was 121.Review of the facility's Bedside Medication Storage policy, dated 12/17, showed:-Bedside medication storage is permitted for residents how wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed apocopate in the judgment of the facility's interdisciplinary resident assessment team;-A written order for the bedside storage of medication is present in the resident's medical record;-Bedside storage of medications is indicated on the resident medication administration record and in the care plan for the appropriate medications;-The resident is instructed in the proper use of bedside medications. The resident should be able to repeat the instructions or demonstrate appropriate use of the medicines. The completion of this instruction is documented in the medical record;-At least once a shift, the nursing staff check for usage of the medications by the resident. Review of Resident #97's medical record, reviewed on 9/25/25, showed:-A quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/5/25, showed the resident cognitively intact;-Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease);-A care plan in use at the time of the investigation, showed: The resident has shortness of breath related to COPD. Goal: Maintain normal breathing pattern. Interventions included: Teach resident when to inhale and exhale while doing strenuous activities. The care plan did not address self-administration of medications;-An order dated 3/24/25, for albuterol sulfate (used to treat asthma) 2 puffs inhale orally ever 4 hours as needed for wheezing and coughing. May keep at bedside;-A progress note, dated 8/20/25, Physician G in today. New order received and noted that resident may keep albuterol inhaler at bedside;-No assessment for self-administration of medications completed. During an observation and interview on 9/25/25 at 9:11 A.M., the resident in his/her room sat on the bed. He/She had oxygen on per nasal cannula set between 2 and 3 liters. The resident said he/she wants to keep his/her inhaler at his/her bedside. The doctor had ordered him/her to have it at bedside, but staff will not give it to him/her. It is a rescue inhaler. He/She needs it at bedside because when he/she needs it, he/she needs it and cannot wait. During an interview on 9/26/25 at 9:56 A.M., the resident said he/she was still never given his/her inhaler. Staff said they have to talk to Physician G. Observation and interview on 9/29/25 at 9:32 A.M., showed the resident pulled out an albuterol inhaler from his/her bedside drawer and said staff gave it to him/her, he/she believes last Friday (9/26/25), to keep at his/her bedside. Review of the resident's medical record, reviewed on 9/29/25, showed no assessment for the resident to self-administer medications. During an interview on 9/30/25 at 8:09 A.M., Certified Medication Technician (CMT) H, the CMT assigned the resident's hall, said if a resident was able to self-administer medications, it would say on the order that the medication may be left at bedside. Typically, this is seen with inhalers or mouth rinses, etc. He/She will encourage residents to be more independent and to self-administer if they are able to. He/She will show residents proper technique and educate them on the orders. Currently, he/she does not have any resident who self-administers their medications. If a resident wants to self-administer medications, they have to go through nurse and doctor to get the order. During an interview on 9/30/25 at 12:24 P.M., the Director of Nursing said the resident had been assessed in the past to self-administer medications, but he/she was not sure if the resident was re-assessed after his/her last admission. If a resident wants to self-administer a medication, staff should assess the resident for safety. If a resident has medications at the bedside, the assessment should be done.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity for one resident (Resident #61) when a Licensed Practical Nurse (LPN) spoke rudely to the resident. The sample was 24. The census was 121.Review of the facility's Resident Rights policy dated 4/26/23, showed:-The facility shall treat residents with kindness, respect and dignity and ensure resident rights are being followed. The resident/resident representative will be informed on their rights upon admission;-Resident rights included: Respect and dignity. Review of Resident #61's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/4/25, showed:-Cognitively intact;-Diagnoses include depression and psychotic disorder. During an observation and interview on 10/1/25 at 8:32 A.M., the resident sat up in bed and drank coffee. LPN A knocked on the door, entered the room and handed the resident a medication cup. The resident took the medication and began to set the medication cup down. LPN A went to take the medication cup from the resident and the resident said he/she could take care of it him/herself. LPN A's facial expression changed, and he/she appeared irritated. He/She turned her back to the resident, started to walk away, and said in a volume easily heard and with a rude tone, see the type of attitude we have to deal with, you don't talk to us that way. He/She then exited the room and closed the door. The resident said staff can be rude. They treat him/her like he/she has dementia. He/She can do for him/herself. During an interview with the Administrator, Director of Nursing, and Corporate Administrator on 10/1/25 at 12:19 P.M., they said staff should speak to residents with respect and face the residents as they speak to them. They should not criticize. 1598315

Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards. Staff failed to schedule follow up appointments with the urologist (a doctor that specialized in the urinary system) for one resident (Resident #5) who has recurrent urinary tract infections and severe urethra erosion (damage to the urinary opening) from prolong use of an indwelling urinary catheter (flexible tubing that carries urine to outside of body into a urine catch bag). The sample size was 6. The census was 123. Review of the facility's Policy and Procedure for Physician Order, dated 9/28/2022, showed: -To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines; -Service provided by licensed nurse, nursing administration and Director of Nursing (DON); -Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders. Review of Resident #5 Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/24/25, showed: -Moderate cognitive impairment; -Indwelling urinary catheter; -Diagnoses included obstructive and reflux uropathy (disorder of the urinary tract), bladder-neck obstruction, cognitive communication deficit, and muscle weakness; -Required maximum assistance from staff for all activities of daily living, total care provide by staff; -Wheelchair dependent. Review of the resident's care plan, in use at the time of the investigation, showed: -Focus: Requires catheterization - indwelling catheter due to diagnosis of obstruction; -Interventions: The resident has a suprapubic catheter (medical device inserted through the abdomen into the bladder to drain urine), size 16 French (Fr - a unit of measurement for the outer diameter of the urinary catheter). With a 10 cubic centimeter (cc) balloon (balloon inflated with water to hold the catheter in place). Position catheter bag and tubing below the level of the bladder and away from entrance door, created 4/2/24. Review of the resident's medical record, showed no documentation the resident ever had a suprapubic catheter as indicated in the care plan. Review of the resident's orders dated 5/30/25, showed: -Provide urinary catheter care every shift; -Replace urinary catheter every other month and as needed (PRN); -Medically necessity urinary catheter size 16 Fr with a 10-cc balloon; -Change catheter drainage bag every month and PRN. Review of the resident's hospital after visit summary, dated 3/14/24 through 3/16/24, showed referral to urology to continue regular urinary catheter exchanges. Review of the resident's medical record, showed the urology follow up visit, dated April 2024 missing from the resident chart. Review of the resident's physician progress notes, dated 6/27/24, showed plan: Schedule follow up appointment with urology due to chronic urinary catheter retention for regular urinary catheter exchanges. Review of the resident's medical record showed no urology appointment made to follow up with urology as ordered. Review of the resident's hospital Discharge summary dated [DATE], showed active issues requiring follow up: Urology outpatient follow-up for suprapubic catheter. Review of the resident's facility medical record showed no urology outpatient follow-up appointment made as ordered by the hospital upon discharge. Review of the resident's Urology Consultation note dated 3/30/25, completed during the resident hospital stay, showed: Patient previously established with urology here, but last seen April 2024. Please reach out at discharge to schedule ongoing urology outpatient follow-up for chronic urinary retention and surveillance of bilateral non-obstructing stones. Review of hospital inpatient Discharge summary dated [DATE], showed active issues requiring follow up with urology. During an interview on 6/6/25 at 11:28 A.M., a representative with the call center for the hospital urology department said the resident had an appointment on 4/26/24 with a referral for a three month follow up appointment. This appointment was never scheduled. The resident was last seen outpatient on 4/26/24. The representative added the facility called today, 6/6/25, to schedule a follow up appointment from hospital visit 3/30/25. This appointment is scheduled for 6/16/25 at 10:40 A.M. During an interview on 6/9/25 at 10:41 A.M., Licensed Practical Nurse (LPN) Q said, when a resident comes back from the hospital or a physician visit., the nurse caring for the resident is responsible to make sure the discharge or office visit instructions are received. The nurse is also responsible to review the instructions and make appointments, add or change orders, and notify the staff of changes. During an interview on 6/9/25 at 11:21 A.M., The Director of Nursing (DON) and Assistant Director of Nursing (ADON) said it is the responsibility of the charge nurse, at the time the resident returns to the facility, to make sure paperwork with follow up orders are received, reviewed, and transcribed into the resident medical records and appointments are made. They expect the charge nurse to set up follow up appointments. They were not aware the resident did not have requested follow up appointments scheduled after the urology visit 4/16/24, hospital stay 1/4/25, or hospital stay 4/1/25 and they expected staff would have made the follow up appointment from the 4/1/25 hospital stay prior to this surveyor onsite visit. They were also not aware the resident has severe urethra erosion from prolong use of an indwelling urinary catheter. During an interview on 6/9/25 at 11:36 A.M., Wound Care Nurse A said he/she was aware of the resident's urethra erosion and indwelling urinary catheter. The urethra erosion was healed and has been there since he/she has been caring for the resident for about six months. He/She also said the resident had a lot of issues with the urinary catheter becoming clogged which led to the catheter leaking and causing skin breakdown that required treatment for moisture associated skin damage (MASD). During an interview on 6/9/25 at 12:13 P.M., the Administrator and Regional Director said the charge nurse is responsible to make sure the doctor's office or hospital has sent paperwork, which includes the discharge summary, new orders, referrals, and visit notes for the returning resident. If the paperwork is not with the resident, the nurse should call and request the paperwork. It is the charge nurse responsibility to make sure they have received, reviewed, updated orders, make follow up appointments, and inform staff of changes. After this has been completed, the nurse supervisor for the unit should review the paperwork to make sure nothing has been missed. They expect requested follow up appointments to be made as soon as the resident returns from the doctor visit or hospital stay. They were not aware the resident did not have requested follow up appointments scheduled after urology visit 4/16/24, hospital stay 1/4/25 or hospital stay 4/1/25 and they expected staff would have made the follow up appointment from the 4/1/25 hospital stay prior to this surveyor onsite visit. They were also not aware the resident has severe urethra erosion from prolong use of an indwelling urinary catheter. MO00255305

Based on interview and record review, the facility failed to ensure their licensed staff was competent in their knowledge of the facility policy for when to provide Cardiopulmonary Resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation to restore blood circulation and breathing) for one resident whose physician ordered him/her as a full code (CPR desired) when staff failed to have knowledge of when CPR would not be indicated in a full code resident, such as when there is evidence of clinical signs of irreversible death (Resident #3). This had the potential to affect 74 residents at the facility who have a full code status. The sample size was 6. The census was 120. Review of the facility's CPR policy, last reviewed [DATE], showed: -The Facility will provide Basic Life Support, prior to the arrival of Emergency Medical Services (EMS) including initiation of CPR to a Resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with the Resident Advance Directives, or a signed Do Not Resuscitate (DNR) order; -Charge Nurse will Initiate CPR Unless: -A valid DNR is in place; -Clinical Evaluation reveals obvious signs of clinical death (rigor mortis (stiffening of the joints and muscles of a body a few hours after death, usually lasting from one to four days), dependent lividity (a reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the blood vessels evident in the lower lying parts of the body in the position of death), decapitation (the total separation of the head from the body), transection or decomposition (the state or process of rotting). -Initiating CPR could cause serious injury/immediate danger to the rescuer; -Licensed employees will maintain a current CPR Certification through a hands-on practice and in-person skills assessment training for healthcare providers; -Responsibility: Licensed nurses, nursing administration, and Director of Nursing (DON). Review of Resident #3's significant change Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated [DATE], showed: -Cognitively intact; -Upper extremity impairment: One side; -Lower extremity: No impairment; -Substantial/maximal assistance (helper does more than half the effort) required for: Toileting, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene; -Mobility: Substantial/maximal assistance required to: roll left to right, sit to lying, lying to sitting on side of bed, sit to stand, toilet transfer, and tub/shower transfer; -Frequently incontinent of bladder and bowel; -Diagnoses include cancer, stroke, high blood pressure, hemiplegia (paralysis on one side of the body), and depression. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Resident requests status of full code-initiate CPR; -Goal: Code status will be maintained through next review; -Interventions: Call for an ambulance in the event of a cardiac arrest, do initiate cardiopulmonary resuscitation measures, notify physician, provide emergency measures as appropriate, observe for any changes in code status. Review of the resident's electronic medical record (EMR), showed: -An order dated [DATE], for full code; -A portable medical order, dated [DATE], signed by the resident and the resident's physician showed: -Cardiopulmonary Resuscitation Orders: Yes CPR: Attempt resuscitation, including medical ventilation, defibrillation, and cardioversion. (Requires choosing full treatments in section B); -Full treatments (required if choose CPR in Section A): Goal-Attempt to sustain life by all medically effective means. Provide appropriate medical and surgical treatments as indicated to attempt to prolong life, including intensive care. Review of the resident's progress notes, showed: -On [DATE] at 5:25 P.M., (late entry) Resident's roommate came up to the nurse's station saying, something is wrong with the resident, he/she is not feeling well, he/she had chemotherapy today. Writer and Certified Medical Technician (CMT) went to go check on resident and ask resident was he/she ok. Resident shook his/her head no and was holding an emesis (action or process of vomiting) bag next to his/her mouth. Writer asked CMT if he/she would get the resident's vitals. Writer then informed the floor nurse and informed him/her that the CMT was getting the resident's vitals; -On [DATE] at 11:10 P.M., Resident resting supine (lying face up) in bed, noted respiration are even and non-labored. Resident responds to tactile stimuli, denies complains of pain. Bed in low position and call light is attached to resident's gown. Resident is aware to use call light if needed; -On [DATE] at 7:21 A.M., this writer summoned to resident's room by his/her roommate at 5:55 A.M., due to the resident not waking up. This writer entered the room and noted that resident had no signs of life. Resident had signs of rigor mortis and per facility policy, CPR was not initiated. This writer last seen resident around 1:00 A.M. Resident appeared to be sleeping per his/her chest rising and falling. Certified Nursing Assistant (CNA) reported last seeing resident doing rounds at 4:30 A.M. during care rounds and reported that resident was awake. Call placed to physician to make aware and call placed to resident's family several times and message left for him/her to call the facility. Call placed to medical examiner. Review of the facility's investigation, showed: -Resident is alert and oriented x 3 with periods of confusion who was admitted to the facility on [DATE]. According to his/her most recent MDS, the resident does have short/long term memory impairment; -On [DATE] at approximately 5:55 A.M., the Nurse was summoned to the resident's room by his/her roommate because the resident was not easily aroused. The charge nurse entered the room and found the resident lying in bed supine. Charge nurse assessed and found the resident without signs or life, there was no pulse or rise and fall of the chest. Code Blue initiated, charge nurse attempted to do CPR, however the resident was cold to touch, and neck was stiff. Second nurse entered the room for assisting. The physician, resident representative was notified on the resident's condition. DON and Administrator made aware; -Upon completion of investigation, it was determined that the resident's Change in Condition was related to an overall gradual decline in care related to diagnosis. The resident was currently going through chemotherapy. The resident last visited the Oncologist (cancer doctor) on [DATE]. The resident was in bed during the day, with no complaints about anything. Registered Nurse (RN) D saw the resident at 1:00 A.M. and he/she was asleep, stable without any complaints. During an interview with the CNA, CNA H stated he/she last seen the resident at 4:30 A.M. when doing rounds and the resident was awake trying to get comfortable in bed. During an interview on [DATE] at 10:20 A.M., Licensed Practical Nurse (LPN) B said he/she last worked with the resident around mid-May and would have to look up the resident's code status. If a resident was a full code and found unresponsive, then LPN B would perform CPR. He/She would have someone call 911 and call a code for more assistance. He/She is not sure why CPR would not be performed on someone who was a full code. LPN B said he/she would have to look up policy, maybe if visible rigor mortis set in, but is unsure. He/She was not working the night the resident passed. During an interview on [DATE] at 11:35 A.M., Resident #3's roommate said the resident was in bed 1 closest to the door. When the resident got chemotherapy, it would wear him/her our and he/she would not want to speak. The resident got chemotherapy that day before he/she passed so was not really talking the day. At approximately 1:00 A.M., he/she heard the aide come in the room to provide care. At around 5:30 A.M., he/she woke up for the day. He/She said the resident's name. When the resident did not respond, he/she went to the nurse's station to notify the nurse. The nurse immediately went to the room and then came back and told the roommate that Resident #3 died . During an interview on [DATE] at 1:40 P.M., Registered Nurse (RN) D said on [DATE], their shift started at 3:00 P.M. on a different unit. At approximately 11:15 P.M., he/she went to Resident #3's unit. At approximately 1:00 A.M., he/she went into Resident #3's room. the resident lay asleep with his/her eyes closed. RN D observed the resident's chest rise and fall with no discomfort. At 4:30 A.M., CNA H went into the resident's room to provide care. RN D said at approximately 5:55 A.M., he/she went to check on the resident. He/She then checked the resident's EMR and the resident was a full code. RN D started to lay the resident's bed down to position him/her to perform CPR. RN D said the resident's neck seemed stiff and the resident would not lay all the way out. His/Her legs would not straighten out. RN D tried to straighten his/her leg but was worried about breaking the resident's leg. RN D decided not to do CPR due to the resident's stiffness. RN I was also in the room. RN D called the DON to verify the CPR policy related to when staff needs to perform CPR. The DON confirmed the policy that CPR is not done if rigor mortis had set in. RN D called the physician. RN D attempted to call the resident's family a couple times but did not answer. RN D called the medical examiner and then talked to the family who came up to the facility. RN D said the facility had in-services in the past on the expectation to not have to do CPR if rigor mortis, but could not remember the date. During an interview on [DATE] at 2:35 P.M., LPN E said he/she is a newer nurse at the facility. All nurses are supposed to be CPR certified. His/Her CPR certification expired not too long ago but he/she is scheduled for a class on Friday [DATE]. The facility provides the certification onsite. LPN E said the night before the resident passed away was his/her first night working. If a resident that was a full code was found unresponsive, he/she would get someone to initiate CPR since he/she is not certified, unless the resident is a DNR. During an interview on [DATE] at 2:45 P.M., LPN L said if he/she found someone unresponsive then he/she would initiate CPR. LPN L said he/she would call out for assistance and have someone call 911 to get EMS on the way. LPN L said there is no reason to not initiate CPR if a full code. The code status can be found in the computer. The facility provides CPR certifications on site. During an interview on [DATE] at 2:50 P.M., CNA G said on [DATE], he/she was the CNA assigned to the resident. The resident reported he/she felt sick that day. The resident went to chemotherapy. The resident said he/she did not feel good and was in pain. The resident was contracted on both of his/her legs and one of his/her hands. He/She was able to sit up on his/her own. The resident's right side was the weak side. CNA G was not sure of the resident's code status since the CNAs do not have much to do with the computer. If he/she found a resident unresponsive, then he/she would initiate CPR then yell to get the nurse. CNA G said the only reason not to initiate CPR is if the resident was a DNR. During an interview on [DATE] at 3:00 P.M., the DON said the morning the resident died she was downstairs on the rehabilitation unit. RN D called the DON and she immediately went upstairs to Resident #3's room. RN D asked the DON if the policy had changed related to when to perform CPR and the DON said she told RN D, no the policy had not changed. The DON said RN D is a newer nurse. RN D called the code but then got a better look at the resident. RN D said no respirations or rise and fall of chest. So per policy, CPR was not done. RN D said the resident was already cold and stiff. During an interview on [DATE] at 7:50 P.M., CNA H confirmed he/she worked on [DATE] and his/her shift started around 3:00 P.M. The resident seemed like his/her normal self. Around 4:30 A.M., he/she provided care and emptied the resident's urinal. CNA H thought the nurse was last in the room at approximately 1:00 A.M. and reported the resident was fine. When the code was called, CNA H was in another room. He/She immediately went in the resident's room. The DON was already in the room. CNA H said the resident was a full code but is not sure if CPR was initiated. There were a lot of nurses in the room, so CNA H said he/she left the room to assist another resident. CNA H said the resident was contracted and weak on one side. He/She liked to pull his/her legs up. The resident could put them down but preferred to keep them up. CNA H does not remember if he/she was in-serviced on CPR. CNA H has been there almost a year. When he/she first started, he/she was not told he/she had to be CPR certified but said he/she is CPR certified now. If a resident is a full code and unresponsive, he/she would start CPR. There would never be a reason not to start CPR. CNA H said the policy was never discussed regarding reasons to not initiate CPR and he/she would automatically do CPR. During an interview on [DATE] at 11:26 P.M., RN I said he/she worked the overnight shift on [DATE] and started his/her shift at 11:00 P.M. on the rehabilitation floor of the facility. RN I said as he/she assisted a resident back to the other side of the facility, RN D came up to him/her, panicked. RN D said, I need you now, it is a code. RN I asked what room and RN D informed him/her that it was Resident #3. RN I had a CNA assist the resident he/she had and went to assist RN D. RN I went in the room. The resident had no pulse and was cold from head to toe. RN D called the code and went to lay the bed down flat to do CPR but it was like rigor mortis set in, irreversible stiffness. The resident's neck seemed stiff, his/her legs were stiff and pulled up. The resident's arms were pulled up too. They would not move. At the time of the code, he/she was not CPR certified. He/She has a class scheduled at the facility in the morning after this shift. RN I said he/she was told by the facility that per policy if a code is called he/she cannot do CPR if he/she is not certified. RN I has been at the facility around 6 years. He/She said he/she was probably in serviced approximately 6 months ago. RN I said when a resident is found unresponsive, the nurse calls a code and initiates CPR until code status is verified. The only two reasons to not do CPR is if the resident is an active DNR or irreversible signs of death is present, such as rigor mortis. Review of the information provided by the facility on [DATE] at 1:30 P.M., showed CPR in-services last completed on [DATE]. Review of the CPR cards, showed RN I's CPR certification was still active and did not expire until [DATE]. During an interview on [DATE] at 2:07 P.M., the Administrator and DON said they would expect staff to be competent on the facility policies. They would also expect staff to understand code status and obvious signs of death as stated in the policy. They would expect the nurse to know what to do if a resident is found unresponsive and be able to act immediately. The DON said RN D did know what to do. RN D only asked to clarify a part of the policy. If the DON had not been there, there would have been another nurse available to ask. That night there were three nurses there. The Administrator said RN D knew what to do but agreed that if RN D had to clarify the policy with the DON or any available nurse, that would cause a delay in care. The Administrator said they have been talking and plan to start quarterly in-services/mandatory meetings over CPR, the policy, and expectations. She said maybe it needs to be monthly because it is important the staff understand. She said they have a lot of full code residents and fragile residents at the facility. MO00237438

Based on interview and record review, the facility failed to provide adequate supervision for one resident after an aide left the resident unattended in the bathroom during toileting (Resident #33). The resident was found in the hallway across the room, laying on their back on the floor, with a gash to the forehead. The resident was sent to the emergency room and returned with bruising to the head, face, and neck areas. The census was 113. The Administrator was notified on 3/8/24 of the past non-compliance. The nursing staff immediately assessed the resident and treated for injuries. Staff called 911 and reported the unwitnessed fall to the resident's next of kin and physician. The facility immediately in-serviced staff on toileting residents. The subject matter included to never leave a resident unattended in the bathroom or shower. If supplies are needed, pull the call light for staff to come assist and to gather all supplies before giving care. Facility also in-serviced staff on the fall policy and change in condition policy. The subject matter included to notify physician, family, and document all falls regardless of transfer to emergency room . It must be in risk management regardless of witness, unwitnessed, or sent to the hospital. All falls must be notified to manager on call and all transfers to emergency room must be notified to manager on call. The noncompliance was corrected on 2/8/24. Review of Resident #33's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 1/15/24, showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, aphasia (language disorder), diabetes, other fracture, and cataracts; -No range of motion impairment; -Required substantial/maximal assistance. Helper does more than half the effort for toileting hygiene, shower/bath, upper and lower body dressing, putting on/taking off footwear, and personal hygiene; -Required substantial/maximal assistance. Helper does more than half the effort for resident to roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer; -Walk 10 feet: Not attempted due to medical condition or safety concerns; -Uses manual wheelchair; -Has the resident had any falls since admission or prior assessment: No. Review of the resident's medical record, showed diagnoses of diabetes, respiratory failure, aphasia, muscle wasting and atrophy (muscle shrinking and weakening), history of falling, need for assistance with personal care, mild cognitive impairment, muscle weakness, repeated falls, and mixed receptive-expressive language disorder. Review of the resident's care plan, revised on 1/23/24, showed: -Focus: Resident is incontinent of bowel and bladder due to cognitive impairment. He/She is unable to communicate or unaware of toileting needs and/or follow directions to participate in toileting program: -Goal: Keep clean, dry, and comfortable daily with use of urinary/bowel incontinence products; -Interventions: Check Resident before and after meals and evening (PM) for incontinent episodes. Document incontinency status each shift. Place call light or other communication device within reach at all times. Provide incontinence/perineal care (cleansing of the surface area to include the buttocks and genitals) after each incontinent episode, use barrier cream; -Focus: Resident has an activities of daily living (ADL) self-care performance deficit, impaired balance, and limited mobility: -Goal: ADL function: Resident requires assistance with ADL care and mobility here on a skilled rehab stay to increase in strength, mobility, endurance, and independence; -Interventions: Personal hygiene: One assist. Toilet use: Does not use bed pan, toilet or commode. Utilize check and change to manage incontinence. Transfer: One assist; -Focus: Resident has limited physical mobility related to weakness: -Goal: Will remain free of complications related to immobility, including contractures, thrombus (blood clot) formation, skin-breakdown, fall related injury; -Interventions: Uses a wheelchair: manual. Ambulation: Does not walk. Locomotion: Dependent one assist via wheelchair; -Focus: Resident is unable to communicate due to expressive aphasia. He/She required staff to anticipate and meet needs daily: -Goal: Make basic needs known on a daily basis; -Interventions: Anticipate and meet needs. Encourage resident to communicate needs daily. Ask simple yes or no questions to meet needs. Ensure/provide a safe environment; -Focus: Resident has history of falls due to multiple factors, cognitive deficits, impaired balance, and the use psychotropic medications: -Goal: The resident will not sustain serious injury; -Interventions: nonskid socks. Anticipate and meet the resident's needs. Dycem (non-slip mat) to wheelchair. High visibility area. Staff to assist with transfers. Staff to do frequent rounding 6/18. Toileting schedule. Use stand up lift with transfers. Review of the resident's progress notes showed: -On 1/29/24 at 2:00 P.M., Certified Nurse Aide (CNA) reported resident being on the floor. When entering resident's room, resident sitting on the floor by his/her wheelchair with his/her shoes off. Resident had attempted to get in the bed per self. Resident able to move bilateral (both sides) lower extremities (BLE)/bilateral upper extremities (BUE) without difficulty. Denies hitting head and pain. No injuries noted. Resident assisted to wheelchair x 3 staff with gait belt; -On 1/30/24 at 10:15 A.M., the resident discussed with interdisciplinary team (IDT) related to 1/29 fall. Resident has history of falls. Safety intervention in place is non-skid socks; -On 2/2/24 at 3:07 P.M., resident sent out to hospital via due to a fall; -On 2/2/24 at 3:34 P.M., Resident has an abrasion noted to the center of forehead that is 1.0 x 0.1 centimeter (cm) and a skin tear to the back of the right hand that is 2.5 x 0.3 cm. Resident also has a knot on the right side of his/her forehead that he/she obtained during a fall; -On 2/3/24 at 12:37 A.M., resident returned from hospital at 10:40 P.M., per stretcher escorted by two paramedics. Resident taken back to room and assisted into bed, resident cleaned, dried, and repositioned. Call light placed within reach. Hospital paper received from paramedics. New orders noted and will be placed in computer. During an interview on 3/8/24 at 10:45 A.M., Registered Nurse (RN) X said he/she did wound care on 2/2/24. It was close to end of shift between 2:00 P.M. to 3:00 P.M. and he/she went to get something from the wound closet. The resident was at the doorway to a room. It was not his/her doorway. The resident's room was across the hall from where he/she was found. His/Her pants were down around his/her thigh area. RN X believed the resident was on his/her side, there was blood on the front of his/her head, and he/she had something on the forehead, maybe lip. Blood was pooling on the floor under him/her, and RN X thought he/she might have an injury on the back of his/her head, but after cleaning it up he/she did not. The wheelchair was not anywhere around. There was a skin tear on right hand as well. There were no residents around him/her. He/She asked the resident why his/her pants were down and what he/she was doing. The only thing Resident #33 could say was he/she was hurting and could not sit up because it hurt. The resident was not moved, staff called an ambulance, and they came and took over. Staff knew that the resident was a fall risk, so they would do more frequent rounds. There was a CNA inside the nurse's station. When RN X asked the resident what happened or how did you fall, the CNA came out to assist. He/She did not know the aide because he/she was new. The CNA said he/she had the resident on the toilet and stepped away for a moment. RN X told the aide that he/she should not leave him/her on the toilet, because they do not have the mental capacity to stay when told. The aide did not say what he/she was doing at the nurse's station. Licensed Practical Nurse (LPN) U was on the other side working with someone, but he/she came over and started helping. He/She also called the DON and the DON arrived and helped. The restorative aid arrived while they waited for the ambulance Review of the resident's skin assessment, dated 2/2/24, showed: -Skin tear on right hand (back) that measured 2.5 cm Length (L) x 0.2 cm Width (W) x 0.1 cm Depth (D); -Other that measured 1.0 cm L x 0.1 cm W (No documentation of site or type); -Abrasion to forehead (no documentation of measurements). Review of the resident's hospital record, showed: -admitted [DATE]; -discharged [DATE]; -Chief complaint: Patient from facility for ground level fall. Emergency Medical Services (EMS) reports patient was left unattended in bathroom, found on ground calling for help, assumed fall from ground, small lacerations to left forehead, alert and oriented to self only, wheelchair bound, cognitive and expressive language disorder, high blood pressure; -Heads, ears, eyes, nose, and throat (HENT): Comments: Forehead abrasion; -Right frontal and scalp soft tissue swelling/hematoma and overlaying lacerations. Review of the resident's hospital discharge record, showed: -Diagnoses: Injury of head, fall, contusion of scalp, and closed fracture of one rib of left side (unable to determine if it was an old or new fracture); -Instructions: You were seen today after a fall. Computed tomography (CT) head was obtained and did not show any acute bleeding, fractures, or other injury. A neck CT scan was also obtained and showed no injuries. Pelvic x-ray showed no injuries either. A chest x-ray showed a rib fracture on the left. Make sure to use incentive spirometer (device used to ensure deep breaths to prevent pneumonia) and Lidoderm (pain medication) patches for pain. Review of pictures of the resident's injuries, provided 3/8/24, showed: -A large area of dark, purple bruising on the right side of the resident's face, below the jaw line. Bruising around the right side of the neck, fading in color. Bruising to the back of the resident's right ear. Bruising underneath the right ear appeared black and greenish in color; -Dark bruising underneath the right eye. The skin around the right eye reddish in color and appeared swollen; -Dark bruising covering the right eyebrow, which fades to a reddish color from right to left; -Dark bruising and reddish bruising on the right side of the resident's forehead; -A small dark scab on the top of the resident's forehead with light greenish/yellowish bruising in the center of the forehead. The forehead appeared swollen. During an interview on 3/8/24 at 10:45 A.M., Registered Nurse (RN) X said he/she works as needed at the facility. He/She was never worked as the wound nurse, but some days he/she comes in and does wound care. The last week or two he/she came in and rounded with the wound doctor. He/She did not recall the resident having a wound prior to the fall. The resident was transported to the hospital not too long ago. Prior to that, he/she was usually up in a wheelchair with moderate assistance with using the bathroom. The resident needed reminders to stay seated in the wheelchair, because he/she cannot walk. RN X measured the resident's injuries and entered it into the computer and on skin assessment. He/She made a nurses note on what injuries the resident had. He/She did not recall if the resident wore nonskid socks. There was no bruising noted before he/she left to go to the hospital. During an interview on 3/8/24 at 10:20 A.M., LPN U said he/she worked on 2/2/24. The last time he/she saw the resident was on 2/2/24 when the resident was transported to the hospital after a fall. LPN U was assigned two units, one being the residnet's unit, but was working on a different unit when it was reported to him/her by the wound nurse that the resident was on the floor. It was midday and definitely after lunch. When LPN U arrived, the resident was laying on his/her back, pants were down, and he/she lay in another resident's doorway. The resident was known for getting up a lot. The other aides that were assigned to the unit were inside resident rooms at the time. It was an unwitnessed fall. He/She was not crying at the time, but said, I'm hurting. He/she had complaints of pain. The resident had a gash on his/her head, blood running to the back of the head to the floor. There were no wounds on the back of the head. The resident was not able to say what happened, he/she was alert x 1-2 (persona and/or place). He/She was confused at the time and typically sometimes more alert. The resident lay in the hall with his/her feet out in the hallway and head was in the doorway to the room. The aide that was assigned to the resident said he/she was toileting the resident and walked away. The wound nurse assessed the resident and LPN U went to retrieve gauze and called 911, the family was notified, and the ambulance arrived quickly. Other than the gash on the resident's head, he/she had scrapes to the arm. The resident's CNA said he/she was grabbing something for the resident. The CNA that was assigned to the resident was new. During an interview on 3/8/24 at 12:30 P.M., CNA Z said he/she was not the resident's CNA at the time of the fall, but remembered the resident having bruising to the neck and face after the fall on 2/2/24. The resident went out to the hospital and he/she returned from the hospital like that. Interventions in place included bed lowered to floor and mat next to the bed. The resident will stand and attempt to leave the toilet and ambulate on his/her own. Staff must stay with him/her side by side in the bathroom and cannot leave him/her alone so they will not get up on their own, becuase the residnets on the unit have dementia and would not know to stay. During an interview on 3/8/24 at 12:00 P.M., Nurse Practitioner (NP) W said he/she saw the resident on 2/6/24 to assess for a change in condition. He/She remembered the resident having a fall on 2/2/24. On 2/6/24, there was old bruising. During an interview on 3/8/24 at 1:23 P.M., LPN EE said the resident could express his/her needs. He/She was in a wheelchair, but he/she would get up and get in or out of the bed. The resident would need staff assistance. Staff should stay with him/her in the bathroom. LPN EE did not believe the resident had a fall in the bathroom before. After the resident fell on [DATE], he/she had bruising on his/her neck. LPN EE saw the resident when he/she came back and saw him/her in the bed and said, wow what happened. The bruises looked fresh, purple, not old bruising. Everything LPN EE saw was dark purple, and believed both eyes were black. He/She believed the resident fell but wondered how he/she fell . The resident was not able to get up on his/her own if there was a fall, but he/she would be able to crawl and/or turn him/herself on his/her back. During an interview on 3/8/24 at 2:22 P.M., the Administrator and DON said CNA FF was assigned to the resident and refused to give a statement. CNA FF was sent home pending an investigation and was terminated. The DON saw Resident #33 before he/she went to the hospital. He/She was across the hall on the floor. There was a nurse helping the resident. He/She was on his/her back and halfway in the door and in the hall. The resident tried to get up. The DON did not see the resident after he/she returned from the hospital. She did not see the bruises as a result and did not know the resident had a fractured rib. The Administrator did not know about the fracture rib. The resident has fallen and did have history of falls. No one saw how the resident fell . The resident could not get himself/herself up. If he/she tried to get up, he/she would need assistance. The Administrator contacted therapy and confirmed that the resident would scoot around if he/she fell . The Administrator said most doorways have a threshold, the resident could have hit the door handle. The resident was in his/her room and went from the bathroom to the hall. The administrator said she would expect staff to provide protective oversight, stay with resident while in the bathroom, and not leave unattended. MO00232813 MO00232138 MO00230981

Based on observation, interview and record review, the facility failed to ensure the floors in the main kitchen and walk in freezer were clean and free from trash and food debris and failed to ensure the air fryer was clean. The sample was 23. The census was 113. Review of the facility's nutritional services sanitation policy, dated 3/31/21, showed: -Policy: nutritional services shall ensure a clean and sanitary work environment; to promote and protect food safety; and to maintain compliance with federal, state, and local regulations governing food sanitation and safety; -Procedure: personnel shall be responsible for daily, weekly, and monthly cleaning assignments as determined by the Dietary Manager and/or his/her designee. Cleaning assignments shall include equipment, cabinets, storage areas, walls, food service-related carts, and refrigeration units. Frequency of completion shall be in conjunction with food safety regulation and with consideration of manufacturer guidelines. Cleaning of equipment condensers, lights, vents/fans, ceiling, ice machine, etc. shall be completed by the maintenance department as determined by the Administrator and in accordance to meet minimum standards of federal, state, and local guidelines and ordinances governing food service. Equipment shall be cleaned, sanitized, delimed, etc. in accordance with manufacturer recommendations. Detergents and sanitizers shall be used in the correct dilutions consistent with federal and state guidelines and ordinances governing food service. Exhaust system and hoods shall be clean, operational, and maintained in good repair. Review of the facility's undated daily/weekly cleaning schedule, showed the following: -Floors should be swept and mopped daily; -The freezer interior and deep fryer should be cleaned weekly. 1. Observation on 3/3/24 of the kitchen, showed the following: -At 8:21 A.M., the walk-in freezer had a solidified, white liquid stain on the ground under a storage rack along with food wrapper trash in various areas of the ground; -At 8:23 A.M., the deep fryer had caked sticky grease on three sides; -At 8:24 A.M., the floor in the dry storage room was sticky with clear liquid on the ground. 2. Observation on 3/5/24 of the kitchen, showed the following: -At 7:51 A.M., the floors in the main area of the kitchen were sticky with food debris in various areas; -At 7:51 A.M., the air fryer was caked with sticky grease on three sides; -At 7:52 A.M., the walk in freezer had a white liquid spilled under a storage rack along with various food wrapper trash on the ground; -At 9:07 A.M., the dry storage room had sticky floors and a bag of drink powder spilled on the ground. 3. During an interview on 3/7/24 at 10:27 A.M., Dietary Aide D said the cooks are responsible for cleaning kitchen appliances and aides are responsible for cleaning the floors and food carts. 4. During an interview on 3/7/24 at 10:29 A.M., Cook E said all dietary staff are responsible for cleaning the kitchen. He/She said the cooks are responsible for cleaning kitchen appliances. He/She expected the kitchen to be clean to avoid possible food contamination. 5. During an interview on 3/7/24 at 10:30 A.M., the Dietary Manager said he expected staff to follow the cleaning schedule. He expected the kitchen floors and appliances to be clean and free from spills and trash. 6. During an interview on 3/7/24 at 12:28 P.M., the Administrator said she expected dietary staff to follow the facility's cleaning schedule and policy.

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 for three sampled residents, including one closed record (Residents #110, #51 and #112). The resident sample was 23. The census was 113. 1. Review of the facility's Comprehensive Person-Centered Care Plan Policy, revised 10/23/19, showed: -Policy: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -Procedure: The Comprehensive Person-Centered Care Plan shall be fully developed within 7 days after completion of the Admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Assessment; -The Interdisciplinary Team, along with the Resident and/or Resident Representative, will identify resident problems, needs, strengths, life history, preferences, and goals; -For each problem, need, or strength a resident-centered measurable goal is developed; -Staff approaches are to be developed for each problem/strength/need. Assigned disciplines will be identified to carry out the intervention; -The Comprehensive Person-Centered Care Plan can be reviewed and/or revised at quarterly intervals in conjunction with the completion of MOS quarterly, significant change and annual assessments; -Upon a Change in Condition, the Comprehensive Person Centered Care Plan or Baseline Care Plan will be updated if applicable. 2. Review of Resident #110's quarterly Minimum Data Set MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses include diabetes, depression, and high blood pressure; -Special Treatments-oxygen therapy: -Continuous: Blank for on admission and while a resident; -Intermittent: Blank for on admission and while a resident; -High Concentration: Blank for on admission and while a resident. Review of the resident's electronic physician's order sheet (ePOS), showed an order revised 9/28/23, for oxygen at 2 liters via nasal cannula for SpO2 (percentage of oxygen in the blood) under 90%. Review of the resident's care plan, initiated 10/9/23, showed: -Focus: The resident has oxygen therapy related to respiratory illness; -Goal: The resident will have no signs/symptoms of poor oxygen absorption through the review date; -Intervention: Oxygen settings: Oxygen via (Specify: nasal cannula at 2 liters continuous). Observation of the resident on 3/4/24 at 10:15 A.M., showed the resident in his/her room. The resident sat in his/her wheelchair. The resident did not have oxygen. On 3/5/24 at 11:15 A.M., the resident sat in his/her wheelchair on the first floor by the elevator. The resident did not have oxygen. The resident said that he/she does not wear oxygen. He/She wore oxygen after he/she had a respiratory infection when he/she was admitted to the facility but that was several months ago. During an interview on 3/7/24 at 12:00 P.M., Licensed Practical Nurse (LPN) F said the nurse will complete the baseline care plan on admission then it is updated by someone else. The resident does not wear oxygen. The resident may have been on oxygen when he/she was on a different floor. During an interview on 3/8/24 at 2:24 P.M., the Administrator and Director of Nursing (DON) said the care plan and order should be updated for the resident. 3. Review of Resident #51's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses of heart failure, kidney failure, peripheral vascular disease (PVD, circulation disorder) respiratory failure, bipolar disorder (a mental disorder). Review of the resident's ePOS, showed: -An order dated 2/9/24, to monitor for signs and symptoms of respiratory distress, jugular vein distention, weight changes, edema (swelling) and/or shortness of breath. Notify physician of any noted symptoms; -An order dated 2/9/24, for oxygen at (blank) liters (L) via (specify route, blank) as needed for (specify reason, blank); -An order dated 2/16/24, to check resident portable oxygen tank daily, change as needed every shift; -An order dated 2/18/24, to change and date oxygen tubing weekly and as needed every night shift every Sunday for preventative measures. Review of the resident's care plan, in use during survey, showed: -Focus: The resident has altered respiratory status/difficulty breathing related to pulmonary edema (swelling of the tissues of the lungs); -Goal: The resident will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern; -Interventions: Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Monitor for signs and symptoms of respiratory distress and report to physician as needed: increased respirations; decreased pulse oximetry (percentage of oxygen in the blood); increased heart rate (tachycardia); restlessness; diaphoresis (excessive sweating); headaches; lethargy; confusion; hemoptysis (coughing up blood); cough; pleuritic pain (sharp chest pain); accessory muscle usage; skin color changes to blue/grey; -The care plan did not identify the resident's use of oxygen or reason for the oxygen Observation on 3/5/24 at 12:26 P.M., showed the resident in the activity room. He/She had an oxygen tank on the back of the wheelchair and a nasal cannula in the resident's nose. On 3/6/24 at 11:26 A.M., the resident lay in bed. The oxygen tank positioned on the back of the resident's wheelchair. The oxygen concentrator in the room, next to the bed, and set at 1 L per nasal cannula. The cannula positioned in the resident's nose. At 5:24 P.M., the resident was in the room and lay in bed with his/her eyes closed. The oxygen concentrator in the room next to the bed, set at 1 L per nasal cannula. The cannula positioned in the resident's nose. During an interview on 3/8/24 at 3:02 P.M., the Administrator and DON said they would expect the resident's oxygen use to be care planned. 4. Review of Resident #112's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses of high blood pressure, kidney failure, septicemia (complication from an infection), urinary tract infection, high cholesterol, stroke, non-Alzheimer's dementia, malnutrition, and adult failure to thrive. Review of the resident's ePOS, showed: -An order dated 2/27/24, for nothing by mouth (NPO) diet, NPO texture; -An order dated 2/27/24, check gastric tube (g-tube, tube inserted into the stomach to provide food, fluid, and medicine) placement prior to feeding/medications; -An order dated 2/27/24, flush tube with water every four hours related to g-tube status; -An order dated 3/4/24, enteral feed, every shift relate to g-tube status, Jevity 1.2 (liquid nutrition) 70 milliliters (ml)/hour. May substitute with Jevity 1.5, if not available; -An order dated 3/5/24, to flush tube with water 100 ml/hour, every four hours related to g-tube status. Review of the resident's care plan, in use during survey, showed: -Focus: The resident has unplanned/unexpected weight loss related to poor food intake; -Goal: The resident will consume 50% two of three meals/day; -Interventions: Give the resident supplements as ordered. Alert nurse/ dietitian if not consuming on a routine basis; -If weight decline persists, contact physician and dietician immediately; -The care plan did not identify the resident's g-tube status, continuous tube feeding, and NPO status. Observation on 3/4/24 at 2:43 P.M., 3/6/24 at 11:30 A.M., 2:50 P.M., and 5:27 P.M., and 3/7/24 at 10:24 A.M., showed the resident in bed. The g-tube machine and stand on the left side of the bed set to infuse tube feeding at 70 liters per hour. During an interview on 3/8/24 at 3:02 P.M., the Administrator and DON said they would expect the resident's NPO status, tube feeding and nutrition to be care planned. 5. During an interview on 3/8/24 at 12:15 P.M., the MDS coordinator said she would expect for care plans to be completed within the first month that a resident arrives to the facility. Once being informed by the nurse managers of any medication or care changes, care plans should be updated. 6. During an interview on 3/8/24 at 2:24 P.M., the Administrator and DON said the care plan should be accurate and reflect the needs of the resident. The MDS coordinator is responsible for the care plan, and it should be completed within 21 days after admission. The MDS coordinator is also responsible for updating the care plan and it should be updated any time there is a change. 44950 46888

46104 Based on observation, interview and record review, the facility failed to ensure three residents who required staff assistance to maintain nail care were provided personal care and hygiene (Residents #112, #72 and #7). The facility also failed to maintain one resident's hair, which was matted and long (Resident #112). The sample was 23. The census was 113. Review of the facility's Nail Care policy, 7/21/22, showed: -Policy: The purpose of Nail Care is to clean the nail bed, trim nails, and prevent infection; -Nails may be cleaned during bathing; -Nursing Assistants do not trim nails on diabetic residents. -Nail Care includes daily cleaning and regular trimming; -Observe/Report changes in the skin color around the nail bed, blueness of the nails, signs of poor circulation, cracking of the skin, swelling, bleeding, etc.; -Stop and report to the Charge Nurse ingrown nails, infection, pain, or nails that are thick and difficult to trim. Review of the facility's Activities of Daily Living (ADLs, bathing, toileting, dressing, etc.) Care Bathing policy, 7/21/22, showed nursing staff will assist in bathing residents to promote cleanliness and dignity. The Charge Nurse will be made aware of residents who refuse bathing; 1. Review of Resident #112's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/5/24, showed: -Severe cognitive impairment; -Diagnoses of anemia, hypertension (HTN, high blood pressure), renal failure, septicemia (a life-threatening complication of an infection), urinary tract infection, hyperlipidemia, stroke, non-Alzheimer's dementia, hemiplegia (paralysis of one side of the body), malnutrition and adult failure to thrive; -Dependent with showers, upper and lower body dressing, put on/take off footwear and personal hygiene. Review of the resident's care plan, in use during survey, showed no documentation regarding the resident's ADL care, goals or interventions. Observation on 3/4/24 at 2:43 P.M., 3/6/24 at 11:30 A.M., 2:50 P.M., and 5:27 P.M., and on 3/7/24 at 10:24 A.M., showed the resident in bed. He/She had long fingernails. There was dirt underneath the nail bed. The resident's hair appeared matted, with a long, thick, matted piece of hair sticking up from the right side of his/her head. Review of the resident's ADL list, dated 3/1, 3/4 and 3/5/24, showed the resident was dependent with showers/baths. Review of the resident's ADL task list, dated 3/1 through 3/7/24, showed staff documented personal hygiene was completed. During an interview on 3/8/24 at 9:20 A.M., Certified Nursing Assistant (CNA) L said he/she was new to caring for the resident. He/She would give the resident a shower. CNA L did not know when the resident's hair was washed and combed. Nails should be cleaned during shower/bed bath time. The nurse may do the resident's nails if they are a diabetic. Observation and interview on 3/8/24 at 9:37 A.M., showed the resident refused his/her nails cut from staff. The Director of Nursing (DON) said she expected nursing staff to care plan the resident's refusal of ADL care. 2. Review of Resident #72's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Required substantial assistance with toileting and bathing; -Required moderate assistance with personal hygiene, upper and lower body dressing; -Diagnoses included HTN, chronic obstructed pulmonary disease (COPD, lung disease) and cognitive communication deficit. Review of the resident's care plan, in use during survey, showed no documentation regarding the resident's ADL care, goals or interventions. Observation on 3/4/24 at 12:01 P.M., showed the resident sat up in a wheelchair at a table in the dining room. All of the resident's nails on his/her left hand were long with a dark substance under all nails. All of the nails on the resident's right hand were long. Observation on 3/5/24 at 10:55 A.M., showed the resident lay on his/her back in bed. The resident's nails on his/her right hand were clean and trimmed. The resident's left hand showed long nails with a dark substance underneath them. Observation on 3/6/24 at 9:43 A.M., showed the resident sat up in his/her wheelchair. The resident's left hand showed long nails with a dark substance underneath them. Observation on 3/7/24 at 8:38 A.M., showed the resident lay on his/her back in bed. The resident's left hand showed long nails with a dark substance underneath them. During an interview on 3/7/24 at 12:20 P.M., CNA DD said the resident will allow staff to trim his/her nails if he/she is approached in a nice manner. CNA DD did not recall if the resident had long or dirty nails. CNA DD said he/she tries to do nail care on residents every two weeks and as needed. He/She said nail care is not documented. If the resident was a diabetic, he/she would clean the nails and notify the nurse the nails need trimmed. CNA DD said if the resident's nails were thick, he/she would notify the nurse the nails are thick and need trimmed. CNA DD had not noticed any residents who had dirty, thick, or long nails that need trimmed. During an interview on 3/7/24 at 12:40 P.M., the DON and Regional Nurse Consultant (RNC) looked at the resident's nails on his/her left hand and said all the nails were dirty and overgrown. They expected staff to keep the resident's nails clean and trimmed. 3. Review of Resident #7's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Required maximal assistance with personal hygiene, bathing, toileting and upper body dressing; -Dependent for lower body dressing; -Diagnoses included heart failure, HTN, need for assistance with personal care, and contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of left hand. Review of the resident's care plan, in use during survey, showed: -Focus: ADL self-care performance deficit; -Goal: Will maintain current level of function with ADLs; -Interventions: -Bathing: One assist, twice weekly and as necessary. Check nail length and trim and clean on bath day and as necessary. Report changes to nurse; -Bed mobility: Totally dependent on staff for repositioning and turning; -Personal hygiene and oral care: Dependent on staff. Observation on 3/4/24 at 10:36 A.M., showed the resident sat in a Broda chair (a specialized reclining chair propelled by staff) in the hallway outside his/her room. The resident's nails on his/her right hand were long and had a dark substance underneath them. The resident's left hand was contracted, the thumb nail was long, and the four fingers were folded in towards the palm of the hand with long nails. Observation on 3/5/24 at 10:36 A.M., showed the resident sat in a Broda chair in front of the nursing station. The resident's nails on his/her right hand were trimmed and clean. The resident's left hand was contracted, the thumb nail was still long, and the four fingers were folded in towards the palm of the hand and the nails were still long. Observation on 3/6/24 at 9:47 A.M., showed the resident lay on his/her back in bed. CNA AA uncovered the resident's hands. The resident's left hand was contracted, the thumb nail was still long, and the four fingers were folded in towards the palm of the hand. Observation on 3/7/24 at 8:35 A.M., showed the resident sat in a Broda chair in his/her room. The resident's left hand was contracted, the thumb nail was still long, and the four fingers were folded in towards the palm of the hand. During an interview on 3/7/24 at 8:35 A.M., Certified Medication Technician (CMT) B said the resident was not a diabetic and any of the nursing staff can trim his/her nails. CMT B looked at the resident's left hand and said the nails were long and needed to be cut. During an interview on 3/7/24 at 12:41 P.M., the DON and RNC looked at the resident's nail on his/her left hand and said all nails on his/her left hand are long and thick and skin is growing underneath the nail bed. They said a nurse would need to trim his/her nails due to the skin growing under the nails. They expected staff to keep the resident's nails clean and trimmed. 4. During an interview on 3/7/24 at 6:44 A.M., CNA BB said nail care is completed with showers and can be done if the nails are observed as dirty while providing care. CNA BB said if a resident's nails need to be trimmed, he/she would trim the nails if the resident was not a diabetic. If the resident was a diabetic, then he/she would notify the nurse that the resident needed his/her nails trimmed. If the resident's nails were thick, he/she would notify the nurse that the nails are thick and need trimmed. CNA BB had not noticed any residents who have dirty, thick, or long nails that need trimmed. 5. During an interview on 3/7/24 at 6:56 A.M., CNA CC said if he/she notices a resident has dirty nails or if they were long, he/she would clean or trim them as needed. He/She said if the resident was a diabetic, he/she would clean the nails and notify the nurse that the nails need trimmed. If the resident's nails were thick, he/she would notify the nurse that the nails are thick and need trimmed. CNA CC said he/she has not noticed any residents who have dirty, thick, or long nails that need trimmed. 6. During an interview on 3/7/24 at 12:33 P.M., the DON and RNC said nursing staff is responsible for ensuring nail care is completed on all residents regularly. Staff should monitor resident's nails during daily care and on shower days. They expected staff to notify the nurse if a resident was diabetic or the nails were thick and the nails need trimmed. 7. During an interview on 3/8/24 at 7:32 A.M., the Administrator said she expected staff to be knowledgeable and follow the facility policies and procedures. 8. During an interview on 3/8/24 at 11:14 A.M., the DON said she expected staff to be knowledgeable and follow the facility policies and procedures.

Based on observation, interview and record review, the facility failed to ensure pain management was provided to residents who require such services for one resident (Resident #5), who was placed on hospice and expressed pain. The facility failed to ensure the pain medication ordered by the hospice company was made available timely. This resulted in the resident expressing pain by yelling out with movement and care. In addition, staff completed wound care on the resident without waiting for pain medication to be administered. The census was 128. Review of the facility's Pain Management policy, dated 11/15/22, showed: -The facility will use a systematic approach to pain management, recognition, evaluation, treatment, and monitoring of pain. Individuals experiencing pain may receive pharmacological/non-pharmacological interventions to assist in pain management; -Evaluate/prevent: Recognize when resident is experiencing pain and identify circumstance when pain can be anticipated. Manage/prevent pain, consistent with the comprehensive evaluation and plan of care, current professional standers of practice, and resident goals/preferences; -Observe for nonverbal indicators: Facial expression (e.g., grimacing, frowning, clenching of the jaw). Negative vocalization (e.g., groaning, crying, whimpering, screaming). Skin conditions. Review of Resident #5's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/6/23, showed: -Severe cognitive impairment; -Extensive assistance required for bed mobility, transfers, dressing, toilet use and personal hygiene; -Total dependence for bathing; -Diagnoses included cancer and dementia. Review of the resident's care plan, in use at the time of the investigation, showed: -Focus: The resident has a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to the sacrum (tail bone area) or potential for pressure ulcer development related to history of ulcers; -Goal: The resident's pressure ulcer will show signs of healing and remain free from infection; -Interventions included: Treat pain as per orders prior to treatment/turning, etc. to ensure the resident's comfort. Review of the resident's medical record, showed: -An order dated 8/23/23, for pain evaluation every shift for monitoring pain level; -An order dated 9/6/23, admit to hospice; -An order dated 9/6/23, for morphine sulfate (narcotic pain medication, can also be used to treat shortness of breath) oral solution 20 milligram (mg) per milliliter (ml). Give 0.25 ml by mouth every 4 hours as needed for shortness of breath or pain. Review of the facility's hospice binder, showed the following for the resident: -A nurse visit assessment dated [DATE] at 11:00 A.M.; -Start date for hospice services to begin 9/6/23; -Medication profile, dated 9/6/23 included an order for morphine sulfate concentrate 0.25 ml every 4 hours as needed for shortness of breath or pain. Observation on 9/7/23 at 7:24 A.M., showed the Certified Wound Care Manager entered the resident's room and said she was coming in to check if the resident had pain. She asked the resident if he/she had pain and the resident said yes. Observation showed the resident had facial grimacing. The Certified Wound Care Manager said she was going to let the nurse know the resident had pain. She usually does the resident's wound treatment at about noon and would let the surveyor know when she is ready, she then left the room. Observation on 9/7/23 at 7:37 A.M., showed the Certified Wound Care Manager returned to the room with treatment supplies. She said the resident's nurse is getting his/her pain medication now. The Certified Wound Care Manager lowered the head of the bed and the resident moaned and had facial grimacing. The Certified Wound Care Manager assisted the resident to his/her right side, the resident moaned loudly. The Certified Wound Care Manager gathered supplies and provided care. The resident yelled ouch as the Certified Wound Care Manager rolled the resident over to his/her right side. After providing incontinence care, the Certified Wound Care Manager cleansed the resident's wound with wound cleanser spray. The resident said ouch and jerked slightly. The Certified Wound Care Manager completed the treatment and the new dressing was applied. She then rolled the resident onto his/her back. The resident yelled out and the Certified Wound Care Manager said I know this part is hard. She continued to roll the resident towards herself, on his/her left side. The resident screamed out. The Certified Wound Care Manager said we are stopping, but continued to finish providing care, only stopping for approximately 2 seconds as she spoke to the resident. The Certified Wound Care Manager then moved the resident's legs and the resident yelled out. She rolled the resident to his/her right side in an attempt to apply the clean brief, and the resident yelled out. The Certified Wound Care Manager allowed the resident to rest on his/her back, then moved his/her pillow under his/her head, causing the resident's head and shoulders to slide over in the bed. The resident yelled obscenities. The Certified Wound Care Manager said I know it hurts. The Certified Wound Care Manager covered the resident with his/her blanket and said let me check on that pain medicine. She removed her gloves, bagged up the trash, gathered the supplies, and left room. Observation on 9/7/23 at 8:01 A.M., showed Therapy Staff A entered the resident's room to see the roommate. The resident told Therapy Staff A that he/she hurt and pointed to his/her buttocks. Therapy Staff A told the resident he/she would talk to the nursing staff. The resident said he/she did not sleep too good. Therapy Staff A raised the resident's head of bed. The resident yelled out loudly. Certified Nursing Assistant (CNA) B entered the room. Therapy Staff A said the resident slid down in bed and needed to scooch up. Staff lowered the head of the bed. The resident yelled out. Staff were then able to pull the resident up in bed. Staff then raised the resident's head of bed, and he/she yelled out. Observation on 9/7/23 at 8:33 A.M., showed CNA C entered the resident's room and said he/she wanted to check on the resident. He/She was day shift and was doing rounds. CNA C lowered the resident's head of bed and the resident yelled out. CNA C said I know, I know, unsecured his/her brief, rolled him/her to the right, and observed the resident was clean. CNA C re-secured the brief. CNA C straightened the resident's bed pad. The resident said ow. CNA C then rolled the resident to his/her back and positioned his/her legs. The resident yelled out. CNA C assisted the resident to his/her left side. The resident yelled out I can't do it. CNA C said I know but I have to get you off your side. CNA C covered the resident with his/her blanket. During an interview on 9/7/23 at 9:35 A.M., the resident's visitor said he/she needs to find the nurse for pain meds. He/She told the nurse the resident needed pain medicine, but he/she still has not received it. During an interview on 9/7/23 at 9:45 A.M., the resident's visitor entered the resident's room and told the resident's spouse the nurse said they are coming with pain medication now, they had to wait for the pharmacy. During observation and interview on 9/7/23 at 9:47 A.M., Licensed Practical Nurse (LPN) D said he/she just got the pain medication order approved from pharmacy. The resident gets morphine 0.25 ml every 4 hours. The order was given last night. Staff have been waiting for pharmacy to approve the order. LPN D administered morphine 0.25 ml under the resident's tongue. LPN D said the time frame to get medications approved and available depends on the situation. If the order is through hospice, the order goes from hospice to the physician. Then, the facility will have to wait for the pharmacy. Staff cannot pull it from stock without pharmacy approval, the machine will not allow it. During a phone interview on 9/7/23 at 10:00 A.M., Pharmacy Representative E said medication orders are sent to the pharmacy from the facility. The morphine order came across this morning, 9/7/23 at 7:41 A.M. Typical turnaround time for pharmacy varies, but Morphine is in the emergency kit and can be pulled by facility staff without waiting for a delivery. During a phone interview on 9/7/23 at 10:17 A.M., the Hospice Administrator said it is the facility's responsibility to ensure the ordered medications are available from pharmacy. If a resident has pain and has orders for pain medication, he/she would expect the resident to get the pain medication as ordered. Comfort is the goal of hospice. During an interview on 9/7/233 at 10:27 A.M., the resident's spouse said he/she wants the resident to be comfortable. During an interview on 9/7/23 at 3:10 P.M., with the Director of Nursing and Administrator, they said when a resident is admitted on hospice and hospice orders pain medications, the process is that the doctor sends the prescription to the pharmacy, but sometimes there is a transmission error. Once the order is received, staff can pull the medication from stock. Ordered medication should be available as soon as possible. The time may vary, but if the hospice company was in at 11:00 A.M. the day before, the medication should have been available by this morning. The wound nurse should have waited to complete the treatment until after the resident had received pain medication. It should not have taken that long to get the resident his/her pain medication. It seems like this was a transmission error with the pharmacy. MO00222814

Based on interview and record review, the facility failed to provide Cardiopulmonary Resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest (cessation of respirations and/or pulse)) for one resident whose physician ordered him/her as a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) and in accordance with the facility's policy (Resident #3). The resident expired. The sample size was 9. The census was 98. The Administrator was notified on [DATE] at 3:00 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility's CPR policy, last reviewed [DATE], showed: -Policy: The facility will provide Basic Life Support, prior to the arrival of Emergency Medical Services (EMS) including initiation of CPR to a resident who experiences cardiac arrest in accordance with the Resident's Advance Directives, or a Signed Do Not Resuscitate (DNR) Order. -Charge nurse will initiate CPR unless; -Valid DNR is in place -Clinical evaluation reveals obvious signs of clinical death: -Rigor Mortis: stiffening of the joints and muscles of a body a few hours after death, usually lasting from one to four days; -Dependent Lividity: a reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the blood vessels evident in the lower lying parts of the body in the position of death. Also called livor mortis; -Decapitation: the total separation of the head from the body; -Transection or decomposition: the state or process of rotting; -Initiating CPR could cause serious injury/immediate danger to the rescuer; -Licensed employees will maintain a current CPR certification through a hands-on practice and in-person Skills Assessment Training for Healthcare Providers; -Responsibility: Licensed Nurses, Nursing Administrators, and Director of Nursing (DON); -Procedure: Full code/CPR: -Upon resident assessment with absent vital signs; -Charge nurse will initiate a Code Blue (an announcement that an adult is having a medical emergency); -Resident who is a Full Code will have CPR initiated immediately; -CPR will continue until EMS arrives to take over CPR; -Another employee will dispatch EMS by placing [DATE] call; -Employee will direct EMS to the resident location in need of life saving efforts; -An employee will make a copy of Face Sheet, History/Physical, and Medication Orders; -Physician will be notified of resident condition, lack of vital signs and CPR initiation; -Family will be informed in resident change in condition and initiation of CPR; -Charge Nurse will document a timeline of events in the inter-disciplinary team (IDT) Notes in Point Click Care (PCC) in the resident medical record. Review of Resident #3's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Severe cognitive impairment; -Required extensive assistance with bed mobility, transfers, dressing, eating and personal hygiene; -Diagnoses included diabetes, Alzheimer's disease and depression. Review of the resident's electronic medical record (EMR), showed: -An order, last revised [DATE], for the resident to be full code; -admitted to hospice on [DATE]. Review of the resident's progress notes, dated [DATE] at 11:02 P.M., showed Registered Nurse (RN) B called to bedside. Resident unresponsive. Cold to touch. No pulse upon feeling or auscultation (listening to the sounds of the body during a physical examination by using a stethoscope) or apical pulse (a pulse point on the chest located at the bottom of the heart). The resident's family called and informed of the resident's passing. Hospice made aware. Physician made aware. Review of the facility's investigation, dated [DATE], showed: -On [DATE] at approximately 11:00 P.M., the CNA went to get the charge nurse, Nurse B. He/She stated to the charge nurse the resident was unresponsive. Upon arrival to the room, the resident was cold to the touch. Nurse B attempted sternal rub (painful stimulation with the knuckles of a closed fist to the center chest of a person who is not alert and does not respond to verbal stimuli), then preceded to listen with his/her stethoscope, there were no signs of life, absent respirations/pulse. Nurse B notified physician, resident representative, DON, and funeral home. During an interview on [DATE] at 1:00 P.M., Certified Nurse Aide (CNA) C said he/she worked the day and evening shift on [DATE]. He/She was assigned to the resident. The CNA said the resident did not act unusual, but was tired and did not want his/her dinner. The resident would do this sometimes so he/she did not think anything was wrong. CNA C said he/she planned to go back and offer the resident dinner again after all the residents left the dining room area. After dinner, he/she went and checked on the resident and the resident was still asleep. At approximately 8:30 P.M., CNA C said he/she went back to the resident's room to perform perineal care. The resident was awake and allowed the care to be performed. CNA C said he/she checked on the resident last, at approximately 10:40 P.M. When he/she went in the room, the resident did not respond. The CNA tried to shake the resident and called the resident by name. The resident still did not respond. The CNA said the resident did not feel cold or warm. The resident's skin felt in-between the two temperatures. The CNA said he/she immediately went and told Nurse B about the resident. CNA C said he/she did not see the nurse perform CPR on the resident. Nurse B just repeatedly asked CNA C what he/she should do next. CNA C said the nurse just sat at the nurses' station stating he/she did not know what to do. During an interview on [DATE] at 3:04 P.M., Nurse B said he/she worked with the resident on the evening shift of [DATE]. Nurse B said his/her shift started at 3:00 P.M. and he/she last saw the resident at approximately 7:00 P.M. At approximately 11:02 P.M., Nurse B said CNA C came to him/her and said, Nurse, the resident is unresponsive. Nurse B said he/she entered the resident's room and did a sternal rub. The resident felt really cold. Nurse B shook the resident and then went and got his/her stethoscope and listened for a heartbeat, but the resident did not have one. The nurse said he/she was not aware of the code status and is new to geriatrics. He/She assumed every resident was a DNR. Nurse B said if he/she knew the resident was a full code, then he/she would have done CPR. The nurse said at approximately 11:15 P.M., he/she felt the resident was deceased and went to talk to Nurse D on the first floor. Nurse D looked up the resident, and informed Nurse B the resident was a full code. Nurse B said I should have done CPR. Nurse B said he/she just assumed the resident was a DNR. Nurse B was not aware of the CPR book. During an interview on [DATE] at 11:00 A.M., Nurse E, the night shift charge nurse, said he/she came in to work on [DATE] at 11:00 P.M. for his/her scheduled shift. Nurse E clocked in and on the way up to the floor, he/she saw CNA C on the first floor. Nurse E said CNA C told him/her the resident had passed away and that he/she let the nurse know. Nurse E said when he/she arrived on the floor he/she instructed Nurse B what to do and Nurse B got frustrated and then went downstairs. At approximately 11:32 P.M., Nurse B went down to Nurse D for help. Nurse E said he/she was just coming on the shift and did not realize the resident was a full code. Nurse E said he/she thought Nurse B had gotten a second nurse to confirm. Nurse E said you have to get a second nurse to check the pulse for a full minute. Nurse E said when a resident is found unresponsive, they should check the code status and call Code Blue over the intercom. Everyone should respond. Someone should grab the crash cart, and someone should call [DATE]. If they are found to be deceased , the physician at the hospital will confirm. Then they call the physician and put a note to release the body. When a Code Blue happens, all nurses are expected to come. CNAs stay on their floor. One of the CNAs on the floor where the code is called will be directed to call [DATE]. The fire department and emergency medical services (EMS) will come. Nurse E thought all of that had been done. By the time his/her scheduled shift started, 30 minutes had passed. Nurse E said they are told all of that in orientation. During an interview on [DATE] at 4:20 P.M., Nurse D said he/she worked the evening of [DATE]. Nurse D said Nurse B came downstairs at approximately 11:00 P.M. Nurse D said it was approximately 12:20 A.M. when he/she filled out the paperwork for Nurse B and that was when he/she saw the resident was a full code. During an interview on [DATE] at 3:30 P.M., the Administrator and the DON said Nurse K was the manager on duty that evening and they are not sure why staff did not call about the incident that evening. The DON said she was not contacted about any events on the [DATE] evening shift. The administrator said Nurse B got more training than most nurses due to his/her limited background in skilled care. The Administrator is not sure if there was something Nurse B did not understand in training. She expected her staff to know where to look for the code status in the EMR and the CPR book and this is part of new employee training. The Administrator said if a resident is a full code, staff should call a Code Blue, which is part of the orientation training and in their policy. The CNA can be sent for what is needed. Nurses should come to help with the code. If there are no signs of life, she would still want a code to be called so another nurse could verify. During an interview on [DATE] at 3:25 P.M., the Medical Director said he was familiar with the incident. The facility called him directly and told him the resident was found to be deceased . The facility then called back and said the resident was a full code and CPR was not initiated. The facility said they were looking into the incident. The Medical Director said the facility needed to address that. The Medical Director said the nurse should be educated and in-serviced. There are very few instances where CPR should not be initiated such as found with obvious rigor mortis or clearly decomposing. He expected the nurse to perform CPR in this instance. The nurse should not assume the resident is a DNR just because they are on hospice. The resident has a right to choose code status. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the 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 the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with the State law (section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violation(s). MO00213841

Based on observation, interview, and record review, the facility failed to ensure there was a safe and effective medication system to ensure a newly admitted resident did not experience a significant medication error. The resident was admitted to the facility on [DATE] from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As of the morning of [DATE], the resident had not received the ordered medications. This resulted in the resident experiencing an elevated blood pressure of ,d+[DATE] (Resident #369). In addition, the facility failed to ensure residents who admitted into the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #368). The facility also failed to provide an ordered gastrointestinal medication (Resident #365). The sample was 23. The census was 110. The administrator was notified on [DATE] at 4:22 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Purpose: To provide guidance to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Policy: -All orders shall be provided by licensed practitioners (physician, nurse practitioner (NP), or physician assistant (PA)) authorized to prescribe such orders; -Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; -Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The required components of a complete order: date and time of receipt of the order, name of the practitioner providing the order, name and strength of the product, quantity or specific duration, dosage and frequency of administration, route of administration, indication and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Orders that are missing required components, are illegible or unclear will be clarified prior to implementation; -The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Discontinued orders will be marked as discontinued with the date, and all new orders will be written in the appropriate area on the POS with the date the order was received; -Clear and complete orders will be transcribed to the appropriate administration record Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Medications will be ordered from the pharmacy to ensure prompt delivery. Medications available from the emergency drug supply shall be utilized for the first dose until a supply arrives from the pharmacy; -Telephone Orders: -Verbal telephone orders may only be received by a licensed nurse; -The order should be clear, concise and contain the required components; -The orders should be read back and verified with the prescriber; -The licensed nurse is required to record the order accurately in the medical record (POS) and on the appropriate administration record (MAR/TAR); -The telephone orders are required to be countersigned by the ordering physician on the next visit, or within 30 days of receipt; -Verbal orders: -Verbal orders may only be received by a licensed nurse; -The order should be clear, concise and contain the required components; -Orders should be read back and verified with the prescriber; -The licensed nurse receiving the order is required to record the verbal; -The licensed nurse is required to record the order accurately in the medical record (POS) and on the appropriate administration record (MAR/TAR); -The telephone orders are required to be countersigned by the ordered physician on the next visit, or within 30 days of receipt; -Written/Faxed orders: -Written/faxed orders require a physician signature in order to constitute a valid order; -The order should be clear, concise and contain the required components; -Orders that are missing required components, illegible or are unclear will be clarified prior to implementation; -The licensed nurse is required to record the order in point click care (PCC), the POS and on the appropriate MAR/TAR; -The written/fax order will be maintained in the medical record until the order is signed by the provider. Review of the facility's medication emergency kit (e-kit) supply list showed: -[MEDICATION(S)] (used to treat pain) 50 milligrams (mg); -[MEDICATION(S)] (used to treat infection) injection 1 gram (gm) and [MEDICATION(S)] injection 500 mg; -[MEDICATION(S)] (used to treat infection) injection 2 gm. 1. Review of Resident #369's hospital history and physical, dated [DATE], showed: -admitted to the emergency department (ED) with [CONDITION(S)] (fast heart rate) of 116 (normal ,d+[DATE]), and hypertensive with a blood pressure of ,d+[DATE] (normal ,d+[DATE]). A urine sample indicated a [CONDITION(S)]; -Assessment and Plan: -[CONDITION(S)]: Asymptomatic pyuria (a high white blood cell count in the urine sample without [CONDITION(S)] symptoms), the patient was severely nauseous with [CONDITION(S)] (dizziness), cannot tolerate oral medications. Concerned for acute mental status change; -Plan: Administer [MEDICATION(S)] (antibiotic) 2 gm every 24 hours -Hypertensive urgency, the patient with elevated blood pressure ,d+[DATE] at the ED and later lowered to ,d+[DATE]. Due to the nausea and dry heaving, unable to tolerate oral [MEDICATION(S)] (used to lower blood pressure); -Plan: Give [MEDICATION(S)] (used to treat high blood pressure) 5 mg once daily in the morning. Review of the resident's facility admission medical record showed: -admitted on [DATE] in the late afternoon; -Admission vital signs: blood pressure ,d+[DATE]. Review of the progress notes, dated [DATE] at 4:38 A.M., showed the resident admitted to the facility on [DATE] at 6:30 P.M. admitted diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was alert and able to make needs to staff. Orders verified with the resident's physician. Skin intact and ambulates with a steady gait. Will continue to monitor; -No further progress notes documented. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders were dated and ordered to start on [DATE]: -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (used to treat infection) 200 mg, give one tablet twice a day for [CONDITION(S)]. Give until [DATE] at 11:59 P.M.; -[MEDICATION(S)] (used to treat hypertension) 6.25 mg, give one tablet twice a day; -[MEDICATION(S)] Hci (used to treat hypertension) 25 mg, give one tablet three times a day; -[MEDICATION(S)] (used to treat hypertension) 20 mg, give one tablet twice a day. Review of the [DATE] MAR, showed the following orders as pending confirmation, and ordered to start on [DATE]: -[MEDICATION(S)] [MEDICATION(S)] 10 mg, give one tablet once a day for hypertension scheduled at 9:00 A.M.; -[MEDICATION(S)] 200 mg, give one tablet twice a day for [CONDITION(S)], scheduled at 8:00 A.M., and 8:00 P.M. Ordered to stop on [DATE] at 11:59 P.M.; -[MEDICATION(S)] 6.25 mg give one tablet twice a day for high blood pressure, scheduled at 8:00 A.M., and 5:00 P.M.; -[MEDICATION(S)] 20 mg give one tablet twice a day for high blood pressure, scheduled at 8:00 A.M., and 5:00 P.M.; -[MEDICATION(S)] 25 mg give one tablet three times a day for high blood pressure, scheduled at 7:00 A.M., 12:00 P.M. and 6:00 P.M.; -No noted medication administration documented from admission on [DATE] through [DATE]. During observation and interview on [DATE] at 9:20 A.M., Certified Medication Technician (CMT) O, stood at the 200 unit medication cart. He/she said all of the residents on the transitional unit were new admissions. CMT O opened the medication cart and showed the surveyor the resident did not have any medications available in the medication cart. CMT O showed the surveyor the resident's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . CMT O said the system did not trigger the resident had any medications to administer by the resident's name in a green color. The green color indicated the resident had ordered medications needed to be administered. The nurse was responsible to acknowledge and activate the ordered medications. When the nurse activates the medication order, the system will trigger the medication order to the nurse or the CMT medication cart. If a ordered medication was not available, the CMT should contact the nurse and the nurse can access the e-kit or the electronic medication distribution system. During an interview on [DATE] at 10:01 A.M., Licensed Practical Nurse (LPN) P said when a resident was admitted , the charge nurse on duty was responsible to verify orders with the physician. The nurse should enter the orders into PCC and ensure the orders are activated. When the orders are activated, the order then was activated in the CMT or nurse order page and the resident's name will show as green color when the administration time was active. LPN P viewed the resident's ePOS and acknowledged the resident's orders, showed in red lettering Pending Confirmation (Allergy Required). LPN O said given the wording on the order, the resident did not have his/her admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . At request of the surveyor, LPN P obtained the resident's blood pressure and reported to the surveyor a reading of ,d+[DATE]. During an interview on [DATE] at 11:30 A.M., the Director of Nurses (DON) and the Corporate Nurse were notified by the surveyors of the resident's missing cardiac and antibiotic medications since admission. Upon review of the resident's medical record in the presence of the surveyors, the DON said the medications were documented as pending in the electronic medical record. The orders reflected there was a piece missing that needed to be completed to be able to activate the orders. The DON and Corporate Nurse said the resident was not receiving the ordered medications and had missed the following medication dosages: -[MEDICATION(S)] give one tablet 10 mg, scheduled at 9:00 A.M., daily: Total missed was four doses including the morning dose of [DATE]; -[MEDICATION(S)] 200 mg one tablet twice daily, scheduled at 8:00 A.M. and 8:00 P.M., give until [DATE] for [CONDITION(S)]. Total missed was eight doses including the morning dose of [DATE]; -[MEDICATION(S)] 6.25 mg one tablet twice daily, scheduled at 8:00 A.M. and 5:00 P.M. Total missed was eight doses including the morning dose on [DATE]; -[MEDICATION(S)] 20 mg give one tablet once daily, scheduled at 8:00 A.M. and 8:00 P.M. Total missed was eight doses including the morning dose on [DATE]; -[MEDICATION(S)] 25 mg give one tablet three times a day, scheduled for 7:00 A.M., 12:00 P.M., and 6:00 P.M. Total missed was ten doses including the morning dose of [DATE]; When a resident was admitted , the orders are entered and activated by the charge nurse. The facility management team conducts a daily clinical meeting Monday through Friday. One of the tasks during the clinical meeting was to pull the order listing report, and this report showed the orders and the management team should do a match back based on the hospital discharge orders. This was a medication reconciliation. A clinical review of the chart was completed on the new admissions. A clinical review ensured admission assessments were completed. The DON and Corporate Nurse said the resident was admitted on [DATE] in the later afternoon and said the resident had not had his/her physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said an agency nurse was the charge nurse on duty and entered the orders into the system. The agency nurse would have activated the orders through to the pharmacy by activating the orders in the electronic record. The management team should have reviewed the resident's admission on Monday [DATE]. The DON did not know what occurred, or why the resident's orders were not activated. He did not know why the chart review was not completed. Review of the resident's medical record showed no documented blood pressure readings from [DATE] through [DATE]. Further review showed no documentation of the physician notified of the medications not given as ordered. Review of the resident's blood pressure on [DATE] at 11:31 A.M., showed a reading of ,d+[DATE]. During an interview on [DATE] at 11:35 A.M., the DON said the resident's current blood pressure was considered a high blood pressure reading. The physician should be notified if medications were not administered or not administered as ordered. All medications are dispensed in house. The facility had an e-kit. If medications are not available, staff should notify the physician. The resident's ordered medications were standard and he/she should have received them. The medications were all available through the [NAME] Dispensing Unit (ADU), which can dispense medications for 24 hours. All newly admitted residents, should receive vitals and assessments every shift for three days. The missed cardiac and antibiotic medications could put the resident at significant risk for a hypertensive emergency or a worsening [CONDITION(S)]. He added that based on review of the progress notes, the staff had not notified the physician the medications were not administered until the surveyor notified the DON. Review of the vital signs, dated [DATE], showed at 12:00 P.M., his/her blood pressure was ,d+[DATE]. Further review of the [DATE] MAR, showed the following medications administered on [DATE] after 12:10 P.M.,: -[MEDICATION(S)] 200 mg tablet start on [DATE] and discontinued [DATE]; -[MEDICATION(S)] (antibiotic used to treat infection) 250 mg tablet give one tablet twice a day for 7 days. Start [DATE]; -[MEDICATION(S)] 6.25 mg one tablet; -[MEDICATION(S)] 20 mg one tablet; -[MEDICATION(S)] 25 mg one tablet. During an interview on [DATE] at 12:31 P.M., the DON said he notified the resident's physician of the medication errors. The physician gave new orders. The physician wanted the antibiotic to start immediately and continue for 7 days. The facility ADU did not contain the ordered [MEDICATION(S)] and the physician ordered a new antibiotic, [MEDICATION(S)] 250 mg twice a day for 7 days. In addition, the physician ordered laboratory tests, and wanted the ordered hypertensive medications to be administered immediately. The DON accessed and removed the ordered medications from the ADU and administered the medications to the resident. He was also taking the resident's blood pressure every 30 minutes for 4 hours. Review of the resident's vital signs, dated [DATE], showed the following blood pressure readings: -At 12:30 P.M.,: ,d+[DATE]; -At 1:00 P.M.,: ,d+[DATE]; -At 1:30 P.M.,: ,d+[DATE]; -At 1:45 P.M.,: ,d+[DATE]; -At 2:00 P.M.,: ,d+[DATE]; During an interview on [DATE] at 2:17 P.M., the resident's physician said the resident was admitted to the facility on [DATE], following a hospitalization for excessive hypertension and a [CONDITION(S)]. On [DATE] in the late afternoon, she received a phone call from a nurse to verify the admission medication orders. She approved all of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no vital signs for her to review, but the charge nurse said the resident had no issues or concerns. The physician reviewed the ePOS and noted the Pending confirmation (Allergy required) in red lettering. The physician reviewed the discharge hospital records and informed the charge nurse, the resident did not have any medication allergies, but had a side effect reaction to some of the medications. She was not aware the resident had not been administered any of the medications since admission at the time of her visit on [DATE]. Outside providers are not able to adjust the orders in the ePOS, only the facility staff can activate or discontinue the order. The physician was very mad the resident had not received these medications, he/she could have had a stroke given his/her recent hypertensive history. Missing the antibiotic could lead to significant bladder or kidney infection. The DON contacted her and she was notified of the missed medication dosages from [DATE] to [DATE]. She ordered laboratory testing and a different antibiotic. The facility had an e-kit and an ADU for medication disbursement. 2. Review of Resident #313's medical record, showed: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission progress note, dated [DATE] at 10:45 P.M., showed the resident admitted to the facility. The resident's skin was intact with the exception of a double lumen (two access ports) peripherally inserted central catheter (PICC, used for long-term intravenous (IV) antibiotics, nutrition or medications, and for blood draws) noted to the right upper arm. The PICC dressing was dry and intact with no signs of infection. All of the ordered medications verified with the physician. Review of the ePOS showed: -An order, dated [DATE] for [MEDICATION(S)] (antibiotic) solution reconstituted. Give 500 mg every 24 hours for infection for 4 days. Review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated [DATE], for [MEDICATION(S)] solution reconstituted. Give 500 mg every 24 hours for infection for 4 days. No administration time was documented; -On [DATE], [DATE], [DATE] and [DATE], no documentation the ordered medication was administered. All days noted as blank. Review of the progress notes, dated [DATE] at 1:53 A.M., showed [MEDICATION(S)] solution reconstituted 500 mg IV every 24 hours for infection for 4 days. Orders sent to pharmacy, awaiting for delivery from pharmacy. No contact to notify the physician documented. Review of the NP visit note, dated [DATE] at 12:21 P.M., showed: -Chief complaint: the resident admitted to the facility following a hospitalization for abdominal and right shoulder pain. In the hospital, he/she was noted to have a right-sided deltoid (shoulder) abscess along with periprostatic fluid (an area of fluid around an inflamed joint). Further review of the progress notes, showed no physician, pharmacy or NP contact regarding the missed antibiotic administration on [DATE] and [DATE]. 3. Review of Resident #42's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Cognitively intact; -Required no set up/physical assist for dressing, eating, bed mobility, and personal hygiene; -Required one staff person assistance for transfers and toileting; -Lower extremity impairment, one side; -Walker/wheelchair for mobility; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's ePOS showed: -An order, dated [DATE], for [MEDICATION(S)] (an antibiotic used to treat serious infections for which other medicines may not work) HCl Solution 1000 mg/200 milliliters (ml). Use 1 gram (gm)intravenously one time a day every Monday, Wednesday, and Friday for infection for 21 days to be given at [CONDITION(S)]. Please send antibiotic with resident to [CONDITION(S)]. Review of the resident's care plan, revised on [DATE], showed: -Focus: Venous ulcer (leg ulcers caused by problems with blood flow (circulation) in leg veins), right leg. Review of the resident's eMAR, dated ,d+[DATE] through ,d+[DATE], showed no documentation regarding the order on [DATE] for [MEDICATION(S)] HCl Solution 1000 mg/200 ml. Use 1 gm intravenously one time a day every Monday, Wednesday and Friday for infection for 21 days given at [CONDITION(S)]. Send the ordered antibiotic with resident to [CONDITION(S)]. Observation and interview on [DATE] at 11:58 A.M., showed LPN BB opened the refrigerator located in the medication storage room and confirmed the resident had four doses of [MEDICATION(S)] remaining. She said he/she sends the resident's [MEDICATION(S)] with the resident to [CONDITION(S)] appointments and places the [MEDICATION(S)] inside his/her [CONDITION(S)] bag. The [CONDITION(S)] center administers the ordered [MEDICATION(S)] medication. When the resident returned from the [CONDITION(S)] center, LPN BB placed the resident's communication sheet inside a bin on the wall behind the nurse's station. Review of the resident's progress notes, showed on [DATE] at 3:23 P.M., the nurse documented the resident did not go to [CONDITION(S)], he/she missed his/her ride. During an interview on [DATE] at 11:09 A.M., the pharmacist said four [MEDICATION(S)] doses were sent to the facility on [DATE], the resident should have had a dose on Friday [DATE], Monday [DATE], Wednesday [DATE], Friday [DATE] and Monday [DATE]. If the resident has four doses in the refrigerator, the resident missed four doses. During an interview on [DATE] at 10:10 A.M., the DON said he was not aware the resident missed his/her appointment on Monday [DATE] and he expected the physician to be notified regarding missed medications. During an interview on [DATE] at 10:36 A.M., the administrator said she was unable to locate any of the [CONDITION(S)] communication sheets. The nurse was responsible to ensure ordered medication was sent with the resident to any appointments. If the pharmacy sent four [MEDICATION(S)] doses and four remained in the facility, it would show the resident was not given the ordered medication. 4. Review of Resident #368's medical record, showed: -An admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's ePOS showed: -An order dated [DATE], for [MEDICATION(S)] HCl 2 gm/100 ml, via intravenous administration with end-date of [DATE]. Review of the resident's progress notes, dated [DATE], showed the resident remained on [MEDICATION(S)] 2 gm for the infection of the left lower extremity stump. Review of the resident's MAR, dated [DATE] through [DATE], showed: -[MEDICATION(S)] to be administered intravenously every 8 hours for 42 days; -No documentation of administration on the following dates and times: -On [DATE] at 6:00 A.M. and 2:00 P.M.; -On [DATE] at 2:00 P.M. and 10:00 P.M.; -On [DATE] at 2:00 P.M. and 10:00 P.M.; -On [DATE] at 6:00 A.M.; -On [DATE] at 10:00 P.M.; -On [DATE] at 2:00 P.M. and 10:00 P.M.; -On [DATE] at 6:00 A.M., 2:00 P.M. and 10:00 P.M.; -On [DATE] at 10:00 P.M.; -On [DATE] at 10:00 P.M.; -On [DATE] at 6:00 A.M.; -On [DATE] at 10:00 P.M.; -On [DATE] at 2:00 P.M.; -On [DATE] at 6:00 A.M., 2:00 P.M. and 10:00 P.M.; -On [DATE] at 2:00 P.M.; -On [DATE] at 2:00 P.M. and 10:00 P.M.; -On [DATE] at 6:00 A.M.; -On [DATE] at 10:00 P.M.; -On [DATE] at 6:00 A.M.; -On [DATE] at 2:00 P.M.; -On [DATE] at 6:00 A.M., 2:00 P.M. and 10:00 P.M.; -On [DATE] at 6:00 A.M., 2:00 P.M. and 10:00 P.M. During an interview on [DATE] at 3:19 P.M., the resident said there were occasions he/she did not receive his/her medications. The resident did not specify which medications. He/she said he/she asked the nurses, but felt they did not care about making sure the medications were administered as ordered. During an interview and observation on [DATE] at 3:19 P.M., LPN X said the resident had an order of the antibiotic to be administered every 8 hours for 42 days. Observed multiple doses of [MEDICATION(S)] HCl 2 gm/100 ml were in the refrigerator, in a locked cabinet in Lafayette hall. The medicines were labeled with resident #368's information. LPN X said the pharmacy delivers several doses at a time. Four bags, a total of 24 doses, were stored in the refrigerator, including 10 expired doses: -Bag #1 contained five doses, with an expiration date of [DATE]; -Bag #2 contained five doses, with an expiration date of [DATE]; -Bag #3 contained six doses, with an expiration date of [DATE]; -Bag #4 contained eight doses, with an expiration date of [DATE]. During an interview on [DATE] at 8:51 A.M., the resident said he/she had not received his/her morning dose of the antibiotic. At 9:00 A.M., LPN P said he/she was not able to administer the medicine, because the midnight shift agency nurse accidentally took home the key to the cabinet where the medication refrigerator was placed. LPN X said the supervisor or management had been made aware and the agency nurse had been contacted. He/she said the resident would receive the medication as soon as he/she had access to the refrigerator. During an interview on [DATE] at 8:47 A.M., the Corporate Nurse said if the medications were not documented in the MAR, it indicates they were not administered. He/she expected the nurses to administer the medications as ordered by the physician. Regional Nurse Consultant U said he/she was aware the agency nurse accidentally took the cabinet key home, but was not made aware of the missed doses. He/she said the facility can provide other options so the resident received the medications as ordered, such as utilizing stock medications and/or notifying the pharmacy. During an interview on [DATE] at 3:00 P.M., Pharmacy Staff GG said the resident's antibiotics are delivered on Mondays and Thursdays. They deliver enough doses to be administered until the next delivery schedule. Twelve doses were delivered on Thursday evening, [DATE], which will be good for four days. The nurses receive the medications and sign upon delivery, and are responsible for storing the medications. During an interview on [DATE] at 9:00 A.M., Primary Care Physician (PCP) HH said the resident was admitted to the facility with vascular graft infection and was prescribed IV antibiotics for six weeks. He/she had seen the resident once since admission. Nurse Practitioner (NP) II visits the residents in the facility three times a week. PCP HH was not aware of the multiple missed doses of the antibiotic. He/she expected the staff to follow the medication orders as prescribed. PCP HH added that incomplete administration of antibiotics could result to worsening of the infection. He/she had not received concerns from NP II regarding the resident's wounds or worsening wound infection. During an interview on [DATE] at 11:24 A.M., NP II said he/she was not aware of the multiple missed doses of the antibiotic. He/she agreed with the physician's statement that it could result in a worsening infection if antibiotics were not administered as ordered. 5. Review of Resident #365's admission MDS, dated [DATE], showed: -Cognitively intact; -Required limited assistance with bed mobility, transfers, dressing, toileting and hygiene; -Occasionally incontinent of bladder; -Frequently incontinent of bowel. Review of the resident's POS, dated [DATE] through [DATE], showed: -An order, dated [DATE] for Lactobacillus (used to protect intestinal flora and prevent serious infection), one capsule by mouth, one time a day for GI support; -The order for Lactobacillus showed pending confirmation as late as [DATE]; -On [DATE], the order showed confirmed by the DON. Review of the resident's MAR, dated [DATE] through [DATE], showed: -An order, dated [DATE], for Lactobacillus, one capsule by mouth, one time a day for gastrointestinal support; -No documentation of the administration of Lactobacillus on [DATE] through [DATE], [DATE] and [DATE]. NOTE: At the time of the 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, based on the additional residents added to the citation the severity of the deficiency was raised 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). MO 685

Based on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice by failing to adequately assess and treat pain for one of three residents investigated for pain concerns. The resident fell and suffered a broken hip, experienced severe pain and was not provided effective pain management (Resident #79). The facility also failed to provide ordered Tylenol for one hospice resident in pain (Resident #264). The sample was 23. The census was 110. Review of the facility's Pain Management Guidelines, revised September 2017, showed: -Purpose: To attain and maintain the highest practicable level of well-being and to prevent or manage pain, the facility to the fullest extent possible will: --Recognize when a resident is experiencing pain; --Identify circumstances when pain can be anticipated; --Evaluate existing pain and cause; -Upon admission, residents will be assessed for pain by using the Nursing Admission Assessment form; -Residents will be screened for pain by using the assessment form quarterly, annually, and with a significant change and/or new onset of pain; --Pain intensity and pain relief will be assessed prior to administration of medication and post pain medication administration to assess for effectiveness of pain medication; -If any resident reports inadequate pain control, resident will have an assessment performed; -Following the pain evaluation, notify the physician of the findings; -Each resident identified for pain will have a Pain Management Care Plan. The Care Plan will have individualized interventions related to that resident's individual control of pain management. The Care Plan may include both pharmacological and non-pharmacological pain management interventions; -The Licensed Nurse will implement a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -The IDT (interdisciplinary team) will discuss the new onset of pain or change in resident pain at the daily stand-up meeting and the IDT Team conference; -The Licensed Nurse, when administering PRN pain medication, will record the drug administration and the following on the MAR: --Pain level prior to pain medication administration; --Pharmacological interventions attempted; --Non-pharmacological interventions attempted; --Follow-up observations post intervention to determine the effectiveness of PRN pain interventions. If resident is asleep or resting, document as an observation; --Note: Those residents that chose hospice benefits for end-of-life care: Hospice assumes responsibility for the professional management of the resident in accordance to the hospice plan of care, and will be utilized to manage resident pain relief to maintain comfort and dignity. 1. Review of Resident #79's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, incomplete and with a target date of 2/17/22, showed: -Brief Interview for Mental Status (BIMS-tool used to assess cognition) score: blank; -Activities of daily living (ADLs, the tasks of everyday life including eating, dressing, transfers, bed mobility, bathing and using the toilet): blank; -Presence and level of pain: blank. Review of the resident's progress notes showed: -3/14/22 at 3:52 A.M., Nurse's note: certified nurse aide (CNA) staff reported resident complains of pain during repositioning, bilateral lower extremities from dangling off bed. Assessment findings: Left leg appears shorter than the right leg and painful to touch. Asked resident if he/she had a fall, he/she replied yes and continued mumbling and grimacing during assessment, with communication barrier noted. Roommate (alert and oriented) stated the resident had fallen yesterday morning, and was usually up walking during the day, but had been lying in bed moaning for some time, Vital signs (VS): Temperature (T)-98.1, pulse (P)-84, blood pressure (B/P)-148/67, oxygen (O2) saturation (sat)-98%/room air (RA). Tylenol administered for pain. Call placed to resident's physician. New order received for STAT x-ray. X-ray ordered, currently awaiting arrival; -3/14/22 at 9:30 A.M., Nurse's note: Physician in this morning and saw resident. Order given to transfer resident to the hospital; Review of the resident's progress notes showed: -3/19/22 at 8:06 P.M., Nurse's note: Patient readmitted back to facility at approximately 3:35 P.M., Dressing intact to left hip. -3/19/22 at 9:31 P.M., Nurse's note: Resident anxious/moaning, laying sideways in bed with feet on the floor. Resident had removed his/her dry dressing from his/her left hip. PRN Tylenol 650 milligrams (mg) was given. Assisted resident back into bed and replaced nasal prongs. Resident did appear a little more comfortable afterwards; -3/20/22 at 3:49 P.M., Nurse's note: Call placed to pharmacy regarding [MEDICATION(S)] ([MEDICATION(S)], pain medication) medication. Medication was scheduled to come out on tonight's delivery; -3/21/22 at 4:45 A.M., Nurse's note: Resident in bed with bed in lowest position. Resident calling out help. When asked if he/she was in pain, resident answered no. When touched, he/she said yes. Tylenol suppository 650 mg given as ordered, with very short positive results. Pharmacy called about pain medications. Responded they should be on next delivery; -3/21/22 at 6:28 P.M., Resident was observed in bed with complaints of pain to his/her hip. He/she was given pain medication as ordered. It was becoming effective, he/she seemed to be a little more comfortable. Review of the resident's electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Tylenol suppository Insert 650 mg rectally every 6 hours as needed for pain, start date 3/19/22. -[MEDICATION(S)] liquid 1 mg/milliliter (ml), give one ml by mouth every two hours as needed for pain, start date 3/19/22 and discontinued 3/28/22; -[MEDICATION(S)] liquid 1 mg/ml, give one ml by mouth every four hours as needed for pain, start date 3/21/22 and discontinued 3/28/22. Review of the resident's March 2022 MAR, showed: -Tylenol suppository Insert 650 mg rectally every 6 hours as needed for pain, start date 3/19/22. Signed out as provided on 3/20/22 at 8:40 A.M. and 3/20/22 at 8:44 P.M.; -[MEDICATION(S)] liquid 1 mg/ml, give one ml by mouth every two hours as needed for pain, start date 3/19/22 and discontinued 3/28/22. Review showed the medication was not documented as administered from 3/19/22-3/21/22; -[MEDICATION(S)] liquid 1 mg/ml, give one ml by mouth every four hours as needed for pain, start date 3/21/22 and discontinued 3/28/22. Signed out as provided on 3/23/22 at 8:22 A.M. Observation on 3/21/22 at 4:39 P.M., showed Licensed Practical Nurse (LPN) P sitting at the Lafayette unit nurse's station CNA FF yelled across to LPN P, saying Resident #79 was still waiting for some pain medication. LPN P yelled back I will get to it. Observation on 3/21/22 at 4:46 P.M., showed LPN P leave Lafayette headed towards the elevator. CNA FF was standing at the [NAME] unit nurse's station, saw LPN P and asked about the resident's pain medication again as LPN P walked past the opening to the nurse's station. LPN P said he/she will have to wait, boarded the elevator and the door shut. During an interview on 3/21/22 at 4:48 P.M., CNA FF said the resident had been complaining of pain and asking for some pain medication since 3:00 P.M. He/she had asked LPN P to give the resident something for pain, but he/she kept saying he/she would get to it. Observation and interview on 3/21/22 at 4:52 P.M., showed the resident's Family Member (FM) A exited the resident's room and told CNA FF the resident was in pain and still waiting on his/her pain medication. CNA FF assured FM A the nurse was aware and would provide the pain medication as soon as he/she could. Family member B said the resident had been moaning and calling out I hurt for at least two hours. FM B said they had asked staff several times for something to ease the pain and nothing had been provided. The resident was observed moaning and crying out at that time. Resident kept repeating it hurts and I hurt. The FMs were very upset they had to sit there and watch the resident suffer in pain for such a long amount of time. FM A said to his/her knowledge, the facility had only provided the resident with Tylenol for pain since the resident had returned from the hospital. He/she did not know why they did not give the resident ordered pain medication when the resident was in so much pain. Observation and interview on 3/21/22 at approximately 4:59 P.M., showed LPN P entered the locked [NAME] unit. When asked about the resident's pain medication, LPN P said, I can't do it right now, but will get to it when I can. LPN P said his/her priority was doing insulin's and passing medications on both halls and would give the resident some pain medication when he/she got to him/her. LPN P walked to the unit exit door at that time and started inputting the door code. FM A asked LPN P about the resident's pain medication and LPN P said, I will do it when I can and exited the unit. During an interview on 3/21/22 at 5:17 P.M., this surveyor notified the Corporate Nurse and Administrator B the resident was in pain and had been waiting approximately two hours for pain medication per family and staff. The Corporate Nurse said that was unacceptable and they would look into it. Administrator B instantly called the unit. The Corporate Nurse said pain was a priority, and the resident had a hip fracture and needs his/her pain medication. When asked if he/she should have been receiving ordered pain medication since his/her readmission, the Corporate Nurse said absolutely. Pain should be assessed on a routine basis and documented in the resident's echart. During an interview on 3/21/22 at 5:27 P.M., Administrator B notified the surveyor that the resident is getting (his/her) pain medication at this time. 2. Review of Resident #264's medical record, showed: -An admitted [DATE]; -Discharge/death in facility, 1/17/22. Review of the resident's hospital discharge instructions, dated 1/14/22, showed he/she was admitted for [CONDITION(S)]. Multiple goals of care discussions were had with family and the decision to artificially prolong life was not something the resident would want. He/she was transitioned to comfort care measures. He/she was discharged to the facility on hospice (hospice care focuses on making you comfortable during the last months of life). Review of the resident's nurse's notes showed: -On 1/4/22 at 12:30 P.M., resident arrived to facility via ambulance. Resident's eyes closed, resting in bed at this time. admitted to facility for hospice care with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -On 1/14/22 at 1:21 P.M., medication verified with physician, noted and ordered. Review of the resident's ePOS, showed: -An order dated 1/14/22, for acetaminophen suppository, 650 mg. Insert 1 suppository rectally every 4 hours as needed for pain or fever; -An order dated 1/14/22, for [MEDICATION(S)] (concentrate) solution (narcotic pain medication) 20 mg/ml. Give 0.5 ml by mouth every 2 hours as needed for pain/shortness of breath (SOB); -An order dated 1/14/22, for pain evaluation every shift for monitoring of patient's pain level. Review of the resident's electronic MAR, showed: -Order dated 1/14/22, for acetaminophen suppository, 650 mg. Insert 1 suppository rectally every 4 hours as needed for pain or fever. 1/14 through 1/17, blank, not documented as administered; -Order dated 1/14/22, for [MEDICATION(S)] (concentrate) solution 20 mg/ml. Give 0.5 ml by mouth every 2 hours as needed for pain/SOB, 1/14 and 1/15, blank, not documented as administered; -Order dated 1/14/22, for pain evaluation every shift for monitoring of patient's pain level. On 1/14, evening and night shift, blank, on 1/15, day shift, blank, evening shift, recorded pain level as 5, night shift, recorded pain level as 5. 3. During an interview on 3/29/22 at 9:02 A.M., the Corporate Nurse said if there are holes (blank areas) in the eMAR, it means it was not done. A lot of medications are available in the facility for new admissions, but if medications are not available, the hospice medical director can write a prescription and the facility can get the medications sent over within two hours. Medications should be administered as ordered. Pain should be assessed on a regular basis.

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing when facility staff did not provide wound treatments as ordered. This affected three residents (Residents #101, #86, and #92) of 23 sampled residents. The census was 110. Review of the facility's Skin Management Guidelines, revised July 2017, showed: -Purpose: -To identify at-risk residents for potential breakdown or ulcerations; -To prevent breakdown of tissue or ulcerations; -To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations; -Risk factors: -Cognitive impairment; -Exposure of skin to urinary or fecal incontinence; -Under nutrition, malnutrition, and hydration deficits; -Upon admission, all residents are assessed for skin integrity by completing an assessment and documenting in the EHR (electronic health record); -Appropriate preventive measure will be implemented on all residents identified at risk and the interventions documented on the Care Plan, may include: -Turn and reposition; -Promotion of clean, dry and well moisturized skin; -Residents admitted with skin impairments will have: -Appropriate interventions implemented to promote healing; -A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Consultation with Wound Care Nurse or surgeon may be appropriate. 1. Review of Resident #101's admission note, dated 2/17/22, showed the admitting nurse documented open area to coccyx and pressure ulcers to lower legs,. No measurements were documented. Record review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders did not include the specific location or type of wound. Review of Resident #101's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/24/22, showed: -admitted on [DATE]; (the resident was originally admitted on [DATE] and then readmitted on [DATE]) -Severely impaired cognition; -Required assistance of two or more staff with bed mobility, transfers, and toilet use; -Required one person assist in dressing and personal hygiene; -At risk for developing pressure ulcers; -Had one or more unhealed pressure ulcers at Stage I (a reddened, intact area on the skin that does not turn white when pressed) or higher; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical record showed additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's hospital transfer chart, dated 2/18/22, showed: -Wound to anterior left leg; -Pressure ulcer to medial coccyx (a triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum); -Pressure ulcer to right hip; -Pressure ulcer to right heel; -Pressure ulcer to left heel; -Pressure ulcer to right medial anterior calf; -Pressure ulcer to left medial posterior calf. The transfer information did not include any orders for wound care. Review of the physician's progress notes, dated 2/19/22, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's progress notes, dated 2/23/22, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's physician's progress notes, dated 2/26/22, showed the physician documented obtain wound consultation (buttocks) and discontinue when consultation complete. Review showed no further notes regarding the wound consultation until 3/14/22, when the order was received by the wound physician. Review of the resident's Initial Wound Evaluation and Management Summary, signed by the wound physician and dated 3/14/22, showed: -Chief complaint: The patient had multiple wounds; -Focused wound exam (Site 1) - Pressure: -Unstageable (full thickness tissue loss which actual depth of the ulcer is completely covered by slough (yellow, tan, gray, green, or brown), or eschar (tan, brown, or black) in the wound bed) sacrum (the triangular bone just below the lumbar vertebrae) full thickness; -Wound Size -Length x Width x Depth (L x W x D): 1.4 x 5.3 x 0.2 cm (centimeters); -Exudate (fluid that leaks out of blood vessels): Light serous (liquid part of blood); -Focused wound exam (Site 3) - Pressure: -Unstageable, right heel partial thickness; -Wound Size - L x W x D: 2 x 2 x cm (D was not measurable); -Exudate: none; -Focused wound exam (Site 4) - Pressure: -Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough) Pressure wound of the left heel partial thickness; -Wound Size - L x W x D: 2 x 1.5 x 0.1 cm; -Exudate: none. Review of the care plan, in use during the survey, dated 3/14/22, showed: -Focus: Impaired skin integrity as evidenced by pressure injury: sacrum, right heel, left heel, diabetic ulcer to right distal leg, at risk of poor healing infection and additional skin breakdown; -Goals: Will exhibit healing without signs and symptoms of infection through review date, interventions will reduce the risk of additional skin breakdown; -Interventions: Apply pressure reducing mattress to bed, wound clinic to follow, perform treatment order, assess wound for signs and symptoms of infection with the dressing change or treatment, report positive findings of redness, warmth, swelling, increased drainage, increased pain, monitor for verbal and nonverbal symptoms of pain, administer analgesics as ordered by physician, update physician regarding effectiveness. Observation on 3/17/22 at 10:06 A.M., showed the resident lay in the supine (face upward) position, with the head of bed elevated at 30 degrees. A strong odor of feces was observed. Observation on the same day at 2:17 P.M., showed the resident lay in the supine position, with a strong odor of feces observed. Observation and interview on 3/18/22 at 10:00 A.M., showed Licensed Practical Nurse (LPN) X assisted the resident onto his/her side, and unfastened a urine saturated brief. An undated dressing was on the resident's right hip. The tailbone (sacral) wound was uncovered and exposed. A light smear of liquid, brown stool was in the sacral wound. The lower right and left buttock wounds were wet with urine and uncovered. The wounds were noted 100% covered with wet slough (yellow, stringy tissue) and the wound edges were red and inflamed. LPN X said all wounds should be covered at all times. The aides should notify the nurse if a wound dressing was uncovered and the nurse was responsible to quickly apply the ordered treatment. He/she pulled the edge of the brief over the resident's hip and said he/she will get wound supplies and apply the ordered treatment. At 11:50 A.M., LPN X assisted the resident onto his/her left side and lowered the sheet below his/her hip. The same urine saturated, loose stool filled brief remained on the resident. The sacral wound remained uncovered and a small amount of stool was smeared in the sacral wound. During an interview on 3/21/22 at 9:17 A.M., Unit Manger C said the wound physician comes to the facility every Monday to see all the residents listed for wound treatments. He/she said when the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Unit Manager C was not aware of the resident's wounds upon admission. He/she assists with admission skin assessments at times, but could not recall assessing the resident. He/she expected the charge nurses to transcribe and follow-up with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 3/21/22 at 12:54 P.M., the wound physician said he/she did not receive a referral for the resident when the physician requested it on 2/19/22 and 2/23/22. When the facility enters the referral orders to their system, it will take a few minutes to receive the orders. He/she then would initiate an evaluation and treatment on his/her next visit. He/she verified wound treatment orders started on 3/14/22, during his/her initial visit. He/she said the resident could experience other complications if wounds were not being treated as soon as possible. He/she expected the nursing staff to follow-up with wound treatments as ordered. 2. Review of Resident #86's admission MDS, dated [DATE], showed: - BIMS score of 15 out of a possible score of 15, showed the resident cognitively intact; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It usually results in movement, thinking and psychiatric disorders); -Moderate cognitive impairment; -Required extensive assistance of one staff for transfers, dressing, toileting, personal hygiene, and bathing; -Independent with bed mobility and eating; -At risk for pressure ulcers; -No unhealed pressure ulcers; -No venous or arterial ulcers; -No other ulcers, wounds, or skin problems; -Skin and ulcer treatments in place: --Pressure reducing device for chair; --Pressure reducing device for bed; --Turning and repositioning program; --Nutrition or hydration intervention to manage skin problems. Review of the resident's care plan, revised on 3/15/22, showed no care plan for wounds/wound care. Review of the resident's wound clinic Initial Wound Evaluation and Management Summary, dated 3/7/22, showed: -Chief complaint: Patient presented with a wound on his/her right heel; -History of present illness: At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. He/she had a wound of the right heel for at least one day duration. There was no exudate. There was no indication of pain associated with this condition; -Exam: --Neurologic/Psychiatric: Oriented to Person, Oriented to Place, Oriented to Situation; --Mood and affect: Co-operative, Involuntary muscle movements; -Skin: --Right lower extremity Wound present. See Focused Wound Exam Below; -Focused wound exam: wound of right heel, full thickness; --Duration: Over one day; --Objective: Healing, Linear cut with callous and dirt; --Wound Size (L x W x D): 2.5 cm by 0.5 cm by Not Measurable cm; --Surface Area: 1.25 cm; --Exudate: None; --Thick adherent devitalized necrotic tissue: 100%; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] --Primary Dressing(s): Hydrogel (a wound dressing which promotes healing, provide moisture, and offer pain relief ) impregnated gauze apply once daily for 30 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 30 days; --Reason for no debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue): Debridement refused. Patient/surrogate made aware of risks of not removing necrosis including infection; sepsis; limb loss or death; -Plan of care reviewed and addressed: My goal for this wound was healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention was 47 days. This estimate was made with an 80% degree of certainty. Review of the resident's ePOS showed: -Right heel: apply Hydrogel impregnated gauze and Kerlix (gauze roll) every day shift for wound management. Start date: 3/10/22 and discontinued 3/15/22. Review of the resident's March 2022 TAR showed: -Right heel apply Hydrogel impregnated gauze and gauze roll every day shift for wound management, dated 3/10/22 and discontinued 3/15/22. Out of 6 opportunities, 3 noted blank and no initials. During an observation on 3/14/22 at 10:13 A.M., the resident sat in a chair in his/her room. The dressing to his/her right foot was dirty with brown and black streaks/smears. The dressing was loose and coming off with the wound exposed. The date was illegible due to half of the tape missing and the other portion smeared. No dressings were applied to his/her left lower extremity. The resident did not know when the dressing was last changed. Review of the resident's wound clinic Wound Evaluation and Management Summary, dated 3/14/22, showed: -Chief complaint: This patient had multiple wounds. -History of present illness: At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. He/she has a stage I pressure wound of the left, lateral ankle for at least one day duration. There was no exudate. There was no indication of pain associated with this condition; -Exam: --Neurologic/Psychiatric: Oriented to Person, Oriented to Place, Oriented to Situation; --Mood and affect: Co-operative; --Examination of left lower extremities: No [CONDITION(S)], foot warm, wound present. See Focused Wound Exam below; --Examination of right lower extremities: Foot warm, wound present. See Focused Wound exam below, No [CONDITION(S)]; -Focused wound exam (site 1): wound of right heel, full thickness; --Duration: Over seven days; --Objective: Healing, Linear cut with callous and dirt; --Wound Size (L x W x D): 3.0 cm by 0.3 cm by Not Measurable cm; --Surface Area: 0.90 cm²; --Exudate: None; --Thick adherent devitalized necrotic tissue: 100 %; --Wound progress: improved; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] --Primary Dressing(s): Hydrogel impregnated gauze apply once daily for 23 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 23 days; --Surgical excisional debridement procedure: ---Reason for procedure: Remove Necrotic Tissue and Establish the Margins of Viable Tissue; ---Procedure note: The wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION(S)]. Then with clean surgical technique, 15 blade was used to surgically excise 0.9 cm² of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. Hemostasis (the stopping of a flow of blood) was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. -Focused wound exam (site 2): Stage I pressure wound of left lateral ankle, partial thickness; --Etiology: Pressure; --Duration: Over one day; --Objective: Healing; --Wound Size (L x W x D): 0.1 cm by 0.3 cm by Not Measurable cm; --Surface Area: 0.03 cm²; --Exudate: None; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] --Primary Dressing(s): Superabsorbent silicone border and faced dressing, apply once daily for 30 days; -Focused wound exam (site 3): Unstageable (due to necrosis-Irreversible cell injury and eventual cell death) of left heel, full thickness; --Etiology: Pressure; --Duration: Over one day; --Objective: Healing; --Wound Size (L x W x D): 0.3 cm by 1.0 cm by Not Measurable cm; --Surface Area: 0.30 cm²; --Exudate: None; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] --Primary Dressing(s): Hydrogel impregnated gauze apply once daily for 23 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 23 days; --Reason for no debridement: Debridement refused. Patient/surrogate made aware of risks of not removing necrosis including infection; sepsis; limb loss or death; -Summarized wound care assessment and individualized treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] --Site 1: Surgical excisional debridement was performed today on this wound. Goal of treatment is healing evidenced by a 28.0% decrease in surface area within the wound bed; --Site 2: This wound is optimized for autolytic debridement using the below treatment plan. My goal for this wound was healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed; --Site 3: This wound was optimized for autolytic (the destruction of tissues or cells of an organism by the action of substances, such as enzymes that are produced within the organism) debridement using the below treatment plan. My goal for this wound was healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 56 days. This estimate was made with an 80% degree the destruction of tissues or cells of an organism by the action of substances, such as enzymes that are produced within the organism of certainty. Review of the resident's medical record showed there was no facility documentation of stage 1 wound on the resident's left ankle and unstageable wound on the resident's left heel. Review of the resident's ePOS showed: -Right and left heels: apply Hydrogel (highly absorbent dressing that promotes healing, provides moisture, and offers pain relief with their cool, high-water content) (delete and define above - 1st time used) impregnated gauze and Kerlix (gauze roll) every day shift for wound management. Start date: 3/16/22 and discontinued 3/22/22; -Left ankle: apply superabsorbent silicone bordered and faced (ultra-absorbent dressing) every evening shift for wound management; Start Date: 3/16/22 and discontinued 3/22/22. Review of the resident's March 2022 TAR showed: -Left ankle. Apply superabsorbent silicone bordered and faced dressing every evening shift for wound management, dated 3/16/22 and discontinued 3/22/22. Out of 6 opportunities, 3 noted blank and no initials; -Right and left heels. Apply hydrogel impregnated gauze, gauze sponge, gauze roll every evening shift for wound management, dated 3/16/22 and discontinued 3/22/22. Out of 6 opportunities, 3 noted blank and no initials. Observation on 3/17/22 at 9:52 A.M., showed the resident lay in bed on his/her right side with his/her eyes closed. The dressing to his/her right foot was falling off and dirty with brown and black smears, with yellow areas. The dressing was falling off and not in the appropriate place, with the right heel wound exposed. No dressings were applied to his/her left lower extremity. Observation on 3/18/22 at 12:09 P.M., showed the resident lay in bed on his/her right side. No dressings were applied to his/her feet. His/her left lateral foot had a cracked area that measured approximately 1.5 inches long by 0.2 cm wide by unable to determine depth. The wound was open with the wound bed exposed and red. The resident's right heel had closed cracked tissue, measuring approximately 1.5 inches long by 0.1 cm wide. The skin to his/her feet was very dry. The resident was asleep and the right side of the feet could not be visualized. Further review of the resident's medical record showed there was no facility documentation of the wound to the resident's left lateral foot. Observation on 3/21/22 at 4:19 P.M., showed the resident sat in his/her bed with no dressing on his/her right and left feet. The resident was continuously moving his/her bilateral lower extremities back and forth on the bed, in a rubbing fashion. The wounds were exposed. Review of the resident's wound clinic Wound Evaluation and Management Summary, dated 3/21/22, showed: -Chief complaint: This patient had multiple wounds. -History of present illness: At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. He/she had a wound of the right, lateral heel for at least one day duration. There was light sero-sanguinous exudate. There was no indication of pain associated with this condition; -Exam: --Neurologic/Psychiatric: Oriented to Person, Oriented to Place, Oriented to Situation; --Mood and affect: Involuntary muscle movements; -Focused wound exam (site 1): wound of right heel, full thickness; --Duration: Over 13 days; --Objective: Healing, Linear cut with callous and dirt; --Wound Size (L x W x D): 1.5 cm by 0.2 cm by Not Measurable cm; --Surface Area: 0.30 cm²; --Exudate: None; --Granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process): 20%; --Other visible tissue: 80%, subcutaneous tissue; --Wound progress: improved; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] --Primary Dressing(s): Hydrogel impregnated gauze, apply once daily for 16 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 16 days; -Focused wound exam (site 2): stage I pressure wound of left lateral ankle, partial thickness; --Etiology: Pressure; --Duration: Over one day; --Objective: Healing; --Wound progress: Resolved 3/21/22; -Focused wound exam (site 3): Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Some slough may be present. May include undermining and tunneling) pressure wound of left heel, full thickness; --Etiology: Pressure; --Duration: Over one day; --Objective: Healing; --Wound progress: Resolved 3/21/22; -Focused wound exam (site 4): wound of right lateral heel, full thickness; . --Duration: Over 1 days; --Objective: Healing; --Wound Size (L x W x D): 0.2 cm by 1.2 cm by 0.1 cm; --Surface Area: 0.24 cm²; --Exudate: Light sero-sanguineous; --Other visible tissue: 100%, subcutaneous dermis; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] --Primary Dressing(s): Hydrogel impregnated gauze apply once daily for 16 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 16 days; -Focused wound exam (site 5): wound of left lateral foot, full thickness; --Duration: Over 1 days; --Objective: Healing; --Wound Size (L x W x D): 0.3 cm by 2.4 cm by 0.1 cm; --Surface Area: 0.72 cm²; --Exudate: Light sero-sanguineous; --Other visible tissue: 100%, subcutaneous dermis; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] --Primary Dressing(s): Hydrogel impregnated gauze, apply once daily for 16 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 16 days; -Focused wound exam (site 6): wound of left medial foot, full thickness; . --Duration: Over 1 days; --Objective: Healing; --Wound Size (L x W x D): 0.2 cm by 1.5 cm by 0.1 cm; --Surface Area: 0.30 cm²; --Exudate: Light sero-sanguineous; --Other visible tissue: 100%, subcutaneous dermis; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] --Primary Dressing(s): Hydrogel impregnated gauze, apply once daily for 16 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 16 days; -Summarized wound care assessment and individualized treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] --Site 1: This wound is currently being optimized for autolytic debridement using the below treatment plan. Most recent surgical excisional debridement was on 3/14/2022. Goal of treatment is healing evidenced by a 66.7% decrease in surface area and a 100% decrease in necrotic tissue within the wound bed. --Site 2: Resolved on 3/21/22; --Site 3: Resolved on 3/21/22; --Site 4: This wound was optimized for autolytic debridement using the below treatment plan. My goal for this wound was healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed; --Site 5: This wound was optimized for autolytic debridement using the below treatment plan. My goal for this wound was healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed; --Site 6: This wound was optimized for autolytic debridement using the below treatment plan. My goal for this wound was healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. Review of the resident's ePOS, reviewed on 3/28/22 at 12:05 P.M., showed: -Right heel: apply Hydrogel impregnated gauze and Kerlix (gauze roll) every day shift for wound management. Start date: 3/10/22 and discontinued 3/15/22; -Right and left heels: apply Hydrogel (highly absorbent dressing that promotes healing, provides moisture, and offers pain relief with their cool, high-water content) (delete and define above - 1st time used) impregnated gauze and Kerlix (gauze roll) every day shift for wound management. Start date: 3/16/22 and discontinued 3/22/22; -Right heel: apply Hydrogel impregnated gauze and Kerlix (gauze roll) every day shift for wound management. Start date: 3/22/22; -Left ankle: apply superabsorbent silicone bordered and faced (ultra-absorbent dressing) every evening shift for wound management; Start Date: 3/16/22 and discontinued 3/22/22; -Eucerin Cream (Skin Protectant). Apply topically to bilateral feet twice a day for dry skin. Start Date: 2/23/22; -No noted order for the left lateral foot wound noted on the 3/21/22 wound clinic's Wound Evaluation and Management Summary. -No noted order for the left medial foot wound noted on the 3/21/22 wound clinic's Wound Evaluation and Management Summary. Review of the resident's March 2022 TAR showed: -Left ankle. Apply superabsorbent silicone bordered and faced dressing every evening shift for wound management, dated 3/16/22 and discontinued 3/22/22. Out of 6 opportunities, 3 noted blank and no initials; -Right and left heels. Apply hydrogel impregnated gauze, gauze sponge, gauze roll every evening shift for wound management, dated 3/16/22 and discontinued 3/22/22. Out of 6 opportunities, 3 noted blank and no initials; -Right heel. Apply hydrogel impregnated gauze, gauze sponge, gauze roll every evening shift for wound management, dated 3/22/22. Out of 6 opportunities, 3 noted blank and no initials; -Right heel apply Hydrogel impregnated gauze and gauze roll every day shift for wound management, dated 3/10/22 and discontinued 3/15/22. Out of 6 opportunities, 3 noted blank and no initials; -Eucerin Cream (Skin Protectant). Apply topically to bilateral (both) feet twice a day for dry skin, dated 2/23/22. Out of 54 opportunities, 22 noted blank and no initials -No noted order for the left lateral foot wound noted on the 3/21/22 wound clinic Wound Evaluation and Management Summary; -No noted order for the left medial foot wound noted on the 3/21/22 wound clinic Wound Evaluation and Management Summary. Observation on 3/23/22 at 3:18 P.M., showed the resident sat up in his/her bed with no dressing on his/her right and left feet. The resident was continuously moving his/her bilateral lower extremities back and forth on the bed, in a rubbing fashion. Further observation showed the wounds were exposed. Observation on 3/24/22 at 5:12 P.M., showed the resident sat in the day area feeding himself/herself dinner with no dressing on his/her right and left feet. Observation on 3/25/22 at 12:51 P.M., showed the resident sat in a chair in his/her room with no dressing on his/her right and left feet. The resident's feet were bare and on the floor with wounds exposed. 3. Review of Resident #92's admission MDS, dated [DATE], showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognitively intact; -Required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; -Independent with eating; -At risk for pressure ulcers; -Had one unhealed Stage I pressure ulcer; -Had one unhealed Stage III pressure ulcer; -Had one venous or arterial ulcer; -Skin and ulcer treatments in place: --Pressure reducing device for chair; --Pressure reducing device for bed; --Nutrition or hydration intervention to manage skin problems; --Pressure ulcer care; --Applications of ointments/medications other than to feet. Review of the resident's baseline care plan, dated 2/4/22, showed: -admitted on [DATE], with skin integrity issues of [CONDITION(S)] (the build-up of fluid in soft body tissues when the lymph system is damaged or blocked) and wound bilateral (both) lower extremities (BLE); -No wound description, measurements, treatments, or other details noted. -No interventions for the resident's wounds. Review of the resident's skin assessment, dated 2/4/22, showed: -No documentation of any pressure wounds. Review of the resident's wound clinic Initial Wound Evaluation and Management Summary, dated 2/7/22, showed: -Chief complaint: This patient has multiple wounds; -History of present illness: At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. He/she has a wound of the right abdomen for at least 1 day duration. There is light sero-sanguineous exudate. There is no indication of pain associated with this condition; -Exam: --Neurologic/Psychiatric: Oriented to Person, Oriented to Place, Oriented to Situation; --Mood and affect: Appropriate; -Focused wound exam (Site 1): Stage III pressure wound of the right lateral shin, full thickness; --Duration: Over one day; --Objective: Healing, Acute DVT 1/26/22; --Wound Size (L x W x D): 3.9 centimeters (cm) by 1.3 cm by 0.1 cm; --Surface Area: 5.07 cm²; --Exudate: None; --Granulation tissue: 20% --Other tissue: 70 % subcutaneous, dermis; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] --Primary Dressing(s): Xeroform sterile gauze apply once daily for 30 days; --Secondary Dressing(s): Gauze sponge sterile apply once daily for 30 days; Superabsorbent silicone border and faced apply once daily for 30 days; - Plan of care reviewed and addressed: Recommendation: Off-load wound; Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able; -My goal for this wound is healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. -Focused wound exam (Site 3): Stage III pressure wound of the left lateral shin, full thickness; --Duration: Over one day; --Objective: Healing, Acute DVT 1/26/22; --Wound Size (L x W x D): 3.5 cm by 1.0 cm by 0.1 cm; --Surface Area: 3.5 cm²; --Exudate: slight sero-sanguineous; --Slough: 25% --Granulation tissue: 65% --Other tissue: 10 % subcutaneous, dermis; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] --Primary Dressing(s): Leptospermum honey apply once daily for 30 days: sheet; Superabsorbent silicone border and faced apply once daily for 30 days; - Plan of care reviewed and addressed: Recommendation: Off-load wound; Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able; -Surgical excisional debridement procedure: Remove thick adherent eschar and devitalized tissue, remove necrotic tissue and establish the margins of viable tissue. The wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION(S)]. Then with clean surgical technique, 15 blade was used to surgically excise 0.88 cm² of devitalized tissue including slough,

Based on interview and record review, the facility failed to safely transfer three of four sampled residents (Residents #1, #2, and #4). Staff failed to use the appropriate amount of staff assistance for gait belt transfers of Resident #1, resulting in a skin tear. Staff members conducted improper gait belt transfers, which resulted in a fall for Resident #2. Staff improperly transferred Resident #4, due to a lack of awareness about the impact of a recent change in condition on the resident's level of participation in transfers. The census was 108. 1. Review of Resident #1's activities of daily living (ADL)/daily care list, updated 4/8/14, showed the following: -Resident oriented to person, always confused, and becomes agitated; -Redirection and encouragement required to decrease agitation when disoriented; -Gait belt with assistance of two staff required for gait belt transfers; -Physical therapy to provide education on proper transfer techniques. During an interview on 7/30/19 at 9:38 [NAME]M., the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, Coordinator said the point of care lists (ADL/daily care lists) provided for Resident #1, was the one in use and reflected all changes and updates made. Review of the resident's care plan, updated 12/31/18, showed the following: -Impaired communication related to a [DIAGNOSES REDACTED]. -Impaired behavior related to Alzheimer's dementia, as evidenced by agitation, restlessness, combativeness, and looking for spouse; -Required assistance with daily ADL care due to cognition and decreased mobility; -Required assistance of two people with a gait belt for transfers. Allow time for the resident to pivot his/her feet and stand with good balance and feet under him/her; -Resident will sometimes resist staff during transfers. Ensure two staff assist with transfers. If the resident is agitated, then approach him/her at a different time; -History of falls and potential for further falls related to impaired cognition and decreased mobility. Review of the resident's quarterly MDS, a federally mandated assessment instrument completed by facility staff, dated 4/1/19, showed the following: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Wheelchair mobility; -Physical and verbal behavioral symptoms directed toward others occurred one to three days; -Required extensive assistance of one with locomotion and dressing; -Required extensive assistance of two or more people with bed mobility, transfers, and toilet use; -Not steady, only able to stabilize with staff assistance moving from seat to stand, moving on and off toilet, and during surface-to-surface transfers. Review of the resident's fall risk model assessment, dated 4/7/19, showed a total score of 9 (a score of five or more indicates high risk). Review of the resident's nurse's notes, showed the following: -6/17/19 at 10:07 P.M., resident max assist, up in wheelchair propelled by staff to dine. Resident resting after meal in bed for a while and then sitting up. Certified Nurse Aide (CNA) B called charge nurse to room, who noted a skin tear to the resident's left lower extremity, 5.0 by 0.5 by 0.1 (unit of measurement not specified). Treatment applied per protocol. Staff notified the resident's power of attorney (POA); -6/18/19 at 9:09 [NAME]M., the nurse manager assured the resident's POA that she would educate staff on the resident's transfer status and follow back up with him/her. During an interview on 7/11/19 at 3:32 P.M., CNA B said during the shift in question, it was his/her first time after orientation working alone. He/she went through orientation on a different side of the unit and was consequently unfamiliar with the residents assigned to him/her that night. No one told CNA B about the point of care list or instructed him/her to use it to read up on his/her residents' care needs. He/she was not given a login for the facility database. Consequently, he/she did not have access to the residents' care plans or point of care lists. He/she asked co-workers what he/she needed to do for each assigned resident. CNA B went up to the nurse's station and asked CNA C about the resident's (Resident #1's) care needs. CNA C said the resident was hard to work with, gave staff a hard time, tended to spit at them, and his/her transfer status was assist of one via gait belt. No one told CNA B the resident had Alzheimer's dementia or that it impacted his/her ability to follow verbal instructions or pivot his/her feet. CNA C instructed CNA B not to check on the resident too often, because it agitated the resident. CNA B used a gait belt to transfer the resident without staff assistance, the resident hit his/her leg on something and incurred a skin tear. During an interview on 7/15/19 at 2:44 P.M., CNA C said he/she worked with CNA B one time. CNA C told CNA B the resident was total care, that CNA B had to lift the resident up with a gait belt, because the resident could not stand on his/her own. It was possible for one person to transfer the resident. However, there should be two people in the room. According to the Human Resources Advisor, CNA C's date of employment was 12/13/16. During interviews on 7/8/19 at 3:10 P.M. and 7/18/19 at 2:11 P.M., the Director of Nursing (DON) said there was a situation in or around (MONTH) (YEAR), when a CNA transferred the resident without staff assistance. During that transfer, the resident got hurt really badly and had to have a skin tear closed with stitches. Nursing discovered the resident was not pivoting well with his/her feet, which could lead to him/her scraping a leg on his/her wheelchair pedal. Due to dementia, the resident could not follow instructions and would not pivot his/her feet. Consequently, it was not safe to transfer the resident without assistance from a second person, because it was not possible to assist him/her and pay attention to what was going on with his/her legs. There was no point in having a second person in the room, if they were not physically assisting with the transfer. During an interview on 7/17/19 at 8:31 [NAME]M., the Rehabilitation Director said the therapy department had not assessed the resident, since the company's arrival at the facility in September. They talked to staff, when conducting a quarterly screen and were informed that the resident had not experienced a functional change in transfer status. According to staff, the resident tended to get combative but it was all in the way staff approached him/her. However, there remained a 50/50 chance of the resident having a behavior and flailing around mid-transfer. So, it was always best for staff to transfer him/her via assist of two for safety. During interviews on 7/8/19 at 3:10 P.M. and 7/18/19 at 2:11 P.M., the DON said CNA B transferred Resident #1 incorrectly. It was CNA B's first day out of orientation and he/she was working alone for the first time. CNA B was trained to look at the residents' point of care lists in the computer. During orientation, CNAs learned how to access the information. 2. Review of Resident #2's undated face sheet, showed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the resident's ADL/daily care list, updated 10/29/18, showed the resident transferred via assist of two with a gait belt. He/she used a wheelchair for mobility. During an interview on 7/30/19 at 9:38 [NAME]M., the MDS Coordinator said the point of care lists (ADL/daily care lists) provided for Resident #2 was the one in use and reflected all changes and updates made. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Wheelchair mobility; -Required supervision of one with locomotion off unit; -Required limited assistance of one with ambulation; -Required extensive assistance of one with bed mobility, transfers, locomotion on unit, dressing, toilet use, and personal hygiene; -Not steady, only able to stabilize with staff assistance moving from seat to stand, ambulating, turning around while ambulating, and during surface-to-surface transfers. Review of the resident's fall risk model assessment, dated 5/29/19, showed a total score of 5. Review of the resident's care plan, dated 6/13/19, showed the following: -Required assistance with ADL care related to [MEDICAL CONDITION]; -Required staff support with transfers; -Required assistance of one with mobility via wheelchair, bed mobility, toileting, bathing/showers, and dressing; -Potential for falls related to limited mobility and [MEDICAL CONDITION]. Review of the resident's physical therapist progress and discharge summary, dated 6/5/19, showed the resident required minimum assistance (1-25%) with transfers. He/she used a walker and manual wheelchair. The resident exhibited increased challenge balancing with functional reaching maintaining three points of contact (one hand and two feet) with walker support. For safety reasons, he/she required the use of a front-wheeled walker with encouragement for functional distance supported via gait belt and contact guard assist (keeping one or two hands on the resident's body to help steady him/her or assist with balance as the resident performs the functional task). Review of the resident's nurse's note, dated 6/18/19 at 8:01 [NAME]M., showed the resident reported he/she had a fall in his/her room, prior to going to bed the previous night. The resident's left outer wrist was a little sore. Nurse A did not note any redness or bruising. The resident's hand grips were normal. He/she could move his/her left wrist and hand without difficulty, but did request as needed (PRN) [MEDICATION NAME]. During an interview on 7/16/19 at 5:31 [NAME]M., Nurse A said the resident reported the incident the day after it occurred. He/she said CNA B had thrown him/her to the floor. However, the resident had a tendency to exaggerate. At times when staff asked the resident to stand, he/she said he/she could not move, then someone else would enter the room and the resident would stand. The resident could stand and transfer independently. It was not that he/she could not move. The resident tended to get nervous and felt like he/she were going to fall. He/she would say staff was trying to pick him/her up, when they were actually guiding him/her into the wheelchair. During an interview on 6/25/19 at 1:15 P.M., the resident said he/she fell on the night of 6/17/19, because both he/she and CNA B attempted to perform a transfer their own way. The resident told CNA B, you can't transfer me from that side, because I'll fall. CNA B continued to transfer the resident in the same manner. As a result, the resident fell between the bed and nightstand. CNA B attempted to get the resident up and fell as well. The resident's ribs hurt so badly, he/she could hardly breathe. During an interview on 7/11/19 at 3:32 P.M., CNA B said staff told CNA B the resident only required assistance of one, that he/she could stand and transfer him/herself. No one informed CNA B of the tendency for the resident's legs to lock up. CNA B denied that the resident ever fell while in his/her care. When he/she attempted to physically assist the resident off of the toilet, the resident said, don't do that. It makes me feel like I'm going to fall. So, CNA B allowed the resident to transfer him/herself into bed independently and only touched his/her leg in order to put it onto the bed. During an interview on 6/25/19 at 12:02 P.M., the DON said the resident had just approached her and asked about the possibility of transferring to a different facility. The DON asked if something had occurred. The resident said yes, that he/she had locked up during a transfer and another CNA (not CNA B) had roughly put the resident into his/her wheelchair. The resident's [MEDICAL CONDITION] had progressed to the point that it sometimes caused his/her legs to lock up. It tended to happen suddenly. When that occurred during the transfer, staff had to complete the transfer for the resident. During an interview on 6/25/19 at 1:15 P.M., the resident said that morning, he/she put on his/her shoes and socks. He/she was sitting up on the side of the bed when CNA D handed him/her a shirt, then told him/her to stand up. The resident stood. CNA D told him/her to turn and sit in his/her wheelchair. The resident said he/she could not do it. The more nervous and scared he/she got, the less he/she could do, and his/her feet would not move. CNA D put the resident back onto the bed, got a gait belt, jerked the resident off of the bed and slammed him/her into the wheelchair, half in and half out of the chair. As CNA D pushed him/her to the bathroom, the resident lost his/her balance and put his/her feet down on the floor, which caused his/her body to jerk forward. At that point, the resident was half hanging out of the wheelchair and had to get him/herself back into the wheelchair. During interviews on 6/25/19 at 12:30 P.M. and 7/15/19 at 1:33 P.M., CNA D said he/she was employed at the facility less than 90 days and was a part-time employee, most recently working only two to three days a week. The outgoing staff was not updating CNA D on behavioral changes or new resident issues. He/she had to ask about those things, because the outgoing staff did not volunteer information. The only things they passed on to CNA D had to do with bad UTIs, fecal impactions, and hospitalization s. No one informed him/her that the resident's legs sometimes locked up, preventing the resident from being able to pivot during transfers. The only thing the outgoing staff told CNA D about the resident was the resident did not like to wear [MEDICATION NAME]. CNA D was off work for three days. On the morning of 6/25/19, he/she attempted to transfer the resident and noticed the resident was not transferring right. He/she was having trouble getting his/her feet together, because he/she could not move them. The resident said, I can't do it. My leg. My leg. CNA D did not want to get in trouble for failing to get the resident up, so he/she laid the resident back down, got a gait belt, put it around the resident's waist, pulled the resident up into a sitting position, then lifted him/her onto his/her feet. The resident was not standing up all the way. The transfer went well, but the resident plopped down into his/her wheelchair. As CNA D pushed the resident to the bathroom, the resident suddenly put his/her feet down on the floor and his/her whole body came up out of the wheelchair. CNA D was startled and had to grab him/her, putting a hand on his/her chest and pushing him/her back down into the wheelchair. No one ever told CNA D what to do, if a resident suddenly could not participate in a transfer. The last time CNA D reviewed the resident's ADL/daily care list, it showed the resident's transfer status was assist of one with a gait belt. Further review of the resident's care plan, did not show any documentation of the tendency for the resident's legs to lock up during transfers, interventions for staff to implement when that occurred, or instruct staff to use the resident's walker for stabilization/added support during transfers when the resident experienced difficulty standing or temporary loss of fine motor control (the coordination of muscles, bones, and nerves to produce small, exact movements). During interviews on 7/8/19 at 3:10 P.M. and 7/18/19 at 2:11 P.M., the DON said CNA B transferred Resident #1 incorrectly and transferred Resident #2 (who requires assist of two with transfers) without staff assistance during the same shift. It was CNA B's first day out of orientation and he/she was working alone for the first time. CNA B was trained to look at the residents' point of care lists in the computer. During orientation, CNAs learned how to access the information. The DON confirmed that the resident did not want to be touched during transfers. The resident's complaint about the transfer performed by CNA D on the morning of 6/25/19, stemmed from the fact that CNA D did not allow the resident to transfer him/herself. Instead, CNA D went ahead and put the resident into the wheelchair. A year ago, Resident #2's [MEDICAL CONDITION] progressed to the point that his/her legs began to lock up from time to time. The DON spoke with the physical therapy department and learned they were transferring the resident with a walker in front of him/her, because the resident was more comfortable being able to grab it, to steady him/herself during transfers and take his/her time. The resident was alert enough to say when he/she was not having a good day physically and could not comply with staff instructions to pivot. The DON said she should have gotten with staff and discussed it with them, because some of the CNAs were attempting to put a gait belt on the resident and stand him/her up unassisted during those times. During an interview on 7/17/19 at 8:31 [NAME]M., the Rehabilitation Director said the resident was discharged from physical therapy on 6/5/19. At that time, his/her transfer status was minimum assistance. Staff did not notify the therapy department about the resident's legs locking up, his/her inability to get to his/her feet or pivot at times during transfers. If they had, then someone from the therapy department would have observed staff transfers of the resident and gave the staff pointers. At least one week of documentation of falls or transfer issues was required, in order to support the need for a transfer assessment. During an interview on 7/15/19 at 10:46 [NAME]M., the MDS Coordinator said she and the nursing staff updated resident care plans. The care plans had to be updated quarterly, annually, and whenever a resident experienced a significant change in condition. She did not recall anyone informing her that Resident #2's legs tended to lock up from time to time during transfers. If nursing had informed the MDS Coordinator, that would have triggered a physical therapy screening and the issue would be documented on the care plan with interventions. A resident's point of care list was a carryover from his/her care plan; an abbreviated version for CNAs to follow showing what should be done for a resident. During orientation, CNAs were taught to refer to the point of care lists on their assigned residents. The MDS Coordinator or nursing staff could update the point of care list. 3. Review of Resident #4's undated face sheet, showed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the resident's discharge MDS, dated [DATE], showed the following: -Short-term memory problems; -[DIAGNOSES REDACTED]. -Signs and symptoms of [MEDICAL CONDITION]: continuous inattention and disorganized thinking; -Extensive assistance with bed mobility, transfers, locomotion on unit, dressing, toileting, and personal hygiene. Review of the resident's nurse's notes, showed the following: -6/5/19 at 2:46 P.M., the resident returned from the hospital to the facility at 2:20 P.M. alert and oriented times three with some confusion. Staff noted left-sided weakness. At 7:14 P.M., staff noted the resident was max assist in bed; -6/6/19 at 2:20 P.M., staff noted general weakness in the resident. He/she required assistance of two via gait belt and was unable to assist with transfers; -6/11/19 at 11:59 [NAME]M., staff noted generalized weakness in the resident and had to use a lift to transfer the resident in the bathroom. Staff educated the resident and said he/she had to assist more with pivoting; -6/12/19 at 10:45 P.M., staff noted the resident required maximum assistance; -6/14/19 at 2:29 P.M., the resident was alert and oriented times two with confusion; -6/24/19 at 2:24 P.M., the resident was assist times one with ADLs and transfers; -6/30/19 at 9:00 P.M., staff noted that the resident was max assist. Review of the resident's care plan, dated 7/15/19, showed the following: -Impaired communication and decision making related to dementia; -Required assistance with daily ADL care related to impaired mobility; -Required assistance of one to two staff support with transfers; -High risk for falls related to history of falls and lack of safety awareness with toileting self without staff assistance. During an interview on 7/30/19 at 9:38 [NAME]M., the MDS Coordinator said when a care plan says assistance of one to two staff support, the CNA assigned to the resident decides how much assistance the resident needs, based on the resident's condition at the time. Further review of the resident's care plan, did not show use of a mechanical lift as a transfer intervention, specify which type of lift was appropriate, and was not updated to reflect the resident's change in transfer status after his/her readmission. Review of the resident's ADL/daily care list, dated 7/15/19, showed the resident required transfer assistance of one via gait belt. Further review of the ADL/daily care list, did not show the resident's need for an increased level assistance with transfers, following his/her readmission, describe when use of a mechanical lift was appropriate or specify which type of lift staff should use. During an interview on 7/30/19 at 9:38 [NAME]M., the MDS Coordinator said the point of care lists (ADL/daily care lists) provided for Resident #4 was the one in use and reflected all changes and updates made. Review of the resident's fall risk model assessment, dated 7/16/19, showed a total score of 5. Review of the resident's physical therapy plan of care, certified from 6/6/19 through 7/3/19, showed the resident presented with a decline in functional mobility due to generalized weakness following a recent hospitalization for UTI,[MEDICAL CONDITION] (severe blood infection which can lead to organ failure and death). The resident and nursing staff noticed a decrease in his/her ability to perform bed mobility, transfers, and wheelchair mobility, resulting in decreased safety and an increased need for assistance. The resident went from requiring minimum assistance (1-25%) with transfers to requiring maximum assistance (76-99%) with bed/chair transfers and moderate assistance with sit to stand transfers (26-75%). A mechanical lift was not required. During interviews on 6/25/19 at 12:30 and 7/15/19 at 1:33 P.M., CNA D said he/she figured out on his/her own how weak the resident was, after the resident's hospitalization . The outgoing CNA from the previous shift told CNA D to transfer the resident via a sit-to-stand lift, but CNA D was taught not to use a mechanical lift without a physician's orders [REDACTED]. So, CNA D performed a gait belt transfer without staff assistance. The resident was limp and unable to assist. CNA D struggled to complete the transfer and the resident slumped down into the wheelchair. During sit-to-stand transfers, CNA D kept having to tell the resident to hold onto the sit-to-stand bar, because the resident was out of it. The resident's medication appeared to be having an adverse affect on him/her. Since the charge nurse was aware of the resident's condition, CNA D did not report his/her observations. During an interview on 7/18/19 at 2:11 P.M., the DON said if the resident was not able to stand up, then it was fine to get a mechanical lift. CNAs did not need a physician's orders [REDACTED]. All they had to do was fill out a stop and watch form and let the charge nurse on duty know afterwards that it was necessary to use a lift to transfer the resident. If the resident was not consistently holding onto the sit-to-stand lift bar, then staff must use a Hoyer lift because, even with the sit-to-stand lift straps in place, the resident could get injured. During an interview on 7/17/19 at 8:31 [NAME]M., the Rehabilitation Director said the resident was hospitalized twice in 2019. He/she received physical and occupational therapy. The therapy department did not advise the use of a sit-to-stand lift with the resident. When he/she returned to the facility at the beginning of June, he/she had a pretty severe UTI. It took the resident three weeks to be fully clear in his/her mind, so that he/she could listen to instructions and participate more in transfers. However, the resident could still be transferred via gait belt. He/she just needed a lot more time to process things. At no point did the physical therapy department recommend the use of a sit-to-stand lift with the resident. In order for a CNA to use a mechanical lift to transfer a resident, he/she must consult with the charge nurse on duty and its use must be care planned. During an interview on 7/15/19 at 10:46 [NAME]M., the MDS Coordinator said she and the nursing staff updated resident care plans. The care plans had to be updated quarterly, annually, and whenever a resident experienced a significant change in condition. A resident's point of care list was a carryover from his/her care plan; an abbreviated version for CNAs to follow showing what should be done for a resident. During orientation, CNAs were taught to refer to the point of care lists on their assigned residents. The MDS Coordinator or nursing staff could update the point of care list. During an interview on 7/18/19 at 2:11 P.M., the DON said it was the responsibility of the CNAs to check the facility database for their assigned residents' current care needs. The morning shift had to hit the ground running and get residents to the dining room for breakfast in an hour, so they were not really checking the point of care information on residents. CNA B did have a login for the facility resident database; it was the same one which enabled him/her to access online learning software. However, CNA B may not have understood that. Some new staff members, who completed orientation had approached the DON and said they did not how to log into the facility database. During an interview on 7/15/19 at 2:30 P.M., CNA [NAME] said there was no point of care information on residents in the facility database. If it was in there, then CNA [NAME] had never seen it. The CNAs did not have access to resident care plans. They had to ask the charge nurse or unit manager, to access the database for them. According to the Human Resources Advisor, CNA E's date of employment was 4/3/18. Review of the facility's policy titled Safe Lifting and Moving of Patients revised 12/2017, showed in order to protect the safety and well-being of associates and residents, and to promote quality care, the facility used appropriate techniques and devices to lift and move residents. Manual lifting of residents was to be eliminated when feasible. Nursing associates, in conjunction with the rehabilitation associates, were expected to assess individual residents' needs for transfer assistance on an ongoing basis. Associates were to document resident transferring and lifting needs in the care plan. Such assessments included: resident's preferences for assistance, resident's mobility (degree of dependency), resident's size, weight-bearing ability, cognitive status, whether the resident was usually cooperative with associates and the resident's goals for rehabilitation, including restoring or maintaining functional abilities. Mechanical lifting devices were to be used for heavy lifting, including lifting and moving residents when necessary. MO 305

See event ID 7X9M12. Based on observation, interview and record review, the facility failed to adequately assess resident falls, implement timely and appropriate interventions to prevent potential falls and injury and follow their policy for fall management for three residents. This failure resulted in serious injury to one resident. The resident required hospitalization to the trauma unit following a fall at the facility, resulting in a liver laceration, scalp laceration and a lower back blast fracture, requiring a back brace for healing (Residents #51, #53 and #54). The facility also failed to maintain an environment free of accident hazards by not maintaining water temperatures in resident rooms and resident shower rooms on the Marquette, Carondelet and Lafayette halls between 105 degrees Fahrenheit (F) and 120 F (Residents #68, #69, #64, #65, #57, #58, #15, #59, #60, #61, #62, #63, #66, #67, #56 and #55). The census was 125. Review of the facility's Managing Falls and Fall Risk policy, dated 12/2017, showed the following: -Policy statement: Based on previous evaluations and current data, the associates will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -Policy interpretation and implementation: -The associate, with attending physician input, will identify appropriate interventions to reduce fall risk. If a systemic evaluation of a resident's fall risk identifies several possible interventions, the associate may choose to prioritize interventions; -Examples of initial approaches may include exercise and balance training or a rearrangement of the room furniture. If medication is suspected as a possible cause of falling, the initial intervention may be to taper or stop the medication; -In conjunction with consultant pharmacist and nursing associates, the physician will identify and adjust medications that may be associated with increased risk for falling, or indicate why medications could not be tapered or stopped, even for a trial period; -If falling recurs despite initial interventions, associates will implement additional or different interventions, or indicate why the current approach remained relevant; -If underlying causes cannot be identified or corrected, associates will try various interventions based on assessment of the nature or category until falling is reduced or stopped, or until the reason for continuation of the falling is identified as unavoidable; -In conjunction with the physician, associates will identify and implement relevant interventions (e.g., hip padding or treatment of [REDACTED]. -Monitoring subsequent falls and fall risk: -Associates will monitor and document each resident's response to interventions intended to reduce falling or risk of falling; -If interventions have been successful in prevention of falls, associates will continue the interventions or reconsider whether the measures are still needed if a problem that required intervention (e.g., dizziness or weakness) had resolved; -If the resident continues to fall, associates will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the physician will help the associates reconsider possible causes that may not previously have been identified; -The associates and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. 1. Review of Resident #51's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/13/17, showed: -Brief Interview for Mental Status (BIMS, screening tool used to assess cognition) score of nine out of a possible score of 15, which indicated moderate cognitive impairment; -No physical behaviors, did not wander and did not reject care; -Trouble falling or staying asleep one to three days of the assessment period; -Fidgety, restless, moved or spoke more slowly one to three days of the assessment period; -Yelled, cursed or verbally threatened others one to three days of the assessment period; -Transferred with assist of one staff; -Walked in room and corridor with staff supervision and set up; -Steady at all times for balance during walking and transitions; -No functional limitation in range of motion (ability to move and extend joints); -Used a cane or crutch to ambulate; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 9/26/17 and in use during the revisit, showed the following: -Problem: History of multiple falls related to impaired gait; -Goal: Fall risk evaluations completed and basic safety interventions implemented; -Approach: Complete fall risk evaluation quarterly; -Keep room clutter free and provide adequate lighting; -Keep call light in reach; -Keep bed at appropriate height; -Keep frequently used items in reach; -Remind resident to use walker; -Wheelchair removed from room due to non use on 1/21/17; -On 5/9/17, reminded of safety awareness and to ask for assistance with attempts to ambulate; -Fall on 7/3/17: Resident came from the bathroom, shoes may have been part of reason for the fall, he/she noted to lean to the side and foot was not inside his/her shoe; -Approach: Resident's responsible party gave permission to discard the shoes on 7/3/17; -Fall on 9/15/17: Resident did not have his/her feet in his/her shoes correctly; -Approach: Staff to monitor closely and make sure his/her shoes were on correctly; -Fall on 9/18/17: Resident began to fall and staff lowered him/her to the floor; -Approach: Monitor for unsteady gait when ambulating, offer assistance. Review of the resident's current physician order [REDACTED]. -An order, dated 10/12/17, for bed and wheelchair alarms (tabbed alarms attached to clothing or pressure pad that will sound loudly when detached from base of unit, used to aid in fall reduction/prevention) for falls; -An order, dated 12/7/17, to discontinue aspirin (blood thinner) 81 milligrams (mg); -An order, dated 12/9/17, for [MEDICATION NAME] (blood thinner) 75 mg daily; -An order, dated 12/11/17, send to the emergency room for evaluation. Further review of the resident's care plan, dated 11/23/17,showed the following: -Problem: Falls; -Goal: No serious injuries that require hospitalization : -Approaches: -Ensure shoes and socks were worn and fit correctly, he/she tried to wear foot wear half off of his/her feet; -Assist with ambulation due to unsteadiness; -Bed and chair alarm on to notify staff when he/she attempted to get up unassisted; -Assist with transfers, as he/she leaned to one side when standing up; -Provide simple cues; -Keep frequently used items in reach; -Keep him/her in highly visible areas; -Keep bed in low position and locked; -Monitor for antidepressant side effects and received blood thinners, staff monitor for excessive or unusual bleeding. Review of the resident's interdisciplinary notes, showed the following: -On 11/27/17 at 11:26 A.M., Resident remained on fall incident follow up (IFU), confused, no pain or discomfort from witnessed fall that morning, tried to ambulate without assistance, lost balance and fell to the floor near nurse station on coccyx (tailbone). Staff notified the physician and obtained a new order for prothombin time / international normalized ratio (PT/INR, blood clotting test); -On 11/28/17 at 7:22 A.M., Staff found the resident on the floor, sitting on his/her buttocks with a golf ball size hematoma (a solid swelling of clotted blood within the tissues) to the back of his/her head. Low bed safety measure in place. Care plan reviewed with no additional interventions noted. Staff notified the physician; -On 11/30/17 at 3:19 P.M., Staff found the resident on the bedroom floor with a lump on the back of his/her head at the left lower lobe posterior (back lower left of the head) area. Staff made the physician aware; -On 11/30/17 at 10:13 P.M., Staff found the resident on the floor after he/she attempted to get into his/her bed, lost his/her footing and fell on to the right hip. Staff noted him/her up walking around without assistance as usual. Fall alarm intervention in place. Care plan reviewed with no additional interventions noted. Staff made the physician aware; -On 12/1/17 at 4:00 A.M., Staff found the resident on his/her back on his/her bedroom floor with no injuries noted. Safety measures in place included a low bed and kept in a highly visible area. Care plan reviewed with no additional interventions. Day nurse would notify physician and family; -On 12/1/17 at 4:41 P.M., Staff observed the resident getting out of his/her wheelchair and fell to the floor, landing on his/her right side before staff could assist. No injuries noted and staff notified the resident's family. Staff made the physician aware and he/she commented that the resident was falling to much and the Director of Nursing (DON) needed to be notified and something had to be done about the resident. Review of the Hendrich fall risk model (scoring tool used to predict likelihood of falls), dated 12/4/17, showed a score of eight, which indicated high risk for falls. Further review of the resident's interdisciplinary progress notes, showed the following: -On 12/4/17 at 4:25 P.M., Staff noted the resident sitting on the floor. Dietary staff witnessed him/her ambulating from the wheelchair and he/she lost his/her balance and landed on his/her buttocks. Staff noted no injuries and documented to keep him/her in a high visibility area. Staff reviewed the care plan with no additional interventions; -On 12/5/17: -At 9:00 A.M., Staff found the resident in his/her bathroom. He/she sat on the floor with his/her hand holding onto the sink edge. Staff noted a purple colored lump to the right side of his/her head. He/she complained of pain and held one hand over the area. Staff administered as needed (PRN) pain medication. Neurological checks appeared normal. Staff made the physician and family aware; -At 10:50 A.M., Staff found the resident on his/her buttocks in his/her room. Staff noted no new injuries, but several bruises from previous falls. The resident attempted to get out of the chair without staff assistance and staff redirected him/her several times; -At 3:45 P.M., Staff found the resident sitting on his/her bedroom floor with no injuries noted. Safety measures in place included a low bed. Staff reviewed the care plan and noted no additional interventions. Staff notified the physician and family; -On 12/6/17 at 2:11 P.M., Staff discussed the plan of care with the physician regarding the resident's frequent falls and increased bleeding risk. Staff noted new orders to discontinue aspirin, continue [MEDICATION NAME] and start gradual dose reduction (GDR, slow reduction of medication, done to reduce potential reduction side effects) of [MEDICATION NAME] (used for [MEDICAL CONDITION] (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) disorders) to determine if GDR will help reduce falls. New order obtained to begin [MEDICATION NAME] 12.5 mg twice a day for two weeks, then [MEDICATION NAME] 12.5 mg daily at bedtime for one week, then stop [MEDICATION NAME]; -On 12/7/17 at 7:40 A.M., Staff noted increased number of bruises. Bruise noted to left inner ear, left mid outer arm and left hip. The resident verbalized pain to both hips, but he/she declined pain medication and only wanted water. Staff also noted a bloody area to the back left side of his/her head. Staff cleaned the area with normal saline and performed neurological checks, which appeared within normal limits. Staff assisted him/her to bed per his/her request. Staff noted the area to the back of the head as soft with dried blood surrounding it with no further drainage noted while cleaning the site. Staff noted the bed in the low position and the walking area clear. Staff continued to monitor the resident; -On 12/7/17 at 8:49 P.M., The resident continued to get up and down out of the wheelchair with no coordination of his/her lower legs without staff assistance. He/she experienced more than five attempts to fall to the floor and all floor staff monitored him/her at intervals. He/she required one to one assistance, was very unsafe alone and not compliant with staff direction. He/she had multiple bruising to the left side of his/her face, left ear, left side of his/her head, left upper arm, both thighs and left buttocks. Further review of the resident's care plan, dated 12/7/17, showed the following: -Monitor the resident's position in the wheelchair and reposition frequently; -Toilet the resident frequently and provide activities to help reduce falls; -The care plan did not show any additional fall occurrance documentation after the 9/18/17 fall. Further review of the resident's progress notes, showed the following: -On 12/9/17 at 10:14 P.M., Staff found the resident on the floor at 3:45 P.M. after he/she propelled him/herself down hallway and slid out of the wheelchair. Safety measures in place included a low bed. Staff reviewed the care plan with no additional interventions noted. Staff awaiting return call from physician and made the family aware; -On 12/10/17 at 7:00 A.M., Staff witnessed the resident stand up from the wheelchair and fell down on his/her buttocks. He/she did not hit his/her head and staff noted no injuries. Fall interventions included to place him/her in a high visibility area. Staff reviewed the care plan with no additional interventions documented. Staff notified the family and asked if family could come sit with the resident. Staff notified the nurse practitioner of falls the prior evening and that day; -On 12/10/17: -At 10:30 A.M., The resident continued to stand up from his/her wheelchair despite reminders. Staff noted multiple large purple bruises to his/her body; -At 11:00 A.M., Family visiting and inquired about the bruising. Family voiced concern because staff reported the resident had no injuries. Staff reminded family of recent falls and the resident not wanting to stay in the wheelchair; -On 12/11/17 at 2:30 A.M., Staff found the resident on the floor of his/her room. He/she lay on his/her back and attempted to get up. Staff observed bleeding to the back of his/her head and applied pressure but could not control bleeding. Staff called for an ambulance to transport the resident to the hospital. Staff notified the family and physician, who gave a new order to send the resident to the emergency department for evaluation. Review of the resident's hospital records, dated 12/13/17 at 5:50 A.M., showed the following: -[DIAGNOSES REDACTED]. support spine to promote healing from spinal fractures or surgery), consult physical therapy for fitting; -Liver laceration grade I/II (grade 1: liver tear with no bleeding, less than 1 centimeter (cm) tear depth and grade II: liver tear with active bleeding, 1 to 3 cm depth and less than 10 cm in length): Monitor complete blood count, stabilize, diet and [MEDICATION NAME] (blood thinner) twice a day; -Left parietal scalp (left top of the head) laceration: Staples, monitor oozing and wound care. Review of the resident's current fall investigation log, received from the DON by fax on 12/12/17, showed the following: -On 11/27/17 at 11:12 A.M., Staff witnessed the resident ambulate in the hallway and he/she fell ; -On 11/28/17 at 6:00 A.M., The resident sat in his/her room with a hematoma to back of his/her head; -On 11/30/17 at 2:14 P.M., Staff found the resident on the floor of his/her room with a hematoma to his/her left lower head; -On 11/30/17 at 10:13 P.M., The resident fell on his/her right hip when he/she attempted to get out of bed; -On 12/1/17 at 4:00 A.M., Staff found the resident on the floor of his/her room, lying on his/her back; -On 12/1/17 at 4:41 P.M., The resident stood up from his/her wheelchair in the hallway and fell on to his/her right side; -On 12/4/17 at 4:25 P.M., Dietary staff found the resident sitting on the dayroom floor; -On 12/5/17 at 9:00 A.M., Staff found the resident in his/her bathroom, holding onto the sink with a lump on the right side of his/her head; -On 12/5/17 at 10:50 A.M., Staff found the resident in his/her room, sitting on floor; -On 12/5/17 at 3:45 P.M., Staff found the resident in his/her room, sitting on floor next to the bed with no injury noted; -On 12/9/17 at 3:45 P.M., Staff found the resident sitting in the hallway; -On 12/10/17 at 7:00 A.M., Staff witnessed the resident stand and fall from his/her wheelchair in the hallway; -On 12/11/17 at 2:30 A.M., Staff found the resident on his/her back on his/her bedroom floor. Staff noted the resident bled from the back of his/her head and sent him/her out to the emergency room ; -The fall investigation log did not show interventions attempted after each fall or detail further investigation into the falls. Observation on 12/11/17 at 1:00 P.M., showed the resident's bed linen removed from the bed and his/her wheelchair near the head of the bed with no safety alarms on the bed or the wheelchair. During an interview at that time, Licensed Practical Nurse (LPN) E said the resident did not use bed or chair alarms. He/she did not know of any orders for bed or chair alarms. The night shift nurse told him/her about the fall the resident had in the early morning and did not report any alarm had sounded. The night shift nurse knew someone needed help when he/she heard the resident's roommate yelling. During an interview on 12/11/17 at 2:30 P.M., Certified Nurse's Aide (CNA) D said he/she normally cares for the resident during the day and was familiar with his/her care needs. He/she learned during report that morning that the resident fell during the night, cut the back of his/her head and went out to the hospital. The resident used a bed and chair alarm a few times in the past, but he/she had not seen any alarms on the resident's bed or wheelchair for a long time. Staff do not walk with the resident. The resident often tried to get out of his/her wheelchair. At one time, the resident walked with a cane. During an interview on 12/12/17 at 1:25 P.M., LPN F said early in the morning on 12/11/17, he/she heard the resident's roommate yell out for help. He/she went to the room and found the resident sitting on his/her buttocks. No bed or chair alarm sounded. The resident attempted to pull him/herself up off the floor. The resident had a cut to the back of his/her head and LPN F attempted to stop the bleeding. The bleeding did not stop, so he/she sent the resident to the emergency room . In the past, the resident used bed and chair alarms, but he/she had not seen the resident use alarms for over a month. He/she heard the resident was admitted to the hospital for a head injury and back fracture. During an interview on 12/12/17 at 2:38 P.M., the resident's family member said the hospital admitted the resident due to a scalp laceration which needed four staples and a lower back fracture from the fall on 12/11/17. The hospital would fit the resident for a special back brace for the fracture. The resident had large bruises across his/her abdomen and left side. At one time, the resident had bed and chair alarms, but the sound frightened him/her, so he/she pulled the alarms off and tried to break them. The resident had not had alarms on for a long time. He/she felt it was difficult for the resident to understand what was happening because he/she only speaks another language. He/she was frustrated with the bruising, frequent falls and recent injury that the resident experienced at the facility. He/she thinks more could be done to help prevent or slow the falls. He/she does not have the time to come and sit with the resident like the facility wanted him/her to do and the rest of the family members are busy as well. During an interview on 12/13/17 at 8:00 A.M., the physical therapy director said skilled therapy was discontinued on 10/4/17. The resident had good balance, poor memory and compulsive, repetitive behaviors. He/she could not see objects clearly and while in a wheelchair, would attempt to get up without assistance. Therapy staff attempted to use a walker for ambulation but was unsuccessful. At the time of discharge from therapy, the resident used a quad cane (cane with four feet to aid in balance) but was too confused. Nursing staff should notify therapy of resident falls and therapy staff should then assess the resident for therapy services. At the time of therapy discharge, the resident started restorative therapy and nursing staff received education that the resident needed close supervision related to his/her frequent fall history. He/she did not remember any alarms used on the resident's bed or wheelchair. During an interview on 12/13/17 at 9:21 A.M., the resident's physician said the resident had [DIAGNOSES REDACTED]. He/she completed therapy in (MONTH) (YEAR) and used a cane at the time of discharge from therapy. He had suggested to facility management the possibility of using a merri-walker (rolling walking/sitting device to aide in mobility) several weeks ago after multiple falls, but management did not respond to his inquiry. The resident experienced advancing dementia, a language barrier and did not appear to understand what was said or express his/her needs. He felt that something bad would eventually happen and was frustrated regarding the frequency of the falls. He expected alarms to be in place as ordered to alert staff when the resident attempted to ambulate without assistance. During an interview on 12/13/17 at 9:40 A.M., the hospital social worker said the resident admitted to the hospital as a trauma patient on 12/11/17 for a [MEDICAL CONDITION] that required four staples for closure and multiple large areas of bruising. A sitter needed to be with the resident for 24 hours a day to maintain safety. A special back brace had been fitted related to a spinal fracture. He/she anticipated the resident would remain admitted for several days and would most likely receive therapy services. He/she was assisting the family to relocate the resident to a different long term care facility. During an interview on 12/13/17 at 10:10 A.M., the DON said physician orders [REDACTED]. The resident used alarms at one time, but he/she would pull them off and break them when the alarm sounded. The resident was not appropriate for alarms and per cooperate policy, merri-walkers are not allowed in the facility. The resident probably would have crawled over the merri-walker and to his/her knowledge, a merri-walker was not attempted. The resident also had a language barrier and it is unclear how much he/she understood. Each fall should be listed on the resident's care plan with updated interventions. Charge nurses view the care plan after each fall and should update the interventions. During daily morning rounds, the MDS coordinator should update care plans for any residents that had a fall. During an interview on 12/13/17 at 3:00 P.M., the MDS Coordinator said the management had asked the resident's family to come and sit with him/her to help keep him/her from falling and occupy him/her. The family told management they did not have the time to come sit with the resident for extended periods of time. He/she adds interventions to the care plans. The facility did not have managers to assist him/her with updating care plans and he/she found it difficult to track them and keep up. The management recently hired more nurse managers, but the new staff are not fully trained yet. Care plan meetings are done quarterly, as needed or if the family requests a meeting with management. During an interview on 12/13/17 at 3:00 P.M., the DON said the facility did not follow the fall policy to evaluate, change or implement new interventions after each of the resident's falls. Charge nurses should have reviewed the resident's care plan and changed or add interventions. During daily morning rounds, the management team discussed falls that occurred the day before and the MDS Coordinator should have made changes to the care plan to include the most recent falls and updated interventions at that time. No current interventions had worked for the resident and he/she continued to fall. Management did not know what else to do. Merri-walkers are not allowed in the facility per policy. 2. Review of Resident #53's care plan, dated 7/31/17, showed the following: -Problem: History of falls related to cognition and unsteadiness at times; -Goal: Remain free from injury related to falls; -Approach: Keep in a highly visible area where staff can keep an eye on him/her; -Keep floors and walkways free from spills and clutter; -Provide adequate, glare free lighting; -Keep frequently used items in reach; -Assist to wear non-skid footwear; -Keep call light in reach; -Provide activities that minimize fall potential while providing diversion and distraction; -Assist at earlier times for bedtime; -Staff monitoring during dining times; -Attempts to get up alone, staff monitor closely; -Assist with repositioning in wheelchair frequently; -Toilet frequently; -Monitor vital signs as ordered for low heart rate; -Monitor for restlessness when up in chair and assess needs. Review of resident's significant change MDS, dated [DATE], showed the following: -BIMS, score of two out of a possible score of 15, which indicated severe cognitive impairment; -No behaviors; -Walked in room or corridor once or twice, needed physical assistance from staff to ambulate; -Not steady during transitions or walking, only able to stabilize with human assistance; -No assistive devices (walker, wheelchair, cane) used for mobility; -Hospice services; -No range of motion impairments; -Experienced two or more falls with no injury and two or more falls with injury, but not major injury; -[DIAGNOSES REDACTED]. Review of the resident's Hendrich fall model score, dated 11/7/17, showed a score of 11, which indicated a high fall risk. Review of the resident's interdisciplinary note, dated 12/9/17, showed the resident noted sitting on the floor in the dining room by a CNA at 5:45 P.M. The resident's wheelchair was unlocked. He/she sat at the dining room table while he/she waited for dinner, attempted to transfer him/herself from the wheelchair to a dining room chair. Staff noted no injuries. Safety measures in place at time of fall included a low bed. Fall interventions in place included to keep him/her in a high visibility area. Staff reviewed the care plan with no additional interventions noted at that time. Further review of the resident's care plan, showed no documentation regarding the fall on 12/9/17. 3. Review of Resident #54's admission care plan, dated 12/7/17, showed the following: -Problem: Potential for falls related to recent admission to community, medical history, confusion and decline in activities of daily living (ADLs, daily self care tasks); -Goal: Remain free from injury related to falls; -Approach: Keep pathways clear and provide adequate lighting; -Keep bed at appropriate height; -Keep personal items in reach; -Transfer him/her per intake information until seen by therapy, then follow therapy recommendations/plan of treatment; -Orientate to room and call light; -Encourage to stay at nurses station, assist by staff and monitor; -Ensure safety with transfers, properly working equipment; -Alarm as indicated. Review of the resident's Hendrich fall model score, dated 12/7/17, showed a score of 10, which indicated a high risk for falls. Review of the resident's interdisciplinary notes, showed: -On 12/8/17 at 10:42 P.M., the resident made multiple attempts to get out of bed and sit on the side of the bed. Staff explained fall hazards and that he/she is a fall risk and had fallen in the recent past, but unable to redirect him/her. Assisted up with Hoyer (mechanical lift used to lift and transfer with a minimum of physical effort) and three staff and placed by the desk to observe and engage in conversation. He/she sat with the nurse and staff for two hours and talked pleasantly and appropriately. Staff then took him/her to bed, with no further attempts to get out of bed; -On 12/9/17 at 4:15 A.M., staff noted the resident threw his/her legs out of bed. Staff monitored him/her every hour, repositioned his/her legs in bed and placed call light in reach; -On 12/10/17 at 1:47 A.M., Staff found the resident sitting on the floor during hourly rounds with his/her back against the bed. Staff noted the bed in the lowest position and the resident confused per usual. He/she stated he/she reached for a sweater to get dressed for the day, but staff noted no visible clothing available. Upon assessment, staff noted an abrasion to the left knee, which measured 0.5 cm.; -On 12/10/17 at 8:30 A.M., the resident appeared confused and tried to get up out of bed unattended; -On 12/10/17 at 6:43 P.M., staff noted the resident in his/her wheelchair, as he/she continued to attempt to stand without assistance. Staff noted the resident very confused about his/her location and about his/her dog; -On 12/11/17 at 1:25 A.M., during a Hoyer lift transfer, the Hoyer legs tilted over, the resident went down to the floor and hit his/her head on the side of the bed. Staff lowered his/her legs to the floor. He/she denied pain and stated he/she hit his/her head. Upon assessment, staff noted no injuries. Staff notified the DON and physician. New orders obtained to send him/her to the emergency room for evaluation; -On 12/11/17 at 7:39 A.M., the resident returned from the hospital, where he/she received a scan of his/her head and neck with no abnormal findings. Staff transferred him/her to bed and placed the call light in reach; -On 12/11/17 at 10:22 P.M., the resident appeared alert and confused. He/she required constant redirection, as he/she attempted to get out of his/her chair, used incomprehensible words, used wrong words in sentences, became violent and cursed staff. At dinner, staff attempted to redirect him/her, as he/she attempted to get out of the chair and fight the nurse. Staff kept him/her at the nurse's station for observation through the night. He/she could not be left alone, as he/she was a high fall risk due to confusion. Staff notified the physician of the behaviors. Further review of the resident's current care plan, showed no documentation regarding the recent falls in (MONTH) (YEAR). 4. Review of Resident #68's quarterly MDS, dated [DATE], showed the following: -BIMS score of 15 out of a possible 15, which indicated cognitively intact; -Extensive assistance required for hygiene; -[DIAGNOSES REDACTED]. Review of Resident #69's quarterly MDS, dated [DATE], showed the following: -BIMS score of one out of a possible 15, which indicated severe cognitive impairment; -Extensive assis

Based on interview and record review, the facility failed to provide ongoing pain assessment, failed to communicate the resident's pain, failed to administrator pain medication, failed to provide a physical assessment after a complaint of pain and failed to read the x-ray results thoroughly for a resident who sustained a femoral fracture at the facility. This affected two of two sampled residents (Residents #2 and Resident #3) The census was 133. 1. Review of Resident #2's undated face sheet, showed he/she was admitted to the facility on [DATE]. Review of the admission nursing assessment, dated 2/24/15 at 7:32 P.M., showed the resident denied current pain. Staff documented the resident had received as needed (PRN) pain medications. Staff did not complete the pain evaluation. Review of the resident's care plan, dated 2/24/15, showed the following: -Problem: the resident needs to have a pain evaluation completed and pain monitored; -Goal: the resident will have a pain evaluation completed upon admission and will have pain controlled; -Approaches: complete pain evaluation upon admission and monitor the resident for changes in pain level. Notify physician of any changes noted. Review of the physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -[MEDICATION NAME] 325 milligrams (mg) two tablets by mouth PRN every four hours. Review of the Medication Administration Record [REDACTED]. Review of the Physical Therapy (PT) note, dated 2/25/15 at 2:19 P.M. showed PT I documented he/she evaluated the resident. The resident required maximal assistance for a sitting position on the edge of his/her bed. The resident demonstrated retropulsiviness (uncontrolled body movements) and required maximal assistance to maintain a sitting position on the edge of the bed. Maximal assistance of two staff was required to bring the resident to a standing position and perform a pivot transfer to the wheelchair. PT I communicated to the charge nurse about the resident's safety and requested he/she be placed at the nurse's station and not be left alone in his/her room. During an interview on 3/4/15 at 9:48 A.M., PTA F said he/she provided physical therapy on 2/26/15. The resident had a [DIAGNOSES REDACTED]. On 2/26/15 the resident could not follow the exercises or verbal instructions. The resident ambulated 20 feet and then 23 feet with maximum assistance with walker management. He/she did not complain of pain on 2/26/15 during the exercises. Review of the physical therapy assistant (PTA) note, dated 2/27/15 at 1:38 P.M., showed PTA F documented the resident rode the exercise bike, at level three, for five minutes for reciprocal motion and strengthening. The resident completed 20 long arc quad (lower extremity kicking exercise) and 20 hip flexion (lower extremity leg exercise to hold the knee up and out) to increase lower extremity stretching for functional mobility. The resident stood at his/her walker for ten minutes with minimum to moderate assist. Gait training with a wheeled walker and moderate assist for 80 feet three times and 40 feet two times with short shuffling steps with verbal and visual instructions to increase bilateral hip/knee flexion and step length. Sit to stand transfers with minimal assist with tactile instructions for hand placement to push up from the wheelchair and to reach back for the wheelchair when transferring from the sit to stand position. During an interview on 3/4/15 at 9:48 A.M., PTA F said he/she provided physical therapy on 2/27/15, the resident did a lot better in therapy. He/she rode the exercise bike for leg strengthening for five minutes with no complaints of pain and ambulated 80 feet three times and 40 feet twice with moderate assistance. The resident participated in sit to stand transfers with minimal assistance and pushed up from the wheelchair arms. The resident did not complain of pain on 2/27/15. During an interview on 3/5/15 at 12:49 P.M., Certified Nurse Aide (CNA) M said he/she worked on 2/28/15 from 11:00 P.M. through 7:00 A.M and was assigned to the resident. The resident was a busy body. He/she tried to get out of bed multiple times throughout the night. The resident's bed was lowered to the floor. CNA M provided incontinence care for the resident multiple times during the shift. CNA M rolled the resident side to side to change the incontinence brief. The resident did not complain during that shift. The resident fell asleep and woke up at approximately 6:00 A.M. CNA M provided incontinence care to the resident and dressed him/her at that time. CNA M transferred the resident to his/her wheelchair with a gait belt. The resident did not complain of pain during the incontinence care or the transfer from bed to wheelchair. The resident stood up well during the transfer and put weight on both legs. Review of the PTA note, dated 3/1/15 at 1:20 P.M., showed PTA G documented the resident participated in the bean bag toss exercise reaching and crossing the midline with one upper extremity support for balance. PTA G assisted the resident to ambulate 120 feet two times with the wheeled walker. The resident did sit to stand transfers with minimal assistance with verbal and tactile cues for hand placement. During an interview on 3/1/15 at 10:20 A.M., PTA G said he/she saw the resident in therapy on 3/1/15 from approximately 12:55 P.M. through 1:30 P.M. The resident stood with his/her walker and participated in the bean bag toss exercise. The resident ambulated 120 feet twice with a wheeled walker with no complaint of pain and no facial grimacing. PTA G wheeled the resident back to the nurse's station. During an interview on 3/4/15 at 8:00 A.M., CNA L said he/she worked on 3/1/15 from 7:00 A.M. through 3:00 P.M. CNA L was assigned to the resident. CNA L heard a loud noise around 2:30 P.M. and went to the resident's room. The resident was on the floor. Nurse J assessed the resident immediately and staff transferred the resident to his/her wheelchair. The resident had skin tears on his/her left arm and left hand but did not complain of any other pain at that time. The resident was a wiggle worm. He/she always tried to stand up from his/her wheelchair and propelled him/herself around the facility. Staff redirected the resident to sit down often. The resident wore a yellow high fall risk band on his/her wrist that was from the hospital so staff kept him/her at the nurse's station to keep an eye on the resident. CNA L did not transfer or toilet the resident after the fall. Review of the nurse's notes, dated 3/3/15 at 9:20 P.M., with a late entry, dated 3/1/15, which showed a CNA reported the resident was on the floor. The nurse observed the resident lay on the floor in his/her room in the supine position (to lay flat), holding his/her head up. The resident denied hitting his/her head. Skin tears were noted to his/her left arm and right hand. The resident was verbal and never lost consciousness. The resident was attempting to put him/herself in bed. During the assessment, the resident said, I am not hurting, I just hurt my arm. The resident was able to move all extremities within normal limits. The resident was assisted off the floor, assisted by two staff and seated in his/her wheelchair. Treatment was provided to the skin tears and the resident was positioned behind the nurse's station. The resident's physician and family were notified of the fall. During an interview on 3/5/15 at 12:45 P.M., Nurse J said he/she worked on 3/1/15 from 6:45 A.M. through 3:15 P.M. He/she recalled the resident did not understand safety awareness and always tried to stand up from his/her wheelchair. Staff redirected the resident often to sit down. Around 2:45 P.M., a CNA notified him/her the resident was found on the floor in his/her room. Nurse J assessed the resident for injuries and did range of motion to ensure the resident was not injured. The resident sustained [REDACTED]. The resident did not complain of pain during the assessment. Three staff transferred the resident to his/her wheelchair and put him/her at the nurse's station so staff could keep an eye on the resident. Nurse J left the facility at 4:00 P.M. and notified the evening shift nurse, Nurse K, that the resident fell and sustained skin tears. No staff reported the resident was in pain after the fall. Nurse J did not provide care for the resident again after this shift. During an interview on 3/9/15 at 11:25 A.M., CNA Q said he/she worked on 3/1/15 from 3:00 P.M. through 11:00 P.M. CNA Q was assigned to the resident. The charge nurse notified CNA Q that the resident fell earlier that day. When CNA Q toileted the resident twice prior to transferring him/her to bed, the resident did not complain of pain during that time. CNA Q provided incontinence care for the resident while he/she lay in bed. While CNA Q rolled the resident side to side, the resident moaned and said, Ohhhhh. CNA Q did not ask the resident if he/she had pain. CNA Q notified Nurse K the resident moaned and grimaced during incontinence care. During an interview on 3/5/15 at 2:15 P.M., Nurse K said he/she worked on 3/1/15 from 3:00 P.M. through 11:00 P.M. Nurse J told him/her the resident fell and sustained a few skin tears but that he/she was ok. Nurse K checked on the resident often during the shift. The resident was at the nurse's station so staff could keep an eye on him/her because the resident would often try to stand up from his/her wheelchair and was a high fall risk. Nurse K did not observe if the resident's left leg was externally rotated that shift. No staff reported to him/her that the resident expressed pain. During an interview on 3/5/15 at 12:49 P.M., CNA M said he/she worked on 3/1/15 from 11:00 P.M. through 7:00 A.M. He/she was assigned to the resident. The nurse reported to him/her the resident fell earlier that day. When CNA M checked on the resident at approximately 2:00 A.M., the resident was awake and watching television. CNA M provided incontinence care to the resident at 2:00 A.M. When CNA M rolled the resident from side to side, the resident yelled out, oh that hurts, that hurts! The resident also cursed and said, Oh[***] that [***] ing hurts! CNA M told the charge nurse about the resident's complaint of pain at 2:00 A.M. CNA M provided incontinence care for the resident again at approximately 4:30 A.M. While he/she rolled the resident from side to side, the resident moaned and yelled out in pain. CNA M thought the charge nurse could hear the resident yelling at the nurse's station. CNA M put the resident's pants on but did not get the resident up that morning because the resident was in severe pain. The resident asked for a heating pad for his/her back to take the pain away. The resident did not attempt to get out of bed during this shift, as he/she did the night shift before. The resident did not move in the bed during the shift. During an interview on 3/5/15 at 10:14 A.M., Nurse C said he/she worked on 3/1/15 from 10:45 P.M. through 7:30 A.M. The evening shift nurse notified him/her the resident fell earlier that day and that the resident was ok and had no complaints of pain. No staff reported to Nurse C of the resident complaining of pain during the shift. He/she administered a subcutaneous injection in the resident's left abdominal area at approximately 5:30 A.M. and observed the resident flinched. Nurse C recalled he/she asked if the resident was in pain and he/she said no. Nurse C did not physically assess the resident further at that time but notified the oncoming day shift, Nurse D of the resident flinching during the injection and told him/her to notify the resident's physician for a left hip x-ray. Nurse C thought the resident's left hip was fractured. Nurse C did not document in the resident's medical record because he/she notified Nurse D and was already staying late at the facility that shift. During an interview on 3/5/15 at 11:00 A.M. Nurse D said he/she worked on 3/2/15 from 6:45 A.M. through 3:15 P.M. Nurse C told him/her in nurse report that the resident flinched when he/she administered a subcutaneous medication injection. Nurse D thought the resident flinched due to the needle injection. Nurse C did not recall Nurse D telling him/her to get an x-ray of the resident's left hip to rule out a [MEDICAL CONDITION]. Nurse D did not do any further physical assessment on the resident at that time. Review of the facility staffing pattern, dated 3/2/15, showed CNA L and CNA BB were assigned to the resident for the 7:00 A.M. through 3:00 P.M. shift. During an interview on 3/2/15 at 8:00 A.M., CNA L said he/she worked at the facility on 3/2/15 from 7:00 A.M. through 3:00 P.M. CNA L could not recall if he/she was assigned to the resident that shift. CNA L did not recall transferring the resident on that day. During an interview on 3/2/15 at 1:35 P.M., CNA BB said he/she was a new employee at the facility and did not recall working with the resident or who the resident was. During an interview on 3/4/15 at 8:50 A.M., the corporate nurse said she observed the resident at the nurse's station at approximately 10:00 A.M. on 3/2/15. The resident was sitting up in his/her wheelchair and smiling. The corporate nurse recalled talking to the resident and observing that he/she needed to be shaved. PTA F came to the floor to get the resident for a therapy session and notified her he/she would talk to OT about getting the resident shaved. The resident did not have signs or symptoms of pain or distress at that time. Review of the PTA note, dated 3/2/15 at 9:27 A.M., showed PTA F documented he/she instructed the resident to do lower extremity exercises including long arc quad, hip flexion and hip abduction and adduction (a lower extremity exercise taking leg away and back toward the midline). The resident did 20 repetitions per exercise twice. During these exercises, the resident complained of left lower extremity pain with all activities on this day. The resident required constant redirection throughout therapy to maintain the task at hand. While the resident stood up for standing balance training, he/she stood in front of the walker with minimal weight bearing on his/her lower left extremity. The resident voiced lower left extremity pain. The resident required minimal assistance to moderate assistance to maintain standing for five repetitions for 30 seconds to two minutes. PTA F attempted gait training with a wheeled walker on multiple occasions, but the resident was limited to one to three steps each time with maximum assistance and maximum tactile instructions. The resident was limited due to left lower extremity pain, as voiced per the resident. At the beginning of the therapy session, the resident required minimal to moderate assistance with verbal and tactile instructions 100% of the time for hand placement and sequencing to push up from the wheelchair and to reach for the walker when standing. By the end of the therapy session, the resident required moderate to maximum assistance for sit to stand transfers. The resident had increased upper extremity shakiness throughout the therapy session. The resident attempted to participate in sit to stand transfers with verbal instructions for hand placement but was unable to lift his/her bottom off the chair without physical assistance. The significant physical decline was reported to nursing, and also reported the resident's frequent complaint of left lower leg/hip pain. During an interview on 3/4/15 at 9:48 A.M., PTA F said he/she provided physical therapy on 3/2/15. He/she wheeled the resident to therapy at approximately 8:50 A.M. The resident placed his/her hands on the wheelchair arms but would not stand up. The resident expressed facial grimacing and said, I can't! I can't! It hurts! The resident told PTA F, I fell out of a window! PTA F assisted the resident to stand up and the resident would sit back down. PTA F attempted to ambulate the resident and he/she walked one to two steps. The resident tried to sit down in the wheelchair. The resident pointed at his/her left thigh area. PTA F did not observe any abnormalities regarding the resident's left leg. He/she continued to instruct the resident to do range of motion exercises on his/her lower extremities, including long arc quad extensions and hip flexion exercises. The resident did approximately ten of these exercises on his/her left leg. He/she continued to verbally complain of left leg pain and had facial grimacing. The resident said, It hurts, I fell out of that window! PTA F wheeled the resident back to his/her floor at approximately 9:15 A.M. He/she went to talk to the resident's nurse but he/she was swamped with four or five other people at the nurse's station. PTA F transferred the resident to his/her bed. During the transfer, the resident yelled out in pain and showed facial grimacing. The resident did not put weight on his/her left lower extremity at that time. PTA F was not aware the resident fell on [DATE]. The resident's family spoke with him/her 20-30 minutes after he/she lay the resident in bed and they told him/her of the recent fall. At approximately 11:00 A.M., PTA F went back to the resident's floor to speak with the resident's nurse. He/she reported to the resident's nurse that the resident had a significant decline in therapy that morning and complained of left leg pain. He/she told the nurse the resident ambulated 120 feet on 2/27/15 with minimal assistance, and that day the resident required maximal assistance with ambulation. The nurse told PTA F he/she would notify the resident's physician and try to get his/her left leg x-rayed. PTA F did not know if the nurse assessed the resident at that time or if he/she administered pain medication to the resident. During an interview on 3/5/15 at 11:00 A.M. Nurse D recalled therapy reported that the resident had a significant decline in therapy since 2/27/15. The resident refused to stand or ambulate on the morning of 3/2/15 and complained of pain and discomfort on his/her left leg during therapy exercises. Nurse D notified the resident's physician and got an order for [REDACTED]. Nurse D did not want to cause more harm to the resident by doing a physical assessment. Therapy did not communicate to Nurse D that the resident did not put weight on his/her left leg when therapy transferred the resident to bed. If the therapist would have communicated the resident's complaint of pain, Nurse D would have palpated the area of pain and assessed for swelling and other abnormalities. Nurse D did not assess if the resident's left leg was externally rotated at that time. Review of a correction/addendum nurse's note, dated 3/3/15 at 4:04 P.M. for 3/2/15, showed the resident was up in his/her wheelchair when the nurse arrived. The resident smiled and showed no signs or symptoms of pain or distress. The resident went to therapy. Therapy staff notified the nurse the resident was unable to stand or ambulate as he/she did before. The resident complained of left hip and pelvis pain. Review of the MAR, dated 3/2/15, showed no documentation of PRN Tylenol administered. Review of the POS [REDACTED]. Review of the nurse's note, dated 3/2/15 at 12:51 P.M., showed the resident continued on incident follow up. The resident complained of hip pain. A left hip x-ray was ordered. Review of the Occupational Therapy (OT) note, dated 3/2/15 at 5:34 P.M., showed OT H saw the resident in the dining room for self feeding. OT H wheeled the resident to his/her room. The resident removed his/her shirt with minimal assistance and put his/her shirt back on with minimal assistance and with maximum verbal cues. Per nursing, the resident fell yesterday and had hip pain and impaired function. An x-ray had been ordered. The resident did not complain of pain at that time. During an interview on 3/4/15 at 10:40 A.M., OT H said he/she saw the resident on 3/2/15 at 5:00 P.M. during dinner time. Nursing staff reported to him/her the resident recently fell , so not to stand the resident up because they were waiting for an x-ray to be completed. OT H asked the resident if his/her left hip hurt and the resident said, Yes, it hurts. The resident was confused related to alcohol detox and was unable to participate in the pain scale at that time. The resident was not grimacing at that time. OT H wheeled the resident to his/her room and assisted him/her to take his/her shirt on and off and on with minimal assistance with maximum verbal cues. The resident did not complain of pain at that time. When a resident was initially evaluated in therapy, the therapist assessed for pain. When a resident did not complain of pain initially, then had a new complaint of pain, he/she would stop the exercises and find the resident's nurse to see if he/she could have pain medication. If the pain was ongoing and interfered with therapy or the resident could not tolerate the pain, OT H would notify the resident's nurse. During an interview on 3/6/15 at 8:45 A.M., CNA N said he/she worked on 3/2/15 3:00 P.M. through 11:00 P.M. and was assigned to the resident. The charge nurse told CNA N the resident fell on [DATE]. When CNA N transferred the resident from his/her wheelchair to his/her bed, the resident complained of back pain and grimaced. CNA N told Charge Nurse E about the resident's complaint of back pain. Nurse E told CNA N the resident was waiting on an x-ray. During an interview on 3/5/15 at 10:14 A.M., Nurse C said he/she worked on 3/2/15 from 10:45 P.M. through 7:30 A.M. Nurse E told him/her they were waiting on an x-ray. No staff reported to Nurse C of the resident complaining of pain during the shift. He/she called the x-ray company around 1:00 A.M. because the x-ray had not been completed yet. The x-ray technician arrived to the facility at approximately 1:30 A.M. He/she was not in the room when the x-ray was obtained. The x-ray results were faxed to the facility at 1:43 A.M. Nurse C said the x-ray report showed the results of the left hip and the left hand on the same page. When he/she read the x ray report, Nurse C read the conclusion at the bottom of the page that showed no acute abnormalities. Nurse C said Nurse E was still at the facility and also read the x-ray to be negative at that time also. He/she gave the x-ray report to Nurse D, the day shift nurse, on 3/3/15 at approximately 7:00 A.M. and notified him/her the x-ray was negative. During an interview on 3/5/15 at 2:15 P.M., CNA P said he/she worked on 3/2/15 from 11:00 P.M. through 7:00 A.M. CNA P was assigned to the resident. The charge nurse was Nurse C. Nurse E stayed late that shift and told CNA P to be careful with the resident because he/she had a fall the day before and was waiting for x-rays to be done. At approximately 11:30 P.M., CNA P entered the resident's room to check on the resident and provide incontinence care. The resident lay in bed and refused for CNA P touch him/her because he/she was hurting. CNA P put a urinal on the resident's bed side table for the resident to use. CNA P thought the x-ray was for his/her hand because the resident complained it hurt. The resident did not want to be bothered or touched at that time. The resident was not trying to get out of bed that shift. Throughout the shift, CNA P checked on the resident. He/she used the urinal a few times. The x-ray technician was at the facility at 1:00 A.M., CNA P was not in the room when the x-ray was taken because he/she was taking care of other residents. At approximately 4:00 A.M., the resident was incontinent, so CNA P just barely moved the resident to change the incontinence brief because he/she was hurting really bad. The resident grimaced as CNA P provided incontinence care. CNA P did not know what was hurting the resident at that time because the resident did not respond to the question. When CNA P attempted to remove the incontinence pad from under the resident, the resident would not move to his/her left side because he/she was guarding that side. When CNA P touched the resident, he/she yelled, Ouch! CNA P said the nurses already knew the resident was in pain, and that was why an x-ray was ordered. As long as CNA P did not physically touch the resident, he/she would not complain of pain. CNA P did not transfer the resident to his/her wheelchair in the morning. The resident lay in bed the entire shift. Review of the MAR, dated 3/2/15, showed no documentation that staff administered Tylenol to the resident. During an interview on 3/9/15 at 10:52 A.M., CNA R said he/she worked on 3/3/15 from 7:00 A.M. through 3:00 P.M. CNA R was assigned to the resident. CNA R could not recall if staff told him/her the resident fell . CNA R and another CNA transferred the resident from his/her bed to his/her wheelchair. CNA R did not recall if the resident expressed pain at that time. CNA R said the resident was usually a one-person transfer but was a two-person transfer that morning because he/she was not standing up well. CNA R did not provide incontinence care for the resident or toilet him/her that morning. The night shift CNA had changed the resident's incontinence brief and the resident was dry. During an interview on 3/5/15 at 11:00 A.M., Nurse D said he/she worked on 3/3/15 from 6:45 A.M. through 3:00 P.M. Nurse D said during nurse report, Nurse C told him/her the resident's x-ray results were negative for fracture. He/she believed Nurse C and did not read the x-ray results him/herself. The resident's physician arrived at the facility at approximately 7:30 A.M. Nurse D notified him the x-ray results were negative for fracture and showed him the x-ray report. Nurse D said the resident's physician said that the resident had a left [MEDICAL CONDITION] and to send the resident to the hospital immediately for further evaluation and treatment. Review of a nurse's note, dated 3/3/15 at 7:35 A.M., showed the resident's primary care physician (PCP) was at the facility and read the x-ray results. The resident's left hip had an intertrochanteric femoral (hip bone) fracture. The resident was put to bed and (was given) nothing by mouth (NPO.) An ambulance transported the resident to the hospital for further evaluation and treatment at 8:20 A.M. The resident's family was notified of the fracture. Review of the x-ray report, showed x-ray results for the resident's left hip and left hand on the same page. The x-ray showed an acute, nondisplaced intertrochanteric femoral [MEDICAL CONDITION]'s left hip. The left hand x-ray results, showed no acute osseous (bone) abnormality. The x-ray results were faxed to the facility on [DATE] at 1:43 A.M. Review of the POS [REDACTED] -Send the resident to the hospital for acute left [MEDICAL CONDITION]; -NPO. During an interview on 3/5/15 at 2:45 P.M., the resident's PCP said as a rule, when a resident fell and had no complaint of pain or injuries, he told staff to observe the resident for pain. After a resident fell and was being seen by therapy, he expected staff to communicate with therapy that the resident had a fall prior to the resident's next therapy session so therapy could be on the lookout for physical decline and signs and symptoms of pain. While a resident was in a therapy session and complained of new pain, the physician expected the therapy staff to stop the therapy session immediately, and wheel the resident to their nurse for further evaluation. While staff provide care for the resident and the resident had a new pain complaint, the physician expected staff to tell the charge nurse immediately so the nurse could physically assess the resident. This included range of motion, palpating the area of pain and also assessing if the resident's leg was externally rotated. If physical therapy was continued and the resident continued to complain of left lower extremity pain, the physician expected staff to stop the therapy exercises immediately to ensure the resident was assessed by a nurse to prevent further damage to the area of concern and cause increased pain. Pain medication should be administered in a timely manner and nursing should re-evaluate the resident's pain level 30-60 minutes later to ensure the pain medication was effective. If the pain medication was not effective, the physician expected staff to notify him. The physician would prescribe a stronger pain medication or send the resident to the hospital for further evaluation and treatment. The resident's PCP expected the nurses to read the x-ray report thoroughly and to notify him that the resident's hip was fractured in a timely manner. He would have ordered the resident to be sent to the hospital for further evaluation and treatment when the x-ray results were faxed to the facility on [DATE] at 1:43 A.M., to ensure the resident received pain medication and treatment for [REDACTED]. After he read the x-ray report, the physician wheeled the resident out of the dining room so the resident would not eat anymore breakfast, because he/she might need surgery. He did not tell staff the resident was to be NPO at that time. The resident did not express signs or symptoms of pain, but he did not physically assess the resident at that time because the x-ray showed his/her hip was fractured. During an interview on 3/4/15 at 12:55 P.M., the Director of Therapy said when a resident had a new complaint of pain, she expected therapy staff to determine the cause of the pain. Staff should report the complaint of pain to the nurse to determine if the resident fell recently. If the resident's nurse was busy, she expected therapy staff to report the complaint of pain to the resident's nurse manager. She expected staff to make the resident comfortable and to determine the resident's complaint of pain on a scale of zero through ten, with ten being the most pain. If the resident continued to complain of pain, she expected therapy staff to do other exercises that did not cause pain. The facility had a stand up meeting Monday through Friday. Falls and accidents were discussed in these meetings and she usually attended them. The Director of Therapy could not recall if she went to the stand up meeting on 3/2/15. No other therapy staff went to the stand up meeting if she did not go. When a resident fell , it was communicated verbally to the therapy department. She was unaware the resident fell on [DATE] until PTA F told her the resident's family member told him/her. It was important to know the resident had a recent fell so the therapy department could assess the mechanism of the fall and to assess for injuries. The Director of Therapy said staff kept a close eye on the resident because he/she tried to get up on his/her own often. The resident's strength and balance were improving and the resident ambulated with minimal assistance prior to the fall. She was unaware of additional interventions put in place after the fall on 3/1/15. During an interview on 3/4/15 at 1:10 P.M., Physical Therapist (PT) I said he/she evaluated the resident on 2/25/15. The resident was confused and was not oriented at all. The resident did not complain of pain during the evaluation. He/she and a CNA transferred the resident from his/her bed to his/her wheelchair with maximum assistance. The resident was pretty out of it at that time. He/she did not hear the resident fell until 3/3/15. PT I did not go to the facility stand up meeting in the morning. He/she expected nursing staff to communicate with therapy that the resident had a fall prior to the next therapy session so therapy staff could be aware of the fall and to keep an eye out for any complaints. When a resident was assessed to have a

Based on observation, interview and record review, the facility failed to appropriately assess and keep the physician informed of a resident's condition when he/she complained of chest tightness, shortness of breath and his/her verbal request to go to the hospital. The resident was not sent to the hospital and expired at the facility (Resident #27). In addition, staff failed to properly assess and monitor a resident with a distended abdomen which resulted in the resident's transfer to the hospital (Resident #28). The facility also failed to follow physician orders [REDACTED]. The census was 139. 1. Review of Resident #27's profile face sheet, showed an admission date of [DATE]. Review of the resident's Resident Status Sheet, undated, showed the following: -Mental attitude: Oriented, well adjusted and alert; -Speaks well; -Feeds self; -Uses the bathroom; -Skin: pacemaker upper left chest Review of the resident's nurse's note, dated [DATE] at 8:00 P.M., showed the following: -[DIAGNOSES REDACTED]. -Alert and oriented to person, place and time; -Incision to left upper chest, pacemaker inserted approximately two weeks ago. Review of the resident's physician's orders [REDACTED]. -New admit: [DATE]; -Emergency orders: blank; -[DIAGNOSES REDACTED]. Review of the resident's electronic nurse's note, dated [DATE], showed the following: -12:30 A.M.: Resident complained of "Feeling funny", requested blood sugar level be checked. Blood sugar 83 (normal range, ,[DATE]), snack provided; -1:15 A.M.: Complained of "not feeling well" unable or unwilling to be more specific when asked. Easily annoyed. States "Nevermind" in a loud voice when questioned further. Blood sugar repeated, 85. Provided with a cup of orange juice, he/she yelled out "I don't' want that", and pushed the cup to the side. He/she sits up on the side of the bed throughout the night, taking short naps by putting his/her head down on the bedside table. Educated multiple times about safety and encouraged resident to lie in bed with the head of bed elevated, but he/she continues to refuse. Certified Nurse Assistant (CNA) instructed to check on resident frequently. (Staff did not document the resident's vital signs or oxygen saturation levels (O2 Sats)); -3:10 A.M.: The resident continues to complain of not feeling well and has requested to go to the hospital. This nurse (Nurse S) again spoke with resident regarding specific symptoms. The resident angrily yelled out "just call 911". Resident still sitting up on the side of the bed, does not appear to be in any acute distress. This nurse informed resident his/her physician would be contacted but specific symptoms/complaints would have to be reported. The resident states "I'm having a [MEDICAL CONDITION]". Questioned resident regarding chest pains and he/she stated it wasn't a pain but chest tightness he/she felt in his/her chest area. Vital signs: Blood pressure ,[DATE] (normal blood pressure, ,[DATE]), Pulse 76 (normal pulse, 60 to 80 beats per minute), Respirations, 18 (normal respiration, 16 to 20 breaths per minute), Temperature 96.9 degrees Fahrenheit (normal temperature, 98.6 degrees Fahrenheit). Asked if he/she was experiencing any shortness of breath (SOB), he/she immediately answered "Yes" and requested oxygen right away. Oxygen saturation (O2 SATs) 94% (normal O2 SATs 97% to 99%) on room air. O2 at 2 Liters started at this time for comfort; -3:30 A.M.: Call placed to the resident's physician, informed of the resident's complaints, symptoms, vital signs and request to go to the hospital. New orders received to: 1:Obtain a Stat (medical abbreviation meaning immediately) electrocardiogram (EKG, test that checks for problems with the electrical activity of the heart), 2. Give [MEDICATION NAME] (antacid) 30 milliliters (ml) now, 3. Give one aspirin 81 milligram (mg) now, 4. Give one [MEDICATION NAME] (medicine that opens blood vessels to improve blood flow) 0.4 mg tablet now (one dose only), 5. O2 2 liters (L) as needed (PRN). Further review of the resident's POS, showed an order dated [DATE] at 3:35 A.M., for the following: -Stat EKG; -[MEDICATION NAME] 30 ml now; -Aspirin (ASA) 81 mg now; -[MEDICATION NAME] 0.4 mg one dose only now; -O2 2 liters PRN. Further review of the resident's nurse's notes, dated [DATE], showed the following: -3:40 A.M.: Stat EKG ordered and medications ordered were administered to the resident at this time. The resident continues to refuse to lie in bed, alert and speaking, no signs of acute distress; -4:39 A.M.: Waiting for Stat EKG. Questioned resident regarding pain/tightness in chest, states he/she's no longer experiencing chest tightness. Does complain of shortness of breath, O2 Sats 94% on O2 at 2 liters (No vital signs were documented); -5:00 A.M.: Sat on side of bed, head of bed elevated, states he/she feels better, believes it was an "anxiety attack". VS: ,[DATE], P 75, R 20, O2 Sats 93% on room air. Still waiting for EKG to be done; -5:30 A.M.: Sat on the side of the bed, head of bed elevated, with one foot up on bed. Asked if he/she wanted assistance to get in bed. Stated he/she would get in bed when it's time to do EKG. No signs of distress; -5:40 A.M.: Called to room Stat by CNA. The x-ray technician in the room at this time. The resident lay in bed, unresponsive with labored breathing, skin cool to touch. 911 called from the resident's room, Stat page for all nurses to come to the room. X-ray technician stated when he/she entered, the resident sat on the side of the bed with his/her head on the bedside table. He/she (x-ray technician) called the resident by his/her name and he/she answered. As the resident lay on the bed, the x-ray technician began placing the EKG leads on the resident's body. Suddenly the resident turned his/her head to the side and wouldn't respond. The x-ray technician pushed the call light, the CNA answered and called for the nurse. He/she assessed the resident at this time and found the resident without a pulse or lung sounds, cardiopulmonary resuscitation (CPR) initiated; -5:50 A.M.: Fire department arrived and placed an automated external defibrillator (AED) on the resident and instructed to continue CPR. The fire department continued CPR until EMS arrived. EMS attached the heart monitor to the resident, Asystole (flatline, no cardiac activity). EMS called time of death at 6:02 A.M.; -6:10 A.M.: The resident's physician called and notified of the 911 call, CPR and death of the resident. During an interview on [DATE] at 2:00 P.M., CNA P said he/she worked the 11:00 P.M. to 7:00 A.M. shift on [DATE]. He/she first saw the resident while making rounds. At approximately 11:30 P.M., the resident turned on his/her call light and asked for some ice water. He/she sat on the side of the bed, stating he/she didn't feel good. CNA P said the resident rang his/her call light all night and asked for the nurse to check his/her blood sugar. The resident said he/she didn't feel good while he/she sat on the side of the bed. CNA P tried to take the resident's blood pressure but couldn't get it because the resident kept tightening his/her arm and squeezing the table with his/her hand. Later, CNA P didn't know what time, he/she saw the resident's light on. When CNA P entered, the resident was leaning over toward the edge of the bed. The resident was still breathing but not responding, with his/her eyes shut. CNA P went to get the nurse because he/she was downstairs. CNA P called the nurse on the phone and he/she came right away. When the nurse arrived, he/she assessed the resident, called 911 from the room and a code blue. CNA P didn't know who started CPR on the resident. During an interview on [DATE] at 9:13 A.M., Nurse S said he/she worked the 11:00 P.M. to 7:00 A.M. shift on [DATE]. He/she made rounds with CNA P at about 11:45 P.M. At that time the resident sat on the side of his/her bed watching TV. At approximately 12:30 A.M., the resident turned on his/her call light and complained of not feeling well. He/she requested for his/her blood sugar to be checked. Nurse S stated the resident had a history of [REDACTED]. Nurse S instructed CNA P to give the resident a snack and milk, stating he/she was the charge nurse on another floor in addition to this floor. At 1:30 P.M., the resident put his/her light on and complained of not feeling well. He/she rechecked the resident's blood sugar which was 85 and instructed CNA P to give the resident orange juice and sugar. When CNA P took the resident the orange juice, the resident said he/she didn't want it. Nurse S came to the floor later and asked the resident what he/she meant about not feeling well. The resident said he/she didn't feel like drinking orange juice. Nurse S tried to get the resident to lay down at that time, but he/she refused. At 3:30 A.M., CNA P told nurse S the resident put on his/her call light again. He/she sat on the side of the bed stating, "Call 911". Nurse S asked the resident what was wrong. The resident said he/she just didn't feel well, and it was his/her chest, talking calmly. The resident said it was not chest pain but chest tightness. Nurse S said the resident wasn't diaphoretic (sweating). Nurse S told the resident that 911 calls were for emergencies. If it was not an emergency, then he/she would just call the resident's doctor. Nurse S called the resident's physician and informed him/her of the resident's complaint of not feeling well, request to go to the hospital, that he/she sat on the side of the bed, was calm, had oxygen on, his/her vital signs were at baseline and showed no grimace or distress. The physician said he/she hated to send the resident to the hospital, and asked if they could get a STAT EKG at the facility. He/she gave orders for a STAT EKG, dose of [MEDICATION NAME], a baby aspirin and one [MEDICATION NAME]. When Nurse S ordered the EKG, they said it would be one to two hours before they could come to the facility. Nurse S didn't call the physician back to inform him/her the STAT EKG couldn't be done for one to two hours. Nurse S checked on the resident after administering the medication, and the resident said he/she felt better. Nurse S last saw the resident at approximately 5:30 A.M., and the resident wouldn't lay in the bed. At approximately 5:45 A.M., CNA P called Nurse S to come to the room. When he/she arrived, Nurse S saw the EKG technician in the room. The resident was still breathing but was unresponsive. Nurse S called 911, and ran to get the crash cart. He/she returned to the room and began CPR. During an interview on [DATE] at 6:38 A.M., Nurse T said he/she responded to the Code Blue at approximately 6:15 A.M.. He/she saw the resident in the bed. The resident's skin color was gray. He/she checked for pulse, and felt none. He/she arrived to the room before the crash cart arrived and began chest compressions. Nurse S began to giving breaths per the Ambu (bag valve mask) bag. They were unable to position the resident on the back board. Emergency Medical Services (EMS) arrived within five minutes. Nurse S told Nurse T, the resident complained of discomfort in his/her lower chest earlier, and he/she (Nurse S) called the physician. During an interview on [DATE] at 8:46 A.M., Nurse U said he/she worked the night shift on [DATE] and responded to the Code Blue. When he/she arrived, Nurse S and Nurse T were in the room performing CPR. Nurse U assisted by tilting the resident's head back. He/she also asked Nurse S and Nurse T if they placed the back board under the resident and they both responded yes. EMS arrived shortly afterwards. During an interview on [DATE] at 10:25 A.M., the x-ray technician said he/she arrived at the facility early in the morning of [DATE]. He/she said upon entering the room, the resident sat on the side of the bed, with his/her head on the bedside table, and a trash can between his/her legs. He/she thought the resident had vomited and asked if he/she was all right. The resident responded no, and said he/she had not vomited. The x-ray technician said the resident's words sounded low and slow. He/she informed the resident of the EKG test and asked if he/she could help him/her to lay on the bed. The resident didn't respond and the x-ray technician pushed the call light. The CNA arrived about 20 to 30 seconds later, assisted the resident into the bed and went to get the nurse. The nurse arrived shortly after, looked at the resident and called 911 from the room. He/she left the room at that time. During an interview on [DATE] at 10:40 A.M., the fire department chief said he/she arrived at the facility approximately 6:00 A.M.. The facility staff were doing CPR when they arrived. The resident had no vital signs and was in full [MEDICAL CONDITION]. EMS arrived shortly afterwards. Review of the resident's EMS Patient Care Report, dated [DATE], showed the following: -Chief complaint: [MEDICAL CONDITION]; -Resuscitation: not attempted, considered futile; -[MEDICAL CONDITION]: not witnessed; -First monitored heart rhythm: Asystole (absence of a heart beat); -Resuscitation discontinued reason: obvious signs of death; -Narrative: Arrived on scene, in bed unresponsive; -Pronounced dead: At 6:02 A.M. During an interview on [DATE] at 8:00 A.M., Nurse Q said if there were no emergency orders on a physician order [REDACTED]. When he/she arrived on [DATE] at 6:45 A.M., Nurse S told him/her the resident expired. During report, Nurse S said the resident complained of chest pain and not feeling well. The physician gave orders for aspirin, [MEDICATION NAME], Stat EKG and [MEDICATION NAME]. Nurse Q reviewed the resident's nurse's note at this time and said he/she would have sent the resident to the hospital if he/she complained of chest tightness. During an interview on [DATE] at 8:00 A.M., the Director of Nurses (DON) also reviewed the resident's nurse's note. She said the resident displayed signs of a [MEDICAL CONDITION]. The nurse should have sent the resident to the hospital when he/she complained of chest tightness, asked the nurse to call 911, and stated "I'm having a [MEDICAL CONDITION]". During an interview on [DATE] at 9:18 A.M., the DON said on the night shift, the registered nurses were considered the nursing supervisors. There were two registered nurses scheduled that night, Nurse S and Nurse T. They should address any concerns that arise in the facility. If a problem arose that they couldn't handle, they should call the manager on call. During an interview on [DATE] at 9:44 A.M., Nurse R said he/she was the manager on call on [DATE]. He/she didn't receive any calls regarding the resident. He/she expected the nurse to call and inform him/her of the resident's change in condition. If the nurse called, he/she would have told the nurse to send the resident to the hospital. In addition, the nurse should have notified the physician of the resident's complaints immediately, no matter how vague they were. During an interview on [DATE] at 1:30 P.M., the administrator reviewed the resident's nurse's note and said he would have sent the resident to the hospital. He said the resident displayed signs of a [MEDICAL CONDITION]. During an interview on [DATE] at 1:00 P.M., the resident's physician said Nurse S called approximately 3:00 A.M. and informed her the resident wanted to go to the hospital. The nurse said the resident's blood sugar was 83, vital signs were stable and O2 Sats were at 94%. She ordered [MEDICATION NAME], aspirin and a STAT EKG because of the resident's recent 10 day ICU hospitalization . The nurse did not tell her the resident complained of chest tightness or that the resident said to call 911 because he/she was having an [MEDICAL CONDITION]. If the nurse informed her of this, she would have sent the resident to the hospital. During an interview on [DATE] at 11:56 A.M., the resident's physician said Nurse S did not inform her the STAT EKG couldn't be done for one to two hours. She would have sent the resident to the hospital if she had known. She expected a call from the nurse to inform her of the resident's response to the [MEDICATION NAME], and baby aspirin. She would have wanted to be informed of the resident's continual complaints of shortness of breath. She didn't know if it would have made a difference in the resident's outcome, but expected to be notified of the resident's response to treatment. During an interview on [DATE] at 12:30 P.M., the administrator and DON said STAT meant to obtain within one hour. The nurse should have notified the physician of the time frame of the STAT EKG. 2. Review of Resident #28's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following; -[DIAGNOSES REDACTED]. -Cognitive impairment; -Required extensive assistance with bed mobility, transfers, dressings, toilet use, personal hygiene and bathing; -Incontinent of bowel and bladder. Review of the resident's daily skilled nurse's note (a two page form), showed the following: -[DATE]: Day shift note: 12:01 P.M., Resident remained in bed, total care with activities of daily living, fed both meals, abdomen distended, bowel sounds positive in all four quadrants. No complaints of pain when palpated. As needed milk of magnesia (MOM, laxative) and [MEDICATION NAME] suppository (used for constipation). No stool felt in the rectum, awaiting results. The first page of the form, used for vitals sign documentation and for staff to check boxes where appropriate, showed nothing checked for the day shift for abdominal distention. -[DATE]: Evening Shift note: Remain on fall precautions, bed in low position. Had medium results from MOM given earlier, dependent on staff for all activities of daily living, transfers, in no acute distress, blood sugar monitored, no signs or symptoms of hypo/[MEDICAL CONDITION] noted. (No documentation whether the resident's abdomen remained distended and nothing marked on the first page of the form regarding abdominal distention); -[DATE]: Night shift note: Blank; -[DATE]: First page of Daily Skilled note: Day shift: vital signs: Temperature (T): 96.3 degrees Fahrenheit (normal temperature, 98.6 degrees Fahrenheit), pulse (P) 119 (normal pulse, 60 to 80 beats per minute), blood pressure (BP) ,[DATE] (normal blood pressure, ,[DATE]). Review of the note showed resident very weak and lethargic, blood pressure down, [MEDICAL CONDITION](fast heart beat), wet lung sounds, order received to send to the emergency room . Review of the resident's hospital physician discharge summary, showed the following: -discharge date : [DATE]; -Diagnoses: [REDACTED]. -In the emergency department, a urinary catheter was inserted, drained 3 liters of urine (3000 mls) with an additional 800 milliliters (ml) over the next four hours; -[MEDICAL CONDITION] related to diabetes and [MEDICAL CONDITION] (enlarged prostate). Review of WebMD website, showed the normal bladder holds ,[DATE] mls of urine. Observation and interview on [DATE] at 1:00 P.M., showed the resident at his/her bedside watching TV. Foley catheter (sterile tube inserted through the urethra into bladder, used to drain urine) drained yellow urine. The resident said he/she felt good today with no complaints. During an interview on [DATE] at 2:00 P.M., the DON said she expected each shift to assess and document whether the resident's abdomen decreased after a bowel movement. She said a distended abdomen could have been a sign of a distended bladder. When in doubt, staff should ask for guidance from the floor manager or the DON. 3. Review of Resident #29's hospital discharge physician order [REDACTED]. -discharge date : [DATE]; -Discharge Diagnosis: [REDACTED]. -[MEDICATION NAME]/[MEDICATION NAME] (inhaler) 0XXX,[DATE].5 milligram (mg)/3 ml, Inhale 3 ml by mouth four times per day. Review of the resident's admission face sheet, showed an admission date of [DATE]. Review of the resident's admission physician order [REDACTED]. -[DIAGNOSES REDACTED]. -[MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 0XXX,[DATE].5 mg per 3 ml inhalation four times per day; -Incentive spirometer (medical device used to help patients improve the functioning of their lungs) every six hours. Review of the resident's progress note, dated [DATE], showed the following: -On skilled care, receiving physical therapy; -Medication review showed the resident hadn't received his/her [MEDICATION NAME] or incentive spirometer. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -an order for [REDACTED]. -Incentive spirometer every six hours, circled on the MAR, ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]. Back of MAR, dated [DATE] at 12:00 P.M.: Incentive spirometer not here. Observation on [DATE] at 1:03 P.M., showed the resident watched TV in his/her room. The resident talked about his/her recent heart surgery and his/her hope to be discharged soon. The incentive spirometer sat on the bedside table. During an interview on [DATE] at 2:00 P.M., the DON said the nurse failed to transcribe the order from the POS to the MAR. The staff should have discovered the error sooner and notified the physician. A medication error had been completed and the resident's medication ordered. 4. Review of the facility's policy, Resident Condition or Status Change, undated, showed the following: -Policy: The facility will promptly notify the resident, the attending physician and/or designee and responsible party of any changes in the resident's condition and or status; -Procedures: The nurse will notify the resident's attending physician and/or designee when there is a significant change in the resident's physical, mental and psychosocial status; -The nurse will record in the resident's medical record any changes in the resident's medical condition or status. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, all nursing staff (RNs, LPNs, CMTs and CNAs) were inserviced on what to do when a resident had a change in condition, cardiac assessment and signs and symptoms of a [MEDICAL CONDITION]. In addition, the facility inserviced all evening and night licensed nurses, CMTs and CNAs prior to working. The nurse involved had been terminated. The facility would continue to monitor residents for change of condition to assure staff followed the policy regarding assessment and proper notification of the physician. The DON instructed the staff to call her regarding any change of condition. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

Based on observation, interview and record review, the facility failed to appropriately assess and keep the physician informed of a resident's condition when he/she complained of chest tightness, shortness of breath and his/her verbal request to go to the hospital. The resident was not sent to the hospital and expired at the facility (Resident #27). In addition, staff failed to properly assess and monitor a resident with a distended abdomen which resulted in the resident's transfer to the hospital (Resident #28). The facility also failed to follow physician orders [REDACTED].#29). The census was 139. 1. Review of Resident #27's profile face sheet, showed an admission date of [DATE]. Review of the resident's Resident Status Sheet, undated, showed the following: -Mental attitude: Oriented, well adjusted and alert; -Speaks well; -Feeds self; -Uses the bathroom; -Skin: pacemaker upper left chest Review of the resident's nurse's note, dated [DATE] at 8:00 P.M., showed the following: -[DIAGNOSES REDACTED]. -Alert and oriented to person, place and time; -Incision to left upper chest, pacemaker inserted approximately two weeks ago. Review of the resident's physician's orders [REDACTED]. -New admit: [DATE]; -Emergency orders: blank; -[DIAGNOSES REDACTED]. Review of the resident's electronic nurse's note, dated [DATE], showed the following: -12:30 A.M.: Resident complained of Feeling funny, requested blood sugar level be checked. Blood sugar 83 (normal range, ,[DATE]), snack provided; -1:15 A.M.: Complained of not feeling well unable or unwilling to be more specific when asked. Easily annoyed. States Nevermind in a loud voice when questioned further. Blood sugar repeated, 85. Provided with a cup of orange juice, he/she yelled out I don't' want that, and pushed the cup to the side. He/she sits up on the side of the bed throughout the night, taking short naps by putting his/her head down on the bedside table. Educated multiple times about safety and encouraged resident to lie in bed with the head of bed elevated, but he/she continues to refuse. Certified Nurse Assistant (CNA) instructed to check on resident frequently. (Staff did not document the resident's vital signs or oxygen saturation levels (O2 Sats)); -3:10 A.M.: The resident continues to complain of not feeling well and has requested to go to the hospital. This nurse (Nurse S) again spoke with resident regarding specific symptoms. The resident angrily yelled out just call 911. Resident still sitting up on the side of the bed, does not appear to be in any acute distress. This nurse informed resident his/her physician would be contacted but specific symptoms/complaints would have to be reported. The resident states I'm having a [MEDICAL CONDITION]. Questioned resident regarding chest pains and he/she stated it wasn't a pain but chest tightness he/she felt in his/her chest area. Vital signs: Blood pressure ,[DATE] (normal blood pressure, ,[DATE]), Pulse 76 (normal pulse, 60 to 80 beats per minute), Respirations, 18 (normal respiration, 16 to 20 breaths per minute), Temperature 96.9 degrees Fahrenheit (normal temperature, 98.6 degrees Fahrenheit). Asked if he/she was experiencing any shortness of breath (SOB), he/she immediately answered Yes and requested oxygen right away. Oxygen saturation (O2 SATs) 94% (normal O2 SATs 97% to 99%) on room air. O2 at 2 Liters started at this time for comfort; -3:30 A.M.: Call placed to the resident's physician, informed of the resident's complaints, symptoms, vital signs and request to go to the hospital. New orders received to: 1:Obtain a Stat (medical abbreviation meaning immediately) electrocardiogram (EKG, test that checks for problems with the electrical activity of the heart), 2. Give [MEDICATION NAME] (antacid) 30 milliliters (ml) now, 3. Give one aspirin 81 milligram (mg) now, 4. Give one [MEDICATION NAME] (medicine that opens blood vessels to improve blood flow) 0.4 mg tablet now (one dose only), 5. O2 2 liters (L) as needed (PRN). Further review of the resident's POS, showed an order dated [DATE] at 3:35 A.M., for the following: -Stat EKG; -[MEDICATION NAME] 30 ml now; -Aspirin (ASA) 81 mg now; -[MEDICATION NAME] 0.4 mg one dose only now; -O2 2 liters PRN. Further review of the resident's nurse's notes, dated [DATE], showed the following: -3:40 A.M.: Stat EKG ordered and medications ordered were administered to the resident at this time. The resident continues to refuse to lie in bed, alert and speaking, no signs of acute distress; -4:39 A.M.: Waiting for Stat EKG. Questioned resident regarding pain/tightness in chest, states he/she's no longer experiencing chest tightness. Does complain of shortness of breath, O2 Sats 94% on O2 at 2 liters (No vital signs were documented); -5:00 A.M.: Sat on side of bed, head of bed elevated, states he/she feels better, believes it was an anxiety attack. VS: ,[DATE], P 75, R 20, O2 Sats 93% on room air. Still waiting for EKG to be done; -5:30 A.M.: Sat on the side of the bed, head of bed elevated, with one foot up on bed. Asked if he/she wanted assistance to get in bed. Stated he/she would get in bed when it's time to do EKG. No signs of distress; -5:40 A.M.: Called to room Stat by CNA. The x-ray technician in the room at this time. The resident lay in bed, unresponsive with labored breathing, skin cool to touch. 911 called from the resident's room, Stat page for all nurses to come to the room. X-ray technician stated when he/she entered, the resident sat on the side of the bed with his/her head on the bedside table. He/she (x-ray technician) called the resident by his/her name and he/she answered. As the resident lay on the bed, the x-ray technician began placing the EKG leads on the resident's body. Suddenly the resident turned his/her head to the side and wouldn't respond. The x-ray technician pushed the call light, the CNA answered and called for the nurse. He/she assessed the resident at this time and found the resident without a pulse or lung sounds, cardiopulmonary resuscitation (CPR) initiated; -5:50 A.M.: Fire department arrived and placed an automated external defibrillator (AED) on the resident and instructed to continue CPR. The fire department continued CPR until EMS arrived. EMS attached the heart monitor to the resident, Asystole (flatline, no cardiac activity). EMS called time of death at 6:02 A.M.; -6:10 A.M.: The resident's physician called and notified of the 911 call, CPR and death of the resident. During an interview on [DATE] at 2:00 P.M., CNA P said he/she worked the 11:00 P.M. to 7:00 A.M. shift on [DATE]. He/she first saw the resident while making rounds. At approximately 11:30 P.M., the resident turned on his/her call light and asked for some ice water. He/she sat on the side of the bed, stating he/she didn't feel good. CNA P said the resident rang his/her call light all night and asked for the nurse to check his/her blood sugar. The resident said he/she didn't feel good while he/she sat on the side of the bed. CNA P tried to take the resident's blood pressure but couldn't get it because the resident kept tightening his/her arm and squeezing the table with his/her hand. Later, CNA P didn't know what time, he/she saw the resident's light on. When CNA P entered, the resident was leaning over toward the edge of the bed. The resident was still breathing but not responding, with his/her eyes shut. CNA P went to get the nurse because he/she was downstairs. CNA P called the nurse on the phone and he/she came right away. When the nurse arrived, he/she assessed the resident, called 911 from the room and a code blue. CNA P didn't know who started CPR on the resident. During an interview on [DATE] at 9:13 A.M., Nurse S said he/she worked the 11:00 P.M. to 7:00 A.M. shift on [DATE]. He/she made rounds with CNA P at about 11:45 P.M. At that time the resident sat on the side of his/her bed watching TV. At approximately 12:30 A.M., the resident turned on his/her call light and complained of not feeling well. He/she requested for his/her blood sugar to be checked. Nurse S stated the resident had a history of [REDACTED]. Nurse S instructed CNA P to give the resident a snack and milk, stating he/she was the charge nurse on another floor in addition to this floor. At 1:30 P.M., the resident put his/her light on and complained of not feeling well. He/she rechecked the resident's blood sugar which was 85 and instructed CNA P to give the resident orange juice and sugar. When CNA P took the resident the orange juice, the resident said he/she didn't want it. Nurse S came to the floor later and asked the resident what he/she meant about not feeling well. The resident said he/she didn't feel like drinking orange juice. Nurse S tried to get the resident to lay down at that time, but he/she refused. At 3:30 A.M., CNA P told nurse S the resident put on his/her call light again. He/she sat on the side of the bed stating, Call 911. Nurse S asked the resident what was wrong. The resident said he/she just didn't feel well, and it was his/her chest, talking calmly. The resident said it was not chest pain but chest tightness. Nurse S said the resident wasn't diaphoretic (sweating). Nurse S told the resident that 911 calls were for emergencies. If it was not an emergency, then he/she would just call the resident's doctor. Nurse S called the resident's physician and informed him/her of the resident's complaint of not feeling well, request to go to the hospital, that he/she sat on the side of the bed, was calm, had oxygen on, his/her vital signs were at baseline and showed no grimace or distress. The physician said he/she hated to send the resident to the hospital, and asked if they could get a STAT EKG at the facility. He/she gave orders for a STAT EKG, dose of [MEDICATION NAME], a baby aspirin and one [MEDICATION NAME]. When Nurse S ordered the EKG, they said it would be one to two hours before they could come to the facility. Nurse S didn't call the physician back to inform him/her the STAT EKG couldn't be done for one to two hours. Nurse S checked on the resident after administering the medication, and the resident said he/she felt better. Nurse S last saw the resident at approximately 5:30 A.M., and the resident wouldn't lay in the bed. At approximately 5:45 A.M., CNA P called Nurse S to come to the room. When he/she arrived, Nurse S saw the EKG technician in the room. The resident was still breathing but was unresponsive. Nurse S called 911, and ran to get the crash cart. He/she returned to the room and began CPR. During an interview on [DATE] at 6:38 A.M., Nurse T said he/she responded to the Code Blue at approximately 6:15 A.M. He/she saw the resident in the bed. The resident's skin color was gray. He/she checked for pulse, and felt none. He/she arrived to the room before the crash cart arrived and began chest compressions. Nurse S began to giving breaths per the Ambu (bag valve mask) bag. They were unable to position the resident on the back board. Emergency Medical Services (EMS) arrived within five minutes. Nurse S told Nurse T, the resident complained of discomfort in his/her lower chest earlier, and he/she (Nurse S) called the physician. During an interview on [DATE] at 8:46 A.M., Nurse U said he/she worked the night shift on [DATE] and responded to the Code Blue. When he/she arrived, Nurse S and Nurse T were in the room performing CPR. Nurse U assisted by tilting the resident's head back. He/she also asked Nurse S and Nurse T if they placed the back board under the resident and they both responded yes. EMS arrived shortly afterwards. During an interview on [DATE] at 10:25 A.M., the x-ray technician said he/she arrived at the facility early in the morning of [DATE]. He/she said upon entering the room, the resident sat on the side of the bed, with his/her head on the bedside table, and a trash can between his/her legs. He/she thought the resident had vomited and asked if he/she was all right. The resident responded no, and said he/she had not vomited. The x-ray technician said the resident's words sounded low and slow. He/she informed the resident of the EKG test and asked if he/she could help him/her to lay on the bed. The resident didn't respond and the x-ray technician pushed the call light. The CNA arrived about 20 to 30 seconds later, assisted the resident into the bed and went to get the nurse. The nurse arrived shortly after, looked at the resident and called 911 from the room. He/she left the room at that time. During an interview on [DATE] at 10:40 A.M., the fire department chief said he/she arrived at the facility approximately 6:00 A.M. The facility staff were doing CPR when they arrived. The resident had no vital signs and was in full [MEDICAL CONDITION]. EMS arrived shortly afterwards. Review of the resident's EMS Patient Care Report, dated [DATE], showed the following: -Chief complaint: [MEDICAL CONDITION]; -Resuscitation: not attempted, considered futile; -[MEDICAL CONDITION]: not witnessed; -First monitored heart rhythm: Asystole (absence of a heart beat); -Resuscitation discontinued reason: obvious signs of death; -Narrative: Arrived on scene, in bed unresponsive; -Pronounced dead: At 6:02 A.M. During an interview on [DATE] at 8:00 A.M., Nurse Q said if there were no emergency orders on a physician order [REDACTED]. When he/she arrived on [DATE] at 6:45 A.M., Nurse S told him/her the resident expired. During report, Nurse S said the resident complained of chest pain and not feeling well. The physician gave orders for aspirin, [MEDICATION NAME], Stat EKG and [MEDICATION NAME]. Nurse Q reviewed the resident's nurse's note at this time and said he/she would have sent the resident to the hospital if he/she complained of chest tightness. During an interview on [DATE] at 8:00 A.M., the Director of Nurses (DON) also reviewed the resident's nurse's note. She said the resident displayed signs of a [MEDICAL CONDITION]. The nurse should have sent the resident to the hospital when he/she complained of chest tightness, asked the nurse to call 911, and stated I'm having a [MEDICAL CONDITION]. During an interview on [DATE] at 9:18 A.M., the DON said on the night shift, the registered nurses were considered the nursing supervisors. There were two registered nurses scheduled that night, Nurse S and Nurse T. They should address any concerns that arise in the facility. If a problem arose that they couldn't handle, they should call the manager on call. During an interview on [DATE] at 9:44 A.M., Nurse R said he/she was the manager on call on [DATE]. He/she didn't receive any calls regarding the resident. He/she expected the nurse to call and inform him/her of the resident's change in condition. If the nurse called, he/she would have told the nurse to send the resident to the hospital. In addition, the nurse should have notified the physician of the resident's complaints immediately, no matter how vague they were. During an interview on [DATE] at 1:30 P.M., the administrator reviewed the resident's nurse's note and said he would have sent the resident to the hospital. He said the resident displayed signs of a [MEDICAL CONDITION]. During an interview on [DATE] at 1:00 P.M., the resident's physician said Nurse S called approximately 3:00 A.M. and informed her the resident wanted to go to the hospital. The nurse said the resident's blood sugar was 83, vital signs were stable and O2 Sats were at 94%. She ordered [MEDICATION NAME], aspirin and a STAT EKG because of the resident's recent 10 day ICU hospitalization . The nurse did not tell her the resident complained of chest tightness or that the resident said to call 911 because he/she was having an [MEDICAL CONDITION]. If the nurse informed her of this, she would have sent the resident to the hospital. During an interview on [DATE] at 11:56 A.M., the resident's physician said Nurse S did not inform her the STAT EKG couldn't be done for one to two hours. She would have sent the resident to the hospital if she had known. She expected a call from the nurse to inform her of the resident's response to the [MEDICATION NAME], and baby aspirin. She would have wanted to be informed of the resident's continual complaints of shortness of breath. She didn't know if it would have made a difference in the resident's outcome, but expected to be notified of the resident's response to treatment. During an interview on [DATE] at 12:30 P.M., the administrator and DON said STAT meant to obtain within one hour. The nurse should have notified the physician of the time frame of the STAT EKG. 2. Review of Resident #28's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following; -[DIAGNOSES REDACTED]. -Cognitive impairment; -Required extensive assistance with bed mobility, transfers, dressings, toilet use, personal hygiene and bathing; -Incontinent of bowel and bladder. Review of the resident's daily skilled nurse's note (a two page form), showed the following: -[DATE]: Day shift note: 12:01 P.M., Resident remained in bed, total care with activities of daily living, fed both meals, abdomen distended, bowel sounds positive in all four quadrants. No complaints of pain when palpated. As needed milk of magnesia (MOM, laxative) and [MEDICATION NAME] suppository (used for constipation). No stool felt in the rectum, awaiting results. The first page of the form, used for vitals sign documentation and for staff to check boxes where appropriate, showed nothing checked for the day shift for abdominal distention. -[DATE]: Evening Shift note: Remain on fall precautions, bed in low position. Had medium results from MOM given earlier, dependent on staff for all activities of daily living, transfers, in no acute distress, blood sugar monitored, no signs or symptoms of hypo/[MEDICAL CONDITION] noted. (No documentation whether the resident's abdomen remained distended and nothing marked on the first page of the form regarding abdominal distention); -[DATE]: Night shift note: Blank; -[DATE]: First page of Daily Skilled note: Day shift: vital signs: Temperature (T): 96.3 degrees Fahrenheit (normal temperature, 98.6 degrees Fahrenheit), pulse (P) 119 (normal pulse, 60 to 80 beats per minute), blood pressure (BP) ,[DATE] (normal blood pressure, ,[DATE]). Review of the note showed resident very weak and lethargic, blood pressure down, [MEDICAL CONDITION](fast heart beat), wet lung sounds, order received to send to the emergency room . Review of the resident's hospital physician discharge summary, showed the following: -discharge date : [DATE]; -Diagnoses: [REDACTED]. -In the emergency department, a urinary catheter was inserted, drained 3 liters of urine (3000 mls) with an additional 800 milliliters (ml) over the next four hours; -[MEDICAL CONDITION] related to diabetes and [MEDICAL CONDITION] (enlarged prostate). Review of WebMD website, showed the normal bladder holds ,[DATE] mls of urine. Observation and interview on [DATE] at 1:00 P.M., showed the resident at his/her bedside watching TV. Foley catheter (sterile tube inserted through the urethra into bladder, used to drain urine) drained yellow urine. The resident said he/she felt good today with no complaints. During an interview on [DATE] at 2:00 P.M., the DON said she expected each shift to assess and document whether the resident's abdomen decreased after a bowel movement. She said a distended abdomen could have been a sign of a distended bladder. When in doubt, staff should ask for guidance from the floor manager or the DON. 3. Review of Resident #29's hospital discharge physician order [REDACTED]. -discharge date : [DATE]; -Discharge Diagnosis: [REDACTED]. -[MEDICATION NAME]/[MEDICATION NAME] (inhaler) 0XXX,[DATE].5 milligram (mg)/3 ml, Inhale 3 ml by mouth four times per day. Review of the resident's admission face sheet, showed an admission date of [DATE]. Review of the resident's admission physician order [REDACTED]. -[DIAGNOSES REDACTED]. -[MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 0XXX,[DATE].5 mg per 3 ml inhalation four times per day; -Incentive spirometer (medical device used to help patients improve the functioning of their lungs) every six hours. Review of the resident's progress note, dated [DATE], showed the following: -On skilled care, receiving physical therapy; -Medication review showed the resident hadn't received his/her [MEDICATION NAME] or incentive spirometer. Review of the resident's Medication Administration Record [REDACTED] -an order for [REDACTED].>-Incentive spirometer every six hours, circled on the MAR, ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]. Back of MAR, dated [DATE] at 12:00 P.M.: Incentive spirometer not here. Observation on [DATE] at 1:03 P.M., showed the resident watched TV in his/her room. The resident talked about his/her recent heart surgery and his/her hope to be discharged soon. The incentive spirometer sat on the bedside table. During an interview on [DATE] at 2:00 P.M., the DON said the nurse failed to transcribe the order from the POS to the MAR. The staff should have discovered the error sooner and notified the physician. A medication error had been completed and the resident's medication ordered. 4. Review of the facility's policy, Resident Condition or Status Change, undated, showed the following: -Policy: The facility will promptly notify the resident, the attending physician and/or designee and responsible party of any changes in the resident's condition and or status; -Procedures: The nurse will notify the resident's attending physician and/or designee when there is a significant change in the resident's physical, mental and psychosocial status; -The nurse will record in the resident's medical record any changes in the resident's medical condition or status. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, all nursing staff (RNs, LPNs, CMTs and CNAs) were inserviced on what to do when a resident had a change in condition, cardiac assessment and signs and symptoms of a [MEDICAL CONDITION]. In addition, the facility inserviced all evening and night licensed nurses, CMTs and CNAs prior to working. The nurse involved had been terminated. The facility would continue to monitor residents for change of condition to assure staff followed the policy regarding assessment and proper notification of the physician. The DON instructed the staff to call her regarding any change of condition. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers received appropriate care and treatment to aid in the prevention and healing of the pressure ulcers for one of five sampled residents who developed pressure ulcers and staff did not notify the physician in a timely manner, obtain treatment orders or continually assess and monitor the condition of the resident's pressure ulcers. (Resident #7). The census was 139. Review of Resident #7's Nursing Comprehensive Admission Data Collection and Assessment form, dated 6/1/12, showed the following: -admitted : 6/1/12 at 2:10 P.M.; -Body diagram: Buttocks circled with excoriated and shearing written in. Review of the resident's physician order [REDACTED]. -An order dated 6/1/12, for [MEDICATION NAME] (a Zinc oxide-based barrier that protects against moisture and minor irritation) ointment to excoriated buttocks twice a day for seven days; -Then start Tenna (Skin-Caring Wash Cream, cleanses, moisturizes and protects the skin from irritation or breakdown by maintaining a protective barrier) applications with each episode of incontinence. -[DIAGNOSES REDACTED]. Review of the resident's Treatment Administration Record (TAR), no date, showed the following: -[MEDICATION NAME] to excoriated areas twice a day for seven days; -6/4/12 through 6/8/12: 7:00 A.M. to 3:00 P.M., staff failed to initial the TAR on 6/4, 6/5, 6/6, 6/7 and 6/8/12; -6/4/12 through 6/8/12: 3:00 P.M. to 11:00 P.M., staff failed to initial the TAR on 6/6/12; -Tenna with each incontinent episode starting 6/9/12, PRN (as needed)written in. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/8/12, showed the following: -Short term memory loss; -Cognitive impairment; -Extensive assistance of two staff for bed mobility and transfers; -Extensive assistance of staff for dressing, toilet use, personal hygiene and bathing; -Incontinent of bowel and bladder; -Risk of pressure ulcers: No; -Did the resident have one or more unhealed pressure ulcers: No. Review of the resident's skilled nurse's notes, showed the following: -6/1/12 at 5:05 P.M., the wound nurse was made aware of excoriated buttocks, treatment in place; -6/2/12 through 6/11/12, no documentation of the resident's skin condition. Review of the resident's POS, no date, showed an order dated 6/11/12, to discontinue [MEDICATION NAME]. Apply [MEDICATION NAME] (a cream used to promote wound healing and the treatment of [REDACTED]. Review of the resident's skilled nurse's notes, showed the following: -6/12/12 at 2:30 P.M., the resident's buttocks healing, [MEDICATION NAME] applied; -6/17/12, no time, incontinent of bowel and bladder, [MEDICATION NAME] ointment applied to buttocks. -6/18/12 through 6/29/12, showed no documentation that staff reevaluated the skin condition on the resident's buttocks. Review of the facility's Licensed Nurse Weekly Skin Assessment, showed the following: -Directions: This form should be completed weekly on all residents per facility policy. Any areas of skin requiring treatment should have a thorough record of documentation in addition to this form, located elsewhere in the chart per facility policy; -6/29/12: Diagram of body with a circle on the buttocks, written in: pink open areas on both buttocks. Any reddened areas that remain after 30 minutes of pressure reduction? Yes. Written in: coccyx (tailbone), buttocks. Any open ulcers (indicate even if being treated) coccyx written in; -7/6/12: Diagram: blank. Any open ulcers, not checked; -7/11/12: Diagram: slight red buttocks, written in. -No Licensed Nurse Weekly Skin Assessments provided for the two remaining weeks of July 2012. Review of the resident's skilled daily nurse's notes, showed the following: -7/1/12 through 7/12/12, no documentation of the pressure ulcers on the resident's buttocks; -7/13/12 at 8:00 P.M., pressure ulcers on the resident's buttocks. No description or measurements documented or that staff notified the resident's physician; -7/14/12 at 7:00 A.M. through 3:00 P.M., excoriation on the buttocks with two pressure ulcers. No documentation of measurements or a description of the pressure ulcers or that staff notified the resident's physician. -No further documentation regarding the pressure ulcers to the resident's buttocks until 8/3/12. Review of the resident's POS, dated 7/1/12 through 7/31/12, showed the following: -Skin assessment check and record weekly; -Preventative skin care; -No treatment order for the pressure ulcers to the resident's buttocks. Review of the resident's TAR, dated 7/1/12 through 7/31/12, showed the following: -Skin assessment check and record weekly; -Preventative skin care; -Protective barrier cream to buttocks after every incontinent episode, no start date: -7:00 A.M. through 3:00 P.M.: staff initialed as applied on 7/13, 7/14/, 7/15, 7/16/, 7/17, 7/18, 7/20, 7/22, 7/23 and 7/29/12; -3:00 P.M. through 11:00 P.M. staff initialed as applied on 7/20, 7/21, 7/22, 7/24, 7/27, 7/28, 7/29 and 7/31/12; -11:00 P.M. through 7:00 A.M., staff initialed as applied on 7/20, 7/21, 7/24,7/25, 7/26, 7/27,7/28, 7/29, 7/30 and 7/31/12. Review of the resident's Bath and Skin Assessment sheets, completed by certified nurses assistants (CNA), showed the following: -Directions: Check whether skin is Normal or Abnormal. Check abnormal if skin is open, bruised, reddened, skin tear etc. If "ABNORMAL", circle the affected areas; -7/13/12: Abnormal checked, bed bath written in, Diagram of back of body: Two x's marked on center of buttocks, open area on bottom written, signed by nurse; -7/17/2: Abnormal checked, Diagram of back of body: large circle covering buttocks, written in: area on buttock, ointment applied, signed by nurse; -7/20/12: Abnormal checked, Diagram of back of body: Large "x" marked on center of buttocks, written in: bottom is open, a little red, signed by nurse; -7/24/12: Abnormal checked, Diagram of back of body: Large circle on buttocks, written in: area on buttocks, ointment applied, signed by nurse; -7/27/12: Abnormal checked, Diagram of back of body: Line pointing to buttocks, written in: open area on bottom, area red, signed by nurse; -8/1/12: Abnormal checked, Diagram of the back of body: Large circle on buttocks, written in "broke down" on buttock area, ointment applied, signed by nurse; -8/3/12: Abnormal checked, bed bath written in, Diagram of back of body: circle on buttocks, written in: sore, left heel circled with red written in. Review of the resident's nurse's note, dated 8/3/12, no time, completed by Nurse P, showed necrotic (dead and dying tissue, black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin) area found on the right side of the resident's coccyx. On the left side of the resident's coccyx, a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.). Border gauze (a type of gauze dressing) applied. Reported and communicated on the 24 hour report sheet. No further description or measurement of the pressure ulcer or that staff notified the resident's physician. No further documentation in the resident's nurses notes, regarding the pressure ulcers until 8/19/12. Review of the resident's Licensed Nurse Weekly Skin Assessment, showed the following: -8/10/12: Diagram of back of body: Buttocks with a circle on coccyx, two circles on the left and right buttock. Written in: Stage II pink open areas and two areas on the left buttock, necrotic, circle around left heel: red area, soft and mushy written in. Any blisters? No. Comments: Left heel pink, mushy, no blister. Any open areas? Coccyx written in. No further description; -8/17/12: Diagram of back of body: Large circle on buttocks and two small circles on the left and right buttocks. Any blisters: No. Any open areas? No. No further description or notation regarding the resident's heels. Review of the resident's nurse's note, showed the following: -8/19/12 at 9:00 A.M.: Stage II noted to the right buttock: 2.0 centimeters (cm) by 1.5 cm, pink wound bed, flat edges, no drainage noted. -Unstageable pressure ulcer (unstageable slough (yellow or white tissue that adheres to the ulcer bed in strings or this clumps, or is mucinous)and/or eschar (dead and dying tissue): Known but not stageable due to coverage of wound bed by slough and or/eschar) to coccyx, measured 1.5 cm by 1.5 cm with a depth of 5.0 cm, beige slough coming out of pressure ulcer, unable to see the wound bed. Review of the resident's POS, dated 8/1/12 through 8/31/12, showed the following: -Added [DIAGNOSES REDACTED]. -8/19/12: Per wound protocol: Cleanse Stage II to right buttock with wound cleaner, apply wound gel (a specialized wound treatment used to maintain moist healing wound environment) with dry dressing daily until healed. Cleanse coccyx pressure ulcer with wound cleaner, apply Santyl (a active enzymatic therapy that continuously removes necrotic tissue from wounds) ointment with [MEDICATION NAME] powder (used to prevent infection), lightly pack and cover with dry dressing daily and as needed. Further review of the resident's nurse's note, showed the following: -8/22/12 at 2:00 P.M.: Found unstageable pressure ulcer to the coccyx, 100% slough, no drainage. Pressure ulcer found distal with moderate drainage and slight odor, appears to be muscle visible in the wound bed. Pressure ulcer cleansed with wound cleaner and packed with [MEDICATION NAME] AG (a specialized wound dressing with antimicrobial properties). The unstageable pressure ulcer being treated with Exuderm (a specialized dressing which provides odor control and fluid management) to protect and allow [MEDICATION NAME]. Review of the resident's Weekly Wound Observation Report, undated, completed by the Wound Care Nurse, showed the following: -Directions: Use separate sheet for each wound site. Evaluate each item by checking the appropriate box; -Diagram: Line pointing to buttocks; -Type of wound: pressure ulcer checked; -Stage: unstageable; -Date first observed: 8/22/12 at 2:00 P.M.; -Location of wound: coccyx; -1.3 cm by 1.6 by 0 depth, undermining: none, wound bed: 100% slough, edges of wound: red, progress: new, pain: yes; -Diagram: Dot placed on top of fold of buttocks; -Type of wound: pressure ulcer checked; -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 and tunneling.); -Date first observed: 8/22/12 at 2:00 P.M.; -Location of wound: Sacral; -Measurement: 1.8 cm by 1.6 cm by 2 cm depth, undermining: checked, 0.9 cm at 12:00 (clock method to describe location of the tunneling), 1.9 cm at 3:00, 3.4 cm at 6:00 o'clock and 1.0 cm at 9:00, drainage: moderate amount of purulent, odor: yes, progress: new, pain: yes; -Diagram: Circle around left ankle; -Type of wound: Deep tissue injury checked; -Stage: unstageable; -Date first observed: 8/22/12, no time; -Location of wound: Left lateral ankle; -Measurement: 1.4 cm by 1 by 0 depth, 100% necrotic, progress: new; -Diagram: Circle around left foot; -Type of wound: Deep tissue injury checked; -Stage: unstageable; -Date first observed: 8/22/12 at 2:00 P.M.; -Location of wound: Left heel; -Measurement: 1.3 cm by 1.8 cm by 0 depth, 50% necrotic, progress: new. Further review of the resident's POS, dated 8/1/12 through 8/31/12, showed the following: -8/22/12: Discontinue Santyl. Cleanse unstageable wound to coccyx with normal saline and cover with Exuderm, change every three days and as needed for soiling, Clean undermining (tissue destruction underlying intact skin along wound margins) Stage IV with wound cleanser, spraying stream into wound, pack with [MEDICATION NAME] AG, leave edge exposed. Change every other day and as needed for soiling; no documentation regarding left ankle or left heel. Further review of the resident's Licensed Nurse Weekly Skin Assessments, showed the following: -8/24/12: Diagram: Front: circle on left outer ankle: necrotic area, written in; Back of diagram: circle on center of buttocks. Any reddened areas that remain after 30 minutes of pressure reduction: yes, left ankle. Any open ulcers : yes, sacrum written in; -8/31/12: Diagram: Back: circle on center of buttocks. Any reddened areas that remain after 30 minutes of pressure reduction? Yes. Any open ulcers: yes, coccyx written in. Review of the resident's POS, dated 8/1/12 through 8/31/12, showed the following: -8/24/12: cleanse coccyx wound with wound cleaner, pack with silver alginate (antimicrobial and absorbant dressing) and cover with a dry dressing every three days and as needed. Cleanse right lower sacrum with wound cleaner and cover with Exuderm every three days and as needed. No documentation regarding left ankle or left heel. Review of the resident's nurses note, dated 8/24/12 at 3:55 P.M., showed an order for [REDACTED]. Review of the resident's hospice nurse's notes, showed the following: -8/28/12 at 5:45 P.M., multiple open areas to the buttocks, coccyx and necrotic left heel, all pressure related areas; -8/30/12 at 10:45 A.M., coccyx pressure ulcer tunneling, with a foul odor, brown drainage, necrotic areas to left heel and left ankle; -Hospice Wound Assessment, dated 8/30/12: -Stage IV: coccyx: 1.0 cm by 1.0 by 4.3 cm depth, foul drainage; -Unstageable: left heel: 1.8 cm by 3.9 cm by ?, wound bed black, no drainage; -Unstageable: left ankle: 1.5 cm 1.1 cm by ?, wound bed black, no drainage; -Stage II: sacrum: 1.5 cm by 0.8 cm by 0. Review of the resident's care plan, dated 9/1/12, showed the following: -Has areas of skin breakdown due to debility, decreased mobility and poor appetite. Also has a [DIAGNOSES REDACTED]. -Goal: Have minimal discomfort associated with pressure areas through next review. -Interventions: Offer food/fluids of choice and assist as needed. Turn/Reposition at least every two hours avoiding pressure to existing pressure areas. Treatments to areas as ordered for comfort. Adjust treatment as needed to provide optimal comfort. Provide [MEDICATION NAME] as needed. Check and change at least every two hours. monitor skin during routine care for potential problem areas such as redness, swelling, warmth. Pressure relieving mattress to bed. Further review of the resident's hospice nurse's notes, showed the following: -9/1/12, New wound care orders for palliative treatment (focuses on relieving and preventing suffering); -9/20/12, two new open areas to coccyx, palliative care to pressure ulcers, great improvement to lower wound, depth 0.3 cm from 4.0 cm. Observation on 9/25/12 at 9:50 A.M., showed the resident lay in bed. Hospice Nurse L said the pressure ulcer to the resident's coccyx has improved. Observation on 9/26/12 at 7:58 A.M., showed CNA D and CNA N positioning the resident in the bed. The left ankle had a pressure ulcer approximately 1.5 cm in diameter, black and necrotic without drainage. The left inner heel had a pressure ulcer approximately 2.5 cm in diameter, black and necrotic without drainage and the right ankle had a black necrotic pressure ulcer measuring approximately 1 cm in diameter. During an interview on 9/26/12 at 8:09 A.M., CNA N said he/she noticed the change in the resident's pressure ulcer on the buttocks, two months ago, while providing perineal care. It looked like a bubble at first, then it got worse. He/she told the charge nurse at that time. During an interview on 9/26/12 at 8:30 A.M., Clinical Nurse Manager O said no one informed him/her of the development of the pressure ulcer to the resident's buttocks on 8/3/12. The nurse should have followed the facility's policy and called the resident's physician to obtain an appropriate treatment order. He/she didn't know why it took from 8/3/12 to 8/19/12 to notify the resident's physician of the pressure ulcer. On 8/19/12, staff notified him/her and the Director of Nurses (DON) of the pressure ulcer and that was when they assessed, measured, documented in the nurse's notes and notified the physician. Observation and interview on 9/26/12 at 10:00 A.M., during a skin assessment, showed the resident lay in bed. Nurse M said he/she doesn't perform a full skin assessment each time he/she does a treatment on the resident. Nurse M measured the pressure ulcer as follows: -the left ankle: 1.4 cm by 1.0 cm with dry eschar; -left inner heel: 2.0 cm by 3.5 cm with dry eschar; -right ankle: .6 cm by .9 cm with dry eschar; -Nurse M said the sacrum/coccyx wound measured 2.0 cm by 2.4 cm with black and yellow slough covering the wound, unable to determine the depth due to the slough. Nurse M said the wound has worsened. -Right buttock pressure ulcer measured 1.6 cm by 1.4 cm with 75% yellow slough covering the wound. Nurse M said the hospice nurse discovered that wound. -Right inner buttock pressure ulcer measured 0.6 cm by 0.7 cm with a 0.5 cm depth with 0.3 undermining. Nurse M said this pressure ulcer developed first. -Nurse M said staff didn't inform him/her of the development of the pressure ulcer on the resident's right inner buttock on 8/3/12. If they had he/she would have gotten a treatment order. Staff informed him/her on 8/22/12 and that was when he/she did the wound assessment and documented it in the nurse's notes. He/she usually doesn't work weekends and did not work 8/19/12. He/she said when staff discovers a wound on evenings, nights or the weekend, they are to call the physician and get a treatment order. During an interview on 9/26/12 at 1:28 P.M., the DON said staff should have followed the facility's policy and called the physician regarding the development of the pressure ulcers. Staff notified her of the pressure ulcer on 8/19/12, and that was when they assessed, documented and notified the resident's physician. She didn't know why staff didn't call the physician nor did she know why it took from 8/3/12 through 8/19/12 for the physician to be notified. The facility has a wound care nurse who does the treatments Monday through Friday. Staff should have informed the wound nurse of the pressure ulcer after calling the physician and obtaining a treatment order. The wound care nurse starts doing treatments when they are a Stage II pressure ulcer. The charge nurses do the treatments to Stage I pressure ulcers and perform the treatments on weekends. During an interview on 10/2/12 at 2:20 P.M., the resident's physician and Medical Director said he would definitely expect staff to notify him of the development of any pressure ulcer. He said the facility has discussed pressure ulcer protocol frequently during their meetings. Staff should have called and notified him when the pressure ulcer developed. He doesn't know why staff failed to notify him. On 10/3/12 at 1:36 P.M., he said he wasn't sure whether the resident's pressure ulcers are preventable due to the resident's malnourished condition, but he believes if the treatment had been started sooner the pressure ulcers would not have been so severe. Review of the facility's Pressure Ulcer Treatment Protocols, undated, showed the following: -Policy: All residents with pressure ulcers will be treated with consistent treatment protocols to aid in the healing process. The following treatment protocols are recommendations. Some pressure ulcers may require consultations for proper treatment. Always obtain physician orders [REDACTED]. -Procedures: 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 one or more of the following parameters: Skin temperature (warmth or coolness), tissue consistency (firm or boggy), sensation (pain, itching) and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues). -Identify cause/risk factor. -Initiate plan of care. -Clean area of any contaminates. -Pat dry; -Apply moisturizer; -Relieve pressure. -Document. -Evaluate and reassess. -Stage II: Identify cause/risk factors. Initiate plan of care, Obtain physician order [REDACTED]. -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.) Identify cause/risk factor. Initiate plan of care. Consult with dietitian. Establish pressure relief. Obtain physician order [REDACTED]. Evaluate and reassess. -Stage IV: Identify cause/risk factor. Initiate plan of care. Review nutritional interventions. Establish pressure relief. Obtain physician orders [REDACTED]. Document. Evaluate and reassess.

Based on interview and record review, the facility failed to identify, assess, monitor and document significant changes in the resident's condition and failed to notify the physician of those changes for one of two sampled residents (Resident #1). The census was 140. Review of Resident #1's face sheet, showed the following: -admitted [DATE]; -Readmitted on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 11/08/11, showed the following: -Problem: The resident was awake, alert, oriented times three (person, place and time) and was able to make his/her needs known but he/she tired easily. -Goal: the resident would receive appropriate level of assistance from staff. -Approach: Monitor the resident for increased shortness of breath with activities; Monitor the resident for changes in functional mobility or in cognitive status; Monitor the resident's ability to follow directions and perform task. -Problem: the resident had an A-V (a passageway, artificial or natural, that allows blood to flow from an artery to a vein without going through a capillary network) shunt no longer being used of the left arm. -Goal: would be free of complications related to [MEDICAL CONDITION]. -Approach: The resident received [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. Monitor the left arm old shunt site for redness, [MEDICAL CONDITION]. Monitor the resident's chest shunt site for signs/symptoms. Review of the resident's admission data collection and assessment sheet, dated 11/17/11, showed the following: -Level of consciousness: alert to place and person but mumbled at times. -The resident's breath sounds were diminished in the right and left lobes of the lung with no shortness of breath and no cough present. Review of resident's physician order [REDACTED]. -Physical and occupational therapy evaluations. Review of the resident's nurses' notes, dated 11/18/11, showed the following: -7:00 A.M. to 3:00 P.M., the resident was disoriented to person and place and required extensive assistance with bed mobility (turning and repositioning), transfers, eating and toilet use. The resident's respiratory status was normal with an oxygen saturation of 95% (normal range, 95 to 100%). The resident's blood pressure was 193/80 (normal range, 90 to 140 over 60 to 90). -3:00 P.M. to 11:00 P.M., the resident was alert and still required extensive assistance with bed mobility, transfers, eating and toilet use. -11:00 P.M. through 7:00 A.M., no documentation of the resident's condition for that shift. Further review of the resident's nurses' notes, dated 11/19/11, showed the following: -7:00 A.M. to 11:00 A.M., the resident was alert and required limited assistance with bed mobility, transfers, eating and toilet use. The resident's respirations were normal with an oxygen saturation of 97%. Review of the resident's [MEDICAL TREATMENT] notes, dated 11/19/11, showed the resident started the procedure at 11:33 A.M., alert and denied any complaints. The resident was discharged back to the facility at 2:30 P.M., via wheelchair with no complaints and vital signs were stable. Further review of the resident's nurses' notes, dated 11/19/11, showed the following: -3:35 P.M., the resident returned from [MEDICAL TREATMENT] with his/her vital signs stable. -No documentation of the resident's condition for the 11:00 P.M. to 7:00 A.M. shift. During an interview on 11/28/11 at 1:00 P.M., Nurse G said he/she did not chart the resident's assessment for the 11:00 P.M. to 7:00 A.M. shift. Nurse G could not remember the resident's vital signs, but remembered the resident was able to open his/her eyes. During an interview on 11/28/11 at 1:30 P.M., Nurse B said the following: -On 11/20/11, Nurse B arrived at the facility and received report at 6:45 A.M., saw the resident around 7:30 A.M., and told the Certified Nurse Assistant (CNA) C to get the resident up out of bed. -Nurse B said the resident looked tired and very sleepy. -Nurse B said he/she assessed the resident, and did not chart the assessment or any vital signs in the resident's chart. -Nurse B saw the resident at noon, but did not perform an assessment on the resident nor charted the resident's condition or vital signs. -At 2:55 P.M., CNA C came to Nurse B and said he/she was unable to wake the resident. -Nurse B called Nurse E and obtained orders from the physician to send the resident to the emergency room . -Nurse B did not call the physician prior to 2:55 P.M. -Nurse B said he/she was the only nurse on duty and did not chart the resident's assessments at 7:30 A.M. and 1:00 P.M. During an interview on 11/28/11 at 2:00 P.M., CNA C said the following: -On 11/20/11 at 7:30 A.M., CNA C went into the resident's room and the resident was very sleepy and difficult to wake up. The resident usually assisted CNA C to dress, but the resident could not raise his/her hands that morning. -CNA C tried to sit the resident on the side of the bed to stand, but the resident was unable to stand. -CNA C called CNA D to help transfer the resident to the wheelchair, but the resident was "dead weight". -CNA D went to get Nurse B and Nurse B told CNA C and CNA D to put the resident in the chair for breakfast. -The resident did not eat breakfast. During lunch, CNA C had to repeatedly wake the resident. -CNA C put the resident to bed at 1:00 P.M., and the resident still did not look right. -At 2:00 P.M., Family Member (FM) I came to CNA C and said he/she was unable to wake the resident. CNA C did not tell Nurse B about the incident and told FM I to let the resident sleep. During an interview on 12/1/11 at 12:58 P.M., CNA C said the following: -On 11/20/11, CNA C did not inform the nurse of the resident's condition after breakfast, lunch or when he/she placed the resident in bed after lunch or when Family Member (FM) I informed CNA C he/she was unable to wake the resident. During an interview on 12/28/11 at 2:20 P.M., CNA D said the following: -On 11/20/11 at 7:30 A.M., CNA C asked CNA D to assist him/her get the resident out of bed and into the resident's wheelchair. -The resident was really lethargic and incoherent and needed the assistance of two CNAs because the resident could not stand on his/her own. -CNA D and CNA C placed the resident in his/her chair and the resident would slump over in the wheelchair. -CNA D and CNA C took the resident to the toilet and the resident was "dead weight" during the transfer. -At 8:00 A.M., the resident's head rolled forward and then backward while up in the wheelchair. CNA D went and told Nurse B. The resident looked like he/she should go to the hospital. During an interview on 11/28/11 at 2:30 P.M., Employee F said on 11/20/11 at 10:00 A.M., the resident was brought to mass in his/her wheelchair. The resident slept throughout the entire mass. The resident was usually awake and talking. During an interview on 11/29/11 at 9:19 A.M., FM I said the following: -On 11/20/11 at 2:00 P.M., he/she came to the resident's room to visit and was unable to wake the resident. The resident would open his/her eyes, but close them. -The resident was breathing heavy and uneven, and FM I went to get CNA C. -FM I told CNA C he/she could not wake the resident. CNA C told FM I to let the resident sleep. -FM I went into the hall and saw an unidentified male, who walked passed the room and he/she went and got Nurse B. -Nurse B told FM I to leave the room and Nurse B closed the door. -Nurse B came out of the room and went to the nurses' station. FM I went up to the nurses' station. Nurse B told FM I the resident was going to be sent to the hospital. During an interview on 11/29/11 at 2:37 P.M., Nurse A said the following: -Nurse A arrived to the floor at 3:00 P.M., and received report from Nurse B at the nurses' station. -Nurse B told Nurse A the resident was going to the hospital for a change in condition. -Nurse A went into the resident's room and performed a sternal rub (designed to illicit a response from a conscious or semi-conscious person). The resident did not respond. -Nurse B told the ambulance staff the resident had been "that way" all day. -The resident's eyes were closed and he/she had Cheyne-Stokes breathing (abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stoppage of breathing). -Nurse A would have sent the resident out to the hospital 911 sooner. Further review of the nurses' notes, dated 11/20/11, showed the following: -2:55 P.M., the resident was in bed very lethargic and hard to arouse and the resident would only open his/her eyes for a few seconds after a sternal rub. The physician was notified and the facility received orders to send the resident to the hospital. -3:10 P.M., Nurse B called emergency medical services (EMS) non-emergent (time of ambulance arrival 20-30 minutes). -3:40 P.M., the resident was transferred via EMS to the hospital. -There was no documentation of the resident's condition prior to 2:55 P.M., on 11/20/11. Review of the EMS patient care report, dated 11/20/11, showed the following: -The ambulance arrived to the facility at 3:10 P.M. Nurse B said the resident fell three weeks ago and had not been the same since the fall. -Nurse B said the resident was normally awake, oriented to person, place and time but was slow to awake today and barely kept his/her eyes open since 9:00 A.M. -The resident was a full code and Nurse B waited to call EMS because he/she "thought the resident would come out of it". -The resident was only responsive to a sternal rub and slightly withdrew with Cheyne Stokes respirations present and periods of apnea (absence of respirations) -The resident pulse was 54 (normal range, 60-100 beats per minute) with an oxygen saturation of 58-60%. -The resident was placed on 15 liters of oxygen via non-rebreather mask and intervenous (IV) fluids. -The resident's oxygen saturation dropped, with periods of apnea [MEDICATION NAME] longer. -The EMS staff intubated (inserting a tube into the windpipe so that oxygen can be supplied to the lungs) the resident enroute to the emergency room . Review of the hospital emergency room transfer/acceptance note, dated 11/20/11, showed the following: -The resident was found unresponsive at the facility and showed signs of Cheyne-Stokes respiration when the EMS staff arrived to the facility. -The resident arrested prior to arrival to the emergency room . -The resident's initial systolic blood pressure was in the 200/100, and the resident was unresponsive. -The resident was admitted to medical intensive care unit, intubated on a ventilator (a machine that keeps air moving in and out of the lungs of a patient who cannot breathe unaided) and paralyzed. Review of the facility's policy, effective 8/1/10, entitled "Charting", showed all observations, and services performed must be recorded in the resident's chart. Review of the facility's policy, dated 12/30/10, entitled "Resident's change in Condition or Status", showed the following: -Policy: the facility will promptly notify the resident's physician and responsible party of any changes in the resident's condition and/or status. -Procedure: The nurse will notify the resident's attending physician when there is a significant change in the resident's physical, mental or psychosocial status. If a significant change in the resident's physician or mental condition occurs, a omprehensive assessment of the resident's condition will be conducted. During an interview on 11/28/11 at 2:25 P.M., Nurse Manager H said he/she expected the nurses to chart their assessments and vital signs in the resident's chart and call the physician if they noted a change in the resident's condition. If the staff was unable to wake the resident, they should have sent the resident out 911. During an interview on 11/28/11 at 3:00 P.M., the Director of Nurses and the Administrator said the following: -They expected the staff to chart their assessments and vital signs of the resident in the resident's chart and call the physician if they noted a change in the resident's condition. During an interview on 12/1/11 at 7:43 A.M., the resident's physician said the following: -No one called her from the facility prior to 2:55 P.M. on 11/20/11. -The physician depended on the nursing staff to assess the residents and inform the physician of the changes. -Any delay in reporting the resident's condition made this incident worse. The nurse should have called her earlier to tell her the resident had a change in his/her condition and she would have sent the resident to the hospital sooner. MO 189

Based on observation, interview and record review, the facility failed to accurately and consistently identify, assess, monitor and document on resident's pressure ulcers. The facility identified seven residents with pressure ulcers, three were chosen for the sample and problems were found with all three including the development of new pressure ulcers that had not been identified. The sample was 21. (Residents #17, #10 and #12) The census 144. 1. Review of Resident #17's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/12/11, showed the following: -Admission on 2/5/11; -Sometimes understands/understood; -Required interpreter to communicate with doctor or health care staff; -Extensive assistance of two (+) persons for bed mobility, transfers and toilet use; -Did not walk; -Extensive assistance of one person required for personal hygiene and bathing; -Mobility device: wheelchair; -Suprapubic urinary catheter (tube inserted into the bladder through the abdomen to drain urine from the bladder); -Frequently incontinent of bowel; -[DIAGNOSES REDACTED]. -High risk for developing pressure ulcers; -One Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister); -No Stage III pressure ulcers (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); -No unstageable pressure ulcers (known but not stageable due to coverage of wound bed by slough and/or eschar (dead tissue)). Review of the resident's "Braden Scale for Predicting Pressure Sore (Ulcer) Risk" form, dated 2/14/11, showed an overall score of 13, or a moderate risk. Review of the resident's care plan, dated 2/15/11, showed the following: -Maximum assistance of one to two persons required for transfers and activities of daily living (ADLs); -Examine skin during bathing for signs and symptoms of breakdown; -Difficult to assess cognition due to language barrier; -Resident had one small Stage II pressure ulcer on admission; -Incontinent of bowel; -Turn and reposition every two hours; -Skin audit to be completed weekly; -Report any red or open areas. Review of the resident's care plan dated 5/11/11, showed the resident's Stage II pressure ulcer had healed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Usually understood/understands; -Extensive assistance of one person required for bed mobility, personal hygiene, toilet use and bathing; -Did not walk; -Always incontinent of bowel; -No pressure ulcers. Review of the resident's physician's orders [REDACTED]. Review of the facility's "Weekly Pressure Ulcer Report", dated 8/27/11 through 9/2/11, showed the resident had the following: -Right ischium (date of origin 8/24/11): Stage II pressure ulcer, measuring 2.0 centimeters (cm) (length), by 1.0 cm (width) by 0.2 cm (depth), 100% granulation tissue (pink or red, associated with a healing pressure ulcer), Exuderm ([MEDICATION NAME] dressing) treatment. Review of the facility's "Weekly Pressure Ulcer Report", dated 9/3/11 through 9/9/11, showed the resident had the following: -Right ischium: Stage II pressure ulcer, measuring 2.9 cm by 1.7 cm by 0.2 cm, 100% granulation tissue, Exuderm treatment. Review of the resident's POS, showed an order, dated 9/12/11, to discontinue the Exuderm to the pressure ulcer on the right ischium and start Santyl (enzymatic ointment that removes necrotic tissue from wounds), daily for 14 days. (Stage II pressure ulcers do not have slough or necrotic tissue) Review of the facility's "Weekly Pressure Ulcer Report", dated 9/10/11 through 9/16/11, showed the resident had the following: -Right ischium: Stage II pressure ulcer, measuring 2.8 cm by 1.6 cm by 0.2 cm., 90% granulation tissue and 10% slough (dead tissue), Exuderm treatment. Review of the resident's "Braden Scale for Predicting Pressure Sore (Ulcer) Risk" form, dated 9/23/11, showed staff failed to complete the assessment. Review of the facility "Weekly Pressure Ulcer Report", dated 9/17/11 through 9/23/11, showed the resident had the following: -Right ischium: Stage II pressure ulcer, measuring 2.9 cm by 1.8 cm by 0.2 cm, 90% granulation tissue and 10% slough, Exuderm treatment. Review of the resident's POS, showed an order, dated 9/28/11, for Santyl to right ischium open areas. Review of the facility's "Weekly Pressure Ulcer Report", dated 9/24/11 through 9/30/11, showed the resident had the following: -Distal right ischium (date of origin: 9/28/11): Stage II pressure ulcer, measuring 1.9 cm by 1.0 cm by 0.2 cm, 100% granulation tissue, Santyl treatment; -Proximal right ischium: Stage II pressure ulcer, measuring 2.9 cm by 1.9 cm by 0.2 cm, 90% granulation tissue and 10% slough, Santyl treatment. Review of the facility's "Weekly Pressure Ulcer Report", dated 10/1/11 through 10/7/11, showed the resident had the following: -Distal right ischium: Stage II pressure ulcer, measuring 1.8 cm by 1.0 cm by 0.2 cm, 100% granulation tissue, Santyl treatment; -Proximal right ischium: Stage II pressure ulcer, measuring 3.0 cm by 2.0 cm by 0.2 cm, 90% granulation tissue and 10% slough, Santyl treatment. Review of the facility's "Weekly Pressure Ulcer Report", dated 10/8/11 through 10/14/11, showed the resident had the following: -Distal right ischium: Stage II pressure ulcer, measuring 1.5 cm by 1.7 cm by 0.2 cm, 100% granulation tissue, Santyl treatment; -Proximal right ischium: Stage II pressure ulcer, measuring 3.3 cm by 2.2 cm by 0.2 cm, 90% granulation tissue and 10% slough, Santyl treatment. Review of the facility's "Weekly Pressure Ulcer Report", dated 10/15/11 through 10/21/11, showed the resident had the following: -Distal right ischium: Stage II pressure ulcer, measuring 1.5 cm by 1.7 cm by 0.2 cm, 100% granulation tissue, Santyl treatment; -Proximal right ischium: Stage II pressure ulcer, measuring 3.3 cm by 2.2 cm by 0.2 cm, 90% granulation tissue and 10% slough, Santyl treatment. Review of the facility's "Weekly Pressure Ulcer Report", dated 10/22/11 through 10/27/11, showed the resident had the following: -Distal right ischium: Stage II pressure ulcer, measuring 1.9 cm by 1.7 cm by 0.2 cm, 100% granulation tissue, Santyl treatment; -Proximal right ischium: Stage II pressure ulcer, measuring 3.7 cm by 2.2 cm by 0.2 cm, 90% granulation tissue and 10% slough, Santyl treatment. Observation on 11/1/11 at 10:50 A.M., showed the resident lay in bed. Certified Nurse Aide (CNA) A finished washing the resident and positioned him/her onto his/her left side which showed the resident had a previously identified Stage II pressure ulcer to the distal right ischium, and the previously identified unstageable pressure ulcer to the proximal right ischium containing approximately 60% black and brown leathery eschar. The resident also had two unidentified Stage II pressure ulcers below the proximal right ischium pressure ulcer. The treatment nurse applied Santyl dressings to the distal and proximal right ischium pressure ulcers but failed to apply treatments to the unidentified Stage II pressure ulcers. Observation on 11/2/11 at 10:50 A.M., showed the resident lay in bed on his/her left side. The treatment nurse and the Director of Nurses (DON) entered the room. The treatment nurse said on 10/27/11, the size of the pressure ulcer on the resident's proximal right ischium looked like it did that day, except it did not have slough or eschar. The treatment nurse identified the pressure ulcer as a Stage II pressure ulcer, on 10/27/11. The DON said she would have staged the pressure ulcer as at least a Stage III, on 10/27/11. The treatment nurse said the pressure ulcer appeared to be the same as on 11/2/11, when he/she applied the treatment. The treatment nurse said the unstageable pressure ulcer measured 3.8 cm by 4.6 cm by unable to determine (UTD). The treatment nurse identified the two new Stage II pressure ulcers as shearing. The DON said they were Stage II pressure ulcers. The treatment nurse measured the two new pressure ulcers as 0.5 cm by 0.3 cm and 1.5 cm by 4.3 cm. The treatment nurse said he/she did not see the new pressure ulcers on 11/2/11. He/She did not call the resident's physician ,on 11/2/11, about the changes of the proximal right ischium pressure ulcer or the two new Stage II pressure ulcers, but should have. The DON said the treatment nurse should have contacted the resident's physician on 11/2/11, when he/she knew the pressure ulcer on the proximal right ischium had necrotic tissue and regarding the two new Stage II pressure ulcers. She expects the treatment nurse to be able to identify and accurately stage pressure ulcers. Review of the resident's nurse's notes, dated 11/2/11 at 11:20 A.M., showed the treatment nurse documented he/she contacted the resident's physician that day and reported the proximal right ischium pressure ulcer had turned black. Around 60% of the wound bed was black and below the two current pressure ulcers were two new Stage II pressure ulcers. New orders received. During a telephone interview on 11/4/11 at 9:45 A.M., the resident's physician said the treatment nurse should have contacted him regarding the deterioration of the pressure ulcer on the proximal right ischium and the two new Stage II pressure ulcers. He would have expected the treatment nurse to be able to properly identify and stage pressure ulcers. 2. Review of Resident #10's admission MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -No short/long term memory loss; -Extensive assistance of staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -admitted with two unstageable pressure ulcers. Review of the resident's hospital discharge orders, dated 9/13/11, showed an order for [REDACTED]. Review of the resident's admission POS, dated 9/13/11 through 9/30/11, showed the following: -New admit, 9/13/11; -[DIAGNOSES REDACTED]. -No documentation of a treatment order for the right toe and left ankle/heel. Review of the resident's Nursing Comprehensive Admission Data Collection and Assessment form, dated 9/13/11, showed the following: -admitted from hospital; -Musculoskeletal Review: Weakness: left arm and left leg, unable to bear weight, range of motion: limited on left side, full loss; -Admission skin assessment: Instructions: Document each area of impairment, document the measurements next to the area of impairment; -Diagram of the front of a body, with nothing marked; -Second diagram of the back a body with a circle around the left foot, no description or measurement noted. Review of the resident's Weekly Wound Observation Report, showed the following: -Type of wound: pressure ulcer; -Stage: unable to determine (utd); -Date first observed: 9/14/11; -Location of wound: left heel; -9/14/11: 7.0 cm by 8.0 by utd, wound bed: necrotic 100%, edges: red, progress: initial, pain: yes, comments: podus boot applied; -9/21/11: 7.0 cm by 8.0 cm by utd, serous drainage, wound bed: necrotic 100%, progress: no change, continue treatment, pain: yes, comment: podus boot on; -The space for an entry, between 9/21/11 and 10/6/11, showed: Hospital written in. Review of the facility's Weekly Pressure Ulcer Report, dated 9/10/11 through 9/16/11, showed no documentation of the resident's pressure ulcers. Review of the resident's POS, showed an order dated 9/15/11, for skin prep to left heel, podus boot to the left heel, wound gel to the left lower calf/ankle and to the right great toe. Review of the resident's treatment administration sheet (TAR), showed the following orders, dated 9/15/11: -Podus boot to left foot: -Skin Prep to left heel once a day; -Wound gel to left calf/ankle once a day; -Wound gel to right great toe once a day. Review of the resident's skilled daily nurse's note, dated 9/16/11, no time, showed the resident complained of left lower leg pain and received pain medication. No documentation whether staff assessed the resident's left leg. Review of the facility's Weekly Pressure Ulcer Report, dated 9/17/11 through 9/30/11, showed the following: -admitted with: 9/14/11: Left heel: Stage, unstageable, size: 7.0 cm by 8.0 cm by utd, 100% necrotic tissue, no drainage, treatment Skin Prep; -Admit with: 9/14/11: Right left toe: Stage III, size 0.9 cm by 0.8 cm by utd, Slough/eschar 100%, light drainage, treatment: hydrogel. No documentation of a pressure ulcer to the resident's Achilles (area which extends from the heel to the calf). Review of the resident's skilled daily nurse's note, showed the following: -9/20/11 at 3:30 A.M., the resident complained of left lower leg pain. At 11:00 A.M., Podus boot in place to left leg.(no documentation whether the staff assessed the resident's left leg or removed the boot); -9/21/11 at 10:35 P.M., the resident complained of left leg pain, rating nine out of ten on pain scale, shower given anyway with spouse assistance with CNA; -9/23/11, no time, complained of pain to the left foot (no documentation whether the staff assessed the resident's left leg); -9/25/11 at 12:00 P.M.: Dressing changed to bilateral feet as ordered. At 5:40 P.M., Tylenol 325 milligram given for complaints of left leg pain, left foot podus boot intact; -9/26/11 at 3:10 A.M.: Complained of left leg pain, temperature of 100.1 Fahrenheit (F), Tylenol two tablets given at 1:30 A.M., temperature 98.7 F, (no documentation whether staff assessed the resident's left leg); -9/26/11 at 2:00 P.M.: A new area of dark black eschar to the left Achilles, orders received for X-ray of both feet, BMP/CBC (blood test); -6:40 P.M.: Sent to the hospital for critical lab value. Review of the resident's hospital discharge orders, dated 10/3/11, showed the following: -Wound care to be evaluated at the nursing home; -[MEDICATION NAME] (topical antiseptic) and dry dressing to the left posterior (back) ankle and heel. Review of the resident's POS, dated 10/3/11, showed the following: -Readmit; -[DIAGNOSES REDACTED]. -Left posterior ankle and heel, cleanse with wound cleaner, apply [MEDICATION NAME] and dry dressing. Review of the resident's Nursing Comprehensive Data Collection and Assessment Sheet, showed the following: -admitted : 10/3/11; -Admission Skin Assessment, complete on admission; -Date: 10/4/11; -Admission skin assessment: Instructions: Document each area of impairment, document the measurements next to the area of impairment; -Diagram of the back of the body: arrow pointing to back of calf, 5.5 cm by 1.25 cm, black, dry, eschar, 1.5 cm by ? cm yellow slough. Review of the resident's POS, showed the following: -10/4/11: Discontinue [MEDICATION NAME], clean left heel and left posterior leg wound with wound cleaner, apply skin prep, leave open to air, wound nurse to assess and treat 10/5/11; -10/6/11: Discontinue skin prep to left Achilles posterior leg, apply foam dressing, change every three days. Review of the resident's care plan, dated 10/11/11, showed the following: -Problem: Multiple pressure ulcers, required maximum assistance to transfer; -Approach: Examine skin during bathing for signs/symptoms of breakdown, monitor care during routine care for potential problem areas such as redness, swelling, warmth; -Monitor area for improvement or deterioration, notify physician as condition warrants. Review of the resident's POS, showed the following: -10/17/11: Make appointment with wound care clinic, Diagnoses: [REDACTED]. -10/17/11: [MEDICATION NAME] (medicated wound gel) to left Achilles pressure ulcer once daily, continue skin prep to left heel; -10/28/11: Left Achilles: cleanse with wound cleaner, apply hydrogel once daily, cover with dry dressing, left heel and lateral medial foot, apply skin prep daily. Review of the resident's TAR, dated 10/3/11 through 10/31/11, showed the following: -No date: Cleanse left posterior ankle and heel with wound cleaner, apply [MEDICATION NAME] and cover with dry dressing, discontinued 10/4/11; -10/4/11: Cleanse left lower leg wounds (no description of which wounds), cleanse with wound cleaner, apply skin prep daily, (discontinued 10/6/11); -10/6/11: Skin prep to left heel, (discontinued 10/28/11); -10/6/11: Foam to left Achilles, change every three days, (discontinued 10/17/11); -10/17/11: Cleanse left Achilles pressure ulcer daily, apply [MEDICATION NAME] gel, (discontinued 10/27/11); -10/27/11: Dry dressing to left foot wounds, change daily; -10/28/11: Cleanse left Achilles with wound cleaner, apply hydrogel once a day, cover with dry dressing; -10/28/11: Cleanse left heel with wound cleaner, lateral and medial foot, apply skin prep. Review of the back of the TAR showed no documentation describing the appearance of the pressure ulcers. Review of the resident's Weekly Wound Observation Report, showed the following: -Type of wound: pressure ulcer; -Stage: unable to determine; -Location of wound: Left Achilles; -Date first observed: 10/2/11; -10/6/11: 6.4 cm by 2.4 cm by utd, wound bed: 100% slough, 100% black, written in the words black and tan, progress: initial assessment written in, treatment continue treatment, pain yes; -10/13/11: 6.6 cm by 2.5 cm by utd, wound bed: 100% slough, 100% black necrotic, the words black and tan written in; -10/18/11: 6.5 cm by 2.4 cm by utd, drainage: yes, wound bed: 50% slough, 50% necrotic, the words black and tan written in, comments changed treatment to [MEDICATION NAME] gel and faxed information to wound specialist; -10/26/11: 6.6 cm by 2.5 cm by utd, drainage: yes, wound bed: 50% slough, 50% necrotic, wound edges red, periwound: [DIAGNOSES REDACTED], progress no change, treatment: continue, pain yes. Observation on 10/31/11 at 10:00 A.M., showed the resident lay in bed. The treatment nurse washed her hands, applied gloves and removed the dressing to the resident's left leg. Observation of the back of the left leg showed approximately 6 cm in length of exposed Achilles tendon and black eschar on the left heel. The resident asked the treatment nurse if his/her heel continued to be black, she answered yes. During an interview on 11/1/11 at 11:00 A.M., the nurse manager for the resident said the CNAs filled out bath sheets for residents and give them to the nurse to address any issues found. When the nurse is finished with them he/she turns the sheets into the nurse manager, for review. The nurse manager was asked to provide the bath sheets from September to the present. She produced only four bath sheets; dated 10/7/11, 10/27/11, 10/29/11 and 11/1/11, which showed nothing marked on the diagram of the body for the resident. She said she could not find any prior bath sheets for the resident. During an interview on 11/2/11 at 2:00 P.M., the treatment nurse said she changed the dressing on the resident's left heel daily but did not look at his/her left leg nor did she know about the left Achilles area pressure ulcer, until 9/26/11. She does wound assessments once a week and documents the measurements. The treatment nurse said the resident wore a podus boot daily and she felt the boot had caused the pressure ulcer to the left Achilles area. During an interview on 11/2/11 at 10:10 A.M., the DON said she would expect the staff to assess the resident's skin during showers, document it on the shower sheets and give it to the nurse. If there was an change in the resident's skin the nurse should assess it at that time, document the findings and call the physician for a treatment order. Staff should have observed some changes with the resident's left Achilles pressure ulcer prior to finding it on 9/26/11. She said the treatment nurse made her aware of the area, on 9/26/11, during the medicare meeting. The resident refused his/her showers but staff should have assessed the resident's skin. During an interview on 11/4/11 at 10:00 A.M., the resident's physician said the resident had severe [MEDICAL CONDITION]. He would expect staff to assess, document and notify him of any changes with the resident's skin. 3. Review of Resident #12's admission MDS, dated [DATE], showed the following: -No short/long term memory loss; -Extensive assistance of staff for bed mobility; -Total assistance of staff for transfers, personal hygiene, bathing and dressing; -Incontinent of bowel. Review of the resident's POS, dated 10/1/11 through 10/31/11, showed an order to cleanse sacral wound with normal saline, apply Santyl ointment, [MEDICATION NAME] (antibiotic powder used to prevent infection) powder, cover with normal saline moistened gauze and cover with a dry dressing once daily. Review of the resident's TAR, dated 10/1/11 through 10/31/11, showed the following: -Skin assessment, check and record weekly, dated 9/22/11, no initials documented to indicate whether weekly skin assessments were done; -Order dated 10/19/11: Cleanse sacral wound with normal saline, apply Santyl and [MEDICATION NAME] powder, cover with normal saline moistened gauze and cover with dry dressing: -Staff initialed the treatment done, 10/20/11 through 10/28/11; -Back of TAR: no documentation of size or description of the wound. Review of the resident's care plan, dated 10/2/11, showed the following; -Pressure ulcer: Sacral pressure ulcer, recent surgical flap, sent home and readmitted due to wound reopening; -Blood blister (Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) to right medial foot, no measurement documented; -Approach: Wound nurse to measure wound weekly and reevaluate. Observation on 10/31/11 at 8:02 A.M., showed the resident lay in bed on his/her left side. During an interview at this time, the treatment nurse said she didn't have the [MEDICATION NAME] powder for the treatment, because the manufacture no longer made it and couldn't find the Santyl. She said she does the treatment, Monday through Friday, but had not notified the physician that she didn't have the [MEDICATION NAME] powder, but would call and notify the physician. During an interview on 10/31/11 at 8:30 A.M., the treatment nurse said she found the resident's Santyl and [MEDICATION NAME] powder. She couldn't explain why she couldn't find the Santyl and the [MEDICATION NAME] powder nor why she said the manufacture didn't make the [MEDICATION NAME] powder. The Santyl ointment and [MEDICATION NAME] powder containers appeared unused. Observation on 10/31/11 at 8:40 A.M., showed the resident lay in bed on his/her right side revealing a dressing to the sacral area and a nickel sized dark circular area to the top of the resident's right foot. The treatment nurse washed her hands, applied gloves and removed the old dressing. After cleaning the wound with normal saline, she applied the Santyl ointment, [MEDICATION NAME] powder and dry dressing but failed to apply the normal saline moistened gauze as ordered. Observation showed a sacral wound measured approximately 5 cm by 1 cm, with yellow slough and nine to ten sutures. During an interview at this time the treatment nurse said she should have applied the normal saline moistened gauze. Observation on 11/2/11 at 7:20 A.M., showed Nurse F performed a skin assessment, as the resident lay on his/her right side. The nurse identified a dark circular pressure ulcer measuring 1.5 cm by 1.5 cm, on the top of right foot and said he/she would notify the resident's physician. During an interview at this time CNA G said he/she gave the resident a bed bath on Monday 10/31/11, but failed to notice the pressure ulcer to the top of the resident's right foot. 4. Review of the facility's Protocol for Pressure Ulcer Prevention, dated 11/29/10, showed the following: -All residents will be evaluated upon admission, readmission and monthly for potential pressure sore formation; -If a resident has a current pressure ulcer or a history of a pressure ulcer in the last six months, they will automatically be placed at high risk; -High Risk: #11: Daily documentation by nurse on daily skin assessment for resident at high risk for pressure ulcers. 5. Review of the facility's Wound Care Program, no date, showed the following: -In developing a treatment plan for wounds, the clinician should assess not only the wound, but the entire person; -The factors which affect wound healing need to be included into the overall treatment plan. 6. During an interview on 11/2/11 at 10:10 A.M., the DON said she expected staff to do a thorough skin assessment, document any areas noted on a skin assessment sheet and turn it into the nurse. The nurse should assess the area, obtain measurements and call the physician for a treatment order. She did not know why staff failed to identify or document the pressure ulcer to the top of the resident's right foot. She said she recently determined the nurses had not been doing weekly skin assessments two days prior to the beginning of the survey and was in the process of restarting them.