Every finding on record at Life Care Center of Bridgeton

Based on observation, interview, and record review, the facility failed to ensure residents had a comfortable environment with hot water temperatures between 105 and 120 degrees Fahrenheit (F) in resident rooms and shower rooms on the north side of the facility, resulting in residents complaining the water temperature was too cold (Residents #11, #7, #8, #10, and #9). The census was 66. Review of the facility's Water Temperature policy, revised 01/21/25, showed:-Policy: The facility monitors all water temperatures on a weekly basis or more often if needed.-Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident;-Procedure: -Shower/Faucet Temperatures:-Temperatures will be taken weekly from one resident's room on each wing on a rotating basis. To ensure safety, include a room close to the hot water tank and a room in which the residents are able to use the sink independently;-Satisfactory temperature range is maintained per state regulations;-All temperatures will be recorded on a temperature log sheet;-The policy did not include the appropriate water temperature range or guidance for what steps to take if temperatures were not within range. 1. Review of the facility's temperature log book, undated, showed:-A space designated to record temperatures in the following locations:--Dietary dishwasher;--Dietary sink;--Laundry sink;--Breakroom sink;--200 hall east (resident room);--Beauty salon;--200 hall west (resident room);--Therapy kitchen sink;--Therapy bathroom sink;--100 hall west (resident room);--Activity sink (day room);--Split hall (resident room);--100 hall east (resident room);-Completed logbook sheets, dated 04/07/26 through 05/13/26, showed:--On 04/07/26, 100 hall west room [ROOM NUMBER], water temperature logged at 103 degrees F;--On 04/15/26, split hall room [ROOM NUMBER], water temperature logged at 103 degrees F and 100 east hall room [ROOM NUMBER] water temperature logged at 104 degrees F;--On 04/20/26, 100 hall west room [ROOM NUMBER] water temperature logged at 104 degrees F;--On 04/29/26, 100 hall west room [ROOM NUMBER] water temperature logged at 103 degrees F;--On 05/05/26, 100 hall west, no room number, water temperature logged at 104 degrees F;--On 05/13/26, activity sink temperature water temperature logged at 104 degrees F and100 hall east room [ROOM NUMBER] water temperature logged at 103 degrees F;--No additional information on log sheets. 2. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/02/26, showed able to make self understood. Observation of the resident's bathroom on 06/03/26 at 10:57 A.M., showed a digital thermometer used to take the temperature of the hot water from the sink. The water remained cool to touch. The water temperature measured 72.2 degrees F. During an interview on 06/03/26 at 11:00 A.M., the resident said the water in his/her bathroom was always cold no matter how long it ran. It was not pleasant to clean up with cold water. The water has been cold for months. 3. Review of Resident #7's admission MDS, dated [DATE], showed able to make self understood. Observation of the resident's bathroom on 06/04/26 at 7:22 A.M., showed the Maintenance Director used a digital thermometer to take the temperature of the hot water from the sink. The water ran for several minutes and remained cool to touch. The water temperature measured 85.6 degrees F. During an interview on 06/04/26 at 7:25 A.M., the resident said the water was lukewarm at best. He/She doesn't want to take a shower in cold water. 4. Review of Resident #8's quarterly MDS, dated [DATE], showed able to make self understood. Observation of the resident's bathroom on 06/04/26 at 7:31 A.M., showed the Maintenance Director used a digital thermometer to take the temperature of the hot water from the sink. The water ran for several minutes and was cool to touch. The water temperature measured 73.6 degrees F. During an interview on 06/04/26 at 7:33 A.M., the resident said the water was always cold. It would get warm if it ran it for a long, long time. 5. Review of Resident #10's quarterly MDS dated [DATE], showed able to make self understood. Observation of the resident's bathroom on 06/04/26 at 7:44 A.M., showed the Maintenance Director used a digital thermometer to take the temperature of the hot water from the sink. The water temperature measured 72.7 degrees F. During an interview on 06/04/26 at 7:45 A.M., the resident said the water had been cold since he/she had been there. 6. Review of Resident #9's 5-day MDS, dated [DATE], showed able to make self understood. Observation of the resident's bathroom on 06/04/26 at 7:47 A.M., showed the Maintenance Director used a digital thermometer to take the temperature of the hot water from the sink. The water ran for several minutes and was cool to touch. The water temperature measured 78.7 degrees F. During an interview on 06/04/26 at 7:48 A.M., the resident said the water was too cold. 7. Observation of the north shower room on 06/03/26 at 10:30 A.M., showed a digital thermometer used to take the temperature of the hot water from the sink. The water ran continuously for several minutes and the water remained cool to the touch. The water temperature measured 103.2 degrees F. 8. Observation of room [ROOM NUMBER] on 06/04/26 at 7:19 A.M., showed a digital thermometer used to take the temperature of the hot water from the sink. The water ran for several minutes and was cool to touch. The water temperature measured 94.7 degrees F. The Maintenance Director entered the bathroom and felt the water. During an interview, the Maintenance Director said the water was cool and he would not want to bathe or shower in it. 9. Observation of occupied room [ROOM NUMBER] on 06/03/26 at 11:25 A.M., showed a digital thermometer used to take the temperature of the hot water from the sink. The water ran for several minutes and the water remained cool to touch. The water temperature measured 87.3 degrees F. 10. Observation of occupied room [ROOM NUMBER] on 06/03/26 at 11:46 A.M., showed a digital thermometer used to take the temperature of the hot water from the sink. The water ran for several minutes and the water remained cool to touch. The water temperature measured 100.3 degrees F. 11. Observation of occupied room [ROOM NUMBER] on 06/04/26 at 7:27 A.M., showed a digital thermometer used to take the temperature of the hot water from the sink. The water ran for several minutes and the water remained cool to touch. The water temperature measured 77.3 degrees F. 12. Observation of occupied room [ROOM NUMBER] on 06/04/26 at 7:35 A.M., showed the Maintenance Director used a digital thermometer to take the temperature of the hot water from the sink. The water ran for several minutes and remained cool to touch. The water temperature measured 71 degrees F. 13. Observation of occupied room [ROOM NUMBER] on 06/04/26 at 7:54 A.M., showed the Maintenance Director used a digital thermometer to take the temperature of the hot water from the sink. The water ran for several minutes and remained cool to touch. The water temperature measured 72.5 degrees F. 14. Observation of occupied room [ROOM NUMBER] on 06/04/26 at 8:40 A.M., showed the Maintenance Director used a digital thermometer to take the temperature of the hot water from the sink. The water ran for several minutes and remained cool to touch. The water temperature measured 88.1 degrees F. 15. Observation of occupied room [ROOM NUMBER] on 06/04/26 at 8:54 A.M., showed the Maintenance Director used a digital thermometer to take the temperature of the hot water from the sink. The water ran for several minutes and remained cool to touch. The water temperature measured 98.1 degrees F. 16. During an interview on 06/04/26 at 7:19 A.M., the Maintenance Director said he checked the water temperatures of a few rooms on every unit weekly. There had been some issues with the water on the south side of the building. He was in the process of obtaining bids for getting new water heaters. 17. During an interview on 06/04/26 at 1:30 P.M., the Administrator said she knew they were having some issues with hot water on the south side of the building. The water tanks had been there since 2011. The facility was in the process of getting bids to either fix or replace the existing hot water heaters. 30279223013116

Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) care needs were met for one resident when staff failed to check and change the resident's incontinence brief every two hours, leaving the resident in a urine-saturated brief for over seven hours (Resident #3). The sample was 12. The census was 66. Review of the facility's ADL care policy, revised 02/12/24, showed the resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/10/26, showed:-Ability to express ideas and wants: Sometimes understood, ability is limited to making concrete requests;-No rejection of care behavior exhibited;-Diagnoses included stroke and hemiplegia (paralysis on one side of the body) or hemiparesis (weakness on one side of the body);-Substantial/maximal assistance required with toileting hygiene;-Always incontinent of bowel and bladder. Review of the resident's care plan, dated 03/07/26 and in use at the time of survey, showed:-Focus: ADL assistance and therapy services needed to maintain or attain highest level of function;-Goal: Resident wishes to attain prior level of function;-Interventions: Assist with mobility and ADLs as needed;-The care plan did not identify the resident's urinary and bowel incontinence. Observations on 06/03/25 at 8:05 A.M. and 12:45 P.M., showed the resident awake in bed. During interviews, when asked if the resident had been cleaned up and changed, he/she shook his/her head no and pulled back his/her blanket to show an adult brief saturated with urine. The brief was saturated with urine seeping onto the pad underneath the resident. During an interview on 06/03/26 at 12:45 P.M., Certified Nursing Assistant (CNA) F said he/she was assigned to the resident. He/She came on duty at 7:00 A.M. and he/she had not checked, changed, and/or repositioned the resident since he/she was on duty. He/She was new to the facility and was running behind. During an interview on 06/03/25 at 1:43 P.M., Licensed Practical Nurse (LPN) G said he/she had not been notified by any staff the resident had not been checked, changed, cleaned, or repositioned since before 7:00 A.M. No staff had asked for his/her assistance with providing care to the resident. During an interview on 06/03/26 at 1:54 P.M., the Director of Nursing (DON) said she expected staff to check, clean, and reposition incontinent residents at least every two hours and as needed. Staff should let the charge nurse know if they were having difficulty with their assignments. It was never acceptable for a resident to go over an entire shift without being assisted with incontinence care. 299140729856872970561

Based on interview and record review, the facility failed to ensure staff followed their abuse and neglect policy. Resident #4 informed Certified Nursing Assistant (CNA) K that CNA P was mean to him/her and twisted his/her right arm tightly. CNA K failed to notify his/her charge nurse of the accusation because he/she did not believe the resident. Due to CNA K's failure to report the resident's allegation, CNA P remained working until the Administrator was notified and suspended CNA P pending the facility's investigation. Ten residents were sampled. The census was 69. Review of the facility's Abuse and Neglect policy, issued on 1/3/22 and reviewed on 11/19/24, showed: -What: To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. Residents must not be subjected to abuse by anyone. This includes staff; -Why: The resident has the right to be free from abuse and neglect. The facility must not use verbal, mental, sexual, or physical abuse; -The facility must develop and implement written policies and procedures that: Establish policies and procedures to investigate any such allegations. Review of the facility's Abuse - Protection of Residents policy, issued on 10/4/22 and reviewed on 5/7/25, showed: -Policy: The facility will ensure that all residents are protected from physical and psychosocial harm during and after an investigation; -Procedure: The following methods to ensure the protection of residents during an investigation may include but are not limited to: -1. Responding immediately to protect the alleged victim and integrity of the investigation; -2. Examine the alleged victim for any sign of injury, including physical examination or psychosocial assessment if needed; -3. Immediate notification of the alleged victim's practitioner and the family/responsible party; -4. Removal of access by the alleged perpetrator to the alleged victim and assurances that ongoing safety and protection is provided for the alleged victim and, as appropriate, other residents; -5. Notification of the alleged violation to other agencies or law enforcement authorities; -6. Evaluation of whether the alleged victim feels safe and if he/she does not feel safe, taking immediate steps to alleviate the fear, such as a room relocation, increased supervision, etc.; -a. Providing emotional support and counseling to the resident during and after the investigation, as needed; -b. Protection from retaliation; -7. Monitor the alleged victim and other residents at risk, such as conducting unannounced management visits at different times and shifts. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/28/25, showed: -Adequate hearing and vision; -Speech Clarity: Clear speech, distinct intelligible words; -Makes Self Understood: Understood; -Ability To Understand Others: Understands, clear comprehension; -Cognitively intact; -Diagnoses of chronic obstructive pulmonary disease (a chronic lung disease) and anxiety. Review of the resident's care plan, located in the electronic healthcare record, showed: -10/19/23: Focus: activity of daily living (ADL) assistance. Goal: Resident wishes to maintain prior level of function. Interventions: Assist with mobility and ADLs as needed. Hoyer (a machine used to transfer residents unable to bear weight) lift for all transfers; -11/8/24: Focus: Resistive to care. Will make false assumptions towards staff and has manipulative perception of healthcare concerns and needs being met. Goal: Will participate in care. Interventions: Allow resident to make decisions about treatment regime to provide a sense of control. Cares in pair, two CNAs when care is being provided. Continued documentation of behaviors. During an interview on 5/29/25 at 10:00 A.M., the resident said a few weeks ago, he/she could not recall the exact date, CNA P was taking care of him/her. CNA P became mean and squeezed his/her right arm so hard it left a bruise which was not visible at the time of the interview. He/She told Licensed Practical Nurse (LPN) A, on the day it happened. LPN A was the only one he/she told and said he/she would take care of it. During an interview on 5/29/25 at 10:25 A.M., LPN A said the resident never told him/her anything about CNA P getting mad at him/her and twisting his/her right arm. He/She has not seen any bruises on the resident's right arm. Had the resident told LPN A, and CNA P was in the building, he/she would have gotten the CNA's statement and sent him/her home immediately. He/She would have reported it to the Administrator or Director of Nursing (DON) immediately and started the investigation. During an interview on 5/29/25 at 10:44 A.M., the Administrator said he visits with the resident almost daily. The resident never told him anything about CNA P being mean to him/her and squeezing his/her arm. This was the first time he heard anything about it. He shakes the resident's hand every time after talking to him/her and he/she had not seen any bruising. During an interview on 5/30/25 at 7:22 A.M., CNA K said he/she took care of the resident every night he/she worked. On 5/8/25 or 5/10/25, he/she returned to work after being on vacation. The resident told him/her that CNA P had been mean and squeezed the resident's hand or wrist tightly and left a bruise. The resident did not say exactly when it occurred. The resident showed CNA K his hand/wrist, but CNA K did not see any bruises. Since there were no bruises and he/she had never seen CNA P be mean to anyone, CNA K thought the resident was making it all up. CNA K did not report the resident's allegations to anyone. Looking back now, he/she should have reported the resident's allegations to the charge nurse whether he/she believed the resident or not. Review of CNA K's written statement, dated 5/30/25, showed: One night he/she walked into the resident's room to do personal care. The resident said CNA P was mean and squeezed his/her arm. Don't you see the bruise? He/She told the resident no. The resident had no bruise or discoloration. Review of CNA K's time punches, showed he/she returned to work on the night shift of 5/6/25. He/She also worked on 5/8/25 and 5/9/25. During an interview on 5/30/25 at 9:15 A.M., CNA P denied being mean to the resident or squeezing the resident's arm. He/She had been nothing but nice to the resident, and could not understand why the resident would say something like that. Review of CNA P's time punches, showed he/she worked on the night shift on 5/1/25 through 5/5, 5/7 through 5/9, 5/12 through 5/14, 5/16 through 5/19, 5/21 through 5/23 and 5/26 through 5/28/25. The resident was in the CNA's group to care for on 5/4/25, 5/14, 5/19 and 5/22/25. During an interview on 5/30/25 at 8:00 A.M., the interim DON and Administrator said they expected staff to follow the facility's policies. Whether CNA K believed the resident or not, he/she should have followed the policy and reported the resident's allegation to the charge nurse. MO00254277

Based on observation, interview and record review, the facility failed to ensure Resident #7 had fall mats in place and the resident's bed was kept in the lowest possible position when the resident was in bed and unattended by staff, and failed to include the fall mats and low bed as interventions on the resident's care plan. The facility also failed to ensure Resident #9's bed was kept in the lowest position when the resident was in bed and unattended by staff. Four residents were sampled. The census was 69. Review of the facility's Fall Management policy, issued on 6/4/20, and revised on 3/11/25, showed: -Policy: The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls; -Federal Regulations: The facility must ensure that the resident remains as free of accident hazards as is possible. Each resident receives adequate supervision and assistance devices to prevent accidents; -Definitions: Accident - Refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident; -Avoidable Accident - This means that an accident occurred because the facility failed to: -1. Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; -2. Evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; -3. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident; -4. Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice; -Fall - Refers to unintentionally coming to rest on the ground, floor, or other lower level. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred; -Risk - Refers to any external factor, facility characteristic or characteristic of an individual resident that influences the likelihood of an accident; -Hazards - Refer to elements of the resident environment that have the potential to cause injury or illness; -1. Hazards over which the facility has control are those hazards in the resident environment where reasonable efforts by the facility could influence the risk for resulting injury or illness; -2. Free of accident hazards as is possible refers to being free of accident hazards over which the facility has control; -Procedure: -1. Residents will be assessed for fall indicators upon admission, readmission, quarterly, change in condition and with any fall utilizing the Fall Risk Assessment; -2. During the admission and readmission process, a care plan will be developed and initiated by the admitting nurse on any residents assessed to be a risk for falls; -3. Upon completion of the other interdisciplinary team's admission and readmission assessments, the interdisciplinary team will review any additional fall risk indicators and revise the resident's care plan as indicated; -4. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change and quarterly Minimum Data Set (MDS), upon a fall event and as needed thereafter; -5. Residents and/or family members will receive education on the fall management care plan and will be provided opportunity for feedback; -6. The interventions to reduce the risk of falls should be individualized based on the resident risk factors and fall history; -Identifying Patients' Fall Potential; -1. All patients have fall indicators. Fall indicators are patient specific information that, when alone or combined with other fall indicators, create a potential for a patient to fall; -2. Accurate and thorough assessment of the patient is fundamental in determining indicators for potential falls; -a. Fall indicators may be identified by multiple disciplines, utilizing various assessments, and including but not limited to review of; physician orders, progress notes, environmental factors, caregiver conversations; -b. Patient conditions may vary throughout the day, week, month or other time period and the identification of patient fall indicators is an ongoing, interdisciplinary assessment process. 1. Review of Resident #7's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/25/25, showed: -Hearing: Minimal difficulty; -Adequate vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Moderately impaired cognition; -Mobility Devices: [NAME] and wheelchair; -Substantial/maximal assistance required for: Roll left and right, lying to sitting on side of bed, sit to stand, chair/bed to - chair transfer, and walk 10 feet; -Diagnoses of heart failure, high blood pressure, diabetes mellitus and stroke; -Did the resident have a fall any time in the last month prior to admission? Yes; -Did the resident have a fall any time in the last 2 to 6 months prior to admission? Yes; -Any falls since admission? No. Review of the resident's care plan, located in the electronic healthcare records (EHR), showed: -5/20/25: Focus: activity of daily living (ADL) assistance and therapy services needed to maintain or attain highest level of function. Goal: Resident wishes to attain prior level of function. Interventions/Tasks: Assist with mobility and ADLs as needed. Therapy services as needed; -5/20/25: Focus: Decline in mobility and strength related to stroke and requires assist with all ADLs and transfer. Goal: Resident will not sustain serious injury requiring hospitalization. Interventions/Tasks: Assist with ADLs as needed. Call light within reach. Complete fall risk assessment. Mechanical lift (a machine used to transfer a resident who can bear partial weight or a machine used to transfer a resident who cannot bear weight). Orient resident to room; -5/27/25: Focus: Resident scored moderate (cognition) on Brief Interview for Mental Status (BIMS, a cognitive assessment completed by facility staff). Goal: Resident will be able to communicate basic needs. Interventions/Tasks: Allow extra time for resident to respond to questions and instructions. Ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed; -The care plan did not address the resident's fall history, current fall risk or interventions specifically keeping the bed in the lowest position and fall mats on the floor when unattended. Review of the resident's Fall Risk Assessments located in the EHR, showed: -5/21/25: A score of 18 (a score of 10 or above indicates the resident is at risk of falling); -5/27/25: A score of 17. Review of the resident's progress notes, located in the EHR, showed: -5/21/25 at 12:14 A.M.: Resident arrived via ambulance and transferred to bed; -5/21/25 at 7:09 A.M.: Called to resident's room by Certified Nursing Assistant (CNA). Resident sitting on floor with back against bed. Bed in lowest position. Assisted back to bed with assist of 2. No apparent injuries noted; -5/21/25 at 12:31 P.M.: BIMS score of 12, revealing moderate cognitive impairment; -5/22/25 at 5:58 Alert and oriented x 2 (orientation is documented as one or more of the following: person, place, time, situation) although he/she wanders mentally at times. Weakness noted to left side. Resident is able to turn and reposition in bed with assist of 1. Call light within reach and bed in lowest position; -5/23/25 at 6:27 P.M.: Resident requires assistance to turn and reposition in bed. Call light within reach and bed in lowest position with floor mats on both sides for safety. Continues on observation related to fall on 5/21/25; -5/24/25 at 8:41 A.M.: Resident able to turn and reposition in bed independently. Call light within reach and bed in lowest position with floor mats on both sides for safety; -5/25/25 at 12:36 P.M.: Resident able to make needs known. Resident able to turn and reposition in bed independently. Call light within reach and bed in lowest position with floor mats on both side for safety; -5/27/25 at 5:54 A.M.: Resident able to turn and reposition in bed independently. Call light within reach and bed is in lowest position with floor mats on both sides for safety; -5/27/25 at 6:09 P.M.: Resident is able to turn and reposition in bed independently. Call light within reach and bed in lowest position with floor mats on both sides for safety. Awake at intervals during the night yelling out Jesus and Nurse; -5/27/25 at 9:45 A.M.: Resident observed in his/her room on the floor in front of wheelchair. When asked how he/she got on the floor resident stated he/she was trying to get up; -5/29/25 at 5:16 A.M.: Resident continues on observation related to unwitnessed fall on 5/27/25. Asleep in bed duration of night. Call light within reach and bed in lowest position with floor mats on both sides for safety; -5/29/25 at 10:21 P.M.: Resident continues on observation for unwitnessed fall on 5/27/25. Asleep in bed duration of the night. Call light within reach and bed in lowest position with floor mats on both sides for safety. Observation on 5/28/25, showed: -At 8:55 A.M., the resident lay in bed unattended by staff. Both of the resident's floor mats were leaned up against the wall near the window. The height of the resident's bed was 21 inches () from the floor to the top of the bed. The resident said he/she had fallen twice since his/her admission. He/She was not injured during the falls. One of the falls was from his/her bed. The facility put the fall mats down after his/her fall from the bed. Sometimes the mats are on the floor and sometimes they aren't. He/She does not mind having the fall mats down and the bed in the lowest position when unattended; -At 1:22 P.M., the resident lay in bed sleeping and unattended by staff. The fall mats remained leaning against the wall and the height of the resident's mattress from the floor to the top of mattress was 25. Observation on 5/29/25 from 9:36 A.M. to 9:44 A.M., showed the resident lay in bed with his/her eyes closed and unattended by staff. Both of the floor mats leaned against the wall. The height of the bed was 22 from the floor to the top of the bed. At 9:44 A.M., Licensed Practical Nurse (LPN) R entered the resident's room and said the resident had fallen twice since his/her admission. He/She verified the mats were leaning against the wall and there were no staff in the room attending to the resident. He/She said the floor mats should be on the floor, one on each side of the bed when staff are not in the room taking care of the resident. The bed should be in the lowest position possible. The LPN lowered the resident's bed to the lowest position at that time and the height of the bed was 13 from the floor to the top of the mattress. The resident said he/she did not mind the bed being in the lowest position or having the floor mats on each side of the bed. During an interview on 5/29/25 at 11:45 A.M., with the interim Director of Nurses (DON) and Administrator, the DON said she expected staff to keep the resident's floor mats on the floor next to the bed and the bed in the lowest position any time there are not staff in the room and the resident is in bed. The resident's care plan should identify the use of the fall mats and the bed in the lowest position possible when the resident is not being cared for. She will update the care plan. Review of the resident's updated care plan on 5/29/25, by the interim DON, showed: -Focus: Resident has had an actual fall with poor balance, he/she is at risk for future falls. Goal: The resident will resume usual activities without further incident. Interventions/Tasks: Ensure bed is in lowest position at all times when in bed. Floor mats to bilateral side of bed. Frequently used items within reach. 2. Review of Resident #9's admission face sheet, located in the EHR, showed an admission date of 9/24/25. Review of the resident's progress note, dated 1/5/25 at 9:27 A.M., showed: Resident observed sitting on the floor mat by his/her bedside. Resident was assessed back into bed. Review of the resident's Fall Risk Assessments located in the EHR, showed: -1/5/25 at 10:01 A.M.: A score of 20; -4/5/25: A score of 16. Review of the resident's quarterly MDS, dated [DATE], showed: -Makes Self Understood: Sometimes understands - responds adequately to simple, direct communication only; -Ability To Understand Others: Sometimes understands - responds adequately to simple, direct communication only; -Severely impaired cognition; -Mobility Devices: Wheelchair; -Substantial/maximal assistance required for: Sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to - chair transfer; -Diagnoses of high blood pressure and dementia; -Any falls since admission or prior assessment? No. Review of the resident's care plan, located in the EHR, showed: -10/4/24: Focus: ADL assistance and therapy services needed to maintain or attain highest level of function. Goal: Will maintain quality of life. Interventions/Tasks: Assist with mobility and ADLs as needed and 1 person assist with transfers. Resident has dementia and may participate in care with cueing and repeated verbal commands; -1/29/25: Focus: Resident has dementia and scored a BIMS assessment that suggest severe cognitive impairment. Goal: Resident will follow 1 to 2 step instructions. Interventions/Tasks: Allow extra time for resident to respond to questions and instructions. Ask yes/no questions to determine resident's needs; -9/27/24: Focus: At risk for falls. Has had falls prior to admission and is at risk for future fall. Goal: Will not sustain serious injury requiring hospitalization. Interventions/Tasks: Anticipate and meet the resident's needs. Assist with ADLs as needed. Call light within reach. Complete fall risk assessment. Ensure mats at bedside. Ensure that bed is in low position. Observation on 5/28/25, showed: -At 9:26 A.M.,: The resident lay in bed unattended by staff. One mat lay on the floor on each side of the bed. The height of the bed was 25 from the floor to the top of the mattress; -At 1:45 P.M.: The resident lay in bed unattended by staff. One mat lay on the floor on each side of the bed. The height of the bed was 27 from the floor to the top of the mattress. Observation on 5/29/25 at 8:15 A.M., showed the resident lay in bed unattended, eating breakfast. The height of the bed from the floor to the top of the mattress was 25. CNA F entered the room. He/She said he/she was not sure if the resident had a history of falls or not, but since there were fall mats down, he/she expected the bed to be in the lowest position when staff are not in the room. The CNA lowered the bed to the lowest position and the height of the bed was 13 from the floor to the top of the bed. During an interview on 5/29/25 at 11:45 A.M., the Administrator and interim DON said they expected the resident's bed to be in the lowest position when staff are not in the room attending to the resident. MO00254505 MO00254738

Based on observation, interview and record review, the facility failed to follow their policy and physician's orders by failing to notify the physician when one resident's blood sugar levels exceeded the physician's ordered parameters. In addition, the facility failed to obtain STAT (now/no delay) lab orders for the resident. The facility identified 22 residents with orders for routine blood sugar checks. Of the six that were sampled one, Resident #13, had blood sugar levels that exceeded the parameters to contact the physician. The census was 73. Review of the facility's Changes in Resident's Condition or Status, issued 11/26/25, and reviewed 9/5/24, showed:-Policy: This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status;-Notification of Changes: A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is: -A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in life threatening conditions or clinical complications); -A need to alter treatment significantly (that is, a need to discontinue an existing form or treatment due to adverse consequences, or to commence a new form of treatment).Review of Resident #13's annual Minimum Data Set (MDS,) a federally mandated assessment instrument completed by facility staff dated 4/1/25, showed:-Makes Self Understood: Rarely/never understood;-Ability To Understand Others: Rarely/never understands;-Diagnoses of high blood pressure, diabetes mellitus (low/high blood sugar level), aphasia (a partial or total loss of language skills), stroke and respiratory failure;-Received insulin injections 7 of the last 7 days.Review of the resident's care plan, located in the electronic health record (EHR), showed:-Focus: 6/20/23: Diabetes Mellitus; --Goal: The resident will have no complications related to diabetes; --Interventions/Tasks: Blood sugar checks as ordered. Diet as ordered. Medication as ordered.Review of the resident's physician's order sheet (POS) and 6/1/25 through 6/30/25 medication administration record (MAR) located in the EHR, showed:-Ordered on 4/11/25, and discontinued on 6/29/25: Notify physician for blood sugar less than 60 or greater than 400;-Ordered on 4/11/25, and discontinued on 6/29/25: Monitor blood sugar four times a day at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. -Ordered on 4/11/25, and discontinued on 6/24/25: Lantus insulin (long-acting insulin) 6 units daily at 9:00 P.M.;-Ordered on 4/11/25, and discontinued on 6/5/25: Humalog (fast-acting insulin) 5 units every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.;-Ordered on 6/5/25, and discontinued on 6/29/25: Novolog fast-acting insulin) 5 units every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.;-Ordered on 6/24/25, and discontinued on 6/29/25: Lantus insulin 16 units daily at 9:00 P.M.Review of the resident's MARs, showed:-5/1/25 through 5/31/25: All of the resident's blood sugar levels were within the acceptable parameters;-6/1/25 through 6/21/25: All of the resident's blood sugar levels were within the acceptable parameters;-6/22/25 through 6/30/25, showed the following blood sugar level readings documented:-12:00 A.M.: 6/22 read 410, 6/23 read 439, 6/25 read 402, 6/26 read 406, 6/27 read 425, 6/28 read 466, and 6/29 read 475;-6:00 A.M.: 4/28 read 526;-12:00 P.M.: 4/28 read 444.Review of the resident's progress notes located in the EHR, showed:-No documentation the resident's physician was notified (at the time the blood sugar level was obtained) regarding the blood sugar levels on 6/22, 6/23, 6/26, 6/27, 6/28 (12:00 A.M. and 12:00 P.M.); -6/24/25 at 9:46 A.M.: Call placed to physician and informed him of multiple elevated BS readings (6/22 and 6/23). Orders received to increase Lantus by 10 units every day;-6/28/25 at 7:02 A.M.: Resident sugar level 526. Physician called and awaiting return call.Review of the nurse's report sheets for the resident, showed:-6/25/25: Blood sugar 402. New order: Increase Lantus to 16 units;-6/28/25: 6:10 A.M., Called physician. Obtain STAT CBC (complete blood count), CMP (comprehensive metabolic panel) and urine (obtain sample for urinalysis);-Review of the resident's EHR showed no documentation the facility obtained the STAT CBC, CMP and urinalysis. Review of the resident's progress note, showed:-6/29/25 at 8:34 A.M. (the next note after the 6/28/25 at 7:02 A.M. entry): 12:00 A.M., upon entering resident's room, he/she was noted to be tachypneic (rapid shallow breathing) with eyes closed. Opened eyes to name but drifted back immediately. Vitals obtained: 152/68 (blood pressure (BP) - normal 120/80), 98.8 (temperature (T) - normal 98.7), 121 (pulse (P) - normal 60-100), 86% on room air (oxygen saturation rate (O2 Sat) - normal 95-100). Blood sugar level 475. Insulin administered per orders. Resident is normally resistant to any touch to his/her abdomen, and he/she is not this time. Skin warm and dry. Cough noted: 12:13 A.M.: Call placed to EMS (emergency medical services) and departed to hospital. 12:16 A.M.: Call placed to physician. 7:15 A.M.: Director of Nursing (DON) informed. Review of the resident's SBAR ( situation, background, assessment, recommendation) Communication Form dated 6/29/25 at 12:13 A.M., showed:-Situation: This started on 6/28/25. Since this started it has gotten worse;-Background: -Changes in the past week : Lantus insulin increased to 16 units daily;-Vital Signs: BP 152/68, P 121, respirations 28 (normal respiration rate 12-20), T 98.8 and O2 Sat 86%;-Decreased level of consciousness;-Non-productive cough;-Review: Sent to hospital. Review of the resident's hospital records, showed:-admission date of 6/29/25;-discharge date of 7/10/25;-Resident admitted with history of stroke with residual left sided deficits, dysphagia (difficulty swallowing) with feeding tube (a tube inserted into the stomach to provide liquid nutrition, fluids and medication). Resident aggressive to nursing home staff at baseline, was altered at the nursing home and brought to the emergency department. Blood sugar in 400-500's;-Resident diagnoses at the time of admission included: septic shock (a life-threatening condition caused by infection and sepsis (systemic infection (affecting the entire body)) due to MRSA (methicillin resistant staphylococcus aureus), encephalopathy (syndrome of overall brain disfunction), acute (sudden) hypoxic (low oxygen level) respiratory failure, and diabetes type 2 insulin dependent;-CMP results dated 6/29/25 at 12:00 A.M. and 1:24 A.M.: Glucose (sugar) level of 534;-Sputum culture results dated 6/29/25 at 6:07 A.M., and updated on 7/2/25 at 7:13 A.M.: MRSA detected. Observations on 7/14/25 at 9:00 A.M. and 1:42 P.M., and on 7/15/25 at 9:09 A.M., showed the resident lay in bed awake and making eye contact, but unable to comprehend or respond to questions. During an interview on 7/15/25 at 9:54 A.M., Licensed Practical Nurse (LPN) D said if a resident's blood sugar exceeded the physician ordered parameter, he/she would contact the resident's physician and document it in the resident's progress note along with any new orders the physician gave. During an interview on 7/15/25 at 10:10 A.M., LPN C said if a resident's blood sugar check exceeded the physician's ordered parameter, he/she would contact and update the physician. He/She would document contacting the physician in the resident's progress notes and would document any new orders on the POS and MAR. During an interview on 7/15/25 at 11:31 A.M., the Director of Nursing (DON), Regional Director of Clinical Services and the Regional [NAME] President said if a blood sugar exceeded the physician's ordered parameters, they expected the nurse to contact the physician at the time the blood sugar was obtained and document contacting the physician as well as any new orders in the resident's EHR.During an interview on 7/15/25 at 12:44 P.M., the Regional Director of Clinical Services said the labs were not obtained. A STAT lab meant it should be obtained now. If it could not be obtained STAT, then the physician should be notified and that should be documented in the EHR.During an interview on 7/15/25 at 2:30 P.M., the Regional [NAME] President said their lab tried to obtain STAT orders within four hours, however the lab said it could take up to 24 hours for lab staff to be at the facility and obtain the lab. MO00256981

Based on interview and record review, the facility failed to designate a person to serve as the director of food and nutrition services with the appropriate certification, when a consultant Registered Dietician (RD) was not employed full-time with the facility. The census was 86. Review of the facility's certified dietary manager job description, undated, showed: -License and certification: Must have completed an approved Certified Dietary Manager course. Must maintain an active certification. During an interview on [DATE] at 9:53 A.M., the Dietary Director said she has her required qualifications but did not have a physical copy of the documentation. During an interview on [DATE] at 10:02 A.M., the Executive Director said he would expect the Dietary Director to have the required certifications. The Dietary Director did have the required certifications, but they have expired.

Based on observation, interview and record review, the facility staff failed to treat residents with dignity when staff removed one resident's personal items without the resident's permission while he/she was out of his/her room receiving a shower (Resident #68). Furthermore, staff spoke to three residents in an unprofessional manner (Resident #68, Resident #29, and Resident #45). Staff also used their personal cell phone while assisting one resident during meal time (Resident #22). The sample was 18. The census was 86. Review of the facility's Dignity policy, reviewed, 9/26/24, showed: -Policy: Each resident has the right to be treated with dignity and respect, interactions and activities with residents by staff, temporary, agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporation of the resident goals, preferences, and choices; Staff must respect the resident's individuality as well as honor and value their input; -Procedure: -All residents will be treated with dignity and respect: Examples of treating residents with dignity and respect include, but are not limited to: -Treating all residents' possessions, regardless of their apparent value to others, with respect; -Respecting residents' private space and property (For example, changing the radio or television station only upon a resident's request, asking permission to access resident's rooms, drawers, cabinets, and closets); -Promoting resident independence and dignity while dining, such as avoiding: -Staff interacting/conversing only with each other rather than with residents while assisting with meals; -Addressing residents by the name or pronoun of the resident's choice; -Residents should not be excluded from conversations during activities or when care is being provided; -Considering the resident's lifestyle and personal choices identified through their assessment processes, to respect and accommodate his or her individual needs and preferences. Review of the facility Cell Phone policy, dated, 1/7/25, showed: -Policy: The facility will ensure the appropriate usage of cell phones to safeguard resident privacy and to ensure the provision of highest quality resident care; -Procedure: Associates should refrain from using cell phone in resident care areas at all times. 1. Review of Resident #68's, quarterly minimum data set, (MDS, a federally mandated assessment instrument completed by facility staff), dated 1/26/25, showed: -The resident is cognitively intact; -No behaviors or rejection of care; -The resident is dependent on staff for showers and bathing. Review of the resident's face sheet, undated, showed diagnoses that included: Anxiety, cognitive communication deficit, spinal stenosis (narrowing) of the lumbar region (lower back), chronic obstructive pulmonary disease (COPD, restricts airways in the lungs making it difficult to breathe). Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is resistant to care; The resident will make false assumptions towards staff and has a manipulative perception of healthcare concerns and needs being met; The resident presents with obsessive compulsive disorder (OCD), increased anxiety, and claustrophobic like behaviors. -Interventions: Give a clear explanation of all care activities prior to and as they occur each contact; If the resident resists activities of daily living (ADL), reassure the resident, leave and return five to ten minutes later and try again; Provide the resident with opportunities for choice during care provision. Review of the resident's progress notes, showed: -On 2/17/25, at 11:14 A.M., the resident is making demands while staff are in the room to get the resident up for a shower. The resident is upset and said that the staff was taking all her things. This nurse was in room with the aide and observed the aide cleaning the resident's room and removing old linens and towels, this was explained to the resident and the resident remained upset. During observation and interview on 2/27/25 at 11:05 A.M., Certified Nursing Assistant (CNA) D propelled the resident on the shower stretcher into the spa room. The resident said he/she hoped no one takes his/her stuff in his/her room while he/she is in the shower. CNA D completed the resident's shower and propelled the resident back to his/her room using the shower stretcher. Once the resident returned to his/her room, he/she immediately looked around the room and noticed that some of his/her clothing on his/her bedside table were missing along with two towels and a bed blanket. The resident was upset and asked CNA D two times, where is my clothing? CNA D replied that he/she didn't see any clothing on the resident's nightstand. The resident said it must have been another staff member that did it. CNA S entered the room and informed the resident that he/she took the resident's towels and bath blanket off the nightstand because it was soiled. CNA S said he/she did not see the resident's clothing. The resident described to CNA S what the clothing looked like. CNA S again said he/she did not take her clothing, and only removed soiled linen that was on the resident's nightstand. CNA S said to the resident, that he/she would will try his/her best to find the clothing. The resident asked CNA S to look in the soiled linen room for his/her clothing because his/her clothing did not have his/her name on it. CNA S said again, he/she would try his/her best to locate the resident's clothing. The resident said he/she was feeling very anxious. During an interview on 2/24/25 at 9:40 A.M., the resident said he/she doesn't want to take showers anymore because when he/she is taken to the shower room by staff, another staff member goes into his/her room and removes linens and clothing without his/her permission. This makes him/her very upset and increases his/her anxiety. The resident said this has happened at least five times within the last six months. During an interview on 2/27/25 at 2:10 P.M. CNA S said he/she had taken the resident's clothing and bed linens off his/her nightstand without the resident's permission. The linens that were on top of the clothing were soiled. CNA S said the resident will not allow the staff to remove things out of his/her room and the resident becomes upset when staff try to do so. CNA S said the resident was a hoarder. He/She will discreetly remove clothing that needs to be laundered when the resident is not in his/her room. During an interview on 2/27/25 at 2:25 P.M. Licensed Practical Nurse (LPN) T said staff should not remove items out of the resident's room without his/her permission. Staff should show the resident the soiled linens and explain to him/her that the linens and clothing were soiled and that they need to be removed. If the resident refuses, then the family may have to be called. During a telephone interview on 3/3/25 at 11:31 A.M., with State Employee X and Resident #68, the resident asked CNA D if the resident was assigned to him/her and informed the CNA that he/she had a bowel movement (BM) and needed to be cleaned up. CNA D did not answer the resident but was heard speaking in the background to someone else. The resident said to State Employee X, this is what CNA D does to me, he/she assists the roommate and ignores me. The resident was heard informing CNA D that his/her light was on for a long time and that he/she has been sitting in BM and needed CNA D's help. CNA D was heard with a raised voice and said to the resident, Your light wasn't on. The resident replied, to CNA D, Yes, it was. CNA D replied with a raised voice, No it was not and said that he/she was waiting on towels. The resident said to CNA D that he/she called to the front desk at least 10 times, and the front desk hangs up on him/her. CNA D was heard with a raised voice, I don't care. You can call the front desk as many times you want. I don't care. The resident said to State Employee X he/she wanted to be treated like everyone else. During an interview on 2/28/25 at 9:34 A.M., the Administrator and the Director of Nursing (DON) said staff are expected to discuss the removal of the soiled linens and clothing prior to doing so. The staff are always professional in speaking with residents and are expected to continue to do so. 2. Review of Resident #29's quarterly MDS, dated [DATE], showed: -The resident is cognitively intact; -The resident is dependent on staff for toileting hygiene; -Diagnoses include: Cognitive communication deficit, high blood pressure, and heart failure. Review of the resident's care plan, in use of time of survey, showed: -Focus: ADL assistance and therapy services needed to maintain or attain highest level of function; -Interventions: Assist resident with mobility and ADLs as needed. During observation and interview on 2/24/25 at 11:25 AM., CNA D and CNA U provided perineum care (peri-care, cleansing the genitals and rectal area) by turning the resident side to side on his/her bed. The resident said he/she feels as though he/she is not turned very much. CNA D said to the resident, You know, things happen, and I tell all my residents they should just be happy to be alive. While washing the resident's back CNA D said to CNA U, I'm only here two days a week and I am glad. I'm a good aide, but I am reconsidering working here. During an interview on 2/24/25 at 11:35 A.M., the resident said the CNAs have a hard job. The resident heard the comments by CNA D and said he/she is happy to be alive. During an interview on 2/27/25 at 2:10 P.M., CNA S said that staff should not speak over the resident. The resident should be involved in the conversations. All interactions with the residents should be positive, upbeat, and professional. Telling the residents that they should just be happy to be alive is something that should not be said by staff. During an interview on 2/2/25 at 2:45 P.M., LPN T said the residents are to be spoken to in a professional manner and staff are not to speak over them during care. The staff should engage the resident in conversation and always be encouraging in a positive way. During an interview on 2/28/25 at 9:34 A.M., with the Administrator and the DON, the DON said she wasn't understanding the context of the conversation that the staff had with the resident related to the comment that CNA D said, I just tell all my residents that they just should be happy to be alive. In general, staff should not be talking over the resident while providing care and are expected to be professional with their conversations with residents. 3. Review of Resident #45's quarterly MDS, dated [DATE], showed: -The resident has moderate cognitive impairment; -Requires maximum assist from staff for toilet hygiene; -Occasionally incontinent of urine and frequently incontinent of bowels. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has ADL self-care deficit related to hemiplegia (weakness to one side of the body), stroke, impaired balance, and limited mobility; -Interventions: Assist the resident with toilet use and hygiene. During an observation and interview on 2/24/25 at 12:15 P.M., CNA S entered the resident's room and the resident said he/she was wet. CNA S checked the resident and said to the resident your diaper is dry. The resident insisted that he/she was wet. CNA S removed the resident's brief and a small amount of stool was observed on the brief. CNA S said to the resident that the resident had a small BM and his/her diaper was not wet. During an interview on 2/27/25 at 2:10 P.M., CNA S said a resident's brief can be called a diaper. He/She thought most residents wouldn't mind but guessed it depended on the resident and what they preferred. He/She didn't know what Resident #45 preferred. During an interview on 2/27/25 at 2:25 P.M., LPN T said it is not appropriate to call the resident's incontinent brief a diaper. A diaper is used on children and an incontinent brief is used on the adult residents. The term diaper is demeaning. During an interview on 2/28/25 at 2:45 P.M., with the Administrator and the DON, they said they would expect staff not to call the resident's incontinent brief a diaper while providing care to the resident. 4. Review of Resident #22's medical record, showed: -Diagnoses included dementia, diabetes, and Parkinson's disease (brain disorder causing unintended or uncontrolled movements); -Severe cognitive impairment. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: ADL assistance and therapy services needed to maintain or attain highest level of function. The resident has a decline due to stroke with left sided weakness, resident is dependent with all daily living needs and transfers, resident is currently working with therapy services to increase functional mobility and strength; -Goal: Resident wishes to attain prior level of function; -Interventions: Assist with mobility and ADLs as needed. Diet is mechanical soft and resident needs to eat in the dining room. Observation on 2/26/25, of lunch in the main dining room, showed: -At 11:52 A.M., CNA M sat at the table next to the resident. CNA M held his/her cell phone in his/her lap, texting. The resident's drinks and dessert were on the table in front of the resident; -At 11:55 A.M., CNA M sat next to the resident, texting on his/her phone and not assisting the resident. The resident's food remained on the table; -At 11:57 A.M., CNA M tested on his/her phone and was not assisting the resident; -At 12: 16 P.M., CNA M texted on his/her phone. The resident's food was on the table in front of the resident, untouched; -At 12:17 P.M., CNA M was still texting on his/her phone. The resident was not eating, and his/her food remained on the table in front of him/her; -At 12:19 P.M., CNA M put his/her phone back in his/her pocket. During an interview on 2/27/25 at 12:52 P.M., Registered Nurse (RN) P said the cell phone policy is that staff are not to have cell phones out in resident care areas. It is not appropriate to be on your phone while assisting residents in the dining room. During an interview on 2/27/25 at 12:55 P.M., CNA O said staff are not to have cell phones in resident areas. He/She would expect staff to be off their phones while assisting residents due to choking risks. During an interview on 2/27/25 at 1:26 P.M., the Dietary Director said she would expect staff to be off their phones during meal service. She would expect staff to have their phones put away while assisting residents. During an interview on 2/27/25 at 1:58 P.M., the Executive Director said he would expect staff to be off their phones while assisting residents in the dining room. Staff should not be on their phones in resident areas. MO00249674 MO00248977 MO00248931 MO00250429 46888

Based on interview and record review, the facility failed to ensure general accounting principles were followed by failing to follow up on outstanding checks during monthly resident trust fund (RTF) reconciliations. This facility identified 35 residents with funds handled by the facility. The census was 89. Review of the facility's Resident Trust Policy and Procedures, reviewed 6/15/22, showed: -In large part, these policies have been developed with the guidance of: -The Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, State Operations Manual, Appendix PP - Interpretive Guidelines for Long-Term Care Facilities; -State laws and regulations must also be followed when they are more stringent or more specific; -Each skilled nursing facility that is owned by the corporation shall: Manage a resident's personal funds via the Resident Fund Management Service (RFMS); -The policy did not provide guidance for follow-up on outstanding checks. Review of the facility's monthly RTF reconciliations from February 2024 through January 2025, showed outstanding checks as follows: -Check #1194, dated 9/30/20: $660.37; -Check #1212, dated 1/29/21: $150.00; -Check #1245, dated 6/30/21: $1,500.18; -Check #1253, dated 7/27/21: $10.00; -Check #1279, dated 9/14/21: $100.00; -Check #1292, dated 10/29/21: $50.00; -Check #1398, dated 12/23/22: $296.45; -Check #1401, dated 12/28/22: $27.26; -Check #1474, dated 8/22/23: $25.00. During an interview on 2/27/25 at 1:10 P.M., the Assistant Business Office Manager (ABOM) said she reconciles the RTF monthly and submits the reconciliations to the corporate office. She was not aware outstanding checks needed to be investigated. Following up on outstanding checks would be overseen by regional or corporate staff. During an interview on 2/27/25 at 1:16 P.M., the Regional Business Office Manger said she was not aware there needed to be routine follow-up for outstanding checks. The monthly reconciliations are reviewed by the corporate office. During an interview on 2/28/25 at 8:52 A.M., the Executive Director said he expects general accounting principles to be followed by the facility and corporate business office.

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing 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 three residents (Residents #26, #29 and #45) with wounds requiring treatments, gastrostomy tubes (g-tube, a tube that is surgically inserted into the abdomen and is used for liquid nutrition and medications), or tracheostomies (a surgically inserted tube inserted into the windpipe to assist with breathing). The sample was 16. The census was 86. Review of the facility's EBP policy, revised 3/21/24, showed: -Policy: The facility should use EBP as an additional MDRO mitigation strategy for residents that meet the following criteria, during high-contact resident care activities: -Infection or colonization with a CDC targeted MDRO when contact precautions do not otherwise apply; -Wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO; -Wounds generally include chronic wounds, such as pressure ulcers (a wound cause by prolong pressure), diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers (wounds that are caused by damaged veins); -Indwelling medical device examples include central line (access that is surgically inserted into a large vein that is used for fluids and medications) urinary catheters (a tube that drains the bladder), feeding tubes, and tracheostomies; -Procedure: The facility should develop a process to communicate with residents who require the use of EBP for all contact resident care activities. The facility may choose to post signage on the door or wall outside of the resident's room indicating the resident is on EBP; -Provide education to affected residents and visitors on the reason and use of EBP; -Examples of high contact resident care activities requiring gown and glove use include: -Dressing; -Bathing or showering; -Transferring; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use: Central line, urinary catheter, feeding tube, and tracheostomy; -Wound care: any skin opening requiring a dressing. Review of the facility's list of residents on EBP, dated 2/24/25, showed Resident # 26, Resident #29 and Resident #45 listed on EBP. 1. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/24, showed: -Speech Clarity: No speech - absence of spoken words; -Makes Self Understood: Rarely/never understood; -Ability to Understand Others: Sometimes understands - responds adequately to simple, direct communication only; -Dependent - Helper does all of the effort. Resident does none of the effort to complete activity: Toileting hygiene, shower/bathing, upper/lower body dressing, and personal hygiene; -Diagnoses: MDRO, pneumonia (an inflammatory condition of the lungs. Symptoms may include productive or dry cough, chest pain, fever, and difficulty breathing.), stroke, seizure disorder, malnutrition, and respiratory failure; -Feeding Tube; -Special Treatments and Programs: Oxygen therapy, suctioning (removes mucus and secretions), and tracheostomy care. Review of the resident's care plan, showed: -1/16/25: Focus: At risk for respiratory illness. Goal: The resident will remain free from respiratory illness. Interventions: Monitor for change in condition and notify physician of findings; -1/16/25: Family is resistive to care and implementation from professional maintenance care and assisting with maintaining baseline-well being. Family removes treatments in place to skin integrity concerns, performs tracheostomy care. Goal: The resident will cooperate with care. Interventions: Educate resident/family/caregivers of the possible outcomes of not complying with treatment or care; -1/16/25: Focus: Impaired cognitive ability/impaired thought process related to TBI (traumatic brain injury). Goal: Resident's needs will be met. Interventions: Allow resident extra time to respond to questions and instructions. Ask yes/no questions; -1/16/25: Focus: Rash, contact dermatitis to buttock and is followed by wound care company. Goals: Will have no complications from rash. The resident will have no signs or symptoms of infection. The rash will heal by next review date. Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Observe skin rashes for increased spread of infection. Seek medical attention if skin becomes bloody or infected; -1/16/25: Tracheostomy tube related to TBI. Goal: Will have no signs/symptoms of infection. Interventions: Observe for changes in level of consciousness, mental status, and lethargy. Review a sign for EBP, located on the door of another resident, showed: -Everyone must: Clean their hands, including before entering and when leaving the room; -Providers and Staff Must Also: Wear gloves and a gown for the following high-contact resident care activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting; -Device care or use: Central line, urinary catheter, feeding tube, tracheostomy; -Wound Care: Any skin opening requiring a dressing. Observation and interview on 2/24/25 at 8:56 A.M., showed personal protection equipment (PPE, gloves, gowns, masks, etc.) hanging on the outside of the room door, but no Enhanced Barrier Precautions sign on the outside of the resident's door or room. Upon entering the room, there was a sign on the inside of the door with instructions on how to remove PPE upon leaving the room. The waste can to discard PPE sat along the wall next to the first bed in the room and was not placed next to the door exit. The resident lay in bed while a family member bathed the resident. The family member wore gloves, and a face mask, but no gown. The resident had a tracheostomy tube with humidified oxygen infusing and a g-tube. When the family turned the resident onto his/her side, an uncovered stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) was noted on the resident's coccyx (tailbone). During an interview, the family member said he/she comes in every morning to bathe the resident. Observation on 2/24/25 at 11:08 A.M., showed no EBP sign on the outside of the room door. Observation and interview on 2/25/25 at 6:57 A.M., showed no EBP sign on the outside of the room door. Upon entering the room, the waste can remained along the wall next to the first bed, and the resident's family member was at the bedside, bathing the resident. The family member wore gloves and a face mask, but no gown. Certified Nursing Assistant (CNA) H entered the room and then went back outside of the room door and got two gowns, one for him/her and one for the family member. While wearing gloves and gown, CNA H helped the family member pull the resident up in the bed. The CNA told the family member whenever personal care is provided, a gown needs to be worn. The family member said he/she had been bathing the resident everyday since the resident had been at the facility, and this is the first time anyone asked him/her to wear a gown. The family member put the gown on and finished bathing the resident. During an interview on 2/28/25 at 7:20 A.M., the facility Infection Preventionist (IP) said she was not aware there was no Enhanced Barrier Precaution sign on the outside of the resident's door, but there should be. It is her and the Unit Coordinator's responsibility to ensure the signs are posted on the outside of the room. Gloves, gowns and masks are required while providing personal care to the resident. The IP had not educated the family member about the enhanced barrier precautions policy. During an interview on 2/28/25 at 9:34 A.M., the Administrator said EBP signs should be posted on the outside of the door or room for residents who meet the enhanced barrier criteria. The trash can should be next to the exit per the facility policy. He and the Director of Nursing (DON) had seen the resident's family wearing a gown before, so they are not sure why the family member said he/she had not never been asked to wear one before. They did not have any documentation showing the resident's family had been educated by the facility on why he/she should wear PPE. The Administrator said he expects staff to follow the policy by ensuring signs are posted and waste cans are next to the exit. 2. Review of Resident #29's quarterly MDS, dated [DATE], showed: -Diagnoses of congestive heart failure, muscle weakness, and toxic liver disease; -Cognitively Intact. Review of the resident's care plan, dated 2/25/25, showed: -Focus: Resident has a venous ulcer (wound caused by abnormal or damaged veins) on the right lateral (lower) leg and left lateral leg, the resident is non-compliant with wound care and is followed weekly by a wound clinic team; -Goal: The resident's ulcer will be healed by the review date; -Interventions: EBP precautions. Review of the resident's Physician's Orders Summary (POS), in use at the time of the survey, showed: -An order, dated 10/22/24, for EBP to be worn every shift during close contact care due to the resident's leg wounds. Observation on 2/24/25 at approximately 10:30 A.M., showed the resident's door did not have an EBP sign posted. The Facility Wound Nurse entered the room without PPE and informed the resident that she was there to change the resident's dressing. CNA D entered into the room without PPE. The Facility Wound Nurse, with gloved hands but no gown, removed the resident's heel protectors and dressing to both legs. While wearing gloves but no gown, CNA D assisted the Facility Wound Nurse, holding the resident's legs while the Facility Wound Nurse dressed the resident's leg wounds. At 11:25 A.M., CNA U entered the room without an isolation gown, applied gloves and said he/she was going to assist CNA D in getting the resident cleaned up. CNA U and CNA D provided perineum care (peri-care, cleansing on the genitals and rectal area) by turning the resident side to side. The resident's upper body touched CNA U's and CNA D's uniform when they turned the resident. Staff did not wear an isolation gown during resident care. Observation on 2/25/25 at 9:13 A.M., showed CNA N and CNA O entered the resident's room to transfer the resident from his/her bed to his/her wheelchair using a full mechanical lift. CNA N and CNA O both put on a pair of gloves upon entering the room. CNA N lifted the resident's feet with one hand while pulling a pillow out from under the resident's feet with his/her other hand and then placed the resident's feet back on the bed. Both CNA N and CNA O rolled the resident onto his/her left side with CNA O leaning up against the resident with his/her clothing touching the resident. The CNAs then rolled the resident to his/her left side with CNA N leaning up against the resident with his/her clothing touching the resident. While lowering the resident into his/her wheelchair from the lift, CNA O leaned against the resident while holding him/her in position with his/her clothing touching the resident. Both CNA O and CNA N did not wear a gown during the resident care During an interview on 2/28/25 at 7:26 A.M., CNA N said he/she did not know if the resident was on EBP precautions. The sign on the resident's door was an EBP sign, which means a gown and gloves needs to be worn when taking care of the resident. 3. Review of Resident #45's quarterly MDS, dated [DATE], showed: -The resident has moderate cognitive impairment; -Diagnoses include kidney disease, pneumonia, stroke, and depression; -Requires maximum assistance from staff for toilet hygiene; -Occasionally incontinent of urine and frequently incontinent of bowels; -The resident has a feeding tube. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has an activities of daily living (ADL) self-care deficit related to hemiplegia (weakness to one side of the body), stroke, impaired balance, and limited mobility; -Interventions: Assist the resident with toilet use and hygiene. -The care plan did not address EBP. Review of the resident's POS, dated 2/24/25, showed: -An order, dated, 2/24/25, EBP for g-tube, every shift. Observation and interview on 2/24/25 at 12:15 P.M., showed an EBP sign posted on the outside of the resident's doors and a caddy filled with isolation gowns, gloves and masks. CNA S entered the resident's room without PPE. The resident said he/she was wet. CNA S applied gloves, checked the resident and changed the resident by turning the resident side to side. The resident's legs touched CNA S's uniform while being turned. During care of the resident, the resident's abdomen was exposed, and a g-tube was present. CNA S did not wear an isolation gown while providing care. During an interview on 2/27/25 at 2:25 P.M., Licensed Practical Nurse (LPN) T said EBP are required for residents who have tracheotomy tubes, urinary catheters, g-tubes and wounds. Staff should be wearing gowns and gloves when providing any type of direct care to the residents. 4. During an interview on 2/28/25 at 7:21 A.M., the IP said Resident #29 has leg wounds and Resident #45 has a g-tube which requires EBP and PPE to be worn by staff when providing direct care. Both residents should have a sign posted for EBP. She would expect staff to be following EBP policies and procedures. She said staff should be wearing a gown, gloves, and regular mask if required. 5. During an interview on 2/28/25 at 9:58 A.M., the Executive Director and DON said staff are expected to wear PPE for residents that meet the EBP criteria. They would expect staff to use PPE during care for Resident #29 and Resident #45. They would expect staff to be following the facility's EBP policy. 42795 . 46888

Based on observation, interview and record review, the facility failed ensure staff obtained a treatment order, and provided daily monitoring for one resident (Resident #26) with a history of dermatitis (skin inflammation, typically characterized by itchiness, redness and rash) on his/her coccyx (tailbone)/sacrum (area located above the coccyx) that was observed to have an open area on the morning of 2/24/25. It was not identified by staff and the physician was not notified until the morning of 2/25/25. In addition, the facility failed to ensure licensed nurses who signed bath sheets showing an open area and/or a circle around the coccyx/sacrum of an anatomical figure on the bath sheet documented an assessment of the findings on the bath sheets. The sample size was 18. The census was 86. Review of the facility's Skin Integrity & Pressure Ulcer (injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure or friction)/Injury Prevention and Management policy, revised on 8/25/21, showed: -Policy: Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards; -Procedure: A skin assessment/inspection should be performed weekly by a licensed nurse. Skin observations also occur throughout points of care provided by Certified Nursing Assistants (CNAs) during activities of daily living care (bathing, dressing, incontinent care, etc). Any changes or open areas are reported to the Nurse. The Nurse will complete further inspection/assessment and provide treatment if needed; -When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident. Review of the facility's Treatment Orders policy, reviewed 5/24/24 and revised on 7/9/24, showed: -Policy: Treatment orders are written per Physician orders. If a resident has multiple wound sites, a complete and separate treatment order must be written for each site; -Based on the comprehensive assessment of a resident, the facility must ensure that: A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing; -Procedure: After observation/evaluation of the affected skin area, the physician is notified; -The physician writes a treatment order that includes at least the following: Site of wound, name of cleanser, name of ointment, type of dressing, and number of times to perform the treatment/duration of treatment. Review of Resident #26's wound company note, dated 11/21/24 (the last time the resident was seen by the wound care company), showed: -Chief Complaint: Patient has a rash; -Buttock: Irritated dermatitis; -Treatment: Zinc oxide based barrier cream as directed; -Reason: Decreased skin irritation; -Incontinence Brief Dermatitis Improved; -Will sign off, please re-consult as needed. Continue present skin care and breakdown prevention. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/24, showed: -Speech Clarity: No speech, absence of spoken words; -Makes Self Understood: Rarely/never understood; -Ability to Understand Others: Sometimes understands, responds adequately to simple, direct communication only; -Functional Limitation in Range of Motion: Impairment on both sides of upper and lower extremities; -Dependent, Helper does all of the effort. Resident does none of the effort to complete activity: Toileting hygiene, shower/bathing, upper/lower body dressing, and personal hygiene; -Dependent: Roll left and right; -Not attempted due to medical condition or safety concerns: Lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer; -Diagnoses: Multidrug Resistant Organism (MDRO,), pneumonia (an inflammatory condition of the lungs. Symptoms may include productive or dry cough, chest pain, fever, and difficulty breathing.), stroke, seizure disorder, malnutrition, and respiratory failure; -Risk of Pressure Ulcers: Yes; -Unhealed Pressure Ulcers: No; -Special Treatments and Programs: Oxygen therapy, suctioning (removes mucus and secretions), and tracheostomy (a surgically created hole in the windpipe) care. Review of the resident's treatment administration record (TAR), dated 1/1/25 through 1/31/25, showed no treatment to the resident's buttock/coccyx or sacrum. Review of the resident's care plan, showed: -1/16/25: Family is resistive to care and implementation from professional maintenance care and assisting with maintaining baseline well-being. Family removes treatments in place to skin integrity concerns, performs tracheostomy care; -Goal: The resident will cooperate with care; -Interventions: Educate resident/family/caregivers of the possible outcomes of not complying with treatment or care; -1/16/25: Focus: Impaired cognitive ability/impaired thought process related to TBI (traumatic brain injury); -Goal: Resident's needs will be met; -Interventions: Allow resident extra time to respond to questions and instructions. Ask yes/no questions; -1/16/25: Focus: Rash, contact dermatitis to buttock and is followed by wound care company; -Goals: Will have no complications from rash. The resident will have no signs or symptoms of infection. The rash will heal by next review date; -Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Observe skin rashes for increased spread of infection. Seek medical attention if skin becomes bloody or infected. Review of the resident's weekly skin integrity data collection notes (completed by the licensed nurse) dated 2/24/25 and 2/21/25, showed -Skin Condition: Open areas/wounds - blank; -Rash - blank; -Describe skin color - normal; -Describe temperature - warm; -Describe moisture - normal; -Describe turgor (refers to how quickly skin returns to normal position after being pinched) - good; -No documentation about a rash or contact dermatitis to the buttocks. Review of the resident's Shower Sheet/Skin Condition Report (anatomical figure on the form completed by the Certified Nurses Aide (CNA) and given to a licensed nurse for review after a shower/bath), forms showed: -2/1/25, evening shift, completed by CNA J: Open area checked, and the sacrum/coccyx area circled. A nurse co-signed the form; -2/5/25, day shift, completed by CNA J: Open area checked, and the sacrum/coccyx area circled, and a licensed nurse had co-signed the form; -2/8/25: No CNA documentation or signature. A licensed nurse checked other and documented incontinence brief dermatitis. The licensed nurse circled the area on the resident's sacrum/coccyx, and documented the shower had been given by the family on day shift; -2/15/25: A licensed nurse checked other and documented incontinence brief dermatitis. The licensed nurse circled the area on the resident's sacrum/coccyx, and documented the shower had been given by the family on day shift; -2/19/25, evening shift, CNA I documented the resident's family did the shower every morning on day shift. The CNA circled the area on the sacrum/coccyx. LPN Unit Coordinator (UC) co-signed the shower sheet; -2/22/25, evening shift. A CNA circled the area on the sacrum/coccyx, and an LPN wrote incontinence brief dermatitis and co-signed the shower sheet. Observation on 2/24/25 at 8:56 A.M., showed the resident lay in bed on a low air loss mattress. A family member was at the bedside bathing the resident. The resident had a tracheostomy tube (a medical device inserted into the trachea to facilitate breathing) with humidified oxygen infusing and a gastrostomy tube (a tube surgically inserted through the abdomen into the stomach to provide hydration, nutrition and medications) with the tube feeding off while the family member bathed the resident. The family member said he/she came in every morning to check on the resident and bathed the resident every day. Another family member came in every evening. The family member said the resident had a red area on his/her coccyx that had been there for months. After he/she bathed the resident he/she applied Desitin (incontinence brief rash medication) that he/she brought in to the area. He/She had seen the CNAs applying Desitin as well as A&D ointment (used to keep moisture off the skin), but not the licensed nurses. He/She removed a few packets of the A&D ointment from the resident's night stand drawer to show the surveyor. He/She turned the resident onto his/her left side, which revealed an inflamed red area on the coccyx/sacrum area that had a white cream applied over it. In the center of the red area was an open area with a small amount of blood drainage. Review of the resident's physician's order sheet (POS), showed no order for Desitin, A&D ointment, or zinc oxide to the resident's buttocks/sacrum/coccyx. Review of the resident's TAR, dated 2/1/25 through 2/28/25, showed no order for Desitin for the dermatitis, and no order for the open area. Observation on 2/25/25 at 7:35 A.M., showed the resident lay in bed. LPN UC and CNA J entered the room to complete a skin assessment. CNA J said he/she had been at the facility for approximately 9 months and the area on the resident's sacrum/coccyx had looked that way on and off the entire time. LPN UC described the sacrum/coccyx area as being red with red drainage and open. He/She worked yesterday on the day shift and no one told him/her about the area being open. He/She was not sure if there was a current treatment or not. Review of the resident's skin wound note in the progress notes, showed: -The LPN UC documented on 2/25/25 at 8:05 A.M., Writer in room to assist with skin assessment. Upon assessment noted that resident has open area to coccyx/sacral wound. Writer completed assessment, informed treatment nurse and called physician to obtain orders. Went back to room to measure area to coccyx/sacral 2.1 centimeters (cm) (length) by 0.5 cm (width) by 0.8 cm (depth). Obtained order to cleanse with normal saline (sodium/water solution), pat dry, apply skin prep (a thin sticky film) to periwound (the area surrounding the open area) apply calcium alginate (an absorbent dressing) and cover with border gauze. Family, Director of Nursing (DON) and treatment nurse informed of new order; -LPN UC documented on 2/25/25 at 9:00 A.M., Follow-up on assessment. Small amounts of blood noted with exudate (drainage) to disposable pad. Noted resident had previous incontinence brief dermatitis. Resident will be followed by the wound care company team for wound treatments. Review of the resident's weekly skin integrity data collection note, dated 2/25/25 at 8:16 A.M., showed: -Skin Condition: Open areas/wounds - blank; -Rash - blank; -Describe skin color - normal; -Describe temperature - very warm; -Describe moisture - moist; -Describe turgor - fair; -Describe findings - No new finding, old wound to coccyx. Physician notified. During an interview on 2/25/25 at 8:20 A.M., the facility Wound Nurse said the resident used to be seen by the wound care company at one time, but it'd been awhile. They had diagnosed the area on the resident's bottom as contact dermatitis. The facility wanted the resident to continue to be seen by the wound care company because the resident's bottom would break open and bleed. The resident was supposed to have an order for zinc oxide ointment (a mineral used to treat incontinence brief rash) on the area every shift, and the CNAs should apply between the nurse's applications. She reviewed the February TAR and confirmed there was no treatment order for the zinc oxide and/or Desitin to be applied every shift. Since the open area was noted on 2/24/25, staff would have provided care (incontinent care and turning and repositioning) to the resident throughout the day and should have noticed the open area and reported it to the charge nurse. If a treatment was not on the TAR, the computer system would not prompt the nurse to apply the treatment. During an interview on 2/25/25 at 8:25 A.M., the Assistant Director of Nursing said the resident's family did not want the resident to use the zinc oxide. They wanted Desitin to be used. No one contacted the physician to get an order for the Desitin as far as she was aware. During an interview on 2/25/25 at 10:33 A.M., CNA I said he/she had worked at the facility for about one year and the resident's bottom has been red and excoriated since he/she had worked there. The family had asked the CNAs to put Desitin cream on the resident's coccyx. If the coccyx was left wet too long it would breakdown and bleed. If it was kept dry and the Desitin was used, it wouldn't bleed. He/She told the nurses about the resident's coccyx in the past. During an interview on 2/25/25 at 11:19 A.M., the facility Wound Nurse said the area on the resident's coccyx was a stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous). During an interview on 2/25/25 at 1:02 P.M., the DON said there should have been on-going assessments of the resident's coccyx by the licensed nurses. There should have been a treatment, either the zinc oxide or Desitin on the TAR for staff to follow. Licensed nurses, not CNAs, should apply the treatment when there was skin broken down. She would have expected the licensed nurse who signed the resident's bath sheets to have assessed the resident's coccyx and documented any changes in the progress notes. If the area on the coccyx changed, she expected the physician to be notified. She confirmed the open area on the resident's coccyx was a stage 2 pressure ulcer. During an interview on 2/28/25 at 9:34 A.M., the Administrator said he expected staff to follow facility policies.

Based on observation, interview and record review, the facility failed to accommodate the needs of one resident with mobility impairments when staff failed to ensure the resident had access to a call light adapted to meet his/her needs (Resident #9). The sample was 18. The census was 86. Review of Resident #9's medical record, showed diagnoses included multiple sclerosis (MS, disease of the central nervous system), quadriplegia (paralysis of all four limbs), seizures, abnormal posture, generalized muscle weakness, contractures to left and right hands, cognitive communication deficit, anxiety, and depression. Review of the resident's significant change Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 2/20/25, showed: -Severe cognitive impairment; -Clear speech; -Makes self understood: Usually understood; -Dependent for eating, oral hygiene, toileting, showers, dressing, rolling left and right, and sit to stand transfer. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident has impaired mobility secondary to MS. Total assist with all activities of daily living (ADLs); -Focus: Resident has a communication problem related to neurological symptoms, weak or absent voice; -Focus: Resident is at risk for falls due to his/her impaired mobility, seizure disorder, and use of psychotropic medications; -Interventions included call light within reach; -The care plan did not identify the resident required a specialized call light. Observations on 2/24/25 at 10:52 A.M., 12:31 P.M., and 1:06 P.M., showed the resident in bed. A push button call light was on the floor behind the head of the bed. Observations on 2/25/25 at 9:06 A.M., 12:40 P.M., and 2:11 P.M., showed the resident in bed. A push button call light was on the floor behind the head of the bed. During an interview on 2/25/25 at 2:11 P.M., the resident said he/she could not move his/her arms or legs. He/She did not have a call light. He/She had no way to call staff for help when needed. Observations on 2/26/25 at 7:20 A.M., 9:14 A.M., and 12:38 P.M., showed the resident in bed. A push button call light was on the floor behind the head of the bed. Observation on 2/27/25 at 8:00 A.M., showed the resident in bed. A push button call light was on the floor behind the head of the bed. During an interview, the resident was soft spoken and provided verbal responses, in addition to nodding and shaking his/her head. He/She said he/she did not have a call light, but would like one. He/She could turn his/her head at a downward angle and demonstrated doing so during the interview. During an interview on 2/27/25 at 1:32 P.M., the Therapy Director said the resident had some mobility issues and could not use a standard call light. She was not sure if the resident had a touchpad call light, and would check with maintenance on getting one. During an interview on 2/27/25 at 1:40 P.M., Certified Nurse Aide (CNA) O said the resident's hands were contracted and he/she could not use a push button call light. The resident talked really quietly but could make his/her needs known. Observation on 2/27/25 at 1:45 P.M., showed the Therapy Director entered the resident's room and picked up the push button call light off the floor from behind the resident's bed. It was connected to a tube she identified as a breath-activated call light. The Therapy Director placed the breath-activated call light on the resident's bedside table and said he/she was going to find a touchpad call light instead. The breath-activated call light was coated with a layer of dust. CNA O and CNA Q looked at the breath-activated call light and said they did not know the resident had that particular call light and the resident did not use it. Observation on 2/57/25 at 1:54 P.M., showed the Maintenance Director tested the breath-activated call light on the resident's bedside table, and it successfully activated the panel on the wall. During an interview, the resident said he/she was happy to be getting a call light and it would make it easier for him/her to communicate. During an interview on 2/27/25 at 2:03 P.M., Registered Nurse (RN) R said the resident moved his/her limbs and had limited mobility. The resident had some minor mobility in his/her neck. He/She could make his/her needs known to an extent. RN R was not aware the resident had a breath-activated call light. Nursing staff should ensure call lights were placed within a resident's reach. During an interview on 2/28/25 at 7:11 A.M., the Infection Preventionist (IP) said the resident used to use the breath-activated call light, but his/her family opted against it. The resident did not really use his/her call light anyway. Yesterday, he/she was given a touchpad call light. He/She could move his/her head enough to be able to use it. The resident's need for a specialized call light should be documented on his/her care plan. During an interview on 2/28/25 at 8:22 A.M., the Director of Nurses (DON) said all residents should have access to a call light they could use. The resident's family member told staff the resident did not use his/her call light, so the family member did not want the resident to have the breath-activated call light. These discussions should be documented in the resident's medical record. Yesterday, the DON spoke to the resident's family member about providing a touchpad call light. The resident had quadriplegia and his/her need for a specialty call light should be documented on his/her care plan. During an interview on 2/28/25 at 9:24 A.M., the Executive Director said he expected staff to ensure call lights were accessible to residents. He expected residents to be provided call lights in accordance with their individual needs.

Based on observation, interview and record review, the facility failed to ensure staff performed appropriate hand hygiene during meal service and failed to serve food in accordance with professional food safety standards, which affected three residents (Resident #22, #24, and #27). The sample was 18. The Census was 86. Review of the facility's hand hygiene policy, dated 6/13/23, showed: -Policy: The facility has adopted the Centers for Disease Control and Prevention (CDC) core infection prevention and control practices for safe healthcare delivery in all settings for indications for hand hygiene; -Procedure: Hand hygiene should be performed before and after contact with resident, after contact with objects or surfaces in the resident's environment. 1. Review of Resident #22's medical record showed: -Diagnoses included dementia, diabetes, and Parkinson's disease (brain disorder causing unintended or uncontrolled movements); -Severe cognitive impairment. 2. Review of Resident #24's medical record showed: -Diagnoses included muscle weakness and dementia; -Severe cognitive impairment. 3. Review of Resident #27's medical record showed: -Diagnoses included depression and muscle weakness; -Moderately impaired cognition. 4. Observation on 2/24/25, of lunch in the main dining room, showed: -At 12:24 P.M., Restorative Aide (RA) BB grabbed onto Resident #27's wheelchair handle as he/she sat down next to the resident at the table; -At 12:25 P.M., RA BB picked up Resident #27's spoon and started to feed the resident; -At 12:28 P.M., RA BB picked up Resident #24's straw, opened it, and placed it in the resident's drink. RA BB then picked up the resident's drink and gave Resident #24 a drink. 5. Observation on 2/26/25, of lunch in the main dining room, showed: -At 11:52 A.M., Certified Nurses Aide (CNA) M sat at a table next to Resident #22. CNA M had his/her phone in his/her hand, texting; -At 11:55 A.M., CNA M was still seated at the table texting on his/her phone. Using his/her right hand, he/she wiped his/her forehead; -At 11:59 A.M., CNA M stood up and positioned Resident #24's feet onto his/her wheelchair foot rest and then propelled Resident #24 out of the dining room; -At 12:00 P.M., CNA M returned to the dining room without sanitizing his/her hands. CNA M walked up to the kitchen doorway, resting his/her hands on the doorframe. He/She was handed a drink for Resident #22 and went to sit back at the table; -At 12:02 CNA M touched his/her chair handles as he/she sat back down. He/She repositioned Resident #27 up closer to the table by pulling the wheelchair's arm rest; -At 12:03 P.M., CNA M used his right hand to wipe his/her head; -At 12:12 P.M., CNA M picked up Resident #27's spoon with his/her right hand and swiped his/her ungloved left hand across the bowl of the spoon, dipped the spoon in the resident's food, and gave the resident a bite; -At 12:13 P.M., CNA M picked up Resident #22's cup and handed it to the resident; -At 12 :14 P.M., CNA M held onto Resident #22's wheelchair handles as he/she stood up from his/her chair and went to the kitchen to get a drink for the resident; -At 12:15 P.M., CNA M sat back down at the table, took his/her phone out of his/her pocket and started texting; -At 12:20 P.M., CNA M took the cup out of Resident #22's hand, and propelled the resident out of the dining room in his/her wheelchair; -CNA M did not sanitize hands when leaving the dining room or entering back into the dining room; -At 12: 21 P.M., CNA M sat back down at the table next to Resident #27. He/She picked up the resident's straw, opened it, and placed it into the resident's drink. He/She rubbed his/her ear with his/her hand. He/She then picked up the resident's silverware and started to cut up the resident's food; -At 12:23 P.M., CNA M scooped up food onto Resident #27's spoon, brought the spoon close to his/her mouth and blew on the food, and then fed the resident; - At 12:24 P.M., CNA M scooped up food onto Resident #27's spoon, brought the spoon close to his/her mouth and blew on the food, and then fed the resident; -At 12:26 P.M., CNA M picked a piece of fried chicken up from Resident #27's plate with his/her ungloved hand and placed it onto the resident's spoon and then fed the chicken to the resident. 6. During an interview on 2/27/25 at 1:55 P.M., CNA L said hand hygiene is to be performed before entering the dining room, after touching residents or objects, and in between assisting residents. It is not appropriate to blow on residents' food to cool it down. Food should be set to the side if it is too warm. It was not appropriate to pick food up with your hands and place it on the fork; that would be a germ issue. 7. During an interview on 2/27/25 at 1:24 P.M., the Dietary Director said all staff should wash or sanitize their hands before entering the dining room, after touching a resident, after touching themselves, or after touching surfaces. She said it is not appropriate for staff to blow on resident food when feeding them. Food should be set aside if it is too warm. It is not appropriate for staff to pick up food with their hands when feeding a resident. She said it is not appropriate for staff to clean silverware with their hands and then use the silverware to feed a resident. 8. During an interview on 2/27/25 at 1:58 P.M., the Executive Director said he would expect hand hygiene to be performed by staff when going between touching residents and objects. He would expect staff not to blow on residents' food. He would expect staff to use utensils to pick up residents' food. He would expect staff to clean silverware with a napkin or to get new silverware for residents. He would expect staff to sanitize their hands after wiping their head with their hand.

Based on observation, interview and record review, facility staff failed to discard expired medications from the medication carts, failed to ensure all medication bottles had a date of expiration, failed to ensure eye drops/ointments were dated when opened, and failed to ensure insulin pens were stored in the refrigerator and not in the medication cart. The facility identified four medication carts, two were sampled, and problems were identified in both. The census was 86. Review of the facility Medication Storage and Administration Quick Reference Guide, dated 8/2022, showed: -Insulin Vials and Pens: Store unopened insulin in the refrigerator; -Ophthalmic Solutions Storage Parameters: Eye medication bottles/tubes with accelerated expiration dates must be dated/initialed upon opening. Follow the manufacturer instructions, or facility policy. 1. Observation of the South 2 medication cart on 2/24/25 at 4:38 P.M., showed: -South 1 medication cart: -One opened stock bottle (used for multiple residents) of Rena Vite tablets (multivitamin) expired on 12/23/24. Licensed Practical Nurse (LPN) A confirmed the expiration date, removed the bottle from the medication cart and said it should be discarded; -One opened tube of bacitracin/polyophthalmic eye ointment (an antibiotic ointment), delivered by the pharmacy on 11/23/24. The ointment tube had no date documented of when it was opened. LPN A said the eye ointment should be discarded 30 days after opening. Without knowing the opening date, staff would not know when to discard the ointment; -One opened tube of bacitracin/polyophthalmic eye ointment, delivered by the pharmacy on 1/6/25. The tube had no date documented of when it was opened. LPN A said the eye ointment should be discarded 30 days after opening. Without knowing the opening date, staff would not know when to discard the ointment; -One opened stock bottle of liquid docusate sodium (laxative), approximately three fourths empty, with no expiration date on the bottle. The LPN Unit Coordinator said there was no expiration date and removed the bottle from the medication cart; -One opened stock bottle of stock folic acid (vitamin B) with an expiration date of 1/2024. The LPN Unit Manager said the folic acid was expired; -One opened bottle of Coenzyme Q10 (a vitamin-like substance made naturally in the body) with an expiration date of 2024 (day and month illegible). The expiration date was confirmed by LPN Unit Coordinator, and removed from the medication cart; -One glargine insulin (long acting insulin) pen, unopened, and delivered from the pharmacy on 2/21/25. The LPN Unit Coordinator said the insulin pen should be stored in the refrigerator until opened. 2. Observation of the South 2 medication cart on 2/24/25 at 4:38 P.M., showed: -South 2 medication cart: -One opened bottle of of prednisolone AC 1% ophthalmic eye drops (used to treat eye inflammation) delivered from the pharmacy on 1/10/25. The eye drop bottle did not have the date it was opened on it; -One unopened aspart insulin (fast acting insulin) pen, delivered by the pharmacy on 2/17/25. The LPN Unit Coordinator said the insulin pen should be stored in the refrigerator until opened; -One opened stock bottle of boric acid vaginal suppositories (used to treat yeast infections). The suppositories had no expiration date listed on the container. The LPN Unit Coordinator said there was no expiration date on the container; -The LPN Coordinator said eye drops and ointments should be discarded after 30 or 31 days after opening. Any medication that is expired or without an expiration date should be removed from the medication cart. During an interview on 2/28/25 at 9:34 A.M., the Administrator said he expected staff to adhere to policies regarding eye drops and ointments so they can be discarded at the appropriate time. He expected staff to follow the facility policies on medication storage. The Director of Nurses said she expected insulin pens to be stored in the refrigerator until ready to use. Expired medications should be not be on the medication cart.

Based on observation, interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being by addressing the residents' behaviors related to his/her anxiety for one resident (Resident #68). The sample was 18. The census was 86. Review of the facility's Behavioral Health Services Policy, reviewed 9/6/24, showed: -Policy: The facility will provide behavior heal care and services that create an environment that promotes emotional and psychosocial will-being, meets each resident's needs, and includes individualized approaches to care; -Procedure: Complete the nursing assessment and social services assessment upon admission/readmission. Quarterly, and as needed with change in condition; -Through this assessment the facility should identify residents who: -Develop decreased social interaction and/or increase withdrawn, angry or depressive behaviors, and may have verbalizations indicating these; -Evaluate whether the resident's distress was attributable to their clinical condition and demonstrate that the change in behavior was unavoidable; -Ensure an accurate diagnosis of mental disorder or psychosocial adjustment difficulty, or Post Traumatic Stress Disorder (PTSD) was made by a qualified professional; - Identify if the resident would benefit based on above assessments in conjunction with: mental health history and current medication regimen , and additional mental health consultation (psychiatry, psychology, and clinical social work). If determined need is present, the facility should consult with attending physician to make a referral to mental health professional for assessment and potential for ongoing follow up; -Initiate behavioral monitoring, behavior management care plan, as indicated by assessment findings, use of psychoactive medications, resident and or responsible party conversations, and observations. The Social Worker is primarily responsible for initiation of the behavioral management care plan. -The facility must provide necessary behavioral health care and services within include: -Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy (self-directing), privacy, socialization, independence, choice and safety; -Ensuring direct care staff interact and communicate in a manner that promotes meant and psychosocial well-being; -Providing an environment and atmosphere that is conductive to mental and psychosocial well- being; -Providing meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community; Meaningful activities are those that address the resident's customary routine, interests, preferences, and enhance the resident's well-being; -Ensuring that pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated; -Communicate the behavioral management care plan to the resident and/or to the responsible party and to relevant member of the interdisciplinary team; -Provide resident/responsible party and staff education as needed; -Review and revise the behavioral management care plan as indicated. Review of Resident #68's face sheet, undated, showed diagnoses included: Anxiety, cognitive communication deficit, and spinal stenosis (narrowing) of the lumbar region (lower back), chronic obstructive pulmonary disease (COPD, restricts airways in the lungs making it difficult to breath). Review of the resident's Spiritual Assessment, dated 10/30/23, showed: -Information source: Resident; -Beliefs: God; -Choice of spiritual participation: Visitor support/ Counselor; -What brings you spiritual peace: Speaking with God; -How can the facility meet your spiritual needs: Nothing at this time; -How are you responding to stress of this illness and/ treatment: The best I can. Review of the resident's Social Service Assessment, dated 10/31/24, showed: -The resident has a current psychiatric related diagnosis; -The resident has a diagnosis of anxiety; -The resident is currently taking Duloxetine 30 mg (medication used to treat depression and anxiety); -Describe the resident's current status, including psychiatric related diagnosis and especially address the problem areas or interventions that Social Services is currently reviewing: None. -No additional Social Service Assessment available for review. Review of the resident's physician order sheets, showed an order, dated 12/27/24, to check for comfort, safety, pain, and incontinence every hour. Review of the resident's Nurse Practitioner (NP) psychiatry progress notes, dated 12/30/24, showed: -Narrative: The resident reported that he/she is doing good. The resident denied feeling sad or anxious. The resident does not feel any issues with her mood or behaviors. The resident commented that he/she only uses the call light when he/she needs to be changed. The resident adamantly refuses any medication changes. Per the nursing report, the resident is compliant with the medication regimen. The resident is noted to use his/her call light very often with minor requests; -Assessment: The resident is currently stable and does not pose a risk to self or others. The resident's past history for emotional difficulties, and personal and social stressors that contribute to the current presentation. The resident is willing to participate in treatment; -Plan: Discussed with staff the ongoing treatment plan. Staff educated regarding the medication regimen and instructed to notify the provider if any adverse reactions emerge. Staff are instructed to report any suicidal or homicidal ideations, or any significant changes in mental status or level of functioning. Assure the resident with safety, nutrition, and hydration. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated, 1/26/25, showed: -Cognitively intact; -No behaviors or rejection of care. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is resistant to care. The resident will make false assumptions towards staff and has a manipulative perception of healthcare concerns and needs being met. The resident presents with obsessive compulsive disorder (OCD), increased anxiety, and claustrophobic like behaviors; -Interventions: Give a clear explanation of all care activities prior to and as they occur for each contact. If the resident resists activities of daily living (ADLs), reassure the resident, leave and return 5-10 minutes later and try again. Provide the resident with opportunities for choice during care provision; -Focus: The resident at times expresses unrealistic ideas or presumptions related to things that may be heard outside of resident's room. The resident make threats towards staff about harming self, and has threatened staff to throw himself/herself on the floor. The resident constantly presses the call light every 10 minutes and calls the from desk at least 10 times per day; -Interventions: Administer medications as ordered. Anticipate and meet the resident's needs. Provide care with two aides. When answering the call light step away and obtain another staff member if needed for extended conversation and provide care to the resident's request. Explain all procedures to the resident before starting and allow the resident to adjust to changes. If reasonable, discuss the resident's behavior. Explain or reinforce why behavior is inappropriate and or unacceptable. Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Praise any indication of the resident's progress or improvement in behavior; -Focus: The resident declines to participate in independent tasks offered to improve daily living; -Interventions: The resident prefers to stay in bed and only wear soft socks foot wear. The resident likes towels in the room at random places and changes the location of where towels are placed. Towels under both sides of pillow, on the bedside table, and the side of the bed. Location changes of the towels vary from day to day and the resident will request at least four to six towels placed in random spots. Review of the resident's diagnoses listed in the electronic medical record (EMR), dated 2/26/25, showed the resident did not have a diagnosis of claustrophobia or OCD listed. Review of the resident's progress notes, showed: -On 2/7/25 at 10:45 P.M., this nurse was summoned to the resident's room by the resident's roommate, this nurse was made aware by the resident's roommate that the resident called the Department of Health and Senior Services (DHSS) with concerns. This nurse spoke with the resident of concerns he/she could help with, and the resident voiced that he/she had no concerns or questions; -No follow up note related to the resident's behavior was documented; -On 2/17/25 at 11:14 A.M., the resident is making demands while staff are in the room to get the resident up for a shower. The resident is upset and said that the staff was taking all his/her things. This nurse was in room with the aide and observed the aide cleaning the resident's room and removing old linens and towels, this was explained to the resident and the resident remained upset; -On 2/17/25, at 11:24 A.M. , the resident was being placed back in bed from having a shower, the resident began to curse, said the staff doesn't do anything for him/her and threatened to call the DHSS because the aide did not leave the call light in reach. The aide informed the resident that he/she was coming right back and that he/she was just obtaining some linens; -No follow up note related to the resident's behaviors was documented. -On 2/19/25 at 1:42 P.M., the resident is frequently on his/her call light despite making frequent rounds and checks; -On 2/19/25 at 11:05 P.M., the resident's physician documented, the resident is quite demanding and wants some sort of inappropriate treatment. At times the resident asks for antibiotics and cough syrup. Rounds were made with the Infection Preventionist (IP) and the IP did not have any concerns but said the resident is very needy and wants medications that are not appropriate; -Plan: Did not address the resident's behaviors or anxiety. -On 2/22/25, at 12:13 P.M., the aide was giving care to the resident's roommate and the resident demanded that the aide stop giving care to the resident's roommate and retrieve the resident's lunch or the resident was going to report the aide; -No follow up note related to the resident's behavior was documented. Observation and interview on 2/24/25 at 9:40 A.M., 2/25/25 at 12:55 P.M., and 2/28/25 at 8:35 A.M., showed the resident lay in bed listening to Christian music. The resident said he/she doesn't want to take showers anymore because when he/she is taken to the shower room by staff, another staff member goes into his/her room and removes linens and clothing without his/her permission. This makes him/her very upset and increases his/her anxiety. The resident said this has happened at least five times within the last six months. The resident said that the unknown about his/her day increases his/her anxiety. He/She is rarely informed on a daily basis who the nurse or who the aides are for the day. He/She requires nebulizer treatments (a medication to assist with breathing) as needed and must wait prolonged periods of time for the treatment. That creates anxiety and increased shortness of breath (SOB). He/She will turn on his/her call light to be cleaned because no one comes in for hours. Sometimes when he/she turns the call light on, staff turn it off without even asking what he/she needs. If he/she doesn't get a response to the call light, the resident will call the front desk. The resident said he/she is incontinent of bowel and bladder and does not like to lay in a soiled brief for extended periods because he/he is prone to urinary tract infection (UTI) and bed sores (wounds that occur laying in one position for extended periods). The resident is grateful that his/her snacks and drinks are provided but feels as though his/her care concerns are landing on deaf ears and the staff get tired of answering his/her light or the front desk phone. He/She lacks a sense of trust with the staff and facility administration because they make it feel like everything that he/she has issues with are not important, lack any type of evidence, or he/she makes things up. The resident does not know how to file a grievance and has never spoken to the Ombudsman. The resident said he/she does not want his/her medication changed related to his/ her anxiety but is open to speak with a counselor. The resident said his/her Christian values are important to him/her. He/She prays a lot to calm his/her nerves. He/She has never been offered any type of chaplain services since he/she has been at the facility. There are certain staff members that he/she works better with, but it seems like those staff members are not assigned to him/her consistently. Review of the facility's grievance log for November and December 2024 and dated January 2025, showed no grievances filed by the resident. Observation on 2/26/25 at 9:29 A.M., showed Certified Nursing Assistant (CNA) N entered the resident's room without knocking, walked past the resident's bed and assisted the resident's roommate. At 9:37 A.M., CNA N exited the room and did not acknowledge the resident while leaving the room. The resident used his/her grabber to maneuver things in the room. Observation and interview on 2/27/25 at 11:05 A.M., showed CNA D propelled the resident on the shower stretcher into the spa room. The resident said he/she hoped no one took his/her stuff in his/her room while he/she is in the shower. CNA D completed the resident's shower and propelled the resident back to his/her room using the shower stretcher. Once the resident returned to his/her room, he/she immediately looked around the room and noticed that some of his/her clothing on his/her bedside table was missing along with two towels and a bed blanket. The resident was upset and asked CNA D two times, Where is my clothing? CNA D said he/she didn't see any clothing on the resident's nightstand. The resident said it must have been another staff member that did it. CNA S entered the room and informed the resident that he/she took the resident's towels and bath blanket off the nightstand because it was soiled. CNA S said he/she did not see the resident's clothing. The resident described to CNA S what the clothing looked like. CNA S again said he/she did not take the resident's clothing, only took the soiled linen that was resting on the resident's nightstand. CNA S said to the resident, I will try my best to find your clothing. The resident asked CNA S to look in the soiled linen room for his/her clothing because his/her clothing did not have his/her name on it. CNA S said again, I will try my best to locate the resident's clothing. The resident said he/she was feeling very anxious. During an interview on 2/27/25 at 2:10 P.M. CNA S said he/she had taken the resident's clothing and bed linens off his/her nightstand without the resident's permission. The linens on top of the clothing were soiled. CNA S said the resident would not allow staff to remove things out of his/her room. The resident became upset when staff tried to do so. CNA S said the resident was a hoarder. He/She would discreetly remove clothing that need to be laundered when the resident was not in his/her room. When working with the resident, two aides were to be in the room to provide care. He/She wasn't sure why but just thought the more the merrier. The resident turned his/her call light on a lot for minor things and was more demanding when DHSS was in the building. CNA S said staff were not to argue with the resident. He/She felt as though staff tried their best to meet the resident's needs with a positive spirit and attitude and not create any emotional distress for the resident. During an interview on 2/27/25 at 12:45 P.M. and 2:25 P.M., Licensed Practical Nurse (LPN) T said he/she thought the resident didn't like the staff and believes the resident's family doesn't like the staff. The resident is on his/her call light frequently and calls the front desk frequently. The resident is always upset about something, and LPN T will try to redirect the resident with being extremely nice to him/her. Staff should not remove items from the resident's room without his/her permission. The resident requires a lot of time sometimes when you answer his/her call light. LPN T said he/she just goes along with the resident's requests and just deals with it because that is the resident's personality. Staff should not argue with the resident when the resident demands things because that increases the resident's anxiety. LPN T was not aware of any type of special behavioral management that is required for the resident. Everyone in the building that works with the resident is aware of the resident's anxiety and behaviors. All behaviors are documented in the progress notes. During an interview on 2/26/25 at 9:35 A.M., the Psychiatry NP AA said he/she has been recommending a counseling service to come in and meet with residents in the facility for at least six months. He/She has been asking the Social Service Director (SSD) to get the counseling services arranged. NP AA said his/her time with the resident is limited but a counselor could spend an extended amount of time with the resident. The resident has anxiety issues related to his/her care and current living situation and would benefit from counseling services. The resident also may have cognitive issues related to time and may not realize how often he/she places the light on. The resident refuses any new medication changes. NP AA encourages staff to be proactive and make sure the resident has everything he/she needs before leaving the resident's room. NP AA said the resident does not refuse his/her visits. During an interview on 2/26/25 at 11:15 A.M., Receptionist Y said that the resident calls the front desk at least three to 30 times a day. The resident is always anxious sounding and upset when he/she calls and says no one is answering his/her light. The resident requires a lot of reassurance. The resident will frequently call and say that he/she needs to be changed. The resident will also request a shower, nebulizer treatments and other medications. The resident mainly requests names of staff who will be taking care of him/her for the day and what staff members are going to be giving him/her medications. Receptionist Y will call the nurses' desk when the resident calls and let them know what the resident's request are. Receptionist Y said the frequent calls to the front desk from the resident have been occurring for at least a year. During an interview on 2/25/25 at 11:30 A.M. and on 2/27/25 at 12:35 P.M. the SSD said he was aware the resident called the front desk a lot with care issues. The resident doesn't get visitors very often and does not come out of his/her room. The resident's family member has recently stopped coming into visit the resident. The SSD was not sure why. The resident is always requesting someone go out and buy him/her snacks, bottled water and soda. The resident had issues with a staff member in the past but was not aware of any issues lately. The resident requires more attention and special focus because he/she calls DHSS so much with complaints. The SSD will go in and make rounds and speak with the resident daily and tries to solve any issues the resident may have, but doesn't file a grievance every time. Staff and/or the SSD will purchase the resident snacks. The facility goes above and beyond making the resident happy with frequent room visits, purchasing [NAME] (a type of peanut butter snack) and drinks with their own money. The SSD was not aware of any spiritual needs for the resident. The Activity department is responsible to complete the Spiritual Assessment. The SSD said he would reach out and see if the resident would like a preacher to visit and pray with him/her. The SSD was aware that the Psychiatry NP has been requesting a counseling service for the resident for at least 6 months. He has informed the Administrator of the counseling service request, but the Administrator said it is tied up with corporate red tape. The SSD also said the Ombudsman has been in to visit the resident. No documentation or e-mails were provided by the SSD related to the Ombudsman visiting the resident when requested. During an interview on 2/25/25 at 2:45 P.M., the Activity Director (AD) said she has been providing daily one on one activities with the resident because the resident does not like to leave her room. The AD and the resident tend to talk about the different holidays coming up. The resident will frequently go off topic and just ask the AD to straighten the resident's bedside table. The AD confirmed a spiritual assessment had not been completed since 10/30/23. The assessments were to be completed yearly. The Activity Department had recently obtained a new assistant within the last two weeks and will begin to read the Bible with the resident. During an interview on 2/28/25 at 9:34 A.M., with the Administrator and the Director of Nursing (DON), the DON said the resident can be pleasant, sweet, kind, demanding, cooperative and aggressive; it varies day to day. The DON said she is in the resident's room [ROOM NUMBER],000 times a day. They were aware the resident calls the front desk with multiple issues and frequently calls DHSS with his/her issues, and all the department heads are involved with the resident's care and needs. The resident will not start his/her day without knowing who the resident's aide is. The facility is being proactive by meeting with the resident everyday and providing snacks when he/she requests. He/She refuses any psychiatric care and does not want to change any medications. The Administrator said the resident develops anxiety when his/her call light is not answered and then he/ she calls the front desk. The Administrator has personally gone down to the resident's room after the resident calls the front desk with his/her requests. A grievance is not completed each time because the residents' concerns are usually dealt with at the time. If a grievance was made each time the resident had an issue, it would be a huge book. The Administrator has adjusted the air conditioner temperature and has fixed a privacy curtain issue. The Administrator and the DON feel as though they go above and beyond by visiting the resident daily and providing snacks out of their own pockets. The resident's behaviors and follow up visits are documented in the resident's EMR. The Administrator was aware of the Psychiatry NP's request for counseling services for the resident. He has been working on the credentialing and vetting process for obtaining the counseling services since last fall. It takes a while because it is a process with steps to follow. All outside companies have to be vetted due to concerns of Medicare and Medicaid fraud and to ensure the recommended provider does not have a relationship with the outside counseling service. The DON said she would expect all assessments to be completed to address the resident's needs and that includes a spiritual assessment. They would expect the staff to answer the resident's call light timely and address the resident's needs in a professional manner. The staff are always professional when speaking with the resident and will continue to do so. The DON feels as though they have tried to work with the resident regarding the resident's concerns but think that is just his/her personality. During a telephone interview with State Employee X and the resident on 3/3/25 at 11:31 A.M., the resident asked CNA D if the resident was assigned to CNA D. The resident informed CNA D that he/she had a bowel movement (BM) and needed to be cleaned up. CNA D did not answer the resident but was heard speaking in the background to someone else. The resident told State Employee X, this is what CNA D does to me, he/she assists the roommate and ignores me. The resident was heard informing CNA D that his/her light was on for a long time and that he/she has been sitting in BM and needed CNA D's help. With a raised voice, CNA D could be heard telling the resident, Your light wasn't on. The resident replied, to CNA D, Yes, it was. CNA D replied with a raised voice, No it was not and said that he/she was waiting on towels. The resident told CNA D that he/she called the front desk at least 10 times and the front desk would hang up on him/her. With a raised voice, CNA D said, I don't care. You can call the front desk as many times you want. I don't care. The resident told State Employee X he/she wanted to be treated like everyone else.

Based on observation, interview and record review, the facility failed to obtain labs as ordered for one resident (Resident #14), and to document a thorough, ongoing assessment following the resident's change in condition, and to appropriately communicate the resident's change in condition to the next shift. In addition, the facility failed to ensure staff provided feeding assistance in accordance with physician orders for one resident identified as dependent on assistance for eating (Resident #9). The sample was 18. The census was 86. Review of the facility's Change in Resident's Condition or Status policy, issued on [DATE], and revised on [DATE], showed: -Policy: This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. -Procedure: The facility will utilize the Lippincott procedure - Change in status, identifying and communicating, long-term care. Review of the facility's Change in Status, Identifying and Communicating, Long-Term Care procedure, revised [DATE], showed: -The facility will utilize the following Interact tools per policy: Situation, Background, Assessment and Recommendation (SBAR); -Introduction: In a long-term care setting, any change from baseline in a resident's status must be identified and addressed. A resident is more likely to return to baseline status and avoid complications when a condition is recognized early so that it can be treated. When a nurse recognizes a potentially life-threatening condition or significant change in a resident's status, the nurse must communicate with other health care team members to meet the resident's needs; -The resident should be assessed for changes from baseline status on admission, at present intervals based on the resident's condition and regulatory requirements, and whenever the resident's status changes. The resident's current status should also be checked against baseline status during medication administration and other routine activities. Notable changes include a decline in functional status, new or increasing confusion, temperature elevation, shortness of breath, and behavior changes. By identifying such risk factors as chronic diseases, previous hospitalization s, and notable conditions in the resident's medical history, the nurse can quickly anticipate some acute changes in status; -A change in condition may happen quickly in just minutes, or slowly over hours or days. The condition may manifest as a change in condition or physical change. Unless the resident's condition is life-threatening, the resident can be assessed and a treatment plan started at the long-term care facility. A focused, thorough assessment of the resident's condition can help identify a recurring fluctuation in signs and symptoms such as a change in blood pressure or increased confusion that happens at the same intervals daily; -At minimum, assessment should include: Reviewing the resident's medical record. Asking how the resident feels and what symptoms the resident has. Obtaining vital signs. Observing the resident's overall condition, including function and cognition. Exploring the resident's complaints; -Recognizing status changes, assessing the resident, and intervening early on allows the resident to receive appropriate care, decreasing the need for transfer to an acute care facility or emergency department; -Every health care team member is responsible for communicating a resident's change in status from baseline; -Clear, professional communication improves diagnosis, care planning and implementation, and continuity of care. Essential elements of such communication include: Reviewing the resident's history, medications, laboratory test results, treatments, and other significant information. Providing details of the resident's current status using objective findings. Documenting communication; -When health care team members provide information in an objective, standardized, and logical sequence, the resident receives safe, quality care timely, appropriate interventions; -Implementation: Identify a suspected acute change in the resident's status. Review the resident's medical record, including advanced directives and health history. Obtain the resident's vital signs and oxygen saturation level using pulse oximetry. Complete a complete physical assessment, focusing on the identified change in the resident's status (for example, assess respiratory status for a resident with decreased oxygen saturation level). Communicate the change in the resident's status to the appropriate practitioner. Implement the treatment plan or initiate the resident's transfer to another health care facility. Document the procedure; -Complications associated with identifying and communicating a change in a resident's status may include: Delay in treatment and disruption in care; -Documentation associated with identifying and communication a change in a resident's status included: Acute status change in status, behavior changes, vital signs, oxygen saturation level, other assessment findings in the appropriate areas in the resident's medical record, nursing interventions and response to those interventions, communication with other health care team members, and diagnostic test results. Review of the facility's Vital Signs policy, issued [DATE] and revised on [DATE], showed: -Policy: Vital signs will be checked as needed and as ordered by the physician to aid in the diagnosis and treatment of the resident's medical condition and to assess for changes in condition. Abnormal vital signs will be reported to the licensed nurse. Review of the facility's Pulse Oximetry policy, revised [DATE], showed: -Introduction: Performed intermittently or continuously, oximetry is a relatively simple procedure used to monitor arterial oxygen saturation noninvasively. Pulse oximetry can aid clinical decision-making; however, it isn't a substitute for a clinical assessment; -Completing the Procedure: If you detect and confirm a low oxygen saturation of peripheral oxygen (SpO2), administer supplemental oxygen, as needed and prescribed, according to your scope of practice. Regularly monitor and document the patient's SpO2 level. Document the procedure; -Documentation: Documentation associated with pulse oximetry includes: date and time, activity level and position, probe site, concentration of supplemental oxygen (if applicable), method of oxygen delivery, SpO2 level, and episodes of desaturation. 1. Review of Resident #14's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Cognitively intact; -Diagnoses included congestive heart failure, chronic respiratory failure with hypercapnia (excessive carbon dioxide in the blood), high blood pressure and kidney failure,; -Oxygen therapy received. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident is at risk for rehospitalization due to diagnoses of congestive heart failure and chronic obstructive pulmonary disease (COPD, lung disease), and poor adherence to diet restriction; -Interventions included: Labs as ordered; -Focus: Resident has congestive heart failure; -Interventions included: Check breath sounds and observe for labored breathing. Labs as ordered. Observe and report as needed (PRN) any signs/symptoms of congestive heart failure; -Focus: Resident has oxygen therapy related to respiratory illness. He/She also uses a continuous positive airway pressure (CPAP, machine that keeps the airways open during sleep for persons with sleep apnea); Interventions included observe for signs/symptoms of respiratory distress and report to physician PRN. Review of the resident's hospital discharge summary, dated [DATE], showed: -hospitalized [DATE] through [DATE] with discharge diagnosis of congestive heart failure; -Special instructions: Basic metabolic panel (BMP, blood test that measures sugar level, electrolytes, fluid balance, and kidney function) on Monday, [DATE]. Review of the resident's electronic physician order summary (ePOS), showed: -An order, dated [DATE], for BMP on Monday, [DATE]; -An order, dated [DATE], for oxygen at 3 liters (L)/minute continuously per nasal cannula; -An order, dated [DATE], for oxygen saturation (O2) rates every shift, may titrate to keep above 92%; -An order, dated [DATE] at 9:47 A.M., for STAT chest x-ray. Review of the resident's electronic medical record (EMR), reviewed [DATE] at 11:30 A.M., showed: -No documentation of a BMP obtained on [DATE]; -O2 sat documented as 95% on [DATE] at 3:22 A.M.; -No documentation of a discussion with the physician related to the x-ray ordered on [DATE]; -No progress notes, assessments, or documentation related to a change in condition on [DATE]. Observation on [DATE] at 10:58 A.M., showed the resident in bed with hands and arms shaking. The resident's oxygen was on via nasal cannula, running at 5L. The resident exhibited short, rapid breathing. During an interview, the resident said he/she started shaking this morning and that is not normal for him/her. He/She described his/her breathing as deep. Observations on [DATE] at 1:11 P.M. and 4:53 P.M., showed the resident in bed with oxygen on via nasal cannula, running at 5L. The resident's breathing was rapid. The resident's eyes were open and he/she did not verbally respond during an attempted interview. Review of the resident's EMR, reviewed [DATE] at 5:50 P.M., showed no progress notes, assessments, or documentation related to a change in condition on [DATE]. Observation on [DATE] at 6:17 A.M. showed Licensed Practical Nurse (LPN) B performed cardiopulmonary resuscitation (CPR) on the resident. The resident expired. Review of the resident's EMR, reviewed [DATE] at 7:08 A.M., showed: -No documentation of BMP obtained on [DATE]; -O2 sat documented as 94% on [DATE] at 12:45 A.M.; -No assessments or documentation related to a change in condition on [DATE]. During an interview on [DATE] at 9:19 A.M., Certified Nurse Aide (CNA) C said on the morning of [DATE], the resident's face was red, his/her lips were blue, and he/she was in and out of his/her normal state of mind. CNA C notified LPN A of the resident's change in condition. LPN A checked the resident's oxygen and it only got up to 78%. During an interview on [DATE] at 9:33 A.M., LPN A said he/she was the nurse assigned to the resident on day and evening shift on [DATE]. After breakfast, the resident was not his/her usual self, wasn't joking as usual, and his/her oxygen was at 60%. He/She did not want to go to the hospital. The resident's physician ordered an increase to the resident's oxygen to get his/her O2 sats to 88%, and a STAT chest x-ray. LPN A read the x-ray results to the physician and a new order was received to adjust the resident's medication. LPN A documented his/her assessments and discussions with the physician in the resident's EMR, but it all disappeared. When his/her shift was over on [DATE], LPN A was giving report to the night nurse, LPN B, when LPN B was pulled away to another resident's room. LPN A did not verbally discuss the resident's change in condition with LPN B. LPN A documented the change in condition on the report sheet and gave the report sheet to LPN B. Review of the report sheet, dated [DATE], showed a handwritten note next to the resident's name, Monitor breathing. O2 sats were low all day off and on. During an interview on [DATE] at 10:25 A.M., LPN B said he/she came in for his/her shift on [DATE] at 10:30 P.M. He/She did not get report from LPN A, who worked day and evening shift. LPN B was not aware the resident had a change in condition or that a STAT x-ray had been obtained that day. The resident has a standing order to check his/her oxygen at each shift and LPN B checked the resident's oxygen shortly after he/she came on shift, and the O2 sats were at 95%. LPN B did not check the resident's oxygen again during his/her shift. He/She removed the resident's CPAP at 5:00 A.M. and put the resident's oxygen on at 3L. He/She was not aware the resident received oxygen at 5L the day before or that he/she had shortness of breath. There was nothing on the report sheet about the resident's change in condition. If LPN B had been made aware the resident had a change in condition, he/she would have checked the resident's oxygen more frequently and would have adjusted the oxygen to ensure the resident's oxygen level was above 88%. During an interview on [DATE] at 8:25 A.M., LPN B confirmed he/she did did not get verbal report from LPN A on the night of [DATE]. He/She reviewed the report sheet when he/she came in for his/her shift and nothing was written next to the resident's name. There was no documentation on the report sheet about the resident's breathing or O2 sats. During an interview on [DATE] at 8:53 A.M., Physician E said staff notified him/her of the resident's shortness of breath. The physician ordered staff to increase the resident's oxygen to 5L and adjust the oxygen so his/her O2 sats were around 92%. He/She ordered a STAT x-ray, which showed increased infiltrates due to the resident's congestive heart failure. He/She expected staff to communicate the changes in between shifts. He/She understands that documentation from staff could improve, and the documentation could improve the communication with staff in between shifts. During an interview on [DATE] at 12:19 P.M., the LPN Unit Coordinator said the resident's BMP was scheduled to be completed on [DATE]. The lab company came out to the facility on that day, but missed his/her labs, as well as the labs for seven other residents. The resident's BMP was scheduled for the next draw day, but he/she expired. The facility has had ongoing issues with their lab company and they are trying a new lab company. During an interview on [DATE] at 9:25 A.M., the Director of Nurses (DON) said the resident returned from the hospital on [DATE] with orders for a BMP to be completed on [DATE]. The lab company came out to the facility on [DATE], but did not draw any of the residents' labs on the schedule for that today. The facility has been having issues with the lab company for a long time. The facility's corporate office makes the determination which lab company to use. On [DATE], LPN A notified her of Resident #14's change in condition. The DON went over next steps with LPN A in great detail, instructing him/her to notify the physician, to document the assessments for a change in condition, and to encourage the resident go out to the hospital. The DON instructed LPN A to document everything that happened, from the time he/she assessed the resident, in the EMR. LPN A did not document anything in the medical record like he/she was supposed to. An SBAR should have been completed at the time of the change in condition. LPN A should have known what to do and there was no explanation why the documentation did not get done. He/She should have documented the resident's vital signs and assessments related to his/her change in condition. LPN A said he/she gave report to LPN B and wrote the oxygen issues down on the report sheet. LPN B should have read the report sheet, as well as the x-ray results, which were at the nurse's station with the report sheet. LPN B should have followed up by encouraging the resident to go out to the hospital and by rechecking his/her oxygen levels, especially when they were up and down so much on [DATE]. During an interview on [DATE] at 9:34 A.M., the Executive Director said he expected nursing staff to communicate changes in condition to the oncoming shift. Nursing staff should document their observations, assessments, and communication with the physician in the resident's medical record. Assessments should be completed in accordance with the facility's policies and procedures. 2. Review of Resident #9's medical record, showed diagnoses included dysphagia (swallowing disorder) following cerebral infarction (stroke), multiple sclerosis (MS, disease of the central nervous system), quadriplegia (paralysis of all four limbs), seizures, abnormal posture, generalized muscle weakness, anxiety and depression. Review of the resident's speech therapy discharge summary, dated [DATE], showed: -[NAME] Assessment of Swallowing Abilities (a screening tool for identifying eating and swallowing disorders in patients with stroke): Patient with overall score of 130, indicates severe dysphagia and severe aspiration; -Diet recommendation: Minced and moist; -Compensatory strategies/positions: To facilitate safety and efficiency, it is recommended the patient use the following strategies during oral intake: General swallow techniques/precautions along with upright posture for greater than 30 minutes after meals. Review of the resident's ePOS, showed an order, dated [DATE], for aspiration precautions. Sit at 90 degree angle (chin to neck angle, not head of bed), alternate liquids and solids, small single sips, small bites, no straws, 100% supervision. Review of the resident's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -Clear speech; -Makes self understood: Usually understood; -Dependent for eating. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Activities of daily living (ADL) assistance and therapy services needed to maintain or attain highest level of function. Resident has MS, he/she is dependent with all daily living needs and transfers; -Goals included: Resident will perform eating with dependent assist; -Interventions included: Assist with mobility and ADLs as needed. He/She requires extensive/total assistance to complete ADLs. Pillow on left side of head; -Focus: Resident has impaired mobility secondary to MS. Total assist with all ADLs; -Goals included: Resident is dependent with feeding; -Focus: Resident has a swallowing problem related to swallowing progression of MS; -Goals: The resident will not have injury related to aspiration through the review date. The resident will have no choking episodes when eating through the review date; -Interventions included: Keep head of bed elevated 45 degrees during meal and thirty minutes afterwards. Refer to Speech Therapist (ST) for swallowing evaluation. Observation on [DATE] at 1:06 P.M., showed the resident sat in bed. The head of the bed elevated approximately 35 degrees and the resident slumped down with his/her head leaning toward his/her left shoulder, with no pillow on the left side of his/her head. CNA D stood next to the resident's bed providing feeding assistance. CNA D scooped a large spoonful of dessert into the resident's mouth. The resident grimaced and pushed the food out of his/her mouth. Observation on [DATE] at 12:40 P.M., showed the resident in bed with the head of bed elevated approximately 35 degrees. The resident slumped down in bed with his/her head leaning toward his/her left shoulder, with no pillow on the left side of his/her head. CNA C stood next to the resident's bed, providing feeding assistance. CNA C held a cup of water to the resident's mouth and he/she used a straw to drink the water. Observation on [DATE] at 12:17 P.M., showed the resident in bed with the head of bed elevated approximately 35 degrees. The resident slumped down in bed with his/her head leaning toward his/her left shoulder, with no pillow on the left side of his/her head. CNA N stood next to the resident's bed providing feeding assistance. During an interview on [DATE] at 8:00 A.M., the resident said he/she cannot reposition him/herself. He/She can turn his/her head downward, but cannot straighten his/her neck or body. Observation on [DATE] at 8:52 A.M., showed the resident in bed with the head of bed elevated approximately 35 degrees. The resident slumped down in bed with his/her head leaning toward his/her left shoulder, with no pillow on the left side of his/her head. CNA D stood next to the resident's bed providing feeding assistance. CNA D held a cup of water to the resident's mouth and he/she used a straw to drink the water. During an interview, CNA D said the resident sometimes has a wedge pillow, but his/her family member doesn't like it and removes it. The resident requires total care and feeding assistance. He/She is a choking risk and has swallowing issues. His/Her current positioning is ok and he/she coughs when he/she has swallowing issues. He/She can have straws. During an interview on [DATE] at 1:34 P.M., ST Z said the resident should sit up at a 90 degree angle while eating due to aspiration precautions. He/She has poor swallowing capabilities. He/She must remain seated at a 90 degree angle for at least 30 minutes after eating. He/She cannot have straws due to aspiration precautions. Straws contribute to poor bolus control and he/she would have better swallowing control with smaller sips. After ST Z assesses a resident, he/she notifies the nurse of his/her recommendation and enters the documentation in the resident's EMR. During an interview on [DATE] at 1:40 P.M., CNA O said the resident requires feeding assistance from staff. He/She cannot move his/her arms or legs. Staff should ensure he/she is sitting straight up while eating. There are no other special instructions to follow while providing feeding assistance. He/She can have straws. He/She does not have issues with swallowing or choking and is not an aspiration risk. Nurses tell CNAs if there are any special precautions to take when providing feeding assistance. During an interview on [DATE] at 2:03 P.M., Registered Nurse (RN) R said the resident requires feeding assistance from staff. Staff should sit at bedside when providing feeding assistance. While eating, the resident must be seated completely upright, at 90 degrees, due to aspiration risk. He/She cannot have straws due to aspiration risk. Straws can cause liquids to go down too quickly. He/She should remain upright for an hour after eating to help with swallowing and digestion. He/She has limited mobility, cannot move him/herself, and leans toward the left side. Aides should ensure the resident is in the correct position when providing feeding assistance. Aides know what the correct position is by getting report from nurse. During an interview on [DATE] at 7:11 A.M., the Infection Preventionist said the resident used to be an aspiration risk but is not anymore. The portion about no straws on his/her physician order should be removed. He/She has to sit straight at 90 degrees while eating and staff should ensure he/she is positioned that way while providing feeding assistance. During an interview on [DATE] at 8:22 A.M., the DON said the resident went out to the hospital on [DATE] and came back with discharge paperwork showing he/she was not an aspiration risk. His/Her physician orders should have been updated when he/she came back from the hospital to show he/she was not an aspiration risk. The resident requires feeding assistance from staff and staff should ensure the resident is seated upright at a 90 degree angle while eating. He/She should remain seated upright for about 15 to 30 minutes after eating to assist with digestion. Staff should utilize pillows to assist in positioning the resident. She expected staff to provide feeding assistance in accordance with physician order. During an interview on [DATE] at 9:34 A.M., the Executive Director said he expected staff to ensure residents are seated upright at a 90 degree angle when providing feeding assistance. He expected staff to provide feeding assistance in accordance with physician orders. MO00248395

Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care needs were met for Resident #29. The facility failed to ensure Resident #29's hair was clean, facial hair was shaved, body was clean and free from odors, and failed to provide foot care. The sample was 18. The census was 86. Review of the facility's ADL care policy, revised 2/12/24, showed: -Policy: The resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse. Review of the facility's foot care policy, dated 8/28/18, showed: -Policy: This facility will ensure that foot care provided is consistent with professional standards of practice and that foot care includes treatment to prevent complications from conditions such as diabetes, peripheral vascular disease (circulatory condition), or immobility. This facility will ensure that foot care also includes assisting the resident in making necessary appointments with qualified healthcare providers such as podiatrists and arranging transportation to and from appointments; -Implementation: Clean and rinse foot, apply lotion to moisturize dry skin; -Documentation: Documentation associated with foot care should include any abnormal findings, any nursing interventions and patient response. Review of Resident #29's quarterly minimum data set (MDS, a federally mandated assessment instrument completed by facility staff), dated 1/24/25, showed: -Diagnoses of congestive heart failure, muscle weakness, and toxic liver disease; -Cognitively Intact. Review of the resident's care plan, dated 2/25/25, showed: -Focus: ADL Assistance and therapy services needed to maintain or attain highest level of function; -Goal: Resident wishes to attain prior level of function; -Interventions: Assist with mobility and ADLs as needed. Resident requires a mechanical Hoyer lift with all transfers; -Focus: Resident is followed weekly by wound care team, and has been non-compliant with wound care; -Interventions: Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. Review of the resident's most recent skin assessment, dated 2/25/25, showed: -Dry skin noted but not the location; -No mention of the resident's toe nails. Observation and interview on 2/24/25 at 9:05 A.M., showed the resident awake in bed. The resident's hair was long, stringy, and oily. The resident's facial hair was unkempt. The resident had a musky odor emitting from him/her. The resident said he/she receives two bed baths a week, but staff do not always wash his/her hair. He/She said he/she sometimes spills his/her urinal on himself/herself. During observation and interview on 2/24/25 at 11:25 A.M., Certified Nursing Assistant (CNA) D and CNA U provided perineum care (peri-care, cleansing the genitals and rectal area) by turning the resident side to side on his/her bed. While the resident was turned to his/her right side, there was a dark amber colored film located on the resident's buttocks, lower and upper back. CNA D said that the resident will spill his/her urinal, and the urine may leak onto the bed pad. The residents in that particular room like the temperature very warm, so it may make the resident sweat more as well. CNA D and CNA U said they try to wipe or scrub off the film, but it always returns. Both of the resident's feet had large chunks of white dry skin, large crevices of cracked skin, and jagged thick toenails. The resident's feet had a yellow like color. The resident's mattress was dark navy blue and white large flakes of dry skin from the resident's feet were visible on the mattress. The resident's hair was stringy and oily. Observation on 2/25/25 at 9:08 A.M., showed both of the resident's feet had large chunks of white dry skin, large crevices of cracked skin, and jagged thick toenails. The resident's right big toe had a thick toenail that appeared red and green. The resident's feet had a yellow like color. The resident's mattress was dark navy blue and white large flakes of dry skin from the resident's feet were visible on the mattress. Observation on 2/26/25 at 1:36 P.M., showed the resident had a dark amber colored film located on the resident's buttocks, lower and upper back. A urine odor emitted from the resident. The resident's hair was oily and stringy. The resident's facial hair was unkempt. During an interview on 2/26/25 at 1:43 P.M., the resident said he/she has not seen a podiatrist since he/she arrived to the facility. He/She would like his/her toenail taken care of and his/her dry skin treated. He/She has a bowel movement everyday and sometimes spills his/her urinal up his/her back. It has been since about December since he/she has had an actual shower and not just a bed bath. His/Her hair had not been washed since the previous week. It had been at least a year since he/she had received a hair cut, and he/she wanted one. He/She had asked staff about a haircut but had never heard back. During an interview on 2/27/25 at 1:02 P.M., the Infection Preventionist said she would expect nursing staff to document the dry skin and nail conditions of the resident's feet in the skin assessment. She would expect staff to ensure the resident is on the podiatrist list. She said the resident's toe nail is not able to be treated by facility staff and should be seen by a podiatrist. She would expect nursing staff to ask the resident if he/she would like his/her facial hair shaved. She would expect staff to wash the resident's hair and ensure it is cut if the resident requests a haircut. She would expect the staff to clean the resident's skin thoroughly during showers or bed baths. During an interview on 2/28/25 at 8:02 A.M., CNA O said he/she would expect residents to receive at least two showers or bed baths a week. He/She would expect staff to be washing residents' hair and skin. He/She would expect staff to be asking residents if they want their facial hair shaved. He/She would expect any skin concerns or issues to be documented in the skin assessment or shower sheet. He/She would expect dry skin to be reported to the nurse. He/She said the resident's toe is beyond bad and should be seen by a podiatrist. He/She does not know if the resident was currently seen by the podiatrist. He/She would expect skin assessments to be completed and accurate. During an interview on 2/28/25 at 8:16 A.M., the Social Services Director said he is in charge of putting residents on the list to see the podiatrist. He would expect nursing staff to let him know if there are any residents who need to see the podiatrist. He was not aware that Resident #29 needed to see the podiatrist. He would expect staff to ask the residents if they would like a hair cut and to let him know. During an interview on 2/28/25 at 8:54 A.M., the Director of Nursing (DON) said she would expect residents to receive at least two showers or bed baths a week. She would expect staff to wash residents' hair and body and shave any unwanted facial hair. She would expect nursing staff to ask residents if they would like a hair cut. She would expect any skin concerns including dry skin or discoloration to be documented on the skin assessment. The social worker is in charge of putting residents on the list to be seen by the podiatrist. Once the nurse completes an assessment of the resident's feet, the resident should be placed on the podiatrist list if there are any concerns that cannot be addressed by facility staff. She would expect skin assessments to be completed and accurate. MO00249583 MO00248931 MO00250429

Based on observation, interview and record review, the facility failed to ensure one resident's physician (Resident #26) was notified after the resident developed an elevated temperature on the evening shift of 2/24/25. The resident was sent to the hospital the next morning on 2/25/25, and admitted with a diagnosis of sepsis (a serious condition in which the body responds to infection) pneumonia (an inflammatory condition of the lungs. Symptoms may include productive or dry cough, chest pain, fever, and difficulty breathing.). The sample size was 18. The census was 86. Review of the facility's Change in Resident's Condition or Status policy, issued on 11/26/18, and revised on 9/5/24, showed: -Policy: This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. In the case of death of a resident, the resident's physician will be notified immediately by facility staff in accordance with State law; -Federal Regulations: A facility must immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is: A significant change in the resident's physical, mental, or psychosocial status; -Documenting communication: When health care team members provide information in an objective, standardized, and logical sequence, the resident receives safe, quality care timely, appropriate interventions; -Implementation: Identify a suspected acute change in the resident's status. Review the resident's medical record, including advanced directives and health history. Obtain the resident's vital signs (temperature - T, pulse - P, respirations - R, blood pressure - BP) and oxygen saturation level (O2 Sat) using pulse oximetry. Complete a complete physical assessment, focusing on the identified change in the resident's status (for example: assess respiratory status for a resident with decreased oxygen saturation level). Communicate the change in the resident's status to the appropriate physician. Implement the treatment plan or initiate the resident's transfer to another health care facility. Document the procedure. Review of the facility's Temperature Measurement policy, reviewed on 2/24/25, showed: -Introduction: Body temperature represents the balance of heat a person produces with the heat that a person loses. A stable temperature pattern promotes proper function of cells, tissues, and organs. A change in this pattern usually signals the onset of illness; -Oral temperature in adults normally ranges from 97 degrees to 99.5 degrees Fahrenheit (F). Axillary (armpit) temperature, the least accurate reading, reads 1 degree to 2 degrees lower; -Documentation associated with temperature measurement includes: Temperature, route used, date and time of measurement, name of physician notified of an abnormal temperature, date and time of physician notification, any prescribed interventions, and response to those interventions. Review of the facility Licensed Practical Nurse (LPN) job description, revised on 11/10/16, showed: -The LPN delivers quality nursing care to patients through interpersonal contact and provide care and services to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient in accordance with all applicable laws, regulations, and corporate standards; -Reports to the Director of Nursing (DON) or other nursing supervisor; -Specific Requirements: Must have advanced knowledge in field of practice. Must possess the ability to make independent decisions when circumstances warrant such action; -Essential Functions: Must be able to knowledgeably and competently deliver quality nursing care to patients. Must be able to chart appropriately and timely. Must be able to report changes in patient condition. Must be able to concentrate and use reasoning skills and good judgment. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/24, showed: -Speech Clarity: No speech, absence of spoken words; -Makes Self Understood: Rarely/never understood; -Ability to Understand Others: Sometimes understands, responds adequately to simple, direct communication only; -Functional Limitation in Range of Motion: Impairment on both sides of upper and lower extremities; -Dependent: Helper does all of the effort. Resident does none of the effort to complete activity: Toileting hygiene, shower/bathing, upper/lower body dressing, and personal hygiene; -Dependent: Roll left and right; -Not attempted due to medical condition or safety concerns: Lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer; -Diagnoses: Multidrug Resistant Organism (MDRO), pneumonia (An inflammatory condition of the lungs. Symptoms may include productive or dry cough, chest pain, fever, and difficulty breathing.), stroke, seizure disorder, malnutrition, and respiratory failure; -Risk of Pressure Ulcers (injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure or friction): Yes; -Unhealed Pressure Ulcers: No; -Special Treatments and Programs: Oxygen therapy, suctioning (removes mucus and secretions), and tracheostomy (a surgically created hole in the windpipe) care. Review of the resident's care plan, located in the electronic medical record (EMR), showed: -1/16/25: Focus: At risk for respiratory illness. Goal: The resident will remain free from respiratory illness. Interventions: Monitor for change in condition and notify physician of findings; -1/16/25: Focus: Impaired cognitive ability/impaired thought process related to TBI (traumatic brain injury). Goal: Resident's needs will be met. Interventions: Allow resident extra time to respond to questions and instructions. Ask yes/no questions; -1/16/25: At risk for rehospitalization due to one hospitalization in the past six months. Goal: Will not have an avoidable rehospitalization related to current medical diagnoses. Interventions: Staff to provide timely communication to physician. Observation on 2/24/25 at 8:56 A.M., showed the resident lay in bed with a family member at bedside, bathing the resident. The resident had a tracheostomy tube (a medical device inserted into the trachea to facilitate breathing) with humidified oxygen infusing and a gastrostomy tube (a tube surgically inserted through the abdomen into the stomach to provide hydration, nutrition and medications) with the tube feeding off while the family member bathed the resident. The family member said he/she came in every morning to check on the resident and bathed the resident every day. Another family member came in every evening. Review of the resident's progress notes, located in the EMR, showed no documentation the resident had an elevated temperature, received Tylenol, or the physician was notified on the evening shift (3:00 P.M.-11:00 P.M.) of 2/24/25 or night shift (beginning at 11:00 P.M. on 2/24/25 and ending 7:00 A.M. on 2/25/25) . Observation on 2/25/25 at 6:57 A.M., showed the resident lay in bed with humidified oxygen infusing through his/her tracheostomy tube. At 7:00 A.M., the resident's family member entered the room. He/She said he/she was concerned about the resident because the other family member that came in during the evening phoned him/her last night around 5:00 P.M. or 5:30 P.M., and said the resident had a temperature of 102.8 F, and staff gave the resident Tylenol. He/She removed the resident's covers and said the resident felt very warm to touch and he/she thought the resident still had a fever. At 7:08 A.M., the day shift nurse entered the room and the family member told him/her the resident felt hot to touch. The nurse said the night nurse told him/her during shift change they had taken the resident's temperature around 4:00 A.M., and it was 99.0 F. Review of the resident's vital and weight section of the EMR, showed the following vitals documented on 2/25/25 at 7:58 A.M.: T-104.1, P-108, R-22, BP-130/42, and O2 Sat of 98%. Review of the resident's progress note, showed on 2/25/25 at 8:18 A.M., the nurse contacted the resident's physician in regards to an elevated temperature and labored breathing. Vitals were taken and the physician said to send the resident out to the emergency room . Family member at bedside and notified. Unit Manager and DON made aware. Review of the resident's hospital notes, dated 2/25/25 at 7:14 P.M., showed an admission diagnosis of sepsis, pneumonia. During an interview on 2/25/25 at 2:53 PM, LPN F said he/she was assigned to the resident on the evening shift of 2/24/25. He/She assessed the resident around 3:30 P.M. and everything was fine. About 7:30 P.M., the resident's family member told him/her the resident felt warm and asked him/her to take the resident's temperature. He/She obtained an axillary temperature and the resident's temperature was 101 F. LPN F gave the resident Tylenol around 7:30 P.M. He/She thought the physician should be called when a resident had a temperature of 100.3 F or greater, but he/she was not sure. He/She did not document anything about the resident's temperature or administering the Tylenol, but should have. He/She did not contact the resident's physician because he/she was waiting on the resident's labs to come in that were obtained on 2/24/25. LPN F got a little swamped during the shift. He/She did not recall the last time he/she reviewed the facility's change in condition policy. During an interview on 2/26/25 at 9:53 A.M., the DON said she would have expected LPN F to have documented the resident's temperature, and administering the Tylenol. She would have expected the LPN to have contacted the physician and documented any new orders as well. During a telephone interview on 2/27/25 at 11:00 A.M., the resident's physician said he had not been made aware of the resident's elevated temperature on the evening of 2/24/25. Had the nurse notified him the resident had either a 101.2 F or 102.8 F fever, he probably would have sent the resident to the hospital. The resident was a complex patient with a tracheostomy. For a patient like that he would not want to wait for results from labs drawn at the facility. He would have expected the nurse to have notified him.

Based on observation, interview, and record review the facility failed to ensure a kitchen exit door was locked and armed after one resident (Resident #1) eloped from the facility through the kitchen door during the early morning hours, and was out of the facility for approximately 30 minutes. The resident was found on the facility's premises, approximately 30 feet from the exit door. The facility census was 74. The facility was notified of past non-compliance on 12/31/24. Facility staff immediately searched for the resident, reported the incident, and began their investigation. The investigation consisted of written statements and interviews. The investigation showed the kitchen door was not locked and armed. Staff were in-serviced on elopement policy, and abuse and neglect. A second alarm was added to the kitchen door. The deficiency was corrected on 12/27/24. Review of the facility's Elopement policy, revised 11/19/24, showed: -Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle; -Upon completion of the other interdisciplinary team's admission and readmission assessments, the interdisciplinary team will review any additional unsafe wandering and/or elopement risk indicators and revise the resident's care plan as indicated; -The interdisciplinary team will review and revise the resident's unsafe wandering management care plan, if indicated, upon completion of each comprehensive, significant change and quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) and upon an unsafe wandering or elopement event; -A specific system will be implemented to notify staff that exit doors have been opened in areas accessible to residents and may include but not be limited to: -Documented and routine testing of door alarms; -Documented and routine testing of staff's response to alarms; -Monitoring practices when door alarms are disabled or during instances of higher traffic such as holidays, special events, or tours; -Monitoring practices for exits that are not visible to staff but readily accessible to residents; -Residents will be assessed for unsafe wandering and elopement indicators upon admission, readmission, change in condition, quarterly and with any unsafe wandering or elopement event utilizing the Elopement Risk Evaluation; -During the admission and readmission process a care plan will be initiated by the admitting nurse on any residents assessed with unsafe wandering or elopement behaviors; -Associates will be provided unsafe wandering and elopement training upon hire, annually and as indicated by the Unsafe Wandering and Elopement Performance Improvement Plans (PIPs); Elopement drills will be conducted at least quarterly. Review of Resident #1 admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, gastroesophageal reflux disease (GERD, acid reflux), renal failure, diabetes, hyperlipidemia (high lipids in the blood), stroke, dementia, seizure disorder, and malnutrition; -Substantial/maximum assistance required for mobility; -Uses walker and wheelchair; -No physical or verbal behaviors; -Wandering behavior not exhibited. Review of the resident's admission elopement assessment, dated 11/28/24, showed the resident was not an elopement risk. Review of the resident's care plan, updated 12/17/24, showed: -Focus: Resident risk for elopement. Disoriented to place, impaired safety awareness, stroke with cognitive deficits, does understand others and is able to make self-understood; -Goal: The resident's safety will be maintained; -Interventions: Assess for fall risk; Complete elopement risk assessment; Encourage to participate in activities to divert from exiting seeking behavior. Review of the facility's investigation, dated 12/17/24, showed: -Approximately 6:44 A.M., Registered Nurse (RN) A contacted the Administrator regarding Resident #1. He/She informed the administrator that Resident #1 had been cared for by his/her aide at approximately 6:20 A.M. He/She performed Activity of Daily Living (ADL) care and got resident dressed for breakfast and assisted him/her to the wheelchair next to his/her bed; -RN A stated approximately 6:30 A.M. he/she noted the resident was not in his/her room so they began to search other residents rooms, and the entire facility staff continued to search. Administrator contacted Director of Nursing (DON) approximately 6:47 A.M. to update on Resident #1. DON phoned Licensed Practical Nurse (LPN) B to search the outside premises. Charge nurse observed the patient adjacent to the building near generator area. LPN B stated no acute distress noted, patient was fully clothed, and current temp of 35 degrees Fahrenheit (F) outdoors on 12/17/24. Vital signs taken and skin assessment completed with no injuries noted at this time. Patient stated he/she was trying to get back home; -Through additional investigation, it was determined that the resident had walked down the hall while the aide and nurses were performing care. Resident #1 entered the dining room area which is closed due to COVID -19 restrictions. He/She then proceeded to enter the exit corridor area by the kitchen where he/she exited the building. He/She was observed roughly 30 feet from the building away from this door near the generator area on the ground; -Approximately 10:35 A.M., upon assessment noted a hematoma (collection of blood under the skin caused by trauma) developing called to physician orders to send patient to hospital for Computed Tomography (CT) scan of the head. Daughter here at bedside. Transferred to for evaluation. Review of the resident's progress notes, showed: -On 12/17/24 at 8:57 A.M., while doing another resident's care, he/she came out, he/she noticed the resident's door was open and his/her door was to be kept closed because of residents' being COVID positive. Resident was last seen at the 6:00 A.M. round in his/her room. He/She went in to look and saw that the resident was not in the room and he/she immediately called for the Certified Nurse Aide (CNA) to begin looking for the resident. He/She thought he/she was in the bathroom but he/she was not. His/herself and the CNA began to search for resident and then the staff on the other hall. The nurse went outside in his/her car to cover the area, along with his/herself and several of the staff. LPN B got out of his/her car and saw something and realized it was the resident on the ground around 20 feet from the building. Rest of the staff was notified, a wheelchair was brought, and resident was assisted after active range of motion was applied. Inside resident was assessed for any bruising, skin tears, etc. none noted at this time. Family made aware. Physician made aware and DON made aware; -At 9:30 A.M., Nurse Practitioner (NP) here today to see resident. A full assessment was completed with normal findings, skin intact, no bruising, no scratches, no bumps, no open areas noted. Resident in room resting at this time. Vital signs within normal limits; -At 10:32 A.M., Writer place call to physician to report that a hematoma has raised on top of forehead. New order to send to emergency room (ER) for CT of head. Writer placed call to ER spoke to staff, gave report of resident, and he/she stated he/she will inform staff and await for his/her arrival. -At 10:34 A.M., Writer spoke to staff and informed them that ambulance was here and that the resident is a Elopement Risk and will let the team know, charge nurse informed 911 that resident was COVID positive when he/she placed call for resident to be transferred; -At 10:54 A.M., Resident sent to hospital for CT scan of the head. Family at bedside when Emergency Medical Service (EMS) arrived. Transferred to stretcher safely; -At 2:52 P.M., Writer informed oncoming charge nurse that resident is at hospital and upon return he/she will remain a one on one, this writer informed LPN. During an interview on 12/26/24 at 10:38 A.M., [NAME] C said he/she was told the resident got out of the kitchen door exit. He/She was there at the time, but he/she did not see or hear anything. During an interview on 12/26/24 at 10:40 A.M., Dietary Aide D said he/she was working in the kitchen at the time. He/She heard the kitchen door click. He/She did not think anything of it because employees go through the door. [NAME] C and a second dietary aide were working in the kitchen at the time. It occurred between 6:00 A.M. and 7:00 A.M. He/She did not open the door that morning or disable the door alarm. During an interview on 12/26/24 at 10:45 A.M., [NAME] C said if the door alarm is off, they can go through the door. They did not have any deliveries the morning of the elopement. He/She did not remember turning off the alarm. The delivery days are Mondays and Thursday. [NAME] C and surveyor checked the date of the elopement and confirmed it was a Tuesday morning. [NAME] C said it was possible the alarm was off and door was unlocked from the day before. They have been in-serviced. Observation and interview on 12/27/24 at 4:00 P.M., showed the door was locked and the alarm on. The red alarm box was also in place and armed. The door was pushed open and the red box alarm sound. The alarm was loud and could be heard inside the kitchen. The exit door opened outside to back of the facility. There are two large generators outside the door on the right side. There is a sidewalk/walkway on flat concrete that stretches approximately 45 feet until a slight curve where there was a wall, creating a blind spot to the exit door. The administrator said the resident was found on the ground behind the wall. Staff drove around the facility in their car and found the resident. During an interview on 12/27/24 at 3:55 P.M., the administrator said staff did 1:1 additional education for the dietary staff. He was aware the door may have been unlocked. The cook had a delivery the previous night and the door was not secured. They have added an additional alarm. It is a red box alarm. It is an additional layer. He would expect staff to ensure doors are closed and checked every shift and to set the alarm. If staff hear the alarm, they are expected to respond to it. If a resident goes through the first alarm, redirect to safety, report to nurse, and document. MO00246776

Based on interview and record review, the facility failed to ensure the rights of one resident of four sampled residents, for unrestricted visitation, when the facility prevented the resident's relative from visiting the resident due to an allegation of the relative being unruly and having erratic behavior. The facility also failed to provide alternate methods of visits via a private setting, room, or by video teleconferencing platform (Resident #1). The census was 77. Review of the facility's policy Locking Entrance and Perimeter Doors: After-Hours visitors policy, revised 07/21/23, showed: -The resident has a right to receive visitors of his or her choosing at the time of his or her choosing; -The facility must provide immediate access to a resident by immediate family and other relatives of the resident; -The facility must provide immediate access to a resident by others who are visiting with the consent of the resident. Review of the facility's policy titled, Area of Focus: Resident Rights, effective 11/27/2023, showed federal and state laws guaranteed certain basic rights while residing in a Long-Term-Care facility. The facility and its associates have the responsibility for ensuring these rights are always upheld the resident is in their care. Centers for Medicare & Medicaid Services outlines at least 48 rights the resident has that span a wide range of topics. -Resident Rights-The resident has a right to a dignified existence, self-determination, and communication, with and access to persons and services inside and outside the facility; -The facility must protect and promote the rights of the resident; -The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States; -The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility; -The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility and the exercise of his or her rights as required under this subpart. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/27/24, showed the following: -Cognitively intact; -Total dependence for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene; -Upper and lower extremity impairment on one side of the body; -No mobility devices used; -Diagnosis include anemia (low blood count), high blood pressure, diabetes, expressive aphasia (unable to speak words), stroke, hemiplegia (paralysis on one side of the body), seizure disorder or epilepsy (uncontrolled shaking) and depression. Review of the resident's progress notes, showed the visitor was the resident's relative. Review of the incident/police report, dated 3/12/24, showed officers were dispatched on 3/12/24 at 2:25 P.M. The family member was in the room with the resident. No physical altercation at this time. Review of the facility's Notice of Trespass and Notice of No Trespass and No Contact, dated 3/13/24 issued via certified mail and process server, showed the facility prohibited the relative from being on or in the parking lot, common area, buildings, or residences owned or managed by Bridgeton Medical Investors LLC. Resident does not have the right to revoke this notice of trespass. Review of the resident's care plan, dated 4/4/24, showed the following: -Limited extremity use to right upper and lower extremity; -Communication problem related to expressive aphasia; -At risk for increased depression; -The care plan did not show any documented reason for the relative's restriction inside the facility. Review of the resident's electronic medical record (EMR), showed: -No documentation or progress notes, by Social Services, nursing staff, or Administration of the allegations of aggression towards staff; -No documentation of alternative visitation accommodations; -No documentation of court order records prohibiting visitation to the facility. During an interview on 5/21/24 at approximately 7:00 A.M., the resident expressed it had been 3 months since he/she has seen his/her relative. Other people are allowed to visit, but not this relative. At 9:00 A.M., the resident expressed by nodding his/her head that he/she did want to see his/her relative and that he/she was sad because his/her relative had not been in to see him/her. During an interview on 5/21/24 at 12:20 P.M., the Administrator and Assistant Director of Nurses (ADON) said the family member was restricted due to cases on casenet for stalking patterns. The Administrator said the relative could not follow boundaries. The deal breaker was when when he/she was found under a resident's bed. He/She was asked to leave, and a police report was done. The lawyers got involved and it was discovered this was a pattern that existed out in the community before the resident came to the facility. During an interview on 5/22/24 at 7:04 A.M., the Corporate Nurse said they can arrange for the resident to visit with his/her relative if he/she chooses to do so. The use of tablets and other forms of electronics can be used if a family member is physically unable to be on campus. The facility will provide electronic access. The resident had not expressed he/she wanted to visit with his/her family member. During an interview on 5/22/24 at 10:40 A.M., the Administrator and ADON said they expected leadership to follow the process to have family members barred from the facility and document that process. Staff should inform the resident if his/her family member had been banned from the facility. Residents have the right to receive visits or visitors while in the facility. Documentation should be charted if a resident family member had threatening behavior. Leadership should have several documented conversations with an individual accused prior to them being restricted from facility. MO00235918

Based on interview and record review, the facility failed to develop and implement policy and procedures to prevent abuse and neglect neglect of residents and prevent misappropriation of resident property when the facility continued to employ staff member, Certified Nurse Aide (CNA) A who was listed on the Employee Disqualification List (EDL, a listing of individuals disqualified from working in a certified home) indicating he/she was ineligible to work in a certified long-term care facility. CNA A was hired on 12/17/14, put on the EDL list on 8/13/20 with a disqualification length of six years, and terminated from the facility on 1/12/24. The census was 74. The administrator was notified on 2/20/24, of the past non-compliance. Upon discovering CNA A was on the EDL on 1/12/24, the facility took him/her off the schedule. An audit of all current employees' background checks was completed on 1/12/24. The facility also requested their pre-hire criminal background check vendor to complete quarterly background checks on all active employees. The deficiency was corrected on 1/12/24. Review of the facility's Abuse and Neglect policy, reviewed 11/27/23, showed: -What: To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hard line, zero-tolerance approach to resident abuse. Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone; -Why: F606 Not Employ/Engage Staff with Adverse Actions. The facility must not employ or otherwise engage individuals who: Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of abuse, neglect, exploitation, misappropriation of property or mistreatment of resident property; -How: The facility has procedures in place to provide protection for the health, welfare and rights of each resident residing in the facility. These procedures include, but are not limited to: -Screening; -Identification; -Training; -Prevention. Review of CNA A's employee file, showed: -Pre-hire EDL check: 12/15/14; -Date of Hire: 12/17/14; -Date of Termination: 1/12/24; -No other background check documentation. Review of the EDL Active Report, showed: -CNA A's name and Social Security Number; -Added: 8/13/20; -Removed: 8/13/26; -Ordered Length: 6 years. During an interview on 2/20/24 at 11:36 A.M., the Administrator said she was alerted on 1/12/24 the facility should run routine background checks, including the EDL. She did not know this process should have been in place. They completed checks for all active employees and CNA A's EDL results showed he/she was on the list. The Administrator told CNA A he/she would be taken off the schedule and could not come back to work until he/she had resolved the EDL issue. CNA A never returned. During an interview on 2/20/24 at 12:48 P.M., the AP/Payroll Coordinator said she'd been in that position since 2021. She knew she needed to run background checks prior to hiring an employee, but did not know they needed to be completed routinely. She has since been educated and planned to do them quarterly. During an interview with the Administrator and Corporate Representative on 2/20/24 at 1:55 P.M., the Administrator said she was not aware screenings needed to be completed post-hire. She understood they were needed to ensure staff were not on the EDL. She was responsible to make sure routine screenings were completed. The Corporate Representative said they would have the vendor used for pre-hire background checks begin running quarterly background checks for all active staff. -

Based on observation, interview, and record review, staff failed to follow facility policies and professional nursing standards for one resident with a gastrostomy feeding tube (g-tube, a tube inserted through the abdomen that brings nutrition directly to the stomach), a diagnosis of dysphagia (difficulty swallowing), and was noted to have a change in condition. Staff failed to document the resident's change in condition and their assessments of the resident and failed to notify the resident's physician of the change in condition. The resident was later found unresponsive, with no signs of life and required cardiopulmonary resuscitation (CPR/initiated when a resident is found with no signs of life), and Emergency Medical Services (EMS) who transported the resident to a hospital where he/she was pronounced dead. Eighteen residents were sampled and problems were identified with one (Resident #14). The census was 68. Review of the facility's Changes in Resident's Condition or Status policy, reviewed on [DATE], showed: -This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. In the case of death of a resident, the resident's physician will be notified immediately by facility staff in accordance with State law; -The facility will utilize the Lippincott procedure (evidence based procedure guide). Review of the Lippincott procedure: Change in Status, Identifying and communicating, Long-Term Care, revised [DATE], included: Critical Notes: 1. Notification will be made to the resident and/or resident representative regarding any change in condition/status and/or any altercation in treatment; 2. The facility will utilize the following INTERACT tools per policy: -In a long-term care setting, any change from baseline in a resident's status must be identified and addressed. A resident is more likely to return to baseline status and avoid complications when a condition is recognized early so that it can be treated. When a nurse recognizes a potentially life-threatening condition or significant change in a resident's status, the nurse must communicate with other health care team members to meet the resident's needs; -The resident should be assessed for changes from baseline status on admission, at present intervals based on the resident's condition and regulatory requirements, and whenever the resident's status changes. The resident's current status should also be checked against baseline status during medication administration and other routine activities. Notable changes include a decline in functional status, new or increasing confusion, and behavior changes; -A change in status may happen quickly in just minutes or slowly over hours or days. The condition may manifest as a change in cognition or a physical change. Other signs and symptoms may be related to function, appetite, mood, sleep, or behavior. Unless the resident's condition is life-threatening, the resident can be assessed and a treatment plan started at the long-term care facility. A focused, thorough assessment of the resident's condition can help identify a recurring fluctuation in symptoms- such as a change in blood pressure or increased confusion-that happens at the same intervals daily; -At a minimum, assessment should include: -Reviewing the resident's medical record; -Asking how the resident feels and what symptoms the resident has; -Obtaining vital signs; -Observing the resident's overall condition, including function and cognition; -Exploring the resident's complaints; -Clinical Alert: -Recognizing status changes, assessing the resident, and intervening early on allows the resident to receive appropriate care, decreasing the need for transfer to an acute care facility or emergency department; -Every health care member is responsible for communicating a resident's change in status from baseline. The nursing assistant (Certified Nursing Assistant (CNA)) is typically the first to notice a change in a resident's status, because the nursing assistant usually spends more time with the resident than other health care team members, allowing the nursing assistant to identify small changes from the resident's norm. A nursing assistant who notices such status changes should report them immediately to a nurse. The nurse, in turn, must communicate a resident's change in status, including assessment findings, to the practitioner. Most cases of cardiopulmonary arrest (the sudden stop of blood flow due to the failure of the heart to contract effectively) are preceded by clinical signs of deterioration that the practitioner should recognize and can treat quickly. -Clear, professional communication improves diagnoses, care planning and implementation, and continuity of care. Essential elements of such communication include: -Providing details of the resident's current status using objective findings, using correct terminology and details, clarifying and questioning orders or feedback that the nurse doesn't understand or that seems inaccurate, and documenting communication; -Vague, subjective communication may lead to misdiagnoses and delayed treatment; -Implementation: -Identify a suspected acute change in the resident's status; -Review the resident's medical record, including advances directives and health history; -Obtain the resident's vital signs; -Perform a complete physical assessment, focusing on the identified change in status; -Communicate the change in the resident's status to the appropriate practitioner; -Implement the treatment plan or initiate the resident's transfer to another health care facility; -Document the procedure, documentation associated with identifying and communicating a change in a resident's status includes: -Acute change in status; -Behavioral changes; -Vital signs; -Other assessment findings in the appropriate areas in the resident's medical record; -Nursing interventions and resident's response; -Communication with other health care team members and practitioner's orders. Review of the facility's Enteral (food or drug administration through a g-tube) Tube Feeding, Continuous, Gastrostomy (surgical opening in the abdominal wall into the stomach, usually for inserting a feeding tube) and Jejunostomy (surgical opening through the skin at the front of the abdomen and the wall of the jejunum (the second part of the small intestine)) policy, revised on [DATE], included: -Assess the resident for GI (gastrointestinal) intolerance of enteral tube feedings every 4 hours by assessing for abdominal distention, monitoring for reports of pain, and observing for passage of flatus and stool; -Complications associated with continuous gastrostomy and jejunostomy enteral feeding tubes may include: -Nausea; -Vomiting; -Diarrhea; -Pulmonary (lung) aspiration (the entry of material (secretions, food/drink, or stomach contents) into the lungs); -Documentation: -Resident's tolerance of the procedure and formula; -GI assessment and findings; -Enteral tube feeding problems or complications: Name of practitioner notified, date and time of notification, prescribed interventions, and patients response to those interventions. Review of Resident 14's admission face sheet, showed diagnoses of dysphagia following cerebral infarction (stroke) and malignant neoplasm (cancerous tumor) of the colon. Review of the resident's Admission Minimal Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Makes Self Understood: Sometimes understood, responds adequately to simple, direct communication only; -Ability to Understand Others: Sometimes understands, responds adequately to simple, direct communication only; -Moderate cognitive impairment; -Extensive assistance of two (+) persons required for bed mobility; -Total dependence of one person required for transfers; -Supervision: oversight, encouragement or cueing required for eating; -Always incontinent of bowel; -Diagnoses of cancer (with or without metastasis (the cancer has spread to other areas), aphasia (partial or total loss of the ability to articulate ideas or comprehend spoken or written language, loss of the power to speech, or of the appropriate use of words), dementia, hemiplegia (paralysis affecting one side of the body)/hemiparesis (weakness affecting one side of the body), seizure disorder, and malnutrition; -Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?: No; -Problem Conditions: Fever, vomiting, dehydration, internal bleeding: Not indicated; -Swallowing Disorder: Loss of liquids/solids from mouth when eating or drinking; -Nutritional Approach: Feeding tube (g-tube); -Proportion of total calories the resident received through tube feeding: 51% or more; -Received speech therapy. Review of the resident's care plan showed: -Focus: Activity of daily living assistance and therapy services needed to maintain or attain highest level of function; -Interventions: Therapy services as ordered; -Focus: Resident had dementia moderate cognitive impairment; -Interventions: Allow time for resident to respond to questions and instructions; -Focus: Impaired communication related to aphasia, at risk of needs not being met; -Interventions: Anticipate and meet needs; -Focus: Resident had a nutritional problem or potential nutritional problem. He/She had a feeding tube in place related to dysphagia; -Interventions: Observe and report as necessary any signs/symptoms of dysphagia: Pocketing food, choking, coughing, drooling, several attempts at swallowing -Focus: Resident required tube feeding related to dysphagia; -Interventions: Check tube placement and gastric contents/residual volume per facility protocol and record. Hold feeding if residual is greater than: left blank. Observe and report as necessary signs and symptoms of aspiration, fever, shortness of breath, abnormal breath sounds, abdominal distention, diarrhea, nausea/vomiting. Speech therapy evaluation and treatment; -Focus: Advanced Directives CPR Full Code; -Interventions: Code status will be reviewed on a quarterly basis; -The care plan did not identify the resident as having frequent nausea/emesis. Review of the resident's current physician's order sheet showed: -Order Date [DATE], Enteral Food Order: Jevity 1.5 (liquid nutrition) at 70 milliliters (ml) x 20 hours via tube feeding pump. Flush with 150 ml water every 4 hours; -Regular diet, puree texture. Thin liquids only in Prevale cup (prevents over delivery of fluids and promotes safer swallowing and drinking independence for those with Dysphagia). Review of the facility's shift report form (a form used to communicate pertinent information about a resident from shift to shift) showed: -[DATE] (3:00 P.M. - 11:00 P.M. shift) at 9:00 P.M. and documented by Nurse F: Vitals Temperature (T) 98.6 (within normal limits), Pulse (P) 97 (normal limits ,d+[DATE]), Respirations (R) 18 (normal limits ,d+[DATE]), Blood Pressure (BP) ,d+[DATE] (normal limits below ,d+[DATE] or above ,d+[DATE]), and blood glucose level (measures amount of sugar in blood) of 158 (normal limits 80 - 150).; -No information documented regarding nausea/emesis, or the resident's stomach content aspirated and being full; -[DATE] (11:00 P.M. - 7:00 A.M. shift) and documented by Nurse D: T - 97.6, P - 90, R - 18, B/P - ,d+[DATE], Oxygen Saturation 96% (O2, amount of oxygen in the blood, normal limits 95%-100%). Emesis started at 4:30 A.M. -No information documented regarding the resident's cognitive status, lung or bowel sounds. Review of the resident's progress notes on [DATE] at 8:52 A.M., showed: -No progress note documented by Nurse F on the evening shift (3:00 P.M. - 11:00 P.M.) on [DATE]; -No progress note documented by Nurse D on the night shift (11:00 P.M. - 7:00 A.M.) beginning on [DATE] and ending on [DATE].-[DATE] at 12:20 P.M.: Nurse G documented: On or about 8:15 A.M., resident observed unresponsive in his/her bed with no vital signs. Continuous tube feeding discontinued, turned off. Resident status full code and Code Blue was announced. Shift staff responded. Code Blue/CPR in progress. 911 notified by staff nurse. On/or about 8:17 A.M. continued code blue/CPR. The emergency medical technicians (EMTs) responders transported resident to hospital on/or about 8:30 A.M. CPR remained in progress during transport. On/or about 8:35 A.M., residents representative and physician notified of resident's status and transport. ADON, Administrator (Executive Director) notified; -A late entry note dated [DATE] at 10:49 A.M. and documented by Nurse D for [DATE] beginning at 11:00 P.M., and ending on [DATE] at 7:00 A.M.: He/She checked on the resident after taking report. The resident's tube feeding was off. The resident's residual was 0 cc's. Head of bed was up. Resident was in no acute distress and watching TV. Lung sounds were clear. The resident did not want his/her vitals taken at that time. The resident said his/her vitals had just been done. The resident denied pain. He/She checked on the resident around 1:30 A.M. and the resident was in no acute distress. Around 1:45 A.M., he/she cleaned the resident's g-tube site and flushed the g-tube, the residual was 0 cc's. The tube feeding remained off. Around 3:30 A.M., the resident was asleep. Around 4:30 A.M., CNA E called him/her to the resident's room. The resident had a large bowel movement. He/She and the CNA cleaned the resident up and the resident had an emesis. Head of bed remained elevated and the resident was in no acute distress. Temperature - 97.6, blood pressure - ,d+[DATE], pulse - 90, respirations - 18 and oxygen saturation was 96% room air. The resident denied pain. Report given to oncoming nurse. Observation on [DATE] at 8:12 A.M., showed the Assistant Director of Nurses (ADON) and Nurse G performing CPR on the the resident. At 8:17 A.M., EMS arrived, continued CPR and at 8:30 A.M. left the facility for the hospital while continuing CPR. Nurse G spoke to an EMS crew member and said he/she found the resident around 8:10 A.M., unresponsive with no vital signs and he/she called a Code (an announcement to indicate someone was having a medical emergency, usually cardiac or respiratory arrest) and began CPR. Review of the EMS report dated [DATE], showed: -Unit notified at 8:12 A.M. Unit dispatched at 8:13 A.M. At scene at 8:17 A.M. At resident at 8:18 A.M. Staff said resident had no prior complaints before witnessed at 4:15 A.M. when resident had one episode of vomiting, but had no changes after. Staff entered the room at 8:10 A.M., to find the resident unresponsive and not breathing. Staff were found doing CPR upon arrival. Staff printed off copy of Do Not Resuscitate (DNR) and it showed resident wanted full resuscitation. Monitor in place, it showed asystole (the heart is not beating). Resident's skin still hot to touch. Suction was performed clearing the airway. Resident moved to ambulance still showing asystole; -Departed from facility at 8:30 A.M. Arrived at hospital at 8:34 A.M. Resident had no changes in route to hospital. Review of the hospital emergency room records dated [DATE], showed: -Resident arrived at 8:37 A.M. in cardiac arrest. Approximately 30 minute downtime. Astyole on arrival. Continued CPR for one round. Time of death called; -ED Disposition: Expired; -Date/Time: [DATE] at 8:45 A.M. Review of the facility's [DATE] shift report form for 3:00 P.M. - 11:00 P.M. showed the resident expired at 8:30 A.M. During an interview on [DATE] at 2:56 P.M., the ADON said she arrived to the facility today around 8:00 A.M. The night shift nurse said the resident had vomited last night. Nurse G (the day shift nurse) found the resident unresponsive this morning, called her and they began CPR. During an interview on [DATE] at 3:14 P.M., Nurse G said Nurse D (the night shift nurse) said in report this morning the resident had a little emesis, but Nurse G was not sure about the time the emesis occurred. When Nurse G went into the resident's room this morning at start of rounds, the resident was in bed and unresponsive. The resident's tube feeding was on and running. He/She turned the tube feeding off and the ADON came in with the crash cart (a cart with equipment and supplies to be used in an emergency when CPR is required). During a telephone interview on [DATE] at 10:19 A.M., Nurse F said on the evening of [DATE], the resident was not acting right, but nothing he/she could figure out. He/She took the resident's vitals and they were normal. He/She aspirated the resident's stomach contents and he/she was full. He/She did not tell Nurse D the resident threw up. He/She told Nurse D the resident might throw up, because the resident was full and Nurse D should turn the resident's tube feeding pump off. During a telephone interview on [DATE] at 11:25 A.M., CNA B said he/she worked the evening shift of [DATE]. The resident was very quiet. The resident did not talk to CNA B like he/she did when CNA B took care of the resident before. The resident usually turned his/her call light on, but he/she was not doing that either. When he/she oriented with another CNA on day shift, that CNA told him/her the resident frequently threw up or acted like he/she was going to throw up when turned or repositioned. When CNA B checked and changed the resident that evening, he/she acted like he/she was going to throw up, but once CNA B raised the head of the bed back up the resident no longer gagged. CNA B did not tell the nurse about the resident gagging, because he/she thought that was normal for the resident. During a telephone interview on [DATE] at 10:40 A.M., CNA E said he/she worked the night shift that started [DATE], and ended the morning of [DATE] at 7:00 A.M. He/She was assigned to take care of the resident that shift and Nurse D was the charge nurse. He/She checked on the resident during first rounds around 11:30 P.M. The resident was sleeping and in no distress at that time. He/She could not recall if the resident's tube feeding was on or off at that time. He/She checked on the resident the second time around 2:30 A.M. The resident's tube feeding pump was off and the resident was responding, but was quiet and just laying there. The last time he/she checked on the resident was around 5:30 A.M. The resident's tube feeding was not on. The resident was alive at that time, but he/she was not responding. The resident had a very large tar bowel movement. The bowel movement was black. It was all over the resident's brief, incontinent pad and sheet. CNA E called Nurse D to see it and the Nurse helped him/her change the resident's bedding. After they changed the bedding, the Nurse was about to leave the room when the resident had a very large emesis. The vomit was coming out of the resident like a water fountain. It was a very large amount. It was liquid and brown in color. CNA E had to do a second bed change. He/She did not leave the resident's room until 6:00 A.M. It took him/her 30 minutes to change the resident's bed twice. The Nurse did not ask him/her to get vitals. The Nurse did not take vitals, listen to the resident's lungs or bowels while CNA E was in the room. During an interview on [DATE] at 6:39 A.M., Nurse D said when he/she arrived on [DATE] around 11:00 P.M., Nurse F, the evening shift nurse, told him/her in report the resident had been throwing up. He/She thought Nurse F said the resident had thrown up twice. At shift change, the resident was alert and able to answer questions. The resident said he/she was ok, which for him/her meant leave me alone. He/She told Nurse F to turn the resident's tube feeding off which was their standard policy. Nurse D said he/she checked on the resident at 12:30 A.M. and the resident was watching TV. He/She flushed the resident's feeding tube, but did not turn the tube feeding pump on. The resident said his/her stomach did not hurt. He/She also checked on the resident about an hour later and the resident was fine. Around 4:00 A.M., CNA E called him/her to come to the resident's room because the resident was having an emesis. The emesis was a copious (large) amount and the color of tube feeding. He/She checked the resident's vitals and asked the resident if he/she was in pain and the resident said no. The vitals were good and he/she wrote them on the shift report sheet. He/She asked the resident if there was anything else they could do to make him/her more comfortable and the resident did not answer that. The resident nodded his/her head that he/she did not need Nurse D to stay with him/her. Nurse D did not document the resident's emesis or his/her assessments and/or interventions in the resident's progress notes. He/She did not call the resident's physician, because the resident was resting after the emesis. There was some commotion going on that morning with another staff member and he/she did not want to hear it any longer so he/she left without documenting. He/She should have called the resident's physician and documented everything in the resident's progress notes. Review of Nurse D's written statement no time indicated, but completed on [DATE], showed: -On Sunday [DATE], he/she worked the night shift (11:00 P.M. - 7:00 A.M.). When he/she arrived to work, he/she took report from the off-going 3:00 P.M. - 11:00 P.M. nurse (Nurse F). During the report, Nurse F told him/her the resident had an emesis during Nurse F's shift; -After report, Nurse D checked on the resident and he/she was watching TV and in no acute distress. He/She sat down to talk to the resident and asked him/her how he/she was feeling. The resident said he/she was fine. He/She then asked the resident if he/she was in any pain and the resident said I'm fine. He/She then asked the resident if his/her stomach hurt and the resident said no I'm not in any pain. The resident was not having any nausea or vomiting. The resident said Nurse F just checked him/her out and he/she did not want anyone poking on him/her now. Nurse D asked the resident if he/she would let Nurse D listen to his/her lungs. He/She listened to the resident's lungs and they were clear. He/She checked the tube feeding residual (fluid/contents that remain in the stomach) and it was 0 cubic centimeters (cc's). The tube feeding had just been newly set up, but the tube feeding was on hold and the pump was off. The resident's head of bed was elevated to his/her preference which was usually 30 to 35 degrees. The resident was comfortably positioned. The resident said he/she hoped he/she did not throw up any more. The resident asked him/her to change the TV channel to the movie channel, which Nurse D did. The resident said he/she planned to watch a movie on TV which was his/her normal routine. Nurse D left the room around 12:30 A.M. and told the resident he/she would be back to check on him/her later. The resident's call light was in reach along with his/her TV remote control; -He/She checked on the resident around 1:30 A.M. and he/she was sitting in the bed watching TV, in no acute distress. The resident responded with a yes nod when asked how he/she was doing. Approximately 1:45 A.M. he/she cleaned the resident's g-tube site. During that time the resident was watching TV and again, in no acute distress. He/She checked the residual and again it was 0 cc's. He/She flushed the resident's g-tube per physician orders and there was no issues noted with the flush. The resident stated he/she was not in any pain at that time. The tube feeding remained off per the resident's request; -As he/she was making walking rounds, the next time he/she checked on the resident was around 3:30 A.M. and the resident was asleep. The resident preferred the TV on all night so he/she left it on; -At around 4:30 A.M., the CNA was doing rounds and called him/her to the room. The resident had a large bowel movement and he/she helped CNA E clean the resident up. The resident motioned to him/her, pointing to his/her mouth, which told him/her the resident may vomit. He/She got the resident's wash basin and the resident had an emesis. The resident was able to tell Nurse D that he/she thought the emesis (vomit) was over. The head of the bed remained elevated and the resident was in no acute distress after he/she vomited. The tube feeding remained off. After cleaning the resident up, clean bed sheets etc., he/she was repositioned for comfort. He/She took the resident's vital signs which were within normal limits. No temperature at 97.6. Other vitals were ,d+[DATE], pulse - 90, respirations - 18 and oxygen level was 96% on room air. The resident denied pain, thanked Nurse D and CNA E, TV was still on and he/she and CNA E left the room; -Before leaving on [DATE], he/she gave report to the on-coming nurse (Nurse G) which included the emesis the resident had on 3:00 P.M. - 11:00 P.M. shift and 11:00 P.M. - 7:00 A.M. shift. During an interview on [DATE] at 8:26 A.M., the Speech Therapist said she was seeing the resident. The resident's swallowing was mild to moderately impaired. His/Her mastication (chewing) was severely impaired. In a addition to the tube feeding, the resident received a puree (baby food consistency) diet and thin liquids using a Provale cup. She last saw the resident on [DATE] and there were no signs of aspiration. During an interview on [DATE] at 9:30 A.M., the Executive Director (Administrator) said she would have expected Nurse D to have notified the resident's physician. The Nurse should have documented his/her assessments and physician notification in the resident's progress notes. She expected staff to follow the facility tube feeding and change in condition policies. During an interview on [DATE] at 11:09 A.M., the Regional [NAME] President of Operations, Regional Director of Clinical Services, and Executive Director said Nurse D should have followed their policies by documenting the resident's emesis and his/her assessments. They would have expected Nurse D to have called the physician and documented the physician's response. During a telephone interview on [DATE] at 11:20 A.M., the Executive Director confirmed staff had not completed a Stop and Watch Early Warning Tool or SBAR (Situation-Background-Assessment-Recommendation) per facility policy. These tools were reviewed in the daily clinical meetings and used by the DON to update the physician and care plan. During a telephone interview on [DATE] at 12:06 P.M., the resident's physician said the resident was in a fragile condition and had a history of anemia and cancer. He would have expected the facility to have obtained the resident's vitals and contacted him. If the resident had a large emesis, he probably would have had the facility send the resident to the hospital for evaluation and x-rays. He would expect staff to follow the facility's change in condition policy.

Based on observation, interview and record review, the facility failed to ensure staff routinely assessed and monitored one resident's pressure ulcer ulcer for 21 days after it was identified on 5/31/22, and first assessed on 6/1/22, as a Stage II (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 blister.). On 6/22/22, the pressure ulcer was larger, had 95% slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous), and was identified as an unstageable pressure ulcer (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.) The resident also had two more Stage II pressure ulcers that were present as early as 6/20/22, with no assessment, physician update, treatment order or documentation (Resident #7). The facility failed to identify a new Stage II pressure ulcer for one resident during a treatment of the resident's existing Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (Black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin, may be present on some parts of the wound bed. Often includes undermining and tunneling.) (Resident #2), failed to assess, update the physician, obtain a treatment order, and document one resident's Stage II pressure ulcer that was observed on 6/22/22, covered with an undated dressing (Resident #3), and failed to assess, update the physician, obtain a treatment order, and document one resident's pressure ulcer as noted on the resident's Admission/Readmission Collection Tool (Resident #1). In addition, the facility failed to ensure staff routinely completed shower/bath sheets, Weekly Skin Integrity Data Collection forms, and Wound Observation Tools as scheduled. Six residents were sampled and problems were identified with four. The census was 69. Review of the facility's Skin Integrity & Pressure Ulcer/Injury Prevention and Management policy, last reviewed on 4/19/22, showed: Intent: -Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury Advisory Panel), and WOCN (Wound, Ostomy, Continent Nurses Society). Regulation: -Based on the comprehensive assessment of a resident, the facility must ensure that: -A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individuals clinical condition demonstrates that they were unavoidable; and -A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Procedure: -A comprehensive skin inspection/assessment on admission and re-admission to the center may identify pre-existing signs of possible deep tissue damage already present. These signs include purple or very dark areas surrounded by edema (fluid/swelling); profound redness, or, or induration (abnormal hardening of the tissue); bogginess; and/or discoloration. These signs possibly indicate an unavoidable 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 indicate undermining (Separation of tissue from the surface under the edge of the wound) and tunneling (Passageways between the skin and various subcutaneous structures in an irregular manner) or Stage IV with slough, drainage, or even eschar within a few days. -A skin assessment/inspection occurs on admission on admission/readmission. Skin observations also occur throughout points of care provided by Certified Nursing Assistants (CNAs) during activity of daily living (ADL) care (bathing, dressing, incontinent care, etc). Any changes or open areas are reported to the Nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection /assessment and provide treatment if needed. -A risk assessment tool, Braden Scale (A pressure ulcer assessment tool used to determine the risk of developing pressure ulcers) or Norton Scale (A pressure ulcer assessment tool used to determine the risk of developing pressure ulcers), determines the risk for pressure injury development. The score is documented on the tool and placed in the resident's medical record using the appropriate form. -Certain risk factors have been identified that increase a resident's susceptibility to develop or impair healing of pressure injuries. Examples include - but are not limited to: -Impaired/decreased mobility and decreased functional ability; -Cognitive impairment; -Exposure of skin to urinary and fecal incontinence; -Under nutrition, malnutrition, and hydration deficits; -A history of a healed injury; -A skin assessment should be performed weekly by a licensed nurse. -Measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care. All residents upon admission are considered to be at risk for pressure injury development due to medical issues requiring nursing care related to disease process and illness or need for rehabilitation services. -Skin inspections with particular attention to bony prominences; -Skin cleansing with appropriate cleanser at the time of soiling and at routine intervals; -Minimize skin exposure to incontinence using devices (briefs) and skin barriers; -Minimize injury due to shear and friction through proper positioning, transfers and turning schedules; -Measures to protect the resident against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care; -Reposition at least every 2-4 hours as consistent with overall patient goal and medical condition; -Utilize positioning devices to keep bony prominences from direct contact; -When skin breakdown occurs it requires attention and a change in the plan of care may be indicated to treat the resident. 1. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/30/22, showed: -Makes self understood: Understood; -Ability to understand others: Understands; -Severely impaired cognition; -Does not reject care; -Required extensive assistance of two (+) persons for bed mobility; -Transfers, walk in room/corridor: Activity occurred only once or twice - activity did occur but only once or twice; -Required extensive assistance of one person for dressing and personal hygiene; -Total dependence of one person required for toilet use; -Required one person physical assistance for bathing; -Always incontinent of bowel and bladder; -Diagnoses of high blood pressure, diabetes mellitus (DM), stroke and depression; -At risk of developing pressure ulcers? Yes; -Unhealed pressure ulcers? No. Review of the resident's care plan, showed: -Focus: ADL assistance needed to maintain highest level of function; -Interventions: Assist with mobility and ADLs as needed. Requires maximum assistance of two for transfers; -Focus: The resident has impaired cognitive ability/impaired thought processes; -Interventions: Allow extra time for the resident to respond to questions and instructions. Ask yes/no questions in order to determine the resident's needs. Communicate with the resident/family/caregivers regarding residents capabilities and needs; -Focus: 9/7/21: Pressure ulcer to the coccyx being treated by wound nurse; -Goal: 9/7/21 and revised on 4/8/22: Minimize risk for symptoms of infection through next review; -Interventions: Educate resident/family regarding skin problem and treatment. Pressure reducing mattress. Treatment as ordered. Weekly skin checks; -Focus: Bowel incontinence; -Interventions: Assist with toileting as needed. Pericare (cleansing of the genitalia and buttocks) as needed; -The care plan addressed a previous healed pressure ulcer, dated 9/7/21, but did not address any new pressure ulcers. Review of the resident's Braden Scales, showed: -5/7/22: A score of 16 (mild risk); -6/7/22: A score of 18 (mild risk). Review of the resident's progress notes, showed: -5/18/22 at 11:33 A.M.: Resident's buttock red in color and small area forming. Treatment nurse informed as well as the Nurse Practitioner (NP). New order for Duoderm (a hydrocolloid dressing typically applied over a pressure ulcer for three to five days before it is removed), Monday-Wednesday-Friday. No assessment of the area was documented including the stage of the pressure ulcer, measurement, color, drainage, etc.; -5/24/22 at 12:15 P.M. and completed by the Registered Dietician: Skin is intact with treatment for redness noted; -5/24/22 at 10:59 P.M. and completed by the physician: Made rounds with the nurse. He/she did not raise any concern regarding the resident. Review of the resident's physician's order sheet (POS), showed: -5/18/22 at 11:37 A.M.: Duoderm and zinc (a paste or ointment used to treat pressure ulcers/wounds), apply to buttock every Monday-Wednesday-Friday. No other information regarding this order was found in the resident's medical record; -6/1/22: Apply honey (Medihoney - an antibacterial ointment) and Duoderm dressing every Monday-Wednesday-Friday. During an interview on 6/22/22 at 12:00 P.M., the Director of Nurse (DON) said she has worked at the facility for about one month, and has been the DON for about three weeks. She looked, but could not find any of the resident's shower/bath sheets prior to 5/17/22. In fact, she could only find one shower/bath sheet for the months of May and June 2022, which was dated 5/20/22. Review of that shower/bath sheet, showed the resident refused his/her shower. No other information was documented on the shower/bath sheet. The DON said she does not know what the previous facility Wound Nurse (WN) and DON did with residents' bath sheets prior to her starting at the facility. Review of the resident's treatment administration record (TAR), dated 5/1/22 through 5/31/22, showed: -Order Date 5/18/22, Discontinue (DC) date of 6/1/22: Duoderm and zinc, apply to buttock topically every day shift on Monday-Wednesday-Friday for wound care; -Nurses initialed the treatment as completed on 5/20, 5/23, 5/25, 5/27 and 5/30. Review of the resident's TAR, dated 6/1/22 through 6/30/22, showed: -Order Date 6/1/22: Apply to buttock topically every day shift Monday-Wednesday-Friday for wound care. Honey and Duoderm; -Nurses initialed the treatment as completed as ordered, except on Friday 6/3, which was left blank. Review of the resident's Weekly Skin Integrity Data Collection form (a skin assessment completed by the charge nurse), showed: -Date (the date the assessment was started) 5/17/22 at 7:12 A.M., and a lock date (the date the assessment was completed) of 5/17/22 at 7:50 A.M.: -Skin Intact: Yes; -Date 5/24/22 at 7:12 A.M., and a lock date of 5/25/22 at 4:38 P.M.: -Skin Intact: Yes; -No other information documented; -Date 5/31/22 at 7:12 A.M., and a lock date of 6/1/22 at 8:16 A.M.: -Skin Intact: No; -Open area/wound; -New Finding: No; -Small open area to sacrum (triangular shaped bone between the lower back and the upper buttocks). Stage II; -No assessment (measurement, color, drainage, etc.) of the open area/wound was documented; -Date 6/1/22 at 12:44 P.M., and a lock date of 6/1/22 at 1:19 P.M.: -Skin Intact: No; -Open area/wound; -New Finding: Yes; -If yes, list the date: 6/1/22; -Small open area to sacrum; -No assessment of the open area/wound; -Date 6/15/22 at 12:44 P.M., and a lock date of 6:29 P.M.: -Skin Intact: Yes. Review of the resident's Wound Observation Tool (completed by the facility WN after a pressure ulcer/wound has been identified), dated 6/1/22, showed: -Date 6/1/22 at 1:40 P.M., no lock date; -Acquired on 6/1/22; -Location: Coccyx (the final segment of the vertebral column between the upper buttocks and the sacrum); -Type: Pressure, Stage II; -First observation of the pressure ulcer, no references; -Granulation tissue (beefy red, new tissue that forms during the healing process); -Drainage: None; -Measurements: Length (L) 0.4 centimeters (cm), Width (W) 0.4 cm, Depth (D) 0.0; -Additional Comments: Patient appetite is diminished, non-compliant with skin program and incontinent of bowel and bladder. Patient educated and verbalized understanding; -Infection: No; -Pain: No; -Treatment Plan: Honey every Monday-Wednesday-Friday; -No other Wound Observation Tools had been completed after 6/1/22. Review of the facility's weekly pressure ulcer/wound tracking reports (a weekly update that shows the current pressure ulcer/wound assessments and treatment) for 5/22/22, 5/29/22, 6/5/22, 6/12/22 and 6/19/22, showed no documentation regarding the resident's pressure ulcer first identified on 5/31/22. Observation on 6/22/22 at 8:55 A.M., showed the resident lay in bed for a skin assessment. The resident said his/her bottom has been sore. The DON and facility WN positioned the resident onto his/her right side. A Duoderm dressing, dated 6/20/22, was on the resident's sacrum/coccyx area, one on the upper right buttock with a date of 6/20/22. The WN said she applied the Duoderm dressings on 6/20/22, which was the first time she saw the pressure ulcers, as she had just started a few days before. The WN removed the Duoderm dressings. Two pressure ulcers were on the sacral/coccyx area, and one crescent shaped pressure ulcer on the upper right buttock. The Stage II pressure ulcer identified on 5/31/22 and 6/1/22, now measured 2.4 cm by 0.8 cm by 0.2 cm with 95% slough and 5% pink tissue. The WN identified the pressure ulcer as unstageable. The second pressure ulcer (undocumented) underneath the sacral/coccyx Duoderm dressing measured 0.5 cm by 0.5 cm by 0.1 cm, with all pink tissue. The WN identified that pressure ulcer as a Stage II. The crescent shaped pressure ulcer on the upper right buttock (undocumented), measured 4.7 cm by 2.2 cm by 0.2 cm., and the WN identified it as a Stage II. The WN said all three pressure ulcers were present on 6/20/22, and are unchanged today. The WN applied Medihoney and a Duoderm dressing on all three pressure ulcers, which is what she said she applied on 6/20/22. She did not know when the two new pressure ulcers were first identified. The DON said she was unaware of the resident's pressure ulcers as she had only been at the facility for about 30 days. Neither knew why any of the pressure ulcers had not been identified on the facility weekly pressure ulcer/wound tracking reports, or why the two new pressure ulcers had not been identified at all. During an interview on 6/27/22 at 8:00 A.M., CNA E said the last time he/she worked with the resident was 6/20/22. The resident had something on his/her bottom that looked like it was trying to heal, it was a different color of skin. The Duoderm dressing had lifted up on the edge, and that's why he/she was able to see it. He/she thinks it was on the coccyx. During an interview on 7/1/22 at 2:20 P.M., the WN said she started at the facility on 6/20/22, and she was in training with another nurse on 6/20/22 when she first saw the resident's pressure ulcers. She was told to put Medihoney and Duoderm on all three pressure ulcers so she assumed there was a treatment order for all three pressure ulcers. She did not know the physician had not been notified the original pressure ulcer had deteriorated or about the two new pressure ulcers. During an interview on 7/7/22 at 9:55 A.M., the resident's physician, who is also the facility's Medical Director, said any pressure ulcer should be fully assessed when first identified. The physician should be notified so a treatment can start and it should be documented in the resident's progress notes. Pressure ulcers should be assessed at least weekly until they are healed. If a pressure ulcer is getting worse, he expected staff to notify the physician so a new treatment can be ordered if necessary. He was not able to recall if he had been notified about the two new pressure ulcers, but if he had been, it should be documented in the resident's progress notes. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Makes self understood: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to understand others: Usually understands - misses some part/intent of message but comprehends most conversation; -Does not reject care; -Total dependence of two (+) persons for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Always incontinent of bowel and bladder; -Diagnoses of anemia (a lack of red blood cells to carry oxygen to the tissues.), high blood pressure, peripheral vascular disease (PVD, an arterial disease characterized by the blockage or narrowing of the arteries), DM and dementia; -At risk of developing pressure ulcers? Yes; -Unhealed pressure ulcers? No; -Does the resident have one or more unhealed pressure ulcers at Stage I or higher? No; -Moisture Associated Skin Damage? Yes; -Applications of ointments/medications other than to feet? Yes.; -Insulin injections received 7 of the past 7 days. Review of the resident's care plan, showed: -Focus: ADL assistance needed to maintain or attain highest level of function; Interventions: Assist with mobility and ADLs as needed. Requires extensive/total assistance to complete ADLs. Total assistance with transfers via Hoyer lift (mechanical device used to transfer a resident unable to bear weight), two person assist; -Focus: Diagnosis of dementia; -Interventions: Consult with family and interdisciplinary team; -Focus: Behavior problem related to resisting care, and scratching self; -Interventions: Anticipate and meet the resident's needs; -Focus: At risk for impaired communication related to cognitive impairment; -Interventions: Anticipate and meet needs; -Focus: At risk for skin breakdown and infection: -Interventions: Pressure reduction mattress and weekly skin checks; -Focus: Bowel incontinence; -Interventions: Assist with toileting as needed; -Focus: Urinary incontinence; -Interventions: Assist with toileting as needed. Perineal care as needed; -The care plan did not identify the resident's pressure ulcer. Review of the resident's Braden Scales, showed: -5/4/22: Score of 15 (mild risk); -6/4/22: Score of 14 (moderate risk). During an interview and record review on 6/22/22 at 12:00 P.M., the DON said residents are to receive a shower/bed bath two times a week. A shower/bath sheet should be completed. The CNAs documented they gave the resident a shower/bath on the following dates for May and June 2022: Shower -5/4, 5/11, 5/14, 6/8, 6/11, and a bed bath on 6/1, and 6/15/22 (this accounts for seven of the 14 shower/bed baths the resident should have received). Of those seven, she could only find two completed shower/bath sheets. Review of those shower/bath sheets showed: -5/5/22: sponge bath, no skin abnormalities were identified; -5/14/22 (the next shower sheet available): The buttocks had been circled and the CNA wrote cream. No other information was documented; -No other shower sheets were available for the remainder of 5/2022. Review of the resident's TAR, dated 5/1/22 through 5/31/22, showed: -An order, dated 2/25/21, for zinc oxide to the buttocks every shift; -No order for staff to monitor the scratches and excoriation on the resident's bottom as identified on the Weekly Skin Integrity Data Collection form, dated 5/27/22; -An order dated 3/5/20: Weekly skin assessments every Thursday evening shift: Staff initialed a skin assessment had been completed on 5/5, 5/12, 5/19, and 5/26. Review of the resident's Weekly Skin Integrity Data Collection forms, showed staff completed two of the four data collection forms: -Date 5/20/22; -Skin Intact: Yes; -Date 5/27/22 at 11:08 A.M., and a lock date of 6/1/22 at 1:15 P.M.; -Skin Intact: Yes; -New Finding: No; -Scratches and excoriation to bottom; -No other information documented. Review of the resident's TAR, dated 6/1/22 through 6/30/22, showed: -An order dated 6/2/22 at 3:25 P.M., and discontinued on 6/3/22 at 3:20 P.M., for Santyl and Duoderm every Monday-Wednesday-Friday; -An initial the treatment was completed on 6/3/22; -An order dated 6/3/22 at 3:20 P.M., for Santyl (an ointment that removes dead tissue from wounds) and cover with Allyvn dressing (an absorbent foam dressing) once daily; -An order dated 6/3/22, for doxycycline (an antibiotic) 100 milligrams (mg) two times a day for 10 days; -An order dated 3/5/20: for weekly skin assessments every Thursday evening shift: Staff initialed a skin assessment had been completed on 6/2, 6/9, and 6/16; -No order to monitor the resident's scratches and excoriation noted on the Weekly Skin Integrity Data Collection form, dated 5/27/22. Review of the resident's Weekly Skin Integrity Data Collection forms, showed staff completed two of the three data collection forms: -Date 6/3/22 at 11:08 A.M., and a lock date of 6/3/22 at 3:09 P.M.; -Skin intact: No; -Open area/wound: Yes; -New finding: No; -Open area to left buttock and right buttock; -No other information documented; -6/10/22: No assessment found; -Date 6/16/22 at 5:56 P.M., and a lock date of 6/16/22 at 6:02 P.M.; -Skin Intact: No; -Open area/wound: Yes; -Sacrum: Open wound/pressure ulcer; -No other information documented. Review of the resident's Wound Observation Tool, completed by the previous WN, showed: -Date 6/1/22 at 3:22 P.M., and a lock date of 6/2/22 at 3:25 P.M.; -Acquired on 6/1/22; -Location: Right buttock; -Type: Pressure, Stage IV; -Epithelial (pink) tissue present: Blank; -Granulation (beefy red) tissue present: Blank; -Slough tissue present: Blank; -Necrotic tissue present: Blank; -Other: Blank; -Drainage: Serosanguineous (thin like water that usually has a light red or pink tinge), small amount; -Measurements: 2.8 cm by 4.0 cm by left blank; -Additional Comments: Resident scratches/digs at his/her bottom. Started off as scratches and has worsened; -Infection: No; -Treatment: Santyl and Duoderm every Monday-Wednesday-Friday. Review of a wound care company progress note, dated 6/3/22 (first assessment by the wound care company), showed: -At the request of the resident's physician, a thorough wound care assessment and evaluation was performed; -Given the extent of necrosis on resident's right buttock, resident to receive doxycycline 100 mg two times a day for 10 days to manage periwound cellulitis and myositis (chronic, progressive inflammation) evident during the exam; -Right Buttock; -Etiology: Pressure; -Stage: Unstageable - Due to Necrosis; -Wound Size: 9.8 by 7.5 by 0.1 cm; -Exudate (Drainage): Moderate; -Thick adherent black necrotic tissue: 50%; -Thick adherent devitalized (devoid of vitality or dead) necrotic tissue: 20%; -Slough: 10%; -Granulation tissue: 20%; -Surgical debridement completed (necrotic tissue was removed with a scalpel); -Treatment: Santyl, apply once daily for 16 days. Extra absorbent fluff sponge apply once daily for 16 days; -No documentation regarding undermining (the location of undermining/tunneling on a wound is described by the hands of a clock). Review of a wound care company progress note, dated 6/21/22 (second assessment), showed: -Right Buttock: -Stage: Unstageable - Due to Necrosis; -Wound Size: 9.8 cm by 7.6 cm by 3.4 cm; -Undermining: 5.6 at 12 o'clock; -Exudate: Heavy; -Thick adherent devitalized necrotic tissue: 30%; -Slough: 30%; -Granulation tissue: 40%; -Surgical debridement completed; -Treatment: Santyl, apply twice a day for the next 16 days. Extra absorbent fluff sponge apply once daily for 16 days - soak in quarter strength Dakin's solution and pack entire cavity; -Wound Progress: Improved. Observation on 6/22/22 at 9:35 A.M., showed the resident lay in bed. The DON and WN assisted the resident onto his/her right side. A dressing dated 6/21/22, and located on the resident's right buttock was removed by the WN, showing a foul smelling unstageable pressure ulcer that measured 7.5 cm by 6.2 cm by 4.1 cm with tunneling of 6.0 cm at 12 o'clock. After completing the treatment to the right buttock, the WN began gathering her supplies, as she had finished. At that time, the surveyor asked the WN to separate the resident's upper buttock folds, which revealed an open area. The WN said she had not seen it while completing the right buttock dressing change. The WN identified the open area as a Stage II pressure ulcer that measured 1.0 cm by 0.3 cm by 0.2 cm. She said she did not see the pressure ulcer there yesterday. She would contact the physician and obtain a treatment order. Review of the wound care company progress note, dated 6/24/22 (third assessment), showed; -Right Buttock: -Stage: IV; -Wound Size: 7.5 cm by 6.2 cm by 4.1 cm; -Undermining: 6.0 cm at 12 o'clock; -Exudate: Moderate; -Thick adherent devitalized necrotic tissue: 20%; -Slough: 20%; -Granulation Tissue: 60%; -Wound Progress: Improved; -Coccyx Partial Thickness; -Stage II; -Wound Size: 1.0 cm by 0.3 cm by 0.2 cm; -Exudate: Light serosanguineous; -Treatment: Zinc ointment apply once daily for 16 days. During an interview on 6/27/22 at 8:00 A.M., CNA E said he/she could not recall the first time he/she saw the resident's pressure ulcer. The resident scratches and digs at his/her buttocks. When they are checking and changing the resident, you have to try to keep him/her entertained so he/she will not scratch his/her bottom. During an interview on 7/7/22 at 2:25 P.M., the wound care physician said he sees the resident once a week, typically on Fridays. He was unable to see the resident on 6/10/22. He ordered the doxycycline on 6/3/22, because the resident's pressure ulcers peri-wound was red and warm. A Stage IV pressure ulcer can develop within 24 hours in a resident like Resident #3, because he/she is not nutritionally robust. The undermining began because as a pressure ulcer begins to get treatment, the necrotic tissue gets cleaned out it is not uncommon for undermining to appear. 3. Review of Resident #3's admission MDS, dated [DATE], showed: -admitted [DATE]; -admitted from acute hospital; -Adequate hearing and vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes self understood: Understood; -Ability to understand others: Understands; -Cognitively intact; -Does not reject care; -Required extensive assistance of two (+) persons for bed mobility; -Transfers: Activity occurred only once or twice - activity did occur but only once or twice; -Walk in room/corridor: Activity did not occur; -Total dependence of two (+) persons required for dressing and toilet use; -Required extensive assistance of one person for personal hygiene and bathing; -Always incontinent of bowel and bladder; -Diagnoses of fractures and other multiple trauma, atrial fibrillation (irregular heart rate/rhythm) and congestive heart failure (a chronic progressive condition that affects the pumping power of the heart); -Weight of 357 pounds (lbs); -At risk of developing pressure ulcers? Yes; -Does the resident have one or more unhealed pressure ulcers at a Stage I (Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin toes only it may appear with persistent blue or purple hues.) or higher?: Yes; -Stage III Pressure Ulcer: 1; -Open lesion(s) other than ulcers, rashes, cuts: Yes; -Surgical Wounds: Yes. Review of the resident's admission medical records, showed the resident was admitted from a hospital after a fall at home resulting in fractures with need for surgical interventions. The resident was admitted with open areas to the right lower extremity, left lower extremity and left posterior thigh. The resident had no other open areas upon admission. Review of the resident's care plan, showed: -Focus: ADL assistance needed to maintain or attain highest level of function; -Interventions: Assist with mobility and ADLs as needed; -Focus: Potential/actual impairment to skin integrity related to surgical wound; -Interventions: Weekly treatment documentation to include measurement of each area of skin breakdown (W, L, D, type of tissue and exudate (drainage) and any other notable changes or observations); -Focus: Bowel Incontinence; -Interventions: Assist with toileting; -Focus: Urinary Incontinence; -Interventions: Assist with toileting and perineal care as needed. Review of the resident's Braden Scales, showed: -5/24/22: A score of 13 (moderate risk); -6/7/22: A score of 14 (moderate risk); -6/14/22: A score of 11 (high risk). Review of the resident's Weekly Skin Integrity Data Collection form, dated 6/16/22 at 2:41 P.M., showed: -Skin Intact: No; -Friction/shearing; -Buttock; -PRN (as necessary) zinc ointment in place; -No assessment documented. During an interview and record review on 6/22/22 at 12:00 P.M., the DON said she could not find any shower sheets completed for the resident from admitted until 6/21/22. Review of the shower/bath sheet, showed the resident's buttocks had been circled and red, cream applied was written on the form. Review of the resident's TAR, dated 6/1/22 through 6/30/22, showed: -6/7/22: Zinc oxide cream. Apply to buttock for redness after brief changes as needed; -Review of the TAR, showed no initials to indicate staff had applied the zinc oxide cream. Observation on 6/22/22 at 10:00 A.M., showed the resident lay in bed as the DON, WN and CNA A assisted the resident onto his/her side for a skin assessment. Observation showed a Duoderm dressing on the resident's coccyx area. There was no date on the dressing. The WN said she had not applied the Duoderm and did not know who had. The WN removed the Duoderm, revealing an open area. The WN identified the area as a Stage II pressure ulcer that measured 0.8 cm by 0.3 cm by 0.2 cm. Both the DON and WN said if a nurse identifies a new area, they are to complete an assessment, document the assessment, notify the resident's physician to obtain an order, the facility wound nurse and the DON, as well as the resident's representative. Neither the DON or WN had any idea who applied the Duoderm to the resident's coccyx or when. CNA A said today was his/her first day working with the resident and he/she had no idea what the resident's skin looked like prior to this day. Review of the resident's progress notes, POS, TAR and weekly pressure ulcer/wound tracking reports, showed no documentation regarding the Stage II pressure ulcer on the resident's coccyx. No documentation who applied the Duoderm, or if the resident's physician had been notified. During an interview on 6/27/22 at 8:00 A.M., CNA E said when the resident was first admitted , his/her skin was not bad on his/her buttocks. After a while, the resident's buttocks were getting red. He/she did not know what nurse put a Duoderm dressing on the resident or when. During an interview on 6/27/22 at 9:50 A.M., Nurse E said the resident came to the facility with sh

Based on interview and record review, the facility failed to thoroughly and timely investigate an allegation of misappropriation and prevent potential further misappropriation in accordance with the facility policy when staff continued to work after the allegation was reported (Resident #4). The census was 69. Review of the facility Protection of Residents: Reducing the Threat of Abuse & Neglect policy, reviewed on 5/16/20 and revised on 8/10/21, showed: Introduction: -To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. Position Statement & Guidelines: -Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. Residents must not be abused by anyone. This includes staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals. It is the policy and practice of this facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation. Policy: -It is the policy and practice of this facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation; -This facility has procedures in place to provide protection for the health, welfare and rights of each resident residing in the facility. In order to provide these protections, the facility has implemented procedures that include, but are not limited to: Screening, training, prevention, identification, protection, and reporting and response; Training: -It is the policy of this facility to develop, implement, and maintain an effective training program on abuse prohibition including but not limited to the following topics: -Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property and exploitation, including sexual abuse; -Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; Prevention: -The facility must identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if any; -Provide residents and representatives with information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution, and provide feed back regarding the concerns that have been expressed; -Provide staff information on how and to whom they may report concerns; Investigation and Protection: -It is the policy of this facility that reports of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. Residents have the right to live at ease in a safe environment without the fear of retaliation when allegations are reported; -Procedure: Following identification of alleged abuse, the resident(s) receive prompt medical attention as necessary and the resident(s) are protected during the course of the investigation to prevent reoccurrence. Staff will respond immediately to protect the alleged victim(s)/others and integrity of the investigation; -When an incident or suspected incident of resident abuse is reported, the administrator/designee will investigate the occurrence. Protection will be provided to the alleged victim and other resident(s) from the alleged perpetrator; -The administrator/designee will complete an incident report; -The administrator/designee will review the Incident Report for completeness and assure that the physician and resident representatives have been notified of the circumstances; -The written summary of the investigation should include, but is not limited to: A review of the Incident Report. An interview with the person(s) reporting the incident. Interviews with any witnesses to the incident. An interview with the resident if appropriate. An interview with the employee(s), as needed. Interviews with staff members on all shifts having contact with the resident at the time of the incident. An interview with the resident's roommate, family, and/or visitors who may have information regarding the incident. Interviews of other residents who received care or services from the alleged perpetrator. A review of all circumstances surrounding the incident; -If the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results of the investigation; -If the investigation is being conducted by the designee, the administrator will be consulted daily concerning the progress of the investigation; -The administrator or his/her designee will keep the resident and/or his/her representative informed of the progress of the investigation. The alleged victim will be protected from retaliation; -The administrator or designee will inform the resident, physician, and/or resident representative of the results of the investigation and the corrective action taken. Emotional support and counseling will be provided to the resident during and after the investigation as needed. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/21/22, showed: -admitted [DATE]; -Adequate hearing; -Vision Moderately Impaired: Limited vision, not able to see newspaper headlines, but can identify objects; -Speech Clarity: Clear speech - distinct intelligible words; -Makes self understood: Ability to express ideas and wants - usually understood, difficulty communicating some words or finishing thoughts, but is able if prompted or given time; -Ability to understand others: Usually understands - misses some part/intent of the message, but comprehends most conversation; -Cognitively intact; -No behavioral symptoms. Review of Resident #13's annual MDS, dated [DATE], showed: -admitted [DATE]; -Hearing and vision adequate; -Speech Clarity: Clear speech - distinct intelligible words; -Makes self understood: Understood; -Ability to understand others: Understands - clear comprehension; -Cognitively intact; -No behavioral symptoms. During an interview on 6/22/22 at 2:05 P.M., Resident #4 said he/she and Resident #13 were asleep when his/her money was taken. He/she did not see Certified Nurse Aide (CNA) I take his/her money. He/she thinks the CNA took his/her money because the CNA was the only one in and out of his/her room that evening. On the morning on 6/18/22, he/she noticed the money was missing and he/she reported it to the nursing staff. On the evening of 6/18/22, the CNA was in the building and working. His/her family representative spoke to the CNA about the missing money. The CNA denied taking the money. He/she was not afraid of CNA I being in the building on the evening of 6/18/22. He/she was upset that someone took his/her money, and he/she did not want the CNA back in his/her room. During an interview on 7/6/22 at 10:45 A.M., Resident #13 said on 6/17/22, the CNA asked him/her if he/she had any money. Resident #4 was out of the building at that time. That's when he/she heard the CNA opening and shutting Resident #4's drawers. He/she did not see the CNA take the money. The CNA had taken care of him/her and Resident #4 a couple of previous times and there had been no issues. During an interview on 7/6/22 at 10:20 A.M., the Accounts Payable (AP)/ Payroll Manager said she has worked at the facility for two years. She was the manager on duty on 6/18/22, and sent a report to the Department of Health and Senior Services (DHSS). She is the weekend manager on duty about one time every two months. As soon as she clocked in (payroll records showed she clocked in at 7:31 A.M. and clocked out at 3:00 P.M.) Nurse F (payroll records showed he/she clocked in at 7:03 A.M. and clocked out at 11:03 P.M.) reported to her that Resident #4 stated CNA I had stolen his/her $45 on the evening of 6/17/22. She immediately interviewed Resident #4, and his/her roommate, Resident #13. After getting the resident's statements, she called the administrator, who told her to report the allegation to the DHSS hotline. She was not aware, per the policy, she should have interviewed other residents and staff and was not given directives from the administrator to do so. This was the first time she was responsible to initiate an abuse investigation. CNA I was not in the building at the time Nurse F reported it to her. She did not call the CNA for a statement, or to tell him/her not to report to work until an investigation had been completed. He/she thinks the CNA worked on the evening shift of 6/18/22. During an interview on 6/22/22 at 2:00 P.M., the Director of Nurses (DON) said the facility is still waiting CNA I's written statement. On 6/20/22, the CNA told her on the phone on 6/20/22, he/she left his/her statement at the 100 Hall nurse's station. She went to both nurse's stations and could not find the CNA's statement. She tried calling the CNA back for clarification, but she was unable to contact the CNA again. The CNA is no longer eligible to work at the facility again. The facility had not reimbursed Resident #4 his/her $45 yet, but they were going to. During an interview on 6/22/22 at 2:25 P.M., the DON said she did not know if CNA I worked on the evening of 6/18/22. If that happened, it should not have. There was an on-going investigation and the CNA should not have been in the building. She will find out if the CNA worked on the evening of 6/18/22. Review of the facility daily staffing reports, showed CNA I was scheduled on the evening shift on 6/17/22, and assigned to the group of residents Resident #4 and Resident #13 resided in. On the evening shift of 6/18/22, the CNA was assigned to another hall providing care to another group of residents. Review of CNA I's Provider Assignment Record, (a form completed and signed by a facility employed staff member as proof the agency staff member worked and is used by the agency for payroll purposes), showed: -6/17/22: The CNA worked 3:00 P.M. until 11:00 P.M.; -6/18/22: The CNA worked 4:00 P.M. until 11:00 P.M. This was signed by Nurse H. During an interview on 7/6/22 at 9:30 A.M., the DON presented the facility investigation. She said she was not aware of the alleged incident until 6/20/20 (Monday), when she came to work. The AP/Payroll Manager was the supervisor on duty on 6/18/22. She notified the administrator of the alleged incident and conducted the investigation. After reviewing the investigation, the DON said she expected to see resident interviews, other than Resident #4 and Resident #13. Someone should have asked other residents if they have had any money or personal belongings that was missing. She expected to see staff interviews, asking them if they had any knowledge of CNA I taking any resident's belongings. Apparently no one told CNA I not to work pending the investigation, as CNA I did work on the evening of 6/18/22. That should not have happened. They were never able to contact CNA I for a statement. Review of the facility investigation, showed the investigation was conducted beginning on 6/18/22. The investigation folder showed: -An interview with Resident #4: The resident said he/she had $45 dollars in his/her wallet, which he/she saw at 5:50 P.M. on 6/17/22. He/she left his/her wallet on his/her over-the -bed table when he/she went to bed on 6/17/22. When he/she woke up on 6/18/22, the money was gone. He/she said CNA I was the only one he/she saw in his/her room on 6/17/22. He/she stated CNA I took his/her money; -An interview with Resident #13: Resident states his/her evening shift CNA was CNA I. He/she came into his/her room to help him/her to bed around 4:15 P.M. on 6/17/22. While in his/her room, the CNA asked if he/she had any money and could he/she give him/her change for $20. He/she told the CNA he/she did not have any money. He/she then asked where Resident #4 was. He/she told the CNA he/she was out. The CNA gave him/her a gown, pulled the privacy curtain and was on Resident #4's side of the room. As he/she was changing, he/she could hear drawers being opened and closed on Resident #4's side of the room; -A copy of the Protection of Residents: Reducing the Threat of Abuse & Neglect policy; -An employee signature page, undated, with 12 employee signatures indicating they had been re-inserviced to the policy; -An employee signature page, dated 6/21/22, with 23 employee signatures indicating they had been re-inserviced to the policy; -A conclusion statement, undated but completed by the administrator, showed: Background Information: Resident #4 is alert and oriented x 4 (person, place, time and situation) and is able to make his/her needs known. He/she requires moderate assistance with activities of daily living (ADL) completion. Primary mode of transportation is his/her standard wheelchair. Resident is long term to the facility; Summary: After completing a thorough investigation, I was unable to substantiate the incident occurred as reported. Funds reimbursed to resident; Plan to Prevent: -Education provided to staff regarding misappropriation of resident funds and property. Alleged employee has been removed from schedule and no longer able to pick up shifts at the facility; -The investigation did not show: -Interviews/statements conducted with residents, other than Resident #4 and Resident #13; -Interviews/statements conducted with any employees, including CNA I. During an interview on 7/6/22 at 10:45 A.M., Resident #4 said the facility had returned his/her money and he/she was thankful for that. During an interview on 7/7/22 at 12:25 P.M., Resident #4's family representative said on 6/17/22, he/she took the resident shopping. The resident had $45 dollars in his/her wallet, which is unusual as he/she does not normally have more than a couple of dollars. The resident said he/she was going to contribute the money to the family reunion/picnic the following day. The family member brought the resident back to the facility between 4:00 P.M. and 5:00 P.M. He/she took the resident back to his/her room. Resident #13, the resident's roommate, told the resident if he/she had any money he/she had better put it up because their CNA had asked him/her if he/she had any money to make change for $20. The next day, 6/18/22, he/she picked the resident up at the facility to go to the family reunion. The resident told him/her that CNA stole his/her money last night. The resident said he/she had reported it to the facility and they said they would handle it. When they returned that evening around 8:00 P.M., Nurse H unlocked the door and let them in. At that time, the resident told him/her there is that CNA who took his/her money. The family member was surprised the CNA would be working. He/she talked to CNA I and asked about the resident's money. The CNA seemed nervous to him/her, but denied taking the resident's money. He/she spoke to Nurse H, explained what was going on and asked why the CNA was working. The nurse said he/she did not know anything about the allegation before he/she told him/her. He/she said he/she would take care of it. The family member was worried because he/she did not want the CNA to retaliate against the resident. The resident was not scared, but he/she was uncomfortable knowing the CNA was in the building. During an interview on 7/8/22 at 2:20 P.M., Nurse H said he/she worked on the evening of 6/18/22. CNA I was in the building and worked that evening. Around 8:30 P.M. or 9:00 P.M., the resident and his/her family member returned to the facility. He/she let them in the building. When they came in, the resident's family member spoke to him/her and told him/her the resident thought CNA I had taken money from the resident on the evening of 6/17/22, and it was their understanding CNA I was not supposed to be in the facility. That was the first he/she had heard of the allegation. No one at the facility told him/her anything about this. He/she immediately spoke to CNA I who denied the allegation. CNA I seemed irritated when he/she asked him/her about it. He/she told CNA I to leave the facility at that time and do not return until speaking to management. CNA I left without incident. During an interview on 7/7/22 at 12:15 P.M., CNA I said no one from the facility contacted him/her to tell him/her not to work on the evening of 6/18/22. He/she was not aware of an allegation that he/she took the resident's money on 6/17/22, until about two days after the alleged incident occurred. The DON called him/her on Monday, 6/20/22. The CNA denied taking the resident's money, or asking the resident's roommate for money or if he/she had change for a $20. He/she did not take the resident's money. During an interview on 7/6/22 at 12:15 P.M., the administrator said she is responsible to ensure allegations of abuse/neglect are investigated thoroughly. The AP/Payroll Manager called her on the morning of 6/18/22. She instructed her to report the allegation to the DHSS hotline. What she knows now, is that CNA I was allowed to work on the evening shift of 6/18/22, and he/she worked the entire shift. That should not have happened, and she takes responsibility. She did not instruct the AP/Payroll Manager to contact the CNA, asking him/her not to report to work until the investigation was completed, and she did not leave word at the facility to send the CNA home if he/she reported for work. During an interview on 7/7/22 at 9:55 A.M., the facility's Medical Director said he expected the facility to follow their policy on investigating abuse and neglect. He expected the facility to not have allowed CNA I back into the facility while there was an ongoing investigation. MO00202733

Based on observation, interview and record review, the facility failed to have a system in place to ensure residents remained free from pressure ulcers and to assess the resident's skin accurately to show the current status of the resident's pressure ulcers, ensure there were treatment orders and interventions implemented for one resident (Resident #276) and also failed to follow the resident's care plan and physician's orders to prevent further breakdown for two sampled residents (Residents #25 and #379) out of 9 reviewed residents. The census was 82. The administrator was notified on 6/30/21 at 2:30 P.M., of the past non-compliance which occurred through 6/19/20. On 6/16/20, the Director of Nursing (DON) was alerted to deficiencies related to the facility wide wound care program and protocols for care. The facility in-serviced the staff on 6/19/20. The facility put a plan of correction in place which included weekly review of wound status reports by the Interdisciplinary team (IDT), daily review of medication and treatment administration records by the DON, daily review of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff who were interviewed were familiar with the pressure ulcer prevention and management policy. Staff appropriately administered treatments to residents who had pressure ulcers. The deficiency was corrected on 6/19/20. Review of the facility's Skin Integrity & Pressure Ulcer/Injury Prevention and Management Policy and Procedure, dated 10/3/19 and reviewed 10/14/20, showed: -Intent: Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing profession standards of the NPUAP and Wound, Ostomy, Continent Nurses Society (WOCN); -Procedure: --A comprehensive skin inspection/assessment on admission and re-admission to the center may identify pre-existing signs of possible deep tissue damage already present. These signs include purple or very dark areas surrounded by [CONDITION(S)]; profound redness, or induration; bogginess; and/or discoloration. These signs possibly indicate an unavoidable Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound)) or IV (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 with slough, drainage, or even eschar) within a few days. A skin assessment/inspection occurs on admission/readmission. Skin observations also occur throughout points of care provided by certified nurse aides (CNAs) during activities of daily living (ADL) care (bathing, dressing, incontinent care, etc). Any changes or open areas are reported to the nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed; --A risk assessment tool, Braden Scale or Norton Scale, determines the patient's risk for pressure ulcer development. The score is documented on the tool and placed in the patient's medical record using the appropriate form; --A skin assessment should be performed weekly by a licensed nurse; --Measures to maintain and improve the patient's tissue tolerance to pressure are implemented in the plan of care. All residents upon admission are considered to be at risk for pressure ulcer development due to medical issues requiring nursing care related to disease process and illness or need for rehabilitation services. Upon admission and throughout stay at a minimum a pressure redistribution surface (Group 1 mattress) in use with turning and repositioning as needed with ADL care/assistance; incontinent care, if needed, to include skin barriers application as needed; preventative wheelchair cushion, if indicated; skin inspections with particular attention to bony prominences; skin cleansing with appropriate cleanser at the time of soiling and at routine intervals; treat dry skin with moisturizers; minimize skin exposure to incontinence using devices (i.e., briefs) and skin barriers; minimize injury due to shear and friction through proper positioning, transfers, and turning schedules; encourage oral food and fluid intake; and improve patient's mobility and activity when potential exists; --Measures to protect the patient against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: reposition at least every 2-4 hours (per NPUAP standards) as consistent with overall patient goal and medical condition; utilize positioning devices to keep bony prominences from direct contact; ensure proper body alignment when side-lying; heel protection/suspension should be implemented while the patient is in bed; maintain head of the bed at the lowest degree of elevation consistent with medical conditions; use lift devices to move patients in the bed; a pressure redistribution mattress surface is placed under the patient; when positioned in a wheelchair, the patient is to be placed on a pressure reduction device and repositioned; when positioned in a wheelchair, consideration is given to postural alignment, distribution weight, balance, and stability; --When skin breakdown occurs, it requires attention and a change in the plan of care to appropriately treat the patient. 1. Review of Resident #379's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/29/20, showed the following: -admitted [DATE]; -Moderate cognitive deficiency, no behaviors; -Required extensive assistance of one or two persons for bed mobility, transfers, dressing, toilet use and personal hygiene; -Wheelchair for mobility; -Occasionally incontinent of bladder, always incontinent of bowel; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -At risk for pressure ulcer, no unhealed pressure ulcers; -Pressure reducing device for chair and bed. Review of the resident's hospital discharge summary, dated 4/19/20, showed the following: -History and physical showed no skin issues. Review of the resident's medical record, showed the following: -A note on 4/22/20 at 9:04 A.M., showing a partial thickness wound noted to left buttocks with defined edges and deep pink center, approximately 2 centimeters (cm) by 8 cm by 1 cm in size. Full thickness unstageable wound to the coccyx (tailbone)/right buttocks that is approximately 14 cm by 9.5 cm by unable to determine depth with approximately 90 to 95% dark brown/black eschar noted. Physician notified and received new orders. -There was no note showing the resident's responsible party was notified of the change of condition; -A physician's order, dated 4/22/20, discontinued on 5/1/20, for left buttock wound; cleanse wound and apply foam dressing and change every three days; -A physician's order, dated 4/22/20, discontinued on 5/1/20, for Santyl (an ointment used to debride wounds) apply to coccyx/right buttocks topically every day shift for debridement of wound. Review of the resident's electronic treatment administration record (ETAR), dated 4/2020, showed the following: -An order dated 4/22/20, discontinued on 5/1/20, for left buttock wound; cleanse wound and apply foam dressing and change every three days; --Documentation showed the treatment was completed as ordered; -An order dated 4/22/20, for Santyl apply to coccyx/right buttocks topically every day shift for debridement of wound; --Documentation showed the treatment was completed as ordered. Review of the resident's hospital discharge summary, dated 5/6/20, showed the following: -admitted on [DATE]; -Discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -discharged back to facility with wound care and Santyl. Review of the facility wound reports, showed the following: -5/3 through 5/9/20 did not include any records of the resident's wounds; Review of the resident's medical record, showed a physician's order, dated 5/6/20, discontinued on 6/4/20, for Santyl ointment 250 unit/gram (gm); Apply to coccyx topically every day shift for wound care. Review of the resident's ETAR dated 5/2020, showed the following: -An order dated 5/6/20, discontinued on 6/4/20, for Santyl ointment 250 unit/gm; Apply to coccyx topically every day shift for wound care; -There were no other treatment orders documented. Review of the nursing wound observation tools, showed the following: -Dated 5/8/20: --Location: Date of onset 5/6/20, admitted ; Coccyx/Sacral (the area located at the base of the spine, just above the coccyx); Unstageable pressure ulcer (PU); Slough and necrotic tissue present; Moderate, purulent exudate (drainage); 16.0 cm by 18.0 cm with tunneling and undermining, signs of infection of fever and odor, pain related to wound, resident screaming out; Treatment: Santyl and dry dressing. Review of the resident's care plan, initiated on 5/8/20, showed the following: -Problem: Resident has a Stage IV PU to sacrum and a Stage IV PU to coccyx and is followed by the wound nurse and wound physician; -Interventions included: administer treatments as ordered, follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the wound physician's wound evaluation and management summary, dated 5/11/20, showed the following: --Location: Sacrum, Stage IV PU, healing; Necrotic 50%, granulation 20%, muscle 20%; Moderate serous drainage; 18.2 cm by 11.5 cm by 3 cm; Treatment: Apply Santyl once a day and cover with gauze border dressing; --Location: Right buttock, Unstageable PU; Slough 80%, granulation 10%, skin 10%; Light serous exudate; 2.1 cm by 2.2 cm by 0.1 cm; Treatment: Apply Santyl once a day, Xeroform gauze (petrolatum based fine mesh gauze dressing), and cover with gauze border dressing. Further review of the resident's medical record, showed no physician orders listed in 5/2020 for treatments to the right buttock. Review of the wound physician's wound evaluation and management summary, showed the following: -Dated 5/14/20: --Location: Sacrum, Stage IV PU, healing; 50% slough, 20% granulation, muscle 30%; Moderate serous drainage; 17.2 cm by 11.4 cm by 1.5 cm with undermining 3.4 cm at 1 o'clock; Treatment: Dakin's solution (antiseptic used to prevent and treat skin and tissue infections) apply twice daily for 30 days, soak half of the rolled gauze with Dakin's solution half strength and pack the wound, then remaining dry rolled gauze, finish by covering with a dry dressing; --Location: Right buttock, Unstageable PU, resolved. Review of the nursing wound observation tool, showed the following: -Dated 5/14/20: --Location: Sacrum, Stage IV PU, unchanged; Necrotic 50%, Muscle 50% tissue present; Moderate serous drainage; 18.2 cm by 11.5 cm, 3 cm deep; Pain related to wound evidence by moaning and facial grimacing; Treatment: Santyl, 4 by 4 border gauze (absorptive dressing); --Location: Date of onset blank, admitted ; Right buttock, Unstageable PU, unchanged; Slough 80%, granulation tissue present; Small amount serous exudate; 2.1 cm by 2.2 cm by 0.1 cm deep; Treatment: Santyl, Xeroform, 4 by 4 dry dressing. Further review of the resident's medical record, showed no physician order in 5/2020 for a treatment to the right buttocks, Unstageable PU, for Santyl, Xeroform, 4 by 4 dry dressing. Review of the resident's Braden Scale, dated 5/14/20, showed at moderate risk for a pressure ulcer. Review of the facility wound reports, showed the following: -Dated 5/10 through 5/16/20: --Location: Date of onset blank; Sacral, Stage IV; 17.2 cm by 11.4 cm by 1.5 cm; Moderate serous drainage; Wound bed: Slough 50%, granulation 20%, muscle 30%; Treatment: Dakin's solution; Improved; --Location: Dated of onset blank; Right buttock, Unstageable; no measurements or description; Resolved; -Dated 5/17 through 5/23/20: --Location: Date of onset blank; Sacrum (sacral), Stage IV; 19 cm by 10.8 cm by 3 cm, undermining 2.4 cm at 2 o'clock; Moderate Serosanguineous drainage; Wound bed: Granulation 20%, slough 50%, muscle 50%; Treatment: Dakin's, 4 by 4 gauze; improved. Review of the wound physician's wound evaluation and management summary, showed the following: -Dated 5/27/20: --Location: Sacrum, Stage IV PU, healing; Slough 20%, granulation 50%, muscle 30%; Moderate serosanguineous drainage; 17 cm by 9 cm by 2.9 cm; Treatment: Dakin's solution apply twice daily for 30 days, soak half of the rolled gauze with Dakin's solution half strength and pack the wound, then remaining dry roll gauze, finish by covering with a dry dressing. Review of the nursing wound observation tool, dated 5/29/20, showed the following: -Date of onset 5/6/20, admitted ; Sacrum, Stage IV PU, improving; Slough 50%, Muscle 30%, granulation tissue present; Moderate amount of serosanguineous exudate; 17.0 cm by 9.0 cm by 2.9 cm deep; Treatment: Dakin's soaked rolled gauze, 4 by 4 border gauze. Review of the resident's ETAR, dated 5/2020, showed the following: -An order dated 5/6/20, discontinued on 6/4/20, for Santyl ointment 250 unit/gm; Apply to coccyx topically every day shift for wound care; -Documentation showed wound treatment was not competed on the following dates: 5/20, 5/21, 5/23, 5/24, 5/29, 5/30 and 5/31; -There were no other treatment orders documented. Further review of the resident's medical record, showed the following: -There was no physician order found in 5/2020 for treatment to the sacrum of Dakin's solution apply twice daily for 30 days, soak half of the rolled gauze with Dakin's solution half strength and pack the wound, then remaining dry roll gauze, finish by covering with a dry dressing; -A progress note dated 6/1/20 at 12:44 P.M., the resident had an elevated temperature, was sweating profusely, and yelling out in pain. The resident's wound located on his/her buttock had a large amount of foul smelling drainage. The nurse notified the physician, who gave orders to send the resident out to the hospital. Review of the resident's hospital discharge summary, dated 6/5/20, showed the following: -COVID-19 test positive on 6/1/20; -Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Indication for admission: admitted with a huge infected Stage IV sacral ulcer; -Hospital Course: Discussed the resident's very poor prognosis with the family and switched to hospice care. Stopped all medications and started comfort measures; -Facility Admission: Admit to facility on hospice. Further review of the resident's medical record, showed the following: -No admission note when the resident was readmitted to the facility on [DATE] detailing new diagnoses, new orders, reconciliation of hospital discharge orders with the physician, or notification to the resident's responsible party of the change of condition; -A physician's order dated 6/5/20, admit to skilled insurance services; -A physician's order dated 6/5/20, admit to Skilled Medicare A Services; -A progress note dated 6/8/20 at 6:46 P.M., the resident was yelling out in pain, the nurse administered as needed (PRN) narcotic pain medication, administered a treatment to the resident's coccyx, discontinued insulin orders, no complications noted at the time of the note. The physician approved skilled therapy for seven days. The resident was alert, needed assistance of one staff member for ADLs and transfers, incontinent of bowel and bladder, care provided as needed. No distress noted and call light within reach; -A progress note dated 6/9/20 at 1:41 P.M., received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -An order dated 6/10/20, discontinued on 6/10/20, ok for skilled services times seven days; -A physician's progress note, dated 6/12/20, seen today for follow-up, the resident was alert and oriented to self with significant memory impairment, looked comfortable and was not in pain. The resident said he/she was hungry and that he/she was okay. Vital signs normal, no shortness of breath, lungs sounded clear, regular bowel sounds noted, slight [CONDITION(S)] (fluid accumulation) in right and left legs. Continue comfort care, pain management, wound care, do not resuscitate and comfort measures only; -There was no order found for comfort measures; -There was no order found for the sacrum between 6/4/20 and 6/9/20; Review of the resident's ETAR, dated 6/2020, showed the following: -An order dated 5/6/20 and discontinued on 6/4/20, for Santyl ointment 250 unit/gm. Apply to coccyx topically every day shift for wound care; -Documentation showed the treatment was not completed for the following days: 6/1, 6/2, 6/3 and 6/4/20. Further review of the resident's medical record, showed: -A physician's order dated 6/09/2020, discontinued on 6/20/20, for sacrum, every day shift for wound; Cleanse wound to sacrum with wound cleanser (WC) or normal saline (NS), pat dry, pack Dakin's soaked to wound then cover with 4 x 4 and tape; -A physician's order dated 6/20/20, ok for skilled services times seven days effective 6/5/20. Review of the resident's ETAR, dated 6/2020, showed the following: -An order dated 6/9/20 and discontinued on 6/20/20, for sacrum every day shift for wound; Cleanse wound to sacrum with WC or NS, pat dry, pack Dakin's soaked to wound then cover with 4 x 4 and tape; -Documentation showed the treatment was not completed on the following days: 6/15, 6/16, 6/17, and 6/18/20. Review of the wound physician's wound evaluation and management summary, dated 6/11/20, showed the following: -Location: Sacrum, Stage IV PU; 17.5 cm by 10.5 cm by 2.8 cm, with undermining of 4 cm at 2 o'clock; Moderate serous exudate; Slough 50%, granulated tissue 20%; Treatment: Dakin's solution twice daily for 30 days, soak half of the rolled gauze with Dakin's solution half strength and pack the wound, then cover with remaining dry rolled gauze, cover with dry dressing. Review of the wound physician's wound evaluation and management summary, dated 6/16/20, showed the following: -Location: Sacrum, Stage IV PU; 16.3 cm by 11.6 cm by 0.5 cm, with undermining of 3.1 cm at 2 o'clock; Moderate serosanguineous exudate; Slough 40%, granulation tissue 30%, muscle 30 %; Improved; Treatment: Dakin's solution twice daily for 20 days, soak half of the rolled gauze with Dakin's solution half strength and pack the wound, then cover with remaining dry rolled gauze, cover with dry dressing. Further review of the resident's medical record, showed the following: -A physician's order dated 6/12/20, for treatment to the sacrum, Dakin's solution twice daily, soak half of the rolled gauze with Dakin's solution half strength and pack the wound, then cover with remaining dry rolled gauze, cover with dry dressing. Further review of the resident's ETAR, dated 6/2020, showed no order documented and dated 6/12/20 for treatment to the sacrum, Dakin's solution twice daily, soak half of the rolled gauze with Dakin's solution half strength and pack the wound, then cover with remaining dry rolled gauze, cover with dry dressing. Review of nursing wound observation tool, dated 6/17/20, showed the following: -Location: Dated of onset 5/6/20, admitted ; Sacrum, Stage IV PU, improving; Slough 40%, Muscle 30%, granulation tissue present; Small amount of serosanguineous exudate; 16.3 cm by 11.6 cm by 0.5 cm deep with undermining of 3.1 cm at the 2 o'clock position; Treatment: Dakin's soaked rolled gauze, 4 X 4 border gauze. During an interview on 6/29/21 at 2:53 P.M., the Medical Director said the following: -The resident was followed by a wound physician due to the severity of the wounds, -He expected nursing staff to follow physician orders; -He expected nursing staff to alert him if they were not following the treatment orders; -It was important to keep the pressure ulcer from acquiring an infection; -Not following physician orders could cause a pressure ulcer to decline; -It was important to provide care for the resident and protect them. During an interview on 6/29/21 at 3:12 P.M., the Wound Physician said the following: -She expected the facility to follow treatments as ordered; -She expected treatments changed daily when a pressure ulcer is located at the coccyx as the wound was exposed to urine and bowel movement which could further compromise wound healing; -She expected nursing staff to notify the physician if the treatments were not followed as ordered; -If she saw a treatment was not followed as ordered, she would speak to the DON or Administrator to notify them of the issue; -Could not heal a wound if nursing staff did not follow treatment orders as the wound could get infected or further compromised. 2. Review of Resident #276's face sheet, showed: -admitted on [DATE]; -discharged on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, dated 6/11/20, showed: -Focus: ADL self-care performance deficit related to limited mobility; -Goal: Will improve current level of function through the review date; -Interventions: --Was totally dependent on staff for bed mobility, bathing, dressing, personal hygiene, and eating; --Was bedfast all or most of the time; -Focus: At risk for break in skin integrity; -Goal: Maintain intact skin with no skin breaks through next review: -Interventions: --Clean and dry skin after each incontinent episode; --Weekly skin check. Review for the resident's Admission/Readmission Collection Tool, dated 6/3/20, showed skin intact. Review of the resident's Braden Scale, dated 6/3/20, showed severe risk for a pressure ulcer. Review of the facility wound reports, showed: -6/3 through 6/16/20, did not include any records of the resident's wounds. Review of the resident's Weekly Skin Integrity Data Collection, dated 6/10/20, showed: -Skin intact; -No new findings. Review of the resident's progress note, dated 6/16/2020 at 10:06 A.M., showed: -Resident was having labored breathing; -Staff spoke with the resident's family, who requested the resident be sent to emergency room (ER); -Call placed to the resident's physician's office to notify of above; -Call placed to emergency medical services (EMS) to transport to the ER at family's request; -Left for ER via stretcher with 2 attendants; -ER called and report given; -No noted observations or documentation of pressure or other wounds. Further review of the resident's progress notes for 6/4/20 through 6/16/20, showed no noted observations or documentation of pressure or other wounds. Review of the resident's hospital's Multidisciplinary Emergency Department Progress Note, dated 6/16/20, showed: - Pressure ulcer to sacrum; --Present on admission; --Wound bed: dusky red, deep purple; --Measurements: 11 cm long by 19 cm wide; --Exudate: scant; --Periwound: non-blanchable redness; - Pressure ulcer to right, medial, anterior leg: --Present on admission; --Wound bed: blister; --Measurements: 1 cm long by 1 cm wide; --Exudate: none; --Periwound: intact; - Pressure ulcer to right hip: --Present on admission; --Wound bed: non-blanchable red; --Measurements: 1 cm long by 3 cm wide; --Exudate: none; --Periwound: intact; - Pressure ulcer to right ear: --Present on admission; --Wound bed: black; --Measurements: 1 cm long by 0.5 cm wide; --Exudate: none; --Periwound: intact; - Pressure ulcer to left ear: --Present on admission; --Wound bed: deep pink; --Measurements: 0.5 cm long by 0.3 cm wide; --Exudate: none; --Periwound: intact. During an interview on 6/16/21 at 1:00 P.M., the DON said the day the resident was sent out to the hospital was her first day working at the facility and she did not remember the resident or the incident. Staff should have been monitoring the resident's skin and noted the areas of pressure prior to the resident being sent out to the hospital. 3. Review of Resident #25's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required extensive assistance from staff for eating; -Total dependence on staff for bed mobility, dressing, personal hygiene and bathing: -Transfers and toileting did not occur; -Required a wheelchair for mobility; -At risk of developing pressure ulcers; -Had one Stage II pressure ulcer that was present upon admission; -Skin and ulcer treatments: --Pressure reducing devices for chair and bed; --Application of non-surgical dressings; --Application of ointments and medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, reviewed 4/1/20, showed: -Focus: ADL self-care performance deficit related to [CONDITION(S)]. Requires extensive/total assistance with ADLs. Refuses turning/repositioning as he/she states it is painful and makes breathing difficult if he/she remains on his/her side. Date initiated: 03/18/19; -Goal: Will maintain current level of function through the review date; -Interventions: --Requires staff assistance to turn in bed. Able to grasp the side rails. Requires extensive/total assistance with ADLs including mobility (able to operate electric wheelchair), oral care, personal hygiene, bathing, eating, dressing, transfers and toileting. Has a [MEDICATION(S)] (an opening in the abdominal wall that's made during surgery. It re-directs urine away from a bladder that's diseased, has been injured, or isn't working as it should) and [CONDITION(S)] (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall) in place that needs assessed and changed by staff. Transfers via Hoyer lift (mechanical lift); -Focus: Has break in skin integrity. Has a low air loss mattress that may be set between 2-5 per manufacturer's guidelines for resident comfort. Resident also has eruptions on his/her abdomen & legs. Resident receives wound treatments per physician order. Date initiated: 11/28/18; -Goal: Minimize risk for symptoms of infection through next review; -Interventions: --Pressure reducing mattress; --Treatment as ordered; -- Weekly skin checks; -Focus: At risk to develop a pressure ulcer related to impaired mobility. Refuses to turn stating it is uncomfortable and difficult to breathe when on his/her side. Alert and oriented X 4 (person, place, time and situation) and aware that it can result in skin breakdown. Date initiated: 3/18/19; -Goal: Maintain intact skin with no skin breaks through next review; -Interventions: --Pressure reducing mattress; --Treatment as ordered; --Weekly skin checks; -Focus: Has a Stage II pressure ulcer to left lateral back. Date initiated: 11/8/19; -Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date; -Interventions: --Administer treatments as ordered; --Assess wound healing: Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician; --Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] --If the resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. Review of the resident's 1/2020 physician's order sheet (POS), showed: -Cleanse area to left lateral back with Dakin's solution or NS, pat dry, apply skin prep to area and allow to dry. Apply Duoderm (an occlusive gel dressing that helps maintain a moist wound bed) dressing for protection. Change every three days related to pressure. Start date 12/24/19; -Cleanse open area to left posterior hip with Dakin's solution or NS, pat dry, apply skin prep to periwound and allow to dry, apply Xeroform and cover with dry dressing. Change every day and as needed if soiled or dislodged. Start date 12/25/19; -Cleanse neck with soap and water. Apply [MEDICATION(S)] (antifungal) powder 0 units/GM to right neck topically every shift for rash. Start date 1/21/20. Review of the resident's 1/2020 Treatment Administration Record (TAR) showed: -Left lateral back wound dressing not signed out as provided for 7 out of ten opportunities; -Left posterior hip wound dressing not signed out as provided for 18 out of 31 opportunities; -[MEDICATION(S)] (moisture barrier cream) to buttocks was not signed out as provided for 26 out of 93 opportunities; -[MEDICATION(S)] ointment to neck not signed out as provided for 26 of 93 opportunities. Review of the resident's 2/2020 POS, showed: -Cleanse area to left lateral back with Dakin's solution or NS, pat dry, apply skin prep to area and allow to dry. Apply Duoderm dressing for protection. Change every three days related to pressure. Start date 2/7/20; - Cleanse area to left lateral back with Dakin's solution or NS, pat dry, apply skin prep to area and allow to dry. Apply Miplex border (antimicrobial foam dressing that absorbs exudate and maintains a moist wound environment) dressing for protection. Change every three days related to pressure. Start date 2/14/20; -Cleanse open area to left buttock with Dakin's solution or NS, pat dry, apply skin prep to periwound, allow to dry, apply Miplex border. Change every three days and as needed if soiled or discolored. Start date 2/14/20; -Cleanse open area to left posterior hip with Dakin's solution or NS, pat dry, apply skin prep to periwound and allow to dry, apply Xeroform and cover with dry dressing. Change every day and as needed if soiled or discolored. Start date 2/7/20; -Cleanse neck with soap and water. Apply [MEDICATION(S)] powder 0 units/GM to right neck topically every shift for rash. Start date 1/21/20. Review of the resident's 2/2020 TAR, showed: -Left lateral back wound dressing not signed out as provided for 2 out of 10 opportunities; -Left posterior hip dressing not signed out as provided for 6 out of 13 opportunities; -[MEDICATION(S)] to the buttocks not signed out as provided for 24 out of 87 opportunities; -[MEDICATION(S)] ointment to neck not signed out as provided for 24 out of 87 opportunities. Note: 3/2020 POS and TAR not provided by the facility upon request. Review of the nursing wound observation

Based on observation, interview and record review, the facility failed to assess, document, notify the physician and monitor one resident's pressure ulcer after staff placed a dressing over the pressure ulcer on an unknown date and time. In addition, staff failed to process and follow hospital readmission orders [REDACTED]. The facility identified eight resident's with pressure ulcers. All eight were sampled and problems were identified with two (Residents #44 and #37). The census was 81. 1. Review of Resident #44's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/27/19, showed: -Moderate cognitive impairment; -Total dependence of one person required for bed mobility, transfers, dressing, eating and toilet use; -Extensive assistance of one person required for personal hygiene; -Incontinent of bladder and bowel; -No pressure ulcers. Review of the resident's care plan, revised 7/16/19, showed: -Focus: Has impaired skin integrity as evidenced by shearing to right hip; -Interventions: Assess location, size and treatment of [REDACTED]. to physician. Avoid scratching and keep hands and body parts from excessive moisture. Clean and dry after each incontinent episode. Educate resident, family and caregivers of causative factors and measures. Encourage good nutrition and hydration. Follow facility protocols for treatment of [REDACTED]. Use a draw sheet of lifting device to move resident. During an interview on 7/23/19 at 8:06 A.M., Certified Nurse Aide (CNA) C, said he/she provided incontinence care for the resident, approximately two weeks ago. He/she observed a small, pink area on the resident's buttocks and reported his/her findings to the charge nurse. Review of the resident's weekly skin assessments, completed on 6/19/19, 6/25/19, 7/2/19 and 7/9/19, showed the resident's skin intact with no new findings. During an interview on 7/19/19 at 9:53 A.M., Nurse F said on the morning of 7/11/19, the overnight nurse told him/her the resident had a new wound on his/her right hip. The overnight nurse did not put a dressing on the wound before passing along the information. Nurse F performed a full skin assessment and noted the wound on the right hip as the only skin concern. The wound was cleaned and dressed and the physician was notified to obtain new orders for treatment. All treatment dressings should be dated and initialed by the nurse. Review of the facility's weekly wound report, dated 7/12/19, showed a new wound noted on the resident's right hip, acquired on 7/11/19. The wound measured 1.2 centimeters (cm) by 2.8 cm, classified as unstageable (not stageable due to coverage of the wound bed by slough (dead tissue usually a cream or yellow color or eschar (dry, black, hard necrotic (dead) tissue). No other wounds identified. Review of the resident's treatment administration record (TAR), dated 7/1/19 through 7/31/19, showed: -An order, dated 7/12/19, to apply skin prep (a liquid film-forming protective dressing) to right foot daily on evening shift. Staff documented as completed on 7/15, 7/16, 7/17 and 7/18/19; -An order, dated 7/12/19, to cleanse outer left ankle with wound cleaner and pat dry. Apply skin prep to periwound (tissue surrounding a wound) and allow to dry. Apply an occlusive dressing and a foam dressing, every two days and as needed. Staff documented as completed on 7/15 and 7/17; -An order, dated 7/12/19, for Santyl (an ointment used to debride ulcers) applied to right hip topically every day shift. Before applying, clean with wound cleaner. Apply occlusive dressing and dry dressing. Change dressing daily and if it becomes soiled or dislodged. Staff documented as completed on 7/14, 7/15, 7/16, 7/17 and 7/18/19. During an interview on 7/19/19 at 11:20 A.M., CNA A said he/she provided incontinence care for the resident on 7/15/19 or 7/16/19, at which time he/she observed wounds on the resident's right hip and back side, under the brief area. He/she reported the wounds to the nurse. The nurse did not clean the area before applying a topical ointment, and he/she did not dress the wound afterward. The resident does not usually wear heel protectors and is never out of bed. Observations of the resident, showed: -On 7/17/19 at 9:51 A.M., the resident lay in a low air-loss (LAL, a specialized inflating/deflating mattress used to prevent and assist in healing pressures) bed on his/her right side, with a pillow in between his/her knees. The resident did not wear heel protectors; -On 7/17/19 at 12:53 P.M., the resident lay in bed on his/her left side, while staff sat at bedside, providing feeding assistance; -On 7/17/19 at 4:37 P.M., the resident lay in bed on his/her left side, without heel protectors; -On 7/18/19 at 9:03 A.M., the resident lay in bed on his/her back, wearing heel protectors; -On 7/19/19 at 7:02 A.M., the resident lay in bed on his/her left side, wearing heel protectors; -On 7/19/19 at 9:48 A.M., the resident lay in bed on his/her back, wearing heel protectors; -On 7/22/19 at 6:38 A.M. and 8:26 A.M., the resident lay in bed on his/her back, without heel protectors; -On 7/22/19 at 10:34 A.M. and 1:40 P.M., the resident lay in bed on his/her back, wearing heel protectors; -On 7/23/19 at 5:41 A.M., the resident lay in bed on his/her back, with feet/heel protectors not visible; -On 7/23/19 at 8:22 A.M., the resident lay in bed on his/her back, with feet/heel protectors not visible. During an interview on 7/19/19 at 10:46 A.M., CNA [NAME] said he/she provided incontinence care for the resident on the evening of 7/17/19. While changing the resident's brief, he/she observed a pink dressing on the resident's right hip and on the area above the tailbone. The resident's foot was wrapped and he/she has been wearing heel protectors, indicating he/she might have a wound on his/her heel. Review of the resident's weekly skin assessment, dated 7/16/19, showed an open area/wound on the right trochanter (hip). No measurements documented. No other skin issues identified. Observations on 7/19/19, showed: -At 5:13 A.M., during a skin assessment, the resident lay in bed on a low air-loss mattress. His/her feet were dry and flaky. Nurse L and CNA M turned the resident to his/her left side revealing a dressing to the right hip, dated 7/18/19. The left upper buttock showed a pink dressing. The dressing appeared worn and dirty, with a date that was unreadable and worn off. The Director of Nursing (DON) assessed the dressing and said she was unable to read the date. She did not know when the dressing was applied. The DON removed the dressing, revealing a pressure ulcer that measured 1.4 cm by 1.7 cm, with a black center which measured 0.8 cm by 1.2 cm. The DON said the pressure ulcer was unstageable. The DON said she would place a dry dressing on the pressure ulcer until she could check the order; -At 1:30 P.M., the resident lay in bed. The facility's wound physician measured the resident's left upper buttock pressure ulcer, 1.1 cm by 1.4 cm. He/she scored the pressure ulcer with a scalpel. He/she said this would help to remove the dead tissue when the treatment is applied. He/she would expect the staff to assess the resident's skin and report any changes to the nurse. This is the second time he/she has assessed the resident. No one reported any changes to the resident's skin until today, 7/19/19. The DON said prior to today, there were no treatment orders for the left buttock ulcer. She agreed the dressing had been on there longer than when the last skin assessment was completed, on 7/16/19. Review of the resident's skin assessments and wound observation tool, dated 7/19/19, showed: -Right trochanter, unstageable. 1.5 cm by 1.5 cm; -Left outer ankle, shearing. 0.5 cm by 0.7 cm; -Right side of heel, Stage II (Partial thickness loss of dermis presenting as a shallow ulcer with a red-pink wound bed without slough. (MONTH) also present as an intact or open/ruptured blister), 1.2 cm by 0.7 cm. Site previously not visible related to dried skin; -Right 5th metatarsal, unstageable, suspected deep tissue injury. 0.8 cm by 0.6 cm; -Left sacrum (hip bone), unstageable. 100% covered in eschar, which sits in center, 0.8 cm by 1.2 cm, with a total wound area of 1.4 cm by 1.7 cm. Review of the resident's medical record, showed: -In (MONTH) 2019, staff documented providing sponge baths or bed baths on 6/5, 6/7, 6/10, 6/19, 6/22 and 6/24/19; -In (MONTH) 2019, staff documented providing bed baths on 7/5, 7/12 and 7/16/19. During an interview on 7/23/19 at 5:27 P.M., DON said she was unable to identify who applied the treatment to the resident's new, unstageable pressure ulcer, noted on 7/19/19. The nurse who administered this treatment should have assessed all of the resident's skin. If a new issue was identified, the nurse should have called the physician to obtain a treatment order. The resident's family should have been notified as well. The nurse who assessed the resident's skin on 7/16/19, said he/she completed a head to toe assessment on that day and the wound on the resident's right hip was the only issue. CNAs should also be assessing the resident's skin during baths or showers. A resident's feet should be washed during baths or showers, and if CNAs identify any concerning areas, they should document their findings and communicate them to the nurse. If the resident had been provided with baths or showers on a routine basis, it may have been possible to prevent the resident's newly identified wounds. Residents should be bathed or showered twice a week and as needed. 2. Review of Resident #37's significant change MDS, dated [DATE], showed: -admission date of [DATE]; -Two (+) persons required for bed mobility; -One person physical assistance required for transfers, dressing, toilet use and personal hygiene; -Functional limitations in range of motion for both upper and lower extremities; -Mobility devices: Wheelchair; -Indwelling urinary catheter (a tube inserted into the bladder to continuously drain urine into a collection bag); -[MEDICAL CONDITION] (surgical opening into the lower abdomen that collects bowel movement into a collection bag); -[DIAGNOSES REDACTED]. -Risk of pressure ulcer: Yes; -Unhealed pressure ulcer: Yes; -Number of Stage II pressure ulcers: None; -Number of 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 the tissue loss. (MONTH) include undermining and tunneling.): 3; -Number of Stage IV pressure ulcers (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.): 1; -Unstageable pressure ulcers: None; -Unstageable - Deep tissue injury: Suspected deep tissue injury in evolution: None. Review of the resident's Braden Scale (an assessment tool used to determine a resident's pressure ulcer risk), dated 5/13/19, showed a score of 14, or moderate risk. Review of the resident's admission and discharge MDS records, showed the resident was admitted to an acute care hospital on [DATE]. Review of the resident's hospital admission treatment orders, dated 5/13/19, showed: -Start 5/15/19: Venelex (an ointment that is used to treat skin wounds, bed sores, diabetic skin ulcers, and other skin conditions resulting from decreased blood flow) apply two times (BID) daily to right medial (middle) heel. (MONTH) cover with foam dressing; -For deep tissue pressure injury, persistent non-blanchable deep red, maroon or purple discoloration or blood filled blister. Review of the hospital discharge orders, printed on 5/18/19 at 12:21 P.M., showed readmission orders [REDACTED]. Review of the resident's admission and discharge MDS records, showed the resident returned from the hospital on [DATE]. Review of the resident's admission/readmission skin assessment, completed by the nurse, dated 5/18/19 at 7:25 P.M., showed no pressure ulcers identified, including the right medial heel. Review of the resident's TAR, dated 5/1/19 through 5/31/19, showed from 5/18/19 through 5/20/19, no order for Ventalex or any treatment to the right medial heel. Review of the resident's health status note, dated 5/20/19 at 8:08 A.M. and recorded as a late entry for 3-11 shift on 5/19/19, showed: -readmitted with [DIAGNOSES REDACTED]. -Open wound to coccyx area (between the small of the back and upper buttocks). Need physician to call back to verify wound orders to apply [DEVICE] (apply's intermittent suction to remove wound drainage); -No documentation regarding the right medial heel. Review of the resident's TAR, dated 5/1/19 through 5/31/19, showed from 5/21/19 through 5/22/19, no order for Ventalex or any treatment to the right medial heel. Review of the resident's nutrition/dietary note, dated 5/22/19 at 2:52 P.M., showed the resident was readmitted on [DATE], with chronic pressure ulcers: sacrum (coccyx) Stage IV, left ischium (area between the lower buttock and upper thigh) Stage III, right ischium Stage III and unstageable right heel. Review of the resident's TAR, dated 5/1/19 through 5/31/19, showed from 5/23/19 through 5/24/19, no order for Ventalex or any treatment to the right medial heel. Review of the facility pressure ulcer report, dated 5/24/19, showed the resident's pressure ulcers included the following: -Date admitted with: 5/18/19; -Location: Right heel; -Type: Unstageable; -Status: New; -Measurements: 2.8 cm by 2.0 cm; -The report did not show a treatment order. Review of the resident's TAR, dated 5/1/19 through 5/31/19, showed from 5/25/19 through 5/26/19, no order for Ventalex or any treatment to the right medial heel. Review of the resident's nurse's progress note, dated 5/26/19 at 8:27 P.M. and completed by the facility wound nurse, showed documentation regarding the resident's pressure ulcer on the sacral region, but no documentation regarding the resident's right medial heel. Review of the resident's TAR, dated 5/1/19 through 5/31/19, showed from 5/27/19 through 5/29/19, no order for Ventalex or any treatment to the right medial heel. Review of the resident's nutrition dietary note, dated 5/29/19 at 3:48 P.M., showed documentation regarding the resident's pressure ulcers, including the unstageable right heel. Review of the resident's TAR, dated 5/1/19 through 5/31/19, showed from 5/30/19 through 5/31/19, no order for Ventalex or any treatment to the right medial heel. Review of the facility pressure ulcer report, dated 5/31/19, showed no documentation regarding the resident's right medial heel. Review of the resident's TAR, dated 6/1/19 through 6/30/19, showed from 6/1/19 through 6/7/19, no order for Ventalex or any treatment to the right medial heel. Review of the facility pressure ulcer report, dated 6/7/19, showed no documentation regarding the resident's right medical heel. Review of the resident's TAR, dated 6/1/19 through 6/30/19, showed: -6/8/19 through 6/12/19: No order for Ventalex or any treatment to the right medial heel; -6/13/19: An order to cover with ABD (a dry dressing pad) every day for closed blister. The order did not show where the blister was located.; -Staff failed to initial the treatment (an indication the treatment was completed) had been completed on 6/20, 6/22, 6/23, 6/26, 6/27 and 6/29/19. Review of the facility pressure ulcer report, dated 6/14/19, showed no documentation regarding the resident's right medial heel. Review of the facility non-pressure ulcer report, dated 6/14/19, showed: -Date acquired: 6/13/19; -Type: Blank; -Location: Heel; -Status: New; -Measurements: sites. Review of the facility pressure ulcer report, dated 6/21/19, showed no documentation regarding the resident's right heel. Review of the resident's non-pressure ulcer report, dated 6/21/19, showed: -Date acquired 6/13/19; -Type: Blank; -Location: Heel; -Status: New; -Measurements: Blank; -The report did not show a treatment order. Review of the facility pressure ulcer report, dated 6/28/19, showed: -Date acquired: 6/13/19; -Type: Stage II; -Status: Open; -Measurements: 1.5 cm by 1.3 cm by 1.0 cm Review of the resident's TAR, dated 7/1/19 through 7/31/19, showed: -6/13/19: An order to cover with ABD every day for closed blister. The order did not show where the blister was located.; -Staff failed to initial the treatment had been completed on 7/1 and 7/2/19; -7/2/19: an order for [REDACTED].>-Staff initialed the first treatment to the right heel on 7/3/19. Review of the resident's progress note, dated 7/2/19 at 9:42 A.M. and completed by the wound nurse, showed he/she assessed a deep tissue injury to right heel, noted hard skin started peeling off leaving red open area 1.5 cm by 1.3 cm by 0.1 cm. No eschar or slough tissue noted. New order for xeroform and foam dressing every three days. Resident encouraged to wear prevalon boots (protective boots) instead of heel protectors. Review of the facility pressure ulcer report, dated 7/5/19, showed: -Date acquired: 6/13/19; -Type: Stage II; -Location: Right heel; -Status: Open; -Measurements: 1.0 cm by 0.7 cm by 0.2 cm. Review of a wound evaluation and management summary, dated 7/12/19 and completed by a wound care company physician at the facility, showed: -Site 6: Unstageable (due to necrosis) of the right medial heel - initial evaluation; -Etiology: Pressure; -Wound size: 0.9 cm by 0.8 cm by 0.1 cm; -Thick adherent devitalized necrotic tissue: 100%; -Procedure Note: This wound was cleansed with normal saline and and anesthesia was achieved using topical [MEDICATION NAME] (local anesthetic) then 0.72 cm of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Review of the facility pressure ulcer report, dated 7/12/19, showed: -Date acquired: 6/13/19; -Type: Unstageable; -Location: Right heel; -Status: Improving; -Measurements: 0.9 cm by 0.8 cm by 0.1 cm. Observation on 7/18/19 at 8:56 A.M., showed the resident lay in bed on a LAL mattress. The LAL unit (controls and settings for the LAL mattress) hung on the foot of the bed. The LAL unit had no lights on the unit (an indication the LAL is not functioning). At 12:17 P.M., there had been no change on the LAL unit and the resident remained in bed. The surveyor asked CNA Q, assigned to take care of the resident, to step in and evaluate the LAL unit. The CNA said he/she had not noticed the LAL unit lights not being on when he/she was in the room earlier. Nurse R, in charge of the resident, entered the room and determined the plug in for the LAL unit was not all the way in the electrical outlet. He/she plugged the cord back in and the LAL unit lit up, indicating it was functioning again. Nurse R told CNA Q if the LAL unit did not have lights on it, it was not functioning properly and needed to be checked. Observation on 7/23/19 at 7:37 A.M., showed the resident lay in bed. The DON completed the resident's treatment to the right medial heel. The pressure ulcer was open, red and measured 0.9 cm by 0.6 cm by 0.2 cm. During an interview on 7/22/19 10:59 A.M., the DON said the admitting nurse on 5/18/19 should have identified the pressure ulcer on the right medial heel and initiated the treatment from the hospital. She did not know why that had not been done. The wound nurse was out of the facility and was unavailable for an interview. She reviewed the resident's medical record and could not find any measurements or a treatment prior to 6/13/19. She called the wound care nurse who said the treatment that began on 6/13/19, and was for the ABD pad for the right medial heel. The nurses complete weekly skin assessments and she did not know why a treatment was not started before 6/13/19. She reviewed the missing initials on the (MONTH) and (MONTH) 2019 TARs and said if the treatment did not have initials, the treatments were not done. Observation on 7/23/19 at 7:37 A.M., showed the resident lay in bed. The DON completed the resident's treatment to the right medial heel. The pressure ulcer was open, red and measured 0.9 cm by 0.6 cm by 0.2 cm. 3. During an interview on 7/19/19 at 12:50 P.M., the DON said nursing staff should complete skin assessments accurately. If a pressure ulcer/wound is observed, the nurse should accurately document their findings and notify the physician to obtain orders for treatment. Nurses should not apply dressings to wounds, unless they have an order from the physician. When a resident is referred to the wound nurse, the wound nurse should complete a full skin assessment on the resident. 4. During an interview on 7/24/19 at 10:18 A.M., the Medical Director's Nurse Practitioner said staff should report new pressure ulcers/wounds to the physician, as soon as they are observed. Once treatment orders are obtained, nursing staff should follow the physicians's orders. For residents identified as being at risk for developing pressure ulcers, the facility should implement interventions, such as heel protecting boots and pressure-relieving equipment. At-risk residents and residents with identified pressure ulcers should be turned and repositioned every two hours. CNAs should wash the resident's feet during showers, and notify the nurse if they observe any skin issues. 5. Review of the facility's Pressure Ulcer/Injury Prevention and Management policy, dated 11/27/18, showed: -A skin assessment should be performed weekly by a licensed nurse; -Measures to maintain and improve the patient's tissue tolerance to pressure are implemented in the plan of care: -Skin inspections with particular attention to bony prominences; -Skin cleansing with appropriate cleanser at the time of soiling and at routine intervals; -Treat dry skin with moisturizers; -Minimize skin exposure to incontinence using devices (i.e., briefs) and skin barriers; -Minimize injury due to shear and friction through proper positioning, transfers, and turning schedules; -Measures to protect the patient against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: -Reposition at least every 2-4 hours as consistent with overall patient goal and medical condition; -Utilize positioning devices to keep bony prominences from direct contact; -Ensure proper body alignment when side-lying; -Heel protection/suspension should be implemented while the patient is in bed.

Based on observation, interview, and record review, facility staff failed to assess, monitor, and develop interventions to prevent one sampled resident (Resident #278) out of 23 residents, with a history of falls and positioning his/her legs off the bed, from falling, failed to ensure the resident's low air loss mattress was set at the appropriate setting and the mattress fit the bed according to manufacturer guidelines. Additionally, facility staff failed to transfer two sampled residents (Resident #4, and #278) safely and effectively. The facility census was 80. 1. Facility fall management policy, revised 11/2016, showed the facility will implement a fall management system that results in reducing patient falls by: -All patients will be assessed for fall indicators upon admission, readmission, quarterly, change in condition and with any fall event; -An individualized fall management care plan will be developed and initiated upon all patient admissions and readmissions; -The interdisciplinary team (IDT) will review and revise, if indicated, all patients' fall management care plans upon the completion of each comprehensive, significant change and quarterly MDS, upon a fall event and as needed thereafter. Care plan revisions will be made at this time as indicated; -Fall management training will be provided to all associates upon hire, annually and as indicated by Fall Management Performance Improvement Plans (PIPs); -Patients and/or family members will receive education on the patient's fall management care plan and provided opportunity for feedback; -Accurate and thorough assessment of the patient is fundamental in determining indicators for potential falls; -Reporting tools that aggregate and collect patient assessment and other information of fall indicators will be utilized in the facility's Fall Management Quality Assurance Performance Improvement activities and are therefore not considered part of the patient's medical record. 2. Review of Resident #278's face sheet showed the resident was originally admitted on [DATE]. Further review showed the resident had a [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/14/18, showed staff assessed the resident as: -Severe cognitive impairment; -No behaviors; -Required extensive assistance of one staff with bed mobility, toilet use, eating, and personal hygiene; -Required limited assistance of one staff with dressing; -Dependent on one staff for bathing; -Frequently incontinent of bladder and always incontinent of bowel; -[DIAGNOSES REDACTED]. -Had a fall in the last month prior to admission; -Had no falls since last assessment dated [DATE]; -Had an unstagable pressure ulcer and a lesion on the foot; and -Received antidepressants three out of the last seven days prior to the assessment. Review of the resident's care plan, last updated on 8/30/18, showed the resident has activity of daily living (ADL) self-care deficits and is at risk for falls related to weakness, physical limitations, incontinence, and alteration in mobility and safety. Review showed staff were directed to do the following: -Provide the amount of assistance/supervision that is needed; -Report changes in ADL self performance to the nurse; -Side rail(s) as an enabler (1/2 rails); -Fall risk assessment; -Provide environmental adaptation such as call light within reach and area free of clutter; -Remind the resident and reinforce safety awareness by locking brakes on bed and chair before transferring, appropriate footwear, and educate/remind resident to request assistance prior to ambulation; -Report falls to physician and responsible party; -Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to coccyx, provide treatment as ordered and has a low air loss mattress; -At increased risk for falls related to self reports of alcohol consumption while on leave of absence (undated); -3/21/18 had fall on floor, educate on waiting for assistance; -5/6/18 had a fall with no injury, monitor and redirect, assist with transfers, remind to lock wheelchair, call light within reach, and frequent monitoring required to monitor safe environment; -6/3/18 had a fall in television room, slid off of couch without injury; -8/23/18 bed in low position always, resident tries to get up without assistance, ensure call light is within reach, remind to call for help when needed; -8/30/18 new bed, slid off the bed, ensure bed is as low as possible and call light is within reach. Review of the resident's hospital records, dated 8/15/18-8/19/18, showed the physician documented the resident was admitted for altered mental status, [MEDICAL CONDITION]-fibrillation (A-Fib)(irregular heart beat), [MEDICAL CONDITION] (kidney infection),[MEDICAL CONDITION] (life-threatening complication of an infection), metabolic [MEDICAL CONDITION] (abnormalities of chemicals that adversely affect the brain function), dementia, and [MEDICAL CONDITION]. Review of the hospital records showed a positive urine culture for [MEDICATION NAME] resistant [MEDICATION NAME] (VRE) and a bone scan on 8/17/18 positive for [MEDICAL CONDITION] metastasis. The resident presented with a fever of 102 degrees Fahrenheit. Review of the resident's hospital discharge orders, dated 8/19/18, showed the physician ordered the resident to take [MEDICATION NAME] (antibiotic) 875-125 milligrams (mg) by mouth every 12 hours for 10 days, and [MEDICATION NAME] (anticonvulsant) 500 mg twice daily. Review of the resident's physician order [REDACTED]. Review of the resident's telephone order sheet (TOS), dated (MONTH) (YEAR), showed staff received the following orders from the physician: -8/21/18 discontinue [MEDICATION NAME] after four days; -8/25/18 send the resident to the emergency room (ER); -8/27/18 obtain an x-ray of the resident's right lower extremity; -8/27/18 low air loss mattress; -8/30/18 verbal order for resident to receive physical therapy (PT), occupational therapy (OT), and speech therapy (ST) evaluation and treatment; -8/30/18 OT clarification: resident to be seen five times per week for 12 weeks including there-ex, therapeutic activities and wheelchair management. Review of the resident's treatment administration record (TAR), dated (MONTH) (YEAR), showed the resident is to have a low air loss mattress. Review showed no documentation to show what setting the mattress was to be on for the resident's weight and firmness. Review of the resident's nursing notes, showed staff documented the following: -3/21/18 Resident was found on the floor beside his/her bed, had increased lower extremity weakness. Resident reported sliding from the bed, found on his/her knees, and when he/she transferred back to bed could not bear weight; -3/22/18 Resident found on floor at approximately 3:00 P.M. with feces on the floor. Resident had no complaints of pain or discomfort and placed at nursing station for further evaluation; -4/22/18 Resident is alert and oriented to person, place, and time, on follow-up for fall, range of motion (ROM) within normal limits (WNL), no injuries, voiced general discomforts, educated to use call light to prevent further falls; -5/6/18 Resident is alert and oriented, able to transfer self in wheelchair, needs assistance with hygiene care. Resident found sitting on the floor in his/her room. The resident reported he/she was trying to sit in the wheelchair and sat on the floor. ROM to all extremities, no injury, and denies pain. Resident assisted to bed with call light within reach; -5/14/18 Resident up in wheel chair resting in room with some confusion. Therapy assisted into wheelchair but once up CNA and nurse had difficulties. Resident has decreased strength and is unable to stand. Sit to stand mechanical lift is to be used for transfers; -5/26/18 Resident found sitting on the floor diagonal to the wheelchair that is behind the resident. The resident does not appear to have hit his/her head. Resident reported trying to get to bed. Call light was in reach and the CNA and nurse used a gait belt to transfer to bed; -5/28/18 Resident is alert and oriented to name, requires total care including turning/repositioning in bed. Call light is within reach. Monitor resident for kicking his/her legs out of the bed, and keep bed in the lowest position; -6/1/18 Resident continues to be non-compliant with transfers. Refused to allow CNA to assist to wheelchair this morning and then was found 45 minutes later on the floor sitting on bottom with legs in front of him/her. Non skid footwear was in place to both feet. The resident stated he/she thought he/she could do it by him/herself. The resident requires assistance of one to two staff; -6/3/18 Resident found sitting on the floor in front of his/her wheelchair. Resident stated that he/she lowered him/herself from his/her wheelchair to the floor. No injuries noted, will continue to monitor, recommend frequent room checks or remove wheelchair to discourage unassisted transfers to the wheelchair; -6/4/18 Resident on the floor, slid off the couch in the television room. Staff assisted resident into wheelchair and then into bed. Call light is within reach, bed in lowest position, and no injuries observed; -6/5/18 Resident lying in bed with bed in low position, locked, and a low air loss mattress. Requires assistance of one to two staff with ADLs and transfers; -6/7/18 Resident transferred to ER related to being lethargic and unable to bear weight; -6/11/18 Resident returned to the facility with [DIAGNOSES REDACTED]. The resident is able to express wants and needs, but has difficulty following directions at this time. Is on antibiotic for VRE; -6/12/18 Maintenance informed about low air loss mattress low pressure. Maintenance stated that the hose needs to be fixed and reconnected, awaiting completion; -6/22/18 Resident found on floor again next to bed. The resident stated that the bed was too low. Range of Motion (ROM) WNL, neuro checks completed and resident denied hitting head. Recommendation of frequent rounds, bed alarm or keep up in the chair next to nursing station. The resident has been given teaching many times, but continues to try and perform ADLs, and resident is very weak in lower extremities; -7/27/18 Resident found on the floor by staff. Resident stated that he/she slid out of the bed trying to look for his/her book. Bed is in the lowest position and call light is within reach. No injuries observed and resident denies pain. Reminded resident to use call light for assistance; -8/15/18 Resident sent to ER because he/she is unable to follow commands, very confused, and a temp of 102 degrees; -8/19/18 Resident returned to the facility, is dependent on staff for ADLs and transfers, bed lowered to floor, call light within reach. Will continue to monitor; -8/25/18 Resident was at nurses station and started hitting head against the wall, with his/her eyes rolling back, and shaking, resident sent to ER; -8/25/18 Resident found on the floor before breakfast in front of his/her wheelchair on the right side of nurses station. Resident was assisted with two staff back to the wheelchair. The resident complained of pain to the right lower extremity. The resident's right foot is swollen and no redness/warmth was observed. Physician notified and received order for an x-ray to the right lower extremity; -8/25/18 Resident returned from hospital with new [DIAGNOSES REDACTED]. Received a new order for antibiotic, potassium, and [MEDICATION NAME]; -8/30/18 Resident found sitting on the floor at the side of the bed. Resident stated he/she slid off of the bed. No injuries were observed and message left for physician. The bed was placed as low as it would go. Review of the resident's medical record on 8/28/18, showed the resident did not have an assessment or consent for the use of bed rails. Review of the resident's medical record on 8/31/18, showed a blank bed rail assessment in the resident's chart without a signature of consent. Review of the Gendon Bariatric Bed manufacturer instructions, undated, showed the mattress should be sufficiently wide enough to prevent any part of the patient's body from falling between the side rail and mattress. Observation on 8/27/18 at 1:55 P.M., showed the resident lay in bed on his/her back with his/her knees bent and feet pressed against the foot board. Low air loss mattress inflated and set on level 3. Observation showed the resident's call light lay on the floor at the head of the bed. Observation on 8/27/18 at 5:30 P.M., showed the resident lay in his/her bed uncovered, with his/her legs off the side of the bed. Further observation showed the resident was visible from the hallway as staff and visitors walked by the resident's room. Observation on 8/28/18 at 9:07 A.M., showed the resident sat up in bed eating breakfast, air mattress on and call light on floor at the head of the bed. Observation showed the resident's bed had 1/2 bed rails with a 2-3 inch opening between the mattress and bed rail, on each side. Observation on 8/28/18 at 3:58 P.M., showed the resident resting in bed with 1/2 bed rails on both sides and the mattress about 2-3 inches from the siderails on both of the sides. Observation on 8/29/18 at 10:24 A.M., showed the resident attempted to remove the pressure relieving boots. Observation showed the head of the bed elevated, lift sheet and resident slid down from head of the bed with the resident unable to straighten his/her legs. The resident lay on his/her right side near the edge of the bed, kicking his/her legs off the side of the bed. Side rails on both sides continue to have a 2-3 inch gap between the mattress and the bed rail and low air loss mattress set at a level 3. Observation on 8/29/18 at 12:33 P.M., showed the resident with his/her head of the bed elevated and feeding him/herself lunch. The low air loss mattress inflated to a level 3 on firmness and both 1/2 side rails up with the mattress 2-3 inches away from the bed rails on each side. Observation on 8/29/18 at 12:27 P.M., showed the resident lay in bed pulling at the sheets and attempting to remove pressure relieving boots. Observation showed the resident pulling at the sheet and both legs off the side of the bed with both 1/2 side rails up and the mattress 2-3 inches away from the bed rails on each side. Observation on 8/29/18 at 2:06 P.M., showed CNA H and CNA I position the sit to stand lift facing the resident, positioned the resdient's feet on the lift with knees positioned against knee pads. The CNAs placed the sling around the resident's torso and attached the sling end loops to the machine. CNA I began lifting the resident with the lift. Observation showed the resident remained in a sitting like position with knees bent and arms extended above his/her head with the sling bunched up under his/her arms. Staff asked the resident to stand up and the resident was unable to bear weight. CNA H and CNA I did not lower the resident back to the bed. Observation showed CNA H began turning the lift toward the chair while CNA I pushed on the resident's bottom. The CNAs lowered the resident into the wheelchair while saying the resident needs to be transferred with a hoyer lift (mechanical lift). CNA H said they are changing the resident's bed to a bariatric bed, because he/she is too long for his/her current bed. Observation on 8/29/18 at 2:15 P.M., showed housekeeping staff push the resident's bed out into hall. Observation showed housekeeping staff place the resident's mattress from his/her bed onto the bariatric frame. Housekeeping staff moved the bariatric bed into the resident's room, placed the headboard, footboard, new 1/2 bed rails, and air mattress overlay machine for the end of the bed. Observation showed housekeeping staff attached the air mattress to the pump and turn it on. Housekeeping staff attempted to place a positioning wedge at the foot of bed to fill the gap. Observation showed the wedge fell through the gap twice before staff layed it partially on the mattress. Housekeeping staff left the room. Observation showed the resident's low air loss mattress was set on level 5, the highest setting, indicating the mattress was fully inflated at the firmest level and a three to four inch gap between the resident's left side bed rail and the mattress. Observation on 8/29/18 at 2:38 P.M., showed CNA H propelled the resident from the hall into his/her room and placed the resident's feet on the sit to stand lift. Certified occupational therapy assistant (COTA) A and CNA H placed a gait belt around the resident's chest and then the sling to the the lift, placing the loops on the end of the sling over the knobs on the lift. The CNA instructed the resident to hold onto the lift, while placing the resident's hands onto the bar of the lift. The CNA lifted the resident with the sit to stand lift, while COTA A held onto the gait belt. Observation showed the resident's knees remained bent in a sitting position and his/her arms fully extended above his/her head with the sling bunching under the resident's arms and the resident was unable to bear weight and assist with standing. The CNA and COTA transferred the resident to his/her bed, while holding onto his/her pants and gait belt while positioning the lift feet under the bed. Observation showed three to four inches between the bed rail on the resident's left side and the mattress. Observation on 8/30/18 at 2:39 A.M., showed the resident lay on his/her left side with one leg off the left side of the bed. Observation showed both 1/2 side rails up with about four inches between the mattress and bed rail on the resident's left side of the bed and a fall mat on the resident's right side of the bed. The resident's roommate moaned out and his/her tube feeding pump beeped. Observation on 8/30/18 at 2:45 A.M., showed the resident's roommate continued to moan out and his/her tube feeding pump beeped. Observation showed Resident #278 had both legs off the left side of the bed and the sheet pulled away. The resident's call light was positioned above the resident's head on the mattress. Observation on 8/30/18 at 3:02 A.M., showed LPN E peek into the room, but did not go in to reposition the resident or fix the resident's roommate's tube feeding machine. Further observation showed CNA DD walked down the hall to another resident's room. Observation on 8/30/18 at 3:26 A.M., showed CNA A entered the resident's room and the resident was on the floor between his/her bed and his/her roommate's bed. The CNA got the nurse and re-entered the resident's room. Observation on 8/30/18 at 3:28 A.M., showed CNA A and LPN E entered the resident's room. Observation showed the resident's air mattress set on level 5, fully inflated. The resident lay on his/her back between his/her bed and his/her roommate's bed. The resident's head was positioned on his/her roommate's small wedge at the foot of the bed, with the call light cord wrapped around the resident's lower legs and the blankets and sheets wrapped around the resident's torso. A fall mat was positioned on the other side of the bed, but not on the resident's left side of the bed. The LPN asked the resident if he/she could sit up and the resident said yes. Observation showed the LPN pulled on the side of the resident's arm and torso, but the resident did not move. The LPN told CNA A to go and get some other staff to help get the resident back to bed. The resident said, I slid out of bed. The LPN and CNA C both placed an arm under the resident's arms and turned the resident to a sitting position on the floor with his/her back resting against his/her roommate's bed and feet under his/her bed. The resident moaned out while saying ough as staff sat the resident up. The LPN asked the resident if he/she was okay after sitting the resident up and the resident said yes. The LPN did not complete ROM or ask the resident if he/she hit his/her head to ensure the resdient did not have any pain or injuries prior to moving the resident. CNA C, CNA K, and CNA CC placed a gait belt around the resident's torso. The three CNAs and LPN unsuccessfully attempted to lift the resident to a standing position and into his/her wheelchair with the gait belt and pulling on his/her brief three times. Observation showed the resident's legs stayed out in front of the resident and the resident unable to assist the staff. The resident said loudly, No, that's not going to work. The CNA's and LPN lowered the resident back down with the resident's back scraping down the side of his/her roommates's bed frame and hitting his/her foot on the resident's bedframe. The LPN asked the CNA's if the bed would lower down any further and the CNA said this new bed will not go down as far as the other bed would. Observation showed the staff move the resident's bed closer to the door away from the resident and position his/her wheelchair closer to the resident. CNA B, CNA C, CNA K, CNA CC, and LPN E attempted to lift the resident with the gait belt and pulling on the resident's brief four more times with the resident's brief ripping and wedging between the resident's gluteal crease and staff lowering the resident to the floor each time. On the fifth attempt, observation showed the CNA's and LPN held onto the gait belt and brief, and lifted on the resident's buttocks to get him/her in the wheelchair. The CNAs and LPN positioned the wheel chair close to the bed, and with the gait belt and holding onto the resident's ripped brief stood the resident up and transferred him/her to the bed. Observation showed the resident was unable to bear weight and assist staff and staff started to lower the resident down towards the ground when CNA CC and the LPN lifted under the resident's upper thighs, barely getting the resident onto the left side of the bed. Staff positioned the resident on his/her right side and covered up the resident. CNA C asked the LPN where to place the single fall mat. The LPN said he/she was on the other side earlier when he/she fell . The CNA placed the fall mat on the right side of the bed and placed the call light by the resident's head of the bed. CNA B raised the head and foot of the bed 30 to 40 degrees before leaving the room. The CNA's and LPN did not position the resident at the head of the bed and the resident told the staff that he/she could not straighten his/her legs, because they were pressed against the footboard. The staff did not check the settings of the low air loss mattress prior to leaving the resident's room. During an interview at the same time, LPN E said the resident's bed was switched out earlier in the day and is not a good fit for the resident. The LPN said the resident slid out of it twice tonight. Observation on 8/30/18 at 4:07 A.M., showed the resident's legs toward the edge of the bed on the right side. Observation showed CNA B lower the foot of the bed and the resident was able to straighten out his/her legs. The resident's 1/2 side rail and mattress remained about 4 inches from each other on the resident's left side. Observation on 8/30/18 at 4:14 A.M., showed LPN E call the physician and notify him/her that the resident slid off of the bed twice and that there were no injuries either time. Observation on 8/30/18 at 4:30 A.M. showed the low air loss mattress as an Easy Air Pressure Guard. The mattress was shorter than the frame and there was approximately five inches between the mattress and the foot of the bed. The mattress was observed to have slid to the right side of the frame causing a four inch gap between the bed rails and the mattress on the left side of the bed. Observation on 8/30/18 at 5:12 A.M., showed the resident lay on his/her right side toward the edge of the mattress holding onto the side rail. The low air loss mattress remained fully inflated to a level 5 firmness. During an interview on 8/30/18 at 5:19 A.M., CNA A said the resident slid off the bed during transitioning from evening to night shift and then again this morning. When staff arrive to work, the CNA's conduct rounds about every two hours at 1 A.M., 3 A.M., and 5 A.M. When the resident places his/her feet out of the bed staff should assist the resident in putting them back in bed or ask the resident to put them back if he/she is able to. He/she was conducting rounds when he/she heard the resident's roommate moaning. He/she entered the room, saw the resident on the floor and went to get the nurse. Review of the nurses 24 hour report of resident's conditions, dated 8/30/18, showed the nurse documented the resident was found sitting on the floor with no injuries. The resident said he/she slid off the bed. Observation on 8/30/18 at 5:24 A.M., showed the resident remained on his/her right side, with a four inch gap between the left bed rail and the mattress, and the air mattress set at level 5, fully inflated. During an interview on 8/30/18 at 5:25 A.M., LPN E said the resident fell twice tonight, the first time was when night shift staff first came in. The LPN said he/she did not know anything about the settings for the air mattress and what the resident's should be set at. He/she is unsure who is responsible for adjusting the settings. When the resident is in the bed, the bed is supposed to be in its lowest position, fall mats on the side of the bed, and call light in place. The resident frequently calls out and throws his/her legs over the side of the bed. The resident can have his/her door closed, but it is usually open. If staff find a resident on the floor the nurse is to assess the resident, ask if they are hurt, and get them off of the floor. Staff should take the resident's vital signs and complete IFU (incident report for falls) in the software, notify the physician and director of nursing (DON) and send to the ER if they are hurt or provide a treatment if they received a wound or injury. LPN E said he/she usually has the resident move his/her extremities, to check for ROM. The LPN said he/she had the resident move his/her extremities with the first fall last night and didn't ask him/her to do so with the second fall. The resident normally transfers with two staff. The resident is different and more confused. He/she has become more dependent on staff, and he/she is heavy with not being able to bear weight. Trying to get the resident on a hoyer lift pad would have been difficult. At the beginning of the night, he/she was bearing more weight. During an interview on 8/30/18 at 5:38 AM. CNA C said he/she helped transfer the resident back to bed earlier in the night when he/she fell . The resident was able to assist at that time and he/she was able to stand with assistance. The resident was on the side by the bathroom when he/she fell at the change of shift. When a resident is found on the floor, the CNA's are expected to notify the nurse. The CNA should make the resident comfortable until the nurse can assess him/her prior to getting the resident off of the floor. The resident is always in bed on night shift. The CNA was told in orientation to not lift residents off of the floor after a fall. Staff are expected to use the hoyer lift to get them up. The CNA said he/she suggested using the hoyer with the resident, but the other staff said the hoyer wouldn't fit. The CNA said he/she even suggested moving the bed out of the way to get the hoyer lift in the room and they said no. The staff should remind residents about the call light. He/she said he/she only used the gait belt to assist with transferring the resident. The CNA said he/she is unsure how to adjust the airflow or what the setting should be on for the air mattress. He/she is unsure who is responsible for ensuring the airlflow is at the right setting. He/she has not received training on the air mattress settings. During an interview on 8/30/18 at 9:41 A.M., the Maintenance Director said that the facility is to get measurements from the bed frame, then fit the air bed to the frame. The Maintenance Director said he did not have the users manual for the bed or the air mattress. The Maintenance Director said nursing staff changed out the mattress. During an interview on 8/30/18 at 10:07 A.M., the DON said during the last week, the resident acted like he/she wanted to get up so staff were getting him/her up in the wheelchair. Staff have been told to do rounds and check on the resident frequently. If staff observe the resident throwing his/her legs off of the bed, staff are expected to ask the resident why he/she is trying to get up. If the resident is up in the wheelchair staff should place him/her in a field of vision. Since the resident has had frequent falls, staff have been instructed to ensure the bed is in the lowest position and they implemented fall mats last Saturday, the same day the resident began having [MEDICAL CONDITION] with no previous history or diagnosis. The resident [MEDICAL CONDITION] with metastasis to the bone and they are thinking that [MEDICAL CONDITION] may be in the brain now. On Monday or Tuesday, staff reported the resident would not stay in the bed so they decided the resident needed a bigger bed. The resident was a little bit too long for the other bed. The DON said he/she was not aware that staff put the resident's previous mattress on the new bed frame and unaware of the changes to the air mattress pump/machine. The DON said he/she guessed that whoever delivered the bed sets up the mattress. The wound nurse should know the settings, but the DON has never looked at the setting. He/she would go by the manufacturer's recommendations. Housekeeping staff should not plug in or set up the level of firmness on the air mattress settings. The DON said they already started educating on the sit to stand lift transfer yesterday. If a CNA notices a change in the residents transfer status or a decline, they need to report it to the nurse. The nurse should assess the resident to see if transfer status changed. If the resident is on the floor, the nurse should complete ROM and if the resident has pain, assess to see if they could have bumped their head. The assessment should be done before they are moved off of the floor. ROM assessment should have been completed even if it was completed during the previous fall, because the resident could have still injured him/herself. The resident's door should be open because staff need to see if the resident's legs are off of the bed. The resident should have a mat on both sides of the bed. The DON said he/she doesn't know why the resident did not have fall mats on the floor prior to the one on the right side of the resident's bed after the resident's first fall last night. During an interview on 8/30/18 at 12:20 P.M., the Medical Director said the resident's bed should have been in the the lowest position, because he/she wiggles out and was recently diagnosed with [REDACTED]. If the resident is unable to bear weight, staff should use the hoyer lift to transfer the resident from the floor to the bed. During an interview on 8/30/18 at 4:07 P.M., the bed frame manufacturer representative said a two inch gap on each side is too much. The sides should be flush with the bed rails, and two inches would be okay at the head and foot of the bed only. 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 low (TRUNCATED)

Based on observation, interview and record review, facility staff failed to provide treatment and services to prevent the development of and/or promote the healing of pressure ulcers. Facility staff failed to implement interventions, complete treatments as ordered, and assess and monitor pressure ulcers for eight residents (Residents #11, #14, #18, #19, #53, #278, #435, and #436) with facility acquired pressure ulcers. The facility census was 80. Review of the Pressure Ulcer/Injury Prevention Policy, dated 11/20/17, directed staff on the following: -A comprehensive skin assessment on admission and re-admission to center may identify pre-existing signs of possible deep tissue damage already present; -A risk assessment tool, Braden Scale (determines the resident's risk for pressure ulcer development), score is documented on the tool and placed in the patients's medical record; -A skin assessment should be performed weekly by a licensed nurse; -Measures to maintain and improve the patient's tissue tolerance to pressure are implemented in the plan of care: -Skin inspections with particular attention to bony prominences; -Skin cleansing with appropriate cleanser at the time of soiling and at routine intervals; -Treat dry skin with moisturizers; -Minimize skin exposure to incontinence using devices and skin barriers; -Minimize injury due to shear and friction through proper positioning, transfers and turning schedules; -Encourage oral food and fluid intake; -Improve patient's mobility and activity when potential exists. -Measures to protect the patient against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: -Reposition at least every 2-4 hours as consistent with overall patient goal and medical condition; -Utilize positioning devices to keep bony prominences from direct contact; -Ensure proper body alignment when side-lying; -Heel protection/suspension should be implemented while the patient is in bed; -Maintain head of bed at the lowest degree of elevation consistent with the medical condition; -Use lift devices to move patients in the bed; -A pressure reduction mattress replacement is placed under the patient; -When positioned in a wheelchair, the patient is to be placed on a pressure-reduction device and repositioned; -When positioned in a wheelchair, consideration is given to postural alignment, distribution weight, balance and stability. -Patient and significant others involved in the patient's care are educated regarding the preventive skin care plan; -When skin breakdown occurs, it requires attention and a change in the plan of care to appropriately treat the patient; -Certain risk factors have been identified that increase a patient's susceptibility to develop or impair healing of pressure ulcers. Examples include, but are not limited to: -Impaired/decreased mobility and decreased functional ability; -Co-morbid conditions, such as end stage [MEDICAL CONDITIONS] disease, diabetes mellitus, or other end of life concerns; -Drugs, such as steroids, that may affect wound healing; -Impaired diffuse or localized blood flow (for example: generalized [MEDICAL CONDITION] or l lower extremity arterial insufficiency); -Patient refusal of some aspects of care and treatment, especially in multi-system organ failure or end-of-life conditions; -Cognitive impairment; -Exposure of skin to urinary and fecal incontinence; -Under nutrition, malnutrition, and hydration deficits; -[MEDICAL CONDITION]; and -A history of a healed ulcer. 1. Review of Resident #14's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/1/18, showed the facility staff assessed the resident as follows: -Brief interview for mental status (BIMS) score of 9 (moderately cognitively impaired); -Requires extensive assistance from staff with bed mobility, transfers dressing, eating, toileting and personal hygiene; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -At risk for the development of a pressure ulcer; -Open lesion on the foot; -Application of a dressing on the feet; -Pressure reducing device on the bed. Further review showed staff assessed the resident's right medial plantar foot wound as a medical device related pressure ulcer on the MDS dated [DATE]. During an interview on 9/5/18 at 6:45 P.M., Licensed Practical Nurse (LPN) G said the wound developed from a brace to the right foot and is located in an area where there is pressure. Review of the resident's comprehensive care plan, dated 6/6/18, directed staff on the following interventions for friction and shearing to the right foot: -Complete Braden Scale quarterly and PRN (as needed); -Complete weekly skin report; -Inspect skin during bathing, especially over bony prominences; -Observe for signs and symptoms of infection or delayed healing and report to physician as needed any redness, drainage that is bloody or purulent (infection); -Refer to therapy as needed; -Report changes in skin status to physician, provide wound care as ordered, and observe effectiveness of response to treatment as ordered. Review of the resident's medical record showed staff documented a skin assessment with an open area on the right plantar foot, dated 5/21/18. Record review of the physician's orders [REDACTED].>Review of the resident's wound module for the right medial plantar (inner and bottom) foot showed staff documented the following: - 5/21/18- Date of Origin for facility acquired right medial plantar foot, measured 3.00 (centimeter) cm x 3.00 cm x 0.10 cm, serous (watery) drainage, no undermining (destruction of tissue under the skin edges) or tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), 25% [MEDICATION NAME] in the wound bed. Further review showed staff did not indicate a Stage for the wound; - 5/29/18- Staff documented the wound measured 3.00 cm x 3.00 cm x 0.10 cm with light serosanguineous (bloody) drainage, no undermining or tunneling, 40% [MEDICATION NAME] and 60% other in the wound bed. Further review showed staff did not indicate a Stage for the wound; - 6/7/18- Staff documented the wound measured 1.00 cm x 1.00 cm with no drainage, no undermining or tunneling, 40% [MEDICATION NAME] (thin tissue covering body surfaces) and 50% eschar (dead tissue) in the wound bed. Further review showed staff did not indicate a depth or a stage for the wound; - 6/20/18 (13 days since last wound assessment)-Staff documented the wound measured 0.50 cm x 0.50 cm with no drainage, no undermining or tunneling, 100 %eschar in the wound bed. Further review showed staff did not indicate a depth or a stage for the wound; - 6/27/18-Staff documented the wound measured 0.40 cm x 0.40 cm with light serosanguineous drainage, no undermining or tunneling, 100% granulation in the wound bed. Further review showed staff did not indicate a depth or a stage for the wound, - 7/13/18 (16 days since last wound assessment)-Staff documented the wound measured 2.00 cm x 2.00 cm with no drainage, no undermining or tunneling, 100% granulation in the wound bed. Further review showed staff did not indicate a depth or a stage for the wound; - 7/25/18 (12 days since last wound assessment)-Staff documented the wound measured 2.00 cm x 2.50 cm with no drainage, no undermining or tunneling, 100% granulation in the wound bed. Further review showed staff did not indicate a depth or a stage for the wound; - 7/31/18-Staff documented the wound measured 1.00 cm x 1.00 cm with no drainage, no undermining or tunneling, 100% eschar in the wound bed. Further review showed staff did not indicate a depth or a stage for the wound; - 8/27/18 (27 days since last wound assessment)-Staff documented the wound measured 1.00 cm x 0.80 cm with no drainage, no undermining or tunneling, 100% eschar in the wound bed. Further review showed staff did not indicate a depth or a stage for the wound. Review of the resident's Treatment Administration Record (TAR), dated (MONTH) (YEAR), showed staff did not provide the treatment using [MEDICATION NAME] (an antiseptic used to kill bacteria and prevent infection) to the right foot wound everyday. Review showed staff did not provide the treatments on 8/2/18, 8/11/18, 8/19/18, 8/25/18, 8/26/18, and 9/4/18. Observation on 8/31/18 at 9:45 A.M., showed LPN G entered the resident's room to provide wound care. LPN G applied gloves and removed the soiled dressing. Observation showed the wound located on the right outer foot just below the 5th toe (an area over a bony prominence). Observation showed the wound covered with hard eschar, approximate dime size with a hard callus surrounding the wound. LPN G cleansed the wound then applied [MEDICATION NAME] to the wound, covered it with gauze and secured it with roller gauze. During this time, LPN G said the resident developed a blister on his/her right lateral foot from a brace and the resident has had the wound for about two months. LPN G said staff are to provide the treatment daily and keep a pillow under the resident's right foot for pressure relief. During an interview on 9/4/18 at 3:50 P.M., the resident said she/he developed a blister from the use of a heavy black boot. Further, the resident said that the staff don't always keep her/his foot elevated at night on a pillow while in bed and staff forget to do the treatment sometimes. Observation on 9/05/18 at 9:10 A.M., showed the last time staff changed the dressing to the resident's right foot was 9/3/18. Observation showed staff hand wrote 9/3/18 directly on the dressing for the right foot wound. 2. Review of Resident #11's quarterly MDS, dated [DATE], showed the facility staff assessed the resident as follows: -BIMS 10 (moderate cognitive impairment); -Requires extensive assistance from staff with bed mobility, transfers, dressing and toileting; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -At risk for the development of a pressure ulcer; -Pressure relieving devices on the bed and chair. Review of the resident's comprehensive care plan, dated 2/27/18, showed staff updated the care plan to include pressure ulcers to the left and right heels as a problem to be addressed on the care plan. Staff updated the resident's care plan to include the following: -8/7/18-wound to left heel, Stage III (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss), treatment as ordered and heel lift boots, -8/22/18-wound to right heel, Stage III, treatment as ordered and heel lift boots. Further review showed the comprehensive care plan, updated 8/7/18, directed staff with the following interventions: -Assist to reposition and shift weight to relieve pressure; -Complete the Braden scale risk assessment quarterly and PRN; -Complete weekly skin assessments; -Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care; -Provide pressure relieving or reduction device, pressure relieving mattress and chair cushion; -Refer to therapy as needed; -Report changes to physician. Review of the resident's medical record, dated 8/7/18, showed staff identified a Stage III pressure ulcer on the resident's left heel. Further review showed the wound measured 4.6 cm x 5.00 cm, slough tissue present. Further review showed staff did not include in the wound assessment the depth of the wound. Review of the residents wound module for the left plantar calcaneus (heel) showed staff documented the following: - 8/7/18-Staff documented 8/7/18 as the date of origin, facility acquired. Further review showed staff documented the wound measured 4.6 cm x 5.00 cm, Stage III, moderate amount of serosanguineous drainage, no undermining or tunneling, 10% of slough and 90% of granulation in the wound bed. Further review showed staff did not include the depth of the wound in the assessment; - 8/14/18-Staff documented the wound measured 4.5 cm x 5.00 cm, Stage III, light amount of serosanguineous drainage, no undermining or tunneling, 5% of slough and 95% of granulation in the wound bed. Further review showed staff did not include the depth of the wound in the assessment; - 8/14/18 (Staff documented two different wound assessments for the same date)-Staff documented the wound measured 2.5 cm x 5.00 cm, Stage III, light amount of serosanguineous drainage, no undermining or tunneling, 10% of slough and 80% of granulation in the wound bed. Further review showed staff did not include the depth of the wound in the assessment. Review of the physician's orders [REDACTED]. Further review dated 8/22/18, showed the physician ordered to cleanse with normal saline then apply manuka pli to the right heel wound, cover with a dry dressing and roller gauze everyday and as needed. Review of the resident's TAR for (MONTH) (YEAR), showed staff did not provide the treatment using manuka to the left heel wound everyday as ordered by the physician. Review of the TAR showed staff did not document that the treatment was provided to the left heel on 8/11, 8/12, 8/18, 8/19 and 8/21. Review of the resident's medical record, dated 8/22/18, showed staff first identified a Stage III pressure ulcer to the resident's right heel. Further review showed the wound measured 3.0 cm x 5.00 cm, slough tissue present, full thickness, red and beefy tissue and loose skin to the edges. Staff did not include in the wound assessment the depth of the wound. Further, staff documented the wound started out as a blood blister. Review of the resident's wound module for the right plantar calcaneus (heel) showed staff documented the following: - 8/22/18-Staff documented 8/22/18 as the date of origin, facility acquired. Further review showed staff did not include an assessment of the right plantar calcaneus wound with measurements, drainage, wound bed and stage; - 8/27/18- Staff documented the right plantar calcaneus measured 3.00 cm x 5.00 cm, light serosanguineous, no tunneling or undermining, granulation 70%, slough 20% to the wound bed. Further review showed staff assessed the resident's wound as a Stage III and did not address the depth of the wound. Observation on 8/30/18 at 2:45 A.M., showed staff did not apply the heel boots while the resident was in bed. Staff placed a pillow underneath the resident's heels, but observation showed both heels lying directly on the mattress. Observation on 8/30/18 at 11:30 A.M., showed LPN G provided the treatment to the resident's heels. LPN G said the right heel wound is new and currently measured 2.5 cm x 4.7 cm. Observation showed the right heel wound bed pink, surrounding skin red and [MEDICAL CONDITION] (swollen). Observation showed the left heel wound measured 2.2 cm x 5 cm with approximately 25% of slough in the wound bed, red and [MEDICAL CONDITION]. During this time, LPN G said both pressure ulcers were facility acquired, full thickness and at a Stage III. LPN G said the staff are expected to keep the pressure relieving boots on the resident at all times. During an interview on 8/31/18 at 9:45 A.M., LPN G said she/he is the wound nurse and provides all of the treatments during the week and weekly wound assessments, but has been pulled from her/his position to perform charge nurse duties. LPN G said she/he was pulled from her/his wound treatments to perform charge nurse duties three times in the last seven days. During an interview on 9/5/18 at 6:15 P.M., LPN V said professional staff are responsible for providing the wound treatments as ordered by initialing the TAR to show documentation that they were completed. 3. Review of Resident #435's medical record showed [DIAGNOSES REDACTED]. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: -BIMS score of 12 out of 15 (cognitively intact); -Required extensive assistance of one to two staff with all activities of daily living; -Incontinent of bowel and bladder; -admitted with three Stage III pressure sores measuring 4.0 centimeters (cm) by 4.0 cm, slough and one pressure sore healed; -Received antibiotics seven out of seven days. Review of the resident's care plan, dated 3/7/18, showed an unstageable pressure sore on coccyx, and directed staff to: -Assist as needed to reposition/shift weight to relieve pressure; -Complete weekly skin checks; -Discuss non-compliance issue with resident/responsible party; -Notify nurse immediately of any new skin breakdown; -Observe effectiveness of treatment as ordered; -Monitor labs as ordered by physician; -Provide incontinence care after each incontinence; -Pressure relieving mattress and chair cushion; -Provide diet as ordered, provide protein supplement; -Wound care as directed by physician. Review of the resident's POS dated 6/06/18, showed an order to cleanse coccyx wound with normal saline (may apply skin prep to peri wound) apply Manuka Pli and cover with dry dressing daily. Review of the resident's wound reports showed the following: -Coccyx pressure sore date of origin 2/27/18, prior to admission; -First documented assessment dated [DATE] showed staff assessed the coccyx area wound as a Stage III, measuring 2.80 cm by 3.50 cm with 0.30 cm depth, total area measured 9.80 cm, light serosanguineous drainage with no undermining/tunneling, no incision, wound base 10% [MEDICATION NAME], 80% granulation, 10% slough, wound edge unattached, and surrounding skin intact and response to treatment improved; -7/4/18 and 7/12/18, blank except documentation that surrounding skin intact and response to treatment improved; -7/16/18, Stage III measuring 1.00 cm by 1.00 cm with 0.50 cm depth, light serosanguineous drainage with no undermining/tunneling, no incision, 10% [MEDICATION NAME], 80% granulation, 10% slough, wound edge unattached and surrounding skin intact, response to treatment improved; -7/25/18, Stage III measuring 3.00 cm by 3.00 cm by 0.50 depth, light drainage, 10% [MEDICATION NAME], 80% granulation, 10% slough, wound edge attached, surrounding skin intact, response to treatment deteriorated; -8/7/18, stage III measuring 3.00 cm by 2.50 cm by 0.40 depth, moderate drainage, 90% granulation, 10% slough, wound edge unattached, surrounding skin intact, response to treatment improved. Review of the medical record showed the resident was sent out to hospital for left above the knee amputation and resident was re-admitted on [DATE]. Review of the wound report, dated 8/22/18, showed the coccyx pressure sore was unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar), slough and/or eschar, light drainage, no undermining/tunneling or incision, 20% [MEDICATION NAME], 10% granulation, 10% slough, wound edge unattached, surrounding skin intact [DIAGNOSES REDACTED], macerated, response to treatment not assessed. Review of the resident's TAR, dated (MONTH) (YEAR), showed staff documented the treatment to the coccyx was not completed on 7/5, 7/6, 7/13, 7/14, 7/16, 7/19, 7/30, and 7/31. Review of the TAR, dated (MONTH) (YEAR), showed staff documented the treatment to the coccyx was not completed on 8/2/18 and 8/11/18. Review of the weekly summary on the back of the TAR, showed staff documented attempted to change resident's dressings but resident refused. The resident yelled at this nurse to go away and leave him/her alone. Incoming nurse aware. Further review of the TAR dated 8/12/18, showed staff documented the treatment was completed. During an interview on 8/29/18 at 9:00 A.M., the wound nurse (LPN G) said he/she was gone from the facility the entire month of (MONTH) and did not return until (MONTH) (YEAR). LPN G said while he/she was gone the charge nurses were responsible for wound treatments/assessments. LPN G said when he/she returned, he/she tried to obtain information on residents wounds from the charge nurses as there was little documentation. Observation on 08/29/18 at 4:57 P.M., showed Certified Nurses Aide (CNA) W and LPN G wore gowns and gloves and entered the resident's room. The resident had liquid feces on his/her buttocks. LPN G cleansed the resident's buttock and changed his/her gloves and removed the resident's old dressing from his/her coccyx. Observation showed a a large amount of blood tinged drainage on the old dressing and a large uneven circular wound to the resident's coccyx. LPN G cleansed the wound with normal saline and 4 x 4 inch gauze. The LPN said the wound to the coccyx is unstageable with 80% slough and eschar in the center with maceration around the bottom periwound. Observation showed the resident continued to have liquid stool. LPN G cleansed the stool and changed gloves without washing his/her hands, placed skin prep around the wound edges, then applied a half dollar size amount of manuka pli directly onto 4 x 4 gauze and placed the 4 x 4 gauze onto the wound bed. The LPN cleansed liquid stool from the resident's bottom, removed gloves, did not wash his/her hands, and applied abdominal wound dressing (used to manage heavy drainage) and adhesive tape over the dressing. Observation showed the LPN applied barrier cream to the buttocks and groin. Further observation showed the LPN changed his/her gloves, without washing his/her hands, removed the resident's right heel lift boot, cut off the dressing to the right foot. Observation showed scant (small) amount of serosanguineous drainage on the soiled dressing and a moon shaped black eschar wound to the resident's outer heel and a dime size circle black eschar area to the lateral right foot. The LPN cleansed both areas, changed gloves without washing hands or sanitizing, applied manuka pli to 4 x 4 gauze and wrapped the foot with kerlix gauze. During the same time, LPN G said when went the resident went to the hospital the wound was a Stage III pressure ulcer with very little slough to the coccyx. The resident was admitted with multiple other areas and some have healed, but these have gotten worse since the resident went back to the hospital. Staff just received a verbal order for the resident to start Closed Pulse Irrigation (CPI) treatment. During an interview on 8/30/18 at 12:19 P.M., the Medical Director/resident's physician said the resident has very bad [MEDICAL CONDITION], which was the cause of wounds on lower legs/feet. The resident's toes then became infected and he/she was placed on [MEDICATION NAME]. He consulted with the resident's podiatrist and they agreed it would be best to amputate above the knee to give the resident the best chance of healing. He said the resident is not compliant with being positioned on his/her side and will move about until he/she gets back on his/her back. He said the resident's nutrition is bad, some days the resident will eat, but it may be two or three days before he/she will eat very much again. He thought the resident should be on hospice due to the resident's poor condition. He said the resident developed [MEDICAL CONDITION] as a result to all the antibiotics. He said the resident's health shakes were held because they can cause diarrhea due to high sugar content. He said the resident's family brought in protein shakes, which contain 30 grams of protein. During an interview on 8/31/18 at 09:00 A.M., the resident's family member said the resident had been living at home alone, then had a stroke and was admitted to the hospital. The resident was at another facility and developed pressure sores which got infected and was transferred back to hospital then came to the facility. The family member said the resident's physician had talked with them about his/her vascular disease causing the pressure sores to develop because of poor circulation. The family member said they are very involved with care, have had meetings with management staff regarding concerns with care issues. The family member said wound care on weekends does not happen. 4. Review of Resident #18's physician's progress note, dated 6/17/18, showed the physician documented the resident has a few complaints of some care issues and are not as responsive as they should be. Review showed the physician documented sacral Decubitus (ulcer) healing well. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as the following: -Modified independence with cognitive skills for daily decision making; -No behaviors, rejection of care, wandering, or changes in behavior; -Required extensive assistance of one staff with bed mobility, transfers, toileting, bathing, and personal hygiene; -Limited assistance of one staff for dressing; -Set-up help only for eating; -Limited range of motion (ROM) to both upper and lower extremities; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -Occasional moderate pain; -Stage III pressure ulcer measuring 1.4 cm by 1.4 cm by 0.2 cm with granulation tissue; and -Has a pressure reducing device in chair and bed, nutrition interventions, and receives pressure ulcer care. Review of the resident's care plan, dated 6/18/18, showed the resident has a stage III pressure ulcer to his/her bottom, incontinence, and impaired mobility secondary to(NAME)Chiari syndrome and sympathetic neuroosteodystrophy (a complex reflex pain disorder). Staff are directed to do the following: -Assist to reposition/shift weight to relieve pressure as needed; -Complete Braden scale risk assessment quarterly as needed; -Complete weekly skin assessment; -Float heels when in bed; -Minimize pressure over bony prominences; -Notify the nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care; -Observe lab results as ordered and report abnormal results to physician; -Position with pillows to maintain proper body alignment; -Provide diet as ordered and observe nutritional status and dietary needs, provide supplemental protein, amino acids, vitamins, minerals as ordered by physician to promote wound healing; -Provide incontinence care after incontinence episodes. Apply barrier cream as needed; -Provide pressure relieving or reduction device, pressure reduction mattress, and chair cushion; -Refer to therapy for positioning as needed; -Report changes in skin status to physician; -Turning and repositioning program every two hours as needed; -Use lifting device, draw sheet to reduce friction; -Avoid skin to skin contact; -Discuss non-compliance issues with the resident/responsible party; -Educate resident/responsible party about pressure ulcer etiology, primary risk factors, treatment, and prevention; -Encourage use of the side rails and/or trapeze to assist turning in bed; -Notify resident/responsible party of any new areas of skin breakdown; -Observe effectiveness of/response of treatments as ordered; -Observe for pain and medicate as needed per physician orders. Review of the physician's progress note, dated 7/26/18, showed the physician documented the resident is upset because he/she was left uncleaned from 12:00 A.M. to 4:00 A.M. Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur)sacral wound examined with the corporate nurse. Wound has worsened and enlarged, wound is bone deep. Can palpate bone, however, wound is clean without significant discharge. Discussed wound care, check C-reactive protein (CRP) and Sedimentation (Sed) rate, will be difficult to heal wound. Review of the resident's Braden Scale Risk Assessment, dated 7/27/18, showed staff assessed the resident at moderate risk for skin breakdown, related to decreased or impaired bed/chair mobility, existing pressure ulcer, history of pressure ulcers, incontinence of bowel and bladder, and pain. Review of the resident's physician order [REDACTED]. -Health shakes with breakfast and dinner (12/15/17); -Cleanse coccyx with normal saline, apply [MEDICATION NAME] (sterile, freeze dried matrix composed of collagen a ND oxidized regenerated cellulose) to the wound bed and cover with dry dressing daily and as needed, ordered 3/13/18 and discontinued 7/27/18; -Low air loss mattress (ordered 2/27/17); and -Cleanse coccyx wound with normal saline, apply santyl (enzymatic deriding ointment) and dry dressing, change daily and as needed (no order date). Review of the resident's telephone order sheet (TOS), dated 7/27/18, showed the physician directed staff to clean the coccyx wound with normal saline, apply santyl, and dry dressing daily and as needed. Review of the resident's TOS, dated 8/7/18, showed the physician directed staff to discontinue santyl, after cleaning wound to coccyx with normal saline, apply manuka pli and saline moistened gauze, cover with dry dressing daily and as needed. Further review showed staff initialed the order was placed on the treatment sheet and in the nurses notes. Review showed staff did not initial the order documented on the POS. Review of the resident's TOS, dated 8/31/18, showed the physician ordered physical therapy (PT) to evaluate and treat wound to coccyx. Review of the resident's physician progress notes [REDACTED]. Review of the resident's physician progress notes [REDACTED]. Review of the resident's treatment administration records (TAR), dated (MONTH) (YEAR) through (MONTH) (YEAR), showed facility staff documented the following: -Cleanse wound with normal saline, apply [MEDICATION NAME] to wound bed, and apply dry dressing daily. Review showed no initials to show completion of treatment on 5/6/18, 5/8/18, 5/26/18, 6/2/18, 6/17/18, 6/22/18, 7/2/18, 7/4/18, 7/6/18, 7/13/18, 7/14/18, 7/18/18, and 7/20/18. Order discontinued on 7/26/18; -Cleanse wound with normal saline, apply Santyl, and dry dressing, change daily and as needed. Review showed staff did not initial to show completion of the treatment on 7/29/18 and 7/31/18, order discontinued on 8/7/18; -Cleanse wound with normal saline, apply manuka pli and saline moistened gauze, cover with dry dressing, change daily and as needed. Review showed staff did not initial to show completion of the treatment on 8/11/18 and 8/19/18. Review of the resident's electronic medical record (EMR) skin assessments, showed staff documented the following: -5/16/18 coccyx pressure ulcer intact, improving, treatment to coccyx. The resident has an o

Based on observation, interview, and record review, the facility failed to ensure staff treated eight out of 23 sampled residents (Resident #4, #19, #21, #23, #29, #278, #435, and #436) and four additional residents (Resident #3, #429, #437 and one anonymous resident) in a manner to maintain their dignity when staff made inappropriate comments to residents during care, stood while assisting multiple residents with feeding and failed to respond in a timely manner to requests for assistance. The facility had a census of 80. 1. Observation on 08/28/18 at 10:00 A.M., showed Resident #3 and Certified Nurses Aide (CNA) H in the resident's bathroom. Observation showed the resident provided pericare to him/herself. CNA H and CNA J assisted the resident in transferring to his/her wheelchair without a brief or pad under the resident. CNA H told the resident, Lift your legs in an abrupt manner. Observation showed the resident sigh and lift his/her legs and the CNA placed the resident's brief and pants on his/her lower extremities. CNA H began pushing down on the resident's knees. When the resident did not lower his/her legs while the CNA pushed on them, the CNA said put your legs down, in an abrupt manner. Observation showed the resident sigh and place his/her head down. The CNA's told the resident to stand up while they pulled up the resident's pull-up and pants. 2. Review of the Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 8/25/18, showed the following: - Brief interview for mental status (BIMS) score of 8 (cognitively impaired); - Required extensive assist of one to two staff for activities of daily living; - Frequently incontinent of bladder and always incontinent of bowel; - At risk for pressure sores. Observation on 8/27/18 at 4:00 P.M., showed Certified Nurse Aide (CNA) N and CNA O provided incontinence care to the resident. Further observation showed the resident was very anxious, making repeated statements to staff not to hurt him/her as he/she had been through a lot. CNA O said to the resident in a harsh tone What have you been through? The resident did not respond to the CNA. During an interview on 9/4/18 at 6:01 P.M., Resident #4's family members (FM) said the following: -The resident's family member said the resident was half out of his/her wheelchair, sliding out, and it took 30 minutes to find staff to transfer the resident to bed on 9/4/18 around 2:30 P.M.; -Staff told them they were going to clean the resident up and it's been three hours; -The resident was still in his/her same clothes and needed his/her incontinence brief changed; -Hospice staff were coming today to evaluate the resident for hospice services. Observation on 9/4/18 at 6:10 P.M., showed the resident lay in bed sleeping, partially dressed and staff had not come in to provide assistance. During an interview on 08/31/18 at 11:07 A.M., the Director of Nurses (DON) said the facility had a recent in-service on resident rights and dignity is a work in progress. He/She said it was not appropriate for staff to say that to a resident. 3. Review of Resident #19's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Minimal depression; -No behaviors or rejection of care; -Required extensive assist of one staff with bed mobility, dressing, and bathing; -Required limited assist of one staff with personal hygiene and eating; -Dependent on one staff for toileting and two staff for for transfers; -Always incontinent of bowel and bladder; -Had one fall; -Received 51% or more of daily nutrition and 501 cubic centimeters (cc) or more of daily fluids through tubefeeding; -At risk for pressure ulcers. Review of the resident's care plan, dated 6/19/18, showed staff assessed the resident as at risk for his/her needs not being met related to memory impairment and relying on staff for most decision-making. Staff are directed to anticipate and provide daily care as indicated, provide/encourage activities that promote memory, promote dignity, converse with the resident and ensure privacy while providing care, and identify themselves with each contact. Additionally, staff documented the resident is at risk for episodes of pain and may forget to alert staff. Staff should monitor for s/s of pain. Staff are directed to administer/observe for effectiveness and possible side effects from pain medication, administer as needed pain medication, notify physician if resident does not state/demonstrate relief or reduction of pain after one hour of receiving the first intervention, and observe and report to nurse signs/symptoms of pain such as crying, resists moving, resists cares, agitation, grimaces, signs/symptoms of worsening pain. Review of the resident's physician order [REDACTED]. -Assess pain every shift; -[MEDICATION NAME] 325 milligrams (mg) two tabs per gastronomy-tube ([DEVICE]) every six hours as needed; and -[MEDICATION NAME] (pain medication) 50mg/325 mg one tab by mouth as need prior to wounds treatment change ordered on [DATE]. Review of the resident's Medication Administration Record [REDACTED] -[MEDICATION NAME] 5 mg/325mg on tablet administered on 8/22/18 at 1:30 P.M., 8/23/18 at 08:00 A.M., and 8/29/18 at 12:00 P.M. -[MEDICATION NAME] 325 mg two tablets on 08/21/18 at 8:00 A.M., 8/28/18 at 9:45 A.M., and 8/30/18 at 7:20 P.M. Observation on 08/28/18 at 09:14 A.M., showed the resident lay on his/her left side with tube feeding infusing and head of bed slightly elevated. Observation showed the resident moaned out loud and staff walked by the room without stopping to assist the resident. Observation on 8/28/18 at 04:29 P.M., showed the resident lay flat in bed, and screamed out. Observation showed the resident stared at a blank TV screen and no staff stopped to address the resident's needs. Observation on 08/29/18 at 08:36 A.M., showed Registered Nurse (RN) R entered the resident's room, without pulling the privacy curtain, turned off the resident tube feeding, disconnected the tubing, administered the resident's medication, and reattached the tube feeding. RN R did not speak to the resident or inform the resident what he/she was doing. Observation on 8/29/18 at 9:00 A.M., RN R said the resident is out of pain medication that he/she needs before his/her treatment is completed. The RN said he/she will have to pull some from the emergency kit (e-kit). Observation on 8/29/18 at 10:58 A.M., showed the resident on his/her left side with feeding infusing, moaning out loud Help. Observation showed no staff enter the resident's room. Observation on 08/29/18 at 03:30 P.M., showed physical therapy (PT) assistant complete the resident's wound treatment. Observation showed the resident moan out with facial grimacing multiple times through the procedure. The PT assistant did not address the resident's moaning and facial grimacing. The PT assistant said he/she has been working with resident for about 2 weeks because the resident's wound deteriorated. Observation on 08/29/18 at 04:34 P.M., showed the resident hollered out help and could be heard at the nurses station. Further observation showed the unidentified nurse enter the resident's room and tell the resident that he/she knows how to use his/her call light. The nurse said he/she would be back after administering medication and then walked past the room. Observation showed the resident continued to yell please help me. Observation on 08/29/18 at 04:40 P.M., showed an unidentified nurse enter the resident's room. Observation showed the nurse tell the resident to keep it in the bed referring to the resident's call light. Continuous observations on 08/30/18 from 02:41 A.M. to 03:47 A.M., showed the resident's door shut to his/her room. Upon entering, observation showed the resident lay on his/her back with the head of bed flat, the resident's tube feeding machine beeping, and the resident moaning out loud with intermittent coughing. No staff entered the room to address the resident's needs. Observation on 08/30/18 at 03:48 A.M., showed LPN E placed a new bottle of tube feeding and flush bag and connect the feeding to the resident. Observation showed the resident continued to moan out with head of bed not elevated. Observation showed the LPN hold a wash cloth up to the resident's mouth and tell him/her to spit out the saliva and mucous in his/her mouth. The LPN left the room and the resident continued to moan. Observation 08/30/18 at 03:56 A.M., showed CNA C placed the tube feeding on hold and asked the resident to spit into a towel. The CNA pulled down the resident's blanket and removed his/her brief from the front, then turned the resident side to side providing pericare. Observation showed the resident cried out with facial grimacing with turning and repositioning. The CNA asked the resident what was wrong after he/she positioned the resident's legs in the bed and the resident said ouch. The resident did not respond. The CNA asked if the resident needed something for pain and the resident shook his/her head yes. Observation on 08/30/18 at 04:18 A.M. to 5:24 A.M., showed the CNA did not report to the nurse when he/she left the resident's room that the resident was in pain and asked for medication. Observation showed the resident continued to holler out help me and loudly moaned. During an interview on 08/30/18 at 05:25 A.M., LPN E said the resident moans out sometimes when he/she has stuff in his/her mouth. The LPN said he/she gave him Tylenol earlier and he/she plans on going back. Review of the resident's MAR, dated (MONTH) (YEAR), showed no documentation of Tylenol administered to the resident on 8/30/18 during the 11:00 P.M. to 7:00 A.M. night shift hours. 4. Review of Resident #21's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance of two staff with bed mobility, toileting, and transfers; -Required extensive assistance of one staff for dressing and personal hygiene; -Dependent on one staff for bathing; -Always incontinent of bowel and bladder; and -Receives 51% or more of daily nutrition by tubefeeding. Observation on 08/28/18 at 08:57 A.M., showed the resident positioned in front of the nurses station with blanket off to the side, shirt raised and abdomen showing, and pant legs pulled up to the resident's knees. Observation showed staff at the nurses desk and staff walking by the resident. Observation on 08/28/18 at 04:20 P.M., showed the resident reclined back in his/her geri-chair with shirt pulled up exposing [DEVICE] and pant legs pulled up above the residents knees. Observation on 08/31/18 at 10:22 A.M., showed the resident up in his/her geri-chair by the nurses station with his/her eyes open. Observation showed the resident's [DEVICE] exposed with his/her shirt up raised up to the resident's chest. 5. Review of Resident #23's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Mild cognitive impairment; -Minimal depression; -No behaviors, rejection of care, wandering, or [MEDICAL CONDITION]; -Required extensive assistance of one staff for bed mobility, dressing, eating, and personal hygiene; -Required extensive assistance of two or more staff for transfers; -Dependent on one staff for bathing; -Required set-up assistance with eating; -No limitations in range of motion (ROM); -Wheelchair for mobility; -Always incontinent of bladder; -Frequently incontinent of bowel; -No falls; -At risk for pressure ulcer development with pressure reducing device in chair and bed; -Received antidepressant medication for the last seven days; -No plans for discharge. Review of the resident's care plan, updated 6/20/18, showed the resident is at risk for psychosocial well-being problem related to the [DIAGNOSES REDACTED]. -Arrange for clergy or spiritual leader of choice to visit, if requested or desired; -Assist in learning stress management/relaxation technique; -Assure the resident that symptoms of grieving are normal and will improve with time; -Determine the resident's executions and discuss each in realistic terms; -Discuss coping strategies with the resident; -Discuss with the resident concerns/fears of being unwanted or feeling useless; and -Give positive reinforcement as initiative/involvement improves/attempts to solve conflicts. Additionally, staff are directed to invite, encourage, remind, and escort the resident to activity programs consistent with the resident's interests, promote dignity, and converse with the resident and ensure privacy while providing care. Review of the resident's Social Service Assessment, dated 12/17/17, showed the social service director (SSD) assessed the resident as: -Adjusting well; -Alert and oriented to person, place, time, and occasionally situation, modified independence with decision making; -Able to make needs known; -Received [MEDICATION NAME] (antidepressant) 60 milligrams (mg) daily; -Anticipated discharge to an assisted living facility (ALF); and -Enjoys cooking, sewing, singing, reading, and use to play the piano. Review of the resident's Social Services note, dated 8/23/18, showed the SSD documented the resident's daughter reported that the resident expressed that he/she has thought about suicide. When the daughter asked why the resident had thought about suicide, the resident replied, They don't like me here. The resident's daughter asked why he/she thinks that no one likes him/her at the facility, the resident replied, He/she has been stealing all of their men/women. The SSD spoke with the resident whom stated that she has thought about suicide. The SSD asked the resident if he/she had a plan and the resident replied he/she has been thinking about what he/she will wear and he/she will use gas. The resident did not report any further plans. The resident stated that he/she feels useless and has no friends. The SSD provided active listening, validation, and encouragement. The Daughter and SSD spoke with the nurse practitioner (NP) who said that he/she will review the resident's medications. an order for [REDACTED]. The DON and administrator made aware. The DON stated that he/she will have staff observe the resident. Social Services will continue to follow as appropriate. Further review of the social services notes, did not show any further documentaion regarding the resident's suicidal thoughts or follow-up. Review of the resident's nurses note, dated 7/22/18, showed staff documented the resident had been screaming out and crying at the start of the shift. Also the resident has shown this behavior over the past week around the same time of day. When asked if something is wrong, the resident is unable to verbalize any specific complaints. When the resident was asked if he/she would like to lay down, the resident agreed. After laying down in bed, the resident became more calm. Review of the resident's nurses note, dated 7/31/18, showed staff documented the resident was yelling out this afternoon in dining room and was redirected a few times by SSD, CNA, and occupational therapist (OT). At this time the resident is by the nursing station showing no apparent unmet needs after he/she was assisted to the restroom. Observation on 8/27/18 at 02:10 P.M., showed the resident sat up in his/her wheelchair, positioned by CNA H at the nurses station, crying. CNA H said to the resident, You are really going to have to quit that crying. There is nothing wrong with you. Observation showed the resident began crying louder and harder. The CNA then asked the resident what he/she had for lunch. The resident responded, I did not eat lunch, and the CNA said, Yes you did. The resident continued to cry harder. Further observation showed the resident stopped crying, began to smile, and answered in a positive manner, when the surveyor asked the resident about his/her stuffed animal that he/she held. During an interview at the same time, RN R said the resident has been crying out more here lately. Staff just have to talk to him/her and he/she will stop crying and perk up. Observation on 08/28/18 at 09:09 A.M., showed the resident sat up in his/her wheelchair, with wheelchair positioned against the wall and facing the nurses station. Observation showed the resident's feet on the foot pedals, eyes closed, and head down with a blanket over him/her. Observation on 8/28/18 at 10:30 A.M., showed the resident remained his/her wheelchair facing the nurses station, with his/her eyes closed and no change in position. Observation on 08/28/18 at 01:24 P.M., showed the resident sat up in his/her wheelchair facing the nurses station, with his/her eyes closed. Continuous observations on 8/29/18 from 8:45 A.M. to 9:15 A.M., showed the resident in his/her wheelchair with both foot pedals, sitting in common TV area staring at the TV. Observation on 8/29/18 at 9:26 A.M., showed the resident say to CNA H, he/she did not want to watch the show on TV. The CNA did not acknowledge or speak to the resident. CNA H walked by the resident and went down hall without addressing the resident Continuous observation on 8/29/18 at 9:30 A.M. to 9:55 A. M, showed the resident remained in the common area staring at the TV. Observation on 8/29/18 at 9:56 A.M., showed the resident in the common area repetitively screaming, I have to get out of here, my daughter is waiting for me. An unidentified CNA walked by and said, Give me just a minute, I will be right back after I finish this. The CNA went into another resident's room. The resident began repetitively screaming loudly, I can't get out. Observation showed the resident began crying. Continuous observations on 8/29/18 from 9:57 A.M. to 10:03 A.M., showed the resident continued to repetitively scream, I cant get out while crying. Continuous observations on 8/29/18 from 10:04 A.M. to 10:09 A.M., showed the resident hollered out HELP, I am going to freeze, while continuing to cry. Further observations showed a CNA walk down the hall multiple times and did not stop to assist the resident. Observation on 8/29/18 at 10:10 A.M., showed the resident continued to holler out and cry. The administrator propelled the resident in front of nurses station and positioned the wheelchair next to other residents against the wall facing the nursing station, and talked with the resident. The resident smiled and talked calmly. Continuous observations on 8/29/18 from 10:11 A.M. to 10:18 A.M., showed the resident continued to holler out and cry. During the observation at 10:14 A.M., the resident hollered out I'm still breathing to four different staff members as they walked by. Staff did not stop to assist the resident. Observation on 8/29/18 at 10:19 A.M., showed the housekeeping supervisor stop and inform the resident that exercise will be at 10:30 A.M. in the dining room. The resident said I do not want to do that. Staff asked the resident what he/she wanted to do and the resident said, I want to go to bed. Observation showed the housekeeping supervisor propel the resident to his/her room and position the wheelchair next to his/her bed. Continuous observations on 8/29/18 from 10:20 A.M. to 10:28 A.M., showed the resident in his/her room crying. During the observation at 10:28 A.M. an unidentified CNA exited another resident's room and asked Resident #23, What is wrong? Before the resident could respond the CNA said, We are going to get you down to activities and exited the room. Observation showed the resident started crying out loudly and repetitively saying I want to get out of here. Observation on 08/29/18 at 10:29 A.M., showed the Activity Director asked the resident What is wrong as he/she was walking by the resident's room. The resident said, I want to get out of here. An unidentified CNA entered the room and began propelling the resident down the hall without informing the resident where they were going. The resident asked where they were going and the CNA told the resident that they were going to activities. Observation showed the resident said to the CNA that he/she did not want to go to activities. The CNA continued to propel the resident into the main dining room. Observation on 8/29/18 at 10:30 A.M., showed the Activity Director and Activity Assistant position multiple residents in a circle and hand them a handle attached to a parachute. Activity personnel placed a ball in the center of the parachute. Further observation showed the resident positioned by a table several feet away from the group performing the activity by himself/herself. Staff did not encourage or ask the resident if he/she would like to participate. Continuous observation on 8/29/18 from 10:30 A.M. to 11:29 A.M., showed the resident remained positioned off to the side of the activity. Further observation showed staff did not encourage or attempt to get the resident to participate. Observation on 8/29/18 at 11:30 A.M., showed staff moved the resident from his/her position during the activity to the dining room table for lunch. Continuous observations on 8/29/18 from 11:31 A.M. to 12:27 P.M., showed the resident remained in the dining room Observation showed the resident fed himself/herself and staff did not engage in conversation with the resident. Observation on 8/29/18 at 12:28 P.M., showed staff propelled the resident down the hall and positioned the resident facing the nurses station. Observation showed staff did not offer to toilet or lay the resident down in bed. Continuous observation on 8/29/18 from 12:30 to 1:00 P.M., showed the resident remained at the nurses station without staff acknowledging the resident. Continuous observations on 8/29/18 from 02:00 P.M. to 3:26 P.M., showed the resident positioned against the wall facing the nurses station with a blanket on his/her lap. The resident cried and said he/she needed to go home. Observation showed staff walked by the resident without addressing the resident's needs. Observation on 8/29/18 at 3:27 P.M., showed the resident drank water out of a plastic cup and straw. Resident #35 place his/her hand on the resident's arm and the resident began to cry and holler out. Observation showed staff did not address the resident crying and hollering. Continued observations on 08/29/18 from 03:28 P.M. to 03:38 P.M., showed the resident sat in his/her wheelchair positioned against the wall facing the nurses station, crying out I want to go home. Observation showed two unidentified nurses sat at the nurses station and staff walked by. Staff did not acknowledge that the resident was crying or attempt to redirect the resident. Observation on 08/29/18 at 03:39 P.M., showed the resident continued to cry. Licensed practical nurse (LPN) Q asked the resident if he/she wanted to take a nap. The resdient did not respond to the nurse. Observation on 08/29/18 at 04:07 P.M., showed an unidentified CNA propel the resident to the dining room and position him/her at a table in the center of the dining room with only one other resident in the dining room, and the CNA exited the dining room. Observation on 08/29/18 at 04:15 P.M., showed the resident in the dining room crying with no staff present. The surveyor asked the resident how he/she was doing and the resident replied not good but was unable to answer why he/she was not good. Observation showed the resident calmed down and quit crying when the surveyor spoke with the resident. Observation on 08/29/18 at 04:21 P.M., showed the Activity Director walked into the main dining room and positioned the resident at his/her dining room table without telling the resident what he/she was doing. Observation showed the Activity Director talking to another resident about playing bingo earlier. Resident #23 said I do not like bingo, and the Activity Director responded loud and harsh, I know that's why I didn't bring you down here. The resident looked down at the table. Continued observations on 8/29/18 from 04:22 P.M. to 04:40 P. M, showed the resident remained positioned at the dining room table. Observation at 4:41 P.M. showed the surveyor requested staff to toilet the resident. CNA U propelled the resident to his/her room. The resident said he/she has not gone to the bathroom all day and probably leaked a little bit. Observation on 8/29/18 at 04:45 P.M., showed CNA U left the resident's room and CNA T provided pericare. Observation on 08/31/18 at 10:28 A.M., showed the resident sat up in his/her wheelchair positioned facing the nurses station. Observation showed the resident had a blanket on his/her lap and sang with intermittent crying. CNA J asked the resident what was wrong as he/she walked by but did not stop for the resident to respond. Continuous observations on 8/31/18 from 10:29 A.M. to 10:42 A.M., showed the resident remained in the same position and continued to sing and cry out without staff attempting to stopping to see what the resident needed. Observation on 08/31/18 at 10:43 A.M., showed the resident remained positioned against the wall facing the nurses station crying and asking to go to his/her room. The Staffing Coordinator asked RN R if it was ok for the resident to go to his/her room and the RN said yes. The staffing coordinator propelled the resident to his/her room and positioned him/her by his/her bed During an interview on 8/29/18 at 2:40 P.M., CNA H said the resident had recently started crying out and doesn't tell staff what is wrong. The resident does this frequently now and the other day he/she had been doing this all shift. If staff talk with him/her, the resident will normally stop crying and that is why he/she was at the nurses station with the CNA. The CNA said the other day he/she had lost patience because he/she was at the end of shift and attempting to document for the day. The CNA said he/she just got frustrated. Usually when we ask the resident if he/she needs to use the restroom or wants to lay day, or if he/she needs something else, the resident will calm down and is able to answer yes or no, but that day he/she was not saying what he/she needed. 6. Observation on 8/29/18 at 11:45 A.M., showed Resident #29 in his/her wheelchair rolling up to a table in the dining room and reaching for the salt shaker. At this time, the Activity Director approached the resident and hollered out and said harshly Don't you get into that! I will get you! The resident tensed up and hollered back at the Activity Director, I will get you! 7. Review of Resident #278's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -No behaviors; -Required extensive assistance of one staff with bed mobility, toilet use, eating, and personal hygiene. -Required limited assistance of one staff with dressing; -Dependent on one staff for bathing; -Frequently incontinent of bladder and always incontinent of bowel; -[DIAGNOSES REDACTED].>-Had a fall in the last month; -Had an unstageable pressure ulcer and a lesion on the foot; and -Received antidepressants three out of the last seven days prior to the assessment. Observation on 08/27/18 at 01:55 P.M., showed the resident lay in bed. An unidentified CNA entered the resident's room without knocking or announcing themselves. Observation on 8/27/18 at 5:30 P.M., showed the resident lay in his/her bed uncovered, with no pants on his/her lower extremities, brief showing and legs off the side of the bed. Further observation showed the resident was visible from the hallway as staff and visitors walked by the resident's room. Observation on 08/31/18 at 10:37 A.M., showed the resident's shirt had multiple spots with food on it. 8. Review of Resident #429's MDS, dated [DATE], showed: - Modified independence in decision making, short and long term memory okay; - No mood or behavior issues; - Required extensive assist of one staff for all activities of daily living; - Incontinent of bladder and bowel; - One stage II pressure sore (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also, present as an intact or open/ruptured blister); -[DIAGNOSES REDACTED]. Observation on 08/27/18 from 5:43 P.M. to 5:48 P.M., showed an unidentified CNA stood to the side of Resident #429 and fed the resident. Observation showed the CNA entered and exited the assisted dining room multiple times while he/she assisted the resident with eating. During an interview on 09/04/18 at 02:55 P.M., the resident said over the weekend he/she had been up in his/her geri-chair since early morning and was not put to bed until 12:00 A.M. The resident said he/she asked the staff to please put him/her to bed as his/her leg and bottom were hurting. He/she said staff never got the nurse to assess for pain medication. He/she said the two staff took him/her to his/her room and said they were going to put others to bed and be back to help him/her. The resident said staff just left me in the room and I was hurting so bad. When staff returned to assist the resident to bed they wouldn't listen to him/her before trying to transfer him/her. The resident said he/she told the staff to get his/her chair closer to the bed. The staff picked him/her up without using a gait belt, one staff grasped his/her arms and the other staff grasped his/her legs. The resident said one staff complained about his/her back hurting. The resident said staff never notified the nurse of his/her pain and he/she did not receive any pain medication. 9. Observation on 8/27/18 at 05:35 P.M., showed an unidentified CNA delivered trays to the assisted dining room. Observation showed the CNA tell another CNA Resident #435 is a feeder as he/she walked away from the food cart. Observation on 8/27/18 at 5:39 P.M., showed an unidentified CNA stood and fed Resident #435 a bite, then walked over to another resident and cut up their food. Observation showed the CNA then left the dining room. 10. Review of Resident #436's medical record showed the resident admitted to facility on 7/22/18, with [DIAGNOSES REDACTED]. Review of the resident's admission MDS, dated [DATE], showed staff assessed the resident as: - BIMS score of 15 out of 15 (cognitively intact); - Required limited to extensive assistance of one staff with all activities of daily living; - Frequently incontinent of bowel and bladder; - At risk for pressure sore development; - Occupational and physical therapy five days a week. Review of the resident record showed the 48 hour care plan was blank. During an interview on 08/29/18 at 09:28 A.M., Resident #436 said staff woke him/her up at 3:30 AM to pre-dress him/her in bed. The resident said that was very unusual. He/She said the staff did not know how to get his/her brace on and had to find the therapy aide to assist them. The resident said sometimes he/she has to wait two hours for staff to come change him/her. A few time he/she had incontinence accidents with urine all over the floor. He/She said residents have to wait for assistance on all shifts. 11. Review of Resident #437's medical record showed the resident admitted to the facility on [DATE], from the hospital for physical therapy after suffering a fall at home. Review of the 48 hour care plan on 8/30/ (TRUNCATED)

Based on observation, interview and record review, the facility failed to notify a resident's physician after identifying pressure ulcers on each heel and excoriated buttocks. Eleven days after identifying the resident's heel pressure ulcers and excoriated buttocks, facility staff sent the resident to a local hospital where hospital staff identified other pressure ulcers in addition to the resident's heels and excoriated buttocks. In addition, after the resident returned from the local hospital, staff failed to notify the resident's physician regarding the resident's severe weight loss. (Resident #30) The census was 77. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/11/12, showed the following: -Usually understood/understands; -Extensive assistance of one person required for bed mobility, transfers, dressing, toilet use and personal hygiene; -Limited assistance of one person required for locomotion on/off the unit; -Frequently incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -Height 60 inches, weight 185 pounds (lbs); -At risk for developing pressure ulcers; -No pressure ulcers. Review of the resident's discharge assessment MDS, dated [DATE], showed the following: -No pressure ulcers; -Weight 187 lbs. Review of the resident's electronic (e) nurse's note, dated 7/22/12 at 11:10 P.M., showed the resident had been admitted to a local hospital for an elevated temperature and urethral bleeding. Review of the resident's e-nurse's note, dated 8/2/12 at 10:13 A.M., showed the resident returned to the facility on [DATE]. Review of the resident's handwritten nurse's notes, dated 8/1/12 at 6:00 P.M., showed the resident returned to the facility, from the hospital, with blistered areas to the left and right heels and excoriated buttocks. The nurse failed to document if he/she notified the resident's physician about the resident's heel blisters or excoriated buttocks. Review of the resident's "Weekly Skin Integrity Data Collection" form, dated 8/1/12, showed the resident had blisters on his/her heels and excoriated buttocks. Review of the resident's "Initial Data Collection Tool/Nursing Services" form, dated 8/1/12, showed the resident had pressure ulcers/blisters on both heels and excoriated buttocks. Review of the resident's "Interim Care Plan", dated 8/1/12, showed the following: -At risk for skin breakdown due to incontinence and immobility. Goal: Maintain intact skin with no skin breakdown. The care plan did not identify the resident's heel blisters or excoriated buttocks; -Bladder incontinence due to the aging process. Clean and dry the skin after each episode of incontinence. Assist of one for toileting needs; -Unable to complete activities of daily living (ADLs) due to dementia. Assistance of one staff for bathing and ADLs. Review of the resident's medical record, showed from 8/1/12 through 8/7/12, no documentation that staff notified the resident's physician about the blisters on his/her heels or his/her excoriated buttocks. Review of the facility's "Weekly Pressure Ulcer Tracking" forms, showed the resident had no pressure ulcers on 8/7/12. Review of the resident's "Weekly Skin Integrity Data Collection" form, dated 8/8/12, showed "blisters", but the nurse failed to identify the location of the blisters. Review of the resident's medical record, showed from 8/8/12 through 8/10/12, no documentation that staff notified the resident's physician about the blisters on his/her heels or his/her excoriated buttocks. Review of the resident's e-nurse's note, dated 8/10/12 at 3:01 P.M., showed the resident had two small open areas on the inner right thigh, near the groin. Both areas were approximately 0.3 centimeters (cm) by 0.8 cm in size with granulating (fibrous) tissue. Physician notified and an order received for triple antibiotic ointment daily. Review of the resident's e-nurse's note, dated 8/13/12 at 12:50 A.M., showed on 8/12/12 at 6:30 P.M., the resident appeared lethargic and difficult to arouse. Resident sent to a local hospital at 7:45 P.M. for assessment. Review of the hospital ED records, dated 8/12/12, showed the resident had been admitted at 11:37 P.M. Review of the resident's hospital skin assessment, dated 8/13/12 at 4:37 A.M., showed the resident had the following pressure ulcers: -Right inner heel pressure ulcer, measured 3.3 cm by 3.5 cm. Suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler compared to adjacent tissue), Wound bed assessment: Brown, black, deep purple. Wound margin: Defined edges, closed. Wound characteristics: Gray/Black devitalized (diminish or destroy the strength or vitality of), purple or maroon localized area of discolored intact skin; -Right lateral foot pressure ulcer, no measurement. Suspected deep tissue injury. Wound bed assessment: Deep pink, black, light purple. Wound margin: Closed. Wound characteristics: Purple or maroon localized area of discolored intact skin; -Right lateral ankle pressure ulcer, no measurement. Wound bed assessment: Black. Wound margin: undefined edges, closed. Wound characteristics: Gray/black devitalized -Left inner heel pressure ulcer, measured 3.0 cm by 2.0 cm. Suspected deep tissue injury. Wound bed assessment: Dusky red, dark purple. Wound margin: Defined edges, closed. Wound characteristics: Purple or maroon localized area of discolored intact skin; -Left inner heel pressure ulcer, measured 3.3 cm by 3.5 cm. Suspected deep tissue injury. Wound bed assessment: Black. Wound margin: Defined edges, closed. Wound characteristics: Gray/Black devitalized. -Left lateral ankle pressure ulcer, measured 2.0 cm by 2.0 cm. Wound bed assessment: Black. Wound margin: Closed. Wound characteristics: Black/Dry eschar (dead tissue); -Right inner thigh, Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow, tan, gray, green, or brown dead tissue). May also present as an intact or open/ruptured blister.) measured 1.0 cm by 0.5 cm with serous drainage (watery, clear fluid). Wound bed assessment: Granulation tissue. Wound margin: Defined edges, open. Wound characteristics: Partial thickness loss; -Right buttock, Stage II pressure ulcer measured 2.0 cm by 0.5 cm without drainage. Wound bed assessment: Pearly pink. Wound margin: Defined edges. Wound characteristics: Partial thickness loss. Review of a hospital progress note, dated 8/13/12 at 6:54 A.M., showed the resident had been admitted through the ED early that A.M. He/She complained of pain when legs and feet were moved or when turned. Multiple intact pressure wounds to feet, open areas to bilateral thighs and right buttock. Foley catheter (tube inserted into the bladder through the urethra) inserted upon arrival and 1300 cubic centimeters of cloudy concentrated urine immediately returned. Review of the resident's hospital note, dated 8/26/12, showed the resident received a peripherally inserted central line (PICC, intravenous (IV) line inserted to run long term antibiotics). Review of the resident's e-nurse's note, dated 8/28/12 at 6:15 P.M., showed the resident returned to the facility from the hospital and refused to have full body assessment completed. Review of the hospital discharge summary, dated 8/29/12, showed the resident had been discharged back to the facility on [DATE]. Discharge [DIAGNOSES REDACTED]. Unstageable (a pressure ulcer that is not stageable due to coverage of wound bed by slough and/or eschar (tan, brown, or black dead tissue)) bilateral heel ulcers, other possible fluid collections in the feet, possible source [MEDICAL CONDITION]. Medications ordered included IV [MEDICATION NAME] (antibiotic) 500 milligrams every 48 hours until 9/11/12 and [MEDICATION NAME] (antibiotic) 2.25 grams every 6 hours until 9/11/12. Review of the resident's nurse's e-note, dated 8/29/12 from 7:00 A.M. to 3:00 P.M., showed the facility identified the following pressure ulcers upon the resident's readmission to the facility: -Right buttock, measured 6.0 cm by 3.5 cm. Area is 80% dark brown and 20% red which makes wound unstageable due to eschar; -Left buttock, measured 5.0 cm by 2.3 cm. Area is 50% dark brown and 50% pink/red, which is unstageable due to eschar; -Right hip, Stage II pressure ulcer, measured 1.0 cm by 1.0 cm by 0.1 cm with red/pink center; -Left hip, measured 3.0 cm by 5.8 cm with 60% dark brown/black/yellow eschar and 40% pink/red tissue. Area unstageable due to eschar present; -Inner left heel, measuring 5.5 cm by 6.0 cm. Soft, dark brown, purple and black area; -Outer left heel, area measured 3.2 cm by 4.5 cm, that was red, dark brown and black, soft to touch; -Inner left ankle, area measured 2.0 cm by 3.0 cm, that was dry and dark brown and black; -Outer left ankle had a dark brown, purple area that measured 1.5 cm by 2.0 cm, that was red and black and soft; -Upper/inner left foot had a soft, brown/black area that measured 2.0 cm by 2.8 cm; -Outer left foot had a 1.5 cm by 2.0 cm red and black soft area; -Inner right heel had a 5.5 cm by 6.5 cm red, brown/black area that was dry in appearance but very soft to touch; -Outer right ankle, had a 4.0 cm by 3.8 cm area, that was dry and dark brown/black in appearance. Review of the resident's "Interim" care plan, dated 8/28/12, showed the resident required some or total assistance to eat/drink and an order for [REDACTED]. Review of the resident's physician's progress note, dated 8/29/12, showed a [DIAGNOSES REDACTED]. Review of the resident's weight history, showed the resident weighed 184 lbs on 9/1/12. Review of the facility's "Weekly Weights", showed the resident refused to be weighed on 9/5/12. Review of the resident's "Nutrition Data Collection/Assessment", completed by the Registered Dietician (RD) on 9/6/12, showed new recommendations for nutritional supplements and weekly weights for four weeks. Recommendations communicated to the DON and physician. Review of the facility's "Weekly Weights", showed the following: -9/18/12: Refused; -9/25/12: 161 lbs, this represents a severe weight loss (a severe weight loss is defined as a loss of more than 5% ine one month, 7.5% in three months or 10% in six months) 23 lb or 12.5% weight loss since 9/1/12. Review of the resident's medical record, showed staff failed to contact the resident's physician or the RD regarding the resident's weight loss on 9/25/12. During an interview on 10/26/12 at 4:25 P.M., the DON said she could not find the resident's weekly weights for 9/12/12. She did not know if they had been obtained or not. If a resident refused to be weighed, she expected staff to try again. She did not know if anyone attempted to weigh the resident again on 9/5/12 or 9/18/12. During a telephone interview on 11/7/12, at 12:30 P.M., the administrator said staff should have contacted the resident's physician about the resident's weight loss on 9/25/12. She spoke to the RD who said staff made her aware of the resident's weight loss on 9/25/12, but she failed to document the weight loss or make any new recommendations in the resident's medical record. Review of the facility's "Weekly Weights", showed no weights obtained for the resident, from 9/26/12 through 10/10/12. During an interview on 10/26/12 at 4:25 P.M., the DON said she could not find the resident's weekly weights from 9/26/12 through 10/10/12. She did not know if staff had obtained them or not. Review of the facility "Weekly Weights", dated 10/11/12, showed the resident weighed 149.8 lbs. This represents a weight loss of 34.2 lbs or 18.58% from 9/1/12 and 11.2 lbs or 6.95% from 9/25/12. Review of the resident's medical record, showed the facility notified the resident's physician and RD regarding the resident's weight loss on 10/11/12. Review of the resident's nurse's e-note, dated 10/23/12 at 10:00 A.M., showed the resident's physician assessed the resident's pressure ulcers and ordered laboratory work. Review of the resident's nurse's e-note, dated 10/24/12 at 11:45 A.M., showed the facility notified the resident's physician regarding the results of the laboratory tests ordered on [DATE]. At 2:00 P.M., on that date, the resident's physician ordered staff to send the resident to the hospital. Review of the hospital progress notes, dated 10/24/12, showed the resident had been admitted for a blood transfusion, no active bleeding, possible [MEDICAL CONDITION] of chronic disease. Observation on 10/26/12 at 11:00 A.M., showed the resident returned to the facility by ambulance from the hospital. During a telephone interview on 11/7/12 at 12:30 P.M., the administrator said the resident was admitted to Hospice on 10/26/12. Observation on 10/26/12 at 2:10 P.M., showed the resident lay in bed. Nurse AA treated the resident's pressure ulcers and obtained the following measurements: -Coccyx unstageable pressure ulcer, measured 8.0 cm by 11.0 cm, covered by brown and yellow eschar; -Right hip, loose scab, measured 1.0 cm by 0.75 cm; -Left buttock unstageable pressure ulcer, measured 5.5 cm by 6.0 cm, and covered by black and brown eschar and yellow slough; -Left medial shin, unstageable, measured 1.8 cm by 1.5 cm, and covered by brown eschar; -Left inner thigh, 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 and tunneling.), measured 2.5 cm by 2.7 cm, and covered with yellow slough; -Right medial knee, unstageable pressure ulcer, measured 4.4 cm by 3.0 cm, covered with 80% - 90% brown eschar; -Right outer ankle, unstageable pressure ulcer, measured 4.5 cm by 3.0 cm; -Right heel unstageable pressure ulcer, measured 5.5 cm by 5.75 cm, covered with black eschar; -Right lateral foot, unstageable pressure ulcer, measured 1.5 cm by 1.0 cm; -Left outer ankle, unstageable pressure ulcer, measured 2.9 cm by 2.0 cm, covered with black eschar; -Left outer heel, unstageable pressure ulcer, measured 1.0 cm by 1.9 cm, covered with black eschar; -Left lateral foot, unstageable pressure ulcer, measured 0.5 cm by 0.5 cm, covered with black eschar; -Left lower shin, unstageable pressure ulcer, measured 1.7 cm by 0.5 cm, covered with yellow slough; -Left inner heel, unstageable pressure ulcer, measured 5.0 cm by 4.75 cm, covered with black eschar. Review of the facility policy for pressure ulcers, revised on 10/7/10, showed the following: -As the body's largest organ, the skin plays a critical role in our ability to interface with a constantly changing environment. Over the years, especially in our advanced years, our skin changes. It becomes drier, thinner, more fragile, and slower to heal, causing the skin to be at a higher risk for injury and disease. For this reason, protecting the skin integrity of older long-term care residents is vital to their physical health; -A pressure ulcer can occur wherever pressure has impaired circulation to the tissue. It is important to recognize and evaluate all areas at risk of constant pressure. It is imperative that a system be in place to: Identify residents at risk for skin breakdown, identify and evaluate factors that can be removed or modified, initiate protocol and treatment to prevent skin breakdowns, provide appropriate intervention and treatment for [REDACTED]. -The facility must ensure: A resident who enters the facility with a pressure ulcer receives care and services to promote healing and prevent additional ulcers; -The skin care program developed by the facility is interdisciplinary and implemented using a team approach; -Members of the team include: nurses, certified nursing assistants, resident (if able), resident's family member/caregiver, physician and/or Medical Director, Registered Dietician, physical/occupational therapy, activities and social services; -The skin care program's interdisciplinary team functions as an action team dedicated to developing and implementing a comprehensive program with a holistic (natural) approach; -Each discipline has a vital role in wound care; -All disciplines focus on assessment, planning, implementing, and documenting care; -Communication is vital and should occur daily at the stand-up meeting, weekly at the Nutrition Intervention Program meeting, and monthly at the Performance Improvement meeting; -At the time of admission, each resident is evaluated for special needs related to skin care. Additionally, all residents receive weekly skin integrity checks performed by licensed personnel. Skin should be checked daily; -On a weekly basis, an in-depth assessment is performed and recorded on the Pressure Ulcer Status Record in the resident's medical record; -The facility's procedures are such that all disciplines are alerted immediately if the resident either has skin breakdown or is at risk for the development of skin breakdown. The Nursing department coordinates the response to resident needs by the following means: With medically directed treatments for residents with an existing problem, with an array of preventative measures practiced on the resident's behalf when the resident has been identified at risk, with a medically directed restorative and therapeutic program for residents who develop a skin problem after admission; -The admitting nurse follows the placement of the resident into bed with a careful full-body skin check. Pertinent information obtained from the check is recorded in the admission note. The admitting nurse completes a Braden Scale risk assessment. If the evaluation shows the resident to be at risk or prone to skin breakdown (scoring 14 or below on the Braden Scale), measures and interventions are considered. During an interview on 10/26/12 at 4:35 P.M., the DON said staff should have monitored the resident's heel blisters and excoriated buttocks after 8/1/12. They should have contacted the resident's physician. She did not know why they did not. She did not know the resident had the heel blisters or excoriated buttocks. She did not know the hospital found all of the pressure areas they did on 8/13/12. During a telephone interview on 11/2/12 at 9:15 A.M., the resident's physician said facility staff should have notified him, on 8/1/12, about the resident's heel pressure ulcers and excoriated buttocks. He would have ordered treatments and/or a low air loss mattress (pressure relieving mattress). He was not aware of the pressure ulcers identified on 8/13/12, until the hospital notified him at that time. It's highly unlikely that the resident would have developed the deep tissue injuries recorded by hospital staff in the few hours from his/her discharge from the facility to his/her admission to the hospital. The resident returned to the facility on [DATE] with IV antibiotics to treat the septic heel pressure ulcers. MO 138