Every finding on record at Life Care Center of Cape Girardeau

Based on observation, interview, and record review, the facility failed to ensure sufficient fluid intake to maintain proper hydration and health by not providing residents with fresh, easily accessible water at bedside, assistance with holding a water cup and cueing/offering resident's hydration for three of the four sampled residents, (Residents #1, #2, #3). The facility census was 79.Review of the facility's undated policy titled, Hydration and Nutrition, dated 09/25/25, directed staff to do the following: - Offer residents sufficient fluid intake to maintain proper hydration and health;- Fluid is available to residents at all times;- Continually assess the resident of the ability to consume and assimilate food and fluid is conducted by nursing personnel and all concerns are reported to the nurse to include the ability to feed self, the imbalance of intake, and signs of dehydration;- Document intake percentages;- Notify the resident's physician of any concerns. 1. Review of Resident #1's progress notes dated 12/01/25 showed:- The resident not eating or drinking; - The resident showed signs of an altered mental status (a sudden change in brain function making a person confused or less alert);- An order to send Resident #1 to the Emergency Department (ED) for evaluation;- The resident returned to the facility on [DATE] with a diagnosis of a Urinary Tract Infection (an infection in the bladder causing issues with urination and painful) (UTI) and with an Antibiotic for the infection. Review of the resident's hospital record showed entry to the ED on 12/01/25 and discharged on 12/02/25 with a diagnosis severe dehydration (defined as a medical emergency requiring intravenous hydration, confusion, lack of urination, extreme thirst rapid pulse and rapid heartbeat) and a UTI. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/03/25, showed:- Cognitively intact;- Dependent with all ADLs, including eating and transfers;- Diagnoses included chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing) anxiety, depression and Acute Cystitis without Hematuria (a bladder infection without blood). Review of the resident's plan of care, dated 12/05/25 showed:- The resident had a UTI on 12/02/25;- Staff to encourage fluid intake;- The resident has an indwelling catheter;- No information regarding the resident's need for assistance with eating or drinking.Review of the resident's labs dated 12/12/25 showed the resident was positive for a UTI.Observation on 12/16/25 at 11:15 A.M. showed Resident #1 in bed. A cup of water sat on the bed side table which was approximately three feet out of the resident's reach. The resident appeared weak and could not sit up. The resident's lips were cracked and peeling.During an interview on 12/16/25 at 11:57 A.M., Resident #1 said fill the water pitchers, but no one offers to assist him/her with drinking. Resident #1 said he/she was too weak to lift and hold the cup. The resident said he/she could not remember the last time the staff had offered him/her water. The resident said he/she was very thirsty and would like to drink some water. The Director of Nurses (DON) came to Resident #1's room and assisted the resident with drinking approximately 500 cubic centimeters (cc). 2. Review of Resident #2's plan of care, dated 09/01/25 showed:- The resident is totally dependent upon staff for all ADL's including eating, drinking and transferring;- The resident is at risk for dehydration;- Staff are to monitor for signs of dehydration and output of urine.Review of the resident's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact;- Dependent on staff with all ADLs;- Diagnoses of Quadriplegia (paralysis affecting all four limbs), acute respiratory failure (life threatening condition affecting lung intake), obesity, Type II Diabetes Mellitus (DM) (a chronic condition affecting the body's insulin production or resistance to it), and disorder of the kidneys (chronic kidney disease often caused by diabetes or high blood pressure).Observation on 12/16/25 at 11:30 A.M., showed Resident #2 in bed with a cup of water on the bed side table located across the bottom half of the bed.During an interview on 12/16/2025 at 11:30 A.M. A.M., Resident #2 said he/she was thirsty and needed a drink. The resident said he/she is aware the water cup is on the bedside table; however, he/she had no way to drink unassisted. Resident #2 said staff routinely fill the cup with water, but he/she could not remember the last time anyone offered him/her a drink between meals or at night.3. Review of Resident #3's plan of care dated 12/05/25 showed:- The resident is cognitively intact;- The resident requires assistance with all ADLs; but can feed him/herself.Review of the resident's admission MDS dated [DATE] showed:- The resident is cognitively intact;- The resident requires some assistance with all ADL's but can feed him/herself; - Diagnoses of depression, anxiety, Type II DM, and a chronic kidney condition. Observation on 12/16/25 at 11:50 A.M. showed Resident #3 in bed with a cup of water on a bed side table located against the wall approximately 6 feet out of the resident's reach. During an interview on 12/16/25 at 1:10 P.M., Certified Nurse Aide (CNA) A said he/she passes ice and water every shift and offers more ice and water as needed. Anytime a CNA enters a room for care or bed check, water is offered. Bed checks are done every two hours and water is offered then. C.N.A. A said all newly hired CNA's should know which residents need assistance and which ones are able to do for themselves. During an interview on 12/16/25 at 1:30 PM, Registered Nurse (RN) B said CNAs are supposed to offer hydration and they don't. RN B said he/she has reported the situation to the unit manager more than once and asked for his/her thoughts on how to improve the situation. RN B said he/she has discussed the matter of the CNAs not performing their duties with management and there has been no change. He/she feels the residents are not getting proper hydration. RN B notified the physician when Resident #1 appeared dehydrated. During an interview on 12/16/25 at 1:50 PM, Licensed Practical Nurse (LPN) A said anytime a CNA enters a resident's room, they should be offering the resident a drink of water. Call lights and water are to be kept within reach of every resident. Those are the expectations. During an interview on 12/16/25 at 2:30 P.M., the DON said she was not aware of the hydration issues with the residents. She said she would expect the staff to be offering fluids to those who cannot drink on their own, regularly through out the shift. COMPLAINT: 2681501

Based on interview and record review, the facility failed to ensure an accurate and consistent system was in place to direct staff when to initiate basic life support for one resident (Resident #1), when on [DATE] at around 10:25 P.M., staff entered the resident's room and found the resident unresponsive with no respirations. Cardiopulmonary resuscitation (CPR - a procedure performed usually involving chest compressions and assisted breathing to revive a person's life) was initiated by facility staff with notification to emergency medical services (EMS) and hospice services. The resident's facility medical record showed a full code status order was entered on [DATE], without any documentation of the resident's wishes or consent for a full code status. The resident's hospice record located in the facility showed the resident's consent and an order for do not resuscitate (DNR) on [DATE], with documentation of the conversation for the DNR as per the resident's choice. The facility census was 92. On [DATE] at 4:25 P.M., the Director of Nursing (DON) was notified of the immediate jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's policy titled, Advance Directives and Advance Care Planning, dated [DATE], showed: - Residents have the right to self-determination regarding their medical care. This includes the right of an individual to direct his or her own medical treatment, including the right to execute or refuse to execute an advance directive; - It is required that the patient is asked about advanced directives, and to document any wishes the patient might have with regard to the care they want or do not want; - The facility is not relieved of its obligation to provide this information to the individual once he/she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time; - Do Not Resuscitate order -A medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest. Existence of an advance directive does not imply that a resident has a DNR order. The medical record must show evidence of documented discussions leading to a DNR order; - Competent - Residents have the right to actively participate in their plan of care. The resident has the right to designate a representative, in accordance with State law, and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. A resident is competent to make a health care decision if he/she understands the nature of his or her illness, understands the treatment options available to him/her, understands the consequences of refusing such treatments, and is able to make and communicate decisions about his/her medical treatment; - Residents or their responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care, including the right to accept or refuse medical care, the right to accept or refuse medical/surgical treatment, organ donation requests, and the formation of advance directives upon admission; - A written description of the facility's policies regarding advance directives and applicable State law is provided to the resident or resident representative. Information is provided in a manner easily understood by the resident or resident representative; - The resident and/or family, upon admission, to determine the need and knowledge relative to advance directives and advanced care planning; - Residents may revise an advance directive either orally or in writing. With an oral reversal, charting is due immediately, the physician is notified immediately, an immediate notation is made on the care plan, and an immediate entry is made in the medical record. With written reversals, the physician is notified, and the plan is permanently adjusted. The physician must give an order for any changes in the advance directives; - If the resident leaves the facility temporarily (e.g., emergency room visit, hospital stay, or diagnostic procedure), a copy of the advance directive is sent with the resident. The facility should also ensure advance directive status (e.g., DNR) is communicated to the receiving provider and transporting provider; - Each time the resident is admitted to the facility, quarterly, and when a change in condition is noted in the resident condition, the facility should review the advance directive and advance care planning (ACP) information. This review should focus on if the existing advance directives and ACP match the current goals of care for the resident. The social services director or designee should document this conversation in the medical record and assist as needed with updating the documents that need revision in accordance with state and federal requirements; - Residents who are competent at the time of admission and who have not previously executed an advance directive are given the opportunity to do so with the assistance of an interdisciplinary team, consisting of, but not limited to: the Medical Director, Executive Director, DON, Director of Social Services, chaplain, and others as appropriate. Social Services ensures that a copy of the advance directive is obtained for the resident's medical record and verifies that there is an appropriate physician's order in the resident's medical record as well; - Documentation in the Minimum Data Set (MDS - a federally mandated assessment to be completed by facility staff) should reflect the appropriate advance directives. This information is reviewed or updated, as appropriate, at least quarterly or more frequently if there is a significant change in the resident's medical condition. Each quarter the care plan team reviews with the resident, his/her advance directives to ensure that they are still the wishes of the resident. Such reviews are made during the quarterly assessment process and recorded on the Resident's Assessment Instrument (RAI); - DNR - Regardless of whether the resident is in a persistent vegetative state or has a terminal condition, all Life Care Centers of America's residents receive full resuscitative measures unless a DNR is written in the resident's medical record and is identified in the resident's advance directive. While the physician's order is pending, the documented verbal wishes of the resident or resident's representative regarding DNR status will be honored, unless state specific guidelines differ; - Social Services or Nursing Administration's documentation of the DNR must be present in the medical record regarding the DNR status and discussion with the resident and/or resident's representative on the consequences and implications of this status. The physician is notified regarding any questions concerning the appropriateness of the resident's code status; - A physician's order and written consent from the resident or resident's representative must be obtained. While the physician's order is pending, staff should honor the documented verbal wishes of the resident or the resident's representative regarding CPR unless state-specific regulations differ; - DNR order is flagged appropriately on the resident's chart to alert staff as to status; - Social Services and/or a member of Nursing Administration reviews the DNR status with the resident and/or family and the receiving physician within 72 hours of admission; - The resident or resident's representative must sign an informed consent as required by state specific requirement indicating that the resident consents to a DNR or no CPR or no resuscitation in the event of cardiac arrest or respiratory failure; - The DNR order is incorporated into the resident's care plan and is periodically reviewed, at least quarterly, including supportive care and comfort measures. These measures will not be withheld when a DNR order exists; - DNR orders may be revoked at any time but must be documented in the resident's chart as such with consent of the resident or the resident's representative; - The resident's physician is notified of any change in condition regardless of the DNR order; - The DON or designee establishes a system to inform all direct care staff of the resident's DNR status; - If the resident is discharged from the facility and re-admitted , the DNR status must be reviewed to determine if it is still appropriate and desired by all parties involved. A new order for DNR is obtained at that time. 1. Review of Resident #1's medical record showed: - An admission date of [DATE]; - A Code Status form signed by the resident on [DATE], with both full resuscitation and Do Not Attempt Resuscitation (DNAR - no medical procedures or measures of resuscitation would be taken including no CPR and not calling 911) marked with an X with a line through the full resuscitation X; - No documentation of a code status in the Resident admission Agreement; - No documentation of a baseline care plan (basic information of resident done with 48 hours of admission) that addressed the resident's code status; - An order for a Full Code status, dated [DATE]; - No documentation of any contact with the resident, the resident's family, or the physician to obtain a proper authorization for a code status change from DNR to Full Code. Review of the resident's hospice binder showed: - Long-term Care/Hospice Coordination of Care Form with code status marked DNAR signed by Hospice Intake Coordinator Nurse H and a facility staff member on [DATE]; - A progress note, dated [DATE] from 2:33 P.M. - 3:46 P.M., showed Hospice Intake Coordinator Nurse H met with the resident at the hospital to sign the hospice admission paperwork. The hospice admission paperwork was discussed with the resident. All of the paperwork was signed by the resident. The hospice admission paperwork discussion included the home DNR form, the outside the hospital DNR form, the hospice consent for treatment, the release of information, and the acknowledgement of information form. The admission form was given to the resident. The resident did not have a durable power of attorney (DPOA) and said he/she had no one but himself/herself. The resident was alert and oriented times four. Vital signs were taken and a full assessment was completed. Medications were reviewed with the resident and the facility nurse. Orders were given to the facility nurse and all questions answered. Instructed to contact the hospice nurse 24 hours a day seven days a week with any questions, concerns, or changes in the resident's condition. Discussed who the hospice nurse and the aide would be and what days they would be making visits; - A code status order signed on [DATE] at 10:48 A.M. by the hospice physician for a no code blue (chest compressions or medications to restart the heart if it stops)/no intubation (breathing tube inserted into the trachea to help with breathing). Review of the facility's investigation of the resident's event on [DATE] showed: - A witness statement, dated [DATE], Licensed Practical Nurse (LPN) D said on [DATE] at 10:25 P.M., LPN D was called to the resident's room by other staff and said the resident was not breathing. A crash cart was brought to the resident's room and CPR was started. EMS was called by a CNA. At 10:33 P.M., Hospice Registered Nurse (RN) G entered the resident's room and said no need to continue CPR as the resident was a no code by the hospice paperwork and advised EMS staff there was no need to enter the facility. At 10:48 P.M., Hospice RN G exited the facility and said he/she would return to the facility to complete the needed paperwork; - A witness statement, dated [DATE], showed CNA E said on [DATE], LPN D told him/her to call ambulance services because the resident was unresponsive. He/She called EMS, returned to the resident's room, and helped assist with CPR until the facility nurse came in and said to stop because the hospice nurse said the resident had DNR papers. Observation and interview on [DATE] at 2:30 P.M. showed: - LPN A said he/she noticed shortly before he/she left on the day shift on [DATE], the resident did not have a code status listed in PCC, so he/she entered it. Staff used the code status that was listed in PCC. Staff entered the resident's information in PCC on [DATE], when the resident was admitted , but didn't list the code status. LPN A did not discuss the code status with the resident on [DATE], because he/she was asleep. He/she looked at the resident's facility admission paperwork which listed him/her as a full code; - LPN A reviewed the resident's admission paperwork packet and he/she could not find the form he/she was referring to for the resident's full code status. LPN A said the nurse that admitted the resident was supposed to complete the paperwork and then the health medical records person was supposed to scan the documents into the resident's file. During an interview on [DATE] at 10:57 A.M., LPN B said the resident was alert and oriented times four and able to make his/her own decisions. He/She finished the admission paperwork on [DATE], since it was not completed on [DATE], when the resident was admitted . The admission paperwork should be completed within the first 24 hours of being admitted . All of the resident's orders in PCC were messed up or not there. The hospice nurse was there the morning of [DATE], for the first two to three hours of his/her shift and helped him/her straighten out the orders. He/She did not recall seeing the hospice binder, but did interview the resident on [DATE], and the resident said he/she wanted to be a full code. He/She did not document this discussion in the resident's medical record. At the time of the discussion, the hospice nurse had already left the building, but was supposed to come back later in the day. By the time the hospice nurse came back, he/she had forgotten to tell the hospice nurse what the resident's wishes were. The admission paperwork was put in a basket by the fax machine and someone came by to collect it and scan the information into the computer. He/She would usually put a code status order in PCC, but since the resident was hospice, hospice residents were usually DNR and this resident wanted to be full code, he/she wanted to clarify the code status change first. He/She gave report to LPN D on [DATE] at around 6:00 to 6:30 P.M. and the resident was at baseline at that time. He/She would look in PCC to see what the code status of the resident would be. The facility had a lot of travel agency workers who often had a lack of communication with what went on in the facility. During an interview on [DATE] at 9:30 A.M., LPN C said he/she remembered working night shift on [DATE], and the resident was alert and oriented with a little confusion at times. He/She made his/her needs known. LPN C said he/she thought it was given in report the resident was a DNR, but had mentioned wanting to change to full code status and gave the same information to the next shift, LPN B, on [DATE]. He/She did not verify the code status with the resident and did not do the admission paperwork, but did help with the admission process by doing the admission assessments. He/She did not do any admission paperwork, but did remember seeing a white binder with the resident's hospice information in it. He/She did not remember looking at the information or what the binder showed was the resident's code status was. He/She would look for the code status in PCC and if it was not signed by the physician and by the resident or the resident representative, then he/she would go by the last known legal code status on file. During an interview on [DATE] at 9:27 A.M., Hospice Manager F said he/she prepared the hospice binders. The hospice binders included all necessary orders, forms, care directions, and staff information related to the resident's care. Once the binder was together, then Hospice Intake Coordinator H delivered the binder to the facility. The intake coordinator conducted a meeting with the resident and the facility staff to review and sign the necessary forms, go over care instructions, and then left the hospice binder at the facility. The hospice binder remained at the facility until the resident expired. After the resident expired, the documents were left with the facility and the empty binder would be taken back to the hospice office. During an interview on [DATE] at 10:02 A.M., Hospice Intake Coordinator Nurse H said Hospice Office Manager F assembled the hospice binders. He/She brought the hospice binder, the field chart, and the signable forms to complete the resident's in-person admission that was put together by Hospice Office Manager F to the facility. He/She met the resident and the resident's facility primary nurse on [DATE]. During the visit on [DATE], both the facility nurse and the resident signed the Long-Term Care Hospice Coordination of Care Form, which showed the resident's DNR code status. He/She reviewed the medications with the facility nurse who signed off on the medications. He/She also went over the resident's plan of care and answered any questions for the facility nurse. After the admission was complete, he/she left the hospice binder, which included the resident's DNR documentation, at the facility. The DNR documentation details included a Hospital DNR that was already signed by the physician, a Hospice DNR order with a verbal consent order by the physician obtained on [DATE], and the signed order by the Hospice physician on [DATE]. The binder included multiple references to the resident's DNR code status. The hospice binder remained in the facility until after the resident expired. After the resident expired, the hospice staff would leave all of the resident's documents from the hospice binder with the facility and retrieve the empty binder. He/She recalled Hospice RN I did his/her first visit on [DATE], and noted the binder was missing from the usual location. The binder was found later at the nurse's station among other binders. During an interview on [DATE] at 10:17 A.M., Hospice RN I said he/she was the primary hospice nurse assigned to the resident and completed the first facility visit on [DATE]. On arrival to the facility on [DATE], the hospice binder was not in the usual location which was a small room behind the nurse's station. He/She eventually found the binder in with other binders on the nurse station desk. He/She spoke with LPN B and found the orders for the resident were messed up. He/She had to provide updated orders to the facility nurse before ending the visit on [DATE]. During an interview on [DATE] at 9:59 A.M., Hospice RN G said he/she received a phone call from LPN D who said the resident was actively coding on [DATE]. He/She was about three minutes from the facility and informed LPN D the resident was a DNR and the hospice binder should confirm that information. Upon arrival to the facility, LPN D was at the front desk looking through the hospice binder. The hospice binder showed the resident was a DNR and should not have been coded. He/She did not enter the facility beyond the front desk and did not witness the code. He/She did not know the exact details of what occurred. EMS arrived shortly after him/her, but the facility nurse stopped EMS at the door and said they were no longer needed. EMS did not enter the facility. He/She then left the facility to answer another hospice patient's needs. He/she returned to the facility within one to one and a half hours, and completed the usual post-death procedures. During an interview on [DATE] at 2:40 P.M., the Director of Nursing (DON) said addressing a resident's code status should be one of the first things done when admitting a new resident. The nurses on the unit were responsible for filling out the admission paperwork packet and it should address the code status. The code status should match between the hospice record and the facility record. The Care Profile in PCC should show the current accurate code status. During a phone interview on [DATE] at 3:12 P.M., the Medical Director said he/she was told about the incident with the resident's code status. He/She did not sign a DNR order. If the resident wanted to be a full code and had conversations with the facility staff about it, then those conversations should be documented somewhere in the resident's medical record. The facility should have the code status and the resident's wishes of a newly admitted resident within 24 hours of admission. The resident's code status should match throughout the resident's medical record. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). Complaint #MO00256082

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 88. The facility policy titled, Food Safety, reviewed 05/01/25, showed: - Food is stored and maintained in a clean, safe, and sanitary manner following federal, state, and local guidelines to minimize contamination and bacterial growth; - Pre-packaged food is placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). The use by date is noted on the label or product when applicable; - The use by date guide is easily accessible to all associates involved with resident food storage; - Dented, leaky, rusted, and swelling cans that could affect food safety are returned to the vendor but stored in a designated area away from other food. These items will not be used; - The Director of Food and Nutrition Services implements practices to eliminate infestation of pests and prevents the contamination of food; - Food is inspected upon delivery for damage, rodent or insect infestation, and spoilage; - Food is labeled with the date received if not already indicated on the item; - If multiple items are packaged in one box, each item will be individually dated with receipt date; - Ambient temperatures in refrigerators/coolers are to remain at or below 41 degrees Fahrenheit ( F) to significantly slow growth of microorganisms; - Ambient temperatures in freezers remain at 0 F or lower and all food is frozen solid; - Temperatures are recorded at least twice daily on the Refrigerator/Freezer Temperature Log using an inside thermometer placed near the door which is the warmest part of the refrigerator, and any problems will be reported immediately to the Director of Food and Nutrition Services /Maintenance; - Opened packages of food are resealed tightly to prevent contamination of the food item and use by date will be used when applicable; - Opened food items will be removed from the original packaging that it was delivered in before being placed in an ingredient bin or storage container; - Food not safe for consumption or the safety of the food is in question will be removed from storage; - Scoops will be stored in a manner that does not have the potential to contaminate the food ingredients. For example, scoops will be stored outside of bins or placed in a holder on the side of the bin. 1. Observation on 05/19/07/25 at 3:24 P.M., of the dry food storage room showed: - An opened bottle of lemon juice that required refrigeration after opening; - A bag of Oreo cookie pieces, a bag of powdered sugar, and a bag of corn bread mix improperly sealed; - Five large plastic bins contained cereal and two large plastic bins contained breadcrumbs with no best by date label; - A large plastic bin with no lid contained bags of dry pasta with debris in the bottom of the bin; - One bag of pasta not dated or labeled. 2. Observation on 05/19/07/25 at 3:26 P.M., of the double door refrigerator located in the front of the kitchen showed: - Three large pitchers of a prepared drink without a labeled date; - Two plastic containers of lunch meat not dated and labeled. 3. Observation on 05/19/07/25 at 3:28 P.M., of the walk-in refrigerator located in the back of the kitchen showed: - Two heads of lettuce, unwrapped/undated in an opened cardboard box; - One watermelon with large crack across the top of it unwrapped/undated in a cardboard box; - Potatoes in a large undated, opened cardboard box on the lower shelf with a fuzzy white/green substance on some of them; - An unsealed and unlabeled bag of celery; - A prepared salad with no date; - An opened and undated block of butter. 4. Observation on 05/19/07/25 at 3:30 P.M., of the walk-in freezer located in the back of the kitchen showed: - Seven bags of frozen vegetables and meat patties sat in opened cardboard boxes improperly sealed and undated. 5. Observation on 05/19/07/25 at 3:31 P.M., of the ice machine located in the front of the kitchen showed: - An ice scoop lay on top of the ice machine. 6. Review of the Food Temperature Logs, dated March 2025 and April 2025, showed: - Food temperature logs for 03/01/25 - 03/09/25 and 03/24/25 - 03/31/25, were not completed for March 2025, with a total of 17 out 30 opportunities missed; - No food temperature logs for April 2025, with a total of 30 out 30 opportunities missed. 7. Review of the Walk-in Refrigerator Logs for the morning shift temperatures, dated March 2025, showed: - 03/04/25 - 50 F; - 03/05/25 - 55 F; - 03/08/25 - 55 F; - 03/09/25 - 51 F; - 03/10/25 - 55 F; - 03/11/25 - 51 F; - 03/12/25 - 52 F; - 03/13/25 - 48 F; - 03/15/25 - blank; - 03/16/25 - 51 F; - 03/17/25 - 45 F; - 03/19/25 - 49 F; - 03/20/25 - blank; - 03/22/25 - 50 F; - 03/23/25 - 55 F; - 03/26/25 - 48 F; - 03/17/25 - 52 F; - 03/49/25 - 49 F; - 03/29/25 - blank; - 03/30/25 - blank; - 03/31/25 - 45 F; - A total of 21 out of 31 days the morning temperatures were left blank or had a temperature higher than 41 F; - Notes to the side of the log the door was left open. Review of the Walk-in Refrigerator Logs for the evening shift temperatures, dated March 2025, showed: - 03/04/25 - 46 F; - 03/05/25 - 46 F; - 03/06/25 - 44 F; - 03/07/25 - 44 F; - 03/08/25 - 48 F; - 03/09/25 - 48 F; - 03/11/25 - 48 F; - 03/12/25 - 50 F; - 03/13/25 - 50 F; - 03/14/25 - 48 F; - 03/15/25 - 48 F; - 03/16/25 - 55 F; - 03/18/25 - 44 F; - 03/20/25 - blank; - 03/22/25 - blank; - 03/23/25 - blank; - 03/24/25 - blank; - 03/25/25 - 42 F; - 03/27/25 - 48 F; - 03/28/25 - 44 F; - 03/30/25 - 42 F; - A total of 21 out of 30 days the evening temperatures were left blank or had a temperature higher than 41 F; - Notes to the side of the log the door was left open. Review of the Walk-in Refrigerator Logs for the morning shift temperatures, dated April 2025, showed: - 04/04/25 - 42 F; - 04/05/25 - 50 F; - 04/11/25 - 56 F; - 04/12/25 - 48 F; - 04/13/25 - 52 F; - 04/15/25 - 49 F; - 04/16/25 - 51 F; - 04/17/25 - 48 F; - 04/18/25 - 54 F; - 04/19/25 - 45 F; - 04/20/25 - 43 F; - 04/22/25 - 42 F; - 04/23/25 - 45 F; - 04/25/25 - 48 F; - 04/26/25 - 42 F; - 04/27/25 - 48 F; - 04/28/25 - blank; - 04/29/25 - 50 F; - 04/30/25 - 45 F; - A total of 19 out of 30 days the morning temperatures were left blank or had a temperature higher than 41 F.; - Notes to the side of the log the door was left open. Review of the Walk-in Refrigerator Logs for the evening shift temperatures, dated April 2025, showed: - 04/03/25 - 42 F; - 04/04/25 - 46 F;; - 04/05/25 - 48 F; - 04/06/25 - 44 F; - 04/07/25 - 48 F; - 04/08/25 - 46 F; - 04/09/25 - 48 F; - 04/11/25 - 46 F; - 04/12/25 - 46 F; - 04/13/25 - 48 F; - 04/16/25 - 72 F; - 04/18/25 - 44 F; - 04/19/25 - 44 F; - 04/20/25 - 42 F; - 04/21/25 - 42 F; - 04/22/25 - 52 F; - 04/23/25 - 42 F; - 04/24/25 - 42 F; - 04/25/25 - 43 F; - 04/26/25 - 43 F; - 04/27/25 - blank; - 04/28/25 - blank; - 04/29/25 - blank; - 04/30/25 - blank; - A total of 24 out of 30 days the evening temperatures were left blank or had a temperature higher than 41 F; - Notes to the side of the log the door was left open. During an interview on 05/22/25 04:30 PM., the Dietary Manager (DM) said he/she would expect items to be appropriately stored, dated, labeled, and the temperature logs completed and with the correct temperature ranges. They had been short staffed. He/She and the Assistant DM were cooking and serving food so things like temperature logs got put on the back burner. During an interview on 05/22/25 at 6:30 P.M., the Director of Nursing (DON) and the Administrator said they would expect items to be appropriately stored, dated, labeled, and the temperature logs completed and within the correct temperature ranges.

Based on observation, interview, and record review, facility staff failed to properly maintain the temperature of cold foods at or below 41 degrees Fahrenheit ( F) at the time of meal service, failed to implement a system to monitor food temperatures at the time of meal service, and failed to ensure refrigerator temperatures were maintained at 41 degrees or below. Failure to maintain foods at the proper temperature had the potential to affect all residents receiving meal service. The facility's census was 88. Facility policy entitled, Food Temperature Control, revised 4/28/25, showed: - Food temperatures are maintained during mealtimes to ensure residents receive safe food served at acceptable temperatures; - Food temperatures are checked at the completion of the cooking process and before food is placed on the serving line; If issues are identified, they are corrected, or the food is discarded; - Food temperatures are recorded prior to meal service on the Food Temperature Record Log; - If the food temperatures are unsatisfactory, the problem areas are corrected before serving the food item(s); - Hot foods are held at a minimum of 135 F or per state requirements; - Cold foods are held at or below 41 F per Centers for Medicare and Medicaid Services (CMS) guidelines, unless state requirements are more stringent; - While potentially hazardous food/time/temperature control for safety (PHF/TCS) Foods are on the serving line, the food will be maintained at a safe temperature; - Salads may be prepared a day prior to serving, stored in a shallow, covered container, and placed in the refrigerator; - Canned items that will be served chilled (i.e., fruits, bean salad, or pudding) may be refrigerated the day prior to use to reach an appropriate temperature; - Milk, juice, and other chilled beverages should remain cold on the serving line and may be placed in a container designed for temperature control; - Food items should not be covered with ice to prevent contamination. 1. Observation on 05/20/25 at 1:28 P.M., of the noon meal test tray showed: - Potato salad with a temperature of 79 F; - Cheesecake with a temperature of 64 F; - Chef salad with a temperature of 72 F. 2. Observation on 05/22/25 at 7:24 A.M., of the breakfast meal test tray showed: - Milk with a temperature of 47 F; - Juice with a temperature of 49 F. Review of the Food Temperature Logs for April 2025 showed: - No documentation of food temperatures for April 2025. Review of the Walk-in Refrigerator Logs for the morning shift temperatures for April 2025 showed: - 04/04/25 - 42 F; - 04/05/25 - 50 F; - 04/11/25 - 56 F; - 04/12/25 - 48 F; - 04/13/25 - 52 F; - 04/15/25 - 49 F; - 04/16/25 - 51 F; - 04/17/25 - 48 F; - 04/18/25 - 54 F; - 04/19/25 - 45 F; - 04/20/25 - 43 F; - 04/22/25 - 42 F; - 04/23/25 - 45 F; - 04/25/25 - 48 F; - 04/26/25 - 42 F; - 04/27/25 - 48 F; - 04/28/25 - blank; - 04/29/25 - 50 F; - 04/30/25 - 45 F; - A total of 19 out of 30 days the morning temperatures were left blank or had a temperature higher than 41 F. Review of the Walk-in Refrigerator Logs for the evening shift temperatures for April 2025 showed: - 04/03/25 - 42 F; - 04/04/25 - 46 F;; - 04/05/25 - 48 F; - 04/06/25 - 44 F; - 04/07/25 - 48 F; - 04/08/25 - 46 F; - 04/09/25 - 48 F; - 04/11/25 - 46 F; - 04/12/25 - 46 F; - 04/13/25 - 48 F; - 04/16/25 - 72 F; - 04/18/25 - 44 F; - 04/19/25 - 44 F; - 04/20/25 - 42 F; - 04/21/25 - 42 F; - 04/22/25 - 52 F; - 04/23/25 - 42 F; - 04/24/25 - 42 F; - 04/25/25 - 43 F; - 04/26/25 - 43 F; - 04/27/25 - blank; - 04/28/25 - blank; - 04/29/25 - blank; - 04/30/25 - blank; - A total of 24 out of 30 days the evening temperatures were left blank or had a temperature higher than 41 F. During an interview on 05/22/25 at 4:30 P.M., the Dietary Manager said he/she knew they did not have all the required temperature logs. They had been short staffed. He/She and the Assistant Dietary Manager had been assisting with cooking and plating the food so the things like the temperature logs were not getting completed/reviewed. He/She knew they were supposed to be completed and reviewed to ensure the equipment and the food was at the correct temperature. With everything they were having to do to help the kitchen staff to ensure food was getting out in time, some things had fallen off or were missed. During an interview on 05/22/25 at 6:30 P.M., the Administrator and the Director of Nursing (DON) said all temperatures logs should be completed and temperatures should be within the correct ranges.

Based on interview and record review, the facility failed to ensure cardiopulmonary resuscitation (CPR - initiation of life sustaining measures in the event the heart stops beating) certified staff accompanied all residents with a full code (initiate CPR in the event the heart stops beating) status when transported to and from appointments in the facility van for two transport drivers (Transport Driver F and Transport Driver G) out of two sampled transport drivers. The facility census was 88. Review of the facility's policy titled, Cardiopulmonary Resuscitation, revised [DATE], showed: - The facility is able to and does provide emergency basic life support immediately when needed, including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physicians' orders, such as do not resuscitate (DNR - do not initiate CPR) and the resident's advance directives; - The facility should ensure that properly trained personnel (and certified in CPR for healthcare providers) are available immediately (24 hours per day) to provide basic life support, including CPR, to residents requiring emergency care prior to the arrival of emergency medical personnel, and subject to accepted professional guidelines, the resident's advance directives, and physician orders; - Did not address the need of CPR certified staff during transportation of residents. 1. Review of Transport Driver F's Employee File showed: - A hire date of [DATE]; - No documentation of CPR certification. 2. Review of Transport Driver G's Employee File showed: - A hire date of [DATE]; - No documentation of CPR certification. During an interview on [DATE] at 5:00 P.M., Employee G said he/she was not CPR certified, and did not know he/she was required when transporting residents. Sometimes staff came along to transport residents, but not always. He/She didn't know if the staff that came along were CPR certified. During an interview on [DATE] at 6:20 P.M., the Director of Nursing (DON) said she would expect transport staff to be CPR certified. During an interview on [DATE] at 6:22 P.M., the Administrator said she would expect transport staff to be CPR certified. She said Certified Nursing Assistants (CNA) and other staff sometimes accompany the residents during transport, but that they did not always. She didn't know if the staff that accompany the residents at times were CPR certified.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Residents #25 and Resident #54) out of 21 sampled residents. The facility census was 88. Review of the facility's policy titled, Certification of Accuracy of the MDS, revised 04/22/25, showed: - Each person completing a portion of the MDS is required to sign the attestation statement certifying they have used the Centers for Medicare and Medicaid Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual to complete the MDS; - The assessment must accurately reflect the resident's status; - The facility is responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment; - The assessment must represent an accurate picture of the resident's status during the observation period of the MDS; - When the MDS is completed, only those occurrences during the observation period will be captured on the assessment. 1. Review of Resident #25's medical record showed: - An admitted [DATE]; - Diagnoses of dizziness and giddiness (feeling unsteady, lightheadedness, or spinning), age-related osteoporosis (decreased bone density), and rheumatoid arthritis (inflammation of the joints). Review of the resident's Monthly Summary, dated 04/05/25, showed: - The resident with bilateral (both sides) contractures of hands; - Resident required assistance with eating.; - Not coded dependent for eating. Review of the resident's quarterly MDS, dated [DATE], showed: - Impairment on both sides of the upper body; - Substantial/Maximal assistance from staff with oral hygiene; - Required set up or clean up assistance for eating. Observations on 05/20/25, of the resident showed: - At 6:27 P.M., the evening meal tray was delivered to the resident's room; - At 6:29 P.M., staff exited the resident's room. Another staff walked by and asked if he/she set up the resident's tray in front of the resident because he/she had to be fed; - At 6:40 P.M., the resident tried to reach his/her arms up and towards the meal tray. The resident yelled for staff to come here; - At 6:49 P.M., staff walked to door and told the resident to hold on as the resident continued to yell for staff to come here; - At 6:51 P.M., staff put on personal protective equipment (PPE), entered the room, and fed the resident. During an interview on 05/22/22 at 3:21 P.M., Certified Nurse Aide (CNA) B said staff must feed Resident #25. 2. Review of Resident #54's May 2025 Physician Order Sheet (POS) showed: - An admitted [DATE]; - Diagnoses of obstructive sleep apnea (intermittent airflow blockage during sleep), kidney failure (kidney's do not function like they should), and obesity (overweight); - An order for continuous positive airway pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open while you sleep)/billevel positive airway pressure (BIPAP - non-invasive ventilation technique that provides two different levels of air pressure to assist breathing during both inhalation and exhalation) on while sleeping/napping and off while awake, dated 03/09/25; - An order for CPAP/BIPAP clean reservoir with warm soapy water, rinse, set out to dry every day shift every 7 days, dated 03/10/25; - An order for CPAP/BIPAP fill humidifier with sterile or distilled water every night shift, dated 03/09/25; - An order to clean CPAP/BIPAP mask with warm soapy water, rinse ,and air dry as needed, dated 03/09/25. Review of the resident's quarterly MDS, dated [DATE], showed: - The resident did not use a CPAP/BIPAP. During an interview on 05/19/25 at 0:12 A.M., Resident #54 said staff did not do anything with his/her CPAP but he/she wished they would. He/She wore it each night and could put it on his/herself, but it was supposed to be cleaned and filled with distilled water. He/She had a friend that came to visit each day and the friend maintained the CPAP machine for him/her. Observation on 05/20/25 at 8:35 P.M., of the resident showed: - The resident lay in bed with CPAP mask on his/her face and the CPAP on. During an interview on 05/23/25 at 9:54 A.M., the MDS Coordinator said he/she would expect the MDS assessments to accurately reflect the current condition of the resident and the medical equipment should be reflected correctly. During an interview on 05/22/25 at 6:30 P.M., the Administrator and Director of Nursing (DON) said they would expect the MDS assessments to be completed accurately per the RAI Manual. 49879

Based on observation, interview, and record review, the facility failed to provide showers for three residents (Residents #25, #54, and #77) out of 21 sampled residents and one resident (Resident #53) outside the sample. The facility's census was 88. Review of the facility policy titled, Activities of Daily Living (ADLs), reviewed 09/10/24, 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; - Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices: - Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in ADLs do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the ADLs; - The facility must provide care and services for the following ADLs: bathing, dressing, grooming, and oral care. 1. Review of Resident #25's medical record showed: - An admitted [DATE]; - Diagnoses of dizziness and giddiness (feeling unsteady, lightheadedness, or spinning), age-related osteoporosis (decreased bone density), and rheumatoid arthritis (inflammation of joints). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 04/07/25, showed: - Cognitive impairment; - Dependent on staff for dressing; - Substantial/Maximum from staff for personal hygiene; - Dependent on staff for showering and bathing. Review of the facility shower scheduled showed: - The resident's scheduled shower days were Saturday and Tuesday. Review of the resident's showers sheets for 02/20/25 - 05/20/25 showed: - No shower sheets for February 2025, and showers not provided with two out of two opportunities missed for showers; - No shower sheets for March 2025, and showers not provided with nine out of nine opportunities missed for showers; - For April 2025, five showers received with four out of nine opportunities missed for showers; - For May 2025, three showers received with two out of five opportunities missed for showers; - A total of 17 opportunities missed out of 25 opportunities for showers. Observation on 05/19/25 at 11:20 A.M., showed the resident lay in bed wearing a hospital gown and disheveled hair. 2. Review of Resident #53's medical record showed: - An admitted [DATE]; - Diagnoses of heart failure (chronic condition where heart does not pump blood as well it should), muscle weakness, reduced mobility, and history of falling. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive status mildly impaired; - Partial to moderate assistance when dressing upper body and substantial/maximum assistance for dressing lower body; - Partial to moderate assistance for personal hygiene; - Substantial/Maximum assistance with showering and bathing. Review of the facility shower scheduled showed: - The resident's scheduled shower days were Monday and Thursday. Review of the resident's showers sheets for 02/20/25 - 05/20/25 showed: - No shower sheets for February 2025, and showers not provided with three out of three opportunities missed for showers; - No shower sheets for March 2025, and showers not provided with nine out of nine opportunities missed for showers; - For April 2025, four showers received with four out of eight opportunities missed for showers; - For May 2025, five showers received with one out of six opportunities missed for showers; - A total of 17 opportunities missed out of 26 opportunities for showers. During an interview on 05/22/25 at 1:56 P.M., the resident said he/she wished staff would give him/her showers more often. His/Her preference for showers would be to have at least two showers a week. 3. Review of Resident #54's medical record showed: - An admitted [DATE]; - Diagnoses of depression (a mental health disorder characterized by depressed mood or loss of interest in actives), anxiety disorder (mental health condition characterized by persistent and excessive worry and anxiety about a wide range of everyday events), obstructive sleep apnea (intermittent airflow blockage during sleep), kidney failure (kidneys do not function like they should), and obesity (overweight). Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive status intact; - Partial or moderate assistance when dressing upper body and dependent on staff for dressing lower body; - Supervision or touching assistance from staff for personal hygiene; - Dependent of staff for bathing. Review of the facility shower scheduled showed: - The resident's scheduled shower days were Thursday and Sunday. Review of the resident's showers sheets for 02/20/25 - 05/20/25 showed: - No shower sheets for February 2025, and showers not provided with one out of one opportunity missed for showers; - For March 2025, one shower received with eight out of nine opportunities missed for showers; - For April 2025, seven showers received with one out of eight opportunities missed for showers; - For May 2025, four showers received with two out of six opportunities missed for showers; - A total of 12 opportunities missed out of 24 opportunities for showers. During an observation and interview on 05/20/25 at 10:12 A.M., showed: - The resident sat in a wheelchair with slightly greasy hair and stubble on his/her lip and chin; - The resident said he/she did not get showered as often and he/she would like and the staff sometimes didn't do a good job. Recently there was a staff member that did not take his/her depends off for him/her shower and he/she was dirty. It was really weird. He/She told other staff he/she did not want that staff anymore and requested different staff come into change him/her and provide him/her showers in the future. His/Her roommate had helped him/her shower in the past due to the staff not providing appropriate assistance. 4. Review of Resident #77's medical record showed: - An admitted [DATE]; - Diagnoses of depression, anxiety disorder, and hemiplegia and hemiparesis (paralysis or weakness on one side of body) following cerebral infarction (stroke) affecting left non-dominant side. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively impaired; - Substantial/Maximum assistance when dressing upper body and dependent on staff when dressing lower body; - Substantial/Maximum assistance with personal hygiene and showering/bathing. Review of the facility shower scheduled showed: - The resident's scheduled shower days were Monday and Friday. Review of the resident's showers sheets for 02/20/25 - 05/20/25 showed: - No shower sheets for February 2025, and showers not provided with three out of three opportunities missed for showers; - No shower sheets for March 2025, with nine out of nine opportunities missed for showers; - For April 2025, seven showers received with one out of eight opportunities missed for showers; - For May 2025, six showers received with no missed showers; - A total of 13 opportunities missed out of 26 opportunities for showers. Observation on 05/19/25 at 2:49 P.M., showed: - The resident lay bed with disheveled hair and stubble on his/her chin and upper lip. During an interview on 05/22/25 at 3:21 P.M., Certified Nurse Assistant (CNA) B said it was the responsibility of the CNAs to complete the showers on their hall. They follow a shower schedule and the residents should receive two showers a week. CNA B said they were supposed to complete a shower sheet even if the resident refused a shower. If a resident refused, the CNAs were supposed to inform the nurse about the refusal. During an interview on 05/22/25 at 6:30 P.M., the Director of Nursing (DON) and the Administrator said the CNAs were responsible for completing showers. There was a shower schedule for the CNAs to follow. They would expect a shower sheet to be completed once the shower or bed bath had been given. If a resident refused a shower, it should be listed on the shower sheet.

Based on observation, interview, and record review, the facility failed to obtain weights as ordered for one resident (Resident #25) out of five sampled residents and one resident (Resident #53) outside the sample. The facility census was 88. Review of the facility's policy titled, Weight Monitoring, Long-Term Care, reviewed 08/19/24, showed: - Weighing a resident in a long-term care facility is an important part of assessing a resident's health. Following a routine weighing schedule helps detect weight changes. Unless otherwise specified, a resident's weight should be recorded at the time of admission, weekly for 4 weeks, and then monthly. Keep in mind that many residents have comorbidities that cause unplanned weight changes, and some residents require more frequent weight assessments; - Weight loss in older adults can result from various conditions. Unplanned weight loss in residents is associated with increased mortality. A decrease in weight of 5% or more in a month and/or more than 10% in six months should be reported to the practitioner for further evaluation. Weight loss can take various forms. For example, cachexia is weight loss associated with loss of muscle mass, whereas sarcopenia is a geriatric syndrome with three components - loss of muscle mass, loss of strength, and reduced performance; - Documentation associated with weight monitoring includes: weight according to your facility's documentation format, assessment findings, date and time that you notified the practitioner of significant weight changes, prescribed interventions, response to those interventions, teaching provided to the resident and family (if applicable), understanding of that teaching, and follow-up teaching needed. Review of the facility's policy titled, Physician Orders, reviewed 02/27/25, showed: - A physician must personally approve in writing a recommendation that an individual be admitted to a facility. A physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines; - All physician/practitioner orders, including verbal/telephone orders, are recorded on the Physician's Order Form for each resident and must be signed and dated within 14 days by the ordering physician, physician assistant, or nurse practitioner unless state regulations mandate sooner; - Upon admission, a written order approving the admission will be obtained from the attending physician. This may be done by telephone order; - As a means of validation, any orders taken verbally or by telephone must be read back in their entirety to the person giving the orders; - The receiving nurse or therapist immediately enters telephone or verbal orders into the clinical software; - It may be necessary to mail or take orders to a provider's office to obtain timely signatures if the provider still manually signs orders. If so, the documents are put in a sealed envelope and marked confidential to protect the privacy information. A log or a copy of all orders is kept for all orders that are sent out to be signed; - Physician orders include the following: Orders for admission to the facility or Medicare Skilled Care if Medicare Part A, Medications and Treatments, Diet, Special medical procedures required for the safety and well-being of the resident, Code status, Lab and x-ray requirements, Discharge, Transfer and Release of Body, Others as necessary and appropriate; - Any orders written by a consulting physician must be reviewed and signed by the resident's attending physician. This may be done by telephone order; - A Monthly Order Summary is signed at least every 30 days by the physician. The summary may be printed and signed with a wet-signature or may be signed electronically; - Orders must be authenticated, signed and dated, by the provider who gave the order. Signatures may be manual or electronic and may be accepted if faxed. (See Authentication of All Record Entries policy for further information.) Stamped signatures are prohibited. 1. Review of Resident #25's May 2025 Physician Order Sheet (POS) showed: - An admitted [DATE]; - Diagnoses of dizziness and giddiness (feeling unsteady, lightheadedness, or spinning), age-related osteoporosis (decreased bone density), and rheumatoid arthritis (inflammation of the joints); - An order for weekly weights every Tuesday day shift, dated 12/11/24. Review of the resident's Weight Record, dated February 2025 - May 2025, showed: - For February 2025, no weights documented on 02/11/25 and 02/18/25, with two missed opportunities out of four weekly weight opportunities; - For March 2025, no weights documented on 03/11/25 and 03/25/25, with two missed opportunities out of four weekly weight opportunities; - For April 2025, no weight documented on 04/01/25, with one missed opportunity out of five weekly weight opportunities; - For May 2025, no weight documented on 05/20/25, with one missed opportunity out of three weekly weight opportunities. Review of the resident's Treatment Administration Records (TARs), dated February 2025 - May 2025, showed: - For February 2025, weights not documented for three missed opportunities out of four weekly weight opportunities; - For March 2025, weights not documented for three missed opportunities out of four weekly weight opportunities; - For April 2025, weights not documented for two missed opportunities out of five weekly weight opportunities; - For May 2025, weights documented. Review of the resident's Care Plan, dated 04/10/25, showed: - Weekly weights loss not addressed. 2. Review of Resident #53's May 2025 POS showed: - An admitted [DATE]; - Diagnoses of heart failure (chronic condition where heart does not pump blood as well it should, muscle weakness, reduced mobility, history of falling, and cardiomegaly (an enlarged heart); - An order for daily weights, one time a day related to cardiomegaly, dated 01/11/25, and discontinued on 04/23/25; - An order for weekly weights every Monday day shift, dated 04/21/25. Review of the resident's Weight Record, dated February 2025 - May 2025, showed: - For February 2025, no weights documented on 02/01/25 - 02/03/25, 02/05/25 - 02/12/25, 02/14 - 02/18/25, 02/21/25 - 02/25/25, 02/27/25, and 02/28/25, with 23 missed opportunities out of 28 daily weight opportunities; - For March 2025, no weights documented on 03/02/25, 03/03/25, 03/05/25, 03/06/25, 03/08/25 - 03/11/25, 03/13/25 - 03/15/25, 03/18/25, 03/22/25 - 03/24/25, 03/26/25 - 03/31/25 with 21 missed opportunities out of 31 daily weight opportunities; - For April 2025, no weight documented on 04/01/25 - 04/03/25, 04/07/25, 04/09/25 - 04/12/25, 04/15/25 - 04/17/25, 04/20/25, 04/21/25 with 12 missed opportunities out of 21 daily weight opportunities and no weight documented on 04/28/25, with one opportunity missed out of one weekly weight opportunity; - For May 2025, no weight documented on 05/05/25, 05/12/25, and 05/19/25 with three opportunities missed out of three weekly weight opportunities. Review of the resident's TARs, dated February 2025 - May 2025, showed: - For February 2025, weights not documented for 18 missed opportunities out of 28 daily weight opportunities; - For March 2025, weights not documented for 19 missed opportunities out of 31 daily weight opportunities; - For April 2025, weights not documented for 11 missed opportunities out of 21 daily weight opportunities and one missed opportunity out of one weekly weight opportunity; - For May 2025, weights not documented for three missed opportunities out of three weekly weight opportunities. Review of the resident's Care Plan, dated 04/22/25, showed: - Did not address the weekly weights. During an interview on 05/22/25 at 3:21 P.M., Certified Nurse Assistant (CNA) B said the nurse would tell the CNAs at the start of the shift if a resident on their hall needed weighed for the day. If weights were not completed by the CNA assigned to the hall, then CNA B would be notified by the nurse which weights did not get completed so CNA B could complete them. CNA B said he/she and other CNAs would not know who needed weighed unless the nurses told them because they couldn't access the information otherwise. During an interview on 05/22/25 at 6:30 P.M., the Director of Nursing (DON) and Administrator said they would expect physician orders to be followed.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #25) out of two sampled residents received timely feeding assistance and one resident (Resident #37) out of 21 sampled residents received an evening meal tray in a timely manner. The facility's census was 88. Review of the facility's policy titled, Feeding a Resident, reviewed 09/10/24, showed: - Properly trained personnel supervised by nursing assist residents as needed with meals and snacks and feed residents who are unable to feed themselves; and nursing personnel provide assistive devices to residents as directed by therapy and provide education to residents regarding the use of assistive devices; - The facility must provide special eating equipment for residents who need them and appropriate assistance to ensure that the resident can use the assistive device when consuming meals and snacks; - Assist resident with toileting and hand hygiene prior to meals, ensure resident is positioned appropriately for meals, sit to assist resident with eating, provide size appropriate bites to residents, offer a liquid between bites to help with swallowing of food, at the end of the meal, assist resident with personal hygiene such as hand hygiene and washing of face, remove tray and place in the designated location in accordance with infection prevention and control procedures, document food and fluid intake, and report any issues with eating to the charge nurse. The facility did not provide a policy regarding passing meal trays. 1. Review of Resident #25's medical record showed: - admitted [DATE]; - Diagnoses of dizziness and giddiness (feeling unsteady, lightheadedness, or spinning), age-related osteoporosis (decreased bone density), and rheumatoid arthritis (inflammation of joints). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment to be completed by the facility), dated 04/07/25, showed: - Cognitive impairment; - Dependent on staff for dressing and showering/bathing; - Substantial/Maximum assist from staff for personal and oral hygiene; - Set up or clean up assistance for eating. During an interview on 05/19/25 at 11:42 A.M., the resident said staff did not pass the evening trays until around 6:00 P.M., and would not come back to feed him/her until they were passed. He/She had to wait 30 minutes to an hour before staff fed him/her and then the food was cold. Observations on 05/20/25, of the resident showed: - At 6:27 P.M., the evening meal tray was delivered to the resident's room; - At 6:29 P.M., staff exited the resident's room. Another staff walked by and asked if he/she set up the resident's tray in front of the resident because he/she had to be fed; - At 6:40 P.M., the resident tried to reach his/her arms up and towards the meal tray. The resident yelled for staff to come here; - At 6:49 P.M., staff walked to door and told the resident to hold on as the resident continued to yell for staff to come here; - At 6:51 P.M., staff put on personal protective equipment (PPE), entered the room, and fed the resident. During an interview on 05/22/22 at 3:21 P.M., Certified Nurse Aide (CNA) B said staff must feed Resident #25. The CNAs were responsible for passing the meal trays on their halls. The CNAs did not have help from any other facility staff to pass trays, except for if they were shorthanded, then the nurses would sometimes help. CNA B said the CNAs were supposed to pass all of the hall trays before feeding the residents that required assistance. The CNAs put the trays in the resident rooms, but were supposed to leave the tray covers on the food and not put it in front of the residents until they were ready to feed them. It typically took 30 minutes to get the hall trays passed, but that time could sometimes vary depending on if residents sent things back to the kitchen or needed replacement options, etc. 2. Review of Resident #37's medical record showed: - admitted [DATE]; - Diagnoses of depression (a mental health disorder characterized by depressed mood or loss of interest in actives), anxiety disorder (mental health condition characterized by persistent and excessive worry and anxiety about a wide range of everyday events), and respiratory failure (lungs cannot properly exchange gases). Observation of the resident on 05/20/25, showed: - At 5:04 P.M., staff served the evening meal in the dining room and the resident was not in the dining room; - At 6:24 P.M., staff delivered trays to the resident's hall, but no tray was delivered to Resident #37's room; - At 7:59 P.M., staff delivered a plate of salad and a plate with a hotdog and a bowl of fruit to the resident. During an interview on 05/20/25 8:01 PM., the resident said he/she didn't get a dinner tray. When a staff member came in to see why his/her roommate put the call light on, he/she told the staff member he/she never received a tray. The resident said he/she usually ate dinner in the dining room, but he/she was tired, had lay down to nap, somehow was overlooked, and didn't get a tray. Sometimes people will get missed. If the Administrator was still at the facility, she would get food for him/her if a tray wasn't received. If the Administrator had already left for the day, he/she wouldn't get anything. Staff do not pass snacks and would not get him/her other food if it was too late and then he/she was out of luck and would not be able to eat until breakfast the next day. During an interview on 05/19/25 at 11:28 A.M., Resident #53 said he/she did not get a breakfast tray today. The resident called to the kitchen to see if they were running late and was told it was already served it. The kitchen sent him/her a tuna fish sandwich. He/She was upset because they served his/her favorite breakfast today and he/she missed it. This was probably the third day this month that he/she had not gotten a breakfast tray. The resident said he/she didn't know why they missed him/her. During an interview on 05/20/25 at 8:05 P.M., Resident #52 said he/she did not get a dinner tray last week. The kitchen was already closed and no one was available to get his/her food, so he/she ended up having a friend order pizza for him/her. During an interview on 05/22/22 at 3:21 P.M., CNA B said he/she knew residents on the rehab hall would sometimes get missed for their meal trays, because they were new and the CNAs wouldn't get the tickets turned in to the kitchen in time. Sometimes the new staff would move the trays around, get them mixed up, and then inadvertently miss passing trays. CNA B said staff should be double checking to ensure they didn't miss anyone, but he/she knew sometimes newer staff would not do that. During an interview on 05/22/25 at 4:30 P.M., the Dietary Manager (DM) said Resident #37 was missed during the evening meal pass on 05/20/25, because he/she usually ate in the dining room. When the CNAs took his/her tray and he/she wasn't in the dining area, they did not bring the ticket back to tell the kitchen he/she needed a hall tray, so he/she ended up getting missed. Sometimes CNAs would miss people on the hall because they would start mixing the trays around in the cart and inadvertently not pass trays that needed to be passed. The door to the kitchen was not locked, so staff could enter the kitchen and get a resident food if they needed to during the evening after the kitchen staff had gone home for the evening. During an interview on 05/22/25 at 6:30 P.M. the Director of Nursing (DON) and the Administrator said they would expect staff to deliver trays to each resident and wait to deliver a tray to a resident who required assistance to eat until they were ready to feed them.

Based on observation, interview, and record review, the facility failed to create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that were significant by putting residents to bed based on staff preference and not resident preference for one resident (Resident #54) and by failing to honor two resident's (Residents #54 and #77) preferences to be shaved regularly out of 21 sampled residents . The facility's census was 88. Review of the facility's policy titled, Area of Focus: Resident Rights, reviewed 11/14/24, showed: - At the time of admission, a resident is afforded certain rights while residing in a Long-Term Care Facility. The facility and its associates have the responsibility for ensuring these rights are always upheld while the resident is in their care. Center for Medicare and Medicaid Services (CMS) outlines at least 48 rights the resident has that span a wide range of topics; - 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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident; - The resident has the right to exercise his/her rights as a resident of the facility; - The facility must ensure that the resident can exercise his/her rights without interference, coercion, discrimination, or reprisal from the facility; - The facility will ensure its associates are educated to the importance of resident's rights. Any violation or potential violation should be reported immediately to their supervisor, the Director of Nursing (DON), Social Services, or Executive Director; - Associates will be trained upon hire and at least annually on Resident Rights and how to ensure that the right are always upheld. The facility will also inform each resident, orally and in writing, of the rights at the time of admission and periodically throughout their stay. 1. Review of Resident #54's medical record showed: - admitted [DATE]; - Diagnoses of depression (a mental health disorder characterized by depressed mood or loss of interest in actives), anxiety disorder (mental health condition characterized by persistent and excessive worry and anxiety about a wide range of everyday events), obstructive sleep apnea (intermittent airflow blockage during sleep), kidney failure (kidney's do not function like they should), and obesity (overweight). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 04/06/25, showed: - Cognitively intact; - Dependent on staff for supervision or touching assistance with personal hygiene. Review of resident's Care Plan, dated 04/07/25, showed: - Resident required Activities of Daily Living (ADLs) assistance and therapy services needed to maintain or attain highest level of function; - Assist with mobility and ADLs as needed; - Resident is a mechanical lift for all transfers with two people. Review of the resident's Shower Schedule, undated, showed: - Scheduled for showers every Thursday and Sunday. Review of the resident's Showers Sheets, dated 02/20/25 - 05/20/25, showed: - No shower sheets for 02/28/25 - 02/28/25, and shaving not provided with three out of three opportunities missed for shaving; - One shower sheet for March 2025, and shaving not provided with nine out of nine opportunities missed for shaving; - Seven shower sheets for April 2025, and shaving not provided with four out of eight opportunities missed for shaving; - Four shower sheets for 05/01/25 - 05/20/25, and shaving not provided with with six out of six opportunities missed for shaving; - A total of 22 opportunities missed out of 26 opportunities for shaving. Observation and interview on 05/20/25 at 10:12 A.M., of the resident showed: The resident with visible whiskers on his/her chin and upper lip; - The resident said he/she would like to be shaved, but staff did not always do it. Sometimes staff would shave him/her during a shower, but the resident did not always receive two showers a week. Also, it depended on who the staff was as to whether he/she was shaved or not. During interviews and observations on 05/20/25, of the resident showed: - At 5:04 P.M., the resident said his/her preference was to go to bed after dinner. Typically he/she would like to be put in bed by 7:00 P.M., but staff would not put him/her to bed until all of the evening meal trays had been passed, the residents were fed, and the meal trays were collected. It was typically anywhere between 8:00 P.M. - 10:00 P.M., before he/she was put in bed; - At 6:22 P.M., the call light was on in the resident's room; - At 6:28 P.M., the light was off in the resident's room; - At 6:28 P.M., the resident said the staff member that responded to the call light told him/her to let them get the evening trays passed, and they would put him/her to bed afterwards; - At 7:20 P.M., the resident sat in his/her wheelchair next to the bed with a throw blanket covering him/her and his/her head lay over on some pillows that were propped up on the side of the bed and the arm of the wheelchair; - At 7:20 P.M., the resident said he/she was tired and would like to go to bed, but no one had come back to put him/her to bed. He/She normally had to prop his/her head on pillows in the wheelchair so he/she could sleep every night until staff would finally come and put him/her to bed; - At 7:46 P.M., the call light was on in the resident's room; - At 7:51 P.M., the call light was off in the resident's room; - At 8:01 P.M., the resident sat in his/her wheelchair in the room; - At 8:09 P.M., two staff entered the resident's room with a mechanical lift; - At 8:30 P.M., staff exited the room and the resident lay in bed; - At 8:30 P.M., the resident said it was always late every night before he/she got to go to bed. Staff would only get him/her up and put him/her back to bed once a day because they didn't have enough staff to get them up multiple times. His/Her preference was to lay back in bed during the afternoon and be gotten back up for mealtimes and activities. His/Her her legs always had red marks on them from being in the wheelchair all day, but he/she didn't want to miss out on things due to staff not being able to get him/her out the bed. 2. Review of Resident #77's medical record showed: - admitted [DATE]; - Diagnoses of depression, anxiety disorder, and hemiplegia/hemiparesis (paralysis/weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively impaired; - Substantial or maximum assistance from staff with personal hygiene, bathing, and showering. Review of the resident's Care Plan, dated 05/06/25, showed: - Required ADL assistance and therapy services needed to maintain or attain highest level of function; - Assist with mobility and ADLs as needed. Review of the resident's Shower Schedule, undated, showed: - Scheduled for showers every Friday and Monday. Review of the resident's Showers Sheets, dated 02/20/25 - 05/20/25, showed: - No shower sheets for 02/28/25 - 02/28/25, and shaving not provided with three out of three opportunities missed for shaving; - No shower sheets for March 2025, and shaving not provided with nine out of nine opportunities missed for shaving; - Seven shower sheets for April 2025, and shaving not provided with six out of eight opportunities missed for shaving; - Four shower sheets for 05/01/25 - 05/20/25, and shaving not provided with with four out of six opportunities missed for shaving; - A total of 22 opportunities missed out of 26 opportunities for shaving. Observation and interview on 05/19/25 at 2:49 P.M., of the resident showed: - The resident with visible whiskers/stubble on his/her chin; - The resident said he/she would like to be shaved on a regular basis. He/She couldn't remember the last time staff offered to shave him/her, but their preference would be to be shaved every day. During an interview on 05/22/25 at 3:21 P.M., Certified Nurse Assistant (CNA) B said the CNAs assigned to a resident's hall were responsible for shaving the residents. Female residents were supposed to be shaved every time they were given a shower, which should be at least twice a week. Male residents should be shaved on their shower days and during in-between showers days if that was their preference. Staff were supposed to accommodate the resident if they wanted to get up and go to bed throughout the day. However the resident would likely have long wait times and not be able to get up or back in bed during the time frames they wanted due to the various tasks required by the staff throughout their shifts. During an interview on 05/22/25 at 6:30 P.M., the DON and Administrator said they would expect residents to be shaved on their shower days, as needed, and upon request. They would expect staff to honor a resident's choices for when they would like to get and go to bed.

Based on observation, interview, and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for four residents (Residents #22, #25, #46 and #83) out of 21 sampled residents. The facility census was 88. Review of the facility's policy titled, Comprehensive Care Plans and Revisions, reviewed 09/11/24, showed: - The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care; - The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care; - When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery, this can include additional interventions on existing problems, updating goal or problem statements, and adding a short-term problem, goal, and interventions to address a time limited condition. 1. Review of Resident #22's medical record showed: - admitted [DATE]; - Diagnoses of reduced mobility, lack of coordination, dementia (a group of thinking and social symptoms that interferes with daily functioning), and legal blindness; - A quarterly Minimum Data Set (MDS - a federally mandated assessment to be completed by the facility staff), dated 03/31/25, showed the resident's vision severely impaired. Review of the resident's Care Plan, dated 12/07/23, showed: - Activities: offer items from activity cart such as magazines, novels, crafts, adult coloring pages, word and number puzzle books, jigsaw puzzles, board games, checkers, cards and dominoes, etc.; - Post activity calendar in resident's room; - Did not address activities appropriate for the resident's blindness. Observations of the resident showed: - On 5/19/25, 5/20/25, 5/21/25 and 5/22/25, the resident sat alone or slept in his/her room with audio books playing. During an interview on 05/19/25 at 1:30 P.M., the resident said he/she stayed in his/her room and listened to audio books every day. He/She couldn't read the activities calendar, but did know he/she had one. The resident said no one came to his/her room to tell him/her the daily activities. During an interview on 5/21/25 at 2:30 P.M., the resident said he/she was not aware of the strawberry shortcake social activity going on, but would love to have some. 2. Review of Resident #25's medical record showed: - admitted [DATE]; - Diagnoses of dizziness and giddiness (feeling unsteady, lightheadedness, or spinning), age-related osteoporosis (decreased bone density), and rheumatoid arthritis (inflammation of joints); - A quarterly MDS, dated [DATE], showed no devices used in bed for the resident; - An order for weekly weights every Tuesday day shift, dated 12/11/24; - An order for 2 Cal Med Pass (a supplemental nutritional drink) three times a day 240 milliliters, dated 04/18/24. Observation on 05/19/25 at 11:20 A.M. showed the resident lay in bed with a fall mat on the floor on the left side of the bed and the resident lay on a concave mattress (a mattress that curves inwards). Review of the resident's Care Plan, dated 04/10/25, showed: - Did not address the fall mat or concave mattress; - Did not address the 2 Cal Med Pass supplement. 3. Review of Resident #46's medical record showed: - admitted [DATE]; - Diagnoses of type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), rheumatoid arthritis, and post traumatic stress disorder (PTSD - a mental health condition caused by an extremely stressful or terrifying event.) Review of the resident's Care Plan, revised 05/08/25, showed: - The care plan did not address the history of PTSD or triggers. During an interview on 05/22/25 at 11:30 A.M., the resident said his/her PTSD triggers were fighting and arguments. Fights and arguments made him/her feel like he/she was in fight or flight mode. The resident had told staff many times that he/she had a PTSD diagnosis. 4. Review of Resident #83's medical record showed: - admitted [DATE]; - Diagnoses of secondary bone cancer (cancer that originates in one part of the body and spreads to the bones), cancer of right breast, secondary brain cancer (cancer that originates in one part of the body and spreads to the brain), major depressive disorder (a mental health condition characterized by persistent low mood, loss of interest or pleasure in activities, and a range of other symptoms that can significantly impact daily life), anxiety disorder (persistent worry and fear about everyday situations), protein-calorie malnutrition (occurs when an individual's intake of protein and calories is insufficient to meet their body's needs), and abnormal weight loss (unintentional reduction in total body mass); - A quarterly MDS, dated [DATE], showed cognition intact. During an interview on 05/19/25 at 2:36 P.M., Resident #83 said he/she was a vegetarian and sometimes was served meat. He/She was served only a plate of potatoes for a meal. Review of the resident's Care Plan, dated 04/23/25, showed: - Resident on a regular diet and Osmolyte (a supplemental feeding) via percutaneous endoscopic gastrostomy (PEG tube - a feeding tube inserted directly into the stomach through the skin) when consumed less than 50% of meals; - Did not address the resident's vegetarian preference. Observation of the resident showed: - On 05/21/25 at 8:24 A.M., the resident sat in bed and a bowl of cereal with 25% eaten sat on the overbed table. During an interview on 05/22/25 at 6:30 P.M., the Director of Nursing (DON) and Administrator said they would expect the care plans to accurately reflect the resident's condition, their individual care needs, and dietary preferences. During an interview on 05/23/25 at 9:54 A.M., the MDS Coordinator said he/she would expect the care plan to accurately reflect the resident's condition, their individual care needs, and dietary preferences. 49879 49999

Based on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures for residents in five rooms. Storing items on the overbed light creates a hazard of the items falling on the resident below, and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 88. The facility did not provide a policy for overbed lighting safety. 1. Observation on 05/19/25 at 11:08 A.M., of room [ROOM NUMBER] showed: - Seven stuffed animals on top of the light fixture above the bed by the door; - Eight stuffed animals on top of the light fixture above the bed by the window. 2. Observation on 05/19/25 at 11:15 A.M., of room [ROOM NUMBER] showed: - Two decorative pictures on top of the light fixture above the bed by the window. 3. Observation on 05/19/25 at 11:20 P.M., of room [ROOM NUMBER] showed: - Seven stuffed animals on top of the light fixture above the bed by the door. 4. Observation on 05/19/25 at 11:42 A.M., of room [ROOM NUMBER] showed: - Eight stuffed animals on top of the light fixture above the bed by the window. 5. Observation on 05/19/25 at 2:45 P.M., of room [ROOM NUMBER] showed: - Eight stuffed animals on top of the light fixture above the bed by the door. During an interview on 05/22/25 at 3:21 P.M., Certified Nurse Assistant (CNA) B said residents, resident family members, and housekeeping put stuffed animals and decor on top of the lights over the beds. He/She did not think they were supposed there due to it being a possible fire hazard. During an interview on 05/22/25 at 6:30 P.M., the Director of Nursing (DON) and Administrator said items should not be placed on the light fixtures due to possible hazards.

Based on observation, interview and record review, facility staff failed to cover resident catheter (tube inserted into the bladder to drain urine) bags to maintain dignity for one resident (Resident #54) out of six sampled residents and for one resident (Resident #38) outside the sample. The facility census was 88. Review of the facility's policy titled, Dignity, revised 09/26/24, showed: - 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 incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input; - A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident; - Staff should refrain from practices demeaning to residents, such as leaving urinary catheter bags uncovered. 1. Review of Resident #38's Physician Order Sheet (POS) showed: - An order for an indwelling catheter to straight drainage with a 16 French (Fr. - size) catheter and with a 5 milliliter (ml) bulb. Change for infection, obstruction or when the closed system is compromised, dated 05/14/25; - An order for catheter care every shift for adequate urine flow and keep the catheter bag placed below the level of the bladder, dated 05/15/25; - An order to secure the catheter with an anchoring device to prevent tension. Check every day shift for soiling or dislodgement and as needed. Change the device when clinically indicated and as recommended by the manufacturer, dated 05/14/25; - An order to change the catheter bag as needed for for infection, obstruction, or when the closed system is compromised, dated 05/14/25. Review of resident's Care Plan, dated 03/24/25, showed: - Did not address the use of a catheter dignity bag or shield. Observation and interview on 05/21/25 at 2:30 P.M., of the resident showed: - The resident sat in a motorized wheelchair in the hallway and the catheter drainage bag hung on the side of wheelchair without a dignity bag or shield; - The resident said it bothered him/her that the catheter drainage bag wasn't covered with a dignity bag and other people could see the contents in the bag. 2. Review of Resident #54's POS showed: - An order to change the catheter bag as needed for infection, obstruction, or when the closed system is compromised, dated 03/11/25; - An order to secure the catheter with an anchoring device to prevent tension. Check every day shift and as needed. Change the device when clinically indicated and as recommended by the manufacturer, dated 03/11/25; - An order for catheter care every shift and keep the catheter bag placed below the level of the bladder, dated 03/10/25. Review of resident's Care Plan, dated 04/07/25, showed: - Did not address the use of a catheter dignity bag or shield. Observation on 05/20/25 at 5:04 P.M., of the resident showed: - The resident sat in a wheelchair in the dining room and ate his/her evening meal. The resident's catheter drainage bag hung underneath the wheelchair and touched the floor without a dignity bag or shield. During an interview on 05/22/25 at 3:21 P.M., Certified Nurse Assistant (CNA) B said residents should have a dignity bag or shield to cover their catheter drainage bag if they were out of their room and the catheter drainage bag should not touch the floor. During an interview on 05/22/25 at 6:30 P.M., the Director of Nursing (DON) and Administrator said he/she expected staff to cover catheter drainage bags and keep them off the floor when residents were out of their rooms.

Based on observation, interview, and record review, the facility failed to maintain adequate infection control practices to prevent the spread of infection during care for two residents (Resident #71 and #83) out of three sampled residents and failed to ensure oxygen tubing was clean for one resident (Resident #53) out of one sampled resident. The facility's census was 88. Review of the facility policy titled, Oxygen Administration (Infection Control, Safety, & Storage), revised, 04/08/25, showed: - Change oxygen supplies (e.g., cannula (a thin, flexible tube inserted in the nostrils used to deliver supplemental oxygen), tubing, humidifier) weekly and when visibly soiled. Equipment should be labeled with the resident name and dated when setup or changed out; - Store oxygen and respiratory supplies in a bag labeled when not in use. Review of the facility's policy titled, Hand Hygiene, revised 06/13/23, showed: - The hand hygiene procedures to be followed by staff involved in direct resident contact; - Associates perform hand hygiene (even if gloves are used) in the following situations: Before and after contact with the resident; After contact with blood, body fluids, or visibly contaminated surfaces; After contact with objects and surfaces in the resident's environment; After removing personal protective equipment (e.g., gloves, gown, eye protection, facemask); and Before performing a procedure such as an aseptic task (e.g., insertion of an invasive device such as a urinary catheter, manipulation of a central venous catheter, and/or dressing care). Review of facility policy titled, Enhanced Barrier Precautions (EBP), dated 04/22/25, showed: - Enhanced barrier precautions are indicated for residents with wounds and/or indwelling medical devices; - Examples of high-contact resident care activities requiring gown and glove use include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, toileting, device care, and wound care. 1. Observation on 05/19/25 at 11:28 P.M., of Resident #53 showed: - The resident lay in bed and the oxygen tubing and nasal cannula lay on the floor out of his/her reach; - The resident's oxygen tubing and nasal cannula stained brown in color. During an interview on 05/19/25 at 11:28 P.M., the resident said he/she was supposed to wear the oxygen all the time. Sometimes he/she took it off or it would come off while asleep. He/She usually put it back on but it fell on the floor and he/she couldn't reach it. Staff did not change the oxygen tubing. Observation on 05/19/25 at 11:37 P.M., of the resident showed: - Certified Medication Technician (CMT) E entered the resident's room and told the resident he/she needed to wear the oxygen; - CMT E picked the oxygen tubing and nasal cannula off of the floor and put the nasal cannula in the resident's nostrils. During an interview on 05/19/25 at 11:45 P.M., CMT E said he/she did not know when or who was responsible for changing the oxygen tubing and nasal cannula. During an interview on 05/22/25 at 3:21 P.M., Certified Nurse Aide (CNA) B said the oxygen tubing and nasal cannula should be changed by Sunday night shift. When oxygen was not in use, it was supposed to be put in a bag that hung from the wall to keep it from touching the floor. If the tubing and nasal cannula touched the floor, it should be changed before the resident used it again. During an interview on 05/22/25 at 6:30 P.M., the Director of Nursing (DON) and the Administrator said they would expect oxygen tubing to be changed weekly and would expect it to be changed if it touched the floor. 2. Observation on 05/20/25 at 7:20 P.M., of Resident #71's incontinent care showed: - CNA A and CNA D performed hand hygiene, put on gown and gloves, and entered the resident's room; - CNA A removed the resident's urine soaked brief, did not change gloves, and did not perform hand hygiene; - CNA A cleaned the resident's front perineal area, did not change gloves, and did not perform hand hygiene; - CNA D positioned the resident on his/her side; - CNA A cleaned the resident's buttocks, did not change gloves, and did not perform hand hygiene; - CNA A placed a clean brief on the resident, did not change gloves, and did not perform hand hygiene; - CNA A moved the resident's bedside table closer to the bed and handed the resident the call light; - CNA A and CNA D removed gloves and performed hand hygiene. 3. Observation on 05/21/25 at 8:24 A.M., of Resident #83's percutaneous endoscopic gastrostomy (PEG - a feeding tube inserted directly into the stomach through the skin) tube feeding showed: - Registered Nurse (RN) Q performed hand hygiene, put on gloves, did not put on a gown, and entered the resident's room; - RN Q performed the PEG tube feeding and water flush; - RN Q removed gloves and performed hand hygiene. During an interview on 05/22/25 at 3:19 P.M., RN Q said EBP should be worn when providing care to residents with open wounds, recent surgery, immunosuppression (suppression of the body's immune system and its ability to fight infections and other diseases), and any indwelling medical devices, such as PEG tubes. During an interview on 05/22/25 at 5:12 A.M., CNA A said hand hygiene should be done before perineal care, when moving between dirty to clean tasks, and after care. During an interview on 05/22/25 at 6:35 P.M., the DON said she would expect hand hygiene and glove changes to be done before care, when going from dirty to clean tasks, and after perineal care. 47447 49999

Based on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This deficient practice affected two medication carts out of three sampled medication carts. The facility census was 88. Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals, revision date of [DATE], showed: - Only authorized facility staff should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas; - Facilities should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding; - The facility should ensure that medications and biologicals that have an expired date on the label, have been retained longer than recommended by manufacturer or supplier guidelines, or have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier; - Once any medication is opened, the facility should follow the manufacturer guidelines with respect to expiration dates for opened medications; - The facility should record the date opened on the primary medication container when the medication has a shortened expiration date once opened; - Medications with a manufacturer's expiration date expressed in a date and year will expire on the last day of the month; - The facility should destroy or return all discontinued, outdated/expired, or deteriorated medications in accordance with the pharmacy return/destruction guidelines and other applicable laws; - The facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis; - The facility should request the pharmacy perform a routine nursing unit inspection for each nursing station to assist the facility in complying with its obligations pursuant to applicable laws. 1. Observation on [DATE] at 9:30 A.M., of the 100 Hall Medication Cart showed: - One round pale orange pill with 50 inscribed on it lay loose in the bottom of the drawer; - Two ,d+[DATE] round light yellow pills lay loose in the bottom of the drawer; - One round white pill with 54.5 inscribed on it lay loose in the bottom of the drawer; - One round green pill lay loose in the bottom of the drawer; - One round small white pill lay loose in the bottom of the drawer; - A labeled medication card of 30 tablets of dicyclomine (a medication used to treat irritable bowel syndrome) 10 milligrams (mg) with an expiration date of [DATE], lay in the bottom of the drawer. 2. Observation on [DATE] at 10:00 A.M., of the 300 Hall Medication Cart showed: - One oblong white pill with APO inscribed on it lay loose in the bottom of the drawer; - One small round white pill lay loose in the bottom of the drawer; - One small round white pill with + inscribed on it lay loose in the bottom of the drawer; - A labeled card of four tablets of levothyroxine (medication for hypothyroidism) 50 micrograms (mcg) lay in the very bottom of the medication cart underneath the left drawer. During an interview on [DATE] at 6:30 P.M., the Director of Nursing (DON) said she would expect all medications to be in proper packaging and labeled.

Based on interview and record review, the facility failed to provide the certified nurse assistants (CNAs) an annual individual performance review or evaluation and failed to provide regular in-service education based on these reviews for one CNA (CNA D) out of two sampled CNAs. The facility census was 88. Review of the facility's policy titled, CNA 12 hours of Inservice Training, dated 06/11/24, showed: - CNA training must be sufficient to ensure continuing competence and be no less than 12 hours per year; - Training must address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff; - CNA in-service hours will be calculated annually by their employment date rather than the calendar year; - In addition to the areas of training identified as part of the annual performance review and facility assessment, the facility will also provide training each year on the following: Dementia management training, Resident abuse prevention training, Care of the cognitively impaired. Review of the Facility Assessment, dated 08/06/24, showed: - The facility does extensive training as to keep all associates current and helping our work environment; - All associates are trained upon hire, annually and as needed on the topics of communication; resident's rights; abuse, neglect and exploitation; infection control; culture change; identification of resident changes in condition; cultural competency; compliance and ethics; dementia and care of the cognitive impaired and abuse prevention strategies for residents with cognitive impairment; and behavioral health. 1. Review of CNA D's Employee File showed: - A hire date of 03/16/07; - No documentation of an annual performance review or evaluation for the time frame from April 2024 through March 2025. During an interview on 05/22/25 at 6:28 P.M.,the Administrator and the Director of Nursing (DON) said they would expect CNAs to have a performance review or evaluation yearly and have education provided based on the reviews.

Based on observation, interview, and record review, the facility failed to provide timely and necessary care by not following through with a transfer from a wheelchair to bed after responding to a call light for one sampled resident (#54) and not following through with peri care request after responding to a resident's call light for one resident outside of the sample (Resident #78). Failure to respond to resident's request for assistance when responding to call lights could place residents at risk for skin breakdown, discomfort and cause emotional distress. This could affect all residents. The facility census was 88. The facility did not provide a policy regarding call light response times. 1. Review of Resident #54's medical record showed: - An admitted [DATE]; - Diagnoses of depression (a mental health disorder characterized by depressed mood or loss of interest in actives), anxiety disorder (mental health condition characterized by persistent and excessive worry and anxiety about a wide range of everyday events), obstructive sleep apnea (intermittent airflow blockage during sleep), kidney failure (kidney's do not function like they should), obesity (overweight). Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive status intact; - Mobility devices used - wheel chair; - Partial or moderate assistance when dressing upper body and dependent on staff for dressing lower body; -Dependent on staff when putting on or taking off footwear; - Dependent of staff for chair to bed transfer. Review of resident's Care Plan, dated 04/07/25, showed: - Resident required Activities of Daily Living (ADLs) assistance and therapy services needed to maintain or attain highest level of function; - Assist with mobility and ADLs as needed; - Resident is a mechanical lift for all transfers with two people. During interviews and observations on 05/20/25, of the resident showed: -At 5:04 P.M., the resident said his/her preference was to go to bed after dinner. Typically he/she would like to be put in bed by 7:00 P.M. The resident said he/she will put on his/her call light, but staff always turn it off and will tell him/her they will be back after all of the evening meal trays had been passed, the residents fed, and meal trays collected. The resident said it does not matter how many times he/her will turn the light on, they will turn it off and tell him/her they will be back after other tasks are completed; - At 6:22 P.M., the call light was on in the resident's room; - At 6:28 P.M., the light was off in the resident's room; - At 6:28 P.M., the resident said the staff member that responded to the call light told him/her to let them get the evening trays passed, and they would put him/her to bed afterwards; - At 7:20 P.M., the resident sat in his/her wheelchair next to the bed with a throw blanket covering him/her and his/her head lay over on some pillows that were propped up on the side of the bed and the arm of the wheelchair; - At 7:20 P.M., the resident said he/she was tired and would like to go to bed, but no one had come back to put him/her to bed. He/She normally had to prop his/her head on pillows in the wheelchair so he/she could sleep every night until staff would finally come and put him/her to bed; - At 7:46 P.M., the call light was on in the resident's room; - At 7:51 P.M., the call light was off in the resident's room; - At 8:01 P.M., the resident sat in his/her wheelchair in the room; - At 8:09 P.M., two staff entered the resident's room with a mechanical lift; - At 8:30 P.M., staff exited the room and the resident lay in bed; - At 8:30 P.M., the resident said it was always late every night before he/she got to go to bed. It is a common occurrence that staff will turn the call light off, not put him/her to bed, say they will be back, but not come back for an hour or more. The resident said his/her legs always had red marks on them from being in the wheelchair for so long. 2. Review of Resident #78's medical record showed: - An admitted [DATE]; - Diagnoses of muscle weakness, reduced mobility, history of falling, cardiomegaly (enlarged heart), chronic kidney disease, stage 4 (severe) (long standing kidney disease leading to organ failure). Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive status intact; - Dependent on staff for toileting; - Dependent on staff for toilet transfers; - Dependent on staff for chair to bed transfers. Review of resident's Care Plan, dated 04/28/25, showed: - ADL Assistance and Therapy Services needed to maintain or attain highest level of function. - Assist with mobility and ADLs as needed. - Total lift with all transfers. During interviews and observations on 05/20/25, of the resident showed: - 6:42 P.M., The call light was on in the resident's room; - 6:43 P.M., The call light was off in the resident's room; - 6:45 P.M., The resident was lying in bed and said he/she needed his/her diaper changed. The resident said a staff member turned the light off and said they would be back in a minute to change him/her; - 7:08 P.M., The call light was on in the resident's room; - 7:12 P.M., The call light was off in the resident's room; - 7:16 P.M., The resident was lying in bed and said he/she still needed to be changed. He/she said a different aide keeps coming in, turning off the call light and telling him/her someone will be back to change him/her; - 7:17 P.M., The call light was on in the resident's room; - 7:17 P.M., The resident appeared visibly distressed and tearful with increased breathing. The resident said the staff do this to him/her all the time and it is very upsetting. He/she said one time he/she laid in a dirty diaper for 10 hours. He/she said another night it was five hours. The resident said he/she did not know the aides that turned off his/her light. He/she said it had been a different aide every time the light was turned off. He/she said he/she is tired of staff doing him/her this way. - 7:42 P.M., The call light was off in the resident's room after an aide entered the room and closed the door. After the aide exited the room, the resident confirmed he/she had gotten changed. During an interview on 05/22/25 at 3:21 P.M., Certified Nurse Assistant (CNA) B said the CNAs are responsible for responding to call lights in a responsible amount of time to assistance with toileting, cleaning residents, and putting them to bed. He/she said they knew there had been an issue with staff turning off the call light, saying they will be back and not addressing the request before leaving the room or in a timely manner. He/she said the staff had to attend an in-service meeting about it. He/she claimed they did not do that and have not seen others do it but knows it does occur at times. CNA B said if he/she were to see a light on will ask what they need and if he/she can't get to it right then she will tell them about how long they will have to wait, will leave the light on and come back as soon as he/she can. During an interview on 05/22/25 at 6:30 P.M., the Director of Nursing (DON) and Administrator said they would expect staff to respond to a call light in a timely manner, address the resident need and then turn the light off after the need was addressed.

Based on observation, interview, and record review, the facility failed to provide an on-going program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This practice affected one resident (Resident #22) out of 18 sampled residents and could potentially affect all residents. The facility census was 88. Review of the facility's policy titled, Therapeutic Activities Program, revised on 04/01/22, and reviewed on 09/27/24, showed; - The facility activities program will be directed by a qualified activities director. The director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion and/or directing/delegating the completion of the activity's component of the compressive assessment; - Directing the activity program includes scheduling activities, both individual and groups, implementing and/or delegation the implementation of programs, monitoring the response and/or reviewing/evaluating the response to the programs to determine if the activities meet the assessed needs of the resident, and making any revisions as necessary; - The facility should implement an ongoing resident centered activities program that incorporates the residents' interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. To create opportunities for each resident to have a meaningful life supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy, and meaning). Review of the May 2025 Activities Calendar showed: - Four activities per day; - The mornings showed coffee with sweet treats, worship, move and groove, or hot chocolate; - The afternoons showed games such as bingo, music, outside exercise, salsa and chips or strawberry shortcake social, and resident council meeting; - Approximately four days per week there was time listed as 1:1. 1. Review of Resident #22's medical record showed: - admitted [DATE]; - Diagnoses of reduced mobility, lack of coordination, dementia (a group of thinking and social symptoms that interferes with daily functioning), and legal blindness; - A quarterly Minimum Data Set (MDS - a federally mandated assessment to be completed by the facility staff), dated 03/31/25, showed the resident's vision severely impaired; - A significant change MDS, dated [DATE], showed the resident's vision severely impaired, very important to participate in activities he/she likes, very important to go outside to get fresh air when weather is appropriate, and somewhat important to do things with groups of people. Review of the resident's Care Plan, dated 12/07/23, showed: - Activities: offer items from activity cart such as magazines, novels, crafts, adult coloring pages, word and number puzzle books, jigsaw puzzles, board games, checkers, cards and dominoes, etc.; - Post activity calendar in resident's room; - Did not address resident's need for activities appropriate for the resident's blindness. During an interview on 05/19/25 at 1:30 P.M., the resident said he/she stayed in his/her room and listened to audio books every day. He/She couldn't read the activities calendar, but did know he/she had one. The resident said no one came to his/her room to tell him/her the daily activities. Observations of the resident showed: - On 5/19/25, 5/20/25, 5/21/25 and 5/22/25, the resident sat alone or slept in his/her room with audio books playing. During an interview on 05/21/25 at 2:30 P.M., the resident said he/she was not aware of the strawberry shortcake social activity going on, but would love to have some. During an interview on 05/22/25 at 8:50 A.M., the Activities Director said he/she sat down with each resident upon admission and had a paper that they filled out to get to know the resident's preferences. He/She said there were not any residents that could not hear or see, but then said that Resident #22 was a little blind and he/she provided books on tape for him/her. During an interview on 05/22/25 at 6:30 P.M., the Director of Nursing (DON) said she would expect activities to include residents who require special accommodations, staff to notify residents of daily activities, and the activities calendar to reflect the daily activities.

Based on interview and record review, the facility failed to refund resident funds within 30 days of discharge or expiration of residents for four residents (Residents #197, #198, #199, and #200) out of a sample of 10 residents. The facility census was 88. The facility did not provide a policy regarding expired or discharged resident funds. 1. Review of Resident #197's census showed billing stopped on [DATE]. Review of the facility maintained Resident Trust Fund Trial Balance Report, dated [DATE] - [DATE], showed: - The resident's balance remained at $367.14. Review of the facility maintained Resident Trust Fund Trial Balance Report, dated [DATE] - [DATE], showed: - The resident's account was closed on [DATE]; - The resident funds of $367.14 remained in the facility account for days 94 days after the resident was discharged from the facility. 2. Review of Resident #198's census showed billing stopped on [DATE]. Review of the facility maintained Resident Trust Fund Trial Balance Report, dated [DATE] - [DATE], showed: - The resident's balance remained at $991.29, with a note the resident expired on [DATE]. Review of the facility maintained Resident Trust Fund Trial Balance Report, dated [DATE] - [DATE], showed: - The resident's account was closed on [DATE]; - The resident funds of $991.29 remained in the facility account for 50 days after the resident expired. 3. Review of the census for Resident #199 showed billing stopped on [DATE]. Review of the facility maintained Resident Trust Fund Trial Balance Report, dated [DATE] - [DATE], showed: - The resident's balance remained at $41.83. Review of the facility maintained Resident Trust Fund Trial Balance Report, dated [DATE] - [DATE], showed: - The resident's balance of $-1064.17 with a note the resident expired on [DATE]. Review of the facility maintained Resident Trust Fund Trial Balance Report, dated [DATE] - [DATE], showed: - The resident's account was closed on [DATE]; - The resident funds of $41.83 remained in the facility account for 71 days after the resident expired. 4. Review of the census for Resident #200 showed billing stopped on [DATE]. Review of the facility maintained Resident Trust Fund Trial Balance Report, dated [DATE] - [DATE], showed: - The resident's balance remained at $220.02. Review of the facility maintained Resident Trust Fund Trial Balance Report, dated [DATE] - [DATE], showed: - The resident's balance remained at $220.02 with a note the account was frozen on [DATE]. Review of the facility maintained Resident Trust Fund Trial Balance Report, dated [DATE] - [DATE], showed: - The resident's account was closed on [DATE]; - The resident funds of $220.02 remained in the facility account for 280 days after the resident was discharged from the facility. During an interview on [DATE] at 5:38 P.M., the Regional Field Controller said Resident #199's account was not closed and his/her social security was removed from the account for the month of November, which caused a negative balance. When the account was closed in December, the error was corrected. He/She did not know where Resident #200 discharged to, so they had no way of knowing where the money needed to be sent. It was decided to put a freeze on the account in October to ensure no money was unintentionally put in or taken out of the account until the correct place to forward the money could be determined. He/She was able to find the correct address for the Resident #200 in February 2025, so the money was then released. Sometimes it was a struggle to get a hold of a resident's family or responsible party to determine where the money was needed to be sent. It was also a struggle to get responses from funeral homes to send the money for burial expenses. It could sometimes take a long time to get money where it needed to be sent after a discharge or expiration of a resident. During an interview on [DATE] at 6:14 P.M., the Administrator said she would expect discharged and expired resident's money to be removed from their accounts and sent to the correct parties within 30 days of them leaving the facility per regulatory guidelines.

Based on observation, interview, and record review, the facility failed to provide information on the location of the State Long-Term Care Ombudsman program (a statewide network of individuals who help residents in long-term care facilities maintain and improve their quality of life by helping ensure their rights were preserved and respected). This practice could have potentially affected all residents in the facility. The census was 88. Review of facility's policy titled, Resident Rights,reviewed 11/19/24, showed: - 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. Observation on 05/21/25 at 2:00 P.M., of the facility showed: - The prior Ombudsman information posted on the wall past the entrance of the facility; - The Ombudsman information posted on approximately 8 X 12 inch paper with the Ombudsman's program and telephone number of the prior representative; - No postings for the current Ombudsman. During a group interview on 05/20/25 at 1:30 P.M., seven residents (Residents #1, #2, # 9, #10, #21, #54, and #71) said they did not know where the Ombudsman information was posted or how to contact the Ombudsman. During an interview on 05/22/25 at 10:30 A.M., the Administrator said the Ombudsman information and telephone number was posted on the wall past the entrance of facility. She was waiting on the current Ombudsman to bring or send the updated information to be posted but did have the contact information. During an interview on 05/23/25 at 11:10 A.M., the Director of Nursing (DON) said the Ombudsman information was posted on the wall past the entrance but didn't know if it was the prior or current Ombudsman's information.

Based on record review and interview the facility failed to ensure an accurate and consistent system was in place to direct staff when to initiate basic life support for one resident (Resident #1) when on [DATE] the Phlebotomist came in around 5:00 A.M. and came to nurse's station and said the resident would not wake up. Licensed Practical Nurse (LPN) E went to the room and the resident did not have a pulse. LPN E and Certified Nurse Aid (CNA) C went to the nurse's station to check the report sheet for code status. The resident was a full code. LPN E returned to the room to begin Cardiopulmonary Resuscitation (CPR) while CNA C checked the electronic medical record for code status and called the code overhead. After a few compressions, CNA C returned to the room and stated the resident was a Do Not Resuscitate (DNR) according to the electronic records. LPN E stopped compressions and 911 was not called. Record review upon the resident's admission, [DATE], a DNR was signed. On a [DATE] re-admission a Full Code was signed. On [DATE] the status was changed to DNR with no order or signature. The resident's spouse said the resident should have been a full code. The facility census was 94. The Administrator was notified on [DATE], of the Immediate Jeopardy (IJ) past non-compliance, which occurred on [DATE]. The facility provided training and in-servicing for all staff regarding the facility's CPR policy and using proper definitions/verbiage when writing and receiving orders for CPR/DNR. The IJ was corrected on [DATE]. Review of the facility's policy titled, Advance Directives and Advance Care Planning, dated [DATE], showed: - Residents have the right to self-determination regarding their medical care. This includes the right of an individual to direct his or her own medical treatment, including the right to execute or refuse to execute an advance directive; - It is required that the patient is asked about advanced directives, and to document any wishes the patient might have with regard to the care they want or do not want; - If an adult individual is incapacitated at the time of admission and is unable to receive information to articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law; - The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time; - Do Not Resuscitate (DNR) order -A medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer cardiopulmonary resuscitation (CPR-life saving measures) in the event of cardiac or respiratory arrest. Existence of an advance directive does not imply that a resident has a DNR order. The medical record must show evidence of documented discussions leading to a DNR order; - Competent - Residents have the right to actively participate in their plan of care. The resident has the right to designate a representative, in accordance with State law, and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. A resident is competent to make a health care decision if he or she understands the nature of his or her illness, understands the treatment options available to him or her, understands the consequences of refusing such treatments, and is able to make and communicate decisions about his/her medical treatment; - Incompetent - When a resident is ''incompetent, he/she is unable to make his or her own decisions. A resident should not be presumed incompetent unless a physician renders an opinion of such, and even then, such presumption could be rebutted or challenged. A resident is in fact incompetent only when a court with jurisdiction over the resident declares such. The court-appointed resident representative exercises the resident's rights to the extent judged necessary by a court. The resident's wishes and preferences must be considered in the exercise of the rights by the representative; - Residents or their responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care, including the right to accept or refuse medical care, the right to accept or refuse medical/surgical treatment, organ donation requests, and the formation of advance directives upon admission; - A written description of the facility's policies regarding advance directives and applicable State law is provided to the resident or resident representative. Information is provided in a manner easily understood by the resident or resident representative; - The resident and/or family, upon admission, to determine the need and knowledge relative to advance directives and advanced care planning; - Residents may revise an advance directive either orally or in writing. With an oral reversal, charting is due immediately, the physician is notified immediately, an immediate notation is made on the care plan, and an immediate entry is made in the medical record. With written reversals, the physician is notified, and the plan is permanently adjusted. The physician must give an order for any changes in the advance directives; - If the resident leaves the facility temporarily (e.g., ER visit, hospital stay, or diagnostic procedure), a copy of the advance directive is sent with the resident. The facility should also ensure advance directive status (e.g., DNR, DNI) is communicated to the receiving provider and transporting provider; - Each time the resident is admitted to the facility, quarterly, and when a change in condition is noted in the resident condition, the facility should review the advance directive and advance care planning (ACP) information. This review should focus on if the existing advance directives and ACP match the current goals of care for the resident. The social services director or designee should document this conversion in the medical record and assist as needed with updating the documents that need revision in accordance with state and federal requirements; - Residents who are competent at the time of admission and who have not previously executed an advance directive are given the opportunity to do so with the assistance of an interdisciplinary team, consisting of, but not limited to: the Medical Director, Executive Director, Director of Nursing, Director of Social Services, chaplain, and others as appropriate. Social Services ensures that a copy of the advance directive is obtained for the resident's medical record and verifies that there is an appropriate physician's order in the resident's medical record as well; - In the absence of an advance directive, incompetent residents have treatment decisions made by appropriate surrogate decision-makers. Such persons may include a court appointed guardian, the holder of a durable power of attorney, or a family member; - When the surrogate decision-maker is not the holder of a durable power of attorney (or a court appointed guardian) and where conflict arises as to the care provided or withheld, the facility provides all medical care until the conflict is resolved or otherwise ordered by a court of law; - Documentation in the Minimum Data Set (MDS) should reflect the appropriate advance directives. This information is reviewed or updated, as appropriate, at least quarterly or more frequently if there is a significant change in the resident's medical condition. Each quarter the care plan team reviews with the resident, his or her advance directives to ensure that they are still the wishes of the resident. Such reviews are made during the quarterly assessment process and recorded on the Resident's Assessment Instrument (RAI); - Do Not Resuscitate (DNR) - Regardless of whether the resident is in a persistent vegetative state or has a terminal condition, all Life Care Centers of America's residents receive full resuscitative measures unless a DNR is written in the resident's medical record and is identified in the resident's advance directive. While the physician's order is pending, the documented verbal wishes of the resident or resident's representative regarding DNR status will be honored, unless state specific guidelines differ; - Social Services or Nursing Administration's documentation of the DNR must be present in the medical record regarding the DNR status and discussion with the resident and/or resident's representative on the consequences and implications of this status. The physician is notified regarding any questions concerning the appropriateness of the resident's code status; - A physician's order and written consent from the resident or resident's representative must be obtained. While the physician's order is pending, staff should honor the documented verbal wishes of the resident or the resident's representative regarding CPR unless state-specific regulations differ; - DNR order is flagged appropriately on the resident's chart to alert staff as to status; - Social Services and/or a member of Nursing Administration reviews the DNR status with the resident and/or family and the receiving physician within 72 hours of admission; - The resident or resident's representative must sign an informed consent as required by state specific requirement indicating that the resident consents to a DNR or no CPR or no resuscitation in the event of cardiac arrest or respiratory failure; - The DNR order is incorporated into the resident's care plan and is periodically reviewed, at least quarterly, including supportive care and comfort measures. These measures will not be withheld when a DNR order exists; - DNR orders may be revoked at any time but must be documented in the resident's chart as such with consent of the resident or the resident's representative; - The resident's physician is notified of any change in condition regardless of the DNR order; - The Director of Nursing or designee establishes a system to inform all direct care staff of the resident's DNR status. - If the resident is discharged from the facility and readmitted , the DNR status must be reviewed to determine if it is still appropriate and desired by all parties involved. A new order for DNR is obtained at that time. 1. Review of Resident #1's medical record showed: - An initial admitted [DATE]; - A code status form marked and signed DNR (Do Not Attempt Resuscitation) on [DATE] by the resident's spouse; - A readmitted [DATE]; - A code status form marked and signed full code on [DATE] by the resident; - A DNR order, dated [DATE], with no documentation as to why the order was changed from full code to DNR; - No documentation of any contact being made with the resident, the resident's family, or physician to obtain proper authorization for a code status change on [DATE]. Review of the resident's care plan, last revised [DATE], showed: - Resident had an advance directive to be a DNR, date initiated [DATE]; - Code status would be reviewed on a quarterly basis and as needed (prn), date initiated [DATE]; - No mention of code status changing to full code, which was signed by the resident, on [DATE]; - No mention of DNR change on [DATE]. Review of the resident's BIMS (Brief Interview for Mental Status: score 0 to 7 severe cognitive impairment, ,d+[DATE] moderate cognitive impairment, ,d+[DATE] cognition intact) showed: - On [DATE], BIMS score was five out of 15; - On [DATE], BIMS score was 12 out of 15; - On [DATE], BIMS score was 15 out of 15; - On [DATE], BIMS score was 15 out of 15. Review of the resident's BCAT (Brief Cognitive Assessment Tool to show cognition with scoring from 0 to 50 with 50 being cognitively intact) done from [DATE] through [DATE] showed a score of 33, stating cognitive impairment and/or mild stage dementia. Review of the resident's hospital record, dated [DATE], showed: - Upon discharge from the hospital on [DATE], the resident was at his/her baseline mental status per spouse alert and oriented to time, person, place, and situation; - Patient has continued to have waxing and waning (increases and decreases in consciousness) consciousness through the course of recent hospital admissions. The resident was placed on delirium precautions and received trazodone prn (as needed). The resident improved and was at baseline mental status at time of discharge on [DATE]; - Code status at discharge: NO CPR. Review of witness statement from CNA C, dated [DATE] at 7:30 P.M., showed: -CNA took the resident to the bathroom at about 2:00 A.M. on [DATE] to use the toilet and had a bowel movement (as reported by the CNA). The CNA put the resident back to bed after using the bathroom. When the lab staff arrived, lab staff went into resident's room and came out to the nurse's station and told facility staff that the resident was not responding. CNA J went into the resident's room, came back out, and said go get LPN E. LPN E, CNA J, CNA D, and CNA C went into Resident #1's room. LPN E checked the resident and said he/she had no pulse. CNA C went to the nurse's station and called the code blue overhead and checked the report sheet which said full code. CNA C then turned on the computer and when the computer screen came up, CNA C checked the resident's name and the computer said he/she was DNR. CNA C then ran down to the room and told the nurse the resident was a DNR and to stop compressions. The nurse stopped compressions and CNA C left the room. Review of witness statement from CNA D, dated [DATE] at 8:30 P.M., showed: - CNA D was on his/her assigned hall on [DATE] around 5:30 A.M., he/she saw commotion and went to the other staff members who stated the resident was unresponsive. CNA D asked if the resident was a full code. LPN E said they looked and said the resident was a full code. CNA D grabbed the crash cart and took it into the room. LPN E and CNA D placed the backboard under the resident and LPN E started compressions. CNA D gave a breath or two via ambu bag (a device to deliver air to someone not breathing or with difficulty breathing). Someone came to the room and said the resident was a DNR. Compressions stopped. Review of witness statement from LPN E, dated [DATE] at 7:45 P.M., showed: - Phlebotomist came in around 5:00 A.M. and came to nurse's station and said the resident would not wake up. LPN E went to the room and the resident did not have a pulse. LPN E and CNA C went to the nurse's station to check the report sheet for code status. At this time the report sheet said full code. LPN E returned to the room to begin CPR while CNA C checked the electronic medical record for code status and called the code overhead. After a few compressions, CNA C returned to the room and stated the resident was a DNR. LPN E stopped compressions and 911 was not called. LPN F came to assist with breaths via ambu bag. No breaths were given before stopping CPR. Review of an interview statement by phone interview between LPN E and the Administrator on [DATE] showed: - LPN E reports during the interview that when he/she entered the room of the resident, the resident's body was cool to touch. Review of the witness statement from LPN F, dated [DATE] at 8:05 P.M., showed: - LPN F saw commotion on unit 300 from unit 200 desk. LPN F went down the hall and followed the staff where the nurse had the crash cart. LPN F connected the ambu bag while the nurse started compressions. The nurse completed less than five compressions before CNA confirmed DNR status. LPN F did not give any breaths. After CPR was stopped, LPN F returned to unit 200. Review of an interview statement by phone interview between LPN F and the Administrator on [DATE] showed: - LPN F reported during the interview that when he/she entered the room of the resident, the resident's body was cold to touch and the resident's color was dusky blue. During an interview on [DATE] at 3:30 P.M., the Director of Nursing (DON) said code status used to be on the report sheet. The code status was removed from the report sheet and so the report sheet currently does not have code status on them. Staff should look in the electronic medical record for the code status. During an interview on [DATE] at 8:15 A.M., Registered Nurse (RN) G said he/she would look in the computer for code status and not anywhere else. He/she would not look at anything like a report sheet for code status as that could not be accurate and lead to mistakes. During an interview on [DATE] at 10:46 A.M., LPN A said the resident was alert and oriented as far as he/she could tell. He/She said the resident was not confused. During an interview on [DATE] at 10:55 A.M., Social Services Assistant (SSA) said the resident was alert and oriented. When the resident first got to the facility, he/she was confused, but the last couple BIMS he/she did, the resident was alert and able to make his/her own decisions. The only time the spouse got involved when making decisions was when the resident suggested the spouse be involved. During an interview on [DATE] at 12:16 P.M., the resident's spouse said the only reason the resident was in the facility was for rehab. The spouse said the resident had been alert and oriented throughout his/her stay at the facility. He/she said there wasn't anything wrong with the resident's mental status until the morning of the 11th, which was the day before he/she passed. The spouse said the resident fought hard to live and was ready to fight and come home. The spouse said the resident did not want a DNR after the first initial DNR signed. The spouse said he/she was present when the resident signed his/her admission documentation, which included the full code. The spouse said the resident was very much alert and oriented at the time. During an interview on [DATE] at 1:40 P.M., Occupational Therapist (OT) H said he/she worked with the resident doing therapy. He/She said the resident seemed alert and oriented and could carry on a conversation just fine. He/She said therapy success staff had planned the resident a success story since he/she was close to completing therapy and going home soon. During an interview on [DATE] at 1:42 P.M., the Director of Rehab said he/she did not remember the resident's cognitive status off hand, but the BCAT score of 33 out of 50 is consistent with the BIMS score of 12 showing some cognition issues. During an interview on [DATE] at 2:11 P.M., the Administrator and DON said code status should be assessed upon admission, readmission, change of condition, at least quarterly and as needed. They said a change of code status should be reflected in the care plan. They said the process to change code status is if a resident has a BIMS of 12 or greater, they will discuss what a DNR and full code is and what they would like and if they have a BIMS of less than 12, then the POA or next of kin will be contacted. Staff can check code status in the electronic records system and in the plan of care. They said when a resident is requesting a code status change, the IDT team should be notified. The IDT team includes the Administrator, DON, MDS, Dietary Manager, Social Services, Activities, Housekeeping, Director of Rehab and Infection Preventionist. During an interview on [DATE] at 2:30 P.M., LPN M said on [DATE] he/she received a phone call from another staff person to change Resident #1's status to a DNR. LPN M said he/she did not know who the staff person was that called and directed the change. He/She thought it might have been a nurse or human resources. LPN M did not verify the order with a signed consent for change of code status or notify the physician, resident and or family any changes. Complaint #MO00249411

Based on observation, interview, and record review, the facility failed to ensure two residents (Residents #1 and #2) out of five sampled residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices related to pain management. The facility's census was 94. Review of the facility policy titled, Pain Assessment and Management, last revised 09/12/23, showed: - Facility must ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive-centered care plan, and the residents' goals and preferences; - Based on assessment, the facility in collaboration with the attending physician/prescriber, other health care professionals, and the resident and/or their representative, develops, implements, monitors, and revises as necessary interventions to prevent or manage each individual resident's pain; - Monitor appropriately for effectiveness and/or adverse consequences; - All residents will be assessed for pain indicators upon admission/readmission, quarterly, and with any change in condition. Review of the facility policy titled, Administration of Medications, last revised 02/13/23, showed: - The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms; - As needed administrations medications should reflect the initial administration and the additional follow-up performed top determine the effectiveness of the medication administered; - Ensure the medication is working the way it should, medications are reviewed regularly, and ongoing observations are done if required. Review of the facility policy titled, Pharmacy, last revised 01/01/22, showed: - During normal business hours, facility staff may contact the pharmacy by phone or fax at the phone/fax provided, or by mail or hand delivery; - After normal business hours, facility staff should contact the pharmacy by dialing the telephone number to page the on-call pharmacist; - If orders for medications are received from the pharmacy/prescriber when the pharmacy is closed, the facility should remind the physician the pharmacy is closed and that a delay in medication therapy can be prevented by using a medication in the facility's emergency medication supply; - If a medication cannot be substituted, ask the physician if the medication can be initiated the following morning; - If a medication is considered essential and cannot be substituted or delayed, contact the emergency number provided. Orders should be directly received from a facility nurse or a licensed physician and cannot be faxed, emailed, or provided to the answering service personnel. 1. Review of Resident #1's medical record showed: - admitted [DATE]; - Diagnoses of unspecified fracture of left femur (serious injury that occurs when the thighbone breaks), unspecified fracture of upper end of left humerus (break near the shoulder joint), multiple fractures of ribs left side, Crohn's disease (chronic inflammatory bowel disease), and chronic pain syndrome. Review of the resident's Physician Order Sheet (POS), dated December 2024, showed: - An order for Norco (pain medication) 5/325 milligrams (mg) by mouth every six hours as needed for moderate pain, dated 11/27/24; - An order for acetaminophen (pain medication) 325 mg two tablets by mouth every six hours as needed for pain, dated 11/21/24; - An order for gabapentin (nerve pain medication) 300 mg by mouth two times a day related to chronic pain syndrome, dated 11/21/24; - An order to assess pain level every shift, dated 11/21/24; - An order for Norco 7.5/325 mg by mouth every six hours as needed for pain, dated 12/18/24 at 9:30 A.M.; - An order to assess pain before starting treatment, dated 11/21/24; - An order to cleanse wound with Vasche (wound cleanser) and apply bordered gauze daily, dated 12/01/24. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 11/25/24, showed: - Primary diagnosis of fractures and other multiple trauma; - Cognition intact; - Impairment of upper extremity on one side and impairment of lower extremity on both sides; - Total dependence for dressing, toileting, personal hygiene, bathing; - Dependent with rolling left and right, lying to sitting on side of bed, sit to stand, and chair transfers; - Substantial to max assist with sit to lying; - Used walker and wheelchair for mobility; - On scheduled and as needed pain medication regimen; - Occasionally had pain interference with therapy activities and day-to-day activities; - Had surgical wounds and skin tears; - Application of nonsurgical dressings and wound care; - Occasional pain. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated December 2024, showed: - Norco 5/325 mg administered on 12/16/24 at 6:02 A.M., for pain level of eight out of 10; - Norco 5/325 mg not administered on 12/17/24 and 12/18/24; - Acetaminophen 325 mg not administered on 12/16, 12/17, or 12/18; - Norco 7.5/325 mg administered on 12/18/24 at 9:47 A.M., for pain level nine out of 10. Review of the resident's Progress Notes showed: - On 12/16/24 at 3:08 P.M., the as needed medication helped the resident's pain. The as needed pain medication available; - On 12/17/24 at 4:53 P.M., staff spoke with the physician's group and was told the pharmacy had to contact them to fill the pain medications. Staff had faxed the pharmacy for refill; - On 12/17/24 at 5:27 P.M., a request for Norco was sent to the pharmacy by fax; - On 12/18/24 at 8:05 A.M., the pharmacy was called to check on the Norco request. The pharmacy would fill the medication script and send the medication out as soon as possible (STAT) run; - On 12/18/24 at 9:12 A.M., a call was placed to the physician's group due to the resident's pain level being a nine and unable to give the prescribed Norco as the facility was waiting for the pharmacy to fill it. Review of the resident's care plan, last revised 12/07/24, showed: - Resident expressed pain related to surgery to the left hip and broken ribs from a fall at home prior to hospitalization ; - Educate resident and family regarding pain management; - Interventions to evaluate the effectiveness of pain interventions, observe and report complaints of pain or requests for pain treatment; - Observe and report changes in sleep patterns, usual routine, decrease in functional abilities, decrease in range of motion, and withdrawal or resistance to care; - Give pain medications as ordered. During an interview on 12/17/24 at 12:57 P.M., Resident #1 said he/she didn't know when he/she got pain medication last. Resident #1 was is in a lot of pain. He/She said his/her pain was currently a nine and a half on a scale from zero to 10. The pain medication normally helped dull the pain but did not take it away completely. Today was the worst it had been. He/She had a high pain tolerance. Resident #1 said he/she hurt yesterday, and staff did not have anything to give him/her, so he/she just had to deal with it. It was not the first time he/she had to go without pain medication. Resident #1 said they would give him/her acetaminophen, but that was it. He/She should receive pain medication every six hours and now he/she couldn't get it at all. Resident #1 didn't know why he/she couldn't get more pain medications. On 12/16/24 at 10:10 P.M., the nurse told him/her they didn't have the pain medication. Resident #1 said he/she was going to leave the facility, because he/she had pain medication at home, but he/she did not have a way to get to his/her home last night. During an interview on 12/17/24 at 1:55 P.M., Resident #1 said he/she was very angry last night, because he/she believed the staff had been lying to him/her about whether staff had given him/her the pain pill. He/She could not sleep due to the pain, and it had caused him/her to have anxiety due to concerns something was wrong with the way he/she had been healing due to the increased pain levels. It had restricted his/her physical range of motion, mobility and prohibited his/her ability to complete daily tasks, such as using the restroom. During an interview on 12/18/24 at 9:30 A.M., Resident #1 said he/she asked for pain medication several times throughout the night on 12/17/24. Staff said they were still out of the medication. He/She still had not received anything for pain and his/her pain level was a nine or nine and a half out of 10. The facility had been out of medication for over two days now and he/she had not received any pain medication. 2. Review of Resident #2's medical record showed: - admitted [DATE]: - Diagnoses of acute kidney failure (the kidneys cannot filter waste from the body), hemiplegia and hemiparesis (weakness or paralysis on the left side of the body) following nontraumatic subarachnoid hemorrhage (a brain bleed) affecting the left non-dominant side, acute respiratory failure with hypoxia (body cannot maintain levels of oxygen and carbon dioxide), unspecified hydronephrosis (kidneys swell and stretch due to buildup of urine), chronic obstructive pulmonary disease (COPD - lung disease that block airflow and make it difficult to breathe). Review of the resident's POS, dated December 2024, showed: - An order for acetaminophen 325 mg two tablets by mouth every six hours as needed for pain or fever, dated 11/18/24; - An order for gabapentin 300 mg three times a day by mouth for nerve pain, dated 11/18/24; - An order for Norco 5/325 mg by mouth every six hours as needed for pain, dated 11/18/24; - An order to assess pain level every shift on scale of zero to 10, dated 11/18/24; - An order to assess pain before starting a treatment every shift, dated 11/18/24. Review of the resident's MAR and TAR, dated December 2024, showed: - Norco 5/325 mg administered last on 12/16/24 at 1:00 A.M., for pain level of seven out of 10 with no follow up pain scale showing if medication was effective; - Norco 5/325 mg not administered on 12/17/24 and 12/18/24; - Acetaminophen 325 mg two tablets administered on 12/16/24 at 2:40 P.M., and 8:52 P.M., for pain levels of seven out of 10 both times with no follow up pain scale showing if medication was effective; - Acetaminophen 325 mg two tablets administered on 12/17/24 at 3:06 A.M., for a pain level of five and at 4:55 P.M., for a pain level of eight with no follow up pain scale showing if medication was effective; - Acetaminophen 325 mg two tablets administered on 12/18/24 at 7:53 A.M., for pain level of seven and at 2:28 P.M., for pain level eight with no follow up pain scale showing if medication was effective. During an interview on 12/17/24 at 1:55 P.M., Resident #2 said he/she had been out of pain medication for two days and it was starting to make him/her anxious and scared. He/She didn't know when the pain medication would be available next and he/she took acetaminophen instead but it did not do much for the pain. The pain caused him/her to not sleep much at night and his/her appetite was gone. He/She had snacks in the room but did not feel like eating anything because of the pain. Resident #2 had asked for pain medication many times, but did not know when he/she would get any. He/She listened to music or tried to read to distract him/herself from the pain. His/Her pain was an eight out of 10 which was worse than normal. During an interview on 12/17/24 at 3:20 P.M., Resident #2 said he/she asked for pain medication about an hour or two ago. He/She said staff just kept saying they were out of the medication. During an interview on 12/17/24 at 1:55 P.M., Resident #2 said not having pain medication had affected everything. He/She said it had affected his/her whole quality of life. It had affected his/her sleep. He/She did not sleep at all last night and it had affected his/her eating. He/She had snacks in his/her room, but he/she had not been able to eat them because of the pain. Activities had been restricted due to being in too much pain to attend them. The pain had been an eight out of ten on the zero through ten pain scale. Resident #2 had been out of pain medication for two days and was fearful and anxious of when he/she will be able to get the pain medication again. He/She listened to music or read to try and distract his/herself from the pain. Maybe the new physician would change something, but had not seen the new physician yet. During an interview on 12/17/24 at 10:10 A.M., Registered Nurse (RN) A said if staff had an order, they could pull the medications from the Emergency (E) kit and two staff must sign off on it. Staff typically tried to order at least three 30 tablet medication cards for the E kit. The facility was currently having issues running out of Norco 5/325 and the nurse managers must reorder it. It had been out for about two days. Resident #1 used Norco 5/325, so he/she had acetaminophen that was ordered, but someone needed to call and get something stronger for him/her. During an interview on 12/17/24 at 1:11 P.M., the Director of Nursing (DON) said the facility had ran out of scripts and had been using the E kit more than management would have liked. The staff would have to call the physician for a one-time order for a stronger dose when they were out of the lower dose pain medication. Staff had not had any issues getting orders from the physician. A count was conducted of the E kit which showed there were no Norco 5/ 325 mg tablets available. During an interview on 12/17/24 at 2:41 P.M., the DON said she believed RN E sent an order request yesterday for the pain medication for Resident #1. The facility could use a different pharmacy if they needed and could see if the physician would order something different the facility had on hand. During an interview on 12/17/24 at 3:25 P.M., Certified Medication Technician (CMT) B said Resident #2 had been out of the medication for a couple of days. As far as he/she knew, the nurse had been calling the pharmacy or dealing with people on the phone working on getting the medication. A couple weeks ago, a different pain medication ran out. He/She could tell the residents were being affected some without their medications and more residents were asking for their pain medication more frequently. During an interview on 12/17/24 at 3:30 P.M., Licensed Practical Nurse (LPN) C said he/she was dealing with getting the residents their medications. If he/she was not able to get the ordered medications, then he/she was trying to get substitute medications until the residents normal medications would be available. Some medications the facility had a backup supply in the E kit but the facility was currently out of Norco 5/325 mg tablets. The pharmacy should bring some of the medications tonight or in the morning. This facility just got a new physician and the pharmacy was getting a new internet system so it was making things a little more complicated and delaying things a little. During an interview on 12/17/24 at 4:00 P.M., the Director of Nursing (DON) said the E kit should be there that night. One of the nurses was getting medication straightened out on 100 Hall. During an interview on 12/17/24 at 4:13 P.M., the DON said the residents on 200 Hall should be getting their medication filled tonight. During an interview on 12/18/24 at 8:36 A.M., Resident #2 said he/she was still out of medication so he/she did not receive any pain medication last night. During an interview on 12/18/24 at 8:50 A.M., the DON said the pharmacy did not bring medications last night for the E kit and some residents. She called the pharmacy this morning and they were filling them now and should be delivered today. During an interview on 12/18/24 at 8:57 A.M., Pharmacy Worker I said on 12/17/24 at 12 P.M., the pharmacy received a request for Resident #1 for Norco 5/325 mg as soon as possible. The pharmacy notified the physician yesterday but had not received anything back yet. He/She went and checked the fax machine and the electronic transmission with nothing from the physician yet. The last script filled and sent was on 11/28/24, and 20 Norco 5/325 tablets were sent at that time. For Resident #2, the pharmacy filled the script on 12/16/24 at 4:30 P.M., and delivered it on 12/17/24. If the facility was out of medications and needed them STAT, then the pharmacy would have filled the medications and sent them to the facility as soon as possible. The pharmacy did not know the facility wanted the medications STAT. Observation on 12/18/24 at 9:22 A.M., of Resident #2's medications showed: - Zero Norco 5/325 mg medication. Observation on 12/18/24 at 9:26 A.M., of the E Kit showed: - Zero Norco 5/325 mg medication. During an interview on 12/18/24 at 3:32 P.M., RN E said the previous physician left 11/17/24, and the new physician started to visit to the facility last week. He/She didn't know exactly which residents the new physician saw, but he/she told the new physician the people he/she knew had problems. He/She was pretty sure the new physician saw Resident #1, because he/she had told the new physician about Resident #1 needing pain medications. The facility ran out of the pain medications over the weekend. They got the E kit filled sometime today, so they now had the pain medication in the facility. During an interview on 12/18/24 at 3:40 P.M., LPN F said staff had ordered pain medication for the E kit and knew it was supposed to be delivered sometime today. During an interview on 12/18/24 at 3:51 P.M., LPN G said there was a crazy process to get prescriptions filled from their new pharmacy. Staff had to call the pharmacy. The pharmacy then sent a fax to the physician's office and the physician sent it back to the pharmacy. It was kind of a difficult process. It had been a process to try and get medications filled. During an interview on 12/18/24 at 4:26 P.M., the DON, the Administrator, and the Corporate Nurse said staff should request a refill when medications reach seven days remaining. If staff couldn't get medication, staff should call for a new script. If staff couldn't get it in a timely manner, staff should request an alternative. If something was unavailable, then staff should contact the physician. The DON thought the pharmacy delivered the E kit replacement at around 1:15 P.M., on 12/18/24. The DON and the Administrator said staff should be assessing residents for pain every shift, on admission, readmission and with a change of condition and as needed. During an interview on 12/19/24 at 10:45 A.M., Pharmacist J said the new script for Resident #2's pain medication left the pharmacy this morning to be delivered. During an interview on 01/02/25 at 9:40 A.M., Pharmacist L said if the facility requested a refill and the scripts were received by 12:00 P.M., then the pharmacy could send the medication out to the facility the same day. For E kit medications, the facility had to fill out a form for certain medications they wanted ordered and the pharmacy could deliver it the same day if placed by 12:00 P.M. If the facility needed medications STAT, then the pharmacy would try to deliver it the same day if possible. If a resident was without pain medication, the resident would probably be in pain and depending on the amount of pain, the facility may need to contact a physician to see if they wanted to try something different until the resident's normal pain medication was available again.

Based on interview and record review, the facility failed to ensure the environment remained free of accident hazards by not ensuring staff utilized a hoyer lift and an appropriate vehicle to accommodate a wheelchair for one resident (Resident #1) resulting in increased pain and anxiety out of three sampled residents. The facility census was 99. The facility did not provide a policy for transfers. 1. Review of Resident #1's medical record showed: - An admitted [DATE]; - Diagnoses of muscle weakness, reduced mobility, history of falling, and chronic kidney disease (long standing disease of the kidneys); - No documentation of a lift assessment. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment completed by the facility staff), dated 11/16/24, showed: - The resident required maximal assistance with mobility. Review of the resident's Physical Therapy (PT) evaluation, dated 11/05/24, showed: - The resident required a Hoyer lift (a mechanical lift) for transfers. - Review of the resident's comprehensive care plan, dated 11/20/24, showed: - Did not address transfers or mobility concerns with individualized interventions. During an interview on 11/26/24 at 12:15 P.M., Therapy F said on 11/20/24, Resident #1 was a changed to a Hoyer lift transfer. The resident had not made a lot of progress in the last month as pain and weakness were contributing factors as well as having a lot going on with medical issues. During an interview on 11/26/24 at 11:00 A.M., Resident #1 said he/she had an appointment on 11/15/24, at an infusion center. Certified Nursing Assistant (CNA) B was with him/her during the appointment. When it was time to leave, no transportation was available from the facility. He/She was transported in a specialized van or bus so he/she could stay seated in the wheelchair. After waiting for two to three hours, the Activities Director (AD) and Licensed Practical Nurse (LPN) A arrived in the AD's personal small car to take him/her back to the facility. CNA B, the AD, and LPN A folded the resident in half like a folding chair to load him/her in the car. He/She screamed in pain but the three staff members kept pushing. The resident was in so much pain and couldn't remember if the staff used a gait belt during the transfer or if he/she received anything for pain after arriving at the facility. Once the staff was in the process of getting him/her in the car, they couldn't stop. The staff almost dropped the resident during the transfer and that was why they kept pushing to get him/her in the car despite he/she screamed/cried out in pain and begged them to stop. It was a horrible experience. The resident dreaded having to go to the doctor because he/she was fearful and anxious of it happening again. The resident said it was a traumatic and painful experience. During an interview on 11/26/24 at 12:24 P.M., Resident #1 said he/she had some knee and back pain and swelling in his/her knees. After the transfer incident on 11/15/24, his/her knee and back pain was significantly worse for a couple days. His/Her bottom burned and hurt from having to sit for several hours in a urine soiled brief. During an interview on 11/26/24 at 3:50 P.M., Resident #1 said he/she had required a Hoyer lift for transfers for at least a month. The resident said his/her legs did not work and he/she couldn't bear weight. During an interview on 11/26/24 at 3:56 P.M., CNA B said he/she was told to go with Resident #1 to his/her appointment at the infusion center on 11/15/24. They arrived around 8:00 A.M., and the resident was done around 1:00 P.M. He/She called the facility and notified staff they were ready to be picked up. Around 2:00 P.M., CNA B called the facility again and was told the facility transportation was not available, but they were working on it. The resident and CNA B waited another couple of hours. CNA B did not have the items required to provide care for the resident. The Administrator had the AD come in his/her personal car to pick them up. The resident was a Hoyer lift transfer, so when the AD and LPN A arrived in the car, Resident #1 told them he/she could not stand. The resident screamed and cried in pain. CNA B said LPN A were aware Resident #1 was a Hoyer lift transfer but attempted to transfer the resident manually and they almost dropped Resident #1 when they tried to get him/her in the back seat of the small car. When they got back to the facility, more people helped to help get Resident #1 out of the car. During an interview on 11/26/24 at 11:15 A.M., the AD said on 11/15/24, there were issues getting transportation arranged for Resident #1 to be picked up from the infusion center. Staff spent several hours trying to get an outside transportation agency scheduled and had issues contacting them. The Administrator told the AD (who was also a CNA) and LPN A to pick up Resident #1 because the infusion center was closing. The AD drove his/her own personal car. Resident #1 was a Hoyer lift transfer. Resident #1 appeared to be in a lot of pain during the transfer, screamed out in pain, and told them to stop. Resident #1 was almost dropped during the transfer into the back seat of the car because they thought the back seat would have more room. A gait belt and the Hoyer lift sling that was underneath Resident #1 were used during the manual transfer. The AD got on one side and LPN A got on the other side of the resident while CNA B got in the back seat of the car to pull on the lift sling to try and help pull the resident into the car. The AD was unaware of a plan for what to do if it happened again. During an interview on 11/26/24 at 11:25 A.M., LPN A said Resident #1 went to an appointment on 11/15/24, at an infusion center with CNA B in attendance because the resident was chair bound. CNA B called several times throughout the day telling the facility staff they were waiting on transport to pick them up after the appointment. The Administrator told LPN A someone would have to go get the resident. At the time, LPN A thought the resident transferred with assistance of one staff and didn't realize he/she required a Hoyer lift. The infusion center was closing and he/she knew the resident had sat for at least five hours, was probably soiled, and needed to be changed. When LPN A and the AD arrived at the infusion center, the resident cried because his/her bottom burned since he/she had sat in a urine soiled brief, and was in pain because he/she had missed the scheduled pain medication. LPN A noticed the Hoyer lift sling and the resident said he/she was a Hoyer lift transfer sometimes. It was awkward to transfer the resident into the car. The resident cried, said he/she was in pain, and wanted them to stop with the transfer. During an interview on 11/26/24 at 2:07 P.M., the facility Transport Coordinator said he/she received around five different calls on 11/15/24, about whether the outside transportation agency was going to pick up Resident #1 from the infusion center. He/She told everyone at the facility the outside transportation agency was going to pick up the resident. The resident was on the waiting on the list to be picked up. The waiting list means first come, first serve and this resident was going to be picked up, but had to wait his/her turn. On 11/15/24 at around 4:00 P.M., an unknown person called the outside transportation agency and told them Resident #1 didn't need to be picked up because facility staff went to get the resident. During an interview on 11/26/24 at 2:19 P.M., the outside transportation agency Staff F said Resident #1 wasn't a scheduled run on 11/15/24. For same day appointments, the facility was supposed to call dispatch, but originally someone had left a voicemail for him/her. By the time he/she got the message, the ride had already been put in with dispatch at 2:04 P.M., on 11/15/24. He/She called the infusion center later and the staff there said someone from the facility was there picking up the resident, and their services were not needed. During an interview on 11/26/24 at 2:53 P.M., the infusion center Staff C said he/she called the facility on 11/15/24, approximately 12 to 13 times and CNA B called too, but couldn't get anyone from the facility to answer the phone. Eventually the facility answered and was told Resident #1 had waited to be picked up for over for two hours, was soiled, needed changed, and was in pain. The facility said they were having issues with the outside transportation agency. The resident appeared to be miserable and in pain. Eventually two facility staff members arrived in what appeared to be a personal car to take the resident back to the facility. During an interview on 11/27/24 at 9:30 A.M., the infusion center Staff E said on 11/15/24, Resident #1 sat a long time in a soiled brief. He/She offered to help CNA B get the resident to the bathroom, but the resident was non-weight bearing and was a Hoyer lift transfer. Eventually, two facility staff members arrived in what appeared to be a personal car. He/She watched from the window as the facility staff to transferred Resident #1 into the car. During an interview on 11/27/24 at 9:40 A.M., the infusion center Staff D said he/she was in the parking lot on 11/15/24, when two facility staff members arrived to transport Resident #1. The resident could not bear any weight on his/her legs. When the facility staff members attempted to pick up the resident, the resident's knees appeared to buckle and he/she heard the resident yell out he/she was going to fall. The facility staff continued to try and get the resident in the car. The resident screamed out in pain and said his/her knees and legs hurt. The resident was a larger person and the staff appeared to struggle to get him/her in the car. The resident appeared to be in significant pain throughout the entire incident. During an interview on 11/26/24 at 12:43 P.M., the Director of Nursing (DON) said they had issues with getting arrangements in place for Resident #1 to be picked up from the infusion center on 11/15/24. She was told LPN A went to get the resident in the facility van, but LPN A realized he/she did not have the correct license to drive the van, so LPN A and the AD took the AD's personal car. She didn't know what happened until they arrived back at the facility. Resident #1 complained of pain with his/her left knee. The resident sat on a Hoyer lift sling when he/she arrived in the car. The resident needed the Hoyer lift due to he/she was normally weaker leading up to his/her infusions and from the appointment. During an interview on 11/26/24 at 4:32 P.M., the Administrator said she knew staff tried to get an outside transportation agency scheduled for Resident #1 on 11/15/24. The infusion center called and said the facility had to get someone there soon because they were closing. They couldn't get the outside transportation agency on the phone so she told LPN A to go pick up the resident since he/she had a license to drive the facility van. She told LPN A to take the AD with him/her. About an hour later, she found out LPN A got to the van and realized he/she did not have the correct license to drive it and instead of coming back in to notify the Administrator, he/she decided to take a personal car to get the resident. Had LPN A notified her, she would have made other arrangements such as an ambulance. She would expect staff to provide appropriate accommodations to residents to ensure they were transferred in a safe manner, either by using a mechanical lift or providing transportation that allowed the residents to be transported in their wheelchairs. Complaint #MO245231

jw KW Based on observation, interview, and record review, the facility failed to identify and treat a facility acquired pressure ulcer (injury to the skin and underlying tissue from prolonged contact with pressure) for one resident (Resident #2) out of five sampled residents. The facility's census was 105. Review of the facility's policy titled, Skin Wound, dated 08/25/21, showed: - Based on 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; - A resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers form developing; - A skin assessment/inspection should be performed weekly by a licensed nurse; - Skin observations also occur throughout points of care provided by Certified Nurse Aides (CNA) during activities of daily living (ADL's). Any changes or open skin areas are reported to the nurse. CNAs will also report to the nurse if the topical dressing is identified as soiled, saturated, or dislodged. The nurse will complete further inspection/assessment and provide treatment if needed. Review of Resident #2's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by the facility staff), dated 06/02/24, showed: - An admitted [DATE]; - Cognition intact; - No rejection of care; - Independent with eating; - One person physical assist with bathing; - Supervision and/or touch assistance of staff for rolling left and right in bed, sit to stand, lying to sitting, chair to bed, and toileting; - Foley catheter (a device that drains urine from the urinary bladder into a collection bag outside of the body); - Incontinent of bowel; - Hemodialysis (a treatment that filters waste and water from the blood) treatments; - No pressure ulcers. Review of the resident's medical record showed: - Resident his/her own responsible party; - Diagnoses of clostridium difficile (c-diff - a bacteria that causes diarrhea and colitis), diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), end stage renal disease (medical condition where the kidneys stop functioning normally and can no longer filter waste from the blood), neurogenic bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should), morbid (severe) obesity (a chronic disease that occurs when someone has an excessive amount of body fat that can negatively impact their health), anxiety, and depression, cognitive communication deficit (trouble reasoning and making decisions while communicating), and history of pressure ulcer of other site, Stage 3 (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). Review of the resident's August 2024 Physician Order Sheets (POS) showed: Encourage resident to reposition every two hours, dated 07/16/24; - No orders for skin care and/or treatment of any wounds. Review of the resident's care plan, updated on 04/24/24, showed: - At risk for break in the skin integrity. Interventions of clean and dry the skin after each incontinent episode, a pressure reducing mattress, weekly skin checks, and a wheelchair cushion; - The resident was resistive to care, refused showers, wanted bed baths but when bed baths were offered, he/she refused them, refused to use toilet, lay in bed and soiled self, refused to assist with ADLs, and wanted staff to do all care. Interventions included allowing resident to amke decisions reagrding treatment to give a sense of control, educate resident regarding of the possible outcomes of not complyi ng with care and treatemets, and if resident resistive to care, leave and wait 5-10 minutes, return later and attempt care agian; - No changes to the skin integrity or noncompliance with care since 04/24/25. Review of the resident's Weekly Skin Integrity assessment, dated 08/19/24, showed blanchable (all redness disappears when light finger pressure is applied, indicating that the local capillaries are undamaged) area of redness to the coccyx and barrier cream applied. Shower sheets were not provided. Review of the resident's progress notes, dated 8/19/24 through 08/22/24, showed: - On 08/19/24, the resident refused to go to dialysis and refused labs to be completed for follow up care. Insisted on just lying in bed all the time. Resident educated on consequences of refusing dialysis, and the resident said, I know, and continued to refuse to go. Resident was incontinent of bowel. Peri care provided with each incontinent episode and PRN. Resident remained on contact isolation at this time for c-diff. Resident told the CNA that he/she did not want to be changed. Resident made aware that not being changed could result in skin integrity issues. The resident agreed to a bed check with reservations about pain when moved. Resident screamed out in pain often and staff encouraged the resident to use bed controls him/herself to control the rate in which bed was placed into position for optimal comfort of the resident and safe working position for the staff; - On 08/20/24, the resident insisted on just lying in bed all the time. - On 08/21/24, the resident insisted on just lying in bed all the time. Resident educated on consequences of refusing dialysis, and the resident said, I know, and continued to refuse to go. Resident incontinent of bowel. Peri care provided with each incontinent episode and PRN; - On 08/22/24, the resident insisted on just lying in bed all the time. The resident was incontinent of bowel. Peri care provided with each incontinent episode and as needed (PRN). During an interview on 08/22/24 at 12:40 P.M., CNA E said the resident refused to allow staff to change or reposition him/her frequently. CNA E said he/she noticed the open wound on the resident's buttocks sometime during his/her shift on 08/21/24, and reported the concerns to LPN B. CNA E could not recall the timing of when he/she reported the wound to LPN B. CNA E did not know what LPN B did. During an interview on 08/22/24 at 12:05 P.M., Licensed Practical Nurse (LPN) B said on 08/21/24, he/she assisted the CNAs with incontinent care of the resident. LPN B said he/she helped roll the resident toward him/her, and held the resident in position so he/she (resident) did not fall out of bed. LPN B said since he/she was facing the front of the resident, he/she could not see any of the resident's buttocks. LPN B said he/she did not assess the resident's skin during the care provided on 08/21/24. The CNAs did not report or say anything to him/her at that time about the resident having any open wounds. The resident was very difficult to handle and resisted or refused care frequently. Staff did encourage the resident to allow them to reposition him/her frequently due to being unable to reposition his/herself. Not sure what the facility policy was on pressure wounds, but should be documented and the physician notified for orders to treat. During an interview on 08/22/24 at 12:30 P.M., CNA C said he/she frequently cared for the resident, although he/she was unaware of the resident having any open wounds. If the staff noticed wounds and/or redness or anything abnormal, we were to immediately report the concerns to the nursing staff to follow up on. The resident did refuse care frequently and did not want to be repositioned in bed. Observations on 08/22/24 at 1:45 P.M., of the resident showed: - Right upper buttock area with open wound measured 3.4 centimeters (cm) x 1.9 cm, with an area of yellow slough (dead cells that accumulate in the wound) measured 1.2 cm x 1.1 cm. An area of necrotic (tissue death that occurs when there is not enough blood flow to the area) tissue measured 0.5 cm x 0.3 cm.; - Right lateral (side) buttock area with open wound measured 0.8 cm x 1.3 cm and reddened in color; - Right medial (middle) buttock area with an open reddened area measured 3.5 cm x 0.5 cm and non-blanchable (redness that doesn't fade when pressure is applied). During an interview on 08/22/24 at 1:55 P.M., the Director of Nursing (DON) said she was not aware of Resident #2 having any open wounds. She would have expected the nursing staff to assess weekly and as needed due to the resident being a high risk for pressure ulcers and moisture associated skin damage with having c-diff. and continued refusals of care. Complaint # MO240798

Based on interview and record review, the facility failed to follow physician orders and provide treatment for two residents (Resident #37 and #71) out of six sampled residents with pressure injuries (injury to the skin and underlying tissue resulting from prolonged pressure on the skin). Resident #37 was admitted from the hospital with a sacral (above the tailbone) wound. The facility failed to complete a comprehensive assessment upon admission and failed to obtain physician orders to treat the wound. The resident was hospitalized 19 days after the facility admission with an infected, unstagable (the stage is unclear due to the base of the wound is covered with dead tissue) sacral wound. The facility census was 100. Review of the facility's policy titled, Skin Integrity & Pressure Ulcers/Injury Prevention and Management, reviewed 03/31/23, showed: - 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; - Certain risk factors have been identified that increase a resident's susceptibility to develop or impair healing of pressure injuries. Examples include comorbid conditions, malnutrition and hydration deficits; - The facility will utilize the following Lippincott procedures (primary evidence-based procedures reference): pressure injury prevention, skin assessment, and long term care. The facility did not provide a policy on pressure injury or wound care. 1. Review of Resident #37's medical record showed: - An admitted [DATE]; - Diagnoses of surgical aftercare of abdominal open wound, type 2 diabetes mellitus (inability of the body to make enough insulin), chronic obstructive pulmonary disease (lung disease that makes it difficult to breathe), diastolic heart failure (heart can't properly fill with blood during the resting period), paroxysmal atrial fibrillation (irregular heart beat), atherosclerotic heart disease (narrowing of the artery walls with plaques), peripheral vascular disease (narrowing of the blood vessels in the legs), and history of amputation of the right leg above the knee. Review of the hospital's discharge papers showed: - A preadmission wound ostomy nurse's progress note, dated 02/12/24 at 9:22 A.M., identified a sacral moisture associated skin damage (MASD) wound of 3.4 centimeters (cm) X 0.5 cm X 0.1 cm, assessed as red, moist and with epithelial (thin layer of tissue below skin) tissue. The area was treated with Vashe (wound cleanser) and covered with a bordered foam dressing. The abdominal surgical wound measured 11 cm X 5.7 cm; - An order, dated 02/13/24, to treat the resident's sacrum, cleanse with Vashe (wound cleanser) and apply silicone bordered foam dressing. Review of the resident's Admission Assessment Tool, dated 02/13/24, showed: - Skin not intact with a wound vac (a machine that applies a vacuum to draw the fluid out of a wound and increase to blood flow to the area) to the abdomen, a sacral ulcer, and friction/shearing to the scrotum; - The resident admitted for a wound vac treatment to the abdomen, a Foley catheter (a tube inserted into the bladder to drain urine) and a sacral wound; - No documentation of the descriptions of the wounds or any specific orders for the treatments; - The facility failed to complete a comprehensive skin assessment upon admission. Review of the resident's Physician's Order Sheet (POS), dated 02/28/24, showed: - No orders for the treatment of the sacral ulcer; - Referral to the wound care clinic to evaluate and treat, dated 2/20/24 (seven days after admission). Review of the resident's Treatment Administration Record (TAR), dated February 2024 - March 2024, showed no documentation of treatment orders for the sacral ulcer. Review of the resident's admission Minimum Data Set (MDS) (a federally mandated assessment completed by the facility), dated 02/19/24, showed: - Cognitive status moderately impaired; - Dependent assistance for shower/bathing self; - Total dependence of one staff for lower body dressing, chair/bed to chair transfer, toilet transfer, and tub/shower transfer; - Foley catheter for neurogenic bladder; - At risk for pressure ulcer; - Resident with no pressure ulcers; - Surgical wound upon admission; - Pressure reducing device for the chair and bed; - Surgical wound care. Review of the resident's care plan, dated 02/13/24, showed: - The resident was at risk for a break in skin integrity; - Weekly skin checks and treatments as ordered; - The resident goals were to maintain intact skin with no breaks through the review period, and minimize risk for symptoms of skin infection through the review period; - Did not specify the skin injury type or location; - Did not address the resident's sacral ulcer. Review of the resident's Shower Sheets, dated February 2024, showed: - On 02/14/24, 02/18/24 and 02/28/24, the Certified Nurse Assistant (CNA) identified the sacral wound and the Licensed Practical Nurse (LPN) acknowledged the CNA observations by the LPN signatures; - On 02/21/24, the CNA identified the sacral wound and the Director of Nursing (DON) acknowledged the CNA observation by the DON signature; - The facility failed to provide a description of the wound, assess or intervene. Review of the resident's skin assessments completed by facility staff, entitled Wound Observation Tool showed: - On 02/14/24, no observation or documentation regarding the sacral pressure ulcer; - On 02/21/24, no observation or documentation regarding the sacral pressure ulcer. Review of the resident's Weekly Skin Integrity Data Collection report, completed on 02/28/24, showed: - Wound clinic to evaluate for orders for the sacrum wound; - Allevyn (silicone adhesive foam dressing to manage drainage) in place. Review of the resident's Wound Care Clinic Visit Summary Report, written and signed 03/05/24, showed: - The actual onsite visit completed on 02/29/24 (16 days after admission and nine days after the initial referral); - The wound on the sacrum measured 10 centimeters X 12 cm X 0.2 cm. Measurements of 3.4 cm X 0.5 cm X 0.1 cm as the last known measurements from the hospital assessment, dated 02/12/24; - Tissue type consisted of granulation (healing with new tissue) 25 percent (%), eschar (dark, dead matter that is cast off from the surface of the skin) 20% and slough (dead tissue separated from the living structure) 55%; - Unstageable due to slough and/or eschar obscuring the base of the wound; - Had a mild odor upon removal of the dressing; - The treatment recommendation of skin prep (a protective dressing) to the peri-wound (the area around the wound). Soak gauze with solution and allow it to sit on the wound for at least 15 minutes prior to the wound change. Apply calcium alginate (a wound dressing) to the wound base. Cover with bordered gauze. Change the dressing daily and as needed for soiling, saturation, or unscheduled removal. Okay to continue the current treatment orders until able to obtain the supplies. Review of the resident's event note, dated 03/03/24 (two days before the wound clinic's report and recommendations were received from the 02/29/24 visit), showed nursing staff alerted to Resident #34's room for complaints of not feeling well. The resident's blood pressure was low, 82/38, and he/she had symptoms of atrial fibrillation. The resident was sent to the emergency room for assessment. Nursing staff called the hospital to gather a report on the resident and was informed the resident was septic (a widespread infection causing organ failure and dangerously low blood pressure). Review of the resident's progress note from the hospital, dated 03/03/24, showed: - Resident admitted to the intensive care unit (ICU) with diagnoses of septic shock, urinary tract infection (UTI) (an infection in the urinary system)/bacteremia (bladder infection, infection in the blood), pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), abdominal surgical and sacral pressure ulcer wounds infections; - The description of the sacral wound was large with black dead tissue, nonblanchable (discoloration of the skin that does not turn white when pressed) on the sacrum, scattered ulcerated lesions (open sores) in the perianal (area surrounding the anus) area; - Sacral wound debrided (remove damaged tissue) to the bone. During an interview on 03/05/24 at 2:50 P.M., LPN C said he/she assessed Resident #34 with the wound care clinic provider on 02/29/24. He/She did not make notes of observations or recommendations during the visit with the provider. He/She did not receive the wound care clinic orders until 03/05/24, which was two days after Resident #34 was admitted to the hospital. During an interview on 03/05/24 at 3:00 P.M., the Wound Care Clinic provider said he/she assessed the resident on 02/29/24, and made recommendations for the treatment to the sacral ulcer. Although the onsite visit for Resident #34 occurred on 02/29/24, the visit notes and recommendations did not get to the facility until 03/05/24. During an interview on 03/19/24 at 2:20 P.M., the resident's family member said on 03/03/24, the resident was admitted to the hospital. The doctor said the abdominal and sacral wounds were infected. The wound on the resident's sacrum was small and almost healed when he/she admitted to the facility but now it is a Stage 4 (a full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. 2. Review of Resident #71's medical record showed: - An admitted [DATE]; - Diagnosis of a Stage 3 (full thickness tissue loss) pressure ulcer. Review of the resident's care plan, last revised 03/11/24, showed a pressure ulcer to the right lower buttock. Review of the resident's wound care showed: - An order to clean the wound on the right buttock with wound cleanser, pat dry, and apply Mepilex (a soft foam wound covering used to manage drainage) daily and as needed until healed, ordered on 11/06/23 and discontinued on 01/20/24; - An order to apply Triad (a coating used to moisturize and protect wounds) to the wound, cover with Allevyn daily and as needed, ordered on 01/22/24 and discontinued on 02/22/24; - An order to clean the wound with wound cleanser, pat dry, apply collagen Hydrogel (a type of wound treatment) to the wound, cover with a four by four border dressing daily and as needed, ordered on 02/23/24 and discontinued on 03/14/24; - A wound care note, dated 03/08/24, showed the hospice nurse reported to the nursing staff nursing the resident said his/her wound care was not being done daily. Review of the resident's TAR, dated December 2023 - March 2024, showed: - For December 2023, no documentation for seven out 31 wound care treatment opportunities; - For January 2024, no documentation for 10 out of 30 wound care treatment opportunities; - For February 2024, no documentation for seven out of 29 wound care treatment opportunities; - For March 2024, no documentation three out of 14 wound care treatment opportunities. During an interview on 03/14/24 at 8:12 A.M., the resident said the staff used to not change the dressing when they should, but they were doing better. During an interview on 03/15/24 at 9:12 A.M., LPN C said he/she completed the wound dressings on Tuesdays and Thursdays and the floor nurses were responsible for doing the dressing changes the other days. If he/she was unable to perform the dressing change on a certain day, he/she notified the floor nurse early in the morning of that day. During an interview on 03/05/24 at 4:00 P.M., the Administrator and DON said they would expect: - Admission orders to be transcribed and implemented on admission; - An admission assessment to be completed and accurate; - New orders from providers to be transcribed and implemented in a timely manner; - Treatments to be completed as ordered; - Nurses signing off shower sheets to ensure the treatment was in place for the wounds and if no order was in place, contact the provider for orders; - Nurses completing skin assessments ensure they were accurate and orders in place; - MDS be accurate and reflect the resident status and care plan. Complaint #MO232652 and MO233045 48247

Based on interview and record review, the facility failed to provide needed care and services to promote the healing of an open abdominal surgical wound for one resident (Resident #37) out of one sampled resident. The failure to thoroughly assess, document, treat and monitor the resident's condition contributed to the resident being hospitalized with sepsis (widespread infection causing organ failure and dangerously low blood pressure) and wound infection. The facility census was 100. The facility did not provide a policy regarding skin assessments, wound management or treatment. 1. Review of Resident #37's medical record showed: - An admitted [DATE]; - Diagnoses of surgical aftercare of an abdominal open wound, type 2 diabetes mellitus (inability of the body to make enough insulin), chronic obstructive pulmonary disease (lung disease that makes it difficult to breathe), diastolic heart failure (heart can't properly fill with blood during the resting period), paroxysmal atrial fibrillation (irregular heart beat), atherosclerotic heart disease (narrowing of the artery walls with plaques), peripheral vascular disease (narrowing of the blood vessels in the legs), and history of amputation of the right leg above the knee. Review of the resident's Admission Assessment Tool, dated 02/13/24, showed: - Skin not intact with a wound vac (a vacuum that pulls fluid and infection from the wound, helping it to heal) to the abdomen; - The resident admitted for wound vac treatment to the abdomen; - No documentation of the description of the wound or any specific orders for treatments; - The facility failed to complete a comprehensive skin assessment upon admission. Review of the resident's hospital Wound Nurse's progress note, dated 02/12/24, showed: - The abdominal wound measured 11 centimeters (cm) X 5.7 cm X 1.5 cm with 1.2 cm tunneling (opening under the surface of the wound); - State of healing early partial granulation (a new connective tissue and microscopic blood vessels form during healing process) with non-healing of the tunneling. Last dressing change on 02/12/24. Review of the resident's post hospitalization admission orders, dated 02/13/24, showed: - An order for a wound vac to the abdomen wound. When changing dressing, cleanse with Vashe (a type of wound cleanser) wound cleanser. Loosely pack white foam (wound dressing that allows for removal from tunneling wounds) to 10 o'clock tunneling and two black foams (wound vac dressing) into the wound bed. Suction at 150 millimeters of mercury (mm/hg). Last changed 2/12/24. Review of the resident's Physician's Order Sheet (POS), dated 02/28/24, showed: - An order to apply the wound vac two times weekly to the abdominal wound and may shower when the wound vac is to be changed. Skin prep (skin protectant) to the outer edges of the wound. Cut black foam to fit, cover with Tegaderm (transparent film dressing applied on top of the foam to seal the wound) and the wound vac appliance every day shift Tuesday and Friday for wound care, dated 02/15/24 with a start date of 02/16/24; - Referral for a wound evaluation and treatment order, dated 2/20/24 (seven days after admission). Review of the resident's admission Minimum Data Set (MDS) (a federally mandated assessment completed by the facility), dated 02/19/24, showed: - Cognitive status moderately impaired; - Dependent assistance for shower/bathing; - Total dependence of one staff for lower body dressing, chair/bed to chair transfer, toilet transfer, and tub/shower transfer; - Foley catheter (a tube inserted in the bladder to drain urine) for neurogenic bladder (lack of bladder control due to a nerve problem); - Surgical wound upon admission; - Pressure reducing device for the chair and bed; - Surgical wound care. Review of the resident's care plan, revised 02/13/24, showed the care plan did not address the abdominal wound. Review of the resident's progress notes/skin assessment notes showed: - On 02/19/24 at 10:47 P.M., the wound vac was unhooked upon arrival, reapplied the machine to the wound. When reassessed, the wound and the pump were not draining with the a clogged line to the pump. Attempted to change to the dressing to a wet to dry dressing until the wound nurse arrived in the morning. Unable to remove the gray sponge from the wound. It was stuck. Covered the sponge material with an ABD (a thick dressing) and secured with tape. - On 02/20/24 at 7:31 A.M., the foam pad was stuck to the wound. The wound was soaked with Vashe, patted dry, wet to dry dressing placed to the wound, covered with ABD pads, and secured with tape. The wound care clinic to evaluate the resident this afternoon for wound care. - On 02/20/24 at 11:15 P.M., the gray sponge was removed by the day shift. The wound nurse never saw the resident this shift. Resident with a wet to dry dressing on the wound. - On 02/24/24 at 5:13 P.M., the wound vac was removed this shift. A wet to dry dressing was placed on the wound. The resident was to follow up with wound care this week to assess and update the treatment orders. - On 02/25/24 at 12:55 P.M., 02/26/24 at 5:47 P.M., 02/27/24 at 5:48 P.M., 02/28/24 at 6:02 P.M., 02/29/24 at 7:47 P.M., 03/01/24 at 12:18 A.M., and 03/03/24 at 8:07 P.M., the wet to dry dressing was changed; - On 03/03/24 at 12:58 P.M., the resident was admitted to hospital; - On 03/05/24 at 11:48 A.M., a late entry for 02/29/24, the wound care clinic was here today and observed the resident's wound. There was an issue with downloading the paperwork into the new system. The progress note was pending. A verbal order was given to cleanse the wound with hypochlorous acid (a type of wound treatment), skin prep to the peri-wound (area around the wound) area, apply calcium alginate (a type of wound treatment) to cut to fit to the wound, and cover with bordered gauze dressing. Change every Tuesday, Thursday and Saturday and as needed for soiling and saturation. No signs or symptoms of infection or foul odor present. Review of the resident's skin assessment notes, showed: - Wound Observation Tool, dated 02/14/24 - Abdomen surgical wound non-healing with overall impression unchanged. 26-50 percent (%) slough (dead tissue that accumulate in the wound fluid) tissue present, granulation tissue present. Large amount of serosanguineous (fluid drainage from the wound) drainage. Measurements of 10.8 cm X 5.9 cm X 1.9 cm with 1.7 cm tunneling. Wound vac in place; - Wound Observation Tool, dated 02/21/24 - Abdomen surgical wound non-healing with overall impression unchanged. 26-50% slough tissue present, granulation tissue present. Large amount of serosanguineous drainage. Measurements 10.8 cm X 5.9 cm X 1.9 cm with 1.7 cm tunneling. Wound vac in place. Review of the resident's Wound Care Clinic Visit Summary Report, written on 03/05/24, and the onsite visit completed on 02/29/24 (16 days after admission and nine days after the initial referral), showed the the initial visit with the abdomen midline-upper wound measured 13 cm X 5.8 cm X 0.3 cm. Tissue type of 90% granulation and 10% slough. Wound recommendations were to apply skin prep to the peri-wound. Soak gauze with solution and allow it to sit on the wound for at least 15 minutes prior to the wound change. Apply calcium alginate to the wound base. Cover with silicone bordered foam (type of dressing). Change dressing every Tuesday, Thursday and Sunday and as needed for soiling, saturation, or unscheduled removal. Okay to continue current treatment orders until able to obtain the supplies. Review of the resident's Event note, dated 03/03/24 (two days before the wound clinic's report and recommendations were received from the 02/29/24 visit), showed the nursing staff alerted to Resident #34's room for complaints of not feeling well. The resident's blood pressure was low, 82/38, and he/she had symptoms of atrial fibrillation. The resident was sent to the emergency room for assessment. Nursing staff called the hospital to gather a report on the resident and was informed the resident was septic and admitted to the intensive care unit. Review of the resident's progress note from the hospital, dated 03/03/24, showed: - Resident admitted to the intensive care unit with diagnoses of septic shock, urinary tract infection (UTI) (infection in the urinary system)/bacteremia (bladder infection, infection in the blood), pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), abdominal wound and a sacral pressure ulcer (injury to the skin and the underlying tissue resulting from prolonged pressure on the skin) infections; - Abdominal wound infection had purulent (pus) thick drainage with possible exposed mesh (screen like material used as a reinforcement for tissue or bone); - Consult general surgery. During an interview on 03/05/24 at 2:50 P.M., Licensed Practical Nurse (LPN) C said he/she assessed Resident #34 with the wound care clinic provider on 02/29/24. He/She did not make notes of observations or recommendations during the visit with the provider. He/She did not receive the wound care clinic orders until 03/05/24, which was two days after Resident #34 was admitted to the hospital. During an interview on 03/05/24 at 3:00 P.M., the Wound Care Clinic provider said he/she assessed the resident on 02/29/24 and made recommendations for treatment to the abdominal wound. Although the onsite visit for Resident #34 occurred on 02/29/24, the visit notes and recommendations did not get to the facility until 03/05/24. During an interview on 03/05/24 at 4:00 P.M., the Administrator and Director of Nursing (DON) said: - Wound care treatments were to be completed per order; - Nurses completing skin assessments were to ensure they were accurate and had orders in place; - The wound care nurse was off work from 02/13/24 - 02/25/24, and the floor nurses were to do the wound care treatments. During an interview on 03/19/24 at 2:20 P.M., the resident's family member said when he/she saw the resident on 02/18/24, the abdominal wound vac dressing was not attached on one end of the wound. He/She asked the nurse to change the dressing and the nurse said they did not really know what they were doing, and the wound nurse was off. On 02/20/24, the wound vac dressing was off. A couple days later, the wound vac had been discontinued and staff were applying wet to dry dressings. On 03/03/24, the resident was admitted to the hospital. The doctor said the abdominal and sacral wounds were infected. The wound on the resident's sacrum was small and almost healed when he/she admitted to the facility but now it was a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). During an interview on 3/27/24 at 11:30 A.M., Family Nurse Practitioner (FNP) O said he/she examined Resident #37 on 02/20/24, and the wound vac was not in place to the resident's abdomen. He/She did not alter the original admission wound orders that were sent from the hospital nor did he/she give orders for the wet to dry dressings. The facility should have followed the wound treatment orders from the hospital when the resdient was admitted . On 02/27/24, he/she saw the resident per the family's request due to his/her altered mental status and antibiotics were started. During an interview on 03/27/24 at 2:41 P.M., LPN Q said he/she worked the night shift so didn't have responsibility for the wound care. On 02/19/24, a CNA informed him/her the resident's wound vac was not hooked up. He/She tried to hook it up and turn it on, but it was clogged with dried blood. He/She was unable to remove the wound vac dressing because it was stuck to the wound. He/She went to the supervisor for help with the dressing and they were unable to remove the dressing and covered the site with an abdominal dressing and taped it down. He/She last worked with the resident on 02/28/24, and the wound vac had not been replaced. During an interview on 03/27/24 at 2:54 P.M., LPN P said on 02/20/24, he/she removed the wound vac per the treatment order to change the dressing. He/She had trouble pulling out the black foam and the dressing had to be soaked for a long time. The wound was dry and eviscerated (deprived of vital content) from the black foam. He/She put on a wet to dry dressing and informed nursing management. The wound vac was never reapplied to his/her knowledge. Complaint #MO232652 and MO233045

Based on observation, interview, and record review the facility failed to fully assess, monitor and/or implement interventions for one (Resident #2) resident who had physician's orders [REDACTED]. The resident experienced vomiting following administration of tube feeding formula. Staff did not consistently check [MEDICAL CONDITION] residuals (amount of tube feeding remaining in the stomach), monitor intake and output (I&Os), document episodes of vomiting, promptly implement the Registered Dietitian's (RD) recommendations or administer tube feedings as per physician's orders [REDACTED]. 1. Record review of Resident #2's physician's orders [REDACTED]. The physician ordered the administration of [MEDICATION NAME] 1.2 (a tube feeding formula) at 65 milliliters (ml) per hour continuously (24 hours per day) with water flushes of 60 ml every six hours and as needed (prn) per protocol. The physician also ordered staff to monitor residuals every eight hours and to check and record I&Os every shift. Review of Resident #2's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 8/17/12, showed the resident had swallowing problems and received nutrition through a feeding tube. Review of I&O sheets, dated 8/24/12 through 8/31/12, showed staff did not document the amount of tube feeding formula or water flushes administered on 14 of 48 opportunities or total daily intake of tube feeding formula or water flushes on 14 of 16 opportunities. Review of a telephone order (TO), dated 8/21/12, showed the physician changed the tube feeding order to [MEDICATION NAME] 1.2 at 78 ml per hour for 20 hours per day with 500 ml water flushes ever 4 hours. The physician directed staff to consult the RD if they had questions and follow the RD's recommendations. Review of a TO, dated 8/23/12, showed the physician ordered the administration of [MEDICATION NAME] 1.0 at 75 ml per hour for 24 hours per day and flush with 350 ml of water every three hours. Review of I&O sheets, dated 9/1/12 through 9/30//12, showed staff did not document the amount of tube feeding formula or water flushes administered on 21 of 180 opportunities or total daily intake of tube feeding formula or water flushes on 46 of 60 opportunities. Staff identified the resident had emesis (vomiting) twice on 9/25/12, twice on 9/27/12 and twice on 9/29/12. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the POS [REDACTED]. Review of a fax communication to the resident's physician's, dated 9/11/12, showed the resident had large, liquid, tube feeding colored emesis. The physician ordered staff to monitor for signs and symptoms of aspiration (the introduction of a foreign substance into the lungs) and call with any changes in condition. Review of a nurse's note, dated 9/30/12, showed staff documented the resident had a small emesis. Review of I&O sheets, dated 10/1/12 through 10/10/12, showed staff did not document the amount of tube feeding formula or water flushes administered on 11 of 60 opportunities or total daily intake of tube feeding formula or water flushes on 10 of 10 opportunities. Staff identified the resident had emesis three times on 10/6/12, three times on 10/7/12 and twice on 10/9/12. Review of nurses' notes, dated October, 2012, showed staff documented the resident had emesis on 10/1/12, 10/6/12, 10/7/12, twice on 10/8/12, 10/10/12 and 10/12/12. Review of the MAR, dated October, 2012, showed staff did not document residuals before administering the tube feedings or water flushes Review of a TO, dated 10/2/12, showed the physician ordered staff to decrease [MEDICATION NAME] to 60 ml per hour and decrease water flushes to 360 ml every four hours. Review of a RD's note, dated 10/3/12, showed the RD noted the resident had no emesis since 9/29/12 according to I&O sheets and had experienced a weight loss from 272.1 pounds to 269 pounds from the previous week. Review of a fax communication to the resident's physician, dated 10/8/12, showed the resident had a large, emesis of curdled tube feeding, reported nausea and experienced a nine pound weight loss in one week. The physician ordered staff to change the continuous tube feeding to [MEDICATION NAME] 1.5 one can every six hours, hold tube feeding until supper that evening and consult the RD for caloric needs. The physician did not order a change in water flushes from 360 ml every four hours. Review of the MAR, dated October, 2012, showed staff did not administer the resident's tube feeding as ordered by the physician from 10/8/12 at 12:15 P.M. until 10/10/12 at 2:00 A.M. (a total of 38 hours). Staff did not initiate the tube feeding after supper on 10/8/12 as ordered by the physician. The MAR indicated [REDACTED].M., staff administered 360 ml water flushes every four hours 10/1/12 through 10/9/12 and administered two 360 ml flushes on 10/10/12. Staff noted on the MAR indicated [REDACTED]. Staff documented they administered six 280 ml water flushes, 280 ml before and 280 ml after [MEDICATION NAME] of 237 ml of tube feeding formula. Review of the POS [REDACTED]. Observations on 10/9/12 at 9:40 A.M. showed the resident retching (straining to vomit.) At 11:20 A.M. and 1:10 P.M., the resident reported nausea and retched. Observations on 10/10/12 at 7:25 A.M. showed the resident vomited tube feeding. At 10:20 A.M., the resident reported nausea. At 2:30 P.M., Registered Nurse (RN) I did not check residuals prior to administering medication. RN I used a plunger to push a water flush through the resident's [DEVICE]. At 4:10 P.M., the resident vomited curdled stomach contents. Observations on 10/11/12 at 7:30 A.M. showed the vomited. At 10:20 A.M., the resident reported nausea. At 4:10 P.M., the resident vomited. During an interview on 10/10/12 at 1:05 P.M., the resident's spouse said they were concerned about the resident vomiting so much. The family said the resident had been vomiting for nine days and he/she did not feel like the facility did anything to stop the vomiting. During an interview on 10/10/12 at 2:40 P.M., Certified Nurse Aide (CNA) H said the resident has been vomiting for two weeks and he/she did not know why something had not been done. During an interview on 10/10/12 at 3:00 P.M., RN I said he/she should have checked for residual before administering any medications. During an interview on 10/12/12 at 9:00 A.M., the Director of Nursing (DON) said staff should have checked residuals before administering anything through the [DEVICE]. She said "nurses should be nurses, use critical thinking and follow through with all orders". During an interview on 10/17/12 at 2:45 P.M., the Medical Director said he expected staff to follow orders and call the physician when a resident had complications. Staff should have checked residuals and document them in the resident's chart. He said the resident was admitted to the hospital, had an ultrasound of the abdomen and had his/her gallbladder removed. During an interview on 10/18/12 at 9:32 A.M., the DON said: - She was new and was unsure if the facility had a protocol for water flushes. - Staff should have documented intake every shift and totaled the amount administered daily. - Staff should have checked residuals every time they "messed with" a tube feeding. - The facility administered [MEDICATION NAME] tube feedings by gravity. Staff should not have used a plunger to administer any [MEDICATION NAME]. - Staff should have documented episodes of vomiting in the nurses' notes and on the I&O sheets. During an interview on 10/18/12 at 12:55 P.M., the RD said: - She was unaware the facility had a protocol for water flushes. - Staff should have documented and totaled I&O sheets. - The RD assessed the resident frequently but staff did not initially notify her of the resident's vomiting. - On 8/16/12, the RD assessed the resident and identified the resident did not receive adequate fluids. At that time, the RD made a recommendation to increase the water flushes. The facility did not obtain physician's orders [REDACTED]. The RD expected staff to implement recommendations sooner. - On 10/1/12, the Nurse Practitioner (NP) decreased the resident's tube feeding due to vomiting. The RD thought the decrease was only for a few hours so she agreed. - On 10/5/12, the physician asked for a consult to increase fiber. The RD recommended continuous feeding. - On 10/8/12, the physician ordered [MEDICATION NAME] tube feedings without a recommendation by the RD. The RD thought the resident's vomiting had been resolved and did not question the change in route of administration. - It was not generally recommended to administer [MEDICATION NAME] tube feedings with nausea and vomiting. - Administration of 280 ml water flushes before and after a [MEDICATION NAME] administration of 237 ml tube feeding formula was too much. The RD said she was not aware of the actual amount of fluid administered as staff did not consistently document intake. Review of the facility's policy for recording intake showed it addressed oral intake and intravenous fluid intake but did not address documentation of tube feeding formula or water flushes. The policy directed staff to document fluid intake on the I&O record but did not address frequency of documentation of completion of daily totals. Review of the facility's tube feeding policy showed it directed staff to administer tube feeding formula and water flushes by holding the syringe above the stomach and allowing the feeding to flow into the stomach very slowly. The policy directed staff to monitor residuals as ordered by the physician and included criteria for holding feedings. The policy did not address when staff should check residuals. Review of the facility's tube feeding policy showed it directed staff to document the administration of tube feeding formula on I&O sheets and MARs. The policy also directed staff to flush the feeding tube with 100 to 200 ml of water between feedings.

Based on observation, interview and record review the facility failed to properly assess, provide treatment and follow physician's orders for one Resident (Resident #5), who reported a swollen, painful toe which resulted in an amputation. The facility census was 56. Record review of Resident #5's February 2012 physician's order sheet (POS) showed the resident entered the facility on 2/6/12 for physical therapy. The resident's [DIAGNOSES REDACTED]. Record review of the Braden Scale (a pressure ulcer risk assessment), dated 2/6/12, showed Resident #5 not at risk for pressure ulcers. However, review of nurse's notes, dated 2/6/12, showed Resident #5 had a pressure ulcer on his/her coccyx upon admission to the facility. Record review of Resident #5's care plan (CP), updated 3/30/12, showed the resident at risk of developing pressure ulcers. The CP directed licensed nursing staff to provide bi-weekly skin assessments and report any changes to the physician. The CP directed nurse aides to provide skin assessment with daily care and report any new areas of skin discoloration immediately to a nurse. Record review of Resident #5's Minimum Data Set (MDS), (a federally mandated assessment instrument completed by facility staff), dated 2/13/12, showed the resident as alert, oriented and cognitively aware. The MDS showed Resident #5 had a Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) on his/her coccyx upon admission to the facility. During an interview on 4/4/12 at 8:00 A.M., Licensed Practical Nurse (LPN) E said on 2/13/12 Resident #5 told LPN E his/her left big toe hurt. LPN E said the toe was red, swollen and had pus underneath the nail. LPN E said he/she told LPN A and Registered Nurse (RN) G about Resident #5's toe hurting. LPN A said Resident #5 would see the podiatrist later that month. LPN E said he/she told LPN A that the resident needed to be seen sooner. LPN E said she did not know what happened after that or if LPN A or RN G assessed the resident's toe. During an interview on 4/4/12 at 9:00 A.M., Certified Nurse Aide (CNA) F said on 2/13/12, about a week after Resident #5 had been admitted to the facility, the resident reported that his/her left, great toe hurt. On 2/13/12, CNA F said he/she told RN G and LPN A about Resident #5's toe. CNA F said, about a week later, he/she found the resident crying because the podiatrist said the toe could not be saved and required amputation. Record review of the February 2012 skin assessment sheets for Resident #5 showed skin assessments completed on 2/14, 2/21, 2/24 and 2/29/12. The skin assessments showed no problems identified with the resident's feet. Record review of a nutritional evaluation, dated 2/17/12, showed Resident #5 complained that his/her left toe hurt. Record review of the nurses' notes showed the following: -On 2/26/12, Resident #5 said his/her left great toe was swollen, had fluid, broke open, leaked blood and fluid, felt better, but requested to see a physician sooner. LPN D wrote that she informed the Charge Nurse. There was no documentation at that time that anyone assessed the resident's toe or called the physician. -On 2/29/12, LPN C contacted the facility physician by fax. The physician ordered TAO, a bandage and to see the facility podiatrist. There was no documentation that the staff contacted the facility podiatrist for guidance. -On 3/2/12, LPN D contacted the resident's physician regarding the resident's toe being red, swollen with pus around base of nail bed and warm to the touch. The physician ordered Keflex (an antibiotic) 500 micrograms (mg) twice a day for 10 days and for the resident to see the nurse practitioner on Tuesday (3/6/12). -On 3/3/12, contacted the pharmacy regarding the new orders. The resident had redness and [MEDICAL CONDITION] of the left foot and toes with yellow drainage at the nail base. Encouraged the resident to elevate his/her feet. -On 3/4/12 and 3/5/12, the staff did not document what the resident's toe looked like but that the resident was taking an antibiotic for the toe infection. -On 3/6/12, the resident went out to an appointment with a podiatrist. -On 3/27/12, the resident was admitted to the hospital for a left toe amputation. During an interview on 4/3/12 at 8:45 A.M., Resident #5 said the following: -His/her left great toe started hurting about a week after admission to the facility and it had a pin-point spot under the left toenail. -Around 2/12/12, he/she started telling the staff that his/her toe hurt. -The staff said he/she would have to wait to see the podiatrist who comes to the facility on the 9th of every month. -His/her toe became swollen, red and huge. -None of the staff offered to make him/her an appointment with a podiatrist. -The facility physician never came in to look at his/her foot. -On 3/5/12 he/she called a podiatrist outside of the facility and made his/her own appointment for 3/6/12. -On 3/6/12 the resident went to the podiatrist. When the resident returned to the facility he/she had a manila envelope filled with instructions and a prescription from the podiatrist. The resident said he/she handed the envelope to a nurse sitting at the desk. -On 3/9/12 the resident returned to the podiatrist office and his/her toe was not better. The podiatrist asked the resident if he/she had been taking his/her antibiotic that the podiatrist ordered on [DATE]. The resident said he/she received the first dose of antibiotic on 3/9/12. The resident said the prescription had been lying around on the nurses' desk and not ordered. -The podiatrist tried to save his/her toe but by then it could not be saved. -When the staff did the skin assessments', he/she did not recall any of them looking at his/her feet. During an interview on 4/4/12 at 8:20 A.M., LPN C said on 2/29/12 he/she had been called down to Resident #5's room to look at the resident's left toe. LPN C said the toe was red, swollen and had pus around the bottom part of the toenail. LPN C said he/she contacted the facility physician who ordered triple antibiotic ointment (TAO) ointment, a bandage and to see the facility podiatrist. LPN C said he/she should have charted what the toe looked like in the nurses' notes or the skin assessment and did not know why he/she didn't do it. During an interview on 4/4/12 at 1:00 P.M., LPN A said he/she was the day charge nurse on 3/6/12. LPN A said he/she did not recall anyone giving him/her an envelope from the podiatrist. LPN A said maybe the driver just laid the envelope down on the desk. During an interview on 4/5/12 at 11:15 A.M., LPN H said he/she worked the morning of 3/9/12. LPN H said the resident said he/she had an appointment that day with the podiatrist. LPN H said the appointment had not been put on the calendar. LPN H said he/she looked through the resident's chart and found orders for the appointment and the new antibiotic. LPN H said he/she gave the resident the antibiotic from the emergency kit. LPN H said he/she found the physician's orders inside the resident's chart on top of the physician's order sheet. Record review of the hospital history and physical (H&P) dated 3/27/12, showed the resident entered the hospital with osteo[DIAGNOSES REDACTED] of the left great toe and had to have it amputated. The H&P showed the resident had been seen by the podiatrist two weeks earlier and an antibiotic ordered. The H&P showed the resident returned to the facility and the medication did not get filled or administered. Observation on 4/3/12 at 8:45 A.M., showed Resident #5 sat in his/her room in a wheelchair. The resident had a large bandage covering his/her entire left foot. During an interview on 4/5/12 at 2:00 P.M., the Director of Nurses (DON) said the facility skin assessment policy and procedure showed that nursing staff are supposed to check the resident's skin daily during care. The licensed nursing staff are supposed to provided a weekly skin integrity check for each resident. The DON said the residents who have diabetes are supposed to receive skin assessments twice a week. The DON said she did not know why the nursing staff had not documented about Resident #5's sore toe. During a telephone interview on 4/11/12, the podiatrist said Resident #5 had osteo[DIAGNOSES REDACTED] (infection in the bone) of the left great toe. The podiatrist said it would be impossible to say what the outcome might have been if there had not been a delay in treatment. The podiatrist said it is standard practice for diabetics to be seen quickly when changes are seen to their feet and especially if they feel pain. Complaint # MO 15 *The higher classification merited due to the extent of the violation and the impact on the resident. *NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review, completed during the on-site visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the on-site visit, all facility staff was in-serviced on policies and procedures concerning missed medications, documentation of assessments, describing and documentation of skin, paperwork from physicians and proper handling of paperwork, who to notify with areas of concern, wound nurse review of bath sheets daily, 24 hour reports and reporting guidelines, diabetic care, foot care, assessing residents during baths, nursing progress notes, alert charting, medical record documentation, physicians' orders and transcription, medication administration and wound care. In-services were also conducted with licensed nurses concerning the emergency kit, contacting the back-up pharmacy and contacting the DON and physician when any medication was not available. Head to toe assessments were completed on all residents and a wound care nurse was put into place five days per week. Monitoring of 24 hour reports, nurses' notes documentation and wound reports ensure all potential problems are identified as implemented to ensure all potential problems are identified. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. The facility needs to ensure all staff receives the in-service training regarding assessments, documentation, communication, care, physician's orders and medication and that all MDSs and care plans are reassessed to ensure all potential problems are identified. This statement does not denote that the facility has complied with state law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violations.