Every finding on record at Lincoln County Nursing & Rehab

Based on record review and interview, the facility failed to ensure two residents (Resident #74 and #25) were free from verbal abuse. On 03/30/26, Housekeeper A yelled at Resident #74 after the resident requested assistance with care and screamed and cursed at Resident #25 when the resident confronted him/her about how he/she talked to Resident #74. The facility census was 85. The administrator was notified of the past noncompliance on 04/09/26, which occurred on 03/30/26. On 03/30/26, the facility terminated Housekeeper W from employment at the facility for the allegation of staff to resident abuse and inserviced all staff on abuse prevention. Review of the facility's undated policy, Abuse Policy, showed the following: -Each resident will be free from abuse. Abuse can include verbal, mental, sexual or physical abuse; -Residents will be protected from abuse, neglect, and harm while they are residing at the facility; -No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection; -The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. 1. Review of Resident #74's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/18/26, showed the following: -He/She had a diagnosis of Alzheimer's disease;-He/She required substantial/maximal assistance with dressing; -He/She required partial/moderate assistance with sitting on the side of the bed to lying flat on the bed, rolling from lying on his/her back to his/her left and right side and returning to lying on his/her back on the bed, and from lying to sitting on the side of the bed;-He/She was dependent on staff to transfer to and from a bed to a chair or wheelchair. Review of the resident's care plan, updated 03/13/26, showed the resident required assistance with activities of daily living and mobility due to weakness and cognitive impairment. During an interview on 04/08/26 at 11:55 A.M., the resident said the following: -Housekeeper W told him/her to 'shut up' and said the words fuck, damn, and shit; -It wasn't right what Housekeeper W said to him/her and it made him/her feel bad inside. 2. Review of Resident #25's Level II Preadmission Screening and Resident Review (PASRR, a federally mandated screening process for individuals with serious mental illness, intellectual disability/developmental disability, and/or related condition who apply for or reside in a nursing facility to evaluate the most appropriate setting and identify service needs based on the mental health condition), dated 10/06/25, showed the following:-He/She had a serious mental illness;-He/She had dependency needs for emotional and physical care;-He/She had a history of domestic violence in his/her two prior marriages;-He/She had a history of mood disorder including depression and anxiety symptoms;-He/She had a diagnosis of major depressive disorder (moderate-severe) with a prior history of suicide attempt;-He/She had poor coping skills and a history of trauma. Review of the resident's quarterly MDS, dated [DATE], showed he/she had moderate cognitive impairment. During an interview on 04/08/26 at 11:53 A.M., the resident said the following: -Housekeeper W was in his/her and Resident #74's room cleaning;-Housekeeper W started yelling at Resident #74 because Resident #74 was yelling for help; -Housekeeper W said Resident #74 had been yelling at Housekeeper W for four hours but Housekeeper W hadn't been in their room for that long; -Resident #25 told Housekeeper W not to talk to Resident #74 that way;-Housekeeper W started cursing at him/her (Resident #25) and called him/her a 'bitch' and said 'damn you'; -It upset him/her (Resident #25) that Housekeeper W picked on him/her because he/she couldn't defend himself/herself. 3. Review of the facility investigation, Initial Reporting Form, completed by the administrator, dated 03/30/26, showed the following:-Allegation type: abuse, mental/verbal;-The Assistant Director of Nursing (ADON) heard two people shouting and cursing at each other;-The ADON walked down the hall and observed Housekeeper W shouting obscenities at Resident #74;-The ADON escorted Housekeeper W from the building and suspended him/her pending investigation;-On the evening of 03/30/26, Housekeeper W was terminated. Review of Housekeeper W's written statement, dated 03/30/26, showed the following: -Housekeeper W was cleaning a resident room;-Resident #74 kept yelling and hollering at Housekeeper W while he/she was cleaning the room; -Resident #74 needed help getting tucked into bed and that was not Housekeeper W's job; -Resident #25 told Resident #74 an aide would be there to help him/her; -The more Resident #74 shouted, the shorter Housekeeper W's temper got and eventually Housekeeper W snapped; -Housekeeper W screamed and cursed at Resident #74. During an interview on 04/14/26 at 2:04 P.M., Certified Nurse Assistant (CNA) CC said the following: -He/She heard Housekeeper W's voice from down the hall and went to Resident #74 and Resident #25's room; -Housekeeper W was nose to nose with Resident #74, and told the resident, Shut the fuck up bitch. I'm trying to do my job; -The ADON responded to the situation and removed Housekeeper W from the area. During an interview on 04/09/26 at 1:43 P.M., CNA AA said when he/she arrived to the residents' room, Housekeeper W was facing Resident #74 about two feet away and told the resident, Shut the fuck up. During an interview on 04/08/26 at 3:33 P.M., the Assistant Director of Nursing (ADON) said the following: -On 03/30/26, he/she heard shouting in a residents' room; -When he/she arrived to the residents' room, Resident #74 sat in his/her wheelchair in the walkway near the sink and was crying and shouting; -Housekeeper W stood slightly behind Resident #74's and to the resident's right side; -Housekeeper W shouted and cursed at Resident #74 and said, I can't do my fucking job; -He/She told Housekeeper W to leave the resident's room and walked Housekeeper W out of the building. During an interview on 04/09/26 at 8:48 A.M., CNA BB said the following: -He/She got to the residents' room just as Housekeeper W was leaving, and Housekeeper W to Resident #74 to, Shut the fuck up;-The ADON told Housekeeper W to leave the building and escorted him/her outside. During an interview on 04/08/26 at 2:13 P.M., the Housekeeping Supervisor said the following: -On the evening of 03/30/26, she called Housekeeper W; -Housekeeper W told him/her he/she had a bad day. Resident #74 asked Housekeeper W to lay Resident #74 down and Housekeeper W said he/she couldn't do that, and an aide would have to lay Resident #74 down; -Housekeeper W said he/she got in Resident #74's face and yelled and cursed at Resident #74. During an interview on 04/08/26 at 5:39 P.M., the Administrator said the following:-She was in her office when the ADON escorted Housekeeper W from the building;-Staff in-servicing on the facility's abuse policy started that day (03/30/26) and was ongoing with staff as they reported to work;-She expected staff to talk respectfully to residents and not to curse at them.

Based on interview and record review, the facility failed to provide a registered nurse (RN) eight consecutive hours a day, seven days a week. The facility census was 85. During an interview on 04/16/26 at 8:45 A.M., the Administrator said the facility did not have a policy directly addressing RN coverage. Review of the facility assessment, updated 01/09/26, showed the facility resources needed to provide competent support and care for the resident population every day and during emergencies included RN coverage eight hours per day. Review of the Centers for Medicare and Medicaid Services (CMS) [NAME] report for Quarter 1, 2026 (reporting period 10/1/25 - 12/31/25) showed the facility did not meet the eight-hour per day RN requirement on 10/19/25, 10/26/25, 10/31/25, 11/01/25, 11/15/25, 11/16/25, 11/22/25, 11/28/25, 11/29/25, 12/12/25, 12/13/25, 12/14/25, 12/21/25, 01/24/26 and 01/29/26. Review of RN time sheet punches and schedules from 10/19/25 through 4/14/26, showed the following: -No RN coverage on 10/19/25, 10/26/25, 10/31/25, 11/01/25, 11/15/25, 11/16/25, 11/22/25, 11/28/25, 11/29/25, 12/12/25, 12/13/25, 12/14/25, 12/21/25 and 01/24/26;-On 01/29/26, RN coverage for 5.28 hours; -On 02/8/26, no RN coverage; -On 03/8/26, RN coverage for one hour; -On 04/02/26, RN coverage for 7.18 hours. During an interview on 04/16/26 at 3:00 P.M., the Staffing Coordinator said the following: -She had been the staffing coordinator since November 2025;-The facility was required to have an RN in the building eight hours each day;-If there was not an RN on the schedule, she let the Director of Nursing (DON) and Administrator know, so they could reach out to corporate to fill the shifts. During an interview on 04/16/26 at 10:45 A.M., the DON said the following: -There should be an RN in the building eight hours of each day;-In the last six to eight months, there had not been an RN in the building eight hours each day;-In the past three months, she felt there had been an RN present in the building eight hours each day. During an interview on 04/16/26 at 10:07 A.M., the Administrator said the following: -She was aware an RN was required in the building eight hours of each day;-The facility had an issue that was identified on the Payroll Based Journal (PBJ, a method to collect auditable and verifiable staffing data from nursing facilities) report with no RN coverage for multiple days in October, November and December 2025;-Since December, she was only aware of one day in January when the facility did not have RN coverage for eight hours.

Based on observation, interview, and record review, staff failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not securely seal food items, store food per manufacturer's instructions, or store food items off the floor. Staff did not practice proper hand and glove hygiene, sanitary dish handling, and consumption of personal food and beverage items. Staff did not maintain surfaces and equipment free from a buildup of grease and debris. Staff failed to ensure an air gap was present at the facility's ice machine drains to prevent possible backflow from the drain back into the ice machines. The facility census was 85. 1. Review of the facility policy, Storage of Dry Food and Supplies, dated May 2015, showed the following:-The dietary department will store food and supplies according to facility guidelines and state regulations;-Food is to be stored a minimum of six inches above the floor;-Food should be protected from splash or other contamination. Review of the facility policy, Safe Food Handling, dated May 2015, showed the following:-Dietary employees will follow safe food handling guidelines to prevent the spread of foodborne illness;-All food should be tightly sealed. Observation on 04/13/26 at 11:03 A.M., during the initial tour of the dietary department, showed the following: -In the reach-in freezers, an open bag of tater tots and an open bag of breaded fish were unsealed and were open to the air; -In the dry storage room, a half-full gallon bottle of soy sauce, with a label that read 'Refrigerate after opening for quality', sat unrefrigerated on the shelf. Two boxes containing 35-pound bottles of frying shortening sat on the floor. During an interview on 04/15/26 at 12:49 P.M., the Dietary Manager said the following: -Food items should be securely sealed and not stored on the floor; -He was unaware the soy sauce should be refrigerated. During an interview on 04/15/26 at 2:27 P.M., the Administrator said she expected staff to store food in a safe and sanitary manner. 2. Review of the facility policy, Handwashing, dated May 2015, showed the following:-Wet hands and forearms with warm water;-Lather hands with antiseptic soap;-Wash hands, giving particular attention to the areas between fingers, around cuticles, and under fingernails. Wash forearms as well;-Rinse thoroughly with warm water beginning at the top of the forearm;-Wipe hands dry with clean paper towel;-Turn off water with paper towel and dispose of paper towel;-Eating and drinking in the dietary department is to occur in designated areas only. Review of the facility policy, Glove Use, dated May 2015, showed the following:-Food items should not be handled with bare hands;-Hand washing per guidelines should occur between each task;-Gloves should be worn if handling food is necessary. Extra caution should be taken when multiple tasks are being completed;-Gloves should be removed when changing or walking away from specific tasks and hands should then be washed per guidelines;-Hands should be washed after disposing of trash or food, after handling dirty dishes, after picking up anything from the floor, when changing tasks, and any other time deemed necessary. Observation on 04/13/26 from 12:08 P.M. to 1:27 P.M., in the kitchen during the lunch meal serviced, showed the following: -Cook HH served food onto residents' plates at the steam table; -Cook HH used his/her bare hands to touch the eating surface of bowls and plates, serving utensil handles, meal tickets, reach-in cooler door handles, and his/her personal cell phone, shirt, and face; -He/She opened and drank from a personal beverage container in the food preparation area; -Cook HH did not wash his/her hands and used his/her bare hands to grasp and place pieces of bread onto residents' plates. Observation on 04/14/26 from 12:07 P.M. to 1:41 P.M., in the kitchen during the lunch meal serviced, showed the following: -Cook KK served food onto residents' plates at the steam table. Dietary Aide II placed items onto residents' meal trays; -Cook KK used his/her gloved hands to touch reach-in cooler door handles, grasp a slice of cheese for a cheeseburger, and touch the microwave door handle to heat soup for residents. He/She removed his/her gloves and put on new gloves without washing his/her hands. [NAME] KK used his/her gloved hands to remove cooked chicken from the bone, tear it into bite-sized pieces, and placed the pieces of chicken onto residents' plates; -Dietary Aide II picked up a meal ticket that dropped onto the floor and placed it back onto the food serving counter. He/She washed his/her hands at the handwashing sink, turned off the faucet handles with his/her clean hands, and continued assisting with the meal service. Dietary Aide II touched and discarded trash items from the counter, did not wash his/her hands, and carried stacks of clean glasses to the serving area; -Cook KK used his/her gloved hands to pick a hamburger bun from the floor. He/She removed his/her gloves, used his/her bare hands to adjust the stove knob, and opened the reach-in freezer door. He/She washed his/her hands at the two-compartment food preparation sink, turned off the faucet with his/her clean hands, and carried his/her used paper towels to the steam table area and sat the used paper towels on the plate warmer. During an interview on 04/15/26 at 1:23 P.M., [NAME] JJ said the following: -Staff should wash their hands anytime they touch items that contaminate their hands, after changing their gloves, and before conducting clean tasks; -After washing their hands, staff should turn off faucet handles with a paper towel and not with their clean hands; -Staff should consume beverages and handle personal items, such as cell phones, away from the food serving and preparation areas; -Staff should not touch food items with their bare hands or with soiled gloves; -Staff should handle plates and cups by the non-eating surfaces of those items. During an interview on 04/15/26 at 12:49 P.M., the Dietary Manager said the following: -Staff should not handle ready-to-eat food items, such as pieces of bread, with their bare hands; -Staff should not handle or consume personal items in the food preparation area; -Staff should wash their hands between tasks, after glove changes, and after anything that contaminates their hands; -Staff shouldn't pick meal tickets off the floor and put them back on the serving line. During an interview on 04/15/26 at 2:27 P.M., the Administrator said she expected staff to prepare and serve food in a safe and sanitary manner. 3. Review of the facility policy, Ice Machine Maintenance, dated May 2015, showed the following:-Empty the ice machine completely;-Clean the chest;-Place a sanitizing solution in the machine for two hours and circulate the solution according to manufacturer recommendations;-Remove the sanitizing solution, rinse with water and allow to air dry. Observation on 04/13/26 at 11:15 A.M., during the initial tour of the dietary department, showed multiple dried, white drips across the exterior and interior surface of the ice machine. There was a moderate accumulation of moist light-brown and pink-colored residue on the plastic above the ice storage area. During an interview on 04/15/26 at 12:49 P.M., the Dietary Manager said the following:-The maintenance supervisor used to clean the ice machine;-Two months ago, he/she found out it was the dietary department's responsibility to clean the ice machine but the Maintenance Supervisor hadn't had the chance to show him/her how to disassemble and clean the machine. During an interview on 04/15/26 at 1:38 P.M., the Maintenance Supervisor said the following: -He cleaned the ice machine twice a year in January and July;-He last cleaned the ice machine in January 2026;-The last time a company came to deep clean and descale the ice machine was last Spring; -He planned to train the dietary staff how to clean the ice machine soon since the ice machine cleaning responsibilities were transferred to the dietary department. 4. Review of the facility policy, Cleaning Floors, dated May 2015, showed the following:-Kitchen floor maintenance will be done after each meal;-Spills need to be mopped up immediately;-Sweep the floor;-Prepare detergent solution according to manufacturer instructions;-Mop one small area at a time, beginning at the rear of the room in a figure eight motion. Use a scraper to remove stubborn stains and debris on floor. Be sure to mop under and around equipment, along walls and in corners;-Rinse the area with clean warm water using a clean mop head. Observation on 04/13/26 at 12:48 P.M., in the kitchen, showed the following: -A heavy accumulation of dark gray residue and food debris on the floor under the six-burner stove, griddle, fryer, and toaster table; -A moderate accumulation of brown residue on the floor throughout the kitchen, especially in the high traffic areas. During an interview on 04/13/26 at 12:40 P.M., the Dietary Manager said a floor technician was supposed to clean and strip the floors in the kitchen soon. Last Saturday and Sunday, [NAME] HH cleaned under the fryer and used a scrub brush to clean under the stove. 5. Review of the facility policy, Ice Machine Maintenance, dated May 2015, showed the following:-Make sure there is an air gap at all inlets for water;-Check for possible leakage or dripping into the machine. Observation on 04/13/26 at 11:15 A.M., of the facility's ice machine located in the alcove next to the kitchen, showed the following: -At the bottom of the ice machine, a 3-foot long section of 1-inch diameter PVC pipe connected the ice machine drain to a 4-inch floor drain. The PVC pipe was propped up by a 0.5-inch diameter rusty metal rod inserted inside the end of the PVC pipe above the floor drain. A large white towel was on the floor by the floor drain and partially blocked the PVC pipe. There was not a sufficient air gap at the drain; -At the back of the ice machine, a 2-foot long clear hose and a 2-foot long white hose connected the upper ice machine drain and were inserted inside a 4-inch flanged PVC drain pipe. The flanged drain pipe connected to a 2-inch diameter 3-foot long PVC pipe that connected directly to the drain of a nearby utility sink. There was not an air gap at the drain. During an interview on 04/15/26 at 1:38 P.M., the Maintenance Supervisor said he was unaware the ice machine drains did not contain air gaps to prevent the potential backflow of liquids back into the machine.

Based on interview and record review, the facility failed to ensure residents received mail on regular mail delivery days, as identified by the United States Postal Service (USPS), including Saturdays. The facility census was 85.Review of the facility's undated policy, Resident Rights, showed the following:-It is the purpose of this facility to meet the Federal and State Mandate in respect to resident rights;-The residents have a right to a dignified existence, self-determination and communication with and access to people and services inside and outside the facility;-The residents have a right to communicate freely; During a group interview on 04/15/26 at 2:00 P.M., Resident #15 and Resident #68 said residents did not receive mail on Saturdays. Resident # 68 said the Business Office Manager (BOM) went to the post office to get the mail Monday through Friday. During an interview on 04/16/26 at 10:07 A.M., the Administrator said the facility staff did not deliver mail to the residents on Saturdays when the BOM was not the manager on duty. The BOM was only at the facility as a manager on duty on the weekends about every six weeks.

Based on observation and interview, the facility failed to provide residents with a safe, clean, and homelike environment, including providing housekeeping and maintenance services necessary to maintain an orderly and comfortable interior. The facility census was 85. Review of the undated facility policy, Cleaning Floors, showed the following:-Spills need to be mopped up immediately;-Sweep the floor, pushing all debris forward, using dustpan to remove debris;-Mop one small area at a time, beginning at the rear of the room in a figure eight motion. Use a scraper to remove stubborn stains and debris on the floor. Be sure to mop under and around equipment, along walls, and in corners. 1. Observation on 04/15/26 at 8:17 A.M., in occupied resident room [ROOM NUMBER], showed a hole in the drywall under the PTAC (packaged terminal air conditioner) unit. There was white spackle on the wall under and to the left side of the PTAC unit. 2. Observation on 04/13/26 at 11:50 A.M., in occupied resident room [ROOM NUMBER], showed dirt and debris on the resident's bed sheets. Observation on 04/14/26 at 2:58 P.M., showed the dirt and debris on the resident's bed sheets. Observation on 04/15/26 at 9:08 A.M., showed dirt and debris on the resident's bed sheets. During an interview on 04/15/26 at 9:08 A.M., the resident said he/she would like staff to change his/her sheets. Observation on 04/15/26 at 12:35 P.M. showed dirt and debris on the resident's bed sheets. 3. Observation on 04/13/26 at 11:50 A.M. showed the following:-A strong urine odor on the 500 hall;-Black scuff marks up and down the 500 hallway;-The floor on the 500 hallway was stick 4. Observation on 04/13/26 at 1:10 P.M., in occupied resident room [ROOM NUMBER], showed the following:-Piles of trash and food on the floor, including an open can of food with a dirty spoon in it, dirty napkins/Kleenex, pieces of food, wrappers from crackers and other food items all along the wall and under the bed;-Several food and personal items piled on the floor and along the wall (not in storage containers);-Food pieces and food stains on the resident's bedding and mattress. 5. Observation on 04/16/26 at 8:08 A.M. showed a strong urine and stale odor on the 500 hall. Observations on 04/13/26 at 1:25 P.M. showed a strong urine odor on the 600 hall. Observation on 04/14/26 at 8:00 AM. showed a strong urine odor on the 600 hall. Observation on 04/15/26 at 8:00 A.M. showed a strong urine odor on the 600 hall. Observation on 04/16/26 at 8:12 AM. showed a strong urine odor on the 600 hall. 6. Observation on 04/14/26 at 8:12 A.M., in occupied resident room [ROOM NUMBER], showed the following:-A puddle of yellow, dried liquid was on the fall mat and floor;-The room smelled like urine. Observation on 04/14/26 at 12:25 P.M., showed the room smelled like urine. Observation on 04/14/26 at 6:05 P.M., showed the following:-A puddle of yellow liquid under the bed;-The room smelled like urine. Observation on 04/15/26 at 8:39 A.M., showed the following:-A puddle of yellow, dried liquid under the bed;-The room smelled like urine. 7. Observations on 04/14/26 from 8:30 A.M. to 3:58 P.M. and on 04/15/26 from 10:06 A.M. to 12:35 P.M., showed the following: -In resident room [ROOM NUMBER], an 8-inch section of cove base trim by the bathroom door was missing, the floor tiles by the window were chipped, a 2-inch long hole was in the drywall behind bed A, and the handle on the wardrobe for bed A was loose and hanging;-In the soiled utility room, one of two room lights did not work and a 6-inch by 8-inch section of the floor tile was missing; -In the 200 hall shower room, a 6-inch by 12-inch section of floor tile behind the toilet was missing; -The door handle to resident room [ROOM NUMBER] was very loose; -In resident room [ROOM NUMBER], a 6-inch section of cove base trim by the bathroom door was missing; -In resident room [ROOM NUMBER], there was a 6-foot by 3-foot by 3-foot area between the bed and the wall and a 3-foot by 3-foot by 8-foot area between the two residents' beds that contained clothes, papers, stuffed animals, decorations, and totes stacked up and in piles. There was no clear walkway on either side of the bed; -The door handle to resident room [ROOM NUMBER] was very loose; -In resident room [ROOM NUMBER], one handle was missing from the wardrobe and the second handle was not securely mounted to the door and had one of two screws missing. There was a 3-inch circular hole in the wall by the bathroom that was not patched or painted; -In resident room [ROOM NUMBER], there was a 6-foot by 6-foot by 10-foot area that contained several papers, boxes, paper towel rolls, trash, food, and beverages stacked on the bedside table, floor, and refrigerator. There was no clear pathway on the floor between the bed and the wall with the window; -In resident room [ROOM NUMBER], the window was cracked; -In resident room [ROOM NUMBER], there was a 3-foot by 2-foot by 10-foot area that contained several books, clothing, and decorations stacked on the floor by the bed. There was no clear pathway on the floor between the bed and the wall with the window; -In the bathroom for resident room [ROOM NUMBER], there was no shower head on the shower fixture; -The door to resident room [ROOM NUMBER], the plastic door covering was coming loose from the door; -In the bathroom for resident room [ROOM NUMBER], there was no shower head on the shower fixture; -The floor of the guest bathroom in the lobby was discolored brown in multiple areas. There were rust stains on the sink and drain. During interviews on 04/14/26 at 3:00 P.M., 04/15/26 at 10:45 A.M. and 1:44 P.M., the Maintenance Director said the following: -Staff encouraged residents to have a clutter-free space in case of an emergency where they might need to evacuate; -Some residents cleared excess items from their rooms in the past but were starting to accumulate items again; -He was unaware of the cracked window in room [ROOM NUMBER]; -The facility had a floor tech who completed work on the floors as needed; -There was a binder at the nurses' station for staff to note maintenance issues, and he checked the binder each Monday morning. Staff informed him verbally of maintenance issues that were urgent. During an interview on 04/15/26 at 2:27 P.M., the Administrator said she expected residents to have a safe, clean, orderly, and comfortable environment at the facility.

Based on interview and record review, the facility failed to administer medications as ordered for five residents (Resident #68, #37, #44, #75, and #73), in a review of 18 sampled residents, and for one additional resident (Resident #7). The facility census was 85.Review of the facility policy, Medication Administration, revised 02/07/2013, showed the following:-Purpose:-Medications are given to benefit a resident's health as ordered by the physician;-Guidelines:-Administer medication;-Important: If the resident refuses medication, indicate failure to administer medication on the medication record by circling initials and making a notation on the back of the medication record (include date, time, what occurred, initials, and title);-Record the medication given on the medication sheet. Review of the undated facility policy, Physician Orders, showed the following: -The following information is provided to assist you in recording physicians' orders:-Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors;-Physician orders must be reviewed and renewed. 1. Review of Resident #7's physician's orders, dated February 2026, showed the following:-Diagnoses of cellulitis (deep inflammation of the tissues just under the skin, caused by infection), diabetes, chronic pain and lymphedema (swelling that with accumulation of large amounts of lymph fluid in the affected region); -Doxycyline (an antibiotic) 100 mg twice daily for ten days (start date 02/25/26);-Lidocaine pain relief adhesive patch, 4 percent (%), apply one patch to left shoulder and one patch to right knee daily;-Torsemide (a diuretic) 20 mg daily;-Trulicity (a once-weekly injection used to improve blood sugar control) 0.75 mg/0.5 mL subcutaneously (SQ, beneath the skin) once a week on Mondays. Review of the resident's medication administration record (MAR), dated February 2026, showed the following:-On 02/02/26, staff documented Trulicity 0.75 mg/0.5 mL was unavailable;-On 02/25/26, staff documented the morning dose of doxycycline 100 mg by mouth was unavailable;-On 02/25/26, staff documented lidocaine pain relief adhesive patch was unavailable; -On 02/25/26, staff documented torsemide 20 mg was unavailable;-On 02/26/26, staff documented lidocaine pain relief adhesive patch was unavailable; -On 02/26/26, staff documented torsemide 20 mg was unavailable;-On 02/28/26, staff documented lidocaine pain relief adhesive patch was unavailable. Review of the facility's E-Kit medications showed the following medications were available:-Doxycycline (antibiotic) 100 mg tablet;-Torsemide (diuretic) 20 mg tablet.(Review showed no documentation staff administered the medications from the E-kit when the resident's medications were not available.) Review of the resident's medical record showed no documentation staff notified the pharmacy when the medications were not available. Review of the resident's physician's orders, dated March 2026, showed an order for lidocaine pain relief adhesive patch, apply one patch to left shoulder and one patch to right knee daily. Review of the resident's MAR, dated March 2026, showed on 03/16/26, staff documented lidocaine pain relief adhesive patch was unavailable. Review of the resident's medical record showed no documentation staff notified the pharmacy when the medication was not available. Review of the resident's physician's orders, dated April 2026, showed the following:-Lidocaine pain relief adhesive patch, apply one patch to left shoulder and one patch to right knee daily;-Potassium chloride 10 mEq, two capsules by mouth daily. Review of the resident's MAR, dated April 2026, showed the following:-On 04/05/26, 04/06/26, 04/07/26 and 04/08/26, staff documented lidocaine pain relief adhesive patch was unavailable; -On 04/08/26 and 04/09/26, staff documented potassium chloride 10 mEq two capsules was unavailable. Review of the facility's E-Kit medications showed potassium chloride (supplement) 10 milliequivalent (mEq) tablet was available. (Review showed no documentation staff administered the medications from the E-kit when the resident's medication was not available.) Review of the resident's medical record showed no documentation staff notified the pharmacy when the medication was not available. During an interview on 04/14/26 at 6:10 P.M., the resident said the facility frequently ran out of his/her medications. 2. Review of Resident #68's physician's orders, dated February 2026, showed the following:-Bupropion (an antidepressant) 150 mg by mouth daily;-Protonix (a medication to reduce stomach acid) 40 mg daily;-Spironolactone (a diuretic) 50 mg daily. Review of the resident's MAR, dated February 2026, showed the following:-On 02/10/26, staff documented bupropion 150 mg daily was unavailable;-On 02/15/26, staff documented Protonix 40 mg was unavailable;-On 02/16/26 and 02/17/26, staff documented spironolactone 50 mg was unavailable. Review of the facility's E-Kit medications showed the following medications were available:-Bupropion (antidepressant) 75 mg tablet;-Pantoprazole (also known as Protonix) 40 mg tablet;-Spironolactone (used to treat high blood pressure, heart failure, or hypokalemia (low potassium levels in the blood) 25 mg tablet. (Review showed no documentation staff administered the medications from the E-kit when the resident's medications were not available.) Review of the resident's medical record showed no documentation staff notified the pharmacy when the medications were not available. Review of the resident's physician's orders, dated March 2026, showed the following:-Celebrex (pain medication) 200 mg by mouth daily;-Spironolactone 50 mg by mouth daily. Review of the resident's MAR, dated March 2026, showed the following:-On 03/21/26, staff documented spironolactone 50 mg was unavailable;-On 03/29/26, staff documented Celebrex 200 mg was unavailable. Review showed no documentation staff administered the spironolactone from the E-kit when the resident's medication was not available. Review of the resident's medical record showed no documentation staff notified the pharmacy when the medication was not available. Review of the resident's physician's orders, dated April 2026, showed an order for duloxetine (a medication used to treat depression and anxiety) 30 mg daily. Review of the resident's MAR, dated April 2026, showed on 04/11/26, 04/12/26, and 04/13/26, staff documented duloxetine 30 mg was unavailable. Review of the facility's E-Kit medications showed duloxetine 30 mg tablet was available.(Review showed no documentation staff administered the medications from the E-kit when the resident's medication was not available.) Review of the resident's medical record showed no documentation staff notified the pharmacy when the medication was not available. During an interview on 04/14/26 at 6:34 P.M., the resident said the facility often ran out of his/her scheduled medications. 3. Review of Resident #37's physician's orders, dated March 2026, showed the following:-admitted to the facility on [DATE];-Diagnoses of atrial fibrillation (irregular heart rhythm), peripheral vascular disease (poor circulation), arthritis, hypothyroidism (the thyroid is not making enough thyroid hormone), hypertension, pain, and GERD;-Amlodipine 5 mg daily;-Eliquis (blood thinning medication) 2.5 mg twice daily;-Gabapentin (used to treat seizures and nerve pain) 100 mg three times daily;-Levothyroxine (thyroid medication) 88 micrograms (mcg) daily;-Lidocaine adhesive medicated patch 4%, apply to right knee daily;-Metoprolol succinate (blood pressure medication) 50 mg daily;-Pantoprazole 40 mg twice daily;-Pravastatin (used to lower cholesterol and triglycerides (fat)) 10 mg at bedtime. Review of the resident's MAR, dated 03/08/26, showed the following:-Staff documented the morning dose of pantoprazole 40 mg was unavailable;-Staff documented pravastatin 10 mg was unavailable, check E-kit, admission after medications delivered; -Staff documented levothyroxine 88 mcg was unavailable;-Staff documented lidocaine adhesive medicated patch was unavailable;-Staff documented metoprolol succinate 50 mg was unavailable;-Staff documented the morning and noon doses of gabapentin 100 mg were unavailable;-Staff documented amlodipine 5 mg was unavailable;-Staff documented the morning dose of Eliquis 2.5 mg was unavailable. Review of the resident's MAR, dated 03/09/26, showed staff documentation the levothyroxine 88 mcg daily was unavailable. Review of the facility's E-Kit medications showed the following medications were available:-Amlodipine (blood pressure medication) 5 milligram (mg) tablet;-Eliquis (blood thinner) 2.5 mg tablet;-Gabapentin (used to treat seizures and nerve pain) 100 mg tablet;-Levothyroxine (thyroid medication) 88 micrograms (mcg) tablet;-Metoprolol succinate (blood pressure medication) 25 mg tablet;-Pantoprazole (also known as Protonix - used to treat gastroesophageal reflux disease (GERD) (stomach contents leak backwards into the esophagus) 40 mg tablet. (Review showed no documentation staff administered the medications from the E-kit when the resident's medications were not available.) Review of the resident's medical record showed no documentation staff notified the pharmacy when the medications were not available. Review of the resident's physician's orders dated April 2026, showed an order for lidocaine adhesive medicated patch 4% apply to right knee daily. Review of the resident's MAR, dated April 2026, showed on 04/06/26 and 04/07/26, staff documented the lidocaine adhesive medicated patch 4% was unavailable. Review of the resident's medical record showed no documentation staff notified the pharmacy when the medication was not available. 4. Review of Resident #44's physician's orders, dated 03/16/26 - 04/16/26 showed the following:-admitted to the facility on [DATE];-Atorvastatin (a cholesterol medication) 20 mg daily;-Lisinopril (a medication used to treat high blood pressure and heart failure) 10 mg daily;-Pantoprazole (a medication used to treat too much acid in the stomach) 40 mg twice daily;-Carbidopa-levodopa (a medication used to treat Parkinson's disease) 10-100 mg three times a day. Review of the resident's MAR, dated 03/21/26, showed the following:-Staff documented the morning dose of pantoprazole 40 mg was unavailable;-Staff documented the morning dose of atorvastatin 20 mg was unavailable;-Staff documented the morning dose of lisinopril 10 mg was unavailable. Review of the facility's E-Kit medications showed the following medications were available:-Atorvastatin 20 mg tablet;-Lisinopril 5 mg tablet;-Pantoprazole 40 mg tablet.(Review showed no documentation staff administered the medications from the E-kit when the resident's medications were not available.) Review of the resident's medical record showed no documentation staff notified the pharmacy when the medications were not available. Review of the resident's MAR, dated April 2026, showed on 04/12/26 staff documented carbidopa-levodopa 10-100 mg (bedtime dose) was unavailable and the medication was not in the E-kit. Review of the resident's medical record showed no documentation staff notified the pharmacy when the medication was not available. 5. Review of Resident #75's undated continuity of care document (CCD) showed his/her diagnoses included Type 2 diabetes mellitus (metabolic disease) with diabetic chronic kidney disease (CKD, impaired kidney function), and long-term use of injectable non-insulin antidiabetic drugs. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/06/26, showed the following:-Moderately impaired cognition;-He/She received an insulin injection in the last seven days. Review of the resident's physician orders, dated March 2026, showed an order for semaglutide (a weekly injection for managing type 2 diabetes) inject 1 mg subcutaneously (beneath the skin) once a week on Wednesday. Review of the resident's MAR, dated March 2026, showed on 03/11/26 at 12:30 P.M., Licensed Practical Nurse (LPN) FF documented semaglutide was not administered due to the medication was not available. (Review showed no documentation staff administered the medication on any other date during the week of 03/08/26-03/14/26.) Review of the resident's medical record showed no documentation staff notified the pharmacy when the medication was not available. Review of the resident's physician orders, dated April 2026, showed an order for semaglutide, inject 1 mg subcutaneously once a week on Wednesday. Review of the resident's MAR, dated April 2026, showed on 04/08/26 at 12:30 P.M., LPN G documented semaglutide was not administered due to the medication was not available. (Review on 04/14/26 showed no documentation staff administered the medication on any date between 04/08/26 and 04/14/26.) During an interview on 04/16/26 at 11:25 A.M., LPN G said the following:-If medication was unavailable during the medication pass, staff should check the overflow medications in the medication room and the E-kit;-Staff should let the charge nurse know if the medication was unavailable in the facility, so the charge nurse could notify the pharmacy. Review of the resident's medical record showed no documentation staff notified the pharmacy when the medication was not available. During an interview on 04/13/26 at 1:42 P.M., the resident said the following:-He/She was to receive weekly injectable medication for his/her diabetes;-He/She didn't receive his/her injection last week because the facility was out of his/her medication and he/she had not yet received it for this week;-The facility ran out of medications frequently. 6. Review of Resident #73's undated CCD showed his/her diagnoses included severe sepsis with septic shock (infection of the blood), urinary tract infection (UTI) (a common infection caused by bacteria entering and spreading within the urinary system, including the bladder, urethra or kidneys). Review of the resident's quarterly MDS, dated [DATE], showed the resident's cognition was intact. Review of the resident's progress notes, dated 03/23/26 at 2:33 P.M. showed the following:-The resident had been admitted to the hospital for septic shock (infection of the blood) due to urinary infection;-He/She will be coming back to the facility with a right midline intravenous (IV) and has already had a course of antibiotic for today, however, he/she will need it for two more days then can go to oral antibiotics on 03/25/26. Review of the resident's physician orders, dated April 2026, showed an order for cefpodoxime (antibiotic) 200 milligram (mg) twice a day for 10 days (administration times of 6:30 A.M. - 2:30 P.M., 2:30 P.M. - 10:30 P.M) for UTI (order start date 04/08/26 and end date 04/18/26). Review of the resident's MAR, dated April 2026, showed Certified Medication Technician (CMT) Y documented cefpodoxime was not administered during the 6:30 A.M.-2:30 P.M. medication pass on 04/13/26 due to the medication was not available. During an interview on 04/13/26 at 1:42 P.M., the resident said the following:-He/She didn't get his/her antibiotic today;-Staff told him/her they were out of his/her antibiotic, and it would hopefully be in by tomorrow; -He/She was worried about missing his/her medication because he/she just returned from the hospital with sepsis and a UTI;-The facility ran out of medications all the time. 7. During an interview on 04/15/26 at 8:30 A.M., CMT Y said the following:-The facility frequently ran out of scheduled medications;-There were a lot of new CMTs who were not restocking the medication carts and ordering medications timely. During an interview on 04/15/26 at 2:01 P.M., CMT U said the following:-If a medication was unavailable in the cart or medication room, staff could usually pull the medication from the facility's E-kit;-If the medication was not in the E-kit, hopefully the facility would receive the medication from the pharmacy later that day; -Staff should let the charge nurse know if a medication was unavailable so the charge nurse could call the pharmacy;-He/She documented the medication was unavailable when the medication was not available to administer. During an interview on 04/16/26 at 11:25 A.M., LPN G said the following:-If medication was unavailable during the medication pass, staff should check the overflow medications in the medication room and the E-kit;-Staff should let the charge nurse know if the medication was unavailable in the facility, so the charge nurse could notify the pharmacy. During an interview on 04/15/26 at 8:12 A.M., the Assistant Director of Nursing (ADON) said the following:-If a medication was not available during the medication pass, staff administering medications should check in the E-kit. If the medication was not in the E-kit, the charge nurse should contact the pharmacy;-It may take the pharmacy two to three days to deliver the medications; -He/She was aware there were issues with medications not being available but thought it was getting better. During an interview on 04/16/26 at 3:49 P.M., the Director of Nursing (DON) said the following:-She were to follow physicians orders and administer medications as ordered;-She was not aware of any issues with residents not receiving their medications;-Everyone knew how to reorder medications. She expected staff to reorder medications as needed; -She expected staff to check the E-kit for medications and to administer medications from the E-kit if the medication was available.

Based on observation, interview and record review, the facility failed to ensure two residents (Residents #60 and #62), in a review of 18 sampled residents, and two additional residents (Residents #31 and #45), who required assistance with activities of daily living (ADLs), received the necessary care and services to maintain good grooming and personal hygiene. The facility census was 85. Review of the facility's undated policy, Activities of Daily Living, showed the following:-The purpose was to assist resident in achieving maximum function;-The policy did not address bathing/showering, dressing or clothing changes. Upon request, the facility provided no other policy related to bathing/showering, dressing or clothing changes. 1. Review of Resident #45's Progress Notes, dated 11/28/25 at 12:52 P.M., showed the resident's family member said the resident had a stroke a few years ago. Since his/her stroke, the resident has been unable to maintain proper hygiene and perform ADLs. Review of the resident's Shower Sheets, dated 03/01/26 - 03/10/26, showed the following:-On 03/04/26, the resident received a shower;-On 03/07/26, the resident refused a shower;-No documentation the resident received a shower 03/05/26 - 03/10/26 (six days). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool to be completed by the facility, dated 03/10/26, showed the following:-Cognitively intact;-Did not reject care;-Independent for shower/bath, upper and lower body dressing and personal hygiene;-Occasionally incontinent of bladder. Review of the resident's care plan, dated 03/13/26, showed the following:-The resident was continent of bowel and bladder most of the time;-The resident was able to maintain personal hygiene on his/her own;-No documentation regarding bathing. Review of the resident's Shower Sheets, dated 03/10/26 - 04/13/26, showed the following:-On 03/11/26, the resident refused a shower. The resident requested a shower tomorrow, 03/12/26;-On 03/12/26, no documentation staff offered or the resident received or refused a shower;-On 03/14/26, the resident received a shower (10 days since his/her last shower on 03/04/26);-On 03/18/26, the resident refused a shower. The resident requested a shower tomorrow, 03/19/26;-On 03/19/26, no documentation staff offered or the resident received or refused a shower;-On 03/22/26, the resident received a shower (eight days since last shower on 03/14/26);-On 03/25/26, the resident refused a shower;-On 04/01/26, the resident refused a shower;-On 04/04/26, the resident refused a shower. The resident requested a shower tomorrow, 04/05/26;-On 04/05/26, no documentation staff offered or the resident received or refused a shower;-On 04/08/26, the resident refused a shower;-On 04/11/26, the resident refused a shower. Staff documented the resident was encouraged to shower but refused.(Review of the resident's shower sheets showed no documentation staff offered the resident a partial bath and/or assistance with personal hygiene when he/she refused to take a shower.) Observation on 04/13/26 at 11:50 A.M., showed the following:-The resident sat on the side of his/her bed;-There was a strong smell of body odor in the room;-The resident's hair was disheveled and greasy;-The resident had white flakes in his/her hair and a dime-sized amount of tan debris in his/her hair by his/her left ear;-The resident had white flaky skin on his/her shirt and dried food debris on the front of his/her pants. During an interview on 04/13/26 at 11:50 A.M., the resident said he/she needed staff assistance to get in and out of the shower. He/She was supposed to receive a shower today. Observation on 04/14/26 at 2:52 P.M., showed the following:-The resident walked down the hallway with his/her walker;-He/She wore the same shirt and pants he/she wore on 4/13/26;-The resident's hair was disheveled and greasy;-There were white flakes in the resident's hair and a dime sized amount of tan debris in the resident's hair by his/her left ear;-There was white flaky skin on the resident's shirt and dried food debris on the front of the resident's pants. During an interview on 04/14/26 at 2:52 P.M., the resident said he/she did not get his/her shower yesterday, maybe he/she would get a shower today. Observation on 04/14/26 at 2:58 P.M., in the resident's room, showed the following:-The resident was not in his/her room;-There was a strong smell of body odor in the room. Observation on 04/15/26 at 9:08 A.M., showed the following:-The resident sat on the side of his/her bed;-He/She wore the same pants he/she wore on 4/13/26 and 04/14/26;-The resident wore the same shirt as 04/14/26;-The resident's hair was disheveled and greasy;-There were white flakes in the resident's hair and a dime-sized amount of tan debris in the resident's hair by his/her left ear;-There was white flaky skin on the resident's shirt and dried food debris on the front of his/her pants. During an interview on 04/15/26 at 9:08 A.M., the resident said the following:-He/She needed staff's help to change his/her clothes;-He/She would like to change his/her clothes daily;-He/She told staff he/she needed assistance. Observation on 04/15/26 at 12:35 P.M., showed the following:-A strong smell of body odor was in the resident's room;-The resident lay on his/her left side in bed;-The soles of the resident's feet were black/brown with debris and dirt;-He/She wore the same pants he/she wore on 4/13/26 and 04/14/26;-The resident wore the same shirt he/she wore on 04/14/26;-The resident's hair was disheveled and greasy;-There were white flakes in the resident's hair and a dime sized amount of tan debris in the resident's hair by his/her left ear;-There was white flaky skin on the resident's shirt and dried food debris on the front of the resident's pants. During an interview on 04/15/26 at 12:57 P.M., Nurse Aide (NA) I said the following:-The resident was independent with changing his/her clothes and personal hygiene;-The resident did not like to take showers;-The resident needed encouragement to change his/her clothes daily. Observation on 04/16/26 at 11:16 A.M., showed the following:-The resident sat on his/her rollator walker at the nurses station;-The resident had body odor;-He/She wore the same pants he/she wore on 4/13/26, 04/14/26 and 04/15/26;-The resident wore the same shirt he/she wore on 04/14/26 and 04/15/26;-The resident's hair was disheveled and greasy;-There were white flakes in the resident's hair and a dime-sized amount of tan debris in the resident's hair by his/her left ear;-There was white flaky skin on the resident's shirt and dried food debris on the front of his/her pants. During an interview on 04/16/26 at 11:16 A.M., the resident said he/she had not received a shower this week. Review of the resident's Shower Sheets, dated 03/23/26 - 04/16/26, showed no documentation the resident received a shower or partial bath for 25 days. During an interview on 04/16/26 at 11:25 A.M., Licensed Practical Nurse (LPN) G said the following:-If a resident refused showers, staff should offer a partial bath or provide assistance with personal hygiene and changing clothes;-A resident should not wear the same pants for four days. 2. Review of Resident #31's quarterly MDS, dated [DATE], showed the following:-Dependent on staff for toileting hygiene and personal hygiene;-Required substantial/maximal assistance with roll left and right;-Always incontinent bladder and bowel. Review of the resident's care plan, dated 04/14/26, showed the following:-The resident was incontinent of bowel and bladder;-Provide incontinence care after each incontinent episode;-Assist of one to two staff with toileting and hygiene. Observation on 04/14/26 at 6:42 P.M., showed the following:-The resident lay awake in bed;-Certified Nurse Assistant (CNA) P and LPN GG entered the resident's room;-The resident was incontinent of urine and a moderate amount soft feces;-There was a very strong urine smell in the resident's room;-The front of the resident's gown was wet with urine;-CNA P performed frontal pericare;-CNA P and LPN GG rolled the resident to his/her left side;-The disposable incontinence pad under the resident was saturated with urine;-CNA P used disposable wipes to perform rectal pericare;-CNA P did not clean the resident's buttocks and thighs (areas in contact with the urine saturated incontinence pad);-CNA P tucked the soiled incontinence pad under the resident's hips and placed a clean incontinence pad under the resident's hips;-CNA P assisted the resident to roll to his/her back in bed;-CNA P removed the resident's soiled gown and placed a clean gown on the resident. 3. Review of Resident #62's care plan, dated 03/17/26, showed the following:-The resident needed assistance with ADLs (e.g. transfers, dressing, toileting, and maintaining personal hygiene);-Assist daily and as needed with hygiene needs;-Provide incontinence care after each incontinent episode. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Dependent on staff for toileting hygiene;-Required substantial/maximal assistance for personal hygiene;-Required partial/moderate assistance for roll left and right;-Always incontinent of bowel and bladder. Observation on 04/14/26 at 7:12 P.M., showed the following:-The resident lay awake in bed;-The resident was incontinent of urine and a large amount of liquid feces;-The resident's incontinence brief was saturated with urine and feces;-There was a strong smell of urine in the room;- CNA P performed frontal pericare and assisted the resident to roll to his/her left side;-CNA P performed rectal pericare;-CNA P did not clean the resident's hips or upper buttocks (areas in contact with the soiled incontinence brief); -CNA P tucked the resident's soiled incontinence brief under the resident's hips and placed a clean incontinence brief under the resident's hips;-CNA P assisted the resident to roll to his/her back and fastened the incontinence brief. During an interview on 04/14/26 at 8:12 P.M., CNA P said the following:-The resident's hips were not visibly wet when he/she rolled the resident so he/she did not clean the resident's hips and thighs;-He/She should clean all wet/soiled areas of the resident's skin when providing pericare. 4. Review of Resident #60's comprehensive MDS, dated [DATE], showed the following:-Severely impaired cognition;-Did not reject care;-Dependent on staff for showering/bathing;-Required substantial/maximal assistance from staff for personal hygiene;-Always incontinent of bowel and bladder. Review of the resident's care plan, last revised 03/13/26, showed the following:-He/She required staff assistance with ADL's: e.g maintain personal hygiene;-He/She is incontinent of bowel and bladder; provide incontinence care after each incontinence episode;-The care plan did not address bathing or document the resident refused care. Review of the resident's shower sheets and the facility shower binder for March 2026, showed the following:-The resident's bathing days were Mondays and Thursdays (day shift);-No documentation the resident received or refused a shower on 03/02/26 through 03/04/26;-On 03/05/26, the resident refused bathing; -No documentation the resident received or refused a shower on 03/06/26 through 03/09/26;-On 03/09/26, the resident refused bathing; -No documentation the resident received or refused a shower on 03/10/26 and 03/11/26;-On 03/12/26, the resident received a shower (first documented shower since the resident returned to the facility from the hospital on [DATE]); -No documentation the resident received or refused a shower on 03/13/26 through 3/15/26;-On 03/16/26, the resident received a shower;-No documentation the resident received or refused a shower on 03/17/26 and 03/18/26;-On 03/19/26, the resident refused bathing; -No documentation the resident received or refused a shower on 03/20/26 through 03/22/26;-On 03/23/26, the resident refused bathing; -No documentation the resident received or refused a shower on 03/24/26 and 03/25/26;-On 03/26/26, the resident received a shower (ten days since his/her last shower on 03/16/26); -On 03/30/26, the resident received a shower. Review of the resident's shower sheets for April 2026, showed the following:-On 04/02/26, the resident received a bed bath; -On 04/06/26, the resident refused bathing. Staff attempted to convince the resident to take a shower and he/she did not comply with the request; forwarded to the director of nursing (DON); -On 04/09/26, the resident refused bathing. Observation on 04/13/26 at 1:05 P.M. showed the following:-The resident lay in his/her bed;-His/Her hair was disheveled;-There was a strong body odor and urine odor in his/her room. Review of the resident's shower sheets for April 2026, showed the resident received a shower on 04/13/26. During interviews on 04/13/26 at 1:10 P.M. and on 04/17/26 at 9:05 A.M., the resident's roommate said the following:-He/She was very concerned about his/her roommate not receiving his/her showers;-The resident was always incontinent of bowel and bladder;-He/She could smell urine and feces all the time;-He/She wore three disposable masks (personal protective equipment) when he/she slept because of the resident's odors. During an interview on 04/16/26 at 8:40 A.M. and 9:07 A.M., CNA Q said the following:-If Resident #60 refused his/her shower, he/she would get the nurse to see if he/she can convince the resident to shower; -Other staff have mentioned the resident refuse a lot. During an interview on 04/16/26 at 9:15 A.M., LPN G said the following:-The resident refused cares a lot; -If the resident refused, he/she would check back later. 5. During an interview on 04/16/26 at 3:49 P.M., the Director of Nursing (DON), said the following:-Staff should clean all soiled areas of a resident's skin when performing peri-care;-She should offer partial baths and continue to encourage residents who refuse to take showers and to change clothes to take one throughout the day.

Based on observation, interview, and record review, the facility failed to ensure three nurse aides (NA J, NA I and NA K), in a review of seven staff reviewed, completed a certified nurse aide (CNA) training program within four months of their employment in the facility. The facility census was 85. During an interview on 04/16/26 at 8:45 A.M., the Administrator said the facility did not have a policy directly addressing the use of NAs and the timeframe to become certified. 1. Review of the current employee list, provided by the facility, showed NA J's date of hire was 08/20/25. Review of NA J's employee file showed no documentation he/she completed a CNA training program within four months of his/her hire date. Review of the facility schedule for April 2026 showed NA J was scheduled to work as an NA from 6:00 A.M.to 6:00 P.M. on 04/03/26, 04/04/26, 04/05/26, 04/08/26, 04/09/26, 04/13/26 and 04/14/26. Review of the facility provided daily staffing sheets for 04/13/26 through 04/16/26 showed the following: -NA J was assigned to resident hall E from 6:00 A.M. to 6:00 P.M. on 04/13/26;-NA J was assigned to resident hall D from 6:00 A.M. to 6:00 P.M. on 04/14/26. Observation on 04/13/26 at 4:03 P.M. showed NA J assisted another staff to transfer Resident #62 from his/her bed to his/her wheelchair. 2. Review of the current employee list, provided by the facility, showed NA I's date of hire was 09/25/25. Review of NA I's employee file showed no documentation he/she completed a CNA training program within four months of his/her hire date. Review of the facility schedule for April 2026 showed NA I was scheduled to work as an NA from 6:00 A.M. to 6:00 P.M on 04/01/26, 04/02/26, 04/06/26, 04/07/26, 04/10/26, 04/11/26, 04/12/26, 04/15/26 and 04/16/26. Review of the facility provided daily staffing sheets for 04/13/26 through 04/16/26 showed the following: -NA I was assigned to resident hall A from 6:00 A.M. to 6:00 P.M. on 04/15/26;-NA I was assigned to resident hall E from 6:00 A.M. to 6:00 P.M. on 04/16/26. Observation on 04/15/26 at 11:05 A.M. showed NA I provided incontinence care for Resident #7 and transferred the resident with a mechanical lift. During an interview on 04/15/26 at 8:20 A.M., NA I said the following:-He/She worked as an NA in the facility for eight months;-He/She just completed CNA class and was waiting to take his/her certification test;-He/She was working on the A hall by himself/herself today. 3. Review of the current employee list, provided by the facility, showed NA K's date of hire was 10/02/25. Review of the facility nursing scheduled for January 2026 through April 2026 showed NA K was scheduled to work as an NA from 10/02/25 through 01/18/26, took leave from 01/19/26 through 02/28/26, and returned to work as an NA on 03/03/26. Review of NA K's employee file showed no documentation he/she completed a CNA training program within four months of his/her hire date. Review of the facility provided schedule for April 2026 showed NA K was scheduled to work as an NA from 6:00 A.M. to 6:00 P.M. on 04/04/26, 04/05/26, 04/07/26, and 04/14/26. He/She was scheduled to work as an NA from 2:00 P.M. to 10:00 P.M. on 04/10/26, 04/11/26, and 04/12/26. Review of the facility provided daily staffing sheets for 04/13/26 through 04/16/26 showed NA K was assigned to resident hall F from 2:00 P.M. to 6:00 P.M on 04/14/26. 4. During an interview on 04/16/25 at 10:45 A.M., the Director of Nursing (DON) said the following: -An NA had four months to complete the CNA training program;-The facility had three NAs (NA K, NA I and NA J) who had worked as an NA for longer than four months; -The NAs started the program as a web-based program and were not successful and transitioned to an in-seat program;-Two of the three NAs were waiting to test, and one NA went on extended leave and wasn't finished with his/her training. During an interview on 04/16/26 at 3:00 P.M., the Administrator said the following: -NAs were required to complete the CNA training within four months of hire;-She was aware there were three NAs who have not completed their CNA training within four months of hire;-All three NAs started the program on a web-based format and were unsuccessful, so they transitioned to an in-seat program;-NA I completed classes and needed to take his/her test, but hadn't scheduled the test yet;-NA J was supposed to take his/her test on the 04/10/26 and while taking his/her test, the test shut off and he/she was not able to get back into the test;-NA K was off on extended leave and had not been added back to the class.

Based on interview and record review, the facility failed to complete a performance review at least every 12 months for three certified nurse assistants (CNAs) and failed develop a process to identify weaknesses and to provide regular in-service education based on the outcome of these reviews. The facility census was 85. Review of the facility policy, Employee Evaluations, dated July 2006, showed the following: -Employee evaluations are primarily viewed as an important management tool, helping to evaluate and increase the quality of an employees' performance and make decisions about work assignments;-Evaluations give guidance to employees on areas of performance where they can improve;-Using the Employee Evaluation form in conjunction with a current job description, the supervisor should review all employees upon the following time schedule: -90 days after the initial date of hire; -Annually, on or near the anniversary of the individual's hire date. 1. Review of the facility assessment, updated 01/09/26, showed services and care offered based on residents' needs:-General care: activities of daily living, mobility and fall/fall with injury prevention, bowel/bladder, skin integrity, mental health and behavior, medications, pain management, infection prevention and control, management of medical conditions, therapy, other special care needs, nutrition and person centered/directed care: psycho/social/spiritual support;-Competencies for general care: facility conducts monthly in-service meetings with staff;-Competency assessments, performance reviews and observed abilities are also completed;-Training is conducted based from assessments and observation results. 2. Review of the facility staff list, provided by the facility, showed Certified Nurse Assistant (CNA) D was hired on 10/29/14. Review of CNA D's employee file showed no documentation staff completed an annual performance evaluation. 3. Review of the facility staff list, provided by the facility, showed CNA E was hired on 10/09/23. Review of CNA E's employee file showed no documentation staff completed an annual performance evaluation. 4. Review of the facility staff list, provided by the facility, showed CNA F was hired on 10/11/23. Review of CNA F's employee file showed no documentation staff completed an annual performance evaluation. 5. During an interview on 04/16/26 at 10:07 A.M., the Administrator said the following: -She believed the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) completed the annual CNA performance reviews -She believed staff conducted in-services related to required elements and any identified areas to review as needed. During an interview on 04/16/26 at 10:45 A.M., the Director of Nursing (DON) said the following:-She did not complete a formal performance evaluation or review for CNAs who were employed for 90 days;-She did not complete a formal performance evaluation or review for CNAs who were employed for 12 months or longer;-She had not formally identified any weaknesses to determine what education pieces should be completed. During an interview on 04/29/26 at 12:29 P.M., the Assistant Director of Nursing (ADON) said the following: -She had been the ADON for about a year;-She did not complete any of the CNA performance evaluations or tracking of staff education;-She had not been told she was responsible for any aspect of the CNA performance evaluations.

Based on observation, interview, and record review, the facility failed to ensure all medications available for administration on the Certified Medication Technician (CMT) cart for halls B/E/F, CMT medication room, and stock medication room were not expired. The facility census was 85. Review of the facility's undated policy, Storage of Medications, showed the following: -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines;-Drugs must be stored in an orderly manner in cabinets, drawers, or carts. 1. Observation on 04/14/26, at 6:07 P.M., of the CMT medication cart for halls B/E/F showed the following: -A sticky residue was in the bottom two drawers which contained stock bottles of medications;-A sticky residue was in the top drawer which contained inhalers and eye drops. Staff's personal items, including keys, were stored with the eye drops;-An opened stock bottle of Vitamin E (a dietary supplement) 180 milligram (mg) soft gel capsules contained eight capsules and had an expiration date of 8/25; -An opened bottle of diphenhydramine/lidocaine/aluminum hydroxide/magnesium hydroxide/simethicone (a liquid medication used to treat mouth sores), approximately 3/4 full, labeled for Resident #24, had an expiration date of 02/20/26. 2. Observation on 04/14/26 at 6:07 P.M. of the CMT medication room and over-the-counter stock/wound care supplies storage room, showed the following: -An opened bottle of Omega-3 (a dietary supplement) 2000 mg had an expiration date of 03/2026; -Two opened 13-ounce containers of stock Reguloid daily fiber (a laxative) had an expiration date of 02/2026;-Five unopened 13-ounce containers of stock Reguloid daily fiber had an expiration date of 02/2026;-An opened 16-ounce bottle of Lactulose (a solution used to treat constipation), labeled for Resident #51, had an expiration date of 08/31/25;-An unopened 16-ounce bottle of Lactulose, labeled for Resident #51, had an expiration date of 08/31/25;-An opened bottle of glucosamine and chondroitin (a dietary supplement) 500 mg/400 mg had an expiration date of 03/2025;-Six unopened bottles of oyster shell calcium and vitamin D (a dietary supplement) had an expiration date of 07/2025. 3. Observation 04/14/26 at 6:40 P.M. of the nurse medication/treatment cart for hall B/D/E showed the following: -An opened bottle of nitroglycerin (a medication to treat chest pain) tablets 0.4 mg, labeled for Resident #91, had an expiration date of 12/2025; -An opened vial of heparin (an injectable medication used as blood thinner to prevent blood clots) 5000 units/ml, approximately 1/2 full, labeled for Resident #84, had an expiration date of 03/31/26;-An unopened vial of heparin, labeled for Resident #84, had an expiration date of 03/31/26;-An opened and in-use pen of Lantus (long-acting insulin used to treat diabetes), containing approximately 10 units, labeled for Resident #46, was not dated to show when staff opened the pen;-An opened stock bottle of arthritis pain relief acetaminophen (a medication used to treat pain) 650 mg had an expiration date of 06/2025; -An opened stock bottle of melatonin (a dietary supplement used to aid in sleep) had an expiration date of 12/2025. One white pill that was a different color and size was intermixed with the melatonin tablets.-An opened stock bottle of naproxen sodium (a medication used to treat inflammation and pain) 220 mg had an expiration date of 03/2025;-The expiration date on an opened stock bottle of acetaminophen 500 mg, containing seven tablets, was not clear to identify when the medication expired;-An opened stock bottle of acetaminophen 325 mg did not have an expiration date. 4. During an interview on 04/14/26 at 7:23 P.M., CMT B said the following:-He/She was unsure if anyone was specifically responsible for checking the medication carts and storage room for expired medications, but felt like everyone who used the medication carts and passed the medications should check for expired medications;-If a resident's medication was expired, staff were to remove the medication from the medication cart and put it in the nurses medication room to be sent back to pharmacy; -If an over-the-counter (stock) medication was expired, he/she felt staff should pull it from the medication cart or storage room and put it on the counter in the CMT medication room for the Director of Nursing (DON) or charge nurse;-Anyone who used the cart was responsible for keeping the carts clean;-Staff's personal items should not be stored in the medication cart. During an interview on 04/14/16 at 7:20 P.M., Licensed Practical Nurse (LPN) L said the following:-All nurses who used the medication/treatment cart were responsible for checking for expired medications;-He/She was not sure what the process was for expired medications, but he/she would give them to the DON or Assistant Director of Nursing (ADON);-Everyone who used the medication carts were responsible for ensuring they were clean;-Staff should not store their personal items in the medication carts. During an interview on 04/16/26 at 10:45 A.M., the DON said the following: -The DON, ADON, all nursing staff who pass medications, and the pharmacists were responsible for checking the medication carts and storage rooms for expired medications; -The staff who used the medication carts were responsible to keep the carts clean and orderly;-Staff should not store their personal items in the medication carts. During an interview on 04/16/26 at 11:51 A.M., the consultant pharmacist said the following:-She was at the facility monthly and conducted spot checks of the medication rooms and medication carts;-She did not check every medication in the medication rooms and on the medication carts;-She did not check the stock medication room for expired medications;-It was ultimately the facility's responsibility to ensure there were no expired medications in the medication room, medication carts or in the stock medication room.

Based on observation, interview, and record review, the facility failed to follow current infection control standards for three residents (Resident #8, # 9 and #62) in a review of 18 sampled and three additional residents (Residents #7, #31, and #34). Staff failed to follow enhanced barrier precautions (EBP) by not wearing appropriate personal protective equipment (PPE) while providing personal care for Residents #34 and #7. Staff failed to perform hand hygiene and change gloves as indicated by facility policy while providing personal care for Residents #8, #9, #31 and #62. The facility census was 85.Review of the facility's policy Enhanced Barrier Precautions to Infection Control Guidance, last revised March 2024, showed the following:-The purpose is to prevent broader transmission of MDRO (multidrug-resistance organisms) and to help protect residents with chronic wounds;-Enhanced Barrier Precautions (EBP) should be implemented for the period of their stay or until wounds have been resolved;-The following residents require EBP, 3.Residents with a wound, regardless of their MDRO status;-Use EBP when providing high-contact resident care activities such as the following: 2.Transferring residents from one position to another; 3.Providing hygiene; 4.Changing bed linens; 5.Changing briefs or assisting with toileting;-Equipment needed- gown and gloves;-Conduct proper hand hygiene before starting care;-Gloves and donning and doffing of gown are required when conducting high-contact resident care activities that are listed above;- Residents with a wound or indwelling medical device AND excretions or secretions that are unable to be covered or contained and are NOT known to be infected or colonized with any MDRO should be placed on contact precautions unless or until a specific organism is identified;-Secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increase potential for environmental contamination and risk of transmission of a pathogen. Review of the facility's policy, Gloves, last revised March 2024, showed the following:-Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash;-Gloves must be changed between residents and between contacts with different body sites of the same resident;-They should reduce the likelihood of contaminating the hands, but gloves cannot prevent penetrating injuries due to needles or sharp objects;-Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to the skin on your hands;-Handling medical equipment and devices with contaminated gloves is not acceptable. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/07/26, showed the following:-Dependent on staff for toileting hygiene and personal hygiene;-Always incontinent of bowel and bladder. -Always incontinent of bowel. Review of the resident's care plan, last revised 04/15/26, showed the following:-He/She required extensive assistance from staff with activities of daily living (ADL) care: dressing, toileting, and maintaining personal hygiene;-Provide incontinence care after each incontinence episode. Observation on 04/14/26 at 7:05 P.M. showed the following:-Certified Nurse Assistant (CNA) R and Nurse Assistant (NA) S entered the resident's room and put on gloves (no observation of hand hygiene prior to donning gloves);-CNA R removed the resident's urine- and feces-saturated Hoyer pad (mechanical lift pad used to transfer residents from one position to another), pants and incontinence brief and placed them in the clear trash and dirty linen bags placed at the foot of the bed;-NA S assisted the resident to turn to his/her left side;-The resident had a large, soft bowel movement that was dried to his/her skin;-CNA R cleaned the resident's bottom with disposable wipes;-CNA R removed his/her gloves, did not perform hand hygiene, and held the resident's hands as NA S removed the resident's shirt;-CNA R touched the doorknob of the resident's room and touched the clean linen cart in the hallway to obtain a clean gown for the resident;-CNA R and NA S attempted to place the gown on the resident in which the resident refused, so NA S covered the resident with his/her blanket and then removed his/her gloves;-CNA R and NA S washed their hands;-CNA R carried the bags of dirty linens and trash to the soiled utility room, did not perform hand hygiene, then walked into the dining room and pushed another resident down the hall in a wheelchair to his/her room. During an interview on 04/14/26 at 8:20 P.M., NA S said he/she should change his/her gloves before and after care. He/She should wash his/her hands before and after care, before and after every task, and between dirty and clean tasks when providing care. During an interview on 04/14/26 at 8:30 P.M., CNA R said the following:-He/She should perform hand hygiene before going into a resident's room and when coming out of a resident's room;-He/She should have washed his/her hands after going from dirty to clean task and before and after glove change when providing care to the resident 2. Review of Resident #31's quarterly MDS, dated [DATE], showed the following:-Dependent on staff for toileting hygiene, upper body dressing and personal hygiene;-Required substantial/maximal assistance with roll left and right;-Always incontinent bladder and bowel. Review of the resident's care plan, dated 04/14/26, showed the following:-The resident was incontinent of bowel and bladder;-Provide incontinence care after each incontinent episode. Observation on 04/14/26 at 6:42 P.M. showed the following:-The resident lay in bed;-CNA P and Licensed Practical Nurse (LPN) GG entered the resident's room;-The resident was incontinent of urine and a moderate amount soft feces;-The front of the resident's gown was wet with urine;-CNA P wore gloves and performed frontal pericare;-CNA P and LPN GG rolled the resident to his/her left side;-The disposable incontinence pad under the resident was saturated with urine;-CNA P performed rectal pericare;-CNA P tucked the soiled incontinence pad under the resident's hips, and without changing gloves or washing his/her hands, placed a clean incontinence pad under the resident's hips and touched the resident's left knee to roll to his/her back in bed;-CNA P removed the resident's soiled gown;-Without changing gloves or washing his/her hands, CNA P placed a clean gown on the resident, placed a clean sheet on the resident, and handed the resident the bed remote;-CNA P removed his/her gloves, and without performing hand hygiene, covered the resident with a blanket and handed the resident pillows and stuffed animals. 3. Review of Resident #62's care plan, dated 03/17/26, showed the following:-The resident needed assistance with ADLs (e.g. toileting and maintaining personal hygiene);-Assist daily and as needed with hygiene needs;-Provide incontinence care after each incontinent episode. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Dependent on staff for toileting hygiene;-Required partial/moderate assistance for roll left and right;-Always incontinent of bowel and bladder. Observation on 04/14/26 at 7:12 P.M., showed the following:-The resident lay in bed and was soiled with urine and a liquid feces; -Without performing hand hygiene, CNA P put on gloves;-CNA P performed frontal pericare and assisted the resident to roll to his/her left side;-CNA P performed rectal pericare;-CNA P tucked the resident's soiled incontinence brief under his/her hips, and without changing gloves or washing his/her hands, CNA P put a clean incontinence brief under the resident's hips, assisted the resident to roll to his/her back, touched the resident's right hip and shirt and repositioned the clean incontinence brief under the resident's hips. CNA P fastened the incontinence brief, placed a pillow under the resident's head, covered the resident with a sheet and lowered the resident's bed. During an interview on 04/14/26 at 8:12 P.M., CNA P said the following:-He/She usually used alcohol-based hand rub (ABHR) prior to applying gloves and washed his/her hands after he/she removed his/her gloves;-He/She should change his/her gloves and perform hand hygiene after performing pericare and prior to touching clean items. 4. Review of Resident #8's quarterly MDS, dated [DATE], showed the following:-Dependent on staff for toileting hygiene and personal hygiene;-Always incontinent of bladder. Review of the resident's care plan, last revised 03/25/26, showed the following:-He/She received antibiotic therapy for urinary tract infection (UTI);-He/She required staff assistance for ADL care: dressing, toileting and maintaining personal hygiene;-He/She was incontinent of bowel and bladder. Observation on 04/14/26 at 8:03 P.M. showed the following:-Nurse Aide (NA) N and Certified Nurse Assistant (CAN) R put on gloves and entered the resident's room (no observation of hand hygiene prior to donning gloves); -NA removed the resident's shirt and cleaned under the resident's breasts;-NA N removed the resident's urine-saturated incontinence brief and provided frontal perineal care for the resident;-NA N did not remove his/her gloves and assisted CNA R to turn the resident to his/her left side;-NA N cleaned the resident's bottom; -NA N tied the soiled linen bag and removed his/her gloves;-NA N carried the soiled linen and trash bags to the soiled utility room down the hall and then used the hand sanitizer in the hallway to perform hand hygiene. During an interview on 04/14/26 at 8:25 P.M., NA N said he/she should perform hand hygiene before and after providing care and between dirty and clean tasks when providing care. 5. Review of Resident #34's physician's orders, dated March 2026, showed the following;-Diagnosis of an open wound to his/her left lower leg;-Wound treatment: cleanse area with cleanser of choice, apply skin prep (protective barrier wipes) to peri wound (skin immediately surrounding a wound), apply collagen powder (a bioactive topical wound dressing that promotes healing) to wound bed, cover wound bed with maxorb AG (a highly absorbent, antimicrobial/alginate dressing), cover with self-adhesive foam dressing once daily. Review of the resident's care plan, last revised 03/10/26, showed the following:-The resident had an ulcer on his/her left ankle;-The resident had a wound which required EBP signage to be placed on the door to inform staff that EBP was required;-Staff to utilize EBP while providing care to the resident. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool to be completed by the facility, dated 03/20/26, showed the resident had a stage III pressure ulcer (Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) present on admission. Observation on 04/13/26 at 4:15 P.M. of the residents' door showed the following:-EBP signage was posted on the resident's door that directed staff to apply a gown and gloves with high-contact resident care activities;-No disposable gowns and gloves were on the door or outside the resident's room. Observation on 04/14/26 at 1:45 P.M., showed the following:-Registered Nurse (RN) A wore gloves, did not wear a gown, and provided incontinence care for the resident and changed the resident's urine-soiled bed sheet;-The resident had a dry dressing on his/her left ankle. During an interview on 04/20/26 at 3:30 P.M., RN A said the following:-He/She did not wear a gown when he/she provided incontinence care and changed the resident's sheet;-He/She only wears a gown and gloves when performing wound care to the resident. Observation on 04/14/26 at 6:27 P.M., showed the following:-The Assistant Director of Nursing (ADON) entered the resident's room and put on gloves;-The ADON did not wear a gown;-He/She assisted the resident to dress in a gown, removed his/her gloves, left the room, returned to the room with two clear bags, put on gloves, picked up the resident's shirt from under the bed and put it in a clear bag; -He/She removed his/her gloves and put them in the trash, removed the bag from the trash can, tied the bag, put a new bag in the trash can and left the room. During an interview on 04/22/26 at 6:30 A.M., the ADON said the following:-Staff should wear a gown and gloves when providing direct patient care/contact for any resident with a wound;-She was not sure if she should wear a gown when putting a gown on the resident; she did not consider that enough direct contact. 6. Review of Resident #7's significant change MDS, dated [DATE], showed the following:-Cognitively intact;-Dependent on staff for toileting hygiene;-Required partial to moderate assistance for roll left and right;-One unhealed pressure ulcer (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). Review of the resident's care plan, revised 04/13/26, showed the following:-The resident has an open area to his/her right lower extremity;-Use EBP precautions;-Currently, on antibiotics for treatment of cellulitis (deep inflammation of the tissues just under the skin, caused by infection) of the right lower extremity. Observation on 04/15/26 at 11:05 A.M., showed the following:-An EBP sign directing staff to apply gown and gloves with high-contact care activities hung on the resident's room door;-The resident lay awake in bed and was incontinent of urine;-The resident had a wound dressing on his/her right lower leg; -NA I and CNA BB entered the resident's room, put on gloves, and did not put on a gown; -NA I performed peri-care for the resident;-NA I and CNA BB dressed the resident and transferred the resident from the bed to the wheelchair with the mechanical lift. During an interview on 04/15/26 at 11:30 A.M., NA I and CNA BB said the following:-The EBP sign on the resident's door was for another resident;-The resident didn't have any open wounds. During an interview on 04/15/26 at 11:30 A.M., the resident Licensed Practical Nurse (LPN) G was the only staff who wore a gown when providing his/her care. 7. During an interview on 04/16/26 at 3:49 P.M., the Director of Nursing (DON) said the following:-Staff should perform hand hygiene after providing perineal cares and before touching a clean surface;-Staff should perform hand hygiene between glove changes.-Staff should wear a gown when providing personal care or any high contact resident care for a resident requiring EBP and who had a wound.

Based on interview and record review, the facility failed to treat one resident (Resident #8), in a review of 18 sampled residents, with dignity and respect when staff told the resident to urinate and defecate in his/her incontinence brief. The facility census was 85.Review of the facility's undated policy, Resident Rights, showed the following:-It is the purpose of this facility to meet the Federal and State Mandate in respect to resident rights;- The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility;-A facility must protect and promote the rights of each resident;-Resident Rights are to be fully respected and adhered to. 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment tool to be completed by facility staff, dated 03/17/26, showed the following:-Moderately impaired cognition;-Dependent on staff for toileting hygiene;-Always incontinent of bowel and bladder. Review of the resident's care plan, last revised 03/25/26, showed the following:-He/She required staff assistance for activities of daily living (ADL) care: for example (e.g.), transfers and toileting;-He/She was incontinent of bowel and bladder. During an interview on 04/13/26 at 12:15 P.M., the resident said the following:-Staff used to take him/her to the bathroom in the hall to have a bowel movement, and now staff want him/her to go on a bed pan or in his/her incontinence brief;-When staff ask him/her to go in his/her incontinence brief, they leave him/her wet/dirty for long periods of time and do not come to check or change him/her frequently;-He/She preferred to go to the bathroom on the to the toilet rather than going in his/her incontinence brief;-He/She had a hard time having a bowel movement lying down; it was much easier when he/she sat on the toilet;-When staff tell him/her to go to the bathroom in his/her incontinence brief, it made him/her feel like nobody cared. During an interview on 04/15/26 at 1:07 P.M., Certified Nurse Assistant (CNA) X said the following:-The resident required a hoyer lift (mechanical lift) for transfers, so it was difficult to get him/her up to the toilet; -It helped the resident have a bowel movement if he/she sat on the toilet, because he/she had constipation; -Staff sometimes used the hoyer lift to put the resident in the shower chair/commode because it was easier for the resident to use the bathroom when he/she sat upright; -The resident asks staff to get him/her up to use the toilet, and we remind him/her to go in his/her incontinence brief, because he/she cannot walk and he/she will usually get distracted and start talking about his/her family member. During an interview on 04/15/26 at 1:10 P.M., Licensed Practical Nurse (LPN) M said the following:-The resident preferred to sit to have a bowel movement;-When Hospice was at the facility, Hospice staff put the resident in a shower chair, and the resident used the commode to go to the bathroom;-He/She tells the resident, You can go to the bathroom in your brief. You have a brief on.-No one had ever instructed him/her not to get the resident up to go to the bathroom. During an interview on 04/15/26 at 10:25 A.M., the Hospice nurse said when Hospice staff got the resident up in the shower chair, the resident used the bathroom on the commode. During interviews on 04/16/26 at 12:20 P.M. and 3:49 P.M., the Director of Nursing (DON) said the following:-She expected staff to treat the residents with dignity and respect;-She should not tell Resident #8 to have a bowel movement in his/her incontinence brief or on a bed pan if the resident preferred to use the toilet and was capable of doing so.

Based on interview and record review, the facility failed to follow facility policy for notifying the physician and resident representative when one resident (Resident #88) had a change in condition. The facility census was 85.Review of the undated facility policy, Condition Change, Resident, showed the following: -Purpose: To observe, record and report any condition change to the attending physician so that proper treatment can be implemented;-Guidelines:1. After all resident changes in physical or mental function, monitor the following: -Observe and inquire if resident has pain. -Observe for personality changes. -Observe for alterations in consciousness. -Observe for generalized weakness. -Observe for gait, posture or balance disorder. -Take vital signs and include temp. -Observe for abdominal pain. -Observe for dyspnea (shortness of breath) or variations in respiration (irregular).2. Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director for emergency situations.3. Notify resident's responsible party.4. Monitor resident's condition frequently until stable.5. Notify physician of condition change, need for treatment orders and/or medication order changes. 1. Review of Resident #88's undated face sheet showed the following:-His/Her family member was his/her representative;-Diagnoses included hypotension (abnormally low blood pressure (BP). Review of the resident's care plan, last revised 01/18/26, showed the following:-He/She was able to perform activities of daily living (ADL) care most of the time without assistance;-Monitor for presence of pain/intolerance during self-care;-Report any further deterioration in status to physician. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool to be completed by facility staff, dated 02/03/26, showed the following:-Moderately impaired cognition;-Did not use oxygen and did not have shortness of breath;-Occasional pain in past five days;-Independent with walking and transfers. Review of the resident's physician order sheet (POS), dated February 2026, showed the following:-Blood pressure weekly per physician; once a day on Monday;-Midodrine tablet, 10 milligram (mg) for hypotension. Hold for systolic (the top number reading) blood pressure (BP) greater than 140 (normal range is 90 - 120); three times a day: 6:00 A.M.-10:00 A.M., 11:00 A.M.- 2:00 P.M., 7:00 P.M.-10:00 P.M. Review of the resident's medication administration record (MAR), dated February 2026, showed the following:-On 02/23/26 (6:00 A.M. - 10:00 A.M.), CMT Y documented the resident's BP as 96/50 (LOW); -On 02/24/26 (6:00 A.M. - 10:00 A.M.), CMT Y documented the resident's BP as 96/49 (LOW).-On 02/24/26 (11:00 A.M. - 2:00 P.M.), CMT Y documented the resident's BP as 86/43 (LOW); -On 02/24/26 (7:00 P.M. - 10:00 P.M.), CMT Z documented the resident's BP as 88/66 (LOW); (Staff administered the resident's midodrine as ordered on 2/23/25 and 2/24/25.) Review of the resident's progress note, dated 02/25/26 at 1:05 A.M., showed on 02/24/26 at 7:30 P.M., Licensed Practical Nurse (LPN) T stepped inside the resident's room and asked the resident what he/she needed. The resident's friend said, I'm concerned about his/her condition. I have been here since 11:00 A.M. and have watched his/her decline since I've been here. He/She is complaining of shortness of breath, increase in pain, not being able to swallow, and I know he/she had a temperature, but I had nothing to check it. LPN T explained the day shift nurse called the physician and left a message, and the physician had not returned their call. LPN T checked the resident's vital signs and BP was 128/94, pulse 102 (normal range is 60-100), respirations 24 (normal range is 12-19) and oxygen saturation (02 sat) was 84 percent (%) on room air (normal range is 95-100%). Staff took an oxygen concentrator to the resident's room and started the resident on 2 liters (L) of oxygen. Review of the resident's electronic medical record showed no documentation the day shift nurse attempted to contact the resident's physician as LPN T indicated in his/her note on 02/25/26 at 1:05 A.M. Review showed no documentation LPN T contacted the resident's representative or physician regarding the resident's change in condition on 02/24/26 at 7:30 P.M. Review of the resident's progress note, dated 02/25/26 at 1:38 A.M., showed LPN T documented on 02/24/26 at 8:15 P.M., LPN T checked the resident's oxygen level which was 90% until the resident started talking, and it dropped to 87%. LPN T explained to the resident he/she still needed the oxygen. LPN T documented he/she would check on the resident later. Review of the resident's progress note, dated 02/25/26 at 4:29 A.M. showed LPN T documented on 02/25/26 at 12:00 A.M., the resident's family representative called stating the resident needed to go to the bathroom but could not get up. Staff went to help the resident. The resident had been up walking, able to get himself/herself out of bed and go to the bathroom on his/her own. The resident was now unable to stand by himself/herself. It took two to three staff to walk with him/her, telling him/her to pick up his/her feet and he/she was totally bent at the waist with his/her head pointed towards the floor. Staff had to get a wheelchair to take the resident to the bathroom and put him/her on the toilet. The resident was leaning over to the left with his/her hand almost on the floor to hold himself/herself up. The resident's color remained pale, 02 sat 81% and he/she was asking for his/her parent. Medical group notified (the note was not clear to show who staff notified). Review of the resident's medical record showed no documentation staff notified the resident's representative of the resident's change in condition. Review of the resident's MAR, dated February 2026, dated 02/25/26 (6:00 A.M. - 10:00 A.M.), showed CMT U documented the resident's BP as 53/32 (LOW). Review of the resident's medical record showed no documentation staff notified the charge nurse or the resident's physician when the resident's blood pressure was low. During an interview on 04/16/26 at 1:20 P.M., CMT U said the following:-He/She was sure he/she reported the resident's low blood pressure reading of 53/32 to the charge nurse (LPN G);-If he/she gets a reading that is low, he/she took the blood pressure a few times to verify accuracy and would have reported it to the nurse. Review of the resident's progress note, dated 02/25/26 at 2:24 P.M., showed LPN G documented staff assessed the resident multiple times throughout the shift. The resident maintained alertness within normal limits (WNL) of baseline. At approximately 12:00 P.M., he/she was made aware CMT U was unable to get the resident's blood pressure. LPN G assessed the resident and was able to get a faint blood pressure of 108/58. When going to document the blood pressure, he/she saw CMT U charted a lower blood pressure earlier in the shift and had not made his/her aware of the blood pressure. CMT U at approximately 1:00 P.M. administered midodrine. The resident's oxygen saturation was at 88% on 2L at that time. Increased the resident's oxygen to 4L and resident's oxygen saturation increased to 94%. Temperature was 97.9 degrees Fahrenheit (normal range is 97.9-99.1 degrees Fahrenheit), pulse was 72, and respirations were 18. The resident remained cognitively at baseline, reported feeling weak and tired. Lung sounds clear (normal is clear) to auscultation (a diagnostic method to listen to internal body sounds - primarily heart, lungs, and intestines - using a stethoscope), no cough, and no outward shortness of breath (SOB). The resident had +1-2 bilateral lower extremity (BLE) edema (excessive accumulation of fluid in the tissue that causes swelling) noted. Call placed to the nurse practitioner (NP) and new order received for labs and STAT (immediate) chest x-ray (CXR). The NP came to the facility at approximately 1:20 P.M. to assess the resident. NP was unable to accurately hear the resident's blood pressure at that time. New order to send the resident to the hospital. Phone call placed to the resident's family representative to make aware. Emergency medical technician (EMT) arrived and transferred the resident to the hospital. During an interview on 04/16/26 at 1:15 P.M., LPN G said the following:-He/She was the charge nurse on 02/25/26;-CMT U did not notify him/her of the resident's low blood pressure reading from that morning;-He/She expected CMT U to have told him/her about the low blood pressure reading because he/she would have notified the physician/nurse practitioner sooner. During an interview on 04/16/26 at 1:30 P.M., the resident's family representative said the following:-Staff did not notify him/her of the resident's decline;-The resident called him/her at 12:00 A.M. (on 02/25/26) stating he/she was unable to get up; -He/She had a close friend who was at the facility visiting the resident, and he/she was the one who told him/her everything that was going on; the facility did not notify him/her of anything. During an interview on 04/16/26 at 3:49 P.M., the Director of Nursing (DON) said the following:-Staff should notify the physician immediately as soon as they are made aware of a change in condition; -She expected staff to notify the resident's representative if the resident had a change in condition. During an interview on 04/16/26 at 1:23 P.M., the resident's Nurse Practitioner (NP) said the following:-Staff notified her by phone (on 2/25/26) regarding the resident's low blood pressure and the inability to obtain a blood pressure reading. She ordered labs and a STAT chest x-ray, then immediately went to the facility to assess the resident and was unable to obtain a blood pressure reading. She sent the resident to the hospital immediately for evaluation;-She would have expected staff to notified him/her sooner with the previous low blood pressure reading (obtained on 02/25/26 during the 6:00 A.M. to 10:00 medication pass).

Based on observation, interview, and record review, the facility failed to implement a hydration program, including offering fluids to one resident (Resident #37), who required extensive assistance with drinking, in a review of 18 sampled residents, to ensure adequate hydration and failed to develop a plan of care to address the resident's need for assistance to drink. Resident #37 had dry lips and frequently requested water/fluids to drink. The facility census was 85.Review of the facility's undated policy, Hydration, showed the following:-Each resident is supplied with sufficient fluid intake to maintain proper hydration;-Fresh water is distributed each shift, pitchers and glasses are within reach of the resident and residents who are unable to pour and drink independently will be given assistance by the staff.;-Guidelines--Assess the resident's need to be on hydration program. The following conditions should be considered: -Recurrent urinary tract infections or other infections -Dehydration -Total dependence -Other conditions at discretion of the nurse;-Consider offering fluids according to the examples below: -On arising - 120 cc water -Breakfast - 400 cc fluid -Mid-morning - 240 cc fluid -Lunch - 400 cc fluid -Mid Afternoon - 120 cc fluid -After nap - 240 cc fluid -Supper - 400 cc fluid -Bedtime- 240 cc fluid -During night offer 120cc every two hours, if awake 1. Review of Resident #37's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 03/13/26, showed the following:-Cognitively intact;-Moderately impaired vision;-Independent with eating. Review of the resident's care plan, revised 04/07/26, showed the following:-The resident had an order for a regular diet with thin liquids;-The resident liked to eat most meals in his/her rooms;-Obtain dietary consult and follow recommendations;(The resident's care plan did not include the type of assistance the resident required for fluid intake.) Observation on 04/13/26 at 1:35 P.M., showed the following:-An unknown staff member sat the resident's lunch tray on his/her bedside table; -The resident's lips and oral mucosa appeared dry;-The resident said, my mouth is dry; -The resident's water pitcher was out of his/her reach; -The unknown staff member left the resident's room and did not offer the resident any fluids. Observation on 04/13/26 at 3:55 P.M., showed the following:-The resident lay in bed;-The resident's lips appeared dry;-The resident's water pitcher sat on his/her bedside table, not within the resident's reach. Review of the resident's Comprehensive Nutrition Assessment, completed by the Registered Dietitian, dated 04/14/26, showed the following:-The resident's ability to eat/drink: extensive assistance;-Total fluids required: 1540 milliters (mL) fluid;-Staff to anticipate needs. Observation on 04/14/26 at 8:35 A.M., showed the following:-The resident lay awake in bed;-The resident's lips were dry with dried purple-brown debris on them;-The resident's water pitcher sat on his/her bedside table, not within the resident's reach. Observation on 04/14/26 at 12:58 P.M., showed the following:-The resident lay awake in bed;-His/Her mouth appeared dry;-A water pitcher sat on the resident's bedside table, not within the resident's reach. Observation on 04/14/26 at 6:11 P.M., showed the following:-The resident lay awake in bed;-The resident's lips and oral mucosa were dry;-A water pitcher sat on the resident's bedside table, not within the resident's reach. Observation on 04/15/26 at 10:41 A.M., showed the following:-The resident's roommate's call light was on;-The resident lay awake in bed;-The resident yelled, Can I have some water?, I want some water;-The resident's lips and oral mucosa appeared dry;-A water pitcher sat on the resident's bedside table, not within the resident's reach;-The resident said, I want some water. My mouth is dry. Observation on 04/15/26 at 11:05 A.M., showed the following:-The resident lay in bed awake;-The resident's lips and oral mucosa appeared dry;-NA I and Certified Nurse Assistant (CNA) BB provided care for the resident's roommate (Resident #7);-Neither NA I nor CNA BB offered the resident fluid;-A water pitcher sat on the resident's bedside table, not within the resident's reach. During an interview on 04/14/26 at 8:57 A.M., the resident's family member said the following:-The resident liked to drink a great deal of water;-The resident couldn't take drinks without assistance;-He/She expected staff to offer the resident fluids frequently. 2. During an interview on 04/15/26 at 8:20 A.M., NA I said the following:-The resident was unable to use his/her call light and staff must anticipate his/her needs;-The resident hollered out or moaned when he/she wanted a drink. During an interview on 04/14/26 at 12:58 P.M., CNA CC said the following:-The resident required staff to give him/her fluids;-Staff should offer water every time they were in the resident's room. During an interview on 04/16/26 at 11:25 A.M., Licensed Practical Nurse (LPN) G said the following:-The resident was at risk for dehydration and needed staff assistance with fluid intake;-Staff should anticipate the resident's needs as the resident was unable to use his/her call light to ask for staff assistance;-Staff should offer the resident fluids frequently. During an interview on 04/16/26 at 3:49 P.M., the Director of Nursing (DON) said the following:-She expected staff to offer water to residents frequently; -She should offer fluids every time they entered a room or more frequently if a resident, like Resident #37, was yelling out that he/she needed water.

Based on interview and record review, the facility failed to implement a system to identify and communicate trauma-informed services for one resident (Resident #6), who had a diagnosis of post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing terrifying, life-threatening events), in a review of 18 sampled residents, to mitigate or eliminate triggers that may cause re-traumatization. The facility census was 85. The facility did not provide a policy related to trauma-informed care. 1. Review of Resident #6's Preadmission Screening and Resident Review (PASRR, a federally mandated process requiring all applicants to Medicaid-certified nursing facilities be screened for serious mental illness and/or intellectual disability/developmental disability before admission)/Mental Illness (MI) Level II Evaluation, dated 04/29/24, showed the following:-admitted to the facility on [DATE];-Diagnoses of major depressive disorder, anxiety, and PTSD;-The resident reported he/she was molested as a child;-The resident reported he/she had bad anxiety and depression that started 10 years ago;-The resident reported feelings of hopelessness, sadness, and anxiety that began at the time;-The resident had suicidal thoughts in the past two years with thoughts of wanting to drive off a cliff after his/her family member passed away;-The resident reported loss of energy/motivation, avoids uncertainty/making decisions, and has diminished pleasure from daily activity;-The resident needs or continues to need the following supports and services: monitoring of behavioral symptoms, trauma-informed services and tools of choice or other positive behavioral support services. Review of the resident's Mental Status Exam (completed by the psychiatrist), dated 04/25/25, showed the following:-The resident reports he/she was feeling depressed and anxious and did not want to be in the facility but stated he/she was homeless, had medical issues including hip pain, and he/she was not sleeping very good;-The resident stated sometimes he/she feels suicidal but has no plan and stated he/she feels worthless. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/13/26, showed the following:-Cognitively intact;-Diagnoses of anxiety, depression and PTSD. Review of the resident's care plan, revised 03/31/26, showed the following:-The resident was at risk for adverse consequences related to receiving antipsychotic medication for treatment of PTSD;-Monitor behavior and response to medication;-Assess/record effectiveness of medication treatment;-Attempt non-pharmacological measures as outlined: reduce noise/stimulation, use validation therapy, encourage light exercise;-Pharmacy consultant review per facility policy and procedure and as needed if deemed appropriate;(Review of the resident's care plan showed no documentation regarding the resident's PTSD triggers or interventions to prevent the resident from experiencing further re-traumatization related to his/her diagnosis of PTSD.) During an interview on 04/15/26 at 3:37 P.M., the resident said the following:-He/She was abused and molested by his/her family member as a child;-He/She was very depressed and lonely;-He/She ate in his/her room and stayed in his/her room except when going outside to smoke; -None of the medications helped his/her depression or anxiety; During an interview on 04/16/26 at 11:25 A.M., Licensed Practical Nurse (LPN) G said the following:-He/She was unsure if the resident had a history of PTSD;-He/She was not aware of an assessment nurses were to complete for residents with PTSD or past trauma;-If a resident had a history of PTSD or past trauma, it should be included in the resident's care plan. During an interview on 04/16/26 at 2:01 P.M., the MDS/Care Plan Coordinator said the following:-She was new to completing MDS and care plans;-PTSD history and PASSR information should be included in the resident's care plan. During an interview on 04/16/26 at 8:40 A.M., the Social Service Designee said the following:-The resident had a history of PTSD on admission to the facility, so he/she arranged for the resident see a psychiatrist;-She did not complete an assessment for residents with a history of PTSD or past trauma; she just set up for the psychiatrist to see the residents; -She didn't realize the resident was abused in the past. During an interview on 04/16/26 at 3:49 P.M., the Director of Nursing said the following:-The admission nurse was responsible for assessing the resident for trauma on admission, and the MDS Coordinator and Social Services should follow up;-PASSR information and a diagnosis of PTSD should be addressed on the resident's care plan;

Based on observation, interview, and record review, the facility failed to provide appropriate care and services to maintain the highest practical well-being for one resident (Resident #1) with a diagnosis of vascular dementia (a person has problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), in a review of five sampled residents. The facility failed to identify situations that triggered the resident causing aggression and combativeness. The facility failed to identify non-pharmacological interventions to help the resident when he/she was combative or refused care. While staff provided incontinence care on 9/18/25, the resident became upset and combative. Staff continued to provide care and transferred the resident with a sit to stand lift while the resident continued to hit staff. The facility also failed to ensure staff received and understood dementia care training. The facility census was 80.The facility did not provide a dementia care policy upon request. 1. Review of Resident #1's undated face sheet showed the following:-The resident admitted to the facility on [DATE];-The resident had diagnoses that included vascular dementia. Review of the resident's care plan, dated 4/30/25, showed the following: -The resident had cognitive loss/dementia;-The resident may have difficulty understanding others at times related to presence of vascular dementia;-Face the resident when speaking, obtain the resident's attention before speaking, provide a quiet non-hurried environment free of background noises and distraction if he/she appears distracted, speak clearly and adjust tone as needed;-The resident had behavioral symptoms;-The resident was at risk for elopement due to confusion, independent locomotion in a wheelchair and medications that suppress the thought process;-Administer medication per physician's order;-Assess the resident quarterly and as needed. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 7/2/25, showed the following:-The resident's cognition was severely impaired;-The resident had no physical, verbal or other behaviors toward himself/herself or others;-The resident had no inattention, disorganized thinking or altered level of consciousness;-The resident did not reject cares;-The resident's behavior was the same as prior assessment;-The resident required substantial to maximum assist from staff for rolling left to right in bed;-The resident was dependent on staff for transfers to and from his/her wheelchair, sitting to standing positions, transfers to and from his/her chair and bed, showering, personal hygiene, and dressing. Review of the resident's progress note dated 7/19/25 at 10:30 A.M, showed the resident could become agitated at times and was alert and oriented to person and place. Review of the resident's progress note, dated 7/20/25 at 9:45 A.M., showed the resident could become agitated at times and was alert and oriented to person and place. Review of the resident's progress note, dated 7/25/25 at 8:24 A.M., showed the resident was combative with cares at times and was alert and oriented to person only. Review of the resident's psychiatric progress note, dated 8/22/25, showed the following:-The resident was seen for a follow up assessment and medication management of chronic psychiatric disorders;-Per the staff, the resident was doing well with no worsening symptoms of psychiatric disorders, no disruptive behaviors, and no new psychiatric or behavioral issues;-The resident had no reported suicidal or homicidal ideations, audio or visual hallucinations or psychosis;-Per the staff, the resident remained stable and at baseline;-The resident's vascular dementia and major depressive disorder were chronic and managed;-The resident had no reported impaired concentration;-The resident's intelligence appeared to be within normal range;-The resident's cognition showed the resident appeared to comprehend, shared information, and responded appropriately to questions;-The resident had limited to poor judgement and fair to good insight;-The resident's short and/or long-term memory was impaired;-The resident's thought process was illogical, loose, his/her mood was appropriate and his/her affect was appropriate. There was no change;-The resident's cognition was at baseline with no change;-The staff and/or resident were instructed to report significant mood or emotional changes or any new psychiatric concerns. Review of the resident's physician order sheet, dated 8/23/25 to 9/23/25, showed the following:-Donepezil (used to treat dementia associated with Alzheimer's disease, a progressive disease that destroys memory and other important mental functions) 10 milligrams (mg) by mouth one time a day at bedtime, start date was 12/2/23;-Zoloft (antidepressant medication)100 mg by mouth one time a day at bedtime, start date was 1/11/25;-Depakote delayed release (used as a mood stabilizer) 250 mg by mouth two times a day, start date was 1/25/25;-Eliquis (blood thinner) 5mg by mouth two times a day, start date was 12/2/23. Review of the resident's progress note, dated 9/18/25 at 3:13 P.M. and 4:11 P.M., showed the following:-The resident's spouse/power of attorney (POA) approached the Social Services Director (SSD) with concerns regarding bruising on the resident's upper forehead (this should be noted as left forearm);-The spouse told the SSD he/she asked the resident if someone had done that to him/her and the resident pointed to Certified Nursing Assistant (CNA) B in the dining room;-The incident was reported to the physician. During an interview on 9/23/25 at 2:50 P.M. the resident's spouse/power of attorney (POA) said the following: -The POA arrived at the facility on 9/18/25 at about 12:30 P.M. and sat with the resident in the dining room;-The POA saw marks on the resident's left forearm that looked like fresh open round sores;-The POA asked the resident what happened. The resident responded he did it while he/she pointed at CNA B;-The POA spoke with the SSD; -CNA B was immediately sent home;-The resident always kept a picture of his/her spouse in his/her shirt. The picture was in a metal frame with a glass front;-Staff said the resident hit his/her left arm with the picture frame. Observation on 9/23/25 at 4:10 P.M. showed the following:-The resident sat in his/her wheelchair watching television in the common area;-Licensed Practical Nurse (LPN) L lifted the bandage on the resident's left anterior forearm;-The resident had four small skin tears (not quite the size of a dime); -As LPN L put the bandage back in place, the resident became agitated and yelled he/she wanted to go to bed. During an interview on 9/24/25 at 9:36 A.M. and 3:28 P.M. CNA D said the following:-He/She was in the resident's room with CNA B to provide peri care and transfer the resident to his/her wheelchair;-During peri care the resident was in bed and the CNAs rolled the resident toward CNA D and the resident did fine. When they rolled the resident towards CNA B, the resident became aggressive and swung his/her arms around. The resident had a picture frame in his/her hand and tried to hit CNA B;-CNA B left the room to get the nurses and the sit to stand lift to transfer the resident to his/her wheelchair;-CNA D and CNA B got the resident into the sit to stand lift and the resident was still combative and swung his/her arms at CNA B;-The resident was never aggressive when CNA D took care of the resident alone. The resident was only aggressive when CNA B was in the room with him/her;-CNA D did not receive dementia care training upon hire at the facility and had not received direction on what to do when Resident #1 was aggressive and combative. During an interview on 9/24/25 at 9:20 A.M. CNA B (who is the same gender as the resident) said the following:-On 9/18/25, CNA D was in the resident's room and asked for help;-CNA B went in the resident's room; put the resident's socks on and noticed the resident had soiled his/her incontinence brief;-He/She and CNA D assisted the resident on the bed and began to change the soiled brief;-During care, the resident yelled and swung his/her fist and open hand at the staff and had a picture frame in his/her right hand;-The resident hit himself/herself with the picture frame on his/her left arm;-CNA B left the room to get the nurses and the sit to stand lift to transfer the resident to his/her wheelchair;-CNA B told the nurses the resident cut his/her arm;-He/She and CAN D transferred the resident to his/her wheelchair with the sit to stand lift. The resident yelled and swung his/her arms during the entire transfer. During an interview on 9/24/25 at 8:20 A.M. LPN F said the following:-On 9/18/25, CNA B came and got LPN F and LPN A at the nurse's station to assist with the resident because he/she was combative during peri care; -CNA B got the sit to stand lift and returned to the resident's room to begin a transfer. CNA B and CNA D assisted the resident into the sling of the sit to stand lift to transfer the resident to his/her wheelchair. During the time the CNAs assisted the resident he/she was combative and aggressively swung his/her arms at the CNAs;-The CNAs completed the transfer even though the resident was combative and aggressive;-LPN F stood at the doorway of the resident's room during the transfer;-On 9/18/25, LPN F did not think the CNAs needed to stop their task because the problem was gone when CNA B left the room after the transfer was completed;-When CNA B left the room, the resident calmed down and was fine;-He/She did not receive dementia care training upon hire at the facility in May 2025. During an interview on 9/24/25 at 8:34 A.M. and 3:34 P.M., LPN A said the following:-CNA B came to the nurse's station and asked if LPN F and LPN A could assist with a transfer for Resident #1;-CNA B and CNA D placed the sling for the sit to stand lift on the resident and attempted to attach it to the lift. The resident swung his/her arms and fist at CNA B during this time;-The CNAs continued with the transfer until it was completed, and the resident was in his/her wheelchair;-The only direction he/she had been given regarding the resident's behavior was to chart when the resident had behaviors;-9/18/25, the day of the resident's behaviors that caused a skin tear, was his/her first day working alone on the floor. LPN A did not know if the resident's behaviors were baseline or not, so he/she did not react to what was going on;-Now he/she knew those behaviors are not a baseline behavior for the resident;-If she had known about the resident's behaviors, he/she would have told the CNAs to stop and walk away and try again a little later;-He/She did not get dementia care training upon hire at the facility; Review of the resident's progress note, dated 9/23/25 at 4:21 P.M., showed the following:-CNA I notified the nurse on duty that during routine care the resident gashed the top of his/her hand;-CNA I said the resident grabbed his/her hand when CNA I rolled the resident in the bed. Review of the resident's progress note, dated 9/23/25 at 4:39 P.M., showed the following:-A new order was obtained to clean top of the left hand with wound cleanser, apply triple antibiotic ointment and cover with a band aid;-Discontinue when healed;-This was a new wound and there was no other documentation to show how the resident obtained the injury. Review of the resident's care plan showed no update regarding the resident's behaviors or response to care staff of the same gender. Review showed no direction for staff regarding individualized interventions related to dementia care. During an interview on 9/25/25 at 10:05 A.M. Nurse Assistant (NA) J said the following:-He/She did not receive any dementia training when hired on 8/8/25 or since hire;-Resident #1 had behaviors when he/she provided peri care and showers;-The resident yelled and cussed at him/her and tried to hit him/her;-NA J learned from experience working with the resident that if he/she talked to the resident calmly the resident would calm down and let NA J provide care;-NA J did not have access to the resident's care plan;-NA J had to ask during report how to care for the residents. During an interview on 9/23/25 at 1:26 P.M. and 3:46 P.M. CNA K said the following:-The resident was often combative; -If two aides of the opposite gender provided care it was best, and the resident did not act out as much; -CNA K did not think the resident liked staff of the same gender to care for him/her;-CNA K frequently got report from CNA I, who was the same gender as the resident, who said Resident #1 was combative, aggressive, or cursed when CNA I provided care;-The resident was changed from a two person assist with a gait belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair and assist with sitting and standing) for transfers to a sit to stand lift;-Once the resident was in the standing position in the sit to stand lift, he/she would let go of the handles and flail his/her arms almost every time;-CNA K did not have any kind of dementia training. During an interview on 10/1/25 at 11:29 A.M. CNA I (who is the same gender as the resident) said the following:-Resident #1 had been very combative and yelled out. The resident had hit CNA I many times before, bit and scratched him/her;-Staff could not redirect the resident when he/she was angry. The resident continued to be upset for about 45 minutes once he/she was upset and then calmed down. During an interview on 9/24/25 at 4:22 the MDS/Care Plan Coordinator said the following:-It was her responsibility to update resident care plans;-She should have updated the resident care plan after the incident with the resident on 9/18/25;-Not all CNAs knew how to access a resident's care plan on the computer. During an interview on 9/24/25 at 4:15 P.M. the Director of Nursing (DON) said the following:-She expected staff to notify her if a resident had behaviors. CNAs should notify nurses, and the nurses should notify the DON;-All staff know non-pharmacological interventions to use if a resident had behaviors; leave the resident and go back later and try again, redirect the resident, and figure out what triggered the resident;-The care plan should have been updated by the MDS/Care Plan Coordinator;-Staff received dementia care training upon hire. During an interview on 9/24/25 at 4:30 P.M. the Administrator said the following:-Staff received dementia care training upon hire;-She expected staff to step away from Resident #1 if he/she had behaviors or resisted cares and then go back later and try again;-She did not know the resident did not like or had a problem with CNA B until the incident on 9/18/25. None of the staff let her know;-She also did not know the resident did not like or had a problem with CNA I and had behaviors when CNA I provided care to the resident. During an interview on 9/30/25 at 9:57 A.M. the resident's Psychiatric Nurse Practitioner said the following:-He/She was not aware the resident had behaviors. This was the first time she heard Resident #1 exhibited behaviors of any kind;-He/She was at the facility on 9/25/25 and spent time with the resident with the SSD in the room. The SSD said the resident was doing fine and had no problems;-He/She expected staff to let him/her know if the resident exhibited behaviors. Just because a problem appeared to be resolved, it did not mean the behavior was over or wouldn't occur again; -The Psychiatric Nurse Practitioner expected staff to have dementia care training; -A staff member's approach with dementia residents was very important;-If staff haven't been trained properly or don't have access to care plans to know how to care for residents, it could be hard for both the staff and the resident. 26241422621418

Based on observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services to maintain comfortable positioning in bed for one resident (Resident #4), nail care for one resident (Resident #10) and bathing for three residents (Resident#1, #5, and #14) who required assistance to perform their activities of daily living, in a review of 14 sampled residents. The facility census was 71. Review of the facility's Bath (Bed) policy, undated showed care of fingernails is part of the bath, be certain nails are clean, and licensed nurses cut fingernails of diabetic residents. 1. Review of Resident #4's undated face sheet, showed the following: -The resident admitted on [DATE]; -Diagnoses included flaccid hemiplegia affecting left dominant side (the left side of the body is completely limp and unable to move effectively) caused by a stroke. Review of the resident's baseline care plan, dated 1/8/25, showed the following: -The resident was cognitively intact; -He/She had disease management concerns of diabetes (chronic condition that occurs when the pancreas can no longer make insulin, or the body cannot effectively use insulin), hypertension (high blood pressure), weakness, post cerebrovascular accident (CVA; stroke) and psychiatric illness; -He/She required assistance of two staff members for bed mobility and transfer; -Assist with activities of daily living care (ADL) as needed to promote health, hygiene, and safety; -Always incontinent of bladder and bowel; -The resident was unable to manage own toileting functions and required all cares to be provided by staff; -The resident will receive cares necessary to maintain hygiene, promote dignity, and avoid skin breakdown; -He/She used incontinence briefs and pads. Review of the resident's nurse's note, dated 12/31/24 at 1:01 A.M., showed the following: -The resident admitted post cerebrovascular accident (CVA, stroke); -Able to make some needs known, the resident speaks rapidly and at times had difficulty expressing needs; -Flaccid from the CVA on the left side; -Dependent on staff for activities of daily living (ADL) required a mechanical lift with transfers, and needed supervision and reminders with eating and completing tasks; -Incontinent of bladder. Observation on 1/16/25 at 11:00 A.M., showed the following: -The resident lay in bed, wearing a facility gown with the head of bed elevated. The resident slid down in bed, his/her legs hung off the foot of the bed, the resident's neck was located in the bed at the angle in the middle of the bed (head of bed raised and foot of bed flat); -A urinal with urine in it sat on the overbed table; -A towel in the bed that the resident rubbed on his/her abdomen. Observation on 1/16/25 at 12:15 P.M., showed the following: -The resident lay in bed on his/her right side on the flat section in the middle of the bed, the head of the bed remained elevated; -His/her legs continued to hang off the foot of the bed; -A Certified Medication Technician (CMT) entered the room and administered medications to the resident's roommate. When finished the CMT emptied the resident's urinal. The towel remained on the resident's bed; -The CMT left the room without repositioning the resident. During an interview on 1/16/25 at 12:15 P.M., the resident said the following: -He/She was not comfortable and felt cramped up; -The staff gave him/her the towel to clean up urine if the urinal spilled; -The resident did not know how long he/she was in this position but wanted to be moved back up in bed and to be dry. Observation on 1/16/25 between 11:00 A.M. and 12:40 P.M., showed the following: -No staff repositioned the resident; -The resident used the towel to wipe over his/her abdomen while he/she complained of feeling wet. During an interview on 1/16/25 at 1:12 P.M., Licensed Practical Nurse (LPN) B said the following: -Staff were supposed to check incontinent residents every two hours; -The resident was incontinent at times. During an interview on 1/16/25 at 3:30 P.M., Certified Nurse Aide (CNA) D said the following: -He/She checked on the residents before lunch for incontinence; -He/She pulled the resident up in bed; -The resident must have slid back down after he/she left. 2. Review of Resident #10's Care Plan, updated 10/7/24, showed staff were to encourage the resident to take time with ADLs and to break tasks into segments to ease respiratory stress. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/1/24, showed the following: -The resident was cognitively intact; -Needed setup assistance from staff for personal hygiene. During an interview on 1/16/25 at 12:45 P.M., Licensed Practical Nurse (LPN) A said the resident required more assistance with ADLs over the past few days. Observation on 1/16/24 at 2:30 P.M., showed the resident had brown debris under the fingernails on his/her left hand. During an interview on 1/16/25 at 2:30 P.M., the resident said the following: -He/She did not know there was brown debris under the fingernails on his/her left hand; -The resident was upset because no one told him/her earlier and the resident did not like his/her fingernails being dirty. 3. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She required supervision from staff with bathing. Review of the resident's care plan, dated 12/19/24, showed the following: -The resident had minimal deficits in ADLs related to minimal weakness, but usually independent in all ADLs; -Determine his/her preferences for shower days to assure the staff were meeting the resident's needs Review of the resident's shower sheets, dated 11/3/24 through 1/15/25, showed the following: -The resident's shower days were Wednesdays and Saturdays; -The staff assisted the resident with a shower on 11/11/24, seven days from the previous shower; -The staff assisted the resident with a shower on 11/20/24, nine days from the previous shower; -The staff assisted the resident with a shower on 12/21/24; -The staff assisted the resident with a shower on 12/28/24, seven days from the previous shower; -The staff assisted the resident with a shower on 1/1/25; -The staff assisted the resident with a shower on 1/8/25, seven days from the previous shower. During an interview on 1/16/25 at 11:30 A.M., the resident said the following; -He/She did not always get a bath twice a week, he/she was lucky to get a bath once a week; -He/She wanted to have two showers a week. 4. Review of Resident #5's care plan, updated 12/10/24, showed the following: -The resident had limited mobility due to hemiplegia and hemiparesis (hemiplegia refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength) following a stroke affecting right side; -The resident preferred showers to bed baths and will receive showers twice weekly. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had modified independent cognitive skills for daily decision making; -He/She required moderate assistance with bathing. Review of the resident's shower sheets, dated 11/3/24 through 1/15/25, showed the following: -The resident's shower days were Tuesdays and Fridays; -Staff showered the resident on 11/25/24; -The staff offered but the resident refused a shower on 12/9/24, 14 days since last shower; -The staff showered the resident on 12/23/24, 14 days since last shower; -The staff offered the resident a shower on 12/26/24, but he/she refused; -The staff offered the resident a shower on 12/30/24, but he/she refused; -The staff offered but the resident refused a shower on 1/13/25, which was 14 days since staff offered the resident a shower. Observation on 1/16/25 at 10:45 A.M., showed the resident lay in bed with eyes closed, his/her hair was disheveled and oily. During an interview with Resident #6 (Resident #5's roommate) on 1/16/25 at 10:45 A.M., the resident said the following: -Resident #5 usually received one shower a week when the facility was short staffed; -When Resident #5 started to smell from across the room, Resident #6 and staff Resident #5 liked convinced him/her to take a bath. 5. Review of Resident #14's Care Plan, updated 8/13/24, showed the following: -The resident displayed signs of moderate dementia sequencing and steps of tasks if asked to deliberately perform, i.e., dressing and showers; -The staff provided cues and supervision for tasks which require numerous steps if the resident appears confused or stressed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She required moderate assistance with showering. Review of the resident's shower sheets, dated 11/3/24 through 1/15/25, showed the following: -The resident's shower days were Wednesdays and Saturdays; -Staff showered the resident on 11/13/24, ten days after previously scheduled shower; -Staff showered the resident on 11/20/24, seven days since the previous shower; -Staff showered the resident on 11/27/24, seven days since previous shower; -Staff showered the resident on 12/4/24, seven days since previous shower; -Staff showered the resident on 12/18/24, 14 days since the previous shower; -Staff showered the resident on 12/29/24, eleven days since previous shower; -Staff showered the resident on 1/1/25; -Staff showered the resident on 1/11/25, ten days since the previous shower. Observation on 1/16/25 at 3:10 P.M., showed the following: -The resident self-propelled the wheelchair down the hallway; -His/Her hair was disheveled and oily. During an interview on 1/16/25 at 3:10 P.M., the resident said he/she did not get a shower twice a week, but did not complain because the staff were busy. During an interview on 1/16/25 at 2:20 P.M., Nurse Aide (NA) C said the following: -Resident showers were often missed; -He/She had difficulty keeping up with brushing hair, brushing teeth and providing incontinence care while making sure all the residents got up in the morning and before meals. During an interview on 1/16/25 at 3:30 P.M., Certified Nurse Aide (CNA) D said the following: -When a resident refused to take a shower/bath, staff were supposed to ask again later on in the shift; -A different staff member should offer the resident a shower/bath because sometimes a resident would refuse for some staff but liked other staff members better; -Staff could offer to give the shower/bath on the next shift or another day. During an interview on 1/16/25 at 12:45 P.M., Licensed Practical Nurse (LPN) A said the following: -Staff are supposed to give residents a shower twice a week; -The aide scheduled on the hall was responsible for making sure the showers were done. During an interview on 1/16/25 at 1:12 P.M., LPN B said when a resident refused a bath or shower, staff were supposed to ask again during the shift and have a different staff member approach the resident about a shower/bath. During an interview on 1/16/25 at 4:00 P.M., the Assistant Director of Nursing (ADON) said the following: -He/She collected shower sheets; -If he/she was aware showers/baths were not completed or offered, it should have been addressed with the staff to ensure the showers/baths were completed. During an interview on 1/23/25 at 9:55 A.M., the Director of Nursing said the following: -Staff were supposed to shower/bath residents twice a week; -For the most part, there was enough staff to complete showers/baths; -The Assistant Director of Nursing tracked the shower sheets; -The staff were supposed to check incontinent residents every two hours; -If a staff member saw a resident needed to be repositioned, staff should reposition or ask for help to reposition a resident; -Staff should check resident fingernails on their shower day and as needed. MO247389 MO248026

Based on observation, interview, and record review, the facility failed to provide sufficient staffing to meet residents' needs, including bathing for three residents (Resident #14, #5, and #1), in a review of 14 sampled residents. The facility census was 71. Review of an email from the Administrator on 1/23/25 showed the facility did not have a policy on staffing. 1. Review of the facility assessment, dated 7/1/24, showed the following: -The facility had an average daily census of 60; -Forty residents required assistance of one to two staff with bathing; -Eighteen residents were dependent on staff for bathing: -Twenty-four residents required assistance of one to two staff for transfers; -Fourteen residents were dependent on staff for transfers; -Based on the average census of sixty, the staffing criteria was 112 certified nurse aide (CNA) hours per day. 2. Review of the facility's daily staffing sheets, dated 12/26/24 through 1/15/2025, showed the following: -On 12/29/24 the census was 68, the CNA hours totaled 84 hours, 28 hours less than the criteria listed in the facility assessment; -On 12/30/24 the census was 68, the CNA hours totaled 101 hours, 11 hours less than the criteria listed in the facility assessment; -On 12/31/24 the census was 68, the CNA hours totaled 104 hours, eight hours less than the criteria listed in the facility assessment; -On 1/1/25 the census was 69, the CNA hours totaled 98 hours, 14 hours less than the criteria listed in the facility assessment; -On 1/2/25 the census was 69, the CNA hours totaled 80 hours, 32 hours less than the criteria listed in the facility assessment; -On 1/3/25 the census was 69, the CNA hours totaled 104 hours, eight hours less than the criteria listed in the facility assessment;; -On 1/4/25 the census was 69, the CNA hours totaled 80 hours, 32 hours less than the criteria listed in the facility assessment; -On 1/5/25 the census was 69, the CNA hours totaled 96 hours, 16 hours less than the criteria listed in the facility assessment; -On 1/6/25 the census was 69, the CNA hours totaled 68 hours, 44 hours less than the criteria listed in the facility assessment; -On 1/7/25 the census was 69, the CNA hours totaled 105 hours, seven hours less than the criteria listed in the facility assessment; -On 1/8/25 the census was 69, the CNA hours totaled 93.5 hours, 18.5 hours less than the criteria listed in the facility assessment; -On 1/11/25 the census was 69, the CNA hours totaled 88 hours, 24 hours less than the criteria listed in the facility assessment; -On 1/12/25 the census was 69, the CNA hours totaled 96 hours, 16 hours less than the criteria listed in the facility assessment; -On 1/13/25 the census was 69, the CNA hours totaled 82 hours, 30 hours less than the criteria listed in the facility assessment; -On 1/14/25 the census was 69, the CNA hours totaled 98 hours, 14 hours less than the criteria listed in the facility assessment; -On 1/15/25 the census was 70, the CNA hours totaled 84 hours, 28 hours less than the criteria listed in the facility assessment. 3. Review of Resident #14's Care Plan, updated 8/13/24, showed the following: - The resident displayed signs of moderate dementia sequencing and steps of tasks if asked to deliberately perform, i.e., dressing and showers; -The staff provided cues and supervision for tasks which required numerous steps if he/she appears confused or stressed. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/26/24, showed the following: -The resident was cognitively intact; -He/She required moderate assistance with showering. Review of the resident's shower sheets, dated 11/3/24 through 1/15/25, showed the following dates when staff provided showers for the resident: -The resident's shower days were Wednesdays and Saturdays; -No documentation the resident received a shower from 11/3/24 through 11/12/24, nine days; -11/13/24; -11/20/24, seven days since the previous shower; -11/27/24, seven days since previous shower; -12/4/24, seven days since previous shower; -12/18/24; -12/29/24, eleven days since previous shower; -1/1/25; -1/11/25, ten days since previous shower. Observation on 1/16/25 at 3:10 P.M., showed the following: -The resident self-propelled the wheelchair down the hallway; -His/Her hair was disheveled and oily. During an interview with the resident on 1/16/25 at 3:10 P.M., the resident said he/she did not get a shower twice a week, but he/she did not complain because the staff were busy. 4. Review of Resident #5's Care Plan, updated 12/10/24, showed the following: -The resident had limited mobility due to hemiplegia and hemiparesis (Hemiplegia refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength) following cerebral vascular accident (CVA, stroke) affecting the right side; -The resident preferred showers to bed baths and will receive showers twice weekly. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had modified cognitive skills for daily decision making; -He/She required moderate assistance with bathing. Review of the resident's shower sheets, dated 11/3/24 through 1/15/25, showed the following dates staff provided the resident a shower: -The resident's shower days were Tuesdays and Fridays; -11/25/24; -Staff offered but the resident refused a shower on 12/9/24, 14 days since last shower; -12/23/24, 14 days since the resident's last shower; -Staff offered the resident a shower on 12/26/24, but he/she refused; -Staff offered the resident a shower on 12/30/24, but he/she refused; -Staff offered but the resident refused a shower on 1/13/25, 14 days since staff offered the resident a shower. Observation on 1/16/25 at 10:45 A.M., showed the resident lay in bed with eyes closed, his/her hair was disheveled and oily. During an interview with Resident #6 (Resident #5's roommate) on 1/16/25 at 10:45 A.M., he/she said the following: -Resident #5 usually received one shower a week because the facility was short staffed; -When Resident #5 started to smell from across the room, Resident #6 and the staff Resident #5 liked, convinced him/her into taking a bath. 5. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She required supervision from staff with bathing. Review of the resident's Care Plan, dated 12/19/24, showed the following: -The resident had minimal deficits in ADLs related to minimal weakness, but was usually independent in all ADLs; -Determine his/her preferences for shower days to assure the staff were meeting the resident's needs Review of the resident's shower sheets, dated 11/3/24 through 1/15/25, showed staff showered the resident on the following dates: -The resident's shower days were Wednesdays and Saturdays; -No documentation staff offered or provided a shower to the resident from 11/3/24 through 11/10/24 (nine days); -11/11/24; -11/20/24, nine days from the previous shower; -12/21/24; -12/28/24, seven days from the previous shower; - 1/1/25; -1/8/25, seven days from the previous shower. During an interview on 1/16/25 at 11:30 A.M., the resident said the following: -He/She did not always get a bath twice a week, he/she was lucky to get a bath once a week; -He/She wanted two showers a week. 6. During an interview on 1/16/25 at 2:20 P.M., Nurse Aide (NA) C said the following: -There was not enough staff to get everything done; -Showers were missed; -He/She had difficulty keeping up with brushing hair, brushing teeth, providing incontinence care while making sure all the residents got up in the morning and before meals. During an interview on 1/16/25 at 1:12 P.M., LPN B said the following: -There was not enough staff to get showers done, especially since the facility cut agency staffing; -The residents were lucky if they received two showers a week; -The facility had four certified nurse aides (CNA) for four halls with some residents requiring two staff members assistance; -Evening shift was the worst with staffing. During an interview on 1/23/25 at 8:56 A.M., the Assistant Director of Nursing said the following: -He/She had difficulty filling open slots on the nursing schedule at times; -The staff member on-call covered when a staff member called off or did not show up for the shift, however, if the on-call staff was already in the building for several hours, then another staff member covered; -He/She did not know the hours per day per discipline required on the facility assessment. During an interview on 1/23/25 at 9:55 A.M., the Director of Nursing said the following: -She assisted the Staffing/Wound Nurse and Assistant Director of Nursing with the schedule; -The issue was multiple staff calling off; -There were four nursing administrative staff to cover openings in the schedule, the Assistant Director of Nursing, Staffing/Wound Nurse, MDS Coordinator, and herself; -She did not know the hours per discipline needed to care for 60 residents as listed on the facility assessment until recently. During an interview on 1/17/25 at 9:53 A.M., the Administrator said the following: -The Director of Nursing, Assistant Director of Nursing, and Staffing/Wound Nurse worked together to make the nursing schedule; -Her expectation was enough nursing staff be scheduled to provide quality care to the residents; -She was not sure if the Staffing/Wound Nurse, Assistant Director of Nursing or Director of Nursing, who were responsible for staffing, knew the number of hours needed per discipline according to the facility assessment. MO247389 MO248026

Based on observation, interview, and record review, the facility failed to maintain a safe and effective medication system when morphine (narcotic with a high potential for abuse) prescribed for Resident #1 and Resident #2, had been tampered with, a card of oxycodone (a potent semisynthetic opioid agonist prescription medication used to treat severe pain) was missing from the facility emergency medication kit, when staff failed to document the narcotic count was completed before and after their shift, and when an Ozempic (prescription injectable medication used to treat type 2 diabetes: and for weight loss) insulin pen was found to be tampered with and the contents replaced by another type of insulin for Resident #4. The facility census was 71. Review of the undated facility policy for Storage of Medication showed the following: -All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more locked mobile medication carts; -Biologicals or medications requiring refrigeration must be kept in a separate, securely fastened refrigerator at or near the nurses' station; or in a refrigerator within a locked medication room. -All controlled substances must be stored under double lock and key. Review of the undated facility policy for Scheduled II-V Medications (Schedule II medications are typically prescribed to treat severe pain, anxiety and insomnia. Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. Schedule V medications are drugs with lower potential for abuse than Schedule IV and consist of preparations containing limited quantities of certain narcotics. Schedule V drugs are generally used for antidiarrheal, antitussive, and analgesic purposes) showed: -Schedule II-V medications may be kept in medication cart lock box, refrigerator, boxes, or double lock box maintained in medication rooms; -Scheduled medications will have disposition records that are in a binder on medication cart or area instructed by the Director of Nursing (DON); -All Schedule II, III, IV and V medications must be counted (comparing number of pills to disposition record) at every change of shift by two Certified Medication Technicians (CMT), or one CMA and one licensed nursing staff. Both personnel must sign verification of correct count for Schedule II, III, IV and V medications. The facility did not provide a requested policy for utilization of the Stat Safe (emergency medication kit). 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD - a lung disease that results from damage to the lungs or airways, which can lead to inflammation and other issues that make breathing difficult), shortness of breath, chronic cough, and kidney disease. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff, dated 8/31/24 showed: -The resident was able to make self understood and able to understand others; -Alert and oriented and able to make appropriate decisions; -Independent with Activities of Daily Living (ADLs); -Has pain at a level 6 (zero being no pain and 10 being unbearable pain) and was taking opioid medication. Review of the resident's Physician Order Sheet (POS) for September 2024 showed an order for morphine concentrate (opioid medication for relief of moderate to severe acute and chronic pain), Schedule II medication solution; 100 milligrams (mg) per 5 milliliter (ml) (20 mg/ml); amt: 0.25 ml; orally for pain every 4 hours as needed with an order date of 2/28/24. Review of the resident's Medication Administration Record (MAR) for September 2024 showed morphine concentrate 0.25 mg administered on 9/10/24 at 5:37 P.M. 2. Review of Resident #2's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses of acute respiratory failure and pain. Review of the resident's quarterly MDS dated [DATE] showed the following: -Sometimes understands others and sometimes able to make self understood; -Unable to make decisions; -Dependent upon staff for ADLs'; -Has occasional pain at a level 4 and receives pain medication as needed. Review of the resident's POS for September 2024 showed and order for morphine concentrate - Schedule II solution; 100 mg/5 ml (20 mg/ml); amt: 0.25 ml; orally with special instructions to give 0.25 ml sublingual (under the tongue) every 4 hours as needed. Review of the resident's MAR for September 2024 showed morphine concentrate 0.25 mg administered on 9/10/24 at 10:20 A.M. and 7:15 P.M. During an interview on 10/15/24 at 12:40 P.M. LPN A said the following: -Resident #1 requested morphine for pain on 9/13/24, when he/she opened the morphine bottle to administer the medication, the morphine had a funny smell, like mint. The morphine he/she had given in the past, had no particular smell. He/She notified the Assistant Director of Nursing (ADON) and upon checking the morphine for Resident #2, noted the resident's morphine had a bubblegum smell. Both were removed and destroyed and the pharmacy replaced the medication; -He/she had counted medication with the off going nurse at 6:00 A.M. on 9/13/24, but had not smelled the medication (morphine). During an interview on 10/4/24 the Director of Nursing (DON) said the following: -It was reported on 9/13/24 by Licensed Practical Nurse (LPN) A that the morphine concentrate for Resident #1 did not smell right. The morphine smelled like mint which was unusual. Upon checking the morphine in the medication cart, the morphine for Resident #2 had a bubblegum smell. Both of the morphine bottles were removed from the medication cart and destroyed. The facility contacted the pharmacy and had the medication replaced. 3. Observation on 10/4/24 at 4:30 P.M. of the Certified Medication Technician (CMT) medication cart showed the following: -A controlled substance shift change log book with individual sheets for the staff to sign by the on coming staff and off going staff that the controlled substance count and number of medication cards was correct; -A notation at the bottom of the sheet signing signified all doses are recorded on the MAR, count sheets match inventory on hand and package log matches actual package count; -No off going signature for 10/1/24 at 7:00 A.M.; -No on coming signature or off going signature for 10/1/24 at 11:00 P.M.; -No off going signature for 10/2/24 at 7:00 A.M. and no on coming signature for 3:00 P.M ; -No off going signature for 10/3/24 or on coming signature for 3:00 P.M. and no count or on coming or off going signature for 11:00 P.M. -No off going signature for 10/4/24 at 7:00 A.M. -Several medication cards for lorazepam (used to relieve anxiety and is a controlled substance) and alpramazole (Alprazolam is frequently prescribed to manage panic and anxiety disorders and is a controlled substance) During an interview on 10/4/24 at 4:30 P.M. the DON and Assistant Director of Nurses (ADON) said the CMTs pass lorazepam (a schedule IV controlled medication to relieve anxiety) and was not a narcotic that needed to be monitored. The facility does not audit the CMT medication carts for any tampering or missing medications. During an interview on 10/4/24 at 4:35 P.M. CMT B said the following: -Two CMT's or a CMT and a nurse will count the number of cards of narcotics in the medication cart and then count the number of pills in each card. They will sign the shift change log indicating that the count was right; -He/She did not count when he/she came on the shift as the day shift CMT had already left and there wasn't a nurse available to count with him/her. During an interview on 10/8/24 at 12:20 P.M. CMT C said the following: -The on coming CMT should count the cards of narcotics with the off going shift CMT or nurse and then the actual pills in each card of the medication; -This should be done at every shift change. 4. Observation on 10/8/24 at 2:00 P.M. of a nurse medication cart for the 100 and 400 halls and the refrigerator in the nurses' medication room showed the following: -A controlled substance shift change log book with individual sheets for the staff to sign by the on coming staff and off going staff that the controlled substance count and number of medication cards were correct; -A notation at the bottom of the sheet signing signified all doses are recorded on the MAR, count sheets match inventory on hand and package log matches actual package count; -No off going signature for 10/1/24 at 7:00 A.M., no count of medication noted for 10/1/24 or an on coming signature for 7:00 A.M.; -No count of medication noted on 10/2/24 or on coming or off going signatures; -No off going signature for 10/3/24 at 7:00 A.M. -No off going signature for 10/6/24 at 11:00 P.M.; -Several bottles of morphine, cards of oxycodone and liquid Ativan (controlled medication) that were kept in the refrigerator in the nurses' medication room Observation on 10/8/24 at 2:15 P.M. of the Med Nurse cart for the 200, 500 and 600 halls and the refrigerator in the nurses' medication room showed the following: -A controlled substance shift change log book with individual sheets for the staff to sign by the on coming staff and off going staff that the controlled substance count and number of medication cards were correct; -A notation at the bottom of the sheet signing signified all doses are recorded on the MAR, count sheets match inventory on hand and package log matches actual package count; -No off going signature on 10/1/24 at 7:00 A.M. or no on coming signature on 10/1/24 at 11:00 P.M. -No off going signature on 10/2/24 at 7:00 A.M. or on coming signature for 11:00 P.M.; -No off going signature for 10/2/24 at 7:00 A.M. or 3:00 P.M. or on coming signature for 3:00 P.M.; -No on coming signature for 10/4/24 at 7:00 A.m. or 3:00 P.M. or no count of medication noted at 3:00 P.M. -Several bottles of morphine, cards of oxycodone and liquid Ativan that were kept in the refrigerator in the nurses' medication room During an interview on 10/8/24 at 3:05 P.M. the DON said she would expect the CMT's and the nurses to count the number of cards that are in the locked narcotic box and the number of pills in each card and the number of liquid bottles and the amount in each bottle when they come on the shift and when they go off shift together and document on the controlled substance shift change log. During an interview on 10/8/24 at 3:10 P.M. the Administrator said the following: -She would expect staff to follow the policy for medication administration and narcotics; -She would expect staff to count the narcotics at the beginning of their shift with the on coming staff and the off going staff; -She would expect all medications to be documented and accounted for. 5. Review of Resident #4's face sheet showed: -admitted to the facility on [DATE]; -Diagnoses of diabetes. Review of the POS for September 2024 showed the following: -Ozempic (semaglutide) pen injector; 2 mg/dose (8 mg/3 ml); amt: 2 mg; subcutaneous with special instructions to inject 2 mg once a day on Wednesday; -Order date of 7/25/24. During an interview on 10/4/24 at 1:30 P.M. the Administrator said the following: -Several weeks ago, a resident's morphine (another resident in addition to Resident #1 and #2), had been tampered with. The DON and ADON had been doing audits of the narcotics three times a week; -On 9/13/24, the facility had two bottles of morphine concentrate that appeared to have been tampered with. The smell of the medication in both of the bottles was not correct. The pharmacy indicated that the morphine concentrate should smell like raspberry. -On 9/25/24, the consultant pharmacist discovered that a card of oxycodone (a Schedule II narcotic used to treat severe pain, for example after an operation or a serious injury, or pain from cancer) was missing from the facility Stat Safe (emergency drug kit). Only the pharmacist had been checking the Stat Safe monthly on their routine visits to the facility; -A couple of weeks ago, a pen of Ozempic (a prescription injectable medication used to treat Type II diabetes in adults), was found to tampered with and replaced with a different type of insulin (replaced with a pen that was not an Ozempic pen). No one had been checking the Ozempic insulin pens to see if the medication had been tampered with. During an interview on 10/8/24 at 3:05 P.M. the DON said she would expect the CMT's and the nurses to count the -When the pharmacist found the missing oxycodone, they discovered that a nurse did not have to have a witness of when they took a medication from the Stat Safe. -She would expect the staff to have to nurses when getting medication out of the Staff Safe, and have two staff members count the narcotic medication at the beginning of each shift and sign that the count is correct. MO242133 MO242628

Based on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 71. Review of the facility policy for Food Temperatures dated 5/2015 showed: -The Dietary Manager or designee is responsible for seeing that all food is the proper serving temperature(s) before trays are assembled; -Keep the temperature of hot foods no less than 140 degrees Fahrenheit (F) during meal service; -Hot foods should be at least 120 degrees F when served to the resident; -Keep the temperature of potentially hazardous cold foods no greater than 40 degrees F. Prepare cold items a day in advance when possible. Please items in freezer 45 minutes before service and use ice baths when needed; -A test meal should be sent with the hall trays when there are food temperature complaints until the temperatures are at the appropriate levels. Record on Temperature Record of Test Trays form; -Do not cook or heat food in the steam able because it fosters bacteriological growth and is detrimental to product quality. Heat food to the proper temperature by direct heat (using a stove, over, steamer, etc.) and then transfer food to the preheated steam table no more than 30 minutes before meal service; -Place cold items such as ham salad and egg salad in the steam table over an ice bath with the well of the steam table turned off. -Potentially hazardous foods are not held at room temperature during meal service. 1. During an interview on 10/4/24 at 2:05 P.M. Resident #8 and Resident #9 said the following: -They get meals in their rooms and the food was cold and often late; -Staff usually brought their breakfast around 8:30 A.M. or 9:00 A.M., lunch around 1:00 P.M. to 1:30 P.M., and supper at 6:00 P.M. to 6:30 P.M. During an interview on 10/4/24 at 2:30 P.M. Resident #10 said he/she eats meals in his/her room. When staff serve the meals the food was almost always cold. During an interview on 10/8/24 at 11:30 A.M. Resident #11 said he/she eats meals in his/her room. When staff serve the meals the food was never hot. Observation on 10/8/24 at 12:05 P.M. showed the following: -Staff served the noon meal to 22 residents in the main dining room with four staff members present; -The meal consisted of vegetable soup, a cold ham sandwich, chips, sliced melon, milk, tea, fruit punch or coffee; -Glasses of milk, tea and fruit punch sat on a cart. None of the items were on ice; -Staff completed meal service to the main dining room at 1:00 P.M.; -At 1:10 P.M. the hall cart for the 400 hall left the kitchen for food service; -At 1:15 P.M. the hall cart for the 500 hall left the kitchen for food service; -At 1:15 P.M. dietary staff prepared four trays for the 100 hall cart. The trays sat on the counter for five minutes as there was no staff in the dining room to place the drinks on the trays and load the trays onto the cart. At 1:22 P.M. a staff member came into the dining room and placed the trays on the 100 hall cart and placed glasses of milk, tea and fruit punch on the trays; -The cart for the 100 hall left the dining room for service with the last tray being served to a resident on the 100 hall at 1:34 P.M. Observation at 1:35 P.M. of food temperatures of the test tray showed the following: -Soup was 118 degrees F; -Milk was 62 degrees F; -Tea was 60 degrees F; -Ham on the sandwich was 52 degrees F. During an interview on 10/8/24 at 1:40 P.M. the Dietary Manager said the following: -She had taken the temperature of the soup before meal service and it was 165 degrees F; -Hot food should be served at 120 degrees F and cold food at 42 degrees or below; -The drinks should have been placed on ice; -She was not sure how to keep the soup hot for serving. During an interview on 10/8/24 at 2:05 P.M. the Administrator said the following: -Beverages should be kept on ice until served; -She would expect the meal to be served in a timely manner and the foods to be at the proper temperatures. MO242628

Based on observation, interview, and record review, the facility failed to have a system in place to ensure staff served hot beverages at an appropriate temperature, in an appropriate cup and placed within one resident's (Resident #63), of 24 sampled residents, reach. The resident sustained a third degree burn and required treatment for the burn. The facility failed to consistently evaluate, implement, and modify interventions, in accordance with current standards of practice, and as necessary, to reduce the risk of falls for two residents (Resident #42, and #52). Resident #42 was sent to the emergency room after he/she experienced a dislocated right shoulder and a laceration above his/her right eye requiring sutures, injuries requiring treatment at the hospital. Resident #52 was sent to the emergency room for a laceration above the left eye requiring glue repair by the emergency room . The facility failed to safely transport two sampled residents (Resident #22, and #68) and two additional residents (Resident #1 and #14) when staff pushed them in wheelchairs without foot pedals and the resident's feet drug the floor. The facility census was 67. Request for a hot liquid or food service policy was made with no policies provided. Review of the facility policy, Fall Prevention, taken from the facility's Fall Prevention Manual, dated 06/2006, showed the following: -Falls are a serious health risk for older persons. Much can be done to prevent falls. Because of the high incidence of falls in the elderly, skilled nursing facilities (SNF) have an important role to play in preventing falls. SNF are in a unique position to identify patient risks and to coordinate a fall prevention and fall reduction program. Moreover, falls can be prevented, and their severity reduced without an increased use of restraints; -Most falls are the result of a complex interaction of environmental, medical, and physical factors. Therefore, one intervention alone is less likely to be as successful as a combination of interventions. This quality improvement project incorporates a patient fall risk assessment, care planning and an exercise component; -Assessment is the cornerstone of a fall prevention program. Literature supports that a fall risk assessment that incorporates a focused history, environmental and physical risks to persons has a positive impact on reduction in fall rates, deaths from falls, and hospitalization rates among residents of long-term residential facilities; -Research shows that care planning by an interdisciplinary team soon after admission, with revisions as conditions change, is the most effective way to provide individualized care. Risk factors identified in the risk assessment should be the basis for an individualized care plan; -A performance-improvement approach to falls and injuries requires interdisciplinary involvement. Therefore, a resident safety management committee should be composed of members from each of the facility's departments and each member should have specific duties and obligations in the fall-management process; -The three steps the committee should take are to collect data, implement both facility-wide and individualized plans, and evaluate those plans; -The fall policy did not address transporting residents in wheelchairs without foot pedals. Review of the undated facility policy, Use of Wheelchairs, showed the following: -Do not remove footrests unless the resident uses feet on floor to enable mobility; -Lower footrests and place the resident's feet on footrests if used; position feet and legs in good body alignment, and elevate leg(s) as ordered. 1. Review of Resident #63's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/18/24, showed the following: -The resident was cognitively intact; -He/She had limited range of motion to bilateral upper and lower extremities; -The resident required setup assistance with eating; -He/She was independent with rolling left and right in bed. Review of the resident's nurse notes, dated 4/28/24 at 1:12 PM, showed the following: -The resident said that very morning he/she received hot water for tea; -The Certified Nurse Assistant (CNA) sat the breakfast tray down and walked out of the room; -The resident moved the bedside tray closer so he/she could eat; -The hot water tipped over and spilled onto the resident's left leg; -The resident's left leg had redness and some raised areas to the back of the left leg; -Staff applied a cool towel, and the resident received Norco (opioid pain medication) and alprazolam (antianxiety) at 10:00 AM; -At 10:00 A.M., the nurse reassessed the resident and found five blisters to the back of the left leg behind the knee; -The nurse received orders to apply Silvadene (topical antibiotic) twice a day, wrap loosely with gauze and apply cool compress; -At 2:10 P.M., the resident rated his/her pain an eight out of 10 (one a scale of one to 10 with 10 being the most pain) to bilateral knees and burn. During an interview on 5/23/24 at 8:30 A.M., CNA C said the following: -He/She worked the shift when the resident was burned on the back of his/her leg with hot liquid (4/28/24); -He/She was in the kitchen getting the room trays ready on the cart; -The dishwashing machine was broken, so the kitchen used disposable (Styrofoam) cups; -The kitchen staff instructed him/her to fill the cup and put aluminum foil cover over the cup. During an interview on 5/20/24 at 12:50 P.M., the resident said the following: -On 4/28/24, the CNA brought in the breakfast tray and sat it on the overbed table out of his/her reach; -Staff brought the hot water for tea in a large Styrofoam cup; -He/She started to pull the overbed table closer to him/her in order to eat; -The cup of hot water fell off the tray and onto the bed; -He/She was covered with a blanket, but the hot water still contacted his/her skin; -He/She tried to get the wet items away from him/her and it burned every time he/she moved anything; -The burn caused constant pain with it being severe most of the time; -The staff told the resident it was his/her fault because he/she won't get out of bed for meals; -He/She experienced pain, however, it was worse with the burn on his/her leg; -He/She preferred pain be less than five out of 10. Review of the resident's medication administration record (MAR), dated April 2024, showed staff administered pain medication as follows:: -Hydrocodone/acetaminophen (opioid pain medication) 5/325 milligrams (mg) on 4/28/24 at 6:45 P.M. for pain at 8/10; -Hydrocodone/Acetaminophen 5/325 mg on 4/29 at 3:00 P.M. for left leg pain at 7/10; -Hydrocodone/Acetaminophen 5/325 mg on 4/29 at 9:58 P.M. for pain at 6/10; -Hydrocodone/Acetaminophen 5/325 mg on 4/30 at 10:30 P.M. for pain at 7/10. Review of the resident's nurse note, dated 4/30/24 at 1:12 P.M., showed the following: -Wound type: third degree burn to posterior left lower extremity, inferior to knee; -Measurements: 2.2 centimeters (cm) by 11 cm by 0.2 cm; -Moderate amount of serous drainage (clear fluid that leaks out of wounds) present; -Updated treatment: cleanse with wound cleanser gently, apply skin prep to peri wound, apply Silvadene to wound bed, cover with non-adherent dressing, secure in place, and change daily. Review of the resident's physician orders, dated 4/30/24, showed an order for Silvadene cream 1%, apply to posterior left lower extremity below knee. Cleanse with wound cleanser gently, apply skin prep to peri wound, apply Silvadene to wound bed, cover with non-adherent dressing, secure in place, and change daily related to burn. Review of the resident's care plan, last updated 4/30/24, showed the following: -The resident had a burn on his/her posterior left lower extremity inferior to knee caused by hot water during mealtime; -Delayed healing factors: poor mobility, high body mass index (BMI) (measure of body fat based on height and weight that applies to adult men and women), spending majority of time laying in bed, incontinence, diagnoses of type II diabetes mellitus (problem in the way the body regulates and uses sugar); -Staff educated the resident on the importance of not consuming meals in bed including spilling hot drinks. Review of the resident's MAR, dated May 2024, showed staff administered the following pain medication: -Hydrocodone/Acetaminophen 5/325 mg on 5/2 at 7:09 A.M. for pain at 8/10; -Hydrocodone/Acetaminophen 5/325 mg on 5/2 at 8:56 P.M. for pain at 6/10; -Hydrocodone/Acetaminophen 5/325 mg on 5/3 at 10:57 A.M. for pain at 5/10; -Hydrocodone/Acetaminophen 5/325 mg on 5/5 at 8:05 A.M. for pain at 7/10; -Hydrocodone/Acetaminophen 5/325 mg on 5/5 at 5:34 P.M. for pain at 6/10. Review of the resident's nurse note, dated 5/9/24 at 11:03 A.M., showed the following: -Burn to the left lateral posterior thigh currently measuring 2.4 cm by 1.5 cm, no drainage; -Left inferior knee measures 6.8 cm by 11.9 cm, scant exudate, yellow in color; -The resident reported pain with the dressing change to the knee. Observation on 5/19/24 at 5:44 P.M., showed the following: -The resident lay in bed with headphones on watching television; -The resident's meal tray sat covered on the over bed table; -The over bed table sat perpendicular to the bed with the tray on the side of the over bed table away from the resident and not within reach. Observation on 5/20/24 at 1:16 P.M., showed the following: -The kitchen staff provided hot water in a red coffee cup with a disposable lid; -Staff obtained the hot water from a spigot on the coffee machine for resident use: -The hot water temperature was 160 degrees Fahrenheit. Review of the National Library of Medicine, dated August 2008, showed hot beverage served at temperatures between 160 degrees Fahrenheit and 185 degrees Fahrenheit can cause significant scald burns (caused by something wet, such as hot water or steam) with brief exposure. Observation on 5/21/24 at 8:50 A.M., showed the following: -The resident lay in bed with headphones on and eyes closed; -The resident's meal tray sat covered on the over bed table; -The over bed table sat perpendicular to the bed with the tray on the side of the over bed table away from the resident, not within reach; -A coffee cup with a lid sat on the far end of the tray. During an interview on 5/22/24 at 9:40 A.M., CNA FF said the following: -The facility provided an in-service to staff about not using Styrofoam cups, and to only use the coffee cups in the kitchen; -The in-service did not include placement of trays or drinking cups within reach; -The in-service did not include allowing the cup to sit and cool prior to giving to a resident. During an interview on 5/22/24 at 9:48 A.M., CNA G said the following: -The facility provided staff training after the resident was burned; -The training included not using Styrofoam cups, only cups provided in the kitchen; -The training did not include where to place the trays or drinks, because staff should already know to keep things safely in the resident's reach; -The training did not include allowing drinks to sit and cool before use. During an interview on 5/23/24 at 6:49 P.M., the Director of Nursing (DON) said the following: -The staff were supposed to use red coffee cups; -The staff needed to take time to hand wash the coffee cups instead of using Styrofoam; -No assessments were done to assess the water temperature in the kitchen for resident use; -CNAs are trained to put items within reach during training to become a CNA. 2. Review of Resident #42's Care Plan, dated 6/28/23, showed the following: -The resident is at risk for injury related to a history of falls related to acute medical condition and fall within 36 hours of admission; -The resident will remain free from injury; -Analyze the resident's falls to determine a pattern/trend, which appear to be related to medical trauma and possibly delirium/confusion. -Give the resident verbal reminders not to transfer without assistance; -Keep the resident's bed in the lowest position with brakes locked; -Keep call light in reach at all times; -Keep personal items and frequently used items within reach; -Place fall mats by bed (both sides); -Staff to provide substantial assistance for pivot transfer,with a gait belt during transfers for balance/safety. Review of the resident's care plan showed staff reviewed the care plan on 5/1/24 and made no changes to the resident's care plan for fall risk. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Scheduled pain medication; -Independent with transfers and walking; -Continent of bowel and bladder. Review of the resident's nurses notes, dated 5/9/24, showed the following: -Heard yelling from the resident's room; -When entering the room, the resident lay on his/her right side holding his/her arm; -The resident had blood dripping from his/her right eyebrow; -Laceration to right eyebrow, along with right shoulder that was displaced; -The resident was unable to move his/her right arm; -The resident was sent to the emergency room via emergency medical services (EMS). Review of the resident census showed the resident went to the hospital on 5/9/24 and returned on 5/10/24. Review of the resident's nurses notes, dated 5/10/24, at 7:36 A.M. the interim Director of Nursing documented the following: -Returned to facility at 7:32 A.M. by ambulance transport from the hospital; -Laceration to right forehead; stitches noted; -The resident had a dislocation of his/her right shoulder, these injuries were from his/her fall in her room last night. Review of the resident's nurses notes, dated 5/10/24, at 1:50 P.M., showed the following: -Skin assessment performed post fall; -Area above right eyebrow measured 4.9 cm in length and 0.5 cm in width; -Sutures in place, left open to air; -Area on right cheek measures 1.6 cm in length and 0.3 cm in width left open to air; -No bruising noted to right shoulder. Review of the resident's medication administration record, dated May 2024, showed the following: -On 5/11/24, staff documented the resident's pain score as five out of 10 (with 10 being the highest) on the evening shift; -On 5/12/24, staff documented the resident received PRN (as needed) Tylenol (pain reliever) 650 milligrams (mg) at 12:21 P.M. and night shift documented a pain score of four out of 10. Review of the resident's nurses notes, dated 5/12/24, showed the following: -Aide reported the resident had an unwitnessed fall; -Upon entering the resident's room, the resident was sitting on his/her buttocks beside his/her bed and was leaning on his/her right arm; -When asked what happened, the resident said, I was about to wet myself; -The resident was educated on using call light for safety due to previous fall. Review of the resident's physician's orders, dated 5/13/24, showed hydrocodone-acetaminophen 5-325 milligrams two times daily for pain. Review of the resident's nurses notes, dated 5/19/24, showed the following: -The resident was found on the floor next to his/her bed; -The resident said he/she slid off the bed and onto his/her bottom; -The resident had chronic pain complaints in his/her right shoulder due to a previous fall and dislocation. Review of the resident's electronic medical record showed no evidence of analysis of the resident's falls, review or revision of the resident's care plan after each fall, or any additional changes to prevent further injuries from falls. Observation on 5/19/24, at 3:45 P.M., showed the resident in his/her wheelchair sitting in the hall by the nurses desk. The resident had sutures to a laceration above his/her right eye brow approximately 4-5 centimeters in length and he/she had a black eye. 3. Review of Resident #52's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included dementia chronic pain, fusion of spine (surgical connection of two bones in the spine to prevent movement), and spinal stenosis (space inside the backbone is too small that can put pressure on the spinal cord and nerves that travel through the spine, can cause pain, tingling, numbness and muscle weakness); -Independent with transfers and ambulation; -No mobility devices used; -Occasionally incontinent of bladder and bowel; -No toileting program; -Scheduled pain medications. Review of the resident's care plan, dated 6/27/23, documented the resident has cognitive loss. The care plan did not identify the resident was at risk for falling. Review of the resident's nurses notes, dated 7/11/23 at 6:39 A.M., showed the following: -The resident continues observation for recent fall. Steri-strips to left hand intact with no drainage noted; -The resident's family member said the resident fell because the resident was trying to get assistance from the staff, for his/her family member (also a resident), and no one answered the call light; -Upon entering the room, the resident was found on top of his/her covers that were in his/her recliner, most likely due to the resident sliding to the floor while lying on top of the items; -The resident denied pain or discomfort and had no visible injuries; -Education was provided to the resident about allowing staff to assist his/her spouse to avoid future injury; -The resident voiced understanding but additional teaching and reinforcement is required related to his/her cognitive decline. No change in status at this time. Review of the resident's nurses notes, dated 7/11/23 at 5:43 P.M., showed the following: -The resident had unsteady gait and lost balance causing a fall when he/she tried to assist staff who were assisting the resident's family member (also a resident); -The resident sustained a laceration to his/her left eye; -The resident was transferred to the emergency room via EMS. Review of the resident's nurses notes, dated 7/11/23 at 10:14 P.M., showed the resident's laceration above the resident's left eye required glue repair by the emergency room . No other injuries noted. Review of the resident's care plan showed no evidence staff updated the resident's care plan, after he/she fell on [DATE], to include/address interventions related to helping his/her (resident) family member. Review of the resident's nurses notes, dated 7/15/23 at 7:47 A.M., showed the following: -The resident sat on the floor to the front and left side of the chair, up against the wall; -The resident said he/she was getting up to help his/her family member (also a resident) and he/she slid out of the chair; -The resident had a small abrasion to his/her lower back from sliding down the wall; -The resident was significantly more confused than baseline, likely related to current diagnosis of urinary tract infection and was currently on antibiotics. Review of the resident's care plan showed no evidence staff updated the resident's care plan, after he/she fell on [DATE], to include/address interventions related to helping his/her (resident) family member. Review of the resident's care plan, updated 7/26/23, showed the following: -The resident was at risk for falls due to declining cognitive level and unsteady gait; -Ensure the resident's room was free of clutter that he/she could potentially trip over; -Increased staff supervision with intensity based on resident need. Review of the resident's nurses notes, dated 8/16/23 at 3:24 P.M., showed the following: -Interdisciplinary note showed the resident had three falls in the month of July; -All of the resident's falls were related to him/her assisting his/her family member (also a resident); -The resident's fall risk score was a 21, which put him/her at a high risk for falls. Review of the resident's Nurses Notes, dated 9/12/23 at 11:45 P.M., showed the following: -The resident sustained a non-injury, witnessed fall in the dining room; -The resident sat at the dining room table and slid out of his/her chair onto his/her bottom. The resident's medical record showed no evidence the facility attempted to identify the root cause of the fall. Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Requires supervision, touch or verbal cues for transfers and ambulating; -Requires partial/moderate assistance from staff for upper body dressing; -Requires substantial maximal assistance from staff for lower body dressing and put on/take off footwear; -Frequently incontinent of bladder and continent of bowel; -Two or more injury falls since last assessment. Review of the resident's nurses notes, dated 9/25/23 at 10:23 P.M., showed the following: -The resident sustained a fall at 1:00 P.M. The resident stood up out of his/her wheelchair and was walking toward the nursing station; -The resident turned around and fell backward, striking his/her left posterior head against the nursing station counter; -The resident was immediately assessed for injury and a silver dollar sized raised area was noted to his/her left posterior head; -Neurological checks initiated per facility protocol. Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on [DATE]. Review of the resident's nurses notes, dated 10/12/23 at 1:48 P.M., showed the following: -The care plan team met with the resident's family member; -The resident receives assistance getting into bed, but was able to get out of bed on his/her own; -The resident will propel his/her wheelchair around the building from time to time; -The resident had not had any recent falls. Review of the resident's nurses notes, dated 10/14/23 at 10:14 P.M., showed the following: -Kitchen staff witnessed the resident fall in the dining room. The resident struck his/her head against the piano and fell to the floor; -The resident had a superficial laceration (cut or tear to the skin) and a silver dollar sized hematoma (localized bleeding), from the fall, to top of his/her posterior (back) head; -The resident was assessed, a dressing was placed on the resident's head wound and neurological checks (series of tests and questions to evaluate the nervous system) initiated. Review of the resident's medical record showed no evidence the facility attempted to identify the root cause of the fall. Review of the resident's care plan, updated 10/14/23, showed the resident fell in the dining room and hit his/her head against the piano. Laceration and hematoma noted. No interventions were added or revised on the resident's care plan. Review of the resident's nurses notes, dated 11/22/23 at 9:56 P.M., showed the resident was found sitting on the floor with his/her legs crossed, going through his/her closet. Review of the resident's medical record showed no evidence the facility attempted to identify the root cause of the fall. Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on [DATE]. Review of the resident's nurses notes, dated 11/24/23 at 6:36 P.M., showed the following: -The resident was sent to the emergency room for further evaluation related to a fall; -The resident has a hematoma to the left ear. Review of the resident's medical record showed no evidence the facility attempted to identify the root cause of the fall. Review of the resident's care plan, updated 11/24/23, showed the following: -On 11/24/23, the resident was found on the floor in the television area; -He/She had been sitting in his/her wheelchair and fell ; -He/She hit his/her head on the floor; -The resident's left ear became red and swollen; received an order to send to the hospital for evaluation; -When the resident was not in his/her room, place the resident by the nurses station for close supervision. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Diagnoses of depression and Alzheimer's disease; -Severe cognitive impairment; -Used a walker; -Frequently incontinent of bladder and bowel; -Requires supervision, touch or verbal cues for transfers and ambulating; -Two or more no injury falls since last assessment -Received an antidepressant medication daily. Review of the resident's nurses notes, dated 12/31/23 at 10:02 P.M., showed the following: -The resident had an unwitnessed fall in his/her room; when staff arrived, the resident was sitting on the floor next to his/her wheelchair; -The resident did not have socks on and had spilled his/her water on the floor; -The resident was holding his/her left hand and had a small cut to his/her left pinky finger and a blood blister, cleansed and bandaged; -Abrasion noted to the resident's left lower back measuring 10 centimeters (cm) in length by 1.3 cm in width; redness to area noted; -Staff placed the resident on neurological checks. Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on [DATE]. Review of the resident's nurses notes, dated 1/6/24 at 2:29 P.M., showed the following: -The resident had a witnessed fall in the living area; -Staff witnessed the resident lower himself/herself to the floor; -Mechanical lift pad caught under the resident's chair. Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Moderate to severe depression; -Does not use a wheelchair; -Always incontinent of bladder and bowel; -Pain medication scheduled, -Non-verbal sounds, facial expressions that could indicate pain in the five days; -Requires supervision, touch or verbal cues for transfers and ambulating; -Two or more no injury falls since last assessment. Review of the resident's nurses notes, dated 5/10/24 at 5:44 P.M., showed the following: -The resident had an unwitnessed fall in his/her room; -Staff observed the resident sitting on his/her buttocks on his/her fall mat; -The resident's bed was in the lowest position at the time; -The resident has a laceration to his/her right forearm; -Neurological checks initiated. Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on [DATE]. Observation on 5/19/24, at 4:33 P.M., showed the following: -The resident lay in his/her bed with the door to his/her room closed; -The resident's bed was low to the ground; -There was a fall mat propped against the dresser across the room; -There was no fall mat next to the resident's bed. During an interview on 5/23/24 at 10:45 A.M., the DON said the following: -The facility has had change over in nursing administration so all systems were not in place; -All of the licensed staff are agency and not full time; -The charge nurse would immediately assess a resident after each fall and treat or get orders to treat any injury accordingly; -Ideally there would be a review of each fall the next day; -During the review, staff would try to determine the cause of the fall, evaluate the care plan to see what can be done to prevent further falls and/or reduce injury if there is a future fall; -If a fall was unwitnessed, or the resident hit their head, then the staff are expected to do neurological checks; -Staff would notify the physician, family, and nursing administration of each fall. 4. Review of Resident #14's care plan, last updated 1/31/24, showed the following; -The resident was at risk for falls due to cerebrovascular disease with hemiparesis and hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) of right dominant side; -Restorative therapy for lower extremity exercise three times per week; -Two person staff to assist with pivot transfers. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had severely impaired cognitive skills for daily decision making; -He/She had disorganized thinking the fluctuated; -He/She was independent with wheelchair locomotion. Observation on 5/19/24 at 5:09 P.M. showed the following: -CNA O pushed the resident in a wheelchair into the dining room; -The wheelchair did not have foot pedals; -The residents feet were touching the floor and dragged along the floor while being pushed. Observation on 5/21/24 at 11:10 A.M., showed the following: -CNA O pushed the resident in a wheelchair from the common television area to his/her room; -The wheelchair did not have foot pedals; -The resident's feet touched the floor three times during locomotion; the resident wore non-skid socks. During an interview on 5/21/24 at 11:40 A.M., CNA O said the following: -He/She did not know where the resident's foot pedals were and did not see them in the resident's room; -The resident usually did well with keeping his/her feet up off the floor. 5. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Uses wheelchair for mobility; -Diagnoses included traumatic brain injury. Observation on 5/19/24 at 5:00 P.M. showed the following: -CNA C pushed the resident in his/her wheelchair on the 400 hallway; -The wheelchair had no foot pedals; the resident's sock feet drug on the tile floor. His/Her right foot was bent back under the wheelchair seat. Observation on 5/20/24 at 2:55 P.M., CNA C pushed the resident in a wheelchair with no foot pedals. The resident's feet drug under the wheelchair. During an interview on 5/23/24 at 9:30 A.M., CNA C said all the foot pedals had been taken off the wheelchairs for unknown reasons. The pedals had been placed in a room on the B hallway. CNA C said the resident did not self propel himself/herself. CNA C said he/she pushed the resident in a wheelchair without pedals. CNA C said that it would be unsafe to transport residents without foot pedals. He/She tried to stop if a resident's feet drug on the floor and reminded the resident to lift their feet. 6. Review of Resident #22's continuity of care document showed the resident's diagnoses included dementia and cognitive communication deficit (difficulty with memory, organization and problem solving that can make it difficult to properly speak, listen, read, write or interact in social situations). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognitive skills for daily decision making; -Supervision for mobility in his/her wheelchair for short distance; -Partial/moderate assistance from staff for wheelchair mobility for long distances. Review of the resident's care plan, revised on 03/28/24, showed the following: -The resident is at high risk for falls related to history of falls, limited mobility and hip/knee contractures; -Used a wheelchair for mobility. Observation on 05/19/24 at 4:45 P.M., showed CNA FF pushed the resident to the dining room in a wheelchair. There were no foot pedals attached to the resident's wheelchair. Both of the resident's feet drug on the floor as CNA FF pushed the resident from the dayroom to the dining room. 7. Review of Resident #68's continuity of care document showed the resident's diagnoses included cerebrovascular disease (a group of condit

Based on observation, interview and record review, the facility failed to routinely assess pain as ordered for one resident, (Resident #38), in a review of 24 sampled residents. The facility failed to make the resident aware he/she had as needed (PRN) medication available for pain and failed to offer PRN pain medications when the resident complained of pain. The resident was agitated and unable to sleep due to pain. The census was 67. During an interview on 05/22/24 at 11:00 A.M., the Director of Nursing (DON) said the facility did not have a specific policy related to pain management. 1. Review of Resident #38's face sheet showed the resident had diagnoses that included joint pain, surgical amputation and acquired absence of left leg above the knee. Review of the resident's significant change Minimum Data Set (MDS) (a federally mandated assessment instrument), completed by facility staff and dated 4/10/24 showed the following: -Clear speech; makes self understood; -Cognitively intact; -No behaviors; -On a pain management program; -Received scheduled and PRN opioids (narcotic pain medication); -Did not receive non-medication interventions; -Pain presence; frequently; -Pain interferes with day to day activities. Review of the resident's pain assessment, dated 4/11/24 and completed by facility staff, showed the following: -Had pain or hurt in the last five days; noted as phantom leg pain of the lower left extremity; -Pain occasionally makes it hard to sleep; -Manner of expressing pain included agitation; -Measures taken to alleviate pain included analgesics; -On scheduled pain regimen that was always effective; -Receives PRN medication for pain. Review of the resident's care plan, last updated 4/13/24, showed the following: -Problem Start Date: 10/12/2023; Category: Pain; Presence of chronic pain in areas of his/her amputation site, back and in general has pain; -Goal: Will verbalize satisfaction with current pain management plan; -Approach: Administer as needed (PRN) or routine medications as ordered; monitor for adverse effects and for effectiveness; report for ineffectiveness. Review of the resident's May 2024 physician order sheet (POS) showed orders for the following: -Hydrocodone (narcotic pain medication) 5/325 milligram (mg), one tablet at 8:00 P.M. (scheduled for block time of 7:00 P.M. to 10:00 P.M.) and one tablet every 12 hours PRN; order date of 10/3/23; -Pain assessment every shift using pain scale of 0 - 10 every shift; scheduled for day, evening and night; order date of 11/3/23. Review of the resident's May monthly summary, dated 5/12/24 and completed by facility staff, showed the following: -Oriented times three; person, place and time; -Makes self understood; -Has not expressed pain verbally or exhibited non-verbal signs/symptoms of pain; -Pain management program was not necessary. During an interview on 5/19/24 at 4:29 P.M., the resident said the following: -His/Her pain was never controlled; -He/She only gets one pill a day. During an interview on 5/20/24 at 9:15 A.M., the resident yelled and said the following: -He/She had a terrible night; just hurt; -I told you my pain is never controlled!; -He/She did not know he/she could ask for additional, as needed, pain medication. Observation and interview on 5/21/24 at 6:02 A.M., showed the following: -The resident sat in his/her wheelchair in his/her doorway rocking back and forth; -When asked if he/she slept better last night, the resident angrily responded, No I didn't, then yelled, because I hurt! -He/She said it would do no good to ask for pain medication because they wouldn't give it to him/her; -Certified Medication Technician (CMT) M stood in the hallway at the medication cart, two doors down from the resident, preparing and administering medications to the residents on the hall. Review of the resident's May 2024 medication administration record (MAR) on 5/21/24 showed the following: -Hydrocodone 5/325 mg, one tablet at 8:00 P.M. (scheduled for block time of 7:00 P.M. to 10:00 P.M.) and one tablet every 12 hours PRN; no documentation staff had ever administered the resident a PRN dose of his/her pain medication; -Pain assessment every shift using pain scale of 0 - 10 every shift; scheduled for day, evening and night; in the administration boxes, staff documented their initials but there were no pain scores documented. Review of the resident's May 2024 progress notes showed no documentation of pain scores. Review of the resident's electronic health record showed no documentation of pain scores under the vital signs tab. During an interview on 5/19/24 at 4:50 P.M., CMT Q said the following: -The resident was usually very angry and does not allow you to watch him/her take his/her medications, let alone ask about his/her pain; -There was a box on the MAR to assess pain; he/she has never put a pain score in the box; -The resident just seemed to be agitated, grumpy and mad all of the time; -He/She has been responsible for the resident's medications and assessments; -He/She has never offered the resident PRN pain medications for pain because the resident never asked for it. During an interview on 5/21/24 at 7:22 A.M., CMT M said the following: -He/She heard the resident yelling earlier that morning but did not pay attention to what he/she was yelling. The resident was always grumpy and yelled; -He/She was not aware there was a box on the MAR to assess pain with a pain score; he/she had never put a pain score in the box; -He/She, as the CMT, was always responsible for the resident's medications and assessments; -He/She has never offered the resident PRN pain medications for pain because the resident never asked for it. During an interview on 5/21/23 at 11:18 A.M., the DON said the following: -She expected staff to follow physician orders; -If the order was to enter a pain score, she expected a pain score to be entered and it should populate on the MAR; -If the pain score was not documented on the MAR, it could be documented in the progress notes or in the resident's electronic health record under vital signs; -Staff should assess pain per physician order and ask the resident to rate the pain; -She expected staff to offer as needed pain medication to anyone they might assess as being in pain; -She was not aware the resident was complaining of more frequent pain and was not able to sleep due to pain.

Based on interview and record review, the facility failed to ensure one resident (Resident #40), who was admitted to the facility with mental illness, received appropriate person-centered and individualized treatment and services to meet his/her assessed needs. Resident #40 presented with behaviors including entering another resident's room (Resident #21) wearing no pants and only a brief, taking a cigarette from another resident and lighting it in the tea room and throwing the lit cigarette in a trash can causing trash to ignite, smoking in his/her room, and yelling and cussing at another resident (Resident #15). The resident frequently made threatening gestures (threats or attempts to choke) other residents. The facility failed to adequately implement meaningful interventions, including non-pharmacological interventions, alternate strategies, or ensure the resident received services to address the resident's behaviors. The facility census was 67. During interview on 6/11/24 at 9:50 A.M. the administrator said he did not have a policy regarding behavior management. 1. Review of Resident #40's face sheet, undated, showed the following: -He/She had a durable power of attorney; -Diagnoses included schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), major depressive disorder (common and serious medical illness that negatively affects how someone feels, the way someone thinks and how someone acts), anxiety disorder (persistent and excessive worry that interferes with daily activities), and history of mood disorder (mental health condition that primarily affects your emotional state). Review of the resident's Pre-Admission Screening and Resident Review Level II (PASRR II) (comprehensive evaluation required as a result of a positive Level I Screening), dated 7/6/20, showed the following: -The resident was physically and emotionally abused by a parent all his/her life and by a second spouse that the resident divorced; -He/She became aggressive when staff woke the resident for breakfast and shower at previous facility; -Assessment and implementation of behavioral support plan included monitoring of behavioral symptoms, provision of behavioral supports, allow the resident to have as much control of his/her care as possible, and give him/her choices in care; -Provision of a structured environment: provide for individual personal space, establish consistent routines, and provide schedule of daily tasks/activities. Review of the resident's care plan, updated on 12/16/21, showed the following: -Problem: Inappropriate sexual behavioral symptoms directed towards residents and staff of the opposite sex. On 12/15/21, the resident touched another resident's private area; -Obtain a psych consult/psychosocial therapy; -Avoid offering staff of the opposite sex for care; -Redirect the resident when appropriate sexual behaviors are present. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/24/23, showed the following: -The resident had moderately impaired cognition; -He/She was independent with rolling left and right in bed, sitting to lying in bed, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, walk tenfeet, and wheelchair locomotion; -He/She received antipsychotic, antianxiety, and antidepressant medications. Review of the resident's psychiatric progress note, dated 12/27/23, showed the following: -The physician saw the resident for a follow up visit of sleep, mood, anxiety, delusions, and medication reconciliation; -The resident had impaired insight and judgement as evidenced by decisions of recent past. Review of the resident's nurse note, dated 1/6/24 at 1:41 P.M., showed the following: -The resident inappropriately touched another resident of the opposite sex in the dining room during lunch; -The residents were separated; -The durable power of attorney (DPOA) was notified of the incident. The DPOA requested the resident be checked for urinary tract infection and to see if any medications had recently been changed as this was out of the resident's normal behavior. Review of the resident's care plan, updated on 1/6/24, showed the following: -Problem: the resident chose to smoke; -He/She was a safe smoker, however, history of elopement so the resident will smoke with supervision; -Designated smoking area, designated smoking times, staff assigned to assist with residents that smoke; -Cigarettes and lighters are kept at nursing station; -Problem: Inappropriate sexual behavioral symptoms directed towards residents and staff of opposite sex. On 12/15/21, the resident touched another resident's private area; -The resident and power of attorney agreed of the benefit from a device for self-gratification, new intervention identified on 1/6/24; -1/6/2, the resident will remain on hallway with predominately same sex residents; - There were no interventions to address the resident's sexually inappropriate behavior when in other common/areas of the facility. Review of the resident's nurse note, dated 1/26/24 a 8:57 P.M., showed the following: -The resident was found walking away from his/her roommate's bed (Resident #8); -Resident #8's face was red and purple in color. He/She said Resident #40 was choking him/her and Resident #8 couldn't breathe; -The nurse assisted Resident #40 out of the room and away from Resident #8; -Resident #40 said Resident #8 was hitting the remote on the bed, and he/she didn't want to hear it, so he/she choked Resident #8; -The staff called for psych evaluation. Resident #40 was discharged with the emergency medical team (EMT) via ambulance. Review of the resident's nurse notes, dated 2/2/24 at 12:45 P.M., showed the following: -The Director of Nursing and Social Services went to the hospital to evaluate the resident; -Per hospital staff, the resident displayed inappropriate sexual behaviors on 1/29/24 and 1/30/24; -Per hospital nurse notes, on 1/31/24, the resident was easily annoyed and angered; -Per hospital care plan, 2/1/24 at 1:30 A.M, the resident was not on sexually acting out precautions, it was then noted at 10:15 A.M., the resident was on sexually acting out precautions; -Per hospital care plan, 2/1/24 at 8:51 P.M., documentation showed the resident was easily annoyed or angered and unable to tolerate the presence of others; -The resident said he/she did not remember anything, however, the resident almost immediately said he/she had an altercation with another resident; -The resident said he/she shocked the roommate by choking him/her because the roommate would not stop banging the remote; -When the staff asked the resident what he/she would do if another situation arrived, to which the resident said he/she would stay away or tell the nurse; -It was explained to the facility staff the resident's behaviors would need to improve before the resident could safely come back to the nursing home. Review of the resident's social services note, dated 2/2/24 at 3:34 P.M., showed the following: -The Social Services Director and DON went to evaluate the resident at the hospital before the resident returned back to the facility; -Based on the assessment, the staff believed it was not possible for the resident to return safely. Review of the resident's nurse note, dated 2/6/24 at 12:30 P.M., showed the following: -The DON spoke with a staff member from the hospital where the resident was located. He/She expressed concern that the resident was exhibiting behaviors on 2/2/24; -Per hospital staff, their physician signed off and the resident was supposed to be discharged ; -Per the hospital they were sending an ambulance at 12:00 because insurance was no longer paying, and they could not keep the resident there. DON expressed concern over sending resident without an assessment, to which hospital staff said it was their policy to have residents out before a certain time. The DON again expressed concern over resident having recent behaviors just four days prior; -Per hospital staff they were sending the resident whether or not the assessment found the resident was still having unsafe behaviors. Review of the resident's nurse notes, dated 2/7/24 at 5:30 P.M., showed the following: -The resident arrived to the facility; -The staff placed the resident on frequent monitoring for 72 hours. Review of the resident's nurse note, dated 2/8/24 at 7:04 P.M., showed the following: -The resident waited for the smoking session to begin and sat in the main dining room; -The resident stood behind another resident with his/her hands up in the choking position; no contact was made with the other resident; -The staff separated both residents. The nurse asked the resident what happened, and the resident said, I did not touch him/her. The resident put his/her hands like this demonstrating for the nurse; -The nurse explained to the resident that what he/she did could be considered a threat; -One-on-one care provided with the resident and will continue until ordered otherwise. Review of the resident's nurse note, dated 2/8/24 at 8:30 P.M., showed the following: -At 7:05 P.M., staff member overheard residents yelling profanity near the smoking exit. Staff observed the resident immediately behind another resident; -The staff moved the resident to a more appropriate distance from the other resident to de-escalate the situation; -The staff placed the resident on one-on-one supervision; -Per witness, the resident wanted to be first in line to smoke. He/She did not ask the other resident (Resident #8), to move. Resident #40 came up behind the other resident and started to kick the other resident's wheelchair, then Resident #40 placed his/her hands bilaterally on the resident's neck with forceful gripping hands; -Per alleged victim, he/she was talking with another resident and Resident #40 came from behind, almost wrapping his/her hands around the alleged victim, the alleged victim asked Resident #40 what his/her hands were doing around his/her throat, and Resident #40 denied it; -Resident #40 said he/she was behind the alleged victim and his/her hands started cramping so he/she stretched them out, about four inches from the alleged victim's neck, and he/she was not upset at the time; -Resident #40 will remain on one-on-one supervision for the safety of all residents. Review of the resident's care plan showed no update to address the incident on 2/8/24 or any additional inverventions implemented after the one on one monitoring was discontinued. Review of the resident's Social Services Director (SSD)'s note, dated 2/22/24 at 1:48 P.M., showed the following: -The SSD spoke with the resident about room change to see if the resident enjoyed the private room and the resident said, doing ok; -The SSD reminded the resident if she had any issues with another resident in the facility, the resident needed to talk to the charge nurse or SSD to help the resident with any concerns or issues at the time. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She was independent with rolling left and right in bed, sitting to lying in bed, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, walk ten feet, and wheelchair locomotion; -He/She received an antipsychotic, antianxiety, and antidepressant; - The resident had no behaviors towards others. Review of the resident's care plan, updated on 3/27/24, and additions dated 1/6/24 showed the following: Problem: The resident displayed aggressive behavior toward peers; -The resident was sent to the emergency department for psychiatric evaluation; -He/She was referred to psychiatric provider for care of behaviors; -Standing order for urinalysis due to altered mental status; -The staff moved the resident to a private room (2/27/24); Problem: The resident continued to inappropriately touch residents of the opposite sex in a sexual manner; -The staff will check the resident for a urinary tract infection; -The staff will observe the resident closely when interacting with peers. Review of the resident's nurse notes, dated 3/30/24 at 1:50 P.M., showed the following: -The staff found Resident #40 in another resident's room of the opposite sex and on the same hall as Resident #40, but he/she was about six feet away from the other resident; -No inappropriate behaviors seen at the time; -The resident made sexual comments to the staff; -The staff notified the nurse practitioner, and new order received for urinalysis; -The staff notified the DON. Staff to closely monitor. Review of the resident's nurse note, dated 3/31/24 at 1:47 A.M., showed the following: -The staff found the resident going into Resident #21's room, a resident of the opposite sex and accross the hall from Resident #40, wearing no pants, only his/her brief; -The staff informed Resident #40 it was inappropriate for him/her to be in there and he/she needed to go back to his/her room; -The resident argued with staff but went back to his/her room. Review of the resident's physician's orders showed a new order, dated 4/1/24, for Provera (progesterone hormone) 5 mg give one tablet orally daily. Review of the resident's nurse note, dated 4/3/24 at 5:11 A.M., showed the following: -Resident #40 approached an independent smoker in the tea room and grabbed the other resident's cigarettes out of his/her hand, stole one, and lit it; -Resident #40 threw the lit cigarette in the trash can causing the trash to smoke; -The staff and the other resident extinguished the lit cigarette. Resident #40 was taken back to his/her room. ) Review of the resident's care plan showed no documentation of the incident of the resident taking another resident's cigarettes and lighter, throwing a lit cigarette in the trash, or interventions to address this behavior. Review of the resident's primary care physician's notes , dated 4/25/24, showed the following: -When the resident had urinary tract infection symptoms, he/she became very hypersexual and had a lot of irritability; -Urine culture on 4/4/24 showed infection with Escherichia coli (E. coli-type of bacteria that normally lives in your intestines) extended-spectrum beta-lactamases (ESBL-enzymes or chemicals produced by germs like certain bacteria that make bacterial infections harder to treat with antibiotics). Review of the resident's nurse practitioner note, dated 5/13/24, showed the following: -Schizoaffective disorder, depressive type - continue aripiprazole (antipsychotic medication) 10 milligrams (mg) daily, Buspar (antianxiety medication) 5 mg twice a day, hydroxyzine (an antihistamine used to treat anxiety) as needed, Seroquel (antipsychotic medication) 25 mg at bedtime, Zoloft (antidepressant medication) 200 mg daily, and monitor mood and behavior; -Major depressive disorder- continue aripiprazole 10 mg daily, Buspar 5 mg twice a day, hydroxyzine as needed, Seroquel 25 mg at bedtime, Zoloft 200 mg daily, and monitor mood and behavior; -Inappropriate sexual behavior - continue Provera (progesterone hormone) 5 mg orally daily and monitor behaviors. Review of the resident's nurse notes, dated 5/18/24 at 10:24 P.M., showed the following: -The staff caught Resident #40 and Resident #15 smoking in the dining room; -The staff took the cigarettes and lighter away from the resident, then educated the resident as to the dangers of what smoking inside can do to him/her and others in the facility; -Neither of the residents were independent smokers. Review of the resident's nurse note, dated 5/23/24 at 6:50 A.M., showed the following: -The nurse heard the resident arguing with Resident #15. Both residents were in wheelchairs at arm's length away from each other by the nurses' station; -Both residents were exchanging words and yelling at one another before a staff member separated them; -Resident #40 said Resident #15 slapped him/her on the arm; -The staff member witnessed Resident #15 slap Resident #40 on the arm and said to stop calling him/her a fat bitch; -The staff started 15 minute observation checks on both residents. Review of the resident's physician orders, dated May 2024, showed the following: -Aripiprazole 10 mg, give one tablet orally daily after lunch for treatment of major depressive disorder; -Buspirone (antianxiety) 5 mg, give one tablet orally twice a day (started on 2/7/24); -Hydroxyzine 25 mg give one tablet orally every six hours as needed for anxiety (started 2/7/24); -Provera 5 mg give one tablet orally daily (started 4/1/24); -Seroquel 25 mg give one tablet orally at bedtime; -Sertraline (antidepressant) 100 mg give two tablets orally daily (started 4/29/24); -Behavior monitoring and behavior interventions every shift (started 9/24/20). Observation on 5/19/24 at 5:00 P.M., showed the following: -Eight residents of the opposite sex lived on the same hall as the resident; (The resident's care plan showed the resident was to be living on a hall with all same sex residents.) -Resident #21 had the resident enter his/her room without pants; -Resident #21 lived across the hall from the resident. During an interview on 5/23/24 at 8:30 A.M., Certified Nurse Assistant (CNA) C said the following: -The staff put the resident on every 15-minute checks when he/she had behaviors; -The resident had a behavior with Resident #15 yesterday (5/22/24); -The resident called Resident #15 a fat bitch, then Resident #15 hit the resident on the arm and told him/her to stop calling him/her a bitch; -The staff separated the residents and put the resident on 15-minute checks; -The staff were supposed to bhe present and monitor the resident, but not required every 15-minutes, when the resident waited at the door for a smoke break; -The staff reminded the independent smokers not to give the resident any cigarettes or a lighter; -The resident stole other residents' cigarettes at times; -CNA C was present when the resident sexually touched Resident #57's crotch; -He/She said, if the resident sits or interacts with any residents of the opposite sex, then he/she will try to move Resident #40 because he/she didn't know when it will happen again. Observation on 5/23/24 at 12:50 P.M., showed the following: -The resident propelled self from dining room towards his/her room; -He/She stopped twice and stared at residents sitting in the common area; - No staff were observed monistoring the resident. During an interview on 5/23/24 at 12:50 P.M., Licensed Practical Nurse (LPN) A said the following: -The resident usually did not come out of his/her room, except to smoke; -The staff were supposed to redirect the resident when he/she had a negative behavior, then call the physician to request a urinalysis order; -The resident kept to himself/herself; -The resident's behaviors were random without triggers. During an interview on 5/23/24 at 1:08 P.M., the Director of Nursing (DON) said the following: -The confrontation between Resident #15 and Resident #40 would not have happened if Resident #15 would have just rolled away; -Resident #40's behaviors were triggered by urinary tract infections, that could not be predicted; -Resident #40 spent most of his/her time sleeping in his/her room and only came out to smoke and sometimes ate in dining room; -The staff were supposed to watch the resident's behaviors when he/she came out of his/her room; -She was aware the resident became angry when he/she slept past the smoking times, however, the resident was usually redirected; -She did not want staff waking up the resident while sleeping because he/she needed it, with the resident's mental health history, his/her brain benefited from sleep; -The staff reminded the independent smokers not to give cigarettes to other residents, however, they still gave other residents cigarettes; -The staff saw the resident throw a lit cigarette in a trash can on 4/3/24 and intervened immediately, nothing happened because of it; -She was going to talk to Resident #15's anger management counselor to request that coping skills were discussed. During an interview on 6/6/24 at 1:32 P.M., the Director of Nursing said the following: -Frequent monitoring depended on the reasoning for the initiation of the frequent monitoring; -The more serious the issue then the more frequently staff were to monitor a resident; -Resident #40 did not have any symptoms related to a urinary tract infection except having a change in behavior; -The intervention to prevent urinary tract infection for the resident was to encourage fluids.

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of 10 residents was free from abuse when Certified Medication Technician (CMT) B yelled and cussed directly at the resident and told the resident he/she was just going to have to fucking wait, wagged his/her finger in Resident #1's face and lunged at the resident. Resident #1 said he/she felt threatened, frightened and abused. The facility census was 70. Review of the facility undated Abuse Policy showed the following: -It was the policy of the facility that each resident would be free from abuse. Abuse could include verbal, mental, sexual or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. Additionally, residents would be protected from abuse, neglect, and harm while they were residing at the facility. No abuse or harm of any type would be tolerated and residents and staff would be monitored for protection; -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also included deprivation by an individual including a caretaker, of goods or services that were necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse and mental abuse. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Verbal abuse was defined as the use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability; -Mental abuse included but not limited to, humiliation, harassment, threats of punishment or deprivation. 1. Review of the resident's Physician Order Sheet dated 9/21/23, showed an order for hydrocodone/acetaminophen (narcotic pain medication) 7.5 milligrams (mg)/325 mg one tablet four times daily at 6:00 A.M., 12:00 P.M., 6:00 P.M. and 12:00 P.M. for pain. Review of the resident's care plan dated 10/18/23 showed the following: -Diagnoses of pain, edema (swelling of tissues in the legs), right and left leg cellulitis (infected tissue), below knee amputation (removal of leg below the knee), sciatica (pinched nerve causing nerve pain), and arthritis; -The resident had potential for acute or chronic pain or discomfort. Staff should administer medications as ordered, monitor and record effectiveness, allow uninterrupted rest periods, assess effects of pain (disturbances in sleep, activity, self-care, appetite, psychosocial), monitor and record any complaints of pain, alleviating and aggravating factors. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 2/29/24 showed the following: -Cognitively intact; -No physical or verbal behaviors; -Received scheduled and as needed pain medications for frequent pain and occasionally disrupted the resident's sleep and day to day activities. Review of the facility Self-Report investigation dated 3/20/24 showed the following: -On 3/20/24 at 6:10 P.M. a verbal dispute with name calling happened between Certified Medication Technician (CMT) B and Resident #1. The language and action of CMT B was abusive and the resident felt threatened. CMT B was asked to give a statement and walked out of the facility; -There was no question the verbal abuse happened. The resident reported being physically in fear. During an interview on 3/26/24 at 10:35 A.M. the resident said the following: -On 3/20/24 at 6:20 P.M. he/she asked CMT B for his/her pain medication that was scheduled for 6:00 P.M. CMT B got upset, was crabbing about it and said there were 75 people here and he/she could not get everyone's medications at the same time. CMT B said Resident #1 was just going to have to fucking wait and wagged his/her finger in Resident #1's face. CMT B cussed, said fuck several times and put his/her finger in Resident #1's face and lunged at the resident; -Resident #1 moved away from CMT B's medication cart, CMT B threw his/her keys and an ink pen almost hitting another resident (unknown resident) with the ink pen. CMT B went down the hall saying he/she was not going to fucking deal with any of these people; -Resident #1 got upset when CMT B argued with him/her and felt threatened when CMT lunged at him her, and wagged his/her finger in the resident's face. It felt abusive at that moment. Review of the resident's written statement dated 3/20/24 showed the following: -Resident #1 asked CMT B for a pain pill. CMT B said it would be a minute and Resident #1 told CMT B he/she would be at the nurses' desk. Resident #1 heard CMT B say there were 75 other residents and he/she was not going to give Resident #1 his/her pain pill yet, CMT B would give the pain pill with the resident's other medications at 8:00 PM; - Resident #1 had a scheduled pain pill every six hours and if not received until 8:00 PM it would be two hours late. Resident #1 asked nicely and then CMT B and Resident #1 raised their voices and cussed saying the F word. At one point it was a little threatening when CMT B lunged forward at Resident #1. Resident #1 thought CMT B was going to hit him/her. If CMT B would have given Resident #1 his/her pain pill none of this would have happened. During an interview on 3/27/24 at 9:15 A.M. Certified Nurse Assistant (CNA) D said the following: -CNA D was at the nurses' desk and saw Resident #1 at CMT B's medication cart. CMT B snapped and yelled at Resident #1 he/she could fucking wait. Resident #1 told CMT B he/she did not understand why he/she needed to wait until 8:00 PM to get his/her pain medication; -CMT B screamed at the resident, said fuck directly at Resident #1, and was in Resident #1's face. CMT B verbally abused Resident #1; -CMT B threw his/her ink pen and almost hit another resident while yelling at Resident #1; -CMT B went outside the facility, came back after 10 minutes and took the medication cart down the hall. Review of CNA D's written statement dated 3/21/24 showed the following: -On 3/20/24 at 6:15 P.M. CNA D was at the nurses' desk and heard Resident #1 ask CMT B for pain medication. CMT B told Resident #1 he/she needed to fucking wait until CMT B came down Resident #1's hall and CMT B was not going to give Resident #1 his/her medication right now; -Resident #1 kept asking for his/her medication and said he/she did not understand why he/she could not get the medication right then. Resident #1 said he/she did not want to wait until after 8:00 P.M. to get the medication; -CMT B started yelling and said Resident #1 could wait and learn to respect CMT B and not be disrespectful; -CMT B and Resident #1 argued and cussed at each other for three to five minutes straight; -Resident #1 left the situation and CMT B threw down his/her ink pen on the medication cart and the pen bounced and almost hit another resident. CMT B walked out of the facility. During an interview on 3/26/24 at 12:30 P.M. Licensed Practical Nurse (LPN) E said the following: -On 3/20/24 around 6:00 P.M., Resident #1 and two other residents waited near the medication cart and CMT B put his/her hands in the air and said they are sitting here waiting on medication. CMT B said he/she liked to give the residents all the evening medications at once; -Resident #1 asked for his/her pain medication and CMT B went off, said he/she would give the pain medication later and raised his/her voice towards Resident #1. CMT B yelled at Resident #1, argued with the resident and threw his /her ink pen, slammed the medication cart and said I am done. CMT B walked outside the facility; -Yelling at the resident was abuse. CMT B verbally abused Resident #1. Review of LPN E's written statement dated 3/20/24 showed the following: -On 3/20/24 at 6:15 P.M. LPN E witnessed CMT B yell at Resident #1. Resident #1 sat by the medication cart and asked CMT B for his/her pain medication; -CMT B yelled and explained in a hateful manner that CMT B was not going to give the resident his/her medications right now and the resident had to wait; -Resident #1 got very upset with CMT B. CMT B yelled and screamed at Resident #1, threw his/her ink pen and walked out of the facility. Review of LPN C's written statement dated 3/20/24 showed the following: -On 3/20/24 at 6:15 P.M., CMT B came up from E-hall and said he/she was getting pissed. LPN C asked why and CMT B said because of this and pointed to Resident #1 sitting next to the medication cart waiting for his/her pain medication; -When CMT B got to the medication cart, Resident #1 asked for his/her medications. CMT B said not yet, when I get to you. Resident #1 replied, I am not waiting until 8:00 or 9:00, I need my medication now, you (CMT B) gave everyone else their medication when they came to the medication cart. CMT B yelled I do not!. CMT B continued to yell back and forth with Resident #1, cussing at the resident and in general. CMT B was approximately one to two feet away from the resident the entire time; -CMT B began throwing ink pens, keys and yelling I am done! CMT B walked outside to take a break and came back in the facility approximately 10 minutes later. CMT B went to his/her medication cart and took the medication cart down the hallway to continue with the medication pass. During an interview on 3/26/24 at 12:00 P.M. the Social Services Designee (SSD) said the following: -He/She heard yelling and screaming near the nurses' desk that got intense. CMT B was at the medication cart with Resident #1. CMT B threw his/her pen and said to Resident #1, fuck this shit, I quit. CMT B went out the facility door; -Resident #1 said he/she asked CMT B for his/her pain medication, CMT B got in Resident #1's face, cussed at the resident and Resident #1 said he/she was afraid; -CMT B was verbally abusive to Resident #1. Review of the Social Services Designee (SSD) written statement dated 3/21/24 showed the following: -At 6:15 P.M. he/she was in the dining room area and heard two people yelling and shouting at each other. The SSD went to the nurses' desk area, where CMT B was yelling and threw his/her ink pen that flew past the SSD's face and hit the wall. At that time CMT B said he/she quit and walked out of the facility. During an interview on 3/29/24 at 3:10 P.M. the Director of Nurses (DON) said CMT B was verbally abusive to Resident #1. CMT B should not have yelled and cussed at the resident. The resident felt threatened by CMT B. During an interview on 3/29/24 at 3:20 P.M. the Administrator said CMT B verbally abused Resident #1 and threatened the resident. CMT B should not have cussed or yelled at the resident for any reason. CMT B was suspended that same day and was terminated due to verbal abuse of a resident. MO #00233510

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #3), in a review of 10 sampled residents, received care and treatment in accordance with professional standards of practice to meet the resident's physical, mental and psychosocial needs. Staff failed to assess the resident, notify the physician and obtain treatment following a change in condition when the resident had ongoing diarrhea, vomiting and increased weakness. The resident required hospitalizaiton for a hypokalemia (a critically low potassium level which can be life threatening), and moisture related skin breakdown. Upon return to the facility, staff failed to ensure supplemental potassium medication and a nutritional supplement were obtained and administered as ordered. Staff also failed to provide incontinence care and provide appropriate care and services to ensure known moisture related skin breakdown treatment was implemented, and failed to ensure safe transfers of the resident from the wheelchair to bed. The facility census was 70. Review of the facility's Resident Condition Change Policy dated March 2015 showed the purpose was to observe, record and report any condition change to the attending physician so proper treatment can be implemented. Review of the undated facility policy Medication Administration showed the following: -Medications are given to benefit a resident's health as ordered by the physician; -Administer medications as ordered by the physician. Review of the undated facility policy Wound Care and Treatment showed the following: -It was the purpose of the facility to prevent and treat all wounds; -Prevention strategies included on-going skin assessment with weekly documentation of status, minimize dry skin, apply house moisturizer to areas of dry skin , after bath and as needed. Minimize friction and sheer through proper positioning, transferring and turning. Develop and implement method of communicating position changing; -Incontinence management included minimize skin exposure to incontinence. Cleanse skin following each episode of incontinence. Review of the facility's undated policy Gait Belt Use showed the following: -Purpose: To provide better control and balance while assisting resident with ambulation and transfer; -Guidelines: Assist the resident to a sitting position, apply belt to resident's waist - tighten to fit snugly with the buckle at the back side, face the resident, bend your knees and place your hands around the gait belt on each side of the resident's waist Bring the resident to a standing position while straightening your knees, after the resident is standing, the belt provides assistance stabilizing the turning the resident. 1. Review of Resident #3's care plan dated 12/14/23 showed the following: -Diagnoses of Alzheimer's, osteoarthritis, pain in legs, atrial fibrillation (irregular heart rhythm that caused poor blood flow and risk of blood clots) and cardiac arrythmia (irregular heart rythym) ; -Potential for pain. Staff should administer medications as ordered, monitor and record effectiveness, encourage sufficient uninterrupted rest periods, assist with comfort and physical support as necessary, avoid undue stress and irritation to joints; -Risk of skin breakdown related to incontinence and limited mobility. Staff should apply barrier cream, encourage to lay down in the afternoon, assist with toileting and hygiene, keep the resident clean and dry. Review of the resident's Physician Order Sheet (POS) dated 2/1/24 showed the following: -Lasix (medication used to treat fluid retention, remove excess fluid by stimulating the kidneys to produce more urine. Lasix also removes potassium from the body) 20 milligrams (mg) daily; -Eliquis (a blood thinning medication used to prevent the development of blood clots) 5 mg twice daily; -Imodium (medication used to treat diarrhea) 2 mg, give 2 tablets as needed after first episode of diarrhea, then 1 tablet after each loose stool, not to exceed 6 tablets in 24 hours; -Zofran (medication used to treat nausea) 4 mg every 6 hours as needed for nausea. Review of the resident's skin assessment dated [DATE] showed staff documented the resident's skin was intact. Review of the resident's nurses note dated 2/21/24 showed staff documented the following: -At 3:53 P.M. the resident's family called to say the resident was struggling with nausea and acid reflux daily. The resident was more confused than usual and requested a urinalysis (a diagnostic lab procedure used to determine urinary changes and infection). Staff notified the physician and awaited new orders; -At 4:40 P.M., physician order received for urinalysis, physician's staff would call back with new orders pertaining to nausea and acid reflux. Review of the resident's record showed no documentation staff obtained a urine sample as ordered. There was no documentation of urinalysis laboratory results (ordered on 2/21/24). Review of the resident's POS dated 2/23/24 showed an order for Prevacid (medication used to treat gastric reflux) 30 mg twice daily. Review of the resident's Medication Administration Record (MAR) dated 2/23/24 through 2/29/24, showed staff did not administer Prevacid 30 mg twice daily as ordered and noted the medication was not available. Review of the resident's record showed no documentation staff notified the physician the Prevacid 30 mg twice daily was not administered from 2/23/24 through 2/29/24. Review of the resident's MAR for 3/10/24 staff did not document administration of Eliquis 5 mg evening dose. Review of the resident's record showed no documentation staff notified the physician the Eliquis 5 mg was not administered as ordered for the evening dose on 3/10/24. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 3/13/24, showed the following: -Severely impaired cognition; -Required substantial staff assistance (staff does more than half the effort) with toileting hygiene, showers, dressing, and personal hygiene; -Independent in bed mobility and transfers; -Independently mobile in a wheelchair; -Frequently incontinent of bladder; -Always continent of bowel; -At risk for pressure ulcers, no current pressure ulcers or other open wounds or moisture associated skin damage. Review of the resident's MAR dated 3/16/24 showed staff did not document administration of Eliquis 5 mg evening dose. Review of the resident's record showed no documentation staff notified the resident's physician Eliquis 5 mg was not administered on 3/16/24 for the evening dose. Review of the resident's MAR dated 3/20/24 at 6:45 A.M. showed staff documented Zofran 4 mg administered for nausea with some relief of nausea as the result. Review of the resident's nurses' notes showed no documentation or assessment indicating the resident had nausea. Review of the resident's MAR showed staff did not document administration of Eliquis 5 mg evening dose on 3/20/24 and 3/21/24. Review of the resident's record showed no documentation staff notified the resident's physician Eliquis 5 mg was not administered on 3/20/24 and 3/21/24 for the evening doses. Review of the resident's MAR dated 3/21/24 at 12:10 P.M. showed staff documented Imodium 2 mg administered for loose stools. Staff did not document the result following administration. Review of the resident's nurses' notes showed no documentation or assessment regarding the resident's diarrhea. Review of the resident's nurses noted dated 3/24/24 showed staff documented the following: -At 3:51 P.M. family visiting and reported the resident had loose stools for the past week. The Imodium was not helping. The resident had loss of appetite and seemed more confused. Staff called the physician for new physician orders; -At 4:17 P.M. a urine specimen was collected pending any new physician orders; -At 5:38 P.M. the resident was listless, vomited and family said the resident's speech was slower than normal. The physician was notified with orders to send the resident to the emergency room . The resident was transported by the family to the emergency room . Review of the resident's urinalysis report obtained by the facility and dated 3/24/24 showed the following: -Nitrite (indicated evidence of bacteria in the urine), result positive (normal negative); -WBC (White Blood Cell, indicated infection), result 6-20 (normal less than 6); -Epithelial Cell (cells that cover the inside of the organ, when present in a urine sample indicated infection), result few (normal negative); -Bacteria (organisms), result TNTC (too numerous to count, indicating a large amount of bacteria, normal negative); -Culture (diagnostic lab procedure used to identify the type of bacteria causing an infection) indicated and completed 3/28/24 with Escherichia coli (bacteria normally present in the intestines, frequent cause of urinary tract infections) confirmed organism. Review of the resident's hospital emergency room report dated 3/24/24 showed the following: -Presented to the emergency room with nausea, vomiting, diarrhea and slurred speech; -Symptoms began earlier in the week. Family noted slurring of the resident's speech while talking on the phone two days previously; -Resident complained of nausea, vomiting and multiple episodes of diarrhea. Vomiting was described as dry heaving with vomitus of mostly sputum. Diarrhea was watery and brown; -Critically low (life threatening) potassium (a type of electrolyte or mineral required to help nerves to function and muscles to contract including the heart muscle. Low potassium can be caused by medications such as Lasix, diarrhea and vomiting, a large drop in blood potassium level can cause abnormal heart rhythms and a very low blood potassium level can cause the heart to stop), level of 1.6 (3.6 to 5.2 normal range); -Intravenous (IV) and oral (by mouth) potassium as well as magnesium (a mineral that helps maintain a normal heart rhythm) bolus administered (a large dose); -Clinical impression of nausea, vomiting and diarrhea, hypokalemia (low blood potassium level), dysarthria (weakness in the muscles used for speech, slowed or slurred speech); -Transfer to another hospital for further management and admit to Intensive Care Unit (ICU). Review of the resident's hospital admission record dated 3/25/24 showed moisture associated skin damage of the buttocks, coccyx (tailbone area), groin and perineal skin folds. All areas beefy red. Review of the resident's hospital discharge records dated 3/28/24 showed the following: -Apply barrier paste to coccyx twice daily and as needed after soiling or incontinence. Cleanse the area and reapply the barrier where needed to provide protection; -While up in the chair, alternate lifting hips or prop on pillow alternating every 15 minutes, while in bed turn every two hours; -Start taking potassium bicarbonate-citric acid (Effer-K, potassium supplement)10 milliequivalents (mEq), effervescent (dissolving powder causes bubbles), take 30 mEq twice daily; -Start taking Ensure MAX protein (nutritional supplement) twice daily. Review of the resident's POS dated 3/28/24 showed the following: -Effer-K 10mEq, administer 30mEq twice daily; -Ensure MAX protein twice daily. Review of the resident's POS showed no physician's order for barrier cream to the coccyx twice daily and as needed after soiling or incontinence. Review of the resident's skin assessment dated [DATE] at 3:39 P.M. showed staff documented excoriation to the buttocks and inner thighs. Review of the resident's MAR showed the following: -On 3/28/24 staff documented the Effer-K 30mEq evening dose was not administered, medication not available; -On 3/28/24 staff documented Ensure MAX protein evening dose was not administered, the supplement was not available; -On 3/28/24 staff documented Eliquis 5 mg evening dose was not administered; -On 3/29/24 staff documented Effer-K 30mEq morning dose was not administered, medication not available; -On 3/29/24 staff documented Ensure MAX protein evening dose was not administered, the supplement was not available. During an interview on 3/29/24 at 9:45 A.M. the resident's family member said the following: -At the end of February, the resident was more confused and family asked for a urinalysis, staff said they could not get the specimen and no urinalysis was completed; -The resident remained confused and had diarrhea for several days. Staff said they gave the resident Imodium. On 3/22/24 staff told the family the resident did not eat breakfast or lunch, vomited and was given Zofran and Imodium; -On 3/24/24 the resident was weak and could not sit up in the bed, his/her lips were cracked and peeling, tongue was dry and cracked. Family asked staff for help and offered Zofran and Imodium. Family requested the resident be sent to the emergency room ; -On 3/24/24 family transported the resident to the emergency room and was present when hospital staff removed the resident's soiled incontinence brief. The incontinence brief contained urine and feces. The resident's buttocks and perineal skin were red and raw with open sores and the resident's skin was tender to the touch; -The emergency room transferred the resident to a larger hospital ICU for treatment of the low potassium, irregular heart rate, nausea, vomiting and diarrhea; -On 3/28/24 the resident returned to the facility. About 8:00 P.M. the resident was incontinent of bowel and bladder, staff changed the resident and the brief was marked with an x by the family. On 3/29/24 at 8:00 A.M. the resident wore the same x marked brief the resident had on 12 hours earlier. Observation on 3/29/24 at 2:30 P.M. showed the following: -The resident sat in the wheelchair with his/her head down and eyes closed. Certified Nurse Assistant (CNA) F woke the resident and lifted the resident under the arms, without the use of a gait belt (a device put on a resident who has mobility issues, by a caregiver prior to that caregiver moving the resident. A gait belt may be used to aid in the safe movement of a resident), and transferred the resident to bed. The resident's incontinence brief sagged in the back as CNA F lifted the resident out of the wheelchair. The resident's legs were slightly bent, and the resident leaned forward toward CNA F as CNA F pivoted the resident towards the bed. The resident moaned during the transfer and did not attempt to stand and bear weight; -CNA F turned the resident to his/her side and pulled the resident's pants and incontinence brief down. The resident's entire buttock skin folds, coccyx and perineal skin folds, extending to the groin areas, were dark red with open areas to the buttocks with dark purple areas noted. A brownish stain was noted on the incontinence brief. No barrier cream was noted on the resident's buttocks or perineal skin folds. CNA F did not change the resident's soiled incontinence brief or provide incontinence care. CNA F pulled the resident's soiled incontinence brief and pants up, positioned the resident on his/her back and left the resident's room. During an interview on 3/29/24 at 2:40 P.M. CNA F said the following: -He/She was working a double shift from 10:30 P.M. on 3/28/24 to 3:00 P.M. on 3/29/24. He/She was responsible for the resident since 10:30 P.M. on 3/28/24. He/She was the only CNA on the resident's hall during the night shift and had assistance if needed from staff on other halls during the day shift; -The resident slept all night and wore an incontinence brief all night. CNA F was sure at some point during the night, he/she had changed the resident's incontinence brief and had changed the resident around 8:00 A.M. on 3/29/24 when the family was visiting. CNA F had not changed the resident since 8:00 A.M. on 3/29/24 and the resident remained in the wheelchair all day. The resident was weak and had difficulty turning. CNA F had taken the resident to the dining room for meals in his/her wheelchair on 3/29/24; -CNA F used either a lift or gait belt for transfers or lifted under the resident's arms like he/she had just lifted Resident #3. The resident had to be lifted today because he/she could not hold any weight on his/her legs. CNA F did not always use a gait belt but he/she should when the resident could not bear weight. There was no gait belt in Resident #3's room for use at the time of the transfer from the wheelchair to the bed; -The resident was dry when he/she pulled the resident's incontinence brief and pants down. He/She did not know what the brown stain was in the resident's incontinence brief. CNA F did not know if the resident had skin issues previously and did not know if the resident needed changed more frequently. The resident was not wet but did have a brownish stain in the brief. CNA F did not know what the redness on the resident's skin was, he/she did see the resident had an open area on his/her buttocks. Review of the resident's record showed no assessment of the resident's reddened and open perineal skin and showed no orders for barrier cream or treatment of reddened and open perineal skin. During an interview on 3/29/24 at 12:00 P.M. Certified Medication Technician (CMT) G said the resident had a new order for Effer-K. The medication was not available in the Stat Safe (emergency medication supply safe provided and stocked by the pharmacy). The order was sent to the pharmacy and should arrive after 5:00 P.M. on 3/29/24. The resident had not received any potassium supplement since his/her return to the facility on [DATE]. CMT G was not aware the resident had a critically low potassium while hospitalized . During an interview on 3/29/24 at 12:40 P.M., the pharmacy nurse consultant said delivery of medications was available 24 hours per day. Staff were aware of the procedure to obtain medications other than the routine delivery. The procedure was posted in the medication room and staff were informed by pharmacy staff. If the pharmacy was not notified of an emergent need, the medication was delivered the following day after 5:00 P.M. at the normal delivery time. The Stat Safe did not contain Effer-K. During interviews on 3/29/24 at 12:20 P.M. and 3:10 P.M., the Director of Nursing (DON) said the following: -She was unaware staff had not administered the resident's Effer-K since the resident's return from the hospital. No stat (emergent) order was sent to the pharmacy and the physician was not notified the medication was not administered. She was not aware the resident had a critically low potassium when admitted to the hospital. It was important the resident received the supplemental potassium; -Staff should always provide incontinence care and prevent skin breakdown. The resident had skin breakdown when he/she went to the hospital caused by the diarrhea and incontinence; -Staff should have assessed the resident and obtained treatment for the resident sooner. Staff did not obtain the urinalysis as ordered on 2/21/24. Staff did not call the physician and report the resident's change in condition. Staff gave the resident Imodium with no relief of the symptoms. Staff were not assessing and monitoring the resident. The family took the resident to the hospital for care; -The DON expected staff to follow the physician's orders, obtain laboratory tests and provide treatments and medications as ordered and keep the physician informed of the resident's ongoing condition. Staff should not miss doses of any resident's medication; -Staff should always do what was needed, and always follow up with any change in a resident's condition, call the physician for treatment orders and implement those orders immediately. During interview on 3/29/24 at 3:20 P.M. the Administrator said staff should always follow the physician's orders, administer medications as ordered and follow up when a resident had a change in condition. Staff should notify the physician of any change in a resident's condition, provide thorough assessments, and implement new physician orders, treatments and laboratory testing immediately. During an interview on 4/11/24 at 10:00 A.M. the physician's nurse said the following: -Facility staff notified the physician of the resident's gastric reflux on 2/21/24 and indicated the resident had some nausea related to gastric reflux. Prevacid was ordered twice daily. Staff had not informed the physician Prevacid twice daily was not admininstered as ordered for six days. Staff had not informed the physician of any missed doses of Eliquis; -Staff sent the resident's hospital discharge orders for review regarding the 3/28/24 hospital discharge. Staff should have administered the resident's supplemental potassium starting the eveing of 3/28/24 and if unavailable called the physician for direction. Staff had not informed the physician the Effer-K was not available and no supplemental potassium was administered as ordered on the evening of 3/28/24 and morning of 3/29/24; -Staff should inform the physician of missed doses of medications, medications unavailable for adminstration and should call the physician regarding any change in condition that required an immediate response; -Staff did not communicate with the physician about the resident's on going nausea, vomiting and diarrhea. If the change in condition was communicated, treatment could have been started sooner and possibly prevented the resident's critically low potassium level and hospitalization . MO#00233663

Based on interview and record review, the facility failed to ensure one resident (Resident #10), in a review of 10 sampled residents, received care and treatment to prevent pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) and received necessary treatment and services consistent with professional standards of practice, to promote healing and prevent new ulcers from developing. The resident, who staff determined was at risk for developing pressure ulcers, developed pressure ulcers to both the right and left heels, the coccyx (tailbone area), left posterior calf (lower back leg area) and right lower leg. The facility census was 70. Review of the facility's undated policy, Pressure Ulcer Care and Prevention, showed the following: -Purpose: To prevent and treat further breakdown of pressure ulcers; -Treatment of pressure ulcers will vary depending on the orders of the attending physician. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers; -Observe skin. Any persistent reddened area that remains after pressure is relieved is a high risk for pressure ulcer to begin; -Apply lotion gently to dry skin; -Change bed linen promptly whenever wet or soiled; -Keep sheets dry, free of wrinkles and free of debris; -Use pressure reducing devices to relieve pressure; -Turn the resident every two hours and position with pads or pillows to protect bony prominences; -Use elbow and heel protectors if needed; -Assist resident at mealtime to assure adequate nutrition. Review of the facility undated policy, Wound Care and Treatment, showed the following: -It was the purpose of the facility to prevent and treat all wounds; -The care plan should reflect the current status of the wound and appropriate goals and approaches; -Prevention strategies included on-going skin assessment with weekly documentation of the status, minimize dry skin, apply moisturizer to areas of dry skin, minimize friction and sheer through proper positioning, transferring and turning; -Incontinence managment included minimize skin exposure to incontinence, and /or wound drainage. Provide incontinence care following each incontinent episode; -Positioning and pressure reduction included for the resident at moderate risk of developing pressure ulcers and did not have a current pressure ulcer, apply pressure-reduction mattress or overlay onto the bed, provide pressure reduction wheelchair cushion. Review of the National Pressure Injury Advisory Panel (NPIAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Injury Advisory Panel 2019, showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling; -Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined; -Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; -Slough: necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy; -Eschar: thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound. 1. Review of Resident #10's Base Line (initial care plan completed on admission) care plan showed the following: -admitted [DATE]; -Diagnoses of dementia, arthritis, heart failure, diabetes, pain and abnormal gait and mobility. -Alert and cognitively intact; -Required assistance of one staff member with bed mobility, hygiene, and bathing; -Required assistance of two staff members with transfers and toileting; -Always incontinent of bowel and bladder. Unable to manage own toileting functions and required all cares to be provide by staff. The resident wore incontinence briefs. Staff should provide cares necessary to maintain hygiene, promote dignity and avoid skin breakdown; -History of falls, was a fall risk, unsteady with transfers and balance, muscle weakness, fatigue and endurance concerns; -Staff should monitor medications, provide a safe environment, monitor condition and report changes to Director of Nursing (DON) and physician as applicable, provide comfort and care, monitor lab values and report to physician; -Staff should provided cushions for the resident's wheelchair, -Goals were to maintain health and safety while performing Activities of Daily Living (ADLs) as independently as possible. Review of the resident's weekly skin assessment dated [DATE] showed staff documented the following: -Right and left heels were firm (normal condition) and intact; -Missing second and third toe on right foot; -Bruising to hands and forearms and scabs to bridge of nose; -No documented pressure ulcers. Review of the resident's Braden Scale (a tool used for predicting pressure ulcer risk, made up of six scored subscales for a total score range from 6-23. A lower score indicated a lower level of functioning and a hgher level of risk for pressure ulcer development) dated 12/28/24 showed the following: -No impairment in ability to respond meaningfully to pressure-related discomfort; -Very moist, skin was often but not always moist, linen must be changed at least once a shift; -Chairfast, ability to walk was severely limited; -Very limited, unable to make frequent or significant changes independently in body or extremity position; -Adequate ability to eat over half of most meals; -Problem with shear and friction, rquired moderate to maximum assist in moving; -Score of 14 indicating moderate risk for developing pressure ulcers. Review of the resident's nurses note dated 12/29/23 showed staff documented the following: -At 3:00 A.M. the resident was alert and oriented with occasional periods of confusion. Incontinent of bowel and bladder; -At 9:47 A.M. the resident was admitted to the facility on [DATE] for physical therapy due to falling, had two falls prior to facility admission. The resident was cooperative with care, able to communicate needs, wore incontinence briefs and used a wheelchair for locomotion. Review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 1/3/24, showed the following: -Cognitively intact; -Independent with eating; -Required partial/moderate assistance (staff provided less than half the effort) with dressing upper body, and bed mobility (turning from side to side in the bed, moving from lying flat in the bed to sitting on the side of the bed and sitting on the side of the bed to lying flat on the bed); -Required substantial/maximum staff assistance (staff provided more than half the effort) with personal hygiene, putting on/taking off footwear, and transfers from a chair, bed or toilet; -Dependent on staff (staff provided all the effort) with toileting, showers, dressing lower body and standing up from a sitting position; -Unable to walk; -Wheelchair for mobility with substantial/maximal staff assistance; -Frequently incontinent of bowel and bladder; -At risk for developing pressure ulcers; -No current pressure ulcers or moisture associated skin damage; -Pressure reducing device (equipment that aims to relieve pressure away from areas of high risk for skin breakdown) for chair. Review of the resident's nurses note dated 1/6/24 at 12:30 P.M. showed staff documented the resident was incontinent of bowel and bladder. A spot was noted on the resident's mid back. The area looked like an old scab. A dressing was placed over the scab and information passed along at change of shift report. Review of the resident's Physician Order Sheet (POS) dated 1/9/24 showed an order to cleanse both heels with normal saline (NS) (a sterile wound cleansing fluid) and pat dry, apply Skin Prep (protective wipe used to form a barrier to help preserve skin integrity and prevent injury to the skin) to bilateral heels daily and heel protector (pressure relieving padded boots) to bilateral feet. Review of the resident's nurses notes showed staff documented the following: -On 1/9/24 a t 10:20 A.M. the resident had a blister (fluid filled skin injury) on each heel. Skin prep applied to heels. The resident required two staff member assistance with transfers; -On 1/10/24 at 5:33 P.M. the resident required assistance of two staff members with all cares and a mechanical lift for transfers. Review of the resident's POS dated 1/16/24, showed wash bilateral heels with wound wash (cleansing wound agent) and pat dry, apply petroleum gauze to open area and cover with non-adherent pads and wrap with gauze. Review of the resident's weekly skin assessment dated [DATE] showed staff documented the resident had open blisters to both heels and redness to the coccyx (tailbone area). Review showed no documentation regarding the size and condition of the open blisters. Review of the resident's nurses notes showed staff documented the following: -On 1/19/24 at 1:56 P.M,. the resident was alert and oriented. Blisters to both heels had opened, dressing change provided as ordered and educated family and resident on pressure relief. Physician notified and request for Wound Care Plus consult (consulting wound care management company) ordered; -On 1/20/24 at 3:04 P.M. the buttock wound treatment was done, the resident was incontinent of bowel and bladder. Review of the resident's wound management report dated 1/22/24 showed staff documented the following: -Stage III presure ulcer of the coccyx, measured 1.2 cm by 2 cm by 0.2 cm deep. Scant amount of bloody drainage, no odor. The wound bed presented with granulation and slough.The peri-wound area was intact, the resident complained of pain with debridement (cleaning of the wound bed). Review of the wound management report dated 1/22/24 showed no documentation regarding the size and condition of the resident's right and left heel open blisters. Review of the resident's POS dated 1/23/24 showed the following: -Cephalexin (an antibiotic) 500 milligrams twice daily for 10 days; -Float (elevate the heels off the bed) the resident's heels at all times as tolerated. Review of the resident's nurses notes showed the following: -On1/23/24 at 10:10 P.M., a urinary catheter (a sterile tube inserted into the bladder to drain urine) was inserted; -On 1/24/24 at 3:28 P.M., the resident continued with urinary catheter due to buttock wound. Resident in bed. Review of the resident's weekly skin assessment dated [DATE] showed staff documented the resident had open wounds on both heels and a Stage II pressure ulcer (a 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 the coccyx. Review of the resident's POS dated 1/24/24 showed Wound Care Plus to evaluate and treat related to pressure ulcers on the heels. Review of the resident's care plan dated 1/24/24 showed the resident required an indwelling urinary catheter for wound healing. Staff should assess the urine drainage every shift. The resident received antibiotic therapy for prevention of wound infection. Staff should provide extra nutritional calories to help with infection and wound healing, obtain wound cultures as indicated and check resident's temperature every shift. Review of the resident's care plan showed no staff direction or interventions regarding the resident's pressure ulcers prevention and treatment. Review of the resident's wound managment report dated 1/24/24 showed staff documented right heel wound was 8.2 cm by 7 cm by 0.1 cm with bloody drainage and mild odor. The wound edges were macerated and soft with edema (swelling) and redness to the surrounding skin. Review of the Wound Care Plus progress note dated 1/24/24 showed the following: -Evaluation and management of multiple wounds; -Wound #1, left heel chronic Stage III pressure injury pressure ulcer (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) with status of not healed. Initial wound encounter measurements 10 centimeters (cm) by 9.4 cm by 0.1 cm deep with bloody drainage, no odor. The peri (surrounding) wound skin exhibited maceration (softening and braking down of skin resulting from prolonged exposure to moisture) and erythema, peri wound skin friable (fragile skin, tears, bruises or breaks easily) and moist. Unable to determine depth of the wound; -Wound #2, right heel chronic unstageable pressure injury (unable to determine the stage) obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Initial wound encounter measurements 8.2 cm by 7 cm by 0.1 cm deep with small amount of blood drainage with mild odor. The peri wound skin exhibited edema (swelling) and erythema (redness), peri wound skin friable and moist, presented with signs and symptoms of infection. Topical antibiotics (placed directly on the skin) prescribed. Unable to determine depth of the wound due to area of eschar (necrotic dead tissue usually black in color, dry, firm and adhered to the wound bed); -Wound #3, coccyx Stage III pressure injury pressure ulcer with status of not healed. Initial wound encounter measurements 1.2 cm by 2 cm by 0.2 cm deep with scant bloody drainage with no odor. The peri wound skin was friable and moist, peri wound skin did not exhibit signs or symptoms of infection; -The resident's affected body parts were recently (last 2 weeks) immobile prior to the wound developing. Nursing staff noted the pressure ulcers were directly from positioning. The ulcers were mixed etiology including pressure; -Education provided regarding proper offloading of affected area to maintain wound healing. Review of the resident's POS dated 1/25/24 showed the following: -Treatment for bilateral heel pressure ulcers. Cleanse with wound wash and pat dry, apply Santyl (medication ointment used to remove damaged tissue from skin ulcers), Mupirocin ointment (antibiotic ointment applied to the skin or wounds to treat infected wounds) and calcium alginate (wound dressing used to promote healing) to wound bed, cover with non-adherent pad, apply ABD pad (thick absorbent dressing used to cover a wound and absorb drainage, provide protection of the wound) to bilateral heels and wrap with loose gauze, change daily and as needed; -Treatment for Stage II pressure ulcer of the coccyx. Cleanse coccyx with wound wash and pat dry, apply skin prep to peri-wound area, apply Santyl and Calcium Alginate to wound bed, cover with self-adhesive dressing, change daily and as needed. Review of the resident's wound management report dated 1/25/24 showed staff documented the following: -Stage III pressure ulcer of the left heel. Measured 10 cm by 9.4 cm by 0.1 cm deep. Small amount of bloody drainage with no odor. The wound bed presented with granulating tissue, slough and eschar. The surrounding skin was macerated and reddened. No signs or symptoms of infection noted. The resident presented with pain during debridement of the wound. Review of the resident's nurses notes showed staff documented the following: -On 1/25/24 at 7:32 A.M. completed initial consult with Wound Care Plus. New wound care orders for the Stage II pressure ulcer of the coccyx and bilateral heels; -On 1/30/24 at 7:05 P.M. the resident's family member reported the resident was not waking up. Staff woke the resident and the resident responded to the family and told staff his/her incontinence brief needed to be changed. Review of the Wound Care Plus progress note dated 1/31/24 showed the following: -Evaluation and management of multiple wounds; -Wound #1, left heel chronic Stage III pressure injury pressure ulcer with status of not healed. Measurements 6.7 cm by 8.1 cm by 0.1 cm deep, small amount of bloody drainage with no odor. Unable to determine depth of the wound; -Wound #2, right heel chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Measurements 8.4 cm by 6.6 cm by 0.1 cm deep with small amount of blood drainage with mild odor. 51% to 75% eschar (one-half to three-fourths of the wound base covered by eschar) Unable to determine depth of the wound due to area of eschar; -Wound #3, coccyx Stage III pressure injury pressure ulcer with status of not healed. Measurements 2.4cm by 3.1 cm by 0.2 cm deep with scant bloody drainage with no odor. Review of the resident's wound managment report dated 1/31/24 showed staff documented the following: -Stage III pressure of the left heel measured 6.7 cm by 8.2 cm by 0.1 cm deep with bloody drainage and no odor. The wound bed tissue contained slough, granulation tissue and eschar. The surrounding skin was macerated wtih redness; -Unstageable pressure injury of the right heel. Obscured full-thickness skin and tissue loss, measured 8.4 cm by 6.6 cm by 0.1 cm with bloody drainage and mild odor. The wound bed presented with granulation tissue, slough and eschar. The wound edges were macerated and soft with edema and redness to the surrounding skin; -Stage III pressure ulcer of the coccyx measured 2.4 cm by 3.1 cm by 0.2 cm. Small amount of bloody drainage with no odor. The wound bed presented with granulation and slough tissue. The surrounding wound skin was intact. The resident complained of pain with debridement. Review of the resident's nurses' notes showed staff documented the following: -On 2/2/24 at 6:35 P.M. the resident had several episodes of loose stools; -On 2/3/24 at 12:46 P.M. the resident was incontinent and reported mild buttock pain; -On 2/3/24 at 10:15 P.M. the resident yelled out and said he/she felt the metal in his/her heels. Staff tried to reposition the resident. The resident remained uncomfortable, as needed pain medication given with no relief. Review of the resident's weekly skin assessment dated [DATE] showed staff documented the right heel and left heels were not assessed. The left foot and ankle had existing issues. The right foot and ankle had existing issues. Bilateral heel wounds, blisters to the right inner and outer lower extremities and a coccyx wound. No staff documentation regarding the size and condition of the wounds. Review of the resident's wound management report dated 2/7/24 showed staff documented the following: -Unstageable pressure injury of the posterior left calf. Obscured full-thickness skin and tissue loss. No drainage noted and no odor. The wound bed contained eschar; -Stage III pressure of the left heel measured 2 cm by 5 cm by 0.1 cm deep with no drainage and no odor. The wound bed tissue was necrotic with eschar. The surrounding skin was macerated wtih redness; -Unstageable pressure injury of the right heel. Obscured full-thickness skin and tissue loss, measured 6 cm by 6.7 cm by 0.1 cm with bloody drainage and no odor. The wound bed presented eschar. The wound edges were macerated and soft with edema and redness to the surrounding skin; -Stage III pressure ulcer of the coccyx measured 2.8 cm by 4.5 cm by 0.1 cm. Small amount of bloody drainage with no odor. The wound bed presented with granulation and slough tissue. The surrounding wound skin was intact. Review of the Wound Care Plus progress note dated 2/7/24 showed the following: -Evaluation and management of multiple wounds; -Wound #1, left heel chronic Stage III pressure injury pressure ulcer with status of not healed. Measurements 2cm by 5cm by 0.1 cm deep, no drainage. Unable to determine depth of the wound; -Wound #2, right heel chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Measurements 6cm by 6.7cm by 0.1 cm deep with small amount of blood drainage with mild odor. 76% to 100% (three-fourths to complete covering of the wound base covered) eschar. Unable to determine depth of the wound due to area of eschar; -Wound #3, coccyx Stage III pressure injury pressure ulcer with status of not healed. Measurements 2.8cm by 4.5cm by 0.1cm deep with scant bloody drainage with no odor; -Wound #4 left posterior calf is chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer with status of not healed. Initial wound encounter measurements 15.7cm by 1.8cm by 0.1 cm depth, no drainage, wound bed 51% to 75% eschar. Unable to determine depth of the wound due to area of eschar. Review of the resident's POS dated 2/8/24 showed the following: -Treatment for Stage III pressure ulcer of the left heel. Cleanse left heel with wound wash pat dry, apply skin prep over stable area of eschar and peri-wound area, change dressing daily and as needed; -Treatment for unstageable pressure ulcer of the right heel. Cleanse right heel with wound wash and pat dry. Apply skin prep to peri-wound area, apply xeroform (a fine mesh gauze dressing that maintained a moist wound environment to promote healing) to wound bed, (cut to fit wound edges), cover with non-adherent pad, apply ABD, cover with loose gauze and change daily and as needed. Review of the resident's POS dated 2/9/24 showed the following: -Treatment for Stage III pressure ulcer of the coccyx. Cleanse coccyx with wound wash and pat dry, apply Santyl to wound bed, cover with super absorbent dressing, change daily every other day; -Treatment for unspecified pressure ulcer of the left posterior calf. Cleanse left posterior calf with NS and pat dry, apply skin prep to peri-wound area, apply xeroform to wound bed, cover with self-adherent dressing and change every other day. Review of the resident's Treatment Administration Record (TAR) for February 2024 showed no documentation staff provided the physician ordered treatment to the resident's Stage III pressure ulcer of the coccyx every other day as scheduled on 2/9/24 or 2/11/24. Review of the Wound Care Plus progress note dated 2/14/24 showed the following: -Evaluation and management of multiple wounds; -Wound #1, left heel chronic Stage III pressure injury pressure ulcer with status of not healed. Measurements 2cm by 4cm by 0.1 cm deep, no drainage. Unable to determine depth of the wound; -Wound #2, right heel chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Measurements 6cm by 10cm with no measurable depth and small amount of bloody drainage with no odor. 76% to 100% eschar; -Wound #3, coccyx Stage III pressure injury pressure ulcer with status of not healed. Measurement 3cm by 4cm with no measurable depth, large amount of bloody drainage with no odor. 76% to 100% eschar; -Wound #4, left posterior calf is chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer with status of not healed. Initial wound encounter measurements 15cm by 2cm with no measurable depth, small amount of bloody drainage, wound bed 51% to 75% eschar. Review of the resident's POS dated 2/15/24 showed the following: -Cleanse right heel with wound wash and pat dry. Apply skin prep to stable eschar and peri-wound area, cover with ABD, wrap loosely with rolled gauze and change daily and as needed for unspecified stage pressure ulcer of the right heel; -Cleanse left posterior calf with NS and pat dry, apply skin prep to peri-wound area, apply Santyl to wound bed, cove with self-adhesive dressing and change daily for unspecified stage pressure ulcer of the left posterior calf. Review of the resident's wound management report dated 2/15/24 showed staff documented the following: -Left posterior calf unstageable pressure ulcer, measured 15 cm by 2 cm with no measurable depth. Bloody drainage with no odor; -Stage III pressure of the left heel measured 2 cm by 4 cm by 0.1 cm deep with no drainage and no odor.The surrounding skin was macerated with redness; -Unstageable pressure injury of the right heel. Obscured full-thickness skin and tissue loss, measured 6 cm by 10 cm with no depth. Bloody drainage was noted with no odor. The wound bed presented with granulation tissue and eschar. The wound edges were macerated and soft with edema and redness to the surrounding skin; -Unstageable pressure injury of the coccyx. Obscured full thickness skin and tissue loss. Measured 3 cm by 4 cm with no measurable depth. Heavy amount of bloody drainage with no odor. The wound bed presented with granulation tissue and eschar. The surrounding wound skin was intact. Review of the resident's TAR for February 2024 showed no documentation staff provided the physician ordered treatment to the resident's Stage III pressure ulcer of the coccyx every other day as scheduled on 2 /15/24, 2/17/24 or 2/19/24. Review of the resident's weekly skin assessment dated [DATE] showed staff documented the following: -Edema (swelling) with right and left heels soft (not normal, indicating tissue injury); -Left and right foot and ankle with existing issues (no specific documentation describing the issues); -No documentation regarding the resident's unstageable pressure ulcer of the coccyx and no documentation regarding an unstageable pressure ulcer of the left posterior calf. Review of the Wound Care Plus progress note dated 2/21/24 showed the following: -Evaluation and management of multiple wounds; -Wound #1, left heel chronic Stage III pressure injury pressure ulcer with status of not healed. Measurements 2.4cm by 2.4cm by 0.1 cm deep, no drainage. Unable to determine depth of the wound; -Wound #2, right heel chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Measurements 7cm by 7.9cm by 0.1cm deep with small amount of bloody drainage with no odor. 76% to 100% eschar; -Wound #3, coccyx Stage III pressure injury pressure ulcer with status of not healed. Measurements 8.7cm by 6.4cm by 0.2cm deep large amount of bloody drainage with mild odor. 76% to 100% eschar; -Wound #4, left posterior calf is chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer with status of not healed. Measurements 16.9cm by 4cm by 0.2cm deep with small amount of bloody drainage, wound bed 51% to 75% eschar. -Wound #5, right lateral lower leg acute unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer with status of not healed. Initial wound encounter measurements 11.4 cm by 4.4 cm by 0.2 cm deep, small amount of bloody drainage with mild odor, wound bed 51% to 75% eschar. Review of the resident's POS dated 2/21/24 showed the following: -Cleanse right ankle and lateral calf with wound cleanser and pat dry. Apply skin prep to peri-wound area and eschar. Apply Santyl and calcium alginate to wound beds. Cover with non-adherent dressing. Apply ABD pad and wrap with loose gauze, change every other day for unspecified stage pressure ulcer of the right ankle and lateral (outer) calf; -Cleanse the right heel with wound cleanser and pat dry, apply skin prep to peri wound area, apply xeroform to wound bed, cover with non-adherent pad, apply ABD pad around affected area, wrap with loose gauze and change every other day and as needed for unstageable pressure ulcer of the right heel. Review of the resident's wound managment report dated 2/21/24 showed staff documented the following: -Unstageable pressure injury of the right lower lateral leg. Obscured full-thickness and tissue loss. Measured 11.4 cm by 4.4 cm by 0.2 cm. Small amount of bloody drainage with no odor. The wound bed contained granulation tissue, slough and eschar. The surrounding skin area showed edema and maceration; -Left posterior calf unstageable pressure ulcer measured 16.9 cm by 4 cm by 0.2 cm. Bloody drainage with no odor. Necrotic tissue was present; -Stage III pressure of the left heel measured 2.4 cm by 2.4 cm by 0.1 cm deep with no drainage and mild odor. The wound bed presented with healing tissue. The surrounding skin was macerated with redness; -Unstageable pressure injury of the right heel. Obscured full-thickness skin and tissue loss, measured 7 cm by 7.9 cm by 0.1 depth. Bloody drainage was noted with no odor. The wound bed presented with eschar. The wound edges were macerated and soft with edema and redness to the surrounding skin; -Unstageable pressure injury of the coccyx. Obscured full thickness skin and tissue loss. Measured 8.7 cm by 6.4 cm by 0.2 cm depth. Heavy amount of bloody drainage with foul odor. The wound bed presented with granulation tissue slough and eschar. The surrounding wound skin showed edema and redness. Review of the resident's TAR for February 2024 showed no documentation staff provided the physician ordered treatment to the Stage III pressure ulcer of the coccyx every other day as scheduled on 2/21/24. Review of the resident's POS dated 2/22/24 showed the following: -Cleanse coccyx wound with wound cleanser and pat dry, apply Mupirocin, Santyl and Calcium Alginate to the wound bed, cover with self-adhesive dressing, change daily for Stage 3 pressure ulcer of the coccyx region. Review of the resident's POS dated 2/26/24 showed the following: -Cleanse right and left heel wounds, apply betadine and cover with foam pad, change daily and as needed for Stage 3 pressure ulcer of the left heel. -Clean

Based on interview and record review, the facility failed to ensure one resident (Resident #1), with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection in a review of ten sampled residents. Staff failed to obtain physician orders for a newly identified pressure ulcer, failed to conduct and document assessment of the resident's pressure ulcers to determine if the wounds were deteriorating and required a change in treatment, and failed to complete dressing changes as ordered by the physician. The pressure ulcers deteriorated and became infected. Staff failed to begin treatment of the infection with antibiotics as ordered by the wound consultant nurse practitioner. The resident required hospitalization to treat the infection and returned to the facility on hospice care on [DATE] and passed away at the facility on [DATE]. The facility census was 70. The administrator was notified on [DATE] at 5:15 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility policy, Wound Care and Treatment, undated, showed the following: -It is the purpose of this facility to prevent and treat all wounds; -There must be a specific order for the treatment; -Apply a clean dressing as ordered. Label with the nurse's initials, date and time; -Documentation of the treatment should be done immediately after the treatment; -Prevention strategies include on-going skin assessment with weekly documentation of status. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated [DATE], showed the following definitions: -Stage I pressure ulcer is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) erythema (redness). Presence of blanchable erythema changes in sensation, temperature, or firmness may precede visual changes; -Stage II pressure ulcer is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present; -Stage III pressure ulcer is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed; -Stage IV pressure ulcer is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location; -Unstageable pressure ulcer is a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; -Deep Tissue Pressure Injury (DTI) is an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure ulcer (unstageable, Stage III or Stage IV pressure ulcer). 1. Review of Resident #1's undated face sheet, showed diagnoses including pressure ulcer sacral region (a large triangular bone at the base of the spine) unspecified stage, pressure induced deep tissue damage unspecified site, pressure ulcer of unspecified buttock, unspecified stage, weakness and altered mental status. Review of the resident's Braden Scale (an tool for predicting pressure ulcer risk; a low score indicates higher levels of risk for pressure ulcer development) assessment form, dated [DATE], completed by facility staff, showed a score of 16, indicating the resident was at risk for pressure ulcer development. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE] showed the following: -Severe cognitive impairment; -Extensive assistance of one staff member for bed mobility; -Dependent on one staff member for transfers, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder; -At risk for pressure ulcers; -The resident did not have any pressure ulcers; -The resident did not have a pressure reducing device for chair or bed and was not on a turning and repositioning program. Review of the resident's weekly skin assessment, dated [DATE] at 10:56 A.M., showed his/her skin was intact. No skin issues present. Review of the resident's nursing note, dated [DATE] at 9:44 P.M., showed the nurse was called into the resident's room due to staff finding two open areas on the resident's skin. One open area on the coccyx (also known as the tailbone is the triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum) measured 2.0 centimeters (cm) by 2.0 cm by 0.1 cm. The other open area was on the left heel and measured 4.0 cm by 3.0 cm by 0.0 and was dark purple to black in color. Staff applied a foam dressing to both areas. Review of the resident's physician order sheet (POS) for [DATE] showed no evidence facility staff obtained a physician's order for treatment of the new skin issues identified on [DATE] until [DATE]. Review of the resident's interdisciplinary team note, dated [DATE] at 9:46 A.M. showed the following: Assessment: Wounds to sacral bone: Stage II 0.5 cm x 0.5 cm x 0.1 cm, round with linear extension to the left side measured 1.5 cm x 0.1 cm., wound bed pink, clean, edges well defined and without maceration (when skin has been exposed to moisture for too long) and peri-wound clean; -Left foot: plantar aspect (bottom of foot) over lateral calcaneus (side of the heel bone) measured 5.0 cm x 5.0 cm x 0 cm. Area not open: DTI (deep tissue injury) with light brown firm/hard cover, mildly boggy (soft) center. Edges well defined; -Left foot: lateral (side) metatarsal (middle bones in our feet between your toes and your ankle bones) near 5th digit: 2.0 cm x 0.5 cm x 0 cm; not open. DTI with firm light brown cover. Edges clearly defined and without maceration; Multiple confounding factors: debility, immobility, contractures of the hips/knees, dementia precluding ability to understand measures to heal, historically poor appetite, dependence for all activities of daily living (ADL), and incontinence. Visual/physical assessment: when in bed the resident lays to the left, with direct pressure to areas noted to have damage. Immobile, contractures. Review of the resident's weekly skin assessment, dated [DATE], at 10:33 A.M. showed left heel, left lateral metatarsal immediate above fifth digit. New order obtained. Review of the resident's care plan, revised on [DATE], showed the following: -Pressure ulcer/injury, skin integrity impairment: pressure induced DTI to the left foot, plantar heel and lateral metatarsal fifth toe, -Assess progress of wound treatments per facility policy, and report need for changes as needed; -Avoid friction, and shearing during transfer and position changes; -Keep bony prominences of legs, knees, heels from direct contact with one another with pillows and pads when in bed; -Pillow behind legs to keep heels from hitting surface of lower chair; -Pillow behind legs when in broad to keep heels from hitting surface of lower chair; -Turning and repositioning every two hours when in bed, using side to side schedule; pillows and pads for alignment, padding and position; -Use heel protectors to relieve pressure on the heels, as well as floating the heels when in bed; -Stage II pressure ulcer to sacrum, incontinent care every two hours and as needed to keep skin clean and dry as possible; barrier cream to surrounding skin; -Keep linens clean and dry, and wrinkle free; -Monitor for wound condition, weekly skin assessment. Report issues to the physician; -The resident will be on a side to side turn schedule when in bed, pillows and pads for positioning, comfort and padding; -Treatment as ordered and monitor for effectiveness. Review of the resident's POS, dated [DATE], showed the following: -Treatment to left heel and left lateral foot pressure induced (DTI) areas; skin prep (a liquid film-forming dressing) to each area, wrap foot with light kling and change every day (start date [DATE]); -Treatment to sacral Stage II: gently cleanse with wound cleanser. Skin prep to periwound. No product to the wound. Cover with a 2 x 2 gauze or folded 4 x 4 gauze, secure with tape, twice a day (start date [DATE]). Review of the resident's medical record showed no evidence facility staff completed a weekly skin assessment on [DATE]. Review of the resident's treatment administration record (TAR), dated [DATE], showed the following: -Treatment to left heel and left lateral foot pressure induced (DTI) areas; skin prep to each area wrap foot with light kling and change every day (start date [DATE]); -The dressing to the left heel was not documented as completed per order on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]; -Treatment to the sacral wound stage II: gently cleanse with wound cleanser. Skin prep to periwound. No product to the wound. Cover with a 2 x 2 gauze or folded 4 x 4 gauze secure with tape, twice a day (start date [DATE]); -The dressing to the sacral wound was not documented as completed on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Review of the resident's medical record showed no evidence the facility staff completed a weekly skin assessment on [DATE]. Review of the resident's TAR, dated [DATE], showed the following: -There was no documentation staff completed a dressing change to the left heel and left lateral foot on [DATE]; -There was no documentation staff completed a dressing change to the sacral wound on [DATE]. Review of the resident's physician order dated [DATE] showed wound care plus (wound care consultant company) to evaluate and treat. Review of the resident' medical record showed no evidence the facility staff completed a weekly skin assessment on [DATE]. Review of the wound care plus consultant note, dated [DATE] at 9:29 A.M., showed the following: -The resident was seen for evaluation and management of multiple wounds; -Sacral and heel wounds with signs and symptoms of infection. Culture and sensitivity (C&S) (a test that detects germs present and determines which antibiotic will be most affective in treating an infection) of the wound was obtained. All wounds were debrided (excision of damaged tissue) and the foot wound was unroofed (opening or taking off the top) due to fluctuance (a pocket of fluid trapped in the tissues), X-ray of sacrum ordered. Treatment plan updated as indicated; Wound assessments: -Wound #1, sacral wound was a chronic unstageable pressure injury, obscured full-thickness skin and tissue loss and has a status of not healed. Measurements were 8.6 cm x 4.0 cm x 0.3 cm. There was a moderate amount of purulent drainage noted which had a strong odor. The wound bed had 1- 25 % pink granulation tissue and 51 - 75 % slough. The periwound skin exhibited edema, scarring and erythema. The periwound was friable (skin that is easily irritated, which makes it prone to bleeding or tearing) and moist. The periwound skin presents with signs and symptoms of infection, C&S pending, X-ray/Scan, topical antibiotic prescribed; -Wound #2, left heel was a Stage III, chronic deep tissue pressure injury, persistent nonblancheable deep red, maroon or purple discoloration, pressure ulcer has received a status of not healed. Measurements were 4.8 cm x 4. 8 cm x 0.1 cm. There was moderate purulent (consisting or containing pus) drainage which had a strong odor. The periwound skin exhibited erythema and edema. The periwound was friable and moist. Periwound skin presents with signs and symptoms of infection, topical antibiotics prescribed; -Wound #3 left, lateral foot was a chronic unstageable pressure ulcer and has received a status of not healed. Measurements were 0.7 cm x 1.0 cm x 0.1 cm depth. Wound bed with 76% to 100% eschar. The periwound skin exhibited callus, fluctuance and ecchymosis (bruising). Review of the resident's culture and sensitivity, report summary dated [DATE], untimed, showed the following: -Sample type was wound; -Organisms detected: Bacteroides fragilis (a bacteria that is a common component of the colon, spread of the bacteria to the blood stream or surrounding tissues results in clinically significant infection); -Enterobacteriaceae bacterium (large family of bacteria); -Enterococcus faecalis (a bacteria found in the intestines,while it tends to be harmless in the colon it can cause serious infection if spread to other areas of the body); -Escherichia coli (a type of bacteria that normally lives in your intestines and can cause skin infections); -Finegoldia [NAME] (a bacteria associated with severe infections); -Proteus mirabilis (a bacteria that can cause wound infections); -Streptococcus viridians group (a bacteria that can cause infections in the tissue under the skin and bloodstream); -Treatment option delafloxacin (oral antibiotic) 450 milligrams (mg) by mouth every twelve hours for five days for possible skin and soft tissue infections; -Alternate treatment options: Ertapenum (intravenous antibiotic, that goes directly in to the bloodstream, used to treat certain serious infections) one gram every 24 hours for five days or Levafloxcin (antibiotic used to treat bacterial infections) 750 mg by mouth and Metronidazole (used to treat various infections caused by bacteria) 500 mg IV (intravenous, administered directly into the bloodstream) every eight hours for five days. Review of the resident's nurses note, dated [DATE] at 10:15 P.M., showed a new order for the resident to start delafloxacin (oral antibiotic) 450 mg by mouth for five days for wound infection. The pharmacy called and the medication was on order and would be delivered on [DATE]. Review of the resident's POS for [DATE] showed the antibiotic order from the culture and sensitivity report dated [DATE] was not transcribed to the POS. Review of the resident's MAR for [DATE] showed the antibiotic order from the culture and sensitivity report dated [DATE] was not transcribed to the MAR. Review of the resident's nurses note, dated [DATE] at 11:47 A.M., showed the following: -The resident presented in the morning with altered mental status and febrile (fever) at 101.3 degrees Fahrenheit (normal temperature 97.0 degrees Fahrenheit to 99 degree Fahrenheit). The resident was awake but non-responsive. Given the resident's decline and staff being unable to reach the power of attorney (POA), the physician gave an order to send the resident to the hospital emergency room for evaluation. The resident left facility at 10:00 A.M. Review of the resident's hospital history and physical, dated [DATE], showed the following: -Reason for admission was sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection) likely secondary to gluteal decubitus ulcer verses other cause; -Right gluteal ulcer with underlying soft tissue gas (underlying infectious process) and associated cellulitis (common, potentially serious bacterial skin infection). Review of the resident's readmission nurses note, dated [DATE] at 1:42 A.M., (recorded as a late entry) showed the resident returned from the hospital at 10:18 P.M., via ambulance. The resident's discharge diagnosis was decubitus ulcer and sepsis. The resident was admitted on hospice care. Review of the resident's nurses note, dated [DATE] at 11:04 A.M., showed the resident died . During an interview on [DATE] at 8:00 A.M. Licensed Practical Nurse (LPN) B said the following: -He/She noted the wounds to the resident on [DATE] and documented the areas found in the resident's nursing notes; -He/She covered the wound with a foam dressing and notified the wound nurse at that time of the wounds. LPN B thought the wound nurse would stage the wounds, notify the physician and obtain treatment orders. During an interview on [DATE] at 4:00 P.M. the facility's assistant director of nursing (ADON)/wound Nurse/LPN D (who no longer worked at the facility) said the following: -A Certified Nurse Aide (CNA) brought to his/her attention the resident had an open area on his/her buttock sometime in [DATE]; -He/She did not recall if orders were obtained for a treatment of the area or not; -If a charge nurse found an open area they should have obtained orders; -He/She may have missed completing some skin assessments on the resident; -The wound care plus nurse practitioner notified him/her of the resident's wound culture results and orders for antibiotics on the evening of [DATE] while he/she was not at work; -He/She notified Registered Nurse (RN) A of the culture and sensitivity results and the antibiotic orders, along with the alternate option, which was available in the E-kit at the facility; -He/She expected RN A to start the antibiotic as ordered. During an interview on [DATE] at 10:36 A.M., RN A said the following: -He/She worked on [DATE], when the ADON/wound nurse called him/her at the facility and said the resident's wound culture was back. The wound care plus nurse practitioner had notified the ADON of the culture results; -Wound care plus ordered an antibiotic and the pharmacy would not have it available until [DATE] (three days later); -The ADON said he/she would call wound care plus and let them know the antibiotic was not available until [DATE]; -RN A worked on [DATE] and [DATE] and noticed the resident's wounds had an odor when he/she was in the resident's room; -RN A checked the resident's temperature and vital signs over the weekend, but did not document her assessment; -On [DATE] the resident was not responsive and was running a fever. RN A contacted the resident's physician and the physician gave the order to send the resident to the hospital. The resident was very ill; -RN A did not notify the resident's physician about the wound culture or antibiotic orders from wound care plus on [DATE]. RN A thought the ADON would take care of notifying the physician. During an interview on [DATE] at 10:30 A.M., the wound consultant nurse practitioner said the following: -He/She would expect the nursing staff to start the antibiotics as ordered; -The resident may have already been septic, but there was no way to know at that time; -The wound status could worsen if the antibiotics weren't started; -He/She gave antibiotic alternatives, if the initial antibiotic was not available. During an interview on [DATE] at 9:38 A.M., the resident's physician said the following: -Staff should have notified him if there was an order for an antibiotic and it was not available; -The antibiotic would have probably improved the resident's health; -There was a system failure. Things could have been done differently including issues with delays in starting antibiotics, not contacting him regarding the culture report and antibiotic orders, the nursing staff not following standard nursing practice, not notifying him of the wound status, not completing dressing changes possibly hastened the resident's health decline, antibiotics may have improved things temporarily. During an interview on [DATE] at 11:30 A.M., and 2:45 P.M., and [DATE] at 3:00 P.M., the director of nursing (DON) said the following: -She would expect skin assessments be completed weekly on each resident; -She would expect staff to obtain treatment orders for any new wounds; -The previous ADON was responsible for wound care and dressing changes when he/she was working; -She did not feel the previous ADON/wound nurse was completing routine weekly wound assessments, completing wound care as ordered, or notifying the residents' physicians as he/she should have; -The resident's pharmacy could not get the antibiotics until [DATE], the resident's condition deteriorated, the wounds had a very strong odor and the resident started running a fever. The DON thought RN A was in contact with wound care plus regarding the antibiotics not being available. During an interview on [DATE] at 2:20 P.M., the administrator said the following: -He would expect skin assessments be completed weekly; -He would expect wound care to be completed as ordered; -Staff should notify the physician of any new open areas immediately; -He would expect antibiotics to be administered as ordered; -Nursing staff should notify the physician of any concerns or changes with a wound. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the G level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00224696

Surveyor: [NAME], [NAME] Based on observation, interview, and record review, the facility failed to consistently assess the potential root cause of residents' falls and evaluate current interventions and/or develop and implement meaningful interventions to reduce the potential for falls for three residents (Residents #20, #27, and #46), in a review of 26 sampled residents. Residents #27 and #46 required sutures (also known as stitches used to hold body tissues together and approximate wound edges after an injury) to repair lacerations (a deep cut or tear in the skin) acquired as a result of falls. The facility also failed to ensure staff safely transferred one sampled resident (Residents #36) and on additional resident (Resident #48) during a mechanical lift transfer, and failed to safely transport one sampled resident (Resident #27) and an additional resident (Resident #48) while in a wheelchair. The facility census was 68. Review of the facility's policy, Implementation of a Fall Prevention Program, dated June 2006, showed the following: -Identify all current residents at risk for falls at the beginning of the program using the facility risk assessment form or a chosen form. -Assess all new residents for fall risk on admission using an additional fall assessment screen. The form should be completed within the first 12 hours following admission by the admitting nurse, or the oncoming nurse; -Reassess all residents as a part of quarterly assessment and care planning; -The effectiveness of a facility's fall prevention program should be part of continuous quality improvement. Keep a fall log to analyze causes of falls and facility trends or needs. The data in the log may point to variables that are present when falls commonly occur. Review the surveillance fall log to make sure the process is working and falls are being prevented. Include tracking of falls on new admissions as an indicator of the effectiveness of fall risk assessment and orientation; -Once trends are identified, the following steps may be taken: 1. Review the trend for a potential cause for this group of falls. Do not assume the cause; 2. Implement an action plan based on root cause; 3. Set a re-evaluation dated to determine how the solution is working; 4. Perform follow-up and document results; 5. Continue the action, if it is working, or perform additional analysis as to why it is not working and decide on a new action plan for implementation. Review of the undated facility policy, Use of Wheelchair, showed the following: -Purpose was to provide mobility for the non-ambulatory resident with safety and comfort and to provide mobility for residents learning to become independent in activities of daily living; -Lower footrests and place resident's feet on footrests if used; -Assist resident to the area of the facility desired. Encourage and instruct resident in proper guidelines for safely propelling the wheelchair. 1. Review of Resident #27's face sheet showed the resident's diagnoses included dementia with behavior disturbance (a group of thinking and social symptoms that interferes with daily functioning) and [CONDITION(S)] (a disorder of the central nervous system that affects movement, often including tremors). Review of the resident's care plan, updated on 8/2/21, showed the following: -The resident was placed on a fall prevention program; -Provide the resident with safety device - dycem (a non-slip material) to wheelchair; -Provide the resident with anti-rollback on wheelchair in case resident forgets to lock wheelchair brakes. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 2/26/22, showed the following: -Severely impaired cognition; -Limited assist of one staff member for bed mobility, transfers, and locomotion on and off the unit; -Walking in room occurred one to two times with assist of one staff member; -Functional limitation in range of motion on one side lower extremity; -Two non-injury falls since last reporting period; -One minor-injury fall since last reporting period. Review of the resident's nursing progress notes dated 4/16/22 at 11:39 A.M., showed the resident was found on the floor in his/her room. The resident's shoes were by his/her closet and the resident only had socks on his/her feet. The resident was sitting on his/her buttocks with his/her feet extended in front of him/her. The resident had clothes in his/her hand from the resident's closet. Review of the resident's care plan showed an update dated 4/16/22 the resident had an unwitnessed non-injury fall. (Review showed no documentation staff evaluated current interventions or identified new interventions after the resident fell on [DATE].) Review of the resident's nursing progress notes dated 5/25/22 at 10:40 P.M., showed the resident was found on the floor by his/her bed. The resident rolled to the right side of the bed onto the floor on the right side. The resident hit his/her head on the plastic tote sitting beside the head of the bed. The resident had a three centimeter (cm) laceration on his/her forehead with a moderate amount of bleeding and two skin tears on his/her left forearm. The resident was sent to the emergency room for evaluation. Review of the resident's nursing progress notes dated 5/26/22 at 3:53 A.M., showed the resident returned from hospital evaluation after receiving sutures for the laceration to his/her forehead following a fall. The resident is resting quietly in bed with the bed in low position and call light in place. Review of the resident's electronic medical record showed staff completed a fall risk assessment on 5/26/22 at 10:17 A.M. due to a change in condition/fall. The fall risk assessment showed the resident was a high fall risk. Review of the resident's nursing progress notes dated 6/2/22 at 7:20 P.M. showed the Interdisciplinary Team (IDT) met and noted the resident's fall on 5/25/22. The resident was unsafe with transfers and standing. Added floor mats beside the bed as an intervention. Review of the resident's care plan showed an update dated 5/25/22, the resident had an unwitnessed fall with injury, found lying beside bed with a three centimeter laceration to the forehead and received two stitches. (Review showed no documentation staff updated the care plan with the new interventions identified in the 6/2/22 IDT meeting after the resident fell on [DATE].) Review of the resident's nursing progress notes dated 8/1/22 at 4:23 P.M. showed the resident was found sitting on the floor at 4:00 P.M. and was unable to explain how he/she got there related to dementia diagnosis. The resident continues on antibiotics one more day for a urinary tract infection. Review of the resident's medical record showed no evidence staff attempted to identify the root cause of the resident's fall on 8/1/22. Review of the resident's care plan showed no documentation the resident fell on [DATE] and no documentation to show staff evaluated current interventions or identified new interventions after the resident fell on [DATE]. Review of the resident's nursing progress notes dated 8/4/22 at 3:30 P.M., showed the resident was found sitting on the floor on the right side of his/her bed and voiced he/she did not fall but slid to the floor out of bed. Review of the resident's care plan showed no documentation the resident fell on [DATE] and no documentation to show staff evaluated current interventions or identified new interventions after the resident fell on [DATE]. Review of the resident's nursing progress notes on 8/14/22 at 10:30 P.M. showed the resident was found sitting on the floor by his/her bed, unable to explain how he/she got there due to confusion. Safety mat placed at bedside. Review of the resident's care plan updated on 8/16/22 showed the resident had a fall on 8/14/22 and fall mats were placed beside the resident's bed. (Staff identified fall mats as an intervention to prevent falls after the resident fell on [DATE] and sustained an injury that required sutures, however, this intervention was not included on the resident's care plan until 8/16/22 after the resident fell on [DATE].) Review of the resident's nursing progress notes on 8/24/22 at 5:30 A.M. showed the resident was found on the floor in his/her room. The resident's call light was within reach and the bed was lowered to the floor for safety. Review of the resident's care plan showed no documentation the resident fell on [DATE] and no documentation of interventions after the resident fell on [DATE]. Review of the resident's nursing progress notes dated 8/25/22 at 11:00 P.M. showed the resident was found lying on the floor in his/her room. The resident had a laceration on his/her forehead and two skin tears on his/her left forearm. Review of the resident's medical record showed no evidence staff attempted to identify the root cause of the resident's fall on 8/25/22. Review of the resident's care plan showed no documentation the resident fell on [DATE] and no documentation to show staff evaluated current interventions or identified new interventions after the resident fell on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Limited assist of one staff member for bed mobility, transfers, and locomotion on and off the unit; -Walking in room occurred one to two times with assist of one staff member; -Functional limitation in range of motion on one side lower extremity; -Two non-injury falls since last reporting period; -One minor-injury fall since last reporting period. Observation on 10/24/22 at 6:43 A.M., showed the following: -Certified Nurse Assistant (CNA) C transported the resident from his/her room to the dining room in his/her wheelchair; -The wheelchair did not have foot pedals; -During the transport, both of the resident's feet drug along the floor. Observation on 10/24/22, at 3:13 P.M., showed the following: -The resident lay in bed with his/her eyes open; -A fall mat lay on the floor on the right side of the resident's bed; -An additional fall mat was folded in half and against the wall; -The resident did not have a fall mat on the floor on the left side of his/her bed; -The height of the bed was at the normal height and not in the low position. Observation on 10/26/22, at 5:02 A.M., showed the following: -The resident lay in bed sleeping; -The resident's bed was not in the low position; -A fall mat lay on the floor on the right side of the resident's bed; -The second fall mat was moved away from the left side of the resident's bed and slightly under his/her roommate's bed. During an interview on 10/27/22, at 2:00 P.M., CNA C said the following: -Sometimes the resident will hold his/her feet up when staff push him/her in the wheelchair; -There are no wheelchair foot pedals in the resident's room; -If foot pedals are needed, the nurse or therapy will get them; -A resident's feet should not touch the floor during transport in a wheelchair because the resident could get hurt or fall out of the wheelchair; -The fall mats are for the resident's safety due to the resident falling a lot; -Staff should put the fall mats on the floor and not lean them against the wall; -If a resident was a fall risk, the bed should be in the low position when the resident is in the bed. 2. Review of Resident #46's care plan, dated 4/27/22, showed the following: -The resident has history of falling related to altered mental status and [CONDITION(S)] (diffuse disease of the brain; -Provide proper, well-maintained footwear. Review of resident's monthly comprehensive assessment, dated 9/07/22 at 5:02 P.M., showed the following: -Problem - Falls: -Interventions - physical therapy and occupational therapy PRN (as needed), staff to assist during transfers, resident to use call light, and monitor for falls; -Progress - The resident had two falls in April. He/She uses a walker to ambulate. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition moderately impaired; -Required total assist of one person for transfers and toileting; -Used a walker and wheelchair for mobility; -Always incontinent of bowel and bladder; -One fall since last assessment. Review of resident's progress note, dated 10/16/22 at 5:54 P.M., showed the following: -A CNA called the nurse to the resident's room at 4:55 P.M.; -The resident was found on the floor face down with his/her head towards the head board and his/her feet towards the foot board; -The resident was yelling for staff to get him/her off his/her stomach; -The resident had a split on his/her forehead on the top right at the beginning of his/her hair line in the center of his/her forehead. It was two cm in length and not open; -The resident complained of left knee pain; -The resident could not remember what happened; -The resident was sent to the hospital. Review of resident's progress notes, dated 10/16/22 at 9:27 P.M., showed the following: -The resident came back to facility at 9:10 P.M.; -The resident had three stitches to the laceration on his/her forehead. Review of resident's care plan, updated on 10/16/22, showed the resident rolled out of bed with laceration to forehead and pain to left knee. (Review of the resident's care plan showed no documentation staff evaluated current interventions or developed new interventions after the resident fell on [DATE].) Review of resident's progress notes, dated 10/17/22, showed the following: -History: The resident had a fall with a laceration to his/her forehead and was sent to the emergency roiagnom on [DATE]. He/She said he/she did not lose consciousness apparently hitting his/her head on the floor. He/She has dementia and can be a poor historian at times. He/She had three sutures placed to the laceration. No acute fracture/head injury confirmed via x-ray and CT scan (computed tomography scan; a medical imaging technique used to obtain detailed internal images of the body.); -Plan: Continue to monitor sutures. Review of resident's paper medical record showed a statement with no date, at 12:50 A.M., showed the following: -The aide on duty found the resident on the floor next to the bed; -The resident said, I laid on the floor; -The resident was on his/her back, feet towards the bed, and his/her head towards the door. The resident's wheelchair was tipped over; -Bruising seen on forehead and injury covered by bandage on forehead. Review of the resident's medical record showed staff began a post fall 72-hour monitoring report on 10/18/22 at 12:50 A.M. Review of the resident's care plan showed no documentation staff evaluated current interventions or developed new interventions after the resident fell on [DATE]. Review of a written statement, dated 10/21/22 at 4:15 P.M., in the resident's paper medical record showed the following: -Staff heard a loud noise come from the resident's room; -The resident was on the floor next to the bed on his/her stomach; -The nurse noted bruising and a lump on the resident's forehead; -New order to apply ice pack, place floor mats next to bed; -Floor mat is on floor. Review of the resident's care plan showed no documentation the resident fell on [DATE] and no documentation staff updated the care plan to include floor mats on the floor. Review of the resident's physician's orders, dated 10/21/22, showed orders to monitor the resident closely and mats on floor due to diagnosis of fall. Review of resident's progress note, dated 10/22/22 at 11:30 A.M., showed the following: -The nurse was called to the resident's room; -The resident lay on his/her left side on the floor mat with his/her head towards the head of bed and feet towards the foot of the bed; -His/Her arm was bent at the elbow holding his/her upper body up; -The resident said he/she was trying to get up to go home. Review of resident's care plan, updated on 10/22/22, showed the resident fell getting out of bed to go home. (Review of the resident's care plan showed no documentation staff evaluated current interventions or developed new interventions after the resident fell on [DATE].) Review of resident's progress note, dated 10/23/22 at 5:51 P.M., showed the resident was up in his/her wheelchair. He/She took himself/herself to the bathroom. Staff attempted to educate the resident. The resident was not receptive. Observation on 10/24/22, at 9:56 A.M., showed the resident asleep in bed. There was no mat on the floor next to the bed. Observation on 10/25/22 at 4:00 P.M., showed the resident was in his/her room in his/her wheelchair. No staff was present in the resident's room. The resident stood from his/her wheelchair and transferred himself/herself to his/her bed. During an interview on 10/27/22, at 11:17 A.M., Nurse Aide (NA) G said the resident had a fall mat by his/her bed, but he/she did not know where it went. During an interview on 10/27/22, at 5:20 P.M., Registered Nurse (RN) O said the following: -The resident required minimal assistance from one person to transfer; -The facility had not identified new interventions for this resident since recent falls; -He/She was not aware there was an order for fall mats. During an interview on 10/27/22, at 5:29 P.M., CNA U said the following: -The resident needs assistance from one staff; -The resident goes to the bathroom by himself/herself; -The resident does not have fall mats in his/her room. 3. Review of Resident #20's admission MDS, dated [DATE], showed the following: -admitted [DATE]; -Diagnoses included stroke and [CONDITION(S)] (paralysis on one side of the body) with right side affect. Review of the resident's fall risk assessment, dated 9/3/22, showed a score of 55, indicating a very high risk for falls. Review of the resident's care plan, dated 7/28/22, showed the following: -The resident is at risk for falls due to [CONDITION(S)] disease with [CONDITION(S)] (muscle weakness or partial paralysis on one side of the body) and [CONDITION(S)] of right dominant side; -Fall mats to side of bed; -On 8/28/22, the resident rolled out of bed. No injury. Bed placed in lowest possible position; -On 9/3/22, the resident rolled out of bed on to mat then to floor, no injury. Replaced fall mats with larger mats due to size. Review of the resident's progress note, dated 9/17/22, showed the resident fell on [DATE] at 7:45 P.M. No complaints of pain and sustained a small laceration to his/her left knee that has been cleaned and bandaged. Review of the resident's medical record showed no documentation regarding further details of the resident's fall on 9/17/22, and no documentation staff attempted to identify the root cause of the fall, evaluated the current interventions or updated the care plan with new interventions after the resident fell on [DATE]. Review of the resident's progress note, dated 9/20/22, showed the resident was sitting on the floor in front of his/her wheelchair. The resident was not able to relay what happened. Review of the resident's medical record showed no documentation staff attempted to identify the root cause of the fall, or evaluated the current interventions or updated the care plan with new interventions after the resident fell on [DATE]. Review of the resident's care plan, updated on 9/29/22, showed staff to assist the resident with transfers, toileting, etc. as needed to reduce risk for falls. Review of the resident's progress note, dated 10/3/22, showed the resident was on his/her buttocks by the door of his/her room. The resident tried to stand up while holding onto the door. The resident was unharmed, alert with confusion as is his/her baseline. Staff assessed the resident and assisted him/her back to his/her wheelchair. One-on-one care not feasible due to short staff of one nurse on the floor with two aides. Review of the resident's medical record showed no documentation staff attempted to identify the root cause of the fall, or evaluated the current interventions or updated the care plan with new interventions after the resident fell on [DATE]. Review of the resident's fall risk assessment, dated 10/3/22, showed a score of 40 indicating low risk for falls. Review of the resident's progress note, dated 10/7/22, showed the resident was observed lying on his/her back on the safety mat on the right side of his/her bed. The resident said he/she rolled out of bed. The resident is alert to self with confusion and forgetfulness. Staff assisted the resident back to bed. Review of the resident's medical record showed no documentation staff attempted to identify the root cause of the fall, or evaluated the current interventions or updated the care plan with new interventions after the resident fell on [DATE]. Review of the resident's progress note, dated 10/16/22, showed staff were summoned to the dining room and found the resident on his/her back on the floor near the 400 hall dining room door with his/her feet facing the door and his/her head toward the tables. The resident's wheelchair was directly behind him/her. Review of the resident's medical record showed no documentation staff attempted to identify the root cause of the fall, or evaluated the current interventions or updated the care plan with new interventions after the resident fell on [DATE]. During interview on 10/26/22 at 12:46 P.M., Licensed Practical Nurse (LPN) B said he/she was unsure if the resident had a history of falls. He/She would find out in report if there were any new falls from the previous shift. During interview on 10/27/22 at 8:23 A.M., LPN D said when a resident falls staff assess the resident for injury and add a progress note in the electronic medical record. The department heads discuss the falls/interventions the next morning in their morning meeting. 4. Review of Resident #48's quarterly MDS, dated [DATE], showed the following: -Diagnoses include dementia and anxiety disorder; -Cognition was severely impaired; -Totally dependent on two staff for transfers. Review of the resident's care plan, revised 11/16/21, showed the following: -May use a hoyer lift or two person assist; -He/She uses a wheelchair for mobility and requires assistance at times and for longer distances. Observation on 10/26/22, at 5:03 A.M., showed the following: -The resident lay in bed; -CNA N and CNA M hooked the resident's hoyer lift pad that lay under the resident to the mechanical lift; -CNA N operated the lift while CNA M moved behind the resident's wheelchair; -CNA N raised the resident up off the bed with the lift, and then maneuvered the mechanical lift toward the resident's wheelchair; -CNA N was behind the lift and CNA M was behind the resident's wheelchair during the transfer; -The resident was free swinging in the air during the transfer; -CNA M used the handles on the lift pad to position the resident in the wheelchair while CNA N lowered the lift. Observation on 10/26/22, at 5:11 A.M., showed CNA N transported the resident in his/her wheelchair from his/her bedroom to the dining room. The resident's wheelchair did not have any foot pedals attached. The resident's right foot drug the floor the entire way to the dining room. During an interview on 10/26/22, at 5:59 A.M., CNA N said the following: -During a hoyer lift transfer, staff who are not running the lift should always have their hands touching the resident for the resident's safety; -CNA M was behind the resident's wheelchair to guide the resident into the wheelchair; -Staff did not have their hands on the resident while the resident was raised into the air and during the transfer; -CNA M should have had his/her hands on the resident during the transfer; -He/She did not get any training on the mechanical lift from the facility; -If a resident cannot hold his/her feet up during transport in a wheelchair, wheelchair pedals should be used to prevent injury; -The resident did not foot pedals in his/her room. During an interview on 10/26/22, at 6:42 A.M., CNA M said the following: -During a hoyer lift transfer, one staff ran the lift and one staff guided the resident to his/her chair, with hands on the resident at all times; -Staff should have their hands on the resident during a transfer for the resident's safety; -He/She helped CNA N transfer the resident to his/her wheelchair; -He/She guided the resident into his/her wheelchair by standing behind the resident's wheelchair; -He/She did not have hands on the resident during the transfer. 5. Review of Resident #36's quarterly MDS, dated [DATE], showed the following: -Cognition severely impaired; -Totally dependent on two staff for transfers; Review of the resident's care plan, revised 12/23/21, showed the following: -The resident was at risk for falls related to weakness, impaired cognition, rigid muscle tone, limited mobility/range of motion, and need for maximum assist for transfers; -Hoyer lift (a sling type mechanical lift) with two assist for all transfers. Observation on 10/24/22, at 7:20 A.M., showed the following: -The resident lay in bed; -CNA C and Nurse Assistant (NA) G placed a hoyer lift pad under the resident; -Staff placed the hooks of the hoyer lift pad onto the lift, and CNA C raised the resident off the bed with the lift; -NA G stood behind the resident's broda chair (tilt-in-space reclining wheelchair); -CNA C moved the lift with the resident in the sling toward the resident's broda chair (tilt in space specialized chair) while NA G continued to stand behind the resident's broda chair; -The resident was free swinging in the air during the transfer as CNA C operated the lift and NA G stood behind the resident's chair. -NA G stood behind the resident's broda chair and grabbed the sides of the lift pad to bring the resident back into the chair as CNA C lowered the resident into the chair. During an interview on 10/27/22, at 2:00 P.M., CNA C said the following: -A hoyer lift transfer requires two staff, one to run the lift and one to position the resident in the wheelchair; -Most of the time staff do not put their hands on the resident when the resident is raised off the bed and transferred to the wheelchair; -He/She did not receive any annual training from the facility on mechanical lift usage. During an interview on 10/27/22, at 2:27 P.M., NA G said the following: -He/She helped CNA C do a hoyer transfer with the resident on 10/24/22; -Staff raised the resident into the air and the resident was free swinging from the bed to the broda chair during the transfer; -He/She stood behind the resident's broda chair to help guide the resident into the chair; -He/She did not feel like he/she had received adequate training on transfers and would like more training. During interview on 10/27/22 at 5:47 P.M., the Director of Nursing (DON) said the following: -Resident #20 had falls and she expected the nurses to put new interventions in place as appropriate after a fall; -Staff discuss falls in the morning stand-up meeting to determine what happened and put new interventions into place; -Nurses can update the care plan or communicate the fall and new interventions to the MDS Coordinator so the care plan can be updated; -During a hoyer transfer, she expected staff to have their hands on the resident at all times for the resident's safety and to make the resident feel more secure; -At no time during a hoyer transfer should a resident be free swinging; -If a resident cannot independently hold their feet up during a wheelchair transport, foot pedals should be used to prevent injury; -Resident #27 and #48 should have foot pedals on their wheelchairs if their feet drag during a transport; -Fall mats would be used for safety for a resident with a history of falls; -If a resident had an order for fall mats, there should be fall mats in the resident's room; -She expected the fall mats to be used and the beds to be lower when a resident who was at risk for falls was in bed; -Interventions should be put in place for residents who are falling.

Based on observation, interview and record review, the facility failed to comprehensively assess and accurately document pain, failed to administer the resident's physician ordered pain medication ensuring the resident's comfort, failed to follow the resident's pain care plan, failed to re-evaluate the effectiveness of the resident's pain medication to ensure the effectiveness of the resident's pain management plan, and failed to follow the facility pain policy and procedure for one resident (Resident #5) of 14 sampled residents. The facility census was 82. 1. Review of the facility's policy, Pain Management Champion Guidelines, undated, showed the following: -Each community will appoint a Pain Management Champion to assist in the oversight and monitoring of the community's pain management program. Components of the Pain Management Program: Pain documentation every shift; admission, quarterly, change of condition or otherwise determined for need of full assessment; weekly monitoring of reports of pain; addressing of pain through routine and as needed medications for breakthrough pain; care planning; staff pain in-services each quarter; -All residents will be assessed each shift for pain and it will be documented on the Medication Administration Record (MAR); -Admission: the pain assessment and evaluation will be completed upon admission in Matrix. The new admission will be reviewed at the morning stand up meeting. At this time, the resident will be reviewed for pain, necessary pain intervention implementation, and care plan reflecting pain needs if applicable. Those residents who are expressing pain greater than their acceptable level of pain will be started on the pain management program and a pain management flow log will be initiated. Be sure their acceptable level of pain is placed on the MAR where the rating is and also circle the type of assessment to utilize for that resident; -Weekly: The Pain Management Champion will: review MARs for residents who are showing increasing pain or as needed (PRN) usage that will need implementation of a pain management program. Complete a full Pain Assessment and Evaluation as needed; Review those on a pain management program and PRN administration for success of current medication administration and write a weekly narrative; Review PRN administration and determine the need for medication adjustments and follow up as needed with physician; Will remove those on pain management who have reached a consistent level of accessible level of pain; Create or update the resident plan of care as needed. This includes type of pain scaled to utilize and also the acceptable level of pain; Look at the one month Casper report and pick five or more residents each week to review at the weekly Interdisciplinary Team (IDT) meeting. This will be done so that all residents triggering for pain are reviewed each month and pain management is initiated as determined necessary or an IDT note written to discussed who has adequate pain control; -Quarterly: complete or review the Pain Assessment & Evaluation (Matrix) for the need for further follow up with Pain Management Program. Be sure to update the care plan and MAR with any changes in acceptable level of pain. 2. Review of Resident #5's Admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 4/24/17, showed the following: -Cognitively intact; -Limited assistance of one staff member with bed mobility; -Extensive assistance of one staff member with transfers and personal hygiene; -Extensive assistance of two staff members with toileting; -The resident frequently had pain or hurting in the last five days; -The resident's worst pain over the last five days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine, was 2 out of 10. Review of the resident's care plan, dated 5/8/17, showed the following: -[DIAGNOSES REDACTED]. -The resident had complaints of pain in back and neck; -Staff should administer pain medications as ordered and return to assess effectiveness and administer non-medication pain relief measures; -Staff should assess effects of pain on the resident, encourage the resident to request pain medication before pain became unbearable, evaluate effectiveness of pain management interventions and adjust if ineffective or adverse side effects emerge, handle the resident gently and try to eliminate environmental stimuli; -Staff should monitor and record any complaints of pain and non-verbal signs of pain and position the resident for comfort. Review of the resident's undated Certified Nurse Assistant (CNA) Care Card showed the following: -Required assistance of one staff member with bed mobility and personal hygiene; -Required assistance of one or two staff members with transfers; -No CNA instruction regarding presence of pain and pain management interventions. Review of the resident's hospital discharge instructions, dated 5/20/17, showed the resident was hospitalized from [DATE] to 5/20/17 for compression [MEDICAL CONDITION] spine. Review of the resident's care plan showed no updates reflecting the resident's pain status and re-evaluation of pain control interventions after the 5/11/17 to 5/20/17 hospital stay for compression [MEDICAL CONDITION] spine. Review of the resident's Physician order [REDACTED]. Review of the resident's Medication Administration Record (MAR) showed the following: -Assess pain each shift, rate 0-10 on pain scale, acceptable level of pain was 5; -On 5/21/17, staff assessed the resident's pain at 0 on the 0-10 pain scale on 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M. shifts. Review of the resident's MAR, dated 5/22/17, showed the following: -At 8:00 A.M., staff administered [MEDICATION NAME] 5/325 mg one tablet for resident complaint of all over pain rated 8/10 (eight on a 0-10 pain scale); -At 8:30 A.M., effectiveness of pain medication was five on a scale of 0-10; -Staff assessed the resident's pain at 0 on the 0-10 pain scale on 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M. shifts. Review of the resident's MAR, dated 5/26/17, showed the following: -At 4:00 P.M., staff administered [MEDICATION NAME] 5/325 mg, one tablet for resident complaint of 8/10 back pain; -At 6:00 P.M., pain medication was effective; -Staff assessed the resident pain at 0 on the 0-10 pain scale on the 3:00 P.M.-11:00 P.M. shift. Review of the resident's MAR showed from 5/27/17 through 6/1/17, staff assessed the resident pain at 0 on the 0-10 pain scale on 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M. to 7:00 A.M. shifts. Review of the resident's MAR, dated 6/2/17, showed the following: -At 12:00 P.M., staff administered [MEDICATION NAME] 5/325 mg one tablet for resident complaint of 7/10 back pain. At 1:00 P.M., pain medication was effective; -Staff assessed the resident's pain at 0 on the 0-10 pain scale on 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M. to 7:00 A.M. shifts. Review of the resident's MAR showed on 6/3/17, staff assessed the resident's pain at 0 on the 0-10 pain scale on 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M. to 7:00 A.M. shifts. Observations and interview on 6/4/17 showed the following: -From 3:20 P.M. through 5:42 P.M., the resident lay in bed without a change in his/her position. His/her head was tilted to the right with his/her chin towards his/her shoulder; -At 5:42 P.M., a family member visited. The resident raised his/her hand, slightly moved his/her head to the left and attempted to speak with the family member. The resident moaned with movement. The family member said the resident continued to decline daily with increased confusion at times; -At 6:35 P.M., Certified Nurse Assistant (CNA) F and CNA Q held the cloth pads under the resident and lifted the resident up in the bed. The resident's eyes opened and he/she moaned with movement. His/her legs and neck were stiff and chin remained tilted toward his/her right shoulder. CNA F and CNA Q did not turn or reposition the resident off his/her back; -At 6:40 P.M., Licensed Practical Nurse (LPN) BB woke the resident, placed medications in the resident's mouth and the resident drank water from a straw and swallowed the medications. The resident's head was tilted to the right with chin towards his/her shoulder. He/she did not move his/her head or neck while swallowing pills and drinking water. Review of the resident's MAR, dated 6/4/17, showed the following: -At 7:22 P.M., staff administered [MEDICATION NAME] 5/325 mg one tablet for resident complaint of 8/10 back pain; -There was no documentation staff evaluated the effectiveness of the resident's pain medication; -Staff assessed the resident pain at 0 on the 0-10 pain scale on the 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M. to 7:00 A.M. shifts. During interview on 6/7/17 at 10:50 A.M., CNA Q said the resident was in a lot of pain on Sunday 6/4/17. He/she refused to turn because of the pain. Observations and interview on 6/5/17 showed the following: -From 5:25 A.M. through 6:20 A.M., the resident lay on his/her back. The resident's head and neck appeared stiff and was tilted to the right with chin towards his/her shoulder; -At 6:20 A.M., LPN Z moved the resident's head to the left, the resident hollered owe and moaned with movement. LPN Z released the resident's head. The resident returned his/her head position to the right with chin pointed toward shoulder. The resident moaned with movement, teeth clinched and neck stiff; -At 6:25 A.M., LPN Z and CNA CC turned the resident to his/her right side. The resident moaned with movement and hollered out. His/her body was stiff, teeth clinched and he/she resisted movement. The resident's head remained tilted to the right with chin pointed towards his/her shoulder. LPN Z said I know it hurts. CNA CC provided perineal care and changed the resident's bed linens. The resident moaned with cleansing of the buttocks and wound areas. He/she cried out when turned side to side. Three open wounds were noted on the resident's buttocks and coccyx (tailbone) areas. The left buttock wound was approximately 2 inches by 1 inch with peeling red wound base, the right buttock wound was approximately 1 inch in diameter with red wound base and the coccyx wound was approximately 1 inch by .5 inch with red wound base. Numerous skin wrinkles and creases were noted over the resident's entire buttocks, back and upper thigh areas. CNA CC left the resident's room and returned with additional linens. CNA CC said Certified Medication Technician (CMT) T was checking on the resident's pain medication. LPN Z said since the resident was crying out with movement, he/she needed pain medication if available. Review of the resident's MAR dated 6/5/17 showed the following: -At 6:25 A.M., staff administered [MEDICATION NAME] 5/325 mg one tablet for resident complaint of 8/10 back pain. Effectiveness of pain medication was effective at 6/10; -Staff assessed the resident pain at 0 on the 0-10 pain scale on the 11:00 P.M.-7:00 A.M. shift; -There was no documentation showing staff addressed the resident's continued pain (greater than 5/10) after administration of the pain medication. During interview on 6/5/17 at 12:05 P.M., the resident said his/her neck hurt anytime it was turned. His/her buttocks hurt bad. He/she had a pain pill this morning and it helped for a little while. During interview on 6/5/17 at 6:30 A.M., CNA CC said the following: -He/she worked the night shift on the resident's hall; -He/she tried to reposition the resident during the night as the resident allowed. The resident had pain when repositioned or moved in the bed. Review of the resident's MAR, dated 6/5/17, showed the following: -At 7:30 P.M., staff administered [MEDICATION NAME] 5/325 mg one tablet for resident complaint of 8/10 neck and back pain. Effectiveness of pain medication was effective eyes closed; -Staff assessed the resident pain at 0 on the 0-10 pain scale on the 3:00 P.M.-11:00 P.M. shift. During telephone interview on 6/5/17 at 10:42 P.M., Registered Nurse (RN) AA said he/she was the night shift charge nurse. He/she thought the resident had pain and would let staff know when he/she was in pain. The resident moaned when staff turned or repositioned the resident in bed. The resident had compression fractures and preferred to keep his/her head tilted to the right. Observation and interview on 6/6/17 showed the following: -At 8:45 A.M., the resident was awake, drinking water with staff assistance and said he/she was unsure if he/she received pain medication today or not. His/her bottom was bad and hurt; -At 10:30 A.M., CNA F rolled the resident to his/her right side. LPN S removed a dressing from the resident's tailbone and buttocks wounds, the resident moaned. The resident's entire buttocks and tailbone area, approximately 8 inches by 8 inches was bright red in a triangle shape encompassing the left and right buttock wounds and the tailbone wound. LPN S said the entire buttock area and the wounds looked worse. The redness was new and was not present yesterday. The resident moaned as LPN S cleansed the wounds and applied an ointment and dry dressing. The resident moaned as CNA F and LPN S rolled the resident side to side, changed the soiled linens and pulled the resident up in the bed. The resident cried out as CNA F and LPN S lifted the resident up in bed. LPN S asked if the resident wanted pain medication. The resident said yes please. CNA F positioned the resident on his/her left side. The resident cried and said not comfortable at all, my neck and back hurts so bad. The resident rated pain at 8/10. Review of the resident's MAR, dated 6/6/17, showed the following: -At 10:49 A.M., staff administered [MEDICATION NAME] 5/325 mg one tablet for resident complaint of 8/10 neck and back pain. Effectiveness of pain medication was 6/10; -Staff assessed the resident pain at 0 on the 0-10 pain scale on the 7:00 A.M.-3:00 P.M. shift, 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M. shifts. -There was no documentation showing staff addressed the resident's continued pain after administration of the pain medication. During interview on 6/7/17 at 11:00 A.M., CMT T said the following: -He/she passed medications including non-narcotic pain medications. The treatment nurse passed narcotic pain medications and provided residents treatments; -The MAR on the medication cart included a pain assessment for every resident on every shift. He/she did not complete a pain assessment on every resident, only the residents he/she gave non-narcotic pain medications; -The residents receiving narcotic pain medications administered by the treatment nurse did not receive a pain assessment every shift. He/she marked 0 on all of their pain assessments because he/she did not give their medications. During interview on 6/7/17 at 12:39 P.M., the Director of Nursing said the following: -Staff should assess a resident's pain level if the resident did not want to turn or reposition in the bed; -Staff should address the resident's pain with medication and non-medication interventions and then attempt repositioning or turning; -He/she expected the medication nurses to assess each resident's pain level shiftly as ordered on the MAR. Reports of pain were documented on the MAR and reported to the pain medication/treatment nurse for further assessment and administration of pain medications. The medication nurse should not document 0 pain level without assessing the resident's pain. A 0 indicated the resident was not having pain; -Any staff member aware of a resident's pain should inform the charge nurse and the pain medication/ treatment nurse; -A resident with consistent 8/10 pain level should be evaluated for new interventions, new physician orders [REDACTED]. -The resident's base line pain level was not 8/10. Staff should look at changes in the resident's overall condition, increase in pain levels and notify the physician for changes in treatment; -Staff communication failure caused the resident's uncontrolled pain and potentially resulted in skin breakdown.

Based on observation, interview, and record review, the facility failed to appropriately assess, identify and notify the physician of a decline in one resident's (Resident #2) pressure ulcer; and failed to turn and reposition two residents (Residents #5 and #9), identified at risk for pressure ulcers, at least every two hours as per facility policy, in a review of 14 sampled residents. Resident #5 developed a pressure ulcer that had not been identified by staff. The facility census was 82. 1. Review of the facility's policy, Pressure Ulcer, Care and Prevention, dated March 2015, showed the following: -Purpose: To prevent and treat further breakdown of pressure ulcers. treatment of [REDACTED]. The nurse is responsible for carrying our the treatment by the attending physician and for implementing measure to prevent pressure ulcers; -Observe skin. Any persistent reddened area that remains after pressure is relieved is a high risk area for a pressure ulcer to begin; -Change bed linen promptly whenever wet or soiled; -Keep sheets dry, free of wrinkles and free of debris; -Use pressure-reducing devices to relieve pressure; -Turn the resident every two hours and position with pads or pillows to protect bony prominences; -Active and passive range of motion may be ordered by the physician at regular intervals and shift his/her weight in wheelchair. Assist at mealtime to assure adequate nutrition; -Offer fluids frequently for adequate hydration. 2. Review of the facility's policy, Positioning the Resident, dated March 2015, showed the following: -Purpose: To relieve pressure and prevent skin breakdown and to relieve pain and promote proper body alignment; -Sheets should be [MEDICATION NAME] and tightened during position changes to prevent creasing resulting in pressure; -Perform range of motion activities during position changes to prevent joint contractures and loss of muscle tone unless contraindicated. 3. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of [REDACTED]. -Ongoing assessment of the skin is necessary to detect early signs of pressure damage; -Do not use massage for pressure ulcer prevention, massage cannot be recommended as a strategy for pressure ulcer prevention; -Repositioning should be considered in all at-risk individuals, repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body; -In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure he/she is exposed to; -When an individual is seated in a chair, the weight of the body causes the greatest exposure to pressure to occur over the ischial tuberosities. As the loaded area in such cases is relatively small, the pressure will be high, therefore, without pressure relief, a pressure ulcer will occur very quickly; -Use support surfaces to prevent heel pressure ulcers, ensure that the heels are free of the surface of the bed, heel protection devices should elevate the heel completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon, and use a pillow under the calves so that heels are elevated (i.e., floating). 4. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 4/26/17, showed the following: -Cognitively intact; -Required limited assistance of two staff members with bed mobility; -Required limited assistance of one staff member with transfers, toileting and personal hygiene; -Functional limitation in range of motion of both upper and lower extremities; -Occasionally incontinent of bowel and bladder; -At risk of developing pressure ulcers and currently had one Stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed) unhealed pressure ulcer present on admission; -Pressure reducing device for the bed, turning and repositioning program, pressure ulcer care, application of nonsurgical dressing other than to feet and application of ointments/medications other than to feet. Review of the resident's Care Plan, dated 4/26/17, showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. -At risk for skin breakdown related to resident required staff assistance with bed mobility, transfers and toileting; -He/she experienced incontinence and had a wound to the tailbone; -Staff should avoid shearing (friction) during positioning, transfers and turning; -Keep skin clean and dry as possible; -Treat tailbone wound as ordered; -Provide incontinence care after each incontinent episode; -Avoid hot water and use a mild cleansing agent that minimizes irritation and dryness of the skin and use moisture barrier product to perineal area; -Staff should conduct a systematic skin inspection weekly; -Keep the resident off of buttocks, and encourage him/her to lie down to promote healing of current skin breakdown; -Maintain the head of the bed at the lowest degree of elevation possible, report any signs of skin breakdown and turn and reposition the resident when in bed. Review of the resident's undated Certified Nurse Assistant (CNA) Care Card showed the following: -Assistance of one staff member with bed mobility and personal hygiene; -No staff direction regarding whether to lay the resident down once or twice; -No staff direction or mention of wound presence, location or treatment. Review of the resident's Braden Scale (a tool used to assess the resident's level of risk for development of pressure ulcers), dated 5/3/17, showed the following: -Sensory perception (ability to respond meaningfully to pressure-related discomfort) scored 4, no impairment; -Moisture (degree to which skin is exposed to moisture) scored 3, occasionally moist; -Activity (degree of physical activity) scored 2, chair fast; -Mobility (ability to change and control body position) scored 3, slightly limited; -Nutrition (usual food intake pattern) scored 3, adequate; -Friction and shear scored 2, potential problem; -Total score 17 indicated mild risk of developing a pressure ulcer. (Record review showed the resident had a Stage II pressure ulcer). Review of the resident's Initial and Weekly Wound Documentation report, dated 5/5/17, showed the following: -Stage II pressure ulcer on the coccyx (tailbone) without tunneling, undermining or sinus tract; -Onset date 4/13/17, present on admission; -Current measurements 3.4 centimeters (cm) long x 2.0 cm wide x 0.2 cm deep; -Prior week measurements 1.5 cm long x 1.5 cm wide x 0.2 cm deep; -Granulation tissue (pink or red tissue with shiny, moist, granular appearance) and no exudate (drainage); -No odor noted; -Macerated (softening) surrounding wound tissue; -Resident expressed or showed no signs of pain related to the wound; -No [MEDICAL CONDITION] (swelling) of the wound area; -Skin and ulcer treatment interventions included pressure reducing device for bed, turning/repositioning program, application of nonsurgical dressings and ointments; -Skin status/outcome of interventions was area improving; -No change in treatment plan, the physician was notified; -Resident non-compliant with lying down between meals, as well as non-complaint with treatment. Resident educated about the importance of compliance. Review of the resident's Initial and Weekly Wound Documentation report, dated 5/15/17, showed the following: -Stage II pressure ulcer on the coccyx without tunneling, undermining or sinus tract; -Onset date 4/13/17, present on admission; -Current measurements 3.6 cm long x 0.7 cm wide x 0.3 cm deep; -Granulation tissue and no exudate; -No odor noted; -Macerated surrounding wound tissue; -Resident expressed or showed no signs of pain related to the wound; -No [MEDICAL CONDITION] of the wound area; -Skin and ulcer treatment interventions included pressure reducing device for bed, turning/repositioning program, application of nonsurgical dressings and ointments; -Skin status/outcome of interventions was area improving; -No change in treatment plan, the physician was notified; -Resident continues with non-compliance resulting in compromised wound healing. Review of the resident's Initial and Weekly Wound Documentation report, dated 5/19/17, showed the following: -Stage II pressure sore on the coccyx without tunneling, undermining or sinus tract; -Onset date 4/13/17, present on admission; -Current measurements 4.5 cm long x 1.5 cm wide x 0.6 cm deep; -Granulation tissue and no exudate; -No odor noted; -Macerated surrounding wound tissue; -Resident expressed or showed no signs of pain related to the wound; -No [MEDICAL CONDITION] of the wound area; -Skin and ulcer treatment interventions included pressure reducing device for bed, turning/repositioning program, application of nonsurgical dressings and ointments; -Skin status/outcome of interventions was area deteriorating; -Change in treatment plan, the physician was notified; -Area continues to decline, directly related to resident non-compliance with treatment orders. Resident refused to lie down between meals despite multiple educational attempts. Treatment orders changed due to wound decline. Review of the resident's Physician Order Sheet (POS), dated 5/19/17, showed the following: -Discontinue current wound treatment; -Cleanse open area to coccyx with normal saline (salt solution cleansing agent); -Apply Santyl (enzymatic [MEDICATION NAME] ointment) ointment to wound bed and cover with a dry dressing daily and as needed. Review of the resident's POS, dated 5/25/17, showed the following: -Discontinue current wound treatment; -Cleanse open area to coccyx with normal saline; -Pack wound with [MEDICATION NAME] gauze (rolled thin gauze used to absorb wound drainage) and cover with a dry dressing daily and as needed. Review of the resident's Initial and Weekly Wound Documentation report, dated 5/26/17, showed the following: -Stage II pressure ulcer on the coccyx without tunneling, undermining or sinus tract; -Onset date 4/13/17, present on admission; -Current measurements 4.0 cm long x 1.9 cm wide x 1.3 cm deep; -Granulation tissue and with moderate serosanguinous (blood and serum) drainage; -No odor noted; -Macerated surrounding wound tissue; -Resident expressed or showed no signs of pain related to the wound; -No [MEDICAL CONDITION] of the wound area; -Skin and ulcer treatment interventions included pressure reducing device for bed, turning/repositioning program, application of nonsurgical dressings and ointments; -Skin status/outcome of interventions was area deteriorating; -Change in treatment plan, the physician was notified; -Resident continues to be non-compliant despite multiple attempts to change behavior. Treatment order changed, would consult outside wound care provider (Wound care specialist that visit the facility and provide assessment and treatment orders for residents wounds). Review of the resident's Weekly Skin Assessment, dated 5/31/17, showed staff documented the resident had an area on the coccyx; the dressing was clean, dry and intact (no documentation of the size or appearance of the pressure ulcer). Review of the resident's medical record showed no evidence staff completed the weekly wound documentation report to show assessment of the resident's pressure ulcer on 6/2/17. Observation on 6/4/17 showed the following: -At 11:51 A.M., the resident sat in a wheelchair. The resident's bed had a regular mattress with no pressure relieving device; -At 3:40 P.M., the resident wore blue jeans over an incontinence brief and lay in bed on a regular mattress with no pressure relieving device. The resident said he/she had bedsores since coming here, nurse changed the wound dressings every morning, think the wounds are healing; -At 4:30 P.M., the resident lay in bed on a regular mattress with no pressure relieving device. Certified Nurse Assistant (CNA) F and CNA V rolled the resident side to side, removed the resident's jeans and slightly soiled incontinence brief and provided incontinence care. A dry wound dressing covered the resident's tailbone area; -At 5:30 P.M., the resident rolled himself/herself to his/her right side. Observation on 6/5/17 showed the following: -At 5:30 A.M., the resident lay in bed on a regular mattress with no pressure relieving device. Staff left the resident's room and closed the door; -At 9:15 A.M., CNA Q opened the resident's door and entered the room. The resident scooted onto his/her back; -At 9:21 A.M. CNA Q sat the resident on the side of the bed and dressed the resident. CNA Q and CNA F assisted the resident to a standing position. A wound dressing covered the resident's tailbone area saturated with yellow-brown drainage. The resident said I have a pressure sore. CNA Q and CNA F pulled up the resident's incontinence brief and pants, and pivoted the resident to the wheelchair. CNA Q said the wound nurse would change the resident's dressing after the resident's shower. The resident's bed had a regular mattress and no pressure relieving device; -At 10:30 A.M., CNA W rolled the resident to the shower room. The resident stood and held the side of the whirlpool tub. CNA W removed the resident's pants, incontinence brief and the drainage saturated wound packing and dressing from the resident's tailbone area and sat the resident on the shower chair. A foul odor was noted as the wound was exposed and the drainage saturated dressing was removed. An approximate 2 inch by 1 inch wound with notable but undetermined depth was noted over the resident's tailbone area with purple tissue surrounding the wound edges. The base of the wound contained a bright white string like tissue. CNA W showered the resident and reached under the shower chair washing the resident's buttocks and wound area with a washcloth and soap. The wound drained bright red drainage. CNA W rinsed and dried the resident's skin, applied lotion and left the shower room. CNA W returned to the shower room with Licensed Practical Nurse (LPN) S; -At 10:40 A.M., CNA W assisted the resident off the shower chair to a standing position. Bloody drainage was noted from the resident's coccyx wound and a bloody ring around the resident's buttocks and onto the shower chair. LPN S cleansed the resident's bleeding coccyx wound and said he/she thought the white stringy tissue in the wound base was exposed tendon. The wound base was beefy inside with depth and the white tendon showed up last week. LPN S touched the white stringy tissue and said the white tissue felt firm. LPN S packed the wound and covered with a dry dressing, securing with tape. CNA W sat the resident in the wheelchair, completed dressing the resident and rolled the resident into the hallway. During interview on 6/5/17 at 11:30 A.M., CNA W said he/she removed the resident's wound dressing and washed the wound with soap and water while showering the resident. The wound nurse provided the resident's wound care after showering. During interview on 6/5/17 at 1:55 P.M., LPN X said he/she provided the resident's wound care on 6/4/17 and saw the white stringy tissue in the wound base. He/she thought the white stringy tissue was muscle or tendon and was a Stage III (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed) or Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer. He/she saw the exposed tendon while providing the resident's wound care last weekend on Friday, Saturday and Sunday. During interview on 6/5/17 at 10:50 A.M., LPN S said the outside wound care provider had never seen the resident's wound. Review of the resident's medical record showed no documentation the physician had been notified in the change in the condition of the resident's pressure ulcer after 5/25/17 and prior to 6/5/17. During interview on 6/5/17 at 12:15 P.M., the Director of Nursing said the resident's wound was measured weekly and was larger in size. If a tendon was exposed, the resident was worse and no longer considered a Stage II pressure ulcer but a Stage III (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) or Stage IV (a full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer. Review of the resident's nurses' note dated 6/5/17 showed the following: -At 2:27 P.M., the outside wound clinic was contacted for consult and scheduled for 6/8/17; -Staff was educated to remind and assist the resident to turn while in bed; -At 8:13 P.M., staff placed a low air loss mattress on the resident's bed. 5. Review of Resident #5's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required limited assistance of one staff member with bed mobility; -Required extensive assistance of one staff member with transfers and personal hygiene; -Required extensive assistance of two staff members with toileting; -Occasionally incontinent of bladder; -At risk for developing pressure ulcers; -No current unhealed pressure ulcers; -Pressure reducing device for the chair. Review of the resident's care plan, dated 4/27/17, showed the following: -[DIAGNOSES REDACTED]. -The resident was at risk for pressure ulcers related to poor bed mobility and incontinence; -Staff should conduct a systematic skin inspection weekly and pay particular attention to the bony areas; -Keep the resident clean and dry with clean, dry and wrinkle free linens, maintain the head of the bed at the lowest degree of elevation possible; -Provide incontinence care after each incontinent episode, report any signs of skin breakdown and use moisture barrier product to perineal areas; -Staff should turn and reposition the resident while in bed. Review of the resident's undated CNA Care Card showed the following: -Continent of bladder at times and wore incontinence briefs; -Required assistance of one staff member with bed mobility and personal hygiene; -No CNA instruction regarding presence or care of open wounds. Review of the resident's hospital discharge instructions, dated 5/20/17, showed the resident was hospitalized from [DATE] to 5/20/17 for compression [MEDICAL CONDITION] spine. Review of the Admit Clinical Assessment, dated 5/20/17, showed the resident was at risk for skin breakdown related to decreased activity level, incontinence and predisposing diseases. The resident's skin was pale and had two skin tears on the left buttock. Review of the nurses' note, dated 5/20/17 at 11:58 A.M., showed the resident returned to the facility following hospitalization . A skin tear to the left buttock was noted and measured 1 cm x 1/2 cm. Review of the Braden scale, completed 5/20/17, showed the following: -Sensory perception (ability to respond meaningfully to pressure-related discomfort) scored 2, very limited; -Moisture (degree to which skin is exposed to moisture) scored 4, rarely moist; -Activity (degree of physical activity) scored 2, chair fast; -Mobility (ability to change and control body position) scored 2, very limited; -Nutrition (usual food intake pattern) scored 1, very poor; -Friction and shear scored 1, problem; -Total score 12 indicated high risk of developing a pressure ulcer. Review of the weekly skin assessment, dated 5/23/17, showed the resident had quarter size purple pressure non-draining areas on the right and left buttocks. Barrier cream was applied and left open to air. Review of the weekly skin assessment, dated 5/30/17, showed the resident had quarter size red and purple areas on the right and left buttocks. Continuous observations and interview on 6/4/17 showed the following: -From 3:20 P.M. through 3:55 P.M., the resident lay in bed on his/her back with head of bed elevated approximately 45 degrees. The resident's head was tilted to the right with chin towards his/her shoulder and eyes closed. The resident wore oxygen supplement per nasal cannula (oxygen dispersed per a nasal tube). A pillow elevated the resident's knees and his/her heels rested on the bed mattress; -From 3:55 P.M. through 5:05 P.M., the resident remained without position change. The resident lay in bed on his/her back with head of bed elevated approximately 45 degrees. The resident's head was tilted to the right with chin towards his/her shoulder and eyes closed. The resident wore oxygen supplement per nasal cannula. A pillow elevated the resident's knees and his/her heels rested on the bed mattress; -From 5:05 P.M. through 5:35 P.M., the resident remained without position change. The resident lay in bed on his/her back with head of bed elevated approximately 45 degrees. The resident's head was tilted to the right with chin towards his/her shoulder and eyes closed. The resident wore oxygen supplement per nasal cannula. A pillow elevated the resident's knees and his/her heels rested on the bed mattress. During interview at 5:35 P.M., Registered Nurse (RN) Y said the resident had an elevated temperature. The physician ordered laboratory tests. -At 5:40 P.M., the resident remained without position change. The resident lay in bed on his/her back with head of bed elevated approximately 45 degrees. The resident's head was tilted to the right with chin towards his/her shoulder and eyes closed. The resident wore oxygen supplement per nasal cannula. A pillow elevated the resident's knees and his/her heels rested on the bed mattress; -At 5:42 P.M., a family member visited and woke the resident. The resident raised his/her hand, slightly moved his/her head to the left and attempted to speak with the family member. The resident lay in bed on his/her back with head of bed elevated approximately 45 degrees. The resident wore oxygen supplement per nasal cannula. A pillow elevated the resident's knees and his/her heels rested on the bed mattress; -At 5:45 P.M., the resident's family member left. The resident's head tilted to the right with chin towards his/her shoulder and closed eyes. The resident lay in bed on his/her back with head of bed elevated approximately 45 degrees. The resident wore oxygen supplement per nasal cannula. A pillow elevated the resident's knees and his/her heels rested on the bed mattress. The resident's family member said the resident slept often and continued to decline daily with increased confusion at times. -From 5:50 P.M. through 6:35 P.M., the resident lay in bed on his/her back with head of bed elevated approximately 45 degrees. The resident's head was tilted to the right with chin towards his/her shoulder and eyes closed. The resident wore oxygen supplement per nasal cannula. A pillow elevated the resident's knees and his/her heels rested on the bed mattress; -At 6:35 P.M., CNA F and CNA Q held the cloth pads under the resident and lifted the resident up in the bed. The resident's eyes opened. CNA F and CNA Q did not turn or reposition the resident off his/her back. The resident remained on his/her back with head of bed elevated approximately 45 degrees. The resident's head was tilted to the right with chin towards his/her shoulder. The resident wore oxygen supplement per nasal cannula. A pillow elevated the resident's knees and his/her heels rested on the bed mattress; -At 6:40 P.M., LPN BB woke the resident, placed medications in the resident's mouth and the resident drank water from a straw and swallowed the medications. LPN BB did not reposition the resident or the head of the bed elevation. The resident remained on his/her back with head of bed elevated approximately 45 degrees. The resident's head was tilted to the right with chin towards his/her shoulder. The resident wore oxygen supplement per nasal cannula. A pillow elevated the resident's knees and his/her heels rested on the bed mattress; -At 6:42 P.M., CNA P placed the resident's supper tray on the bedside table. CNA P did not reposition the resident. The resident remained on his/her back with head of bed elevated approximately 45 degrees. The resident's head was tilted to the right with chin towards his/her shoulder. The resident wore oxygen supplement per nasal cannula. A pillow elevated the resident's knees and his/her heels rested on the bed mattress; -At 6:55 P.M., CNA F removed the resident's supper tray. CNA F did not reposition the resident. The resident remained on his/her back with head of bed elevated approximately 45 degrees. The resident's head was tilted to the right with chin towards his/her shoulder. The resident wore oxygen supplement per nasal cannula. A pillow elevated the resident's knees and his/her heels rested on the bed mattress. (The resident was no repositioned for three hours and 35 minutes). Observations on 6/5/17 showed the following: -From 5:25 A.M. through 6:20 A.M., the resident lay on his/her back with head of bed elevated approximately 45 degrees. The resident's head was tilted to the right with chin towards his/her shoulder. The resident wore oxygen supplement per nasal cannula. A pillow elevated the resident's knees and his/her heels rested on the bed mattress; -At 6:20 A.M., LPN Z and CNA CC turned the resident to his/her right side. The resident moaned with movement. Three open wounds were noted on the resident's buttocks and coccyx areas. The left buttock wound was approximately 2 inches by 1 inch with a peeling red wound base, the right buttock wound was approximately 1 inch in diameter with a red wound base, and the coccyx wound was approximately 1 inch by 1/2 inch with a red wound base. Numerous skin wrinkles and creases were noted over the resident entire buttocks, back and upper thigh areas. CNA CC washed the resident's buttocks and cleansed the resident's buttocks and wound areas. The resident moaned with cleansing of the buttocks and wound areas. LPN Z said he/she thought the resident came back from the hospital with open wounds. LPN Z and CNA CC repositioned the resident on his/her left side. During interview on 6/5/17 at 6:30 A.M., CNA CC said the following: -He/she worked the night shift on the resident's hall; -He/she did not know the resident had open wounds on his/her buttocks and coccyx; -The resident was hospitalized recently and had declined since returning to the facility; -He/she tried to reposition the resident during the night as the resident allowed. The resident had pain when repositioned or moved in the bed. During interview on 6/5/17 at 7:00 A.M., LPN Z said the following: -He/she was one of the night shift charge nurses and worked the resident's hall; -He/she did not know the resident had open wounds on his/her buttocks and coccyx. During interview on 6/5/17 at 7:05 A.M., LPN E said he/she was a day shift charge nurse and he/she was unaware the resident had open wounds on his/her buttocks and coccyx. The resident had no physician's order for wound treatments. During interview on 6/5/17 at 9:15 A.M., LPN S said the following: -He/she was the wound treatment nurse; -The resident had three open areas on the coccyx and buttocks; -He/she assessed and measured the wounds. The coccyx wound measured 1.0 centimeters (cm) x 0.5 cm x 0.1 cm deep. The left buttock wound measured 3.0 cm x 0.8 cm x 0.1 cm deep. The right buttock wound measured 1.0 cm x 1.5 cm x 0.1 cm deep; -He/she thought the resident's wound were pressure ulcers or caused by shearing; -He/she did not know the resident had open wounds until today. Review of the resident's POS, dated 6/5/17 at 9:15 A.M., showed the following: -Cleanse open areas to coccyx, left and right buttocks with normal saline; -Apply [MEDICATION NAME] (antibiotic ointment) and dry dressing twice daily and as needed. Observation on 6/6/17 at 10:30 A.M. showed the following: -CNA F rolled the resident to his/her right side; -LPN S removed a dressing from the resident tailbone and buttocks wounds; -The resident's entire buttocks and tailbone area, approximately 8 inches x 8 inches was bright red in a triangle shape encompassing the left and right buttock wounds and the tailbone wound. LPN S said the entire buttock area and the wounds looked worse. The redness was new, was not present yesterday. 6. Review of Resident #9's care plan, dated 11/18/16, showed the following: -The resident was at risk for pressure ulcer related to poor mobility and urinary incontinence; -Staff was to avoid shearing resident's skin during positioning, transferring and turning; and was to report any signs of skin breakdown (soreness, tenderness, red or broken areas). Review of the resident's Braden Scale, dated 2/16/17, showed the resident was at a mild risk for developing pressure ulcers. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required limited assistance of two staff for bed mobility; -Frequently incontinent of bladder; -At risk for developing pressure ulcers. Review of the resident's POS, dated 5/26/17 to 6/25/17, showed the following: -[DIAGNOSES REDACTED]. condition in which the heart does not pump blood as well as it should); -admitted to hospice on 11/9/16 ([MEDICAL CONDITION]). Continuous observations on 6/5/17 showed the following: -At 9:14 A.M., the resident sat in his/her wheelchair in his/her room; -At 9:40 A.M., the resident remained in the same position; -At 10:00 A.M., the resident remained in the same position; -At 10:20 A.M., the resident remained in the same position; -At 10:57 A.M., the resident remained in the same position; -At 11:30 A.M., the resident remained in the same position; -At 11:43 A.M., the resident remained in the same position; -At 1:20 P.M., the resident remained up in his/her chair; -At 2:05 P.M., the resident remained in the same position; -At 2:21 P.M., the resident remained in the same position; -At 2:27 P.M. staff assisted the resident to bed. The resident's urine soiled brief was removed. The resident's coccyx/adjoining buttock areas were reddened. -The resident sat in his/her wheelchair for five hours and 13 minutes. During interview on 6/5/17 at 2:35 P.M., CNA I said the following: -He/she had toileted the resident a little after 1:00 P.M.; -He/she and other staff reported to the charge nurse when a resident had redness and they would that they would report the resident's redness. During interview on 6/7/17 at 2:20 P.M., CNA I said he/she thought he/she reported the resident's redness to the charge nurse but could not remember for sure or who he/she reported it to. During interview on 6/6/17 at 10:51 A.M., LPN E said he/she was not aware of any pressure areas or redness on the resident. During interview on 6/6/17 at 10:56 A.M., LPN S said that he/she was not aware of any pressure areas or redness on the resident. During interview on 6/6/17 at 1:49 P.M., LPN E said the following: -He/she would consider redness to a coccyx to be pressure; -He/she was not aware the resident had a reddened coccyx; -He/she worked 6/5/17 and today, and no staff had reported this to him/her; -He/she would expect staff to report redness to him/her; -Staff would need to lay the resident down more often. During interview on 6/6/17 at 3:21 P.M., LPN E said he/she did assess the resident's coccyx and thought the redness was from being in the chair too long. He/she applied barrier cream to the area and reported it to the oncoming nurse. During interview on 6/6/17 at 3:23 P.M. and 4:47 P.M., LPN H said he

Based on observation, interview, and record review, the facility failed to provide maintenance care of an implanted venous port (a device placed under a patient's skin which allows for the administration of treatments and medications directly into a vein) for one resident (Resident #1), in a review of of nine sampled residents, by not performing dressing and needle changes per the facility policy. The facility failed to provide documentation the resident's port site dressing and needle were changed while the resident was receiving antibiotic therapy for a wound infection from 12/5/15 through 12/13/15. The resident was hosptalized on [DATE] and had an infection in the port. Hospital staff applied a dressing over the port, initialed and dated the dressing 12/13/15. The resident returned to the hospital on [DATE]. The dressing over the resident's port was dated 12/13/15 and contained the hospital nurse's initials. The dressing and the needle of the port had dirt and debris on them and the area under the port was dirty and slimy. Staff failed to ensure the resident's dressing was changed per facility policy and failed to ensure care was provided to prevent infection. The facility census was 70. 1. Review of the pharmacy service provider's policy, provided by the facility as their policy for implanted venous ports, dated 1/15/04 and last revised 7/1/12, showed licensed nurses are to perform cares of the implanted venous ports. The non-coring safety needles are changed every seven days. Review of the pharmacy service provider's policy, Appendix A.1 Infusion Maintenance Table, dated 2008, provided by the facility as their policy, showed the nurse is responsible for reviewing the complete policy for indicated therapies before performing infusion therapy. Implanted venous ports should have transparent dressing changes on admission, every week and as needed (PRN). 2. Review of Resident #1's physicians order sheets dated 10/26/15 through 11/25/15 showed the resident's [DIAGNOSES REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 10/28/15, showed the following: -Moderately impaired cognition; -Totally dependent of two staff for all activities of daily living (ADL)s; -Did not reject care; -Indwelling urinary catheter; -Infections: Multidrug resistant organism and urinary tract infection in the last 30 days; -No intravenous medications; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 9/21/15 and last updated 12/4/15, showed the following: -Problem: Resident has Power Port (brand of implanted venous port) to right upper chest; -Goal: Port site will remain free of signs and symptoms of infection or complications; -Approach: Intravenous antibiotic as ordered by physician and directions to see Power Port information pack in front of chart; -The care plan did not include when to change the dressing at the port site or when to change the needle. Review of the Power Port information packet, as addressed in the resident's care plan, showed there was no guidance which would have directed nursing staff on how to care for the port. Review of the resident's Medication Administration Record [REDACTED]. The order was discontinued on 12/7/15 and orders were obtained on 12/7/15 for [MEDICATION NAME] 120 mg every 12 hours intravenously (IV). Staff documented the resident received the medication as ordered through 12/13/15. Review of the resident's interdisciplinary note, dated 12/8/15, showed the resident continued with wound care to right buttock. Last wound culture positive for pseudomonas (bacteria), on IV [MEDICATION NAME] (antibiotic). Review of the resident's TAR, dated 11/26/15 to 12/25/15, showed Power Port dressing changes weekly when receiving antibiotic therapy (the order was crossed through and showed discontinued on 11/6/15). There was no documentation of weekly dressing changes between 11/26/15 and 12/25/15. (The resident received IV antibiotic therapy from 12/5/15 through 12/13/15. The facility's policy directed staff to change the dressing weekly and the needle every seven days.) Review of the resident's nurse's notes, dated 12/13/15, showed he/she was sent to the hospital due to positive blood culture results. Review of the resident's hospital history and physical, dated 12/13/15, showed the facility called the emergency medical service when the resident had abnormal labs this morning of [MEDICATION NAME] at the level of 8.0. The patient has been receiving the antibiotic for his/her Stage IV decubitus ulcer. Also, reported a change in color of urine to brown which eventually turned yellow from his/her indwelling catheter. In addition, nursing reported the resident was more lethargic since morning. Review of the resident's blood culture collected from the resident's port site, dated 12/13/15, showed the growth of [MEDICATION NAME] faecalis (bacteria in the gastrointestinal tract). Review of the resident's hospital progress note, dated 12/15/15, showed [MEDICAL CONDITION] thought secondary to urinary tract infection [MEDICAL CONDITION] although now has positive blood cultures from the port which likely is infected growing [MEDICATION NAME] faecalis. Review of the resident's hospital discharge summary, dated 12/17/15, showed the following: -Discharge [DIAGNOSES REDACTED]. -Blood culture from the resident's port-a-cath site grew [MEDICATION NAME] faecalis sensitive to [MEDICATION NAME] (antibiotic). The resident will remain on IV [MEDICATION NAME] for ten more days to treat [MEDICATION NAME] faecalis bacteremia (presence of bacteria in the blood). Bacteremia possible source is port-a-cath. -Discharge medications: [REDACTED]. Check [MEDICATION NAME] trough (measures level of medication in the blood) on 12/29/15, 30 minutes before the dose. After resident completes course of antibiotics, may remove the port-a-cath and place a new one at a different site. Review of the admissions checklist for the resident, dated 12/17/15, completed upon the resident's readmission to the facility from the hospital, showed Licensed Practical Nurse (LPN) D initialed the section on the form which read: IV orders written to include a flush order every shift and dressing change every week and PRN. During interview on 1/14/16 at 3:00 P.M., LPN D said the following: -His/her initials on the resident's admission checklist, dated 12/17/15, indicated IV orders were written to include a flush order every shift and dressing change every week and PRN; -He/she did not realize there was not an order on the resident's physician orders [REDACTED]. -He/She must have missed obtaining the orders and writing them. Review of the resident's MAR indicated [REDACTED]. Staff were to flush the port with saline and [MEDICATION NAME] (blood thinner) every shift). Review of the resident's Physician order [REDACTED]. Review of the resident's MAR indicated [REDACTED] -The order for [MEDICATION NAME] 750 mg/150 milliliters (ml) IV solution, 1000 mg IV daily was discontinued on 12/21/15; -On 12/21/15, orders were received to start [MEDICATION NAME] 1 gram every 12 hours. This order was given as ordered and discontinued on 12/24/15; -On 12/24/15, orders were received to start [MEDICATION NAME] 1 gram every 24 hours. Review of the resident's physicians orders showed an order dated 1/4/16 for [MEDICATION NAME] (antibiotic) 1.25 grams intravenous (IV) every 24 hours. (There were no orders obtained to change the dressing to the port site or to change the Huber needle.) Review of the resident's nurses notes, dated 1/4/16, showed the resident was receiving [MEDICATION NAME] IV for [MEDICAL CONDITION] and urinary tract infection [MEDICAL CONDITION]. Review of the resident's physician orders [REDACTED]. -An order dated 1/7/16 to obtain a urinalysis (evaluation of a sample of urine), complete blood count (test used to evaluate overall health), basic metabolic panel (test which evaluates the blood glucose level, electrolytes and kidney function) and blood cultures times two; -An order dated 1/9/16 to transfer the resident to the hospital ER for evaluation. Review of the resident's hospital notes, dated 1/9/16, showed the resident had arrived in the emergency room (ER) from the facility due to positive blood culture results. The note stated the resident had mental status changes on 1/7/16 and blood cultures were drawn at that time. Review of nursing assessment from the hospital, dated 1/9/16, showed hospital Registered Nurse (RN) F documented the resident was transferred to the hospital from the facility. The dressing on the resident's port was the dressing he/she placed on the port site on 12/13/15. Upon removing the dressing that was not intact around the edges, the dressing and the needle of the port had dirt and debris on it. During interview on 1/9/16 at 2:50 P.M., hospital Registered Nurse (RN) F said the resident came to the hospital emergency roiagnom on [DATE] with signs of infection. The resident was a quadriplegic with contractures and required total care from staff. The resident had a port for intravenous access in the right [MEDICATION NAME] (right upper chest area) that had the same dressing in place from the last emergency room visit on 12/13/15. RN F said the dressing contained his/her initials and dated 12/13/15. He/She removed the dressing and found the skin over the port was dirty and slimy. The area required two cleansing swabs to effectively clean the site before accessing the port. Review of the resident's blood culture obtained from the port site showed growth of Proteus mirabilis (bacteria found in the gastrointestinal tract), isolated. Review of the hospital records, dated 1/9/15, showed the resident was being discharged back to the facility after visiting the hospital ER. Review of the resident's medical record showed no documentation the Huber needle was changed every seven days as directed by the facility's policy after orders were obtained to flush the port on 12/17/15. The facility did not change the needle between 12/17/15 and 1/9/16, when the resident went to the hospital. Review showed no documentation staff performed weekly dressing changes to the port site as directed by facility policy between 12/17/15 and 1/9/16. Review of the resident's Physician order [REDACTED]. -Change needle of power port using sterile technique every seven days; -[MEDICATION NAME] (antibiotic) IV 750 mg every 48 hours times five doses; -Continue [MEDICATION NAME] as per previous physician orders. Observation on 1/12/16 at 11:10 A.M. showed the resident lay in a low bed with the head elevated 45 degrees. The port site was visualized on the right upper chest area and was covered with a transparent dressing, dated 1/9/16. During interview on 1/12/16 at 2:45 P.M., Licensed Practical Nurse (LPN) C said treatments including dressing changes should be addressed on the TAR and should be charted on the TAR and in the nurses's notes. During interview on 1/12/16 at 4:00 P.M., the Director of Nursing (DON) said the facility used the pharmacy service provider's recommendations for port care. During interview on 1/14/16 at 2:00 P.M., the Director of Nursing (DON) said the following: -When the resident was first admitted to the facility, the staff were inserviced to follow the pharmacy/facility's policy regarding care of the port; -He/she would expect staff to follow the pharmacy/facility policy in the absence of a physician's orders [REDACTED].>-If upon admission of a resident, there were no order to change a port dressing, she would expect the admitting nurse to obtain one, while following the pharmacy/facility's policy in the meantime; -There is an admission checklist for the admitting nurse to fill out which directs them to specifically address intravenous accesses and catheters and they should be getting orders any necessary orders at that time; -All nursing staff were aware they were to follow the policy; -All nursing staff were responsible for failing to change the resident's port dressings and failing to obtain orders for the dressings; -She would expect staff to document dressing changes of a port in the TAR as well as the nurse's notes. Complaint #MO 744

Based on observation, interview, and record review, the facility failed to turn and reposition three residents (Residents #2, #8, and #9) who were at risk for developing pressure ulcers, failed to identify a new open area for Residents #2, and failed to follow physician orders [REDACTED].#7 and #8, out of 13 sampled residents. The facility census was 72. 1. Review of the manual titled Nurse Assistant in a Long-Term Care Facility, Student Reference, 2001 Revision, showed the following: -A pressure ulcer is an inflammation, sore, or lesion that develops over areas where the skin and tissue underneath are injured due to a lack of blood flow and oxygen supply to an area of the body; -This lack of circulation/blood flow and oxygen supply usually happens because of continuous pressure on the skin over a bony prominence resulting from the way or length of time a resident is positioned; pressure is the main cause; -Residents prone to forming pressure ulcers include elderly residents due to sluggish circulation, poor hydration, poor nutrition, and lack of exercise/mobility; paralyzed, thin, malnourished, obese, and incontinent residents; and residents with chronic diseases; -Prevention of pressure ulcers includes: change the resident's position at least every 2 hours or more frequently if indicated in the care plan, encourage residents in a geri chair or wheelchair to raise themselves every 10-15 minutes, use anti-pressure devices, promote good circulation by giving passive and active ROM exercises, promote good skin condition, and prevent friction on the resident's skin; -Turning should be scheduled for residents who are helpless; -A pressure ulcer can be as stressful to the human body as major surgery; it is worth every effort to prevent one; for every minute it takes to cause a pressure ulcer, it takes weeks to heal. 2. Review of the Prevention and treatment of [REDACTED]. -Ongoing assessment of the skin is necessary to detect early signs of pressure damage; -Repositioning should be considered in all at-risk individuals, repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body; -In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure he/she is exposed to; -When an individual is seated in a chair, the weight of the body causes the greatest exposure to pressure to occur over the ischial tuberosities. As the loaded area in such cases is relatively small, the pressure will be high, therefore, without pressure relief, a pressure ulcer will occur very quickly. 3. Review of the facility's policy Pressure Ulcer Care and Prevention, dated March 2015, showed the following: -Purpose: To prevent and treat further breakdown of pressure sores; -treatment of [REDACTED]. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers; -Guidelines included turn the resident every two hours and position with pads or pillows to protect bony prominences, whenever possible, teach the resident to change his/her own position at regular intervals and shift his/her weight in wheelchair. 4. Review of the facility's Wound Care and Treatment policy dated March, 2015, showed the following: -It is the purpose of this facility to prevent and treat all wounds; -There must be a specific order for the treatment; -Documentation of the treatment should be done immediately after the treatment; -The care plan should reflect the current status of the wound and appropriate goals and approaches. 5. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 4/14/15, showed the following: -Brief Interview for Mental Status (BIMS) score of ten, indicating cognition moderately impaired; -Extensive assist of two staff and physical assist for bed mobility, transfers, toilet use and bathing; -At risk for pressure ulcers; -Supra-pubic urinary catheter (a tube that drains urine from the bladder) in place. Review of the resident's care plan last updated 4/15/15, showed the following: -Pressure ulcer care plan and interventions resolved on 2/27/15; -Impaired skin integrity care plan and interventions resolved on 4/20/15; -The care plan did not include preventative skin care interventions. Review of the resident's Braden Scale (used to assess the resident's level of risk for development of pressure ulcers) dated 4/15/15, showed a score of 14, indicating moderate risk. Review of the resident's head to toe skin assessment dated [DATE], showed the following: -Skin warm and dry to touch; -Coccyx red; -No open areas documented. Observation on 5/11/15 at 5:05 P.M., showed the following: -Nurse Assistant (NA) K and Certified Nurse Assistant (CNA) L turned the resident to his/her right side to place an incontinence brief on the resident; -An open area at the top of his/her coccyx measuring approximately 1.0 centimeter (cm) x 0.5 cm; -CNA L verified the open area at the top of the resident's coccyx; -CNA L said, "I think the staff know about it". Review of the resident's nurse's notes on 5/11/15 at 5:30 P.M., showed the last nurse's note dated 5/4/15 at 4:00 P.M. did not include documentation of an open area on the coccyx. Review of the resident's Physician order [REDACTED].M., showed no orders for treatment of [REDACTED]. Continuous observation on 5/12/15 showed the following: -At 6:45 A.M., CNA E and CNA I transferred the resident into his/her wheelchair; -At 6:55 A.M., the resident sat in a wheelchair in the dining room at a table; -At 7:10 A.M., the resident sat in a wheelchair in the dining room at a table; -At 7:25 A.M., the resident sat in a wheelchair in the dining room at a table; -At 7:45 A.M., the resident sat in a wheelchair in the dining room at a table; -At 8:05 A.M., the resident sat in a wheelchair in the dining room at a table; -At 8:15 A.M., the resident sat in a wheelchair in the dining room at a table, and staff served his/her breakfast tray; -At 8:30 A.M., the resident sat in a wheelchair in the dining room at a table; -At 8:43 A.M., the resident sat in a wheelchair in the dining room at a table; -At 8:48 A.M., the resident sat in a wheelchair in the dining room at a table, and the Director of Nursing (DON) sat at the table with the resident; -At 9:07 A.M., the DON wheeled the resident in his/her wheelchair to his/her room; -At 9:30 A.M., the resident sat in a wheelchair in his/her room; -At 9:50 A.M., CNA E and CNA M transferred the resident to his/her bed. The resident remained in his/her wheelchair from 6:45 A.M. to 9:50 A.M. for a total of three hours and five minutes without being repositioned. Staff did not reposition, toilet or check the resident for incontinence. Observation on 5/12/15 at 10:00 A.M., showed the following: -The resident lay on his/her right side in his/her bed; -A small open area at top of his/her coccyx, approximately 1.0 cm x 0.5 cm; -CNA M verified the open area at the top of the resident's coccyx; -CNA E said, "I think it has been there before"; -CNA M applied barrier cream to the coccyx. During interview on 5/13/15 at 2:50 P.M., Licensed Practical Nurse (LPN) D, said: -He/she does the treatments for all the residents; -He/she was not aware the resident had an open area. During interview on 5/13/15 at 3:15 P.M., LPN A said: -The aides are supposed to mark open areas on shower sheets; -He/she was not aware of any open areas on the resident; -The shower sheet for 5/13/15 showed no open areas. Observation on 5/13/15 at 3:40 P.M., showed the following: -The Director of Nurses (DON) measured the wound on the resident's coccyx; -The wound measured 1.2 cm x 0.2 cm x 0.1 cm; -The DON asked LPN D to call the resident's physician for treatment orders. Review of the resident's POS on 5/14/15 at 8:50 A.M., showed the following daily treatment order for his/her coccyx; -Cleanse the wound with normal saline and pat dry; -Apply dot of silvagel (provides a moist wound environment to treat partial or full thickness wounds against broad spectrum bacteria and fungi) to open area; -Apply cut to fit pad to cover the wound; -Apply [MEDICATION NAME] tape to assure dressing is in contact with wound. During interview on 5/14/15 at 8:35 A.M., CNA M said: -He/she reports open areas to charge nurse and treatment nurse; -He/she fills out a stop and watch sheet (an assessment form used to notify nursing staff of any changes in the resident's condition) and gives it to the DON; -He/she doesn't normally work the resident's hall; -He/she thought the charge nurse knew about the open area; -He/she didn't tell anyone about the resident's open area. During interview on 5/14/15 at 10:20 A.M., CNA E said: -Staff report open areas to charge nurse; -The CNAs fill out a stop and watch sheet and give to the DON; -He/she didn't report the resident's open area to anyone; -He/she thought the nurses knew about it. 6. Review of Resident #8's quarterly MDS dated [DATE], showed the following: -BIMS score of seven, indicating cognition severely impaired; -Extensive assistance of two staff for bed mobility, transfers, toilet use and personal hygiene; -Frequently incontinent of urine; -At risk for pressure ulcers; -Currently had a pressure ulcer. Review of the resident's care plan dated 3/18/15 showed the following: -Turn and reposition every two hours and as needed for comfort; -Keep clean and dry, minimize skin exposure to moisture. -Treatment to pressure ulcer as ordered with monitoring for efficacy. Review of the Pressure Wound Report dated 5/8/15 showed the following regarding the resident: -Right posterior heel wound measures 1.1 cm x 0.5 cm x 0.6 cm; -Coccyx wounds measure, proximal 0.9 cm x 0.2 cm x 0.1 cm, distal wound 3.3 cm x 0.4 cm x 0.1 cm. Review of the resident's POS dated 4/26/15 to 5/25/15 showed the following orders dated 5/9/15: -Treatment to coccyx: cleanse with normal saline, pat dry, apply thin layer of [MEDICATION NAME] (topical antimicrobial drug) to wound bed, place small strip ABD to cover wound, secure with [MEDICATION NAME] tape twice daily; -Treatment to right posterior heel: cleanse with normal saline, apply Santyl ([MEDICATION NAME] ointment) to wound bed, apply ABD, and wrap with ace wrap daily. Review of the resident's Treatment Administration Record (TAR), dated 4/26/15 through 5/25/15, showed the following: -New treatment orders for the resident's coccyx wounds and right posterior heel wound started on 5/9/15; -No evidence to show staff provided the resident's physician ordered treatments to the resident's right heel or to his/her coccyx wounds on 5/10/15 or 5/11/15. Review showed the resident's TAR did not contain any information to show staff provided the resident's physician ordered treatment on 5/10/15 or 5/11/15 to promote healing and prevent further decline. Observation on 5/11/15 at 4:08 P.M., showed the following: -Nurse Aide (NA) K and CNA N entered the resident's room; -The resident told staff he/she wanted to get out of bed; -CNA N provided perineal care for the resident; -The resident had an open area to coccyx with a slit appearance; -There was no dressing on the coccyx wound; -The dressing on the right posterior heel was dated 5/9/15. Continuous observation on 5/12/15 showed the following: -At 5:30 A.M., the resident sat in a wheelchair in the dining room at a table; -At 5:45 A.M., the resident sat in a wheelchair in the dining room at a table; -At 6:00 A.M., the resident sat in a wheelchair in the dining room at a table; -At 6:10 A.M., the resident sat in a wheelchair in the dining room at a table; -At 6:30 A.M., the resident sat in a wheelchair in the dining room at a table; -At 6:45 A.M., the resident sat in a wheelchair in the dining room at a table; -At 7:10 A.M., the resident sat in a wheelchair in the dining room at a table; -At 7:25 A.M., the resident sat in a wheelchair in the dining room at a table; -At 7:45 A.M., the resident sat in a wheelchair in the dining room at a table; -At 8:05 A.M., the resident sat in a wheelchair in the dining room at a table; -At 8:12 A.M., the resident was served breakfast, remained sitting in wheelchair in dining room; -At 8:25 A.M., the resident sat in a wheelchair in the dining room at a table, eating his/her breakfast; -At 8:45 A.M., the resident propelling self in his/her wheelchair toward his/her room; -At 9:05 A.M., the resident sat in a wheelchair in his/her room. Observation on 5/12/15 at 9:15 A.M., showed the following: -CNA E transferred the resident to the toilet; -The resident's incontinency brief was saturated with urine; -CNA E provided perineal care; -CNA E assisted the resident to his/her bed. The resident remained in his/her wheelchair from 5:30 A.M. to 9:15 A.M., for a total of three hours and 45 minutes without being repositioned. Staff did not reposition, toilet or check the resident for incontinence. Observation on 5/12/15 at 1:15 P.M., showed the following: -LPN D and CNA E entered the resident's room to provide treatments to wounds; -The resident lay in his/her bed; -CNA E turned the resident to his/her right side; -There was no dressing on the coccyx wound; -LPN D provided wound care as ordered to the coccyx wounds; -LPN D said the dressing was changed on the day shift and on the evening shift; -LPN D removed the dressing from the resident's right heel which was dated 5/9/15; -LPN D verified the dressing date was 5/9/15; -LPN D provided wound care as ordered to the right posterior heel. During interview on 5/12/15 at 1:25 P.M., LPN D said: -The dressing to the resident's coccyx wound was ordered to be changed twice a day; -He/she did not know why there were no dressing on the coccyx wound; -The dressing to the resident's right posterior heel was changed daily; -He/she did not work the last few days. Observation on 5/13/15 at 2:50 P.M., showed the following: -The DON measured the resident's coccyx and right posterior heel wound; -The right posterior heel wound measured 0.5 cm (L) x 1.1 cm (W) x 0.2 cm (D) ; -The proximal coccyx wound measured 2.0 cm (L) x 0.2 cm (W); -The medial coccyx wound measured 0.5 cm (L) x 0.3 cm (W); -The distal coccyx wound measured 4.5 cm (L) x 0.3 cm (W); -The DON said the wound bed was beefy red and had maceration (the softening and breaking down of skin resulting from prolonged exposure to moisture) at the distal right side and he/she thought the middle to the distal wound healed creating three separate wounds. During interview on 5/14/15 at 9:30 A.M., Registered Nurse (RN) C said: -He/she was new to the facility; -He/she had worked two days on his/her own; -He/she failed to do Resident #8's treatments on 5/10/15 and 5/11/15. During interview on 5/14/15 at 10:10 A.M., the DON said: -The treatment nurses were responsible for all treatments; -The charge nurses were not responsible for treatment nurses' duties. During interview on 5/14/15 at 2:10 P.M., the DON said: -He/she would expect staff to report an open area to the charge nurse or treatment nurse; -He/she would expect nurses to follow physician orders; -He/she would expect nurses to change wound dressings as ordered; -He/she would expect a dressing to be on a wound if the dressing was ordered. 7. Review of Resident #7's quarterly MDS, dated [DATE], showed the following: -Severely impaired daily decision making skills; -Short term and long term memory problems; -Rarely or never made self-understood; -Extensive assist of two staff and physical assist for bed mobility, transfers, toilet use, dressing; -Dependent of two or more staff for bathing; -Did not rate urinary continence, no external or indwelling catheter; -Always incontinent of bowel; -At risk for pressure ulcers; -One Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) pressure ulcer. Review of the resident's care plan dated 4/21/15, showed the following: -Indwelling catheter (a catheter held in the bladder by an inflatable balloon to continuously drain urine) to promote healing; -Low air loss bed (a mattress designed to treat and prevent pressure ulcers). -Keep clean and dry, and minimize skin exposure to moisture; -Perineal care every two hours and as needed to minimize skin surface contamination; -Treatment to pressure ulcer as ordered by the physician with monitoring of the effectiveness; -Stage IV right heel pressure ulcer healed. Review of the Pressure Wound Report dated 5/8/15, showed left lateral hip Stage IV pressure ulcer 0.2 length (L) cm x 0.1 width (W) X 3.1 cm depth/tunnel (D). Onset of the pressure ulcer was 9/24/14. Review of POS dated 4/26/15 - 5/25/15, showed the following orders: -Right heel scabbed area-apply skin prep, cover with a ABD (highly absorbent dressing that provides padding and protection for wounds) and wrap with kling daily; -Treatment to left lateral hip, cleanse with Dakins Solution (antiseptic solution containing sodium hydrochlorite and developed to treat infected wounds) 1/4 strength. Cut 3.0 cm x 0.5 cm promogram (a dressing that absorbs drainage and contains a low level of silver that aids in killing bacteria) and place within the tunneled area at 8:00 o'clock. Pack with Dakins soaked plain strips, cover with an ABD pad and secure with [MEDICATION NAME] (tape) every day. Review of the resident's TAR, dated 4/26/15 through 5/25/15, showed the following: -New treatment orders for the resident's left hip wound started on 4/19/15 for cleanse with Dakins Solution (antiseptic solution containing sodium hypochlorite and developed to treat infected wounds) 1/4 strength. Cut 3.0 cm x 0.5 cm promogram (a dressing that absorbs drainage and contains a low level of silver that aids in killing bacteria) and place within the tunneled area at 8:00 o'clock. Pack with Dakins soaked plain strips, cover with an ABD pad and secure with [MEDICATION NAME] (tape) every day; -Treatment order for the resident's right heel scabbed area started on 3/13/15 to apply skin prep, cover with a ABD (highly absorbent dressing that provides padding and protection for wounds) and wrap with kling daily; Review showed the resident's TAR did not contain any information to show staff provided the resident's physician ordered treatment on 5/10/15 or 5/11/15 to promote healing and prevent further decline. Observation on 5/12/15 at 6:59 A.M., showed the following: -CNA M and CNA I entered the resident's room to get the resident up for breakfast; -CNA M pulled the resident's covers back; -The resident's left hip dressing and incontinence brief were soiled with dark brown and red thick foul smelling drainage; -The dressing on the left hip was dated 5/9/15; -CNA M verified the dressing was dated 5/9/15; - The resident's dressing to his/her right heel was black in color and did not have a date on the dressing; -CNA M and CNA I changed the resident's incontinence brief and continued with care. Observation on 5/12/15 at 2:00 P.M., showed; -The dressings on the resident's left hip and right heel had been changed and were no longer soiled; -The smell of the resident's wound was minimal; -The dressings were dated 5/12/15. During interview on 5/12/15 at 2:40 P.M., LPN D said: -He/she did the treatments and changed the dressings on the resident's right heel and left hip today (5/12/15); -The treatments to the resident's right heel and left hip were ordered daily; -The left hip dressing was dated 5/9/15 and the right heel dressing did not have a date on it prior to his/her removing the dressings; -The resident's left hip wound was saturated with brownish red and green drainage and had a very foul smelling odor. -The left hip wound had deep red outside edges and the center was white; -The right heel had a scab but was not red or opened; -He/she did not measure the wounds and did not document on the wounds; -The DON and a wound doctor assess, measure, and document wounds every Friday; -He/she did not work the last few days and wasn't sure why the dressings were not changed daily. Observation on 5/13/15 at 10:10 A.M., showed: -Quarter size brownish red drainage on the resident's left hip dressing; -The dressing to the right heel was intact without visible drainage; -The DON removed the dressings dated 5/12/14 from the resident's left hip and right heel; -The DON measured the left hip wound; -The left hip wound measured 0.2 cm (L) x 0.8 cm (W) x 3.4 cm tunnel, with red outer edges and pink and white center; -The right heel was scabbed over without redness or open areas. During interview on 5/14/15 at 9:30 A.M., RN C said: -He/she was new to the facility; -He/she had worked two days on his/her own; -He/she failed to do Resident #7's treatments on 5/10/15 and 5/11/15. 8. Review of Resident #9's admission MDS dated [DATE], showed the following:-BIMS score of six, indicating cognition severely impaired; -Limited assist of one staff for bed mobility, transfers, toilet use and personal hygiene; -Occasionally incontinent of urine; -At risk for pressure ulcers. Review of the resident's care plan dated 4/14/15, showed the following: -Keep clean and dry, minimize skin exposure to moisture; -Use moisture barrier product to perineal area; -Report any signs of sign breakdown. Review of the resident's Braden Scale dated 4/27/15, showed a score of 17, indicating mild risk for development of pressure ulcers. Continuous observation on 5/12/15, showed the following: -At 5:30 A.M., the resident sat in a wheelchair at the nurse's station; -At 5:45 A.M., the resident sat in a wheelchair at the nurse's station; -At 5:55 A.M., the resident sat in a wheelchair at the nurse's station; -At 6:10 A.M., the resident sat in a wheelchair at the nurse's station; -At 6:20 A.M., the resident sat in a wheelchair at the nurse's station; -At 6:45 A.M., staff pushed the resident in his/her wheelchair to the dining room; -At 7:00 A.M., the resident sat in a wheelchair in the dining room at a table; -At 7:12 A.M., the resident sat in a wheelchair in the dining room at a table; -At 7:25 A.M., the resident sat in a wheelchair in the dining room at a table; -At 7:45 A.M., the resident sat in a wheelchair in the dining room at a table; -At 8:05 A.M., staff assisting the resident to eat, remains in wheelchair in the dining room; -At 8:15 A.M., staff pushed the resident in his/her wheelchair to the nurse's station; -At 8:30 A.M., the resident sat in his/her wheelchair at the nurse's station; -At 8:43 A.M., staff wheeled the resident in his/her wheelchair to his/her room; -At 8:50 A.M., staff transferred the resident to his/her bed. The resident remained in his/her wheelchair from 5:30 A.M. to 8:50 A.M. for a total of three hours and 20 minutes without being repositioned. Staff did not reposition, toilet, or check the resident for incontinence as directed and to assist in preventing a decline in the resident's skin condition. 9. During interview on 5/14/15 at 9:05 A.M., LPN A said: -He/she would expect staff to turn and reposition residents every two hours; -He/she would expect staff to report any open areas to charge nurse; -If staff reported an open area, he/she would assess the wound and notify the physician for treatment orders. During interview on 5/14/15 at 2:10 P.M., the DON said: -He/she would expect staff to turn and reposition residents every two hours; -He/she would expect staff to report all open areas to the charge nurse or treatment nurses.

Based on observation, interview, and record review, the facility staff failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for two residents (Residents #7 and #8), in a review of 13 sampled residents. Facility staff failed to obtain PT/INR ([MEDICATION NAME]/international normalized ratio, blood test to determine clotting factors) lab work as ordered by the physician after the initiation of [MEDICATION NAME] (anticoagulant) therapy for Resident #7 and failed to inform the physician the lab was not completed until six days after it should have been completed. Resident #7's lab results were critically high which resulted in him/her receiving an injection of Vitamin K (medication needed for adequate blood clotting). The facility staff also failed to properly assess and provide nursing interventions for Resident #7's [MEDICAL CONDITIONS]. The staff failed to hold [MEDICATION NAME] for two days as ordered by the physician for Resident #8, whose PT/INR results were elevated. After two days, the resident's PT/INR was critically high and the physician ordered Vitamin K. The facility census was 71. 1. Review of The Lippincott Manual of Nursing Practice, seventh edition, dated 2001, showed: -[MEDICAL CONDITIONS] is [MEDICAL CONDITION] (blood clot) of deep rather than superficial veins. Two serious complications are [MEDICAL CONDITION] embolism (blood clot that has traveled to the lung blocking a main artery) and postphlebiti[DIAGNOSES REDACTED] (blood clot becomes embedded in a vein and destroys the vein); -Three antecedent factors are believed to play a significant role in the development of a venous [MEDICAL CONDITION]: stasis of blood; injury to the vessel wall; altered blood coagulation; -[MEDICAL CONDITION]-related situations included: venous stasis following operations, childbirth, or bed rest; prolonged sitting or as a complication of varicose veins; injury to a vein; -Nursing assessment: obtain history of risk factors for [MEDICAL CONDITION]; note symmetry or asymmetry of legs. Measure and record leg circumferences daily; Observe for evidence of venous distention or [MEDICAL CONDITION], puffiness, stretched skin, hardness to touch; Examine for signs of obstruction due to occluding thrombus-swelling; hand-test extremities for temperature variations; assess for calf pain, which may be aggravated when foot is dorsiflexed (backward flexion) with the knee flexed (Homans' sign); -Nursing interventions and management: avoid rubbing or massaging calves and thighs; instruct the patient to avoid standing or sitting in one place for prolonged periods or crossing legs when seated; Assess distal peripheral pulses, capillary refill, and sensation of lower extremities; check for positive Homans' sign; prevent the use of bed rolls or knee gatches in patients at risk; initiate anticoagulant therapy as prescribed; prevent swelling and stagnation of venous blood by applying appropriately fitting elastic stockings or wrapping the legs from the toes to the groin with elastic bandage. 2. Review of the Nursing 2011 Drug Handbook showed the following information related to [MEDICATION NAME] therapy: -Black Box Warning: [MEDICATION NAME] can cause major or fatal bleeding which is more likely to occur during the starting period; -PT/INR determinations are essential for proper control; -Elderly patients and patients with [MEDICAL CONDITION] are especially sensitive to the drug's effect. 3. Review of Mosby's Manual of Diagnostic and Laboratory Tests second edition showed the following lab values for [MEDICATION NAME] (PT) and International Normalized Ratio (INR): -Normal Findings for the PT is 11.0-12.5 seconds; -Critical Values for the PT is greater than 20 seconds; -Therapeutic INR is usually considered to be 2.0-3.5 in most institutions. 4. Record review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/15/13, showed: -Short and long term memory problem; -Severely impaired decision making; -No behavior symptoms; -Did not reject care; -Required extensive assistance of two for bed mobility and transfers; -Walk in room and corridor did not occur; -Required extensive assistance of one for locomotion, dressing, eating, toilet use, and personal hygiene; -Frequently incontinent of bowel and bladder. Record review of the resident's nurse's notes, dated 2/11/14, showed: -New orders received from the resident's physician for complete blood count (CBC), sedimentation rate, and D-Dimer (lab test used to rule out presence of blood clot) for left leg [MEDICAL CONDITION]; -The notes showed staff completed no assessment of the resident. Record review of the resident's lab results, collected on 2/12/14 and reported 2/13/14 showed D-Dimer results were 883 nano-grams (ng)/milliliter (ml) (normal is less than 230). Record review of the resident's physician telephone order for 2/13/14 showed an order for [REDACTED]. Record review of the resident's venous doppler results of the left lower extremity (LLE), dated 2/13/14, showed acute [MEDICAL CONDITION] of the LLE, extensive and occlusive. Record review of the resident's telephone order for 2/13/14 at 5:00 P.M. showed: -[MEDICATION NAME] (medication used to thin the blood) 5 mg (milligram) daily; -INR (international normalized ratio, a comparative rating of a resident's [MEDICATION NAME] used as a standard for monitoring the effects of [MEDICATION NAME]) in five days. Record review of the resident's nurse's notes showed: -No documentation of assessment related to the resident's [MEDICAL CONDITION] and [MEDICAL CONDITION] between 2/13/14 and 2/23/14; -Review showed no documentation staff attempted to obtain a blood specimen for the PT/INR ordered for 2/18/14 until 2/23/14 (five days after the physician's orders [REDACTED]. -No documentation staff notified the physician the PT with INR had not been drawn until 2/23/14. During an interview on 4/8/14 at 1:40 P.M., the assistant director of nursing (ADON) said he/she was unable to find a PT with INR for the resident between 2/13/14 and 2/23/14. Record review of the resident's lab results, dated 2/23/14, showed the blood specimen clotted and the laboratory was unable to complete the PT with INR. Record review of the resident's lab results, dated 2/24/14 (six days after the physician ordered it to be drawn), showed: -Lab was drawn 2/24/14 at 11:00 A.M.; -Lab was reported 2/25/14 at 8:14 A.M.; -PT 101.7 seconds, critical (normal 9.7-12.4 seconds); -INR 9.37 ratio, critical (normal 0.8-1.2 ratio). Record review of the resident's nurse's notes showed no documentation staff completed an assessment of the resident related to [MEDICAL CONDITIONS], and critical PT with INR on 2/24/14. Record review of the resident's nurse's notes, dated 2/25/14 at 9:00 A.M., showed: -Critical PT with INR reported to the physician; -Vitamin K, 10 mg/ml injectable (used to reverse the effects of [MEDICATION NAME]) subcutaneously (sq) one time only; -Hold [MEDICATION NAME] until further notice; -Repeat PT with INR and CBC on 2/26/14; -No documentation staff completed an assessment of the resident related to [MEDICAL CONDITIONS], and critical PT with INR. Record review of the resident's lab results, dated 2/26/14, showed: -PT 16.1 seconds; -INR 1.46 ratio. Record review of the resident's nurse's notes, dated 2/26/14 at 6:45 (A.M. or P.M. not specified), showed: -No bruising noted on hands, arms, or legs due to increased PT with INR; -Bleeding precautions monitored. Record review of the resident's physician nursing home note, dated 2/27/14 showed: -No bleeding; -No leg pain; -Bilateral feet: purple toes, cool, capillary refill less than two seconds; -Plus four [MEDICAL CONDITION] of left calf; -[MEDICAL CONDITION] - resume [MEDICATION NAME]; -Hypercoagulable state. Vitamin K. [MEDICATION NAME] held. Record review of the resident's physician order [REDACTED]. -[MEDICATION NAME] 3 mg daily; -INR on Monday (3/3/14). Record review of the resident's lab results on 3/3/14 showed: -PT 19.1 seconds; -INR 1.73 ratio. Record review of the resident's nurse's notes 2/27/14-3/3/14 showed no documentation staff completed an assessment of the resident related to [MEDICAL CONDITIONS] and fluctuating PT with INR levels. Record review of the resident's physician telephone order, dated 3/4/14, showed: -Change [MEDICATION NAME] to 3.5 mg daily; -Recheck PT with INR in two weeks. Record review of the resident's nurse's notes 3/3/14-3/17/14 showed no documentation staff completed an assessment of the resident related to [MEDICAL CONDITIONS], and fluctuating PT with INR levels. Record review of the resident's care plan, dated 3/17/14, did not address the resident's lower extremity [MEDICAL CONDITION], initiation of [MEDICATION NAME], or [MEDICAL CONDITION] of LLE. Record review of the resident's nurse's notes on 3/18/14 at 10:00 P.M. showed: -Telephone call from lab with critical PT with INR; -Paged the resident's physician with no response back; -Monitoring resident for bleeding and bruising; -No brushing resident's teeth, shaving, or transfers until the physician returns call. Record review of the resident's lab results dated 3/18/14 showed: -Lab was collected on 3/18/14 at 4:25 A.M.; -Lab was reported on 3/18/14 at 9:23 P.M.; -PT 66.8 seconds; -INR 6.13 ratio. Record review of the resident's nurse's notes, dated 3/19/14 at 6:30 A.M., showed: -Hold [MEDICATION NAME]; -Recheck PT with INR tomorrow. Record review of the resident's lab results dated 3/19/14 showed: -PT 46.5 seconds; -INR 4.25 ratio. Record review of the resident's lab results dated 3/20/14 showed: -PT 26.6 seconds; -INR 2.42 ratio. Record review of the resident's physician nursing home note, dated 3/20/14, showed: -2+/4 [MEDICAL CONDITION] in extremities; -[MEDICAL CONDITION]-on [MEDICATION NAME]; -Hypercoagulable state; -[MEDICAL CONDITION], blood pressure low. Consider [MEDICATION NAME] (medication that pulls fluid from the body). Record review of the resident's POS, showed a written order, dated 3/20/14: -[MEDICATION NAME] 3 mg daily; -PT with INR in one week. Record review of the resident's lab results dated 3/26/14 showed: -PT 18.6 seconds; -INR 1.68 ratio. Record review of the resident's physician telephone order, dated 3/27/14, showed: -An X marked over the date, 3/27/14, in the discontinued date box with 3 mg daily written next to it (no medication listed); -3.5 mg daily on a second line (no medication listed); -No orders for follow-up PT with INR noted on the telephone order. Record review of the resident's undated POS showed a transcribed telephone order received for PT with INR in two weeks, noted 3/27/14. Record review of the resident's nurse's notes showed an entry, dated 3/27/14: -Discontinue [MEDICATION NAME] 3 mg; -New order for [MEDICATION NAME] 3.5 mg; -PT with INR in two weeks. Observation on 4/7/14 showed: -At 3:20 P.M., staff pushed the resident out of his/her room in a wheelchair. The resident had house slippers on. The resident's feet slid along the floor as staff pushed him/her. The resident's legs were at a 90 degree angle while in the wheelchair; -At 4:20 P.M., the resident sat in the wheelchair in the dayroom next to the nurse's station with his/her eyes closed. The resident occasionally opened his/her eyes and looked around; -At 4:27 P.M., the resident was asleep in the wheelchair; -At 4:30 P.M., restorative aide (RA) R woke the resident and pushed him/her into the dining room. The resident's feet slid on the floor while RA R pushed him/her; -At 5:30 P.M., the resident sat at the dining room table with his/her head on the table and leaning to the right; -At 6:05 P.M., the resident sat at the dining room table eating his/her evening meal; -At 7:10 P.M., the resident sat in his/her wheelchair in the dayroom in front of the TV; -At 7:45 P.M., the resident propelled his/her wheelchair with his/her feet down the hallway. Office staff pushed the resident into his/her room; -At 7:55 P.M., Certified Nurse Assistant (CNA) M assisted the resident to bed. The resident complained of his/her bottom hurting. The resident's bilateral feet and lower calves were [MEDICAL CONDITION] and dark red in color. The resident's toes on both feet were purple in color. During an interview on 4/7/14 at 5:30 P.M. RA R said: -He/she brought the resident to the dining about 4:30 P.M. for exercises; -Sometimes the resident participates but the resident was sleepy today; -He/she moved the resident from the activity to the dining room table. Observation on 4/8/14 from 11:50 A.M. until 3:00 P.M. showed: -The resident sat up in his/her wheelchair with his/her legs bent at a 90 degree angle with both feet on the floor; -The resident's lower extremities were [MEDICAL CONDITION] and dark red in color. Observation on 4/9/14 showed: -At 12:00 P.M., the resident sat up in his/her wheelchair in the dining room waiting for his/her noon meal; -From 1:15 P.M. until 4:45 P.M., the resident remained up in his/her wheelchair in the dayroom. The resident's legs were [MEDICAL CONDITION], red in color and both his/her feet rested on the floor; -At 5:00 P.M., the resident sat in his/her wheelchair in the dining room. During an interview on 4/9/14 at 4:00 P.M., the DON said: -Routine nursing interventions for a lower extremity [MEDICAL CONDITION] would include a blood thinner and monitoring PT with INR. The resident would be on bleeding precautions such as no shaving, not brushing teeth, and not rubbing the resident's legs. The resident would have a soft tooth brush; -If a resident had a lower extremity [MEDICAL CONDITION], the interventions would be on the care plan; -A resident with a lower extremity [MEDICAL CONDITION] should have a position change normally every two hours but sometimes 45 minutes to one hour; -She did not know if staff had tried ACE bandages or support hose for the resident; -Nursing interventions the staff had tried for the resident included administering the [MEDICATION NAME] as ordered and not leaving the resident sitting in his/her chair all day long; -The process from the time an order for [REDACTED]. -If a resident had a PT of 101.7 and an INR of 9.37, she would expect staff to notify the physician, complete an assessment, obtain a set of vital signs, and look for any bruising. It is absolutely documented. 5. Review of Resident #8's Care Area Assessment (CAA) (provides a framework for guiding the review of triggered areas and a basis for additional assessment of potential issues including related risk factors identified in the MDS) Summary Report, dated 3/16/14, showed staff assessed the resident as follows: -Cognition moderately impaired; -Required extensive assistance with bed mobility, transfers, and locomotion on unit; -Required limited assist with dressing, toileting, and personal hygiene Review of the resident's POS, dated from 3/9/14 to 3/25/14, showed the following: -[DIAGNOSES REDACTED]. -[MEDICATION NAME] 5 mg by mouth (po) every day for [DIAGNOSES REDACTED]. -Laboratory orders, PT/INR, no frequency indicated. Review of the resident's lab results, dated 3/11/14, showed the following: -[MEDICATION NAME] time was 21.1; -INR was 1.91; -New handwritten order on lab report instructed staff to increase [MEDICATION NAME] to 5.5 mg and re-check PT/INR in two weeks. Review of the resident's POS, dated from 3/9/14 to 3/25/14, showed the following: -New order, dated 3/14/14, handwritten on the order sheet to increase [MEDICATION NAME] to 5.5 mg daily; -Re-check lab in two weeks. Review of the resident's lab results, dated 3/17/14 with a faxed date of 3/19/14, showed the following results: -[MEDICATION NAME] time was 42.3; -INR was 4.54; -New order handwritten on lab report showed to hold today and tomorrow. Review of the resident's [MEDICAL TREATMENT] center POS, dated 3/19/14 and faxed to the facility on [DATE] at 9:05 A.M. showed: -Hold [MEDICATION NAME] on 3/19/14 and 3/20/14 due to high PT/INR; -Will check STAT (immediately) level on 3/21/14. Review of a second POS from the [MEDICAL TREATMENT] center, dated 3/19/14 and faxed to facility showed: -HOLD [MEDICATION NAME] Wednesday (3/19/14) and Thursday (3/20/14); -STAT PT/INR level to be drawn 3/21/14 before [MEDICAL TREATMENT]. Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's lab results, dated 3/21/14 and faxed to facility on 3/21/14 at 8:00 A.M., showed: -The lab placed a panic call at 7:13 A.M.; -[MEDICATION NAME] time was 112.3; -INR was 10.7; -New order handwritten on lab report showed: 1) Vitamin K, 5 mg, po now, 2) INR in A.M., 3) Hold [MEDICATION NAME]. Review of the resident's POS dated from 3/9/14 to 3/25/14 showed new order handwritten on the POS on 3/21/14 for 1) Vitamin K, 5 mg PO NOW, 2) INR in A.M., 3) Hold [MEDICATION NAME]. Review of the resident's medical record showed no documentation the facility obtained the PT/INR on 3/22/13 as ordered by the physician. Review of the resident's [MEDICAL TREATMENT] center POS, dated 3/21/14 and faxed to facility on 3/21/14 at 8:00 A.M., showed: -STOP [MEDICATION NAME] for now, for Central Venous Catheter (CVC) removal next week and elevated PT/INR; -Will re-check on Monday; -Vitamin K per protocol. Review of the resident's lab results, dated 3/28/14 and faxed to facility on 3/31/14 at 12:58 P.M., showed: -[MEDICATION NAME] time was 14.6; -INR was 1.32; -New order handwritten on lab report showed: 1) on hold till after procedure, 2) re-check one week after procedure. During interview on 4/9/14 at 2:00 P.M., Licensed Practical Nurse (LPN) T said the resident's [MEDICATION NAME] was not held on 3/19/14 and 3/20/14 because the order did not get put on the MAR. He/she was unsure who was responsible for putting orders on the MAR, but the treatment nurse was responsible for putting faxed orders on the MAR. He/she the resident received Vitamin K due to a high PT/INR. The resident's PT/INR was high previously and staff did not hold the resident's [MEDICATION NAME] for two days as the physician ordered. He/she notifies the physician with high lab results and documents that the physician was notified in nurse's notes. During interview on 4/9/14 at 2:00 P.M., LPN U said the ADON was responsible to check that telephone orders were on the MAR. During interview on 4/9/14 at 4:40 P.M., medical records staff V said he/she could find no lab results for an INR for 3/22/14. During telephone interview on 4/16/14 at 11:17 A.M., LPN T said the following: -There was no documentation in the chart the physician was notified of the resident's [MEDICATION NAME] not being held on 3/19/14 and 3/20/14 as ordered; -Residents on [MEDICAL TREATMENT] had their labs drawn at [MEDICAL TREATMENT] on the days they were at [MEDICAL TREATMENT] and the facility drew the labs on the days a resident did not have [MEDICAL TREATMENT]; -There was no documentation/results in the resident's chart of a PT/INR drawn on 3/22/14; -There was no documentation in the chart the physician was notified of lab not drawn on 3/22/14 as ordered. 6. During interview on 4/17/14 at 1:40 P.M., Resident #3's and Resident #8's physician said: -The facility staff was usually pretty good about calling him/her when they forgot to do something; -If the staff had called to let him/her know they had forgotten to hold a [MEDICATION NAME], he/she would tell the staff to stop the medication and to check the PT with INR; -He/she would expect the staff to notify him/her if they did not hold a [MEDICATION NAME] or forgot to draw a PT with INR. He/she would expect this to be documented in the resident's record.

Based on interview and record review the facility failed to protect one of 17 sampled residents (Resident #22) right to retain and use personal possessions when staff disposed of his/her motorized wheel chair. The facility census was 69. 1. Review of Resident #22's Social Services progress note dated 09/06/11, showed the following: -One on one with the resident today along with the Administrator and Director of nursing (DON); -Spoke to the resident regarding his/her room and clutter; -The resident agreed to allow housekeeping to deep clean and get rid of his/her old wheelchair and scooter. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated 01/31/12, showed the following: -Cognitively intact; -Transferred with extensive assistance of two people; -Dressed with limited assistance of one person; -Fed self. Review of the resident's inventory list dated 02/2012, showed the electric wheelchair was disposed of on "09/06/11". During interview on 04/02/12 at 4:15 P.M., the resident said the following: -The staff did not want the resident to have his/her motorized wheelchair in his/her room; -He/she did not know where staff kept his/her motorized wheel chair. During interview on 04/03/12 at 12:30 P.M., the Administrator said the following: -Staff talked to the resident about his/her cluttered room; -The motorized wheelchair was not working; -The motorized wheelchair was disposed of; -Broken medical equipment is picked up at facility by an individual that takes scrap metal for disposal; -The social services director had spoken with the family about the motorized wheelchair disposal. During interview on 04/03/12 at 12:35 P.M., the Director of Nursing (DON) said the following: -The resident "okayed" the facility to remove the wheel chair from his/her room; -The facility helped him/her clean his/her cluttered room. During interview on 04/04/12 at 10:40 A.M., the Social Services Director said the following: -She talked with family about cleaning the resident's room; -The resident's family did not have room to store the motorized wheel chair; -She was unsure if she had talked with the family regarding disposal of the motorized wheel chair. During interview on 04/03/12 at 3:00 P.M., the resident said the following: -He/she had been upset and cried many times about not knowing where his/her motorized wheelchair was; -He/she would never have authorized staff to take his/her motorized wheelchair away; -He/she had the motorized wheel chair when admitted to the facility in January of 2009; -He/she said the motorized wheelchair was in need of a new battery. During interview on 04/03/12 at 3:15 P.M., the resident's family member said the following: -The facility parked the resident's motorized wheel chair because of his/her high ammonia(an alkaline gas in the blood; increased levels are found in liver failure) levels; -The resident was placed in a manual wheel chair for safety concerns at that time; -The motorized wheel chair was a $12,000.00 chair that was customized for the resident; -He/she did not authorize the facility to dispose of the motorized wheelchair; -He/she was never contacted to come and get the motorized wheelchair or that the facility would dispose of it. The delivery ticket provided by the family on 04/09/12, showed the following: -The motorized wheel chair was delivered on 01/06/09; -Instructed on proper use of equipment; -Charging of the motorized wheel chair; -Warranty information; -The toll free number of the provider; -The motorized wheel chair was retailed for $11,030.00; -The charger was $275.00; -The battery was $190.00; -The foot plate was $180.00; -The safety belt was $50.00; -Right and left elevated leg rests $360.00; -The billed total was $12,258.00 retail price. During interview on 04/03/12 at 3:45 P.M., the Maintenance Supervisor said the following: -The resident's room was cluttered and unsafe; -The resident was asked to move some things out of his/her room including the electric wheelchair that was not working; -The facility was going to junk the chair because it was broken; -The electric wheelchair was taking up too much space; -The resident had agreed to let the facility remove the wheelchair from his/her room; -He/she had not called to see if the electric wheelchair could be serviced; -He/she was unaware if the family had been contacted; -The facility contacted a man that disposed of unworkable medical equipment and takes it for scrap metal disposal. During interview on 04/09/12 at 11:30 A.M, the motorized wheel chair provider representative said the following: -The motorized wheel chair can be serviced for the life of the chair; -The motorized wheel chair never gets too old that it can not be fixed; -There was no documentation the provider had been notified that the chair needed service. During interview on 04/10/12 at 8:30 A.M., the scrap metal dealer said the following: -He/she said picked up unworkable equipment from the facility and took to scrap metal yard; -He/she recalled he/she took the motorized wheel chair from the facility sometime in September, 2011.

Based on observation, interview and record review, the facility failed to ensure staff provided services to promote each resident's highest practicable physical and emotional well-being for one of 17 sampled residents (Resident #1) who experienced severe pain. The facility census was 69. 1. Review of Resident #1's care plan dated 03/23/12, showed the following: Pain -Pain management program due [MEDICAL CONDITION] and arthritis; Goal -The resident will verbalize decrease in pain with pain program; -Assess pain using a pain scale of 0-10; -Give pain medication as ordered; -Assess for breakthrough pain and treat according to physician order; -Report increased pain to physician; -The only specific intervention for pain management was medication. Review of the physician's orders [REDACTED]. -Spinal [MEDICAL CONDITION]; -[MEDICAL CONDITION]; -Arthritis; Pain medications -[MEDICATION NAME] (an opioid [MEDICATION NAME]) 75 mcg (micrograms) [MEDICATION NAME] change every 72 hours; -[MEDICATION NAME] 10/325 (an opioid [MEDICATION NAME]) mg (milligram) by mouth (po) every four hours as needed (prn) for pain. Review of the residents pain evaluation dated 03/23/12, showed the following: -Inability to perform activities in daily living (ADL); -Participation in activities; -Decrease in physical/social activity; Relief of pain: -Pain medication and frequent position changes; -His/her acceptable pain level is a 2 or 3; Resident pain descriptions were the following: -Distressing; -Severe; -Excruciating; Additional symptoms associated with pain: -Anxiety; Pain medication being used: -[MEDICATION NAME] 50 mcg every 72 hours; -[MEDICATION NAME] 200mg daily as needed for pain; -[MEDICATION NAME] 10/325mg every four hours as needed for pain; Conclusion: -No pain intervention, was not necessary; -Re-assess quarterly or with onset of pain. Review of the resident data collection on admitted d 03/23/12, showed the following: -Pain was daily in lumbar (back); -Intensity: -Distressing pain; -Severe pain; -Excruciating pain; -The resident slept in recliner secondary to lumbar pain. Review of the skilled daily nurse's notes, showed the following: - On 03/24/12, on the day shift, the category that addressed pain origin, location, and intensity scale were left blank; -The nurse's notes showed no documentation that addressed the resident's pain; -On 03/28/12, on the day shift, the category that addressed pain origin, location, and intensity scale were left blank; -The nurse's notes showed no documentation that addressed the resident's pain; -On 03/29/12, on the evening shift, the category that addressed pain origin, location, and intensity scale were left blank; -The nurse's notes showed no documentation that addressed the resident's pain; -On 03/30/12, on the day shift, the category that addressed pain origin, location, and intensity scale were left blank; -The nurse's notes showed no documentation that addressed the resident's pain. Review of the residents Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 03/30/12 showed the following: -Cognition was moderately impaired; -Required extensive assistance of one with transfers; -Required extensive assistance of one with bathing; -Pain was frequent; -Limited day to day activities due to the pain; -Numeric pain rated a 5 on a pain severity score of 0-10 with 0 being no pain and 10 being the worst pain. During interview on 04/02/12 at 11:10 A.M., the resident said the following: -He/she was in his/her wheelchair and said the pain was a 10 on a pain severity scale of 0-10 in his/her back; -He/she reported pain medicine was not strong enough; -He/she reported pain was so intense, was unable to eat at his/her meal. During interview on 04/02/12 at 2:10 P.M., the resident was sitting in the recliner and said the pain was an 8 on a pain severity scale of 0-10 in his/her back. The resident showed facial grimacing and moaned "Oh,Uh,Oh." During interview on 04/02/12 at 5:40 P.M., the resident was sitting in his/her wheelchair and said his/her pain was a 10 on a pain severity scale of 0-10 in his/her back. During observation on 04/02/12 at 5:45 P.M., the resident ate only a few bites of supper. During interview on 04/02/12 at 6:15 P.M., the resident said the following: -He/she was sitting in his/her wheelchair and rated his/her pain a 10 on a pain severity scale of a 0-10; -He/she reported his/her last pain pill was at 12:00 Noon. Review of the (POS) dated 04/02/12, showed an order received at 9:15 P.M. for [MEDICATION NAME](opioid narcotic) 15mg every 12 hours. Review of the request for removal of a controlled substance form for the emergency supply kit (which contained MS Contin) dated 04/02/12 showed the facility received the authorization from pharmacy to open the kit at 11:00 P.M. Review of the MAR, showed [MEDICATION NAME] 10/325 mg was administered at 3:10 A.M. on 04/03/12. During interview on 04/03/12 at 5:40 A.M., LPN G said the following: -He/she said [MEDICATION NAME] ordered on [DATE] and was not received from the pharmacy, so gave [MEDICATION NAME] 10/325 mg; -The physician had ordered the [MEDICATION NAME] 04/02/12 at 9:15 P.M.; -LPN G said had to have permission from the physician and the pharmacist to open the emergency kit. During interview on 04/03/12 at 5:50 A.M., the resident was sitting in recliner, and said his/her pain a 10 on a severity scale of 0-10 in his/her back. During interview on 04/03/12 at 6:03 A.M., LPN E said the following: -When he/she gave an I.V. (intravenous medication) to the resident at 3:10 A.M. that morning, the resident complained of back pain and rated it "9 out of 10" on pain scale; -He/she checked on the resident about 30 minutes later and the resident appeared asleep; -He/she had administered [MEDICATION NAME] mg one tablet to the resident at approximately 6:00 A.M. this morning; -The resident had a [MEDICATION NAME] ([MEDICATION NAME]) (narcotic pain medication) 75 mcg/hr. patch last applied on 04/01/12. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. on 04/03/12. (Staff failed to administer the ordered [MEDICATION NAME] approximately 9 hours). Review of the emergency drug kit supply list (undated), showed the following: -[MEDICATION NAME] sulfate CR 15mg tablet (MS Contin); -One card available with 6 tablets on the card. During interview on 04/03/12 at 6:20 A.M., LPN E said the following: -He/she was medication nurse on night shift. He/she was unaware if the authorization for the medication to be administered had been approved through pharmacy; -He/she should have administered the medication after the approval from the pharmacy was received; -He/she should have administered the first dose, documented the time given. During interview on 04/03/12 at 6:25 A.M., LPN G said the following: -The nurse was the charge nurse on the night shift. He/she was unsure when the approval was received from the pharmacy; -The nurse could not find the authorization form; -The nurse said should have found the authorization from the pharmacy and administered the first dose of pain medication after had received fax the night before. During interview on 04/03/12 at 6:35 A.M., the resident was sitting in the recliner he/she reported his/her pain was a 10 on a pain severity scale of 0-10 in his/her back. During interview, he/she moaned "Oh, oh, uh." Review of the MAR indicated [REDACTED]. was administered at 10:00 A.M. During interview on 04/03/12 at 10:30 A.M., the resident was sitting in the recliner and said his/her pain was a 10 on a pain severity scale of 0-10 in his/her back. During interview on 04/03/12 at 11:20 A.M., CNA Y said the following: -He/she knew the resident was in pain, and moans, and hard to get him/her comfortable; -The resident slept in his/her recliner; -The resident required one staff assistance with walker and gait belt to assist up from recliner to the wheelchair to go to the bathroom at least once or twice a night; -Had "normal discomfort" when transferred. Review of the MAR indicated [REDACTED]. was administered at 2:00 P.M. During interview on 04/03/12 at 2:45 P.M., the resident was sitting in the recliner and said his/her pain was a 7 on a pain severity scale of 0-10 in his/her back. During interview on 04/04/12 at 8:10 A.M., the resident was sitting in wheelchair and said his/her pain was a 10 on a pain severity scale of 0-10 in his/her back and legs. He/she said, "Please help me. I hurt so bad." Review of the MAR indicated [REDACTED].M. During interview on 04/04/12 at 8:15 A.M., the Director of Nursing (DON) said the following: -The staff had administered the PRN [MEDICATION NAME] routinely for breakthrough pain; -The resident was admitted to hospice on 04/03/12 and they would handle pain control. Review of the nurse's notes dated 04/04/12, showed the following: -The resident's pain was a 10/10; -The resident received as needed [MEDICATION NAME] routinely for breakthrough pain. During interview on 04/04/12 at 8:45 A.M., the resident said his/her pain was a 10 on a pain severity scale of 0-10 in his/her back. He/she moaned "Oh,Uh, Oh, Um, Um." During interview on 04/04/12 at 8:50 A.M. Certified Medical Technician (CMT) K said the following: -Pain is assessed when he/she administered PRN medications; -There is a pain control book at the nurse's desk that pain is documented in each shift; -The resident may not have received a sheet because of change over. During interview on 04/04/12 at 8:55 A.M., RN L said the resident's change over pain assessment sheet of 03/26/12, (on 03/26/12, the new MAR's began for the month and a new pain assessment sheet is usually done at this time)was probably not done. During interview on 04/04/12 at 9:00 A.M. the DON said the following: -The resident did not get a pain management sheet made because of the change over on 03/26/12; -The pain management sheet addressed pain intensity on a scheduled basis; -The nurses notes should be documented for pain. Observation on 04/04/12 at 9:55 A.M., showed the following: -CNA X lifted the resident with a gait belt; -The resident said "Oh my back, Oh my back" as transferred to the recliner; -CNA X said he/she would report his/her pain to the charge nurse. During interview on 04/04/12 at 11:20 A.M., RN M said the following: -The residents pain should be evaluated at least twice a shift; -Licensed nurse was responsible for documentation in pain management book; -The resident's pain should be documented on daily skilled nurse's notes; -The pain documentation should include the severity and location categories; -A new assessment is completed with medication change, increased pain, or quarterly. Review of the MAR indicated [REDACTED].M. During interview on 04/04/12 at 4:40 P.M., the resident was sitting in recliner and said pain in his/her back an 8 on pain severity scale of 0-10. During interview he/she moaned "Oh, Oh, Oh." Review of the MAR indicated [REDACTED].M. During interview on 04/06/12 at 9:00 A.M. the DON said the following: -He/she would expect staff to assess the resident for pain; -He/she would expect staff to administer the resident pain medication if ordered; -He/she would expect staff to document the pain severity, location, and duration.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for two residents (Residents #6 and #12) of 17 sampled residents, known to wander and display physical aggression from entering other residents rooms which resulted in one resident (Resident #2) who fell and fractured a hip, and to prevent them from urinating on other residents floors (Residents #11 and #25); failed to safely transfer one resident (Resident #5) with assistive devices to prevent accidents. The facility census was 69. 1. Review of Resident #2's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 01/17/12, showed the following: -Had moderate impairment with cognition; -Understood/understands; -Inattention fluctuated; -Had disorganized thinking that fluctuates; -Was independent with ambulation and toileting; -Had impairment one side upper extremity; -Had one fall since admission prior to assessment with no injury. Review of Resident #2's nurses notes showed the following: -On 03/22/12 at 6:40 A.M., the resident was found on the floor in his/her room; -Resident stated another resident (Resident #12) in a wheelchair tried entering his/her room and rolled his/her wheelchair into Resident #2 it caused him/her to fall; -Resident complained of right hip pain; -Physician notified with a new order; -Family notified; -At 9:20 A.M., mobile x-ray arrived to x-ray resident's right hip and pelvis; -At 11:00 A.M., the physician notified of x-ray results waiting call back; -At 12:00 Noon, physician returned call with new order received to send to ER to evaluate and for treatment; -At 12:45 P.M., Ambulance notified of transport to the hospital. Review of the resident's history and physical from the hospital dated 03/26/12 showed a hip fracture that resulted from the fall. Patient underwent nailing with intramedullary (in the marrow) hip screw device on 03/22/12. Review of the resident's data collection admission notes dated 03/30/12, showed the following: -Pain right hip and leg, distressing ache; -Skin condition: Upper (right leg) 12 staples and lower 7 staples with no signs/symptoms of infection; -Discolored area; -IV (intravenous) site bruise; -Old scars, buttocks slightly reddened; -Paralysis left hand and fingers. (During interview the resident said his/her wrist had been this way since he/she was 9 months old). Review of the resident's temporary care plan dated 3/30/12, showed the following: -Resident non-ambulatory; -Turning and repositioning; -Fall risk evaluation score was 17, with 10 or above high risk; -Assist times two; -Bed mobility assist times one; -Used bed pan assist times one; -Wheelchair. During interview on 04/02/12 at 5:50 P.M., Resident #2 said the following: -His/her right hip was broken; -He/she said Resident #12 wasn't supposed to be in his/her room; -He/she said he/she was coming out of his/her bathroom and Resident #12 was at the door and it caused him/her to be knocked down; -He/she said Resident #12 came in his/her room frequently before the fall; -He/she said before his/her fall, he/she was independent, able to walk and go to the bathroom him/herself; Observation on 04/03/12 at 11:15 A.M. showed the following: -The resident needed assistance of two for transfers and to toilet on the bedside commode; -The resident was non weight bearing on his/her right leg/foot; -Two clean and intact dressings were on his/her right upper outer thigh. Review of Resident #12's MDS, dated [DATE], showed the following: -He/she usually understands and was understood; -Had short-term and long-term memory problems; -Was moderately impaired in cognition with daily decision-making; -Had inattention and disorganized thinking; -Had little interest or pleasure doing things; -Trouble concentrating on things; -Being short tempered and easily annoyed; -Had no physical behavioral symptoms directed toward others; -Had no verbal symptoms directed toward others; -Had no rejection of care; -Wandering present, but did not place the resident at significant risk of getting to a potentially dangerous place, and did not intrude on privacy of activities of others. Review of the resident's Care Area Assessment (CAA) Summary sheet dated 08/15/11, showed the following: CAA results: Cognitive loss/dementia was triggered and checked was addressed in the care plan and to see the CAA summary. The CAA summary showed the resident had a [DIAGNOSES REDACTED]. -Appropriate due to deficit and poor memory; -CAA results: Mood was triggered and checked was addressed in the care plan and to see the CAA summary. The CAA summary showed the resident was quiet, friendly, easily upset, interferes with care and can be anxious at times, does wander around the facility in his/her wheelchair, will pick up things that aren't his/hers and at times it is very difficult to get them back; CAA results: Behavior was triggered and checked was addressed in the care plan and to see the CAA summary. The CAA summary showed the resident was resistant to care especially showers, he/she will scream and strike out at staff, wanders around the facility and will pick stuff up off of desk, and then it is very difficult to get it away from him/her, staff are to leave in a safe environment and return in 15 minutes if refusing care. Review of the resident's care plan reviewed 08/18/11, showed the following: -Mood category showed the resident yelled during showers; -Acknowledge the importance of individual space; -There was no care plan that addressed the resident's behavior of wandering. During interview on 04/04/12 at 11:45 A.M., the Director of Nursing (DON) said the following: -The resident's incident happened on 03/22/12; -Resident #12 was wheeling down the hall, and would open doors; -She said Resident #12 opened the door to Resident #2's room and Resident #2 was there to go into the bathroom or closet and the door hit Resident #2 and he/she fell ; -X-ray was done, and the resident went to the hospital and a STOP sign was placed across the doorway; -She said Resident #12 doesn't hit or kick, but he/she collected things and opened doors; -She said Resident #12 goes to activities and will leave, and he/she will take things and then takes off with them. Observation showed the following: -On 04/04/12 at 3:10 P.M., LPN F changed the resident's dressing to the resident's right leg; -The resident said he/she was feeling okay and had no pain at the time; -The upper right outer thigh area had 12 staples; -There was another incision below the upper one that had 7 staples, with some light blue bruising near the incision site; -There was no redness or drainage noted from the incision sites; -Staff took an alcohol swab and wiped over the incision sites and applied a clean dry gauze dressing. During interview on 04/04/12 at 4:15 P.M., LPN F said he/she was told in report that another resident, Resident #12 had gone into Resident #2's room, and as the resident was coming out of the bathroom there was pushing and pulling on the door and Resident #2 fell . 2. Review of Resident #6's admission MDS dated [DATE], showed the following: -Severely impaired cognition; -Had physical behaviors that occurred 1 to 3 days (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually); -Wandering behavior occurred daily; -Occasionally incontinent of bladder; -[DIAGNOSES REDACTED]. Review of the care plan dated 05/24/11 and reviewed on 02/09/12, showed the following: Behaviors: -Wanders around facility and will shake doors (Staff wrote "No longer shakes doors"); Approaches included: - Allow to move throughout building, and remove from area if disturbing others; -Assist back to bed when up at night; -Encourage and allow to walk to activities and meals; -Provide frequent and consistent supervision; - Redirect as needed when wandering noted; -The care plan did not include interventions to prevent the resident from entering other residents' rooms uninvited. Review of Resident #11's MDS, dated [DATE] showed the following: -He/she was moderately impaired with cognition; -Understood and understands; -Inattention fluctuated; -Had disorganized thinking that fluctuates; -No mental status change; -No behaviors; -Was ambulatory. During an interview on 04/05/12, at 10:00 A.M., Resident #11 said the following: -He/she said it was night time and Resident #6 came into his/her room, squatted down and "peed" on the floor, and then climbed in bed next to him/her and hit him/her on the back of the head; -It hurt, so he/she punched the resident back and put him/her out of the room; -Staff LPN A was at the desk; -LPN A didn't know the resident was in his/her room, but told him/her to turn the call light on and not to hit and staff would get him/her; -The resident was in his/her room about 15 minutes; -It made him/her mad. Review of Resident #25's MDS, dated [DATE], showed the following: -Had severe impairment with cognition; -He/she understood and understands; -Short-term and long-term memory was left blank; -Inattention fluctuates; -Disorganized thinking fluctuates; -Mobility device wheelchair. During interview on 04/05/12 at 8:45 A.M., Resident #25 said the following: -He/she said a resident and said Resident #6's first name, who came into his/her room and "pissed" on the floor; -He/she comes in and out of his/her room several times like it is his/her room; -He/she feels terrible about it; -He/she didn't like it, and said the resident gets on his/her nerves. Review of the nurses notes showed the following: -On 12/14/11 at 3:00 P.M., Resident #6 entered another unknown resident's room (believed to be Resident #11) . Resident #11 asked Resident #6 to leave. Resident #6 was confused and thought that this was his/her room. Resident #6 slapped #11 across the face and this resident became upset and grabbed Resident #6 by the arms and pushed him/her out of the room. Resident #6 tried to slap Resident #11 again and this resident slapped Resident #6 which sent his/her glasses flying and then slammed his/her own room door. Resident #6 received three skin tears on his/her left arm by the elbow and one skin tear on the right arm near the elbow; -On 12/15/11 at 12:50 A.M., the resident was alert with confusion and up in the television area; -On 12/15/11 at 7:30 A.M., the resident was ambulating about the commons area and was alert with confusion; -On 12/15/11 at 9:30 P.M., the resident wanders in and out of other resident rooms frequently. Review of the nurses notes dated 04/01/12, showed the following: -At 11:45 A.M., Resident #6 went up to Resident #10 and slapped his/her right hand two times; -Staff redirected Resident #6; -Then Resident #6 went around the nurses station and "attacked the same resident again". Resident #6 went up behind Resident #10 and pushed him/her back while he/she was sitting in his/her wheelchair; -While staff was documenting this behavior in the nurses notes, Resident #6 went to Resident #26 and pulled his/her hair. -Staff administered PRN (as needed) Zyprexa (an antipsychotic medication) to Resident #6. During interview on 04/03/12 at 6:58 A.M., the ADON (Assistant Director of Nursing) said the incident documented in Resident #6's nurses notes on 12/14/11 at 3:00 P.M. was with Resident #11. The other incident on 04/01/12 at 11:45 A.M. was when the resident slapped Resident #10's hands. During interview on 04/03/12 at 10:52 A.M., the DON (Director of Nursing) said the following: -Approximately two months ago on the evening shift, the resident wandered into Resident #11's room and Resident #11 told Resident #6 to get out of his/her room; -Resident #6 rarely wanders into resident rooms except if looking for a toilet; -The resident was easily redirected; -Asked Resident #11 if he/she wanted a STOP sign to use on his/her room door; -Told Resident #11 to use his/her call light when Resident #6 came into his/her room. During interview on 04/03/12 at 1:25 P.M., Licensed Practical Nurse (LPN) Q said the following: -On 04/01/12 at around 11:45 A.M., he/she was up at the nurses station when Resident #6 and Resident #10 were up in front of the nurses desk; -Resident #6 walked by and slapped Resident #10 on the hand; -Resident #10 told Resident #6 not to slap him/her; -Resident #6 slapped Resident #10's hand again; -Resident #10 went one way around the nurses desk and Resident #6 went the other way around the nurses desk; -At that time, LPN Q did not see but other staff told him/her that Resident #6 pushed Resident #10 behind him/her on the back while the resident was in/her wheelchair; -After LPN Q administered a medication to Resident #6. 3. Review of Resident #5's admission MDS dated [DATE], showed the following: -Severely impaired cognition; -Transferred with extensive assistance of one staff; -Not steady on his/her feet and only able to stabilize with human assistance; -[DIAGNOSES REDACTED]. Observation on 04/03/12 at 5:39 A.M., showed the following: -CNA W transferred the resident from the bed to the wheelchair and held on to his/her arm (right arm was in a plaster cast) without using a gait belt. During interview on 04/03/12 at 5:42 A.M., CNA W said the following: -Resident #5 stands and pivots with staff assistance; -Supposed to use the gait belt to transfer the resident. Observation on 04/04/12 at 11:59 A.M. showed the following: -CNA X wheeled the resident to his/her room to toilet resident; -CNA X pushed wheelchair into the bathroom and had the resident stand and hold on to the hand rail (Resident had to use only left hand since right arm was in a cast); -He/she pulled the resident's slacks down and removed the incontinence brief; -After the resident toileted, CNA X assisted the resident back into the wheelchair without using a gait belt and without first locking the brakes; -As the resident sat down, the wheelchair moved forward and backward. During interview on 04/04/12 at 12:09 P.M., CNA X said the following: -Should have used a gait belt since more safe; -Thought the wheelchair was locked at least on one side before transferring the resident from the toilet to the wheelchair.