Every finding on record at Lutheran Nursing Home

Based on interview, and record review, the facility failed to ensure the safety of one sampled resident (Resident #2) out of six sampled residents when on 8/3/26 the resident transported to a physician visit without an escort and then failed to transport him/her back to the facility in a timely manner after the appointment. The facility census was 82 residents.The Administrator was notified on 8/12/26 of the past noncompliance which began on 8/3/26. The facility immediately began education and implemented a new policy to have the facility receptionist review all appointments for the following day, to ensure that staffing is available for any resident requesting to have a staff member accompany them to an appointment. If the facility is unable to meet the request, the receptionist will then call the resident's family to see if they're available to accompany the resident and if not, look into the possibility of rescheduling the appointment. All appointments for the day are again discussed during the morning stand-up meeting. The deficiency was corrected on 8/4/26. Review of the facility's policy, Transportation, dated January 2026 showed:-Residents would be assisted in making transportation arrangements to and from the source of service, if the resident needed assistance.-When determining if the resident needed assistance with transportation arrangement, the facility would have considered the residents' clinical, physical, mental, and financial condition.-Inquiries concerning transportation should be referred to social services. 1. Review of Resident #2's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 7/9/26 showed:-His/Her Brief Interview for Mental Status (BIMS) score was 12 indicating he/she was moderately cognitively impaired.-He/She used a walker and had abnormalities of gait and mobility.-Problem related to life management.-Need for assistance with personal care.-Repeated falls.-The resident had a guardian.-He/She had diagnosis that included: --Dementia (a decline in memory, language, problem-solving, and other thinking skills that interfered with daily life).--Convulsions (a medical condition where the body muscles rapidly and repeatedly contract and relax, causing uncontrolled shaking).--Cognitive communication deficit (trouble with communication caused by disrupted thinking skills).--Hallucinations (a false perception in which a person sees, hears smells, tastes, or feels things that were not actually there). Review of the resident's care plan dated 5/2/26 showed:-Staff was to remind him/her of event and offer him/her transportation to the destination.-He/She could propel his/her wheelchair short distances but needed assistance with longer distances.-He/She had an actual fall, 4/12/26.-He/She had cognitive loss/Dementia. Review of the facility August (2026) Transport Log showed:-On Monday 8/3/26 the resident had an orthopedic physician (a physician who diagnoses, treats, prevents and rehabs conditions of the musculoskeletal system (muscles and bones), appointment at 10:00 A.M.-Transportation was set up with Medical Transportation Company A.-A Certified Nursing Assistant (CNA) was needed to go with the resident. During an interview on 8/12/26 at 10:00 A.M. the resident said:-On 8/3/26 he/she had an appointment at the physician's office in which he/she thought he/she was having surgery on his/her misshaped finger.-He/She had told the Social Service Director (SSD) that he/she needed someone to go with him/her.-The facility made the appointment and arranged transportation for him/her.-The night before the appointment the facility taped the paperwork on his/her door to take with him/her to the appointment.-He/She did not know which physician he/she was going to see but it was out of town.-He/She had talked to the Director of Nursing (DON) about needing someone to accompany him/her.-When it was time to leave and his/her transportation arrived at the facility there was no one available to go with him/her as they were short- handed that day.-He/She went to the physician's appointment by himself/herself.-He/She did not have surgery but had a steroid injection (medication used to decrease swelling and pain).-He/She sat in the physician's lobby for a long time, maybe more than an hour, then decided no one was going to pick him/her up to go back to the facility.-He/She had the receptionist call the facility.-He/She did not have a cell phone of his/her own.-After several attempts to contact the facility, the facility said a rideshare driver was coming to pick him/her up.-He/She waited several hours before the rideshare driver showed up.-The driver did not help him/her into the car and seemed very angry.-The driver made him/her feel uncomfortable. During an interview on 8/12/26 at 10:30 A.M. Licensed Practical Nurse (LPN) A said:-At times the resident was confused.-He/She knew the resident had a physician's appointment as it was on the facility Transport Sheet.-The resident was to have a CNA go with him/her to the physician's appointment.-The SSD makes the appointments.-The resident was to go to an appointment at an Orthopedic physician's office out of town, (45 minutes away).-He/She had talked to the resident after he/she returned from the physician's appointment.-He/She was not the resident's nurse that day.-The resident told him/her that no one had come to pick him/her up to bring her back to the facility and he/she had waited hours in the lobby of the physician's office after his/her appointment.-The resident had been gone for many hours.-The residents do not have to sign out if they are going to an appointment.-He/She had told the DON about the issue, and he/she was already aware of the issue.-The DON was ultimately responsible for ensuring the residents' appointments were set up as well as transportation. During an interview on 8/12/26 at 11:00 A.M. The SSD said:-He/She calls Medical Transportation Company A and informs them that there were two trips, one to the appointment and one trip returning from the appointment.-He/She prints the monthly schedule.-If a resident needed a CNA to accompany them then that was noted on the schedule.-The transportation schedule is also posted at the nurses' station.-He/She was not working that day.-The DON handled the situation that day.-Medical Transportation Company A said that their computer system went down and the return trip was missed.-He/She was not aware if this situation had happened before. During an interview on 8/12/26 at 12:15 P.M. the Administrator said:-He/She was notified by the Physician's office that no one had come to pick up the resident to take him/her back to the facility after the appointment.-He/She had called Medical Transportation Company A, and they had a computer down and had missed picking the resident for pick up.-The transportation company did not have anyone available to pick up the resident so they called a rideshare company to transport the resident back to the facility.-The facility van was already in use so it was not available.-If it was listed on the facility Transport Sheet that the resident needed a CNA to go with him/her one should have gone with him/her to the appointment.-A CNA was not sent with the resident although it was noted on the Transport sheet the resident needed one.-The DON was ultimately responsible for ensuring a CNA went with a resident to the appointment if needed and ultimately responsible for ensuring they had transportation. During an interview on 8/12/26 at 1:20 P.M. the DON said:-The physician's office called about the resident not having transportation back to the facility about 11:00 A.M. on 8/3/26.-He/She called Medical Transportation Company A and informed the Administrator that their (the medical transportation company) computer had been down and they did not have anyone to bring the resident back to the facility.-The facility's van was in use.-He/She called Medical Transport Company A back and they offered to send a rideshare driver to pick up the resident and return him/her to the facility.-The rideshare driver picked the resident up from the physician's office about 2:30 P.M. and brought him/her back to the facility about 3:30 P.M. or so.-The resident should have had a CNA go with him/her to the appointment.-He/She was ultimately responsible. 3132469

Based on interview and record review, the facility failed to ensure appropriate behavioral monitoring was in place for one sampled resident (Resident #3) out of 14 sampled residents. The facility census was 84 residents.Review of the facility's policy titled Behavioral Assessment, Intervention, and Monitoring dated February 2025 showed:-Residents would have minimal complications associated with the management of altered or impaired behavior.-Behavioral symptoms were identified using facility-approved behavioral screening tools and comprehensive assessment.-The facility complied with regulatory requirements related to the use of psychotropic medications.- Behavior was the response of an individual to a wide variety of factors.-These factors may include medical, physical, psychosocial, psychiatric, or environmental causes.-Behavior was regulated by the brain and was influenced by past experiences, personality traits, environment, and interactions with other people.-Behavior could be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that could not be articulated.- Behavioral interventions referred to individualized, nonpharmacological approaches to care that were provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities, as well as maintaining or improving a resident's mental, physical, or psychosocial well-being.-As part of the comprehensive assessment, staff evaluated the following:--The resident's usual patterns of cognition, mood, and behavior.--The resident's usual method of communicating things like pain, hunger, thirst, and other physical discomforts.--The resident's typical or past responses to stress, fatigue, fear, anxiety, frustration, and other triggers.--The resident's previous patterns of coping with stress, anxiety, and depression.-The nursing staff would identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition which included:--Onset, duration, intensity, and frequency of behavioral symptoms.--Underlying medical conditions.--Any recent precipitating or relevant factors or environmental triggers.-Appearance and alertness of the resident and related observations.-A circumstance that warranted a behavioral assessment of a resident included new or worsening change in status or condition.-New onset or changes in behavior were evaluated and documented, regardless of degree of risk to the resident or others.-The interdisciplinary team (IDT) evaluated behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and developed a plan of care accordingly.-The care plan included at a minimum:--A description of the behavioral symptoms.--Targeted and individualized interventions for behavioral and/or psychosocial symptoms.--The rationale for the interventions and approaches.--Specific and measurable goals for targeted behaviors.--How staff will monitor the effectiveness of the interventions.-Interventions were individualized and part of an overall care environment that supported physical, functional, and psychosocial needs, and strives to understand, prevent, or relieve the resident's stress or loss of abilities.-The resident and family or representative were involved in the development and implementation of the care plan.-The IDT monitored for and documented any new, worsening, or improves symptoms in the resident's behavior, mood, and function.-Interventions were adjusted based on impact on behavior and other symptoms.1. Review of Resident #3's admission Record showed he/she admitted to the facility with a diagnosis of unspecified dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses), unspecified severity, with agitation.NOTE: The resident's admission Record also indicated that the resident had been diagnosed with generalized anxiety disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats) on 3/17/25.Review of a Health Status Note dated 1/31/26 at 8:30 P.M. regarding Resident #3 showed:-The resident was having aggressive behaviors that day and evening.-The resident was yelling at other residents and pushing at them when they did not do what he/she wanted.-The resident was also pushing and hitting employees that were attempting to redirect the resident away from other residents.-The resident was yelling when a resident or staff member did not move in the direction he/she wanted them to.-The resident punched the Certified Medication Technician (CMT) in the jaw and sternum.-The resident eventually laid down and fell asleep.Review of a Health Status Note dated 2/8/26 at 5:43 P.M. regarding Resident #3 showed:-The resident had been combative since 11:00 A.M. that morning.-The resident was unable to be re-directed.-The resident was hitting, kicking, and pushing staff.-The resident refused to eat at any meal.-The resident's family took the resident out for about an hour and the resident refused to eat with them.-The resident's seemed to be daily in the last few days.-The Director of Nursing (DON) was notified of the resident's escalating behaviors.Review of a Health Status Note dated 2/20/26 at 9:10 P.M. regarding Resident #3 showed:-The resident had aggressive behaviors that day.-The resident had hit another resident.-The resident attempted to lock himself/herself in another resident's room.-The resident attacked the nurse and CNA.-The resident was punching, spitting, and attempting to bite anyone within reach.-It took two staff members to get the resident back to his/her room and away from other residents.-When the resident was in his/her room, the resident calmed down and started to make his/her bed.-The resident then continued to wander around attempting to enter other residents' rooms and behaving aggressively.-The nurse had contacted the physician and the resident's son.-The son requested to be contacted when the resident had aggressive behaviors.-By the time the nurse got back to the resident, he/she had laid himself/herself down in bed.Review of a Health Status Note dated 2/22/26 at 5:12 P.M. regarding Resident #3 showed:-The nurse had made a call to the resident's son to discuss agitation and combative behavior.-The resident had been happy early in the day and let the nurse feed him/her lunch.-At approximately 2:00 P.M. the resident became agitated and very combative with staff and towards other residents.-Staff sat with the resident one-to-one (1:1- a term used by healthcare support workers whose role was to provide one-to-one nursing or observation care to an individual patient/resident for a period of time) to avoid behaviors.-The resident had refused supper up to that point in time.Review of a Health Status Note dated 3/16/26 regarding Resident #3 showed:-A Certified Nursing Assistant (CNA) had reported to the nurse that the resident had hit another resident with a plastic hanger from his/her room.-The resident had not remembered who the CNA was and had swung at the CNA multiple times.-The CNA was able to redirect and deescalate the resident.-The resident did not have any concerns at that time.Review of the resident's Medication Administration Record (MAR)/Treatment Administration Record (TAR) dated March 2026 showed the resident did not have any behaviors from the evening of 3/27/26 through 3/31/26.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff) dated 3/19/26 showed:-The resident had severely impaired cognition.-The resident had physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing) which occurred between one and three days during the seven-day look back period.-The resident has verbal symptoms directed toward others (threatening others, screaming at others, cursing at others) which occurred between one and three days during the seven-day look back period.-The resident had other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) which occurred between one and three days during the seven-day look back period.Review of a Health Status Note dated 3/22/26 at 4:42 P.M. regarding Resident #3 showed:-The resident had been agitated most of the afternoon.-The resident had attempted to hit other residents but had been redirected by staff.-The resident had been put on o1:1 observation due to his/her combative and agitated demeanor.-The resident had to be followed everywhere he/she went to avoid confrontations with other residents.-The resident was very hard to re-direct.Review of the resident's care plan dated 3/26/26 showed:-The resident had the potential for changes in mood and behavior related to his/her diagnosis of dementia and that the resident had increased agitation at times with a goal of not harming self or others over the next review period.-The resident's goal had not been updated since 4/24/24.-The following interventions were in place:--Administer medications as ordered on the physician order sheet (POS)/MAR.--Monitor/document for side effects and effectiveness.--Approach the resident in a calm manner.--Assess for need to toilet or assist with cares after incontinent episodes.--Assess for signs and symptoms of hunger/thirst.--Assess for signs and symptoms of pain/discomfort and treat before becoming breakthrough pain.--Call the resident by his/her name when approaching the resident.--The resident was usually redirected.-The resident's interventions had not been updated since 2024.Review of the resident's order summary report dated April 2026 showed:-An order for behaviors-monitor for the following:--Itching.--Picking at skin.--Restlessness (agitation).--Hitting.--Increase in complaints.--Biting.--Kicking.--Spitting.--Cussing.--Racial slurs.--Elopement.--Stealing.--Delusions.--Hallucinations.--Psychosis.--Aggression.--Refusing care.-The order was dated 3/26/26.Review of the resident's MAR/TAR dated April 2026 showed the resident did not have any behaviors from 4/1/26 through the morning of 4/9/26.Review of a Health Status Note dated 4/4/26 at 6:23 P.M. regarding Resident #3 showed:-The nurse had been called back to the unit because the resident had become agitated with staff.-The resident was aggressively pulling on the old nurse station gate, and the gate came off its hinges.-In an attempt to redirect the resident, the nurse was struck in the face and caused a bloody lip.-Another staff member had heard the noise in the hallway.-The nurse was then able to contain the resident to prevent any harm to residents.-The nurse did a skin assessment, and it showed the resident had bruising to his/her right arm.-The resident denied any pain.-When the nurse asked the resident what happened, the resident had no knowledge of the incident.During an interview on 4/9/26 at approximately 3:00 P.M. Nursing Assistant (NA) B said:-The resident was aggressive pretty often, more than once a week.-If the resident was in the mood to fight with staff, then the staff just left the resident alone.-He/She had not been educated on how to manage behaviors.-The main intervention he/she used with the resident was to leave him/her alone.-He/She didn't really feel like he/she was properly trained to be on the special care unit.During an interview on 4/9/26 at approximately 3:20 P.M. Licensed Practical Nurse (LPN) A said:-The resident had cycles of behaviors.-The resident could become very physically aggressive towards the staff.-The resident's behaviors have increased in the last few months.-The resident has had a general decline in health in the last two months.-The resident wasn't always easily redirectable.-When the resident had a behavior, the nurses were supposed to document a note in the resident's Electronic Medical Record (EMR).-He/She was not always very good about documenting the resident's behaviors because the resident had a baseline of behaviors that the resident usually exhibited.-The behaviors the resident exhibited that were a part of the resident's baseline included:--Complaining.--Racial slurs.--Stealing.--Delusions.-As part of the resident's decline in health the resident has had an increase in hitting and general aggression.-He/She did not feel the staff that worked on the special care unit were prepared to work on the unit.-He/She did not feel like the facility was doing appropriate education for the special care unit.-The resident was not very redirectable and usually just did whatever he/she wanted.During an interview on 4/9/26 at approximately 3:45 P.M. the MDS Coordinator said:-He/She had been in his/her position for one and a half years.-He/She had not been educated on care plans.-No other staff besides him/her were involved in care plans.-Nurses were the only staff members with access to care plans.-The CNAs had charting that they could complete related to resident behaviors.-The nurses were also responsible for behavioral monitoring.-The nurses were expected to put a note in residents' EMRs when behaviors were exhibited.-The resident's care plan was accurate but could have been more specific.-It was all about how staff approached the resident when exhibiting a behavior.During an interview on 4/9/26 at 4:26 P.M. CNA A said:-The resident was exhibiting more behaviors recently.-The resident was more aggressive than he/she had been in the past.-The resident was redirectable and when addressing the resident's behaviors, he/she was usually able to take the resident away from the situation.-It was a day-to-day issue with the resident, meaning some days he/she responded well to staff intervention and some days he/she did not.-Care plans should be up to date with appropriate interventions.-He/She was unable to get into care plans but would share any pertinent information to the nurse.During an interview on 4/9/26 at 5:00 P.M. CNA B said:-The resident had increased behaviors.-The resident mainly had an increase in aggressiveness with more physical contact.-The resident's behaviors had been worse in the last two months.-There was not a specific time of day in which the resident exhibited more behaviors.-The resident typically exhibited behaviors multiple times a week.-Staff could not approach the resident with matching energies when the resident was exhibiting behaviors.-The resident usually responded well to sweet talk.-He/She tried to learn about the resident's past so it would be easier to redirect them.-He/She no longer had access to care plans.-If he/she had a question about a resident's care plan then he/she would just ask the nurse.-The resident's care plan was not up to date or accurate.-The resident's care plan needed to be updated to reflect the resident's current status.During an interview on 4/9/26 at 5:49 P.M. LPN B said:-He/She was quite familiar with the resident.-The resident has had an increase in behaviors.-The resident had increased aggression and restlessness.-He/She felt the facility did not keep the special care unit appropriately staffed during the night shift due to the resident's increased behaviors.-He/She could pull up resident care plans but did not change or edit the care plans.-The resident's care plan needed to be updated to reflect the resident's current behaviors and interventions he/she responded to.-It was all in how staff approached the resident when he/she was exhibiting a behavior.-The resident was no longer easily redirectable.-The resident needed a calm approach and there were some nicknames that he/she liked to be called which would help him/her calm down.-He/She was not very good at charting the resident's behaviors.-Before the behavioral monitoring was put into place, the nurses were expected to document a note when the resident had a behavior.-The current order in place for the resident's behavioral monitoring could be marked with a Y for yes, the resident had behaviors or with a N for no exhibited behaviors.-If staff marked Y the staff were note directed automatically to put a note into the resident's EMR.-He/She usually marked N regardless of if the resident had a behavior because nurse management would not really do anything with the information if he/she marked Y.-The resident's March MAR/TAR was not accurate related to the resident's behavioral monitoring.-The resident's April MAR/TAR was not accurate related to the resident's behavioral monitoring.During an interview on 4/9/26 at 6:35 P.M. the DON and the Administrator said:-The resident had increased behaviors.-The resident's behaviors seemed to have increased in the last month.-The resident's care plan was not up to date.-The resident's care plan needed to be up to date and reflect the resident's current status.-The MDS Coordinator was the only person that could edit care plans.-The resident had a medication change on 3/26/26 which was why the behavioral monitoring was put in place.-The resident did not have ordered behavioral monitoring in place prior to 3/26/26.-The CNAs could document behaviors within their charting.-Any time a resident exhibited a behavior the nurses needed to document a note.-The nurses were still expected to document a note when the resident exhibited any behaviors when marking Y on the MAR/TAR.-The resident's April MAR/TAR was not accurate related to the resident's behavioral monitoring.-Staff should have marked Y on 4/4.26 when the resident had pulled the gate off the hinges and hit staff. 2973592

Based on interview and record review, the facility failed to ensure International Normalized Ratio (INR- used to monitor the effectiveness of blood thinning drugs) tests were ordered upon admission and completed for one sampled resident (Resident #4) out of 14 sampled residents. The facility census was 84 residents.Review of the facility's policy titled Anticoagulation (the use of medicine commonly called blood thinners, to prevent or treat harmful blood clots)-Clinical Protocol dated November 2018 showed:-As part of the initial assessment, the physician and staff would identify individuals who were currently anticoagulated.-In addition, the should assess and document/report the following:--Current anticoagulation therapy, including drug and current dosage.--Recent labs, including therapeutic dose monitoring.--Other current medications.--All active diagnoses.-The physician should monitor the INR very closely while the individual was receiving warfarin (a blood thinner), to ensure INR stabilized within a therapeutic range.-The physician would order appropriate lab testing to monitor anticoagulant therapy and potential complications.-If warfarin was used, staff should use a warfarin flow sheet or some comparable means to follow trends in anticoagulant dosage and response in individuals on warfarin.1. Review of Resident #4's admission Record showed the resident admitted to the facility on [DATE] with the following diagnoses:-Unspecified symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage (a life-threatening type of stroke caused by bleeding into the space surrounding the brain).-Presence of prosthetic heart valve.Review of the resident's care plan dated 2/27/26 showed the resident was on anticoagulant therapy with an intervention for labs and diagnostics as ordered, report abnormal results to the resident's physician.Review of the resident's Order Summary Report dated March 2026 showed:-An order for Warfarin Sodium Oral Tablet, give five milligrams (mg) by mouth in the evening.-No INR test orders in place. Review of the resident's discharge summary from the local hospital on 4/8/26 showed:-The resident was on warfarin five mg.-The resident had a high INR upon admission to the hospital.-The resident needed his/her INR checked early next week, following admission to the facility.-The resident needed closer follow-up with weekly INR checks for the next several weeks.During an interview on 4/8/26 at 11:30 A.M. the Director of Nursing (DON) said:-The Assistant Director of Nursing (ADON) was responsible for putting all admission orders into the residents' Electronic Medical Records (EMRs).-The ADON no longer worked at the facility.-The resident had not had any INR testing completed while at the facility.During an interview on 4/9/26 at 9:37 A.M. Registered Nurse (RN) A said:-He/She was not responsible for putting in admission orders into the residents' EMRs.-The ADON was responsible for putting all admission orders into the residents' EMRs.-The ADON no longer worked at the facility.During an interview on 4/9/26 at 11:49 A.M. Physician A said:-He/She expected the facility to follow all discharge instructions.-He/She usually requested for staff to ask for the discharge summaries for all residents admitted to the facility under his/her care so everything could be reviewed.-To his/her knowledge, the facility puts in all discharge instructions when a resident admitted to the facility.-He/She expected the facility to ensure all discharge instructions were followed and ordered when a resident admitted to the facility.-INRs were checked per resident need.-The resident's INR orders should have been put into the resident's EMR.-The resident should have had weekly INR orders in place with his/her history while at the hospital.During an interview om 4/9/26 at 12:55 P.M. the Unit Manager said:-The ADON was responsible for putting in all admission orders into the residents' EMRs.-The ADON no longer worked at the facility.-He/She was unsure if anyone ensured all orders were in place after the ADON put in the admission orders.-Lab orders were also to be put into the labs ordering system.-He/She had not seen the resident's discharge paperwork.-Based of the instructions he/she saw when handed the resident's discharge paperwork, he/she would have put INR testing orders into the resident's EMR.-He/She would have also called Physician A to ensure that the doctor agreed with the INR order.During an interview on 4/9/26 at 6:35 P.M. the DON said:-He/She was unsure why the ADON had not put all of the resident's admission orders into the resident's EMR.-There was not anyone that went behind the ADON to ensure all orders were in place.-The resident should have had INR testing completed while at the facility. -The facility had an anticoagulation policy in place and was unsure how the testing was missed.2959995

Based on interview and record review the facility failed to ensure an investigation was completed after a resident-to-resident altercation occurred when Resident #3 hit Resident #14 out of 14 residents sampled residents. The facility census was 84 residents. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated September 2022 showed:-All allegations were thoroughly investigated.-The Administrator initiated investigations.-Investigations may be assigned to an individual trained in reviewing, investigating, and reporting such allegations.-The individual conducting the investigation at a minimum:--Reviewed the documentation and evidence.--Reviewed the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident.--Observed the alleged victim, including his/her interactions with staff and other residents.--Interviewed the person(s) reporting the incident.--Interviewed the resident (as medically appropriate) or the resident's representative.--Interviewed the resident's attending physician as needed to determine the resident's condition.--Interviewed the staff members (on all shifts) who had contact with the resident during the period of the alleged incident.--Interviewed the resident's roommate, family members, and visitors.--Reviewed all events leading up to the alleged incident.--Documented the investigation completely and thoroughly.1. Review of Resident #3's admission Record showed the resident admitted to the facility with a diagnosis of unspecified dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses), unspecified severity, with agitation.Review of Resident #14's admission Record showed the resident admitted to the facility with a diagnosis of Alzheimer's Disease (a progressive, irreversible neurological disorder that destroys memory, thinking, and eventually the ability to function) with early onset.Review of a Health Status Note dated 2/20/26 at 9:10 P.M. completed by Licensed Practical Nurse (LPN) C showed:-Resident #3 had aggressive behaviors that day.-Resident #3 hit a resident.-The resident attempted to lock himself/herself in another resident's room while he/she had family in the room.-The resident attacked LPN C and a Certified Nursing Assistant (CNA) which included punching, spitting, and attempting to bite anyone within reach.-LPN C notified the resident's son after the altercation occurred.-LPN C notified the resident's physician after the altercation occurred.Review of Resident #3's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff) dated 3/19/26 showed the resident had severely impaired cognition.Review of Resident #14's quarterly MDS dated [DATE] showed the resident had moderately impaired cognition.During an interview on 4/9/26 at 5:00 P.M. CNA B said:-An investigation needed to be completed when an allegation of abuse was reported.-The Administrator was responsible for completing abuse investigations.During an interview on 4/9/26 at 5:49 P.M. LPN B said:-When an allegation of abuse was reported an investigation needed to be completed.-The Administrator was responsible for completing the abuse investigations.-He/She was unsure of the timeframe of when the investigation needed to be completed.During an interview on 4/9/26 at 6:35 P.M. the Director of Nursing (DON) and the Administrator said:-They had not been told about the resident-to-resident altercation between Resident #3 and Resident #14 that occurred on 2/20/26.-They did not complete an investigation related to the resident-to-resident altercation between Resident #3 and Resident #14 that occurred on 2/20/26.-They would have completed an investigation related to the resident-to-resident altercation between Resident #3 and Resident #14 that occurred on 2/20/26 if it had been reported to them.-An investigation should have been completed investigation related to the resident-to-resident altercation between Resident #3 and Resident #14 that occurred on 2/20/26. 2973592

Based on interview and record review, the facility failed to report a resident-to-resident altercation when Resident #3 hit Resident #14 out of 14 sampled residents. The facility census was 84 residents.Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated September 2022 showed:-All reports of resident abuse were reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management.-If resident abuse was suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.-The administrator or the individual making the allegation immediately reports his or her suspicions to the following agencies:--The state licensing/certification agency responsible for surveying/licensing the facility.--The local/state ombudsman.--The resident's representative.--Law enforcement officials.--The resident's attending physician.--The facility medical director.-Immediately was defined as:--Within two hours of an allegation involving abuse or result in serious bodily injury.--Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.-Verbal/written notices to agencies were submitted via special carrier, fax, e-mail, or by telephone.-Notices included as appropriate:--The resident's name.--The resident's room number.--The type of abuse that was alleged.--The date and time the alleged incident occurred.--The name(s) of all persons involved in the alleged incident.--What immediate action was taken by the facility.1. Review of Resident #3's admission Record showed the resident admitted to the facility with a diagnosis of unspecified dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses), unspecified severity, with agitation.Review of Resident #14's admission Record showed the resident admitted to the facility with a diagnosis of Alzheimer's Disease (a progressive, irreversible neurological disorder that destroys memory, thinking, and eventually the ability to function) with early onset.Review of a Health Status Note dated 2/20/26 at 9:10 P.M. completed by Licensed Practical Nurse (LPN) C showed:-Resident #3 had aggressive behaviors that day.-Resident #3 hit a resident.-The resident attempted to lock himself/herself in another resident's room while he/she had family in the room.-The resident attacked LPN C and a Certified Nursing Assistant (CNA) which included punching, spitting, and attempting to bite anyone within reach.-LPN C notified the resident's son after the altercation occurred.-LPN C notified the resident's physician after the altercation occurred.-There was no mention of notification to the Administrator or DON in the note. Review of Resident #3's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff) dated 3/19/26 showed the resident had severely impaired cognition.Review of Resident #14's quarterly MDS dated [DATE] showed the resident had moderately impaired cognition.During an interview on 4/9/26 at 5:00 P.M. CNA B said:-He/She had worked on 2/20/26.-He/She had come into work after the incident occurred.-He/She could not remember if LPN C had discussed a resident-to-resident altercation with him/her.-A resident-to-resident altercation could be verbal or physical abuse and needed to be reported immediately.-If he/she witnessed a resident-to-resident altercation, then he/she would report it to the nurse and/or the Director of Nursing (DON).-If LPN C did not report the resident-to-resident altercation, then LPN C should have reported the altercation.During an interview on 4/9/26 at 5:49 P.M. LPN B said:-All resident-to-resident altercations needed to be reported to the Administrator or DON immediately.-The facility had two hours to report an abuse allegation to the Department of Health and Senior Services (DHSS).-LPN C most likely told the DON and/or Administrator about the altercation but forgot to mention it in his/her note.-If LPN C did not report the altercation, then LPN C should have reported the incident immediately to the DON and/or Administrator.During an interview on 4/9/26 at 6:35 P.M. the Administrator and DON said:-They had not been told about the resident-to-resident altercation between Resident #3 and Resident #14 that occurred on 2/20/26.-They expected all staff members to report any kind of abuse immediately.-The facility has a two-hour window to report abuse to DHSS.-They did not report the altercation that occurred on 2/20/26 because they had not been told about it.-If they had been told about the resident-to-resident altercation on 2/20/26 then they would have reported the incident to DHSS within the regulated timeframe.During a phone interview on 4/10/26 at 2:33 P.M. LPN C said:-Resident #3 had been involved in altercations in the past.-He/She remembered the specific incident after reading him/her the Health Status Note from 2/20/26 at 9:10 P.M.-He/She could not initially remember the other resident involved in the incident.-He/She remembered texting the DON about the incident.-He/She still had the text to the DON and stated that Resident #14 had been the resident involved in the altercation with Resident #3.-No injury had occurred during the altercation.-He/She was not sure if the altercation counted as abuse because Resident #3 usually had aggressive behaviors towards the other resident's on the unit.-He/She thought a resident-to-resident altercation counted as abuse when there was malintent and injury.-He/She thought his/her text might not have been specific enough to indicate that Resident #3 had hit Resident #14.Review on 4/10/26 at 2:53 P.M. of LPN C's text to the DON showed:-The text message had been sent to the DON on 2/20/26 at 7:19 P.M.-Resident #3 and Resident #14 had hit each other again.-Resident #3 and Resident #14 were just grumpy old ladies and no injuries occurred. 2973592

Based on interview and record review, the facility failed to conduct quarterly Criminal Background Checks for eight out of 10 sampled employees (Employees AA, BB, CC, DD, EE, FF, GG and HH). The facility census was 70 residents. Review of the facility Background Screening Investigations policy dated 8/23/24 showed: -The Employee Disqualifications List (EDL) is maintained through the Department of Health and Senior Services (DHSS).-The EDL is checked prior to date of hire and quarterly thereafter.1. Review of Employee AA's personnel record showed:-His/her hire date was 1/13/25.-His/her EDL check date was 1/13/25.-His/her quarterly EDL checks were due in April 2025 and July 2025 and were not completed.2. Review of Employee BB's personnel record showed:-His/her hire date was 2/17/25.-His/her EDL check date was 2/12/25.-His/her quarterly EDL check was due in May 2025 and was not completed.3. Review of Employee CC's personnel record showed:-His/her hire date was 3/31/25.-His/her EDL check date was 3/27/25.-His/her quarterly EDL check was due in June 2025 and was not completed.4. Review of Employee DD's personnel record showed:-His/her hire date was 9/30/24.-His/her EDL check date was 9/27/24.-His/her quarterly EDL checks were due in December 2024, March 2025 and June 2025 and were not completed.5. Review of Employee EE's personnel record showed:-His/her hire date was 8/19/24.-His/her EDL check date was 8/9/24.-His/her quarterly EDL checks were due in November 2024, February 2025 and May 2025 were not completed.6. Review of Employee FF's personnel record showed:-His/her hire date was 2/3/25.-His/her EDL check date was 1/30/25.-His/her quarterly EDL checks were due in April 2025 and July 2025 and were not completed. 7. Review of Employee GG's personnel record showed:-His/her hire date was 8/5/24.-His/her EDL check date was 8/2/24.-His/her quarterly EDL checks were due in November 2024, February 2025 and May 2025 and were not completed8. Review of Employee HH's personnel record showed:-His/her hire date was 11/21/24.-His/her EDL check date was 11/22/24.-His/her quarterly EDL checks were due in February 2025 and May 2025 and were not completed.9. During an interview on 7/31/25 at 2:20 P.M. the Human Resources (HR)/ Business Office Manager (BOM) said:-He/she did not have any employee records of quarterly EDL checks.-The only time the facility did EDL checks was at the time the employee was hired.10. During an interview on 8/1/25 at 11:35 A.M. the Administrator said:-EDL checks were to be done upon hire and quarterly.-The BOM was responsible for completing EDL checks both upon hire and quarterly.-No one had been monitoring to ensure that quarterly EDL checks were completed.

Based on interview and record review, the facility failed to ensure one sampled resident's (Resident #9) urine sample was picked up by the laboratory according to acceptable standards of practice and failed to ensure effective coordination with the lab, thereby delaying necessary treatment, out of 18 sampled residents. The facility census was 70 residents.Review of the facility's Urinary Tract Infection/Bacteriuria - Clinical Protocol procedure, revised April, 2018, showed:-The physician and staff will identify individuals with a history of symptomatic Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system), those with risk factors for UTI, and those with possible signs and symptoms of a UTI.-The physician will help nursing staff interpret any signs, symptoms, and lab tests and will order appropriate treatment for verified or suspected UTIs and/or urosepsis based on pertinent assessment.Review of the American Society of Microbiology (ASM) website showed:-Once a urine sample has been collected it must be transported to the laboratory.-Urine samples should be plated (transferring a measured amount of urine onto [NAME] plates to cultivate and identify microorganisms that may be causing a UTI) within two hours of collection. Boric acid or refrigeration can extend the time between collection and plating to 24 hours.-Plates are typically incubated at 35 - 37 degrees Celsius for 24 to 48 hours.-It usually takes a day for bacteria from a urine sample to grow to a sufficient quantity they can be detected and identified using standard clinical microbiology lab techniques. If the urine from a person with UTI symptoms confirms a likely UTI, a doctor can start antibacterial treatment based on the most likely causative organisms while waiting for the culture results to tailor therapy.1. Review of Resident #9's admission Record showed the resident was admitted to the facility on [DATE] with diagnoses that included a UTI.Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 6/12/25, showed the resident:-Did not have a urinary catheter (device to drain urine from the bladder).-Was cognitively intact.-Was frequently incontinent of urine.-Had no UTI within the past 30 days.Review of the resident's nursing note, dated 7/17/25 at 3:16 P.M., showed:-The resident complained of burning while urinating. -An order was received to obtain a urinalysis (UA) with culture and sensitivity (a two-part laboratory test used to diagnose and guide treatment for UTI) for signs and symptoms of UTI per physician.-The lab order was entered into resident's record and in laboratory.Review of the resident's Nurse Practitioner (NP) note, dated 7/22/25 showed:-The resident reported dysuria (discomfort, pain, or burning while urinating).-Order for a UA to see if resident has a UTI and would wait for results. -Would order antibiotic therapy (ABT) if indicated. The resident verbalized understanding.-The physician was notified and aware. -The physician expressed concerns that that UA was collected on 7/17/25 and there were still no results.Review of the resident's nursing notes dated 7/24/25 showed:-At 1:36 P.M. the nurse followed up with the lab for the UA that was collected on 7/23/25. The person gave the number for the representative in the area because the lab was not found. The order had been placed for the lab. The urine was collected and in the hazardous refrigerator on 7/23/25 and was not in the refrigerator on 7/24/25. Phone number for the representative was given to the Director of Nursing (DON).-At 2:09 P.M. the nurse attempted unsuccessfully three times to reach the representative. He/She contacted the laboratory direct number and the specific location of the urine within the company could not be determined.Review of the resident's Urine Culture (laboratory test to detect and identify bacteria or other organisms in a urine sample) Partial Report, dated 7/25/25 showed:-Urine was collected on 7/23/25.-White blood cell counts in urine were abnormally high.-Microbiology tests to follow in a separate report.-No specific organism was identified as being abnormally numerous on the partial report.Review of the resident's nursing notes dated 7/25/25 showed:-At 10:13 A.M. urine was picked up this morning in route to the lab.-At 2:36 P.M. an order for Macrobid oral capsule 100 milligram (mg). Give one capsule by mouth two times daily for UTI for five days.-At 2:38 P.M. an order for Pyridium oral tablet 100 mg by mouth every 12 hours as needed for UTI for three days.Review of the resident's Order Summary Report (OSR) and Medication Administration Record (MAR) dated July 2025 showed the resident started on Macrobid 100 mg on 7/26/25.Review of the resident's nursing note dated 7/27/25 at 11:43 A.M. showed the resident started on ABT on 7/26/25 and had not wanted Pyridium for discomfort.Review of the resident's NP note, dated 7/29/25 showed:-The resident started on Macrobid 100 mg by mouth for five days on 7/26/25.-The resident reported feeling much better since he/she started the ABT.Review of the resident's Urine Culture Final Report, dated 7/29/25, showed:-The specimen was collected 7/23/25.-Results showed Proteus Mirabilis (a common cause of bacterial infection) of over 100,000 colony forming units (CFU)/ml (indicative of a significant UTI).During an interview on 7/28/25 at 12:15 P.M. the resident said:-He/She was finally being treated for a UTI.-It took a week and a half to start treatment for a UTI because nobody knew what happened with the first two urine samples. -Staff ended up taking three different urine samples. During an interview on 7/30/25 at 11:10 A.M. the resident said:-He/She was still taking an antibiotic but didn't know the name of the medication.-He/She felt much better after starting the treatment and had been very weak with the UTI.During an interview on 7/31/25 at 2:08 P.M. Certified Nurse Assistant (CNA) C said:-The resident first complained about pain during urination a couple of weeks ago. -He/She reported the complaint to the nurse at the time.-The resident complained of urinary pain three or four times since then and he/she always reported it to whoever the nurse was at the time, which was the facility protocol for CNAs. During an interview on 7/31/25 at 2:33 P.M. Licensed Practical Nurse (LPN) C said: -The resident first started complaining of pain during urination on 7/17/25. The resident's family was in the room when he/she reported it. The resident was lying in bed and said his/her back and tummy also hurt. -Two or three hours later around supper time the resident said he/she felt better and his/her back pain had stopped. -The CNAs also reported the resident said he/she felt better. -A UA was ordered on 7/17/25 when the resident first complained of pain while urinating and the lab was notified. -On 7/17/25 he/she placed the urine in the refrigerator and filled out a label for the urine sample cup. -The resident asked him/her about lab results on 7/22/25.-He/She found the same urine sample with the same label in the refrigerator on 7/22/25, so it apparently never got picked up. -The urine should have been picked up the early morning hours of 7/18/25.-Urine should be collected and placed in the refrigerator and picked up in time for the culture to be started within 24 hours.-The urine culture was reordered that same day. -The resident wasn't able to produce a urine sample into a urine hat (a container designed to fit on a toilet seat used to collect urine samples) before 6:00 P.M. on 7/22/25 so it was collected on the following shift and got picked up by the lab in the early morning hours of 7/23/25. The urine was gone when he/she returned to work at 6:00 A.M. on 7/23/25, but there were no results from the lab by 7/24/25 so he/she called the lab on 7/24/25 to follow up. He/She was told the lab order was not found. -The DON followed up with another order. -The resident's urine was collected again the evening of 7/24/25. -He/She worked only three days a week but read a nursing note that showed the urine was picked up on 7/25/25. -The resident had started ABT when he/she returned to work on 7/29/25. During an interview on 8/1/25 at 9:03 A.M. LPN B said:-He/She worked three days a week, with days off varying.-He/She and LPN C were the main nurses working the resident's side of the facility.-The resident was good about telling staff when something was bothering him/her.-From nurses' notes he/she could see the resident complained of a burning sensation when urinating and that a urine sample was collected on 7/17/25. He/She didn't know when it was picked up.-A note on 7/23/25 showed the lab lost the urine. The nurse was given the lab representative's contact information.-Sometime towards the beginning of last week, maybe around 7/25/25, a CNA reported the resident complained of burning while urinating.-Nursing notes showed another urine sample was picked up the morning of 7/25/25. All he/she needed to do was wait for the urine results.-The resident started on an antibiotic on 7/26/25.-He/She didn't think the nine-day wait from the time the urine was first collected to the resident eventually starting ABT on 7/26/25 was standard of practice. The longest they should have to wait was 72 hours to give time for the urine to be picked up and for the culture to grow. The resident should be able to get any needed antibiotic once the lab results were back. -The lab courier came daily Monday through Friday and didn't come on the weekends. -Management informed nurses that the lab specimens wouldn't be picked up on the weekend. -Nurses could do STAT (quick turn-around time) orders but the lab courier wouldn't come on the weekend. If nurses put in an order one day the lab courier would come early the next morning except for Saturday and Sundays.-He/She thought lab specimens should be picked up seven days a week. There shouldn't be more than 24 hours between collecting the sample and the lab picking it up for testing.During an interview on 8/1/25 at 10:05 A.M. CNA A said:-The resident complained about a week and a half ago to multiple CNAs that he/she was urinating more frequently and felt urgency to urinate and that he/she wasn't feeling good and felt weak. Several days ago, the resident said he/she wasn't going to make it through the night because of the symptoms. -He/She reported it to the nurse along with another CNA that the resident had complained. The resident complained several times throughout the day and he/she and the other CNA told LPN C each time. -LPN C told him/her and the other CNA to collect the resident's urine in a urine hat while the resident sat on the toilet. -They couldn't get a sample that day before they left at 6:00 P.M. The nurse told the oncoming nurse and he/she and the other CNA told the oncoming CNA for the next shift to keep trying to get a UA sample.-He/She heard there was an issue where the lab didn't pick the sample up or they lost it and they had to get another one. -He/She heard nursing talking about the sample having been in the refrigerator too long and they had to get another sample.During an interview on 8/1/25 at 11:20 A.M. the DON said:-The facility got three urine samples from the resident.-He/She thought the lab had deleted the resident's order completely the first time. -The second time they picked it up, but the lab couldn't find the results. The nurse made sure it got picked up then. -He/She ordered the lab for a third time STAT and was told it would be picked up the same day. -The urine sample should have been picked up the first time it was ordered, and results should have been available within 3 days and an antibiotic started.-The lab didn't pick up specimens on Saturday or Sunday mornings or normally do STAT orders. -A weak or more was too long of a turnaround. -Once urine was picked up the facility should have results within 72 hours and antibiotics should be started within 3 or 4 days. -Another option was to send the resident to the emergency room on the weekends.

Based on interview and record review, the facility failed to identify, assess and provide supportive interventions for two sampled residents (Resident #11 and #40), with a diagnosis of Post-Traumatic Stress Disorder (PTSD a mental health condition triggered by a terrifying event either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of 18 sampled residents. The facility census was 70 residents.Review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed:-Trauma-informed care shifts the focus from What's wrong with you? to What happened to you?-A trauma-informed approach to care acknowledges that health care organizations and care teams need to have a complete picture of a patient's life situation - past and present - in order to provide effective health care services with a healing orientation.-Adopting trauma-informed practices can potentially improve patient engagement, treatment adherence, and health outcomes, as well as provider and staff wellness. It can also help reduce avoidable care and excess costs for both the health care and social service sectors.-Trauma-informed care seeks to:--Realize the widespread impact of trauma and understand paths for recovery.--Recognize the signs and symptoms of trauma in patients, families, and staff.--Integrate knowledge about trauma into policies, procedures, and practices; and--Actively avoid re-traumatization. Review of facility policy titled Trauma-Informed and Culturally Competent Care revised [DATE], showed:-Guided staff when providing care that was culturally competent and trauma-informed in accordance with professional standards of practice.-Addressed the needs of trauma survivors that minimized triggers and/or re-traumatization.-All staff were guided in evidence-based organizational and interpersonal strategies that supported trauma-informed and culturally competent care. -Developed an individualized care plans that addressed past trauma in collaboration with the resident and family, as appropriate.-Identified and decreased exposure to triggers that might have re-traumatize the resident. -Recognized the relationship between past trauma and current health concerns. -Developed individualized care plans that incorporated language needs, culture, cultural preferences, norms, and values. 1. Review of Resident #11's admission Record showed the resident admitted to the facility on [DATE] with a diagnosis of PTSD.Review of the resident's Level One Pre-Admissions Screening and Resident Review (PASRR-federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment) dated [DATE] showed the resident had a diagnosis of PTSD. Review of the resident's care plan dated as revised on [DATE] showed:-He/She had PTSD. -He/She had a history of abuse. -The resident's triggers were not addressed.-The resident's interventions were not addressed. Review of the resident's Trauma Informed Care assessment dated [DATE] showed:-The resident had trauma in the past.-Had nightmares about the event.-Tried hard not to think about the event or went out of the way to avoid situations that reminded him/her of the event.-Felt numb or detached from people, activities, or surroundings. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated [DATE] showed:-The resident was cognitively intact. -The resident had PTSD. During an interview on [DATE] at 11:17 A.M. the resident said:-He/she had a diagnosis of PTSD.-He/She had not been asked about what his/her triggers were or interventions to the triggers During an interview on [DATE] at 8:59 A.M., Certified Nursing Assistant (CNA) A said: -He/She knew the resident had a diagnosis of PTSD.-The only trigger he/she knew of was resident's door to his/her room being left open. -He/She would look on the care plan for the triggers and interventions. -He/She would have expected triggers and interventions to be in the care plan.-He/She was unsure if triggers or interventions were listed in the care plan.-If the interventions and triggers were not in the care plan, he/she would have informed the nurse. During an interview on [DATE] at 8:59 A.M., Licensed Practical Nurse (LPN) B said:-He/She was familiar with the resident.-He/She knew the resident had a diagnosis of PTSD.-He/She was unfamiliar with the residents' triggers or interventions.-The resident's triggers and interventions should have been listed in the care plan.-He/She was unfamiliar if the triggers and interventions were listed in the care plan.-The MDS Coordinator was responsible for care plans.-He/She would tell the MDS Coordinator if there were not triggers or interventions listed in the care plan. During an interview on [DATE] at 9:18 P.M., the MDS Coordinator said:-The resident had a diagnosis of PTSD.-When a resident had a diagnosis of PTSD the triggers and interventions would have been listed in the care plan.-The event that caused the PTSD would be addressed in the care plan.-PTSD should not have been listed with other diagnosis but in it's own place in the care plan. -He/She audited the care plans. During an interview on [DATE] at 11:26 A.M., the Director of Nursing (DON) said:-The MDS Coordinator was responsible for the care plans.-The resident had a diagnosis of PTSD.-When a resident had a diagnosis of PTSD there would be triggers and interventions listed in the care plan.-He/She did not know the resident's triggers or interventions. -The information of the resident's triggers and interventions should have been in the care plan. -Care plans were audited by the MDS Coordinator and the Inter-Disciplinary Team (IDT). 2. Review of Resident #40's admission Record showed the resident was admitted to the facility on [DATE] with diagnoses that included:-PTSD-Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety).-Major depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).-Bipolar disorder, unspecified (a mental health condition characterized by severe shifts in mood and energy levels). Review of the resident's Trauma Informed Care Assessment – PTSD, dated [DATE] showed the resident:-Had experienced an unusually frightening, horrible, or traumatic experience.-Had nightmares within the past month about the events that were especially frightening or traumatic.-Tried hard not to think about the events or avoided situations that reminded him/her of the events.-Had been constantly on guard or easily startled. Review of the resident's medical record showed:-No further PTSD or Trauma Informed Care assessments were available in the resident's medical record. -No further PTSD or Trauma Informed Care assessments were provided when requested. Review of the resident's most recent PASRR Level II (a comprehensive evaluation for individuals who screen positive on the initial Level I PASRR screening to determine the need for specialized services and care), dated [DATE], showed the resident: -Had a long history of depressive symptoms beginning at the approximate age of 16, history of a suicide attempt at age [AGE], and cutting approximately seven years ago. The resident reported persistent symptoms of feeling down, depressed, worthless, irritable, and anxious, and having difficulty with concentration, coping, excessive worry, and motivation. -Had a spouse whom the resident felt very close to and who was a significant source of support, but the spouse passed away in [DATE]. He/she also used to like to spend time with his/her pet when he/she lived at home.-Had a very supportive family member (Family Member A) whom he/she talked with frequently.-Required a high level of care and supervision where his/her cognitive, physical, and psychiatric needs could be managed effectively, ensuring his/her safety.-Recommendations were for therapeutic counseling due to his/her history of visual and auditory hallucinations, grief over his/her spouse's death, and feelings of isolation. He/she would benefit from regular therapy sessions given his/her openness to exploring this option and the potential to improve coping skills and emotional regulation.-Required ongoing assessment of mood, thought processes, and behaviors for intervention purposes. His/her behavioral plan may include discussion of feelings, coping mechanism identification, problem solving techniques, providing resources for support, and clinical interventions.-Should have a crisis intervention plan with clear steps to be taken with the resident during a crisis due to his/her history of suicidal ideations/attempts. Review of the resident's admission MDS dated [DATE], showed the resident: -Was moderately cognitively impaired.-In the past two weeks:--Had little to no interest 12 to 14 days.--Felt down, depressed, or hopeless two to six days.--Had difficulty falling asleep, staying asleep or slept too much 12 to 14 days.--Had trouble concentrating 12 to 14 days.-It was very important for the resident to be around animals and participate in religious services and somewhat important for him/her to go outside for fresh air.-Was diagnosed with PTSD, anxiety, depression, and bipolar disorder. Review of the resident's quarterly MDS, dated [DATE] showed the resident:-Was cognitively intact.-Felt down, depressed, or hopeless two to six days within the past two weeks.-Experienced hallucinations (perceptions in the absence of real external stimuli) and delusions (firmly held beliefs contrary to reality). Review of the resident's Comprehensive Care Plan, revised [DATE], showed:-A trauma informed care plan was initiated [DATE]. It showed the resident would have fewer episodes due to trauma over the next quarterly review period. The resident was sexually abused prior to admission. The psychiatric Nurse Practitioner (NP) was to follow up. The trauma informed care plan did not show how staff were to know when the resident's trauma was triggered, what the resident's triggers were, or what they should do to lessen the likelihood of triggering the resident. -A PASRR care plan, revised [DATE], showed the resident was in need of specialized services due to his/her mental health needs. Goals were for the psychiatrist to evaluate the residents' response to psychotropic medications and the need for other services. No counseling services were mentioned on the care plan.-A Mood care plan, initiated [DATE], showed the resident had problems related to bipolar, depression, and PTSD. Nursing was to assist the resident, family, and caregivers in identifying strengths and coping skills and to reinforce these. No specific strengths or coping techniques were mentioned. Staff were to monitor, record, and report to the physician any increased anger, mood changes, agitation, feelings of being threatened, thoughts of harm, or possession of objects that could be used as weapons. -A psychological well-being care plan, initiated [DATE], showed the resident had problems related to depression, bipolar, anxiety, and PTSD. Nursing was to provide opportunities for the resident and family to participate in the resident's cares. When conflicts arise, remove the resident to a calm and safe environment and allow him/her to vent feelings. Approach resident in a calm manner, calling the resident by name. If physically or verbally aggressive assure resident is safe and leave him/her alone for five or 10 minutes before reattempting or have another staff member reattempt cares.-A PTSD care plan, initiated [DATE], showed:--The resident was diagnosed with PTSD and had a history of childhood abuse and fearfulness of being outside his/her living quarters. The goal was for the resident to verbalize feelings related to emotional triggers and have fewer incidents of emotional discomfort related to PTSD through the quarterly review date. The plan didn't show how staff were to tell if the resident was experiencing discomfort related to PTSD. --Interventions were for staff to allow the resident to verbalize feelings and to increase communication with the resident; explain treatments, procedures, and labs; monitor and document the resident's feelings relative to triggering events and allow a safe space to voice fears, frustrations, and concerns; create a plan for a healthy response to stress; psychiatry and mental health counseling as indicated/ordered; and remove the resident to a calm, safe environment. ---Note: There was no plan for what the resident or staff should do in the event the resident was triggered or documentation of the resident's triggers. The plan didn't specify if there were any restrictions on who provided personal cares to the resident. The plan didn't specify if counseling services would be offered or show how staff were to know if counseling services were indicated.---Note: The intervention to have a staff member accompany the resident to medical appointments was not in the resident's care plan.-There was no crisis intervention plan with clear steps to be taken with the resident during a crisis related to his/her history of suicidal ideation/attempts as was recommended in the resident's most recent PASRR. Review of the resident's electronic medical record on [DATE] showed no documentation the resident received or was offered counseling services. Observation on [DATE] at 11:35 A.M. showed the resident was lying awake in bed. The resident's affect was flat when he/she spoke. During an interview on [DATE] at 11:38 A.M. the resident said:-He/She told the physician a couple of days ago he/she thought his/her depression medication needed to be increased and the doctor agreed.-Nobody at the facility had ever asked him/her about PTSD.-Staff almost always knocked and announced themselves before entering his/her room, but when they enter quickly it triggered his/her anxiety and PTSD. -He/She avoided certain shows that triggered his/her PTSD.-He/She was still bothered by past traumas, but nobody at the facility had asked him/her about them or if he/she wanted counseling. He/she was open to counseling, but didn't trust many people. It would have to be the right counselor that he/she trusted.-He/She didn't know if he/she had a PTSD care plan. Nobody had ever mentioned it to him/her or asked him/her what he/she needed related to PTSD. Observation on [DATE] at 10:45 A.M. showed the resident was lying awake in bed. During an interview on [DATE] at 10:47 A.M. the resident said:-The physician increased his/her depression medication, but he/she wasn't sure what the medication was. -Family Member A was his/her main support system and visited or spoke with the resident on the phone daily.-He/She had a diagnosis of PTSD since he/she was [AGE] years old which was caused by sexual and physical abuse and he/she still experienced emotional trauma from that. He/She had been abused as a young child as well. Someone had pulled out his/her hair when he/she was quite young.-He/She was open to counseling and thought it could be helpful, but it had to be a good match, or it would stress him/her out. -Going outside or going places sometimes triggered his/her PTSD. It was bad going to the doctor's office. It made his/her PTSD and anxiety go way up. When he/she went to the doctor's the facility let his/her CNA go with him/her. His/her anxiety would be worse if they didn't. During an interview on [DATE] at 2:08 P.M. Certified Nursing Assistant (CNA) C said:-He/She thought the resident had depression because he/she would sleep during the day or withdrawal. -He/She didn't know if the resident had anxiety.-He/She didn't know if the resident had a history of depression and didn't know he/she had been diagnosed with PTSD.-He/She didn't know what the resident's PTSD triggers were or what staff were supposed to do to lessen the likelihood of triggering the trauma.-He/She knew the resident preferred female caregivers.-Trauma Informed Care meant being informed of the resident's past trauma and included how staff should respond to the resident. -An emotional trigger could be loud noises or anything that set someone off. Watching something on TV could trigger a response or seeing someone else being abused. -He/She didn't know the resident's triggers. -It would be helpful to know who was diagnosed with PTSD and what their triggers were to avoid an adverse reaction.-Staff's approach to residents mattered and this was especially true of Resident #40. He/she tried to joke around and approach residents with an upbeat mood to keep the residents' moods and attitudes more positive in general. -He/She reviewed the resident's electronic medical record to see the residents' care plans and charted on each resident daily. -The resident's care plan showed he/she was at risk for changes in mood and staff should report this to the nurse. Staff were to reattempt care or have another staff reattempt cares.-His/Her TIC plan didn't show what CNAs were to do to avoid triggers.-His/Her Mood care plan showed staff were to report increasing anger, agitation, or possession of items that could be used as weapons.-The resident's PTSD care plan showed staff were to remove the resident to a safe area and allow him/her to share feelings, but didn't show what might trigger the retraumatization. During an interview on [DATE] at 9:40 A.M. CNA A said:-Some days the resident needed encouragement to come out of his/her room, to bathe, change clothes, and go to the bathroom. He/she would get a little down and tended to stay quiet and to himself/herself. -The resident was more open with staff after he/she got to know them. -The resident was diagnosed with depression and anxiety. -The resident would bounce his/her leg or leave activities and wanted to be by himself/herself.-He/She read the resident's care plan and thought he/she had a PTSD diagnosis. -When the resident was at the hospital a short time back he/she had increased agitation and threw his/her shoe, but he/she was out of his/her typical routine. The resident was in significant pain at the time. -The resident mentioned he/she had a rough childhood and was physically and sexually assaulted over a period of time. The resident mentioned a few events, but nothing very specific.-He/She only wanted three specific staff members to help him/her with bathing. -He/She didn't think the resident was working with the facility social worker or with a counselor to work through his/her PTSD. At least the resident never mentioned that.-The resident never mentioned his/her triggers. -He/She didn't remember triggers being in the resident's care plan. They probably should be. -He/She normally offered to do the resident's shower when the agency staff worked.-He/She didn't know how the resident would react if his/her PTSD was triggered. -The resident needed staff to assist him/her in getting dressed. -There should be direction in the care plan to specify what staff needed to know to not to trigger any PTSD symptoms. During an interview on [DATE] at 10:25 A.M. Family Member A said:-He/She was the resident's main support. The resident also had a close bond with his/her spouse, but the spouse died about a year ago and that had been very hard for the resident.-It was also very hard for the resident to go from living for years independently in his/her own home with his/her spouse and pet to living in a facility alone. The resident had a lot of losses within the past year and he/she had medical concerns he/she worried about a lot as well.-The resident had a long history of physical and sexual abuse since childhood and was diagnosed with PTSD. -He/She thought the resident could benefit from counseling if it was with the right therapist. -He/She definitely shouldn't have a male counselor and it would likely be three months or longer for the resident to feel comfortable with any therapist.-He/She told the facility the resident should never have male staff providing any personal cares such as changing his/her briefs, showering, or dressing, and they should not enter his/her room to provide cares.-The resident had told him/her multiple times since he/she has been at the facility that he/she had thoughts of harming himself/herself. The resident said he/she would never act on those urges since he/she promised Family Member A he/she wouldn't, but those urges were still there. During an interview on [DATE] at 10:47 A.M. the Social Services Designee (SSD) said: -He/She knew very little about the resident's past trauma. What he/she knew was through Family Member A.-He/She had never spoken to the resident about his/her past trauma. The resident's family said he/she was happy and doing better at the facility. When he/she was new to the facility the resident wouldn't come out of his/her room, but was doing better with that.-He/She thought counseling might be more triggering. The resident only spoke to Family Member A about his/her past traumas.-Family Member A reported the resident verbalized in the past he/she felt like harming himself/herself. He/she wasn't aware the resident felt that way since he/she had been at the facility.-The resident should have a care plan that addressed his/her urge to harm himself/herself.-He/She wasn't sure if the resident was ever offered any counseling services since he/she had been at the facility.-The nursing staff or family should bring it to his/her attention they think counseling might help.-He/She was responsible for arranging counseling services.-He/She and the MDS Coordinator had access to the resident's Level II PASRR which should show the supports he/she needed. -He/She wasn't aware of any specific Level II PASRR recommendations.-He/She was responsible for talking with the family or resident about any mental health concerns and bringing them up with all Department heads in daily morning meetings.-He/She wasn't aware that there were any specific staff who should not provide cares. -The care plan should specify who should provide certain cares for the resident depending on his/her comfort level. The charge nurse was responsible for seeing what the resident felt comfortable with related to his/her cares. If the resident didn't feel comfortable then he/she (SSD) should have a conversation with the resident. -He/She had a good relationship with the resident so he/she would be the best person to talk with the resident about it. -The MDS Coordinator was responsible for the PTSD care plan. -He/She did the Trauma Informed Care assessment which the MDS Coordinator could see in the medical record. -He/She worked closely with the MDS Coordinator to contribute to the PTSD care plan. During an interview on [DATE] at 11:20 A.M. the Director of Nursing (DON) said:-The PTSD care plan should identify the resident's triggers and show how staff can mitigate triggers that might retraumatize the resident.-Staff should know what to do to mitigate triggers. They should be able to find that information in the care plan.-Involved family members and the resident should absolutely be part of the PTSD care planning to provide information on the resident's history. The best person to work with the resident and family on that was someone the resident felt close to and safe with.-The MDS Coordinator was responsible for the PTSD care plan with input from other staff.

Based on interview and record review, the facility failed to ensure two sampled Nursing Assistants (NA) (NA B and NA C) had completed the state approved Certified Nursing Assistant (CNA) training program within four months of his/her facility employment. The facility census was 70 residents.Review of the facility Nursing Assistant Qualifications and Training Requirements policy dated August 2022 showed:-The facility would not employ any individual as a Nursing Assistant for more than four months unless that individual had completed a training program and competency evaluation approved by the state.1. Review of NA B's personnel file showed:-His/her hire date was 2/17/25.-He/She had worked at the facility for over five months.-There was no record of the employee having completed CNA training.2. Review of NA C's personnel file showed:-His/her hire date was 8/19/24.-He/She had worked at the facility for over eleven months.-There was no record of the employee having completed CNA training.3. During an interview on 7/31/25 at 2:20 P.M. the Human Resources (HR)/ Business Office Manager (BOM) said:-He/she did not yet have any paperwork to show that NA B and NA C were CNAs.-NA B and NA C were still working at the facility as NAs.During an interview on 8/1/25 at 11:26 P.M. the Director of Nursing (DON) said:-An NA can only work in the facility for four months.-NAs must become CNAs within 16 weeks of their hire date.-The Administrator was responsible for ensuring the four month time frame was met for NAs becoming CNAs.During an interview on 8/1/25 at 11:35 A.M. the Administrator said:-NAs were to become CNAs within 16 weeks of their date of hire.-He/she tracked the NAs to ensure they were CNAs within four months of their hire date.-He/she had not been aware that NA B and NA C had not become CNAs within four months of their hire date.

Based on interview and record review, the facility failed to ensure appropriate follow-up was completed for pharmacy recommended gradual dose reductions (GDR- stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or medication can be discontinued) for two sampled residents (Resident #2 and #6) out of 18 sampled residents. The facility census was 70 residents.Review of the facility's policy titled Tapering Medications and Gradual Drug Dose Reduction dated July 2022 showed:-Tapering that is applicable to psychotropic medications are referred to as GDRs.-Residents who use psychotropic medications should receive GDRs and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.-The physician would order appropriate tapering of medications, as indicated.-Residents who use psychotropic medications should receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs.-During the first year in which a resident was admitted on a psychotropic medication, or after the facility has initiated such medication, the facility would attempt to taper the medication during at least two separate quarters, unless clinically contraindicated.-After the first year, tapering would be attempted at least annually, unless clinically contraindicated.-The tapering may be considered clinically contraindicated if:--The continued accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.--The resident's target symptoms returned or worsened after the most recent attempt at tapering the dose within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.1. Review of Resident #2's Physician Order Sheet (POS) dated March 2025 showed:-Mirtazapine Oral Tablet (used to treat depression) 7.5 milligrams (mg), give one tablet via Gastrostomy (G-Tube- an opening into the stomach from the abdominal wall, made surgically for the introduction of food) in the evening related to Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).-Paroxetine HCl Tablet (used to treat multiple different mental health conditions) 20 mg, give one tablet via G-Tube one time a day related to MDD.-Bupropion HCl Oral Tablet (used to treat depression) 75 mg, give one tablet via G-Tube two times a day related to MDD.-Risperidone Tablet (an anti-psychotic medication used to treat different mental health conditions) 0.25 mg, give one tablet via G-Tube two times a day related to Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats), Unspecified and restlessness/agitation.-Lorazepam Oral Tablet (used to treat anxiety) 0.5 mg, give one tablet via G-Tibe three times a day for anxiety. Review of the resident's medication regimen review dated 3/5/25 showed:-The resident had been receiving Risperidone 0.25 mg, Lorazepam 0.5 mg, Bupropion 75 mg, Mirtazapine 7.5 mg, and Paroxetine 20 mg.-The pharmacist recommended a GDR for the medications.-The provider check marked the box disagree and did not give a rationale for continuing the current dosages of the medications.Review of the resident's POS dated May 2025 showed:-Mirtazapine Oral Tablet 7.5 mg, give one tablet via G-Tube in the evening related to MDD.-Paroxetine HCl Tablet 20 mg, give one tablet via G-Tube one time a day related to MDD.-Bupropion HCl Oral Tablet 75 mg, give one tablet via G-Tube two times a day related to MDD.-Risperidone Tablet 0.25 mg, give one tablet via G-Tube two times a day related to Anxiety Disorder, Unspecified and restlessness/agitation.-Lorazepam Oral Tablet 0.5 mg, give one tablet via G-Tibe three times a day for anxiety. Review of the resident's medication regimen review dated 5/7/25 showed:-The resident had been receiving Risperidone 0.25 mg, Lorazepam 0.5 mg, Bupropion 75 mg, Mirtazapine 7.5 mg, and Paroxetine 20 mg.-The pharmacist recommended a GDR for the medications.-The provider check marked the box disagree and did not give a rationale for continuing the current dosages of the medications.2. Review of Resident #6's POS dated April 2025 showed:-An order for Brexpiprazole Oral Tablet (Rexulti- an atypical anti-psychotic medication used to treat multiple mental health conditions and agitation with dementia) 2 mg, give one tablet by mouth one time a day related to Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) Unspecified Severity, With Agitation.Review of the resident's medication regimen review dated 5/7/25 showed:-The resident had been receiving Rexulti 2 mg.-The pharmacist recommended a GDR be completed.-The provider check marked the box disagree and did not provide a rationale for continuing the current dose.3. During an interview on 8/1/25 at 9:48 A.M. Licensed Practical Nurse (LPN) A said:-The nurses and nurse management ensure the completion of monthly medication regimen reviews.-The doctor needed to put the rationale of why he/she did not want the GDRs completed for Resident #2 and Resident #6 on the recommendation sheet.During an interview on 8/1/25 at 10:13 A.M. the Assistant Director of Nursing (ADON) said:-The Director of Nursing (DON) was responsible for completing the monthly pharmacy recommendations.-The doctor needed to provide the rationale of why he/she did not want the GDRs completed for Resident #2 and Resident #6 on the recommendation sheet.-GDRs needed to be completed as part of the regulation for psychotropic medication.During an interview on 8/1/25 at 11:19 A.M. the DON said:-He/She was responsible for ensuring the appropriate follow-up was completed for the monthly medication reviews.-The doctor needed to provide the rationale of why he/she did not want the GDRs completed for Resident #2 and Resident #6 on the recommendation sheet.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #12) was referred to an oral surgeon in a timely manner out of 18 sampled residents. The facility census was 70 residents.Review of the facility's policy titled Dental Services dated December 2016 showed:-Social Service representatives would assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible.-All dental services provided were recorded in the resident's medical record. 1. Review of Resident #12's admission Record showed he/she was admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis (a medical procedure that filters and cleanses the blood).Review of the resident's care plan dated 4/4/25 showed:-The resident had upper and lower dentures.-The goal for the care plan was for the resident to be free of oral pain and lesions over the next review period.-An intervention that was put in place by the facility included:--Assure the resident received dental consults as needed.Review of a dental summary report dated 4/29/25 showed:-The resident had a chipped tooth.-The dentist was only able to perform a limited exam due to the resident's dental pain.-The resident needed to be referred to an oral surgeon.-The resident was seen due to broken teeth on his/her right side of the mouth.-The resident reported that the broken teeth to his/her right side of the mouth had been a problem for about a month prior to the exam.-The resident needed multiple teeth removed in four to six areas of the oral cavity.-The resident thought that he/she already had a referral to an oral surgeon in place and was awaiting to hear back about an appointment.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 5/15/25 showed:-The resident was cognitively intact.-The section for oral/dental status was not completed.During an interview on 7/29/25 at 10:42 A.M. the resident said:-He/She had recently seen the dentist.-Nothing had really been done by the dentist during the exam.-He/She needed to see an oral surgeon because he/she needed some teeth to be removed.-To his/her knowledge an appointment had not been set up with an oral surgeon.-His/Her mouth felt really uncomfortable.Observation on 7/29/25 at 10:42 A.M. of the resident's mouth showed that he/she had missing teeth.During an interview on 7/30/25 at 12:32 P.M. the Social Services Designee (SSD) said:-The business office manager (BOM) set up the resident's dental services.-He/She did not know that the resident needed to be referred to an oral surgeon.-There was a chance that the referral could have been completed by a nurse.-If a nurse had completed a referral, then the nurse would have filled out a transportation sheet.-He/She had not received any transportation sheets related to the resident seeing an oral surgeon.During an interview on 7/30/25 at 1:26 P.M. the resident said:-He/She had seen dentist twice since his/her admission to the facility. -He/She thought he/she had been told that the facility was having a hard time finding an oral surgeon that accepted the resident's insurance and that was why he/she had not seen an oral surgeon yet.-His/Her mouth pain was usually ranked as a five out of ten on a numerical pain scale (a tool used to quantify pain intensity, typically using a scale from zero to ten, where zero represents no pain and ten represents the worst pain imaginable).-He/She had gotten used to the pain because it had been so long since he/she last saw the dentist.-He/She just felt terrible about the whole situation because the problem was only getting worse especially to the back of his/her mouth.During an interview on 7/30/25 at 1:35 P.M. the BOM said:-The SSD would have been the person responsible for sending the resident's oral surgeon referral.-The facility had the dentist come to the facility quarterly.-If there had been questions related to a dental note, then the SSD should have reached out to the dentist to get clarification.-He/She was unaware that the resident needed to be seen by an oral surgeon.During an interview on 8/1/25 at 9:15 A.M. Certified Nursing Assistant (CNA) A said:-He/She was not sure when the resident was last seen by the dentist.-He/She was unsure of who reviewed dental notes to ensure referrals and follow-ups were completed.-He/She was unaware that the resident needed to be seen by an oral surgeon.-The resident had complained of mouth pain in the past.-The resident would tell CNA A that the food that was served to him/her was too hard to chew and requested something else to eat.-The SSD would have been the person responsible for sending out the oral surgeon referral.-The referral should have been completed by that point in time.During an interview on 8/1/25 at 9:51 A.M. Licensed Practical Nurse (LPN) A said:-He/She was unsure when the resident last saw the dentist.-The resident had not complained of any oral pain to him/her.-He/She was unaware the resident had chipped/broken teeth.-The Assistant Director of Nursing (ADON) and/or the Director of Nursing (DON) reviewed the dental notes after the dentist came to the facility.-The ADON and/or the DON would have told the SSD that an oral surgeon referral needed to be completed.-The ADON and/or the DON should have ensured that a referral had been sent to an oral surgeon.-There should have been the same day and up to 72 hours follow-up completed after the dental notes were sent to the facility.-A referral should have been completed by that point in time.During an interview on 8/1/25 at 10:21 A.M. the ADON said:-He/She was unsure when the resident last saw a dentist.-The BOM was responsible for reviewing and uploading dental notes to residents' electronic medical records (EMR).-The BOM should have given the dental note to the SSD, so the SSD could complete the oral surgeon referral.-He/She was unaware that the resident needed to be seen by an oral surgeon.-He/She was unsure of why no follow-up had been completed after the dental note was received by the facility.-He/She was unsure if the resident had complained of any mouth pain.-CNA A should have reported the mouth/chewing pain to the nurse.-The referral should have been completed within a week of the facility receiving the dental note.-The referral should have been completed by that point in time.During an interview on 8/1/25 at 11:19 A.M. the DON said:-He/She was unsure when the resident last saw a dentist.-He/She was unaware that the resident needed to be seen by an oral surgeon.-The BOM and the SSD reviewed notes after residents were seen by providers to ensure appropriate follow-up was completed.-He/She was unsure if the resident had any mouth pain.-The BOM would have been responsible for giving the dental note to the SSD.-The SSD would have been responsible for completing the referral to the oral surgeon. -The referral should have been completed within a week of receiving the dental note.

Based on observations, interview, and record review, the facility failed to ensure appropriate care for one sampled resident (Resident #2) with a Gastrostomy (G-Tube- an opening into the stomach from the abdominal wall, made surgically for the introduction of food) out of 18 sampled residents. The facility census was 70 residents.Review of the facility's policy titled Enteral (involving or passing through the intestine, either naturally via the mouth and esophagus, or through an artificial opening) Feeding-Safety Precautions dated November 2018 showed:-The purpose of the policy was to ensure the safe administration of enteral feeding.-Change administration sets for open-system enteral feedings at least every 24 hours, or as specified by the manufacturer.-Check the enteral nutrition label against the order before administration and check for the following information:--Resident name, ID, and room number.--Type of formula.--Date and time formula was prepared.--Route of delivery.--Access site.--Method.--Rate of administration.-Elevate the head of bed (HOB) at least 30 degrees during tube feeding and at least one hour after the feeding.1. Review of Resident #2's admission record showed he/she admitted to the facility with the following diagnoses:-Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and restricted oxygen to the brain) Due to Thrombosis (clotting of the blood) of Right Middle Cerebral Artery.-Dysphagia (difficulty or discomfort in swallowing) Following Cerebral Infarction.-Cognitive Communication Deficit (a communication impairment resulting from difficulties with cognitive processes like attention, memory, and problem-solving, rather than primary speech or language problems).-Other Symptoms and Signs Involving Cognitive Functions and Awareness.-Gastrostomy (G-Tube- an opening into the stomach from the abdominal wall, made surgically for the introduction of food) Status. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/5/25 showed:-The resident had severely impaired cognition.-The resident was fully dependent on staff with rolling from side to side.-The resident had a feeding tube.Review of the resident's care plan dated 7/9/25 showed:-The resident had a feeding tube due to his/her dysphagia.-The following interventions were in place:--Administer tube feeding as ordered per the Physician Order Sheet (POS), which indicated that the resident received Jevity (calorically dense, fiber-fortified therapeutic nutrition for tube feeding) -Assure the head of bed (HOB) was elevated 30 to 45 degrees.-Clean and change all equipment used for the resident's tube feeding per facility policy.Review of the resident's POS dated July 2025 showed:-An order for staff to change the tube feeding bag daily, ensure to date and initial when new a bag was placed in the morning with a start date of 7/29/25.-Elevate HOB 30 degrees or more at all times, as tolerated by the resident, for shortness of breath while lying flat.-Isosource (a nutritionally complete, calorically dense tube feeding formula that contains fiber to help support digestive health and bowel function) 1.5 Cal, to run at 50 milliliters (ml)/hour for 22 hours a day, on at 8:00 A.M. and off at 6:00 A.M.Review of the resident's Medication Administration Record (MAR)/Treatment Administration Record (TAR) dated July 2025 showed:-No order in place for HOB elevation 30 degrees or more related to the tube feeding.-No order in place for the staff to change the tube feeding bag daily, ensure to date and initial when new bag was placed in the morning prior to 7/29/25.Observation on 7/28/25 at 10:24 A.M. showed:-The resident's HOB was not at a 30-to-45-degree angle.-The resident's tube feeding bag was not labeled with the resident's name, date, hang time, rate of administration, and the nurse's initials.Observation on 7/29/25 at 9:31 A.M. showed:-The resident's HOB was at a 30-to-45-degree angle, but the resident had slid down in bed and was lying at a less than a 30-degree angle.-The resident's tube feeding bag was not labeled with the hang time or the nurse's initials.Observation on 8/1/25 at 7:51 A.M. showed the resident's HOB was not at a 30-to-45-degree angle.During an interview on 8/1/25 at 9:22 A.M. Certified Nursing Assistant (CNA) A said:-Residents who received tube feeding needed to have their HOB elevated at a 30-degree angle.-Nurses and CNA's ensured the resident was in the correct position while the tube feeding was running.-The resident was unable to position himself/herself independently.-Care plans should be up to date and reflect the resident's current status.-The resident's care plan should include all tube feeding orders.During an interview on 8/1/25 at 9:43 A.M. Licensed Practical Nurse (LPN) A said:-Residents who received tube feeding needed to have their HOB elevated at a 45-degree angle.-When tube feeding was hung the nurse needed to put the date and time of when the tube feeding was hung on the label.-Nurses and CNA's ensured the resident was in the correct position while tube feeding was running.-The resident's current tube feeding order was Isosource 1.5 Cal, but when the resident first admitted to the facility, he/she had an order for Jevity.-The resident was fully dependent on staff for positioning.-The MDS Coordinator was responsible for making and updating care plans.-The resident's care plan should be up to date and reflect their current status.-The resident's care plan needed to be updated.-The resident's care plan should include all of the resident's current tube feeding orders.During an interview on 8/1/25 at 10:02 A.M. the Assistant Director of Nursing (ADON) said:-Residents who received tube feeding needed to have their HOB elevated at least to 45 degrees.-Tube feeding bottles and bags needed to be labeled with date, time hung, rate, and initialed by the nurse.-If he/she were to find the resident's tube feeding bag unlabeled or mislabeled, he/she would notify the doctor and re-hang new tube feeding.-The resident was fully dependent on staff for positioning.-Nurses were responsible for ensuring residents were in the correct position while tube feeding was running.-If he/she were to observe the resident not in the correct position, he/she would stop the tube feeding, assess the resident, and notify the doctor.-He/She thought the resident had Jevity ordered as the resident's tube feeding formula.-The MDS coordinator was responsible for making and updating care plans.-The resident's care plan should be up to date and reflect the resident's current status.-The resident's care plan needed to be updated to include all of the resident's current tube feeding orders.During an interview on 8/1/25 at 11:19 A.M. the Director of Nursing (DON) said:-Residents who received tube feeding needed to have their HOB elevated to 30-degrees.-The facility policy indicated that the resident's HOB should be at 30-degrees.-The resident's tube feeding bag should be labeled daily with the date, time, and nurse's initials.-The nurse should have labeled the tube feeding bag on 7/28/25.-If staff were to observe the resident's tube feeding bag unlabeled or mislabeled, he/she expected staff to dispose of the tube feeding that was hanging and start a new tube feeding.-The CNA's and nurses ensured the resident was in the correct position while the resident's tube feeding was running.-The CNA's were to inform the nurse that the resident needed to be repositioned if the resident was not in the correct position.-The resident was unable to position himself/herself independently.-He/She thought the resident had Jevity ordered as the tube feeding formula.-Care plans were completed and updated by the MDS coordinator.-The resident's care plan needed to be updated.-The resident's care plan needed to include all of the resident's current tube feeding orders.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #12) received timely vision services out of 18 sampled residents. The facility census was 70 residents. Review of the facility's policy titled Visually Impaired Resident, Care of dated March 2021 showed:-Assistive devices to maintain vision included glasses, contact lenses, magnifying lens, and any other device used by the resident to assist with visual impairment.-It was not required of the facility to provide devices to assist with vision, but it was their responsibility to assist the resident and representatives in locating available resources, scheduling appointments, and arranging transportation to obtain needed services.-Residents who have lost or damaged their devices would be assisted in obtaining services to replace the devices.1. Review of Resident #12's admission Record showed he/she was admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis (a medical procedure that filters and cleanses the blood).Review of the resident's Not Seen Visit Report dated 4/14/25 showed:-The resident was supposed to be seen by an eye doctor.-The resident was out of the facility at the time of the visit.-Note: This date aligned with a day that the resident would have been at dialysis.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 5/15/25 showed:-The resident was cognitively intact.-The resident used corrective lenses.Review of the resident's care plan dated 7/3/25 showed no care plan related to the resident's vision needs.During an interview on 7/29/25 at 10:44 A.M. the resident said:-He/She was missing his/her glasses.-He/She had not seen an eye doctor recently.-He/She had poor vision without his/her glasses.-He/She utilized reading glasses at that point in time because they were better than not having glasses at all.Observation on 7/29/25 at 10:44 A.M. of the resident's room showed the resident only had a pair of reading glasses at his/her bedside.During an interview on 7/30/25 at 12:32 A.M. the Social Services Designee (SSD) said:-The resident had not complained to him/her about missing glasses.-The Business Office Manager (BOM) was the person who set up vision services at the facility.-He/She was unaware that the resident was not seen by the eye doctor when they last came to the facility.During an interview on 7/30/25 at 1:24 P.M. the BOM said:-He/She was not aware that the resident was not seen by the eye doctor when they were last at the facility.-The resident was most likely at dialysis when the eye doctor came to the facility.-There was not an eye appointment that had been scheduled after the resident missed seeing the eye doctor due to being at dialysis.-The eye doctor came to the facility quarterly.-The facility did not choose the dates in which the eye doctor came to the facility.-There were always residents who missed their quarterly appointments due to being out of the facility when providers came to the facility.-He/She was unaware the resident was missing his/her glasses.-If an emergency were to arise in which any resident needed to be seen by an eye doctor, then an appointment could be set up outside of the quarterly visits.-He/She was unsure what exactly counted as a vision emergency, or if it included missing glasses.During an interview on 8/1/25 at 9:15 A.M. Certified Nursing Assistant (CNA) A said:-The SSD was responsible for setting up eye appointments.-The resident would not have had to ask to be seen by the eye doctor because the resident would have been seen by the eye doctor that came to the facility.-When the eye doctor came to the facility to see residents, management would give the nurses and CNAs a list of residents to be seen.-The CNAs and nurses were responsible for ensuring that the residents were ready and taken to wherever the provider had set up at the facility to be seen -If a resident was not at the facility when the provider came to the facility the CNAs were responsible for reporting that to the charge nurse.-The resident usually came back from dialysis around lunch time.-The providers that come to the building were usually at the facility all day, so he/she was unsure why the resident would not have been seen.-He/She was unaware that the resident had not seen the eye doctor when they last came to the facility.-The resident wore glasses.-He/She was unaware that the resident was missing his/her glasses.-He/She thought the resident's reading glasses were the resident's normal pair of glasses.-The resident had not complained to him/her about missing glasses.-He/She was unsure if there was a specific facility policy or procedure related to missed quarterly appointments.-Care plans should be up to date and reflect the resident's current status to include vision needs.During an interview on 8/1/25 at 9:39 A.M. Licensed Practical Nurse (LPN) A said:-The SSD was responsible for setting up eye appointments.-The SSD would go around and ask residents if they wanted to be seen by the eye doctor.-When the eye doctor came to the facility, the SSD or BOM would give the list of residents to be seen by the provider.-The nurses were responsible for ensuring that the listed residents were ready and taken to wherever the provider had set up in the facility.-If the resident was at dialysis when the eye doctor came to the facility, then the facility could ask the doctor to stay until the resident returned or set up a different appointment for the resident.-He/She was not aware that the resident had missed his/her eye doctor appointment.-He/She was unaware that the resident used prescription lenses.-The resident had never asked him/her to be seen by the eye doctor.-He/She was unaware that the resident was missing his/her glasses.-Care plans should be up to date and reflect the resident's current status to include vision needs.During an interview on 8/1/25 at 9:55 A.M. the Assistant Director of Nursing (ADON) said:-The SSD was responsible for setting up eye doctor appointments.-For residents who qualified, there was an eye doctor that came to the facility to see the residents.-Residents needed to ask if they wanted to be seen by the eye doctor.-A list of the residents that were to be seen was sent to the facility and the date of when the provider would be at the facility was sent ahead of time.-The nurses and CNAs were responsible for ensuring that the residents were ready and taken to wherever the provider set up in the facility.-If a resident was not at the facility when the eye doctor came to the building, then they would be seen the next time the eye doctor came.-He/She thought a family member had provided the resident with a different pair of glasses.-If the resident was out of the facility due to being at dialysis when the eye doctor came to the facility, then the facility would need to set up an appointment with an outside source.-The facility could have tried to find out who the resident saw in the past and set up an appointment at that practice.-The resident should have seen an eye doctor by that point in time.-Care plans should be up to date and reflect the resident's current status to include vision needs.During an interview on 8/1/25 at 11:19 A.M. the Director of Nursing (DON) said:-The BOM set up the vision services at the facility.-The BOM would assist the resident in putting them on the correct insurance to be able to be seen by the eye doctor that came to the building.-Once the resident was on the correct insurance, they could be placed on the list to be seen by the eye doctor when they next came to the facility.-The facility was given a list of the residents that were to be seen by the eye doctor and that list was given to each nursing station.-The nurses would then be responsible for ensuring that the residents were ready and taken to where the provider had set up in the facility.-Missing glasses would count as something emergent if the resident depended on them to see.-He/She was unsure what would need to be done for the resident if they could not see the eye doctor on the day that they came to the facility.-He/She thought the resident's glasses were taken home by a family member due to being broken prior to the DON working for the facility.-Care plans should be up to date and reflect the resident's current status to include vision needs.-He/She was unsure of when the resident last saw an eye doctor.

Based on observation, interview and record review, the facility staff failed to follow the facility policy and the resident's care plan by transferring one sampled resident, (Resident #1) without using two staff or using a gait belt, out of five sampled residents. The facility census was 54 residents. The Administrator was notified on 7/8/24 Past Non-Compliance which occurred on 6/23/24. An all nursing staff in-service was completed on resident transfers prior to start of the next shift. The deficiency was corrected 6/25/24. Review of the facility policy for Safe Lifting and Movements of Residents revised July 2017 showed: -The purpose of the policy was to protect the safety and well-being of staff and residents, and to promote quality care, using appropriate techniques and devices to lift and move residents. -The manual lifting of residents was to be eliminated whenever feasible. -The facility nursing staff along with the rehabilitation staff was to assess individual residents' needs for transfer assistance on an ongoing basis, documenting the residents' transferring and/or lifting needs in the residents' care plan. -All facility staff responsible for direct resident care was to have been trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 1. Review of Resident #1's facility Admission Record showed he/she was admitted on [DATE] with the following diagnose: -Alzheimer's disease-(a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception) -Muscle weakness. -Abnormal gait and mobility. -Repeated falls. Review of the resident's Nursing Care Plan revised on 3/26/24 showed: -He/she needed assistance from facility staff with Activities of Daily Living (ADLs) such as transferring. -He/she liked to go to bed after dinner. -Due to the resident's Alzheimer's disease and dementia, he/she had increased behaviors, becoming emotional and crying during the evening time. -The facility staff was to talk with the resident and hold his/her hand when he/she was emotional. -The facility staff was to use one to two staff to assist the resident with transfers. -The facility staff was to use a gait belt to transfer the resident. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 5/16/24 showed: -He/she was not cognitively intact and not interviewable. -He/she required partial to moderate assistance from facility staff to transfer from the chair to the bed. Review of the resident's Physician Order Sheet (POS) dated 5/20/24 showed the facility staff was to use a gait belt for transferring the resident. Observation of an un-timed video taken via a camera placed in the resident's room and provided by the resident's family dated 6/23/24 showed: -Certified Nursing Assistant (CNA) A wheeled the resident into the resident's room via wheelchair. -The resident was flailing his/her arms and appeared to be yelling. -The resident picked up what appeared to be a stuffed animal and threw it at CNA A. -CNA A prepared the bed for the resident and locked the wheelchair. -CNA A then took the resident under his/her arms and transferred him/her into the bed without using a gait belt or obtaining assistance from another staff member, causing the resident to fall onto the bed. -CNA A then placed the resident's legs into the bed and covered him/her up with a blanket. -CNA A turned off the lights and the resident calmed down. During an interview on 7/8/24 at 12:14 P.M., CNA A said: -He/she came on the shift and immediately needed to get the resident to his/her room and into bed so he/she could calm down. -He/she asked around for help, but everyone was busy. -He/she knew the resident was a two-person transfer as well as that a gait belt was required for the resident's transfer. -He/she did not have a gait belt and the resident was so upset he/she just wanted to get him/her into bed. -The resident had spit on him/her earlier as well as thrown water in his/her face so knew the resident calmed down once he/she got into bed. -He/she just did what he/she had to do to get the resident calmed down. -The resident was not hurt, and he/she meant no harm. During an interview on 7/8/24 at 12:30 P.M., Licensed Practical Nurse (LPN) A said: -If the resident became agitated, he/she calmed down once he/she was placed into bed. -CNA A should have obtained assistance and used a gait belt to transfer the resident into the bed. -If CNA A was having issues obtaining help for the transfer, he/she should have waited to transfer the resident. -He/she did not recall CNA A asking him/her for assistance. Observation of Resident #1 on 7/8/24 at 12:45 P.M., showed: -The resident was in his/her wheelchair in the dining room. -When asked how he/she was and if he/she was doing okay, he/she just smiled. -When asked if he/she had issues with any staff or had been injured during a transfer, he/she just smiled. During an interview on 7/8/24 at 1:00 P.M., the Director of Nursing (DON) said: -He/she would have expected CNA A to follow the physician's order and the nursing care plan and obtain assistance with the resident's transfer from the wheelchair to the bed. -He/she would have expected CNA A to have used a gait belt to transfer the resident. During an interview on 7/8/24 at 1:10 P.M., the facility Administrator said: -He/she would have expected the CNA to have a gait belt available prior to his/her shift began. -He/she would have expected CNA A to both obtain assistance for the resident's transfer and use the gait belt during the transfer. -He/she would have expected the CNA to not complete the transfer until he/she had assistance and a gait belt. MO00238041

Based on interview, and record review, the facility failed to ensure three sampled residents (Resident #1, Resident #3, and Resident #4) were treated with dignity and self-determination related to their bathing/showering preferences out of five sampled residents. The facility census was 62 residents. Review of the facility's undated policy titled Bathing Policy showed: -It was the responsibility of the licensed nurse and/or nursing assistants to ensure baths/showers were completed. -Residents would receive a whirlpool bath, shower, or bed bath at least weekly and pro re nata (PRN- as needed). -Nursing would update bathing schedule as needed. 1. Review of Resident #1's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Rheumatoid Arthritis (Arthritis- swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age) (a chronic inflammatory disorder usually affecting small joints in the hand and feet). -Pressure Ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure to the skin) of Right Hip, Unstageable. -Generalized Muscle Weakness. -Pain in Right Hip. -Mild Cognitive Impairment (a condition in which people have more memory of thinking problems than other people their age). -Contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity in the joints), Left Shoulder. -Contracture, Left Elbow. -Contracture, Left Wrist. -Low Back Pain. Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/7/24 showed: -The resident was cognitively intact. -In the section functional abilities and goals, the resident was marked as not applicable related to shower/bathe self (the ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair), this did not include transferring in/out of tub/shower. -The MDS did not include preferences for customary routine and activities. Review of the resident's Care Plan dated 4/23/24 showed: -The resident had a stage IV pressure ulcer (a wound with full thickness skin loss extending through the fascia with considerable tissue loss) which was acquired on 4/7/23. -The resident had and Activities of Daily Living (ADLs) functional status/rehabilitation potential with the following interventions: --To talk with the resident and explain what he/she could do to assist with ADL/hygiene tasks and allow the resident to do what he/she could do what he/she could do to care himself/herself. --He/She preferred whirlpool baths and for the staff to wash his/her hair while being bathed. --He/She would only receive bed baths when the wound care company put a specific dressing on the resident. NOTE: The care plan does not address staff preferences or times for bathing needs. During an interview on 5/6/24 at 11:15 A.M. the resident said: -He/she pointed to his/her hair and called it greasy. -He/She received a bath once a week. -He/She had a wound which made getting a whirlpool bath difficult. -He/She could not remember when his/her last bath was. During an interview on 5/6/24 at 2:47 P.M. the resident said: -It depended on who was working whether or not he/she received a bath on his/her normal bath day. -Some of the staff don't do his/her bath to his/her liking. -He/She did not always feel clean after getting bathed by staff. -He/She felt uncomfortable when he/she did not feel clean after a bath. -He/She had told management that there were certain staff members that he/she had not wanted to receive baths from. -He/She was teary-eyed near the end of the interview. During an interview on 5/6/24 at approximately 3:15 P.M. Certified Nurses Aide (CNA) C said: -He/She was the assigned aide for the resident that shift. -He/She was unsure of any bathing preferences for the resident. During an interview on 5/6/24 at 3:26 P.M. Licensed Practical Nurse (LPN) C said: -The resident did not like for male staff to do his/her baths. -The resident did not like for his/her baths to be done in the evening. -The resident normally received bed baths due to his/her wound. -A shower would be the most appropriate type of bath for the resident. During an interview on 5/6/24 at 3:32 P.M. the Director of Nursing (DON) said: -The resident received a lot of bed baths but could receive different forms of baths. -The resident had a wound that made it difficult for Resident #1 to get up and around. -The resident refused baths frequently. -The resident was very particular in when he/she received a bath. -When the resident refused a bath, then he/she would normally reproach the resident at a later time. -He/She had not received any complaints from the resident related to staff bathing preferences. 2. Review of Resident #3's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration. Confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and restricted oxygen to the brain). Review of the resident's Quarterly MDS dated [DATE] showed: -The resident was cognitively intact. -The resident needed partial/moderate assistance (helper does less than half the effort) related to showering/bathing self. -The MDS did not include preferences for customary routine and activities. Review of the resident's Care Plan dated 3/15/24 showed: -The resident had ADL functional status/rehabilitation potential with the following interventions: --Encourage the resident to wash his/her upper body parts within reach with a prepared washcloth. --He/She preferred a whirlpool bath and to wash his/her hair when bathing. --Talk with the resident and explain what he/she could do to assist with the ADL task. During an interview on 5/6/24 at 12:49 P.M. the resident said: -He/She received a bath about once a week. -He/She never got bathed more than once a week. -It was his/her preference to be bathed more than once a week. During an interview on 5/6/24 at 2:59 P.M. the resident said it was tough to only get one shower a week because he/she was used to showering every day prior to being a resident at the facility. 3. Review of Resident #4's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Chronic Obstructive Pulmonary Disorder (COPD- a disease process that decreases the ability of the lungs to perform ventilation). -Other Chronic Pain. -Generalized Muscle Weakness. -Problem Related to Life Management Difficulty. -Unspecified Osteoarthritis (OA-a type of arthritis that that occurs when flexible tissue at the ends of bones wears down). Review of the resident's Care Plan dated 3/26/24 showed: -The resident required assistance with ADL/hygiene tasks with the following interventions: --He/She preferred a whirlpool bath and to wash his/her hair when bathing. --Talk with the resident and explain what he/she could do to assist with the ADL tasks. --Allow him/her to do what he/she could do for themselves so he/she could maintain his/her highest level of functioning. Review of the resident's Quarterly MDS dated [DATE] showed: -The resident was cognitively intact. -The resident needed partial/moderate assistance (helper does less than half the effort) related to showering/bathing self. -The MDS did not include preferences for customary routine and activities. During an interview on 5/6/24 at 12:54 P.M. the resident said: -He/She received a bath once a week. -His/Her last bath was on 4/29/24. -He/She preferred to be bathed more than once a week especially in the summertime when he/she sweated more often. During an interview on 5/6/24 at 2:56 P.M. the resident said: -Only receiving one bath a week made him/her feel icky and embarrassed. -He/She thought that there were not enough staff to receive more than one bath a week. 4. During an interview on 5/6/24 at 12:20 P.M. Certified Occupational Therapist Assistant (COTA) A said that he/she had helped with bathing residents in the past as part of his/her therapy services. During an interview on 5/6/24 at 1:28 P.M. CNA A said: -He/She did not normally do resident baths. -The facility had bath aides that would give residents baths. -He/She had received complaints from residents related to missing the dates they were supposed to be bathed/showered on. -The facility policy was for the residents were to be bathed two times a week. -He/She was unsure of any bathing preferences of the residents he/she normally took care of. -The facility had recently hired a new bath aide, but he/she thought they had not started yet. During an interview on 5/6/24 at 1:37 P.M. LPN A said: -The facility had designated aides to do resident baths. -Residents were to receive two baths a week. -He/She thought that most residents received baths two times a week. -He/She had not received any complaints from residents related to bathing or not following preferences. During an interview on 5/6/24 at 1:43 P.M. the Staffing Coordinator said: -When he/she made the schedule he/she put bath aides on the schedule. -He/She had to frequently pull the bath aide to work as a regular aide for the residents. -Not all residents were bathed/showered two times a week. -The facility had recently hired a new bath aide, but they had not started yet. During an interview on 5/6/24 at 2:11 P.M. CNA B said: -He/She normally worked on the memory care (special care) unit. -He/She was not responsible for bathing residents. -If staffing allowed, then he/she would do the baths on the unit. During an interview on 5/6/24 at 3:26 P.M. LPN C said: -The CNAs were responsible for completing resident baths. -There were usually assigned aides to do resident baths. -He/She had not received any complaints from residents related to bathing. During an interview on 5/6/24 at 3:32 P.M. the DON said: -The facility had a bath aide until the end of the previous week. -The Administrator kept track of resident bathing. -The residents were to receive two baths a week, but normally only received one bath a week. -Bathing preferences should be on resident care plans. -The MDS Coordinator was responsible for the care plans, but was not at the facility at that time. -He/She had not received any complaints related to bathing from Resident #1, Resident #3 or Resident #4. -To his/her knowledge the facility was following Resident #1's, Resident #3's, and Resident #4's bathing preferences. During an interview on 5/6/24 at 3:47 P.M. the Administrator said: -Residents received baths once a week, which was facility policy. -There were some residents who asked for PRN baths. -When residents asked for PRN baths or to be bathed more frequently, the facility did their best to accommodate bathing preferences, but could not always guarantee the preference would be followed. -Resident bathing preferences should be care planned. MO00234673

Based on interview and record review, the facility failed to have a process in place to ensure Cardiopulmonary Resuscitation (CPR- an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who was in cardiac arrest) certified staff were available on all shifts. The facility census was 47 residents. Review of facility's undated policy Cardiopulmonary Resuscitation (CPR) showed: -It was the policy of this facility to provide Basic Life Support (BLS), including CPR, when a resident required such emergency care, prior to arrival of emergency medical services, subject to the physician order and residents choices indicated in the residents advance directive (documents that allow one to communicate their health care preferences when decision-making capacity is lost). -Nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association (AHA). -CPR certified staff would be available at all times. -CPR certified staff members would maintain current CPR certification for healthcare providers including hands-on skill practice and in person assessments and demonstration of skills. -Prompt imitation of CPR was essential as brain death would begin in four to six minutes following cardiac arrest if CPR was not initiated within that time. -Only current BLS/ACLS (Advanced Cardiac Life Support) certified personnel would provide basic life support, including CPR, to a resident who required such emergency care prior to arrival of emergency medical personnel. -CPR certified staff would be available at all times. 1. Review of the facility's list of CPR certified staff showed there were 20 CPR certified employed in the facility. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. During an interview on [DATE] at 8:25 A.M., Certified Nursing Assistant (CNA) A said: -All CNA's and nurses were supposed to be CPR certified. -He/she was CPR certified. -The schedule did not designate who was CPR certified. During an interview on [DATE] at 8:28 A.M., Licensed Practical Nurse (LPN) A said: -He/she was CPR certified. -He/she thought all staff were CPR certified. -The staffing sheets did not designate who was CPR certified. During an interview [DATE] at 8:30 A.M., Registered Nurse (RN) A said: -He/she was CPR certified. -Not all staff were CPR certified at the facility. -All licensed nurses were supposed to be CPR certified. -There was nothing on the staffing schedule that listed who was CPR certified. -He/she thought it was policy is that all licensed personnel were supposed to be CPR certified so no official list was used. -When he/she used to do the scheduling he/she went by the facility policy. During an interview on [DATE] at 8:36 A.M., Laundry Assistant (LA) A said: -If a resident was found non-responsive he/she would check on the resident and if the resident was not breathing he/she would contact the nurse, or find a phone and use the intercom to call for help. -He/she had no idea of who is CPR certified in the building. -He/she assumed all nurses were CPR certified. -There was nothing on the staffing schedule that denoted who was CPR certified. -He/she did not look at the staffing schedule. During an interview on [DATE] at 8:48 A.M., CNA B said: -When a resident was found unresponsive he/she would yell out of for help. -He/She was CPR certified but would call for the nurse and start CPR. -All nurses should be CPR certified. -There was nothing on the schedule that denoted who was CPR certified. During an interview on [DATE] at 8:50 A.M., CNA C said: -When a resident was found unresponsive he/she would check the residents pulse and see if resident is breathing and if not he/she would start CPR. -He/she was CPR certified. -There was nothing on the schedule that denoted who was CPR certified. -He/she assumed all nurses were CPR certified. -He/she was an agency employee and had to CPR certified to work. During an interview on [DATE] at 11:32 A.M., Director of Nursing (DON) said: -He/she started doing the staffing as of this week. -It was his/her expectation that all nurses and CNA's were CPR certified. -There was nothing on the schedule that designated who was CPR certified. -There was currently no list of staff that were CPR certified and when the certification expires.

Based on observation, interview, and record review, the facility failed to follow physician orders for applying Sequential Compression Devices (SCD- sleeves with separated areas or pockets of inflation, which works to squeeze on the appendage in milking action) for one sampled resident (Resident #44) out of 12 sampled residents. The facility census was 47 residents. A policy for SCD use was requested and not received at the time of exit. 1. Review of Resident #44's Face Sheet showed he/she was admitted to the facility on [DATE] with following diagnoses: -Lymphedema (swelling in the arms or legs caused by lymphatic system blockage). -Chronic pain. Review of the residents Annual Minimum Data Set (MDS-a federally mandated assessment completed by the facility staff for care planning) dated 8/2/23 showed: -He/she was cognitively intact. -He/she needed total two person assist with transfers. -He/she had frequent pain. Review of the resident's care plan dated 8/7/23 showed staff were to ensure that SCD's are applied as physician ordered for his/her lymphedema. Review of the resident's electronic medical record Order Summary Report dated 9/2023 showed sesquential compression of bilateral (both legs) lower extremities daily nursing to apply one hour between lunch and supper in the afternoon. Order start date 5/15/23. Review of the residents Treatment Administration Record (TAR) dated 9/2023 showed SCD's to be applied daily for one hour at 2:00 P.M., for lymphedema. During an interview on 9/25/23 at 1:01 P.M., the resident said: -SCD's were brought in his/her room a while ago and have sat right there on the floor. He/she had not ever used them. -His/her legs had sometimes wept fluid and hurt. Observation on 9/25/23 at 1:01 P.M., showed: -His/her lower SCD leg sleeves were rolled up on the floor. -His/her SCD machine had electric cord rolled up and not connected to the electric outlet. -His/her lower legs were swollen. No redness or weeping. Observation on 9/26/23 at 2:31 P.M., showed: -SCD's boots on floor, one sleeve caught under the bed leg. -SCD not plugged in and electric cord rolled up. During an interview on 9/26/23 at 2:31 P.M., the resident said staff had not applied SCD's yesterday and that they had never been used. During an interview on 9/27/23 at 7:30 A.M., the resident said staff had not applied SCD's yesterday. Observation on 9/27/23 at 7:30 A.M., showed; -SCD's boots on floor, one sleeve caught under the bed leg. -SCD not plugged in and electric cord rolled up. Observation on 9/28/23 at 9:07 A.M., showed: -SCD's boots on floor, one sleeve caught under the bed leg. -SCD not plugged in and electric cord rolled up. During an interview on 9/28/23 at 9:07 A.M., the resident said the SCD's had not been applied yesterday. They have never been used on him/her. During an interview on 9/28/23 at 8:48 A.M., Certified Nursing Assistant (CNA) C said: -He/she would report increased leg swelling to the charge nurse. -He/she would encourage residents to elevate legs if swollen. -He/she would apply compression hose if it was ordered by the physician. -He/she did not know anything about SCD's as the nurses do that for the resident. During an interview on 9/28/23 at 8:53 A.M., License Practical Nurse (LPN) A said: -He/she would elevate the resident's legs if swollen and notify the physician if swelling is new and ask for compression stockings and labs (blood tests). -He/she was aware of the SCD orders or the resident and applied them shortly after lunch for an hour. The resident tolerated the SCD's and has not refused to have them applied and documented in the resident's Treatment Administration Record (TAR). During an interview on 9/28/23 at 11:23 A.M., Director of Nursing (DON) said: -He/she would expect physician orders to be followed and documented in the resident TAR. -He/she was not aware that the resident was not getting his/her SCD's applied.

Based on observation, interview, and record review, the facility failed to ensure accurate documentation and reconciliation of narcotic pain medications for two sampled residents (Resident #35 and #38); and to notify the physician of unavailable pain medication in a timely manner for one sampled resident (Resident #38) out of 12 sampled residents. The facility census was 47 residents. Review of the facility's undated Oral Medication Administration policy showed: -Review the five rights of medication administration including the right drug name, right drug dose, and right time. -Check narcotic record for previous drug count and compare with supply available. -Compare Medication Administration Record (MAR) with prepared drug label/container. -Record administration of oral medication on MAR by placing nurse's initials or signature. Review of the facility's Controlled Substances policy updated 11/14 showed: -Separate records are maintained for controlled drugs. -When a Class Il drug (controlled substance - narcotic) is administered, record of that administration must be recorded on a proof of use form (Controlled Substances Medication Record). -The following information is documented by the individual administering the drug; date, amount, and signature of nurse. -Controlled drugs are destroyed in the presence of two licensed staff members. The following information is documented when a drug is destroyed: date, name of drug, and amount destroyed. 1. Review of Resident #35's Face Sheet showed he/she was admitted to the facility on [DATE] with the a diagnosis of Peripheral Neuropathy (damage to the nerves in the extremities). Review of the resident's July 2023 physician's Order Recap Report showed: -Tramadol (a narcotic pain medication) 50 milligrams (mg) one tablet by mouth every four hours for comfort measures dated 7/24/23 and discontinued on 7/25/23. -Tramadol 50 mg one tablet by mouth every four hours for pain dated 7/25/23 and discontinued on 7/31/23. -Hydrocodone-Acetaminophen (Norco - a narcotic pain medication) 5-325 mg one tablet by mouth every six hours as needed for pain dated 7/31/23 and discontinued on 8/8/23. Review of the facility's Emergency Medication Kit access the resident in July 2023 showed: -Tramadol 50 mg removed five times. -Hydrocodone-Acetaminophen 5-325 mg removed two times. Review of the resident's Medication Administration Record (MAR) dated July 2023 showed: -Tramadol 50 mg one tablet by mouth every four hours for pain dated 7/25/23 and discontinued on 7/31/23 documented as administered three times. --Two doses of Tramadol 50 mg removed from the emergency kit were not accounted for. -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 7/31/23 documented as administered one time. --One dose of Hydrocodone-Acetaminophen 5-325 mg removed from the emergency kit was not accounted for. Review of the resident's August 2023 physician's Order Recap Report showed: -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 7/31/23 and discontinued on 8/8/23. -Hydrocodone-Acetaminophen 5-325 mg two tablets by mouth every six hours as needed for pain dated 8/8/23 and discontinued on 8/8/23. -Hydrocodone-Acetaminophen 10-325 mg one tablet by mouth every six hours as needed for pain dated 8/8/23 and discontinued on 8/9/23. -Hydrocodone-Acetaminophen 10-325 mg 0.5 tablets by mouth every six hours as needed for pain dated 8/9/23. -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 8/17/23. Review of the facility's Emergency Medication Kit access the resident in August 2023 showed Hydrocodone-Acetaminophen 5-325 mg removed three times. Review of the resident's Individual Patient Narcotic Record for Hydrocodone 5/325 mg received on 8/5/23 showed: -41 tablets were removed from the narcotic card. -Two tablets were removed on 8/8/23 at 5:50 P.M. -On 8/12/23 one tablet was removed at 3:30 A.M., one was removed at 7:00 A.M. and one was removed at 11:00 A.M. These were less than every six hours per the physician's orders. --NOTE: This order was discontinued on 8/8/23. -On 8/13/23 one tablet was removed at 1:00 A.M. and one tablet was removed at 6:00 A.M. This was less than every six hours per the physician's orders. --NOTE: This order was discontinued on 8/8/23. -On 8/22/23 one tablet was removed at 5:15 A.M. and one tablet was removed at 8:00 A.M. This was less than every six hours per the physician's orders. --NOTE: This order was discontinued by the resident's physician on 8/8/23 and restarted on 8/17/23. Eight tablets of Hydrocodone 5-325 mg were removed from the narcotic card without a valid physician's order. Review of the resident's Controlled Substances Medication Record for Hydrocodone 10-325 mg received on 8/8/23 showed: -Directions for use: take one tablet every six hours for pain. -An undated hand-written note at the top of the page: New order - only give 0.5 tab. -One tablet was documented as removed four times. --NOTE: The order for one tablet was discontinued on 8/9/23. Three doses were documented as one tablet removed without a valid physician's order. -Eight tablets were documented as removed, cut by staff with a second staff person signing as witnessing the waste of 0.5 tablets. Review of the resident's August 2023 MAR showed: -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 7/31/23 and discontinued on 8/8/23 administered seven times. -Hydrocodone-Acetaminophen 5-325 mg two tablets by mouth every six hours as needed for pain dated 8/8/23 and discontinued on 8/8/23. No documentation any doses were administered. -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 8/17/23 administered 11 times. --NOTE: 18 tablets out of the 41 tablets removed from the narcotic card were documented as administered to the resident with 23 tablets unaccounted for. -Hydrocodone-Acetaminophen 10-325 mg one tablet by mouth every six hours as needed for pain dated 8/8/23 and discontinued on 8/9/23 documented as administered to the resident two times. -Hydrocodone-Acetaminophen 10-325 mg 0.5 tablets by mouth every six hours as needed for pain dated 8/9/23 documented as administered to the resident 12 times. --NOTE: Eight 0.5 tablets and four whole tablets were documented as removed from the Narcotic Card. Review of the resident's September 2023 physician's Order Recap Report showed: -Hydrocodone-Acetaminophen 10-325 mg 0.5 tablets by mouth every six hours as needed for pain dated 8/9/23. -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 8/17/23 and discontinued on 9/26/23. -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 9/26/23 with orders to discontinue when Oxycodone is received from the pharmacy. Review of the resident's Individual Patient Narcotic Record for Hydrocodone 5/325 mg received on 8/5/23 showed: -19 tablets were removed from the narcotic card with the last dose removed on 9/15/23. Review of the resident's Individual Patient Narcotic Record for Hydrocodone 5/325 mg received on 8/17/23 showed 18 tablets were removed from the narcotic card in September 2023. Review of the resident's Controlled Substances Medication Record for Hydrocodone 10-325 mg received on 8/8/23 showed: -Directions for use: take one tablet every six hours for pain. -An undated hand-written note at the top of the page: New order - only give 0.5 tab. -One tablet was documented as removed five times. --NOTE: The order for one tablet was discontinued on 8/9/23. Five doses were documented as one tablet removed without a valid physician's order. Review of the resident's September 2023 MAR showed: -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 8/17/23 administered 30 times. --NOTE: A total of 35 tablets were removed from the resident's narcotic cards. Five tablets are unaccounted for. -Hydrocodone-Acetaminophen 10-325 mg 0.5 tablets by mouth every six hours as needed for pain dated 8/9/23 administered six times. --NOTE: Five whole tablets were documented as removed from the Narcotic Card. Observation and interview on 9/28/23 at 8:27 A.M. with Licensed Practical Nurse (LPN) B showed: -The resident had narcotic cards for Hydrocodone-Acetaminophen 5-325 mg and for Hydrocodone-Acetaminophen 10-325 mg. -The cards of Hydrocodone-Acetaminophen 10-325 mg included whole tablets. -The resident had Controlled Substances Medication Records for each narcotic card. -The Controlled Substance Medication Record for Hydrocodone-Acetaminophen 10-325 mg include a handwritten note to only give 0.5 tabs. -LPN B said: -Staff cut the Hydrocodone-Acetaminophen 10-325 mg in half to administer to the resident. -The resident's Hydrocodone-Acetaminophen 10-325 mg order was originally for one tablet then the physician changed the order. -Staff did not return or destroy the whole Hydrocodone-Acetaminophen 10-325 mg medication cards and instead would just cut each tab in half and destroy the other half tab with a second staff person. -Staff should document medication administration correctly on the resident's MAR. -If staff remove a Hydrocodone-Acetaminophen 10-325 mg half tablet, it should be documented on the Hydrocodone-Acetaminophen 10-325 mg half tablet entry on the resident's MAR. -He/She wasted half a tablet of the Hydrocodone-Acetaminophen 10-325 mg when he/she removed it, but acknowledged the narcotic card did not show the tablet was wasted. -When staff do not show the additional half tab was wasted, it would appear a whole tab was administered. -The resident's MAR and narcotic count log should match. During an interview on 9/28/23 at 8:45 A.M., Registered Nurse (RN) A said: -Staff can cut the Hydrocodone-Acetaminophen 10-325 mg tablet in half to administer to the resident. -If staff cut the Hydrocodone-Acetaminophen 10-325 mg in half and waste half the tablet, two staff should sign the wasted amount. -The MAR and narcotic count sheets should match. -If a dose was removed from the narcotic log, it should be documented on the correct dose on the MAR. During an interview on 9/28/23 at 11:26 A.M., the Director of Nursing (DON) and Assistant Administrator said: -Staff should not cut medications in half to obtain the correct dose, it should come from pharmacy already cut. -The narcotic log and MAR should match. -If a narcotic is removed from the narcotic count sheet, it should be documented under the correct dose on the MAR. -At this time no one was auditing the narcotic count sheets to ensure they matched the resident's MAR. 46890 2. Review of the facility's undated policy Change of Condition Protocol showed the resident's physician to be notified of a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Review of Resident #38's Face Sheet he/she was admitted on [DATE] with the a diagnosis of low back pain. Review of the resident's electronic medical record admission orders dated 9/5/23 showed Norco (a narcotic pain medication) 7.5-325 mg one by mouth every 4 hours as needed for pain. Review of the resident's electronic MAR for 9/5/23 thru 9/9/23 showed he/she did not receive Norco 7.5-325 mg as needed every four hours for pain. Record review of the resident's progress notes dated 9/9/23 showed: -Staff notified his/her physician of unavailability of the residents Norco 7.5-325 mg. --NOTE: Staff had not notified the resident's physician of not having the ordered as needed pain medication Norco 7.5-325 mg until five days after his/her admission to the facility. -Norco 7.5-325 mg was discontinued by the physician and an available Norco 5-325 mg in the facility emergency kit was ordered by the physician for one by mouth every 6 hours as needed for pain. Review of the resident's Admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 9/11/23 showed: -He/she was cognitively intact. -He/she had pain present and frequently in pain. -He/she was on a scheduled pain medication. Review of the resident's pain care plan initiated on 9/14/23 showed: -He/she received pain medication. -He/she would state relief of breakthrough pain with use of as needed pain medications or non-pharmaco logical interventions. -Staff would administer his/her as needed pain medication as ordered by physician. -Staff would monitor effectiveness of his/her pain interventions and notify his/her physician if not effective. Review of the resident's electronic medical record on 9/23/23 showed: -The physician had discontinued his/her order for Norco 5-325 mg one every 6 hours as needed for pain. -The physician had ordered Norco 7.5-325 mg one tablet every 6 hours as needed for pain. Review of the resident's Individual Patient Narcotic Record for Norco 7.5-325 received on 9/23/23 showed: -Eight tabs removed from the narcotic card. -On 9/23/23 one dose removed at 8:00 A.M. -On 9/23/23 one dose removed at 8:30 P.M. -On 9/24/23 one dose removed at 10:00 A.M. -On 9/25/23 one dose removed at 3:00 A.M. -On 9/25/23 one dose removed at 5:20 P.M. -On 9/26/23 one dose removed at 7:00 A.M. -On 9/26/23 one dose removed at 10:30 P.M. Review of the resident's electronic MAR dated 9/2023 showed: -Norco 7.5-325mg one tablet every 6 hours as needed for pain. --One dose on 9/23/23 was not accounted for. --One dose on 9/24/23 was not accounted for. --One dose on 9/25/23 was not accounted for. During interview on 9/25/23 at 12:13 P.M., Resident #38 said: -It had taken the facility ten days to get him/her the correct dosage of pain medication that was ordered from the hospital. -He/She had only received Tylenol for the first five days of admission. -He/She had requested the stronger pain medication numerous times and staff had told him it had not arrived from the pharmacy and were waiting on a prescription to be signed. During an interview on 9/28/23 at 8:53 A.M., Licensed Practical Nurse (LPN)A said: -He/she would check the electronic MAR for current as needed pain medications and sign it out in the residents MAR and on the resident's narcotic count sheet. -He/she would notify the resident's physician immediately if an as needed pain medication is not available to get new orders for a pain medication that is available in the facility emergency kit. During an interview on 9/28/23 at 11:23 A.M., Director of Nursing (DON) said: -He/she would expect resident narcotic count sheets match the residents electronic MAR. The nurses should be signing the narcotic count sheet and the electronic MAR when administering a narcotic medication. -He/she is responsible for auditing the narcotic counts. He/she has been auditing the narcotic count sheets but not the electronic MAR. -He/she would expect nursing to contact the pharmacy and physician immediately if a narcotic medication is not available. -He/She would not expect nursing to wait five days to contact the physician for unavailable medication.

Based on observation, interview and record review, the facility failed to follow infection control protocol for cross-contamination with the placement of the resident's urinary catheter drainage bag (a bag that collects urine that is attached to a tube that is inside the bladder) for one sampled resident (Resident #38) out of 12 sampled residents. The facility census was 47 residents. Review of the facility's undated Infection Control and Safe Practice Policy showed the facility will apply standard precautions practices at all times, to as far as possible to prevent the transmission of infection. 1. Review of Resident #38's Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Obstructive and Reflux Uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). -Malignant Neoplasm of the Prostate (a disease in which cancer cells form in the tissues of the prostate). -Chronic Kidney Disease (a condition characterized by a gradual loss of kidney function over time. Review of the resident's electronic medical record Order Summary Report dated 9/23 showed: -Catheter care every shift; to dependent drain; check placement of leg strap (a device that secures catheter tubing to prevent pulling or tugging) every shift; ensure bag is stored in dignity bag off the floor. Review of the resident's Care Plan dated 9/8/23 showed: -He/she had an indwelling catheter. -He/she would not have urinary discomfort. -To ensure his/her urinary catheter drainage bag was secured in a privacy bag. Review of the resident's Admission Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff for care planning) dated 9/11/23 showed: -He/she was cognitively intact. -He/she needed extensive assist with activities of daily living. -He/she had an indwelling urinary catheter (a hollow tube inserted and left in the bladder to drain urine from the bladder into a bag outside his/her body). Observation on 9/26/23 at 9:40 A.M., 10:31 A.M., and 12:02 P.M. showed his/her urinary catheter bag was hanging off his/her walker touching the floor not covered with a dignity bag or barrier between the floor and the urinary catheter bag. During an interview on 9/28/23 at 8:48 A.M., Certified Nursing Assistant (CNA) C said: -He/she would place urinary catheter bag in a dignity bag and keep bag off of the floor. -He/she had catheter care education on Monday 9/11/23. During an interview on 9/28/23 at 8:53 A.M., Licensed Practical Nurse (LPN) A said he/she would make sure catheter bag is in a dignity bag and not on the floor. During interview on 9/28/23 at 11:23 A.M., Director of Nursing (DON) said: -He/she would expect urinary catheter bags be covered with a dignity bag and would not expect them to be on the floor. -He/she would be responsible to monitor facility infection control practices.

Based on observation, interview, and record review, the facility failed to meet the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility. The facility staff also failed to wash or sanitize hands between glove changes during suprapubic (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) care and ensure dignity bag (covering used to hold urine catheter bag out of sight) did not make contact with the floor for one resident (Resident #21) and use appropriate infection control procedures to prevent the possible spread of [CONDITION(S)] (C. diff - an infection which typically occurs after use of antibiotic medications that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon and is shed in feces) for one sampled resident with suspected C.Diff (Resident #48) out of 15 sampled residents. The facility census was 58 residents. 1. Record review of the facility's EP plan in a binder entitled Facility Disaster Manual, provided by the ESS from the main conference room and last reviewed on 2/16/22 showed a 4-page document entitled Water Management Program to Reduce the Risk of Legionella, under the tab Water Outage, that did not include the following CMS requirements for a waterborne pathogen program: -A facility-specific risk assessment that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard. -A completed Centers for Disease Control (CDC) toolkit assessment including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -A schematic or diagram of the facility's water system with a written explanation of the water flow throughout the facility. -A facility-specific infection prevention program or plan to deal with outbreaks of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing [CONDITION(S)] (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever.) and/or other waterborne pathogens. -A program and/or flowchart that identified and indicated specific potential risk areas of growth within the building with assessments of each individual area's potential risk level. -Testing protocols and acceptable ranges for control measures with a method of monitoring them specifically at this facility. -Facility-specific interventions or action plans for when control limits are not met. -Documentation of any site log book being maintained with any dated cleanings, sanitizings, descalings, and inspections mentioned. Record review on 4/7/22 at 11:17 A.M., of the facility's Emergency Preparedness (EP) plan in a binder entitled OSHA Plan - MSDS Plan - Disaster Preparedness obtained from the East Nurse Station and last reviewed on 2/16/22 showed an absence of a water-borne pathogen prevention program. Observations during the facility Life Safety Code (LSC) inspection with the Environmental Services Supervisor (ESS) on 4/8/22 between 10:04 A.M. and 2:21 P.M. showed the following: -There was a boiler room in the basement. -There was a plumbing backflow access. -There were two resident shower/bathtub rooms. -Each resident room had a private or shared bathroom. -There was an ice machine and a dehumidifier. During an interview on 4/8/22 at 11:09 A.M., the ESS said the following: -He/she knew the facility's water-borne pathogen prevention program was in their disaster manual under the Water Outage tab because he/she wrote it. -If there was not a copy in the disaster manual at the East Nurse Station now, there used to be. During an interview on 4/12/22 at 12:08 P.M., the Assistant Administrator said the ESS and the previous Maintenance Director put the facility's water-borne pathogen prevention program together and he/she believed they tried to go by government guidelines. 2. Record review of the facility policy Suprapubic Catheter Care, dated 11/21, showed: -Procedure steps included the following: --Check physician orders for catheter care. --Wash hands and change gloves. --May apply dressing as needed for drainage. Review of facility Use of Foley Catheter Policy, dated 11/21, showed: -All residents with foley catheters should be checked frequently for the following: --Drainage tubing should not be kinked, bent or touching the floor. --Urinary drainage bag should be securely fastened to the bed, off the floor. Record review of Resident #21's Face Sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). -Retention of urine (a condition in which you cannot empty all the urine from your bladder). Record review of the resident's Care Plan, dated 5/13/21, showed: -He/she had a supra pubic catheter (drains urine from your bladder. It is inserted into your bladder through a small hole in your belly). -Staff were to provide catheter care every shift and as needed per facility policy, dated 8/9/21. -Staff were to ensure the drainage bag was placed in a dignity bag when in bed, dated 8/9/21. Record review of the resident's Physician Order Report, dated 4/1/22 to 4/30/22, showed he/she had an order dated 10/17/21 for a supra pubic catheter care. Observation on 4/11/22 at 9:35 A.M., showed the resident: -Had a supra pubic catheter. -The catheter drainage bag was in a dignity bag under his/her wheelchair. Further observation showed the dignity bag was in contact with the floor. Observation on 4/11/22 at 1:44 P.M., showed the resident: -Was lying in bed. -The supra pubic catheter drainage bag was hanging from bed and was on the floor. During an interview on 4/12/22 at 5:28 A.M., Licensed Practical Nurse (LPN) D said: -Catheter care should be done every shift. -Drainage bags should be put in a dignity bag appropriately. -Drainage bags should be hung on the wheelchair or on the bed below the bladder. Observation on 4/12/22 at 12:29 P.M., of LPN A completing the resident's catheter care showed he/she: -Obtained supplies from treatment cart with bare hands. -Used scissors to cut the 4x4 gauze. -Gathered supplies from top of treatment cart with un-sanitized hands. -Obtained a towel in route to resident's room. -Placed the towel on the bedside table as a barrier. -An almost full package of gauze, wound cleanser, and partially used roll of tape were placed on the cloth barrier. -Obtained gloves, sanitized his/her hands, and applied clean gloves. -Removed the resident's dressing and discarded it into trash can. -Changed his/her gloves without washing or sanitizing his/her hands. -Obtained gauze from package and sprayed the gauze with wound cleanser. -LPN A wiped the insertion site and discarded used gauze in trash can. -With the same gloved hands, he/she obtained more gauze from the package, sprayed it with wound cleanser and wiped the insertion site and discarded gauze in trash. -Removed gloves, sanitized hands, and applied clean gloves. -LPN A obtained a marker from his/her pocket and marked the tape. -Cut gauze placed over insertion site, -Applied tape to the top portion of gauze. -Obtained second piece of tape from the roll and applied to the bottom side of gauze. -LPN A removed his/her gloves and discarded them in trash and did not wash his/her hands. -LPN A covered resident and raised the head of the bed. -Picked up supplies with un-sanitized hands. -Tucked supplies against body and sanitized his/her hands. -Placed all unused supplies back in treatment cart without being sanitized. During an interview on 4/12/22 at 12:30 P.M., LPN A said he/she would not have done anything differently. Observation on 4/13/22 at 8:30 A.M., of the resident showed: -He/she was sitting in his/her wheelchair in his/her room. -His/her drainage bag was hanging under his/her wheelchair. -His/her catheter tubing and drainage bag was on the floor. During an interview on 4/13/22 at 10:38 A.M., the Director of Nursing (DON) said: -He/She expected supra pubic catheter care to be done like any other catheter care. -He/she would expect them to introduce himself/herself to the resident, wash their hands prior to starting cares, put on clean gloves, complete the catheter care, remove gloves, and wash hands when finished. -Multi-use items should be wiped down to disinfect prior to returning to the treatment cart. 3. Review of the CDC's website for C. diff guidelines for healthcare professionals, dated 7/20/21, showed: -Healthcare workers should wear gloves and a gown when treating patients suspected of having C. diff, even during short visits. -Hand sanitizer does not kill C. diff. Record review of the facility's Infection Prevention and Control Manual, dated 2019, showed staff were instructed to: -Disinfect reusable equipment between resident uses with hospital grade disinfectant. -Disinfect equipment before removal from a room of a resident on Contact Precautions (precautions taken to prevent the spread of infectious agents which are spread by direct or non-direct contact with the resident or their environment). Record review of the facility's Infection Prevention and Control Manual Transmission-Based Precautions with the subset Procedure for Contact Precautions, dated 2019, showed staff were instructed to: -Don (put on) gloves upon entry to resident's room. -Don gown upon entry to resident's room. -Remove gown and gloves and perform hand hygiene before leaving the resident's care environment. -Clean and disinfect equipment used for multiple residents after use. Record review of Resident #48's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] {new} coronavirus] infection). Review of the resident's MDS, dated [DATE], showed the resident's was frequently incontinent of bowel. Record review of the resident's care plan, updated 4/7/22, showed potential for injury related to signs and symptoms of C. diff. Record review of the resident's laboratory requisition sheet showed a stool sample was collected for suspected C. diff testing 4/7/22 at 08:30 A.M. Observation of the resident's room on 4/7/22 at 10:21 A.M., showed: -No precautions noted on the resident's door. -No personal protective equipment (PPE- equipment worn to minimize exposure to a variety of hazards. Examples of PPE include such items as gloves, face masks or face shields, respirators, foot, and eye protection) near door or in his/her room. Observation on 4/8/22 at 9:03 A.M., showed: -The resident's door now had a stop sign attached to it which instructed anyone entering the room to check with the nurse first. -There was no PPE near the door or in his/her room. During an interview on 4/8/22 at 9:03 A.M., Registered Nurse (RN) A said: -The resident was now on contact precautions due to suspected C. diff. -He/she suspected C. diff due to the resident's recent use of antibiotics and three or more loose stools in a 24 hour period. Observation on 4/11/22 at 9:08 A.M., showed: -Stop sign indicating precautions remained on the resident's door. -No PPE was available nearby. During an interview on 4/11/22 at 9:08 A.M., LPN B said the resident's labs to determine if he/she had C. diff results were not back yet. Observation on 4/11/22 at 9:11 A.M. showed: -Certified Medication Technician (CMT) A and Certified Nurses Aide (CNA) D entered the resident's room with the sit to stand lift. -CMT A and CNA D put on gloves. Staff did not apply gowns. -CNA D lowered the resident's pants while he/she was standing. -CMT A removed the resident's pants once he/she was safely moved to his/her bed and verbalized the resident had been incontinent of stool. -CNA D cleaned stool from the resident's front side while CMT A assisted. -CMT A removed gloves, did not perform hand hygiene, and moved things in the resident's closet to find a new brief. -CMT A put on new gloves without performing hand hygiene. -CMT A held biohazard bag for CNA D to put fecal covered wipes in. -CMT A then placed new brief under resident with the same gloves. -CMT A removed his/her gloves, performed hand hygiene, then picked up biohazard bag and tied it closed. -CNA D removed the sit to stand lift from the resident's room and put it in the storage area. -At 9:32 A.M., when asked if they would have done anything differently both staff responded no. During an interview on 4/11/22 at 1:31 P.M., Nurse Aide (NA) A said: -Night shift was responsible for cleaning equipment. -C. diff precautions included wearing a gown, but the resident had been started on antibiotics so they were no longer required. During an interview on 4/11/22 at 1:50 P.M., LPN B said he/she had received the resident's lab results and the resident did not have C. diff. During an interview on 4/12/22 at 7:21 A.M., LPN C said: -Staff should clean equipment with bleach wipes between resident uses. -He/She would expect a dedicated stethoscope, gown, gloves, and goggles or a face shield for residents with transmission-based precautions. -He/She would not use gowns or goggles/face shield for a resident with C. diff as it was not needed. During an interview on 4/12/22 at 10:44 A.M., LPN B said: -Staff should clean the sit to stand lift with bleach wipes after every use. -Staff only needed gloves and good hand hygiene when working with suspected C. diff residents. During an interview on 4/13/22 at 8:29 A.M., RN A said: -Staff should clean the sit to stand lift with bleach wipes between resident uses. -C. diff precautions included wearing gloves and thorough hand washing, gowns and face shields were not required. During an interview on 4/13/22 at 10:39 A.M., the DON said: -Staff should clean the sit to stand lift immediately if soiled, otherwise weekly. -Staff should clean the lift with bleach wipes before it is removed from the room of a resident on contact precautions.

Based on observation, interview and record review, the facility staff failed to investigate and document an incident of unknown origin for one sampled resident (Resident #5) who was ambulatory without assistive devices, who reported to facility staff that he/she fell and his/her leg was no longer working, and staff continued to ambulate and transfer the resident until x-rays showed the resident had a hip fracture; to prevent an avoidable fall by failing to provide protective oversight and secure the physician's orders [REDACTED].#6), resulting in a fall with injury; and to ensure fall investigations were comprehensive to determine the cause of a fall for three (Resident #5, #6, and #8) out of 15 residents. The facility census was 88 residents. Record review of the facility's Fall Policy and Procedure revised August 2013, showed: -It's purpose was to provide a systematic follow-through of resident falls so that appropriate care after the fall is complete. -If the charge nurse determines the resident's need to go to the hospital, the resident will be consulted first, and then the resident's physician and family will be notified. -If all members involved agree the resident will be sent to the hospital, 911 will be called. -The staff will obtain vital signs for the resident as soon as possible after the fall and at least once a shift for 72 hours with assessment of the resident. -Neurological checks (neurochecks; neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs) will be done on any resident with head injury or a non-witnessed fall for 72 hours. (every 15 minutes for four times, every 30 minutes two times, every one hour two times and then every shift). -Staff shall complete an incident report and a fall investigation report. -Staff will make sure to do a complete report in the resident's nurse's notes. -The Fall Committee will review all falls weekly. -Fall assessments are done on admission and quarterly. -The resident's care plan will be updated with each fall incident. -The resident's care plan intervention related to falls, will be stated on the fall investigation form. -Therapy will screen all residents after their falls. Record review of the facility's Investigation Policy and Procedure for Unusual Events dated July 2011, showed: -Staff or residents shall report an unknown event; and staff will investigate the potential incident. -The purpose is to provide a systematic follow-through of resident potential incident so that appropriate care is complete. -Staff or residents shall report unusual events/complaints to the charge nurse. The charge nurse shall assess the resident. -Staff will notify the Director of Nursing (DON), the resident's physician and family members of the potential incident. -The staff member shall monitor the resident for any abnormal activity or behaviors. -If the resident has any abnormal activity or behaviors report to the resident's physician. -The staff shall follow any new physician orders [REDACTED]. 1a. Record review of Resident #5's Face Sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff for care planning dated 7/15/14, showed he/she: -Was confused with short and long-term memory loss. -Did not need any assistance for transfers, ambulation, toileting and only needed minimal assistance with dressing. -Did not have a history of falling and had no falls since admission. -Had no range of motion deficits in his/her upper or lower extremities. Record review of the resident's Fall Risk Evaluation dated 7/2/14, showed he/she scored an 8 (a total score of 10 or more represented high risk for falls). Record review of the resident's physician's orders [REDACTED]. Record review of the resident's Nursing Notes showed: -On 9/3/14 on the 10:00 P.M. to 6:00 A.M. shift, nursing documented the nursing staff called the nurse to the resident's room because the resident complained of his/her leg not working. He/she said, "don't you know (I have) had three falls in one day." Nursing staff reported no falls and no bruising (on the resident). The resident's legs were bending and moving. Nursing staff placed a gait belt on the resident and assisted him/her to his/her bed without difficulty. The resident was using the call light as a telephone (placing it to his/her ear). -On 9/3/14 at 8:00 A.M., the resident had increased confusion and would not walk. He/she was able to move all of his/her extremities without difficulty. There were no signs or symptoms of a fall, and no redness or bruising was noted. The resident fed himself/herself, was incontinent of urine and his/her urine had a strong odor and was amber colored. He/she was very weak. Nursing staff encouraged fluids, notified the resident's physician, and received a physician's orders [REDACTED]. The resident's vital signs were also taken. -On 9/3/14 at 10:00 A.M., the lab obtained a urine sample from the resident for urinalysis testing. -On 9/3/14 at 1:00 P.M. nursing called the resident's physician office because the resident was not walking (when the resident was independently ambulating) and had increased confusion. They were unable to reach the physician but his/her office staff asked the nurse to fax in the information regarding the resident. -On 9/3/14 at 3:30 P.M., the resident was sleepy, his/her vital signs were taken, and he/she had an elevated temperature of 99.2. Nursing staff gave the resident Tylenol for his/her elevated temperature. -On 9/3/14 during the evening, the resident's temperature was 99.8. -On 9/3/14 at 9:30 P.M., the resident's temperature was 99.8 and nursing staff gave him/her Tylenol. -On 9/3/14 at 9:40 P.M., the nurse documented the resident was sleepy during this shift and did not eat supper. He/she was transferred with two persons assisting him/her without difficulty (the note did not state staff transferred the resident with a mechanical lift). -On 9/3/14 at 9:45 P.M., the nursing staff had not received a fax from the resident's physician. -Nursing Notes on 9/3/14 did not show any further action taken by the nursing staff to notify the resident's physician or a physician on call in his/her absence. The notes did not show the nursing staff began neurological checks on the resident. Record review of the resident's Nursing Notes dated 9/4/14, showed: -At 12:00 A.M. the resident's vital signs were taken, his/her temperature was 97.0, and he/she had no complaint when he/she was taken to the bathroom at the start of this shift. -At 9:00 A.M., the resident's vital signs were blood pressure 133/69, pulse 81, and temperature 97.8. The resident was very weak and needed assistance with his/her ambulation. Nursing staff received a new physician's orders [REDACTED]. -At 12:30 P.M., nursing staff faxed the resident's physician concerning the resident being non-ambulatory when he/she had been ambulating independently, and that the urinalysis results did not show anything abnormal. Nursing staff asked if they needed to get additional labs. -At 1:30 P.M., the nursing staff received a new physician's orders [REDACTED]. hip and leg since the resident was unable to bear any weight. -At 5:00 P.M., the mobile x-ray vendor came to the facility to complete the x-ray on the resident's hip and leg. -At 6:05 P.M., the results of the x-ray showed a suspected an impacted fracture of the resident's left femoral head. The nursing staff notified the resident's physician of the results of the x-ray and obtained orders to send the resident to the hospital for further evaluation and treatment. Nursing staff notified the resident's responsible party. -At 6:35 P.M., the resident was transferred to the hospital and at 9:25 P.M. the hospital informed the nursing staff the resident was going to be admitted . Record review of the resident's Mobile X-ray results dated 9/4/14, showed the resident's left hip and leg were reviewed and the x-ray showed "there is cortical angulation at the lateral femoral head neck junction, suspicious for an impacted fracture." There was no fracture or dislocation visualized at the knee and no displaced fracture at the resident's pelvis. Record review of the resident's Medical Record showed no documentation that the nursing staff started neurological checks on the resident once his/her condition began to change on 9/3/14 after he/she stated he/she had fallen, and no documentation the nursing staff initiated a fall investigation protocol or injury of unknown origin/unusual occurrence investigation once the mobile x-ray showed there was suspicion of a hip fracture. Record review of the resident's Hospital discharge date d 9/8/14, showed the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident had left hip surgery on 9/5/14, and was discharged back to the facility on [DATE], with physician's orders [REDACTED]. Record review of the resident's Nursing Admission assessment dated [DATE], showed the resident was readmitted to the facility (from the hospital) on 9/8/14 at 1:40 P.M. The description showed the resident had dark purple bruising to his/her left and right arm, trace edema (swelling in the tissues) in his/her right hand, a surgical incision to his/her left hip with large staples and light purple bruising to the site, and dry and peeling skin to his/her left heel. Record review of the resident's Significant Change MDS dated [DATE], showed he/she: -Needed extensive assistance with transferring and ambulation. -Needed assistance with hygiene and bathing and was incontinent of bowel and bladder. -Was at risk for skin breakdown. -Had a range of motion impairment on his/her left side. Record review of the resident's Care Plan dated 9/16/14, showed he/she recently fractured his/her hip and needed one to two persons to assist him/her with bed mobility, transferring, ambulation, toileting, dressing and grooming. It showed the resident had long and short term memory loss, staff was to complete daily cares (bathing, dressing), assess the resident's skin daily, observe all of the resident's bony prominences daily for changes in skin, and ensure the resident was wearing heel protectors (when) in bed. Record review of the resident's medical record showed no documentation showing the facility tried to determine how the resident may have broken his/her hip, no documentation showing the facility ruled out a fall as the possible cause of his/her fracture, or that they completed a report of injury of unknown origin after they found out the resident had a hip fracture. Observation and interview on 11/3/14 at 9:20 A.M., showed the resident resided on the secured skilled care unit and was sitting in the dining/day room with other residents. Certified Nursing Assistant (CNA) X and CNA Z said the resident had a hip fracture that they thought may have been from a fall, but they were not sure because the resident was confused and had shown no signs of bruising or indication that he/she had fallen or when he/she may have fallen. They said the resident began having difficulty walking (the resident was ambulatory without assistance or assistive device prior to this), and when they had an x-ray done, they found that his/her hip was broken. They said the nursing staff did not know how or when he/she may have broken his/her hip because no one reported that the resident had fallen. Observation on 11/3/14 at 10:30 A.M., showed the resident was in the hallway with the physical therapist transferring from a sitting to standing position with minimal assistance, and walking down the hallway using his/her roller walker with standby assistance from the therapist. During an interview on 11/4/14 at 11:05 A.M., Licensed Practical Nurse (LPN) Z said: -When he/she last worked (prior to 9/3/14) the resident was ambulating without any problems, but when he/she came back in to work the resident was no longer walking. -He/she assessed the resident and did not find any bruising or indication that the resident had broken anything, he/she had range of motion in his/her limbs and there was no report that the resident had fallen. -They notified the resident's physician to request labs and thought the resident may have had a urinary tract infection. -They could not determine why the resident would no longer walk but they could not say definitely that the resident fell . -They decided to have the resident's hip and leg x-rayed since the resident refused to walk, and when the mobile x-ray results came back showing the resident had a fracture, they notified the resident's physician and family, and sent the resident to the hospital. -The resident had surgery on his/her hip while in the hospital, and when the resident was readmitted to the facility, they completed the admission assessment and documented on the resident's aftercare (to include updating the resident's care plan) and ambulation status. -They did not write a report on an injury of unknown origin nor did they write a fall investigation report because they did not know how or when the resident fractured his/her hip. -They only documented on the resident's progress after he/she returned from the hospital. During an interview on 11/5/14 at 12:24 P.M., the DON said: -At the time they did not know what had occurred or what was wrong with the resident, so they did not complete a report (injury of unknown origin or fall investigation). -They were trying to determine what was wrong with the resident, and because the resident did not have any bruising and there was no indication that he/she fell , they would not have written a report or began a fall investigation. -Once they found out the resident's hip was fractured they did not know when the fracture occurred or how it occurred, so they continued to monitor and treat the resident after he/she returned from the hospital. -They could not be sure that a fall was how the resident became injured. -They discussed completing an unusual occurrence report but they did not complete one. 1b. Record review of Resident #5's Physician's Note dated 10/14/14, showed the resident was continuing to improve after his/her left hip fracture, but he/she was less mobile and was not doing as well since that occurrence. It showed the resident was a little bit more confused and less alert at times. Record review of the resident's Fall Risk assessment dated [DATE], showed he/she scored 13 (a score of 10 or more was considered high risk for falling). Record review of the resident's Weekly Medicare Review Summary showed on 10/19/14, the resident continued to work with OT and PT for muscle strengthening, balance, posture and ambulation. The resident had improved with ambulating with his/her walker but ambulated only short distances with nursing assistance and still transferred with the assistance of nursing staff. On 10/20/14, nursing staff reported the resident transferred himself/herself without staff assistance and took five steps. Record review of the resident's Nursing Notes dated 10/1/14 to 10/31/14, showed: -On 10/26/14 the resident tried to get up without assistance, and he/she needed one to two persons to assist with ambulation and transferring. -On 10/23/14, the resident tried to get up without assistance, had an unsteady gait, shuffled his/her feet, and staff needed to cue the resident to take bigger steps. -On 10/26/14, the resident needed a lot of cueing when walking with his/her roller walker; he/she tried to get up without assistance, and sensor alarms were in place. Record review of the resident's Weekly Medicare Review Summary showed on 10/28/14, the resident continued to receive therapy services and needed assistance with ambulation and transfers. Staff must often control the resident's walker for the resident. The resident had attempted several self-transfers and staff had to provide assistance to the resident. The resident had poor safety awareness and advanced dementia. Therapy services were to continue to provide balance, strengthening, ambulation and transferring training to the resident. Record review of the resident's Fall Investigation Form dated 10/31/14, showed on 10/31/14 (no time documented) a Certified Medication Technician (CMT) saw the resident tried to stand up by himself/herself and fell on his/her bottom in the dining room. The resident had no apparent injuries. The interventions that were in place prior to the incident were chair and bed alarms, gait belt and walker with one to two persons to assist while ambulating. Interventions initiated to prevent further falls showed staff spoke with therapy to continue balance and strengthening training. The special services given to the following shift was to continue to monitor the resident's vital signs. The investigation did not show any environmental factors that may have impacted the resident's fall, where staff was (how close were they to the resident prior to his/her fall), and whether the resident's sensor alarm was on and working. The investigation did not show how they would prevent further falls (closer monitoring) that were not already in place. During an interview on 11/4/14 at 6:00 A.M., LPN K said if they witness a fall or find a resident on the floor, the nurse was supposed to complete the fall investigation report, start neurological checks and monitor the resident for 72 hours. He/she said the report should be a detailed report on how the resident fell or show in detail the circumstances that they found the resident on the floor. 2. Record review of Resident #8's Face Sheet showed he/she was admitted on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident's Annual MDS dated [DATE], showed he/she: -Was confused with short and long-term memory loss. -Needed extensive assistance from staff to transfer, was not able to steady himself/herself in a standing position without staff assistance, but had no upper or lower extremity range of motion deficits. -Had no falls since admission and no history of falls. -had a history of [REDACTED]. Record review of the resident's Care Plan dated 7/18/14, showed he/she had long and short term memory deficits, was alert to person, had impaired decision making abilities, had behaviors, and was at risk for falling. Interventions showed staff should: -Provide one to two person assistance with transfers and ambulation. -Ensure the resident had on proper footwear with transfers and ambulation. -Not leave the resident alone/unattended when in the bathroom or dining room. -Be aware that the resident sometimes would sit himself/herself on the floor at times, and staff was to ensure the resident's safety. -Provide a sensor alarm for his/her bed. Record review of the resident's Nursing Notes showed: -On 8/29/14 at 2:30 P.M., the resident was yelling, trying to crawl out of his/her bed. (Nursing staff) put the resident back into his/her bed and the resident continued to yell. At 3:30 P.M., the resident continued having behaviors, nursing staff called the resident's physician due to his/her increased agitation and received a physician's orders [REDACTED]. At 8:30 P.M., the nurse notified the resident's daughter about the medication change. -On 8/30/14 at 4:00 P.M., the resident was banging on his/her side rail and yelling. Nursing staff took the resident to the bathroom then to the dining room. At 5:00 P.M., the resident complained a little, but was calmer than previously. At 6:30 P.M., the resident wanted to go to bed, but when he/she was taken to bed he/she became agitated, loud and was yelling out. Nursing staff took the resident to the dining room where he/she calmed down and began working on a puzzle. At 7:40 P.M., the nursing staff spoke with the resident's family about the resident's behaviors and the increase in his/her anti-anxiety medication. -On 8/31.14 at 6:45 A.M., staff heard a noise, went into the dining room and found the resident sitting on the floor. The resident said he/she was crawling. Nursing staff took the resident's vital signs and notified the resident's family and the DON of the incident. The resident did not have any injuries. Record review of the resident's Fall Investigation Form showed: -The incident occurred on 8/31/14 at 6:45 P.M., -There were two CNA's and one CMT in the area at the time of the incident (staff was not named in the report). -Nursing staff was unable to determine the reason/potential reason for the incident. -The resident had a sensor alarm in place prior to the incident and was wearing shoes. --Interventions initiated to prevent further occurrence showed: "Resident change in medications related to an increase in behaviors will follow for any acute side effects." -Specific instructions for nursing staff on the following shift was to complete neurological checks and 72 hour monitoring. -The investigation did not show whether the resident was in the dining room alone or with other residents and/or staff, whether the resident was standing or sitting down in a chair/wheelchair prior to the incident, whether the sensor alarm was attached/working and sounding (if the resident was sitting down), if the incident was witnessed (and by whom, if so), in what position was the resident found by staff that saw him/her, what the environmental factors were, the time nursing staff last saw the resident prior to the incident, the root cause analysis of what may have caused the incident and what the staff was planning to do to prevent the incident from occurring again. The facility staff also did not show the date and time the resident's physician and family were notified about the incident. There was no follow-up documentation that showed the facility reviewed the incident and whether newly implemented interventions were effective. Record review of the resident's Unusual Occurrence Report showed: -The resident had a fall on 8/31/14 at 6:45 P.M. in the dining room. -The resident's vital signs were taken and the resident's family (at 6:50 P.M.) and physician (at 7:42 P.M.) were notified on 8/31/14. -The narrative showed the resident was sitting in a chair in the dining room when staff heard a noise, finding the resident sitting on the floor. The resident was unable to provide an explanation of the incident. Nursing staff assessed the resident for injuries and none were noted. At the time of the incident the sensor alarm was on and the resident was wearing non-skid footwear. -The final outcome of the occurrence showed: Recent changes in the resident's medication for increased behaviors will be followed for any acute side effects. -The report did not show the root cause analysis of why the resident fell , did not show whether the resident had behaviors at the time of the incident and if so, what interventions were being implemented prior to the resident's fall, did not show the time the nursing staff last saw the resident sitting in his/her chair, did not show if the sensor was sounding at the time they found the resident, did not show why staff was not monitoring the resident (the resident was not to be left unattended in the dining room according to his/her care plan), and did not show any additional interventions to try to prevent further falls in the dining room. Observation on 11/3/14 at 2:14 P.M., showed the resident in the locked special care unit was laying down on his/her bed. The bed was low to the floor with a sensory alarm attached. The resident's call light was within reach and there was a floor mat beside the resident's bed, on the floor. The resident was pleasantly confused and unable to answer questions about his/her fall. During an interview on 11/6/14 at 9:20 A.M., LPN L said: -They are supposed to document in as much detail as possible on the fall investigation form. -The documentation should be descriptive and show what occurred or what they thought may have occurred. -After looking at the resident's investigation report dated 8/31/14, the nursing note nor investigation were descriptive enough and did not have all of the information regarding the incident documented. -There was a fall risk committee that met monthly and they were supposed to review all falls and determine if current interventions were accurate or new interventions were implemented. -The MDS Coordinator was supposed to update the resident's care plan with any new interventions after the resident's fall. -Each charge nurse received an updated fall risk list that showed all of the residents who were a fall risk and this list was updated monthly. During an interview on 11/6/14 at 2:56 P.M., the DON said: -The fall investigation is a two page form and the Fall Investigation Form is the second page of the form that is placed in the resident's medical record along with the neurological check form and the 72 hour monitoring sheets. -The first page of the Fall investigation is completed by the nurse once the incident occurs and includes a more detailed account of the incident, to include the body diagram for injuries, dates and times of the physician and family notifications, witnesses to the incident, interventions provided prior to the incident and newly implemented interventions after the incident occurred. -The second page was a brief summary of the first page and was primarily used to show the interventions implemented for the resident after the fall. -Once the investigation was completed, it was given to him/her and the Administrator for review. The second page was placed in the resident's medical record and the first page was kept internally as part of the facility's quality assurance report. -The facility did not share the first page with anyone outside of the facility and had not ever read the report to anyone. -There should have been corresponding nursing notes that gave a detailed summary of the fall (witnessed or unwitnessed) and any interventions that were implemented for the resident afterwards. -They also had a monthly fall risk meeting where they discussed all falls and determined if current interventions were still adequate or if new interventions were necessary for each resident at risk. Once those interventions were changed the MDS Coordinator updated the resident's care plan. -He/she tracked all falls and incidents on the incident occurrence report which also provided a summary of the incident, notifications and outcomes (implemented interventions). 3. Record review of Resident #6's Admission Face Sheet showed he/she was admitted on [DATE] with [DIAGNOSES REDACTED]. -Falls. -Difficulty walking. -Muscle weakness (a condition of general muscle weakness or discomfort). -Parkinson's Disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). -Chronic Kidney Disease Stage II (inability of the kidneys to excrete wastes, concentrate urine and stages of chronic kidney disease damage). -Blindness. -Dementia (a loss of thinking, remembering and reasoning so severe that it interferes with an individual's daily functioning and may cause changes in personality, mood, and behaviors). Record review of the resident's Face Sheet showed he/she had a hospital stay from 7/9/14 to 7/14/14. Record review of the resident's Fall Risk Evaluation Form dated 7/14/14, showed he/she: -Had intermittent confusion at times. -had a history of [REDACTED]. -Was wheelchair bound and not able to ambulate. -Was on medication that can cause the resident to become confused or lethargic (excessive sleepiness). -Had a total score of 20 and he/she should be considered at high risk for potential falls. Record review of the resident's Physician Telephone Order dated 7/15/14, showed he/she: -Had a wheelchair seatbelt (used as a restrictive device or protective devise, to limit the movement of his/her body in a way that would engage in behavior that places him/her at risk for potential injury) fastened around him/her while up in the wheelchair. -Had a pressure sensor pad (bed and chair sensor pads provide an early notification to a caregiver when a person is about to get up or wander, and are used in fall prevention interventions to help reduce the risk of falls and injuries) on his/her wheelchair, recliner and bed. -Had a high low bed (the bed is lowered to the floor level while in bed) with a fall mat (floor cushion mat used for resident with a fall risk or history of falling or rolling out of bed) beside his/her bed. Record review of the resident's Nurses Medicare Notes dated 7/21/14 at 4:00 P.M., showed: -He/she was found on his/her left side with his/her arm under him/her lying on the floor between his/her recliner and the foot of his/her bed (staff wrote in the resident's nurses notes) "on his/her head." -His/her seat belt was not fastened while he/she was up in the wheelchair. -Had been unresponsive for two minutes after the fall. -Neurological checks were started after his/she "came to" and were within normal limits. -He/she had three skin tears (an avulsion, a complete partial tearing away of a structure or part of the skin) to his/her left arm. -His/her physician was notified of the resident's fall and no new physician orders [REDACTED]. Record review of the resident's Fall Investigation form dated 7/21/14 at 4:00 P.M., showed: -His/her physician and family were notified of the resident's fall. -He/she had skin tears to his/her left elbow, hand and wrist. -He/she had bruising around his/her skin tears. -His/her nurse's summary said the reason for the resident's fall was due to the resident's wheelchair seatbelt was not latched, and the resident had leaned forward in his/her wheelchair resulting in a fall. -He/she had a fall intervention in place prior to his/her fall, was to have his/her seatbelt secured while in his/her wheelchair, and was to have his/her bed in the low position with sensor pads and alarms while in his/her bed. -An updated fall intervention to prevent further falls was to educate staff on the use of the resident's wheelchair seatbelt while up in his/her wheelchair, and the use of chair sensors pad and bed alarms. -The fall investigation form had specific instructions for the following nursing shift, to make sure the resident's wheelchair seat belt was secured and his/her wheelchair was to be in a tilted positions and with alarms in place and the alarm functioning properly. The form did not instruct staff in what position to tilt his/her wheelchair. -The form reviewed and signed by the DON on 7/22/14, and by the facility Administrator on 7/24/14. Record review of the resident's physician progress notes [REDACTED]. -The resident had problem of leaning forward in his/her wheelchair and would cause him/her to fall out of his/her wheelchair. Record review of the resident's Physician Telephone Order dated 7/26/14, showed he/she: -Had been discharged from Medicare A services. -Referred to Hospice Care (care that focuses on relieving symptoms and supporting patients with a live expectancy of six months or less) for evaluation of services. Record review of the resident's Physician Telephone Order dated 7/28/14, showed the resident was admitted to Hospice Care with a [DIAGNOSES REDACTED]. Record rev

Based on observation, interview, and record review, the facility staff failed to promptly identify, care plan, implement, and document measures to prevent skin breakdown for one sampled resident (Resident #2), who had a significant impairment of his/her mobility due to [MEDICAL CONDITION] (loss of movement and sensation of both legs), was admitted to the facility without any pressure ulcers, developed a pressure ulcer, and was transferred to the hospital for treatment of [REDACTED]. plan to accurately reflect his/her condition out of 15 sampled residents. The facility census was 88 residents. Record review of the facility's Skin Care Protocol for Potential Alteration in Skin Integrity dated 12/2010, showed: -The risk of pressure ulcer development was higher for: --Individuals who were incontinent (involuntary loss or leakage of urine or stool), confused, or obese; --Residents with impaired sensation; --Residents who were unable, unwilling, or restricted from changing their own position: and -Licensed nurses were to complete a skin risk assessment for residents upon admission, and as needed, if any of the following criteria was met: --If, on admission, the resident scored an 18 or less on the Braden Scale (a tool used for predicting pressure ulcer risk); --If medical assessments found significant changes documented, such as: ---Decreased activity level, bed mobility, and/or physical condition; ---Declines in the resident's nutrition and/or hydration status and incontinence; ---A resident who had existing skin breakdown or one who had a known history of previous skin breakdown. -Initial and on-going assessment showed staff was to: --Assess the resident's skin on admission and every eight hours for: warmth, redness, and tenderness; dryness, rashes, [MEDICAL CONDITION], blisters, discoloration and breakdown; and inspect the resident's feet, bony prominences, skin folds, dependent areas, buttocks, perineal area (surface area between the thighs extending from the pubic bone to the tail bone), and skin beneath immobilizers, braces, and positioning devices; --Consider applying an air mattress overlay to the resident's bed; --Consider a pressure-relief cushion in the resident's chair/wheelchair. --Reposition the resident every two hours when in his/her bed or chair. The staff was to avoid positioning the resident directly on the trochanter (the point at which the hip and thigh muscles attach) when side lying in bed. The head of the bed (HOB) should be at the lowest level that was consistent with the resident's medical condition and staff should limit the amount the HOB was elevated to "< 30 degrees," unless contraindicated. Anytime the head of the bed was elevated, the foot of the bed should also be elevated to alleviate shearing (the interaction of both gravity and friction against the surface of the skin which occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and/or tears the underlying capillaries and blood vessels causing tissue damage); --Use a cloth pad or turn sheet to lift/reposition the resident in bed to alleviate friction/shearing forces when moving a resident. These tissue injuries could also be reduced by using lubricants, protective films, protective dressings (such as [MEDICATION NAME] - an adhesive dressing which combined absorbent materials with an adhesive substance to manage and contain light to moderate drainage) and protective padding; -Skin care: The staff was to: --Minimize the force applied to the skin during skin care. The staff was to avoid massaging over pony prominences; provide perineal care daily and after each episode of incontinence (pad/brief change); and ensure the resident's bed linens and protectors were , dry, and wrinkle-free with each repositioning activity; -Educate the resident on: --The need to make frequent position changes at least every two hours when in bed; --Active/passive Range of Motion (ROM) activities; --The importance of diet/fluid intake; --The need to inspect his/her skin daily for reddened areas, broken skin, bruised areas, blisters, and swelling; and the actions to be taken when abnormalities occurred; -The nurse should: --Report to the resident's physician any evidence of skin breakdown, signs and symptoms of cutaneous (related to, or affecting the skin) infection, and nutritional/weight loss problems; --Consult the resident's physician regarding recommendation for product selection for actual skin break down. -Documentation included recording the pressure score risk on the Braden scale (a tool used to assess the resident to see if he/she is at risk for developing pressure ulcers), recording the skin integrity score in the resident's Nurse's Notes and Care Plan; and recording the evaluation of the effectiveness of maintaining the resident's skin integrity in the resident's Nurses Notes and in the resident's Care Plan. Record review of the facility's undated Certified Nursing Assistant (CNA) Bath Assessment Sheet showed: -There was a front and a back view of the body diagram on the left side of the paper; -Below the body diagrams were lines for the following information: The client's name; the CNA providing the bath; the date the bath was completed; the shift on which the bath was completed; and the nurse who reviewed the form; -The following questions were to be answered "yes" or "no," and identified as either new or old: 1) Any reddened areas that remain after gentle massage? 2) Any excoriated or galled areas? 3) Any bruises or discoloration? 4) Any open areas, skin tears, or abrasions? 5) Any blisters? 6) Any open ulcers? (Indicate even if treated) 7) Any dry or flaky skin? 8) Any problems with fingernails or toenails? 9) Any build-up of visible cerumen (wax) in the ears? 1. Record review of Resident #2's Face Sheet showed he/she: -Was admitted to the facility 8/25/14; -Had diagnoses which included, but were not limited to: --Closed dorsal (refers to the back side of an animal or plant) vertebrae (bones of the spinal column) fracture; --[MEDICAL CONDITION] (impairment in sensory or motor functioning of the lower extremities); --Generalized pain; and --Muscle weakness. Record review of the resident's Medical Record showed: -He/she had been transferred from a hospital to the facility on [DATE]; -The resident'[MEDICAL CONDITION] ([MEDICAL CONDITION] - a surgical opening into the wind pipe into which a tube is inserted to allow passage of air and removal of secretions) dressing was intact; -Wound care instructions showed: --To keep the resident's wound(s) clean; --To inspect the resident's incisions daily and clean them with mild soap and water daily; --To complete daily lumbar dressing changes. (There was no documentation in the hospital transfer information which showed if the resident had any skin issues on his/her buttocks, sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity), or coccyx (tailbone) areas at the time of discharge.) Record review of the resident's Admission Assessment (nursing) dated 8/25/14, showed he/she: -Had skin described as pink, warm, and dry. Wounds were identified on the resident's "back, below (the) PEG tube (percutaneous endoscopic gastrostomy tube- a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat), trach;" -Had paralysis of both lower extremities; -Was dependent for bathing, dressing, peri-care (care to the area between the anus and the exterior genitalia), and bed mobility (was unable to turn self in bed); -Needed a total body mechanical lift and the assistance of two staff members for transfers, and used a wheelchair with staff assistance for mobility; -Had an indwelling urinary catheter (a tube passed through the urethra into the bladder to drain urine; kept in place by a fluid-filled balloon) and wore briefs due to bowel incontinence; -Had the following issues identified on his/her admission skin assessment: --Two bruises were present on his/her left upper arm and the second to his/her right abdomen; --A duoderm (flexible dressing that adheres to skin) was in place on his/her neck at an [MEDICAL CONDITION]. An old surgical incision was noted to the resident's back and a small wound was present on the resident's abdomen below the PEG tube site. The skin at the resident's chest and abdominal skin folds were red. The resident's buttocks were "also red." The body diagram on the form was marked and showed he/she had reddened areas at the chest area and in the peri-area (surface area between the thighs extending from the pubic bone to the tail bone), both at the front and back. Record review of the resident's physician's orders [REDACTED]. -admission orders [REDACTED] -Clean incisions daily with soap and water; daily lumbar dressing change; cleanse PEG tube site with normal saline and apply a clean dressing; -Zinc oxide (a skin protectant) to affected area twice a day (no specific site/area for this treatment was identified in the order); -[MEDICATION NAME] (the brand name of a petroleum-based ointment used on the skin as a barrier/protectant for people with incontinence) to red/irritated areas (no specific site/area was identified). Record review of the resident's Medication Administration Record [REDACTED] -Documentation of treatments to the wound on his/her lower back, the open area to his/her neck, and to his/her feeding tube site. He/she was to have lotion and a skin protectant applied to his/her lower legs bilaterally (both sides), however, there was no [DIAGNOSES REDACTED]. -Documentation that he/she received [MEDICATION NAME] to red/irritated areas six times. The location where the [MEDICATION NAME] was applied was not recorded on the treatment sheet; -Documentation that showed he/she received no applications of Zinc oxide from 8/25/14 through 8/31/14. Twice staff initials were circled showing the application was not completed. The remaining times for application had been left blank by the facility staff. Record review of the resident's Nursing Notes dated 8/25/14 showed he/she: -Had a surgical wound to his/her back, a small wound at the PEG tube site, and his/[MEDICAL CONDITION] was covered with a duoderm; -Had redness and soreness at his/her peri-area and chest area; -Was paralyzed and transferred via the use of a total body mechanical lift; -Requested to stay in bed; -Was repositioned frequently as he/she was unable to position himself/herself; -Had the head of the bed up to promote air exchange; -Was noted to be very "sweaty." (There was no documentation showing the facility staff suspected any type of deep tissue injury (SDTI) at the resident's sacrum/coccyx or that he/she had any skin issues on his/her buttocks.) Record review of the resident's admission Braden Scale dated 8/25/14 showed he/she had a total score of 14, showing he/she was not at high risk for pressure ulcer development (a total score of 12 or less represented high risk). This total score did not reflect the resident's immobility and sensory deficits related to his/her paralysis from the waist down as the staff completing the assessment showed the resident had no sensory impairment. It also showed the resident's skin was only occasionally moist, however, he/she was incontinent of his/her bowels and was described as "very sweaty." Record review of the resident's Interim Care Plan (ICP) dated 8/25/14, showed in part he/she: -Was at risk of having unmet Activities of Daily Living (ADLs - one or more of the following: Eating, Dressing, Bathing, Toileting, Transferring and Walking). Interventions included: --Encouraging the resident to do what he/she could do for himself/herself; --Assisting the resident with his/her ADLs, as needed; ---The care plan did not identify that the resident required extensive to maximum assistance with most of his/her ADLs, including bed mobility, transfers, dressing, bathing, and toileting; -Was at risk for impairment due to immobility. Interventions included: --Ensuring the resident's side rails were up to aid bed mobility; --Encouraging range of motion (ROM); --Ensuring the resident received Physical Therapy (PT), if ordered; --Using a wheelchair, as ordered, and assisting the resident with transportation on and off the unit, as needed; ---The resident's ICP did not identify the resident was paraplegic and therefore unable to perform ROM to his/her lower extremities; did not show staff needed the use of a total body mechanical lift or the assistance of two staff members for transfers or that the resident actually needed the staff's assistance in order to move about the facility in his/her wheelchair at the time of his/her admission to the facility; -Had potential for impairment of skin integrity. The goal was for the resident's skin to remain intact over the next 21 days. Interventions included: --Assessing the resident's skin daily; --Keeping the resident's skin clean and dry; --Encouraging the resident to reposition every two hours, and as needed, and providing assistance, as needed; --The bath aide assessing the resident's skin on bath days; --Monitoring the resident's skin during AM and PM cares; --Reducing factors that contribute to pressure sore formation; --Completing any treatment, as ordered; --Documenting the healing process weekly and as needed; --Observing for signs and symptoms (s/s) of infection, i.e., redness, warmth, purulent drainage (pus), and notifying the nurse and physician; -The resident's ICP: --Did not identify any specific need to monitor the resident's sacrum, coccyx, or buttocks due to the redness; --Did not identify if the resident had actual skin issues which required monitoring and treatment, i.e.,[MEDICAL CONDITION], PEG tube site, and back incision; --There was no documentation showing the resident had redness at his/her chest or bottom; --There were no specific interventions identified to help prevent actual impairment of the resident's skin which might result due to his/her paraplegic condition. The resident's ICP did not identify how high the head of his/her bed should be to prevent undue pressure on his/her coccyx or sacrum while he/she was in bed or any pressure-relieving devices to be used when the resident was up in his/her wheelchair, such as pressure-relieving cushions, or when he/she was in bed, such as a pressure-reliving mattress or alternating air mattress. Record review of the resident's POS dated 8/26/14 showed an order for [REDACTED]. Record review of the resident's Nurse's Notes dated 8/26/14 showed he/she: -Was incontinent of his/her bowels; -Required extensive to total assist with many ADLs; -Was found to be septic and was started on antibiotic therapy; -Had wounds at his/her back and PEG tube. (There was no documentation showing the resident had wounds on his/her sacrum, coccyx, or buttocks, and there was no documentation related to the red skin at the resident's chest/abdominal folds which had been identified upon his/her admission to the facility.) Record review of the resident's Nurse's Notes dated 8/27/14, showed he/she: -Required limited assistance with his/her bed mobility, i.e., he/she grasped side rails to pull self over to be turned, but required assistance from staff to maintain a side-lying position; -Had a surgical area on his/her back which was treated along with the resident's wound at his/her PEG tube site; -Was incontinent of his/her bowels. (There was no documentation showing if resident had wounds on his/her buttocks, sacrum or coccyx, nor was there any documentation related to the condition of the resident's skin at his/her chest/abdominal folds.) Record review of the resident's Certified Nursing Assistant's (CNA) Bath Assessment Sheet dated "8/28," showed he/she: -Had "old" open areas, skin tears, or abrasions and had dry flaky skin identified by the facility staff. A circle had been marked in the middle of the back of body diagram and at the front of the neck on the body diagram on the paper, however, there was no documentation showing if the areas were open, abraded (scrap or wear away), or if a skin tear was present. There was no documentation showing where the resident's skin was dry and flaky; -Had no reddened areas that remained after gentle massage; had no excoriated (scratches or abrasions of the skin) or galled (to become irritated, chafed, or sore) areas; and had no open ulcers; -The form was signed by the CNA as well as a nurse. (There was no documentation showing any areas of concern at the resident's buttocks, sacrum, or coccyx area.) Record review of the resident's Physician's Progress Notes dated 8/28/14, showed he/she: -Had a long hospital stay for a complex pathologic [MEDICAL CONDITION] dorsal spine; -Had become paraplegic having no muscle function or sensation from the waist down; -Had continuing discomfort in the lower back region; -Had experienced respiratory distress and required ventilator therapy for a considerable time which required a [MEDICAL CONDITION]. The [MEDICAL CONDITION] site was healing and closing nicely. His/her skin was "without [MEDICAL CONDITION]," was moist and well perfused (was getting an adequate blood supply). Record review of the resident's POS dated 8/28/14 showed the following orders: -Remedy cleansing lotion (the brand name of a lotion used to cleanse, moisturize, protect, and nourish the skin) followed by Nurtrashield (the brand name of a type of moisture barrier used to protect the skin) to the resident's lower extremities bilaterally; -Cleanse the wound to the lower back with Normal Saline (NS - a sterile mixture of salt and water; called "normal" because it's salt concentration is similar to what's found in tears, blood, and other body fluids), apply 4 x 4 gauze daily; -Cleanse the open area to the resident's neck with NS, apply 4 x 4 gauze on bath days; -Cleanse the PEG tube site with NS, apply [MEDICATION NAME] (an ointment that works as a lubricant to provide protection for wounds as well as actively promotes wound healing by stimulating blood vessel activity and removal of unhealthy tissue), then cover with a 4 x 4 gauze three times a day; -Wound culture of the open area on the resident's lower back. (There were no orders related to any skin conditions on the resident's sacrum, coccyx, or buttocks.) Record review of the resident's Nurse's Notes showed: -On 8/28/14 he/she: --Had a surgical site at his/her medial spine which was draining yellow-green drainage; --New wound care orders were obtained and wound care was provided to the resident's spine wound, his/her PEG tube site, and to the resident's [MEDICAL CONDITION]; --A wound culture was obtained from the resident's surgical site on his/her spine; --Attempted to use of a bedpan. There was no documentation showing how long he/she was on the bedpan, how the resident tolerated this, or if the trial had been successful. (There was no documentation showing any skin issues at the resident's buttocks, sacrum, or coccyx); -On 8/29/14, the resident: --Received wound care; (There was no documentation showing the resident had any new skin issues at his/her spine nor did it show any skin changes at the resident's sacrum, coccyx, or buttocks); -On 8/30/14, the resident: --Received wound care treatment to his/[MEDICAL CONDITION] PEG tube sites; --Had an open area to the lower spine which was cleansed with soap and water and a dressing was applied; (The physician's orders [REDACTED]. (There was no documentation showing the resident had any new skin issues at his/her spine or any issues his/her sacrum, coccyx, or buttocks). Record review of the resident's admission Minimum Data Set (MDS; a federally mandated assessment tool required to be completed by facility staff for care planning) dated 8/30/14, showed he/she: -Had clear speech, was able to make himself/herself understood, and was able to understand others; -Was cognitively intact; -Required set-up help for eating; -Required the extensive assistance of one staff person for personal hygiene; -Required the extensive assistance of two staff people for bed mobility, dressing, toilet use and bathing; -Required the total assistance of two staff people for transfers; -Had functional limitation in ROM in both lower extremities; -Was always incontinent of his/her bowels; -Had an indwelling urinary catheter; -Used "as needed" (prn) pain medication and non-pharmacological interventions to manage his/her frequent pain which the resident rated at a six (6) on a 0-10 pain scale: 0=no pain, 10=worst pain possible; -Was at risk for pressure ulcers, but had none, and he/she had no venous or arterial ulcers; -Had surgical wounds; -Used a pressure reducing device in his/her wheelchair and for his/her bed; received surgical wound care and had ointments/medications applied to areas other than his/her feet. Record review of the resident's Nurse's Notes showed: -On 8/31/14 he/she: --Had an indwelling urinary catheter and was incontinent of his/her bowels. His/her buttocks "remained" red, a treatment was done, and the resident was positioned on his/her side; --The head of the resident's bed was elevated during the night shift to promote air exchange (the degree of elevation was not identified); --The resident received dressing changes to his/her surgical and PEG tube sites, and to his/her lower legs. His/[MEDICAL CONDITION] was noted to be dry and intact; (There had been no documentation showing the resident's buttocks had been "red" since the resident's admission. The facility staff did not identify the extent of the redness, the location of the redness on the resident's buttocks, or what the staff was doing to help treat the area. There was no documentation showing any changes or new skin issues at the resident's spine.) Record review of the resident's Nurse's Notes showed: -On 9/1/14 he/she: --Had redness in his/her peri-area and received treatment per orders; --Continued to have wounds to his/her lower back, neck, and abdomen and received treatment for [REDACTED]. --Staff propelled the resident's wheelchair; (There was no documentation showing the condition of the resident's buttocks, i.e., if redness persisted, etc.); -On 9/2/14 he/she: --Received treatments to his/her wounds; --Was propelled in his/her wheelchair by staff to a meal and then propelled himself/herself back to his/her room from the dining room; (There was no documentation related to the condition of the resident's peri-area or his/her buttocks nor was there any documentation showing the facility staff was monitoring the resident's spine for changes due to his/her wheelchair). Record review of the resident's CNA Bath Assessment Sheet dated "9-3," showed documentation which was unchanged from what was previously noted on "8/28," i.e., questions #4 and #7 were answered "yes." Staff marked question #4 as "old" but did not identify the resident's dry, flaky skin (question #7) as either new or old. (There was no documentation showing any skin problems at the resident's buttocks, sacrum, coccyx, or peri-area.) Record review of the resident's Weekly Medicare Review notes dated 9/2/14, showed he/she: -Was working with PT for sitting balance, rolling from side-to-side in bed, and increasing his/her sitting tolerance; -Was working with OT for wheelchair management, dressing and fine motor coordination; -Had no feeling or sensation to his/her lower extremities at all; was dependent for transfers and required two staff and a total body mechanical lift to do it; required the extensive assistance of one staff for dressing; extensive assistance of two staff members for bed mobility, and the extensive assistance of one staff person for peri-care and toileting; and had an indwelling urinary catheter. -The resident refused a specialty wheelchair at that time; -It was "reasonable and necessary to continue skilled therapy to facilitate adaptation to [MEDICAL CONDITION] and decrease the risk for complications and injuries." Record review of the resident's POS showed orders written 9/3/14 for staff to: -Administer a multivitamin with minerals and Vitamin C 500 mg daily. There were no diagnoses accompanying these orders; -Apply "A&D ointment (used to prevent, treat, and relieve rashes caused by incontinence) to affected (area) every shift." (The order did not identify the location where the staff was to apply the A&D ointment.) Record review of the resident's Care Area Assessment (CAA)(a problem oriented framework for arranging MDS information and additional clinically relevant information about an individual's health problems or functional status) dated 9/3/14 showed he/she: -Was paraplegic; -Required the assist of two staff members and a total body mechanical lift for transfers; -Required the assistance of one to two staff members for bed mobility; -Had an indwelling urinary catheter and was incontinent of his/her bowels; and -Was free of pressure ulcers. Record review of the resident's comprehensive Care Plan dated 9/3/14, showed he/she: -Had issues with ADL function/rehabilitation and required one staff assistance with his/her ADLs and hygiene. Interventions showed the resident required the assistance of one to two staff members for transfers, dressing, and bed mobility. He/she required the use of a total body mechanical lift for transfers as he/she was paraplegic and non-ambulatory. It also showed he/she was dependent on staff to propel his/her wheelchair and was able to participate in care involving his/her upper body; -Was at risk for skin breakdown. His/her goal was to remain free of pressure ulcers through the next review period. Interventions included: --Assessing his/her skin with bathing and daily with person cares; --Notifying the nurse if any areas of redness or altered skin integrity was noted; --Ensuring the resident was repositioned at least every two hours, his/her skin was kept clean and dry, he/she was provided adequate peri- and catheter care as the resident was incontinent of feces and he/she had an indwelling urinary catheter. Staff was to lotion the resident's skin daily, and as needed; observe the resident's bony prominences daily and report and document redness or breakdown of his/her skin. [MEDICATION NAME], A & D ointment, and/or [MEDICATION NAME] cream was to be applied as per the POS/TAR. Staff was to make sure a low air loss mattress was on the resident's bed (this entry was not dated or initialed); -Had a surgical wound on his/her lumbar spine. His/her goal was to be free from infection and healing. Interventions showed to follow the physician's orders [REDACTED]. Record review of the resident's Nurse's Notes showed on 9/4/14 he/she: -Received treatments to his/her PEG tube site, feet/lower legs, and spine; -Was found to have an unstageable pressure wound (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown tissue) and/or eschar (tan, brown or black tissue) in the wound bed) to his/her coccyx. Eschar was present in the wound bed. There was no maceration (softening by soaking in a liquid) to the edges of the wound and no redness. The wound measured 2.2 centimeters (cm) x 1.8 cm. Documentation showed a new order was received to cleanse the wound with NS, apply Santyl (an ointment used for the debridement (removal of dead or dying tissue) of pressure ulcers), and cover the wound with foam dressing daily and as needed. Record review of the resident's POS showed orders were received on 9/4/14 for the following: -Cleanse wound to coccyx with NS, apply Santyl, and cover the site with foam dressing. The dressing was to be changed daily and as needed; -Low air loss/alternating air pressure mattress to bed; -Consult wound care specialist. Record review of the resident's Wound Assessment form dated 9/4/14, showed he/she: -Had a pressure ulcer at his/her sacrum/coccyx area that measured 2.8 cm. x 2.0 cm x 0.2 cm which was described as partial 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; it may include undermining or tunneling); -Had no pain at the site; - Had slough present at the wound bed at 76-100% and was yellow in color. There was no black eschar; - Had 25% granulation tissue present. The tissue surrounding the wound showed [DIAGNOSES REDACTED] (redness), and there was a moderate amount of thin, sero-sanguinous (containing blood and watery drainage) drainage present. There was no odor; - Had treatment orders included cleansing the area with NS, applying Santyl, and covering the area with foam daily, and as needed; - Had pressure-relieving measures in use at the time had been a gel cushion and turning the resident every two hours. -On 9/4/14 the resident was provided with an air mattress and a tilt-in-space wheelchair. Record review of the resident's Pressure Ulcer Care Plan showed several entries had been added to this problem: -Had a Stage III pressure ulcer at his/her coccyx (dated 9/4/14); -The word "healed" was written off to the side of the intervention showing the resident had a surgical wound on his/her lumbar spine and neck (undated entry); -"Stage II left buttock & Stage III pressure ulcer on my coccyx (date unclear on documentation);" -"A Roho cushion (a brand of wheelchair cushion used to help prevent sores and help improve the healing process) has been ordered for my wheelchair (undated);" -"Ensure low loss air mattress is on my bed (undated);" -"Administer Vitamin C for wound healing (undated);" -"Wound specialist nurse consults (undated);" (The resident's care plan did not address the types of products to be used while the resident used his/her low air loss mattress, i.e., paper under pads to allow for air circulation to help keep the resident's skin dry nor did it show if the resident was on any particular turning schedule, needed to off load pressure from his/her bottom to facilitate healing, or that he/she should be one of the last up and one of the first put to bed to help with the healing process.) Record review of the resident's Nurse's Notes showed: -On 9/5/14 he/she: --Was dependent on staff for bed mobility and peri-care; --Received treatment to his/her previously identified wounds (surgical, PEG tube, and neck) as well to his/her coccyx. Per documentation, the resident's coccyx area was cleansed with NS, Santyl was applied, and the site was covered with a foam dressing. There had been a moderate amount of yellowish-brown-colored drainage on the old dressing. No redness was noted around the wound edges; --Propelled himself/herself in his/her wheelchair; -On 9/6/14 he/she: --Had a coccyx wound which was red with light brown drainage. --There were back wounds "x 2," i.e., the superior (upper) wound was midline and measured 0.5 cm x 0.3 cm x 0.5 cm. The inferior (lower) wound was midline at the lower back and measured 0.7 cm x 0.5 cm x 0.3 cm; (Previous documentation showed only one wound at the resident's spine); -On 9/7/14 he/she: --Had a wound at his/her coccyx with yellow slough which wiped off while cleansing the wound with NS. The wound bed was red and moist with yellow-brown discharge noted; --Had wounds at his/her back; both had a small amount of yellow-brown discharge; --The superior wound was pink with a small amount of white tissue. The inferior wound bed was pink with a moderate amount of white tissue; --Was dependent on staff for bed mobility and transfers, but would help when turning from side-to-side; -On 9/8/14 he/she: --Received his/her wound treatments; --Had a small amount of greenish-yellowish drainage on the coccyx dressing and a small amount of brownish drainage to the PEG tube dressing. There was a small amount of yellowish drainage on the old dressing on the resident's spine; -Had frequent back pain which he/she rated as "8 out of 10" at its worst during the previous five days. -Was turned side-to-side fo