Every finding on record at Magnolia Square Nursing and Rehab

Based on record review and interview, the facility failed to protect the resident's right to be free from verbal and emotional abuse when one staff member (Certified Nurse Aide (CNA) B) spoke to one resident (Resident #1) in an aggressive manner, continued care when the resident said it hurt, and degraded the resident by telling the resident they would have to use a bed pan. The facility census was 89.Review of the facility's policy titled, Report Abuse, not dated, showed the following: -The facility will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the residents, family members, other residents, etc.-Abuse is defined as the willful infliction of injury; unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish; or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.Review of the facility's policy titled, Preventing Resident Abuse, not dated, showed preventing resident abuse was a primary concern for the facility. It was the facility's goal to achieve and maintain an abuse-free environment.1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admission date of 09/04/25;-Diagnoses included thoracic spondylosis without myelopathy or radiculopathy (refers to degenerative wear and tear of the spine in the mid-back (thoracic) region), hyperlipidemia (high levels of fat in blood), and osteoporosis (a common disease characterized by, or causing, low bone mass and structural deterioration, making bones fragile and prone to fracture).Review of the resident's quarterly Minimum Data Set (MDS - federally mandated assessment completed by facility staff), dated 12/11/25, showed the following: -The resident was cognitively intact;-The resident required partial to moderate assistance with toileting, hygiene, lying to sitting, sitting to lying, sit to stand, bed to chair transfer and toilet transfer;-The resident received scheduled pain medication and as needed pain medication.Review of the resident's care plan, reviewed on 12/24/25, showed the following: -The resident was totally dependent on one staff for toilet use;-The resident required moderate assist by one staff to move between surfaces;-Encourage the resident to use call light.Review of the resident's medical record showed staff documented the following: -On 01/11/26, at 12:46 P.M., the resident's family presented to nurses' station and informed charge nurse (Registered Nurse (RN) F) that resident reported to them that a certified nurse aide (CNA) was rough and rude while providing care to the resident during the night. The RN went to room to interview resident upon family's report. The RN notified the Director of Nursing (DON) and Assistant Director of Nursing (ADON) of report and interview;-On 01/12/26, at 3:38 A.M., Licensed Practical Nurse (LPN) H was notified by CNA B that the resident had complaints of pain when ambulating to toilet. The resident had persistent and chronic pain. It was reported that the bed pan was offered and refused by resident. The resident did not request any as needed pain medication. Resident usually, will take one pain medication overnight.Review of a written statement, dated 01/11/26, showed the resident told RN F and LPN J the following: -Between 2:00 A.M. and 2:30 A.M. in the morning, the resident pushed his/her call light to use the bathroom;-When CNA B answered call light, CNA B said he/she was training CNA E who was with him/her;-CNA B was very loud and rude and said if the resident didn't learn to transfer his/herself that he/she would be putting the resident on the bed pan;-The resident said he/she wouldn't use the bed pan;-CNA B was between the resident and resident roommate's bed, squatted down yelling at him/her;-The resident said that CNA B was rough with him/her and just flopped the resident in his/her chair;-The resident told CNA B that he/she was hurting the resident. CNA B did not stop or check to see why the resident was hurting. The resident kept telling CNA B his/her foot was caught and the CNA B continued to move the resident;-When CNA B put the resident back in bed, CNA B was still rough and rude at that time;-The resident stated after that he/she heard other residents yelling you are hurting me;-The resident was asked if he/she was fearful and the resident replied, he/she wouldn't say fearful but cautious;-The resident did not want CNA B back in his/her room.During an interview on 01/13/26, at 8:02 A.M., the resident said the following:-About 2:30 A.M., on 01/11/26, the resident pushed her call light for assistance to use the restroom;-CNA B responded to the room with CNA E;-CNA E stayed at the door to the resident's room;-CNA B was rough with the resident while assisting the resident out of bed and into his/her wheelchair;-CNA B brought the resident back to bed after using the restroom;-While CNA B was transferring the resident back to bed, the resident's left leg got caught in the wheelchair;-The resident told CNA B that he/she was hurting his/her leg and to please be careful;-CNA B continued jerking on the resident and the resident told CNA B, please you're hurting me, my foot is caught in the wheelchair;-After the resident was back in bed, CNA B squatted down between the resident's bed and his/her roommate's bed, got in the resident's face, and said to the resident, if you don't transfer on your own, I will put you on a bed pan;-The resident replied to CNA B, you won't find me on your bed pan;-CNA E who was still standing at the door said to CNA B, I think we better get out of here;-The resident said that he/she was very quiet the rest of the night, scared to death to ring her call light, and scared that CNA B would come back to the resident's room;-The resident said he/she needed to use the bathroom later that night but did not use his/her call light again until the day shift came on;-The resident reported the incident that day to his/her family and CNA C;-The resident said she had a good cry that night. He/she was mad, felt disrespected, and like that CNA B did not care;-He/she had anxiety the following evening in anticipation that CNA B would be back to work that night;-RN F took the resident's statement about the incident;-The resident said while lying in bed after the incident, he/she heard a female resident say, you are hurting me and a male resident say, that hurts;-The resident said that he/she was worried that CNA B had the code to the door and could get back into the facility.During an interview on 01/13/26, at 8:43 A.M., Resident #2 said the following:-The resident was awake when Resident #1 pushed his/her call light;-CNA B came into the room and Resident #2 heard banging while CNA B was transferring Resident #1 to the wheelchair;-CNA B threw Resident #1's pillows in the chair and grabbed the covers on Resident #1's bed and yanked them back;-CNA B was trying to transfer Resident #1 from behind to put him/her back in bed;-Resident #2 turned his/her head for a while to avoid getting upset with how CNA B was treating Resident #1;-Resident #2 did not hear Resident #1 say anything but could tell by the look on Resident #1's face that Resident #1 was in pain;-Resident #2 saw CNA B squat down between the resident's beds but did not hear what CNA B said to Resident #1.Review of a written statement, not dated, showed CNA B noted the following:-On Saturday, 01/10/26, at approximately 10:15 P.M., CNA B assisted the resident to the restroom;-The resident complained of pain while CNA B was tried to help the resident move his/her feet over the edge of the bed to help him/her sit up to transfer from bed to the chair;-While transferring the resident, he/she said several times within each transfer that it was hurting him/her;-CNA B helped him/her from the chair back into the bed where the resident's right foot got caught under the wheelchair;-CNA B tried to help the resident get his/her foot uncaught by lifting the wheelchair. The resident proceeded to complain of pain which CNA B understood, but also advised the resident that for his/her safety concerns and not wanting to inflict pain onto him/her since he/she was unable to help stand or pivot that it would be best to use another option such as the bed pan to ensure his/her safety;-The resident told CNA B that suggesting the bed pan was unnecessary and that he/she wasn't going to use it;-CNA B reported this situation to the nurse.During an interview on 01/15/26, at 3:02 P.M., CNA B said the following: -Resident #1 pushed his/her call light around 10:15 P.M., on 1/10/26, the resident needed assistance using the restroom;-While CNA B was moving the resident's feet around the bed the resident said that hurt, be slower;-CNA B said that the resident was not helping with the transfer, CNA B was lifting the resident up and putting him/her in the wheelchair;-The resident exerts all her energy during the day and during the night the resident is not able to assist with his/her transfers;-While assisting the resident back to bed the resident was complaining of pain;-CNA B suggested to the resident that because of his/her pain it might be better if the resident used a bed pan;-The resident said he/she would not use a bed pan;-The resident's foot got caught in the wheel of the wheelchair and CNA B got the residents foot unstuck;-CNA B reported to LPN H that the resident was unable to assist with the transfer and CNA B offered the resident a bed pan.During an interview on 01/14/26, at 12:34 P.M., CNA E said the following: -On 1/10/26, CNA E was shadowing CNA B on the overnight shift;-The resident had used the call light to call for assistance;-CNA B went into the resident's room while CNA E stood at the resident's door;-CNA B was rude to the resident and was being aggressive with the resident;-While CNA B was transferring the resident back into bed the resident said you are hurting me;-The resident's leg had gotten caught under the arm of the wheelchair;-CNA B continued to transfer the resident to the bed;-Once the resident was in bed, CNA B got in the resident's face and said if you don't like the way I transfer you then you can use the bed pan;-The resident told CNA B that he/she would not use a bed pan;-CNA B was arguing with the resident about using the bed pan;-CNA E could tell the resident was upset and told CNA B I think we need to go;-CNA E said that CNA B's aggression and rudeness with the resident made him/her uncomfortable;-CNA B left the resident's room and told LPN H that if the resident did not like the way CNA B transferred him/her then he/she could start using the bed pan.During an interview on 01/13/26, at 5:33 A.M., CNA A said the resident told him/her that CNA B was rude to him/her and told the resident he/she would have to use the bed pan if he/she did not get up on her own.During interviews on 01/13/26, at 5:41 A.M. and 12:52 P.M., CNA C said the following: -The resident said that the overnight aide (CNA B) had been rough and hateful with him/her;-CNA B told the resident if you can't get out of bed then you will start using the bed pan;-The resident told CNA B he/she would not use a bed pan and would use the toilet;-On 1/11/26, the resident told CNA C that he/she needed to use the restroom overnight on 01/10/26 and pushed his/her call light;-CNA B came in and told the resident that he/she could use a bed pan;-The resident told CNA B that he/she can get out of bed;-The resident said that CNA B hurt his/her leg while transferring the resident back to bed;-He/she had never seen the resident so upset before this incident;-The resident told CNA C that he/she did not want CNA B back in the resident's room.During an interview on 01/13/26, at 6:11 A.M., CNA D said the resident told him/her that CNA B was trying to make the resident use a bed pan.During an interview on 01/15/26, at 9:54 A.M., LPN J said the following: -On 11/11/26, RN F asked LPN J to be a witness while RN F interviewed the resident;-The resident said he/she pushed his/her call light for assistance using the restroom;-The resident said CNA B came into his/her room. CNA B squatted down in front of the resident and told the resident that if he/she did not get up that CNA B would get the bed pan for the resident;-The resident said that CNA B was mean, hateful, and really aggressive;-The resident told RN F that he/she did not want CNA B back in his/her room and asked RN F not to tell CNA B that he/she reported the aide;-LPN J could tell by the resident's voice that she was upset. The resident's voice was quivering;-The resident said that after CNA B left the room the resident could hear other residents saying no, stop, you're hurting me;-LPN J said due to the impact the interaction between the resident and CNA B had on the resident, he/she would consider the interaction abuse.During an interview on 01/13/26, at 1:35 P.M., the DON said the following: -The resident made a complaint to staff on 01/11/26 regarding CNA B;-Skin assessment completed with the resident, showed no injury or bruising noted;-Staff notified the DON and the physician. The family was present at the time the complaint was made;-Facility made self-report;-RN F interviewed the resident on 01/11/26 and the resident was put on hot racking (shift monitoring for change in mood and behavior).During an interview on 01/15/26, at 2:21 P.M., the Administrator said the following: -The Administrator would be concerned if a resident reported that a staff member had gotten in the resident's face;-The resident had chronic pain, and the Administrator would not be concerned if the resident said you are hurting me;-The Administrator did not feel that the incident involving the resident and CNA B was abuse;-The Administrator's thought process for the resident's comment of after CNA B left, the resident heard other residents yelling you're hurting me was that the resident meant in the past, not necessarily the night of the incident.Complaints #2713432 and #2713446

Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards, when hot water at the in room hand sinks of seven residents (Residents #24, #44, #46, #48, #54, #65, and #72), of 18 sampled residents on the Special Care Unit measured between 123.2 degrees Fahrenheit (F) and 129.9 degrees F. The residents were cognitively impaired and unable to regulate water temperatures. The facility census was 97. The Administrator was notified on 02/10/25, at 7:47 P.M., of an Immediate Jeopardy (IJ) which began on 01/14/25. The IJ was removed on 02/12/25 as confirmed by surveyor onsite verification. Review of the facility's policy and procedure titled, Water Temperatures, Safety of, showed the following: -Tap water in the facility shall be kept within a temperature range to prevent scalding of residents; -Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures on no more than the maximum allowable temperature per state regulation. Review of the Journal of American Medical Association's article Scald Burns from Hot Tap Water, dated 1981, showed the following: -At 120 degrees F, the time required for a 3rd degree burn (a burn that damages all three layers of the skin ) was 5 minutes; -At 124 degrees F, the time required for a 3rd degree burn was 3 minutes; -At 127 degrees F, the time required for a 3rd degree burn was 1 minute; -At 133 degrees F, the time required for a 3rd degree burn was 15 seconds. 1. Review of a plumbing contractor's invoice, dated 01/14/25, showed the following: -Arrived onsite and inspected the water heater with a mixing valve. Found a shut off for the recirculating pump that was on and needed to be off. Valve being on was causing the recirculation pump to pump against the tempered water; -Shut valve off and adjusted mixing valve slightly to allow warmer water; -Tempered water was reading approximately 118 degrees F to 120 degrees F at the main feed line; -Informed customer (facility) to keep all mop sinks and three compartment sinks completely off when not in use to prevent hot water mixing issues. 2. Review of Resident #24's ''Admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline) with late onset. Review of the resident's quarterly 'Minimum Data Set (MDS - a federally mandated assessment complete by facility staff), with an Assessment Reference Date (ARD) of 02/06/25, and located in the ''MDS'' tab of the EMR, showed the resident had severe cognitive impairment. Review of the resident's ''Care Plan,'' under the ''Care Plan'' tab of the EMR and with a review date of 02/07/25, showed the resident was an elopement risk/wanderer related to dementia (an umbrella term for a decline in cognitive abilities, including memory, thinking, and reasoning, that significantly impacts daily life, and is not a normal part of aging). Observation on 02/10/25, at 11:19 A.M., showed the resident sat in his/her wheelchair in the dining room socializing with other residents while waiting for lunch to be served. The resident was not interviewable. Observation on 02/10/25, beginning at 1:53 PM, showed the Maintenance Director measured the water temperature at the resident's hand washing sink. The hot water temperature measured 129.9 degrees F. Observation on 02/10/25, at 3:57 P.M., showed the Maintenance Director measured the water temperature at the resident's sink after making an adjustment to the water temperature. The hot water measured 128 degrees F. During an interview on 02/10/25, at 6:14 P.M., the Certified Nurse Aide Unit Director (CNA/UD) 5 said the resident would not be able to regulate the water temperatures from the bathroom sink and might not know to pull his/her hands away from the hot water to keep from being scalded. 3. Review of Resident #44's ''Admission Record,'' located in the ''Profile'' tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia. Review of the resident's quarterly MDS, with an ARD of 01/03/25 and located in the ''MDS'' tab of the EMR, showed the resident had severe cognitive impairment. Review of the resident's ''Care Plan,'' under the ''Care Plan'' tab of the EMR and with a review date of 02/10/25, showed the resident was an elopement risk/wanderer related to dementia. Observation on 02/10/25, at 10:50 A.M., showed the resident was in his/her room lying in bed. The resident was not interviewable. Observation on 02/10/25, beginning at 1:53 PM, showed the Maintenance Director measured the water temperature at the resident's hand washing sink. The hot water hot water temperature measured 123.4 degrees F. During an interview on 02/10/25, at 6:14 P.M., the CNA/UD 5 said the resident would not be able to regulate the water temperatures from the bathroom sink and might not know to pull his/her hands away from the hot water to keep from being scalded. 4. Review of Resident #46's ''Admission Record,'' located in the ''Profile'' tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia. Review of the resident's quarterly MDS, with an ARD of 11/28/24 and located in the ''MDS'' tab of the EMR, showed the resident had severe cognitive impairment. Review of the resident's ''Care Plan,'' under the ''Care Plan'' tab of the EMR and with a review date of 11/22/24, showed the resident was an elopement risk/wanderer related to dementia. Observation on 02/10/25, at 10:43 AM, showed the resident sat in the dining room watching television. The resident was not interviewable. Observation on 02/10/25, beginning at 1:53 PM, showed the Maintenance Director measured the water temperature at the resident's hand washing sink, on the memory care unit. The hot water measured 125.1 degrees F. During an interview on 02/10/25, at 6:14 P.M., the CNA/UD 5 said the resident would not be able to regulate the water temperatures from the bathroom sink and might not know to pull his/her hands away from the hot water to keep from being scalded. 5. Review of Resident #48's ''Admission Record,'' located in the ''Profile'' tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia and Alzheimer's disease with late onset. Review of the resident's quarterly ''MDS,'' with an ARD of 11/27/24 and located in the ''MDS'' tab of the EMR, showed the resident had severe cognitive impairment. Review of the resident's ''Care Plan,'' under the ''Care Plan'' tab of the EMR and with a review date of 11/22/24, showed the resident was an elopement risk/wanderer related to dementia. Observation on 02/10/25, at 11:23 AM, showed the resident sat in the dining room. The resident was not interviewable. Observation on 02/10/25, beginning at 1:53 PM, showed the Maintenance Director measured the water temperatures at the resident's hand washing sink. The hot water measured of 124.3 degrees F. During an interview on 02/10/25, at 6:14 P.M., the CNA/UD 5 said the resident would not be able to regulate the water temperatures from the bathroom sink and might not know to pull his/her hands away from the hot water to keep from being scalded. 6. Review of Resident #54's ''Admission Record,'' located in the ''Profile'' tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia. Review of the resident's quarterly MDS, with an ARD of 12/02/24 and located in the ''MDS'' tab of the EMR, showed the resident had moderate cognitive impairment. Review of the resident's ''Care Plan,'' under the ''Care Plan'' tab of the EMR and with a review date of 11/22/24, showed the resident needed secured/special care neighborhood due to dementia (wandering). Observation on 02/10/25, beginning at 1:53 PM, showed the Maintenance Director measured the water temperature at the resident's hand washing sink, on the memory care unit. The hot water temperature measured of 125.0 degrees F. During an interview on 02/10/25, at 6:14 P.M., the CNA/UD 5 said the resident would not be able to regulate the water temperatures from the bathroom sink and might not know to pull his/her hands away from the hot water to keep from being scalded. 7. Review of Resident #65's ''Admission Record,'' located in the ''Profile'' tab of the EMR, showed the following: -admitted [DATE]; -Diagnosis of Alzheimer's disease with late onset. Review of the resident's quarterly MDS, with an ARD of 02/03/25 and located in the ''MDS'' tab of the EMR, showed the resident had severe cognitive impairment. Review of the resident's ''Care Plan,'' under the ''Care Plan'' tab of the EMR and with a revision date of 07/30/24, showed the resident was an elopement risk/wanderer related to Alzheimer's disease. Observation on 02/10/25, at 11:26 A.M., showed the resident sat in the dining room. The resident was not interviewable. Observation on 02/10/25, beginning at 1:53 PM, showed the Maintenance Director measured the water temperature at the resident's hand washing sink. The hot water temperature measured 123.2 degrees F. During an interview on 02/10/25, at 6:14 P.M., the CNA/UD 5 said the resident would not be able to regulate the water temperatures from the bathroom sink and might not know to pull his/her hands away from the hot water to keep from being scalded. 8. Review of Resident #72's ''Admission Record,'' located in the ''Profile'' tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia. Review of the resident's quarterly MDS, with an ARD of 11/18/24 and located in the ''MDS'' tab of the EMR, showed the resident had severe cognitive impairment Review of the resident's ''Care Plan,'' under the ''Care Plan'' tab of the EMR and with a revision date of 11/26/24, showed the resident could benefit from placement on the secure neighborhood due to need for safe environment and special programing. Observation on 02/10/25, at 11:23 A.M., showed the resident sat in the dining room. The resident was not interviewable. Observation on 02/10/25, beginning at 1:53 P.M., showed the Maintenance Director measured the water temperature at the resident's hand washing sink. The hot water temperature measured of 124.3 degrees F. During an interview on 02/10/25, at 6:14 P.M., the CNA/UD 5 said the resident would not be able to regulate the water temperatures from the bathroom sink and might not know to pull his/her hands away from the hot water to keep from being scalded. 9. During interviews on 02/10/25, at 3:08 P.M. and 3:32 P.M., the Maintenance Director said the following: -After the plumbing company provided services for hot water temperatures on 01/14/25 he did not increase monitoring of the temperatures. He completed weekly checks of water temperatures of one room at each end of the hall for all three halls in the facility. -The reason the plumbing company came to the facility for services on 01/14/25 was due to the hot water at the mop sink on unit 100 was cold and the resident in room [ROOM NUMBER] complained the hot water was cold. -After adjustments were made to the water temperatures, he waited until the following day to follow up on the water temperatures. Observation and interview on 02/10/25, at 3:45 P.M., with the Maintenance Director showed the water temperature at the water tank for units 100 and 300 measured 123 degrees F. The Maintenance Director said the hot water valve needed to be adjusted. After adjustments were made, he would wait until the following day to check to make sure the temperature had come down below 120 degrees. During an interview on 02/11/25, at 10:31 A.M., the Administrator said they were continuing to take temperatures and were looking to see what the underlying problem with the hot water temperatures might be. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level.

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when staff failed to perform proper hand hygiene during and after incontinent care and wound care for one resident (Resident #7) out of a total sample of 20. The facility census was 97. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised on 08/2015, showed the following: -Hand hygiene is the primary means to prevent the spread of infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors before and after direct contact with residents; before performing any non-surgical invasive procedures; before handling clean or soiled dressings, gauze pads, etc; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after contact with blood or bodily fluids; and after handling used dressings, contaminated equipment. 1. Review of Resident #7's undated Admission Record, located in the electronic medical record (EMR) under the Resident tab, showed the following: -Readmitted [DATE]; -Diagnoses included congestive heart failure (CHF - a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply), acute and chronic respiratory failure, diabetes type II, and chronic kidney failure. Review of the resident's Care Plan, revised on 09/26/23 and located in the EMR under the Care Plan tab, included the risk for impaired skin and an actual integrity issue related to excoriation. Observation on 02/13/25, at 4:05 P.M., showed the following: -Certified Nursing Assistant (CNA) 1 and Wound Nurse (WN) 1 performed hand hygiene and applied gowns and gloves prior to entering the resident's room; -The resident was noted to be incontinent of bowel. WN1 performed incontinent care and passed the soiled wipes to CNA1 across the resident's chest. -WN1 and CNA1 turned the resident on his/her left side, and WN 1 performed incontinent care to the buttock/rectal area. WN1 cleaned the resident with numerous disposable wipes and handed the soiled wipes to CNA1 to dispose of, crossing the resident's chest each time. -Without changing his/her gloves or performing hand hygiene, WN1 removed a dressing from the resident's gluteus wound and continued to clean the resident's buttocks and anal area, wiping towards the wound. -WN1 removed the soiled brief from underneath the resident, passed it to CNA1, crossing the resident's chest. WN1 then removed his/her gloves, and without performing hand hygiene, applied new gloves, and cleansed the resident's gluteus wound. -After the care was performed, CNA1 adjusted the resident's pillow and clothing without changing his/her gloves or performing hand hygiene. During an interview on 02/13/25, at 4:25 P.M., WN1 confirmed that he/she did not perform hand hygiene between glove changes but should have. WN1 confirmed she should not have cleaned the resident's buttocks and anal area with fecal material towards the exposed wound. During an interview on 02/13/25, at 4:50 P.M., CNA1 confirmed that he/she did not perform hand hygiene or apply a clean pair of gloves after handling the soiled incontinent products and before adjusting the resident's pillow and gown. During an interview on 02/13/25, at 5:57 PM, the Infection Preventionist (IP1) said staff should wash their hands with soap and water prior to setting up, before handling clean or soiled dressing, and before moving from a contaminated body area to a clean body area.

Based on interviews and record review, the facility failed to ensure all allegation of possible neglect were reported within two hours to the State Survey Agency (SSA - Department of Health and Senior Services (DHSS)) when staff did not report an allegation of possible neglect received from one resident's (Resident #1) family. The facility also failed to ensure all staff were properly trained on the reporting guidelines regarding allegations of neglect. The facility census was 102. Review of the facility's policy titled Preventing Resident Abuse, undated, showed the following information: -The facility will not condone any form of resident abuse and will continually monitor the facility's policies, procedures, training program, and systems to assist in preventing resident abuse; -It is the responsibility of the employees, facility consultants, attending physicians, family members, visitors and volunteers to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source and theft or misappropriation of resident property to the administrator or his/her designee; -When an alleged or suspected case of abuse, neglect, injuries of an unknown source, or misappropriation of resident property is reported the facility administrator or his/her designee will notify the following persons or agencies of such incident: the SSA, the responsible representative, law enforcement, and the physician; -Notices to the above agencies/individuals shall be made within the time limitations of the State law after the occurrence of the incident or when the facility learns of the abuse; -The administrator or designee shall report to the SSA according to the facility abuse and neglect policy and local law enforcement agency. -If there is serious bodily injury the report must be made within two hours of forming a reasonable suspicion; -If there is no serious bodily injury the report must be made within 24 hours of forming reasonable suspicion. 1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admitted [DATE]; -Diagnoses included amyotrophic lateral sclerosis (ALS - a nervous system disease that weakens muscles and impacts physical function), foot drop for left and right foot (difficulty lifting front part of foot), and dysarthria (a motor speech disorder that makes it difficult to speak clearly due to issues with the muscles used for speech). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/24/24, showed the following: -Cognition moderately impaired; -Required total assistance from staff with bed mobility, transfers, dressing, hygiene, toileting, and bathing. Review of the resident's care plan, undated, showed the following: -Resident has an activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) self-care performance deficit related to ALS diagnosis; -Totally dependent on one to two staff for toilet use. -Deficit in communication related to ALS diagnosis; -Staff to check for incontinence every two hours. During an interview on 08/22/24. at 10:42 A.M., the resident communicated the following: -A few nights ago, he/she was left on the toilet from approximately 2:00 A.M. until approximately 8:00 A.M.; -His/her bottom hurt from it; -The aide got busy and forgot about him/her. Review of a typed conversation between the resident's durable power of attorney (DPOA) and the Director of Nursing (DON), dated 08/19/24, showed the following: -The DPOA informed the DON the resident was placed on the toilet and left for six and half hours during the night; -The DPOA said the resident was not removed from the toilet until 8:00 A.M., by a home care giver who came to visit the resident. Review of the facility's grievance log showed the following: -On 08/19/24 the resident's DPOA filed a grievance regarding patient care. -Staff noted the grievance was resolved on 08/21/24. -The Administrator signed the grievance as resolved. Review of a grievance form regarding the resident, dated 08/19/24, completed by the DON and signed by the Administrator, showed the following: -The resident's DPOA filed a grievance concerning the patient care and treatment; -The concern was prolonged toileting wait time; -Resolution was all staff educated and in-serviced. One-on-one education provided to certified nurses aide and new call light cord installed. Review of the grievance records and the resident's medical record showed the facility staff did not document notifying the DHSS of the allegation of possible neglect. Review of DHSS records showed the home did not self-report the allegation of possible neglect to DHSS. During an interview on 08/22/24, at 10:15 A.M., Licensed Practical Nurse (LPN) A said the following: -All allegations of neglect should be reported to the SSA within two hours; -If a resident was left on the toilet for any extended period of time, like six hours, this would be neglect. During an interview on 08/22/24, at 12:55 P.M., Certified Nurse Aide (CNA) B said the following: -All allegations of neglect should be reported to the charge nurse and then the facility has two hours to report the allegation to the SSA. -If a staff left a resident on the toilet from 2:00 A.M. to 8:00 A.M. that would be neglect. During an interview on 08/23/24, at 11:55 A.M., the resident's Nurse Practitioner (NP) said the resident should not be left on the toilet. If a resident was left for six hours this would be neglect. During an interview on 08/22/24, at 11:55 A.M., the DON said the following: -The resident's DPOA had reported to him the resident had been left on the toilet on 08/19/24 for an extensive amount of time; -The DPOA was concerned about why the resident was left on the toilet for so many hours and if the resident's skin was compromised; -He began an investigation and interviewed the resident and staff to include the named staff; -He did not report to the SSA because he thought the facility could do the investigation and then report to the SSA if they believed any abuse or neglect occurred; -He did not know he had to report any allegations of neglect; -He said if the investigation showed the resident had been left on the toilet for six and half hours they would consider that neglect. During an interview on 08/23/24, at 3:00 P.M., the Administrator said the following: -All allegations of abuse or neglect should be reported to the SSA within two hours; -Staff should be checking on residents every two hours and as needed; -The DON should have reported the allegation of the resident being left on the toilet all night to the SSA within the two hour required time frame and investigated this as neglect; -If a resident was left on the toilet for any extended period of time to include six hours this would be considered neglect. MO00240792 MO00240938

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed in a manner to prevent possibly contamination when staff failed to maintain failed to properly label and cover food in the walk-in cooler and failed to keep the stove hood, the cooler fans, and the vents above the dish area clean and free from debris. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 100. 1. Review of the US Food and Drug Administration policy, under the section of Food Labeling and Handling, currently updated 03/04/23, showed the following: -Facility staff must ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated; -Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded. Review of the facility's policy titled, Food Receiving and Storage, revised October 2017, showed the following: -All foods stored in the refrigerator will be covered, labeled, and dated (use by) date; -Opened containers must be dated and sealed or covered during storage. Observations on 12/10/23, beginning at 3:14 P.M., of the kitchen's walk-in cooler showed the following: -A plastic bag containing three boiled eggs, which had been opened, with no open or used by date noted; -Four trays on a rack, with several small bowls of uncovered jello; -One tray with four cups of what appeared to be pudding, uncovered, undated, and unlabeled; -One bag of cooked sausage patties and pieces of toast with no description or date of when prepared. During an interview on 12/13/23, at 133 P.M., Dietary Aide (DA) A said the following: -All foods should be dated with the date they're opened; -He/she doesn't know how long food can sit once opened; -He/she wouldn't serve food to residents that's not dated or outdated; -All foods put in the refrigerator should be covered. During an interview on 12/13/23, at 137 P.M., DA B said the following: -Foods should be dated with the date they're opened; -Opened foods should be used within four days; -Foods put into the refrigerator should be covered. During an interview on 12/13/23, at 1:45 P.M., Dietary Manager said the following: -Opened foods should be dated with the date opened; -Opened foods should be used within seven days; -If the foods are over seven days, or undated foods should be discarded; -He/she put the sausage patties and toast in the refrigerator one day after breakfast and forgot to date them; -All foods in the refrigerator should be covered. During an interview on 12/13/23, at 1;45 P.M., the Administrator said the following: -Foods should be dated when they're opened; -He/she is not sure how long foods can be safely used once they're opened; -If the foods are past the safe date, they should be thrown away. 2. Review of the facility's December 2023 cleaning schedule showed the the range hood listed, but it did not specify how often it needed cleaned and no staff had checked cleaning it. Observations on 12/10/23, beginning at 3:14 P.M., and on 12/13/23, beginning at 10:24 A.M., showed the hoods above the stove had a build-up of grease and lint on them (which could fall and contaminate food being prepared). During an interview on 12/13/23, at 1:33 P.M., DA A, said the following: -The stove hoods are cleaned by an outside agency every six months and they're due to be cleaned on 12/27/23; -Kitchen staff don't clean the stove hoods; -It is not appropriate for the stove hoods to have lint as it could fall into the food being cook. During an interview on 12/13/23, at 1:37 P.M., DA B, said the following: -Stove hoods are cleaned by another company. There is a white sticker that tells when they've been cleaned; -Kitchen staff don't clean the stove hoods; -If they have lint in the hood, it could fall into the food. During an interview on 12/13/23, at 1:45 P.M., the Dietary Manager said the following: -An outside company cleans the stove hoods every six months; -Kitchen staff clean the back splash, but they don't do anything with the stove hoods; -Lint on the stove hoods could fall into the food. During an interview on 12/13/23, at 1;45 P.M., the Administrator said the following: -Stove hoods are cleaned routinely by an outside source; -She is not sure if the staff maintain in between the cleanings of the agency; -She would expect them to be clean and not have lint to possibly fall into the food. During an interview on 12/13/23, at 1;:5 P.M., the Maintenance Supervisor said the following: -He/she cleans the heads of the stove hoods, but a company comes in and does the actual cleaning of the stove hoods yearly, they're due to come on 12/27/23; -Staff clean them daily. 3. Review of the facility's December 2023 cleaning schedule for showed the following: -Freezer, not specifying the fans, to be cleaned every two weeks; -Staff documented cleaning the freezer eight times from 12/01/23 through 12/11/23. Observations on 12/10/23, beginning at 3:14 P.M., and on 12/13/23, beginning at 10:24 A.M., showed the two fans located in the walk-in refrigerator had a black substances on the undersides of the grill covers with uncovered foods in front of them (potentially contaminating the food). During an interview on 12/13/23, at 1:33 P.M., DA A, said he/she doesn't know who is supposed to clean the fans in the walk-in refrigerator. During an interview on 12/13/23, at 1:45 P.M., the Dietary Manager said the following: -Maintenance is the one who cleans the fans in the walk-in refrigerator; -It would not be good for the fans to be dirty as it could blow onto the food. During an interview on 12/13/23, at 1:45 P.M., the Administrator said the following: -The Dietary Manager is good about alerting maintenance if the fans need to be cleaned; -He/she didn't know the fans have a black substance on them; -Would expect the fans to be clean so it doesn't blow onto food. During an interview on 12/13/23, at 1:45 P.M., the Maintenance Supervisor said the following: -He/she has not been told it's his/her responsibility to clean the fans in the walk in refrigerator. He/she didn't know if there was a corporation that comes into clean them; -He/she didn't know they have black substance on them. 4. Observations on 12/10/23, beginning at 3:14 P.M., and on 12/13/23, beginning at 10:24 A.M., showed two vents in the dishwashing area over half covered with fuzzy lint. There was also lint on the ceiling above the sink. During an interview on 12/13/23, at 13:3 P.M., DA A, said the following: -Maintenance cleans the ceiling and the vents once or twice per month; -it is not appropriate for them to have fuzzy lint as it could fall into the food or on clean dishes; -He/she lets maintenance know when he/she sees the lint During an interview on 12/13/23, at 1:37 P.M., DA B, said the following: -Ceiling and vents are cleaned by maintenance but he/she is not sure if there is a set schedule; -He/she would let maintenance know if there was lint on the ceiling or vents as this could fall into the food. During an interview on 12/13/23, at 1:45 P.M., the Dietary Manager said the following: -The previous maintenance supervisor cleaned the vents and ceiling on a schedule; -If kitchen staff see lint or dirt they let maintenance know or one of the kitchen staff will take care of it; -The vents shouldn't have lint as it could fall into the food. During an interview on 12/13/23, at 1;45 P.M., the Maintenance Supervisor said the following: -He/she has not been told he/she is supposed to clean the vents/ceilings in the kitchen; -He/she expects the vents/ceiling would be cleaned monthly or as needed.

Based on observation, interview, and record review, the facility failed to provide a sanitary and comfortable environment for residents, staff and the public, when staff failed too keep light fixtures throughout the facility clean and free from dead bugs and debris. The facility census was 100. 1. Observations on 12/12/23, beginning at 1:35 P.M., showed the following: -Ceiling light fixtures throughout the common areas of the facility had dead bugs and debris in them; -On the 100 upper hall (rooms 100 to 112) large bugs, dust, and debris were observed in five of the ten hall ceiling light fixtures; -In the back area of the main dining room (MDR) there were four of the five light fixtures with debris in them; -In the MDR there were 16 of the 16 light fixtures that had dust and debris in them; -Outside of the MDR, near the soiled laundry room A32 and exit off the upper 200 hall, one of two light fixtures had dead bugs and debris in it; -The 200 hall/300 hall had two of eight light fixtures with bugs and debris present. Observations on 12/12/23, at 1:45 P.M., of the 100 hall Special Care Unit (SCU) showed the following; - Dark splatters on the light fixture in the medication preparation room; -The 100 hall spa, by the electrical room, light fixture had bugs/debris present; -The 100 hall, by exit door near the electrical room, light fixture had bugs and debris present; -West of room [ROOM NUMBER]C, by exit door, the overhead light in the hall had bugs and debris present; -Near room [ROOM NUMBER]A and 1B, the light fixture had debris and bugs present. During an interview on 12/14/23, at 2:44 P.M., the Maintenance Supervisor (MS) said the following: -He repairs any light fixtures and when he does any maintenance or light bulbs need to be replace. He will clean the light fixture at that time; -He has seen some debris and bugs in the light fixtures throughout the facility, but did not know he was responsible for cleaning them. During an interview on 12/14/23, at 3:34 P.M., the Administrator said the following: -The MS is responsible for cleaning the light fixtures: -The previous maintenance supervisor took the light fixtures down and cleaned them periodically or when light bulbs needed to be replaced; -She was not aware of any issues with the dirty light fixtures; -The light fixtures should be kept cleaned at all times. 45176

Based on interview and record review, the facility failed to protect all residents from misappropriation of property when staff could not account for all of one resident's (Resident #1) diazepam (a controlled medications used for to treat anxiety) while the medication was in the possession of the home. The facility census was 80. Record review of the facility policy Investigating Incidents of Theft and/or Misappropriation of Resident Property, revised April 2017, showed the following: -Residents have the right to be free from theft and/or misappropriation of personal property; -Misappropriation of resident property is defined as the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Record review of the facility Policy Procedures for Controlled Substances, undated, showed in any situation where a properly labeled and identified controlled substance is brought into facility with resident upon admission, every effort must be made to return this quantity with family member or admitting personnel. If controlled substance brought into facility with resident cannot be returned to family or admitting personnel and/or is to be received and used until supply is received from facility's designated provider pharmacy, this quantity of controlled substance must be identified and quantity entered into bound narcotic book. 1. Record review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included sepsis (serious condition resulting from presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), cirrhosis (a chronic disease marked by degeneration of cells, inflammation, and fibrous thickening of tissue typically a result of alcoholism or hepatitis) of liver, major depressive disorder, viral hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), pain , chronic pain syndrome, opioid (narcotic) dependence, Type 2 diabetes mellitus with hyperglycemia (high blood glucose). Record review of the resident's medication list from the hospital, dated 10/28/22, showed an order for diazepam 5 milligrams (mg) tablet with no frequency, route, and indication for use. Record review of the resident's Order Summary Report, dated 10/28/22, showed no physician's order for diazepam 5 mg. Record review of the resident's Progress Notes, dated 11/23/22, showed the nurse practitioner saw the resident and the resident discussed ongoing neuropathy (nerve) pain to both feet and had increasing anxiety. Orders received to resume diazepam as taken prior to hospitalization , 5 mg every 8 hours routinely. Record review of the resident's Order Summary Report, dated 11/23/22, showed the following: -Physicians' order for diazepam 5 mg, give 5 mg by mouth every 8 hours for anxiety. Medication was scheduled for 6:00 A.M., 2:00 P.M., and 10:00 P.M. Record review of the resident's Medication Administration Record (MAR) showed the following: -Staff administered diazepam 5 mg to the resident on 11/27/22 through 12/7/22 at 6:00 A.M., 2:00 P.M., and 10:00 P.M. with staff administering one dose of the diazepam 5 mg at 6:00 A.M. on 12/7/22 prior to the resident's discharged . Record review of the facility's investigation for missing narcotics, dated 12/12/22, showed the following: -On 11/27/22, staff discovered a prescription pill bottle of diazepam 5 mg tablets in the resident's purse in the resident's room. Licensed Practical Nurse (LPN) G and unknown certified medication technician (CMT) took the resident's prescription bottle and counted 77 diazepam tablets. They taped the bottle and initialed it and locked this in the cabinet in the medication room where the E-kit (emergency kit - medications needed right away before the pharmacy delivers them) was located; -On 11/27/22, the day shift LPN A, received report from the night nurse (LPN G) that the resident's medication was locked in the cabinet in the medication room. Later that day, the resident complained of anxiety. LPN A and Registered Nurse (RN) B went to obtain the resident's medication. They counted and verified that the medication was diazepam. Both nurses counted 77 diazepam 5 mg tablets in the resident's prescription bottle. They divided the tablets in a count of 20 tablets and placed them in small plastic bags, then stapled and labeled each plastic bag, and placed the plastic bags in a long white envelope. Each nurse initialed the white envelope. The remaining 17 diazepam tablets were put in the resident's prescription pill bottle and placed in the medication cart and logged the 17 diazepam tablets into the narcotic book; -On 12/2/22, LPN C, CMT D, and CMT E, went into the medication room's locked medication cabinet to get one plastic bag of 20 diazepam tablets because one 5 mg tablet of diazepam was in the medication cart. There were three plastic bags with 20 diazepam tablets in each bag in the white envelope. LPN C, CMT D and CMT E removed one bag of 20 diazepam tablets and counted out 20 diazepam 5 mg tablets and transferred the 20 tablets into the resident's pill bottle and placed this in the medication cart, and added the 20 tablets to the narcotic book count. LPN C, CMT D, and CMT E put a new neon green/yellow sticker on the envelope and wrote #40 on the envelope to indicate 40 diazepam 5 mg tablets remaining; -On 12/5/22, the pharmacy sent 60 diazepam tablets for the resident, but these were not needed, as staff utilized resident's own diazepam medications located in the medication cart; -On 12/7/22, the resident was due to being discharged from the facility. LPN F was getting the resident's medications ready and discovered that in the envelope marked 40 diazepam tablets, there was only one plastic baggie marked 20 tablets, instead of two baggies with 20 tablets in each baggie; -Staff immediately notified administration and performed a thorough search of the medication room, cabinets, and medication carts for the potential missing diazepam medications; -A full investigation was launched; -The findings of the investigation were inconclusive. Record review of LPN G's written statement, dated 12/9/22, showed on 11/25/22, an unidentified certified nurse aide (CNA) told LPN G that the resident had medication in his/her room. LPN G and CMT went to the resident's room and the resident opened his/her purse and they found several bottles of medication. One bottle of narcotic that was counted and there were 77 tablets. They taped the bottle and initialed it and put it in the medication room in the locked cabinet. When LPN G returned to work, there was the resident's prescription bottle in the CMT cart and the CMT was counting the medication. The CMT told him/her they counted 20 tablets out and was using them. LPN G saw the medications in the CMT cart and did not look back in the locked medication cabinet to see how many medications were left. During an interview on 1/5/23, at 4:40 P.M., LPN G said the following: -The night CNA H came to him/her to report the resident had narcotic medications in his/her room; -CMT I went with LPN G to the resident's room and said to the resident that they needed the medications; - LPN G and CMT I took the medication to the medication room and counted 77 tablets; - LPN G and CMT I initialed on the tape and placed the medication bottle in the locked e-kit cabinet; -He/she did not know what to do and did not know the protocol for handling a resident's own home narcotic medication at the facility; - LPN G worked until 6:00 A.M. and passed this on in report to the day charge nurse about finding 77 narcotic medications in the resident's room, which they removed and locked the medications up in the medication room locked cabinet; - LPN G said many days later, he/she noticed many pills in the narcotic count and an unidentified CMT said they had separated the pills from the cabinet and put into the resident's medications on the medication cart; -The resident's medications should have went into the narcotic count on the cart and counted every shift change. Record review of LPN A's written statement, undated, showed on 11/27/22, LPN A received report that the resident's Valium (diazepam) 5 mg was in the locked cabinet in the medication room. Upon assessment, the resident complained of anxiety. LPN A and an unidentified nurse went into the medication room to count and verified the medication. There was 77 Valium 5 mg tablets and LPN A and unidentified nurse placed 17 Valium tablets back into the resident's prescription bottle and placed them on the medication cart. LPN A wrote the 77 narcotic Valium 5 mg medications in the narcotic book to be accounted for. LPN A and the unidentified nurse took the remaining 60 tablets and placed them in plastic envelopes in quantities of 20 tablets, then stapled the plastic bags shut and wrote #20 on them. They took the three bags of 20 tablets which equaled 60 tablets, and place them in a facility envelope and sealed it shut, and placed scotch tape on them. They signed over the tape and envelope with their names and the #60 Valium on the envelope. LPN A placed that envelope into a large pharmacy bag with the resident's name on it and placed the bag into the locked cabinet in the medication room. During interview on 1/5/23, at 10:55 A.M., LPN A said the following: -Staff found the resident with a prescription bottle of diazepam (Valium) 5 mg medication and staff put the resident's Valium up in the locked cabinet in the south hall medication room; -The night nurse told him/her the resident's Valium was in the locked cabinet, but did not know how long it had been in the cabinet; -When LPN A did rounds, the resident said to him/her that he/she had anxiety and pain. He/she went to the med room and didn't think diazepam was in the e-kit which it was not; -There was no narcotic sheet for the 77 (Valium). Registered Nurse (RN) B counted #77 valium with him/her; -They put the Valium 5 mg tablets in groups of 20 tablets and put into a baggy, then put the three baggies in an envelope, signed it, and taped it. They put the 17 diazepam tablets in the resident's prescription bottle in the medication cart and filled out a narcotic sheet for the medication count. Record review of RN B's undated written statement showed on November 27, 2022, LPN A asked RN B to come over to the south side nurse's station because there was medication found in Resident #1's purse the previous night by the night shift nurse. The medication was Valium 5 mg and there were 77 tablets in the bottle. Since Resident #1 did not have any supply left from the pharmacy, as well as the resident's physician was out of the country, they took it upon themselves to use Resident #1's diazepam medication from home until the physician provided a new prescription to the pharmacy. To ensure counting with accuracy, they decided that it was best to place the medication in clear pouches to better count these during the narcotic count. LPN A and RN B placed 20 diazepam tablets into three different pouches that were see through and easier to count and 17 diazepam 5 mg were placed in the resident's prescription bottle and placed those in the medication cart since Resident #1 had this medication diazepam scheduled three times a day. LPN A and RN B both signed each of the three pouches and the envelope that they placed the three pouches in. They sealed the pouches with staples and red dots with their initials on it and the date and the amount in each pouch in the white envelope. They signed and dated the amount that were in the pouches. LPN A placed them in the E-kit cabinet for safekeeping until more were needed. During interview on 1/5/23, at 10:37 A.M., RN B said the following: -LPN A had called him/her from the south side and asked RN B to help him/her figure out the prescription bottle found in the resident's purse on the night shift. The diazepam 5 mg prescription bottle had 77 tablets after RN B and LPN A counted them; -They decided to divide the pills into packages of 20 tablets and put in a clear plastic pill plastic crusher bags into 20 tablets for three packages and then put 17 diazepam tablets in the medication cart; -They wrote #17 diazepam 5 mg tablets on the narcotic record sheet. They put the other three packages of 20's into the e-kit in the locked cabinet; -Only the south medication room has the e-kit and there was one key. The nurses have the key only and no CMTs have access to the medication room key; - Both RN B and LPN A signed the envelope and sealed it and placed this envelope into the cabinet and locked the cabinet before RN B left. Record review of LPN F's written statement, dated 12/7/22, showed when LPN F was collecting medications for the resident's discharge to home. An unidentified CMT gave a prescription bottle of diazepam to LPN F. The prescription bottle was labeled from a retail pharmacy and had been filled on 9/29/22. There were six tablets left in the bottle. The unidentified CMT said that we were given permission by the Director of Nursing (DON) to give the resident's home medications due to an issue with the physician's signature on the script. LPN F asked LPN C to get resident's medications since LPN F had control of the resident's narcotic medications. LPN C gave LPN F a plain mailing envelope with stickers and writing on it. There were two red stickers with initials on the flap at each end, a red sticker with #60 on it in the middle and this was covered by a larger yellow sticker with #40 on it. The writing on one short end was #20 removed and #40 left on envelope. There were two individual signatures and initials below the signatures. LPN F took the envelope to the DON before opening it to have someone else as witness. During interview on 1/10/23, at 9:14 A.M., LPN F said he/she typically worked on the south side and became aware of the resident's Valium medication on the date of discharge 12/7/22; -LPN F was not aware of the resident's home medications in the cabinet until the resident's discharge; -The unidentified CMT told LPN F that the resident had medications on the medication cart and gave the resident's prescription bottle of Valium to him/her. The CMT told LPN F that the resident had more medications in the e-kit locked cabinet. The CMT brought a plastic bag with medication, and an envelope with signatures and numbers on it. It did not say what medication was in the envelope and did not have the resident's name on it. LPN F went to the DON's office to open the envelope; -The DON said he/she was unaware of the resident's own prescription Valium locked up in the cabinet in the med room; -LPN F and the DON opened the envelope that said #40 inside. There was only one plastic baggy with 20 Valium 5 mg tablets. The envelope was secured with stickers that held the envelope flap down but it did not stick well. The envelope flap was secured partially. The prescription bottle of Valium on the medication cart had six 5 mg tablets left inside; -LPN F said he/she would expect staff to keep a narcotic record for the Valium even when locked up in the cabinet. Record review of the resident's narcotic sheet showed the following: -Diazepam 5 mg with directions for staff to administer one tablet by mouth every 8 hours routine; -Balance forward was 17 diazepam 5 mg tablets; -First date recorded was 11/27/22, at 8:00 A.M., with one dose administered to leave a remaining balance of 16 diazepam 5 mg tablets; -On 12/2/22, at 8:00 A.M., staff recorded one diazepam 5 mg tablet as the remaining balance; -Under the received from pharmacy column, staff documented pulled 20 from envelope; -Balance Forward was 21 diazepam 5 mg tablets; -On 12/7/22, staff administered one diazepam 5 mg tablet at 8:00 A.M. with a remaining balance forward of six diazepam 5 mg tablets; -There was no other narcotic sheet record with the resident's total number of 77 diazepam 5 mg tablets from the resident's home medication that was locked in the e-kit narcotic locked cabinet. Staff administered a total of 31 diazepam 5 mg tablets to the resident between 11/27/22 to 12/7/22. During interview on 1/12/23, at 12:30 P.M., CMT I said the following: -LPN G told him/her to go to the resident's room to take the Valium (diazepam) 5 mg to count and lock up; -The prescription bottle for the diazepam had #90 on the bottle, but there were 77 diazepam 5 mg counted; -LPN G taped the lid with the #77 to prove they counted this amount of diazepam 5 mg; -He/she did hint to LPN G that they should put the #77 total diazepam 5 mg on a narcotic sheet in the locked cabinet but thought LPN G did not know what to do with the diazepam 5 mg medication. During interviews on 1/6/23, at 3:35 P.M., and 1/23/23, at 12:30 P.M., the DON said the following: -She expected all staff to reconcile all narcotic medications and do this every shift. This would include narcotic medications in the e-kit; -She was unaware of Resident #1's diazepam kept in the locked medication cabinet in the med room until the day the resident was discharged to home. During interview on 1/5/22, at 11:15 A.M., the Administrator said the following: -On 11/27/22, the resident told a nurse or medication technician that he/she had diazepam in his/her purse. The staff should have told the DON that they found the diazepam medication, but they took the prescription bottle, initialed it, and locked it in the cabinet; - Staff did not count the pouches of diazepam 5 mg tablets that were in the e-kit cabinet each shift. Sometime between 12/2/22 and 12/7/22, one pouch of 20 diazepam 5 mg tablets went missing. MO00210901

Based on interview and record review, the facility failed to provide care in accordance with standards of practice when upon admission, staff failed clarify admission orders from the hospital and obtain an order for a medication for one resident (Resident #1) The facility census was 80. Record review of the facility policy Reconciliation of Medications on Admission, revised July 2017, showed the following: -Purpose is to ensure medications safety by accurately accounting for the resident's medications, routes, and dosages upon admission or readmission to the facility; -Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over-the- counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions; -Reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes; -Helps to ensure that all medications, routes, and dosages are appropriate for the resident and his/her condition, and do not interact in a negative way with other medications/supplements on the list; -If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy such as contact the physician from the referring facility or contact the resident's primary physician in the community. Record review of the facility Admission Packet Policy and Procedures on Pre-Admission Medications, undated, showed residents admitted to the facility are not permitted to bring medications into the facility upon admission unless the residents' personal physician prescribes the medications, and packages and labels them according to the requirements of State and Federal law. All subsequent medications administered on the premises of the facility must be obtained by physician order on the date of or subsequent to admission to the facility. Record review of the facility Policy Procedures for Controlled Substances, undated, showed in any situation where a properly labeled and identified controlled substance is brought into facility with resident upon admission, every effort must be made to return this quantity with family member or admitting personnel. If controlled substance brought into facility with resident cannot be returned to family or admitting personnel and/or is to be received and used until supply is received from facility's designated provider pharmacy, this quantity of controlled substance must be identified and quantity entered into bound narcotic book. 1. Record review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included sepsis (serious condition resulting from presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), cirrhosis (a chronic disease marked by degeneration of cells, inflammation, and fibrous thickening of tissue typically a result of alcoholism or hepatitis) of liver, major depressive disorder, viral hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), pain , chronic pain syndrome, opioid (narcotic) dependence, Type 2 diabetes mellitus with hyperglycemia (high blood glucose). Record review of the resident's medication list from the hospital on admission 10/28/22, showed diazepam (an antianxiety medication) 5 milligram tablet with no frequency, route, and indication for use. Record review of the resident's record showed the staff did not document contacting a physician or hospital to clarify the order listed. Record review of the resident's Order Summary Report, dated 10/28/22, showed no physician's order for diazepam 5 mg. Record review of the resident's progress notes, dated 11/23/22, showed the nurse practitioner saw the resident and the resident discussed ongoing neuropathy (nerve) pain to both feet and had increasing anxiety. Orders received to resume diazepam as taken prior to hospitalization , 5 mg every 8 hours routinely. Record review of the resident's Order Summary Report, dated 11/23/22, showed the following: -A physicians' order for diazepam 5 mg, give 5 mg by mouth every 8 hours for anxiety. The medication scheduled for administration at 6:00 A.M., 2:00 P.M., and 10:00 P.M. During an interview on 1/5/23, at 10:55 A.M., Licensed Practical Nurse (LPN) A said the resident did not have an order for Valium (diazepam) at admission even though the resident told him/her it was a normal medication he/she took. When the resident came from the hospital, he/she did not have that medication ordered. The resident's physician was out of the country at the time and LPN A did not call the physician's nurse practitioner. During interviews on 1/5/23, at 10:37 A.M., and on 1/6/23, at 12:52 P.M., Registered Nurse (RN) B said the following: -The resident's physician was out of the country and staff were to call the physician's nurse practitioner and he/she was to call one of the hospital physician's on call to get an order for diazepam 5 mg. The RN was not sure if this was done for the resident. During an interview on 1/6/23, at 12:00 P.M., Certified Medication Tech (CMT) E said the resident was very anxious, upset, and irritated and had requested his/her diazepam medication; During interview on 1/6/23, at 2:50 P.M., CMT D said the following: -The resident did get anxious and asked for a nerve pill. The resident seemed to get more anxious when getting ready to leave or discharge; -They had to get an order for Valium in November 2022 and sometimes it takes a while like a couple of days for the pharmacy to get narcotic medications filled since they need a hard prescription signed by the physician. During interview on 1/6/23, at 2:35 P.M., the Director of Nursing (DON) and RN J said the following: -They were not aware of of the resident's incomplete physician's order for diazepam 5 mg on admission; -Staff were expected to get a complete order for the diazepam 5 mg from the physician; -Would have expected staff to reconcile all medication orders with the physician upon admission within a time frame of one to two hours. During interview on 1/6/23, at 3:30 P.M., the Administrator and DON said the following: -The facility pharmacy is in Arkansas and pharmacy deliveries on new admissions come in the afternoon and in the evening; -They do have a double check system they call match back and this occurs in their start up meeting daily with staff. One person looks at discharge and admission orders while the other staff person put this into the EMR (electronic medical record) system to see if they match; -They may have missed doing this process the week the resident was admitted to the facility due to sickness and staff not working; -When they send a narcotic prescription to the pharmacy, the pharmacy needs the original prescription with the actual physician's signature and it is challenging to get this. The physicians don't send the prescription or leave before getting this done; -It should take no more than 12 hours to get prescriptions filled for the residents on admission.

Based on record review and interview, the facility failed to have staff provide routine showers/baths to f residents (Resident #1, #3, #4, and #5) as care planned and failed to care plan one resident's (Resident #2) shower/bathing preference. These residents were dependent on staff for help with showers. The facility census was 80. Record review showed the facility did not provide a shower schedule for residents. 1. Record review of Resident #1's face sheet (a one-page summary of important information about a resident) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, dated 10/13/21, showed the following: -Self-care performance deficit related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Requires one to two staff with dressing, grooming, and personal hygiene; -Requires assist by one staff with showers/whirlpool and shampooing weekly as necessary; -Limited physical mobility related to weakness and cognitive deficit. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 2/14/2022, showed the following: -Moderate cognitive impairment; -Minimal assistance with one person physical assist for bed mobility, transfers, dressing, eating, and personal hygiene; -Requires one person physical assistance in part of bathing activity Record review of the resident's electronic bathing documentation, dated 2/1/22 to 4/5/22, showed the resident received a shower on the following days: -On 2/13/22 (at least 13 days after the resident's last documented shower; -On 3/11/22 (almost one after the resident's last documented shower; -On 3/16/22; -On 4/4/22 (19 days after the resident's last documented shower). Record review of the resident's record showed staff did not document any resident refusals of showers/baths. During interviews on 4/5/22, at 10:09 A.M., and on 4/6/22, at 3:25 P.M., the resident said the following: -He/she is supposed to get a shower twice a week; -The resident said he/she feels filthy; -The resident tells staff every day, and staff say, Oh, maybe tomorrow, but no one ever gives the resident a shower; -Not getting a shower makes him/her feel gross. Observation on 4/5/22, at 3:28 P.M., showed the resident ask Licensed Practical Nurse (LPN) E if he/she could have a shower. LPN E replied that he/she would have to check to see when the resident's shower day was. 2. Record review of Resident #2's face sheet showed the following: -admitted [DATE]; -discharge date of [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, dated 11/19/21, showed the following: -The resident has activity of daily living self-care performance deficit related to impaired balance due to [CONDITION(S)] (paralyzed in both upper and lower extremities); -Requires limited assistance by one staff with showering twice weekly and as necessary; -Requires set up assistance by one staff with personal hygiene and oral care. (Staff did not care plan how often the resident would like showers/baths.) Record review of the resident's discharge MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with activities of daily living for bed mobility, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene; -Requires physical help in part of bating activity. Record review of the resident's record showed staff did not document any resident refusals of showers/baths. Record review of the resident's shower sheets, dated 2/1/22 to 4/5/22, showed the resident received showed on the the following days; -On 2/16/22. (Staff did not provide any other shower documentation.) 3. Record review of Resident #3's face sheet, showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Intact cognition; -Limited assistance of one staff for personal hygiene; -Physical help in part of bathing activity with one person physical assist; -Lower extremity impairment on one side. Record review of the resident's care plan, revised 4/2/22, showed the following: -Required a mechanical (hoyer) lift (a mobility tool used to help lift one out of bed without assistance of another person) with two staff assistance for transfers; -Required maximum assistance by one staff with showering two times weekly and as necessary; -Provide sponge bath when a full bath or shower cannot be tolerated; -The care plan did not address the resident's preferences for how often they would like to shower. Record review of the resident's shower documentation, dated 2/1/22 to 4/5/22, showed the resident received a shower on the following days: -On 2/6/22; -On 3/1/22 (time period of 23 days since the previous shower); -On 3/2/22; -O 3/23/22 (time period of 21 days since the previous shower); -On 4/1/22 (time period of nine days since the previous shower). Record review of the resident's record showed staff did not document any resident refusals of showers/baths. During interview on 3/30/22, at 2:09 P.M., the resident said he/she got a shower last week on Tuesday. He/she sweats badly since in bed all the time so routine showers are needed. During an interview on 4/5/22, at 1:30 P.M., the shower aide, Certified Nurse Aid (CNA) H, said he/she had been hired in the past two weeks as shower aide only and had not given the resident a shower yet since it required two staff to transfer the resident. 4. Record review of Resident #4's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, revised 2/12/22, showed the following: -The resident requires extensive assistance by one staff with bathing/showering twice weekly and as necessary; -Provide sponge bath when a full bath or shower cannot be tolerated. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Intact cognition; -Limited assistance of one staff for personal hygiene; -Physical help in part of bathing activity; -Impairment of one lower extremity. Record review of the resident's shower documentation, dated 2/1/22 to 4/5/22, showed the following: -On 3/15/22, the resident had a bed bath; -On 3/20/22, the resident had a shower; -On 3/24/22, the resident refused a shower; -Staff did not document any additional showers or baths after 3/24/22. During interviews on 3/30/22, at 1:16 P.M., and 4/5/22, at 1:45 P.M., the resident, who was in bed wearing a hospital gown, said the following: -He/she sits in urine frequently and needs showers due to this; -He/she had never refused a shower except once when he/she had a shot in his/her hip and he/she did not want to be transferred by the mechanical lift because it would hurt his/her hip. 5. Record review of Resident #5's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, revised 3/28/2020, showed the resident required extensive assistance by one staff for showering twice weekly and as necessary. Record review of the resident's MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Extensive assistance with one staff for bed mobility, transfers, and toileting; -Did not walk; -Bathing activity did not occur during the entire period; -Used a wheelchair. Record review of the resident's shower documentation sheets, dated 2/1/22 to 4/5/22, showed the following: -The resident received a shower on 2/13/22 and then on 3/3/22 (a total time period of 18 days between showers; -On 3/7/22, the resident refused a shower; -On 3/21/22, staff gave a shower to the resident (A total time period of 18 days since the resident was offered a shower on 3/7/22); -On 3/28/22, the resident refused a shower; -On 4/2/22, staff gave a shower to the resident. During interviews on 3/30/22, at 3:15 P.M., and on 4/5/22, at 1:04 P.M., the resident said the following: -He/she would like to have a shower at least twice a week; -He/she had to crab about getting a shower this last Sunday morning before staff gave a shower to him/her; -He/She did not understand why he/she couldn't get showers twice a week; -He/she had refused a shower before because he/she had felt sick, but staff never came back to offer another shower to him/her that day. 6. During interview on 3/30/22, at 1:55 P.M., Nurse Aide (NA) K said the following: -He/she did occasional showers on the residents; -He/she thought the residents' odd room numbers had shower days on certain days and residents on even number rooms on even number days of the week. 7. During interview on 3/30/22, at 3:00 P.M., LPN A said he/she did not monitor or track showers on the evening shift. The staff give him/her a list if they give a shower to a resident. 8. During an interview on 4/5/22, at 12:58 P.M., NA D said residents do not always get a shower when they want one. The facility is short-staffed. He/she said the facility did hire a shower aide about two weeks ago. Frequency of showers has gotten better since then. If the shower aide is off some aides give showers too if there are enough of them. 9. During interview on 4/5/22, at 1:10 P.M., NA F said the following: -If a resident asks for a shower, it depends on how busy they were and usually tell the other aides in case they have the time; -No one was assigned to do showers since the shower aide quit; -They have a list for showers each day; -They would ask what time they want a shower and would go back once or twice in same day if they refused to take one that day; -Each resident was to get a shower two to three times a week. 10. During an interview on 4/5/22, at 1:14 P.M., LPN A said typically the residents get a shower when they want one. Residents sometimes complain of not getting showers. If there are available staff, staff can give showers on the spot. Often in the evening staff can give showers to residents who request them. Showers are supposed to be given twice a week. The facility has a new hire shower aide, so LPN A was unsure if there is an actual shower schedule currently. LPN A said he/she has not laid eyes on a shower schedule. LPN A said he/she would have to check shower sheets to know if a resident has had a shower. 11. During interview on 4/5/22, at 1:17 P.M., LPN G said the following: -He/she worked off and on the past two months at the facility; -If a resident was to get a shower that day, it was written on the daily nursing roster sheet if there was a shower aide that day; -If there was no shower aide, they would ask one of the aides to do showers in addition to their regular CNA work; -It had been a few days since showers were given to residents; -He/she had never seen a shower schedule or book for the showers given; -If a resident asks for a shower, he/she goes to the aide and asks for them to give a shower to the resident, but no resident had asked lately for a shower; -He/she felt the showers were getting better lately since there had been a shower aide on the schedule who had been giving showers to residents. 12. During interview on 4/5/22, at 1:30 P.M., the shower aide, CNA H, said the following: -Hired to work Monday through Friday from 6:00 A.M. to 2:00 P.M. as the shower aide; -There were no showers after 2:00 P.M. unless the evening staff gave them to the residents; -There was no shower plan or schedule when hired; -He/She wrote down every resident's name and day to give them a shower; -He/She gives eight to ten showers a day and had placed names in sections such as one side like 100 hall and 300 hall; -He/She hoped to give residents a shower twice a week, but did not know the residents' preferences since some residents do want showers in the evening; -There were no showers on weekends unless aides who worked the weekends would give a resident a shower; -He/She fills out a shower sheet on each resident he/she gave a shower to and filled out the entire sheet. 13. During an interview on 4/5/22, at 2:46 P.M., NA B said when he/she is able he/she will give residents showers if they request them. He/she said the facility has a shower aide. NA B said residents do complain about not getting showers. When this happens, NA B gives them a shower as soon as possible. 14. During an interview on 4/6/22, at 8:40 A.M., CNA C said recently the facility hired a shower aide so shower frequency is getting better. He/she said the facility has a shower book that has every resident's name and when they're supposed to get a shower. CNA C could not find the shower book after looking for it. He/She checked at both nurses' stations. CNA C said residents are supposed to get a shower twice a week. Residents complain to CNA C all the time about not getting their shower. If a resident wants a shower, provided they had the staff, CNA C gives them a shower then, and CNA C checks when the resident was showered last. 15. During an interview on 4/6/22, at 9:40 A.M., the Assistant Director of Nursing (ADON) said there was no list or book of who gets a shower on what day. Staff get that information from their electronic charting system. The shower sheets were kept in the shower book. 16. During an interview on 4/6/22, at 10:36 A.M., the Director of Nursing (DON) said when residents ask for a shower they get one. The DON said he/she has given them, and the ADON has given them. Also, the facility's as needed nurses come in and give them. The CNA training instructor has the NAs give bed baths also as part of training. Some residents don't care that they don't get showers, and some residents refuse when they're offered. The DON said each resident has an assigned shower day twice a week and as needed. The facility has a new shower aide on north side. The DON said he/she recently talked with the new shower aide about splitting his/her days between north and south side. Staff are expected to document showers on a shower sheet. Some NAs did not realize a bed bath counts as a shower, so they were not documenting those. The DON said he/she educated the NAs on that. 17. During an interview on 4/6/22, at 12:10 P.M., the Administrator said the residents' shower days were already set up in the electronic medical record system. Their administrative staff such as the DON and ADON have helped give showers to residents. MO 297, MO 914, MO 059, and MO 111

Based on record review and interview, the facility failed ensure timely assessment of residents after a fall when staff did not notify the nurse of one resident's fall (Resident #1) until the following day. The facility census was 80. Record review of the facility's Assessing Falls and their Causes Policy, revised March 2018, showed the following: -After a fall, if a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities; -Obtain and record vitals as soon as it is safe to do so; -When a resident falls, the following information should be recorded in the resident's medical record: -The condition in which the resident was found; -Assessment data, including vital signs, and any obvious injuries; -Interventions, first aid, or treatment administered; -Notification of the physician and family, as indicated; -Completion of a falls risk assessment; -Appropriate interventions taken to prevent future falls. Record review of the facility's Certified Nurse's Aide (CNA) Job Description, undated, showed the following administrative functions for CNAs: -Report all changes in the patient's condition to the Nurse Supervisor/Charge Nurse as soon as observed, and practical; -Report all accidents and incidents you observe on the shift that they occur. 1. Record review of Resident #1's face sheet (a one-page summary of important information about a resident) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, dated 10/13/21, showed the following: -Self-care performance deficit related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Requires limited assistance by one to two staff to turn and reposition in bed every two hours and as necessary; -Requires extensive assistance by one staff to move between surfaces as necessary; -Limited physical mobility related to weakness and cognitive deficit; -High risk for falls related to gait/balance problems, [CONDITION(S)] drug use, and impaired mobility; -Actual falls on 2/3/2019 and 4/1/2019 with no injuries. Record review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff). dated 8/14/21, showed the following: -Moderate cognitive impairment; -Limited assistance, one person physical assist with bed mobility, transfers, locomotion on and off the unit, dressing, and personal hygiene. Record review of the resident's nurse's note dated 2/2/22, at 11:30 A.M., showed Licensed Practical Nurse (LPN) A documented the following: -CNAs reported resident complaint of pain to right shoulder during incontinence check/preparing to get out of bed for lunch. On assessment resident complained of pain with light palpation and could not tolerate passive range of motion to right upper extremity. Physician was called, and x-ray of shoulder ordered. Record review of the resident's vitals showed staff did not document vitals on 2/2/22 with the nurses' assessment of the resident's shoulder pain. Record review of the resident's nurse's note dated 2/2/22, at 8:55 P.M. showed LPN A documented the following: -Xray results reported to on call nurse practitioner. Deformity of humeral (the long bone in the arm that runs from the shoulder to the elbow) head and neck suggest chronic fracture. New order received for [MEDICATION(S)] (a pain medicine similar to opiates, so it is called a synthetic opiate), one by mouth every six hours as need for pain, if Tylenol ineffective. Record review of the resident's nurse's note dated 2/3/22, at 10:30 P.M., showed the following: -Continues on charting related to recent witnessed fall and increased complaint of right shoulder pain. No acute fracture per x-ray. No complaints at this time. No other new complaints or changes voices or reported post fall. Record review of the resident's nurses notes showed no nurses' note entered regarding a witnessed fall on the day that it occurred. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 2/14/2022, showed: -Moderate cognitive impairment; -Required minimal assistance with one person physical assist for bed mobility, transfers, dressing, eating, and personal hygiene; -Only able to stabilize with human assistance when moving on and off toilet and when transferring between bed and chair or wheelchair, unsteady; -Used a wheelchair for mobility; -No falls since admitted or the prior assessment. During an interview on 4/5/22, at 10:09 A.M., the resident said he/she fell during a transfer once about a month ago. The resident said only one aide was transferring him/her, and the aide was really small and new. Sometimes one aide transfers the resident, and sometimes there are two aides that transfer him/her. After the resident fell , the aide went and got another aide to help get the resident up off the floor. The resident said he/she did not hit his/her head, but that he/she hit his/her shoulder. The resident had injured his/her right shoulder before this fall, but it had healed. During an interview on 4/5/22, at 1:14 P.M., LPN A said CNAs check the plan of care charting under tasks and the care plan for level of assistance for residents during transfers. Aides are good at helping each other with transfers. The resident had a fall during a transfer. LPN A was working the day it happened. He/she stayed till 10:00 P.M. that day (2/1/22). The aides did not notify him/her or the other nurse the day the resident fell . The next day the resident was complaining of some pain in his/her right shoulder. The aides asked LPN A the day after the fall to go down and assess the resident. LPN A assessed the resident and found him/her resistant to range of motion in his/her shoulder with increased pain. LPN A called the doctor, got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN A said after the x-ray and through that second day the resident had no complaints of pain. The resident's fall happened with two young newer aides. During an interview on 4/5/22, at 2:46 P.M., Nurse Aide (NA) B said a resident's number of staff needed for transfer assistance is listed on their MDS care sheet on their closet door and also in their care plan. When he/she was transferring the resident once the resident fell (on 2/1/22). NA B said the resident was an extensive two person assist. He/she was confident he/she could transfer the resident him/herself. He/she thought he/she would be okay because the resident stands on his/her own, but that the resident was wearing non-grip socks so his/her socks slid on the floor. NA B said the resident slid along NA B to the floor, but that NA B was guiding the resident with a gait belt. NA B brought the resident down to the floor with a gait belt. The resident did not hit his/her head or shoulder, and the resident had no complaints of pain. NA B then went and got CNA C, who helped NA B get the resident back in bed. NA B said the facility was understaffed that night, so he/she did not tell the nurse about the fall until the next day. During interviews on 4/6/22, at 8:40 A.M. and 10:14 A.M. CNA C said it has been over month since the resident fell . He/she thinks it happened in February 2022. CNA C said that NA B hit the call light for help and CNA C was walking by and went to the assist NA B. The resident was on the ground, but NA B was holding the resident's upper body to keep it off the ground. NA B was supporting the resident's back. CNA C said him/her and NA B got the resident up off the floor. The aides asked the resident how he/she was and if anything hurt, and the resident said he/she was in no pain. CNA C said neither him/her or NA B told the nurse initially about the resident's fall. If a resident falls, aides are to never leave the resident, call for help, and get the nurse. The nurse will tell the aides whether vitals should be done every 15 minutes for an hour. It depends on whether or not a fall was witnessed or not. CNA C said the resident's fall was an assisted fall, so it is up to the nurse whether or not aides do vitals with an assisted fall. If the nurse feels they are necessary then aides do the vitals. During an interview on 4/6/22, at 10:20 A.M., LPN A said when a resident falls he/she expects aides to notify the nurse and to not leave the resident's side. Vitals are done situationally by the aides depending on how much other work the nurse has. For example, if there is an injury, LPN A will have aides do the vitals while he/she tends to the injury. The nurse would get a baseline set of vitals for any change in condition. LPN A said he/she does not know if vitals were done when the resident initially fell . Vitals should have been done the next day when LPN A assessed the resident. During an interview on 4/6/22, at 10:36 A.M., the Director of Nursing (DON) said the nurses should know a resident's level of assistance for transfers and any changes in assistance are care planned. The DON goes over assistance level with new aides in orientation. The DON expects aides to ask a resident's level of assistance before transferring the resident. If aides do not know they should not transfer the resident. If a resident falls the aide should ask for help, not move the resident, and have the nurse come and assess the resident first. The DON said vitals are a group effort. Neuro assessments done by the nurse. The DON expects vitals to be done with every fall, witnessed or unwitnessed. There was an assisted fall with the resident on 2/1/22. During an interview on 4/6/22, at 11:33 A.M., the Assistant Director of Nursing (ADON) said the MDS care plan sheet in the resident's closet shows a resident's level of assistance needed for transfers. With the resident, the ADON was told that staff were transferring the resident into bed and they had to lower him/her to the ground. With falls, aides should notify the charge nurse, and the nurse should assess the resident before the resident is picked up from the floor. The nurse should notify the doctor, family, representative, and DON or ADON. The ADON said that was not done when the resident fell . The ADON remembers staff telling him/her about the fall the next day. At that time they told the ADON the resident was complaining of shoulder pain, and then the ADON found out the aides had assisted the resident to the floor the evening before that. The ADON said he/she expects staff to get vitals too after a fall. The charge nurse decides if they get their own set of vitals or if they want their aides to get the vitals. During an interview on 4/6/22, at 1:14 P.M., the Administrator said the closet care plan shows the level of assistance for transferring residents. He/she said there was a brand new NA who was transferring the resident, and the NA ended up lowering the resident to the ground. The NA told the other CNA about the fall, and neither of them reported it to the nurse when it happened. Managers found out about the fall the next day. The Administrator said he/she expects the aide to immediately report the fall to the nurse, so the nurse can do an assessment for pain and range of motion. Vitals should be taken with any fall. Aides should not touch or lift a fallen resident until the nurse comes and assesses the resident. MO 059

Based on observation, interview, and record review, the facility failed to ensure medications were on hand as needed for all residents when staff failed to administer eye drop medication for [CONDITION(S)] (increased pressure in the eye ball eventually leading to [CONDITION(S)]) due to being out of the medication and failed to administer the correct form of [MEDICATION(S)] (a form of vitamin B3, an essential human nutrient) due to not obtaining the correct medication for one resident (Resident #4). The facility census was 80. Record review of the facility policy Administering Medications, revised April 2019, showed the following: -Medications are administered in accordance with prescriber orders, including any required time frame; -Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication, honoring resident choices and preferences consistent with his or her care plan. Record review of the facility policy Unavailable Medications, dated 1/1/15, showed the following: -The facility must make every effort to ensure that medications are available to meet the needs of each resident; -Nursing staff shall notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy or therapies that are available; -If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the facility medical director for orders and/or direction; -Obtain a new order and cancel/discontinue the order for the non-available medication; -Notify the pharmacy of the replacement order. 1. Record review of Resident #4's face sheet showed the following: -Admission was 8/16/21; -Diagnoses that included fracture of the right fibula (bone in the lower leg that stretches from the knee to the ankle), [CONDITION(S)] syndrome (immature red blood cells do not mature and are not healthy), refractory [CONDITION(S)] (blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells), aortic aneurysm (enlargement of the aorta which is the main largest artery in the body), difficulty in walking, [CONDITION(S)] (abnormal heart rhythm), hypertension (high blood pressure), depression, anxiety, and obesity. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 2/19/22, showed the following: -Intact cognition; -Extensive assistance with two staff for bed mobility, dressing, and toileting; -Total dependence on two staff for transfers; -Did not walk. Review of the resident's current care plan showed staff did not care plan regarding the resident's eye drops and [MEDICATION(S)]. Record review of the resident's physician's orders, showed the following: -An order, dated 8/16/21, for [MEDICATION(S)] solution (used to treat [CONDITION(S)] or high fluid pressure in the eye) 0.2%. Staff to instill one drop in both eyes two times a day; -An order, date 10/30/21, for [MEDICATION(S)] ER tablet 500 milligrams (mg) one tablet by mouth one time a day. Record review of the resident's March 2022 Medication Administration Record (MAR) showed the following: -[MEDICATION(S)] solution 0.2%. Staff to instill one drop in both eyes two times a day. Staff initialed administering the medication to the resident on 3/31/22. Record review of the resident's progress notes dated 3/31/22, at 8:31 A.M., showed Certified Medication Technician (CMT) J noted [MEDICATION(S)] solution 0.2% was not there in the facility, and the supervisor was aware. Record review of the resident's April 2022 MAR showed the following for the [MEDICATION(S)] solution 0.2%; -On 4/1/22, at 8:00 A.M., staff initialed they administered the medication and at 8:00 P.M., the medication was unavailable; -On 4/3/22, staff initialed they administered the medication at 8:00 A.M. and at 8:00 P.M., the medication was unavailable; -On 4/4/22, at 8:00 A.M. and at 8:00 P.M., the medication was unavailable; -On 4/5/22, at 8:00 A.M. and at 8:00 P.M., the medication was unavailable. Record review of the resident's progress notes showed the following: -On 4/1/22, at 8:33 A.M. and 7:04 P.M., CMT J noted the [MEDICATION(S)] eye drops were not given since they were not there, and the nurse/Director of Nursing (DON) were aware; -On 4/3/22, at 9:28 P.M., CMT J noted the [MEDICATION(S)] eye drops were not there; -On 4/4/22, at 7:41 A.M., CMT J noted the [MEDICATION(S)] eye drops were not there; -On 4/4/22, at 8:26 P.M., CMT I noted the [MEDICATION(S)] eye drops were not there; -On 4/5/22, at 8:26 A.M., CMT M noted the [MEDICATION(S)] eye drops were not there; -On 4/5/22, at 10:05 P.M., CMT I noted the medication was ordered 4/5/22 and would arrive that night. Record review showed staff did not document notifying the physician of the missing doses of eye drops. Record review of the resident's March 2022 MAR showed the resident's medication [MEDICATION(S)] ER tablet 500 mg one tablet by mouth one time a day was signed by staff that it was administered to the resident every day except 03/01/22 when it was unavailable. Record review of the resident's progress notes, dated 3/1/2022, showed CMT I noted the medication was not available. Record review of the resident's April 2022 MAR showed the resident's medication [MEDICATION(S)] ER tablet 500 mg one tablet by mouth one time a day was signed by staff that it was administered to the resident every day. Record review showed staff did not document notifying the physician of regarding administration of a different form of [MEDICATION(S)] During an interview on 4/5/22, at 1:45 P.M., the resident said the following: -Staff were not giving him/her the correct medication of [MEDICATION(S)]; -He/She was to get the extended release form of the [MEDICATION(S)] and wanted the physician to get this from another pharmacy; -The regular [MEDICATION(S)] caused him/her to have greater hot flashes and flushing and he/she had to pour water over him/herself while in bed to cool off; -The extended release [MEDICATION(S)] works better for him/her; -He/she was not getting his/her eye drops for [CONDITION(S)] (loss in the center of the vision) twice a day as ordered; -He/she was afraid that he/she would go blind if he/she did not get the eye drops. He/she was already losing his/her sight. During interview on 4/5/22, at 2:05 P.M., CMT I said the following: -The facility had the [MEDICATION(S)] in 500 milligrams (mg) and not the extended release form of [MEDICATION(S)] for the resident. The resident says he/she needed the extended release form and CMT I said he/she was not sure why central supply had not ordered this; -They had been giving this [MEDICATION(S)] 500 mg, not the extended release form, for about a month now; -They did have the regular [MEDICATION(S)] 500 mg to give the resident; -They did have a bottle of [MEDICATION(S)] 100 mg tablets and gave five tablets to the resident until the bottle of [MEDICATION(S)] 500 mg tablets came in, but even this was not the extended release [MEDICATION(S)]; -He/she had seen the [MEDICATION(S)] 500 mg bottle in the medication room cabinet, but it was no longer in the cabinet. -The resident's eye drops [MEDICATION(S)] 0.2% had been out about a week; -The pharmacist said it was too early to re-order eye drop [MEDICATION(S)] 0.2%. Observation on 4/5/22, at 2:06 P.M., of the medication cart and medication room cabinet showed there was no [MEDICATION(S)] 500 mg capsules on the medication cart or in the medication room cabinet. The plastic bag labeled for the [MEDICATION(S)] eye drops was labeled as reordered on 3/5/22. Record review of the resident's electronic medical record showed the [MEDICATION(S)] eye drops were last re-ordered 3/27/22 and status was on the order sheet. During an interview on 4/5/22 at 2:17 P.M., CMT J said the following: -The pharmacist said they sent three bottles of [MEDICATION(S)] eye drops in one package for the resident; -He/she emptied the bottle which he/she thought it was 5 milliliters (ml) and the pharmacy said they sent 15 ml bottles of the [MEDICATION(S)] 0.2%; -The pharmacy said they would send the refill for the [MEDICATION(S)] eye drops for the resident in 18 to 19 days unless the facility pays for the medication; -He/She talked to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) about this eye drop medication for the resident and the DON said they would have to wait to get the [MEDICATION(S)] eye drops for the resident; -He/she did not call the physician, but had told the DON and ADON about the medication that had ran out and unable to administer to the resident; -The [MEDICATION(S)] 500 mg bottle was now in central supply room since it was the wrong one and the central supply staff was there. During an interview on 4/5/22, at 2:23 P.M., the central supply staff said the following: -He/she began as central supply and transportation on 04/04/22; -CMT J brought the [MEDICATION(S)] 500 mg bottle to him/her and he/she was to get this [MEDICATION(S)] 500 mg ER from a local pharmacy; -The DON was taking care of the ordering and re-ordering medications. During interview on 4/5/22, at 2:26 P.M., the ADON said someone was to go to the local pharmacy to pick up the [MEDICATION(S)] 500 mg ER for the resident. He/she did not know about the [MEDICATION(S)] eye drops for the resident. During interviews with the DON and administrator on 4/5/22, at 2:30 P.M., and on 4/6/22, at 8:36 A.M., the DON said the following: -He/she was aware that staff said they received one 5 ml eye drop bottle of [MEDICATION(S)] 0.2% for the resident and the pharmacy said they sent 15 ml. The [MEDICATION(S)] eye drop bottles come in 5 ml bottles; -On 03/31/22 or 04/01/22, he/she told CMT J to contact the pharmacist about the eye drops since CMT J could only find one bottle of the [MEDICATION(S)] 0.2% eye drops for resident; -He/she did not know when the resident last received the [MEDICATION(S)] eye drops since no one followed up with this; -For the resident's [MEDICATION(S)] 500 mg ER twice daily order, he/she did not know which physician originally ordered the prescription; -The resident said he/she was allergic to all others of [MEDICATION(S)]; -He/she explained to the resident that he/she couldn't get the [MEDICATION(S)] 500 mg ER from their pharmacy or the local pharmacy since this had to be special ordered; -They should have contacted the physician since the resident said he/she needed the extended release and not the other regular [MEDICATION(S)]; -He/she was unsure how long this had been going on with the [MEDICATION(S)] for the resident; -The [MEDICATION(S)] was over the counter normally, but it was not usually in the extended release form; -The charge nurse should have called the physician and gotten the order changed when they couldn't get the residents [MEDICATION(S)] extended release 500 mg; -He/she thought this may had been going on for the past two weeks with the [MEDICATION(S)]. MO 297 and MO 111

Based on observation, interview, and record review, the facility staff failed to consistently provide cueing assistance at meal time for one resident (Resident #32) who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility's policy, titled Weight Assessment and Intervention, dated September 2008, showed the following: -The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents; -Care planning for weight loss or impaired nutrition would be a multidisciplinary effort and will include the physician, nursing staff, dietician, consultant pharmacist, and the resident or resident's legal surrogate; -Individualized care plans would address, to the extent possible, the identified cause of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and assessment; -Interventions for undesirable weight loss shall be based on careful consideration of the following resident choices and preferences; nutrition and hydration needs of the resident; functional factors that may inhibit independent eating; environmental factors that may inhibit appetite or desire to participate in meals; chewing and swallowing abnormalities and the need for diet modifications; medications that may interfere with appetite, chewing, swallowing, or digestion; the use of supplementation and/or feeding tubes; and end of life decisions and advance directives. 1. Record review of Resident #32's face sheet (a brief resident profile sheet) showed the following: -An admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's vital signs showed the following: -On 6/1/2020, the resident's weight was 195 pounds; -On 1/5/2021, the resident's weight was 155 pound (a 25.64 % loss). Record review of the resident's Physician's Progress Note dated 1/13/2021, at 12:23 P.M., showed staff to assist resident with eating. Record review of the resident's care plan, updated 3/22/2021, showed the following: -Resident may have nutritional problems or potential problems related to unplanned weight gain (vitals showed weight loss), related to CHF and loosely fitting dentures. Resident has a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Provide and serve diet as ordered; -Regular-enhanced diet, mechanical soft texture (a diet that involves foods that are physically soft), regular consistency; -Monitor and report any signs of dysphagia (difficulty swallowing), pocketing (holding food in the cheeks), choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or if appears concerned during meals; -Monitor and report to the physician signs and symptoms of malnutrition, such as emaciation (becoming so thin that bones protrude under the skin), muscle wasting, significant weight loss equal to or above 5% in one month, 7.5% in 3 months, or 10 % in 6 months. Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 4/17/2021, showed the following: -Resident was severely cognitively impaired; -The resident did not refuse cares; -The resident required oversight, encouragement, and cueing for eating; -Resident had a 5% or more weight loss in the prior month, or 10% or more loss in the prior 6 months and was not on a weight loss plan. Record review of the resident's vital signs showed the following: -On 6/14/2021, the resident's weight was 147 pounds (5.81% loss). Record review of the resident's Progress Notes dated 6/18/2021, at 6:57 P.M., showed an interdisciplinary team (IDT) weekly weight note that listed interventions facility staff had implemented to prevent the resident's weight loss as: -[MEDICATION(S)] (an antidepressant used to help increase appetite and weight gain in older adults); -Two cal (a calorie and protein dense nutritional drink to assist with weight gain); -Snacks twice daily; -Super cereal (a calorie dense hot cereal) at breakfast; -Weekly weights; -Total assist in the dining room. Observations on 6/23/21, from 11:27 A.M. to 12:35 P.M. (continuous), of the assisted dining room showed the following: -At 11:27 A.M., the resident was seated in the dining room at a table; -At 11:39 A.M., staff brought the resident's tray and opened items. The resident had a mechanical soft Salisbury steak, chopped up potatoes, a roll, cherry cobbler, ice cream, milk, Kool aid, and water. The resident picked up his/her milk and started drinking. The resident then picked up coffee and drank. Resident put down his/her coffee and picked up milk and drank. Facility staff did not ask if the food was okay, offer an alternative, or offer assistance; - At 11:47 A.M., the resident sat in his/her chair at the table. Staff had not offered assistance or cued him/her to eat. The resident was not eating; -At 11:58 A.M., the resident picked up the cobbler and started to eat. He/she ate two bites, then, after a few minute took two more bites of cobbler; -At 12:11 P.M., staff had not offered assistance to cued him/her to eat; -At 12:12 P.M., the resident picked up his/her roll and started eating it. Approximately 25 percent of the roll was eaten; -At 12:18 P.M., the resident started eating his/her ice cream. The resident consumed all of the ice cream. Staff did not prompt or cue resident to eat. Staff did not offer to assist resident; -At 12:35 P.M., staff took resident to his/her room. Staff did not ask resident if he/she would like more food. Staff did not ask if resident would like an alternative. Resident had eaten his/her ice cream, cobbler, and approximately 25 percent of a dinner roll. Observations on 6/24/2021, from 7:45 A.M. to 8:20 A.M. (continuous), of the assisted dining room showed the following: -At 7:45 A.M., the resident sat seated in dining room at the table. He/she had a plate with eggs, mechanical soft sausage, super cereal, toast, milk, and coffee; -At 8:00 A.M., the Director of Nursing (DON) came by and asked resident how the resident was, and adjusted his/her clothing. The DON did not cue the resident to eat or offer to assist the resident; -At 8:15 A.M., the DON asked the resident if he/she would like to eat more or an alternative. The DON did not offer assistance with eating; -At 8:20 A.M., staff took the resident to his/her room. Resident ate approximately 50% of the toast and 75% of the super cereal. He/she drank approximately 50% of the milk and 50% of the coffee. Staff did not offer any alternative food or to assist the resident prior to taking him/her to his/her room. Observations on 6/24/2021, from 11:44 A.M. to 12:32 P.M. (continuous), of the assisted dining room showed the following: -At 11:44 A.M., staff gave the resident coffee and lemonade; -At 11:47 A.M., staff brought the resident's meal to him/her. The staff unwrapped the resident's silverware and uncovered his/her food. Resident started eating pasta. Resident also had mixed vegetables, cake, and bread. Staff did not cue or offer to assist; -At 11:59 A.M., the resident was taking sporadic bites. Staff did not offer assistance or cue the resident to eat; -At 12:04 P.M., staff offered the resident more coffee, but did not cue him/her to eat more food; -At 12:07 P.M., the resident began eating his/her ice cream; -At 12:13 P.M., staff had not offered to assist resident or cued resident to eat; -At 12:29 P.M., staff asked the resident if he/she was finished eating and washed the resident's hands. Facility staff did not offer the resident an alternative or cue the resident to eat more; -At 12:32 P.M., staff took the resident to his/her room. The resident ate less than 25% of his/her meal. Observations on 6/25/2021, from 11:34 A.M. to 12:02 P.M. (continuous), of the assisted dining room showed the following: -At 11:34 A.M., the resident's food was brought out. Staff opened his/her silverware. The resident had fried fish, curly fries, and pudding. The staff did not cue or offer to assist the resident; -At 11:44 A.M., staff came and cut fish for resident and put tartar sauce on the fish for the resident. Staff gave him/her fork instead of spoon. The staff did not cue or offer to assist the resident; -At 11:51 A.M., the resident started eating his/her pudding; -At 12:02 P.M., staff came and asked resident how he/she was doing, and if he/she was going to eat some more. During an interview on 6/25/2021, at 8:00 A.M., the Kitchen Supervisor said when a resident has weight loss, staff should look at the resident, the DON and restorative therapy gets together and will add snacks, and shakes. Weights are done more frequently, and possible underlying issues are considered. The restorative aides assist in dining. Residents are weighed every week. She is not part of the IDT. The Dietary Manager is on leave and she is on the IDT. A resident who has had a significant weight loss should be assisted. During an interview on 6/25/21, at 8:46 A.M., Restorative Nursing Aide (RNA) A, said if a resident has weight loss, the staff will add snacks, shakes, and weekly weights. The DON and physician will be notified. If a resident is in the dining room and is not eating, staff should ask if they are doing ok and need some help. An alternative food item would be offered. A speech therapy (ST) evaluation would be ordered if needed if a resident had been getting choked on food while eating. The resident had weight loss starting when he/she was diagnosed with COVID-19. He/she was given snacks and shakes. Staff weighed the resident weekly. He/she had speech therapy for two weeks and different textures tried. He/she was in assisted dining. He/she had assist with dining and did not like different textures. During an interview on 06/25/21, at 9:09 A.M., Registered Nurse (RN) B said if a resident had weight loss, staff should let the nurses know. Staff would make the physician and dietary department aware. The resident would be offered snacks, shakes, supplements, and weight monitoring would increase. If staff notices resident having difficulty eating, staff should assist and let someone know the resident is having difficulty so an assessment is done to see what the underlying problem was. The resident started losing weight when he/she had COVID-19. The nursing department got involved, the Registered Dietitian was consulted, restorative therapy was involved, and ST did an assessment. The resident is in assisted dining. He/she is able to eat by his/herself. He/she should have someone cuing him/her to eat if he/she is not eating. During an interview on 6/25/21, at 9:15 A.M., the MDS Coordinator/Care Plan Coordinator said when a resident has a change or addition to their care plan, staff alerts her to the change and the change is made. Things that should be on the care plan include activities of daily living (bathing, grooming, the amount of staff needed to provide care), hospice, diet, certain preferences, weight gain or loss. If a resident needs assist in the dining room, that would be listed under ADLs. The IDT team discusses weight loss. The resident is discussed and is listed on IDT as total assist. He/she does not like someone sitting with him/her and assisting him/her, but someone should cue him/her to continue eating. During an interview on 6/25/21, on 9:22 A.M., Licensed Practical Nurse (LPN) C said if a resident starts showing weight loss, staff should let dietary know, provide the resident extra snacks, and let the physician know. The physician might order medications or increase the frequency of weights. Staff will start monitoring in the dining room to see if the resident is having problems. If a resident has difficulty eating, staff should assist and let nursing know they needed assist. The resident had weight loss after COVID-19. Staff has offered snacks, two cal, enhanced diet, [MEDICATION(S)], and the resident is in assisted dining. She does not like staff sitting by her to help, but staff should be cueing her. During an interview on 6/25/21, at 10:39 A.M., Certified Nursing Assistant (CNA) D said if a resident started showing weight loss, staff should let the nurse know. Staff should get with restorative therapy, and let the doctor know. Speech therapy is consulted if needed. Weights are taken by a set person at a set time for consistency. The resident may get a supplement if needed. If someone is having difficulty eating, staff will assist. The resident goes to assisted dining. She is able to eat by his/herself, but staff should be cueing him/her if he/she is not eating. During an interview on 6/25/21, at 11:06 A.M., the DON said if a resident has weight loss staff should report to nursing and start implementing interventions. Staff should see if the interventions are effective and sit with the providers to see what other options are available before using medications. The Registered Dietician should be consulted. The families are made aware. Snacks and supplements are added. The resident has been challenging. His/her intake is up and down. He/she may eat 25%, or he/she may eat 75%, or he/she may not eat. He/she hasn't responded to intervention. He/she eats better when staff is interacting with her. Staff should be cuing him/her or providing conversation. During an interview on 6/25/21, at 12:05 P.M., the Administrator said she expects staff who has observed a resident with weight loss, to get orders from physician, and start interventions such as shakes, snacks, medications, and assisted dining. Anyone who is on weight monitoring is in the assisted dining. If staff observes someone has slowed down eating, they should encourage bites, or ask if they would like an alternative. It is difficult to get the resident to eat, but staff should be cueing and encouraging him/her if he/she is not eating.

Based on interview and record review, the facility failed to protect residents from misappropriation of property when one resident's (Resident #1) card of 20 [MEDICATION NAME] tablets (pain medication to treat mild to moderate pain) went missing while in possession of the facility staff. A sample of seven residents was selected for review. The facility census was 100. The administrator was notified on 0[DATE] of the Past Non-Compliance which occurred between 02/01/20 and 02/02/20. Facility staff started an investigation, began in-servicing licensed staff who were involved in medication pass on policies and procedures regarding receiving narcotics, and timely reporting to management. Facility staff also notified Department of Health and Senior Services (DHSS) and local law enforcement. The noncompliance was corrected on 02/03/20. Record review of the facility's policy titled, Controlled Substances, dated April 2019, showed the following: -Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on premises; -Controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications; -Access to controlled medications remains locked at all times and access is recorded; -Controlled Substances are reconciled upon receipt, administration, disposition, and at the end of each shift; -Upon receipt of medication, the nurse receiving the medication and the individual delivering the medication verify the name, dose and quantity of each controlled substance being delivered; -Both individuals sign the controlled substance record of receipt; -An individual resident controlled substance record is made for each resident who is receiving a controlled substance, which includes; name of resident, name and strength of the medication, quantity received, number on hand, name of physician, prescription number, name of issuing pharmacy, and date and time received. 1. Record review of Resident #1's face sheet (a one page summary of important information about resident) showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's Order Summary Report from the sending facility, dated 0[DATE], showed the following: -An order, dated 12/08/19, for [MEDICATION NAME]-[MEDICATION NAME] tablet 5-325 milligrams (mg), one tablet by mouth every six hours as needed for pain. Record review of the resident's nurse's note, dated 02/01/20, showed resident arrived at the facility at 12:20 P.M. Resident was discharged from previous facility with medications. Record review of the resident's February 2020 Physician order [REDACTED]. -An order, dated 02/02/20, for Tylenol Extra Strength 500 mg, one tablet three times a day for pain. The order was discontinued on 02/03/20; -An order, dated 02/03/20, for Tylenol Extra Strength 500 mg, two tablets three times a day for pain. (The order sheet did not include an order for [REDACTED].>Record review of the facility's Missing [MEDICATION NAME] Investigative Summary, dated 02/07/20, showed the following: -On Saturday, 02/01/20, at approximately 12:30 P.M., the resident was transferred to current facility from another facility; -The resident brought a blue bag with her which contained her medications from the sending facility; -Certified Medication Technician (CMT) A notified the nurse of the medications and the nurse requested the bag of medications be placed in the locked medication room; -During the admission process, the nurse on duty, Licensed Practical Nurse (LPN) B, said he/she reviewed the medication orders and did not see an order for [REDACTED].>-On Sunday, 02/02/20, the charge nurse said the resident requested a [MEDICATION NAME] (the name brand for [MEDICATION NAME]) for pain, but she did not have an order; -CMT A advised that he/she thought he/she had seen the narcotic in the resident's medication bag; -The sending facility was contacted and verified there was not an order for [REDACTED].>-The sending facility said on Monday, 02/03/20, they would send the list of medications the resident signed off on; -The Administrator viewed video footage and observed CMT C handling the bag with the meds; -CMT C was observed out of camera sight a few times and it was not clear what he/she was doing; -CMT C was then viewed walking outside, for approximately five minutes; -On 02/01/20, at approximately 9:00 P.M., CMT C was overheard advising the nurse that he/she had put all of resident's meds away in his/her medication cart; -On 02/03/20, the sending facility provided documentation showing the resident was sent to the facility with 20 [MEDICATION NAME] 5/325. Record review of CMT A's written statement, dated [DATE], showed the following: -On Saturday, 02/01/20, LPN B was working on the new admission; -CMT A asked if he/she could look at the resident's medications; -LPN B handed CMT A the bag of medications; -CMT A observed a half size card for Hydro/[MEDICATION NAME] pain pills that said as needed every six hours; -CMT A asked LPN B if he/she wanted to put the pain pills in his/her (LPN B) cart, as CMT's do not give PRN pain medications; -LPN B said he/she did not have time and advised to put the bag in the medication room; -Upon leaving shift, CMT A notified CMT C of the new admit and that the resident's med orders were not in yet, however the resident's bag of medications was in the med room on the counter; -On Sunday, 02/02/20, Registered Nurse (RN) D asked CMT A if the resident had pain pills yesterday; -CMT A advised that he/she did and that resident's bag of meds were on the counter in the medication room when CMT A left shift; -CMT A looked through his/her medication cart, along with RN D's cart; -LPN B, who was on shift, advised there were not orders for a narcotic; -CMT A requested LPN B contact the sending facility who advised there was no current order; -The sending facility did confirm that a card of [MEDICATION NAME] was sent with the resident. During an interview on 0[DATE], at 11:25 A.M., CMT A said on Saturday, 02/01/20, the resident's medications were sitting in a blue bag at the nurses' station. CMT A asked LPN B if he/she could look in the bag to see what the resident was taking. CMT A could see a half sheet of [MEDICATION NAME] and an inhaler. CMT A asked LPN B if he/she wanted the pain pills, as it said they were as needed on the card. LPN B told her no and asked CMT A to place the bag in the medication room on the counter. At shift change, CMT A told CMT C that she was not for sure of the resident's medication list, but that her bag of medications was on the counter in the medication room. CMT A did not inform CMT C of the narcotics in the bag. On Sunday, 02/02/20, when CMT A arrived at work, the overnight nurse (RN D) asked if the resident had any pain pills because the resident was asking for [MEDICATION NAME]. CMT A told RN D that the resident admitted with [MEDICATION NAME]. They checked the carts and the medication room for the narcotics, but could not find them. CMT A said when residents are admitted , they will obtain the medication list from the nurse to see when meds are to be administered and what has already been administered that day. The nurse normally will review the medications and will advise the CMT when they can be placed in the cart. As needed narcotic medications are kept in the nurses' cart. Record review of LPN B's written statement, undated, showed the following: -On Saturday, 02/01/20, at 11:00 A.M., LPN B received report from the sending facility; -Sending facility advised they were sending the resident with all of his/her medications; -LPN B accepted the bag of medications from the resident upon arrival; -LPN B gave CMT A the bag of meds and directed to place the medications in the med room until LPN B could get med orders in the computer; -CMT A approached nurse and attempted to give LPN B meds that belonged in the nurses' cart; -LPN B advised CMT A that he/she could not go through the medications at that time; -CMT A advised LPN B that the resident had a pain medication in the bag; -At 2:00 P.M., LPN B had finished putting the resident's medications in the computer; -LPN B noticed the only pain medication ordered was Tylenol; -CMT C asked if the resident had medications. LPN B advised they were in the blue bag in the medication room; -LPN B asked CMT C to go through the resident's medications to ensure they were all there; -CMT C asked permission to put the medications in her cart; -LPN B advised CMT C that CMT A said there were a few things that needed to be placed in the nurses' cart and to leave those items in the medication room; -While counting medications, LPN B observed cigarettes and pain cream in the resident's bag in medication room; -On Sunday, 02/02/20, CMT A said he/she could not find the resident's pain medication that came with the resident yesterday; -LPN B advised that the resident only had an order for [REDACTED].>-CMT A said the resident is asking for [MEDICATION NAME] and he/she though he/she saw a small card of [MEDICATION NAME]; -LPN B attempted to contact CMT C, with negative results, however CMT C texted CMT A and advised he/she did not see any [MEDICATION NAME]; -LPN B notified the Assistant Director of Nursing (ADON) in the afternoon of the situation. During an interview on 0[DATE], at 2:20 P.M., LPN B said Saturday, 02/01/20, was very busy. LPN B took report from sending facility who said the resident was sent with all medications, including pain medications, but did not specify what kind of pain medication. LPN B received the orders and saw that the only pain medication listed was Tylenol. LPN B did not look in the bag of medications that the resident had in her possession. When the resident arrived, LPN B started entering his/her medications from the orders. LPN B sat the resident's medication bag next to him/her at the nurses' station. LPN B gave the bag to CMT A and asked him/her to place the bag in the medication room. CMT A asked her if she was ready to put the resident's medications into her (LPN B's) cart, and LPN B said he/she did not have time, as the medications were not in the computer yet. At shift change, CMT C asked if he/she could match the orders and put the medications in the cart. LPN B said normally the nurse will compare the two, but he/she told CMT C he/she could, as LPN B ran out of time. On Sunday, 02/02/20, CMT A asked LPN B about the narcotic, as the resident asked for a pain pill. LPN B said he/she was unsure because they were not on the orders. CMT A advised LPN B that he/she saw a card in resident's medication bag that appeared to be a narcotic. The RN supervisor was notified of the possible missing medication. Record review of RN D's written statement, undated, showed the following: -On Sunday, 02/02/20, during morning report, RN D notified oncoming nurse, LPN B that the resident's physician needs to be contacted about his/her [MEDICATION NAME], if he/she has more pain not relieved by Tylenol; -The resident was taking [MEDICATION NAME] at previous facility, according to the resident and his/her paperwork; -LPN B advised he/she knew that and that CMT A had tried to get him/her to advised him/her what to do with it, but LPN B was too busy; -CMT A advised RN D that LPN B was too busy and was advised to place the resident's bag in the medication room on the counter; -On Saturday, 02/01/20, after CMT C put the resident's medications away, RN D only saw the resident's cigarettes in the bag; -The CMT cart, nurses' cart, and the medication room were all searched; -RN D did not see the [MEDICATION NAME] at any time and was not aware the resident should have had any at the facility until Sunday, 02/02/20. During an interview on 0[DATE], at 1:45 P.M., LPN E said a CMT only places medications in their carts after a nurse reviews them. When a new admit arrives, the nurse will check the resident's medications against their orders. The medications are then given to the CMT to place in their cart, or if they are as needed narcotics, the nurse will place the medication in their (the nurses') cart. Although not common, if a resident arrives from home with medications, the family will be given the medications to take home. If a resident arrives from another facility with medications, the medications are taken immediately from the resident, and put away immediately. During an interview on 0[DATE], at 4:30 P.M., with the Administrator, Director of Nursing (DON), and ADON, the Administrator said the resident was admitted from another facility on 02/01/20. The sending facility sent the resident with his/her medications in a bag. The resident did not come to the facility with an order for [REDACTED]. On 02/01/20, during the evening shift, CMT C went through the resident's bag of medications and asked LPN B if he/she could put the medications in his/her cart. The Administrator reviewed video footage and CMT C could been seen on the video going through the medications and leaning down by the cart, and then walking away from cart, out of the room, and out of the building. CMT C was out of the building for approximately five minutes. The Administrator said that very few residents admit with medications. Most come with orders, which are filled by the facility's pharmacy. The facility will not accept medications from a resident if they are admitting from home. They will send the medications home with the family. The DON said that he/she or the ADON verify that all admissions are complete correctly. On Mondays, they review all admits, and review medications and the orders. They also review the pharmacy manifest, to verify the medications being delivered match the orders. Additionally, the pharmacy packing slips are compared to medications to be placed in the cart. The ADON will check carts weekly. Nursing staff (LPNs and RNs) are the only staff to take possession of any narcotics. The nurse will immediately log in the medication in the narcotic book. If a resident is admitted to the facility without an order for [REDACTED]. MO 271

Based on observation, interview, and record review, the facility failed to consistently serve all residents food at an appetizing temperature. The facility census was [AGE]. Record review of the 2013 Missouri Food Code showed the following: -Provision shall be made to assure that hot food is served hot and cold food is served cold; -The temperature of potentially hazardous food shall be forty-five degrees Fahrenheit (45°F) or below or one hundred forty degrees Fahrenheit (140°F) or above at all times; -Potentially hazardous food requiring refrigeration after preparation shall be rapidly cooled to an internal temperature of forty-five degrees Fahrenheit (45°F) or below. Potentially hazardous food to be transported shall be prechilled and held at a temperature of forty-five degrees Fahrenheit (45°F) or below. Record review of the facility's policy titled Assistance with Meals, dated October 2009, showed the following: -For all residents, hot foods shall be held at a temperature of 136 degrees or above until served; -Cold foods shall be held at 40 degrees or below until served; -Nursing and Dietary Services will establish procedures such that delivery of food to serving areas accommodates this requirement. 1. During an interview on 01/13/20, at 10:00 A.M., Resident #1 said his/her room tray is sometimes served cool. During an interview on 01/13/20, at 10:10 A.M., Resident #2 said his/her room tray is not served hot enough. During an interview on 01/13/20, at 10:25 A.M., Resident #3 said his/her room tray is not served warm. During an interview on 01/13/20, at 10:55 A.M., Certified Nurse Aide (CNA) A said a resident complained this morning (01/13/20) that his/her breakfast was not warm. During an interview on 01/13/20, at 11:15 A.M., CNA B said some residents that receive hall trays have voiced concerns over the temperature of the food (not warm). During an interview on 01/13/20, at 11:25 P.M., CNA C said residents have voiced concerns over the temperature of hall trays (not warm). Record review of facility's serving temperatures for lunch serve out, dated 01/13/20, showed the following; -Beef internal temperature of 168 degrees Fahrenheit (F), macaroni and cheese 174 degrees F, and coleslaw 38 degrees. Observation on 01/13/20, at 12:00 P.M., showed the following; -Trays were in hall cart and delivered to appropriate hall; -A tray was removed from the cart at 12:07 P.M.; -Beef riblet had an internal temperature of 98 degrees F, macaroni and cheese a temperature of 101 degrees F, and coleslaw [AGE] degrees F; -Coleslaw was in a bowl on the plate under the plate lid; -Food was cool to lukewarm to taste. During an interview on 01/13/20, at 12:40 P.M., Resident #1, who received a hall tray, said the food could have been warmer. During an interview on 01/13/20, at 12:45 P.M., Resident #3, who received a hall tray, said the food was just lukewarm. During an interview on 01/13/20, at 1:05 P.M., the Dietary Manager (DM) said he/she temps the food prior to serve out, but does not temp the food again during or after serve out. During an interview on 01/13/20, at 1:10 P.M., with the Assistant Director of Nursing (ADON), Acting Director of Nursing (DON), and the Administrator, the Administrator said he/she has not been aware of any complaints regarding the temperature of the food since the facility received new hall tray carts. Once the trays have been placed in the cart, it is the expectation that the hall trays are delivered within 10 to 15 minutes. There can be a delay in delivery of hall trays depending on much assistance each resident requires for meal setup. The hall trays should temp close to the serving line temperature and coleslaw should not be served on a covered hot plate. MO 558/MO 789

Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS- ) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents (Resident #31 and #54) who remained in the facility after discharge from Medicare Part A services and for one resident (Resident #150) who discharged home. The facility census was 97. Record review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following information: -If the Skilled Nursing Facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of either the SNFABN (form CMS- ) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them his/herself or through other insurance they may have; -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. 1. Record review of Resident #31's electronic health record (EHR) showed the following information: -discharged from therapy on 1/31/19; -The resident remained in the facility; -The facility did not provide the resident or the resident's responsible party a SNFABN (form CMS- ) or any uniform denial letter. 2. Record review of Resident #54's EHR showed the following information: -discharged from therapy 4/12/19; -The resident remained in the facility; -The facility did not provide the resident or the resident's responsible party a SNFABN (form CMS- ) or any uniform denial letter. 3. Record review of Resident #150's EHR showed the following information: -discharged from therapy 3/28/19; -The resident discharged home; -The facility did not provide the resident or the resident's responsible party a SNFABN (CMS- ) or any uniform denial letter. 4. During an interview on 7/16/19, at 10:30 A.M., Corporate Compliance Officer A said the facility could not locate the ABN or denial notices for the three residents. He/she said the facility had to recently terminate the person responsible for doing the notices. 5. During an interview on 7/17/19, at 8:15 A.M., the administrator said he/she could not locate the ABN or denial notices for the three residents selected for review. She said the staff person who was responsible was recently terminated.

Based on record review and interview, the facility failed to complete a baseline care plan within 48 hours of admission for two residents (Resident #9 and #83) and failed to document reviewing or providing a copy of a baseline care plan to the resident and/or resident representative for one resident (Resident #198). A sample of 20 residents was selected for review out of a facility census of 97. 1. Record review of Resident #9's facility face sheet (a document that gives a resident's information at a quick glance) showed the following information: -Date of admission 3/27/19; -[DIAGNOSES REDACTED]. Record review of the resident's medical record showed no record of a baseline care plan. During an interview on 7/19/19, at 2:09 P.M., Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) Coordinator F said the facility did not have a baseline care plan for the resident. 2. Record review of Resident #83's facility face sheet showed the following information: -Date of admission 6/20/19; -[DIAGNOSES REDACTED]. Record review of the resident's medical record showed no record of a baseline care plan. During an interview on 7/19/19, at 2:09 P.M., MDS Coordinator F said the facility did not have a baseline care plan for the resident. 3. Record review of the Resident #198's face sheet showed the following information: -Date of admission 7/13/19; -[DIAGNOSES REDACTED]. Record review of the resident's baseline care plan with, an initiated date of 7/15/19, showed the following information: -admitted [DATE]; -Required a regular diet; -Oriented to person and place; -Required extensive assistance with bathing, bed mobility, dressing, grooming, and toileting; -Has limited physical mobility related to recent surgery to the right lower leg; -High fall risk; -Limited mobility related to recent surgery to lower extremity. Record review of the resident's social services notes showed no documentation of a baseline care plan reviewed or signed by the resident. During an interview on 07/23/19, at 12:11 P.M., the resident said that he/she did not receive a copy of the care plan. 3. During an interview on 7/19/19, at 2:09 P.M., MDS Coordinator F said baseline care plans should be completed in 48 hours and be under the care plan tab. The facility does not document when they give a copy of it to the resident or the resident's representative. Staff put a copy of the care plan in the resident's closet so staff know how to care for the residents. 4. During an interview on 7/19/19, at 4:00 P.M., the administrator said she was informed the residents and or/resident representatives were not being given a copy of the baseline care plans. She knew this was a requirement. Baseline care plans are required to be completed within 48 hours of admission to the facility.

Based on record review and interview, the facility failed to provide the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification of a transfer or discharge to the hospital for one resident (Resident #9). A sample of 20 residents was selected for review out of a facility census of 97. Record review of the facility policy titled, Transfer or Discharge Notice, from the Nursing Services Policy and Procedure Manual for Long-term Care, revised (MONTH) (YEAR), showed the policy did not address a written notification be sent to the ombudsman when a resident transferred to the hospital. 1. Record review of Resident #9's wound care center document, dated 5/30/19, showed the resident seen at the wound care center and that the resident needed to go to the emergency room for intravenous antibiotics. The wound care center said they would follow-up with the resident at the hospital and would provide the facility with wound care orders for the resident prior to the resident being discharged back to the facility. Record review of the resident's nurses' notes showed the following information: -On 6/01/19 (no time listed), the resident was currently in the hospital. The note did not say when the resident went to the hospital or why staff sent him/her to the hospital; -On 6/07/19, at 4:00 P.M., the resident returned from the facility by ambulance. He/she presented with no complaints or concerns. Staff transferred the resident to his/her wheel chair. The resident's pain assessment showed a 7 out of 10 on the pain scale to his/her right leg. Staff administered as needed (PRN) pain medication to the resident. The resident went to the dining room for dinner. Staff to continue to assess for change of condition. During an interview on 7/24/19, at approximately 10:00 A.M., the administrator said the resident did not go directly to the hospital as the wound care center ordered. The resident insisted on coming back to the facility prior to going to the hospital. The resident discharged from the facility on 5/30/19, at 5:30 P.M., per the wound care center's recommendation. During an interview on 7/24/19, 12:13 P.M., the Director of Nursing (DON) said the facility sends written notification to the resident and/or family when a resident is transferred to the hospital, but has not been sending written notification to the ombudsman. She said the facility sends the notification at the time the resident is transferred to the hospital and this notification is scanned into the resident's electronic health record (EHR). During an interview and record review on 7/24/19, at 12:38 P.M., the administrator said the facility has not been sending the ombudsman notifications. The person who had been doing these no longer works at the facility. The administrator showed the surveyor the binder where the notifications had been sent. The last notification to the ombudsman was (MONTH) 2019. The binder did not have the ombudsman notification of the hospitalization for the resident.

Based on observation, interview, and record review, the facility failed to notify the Registered Dietitian (RD) to complete nutritional assessments for two residents (Resident #10 and #12) identified at nutritional risk out of a sample of 20. The facility census was 97. Record review of the facility policy, titled Nutritional Assessment, dated (MONTH) 2011, showed the following information: -The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. 1. Record review of Resident #10's face sheet (brief resident information sheet) showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED].; acquired absence of left leg above knee; [MEDICATION NAME] degeneration (a [MEDICAL CONDITION] condition affecting the central part of the retina and resulting in distortion or loss of central vision); [MEDICAL CONDITION]; anxiety; dysphagia (difficulty or discomfort in swallowing); and [MEDICAL CONDITION] (a condition of increased pressure within the eyeball causing gradual loss of sight). Record review of the resident's dietary assessment, dated 1/19/17, showed the following information: -At medium nutritional risk with a score of 20.0; -Staff offered the resident a regular diet. Resident's intake usually good. He/she chooses salads for meals for weight loss goals. Record review of the resident's care plan, dated 4/1/19, showed the following information: -History of swallowing problem due to a [DIAGNOSES REDACTED]. -Regular diet with thin liquids; -Instruct the resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly; -Resident eats meals in the main dining room; -Resident to eat meals with supervision of staff; -May crush medications as need as appropriate; -Inform nursing staff of the resident's risk for aspiration with eating; -Spouted cup with meals; -Weighted utensils with meals; -Speech therapy to evaluate and treat as indicated for dysphagia. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/8/19, showed the following information: -Moderate cognitive impairment; -Required supervision for eating; -Required extensive assistance for bed mobility, dressing, and hygiene; -Total dependence on staff for transfers and toileting; -No loss of liquids or solids from the resident's mouth; -Resident did not hold food in mouth; -Resident did not cough or choke during meals or swallowing medications; -No complaint of difficulty or pain when swallowing. Record review of the resident's dietary note, dated 6/11/19 (2 years and 5 months since the date of the last dietary assessment), showed the dietary manager documented the following information: -Regular diet; -Fair appetite with 25-75% intake; -Weight 236 pounds; -Body Mass Index (BMI) 37; -Weight history 178-242 pounds; -At medium nutritional risk; -When resident eats, it is with excessive sugar; -Need to monitor for healthier intakes. Record review of the resident's (MONTH) 2019 physician order sheet (POS) showed a regular diet, regular texture, and regular consistency. Record review of the resident's diet card showed a regular diet, spouted cups, and weighted utensils. Record review of the resident's record showed no documented assessment of the resident completed by the RD since 1/19/17. During an observation and interview on 07/16/19, at 12:53 P.M., the resident said the head of the bed needed raised when eating as he/she has some difficulty swallowing. He/she eats in his/her room and can eat independently with staff set up. The resident's hands shook and the front of his/her clothing was wet from neck to waist. The resident had just finished eating. The resident had food spills on his/her chest and chin. The resident's liquids were in cups with lids and handles. The resident used regular utensils and said he/she prefers regular utensils. During an interview on 07/24/19, at 1:45 P.M., Certified Nurses Aide (CNA) D said the resident is on a regular diet. The resident has [MEDICAL CONDITION] and has lidded cups with handles. Staff set the meal up for the resident, opening cartons and cutting up food. The resident eats 75-100 % of meals. The resident has said that his/her pills feel stuck at times. During an interview on 07/24/19, at 2:00 P.M., Licensed Practical Nurse (LPN) [NAME] said the resident stays up late at night and does not always eat breakfast. The resident has some skin redness, but no open sores. He/she wears a cushion boot due to decreased mobility and pressure sore prevention. The resident is total assist with transferring and his/her health conditions warrants good nutrition. During an interview on 7/24/19, at 1:30 P.M., the RD said he/she did not complete a nutritional assessment on the resident since the last assessment completed on 1/19/17, as the facility did not notify her of any due dates. During an interview on 7/25/19, at 1:45 P.M., the administrator said staff missed notifying the RD of nutritional assessment due dates for the resident. 2. Record review of Resident #12's face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's nutritional assessment, dated 2/15/18, completed by the RD, showed the following information: -Mechanical soft diet with nectar thick liquids; -Average intake of 50-60% of meals; -At high nutritional risk with a score of 26.0. Record review of the resident's care plan, last revised 6/19/18, showed the following information: -Potential nutritional problems; -Divided plate; -Monitor/record/report to physician signs and symptoms of malnutrition; -Provide and serve diet as ordered; -RD to evaluate and make diet change recommendations as needed. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Required extensive assistance with bed mobility, dressing, eating, and hygiene; -Dependent on staff for transfers and toileting. Record review of the resident's (MONTH) 2019 POS showed the resident had an order for [REDACTED]. Record review showed no additional nutritional assessments completed since 2/15/18 (one year and 5 months prior). Observation on 7/17/19, at 12:57 P.M., showed staff assisted the resident with eating in the assistive dining area with a divided plate, mechanical meat, and a bowl of yogurt. 3. During an interview on 7/24/19, at 10:50 A.M., the Dietary Manager (DM) said she completes a dietary profile within one to two weeks after a resident's admission. She reviews food preferences with the resident and checks the dietary order. DM meets with each resident quarterly, reviews records and attends care plan meetings and documents in the residents' record. Some of the Registered Dietitian (RD) duties include checking residents with weight loss and completing nutritional assessments. The RD is in the facility weekly. The DM did not know how often the RD completes a nutritional assessment on each resident. 4. During an interview on 7/25/19, at 1:45 P.M., the Director of Nursing (DON) said the Registered Dietitian is in the facility frequently and reviews residents with weight loss and wounds. The RD should review every resident quarterly. 5. During an interview on 7/24/19, at 1:30 P.M., the RD said she reviews all residents with particular focus on weight loss, residents on [MEDICAL TREATMENT], and residents with wounds. She completes quarterly and annual assessments on all residents. Resident face-to-face is not necessary for quarterly or annual reviews, but she tries to meet with residents, especially if triggered for weight loss. 6. During an interview on 7/25/19, at 1:45 P.M., the administrator said the expectation for the RD is a quarterly nutritional assessment and a yearly diet profile.

Based on observation, interview, and record review, the facility failed to ensure two residents (Resident#15 and #29 ) were treated with dignity and respect when staff did not assist a resident to the bathroom timely , did not provide a resident water after medication administration as requested, and did not honor a request that medication be mixed with more apple sauce. The facility census was 97. Record review of the facility's policy titled Quality of Life-Dignity, dated 2001, showed the following information: -Residents shall be treated with dignity and respect at all times; -Be assisted in maintaining and enhancing his or her self-esteem and self-worth; -Staff will speak to residents respectfully at all times; -Promote dignity by promptly responding to the resident's request for toileting assistance; -Staff shall treat cognitively impaired resident's with dignity and sensitivity by addressing the underlying motives or root causes for behavior and not challenging or contradicting the resident's beliefs or statements. 1. Record review of Resident#29's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admitted [DATE]; -[DIAGNOSES REDACTED]. sugar), and [MEDICAL CONDITION] (a serious mental disorder in which people interpret reality abnormally). Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument complete by facility staff), dated 10/20/18, showed the following information: -Moderate cognitive impairment; -Required extensive assistance for dressing, toilet use, personal hygiene, and bed mobility; -Total dependence for transfer, locomotion on and off the unit. Record review of the resident's care plan dated, last reviewed 4/23/19, showed the following information: -Resident is at risk for falls related to [MEDICAL CONDITION]; -Anticipate and meet the resident's needs; -A self-care performance deficit related to weakness and general debility of aging; -Assist with personal hygiene as needed; -Requires the use of a Hoyer lift (a device used for transfers when a person requires 90-100% assistance) and two staff to assist with transfers. Observations and interviews on 07/17/19 showed the following: -At 2:08 P.M., the resident notified the surveyor that he/she needed to use the bathroom and appeared anxious (hands were shaking and brow was furrowed). Resident said he/she had informed two aides his/her needs for the bathroom and he/she had been waiting a while; -At 2:08 P.M., Certified Nurse Aide (CNA) M said he/she knew the resident needed to go to the bathroom, but was working at the other end of the hall and would need to get a second staff member to help assist with the resident; -At 2:27 P.M., the activities director spoke with the resident, who remained anxious. The resident reported the resident had been waiting on staff to use the bathroom. The activities director said she would get someone to assist the resident; -At 2:35 P.M., CNA M inquired if the resident still needed to use the bathroom; -At 2:36 P.M., CNA N came to help assist the resident to the bathroom. During an interview on 7/17/19 at 4:30 P.M., the Director of Nursing (DON) said it is unacceptable for the resident to have had to wait 30 minutes for staff to assist him/her to the bathroom. Observation and interviews on 7/18/19, at 8:26 A.M., showed the following: -The resident appeared to be in distress requesting several times that the surveyor help him/her because the medication just given was still melting in his/her mouth. The resident needed more water to drink and staff would not give him/her any; -Certified Medication Technician (CMT) H said he/she had given the resident water already; -CMT H stood at the medication cart. After the third time the resident asked for water the CMT sighed and poured a cup of water for the resident; -The resident asked that the water be given slowly; -Following drinking the cup of water the resident appeared calm and had no more concerns voiced. During an interview on 7/24/19 at 2:35 P.M., the DON said a resident should be given water upon request. 3. Record review of Resident#15's face sheet showed the following information: -admitted [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly MDS assessment, dated 3/30/19, showed the following: -Mild cognitive impairment; -Required extensive assist with bed mobility, transfer, dressing, toilet use, and personal hygiene; -Required no help with eating. Record review of the physician's orders [REDACTED]. -Staff may crush medications and administer them simultaneously in applesauce or pudding; -Ensure the resident consumes all of the medication. Observations on 7/18/19, at 8:49 A.M., showed the following: -CMT H crushed/prepared 19 medications into a medication cup; -CMT H mixed powder with approximately 1 teaspoonful of applesauce as the powder filled the cup half full; -The resident asked the CMT to stir the mixture more due to powder remaining in the bottom of the cup; -The resident asked the CMT to use a larger cup to mix the medication and the CMT did not respond; -The resident was given a bite of mixture, grimaced, said it tasted awful, and asked to have it mixed in a bigger cup with more apple sauce; -CMT H said he/she didn't need to do that; -The resident was given another bite, grimaced, and asked again to have this mixed with more applesauce; -CMT H did not honor this request. During an interview on 7/18/19, at 3:00 P.M., Licensed Practical Nurse (LPN) J said that a resident's medication should be mixed with more applesauce if desired and it does not conflict with the physician's orders [REDACTED]. During an interview on 7/19/19, at 2:30 P.M., CMT K said that if a resident wanted their medication mixed with more applesauce they would do it. During an interview on 7/24/19, at 2:35 P.M., the DON said she would expect CMT staff to honor the request of a resident who asks medication to be mixed with more applesauce, unless there is medical reason not to.

Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #83 and #247) had a physician's order indicating where and when the resident was to go for [MEDICAL TREATMENT] (a process of cleaning the blood by a special machine necessary when the kidneys are not able to filter the blood) treatment. A sample of 20 residents was selected in a facility with a census of 97. Record review of the Nursing Guidelines Manual, dated (MONTH) (YEAR), regarding [MEDICAL TREATMENT] showed the following information: -Care of the shunt/fistula/graft/port: keep the area clean and dry, feel for the thrill sensation (a vibrating sensation that can be felt) daily, inspect the access site for redness, swelling or warmth, avoid excessive pressure of the puncture site after [MEDICAL TREATMENT], watch for bleeding after [MEDICAL TREATMENT] and monitor for signs of infection. Nursing to maintain the dressing to access site at all times. Nurses to check the dressing every shift to maintain, be reapplied or reinforced as needed; -Nurses will check the thrill sensation daily and document daily on the resident's treatment record; -Nurses to notify the physician for fever not connected to a cold or flu, pain in or around the access site, pain after [MEDICAL TREATMENT], loss or weakening of the thrill sensation at the access site or any bleeding noted after returning from [MEDICAL TREATMENT]; -A [MEDICAL TREATMENT] communication record will be sent with the resident on each [MEDICAL TREATMENT] visit. All concerns in the last 24 hours will be addressed, including the last medications given and the facility contact person. The [MEDICAL TREATMENT] unit will complete the lower portion of the report to include the resident's weight prior to and after [MEDICAL TREATMENT], any labs completed, medication given, follow up information and any new physician orders. The lower portion is signed by the [MEDICAL TREATMENT] nurse and returned to the facility. The record will be maintained in the resident's medical record. Record review of the facility's policy titled, Care of a Resident with End Stage [MEDICAL CONDITIONS], from the Nursing Services Policy and Procedure Manual for Long-Term Care, revised (MONTH) (YEAR), showed the following information: -Residents with [MEDICAL CONDITION] will be cared for according to currently recognized standards of care; -Staff caring for residents with [MEDICAL CONDITION], including residents receiving [MEDICAL TREATMENT] care outside of the facility, shall be trained in the care and special needs of these residents; -Education and training of staff includes the following the nature and clinical management of [MEDICAL CONDITION] (including infection prevention and nutritional needs; the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis; signs and symptoms of worsening condition and/or complications of [MEDICAL CONDITION]; how to recognize and intervene in medical emergencies such as hemorrhages and septic infections; how to recognize and manage equipment failure or complications (according to the type of equipment used in the facility); timing and administration of medications, particularly those before and after [MEDICAL TREATMENT]; the care of grafts and fistulas; and the handling of waste; -Education and training of staff in the care of [MEDICAL CONDITION]/[MEDICAL TREATMENT] residents may be managed by the contracted [MEDICAL TREATMENT] facility or by the clinician with training in [MEDICAL CONDITION] and [MEDICAL TREATMENT] care; -Agreements between this facility and the contracted [MEDICAL CONDITION] facility include all aspects of how the resident's care will be managed including how the care plan will be monitored and implemented; how information will be exchanged between the facilities; and responsibility of waste handling, sterilization and disinfection of the equipment; -The resident's comprehensive care plan will reflect the resident's needs related to [MEDICAL CONDITION]/[MEDICAL TREATMENT] care. 1. Record review of Resident #83's face sheet (a document that gives a resident's information at a quick glance) showed the following information; -Date of admission 6/20/19; -[DIAGNOSES REDACTED]. Record review of the resident's nursing admission summary dated 6/20/19, at 5:48 P.M., showed the resident admitted to the hospital on [DATE] due to the resident had stopped going to [MEDICAL TREATMENT]. The resident had altered mental status and missed two weeks of [MEDICAL TREATMENT]. The resident had a high toxicity (toxic substances in the blood). The resident was on [MEDICAL TREATMENT] and the tunnel port was in the right chest. The resident's follow-up appointment with [MEDICAL TREATMENT] was on 6/21/19, at 12:30 P.M. The resident was on a renal, no added salt diet and went to [MEDICAL TREATMENT] Monday, Wednesday, and Friday. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/27/19, showed the following information: -Moderately impaired cognitive functioning; -No rejection of care; -Continent of bowel and bladder; -Received [MEDICAL TREATMENT]. Record review of the resident's care plan, dated 6/27/19, showed the following interventions related to [MEDICAL CONDITION]: -Acute chronic kidney failure; -Auscultate (listen to) heart and lung sounds every shift and document findings; -[MEDICAL TREATMENT] three times a week (did not specify the days or times for the [MEDICAL TREATMENT]); -Give medications as ordered by the physician; -Monitor for signs and symptoms of hypovolemia (a decreased volume of circulating blood in the body) or hypervolemia (also known as fluid overload where there is too much fluid in the body). Record review of the resident's (MONTH) 2019 physician order sheet (POS) showed no physician's order for [MEDICAL TREATMENT], where to send the resident for [MEDICAL TREATMENT], what days the resident was scheduled for [MEDICAL TREATMENT], or how often to check the [MEDICAL TREATMENT] fistula or port (an access site for [MEDICAL TREATMENT]-a machine used to clean your blood). Observation and interview of the resident on 7/17/19, at 8:41 A.M., showed the resident stood next to his/her bed and put on his/her belt. The resident said he/she goes to [MEDICAL TREATMENT] three times a week on Monday, Wednesday, and Friday. Staff send food with him/her to [MEDICAL TREATMENT]. Staff check his/her [MEDICAL TREATMENT] port occasionally, but he/she did not know how often. He/she had no infections at the [MEDICAL TREATMENT] port and had no concerns with his/her [MEDICAL TREATMENT]. The facility arranged the transportation. The resident denied having any special diet. 2. Record review of Resident #247's face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's nurse's note, dated 6/28/19, showed the following information: -The resident had an upper left extremity graft used for [MEDICAL TREATMENT]; -Thrill and bruit intact; -The resident said he/she had [MEDICAL TREATMENT] on Monday, Tuesday, Thursday, and Saturday and will need transportation; -The resident said the [MEDICATION NAME] cream (medication to numb the area) to the fistula with dressing prior to [MEDICAL TREATMENT] has to be done by him/her. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Oriented to person, place, time, situation, adequate concentration levels; -Propelled self in wheelchair; -No behaviors. Record review of the resident's baseline care plan, dated 6/28/19, showed the following information: -Focus area of [MEDICAL CONDITION]; -Interventions included [MEDICAL TREATMENT] three times per week (resident receives [MEDICAL TREATMENT] four times per week); -Dietary consult to regulate protein and potassium intake; -Fluids as ordered; -Administer medications as ordered by physician; -Plan rest periods. Record review of the diet nutrition assessment, dated 7/10/19, showed the following information: -The resident ate meals in his/her room; -The resident was on [MEDICAL TREATMENT]; -At low nutritional risk. Record review of the resident's (MONTH) 2019 POS showed no order for [MEDICAL TREATMENT], the location of [MEDICAL TREATMENT], the frequency of [MEDICAL TREATMENT], or care of the port or access site. Observations and interviews on 7/16/19, at 11:15 A.M., and 7/25/19 at 10:00 A.M., showed a well-healed access site on the resident's upper, inner left arm. The resident said the following: -He/she goes to [MEDICAL TREATMENT] four times per week; -Staff do not monitor the site or check him/her upon return from [MEDICAL TREATMENT]; -The resident cares for the access site; -The resident has been receiving [MEDICAL TREATMENT] for nine years. During an interview on 7/25/19, at 10:15 A.M., Licensed Practical Nurse (LPN) G said the resident prefers to care for his/her own access site. 3. During an interview on 7/25/19, at 10:15 A.M., LPN G said the following: -Upon a resident's admission, staff know if the resident receives [MEDICAL TREATMENT]; -A physician order would be in the resident's medical record when a resident is receiving [MEDICAL TREATMENT]; -Orders for residents on [MEDICAL TREATMENT] are typically for [MEDICATION NAME] to the access site unless residents prefer to apply it independently. 4. During an interview on 7/24/19, at approximately 12:00 P.M., MDS Coordinator F said he/she had been doing MDS assessments since March. He/she had never done MDS assessments prior to March. For [MEDICAL TREATMENT] residents, he/she has been including in the resident's care plan, interventions related to [MEDICAL CONDITION] and they go to [MEDICAL TREATMENT] and how many times a week they go. He/she did not list the specific days the resident attended [MEDICAL TREATMENT] because of holidays and at times the days of [MEDICAL TREATMENT] have to be adjusted. If he/she knew of any special diet or fluid restrictions, he/she had been listing this under nutritional needs not [MEDICAL CONDITION]. He/she had not been addressing the location of the [MEDICAL TREATMENT] port in the care plan. The facility should also have an order for [REDACTED]. 5. During an interview on 07/24/19, at 9:00 A.M., the Director of Nursing (DON) said the following: -Residents' care plan should include that they receive [MEDICAL TREATMENT], assessment of the port, means of communication between the facility and [MEDICAL TREATMENT], frequency to [MEDICAL TREATMENT], and if they have fluid restrictions; -Facility physician defers to the nephrologist for orders; -The facility did not have orders for two of the [MEDICAL TREATMENT] residents. There should have been an order for [REDACTED].>6. During an interview on 7/24/19, at 5:00 P.M., the administrator said [MEDICAL TREATMENT] should be addressed in the resident's care plan and the facility should have a physician's order for the [MEDICAL TREATMENT]. The DON brought it to her attention today that two of the [MEDICAL TREATMENT] resident's did not have a physician's order for [MEDICAL TREATMENT] and there were concerns regarding the care plans of the [MEDICAL TREATMENT] residents.

Based on record review, observation and interview the facility failed to identify, assess, notify the physician and obtain treatment orders for multiple Stage II pressure ulcers (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater) for one Resident (Resident #13) in a selected sample of 18 residents. The facility identified one resident with a pressure ulcer in a census of 105. According to The Merck Manual of Geriatrics (third edition) Risk Factors for the development of pressure ulcers include the following: -Moisture (as it occurs with urinary and fecal incontinence) -Unrelieved pressure for more than two hours; -Immobility; -Inactivity; -Infection; -[MEDICAL CONDITION]; -Declined ability to respond to pressure related discomfort. Record review of the facility's Management and Prevention of Pressure Ulcer policy, revised 02/2011, showed the following information: -Our facility will ensure that every resident with pressure ulcers will receive necessary treatment and services to promote healing and prevent infection; -Residents identified at risk will be placed on a turn and position schedule; -The skin and body alert records will be initiated on the resident's assigned bath day for those residents at risk or currently with pressure ulcers and any resident on which the certified nurse assistant (CNA) identifies a skin problem. The form will be completed by the CNA assigned to that resident. The form will then be forwarded to the charge nurse for documentation completion and then on to the Director of Nursing (DON) or designated wound nurse for review; -The attending physician and responsible party will be notified of residents that have a change in skin condition; -All interventions and notifications shall be documented and a weekly skin documentation will be initiated. 1. Record review of Resident #13's admission assessment, dated 08/11/11, showed staff admitted the resident to the facility. The nurse documented the resident had redness present on his/her buttocks and no other skin issues. Record review of the resident's care plan, last updated 08/23/11, showed the following information: -At risk for alteration in skin integrity due to frequent incontinence and decreased mobility; -Treatments as ordered by the physician; -Apply moisture barrier cream as needed; -Monitor skin for new areas of redness or irritation and report to the physician as needed; -Provide pressure relieving devices for bed and wheelchair; -Reposition every two hours and as needed for comfort and pressure relief; -Required mechanical lift for transfers. Record review of the September 2011 physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Apply [MEDICATION NAME] (moisture barrier) cream to the resident's anal area two times a day; -Moisture barrier as needed; -Therapeutic mattress. Record review of the resident's 30-day Minimum Data Set (MDS), a federally mandated comprehensive assessment tool, required to be completed by facility staff, dated 09/03/11, showed the following information: -Cognitively intact; -Required extensive assistance with personal hygiene; -Dependent on staff for bed mobility, transfers, dressing and toilet use; -Always incontinent of bowel and bladder; -At risk for the development of pressure ulcers; -No unhealed pressure ulcers present. Record review of the treatment administration record (TAR), dated 09/01-09/15/11, showed the following information: -[MEDICATION NAME] cream to the resident's anal area two times a day; -Staff initialed the treatment sheet 25 out of 29 opportunities indicating staff applied the cream to the resident's anal area. Record review of the Skin Alert/Body Alert sheets, dated 09/08/11 and 09/12/11, completed by the bath aide and signed by a nurse, showed staff documented the resident's skin was clear. Record review of the nurses' notes, dated 09/08-09/12/11, showed the following information: -On 09/08/11, 09/09/11, and 09/12/11 the day shift, evening shift and night shift nurses documented the resident had "reddened buttock"; -On 09/11/11 the day shift and night shift nurses documented the resident's skin was within normal limits (WNL); -On 09/12/11, at 2:30 A.M., the resident complained of "butt" pain and rated the pain as an eight out of a scale of ten. Staff repositioned the resident for comfort. The day shift and night shift nurses documented the resident's skin was WNL. Observation on 09/13/11, at 11:02 A.M., showed the resident lying in bed positioned on his/her back. As CNA A and CNA B entered the resident's room to perform perineal care (cleansing of the genitalia and surrounding areas). The resident said his/her "butt" hurt. The aides rolled the resident onto his/her right side. There was one dime-sized Stage II pressure ulcer and one quarter-sized pressure ulcer on the resident's left buttock. Both Stage II pressure ulcers had pink wound beds and no drainage. The surrounding tissue was intact but purple in color. As CNA A performed perineal care to the resident's buttocks, the resident flinched and said "ow!" During an interview on 09/13/11, at 11:02 A.M., CNA B said he/she first noticed the open areas a few days ago. Record review of the resident's current medical record on 9/13/11 and 09/14/11 showed no indication the nurses identified, assessed and notified the physician regarding the two Stage II pressure ulcers on the resident's left buttock. Record review of nurses' notes, dated 09/14/11, showed the day shift, evening shift and night shift nurses documented the resident had "reddened buttock". Interview and observation on 09/14/11, at 1:19 P.M., showed the resident sat in his/her room in his/her geriatric chair (geri-chair) (a reclining cushioned high back wheelchair). The resident said he/she was not doing too well and said his/her bottom hurt. During an interview on 09/15/11, at 2:45 P.M., Licensed Practical Nurse (LPN) C said the resident had a reddened, non-opened area on his/her bottom that is treated with [MEDICATION NAME] cream. During an interview on 09/15/11, at 2:45 P.M., LPN D said the last he/she knew the resident's buttocks were just red. During an interview on 09/15/11, at 2:50 P.M., CNA F said the resident did not have an open wound on his/her buttocks but did have an area that looked like a scar from an old pressure ulcer. The CNA said the area looked like it "was trying to come open" so staff applied [MEDICATION NAME] (a moisture barrier) cream. Observation and interview on 09/15/11, at 3:00 P.M., showed the resident lying in bed positioned on his/her back. As the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) entered the resident's room, the resident said his/her "butt" hurt. The DON and ADON rolled the resident onto his/her right side that revealed three Stage II pressure ulcers. The DON described the wounds as "two pea-sized open areas, one nickel-sized open area and one pea-sized open area" on the resident's left buttock, and described the wounds as open, sheared and red. The DON said the wound care nurse reported, to her, the resident had shearing on his buttocks. The DON said staff document pressure ulcer assessments on the skin log. According to the U.S. Dept. of Health and Human Services Clinical Practice Guidelines #15, shearing forces are produced when adjacent surfaces slide across one another. As a result of shear, many blood vessels in the sacral area are likely to become twisted and distorted, and tissue may become ischemic (lacking oxygen) and necrotic (tissue death). Observation on 09/15/11, at 3:03 P.M., showed the DON reviewed the treatment book, the weekly skin assessment book and the nurses' book and could not find documentation of an assessment of the resident's pressure ulcers. Record review of the Skin Alert/Body Alert sheets, dated 09/15/11, completed by the bath aide and signed by a nurse, showed staff documented the resident had a reddened area on his/her left buttock. Record review of a nurses' note, dated 09/15/11, showed the following information: -A nurse completed a skin assessment and found four open/sheared areas to his/her left buttock; -A nurse measured the wounds as follows: #1-0.3 centimeters (cm) x 0.7 cm, #2-0.3 cm x 0.7 cm, #3-1.6 cm x 1.5 cm and #4-0.5 cm x 1.0 cm and described the four wounds as red with pink wound edges and had no bleeding and no depth. Record review of a physician's orders [REDACTED]. During an interview conducted on 09/16/11, at 9:50 A.M., CNA G said if he/she finds a new open wound, on a resident, he/she immediately reports it to the charge nurse. He/she said the CNAs do not document notification of the nurse. During an interview conducted on 09/16/11, at 9:50 A.M., Bath aide (BA) E said if he/she discovers a new wound, he/she reports the area to the nurse immediately and documents the location of the wound on the skin alert/body alert sheets. The BA said he/she noticed the wounds, on the resident's buttocks Monday (09/12/11) or Tuesday (09/13/11) and reported the area to the nurse. The skin looked like the top layer was rubbed off but he/she was unable to document the area as "opened" on the Skin Alert/Body Alert sheet because he/she was not a nurse.