Every finding on record at Mary, Queen and Mother Center

Based on observation, interview and record review, the facility failed to maintain its call light system in working order and according to the stipulations in the state exception granted to them, allowing use of the current call light system. This deficiency had the potential to affect all residents and affected one sampled resident who had a toe injury (Resident#1). The sample size was four. The census was 74. Review of the facility's call light policy dated 6/9/17, showed:It is the policy of the facility to provide quality long-term care to residents. All residents will have a call light within reach while in bed or sitting next to the bed.Answering call lights is the responsibility of all Nursing Staff members with priority given to bathroom call lights. A call light should not be turned off in the resident's room until the resident's needs are met. A call light should not be disconnected at any time.In order to ensure that call lights are responded to in a timely manner, Nursing Staff - Charge Nurses and Certified Nurse Aides (CNAs) will carry pagers programmed to vibrate when a call light is on. The room number and/or location will be displayed on the pager.Procedure:Distribution and Return of Pagers:-Nurse Managers, Charge Nurses, and Supervisors will carry pagers when on duty.-Pagers will be distributed to all Charge Nurses and CNAs at the beginning of every shift by the Charge Nurse when she/he gives them report.-Pagers will be returned at the end of each shift when the Charge Nurses and CNAs give report to the oncoming shift Charge Nurses and CNAs.-Nurses and/or Certified Medication Technicians (CMTs) who are passing medicine will not be assigned pagers as this would disrupt medication administration and could cause medication errors. Pagers Leaving the BuildingPagers are not to leave the building at any time. If a pager is inadvertently taken out of the facility, it must be returned as soon as possible.Lost PagersSince pagers are costly, it is important that every staff member takes responsibility to ensure that pagers are handled safely and protocol is followed to return pagers at the end of each shift.Response Time ReportNursing Management and/or Quality Nurse will review the response time report on a monthly basis for all nursing units. If a problem is identified, the Director of Nursing or designee will be responsible to continue monitoring for an appropriate time frame. Employees identified with prolonged response time will be counseled by their immediate supervisor. Review on of the facility's exemption letter dated 12/10/25, from the Missouri Department of Health and Senior Services, Division of Regulation and Licensure, Section for Long Term Care Regulation (SLCR), showed stipulations for the exception for their wireless call light system. The following stipulations included: 19 CSR 30-85.012 (124): Facilities shall provide an electrically powered nurses' call system with indicator lights at the corridor entrance of each bedroom. Audible signals and indicating panels shall be located in each nurses' station and utility room. Facilities shall provide signal buttons at the head of each resident bed, in each toilet room and in each bathroom. -The exception applies to the omission of indicator lights at the corridor entrance of each resident bedroom and the audible signals and indicating panels in each nurses' station and utility room. It does not apply to the remainder of the requirement.-The operator will ensure that the wireless nurse call system is fully operational twenty-four (24) hours per day, seven (7) days a week.-The operator will maintain, at a minimum and in accordance with the manufacturer's recommendations, all the features of the wireless call system provided to the SLCR on September 25, 2025, and notify the SLCR of system changes.-The operator shall ensure that all direct care staff carry and utilize the nurse call pagers at all times.-The operator will continue to implement the Call Light Policy as provided to the SLCR on June 3, 2025, to ensure no direct care staff is without a pager.-The operator will maintain a sufficient supply of wireless nurse call pagers for all direct care staff, including the additional twenty-five (25) wireless pagers purchased on April 1, 2025.-The operator will ensure that a wireless nurse call system report is available to the SLCR staff for review upon request.-The operator will ensure that resident care and services are not adversely affected in any way by the exception.**Please note, should the facility be issued a citation for failure to comply with federal regulation F919 regarding the nurse call system and/or the stipulations outlined in this determination notice, the exception will be reviewed for possible rescission and the facility may be required to reinstall the indicator lights at the corridor entrance of each bedroom and the audible signals and indicating panels in each required nurses' station and utility room to meet the requirement. 1.Review of Resident #1's significant change Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/16/25, showed the following:-Dependent on staff for care;-Cognitively intact;-Diagnoses of renal failure, depression, heart failure, and bipolar disease (mental Illness with severe mood swings from major depression to manic episodes). Review of the progress notes dated 12/15/25 at 10:51 A.M., showed the Hospice Nurse identified open areas to bilateral toes and left third toe. The nurse informed the Director of Nursing (DON), notified family, and the physician. The physician gave new orders to treat the areas. During an interview on 12/18/25 at 9:00 A.M., Resident #1 said on 12/15/25 at 4:00 A.M., he/she needed staff assistance due to pain in his/her feet. The pain felt like electric shock in her/his feet. The Resident used the facility's call light system to request staff assistance. The Resident reported the call light system failed, and no staff came to his/her room until his/her Hospice Nurse arrived around 8:30 A.M. and attended to her/his need. The resident said she/he can't yell loud enough to get anyone's attention when her/his call light fails. This is not the first time the system failed to notify staff for assistance. It has been months since the call light worked properly, and facility Administration along with the Maintenance Department were aware. Staff tried to fix it several times. After working on it, the system functioned properly for a while, and then it will eventually return to working sporadically. 2. Observation on 12/18/25 at 1:10 P.M. showed CNA A working without a pager on the St. [NAME] Hall.During an interview on 12/18/25 at 3:00 P.M., CNA A said there wasn't a pager on his/her person. Staff used to carry pagers, but it all stopped some time ago. CNA A reported no knowledge of an exception and the requirement of carrying a pager due to the exception stipulations.Observation and interview on 12/19/25 at 8:50 A.M., showed CNA B working the floor on his/her shift. CNA B acknowledged there was no pager on her/his person, and he/she hasn't used one for some time. CNA B was unaware of the stipulation in the facility exception.Observation on 12/19/25 at 9:00 A.M., showed three CNAs (CNA A, CNA B, CNA C) working the floor and none had pagers on their person.During an interview on 12/19/25 at 9:15 A.M., CNA D said there is not a pager on him/her, and he/she never has had one. CNA D \said he/she was a new employee. The pager stipulation had never been mentioned to him/her when he/she started. During a telephone interview on 12/19/25 at 8:50 A.M., Licensed Practical Nurse (LPN) G said she/he does not use a pager anymore. Staff used to be required to have the pagers on their person, but it's not enforced anymore. He/she could not recall when it stopped, but it's been a while.During a telephone interview on 12/19/25 at 8:55 A.M., CMT F said they have not worn a pager when working the floor for at least three months. It was about the beginning of last summer when staff stop wearing pagers or Administration stopped monitoring for compliance. 3. During an interview on 12/19/25 at 8:00 A.M., LPN E said the staff do not utilize the pagers anymore and it's been a while since they have carried one on their person. LPN E could not say exactly when the staff stop utilizing the pagers as required by the exception. The wearing of the pagers was enforced regularly in the past and pagers were used, but it had fallen to the way side, and the majority of staff do not wear the pagers as required. LPN E estimated it had been a couple of months ago when having the pagers became less of a focus. LPN E reported no knowledge regarding the stipulation of staff required to have pagers on their person due to the call light system's exception. LPN E also said Resident #1's call light has not functioned properly for a few months, and he/she has fixed it him/herself, but that was temporarily, as it reverts to functioning improperly after some use. LPN E thought there was an electrical short in Resident #1's call light. 4. During an interview on 12/19/25 at 12:28 P.M., the Maintenance Director said the call light system is monitored by an outside agency and there are no internal audits to ensure the system is functioning properly throughout the facility. In addition, there are no alerts that come to the facility if the system is not functioning properly. The CNAs should be the ones monitoring the lights for proper functioning. Resident #1's call light has been malfunctioning for some time, and he has fixed it a few times. The call light will work properly after applying a fix but has reverted back to not functioning properly every time. There are pagers available for staff, but the majority of staff have stopped using them. 5. During an interview on 12/19/25 at 2:40 P.M., the Administrator said she acknowledged there are stipulations per the exception granted to the facility regarding their call light system. Staff should be wearing pagers when they are working the floor per the exception stipulation, and she was not aware staff were not wearing the pagers. They do not have an internal audit system to ensure the call light system is functioning properly, and the DON is responsible for monitoring nursing staff to ensure pagers are being used in accordance with the stipulation in their exception letter granted to them for using the current wireless call light system. 2694682

Based on interview and record review, the facility failed to notify a resident's responsible part after a change in condition that required an alteration in the resident's treatment plan (Resident #1). The sample size was 3. The census was 74.Review of the facility's Notification of Change Policy dated 11/28/17, showed the purpose of this policy ensures the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification: -Compliance guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's member or legal representative when there is a change requiring such notification; -Circumstances requiring notification include new treatment. Review of Resident #1's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 8/22/25, showed:-Intact cognition;-Diagnoses included stroke with hemiplegia and hemiparesis of right dominant side, open wound of left breast subsequent encounter of left breast biopsy, and seizures. Review of the resident's nursing progress notes, showed:-On 10/16/25 Surgical area of left breast dehisced (opened). Physician and nurse manager notified, received orders for antibiotic times 7 days, triple antibiotic ointment and dry dressing;-On 10/22/25 Resident representative contacted informed of dehisced surgical wound to left breast, current antibiotic and wound care orders. Representative requested resident to be sent to hospital;-No documentation the resident representative was notified of the change in condition prior to 10/22/25. During an interview on 11/3/25 at 8:03 A.M., the Administrator and Registered Nurse (RN) A said the nurse on the floor, Licensed Practical Nurse (LPN) D, called the physician and was supposed to call the family but according to the records, he/she did not call the family about the resident's change in condition. The resident had been on an antibiotic for a couple days when the family texted RN A and said they were just informed by the resident that the resident's surgical incision was open and infected and the resident was started on an antibiotic. During the text the family requested the resident to be sent to the hospital for follow up. During an interview on 11/4/25 at 12:38 P.M., The administrator and RN B said they would expect staff to notify family as soon as possible when a resident has a change in condition and definitely before their shift is over. 2651240

Based on observation, interview and record review, the facility failed to provide services per acceptable standards of practice for one resident (Resident #1), when the facility failed to following physician orders for a left breast lumpectomy (surgical procedure to remove a potentially cancerous lump) surgical incision by not maintaining resident NPO (nothing to eat by mouth) status at midnight the night before surgery. The facility failed to obtain physician ordered treatments for the surgical site and provided treatments without a physician order. In addition, the facility failed to properly perform accurate head to toe weekly skin assessments. The sample size was 3. The census was 74.Review of the facility's Wound Treatment Management Policy, dated 11/28/17, showed:-Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders;-Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change;-In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse;-Treatments will be documented on the Treatment Administration Record (TAR) or in the electronic health record;-The effectiveness of treatments will be monitored through ongoing assessment of the wound; -Considerations for needed modifications include Lack of progression towards healing; Changes in the characteristics of the wound. Review of the facility's Physician Orders Policy, dated 3/5/20, showed: -Purpose: To provide quality medical care of the residents by accurate follow-through of physician's orders;-All Physician Orders will be transcribed to the electronic Medical Administration Record (eMAR). Review of Resident #1's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 8/22/25, showed:-Cognitively intact;-Diagnoses included stroke with hemiplegia (partial paralysis on one side) and hemiparesis (partial weakness on one side) of right dominant side, and open wound of left breast subsequent encounter of left breast biopsy. Review of the resident's Care Plan, in use at the time of the investigation, showed:-Problem start date 8/12/25, edited 10/28/25: Resident #1 had a lumpectomy to left breast;--Goal: Resident will not exhibit signs of infection;--Approach: Observe and report localized infection, localized pain, redness, swelling, and tenderness. Provide skin care/treatment to left breast. Report signs of hematoma (collection of blood under the skin), hemorrhage (bleeding), purulent (puss) drainage, odorous drainage;-Problem start date 10/27/25, edited 10/28/25: Resident #1 has impaired skin integrity related to left breast lumpectomy. He/She has an open area to left breast;--Goal: Resident will be free from signs and symptoms of infection and will demonstrate optimal healing; --Approach: Nursing responsible to assess and evaluate wound size, depth, color and drainage present every week. Certified Nurse Assistance (CNA) and nursing responsible to keep skin clean and dry. CNA, nursing, and therapy responsible to minimize force and friction to skin. Nursing to provide treatment as ordered. Review of the resident's July 2025 progress notes showed: -On 7/29/25 Resident Leave of Absence (LOA) surgical consult related to biopsy of breast;-On 7/29/25 Resident returned with surgical consult paperwork, papers given to supervisor. Resident upset about possible surgery. Review of the resident's Surgical Nurse Practitioner (NP) after visit summary notes, dated 7/29/25, showed preparation for surgery: Nothing to eat or drink (including water) after midnight the night before surgery (no gum, mints or cigarettes). Review of the resident's August 2025 progress notes, showed on 8/11/25 at 8:32 A.M., resident scheduled for surgery today, 8/11/25. Order for Nothing by Mouth (NPO) 8/10/25 - 8/11/25 and ate a bowl of cereal for breakfast. Nurse manager notified; resident left via transport at 8:33 A.M. Review of the resident's Surgeon History and Physical (H&P), dated 8/11/25, showed assessment/plan - Time of surgery delayed due to patient NPO time, still planning surgery later today. Review of the resident's August 2025 progress notes, showed on 8/12/25 at 3:38 P.M. Resident returned from hospital with transport papers post breast mass removal. Dry dressing covering intact Dermabond (medical-grade topical skin adhesive used for closing wounds) to left breast, surgical glue not to be removed it will wear off. No drainage seen. Review of the resident's Surgical discharge orders, dated 8/12/25, showed safety Instructions and when to notify the physician:-Watch for signs and symptoms of temperature higher than 101 degrees Fahrenheit (F);-Pain that gets worse or does not get better after taking pain medication(s) as directed;-Nausea or vomiting or cannot eat or drink;-Bleeding from incision site;-If Incision site looks infected (red, swollen, warm to the touch, or non-clear, foul-smelling drainage);-Assess for numbness, tingling, or changes in color in your arm;-Do not remove the surgical glue. It will wear off;-May take showers with incision uncovered;-Dressing may be removed anytime. Review of the resident's August 2025 progress notes, showed: -On 8/13/25: Resident resting in bed left breast surgical site dry dressing intact, no drainage;-On 8/21/25: Area to left breast has scant (small amount) drainage, dressing applied. Nurse manager, physician and resident representative notified;-On 8/23/25: Two steri-strips to left breast site. Dressing applied per resident request. Review of the resident's August 2025 weekly nursing focused skin assessments on 8/19, 8/25, and 8/28/25 showed no documentation of a left breast surgical biopsy wound. Review of the resident's surgical post-op follow up appointment, dated 8/28/25, showed:-Physical examination: Incision slightly superficially open with a small separation in the incision and some pink tissue at the incision edge at the lateral (side) peri (area surrounding) areolar incision (surgical incision around the pigmented area of the breast nipple), drainage is slightly bloody, no palpable seroma (collection of fluid) or hematoma (collection of blood). Skin glue was removed and replaced with Steri-Strips. A nonstick dressing was placed;-Assessment plan: Physician offered another follow-up to ensure resident #1 is fully healed but given that the resident stays in a nursing home and needs to take transportation to get here and resident family member has to come in town to come along with the resident, physician offered that the resident could just follow-up as needed if he/she feels it is not healing completely on its own. However, the physician does anticipate that the slight separation in the incision is going to heal on its own without any further intervention and just local wound care. There are no current signs of infection. Review of the Resident's September 2025 weekly nursing focused skin assessments on 9/1, 9/4, 9/18, and 9/25/25, showed no documentation of a left breast surgical biopsy wound. Review of the resident's September 2025 progress notes, showed on 9/20/23, Skin assessed for redness and signs/symptoms of infection, none noted. Review of the resident's physician orders, showed:-No orders to monitor or provide surgical wound care to left breast lumpectomy on 8/11/25, surgical incision prior to 10/16/25;-No order for the steri-strips that were applied on 8/23/25;-An order dated 10/16/25 through 10/22/25, to clean left breast wound with wound cleaner, pat dry, apply Triple Antibiotic Ointment (TAO), cover with dry dressing;-An order dated 10/16/25 through 10/24/25, for Doxycycline (antibiotic) 100 milligram (mg) two times a day for ten days for left breast wound infection;-An order dated 10/16/25, scheduled follow up with surgeon for left breast wound; -An order dated 10/20/25, for a wound care provider to evaluate and treat;-An order dated 10/22/25 through 10/24/25, to cleanse with Vashe (wound cleaner), apply collagen powder to wound bed and cover with dry dressing every other day and as needed;-An order dated 10/22/25, to send resident to the hospital for dehisced (wound seperation) of left breast surgical wound;-An order dated 10/27/25 through 11/1/25, for amoxicillin-clavulanate (antibiotic) 875/125 mg take one tablet by mouth two times a daily for 5 days;-An order dated 10/27/25 through 11/1/25, for doxycycline (antibiotic) 100 mg two times a day for five days;-An order dated 10/27/25, to cleans left breast with normal saline, apply xeroform (sterile wound dressing made of fine-mesh gauze impregnated with a blend of petrolatum (Vaseline) and bismuth tribromo phenate (a substance that kills bacteria). Cover with dry dressing daily and as needed if soiled. Review of the Resident's October 2025 progress notes, showed: -On 10/16/25, surgical area to left breast dehisced (wound separation). Physician and nurse manager notified;-On 10/20/25, antibiotic therapy, left breast minimal drainage noted;-On 10/21/25, antibiotic therapy for left breast no drainage noted;-On 10/22/25, antibiotic completed small amount of dry blood on old dressing noted;-On 10/22/25, resident representative contacted nurse, informed of dehisced surgical wound to left breast and current antibiotic treatment and wound care orders. Representative requested resident to be sent to the hospital;-On 10/27/25, resident returned from hospital. Review of the resident's wound care provider notes, dated 10/21/25, showed resident had a surgical excision of a cyst on 8/25/25. He/She has been released from care of that surgeon. Wound is currently dressed with a dry dressing. Surgical dehiscence measurements length 1.5 centimeters (cm), width 1.0 cm, depth 0.1 cm, undermining (wound extends under the wound edges) at 12 o'clock (location when compared to the face of a clock) 1.4 cm, wound is wet and draining, tissue red/pink, and bumpy, healable. New wound care orders to cleans with hypochlorous acid, no need to rinse, apply calcium alginate to wound base cut to fit inside wound edges. Do not place on skin, cover with self-adherent super absorbent dressing, change dressing every two days and as needed if soiled or saturated. Review of the resident's weekly nursing focused skin assessment, showed on 10/30/25 no alterations kin skin, comments-no new skin issues noted. Dressing changed on left breast per order. During an interview on 11/3/25 at 8:03 A.M., Registered Nurse (RN) A said on 10/16/25 he/she was assisting a CNA with Resident #1. The resident asked RN A to look at his/her left breast, he/she had a silicone dressing (wound dressing with soft tacky silicone adhesive to secure itself to the skin without sticking to the wound bed) on it. RN A said he/she does not remember if it had a date or initials on it and there was thick yellow drainage coming from breast surgical wound, no odor and the bandage was not saturated. The resident reported to RN A that the dressing had been on there for three weeks without being changed but did not remember the nurse who put the dressing on. The physician was notified, and orders were received for oral antibiotics and wound care. RN A said he/she review the TAR and did not find a treatment plan for the resident's left breast after he/she returned from lumpectomy on 8/13/25. During an interview on 11/3/25 at 8:29 A.M., the resident said the facility did not take care of his/her breast incision after his/her lumpectomy, and left the dressing on for three weeks until he/she asked RN A to look at it because it was bothering him/her with a little pain and discomfort. When RN A removed the dressing, it had yellow stuff coming from the wound. The resident also said RN A notified the physician and he/she was started on oral antibiotics and wound care to the site. During an interview on 11/4/25 at 12:38 P.M., the Administrator and RN B said when residents have a surgical procedure, they would expect nursing to assess the site, obtain vital signs, and review orders sent with the resident after the procedure. If no orders were sent, they expected nursing staff to call and receive surgical incision orders. Upon the resident's return after a surgical procedure, the nurse should complete an assessment, vital signs, and surgical site orders should be documented and entered the resident's medical chart, and orders entered under physician orders and treatment administration record. Nurses should not complete wound care or dressing changes without an order and all physician orders should be followed. They expected staff to monitor the surgical site daily and document findings until the area is healed. They would expect weekly skin assessments completed by nursing to be thorough and include all open areas including surgical incisions. They were aware the resident's lumpectomy incisional wound had not been followed up on and physician orders were not entered into resident's orders and treatment administration records. They were aware a nurse applied steri strips and wound dressing to the resident's incisional site without a physician order. They were also aware the resident was given cereal the morning of surgery when there was an ordered for NPO after midnight. The nurse is supposed to inform the CNAs so they remove water cups. They are unsure how this happened because there was a physician order and treatment administration record for resident to be NPO after midnight. 2651240

52419 Based on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining water temperatures in resident rooms on the [NAME] Hall in the [NAME] community between 105 degrees Fahrenheit (F) and 120 F. The [NAME] hall and [NAME] Hall are both parts of the dementia unit. The facility identified three residents with confusion, who wander and who are able to ambulate without assistance (Residents #74, #26, and #13). This affected two sampled resident rooms (Residents #40 and #85) and one spa room hand washing sink . The water temperatures at the handwashing sinks measured as high as 135.9 degrees F. In addition, staff failed to ensure hazardous chemicals were not accessible to residents on the dementia unit. There are 23 residents on the dementia unit with 22 in certified beds. The census was 93 with 85 in certified beds. The administrator was notified on 3/19/25 at 8:05 P.M. of an Immediate Jeopardy (IJ) which began on 3/19/25. The IJ was removed on 3/20/25 as confirmed by surveyor onsite verification. Review of the facility's Safe Water Temperatures policy, dated January 2025, showed: -It is the policy of this facility to maintain appropriate water temperatures in resident care areas; -Direct care staff will monitor residents during prolonged exposure to warm or hot water for any signs or symptoms of burns and will respond appropriately; -Staff will be educated on safe water temperatures upon employment and on a regular basis; -Thermometers will be available as needed for use by all staff; -Staff will report abnormal findings, such as complaints of water too cold or hot, burns or redness, or any problems with water temperatures; -Water temperatures will be set to a temperature of no more than 120 degrees F, or the states allowable maximum water temperature; -Maintenance staff will check water heater temperature controls and the temperature of tap water in all hot water circuits weekly and as needed. Review of the facility's Storage of Chemicals and Sharps policy, dated 12/8/17, showed: -Purpose: To keep residents free from accidents and injury; -Nursing staff is to obtain chemicals from housekeeping for cleaning; -Nursing is to use chemicals, when finished return to housekeeping or place in secure area, such as medication room; -Staff is not to leave chemicals or sharps, such as razors unattended in spa or resident rooms; -No chemicals or sharps are to be unattended in spa or resident rooms. 1. Review of Resident #40's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/15/25, showed: -Severe cognitive impairment; -No wandering behavior; -Mobility devices: Used a wheelchair and walker; -Substantial/maximal assistance required for personal hygiene and toileting hygiene; -Dependent for shower/baths; -Primary medical condition category: Progressive neurological condition; -Diagnoses included dementia. Review of the resident's care plan, in use at the time of the survey, showed: -Problem start date 3/23/22, needs assist with activities of daily living (ADLs); -Goal: Maintain current ADL function; -Approaches included: Bathing days Wednesday and Saturday evening. Bathing assist as needed. Dressing/grooming assist as needed. Locomotion: No device up ad lib (as desired). Toileting assist as needed. Review of the resident's quarterly elopement risk assessment, dated 12/7/24, showed: -Is the resident cognitively impaired with poor decision-making skills: Yes; -Is the resident mobile, ambulatory, or with a wheelchair: Yes; -No elopement risk present. Observation on 3/19/25 at 11:55 A.M. and 3/20/25 at 7:19 A.M., showed the resident sat in a Broda chair (medical reclining chair) in the television area of the locked unit. During an interview on 3/19/25 at 6:38 P.M., Licensed Practical Nurse (LPN) B said the resident requires a mechanical lift to transfer. He/She requires staff assistance with personal care. Observation on 3/19/25 of the resident's room hand washing sink, showed: -At 5:34 P.M., the water measured 130 degrees F with a calibrated digital thermometer. Steam visibly rose from the faucet. The water was hot to the touch; -At 5:47 P.M., the water measured 130.3 degrees F and 131.1 degrees F, taken with two separate calibrated digital thermometers. Steam visibly rose from the faucet; -At 5:49 P.M., the water measured 132.1 degrees F, taken with an infrared thermometer. Observation on 3/19/25 at 11:55 A.M., on 3/20/25 at 1:58 A.M., and 3/21/25 at 10:10 A.M., showed a bucket located in the resident's room under the sink that contained, a half-gallon sized bottle of bleach and bottle of hand soap with no lid, accessible to residents. Observation and interview on 3/19/25 at 7:01 P.M., showed the Administrator and surveyor took water temperatures in Resident #40's room at the handwashing sink. The surveyor used a calibrated digital thermometer, and the Administrator used a thermometer with dial. The Administrator said she believed her thermometer was calibrated. Water was turned on and allowed to run for 2 minutes, both the surveyor and administrator measured the temperature of the water. The water at the hand washing sink measured 135.9 degrees F on the surveyor's thermometer. The Administrator's thermometer measured 100 degrees F. The Administrator said she was not sure now if her thermometer was calibrated; she picked it up in dietary. The Administrator confirmed she saw steam rise from the sink when the water ran. During an interview on 3/21/25 at 1:11 P.M., the Administrator said chemicals should not be stored in resident rooms. She expected staff to remove them. Staff should report chemicals to the charge nurse and/or maintenance supervisor so they can be removed. The risk of chemicals being stored in resident rooms is if it got on residents' skin, it could burn them, or they could drink them. Residents who wander would be at risk. 2. Review of Resident #85's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Wandering behavior occurs daily; -Mobility devices: Used a walker; -Toileting- set up or clean up assistance; -Personal hygiene- set up or clean up assistance; -Independent with mobility except for tub/shower transfer, which required set up or clean up assistance. Review of the resident's care plan, in use at the time of the survey, showed: -Problem start date 8/30/24: Needs assist with ADLs; -Goal: Maintain ADL function; -Approach: bathing, bed mobility, dressing, grooming assist times one; -Problem start date 9/12/24: Elopement risk due to wandering; -Goal: Remain safe through next review date; -Approach: Redirect to common areas. Review of the resident's medical record, showed diagnoses included Alzheimer's disease with early onset. During an interview on 3/19/25 at 6:38 P.M., LPN B said the resident requires a wheelchair and staff assistance for locomotion. He/She requires staff assistance with personal care. Observation on 3/19/25 of the resident's hand washing sink, showed: -At 5:36 P.M., the water measured 125 degrees F with a calibrated digital thermometer; -At 5:50 P.M., the water measured 125.6 degrees and F 125.9 degrees F, taken with two separate calibrated digital thermometers; -At 5:51 P.M., the water measured 126.5 degrees F with a calibrated digital thermometer; -At 5:52 P.M., the water measured 126.6 degrees F and 126.3 degrees F, taken with two separate calibrated digital thermometers. Observation on 3/19/25 at 7:04 P.M., the surveyor and Administrator entered the resident's room. The hot water ran for two minutes while the surveyor and Administrator placed their thermometers under the hot water. The surveyor's thermometer measured 130 degrees F at the handwashing sink. The Administrator confirmed her thermometer was not reaching the temperature shown on the surveyor's thermometer, but saw steam from the sink and said it was too hot. Maintenance is responsible for taking water temperatures. One room is done daily. There are two main staff that are responsible for water temperatures. The Administrator confirmed the water was too hot. If the water is too hot, it could burn the resident's skin. She expected the water temperature to be between 105 degrees F to 120 degrees F. If the water was outside the range, she would expect staff to notify maintenance. It is important to have appropriate water temp for safety for residents in memory care unit. 3. During an interview on 3/19/25 at 5:52 P.M., LPN B said Residents #74, #26 and #13 all have recent wandering behaviors, have confusion, and are ambulatory. Review of the Resident #74's admission MDS, dated [DATE], showed: -Moderately impaired cognition; -Wandering behavior not exhibited; -Mobility devices: Used a wheelchair; -Diagnoses included dementia. Review of the resident's care plan, in use at the time of the investigation, showed: -Problem start date 1/18/25: Elopement risk; -Goal: Remain safe; -Approach: Redirect to common area for closer observation. Review of the resident's elopement risk assessment, dated 2/12/25, showed: -Wandering with no rational purpose and attempting to open doors; -Diagnosis of dementia; -Does the resident present an elopement risk: yes. Observation on 3/19/25 at 5:25 P.M., showed the resident wandered into a different resident's room on [NAME] hall and began to yell at the resident in the room to get out of bed. He/She then began to undress in the room. The other resident told this resident to get out of the room because it was not his/her room. No staff in the hallway in hearing range of the residents yelling were available to redirect the resident's wandering behavior. Review of Resident #26's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Wandering behavior not exhibited; -Mobility devices: [NAME] and wheelchair; -Diagnoses included Alzheimer's disease and anxiety. Review of the resident's care plan, in use at the time of the survey, showed: -Problem start date 9/16/21: Elopement risk. Resident frequently checks door handles and tries to open them or push the door open; -Goal: Remain safe; -Redirect to common area and get him/her interested in group activity. Observation of the resident, showed: -On 3/19/25 at 1:50 P.M., the resident up in a wheelchair in the unit dining room; -On 3/20/25 at 10:08 A.M., the resident self-propelled on the locked unit in his/her wheelchair and asked staff where he/she should go. At 10:31 A.M., staff assisted the resident to his/her room in his/her wheelchair. Review of Resident #13's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Wandering behavior not exhibited; -Mobility devices: [NAME] and wheelchair; -Diagnoses included progressive neurological conditions, diabetes and dementia. Review of the resident's care plan, in use at the time of the survey, showed: -Problem start date 11/3/20: ADL functional status/rehabilitation potential. The resident needs assistance with ADLs; -Goal: Maintain current ADL function; -Approach: Locomotion with a walker. Observation on 3/20/25 at 1:54 P.M., showed the resident sat in a wheelchair in the locked unit dining room and self-propelled in the wheelchair. The resident was confused and unable to answer questions. Observation of the [NAME] Hall spa room hand washing sink, on 3/19/25, showed: -At 5:59 P.M., the water temperature measured 122 degrees F; -At 6:00 P.M., the water temperature measured 125.6 degrees F. During an interview on 3/19/25 at 6:43 P.M., Certified Nursing Assistant (CNA) A said he/she is agency and works at the facility about two times a week. Residents have told him/her the water has been hot. Sometimes staff must play around with the knobs. 4. Observation on 3/20/25 at 7:45 A.M., of the water tank/boiler room, showed two small boilers on the left side of the room. Boiler #1 read 134 degrees F. Boiler #2 read 155 degrees F. Pipes ran from the boilers into two large holding tanks. The temperature on holding tank #1 read, 134.9 degrees F. The temperature on holding tank #2 read, 131 degrees F. Pipes ran from the holding tanks to a mixing valve on the wall. The temperature on the mixing valve read, 110 degrees F. During an interview on 3/20/25 at 7:50 A.M., the Maintenance Supervisor said the tanks provided water to the facility. He takes water temperatures every day at the tanks. He usually takes them in the morning and does not check the tanks in the afternoon. The temperature on the mixing valve was higher yesterday, but he did not know the exact temperature. No one had complained to him about the water being too hot until the prior night. At 12:30 P.M., the Maintenance Supervisor said he thought there was a problem with the mixing valve which caused the temperatures to be higher than they were reading at the discharge pipe. He usually took temperatures the first thing in the morning, and it was possible the temperatures might have changed after all of the residents received their showers. Review of the boiler/water heater temperatures on 3/20/25, showed the following: -On 3/18/25 at 5:30 A.M., Boiler #1 - 144 degrees F, Boiler #2 - 151 degrees F, Storage tank #1 - 135.3 degrees F., Storage tank #2- 133.7 degrees F, Discharge pipe -120 degrees F; -On 3/19/25 at 5:30 A.M., Boiler #1 - 156 degrees F, Boiler #2 - 134 degrees F, Storage tank #1 - 126 degrees F., Storage tank #2- 133.7 degrees F, Discharge pipe -120 degrees F; -On 3/20/25 at 7:00 A.M., Boiler #1 - 157 degrees F, Boiler #2 - 152 degrees F, Storage tank #1 - 134.4 degrees F., Storage tank #2- 131.8 degrees F, Discharge pipe -105 degrees F. NOTE: At the time of the survey, the violation was determined to be at the immediate 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 remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on interview and record review, the facility failed to ensure as needed (PRN) psychiatric medications were re-evaluated after 14 days of use for one of five residents reviewed for unnecessary psychotropic medications (Resident #68). The census was 93 with 85 residents in certified beds. Review of the facility's Psychotropic Medication policy, dated 12/8/17, showed: -The intent of this policy is to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint; -PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend to the order beyond the 14 days. Review of Resident #68's medical record, showed fracture of unspecified part of neck of right femur (bone of the upper leg), dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the resident's physician order sheets (POS), dated 2/19/25 through 3/19/25, showed the following: -A General order, dated 2/14/25, unless a longer duration is specified, discontinue PRN orders for antidepressants, anxiolytics, and hypnotics after 14 days and call provider with an update; -An order dated, 2/19/25, for trazodone tablet (antidepressant and/or used to treat anxiety); 25 mg by mouth, three times a day PRN for anxiety; -No end date noted for the PRN order. Review of the resident's Medication Administration Record, for February and March 2025, showed: -Staff documented the administration of trazodone on 3/6 at 10:56 A.M. and 7:32 P.M.; on 3/7 at 10:46 A.M.; on 3/8 at 9:52 A.M. and 4:33 P.M.; on 3/9 at 8:13 P.M.; on 3/10 at 7:40 P.M.; on 3/11 at 10:31 A.M. and 9:09 P.M.; on 3/12 at 11:29 A.M.; on 3/13 at 3:15 P.M.; on 3/14 at 8:58 A.M.; on 3/17 at 10:30 A.M. and 8:56 P.M.; on 3/18 at 7:57 A.M. and 12:24 P.M.; on 3/19 at 10:02 A.M.; and on 3/20/25 at 7:53 A.M. During an interview on 3/21/25 at 10:01 A.M., the Director of Nursing (DON) said she expected nursing to follow the facility's policy to discontinue PRN orders for psychotropic medications after 14 days and call the provider with an update.

Based on observation, interview and record review, the facility failed to prevent a significant medication error for one resident with spinal cord cancer undergoing radiation therapy (Resident #386). The facility failed to properly classify the Schedule III medication (substances that have moderate potential for abuse and dependence) Dronabinol (synthetic form of tetrahydrocannabinol (THC) medication used to treat nausea and vomiting caused by chemotherapy) in the medical record, leading to its incorrect assignment to Certified Medication Technicians (CMTs) instead of to a Licensed Practical Nurse (LPN) or Registered Nurse (RN). As a result, the CMTs documented the medication was unavailable for eight days without notifying nursing management. In addition, one nurse administered the Dronabinol on [DATE] and [DATE], but failed to inform management after he/she was unable to document the administration in the medical record. The census was 93 with 85 in certified beds. Review of the facility's Medication Administration policy, reviewed [DATE], showed: -Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Policy explanation and compliance guidelines: Keep medication cart clean, organized, and stocked with adequate supplies; -Cover and date fluids and food; -Identify resident by photo in the Medication Administration Record (MAR); -Wash hands prior to administering medication per facility protocol and product; -Knock or announce presence; -Explain purpose of visit; -Provide privacy; -Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters; -Position resident to accommodate administration of medication; -Ensure that the six rights of medication administration are followed: -Right resident; -Right drug; -Right dosage; -Right route; -Right time; -Right documentation; -Review MAR to identify medication to be administered; -Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time; -Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects; -Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician; -If other than by mouth (PO) route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.); -Identify expiration date. If expired, notify nurse manager; -Remove medication from source, taking care not to touch medication with bare hand; -If administering chemotherapeutic or immunosuppressant medications, follow pharmacy instructions for handling and administering of those specific medications. At a minimum, gloves must be worn when preparing and giving these medications, with hand hygiene before and after administration. Follow pharmacy instructions for further personal protective equipment (PPE) use, if indicated. Discard packages as per pharmacy instructions; -Observe resident consumption of medication; -Wash hands using facility protocol and product; -Sign MAR after administered. For those medications requiring vital signs, record vital signs onto the MAR; -If medication is a controlled substance, sign narcotic book; -Report and document any adverse side effects or refusals; -Correct any discrepancies and report to nurse manager. Review of the facility's Physician's Orders policy, reviewed [DATE], showed: -Procedure: All Physician Orders will be transcribe to Matrix (EMAR electronic medical administration record); -Medications and treatments (It is considered prescription in Matrix): If there are orders for medication change (medication name and dosage), the nurse must discontinued the previous medication (prescription) order and then enter the new medication (prescription) one; -If a medication (prescription) is discontinued, go into Matrix, then in orders and then discontinued; -Assigning medication (prescription) to the flow sheet (medication, nurse medication, dietary, general order, enteral order, treatment, P.M. medication); -A change in dosage of frequency of the medication (prescription) will require for the nurse to discontinued the previous medication (prescription), and then enter a new medication (prescription) in Matrix (click orders, then continue). The nurse can edit the frequency (BID (twice a day), TID (three times a day), qd (once a day), qod (every other day). The nurse can edit the frequency without changing the dosage of the medication (prescription); -Medications (prescriptions) will be E-prescribed (electronically prescribed) or electronically faxed to pharmacy through Matrix. General orders (ace wraps, [NAME] hose), do not fax to the pharmacy but do need a physician order. For narcotic prescriptions, manually fax over the doctor's prescriptions to the pharmacy. Nurse can also call the doctor and ask the doctor to fax over the prescription for narcotics; -The nurses and the CMTs are to call the shift supervisors for available medications in the E-kit; -Allergies listed on the face sheet also appear in eMAR. Review of Resident #386's medical record, showed: -admitted on [DATE]; -Diagnoses included malignant neoplasm (cancer) of spinal cord, heart failure, acute respiratory failure with hypercapnia (body unable to remove excess carbon dioxide from the bloodstream), depression, and diabetes; -A care plan, in use during survey, showed the resident has cancer and he/she receives radiation treatments to the spine. -Review of the resident's oncology record, showed he/she had radiation therapy on ,d+[DATE] through [DATE]. Review of the resident's electronic Physician's Orders Sheet (ePOS), dated [DATE], showed: -An order dated [DATE], for Dronabinol 2.5 milligram (mg), Schedule III (substances that have moderate potential for abuse and dependence) capsule. Administer one capsule orally, once an evening with dinner; -Dronabinol 2.5 mg was discontinued on [DATE]; -An order, dated [DATE], for Dronabinol 2.5 mg, Schedule III capsule. Administer one capsule orally, once an evening with dinner. Review of the resident's electronic Medication Administration Record (eMAR), dated [DATE], showed: -An order, dated [DATE], for Dronabinol 2.5 mg, one capsule, once an evening at dinner, between 4:00 P.M. and 11:00 P.M., showed: -On [DATE] at 7:29 P.M., CMT documented not administered, drug/item unavailable; -On [DATE] at 7:12 P.M., CMT documented not administered, drug/item unavailable; -An order, dated [DATE], for Dronabinol 2.5 mg, one capsule, once an evening at dinner between 4:00 P.M. and 11:00 P.M., showed: -On [DATE] at 5:20 P.M., [DATE] at 7:15 P.M., [DATE] at 7:05 P.M., [DATE] at 7:33 P.M., [DATE] at 4:08 P.M., and [DATE] at 8:16 P.M., CMT documented not administered, drug/item unavailable. Observation and interview on [DATE] at 12:07 P.M., showed Registered Nurse (RN) G was asked to see the resident's medication, Dronabinol. He/She received the key from the nurse, and both entered the medication room. The key was used to open the medication lock box. Inside the lockbox showed two bubble packs of Dronabinol. The first bubble pack, dated [DATE], showed a seven day supply of the medication. There were five pills remaining in the pack. The second bubble pack of Dronabinol was dated [DATE]. There were 30 pills in the bubble pack and none were popped. RN G said the second bubble pack was from the resident's previous facility. RN G said only nurses can administer narcotics, and could only administer the Dronabinol. During an interview on [DATE] at 1:56 P.M., the Director of Nursing (DON) said if a medication was not found by staff, she expected staff to look in the Omnicell (automated dispensing cabinet) for backup medications or the emergency kit (E-Kit, small supply of medications). If it is not available, they would contact pharmacy to find out where the medication is. The CMTs and nurses are responsible for ensuring medications are administered as ordered. The DON expected staff to report the Dronabinol was unavailable since at least [DATE]. The physician should have been notified. Dronabinol cannot be administered by a CMT. The DON believed the medication could have been added to the CMT Medication Administration Record (MAR). The medication is locked and only nurses can administer it. The DON expected the medication to show on the nurse's MAR. The medication is a Schedule III drug, so that should have prompted the CMTs that the medication is only administered by a nurse. It is important for the resident to have this medication because it helps him/her to eat. The resident has cancer. Review of the resident's controlled substance record, showed: -Medication: Dronabinol 2.5 capsule, take one capsule by mouth once daily; -On [DATE] at 5:19 P.M., Dronabinol was administered by LPN H; -Quantity remaining: 6; -On [DATE] at 4:31 P.M., Dronabinol was administered by LPN H; -Quantity remaining: 5. During an interview on [DATE] at 8:45 A.M., the resident said the weekend went well for him/her. Since he/she had been admitted to the facility, his/her level of nausea had been the same. During an interview on [DATE] at 8:45 A.M., LPN H said the medication first popped up for him/her to administer it on [DATE]. He/She did not administer the medication on [DATE] because the resident was on leave of absence (LOA). LPN H is off at 7:00 P.M. and the resident returned before he/she left for the day, but he/she thought the relief would give it. The range was still okay, and it could be given until 11:00 P.M. LPN H did not notify the oncoming staff to administer the medication during report. On [DATE], it was administered. The order popped up for him/her, but it would not accept him/her. He/She was able to sign the medication out in Mediprocity, but not in the MAR. It was still an active order, and the resident had to have his/her medication. LPN H had every intention to notify the managers on [DATE] during the meeting, but it did not happen. The resident received the medication, so he/she was not going to call managers for that. LPN H did not know if the medication showed up on the CMT MAR. During an interview on [DATE] at 7:09 A.M., the DON said when staff first put in the order for Dronabinol, it was put under the medication category which will populate under the CMT's MAR. It has been fixed. The CMTs were also educated. If a drug is not available, it does not mean you keep moving. They are expected to notify the nurse so they can find out what happened. If that happened, the nurse would have said, that is a Schedule III medication, investigated it, and fixed it. The resident would not have missed the medication. The DON spoke to LPN H, who said he/she administered the Dronabinol on [DATE] and [DATE]. It was in the system for LPN H to administer it, but it was still listed under the medication category for CMT to administer it. The narcotic record in Mediprocity showed it was given on Tuesday and Wednesday. LPN H said he/she did not administer it on Monday because too late. The medication was pulled out of Mediprocity, but it was not documented in the MAR. If staff did not administer medication, the DON also expected it to be documented in the progress notes. The resident goes to radiation a lot.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility had two medication rooms and eight medication carts. Both medication rooms, three medication carts, and one treatment cart were reviewed, and issues were found with two medication carts and the treatment cart. The census was 93 with 85 in certified beds. Review of the facility's Storage of Medication Requiring Refrigeration, dated [DATE], showed date label of any multi-use vial when the vial is first accessed (needle punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Review of the facility's Medication Administration policy, dated [DATE], showed: -Identify expiration date. If expired, notify nurse manager; -The policy failed to show insulin should be dated when opened. Review of the facility's Medication Storage Policy, dated [DATE], showed: Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications with worn, illegible or missing labels. These medications are destroyed in accordance with the facility's destruction of unused drugs policy. 1. Observation of the nurse cart on [NAME] and [NAME] Hall on [DATE] at 9:14 A.M., showed the cart had two tubes of Premarin vaginal cream (female hormones) that were open and expired. The expiration date was [DATE]. 2. Observation of the nurse cart on [NAME] and [NAME] Hall on [DATE] at 9:20 A.M., showed seven out of 11 insulin pens were open and undated. Observation of the nurse cart on Hope community Hall on [DATE] at 9:49 A.M., showed one out of three insulin pens were open and undated. During an interview on [DATE] at 9:20 A.M., Licensed Practical Nurse (LPN) E said insulin should be dated when opened by the nurse who opened it. During an interview on [DATE] at 8:25 A.M. , the Director of Nursing (DON) said insulin should be stored in the refrigerator until open. The nurse who opened the insulin was responsible for dating the insulin. Both the nurse and nurse managers are responsible for checking the carts for expiration dates. 45083

Based on interview and record review, the facility failed to ensure residents who received hemodialysis (dialysis, procedure to remove waste products and excess fluid from the blood when the kidneys are not working properly) services had written communication with the dialysis center. The facility identified one resident who received dialysis services (Resident #34). The sample was 19. The census was 93 with 85 in certified beds. Review of the facility's Dialysis policy, dated 4/30/18, showed: -Policy: It is the policy of the facility to provide appropriate care to residents requiring hemodialysis. -Procedure: The facility will develop an appropriate care plan. Staff will evaluate the resident's response to dialysis and develop/revise the care plan in collaboration with the dialysis facility: monitoring vital signs, weights, nutritional, and fluid needs or any restrictions, lab results, and who to notify with concerns; approach to administering medications before, during, or after dialysis according to practitioner's orders. Review of the facility's Dialysis Communication Form, showed: -Pre-dialysis information included: -Medication administered prior to dialysis: -Meal/snack sent; -Shunt location/status; -Vitals: Temperature (T), Pulse (P), Respirations (R), Blood Pressure (B/P); -Additional information (change in condition, physician order changes, new labs since last visit); -Dialysis center information: -Pre-weight; -Post weight; -Dialysis start time: -Dialysis end time; -Fluid removal; -Meal/snack intake; -Shunt location/status: -Vital signs and pain; -Additional information (change in condition, medications administered, labs drawn, lab results); -New physician orders/recommendations; -Nurse signature; -Post dialysis information: -Shunt location/status; -Bruit (a rumbling sound that is heard over the access site) /thrill (a rumbling sensation that is felt over the access site) present; -Bleeding; -General condition of resident; -Nurse signature; -Vitals, type, values, details, date and time taken and taken by; -Notes. Review of Resident #34's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 2/26/25, showed: -Moderately impaired cognition; -Diagnoses included: stroke, high blood pressure, heart failure, end stage renal disease (ESRD, chronic irreversible kidney failure); -Hemodialysis, while a resident. Review of the care plan in use at the time of survey showed: -Problem: Dialysis Monday, Wednesday and Friday (M-W-F) pick up at 5:30 A.M.; -Goal: To be ready on time; -Interventions included: Flowsheet: Activities of Daily Living (ADL) once a day on M-W-F; 4:00 A.M. - 5:00 A.M.; -Problem: Resident had a port to left upper chest (dialysis catheter (a soft, flexible tube (hollow tube) used to provide access to the bloodstream for dialysis treatment,) history of renal failure. Dialysis on M-W-F; -Goal: Resident will not exhibit signs or symptoms of infection at renal dialysis port access site; -Interventions included: Confer with renal center as needed. The care plan did not address completion of a communication form with the dialysis clinic. Review of the physician order sheet, in use at the time of survey, showed: -A physician order for dialysis on Monday and Friday, start date 2/3/25; -A physician order for: Complete dialysis communication form (resident/ observation tab), complete post-dialysis information and hit complete once resident returns from appointment. Turn in completed section from dialysis center to medical records, once a day on M and F; -A physician order for: Complete dialysis communication form. Complete pre-dialysis portion, hit save then hit report to print and send with resident to appointment. Once a day on M and F; -If resident refused to go to dialysis, please call transportation as soon as possible to cancel the ride (dialysis days on M-W-F). Review of the Medication Administration Record (MAR)/Treatment Administration Record (TAR)) dated 2/3/25 through 2/28/25, showed: -A physician order for: Complete dialysis communication form (resident/observation tab), complete post-dialysis information and hit complete once resident returns for appointment. Turn in completed section from dialysis center to medical records, once a day on M and F, start date was 2/3/25; -Documentation showed: -On 2/3/25, not administered: Drug/item unavailable; -On 2/7, 2/14, 2/17, 2/21, and 2/28/25 staff documented as completed; -On 2/10, left blank; -On 2/24, resident refused; -A physician order for: complete dialysis communication form. Complete pre-dialysis portion, hit save then hit report to print and send with resident to appointment. Once a day on M and F, start date was 2/3/25; -Documentation showed: on 2/7, 2/10, 2/14, 2/17, 2/21, and 2/28/25 staff documented as completed. Review of the dialysis communication forms dated 2/1/25 through 2/28/25, showed: -On 2/6/25, pre-dialysis information: Vital signs were blank; dialysis center information was blank; post-dialysis information was blank; -On 2/17/25, pre-dialysis information: Vital signs were blank; and the dialysis center information was blank; post-dialysis information: vitals and notes were blank; -On 2/ 21/25, pre-dialysis information: Vital signs were blank; dialysis center information: was blank; post-dialysis information: was blank; -On 2/27/25, pre-dialysis information: Vital signs were blank; dialysis center information was blank; post-dialysis Information was blank; -On 2/7, 2/10, and 2/14/25: No dialysis communication forms were completed. Review of the progress notes dated 2/1/25 through 2/28/25, showed: -On 2/24/24 the resident refused dialysis: -Staff did not document any additional information regarding the resident's refusal of dialysis or if staff called the dialysis center to request the dialysis communication form be sent to the facility. Review of the vital signs tab in the electronic medical record (EMR), dated 2/1/25 through 2/28/25, showed staff did not document any vital signs on 2/7, 2/10, 2/14, 2/17, 2/21, 2/24 and 2/28/25. Review of the MAR/TAR dated 3/1/25 through 3/21/25, showed: -A physician order for: Complete dialysis communication form (resident/observation tab) complete post-dialysis information and hit complete once resident returns for appointment. Turn in completed section from dialysis center to medical records, once a day on M and F; -On 3/3, 3/7, 3/10, 3/14 and 3/17/25 staff documented as completed; -A physician order for: Complete dialysis communication form. Complete pre-dialysis portion, hit save then hit report to print and send with resident to appointment. Once a day on M and F; -On 3/3, 3/7, 3/10, 3/14, 3/17 and 3/21/25 staff documented as completed. Review of the dialysis communication form dated 3/1/25 through 3/21/25, showed: -On 3/3/25: pre-dialysis information: Vitals were blank; and dialysis center information was blank; post-dialysis information: vitals and notes were blank; -On 3/7/25, pre-dialysis information: Vital signs were blank; dialysis center information was blank; post-dialysis information was blank; -On 3/17/25, pre-dialysis information: Vitals were blank; and dialysis center information was blank; -On 3/21/25, pre-dialysis information: Vitals were blank; dialysis center information: pre-weight, post weight, dialysis start time; dialysis end time; fluids removed, meal/snack intake, shunt location/status, T, P, R, pain, and additional information was blank; -On 3/10 and on 3/14/25 no forms were completed. Review of the progress notes dated 3/1/25 through 3/19/25, showed, staff did not document the resident's refusal of dialysis or if staff called the dialysis center to request the dialysis communication form be sent to the facility. Review of the vital signs tab in the EMR, dated 3/1/25 through 3/21/25, showed, no vital signs were documented on 3/3, 3/7, 3/10, 3/14, 3/17 and 3/21/25. During an interview on 3/21/25 at 1:35 P.M., Licensed Practical Nurse (LPN) F said residents who received dialysis services should have their vital signs checked before going to dialysis. The resident should take a snack, a copy of the dialysis communication form, face sheet and continuity of care (CCD) to dialysis. When the resident returned from dialysis, LPN F said he/she would complete the post-dialysis communication sheet and assess the resident for pain and any adverse reactions. If the dialysis center did not return the communication form, LPN F would call the dialysis center to ask them to send it over and document it in the progress notes. During an interview on 3/21/25 at 1:53 P.M., LPN E said residents who received dialysis should have a pre-dialysis assessment completed before they went to dialysis. This included checking blood pressure, the access site and observing for signs and symptoms of bleeding. The communication form should be sent with the resident. When the resident returned from dialysis a post-dialysis assessment should be completed. If the dialysis center did not send the communication form back, LPN E did not need to do anything. During an interview on 3/21/25 at 2:15 P.M., the Director of Nursing (DON) said if a resident refused to go to dialysis, it should be documented in the progress notes. The nurse who completed the pre-assessment started the dialysis communication form and sometimes the nurse who completed the post-dialysis assessment would start a new dialysis communication form. Once the dialysis communication was processed, the form was processed and given to medical records who shredded the forms. The DON would expect for the dialysis communication forms to be completed. If the dialysis center did not return the form, the nurse should call the dialysis center to have them fax it over and document it in the progress notes.

Based on observation, interview and record review, the facility failed to follow acceptable infection control and prevention practices during personal care for three of four observations of personal care provided to incontinent residents (Residents #24, #43, and #68). In addition, the facility failed to follow their tuberculosis (TB, infectious lung disease) policy and procedures, for five of 10 employee sampled. The census was 106 with 103 residents in certified beds. Review of the facility's Hand Hygiene policy, dated [NAME] 5, 2020, showed: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility; -Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub; -Staff will perform hand hygiene when indicated, using proper techniques consistent with accepted standards of practice; -The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility's Perineal Care policy, dated October 14, 2021, showed: -It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown; -Perineal care refers to the care of the external genitalia and the anal area; -Perform hand hygiene and put on gloves; -Cleanse the genital area; -Change gloves if soiled and continue with perineal care; -Apply skin protectant as needed, reposition as desired, cover the resident; -Remove gloves and discard. Perform hand hygiene; -The policy did not direct staff to remove gloves and perform hand hygiene after completing personal care and before touching the resident or clean resident surfaces to prevent contamination from potentially soiled gloves. 1. Review of Resident #24's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/15/23, showed: -Cognitively intact; -Always incontinent of urine, frequently incontinent of bowel; -Diagnoses included debility and depression; -Toileting and personal hygiene: Partial/moderate assistance. Helper does less than half the effort. Review of the resident's care plan, last revised 11/28/23, showed: -Problem: Activity of daily living (ADL) functional status/rehabilitation potential. The resident needs assist with ADLs; -Goal: Maintain current ADL function; -Approaches included: Bowel movements, monitor and record daily. Toileting assist time one. Observation on 1/4/24 at 7:03 A.M., showed Certified Nursing Assistant (CNA) E and CNA D provided personal care to the resident. CNA E unsecured the resident's brief. The brief was saturated with urine. CNA E cleansed the resident's genital area and while wearing the same gloves, rolled the resident to his/her left side. CNA E removed the resident's brief and cleansed the resident's buttocks area. While wearing the same gloves, CNA E grabbed a clean brief and tucked it under the resident's hips. CNA E then assisted the resident to turn to the other side and touched the resident's hips, legs, and feet with the same soiled gloves before removing the gloves, covering the resident with his/her blanket without first performing hand hygiene, and then washed his/her hands. 2. Review of Resident #43's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Always incontinent of urine, frequently incontinent of bowel; -Diagnoses included cancer and debility; -Toileting and personal hygiene: Substantial/maximal assistance. Helper does more than half of the effort. Review of the resident's care plan, last revised 10/31/23, showed: -Problem: ADL functional status/rehabilitation potential. The resident needs assist with ADLs; -Goal: Maintain current ADL function; -Approaches included: Bowel movements, monitor and record daily. Observation on 1/4/24 at 6:50 A.M., showed CNA D and CNA E provided personal care to the resident. CNA D unsecured the resident's brief. The brief was wet with urine. CNA D cleansed the resident's genital area and while wearing the same gloves, rolled the resident to his/her left side. Bowel movement was visible on the brief and resident's skin. CNA D cleansed the resident's buttocks area and dried the area with a clean towel. He/she then removed a pair of gloves and revealed a second pair of gloves under the original pare used to provide care. CNA D applied barrier cream to the resident's skin, removed his/her gloves, and without washing his/her hands, placed new gloves on. He/She assisted to put the clean brief on the resident before removing his/her gloves and washing his/her hands. 3. Review of Resident #68's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Always incontinent of bowel and bladder; -Diagnoses included dementia and depression; -Toileting and personal hygiene: Dependent, helper does all of the effort. Resident does none of the effort to complete the activity. Review of the resident's care plan, last revised 12/12/23, showed: -Problem: Resident needs assist with ADLs max assist; -Goal: Maintain current ADL function; -Approaches included: Bowel movements, monitor and record daily. Toileting 1 to 2 assist. Observation on 1/4/24 at 10:36 A.M., showed CNA F and CNA M provided personal care to the resident. CNA F unsecured the resident's brief. The brief was wet with urine. CNA F cleansed the resident's genital area and while wearing the same gloves, rolled the resident from side to side, as he/she cleansed all areas, all while wearing the same gloves. Bowel movement was visible on the rag used to cleanse the resident's rectum area. CNA F, while wearing the same gloves, rolled the resident from side to side to remove the soiled linen and place a clean brief under the resident, before removing his/her gloves and washing his/her hands. 4. During an interview on 1/5/24 at 2:19 P.M., the Interim Director of Nursing said gloves should be changed after cleaning an area and before dressing the resident after providing care. Hand hygiene should occur with every glove change. Double gloving does not replace the need to perform hand hygiene after removing gloves and should not be done. 5. Review of the facility's Employee Physical Examinations, Purified Protein Derivative (PPD, tests for TB)/TB Testing, and Hep A/B (hepatitis virus) Vaccinations policy, dated August 2005, showed: -Each employee is required to have a physical examination and 2-step PPD/TB test upon employment and then be tested annually for TB; -All new employees are required to have an initial test of a two-step TB test prior to starting employment. The initial test will be administered during the physical examination prior to the first day of orientation, unless the applicant presents proof of a positive PPD/TB test with a negative chest x-ray or a negative PPD/TB test that is current (within the last 30 days). The PPD/TB test must be read two to three days from the date administered; -If the initial test is negative, the second PPD/TB test must take place within one to three weeks after the first test was administered. The results of the second test must be read within two to three days after administration. Review of Staff HHH employee records, showed: -Date of hire 1/30/23; -No documentation of a first step or second step PPD, or any chest x-ray. Review of Staff III employee records, showed: -Date of hire 1/30/23; -No documentation of a first step or second step PPD, or any chest x-ray. Review of Staff AAA employee records, showed: -Date of hire 12/18/23; -First step PPD given 12/18/23 and read negative 12/21/23, after date of hire; -No second step PPD. Review of Staff FFF employee records, showed: -Date of hire 6/19/23; -First step PPD given 6/16/23 and no documentation the first step was read; -No second step PPD. Review of Staff GGG employee records, showed: -Date of hire 2/27/23; -First step PPD given 2/27/23 and read negative 3/1/23, after date of hire; -No second step PPD. Review of Staff JJJ employee records, showed: -Date of hire 1/17/23; -First step PPD given 1/4/23 and read negative on 1/6/23; -Second step PPD given 1/17/23 and no documentation the second step was read. During an interview on 1/4/24 at 2:27 P.M., the Chief Executive Officer (CEO) said he would expect the facility's employee PPD policy to be followed. He will check to see if he can locate any of the missing information. On 1/5/24 at 12:33 P.M., the CEO said they were not able to locate any of the missing employee PPD or TB testing information.

46888 Based on observation, interview and record review, the facility failed to provide residents food that was palatable and at a safe and appetizing temperature for five residents (#32, #41, #58, #359, and #360) and residents on the rehabilitation hall. The sample was 21. The census was 106 with 103 residents in certified beds. Review of the facility's Record of Food Temperatures policy, dated 12/11/18 showed: -Policy: it is the policy of this facility to record food temperatures daily to ensure food is at its proper serving temperature before trays are assembled; -Guidelines: Hot foods will be held at 135 degrees Fahrenheit (F) or greater. If the food temperature falls into an unsafe range, immediately follow procedures for reheating previously cooked food. Potentially hazardous food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 degrees F. No food will be served that does not meet the food code standard temperatures -The policy did not address food temperatures at the time of service. 1. Review of Resident #32's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/5/23, showed: -Cognitively intact; -Diagnoses of diabetes and chronic kidney disease. During an interview on 1/3/24 at 10:01 A.M., the resident said he/she did not like the food that is served due to it always being cold. 2. Review of Resident #41's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses of heart failure and chronic kidney disease. During an interview on 1/3/24 at 10:24 A.M., the resident said the food tastes horrible and was cold most of the time. 3. Review of Resident #58's quarterly MDS, dated [DATE] showed: -Moderately impaired cognition; -Diagnoses of heart failure and Alzheimer's disease. During an interview on 1/3/24 at 9:42 A.M., the resident said he/she did not like the food due to the taste. 4. Review of Resident #359's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart disease, high blood pressure, heart failure, renal (kidney) failure, and high cholesterol. During an interview on 1/3/24 at 9:39 A.M. and 1/5/23 at 11:49 A.M., the resident said the food was too salty and was not good for him/her because he/she has heart and kidney problems. The food generally tasted and looked like the staff took the food out of the trash and served it to the residents. 5. Review of Resident 360's face sheet, showed diagnoses that included heart disease, heart failure, high blood pressure, diabetes, kidney disease, and high cholesterol. During an interview on 1/3/23 at 9:29 A.M., the resident said he/she was just recently admitted and was said the food was awful. The artificial eggs served at breakfast were the worst. The food was always cold. 6. Observation on 1/4/24 at 12:04 P.M., of lunch trays served on the rehabilitation hallway, showed the following: -Garlic bread measured 111.7 degrees F; the bread tasted hard and dry; -Chicken penne pasta measured 111 degrees F; the pasta was lukewarm and tasted bland; -Zucchini and onion dish; the zucchini was overcooked and melted in your mouth. 7. Observation on 1/5/24 at 11:33 A.M., of lunch trays served on the rehabilitation hallway, showed the following: -Herb baked fish tasted dry; -Scalloped potatoes were dry; -Broccoli had a soggy texture. 8. During an interview on 1/8/24 at 7:43 A.M., Dietary Aide T said he/she would expect for food to be served to residents at a safe temperature. He/She said this was important for the residents' health. He/ She said that the food served to residents should taste and look palatable. 9. During an interview on 1/8/24 at 7:34 A.M. the Administrator said she would expect for food to be served at the appropriate temperatures. She would expect for food to look and taste palatable.

Based on interview and record review, the facility failed to ensure certified nursing assistants (CNAs) received the required 12 hours of annual in-service training, tracked by hire date, for three of 5 CNAs sampled. The facility had 31 CNAs employed for more than a year. The census was 106 with 103 residents in certified beds. Review of the facility's Facility Assessment Tool, last reviewed 10/18/23, showed staff training/education and competencies: Required in-service training for nurse aides: -Training to ensure the continuing competencies of nurse aides, no less than 12 hours per year; -Dementia management training, training on the care of cognitively impaired individuals, and resident abuse prevention training; -Additional training offered as needed to address areas of weakness as determined in nurse aides' performance. 1. Review of CNA A's employee file, showed: -Date of hire 11/3/2004; -No documented in-service training completed during the last complete year, calculated by hire date (November 2022 through October 2023). Review of a staff training spread sheet, showed no documented training provided during the last complete year, calculated by hire date (November 2022 through October 2023). 2. Review of CNA B's employee file, showed: -Date of hire 3/16/05; -No documented in-service training completed during the last complete year, calculated by hire date (March 2022 through February 2023). Review of a staff training spread sheet, showed no documented training provided during the last complete year, calculated by hire date (March 2022 through February 2023). 3. Review of CNA C's employee file, showed: -Date of hire 5/14/14; -No documented in-service training completed during the last complete year, calculated by hire date (May 2022 through April 2023). Review of a staff training spread sheet, showed no documented training provided during the last complete year, calculated by hire date (May 2022 through April 2023). 4. During an interview on 1/4/24 at 2:27 P.M., the Chief Executive office (CEO) said the facility does not currently have a nurse educator. He was not sure how CNA training was tracked. He will check and provide any information found. On 1/5/24 at 12:33 P.M., the CEO said the spread sheet provided is the most comprehensive tracking of training hours for CNAs. 5. During an interview on 1/5/23 at 2:23 P.M., the Administrator said she would expect CNAs to have the required 12 hours of in-service training.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week during the fiscal year quarter 4 2023 (July 1 - September 30). The census was 106 with 103 residents in certified beds. The administrator was notified on 1/8/24, of the past non-compliance. The facility has contracted for RN agency staff to cover for days where no facility employed RN was available. The deficiency was corrected on 10/1/23. Review of the facility's Facility Assessment Tool, last reviewed 10/18/23, showed: -Facility resources needed to provide competent support and care for the resident population every day and during emergencies: Nursing services (Director of Nursing, nursing management, nursing shift supervisor, Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant, Certified Medication Technician, Minimum Data Set Nurse); -Staffing Plan: Licensed nurses providing direct care: 4 on days/3 on nights; -The staffing plan did not address the required 8 hours of Registered Nurse Coverage required daily. Review of the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for fiscal year quarter 4 2023 (July 1 - September 30), for the facility, showed no RN coverage for the following dates: -July 2, 8, 16, 22, 23,29, and 30; -August 5, 6, 13, 19, and 27; -September 2, 4, 10, 16, 24, and 30. During an interview on 1/3/24 at 8:34 A.M., the Administrator said the days triggered on the PBJ report for quarter 4 indicating no RN coverage is accurate. The facility has since contracted with a nurse staffing agency to provide the required RN coverage. On 1/5/24 at 2:18 P.M., the Administrator said the facility identified during quarter 4, 2023 that they did not have sufficient RN coverage. They have had 8 hours of RN coverage daily since October 2023 with the use of the nurse staffing agency.

Based on observation, interview and record review, the facility failed to ensure care was provided in accordance with professional standards of practice for one resident when staff failed to change the dressing on a left lower leg wound as ordered (Resident #45). The resident's left lower leg wound was not tracked by the facility for wound healing status and condition and staff failed document assessments of the wound. The facility identified 11 residents with non-pressure wounds. The census was 106 with 103 residents in certified beds. Review of the facility's Skin Assessment policy, dated November 11, 2017, showed: -Purpose: To ensure that residents who enter the facility without pressure ulcers, do not develop pressure ulcers, skin alteration, and to institute proper interventions; -A complete head to toe skin assessment will be performed on all residents by the charge nurse or designee upon admission/re-admission, then weekly and upon any change in condition of the skin. The charge nurse/designee will document the skin assessment and notify the physician and responsible party of new skin abnormalities or worsened skin abnormalities and evaluate effectiveness of new interventions; -The wound nurse/designee will evaluate and assess skin abnormalities during his/her rounds and document appropriately. Review of the facility's Clean Dressing Change policy, dated March 6, 2020, showed: -It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes; -Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound; -Measure wound using disposable measuring guide; -Apply topical ointments or crease and dress the wound as ordered. Review of Resident #45's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 12/14/23, showed: -Severe cognitive impairment; -Diagnoses included Alzheimer's disease and malnutrition; -Skin conditions included skin tear(s) and moisture associated skin damage. Review of the resident's event report, dated 12/14/23, showed: -Activity during skin tear/laceration occurrence: Fall; -Certified Nursing Assistant (CNA) informed this nurse that the resident was on the floor in his/her room. This nurse went in to assess the resident and the resident has a cut on his/her hairline and a laceration on his/her left knee. Review of the resident's medical record, showed: -A progress note dated 12/14/23 at 11:51 A.M., skin tear is currently being treated by hospice nurse. Hospice nurse left new orders for treatment for skin tear; -A progress note date 12/16/23 at 1:30 A.M., resident in center of bed resting. Skin tear to forehead and knee noted. Treatment in place via hospice nurse; -No further documentation of the resident's left knee skin tear. Review of the resident's electronic physician order sheet (ePOS), showed: -An order dated 12/15/23, wound treatment to left knee. Wound cleanser, xeroform (non-adherent dress used to maintain a moist wound environment) abd pad (absorbent dressing), wrap with gauze and paper tape to keep in place. Once a day on the 7:00 A.M. through 7:00 P.M. shift; -An order dated 1/17/23, charge nurse to do focused observations: Skin section, once a day on Monday 7:00 P.M. to 7:00 A.M. shift. Review of the resident's weekly skin assessment, dated 12/18/23, showed old bruises to upper and lower extremities. Old skin tear to left knee, dressing intact. Review of the resident's medical record, reviewed on 1/5/23, showed: -Staff initialed competition of the scheduled weekly skin assessment on 12/25/23 and 1/1/24; -No weekly skin assessment completed since 12/18/23. Review of the resident's care plan, last revised 12/19/23, showed: -Problem: Resident has history of skin tears to both upper and lower extremities; -Goal: Resident will not sustain skin tears to extremities; -Approach included: Monitor fragile skin to all extremities for skin tears. Review of the facility's wound summary report, for the dates of 10/1/23 through 12/31/23, showed the resident's left knee skin tear was not tracked or assessed by the facility. Observation on 1/5/24 at 1:37 P.M., CNA H and CNA I transferred the resident to bed. A dressing on the left lower leg sagged and steri-strips were visible on the knee. The dressing dated 1/2 at 11:10 A.M. At 1:55 P.M., Licensed Practical Nurse (LPN) J entered the room with treatment supplies. He/She removed the dressing from the resident's left lower extremity. The dressing had blood that stuck to the wound. LPN J used wound cleanser spray to loosen the dressing from the dried blood. The wound was linear and extended from on top of the knee and down to below the knee. The ordered treatment was applied. Review of the resident's January 2023 medication administration record showed staff documented the resident's left knee treatment as completed on 1/3 and 1/4/24. During an interview on 1/5/24 at 2:24 P.M., the Interim Director of Nursing (DON) said skin assessments are completed weekly. The ordered treatment should be completed daily as ordered. During an interview on 1/8/24 at 7:33 A.M., the Administrator said the resident's left knee wound should be on the wound tracker. Measurements are taken weekly and staff should be documenting the appearance and condition of the wound weekly.

Based on observation, interview and record review, the facility failed to ensure each resident received assistance devices to prevent accidents, for one resident transferred without the use of a mechanical lift. Staff failed to use a gait belt and failed to ensure the resident was safe to transfer without the use of a mechanical lift. In addition, staff failed to evaluate the use of a Broda chair (medical reclining chair) with a tray for safety (Resident #62). The census was 106 with 103 residents in certified beds. Review of the facility's Safe Resident Handling/Transfers policy, revised 7/10/23, showed: -It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines; -All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used; -The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status; -The resident's mobility needs will be addressed on admission and reviewed quarterly after a significant change in condition or based on direct care staff observations or recommendations. Review of Resident #62's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/22/23, showed: -Ability to understand others: Rarely/never understands; -Resident is rarely/never understood; -Inattention, disorganized thinking, altered level of consciousness: Behavior continuously present, does not fluctuate; -Chair/bed-to-chair transfer and toilet transfer: Partial/moderate assistance, helper does less than half the effort; -Diagnoses included Alzheimer's disease and anxiety disorder. Review of the resident's care plan, last reviewed/revised 10/31/23, showed: -Problem: The resident requires assistance with activities of daily living (ADL); -Goal: Maintain current ADL function; -Approach included: Transfer with assist of one. Review of the resident's hospice binder, showed: -admitted to hospice on 11/14/23; -No order for Broda chair with lap tray; -No progress notes that a Broda with lap tray was ordered; -Durable medical equipment (DME) provided by hospice; -Hospice care plan, dated 12/6/23 Broda chair with lap tray not listed. Review of the electronic medical record (eMR) on 1/3/24 at 5:48 P.M., showed a medical equipment receipt, dated 11/20/23 for delivery of a 20 inch Broda chair with a grey tray. Review of the resident's ePOS on 1/3/24 at 3:12 P.M., showed no order for a Broda chair with lap tray. Review of the resident's care plan on 1/3/24 at 5:24 P.M., showed no interventions related to a Broda chair with a lap tray. Observation on 1/3/24 at 10:18 A.M., showed the resident sat in a Broda chair that reclined approximately 30 degrees with a lap tray latched across the front of the resident. The resident scratched the top of the lap tray with his/her right hand and leaned over the lap tray and looked at the ground. Observation on 1/4/24 at 9:18 A.M., showed Hospice Certified Nursing Assistant (CNA) K propelled the resident out of his/her room in a Broda chair and brought the resident into the shower room. He/She assisted the resident to get undressed as the resident sat in the chair. The resident's legs appeared tight and drawn up towards his/her body. Hospice CNA K brought the shower chair close to the resident's Broda chair, and locked the Broda chair wheels. Hospice CNA K grabbed the resident under his/her arms, lifted the resident out of the chair, and transferred the resident into the shower chair. The resident's toes drug along the floor, and he/she did not bear any weight. The resident began to slide down off of the shower chair. Hospice CNA K stood behind the resident, placed his/her arms under the resident's arms and pulled the resident up to position him/her in the shower chair. Hospice CNA K gave the resident a shower, dried the resident, and assisted the resident to get dressed. Hospice CNA K moved the shower chair close to the resident's Broda chair, hugged the resident from the front and placed his/her arms under the resident's arms, and then assisted the resident to stand. The resident stood on his/her feet with his/her knees slightly bent. Hospice CNA K then moved the resident at a 90 degree angle to his/her Broda chair. The resident's feet drug on the ground. The resident did not attempt to take steps or to pivot. No gait belt was used. Observation on 1/4/24 at 10:51 A.M., showed the resident sat in his/her Broda chair in the small dining room without the Broda lap tray. CNA M went into the resident's room and retrieved the lap tray and placed it on the resident's Broda chair. During an interview on 1/4/24 at 11:01 A.M., CNA M said the resident just recently received the Broda chair and lap tray after the resident was signed up with hospice. CNA M said the lap tray is for the resident's safety, to keep the resident from falling out and to keep the resident from grabbing other residents and staff. The lap tray should be placed on the Broda chair when the resident is up in the Broda chair. CNA M said the lap tray is removed when the resident is assisted with meals. Observation on 1/4/24 at 12:04 P.M., showed Licensed Practical Nurse (LPN) P asked CNA M if the resident should be at the dining room table with or without the lap tray. CNA M removed the lap tray and placed the resident at the dining room table in his/her Broda chair and placed the lunch plate in front of the resident on the dining room table. LPN P sat down and assisted the resident with eating lunch. During an interview on 1/5/24 at 7:42 A.M., CNA L said he/she is the resident's CNA. The resident can transfer with staff assist of one. The resident can bear weight, but cannot take steps, just holds his/her weight still. He/She is a fall risk. Observation on 1/5/24 at 8:38 A.M., showed the resident in the large dining room, placed next to a dining room table without the lap tray. Staff assisted the resident with breakfast. Observation on 1/5/24 at 9:57 A.M., showed the resident sat in the Broda chair with a lap tray on in the large dining room, in front of a TV. During an interview on 1/5/24 at 12:03 P.M., CNA M said the resident has had the lap tray for around a month. CNA M said the charge nurse informs the CNAs when the tray should be used. During an interview on 1/5/24 at 12:21 P.M., Certified Medication Technician (CMT) Q said the resident has had the lap tray for the last month. CMT Q said he/she was unsure why the resident has the tray. CMT Q said the resident can pick up a cup and drink on his/her own and drinks are placed on the tray for the resident. During an interview on 1/5/24 at 12:31 P.M., LPN R said he/she is unsure why the resident has a lap tray and assumed the tray was to prevent the resident from falling, because the resident does not have it on while eating. LPN R said if a resident has a lap tray, there should be a physician's order for the lap tray. LPN R said if a resident has a lap tray, it should be listed in the resident's care plan. During an interview on 1/5/24 at 12:50 P.M., Nurse Manager (NM) S said the lap tray is used for the safety of the resident because the resident is constantly moving and can't sit up in regular wheelchair. NM S said the resident should have the lap tray on at all times while up in the Broda chair and it may be removed during meals. The resident recently was admitted to hospice and received the lap tray after admitting to hospice. NM S said the resident should have a physician order and a care plan for the lap tray. During an interview on 1/5/24 at 2:13 P.M., the Administrator and interim Director of Nursing (DON) said they expected the resident to have an order and a care plan for the lap tray. They expected staff to follow and be knowledgeable of the policies and procedures of the facility. During an interview on 1/5/24 at 2:19 P.M., the Interim Director of Nursing said resident transfer status is determined either by therapy or with a physician order. If staff have concerns with the resident's transfer status, they can ask therapy to evaluate the resident or obtain an order for a new transfer status. For residents who transfer with staff assistance, if a resident is not able to follow directions or take steps, staff should reach out to the physician about their transfer status. For a resident that does not require a mechanical lift, but does require assistance, a gait belt should be used, they should be able to bear weight, follow directions, and pivot their feet. Review of the resident's care plan on 1/8/24 at 7:10 A.M., showed: -Edited 1/5/24; -Problem: The resident has a lap tray for meals and activities; -Goal: Maintain current activities of daily living (ADLs, bathing, toileting, dressing, etc.) function; -Approach start date 1/5/24: Resident may have lap tray for meals and activities, remove as needed every shift. Review of the resident's ePOS, on 1/8/24 at 7:12 A.M., showed an order dated 1/5/24, Broda chair with lap tray. During an interview on 1/8/24 at 7:34 A.M., the Administrator said the resident should have had an order and a care plan for the Broda chair with lap tray prior to 1/5/24.

Based on observation, interview and record review, the facility failed to ensure one resident, who was incontinent of bowel and bladder, received the necessary services to maintain good personal hygiene when the resident was assisted into his/her chair by the night shift and was not checked or cleaned of urinary and bowel incontinence until approximately seven hours later. The resident's brief was saturated with urine and bowel movement when assisted to be cleaned. The sample was 21. The census was 106 with 103 residents in certified beds. Review of the facility's Perineal Care policy, dated October 14, 2021, showed: -It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown; -Perineal care refers to the care of the external genitalia and the anal area. Review of Resident #45's quarterly Minimum Data Set (MDS, a federally mandates assessment instrument completed by facility staff), dated 12/14/23, showed: -Severe cognitive impairment; -Diagnoses included Alzheimer's disease and malnutrition; -Personal hygiene: Substantial/maximal assistance- helper does more than half of the effort; -Always incontinent of bowel and bladder; -Skin conditions included skin tear(s) and moisture associated skin damage. Review of the resident's care plan, last reviewed/revised 12/19/23, showed: -Problem: Activities of daily living (ADL) functional status/rehabilitation potential; -Goal: Work on increasing independence with ADLs through next review; -Approaches included: Bowel movements, monitor and record daily. Toileting assist times two. Review of a sign posted on the resident's wall, showed to provide opportunities to use the bathroom. Observation on 1/5/24 at 7:26 A.M., showed the resident sat in his/her medical reclining chair in his/her room. At 8:21 A.M., the resident sat in the main dining room at a table as breakfast was served. Certified Nursing Assistant (CNA) H said the resident requires a mechanical left to go back to bed. Night shift got him/her up this morning. He/She will get the surveyor when he/she assists the resident back to bed, staff have to transfer the resident to bed to check for incontinence. At 8:35 A.M., staff propelled the resident into his/her room and exited the room. The resident sat in his/her room in his/her chair. At 9:08 A.M., Nurse Practitioner (NP) O entered the room to visit the resident. The resident reported his/her bottom hurt. At 9:13 A.M., NP O exited the room. The resident remained up in his/her chair. At 10:12 A.M., the resident's family visited with the resident in his/her room. He/She remained up in his/her chair. At 11:28 A.M., the resident's family propelled the resident into the dining room in his/her chair and left the facility. At 12:15 P.M., staff propelled the resident from the dining room to the activity room in his/her chair. At 1:19 P.M., staff propelled the resident from the activity room to the area outside of the nurse's station. The resident remained in his/her chair. At 1:24 P.M., a different resident's visitor stopped to talk to the resident. The resident said he/she was so uncomfortable and wanted to go to bed. The visitor said he/she would report this to staff. He/She informed a staff person located near the nurse's station. The staff person said he/she will let the resident's aides know. At 1:29 P.M., CNA H asked the resident if he/she wanted to go to the bathroom. The resident said he/she would like to. CNA H began to propel the resident to his/her room. CNA H said his/her shift started at 6:30 A.M. Night shift always gets the resident up. The resident is not a heavy wetter, so he/she does not need to be checked as much. CNA H said he/she needed to get help and exited the room. The resident sat in his/her chair in his/her room. A strong odor of stagnant urine was noted near the resident. The resident said his/her bottom hurt and he/she wanted to go to bed. At 1:37 P.M., CNA H and CNA I arrived to the room and transferred the resident into bed. Staff assisted the resident to turn to his/her left side and a half dollar sized wet spot was visible on his/her pants. Staff removed the resident's pants and unsecured his/her brief. The resident's brief was saturated with urine. All areas of cotton appeared wet and soiled. The resident had a large liquid bowel movement in the brief. The resident's buttocks was reddened. Staff cleaned the resident and applied barrier cream and a new brief. At 2:10 P.M., Licensed Practical Nurse J said he/she was informed earlier this morning that the resident had reported pain to his/her bottom. He/she increased the resident's oxygen because he/she though his/her oxygen was low, and it helped. During an interview on 1/5/24 at 2:24 P.M., the Interim Director of Nursing said for residents who are incontinent of urine and bowel, they should be checked every couple of hours or as needed. If a resident reports his/her bottom hurts to staff, staff should attend to them.

Based on observation, interview and record review, the facility failed to ensure care was provided in accordance with professional standards of practice for one resident when staff failed to have a dressing on the resident's coccyx as ordered (Resident #68). The sample was 21. The census was 106 with 103 residents in certified beds. Review of the facility's Provision of Physician Ordered Services policy, dated 12/8/17, showed: -Policy: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality; -Policy Explanation and Compliance Guidelines: - 1. Physician orders should be obtained for administration of all medications and treatments; -2. Registered professional nurse or licensed professional nurse under the direction of a registered professional nurse may carry out orders from a physician, physician assistant, nurse practitioner or clinical nurse specialist licensed by any state regulatory board to prescribe medications and treatments; -3. A physician order is not needed for a registered nurse to perform independent nursing acts, as long as the nurse defensibly has the required specialized education, judgment and skill. Review of the facility's Comprehensive Care Plan policy, dated 12/8/17, showed: -Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -Policy Explanation and Compliance Guidelines: -1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally- competent; -2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record; -3. The comprehensive care plan will describe, at a minimum, the following: -a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -b. Any services that would otherwise be furnished, but are not provide due to the resident's exercise of his or her right to refuse treatment. -c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes) recommendations; -d. The resident's goals for admission, desired outcomes, and preferences for future discharge; -e. Discharge plans, as appropriate; -f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate; - 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: - a. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan; -b. A licensed nurse with responsibility for the resident; -c. A nurse aide with responsibility for the resident; -d. A member of the food and nutrition services staff; -e. The resident and the resident's representative, to the extent practicable; -f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Examples include, but are not limited to: -i. The RAI Coordinator; -ii. Activities Director/Staff; -iii. Social Services Director/Social Worker; -iv. Licensed therapists; -v. Family members, surrogate, or others desired by the resident; -vi. Administration; -vii. Mental health professional; -viii. Chaplain; -5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment; -6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed; -7. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative; -8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of Resident #68's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included diabetes, dementia and malnutrition; -At risk for pressure ulcers (injury to the skin caused by pressure or friction); -One Stage III pressure ulcer (full thickness tissue loss). Review of the resident's electronic Physician Order Sheet (ePOS), showed an order, dated 12/8/23, to change top blue adhesive dressing on sacral (tailbone/coccyx area) wound every three days, or replace the dressing as needed if the top blue adhesive dressing is absent or coming off wound site. Review of the resident's care plan, last reviewed/revised on 1/3/24, showed: -Problem: The resident has a pressure area to the coccyx with treatment in place; -Goal: Area to improve with no signs of infection; -Approach included: Notify nurse if dressing to coccyx is soiled or removed. Observation on 1/4/24 at 10:36 A.M., showed Certified Nursing Assistant (CNA) F and CNA M entered the resident's room to provide personal care. CNA F unsecured and removed the resident's brief. The resident had an open area, approximately the size of a half dollar, to the coccyx. No dressing was in place. CNA F said he/she needs to get the nurse to let him/her know the dressing was not on. At 10:51 A.M., Registered Nurse (RN) N entered the room and staff told him/her the dressing was off. RN N said he/she needed to go get supplies. CNA F said the dressing was on the day prior because he/she saw it while caring for the resident, but it was not on today. He/She verified it was not in the brief or in the bed and said it probably fell off on the night shift. The resident might have had a bowel movement and the aide could have taken it off. At 10:56 A.M., RN N returned and reapplied the dressing. He/She said the wound care company comes in weekly to assess the wound and applies the entire dressing. Staff will change the outer dressing if it becomes soiled. He/She verified neither the inner nor outer dressings were on the resident when he/she came into the room. During an interview on 1/5/24 at 2:19 P.M., the Interim Director of Nursing (DON) said if a treatment comes off during care or if it is identified there is no dressing on a wound, she expected staff to report it to the nurse. The risk of leaving a wound open and potentially exposed to urine or bowel movement is the risk of infection. 46104

Based on interview and record review, the facility failed to ensure one resident was free from employee to resident abuse in which a resident's spouse restrained the resident while an agency nurse forced a syringe of medication into the resident's closed mouth, despite his/her verbal protests and physical resistance, for one of three sampled residents (Resident #4). The census was 121. The administrator was informed on 11/28/22 of an Immediate Jeopardy (IJ), which began on 10/16/22. The IJ was removed on 12/6/22 as confirmed by surveyor on-site verification. Review of the facility's policy titled, Freedom from Abuse, Neglect and Exploitation Policy and Procedure, developed 11/27/17, showed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraints not required to treat the resident's medical symptoms. An owner, licensee, administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. All new employees or volunteers were to receive training on the abuse, neglect and exploitation policy prior to direct or indirect resident contact. The facility was to provide identification, ongoing assessment, and care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Employees must always report any abuse or suspicion of abuse immediately to the administrator. If a family member, resident representative or resident was possibly contributing to the potential abuse and the resident could be at risk, then the situation was to be evaluated and options identified and put into place for resident protection. The facility was to take all necessary actions as a result of an abuse investigation, including analyzing the occurrence to determine the reason that the abuse occurred and what changes needed to be made to prevent further occurrences: defining how care systems and processes would be changed to protect residents, training staff about the changes made as a result of the investigation and reporting, corrective action for staff involved in the incident, identifying the staff responsible, monitoring the implementation of the changes made to the abuse prevention plan. Review of the facility's undated resident rights policy, showed residents of nursing homes had rights which were guaranteed to them under Federal and State laws. The laws required nursing homes to treat each resident with dignity and respect and care for each resident in an environment which promoted and protected their rights. Residents had the right to a dignified existence: to be treated with consideration, respect and dignity, as well as having their individuality, wishes and preferences recognized. They were to be free from abuse, neglect, exploitation and misappropriation of property. The right to a dignified existence also included exercising their rights without interference, coercion, discrimination or reprisal. Review of Resident #4's undated face sheet, showed an admitted [DATE] and his/her spouse listed as durable power of attorney (DPOA) for health care and finances (allows an individual/agent to make decisions regarding the resident's health care and finances, if the resident is unable to make decisions or communicate due to severe illness or injury). The facesheet lists malignant neoplasm of brain unspecified (brain cancer), encephalopathy unspecified (admission), headache unspecified, essential (primary) hypertension (high blood pressure), anxiety disorder unspecified and other seizures. Review of the record, showed no DPOA on file, nor was there documentation by a physician of the DPOA enacted due to incompetency by the resident. Review of the resident's care plan, updated 10/14/22, showed the following: -Potential for pain due to diagnosis of cancer; -Reposition for comfort. If this is not effective, then the resident has as needed (PRN) medication; -Caregiver role strain with the resident's terminal cancer; -Encourage communication between caregiver and staff. Review of the resident's October 2022, physician's orders, showed the following: -10/14/22, Lorazepam Intensol (sedative used to treat anxiety) Schedule IV concentrate 2 milligrams (mg)/millimeters (mL), amount: 0.25 mL. Special instructions: for comfort; -10/15/22, haloperidol lactate concentrate (high-potency antipsychotic used to treat mental/mood disorders) 2 mg/mL, amount: 0.5 mL oral. Special instructions: give with scheduled Lorazepam every 4 hours; -Morphine concentrate (treats moderate to severe pain) Schedule II solution 100 mg/5 mL (20 mg/mL) amount: 0.5 mL every 4 hours; -Morphine concentrate Schedule II solution 100 mg/5 mL (20 mg/mL) amount: 0.5 mL every 2 hours PRN for pain/shortness of breath. Review of the resident's progress notes, showed on 10/15/22 at 2:37 P.M., the resident's spouse approached an unspecified nurse and requested the resident receive morphine every two hours. The nurse explained he/she could make hospice aware of the request. The spouse told the nurse when the resident was asleep, they needed to administer the medication to the resident and they did not have to ask the resident if they could give it to the resident. The nurse explained the nurse could not force it into the resident's mouth, when the resident pursed his/her lips tightly and turned his/her head. At 8:36 P.M., the resident's spouse approached another nurse and said the resident needed PRN morphine. When the nurse asked the resident if he/she was in pain, his/her spouse answered for him/her. The spouse also told the nurse if the resident refused his/her pain medications, the nurse was to give them to the spouse so the spouse could administer them. The spouse wanted staff to administer the resident's routine and PRN medications around the clock, regardless of how the resident was feeling. The spouse said the resident did not know what he/she was talking about. The nurse said he/she could not give the spouse the resident's medications to administer, the spouse said, yes you can. The nurse spoke with the Director of Nursing (DON) to make her aware of the spouse's behaviors. Review of Certified Nurse's Aide (CNA) B's written statement, dated 10/16/22, showed on 10/16/22, the resident's spouse activated the resident's call light and requested ice water. As CNA B was leaving, the spouse came out of the room and also asked the nurse to give the resident some medications for pain. As CNA B was coming back to the room, the spouse asked the nurse (Nurse A) to put the medications into the resident's mouth. The resident said no. So, the resident's spouse started holding the resident's arms and legs and told the nurse to go ahead and do it. The spouse said to put it into the resident's mouth, because the resident had brain cancer and did not know if he/she was in pain. CNA B said to the nurse, you can't do that. The nurse and spouse said that Nurse could, that it was in the resident's chart. So, the nurse put the medications in the resident's mouth. The resident started spitting it out, angering the spouse. So, CNA B and the nurse walked out of the room. CNA B asked the nurse, are you sure about what you just did? The nurse said, yes that he/she was going by what was in the resident's chart. However, it did not look right to CNA B. The nurse said that everything was in the computer regarding the resident's medications and what was going on with his/her brain cancer. CNA B said,okay, I was just asking because I don't have all that information. But, it just don't look good, that's all and I'm sorry if that's what it says and I know that you're the charge nurse. But, I was just asking. The nurse said it was okay, that everything is in here, that the resident was okay and would be fine. Review of Nurse A's statement, dated 10/19/22 at 1:18 P.M., showed at 2:00 P.M., the resident's spouse came out of the door (to his/her room) and signaled for Nurse A and the CNA to come in. The spouse told them the resident had to go to the bathroom. When they entered the room, the resident was trying to get out of the bed. Nurse A and the CNA held the resident to the side, to make it seem like he/she was peeing into a urinal. The resident kept trying to stand, saying he/she needed to get up. The spouse came back in and was by the resident's legs, rubbing them. The resident laid there for a minute, looking confused and rubbing his/her head with both hands. The spouse then said, ok, it's time to take your medicine. Nurse A put the first syringe by the resident's mouth and tried to administer the medication. Half of it got into the resident's mouth, before his/her hand came up and pushed the nurse's hand. The resident moved his/her head. Nurse A tried to go back towards the resident's mouth with a syringe and he/she moved his/her head again. The spouse was trying to soothe the resident to take it, but he/she was very agitated. He/she started kicking and swinging his/her hands. The spouse asked if Nurse A could give the next medication, so Nurse A tried to put the syringe of medication by the resident's mouth again. The resident was moving his/her head and spitting. He/she was kicking hard and the spouse was trying to hold the resident's legs down. Nurse A told the spouse that the medication was not getting into the resident's mouth. The spouse asked if Nurse A could return at 4:00 P.M. and administer a PRN dose. Review of the resident's progress notes, showed no entry on 10/16/22, involving medication administration by Nurse A. Review of the facility's self-report cover sheet, e-mailed on 10/19/22, showed the alleged incident involving the resident, Nurse A and the resident's spouse showed since the resident's admission on 10/13/22, the resident's spouse continued to ask for increases in pain and agitation medications without the consent of the resident. The resident's spouse was insisting that the nurses administer medications to the resident which were not warranted, based on pain observations and resident consent. The resident could voice pain levels and refuse medications, but the spouse was insisting that the staff follow the spouse's instructions on providing pain and agitation medications. The administrator and DON spoke with the resident's hospice company, in order to ask for additional assistance on communication to the spouse of the protocols the facility must follow when administering routine and PRN medications. During an interview on 11/11/22 at 4:04 P.M., Nurse C said the resident was alert enough to open his/her mouth, but would clench his/her teeth or turn his/her head away when he/she attempted to administer medications. The resident's spouse attempted to get Nurse C to forcefully administer the resident's medications, instructing him/her to push it through the resident's lips and towards the inside of the cheek. Nurse C told the resident's spouse that was against the law. During an interview on 11/8/22 at 3:00 P.M., the resident said on the day in question, Nurse A brought in three syringes of medication and did not identify what medications the syringes contained or ask the resident if he/she wanted to take the medications. The resident verbally declined them. His/her spouse said he/she was going to get them anyway. Without saying anything, Nurse A attempted to administer the first syringe. The resident was pushing it away. He/she fought to keep the syringe away from his/her mouth, so his/her spouse held him/her down. The resident said, no, I don't want it. Nurse A pushed another syringe into the resident's mouth. CNA B said, what are you doing? You ain't supposed to be doing that. Nurse A pushed the third syringe into the resident's mouth. The liquid medication was going into his/her mouth so fast, he/she was forced to swallow some of it. The resident resisted with all of his/her strength, but he/she was weak and helpless. All he/she could do was turn his/her head away. Some of the medication went up his/her nose, and some went all over his/her face and dried there. The medications the resident was forced to swallow drugged him/her to the point that he/she could not move or think clearly that night. All he/she could do was lie there with tears streaming out of his/her eyes. He/she found the incident very distressing and felt that it was physical and mental abuse. Afterwards, the resident was so fearful of staff, he/she did not want to be touched or drink any water (believing his/her spouse was adding the liquid morphine to it). The resident began declining all medications, as well as food and water fearing they contained medication. Without the pain medication in his/her system, the resident could think clearly and regained the ability to walk unassisted. The resident got him/herself off of hospice and discharged from the facility. After leaving the facility, he/she did not sleep through the night. Every time he/she heard a noise, he/she woke up afraid, thinking that someone was coming to administer medication. During an interview on 11/4/22 2:50 P.M., the resident's spouse said he/she urged staff to administer the resident's medications, based on the hours (the scheduled times) ordered by hospice of morphine for pain, Lorazepam for anxiety and haldol which was a mood stabilizer. On the day in question, the resident did knock Nurse A's hand away and turn his/her head as Nurse A administered the first syringe of medication. He/she tended to resist all medications, because he/she did not believe in them. The spouse said, [NAME], we need to take this for your anxiety. The spouse did not recall the resident swinging his/her hand or kicking or crying out. The spouse did not hold down the resident's arms or legs. The spouse just rubbed the resident's stomach and chest, in order to calm him/her down. The resident was not agitated and shouting. He/she did say he/she did not want to do the medications anymore. The spouse could not recall whether or not the resident was calling out for his/her daughter that day, or if that had occurred on a different day. Nurse A could not get the next syringe past the resident's lips. The spouse could not recall how many syringes of medication Nurse A attempted to administer, but recalled that the resident would not take any more medication. During interviews on 10/28/22 at 2:30 P.M. and 11/8/22 at 3:00 P.M., Nurse A said on 10/16/22, he/she was providing care to the resident for the first time. During the change of shift report, the outgoing nurse reported the resident had been at the facility for two days and received routine Ativan, haldol and morphine every four hours as well as PRN Ativan and morphine in between those doses every two hours. The outgoing nurse also said the resident's spouse was adamant about the resident receiving medications on time. At times, the spouse was also adamant about the resident receiving his/her PRN medications, regardless of whether or not the resident requested it. The outgoing nurse went on to report the resident had brain cancer, was not eating a lot and sometimes would hit the nurses' hand or move his/her head or spit out medications, while they were being administered. Nurse A did not receive any instructions on what to do, when any of those things occurred. At 2:00 P.M. that day, Nurse A went to the resident's room, accompanied by CNA B, to administer scheduled medications. The resident's spouse and children were present. The spouse had the children leave the room. The resident's spouse started rubbing the resident's legs and saying, it's time for your meds. Nurse A administered the first syringe of medications via the corner of the resident's closed mouth. Half of it went in, before the resident moved his/her head to the side. Nurse A tried again, attempting to stick a second syringe of medications in through the corner of the resident's mouth, so the resident would not choke. The resident started kicking and swinging his/her arms. His/her spouse pushed the resident's legs back down and held them. When the resident swung at the spouse, he/she grabbed his/her arms and held them down. The spouse said, can we try to give the next medication? The resident moved his/her head. Nurse A attempted to administer a total of two vials of medication. The resident did not receive any of the second vial. Nurse A had tried to push the syringe into the resident's mouth, but the resident resisted and had his/her mouth locked. The resident was not crying, but he/she was shouting (he/she's) trying to kill me. His/her spouse told Nurse A to administer the resident's PRN medication in two hours. Nurse A agreed to do so, because the resident was agitated and Nurse A felt Ativan might help. At 4:00 P.M., Nurse A went back. At that time, a family member calmed and soothed the resident, who had no problem taking the PRN medication. A week after the incident occurred, the DON called Nurse A, informed him/her the facility was conducting an investigation, requested a written statement and told Nurse A he/she should have stopped when the resident refused the medications and told the resident that Nurse A would return later to attempt the medication pass. Nurse A last worked at the facility a year ago. Prior to the incident, Nurse A had not received any education on the facility policies and no one informed him/her there was a binder at the nurse's station containing facility policies. During interviews on 10/28/22 at 2:30 P.M. and 11/8/22 at 3:00 P.M., CNA B said on 10/16/22, the resident was fairly new to the facility, appeared to be alert enough to know what was going on and was not normally combative. When CNA B saw him/her, the resident was lying in bed, waiting for water. While CNA B was present, the spouse said it was time for the resident's medications. The resident said, No, I don't need anything. Nurse A entered the room, introduced him/herself and told the resident he/she had the resident's medications. The resident said, I told you I don't want it. The spouse became annoyed and said, well you're gonna get it. The spouse told Nurse A to put the medications into the resident's mouth anyway, because the resident was confused. Nurse A pushed one of the syringes of medication into the resident's mouth. The resident turned his/her head away and spit out some of the medications. Nurse A attempted to administer a second syringe of medications. The resident tried to block it with his/her hand and the resident's spouse held down his/her arms. The resident started kicking, trying to get away and crying out for his/her daughter. The spouse held down his/her legs. The resident clamped his/her mouth shut and Nurse A pushed the syringe of medications past his/her lips through the side of his/her mouth. The resident started crying and saying, I told you I don't want it. CNA B spoke up and said, hey, you can't do that. The spouse turned and looked at CNA B, saying it was all in the resident's chart that he/she had brain cancer, was confused, did not know what was going on or what he/she was doing. Nurse A attempted to administer a total of three syringes of medication. When the resident's daughter entered the room, he/she told the daughter his/her spouse held him/her down and a nurse squirted the medications into his/her mouth. The resident said, (he/she's) trying to kill me. I told you, (he/she's) trying to kill me. Afterwards, CNA B reminded Nurse A the resident had the right to refuse medications. Nurse A said it was all in the resident's chart he/she had brain cancer, the resident was confused and did not know what he/she was saying or what he/she was doing. The resident had only been in the facility for a few days and CNAs did not have access to a resident's entire chart. However, CNA B believed what he/she had witnessed was abuse, due to the resident having been held down while Nurse A administered medications even though the resident's teeth were clenched together and the resident was crying out for his/her daughter. CNA B was also aware he/she was supposed to report any observed or suspected abuse within two hours. However, when the resident's spouse and Nurse A both said the resident's confusion was documented in the resident's chart, CNA B felt continuing to question their actions may have been overstepping CNA B's bounds. He/she started thinking that perhaps, the resident did not know what he/she was doing in refusing the medications and fighting during medication administration. His/her spouse said the resident needed the medication. The incident occurred during the day shift on Sunday (10/16/22). The incident continued to bother CNA B, because it just didn't look right. So, CNA B reported it the next time he/she worked, which was Tuesday (10/18/22). He/she went to Social Worker D and started asking questions. During interviews on 11/7/22 at 4:06 P.M. and 11/8/22 at 3:22 P.M., Social Worker D said CNA B reported the allegation of the resident's spouse holding the resident down while the nurse administered medications against the resident's wishes to Social Worker D on Tuesday (10/18/22). Social Worker D was on his/her way to a care planning meeting at the time and instructed CNA B to go and tell the administrator. After learning of the incident, Social Worker D spoke to the resident who said he/she recalled being held down, after saying he/she did not want the medications and the nurse gave it to him/her anyway. The resident said Nurse A was trying to put it into the resident's mouth while the resident's teeth were gritted. Social Worker D asked about the spouse being continued to allow to visit and the resident did not say that he/she did not want his/her spouse to visit. During interviews on 10/21/22 at 10:10 A.M. and 11/4/22 at 1:29 P.M., the DON said on the resident's first day, his/her spouse came in demanding a larger amount of pain medication than was typically given. The spouse was upset the resident's physician had declined a request for higher doses. When staff attempted to administer the resident's medications, the resident would clench his/her teeth, shake his/her head and voice concerns about the medications. The resident said he/she did not want any more pain medication, because it made him/her loopy. The resident's level of alertness went back and forth, when he/she received the medications. The DON had not observed any indications the resident needed pain medication or haldol to keep him/her calm. As the days progressed, the resident increasingly clenched his/her teeth during med pass. The nurses were verbally instructed, shift by shift, via the outgoing nurse during the change of shift report, to inform the resident whenever they were about to administer morphine. They were told not to administer it, if the resident declined it. The spouse wanted them to force the medications into the resident's mouth. The DON expected the nurses to know if a resident declined medications, then they were not to administer it. Based on nursing judgement, nurses should know that a line was crossed, if a family member held down a resident. They should go and get a nursing supervisor. The facility did not provide training or orientation to temporary staff regarding facility policies. However, agency staff were informed there was a resource binder at each nurses station, to which they could refer for facility policies as guidance on how to handle difficult situations. Based on the facility's resident rights policy, a resident had the right to refuse medications. A nurse forcing a resident to take medications against their will was a form of abuse. During an interview on 11/7/22 at 2:37 P.M., the administrator said the incident occurred on 10/16/22, but CNA B reported the incident and actually wrote his/her witness statement on 10/18/22, which was the next day he/she worked. Social Worker D said CNA B reported the incident to Social Worker D on Tuesday (10/18/22). The facility reported the allegations to DHSS the same day, via the self-report cover sheet and the written statements of Nurse A and CNA B, because they realized Nurse A and the resident's spouse physically and mentally abused the resident. The administrator expected staff to report abuse allegations immediately to the charge nurse. CNA B had undergone training on the abuse and neglect policy in the past. During those sessions, other employees in the chain of command were identified to whom he/she could report abuse allegations. CNA B also received a list of contact phone numbers for those individuals. The DON said after the incident, she informed CNA B the abuse allegations should have been reported immediately. The DON said she informed CNA B that CNA B should have immediately reported the abuse allegations to a supervisory staff person someone in management. According to the administrator, she and the DON met with the resident's spouse after the incident and asked what happened. The spouse said he/she had to hold the resident down, due to the resident kicking his/her legs, swinging his/her arms and refusing medications. The spouse claimed that he/she rubbed or held the resident's legs in order to calm the resident. They did not discuss with the resident's spouse the inappropriateness of the spouse's actions in violating the facility resident rights and abuse prohibition policies. The resident was able to make his/her needs known, even though the resident's spouse said the resident was confused. The administrator felt Nurse A and the resident's spouse engaged in mental and physical abuse of the resident on 10/16/22. Individuals from temporary agencies working in the facility were considered contracted employees. Initially, staff were going by what the spouse said about the resident scratching his/her head as an indication he/she was in pain. Then, the resident started coming to and refusing his/her medications. In the midst of refusing his/her medications, the resident said they made him/her loopy and very tired. As the resident took less medication, due to declining them, the resident was able to express the medications made him/her feel loopy and tired. Not taking the medications allowed the resident to formulate his/her thoughts. The resident improved to the point he/she got off of hospice and was ambulating, when he/she was discharged from the facility. Note: At the time of the complaint investigation, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review, it was determined the facility had implemented corrective action to address and lower the violation at that time. A revisit/final revisit will be conducted to determine if the facility is in substantial compliance with the participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State Law (Section 198.0261 RSMo) requiring that prompt remedial action be taken to address Class I violation(s). MO00208742

Based on interview and record review, the facility staff did not follow their Abuse Prohibition policy and immediately report an incident of employee to resident abuse. A certified nurse aide (CNA) witnessed an agency nurse forcing a syringe of medications into a resident's closed mouth, while the resident protested and was restrained by his/her spouse. This affected one of three sampled residents (Resident #4). The census was 121. Review of the facility's policy titled, Freedom from Abuse, Neglect and Exploitation Policy and Procedure, developed 11/27/17, showed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraints not required to treat the resident's medical symptoms. An owner, licensee, administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. All new employees or volunteers were to receive training on the abuse, neglect and exploitation policy prior to direct or indirect resident contact. The facility was to provide identification, ongoing assessment, and care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Employees must always report any abuse or suspicion of abuse immediately to the administrator. If a family member, resident representative or resident was possibly contributing to the potential abuse and the resident could be at risk, then the situation was to be evaluated and options identified and put into place for resident protection. The facility will ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that may constitute a reasonable suspicion of a crime are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including the state survey agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures. Review of Resident #4's undated face sheet, showed his/her spouse listed as durable power of attorney (DPOA) for health care and finances (allows an individual/agent to make decisions regarding the resident's health care and finances, if the resident is unable to make decisions or communicate due to severe illness or injury). Review of the record, showed no DPOA on file, nor was there documentation by a physician of the DPOA enacted due to incompetency by the resident. Review of CNA B's written statement, dated 10/16/22, showed on 10/16/22 the resident's spouse activated the resident's call light and requested ice water. As CNA B was leaving, the spouse came out of the room and also asked the nurse (Nurse A) to give the resident some medications for pain. As CNA B was coming back to the room, the spouse asked the nurse to put the medications into the resident's mouth. The resident said no. So, the resident's spouse started holding the resident's arms and legs and told the nurse to go ahead and do it. The spouse said to put it into the resident's mouth, because the resident had brain cancer and did not know if he/she was in pain. CNA B said to the nurse, you can't do that. The nurse and spouse said that the nurse could, that it was in the resident's chart. So, the nurse put the medications in the resident's mouth. The resident started spitting it out, angering the spouse. CNA B and the nurse walked out of the room. CNA B asked the nurse, are you sure about what you just did? The nurse said yes, that he/she was going by what was in the resident's chart. However, it did not look right to CNA B. The nurse said that everything was in the computer regarding the resident's medications and what was going on with his/her brain cancer. CNA B said,okay, I was just asking because I don't have all that information. But, it just don't look good, that's all and I'm sorry if that's what it says and I know that you're the charge nurse. But, I was just asking. The nurse said it was okay, that everything is in here, that the resident was okay and would be fine. Review of the resident's progress notes, showed no entry on 10/16/22 involving medication administration by Nurse A. Review of Nurse A's statement, dated 10/19/22 at 1:18 P.M., showed the resident's spouse came out of the door (to his/her room) and signaled for Nurse A and the CNA to come in. After the spouse said it was time for the resident's medicine, Nurse A put the first syringe by the resident's mouth and tried to administer the medication. Half of it got into the resident's mouth, before his/her hand came up and pushed the nurse's hand. The resident moved his/her head. Nurse A tried to go back towards the resident's mouth with a syringe and he/she moved his/her head again. The spouse was trying to soothe the resident to take it, but he/she was very agitated. He/she started kicking and swinging his/her hands. The spouse asked if Nurse A could give the next medication, so Nurse A tried to put the syringe of medication by the resident's mouth again. The resident was moving his/her head and spitting. He/she was kicking hard and the spouse was trying to hold the resident's legs down. Nurse A told the spouse that the medication was not getting into the resident's mouth. Review of the facility's self-report cover sheet, e-mailed on 10/19/22, showed the alleged incident involving the resident, Nurse A and the resident's spouse showed since the resident's admission on 10/13/22, the resident's spouse continued to ask for increases in pain and agitation medications without the consent of the resident. The resident's spouse was insisting that the nurses administer medications to the resident which were not warranted based on pain observations and resident consent. The resident could voice pain levels and refuse medications, but the spouse was insisting that the staff follow the spouse's instructions on providing pain and agitation medications. The administrator and Director of Nursing (DON) spoke with the resident's hospice company, in order to ask for additional assistance on communication to the spouse of the protocols the facility must follow when administering routine and PRN medications. During an interview on 11/8/22 at 3:00 P.M., the resident said on the day in question, Nurse A brought in three syringes of medication and did not identify what medications the syringes contained or ask the resident if he/she wanted to take the medications. The resident verbally declined them. His/her spouse said he/she was going to get them anyway. Without saying anything, Nurse A attempted to administer the first syringe. The resident was pushing it away. He/she fought to keep the syringe away from his/her mouth, so his/her spouse held him/her down. The resident said, no, I don't want it. Nurse A pushed another syringe into the resident's mouth. CNA B said, what are you doing? You ain't supposed to be doing that. Nurse A pushed the third syringe into the resident's mouth. The liquid medication was going into his/her mouth so fast, he/she was forced to swallow some of it. The resident resisted with all of his/her strength, but he/she was weak and helpless. All he/she could do was turn his/her head away. Some of the medication went up his/her nose, and some went all over his/her face and dried there. The medications the resident was forced to swallow drugged him/her to the point that he/she could not move or think clearly that night. All he/she could do was lie there with tears streaming out of his/her eyes. He/she found the incident very distressing and felt that it was physical and mental abuse. Afterwards, the resident was so fearful of staff, he/she did not want to be touched or drink any water (believing his/her spouse was adding the liquid morphine to it). The resident began declining all medications, as well as food and water fearing they contained medication. Without the pain medication in his/her system, the resident said he/she could think clearly and regained the ability to walk unassisted. The resident got him/herself off of hospice and discharged from the facility. After leaving the facility, he/she did not sleep through the night. Every time he/she heard a noise, he/she woke up afraid, thinking that someone was coming to administer medication. During an interview on 11/4/22 2:50 P.M., the resident's spouse said on the day in question, the resident did knock Nurse A's hand away and turn his/her head as Nurse A administered the first syringe of medication. He/she tended to resist all medications, because he/she did not believe in them. The spouse said, [NAME], we need to take this for your anxiety. The spouse did not recall the resident swinging his/her hand or kicking or crying out. The spouse did not hold down the resident's arms or legs. The spouse just rubbed the resident's stomach and chest, in order to calm him/her down. The resident was not agitated and shouting. He/she did say he/she did not want to do the medications anymore. Nurse A could not get the next syringe past the resident's lips. The spouse could not recall how many syringes of medication Nurse A attempted to administer, but recalled that the resident would not take any more medication. During interviews on 10/28/22 at 2:30 P.M. and 11/8/22 at 3:00 P.M., Nurse A said on 10/16/22 at 2:00 P.M., Nurse A administered one syringe of medications via the corner of the resident's closed mouth. Half of it went in, before the resident moved his/her head to the side. Nurse A tried again, attempting to stick a second syringe of medications in through the corner of the resident's mouth. The resident started kicking and swinging his/her arms. His/her spouse pushed the resident's legs back down and held them. When the resident swung at the spouse, he/she grabbed his/her arms and held them down. Nurse A had tried to push the syringe into the resident's mouth, but the resident resisted and had his/her mouth locked. A week after the incident occurred, the DON called Nurse A, informed him/her the facility was conducting an investigation, requested a written statement and told Nurse A he/she should have stopped when the resident refused the medications and told the resident that Nurse A would return later to attempt the medication pass. Nurse A last worked at the facility a year ago. Prior to the incident, Nurse A had not received any education on the facility policies and no one informed him/her there was a binder at the nurse's station containing facility policies. During interviews on 10/28/22 at 2:30 P.M. and 11/8/22 at 3:00 P.M., CNA B said on 10/16/22, CNA B believed what he/she had witnessed was abuse, due to the resident having been held down while Nurse B administered medications even though the resident's teeth were clenched together and the resident was crying out for his/her daughter. CNA B was also aware he/she was supposed to report any observed or suspected abuse within two hours. However, when the resident's spouse and Nurse A both said the resident's confusion was documented in the resident's chart, CNA B felt continuing to question their actions may have been overstepping CNA B's bounds. He/she started thinking that perhaps, the resident did not know what he/she was doing in refusing the medications and fighting during medication administration. His/her spouse said the resident needed the medication. The incident occurred during the day shift on Sunday (10/16/22). The incident continued to bother CNA B, because it just didn't look right. So, CNA B reported it the next time he/she worked, which was Tuesday (10/18/22). He/she went to Social Worker D and started asking questions.On 11/8/22, the DON spoke with CNA B about the requirement to report abuse within two hours of suspecting, observing or learning of it. There was now a paper at the nurse's station listing phone numbers for the DON, administrator and management. It was the first time, since the incident, that anyone had spoken to CNA B about his/her delay in reporting the incident. During interviews on 11/7/22 at 4:06 P.M. and 11/8/22 at 3:22 P.M., Social Worker D said CNA B reported the allegation of the resident's spouse holding the resident down while the nurse administered medications against the resident's wishes to Social Worker D on Tuesday (10/18/22). Social Worker D was on his/her way to a care planning meeting at the time and instructed CNA B to go and tell the administrator. After learning of the incident, Social Worker D spoke to the resident who said he/she recalled being held down, after saying he/she did not want the medications and the nurse gave it to him/her anyway. The resident said Nurse A was trying to put it into the resident's mouth while the resident's teeth were gritted. During interviews on 10/21/22 at 10:10 A.M. and 11/4/22 at 1:29 P.M., the DON said she had not observed any indications the resident needed pain medication or haldol to keep him/her calm. As the days progressed, the resident increasingly clenched his/her teeth during med pass. The nurses were verbally instructed, shift by shift, via the outgoing nurse during the change of shift report, to inform the resident whenever they were about to administer morphine. They were told not to administer it, if the resident declined it. The spouse wanted them to force the medications into the resident's mouth. The DON expected the nurses to know if a resident declined medications, then they were not to administer it. Based on nursing judgment, nurses should know that a line was crossed, if a family member held down a resident. They should go and get a nursing supervisor. The facility did not provide training or orientation to temporary staff regarding facility policies. However, agency staff were informed there was a resource binder at each nurses station, to which they could refer for facility policies as guidance on how to handle difficult situations. Based on the facility's resident rights policy, a resident had the right to refuse medications. A nurse forcing a resident to take medications against their will was a form of abuse. During an interview on 11/7/22 at 2:37 P.M., the Administrator said the incident occurred on 10/16/22, but CNA B reported the incident and actually wrote his/her witness statement on 10/18/22, which was the next day he/she worked. Social Worker D said CNA B reported the incident to Social Worker D on Tuesday (10/18/22). The facility reported the allegations to DHSS the same day, via the self-report cover sheet and the written statements of Nurse A and CNA B, because they realized Nurse A and the resident's spouse physically and mentally abused the resident. The Administrator expected staff to report abuse allegations immediately to the charge nurse. CNA B had undergone training on the abuse and neglect policy in the past. During those sessions, other employees in the chain of command were identified to whom he/she could report abuse allegations. CNA B also received a list of contact phone numbers for those individuals. The DON said after the incident, she informed CNA B the abuse allegations should have been reported immediately. The Administrator felt Nurse A and the resident's spouse engaged in mental and physical abuse of the resident on 10/16/22. Individuals from temporary agencies working in the facility were considered contracted employees. MO00208742

Based on observation, interview and record review, the facility failed to ensure food was served palatable and at a safe and appetizing temperature during meal service by failing to maintain the temperature of hot food at least at 120 degrees Fahrenheit (F) for two of two meals sampled. The census was 128. 1. During an interview on 10/13/21 at 12:07 P.M., three of six residents in the rehab dining area said on a scale from one to ten, the food is rated a five and is often luke warm. 2. Review of Resident #102's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/13/21, showed: -Cognitively intact; -Diagnoses included non-traumatic [CONDITION(S)] and anxiety disorder. During an interview on 10/12/21 at 1:00 P.M., the resident said the food is not the best. He/she had to ask staff to cut his/her food for him/her because it is served with plastic utensils and on Styrofoam. The facility has been serving meals like this ever since COVID-19 began. He/she would like regular utensils and plates. 3. Observation on 10/14/21 at 8:02 A.M., of a sampled breakfast meal tray, showed the eggs measured 104 degrees F and the meat measured 98 degrees F. 4. Observation on 10/14/21 at 11:18 A.M., showed the dietary staff began to prepare the food on the steam table located in the Memory Care unit. At 11:30 A.M., staff began to put the food inside Styrofoam containers. At 11:45 A.M., staff transported approximately 14 Styrofoam containers on a cart to the Rehab unit. There were eight residents seated in the dining room in the Rehab unit. At 11:49 A.M., the first resident was served in the Rehab unit. At 12:03 P.M., all eight residents seated in the dining room were served their meal. The residents were served cheeseburgers and French fries. Certified Nurse Aide (CNA) V began to transport the rest of the Styrofoam containers when the surveyor sampled one for a test tray. At 12:05 P.M., the surveyor used a calibrated electronic thermometer to take the temperature of the meal. The cheeseburger had a temperature of 91.2 degree F. The cheeseburger was cold to the touch and the cheese slice was not melted. The French fries had a temperature of 84.8 degrees F. The French fries were cold, soft and limp. During an interview on 10/14/21 at 12:08 P.M., CNA V said he/she microwaves the Styrofoam containers before the residents are served in their room. He/she did not microwave the food for the residents in the dining room because they were served first and the food was still hot. During an interview on 10/14/21 at 12:18 P.M., Resident #79 confirmed he/she ate in the dining room. The cheeseburger was cold and it had a charcoal taste to it because it was likely the frozen kind. The French fries were cold as well. The food that is served is often cold. 5. During an interview on 10/14/21 at 1:30 P.M., three out of seven residents at the resident council meeting said the cheeseburgers were cold at lunch. They ate their meal in the Cardinal cafe. They described it as a cold burger with a cold piece of cheese on it. All seven residents agreed the eggs at breakfast are cold. The majority of the food is served warm in the Cardinal cafe, so they are surprised when food is actually served hot. 6. During an interview on 10/18/21 at 9:17 A.M., the dietary manager (DM) said the staff records the temperature of the food prior to it being served to the residents. The DM said the food temperatures for hot food should be over 135 degrees F on the steam table and for meal services and the cold items should be under 40 degrees F. The DM said low temperatures are not acceptable. The expectation is if the temperatures are under the required temperature, the food should be brought back to the kitchen. The DM said the lead server or the cook should ensure this is done. MO 853

Based on observation, interview and record review, the facility failed to ensure each resident is treated with dignity and respect. Staff complained about their workload and lack of knowledge of the job in front of a resident, called the resident's brief a diaper, talked about the resident's personal conditions loud enough for the roommate to hear, and talked amongst each other and not with the resident during care (Resident #102). Staff took a soda away from one resident without first discussing it with the resident or offering choices (Resident #84). Staff failed to ensure privacy during care when they failed to pull a privacy curtain resulting in a visitor walking into the room with the resident exposed and failed to close the window blinds as cars drove past the room during care (Resident #29). Staff failed to serve residents' meals timely in the main dining room as tablemates ate and staff stood over one resident to assist him/her with the meal (Resident #44). Staff failed to treat a resident with dignity when telling a resident to hurry up (Resident #475). In addition, staff served resident meals in Styrofoam containers and with plastic utensils for all meals observed during the survey (Resident #119). The census was 128. 1. Review of Resident #102's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/13/21, showed: -Cognitively intact; -Extensive assistance required for bed mobility, dressing, toilet use and personal hygiene; -Total dependence, two staff assistance required for transfers; -Always incontinent of urine, frequently incontinent of bowel; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, dated 9/14/21, showed: -Problem: Needs assistance with activities of daily living (ADLs) due to pain and weakness; -Goal: Maintain current ADL function; -Approach: Transfer Hoyer lift (mechanical lift), bathing and bed mobility assist of one. Observation on 10/14/21 at 8:12 A.M., showed Certified Nursing Assistant (CNA) M and CNA L provided care to the resident. The resident lay in bed on his/her left side with the left side of the bed against the wall. CNA M and CNA L looked at the bed and said to each other that they are both agency and neither knows how to work the residents bed to get it away from the wall. CNA M said loudly and in a complaining tone that it would be hard to provide care because he/she does not know how to work the facility's equipment. At 8:20 A.M., Licensed Practical Nurse (LPN) N entered the room. CNA L told the resident that they were going to remove his/her diaper. CNA M asked LPN N if he/she knew how to move the bed and LPN N said no, looked around at the bed, and then assisted the CNAs to drag the bed across the floor. CNA L moved to the left side of the bed, between the bed and wall and assisted the resident to his/her left side and removed his/her brief. The resident appeared to have a rash on his/her buttocks. CNA L asked CNA M if the resident had any cream. CNA M said, I don't know, I don't know these people. CNA L said loudly that he/she needs the cream because the resident is broke down on his/her butt. Observation at this time, showed the resident's roommate on the other side of the curtain, awake. LPN N and CNA M exited the room. CNA L continued to assist the resident with care. He/she rolled the resident side to side and said, I'm gonna pull the diaper between your legs in case of an accident. CNA L pulled the resident's brief between the resident's legs and said loudly enough for the roommate to hear, he/she probably has breakdown cause of the diaper too tight. CNA M and LPN N entered the room with a cup of cream and CNA L applied the cream to the resident's buttocks and said loudly I'm trying to make sure the diaper not too tight. Both CNAs assisted the resident to get dressed and placed the Hoyer lift pad under the resident. CNA M said Jesus they done say this man/lady was a Hoyer but [NAME]! The tone sounded to be complaining and the voice was loud. Both CNAs transferred the resident with the use of the Hoyer lift from the bed to the wheelchair and talked amongst each other and talked over the resident during the entirety of the transfer. Neither staff talked directly to the resident or explained the steps in the process during the transfer. At times during the transfer, the resident started to talk, but staff never responded or acknowledged if they heard the resident. During an interview on 10/18/21 11:45 A.M., with the administrator and Director of Nursing (DON), they said staff should speak respectfully to residents. It is not appropriate to call a brief a diaper in front of the resident. It is not appropriate to complain about the job, about not knowing the job, or about the workload in front of the resident. 2. Review of Resident #84's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Supervision with eating; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/12/21 at 11:55 A.M. of the main dining area, showed the resident sat at a table eating his/her lunch and drinking a soda. Nurse T went to the resident and took the soda out of the resident's hand and said you have a Urinary Tract Infection ([CONDITION(S)]), you can't have this soda. Nurse T did not ask the resident if she could take the soda. During an interview at that time, the resident said he/she did not know what was going on and he/she did not like the fact Nurse T took the soda out of his/her hand. 3. Review of Resident #29's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Extensive assistance required with transfers, dressing, toilet use and personal hygiene; -Frequently incontinent of bowel and bladder; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident's care plan, dated 8/3/21, showed: -Problem: Needs assistance with ADLs; -Goal: Maintain current ADL function; -Approach: Bed mobility, bathing, dressing and grooming assist with one. Transfers with two assist using gait belt and wheelchair. Ability to assist fluctuates. Observation on 10/15/21 at 9:25 A.M., showed Nurse I entered the resident's room to perform care. The resident had a large window at the back of his/her room with a valance to cover the top. The resident had blinds but the blinds were pulled up so only half of the window was covered. During an interview with the resident before the nurse started care, the resident said everyone can see in his/her window and see everything too. The nurse performed the first part of the resident's care to both of the resident's lower extremities. The nurse pulled the privacy curtain that was at the end of the resident's bed. The privacy curtain only partly covered the view of the resident. The resident's stomach and left hip were exposed. The nurse changed gloves, looked out of the window and wiped under resident's stomach with a normal saline soaked gauze, then wiped by the resident's left hip. The nurse then patted the areas dry with a dry gauze and applied the prescribed powder on the areas. The nurse changed gloves, checked the paper orders, and pushed the call light. The nurse said he/she would need help with the rest of the care. A staff member came into the room, shut the door and began talking to the nurse with the resident exposed. The nurse stopped putting powder on the resident to talk to the staff member about medication counts and instructed the staff person to send a CNA into the room. The staff member left the room and the nurse continued to place powder on the resident. The nurse re-secured the left side of the resident's brief. The resident voiced that he/she wanted to be put in the chair that was in the room. CNA D knocked and entered the resident's room. The CNA stood next to the resident's head of the bed. The CNA then closed the resident's blinds and lowered them to the window sill. The nurse told the CNA, oh thank you. The CNA assisted the nurse with the resident's care. While the resident lay on his/her left side receiving personal care, a knock was heard at the door and a person came in about two steps. The nurse said, we are performing a treatment. The person left the room. The nurse and the CNA continued performing care to the resident. During an interview on 10/18/21 at 10:19 A.M., the DON said if the resident has a private room she would not necessarily expect the privacy curtain to be closed all the way but if there was any chance that someone could have seen in the resident's room then the blinds should have been closed. 4. Review of Resident #44's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Limited assistance with bed mobility, personal hygiene, dressing, and transfer assist with one; -Supervision, oversight, encouragement, or cueing with eating; -Extensive assist with toileting; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident's care plan, dated 8/17/21, showed: -Problem: Needs assistance with ADLs; -Goal: Maintain current ADL function; -Approach: Bed mobility assist with one, bathing assist with one, dining location-Hope assist as needed. Observation on 10/12/21 at 11:30 A.M. showed, the resident sat at a table in the Hope dining room with another resident. CNA F sat at a different table with two resident's and fed them lunch. One of the resident's table mates was served lunch in a Styrofoam container at 11:30 A.M. and the other was served lunch in a Styrofoam container at 11:40 A.M. At 11:47 A.M., Resident #44 was observed in a Broda chair (medical reclining wheeled chair) at the table. The resident had a closed Styrofoam container in front of him/her and two cups behind the container. At 11:50 A.M., the resident tried to open his/her silverware and spilled some of his/her drink. The resident across from him/her told the resident, you're making a mess. At 11:55 A.M., CNA F got up from the other table and talked to other staff in the dining room. At 11:56 A.M., a staff person served residents in the dining room their dessert in small Styrofoam bowls. He/she placed a dessert bowl in front of Resident #44, next to the unopened Styrofoam container of food. CNA F walked back to the table that he/she had left and sat back down. Resident #44 reached for the dessert bowl and was unsuccessful. At 12:02 P.M., the resident tried to pull the dessert towards him/her. At 12:04 P.M., CNA F left the table with the two residents that he/she had been helping and went to the resident's table. The resident's tablemate requested a refill of his/her drink from CNA F. The CNA left the table, came back to the table with the drink, then opened up Resident #44's food. At 12:06 P.M., CNA F started feeding Resident #44. CNA F stood over the resident while assisting the resident. The CNA wiped the resident's face and shirt and then assisted with the other resident's in the dining room. During an interview on 10/18/21 at 11:45 A.M., the administrator and DON said all residents at a table should be served at the same time. It would not be dignified for a resident to watch the person across from them eat while they have to wait to be fed. It is not dignified to stand over a resident while feeding them. 5. Review of Resident #475's care plan, dated 10/13/21, showed: -Problem: Needs assist with ADLs; -Goal: Maintain current ADL function; -Approach: Bed mobility assist with one, dining location-rehab dining assist as needed, personal devices-hearing aids and glasses; -Problem: Hearing impairment, has hearing aids; -Goal: To communicate within limitations over the next 3 months; -Approach: Get attention before speaking and increase voice volume. Observation on 10/13/21 at 4:12 P.M., showed CNA E entered the resident's room. The CNA asked the resident if the resident wanted to go to the dining room. The CNA stated I need a yes or no, I have a lot to do. The resident and the CNA came out of the resident's room and the CNA propelled the resident to the rehab dining room. During an interview on 10/18/21 at 11:45 A.M., the DON and the administrator said their staff should speak respectfully to the residents. A staff member telling a resident they need an answer because the staff has a lot to do would not be respectful to a resident. 6. Observation on 10/12/21 at 8:30 A.M., of the breakfast meal service in the main dining room, showed the meal served on Styrofoam plates with plastic utensils. The drinks were served in Styrofoam cups. Observation on 10/12/21 at 11:35 A.M., of lunch meal service in the memory care unit, showed the meal served in Styrofoam containers with plastic utensils. Observation on 10/12/21 at 11:45 A.M., of lunch meal service in the Cardinal cafe, showed the meal served in Styrofoam containers with plastic utensils. Observation on 10/13/21 at 12:09 P.M., of lunch meal service on [NAME] Hall, showed the meal served in Styrofoam containers with plastic utensils. Observation on 10/14/21 at 7:44 A.M., of the breakfast meal service on John hall, showed the meal served in Styrofoam containers with plastic utensils. Observation on 10/14/21 at 12:05 P.M., of lunch meal service on the memory care unit, showed the meal served in Styrofoam with plastic utensils. Observation on 10/14/21 at 4:18 P.M., of dinner meal service in the Cardinal cafe, showed the meal served in Styrofoam with plastic utensils. Review of Resident #102's quarterly MDS, dated [DATE], showed: -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/12/21 at 1:00 P.M., the resident said the food is not the best. He/she had to ask staff to cut his/her food for him/her because it is served with plastic utensils and on Styrofoam. The facility has been serving meal like this ever since COVID-19 began. He/she would like regular utensils and plates. During an interview on 10/18/21 at 9:21 A.M., the Dietary Manager (DM) said the administrator instructed him to use the Styrofoam because they were under staffed in the kitchen. The DM said they have been using the Styrofoam for the past couple of months.

Based on observation, interview and record review and in accordance with Centers for Disease Control and Prevention (CDC) guidelines for 2019 Novel Coronavirus disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome coronavirus 2 ([DIAGNOSES REDACTED]-CoV-2). Common symptoms include fever, cough, fatigue, shortness of breath, and loss of smell and taste), the facility failed to protect residents in the facility by not following acceptable infection control practices for COVID-19. The facility placed a resident (Resident #3) who had an increased risk of infection, was receiving [MEDICAL CONDITION], had tested negative for COVID-19 and did not meet the definition to be placed on the COVID-19 unit per facility policy, on the Veronica Hall COVID-19 unit. During meal service, staff failed to remove potentially contaminated gloves and gown after entering a room of a resident positive for COVID-19 (Resident #5) and before entering the room of Resident #3. Three residents (Residents #12, #10 and #11) tested positive for COVID-19 and were transferred to Veronica Hall between the dates of [DATE] and [DATE], when the facility transitioned the Veronica Hall into the COVID-19 unit. A resident (Resident #8) was a resident on Veronica Hall prior to it becoming the COVID-19 unit, was negative for COVID-19 at the time Veronica Hall was transitioned to the COVID-19 unit and was not moved off the unit. He/she later tested positive for COVID-19. The resident expired on [DATE]. The facility failed to ensure a resident (Resident #9), identified as a person under investigation (PUI) for COVID-19, remained off of the positive COVID-19 unit while test results were pending. The resident never tested positive for COVID-19 and remained on the unit from [DATE] until [DATE]. In addition, the facility failed to follow acceptable infection control practices when they failed to post notice of contact precautions for one resident (Resident #1) with [MEDICAL CONDITION] ([MEDICAL CONDITION], a bacterium that causes diarrhea) which resulted in a staff person entering the room without the required personal protective equipment (PPE) and failed to follow proper infection control practices when checking a resident's blood sugar level (Resident #4). At the time of the survey, the Veronica Hall COVID-19 unit contained 13 residents. Of those 13 residents, four had not been identified as positive for COVID-19 on the facility's COVID-19 tracking log as of [DATE]. This failure had the potential to affect all residents determined by the facility to be PUI. The resident sample was 12. The census was 98. The administrator was notified on [DATE] at 2:25 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the CDC.gov website, updated [DATE], showed Preparing for COVID-19 in Nursing Homes: -These recommendations supplement the CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings and are specific for nursing homes, including skilled nursing facilities; -If extended use of gowns is implemented as part of crisis strategies, the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohort in the same area of the facility and these residents are not known to have any co-infections (e.g., [MEDICAL CONDITION]); -Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19: -Identify health care providers who will be assigned to work only on the COVID-19 care unit when it is in use; -Have a plan for how residents in the facility who develop COVID-19 will be handled: -Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of [DIAGNOSES REDACTED]-CoV-2 testing. They should not be placed in a room with a new admission nor should they be moved to the COVID-19 care unit unless they are confirmed to have COVID-19 by testing. While awaiting results of testing, health care providers should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Cloth face coverings are not considered PPE and should only be worn by health care providers for source control, not when PPE is indicated. Review of the facility's COVID-19 Action Plan, dated [DATE], showed: -Policy statement: As of today, the following action plan captures the most up to date information enabling the facility to be proactive in adopting practices to keep our residents, staff, and visitors safe. The practices are based on infection prevention and control recommendations from the CDC and World Health Organization (WHO) and is based on the currently limited information available about COVID-19. The information is subject to change as more information becomes available; -Background: [MEDICAL CONDITION] that causes COVID-19 places residents at senior living and skilled nursing communities at the highest risk. The incubation period is two to 14 days and there are reports of transmission before a patient is symptomatic. Current symptoms have included mild to severe respiratory illness with fever, cough, and difficulty breathing. It has also been determined older adults and individuals with severe chronic medical conditions, such as heart, lung or kidney disease are at higher risk. Person to person transmission most commonly occurs during close exposure to a person infected with COVID-19, primarily via respiratory droplets produced when the infected person coughs or sneezes. Droplets can land in the mouths, noses or eyes of people who are nearby or possibly be inhaled into the lungs of those within close proximity. It may also be possible that a person can get COVID-19 by touching a surface or object that has [MEDICAL CONDITION] on it and then touching their mouth, nose or possibly their eyes; -Definitions: -Standard Precautions: Infection prevention practices that apply to all residents, regardless of suspected of confirmed [DIAGNOSES REDACTED]. Standard precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, regardless of whether they contain visible blood, non-intact skin, and mucous membranes may contain transmissible infectious agents; -Transmission based precautions: The second tier of basic infection control are to be used in addition to standard precautions for patients who may be infected of colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission; -Contact precautions: Procedures that reduce the risk of spread of infections through direct or indirect contact. Transmission occurs with physical contact of the infected patient or handling of a contaminated object in the infected patient room; -Droplet precautions: Refer to actions designed to reduce/prevent the transmission of pathogens (harmful microorganisms) spread through close respiratory or mucous membrane contact with respiratory secretions; -PPE: Protective items or garments worn to protect the body or clothing from hazards that can cause an injury and to protect residents from cross-contamination. This includes but is not limited to gloves, gowns, goggles, facemasks or respirators; -Cohort: Practice of grouping residents infected with the same infectious agent together to confine their care to one area and prevent contact with susceptible residents. During outbreaks, healthcare staff may be assigned to a specific cohort of resident to further limit opportunities for transmission; -Hand hygiene: Cleaning one's hands that substantially reduces potential pathogens on the hands. Hand hygiene is considered a primary measure for reducing the risk of transmitting infection among patients and health care personnel. Hand hygiene procedures include the use of alcohol based hand rubs (ABHR, containing 60 percent (%)-95% alcohol) and hand washing with soap and water; -Proactive approach to keep residents, staff and visitors safe: The infection preventionist (IP) will provide education on hand hygiene, use of PPE to include donning (placing on) and doffing (removal), utilization of standard precautions; -Preventing the spread of COVID-19: In an effort to prevent the potential spread of the disease, the following will be implemented for each skilled nursing facility (SNF): -Transition area: Each community will develop a plan that includes an identified area or group of rooms that will be utilized for all residents that have been newly admitted or readmitted to the community and their COVID-19 status is negative or unknown and for current residents that have had a sudden onset of fever greater than 100.0 degrees and/or respiratory symptoms, but have not tested positive for COVID-19; -Recovery area: Each community will develop a plan that includes an identified area or group of rooms that will be utilized for residents that are admitted or readmitted to the community that have been tested and are COVID-19 positive or are current residents that have been tested and are COVID-19 positive; -These two areas will be in separate areas within each community; -A plan for consistent staffing for each of these SNF units will be developed to the best ability of the community; -Suspected COVID-19 positive (sudden onset of fever above 100 degrees and/or respiratory symptoms): -Move the resident to the transition area (private room if available, otherwise cohort with others with like symptoms or diagnoses); -Immediately place the resident on droplet precautions; -Provide isolation set up with gown, facemasks with shield or goggles, gloves and door signage; -Notify the medical provider of the change in condition; -Staff request an influenza (flu) swab, chest x-ray, blood work and perform in house COVID-19 testing; -While waiting for the results of laboratory values and COVID-19 testing, the resident will remain in the transition area; -If the resident's COVID-19 test is positive the resident will immediately be moved to the recovery area; -Staff perform respiratory assessment including vitals every shift; -CDC guidance for PPE: Gowns summary: -Extended use of isolation gowns (disposable or cloth), such as the same gown is worn by the same health care provider (HCP) when interacting with more than one patient know to be infected with the same infectious disease when these patients housed in the same location (COVID-19 patients residing in an isolation cohort). This can be considered only if there are no additional co-infection [DIAGNOSES REDACTED]. Review of the facility's hand hygiene policy, dated [DATE], showed: -Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility; -Definitions: -Hand hygiene: is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub or ABHR; -Policy explanation and compliance guidelines: -Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; -ABHR is the preferred method for cleaning hands in most clinical situations. Wash hands whenever hands are visibly dirty, before eating and after using the restroom; -The use of gloves does not replace hand hygiene. If the task requires gloves, staff should perform hand hygiene prior to donning gloves and immediately after removing gloves. 1. Review of Resident #3's medical record, showed the following: -[DIAGNOSES REDACTED]. -Progress notes, showed: -On [DATE] at 9:44 A.M., the resident left the facility for a [MEDICAL CONDITION] appointment; -On ,[DATE] through [DATE], no documentation of a coronavirus screenings noted; -On [DATE] at 8:52 A.M., the resident noted to have a temperature (T) of 99.1 (normal range is 97XXX,[DATE].8) Fahrenheit (F), the nurse practitioner (NP) was notified, no new orders received; -At 11:32 A.M., a nasal swab was obtained for COVID-19; -At 1:14 P.M., a call was received from the resident's NP and a new order to test the resident for COVID-19 ordered; -At 3:40 P.M., the resident was moved to the Veronica hall COVID-19 unit. Review of the resident's electronic physician order [REDACTED]. -an order for [REDACTED].>-An order to monitor respiratory status every shift. Notify the physician of any changes; -An order to monitor vital signs every four hours. Notify the physician of any acute changes. Further review of the resident's progress notes, showed: -On [DATE] at 8:40 P.M., the laboratory called with critical low hemoglobin (HGB, indicator of [MEDICAL CONDITION]) level. The resident's HGB was 6.9, the physician was notified, and an order received to send the resident to the hospital. At 8:35 P.M., the resident left by ambulance to go to the hospital; -On [DATE] at 7:51 P.M., the resident readmitted to the facility and arrived by ambulance and in route to the Veronica Hall COVID-19 unit in a wheelchair. The resident admitted with a left shoulder fracture and a sling to left shoulder on and intact. Circulation and sensation intact. Diagnosis: [REDACTED]. Review of the resident's hospital discharge summary of care, dated [DATE], showed: -[DIAGNOSES REDACTED]-COV-2 (Covid-19) test: none detected; -an order for [REDACTED]. Four cycles of [MEDICAL CONDITION]. Each cycle of [MEDICAL CONDITION]: 21 days of Capecitabine with seven days off. Start date: [DATE]; -Diagnosis: [REDACTED].>-Next steps include an appointment [DATE] to [MEDICAL CONDITION] treatment infusion center; -Covid-19 prevention: Wash your hands frequently and practice appropriate social distancing, for more information a link was provided for CDC, coronavirus 2019, prepare and prevent website; -Drug education information: Capecitabine is an anti-cancer [MEDICAL CONDITION] drug. Side effects that are common, occurring in greater than 30% of patients included low white blood cell count. This can put the patient at increased risk for infection. Side effects occurring in about ,[DATE]% of patients included fever. During an interview on [DATE] at 8:35 A.M., Licensed Practical Nurse (LPN) E said the Veronica hall is the unit with residents who have tested positive for COVID-19 or are considered PUI. Review of Resident's #5's medical record, showed: -Resided on the Veronica Hall since [DATE]; -[DIAGNOSES REDACTED]. -A progress note, dated [DATE] at 11:14 A.M., showed the resident's Covid-19 test results are negative; -The resident's census report, showed the resident remained on the Veronica Hall during the time it transitioned to the COVID-19 unit; -A progress note, dated [DATE] at 12:03 P.M., a nursing note: A nasal swab obtained for COVID-19 with the resident's consent. The specimen ready for pick up; -Review of the COVID-19 laboratory report, showed: -COVID-19 sample collected on [DATE] at 9:43 A.M.; -Reported results: Positive; -Further review of the progress notes, showed on [DATE] at 1:14 P.M., the facility received the resident's COVID-19 test results. The resident tested positive. Observation on [DATE] of the Veronica hall COVID-19 unit, showed: -At 8:39 A.M., the fire doors closed and four signs posted on the outside of the fire doors: -An 8 x 11 inch laminated paper stated Stop, contact and droplet precautions in addition to standard precautions; -A sign Stop droplet precautions. Everyone must clean hands before and after entering and exiting rooms. Make sure eyes, nose and mouth are covered before room entry and remove face protection before room exit; -A sign All staff must wear N95 mask at all times in patient care areas; -A picture display instructing persons how to don and doff a surgical mask and apply hand sanitizer; -At 11:26 A.M., a food cart contained approximately 13 Styrofoam container meals left on the unit just inside the closed fire doors. The top level of the food cart contained beverage pitchers and disposable utensils. The lower level contained multiple pieces of dessert covered with a single sheet of large plastic wrap; -At 11:30 A.M., two certified nurse aides (CNAs) wore N95 masks, approached the meal cart and donned disposable isolation gowns, gloves and a face shield from an isolation PPE cart outside of the first occupied room at the top of the hall and started passing the meals to resident rooms; -The CNAs passed the individual meals, drinks and desserts to eight resident rooms without changing any of their PPE, including gowns and gloves. No hand hygiene performed between the different resident rooms. A CNA entered the room of Resident #5 (positive for COVID-19) and passed the tray. He/she exited the room with the same PPE and without performing hand hygiene, obtained a new food tray from the food cart and passed it to Resident #3 (negative for COVID-19); -At 12:00 P.M., observation of Resident #3's room, showed a sign on the door, which read contact precautions. The door stood open and a three drawer isolation supply container located outside the door. The resident walked without assistance to the doorway and talked to the staff. During an interview on [DATE] at 12:51 P.M., the IP said staff may don droplet PPE on the Veronica unit and pass individual meal trays to residents and wear the same PPE room to room. The staff must doff the worn PPE if the staff touch the resident in the room or provide any care, staff then should perform hand hygiene before leaving the room and then would don PPE before resuming the meal tray pass. The IP then said, at a minimum, all staff should be doffing and donning gloves and performing hand hygiene before entering and exiting any resident room. That is standard infection control practice. The Veronica unit houses both resident's considered PUI and active COVID-19 positive residents. If staff do not wash hands in between room passes that could increase the transmission of COVID-19 among the unit residents. Staff should have completely changed PPE, except the N95 masks, after passing a meal to Resident #5 and before passing a tray to Resident #3. During an interview on [DATE] at 12:20 P.M., the administrator said the residents who are on the Veronica Hall COVID-19 unit have either tested positive or are a PUI. Resident #3 was moved to the unit because he/she had symptoms of COVID-19. Resident #3's COVID-19 test results are pending. When the resident was readmitted to the facility, he/she was readmitted to the Veronica hallway because he/she would be under investigation/observation for 14 days, because the resident had been in the hospital. During an interview on [DATE] at 2:00 P.M., the administrator and the IP said Resident #3 had been moved onto the Veronica unit because he/she was having COVID-19 like symptoms. The resident had a temperature of 99.4 F, and the nurse practitioner ordered a COVID-19 test. Later that day the resident was sent to the hospital for critical labs. While the resident was at the hospital, the hospital obtained a COVID-19 test, and the results were negative and had been reported back to the facility when the resident was readmitted . When the resident was readmitted to the facility, the resident would be considered under investigation because he/she was in the hospital. If space allows, the facility tries to keep those residents who are admitted or readmitted to the facility at the top of the hallway in the rooms on the outside of the fire doors of the Veronica hall for transition or observation. These room are based on availability. When the resident was readmitted , those rooms were occupied, so the resident was admitted on the COVID-19 positive hallway, the Veronica unit/hall, for 14 days. At this time the laboratory had not provided the COVID-19 test results from the test taken at the facility. Typically, it takes 72 hours for the test results to come back. The administrator said the labs are struggling to keep the testing and result reporting timely due to the increase in testing. Anyone who is immunocompromised would be considered high risk for infection, examples included someone with the [DIAGNOSES REDACTED]. Resident daily COVID assessments would be located under the progress notes in each resident chart. Staff should be providing and documenting COVID assessments twice a day. At this time, Resident #3 remained on the Veronica hallway. During a phone interview on [DATE] at 9:32 A.M., the administrator said the Veronica hall is the only hall used to house both COVID-19 positive and PUI residents. For a resident to be able to come off of the Veronica hall, they must first receive two negative COVID-19 test results. During an interview on [DATE] at 12:17 P.M., Physician A, the physician for Resident #3, said he/she had not been aware the resident had been placed on the Veronica hallway, a COVID-19 positive unit. The resident [MEDICAL CONDITION] and is currently receiving [MEDICAL CONDITION]. Both [MEDICAL CONDITION] [DIAGNOSES REDACTED]. When he/she learned that the resident was living on the Veronica unit, he/she emailed the facility infection control nurse on [DATE] and instructed the facility to move the resident out of the unit due to his/her risk level. The resident should not have been placed on an active COVID-19 unit while his/her COVID-19 testing was pending. During an interview on [DATE] at 12:19 P.M., the IP said that Resident #3's physician had emailed him/her on [DATE] and instructed the facility to move the resident off of Veronica hall. The resident had received his/her second negative COVID-19 test shortly before the email had been received from the resident's physician and the resident had been free of symptoms for 72 hours and was already being moved to another unit. The resident will continue to be observed on his/her new unit for the continuation of the 14 day observation period since his/her first negative test result from the hospital. Observation on [DATE] at 12:20 P.M., at the entrance to Veronica Hall, showed a sign posted: Hand Hygiene before you go into a room. Hand hygiene when you come out of the room. This includes passing trays, doing one on one visits, dropping items off, etc. During an interview on [DATE] at 12:24 P.M., the IP said an N95 mask is required on the COVID-19 unit and all other PPE is placed on before entering the resident's room. During an interview on [DATE] at 12:28 P.M., Licensed Practical Nurse (LPN) B said N95 masks and face shields are reused for a week. Everything else is one time use. Gowns can only be worn in one room. 2. Review of information, sent by the facility on [DATE], showed: -Resident #12: -tested for COVID-19 on [DATE], the results returned positive on [DATE]; -On [DATE], transferred to Veronica hall; -Resident #10: -tested positive for COVID-19 at the hospital on [DATE]; -Returned to the facility on [DATE] to the Joachim Hall; -On [DATE], transferred to Veronica hall, the new COVID-19 unit; -Resident #11: -tested for COVID-19 on [DATE], the results returned positive on [DATE]; -On [DATE], transferred to Veronica hall. Review of Resident #8's medical record, showed: -admitted to the Veronica hall on [DATE]; -[DIAGNOSES REDACTED]. -A progress note, dated [DATE] at 11:17 A.M., showed a nasal swab obtained with patient's consent for COVID-19 test; -A progress note, dated [DATE] at 11:14 A.M., showed the facility received the resident's COVID-19 test back and the resident tested negative; -The resident's census report, showed the resident remained on Veronica hall as it was transitioned into the COVID-19 unit; -A progress note, dated [DATE]: -At 8:23 A.M., the resident's physician assessed the resident today. He/she was informed the resident placed on oxygen (O2) at 3 liters per nasal cannula on the night shift. The resident had no fever (afebrile) at 97.3 degrees F, pulse 95, respirations 18, blood pressure ,[DATE] and oxygen saturation (oxygen level in the blood, normal range is ,[DATE]% on room air) at 91% with 3 liters oxygen. The resident's eyes are closed and his/her lungs sounded clear but diminished; -At 8:34 A.M., a physician noted the resident was seen for [MEDICAL CONDITION] (low oxygen level); -At 8:59 A.M., the resident's oxygen saturation at 90% with 3 liters of oxygen applied. His/her lungs sounded diminished and noted a dry cough; -At 9:56 A.M., new orders received for chest x-ray for [MEDICAL CONDITION], retest the resident for COVID-19, apply oxygen to keep oxygen level at 90% or above, monitor oxygen saturation; -At 10:46 A.M., the chest x-ray obtained. The resident noted to lay resting quietly in bed; -At 2:20 P.M., new orders received to obtain a COVID-19 test; -At 3:01 P.M., a physician visit note: The resident assessed related to a change in condition. The facility nurse had reported the resident became hypoxic during the night (O2 saturation in the 80's on room air) and oxygen applied at 3 liters had been initiated. The nurse reported no distress and the resident observed to be lying in bed and staff assisted the resident to eat his/her breakfast. His/her room is currently situated in a hallway with lab confirmed positive COVID-19 patients. The treatment plan noted [MEDICAL CONDITION] and rule out pneumonia and COVID-19 virus infection. Check chest x-ray and nasopharyngeal swab for COVID-19. Adjust oxygen with pulse oximetry to keep oxygen saturation level at 90% or greater; -At 7:06 P.M., a nursing progress note: the resident's chest x-ray results reported to his/her physician. No new orders received; -Review of the resident's COVID-19 laboratory test results, showed COVID-19 test ordered and collected on [DATE] at 12:27 P.M. Results: Positive; -Review of the resident's room census sheet, showed on [DATE] the resident noted as admitted to hospice services and remained on the Veronica hallway; -Review of the progress notes, dated [DATE], showed: -At 9:21 A.M., the resident in bed unresponsive. The head of the bed noted to be elevated. His/her lungs are congested and respirations are labored at 30 breaths a minute (normal 12 through 20). Temperature 99.9 degrees F and his/her skin noted to be warm to the touch. Tylenol administered; -At 9:46 A.M., a call placed to the resident's physician and verified [MEDICATION NAME] (narcotic pain medication, can also be used to treat shortness of breath) orders; -At 10:02 A.M., ordered [MEDICATION NAME] administered for labored respirations. The resident's responsible party at the resident's bedside. The resident's oxygen saturation not registering on the pulse oximetry (device used to measure the percentage of oxygen in the blood); -Review of the progress notes, dated [DATE], showed: -At 8:31 A.M., New orders received from the resident's physician for comfort medications and to discontinue all other medications except comfort medications and oxygen. [DIAGNOSES REDACTED]. The resident is receiving hospice services; -At 8:30 P.M., the resident in bed. Head of bed elevated. Oxygen at 3 liters in use. The nurse notified by the CNA that the resident observed not to be breathing. Lungs sounds ceased and no heart rate. Time of death verified with another nurse. Hospice provider notified and the hospice nurse arrived to attend the resident. [DIAGNOSES REDACTED]. -At 11:31 P.M., funeral home received the resident remains. During a phone interview on [DATE] at 9:06 A.M., the administrator said Resident #8 had been living on the Veronica hallway for several months. As the facility's COVID-19 positive numbers increased and to help with facility staffing, the Veronica unit was turned into the COVID-19 unit. Resident #8 stayed on the Veronica hall during the transition since his/her room was already there. The Veronica hallway had been transitioned into the COVID-19 unit sometime in mid-June. Resident #8 had tested COVID-19 negative in June, then experienced a change in condition over a week later and had been retested . The facility obtained the test, but the results did not get reported to the facility before the resident's death. Staff presumed the resident had developed COVID-19 after the negative test result due to the symptoms he/she developed. The resident had been on the Veronica hall since [DATE]. 3. Review of Resident #9's medical record, showed: -A face sheet, included [DIAGNOSES REDACTED]. -A census report, showed on [DATE], the resident resided on the Magdalen Hall; -A COVID-19 lab report: -Collected [DATE]; -Result: Negative; -A progress note, dated [DATE]: -At 6:26 A.M., resident is complaining of pain upon urination and this nurse has called the exchange to leave a message for the doctor; -At 6:30 A.M., received call back from the doctor, new orders for STAT (immediate) urinary analysis (UA, lab to test for urinary tract infection). Orders put in lab, called lab stated they are not picking up STAT UA unless there is blood work; -At 12:05 P.M., urine collected, placed in fridge for pick up tomorrow; -No further documentation to show if the urine sample was picked up, if the resident had a urinary tract infection or other documentation of the UA as late as [DATE]; -A progress note, dated [DATE]: -At 8:57 A.M., no cough, sore throat, shortness of breath, loss of taste or smell, diarrhea, vomiting, fatigue or malaise. Headache, yes. Physician notified. Body aches, yes, arms; -At 8:59 A.M., the resident stated I'm not feeling good. I have a headache and my arms hurt. Vital signs included a temperature of 98.2 degrees F (within normal limits). Call placed to the physician; -At 10:29 A.M., received a call from the physician. Order obtained to do COVID-19 test; -At 12:01 P.M., COVID-19 nasal swab obtained with resident's consent; -At 12:28 P.M., transferred to Veronica hall as ordered; -A census report, showed the resident moved to Veronica Hall COVID-19 unit on [DATE]; -An order dated [DATE], for droplet precautions x14 days or until negative test; -A COVID-19 lab report: -Collected [DATE]; -Result: Negative; -A progress note, dated [DATE] at 12:21 A.M., showed dry cough; -A progress note, dated [DATE] at 5:50 P.M., nasal swab obtained with resident consent for COVID-19 test. Resident test from [DATE] was negative. Patient was re-tested due to symptoms from weekend; -No further documentation of symptoms consistent with COVID-19 through [DATE]; -A progress note dated [DATE] at 9:17 A.M., received the resident's COVID-19 test back and tested negative; -A census report, showed the resident not moved off the Veronica Hall COVID-19 unit until [DATE]. During an interview on [DATE] at 12:28 P.M., LPN B said they currently have two residents on the COVID-19 unit who are negative for COVID-19. One had been positive and is now negative and the other, Resident #9, never tested positive. He/she only had signs and sy

Based on interview and record review, the facility failed to thoroughly and accurately assess, document and notify the physician of a change in condition sustained by one resident with a history of chronic respiratory issues, including pneumonia and upper respiratory infections. Staff documented the resident was assessed by his/her physician on 4/3/19. Facility staff reported the resident had a cough and congestion at that time. Staff failed to assess the resident and document an assessment. A lab was ordered and drawn on 4/4/19. The lab results were abnormal, and facility staff failed to notify the resident's physician or responsible party. Staff failed to assess or document an assessment of the resident's respiratory status including lung sounds and oxygen saturation. On 4/15/19, staff documented the resident spit up green and yellow mucus. The nurse documented the resident's physician was notified of the resident's change in respiratory status, but failed to document the assessment and failed to notify the evening/night nurse of the resident's cough during report. The resident remained at the facility for 13 days with abnormal labs and a cough/congestion. When transferred to the hospital on [DATE], it was determined the resident's lung conditions had gotten worse since his/her 3/19/19, hospital admission. (Resident #208) The sample was 31. The census was 154. Review of the facility's acute change in condition policy, dated 12/11/18, showed: -Purpose: the purpose of this policy is to ensure that the physician is notified for any resident who has a noticed change in condition and appropriate interventions are implemented; -Procedure: direct care staff will be trained to recognize subtle but significant changes in resident condition (i.e. decrease in oral intake, increased agitation, changes in skin condition) and to communicate these changes to the charge nurse immediately; -The charge nurse will complete an assessment of the resident and collect pertinent information regarding the resident (i.e. vital signs, recent lab/test/radiology (x-ray) results, [DIAGNOSES REDACTED]. -The charge nurse will contact the primary care physician to notify them of the resident's change in condition. The charge nurse will repeat any verbal orders to the resident's physician to ensure accurate transcription. The charge nurse will contact the facility's medical director for additional guidance or consultation if the resident's physician does not respond timely or respond appropriately; -The charge nurse will notify the resident's responsible party and notify them of the resident's change in condition; -The charge nurse will document the changes in condition in the resident's medical record; -The charge nurse will notify the Director of Nurses (DON) or designee if the resident's condition changes; -The charge nurse will communicate the change in condition to incoming staff via verbal report and written on the 24 hour report log for follow up. Review of the resident's face sheet, showed: -admitted on [DATE]; -[DIAGNOSES REDACTED]. Review of Resident #208's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/22/18, showed: -Diagnosis: [REDACTED].>-Severe cognitive impairment; -Long and short term memory problems; -Incontinent of bowel and bladder; -Required extensive assistance from staff for bed mobility, dressing and personal hygiene; -Required total assistance from staff for transfers, toileting and bathing; -Non-ambulatory; -Gastrostomy tube ([DEVICE], a tube surgically inserted into the stomach for the administration of food, fluids and medications). Review of the resident's care plan, dated 1/15/19, showed: -Problem: Potential for complication related to respiratory infection. Resident was started on antibiotic for a suspected upper respiratory infection on 12/8/18, 2/24/19 and on 3/8/19; -Goal: Will not exhibit signs of respiratory infection as evidenced by fever, decreased oxygen saturation (O2 sat, oxygenation of the blood) and abnormal lung sounds; -Approaches (start date 3/9/19 for all approaches): Administer antibiotics per physician's orders [REDACTED]. Review of the resident's medical record, showed discharges to the hospital multiples times in 2019, for respiratory concerns and antibiotic usage for upper respiratory infections and pneumonia. Review of the resident's physician's orders [REDACTED]. -1/29/19 through 2/8/19, [MEDICATION NAME] (antibiotic) 500 milligrams (mg) per [DEVICE] every morning; -2/23/19, chest x-ray ordered for complaint of cough and congestion; -2/24/19 through 3/2/19, [MEDICATION NAME] oral solution 500 mg at bed time for upper respiratory infection (URI); -3/8/19, [MEDICATION NAME] (water pill) 40 mg/5 milliliters (ml) by mouth every morning; -3/8/19, [MEDICATION NAME] solution for nebulizer breathing treatment 2.5 mg/3 ml every six hours when needed (PRN) for dyspnea; -3/8/19, [MEDICATION NAME] (cough medicine) 10 ml per [DEVICE] every four hours PRN cough; -3/9/19 through 3/13/19, [MEDICATION NAME] 500 mg per [DEVICE] for pneumonia; -3/12/19, chest x-ray; -3/12/19, chest x-ray; -4/3/19, chest x-ray. Review of the resident's physician's long term care follow-up visit, dated 4/3/19, showed the physician documented a nurse reported the resident had blood tinged sputum and coughing that morning. Review of the resident's vital signs, dated 4/3/19, showed: -At 9:16 A.M., blood pressure (B/P): 115/65 (normal 120/80), no other vital signs were documented. -At 10:37 P.M., B/P: 113/68; -No other vital signs were documented. Review of the resident's nurse's note, dated 4/3/19 at 10:46 A.M., showed staff documented the resident's physician assessed the resident that day. A prior shift nurse reported to the physician the resident was coughing and had congestion. A chest x-ray was ordered and awaiting results. Will continue to monitor the resident throughout the shift. Review of the resident's chest x-ray results, dated 4/3/19 at 11:10 A.M., showed the findings consistent with [MEDICAL CONDITION] ([MEDICAL CONDITION], heart does not pump correctly) and [MEDICAL CONDITIONS] (fluid in the lungs), and there was a superimposed opacity (lung abnormalities with increased density) within the left base which may represent infectious process. The following was handwritten on the chest x-ray results page: [MEDICATION NAME] (water pill) 60 mg for three days then 40 mg after that and a Basic Metabolic Panel (BMP, laboratory test used to assess and monitor electrolyte status, kidney function and blood sugar level) ordered for 4/4/19. Staff documented: noted on the chest x-ray results. Review of the resident's POS, dated 4/3/19, showed a new order to increase [MEDICATION NAME] to 60 mg for three days. Review of the resident's nurse's note, dated 4/3/19 at 6:43 P.M., showed staff documented the chest x-ray results were reported to the physician. A new order to increase [MEDICATION NAME] to 60 mg for three days and then back down to regular the dose of 40 mg a day was ordered. A BMP was ordered to be drawn on 4/4/19. The resident was resting in bed. Will continue to monitor the resident throughout the shift. Further review of the resident's nurse's notes, dated 4/3/19, showed no assessment of the resident's respiratory condition. Review of the resident's POS, dated 4/4/19, showed an order for [REDACTED].>Review of the resident's vital signs, dated 4/4/19, showed: -At 9:37 A.M., B/P: 116/60; -No other vital signs were documented. Review of the resident's nurse's note, dated 4/4/19 at 6:25 P.M., showed staff documented the resident was resting in bed. No complaint of pain. Position changed frequently in bed. No signs or symptoms of distress noted with postural change. Resident was pleasant and cooperative. Family at bedside during the evening. Will continue to monitor resident throughout shift. No assessment of the resident's respiratory status was documented. Review of the resident's vital signs, dated 4/4/19, showed: -At 10:50 P.M., B/P: 126/51; -No other vital signs were documented. Review of the resident's complete blood count with differential (CBC, a blood test that can detect the presence of infection), dated 4/4/19, showed: -White blood cells (WBCs, cells that fight infection): 12.0 (normal range 4.5 - 10.8); -Red blood cells (RBCs, cells that carry oxygen): 2.74 (normal range 3.90 - 5.40); -Hemoglobin (cells that carry oxygen from the lungs to the body tissues): 9.2 (normal range 12.0 - 16.0); -Hematocrit (proportion of red blood cells in the blood): 28.5 (normal range 36.8 - 48.0%.) Review of the resident's medical record, showed no documentation the resident's physician was notified of the above lab results on 4/4/19. Review of the resident's vital signs, dated 4/5/19, showed: -At 9:40 A.M., B/P: 110/58; -At 9:09 P.M., B/P: 101/58; -No other vital signs were documented. Review of the resident's medical record, showed no assessment documented regarding the resident's respiratory status on 4/5/19. Review of the resident's vital signs, dated 4/6/19, showed: -At 8:45 A.M., B/P: 136/70, Temperature (T): 97.6 (normal 98.6); -At 11:45 P.M., B/P: 122/74; -No other vital signs were documented. Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's nurse's note, dated 4/6/19 at 6:22 P.M., showed staff documented the resident remained on continuous feeding per [DEVICE]. Feeding infusing without difficulty. Flushed per protocol. Head of bed elevated while in bed. Denies any discomfort. Family at bedside during the evening. Will continue to monitor resident throughout shift. No assessment of the resident's respiratory status was documented. Review of the resident's vital signs, dated 4/7/19, showed: -At 9:14 A.M., B/P: 148/78; -At 10:42 A.M., T: 96.8; -No other vital signs were documented. Review of the resident's nurse note, dated 4/7/19 at 10:43 A.M., showed staff documented the resident continues on feeding per [DEVICE]. Feeding infusing without difficulties. Flushed per protocol. Head of bed elevated while in bed. Denies any discomfort. Family visiting. Call light within reach. Review of the resident's vital signs, dated 4/8/19, showed: -At 12:57 A.M., B/P: 140/74; -At 1:56 P.M., B/P: 94/60; -No other vital signs were documented. Review of the resident's medical record, showed no assessment documented regarding the resident's respiratory status on 4/8/19. Review of the resident's vital signs, dated 4/9/19, showed: -At 6:25 A.M., B/P: 103/67; -At 1:48 P.M., B/P: 129/66; -No other vital signs were documented. Review of the resident's MAR, dated 4/9/19, showed Nurse A administered PRN [MEDICATION NAME] nebulizer breathing treatment at 5:18 P.M. for cough. Review of the resident's vital signs, dated 4/9/19 at 7:53 P.M., showed staff documented O2 sat: 98% (Normal 95 - 100%), Pulse (P) 102 (normal 60 - 100), Respirations (R): 20 (normal 12 - 20), T: 96.6. Review of the resident's medical record, showed no assessment documented regarding the resident's respiratory status on 4/9/19. Review of the resident's vital signs, dated 4/10/19, showed: -At 9:23 A.M., B/P: 138/78; -No other vital signs were documented. Review of the resident's MAR, dated 4/10/19 at 9:26 A.M., showed staff documented the PRN nebulizer breathing treatment was effective. Review of the resident's medical record, showed no assessment documented regarding the resident's respiratory status on 4/10/19. Review of the resident's vital signs, dated 4/11/19, showed: -At 11:26 A.M., B/P: 119/56; -No other vital signs were documented. Review of the resident's medical record, showed no assessment documented regarding the resident's respiratory status on 4/11/19 Review of the resident's vital signs, dated 4/12/19, showed: -At 6:48 A.M., B/P: 132/74; -At 8:27 A.M., B/P: 123/70; -No other vital signs were documented. Review of the resident's medical record, showed no assessment documented regarding the resident's respiratory status on 4/12/19. Review of the resident's vital signs, dated 4/13/19, showed: -At 1:21 A.M., B/P: 116/74; -At 10:18 A.M., B/P: 126/84; -At 9:44 P.M., B/P: 102/58; -No other vital signs were documented. Review of the resident's medical record, showed no assessment documented regarding the resident's respiratory status on 4/13/19. Review of the resident's vital signs, dated 4/14/19, showed: -At 11:00 A.M., B/P: 109/61; -No other vital signs were documented. Review of the resident's medical record, showed no assessment documented regarding the resident's respiratory status on 4/14/19. Review of the resident's vital signs, dated 4/15/19, showed: -At 6:53 A.M., B/P: 104/66; -At 9:27 A.M., B/P: 110/68; -No other vital signs were documented. Review of the resident's nurse's note, dated 4/15/19 at 5:20 P.M., showed Nurse B documented he/she was made aware the resident spit up what appeared to be green and yellow colored mucus. Lung sounds clear, small non-productive cough. Call placed to the resident's physician to make aware, resident resting in bed. Will continue to monitor the resident throughout the shift. No additional assessment of the resident's respiratory status was documented. Review of a written statement, dated 5/21/19, showed Nurse B documented on 4/15/19, he/she was made aware of the resident spitting up by the resident's family. Nurse B was not present when the resident spit up. He/she notified the resident's physician of the resident spitting up. Nurse B never saw emesis (vomit) or mucus from the resident. Review of the resident's vital signs, dated 4/15/19, showed: -At 9:17 P.M., B/P: 118/66; -No other vital signs were documented. Review of the resident's vital signs, dated 4/16/19, showed: -At 10:11 A.M., B/P: 119/67; -No other vital signs were documented. Review of the resident's nurse's note, dated 4/16/19 at 10:28 A.M., showed the resident's physician called to request an update report with resident throughout the night. Will continue to monitor throughout shift. No documented assessment of the resident's respiratory status. Review of the resident's vital signs, dated 4/16/19, showed: -At 10:52 A.M., B/P: 119/67, P: 100, R: 18, T: 97.6; -No other vital signs were documented. Review of the resident's nurse's note, dated 4/16/19 and 4/17/19, showed no further assessment of the resident's respiratory status. Review of the residents nurse's note, dated 4/17/19 at 7:49 A.M., showed staff documented the resident was assessed to have a wound on his/her left inner ankle. The resident's physician and responsible party were notified and the resident was transferred to the hospital in a timely manner. Review of the resident's hospital record, dated 4/17/19, showed a chest x-ray showed worsening bibasilar (lower) infiltrate or atelectasis (collapsed lung) since 3/19/19. Hospital [DIAGNOSES REDACTED]. During an interview on 5/28/19 at 2:35 P.M., Nurse A said he/she worked 6:30 A.M. through 6:30 P.M., on 4/9/19. He/she was familiar with the resident and assigned to him/her often. The resident had chronic respiratory issues, including pneumonia and URIs. The resident coughed all the time. Nurse A recalled the resident was coughing on 4/9/19, he/she assessed the resident's lungs and administered a PRN nebulizer treatment. The nebulizer treatment was effective. Nurse A called the resident's responsible party and let him/her know the resident was coughing and a nebulizer treatment was administered. He/she forgot to document the assessment in the resident's medical record but recalled the resident's lungs were clear. During an interview on 5/23/19 at 12:30 P.M., Nurse B said the resident had chronic respiratory issues, he/she had pneumonia a lot in the past. On 4/15/19, the resident's responsible party reported to him/her the resident was spitting up green and yellow mucus. He/she assessed the resident's lung sounds and notified the resident's physician, who ordered a chest x-ray. Nurse B notified the resident's physician of the chest x-ray results and he ordered to increase the resident's water pill for three days. Nurse B was not aware lab results needed to be faxed or called to the resident's physician. He/she works 12 hour shifts from 6:30 A.M. through 6:30 P.M., after 5:00 P.M., his/her shift winds down and everything needing to be completed after that time was passed onto the next shift. Nurse B said tasks not completed are passed onto the next shift in nurse report. During an interview on 5/21/19 at 1:15 P.M., Nurse C said he/she worked 7:00 P.M. through 7:00 A.M., and was often assigned to the resident. The resident had chronic respiratory issues and often had pneumonia. The resident coughed all the time and would sometimes cough up green and/or yellow mucus, this was baseline for the resident. Day shift staff are responsible for calling and/or faxing resident physician offices because they are not open by the time he/she gets to the facility. He/she was not aware of lab results needing to be reported to the resident's physician. During interviews with two agency certified nurse aides (CNAs) and three facility CNAs said they did not recall the resident or if he/she had a cough or congestion in (MONTH) 2019. During interviews on 5/21/19 at 12:45 P.M. and 5/29/19 at 8:20 A.M., the DON said when a resident has a change in condition, staff are expected to get a full set of vital signs for the resident and notify the resident's physician and responsible party. The assessment and notification of the resident's physician and responsible party should be documented in the resident's medial record. When a resident was assessed to have a cough, she expected staff to assess the resident at least once a shift. The resident had a [DEVICE], so staff should have assessed his/her lungs every shift and documented the assessment in the resident's medical record. Because the resident had a history of [REDACTED]. Lab results can either be called or faxed to the resident's physician's office. All staff are responsible for ensuring the resident's physician was notified of lab results. The DON was aware the resident's lab results, dated 4/4/19, showed abnormal labs. She spoke to the nurses assigned to the resident at that time and could not determine what occurred. The resident's lab results were not called or faxed to the resident's physician office. She expected staff to assess the resident's respiratory status and then administer the PRN nebulizer treatment. Staff are expected to document the resident's respiratory assessment, including lung sounds and a full set a vital signs in the resident's nurse's notes. Staff are expected to reassess the resident's respiratory status within 30 minutes after the nebulizer treatment was administered and document if the treatment was effective or not in the resident's medical record. She expected staff to document a full set of post nebulizer breathing treatment vital signs as well. During an interview on 5/28/19 at 10:00 A.M., the resident's physician said the resident had multiple chronic respiratory issues with [DIAGNOSES REDACTED]. When the resident had symptoms of a cough or congestion, he expected staff to assess the resident's respiratory status including lung sounds, and a full set of vital signs including blood pressure, heart rate, respirations and oxygen saturation. When he orders labs, the facility staff either call him or fax the lab results to the office. He either gives a verbal order or documents new orders on the lab results and faxes it back to the facility. If there are no new orders, he documents NNO on the lab results. He was not aware of the abnormal lab results, dated 4/4/19, that showed the resident had high WBCs and low RBCs. The high WBCs means the resident should have been assessed for infection. He worked closely with the resident's responsible party and he knows if he/she knew of the abnormal lab results on 4/4/19, he/she would have wanted the resident to be evaluated in the emergency room . MO 277

Based on interview and record review, the facility failed to have a system in place regarding assessments of the skin underneath removable splint/soft casts. Of the two residents sampled with removable splint/soft casts, one had a leg splint/soft cast attached by an ace wrap with a leg immobilizer over it. The resident was admitted to the facility with no pressure ulcers. Staff failed to adequately monitor/assess the skin under the removable splint/soft cast and the resident developed an unstageable pressure ulcer on the left heel (Resident #1). The census was 140. Review of Resident #1's face sheet, showed an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's admission progress note, dated 8/17/17 at 6:20 P.M., showed staff documented the resident arrived at 2:50 P.M., was alert and oriented and could make his/her needs known. Review of the resident's progress note, dated 8/17/17 at 10:26 P.M., showed staff documented the resident's skin was assessed. The resident had a wound on his/her left forearm and an ace wrapped, removable splint/soft cast on his/her left lower leg. Per the hospital, they were not treating the resident's left leg and there was to be an immobilizer on the left leg. The resident's physician reported the resident fractured his/her left leg approximately two weeks prior to the recent hospitalization . The resident was to be assessed by an orthopedic physician for the leg fracture. The physician stated he would be in the next day to assess the resident and not to do anything to the left leg until assessed by the orthopedic physician. There was no documented assessment of the skin underneath the left leg splint/soft cast. Review of the resident's admission physician's order sheet (POS), dated 8/17/17, showed no order for a left leg splint/soft cast, ace wrap or immobilizer. Review of the resident's medical record, showed no admission nursing assessment, interim care plan or Braden scale assessment (for predicating pressure ulcer risk) documented for 8/17/17. Review of resident's admission nursing assessment, dated 8/18/17 at 3:55 A.M., showed staff documented the resident's skin status as warm, dry and with redness. The resident's right arm had a medium size bruise on the inner elbow with swelling. The resident's left anterior (front) elbow had a skin tear with a dressing in place. There was no documented assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's medical record, dated 8/19/17 through 8/20/17, showed no documentation of an assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's progress note, dated 8/21/17 at 2:06 P.M., showed the nurse and nurse practitioner removed the splint/soft cast from the resident's left leg when he/she complained of pain. Staff documented the resident's left leg was red. There was no assessment of the resident's left heel documented. Review of the resident's POS, dated 8/21/17, showed an order to call the resident's orthopedic physician to schedule a follow up appointment. This order was discontinued the same day. Review of the resident's progress note, dated 8/21/17 at 4:13 P.M., showed staff documented the resident's physician discharged the resident to the hospital for further evaluation and treatment (of a condition unrelated to his/her left leg). Review of the resident's progress note, dated 8/22/17 at 7:17 A.M., showed staff documented the resident was admitted to the hospital for a urinary tract infection and [MEDICAL CONDITION] (bloodstream infection). Review of resident's readmission nursing assessment, dated 8/24/17 at 4:10 P.M., showed the following skin assessment: -Temperature: Warm; -Moisture: Dry; -Color: Normal; -Petechia (broken capillary blood vessels) present: No; -Alterations in skin: Yes, a medium size bruise on the right inner elbow with swelling. The left anterior elbow had a skin tear with a dressing in place. No documented assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's progress note, dated 8/24/17 at 5:36 P.M., showed staff documented the resident returned to the facility with an immobilizer on his/her left leg. Review of the resident's readmission POS, dated 8/24/17, showed the following: -No order for a left leg splint/soft cast, ace wrap or immobilizer; -Charge nurse to do focused skin observation on shower days every Wednesday and Saturday evening. During an interview on 10/3/17 at 8:45 A.M., the Assistant Director of Nurses (ADON) said a focused skin observation was a skin assessment conducted twice a week by a nurse usually on a resident's shower day. The nurse documents a head to toe assessment of the resident's skin, but does not do any measurements. The ADON said the assessment is to be documented in the medical record. Review of the resident's readmission Braden scale assessment (the first one completed), dated 8/24/17, showed staff documented a score of 13 (a score of 13-14 indicates moderate risk). Review of the resident's first care plan, dated 8/24/17, showed the following: -Problem: Potential for skin breakdown related to incontinence; -Goal: Reduce risk of skin breakdown; -Approaches: Observe skin during care and report changes; -The care plan did not address the splint/soft cast, ace wrap or immobilizer on the resident's left lower leg. Review of the resident's progress note, dated 8/25/17 at 5:18 A.M., showed staff documented the immobilizer on the resident's left leg was reinforced throughout the night as needed, but no assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's weekly skin assessment, dated 8/26/17 at 9:54 P.M., showed the following: -Temperature: Warm; -Moisture: Dry; -Skin color: Normal; -Petechia present: No; -Skin turgor: Normal: -No documented assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's progress note, dated 8/26/17 at 2:18 A.M., showed staff documented the left leg splint/soft cast, ace wrap and immobilizer were removed, reapplied and the resident was repositioned for comfort. Review of the resident's medical record, dated 8/27/17, showed no documented assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's progress note, dated 8/28/17 at 4:02 A.M., showed staff documented the resident complained of pain to his/her left inner ankle. Staff loosened the ace wrap and assessed the resident's foot went from purple to pink in color. There was no documented assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's progress notes, dated 8/29/17, showed the following: -At 4:53 P.M., the resident's physician was at the facility and aware the resident's left leg splint/soft cast was not fitting well. An order was obtained to get a follow up appointment scheduled with the orthopedic physician and to make sure the appointment was soon; -At 4:59 P.M., the orthopedic physician's office was closed at that time. Will arrange the follow up appointment in the morning. Review of the resident's medical record, dated 8/29/17, showed no documented assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's weekly skin assessment, dated 8/30/17 at 9:53 P.M., showed the following: -Temperature: Warm; -Moisture: Dry; -Petechia: No; -Skin turgor: Normal; -Alterations in skin: Yes. Cast and immobilizer on and intact on the resident left leg; -No documented assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's progress notes, dated 8/30/17, showed no documentation staff called the orthopedic physician's office to schedule a follow up appointment. Review of the resident's medical record, dated 8/30/17, showed no documented assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's progress note, dated 8/31/17 at 5:57 P.M., showed staff documented the resident had a follow up orthopedic appointment scheduled, on 9/1/17 at 9:00 A.M., but the appointment was canceled because no transportation was available due to the short notice. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/31/17, showed the following: -[DIAGNOSES REDACTED]. -Understood/understands; -Brief Interview for Mental Status (BIMS, a brief screen for cognitive impairment) score: 9 of 15 (a score of 8-12 indicates moderately impaired cognition); -Extensive assistance with dressing, toileting, transfers, personal hygiene and bed mobility; -Total assistance with bathing; -Frequently incontinent of bowel and bladder; -Non-ambulatory; -At risk for pressure ulcers; -No pressure ulcers; -No foot ulcers, wounds or skin problems; -No treatment to feet. Review of the resident's medical record, dated 8/31/17, showed no documented assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's progress note, dated 9/1/17 at 4:53 P.M., showed staff documented the orthopedic physician's appointment was rescheduled for 9/7/17 at 10:30 A.M. Review of the resident's medical record, dated 9/2/17, showed no documented assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's weekly skin assessment, dated 9/2/17 at 6:59 P.M., showed the following: -Temperature: Warm; -Moisture: Dry; -Skin color: Normal; -Skin turgor: Normal; -No documented assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's progress note, dated 9/3/17 at 10:05 A.M., showed staff documented the resident complained of left heel pain. Staff unwrapped the ace wrap on the resident's left leg and assessed a 1.5 inch by 1.75 inch black area on the resident's left heel. Skin prep (a wipe that forms a protective film to protect the skin) administered per physician's orders. The resident said he/she felt better after the immobilizer was loosened and pressure was off the left heel. The resident's physician was notified of the black area on the resident's left heel. Review of the resident's Braden scale assessment, dated 9/4/17, showed staff documented a score of 12 (a score of 10-12 indicates high risk), a change in skin condition and a black area on the resident's left heel. Review of the resident's POS, dated 9/4/17 through 9/8/17, showed a new order for skin prep to the left heel twice a day (BID). Review of the resident's treatment administration record (TAR), dated 9/4/17 through 9/8/17, showed staff documented the administration of skin prep to the resident's left heel. Review of the resident's physician's note, dated 9/5/17, showed the resident had a 2 centimeter (cm) by 2 cm dark hard area located on his/her left heel. Review of the resident's nurse practitioner's progress note, dated 9/5/17, showed the following: -Patient history: The 3.5 cm by 3.5 cm area of redness on the resident's left heel was now dark with black edges. The resident's physician does not want a facility wound specialist to assess the area and wishes treatment to be limited to skin prep application to area BID; -Pain assessment: Pain in left heel with contact; -Physical exam: -General appearance notes: Pressure wound to left heel is 3.5 cm by 3.5 cm with black edges, no slough (yellow or white tissue that adheres to the ulcer in strings or thin clumps, or is mucinous) was present; -Musculoskeletal: Left lower extremity immobilizer was poorly fitting; -Neurological: alert and oriented; -Plan: Assess: ongoing tenderness to left heel with 3.5 cm by 3.5 cm black area that had developed. The resident's physician does not want a consult with the facility wound specialist for left heel pressure wound; -Plan: Monitor for increased pain or swelling. Elevate extremity above the heart throughout the day and night. Apply skin prep BID to left heel and monitor for further deterioration at site. Review of the resident's TAR, dated 9/6/17, showed an initialed box to indicate the completion of a focused observation/skin assessment. Review of the resident's medical record, showed no results of the focused observation/skin assessment documented for 9/6/17. Review of the resident's care plan, dated 9/6/17, showed staff documented a black area on the resident's left heel was assessed on 9/4/17. There were no additional approaches or goals documented on the care plan. Review of the resident's weekly Braden scale assessment, dated 9/7/17, showed staff documented a score of 15 (a score of 15-18 indicates at risk). Review of the resident's orthopedic physician's progress note, dated 9/7/17, showed the resident was six weeks post a tibia fracture. The resident wore a splint/soft cast since the injury. The splint/soft cast was removed today and a partial thickness pressure ulcer was assessed on the resident's left heel. Apparently the splint/soft cast was loosened at some point and 4 by 4s (square pads of gauze) were packed between the resident's left heel and the splint/soft cast. Plan: The splint/soft cast was removed and a knee immobilizer was applied. The knee immobilizer should be as high as possible and taken off once a day for hygiene. A wound care nurse should assess the pressure ulcer on the resident's left heel and elevate the left foot at night with pressure ulcer protected from weight bearing. Review of the resident's progress note, dated 9/7/17 at 2:20 P.M., showed staff documented the following orders from the orthopedic physician: -Discontinue splint/soft cast; -Knee immobilizer off once a day for hygiene and lotion; -Place pillow or splint to relieve heel while in bed (podus boot) (a foot boot that helps in the healing and prevention of heel pressure ulcers. The large heel cavity helps keep the heel free from pressure); -Resident to see wound care nurse for pressure ulcer on the heel; -Follow up appointment 10/19/17 at 10:00 A.M.; -The resident's personal care physician (PCP) approved all orders from the resident's orthopedic physician except the wound care order. Review of the resident's POS, dated 9/7/17, showed an order for [REDACTED]. Review of the Facility's Wound Summary Report, dated 9/8/17 at 2:42 P.M., showed staff documented the resident had a pressure ulcer on his/her left heel. The pressure ulcer was not present on admission and it was declining. There was no additional assessment documented on the facility's wound report. Review of the resident's wound management assessment, dated 9/8/17 at 2:43 P.M., showed the following: -Wound type: Pressure ulcer; -Wound location: Left heel; -Wound present on admission or re-admission: No; -Wound measurement: 3.5 cm by 3.5 cm; -Wound depth: None; -Wound exudate (drainage): None; -Wound odor: None; -Wound Stage: Unstageable (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar); -Wound tissue type: Necrotic (dead) tissue. Review of the resident's nurse practitioner's progress note, dated 9/8/17, showed the following: -Patient history: The resident was assessed by the orthopedic physician on 9/7/17, for follow up. The orthopedic physician discontinued the splint/soft cast, the resident will use the immobilizer only. May remove immobilizer once daily for hygiene. A podus boot was ordered for the left foot to prevent further tissue damage to the resident's left heel. The orthopedic physician also ordered a wound care nurse to assess the resident but the resident's PCP canceled that order. Follow up with orthopedic physician scheduled for 10/19/17 at 10:00 A.M. The resident reported improvement in comfort after discontinuing the splint/soft cast and initiation of padding his/her left heel; -Pain assessment: Intermittent pain in the left heel; -Physical exam: -General appearance: Pressure injury to left heel remained unchanged in black perimeter, center still blanchable (skin becomes pale in response to gentle pressure); -Musculoskeletal: Left lower extremity remains in an immobilizer; -Plan: -Assess: Remains in a leg immobilizer, however the splint/soft cast has been removed and apply [MEDICATION NAME] (an iodine antiseptic) BID to left heel and monitor for further deterioration at site. Review of the resident's POS, dated 9/8/17, showed podus boot, prop on a pillow to relieve heel while in bed. Review of the resident's TAR, dated 9/8/17 through 9/14/17, showed staff documented [MEDICATION NAME] administered BID, but no location specified. Review of the resident's General Administration History, dated 9/8/17 through 9/27/17, showed podus boot, prop on pillow to relieve heel while in bed administered at bedtime, showed the following: -Staff documented on 9/8/17, bunny boots (pressure reducing devices) no podus boot available at this time; -Staff documented 9/9 through 26/17, podus boot on at bedtime. Review of the resident's weekly skin assessment, dated 9/9/17 at 8:13 P.M., showed the following: -Temperature: Warm; -Moisture: Dry; -Skin color: Normal; -Petechia present: No; -Skin turgor: Normal; -No documented assessment of the skin underneath the resident's left leg splint/soft cast. Review of the resident's progress note, dated 9/10/17 at 1:26 P.M., showed staff documented the administration of the dressing to the resident's left heel as ordered. Review of the resident's POS, dated 9/10/17, showed no order for a dressing to the heel. Review of the resident's progress notes, dated 9/11/17, showed staff documented the following: -At 3:12 A.M., a podus boot was not available so the resident wore bunny boots until the podus boot arrived; -At 4:17 A.M., the black area on the resident's left heel measured 4.0 cm by 3.5 cm; -At 1:24 P.M., the resident had heel protectors on until the podus boot is available. Review of the resident's progress note, dated 9/12/17 at 11:36 A.M., showed staff documented heel protectors were on, the podus will be applied as soon as available. Review of the resident's monthly Braden scale assessment, dated 9/13/17, showed staff documented a score of 17. Review of the resident's progress note, dated 9/13/17, showed staff documented: -At 5:22 A.M., a podus boot on the resident's left foot at all times; -At 1:28 P.M., heel protectors on bilateral feet. Review of the resident's weekly skin assessment, dated 9/13/17 at 11:09 P.M., showed the following: -Temperature: Warm; -Moisture: Dry; -Skin Color: Normal; -Petechia present: No; -Skin turgor: Normal; -Alterations in skin: Yes, the resident's left heel was black. No additional assessment documented regarding the pressure ulcer on the resident's left heel. Review of the resident's POS, dated 9/13/17, showed an order for [REDACTED]. Review of the resident's TAR, dated 9/13/17 through 9/27/17, showed staff documented the resident's immobilizer was loosened BID for hygiene and lotion. Review of the resident's POS, dated 9/14/17 through 9/20/17, showed an order to administer [MEDICATION NAME] to the resident's left heel BID. Review of the resident's TAR, dated 9/14/17 through 9/20/17, showed staff documented the administration of [MEDICATION NAME] to the resident's left heel BID. Review of the resident's progress note, dated 9/14/17 at 3:23 A.M., showed staff documented the resident's left heel had a black spot. An immobilizer on at all times and intact and bilateral heel protectors on and intact. Review of the resident's nurse practitioner's progress note, dated 9/14/17, showed the following: -Patient history: Follow up with orthopedic physician scheduled for 10/19/17 at 10:00 A.M. -Pain assessment: No complaint of pain; -Physical exam: -General appearance: Pressure injury to left heel measured 4.0 cm by 3.5 cm; -Plan/Assess: the resident's left leg remains in a leg immobilizer with removal daily for skin care. Ongoing tenderness to the resident's left heel 4.0 cm by 3.5 cm black area, center blanches, follow up with orthopedic physician on 10/19/17 at 10:00 A.M. Review of the resident's weekly Braden scale assessment, dated 9/14/17, showed staff documented a score of 13. Review of the resident's TAR, dated 9/16/17, showed an initialed box to indicate the completion of a focused observation/skin assessment. Review of the resident's medical record, showed no results of the focused observation/skin assessment documented for 9/16/17. Review of the resident's physician's note, dated 9/19/17, showed the area on the resident's left heel was a dry, hard scab. The dry scab began as a blood blister. Keep area dry and watch for infection. No measurement of the area documented. Review of the resident's TAR, dated 9/20/17, showed an initialed box to indicate the completion of a focused observation/skin assessment. Review of the resident's medical record, showed no results of the focused observation/skin assessment documented for 9/20/17. Review of the resident's POS, dated 9/20/17, showed an order for [REDACTED]. Review of the resident's wound assessment from the wound specialist, dated 9/20/17, showed the following: -Chief complaint: An unstageable pressure ulcer on the resident's left heel; -Location: Posterior area of the left heel; -Context: Due to pressure; -Associated signs and symptoms: Left heel pressure ulcer was covered with soft moist eschar (dead tissue) with open edges and serosanguinous (a semi-thick reddish fluid) exudate; -Musculoskeletal: Wheelchair bound; -Wound assessment: Left, posterior has a primary etiology of pressure ulcer and was a chronic unstageable pressure ulcer obscured full-thickness skin and tissue loss pressure ulcer and has received a status of open. Initial wound encounter measurements are 7.0 cm by 4.0 cm, with an area of 28 square cm. The resident reported a wound pain of 3/10. The wound bed was 76-100% moist, black eschar. The periwound (the area surrounding the pressure ulcer) skin color, moisture and texture was normal. The temperature of the periwound area was within normal limits (WNL) and did not exhibit signs or symptoms of infection; -General notes: The edges of the soft eschar was open; -Wound orders: Cleanse wound with cleanser, apply alginate (wound dressing used to manage exudates in partial to full-thickness wounds, providing a moist environment for healing) to wound bed, apply [MEDICATION NAME] to wound bed, cover wound with ABD pad (a wound drainage absorbent dressing), secure dressing with tape and change daily; -Pressure relief/offloading: Offload heel with a podus boot. Review of the resident's wound management assessment, completed by a facility nurse manager, dated 9/20/17 at 2:54 P.M., showed the following: -Wound type: Pressure ulcer; -Wound location: Left heel; -Wound Stage: Unstageable; -Wound present on admission or re-admission: No; -Wound measurement: 7.0 cm by 4.0 cm; -Can depth be measured? No; -Exudate amount: Light; -Exudate color and consistency: [MEDICAL CONDITION] (yellow or tan, cloudy and thick); -Wound odor present: No -Wound tissue type: Necrotic tissue; -Percent of wound covered by eschar (dead) tissue: 100%; -Wound edges/margins: Macerated (softening and breaking down of skin resulting from prolonged exposure to moisture)/soft; -Skin surrounding wound: assess within 4 cm of wound edge: [MEDICAL CONDITION]; -Wound healing status: Declining. Review of the resident's POS, dated 9/20/17 through 9/27/17, showed a wound specialist order for a dressing change to the left heel, swab with [MEDICATION NAME], cover with 7 cm by 4 cm alginate dressing, an ABD pad and secure the dressing with tape. Review of the resident's TAR, dated 9/20/17 through 9/27/17, showed staff documented the administration of the dressing change to the resident's left heel, completed as ordered. Review of the resident's medical record, showed no further assessment of the black area on the resident's left heel, from 9/21/17 through 9/27/17, and no documentation regarding when the podus boot was ordered or applied. Review of the resident's weekly Braden scale assessment, dated 9/21/17, showed staff documented a score of 16. Review of the resident's TAR, dated 9/23/17, showed an initialed box to indicate the completion of a focused observation/skin assessment. Review of the resident's medical record, showed no results of the focused observation/skin assessment documented for 9/23/17. Review of the resident's progress note, dated 9/27/17 at 12:52 P.M., showed staff documented the resident discharged from the facility. During an interview on 10/17/17 at 11:00 A.M., Nurse D said he/she worked 7:00 A.M. through 7:00 P.M., and was assigned to the resident often. The resident was alert and oriented and able to make his/her needs known. The resident was admitted with a left leg posterior half splint/soft cast with an ace wrap around it. He/she never took the splint/soft cast off, because there was no physician's order to do so. When the resident complained of left ankle pain on 8/21/17, the nurse practitioner notified the resident's PCP and obtained an order to remove the splint/soft cast to assess the ankle. Nurse D stabilized the resident's left leg while the nurse practitioner assessed the resident's left ankle. He/she observed the resident's left heel while the splint/soft cast was off and did not see a black area. He/she documented the findings of the resident's skin underneath the splint/soft cast in the resident's medical record. The resident transferred to the hospital, due to change in medical condition the same day and then returned to the facility on [DATE]. After the resident was readmitted , Nurse D recalled the resident's left leg splint/soft cast was ill fitting. He/she notified the resident's PCP on 8/29/17, of the splint/soft cast not fitting properly and a follow up with the resident's orthopedic physician was ordered. Nurse D called the resident's orthopedic physician's office the same day to set up a follow up appointment, but the office was closed. He/she communicated the need for a follow up appointment in nurse report and documented it on the 24 hour report sheet. During an interview on 10/17/17 at 8:30 A.M., Nurse A said he/she worked 7:00 A.M. through 7:00 P.M. on 8/24/17, and was the nurse who readmitted the resident to the facility. The resident had a splint/soft cast on his/her left leg, covered with an ace wrap and a leg immobilizer. Nurse A said he/she called the resident's PCP for orders regarding the resident's left leg splint/soft cast. The resident's PCP said not to touch the splint/soft cast until the resident was assessed by the orthopedic physician. Nurse A did not assess the skin under the resident's left leg splint/soft cast because the PCP said not to remove the splint/soft cast. Nurse A recalled the splint/soft cast covered the resident's heel and the ace wrap covered the resident's toes. He/she notified the resident's PCP of the orthopedic physician's new orders on 9/7/17, and all orders were approved except for the wound specialist order. The PCP declined to have the resident assessed by a wound specialist at that time. Nurse A said he/she was busy that shift and notified the next shift nurse to transcribe the orthopedic physician's orders to the resident's POS. The facility usually has podus boots in central supply but there were none in stock on 9/7/17. Nurse A notified the central supply staff member of the order for the podus boot. The resident wore bunny boots for at least a week while waiting on the podus boot to arrive. Supervisors were aware the podus boot was not available. Nurse A did not know when the podus boot arrived or when it was applied to the resident's left foot. A podus boot has a hole in the heel, which keeps pressure off the heel. A podus boot and a bunny boot were not similar. During an interview on 10/3/17 at 12:20 P.M., Nurse Manager C said he/she assessed the resident, who upon readmission on 8/24/17, had a splint/soft cast and a leg immobilizer. A charge nurse, name unknown, notified him/her of a new black area on the resident's left heel on 9/8/17. He/she assessed the black area, as an unstageable pressure ulcer. The unstageable pressure ulcer was acquired at the facility while the resident resided on the skilled rehabilitation unit. He/she reported the area to the Assistant Director of Nurses (ADON). When a new area was assessed staff are expected to describe the area in the nurse's notes and follow up with wound care and the resident's PCP for treatment orders. During an interview on 10/3/17 at 1:05 P.M., Nurse Manager B said when the resident was admitted to the facility in 8/2017, there was a splint/soft cast on his/her left leg that went from the resident's toes to his/her upper calf and a leg immobilizer that went from the resident's left ankle to his/her mid-thigh. The resident transferred to his/her hall two weeks prior to discharge and already had a large facility acquired pressure ulcer on his/her left heel. Nurse Manager B thought the resident should be assessed by the facility's wound specialist. Staff contacted the resident's PCP three times to get an order for [REDACTED]. The wound specialist assessed the pressure ulcer on the resident's left heel the same day and it was determined to be an unstageable pressure ulcer. During an interview on 10/30/17 at 10:50 A.M., the central supply staff member said he works full time, from 6:30 A.M. through 3:00 P.M., Monday through Friday. When a new device was ordered, staff put a note on his desk. Most devices take three days for delivery to the facility. Podus boots are usually available at the facility, but they ran out of them in 9/2017. He was not aware they did not have any in stock. He is the only employee who orders supplies at the facility. He ordered six podus boots on 9/8/17, but the former administrator did not approve the invoice due to cost. He and the administrator went back and forth multiple times over the invoice and finally four podus boots were approved to be ordered on [DATE]. Podus boots and bunny boots are not the same device. There is a hole in the heel of a podus boot so there is no direct pressure on the heel. Bunny boots just pad the heel. During an interview on 11/2/17 at 9:50 A.M., a representative of the facility's medical supply company said an invoice was received on 9/15/17, for four podus boots. The shipment was delivered and signed for by facility staff, on 9/2017 at 10:58 A.M. During interviews on 10/3/17 at 8:45 A.M. and 2:00 P.M., with the ADON while the administrator was present, the ADON said the resident was admitted to the facility with a left leg splint/soft cast and a leg immobilizer, on 8/17/17. When the resident was admitted to the facility, the assigned nurse was responsible to document all admission paperwork was completed. When the assigned nurse was not able to complete the required admission assessment paperwork she expected the offgoing nurse to notify the next shift nurse in nurse report what additional admission assessment was not co (TRUNCATED)

See the deficiency cited at F 323. For examples see, abbreviated survey dated 8/26/11, at Event IDN9QF12.

Based on observation and interview, the facility failed to keep razors, cleaning products containing bleach and isopropanol (ingredient found in rubbing alcohol), secured in the Joachim and Zachary hall spa rooms. Thirty-three cognitively impaired residents resided on these halls, of which seven residents were ambulatory. The census was 189 with 116 in certified beds. 1. Observations of the Zachary hall spa room storage cabinet on 6/23/11 at 9:45 A.M. and on 6/29/11 at 8:26 A.M., showed the following: -Door to the spa room open; -No facility staff in the area; -Door to the storage cabinet contained no lock; -32 ounce bottle of Pro-Con (blue glass cleaner) on bottom shelf. The warning label, showed the product contained isopropanol, not to inhale spray or vapors, if swallowed, drink large amounts of water and contact a physician; -A box of more than 20 blue disposable razors. 2. Observations of the Joachim hall spa room storage cabinet on 6/23/11 at 10:05 A.M. and on 6/29/11 at 8:30 A.M., showed the following: -Door to the spa room open; -No facility staff in the area; -Door to storage cabinet contained no lock; -Two, 32 ounce bottles of Comet liquid cleaner on a shelf at eye level. The warning label, showed the product contained bleach, not to swallow, keep out of the reach of children and if consumed call a physician immediately; -Six, blue disposable razors. 3. During an interview on 6/29/11 at 9:35 A.M., the Administrator said the following: -He would not expect hazardous chemicals and/or razors to be accessible to residents unless it had been pre-determined to be safe for the resident to use independently; -Unlocked hazardous chemicals and razors are potential accidents; -The facility needed to re-evaluate the storage practices of hazardous chemicals and razors in the spa storage cabinets.

This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiency dated 6/29/11. Based on observation, interview and record review, the facility failed to assess, monitor, provide supervision and investigate injuries in order to prevent future injuries from occurring for four of 21 sampled residents (Resident #13, #40, #31 and #27). The census was 184 with 116 in certified beds. 1. Review of Resident #13's face sheet, showed the following: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/26/10, showed the following: -Required total assistance from the staff for transfers; -The resident's functional limitation in range of motion was impaired on both sides of the resident's upper and lower extremities. Review of the resident's physician order [REDACTED]. Review of the resident's care plan, dated 2/28/11, showed the following: -Problem: the resident at risk for falls due to a history of falls. -Goal: the resident would remain free from injury or incidence. -Approaches: the bed in the lowest position, wheelchair and bed alarm, sensor pad and scoop mattress. Instruct staff in safety awareness. -Problem: the resident required assistance for transfers. -Goal: the resident would be appropriately groomed and dressed. -Approaches: the resident was total care and required transfer with assist of two and a Hoyer lift. Review of the resident's nurses' notes, dated 3/2/11 with no time documented, showed an unidentified Certified Nursing Assistant (CNA) lowered the resident to the floor while the resident was in the Hoyer lift. During an interview on 8/23/11 at 3:35 P.M., CNA MM said he/she assisted the resident from the chair to the bed on 3/2/11, and the resident slid out of the Hoyer pad. Review of the fall committee review, no date, regarding the resident sliding out of the Hoyer lift on 3/2/11, showed the following: -Description of incident: transferred with Hoyer and resident lowered to floor. -Action plan: there was no documentation from the fall committee for an action plan for this fall. During an interview on 8/23/11 at 4:00 P.M., Director of Nursing (DON) K said the following: -She was not aware the resident slid out of the Hoyer pad on 3/2/11. -All residents were assessed after a fall, and placed on the resident's fall list for the committee to review. -The interventions and care plans were updated at that time. Review of the resident's care plan, showed no change or update in the resident's interventions after the resident's fall on 3/2/11. Review of the resident's fall assessment, showed the following: -3/18/11, staff assessed the resident's scored as 14 (greater than 10 meant high risk for falls). Review of the resident's nurses' notes, dated 4/1/11, showed the following: -7:30 A.M., the resident called for help and two unidentified nursing staff proceeded to place the resident on the Hoyer lift to reposition the resident in the chair. The resident continued to slide out of the Hoyer lift and as a result was lowered to the floor by the nursing staff. Review of the fall committee review, no date, regarding the resident sliding out of the Hoyer pad, showed the following: -Description of incident: the resident slid out of his/her wheelchair. The nurse and the CNA tried to readjust the resident with a Hoyer lift, but the resident slid out and was lowered to the floor. -Action plan: there was no documentation from the fall committee for an action plan for this fall. During an interview on 8/23/11 at 4:00 P.M., DON K said she was not aware the resident slid out of the Hoyer pad on 4/1/11. Review of the resident's care plan, showed no change or update in the interventions after the fall on 4/1/11. Review of the resident's quarterly MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Able to understand self and others; -Required extensive assistance from the staff for bed mobility, transfers, dressing, toilet use and personal hygiene; -The resident's functional limitation for range of motion was impaired on both sides of the resident's upper and lower extremities. Review of the resident's care plan, dated 5/26/11, showed no change in the interventions related to falls. Review of the resident's nurses notes, dated 6/6/11,(no time documented), showed the following: -A fall was reported to physician. The resident had an increase in confusion and saw things that were not there. -There was no documented description of the fall or an assessment of the fall by the nursing staff in the nurses' notes. Review of the resident's care plan, showed no documentation of the fall on 6/6/11 nor a change in the interventions related to the fall. Review of the resident's nurses' notes, showed the following: -8/12/11 at 12:30 P.M., an unidentified CNA lifted the resident up in the Hoyer lift and noted the resident slipping out of the Hoyer pad and lowered the resident back on the bed. -The CNA noted the chains of the Hoyer lift rubbed against the resident's arm and caused a bruise. Further review of the nurses' notes, dated 8/19/11, showed the following: -At 4:20 P.M., Nurse JJ was called to the resident's room and saw the resident on the floor. -CNA KK and CNA LL transferred the resident in the Hoyer lift and the resident started to slip out of the pad and the resident was lowered to the floor. -Nurse JJ noted the resident's right lower leg was rotated outward. -The resident was sent to the hospital emergency room for evaluation. During an interview on 8/25/11 at 12:36 A.M., CNA LL said the following: -On 8/19/11, the resident sat in his/her wheelchair and placed his/her call light on. The resident wanted to be changed. The resident sat on the Hoyer pad in his/her wheelchair. -CNA LL and CNA KK provided care for the resident and in the process, moved the resident back to the wheelchair. The resident started to slide forward out of the Hoyer pad and slid to the floor. During an interview on 8/23/11 at 3:45 P.M., CNA KK said the following: -On 8/19/11, the resident was transferred from the chair to the bed by CNA LL and CNA KK. -CNA KK positioned the Hoyer lift and elevated the resident off of the bed. CNA LL noticed the resident started to slide out of the Hoyer pad. -CNA LL grabbed the pad and the resident slid to the floor. During an interview on 8/23/11 at 3:35 P.M., CNA MM said the following: -He/she approached the resident's door and saw the resident sat on his/her butt. The Hoyer pad was pulled up over the resident's back and the Hoyer lift was tilted over the resident's legs. Review of the hospital emergency room summary, dated 8/19/11, showed the following: -The resident presented with right ankle injury after a fall during a transfer in a Hoyer lift when the mechanism failed and struck the resident's right ankle. -The resident had pain and significant swelling and ecchymosis (bruising) of the right ankle. -Vicodin (narcotic pain medicine) 5/500 prn (as needed) for pain. Review of the resident's emergency room x-rays, dated 8/19/11, showed the following: -Displaced bimalleolar (bones involving the ankle) fractures of the distal tibia (inner bone of the lower leg), medial malleolus and distal lateral fibula (outer bone of the lower leg). During an interview on 8/23/11 at 11:51 A.M., Occupational Therapist (OT) OO said the following: -Screening for the mode of transfer and the type of equipment used by the residents should be done on admission, every three months and after the resident had a fall. -Therapy and nursing, with a physician's input, determined the mode of transfer and the type of equipment needed for the resident. -Resident #13 was weak, unable to walk with no muscle tone and had no support of his/her lower extremities. The type of Hoyer pad he/she needed must have lower extremity support. -The Hoyer pad the resident had did not have straps between his/her legs and did not give the resident support during the transfers. -The resident would benefit from a pad with straps to support the resident's legs. Observation on 8/23/11 at 2:00 P.M., showed the resident sat in his/her wheelchair with his/her right foot and leg in a soft cast wrapped in an ace wrap and elevated. His/her left arm was in a sling. Multiple bruising was noted from the resident's left hand, extending upwards towards his/her elbow. During an interview on 8/23/11 at 2:00 P.M., the resident said the staff changed him/her and the Hoyer lift fell on his/her leg. The resident complained of pain in his/her leg and arm. Review of the nurses notes, showed the following: -On 8/22/11 at 1:30 A.M., the nurse wrote vicodin given at bedtime prior to transfer for leg pain. On 8/22/11 7:00 A.M. to 3:00 P.M. shift, resident complains of pain, vicodin given with some relief. Ortho appointment set up. Dr. here new orders given. Review of the medication administration record, showed an order to routinely give vicodin every 6 hours and the resident also had an order for [REDACTED]. During an interview on 8/23/11 at 3:45 P.M., CNA KK said he/she was not aware there were different Hoyer pads used with a resident with lower extremity weakness and no one at the facility informed him/her of the difference. During an interview on 8/25/11 at 9:27 A.M., CNA YY said he/she knew Hoyer pads come in different sizes and shapes. CNA YY was not aware of which type of pad to use with Resident #13. During an interview on 8/25/11 at 9:31 A.M., Nurse Y said the following: -The resident had a Hoyer pad that cradled the resident's body and did not provide support to the resident's lower extremities. -He/she would use a pad that provided support and would not use a pad that cradled the resident which may cause the resident to slide out. -Nurse Y did not know why the resident had a pad which did not support the resident's lower extremities. During an interview on 8/25/11 at 9:42 A.M., Nurse PP, a member of the fall committee, said the following: -The fall committee discussed the type of equipment needed for the resident. -A resident with no lower body strength should use the Hoyer pad which crossed between the resident's legs. This type of pad would provide support for the resident during transfer. During an interview on 8/25/11 at 9:48 A.M., Lead CNA QQ said the following: -The resident had no lower body strength and should have had a pad that crossed between the resident's legs. -The pad which crossed between the legs would support the resident and the resident would not slide out. -The staff was not told which pad to use and the staff only used the Hoyer lift assigned to the resident. During an interview on 8/25/11 at 12:31 P.M., Nurse RR said the following: -The fall committee reviewed incidents, developed and modified interventions on the resident after each fall. -Therapy and nursing decided the type of assistive device to be used by the staff for the residents. -When the CNAs had a problem with a resident's transfer, they went to the charge nurse. The charge nurse, with therapy, determined if the type of equipment was appropriate to meet the needs of the resident. -He/she was not aware the resident slid out of the Hoyer lift on 3/2/11, 4/1/11, 8/12/11, and 8/19/11. -He/she expected the staff to have assessed and reassessed the reason why the resident slid out of the Hoyer pad. -The resident who had no lower body strength should use a Hoyer lift with straps between the legs for support. Review of the facility's policy entitled, "Transfer", dated 7/12/09, showed the following: -Purpose: to insure optimum safety and comfort and to minimize the risk of injury for the resident. During an interview on 8/25/11 at 1:32 P.M., the Director of Therapy said the following: -She expected the nursing staff to inform therapy if a resident had any problems with transfers or equipment related to the transfers. -Therapy relied on the nursing staff to inform them of any changes in the resident's condition or any problems with transfer or equipment. During an interview on 8/25/11 at 12:48 P.M., Physician R said the following: -She expected the facility to follow their procedure or policy to assess the resident to determine the mode of transfer and the equipment needed to perform the transfers. -She expected the staff to use the appropriate equipment and Hoyer pad for the transfer of the residents. -The resident with no lower body strength needed the support from a Hoyer pad with straps. -She expected the staff to reevaluate the equipment to make sure it met the needs of the residents. -She was not aware the resident slid out of the Hoyer lift on 3/2/11, 4/1/11, 8/12/11, and 8/19/11. During an interview on 8/26/11 at 9:30 A.M., the administrator said he expected staff to use the appropriate equipment that met the needs of the residents. 2. Review of Resident #40's face sheet, showed the following: -Readmitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's MDS, dated [DATE], showed the following: -Required extensive assistance from the staff for bed mobility, transfers and toilet use; -The resident's functional limitation in range of motion was impaired on both sides of the resident's upper and lower extremities. Review of the resident's care plan received from the facility on 8/23/11, dated 4/26/11, showed the following: -Problem: the resident required assistance for activities for daily living (ADLs) due to generalized weakness; -Goal: the resident would be able to participate with ADLs; -Approach: transfers, the resident was limited with his/her transfers. Staff to assist as needed. Use a Sara lift (Stand and Rise Assisted Lift, a mechanical lift which requires some weight-bearing ability and upper body strength to hold a bar. Used to stand the resident in his/her room, toilet, bathing or common area). Review of the resident's restorative therapy record, dated 6/6/11, showed the following: -Transfer: the resident went from a minimal assistance to a moderate assistance; -Cognition: the resident needed encouragement; -Status: The resident had really declined in his/her ambulation for distance and endurance. The resident had problems with transfers with not picking up his/her left foot when he/she pivoted (turning). Review of the resident's physician order [REDACTED]. During an interview on 8/24/11 at 10:20 A.M., Nurse DD said the following: -The resident told Family Member SS, he/she complained of left shoulder pain on 8/5/11. Nurse DD did not call the resident's physician or inform the nursing staff of the resident's complaint of left shoulder pain or document the resident's complaints in the nurses' notes. -Nurse DD said he/she did not have time to document the incident in the nurses' notes because he/she was getting off duty. -Nurse DD did pass this information onto the next shift. Review of the resident's nurses' notes, showed the following: -On 8/6/11 at 3:00 P.M., the resident complained of left shoulder pain. On a scale of one to ten, the pain was a nine. -On 8/8/11 at 11:30 A.M., the resident complained of left arm, left shoulder down to the elbow, and left rib pain. At 4:30 P.M., the resident complained of left shoulder and rib pain. An x-ray of the resident's left shoulder was done. The resident was sent to the emergency room for evaluation. During an interview on 8/24/11 at 9:31 A.M., Nurse X said he/she worked during the 7:00 A.M. through 3:00 P.M. shift on 8/8/11, and found the resident in his/her bathroom on the toilet unattended. Nurse X and an unidentified CNA transferred the resident without a gait belt from the toilet to the resident's wheelchair. They did not use the SARA lift or a gait belt during the transfer. Nurse X did not document this incident in the resident's nurses' notes. During an interview on 8/24/11 at 10:20 A.M., Nurse DD said when he/she returned to the facility to work on 8/8/11 during the 3:00 P.M. through 11:00 P.M. shift, the resident still complained of left shoulder pain. He/she called the resident's physician for x-rays. Review of the resident's hospital emergency room record, dated 8/9/11, showed the resident was sent to the emergency room due to a left humerus fracture. Review of the hospital's x-ray of the left humerus (upper arm bone), dated 8/9/11, showed the result of no fracture. The resident was returned to the facility. Review of the resident's nurses' notes, showed the following: -8/10/11 through 8/12/11, there were no documentation of nurses' notes for all three shifts. -8/13/11 at 6:25 P.M., digitally removed a large amount of stool from the resident. No documentation of the resident's pain level. -8/14/11 through 8/17/11 no documentation of the resident's condition related to pain or how the fracture occurred for all three shifts. -8/18/11 at 6:30 P.M., the resident was transferred in the Sara lift and became unresponsive for 30 seconds. There were no documented nurses' notes on the resident's condition for the remainder of the shift, nor for the 11:00 P.M. through 7:00 A.M. shift. Further review of the resident's nurses' notes, dated 8/19/11, showed the following: -7:45 A.M., the resident remained in bed. There were no documented nurses' notes on the resident's condition. -12:05 P.M., the resident complained of left shoulder pain. -2:30 P.M., the resident complained of left pain below the resident's neck and tender to the touch. Review of the resident's nurses' notes, dated 8/20/11, showed the following: -12:15 A.M., the resident complained of left arm pain. There was no further documentation of the resident's left arm or left shoulder pain from 7:00 A.M., until 2:00 P.M. -2:00 P.M., the resident's Family Member (FM) SS said the resident complained of an increase in pain to the left shoulder area with dusky bruising to the left side of the neck. The shoulder was tender to touch. Review of the resident's left clavicle x-ray, dated 8/20/11, showed a displaced acute fracture of the mid-clavicle. During an interview on 8/23/11 at 11:51 A.M., Occupational Therapist (OT) OO, said the following: -Screening for the mode of transfer and the type of equipment used by the residents should be done on admission, every three months and after the resident had a fall. -Therapy and nursing, with a physician input, determined the mode of transfer and the type of equipment needed for the resident. -The resident had a previous fracture and had no upper body strength. -The resident's cognitive functioning had affected the resident in his/her transfers. During an interview on 8/24/11 at 1:53 P.M., DON K said the following: -The type of resident who should use the Sara lift must be able to hold onto the bars for support. -The residents who are unable to hold onto the bars should be reassessed by nursing and therapy. -The evaluations were done on admission, every three months, and if there was a change in condition of the resident. -A change in the resident's inability to hold on to the Sara lift bars should have been reassessed by nursing and therapy. Review of the resident's care plan, faxed to the surveyor on 8/24/11 at 4:32 P.M., and dated 4/26/11, showed an new intervention on the printed document: -Assist of two. (This information was not present on the original care plan obtained from the facility on 8/23/11.) During an interview on 8/25/11 at 9:42 A.M., Nurse PP, a member of the fall committee, said the following: -The fall committee discussed the type of equipment needed for the resident. -A Sara lift was used when a resident had upper body strength and was able to stand. -Without the upper body strength, the resident could slide through the pad. -Nurse RR was in charge of the fall committee and the evaluation for the types of equipment the residents used. During an interview on 8/25/11 at 9:48 A.M., Lead CNA QQ said the staff only used the Sara lift assigned to the resident. During an interview on 8/25/11 at 12:31 P.M., Nurse RR said the following: -The fall committee reviewed the incidents, developed and modified interventions for the residents after each fall. -Therapy and nursing decided the type of assistive device to be used by the staff for the resident. -When the CNAs had a problem with the resident's transfer, they went to the charge nurse and the charge nurse, with therapy, determined if the type of equipment was appropriate to meet the needs of the resident. -He/she expected the staff to have assessed and reassessed if the type of equipment was appropriate to meet the needs of the resident. -The resident who had no upper body strength should not use a Sara lift. During an interview on 8/25/11 at 1:32 P.M., the Director of Therapy said the following: -The type of resident who would benefit from the use of a Sara lift would be able to bear weight on the lower extremities and be able to hold or grip the bars on the Sara lift. -She expected the nursing staff to inform therapy if a resident had any problems with transfers or equipment related to the transfers. -Therapy relied on the nursing staff to inform them of any changes in the resident's condition. During an interview on 8/26/11 at 9:30 A.M., the administrator said he expected the staff to use the appropriate equipment that met the needs of the residents. 3. Review of Resident #31's quarterly MDS, dated [DATE], showed the following: -Cognitive impairments; -No behaviors; -Extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene; -Incontinent of bowel and bladder; -No ulcers, wounds or skin problems present. Review of the resident's nurse's notes, showed the following: -5/11/11 at 9:00 P.M., a certified nurse aide (CNA) called the nurse to the shower room. The resident had blood on his/her left sock. The resident's left leg was edematous (swollen). The sock was removed and staff noted a 3.0 centimeter (cm) skin tear on the back of the resident's left leg; -5/13/11 at 6:30 P.M., a CNA called the nurse into the resident's room. The CNA stated the resident was in his/her wheelchair going into his/her room and bumped his/her right leg on the foot board of the bed. The resident obtained a skin tear to the right leg. Review of the resident's rehabilitation screen dated 6/6/11, showed a quarterly review and no change in status. No evaluation indicated. Review of the resident's quarterly MDS dated [DATE], showed the following: -Cognitive impairments; -No behaviors; -Extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene; -Incontinent of bowel and bladder; -No ulcers, wounds or skin problems present; -Application of a non-surgical dressing to an area other than the feet. Further review of the resident's nurse's notes, showed the following: -6/11/11 at 1:30 P.M., staff changed the dressing to the right leg. Staff cleaned the wound, minimal serosanguineous (composed of serum and blood) drainage present; -7/5/11 at 12:40 A.M., staff noted a skin tear to back of the left forearm. The CNA said he/she attempted to see if the resident had been incontinent. The resident began to pull his/her blanket and obtained a skin tear; -7/21/11 at 4:00 A.M., all dressings to the resident's skin tears dry and intact. Geri-sleeves (used to prevent/reduce the occurrence of skin tears) in place. Both legs edematous and reddened; -8/3/11, (3:00 P.M. to 11:00 P.M., shift) staff changed the dressings on both legs; -8/13/11 at 12:15 A.M., the dressings on both arms are intact (No previous documentation regarding the right arm skin tear); -No further description or information regarding the cause of the multiple skin tears. Review of the resident's care plan on 8/17/11, showed staff updated 6/13/11, showed the following : -Problem: 5/11/11, skin tear on the right leg; -Approach: -treat the skin tear as ordered; -assess the resident for signs and symptoms of skin breakdown during activities of daily living care; -No updates to address additional skin tears or intervention. Review of the same care plan faxed by the facility on 8/18/11 at 2:13 P.M., showed the following addition: -5/13/11, (hand written) Tubigrip (an elasticized multi-purpose bandage that provides effective support with complete freedom of movements. Can be used to treat general edema, weak joints and soft tissues) to both arms and legs, nursing judgement. Review of the resident's physician order [REDACTED]. -[DIAGNOSES REDACTED]. -5/13/11, right leg skin tear, apply triple antibiotic ointment (TAO) and cover with a dry dressing once daily; -5/13/11, left leg skin tear, apply TAO and cover with a dry dressing once daily; -7/19/11, right hand skin tear, apply TAO and cover with a dry dressing (no frequency indicated); -7/19/11, right arm skin tear, apply Vaseline gauze (a fine mesh absorbent gauze impregnated with petroleum) every other evening; -7/26/11, left hand, apply TAO and a dry dressing once daily until healed; -7/26/11, left arm skin tear, apply Vaseline/petroleum dressing/gauze every other evening and cover with a gauze roll. Observation and interview on 8/18/11 at 9:35 A.M., showed the resident lay in bed awake, both his/her forearms wrapped with gauze from the wrist to the elbow. Both of the resident's legs were covered with Tubipad (tubular bandages with a layer of foam). The resident's feet and legs had 4+ pitting edema (pitting edema can be demonstrated by applying pressure to the swollen area by depressing the skin with a finger. If the pressing causes an indentation that persists for some time after the release of the pressure, the edema is referred to as pitting edema. Any form of pressure, such as from the elastic in socks, can induce pitting with this type of edema). Nurse X said all the areas with dressings were skin tears and he/she was unsure how the areas were obtained. He/she had not observed the resident's skin tears recently but previous observations showed the skin tears were really "nasty looking". Nurse X removed the gauze Vaseline and gauze wrap dressings from both of the resident's arms and showed the following: -On the back of the right forearm below the elbow, an area of pink tissue with no top layer of skin, approximately 7.0 cm long, 3.0 cm wide and less 0.1 cm deep; -On the resident's left forearm an area of pink tissue with no top layer of skin approximately 13.0 cm in length down the resident's arm, 4.0 cm wide at the top, 2.0 cm wide in the center and 5.0 cm wide at the bottom of the skin tear. The resident's left arm and hand showed several bruises dark purple in color. -Nurse X removed the Tubipad from the resident's right leg. The resident grimaced as the nurse removed the bandage. The resident's leg was indented at the center of the calf showing striated indentures in the shape of the Tubipad and gauze. The resident's calf appeared in the shape of an hour glass dented in where the Tubipad previously lay. The resident's right leg showed a pink tissue area with no top layer of skin approximately 1.5 cm long and 3.0 cm wide on the right outer portion of the leg below the knee. The inner side of the leg near the knee, showed a pink tissue area with no top layer of skin approximately 3.0 cm long by 2.0 cm wide. Nurse X removed the Tubipad and dressing from the resident's left leg and showed indention and striated indentures in the pattern of the Tubipad and gauze. Bruising was present and other small skin lesions. A pink tissue area with no top layer of skin approximately 8.0 cm long and 3.0 cm wide present on the outer side of the resident's calf below his/her knee. At the surveyors request, Director of Nursing (DON) L observed the resident's legs and instructed the staff to obtain a larger sized Tubipad bandage. During an interview on 8/18/11 at 9:50 A.M., with the administrator, DON K and DON L present, DON L said the following: -Staff implemented TubiGrip to prevent the resident's skin tears, she was not sure when the TubiGrip was initiated; -The resident's skin tears started out smaller and as "things progressed" the skin tears increased in size; -There have been different orders previously used to treat the skin tears; -Staff do not consistently document skin tear descriptions; During the same interview DON K said the following: -Staff do not measure skin tears; -Staff are to monitor skin tears, if there is a change in the skin tear's condition, staff should call the physician and obtain a different order. Review of a nurse's note (not in the resident's record on 8/17 or 8/18/11 during the onsite visit), faxed to the surveyor on 8/19/11 at 7:30 A.M., showed on 5/13/11 at 5:00 P.M., (late entry) due to the resident having frail skin staff will use Tubigrip to both of the arms and legs for added protection. During an interview on 8/18/11 at 3:35 P.M., DON L said the nurse forgot to add the information from 5/13/11 to the care plan and nurse's notes at that time, so he/she added it before the information was faxed to the surveyor. During an interview on 8/22/11 at 10:00 A.M., the resident's physician said the following: -Staff should notify him/her when skin tears are getting worse; -Staff should apply the appropriate size TubiGrip to avoid constriction and/or pressure. Review of the Tubipad Manufacturer's label on 8/22/11, showed the following: -Tubipad an elasticized tubular bandage with a layer of polyurethane foam; -Used for the prevention and treatment of [REDACTED]. -Instructions for use, pull into position over the area to be protected, with the foam padding next to the skin. If you are in doubt about the condition or if the condition worsens, discontinue use and seek medical advice. Review of the manufacture's information on 8/22/11, showed Tubigrip provides tissue support in the treatment of [REDACTED]. 4. Review of Resident #27's annual MDS dated [DATE], showed the following: -Severe cognitive impairment; -A non-ambulatory status; -No behavior issues; -Extensive staff assistance required for bed mobility, transfers and dressing; -Total staff assistance required for eating, hygiene and bathing. Review of the resident's rehabilitation screen dated 6/6/11, showed a quarterly review and no change in status. No evaluation indicated. Review of the care plan dated 6/8/11, showed the following: -Use tubi-grips due to resident scratching him/herself; -Follow facility skin care policy due to potential for skin breakdown resulting from incontinence and decreased bed mobility; -Potential for falls due to use of psychiatric medications; -No documentation of bruising or possible interventions. Review of the quarterly MDS notes dated 6/28/11, showed the resident's responsible party attended a care plan meeting at the facility. He/she asked about repairs needed to the resident's wheelchair. The note showed the social service director (SSD) would follow up on the repairs. Review of an e-mail dated 6/28/11 at 12:08 P.M., showed the SSD sent DON L and the central supply coordinator a message regarding the care plan with the residents responsible party concerning a new wheelchair. The current chair was broken. The SSD noted she thought she had talked to someone about this in the past. Review of the nurse's notes dated 7/13/11 at 1:00 P.M., showed a CNA brought the resident to Nurse Y after lunch with a deep purple colored bruise measuring 3 cm. by 2 cm. The resident's wheelchair was broken. Maintenance staff and occupational therapy (OT) staff fixed the chair. Resident's responsible party (RP) and physician made aware. New physician's orders [REDACTED].