Every finding on record at Maywood Terrace Living Center

Based on interview and record review, the facility failed to provide protective oversight for one sampled resident (Resident #5). The facility staff failed to provide suicidal precautions per facility policy and supervision for a resident who expressed on [DATE], to Certified Medication Technician (CMT) A that he/she wanted to die. CMT A said he/she was given no instructions on what to do under these circumstances and no suicidal precautions were put in place. On [DATE] about 8:00 A.M., the resident pulled out his/her dialysis catheter (a flexible plastic tube placed into a large vein (usually in the neck, chest, or groin) to remove and clean blood through a dialysis machine when a person's kidneys fail) after the CMT last rounded about 7:20 A.M. At 8:20 A.M., CMT A found the resident unresponsive, without pulse, and lying in a pool of blood. EMS (emergency medical services) pronounced the resident deceased at 9:12 A.M. The facility census was 55 residents.On [DATE] at 2:35 P.M., the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on [DATE]. On [DATE], facility administration was notified of the incident, an investigation immediately began, and corrective actions were implemented. The immediate jeopardy was corrected [DATE]. Review of facility the policy entitled Admissions Policies, revised [DATE], showed:-The objectives of our admission policies were to have assured that appropriate medical and financial records were provided to the facility prior to or upon the resident's admission.-It would be the responsibility of the administrator, through the admissions department, to have ensured that the established admission policies, as they may apply, were followed by the facility and resident. Review of facility policy entitled Suicide Threats, revised [DATE], showed:-Resident suicide threats would be taken seriously and addressed appropriately.-Examples of suicidal threats included statements such as: I'm going to kill myself, I want to harm myself, and/or giving a specific plan of how the resident may harm themself.-A staff member would have remained with the resident until the nurse supervisor/charge nurse arrives to evaluate the resident and deemed the resident safe.-After the resident was assessed in more detail, the nurse supervisor/charge nurse would have notified the resident's attending physician and responsible party and would seek further direction from the physician in the event the resident is actively suicidal.-All nursing personnel and other staff involved in caring for the resident would have been informed of the suicide threat and instructed to report changes in the resident's behavior immediately.-As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may have been initiated.-If the resident remained in the facility, staff would have monitored the resident's mood and behavior and updated care plans accordingly, until a physician had determined that a risk of suicide did not appear to be present. 1. Review of Resident #5's Pre-admission Screening and Resident Review (PASRR -a federal mandate that required Medicaid-certified nursing facilities to have evaluated and documented whether nursing home applicants or residents had a serious mental illness, intellectual disability, or related condition, and to have ensured they received appropriate placement and specialized services) (DA-124 A, B are the initial assessments for social and medical concerns and the 124 C is the Level 1 screening for individuals with mental illness diagnosis and intellectual/developmental disabilities), dated [DATE], indicated a PASRR Level 2 evaluation (an in-depth, face-to-face clinical assessment required by federal law when a preliminary Level 1 screen showed signs of a serious mental illness (SMI), intellectual disability (ID), or developmental disability (DD)) was required. Review of the resident's PASRR Level 2 evaluation, dated [DATE], that was found in the resident's medical record showed: -The resident had documented hospital emergency room visits for mental health issues in the past. -The resident was admitted to the hospital after he/she pulled out his/her temporary dialysis catheter.-He/She had made statements that he/she did not want to live anymore. -The incident occurred on the date of admission to the hospital. -He/She heard a voice that told him/her to continue with dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys were not able to filter the blood).-He/She required one to one monitoring and suicide precautions from [DATE] (date of admission to hospital) through [DATE].-Psychiatric consult notes documented:--Sleep disturbance.--Chronic pain.--Elevated anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus) level.--Psychomotor agitation (a medical symptom marked by unintentional, repetitive physical movements driven by inner mental tension and anxiety).--Constricted affect (a narrowed or limited range of outward emotional expression).--Dysphoric mood (a profound state of emotional discomfort, unease, and general dissatisfaction).-The resident required crisis intervention services:--The plan was to have emotional support, education, safety planning and case management to handle immediate crisis.--The plan was to have been developed to create clear steps that were to be taken to support the resident during a behavioral health crisis.--The plan was to have included who to contact for assistance, how to work together with the resident during a crisis, and how to have determined when the crisis was over.--The plan would have also identified a physician and emergency medical services that would have been contacted. --The resident required suicidal precautions be implemented. --The resident required 24-hour nursing care and supervision to ensure he/she was safe. Review of the Bock Associates referral letter, dated [DATE], showed the resident required:-Behavioral Support Plan.-Structured Environment.-ADL (activities of daily living) Program.-Medication Therapy.-Crisis Intervention Services.-Personal Support Program. Review of the transferring facility's Order Summary Report showed an order to monitor closely for clinical worsening, suicidality or unusual changes in behavior every shift, order dated [DATE]. Review of the residents admission Record showed the resident admitted to the facility on [DATE] with the following diagnosis. -End Stage Renal disease (ESRD) (a permanent kidney failure where your kidneys work at less than 15 percent of their normal capacity).-Major Depressive disorder (a common mental health condition. It causes lasting sadness, hopelessness, and a loss of joy in daily life. It goes far beyond normal grief or passing sadness and affects how you think, feel, and act for at least two weeks).-Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety). Review of the resident's baseline care plan, dated [DATE], showed:-Suicidal ideation, previous suicide attempt, or self-harm behaviors were not addressed.-No suicide precautions were listed.-No interventions for suicide preventions were listed. -No self-harm behaviors were listed. Review of a progress note for the resident, dated [DATE] at 10:46 A.M., typed by Licensed Practical Nurse (LPN) A showed:-At approximately 8:20 A.M., the nurse was called into the residents' room by a Certified Nurse Aide (CNA) A. -LPN A observed the resident lying on bed flat on his/her back with legs off the bed. -The resident was lying in a pool of blood and was unresponsive to verbal and physical stimulation. -LPN A checked for a pulse and was unable to obtain a pulse. -LPN A initiated the code, delegated one staff member to check code status, one to grab the crash cart, one to call EMS and three to put the resident on the floor. -Once code status was confirmed at 8:30 A.M., this nurse started CPR (cardiopulmonary resuscitation) and continued for five cycles until EMS arrived and took over on [DATE] at 8:43 A.M.-Family member and the Director of Nursing (DON) were notified. EMS pronounced the resident had passed away on [DATE] at 9:12 A.M. Review of the facility investigation, dated [DATE], showed: -CMT A said that on [DATE] at about 2:00 P.M., Resident #5 reported that he/she wanted to die. -The comment was immediately investigated by the DON.-Upon an interview with the resident, the resident did not state any plan to self-harm and his/her mood and affect immediately improved after scheduled medications were given.-CNA A last saw the resident on [DATE] at 7:00 A.M. -The CNA discovered the resident on [DATE] at 8:20 A.M. with large amounts of blood coming from the resident's dialysis catheter. During an interview on [DATE] at 9:20 A.M., CMT A said: -On [DATE], the resident told him/her that he/she wanted to die. -The resident did not have a plan of how he/she was going to self-harm.-He/She told the Assistant Director of Nursing (ADON).-The ADON went and talked to the resident. -He/She was not given any instructions on what interventions to do for the resident after he/she talked to the ADON.-The resident was a new resident to him/her.-No one at the facility had expressed that the resident had a prior suicide attempt in June of 2026. During an interview on [DATE] at 3:01 P.M., CNA A said: -The resident said that he/she wanted to die on [DATE] in the morning, but had no plan. -He/She told the ADON this.-He/She received no instructions from the ADON on what interventions to put in place.-He/She redirected the resident and moved him/her near the nurse's desk. -The resident was wanting something to sleep.-After the resident was given medication he/she seemed to get better-Had he/she known the resident had a previous suicide attempt he/she would have expected that interventions would have been put in place to protect the resident. -The interventions that were usually put in place were 15 minute checks or having the resident at the nurse's desk.-He/She found the resident on [DATE] at about 8:20 A.M. while passing breakfast trays.-The resident was found in a large pool of blood.-He/She called for the nurse. -The resident appeared to not be breathing. During an interview on [DATE] at 9:31 A.M., the ADON said: -No one had told him/her the resident had said that he/she wanted to die. -No one had brought to his/her attention the prior suicide attempt in June.-The MDS (minimum data set) Coordinator and DON were working the floor on [DATE]. -He/She had no interactions with the resident other than putting a Band Aid on his/her hand a day before, on [DATE]. During an interview on [DATE] at 1:15 P.M., LPN A said: -The resident arrived early evening on [DATE].-He/She reviewed paperwork sent with the resident from the transferring facility and there was no documentation of previous suicide attempt. -Prior to the resident arriving at the facility, he/she had received report from the transferring facility nurse and in that report, there was no mention of a suicide attempt or suicidal ideation, self-harm, or previous self-harm attempts. -It was his/her expectation that if something like that happened recently then that should have been given in report by the transferring facility nurse who had called with report. -During his/her time with the resident the resident never expressed any ideas of wanting to self-harm or suicidal ideation. -On [DATE], the resident was pleasant and had no suicidal ideation, no statement of wanting to harm self that he/she was aware of. -If he/she had known, the resident had a past suicide attempt of suicidal ideation then he/she would have put interventions in place to keep the resident safe. -The interventions that were usually put in place were 15-minute checks, having the resident at the nurse's desk, sending the resident out for evaluation by psychiatry. Review of a progress note for the resident, dated [DATE] at 3:43 P.M., by the Social Services Director (SSD) showed:-On Friday ([DATE]) evening, prior to the end of my workday, I was notified by the resident's family the resident had expressed thoughts of wanting to end his/her life in the past. -At the time, I was aware the resident had documented diagnoses, including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), anxiety, and dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses), and that similar statements and behaviors had been documented in his/her history. Based on the timing, I planned to document the family report in the electronic medical record (EMR) on Monday morning. -Before I returned to work, I was informed the resident had passed over the weekend. -This statement reflects my personal knowledge of the information provided to me and my intended actions regarding documentation. During an interview on [DATE] at 12:01 P.M., SSD said:-He/She wrote the progress the family had reported the resident had suicidal thoughts with no action right after admission on Thursday [DATE]. -He/She was going to address the family report of suicidal ideation on Monday [DATE] with the nursing staff and the DON; however, the resident died prior to his/her arrival to work. During an interview on [DATE] at 1:33 P.M., the MDS Coordinator said:-He/She was a part of the admission process. -From the time the resident arrived at the facility he/she expressed no thoughts of harming self. -He/She worked the night [DATE] as charge nurse and the resident had reported no thoughts of wanting to harm self. -None of the care staff for the resident had reported the resident had any thoughts of suicidal ideation. -Family Member A did not report during the admission process that the resident had ever tried suicide or thoughts of suicidal ideation. -Family Member A had not reported the reason why the resident had been hospitalized , just focused on the resident's time at the other nursing home.-His/Her time was focused on the admission process and getting information for the base line care plan. -Had the family reported the resident had attempted suicide then that would have been in the base line care plan and interventions put in place.-Had the prior facility disclosed the information of suicide attempt or suicidal ideation then the information would have been placed in the base line care plan with interventions. During an interview on [DATE] at 1:46 P.M., the DON said:-During the resident's time at the facility the resident had not made any remarks about wanting to die that were not resolved with medication. -He/She was unaware the resident had a prior suicide attempt. -The nursing home that transferred the resident to the facility had not informed the facility of the resident's past of self-harm. -Had he/she known of this, the base line care plan would have reflected this and frequent checks wound have been ongoing. During an interview on [DATE] at 11:50 A.M., the MDS Coordinator said:-All admission documents would have been reviewed within 24 hours.-For Resident #5 there was no mention of past suicide attempts, suicidal ideation, or self-harm listed in the last physician history and physical. -It was his/her expectation that if a resident had a history of self-harm or thoughts of self-harm that it would have been listed in the history and physical. -Resident #5 was admitted to the facility around 6:00 P.M. on [DATE], so paperwork would have been reviewed the next day. -For Resident #5 the facility did not receive all the paperwork needed from the transferring facility. --There were pages missing from the orders, and there was no DA-124.--The resident's orders showed the order section for the resident was 10 pages in length, but the facility only received seven out of the 10 pages. --There was an identification (ID) number for the DA-124, but the number was the wrong number for the resident. --On [DATE], he/she called the transferring facility to get the correct ID number for the DA-124 from the transferring facility. --When he/she called the transferring facility, he/she was told the person that he/she needed to talk to was not in and would have to call back. --He/She called the transferring facility back on [DATE] and got the correct ID number for the DA-124. --By the time he/she was able to print the DA-124 and the PASRR Level 2 it was later in the day, and he/she figured that he/she would just review it the next day.--He/She put the DA-124 and PASARR level 2 on his/her desk. During an interview on [DATE] at 12:04 P.M., SSD B from the transferring facility said:-All the paperwork was sent to the facility on [DATE].-The information sent was the admission record, care plan, orders, DA-124, and PASRR level 2.-He/She was never notified by the facility of any missing paperwork.-The paperwork was sent only one time that he/she was aware of. -All paperwork was sent to the facility in the referral packet. During an interview on [DATE] at 9:40 A.M., the DON said:-The resident arrived at the facility on [DATE] at 6:16 P.M. so all the admission paperwork sent with the resident from the transferring facility should have been reviewed on [DATE].-The admission paperwork should have been looked at by the SSD.-The SSD would send the paperwork to the MDS Coordinator, ADON, and himself/herself to review.-It was her expectation that all the admission paperwork be reviewed on the day received, unless received later in the day then on the following day. -When admission paperwork was reviewed and showed a history of self-harm, suicide attempt, or suicidal ideation then the facility would have put the appropriate interventions in place.-The interventions for suicide precautions could have included 15-minute checks, place next to nurses' station, one-to-one monitoring, etc. -He/She evaluated the resident when the statement was made, gave PRN medication and then the resident was satisfied and no longer wanted to harm him/herself. -His/Her expectation for staff was to assess and evaluate the resident when the resident said they wanted to harm themself. During an interview on [DATE] at 3:24 P.M., the resident's Family Member A said:-He/She thought it was a miscommunication between the facilities. -The facility was unaware of the resident's previous self-harm attempt.-He/She told the SSD the resident had made comments about making suicidal comments before. During an interview on [DATE] at 2:03 P.M., the Staffing Coordinator said:-He/She was familiar with the resident.-The resident had not expressed thoughts of suicidal ideation to anyone that he/she was aware of. -He/She was unaware of resident's history of suicide attempt.-Had he/she known of the resident's history of attempted suicide he/she would have talked to management to maybe have had the resident placed on one to one monitoring and would have informed staff of the need to watch the resident for suicidal ideation or possible suicide attempt.-As far as he/she knew no one at the facility knew of the resident's past of suicidal ideation and suicide attempt, and the transferring facility did not relay that information of suicide attempt. During an interview on [DATE] at 12:01 P.M., the SSD said if family revealed a history of past suicide attempt, suicidal ideation, self-harm, or thoughts of self-harm that would be reported to the DON, ADON, and MDS Coordinator immediately. During an interview on [DATE] at 1:55 P.M., ADON said:-The resident never reported wanting to self-harm to him/her.-None of the care staff caring for the resident reported to him/her the resident had voiced wanting to self-harm. -He/She was unaware of history of suicide attempt. -The resident was not having behaviors of suicidal ideation or suicide attempts. -If he/she knew the resident had had a history of suicide attempt or suicidal ideation he/she would have notified DON and placed the resident on one-to-one monitoring.-The resident gave no signs of wanting to commit suicide. During an interview on [DATE] at 2:48 P.M., CMT B said:-If the resident had a history of suicide attempt, suicidal ideation, or self-harm he/she would have expected that some sort of interventions would have been put in place to keep resident safe. -It was not given in report the resident had a previous suicide attempt. During an interview on [DATE] at 12:10, the DON and Administrator said the expectation for the admission process was that the admission paperwork that was brought with the resident would be reviewed the day the resident came into the facility or for after hour admissions the paperwork would be reviewed the next day by himself/herself and the MDS Coordinator. During an interview on [DATE] at 5:30 P.M., Medical Director said;-He/She had not been informed the resident had said that he/she wished they were dead.-It was his/her expectation if a resident had a history of suicide attempt, the facility would have had interventions in place. -It was his/her expectation if a resident had a history of suicide attempt or suicidal ideation that he/she would have been informed.-It was his/her expectation the facility would have reviewed all the paperwork at the time it was received, especially the PASRR Level 2. -It was his/her expectation if there was paperwork missing in the referral packet the facility would have requested all the paperwork from the transferring facility before accepting a new resident so an informed decision could be made. CMP 3125021

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #1) out of six sampled residents, was free from a significant medication error when on 4/1/26 the resident was administered five milliliters (mL) of Methadone HCL Oral solution (a long acting synthetic opioid used for chronic pain) instead of 0.5 mL that was ordered. The facility census was 48 residents.Review of the facility's policy, Administering Medications, dated April 2019 showed:-The Director of Nursing (DON) supervises and directs all personnel who administer medications.-Medications to be administered in accordance with prescriber's orders. -Medication errors to be documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and the need for additional staff training.-If a dosage was believed to be inappropriate or excessive for a resident, or a medication identified as having potential adverse consequences for the resident or suspected of being associated with adverse consequences, the person preparing or administering the medication should contact the prescriber, the resident's attending physician or the facility's Medical Director to discuss the concerns.-The individual administering the medication was to check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. (The five rights of medication administration). Review of the facility's policy, Medications Brought to the Facility by the Resident/Family dated April 2007 showed:-The facility should not ordinarily permit residents and families to bring medications into the facility.-The facility discourages the use of medications brought in from outside and would inform residents and families of that policy.-If a medication was not available or it was determined to be essential to the resident's life to be able to take a medication brought in from outside, the DON with the support of the attending physician and consultant pharmacist should check to ensure:-The contents of each container were labeled in accordance with established policies.-The contents of each container have been verified by a licensed pharmacist. Review of the facility's policy, Specific Medication Administration Procedures, dated 7/1/24 showed staff were to:-Review the 5 rights of medication administration three times.-Prior to removing the medication from the container; check the label against the order on the Medication Administration Record (MAR). 1. Review of Resident #1's admission Referral Packet dated 3/27/26 showed he/she had physician's orders that included Methadone 5 mg/5 mL solution, take 5 mg by G-Tube every 8 hours as needed for pain dated 3/17/26. Review of the resident's face sheet showed: -admitted on [DATE].-Diagnoses of Epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures (a temporary, uncontrolled surge of electrical activity in the brain that causes disturbances in movement, behavior, sensation, or awareness) caused by abnormal electrical activity in the brain), deletions from the autosomes (a genetic disorder which causes a mutation causing a wide range of developmental delays), pneumonitis (inflammation of the lung tissue due to inhalation of food and vomit), sepsis (a life- threatening emergency caused by the body's extreme dysfunctional response to an infection)and dysphagia (difficulty swallowing).-Gastrostomy Status (G-Tube is a surgical procedure where a feeding tube is placed directly into the stomach through the abdominal wall to provide nutrition, fluids, or medications).-Was on Hospice care (specialized comfort care for individuals with a terminal illness of six months or less to live). Review of the resident's Nurses' Note dated 3/30/26 showed the Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff for care planning) Coordinator had returned to the office to transcribe the resident's orders into the chart from the hospice paperwork received on 3/28/26 with Durable Power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known)/family member stating there was no change in the orders. Review of the resident's Hospice Note, dated 3/30/26, showed: -The resident had physician's orders for Methadone 10 mg/mL concentrate, give 0.5 mL (5 mg) per G-Tube every eight hours, last filled on 3/27/26.-On 3/30/26 the hospice nurse should have collaborated with the facility staff regarding the patient's medications. Review of the resident's Baseline Care Plan dated 3/30/26 showed he/she had:-PURA (Purine Rich Element Binding Protein A) syndrome (a rare genetic disorder that affects neurodevelopment).-Generalized pain.-An end stage disease, with a terminal prognosis (life expectancy less than six months). Review of the resident's admission MDS dated [DATE] showed the resident was non- verbal, unable to provide a Brief Interview for Mental Status (BIMS)- score was 99. Review of the resident's Physician's Order Sheet (POS) dated March 2026 showed the following orders:-Family to supply all medications, dated 3/30/26.-The resident was to receive Methadone HCL Oral solution 5 mg/5mL, give 5 mL by mouth three times a day for pain, dated 3/30/26. Review of the resident's Medication Administration Record (MAR) dated March 2026 showed:-The resident to receive Methadone HCL oral solution 5 mg/5 mL give 5mL by mouth three times a day for pain. -He/She was to be given one bedtime dose on 3/30/26.-The following day (3/31/26) he/she was to be administered three doses (morning, noon, and bedtime).-Facility staff documented that all doses were administered. Review of the resident's POS dated April 2026 showed the following orders:-Family to supply all medications, dated 3/30/26.-The resident was to receive Methadone HCL Oral solution 5 mg/5 mL, give 5 mL by mouth three times a day for pain, dated 3/30/26, and discontinued on 4/1/26.-Showed the corrected medication order entry for Methadone HCL Oral Concentrate 5 mg/0.5 mL. Give 0.5 mL enterally (feeding tube) every 8 hours for pain, dated 4/1/26, and documented to be on hold 4/1/26 to 4/4/26. Review of the resident's MAR dated April 2026 MAR showed:-The resident was to receive Methadone HCL oral solution 5 mg/5 mL give 5 mL by mouth three times a day for pain was given:-The morning dose on 4/1/26 was documented as administered. Review of the resident's Hospice Note, dated 4/1/26 showed: -On 4/1/26 at 1:35 P.M., the DON had called and reported the resident had received a total of 25 mg of Methadone rather than the prescribed dose of 5 mg. -The person (nurse) who had administered the medication saw 5.0 mL instead of 0.5 mL. -This (error) was not discovered until approximately 1:00 P.M. (on 4/1/26).-Per the DON's report the resident was sleeping, respirations were 14 to 16 (per minute), they did not do any additional vital signs because he/she was sleeping.-Upon examination of the bottle of Methadone the concentration was 10 mg/mL with a dosage of 0.5 mL (to be given) every eight hours. -The DON reported the nurse administered Methadone 5 mL instead of 0.5 mL. -The medication was entered incorrectly into the computer system.-The nurse who gave the medication noticed the discrepancy between the computer screen and the bottle but decided to dose based on what the computer said instead of what the bottle said.-The nurse, Licensed Practical Nurse (LPN) A did not perform any safety checks or alert the DON prior to administration. -The DON said the dose was given at 8:00 A.M. and the patient went to sleep at 9:00 A.M. or 9:30 A.M. and had been asleep since then. -The DON was not made aware of anything until 11:30 A.M. (on 4/1/26), more than three hours after the dose was given. -The DON said he/she should have double-checked the computer order. Review of the facility investigation dated 4/1/26 included a picture of the resident's bottle of Methadone (a specific brand-name, cherry-flavored, pre-mixed liquid formulation of methadone, designed to be 10 times more concentrated (10 mg/mL) than traditional pharmacy-compounded methadone solutions (1 mg/mL) showed Methadone Hydrochloride (HCL) 10 mg/mL concentration, last filled 3/17/26, take 0.5 mL (5 mg) by G-Tube every eight hours. Review of the resident's Nurses' Note dated 4/1/26 at 4:30 P.M., completed by the DON showed he/she called Poison Control and was advised to monitor the resident's vital signs for two to three days due to the half-life of the medication given. During an interview on 4/15/26 at 1:00 P.M., LPN A said:-The resident admitted to the facility on [DATE].-His/Her first day working with the resident was on 4/1/26.-All the resident's medications were to be administered through his/her feeding tube.-The order on the resident's MAR showed to administer Methadone 5 mL/5 mg three times a day (TID) via the resident's feeding tube.-He/She went to administer the resident his/her medication at 7:45 A.M. (4/1/26), on the way to the resident he/she spilled the medication, he/she obtained and gave a replacement dose.-He/She informed the DON that he/she needed help wasting the dose that was spilled in the Mediprosity (electronic narcotic tracking system) system.-About 10:30 A.M., he/she and the DON went to document the spilled amount as a waste. -He/She and the DON then discovered the medication error as the Mediprosity system said to administer 0.5 mL not 5.0 mL that was given. -He/She had looked at the order on the MAR and had not compared what the order on the bottle of Methadone to the order on the MAR. -The DON informed the resident's LPN D a family member of the resident working at the facility of the error. -The DON verified what the correct dose was with the DPOA, which should have been to administer Methadone HCL Oral Concentrate 5 mg/0.5 mL. Give 0.5 mL enterally (feeding tube) every 8 hours for pain-He/She should have compared the order on the MAR to what the order on the medication bottle showed.-In the past hospice has changed orders but used the same bottle with a different amount to have been given. -He/She was aware of the five rights of medication administration and had not followed it. During an interview on 4/15/26 at 3:15 P.M., the DON said:-On 4/1/26 at around 11:00 A.M., LPN A said he/she had spilled the resident's Methadone and needed to waste it in the Mediprosity system.-The nurse said he/she needed to waste 5 mL. -LPN A should have given 0.5 mL but gave 5.0 mL of the Methadone.-They recorded the waste as the LPN had spilled the medication and needed a second dose which he/she had given to the resident. -He/She went to assess the resident, who was sitting in his/her chair resting with his/her eyes closed.-Hospice had documented the resident was terminal and had been receiving hospice care at home. -The medications for the resident had come from home supplied by LPN D, who was a nurse at the facility. -The physician had written an order stating the family was to supply the medications.-The facility pharmacy should have verified the medications LPN D had brought in.-He/She had put the order in Mediprosity. -The order on the bottle of Methadone from home said to give 0.5 mL TID.-The LPN D had entered the order into the MAR system which said to give 5 mL not 0.5 mL that was on the bottle. -Usually, the physician was notified of the ordered medications and would sign off on them.-The resident's original orders had come from hospice. -He/She had not had anyone bring in their own medications upon admission.-The medications were verified by the hospice pharmacy before they went to the resident's home.-He/She did not know anything about hospice nurse coming into the facility to verify the resident's medications. During an interview on 4/15/26 at 1:50 P.M., the Administrator said:-He/She had started a QAPI about the medication error on 4/1/26. The root cause was the facility received an order from hospice that showed to give 5 mL TID.-On the bottle of Methadone that the family had brought in from home provided by hospice showed to give 0.5 mL. -The resident had been given the correct dose once on 3/30/26 and three times on 3/31/26.-The error happened on 4/1/26 with the morning dose. -The coroner came to the facility and took the bottle of Methadone with him/her after the resident passed. -The facility had a picture of the bottle of Methadone the coroner took with him/her.-The picture of the resident's bottle of Methadone showed:--Take 0.5 mL (5 mg) by G Tube every (8 hours) Methadone HCL 10 MG/mL. (0.5 mL equals 5 mg, 5 mL equals 50 mg). During an interview on 4/17/26 at 9:00 A.M., LPN B said:-He/She worked with the resident on 3/31/26.-He/She took the medication from the nurses' cart and followed the directions on the bottle.-He/She gave the morning and noon dose of medication on 3/31/26.-He/She knows about the five rights of medication administration and did not follow them.-He/She should have compared the bottle of Methadone to the order on the computer and did not do that or he/she may have caught the discrepancy if he/she had.-He/She gave the medication to the LPN D to give to the resident on 3/31/26 and signed off on it as given.-He/She should not have given the medication to LPN D as he/she did not see the resident take the medication, but he/she was very busy.-Hospice came in to see the resident. During an interview on 4/17/26 at 9:30 A.M., LPN C said:-He/She had worked with the resident a couple of weeks ago.-He/She administered the dose that was on the bottle, but did not look at the MAR.-If he/she had compared what was on the bottle to what the MAR said he/she may have noticed the discrepancy. -He/She knows about the five rights of medication administration and had not followed them.-He/She worked nights and administered the Methadone on 3/30/26 and 3/31/26 the night dose.-The resident was up until 3:00 A.M.-The medications should have been checked by the facility pharmacy when they were brought into the facility. During an interview on 4/17/26 at 9:30 A.M., the Hospice Medical Director said:-The dose was to have been 0.5 mL. The prescription was 10 mg/mL so if the resident received 5.0 mL then the resident received 50 mg.-They do not send medications from the home to a facility.-The hospice nurse went to the facility to do the medication reconciliation and facility staff declined to allow the hospice nurse to do the review. During an interview on 4/17/26 at 10:10 A.M., the facility Pharmacist said:-Medications were verified by the hospice pharmacist before they were sent to the resident's home.-He/She would not have accepted the medications if he/she was the facility especially since there was an opened bottle (the Methadone) as you would not be able to verify the contents.-Usually, hospice would send them the prescriptions before the resident went to the facility, and they would fill the prescription at no cost to family then it would be sent to the facility.-The wrong amount was entered into the computer.-The nursing home staff should have verified the amount on the bottle of Methadone to the prescription on the computer. -They deliver to the facility six days a week. During an interview on 4/21/26 at 10:00 A.M., Hospice Registered Nurse (RN) A said:-On 3/30/26 the resident was admitted to the facility with a medication list and the medications which included a bottle of Methadone.-He/She was told the medication had already been verified and entered into the computer system, so it was done.-If he/she had verified the medications he/she would have caught discrepancy in the order and on the opened bottle of Methadone.-The bottle of Methadone was 10 mg/1 mL, 0.5 mL was to have been given three times a day.-50 mg was given.-New medications should have been ordered from the pharmacy and verified by the nurse who accepted the medications from the pharmacy. 2972671

Based on observation, interview and record review, the facility failed to ensure safe storage and labeling of narcotic medication to include the date and resident's name when opened for one sampled resident (Resident #18) and one supplemental resident (Resident #37) out of 13 sampled residents and 12 supplemental residents that were stored in one of one medication carts; failed to ensure there were no expired medications in the medication room refrigerator, failed to ensure that expired medical dressing supplies were disposed of, failed to ensure an opened insulin pen was dated, labeled, and properly stored, failed to ensure that resident's personal food and drink items, supplements, and medications were not stored in the same refrigerator and failed to ensure proper defrosting was done in one out two medication storage rooms. The facility also failed to ensure the refrigerators were properly cleaned and medications were stored in a clean and sanitary environment to maintain drug integrity and prevent contamination in two out of two medication storage rooms. The facility census was 49 residents.Review of the facility Medication Administration policy dated April 2019 showed:-Insulin pens are clearly labeled with the resident's name or other identifying information. -Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident.-The expiration/beyond use date on the medication label is checked prior to administering.-When opening a multi-dose container, the date opened should be recorded on the container. Review of the facility's Medication Storage of the Facility policy dated 7/1/24, did not address any types of medications other than controlled (a drug or chemical whose manufacture, possession, and use is regulated by a government and hold the risk of abuse or dependence). Review of the facility's maintenance and cleaning log form dated 3/14/17, showed a blank form with no entries for refrigerator cleanings. The forms indicated the refrigerators were to be cleaned every month. 1. Review of Resident #18's admission record showed he/she was receiving hospice care/services (a special kind of care that focuses on a person's quality of life and dignity as they near the end of their life) related to a stroke. Review of the resident's physician order sheet (POS) dated March 2026 showed:-Morphine Sulfate (Concentrate) Oral Solution 20 milligrams/milliliters (mg/ml) (Morphine Sulfate), give 0.25 ml by mouth every one hour as needed for air hunger and pain ordered on 12/16/25.-Morphine Sulfate (Concentrate) Solution 20 mg/ml give 0.25 ml by mouth three times a day for increased pain and agitation ordered on 3/8/26. -Lorazepam (used to manage anxiety, terminal agitation, restlessness, and severe shortness of breath) Concentrate 2 mg/ml give 0.25 ml by mouth every three hours for increase pain and agitation was ordered on 3/7/26. Review of the resident's nursing medication administration record (MAR) dated 3/1/26 to 3/31/26 showed:-Morphine as needed was given 3/3/26 and was effective. -New order for scheduled morphine was dated 3/7/26. -Refer to medication administration related to morphine. Observation on 3/9/26 at 12:38 P.M., of the resident's morphine bottle showed:-Licensed Practical Nurse (LPN) B and Regional Nurse had a potential concern due to a possible color change with the resident's morphine. -The resident's bottle of morphine had no date on the bottle or on the box when the medication was opened. During an interview on 3/9/26 at 12:38 P.M. LPN B said he/she would replace the resident's morphine medication out of the facility's emergency medication kit (E-Kit). Observation on 3/9/26 at 1:13 P.M., of medication administration by LPN B showed: -He/she had obtained house stock bottle of morphine out of the E-Kit and entered new medication data into the facility new electronic monitoring system and electronic narcotic medication accountability system, (replaced paper tracking of controlled substance medications). -LPN B gave the resident a scheduled dose of morphine 0.25 ml three times a day for pain and shortness of air. Observation on 3/9/26 at 1:30 P.M., of the west nurse's medication cart, with LPN B showed the resident had an open box of lorazepam (used to treat anxiety) 2 mg/ml the bottle was not labeled with the resident's name or dated when it was opened. 2. Review of Supplemental Resident #37's admission record showed he/she admitted with a diagnosis of encephalopathy (a broad term for any disease, damage, or malfunction of the brain that alters mental state, causing symptoms like confusion, memory loss, and personality changes). Review of the resident's POS dated 2/21/26 showed:-Morphine Sulfate (Concentrate) Solution 20 mg/ml Give 0.25 ml by sublingually every four hours as needed for moderate pain and shortness of air.-Morphine Sulfate (Concentrate) Solution 20 mg/ml Give 0.50 ml by sublingually every four hours as needed for mild pain and shortness of air.-Morphine Sulfate (Concentrate) Solution 20 mg/ml Give 0.75 ml by sublingually every four hours as needed for moderate pain and shortness of air. -Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 1ml by sublingually every four hours as needed for moderate pain and shortness of air.-Hospice services discontinued on 3/9/26. Observation on 3/9/26 at 1:30 P.M., of the west nurse's medication cart, with LPN B showed the resident had a box with morphine 20mg/ml there was no date on the box or bottle when it was opened. 3. Observation on 3/9/26 at 1:15 P.M. of the north unit medication storage room showed:-Excessive ice buildup in the freezer section of the refrigerator that needed defrosting.-The medication refrigerator had visible debris, dried spills, and residue on the interior surfaces.-One opened ice cream dessert cup in the medication refrigerator.-One can of soda/energy drink in the door of the medication refrigerator.-The medication refrigerator contained food, drink, supplements, and medications.-15 bagged and unbagged bisacodyl (fast-acting, stimulant laxatives used to relieve occasional constipation) suppositories that expired on 3/27/25, 10/07/25 and 1/16/26.-There were food items that included packaged snacks, on the counter.-Multiple wound care bandages that expired in October 2025.-One NovoLog insulin pen on the counter unlabeled, undated, not in the original pharmacy bag with a pen needle still attached.-The overall condition of the room lacked a routine and thorough cleaning as evidenced by visible dust and residue on the surfaces and the floor. 4. Observation on 3/9/26 at 2:12 P.M. of the west medication storage room showed the medication refrigerator had visible debris, dried spills, as well as residue and dust on interior surfaces and the floor. There was paper/cardboard on the floor. 5. During an interview on 3/9/26 at 12:56 P.M. Certified Medication Technician (CMT) D said: -Medication should be dated when opened on the box and the medication bottle. -CMT's were only allowed to administer scheduled narcotics.-The facility had a new control substance electronic accountability system. During an interview on 3/9/26 at 1:32 P.M., LPN A said:-He/She was not sure what the cleaning or defrosting schedule was.-Expired items should not be kept in the refrigerator.-Supplements and medications should be in separate refrigerators.-There should not be personal food items in the same refrigerator with medications and supplements.-All medications should have been labeled.-There should not have been an insulin pen unlabeled, undated, with the needle still attached on the counter. During an interview on 3/9/26 at 1:40 P.M. LPN B said:-Medication should be labeled with the resident's name and the date it was opened on the medication container (storage box) and the bottle of medication. -The facility had a new medication electronic accountability system for controlled substances. -The system required licensed nurses and CMT's to enter the electronic medication control substance medication system when a controlled substance medication had been given and tally the amount left. During an interview on 3/13/26 at 11:35 P.M., LPN C said:-He/She was not sure what the cleaning and defrosting schedule was.-The housekeeping department was responsible for cleaning the refrigerators.-He/She would not expect medications, supplements, and residents' personal food and drink items to be stored in the same refrigerator.-There should never be food or unlabeled medication, such as insulin pens and needles on the medication room counter.During an interview on 3/13/26 at 12:15 P.M., Housekeeper B said:-The housekeeping department was responsible for cleaning the medication refrigerators.-The cleaning schedule was twice a month.-The defrosting schedule was every two weeks. During an interview on 3/13/26 at 12:24 P.M., the DON said:-The medication refrigerators should be cleaned weekly.-The medication refrigerators should be defrosted as needed.-The night shift nurse was responsible for making sure this was done.-He/She would not expect medications, supplements, and residents' personal food and drink items to be stored in the same refrigerator.-There should never be food or unlabeled medication, such as insulin pens and needles on the medication room counter. During an interview on 3/16/26 at 12:58 P.M., the Director of Nursing (DON) said:-He/she would expect licensed nurses and CMT's to ensure medications were labeled with the resident's name and the date the medication was opened on the container and the bottle. -Night nursing staff were responsible for auditing the medication cart for safe storage and labeling of medications.

Based on observation and interview, the facility failed to maintain nozzles of the dishwasher spray wand free of debris; failed to maintain the vent over the clean side of the dishwasher free of a heavy buildup of dust; failed to discard one damaged mitten; failed to ensure there was an air gap between the drain from the ice machine and the floor drain; failed to ensure the container of utensils didn't have debris at the bottom of the utensil container; failed to ensure the lemon juice was refrigerated; failed to ensure the light fixtures in the kitchen were free from a dust buildup; failed to have the correct kind of sanitizer test strips available; failed to maintain two cutting boards free from numerous grooves and indentations; failed to ensure both light bulbs for the range hood illuminated; and failed to use a three step process to wash the food processor after use, in the upstairs kitchenette. This practice potentially affected all residents. The facility census was 49 residents. 1. Observation on 3/9/26 from 10:34 A.M. to 10:42 A.M., during the initial kitchen observation showed:-A buildup of dust inside the vent over the clean side of the dishwasher. -One damaged mitten.-The absence of an air gap between the drainage pipe from the ice machine and the floor drain.-One bottle of lemon juice that was unrefrigerated.-The presence of dust on the light fixtures over the freezer and the dishwashing area.2. Observation on 3/12/26 from 6:11 A.M. to 9:09 A.M., during the breakfast meal preparation showed:-A buildup of dust inside the vent over the clean side of the dishwasher. -One damaged mitten.-The absence of an air gap between the drainage pipe from the ice machine and the floor drain.-One bottle of lemon juice that was unrefrigerated.-The presence of dust on the light fixtures over the freezer and the dishwashing area.-The presence of a pink substance in the ice machine.-The presence of debris on the bottom of the utensil container.-The absence of chlorine test strips to match their chosen sanitizer of chlorine.-One yellow cutting board damaged and with stains that could not be removed.-One light bulb on the range hood that was not illuminated.-Numerous indentations on the cutting board at the steam table.-The handle of the margarine brush was damaged and not able to be cleaned.-The Dietary Manager (DM) used a one step process without dishwashing liquid, to wash the food processor in the upstairs kitchenette.3. During an interview on 3/12/26 at 11:07 A.M. the DM said:-He/She took over as the DM two weeks ago.-The lemon juice had set out for about two weeks. -The dietary department had not started a program of regular inspection for the cutting boards.-The light bulb had been out for a couple of months. -He/She just washed the food processor and did not use any dishwashing liquid because it was done that way in the past.-He/She did not notice there was dust on the light fixtures.-He/She had to order to the test strips.-He/She had worked for about a year at the facility and the cutting board at the steam table had those indentations for all that time-He/She needed to throw out the mitten with the holes. -The handle for the margarine brush was very damaged from being melted so many times.

Based on observation, interview and record review, the facility failed to ensure infection control practices to prevent cross contamination were implemented during resident indwelling urinary catheter (a flexible, thin tube inserted into the bladder to drain urine when a person cannot urinate naturally) and incontinence care for two sampled resident (Resident #5, and #6) and during wound care for one sampled resident (Resident #6); failed to ensure appropriate hand hygiene was performed during incontinence care for one resident (Resident #35); failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff did not use the proper Enhanced Barrier Precaution (EBP) signage for one resident with an indwelling medical device (Resident #10) and failed to ensure that the Personal Protection Equipment (PPE) carts in hall were adequately stocked; failed to ensure proper sanitation of shared medical equipment before use, between residents and after use for one sampled resident (Resident #41) and one supplemental resident (Resident #48); failed to maintain a sanitary environment when basins used for resident care, were stored directly on the bathroom floor for two sampled residents (Resident #35 and #10) who were dependent on staff for Activities of Daily Living (ADLs) and incontinence care; failed to ensure appropriate infection prevention and control techniques and maintain aseptic (essential infection control practices, such as hand hygiene, PPE use, and creating a sterile field, designed to prevent healthcare-associated infections (HAIs) practices during administration of eyes drops for one supplemental resident (Resident #46) and failed to perform proper hand hygiene and apply gloves before he/she picked up food with his/her hand and placed it into the residents' mouth for one supplemental resident (Resident #19) out of 13 sampled residents and 12 supplemental residents; and failed to complete tuberculosis (TB-a contagious, often severe infection primarily affecting the lungs caused by Mycobacterium tuberculosis bacteria) testing timely upon hire for five of 9 sampled employees. The facility census was 49 residents.Review of the facility Handwashing policy and procedure dated October 2022, showed there was no documentation showing when the nursing staff should wash or sanitize their hands during resident care. It showed how to wash hands. Review of the facility Catheter Care policy and procedure dated October 2022, showed:-The staff should wash hands and explain the procedure to the resident. -Place a towel under the catheter tubing before washing. Apply soap to the washcloth and clean around meatus (the urethral opening and the external portion of a urinary catheter to prevent infections), avoiding tugging the catheter, moving in one direction, away from the meatus. Use a clean cloth for each stroke. Rinse around the meatus and use a clean cloth for each stroke. -With a clean dry towel dry around the meatus. Rinse at least 4 inches of the catheter nearest the meatus, moving away from the meatus. Use a clean cloth for each stroke. With a clean dry towel, dry at least 4 inches of the catheter nearest to the meatus, moving away from the meatus. Remove and discard gloves and wash hands. Review of the facility's Enhanced Barrier Precautions policy dated 3/20/24 showed:-Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reducetransmission of multidrug-resistant organisms that employs targeted gown and gloves use during highcontact resident care activities.-All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions.-The facility will have the discretion on how to communicate to staff which residents requirethe use of EBP, as long as staff are aware of which residents require the use of EBP prior toproviding high-contact care activities.- Enhanced barrier precautions will be initiated for residents with any of the following:I. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealedsurgical wounds, and chronic venous stasis ulcers) and/or indwelling/implanted medicaldevices (e.g., central lines, po11s, urinary catheters, feeding tubes,tracheostomy/ventilator tubes) even if the resident is not known to be infected orcolonized with a MDRO.II. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do nototherwise apply.-Make gowns and gloves available immediately near or outside of the res ident's room. Note:face protection may also be needed if performing activity with risk of splash or spray (i.e.,wound irrigation, tracheostomy care).-Ensure access to alcohol-based hand mb in every resident room (ideally both inside andoutside of the room).-Provide education to residents and visitors.- Place a yellow sticker or magnet on the name plate of the resident's door to identify the needof EBP. A medical equipment sanitation policy was requested but not provided at the time of exit. Review of the facility's Eye Drop Administration policy revised on 09/17/25 showed:- Equipment Required:A. Eye drop medication.B. Gauze pad, cotton ball, or tissue.C. Examination gloves.D. Barrier (e.g., disposable tray or plastic cup).E. Medication Administration Record (MAR).F. Waste receptacle.G. Drug reference (available in facility).-If administering medications to both eyes, use a different gloved finger to apply pressure to the inner tear duct. If the eye medication is an antibiotic or anti-viral and the resident has an active eye infection, change gloves between eyes. If one eye is infected, treat the infected eye last. A donning gloves policy was requested but not provided. The facility only provided a list of instructions on how to don gloves. 1. Review of Resident #6's admission record showed he/she admitted with the following diagnoses:-Stage IV pressure injury/wound (a severe, full-thickness wound involving extensive tissue loss, with directly exposed muscle, tendon, or bone) to the coccyx (tail bone area).-Had an indwelling urinary catheter. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff for care planning) dated 1/5/26 showed:-Usually understands may miss some or part/intent of message but comprehends most conversation.-admitted with an indwelling catheter. -admitted with pressure wound. Review of the resident's Care Plan initiated on 1/19/26 and revised on 3/3/26 and 3/11/26 showed:-The resident had wounds. --Wound care and treatment to wound as ordered by prescriber. -The resident was on EBP related to wounds and indwelling catheter initiated on 3/11/26. --Direct care staff were to follow EBP and to utilize gowns and gloves for all personal cares. -He/she had an indwelling urinary catheter: 18 French (Fr a measure of the outer diameter of a catheter) with a 10 cubic centimeters (cc) balloon due to pressure ulcer to the coccyx. --Position urinary catheter bag and tubing below the level of the bladder and way from entrance room door. Review of the resident's Physician Order Sheet (POS) dated March 2026 showed:-EBP related to wounds. Wear gown and gloves for all high contact resident care activities, was ordered on 1/9/26. -Irrigate urinary catheter with 30 milliliters (ml) of normal saline as needed for occlusion, was ordered on 11/19/25.-Change urinary catheter: 18 Fr with a 10 ml [NAME] bulb, related to Stage IV pressure injury as needed for occlusion or leakage and one time a day starting on the 25th and ending on the 25th every month, was ordered on 11/19/25. -Nursing staff were to cleanse the resident wound to the sacrum with wound cleanser/normal saline pat dry with 4x4 gauze pad and pack wound with collagen particles powder, then cover the wound with a dry dressing, change dressing every dayshift and as needed if soiled, was ordered on 3/6/26. Observation on 3/10/26 at 10:08 A.M., of the resident's care showed Certified Nursing Assistant (CNA) A:-Entered the resident's room and put on gloves then proceeded to empty the resident's foley catheter drainage bag. -Laid the graduate container on top of the mattress at the foot of the resident's bed while empty the drainage bag. -Emptied the graduate container in the toilet, removed the gloves and sanitized his/her hands. -Was waiting on another staff member to assist with resident care and transfer. Observation on 3/10/26 at 10:15 A.M., of the resident's catheter care showed:-The resident had no signage posted for EBP. -CNA A and CNA B entered the resident room with no gown applied and grabbed clean gloves from box. -CNA A dropped one of the gloves and then grabbed the glove off the ground and put it on his/her hand. -CNA A proceed to provide urinary catheter care and incontinent care for the resident, with the glove that had been dropped on the ground. -CNA A completed the care in the front and with same gloved hands turned the resident to his/her side and completed incontinent care to the resident's bottom. -CNA B placed the resident's urinary catheter bag on his/her mattress at the foot of the bed during personal cares (at the level of the bladder).-CNA A removed his/her soiled gloves and without sanitizing his/her hands, placed clean gloves on his/her hands. -CNA B reentered the room placed clean gloves on his/her hands without washing or sanitizing his/her hands.-Resident care was completed by CNA A. -CNA A and CNA B removed the soiled gloves and washed their hands with soap and water prior to leaving the resident's room. Observation on 3/10/26 at 10:30 A.M., of the resident's wound care showed:-The Infection Control Preventionist (ICP) and Licensed Practical Nurse (LPN) A entered the resident's room and applied gown and gloves. -The old dressing was falling off and was removed by LPN A.-The coccyx wound had no drainage noted and was the size of quarter. -LPN A provided wound care he/she cleansed the wound with wound cleanser, with same gloved hands, he/she applied collagen particles powder with fingertips of gloved hand into the resident's wound bed. -With the same gloves, LPN A applied the dry dressing. -He/she removed the gloves and washed his/her hands prior to leaving the area. During an interview on 3/10/26 at 2:40 P.M. with CNA A and CNA B said:-They were supposed to wash or sanitize their hands upon entering the resident's room, after they leave the room, after removing their gloves and after completing a dirty task. -The resident's catheter bag could not be on the floor, so they used the basin to put it in when the resident is in bed. During an interview on 03/13/26 at 11:58 A.M., CNA D said: -He/she would wash his/her hands upon entry of the resident room and before leaving the room. -He/she would sanitize or wash hands before and after incontinent care or catheter care.-He/she did not always sanitizer his/her hands between glove changes, only if visibly soiled gloves.-He/she should not use gloves that have dropped on the ground, he/she would have obtained a new clean glove. -He/she would apply clean gloves and place a barrier on the ground before placing the graduate container on top then empty the catheter drainage bag into the graduate. -Resident's on EBP would have an isolation cart that would have gown, gloves, mask, booty's if needed to provide direct contact care. During an interview on Review of 3/16/26 10:04 A.M., the MDS Coordinator/ICP and Regional Registered Nurse (RN) said:-He/She would expect care staff to sanitize or wash hands from a dirty to clean process, after complete incontinent care and between each glove change or when gloves were visibly soiled. -Residents with indwelling catheter would be on EBP and signage should be posted on the resident's door.-He/She would expect care staff who provided direct resident catheter care to wear a gown, gloves, mask and if need safety glasses if potential splatter.-He/She would expect care staff to change gloves and sanitize their hands from the dirty to clean process.-He/She would expect care staff to not use a glove it was dropped on the floor. -He/She would expect wound care treatment of collagen particles powder to be applied with clean gloved hands. During an interview on 3/16/26 at 11:53 A.M., LPN A said:-He/She should have changed gloves between a dirty to clean process and then sanitized his/her hands between each glove change. -He/She should have removed the dirty gloves and sanitized his/her hands then applied new clean gloves prior to applying the collagen particles powder to the wound bed. During an interview on 3/16/26 at 12:58 P.M., the Director of Nursing (DON) said:-He/She would expect facility staff to always position the urinary catheter bag and tubing below the bladder. -He/She would expect all care staff to perform hand hygiene between each glove change and from a dirty to clean process.-If gloves were visibly soiled then he/she would expect care staff to remove gloves, sanitize hands, then apply new clean gloves to hands. -He/She would expect care staff not to use any gloves that had fallen on the ground. -He/She would expect nursing staff to apply wound care treatment of collagen particles powder with clean gloved hands and should not place collagen particles powder in wound bed with dirty/soiled gloves. 2. Review of Resident #35's face sheet showed the resident was admitted with the following diagnoses:-Chronic Obstructive Pulmonary Disease (COPD inflammatory lung disease that causes obstructed airflow from the lungs, resulting in breathing difficulties).-Heart failure (CHF the heart can't pump blood well enough to meet your body's needs).-Morbid Obesity with Alveolar Hypoventilation (a condition where severe obesity (BMI ≥30) causes chronically low oxygen and high carbon dioxide levels in the blood due to impaired breathing.-Obstructive Sleep Apnea (OSA a serious sleep disorder where breathing repeatedly stops and starts due to throat muscles relaxing and blocking the airway).-Mixed Simple and Mucopurulent Chronic Bronchitis (a long-term inflammatory condition affecting the bronchi, characterized by persistent cough and mucus production).-Chronic Respiratory Failure with Hypoxia (a long-term inability of the respiratory system to properly oxygenate blood and eliminate carbon dioxide, often due to COPD, neuromuscular disorders, or obesity).-Chronic Respiratory Failure with Hypercapnia (too much carbon dioxide (CO2) in your blood. If your body can't get rid of carbon dioxide, a waste product, there isn't room for your blood cells to carry oxygen).-Dyspnea (shortness of breath or difficulty breathing).-Personal history of other diseases of the respiratory system.-Osteoarthritis (most common form of arthritis when the protective cartilage that cushions the ends of the bones wears down over time). Review of the resident's admission MDS dated [DATE], showed:-The resident was cognitively intact.-He/She was dependent on staff for eating, toileting, bathing, dressing, personal hygiene, and mobility.-He/She had lower extremity impairment on one side. Review of the resident undated care plan showed:-The resident was dependent on staff for meeting physical needs related to physical limitations.-He/She has an ADL self-care performance deficit and was dependent on two staff for personal hygiene. Observation on 3/9/26 at 10:50 A.M. showed three basins uncovered lying on the bathroom floor. Observation on 3/10/26 at 10:26 A.M. showed three basins uncovered lying on the bathroom floor. Observation on 3/11/26 at 11:10 A.M. during incontinence care showed:-CNA J entered the resident's room to do incontinence care, donned (put on) gloves without performing hand hygiene and adjusted the blinds closed.-Doffed (took off) gloves and threw into trash.-Donned gloves without performing hand hygiene and lowered the head of the resident's bed using the bed remote.-Removed the resident's linens and gown the pulled down resident's brief and cleaned the resident's front perineal area with wipes, removed additional wipes from the package with the same hand that perineal care was done with, turned resident to his/her right side and cleaned buttock area from front to back with wipes.-Doffed gloves and did not perform hand hygiene, moved wipes package and touched resident, did not perform hand hygiene.-Donned gloves, turned resident to his/her left side, completely removed dirty brief from under the resident, cleaned the resident front to back with wipes, removed additional wipes with the same hand used for perineal care, with the same gloves on, put a clean brief in place under the resident and applied barrier cream from tube.-Rolled the resident flat on his/her back and adjusted the brief around them.-With the same gloves on, continued to fasten the brief on the resident and adjusted his/her gown over them.-Doffed gloves, did not perform hand hygiene, picked up and moved the trash can with bare hands, removed package of wipes from bed, touched bedside table to move it, adjusted the head and foot of bed using the remote, adjusted the resident's nasal cannula (a lightweight, flexible tube used to deliver supplemental oxygen to patients with breathing difficulties) back into his/her nose, adjusted the bed again using the remote, removed blanket from the bed.-Without performing hand hygiene, donned gloves and collected the trash bag from the can and took out of room to the soiled utility room.-Returned to room and without gloves on, placed a new liner into the trash can. Did not perform hand hygiene.-Removed another blanket from the bed and took it out of the room to the dirty linen room without gloves on. During an interview on 3/11/26 at 1:00 P.M., CNA J said:-He/She had received training on hand hygiene during onboarding. The types of hand hygiene that could be performed were hand washing or using hand sanitizer.-He/She could use some additional training.-Whichever hand that was used for perineal care should not be switched with clean hand that had not.-Hand hygiene should have been done when changing gloves, after they were removed and before putting on a new pair.-After performing incontinence care, gloves should be removed, hand hygiene performed, new gloves should be put on before resuming contact with the resident or their things. Observation on 3/12/26 at 2:18 P.M. showed three basins uncovered lying on the bathroom floor. During an interview on 3/13/26 at 11:15 A.M., CNA H said:-Hand hygiene should be performed between glove changes and before and after cares.-The same hand used for peri-care should not be used to grab clean wipes.-Staff should not touch residents' belongings after performing peri care and before removing gloves and performing hand hygiene.basins should never be on the floor and uncovered. They should be kept at bedside or behind toilet. During an interview on 3/13/26 at 11:35 A.M., the LPN B said:-He/She would perform hand hygiene between gloves changes, before and after care and use hand sanitizer every third person in general.-The same hand used to perform peri-care should not be used to grab clean wipes.-Resident's belongings should not be touched with dirty gloves on.-Basins should not be kept on the floor at any time and should be kept in a trash bag tied to the bathroom handrail. During an interview on 3/13/26 at 12:24 P.M., the DON said:-Training on infection control was given through Relias (a comprehensive, cloud-based learning platform to improve employee performance, ensure regulatory compliance, and enhance patient care) and monthly in-services.-Hand hygiene should be performed before resident contact, after performing care and after glove changes.-He/She would not expect staff to touch anything in a resident's room during peri-care and return to peri-care without a glove change and hand hygiene being performed.basins should never be on the floor and uncovered. Nursing staff should make sure of this. 3. Review of Resident #10's face sheet showed the resident was admitted with the following diagnoses:-Type 2 Diabetes Mellitus with Diabetic Neuropathy (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin)(damage to the nerves resulting in sensory loss in the extremities).-Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).-Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus).-Chronic Pain Syndrome (a long-term condition where pain persists or recurs for more than 3 to 6 months).-Neuromuscular Dysfunction of Bladder (a condition where nerve damage or disease interrupts signals between the brain and bladder, causing loss of bladder control).-Muscle weakness.-Unspecified lack of coordination.-Need for assistance with personal care. Review of the resident's admission MDS dated [DATE] showed:-The resident was cognitively intact.-He/She had impairment on one side in upper extremities and impairment on both sides in lower extremities.-He/She had an indwelling catheter (a tube passed through the urethra into the bladder to drain urine).-He/She had a neurogenic bladder diagnosis.-He/She was dependent on staff for mobility, dressing, bathing, and personal hygiene. Review of the resident's undated care plan showed:-The resident was on EBP's related to having a catheter but did not have any interventions about signage or what PPE should be stocked in the carts. -The resident had an indwelling catheter.-Interventions were that direct care staff was to utilize gloves and gowns for all personal care. Observation on 3/9/26 at 10:21 A.M. showed:-There was no EBP signage outside of the resident's room and there were four PPE carts on the hall, three did not contain gowns, hand sanitizer or gloves.-One basin and one commode specimen collection hat uncovered lying on the floor of the bathroom. Observation on 3/10/26 at 11:03 A.M. showed:-There was no EBP signage outside of the resident's room and there were four PPE carts on the hall, three did not contain gowns, hand sanitizer or gloves.-One basin and one commode specimen collection hat uncovered lying on the floor of the bathroom. Observation on 3/11/26 at 10:22 A.M. showed:-There was no EBP signage outside of the resident's room and there were four PPE carts on the hall, three did not contain gowns, hand sanitizer or gloves.-One basin and one commode specimen collection hat uncovered lying on the floor of the bathroom. Observation on 3/12/26 at 2:15 P.M. showed there was no EBP signage outside of the resident's room and there were four PPE carts on the hall, three did not contain gowns, hand sanitizer or gloves. During an interview on 3/13/26 at 11:15 A.M. CNA H said:-He/She did not remember what EBP stood for.-He/She had received training on this during orientation.-Residents who would require EBP had catheters and ostomies.-Items that should be stocked in the PPE carts were gowns, goggles, shoe covers, gloves, masks and hair cover.-All nursing staff was responsible for making sure the carts are stocked.-A risk of not following EBP protocol and using the proper PPE would be spreading germs.-Basins and commode specimen hats should not be on the floor in the bathroom. During an interview on 3/13/26 at 11:50 A.M. LPN B said:-Residents who required EBP were those with catheters, wounds, feeding tubes (a medical device used to deliver nutrition, fluids, and medication directly into the stomach or small intestine), tracheostomies (an opening (stoma) in the neck into the trachea (windpipe) to establish a direct, stable airway) and any opening leading to outside of the body.-There should be signage outside the room of all resident's who are on EBP.-The signage should contain what reason the resident is on EBP and what PPE is necessary.-The PPE carts should contain gowns, face masks, eye shields, gloves, biohazard bags and booties.-The wound care nurse and all nursing staff are responsible for making sure the carts are stocked.-Some of the risks of not following EBP protocol and using the proper PPE would be spreading bacteria and infection.- Basins and commode specimen hats should not be on the floor in the bathroom. During an interview on 03/13/26 at 12:24 P.M. the DON said:-Training on EBP has been given through Relias, in-services and through Performance Improvement Project (PIP- a structured, data-driven initiative used within QAPI (Quality Assurance and Performance Improvement) to improve care, safety, or services).-Residents who require EBP include tracheostomies, feeding tubes, foley catheters, wounds and openings on the body.-There should be signage outside the room of all residents who are on EBP.-Gloves, gowns, face shields, and masks should be stocked in the PPE carts.-Night shift nurses are responsible for making sure the carts are stocked.-A risk of not following EBP protocol and using the proper PPE would be infection.- Basins and commode specimen hats should not be on the floor in the bathroom. 4. Review of Resident #41's face sheet showed the resident was admitted with the following diagnoses:-Atrial Fibrillation (A-Fib abnormal heart rhythm).-Hypertensive heart disease with heart failure (chronic high blood pressure forces the heart to work harder, causing the left ventricle to thicken (hypertrophy) and eventually become too weak or stiff to pump effectively).-Hypertension (high blood pressure).-Peripheral Vascular Disease (a slow-developing condition where narrowed blood vessels, usually arteries, restrict blood flow to the limbs).-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses)-Anxiety.-Chronic Kidney Disease (CKD- long-term, progressive loss of kidney function, often causing waste buildup and fluid retention primarily caused by diabetes and high blood pressure). Review of the resident's Quarterly MDS dated [DATE] showed:-The resident had moderate cognitive impairment.-He/She had active diagnoses of heart failure, hypertension, kidney failure and dementia. Review of the resident's POS dated 3/12/26 showed:-Amlodipine Besylate oral tablet 5 milligrams (mg) by mouth one time per day for hypertension. Hold if blood pressure is less than 110/55 or heart rate (pulse) is less than 55. Notify physician of held medications.-Aspirin oral tablet chewable 81 mg give one tablet by mouth one time a day for prophylaxis (for prevention) related to atrial fibrillation, hypertensive heart disease with heart failure and peripheral vascular disease. Observation on 3/11/26 at 11:40 A.M. showed Certified Medication Technician (CMT) C applied a shared, blood pressure wrist cuff to the resident's left wrist to obtain a blood pressure reading without sanitizing it prior to use. The blood pressure was obtained, and the blood pressure cuff was not sanitized after use. 5. Review of Resident # 48's face sheet showed he/she was admitted with the following diagnoses:-A-Fib.-Heart failure.-Hypertensive Chronic Kidney Disease (a condition where high blood pressure causes long-term damage to the kidneys). Review of the resident's admission MDS dated [DATE] showed:-The resident had moderate cognitive impairment.-He/She had active diagnoses including Atrial Fibrillation and heart failure. Review of the resident's POS dated 3/12/26 showed:-Amiodarone HCI oral tablet 200 mg give one tablet by mouth one time a day for Congestive Heart Failure (CHF- a chronic, progressive condition where the heart cannot pump blood efficiently, causing fluid buildup in the lungs and body) and Atrial Fibrillation.-Metoprolol Tartrate oral tablet 25 mg give one tablet by mouth two times per day for hypertension. Hold if systolic (the top number measures the pressure in the arteries when the heart beats) blood pressure is less than 110 or pulse less than 60. Observation on 3/11/26 at 12:38 P.M. showed CMT C applied a shared, blood pressure wrist cuff to the resident's left wrist in order to obtain a blood pressure reading without sanitizing it prior to use. The blood pressure was obtained, and the blood pressure cuff was not sanitized after use. During an interview on 3/11/26 at 12:45 P.M. CMT C said:-He/She received an in-service on infection control around December 2025 from the former Administrator.-The wrist blood pressure cuff was shared medical equipment and should be sanitized before and after use for each resident. During an interview on 3/13/26 at 11:50 A.M., LPN B said the blood pressure cuff was shared medical equipment and should sanitized before and after use for each resident. During an interview on 3/13/26 at 12:24 P.M., the DON said he/she would expect for shared medical equipment like wrist blood pressure cuffs to be sanitized before and after use and between residents. 6. Review of Resident #46's face sheet showed the resident was admitted with the following diagnoses:-Absolute Glaucoma (he final, end-stage of untreated or uncontrolled chronic glaucoma, characterized by total blindness, severe pain, and extremely high intraocular pressure).-Age related Osteoporosis (bone disease characterized by decreased density and strength, often causing no symptoms until a fracture occurs).-Need for assistance with personal care.-Muscle weakness. Review of the resident's Quarterly MDS dated [DATE] showed:-He/She had moderate cognitive impairment.-He/She was dependent on staff for mobility, dressing, bathing, personal and oral hygiene.-He/She had medically complex conditions. Review of the resident's POS dated 3/12/26 showed:-Artificial Tears Ophthalmic Solution 1% instill one drop in both eyes two times a day for dry eyes.-Carteolol HCI Ophthalmic Solution 1% instill one drop in both eyes in the morning for absolute glaucoma. Review of the resident's undated care plan showed:-He/She was very hard of hearing; staff were to use low tones when speaking and speak close to his/her ear.-He/She had impaired visual function; staff were to monitor and document any signs or symptoms of acute eye problems and tell him/her where they are placing items and be consistent. Observation on 3/11/26 at 11:50 A.M. showed:-CMT C washed his/her hands appropriately, applied gloves, administered Artificial Tears eye drops to both of the resident's eyes, applied and held pressure to inner corner of the left eye with the right index finger of gloved hand with no barrier between glove and resident's eye area. -Repeated this on the right eye with the same gloves on.-Removed gloves and performed hand hygiene. Observation on 3/11/2026 at 12:23 P.M. showed:-CMT C returned to the room, performed hand hygiene, donned gloves, administered Carteolol Ophthalmic eye drops to both of resident's eyes, applied and held pressure to the inner corner of left eye with the right index finger of gloved hand and without a barrier between the glove and the resident's eye area. -Repeated this on the right eye with the same gloves on.-Removed gloves and performed hand hygiene. During an interview on 3/11/26 at 12:45 P.M. CMT C said:-He/She received an in-service on infection control December 2025, from the previous Administrator.-He/She should not have applied pressure to inner eye area with bare gloves and should have put a barrier between glove and the resident's eye such as tissue instead.-Not doing this would run the risk of cross contamination, because of all the things he/she touched with the gloves on prior.

Based on observation, interview and record review, the facility failed to maintain the plumbing system to ensure the hot water temperatures were kept at or above 105 F (degrees Fahrenheit) in resident rooms 31, 34, 25, 23, 24, 19; and below 120 F in resident room [ROOM NUMBER], 13, 12, 11, 9, 7, and 4; failed to install an inline temperature gauge (a thermometer which provides real-time, precise monitoring for liquids or gases within pipes, hoses, and industrial systems) on the water heaters which served the [NAME] and North halls; failed to place handles on the faucets on the janitor's closets. The practice of not maintaining the system to ensure the temperature of hot water, stayed within the range of 105 F to 120 F, potentially affected all residents. The facility census was 49 residents. Review of the facility's undated weekly temperature log guidelines, showed:-Check two random rooms per wing for proper water temperatures.-Resident rooms should reach water temperature of 105 F to 120 F, maximum.-If a resident room's water temperature was below 105 F, look for a cold-water mix at a fixture such as a whirlpool, shower faucet, or chemical additive machine, turn the cool side off. If a low water temperature still occurred, call for service.-If a resident rooms water temperature was above 120 F, adjust the water heater, look for a hot water leak, or check mixing valves. If high water temperature still occurred, call for service.-Kitchen and laundry room temperatures should reach 140 F, unless low temperature chemicals were being used.-When it was necessary to replace a faucet, make sure it was replaced with a double lever faucet.1. Review of water temperatures documented by the facility on 2/27/26, showed:-At 10:45 A.M., the hot water temperature in an unknown resident room was 119.1 F.-At 10:52 A.M. the hot water temperature in resident room [ROOM NUMBER] was 111.3 F.-At 11:15 A.M., the hot water temperature in resident room [ROOM NUMBER] was 111.7 F.-At 11:18 A.M. the hot water temperature in resident room [ROOM NUMBER] was 107.2 F.Review of water temperatures documented by the facility on 3/2/26, showed:-At 10:58 A.M., the hot water temperature in resident room [ROOM NUMBER] was 106.7 F.-At 11:15 A.M. the hot water temperature in resident room [ROOM NUMBER] was 117.3 F.-At 11:18 A.M., the hot water temperature in resident room [ROOM NUMBER] was 105.0 F.-At 11:21 A.M. the hot water temperature in resident room [ROOM NUMBER] was 110.5 F.Review of water temperatures documented by the facility on 3/11/26, showed:-At 7:43 A.M., the hot water temperature in resident room [ROOM NUMBER] was 101.0 F.-At 7:56 A.M. the hot water temperature in resident room [ROOM NUMBER] was 107.3 F.-At 8:31 A.M., the hot water temperature in resident room [ROOM NUMBER] was 108.9 F.2. Observation on 3/10/26 of hot water temperatures with the Maintenance Director and Maintenance Person B showed the following temperatures did not get to or exceed 105 F after the water was flowing for two minutes or more:-At 9:19 A.M., the hot water temperature in resident room [ROOM NUMBER] was 101.9 F.-At 9:23 A.M., the hot water temperature in resident room [ROOM NUMBER], was 102.2 F.-At 9:39 A.M., the hot water temperature in resident room [ROOM NUMBER], was 102.2 F. -At 9:52 A.M., the hot water temperature in resident room [ROOM NUMBER], was 101.6 F.-At 10:00 A.M., the hot water temperature in resident room [ROOM NUMBER], was 102.7 F.-At 10:19 A.M., the hot water temperature in resident room [ROOM NUMBER], was 90.5 F.Observation on 3/10/26 of hot water temperatures with the Maintenance Director and Maintenance Person B showed the following temperatures exceeded 120 F after the water was flowing for two minutes or more:-At 11:09 A.M., the hot water temperature in resident room [ROOM NUMBER] was 123.9 F.-At 11:15 A.M., the hot water temperature from sink in the [NAME] Hall Shower room was 123.9 F and there was a leak from the sink in the [NAME] Hall shower room.-At 11:29 A.M., the hot water temperature in resident room [ROOM NUMBER], was132.2 F. -At 11:47 A.M., the hot water temperature in resident room [ROOM NUMBER], was 126.3 F. -At 11:55 A.M., the hot water temperature in resident room [ROOM NUMBER], was 125.2 F. -At 11:58 A.M., the hot water temperature in resident room [ROOM NUMBER], was 122.7 F.-At 12:02 P.M., the hot water temperature in resident room [ROOM NUMBER], was 121.6 F. -At 12:14 P.M., the hot water temperature in resident room [ROOM NUMBER] was 121.1 F.-At 1:42 P.M., during a recheck of the water temperature in resident room [ROOM NUMBER], the hot water was 123.4 F.3. Observation on 3/10/26 at 11:38 A.M., showed the following at the hot water heaters in the boiler rooms:-The absence of an inline temperature gauge on the pipes going forth from the hot water heaters which provided water to the [NAME] and North Halls.-The temperature at the water heater which provided hot water to the [NAME] Hall, where cold water temperatures were observed, was set at 120 F.-The temperature at the water heater which provided hot water to the North Hall, where hot water temperatures were observed, was set at 115 F.4. During an interview on 3/10/26 at 11:16 A.M., Maintenance Person B said he/she was unaware of the leaky sink because the facility, was not his/her usual facility.During an interview on 3/10/26 at 11:41 A.M., the Maintenance Director said he/she readjusted the hot water temps after some of the readings of hot water temperatures were observed during the room-to-room inspections.During an interview on 3/10/26 at 1:56 P.M., the Maintenance Director said he/she had learned, on the [NAME] Hall if the housekeepers ran too much cold water from the janitors' closets, the water on that hallway would generally be cold.During an interview on 3/11/26 at 3:06 P.M., Company Maintenance Person C said:-He/She and a plumber from Company B, found a janitor's closet where both the hot water and the cold-water lines were left open. -The handles were removed at some time in the past, so the water continued to flow. -The plumber said leaving the water on caused a crossover of cold water into the hot water which flowed to the [NAME] Hall. -To correct this issue, they turned off the hot water and left the cold water on. They burped (a process of removing trapped air or breaks vacuum locks causing gurgling, slow drains, or noisy pipes, which is done by running all faucets simultaneously, starting from the lowest point to the highest) the lines.-He/she tried to make sure the water was running in the system.-They shut down the hot water so that the crossover was not happening. -The best result would be to place the handles back on the faucets and turn off the hot water when it was not in use.During an interview on 3/11/26 at 3:19 P.M., the Regional Operations Consultant said the Housekeepers needed to turn the hot water off when they were not using the hot water.During a phone interview on 3/12/26 at 11:00 A.M., Plumber A said:-The facility had sporadic (occurring at irregular intervals) water temperatures.-He/She found a faucet in a janitor's closet on the [NAME] hall where both the cold and hot water was on and that caused the hot water to be diluted. -There were three hot water heaters in the basement. -The tanks should be set between 118 F and 120 F; and he/she set both heaters at 118 F. -One of the hot water heaters was set at 140 F and that caused the hot water on the North hall.-Installing inline temperature gauges on the other water heaters would help.-The cold line diluted the hot water when the sink in the janitor's closet was left flowing.-The faucets in the janitor's closets needed handles.-If a person went into the janitor's closet and turned the hot water on and used it and then turned it off, it should not be a problem for that facility.During a phone interview on 3/20/26 at 10:32 A.M., the Maintenance Director said he/she let the water flow for two minutes or longer, when he/she checked water temperatures.

Based on observation and interview, the facility failed to maintain the floor in the restroom of resident room [ROOM NUMBER] in good repair; failed to maintain the fans free of a heavy buildup of dust in resident rooms [ROOM NUMBER], Resident #10's room, Resident #9's room, the therapy room, and failed to prevent a torn sling (a specialized fabric harnesses used with mechanical lifts to safely transfer individuals with limited mobility between beds, wheelchairs, toilets, and showers) from being used to transfer Resident #3. This practice potentially affected at least 15 residents who reside in or used those areas. The facility census was 49 residents. 1. Observation on 3/10/26 at 9:30 A.M., showed a 10 inch (in.) long by 0.5 in wide area of floor damage in the restroom of resident room [ROOM NUMBER].During an interview on 3/10/26 at 9:30 A.M., the Maintenance Director said that floor damage had been there for as long as he/she had worked at the facility.2. Observation on 3/10/26 at 9:39 A.M., showed a fan with a heavy buildup of dust in resident room [ROOM NUMBER].Observation on 3/10/26 at 9:52 A.M., showed a fan with a heavy buildup of dust in resident room [ROOM NUMBER]. During an interview on 3/10/26 at 9:53 A.M. the District Housekeeping Manager said the fans should be cleaned every 2 weeks.Observation on 3/10/26 at 9:56 A.M. showed a fan with a heavy buildup of dust in Resident #10's room.During an interview on 3/10/26 at 9:57 A.M., Resident #10, a resident who was identified by his/her Admission's Minimum Date Set (MDS-- a federally mandated assessment tool completed by the facility for care planning) dated 2/4/26, as a resident who was cognitively intact, said he/she had the fan for a few weeks, and the housekeeping department had not cleaned it.Observation on 3/10/26 at 10:06 A.M., showed a fan with a heavy buildup of dust in Resident #9's room.During an interview on 3/10/26 at 10:07 A.M., Resident #9, a resident identified by the quarterly MDS dated [DATE], as a resident who was cognitively intact, said the last time his/her fan was cleaned was in the summer of 2025.Observation on 3/10/26 at 10:19 A.M., showed a fan with a heavy buildup of dust in resident room [ROOM NUMBER].3. Review of Resident#3's face sheet showed diagnoses which included:-Chronic Obstructive Pulmonary Disease (COPD--a progressive, incurable lung disease that makes breathing difficult by damaging airways and air sacs).-Morbid obesity.-Discogenic back pain (pain originates from damaged or degenerated intervertebral discs, often causing chronic, localized axial low back pain, particularly when sitting, bending).-Bilateral primary osteoarthritis (the most common chronic joint disease, caused by the breakdown of cartilage leading to pain, swelling, and reduced mobility).-Reduced mobility. Review of the resident's annual MDS dated [DATE] showed he/she:-Was cognitively intact. -Was dependent on two or more facility staff for moving from a sitting to lying position, sitting to standing transfers, chair to bed transfers, for toileting, -Did not have the ability to walk.-Was dependent on two or more facility staff for mobility in a wheelchair. Observation on 3/10/26 at 9:42 A.M., showed a torn sling in a chair in the resident's room During an interview on 3/10/26 at 9:42 A.M., the resident said: -The sling in the chair was the sling staff used to transfer him/her. -He/she told them that a different sling was needed because it was torn.Observation on 3/12/26 at 2:03 P.M., showed the resident was sitting in his/her wheelchair in the therapy room with the torn sling under him/her. During an interview on 3/12/26 at 2:05 P.M., the resident said:-The staff used the sling to transfer him/her from his/her bed to the wheelchair.-He/She told them to get rid of the sling on 3/10/26. During an interview on 3/12/26 at 2:09 P.M., the Physical Therapist Assistant said the sling that was used for the resident needed to be replaced. During an interview on 3/12/26 at 2:12 P.M., Licensed Practical Nurse (LPN) B said he/she would check the sling for any holes or rips that jeopardized the safety of the resident.During an interview on 3/12/26 at 2:24 P.M., Certified Nursing Assistant (CNA) E said:-He/she took a sling out of the clean utility closet. -He/she used that sling to transfer the resident.-He/she did not check to see if the sling was torn or ripped.-He/she should have checked for damage to the sling. During an interview on 3/12/26 at 2:35 P.M., the Director of Nursing (DON) said he/she would expect CNAs to check for rips or tears and that the handles were attached, and the loops of the sling were in order.

Based on observation, interview and record review, the facility failed to accurately assess and document resident care areas on the Facility Matrix for two sampled residents (Resident #3 and #35) for respiratory care, opioid and insulin use and failed to ensure an accurate assessment was completed and behavior was selected as a care plan area for one sampled resident (Resident #53) with known and documented behaviors prior to and after admission out of 13 sampled residents. The facility census was 49 residents. 1. Review of Resident #53's Face Sheet showed the resident was admitted with diagnoses that included:-Neurocognitive disorder (a progressive, incurable brain disease characterized by abnormal deposits of protein, known as Lewy bodies, in neurons. It causes severe cognitive decline, fluctuating attention, recurrent visual hallucinations, and motor symptoms).-Diabetes.-High cholesterol.-High blood pressure. Review of the resident's Nursing Notes from the transferring nursing facility dated 1/21/26 to 2/16/26 showed:-The facility was monitoring the resident for behaviors including wandering, anxiety (a normal human reaction to stress, involving feelings of fear, dread, uneasiness, and tension, often accompanied by physical symptoms like rapid heart rate, muscle tension, and sweating) and depression. The resident received Ativan (anti-anxiety medication) three times daily for anxiety/behavior.-1/21/26 nursing staff gave the resident a baby doll and asked the resident to babysit and the resident was excited to do so stating he/she would take good care of him/her.-1/29/26 the resident was in another resident's room going through their belongings. Staff redirected the resident out of the room. The resident was difficult to redirect and became agitated. The resident refused to sit down in front of the nursing station and continued to wander.-2/6/26 the resident remained up through the night and did not go to bed until 3:30 A.M. -2/15/26 at 9:20 A.M., the resident was going into other resident rooms, grabbing their possessions. Staff tried to redirect the resident, and the resident resisted and began screaming, crying and yelling. At 9:45 A.M., the resident entered another resident's room while staff was getting that resident dressed and refused to leave. The nurse redirected the resident out of the room.-2/18/26 the resident was seen wandering toward the exit door and was accompanied by the therapist back to his/her area. Staff placed a wanderguard (a specialized wander management system used in senior living and memory care facilities to monitor residents with cognitive impairments, such as dementia) and placed the resident on one-to-one monitoring due to his/her high elopement risk. Review of the resident's Elopement Evaluation dated 2/27/26 showed the resident:-Did not have a history of elopement while at home.-Had a history of attempting to leave the facility without informing staff.-Wandered and verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door.-Wandering behavior was not goal directed, and the behavior was likely to affect the safety, privacy or well-being of self/others. Review of the resident's Behavior Notes showed:-On 2/27/26 at 4:10 P.M., The resident had been in and out of resident rooms going through other resident's belongings. The resident had been hard to redirect. The resident had been trying to touch other residents throughout the shift. The resident had been redirected throughout the shift. The resident was alert/oriented to self only. The resident had been resistant to care throughout shift. Monitoring was to continue.-On 2/27/26 at 7:41 P.M., The resident had increased agitation, had been attempting to push other residents in wheelchair. The resident had been taking other residents belongings and wondering in and out of other resident rooms. The resident was resistant to redirection. The resident had been offered snacks and different activities with quickly returning to what he/she was doing prior to being redirected. When the resident was being redirected, he/she became combative with staff. This nurse called the Nurse Practitioner (NP) on duty who said to give the resident prn order of Ativan every 6hrs. Power of Attorney (POA) aware of new order at that time.-On 2/28/26 at 10:21 P.M., The resident had periods of restlessness. The PRN Ativan was effective. The resident was resting at that time. Review of the resident's Physician's Order Sheet (POS) dated March 2026, showed physician's orders for:-Trazodone 50 milligram (mg) give 1 tablet by mouth at bedtime for insomnia (active 2/26/26).-Buspirone 5 mg give 1 tablet by mouth three times daily for anxiety (active 2/26/26).-Divalproex Sodium 250 mg give 1 tablet by mouth twice daily for mood (active 2/26/26).-Lorazepam 0.5 mg give 1 tablet by mouth three times daily for anxiety/behaviors (active 2/26/26).-Lorazepam 0.5 mg give 1 tablet by mouth every 6 hours as needed for anxiety/agitation (active 2/27/26). Review of the resident's Behavior Notes showed:-On 3/1/2026 at 3:56 P.M., The resident continued to have restless behavior. The resident had received Ativan as per order. The resident would have positive effects from medication for a while and would begin to have restless behaviors such as going through other resident belongings and pushing other residents in wheelchairs. The resident became combative when staff attempted to redirect him/her to other activities. The resident was coloring in the public dining room.-On 3/1/26 at 7:19 P.M., The resident had been agitated and restless throughout the evening. The resident had received Ativan with no results at this time. The resident had been unable to be redirected. The resident pushed at staff when staff had attempted to redirect him/her. The resident did take his/her baby doll and was walking around with the doll at that time.-On 3/1/26 at 7:45 P.M., This nurse called the nurse practitioner about the resident's agitation. The nurse practitioner gave a new order to increase Depakote to three times daily and Ativan to four times daily. This nurse called the resident's responsible party, who stated understanding and thanked nursing staff for care given to the resident. Review of the resident's Care Plan dated 3/1/26, showed the resident had a behavior management plan with a goal to monitor /manage the resident's undesirable behaviors and keep the resident safe. Interventions showed:-Attempt an alternate time to provide care refused, per resident's preference.-Consult pastoral care, as needed.-Educate resident/representative on the necessity of care attempted to provide.-Ensure the safety of resident and others.-Monitor for signs/symptoms of infection.-Re-orient resident to person, place, time and situation.-NOTE: The care plan did not show the behaviors the resident had exhibited prior to admission and since admission (restlessness, agitation, combativeness/pushing staff, infringing on resident personal space, interfering with cares) and did not address specific interventions implemented to address pre-identified behaviors (coloring/reading, snacks baby doll, medication). Review of the resident's POS dated March 2026, showed:-Divalproex Sodium 250 mg give 1 tablet by mouth three times a day for mood (active 3/1/26).-Lorazepam 0.5 mg give 1 tablet by mouth four times a day for anxiety/behavior (active 3/1/26). Review of the resident's Behavior Notes showed on 3/4/26 at 1:40 P.M., The resident was unaware of other residents' personal space several times throughout this shift. The resident continued to need to have redirection from infringing on other residents' personal space. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/4/26, showed the resident: -Had severe cognitive impairment with inattention.-Was inattentive, but had no behavior symptoms, hallucinations or delusions.-Had no verbal or physically aggressive behaviors towards others. -NOTE: The MDS did not show behaviors that were exhibited by the resident that were documented and submitted to the facility upon admission (resident had behavior symptoms and combativeness toward staff). Review of the resident's Behavior Notes showed:-On 3/5/26 at 4:28 P.M., The resident continued to attempt to touch other residents. The resident was taking other residents belongings. The resident had been pacing back and forth on the unit throughout the day.-On 3/9/26 at 3:06 P.M., The resident continued to have restless behaviors. This nurse notified the nurse practitioner who gave a new order to increase Busbar to three times daily. The nurse notified the resident's responsible party and was okay with the medication adjustment. Observation and interview on 3/9/26 at 10:11 A.M., showed the resident was not in his/her room. He/she was standing at the nursing station dressed for the weather without odor. He/She was not wearing shoes or socks and was ambulating independently around the nursing station. The resident was inquisitive but was not able to be interviewed. Licensed Practical Nurse (LPN) A said:-The resident was new to the facility and had only been on the locked unit 2-3 weeks.-The resident refused to wear socks or shoes.-The resident usually wandered throughout the unit and had wandered into resident's rooms, so they tried to monitor him/her to prevent that behavior. Observation on 3/10/26 at 2:52 P.M., showed:-The resident was wandering on the unit without socks or shoes on. -The resident was walking around the nursing station and nursing staff was interacting with him/her. During an interview on 3/10/26 at 2:52 P.M. Certified Nursing Assistant (CNA) B said:-They usually tried to keep the resident active by giving him/her linen to fold, there was a magazine that he/she liked to look at and they gave that to him/her, or a puzzle or snacks to occupy the resident.-The resident would engage in activities but he/she had a very short attention span so it was only for short time periods that they would occupy his/her attention.-LPN A brought a stack of towels for the resident to fold and CNA A brought the resident a grilled cheese sandwich with an orange soda and encouraged the resident to sit down and eat (which the resident did and was not agitated or anxious). During an interview on 3/10/26 at 2:52 P.M. CNA A said: -The resident used to be a CNA at the facility, and he/she liked to help with tasks in the unit and wanted to help other residents. -Staff usually could not get the resident to sit through the lunch period so they would give him/her snacks throughout the day so he/she would eat. -The resident would invade other resident's personal space, and they didn't like it, but he/she thought it was because the resident used to be a CNA. -The resident could become agitated at times and difficult to redirect.-The resident was very pleasantly eating her snack while staff was socializing with her. -The resident's relative came to visit him/her this afternoon around lunch time. They had to watch him/her because he/she would wander into resident rooms, but they watched him/her, so he/she did not get into anyone's room. Observation on 3/11/26 at 10:34 A.M., showed:-The resident was dressed for the weather without odor. -He/She was standing at the table in the dining/activity area with a stuffed animal and was talking to one of his/her peers. -He/She then began walking around the room. Staff went over to him/her and began to involver him/her in a game activity. -The resident then put the game away after about seven minutes, got a magazine, sat down and began reading it-looking at the pictures. After a few minutes, the resident stood up and started to push in chairs at the main table then tried to interact with peers who ignored him/her. -He/She picked up his/her stuffed animal from the table and walked over to two peers who were putting together a puzzle and looking at magazines, and they did not interact with him/her and told him/her to go away. -At 11:05 AM nursing staff took the resident out of the dining/activity area and took him/her to the nurse's station to interact directly with him/her. The resident did not show any symptoms of aggression agitation or anxiety. During an interview on 3/11/26 at 2:58 P.M., the MDS Coordinator said:-He/She was newly hired to the facility and the MDS assessments were not all up to date.-He/She was behind on completing the MDS assessments on the residents.-MDS assessments should be accurate and reflect the resident's health status.-The MDS assessment identified the problem areas that determined the care plan/interventions, so it needed to accurately reflect the resident health, behaviors and abilities. -Information they received about the resident should be included when completing the MDS assessment and care planning. -Care Plans should be comprehensive and accurately reflect the resident's care needs and interventions.-The facility matrix was supposed to show the health care areas of the resident that come from the MDS Assessment. -The facility matrix was as up to date as he/she was aware of. During an interview on 3/16/26 at 10:18 A.M., the Director of Nursing (DON) said:-He/She expected MDS Assessments to be timely and they should represent what the resident looked like at the time it was completed.-The resident matrix should reflect the current status of the resident also. -The resident's initial care plan should be based on the assessment and the care areas that were triggered.-The care plan should be updated as the resident's needs and health status changed. -If they were made aware of the resident's behaviors upon the resident's admission, it should have been reflected on the MDS assessment, and the behaviors and interventions should have been on the resident's initial care plan.-As the resident's behaviors occurred/changed, they should update the care plan and care plan interventions.-He/She expected the facility matrix to be current. 2. Review of Resident #3's face sheet showed the resident was admitted with diagnoses that included:-Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation).-Major depressive disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).-Morbid (severe) obesity (excessive body fat that severely impairs health, increasing risks for diabetes, heart disease, and hypertension).-Anxiety.-Reduced mobility. Review of the resident's Annual MDS dated [DATE] showed:-The resident was cognitively intact.-He/She was dependent on staff for help with eating, bathing, dressing, mobility and personal hygiene.-There was no diagnosis of Diabetes.-It was not indicated that the resident was receiving insulin injections.-It was not indicated that the resident received oxygen therapy. Review of the resident's undated care plan showed:-There was no focus, goal or interventions related to Diabetes or insulin use.-The resident had COPD with the following interventions:--Give aerosol or bronchodilators (a drug that causes widening of the bronchi )as ordered.--Monitor for difficulty breathing on exertion and remind resident not to push beyond endurance.--Monitor for signs and symptoms of respiratory insufficiency.--Monitor/document/report as needed any signs and symptoms of respiratory infection. Review of the resident's POS dated 3/12/26 showed:-Blood glucose monitoring two times per day. Call physician if blood sugar was less than 70 or greater than 400.-Oxygen at three liters (L) via nasal cannula with exertion as need for COPD.-Oxygen-change ear wraps every night shift every Thursday.-Oxygen-tubing and humidifier change every night shift every Thursday.-Albuterol Sulfate HFA inhalation aerosol solution one puff inhale every 6 hours as needed for shortness of air related to COPD.-Ipratropium-Albuterol solution 0.5-2.5 mg/3ml one vial inhale orally three times a day related to COPD.-Trelegy Ellipta inhalation aerosol powder breath activated 100-62.5-25 micrograms (mcg) one puff inhale orally one time a day for COPD.-Victoza subcutaneous solution pen injector 18 mg/ml inject 1.2 mg subcutaneously one time a day for Diabetes type 2. 3. Review of Resident #35's face sheet showed the resident was admitted with the following diagnoses:-COPD.-Heart failure.-Morbid (severe) obesity.-Pulmonary hypertension.-Mixed and simple mucopurulent chronic bronchitis.-Chronic respiratory failure with hypoxia.-Chronic respiratory failure with hypercapnia.-Osteoarthritis.-Dyspnea.-Personal history of other diseases of the respiratory system. Review of the resident's admission MDS dated [DATE] showed:-The resident was cognitively intact.-He/She was dependent on staff for assistance with eating, bathing, dressing, personal hygiene, transferring, and mobility.-Opioid use was not indicated.-COPD and heart failure were indicated as health conditions. Review of the resident's undated care plan showed there was no focus, goal or interventions for oxygen/respiratory care or pain/opioid use. Review of the resident's POS dated 3/12/26 showed:-Head of bed to be elevated to no less than 30 degrees at all times while in bed for shortness of air while lying flat for COPD, acute respiratory failure with hypoxia and chronic respiratory failure with hypercapnia.-Oxygen at 3.5L/min via nasal cannula every shift for COPD.-Oxygen tubing and humidifier change every night shift every Thursday.-Oxygen-change ear wraps every night shift every Thursday.-Pain assessment every shift.-Fluticasone-Salmetrol aerosol powder breath activated 250-50 mcg/dose one inhalation inhale orally every 12 hours for COPD.-Ipratropium-Albuterol solution 0.5-2.5 mg/3ml inhale orally every four hours as needed for shortness of air or wheezing via nebulizer.- Ipratropium-Albuterol solution 0.5-2.5 mg/3ml inhale orally every six hours related to pneumonia.-Oxycodone HCI oral tablet 5 mg give one tablet by mouth ever eight hours as needed for pain.-ProAir HFA inhalation aerosol solution 108 two puffs orally every 6 hours as needed for wheezing and shortness of air. Observation on 3/12/26 at 2:18 P.M showed resident was in bed and receiving his/her breathing treatment via nebulizer. 4. During an interview on 3/11/26 at 2:58 P.M., the MDS Coordinator said:-He/She was newly hired to the facility and the MDS assessments were not all up to date.-He/She was behind on completing the MDS assessments on the residents.-MDS assessments should be accurate and reflect the resident's health status.-The MDS assessment identified the problem areas that determined the care plan/interventions, so it needed to accurately reflect the resident health, behaviors and abilities. -Information they received about the resident should be included when completing the MDS assessment and care planning. -Care Plans should be comprehensive and accurately reflect the resident's care needs and interventions.-The facility matrix was supposed to show the health care areas of the resident that come from the MDS Assessment. -The facility matrix was as up to date as he/she was aware of. During an interview on 3/16/26 at 10:18 A.M., the Director of Nursing (DON) said:-He/She expected MDS Assessments to be timely and they should represent what the resident looked like at the time it was completed.-The resident matrix should reflect the current status of the resident also. -The resident's initial care plan should be based on the assessment and the care areas that were triggered.-The care plan should be updated as the resident's needs and health status changed. -If they were made aware of the resident's behaviors upon the resident's admission, it should have been reflected on the MDS assessment, and the behaviors and interventions should have been on the resident's initial care plan.-As the resident's behaviors occurred/changed, they should update the care plan and care plan interventions.-He/She expected the facility matrix to be current.

Based on observation, interview and record review the facility failed to ensure the care plan for Activities of Daily Living (ADL's) included the preference for bathing/showering was assessed and documented for one sampled resident (Resident #24); and failed to ensure bathing was completed and documented twice weekly by nursing staff for five sampled residents (Resident #32, #24, #3, #10, and #35) out of 13 sampled resident's. The facility census was 49 residents. Review of the facility's ADL's Policy and Procedure revised in April 2025 showed:-Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).-Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, to include appropriate support and assistance with personal hygiene to include bathing, dressing, grooming, and oral care).-If the resident refuses care and treatment the facility staff were to inform:--The resident and/or representative of the risks and benefits of the proposed care or treatment; and the resident has been offered alternative interventions to minimize further decline; and the refusal and details of the interventions refused are documented in the resident's clinical record. Review of the facility's blank Skin Monitoring: Comprehensive Certified Nursing Assistant (CNA) Shower Review form showed:-Perform a visual assessment of the resident's skin when giving a shower. Report any abnormal looking skin (as described below) to the charge nurse immediately. Forward any problems to the Director of Nursing (DON) for review. Use this form to show the exact location and description of the abnormality. Using the body image chart below, describe and graph all abnormalities by number. -CNA signature and date shower and assessment was completed. -Document if toenails or fingernails needed trimmed.-If resident was shaved. -Charge nurse signature and charge nurse assessment and intervention.-Director of Nursing (DON) signature. -NOTE: If the resident refused their shower/bath, the charge nurse must be notified after two attempts, and the charge nurse should ask a third time. If the resident still refused, resident must sign below indicating refusal. If the resident was unable to sign, write unable to sign and have two staff members witness, including charge nurse. 1. Review of Resident #32's admission Record showed he/she had the following diagnoses:-Acquired absence of right and left leg below the knee (amputation of lower extremities).-Stroke affecting right side of the body. Review of the resident's Electronic Medical Record (EMR) showed his/her scheduled bath days were on Tuesday and Friday during the day shift. Review of the resident's Care Plan initiated on 6/23/25 showed:-The resident had self-care performance deficit. -He/she required assistance from facility care staff for showering. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review form dated 2/13/26 showed:-A handwritten printed signature of the CNA that provided shower and was dated of 2/13/26.-Did not have documentation of the type of personal care provided and no charge nurse signature for review of the shower form. -NOTE: The facility was not able to provide additional documentation that showers were provided two times a week from 2/14/26 to 3/13/26. Review of the resident's EMR under task dated 2/13/26 to 3/13/26 showed the resident required assistance from staff for shower/bathing care dated 2/13/26. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 3/10/26 showed.-He/She was cognitively intact. -He/she was able to make his/her needs known.-Required assistance of facility staff for ADL's including bathing. During an interview on 3/10/26 at 9:50 A.M., the resident said:-He/she required assistance from facility staff for all personal care. -He/she was not getting baths/showers two times a week. -He/she did not remember when his/her last shower was. 2. Review of Resident #24's admission Face Sheet showed he/she was admitted with the following diagnoses: -Paraplegia (paralysis that affects your legs, but not your arms).-Neuromuscular Dysfunctional bladder (loss of bladder control caused by nerve damage from illnesses or injuries). -Suprapubic urinary catheter (a flexible tube inserted into the bladder through the abdominal wall). Review of the resident's initial MDS dated [DATE] showed the resident was admitted to the facility on [DATE]. Review of the resident's Care Plan initiated on 2/13/26 showed: -The resident did not have patience for assistance.-There was no ADL care plan that included the type of assistance the resident required during baths/showers.-There was no care plan that included the resident's preference for baths/showers and personal cares. Review of the resident's admission MDS initiated on 2/20/26 showed:-He/She was cognitively intact. -Had difficulty communicating his/her needs.-NOTE: The facility had not submitted the resident's admission MDS as of 3/16/26. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review form dated 2/13/26 and 3/10/26 showed: -Had wrong resident first name listed and hand printed signature of the CNA completed the resident shower. -Did not have the type of personal care provided and no charge nurse signature for review of the resident's CNA skin monitoring and shower review form. -The resident had documentation of two showers out of eight scheduled opportunities.-NOTE: The facility did not have any additional documentation of any showers provided and completed or documentation that showers were refused from 2/14/26 to 3/9/26. During an interview on 3/10/26 at 11:15 A.M., the resident said:-He/she had concerns with not getting assistance with resident care and bathing.-Required assistance with transfers from the bed to the wheelchair. -He/she had difficulty with speech and in his/her expression of needs at times. 3. Review of Resident #10's face sheet showed the resident was admitted on [DATE] with the following diagnoses:-Muscle weakness.-Unspecified lack of coordination.-Abnormal posture.-Need for assistance with personal care. Review of the resident's annual MDS dated [DATE] showed:-The resident was cognitively intact.-He/She had upper extremity impairment on one side and lower extremity impairment on both sides.-He/She required substantial/maximal assistance for bathing. Review of the resident's undated care plan showed the resident did not have a care plan for ADLs for the resident's cares. Review of the resident's paper bath sheets dated February 2026 to March 2026 showed:-Between 2/11/26 and 2/28/26 the resident did not receive four baths out of six opportunities.-Between 3/1/26 and 3/10/26 the resident did not receive any baths out of three opportunities. Review of the resident's EMR showed:-The resident did not receive six baths out of nine opportunities. -Staff documented not applicable on 2/18/26, 2/20/26, 2/25/26, 2/28/26, 3/4/26 and 3/7/26. Observation on 3/9/26 at 10:21 A.M., showed the resident had an odor and was lying in the bed with hair uncombed and greasy. During an interview on 3/9/26 at 10:21 A.M. the resident said:-He/She did not get showers all the time when he/she was supposed to get them.-He/She would like to get showers in the evening, but the facility was short staffed and couldn't do it, so they always offered them in the morning. 4. Review of Resident #35's face sheet showed the resident was admitted with the following diagnoses:-Morbid (severe) obesity.-Body Mass Index (BMI) 50.0-59.9, Adult. Review of the resident's admission MDS dated [DATE] showed:-The resident was cognitively intact.-He/She had lower extremity impairment on one side.-He/She was dependent on staff for bathing. Review of the resident's undated care plan showed:-He/She had an ADL self-care performance deficit related to activity intolerance and impaired balance.-He/She was totally dependent on staff to provide showers. Review of the resident's paper bath sheets dated February 2026 to March 2026 showed:-Between 2/11/26 and 2/28/26 the resident did not receive four baths out of six opportunities.-Between 3/1/26 and 3/10/25 the resident did not receive two baths out of three opportunities. Review of the resident's EMR showed:-The resident did not receive six baths out of nine opportunities. -Staff documented not applicable on 2/11/26, 2/14/26, 2/20/26, 2/25/26, 2/28/26 and 3/03/26. During an interview on 3/9/26 at 10:50 A.M., the resident said:-He/She was not getting baths on a regular basis.-There was not enough staff to make sure everyone got their baths.-The facility did not have a bath aide for a long time.-He/She preferred to have baths after he/she had received his/her scheduled pain medication because he/she was stiff and sore before then.-He/She often felt dirty and wished she/he could get bathed twice per week. 5. Review of Resident #3's face sheet showed the resident was admitted with the following diagnoses:-Morbid (severe) obesity due to excess calories.-Body Mass Index (BMI) 50.0-59.9, Adult.-Bilateral osteoarthritis (a degenerative disease of the bones and joints) of hip.-Reduced mobility. Review of the resident's annual MDS dated [DATE] showed:-The resident was cognitively intact.-He/She had bilateral extremity impairment.-He/She required substantial/maximal assistance by staff for bathing. Review of the resident's undated care plan showed:-The resident's bath days were Tuesday and Friday on evening shift.-ADL/Functionality as a focus area but no interventions related to bathing. Review of the resident's paper bath sheets dated February 2026 and March 2026 showed:-Between 2/11/26 and 2/28/26 the resident did not receive four baths out of six opportunities.-Between 3/1/26 and 3/10/26 the resident did not receive two baths out of three opportunities. Review of the resident's EMR showed:-The resident did not receive five baths out of nine opportunities. -Staff documented not applicable on 2/11/26, 2/18/26, 2/20/26, 2/28/26 and 3/4/26. During an interview on 3/9/26 at 11:28 A.M., the resident said:-He/She did not always get a shower twice per week. -He/She would like to receive a shower twice a week. -He/She preferred showers in the evening or at night, but the staff was too busy.-His/Her hair was messy and uncombed, and he/she did not like that. 6. During an interview on 3/11/26 at 2:10 P.M., Administrator said: -Resident #32 and Resident #24 were scheduled for two baths a week.-He/She had transcribed information from the resident's EMR, under CNA task section onto Resident #32's and Resident #24's Skin Monitoring: Comprehensive CNA Shower Review forms. -Resident #32 and Resident #24 were missing documentation of showers/baths given or refused.-He/she would expect the assigned CNA's to complete shower sheets and also document care provided in the resident's EMR under the CNA task. During an interview on 3/13/26 at 11:15 A.M., CNA H said:-Residents should get showers two days per week on their bath days unless they refused.-Resident's bath times should be made according to their preference.-He/She could find the resident's preferences in the care plan, shower book or by asking the resident.-Each resident was assigned bath days and times.-If a resident asked for a different bath time, he/she would try to come back.-He/She was assigned five to six baths per shift.-If he/she was not able to get all the baths done, they would let the charge nurse know and try the next day. During an interview on 3/13/26 at 11:35 A.M., Licensed Practical Nurse (LPN) B said:-Residents could choose when they wanted to take baths.-He/She could find preferences on the clinical assessment that was done during admission and could be found under the assessments tab.-He/She was aware that Resident #35 would prefer showers after his/her pain medication had been given and not in the morning.-Residents should be care planned for ADLs which included bathing/showering.-If a resident did not get their showers, they would get it the next shift or the next day.-There was enough staff to get showers done when they showed up. During an interview on 3/13/26 at 11:58 A.M., CNA D said:-The facility had just hired a new shower aide, that would be assigned resident baths Monday through Friday. -Currently, the resident's assigned CNA was responsible to ensure the resident's baths/showers were completed during day shift. -He/she would document on the resident's shower sheet and in the resident's EMR under CNA Task section for shower or bath that was provided or refused. -He/she was not aware Resident #32 had refused personal cares to include showers. -Resident #24 seemed to get frustrated easily during all personal cares but was not aware if he/she had any missed any showers. During an interview on 3/13/26 at 12:24 P.M., the DON said:-Residents could choose when they wanted to take their baths. -He/She recommended that staff let him/her, the Administrator or the charge nurse know if there was a problem with the scheduling of baths so they could reassess the schedule.-Resident bath schedules could be found in bath binder at the nurse's station.-Bath sheets should be filled out completely and were ultimately turned into him/her.-He/She tried to encourage showers at varying times with Resident #10, but he/she refused.-All residents should be care planned for ADLs that included bathing.-If a resident did not receive a bath due to staff call offs, they would try to figure out scheduling for the next day.-If a resident refused, staff was to try again later. Staff needed to be reeducated on how to document refusals.-The nursing staff and he/she were responsible for making sure that showers/baths were getting done. During an interview on 3/13/26 at 12:24 A.M., the Administrator said:-If a resident did not get their bath/shower on their scheduled day, then staff should let the charge nurse know immediately, he/she or the DON would try to reschedule with the resident.-He/She believed that some of the staff was possibly confusing not applicable with refusal when charting.-The facility was currently doing Performance Improvement Project (PIP) – (in long-term care is a structured, data-driven initiative used by nursing homes and care facilities to identify specific areas of concern) audits for showers. During an interview on 3/13/26 at 2:17 P.M., LPN B said:-He/She was not aware of Resident #32 refusing cares or showers.-Resident #24 had a history of refusal of care.-He/she would have the resident sign the shower form for any refusal of care/showers. -The assigned CNA would be expected to document in the resident's EMR under CNA task any care provided and any refusal of cares. -CNA's were to notify nursing staff of any refusal of cares. During an interview on 3/16/26 at 10:14 A.M., the MDS Coordinator said: -He/she was behind on completing MDS and care plan updates to include admission since 2/2026 since February when other nursing management staff no longer working at the facility. -admission MDS and comprehensive care plan should be completed within 7-14 days after admission. -Resident #24 admission MDS and Care areas had not been completed and submitted as of 3/16/26. During an interview on 3/16/26 at 12:58 P.M., the DON said:-The facility did not have an assigned shower aide at that time of review. -The CNA assigned to the resident would be responsible for providing and documenting showers/bath provided or refused. -He/She was still learning the resident's scheduled bath days and preferences. -Resident #24 had a history of refusal of care and he/she had to beg the resident to change clothes daily and let staff assist the resident with personal cares. -He/she had stayed late to ensure Resident #32 was given a shower if needed. -CNA staff were responsible for documenting showers/baths on the shower sheet and in the resident's EMR under CNA task.

Based on observation, interview and record review, the facility failed to post the facility census and actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs) and Certified Nursing Assistants (CNAs) directly responsible for resident care per shift and to update the posting daily for view by residents, family members and visitors. The facility census was 49 residents. Policies for all areas of staffing were requested on 3/16/26 and were not received at the time of exit.1. Observation on 3/9/26, 3/13/26 and 3/16/26 showed there was no posting of the facility staffing that included facility name, date, census, the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care.Review of the facility staffing sheet dated 3/9/26 showed the facility had no documentation of the facility census for the day and night shifts. Observation on 3/10/26 showed the facility staffing sheet did not document the actual hours worked for Registered Nurses (RN's) for the day or night shift and did not document the facility census for the night shift.Observation on 3/11/26 showed the facility staffing sheet did not document the facility census for the day or night shifts.Observation on 3/12/26 showed the facility staffing sheet did not document the facility census for the day or night shifts.Review of the facility staffing sheet dated 3/13/26 showed the facility had no documentation of the actual hours worked for RNs for the day or night shift and did not document the facility census for the day or night shifts.During an interview on 3/13/26 at 12:24 P.M., the Administrator said:-The facility did not currently have a Staffing Coordinator.-He/She often acted in that role.-Staffing sheets should be posted daily and filled out completely.-Copies of daily nursing sheets were kept in a binder at the nurse's stations.-Either he/she or the Director of Nursing (DON) would be responsible for this.Review of the facility staffing sheet dated 3/16/26 showed the facility had no documentation of the facility census for the day or night shifts.

Based on observation and interview, the facility failed to ensure hot foods on room trays for at least 5 residents on the [NAME] Hall were maintained at or above a temperature of 120 F (degrees Fahrenheit). The facility census was 49 residents. 1. Observation on 3/12/26 at 8:16 A.M., showed the pancakes were 152.7 F and the sausage patties were 170.6 F on the steam table. Observation on 3/12/26 at 9:01 A.M., showed the food cart was loaded with the meals for room trays and was delivered to the [NAME] Hall for delivery to the residents. Observation on 3/12/26 at 9:17 A.M., showed the pancakes had a temperature of 88.7 F and the sausage had a temperature of 85.8 F on a room tray that was refused by a resident.Observation on 3/12/26 at 9:24 A.M., showed the pancakes had a temperature of 86.3 F on a room tray that refused by Resident #18.During an interview on 3/12/26 at 9:26 A.M., Certified Medication Technician (CMT) C said:-He/She usually worked the day shift.-Had not seen anyone from the dietary department come to the halls and check the temperatures of the room trays.During an interview on 3/12/26 at 9:55 A.M., the Dietary Manager (DM) said:-He/She had not sent anyone from the dietary department to the halls to check the temperatures of the room trays.-In the past there had been complaints about cold food on the room trays.-When he/she was hired as the DM, he/she was not trained on the state regulations.During an interview on 3/13/26 at 1:24 P.M., Resident #32, a resident identified by the admission Minimum Data Set (MDS-- a federally mandated assessment tool completed by the facility for care planning) dated 2/27/26 as cognitively intact, said:-He/she had been served cold food in the past.-All the meals, but especially the French fries and the meat loaf had been cold at some point.-He/she received cold food at least three times per week.-When he/she received cold food he/she was not happy.-He/She no longer had access to the microwave.During an interview on 3/13/26 at 1:45 P.M., Resident #39, a resident identified by the quarterly MDS dated [DATE], as cognitively intact, said:-He/She had been served cold food in the past.-The lunch meals were the ones that were cold most of the time, but only when he/she ate in his/her room.-He/she received cold food three or four times a week.-When he/she received cold food he/she was not happy.During a phone interview on 3/18/26 at 1:16 P.M., the Registered Dietitian (RD) said he/she would expect that someone from the dietary dept would check the temperatures of room trays on an interval basis.

Based on interview and record review, the facility failed to provide the required 12 hours of nurse aide in-service training either at the time of hire or within the last 12 months that included the topics of dementia (a progressive mental disorder causing confusion, and impairment of control, memory, judgement, and impulses), Abuse, Neglect and Exploitation (ANE) and behavior management (focuses on person-centered, non-pharmacological approaches to address challenging behaviors (e.g., aggression, wandering) as communication of unmet needs) for four out of five sampled nursing staff Certified Nursing Assistants (CNA D and CNA J), Licensed Practical Nurse (LPN) C and Registered Nurse (RN) A. The facility's census was 49 residents. A policy for staffing competencies and in-service training was requested on 03/16/26 but has not been provided to date.1. Review of CNA D's Relias (a computer-based training program presented and tracked training topics and hours) course completion history dated March 2025 to March 2026 and in-services documentation dated March 2025 through February 2026 showed:-He/She was hired on 2/2/26.-His/Her Relias course completion history showed he/she completed 0.0 hours for required topics during the dates listed above.-There was no in-service documentation showing completion of the required topics or number of hours met.2. Review of CNA J's Relias course completion history dated March 2025 to March 2026 and in-services documentation dated March 2025 through February 2026 showed:-He/She was hired on 2/12/26.-He/She completed Relias training on 2/12/26 titled Managing Aggressive Behaviors, no hours were provided.-His/her Relias course completion history showed he/she completed 0.0 hours for the Dementia and ANE topics.-There was no in-service documentation showing completion of the required topics or number of hours met.3. Review of LPN C's Relias course completion history dated March 2025 to March 2026 and in-services documentation dated March 2025 through February 2026 showed:-He/She was hired on 3/5/26.-His/Her Relias course completion history showed he/she completed 0.0 hours for required topics during the dates listed above.-There was no in-service documentation showing completion of the required topics or number of hours met.4. Review of RN A's Relias course completion history dated March 2025 to March 2026 and in-services documentation dated March 2025 through February 2026 showed:-He/She was hired on 2/18/24.-He/She completed in-service training for Dementia and ANE during the dates listed above, no completion times were recorded.-His/Her Relias course completion history showed he/she completed 0.0 hours for Behavior Management.-There was no in-service documentation showing completion of Behavior Management or number of hours met.5. During an interview on 3/13/26 at 11:15 A.M., CNA H said:-He/She had received training through Relias online during orientation.-He/She had not attended any in person in-services to date.-The staff was responsible for making sure they completed all Relias training.During an interview on 3/13/26 at 11:35 A.M., LPN B said:-He/She received all training through Relias and in-services.-In-services were usually held monthly.-There had not been a skills fair since he/she had worked here.-The staff was responsible for making sure they completed all Relias training.During an interview on 3/16/26 at 12:24 P.M., the Director of Nursing (DON) said:-CNAs should have at least 12 hours of training in the required topic areas.-All staff should receive training in Alzheimer/Dementia care, ANE and behavior management either upon hire or within at least past 12 months.-He/She ensured this training was completed through Relias training, in-services and during onboarding of new staff.-There had not been any skills checkoffs done with nursing staffing in the past year, but he/she intended on having them annually.-The skills checkoffs should include basic skills and required training.-He/She was responsible for making sure required training and skills checkoffs were done.During an interview on 3/16/26 at 12:24 P.M., the Administrator said:-He/She had been operating in their role since 2/2/2026.-He/She was responsible for making sure that training was given.-The facility plans to include Performance Improvement Projects (PIPs) which were mandatory Quality Assurance and Performance Improvement (QAPI) initiatives for long term care (LTC) facilities to address care quality.

Based on interview and record interview, the facility failed to ensure the right to be informed when one sampled resident (Resident # 41) out of 13 sampled residents, was not provided information demonstrating the risks and/or benefits of the medication Xanax (a medication used to treat anxiety caused by depression (a mental health condition creating persistent feelings of sadness, hopelessness, and loss of interest in activities), anxiety disorders and panic disorder. The facility census was 49 residents. Review of the facility's Resident Rights policy, undated, showed:-The resident has the right to be fully informed in a language which he or she can understand.-The resident has the right to be informed of and participate in his or her treatment.-The resident has the right to be informed in advance, by the attending physician or other practitioner or professional, of the risks and benefits of proposed carte, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.-The resident has the right to be informed in advance of changes to the plan of care.Review of the facility's Psychotropic Medication Use policy, dated February 2025, showed:-Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication,the staff and physician will review the following with the resident/representative prior to obtainingdocumented consent or refusal:a. non-pharmacological alternatives.b. the indications and rationale for the recommendation.c. the potential risks and benefits (including possible side effects, adverse consequences, and black boxwarnings); andd. the resident's/representative's right to accept or decline the treatment.1. Review of the Resident #41's face sheet, dated 3/12/26, showed:-The resident was admitted on [DATE] and re-admitted on [DATE].-The resident was diagnosed with anxiety.Review of the residents quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 12/31/25, showed:-The resident was cognately intact.-The resident was taking antipsychotic medication.Review of the resident's Physician Order Summary, dated March 2026, showed the resident was ordered Xanax oral tablet 0.5 milligrams (mg), give 0.5 mg by mouth three times a day for anxiety.Review of the resident's Electronic Health Record (EHR) showed no evidence the resident was informed of the risks and/or benefits of Xanax.Review of the resident's undated Care Plan showed h/she did not have a focus, goals, or interventions for taking antipsychotic or antianxiety medications.During an interview on 3/11/26 at 11:40 A.M., the resident said:-He/She didn't always get medications on time.--Note: the facility uses a liberalized medication pass.-He/She knew he/she was taking medication for anxiety but did not remember the name of the medicine.-He/She did not remember anyone explaining the risks and/or benefits of the medication or signing a consent before starting the medication.During an interview on 03/13/26 at 11:35 A.M., Licensed Practical Nurse (LPN) B said:-The process to inform the resident and/or resident representative of the intended benefits and potential side effects of the resident's medication regimen consisted of having the resident sign a consent form for antipsychotic medication use that listed all the benefits and side effects and care plan the use.-Residents who took antipsychotic medications should sign a consent form that stated all risks and benefits.-The resident did not have a care plan and did not have a signed consent form for antipsychotic medication use.During an interview on 3/13/26 at 12:24 P.M., the Director of Nursing (DON) said:-The resident should have received and signed a consent form for psychotropic medication use with all the risks and benefits explained.-The resident should have had a care plan for psychotropic drug use but did not.

Based on observation, interview, and record review, the facility failed to ensure bedrails were provided and utilized in accordance with resident needs, physician orders, and care plan for one sampled resident (Resident #3) who was approved for the use of bedrails out of 13 sampled residents. The facility census was 49 residents. A bedrail policy was requested on 3/16/26 and was not provided at the time of exit. 1. Review of Resident #3's face sheet showed he/she was admitted on [DATE] with the following diagnoses:-Chronic pain (lasts months or years and can affect any part of your body).-Morbid obesity (a severe form of obesity characterized by a body mass index (BMI) of 40 or higher, or a BMI of 35 or higher with obesity-related health complications).-Bilateral primary Osteoarthritis of hip (a common, progressive degenerative joint disease characterized by the breakdown of articular cartilage, the tissue that cushions joint ends).-Anxiety disorder (excessive, uncontrollable fear or worry that interferes with daily life, lasting for months).-Reduced mobility (the ability to move freely and independently, encompassing joint range of motion, muscle strength, and neuromuscular coordination).Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 12/19/25, showed:-He/She was cognitively intact.-He/She needed assistance with activities of daily living.-He/She was dependent on staff assistance with transfers.Review of the resident's bedrail assessment dated [DATE] showed:-Side rail placement was recommended on both sides of the resident's bed and were to serve as an enabler to promote independence. -The resident had expressed a desire to have side rails/assist bar.Review of the resident's Physician Order Sheet (POS) dated March 2026 showed:-May have bedrails for assistance with bed positioning and self-mobility, consent and therapy screen complete. Ordered on 4/23/25.-May have grab bars for bed for self-repositioning. Ordered on 2/19/26.-Continue skilled Physical Therapy (PT) three times per week for 30 days. Ordered 2/26/26.-Occupational Therapy (OT) clarification order: OT to see patient four times a week for 30 days for therapeutic exercise, therapeutic activity, neuromuscular re-education, self-care training, group as indicated. Ordered on 3/6/26.Review of the resident's undated care plan showed:-The resident required a full body mechanical lift for transfers related to immobility secondary to bilateral hip osteoarthritis.-The resident used bedrails daily.-Interventions included:--U rail on bed to aid in bed mobility.--Ensure valid consent on chart prior to initiating bedrail.--He/She used bedrails for bed mobility and enabled him/her to move. Observation on 3/9/26 at 11:28 A.M., showed:-The resident was lying in bed resting.-There were no rails of any kind installed on his/her bed or on floor parallel to the resident's bed.During an interview on 3/9/26 at 11:28 A.M. the resident said he/she:-Was not able to change positions in bed on his/her own and needed to call for assistance to do so.-Had been assessed by PT and approved for the use of bedrails since March 2025.-Attended therapy during the week in order to maintain and build strength for mobility.Observation on 3/16/26 at 11:24 A.M., showed:-The resident was lying in bed resting.-There were no rails of any kind installed on his/her bed or on floor parallel to the resident's bed.-The resident was not able to change position in bed independently.During an interview on 3/16/26 at 11:24 A.M. the resident said he/she:-Having bedrails and/or an assist bar would help him/her by strengthening his/her arms; help him/her reposition in bed; help him/her to sit up in bed; and help him/her to transfer himself/herself in and out of bed without assistance.-Not having bedrails or an assist bar caused him/her to call for assistance for all of those things instead of being able to do them by himself/herself and helping to maintain some of his/her independence.-It was depressing, overwhelming and made him/her feel helpless. -It is very important that he/she could transfer himself/herself to the wheelchair and toilet and turn on his/her own.-He/She did not like the fact that he/she had to be changed in bed after an incontinent episode.-NOTE: Th resident became upset and began crying.During an interview on 3/16/26 at 11:28 A.M., Licensed Practical Nurse (LPN) B said:-The resident would benefit from bedrails because it would help him/her to reposition himself/herself while in bed and help with self-transfers.-He/She understood the process for a resident to obtain bedrails was for a nurse to complete an assessment form in Point Click Care (PCC cloud-based healthcare technology platform and Electronic Health Record (EHR) system, specifically built for the long-term and post-acute care), then therapy performed an assessment, then it went to the Corporate Regional Nurse.-He/She was not sure how long the process for bedrails should take.-He/She would expect a resident who had an order for bedrails since April 2025, would have them installed by now.-He/She was not sure why the bedrails had not been installed.-He/She re-initiated the process in February 2026 that had not been completed the prior year.-He/She was aware that it was the resident's desire to maintain and increase his/her independence.-He/She was aware that the resident was feeling depressed and helpless not being able to change position in bed or transfer himself/herself in order to be able to go to the bathroom without calling and asking staff for assistance.During an interview on 3/16/26 at 12:20 P.M., the Maintenance Director said:-The process for a resident getting bedrails installed was, it was discussed in morning meeting, it went through the therapy department for assessment, a physician's order was obtained, then he/she got the work order which was recorded in the logbook.-All new beds came with rails so there was no need to order them.-He/She kept them on hand.-Ultimately the nurses and Director of Nursing (DON) were responsible for making sure the process was done.-He/She remembered the resident bedrail order being brought up in a meeting some time ago but had not received a work order for it as of today.-He/She did not have a current bedrail work order for the resident.During an interview on 3/16/26 at 12:42 P.M., the Physical Therapy Assistant (PTA) said:-The resident was receiving PT and OT on multiple days every week for strengthening, transferring from back to lying on side of bed, lower extremity muscle strength and standing frame strengthening for lower body strength.-The process for a resident to receive bedrails was that therapy would do an assessment, therapy would decide if they were appropriate, nursing would do assessment, a physician's order would be obtained then maintenance would install them.-This information was documented in the therapy charting system under the resident narrative.-He/She would expect that the entire process to be completed within two weeks.-He/She would expect that a resident who had an order for bedrails since April 2025 to have them installed by now.-The resident had expressed concern about not receiving his/her bedrails.During an interview on 3/16/26 at 12:49 P.M., the DON said:-The resident would benefit from having bedrails because they would be able to help with turning during cares and dressing.-The process for a resident receiving bedrails was, the nurse completed an assessment form in PCC.-After they got an ok from therapy, maintenance was supposed to write it down in the maintenance log, but he/she had personally never seen it. They also used WhatsApp (a messaging application that allowed users to send texts, voice notes, images, videos, documents, and make video/audio calls over the internet) to communicate work orders to the maintenance department.-This process should take 48 hours at the most.-He/She was aware that the resident wanted bedrails.-There was no reason the resident's bedrails should not be installed.-He/She was not aware that the resident was feeling depressed and helpless not being able to change position in bed or transfer by himself/herself to be able to go to the bathroom without calling and asking staff for assistance.-He/She was not sure if the facility had any bedrails on hand.-He/She needed to check with the Maintenance Director to see where they were in the process to get the resident's bedrails installed.

Based on interview and record review, the facility failed to ensure Third Party Liability (TPL- a form which is sent to Missouri (MO) Health Net, which gives an accounting of the remaining balance of that resident's funds in the resident trust account) forms were completed and sent to Missouri (MO) Healthnet (a state agency which administers the provision and payment of services for Missouri's Medicaid program) within 30 days of death for two discharged residents (Resident #101 and #102). The facility census was 49 residents. 1. Review of Resident #101's Resident Trust Transaction History dated 2/1/26 through 3/11/26, showed he/she:-Passed away on 2/1/26.-Had $20.15 left in his/her account.During an interview on 3/11/26 at 12:01 P.M., the Business Office Manager (BOM) said:-He/She did not submit a TPL on behalf of the resident.-There has been a lot of change around the facility, so somethings got dropped.2. Review of Resident #102's Resident Trust Transaction History dated 12/1/25 through 3/11/26, showed he/she:-Passed away on 1/19/26.-Had $0.00 in his/her account at the time of death.During an interview on 3/11/26 at 12:26 P.M., the BOM said there were a lot of changes during the time of the death of the resident.

Based on observation, interview, and record review, the facility failed to meet professional standards of practice when staff obtained the blood pressure (the force of circulating blood pushing against the walls of your arteries as the heart pumps it around the body) using a wrist cuff while the residents' arms remained in a dependent (lowered) position, which could result in inaccurate readings for two sampled residents (Resident #41 and #48) out of 13 sampled residents. The facility census was 49 residents. A policy for blood pressure equipment usage was requested but not provided by the date of exit. 1. Review of Resident #41's face sheet showed the resident was admitted to the facility with the following diagnoses:-Hypertensive (high blood pressure) heart disease with heart failure (the heart cannot pump enough blood to meet the body's needs).-Essential Hypertension.-Hypertensive heart and chronic kidney disease with heart failure (a complex condition where long-term high blood pressure causes severe cardiac strain and kidney dysfunction).Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 12/31/25, showed:-The resident was moderately cognitively intact.-He/She had active diagnoses of heart failure, hypertension, renal failure and Dementia (progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).Review of the resident's Physician Order Sheet (POS) dated March 2026 showed:-Amlodipine Besylate oral tablet 5 milligram (mg) give one tablet by mouth one time a day for hypertension. Hold if blood pressure was less than 110/55 or heart rate was less than 55. Notify Nurse Practitioner (NP)/Medical Doctor (MD) of held medications.-Aspirin oral tablet chewable 81 mg give one tablet by mouth one time a day for prophylaxis (action taken as a prevention) related to hypertensive heart disease with heart failure.Observation on 3/11/26 at 11:40 A.M. showed Certified Medication Technician (CMT) C, during medication pass:-Applied a wrist blood pressure cuff to the resident's left arm and obtained a blood pressure reading while the resident's arm was in a dependent position, below the level of the heart. -He/She did not reposition or support the resident's arm at heart level during the procedure.2. Review of Resident #48's face sheet showed the resident was admitted with the following diagnoses:-Hypertensive chronic kidney disease.-Heart failure.Review of the resident's admission MDS dated [DATE] showed:-The resident was moderately cognitively impaired.-He/She had an active diagnosis for heart failure.Review of the resident's POS dated March 2026 showed Metoprolol Tartrate oral tablet 25 mg give one tablet by mouth two times per day for hypertension. Hold if systolic blood pressure (SBP- measures the maximum force exerted by your arteries when the heart contracts) was less than 110 or pulse was less than 60.Observation on 3/11/26 at 12:38 P.M. showed CMT C, during medication pass:-Applied a wrist blood pressure cuff to the resident's left arm and obtained a blood pressure reading while the resident's arm was in a dependent position, below the level of the heart. -He/She did not reposition or support the resident's arm at heart level during the procedure.-He/She held the resident's metoprolol medication due to reading of 98/86. He/she did not recheck it.3. During an interview on 3/11/26 at 12:45 P.M, CMT C said:-The proper way to take a blood pressure using a wrist cuff was to have the resident relax the arm, not talk and not have legs crossed.-The wrist cuff should be held at the level of the heart while being used.During an interview on 3/13/26 at 12:24 P.M., the Director of Nursing (DON) said the wrist blood pressure cuff should be held at the level of the heart when being used for best accuracy.

Based on observation, interview and record review, the facility failed to ensure the resident's urinary catheter (a flexible, thin tube inserted into the bladder to drain urine when a person cannot urinate naturally) drainage bag (a medical device that connects to a catheter to collect urine draining from the bladder) was placed below the resident's bladder during a transfer and during incontinence care for one sampled resident (Resident #5); and failed to ensure a suprapubic urinary catheter (is a flexible tube inserted into the bladder through the abdominal wall) tubing was not dragging on the ground while up in wheelchair; failed to ensure the suprapubic catheter was addressed in a care plan; and failed to ensure Enhanced Barrier Precaution (EBP, for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status) signage was on the resident's door for one sampled resident (Resident #24)out of 13 sampled residents. The facility census was 49 residents. Review of the facility Catheter policy and procedure dated October 2022, showed:-The staff should wash hands and explain the procedure to the resident. -Place a towel under the catheter tubing before washing. Apply soap to the washcloth and clean around meatus (the urethral opening and the external portion of a urinary catheter to prevent infections), avoiding tugging the catheter, moving in one direction, away from the meatus. Use a clean cloth for each stroke. Rinse around the meatus and use a clean cloth for each stroke. -With a clean dry towel dry around the meatus. Rinse at least 4 inches of the catheter nearest the meatus, moving away from the meatus. Use a clean cloth for each stroke. With a clean dry towel, dry at least 4 inches of the catheter nearest to the meatus, moving away from the meatus. Remove and discard gloves and wash hands.-The policy did not show where the catheter bag should be placed. 1. Review of Resident #5's Face Sheet showed the resident was admitted with diagnoses including:-Cerebral palsy (a group of permanent neurological disorders that affect movement, muscle tone, and posture due to abnormal brain development or damage, typically occurring before, during, or shortly after birth).-Diabetes.-Dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change)-Cognitive communication deficit.-Urinary tract infection (history) and urinary retention (the inability to fully or partially empty the bladder, causing urine to build up, which can lead to pain, pressure, and potential kidney damage). Review of the resident's list of Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) showed the resident's MDS had not been completed. Review of the resident's Care Plan dated 1/5/26 showed he/she:-Had a self-care deficit.-Was dependent on staff for all his/her physical needs.-Needed two persons to assist with transfers and toileting. -Used a mechanical full body lift for transfers that required two people to assist with transfers.-Had an indwelling catheter for urine retention and staff was supposed to position the resident's catheter below the level of the bladder and away from the entrance to his/her room door. Review of the resident's Physician's Order Sheet (POS) dated March 2026, showed physician's orders for:-Urinary catheter 16 French (Fr) 30 cubic centimeters (cc) (references an indwelling catheter, featuring a 16 Fr diameter tube for draining urine and a large 30 cc balloon designed to secure the catheter, often used post-operatively for bladder retention) as needed for occlusion or leakage related to urine retention.-Change catheter anchor one time daily on Sunday for catheter care.-Urinary catheter care every shift for urinary retention. -Irrigate with 30cc to 50cc of normal saline (salt water) every shift for catheter care.-Change catheter drainage bag once daily on Sunday for catheter care. Review of the resident's Infection Note dated 3/7/26 showed:-The resident was receiving an antibiotic for treatment of a urinary tract infection.-His/Her catheter was draining clear yellow urine. -The resident was alert and oriented to person and place, was taking fluids well and denied urinary pain. Observation on 3/10/26 at 2:25 P.M., showed the resident was sitting up in a specialized positioning wheelchair in the dining room. The resident's catheter bag was below the resident's bladder in a privacy bag at the side of his/her wheelchair. Certified Nursing Assistant (CNA) A took the resident to his /her room and said he/she was going to transfer the resident so he/she could perform incontinence care. CNA B entered the resident's room and sanitized his/her hands. Both CNA A and CNA B put gowns on and gloved. The following occurred:-CNA A took the resident's catheter bag out of the privacy bag and placed the catheter bag on the resident's lap. He/She then hooked the lift sling onto the lift.-CNA A and CNA B then lifted the resident up from his/her wheelchair and moved the resident to his/her bed.-CNA B assisted with positioning the resident as CNA A lowered the resident to his/her bed. -CNA B then removed the resident's catheter bag from his/her lap and held it while the resident was being lowered then he/she placed the resident's catheter bag at the foot of the resident's bed which was at the level of the resident's bladder. -CNA A and CNA B rolled the resident to the side to remove the sling from under him/her then began to perform incontinence care on the resident. -CNA B removed the resident's brief. CNA A opened the cleansing cloths and used one wipe one swipe process to clean the resident from front to back. -CNA A did not clean down the resident's catheter tubing. He/She left the resident open to air without briefs.-CNA A then removed the resident's catheter bag from the bed and put it in the basin on the floor. He/She then covered the resident and lowered the resident's bed.-Both CNA A and CNA B removed and discarded their gloves. CNA A then sanitized his/her hands prior to exiting the resident's room. -CNA B gathered the trash and went outside of the resident's room to discard the trash bag then washed his/her hands. During an interview on 3/10/26 at 2:40 P.M. CNA A said:-When transferring the resident, he/she placed the resident's catheter bag in the resident's lap, but it shouldn't have been there because it was supposed to be below the resident's bladder. -When the resident was in bed, he/she forgot to place the resident's catheter bag at the side of his/her bed below his/her bladder. -The resident's catheter bag should always be kept below the bladder, so the urine did not flow back into the resident's urinary tract.-He/She did not remember whether he/she cleaned down the resident's catheter tubing. During an interview on 3/13/26 at 12:29 P.M., Licensed Practical Nurse (LPN) A said:-The resident's catheter bag should be placed below the resident's bladder at the side of the lift or one of the CNA staff could hold the catheter bag in their hand but below the resident's bladder, so it did not backflow into the resident's bladder.-The resident's catheter bag should never be placed on the resident's lap or on his/her bed because the resident had a history of urinary tract infections and was highly susceptible for risk of urinary infections. -As the nursing staff lowered the resident to his/her bed the resident's catheter bag should have been kept below the bladder. When they lowered the resident into his/her bed, they should have put the resident's catheter bag below his/her bladder at the side of his/her bed.-During catheter care nursing staff should clean the resident from front to back then clean down the catheter tubing, away from the bladder, with a clean cloth.-The resident's catheter bag should never be touching the floor and should always be covered. During an interview on 3/16/26 at 10:18 A.M. Director of Nursing (DON) said:-The catheter bag should be placed below the bladder but should not drag the floor or be placed on the floor. -During catheter care they should clean the resident's peri area and then wipe down the catheter tubing away from the resident's peri area.-During a transfer the catheter bag should always be below the bladder, not on the resident's lap or on the bed. -The nursing staff should have kept the resident's catheter below his/her bladder by placing it on the bedframe once they transferred him/her to his/her bed. 2. Review of Resident #24's admission Face Sheet showed he/she was admitted with diagnoses of: -Paraplegia (-is paralysis that affects your legs, but not your arms.-Neuromuscular Dysfunctional bladder (a loss of bladder control caused by nerve damage from illnesses or injuries). -Suprapubic urinary catheter (is a flexible tube inserted into the bladder through the abdominal wall). Review of the resident's Care Plan initiated on 2/13/26 showed: -He/she was at risk for impaired urinary elimination. -The resident was on EBP.-NOTE: The resident did not have a care plan for his/her suprapubic catheter as of 3/16/26. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) initiated on 2/20/26 showed:-He/she was cognitively intact.-Indwelling catheter was checked marked.-He/She had difficulty communicating his/her needs.-NOTE: The facility had not submitted the resident's admission MDS as of 3/16/26. The MDS was 2 1/2 weeks late. Review of the resident's Physician Order Sheet (POS) dated March 2026 showed: -Enhanced Barrier Precautions related to a suprapubic catheter and wounds ordered on 2/12/26. -Provide urinary catheter care every shift. -Urinary Catheter: may use a leg drainage bag, with an 18 French (Fr a measure of the outer diameter of a catheter) 30 cubic centimeter (cc) bulb, connected to urinary drainage bag, and nursing staff to change catheter with insertion tray and change urinary bag & band every month, ordered on 2/12/26.-Urinary Catheter: 18 Fr, with a 30cc bulb provide catheter care maintenance every shift as ordered and as needed for occlusion or leakage ordered on 2/25/26.-Irrigate urinary catheter with 50-60 cc of normal saline every shift for catheter care was ordered on 2/25/26.-Change urinary catheter bag and anchor band every week on Sunday. Review of the resident's Health Status Notes dated 3/9/2026 at 9:40 A.M., showed he/she was being transported to a doctor's appointment, when his/her suprapubic catheter came out (dislodged). This nurse advised the van driver to take the resident to the local hospital emergency room to have the suprapubic catheter replaced. This nurse had notified the DON and the resident's family member. Both verbalized understanding of situation. Observation on 3/10/26 at 11:42 A.M., of the resident showed:-He/she was up in his/her wheelchair. -His/her urinary catheter drainage bag was in a privacy bag and secured under his/her wheelchair. Review of the resident's Order Note dated 3/10/2026 at 5:54 P.M., as a late entry showed the resident had approximately 850 milliliters (ml) of bright yellow urine emptied from foley bag. Observation on 3/11/26 at 10:10 A.M., of the resident showed: -The resident was in bed with his/her eyes closed. -Suprapubic urinary catheter drainage bag was hung on the right side of the bed frame. -The catheter drainage bag was not placed in a privacy bag and was noted to have darker tea colored urine in the drainage bag. Observation on 3/13/26 at 12:20 P.M., of the resident showed:-He/She was up in his/her wheelchair propelling himself/herself down the hallway.-The urinary catheter tubing was dragging on ground underneath his/her wheelchair.-The resident's urinary catheter tubing was getting taggled up with resident feet while propelling in his/her wheelchair. Observation on 3/13/26 at 12:23 P.M., of the resident showed:-He/She had wheeled himself/herself to the dining room for lunch. -The resident had wheeled over his/her urinary catheter drainage tubing and had blocked the flow of urine in the tubing. -He/she then backed up from table and again rolled over urinary catheter drainage tubing a few times while waiting for lunch. -The resident's wheelchair left wheel sat on top urinary catheter tubing kinking the tube while eating lunch. Observation on 3/13/26 at 12:39 P.M., of the resident showed:-He/she had propelled himself/herself outside to smoke while the urinary catheter drainage tube dragged on the ground. -The resident and an unknown staff member were outside while the resident smoked. -The resident's urinary catheter tubing laid on the ground while outside. -He/she had darker yellowish urine in the urinary catheter drainage tubing. -There was no obvious leakage of liquids. Observation on 3/13/26 at 12:47 P.M. of the resident showed:-Unknown staff member and resident attempted to come back inside the facility.-The resident's urinary catheter tubing was dragging on the ground and was getting tangled underneath the wheels and footrest, as the resident tried to enter the building. -As the resident wheeled over the urinary catheter drainage tubing, an unknown kitchen staff member stopped the resident and said to the resident that his/her urinary catheter tubing was dragging the ground and was tangled up in the wheels. -The kitchen staff member applied gloves and readjusted the urinary catheter tubing, so it was safely secured under his/her wheelchair and was able to enter the facility. During an interview on 3/13/26 at 11:58 A.M., CNA D said: -The resident's urinary catheter tubing should be secured under the wheelchair and should not be dragging or touching the ground. -Residents on EBP should have signage posted and direct care provider were to wear gloves and gowns. During an interview on 3/13/26 at 2:17 P.M., LPN B said:-He/she did not notice the resident's tubing dragging until he/she saw kitchen staff assisting the resident. -Urinary catheter tubing should not be dragging on the ground and should be secured under the wheelchair. During an interview on 3/16/26 at 10:04 A.M., Acting Infection Control Preventionist (ICP) and Regional Registered Nurse (RN) said:-Residents with suprapubic catheter should be placed on EBP and signage should be posted on the door. -While providing direct catheter care, the use of gown, gloves, mask and if need safety glasses for potential of splatter were required.-Urinary catheter tubing should be placed securely underneath the wheelchair with the drainage bag in a dignity bag along with excess tubing. -If the resident's urinary catheter tubing had been dragging on the ground and was run over with his/her wheelchair, he/she would expect nursing staff to have changed the drainage bag and tubing. -He/She would expect nursing staff to complete a full resident assessment to ensure the suprapubic catheter was in place and functioning as it should. During an interview on 3/16/26 10:14 A.M., MDS Coordinator said: -He/she was behind on completing MDS's and updating the resident's care plan. -The admission MDS and admission comprehensive care plan should be completed within 7-14 days after admission. -The resident's admission MDS and care areas had not been completed and submitted as of 3/16/26.-The resident's admission comprehensive care plan had not been completed as of 3/16/26. During an interview on 3/16/26 at 11:53 A.M., LPN A said:-The catheter drainage bag and tubing should not be dragging on the ground.-If the catheter drainage bag was found to have been dragging on the ground staff needed to change the catheter and tubing. During an interview on 3/16/26 at 12:58 P.M., the DON said:-The catheter drainage bag and tubing placement should be kept secured under the wheelchair.-The residents catheter tubing should never touch the ground. -He/She would expect staff to position the catheter tubing, so it was not touching the ground underneath the resident wheelchair. -He/She would expect to have an up-to-date MDS and care plan for the resident's suprapubic catheter.

Based on observation, interview and record review, the facility failed to properly store and properly label respiratory equipment to include nasal cannula (a lightweight, flexible tube with two prongs inserted into nostrils used to deliver supplemental oxygen to people with breathing difficulties) and nebulizer mask/mouthpiece (a medical devices that fits over the nose and mouth, delivering liquid medication as a fine mist to the lungs) and tubing when not in use; and failed to ensure monitoring and weekly changing of oxygen nasal cannula tubing that was dated 6/26/25 for one sampled resident (Resident #32) who was at risk for respiratory distress out of 13 sampled residents. The facility census was 49 residents.Review of the facility's Oxygen safety policy revised on July 2024 showed: -Do not store oxygen cylinders in any resident room or living area.-Ensure oxygen cylinders in use were on approved carts or stands, and were attached to the residents' beds Review of the facility Administering Medications through a Small Volume (Handheld) Nebulizer revised October 2012 showed:-When equipment is completely dry, store in a plastic bag with the resident's name and the date on it.-Change equipment and tubing every seven days, or according to facility protocol.-Disinfect outside of the compressor between residents, according to manufacturer's instructions. 1. Review of Resident #32 admission record showed he/she had diagnoses of: -Acquired absence of right and left leg below the knee (amputation of lower extremities).-Stroke affecting right side of the body.-Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation (is a sudden worsening of symptoms-increased breathlessness, cough, or sputum production-beyond normal day-to-day variations).Review of the resident's Care Plan initiated on 6/23/25 showed:-The resident had self-care performance deficit. -The resident had altered respiratory status/difficulty breathing related to diagnosis of COPD.-Did not have care plan related use of oxygen nightly or use of nebulizer treatments as needed. Review of the resident's physician order sheet (POS) dated March 2026 showed: -He/She had an order for oxygen to run at 3 liter/minute via nasal canula every night related to COPD, was ordered on 1/11/26.-Change tubing weekly and wash filter weekly with mild soap and water, weekly on Thursday. -Tubing was to be dated and stored in a bag when not in use. Change tubing every Thursday during day shift, was ordered on 1/15/26.-Nebulizer tubing changed weekly on Thursday. Date and bag tubing when in use every day shift every Thursday was ordered on 1/15/26.-Albuterol Sulfate nebulization solution (2.5 milligram (MG)/3 milliliter (ml) 0.083% give 2.5 mg inhale orally via nebulizer every 6 hours as needed for shortness of breath, was ordered on 1/11/26. Review of the resident's medication administration record (MAR) and treatment administration record (TAR) dated 3/1/26 to 3/31/26 showed no documentation of oxygen tubing and nebulizer tubing had been changed weekly.Observation on 3/9/26 at 11:26 A.M., of the resident's room showed: -The bed was in the left corner of the room.-The nasal cannula (NC) was draped over the O2 cylinders (is also known as oxygen tanks in the medical field, are containers that store compressed oxygen gas) tank and not in a storage bag. -The NC tubing was dated 6/26/25.Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 3/10/26 showed.-The resident was cognitively intact. -He/she was able to make his/her needs known.-Required assistance of staff for activities of daily living (ADL) including bathing. -Required dialysis services time of admission.Observation on 3/10/26 at 9:11 A.M., of the resident's room showed: -He/She was not in the room. -He/She had O2 cylinders in a metal frame stand with nasal cannula tubing connected, the tubing was dated 6/26/25. -Had a nebulizer mask and tubing hung on the O2 cylinder tank.-No respiratory tubing storage bag found in room. During an interview on 3/12/26 at 8:20 A.M., the resident said:-He/she did use the oxygen per nasal cannula sometimes at night. -He/she did not remember the last time he/she had used the nebulizer machine. Observation on 3/12/26 at 8:20 A.M. showed:-The resident's O2 nasal cannula tubing dated 6/26/25.-The tubing was connected to O2 cylinder. -The tubing was not stored in plastic bag. During an interview on 3/13/26 at 11:58 A.M., Certified Nursing Assistant (CNA) D said: -The resident had been using O2 at nighttime.-O2 tubing was to be monitored by nursing staff and tubing changed by nursing staff. -O2 tubing and nebulizer tubing should be stored in a labeled bag. During an interview on 3/13/26 at 2:17 P.M., Licensed Practical Nurse (LPN) B said:-Oxygen tubing and masks should be dated.-Oxygen tubing and masks should be stored in a bag with the resident's name and date. -The resident's O2 tubing and nebulizer tubing/mask should be stored in a plastic bag when not in use. -The night shift would be responsible to change the O2 and nebulizer tubing every week on Sunday.-He/she not aware the resident still had O2 in room. The last time he/she remembered the resident using O2 was back in July 2025. -He/she was not aware the resident had O2 with nasal cannula tubing dated 6/26/25 in his/her room.-The resident had not been getting nebulizer treatments. During an interview on 3/16/26 at 12:58 P.M., the Director of Nursing (DON) said:-The night shift staff were responsible for changing out respiratory tubing to include nasal cannula and nebulizer masks every week on Sunday. -O2 tubing and nebulizer tubing should be stored in dated plastic bag when not in use. -All staff would be responsible for monitoring to ensure respiratory supplies were stored properly when not in use.-He/she was not aware the resident had nasal cannula tubing dated 6/26/25 and was not aware there was an O2 cylinder in the room.

Based on observation, interview and record review the facility failed to secure and obtain a signed copy of the dialysis (a treatment to remove extra fluid and waste when kidneys fail) contract; and failed to ensure dialysis communication forms were completed and reviewed by facility staff and the dialysis clinic for one sampled resident (Resident #32) out 13 sampled residents. The facility census was 49 residents. Review of the blank dialysis communication form located at the west nursing station showed: -A reminder to complete the top section of the dialysis communication form.-To ensure the bottom section was completed by dialysis, if returned uncompleted then call dialysis for the documentation.1. Review of Resident #32's admission record showed the resident had the following diagnoses:-Stage 4 chronic kidney disease (CKD, is a severe, advanced condition (eGFR 15-29) indicating significant kidney damage, acting as the final stage before failure).-Congested Heart Failure (CHF the heart can't pump enough blood, which can cause fluid buildup).Review of the resident's care plan initiated on 6/23/25 showed:-The resident needed hemodialysis related to stage four hypertensiveCKD, he/she had fluid overload or potential fluid volume overloadwith diagnosis of dialysis.-Recommendation for fluid restriction limit of 2000 milliliter (ml) daily related to fluid overload secondary to CHF. Review of the resident's dialysis communication forms dated 2/4/26 to 2/17/26 showed: -The middle portion was not completed by the dialysis staff on the forms dated 2/4/26, 2/6/26, 2/9/26, 2/11/26, 2/13/26 and 2/17/26.-The last portion was to be completed by facility staff and signed by nursing was left blank on the forms dated 2/4/26, 2/6/26, 2/9/26, 2/11/26, 2/13/26 and 2/17/26.Review of the resident's alert note dated 2/20/26 at 3:41 P.M. showed: -The resident had come to staff after he/she returned from dialysis stating he/she did not feel well and reported Nausea/Vomiting.-The nurse had the resident lay down.-After 30 minutes the resident started to scream and yell for his/her mother. He/She kept yelling Mama get me up, please Mama please get me up. -The nurse went into the resident's room to complete an assessment. -The resident's left arm, where he/she had a new dialysis fistula/shunt (a procedure that connects an artery to a vein in preparation for dialysis) placed about one week ago, was hot to touch upon palpation, shiny and bleeding. -The nurse held pressure upon noticing the area was bleeding and called emergency medical services (EMS) and received a new physician's order to send the resident to the hospital to evaluate and treat.Review of the resident's dialysis communication form dated 2/27/26 showed: -Dialysis had not completed the middle portion.-The last portion to be completed by facility staff and signed by nursing was left blank.Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 3/10/26 showed.-He/She was cognitively intact. -He/She was able to make his/her needs known.-He/She required assistance of facility staff for activities of daily living (ADL) including bathing. -He/She required dialysis services.Review of the resident's physician order sheet (POS) dated March 2026 showed: -Dialysis clinic care on Monday, Wednesday, and Friday. Contact the dialysis clinic as needed and complete the dialysis communication form and send with the resident on the morning of dialysis. The form was to be completed by facility and dialysis clinic staff. Was ordered on 1/12/26.-Check dialysis site for bleeding and signs or symptoms of infection every shift ordered on 1/11/26. -Obtain weights and vital signs pre and post dialysis, record on the dialysis communication form two times a day every Monday, Wednesday, and Friday ordered on 1/12/26.-Remove the dressing from the dialysis port one time a day, every Tuesday, Thursday, and Saturday ordered on 1/13/26. Review of the resident's dialysis communication form dated 3/1/26 to 3/12/26 showed: -Only received one form dated 3/2/26.-Dialysis did not complete the middle portion.-The last portion to be completed by facility staff and signed by nursing was left blank. -There were no forms received dated 3/4/26, 3/6/26, 3/9/26, and 3/11/26.During an interview on 3/11/26 at 11:32 A.M. the resident said:-He/She just returned to the facility from the dialysis clinic. -He/she had an upper chest catheter port and dialysis shunt in his/her left arm. -Nursing staff had not checked either site yet. -He/she did not have a copy of the completed dialysis communication sheet for 3/11/26. Observation on 3/12/26 at 7:49 A.M., of the resident showed:-The MDS Coordinator assessed the resident's shunt dressing on his/her left arm and right chest area central line catheter.-The dressings were intact. -The MDS Coordinator checked the resident blood sugar, the result was 172, sliding scale insulin order showed the resident required one unit of insulin which the resident declined. -The MDS Coordinator said he/she would document monitoring the shunt, the central line catheter, and blood sugar in the resident's treatment administration record (TAR).During an interview on 3/12/26 at 11:54 A.M., the Regional Nurse said:-The facility did not have a dialysis policy or current contract for dialysis services at that time.-The facility had changed administrative staff and were not able to find the current contract for the dialysis center. -The facility had contacted the dialysis company and the person who would have access to the contract was out of the country. During an interview on 3/13/26 at 2:17 P.M., Licensed Practical Nurse (LPN) B said:-The resident had a dialysis binder that he/she took with him/her on dialysis days.-The facility staff completed the top portion of the communication sheet and sent it with the resident in the binder. -He/she did not check the dialysis binder and night staff were responsible for completing the top portion of the dialysis communication form. -He/she would expect staff to complete the resident weight, vital signs and fistula monitoring (essential for ensuring the longevity and function of a dialysis access, typically involving daily self-checks (look, listen, feel) and regular clinical surveillance. Key signs of a healthy fistula include a consistent vibrating thrill and a whoosh sound bruit), before and after dialysis and on non-dialysis days. -Staff was responsible to check the resident's dialysis access site, for thrill and bruit and the chest catheter port dressing was intact and not bleeding. -Staff was responsible to review the dialysis communication sheet after each dialysis clinic day. During an interview on 3/16/26 at 12:58 P.M., the Director of Nursing (DON) said:-The dialysis communication form was to be completed pre and post dialysis by facility staff. -The facility sent the resident with the top portion of the communication form completed.-The form did not always return with the resident completed by dialysis. -He/She would expect staff to contact dialysis to have the form completed and returned. -He/She would expect staff to have documentation of the nursing assessment of the resident pre and post dialysis care. -He/She would expect staff to document on the resident's communication form, in the resident progress notes and on the TAR.

Based on interview and record review, the facility failed to ensure residents with a diagnosis of Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) had a personalized care plan to ensure services to promote the resident's highest level of functioning and psychosocial needs for one sampled resident (Resident #41) out of 13 sampled residents. The facility census was 49 residents. Review of the facility's Dementia-Clinical Protocol policy showed:-For the individual with confirmed Dementia, the Interdisciplinary Team (IDT) would identify a resident-centered care plan to maximize remaining function and quality of life.-The IDT would identify and document the resident's condition and level of support needed during care planning and review changing needs as they arose.1. Review of Resident #41's face sheet showed the resident was admitted with the following diagnoses:-Unspecified dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Other symptoms and symptoms involving cognitive functions and awareness.-Cognitive communication deficit.-Delusional disorders (a type of mental health condition in which a person can't tell what's real from what's imagined).-Amnesia (refers to the loss of memories, including facts, information and experiences).-Hallucinations (the experience of seeing, hearing, feeling, or smelling something that does not exist).-Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 12/31/25, showed he/she:-Had moderate cognitive impairment.-Had a diagnosis of Dementia.-Was often socially isolated.-Needed supervision or touching assistance with bathing, tub/shower transferring, walking and turning.-Had a diagnosis of Depression (a common, serious mood disorder characterized by persistent sadness, loss of interest in activities).-Was taking antipsychotic medications (medications designed to treat psychotic symptoms such as hallucinations, delusions, and disorganized thinking) on a routine basis.-Was taking antidepressant medications (medications used to treat depression, anxiety disorders, and other conditions like chronic pain or insomnia).Review of the resident's undated care plan showed he/she:-Dementia was not addressed in the care plan.-Had an activities of daily living (ADL are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) self-care performance deficit.-Had impaired thought processes related to Dementia with interventions to communicate with his/her family/caregivers regarding resident's capabilities and needs and discuss concerns about confusion, disease process and nursing home placement with her family/caregivers.During an interview on 3/13/26 at 12:12 P.M., the Director of Nursing (DON) said:-He/She would expect a resident with a Dementia diagnosis would have it recorded on the MDS.-He/She would expect a resident with a Dementia diagnosis would be care planned for that diagnosis.-The resident's care plan was not person centered or complete.-Types of areas that should be included in a care plan for Dementia care would include daily orientation, constant monitoring, frequent checks and assistance with ADL's.-The nursing staff would know how to care for a resident with Dementia by looking at the report sheet that should be on each unit which contained individual care needs as well as the resident's diagnoses, but no one was using them right now.-The MDS Coordinator was responsible for updating the resident's care plan.During an interview on 3/13/26 at 2:10 P.M., the MDS Coordinator said:-The process for selecting care areas was to use the information from the resident's hospital records and ask them for additional information if needed, any information that came with them upon admission, in house assessments and progress notes. -He/She would ask the nurses to fill out functional abilities (GG) section of the MDS when available.-He/She was told during training, if a resident was not being treated for Dementia with medication, then he/she could not record it on the MDS.-The DON was helping him/her to get caught up on the MDS's and make corrections. They tried to look at MDS's daily.-The resident should be care planned for Dementia.-He/She was responsible for updating the resident's care plan.

Based on observation, interview and record review, the facility failed to completely assess and document one resident's (Resident #1) skin upon admission to the facility and notify the resident's physician of a scab (crust that forms over a sore or wound) on the resident's left heel at the time of the resident's facility admission, failed to ensure treatments were completed for the resident's left heel and edema (swelling) in the resident's legs, failed to ensure weekly licensed nurse skin assessments and completion of and licensed nurse review of Certified Nurse (CNA) shower sheets, failed to notify the resident's physician of the resident's left heel skin breakdown to his/her legs, and failed to ensure the resident's emergency room physician's instruction for the resident's anticoagulant medication to be held for two doses and then resumed was reviewed by a licensed nurse and written on the resident's Physician's Orders Sheet (POS) and Medication Administration Record (MAR) resulting in the resident receiving one dose of his/her anticoagulant medication during the time it was to be held, out of four sampled residents. The facility census was 49 residents. Review of the facility Bath, Shower/Tub policy revised February 2018 showed: -Document: --The date and time the shower/tub bath was perform the name and title of the individual(s) who assisted the resident with the shower/tub bath; --If the resident refused the shower/tub bath, the reason(s) why and the interventions taken; --The signature and title of the person recording the data. -Notify the physician of any skin areas that may need to be treated. Review of the facility Change in a Resident's Condition or Status policy revised February 2021 showed: -The facility promptly notifies the resident's physician of changes in the resident's medical/mental condition and/or status. -Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. -The nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility Admission Notes policy revised September 2021 showed: -When a resident was admitted to the facility, the admitting nurse must document information as may apply in the nurse's notes, admission form, or other appropriate place, as designated by facility protocol including the general condition of the resident upon admission. -A statement indicating that the nursing history and preliminary assessment was completed or had been started. -No specific instruction to assess and document the resident's skin. Review of the undated facility Weekly Skin Integrity Review form showed: -Areas to indicate skin was intact, bruises, rash, blisters, redness, skin tear and instruction to see reverse side for comments and open area new or old with instruction to proceed to Wound Documentation form. -A body map (a chart showing the front and back of the body upon which to mark locations of skin abnormalities). -Areas for Assessment of Skin Concerns/Measurements/Description for a four-week time frame. Review of the facility Adverse Consequences and Medication Errors policy revised February 2023 showed: -A medication error was defined as the preparation or administration of drugs which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 1. Review of Resident #1's Face Sheet showed: -He/she was admitted to the facility on [DATE]. -He/she had diagnoses hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body). Review of the resident's Admission Nursing Evaluation dated 1/5/24 showed: -He/she had two scabs on his/her right foot, a scab on his/her lower legs and weeping edema of his/her left lower leg. -There was a notation to see the nurse's note. Review of the resident's Nurse's Progress Notes dated 1/5/24 showed no mention of his/her skin. Review of the resident's Daily Skilled Nurse's Note dated 1/5/24 showed no assessment of his/her skin. Review of the resident's Daily Skilled Nurse's Note dated 1/6/24 through 1/31/24 showed no mention of/assessment of his/her heels/toes. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning) dated 1/12/24 showed: -He/she had mild cognitive impairment. -He/she had no skin sores. Review of the resident's Physician's Orders Sheet (POS) for January 2024 showed: -Diagnoses of chronic kidney disease, stage 3 and partial paralysis on his/her left side. -No physician's order for treatment of his/her including scabbed areas and weeping edema in his/her legs or skin tears. Review of the resident's January 2024 Treatment Administration Record (TAR) showed: -Weekly skin assessment by wound nurse (dated 1/5/24) with no notes regarding any wounds. -Weekly skin assessment signed off as completed on 1/12/24 with no notes regarding any wounds. -An undated notion on the back of the TAR dated of an existing area on his/her left lower leg, skin tear, and treatment in place. Note: there was no physician's order on his/her January POS to treat a skin tear on his/her left leg and no treatment for a skin tear documented on his/her January 2024 TAR. -Weekly skin assessment signed off as completed on 1/19/24 without notation on the back of the TAR regarding findings of the skin assessment. -Weekly skin assessment signed as completed on 1/26/24 with notation on the back of the TAR dated 1/26/24 of an open area and bruise on his/her left knee. Review of the resident's February 2024 POS showed the following orders dated 2/5/24: -Lasix (medication that treats swelling) 20 milligrams (mg) and potassium 10 milliequivalents (mEq - the unit of measure used for minerals in the blood) daily. -Cleanse his/her left leg open area with normal saline (cleansing solution), Xeroform (non-stick dressing that maintains a moist environment to promote wound healing); cover with bordered gauze (a protective dressing); there was no frequency for the order. Review of the resident's February 2024 POS showed the following physician's orders dated 2/10/24: -Discontinue previous left leg wound treatment. -Cleanse his/her left leg with wound cleanser (WC - a gentle cleanser for wounds at all stages of the healing process) or normal saline (NS - a cleanser that helps remove dirt and debris from wounds and promotes healing), wrap leg with Kerlix (rolled woven gauze) then wrap with ace bandage (elastic compression wrap bandage) daily for weeping edema and as needed for soilage. Review of the resident's Skin Monitoring Comprehensive Certified Nursing Assistant (CNA) Shower Review (CNA Shower Sheet) dated 2/12/24 showed: -The resident had edema in his/her left leg. -The charge nurse signature and date were blank. Review of the resident's February 2024 TAR showed: -Weekly skin assessment signed off as completed on 2/17/24 and a notation on the back of the TAR dated 2/17/24 of multiple open areas on his/her lower left leg from weeping edema. -Left lower extremity cleanse with WC/NS, Xeroform (fine mesh gauze) to wound beds, cover with ABD (gauze pad dressing) and wrap with Kerlix (rolled woven gauze dressing), then wrap with elastic wrap on Monday, Wednesday and Friday for weeping edema dated 2/19/24. Review of the resident's February 2024 POS showed the following physician's orders dated 2/19/24 showed: -Cleanse lower left leg with WC or NS (WC/NS). -Xeroform to wound beds, cover with ABD, wrap with Kerlix, then wrap with elastic wrap - Monday, Wednesday and Friday and as needed for soiling. Review of the resident's February 2024 POS showed the following physician's order dated 2/21/24 showed: -Contracted wound care consultant company to follow up to his/her left lower leg ulcer. -Note: There was no documentation that showed this consult was completed. Review of the resident's February 2024 POS showed the following physician's orders dated 2/21/24 showed: -Get venous doppler (a diagnostic test used to check blood circulation in the large veins in the legs/arms) regarding his/her left lower leg edema. --Note: There was no documentation that showed the venous doppler was completed. -Lasix 20 mg by mouth daily for 14 days. - Potassium chloride. Review of the resident's Nurse's Progress Notes dated 2/25/24 showed: -His/her heel (no identification of which heel, no measurements or further description) was now dark in color. -Will get resident set up to be followed by wound company. Review of the resident's Nurse's Progress Notes dated 2/27/24 showed: -Upon assessment the resident's left heel, toes to affected area were purple in color. -There was a small amount of drainage (no description of color/odor of the drainage). -His/her left purple heel had an open area (there was no measurement or further description of the open area). -His/her physician was notified of the status of his/her left leg and ordered the resident be sent to emergency room for further evaluation. Review of the resident's Nurse's Progress Notes dated 2/27/24 at 1:15 PM. showed: -Dressing removed from residents left lower leg due to residents two middle toes being discolored. -Upon further removal of dressing his/her heel was observed splitting at the upper back area. -The licensed nurse notified the Director of Nursing (DON) and the Corporate Nurse. -Resident sent to hospital non-emergent (a medical condition requiring treatment within 2-24 hours). Review of the residents February 2024 POS showed the following order dated 2/27/24 to send resident to hospital stat (immediately) for further evaluation. Review of the resident's hospital records for his/her 2/27/24 admission showed his/her primary diagnosis was cellulitis (a deep infection of the skin caused by bacteria that usually affects the arms and legs; normal skin can be affected, but it usually happens after some type of injury causes an opening in the skin) with gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection). Review of the resident's Nurse's Progress Notes dated 3/1/24 showed: -He/she had vascular surgery amputating two toes. -Additional surgery being discussed at hospital. Review of the resident's hospital Operative Report dated 3/6/24 showed: -His/her preoperative and postoperative diagnoses were critical limb ischemia (a severe blockage in the arteries of the lower legs which markedly reduces blood-flow) with nonhealing open sores of both lower legs and nonrevascularizable arterial perfusion (blockage of and inability to restore normal oxygenated blood flow) of both feet. -Procedure was above the knee amputation (surgical removal) of both legs. Review of the resident's hospital discharge summary dated 3/9/24 showed: -He/she was admitted on [DATE] with admitting diagnoses of severe sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), group A strep bacteremia, necrotizing fasciitis (an aggressive skin and soft tissue infection that causes death of the muscle and tissues under the skin), and treatment of above the knee amputation of both legs. -Atherosclerotic Peripheral Vascular Disease (ASVD -disease or disorder of the circulatory system outside of the brain and heart), non-healing wounds of both lower legs. -He/she would be discharged to the long-term care facility with ongoing intravenous (access into a large vein for administration of fluid or medication) antibiotics. Review of the resident's Nurse's Progress Notes dated 3/10/24 showed: -He/she was readmitted to the facility and arrived at or about 5:00 P.M. -Refer to Admission Skin Assessment. -Note: Review of the resident's medical record showed no Admission Skin Assessment for 3/10/24. Record review of the resident's care plan dated 3/10/24 showed: -He/she needed assistance with his/her activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting). -He/she had surgical incisions from amputations of both his/her legs above the knees secondary to nonhealing ulcerations, poor circulation, atherosclerosis (hardening of arteries) and poor revascularization. -He/she needed incision care (monitoring for infection and daily cleansing), pain medication, and assistance with positioning. Review of the resident's March 2024 POS showed the following orders dated 3/10/24: -May readmit resident to skilled services. -Place midline (also called a midline catheter is a long, thin, flexible tube that is inserted into a large vein in the upper arm. It is used to safely administer medication into the bloodstream) for IV (intravenous) antibiotic. -Ampicillin/sulbactam (antibiotic medications) 95 milligrams (mg) IV every eight hours for severe sepsis dated 3/10/24 -Micafungin (antifungal medication) 50 IV daily every eight hours for severe sepsis. -Cleanse incisions (surgical cuts) with WC, pat dry, apply 4 inch by 4 inch (4X4) gauze, Kerlix and elastic wrap, daily. Review of the resident's Nurse's Progress Notes dated 3/17/24 showed the resident's Durable power of Attorney (DPOA- person previously named to make decisions for an individual in the event of inability to make wishes known) was contacted and gave verbal permission for resident to be seen by the consultant wound company. Observation on 4/5/24 at 9:58 A.M. showed the resident: -Was alert and lying in bed with a low air loss mattress (LAL - a mattress that provides airflow to help keep skin dry as well as to relieve pressure with alternating air cells that expand and contract to shift pressure). -He/she had bilateral above the knee amputations. -He/she said that he/she had previously had strokes that resulted in limitations in moving his/her arms. -Now with not having his/her legs it was more difficult for him/her to move in bed; also, he/she needed the head of his/her bed up to help him breathe and without his/her lower legs, he/she kept sliding down in his/her bed. During an interview on 4/5/24 at 10:07 A.M. Licensed Practical Nurse (LPN) A said: -He/she had not been the charge nurse on the resident's hall until after April 1, 2024. -He/she had passed medications on the resident's hall prior to April 1, 2024, but had not had other duties on the resident's hall. -He/she only given the resident his/her medications and had not done weekly licensed nurse skin assessments and had not seen or assessed the resident's skin prior to the week of April 1, 2024. During an interview on 4/8/24 at 2:45 P.M. the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said: -The DON and ADON were not employed at the facility prior to the resident's bilateral above the knee amputations. -In January 2024 the previous DON had instructed licensed nursing staff to discontinue highlighting weekly skin assessments on residents' TARs. -This resulted in charge nurses no longer completing weekly skin assessments. -The DON started his/her employment at the facility in late February 2024; in late March 2024, he/she discovered that the wound nurse had not been doing his/her job, including that he/she had not been completing weekly licensed nurse skin assessments and had not been assessing and documenting on resident wounds week; shortly thereafter the wound nurse's employment was terminated, and the ADON left his/her position. -Weekly licensed nurse skin assessments had not been completed for the resident or for any of the other residents at the facility since February 1, 2024. -As of April 2024, the new ADON was now ensuring weekly skin assessments were completed for all residents and that weekly wound documentation was completed on all resident wounds. During an interview on 4/11/24 at 10:58 A.M. the ADON said the facility located only one shower sheet dated 2/12/24 for the resident prior to 2/27/24. 2. Review of the resident's April 2024 POS showed: A diagnosis of atrial fibrillation (AFib - an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). -Eliquis (Apixaban - blood thinner for use in patients with AFib to reduce the risk of blood clots and stroke) five milligrams (mg) dated 1/5/24. Review of the resident's hospital emergency room record dated 4/4/14 showed: -He/she was seen for hematuria (blood in his/her urine). -Hold the next two doses of Eliquis, may resume Eliquis in the evening on April 5, 2024. Review of the resident's April 2024 POS on 4/5/24 showed: -A diagnosis of atrial fibrillation (AFib - an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). stroke). -No physician's order to hold two doses of his/her Eliquis and resume his/her Eliquis in the evening on April 5, 2024. Review of the resident's MAR on 4/5/24 showed: -No instructions dated 4/4/24 to hold two doses of his/her Eliquis and to resume his/her Eliquis in the evening on April 5, 2024. -No documentation the resident's Eliquis had been given on his/her 4/4/24 evening dose or on his/her 4/5/24 morning dose. -No documentation that any of the resident's morning medications had been given on 4/5/24. Review of the resident's hospital record dated 4/4/24 showed: -Hold the next two doses of Eliquis. -May resume Eliquis tomorrow evening, 4/5/24. Review of the resident's April 2024 POS and MAR on 4/5/24 showed: -No physician's order or instruction to hold his/her Eliquis for two doses. -No physician's instruction to resume his/her Eliquis tomorrow evening, 4/5/24. During an interview with on 4/5/24 at 3:28 P.M. Certified Medication Technician (CMT) A CMT A said: -He/she gave the resident all of his/her morning medications, including his/her Eliquis. -He/she usually signed medications as given on the MARs immediately after giving medications to each resident but had not done so that morning with this resident; he/she had been distracted from his/her normal routine. -He/she did look at the resident's MAR as he/she was preparing his/her medications and did not see any instruction to hold the resident's Eliquis. -He/she also had not been told the resident's Eliquis was to be held for two dosed and then resumed on the evening on 4/5/24. During an interview on 4/5/24 at 3:38 P.M., LPN A said: -The resident went to the emergency roiagnom on [DATE] and returned in the evening on 4/4/24. -He/she was not told in report any information that the resident's Eliquis was to be held. -The night licensed nurse should have reviewed the paperwork from the hospital emergency room , called the resident's physician and gotten an order to hold the resident's Eliquis for two doses and resume the resident's Eliquis on the evening of 4/5/24 and should have relayed that information to the day licensed nurse in change of shift report. -Normally the licensed nurse on duty at the time a resident returns from hospital was responsible for reviewing all paperwork from the hospital, then notifying the resident's physician, obtaining any needed orders and writing those orders on the MAR, then writing that information on the 24-hour report that is used to report pertinent information to the oncoming licensed nurse at shift change. -He/she received no information regarding the resident's Eliquis in shift report and he/she also had not had any time to review the resident's 4/4/24 emergency room information. -He/she had now read the resident's 4/4/24 emergency room record and saw that his/her Eliquis was to have been held for two doses and then resumed for the evening on 4/5/24. -He/she also spoke with CMT A who had told her he/she had given the resident his/her 4/5/24 morning dose of Eliquis but had not signed that his/her medications had been given. -He/she would be contacting the resident's physician's Nurse Practitioner (Registered nurses with advanced education and training and are licensed, and independent health care clinicians who diagnose and treat illnesses) regarding the resident's Eliquis. During an interview on 4/5/24 at 3:56 P.M., LPN A said: -He/she had contacted the resident's NP and had reported the resident's Eliquis administration for his/her morning dose on 4/5/24 as well as the instructions from theER on [DATE] regarding his/her Eliquis as medication error. -The NP gave orders for the resident's Eliquis to be held for the evening dose on 4/5/24 and resume his/her Eliquis for his/her morning dose on 4/6/24. -He/she had also reported the situation with the resident's Eliquis to the DON. During an interview on 4/5/24 at 4:05 P.M. the DON said: -He/she had been made aware of the medication error regarding the resident's Eliquis. -The NP had been contacted and had given orders regarding the resident's Eliquis. 3. During an interview on 1/9/24 at 12:13 P.M. the resident's physician said: -He/she had not been notified of the resident having scabs on his/her left heel or th edema in his/her left leg; he/she should have been notified of this on 2/5/24 so that he/she could give treatment orders. -He/she had not been notified of changes in the condition of the resident's left leg when at the facility on 2/27/24. He/she saw that there was a dressing on the resident's left leg and the resident had two necrotic toes on his/her left leg; at that time he/she did not suspect an infection but did believe there were circulation problems and first ordered a doppler study and then ordered the resident be sent to emergency room . -Given the resident's poor circulation in his/her lower legs, he/she did not think the outcome for the resident would of changed. -He/she expected the licensed nurses to completely assess residents' skin on admission and weekly, and complete weekly wound assessments for any existing wounds, document what they see, notify him/her of findings including scabs, discoloration, open areas, edema or any other any abnormal findings and notify him/her of any changes or concerns so that treatments could be started or changed when needed. -The NP had been called regarding the medication error with the resident's Eliquis, had given orders and had informed him/her of the medication error. -He/she expected that when a resident was admitted , readmitted or returns from an emergency room a facility licensed nurse reviews all medications/treatments the resident was to receive and contact him/her for orders for all intended medications/treatments the resident was to receive. During an interview on 4/11/24 at 10:58 A.M. the ADON said there should have been weekly licensed nurse skin assessments and weekly licensed nurse wound documentation for the resident fully documenting the measurements description of all wound and skin conditions. During an interview on 4/11/24 at 12:45 P.M. the DON said: -He/she was not employed at the facility prior to the resident's bilateral above the knee amputations. -The DON started his/her employment at the facility in late February 2024; in late March 2024, he/she discovered that the wound nurse had not been doing his/her job, including that he/she had not been completing weekly licensed nurse skin assessments and had not been assessing and documenting on resident wounds week; shortly thereafter the wound nurse's employment was terminated, and the Assistant Director of Nursing (ADON) left his/her position. -Weekly licensed nurse skin assessments had not been completed for the resident or for any of the other residents at the facility since February 1, 2024. -As of April 2024, the new ADON was now ensuring weekly skin assessments were completed for all residents and that weekly wound documentation was completed on all resident wounds. -At the time the resident was admitted to the facility on [DATE], his/her skin assessment should have included a complete description and measurements of scabs on his/her left heel, and any other scabs or alterations in his/her skin on any part of his body, including both of his/her legs and feet; the edema in his/her left leg should have been described accurately. -On 1/5/24 the resident's physician should have been notified of the resident's scabs on his/her left heel and edema in his/her left leg; treatments should have been put in place; the resident's skin and wounds should have been assessed and documented weekly with notification to the resident's physician of any changes in the resident's skin/edema. -The previous shower aide also was no longer employed at the facility and there was a new shower aide as of April 1, 2024. -Shower aides were to fill out a shower sheets following each shower and were to mark briefly identify any abnormal skin issue skin areas, whether new or not. -If there was a new open area or increased drainage or other concern, the shower aide was to take the shower sheet to the charge nurse right then and say what he/she saw; the charge nurse was to then go and assess the resident, document what he/she saw, including measurements and full description and then call the physician for orders. -The shower aide was to give all shower sheets to the charge nurse during the shift and the charge nurse was to review and sign the sheets prior to end of his/her shift and forward the shower sheet to the DON for the DON's review; the DON/ADON then was to ensure physician's had been notified and treatments were in place for residents' skin conditions. MO00234138

Based on observation, interview and record review, the facility failed to provide services to prevent the development of an unstageable pressure injury for one sampled resident (Resident #11) who had a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the left hand, by not completing thorough weekly skin assessments, by not cleaning the resident's contracted left hand to prevent maceration (the presence of an excessive amount of moisture) and a yeasty odor; by not consistently documenting and notifying the resident's physician of resident refusals of treatment and cares; to provide services to promote healing and prevent the development of new pressure injuries for a resident who was admitted to the facility with four unstageable pressure injuries (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) by not repositioning, not providing incontinence care, and not positioning the resident in a way that supported the lower extremities and thus increasing the amount of pressure on the resident's head, back, and coccyx (tailbone) areas; to notify the resident's physician of a newly developed open area, to obtain a treatment order for a newly developed open area, to monitor and maintain a low air loss mattress (a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) at the appropriate setting for one sampled resident (Resident #6); and to coordinate care with an outside wound treatment company to determine treatment orders once the resident's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) healed for one sampled resident (Resident #3) out of 11 sampled residents. The facility census was 45 residents. Record review of the facility's policy titled Pressure Ulcer Treatment dated September 2013 showed: -The purpose was to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers; -The pressure ulcer treatment program should focus on the following: --Assessing the resident and the current status of the pressure ulcer(s); --Current support surfaces; --Pressure ulcer care; --Managing bacterial colonization and infection; --Education and quality improvement; -When eschar is present, a pressure ulcer cannot be accurately staged until the eschar is removed; -Suspected deep tissue injury definition purple or maroon localized area of discolored intact skin, this area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; -Stage one pressure ulcer, intact skin with non-blanchable redness of a localized area usually over a bony prominence; -Stage two pressure ulcer, partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum-filled blister; -Stage three pressure ulcer, full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss may include undermining and tunneling; -Stage four pressure ulcer, full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling; -Unstageable, full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed; -Pressure ulcer treatment requires a comprehensive approach; -Documentation should be recorded in the resident's medical record, treatment sheet or designated wound form and should include the following: --The date and time the dressing was changed; --Would appearance, including wound bed, edges, presence of drainage; --The name and title of the individual changing the dressing or initials; --The type of dressing used and wound care given; --All assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound; --How the resident tolerated the procedure; --Any problems or complaints (pain or discomfort) made by the resident related to the procedure; --If the resident refused the treatment and the reason(s) why; --The signature and title of the person recording the data or initials; -Notify the supervisor if the resident refuses the procedure or interventions; -If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives, document family and physician notification of refusal; and -Report other information in accordance with facility policy and professional standards of practice. Record review of the facility policy titled prevention of pressure ulcers dated September 2013 showed: -The purpose was to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors; -Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue; -The most common site of a pressure ulcer is where the bone is neat the surface of the body including the back of the head, around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles and toes; -Pressure can also come from splints, casts, bandages and wrinkles in the bed linen, if pressure ulcers are not treated when discovered they quickly get larger, become very painful for the resident, and often times become infected; -Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (perspiration, feces, urine, wound discharge, soap residue) decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition; -Once a pressure ulcer develops, it can be extremely difficult to heal, pressure ulcers are a serious skin condition for the resident; and -The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family and addressed. 1. Record review of Resident #11's annual Minimum Data Set (MDS a federally mandated assessment tool completed by the facility staff for care planning) dated 6/30/16 showed he/she: -Had the following Diagnoses: [REDACTED]. --Chronic pain; --Intervertebral disc degeneration (the effect of natural daily stresses and minor injuries that cause spinal discs to gradually lose water as the rigid outer shell of a disc weakens. As discs weaken and lose water, they begin to collapse. This can result in pressure being put on the nerves in the spinal column, causing pain and weakness) in the lower back; --There was no [DIAGNOSES REDACTED]. -Had range of motion limitations in one of his/her upper extremities; -Had occasional pain; and -Did not have any skin issues. Record review of the resident's skin care plan dated 6/30/16 showed he/she: -Was at risk for skin breakdown, bruises, skin tears, and pressure ulcers (did not say why the resident was at risk); -An entry dated 3/22/17 said left second finger; -Would remain free of skin issues; -Had the following approaches/interventions: --Monitor for a change in the ability to toilet self and do hygiene and report for follow up; --Make sure shoes are on his/her feet that fit properly; --Keep pathways tidy and cleared; --The licensed nurse was to do skin assessments weekly; --Note any changes to the resident's skin integrity during the resident's bath/shower; --Keep linens clean and dry and wrinkle free; --Apply barrier cream with any incontinence episodes or as needed for redness; --Monitor for bruising; and --An entry dated 3/22/17 said treatment as ordered by contracted wound company was added. Record review of the resident's Physician visit progress notes dated 2/1/17 showed the resident: -Had no new concerns; -Had decreased range of motion; and -Did not have rigidity and contractures marked under the joint section of the musculoskeletal section. Record review of the resident's Physician Order Sheet (POS) dated 3/15/17 to 4/14/17 showed he/she: -Had an order for [REDACTED].>-Had an order to cleanse the open area on the left second finger, apply skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) daily until healed. Record review of the resident's Treatment Administration Record (TAR) dated 3/15/17 to 4/14/17 showed the resident: -Had an order for [REDACTED]. to 11:00 P.M. shift; -Had a square box around 3/17/17 with initials in the box; -Had no bruises, open areas, redness, skin without issues written on the back of the TAR for 3/17/17; -Had a square box around 3/24/17 with initials in the box that were circled; -Had Resident refused skin assessment, I'm tired of being messed with written on the back of the TAR for 3/24/17; -Had a physician's order to cleanse the open area on the left second finger and apply skin prep daily until healed dated 3/22/17 to be done by the 7:00 A.M. to 3:00 P.M. shift; -Had an arrow pointing to the 23 rd of March to begin the treatment; -Had no initials in the box for March 29, 2017 to show the treatment had been done; and -Did not have an explanation of why the treatment was not done on March 29, 2017. Record review of the resident's MDS dated [DATE] showed he/she: -Had range of motion limitations in one of his/her upper extremities; -Had occasional pain; and -Did not have any skin issues. Record review of the resident's Nurse's notes dated 3/22/17 showed he/she: -Had an open area on his/her left second finger that might have been caused by the resident's thumb (there was no mention of the resident's hand being contracted and the positioning of any of the resident's fingers); -Did not know how the open area happened; -Did not have any function in his/her left hand; and -Was referred to the facility's contracted wound company. Record review of the resident's wound report from the contracted wound company dated 3/22/17 showed: -The resident had an unstageable wound that was 100% covered with eschar (tan, brown or black tissue); -The wound measured 0.5 centimeters (cm) x 1.0 cm; -The wound was on the second digit (the index finger); and -The wound was to be cleaned with soap and water, dried thoroughly and skin prep applied daily. Observation of and interview with the resident on 3/28/17 showed the resident: -Had a contracted left hand that he/she kept covered by the left sleeve of his/her shirt; -Was not able to move his/her thumb, index finger or middle finger; -Had the ability to move the ring finger and the little finger a little bit with a lot of effort; -Said his/her left hand had been contracted for years; -Had an odor that came from the left hand; -Said he/she was embarrassed by the odor from his/her hand; -Said he/she had been told by staff that he/she needed a bath because his/her feet stunk; -Said he/she had told staff it was not his/her feet that stunk, it was his/her left hand; -Was able to move his/her left thumb using his/her right hand; -Had an unstageable area on his/her index finger that had black eschar covering 100% of the area; -Had puckering of the tissue that surrounded the eschar; and -Did not have any feeling in his/her thumb, index finger and middle finger. Record review of the resident's Telephone Orders dated 3/28/17 showed he/she: -Had an order for [REDACTED].>-Had a clarification order for skilled OT 3x/week x 4 weeks for contracture management, orthotic management, Activities of Daily Living (ADL) retraining, therapeutic exercises, therapeutic activities, neuro re-education, and resident and staff education (this order was written six days after the unstageable wound was discovered). Record review of the resident's initial treatment plan for rehabilitation dated 3/28/17 showed he/she: -Was to receive contracture management; -Had a wound on the left upper extremity possibly from left upper extremity contracture; -Required increased assistance for hygiene; -Had skin breakdown due to decreased range of motion and joint alignment; -Had a macerated palm; and -Was able to work a flat towel between the thumb and the palm. During an interview on 3/29/17 at 1:05 P.M. Physical Therapist Assistant (PTA) A said: -The resident was currently on the therapy caseload; -Residents were screened by therapy on a quarterly basis following the MDS schedule; and -The nursing department would sometimes notify the therapy department if a resident needed services. Observation and interview on 3/29/17 at 2:40 P.M. showed Certified Nursing Assistant (CNA) A: -Opened the resident's left hand by grasping the resident's fingers and moving them away from the palm of the resident's hand; -Said the resident received baths on the evening shift; -Did not know how staff on the evening shift opened the resident's hand to wash it; -Said the licensed nurse would open it on the day shift because of the treatment that was done; -Said he/she did not open the resident's hand to check the skin when he/she worked; -While CNA A held the resident's left hand open an odor was present; -The resident made a face and said yuck when the odor was very noticeable; -CNA A did not offer to wash the resident's left hand at that time; -The resident's left fingers were able to be moved by CNA A with little effort; -The resident did not express any complaints of pain when CNA A opened the resident's left hand; and -The resident's left palm was dark pink in color and was moist with a yeasty odor. 2. Record review of Resident #6's admission nursing evaluation dated 10/14/16 showed he/she: -Was oriented to person only; -Required assistance of one person with locomotion, dressing and eating; -Required assistance of two persons with transfers; -Did not have the amount of assistance required for bed mobility, toileting, personal hygiene, and bathing; -Used a wheelchair for mobility; -Was incontinent of bowel and bladder; -Used briefs; -Had a pressure injury to the back of the head; -Had a pressure injury to the spine/back; -Had a pressure injury to the coccyx; and -Did not have any staging, description, measurements and characteristics of any of the pressure injuries. Record review of the resident's contracted wound company progress notes dated 10/18/16 showed the resident: -Was admitted to the facility with multiple wounds; -Had an unstageable pressure injury on the coccyx; --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours; -Had an unstageable pressure injury on the posterior head; --Was to be turned and repositioned every two hours; -Had an unstageable pressure injury to the back; --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours; -Had an unstageable pressure injury to the left elbow (this was not identified on the admission nursing evaluation); and --Was to wear/use elbow protectors and was to be turned and repositioned every two hours. Record review of the resident's Braden scale for predicting pressure injury dated 10/19/16 showed he/she: -Had very limited sensory perception: --Responds only to painful stimuli; --Cannot communicate discomfort except by moaning or restlessness; -Was often moist: --Skin was often, but not always moist; --Linen must be changed as often as three times in 24 hours; -Was chair-fast: --Ability to walk was severely limited or non-existent; --Could not bear his/her own weight and/or must be assisted into his/her chair or wheelchair; -Had slightly limited mobility: --Made frequent though slight changes in body or extremity position independently; -Probably had inadequate nutrition: --Rarely ate a complete meal and generally ate only about ½ of any food offered; --Protein intake included only three servings of meal or dairy products per day; --Occasionally would take a dietary supplement; -Had a potential friction and shear problem (the resident required total assistance from two persons with transfers according to the resident's admission nursing evaluation): --Moved feebly or required minimum assistance; --During a move the resident's skin probably slid to some extent against the sheets, chair, or other devices; --Maintained relatively good position in the chair or bed most of the time but occasionally slid down; and -Had a total score of 13 which placed the resident at a moderate risk for skin breakdown. Record review of the resident's contracted wound company progress notes dated 10/25/16 showed he/she: -Had an unstageable pressure injury on the coccyx; --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours; -Had an unstageable pressure injury on the posterior head; --Was to be turned and repositioned every two hours; -Had an unstageable pressure injury to the back; --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours; -Had a stage two (partial-thickness skin loss with exposed dermis) pressure injury to the left elbow; and --Was to wear/use elbow protectors and was to be turned and repositioned every two hours. Record review of the resident's skin care plan dated 10/28/16 showed he/she: -Had an unstageable pressure injury on his/her coccyx, parallel to his/her spine, back of his/her head and elbow; -Required repositioning every two hours by two people, -Required a pressure reducing device on his/her wheelchair seat; -Required wound care as ordered by his/her physician; -Required a referral to a dietician to evaluate his/her nutritional status; -Required weekly evaluation of wounds; -Required daily observation of his/her skin with routine cares; -Required a full skin evaluation weekly with his/her shower and -Required elbow protectors on both elbows. Record review of the resident's contracted wound company progress notes dated 11/1/16 showed he/she: -Had an unstageable pressure injury on the coccyx; --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours; -Had an unstageable pressure injury on the posterior head; --Was to be turned and repositioned every two hours; -Had an unstageable pressure injury to the back; --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours and -Had a stage two pressure injury to the left elbow that had healed. Record review of the resident's Nurse's notes dated 11/3/16 showed he/she: -Had a skin wound review completed; -Was admitted to the facility with the following wounds: --An unstageable pressure injury on his/her coccyx; --An unstageable pressure injury on his/her back of head; --An unstageable pressure injury on his/her back and --A Stage II pressure injury to his/her left elbow. Record review of the resident's contracted wound company progress notes dated 11/8/16 showed he/she: -Had an unstageable pressure injury on the coccyx; --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours; -Had an unstageable pressure injury on the posterior head; --Was to be turned and repositioned every two hours; -Had an unstageable pressure injury to the back and --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours. Record review of the resident's contracted wound company progress notes dated 11/15/16 showed he/she: -Had an unstageable pressure injury on the coccyx; --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours; -Had an unstageable pressure injury on the posterior head; --Was to be turned and repositioned every two hours; -Had an unstageable pressure injury to the back and --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours. Record review of the resident's contracted wound company progress notes dated 11/29/16 showed he/she: -Had an unstageable pressure injury on the coccyx; --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours; -Had an unstageable pressure injury on the posterior head; --Was to be turned and repositioned every two hours; -Had an unstageable pressure injury to the back;\ and --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours. Record review of the resident's contracted wound company progress notes dated 12/06/16 showed he/she: -Had an unstageable pressure injury on the coccyx; --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours; -Had an unstageable pressure injury on the posterior head; --Was to be turned and repositioned every two hours; -Had an unstageable pressure injury to the back and --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours. Record review of the resident's contracted wound company progress notes dated 12/13/16 showed he/she: -Had an unstageable pressure injury on the coccyx; --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours; -Had an unstageable pressure injury on the posterior head; --Was to be turned and repositioned every two hours; -Had an unstageable pressure injury to the back and --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours. Record review of the resident's contracted wound company progress notes dated 12/20/16 showed he/she: -Had a Stage III pressure injury on the coccyx; --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours; -Had an unstageable pressure injury on the posterior head; --Was to be turned and repositioned every two hours; -Had an unstageable pressure injury to the back and --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours. Record review of the resident's Nurse's notes dated 12/25/16 showed he/she: -Returned to the facility; -Had a dressing to his/her coccyx; -Had a dressing to his/her right hip; -Did not have a dressing to his/her left hip; and -Had a 2.0 centimeter (cm) linear open area noted to the inner aspect of his/her left heel. Record review of the resident's Nurse's notes dated 12/26/16 showed the resident: -Had a dressing to his/her coccyx that was dry and intact but was malodorous and -Did not have any documentation showing the dressing was removed for evaluation of the wound and the origin of the odor. Record review of the resident's Hospice (end of life care) admission progress note dated 12/26/16 showed the resident: -Was admitted to hospice services on 12/26/16; -Was receiving a pureed diet with nectar thick liquids; -Was pocketing food; -Was in bed 90% of the time; -Had two wounds that were not healing (the resident had three wounds); -Had a Stage III pressure injury to his/her coccyx; -Had an unstageable pressure injury to his/her back and -There was no mention of the unstageable wound to the back of the resident's head in the hospice wound notes. Record review of the resident's Hospice wound notes dated 12/27/16 showed he/she: -Had a Stage III pressure injury to the coccyx; -Had an unstageable pressure injury to the back and -Had redness to his/her back and hip (documentation did not say which hip). Record review of the resident's contracted wound company progress notes dated 12/27/16 showed he/she: -Had a Stage III pressure injury on the coccyx; --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours; -Had an unstageable pressure injury on the posterior head; --Was to be turned and repositioned every two hours; -Had an unstageable pressure injury to the back and --Was to have an air mattress, seat cushion, and was to be turned and repositioned every two hours. Record review of the resident's Nurse's notes dated 12/30/16 showed: -The staff reviewed the wounds; -The documentation showed the resident had three wounds, one to his/her back, one to his/her posterior head, and one to his/her coccyx and -There was no descriptions or characteristics of the wounds documented. Record review of the resident's Hospice wound notes dated 1/5/17 showed he/she: -Had a Stage III pressure injury to his/her coccyx; -Had a wound to his/her back that was unable to be seen because the resident was not cooperating with staff; and -Had redness on his/her sacrum and coccyx areas; -Was to have the following preventative measures in place: --Specialty mattress; --Elbow/heel protectors; --Pillows/padding; --Incontinence care and --Turning/repositioning. Record review of the resident's Hospice wound notes dated 1/9/17 showed he/she: -Had an unstageable wound on the posterior head that had necrotic (dead) tissue; -Had a stage three pressure injury to his/her coccyx; -Had an unstageable pressure injury to his/her upper mid back; -Had a stage one (not blanchable red tissue that is not open) to his/her right hip (this was a new area) and -Had redness to his/her spine and buttock. Record review of the resident's Hospice wound notes dated 1/16/17 showed he/she: -Had an unstageable pressure injury to his/her upper mid back; -Had a Stage I pressure injury to his/her right hip; -Had a Stage I pressure injury to his/her left hip (this was a new area); -Had a Stage III pressure injury to his/her coccyx; -Did not have any documentation of a pressure injury to his/her posterior head (was an unstageable area on previous wound notes) and -Had redness on his/her buttocks. Record review of the resident's Hospice wound notes dated 1/23/17 showed he/she: -Had an unstageable pressure injury to his/her mid back; -Had a Stage III pressure injury to his/her coccyx; -Had a Stage I pressure injury to his/her right hip; -Had a Stage I pressure injury to his/her left hip; -Did not have any documentation of a pressure injury to his/her posterior head (was an unstageable area on previous wound notes) and -Had redness to his/her buttocks. Record review of the resident's Hospice wound notes dated 1/31/17 showed he/she: -Had a Stage IV pressure injury to his/her coccyx; -Had an unstageable pressure injury to his/her mid back; -Had a Stage I pressure injury to his/her right hip; -Had a Stage I pressure injury to his/her left hip; -Had a pin point open area to his/her left hip (an open area is a Stage II pressure injury not a stage one) and -Had no new wound care orders. Record review of the resident's Hospice wound notes dated 2/7/17 showed he/she: -Had a Stage IV pressure injury on his/her coccyx; -Had a Stage II pressure injury on his/her upper back; -Had a Stage I pressure injury to his/her right hip; -Had a Stage I pressure injury to his/her left hip; -Did not have any documentation about the pin point open area on his/her left hip; -Did not have any documentation of a pressure injury to his/her posterior head (was an unstageable area on previous wound notes); -Had redness on his/her left and right hips, left and right knees and his/her coccyx and -Had no new wound care orders. Record review of the resident's Hospice wound notes dated 2/14/17 showed he/she had a wound on his/her sacrum that had no other documentation (no measurements, characteristics, and type and stage of the wound). Record review of the resident's Hospice wound notes dated 2/21/17 showed he/she: -Had a Stage I pressure injury on his/her left hip; -Had a Stage IV pressure injury on his/her coccyx; -Had a Stage II pressure injury on his/her mid spine/back and -Did not have any documentation of a pressure injury to his/her posterior head. Record review of the resident's Hospice notes dated 3/6/17 showed there was no documentation about any of the resident's pressure injuries. Record review of the resident's Hospice notes dated 3/9/17 showed he/she: -Had wound care provided by the facility charge nurse before the Hospice staff arrived at the facility; -Had improvement in the sacral wound; -Had a mid-back wound that was almost healed and -There was no documentation or mention of the pressure injuries on his/her left hip and posterior head. Record review of the resident's Hospice notes dated 3/13/17 showed the wounds were not addressed at that visit. Record review of the resident's Nurse's notes dated 3/15/17 showed: -The staff reviewed the plan of care for wounds; -The resident had five wound areas listed the back, posterior head, coccyx, right hip, and left hip; -There were no measurements for any of the areas documented and -There was no wound descriptions or characteristics documented. Record review of the resident's Hospice notes dated 3/16/17 showed he/she: -Had a Stage IV pressure injury on his/her sacrum; -Had a Stage II pressure injury on his/her spine (upper portion); -Had a wound on his/her left hip that had healed and -Did not have any documentation of a pressure injury to his/her posterior head. Record review of the resident's Hospice notes dated 3/24/17 showed he/she: -Had a Stage IV pressure injury on his/her sacrum; -Had a pressure injury/moisture area on his/her scrotum (no stage was documented); -Had a Stage II pressure injury on his/her mid-spine and -Did not have any documentation of a pressure injury to his/her posterior head. Observation of the resident on 3/27/17 showed: -At 5:20 A.M.: --Was in bed positioned on his/her back; --Did not have elbow protectors on the left or right elbow; --Was on a low air loss mattress with the setting at 9; ---The low air loss mattress settings were based on the resident's weight, the higher the setting the higher the weight; ---A setting of 1=35 pounds, 2=70 pounds, 3=105 pounds, 4=140 pounds, 5=175 pounds, 6=210 pounds, 7= 280 pounds, 8=315 pounds, and 9=350 pounds; -At 8:43 A.M.: --Was in dining room sitting in his/her Broda (a superior repositioning chair that provides exceptional resident comfort while reducing the time and effort required of caregivers) chair and --Was sitting upright with a foot board under his/her feet supporting his/her lower extremities. Continuous observation on 3/28/17 from 7:45 A.M. to 12:41 P.M. showed the resident: -At 7:45 A.M.: --Was sitting in his/her Broda chair in the dining room; --Was reclined back slightly in the Broda chair; --Was leaning toward the left; --Had his/her eyes closed --Had the back of his/her head and his/her back on the back of the Broda chair with no additional support or cushioning; -At 8:09 A.M.: --Was sitting in his/her Broda chair at the dining table

Based on observation, interview, and record review, the facility failed to provide oversight and coordination of care of a deteriorating traumatic wound to the left lower calf caused by a PRAFO boot (Pressure Relief Ankle Foot Orthosis - a device that is worn on the calf and foot similar to a boot to relieve pressure to heels when ambulating or lying down, generally intended as early intervention for a recovering therapy patient), complete weekly skin assessments by a licensed nurse, accurately document wound documentation, wound reports, skin reports, and bath sheet records, and update the wound care plan for one sampled resident (Resident #1); and to administer and document non-pharmacological interventions for pain for one resident (Resident #10) out of 12 sampled residents. The facility census was 49 residents. Record review of the facility's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) policy dated 2003, showed a skin assessment should be performed on residents weekly. 1. Record review of Resident#1's face sheet dated 7/10/12, showed the resident was admitted to the facility on [DATE]. Record review of the resident's lab results dated 11/12/12, showed his/her white blood count (a blood test to measure the number of white blood cells which help fight infections), [DIAGNOSES REDACTED] absolute (the number of white blood cells that are [DIAGNOSES REDACTED]s, which are a type of white blood cell that help fight infection; a diminished presence of [DIAGNOSES REDACTED]s would make the person vulnerable to infection), and monocyte absolute (the count of another type of white blood cells that help fight infection) all within normal range. Record review of the resident's Braden Scale (a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers) dated 1/8/13, showed the staff assessed the resident to be at moderate risk of pressure ulcers. Record review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 1/15/13 - 2/14/13, showed no documented weekly skin assessments completed by licensed nursing staff. Record review of the resident's physician's progress note dated 1/16/13, showed no documentation regarding wounds, pressure reduction or PRAFO boots. Record review of the resident's pressure ulcer care plan dated 1/24/13, showed the resident was at risk for skin breakdown related to him/her being a fall risk and having fragile skin, and directed staff to do the following interventions: - Ensure the resident wears shoes to protect his/her feet when he/she was out of the room. - Utilize a pressure reduction mattress to his/her bed. - Utilize a pressure reduction wheelchair cushion. - Notify the physician of any changes in skin integrity. - Monitor skin and document any concerns with his/her baths. - Report any concerns found during baths to the charge nurse. - The nurse was to assess the skin weekly and as needed and to document the results. Record review of the resident's telephone orders dated 1/28/13, showed physician's orders [REDACTED]. The order did not specify what this meant specifically and did not include instructions regarding PRAFO boots. Record review of the resident's physician's orders [REDACTED]. - an order for [REDACTED]. The order did not specify what this meant specifically, and did not include instructions regarding PRAFO boots. - No documentation regarding the use of a PRAFO boot. Record review of the resident's pressure ulcer care plan dated 1/24/13, showed the following: - Provide pressure relief by lifting the heel (not a PRAFO boot) to prevent skin impairment. During an interview on 4/10/13 at 11:00 A.M., Licensed Practical Nurse (LPN) A reviewed the delivery receipt and said that the resident received his/her low-air-loss mattress (used to treat and prevent pressure ulcers by redistributing the weight as uniformly as possible) on 1/30/13. Record review of the resident's pressure ulcer care plan dated 1/24/13, showed: - The resident was at risk for skin breakdown related to him/her being a fall risk and having fragile skin, - Direction for staff to utilize a pressure reduction mattress to his/her bed, and - The care plan did not specify to use a low air loss mattress which was utilized beginning 1/30/13. Record review of the resident's TAR dated 1/15/13 through 2/14/13, showed documentation to provide the resident a PRAFO to his/her lower left extremity at all times for pressure reduction, and it was documented as being in place on 2/1/13, 2/4/13 - 2/9/13, and 2/11/13 - 2/14/13. Record review of the resident's Certified Nursing Assistant (CNA) bath sheets dated 2/1/13 through 2/19/13, showed there was three days when all questions were answered "no" regarding whether there were any skin concerns, but the resident's left heel was circled. Record review of the wound consultation form dated 2/5/13, showed: - This was the wound company's first visit for this resident. - The resident's chart was reviewed on 2/5/13. (There was no documentation regarding the PRAFO boot at this point on the POS, on the telephone orders, or in the physician's progress notes). - An additional treatment intervention included aggressive offloading of this area (the left lower extremity) at all times. Record review of the wound company's consultation form dated 2/12/13, showed: - An additional intervention included aggressive offloading of this area at all times. Record review of the resident's MAR and TAR dated 2/15/13 - 3/14/13, showed no weekly skin assessments completed by licensed nursing staff. Record review of the resident's TAR dated 2/15/13 through 3/14/13, showed documentation to provide a PRAFO (this was crossed out and soft boot from Physical Therapy (PT) was written in) to his/her left lower extremity at all times for pressure reduction was documented as being in place the entire month. Record review of the resident's POS dated 2/15/13 - 3/14/13, showed physician's orders [REDACTED]. - Multivitamin with minerals, one tablet daily for three weeks. - Vitamin C 500 milligrams (mg), one tablet daily until healed. - Zinc 220 mg, one tablet daily for 14 days. Record review of the resident's MAR and TAR dated 2/15/13 - 3/14/13, showed: - The physician's orders [REDACTED]. - The physician's orders [REDACTED]. - The physician's orders [REDACTED]. Record review of the resident's daily skilled nurse's notes dated 2/18/13, showed: - A 2.0 centimeter (cm) by 1.0 cm purple discoloration noted to the resident's left lateral lower leg. - The bruise was discussed with therapy and the PRAFO to the left lower extremity was changed. Record review of the resident's pressure ulcer care plan dated 1/24/13, showed: - On 2/18/13, the care plan was updated to reflect that the resident had a bruise on his/her left calf from PRAFO boots, but this entry was crossed out. - There was an undated intervention to give medications as ordered by physician for wound healing. Record review of the wound company's consultation form 2/19/13, showed: - An additional treatment intervention included aggressive offloading of this area at all times. Record review of the facility's wound documentation (on plain paper/no form/no title) dated 2/20/13, showed: - The resident had a bruise on the left lateral lower leg that measured 2.0 cm by 1.0 cm that was purple, with 1.0 cm redness of the area of skin surrounding the wound, and it was noted that the PRAFO was too tight and was replaced. - Additional current interventions included tube feeding, Vitamin C, Zinc, Multi-vitamin, PRAFO, and low air loss mattress. During an interview on 4/12/13 at 10:30 A.M., LPN A said: - He/she felt on 2/20/13 that the PRAFO boot was too tight. - He/she could feel the form outside boot from the inside of the boot. - He/she thought a different boot would resolve the problem. Record review of the resident's daily skilled nurse's note dated 2/21/13 on the evening shift, showed it was documented that the resident had a brace on his/her right foot (refer to the PRAFO order that was for the left lower extremity) and leg and treatments were done to the resident's left heel. Record review of the resident's nurse's note dated 2/22/13 at 2:40 P.M., showed that a phone call was placed to the Nurse Practitioner (NP) notifying him/her of a lesion to the resident's left lateral lower leg that measured 3.0 cm by 1.5 cm that was beefy red with scant serosanguinous (with blood) drainage, had no redness of the area of skin surrounding the wound, and had superficial depth. An order was received and noted. Record review of the resident's physician telephone order dated 2/22/13, showed a physician's orders [REDACTED]. Record review of the wound company's consultation form 2/27/13, showed: - An additional treatment plan included aggressive offloading of this area at all times. Record review of the facility's wound documentation (on plain paper/no form/no title) dated 2/28/13, showed: - The resident had a superficial open area from the bruise on his/her left lower leg that measured 3.0 cm by 1.5 cm that was treated with Xeroform with border dressing daily. - Additional current interventions included Vitamin C and a PRAFO boot. Record review of the resident's CNA bath sheet dated 3/1/13, showed no area of concern to the resident's left leg. Record review of the wound company's consultation form 3/5/13, showed: - An additional treatment plan included aggressive offloading of these areas at all times. Record review of the resident's CNA bath sheet dated 3/8/13, showed no areas of concern regarding the resident's skin. Record review of the resident's POS dated 2/15/13 - 3/14/13, showed physician's orders [REDACTED]. - [MEDICATION NAME] (an antibiotic) 400 mg for ten days (it did not state what the medication was for). - A chest x-ray for possible aspiration (breathing in fluid or foreign material, especially stomach contents or food). Record review of the resident's CNA bath sheet dated 3/12/13, showed no area of concern to the resident's left leg. Record review of the wound company's consultation form dated 3/12/13, showed: - The resident's chart was reviewed on 2/5/13 (There was no documentation regarding the PRAFO boot at this point on the POS, on the telephone orders, or in the physician's progress notes). - An additional treatment intervention included aggressive offloading of this area at all times. Record review of the facility's weekly skin documentation dated 3/13/13, showed: - The resident had an open area to his/her left lower leg that measured 2.0 cm by 1.2 cm that was treated with Xeroform with border dressing daily. Record review of the resident's CNA bath sheets dated 3/15/13 and 3/19/13, showed no area of concern to the resident's left leg. Record review of the resident's POS dated 3/15/13 through 4/14/13, showed physician's orders [REDACTED]. - Dated 1/28/13 for PRAFO to his/her left lower extremity at all times except during bath and cares for the open wound to his/her left heel. - Dated 2/15/13 for Vitamin C 500 mg, one tablet until healed for wound healing. - Dated 2/22/13 to cleanse the open area to the left lateral lower leg with normal saline, pat dry, and apply Xeroform with border dressing daily until healed. Record review of the resident's TAR dated 3/15/13 through 4/14/13, showed documentation to provide a PRAFO (crossed out and "soft boot" written in) to his/her left-lower extremity at all times for pressure reduction, documented as being in place 3/15/13 - 3/30/13, and that it was discontinued on 3/30/13. Record review of the resident's MAR dated 3/15/13 - 4/14/13, showed: - The physician's orders [REDACTED]. Record review of the wound company's consultation form dated 3/19/13, showed: - The resident's chart was reviewed on 2/5/13. - The resident had a traumatic wound to his/her left posterior calf (the report actually said hip but this was an error) that was seen for the first time by the wound company. It was slough/eschar (dead tissue) covered (unable to visualize the entire wound base or completely covered with non-granulation tissue), measuring 1.6 cm by 0.6 cm by 0.2 cm with scant serosanguinous exudate, 100% necrotic (dead) tissue, no odor, and no [DIAGNOSES REDACTED] (redness) present. - Treatment orders included to cleanse with wound cleanser and apply Vaseline gauze daily to the wound bed. - An additional treatment plan included aggressive offloading of this area at all times. During an interview on 4/10/13 at 1:25 P.M., LPN A said the Xeroform should have been discontinued on 3/19/13 (when the order was changed to Vaseline gauze). Record review of the facility's skin documentation dated 3/20/13, showed: - The open area to the resident's left lateral lower leg measured 2.0 cm by 1.0 cm, was treated with Xeroform with border dressing daily, and was seen by the wound company. Record review of the resident's CNA bath sheets dated 3/22/13 and 3/26/13, showed no area of concern to the resident's skin, and circled the resident's left heel only. Record review of the wound company's consultation form dated 3/26/13, showed: - The resident's chart was reviewed on 2/5/13. - The resident had a traumatic wound to his/her left posterior calf that was slough/eschar covered, measuring 2.2 cm by 0.9 cm by 0.1 cm, with scant serosanguinous exudate, 100% necrotic tissue, no odor, and no [DIAGNOSES REDACTED] present, - Treatment orders included to cleanse with wound cleanser and to apply a Vaseline gauze daily to the wound bed; - The wound was worsening; and - An additional treatment intervention included aggressive offloading of these areas at all times. Record review of the resident's facility's weekly skin documentation dated 3/27/13, showed: - The resident had an open area to the left lateral lower leg that was an abrasion from the brace and was treated with Vaseline gauze. - Vitamin C was an additional intervention. Record review of the resident's physician's telephone order dated 3/30/13, and the resident's POS dated 3/15/13 through 4/14/13, showed physician's orders [REDACTED]. - Float his/her heels. - Not wear boots. - Watch for a temperature spike. Record review of the resident's physician's telephone order dated 4/1/13, and the resident's POS dated 3/15/13 through 4/14/13, showed physician's orders [REDACTED].M. for PRAFO boots to his/her bilateral (both sides) lower extremities for pressure relief for his/her heel wounds. Record review of the resident's TAR dated 3/15/13 - 4/14/13, showed: - physician's orders [REDACTED]. This order was followed 3/31/13 through 4/1/13, and then discontinued (no discontinue date noted). - There were no additional skin or wound assessments. Record review of the resident's telephone order dated 4/1/13, showed a physician's orders [REDACTED]. Record review of the resident's pressure ulcer care plan dated 1/24/13, showed: - There was an undated (Refer to the physician's orders [REDACTED]. Record review of the resident's CNA bath sheet dated 4/2/13, showed no area of concern to the resident's skin, and circled the resident's left heel only. Record review of the wound company's consultation form 4/2/13, showed: - The resident had a traumatic wound to his/her left posterior calf that was slough/eschar covered, measured 2.1 cm by 1.2 cm by 0.1 cm with no exudate, 100% necrotic tissue, no odor, and no [DIAGNOSES REDACTED] present. - Treatment orders included to cleanse with wound cleanser and apply skin prep daily to wound bed. - The wound was worsening. - An additional treatment intervention included aggressive offloading of these areas at all times. Record review of the resident's TAR dated 3/15/13 - 4/14/13, showed: - A PRAFO (crossed out and "soft boot" written in) to his/her left lower extremity at all times for pressure reduction was documented as being in place 3/15/13 - 3/30/13, and that it was discontinued on 3/30/13. - PRAFO's to bilateral lower extremities for pressure relief were documented as being in place 4/2/13 through current (4/11/13). - Undated physician's orders [REDACTED]. This order was followed 4/2/13 through 4/11/13. - physician's orders [REDACTED]. Record review of the facility's weekly skin documentation dated 4/3/13, showed: - The resident had a traumatic open wound to the left calf that measured 2.2 cm by 1.2 cm by 0.1 cm, and was treated with skin prep. Record review of the resident's facility weekly skin report dated 4/3/13, showed the facility documented the resident had one open wound to the left calf that was a traumatic injury, measuring 2.2 cm by 1.2 cm by 0.1 cm, and was treated with skin prep. Record review of the resident's physician's progress note completed by the NP dated 4/3/13, showed: - The resident had [DIAGNOSES REDACTED]. disease (GERD - back-up of stomach acid/heartburn), and dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). - The resident had wounds to his/her lower extremities that were deteriorating, had new areas, and were managed by the wound team. Record review of the resident's CNA bath sheet dated 4/5/13, showed areas of concern to the resident's skin and circled the resident's left heel only. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) dated 4/7/13, showed staff assessed the resident: - Was over [AGE] years old. - Had short and long-term memory impairment. - Had severely impaired cognitive skills for decision-making. - Was usually understood and usually understood others. - Had little interest in doing things 12-14 days out of the past two weeks. - Felt tired or had little energy 12-14 days out of the past two weeks. - Did not display any behavioral symptoms. - Did not reject care. - Was totally dependent upon staff for bed mobility, transferring from one surface to another (such as bed, chair, wheelchair), dressing, eating, using the toilet, personal hygiene, bathing and locomotion. - Did not stand. - Was incontinent of bowel and bladder. - Did not have an active [DIAGNOSES REDACTED]. - Had [DIAGNOSES REDACTED]. pressure ulcer. - Did not receive any pain medications. - Was five feet tall and weighed 107 pounds. - Received tube feedings. - Received a mechanically altered diet (a change in texture of food or liquids e.g., pureed food or thickened liquids). - Received 51% or more of his/her total calories through tube feeding. - Had one unstageable pressure ulcer that was not present on admission. - Had two Stage 2 pressure ulcers that were not present on admission. - Had an infection of the foot. - Had surgical wounds. - Received a diuretic (medication that reduces the amount of water in the body). During an interview on 4/17/13 at 11:30 A.M., Registered Nurse (RN) A said he/she completed the pressure ulcer and other wounds section of the MDS by referring to the facility skin and pressure ulcer reports. Record review of the wound company's preliminary report consultation form dated 4/9/13, showed: - The resident had a traumatic wound to his/her left posterior calf (first seen by the wound company on 3/19/13) that presented as full thickness (through the epidermis and dermis into the subcutaneous tissue, fascia, etc.), measuring 3.1 cm by 2.9 cm by 0.5 cm with scant serosanguinous exudate, 25% slough, 75% necrotic tissue, mild odor, and [DIAGNOSES REDACTED] present. - It was debrided and post-debridement measurements were 3.1 cm by 2.9 cm by 0.07 cm. - The tendon (tissue that connects muscle with the bone) was exposed. - Treatment orders included to cleanse with wound cleanser, apply Santyl, cover with Vaseline gauze, and cover with dry dressing daily. - An additional intervention included aggressive offloading of these areas at all times. Observation on 4/9/13 at 1:50 P.M., showed the resident was in bed with wounds to bilateral heels and to his/her left calf that were all open to the air. During an interview on 4/9/13 at 1:55 P.M., LPN A said the wound company had seen the resident earlier and that he/she still needed to do the resident's dressing change. Observation on 4/9/13 at 2:25 P.M., showed the resident was in bed with wounds to bilateral heels and to his/her left calf that were all open to air. During an interview on 4/9/13 at 2:25 P.M., LPN A said the wound company saw the resident about 11:30 A.M. that morning. Observation and interview on 4/9/13 from 2:33 P.M. to 2:53 P.M., showed: - The resident had a wound to the left outer aspect of the mid-calf that was about the size of a half dollar. The wound had an area of eschar near the center. The outer edge was dark red, and there was bloody drainage. There was an area of redness approximately four inches in length extending from the wound toward the knee and another area of redness approximately four inches in length extending from the wound toward the foot. - At 2:42 P.M., LPN A said the wounds had been open to air since they were seen by the wound company around 11:30 A.M. - LPN A completed treatments to the left calf, left heel and right heel (cleansed with normal saline, applied Santyl and covered). Record review of the resident's facility weekly pressure sore report dated 4/10/13, showed: - The resident had trauma to the left lateral lower leg (Site 2) that was treated with Santyl, Vaseline gauze and roll gauze. There were no measurements or description. During an interview on 4/10/13 at 11:00 A.M., Physician A (the Primary Care Physician) said: - He/she originally wanted a PRAFO boot for pressure reduction to the heel as the resident had developed a pressure ulcer to his/her left heel. - The PRAFO boot rubbed the resident's left calf and caused what initially appeared as a bruise. - The PRAFO boot was a calculated risk. The PRAFO would provide pressure reduction to the resident's heel but would increase the risk of breakdown elsewhere. - He/she ordered Vitamin C until the wounds were healed because it helps with tissue reformation. - The resident had [MEDICAL CONDITION]. - They had suggested hospice (end of life care) but the resident's family declined. - He/she was not surprised the resident's calf wound was not healing. - The resident's calf wound probably won't heal. During an interview on 4/10/13 at 11:00 A.M., LPN A said they had tried three different PRAFO boots on the resident. During an interview on 4/11/13 at 1:30 P.M., the Director of Nursing (DON) said: - The CNA's did skin assessments with bathing and documented the results on the bath sheets. - The licensed nurses were responsible for doing weekly skin assessments and documenting the results on the TAR. Record review of the resident's lab results dated 4/11/13, showed: - His/her white blood count was elevated at 15.2 (reference range 4.1-11.1). - His/her [DIAGNOSES REDACTED] absolute was elevated at 12.3 (reference range 2.3-7.8). - His her monocyte absolute was elevated at 2.0 (reference range 0.3-1.2). - [MEDICATION NAME] (an antibiotic) 750 mg was ordered daily for ten days. During an interview on 4/12/13 at 9:35 A.M., RN A (former MDS Coordinator) said: - The nurse's give the MDS Coordinator copies of the telephone orders for care plan updates. - He/she did not know why the care plan was not updated to reflect the current wound status. During an interview on 4/12/13 at 10:30 A.M., LPN A said he/she was the one who was documenting the resident's wounds for the facility. During an interview on 4/12/13 at 12:10 P.M., LPN A said: - He/she had been following the Santyl order beginning 4/2/13 and not the skin prep order (refer to the wound company's report on 4/2/13 with orders for skin prep to all three areas). Record review of the resident's Braden scale dated 4/7/13, showed the staff assessed the resident to be at moderate risk of pressure ulcers. During an interview on 4/10/13 at 2:06 P.M., NP A (for the wound company) said: - The facility staff should have covered the wounds within a few minutes of him/her seeing the resident. - Heat loss from the wounds not being covered can damage the tissue. - He/she did not know the resident was wearing PRAFO boots. - The PRAFO boot could be why the left calf wound was getting worse. - Heel protectors or heels elevated might be better options. - The wound did have an odor when he/she saw it last. - He/she removed the eschar when he/she saw it last and was waiting to see if the odor went away with the removal of the eschar. - The Xeroform and Vaseline gauze were very similar, so the facility continuing to follow the Xeroform order probably did not make any difference. During an interview on 4/11/13 at 11:50 A.M., LPN A said all residents were supposed to have a skin assessment completed weekly by a licensed nurse, and he/she does not know how the skin assessments dropped off of the resident's TAR. Record review on 4/12/13 of the resident's current care plan dated 1/24/13, showed the care plan was not updated to reflect all of the resident's wounds and interventions. During an observation and interview on 4/12/13 at 9:50 A.M., Physician B (the Wound Physician) said: - Half of the wound (the half that was black) to the left lateral calf was going to die and come off. - The PRAFO boot would cause pressure and needed to be discontinued. During an interview on 4/12/13 at 9:50 A.M., the DON said Physician A said previously that he/she would agree to Physician B's recommendations from today. During an interview on 4/12/13 at 1:00 P.M., the DON said: - They should have followed the physician's orders [REDACTED]. - Documentation should be accurate. - Bath sheets should document all areas of skin concern including existing and new areas. - When the heel was circled on the bath sheets, there should have been an explanation instead of marking all no's to areas of concern. - The wounds should have been covered fairly quickly (on 4/9/13), and that three hours was too long for the wounds to have been left uncovered. - There should have been weekly skin assessments completed by a licensed nurse and documented on the TAR. - The calf wound should have been added to the care plan and not just left as a bruise on the care plan. - He/she did not know how they could have known that the wound company was not aware that the resident was using PRAFO boots. - The nursing staff should have been more proactive on this and questioned why the calf wound was not improving. - The resident's calf wound started as a bruise that was caused by the PRAFO boot, which was too tight. - They did get a new boot when they realized the PRAFO was too tight. During an interview on 4/12/13 at 1:00 P.M., the Administrator said they thought the wound company was managing the resident's wounds. 2. Record review of the facility's policy titled, "Administering Pain Medications," revised September, 2003, included the following information: - The purpose of this procedure was to provide guidelines for assessing the resident's level of pain prior to administering non-narcotic or narcotic [MEDICATION NAME] (medications that provide pain relief). - Review the resident's care plan to assess for any special needs of the resident. - The resident's experience of pain is highly individual and subjective. Pain is whatever the resident says it is. - Intense pain can result from even minor procedures or surgery. - Be familiar with the physiological and behavioral signs of pain. - Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after [MEDICATION NAME] relief is obtained. - The pain assessment consists of gathering both subjective and objective data. - Obtain objective information through assessment: Behavioral responses to (acute) pain: facial wrinkling, grimacing; crying or moaning, aggression, hitting, or biting, increase in body movements, guarding, decreased interaction, need for more rest, and/or irritability/mental confusion. - Evaluate the effectiveness of non-pharmacological interventions (e.g., repositioning, warm or cold compresses, etc.). - The following information should be recorded in the resident's medical record: -- Subjective evidence of pain. -- Objective evidence of pain. -- Condition of the pain site, if appropriate. -- The drug name, dose, time, date and route of administration. -- The resident's response to the medication. -- The name and title of the individual assessing the resident for pain and administering the medication. -- Any adverse reaction experienced by the resident. 2. Record review of Resident #10's Face Sheet dated 2/21/13, showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. - Dementia (a progressive loss of cognitive function marked by memory problems and confused thinking); - Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living); - [MEDICAL CONDITION] (decrease in bone mass and density and enlargement of bone spaces producing fragility); - Abnormality of gait (a variation from the usual manner or style of walking); - [MEDICAL CONDITION] (below normal function of the [MEDICAL CONDITION] which regulated metabolism); and - Dysphasia (impairment in the production of speech and failure to arrange words in an understandable way). Record review of the resident's admission MDS dated [DATE], showed the following information: - The resident had severely impaired cognitive skills for daily decision making. - The resident had no indicators of [MEDICAL CONDITION], hallucinations or [MEDICAL CONDITION]. - The resident had no behavioral symptoms. - The resident required limited assistance for all activities of daily living (ADL's - how a resident self-performs grooming, eating, walking, bathing, etc.). - At no time within a period of five days of the assessment reference date (ARD) 2/12/13, was the resident on a scheduled pain medication regimen. - The resident did not receive as needed (PRN) pain medications during the assessment period. - The resident did not receive non-medication interventions for pain. Record review of the resident's Care Plan dated 2/19/13, showed: - The resident complained of or showed evidence of pain at times. - The