Every finding on record at Medicalodges Neosho

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse by other residents when one resident (Resident #1) exhibited abusive behaviors including touching breasts of one resident (Resident #2) after the facility placed the resident (Resident #1) on one-on-one with a staff The facility census was 54.Review of the facility's policy titled Abuse, Neglect and Exploitation, revised 10/2022, showed the following:-The resident has the right to be free from verbal, sexual, physical and mental abuse and involuntary seclusion. It is the policy of Medicalodges, Inc., to treat each resident with respect, kindness, dignity and care, to keep them free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect;-Abuse is the willful infliction of injury; the unreasonable confinement, neglect, intimidation or punishment resulting physical harm, pain or mental anguish or deprivation by an individual (including a caretaker) of goods or services necessary to attain or maintain physical, mental and psychosocial well-being;-Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault;-The facility shall ensure sufficient staffing on all shifts to meet the needs of the residents;-All staff assigned shall be knowledgeable of the individual care needs of the residents to whom they are assigned;-The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur;-Resident care plans shall include problems observed and/or a history of previous problems such as signs of self-injurious behavior, wandering into other resident rooms, communication disorders, etc. which might result in aggressive behavior, agitation and/or conflict. Interventions shall be part of the care plan, and all staff shall be knowledgeable and have ready access to this information. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following:-admission date of 09/27/24;-Diagnoses included anoxic (lack of oxygen) brain damage, paraphilia (unusual sexual desires, typically involving extreme or dangerous activities), and sexual dysfunction. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 04/07/26, showed the following:-Moderate cognitive impairment;-Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred four to six days but less than daily;-The resident was independent with activities of daily living (ADL - dressing, eating, bathing, etc.) with the exception of set-up assistance from staff to shower. Review of the resident's care plan, revised 04/27/26, showed the following:-He/she had occasional behaviors;-He/she had behaviors of sexual nature such as exposing his/her genitals;-He/she touched hands of residents of the opposite gender;-Monitor his/her behaviors and redirect his/her as needed. He/she needed reminders regarding appropriate group behaviors at times;-Please encourage him/her to participate in activities of his/her choice;-He/she had a deficit in cognitive functioning characterized by deficit in memory, judgement, decision making and thought process related to cognitive changes;-Administer his/her medication as ordered;-Please report to his/her nurse and/or physician of any noted changes in his/her behavior or cognitive status. 2. Review of Resident #2's face sheet showed the following:-admission date of 12/12/22;-Diagnoses included dementia and high blood pressure. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Wandered four to six days but less than daily;-Independent for eating and putting on and taking off footwear, required supervision of staff for oral hygiene and maximum assistance of staff for toilet hygiene, bathing, upper and lower body dressing and personal hygiene. Review of the resident's care plan, revised 10/06/25, showed the following:-Resident had increased behaviors;-At times, the resident may wander into other rooms and bring items in or out of other rooms. Due to this, at times my items may get misplaced. Please help to monitor this and assist him/her as needed with locating items;-Encourage him/her to participate in activities of his/her choice;-Resident had a stop sign on his/her door to keep other residents from entering his/her room and taking his/her personal items. Please ensure that it is up;-Resident had a deficit in cognitive functioning affecting his/her speech, memory and complex decision making related to dementia;-Cognitive loss that affected his/her memory;-Please observe and report any changes in his/her cognitive status. 3. Review of the facility's investigation, dated 04/24/26, showed the facility placed Resident #1 on one-on-one on 04/24/26 and placed an alert to continue one-on-ones with the resident. Review of the facility's investigation, received 04/28/26, showed the following:-Resident #1 went up to Resident #2 and grabbed his/her breast;-Resident #1 was one-on-one at the time, however Certified Medication Technician (CMT) B did not personally intervene;-CMT B summoned the Certified Nursing Assistant (CNA) A, however Resident #1 grabbed Resident #2's breast before the CNA could intervene;-Action plan initiated and notification to residents chart to continue one-on-one until Resident #1 went out to the hospital;-The allegation was verified by evidence collected during the investigation based on the witness statement from the occurrence. Resident #1 was one-on-one with staff due to seeking out sexual attention and staff failed to intervene and redirect Resident #1 prior to him/her grabbing Resident #2's breast. Review of the Resident #1's risk assessment dated [DATE], at 3:20 P.M. showed the following:-CNA came to this nurses' office to report an incident where the resident touched another resident's breast in the dining room;-The CNA was alerted by med tech that the resident stopped and stood by the other resident, after getting a cup of coffee;-CNA entered the dining room to redirect him/her away from the other resident and the resident reached out and touched the other resident's right breast before she could stop him/her;-The resident remained on 1:1 observation and taken to his room by CNA. 4. During an interview on 04/29/26, at 1:14 P.M., CNA C said the following:-The facility implemented interventions of increased monitoring and redirection with the Resident #1;-He/she believed the resident was placed one-on-one after an incident on 04/21/26 but Administrator had not assigned a specific staff member to the resident;-Resident #1's behaviors had gradually gotten worse since he/she started in 09/2025. The administration told the CNAs to keep the resident separated from the residents of the opposite gender;-He/she believed Resident #1 had behaviors daily;-The CNAs charted the resident's behaviors in their chart;-If he/she witnessed resident to resident abuse, he/she separated the residents and then immediately reported to the Director of Nursing (DON), Assistant Director of Nursing (ADON), or charge nurse;-If a resident was placed one-on-one, the resident should have a staff member with them at all times and the staff should only be assigned that duty;-If a resident touched another resident's breast, he/she considered that sexual abuse. During interviews on 04/29/26, at 9:50 A.M. and 1:23 P.M., CNA D said the following:-He/she was not told Resident #1 was one-on-one. He/she was told to keep a close eye on the resident due to sexual behaviors of the resident. Resident #1 exposed self and touched chest and private areas of other residents;-The resident was on medication due to his/her behaviors;-The resident's behaviors were better until this last week when something suddenly changed with the resident;-Interventions for the resident's behaviors included redirection, increased monitoring, and medication;-He/she did not know Resident #1 was placed one-on-one;-If Administration did not assign a specific staff member to Resident #1;-If he/she witnessed resident to resident abuse, he/she separated the residents and immediately reported to the DON or charge nurse;-If a resident was one-on-one, Administration should assign a staff member specifically to stay with that resident;-The facility did not always staff two CNAs on the locked unit, but if he/she was the only staff member, he/she asked for assistance if he/she needed it. During an interview on 04/29/26, at 12:29 P.M., CNA A said the following:-On 04/25/26, at approximately 4:00 P.M., Resident #1 was in his/her bed, and the CNA was beside the resident's room watching the resident;-The resident got up and walked to the dining room to get a cup of coffee;-When the resident walked into the dining room, the CNA could not see the resident because there was a wall between where the CNA was positioned and the resident was in the dining room;-CMT B passed medications in the dining room and told the CNA to go check on the resident because the resident was close to Resident #2;-When the CNA entered the dining room, he/she saw Resident #1 touch Resident #2's breast;-He/she removed Resident #1 from the dining room away from Resident #2;-The locked unit had two staff assigned to the hall that day;-He/she was not assigned to be one-on-one with Resident #1 that day and still had other duties with other residents to perform;-The resident was placed one-on-one on 04/24/26, but Administration did not specifically assign a specific staff member to watch the resident on 04/25/26;-Interventions for the resident's behaviors included giving the resident a snack or activity, redirect and separated from other residents and the resident received medications from his/her sexual behaviors;-The resident knew what he/she was doing and when staff watched him/her;-If he/she witnessed resident to resident abuse, he/she separated the residents and reported to the charge nurse immediately;-If Administration placed a resident one-on-one, staff should stay with the resident everywhere the resident went and should only be assigned to that resident;-Administration did not assign specific staff when a resident was placed one-on-one to his/her knowledge. During an interview on 04/29/26, at 1:30 P.M., Licensed Practical Nurse (LPN) F said the following:-On 04/25/26, CNA A reported to the MDS Coordinator that Resident #1 got up to get coffee and touched Resident #2's breast;-Administration placed Resident #1 on 15-minute checks and then placed the resident one-on-one, but the LPN did not know when this happened;-Staff separated Resident #1 from Resident #2, notified the residents' responsible parties, physician and the police department;-The physician sent Resident #1 out for psychiatric evaluation;-He/she considered Resident #1 touching Resident #2's breast sexual abuse;-Interventions for the resident's behaviors included staff closely watching the resident and redirecting the resident away from residents of the opposite gender and medication;-If Administration placed the resident one-on-one, they should assign a specific staff member to the resident;-If a CNA or CMT witnessed resident to resident abuse, they separated the residents and reported it to the charge nurse immediately. During an interview on 04/29/26, at 2:08 P.M., CMT B said the following:-On 04/25/26, he/she passed medications in the dining room of the locked unit. When he/she did this he/she had to watch closely while they took their medications;-He/she saw Resident #1 stand by Resident #2 and told CNA A and the CNA responded;-He/she did not respond to the residents because he/she did not see any touching;-CNA A notified the MDS Coordinator immediately;-He/she was not given any direction related to Resident #1 being one-on-one, and administration did not assign a specific staff member to the resident that day to his/her knowledge;-He/she did not know the resident was one-on-one on 04/25/26;-If he/she witnessed resident to resident abuse, he/she separated the residents and reported it to the charge nurse immediately. During an interview on 04/29/26, at 2:24 P.M., CNA G said the following:-He/she worked the locked unit on 04/25/26;-He/she knew staff were to watch Resident #1 closely but did not know the resident was one-on-one;-Administration did not specifically assign a staff member in the locked unit one-on-one with the resident on 04/25/26;-Interventions for the resident's behaviors included redirection and give the resident an activity;-He/she considered Resident #1 touching Resident #2's breast sexual abuse'-If he/she witnessed resident to resident abuse, he/she separated the residents then reported to the charge nurse immediately. During an interview on 04/29/26, at 3:42 P.M., LPN H said the following:-If a CNA or CMT witnessed resident to resident abuse, they separated and protected the residents and then reported to the charge nurse immediately;-The charge nurse reported to the DON immediately, assessed the residents and notified the residents' responsible parties and physician;-If a resident was one-on-one, a specific staff member was assigned to always keep eyes on that resident. During an interview on 04/29/26, at 2:37 P.M., the MDS Coordinator said the following:-Interventions for Resident #1 behaviors included increased monitoring, medication and offering the resident activities;-On 04/25/26, Resident #1 stood by Resident #2 and CNA A saw Resident #1 grab Resident #2's breast;-CNA A reported the incident to him/her;-Resident #1 was on one-on-one supervision at the time;-CNA A was assigned to be the one-on-one staff member with the resident;-He/she knew the resident was one-on-one because the Administrator informed him/her;-On 04/25/26, two staff were assigned during the day to the locked unit;-The resident was placed one-on-one on 04/24/26;-The night of 04/24/26, only one staff was assigned to the locked unit and that overnight CNA was to call for assistance if they needed a break or to assist another resident;-The Administrator said the resident was one-on-one during waking hours;-During the overnight hours from 04/24/26 to 04/25/26 no staff member was assigned one-on-one with the resident;-If a CNA or CMT witnessed resident to resident abuse, they should separate the residents and report to their charge nurse immediately;-If a resident was one-on-one, a specific staff member was assigned to that resident and that staff member always kept eyes on the resident within close vicinity of the resident;-He/she did not know who was responsible for assigning a staff member to one-on-one duties;-The staff member assigned to the resident filled out a form every 15 minutes related to where the resident was and what the resident was doing. During an interview on 04/29/26, at 4:13 P.M., the ADON said the following:-Interventions for Resident #1's behaviors included education, increased monitoring and medication;-The Administrator placed the Resident #1 one-on-one on 04/24/26 during waking hours;-He/she understood CNA A knew Resident #1 was one-on-one and that the CNA was assigned to the resident;-The Administrator said CNA A sat outside the resident's door and CMT B witnessed the incident between Resident #1 and Resident #2;-He/she did not know if Resident #1 had a specific staff member assigned to the resident on 04/25/26;He/she considered Resident #1 grabbing Resident #2's breast sexual abuse that was preventable;-If a resident was one-on-one, the charge nurse assigned a specific staff member to that resident;-The charge nurses knew who was one-on-one through report from the administrative staff;-The administrative team was responsible for ensuring the charge nurses knew to assign a specific staff member to a resident that was one-on-one and the charge nurse was responsible for ensuring staff followed through with their one-on-one duties. During an interview on 04/29/26, at 4:49 P.M., the Administrator said the following:-Interventions for the resident's behaviors included redirection, increased monitoring and medication;-The physician increased the resident's medication dose on 04/24/26 with the residents first increased dose given on 04/25/26;-He/she placed the resident one-on-one on 04/24/26 for the waking hours because the resident typically slept through the night;-He/she informed night staff to request assistance to sit with the resident if they needed a break or to assist with another resident as could not guarantee the resident would sleep all night;-On 04/25/26, CNA A was assigned one-on-one with the resident;-CNA A should have followed the resident into the dining room;-If a resident was one-on-one, the nursing administration team assigned a specific staff member to always stay with them;-The staff knew what residents were one-on-one by an alert that was placed in the electronic documentation system for CNAs to see and staff were notified by the nursing administration team. Complaint #2994354

Based on observation, interview, and record review, the facility failed to establish and maintain a complete infection control program when staff failed to use Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs - microorganism that has developed resistance to one or more classes of antibiotics, making infections caused by it more difficult to treat) in nursing homes) during wound care for two residents (Residents #29 and #48). The facility census was 55.Review of Centers for Disease Control and Prevention' (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs, dated 04/02/24, showed the following:-MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs;-EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities;-EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO;-Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens,changing briefs or assisting with toileting, device care or use of central line (a long, flexible tube inserted into a large vein in the chest, neck, or arm, with the tip ending close to the heart), urinary catheter (a thin, flexible, indwelling urinary tube inserted through the urethra into the bladder to drain urine continuously), feeding tube (a medical device used to deliver liquid food, fluids, and medications directly to the stomach or small intestine), tracheostomy (a surgical procedure that creates an opening, called a stoma, through the neck directly into the windpipe (trachea) /ventilator (a medical machine that helps a patient breathe or fully breathes for them)and wound care of any skin opening requiring a dressing. Review of the facility policy titled, Infection Management Process, revised 11/2023, showed the following:-CDC will be the resource for implementation of appropriate isolation procedures and immunization schedule;-EBP applies to all residents with wounds, indwelling devices regardless of MDRO colonization status. 1.Review of Resident #29 face sheet (a form that provides resident details) showed the following:-admission date 03/10/26;-Diagnoses included pressure ulcer of left heel stage 3 (a serious, full-thickness wound extending through the skin into the subcutaneous fat layer). Review of the residents' quarterly Minimum Data Set (MDS-federally mandated assessment tool administered by staff), dated 04/15/26, showed the resident had sever cognitive impairment. Review of the resident's care plan, revised 03/11/26, showed the following:-Stage 3 pressure ulcer to left heel;-Treatment in place;-Float heels while in bed.(Staff did not care plan related to EBP.) Observation on 04/22/26, at 2:01 P.M., showed the following:-Resident lying in bed with no EBP sign or supplies in room;-LPN A entered the resident's room, washed hands, donned gloves, and created a clean area for supplies. The LPN did not don gown;-LPN A completed wound care without donning gown;-LPN A Washed hands and exited room. 2. Review of Resident #49's face sheet showed the following information:-admission date of 10/01/25-Diagnoses include diabetic foot ulcer (wound primarily caused by complications of diabetes). Review of the residents' quarterly MDS, dated [DATE], showed the following:-No cognitive impairment related to daily living decision making;-At risk for developing pressure ulcers. Review of the resident's care plan, revised 03/11/26, showed the following:-Required staff assistance with all activities of daily living;-Diabetic ulcer to the right heel;-Current wound treatment in place.(Staff did not care plan related to EBP.) Observation on 04/22/26, at 2:45 P.M., showed the following:-No EBP signage or supplies in room;-LPN A entered room, washed hands, donned gloves, and created a clean area for supplies. LPN A did not don gown;-LPN A completed wound care without donning gown.-LPN A washed hands and exited room. 3. During an interview on 04/23/26. at 10:15 A.M., the Infection Preventionist said the following:-EBP is to protect vulnerable residents from staff members;-He/she thought EBP only applied to residents with current MDRO infections;-Signs should be posted on the doors of residents on EBP to alert staff. During an interview on 04/23/26, at 1:25 P.M., LPN A said the following:-EBP precautions apply to all residents with wounds;-Residents on EBP should have a sign on the door alerting staff. During an interview on 04/24/26, at 11:30 A.M., the Assistant Director of Nursing (ADON) said the following:-All residents on EBP precautions should have a sign on their door alerting staff;-EBP includes gowns and gloves and applies to all residents with wounds;-He/she expected all staff to follow EBP precautions when completing wound care. During an interview on 04/24/26, at 3:25 P.M., the Director of Nursing (DON) said the following:-He/she believed EBP only applied to residents with MDRO infections;-Facility policy was EBP applies to all residents with wounds. During an interview on 04/24/26, at 4:17 P.M., the Administrator said the following:-EBP included all wounds;-He/she expected staff to follow facility EBP policy.

Based on interview and record review, the facility failed to implement a complete abuse and neglect program that completed all screenings when staff failed to complete a Nurse Aide (NA) Registry (a registry which shows if someone has a Federal Indicator (indicates individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term care facility) for one (Registered Nurse (RN) H) of four sampled employees . The facility census was 55. Record review of the facility's Abuse, Neglect and Exploitation Policy, revised October 2022, showed the following:-The resident has the right to be free from verbal, sexual, physical and mental abuse and involuntary seclusion;-The appropriate certification and/or licensing agencies will be contacted for the current status of the employee's license or certification for employment. The person making the call will document registry verification, and the written response will be maintained in the employee's personnel file/verification of work eligibility notebook. 1. Record review of RN H's personnel record showed the following:-Hire/Start date of 12/23/25;-The facility did not document completion of NA registry check for the RN prior to or upon hire. During interviews on 04/24/26, at 11:25 A.M., 1:00 P.M., and 1:15 P.M., the Business Office Manager (BOM) said the following:-She ran the NA Registry check on all staff except for the RNs and the licensed practical nurses (LPN).-Corporate ran all the checks on all licensed nurses;-She talked with her corporate office, and they do not run the NA registry checks on any nurses. During an interview on 04/24/2,6 at 4:17 P.M., the Administrator said she did not know the facility should check the NA registry on all staff to include the nurses, before they start work.

Based on observation, interview, and record review, the facility failed to ensure they maintained a medication administer error rate of less than 5% when staff failed to administer the correct medication to one resident (Resident #4) and failed to administer a medication to one resident (Residents #18), resulting in 2 errors out of 28 opportunities (a medication error rate of 7.1%). The facility census was 55.Review of the facility policy Medication Error Reporting and Adverse Drug Reaction Prevention, dated 01/23, showed the following:-The facility utilizes a system to assure that medication usage is evaluated on an ongoing basis;-Medication error shall be defined as any preventable event that may cause or lead to inappropriate medication use. 1.Review of Resident #18 face sheet showed the following information:-admission date of 03/26/26-Diagnoses included Parkinsons (a neurological disease), dementia (a progressive neurological disease), and hypertension (high blood pressure). Review of the residents' comprehensive Minimum Data Set (MDS-federally mandated assessment tool administered by staff), dated 03/26/26, showed the resident was cognitively intact Review of the resident's care plan, revised 04/14/26, showed the following:-Required staff assistance with activities of daily living due to physical impairments;-He/she required nursing observation for side effects of Plavix (a medication used to help prevent blood clots) such as bleeding or bruising. Review of the resident's April 2026 Physician Orders (POS) showed an active order for Plavix 75 milligrams (mg) once a day. Observation of medication pass on 04/23/26, at 10:00 A.M., showed Registered Nurse (G) did not administer the resident's Plavix. 2. Review of Resident #4 face sheet showed the following information:-admission date of 06/21/24;-Diagnoses include hypertension (high blood pressure), hyperlipidemia (high lipid values), and chronic kidney disease (CKD - the long-term, gradual loss of kidney function, preventing them from properly filtering blood and waste). Review of the residents' quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's care plan, revised 02/24/26, showed the following:-Requires staff assistance for activities of daily living due to physical limitations;-Takes medications to manage chronic pain;-Resident at risk for side effects due to taking multiple medications; Review of the resident's April 2025 POS showed an active order for ferrous gluconate (iron) 324 mg one time a day. Observation of medication pass on 04/23/26, at 10:15 A.M., showed RN G gave the resident ferrous sulfate 325 mg instead of ferrous gluconate 324 mg. 3. During an interview on 04/23/26, at 1:25 P.M., Licensed Practical Nurse (LPN) A said the following:-Giving the wrong medication would be a med error;-Staff should follow the three rights to ensure they are giving the proper medication. During an interview on 04/23/26, at 1:45 P.M., the MDS Coordinator said the following:-Staff should ensure the right medication, right person, right time, right dose, and verify resident with picture on the electronic medication administration record (eMAR) to help prevent medication errors;-Errors should be reported to the Director of Nursing (DON) right away. During an interview on 04/24/26, at 11:30 A.M., the Assistant Director of Nursing (ADON) said the following:-A medication error can be the wrong dose, wrong drug, wrong time, or medication not given;-He/she expected staff to be careful to help prevent medication errors;-He/she expected staff to administer medications without errors. During an interview on 04/24/26, at 3:25 P.M., the DON said the following:-He/she would consider it a medication error if a medication were not given, missed, wrong medication given, wrong time, or wrong dose;-He/she expected staff to follow the 5 rights to help prevent medication errors. During an interview on 04/24/26, at 4:17 P.M., the Administrator said the following:-Giving the wrong medication would be a medication error;-He/she expected staff members to follow the 5 rights of medication administration to help prevent medication errors.on to help prevent medication errors.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans for four residents (Residents #5, Resident #12, Resident #26 and Resident #47) that addressed side rails usage. The facility census was 50. Review of the facility's policy titled, Electronic Care Plan, dated 12/2018, showed the following: -The facility is to develop a plan of care to attain and maintain the highest practical level of physical, psychological, emotional and social well-being for each resident in the facility. Review of the facility's policy titled, Side Rail Use and Assessment, undated, showed the following: -To ensure the automatic use of side rails of any size or shape is avoided, a decision to use, reduce or remove side rails occurs within the framework of an individual resident assessment and is clearly documented, and the use of side rails for either positioning and mobility or for the treatment of a medical/psychological symptom or condition is accompanied by an individualized care plan; -Use of side rails and interventions to ensure safe use will be included in the resident's care plan. 1. Review of Resident #5's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Diagnoses included Alzheimer's disease. Review of the resident's electronic record showed a Side Rail Consent Form was signed by the resident on 02/22/24, indicating information regarding the risks and benefits of using a side rail of any sort was received, and the resident chose to utilize a transfer bar,1/4 rail, or 1/2 rail. Observations on 04/16/24, at 9:21 A.M. and 1:35 P.M., on 04/17/24, at 10:26 A.M., and on 04/18/24, at 11:25 A.M., showed the resident had a raised u-shaped grab bar on the right side of the bed against the wall. Review of the resident's care plan, last revised 02/19/24, showed staff did not care plan the use of side rails/u-shaped grab bar. 2. Review of Resident #12's face sheet showed the following: -admitted [DATE]; -Diagnoses included cognitive communication deficit, other abnormalities of gait and mobility, mild cognitive impairment of unknown cause, and delusional disorders. Review of the resident's electronic record showed a Side Rail Consent Form was signed by the resident's representative on 01/24/24, indicating information regarding the risks and benefits of using a side rail of any sort was received, and the resident chose to utilize a transfer bar,1/4 rail, or 1/2 rail. Interview and observation on 04/15/24, at 11:07 A.M., showed the following: -The resident had bilateral quarter side rails in raised position on the bed; -The resident said the side rails were put on when he/she fell out of bed. Observation on 04/16/24, at 1:33 P.M., showed bilateral quarter side rails in raised position. Interview and observation on 04/17/24, at 2:11 P.M., showed the following: -Bilateral quarter side rails were in raised position on the resident's bed; -The resident said he/she used the side rails for bed mobility. Observation on 04/18/24, at 11:25 A.M., showed resident lying in bed with eyes closed, bilateral quarter side rails in lowered position. Review of the resident's care plan, last revised on 02/03/24, showed staff did not address the use of side rails on the care plan. During an interview on 04/18/24, at 2:16 P.M., Licensed Practical Nurse (LPN) C said the resident had side rails and used them for mobility and transfer during cares provided by staff. 3. Review of Resident #26's face sheet showed the following: -admitted [DATE]; -Diagnoses included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), and unspecified dementia. Review of the resident's electronic record showed a Side Rail Consent Form was signed by the resident's representative on 09/08/22, indicating information regarding the risks and benefits of using a side rail of any sort was received, and the resident chose to utilize a transfer bar,1/4 rail, or 1/2 rail. Observation on 04/16/24, at 1:27 P.M., showed bilateral u-shaped grab bars in raised position on the resident's bed. Observation on 04/17/24, at 10:26 A.M., showed the resident in bed with eyes closed with bilateral u-shaped grab bars in raised position. Observation on 04/18/24, at 11:25 A.M., showed the resident in bed with bilateral u-shaped grab bars in raised position. Interview and observation on 04/18/2024, at 2:07 P.M., showed the following: -Resident in bed with bilateral u-shaped grab bars in raised position; -The resident said he/she does not use the grab bars. Review of the resident's care plan, last revised 04/01/24, showed staff did not address the use side rails on the resident's care plan. During an interview on 04/18/24, at 2:16 P.M., LPN C said the resident had side rails and used them for mobility and transfer during cares provided by staff. 4. Review of Resident #47's face sheet showed the following: -admitted [DATE]; -Diagnoses included cognitive communication deficit, presence of left artificial hip joint, and fracture of left femur. Review of the resident's electronic record showed a Side Rail Consent Form was signed by the resident's representative on 02/22/24, indicating information regarding the risks and benefits of using a side rail of any sort was received, and the resident chose to utilize a transfer bar,1/4 rail, or 1/2 rail. Interview and observation on 04/15/24, at 2:57 P.M., showed the following: -U-shaped grab bar in raised position on the left side of the bed; -The resident said he/she used the grab bar for transfer and bed mobility. Observations on 04/16/24, at 1:34 P.M., on 04/17/24, at 10:26 A.M., and on 04/18/14, at 11:25 A.M., showed the u-shaped grab bar in raised position on left side of the bed. Interview and observation on 04/18/24, at 2:05 P.M., showed the following: -U-shaped raised side grab bar on left side of the bed; -He/she uses the grab bar to get in and out of bed. Review of the resident's care plan, initiated on 02/22/24, showed staff did not care plan the use of the side rails/grab bars. 5. During an interview on 04/18/24, at 2:16 P.M., LPN C said staff should care plan all side rails. 6. During an interview 04/18/24, at 2:29 P.M., Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) Coordinator E said staff should include residents with full side rails in the care plan. He/she was unsure and needed to verify if grab bars and quarter rails should be included in the care plan. 7. During an interview on 04/18/24, at 4:22 P.M., the Director of Nursing (DON) said staff should care plan all side rails. 8. During an interview on 04/18/24, at 5:46 P.M., the Administrator said side rails should be included in the care plan.

Based on observation, interview, and record review, the facility failed to timely notify the physician, responsible party, and registered nurse on-call of a fall for one resident (Resident #41) who complained of pain and decreased mobility to his/her left hip/leg, potentially contributing to a delay in the treatment of this resident's fractured femur, out of 16 sampled residents in a facility with a census of 50. Review of the facility policy titled, Falls Management, revised December 2022, showed the following: -The facility strives to minimize the risk for resident falls and to reduce injuries associated with resident falls; -After a fall occurs the licensed nurse is to initiate the risk management event reporting process. The process is to include a physical assessment including injuries sustained including description, location, measurements, and treatment, vital signs, pain, neurological checks, are to be completed when the head comes in contact with another surface of when the fall is unwitnessed; -Fall occurrences are to be documented in the clinical record including environmental, situational, or psychological factors, location, time found, position, adaptive equipment, actions taken, and new interventions implemented; -Physician and responsible party are to be notified following a fall; -Witness statements are to be obtained including time last seen, care provided prior to fall, and resident location prior to fall -Resident statements are to be obtained, when possible; -Physician and responsible party are to be notified following a fall occurrence with documentation of notification present in the clinical record. 1. Review of Resident #41's face sheet showed: -admitted [DATE]; -Readmitted [DATE]; -A legal guardian listed as the responsible party/emergency contact #1; -Two additional emergency contacts listed with phone numbers. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/30/23, showed the following: -Moderate cognitive impairment; -Resident independent with all activities of daily living (ADL), except required substantial to maximum staff assistance with showers; -Resident ambulated without the use of an assistive device; -Resident always continent of bowel and bladder; -Resident had no falls; -Resident had no pain. Review of the resident's fall note dated 03/10/24, at 1:00 A.M., showed Licensed Practical Nurse (LPN) N documented the following: -Description of fall: While answering a call light, a certified nurse assistant (CNA) found the resident on the floor, midway into the bathroom. Resident was lying on his/her right side with his/her torso on the floor in the bathroom and his/her legs in the bedroom. Resident immediately reported left hip pain before being moved off the floor. CNA and nurse were able to lift resident off the floor and into a wheelchair. Resident was taken to the nurses' station for assessment. Resident was not able to stand long enough to remove his/her jeans for staff to view his skin due to the pain; -Resident description of fall: Resident reported he/she was going to the bathroom, and he/she slipped because, These slippers are slick; -Description of environment: Resident's room and floor were clean, clear, and unobstructed in the living quarters and bathroom; -Resident assessment: Head to toe assessment completed, range of motion (ROM) of right upper extremity (RUE), left upper extremity (LUE), and right lower extremity (RLE) was within normal limits (WNL) for the resident. The resident was not able to bear weight well or walk far on his/her left leg. The resident was not able to stand long enough to remove his/her jeans for staff to view his/her skin due to the pain. Neurological checks (an assessment conducted to determine if any neurological changes have occurred) started and were WNL. Two staff assisted the resident into a wheelchair; -Vital Signs (VS - temperature, pulse rate, blood pressure, and respiratory rate) and neurological checks stable. No new injuries or bruises noted upon assessment. The resident was not able to stand long enough to remove his/her jeans for us to view his/her skin due to the pain. The resident reported pain at a 7/10 in his/her left hip; -Injuries and interventions: The resident reported pain at 7/10 in his/her left hip. Tylenol 1000 milligram (mg) was administered to the resident. Within 30 minutes of Tylenol administration, the resident reported his pain being 3/10; -Pain and intervention: The resident reported pain at 7/10 in left hip. Tylenol 1000 milligrams (mg) was administered to resident. Within 30 minutes of Tylenol administration, resident reported his pain being 3/10. The resident declined being taken to the emergency room (ER) on three different occasions; -Fall interventions: After observing the resident at the nurse station for more than an hour, staff assisted resident to his room and helped him into his recliner. Call light was given to the resident. The resident's walker was placed in front of recliner; -Physician notification and response: via communication folder; -Responsible party notification and response: Will contact at a more appropriate time; -Administrator and Director of Nursing (DON) notification: per protocol. Review of the resident's medication administration record (MAR) note, dated 03/10/24 at 1:07 A.M., showed LPN N documented the following: -Order for Tylenol extra strength 500 mg, give 1000 mg by mouth every 6 hours as needed for unspecified pain; -Nurse administered Tylenol extra strength 500 mg two tablets to equal 1000 mg for left hip pain after fall; -Pain rating of 7 out of 10 (on a scale of 0-10, with 10 being the worst pain). Review of the resident's medication administration record (MAR) note, dated 3/10/24 at 3:25 A.M., showed LPN N documented the following: -Tylenol administration was effective; -Follow up pain scale was 3. Review of the resident's nurse note, dated 03/10/24 at 10:33 A.M. showed LPN M documented the following: -At 7:15 A.M., the nurse went down to the resident's room to evaluate the resident; -The resident was unable to bend his/her left leg at all, due to too much pain; -The resident was able to move and bend his/her right leg; -The nurse explained to the resident he/she needed to go get checked out at the hospital to evaluate his/her left leg and to get X-rays. The resident said, Okay; -At 7:20 A.M., the nurse placed a call to the resident's responsible party to give an update and to notify the facility was sending the resident to the emergency room for evaluation and X-rays of the left hip. Responsible party said he/he would meet the resident at the emergency room ; At 7:40 A.M., the ambulance arrived to transport the resident to the emergency room . Review of the resident's progress note, dated 03/15/24 at 9:56 A.M., showed Director of Nursing (DON) documented the following: -Resident reviewed due to a fall in his/her room on 03/10/24 at 12:50 A.M.; -The CNA went to answer the resident's resident call light and upon entering the room, the CNA noted resident to be sitting on the floor partially into his/her bathroom; -The CNA called for the charge nurse. Upon assessment by the charge nurse, the resident complained of left hip pain however, he/she adamantly refused to be sent to hospital for evaluation/treatment; -The CNA and nurse assisted the resident up from the floor and into a wheelchair where he/she remained one-on-one with staff immediately following the fall; -The staff obtained vital signs and initiated neurological checks; -Staff administered pain medication administered as ordered with good effect for pain control; -The charge nurse attempted to talk the resident into going to the hospital multiple times, however the resident adamantly refused, therefore resident was assisted into his/her recliner per his/her request; -Staff attempted to complete a head-to-toe skin assessment, however it was limited due to the resident's pain; -Range of motion (ROM) were within normal limits for the resident in all areas except the left hip, which was noted with limited ROM WNL during the assessment, hence the reason the charge nurse tried diligently to get the resident to agree to a hospital visit; -The resident remained in his/her recliner until the day shift nurse arrived on shift; -After shift change, the day shift nurse went to assess the resident and was able to convince him/her to go to hospital for further evaluation and treatment of possible left hip fracture; -The facility notified the resident's responsible party of the incident and of the resident being transferred to the hospital on 03/10/24 at 7:20 A.M.; -The facility notified the physician on 03/10/24 and the physician agreed with the resident being sent to the hospital; -It was noted during the initial assessment, the resident was wearing slippers on his/her feet with minimal traction on the bottom, when asked where the slippers came from the resident was unable to tell staff; -Staff removed the resident's slippers from his/her room and provided education to the family related to proper footwear for added safety during transfers/ambulation. Review of Nurse Practitioner (NP) G's visit note, dated 03/21/24, showed, in part, the following: -The resident had a recent left hip surgery at the hospital for a broken hip after a fall on 03/10/24; -The resident returned to the facility on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed: -Diagnosis of non-displaced intertrochanteric (directly below the hip joint) fracture of left femur (upper leg bone) with subsequent encounter for closed fracture with routine healing; -Dependent on staff for toileting hygiene, lower body dressing; -Required substantial or maximum assistance with transfers; -Used a wheelchair for mobility device; -Occasionally incontinent of bowel and bladder; -Sustained 2 falls since admission, non-injury. Review of the resident's care plan, revised on 03/28/24, showed: -Resident at risk for falls; -Staff to encourage the resident to change positions slowly; -Education provided to staff to offer to assist the resident to bed after dinner for added safety; -Resident had limitations on his/her left side, please place items on the right side of his/her bed/chair; -Staff to place commonly used items within the resident's reach; -Resident to use handrails to assist with ambulation; -Resident to wear appropriate shoes and non-slip footwear; -Resident to use a walker to assist with walking; -Ensure the call light is within reach and encourage the resident to use it to ask for assistance; -Please inform the resident's family and physician of changes in his/her status; -Please make sure the pathway in the resident's room remains clean and unobstructed. Observation on 04/16/24 at 10:20 A.M. and at 2:25 P.M., showed: -The resident sat in a recliner in his/her room, watching television; -The resident wore a pair of tennis shoes on his feet; -The resident showed no obvious signs of distress. During an interview on 04/17/24 at 11:40 A.M., LPN C said the following: -If a resident fell , he/she would perform a head-to-toe assessment for injuries; -If the resident did not complain of hip pain, he/she would check for any abnormal internal or external rotation or shortening of the legs and see if the resident was able to move the extremity; -If he/she observed any issues or complaints of hip pain, he/she would immediately contact the resident's physician to notify of the resident fall, condition, ask about an X-ray order. During an interview on 04/17/24 at 1:32 P.M., Certified Medication Technician (CMT) J said the following: -On 3/10/24, he/she arrived to work at approximately 6:00 A.M.; -When the day nurse arrived, he/she immediately went to the resident's room, assessed the resident, and sent the resident out via ambulance to the emergency room for evaluation. During a phone interview on 04/17/24 at 2:26 P.M., Licensed Practical Nurse (LPN) M said the following: -He/she worked day shift (7:00 A.M. to 7:00 P.M.) at the facility as the charge nurse; -He/she worked on the morning of 03/10/24, upon arrival to work, the night nurse reported the resident fell during the night; -The night nurse reported after assessing the resident, he/she refused to go to the emergency room ; -Both nurses went to the resident's room; -The day nurse asked the resident if he/she could lift his/her leg, but he/she could not; -The day nurse told the resident he/she needed to go to the hospital and the resident agreed to go. During an interview on 04/18/24 at 9:59 A.M., Director of Nursing (DON) said the following: -The resident was able to walk prior to the fall on 3/10/24; -If a resident had a fall with injury, the nurse on duty should have immediately notified the physician and the resident's responsible party or next of kin; -According to the resident's fall report, the facility notified the resident's responsible party and 7:20 A.M. of the resident's fall. During a phone interview on 04/18/24 at 12:14 P.M., LPN N said the following: -After the resident fell on [DATE], the resident expressed pain and guarding (behavior that is aimed at preventing or alleviating pain) of his/her left side. The resident would not bear weight on his/her left leg or move his/her left leg; -Staff assessed the resident's vital signs (VS, temperature, pulse rate, blood pressure, and respiratory rate) and the nurse performed a quick visual assessment of the resident; -The resident showed no obvious deformities or shortening of his/her legs, so staff assisted the resident up into a wheelchair and brought the resident out to nurse's desk due to the resident insistence on getting up and drinking coffee; -The nurse administered Tylenol and the resident showed some improvement in pain; -The nurse planned to send the resident out to the emergency room due to concerns of the resident guarding and not wanting to move his/her left leg; -The nurse asked, but the resident refused to go to the emergency room three times; -The nurse did not call the physician about the resident's fall and assessment, but he/she did contact the on-call registered nurse (RN). The nurse (LPN N) said he/she was unsure who that on-call RN was that night; -The next morning, the day shift nurse came in and the day shift nurse notified the resident's family of the fall and injury and the resident agreed to go to the emergency room for evaluation; -It is normally the responsibility of the on-call RN to notify the resident's physician; -He/she did not speak to the physician; -On the morning of 3/10/24, the day nurse assessed the resident, and he/she did not want to bear weight on his/her right leg and did not want to move his/her right leg, so the day nurse notified the resident's responsible party and the resident agreed to go to the hospital; -The nurse (LPN N) said he/she thought the day nurse or on-call RN notified the resident's physician, but the nurse was unsure. During an interview on 04/18/24 at 1:02 P.M., the resident's nurse practitioner (NP) G said the following: -He/she would expect the facility to call the resident's physician after a fall with hip pain and limited range of motion to that extremity as soon as possible after the fall. During an interview on 04/18/24 at 3:20 P.M., the DON said the following: -The DON spoke with the resident's physician and the physician recalled the DON notified him/her of the resident's fall on 03/10/24, sometime after staff sent the resident out to the hospital, but could not recall an exact time; -The charge nurses should contact the on-call registered nurse (RN), and then the RN directs the charge nurse on what they need to do after a fall, before they contact the resident's physician; -If the charge nurse working the night of the fall had contacted the DON, he/she would have instructed the charge nurse to call and notify the resident's physician; -The physician's expectation was for the facility to contact him within 24 hours after a fall; -In this situation, the night nurse or the on-call RN should have notified the resident's physician and family. The DON did not feel the way in which the nurse handled the fall follow-up was an issue and therefore he/she did not conduct an investigation after the fall; -He/she assumed the on-call RN, which was the ADON, educated the night nurse about not contacting the resident's physician; -The DON did not follow-up with the ADON to ensure he/she provided education to the night nurse regarding not notifying the resident's physician or responsible party; -The DON should have followed up with the ADON to ensure he/she educated the night nurse on the need to timely notify the resident's physician and responsible party; -The ADON and the day shift charge nurse sent the resident out to the hospital that morning after the fall. During an interview on 04/18/24 at 4:03 P.M., Administrator said the following: -The nurse should notify a resident's physician of a resident fall within 24 hours per the physician's protocol, but some of it is a case-by-case basis; -The night nurse should have called the DON, if he/she suspected a resident injury and then go from there; -The night nurse probably should have called the resident's physician before sending the resident out to the hospital; -The night nurse should have notified the resident's responsible party and the earliest possible time. During an interview on 4/25/24 at 9:25 A.M., Assistant Director of Nursing (ADON) said the following: -He/she was the RN on-call for the facility on the night of 03/09/24-03/10/24; -The night nurse, LPN N, did not contact the ADON immediately after the resident's fall, as was the expectation of the facility; -The night nurse waited to contact the ADON until approximately 6:00 A.M., via text message and the message did not name a resident. The message read a resident slipped on the floor due to sick slippers and his/her left hip was sore and he was refusing to go to the hospital; -The ADON arrived at work within an hour, obtained report, and went to the resident's room along with LPN M, the day nurse, to assess the resident. The resident could not move his/her left leg at all and complained of pain to the leg. The nurse told the resident he/she needed to go to the hospital because the nurse suspected the resident cold have fractured a bone in his/her leg/hip. The resident agreed to go to the hospital; -Afterwards, the ADON educated the night nurse, LPN N, regarding the need to contact the RN on-call and the resident's responsible party immediately after a fall, if the nurse suspected serious injury/fracture; -The ADON said he/she asked why staff assisted the resident into a wheelchair and brought the resident to the nurse station after the fall and LPN N said for closer monitoring and assessment of the resident; -The facility physician preferred not to be contacted during the night, if the facility RN determined a resident needed to go to the hospital. The facility would typically send a resident to the hospital and notify the physician the following morning. This was not written policy, but was the physician's preference.

Based on interview and record review, the facility failed to notify and coordinate with the State-designated authority following newly evident or serious mental illness for one resident (Resident #51) who had a negative Level I Preadmission Screening and Resident Review (PASARR - Level I is administered to determine if a PASARR Level II (an in-depth evaluation and determination of an individual by a Medicaid-certified nursing facility, evaluation is needed prior to admission for possible serious mental disorders, intellectual disabilities and related conditions to ensure that residents identified receive care and services in the most integrated setting appropriate to their needs)). The facility census was 50. Review showed the facility did not provide a policy regarding PASARR requirements. Review of the Missouri Department of Health and Senior Services web-site showed the following: -The PASARR is a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment. The screening assures appropriate placement of persons known or suspected of having a mental impairment(s) and also that the individual needs of mentally impaired persons can be and are being met in the appropriate placement environment. 1. Review of DHSS Licensure Records show all the facility beds are dually certified for Medicaid and Medicare. Review of Resident #51's Level I Nursing Facility PASARR, dated 02/02/24, showed the following information: -Does not show any signs of symptoms of major mental disorder; -Had not been diagnosed as having a major mental disorder; -Primary reason for nursing facility placement not due to a mental illness; -Does not have any areas of impairment due to serious mental illness; -Had not received intensive psychiatric treatment in the past two years; -Not known or suspected to have mental retardation that originated prior to age 18; -Not known or suspected to have a special admission condition. Review of resident's current face sheet (gives basic profile information at a glance) showed the following information: -admitted [DATE]; -Admission diagnoses included recurrent depressive disorders, nicotine dependence, and psychosis not due to a substance or known physical condition; -Diagnosis, dated 02/05/24, of schizophrenia (mental disorder including symptoms of delusions, hallucinations, and disorganized thinking/speech); -Diagnosis, dated 02/07/24, of cognitive communication deficit. Review of the resident's medical record showed staff did not refer the resident after a significant change in status for additional PASARR review. During an interview on 04/18/24, at 12:20 P.M., the Business Office Manager (BOM) said nursing staff screen any potential residents for admission and placement at the facility. Review will be completed of the PASARR Level I screening by the referring agency. The nursing staff will add any additional diagnoses or clarification of resident care needs to the extended portion of the screening form. The nursing staff should request a new PASARR screening only if resident has Medicaid as a payor source. If a resident does not have Medicaid as a payor source, the nursing staff complete the screening form, but do not summit the form for further determination is needed. The screening form will remain in the resident's file if there is a question of benefits. Based on the screening conducted prior to admission with the diagnosis of schizophrenia with behaviors the the resident should have been resubmitted for further review of their PASARR Level I screen. During an interview on 04/18/24, at 2:40 P.M., the Infection Control Nurse said the facility nursing staff review all Level I PASARR screens received for any possible facility admission. She completes the nursing facility portion of the form and places it the resident file. Re-submission of the PASARR is only done if the BOM requests for payment source. She has no knowledge of who is required to have the Level II screen, but completes the skill level screening to determine additional care needs and provide a skill level score if one is required to be submitted. She stated that the resident's diagnosis of schizophrenia and increased level of care was not indicated on the screen received prior to admission and would indicate changes on the resident's care needs. During an interview on 04/18/24, at 3:22 P.M., the Director of Nursing (DON) said all residents are screened for the Level I PASARR prior to admission. The BOM is provided a confirmation code of the resident's submission and determines if the form should be resubmitted based on their payment source. The Infection Prevention Nurse completes the additional nursing facility portion of the application and keeps this in the resident's file. It is only submitted if it was requested. The resident's Level I screen was missing screening information and should have been submitted based on his/her schizophrenia diagnosis and increase level of care needs. This should have been completed due to the resident being admitted to a certified nursing bed and not due the residents payor source. During an interview on 04/18/24, at 06:05 P.M., the Administrator said he was not familiar with the PASARR screening requirements until the current certification survey. Based on discovery of incomplete resident information submitted on the prior screening form, the facility staff should have resubmitted the Level I screen for determination of eligibility regardless of payor source for a certified facility admission.

Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when when staff failed to clean/maintain the toilet riser in one resident's (Resident #29) bathroom. The facility census was 50. Review of the facility's policy titled, Housekeeping, Laundry and Maintenance, undated, showed staff to clean all resident bathrooms daily and provide emergency cleaning as need arises. 1. Review of Resident #29's face sheet (admission data), dated 04/18/24, showed an admitted [DATE]. Review of the resident's Care Plan, dated 03/31/24, showed the following: -Cognitive skills intact; -Independent with decision making; -Required staff assistance with activities of daily living (ADL) due to limitations. Observations on 04/14/24, at 4:28 P.M., and on 04/16/24, at 10:08 A.M., of the resident's bathroom showed the resident's toilet riser over the facility stool with six layers of curling non-adhered duct tape and a brown fecal-like substance on or around the duct tape. The adhered duct tape attached a clear sheet of plastic from the riser and allowed the end of the plastic to fall into the toilet bowl water. There was a brown fecal like substance on the clear sheet of plastic. A brown fecal-like substance was present on the back of the riser in the center of the circular opening to the riser. During interviews on 04/16/24, at 10:00 A.M., and on 04/17/24, at 9:00 A.M., Housekeeper A said the following: -Staff clean the residents' rooms daily. The cleaning included the floors, toilets, and sinks. If a toilet riser is present, they should move it out and clean behind it and the toilet riser; -The duct tape is removed daily and adhesive scraped off daily with a scraping tool. Replacement duct tape and plastic are in the storage closet; -Housekeeper B clean's the resident's room at the resident's request. During an interview on 04/17/24, at 9:30 A.M., Housekeeper B said that the resident will not allow him/her to change the duct tape or the plastic in the bathroom. He/she sprays it with a cleaning solution and wipes it down the best he/she can. The Housekeeping Supervisor was aware of the resident not allowing the riser to be cleaned correctly. They have never changed the duct tape or the plastic sheeting when cleaning the bathroom. During an interview on 04/17/24, at 10:00 A.M., the Housekeeping Supervisor said she is aware of the resident not allowing the staff to remove the duct tape or plastic sheeting so they can clean the riser properly. She instructed her staff to spray it with a disinfectant and do the best that they can. During an interview on 04/18/24, at 10:20 A.M. the Administrator said he has spoken to resident # 29 on multiple occasions about how the staff need to change the duct tape and plastic regularly, but that he/she is not responsive to it. 33187

Based on interview, and record review, the facility failed to promote self-determination of all residents when staff failed to work with one resident (Resident #27) who requested a room change due to conflict with a roommate. A sample of 16 residents was reviewed in a facility with a census of 50. Review of the facility form titled, Resident Rights, undated, showed the following: -The facility shall ensure that each resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility shall protect and promote the rights of each resident as set forth in the following standards; -The sharing of personal space will only be by agreement of each resident. When this is not acceptable, each resident will be given the choice of another person with whom to share space, if available, or a private room at established private room rates. 1. Review of Resident # 27's current face sheet showed: -admitted [DATE]; -Readmitted [DATE]; -Diagnoses included depression. Review of the resident's care plan, dated 03/12/21, showed the following: -The resident had mood/behavior and psychosocial problems. He/she can be manipulative, passive/aggressive, and attention seeking at times; -Resident has been known to make grandiose statements and false accusations at times due to fluctuations in his/her cognition; -Resident has been known to make inappropriate sexual comments towards staff at times; -Staff to monitor behavior episodes and attempt to determine underlying cause. Review of the resident's quarterly Minimum Data Set (MDS - a federally-mandated assessment tool completed by facility staff), dated 02/10/24, showed the following: -Cognitively intact; -No verbal or physical behavioral symptoms directed toward others; -No hallucinations or delusions. Review of the resident's social service progress note dated 02/20/24, at 2:53 P.M., showed the Social Service Designee (SSD) documented the following: -The SSD called the resident's responsible party on 02/20/24 to ask if it was okay to move the resident to a different room for now. If the resident liked the move, staff might leave the resident in the room. The resident's move was due to his/her roommate having a lot of family coming and going. The resident's responsible party said he/she was good with the room change, if the resident was good with the move. Staff asked the resident, and he/she was good with changing rooms as long as his/her television would also be moved. Review of the resident's room census showed: -On 02/22/24, staff moved the resident into a room with Resident #39; -On 02/26/24, staff moved the resident to a different room; -On 03/04/24, staff moved the resident back into the room with Resident #39. Review of a resident's behavior note dated 03/12/24, at 3:06 A.M., showed Licensed Practical Nurse (LPN) F documented the following: -Resident yelling at roommate calling him/her, A bitch; -Resident angry over the temperature in the room and the bedroom door being shut; -Unit turned down and the door cracked. Review of the resident's behavior note dated 03/17/24, at 1:09 P.M., showed LPN F documented the following: -Resident hit his/her light and when this nurse answered it. The resident told this nurse that he/she wanted everything in the room turned off. The resident's roommate was still awake watching television. This nurse asked the roommate if he/she could turn the television down a little bit. The roommate said that was fine. The nurse turned the television down and the resident started screaming, That's not what I want I want it all shut the fuck off so I can go to sleep. The nurse explained he/she could not turn the roommate's things off until the roommate was ready to go to bed. The resident began screaming and cursing at the roommate, initiating the roommate to start screaming and cursing at the resident; -Resident is requesting to move to another room. During interviews on 04/16/24, at 2:25 P.M., and on 04/18/24, at 8:54 A.M., the resident said the following: -He/she does not get along with his/her roommate, Resident #39; -They argue with one another daily; -Resident #39 is bossy with the resident; -He/she has been telling staff of wanting to move away from his/her current roommate (Resident #39) because the roommate tries to control everything and butts into Resident #27's conversations; -The two residents argue with one another and do not get along with one another. During an interview on 04/17/24, at 8:54 A.M., the resident's responsible party said the following: -The resident was very set in his/her ways; -The resident and his/her roommate, Resident #39, did not get along with one another; -They mostly just aggravated one another; -The facility decided the resident and Resident #39 were so much alike, they would just keep them together in the same room; -The responsible party said he/she did not necessarily think that was a good idea, but he/she went along with the facility's plan to place the two residents back in the same room together. 2. Review of the Resident #39's face sheet showed the following: -admitted [DATE]; -Diagnoses included severe dementia and depression. Review of the resident's care plan, revised on 02/05/24, showed the following: -Behaviors included crying, sadness, self-isolation, anxiety, yelling, physical aggression, delusions (misconceptions or beliefs that are firmly held, contrary to reality), disorganized thinking, and inattention; -Deficit in cognitive functioning characterized by deficit in memory, judgement, decision making, and thought process related to dementia; -Report to the nurse and/or physician of any note changes in the resident's behavior/cognitive status. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Mildly impaired cognitive function; -No verbal or physical behavioral symptoms directed toward others; -No hallucinations or delusions. Review of the resident's social service progress note dated 02/20/24, at 2:25 P.M., showed the following: -SSD called the resident's responsible party and asked if he/she was okay with moving another resident into the room with the resident and the responsible party said it was good with him/her. Review of the resident's behavior note dated 03/12/24, at 3:09 A.M., showed LPN F documented the following: -Resident yelling at roommate calling him/her A bitch; -Resident angry about roommate not wanting the room too warm and the door to be shut, so resident screaming at the roommate; -Temperature turned down a little and door cracked. Review of the resident's behavior note dated 03/12/24, at 10:25 P.M., showed LPN F documented the following: -Resident screaming and cursing at roommate because roommate stated it was too hot in the room and requested the nurse to turn the heat down a little bit. When the nurse went to turn the heat down, the heat was at 82 degrees Fahrenheit (F). The nurse turned the heat down a few degrees and the resident started screaming at the roommate, calling the roommate, a fucking dumb bitch telling the roommate to, Shut the fuck up about the temp in the room. 3. During an interview on 04/17/24, at 11:40 A.M., LPN C said the following: -Resident #27 and Resident #39 do not get along well with one another; -Their biggest issue is the television volume. The facility had provided both residents with headsets, but the residents refuse to wear these headsets; -When the resident had issues with one another, he/she usually assisted the residents in working out a compromise; -He/she never heard the two residents curse one another, but other nurses have reported the residents cursing and yelling at one another; -If he/she observed cursing and yelling, he/she would separate the residents, notify the Director of Nursing (DON), and call the residents' responsible parties; -In the past, on the night shift, Resident #27 and Resident #39 were reportedly arguing with one another and LPN F moved Resident #27 into a different room, but the DON had staff move Resident #27 back into the room with Resident #39 a few days later; -He/she was unsure why the DON had staff move the residents back in together. 4. During an interview on 04/17/24, at 2:13 P.M., LPN F said the following: -He/she worked full time on the night shift (7:00 P.M. - 7:00 A.M.); -Resident #27 and Resident #39 had verbal issues with one another, just heated arguments; -The residents curse at one another over the heat and air conditioner, the television, the curtains, and the lights; -At one point, the residents had a heated argument and LPN F contacted the DON and moved Resident #27 to the next room at the resident's request; -Within a few days, the facility moved Resident #27 back in with Resident #39 after discussing the decision with each resident's responsible party; -He/she asked the day shift staff why the two residents were moved back in together and the day shift staff said the residents were moved back in together because they were not able to physically abuse one another. 5. During an interview on 04/17/24, at 3:15 P.M., Certified Nurse Assistant (CNA) H said the following: -Resident #27 and Resident #39 had days they argued in raised voices. The arguments were generally over the television volume, but he/she had not heard the residents cursing at one another. 6. During an interview on 04/18/24, at 11:49 A.M., CNA I said the following: -Resident #27 and Resident #39 disagree over the room temperature and occasionally curse and yell at one another, but neither resident are upset by the disagreements. 7. During an interview on 04/18/24, at 9:20 A.M., SSD said the following: -In the past, Resident #39 frequently cursed and yelled at Resident #27 when Resident #27 turned the television on in the room; -SSD talked with the residents when they had issues with one another and the SSD could generally resolve their arguments; -The residents cursed and yelled at one another in the very beginning when the two first became roommates; -Since the two were temporarily separated and then placed back together, they no longer argue with one another; -The DON wanted to move the two residents back together, because Resident #27's other roommate passed away and the DON wanted to keep the other resident room vacant for possible admissions. 8. During an interview on 04/18/24, at 1:02 P.M., Nurse Practitioner (NP) G said the following: -If two residents were not getting along with one another, the facility staff need to talk to the residents and move them to different rooms; -In the past when roommates had issues, the residents tell staff and staff move the residents to separate rooms. 9. During interviews on 04/17/24, at 8:44 A.M., and on 04/18/24, at 9:59 A.M. and 3:20 P.M., the DON said the following: -Resident #27 and Resident #39 were having issues getting along over room temperature and the television, so one of the nurses moved Resident #27 into another room; -The DON subsequently met with both residents' responsible party, and the responsible parties for each resident spoke with their respective resident; -Staff then moved Resident #27 back in the room with Resident #39 because Resident #27's other roommate discharged from the facility and Resident #27 could not afford a private room; -The residents started getting along better, once they realized they needed to get along with each other; -The residents agreed to move back in together; -Neither of the residents are the nicest, but the facility tried different roommates in the past and Resident #39 did not get along with anyone; -The DON said there was no reason not to move the residents back in together because they act like siblings and will eventually get along with each other; -The DON said he/she thought the responsible parties for both residents knew that neither resident really wanted a roommate, but either would not or could not pay for a private room. The families said if he residents were not going to get along with anyone to put the two back together in the same room; -The nurse did not notify the DON the residents were cursing and yelling at one another. The nurse told the DON the resident was yelling at the nurse; -If the nurse notified the DON the residents were cursing and yelling at one another, the DON would have instructed the nurse to separate the residents; -He/she could offer another available room to Resident #27 at this time. During an interview on 04/18/24, at 4:03 P.M., the Administrator said the following: -Resident #27 and Resident #39 both have a negative attitude, in general, and have had disagreements with each other over the television; -Neither of the residents wanted a roommate, but neither can afford a private room; -The Administrator was told at a morning meeting of the department heads that neither of the residents wanted a roommate; -The Administrator was not aware Resident #27 and Resident #39 were yelling at and cursing one another; -Nursing staff told the Administrator the residents were mad at nursing staff and the yelling was directed at the staff; -If the residents were yelling and cursing at one another, he/she expected staff to immediately de-escalate the situation, remove one of the residents from the room, and notify the DON and the Administrator; -The Administrator would then contact the Regional Director for further guidance; -The Administrator said the common sense approach would be find different roommates for the residents.

Based on interview and record review, the facility failed to immediately notify the physician and responsible party of a fall with injury for one resident (Resident #41) out of 16 sampled residents in a facility with a census of 50. Review of the facility policy titled, Falls Management, revised December 2022, showed the following: -After a fall occurs the licensed nurse is to initiate the risk management event reporting process. The process is to include a physical assessment; -Physician and responsible party are to be notified following a fall; -Physician and responsible party are to be notified following a fall occurrence with documentation of notification present in the clinical record. 1. Review of Resident #41's face sheet showed: -admitted [DATE]; -Readmitted [DATE]; -A legal guardian listed as the responsible party/emergency contact #1; -Two additional emergency contacts listed with phone numbers. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/30/23, showed the following: -Moderate cognitive impairment; -Resident ambulated without the use of an assistive device; -Resident had no falls; -Resident had no pain. Review of the resident's fall note dated 03/10/24, at 1:00 A.M., showed Licensed Practical Nurse (LPN) N documented the following: -While answering a call light, a certified nurse assistant (CNA) found the resident on the floor, midway into the bathroom. Resident was lying on his/her right side with his/her torso on the floor in the bathroom and his/her legs in the bedroom. Resident immediately reported left hip pain before being moved off the floor. CNA and nurse were able to lift resident off the floor and into a wheelchair. Resident was taken to the nurses' station for assessment. Resident was not able to stand long enough to remove his/her jeans for staff to view his skin due to the pain; -The resident was not able to bear weight well or walk far on his/her left leg. The resident was not able to stand long enough to remove his/her jeans for staff to view his/her skin due to the pain; -The resident reported pain at a seven out of ten in his/her left hip; -Within 30 minutes of Tylenol administration, the resident reported pain of three out of ten; -The resident declined being taken to the emergency room (ER) on three different occasions; -Physician notification and response: via communication folder; -Responsible party notification and response: Will contact at a more appropriate time; -Administrator and Director of Nursing (DON) notification: per protocol. (Staff did not document immediate notification of the resident's physician and responsible party of the fall with injury.) Review of the resident's nurse note dated 03/10/24, at 10:33 A.M., showed LPN M documented the following: -At 7:15 A.M., the nurse went down to the resident's room to evaluate the resident; -The resident was unable to bend his/her left leg due to too much pain; -The resident was able to move and bend his/her right leg; -The nurse explained to the resident he/she needed to go get checked out at the hospital to evaluate his/her left leg and to get X-rays. The resident said, Okay; -At 7:20 A.M., the nurse placed a call to the resident's responsible party to give an update and to notify the facility was sending the resident to the emergency room for evaluation and X-rays of the left hip. The responsible party said he/he would meet the resident at the emergency room ; -At 7:40 A.M., the ambulance arrived to transport the resident to the emergency room . (Staff did not document physician notification of the fall with injury. Staff notified the resident's responsible party over six hours after the fall occurred.) Review of the resident's progress note dated 03/15/24, at 9:56 A.M., showed the Director of Nursing (DON) documented the following: -Resident reviewed due to a fall in his/her room on 03/10/24 at 12:50 A.M.; -The CNA went to answer the resident's resident call light and upon entering the room, the CNA noted resident to be sitting on the floor partially into his/her bathroom; -The CNA called for the charge nurse. Upon assessment by the charge nurse, the resident complained of left hip pain however, he/she adamantly refused to be sent to hospital for evaluation/treatment; -Staff administered pain medication administered as ordered with good effect for pain control; -The charge nurse attempted to talk the resident into going to the hospital multiple times, however the resident adamantly refused; -Staff attempted to complete a head-to-toe skin assessment, however it was limited due to the resident's pain; -After shift change, the day shift nurse went to assess the resident and was able to convince him/her to go to hospital for further evaluation and treatment of possible left hip fracture; -The facility notified the resident's responsible party of the incident and of the resident being transferred to the hospital on 03/10/24 at 7:20 A.M. (over six hours after the fall with injury occurred); -The facility notified the physician on 03/10/24 and the physician agreed with the resident being sent to the hospital. Review of Nurse Practitioner (NP) G's visit note, dated 03/21/24, showed the following: -The resident had a recent left hip surgery at the hospital for a broken hip after a fall on 03/10/24; -The resident returned to the facility on [DATE]. During an interview on 04/18/24, at 12:14 P.M., LPN N said the following: -After the resident fell on [DATE], the resident expressed pain and guarding (behavior that is aimed at preventing or alleviating pain) of his/her left side. The resident would not bear weight on his/her left leg or move his/her left leg; -The resident showed no obvious deformities or shortening of his/her legs, so staff assisted the resident up into a wheelchair and brought the resident out to nurse's desk due to the resident insistence on getting up and drinking coffee; -The nurse administered Tylenol and the resident showed some improvement in pain; -The nurse planned to send the resident out to the emergency room due to concerns of the resident guarding and not wanting to move his/her left leg; -The nurse asked, but the resident refused to go to the emergency room three times; -The nurse did not call the physician about the resident's fall and assessment; -The next morning, the day shift nurse came in and the day shift nurse notified the resident's family of the fall and injury and the resident agreed to go to the emergency room for evaluation; -It is normally the responsibility of the on-call RN to notify the resident's physician; -He/she did not speak to the physician; -On the morning of 3/10/24, the day nurse assessed the resident, and he/she did not want to bear weight on his/her right leg and did not want to move his/her right leg, so the day nurse notified the resident's responsible party and the resident agreed to go to the hospital; -The nurse (LPN N) said he/she thought the day nurse or on-call RN notified the resident's physician, but the nurse was unsure. During an interview on 04/17/24, at 11:40 A.M., LPN C said the following: -If a resident fell , he/she would perform a head-to-toe assessment for injuries; -If the resident did not complain of hip pain, he/she would check for any abnormal internal or external rotation or shortening of the legs and see if the resident was able to move the extremity; -If he/she observed any issues or complaints of hip pain, he/she would immediately contact the resident's physician to notify of the resident fall, condition, and ask about an X-ray order. During an interview on 04/25/24, at 9:25 A.M., the Assistant Director of Nursing (ADON) said the following: -He/she was the RN on-call for the facility on the night of 03/09/24 to 03/10/24; -The night nurse, LPN N, did not contact the ADON immediately after the resident's fall, as was the expectation of the facility; -The night nurse waited to contact the ADON until approximately 6:00 A.M., via text message and the message did not name a resident. The message read a resident slipped on the floor due to sick slippers and his/her left hip was sore and he was refusing to go to the hospital; -The ADON arrived at work within an hour, obtained report, and went to the resident's room along with LPN M, the day nurse, to assess the resident. The resident could not move his/her left leg at all and complained of pain to the leg. The nurse told the resident he/she needed to go to the hospital because the nurse suspected the resident cold have fractured a bone in his/her leg/hip. The resident agreed to go to the hospital; -The LPN needed to contact the RN on-call and the resident's responsible party immediately after a fall, if the nurse suspected serious injury/fracture; -The facility physician preferred not to be contacted during the night, if the facility RN determined a resident needed to go to the hospital. The facility would typically send a resident to the hospital and notify the physician the following morning. This was not written policy, but was the physician's preference. During an interview on 04/18/24, at 1:02 P.M., the resident's Nurse Practitioner (NP) G said he/she would expect the facility to call the resident's physician after a fall with hip pain and limited range of motion to that extremity as soon as possible after the fall. During interviews on 04/18/24, at 9:59 A.M. and 3:20 P.M., the DON said the following: -The resident was able to walk prior to the fall on 03/10/24; -If a resident had a fall with injury, the nurse on duty should have immediately notified the physician and the resident's responsible party or next of kin; -According to the resident's fall report, the facility notified the resident's responsible party and 7:20 A.M. of the resident's fall; -The DON spoke with the resident's physician and the physician recalled the DON notified him/her of the resident's fall on 03/10/24, sometime after staff sent the resident out to the hospital, but could not recall an exact time; -The charge nurses should contact the on-call registered nurse (RN), and then the RN directs the charge nurse on what they need to do after a fall, before they contact the resident's physician; -If the charge nurse working the night of the fall had contacted the DON, he/she would have instructed the charge nurse to call and notify the resident's physician; -The physician's expectation was for the facility to contact him within 24 hours after a fall; -In this situation, the night nurse or the on-call RN should have notified the resident's physician and family. During an interview on 04/18/24, at 4:03 P.M., the Administrator said the following: -The nurse should notify a resident's physician of a resident fall within 24 hours per the physician's protocol, but some of it is a case-by-case basis; -The night nurse should have called the DON, if he/she suspected a resident injury and then go from there; -The night nurse probably should have called the resident's physician before sending the resident out to the hospital; -The night nurse should have notified the resident's responsible party and the earliest possible time.

Based on observation, interview and record review, the facility failed to perform wound care following professional standard of practice and in manner to prevent possible contamination of the wound when staff failed to following infection control practices, including appropriate handwashing, during the wound care treatment for two residents (Resident #1 and Resident #2). The facility census was 54. Review of the facility policy, Handwashing, undated, showed the following: -Hands must be washed in such a manner as to decrease the transmission of pathogenic organisms. Hands should be washed carefully for at least 15 seconds; -After caring for one resident and before caring for the next resident; -Before and after any resident care; -Before and after all procedures such as doing dressings and treatments; -Employees should refer to the CDC (Centers for Disease Control and Prevention) hand hygiene guidelines for the proper handwashing procedure; -Staff must wash their hands on entering and before leaving a room. Review of the CDC.gov website, showed Hand Hygiene Guidance to include the following: -Healthcare personnel should use an alcohol-based rub or wash with soap and water for the following clinical indications; -Immediately before touching a patient; -Before moving from work on a soiled body site to a clean body site on the same patient; -After touching a patient or the patient's immediate environment; -After contact with blood, body fluids, or contaminated surfaces; -Immediately after glove removal; -Healthcare facilities should: -Ensure that healthcare personnel perform hand hygiene with soap and water when hands were visibly soiled; -Ensure that supplies necessary for adherence to hand hygiene were readily accessible in all areas where patient care was being delivered; -Unless hands were visibly soiled, an alcohol-based hand rub was preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. 1. Review of Resident #1's face sheet (admission information) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease that blocks air flow and makes it difficult for one to breathe), cerebral infarction (stroke - when blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), iron-deficiency anemia (the blood doesn't have enough healthy red blood cells and leads to reduced oxygen flow to the body's organs), sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), peripheral vascular disease (the reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), embolism (a blocked artery caused by a foreign body, such as a blood clot or an air bubble), and thrombosis (a blood clot within blood vessels that limits the flow of blood). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 09/16/23, showed the following: -Five venous (a wound on the leg or ankle caused by abnormal or damaged veins) and arterial ulcers (painful, deep sore or wound in the skin of the lower leg or foot) present; -Application of nonsurgical dressings (with or without topical medications) other than to feet; -Application of treatments/medications other than to feet. Review of the resident's October 2023 Physician's Orders showed the following: -An order, dated 10/17/23, for staff to cleanse the left leg areas with wound cleanser, apply Santyl (prescription medication that removes dead tissue from wounds so they can start to heal) and hydrofera blue (a silicon, adhesive border dressing foam applied to the wound bed), cover with ABD (large gauze pad used to absorb heavily draining wounds) and wrap with gauze wrap and ace wrap daily. Observations on 10/18/23, 9:45 A.M., showed the following: -Licensed Practical Nurse (LPN) A removed supplies from the treatment cart and entered the resident's room. The resident was in bed; -Without washing or sanitizing hands, LPN A applied gloves (possibly contaminating the gloves) and placed the wound dressing supplies on the resident's bedside table (possibly contaminating the dressing supplies); -LPN A went back to the treatment cart and got an ABD dressing; -Without washing or sanitizing hands, LPN A put on gloves (possibly contaminating the gloves) and pulled back the sheet from the resident's lower left leg, removed the resident's gauze wrap and soiled dressings, and put them in the resident's trash can (contaminating the LPN's gloves); -Without removing gloves or performing hand hygiene, LPN A cleansed the wounds with wound cleanser and gauze (potentially introducing contamination into the wound); -LPN A removed his/her gloves and threw them in the trash can; -The LPN went to the treatment cart in the hall to get more clean dressings and put on another pair of gloves, without washing or sanitizing his/her hands; -LPN A performed the treatment on the resident's lower left leg (potentially contaminating the wound), removed his/her gloves, and without washing or sanitizing his/her hands, initialed and dated the gauze. The LPN then wrapped the ace bandage over the dressings. He/she put the resident's long black sock over top the dressings. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), Type II diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose), and chronic kidney disease. Review of the resident's annual MDS, dated [DATE], showed the resident had an indwelling suprapubic catheter (tube surgically inserted into the bladder through the abdominal wall that drains urine). Review of the resident's current care plan, undated, showed the following: -Alteration in skin integrity related to self-inflicted trauma wound to abdomen; -Have history of scratching abdomen, specifically around the naval and dressing covering the suprapubic catheter site, causing self-inflicted wounds. Review of the resident's October 2023 Physician's Orders showed the following: -An order, dated 10/17/23, for staff to cleanse the left abdomen areas with wound cleanser and apply fibercol (a sterile, soft, absorbent wound dressing) and cover with super absorbent dressing every day. Observation on 10/18/23, at 10:05 A.M., showed the following: -LPN A entered the resident's room with dressing supplies; -LPN A went to the sink and quickly washed hands and put on gloves; -LPN A went to by the resident's bed, touched his/her own face and then the resident's sheets (contaminating his/her hands), and then put on his/her gloves (potentially contaminating the gloves); -LPN A removed one right hand glove, went to the treatment cart to get a pair of scissors for the treatment with the uncovered right hand; -The LPN A reentered the room, put on the right glove and removed the resident's dressing with heavy dark drainage from the resident's abdomen. (The LPN did not perform hand hygiene before regloving, potentially contaminating the glove); -Without performing hand hygiene, LPN A cleansed the resident's abdominal wound with gauze and wound cleanser (potentially introducing contaminates); -LPN A removed his/her gloves and without washing or sanitizing hands and put on a new pair of gloves. The LPN applied the dressing (with the potentially contaminated gloves); -LPN A removed his/her gloves, did not wash or sanitize his/her hands, and then taped another absorbent dressing on top. 3. During an interview on 10/18/23, at 2:00 P.M., LPN A said staff were to wash hands when they entered a resident's room, fully wash hands when soiled, before and after doing a wound treatment, between resident's rooms, and when removed or changed gloves. He/she forgot to wash his/her hands after removing gloves and during Resident #1 and Resident #2's treatment between removing soiled dressings and applying clean dressings. He/she did have hand sanitizer on the treatment cart, but did not carry it on him/her. 4. During an interview on 10/18/23, at 3:50 P.M., the Director of Nursing (DON) said she expected staff to wash their hands when they entered a resident's room, before putting on gloves and removing gloves, between dirty and clean, removing dressing, and wash and/or sanitize hands when doing a wound treatment and applying the dressing, and before leaving the resident's room. Staff can sanitize their hands unless the hands were soiled and then they were to wash hands. MO00225986,MO00226006

Based on observation, interview, and record review, the facility failed to document identification and use of possible alternatives prior to use of side rails; failed to document side rail assessments of risk versus benefits; failed to obtain written informed consents for the use of side rails prior to installation; and failed to complete ongoing assessments of appropriateness of side rails use for six residents (Resident #8, #33, #35, #40, #97, and #98). The facility's census was 49. Record review of the facility's undated policy, Side Rail Use and Assessment, showed the following: -The facility will use the Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals and Long Term Care Facilities and Home Care Settings, dated 2003, developed by the hospital bed safety workgroups as the primary protocol for the use of side rails. A copy of this document shall be maintained in each facility; -Purpose to ensure automatic use of side rails of any size or shape are avoided; -A decision to use, reduce or remove side rails occurs within the framework of an individual resident assessment and is clearly documented; -The creation of a safe bed environment, taking into account each resident's medical/psychological needs, comfort and freedom of movement; -The use of side rails is based on resident's assessed medical/psychological needs is documented clearly including risks, benefits and other alternatives and is periodically reviewed; -The use of side rails either for positioning and mobility or for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Each resident will receive an individualized assessment process. Each resident will be assessed for the use of side rails upon admission, readmission. significant change in status and quarterly using the Side Rail Use and Assessment form; -For each resident for which side rails are indicated to provide safety to a medical or psychological diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Side rails determined to be a physical restraint will be addressed in the following manner: A physicians order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Record review of Resident #33's admission data sheet showed the resident admitted to the facility on [DATE]. During observation and interview on 5/20/22, at 10:50 A.M., the resident said the quarter side rail was on the bed when he/she arrived to the facility. He/She was not sure why it is on the bed, but said he/she never used it. Staff did not talk to him/her about the side rail or why it was on the bed or any risk information. The resident's bed had a quarter side rail on one side of the bed. Record review of the resident's May 2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's current care plan showed staff did not care plan the use of side rails. Record review of the resident's medical record showed staff did not document identification and use of possible alternatives prior to use of the side rails, assessment of risk versus benefits of side rail use, obtaining informed consent for the use of side rails prior to installation, or ongoing assessments to ensure the side rails were appropriate for use. 2. Record review of Resident #97's admission data sheet showed the resident admitted to the facility on [DATE]. During observation and interview on 05/20/22, at 11:00 A.M., the resident said the side rail U-Bar was on the bed when he/she arrived to the facility. He/she was not sure why its on the bed, but he/she uses it to help pull self up in bed. The resident said no staff ever talked to him/her about the side rail U-Bar or why it was on the bed or any risk information. The resident's bed had a quarter side rail (U-Bar) on one side of the residents bed. Record review of the resident's May 2022 POS showed no order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's initial care plan showed staff did not care plan the use of side rails. Record review of the resident's medical record showed staff did not document identification and use of possible alternatives prior to use of the side rails, assessment of risk versus benefits of side rail use, obtaining informed consent for the use of side rails prior to installation, or ongoing assessments to ensure the side rails were appropriate for use. 3. Record review of Resident #98's admission data sheet showed the resident admitted to the facility on [DATE]. During observation and interview on 05/20/22 at 11:15 A.M., the resident said the quarter side rails were on the bed when he/she arrived to the facility. He/She was not sure why it is on the bed, but he/she uses it to help pull him/her self up in bed. No staff member talked to him/her about the side rail or why it was on the bed or any risk information. The resident's bed had a quarter side rail on both sides of the resident's bed. Record review of the resident's May 2022 POS showed no order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's initial care plan showed staff did not care plan the use of side rails. Record review of the resident's medical record showed staff did not document identification and use of possible alternatives prior to use of the side rails, assessment of risk versus benefits of side rail use, obtaining informed consent for the use of side rails prior to installation, or ongoing assessments to ensure the side rails were appropriate for use. 4. Record review of the Resident #8's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 2/23/22, showed the following information: -admitted to the facility 9/19/19; -readmitted from a hospital on 2/16/2022; -Extensive assistance of two persons for bed mobility; -Total dependence on two staff for transfers. Observation on 5/17/2022, at 3:45 P.M., showed the resident rested in bed. Silver metal half length side rails were in the raised position on both sides of the bed. Observation on 5/19/2022, at 2:20 P.M., showed the resident rested in bed with half side rails in the raised position on both sides of the bed. During an interview on 5/20/2022, at 11:50 A.M., the resident said he/she had not requested the side rails on the bed. The rails were already in place when he/she got there. The resident said he/she did feel more secure with them in place, to prevent falling out of bed, and used the rails to hold onto while turning side to side. Record review of the resident's May 2022 POS showed no order for side rails. Record review of the resident's care plan, dated 2/23/2022, showed staff did not care plan use of side rails. Record review of the resident's Side Rail Assessment, dated 2/16/2022, showed the following information: -Resident able to turn side to side in bed with use of side rail, with or without assistance; -Based on assessment, side rails will be utilized on one or both sides of bed to promote increased independence, participation in bed mobility and positioning; -The assessment did not show documentation of informed risk consent for the use of side rails. 5. Record review of the resident's significant change MDS, dated [DATE], showed the following information: -admitted to the facility on [DATE]; -Extensive assistance of one person for bed mobility; -Supervision for transfers. Observation on 5/17/2022, at 3:43 P.M., showed half length side rails were attached to both sides of the bed, in the raised position. During an observation and interview on 5/18/2022, at 2:23 P.M., the resident rested in bed with half side rails in the raised position on both sides of the bed. The resident said he/she likes to use the rails to help with repositioning in bed. Observation on 5/19/2022, at 2:27 P.M., showed half length side rails were attached to both sides of the bed, in the raised position. Record review of the resident's May 2022 POS showed no order for side rails. Record review of the resident's care plan, dated 4/15/2022, showed staff did not care plan use of side rails. Record review of the resident's Side Rail Assessment, dated 4/11/2022, showed the following information: -Resident able to get in/out of bed with use of side rail, with or without assistance; -Resident able to turn side to side in bed with use of side rail, with or without assistance; -Resident currently uses side rail for positioning, support or mobility; -Based on assessment, side rails will be utilized on one or both sides of bed to promote increased independence, participation in bed mobility and positioning; -The assessment did not show documentation of informed risk consent for the use of side rails. 6. Record review of the Resident #40's 5-day entry MDS, dated [DATE], showed the following information: -admitted to the facility on [DATE]; -readmitted from a hospital on 5/5/2022; -Extensive assistance of one person for bed mobility; -Two persons for transfers. Observation on 5/17/2022, at 3:49 P.M., showed the resident rested in bed with quarter side rails in the raised position on both sides of the bed. During an observation and interview on 5/19/2022, at 2:23 P.M., the resident rested in bed, with quarter side rails in the raised position on both sides of the bed. The resident said he/she likes having the rails and uses them to help move in bed. Record review of the resident's May 2022 POS showed no order for side rails. Record review of the resident's care plan, dated 5/5/2022, showed staff did not care plan the use of side rails. Record review of the resident's Side Rail Assessment, dated 5/5/2022, showed the following information: -Resident able to get in/out of bed, with or without assistance; -Resident not able to get in/out of bed with use of side rail, with or without assistance; -Resident able to turn side to side in bed with use of side rail, with or without assistance; -Resident currently uses side rail for positioning, support or mobility; -Based on assessment, side rails will be utilized on one or both sides of bed to promote increased independence, participation in bed mobility and positioning; -The assessment did not show documentation of informed risk consent for the use of side rails. 7. During an interview on 5/19/2022, at 1:53 P.M., the Maintenance Director said the nurses give the maintenance department a work order when a resident needs side rails on their bed. Maintenance would then switch out the resident's bed for one with side rails already installed and attached. He was not aware of safety gap measurement requirements or guidelines, but checked the rails for firm attachment prior to use. Maintenance did a monthly wellness safety check of all beds to ensure the rails were not loose. 8. During an interview on 05/19/22, at 3:04 P.M., the Director of Nursing (DON) said there is an option for a grab bar and an quarter assist bar that staff check and these are not considered a side rail. Staff just go over and review with the resident, or family, the risk for entrapment and there is a verbal consent, nothing documented. The Maintenance Supervisor (MS) measures all the gaps between the grab bars/side rails and the bed. 9. During an interview on 05/19/22, at 4:06 P.M., with the Administrator and DON, the DON said she could not find the measurements for the side rails. DON said when she talked to MS he did not remember doing any gap measurements, but thought after she reminded him that he did the do some gap measurements in 2019 but there was no documentation of the measurements.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less then 5% when staff made three errors out of 33 opportunities, resulting in an error rate of 9.09%, when staff failed to correctly flush between medications administered via PEG-tube (percutaneous endoscopic tube: inserted through the wall of the abdomen directly into the stomach, used to give drugs, liquids, liquid food) for one resident (Resident #1). The facility had a census of 49. According to an article written by [NAME], RPh (Registered Pharmacist), FASCP (fell owship; American Society of Consultant Pharmacists); Pharmacy & Therapeutics: A Peer-Reviewed Journal for Managed Care and Hospital Formulary Management, October 2013; all medications given through a feeding tube should be set up and administered separately, flushing before, in between, and after all medications. Record review of the facility provided policy titled Medication Administration - Enteral (Feeding) Tubes (2007), showed the following information: -The nursing care center assures the safe and effective administration of enteral formulas and medications; -Interactions between medications, and interactions of multiple medications, are considered before administering medications through the enteral tube; -Medication administration and flushing of the tube after each individual medication is given is required if there are known compatibility problems between medications to be mixed together; -Administering the medications separately aids in avoiding interactions and clumping; -The enteral tubing is flushed with at least five milliliters (ml) of water between medication administrations. 1. Record review of Resident #1's face sheet (provides basic profile information) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 4/20/2022, for calcium tablet, 600 milligram (mg), administer via PEG-tube one time a day; -An order, dated 4/20/2022, for multivitamin tablet, administer via PEG-tube one time a day; -An order, dated 4/20/2022, for [MEDICATION(S)] tablet (treats high blood pressure), 25 mg, administer via PEG-tube two times a day. Record review of the resident's care plan, dated 5/20/2022, showed recent placement of an enteral tube; administer medications as ordered. Observation on 5/18/2022, at 9:07 A.M., showed the following: -Licensed Practical Nurse (LPN) A placed one tablet calcium 600 milligram (mg); multivitamin; and [MEDICATION(S)] 25 mg into a plastic sleeve; -LPN A used a hand-crank tool to crush the tablets in the plastic sleeve; -LPN A poured the crushed medications into a plastic medication cup and added water to dissolve the contents; -The LPN flushed the resident's tube with 30 milliliters (ml) of water, then administered the mixed medications into a syringe attached to the PEG tube. A portion of the medication mixture would not flow into the tubing, causing it to clog. The LPN poured the remaining non-administered medications from the syringe back into the medication cup, added more water to dilute the mixture, and poured the mixture back into the tubing. The remaining medication mixture flowed into the tubing; -The LPN flushed the tubing with 30 ml of water. During an interview on 5/20/2022, at 11:30 A.M., LPN A said he/she usually combined the resident's medication for administration via the PEG-tube. During an interview on 5/19/2022, at 12:29 P.M., the Director of Nursing (DON) said the facility did not have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said staff should not be combining the medications. During an interview on 5/20/2022, at 9:25 A.M., LPN B said staff should crush and dissolve each medication in 15 ml of water, administer the medications via PEG-tube individually, and flush in between medications. LPN B said they should not combine medications into one cup for administration. During an interview on 5/20/2022, at 12:31 P.M., with the Administrator and DON, the DON said medications administered via tube should be separated and flushed in between each. The Administrator verbalized agreement with the DON's statement.

Based on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff failed to correctly flush between medications administered via PEG-tube (percutaneous endoscopic tube - inserted through the wall of the abdomen directly into the stomach, used to give drugs, liquids, liquid food) for one resident (Resident #1). The facility had a census of 49. According to an article written by [NAME], RPh (Registered Pharmacist), FASCP (fell owship; American Society of Consultant Pharmacists); Pharmacy & Therapeutics: A Peer-Reviewed Journal for Managed Care and Hospital Formulary Management, October 2013; all medications given through a feeding tube should be set up and administered separately, flushing before, in between, and after all medications. Record review of the facility provided policy titled Medication Administration - Enteral (Feeding) Tubes (2007), showed the following information: -The nursing care center assures the safe and effective administration of enteral formulas and medications; -Interactions between medications, and interactions of multiple medications, are considered before administering medications through the enteral tube; -Medication administration and flushing of the tube after each individual medication is given is required if there are known compatibility problems between medications to be mixed together; -Administering the medications separately aids in avoiding interactions and clumping; -The enteral tubing is flushed with at least 5 ml of water between medication administrations. 1. Record review of Resident #1's face sheet (provides basic profile information) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 4/20/2022, for calcium tablet, 600 mg, administer via PEG-tube one time a day; -An order, dated 4/20/2022, for multivitamin tablet, administer via PEG-tube one time a day; -An order, dated 4/20/2022, [MEDICATION(S)] (used to treat high blood pressure) tablet, 25 mg, administer via PEG-tube two times a day. Record review of the resident's care plan, dated 5/20/2022, showed recent placement of an enteral tube; administer medications as ordered. Observation on 5/18/2022, at 9:07 A.M., showed the following: -Licensed Practical Nurse (LPN) A placed one tablet of calcium 600 mg, multivitamin, and [MEDICATION(S)] 25 mg into a plastic sleeve; -LPN A used a hand-crank tool to crush the tablets in the plastic sleeve; -LPN A poured the crushed medications into a plastic medication cup and added water to dissolve the contents; -The LPN flushed the resident's tube with 30 milliliters (ml) of water, then administered the mixed medications into a syringe attached to the PEG tube. A portion of the medication mixture would not flow into the tubing, causing it to clog. The LPN poured the remaining non-administered medications from the syringe back into the medication cup, added more water to dilute the mixture, and poured the mixture back into the tubing. The remaining medication mixture flowed into the tubing; -The LPN flushed the tubing with 30 ml of water. During an interview on 5/20/2022, at 11:30 A.M., LPN A said he/she usually combined the resident's medication for administration via the PEG-tube. During an interview on 5/19/2022, at 12:29 P.M., the Director of Nursing (DON) said the facility did not have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/20/2022, at 9:25 A.M., LPN B said staff should crush and dissolve each medication in 15 ml of water, administer the medications via PEG-tube individually, and flush in between medications. LPN B said they should not combine medications into one cup for administration. During an interview on 5/20/2022, at 12:31 P.M., with the Administrator and the DON, the DON said medications administered via tube should be separated and flushed in between each. The Administrator verbalized agreement with the DON's statement.

Based on observation, interview, and record review, the facility failed to provide protective oversight to all residents on the locked memory care unit (MCU) when one resident (Resident #1), with a history of exit seeking, left the unit through an unlocked door while the MCU staff provided a shower to another resident. The resident did not have a coat on in the subfreezing temperatures and was found two and a half miles from the facility. Staff also failed to update the care plan, timely, after prior wandering, exit seeking, and elopements. The facility census was 42. The administrator was notified on 1/22/2022, at 12:25 P.M., of an Immediate Jeopardy (IJ) which began on 1/21/2022. The IJ was removed on 1/22/2022, as confirmed by surveyor onsite verification. Record review of the facility's policy titled, Resident Elopement Policy & Procedure, dated 12/2019, showed the following: -Elopement occurs when a resident leaves the premises or a safe area without the necessary supervision or authorization to do so; -Risk for elopement to be identified and an individualized care plan developed based on risk; -Staff to investigate and report instances of potential elopement; -The facility to have a process to monitor security of the premises on a routine basis; -Residents are to be assessed for elopement risk within the first 24 hours of admission, quarterly, annually, behaviors indicating potential elopement risk, and with any significant change; -Assessments are to be documented in the clinical record; -Staff are to immediately report any resident who tries to leave the premises, is returned to the premises, or is suspected of being missing to the charge nurse or to the Director of Nursing (DON); -If it is determined the resident exited through a door, door alarm systems are to be tested and confirmed in working order, as close to the time of the event as feasible. Record review of the facility's policy titled, Emergency Contingency Staffing, dated 4/2020, showed the following: -During an emergency situation and staffing shortage, to the extent possible, the facility will provide sufficient staff to meet the essential daily care needs of resident. 1. Record review of Resident #1's face sheet (a brief resident summary) showed the following: -admitted [DATE]; -Diagnoses included [CONDITION(S)] (a disorder of the central nervous system that affects movement, often including tremors) and dementia with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and functioning because of abnormal microscopic protein deposits in the brain). Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 8/12/2021, showed the following: -The resident was cognitively intact; -He/she did not exhibit wandering during the evaluation period; -He/she required two staff to assist him/her for transfers, did not walk in corridor, and one staff to assist for walking, dressing, toileting, and hygiene; -He/she uses a wheelchair and walker for ambulation. Record review of the resident's Progress Notes showed the following: -On 9/5/2021, at 1:08 P.M., facility staff documented the resident was walking by the nurses' desk with his/her arms full of his/her belongings. The nurse and certified nursing assistant (CNA) ran down the hallway to catch the resident. The nurse went to the resident's room and got his/her wheelchair. The resident asked to speak to his/her spouse. Staff informed spouse of the event. Record review of the resident's current care plan showed staff did not update the care plan the with 9/5/2021 event or any new interventions. Record review of the resident's Progress Notes showed the following: -On 9/11/2021, at 6:10 P.M., facility staff documented the door alarm was going off on one of the halls on the East. The CNA stepped out of the room and saw the resident outside. The CNA ran to the resident and easily redirected him/her back into the building. The resident was placed on 15-minute checks (the staff documented the resident's whereabouts every 15 minutes). The resident's spouse and physician were notified. Record review of the resident's current care plan, showed the following: -On 9/13/2021, the resident at times wanders and might attempt to leave the building on his/her own; -On 9/13/2021, the facility staff to report to the nurse if the resident had increased wandering or pacing; -On 9/13/2021, staff directed if resident started to pack belongings, it was a sign he/she was thinking about leaving; -On 9/13/2021, staff to notify the physician if needed; -On 9/13/2021, staff directed to ask resident why he/she was wandering; try to meet his/her needs to keep him/her from wandering, reassure resident; toilet often; offer snacks; and assess for pain. Record review of the resident's Progress Notes showed the following: -On 9/26/2021, at 6:25 P.M., the CNA came to the nurse and stated the resident was walking up the hall by his/her room. When the CNA tried to redirect the resident and assist him/her back to his/her room, the resident grabbed the CNA by the wrist and pushed the aide into the door. The CNA was able to redirect the resident back to his/her room to sit down. The resident was very agitated and stated I have to get to work. The resident's spouse was called to talk to the resident to attempt to calm him/her. When the resident finished talking with his/her spouse, he/she got up from the bed and walked the hall, assisted, a couple more times before sitting in his/her wheelchair at the nurses' station for a snack. Record review of the resident's current care plan showed staff did not update the care plan with 9/26/2021 event or any new interventions. Record review of the resident's Progress Notes showed the following: -On 10/2/2021, at 6:55 P.M., facility staff documented the resident went out the service hall door, the alarm sounded and two CNAs went to the door and redirected the resident from the service hall back to the common area near the nurses' desk. The resident's spouse arrived shortly after the event and sat one-on-one with the resident for a while. The resident was placed on 15-minute checks for added safety due to increased wandering. The resident's physician was notified. Record review of the resident's current care plan showed staff did not update the care plan the with 10/02/2021 event or any new interventions. Record review of the resident's Progress Notes showed the following: -On 10/8/2021, at 1:50 P.M., facility staff documented, anytime resident is awake, he/she is basically one-on-one (a staff member with resident at all times) with staff. The physician and family are aware. Record review of the resident's Progress Notes showed the following: -On 10/21/2021, at 6:34 P.M., staff documented they notified the resident's spouse that the resident went out the dining room door, and that he/she was alright. The DON was notified about the event and 15-minute checks were started. The resident's spouse told staff the resident was hallucinating when he/she was visiting the resident. Record review of the resident's current care plan showed staff did not update the care plan the with 10/21/2021 event or any new interventions. Record review of the resident's Progress Notes showed the following: -On 10/23/2021, at 2:29 P.M., staff documented the resident had been very anxious, restless, and thinking he/she was working and needing to have the electrician come look at the refrigeration system. The resident had been noted to be having hallucinations, and talking to people unseen by staff. The resident was adamant he/she worked at the hospital and needed the staff to leave him/her alone so he/she could work. The resident was one-on-one with staff. The resident was seen by the physician who observed his/her behaviors and made medication adjustments. Record review of the resident's current care plan showed staff did not update the care plan the with 10/23/2021 event or any new interventions. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/6/2021, showed the following: -The resident was moderately cognitively impaired; -He/she did not exhibit wandering during the evaluation period; -He/she required one staff to assist him/her for transfers, walking, dressing, toileting, and hygiene; -He/she uses a wheelchair for ambulation. Record review of the resident's Progress Notes showed the following: -On 12/10/2021, at 6:50 P.M., staff documented the resident was agitated and would not be redirected. The resident was having hallucinations that someone was going to give him/her a shot. The resident pushed and hit at staff which caused a one centimeter (cm) skin tear to his/her left forearm. The CNA talked to the resident and had his/her spouse talk to the resident. The resident believed someone from the lab was going to give him/her a shot, which made him/her more agitated. The resident was still agitated after speaking with his/her spouse, but the nurse left the resident with the CNA and the resident calmed some. The physician was notified. Record review of the resident's current care plan showed staff did not update the care plan the with 12/10/2021 event or any new interventions. Record review of the resident's Progress Notes showed the following: -On 12/14/2021, at 11:32 A.M., staff documented the resident was noted with a sudden onset manic episode resulting in him/her getting out of his/her wheelchair and ambulating unassisted out the southeast door, down the sidewalk, and in to the parking lot. Staff immediately followed behind the resident. When staff attempted to redirect the resident back into the building, the resident quickly turned on his/her heels and swung his/her fist at the staff member, and fell on to the pavement in the parking lot. No injury was seen, however, the resident continued to be aggressive anytime staff tried to approach him/her. The resident continued to ambulate through the side yard, and back into the facility, up and down the 400 hallway multiple times, and picked up multiple loose items as he/she walked, such as water jugs, wet floor signs, as if he/she was trying to work out. The resident eventually calmed enough to sit on the couch and rest for a short time. Staff remained one-on-one with the resident. A small skin tear was noted to the resident's right knee and dressed by the nurse. The resident's spouse was called and he/she advised the staff to send the resident to the hospital if that was what needed to be done. Record review of the resident's care plan showed the following: -On 12/14/2021, staff documented under the fall intervention that the physician had discontinued [MEDICATION(S)] (a medication used to treat depression) related to an increase in aggressive physical and verbal behaviors with difficulty redirecting; -On 12/14/2021, staff documented under the fall intervention that staff was one-on-one with the resident during and following an incident where the resident became manic and aggressive both verbally and physically with staff, which caused the resident to lose his/her balance and fall. -Staff did not update the care plan regarding the elopement or exit seeking behaviors. Record review of the resident's Progress Notes showed the following: -On 12/14/2021, at 1:36 P.M., staff documented the resident was sent to the hospital for evaluation and treatment due to increased anxiety; -On 12/14/2021, at 9:56 P.M., staff documented the resident arrived back to the facility at 8:30 P.M., with no new orders; -On 12/15/2021, at 6:09 P.M., staff documented the resident tried to elope out the 400 North door. The certified medication technician (CMT) could see the resident the entire time. The nurse assisted the resident to get back inside the building. The resident told staff it was about to storm and he/she needed to go home to lock the door and check on the kids. The CMT told the resident that his/her kids were grown and his/her spouse was ok. The CNA got the resident back to his/her room. The resident was placed on 15-minute checks and his/her spouse was contacted. Record review of the resident's current care plan showed staff did not update the care plan the with 12/15/2021 event or any new interventions. Record review of the resident's Progress Notes showed the following: -On 12/16/2021, at 7:35 P.M., staff documented the resident stood from his/her wheelchair and began running down the southeast hallway and out the ambulance door into the front parking lot. The charge nurse followed the resident from the time he/she stood from his/her wheelchair. The resident continued to run through the parking lot headed west into the side yard of the parking lot, fell to his/her knees in the side yard, and when the nurse attempted to assist him/her up, got up and began running back into the parking lot. The resident thought his/her spouse was in one of the vehicles in the parking lot and wanted him/her to take the resident home. The resident grabbed the door handle of one of the vehicles and opened the door, and when he/she realized it was not his/her spouse in the vehicle, let the door handle go, and walked with assistance to the front porch of the facility and sat in a chair for approximately 45 minutes before agreeing to go inside. The resident's spouse was called, the physician was called and ordered [MEDICATION(S)] (an antipsychotic medication) 15 milligrams (mg) immediately and then twice daily. The physician said he/she would be in the next day to review the resident's other medications. Record review of the resident's current care plan showed staff did not update the care plan with the 12/16/2021 event or any new interventions. Record review of the resident's Progress Notes showed the following: -On 1/21/2022, at 6:12 P.M., staff documented that at approximately 2:04 P.M., the DON was notified by CNA B that he/she was unable to locate the resident. The resident was last seen in his/her room by Restorative Nursing Assistant (RNA) C while working with him/her on exercises. The facility staff began to search for the resident. Staff notified the police, the resident's spouse, physician and the State Agency were notified. At approximately 2:20 P.M., the police notified the facility that someone matching the resident's description had been located. The resident was returned to the facility by his/her spouse in his/her private vehicle. A head to toe assessment was completed and the resident was noted to have a small skin tear to his/her left elbow, an abrasion (scrape) to his/her right knee and to the palm of his/her hand. The resident was dressed in sweat pants, a sweatshirt, and tennis shoes. The resident was placed on one-on-one with staff. An alarm was placed on the door where the resident exited. Record review of the website localconditions.com, dated 1/21/2022, showed the temperature for the city the home is located in for 1:00 P.M. to 2:30 P.M., ranged between 26.6 degrees Fahrenheit (F) and 30.2 degrees F. Record review of Apple Maps showed the distance to where the resident was found was 2.4 miles from the facility. Record review of the resident's Elopement Risk Assessment, dated 1/21/2022, showed the following: -The resident was at high risk for elopement. (Record review of the resident's chart showed staff did not complete any other Elopement Risk Assessments.) During interviews on 1/22/2022, at 9:18 A.M. and 11:10 A.M., CNA B said on 1/21/2022, he/she gave care to the resident in the day room of the MCU around 12:30 P.M. The resident had restorative therapy around 1:20 P.M., and the aide could not locate the resident around 1:55 P.M. The aide was working the hall by him/herself and giving another resident a shower. He/she did not hear an alarm go off. Usually, the aide will let a CMT or nurse know when he/she takes a resident to the shower, but did not on that day. The resident has tried to go home before, and as a check, the aide will yell out his/her name when she finishes a task and the resident will respond. During interviews on 1/22/2022, at 9:25 A.M., and 1/24/2022, at 1:00 P.M., the DON said the resident went out an unlocked, unalarmed door (storage room) to an unlocked gate. The resident got approximately two and a half miles away from the facility before he/she was returned. The DON expects the aides working the MCU to let a nurse or CMT to know when they are doing a shower or going off the hall so the hall will be covered. Staff should update care plans with any new interventions. Observation on 1/22/2022, at 11:55 A.M., showed the following: -At the end of the MCU hallway was a medical records storage room; -The storage room had a door that opened into another room that also contained medical records; -From the attached room, a door opened to the outside; -The door opening to the outside went out to a chain-link fenced area with an unlocked gate. During an interview on 1/22/2022, at 9:55 A.M., Licensed Practical Nurse (LPN) F said the resident has tried to elope before. If an aide on the MCU is working alone, they let the CMT or nurse know if they are doing showers or taking a break and the CMT or nurse will cover the hall. During an interview on 1/22/2022, at 10:12 A.M., CNA A said there is usually just one aide on the MCU. He/she was unsure what would happen if something happened with a resident while the aide is busy with another resident. During an interview on 1/22/2022, at 11:20 A.M., CMT E said the aides in the MCU will tell him/her when they are doing a shower or stepping off the hall so he/she can keep an eye on the hall. The aide will usually try to do as many showers as they can while the CMT is working on the MCU. During an interview on 1/24/2022, at 10:30 A.M., Maintenance Staff G said he doesn't do regular door checks, but knows the door was checked recently and was locked. The doors were being checked at least monthly when the shred company comes to retrieve shredded paper. Maintenance has a key to the office where the resident went out, the front office might have a key, and medical records has a key. The Administrator checks the door on his rounds. Maintenance Staff G said he has never found the door unlocked. During an interview on 1/24/2022, at 11:35 A.M., the MDS/Care Plan Staff H said the care plan should include if the resident wanders or is an elopement risk, or has actually eloped. No other residents have eloped besides this resident. The resident thinks he/she is still working, and sometimes becomes violent. He/she has been one-on-one with staff before. He/she transitioned to the MCU. The interventions from the December incident were put under the Fall category instead of the Behavior or Elopement category. During an interviews on 1/22/2022, at 12:00 P.M., and 1/24/2022, at 12:57 P.M., the Administrator said he goes every day, four times daily and checks doors in the facility. He has never found the door on the MCU to be unlocked. He was having maintenance check the doors as well, but was not sure they were doing it so he started doing it as part of his daily checks. The staffing on the hall is adequate for the census, and the facility has several staff members out due to illness. The MCU staff are to let another staff member know when they are showering a resident or taking a break so the hall is not unsupervised. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 211

Based on observation, interview, and record review, the facility failed to records were accurate when staff staff failed to fully document in residents' medical records assessments or interventions attempted or provided during two residents' (Resident #1 and Resident #10) change of conditions, that resulted in hospitalization . The facility with a census of 59. Record review of the facility's (undated) guidance to staff regarding when staff should report change of condition to the provider showed the following information: -Immediate notification when any symptom, sign, or apparent discomfort that is acute or sudden in onset and a marked change in relation to normal symptoms, or unrelieved by measures already prescribed; -Report why vital signs were taken; -Signs and symptoms with urgency of action; -Abrupt significant change in cognitive function from usual or without altered level of consciousness would require immediate action; -Acute onset of three or more episodes of loose stools (bowel movements) required immediate action; -Persistent multiple loose stools with stable vital signs required non-immediate action; -Sudden loss of consciousness required immediate action; -Persistent or recurrent (two or more within 12 hours) vomiting, with or without abdominal pain, bleeding, distention/fever required immediate action. Record review showed the facility did not provide a policy regarding required documentation regarding changes in condition. 1. Record review of Resident #1's face sheet (brief resident profile sheet) showed the following information: -Readmission to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated [DATE], showed the following information: -Cognitively intact; -Required extensive assistance for bed mobility, transfers, and toilet use; -Always incontinent of bowel and bladder. Record review of the resident's care plan, print date [DATE], showed the following information: -Required staff assistance with activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) related to physical limitations; -Able to eat by self with meal set up help; -Required assistance of two staff with transfers; -Required extensive to total assistance for bed mobility, transfers, and toileting; -If resident becomes seriously ill, the family and physician will be notified so instructions may be given. Resident or resident's family/physician may want to send resident to hospital, to start medications, or other interventions; -Incontinent of urine at times. Record review of the resident's alert progress note dated [DATE], at 11:15 A.M., showed the DON documented resident had not had a bowel movement in three days. Staff administered Milk of Magnesia (MOM - [MEDICATION(S)]) per orders on this date. Staff assessed bowel sounds active with abdomen soft and non-tender. Record review of the resident's bowel and bladder elimination task flow sheet, dated [DATE], showed the resident had a large loose continent bowel movement. Record review of the resident's vital sign summary dated [DATE], at 12:42 A.M., showed staff documented the resident's temperature as 97.9 degrees. (Staff did not document any additional vital signs as checked at that time and did not note any concerns or assessment.) Record review of the resident's skin condition note dated [DATE], at 7:55 A.M., showed Licensed Practical Nurse (LPN) A documented no new skin conditions. (The LPN did not document any additional concerns or assessment.) Record review of the resident's vital signs summary sheet showed staff documented the resident's blood pressure and pulse as checked on [DATE], at 8:16 A.M. The resident's blood pressure registered as ,d+[DATE] millimeters of Mercury (mm/Hg - normal is ,d+[DATE] mm/Hg or lower) and pulse registered at 91 beats per minute (normal is 60 to 100 beats per minute). (Staff did not document any additional vitals or assessment.) Record review of the resident's vital sign summary record and the progress notes showed staff did not document an assessment or vital signs on [DATE], after 8:16 A.M. Record review of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -At 9:05 A.M., staff administered [MEDICATION(S)] (medication used to prevent nausea and vomiting) 4 milligrams (mg) due to resident vomiting and requesting it. Staff will monitor for effectiveness; -At 10:11 A.M., LPN A documented the medication ineffective. Record review of the resident's social service progress note dated [DATE], at 4:54 P.M. showed the Social Service Designee (SSD) documented the resident went to the hospital on [DATE]. Resident transported via ambulance with EMS drivers. Record review of the resident's progress notes showed staff did not document the circumstances, assessment of resident, the notification of the physician or family, or the time the resident sent to the hospital by ambulance. Record review of the resident's social service progress note, dated [DATE], showed the SSD documented the resident admitted to the hospital on [DATE] for acute kidney injury (condition in which the kidneys suddenly can't filter waste from the blood). The SSD attempted to call the resident's family regarding the hospital transfer on [DATE]. Family did not answer the phone, unable to leave a message. During interview on [DATE], at 1:38 P.M., Certified Nursing Assistant (CNA) B said the resident had first incident of vomiting and diarrhea on [DATE]. He/she thought the resident left the facility around lunchtime, when he/she was passing trays. The resident had an episode of vomiting earlier in the day, around 9:00 A.M. Then, he/she had vomiting and diarrhea around noon. The aide got the nurse and thinks the nurse (LPN C) checked the resident's vital signs. The resident said his/her stomach hurt. During an interview on [DATE], at 10:21 A.M., Certified Medication Technician (CMT) D said the resident had vomiting and/or diarrhea recently. On [DATE], the CMT assessed the resident and told the nurse. The CMT obtained the resident's vital signs, including temperature and wrote them on a piece of paper and gave them to the nurse. The vital signs included temperature, blood pressure, and pulse, everything. The aides cleaned the resident from the vomiting and diarrhea around 9:00 to 10:00 A.M., after morning medications. The aides said the resident was sick the night before and the day before. They said they received that information in report. Both nurses already knew the resident had vomiting and diarrhea before that. Their initial thought was since the resident took [MEDICATION(S)] ([MEDICATION(S)]) that morning, it was related to that. The CMT thought it was more than just the medications. The nurses got the DON and someone called the nurse practitioner (NP). The nurse practitioner called back and talked to LPN C. LPN C told the NP the resident had diarrhea all morning, all night, and the day before. The nurses administered [MEDICATION(S)] that morning and it did not seem to help. The NP asked if the vomit had odor. They did not think it did, not unusual odor. It was dark in color. They sent the resident out pretty quick, little after 10:00 A.M. The resident was not unresponsive, but was confused. The resident said his/her stomach hurt, but then the nurse asked and the resident said it did not hurt. The resident was alert. During an interview on [DATE], at 2:09 P.M., LPN C said staff sent the resident to the hospital for explosive diarrhea earlier in the week. The resident had several episodes and kept having it. It started that day. It was loose stools. He/she thought the diarrhea occurred about lunchtime and then had a few episodes of it. The resident had one to two episodes of vomiting, not sure if bile colored. Prior to that day, the resident did not have any issues with vomiting or diarrhea. The explosive diarrhea was unusual for the resident. The resident left on [DATE], mid-day. The resident's vital signs were not bad. Staff document vital signs in the nurses' notes or on the report sheet. During an interview on [DATE], at 11:22 A.M., LPN A said the day staff sent out the resident is when the resident had loose stools and vomiting. Staff called the provider. The resident started vomiting, but said stomach did not hurt. The resident received a [MEDICATION(S)] the day before (Monday, [DATE]). The resident had no documented bowel movement for five days. The resident couldn't remember when he/she last had a bowel movement. Usually, the resident can tell staff, but he/she just couldn't remember. LPN C was his/her nurse and talked to the nurse practitioner who then sent the resident to the hospital. Staff had already given the resident [MEDICATION(S)]. The resident had vomiting that day around 10:00 A.M. The resident had diarrhea through the night before with no issues prior to that. The resident left around lunchtime because he/she pulled an aide to help the emergency medical services (EMS) get the resident on the cart. LPN C completed vital signs on the resident. Staff should document vital signs in the computer under vital signs. The resident complained of vomiting and loose stools. The resident was not unresponsive, but always kind of tired. During an interview on [DATE], at 12:05 P.M., the Director of Nursing (DON) said the resident had vomiting and diarrhea. The resident went to the hospital because of it. The resident did not feel well. The CNA reported vomiting and diarrhea. The nurse saw the resident. The resident had profuse amounts of both. The resident was not his/her normal self. The resident was alert and able to talk. The resident was not unresponsive and could answer questions. Staff called the nurse practitioner and order received to send the resident out to the hospital. The DON thought the resident possibly had a bowel obstruction because it had been a few days since the resident had a good bowel movement. The nurse called the hospital that evening to check on the resident. They said acute kidney injury and they were keeping the resident. 2. Record review of Resident #10's face sheet, showed the following information: -Readmitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Required extensive assistance for bed mobility, dressing, eating, toilet use, and personal hygiene; -Always incontinent of bowel and bladder. Record review of the resident's care plan, print date of [DATE], showed the following information: -Able to feed self with supervision following meal setup. The resident required the use of little spoons unless staff there for cueing to take smaller bites; -Offer a small spoon for smaller bites to help in preventing choking; -Required extensive staff assistance with bed mobility, transfers, dressing, and toileting; -Resident has had difficulty of following what is said to the resident, sluggish and lethargy, which has triggered [CONDITION(S)]. Please monitor resident for changes and notify the physician with changes; -Please observe and report any changes in the resident's cognitive status; -If resident becomes seriously ill, the family and physician will be notified so instructions may be given. Resident or family/physician may want resident sent to hospital to start medications or other interventions; -Resident had constipation. Please monitor resident's bowl pattern as per protocol; -Resident had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Report any changes in odor or color of urine to the nurse. Resident had history of [CONDITION(S)]. Record review of the resident's alert progress note dated [DATE], at 11:14 A.M., showed no bowel movement in three days. The alert noted staff administered MOM per orders on that date. Bowel sounds active with abdomen soft and non-tender. Record review of the resident's alert progress note dated [DATE], at 12:23 P.M., showed no bowel movement in three days. Staff administered MOM on [DATE]. Staff will monitor for effectiveness. Record review of the resident's bowel and bladder elimination task form showed the following information: -The resident did not have a documented bowel movement from [DATE] through [DATE]; -Staff did not document any bowel or bladder information on [DATE]. Observation on [DATE], at approximately 11:45 A.M., showed the resident sat in his/her wheelchair in the resident's room. The resident appeared confused and did not respond when asked a question. Record review of resident's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M., showed the resident unable to safely take medication (Med Pass 2.0, nutritional supplement) at that time. Resident was very lethargic at that time. (Staff did not document any additional vitals or assessment of the resident.) Observation and interview on [DATE], at 1:23 P.M., showed EMS workers at the facility taking the resident by ambulance to get checked out. LPN C said it is possible the resident aspirated (condition when food enters the airway or lungs by accident). During an interview on [DATE], at 1:26 P.M., the administrator said the resident had an episode. The resident has them periodically. During an interview on [DATE], at 1:38 P.M., CNA B said the resident started vomiting today, just today, just a few minutes ago. The resident did not complain of nausea. The resident ate breakfast fine. The aide checked the resident after passing trays and the resident had been sick. The aide got the nurse. This occurred at about noon. The nurse came quickly to look at the resident. The nurse checked the resident's vital signs and oxygen saturation and they were fine. The aide did not see the blood pressure, because the aide was just in the room, not the one taking the vital signs. During an interview on [DATE], at 1:50 P.M., CNA E said the resident had been eating lunch and thought maybe he/she aspirated. The resident was coughing, which was normal for him/her. The aide went in and the resident lay on the bed and looked pale. The resident did not respond well. The resident's oxygen saturation was 96% and pulse was in the 50's. The DON was in the room and the charge nurse called the family. All decided to send the resident out to the hospital. The aide did not know for sure about nausea/vomiting, or diarrhea today. The resident was fine yesterday. He/she did not know of any episodes recently. During an interview on [DATE], at 2:09 P.M., LPN C said the resident had been in isolation since his/her roommate went to the hospital. Staff sent the roommate out because of explosive diarrhea earlier this week. This resident threw up. The resident has bouts of coughing. The resident coughs so hard, it is kind of normal for him/her. The resident will try to eat, cough, stop eating. The nurse thought maybe the resident aspirated. The resident was not responsive for awhile, about five minutes. Then, the resident spoke to the DON. CNA B and LPN C took the resident to the bathroom in the shower. The resident sat on the toilet, to have a bowel movement they thought. The resident went unresponsive again while on the toilet. LPN C called the resident's family member and he/she wanted the resident out to the hospital. The resident's oxygen saturation was 95%. The DON listened to the resident's lungs and they were clear. Someone checked the resident's blood pressure, but he/she did not remember what it was. They had put this resident in isolation just in case of any changes to keep an eye on him/her to see if anything else happened. Record review of the resident's vital sign summary showed staff documented the resident's temperature on [DATE], at 2:31 P.M. It registered at 97.5 degrees. During an interview on [DATE], at 3:45 P.M., the DON clarified the nurse sat down and documented the temperature on [DATE], at 2:31 P.M. It was not the actual time staff actually checked the temperature. If it was in response to the change of condition, it would have been documented in the nurses' note, explaining it. Record review of the resident's nurses' note dated [DATE], at 6:50 P.M., showed LPN C called the hospital to check on the resident. The ER nurse said they found a [CONDITION(S)] and were going to administer the intravenous (IV) antibiotic (ABT) to the resident and then send him/her back. The resident had clear lungs and no aspiration. Record review of the resident's bowel and bladder elimination task form, showed staff documented the resident had a small, continent loose bowel movement on [DATE], at 6:59 P.M. Record review of the nurse's note dated [DATE], at 3:57 A.M., showed the resident returned to the facility at 9:05 P.M. from the hospital via ambulance. Resident treated with IV antibiotic for [CONDITION(S)]. Resident stable and alert upon returning. Resident continued treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's social service progress note dated [DATE], at 10:09 A.M., showed resident sent to the emergency room around 1:00 P.M. on [DATE]. Resident transported via ambulance with emergency medical technician (EMT) drivers. Resident returned around 9:05 P.M. via ambulance with EMT drivers. Resident noted to have [CONDITION(S)] and given IV ABT. Record review of the resident's medical record showed no additional documentation of vitals or assessments of the resident prior to the hospital visit. During an interview on [DATE], at 10:21 A.M., CMT D said the resident had an issue with vomiting since being at the facility, off and on. The resident started to have diarrhea, but it was different than Resident #1's. During an interview on [DATE], at 12:05 P.M., the DON said the CNA got LPN C. The resident was not responsive. The resident has a history of diarrhea/constipation. LPN C assessed the resident and the resident had fluctuating responsiveness, one to two word responses. They completed a full set of vital signs for the resident and they were okay for him/her. The resident had no bowel movement for a couple days. They gave the resident a [MEDICATION(S)] and thought the diarrhea was from that. They called the resident's spouse and said going to watch him/her. LPN C and an aide put the resident on the toilet and the resident had a vagal (vasovagal, a sudden drop in heart rate or blood pressure leading to [CONDITION(S)], often in reaction to a stressful trigger) response on the toilet. Staff called the resident's spouse and the physician and sent the resident out to get checked. 3. During an interview on [DATE], at 9:40 A.M., CNA F said if a resident is having a change in condition, he/she will ask the resident if feels okay, any changes, and then tells the nurse. They usually go talk to the resident together. If a resident looks hot, he/she will check vital signs. The vital signs should be documented on the laptop at the desk or on the report sheet at the desk. They write all information, such as routine vital signs, twice a day. If a resident is having vomiting or diarrhea, staff should check vital signs and tell the nurse or tell the bosses, like the DON. Ask the resident if having an upset stomach, don't feel good, or if usually pretty alert, tell the nurse. Staff document on the report sheet about vomiting and diarrhea. If a resident is lethargic or unresponsive, check their breathing and start cardiopulmonary resuscitation (CPR - a lifesaving technique that is used when someone stops breathing or heartbeat has stopped) if needed. Let the nurse know and the DON. Staff check vital signs and document them on a piece of paper, then put it in the tablet under the vital signs. Nurse also document the vital signs on the computer. 4. During an interview on [DATE], at 10:21 A.M., CMT D said if a resident is having a change in condition, staff should obtain vital signs and report the change to the nurse. The vital signs should be documented on the computer or written on a sheet of paper to give to the nurse and the nurse documents the signs and symptoms and the vital signs. The staff should always report any changes to the nurse. For vomiting and diarrhea, the nurses might document about it, the CMT does not. 5. During an interview on [DATE], at 2:23 P.M., LPN C said the nurse should document in the nurses' notes when a resident is sent to the hospital. There is paperwork that is sent with the resident, including do not resuscitate (DNR - do not provide life saving CPR) paperwork, face sheet, and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It is like a facesheet, but says transfer-discharge. Staff document vital signs in the nurses' notes or on the report sheet. 6. During an interview on [DATE], at 11:22 A.M., LPN A said if a resident is having a change in condition, staff should obtain all vital signs, including temperature, pulse, blood pressure and complete a full assessment. They should notify the physician or provider and let them know what is going on with the resident. The nurse should document in the nurses' note in the computer and call the family of any orders received in response to the change in condition. Staff should document the vital signs in the vital sign tab summary on the computer and the nurses' notes. The nurse should document in the nurses' notes the notification to the physician and the family. For diarrhea, the aides can document on the CNA side in the bowel movement task regarding loose bowel movements. Vomiting should be documented in the nurses' notes. When the nurse receives an order to send a resident out to the hospital, they should call the family and let them know of the transfer and what is going on. 7. During an interview on [DATE], at 12:05 P.M., the DON said when a resident has a change of condition, staff should complete a head to toe assessment. They should document in the nurses' notes or a discharge note in the progress notes. If a resident is sent out, staff email or call and let administration know. If a resident has a change of condition, the CNA should notify the nurse, assistant director of nursing (ADON), or DON to notify so the resident can be assessed. The aide can always call the DON is the aide feels like something is going on with a resident. If a nurse sees a resident vomiting or having diarrhea, the nurse should document in the progress notes. The CNA documents the diarrhea or bowel movement in the computer under the Tasks section. That is where the CNA documents everything. They should also notify a nurse if something is different than a resident's normal. 8. During an interview on [DATE], at 3:31 P.M., the administrator said when a resident has a change in condition, staff should complete a full nursing assessment, check vital signs, call the physician and family. Staff should document the vital signs, assessment, and notification of the physician and family. The administrator and DON makes a note. Staff knew Resident #1 was having a gastrointestinal (GI) episode. MO 431

Based on observation, interview, and record review, the facility failed to fully implement their infection control policies and Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) recommended infection control practices during the coronavirus disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome coronavirus 2 ([DIAGNOSES REDACTED]-CoV-2)) pandemic when staffed failed to have a system in place to encourage social distancing (greater than six feet apart) for 10 out of 11 residents on the special care unit (SCU) during meals. The facility census was 72. Record review of the COVID-19 CDC guideline titled, Infection Prevention and Control (IPC) Guidance for Memory Care Units reviewed on 5/12/20, included the following: -Limit the number of residents or space residents at least 6 feet apart, as much as feasible, when in a common area; -Gently redirect residents who are ambulatory and are in close proximity to other residents or personnel. Record review of CMS COVID-19 Long-Term Care Facility Guidance showed the following: -Nursing home residents are at high risk for infection, serious illness, and death from COVID-19; -Enforce social distancing among residents (measures to reduce the spread of contagious disease by maintaining a physical distance between people and reducing the number of times people come into close contact with each other). Record review of the facility's policy, titled Checklist for Controlling COVID-19 in Long Term Care Facility, dated 4/3/20, showed the following:-Suspend all communal dining and activities; -Residents should remain in their rooms except for medically necessary reasons. If a resident must leave their room, resident is to apply a facemask, perform hand hygiene, and maintain social distancing. 1. During an interview on 6/12/20 at 11:20 A.M., Dietary Aide A said the residents who resided in the SCU usually sat two residents per table across from each other. During an interview on 6/12/20, at 11:25 A.M., Certified Nurse Aide (CNA) B said the following: -Staff seated two residents per table during meals; -He/she did not know the size of the dining room tables. Observations in the SCU on 6/12/20, from 11:46 A.M. through 12:20 P.M., showed the following: -Staff assisted residents in the dining room and sat residents at tables with other residents; -Staff did not attempt to socially distance any of the residents from one another; -Ten residents sat at five square dining tables, two residents to a table; -Residents at the same tables sat approximately four feet from one another throughout the meal. During an interview on 6/12/20, at 11:46 A.M., CNA C said three residents used to sit at each table, now only two residents sat at each table. During an interview on 6/12/20, at 11:55 A.M. and 12:15 P.M., Licensed Practical Nurse (LPN) D (the infection preventionist) said the following: -Before COVID 19 restrictions, residents sat where they wanted in the dining room. Now, only two residents sat to a table; -LPN D thought there was about six feet between the two residents when seated across from each other; -The residents seated across from each other were not roommates. During an interview on 6/12/20, at 12:10 P.M. and 1:30 P.M., the Administrator said the following: -Residents who sat at the same dining tables should be roommates; -The tables in the SCU dining room measured about four feet square. -The SCU staff had no seating chart until today; -The residents who sat at the same dining table today were not roommates. During an interview on 6/12/20, at 1:05 P.M., the Director of Nursing (DON) said the following: -Most residents ate their meals in their room; -Staff seated roommates together in the SCU dining room; -She just finalized a seating chart for the SCU dining room; -Most of the SCU staff knew to seat roommates together at a table.

Based on observation, interview, and record review, the facility failed to provide a [MEDICAL CONDITION] (a breathing machine that provides continuous positive airway pressure) and obtain clarifying orders regarding the [MEDICAL CONDITION] for one resident (Resident #1) whose hospital discharge summary stated the resident needed a [MEDICAL CONDITION] at night. A sample of 14 residents was selected for review. The facility census was 83. Record review of the facility's policy titled Admission Procedures, dated 6/3/14, showed the following information: -The charge nurse shall obtain orders and transcribe them into the computer; -Order medication and supplies (if not done previously). Record review of mayoclinic.org showed normal pulse oximeter readings (measurement of [MEDICATION NAME] blood expressed as a percentage) usually range from 95 to 100 percent; values under 90 percent are considered low. 1. Record review of Resident #1's face sheet showed the following information: -Initial admission date of [DATE]; -Readmission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 10/27/18, showed the following information: -[MEDICAL CONDITION]; -Anxiety disorder. Record review of the resident's (MONTH) (YEAR) physician order sheet (POS) showed the following: -An order, dated 2/21/18, for oxygen as needed (PRN) at two liters via nasal cannula, to keep saturation levels above 90%; -An order, dated 2/21/18, for oxygen at two liters via nasal cannula to keep saturation levels above 90%, every shift. Record review of the resident's progress note, dated 12/5/18, showed the following: -At 4:32 P.M., resident observed with jerking of his/her upper extremity with pupils fixed at two millimeters. Resident unable to keep eyes straight. Oxygen saturation at 76% on two liters oxygen. Oxygen administration changed to three liters and oxygen saturation levels moved up to 88%. When resident was awake oxygen level moved up to 93%. -At 5:43 P.M., staff documented staff were unable to read oxygen saturations and notified the family. The family requested the resident to be sent to the emergency room ; -At 6:00 P.M., resident left the facility in an ambulance. Record review of the resident's hospital discharge summary, dated 12/10/18, showed the following: -admitted at the hospital on [DATE] with low oxygen saturations; -Had similar presentations in the past; -Hypoxic (a condition in which the body is deprived of adequate oxygen supply) in the emergency room , with saturation levels in the mid 70% on room air; -Placed on an 8-liter nonrebreather (a device used to assist in the delivery of oxygen); -Noted to have increased somnolence (drowsiness) the next day; -Placed on Bilevel Positive Airway Pressure ([MEDICAL CONDITION] - a machine designed to increase the pressure when individual inhales to keep the airways in the nose and throat from closing while you are sleeping) and somnolence improved; -He/she used to have a [MEDICAL CONDITION] (breathing machine that provides continuous positive airway pressure) at home; -Resident used a [MEDICAL CONDITION] at home; -Likely will need a [MEDICAL CONDITION] at night at the facility; -Social services was able to arrange a [MEDICAL CONDITION] with the facility. Record review of the resident's clinical health review form dated 12/10/18, at 11:11 P.M., and signed by the Assistant Director of Nursing (ADON) on 12/11/18, showed the resident had the following appliances/devices; -[MEDICAL CONDITION]; -Oxygen; -Staff checked Yes the resident utilize respiratory appliances/devices as ordered. Record review of the resident's vital signs documentation in the electronic health record (EHR) showed the following information: -On 12/15/18, at 9:30 [NAME]M., staff documented the resident's oxygen saturation level was 66 %; -On 12/15/18, at 10:25 [NAME]M., staff documented the resident's oxygen saturation level was 93%. Record review of the resident's progress notes, dated 12/15/18, showed the following information: -At 10:28 [NAME]M., resident was lethargic, not responding to stimuli. Resident's oxygen saturation while receiving oxygen at 2 liters was 66%. Staff increased oxygen administration to three liters and the oxygen saturation increased to 70%. Staff increased the oxygen administration to four liters and oxygen saturations increased to 93%. Staff notified the on call physician and family and the physician instructed staff to call the ambulance; -At 11:00 [NAME]M., staff documented the resident was unable to respond to morning medications; -At 11:11 [NAME]M., staff document the resident transferred by ambulance to the hospital. Record review of the resident's admission physician order sheet (POS), for dates 12/10/18 through 12/15/18, showed staff did not document an order regarding use of a [MEDICAL CONDITION]. Record review of the resident's nurses' notes and progress notes, dated 12/10/18 through 12/15/18, showed staff did not document regarding use of the [MEDICAL CONDITION], attempts to obtain orders for settings of the [MEDICAL CONDITION], or notification of the physician that the [MEDICAL CONDITION] was not being used. Record review of the resident's Medication Administration Record [REDACTED]. Record review of the resident's care plan showed staff did not address use of the [MEDICAL CONDITION] on the care plan after readmitted to the facility on [DATE] and prior to leaving on 12/15/18. Observation and interview on 12/20/18, at 10:05 [NAME]M., showed, the resident's room contained an oxygen concentrator. The resident had his/her nasal cannula connected. The resident sat in his /her wheel chair, the resident's breathing was uneven when she talked and said the following: -He/she always had a [MEDICAL CONDITION] machine at home; -The hospital arranged with the facility to get his/her [MEDICAL CONDITION] ordered. During an interview on 12/20/18, at 1:10 P.M., Certified Nurse Aide (CNA) A said the following: -The resident had a [MEDICAL CONDITION] machine in the room, when he/she came from the hospital on [DATE]; -He/she never saw the resident using the [MEDICAL CONDITION]. During an interview on 12/20/18, at 1:15 P.M., CNA B said the resident did not have a [MEDICAL CONDITION] in his/her room on 12/15/18. During an interview on 12/20/18, at 1:20 P.M., CNA C said he/she did not recall if the resident had a [MEDICAL CONDITION] machine. During an interview on 12/20/18, at 3:20 P.M., the social services worker (SSW) said the following: -She was not responsible for the admission process when a resident comes back from the hospital; -He/she received a call from the resident representative on 12/17/18; -The resident's representative was very upset and asked why the resident's [MEDICAL CONDITION] was not in the resident's room; -The resident came from the hospital on [DATE]; -On 12/15/18, the resident suffered respiratory problems; -She informed the Director of Nursing (DON) through email about the resident's family requesting a [MEDICAL CONDITION] ordered; -She did not receive a response from the DON. During an interview on 12/20/18, beginning at 3:30 P.M., Licensed Practical Nurse (LPN) D said the following: -He/she received a call from the hospital on [DATE], before the resident discharged from the hospital; -The hospital staff requested the facility to order a [MEDICAL CONDITION] for the resident; -He/she processed the resident when he/she arrived at the facility from the hospital on [DATE]; -He/she notified the Assistant Director of Nursing (ADON) and asked her to order a [MEDICAL CONDITION] machine for the resident; -The resident did not have a [MEDICAL CONDITION] with her when he/she came from the hospital; -He/she did not know why the [MEDICAL CONDITION] was not ordered for the resident; -Facility management does the re-admission process for returning residents. During interviews on 12/26/18 at 12:59 P.M. and 1:10 P.M., LPN H said the following: -He/she is in charge of the medical records department; -He/she reviews orders and makes sure staff enter medical records correctly; -On 12/10/18, during a staff meeting, the DON said the resident needed a [MEDICAL CONDITION]; -The DON said the resident was using a [MEDICAL CONDITION] in hospital. During an interview on 12/26/18, at 1:10 P.M., LPN I said when the resident came from the hospital on [DATE], there was a note for the DON to get a [MEDICAL CONDITION] for the resident. The ADON said, the DON would get a [MEDICAL CONDITION] for the resident. During an interview on 12/26/18, at 3:30 P.M., the ADON said the following: -The charge nurse completes the re-admission process when a resident comes back from hospital; -Staff look at anything that stands out in the hospital discharge summary paperwork; -The charge nurse notified her the hospital called and requested the facility to provide a [MEDICAL CONDITION] for the resident; -When staff place an order for [REDACTED].>-She talked to the DON about the resident's need for a [MEDICAL CONDITION]; -The resident did not have a [MEDICAL CONDITION]; -He/she forgot to discuss the error with the DON. During an interview on 12/26/18, at 4:50 P.M., the DON said the following: -The hospital called and requested a [MEDICAL CONDITION] for the resident; -There was no physician orders for a [MEDICAL CONDITION]; -Staff should have called the hospital back and asked for the order. During an interview on 12/26/18, at 5:15 P.M., the administrator said staff should have made a follow up and placed an order for [REDACTED]. MO 839

Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for the transfer, and failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification, for seven residents (Resident #2, #5, #24, #34, #39, #52, and #54) out of 18 sampled residents. The facility census was 78. Record review of the (undated) facility policy/procedure titled, Transfer or Send Someone Out showed the following information: -Complete a send transfer report; -A copy of ambulance report; -Do Not Resuscitate and/or Advanced Directive paper work; -Copy of the bed hold policy; -The policy/procedure did not direct staff to send a written notice to the resident, resident representative, or the Ombudsman of the resident's transfer to the hospital. 1. Record review of Resident #2's nurses' notes showed the following information: -On 9/28/18, at 10:06 A.M., a nurse notified the family of the resident having to be fed at dinner on 9/27/18 and refusal of breakfast this morning. Staff notified the resident's physician as well; -On 9/28/18, at 3:39 P.M., the physician saw the resident and evaluated him/her. New orders received to send the resident to the emergency department (ED) to be evaluated and treated as indicated. The physician spoke to the family and notified them of the transport to the ED. The staff notified the ambulance district of the need for the transfer; -On 9/28/18, at 3:50 P.M., the resident left the facility accompanied by two Emergency Medical Services (EMS) attendants via ambulance; -On 9/28/18, at 7:15 P.M., contact made with the hospital. The resident showed positive for a urinary tract infection [MEDICAL CONDITION] with Escherichia coli (a species of bacterium normally present in the gastrointestinal tract that can cause diarrhea diseases). The resident admitted to the hospital related to sinus [MEDICAL CONDITION] (heart rate is slower than normal) and UTI. Contact made with the Durable Power of Attorney (DPOA) and the facility staff reviewed the bed hold policy with the DPOA; -On 10/01/18, at 5:39 P.M., staff notified the physician of the resident's return and current medications. Record review of the resident's medical record showed no letter sent to the responsible party or to the Ombudsman regarding the transfer on 9/28/18. 2. Record review of Resident #5's nurses' notes showed the following information: -On 7/19/18, at 12:39 A.M., risk progress note, the resident became agitated because the roommate was in the bathroom when he/she wanted to go into the bathroom. The staff assisted the roommate to get ready for bed and to toilet. Resident #5 began yelling at the staff and the roommate which brought other staff to the room. The other staff attempted to redirect Resident #5 so the certified nurse assistant (CNA) could remove the roommate from the bathroom. However, Resident #5 refused to move out of the way. He/she became more agitated and hit the roommate in the face with his/her fist more than once. Staff attempted to intervene and remove the roommate from the room. However, before staff could get the roommate out of the room, Resident #5 hit him/her two more times. Staff removed the roommate from the room and took him/her to another room out of Resident #5's eyesight. Resident #5 then aggressively started charging at the CNA with his/her walker. Staff attempted reeducation with the resident and he/she did go back to his/her room. Staff notified the physician and ordered the resident to be sent to the emergency department for further evaluation and treatment. The facility notified EMS who arrived within 15-20 minutes and took over the situation. EMS assisted the resident onto the gurney and out of the facility. All other notifications made timely. Staff documented they notified the resident's family but did not document they sent a written notice of the transfer to the resident, resident representative, or to the Ombudsman; -On 7/19/18, at 12:40 A.M., at risk progress note revised. The incident occurred at 10:25 P.M. (7/18/18); -On 7/26/18, the resident readmitted to the facility. Record review of the resident's medical record showed no letter sent to the responsible party or to the Ombudsman regarding the transfer on 7/19/18. 3. Record review of Resident #24's nurses' notes showed the following information: -On 5/30/18, at 8:12 A.M., the resident discharged today to be admitted to a Geriatric/Psychiatric unit. The resident exhibited behavior of wanting to leave the unit and locate his/her car, slapping a nurse, threatening to break items, and an elopement risk. The social service staff will follow-up with the Geriatric/Psychiatric unit for updates regarding the resident. Two family members transported the resident to the Geriatric/Psychiatric unit. Staff documented they notified the resident's family, but did not document they sent a written notice of the transfer to the resident, resident representative, or the Ombudsman; -On 6/05/18, at 7:33 P.M., the resident readmitted to the facility from the Geriatric/Psychiatric unit. Family members transported the resident. Record review of the resident's medical record showed no letter sent to the responsible party regarding the transfer on 5/30/18. Record review of the resident's nurse's notes showed the following information: -On 6/28/18, at 3:46 P.M., the resident discharged from the facility and admitted to a Geriatric/Psychiatric unit. The resident's family provided transportation to the Geriatric/Psychiatric unit. The family signed the consent forms for the admission to the Geriatric/Psychiatric unit. The facility did not document sending a written notice to the resident, resident representative, or to the Ombudsman regarding the discharge; -The resident re-admitted to the facility on [DATE] following the Geriatric/Psychiatric hospital stay. Record review of the resident's medical record showed no letter sent to the responsible party regarding the transfer on 5/30/18 or the 6/28/18. 4. Record review of Resident #52's nurses' notes showed the following information: -On 7/01/18, at 1:52 P.M., an at risk progress note showed the resident had a fall and staff found the resident on the floor in front of his/her roommate's bed with his/her feet tangled together and with his/her tooth brush in hand. Staff asked what the resident had been doing and he/she said trying to wrap his/her tooth brush. The resident was alert and oriented to person, place, and time. The resident complained of severe pain in his/her left hip. Staff called the physician and gave an order to send the resident to the emergency room for evaluation and treatment due to possible fracture of left lower extremity. All other notifications made per facility protocol. The hospital reported the resident had a fracture to his/her left hip. When the resident returns from the hospital, therapy will evaluate the resident for safety with ambulation, transfers, and mobility of left lower extremity. The facility did not document a written notice of the discharge to the hospital had been given to the resident, resident's representative, or to the ombudsman; -The resident readmitted to the facility on [DATE]. Record review of the resident's medical record showed no letter sent to the responsible party regarding the resident's transfer on 7/01/18. 5. Record review of Resident #34's nurses' notes showed the following information: -On 10/5/18, at 1:53 A.M., upon inspection, the resident's percutaneous endoscopic gastrostomy (PEG) tube was out and lay on the resident's abdomen. While staff assessed the tube, it appeared the balloon broke on the side and would not hold air. The nurse and two aides cleaned up the resident and the bed. The staff tried to reinsert the catheter tubing, but the resident was not relaxed and was coughing, making it impossible to reinsert the catheter. Staff contacted the resident's guardian regarding the issue. The guardian said to let the resident rest until morning and try to reinsert the catheter tube at that time. Staff informed the resident of this information and staff sent a note to the physician. -At 9:10 A.M., the physician directed the staff to take the resident to the hospital. Staff notified the guardian to let him/her know the ambulance was transporting the resident to the hospital. -At 7:25 P.M., the guardian called and let the facility know the hospital did get the PEG tubing back in. The resident had an elevated temperature and congestion and he/she would be admitted . Record review of the resident's medical record showed no letter sent to the resident, responsible party, or to the Ombudsman regarding the resident transfer to the hospital or admission to the hospital on [DATE]. During an interview on 10/15/18, at 5:05 P.M., the resident's guardian said facility staff contacted him/her by phone regarding the resident going to the hospital. He/she never received any written document regarding the transfer and admission to the hospital. There is just an understanding the resident will return to the facility when he/she is released from the hospital. During an interview on 10/18/18, at 9:47 A.M., the Director of Nursing (DON) said she did not realize they were to send written documentation of hospitalization s and they usually contacted the parties. She did not think Resident #34's guardian received a letter, but was called. 6. Record review of Resident #39's nurses' notes showed the following information: -On 7/30/18, at 11:38 A.M., the nurse obtained a bowel movement sample that morning. The bowel movement was very dark black, with red blood also around the bowel movement. Staff placed a call to the nurse practitioner (NP) at approximately 9:30 A.M., still awaiting return call; -On 7/30/18, the NP returned the call and wanted stat (immediate) complete blood count (CBC) and computerized tomograph (CT) scan of abdomen. The only way to do all the tests is to send the resident to the emergency room (ER). The resident requested a specific hospital. The resident left via ambulance at 2:30 P.M. Staff notified the family member of the transfer, who was currently at the facility. Staff did not document they sent a written notice of transfer to the resident, the resident's representative, or the Ombudsman. Record review of the resident's social service note, dated 7/31/18, at 9:37 A.M., showed a discharge note. Resident #39 sent to the hospital yesterday, no bed hold will be paid. Continue to monitor until readmission is complete. Staff did not document they sent a written notice of the transfer to the resident, the resident's representative, or the Ombudsman. Record review of the resident's nurses' notes, dated 8/3/18, at 6:08 P.M., showed the resident returned via home van at 3:15 P.M. Record review of the resident's nurses' notes showed the following information: -On 8/15/18, at 1:43 P.M. (late entry) resident taken to the hospital via family car for hemoglobin of 7.0. The physician's office called with the low values and wanted the resident to go to the hospital to received blood and stay overnight for a scope on 8/16/18. All appropriate papers sent to the resident's representative; -On 8/19/18, the resident returned from the hospital and placed in his/her old room. Staff did not document they sent a written notice of transfer to the resident, the resident's representative, or the Ombudsman. Record review of the resident's medical record showed no letter sent to the responsible party regarding the transfers on 7/30/18 and 8/15/18. 7. Record review of Resident #54's nurses' notes showed the following information: -On 10/13/18, at 5:13 P.M. the resident was slow to respond, cool to touch, pale in color, current blood glucose was 130. On call physician notified of change in baseline and gave order to send the resident to the ER for evaluation and to treat as indicated. Staff spoke to the resident's family by telephone at 4:55 P.M. and was told to send the resident to a particular hospital. -On 10/13/18, at 8:57 P.M., the resident admitted to the hospital with [REDACTED]. Staff notified the resident's family about the bed hold via telephone and bed hold paperwork was sent on transfer. Staff did not document they sent a written notice of the transfer to the resident, the resident's representative, or the Ombudsman. Record review of the resident's medical record showed no letter sent to the responsible party regarding the transfer on 10/13/18. 8. During an interview on 10/17/18, at 3:12 P.M., Registered Nurse (RN) A said the only notification the nurses send to the family or resident is regarding the bed hold policy. The nurses do not send out the transfer notification letter to the family. RN A said social services or the business office might handle mailing out this notification. 9. During an interview on 10/17/18, at 2:23 P.M., the social services director (SSD) said if a resident is hospitalized , the facility will try to contact the family. She did not know of any type of letter being sent. The social services director said she does not mail the transfer notification letter to the family. If this notification is sent, it might be completed by the nurses or the business office. 10. During an interview on 10/18/18, at 11:07 A.M., the business office manager said he/she does not mail out a notification or transfer letter to the resident or the family. The only information provided by mail or in the transfer packet from the nurses' station is the bed hold notification. 11. During an interview on 10/18/18, at 3:45 P.M., the Director of Nursing (DON) said the facility had given verbal notices to all of the families for the residents' transfers to the hospital. She said she did not know the facility was required to give written notices to the resident, resident's representative, or to the Ombudsman. The DON said the facility had contacted the Ombudsman to find out how the Ombudsman would like to be notified of all the residents sent to the hospital. The facility and Ombudsman have agreed the facility would send a report to the Ombudsman at the end of each month with a list of residents who went to the hospital. 12. During an interview on 10/19/18, at 12:45 P.M., the administrator said she misunderstood about the written discharge notices that had to be sent to the resident, resident representative, and Ombudsman. The DON had been sending a report to the corporate office not a written notification to the Ombudsman, resident, or resident representative. They have already spoken to the Ombudsman and have compiled a report for the previous months and have made arrangements to send a report to the Ombudsman at the end of each month with a list of residents who had been transferred to the hospital. The facility will begin these notifications to the residents, residents' responsible party, and the Ombudsman.

Based on observation and interview, the facility failed to provide a switch in all toilet rooms which would activate the resident call light system when activated by omitting the switches in two toilet rooms located near the service hall. This deficient practice had the potential to affect all residents, staff, and visitors who might need to use the toilets and would need staff assistance. The facility had a capacity of 120 with a census of 78. 1. Observation on 10/17/18, at 11:00 A.M., showed two locked public toilet rooms located near the service hall. Both toilet rooms remained without a call light activation switch. During an interview on 10/17/18, at 2:45 P.M., the maintenance supervisor said he did not know of the need for call light activation switches in public toilet rooms.

Based on interview and record review, the facility failed to adequately monitor [MEDICATION NAME] (PT: test of clotting time made by determining the time for clotting to occur after [MEDICAL CONDITION] and calcium are added to plasma. This test evaluates the effect of administration of anticoagulant drugs) and International Normalized Ratio (INR) levels (system of standardizing [MEDICATION NAME] (PT) time in oral anticoagulant therapy) for three residents (Resident #5, #7, and #6) who received the medication [MEDICATION NAME] (oral anticoagulant). Resident #5 admitted to the hospital on [DATE] for a [DIAGNOSES REDACTED]. The facility failed to follow physician orders [REDACTED].#4, #8, #9, #10, and #11) for appropriate [MEDICATION NAME] dosing based on INR lab results in a facility with eight residents receiving [MEDICATION NAME] and with a total census of 91. Record review of the American Academy of Family Physician's Journal (1999) showed the following information: -[MEDICATION NAME] (generic form of [MEDICATION NAME]) is the oral anticoagulant most frequently used to control and prevent [MEDICAL CONDITION] disorders. Prescribing the dose that both avoids hemorrhagic complications and achieves sufficient suppression of [MEDICAL CONDITION] requires a thorough understanding of the drug's unique pharmacology. [MEDICATION NAME] has a complex dose-response relationship that makes safe and effective use a challenge. For most indications, the dose is adjusted to maintain the patient's International Normalized Ratio (INR) at 2 to 3. -When a patient is started on an oral anticoagulant, INR monitoring should be performed on a daily basis until the INR is within the therapeutic range for at least two consecutive days. Then INR monitoring should be performed two to three times a week for one to two weeks. If the patient remains stable, this interval can be widened to a monitoring frequency of once every four to six weeks. If dosage adjustments are necessary, INR monitoring should be performed more often until a new state of stability is achieved. -Because [MEDICATION NAME] has a long half-life, increases in the INR may not be noted for 24 to 36 hours after administration of the first dose, and maximum anticoagulant effect may not be achieved for 72 to 96 hours. 1. Record review of Resident #5's discharge summary from the hospital, dated 4/30/12, showed the following information: -Final [DIAGNOSES REDACTED]. -Probable pneumonia, cultures negative, treated with intravenous antibiotics. Will discontinue all antibiotics; -Left [MEDICAL CONDITION], status [REDACTED]. -[MEDICAL CONDITION] secondary to acute blood, resolved, status [REDACTED]. -Moderate [MEDICAL CONDITION]; -Special instructions goal: INR 2-3, pharmacy to dose accordingly and discharge medications included aspirin 325 mg daily (nonsteroidal [MEDICAL CONDITION]). Record review of the hospital discharge order medication profile, dated 4/30/12, showed the following information: -The resident received [MEDICATION NAME] 2.5 mg on 4/29/12, at 5:59 P.M.; -The physician ordered [MEDICATION NAME], pharmacy to dose daily according to the goal INR of 2-3. Record review of the patient transfer form from the hospital to the facility, dated 4/30/12, showed the following information: -Primary [DIAGNOSES REDACTED]. -Alert and oriented; -Medication list, including Aspirin 325 mg daily and [MEDICATION NAME], pharmacy to dose for goal INR 2.0-3.0. Record review of the nurses' notes, dated 4/30/12, at 6:49 P.M., showed the resident arrived to the facility at 5:45 P.M. per ambulance. Record review of the active orders on the April 2012 POS, reviewed by a nurse on 5/1/12, showed the following information: -On 4/30/12, the physician ordered aspirin 325 mg every day; -The orders did not include any information about [MEDICATION NAME] or PT/INR orders. Record review of the April 2012 MAR indicated [REDACTED]. Record review of a partial copy of the transfer form medication list, showed an order written [REDACTED]. On 5/2/12, licensed practical nurse (LPN) A noted the order. The copy had the date 5/2/12, at 12:00 P.M. from the physician's office at the top left hand part of the page. Record review of the nurses' notes, dated 5/2/12, at 1:52 P.M., showed LPN A documented receiving orders for [MEDICATION NAME] 5 mg, one at suppertime and PT/INR on 5/5/12. Record review of two laboratory reports, with collection date of 5/1/12 showed the following information: -One with a reported date of 5/2/12, showed the [MEDICATION NAME] level was 25.4, INR 2.1; -LPN A faxed the laboratory report on 5/2/12; -The other laboratory report had a reported date of 5/1/12 with the same levels, showed registered nurse (RN) B faxed it on 5/3/12. Record review of the nurses' notes, dated 5/2/12, at 11:45 A.M., showed LPN A called the laboratory regarding the PT/INR that was drawn yesterday (5/1/12). The nurse documented he/she had not received the laboratory report yesterday. The nurse documented he/she would call the physician's office again. The nurse was trying to help the facility staff follow-up yesterday and could not find the resident in the system. Record review of a fax of the laboratory report, with collection date of 5/1/12, showed the physician's office faxed the reply on 5/3/12. The physician ordered to continue [MEDICATION NAME] 5 mg every day and to recheck the PT/INR on 5/4/12. LPN C noted the order on 5/3/12. Record review of the nurses' notes, dated 5/3/12, at 9:46 A.M., LPN C documented receipt of an order from the resident's primary care physician for PT/INR drawn on 5/2/12 to continue [MEDICATION NAME] 5 mg every day and recheck the PT/INR on 5/4/12. Record review of the May 2012 MAR, showed an order dated 5/2/12, for [MEDICATION NAME] 5 mg, one tablet every day scheduled to be given at 5:30 P.M. Facility staff administered the first dose of [MEDICATION NAME] on 5/3/12. Per the hospital records, the resident received the previous dose of [MEDICATION NAME] 2.5 mg on 4/29/12 (3 days without any [MEDICATION NAME] administered). Record review of the laboratory test, collected on date 5/7/12, showed the [MEDICATION NAME] level was 26.2, INR level was 2.5. RN B faxed the laboratory results on 5/7/12. Record review of the care plan, dated 5/11/12, showed the following information: -At risk for skin breakdown; -Please monitor and report any changes, skin tears, or bruising while providing daily cares; -The resident has medications that have a "Black Box Warning" that need to be monitored; -If my health status changes, please have physician review medications for potential change; -Monitor labs/diagnostic tests as ordered by physician; -Pharmacist to review medications monthly and as needed; -Please monitor and report any concerns to the physician immediately; -Please note medications that have a black box warning on the physician order [REDACTED]. -See the MAR indicated [REDACTED]. -The care plan did not address [MEDICATION NAME] or any precautions to watch for while on [MEDICATION NAME]). Record review of the skilled charting nurses' note, dated 5/16/12, showed the resident alert and oriented. The resident said he/she was very tired from the trip to the physician's office. The resident is able to feed self and take fluids without difficulty. Record review of the skilled charting nurses' notes, dated 5/18/12, at 4:33 A.M., showed the resident alert and oriented, and independent with eating. The nurse documented the resident is turning call light on frequently at night, sometimes for bedpan and sometimes because he/she is confused. The resident's lungs were clear and temperature was 97.6 degrees. Record review of the skilled charting nurses' notes, dated 5/19/12, showed the following information: -At 3:29 A.M., the resident was alert and oriented, lungs clear, temperature 98.7 degrees with an oxygen saturation of 91% on room air. -At 10:31 A.M., the resident is alert to name, but not to time and place. The resident's lungs are clear. -At 8:43 P.M., the resident is oriented with clear lung sounds. The resident's family member reported the resident had been coughing a lot and it was dark green. The resident had a temperature of 100.3 degrees, oxygen saturation was 86% on room air. The nurse listened to the resident's lungs and assessed the resident had drainage down his/her throat. The nurse discussed with the family member he/she would get oxygen and medication to bring down the temperature. The nurse called the physician and asked for treatment for [REDACTED]. The nurse said this was done. [MEDICATION NAME] (antibiotic) 750 mg for 5 days and mobile chest x-ray ordered. Unless the condition worsens to life threatening, the x-ray won't be called until Monday because that is x-ray's protocol. The resident's oxygen saturation increased to 94% on two liters of oxygen. Record review of the telephone order, dated 5/20/12, at 1:00 A.M., the physician discontinued [MEDICATION NAME] due [MEDICATION NAME]. The physician ordered [MEDICATION NAME] (cephalosporin antibiotic) intramuscularly (IM) 1 gram (gm), and Z-pack ([MEDICATION NAME], antibiotic) with first dose of 500 mg and then 250 mg for 4 days. Record review of the nurses' note, dated 5/20/12, at 3:33 A.M., the nurse documented receipt of orders from the emergency room physician for [MEDICATION NAME] 1 gm and to start the z-pack ([MEDICATION NAME]). The nurse faxed the pharmacy and talked to the pharmacist and received the okay to remove the [MEDICATION NAME] from the emergency kit. The nurse administered the injection. The nurse documented to notify family and the primary care physician in the morning. Record review of the nurses' note, dated 5/20/12, at 7:42 P.M., showed the resident coughed with congestion and drainage in throat. The resident's temperature was 99.5 degrees, oxygen saturation was 86% on room air. The nurse replaced the oxygen and the oxygen saturation level increased to 94%. Record review of the infection note, under the nurses' notes, dated 5/20/12, at 9:24 P.M., showed the nurse documented the resident had an episode of diarrhea with fresh blood in his/her bowel movement and also from the skin around the stoma ([MEDICAL CONDITION]). The nurse documented he/she would monitor this as possible adverse reaction to [MEDICATION NAME] IM the resident received. The nurse did not document notification to the physician regarding the signs of bleeding. Record review of the nurses' note, dated 5/21/12, at 9:37 A.M., showed LPN A notified the physician regarding the orders obtained over the weekend for the [MEDICATION NAME] 500 mg IM, one time, Z-pack ([MEDICATION NAME]), chest x-ray being obtained today, and reported the resident's vital signs. The nurse asked for orders for oxygen as needed. Record review of the radiology report, dated 5/21/12, showed no acute congestion, pneumonia, or effusion. Record review of the nurses' notes, dated 5/21/12, at 11:17 P.M., showed the RN B received results of the x-ray and relayed the results to the primary care physician at 3:30 P.M. The physician did not provide any new orders. Record review of the nurses' notes, dated 5/22/12, at 1:12 P.M., showed RN D documented the chest x-ray results were negative. The nurse left a message for the physician and also documented he/she would fax the written results to the physician's office. Record review of the skilled charting nurses' notes, dated 5/22/12, showed the resident reported a back ache with a level of pain of 6 out of 10. The nurse administered pain medication to the resident. Record review of the resident's 30 day Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 5/27/12, showed the following information: -Moderate cognitive impairment; -Required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene; -The resident currently had an ostomy ([MEDICAL CONDITION]); -[DIAGNOSES REDACTED]. -The resident had a weight loss of 5% or more in the last month; -The resident received an anticoagulant during the previous 7 days. Record review of the nurses' notes, dated 5/29/12, showed the nurse placed a call to the primary care physician regarding order request for speech therapy to evaluate and treatment for [REDACTED]. Record review of the active POS for June 2012, printed on 5/29/12, showed the following information: -The previous order on 4/30/12,for aspirin 325 mg every day; -Order date of 5/2/12 for [MEDICATION NAME] 5 mg, one tablet by mouth at 5:30 P.M. The order did not specify the frequency to be administered. -The POS did not list any orders for the frequency of the PT/INR to be checked. Record review of the skilled charting nurses' note, dated 5/30/12, the nurse documented the resident said he/she did not hurt, but was tired today. The resident was alert to name, but not always to time and place. Record review of the skilled charting nurses' note, dated 5/31/12, at 2:47 A.M., the nurse documented the resident was alert and oriented with occasional confusion. The resident has been confused this shift, asking to be taken off the bedpan when he/she is not on it. At 9:07 P.M., the nurse documented the resident was oriented with confusion. Record review of the skilled charting nurses' note, dated 6/1/12, at 11:01 A.M., showed LPN A documented the resident was alert and oriented. The resident's mouth was dry upon getting up. The staff gave the resident a drink and he/she was okay. The resident's intake was good for breakfast, feeding self with no problems noted. Staff transferred the resident per two staff from the bed to the wheelchair to the toilet. The resident had gone per the wheelchair in the van to Physician E's office for an appointment. Record review of the discharge summary, dated 6/1/12, at 2:22 P.M., staff did not take the resident's vital signs before he/she left for appointment with Physician E. The resident had gone to the physician's office for an appointment. The physician had the resident transferred to the emergency room to be evaluated. The hospital admitted the resident for [MEDICATION NAME] toxicity. During interview on 6/8/12, at 12:52 P.M., the family member said the staff never talked about the resident's medication/INR/blood. When the resident first admitted to the facility, he/she heard something about a blood test, but nothing since then. On 5/30/12, the facility called the family member and said there were problems with the van. The family member asked if it was okay to take the resident in a private van with help. On 5/31/12, the family member saw the resident in the afternoon. The resident was very tired and the family member could not get the resident aroused. Usually, the family member could just say the resident's name and the resident wakes up. After trying awhile, the family member decided to let the resident rest. The family spoke to the nurse about the resident begin tired and the nurse commented the resident was very sleepy today and did not wake up for his/her snack. The family member came back early evening of 5/31/12 and the resident was still asleep. The family member got the resident to wake up for awhile, but he/she was still concerned that the resident was not okay. The resident had no color. On 6/1/12, the family member arrived at the facility at approximately 7:45 A.M. The resident sat in the dining room at a table and had eaten a few bites. The resident's right arm was shaking and the resident's left arm was jerking. The family member said he/she could tell immediately something was not right. The family member took the resident to the room and pushed him/her to the sink. Usually, the resident would start reaching for water and toothbrush. The resident did not. The resident had a blank stare. The family member got the items together and the resident could barely brush his/her teeth at all. Two aides entered the room. The family member told them he/she thought something was wrong with the resident. The aides did not say anything and toileted the resident. The family member and staff took the resident to be loaded. The family member said he/she did not think it was a good idea, but the resident said "let's try". By the time, the resident arrived at the physician's office, the resident was getting worse and unresponsive at times. The family member went in and asked for someone to see the resident quickly. The physician looked at the resident and said the resident needed to be at the emergency room . This was at approximately 9:00 A.M. The resident went to the emergency room and initially declined treatment because he/she hurt so bad. But, once they figured out, the resident was bleeding and needed vitamin k and a transfusion, the resident agreed. During interview on 6/11/12, at 11:35 A.M. LPN A said the frequency for checking PT/INR depended on the original orders from admission. Sometimes, the physician gives a specific order for Tuesday and Thursday. Sometimes, a physician orders [REDACTED]. When the lab results come in, the nurse should call the physician immediately regarding the PT/INR results. Hopefully, the physician responds by the end of the day with a return call. If a PT/INR result comes back on a weekend, the nurse calls the on-call physician and gets orders. The nurse then calls the primary care physician on Monday. The nurse should document the physician's response to the laboratory results on the nurses' notes and on a telephone order form. The nurse said they have been instructed to not fax the physician of the laboratory results, but should call first. The nurse can then fax if the physician requests that. If a lab result is critical, the nurse said he/she calls and faxes the physician. When the lab is faxed, the staff writes the last laboratory results and the current [MEDICATION NAME] order. If the physician does not respond by the end of the shift, the nurse said he/she calls again and then passes it on to the next shift. If no response by the next day, then the nurse calls again in the morning. If the physician orders [REDACTED]. If it is the weekend, lab will not come and draw the lab on the weekend unless it is ordered STAT. Laboratory would come and draw it the following Monday. The nurse said 5/5/12 was a Saturday. That is why it was not drawn until 5/7/12. The nurse said the 5/7/12 PT/INR laboratory test would have come back on the evening shift. The nurse said the new nurses are being trained as they go along. RN B is a new nurse. The nurse said the resident went for a physician's appointment with Physician E and he/she noticed a difference in the resident. The nurse said he/she did not know what occurred. Either the physician's office or the family member told social services the resident was going to the hospital. At that time, they thought the resident had a possible stroke. The nurse called the hospital to find out what was going on with the resident and the hospital said the resident had been admitted for [MEDICATION NAME] toxicity. The nurse said the resident was pretty normal that morning. The resident was a "little slow on the draw", but the resident's vital signs were good. The resident had periods of confusion. The resident's speech was clear. The resident's mouth was dry when he/she got up; staff gave the resident a drink. The resident ate breakfast and fed self. The resident was fine when he/she left. He/she was able to respond and said he/she was hoping for a good report from the physician. The staff toileted the resident and he/she did okay. The resident was able to stand and turn. The resident did not have any shaking or jerking. At 1:13 P.M., the nurse said he/she was not aware of any bleeding episode with the resident. After discussing the note on 5/19/12, the nurse said "they" thought the bleeding might have been from the [MEDICATION NAME] and it was just one episode of bleeding. The nurse said on 5/21/12, he/she told the physician about the bleeding and having just been given the [MEDICATION NAME] IM. The physician said it might just have been "flushing out the impurities in the system". The nurse had called over the weekend (5/19/12) regarding the respiratory issues and received an order for [REDACTED]. During interview on 6/11/12, at 1:37 P.M., RN B said the laboratory results come in on the printer and staff lay the lab test results on the desk. The nurse said he/she faxed the lab to the physician's office on 5/7/12. After it was faxed, he/she placed it in the chart in the laboratory section. The nurse said he/she did not receive any response back from the physician personally. Since the INR fell in the therapeutic range, then it was just faxed. If it had been out of range, then he/she would have called. When questioned how he/she knew the physician received the fax, the nurse said they receive a confirmation sheet that the fax went through. The nurse said he/she did not know for sure if the physician saw the fax. The nurse said he/she did not remember anything abnormal with the resident. The nurse did not know about any bleeding and did not remember anyone reporting the resident having any bleeding. During interview on 6/11/12, at 3:20 P.M., the director of nursing (DON) said the resident had not been feeling well for a couple of days. The resident said, "don't feel good". The DON told the resident he/she had an appointment with the physician that morning. At the physician's office, the resident apparently blanked out and the office sent the resident to the hospital, thinking possible stroke or [MEDICAL CONDITION] (TIA). After the resident got to the hospital, the resident was admitted for [MEDICATION NAME] toxicity. The resident's INR was 9.2. When asked if she had reviewed the medical record and knew what happened, the DON said yes, she did. The resident discharged from the hospital with orders to keep the INR between 2 and 3. The resident did not have specific orders for [MEDICATION NAME] so the staff got an order for [REDACTED]. Staff did not get an order for [REDACTED]. After it was faxed on 5/7/12, the nurse should have put a copy in the 24 hour book to ensure follow-up. Typically, the DON expects a response from the physician for when the next draw is to be completed. The medical records nurse should have caught that there was no response from the physician and followed up. Last Thursday (June 7, 2012), the administrative staff began reviewing all telephone orders, any medication orders to ensure they got placed on the MAR indicated [REDACTED]. The administrative staff is checking every morning for this. The night shift prints off the physician orders, telephone orders and making sure they get followed up on also. The DON and ADON are reading every nurses' note and making sure follow-up is completed. During interview on 6/13/12, at 2:21 P.M., the resident's physician, Physician G at the facility, said the facility had not notified him/her of the situation with the resident. The physician said he/she saw the resident the end of May. Upon reviewing his/her records, the physician said 5/25/12 would have been the last time he/she might have seen the resident. The physician said he/she did not remember if he/she saw the 5/7/12 PT/INR. The physician said he/she gets so many that he/she could not remember specifically. When questioned about the different orders received and which one came from where, the physician said he/she had a note in the office records of a PT/INR order to be drawn on 5/5/12. The physician said he/she would expected it to be drawn on 5/5/12 as ordered and then staff should let him/her know the results. When given the values and the situation leading up to the lab test on 5/7/12, the physician said if someone is stable, then he/she would recheck the PT/INR in a month. If they are adjusting the levels, then he/she would have wanted it checked in 1-2 weeks. The physician said no one had notified him/her the resident was no longer in the facility. The physician said he/she was certainly not aware the resident had been admitted to the hospital intensive care unit (ICU) for [MEDICATION NAME] toxicity. The physician had not been made aware the resident was in the hospital. During interview on 6/13/12, at 1:30 P.M., the medical director, Physician F, said he had not been made aware of the situation that occurred with the resident. 2. Record review of Resident #7's care plan, reviewed on 2/29/12, showed it did not address [MEDICATION NAME] and precautions while taking [MEDICATION NAME]. Record review of active POS for February 2012, showed the following information: -On 2/15/12, the physician ordered Baby aspirin, 81 mg, give one daily; -On 2/15/12, the physician ordered [MEDICATION NAME] 5 mg, at 6:00 P.M. The order did not specify how often it was to be given; -On 2/15/12, the physician ordered [MEDICATION NAME] 90 mg injection (anticoagulant) every 12 hours. Record review of the lab report, with collection date of 2/16/12, showed [MEDICATION NAME] level was 14.0, INR 1.2. Staff faxed the lab report on 2/17/12. On 2/17/12, the physician faxed back with two questions to the staff: " Is patient on [MEDICATION NAME]? How much [MEDICATION NAME]? " On 2/17/12, the nurse faxed the lab report to the physician telling the physician the resident is on [MEDICATION NAME] 5mg every day. Record review of the lab report, with collection date of 2/17/12, showed the [MEDICATION NAME] level was 17.3 and INR was 1.5. The nurse documented the physician reviewed the lab results on 2/17/12, at 5:20 P.M. Record review of the telephone order form, dated 2/17/12, showed the physician ordered: -Increase [MEDICATION NAME] to 6 mg every day; -Check PT/INR every 3 days for 12 days; -When PT/INR is 2.0 or greater, discontinue the [MEDICATION NAME]. Record review of three lab reports, with collection date of 2/20/12, showed the [MEDICATION NAME] level was 22.4 and the INR was 1.9. The remote print date was 2/20/12. On 2/21/12, LPN A wrote on one lab report [MEDICATION NAME] was given this morning and faxed the report on 2/21/12. On a second lab copy, the physician wrote on 2/21/12, discontinue the [MEDICATION NAME]. On 2/22/12, the nurse noted the order. On 2/22/12, staff faxed another lab copy. Staff wrote on the lab, [MEDICATION NAME] discontinued 2/22/12. The staff asked if the physician wanted PT/INR continued every third day for 12 days as requested. Record review of the lab report, dated 2/23/12, showed [MEDICATION NAME] level was 27 and the INR was 2.3. Staff faxed the lab on 2/23/12. On 2/24/12, the physician ordered no change in [MEDICATION NAME] dosage. Record review of the active POS March 2012, printed on 2/29/12, showed the following information: -The previous order 2/15/12 of aspirin 81 mg, one tablet every day; -The previous order 2/17/12 for [MEDICATION NAME] 6 mg, at 4:00 P.M. The order did not reflect the frequency of the dose. -The POS contained the order dated 2/17/12 for PT/INR to be checked every 3 days for 12 days. The POS did not contain any other orders for PT/INR monitoring. Record review of the March 2012 MAR indicated [REDACTED]. Record review of the lab report, collected on 3/1/12, showed [MEDICATION NAME] 40.1 and INR 3.2. Staff faxed the lab on 3/4/12. Record review of the telephone order, dated 3/4/12, showed the physician ordered: - Continue [MEDICATION NAME] 6 mg for 5 days. -Give [MEDICATION NAME] 3 mg the other two days. -Redraw PT/INR in 10 days. -Continue to monitor stools. If diarrhea starts again, call Physician F. Record review of the active physician orders [REDACTED]. -On 3/4/12, the physician ordered [MEDICATION NAME] 3 mg, one tablet two times a week. Record review of the nurses' note, dated 3/5/12, showed Physician F called at 1:50 P.M. for PT/INR on Thursday (3/8/12) Record review of the nurses' note, dated 3/6/12, at 9:37 A.M., the nurse documented orders for PT/INR on Thursday, 3/8/12. The requisition in the lab book is for 3/13/12 (Tuesday). The nurse documented the specimen will be needed before then. Record review of the nurses' note, dated 3/9/12, at 8:51 A.M., showed the following orders received per fax from Physician F. The physician ordered to hold [MEDICATION NAME] on 3/9/12 and 3/10/12 and start [MEDICATION NAME] 4 mg every day on 3/11/12. PT/INR in one week, lab notified. Record review of the active physician orders [REDACTED]. -On 3/9/12, the physician ordered [MEDICATION NAME] 4 mg, one tablet at 5:30 P.M. The order did not specify the frequency for the medication to be administered. -On 3/9/12, the physician ordered PT/INR in one week on 3/15/12. Record review of the March 2012 MAR indicated [REDACTED]. On 3/9/12 and 3/10/12, staff held the [MEDICATION NAME]. On 3/11/12, staff handwrote an order for [REDACTED]. On 3/16/12, staff did not initial administering [MEDICATION NAME]. Record review of the March 2012 consolidated orders report, did not show any orders to hold [MEDICATION NAME]. The orders reflected the order for [MEDICATION NAME] 3 mg, two days a week and [MEDICATION NAME] 4 mg, at 5:30 P.M. It did not reflect the frequency for administration of the 4 mg. (This report should reflect all orders that were input into the system and remained in the system during the month of March 2012. Record review of the lab report, collected on 3/8/12, showed the [MEDICATION NAME] 62.3 and INR 4.9. The nurse faxed the report on 3/8/12. The nurse wrote on the lab the resident currently received [MEDICATION NAME] 6 mg. Record review of the lab report, collected on 3/15/12, showed the [MEDICATION NAME] was 26.6 and INR 2.2. The nurse faxed the report on 3/15/12. On the lab report, the nurse wrote the resident received [MEDICATION NAME] 4 mg, with order date of 3/11/12. Record review of the lab report, collected on 3/22/12, showed the [MEDICATION NAME] was 46 and INR was 3.7. The nurse faxed it on 3/26/12. The nurse wrote on the lab the resident currently received [MEDICATION NAME] 6 mg every day that started on 2/17/12. (The current order was for [MEDICATION NAME] 4 mg that began on 3/11/12). It is unclear where the order was for this PT/INR to be collected is located. Record review of the nurses' notes, dated 3/26/12, showed the nurse faxed the lab values to the physician. Record review of the nurses' notes, dated 3/27/12, at 9:24 A.M., the physician ordered a repeat PT/INR today and staff to call with results. Record review of the active physician orders [REDACTED]. -On 3/27/12, the physician ordered repeat PT/INR today, one time only; Record review of the lab report, collected on 3/27/12, showed the [MEDICATION NAME] was 34.5 and INR was 3.5. The therapeutic range listed was 2.0-3.5. The nurse called the results to Physician F's office on 3/28/12. Record review of the nurses' notes, dated 3/28/12, at 11:38 A.M., the nurse documented lab values received and called to Physician F's office. Record review of the lab report, collected on 3/29/12, showed the [MEDICATION NAME] was 58.9 and INR was 4.6. Record review of the nurses' notes, dated 3/29/12, at 11:46 A.M., the physician ordered PT/INR in one week. Record review of the active physician orders [REDACTED]. -On 3/29/12, the physician ordered PT/INR in one week one time, 4/5/12. Record review of the lab report

Based on interview and record review, the facility failed to assess, monitor, and obtain treatment in a timely manner for one resident (Resident #1), who had increased pain, decreased oxygen saturation level and a significant decline after a fall which resulted in a [MEDICAL CONDITION] that required admission to the hospital. The facility failed to assess, monitor, and obtain treatment in a timely manner for one resident (Resident #4), who fell and sustained a [MEDICAL CONDITION] in a facility with a census of 93. 1. Record review of Resident #1's care plan, dated 4/28/10, showed the following information: -Staff to provide set-up/supervision with verbal cues and physical prompts as needed for bed mobility, ambulation, transfers, dressing, eating, and oral hygiene. -Monitor for layering of clothes and ensure adequate personal hygiene. The resident dribbles a little or does not get completely wiped good per self after bowel movements. The resident occasionally needs limited to extensive assistance for adequate personal hygiene. -Encourage continued active participation in all activity of daily living; -Refer to therapy for screening of any new onset activity of daily living (ADL) declines that are sustained greater than two weeks that are not self-limiting; -Monitor for any changes in usual gait pattern, balance, and report any declines sustained greater than two weeks for possible need of therapy referral; -Encourage prompted toileting upon waking, before and after meals, bedtime; -Alterations in comfort: rare complaints of pain, is now on as needed [MEDICATION NAME] program to promote comfort. Record review of the skin condition note, dated 8/23/11, at 2:32 P.M., showed the resident was up with assist of one staff. The resident ambulated without assistive devices, but needed stand by assist of one staff. Record review of the pain flow sheet, dated 8/10/11 through 8/31/11, showed the resident had initial pain ratings of 4-6. Staff documented the reason for administration of [MEDICATION NAME] was for knee pain, rubbing wrists and/or knees, grimacing, and complaints of pain. The follow-up pain rating showed the resident did not have any pain. Record review of the quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 9/10/11, showed the following information: -Short and long term memory problems; -Severely impaired decision-making skills; -Required extensive assistance for bed mobility, transfers, dressing, and walking in the room and corridor; -Total dependence on staff for toilet use and personal hygiene; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -The resident could not answer questions regarding pain; -The staff documented the following indicators of pain in the previous 5 days: facial expressions and protective body movements. Record review of the skin condition note, dated 9/14/11, at 3:34 P.M., showed the resident was up with assist of one staff member. Stand by assistance of one staff was required for ambulation due to confusion. The resident was able to position and reposition self independently. Record review of the pain flow sheet, dated 9/1/11 through 9/23/11 at 4:00 A.M., showed the resident's initial pain ratings were a range of 4-8. The resident complained of leg pain, breast area pain and showed grimacing and moaning. The follow-up pain ratings ranged from the resident did not have pain to a pain level of "4". Record review of the nursing progress notes, showed the following information: -On 9/23/11, at 10:24 A.M., the nurse documented the resident had a fall at 7:00 A.M. The nurse documented the resident did not have any signs of pain and vital signs were: temperature 97.8 degrees, pulse 80, respiratory rate 18, and blood pressure 120/70. The resident's oxygen saturation rate was 96% on room air. The resident had a scrape to the right knee and right elbow. Staff checked the resident's range of motion, recorded his/her vital signs, and assisted the resident to a standing position, then checked the resident for range of motion. The nurse notified the on-call physician at 9:30 A.M.. Record review of a fax transmission cover sheet, dated 9/23/11, showed staff notified the physician regarding the fall. The nurse documented the resident fell in his/her room, stumbled, and sustained an abrasion to the right elbow and knee. The resident did not have any other injury. Record review of the nurses' notes showed the following information: -On 9/23/11, at 11:00 A.M., the resident had emesis, temperature of 101.1 degrees and oxygen saturation rate of 87% on room air. The nurse documented there were no orders to treat the nausea and vomiting, so the nurse notified the physician. -On 9/23/11, at 1:02 P.M., the nurse documented the physician returned his/her call and ordered Tylenol 500 mg suppository every six hours for temperature elevation and a medication for the nausea and vomiting. If the vomiting persisted, staff should send the resident to the emergency room . The resident's temperature at this time was 101.7 degrees. -On 9/23/11, at 5:00 P.M., the resident's temperature was 102.1 degrees. The nurse administered a Tylenol suppository. During an interview on 2/8/12, at 12:34 P.M., licensed practical nurse (LPN) A said the staff called the physician probably about the emesis and the oxygen saturation levels. The physician gave an order for [REDACTED]. Record review of the pain flow sheet showed the following information: -On 9/23/11, at 10:45 P.M., staff used the Wong/Baker Face pain scale, and documented the resident's initial pain rating as "8". Staff documented the reason for pain medicine administration was for pain to breasts and grimacing. The resident's follow-up pain rating was "2". -On 9/24/11, at 9:05 A.M., staff used the face scale and documented an initial pain rating of "6". Staff documented the resident moaned and rubbed legs. On follow-up, the pain rating was "0". Record review of the nurses' notes, showed the following information: -On 9/24/11, at 10:16 A.M., the resident had a blood pressure of 80/56 and oxygen saturation rate of 76% on room air. The nurse applied two liters of oxygen per nasal canula. -On 9/24/11, at 3:35 P.M., the nurse documented the resident's oxygen saturation rate was 70% on room air. The nurse placed oxygen on the resident. The nurse documented he/she faxed the physician regarding this and asked for an as needed oxygen order. According to Mosby's Manual of Diagnostic and Laboratory Tests, normal pulse oximetry value in the elderly should be equal to or greater than 95% and a critical pulse oximetry value when equal to or less than 75%. During interview on 2/8/12, at 12:34 P.M., LPN A said, referring to the nurses' note on 9/24/11, he/she would probably call the physician at that time because he/she tends to "freak out" when the oxygen saturation level is in the 70's. The fax would be in the paper chart. Sometimes, the physician would put his/her response on the fax or as a verbal order. If the physician did not respond, the facility staff would know because the central supply monitors the equipment and they would question the use of oxygen without an order. After the fax is addressed, the fax confirmation sheet is thrown away. Record review of the pain flow sheet showed the following information: -On 9/24/11, at 5:10 P.M., staff used the pain and number pain scale. The resident's initial pain rating was "6". Staff documented the resident was in bed grimacing. The resident's follow-up pain rating was "none". Record review of the pain flow sheet, dated 9/25/11, at 1:00 A.M., showed the staff used the face scale and documented the resident's initial pain rating was an "8" and the resident was hollering out when turned. Staff wrote "right hip/thigh" as the location of the pain with question marks behind it. Staff administered Tylenol 500 mg, two tablets for the pain. The follow-up pain rating was "2". Record review of the nurses' notes, showed the following information: -On 9/25/11, at 1:51 A.M., the nurse documented staff noted the resident hollered out when turning during pericare. The resident hollered and braced his/her self as if to prevent being turned because of pain in the right leg. The resident did not acknowledge pain when the nurse gently palpated the right hip and thigh, but hurt when the leg was moved. The resident had a temperature of 100.3 degrees and oxygen saturation rate was 92% on room air. The resident took the oxygen off at intervals, but did reapply satisfactorily. The nurse gave the resident Tylenol 500 mg, two tablets for the elevated temperature and pain. -On 9/25/11, at 8:18 A.M., LPN A spoke to the resident's family and notified him/her of the resident's knee and hip still aching and staff administered pain medication for that and the fever. The resident's family member said he/she would like to wait until Monday to have x-ray come so the resident did not have to be sent out of his/her environment to the emergency room . The nurse documented he/she would fax the physician today and ask for an x-ray to rule out [MEDICAL CONDITION] knee and hip. -On 9/25/11, at 10:46 P.M., the nurse documented the resident cried out when being rolled in bed and family wanted to have the x-ray done tomorrow just to be sure the resident's hip was okay after the fall. The resident's oxygen saturation rate had been in the 60's to 70's without oxygen. The night nurse just told this nurse the resident was in bed without oxygen and the resident's oxygen saturation level was 45% on room air and the nurse placed oxygen on the resident. The resident's family did not want the resident sent out because he/she cannot communicate with people and just laughs. During interview on 2/8/12, at 12:34 P.M., LPN A said 9/25/11 was on a weekend. The resident's family said to wait until Monday for the x-rays. The family did not want the resident sent out. The resident's oxygen saturation was dropping. That was not normal for the resident. The nurse said applying oxygen was nursing judgment. They applied oxygen to the resident and then watch the resident for couple days. Staff remove the oxygen when the resident goes to a meal and rechecks the oxygen level after the meal. If the oxygen saturation level is still dropping, then they call the physician to get an order for [REDACTED]. Record review of the pain flow sheet, showed the following information: -On 9/25/11, at 11:45 A.M., the resident's initial pain rating was "6" per the face scale. Staff documented the resident rubbed his/her leg and hip and grimaced. On follow-up, the resident's eyes were shut. -On 9/25/11, at 2:10 P.M., the resident's initial pain rating was "6" per the face and number scale. The resident showed grimacing. The follow-up pain rating was "2". -On 9/25/11, at 6:35 P.M., the resident's initial pain rating was "6". The resident showed grimacing. The follow-up pain rating was "2". Record review of the nurses' notes, showed the following information: -On 9/26/11, at 12:18 A.M., the nurse documented staff found the resident in bed at 10:30 P.M., without oxygen on and the resident's oxygen saturation rate was 44%. The nurse placed two liters of oxygen on the resident. The resident's oxygen saturation level increased to 66%. -On 9/26/11, at 12:10 A.M., the level increased to 84% on two liters of oxygen. -On 9/26/11, at 4:36 A.M., the resident's oxygen saturation level was 84% on two liters of oxygen. Staff checked the resident's oxygen level several times this shift and it has stayed between 82% and 85% with two liters of oxygen. -On 9/26/11, at 12:46 P.M., the nurse called and faxed the physician requesting an x-ray. The physician had not responded at this time. Record review of the nurses' notes, showed the following information: -On 9/27/11, at 9:45 A.M., the resident's oxygen saturation level was 80% on room air. The nurse documented the resident's oxygen was in place this morning. The resident did much better with standing today. The resident ambulated from the main shower room to the restorative room. -On 9/27/11, at 12:41 P.M., the nurse faxed the physician regarding a laboratory test. The physician faxed back regarding the laboratory request. The nurse called the physician regarding the other faxes and the physician said he/she had not received them. The nurse re-faxed the physician and received confirmation the physician had received them. The nurse documented he/she was waiting for further orders regarding the oxygen order and x-ray order. The resident was much improved over what he/she had been and the oxygen levels were still varying. Record review of the restorative nursing notes, dated 9/27/11, at 12:55 P.M. to 1:18 P.M., showed the restorative aide had the resident stand with assistance. The resident would take a few steps and try to sit. The resident showed signs of discomfort when trying to step with the left leg. The aide reported it to the charge nurse. Record review of the pain flow sheet, dated 9/27/11, at 6:30 P.M., showed the resident's initial pain rating was "6" per the face and number scale. The resident showed grimacing. The follow-up pain rating was no pain. Record review of the nurses' notes, dated 9/28/11, at 12:30 P.M., showed the resident's oxygen saturation level was 93% on room air. The resident did not complain of pain. The resident's oxygen saturation level, while at rest, was 93% on room air. The resident's oxygen level later dropped to 79%. Staff placed oxygen on the resident and the level increased to 92%. Record review of the pain flow sheet, dated 9/28/11, at 3:50 P.M., showed the resident's initial pain rating was a "6" per the face and number scale. The resident showed grimacing. The follow-up pain rating was no pain. Record review of the nurses' notes, dated 9/30/11, at 12:30 P.M., showed the resident's oxygen saturation level was 88% on room air. The resident had been working with the restorative aide and did part of what was asked, but refused to stand for him/her. The resident was resistant to getting up from the chair. The resident did not complain of pain. Record review of the pain flow sheet, dated 9/30/11, at 3:40 P.M., the resident's initial pain rating was "6" per the face scale. The resident showed grimacing. The follow-up pain rating was no pain. Record review of the restorative nursing notes, dated 10/2/11, at 9:00 A.M. to 9:20 A.M., showed the aide documented the resident did well with the lower extremity restorative. The resident went forwards and backwards. The resident would not stand. The resident pushed the aide away when he/she asked the resident to stand. The resident showed signs of discomfort. The aide reported it to the charge nurse. Record review of the nurses' notes, dated 10/3/11, at 12:53 P.M., the nurse documented the resident had been up ad lib (as desired) with assist of one staff. The resident did not stand well for nursing staff. Record review of the care plan, dated 4/28/10, showed on 10/3/11, staff wrote in for staff to assess pain, location, duration, type, intensity, what makes pain worse, and what makes pain better. Record review of the skin condition note, dated 10/4/11, at 4:26 P.M., showed the resident is up with assist of one staff member for transfer to bed or wheelchair. Record review of the restorative nursing notes, dated 10/4/11, at 8:45 A.M. through 9:00 A.M., showed the aide documented the resident showed signs of discomfort with the right leg. The aide showed it to the physical therapy staff. The PT staff said the nurse needed to see it. The aide was unable to get the resident to stand that day. Record review of the nurses' notes, dated 10/4/11, at 1:02 P.M., showed the nurse documented in a monthly summary the resident was total assist for all activities of daily living. The resident is unable to go to the bathroom per self. The resident has had some falls in the past two weeks and is still recouping from it. The resident's right leg is slightly [MEDICAL CONDITION] today. The resident does not complain of pain, but will not walk for staff. Record review of the nurses' notes, showed the following information: -On 10/5/11, at 9:22 A.M., the nurse documented an order from the physician to send the resident to the emergency room to rule out fracture and [MEDICAL CONDITION] of the right leg. The resident's right leg is significantly more swollen than the left. It is not red or warm to touch. Record review of Brunner and Suddarth's textbook of Medical-Surgical nursing, 7th edition, showed the following information: -The exact cause of venous [MEDICAL CONDITION] remains unclear, three antecedent factors are believed to play a significant role in its development: stasis of blood, injury to the vessel wall, and altered blood coagulation. The presence of at least two factors appears to be necessary for [MEDICAL CONDITION] to occur. -Direct vessel trauma, such as after a fracture or dislocation, can damage veins; -Venous [MEDICAL CONDITION] can occur in any vein but is most frequent in the veins of the lower extremities. [MEDICAL CONDITION] is inflammation of the walls of the veins, often accompanied by the formation of a clot. -Venous thrombi that grow larger has a danger of the clot detaching and producing occlusion of the [MEDICAL CONDITION] blood vessels. -Obstruction of the deep veins of the legs produces [MEDICAL CONDITION] and swelling of the extremity because the outflow of venous blood is inhibited. Record review of the hospital x-ray completed on 10/5/11, of the right tibia and fibula (lower leg), showed the two views of the right tibia and fibula were normal. The hospital did not x-ray the right hip during the hospital stay. Record review of the physician's progress note, dated 10/5/11, at 11:30 A.M., showed the physician saw the resident for swelling of the right leg after an injury two weeks ago. The x-rays were negative for fracture. The resident did have a [MEDICAL CONDITION] of the right leg. Record review of the nurses' notes showed the following information: -On 10/5/11, at 12:01 P.M., LPN A documented the resident has occasional episodes of low oxygen saturation levels between 60-85%. The nurse asked for an as needed order for two liters of oxygen as needed. -On 10/5/11, at 1:08 P.M., the nurse documented the resident had returned from the emergency room with a [DIAGNOSES REDACTED]. -On 10/5/11, at 4:07 P.M., the nurse documented receiving order for oxygen at two liters as needed (approximately 1 ? weeks after the initial low oxygen saturation levels) During interview on 2/8/12, at 12:34 P.M., LPN A said, in reference to the 10/5/11 nurses' note, the staff probably had not received an order for [REDACTED]. There might have been some confusion during the switchover. Staff should notify the physician of a low oxygen saturation level within 24 hours. Otherwise, usually within 24 hours, it will resolve on its own. If not, then something is wrong and staff should call the physician to be on the safe side. If a physician gives a verbal order, the nurse writes a telephone order and puts it in the computer Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Some physicians might write on a physician order [REDACTED]. Record review of the pain flow sheet, showed the following information: -On 10/5/11, at 3:50 P.M., the resident's initial pain rating was "6" per the face and number scale. The resident showed grimacing. The resident's follow-up pain rating was no pain. -On 10/6/11, at 2:40 P.M., the resident's initial pain rating was "4" per the face and number scale. The resident had "leg pain". The resident's follow-up pain rating was no pain. Record review of the skin condition note, dated 10/11/11, at 3:15 P.M., showed the resident is up with assist of one staff person to the wheelchair. Record review of a nursing communication form to the physician, dated 10/17/11, at 10:42 A.M., showed the nurse requested an order for [REDACTED]. Record review of the physical therapy evaluation, dated 10/18/11, showed the reason for referral as exacerbation of reduced ability to safely ambulate, pain, reduced functional activity tolerance and increased need for assistance from others placing patient at risk for increased pain, falls, and further decline in function and increased dependency upon caregivers. The physical therapy staff documented the resident's pain level at rest was 10 out of 10, constant. The location of the pain was the right lower extremity due to [MEDICAL CONDITIONS]. The resident could not describe the pain. The resident's pain level with movement was 10 out of 10, constant. The location of the pain was the right lower extremity due to [MEDICAL CONDITION]. The resident could not describe the pain. The pain level was determined based upon behaviors exhibited by the resident. The resident was defensive to touch and had reflexive responses, such as "ouch, "stop". The pain limits the resident's functional activities. The physical therapy staff clinical impression was the resident currently received treatment for [REDACTED]. The limb is still warm to touch, with redness and [MEDICAL CONDITION]. The resident is very defensive to touch and demonstrates severe protective mechanisms like thrusting back on the wheelchair when asked to lean forward or when preparing to get the resident up. The resident's bed mobility has been more difficult per the aide. Record review of the pain flow sheet, showed the following information: -On 10/23/11, at 1:00 A.M., the resident's initial pain rating per the face scale was an "8". The resident grimaced and moaned loudly with movement. The follow-up pain rating was "2". Record review of the skin condition note, dated 10/26/11, at 2:32 P.M., the resident is up with assist of two staff for transfer to the wheelchair. The resident is unable to propel self. Record review of the pain flow sheet, showed the following information: -On 10/26/11, at 3:40 P.M., the resident's initial pain rating per the face and number scale was "6". The resident grimaced and just had physical therapy. The follow-up pain rating was no pain. -On 10/29/11, at 1:00 A.M., the resident's initial pain rating per the number scale was "8". The resident moaned during cares. The follow-up pain rating was no pain. -On 10/31/11, at 2:00 A.M., the resident's initial pain rating per the face scale was "8". The resident moaned during perineal care. The follow-up pain rating was "2". Record review of the skin condition note, dated 10/31/11, at 10:49 A.M., showed the resident is up with assist of two staff for transfers and one staff for mobility. On 11/1/11, at 8:05 P.M., the nurse documented the resident up with assist of two staff for transfers to bed or wheelchair. The resident is unable to propel self. Record review of the November 2011 treatment administration record (TAR) showed staff assessed the resident's pain level as an "8" on 11/3/11 and 11/4/11 on the night shift. Record review of the November 2011 Medication Administration Record, [REDACTED]. Record review of the November 2011 TAR, showed the resident's pain level was "8" on 11/8/11 and "6" on 11/9/11 on the night shift. Record review of the November 2011 MAR indicated [REDACTED]. Record review of the pain flow sheet, showed on 11/12/11, at 1:45 P.M., the resident's initial pain rating was "8" per the number scale. The resident had pain. The follow-up rating showed the resident did not have pain. Record review of the nursing monthly summary, dated 11/13/11, at 1:30 P.M., showed the resident is up in the wheelchair per Hoyer lift (mechanical lift that completely lifts and transfers the resident from one location to another) with two staff assist due to the resident not standing well and less pain for the resident. Record review of the medicare/risk progress note, dated 11/16/11, at 11:01 A.M., showed the nurse documented the resident continued on physical and occupational therapy, but has increased pain with all activities and is very retropulsive. The resident is reluctant to complete therapy due to complaints of pain. The resident will not bear weight. The nurse documented nursing staff to follow-up on x-ray of the hip. Record review of the nurses' notes, dated 11/16/11, at 3:32 P.M., showed the nurse documented the resident continued to have swelling from the knee to the toes, very warm to touch. The resident continues to complain of extreme pain and will not bear weight on the right leg. Staff administers [MEDICATION NAME] 5/500 as needed for pain with very little relief. The nurse faxed the note to the physician on 11/16/11, at 4:05 P.M. Record review of the nursing communication form, dated 11/17/11, at 11:38 A.M., showed the nurse notified the physician the resident is currently unable to bear weight on the right leg, is treated with [MEDICATION NAME] for the [MEDICAL CONDITION], and is being monitored this way. Staff have used the Hoyer lift on the resident with two staff assist. The nurse told the physician he/she needed an order for [REDACTED]. The nurse asked the physician what can be done for pain management for the resident. Record review of the nurses' notes, dated 11/17/11, at 3:30 P.M., showed the physician called and requested the resident go to the emergency room for evaluation. Record review of the transfer note, dated 11/17/11, at 4:45 P.M., showed the nurse documented using Hoyer lift for transfers, no ambulation at this time, needs total assistance for bathing, dressing, and toileting. The resident is incontinent of bowel and bladder. The resident is confused and disoriented. The nurse documented an ambulance was at the facility to transfer the resident to the hospital. Record review of the nurses' notes, dated 11/17/11, at 6:22 P.M., showed the emergency room called and reported a [DIAGNOSES REDACTED]. The plan was to send the resident back to the facility and do surgery on Monday. Record review of the physician order's, dated 11/17/11, at 7:59 P.M., showed the physician ordered the resident transferred to the facility with a non-weight bearing status. The resident has an old [MEDICAL CONDITION] hip. No physical therapy until this is resolved. Record review of the pain flow sheet, dated 11/17/11, at 9:30 P.M., the resident's initial pain rating was an "8" per the face scale. The reason for administration of the pain medication was "hip pain". Staff did not document a follow-up pain rating. Record review of the nurses' notes, dated 11/18/11, at 6:59 A.M., showed the nurse entered a late entry for 11/17/11; the physician has been sent two faxes in regards to the resident's right leg. The nurse received the following orders including: Hoyer lift due to pain in the resident's right leg. The nurse medicated the resident for pain. Record review of the pain flow sheet, dated 11/18/11, at 1:00 A.M., showed the initial pain rating was a "10" per the face scale. The resident was moaning, had facial grimacing with cares. The follow-up pain rating was "2". Record review of the hospital discharge summary, admitted [DATE] and discharge date [DATE], showed the following information: -Admission Diagnosis: [REDACTED]. -The resident presented to the hospital for management of a [MEDICAL CONDITION]. The resident initially presented with pain and swelling in the right leg and was diagnosed with [REDACTED]. However, after discussions with the family, it was felt that the resident should be put in traction. The resident is now admitted to the hospital directly from the nursing home to be placed in traction to manage the treatment for [REDACTED]. Record review of the orthopedic surgeon consultation, dated 11/18/11, showed the resident admitted to the hospital due to inability of the resident to move the right hip without pain and x-ray found the resident to have a displaced (description of the fragment placement) femoral neck fracture with some healing around the femoral neck and shortening of the hip. The resident had pain with palpation of the right hip and pain with any passive or active motion. Record review of Brunner and Suddarth's textbook of Medical-Surgical nursing, 7th edition, showed the following information: -Clinical manifestations of a fracture are pain, loss of function, false motion, deformity, shortening, local swelling and discoloration; -The pain is a continuous type and increases in severity until the bone fragments are immobilized. The muscle spasm that accompanies fracture is natural splinting to minimize further movement of the fracture fragments; -The extremity cannot function properly because normal function of the muscles depends on the integrity of the bones to which they are attached. -In fractures of long bones, there is actually shortening of the extremity because of the contraction of the muscles that are attached above and below the site of the fracture. The fragments may often overlap as much as 1-2 inches. -Fractures of the neck of the femur are more difficult to heal because the blood system supplying blood to the head and the neck of the femur may be damaged with the fracture. The nutrient vessels within the bone may be interrupted, and the bone cells may die. -With most fractures of the femoral neck, the patient is in pain, is unable to move the leg without significant increase in pain, and is able to achieve some comfort with the leg slightly flexed in external rotation. During an interview conducted on 01/28/12, at 2:00 P.M., LPN A said the resident could not communicate but did laugh and smile. After the resident had the fall, he/she acted differently. Before the fall, the resident was able to sit comfortably in a chair but after the fall he/she was stiff and did not want to sit. The nurse said the resident had discomfort with transfers but it was subjective. During cares the resident never hollered, cried out or said he/she was in pain. The resident's family also noticed he/she was stiffer. The resident used to participate in the walk to dine program but after the fall he/she just would not walk. LPN A said when he/she found out the resident had a broken hip, he/she felt terrible the resident had a fracture and suffered. During an interview conducted on 01/28/12, at 2:25 P.M., Certified Nurse Aide (CNA) E said after the resident fell he/she had good days and bad days. Transferring seemed to hurt him/her the most. He/she would stiffen his/her arms and not put any weight on his/her leg. Almost every time we would roll the resident onto his/her side, the resident would moan so we tried to be as gentle as we could. Some days the resident hurt so bad we just kept him/her in bed. During an interview conducted on 01/28/12, at 2:40 P.M., CNA F said the resident used to walk with a walker but after he/she fell , he/she used the wheelchair. If we had to lift up or move his/her leg while performing cares the resident would holler, he/she was in constant pain. During an interview conducted on 01/28/12, at 3:33 P.M., registered nurse (RN) B said if a resident's oxygen saturation was low he/she would apply Oxygen and monitor the resident. If the O2 did not increase the oxygen saturation the nurse would obtain vital signs (blood pressure, pulse rate and respiratio

Based on interview and record review, the facility failed to implement prevention devices for one resident (Resident #2), assessed as at risk for pressure sore development and developed pressure sores, failed to adequately assess pressure sores on a routine basis, and did not notify the physician in a timely manner to obtain treatment orders for pressure sores. The facility failed to adequately assess pressure sores on a routine basis, failed to notify the physician and obtain a treatment order for a pressure sore, and failed to implement prevention devices for one resident (Resident #1), who had a functional decline that increased his/her risk for pressure sore development and developed pressure sores. The facility failed to implement prevention devices for one resident (Resident #3), assessed at risk for pressure sore development and developed pressure sores, failed to adequately assess pressure sores on a routine basis, and failed to notify the physician of changes in the pressure sore to change treatment as indicated, and failed to consistently implement prevention interventions in a facility with a census of 93. Record review of the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of [REDACTED]. Washington DC: National Pressure Ulcer Advisory Panel; 2009 showed the following pressure ulcer classification system: -Stage I-intact skin with non-blanchable redness of a localized area usually over a bony prominence; -Stage II-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. Bruising indicates suspected deep tissue injury; -Stage III-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 IV-full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often 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. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the "the body's natural cover" and should not be removed; -Suspected deep tissue injury- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. 1. Record review of Resident #2's face sheet, showed an initial admitted to the facility on [DATE]. Record review of the active physician order sheet (POS), dated November 2011, showed the following information: -On 11/8/11, the physician ordered the Braden scale (an assessment that determines the level of risk for pressure ulcer development) once a week for 4 weeks; -The physician orders did not include any treatment for [REDACTED]. Record review of the resident's admission Braden scale, dated 11/8/11, showed resident had a score of 14 indicating the resident as moderate risk for pressure ulcer development. Record review of the skin condition assessment, dated 11/8/11, showed the following information: -Resident was forgetful and had confusion; -The resident had a fractured left hip, history of fracture on the right side, declining physical and mental status; -The resident's overall skin condition is pale, warm and dry to touch, fair turgor, tenting, multiple healing bruises, and dry scabbed area on the right arm; -Staff did not document any protective padding or equipment used for the resident; -The nurse documented the resident had bruising up the left side of the trunk and right arm. Record review of the admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 11/15/11, showed the following information: -Short and long term memory problems; -Severely impaired decision-making skills; -Total dependence on staff for bed mobility, transfers, dressing, and toilet use; -Required extensive assistance for personal hygiene; -Staff assessed the resident was at risk for pressure ulcer development; -Staff documented the resident did not have any pressure ulcers; -Staff documented the resident had pressure-relieving devices for the chair and bed. Staff had the resident on a turning and repositioning program. Record review of the Braden scale, dated 11/15/11, showed the resident scored 15 on the assessment indicating the resident at mild risk for pressure ulcer development. Record review of the skin condition note, dated 11/15/11, at 1:47 P.M., showed the resident needed assistance of three staff to transfer, with no weight bearing on the left side. The nurse documented the resident did not have any protective padding or equipment used. The resident did not have any open wounds or pressure ulcers. Record review of the skin condition note, dated 11/20/11, at 4:49 P.M., showed the nurse documented the resident had a 10 centimeter (cm) x 13 cm fluid-filled spot on the left upper back. The resident had a right heel pressure sore, measuring 2 cm x 2 cm. The nurse documented wound care applied and bandaged and heel protectors put on while in bed. The nurse did not document notification of the physician or family. The nurse did not provide any additional information regarding the stages of the pressure sores, the characteristics of the pressure sores, and if the resident had any pain with the pressure sores. Record review of the Braden scale, dated 11/22/11, showed the resident scored a 15. Record review of the skin condition note, dated 11/22/11, at 9:30 P.M., showed the nurse documented the resident did not have any open wounds, pressure sores, or superficial impairments. The nurse documented the resident did not have any protective padding or equipment used. Record review of the skin condition note, dated 11/28/11, at 9:27 A.M., showed the nurse documented the resident had a round blackened area on the right heel and dressing applied. The resident had heel protectors in place. The resident had a padded wheelchair as the protective padding or equipment used. The nurse documented the right heel wound as a pressure sore. The nurse did not document notification of the physician or the family of the pressure sore. The nurse did not document the size, the presence of drainage, stage of the pressure sore, pain, if present; the color and type of tissue or necrosis, or a description of the wound edges and surrounding tissue. Record review of the nurses' note, dated 11/28/11, at 10:22 A.M., showed the Assistant Director of Nursing (ADON) documented the resident had a small black area to the right heel and asked for an order to apply [MEDICATION NAME] (provides a protective barrier on skin) daily. The nurse did not document a response from the physician. Record review of the skilled charting note, dated 11/28/11, at 11:24 A.M., showed the nurse documented the resident had an area on the right heel that the ADON would be checking and recommending treatment. Record review of the Braden scale, dated 11/28/11, showed a score of 15. Record review of the November 2011 treatment administration record (TAR), showed staff did not document a treatment order for any wound or pressure ulcer for the resident. Record review of the active physician order sheet (POS), dated December 2011, showed the following information: -On 11/8/11, the physician ordered a skin assessment every week; -The physician order sheet did not include treatment orders for wounds or pressure ulcers. Record review of the skilled charting note, dated 12/2/11, at 8:45 P.M., showed the nurse documented the resident had a Stage III pressure ulcer to the right heel. The nurse documented staff faxed the physician regarding the right heel. The nurse did not document on the pressure sore, such as size, drainage, color and type of tissue in the wound bed, pain, or description of the wound edges and surrounding tissue. The nurse did not document any response from the physician. Record review of the fax sent to the physician, dated 12/2/11, at 9:40 P.M., showed the resident had a 2 cm x 2 cm, Stage III pressure ulcer on the right heel. The nurse cleansed the wound with wound cleanser, applied [MEDICATION NAME] (fine mesh external gauze dressing impregnated with an antiseptic petroleum blend) dressing, and sponge dressing. This treatment will be done every day and as needed until healed, unless the physician specified otherwise. Record review of the skin condition note, dated 12/2/11, at 9:41 P.M., showed the nurse documented the resident had a 2 cm x 2 cm pressure sore on the right heel. The nurse faxed the physician on 12/2/11, at 9:45 P.M. The nurse cleansed the pressure sore with wound cleanser, [MEDICATION NAME] dressing, and sponge foam bandage, and wrapped the area. This treatment was to be done every day and as needed until healed. The resident had Spenco boots but he/she took them off. The nurse did not document any response from the physician. Record review of the December 2011 TAR, showed a treatment, dated 12/2/11, to clean the pressure ulcer on the right heel with wound cleanser, apply [MEDICATION NAME], sponge dressing, and wrap every day and as needed until healed. Staff documented initiating the treatment on 12/2/11 for day shift (6:00 A.M. to 2:00 P.M.). Staff documented completing the treatment 12/2/11 through 12/11/11. Record review of the skilled charting note, dated 12/3/11, at 10:06 A.M., showed the nurse documented the resident did not have any skin issues. Record review of the skilled charting, dated 12/3/11, at 6:54 P.M., showed the nurse documented the resident had a Stage III pressure ulcer to the right heel. Record review of the medicare 30 day MDS, dated [DATE], showed the following information: -The facility assessed the resident as at risk for pressure ulcer development; -The resident had one Stage II pressure ulcer (instead of Stage III as documented on 12/2/12 and 12/3/12), oldest date 12/2/11. The most severe tissue type was [MEDICATION NAME] (involving the outer layer of the skin) tissue; -The facility documented the resident had pressure-relieving devices for the chair, bed, turning and repositioning program, and ulcer care. Record review of the skin condition note, dated 12/6/11, at 12:26 P.M., showed the nurse documented the resident had a pressure sore to the right heel. The ADON changed the dressing today. The nurse documented the protective padding and equipment used as "briefs". The nurse did not provide any other assessment regarding the pressure sore. Record review of the facility's weekly pressure sore quality improvement (QI) log (a document that is not part of the resident's medical record), dated 12/6/11, showed the resident had a right heel pressure ulcer, Stage II, acquired in the facility on 12/2/11. The nurse documented the pressure ulcer measured 1.5 cm x 1.8 cm x 0.2 cm depth and the pressure ulcer had drainage and odor. The nurse did not provide any other description of the pressure sore. The nurse did not describe the amount, color or type of drainage. The nurse documented the treatment as [MEDICATION NAME]. The nurse did not document any preventive equipment in place or initiated. The nurse did not document when, or if, the physician or family were notified of the pressure ulcer. Record review of the nurses' note, dated 12/8/11, at 6:59 A.M., showed the ADON documented a request to the physician regarding the resident had an open area to the right heel with slough and foul odor. The nurse did not document any other assessment information of the pressure sore. The ADON asked to change the order to wound cleanser, apply [MEDICATION NAME] (antibiotic ointment)/santyl (an enzymatic [MEDICATION NAME] ointment used to remove dead skin from wounds) to the wound bed, borderfoam (all-in-one foam dressing that effectively absorbs and retains exudate and maintains a moist wound environment) and wrap with Kerlix daily. The nurse did not document any response from the physician. Record review of the skilled charting note, dated 12/8/11, at 9:13 A.M., showed the nurse documented the resident had a heel protector in place over the pressure ulcer on the right heel. The nurse did not document any preventive heel protector for the left foot. Record review of the care plan, dated 12/8/11, showed the following information: -At risk for skin breakdown; -Incontinent of bowel, monitor continence status between toileting to ensure resident stays clean and dry; -Certified nurse assistant (CNA) to inspect skin during baths, dressing, and toilet, and report concerns to the charge nurse. Licensed nurse to assess skin weekly and as needed. Consult with the physician for any needed treatment orders. -Provide pressure-relieving device to bed and wheelchair; -Assist with repositioning with rounds. -The care plan did not list any actual skin breakdown or address any interventions put into place related to specific skin breakdown. Record review of the nurses' notes, dated 12/8/11, at 8:23 P.M., showed the nurse documented the physician came to the facility and ordered [MEDICATION NAME] (antibiotic) 150 mg, two capsules for 10 days and [MEDICATION NAME] (antibiotic ointment), to the wound edges on the right heel, three times a day for 10 days. Record review of the December 2011 TAR, showed staff documented a treatment (undated) to apply [MEDICATION NAME] to the wound edges on the right heel three times a day. Staff documented the ointment not available on 12/9/11 and initiated the treatment on 12/10/11. Staff documented providing the treatment through 12/11/11. Record review of the skilled charting note, dated 12/10/11, showed the resident had a pressure ulcer to the right foot. The nurse did not document any other assessment information of the pressure sore. Record review of the infection nursing note, dated 12/10/11, showed the resident to start [MEDICATION NAME] for the wound to the right foot. Staff faxed the order to the pharmacy and awaited delivery of the medication to start the first dose. Record review of the December 2011 active POS did not show any treatment orders for pressure ulcers or wounds. Record review of the resident's face sheet, showed the most recent hospital stay was from 12/12/11 through 1/4/12. Record review of the resident's medical record showed on 12/27/11, the resident admitted to the hospital for surgery of the left [MEDICAL CONDITION]. Record review of the nurses' notes, dated 1/4/12, at 10:55 P.M., showed the resident arrived at the facility at 5:39 P.M. via ambulance. The resident's periarea and buttocks were bright red and excoriated. The nurse documented treatment orders in place. The right heel had a bandage that was clean, dry, and intact. Record review of the nursing communication form, dated 1/5/12, at 1:44 P.M., showed the nurse faxed the physician regarding the resident had been [MEDICATION NAME] for wound healing during the recent hospital stay. The resident's primary [DIAGNOSES REDACTED]. The resident currently has a wound to the heel and to the buttock. The nurse asked for an order for [REDACTED]. Record review of the Braden scale, dated 1/5/12, showed a score of 13 indicating the resident at moderate risk for pressure ulcer development. Record review of the skin condition note, dated 1/5/12, at 4:58 P.M., showed the resident had an open area to the right heel, measuring 1.2 cm x 0.9 cm, with a depth of 0.5 cm. The treatment was to cleanse with wound cleanser, apply santyl, cover with gauze, and secure twice a day until resolved. The resident had an unstageable pressure ulcer to the right buttock, measuring 2.7 cm x 5 cm x 2 cm depth. Treatment was to cleanse with wound cleanser, apply santyl, gauze, and secure twice a day until resolved. The nurse documented low air loss mattress, positioning pillows, heel protectors, and wheelchair cushion in place for the resident. The wound nurse documented the resident admitted from the hospital with the above areas noted. The primary care physician was aware. The nurse documented the resident placed on the low air loss mattress earlier that day and [MEDICATION NAME] supplement twice a day. The nurse did not document the stages of all the pressure sores, a description of the pressure sores, such as any drainage, pain, color and type of tissue in the wound bed or necrosis, or any description of the wound edges and surrounding tissue. Record review of the skin condition assessment, dated 1/5/12, showed the protective padding and equipment used were a wheelchair, gait belt, and briefs. The resident's coccyx was red and excoriated (injury to the surface of the skin). The resident's right heel had an approximate 3 cm x 3 cm open area. The nurse did not document additional assessment information of the pressure sores. The nurse documented treatment orders in place for current skin issues. Record review of the January 2012 active physician order sheet (POS), showed the physician ordered the following: -On 11/30/11, the physician order for [REDACTED]. -On 1/4/12, clean right heel with wound cleanser, apply Santyl to the wound bed, cover with gauze twice a day until resolved. Record review of the February 2012 active POS, showed the physician ordered the following: -On 1/4/12, the physician ordered a high protein diet for the resident; -On 1/4/12, staff to clean the right heel with wound cleanser, apply santyl to the wound bed; Cover the pressure ulcer with gauze twice a day until resolved. -On 1/5/12, the physician [MEDICATION NAME] liquid twice a day for the unstageable pressure ulcer. -On 1/5/12, cleanse right buttock pressure ulcer with wound cleanser, apply Santyl, cover with gauze and secure twice a day until resolved. On the POS, staff documented it was an "unstageable" pressure ulcer. -On 1/13/12, the physician ordered a low air loss mattress. Record review of the skin condition note, dated 1/10/12, at 9:06 A.M., showed the resident had an ulcer on the right buttock, which was being treated with Santyl ointment twice a day. The resident had a pressure wound on the right heel, which was being treated with Santyl ointment twice a day. The nurse documented the protective padding/equipment used as padded wheelchair, briefs, air bed, and heel protectors. The nurse did not document additional assessment of the pressure sores. Record review of the facility's weekly pressure sore QI log (a document that is not part of the resident's medical record), dated 1/10/12, showed the resident had a Stage II pressure ulcer to the right heel, measuring 1.4 cm x 1.4 cm x 0.4 cm. The pressure ulcer had odor and drainage. The current treatment was Santyl with the dietary intervention [MEDICATION NAME] twice a day. The nurse documented the preventive equipment in place as heel protectors, positioning pillows, and air mattress. The resident had a Stage III pressure ulcer to the right buttock, measuring 3 cm x 4 cm x 2 cm. The pressure ulcer had odor and drainage. The current treatment was Santyl. The nurse did not describe the type, color, and approximate amount of drainage. The nurse did not describe the wound bed for color and type of tissue or necrosis or a description of the wound edges and surrounding tissue. Record review of the readmission MDS, dated [DATE], showed the following information: -The resident had one Stage II pressure ulcer; -The resident had one Stage III pressure ulcer, measuring 3.0 cm 4.0 cm x 2.0 cm. The most severe tissue type was slough. Record review of the February 2012 active physician order sheet (POS), showed on 1/13/12, the physician ordered a low air loss mattress (specialized mattress that consists of air- filled sacs inflated at a constant pressure, through which air can pass). Record review of the skin condition note, dated 1/17/12, at 10:57 A.M., showed the resident had an ulcer to the right heel and received Santyl and gauze dressing treatment. The resident had an ulcer to the right buttock and received Santyl and gauze dressing treatment. The nurse documented the resident had briefs, heel protectors, air bed, "chucks" (disposable bed pad), and padding in the wheelchair. The nurse did not document additional assessment information of the pressure sore. Record review of the facility's weekly pressure sore QI log, dated 1/17/12, showed the right heel pressure ulcer, Stage II, measured 0.8 cm x "07" x less than 0.2 cm. The pressure ulcer did not have odor or drainage. The current treatment was Santyl. The right buttock pressure ulcer, Stage III, measured 2.5 cm x 4.4 cm x 1.3 cm. The current treatment was Santyl. The pressure ulcer had odor and drainage. This record showed the right buttock pressure ulcer as facility acquired on 1/4/12. The nurse did not describe the type, color, and approximate amount of drainage. The nurse did not describe the color and type of tissue or necrosis of the wound bed or a description of the wound edges and surrounding tissue. Record review of the skin condition note, dated 1/23/12, at 10:57 A.M., showed the resident had an open wound to the right buttock, treated with Santyl. The resident had an open wound to the right heel. The nurse documented the protective padding/equipment used was a wheelchair, air bed, heel protector to the right heel, incontinent briefs. The nurse did not document any additional assessment information of the pressure sores, such as staging, size, drainage, pain, wound bed, or description of the wound edges and surrounding tissue. Record review of the weekly pressure sore QI log, dated 1/24/12, showed the right heel pressure ulcer, Stage II, measured 0.6 cm 0.5 cm, with less than 0.2 depth. The pressure ulcer did not have any odor or drainage. The current treatment was Santyl. The right buttock pressure ulcer, Stage III, measured 2.4 cm x 3.2 cm x 0.5 cm. The pressure ulcer had drainage and odor. The nurse did not document any additional assessment information of the pressure sore. Record review of the skilled charting note, dated 1/27/12, at 3:23 A.M., showed the nurse documented the resident had skin alterations of the right heel. The resident had a dressing on the right heel and the right buttocks. Record review of the skilled charting note, dated 1/27/12, at 8:39 A.M., showed the nurse documented the resident had a treatment to the upper right buttocks and the right heel wound was no longer open. It was being treated preventatively at this time. Record review of the skilled charting note, dated 1/30/12, at 7:44 P.M., showed the nurse documented the resident had redness to the buttocks and a wound to the right heel. Record review of the skin condition note, dated 1/31/12, at 11:20 A.M., showed the nurse documented the resident had a wound on the right buttock, which is being treated with Santyl and a wound on the right heel that is improving and treated with Santyl. The nurse documented the protective padding/equipment used was a padded wheelchair with leg supports and foot pedals, air bed, and trapeze. The nurse did not document the stages, size, drainage, color, odor, or amount, wound bed, description of the wound edges and surrounding tissue. Record review of the weekly pressure sore QI log (a document that is not part of the resident's medical record), dated 1/31/12, showed the right heel pressure ulcer was closed, measured 1.5 cm x 1 cm x less than 0.2 cm depth. The pressure ulcer did not have drainage or odor. The treatment was Santyl. The right buttock pressure ulcer, Stage III, measured 2 cm x 4 cm x 1.0 cm. The pressure ulcer did not have any odor, but did have drainage. The current treatment was Santyl. The nurse did not document additional assessment information of the pressure sores. Record review of the quarterly MDS, dated [DATE], showed the following information: -The resident had one Stage I pressure ulcer; -The resident had one Stage III pressure ulcer that was present upon admission/reentry to the facility, measured 2.0 cm x 4.0 cm x 1 cm. The most severe type of tissue was slough. Record review of the nurses' note and nursing communication note to the physician, dated 2/5/12, at 7:59 A.M., showed the nurse documented a 5 cm pressure wound on the distal left lower leg, just below the kneecap. The nurse documented he/she treated it with safe gel (dressing that provides a moist wound-healing environment by hydrating dry or necrotic tissue and reduces wound dead space) and a foam dressing, secured with tape. The nurse documented he/she would look to see what was causing the pressure to the area and hopefully resolve it. The nurse asked the physician if this was an acceptable treatment and how often to change the dressing. On 2/6/12, the physician responded back with an order for [REDACTED]. Record review of the skilled charting note, dated 2/5/12, at 8:33 A.M., showed the nurse documented the resident continued to have treatment to the right buttocks. The right heel was healed. Behind the left knee, the resident had a reddened area with a core-looking spot. The nurse dressed the area with a borderfoam dressing and documented he/she would notify the physician of this. Record review of the nurses' notes, dated 2/7/12, at 4:52 A.M., showed the nurse documented orders received for a wound consult to the left distal leg, just below the knee. Record review of the skilled charting note, dated 2/7/12, at 9:37 A.M., showed the nurse documented the skin alterations as the resident having right buttocks treatment, area behind the left knee. The nurse received an order from the physician for the area behind the left knee. Record review of the skin condition note, dated 2/7/12, at 10:13 A.M., showed the nurse documented the resident had an open wound to the left upper buttock, which was receiving treatment and the wound to the heel was closed and left open to air. The resident had an area to the left lower leg just below the knee to be assessed by the ADON. The protective padding/equipment used included briefs while up in the wheelchair, chucks in bed, air mattress, and grab bar. The nurse did not document additional assessment information of the pressure sores. Observation on 2/8/12, at 11:43 A.M., showed the resident lay on his/her back on an air mattress on his/her bed. At 12:30 P.M., staff transferred the resident to the hospital by ambulance. Record review of the transfer note, dated 2/8/12, at 3:37 P.M., showed the nurse documented the physician ordered the resident to transfer to the hospital emergency room for evaluation. Record review of the discharge note, dated 2/8/12, at 3:41 P.M., showed the nurse documented the resident became dizzy and hypotensive (low blood pressure) during physical therapy and also had [MEDICAL CONDITION](heart rate greater than 100). The nurse documented the resident's skin condition as, open wound to the right heel and right sacrum. During interview on 2/10/12, at 12:00 P.M., the administrator said the resident admitted to the facility with a small area on the heel. When first admitted , the resident had a [MEDICAL CONDITION], was non-weight bearing, and was a non-surgical candidate. At some point, the physician determined the resident was a surgical candidate. The resident was out of the facility for at least a month. When the resident readmitted to the facility, the resident came back with significant wounds. The resident had a area to the coccyx, foot drop, and a wound on the foot. The discharge paperwork from the hospital did not reflect the wounds at all. When a resident is admitted or readmitted , the staff try to assess and shower the resident as soon as possible to look at the resident's skin. During interview on 2/14/12, at 1:28 P.M., the ADON said the pressure sore on the right heel was acquired in the facility. It looked good when the resident left for the hospital. It did not have any depth and was not big. When the resident came back from the hospital, the resident came back with a Stage III on the buttock and the heel was worse. The resident has a low air loss mattress, positioning pillows, and heel protectors. The facility started the low air loss mattress when the resident readmitted to the facility. The resident had the positioning pillows and heel protectors in place before he/she came back from the hospital with the Stage III pressure sore on the buttock. 2. Record review of Resident #1's quarterly MDS, dated [DATE], showed the following information: -Short and long term memory problem; -Severely impaired decision-making skills; -Required extensive assistance for bed mobility, transfers, walking in room and corridor, and dressing; -Total dependence on staff for toilet use and personal hygiene; -Always incontinent of bowel and bladder; -The facility assessed the resident as not at risk for pressure ulcer development; -The resident did not have any current pressure ulcers; -The resident had a pressure-reduction device for the bed. Record review of the care plan, initiated on 4/28/10, showed the following information: -Provide setup/supervision with verbal cues and physical prompts as needed for bed mobility, ambulation, transfers, dressing, eating, and oral hygiene; -Monitor for layering of clothes and ensure adequate personal hygiene. The resident sometimes dribbles a little or does not get completely wiped good per self after bowel movements; -Potential for altered skin integrity related to [MEDICAL CONDITION] and frequently incontinent of urine, bowel movement, ineffective self pericare, and varied nutritional intake; -Maintain pressure reducing mattress. Monitor skin during showers two times per week for any skin concerns and report to the nurse immediately. Licensed nurse to perform a skin assessment and consider weekly if there is any active skin concerns; -Monitor the resident's continued ability to make independent position changes and bed mobility. -Monitor the resident's ability to provide self effective pericare with toileting efforts and provide assist of one staff to ensure hygiene and dignity. Record review of the skin condition note, dated 9/7/11, at 4:06 P.M., showed the nurse documented the resident was up ad lib and required stand by assist of staff related to confusion. The nurse documented the protective padding/equipment used was pillows for repositioning and heel protectors while in bed. Record review of the skin condition note, dated 9/14/11, at 3:34 PM., showed the nurse documented the resident was able to position and reposition self independently Record review of the fall nursing note, dated 9/23/11, at 10:24 A.M., showed the resident fell at 7:00 A.M. Staff checked the resident's range of motion. Staff assisted the resident to stand and noted the resident had a scrape on the right knee and right elbow. Record review of the nurses' notes, dated 9/25/11, at 10:46 P.M., showed the nurse documented the resident cried out when being rolled in bed and family wanted x-ray done tomorrow just to be sure the hip was okay from the fall. Record review of the care plan showed staff reviewed and updated the care plan on 10/3/11, instructing staff to monitor the resident's risk for pressure sore development via the Braden scale and skin assessments. Record review of a skin condition note, dated 10/11/11, at 3:15 P.M., showed the nurse documented the resident was up to the wheelchair with assist of one staff to the wheelchair. The resident was incontinent of bowel and bladder. The nurse documented the protective padding/equipment used was "briefs". The resident did not have any wounds or pressure ulcers. Record review of a skin co

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". A monitoring visit was completed on 5/05/11. Based on interviews, observations and record review completed during the onsite revisit, it was determined the facility had implemented corrective action to address and lower the violation at this time. The facility had provided in-service training on how to assess pain, use of a numeric pain scale (0-10), identification of non-verbal behaviors related to pain, and pain in dementia residents. The facility in-serviced the staff regarding proper pain related documentation, the need to reassess the resident's pain levels following an intervention and how to document the interventions effect. The facility has nursing staff assess each resident's pain level during each shift and document the results on the resident's MAR. The DON audits the residents pain documentation and interventions weekly. Record review of four resident charts showed staff failed to consistently assess, monitor and treat resident's identified with pain. One resident complained of severe pain during a wound care treatment. The facility failed to treat this resident's pain. The facility failed to assess all four resident's pain each shift. A resident consistently complained of pain rated at a 6-8 on a scale of 1 to 10. The resident had an order for [REDACTED]. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "G" level. This statement does not denote that the facility has complied with State Law (Section 198.026.1 RSMo) requiring that prompt remedial action to be taken to address Class I violation.

Based on observation, interview and record review the facility failed to immediately report allegations of possible physical abuse to the administrator, including timely notification of family members and physicians, failed to start the investigation on the day the allegations were reported and failed to initiate measures to ensure the safety of the residents, in two separate incidents after staff members alleged one staff member (Certified Nurse Aide E), with a history of prior allegations, handled two residents (Resident #2 and #8) in a rough manner . Facility census was 99. 1. Record review of the facility's Abuse, Neglect and Exploitation policy, last updated 06/08/07, showed the following information: - All unexplained bruising, skin tears, reluctance of a resident to accept care from certain staff members and abrupt changes in behavior as well as any pattern of injury shall be reported to appropriate staff. - It is the responsibility of every employee of the facility to report any abuse and/or neglect. - The administrator and Director of Nursing (DON) are responsible for the investigation of alleged violations and reporting the results of the investigation to the proper authorities. - The staff member taking the report will initiate a Risk Management Report and notify all appropriate entities including the resident's physician, DON, administrator and family within 24 hours. - The DON/Administrator shall initiate a thorough and credible investigation, assess and interview the resident if possible, obtain statements, interview and document the response from the alleged abuses and conference/suspend them until the investigation is complete and/or terminate the employee as determined by the investigation. - Any time a report of possible abuse, neglect or exploitation is made against an employee, that employee should be immediately sent home and suspended without pay by the person in charge until a thorough investigation can be conducted by the DON/Administrator. The resident involved shall be immediately assessed for injury, assured of protection from further harm and monitored closely with both medical and social service intervention as indicated. 2. Record of the facility's Risk Management Report packet showed the packet included a Risk Management Report (Resident) form, a Witness Statement form and an Accident Investigation Report form. Record review of the facility's Risk Management Report (Resident) form showed staff were to complete it with information that included where and when injury occurred, how the injury occurred, what was injured, witnesses and notification of family and physician. Record review of the facility's Witness Statement form showed staff were to complete it with information that included a description of the what, where, when, how and why of what happened and any other significant observations. Record review of the facility's Accident Investigation Report showed staff were to complete it with information that included the date of incident, date of investigation, notification of family and physician, what happened, witnesses and corrective action plan. 3. Record review of Resident #2's face sheet showed staff admitted the resident to the facility on [DATE] with the following Diagnoses: [REDACTED]. - [MEDICAL CONDITION]; - Generalized pain; - Anxiety; - Depression; - History of fracture to the forearm. Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/25/11, showed the following information: - Short and long term memory problems; - Moderately impaired cognitive skills for daily decision making; - Required total dependence of one to two staff members for bed mobility, transfers, locomotion, toilet use and personal hygiene; - Functional limitation in range of motion on both sides of the body to lower extremities; - Did not resist care; - No bruises. Record review of the resident's nurse's note, dated 04/03/11 at 12:02 P.M., showed the following information: - The resident had a bruise on his/her left wrist. - The resident had a large hematoma (bruise) on his/her right forearm that was painful to touch. - The resident was able to move his/her arm, fingers and wrist without pain. (Staff did not document notifying the resident's physician or family of the bruising. Staff did not document how the bruising occurred.) During an interview on 04/12/11, at 2:05 P.M., Certified Nurse Aide (CNA) FF said the following: - On 04/03/11, he/she heard the resident calling out from his/her bedroom. - He/she saw CNA E struggling with the resident. - CNA E had his/her hand wrapped around the resident's right forearm. - He/she asked CNA E to leave the room. - The resident had a red area where CNA E held the resident's right forearm. - The resident appeared to be in pain following the incident. - He/she reported the incident to Licensed Practical Nurse (LPN) A. - He/she told LPN A the bruised area to the resident's right forearm was exactly where CNA E held the resident's arm. - The bruise to the resident's right forearm was large. - CNA FF could "feel" the resident's bone was not broken. - CNA E continued to work the rest of the weekend. Record review of the resident's skin monitoring shower sheet, dated 04/06/11, showed the resident had a large purple bruise and knot to his/her right forearm. The shower sheet was signed as reviewed by Registered Nurse (RN) BB on 04/06/11. Record review of the resident's skin assessment, dated on 04/06/11, showed the resident had irritation under his/her right breast. (The facility staff failed to document the hematoma on the resident's left hand or the large bruise on the resident's right wrist/forearm.) Record review of the resident's nurse's note, dated 04/10/11 at 8:11 P.M., showed the following information: - The resident received a hematoma on his/her right arm on 04/03/11. - The hematoma was painful to the touch. - Resident had complete range of motion in his/her right arm. - The resident had difficulty gripping with his/her right hand. - The hematoma was 2.5 centimeter (cm) by 2.0 cm in size. (Staff notified the physician seven days after the bruise was first documented. The staff did not document notifying the resident's family of the bruising. Staff did not notify the resident's family or physician how the resident obtained the bruise.) Record review of the resident's physician/nurse communication sheet, dated 04/10/11, showed the staff notified the physician of the following information: - The resident received a hematoma on his/her right arm on 04/03/11. - The hematoma was painful to the touch. - Resident had complete range of motion in his/her right arm. - The resident had difficulty gripping with his/her right hand. - The hematoma was 2.5 by 2.0 centimeters (cm) in size. (Note: The physician responded to the communication with an order to observe the area.) During general observations on 04/12/11, at 10:30 A.M., the resident sat in his/her wheelchair near the nurse's station/television area. The resident's left hand and right forearm were bruised. During observation and interview on 04/12/11, at 10:35 A.M., the resident sat in his/her wheelchair in his/her room. Certified Medication Technician (CMT) EE was present in the resident's room. The resident had a dark purple round bruise to the top of his/her left hand approximately 4 cm in diameter and a large bruise to his/her right forearm approximately 2.5 cm by 2.5 cm with a 2.0 cm raised knot in the center of the injury. The forearm bruise was light to dark purple in color and appeared to be very painful to the resident. When the CMT raised the resident's sleeve for inspection the resident cried out "ouch" and moaned. The resident guarded the injury and attempted to pull his/her arm away. The resident said, "someone was rough with me when helping me to bed" and the resident said "it was someone who works here". The resident could not remember if the staff member was male or female at that time. The resident said his/her arm hurt. When asked how the resident received the bruise to the top of his/her left hand, the resident responded by saying, "that's where they grabbed me". The resident said he/she had not seen the physician regarding the injuries. The resident said his/her right forearm currently hurt. The resident denied pain to any other area of the body. During an interview on 04/12/11, at 10:38 A.M., CMT EE said the following: - He/she only works weekends. - He/she did not know how the resident received the injury. - He/she heard CNA E caused the bruising to the resident's left hand and right forearm during a transfer. - He/she believed CNA FF witnessed the incident. - He/she noted the bruising on the resident's left hand and right forearm on 04/08/11. - He/she reported the injury to LPN A immediately upon discovery. - He/she assumed the incident was being addressed. - The bruised areas appeared to cause the resident pain. During an interview on 04/12/11, at 11:05 A.M., CMT I said the following: - He/she heard CNA E transferred the resident from his/her bed to the wheelchair for breakfast. - He/she said CNA E appeared upset or irritated the day on the incident. - CNA E told CMT I, the resident caused the injuries to him/herself by being combative. - The resident could be combative at times first thing in the morning. - CNA FF saw CNA E with his/her hand on the resident's right wrist. - CNA FF had to ask CNA E to leave the resident's room. - He/she reported the incident to LPN A. - He/she instructed LPN A to document the incident as per policy and procedure. - CNA E had additional incidents investigated a few months ago regarding improperly handling residents. During an interview on 04/12/11, at 11:25 P.M., LPN G said the following: - The resident had resisted care in the past in the mornings. - CNA E can be "gruff" with residents at times. - He/she had never witnessed CNA E harm or mistreat a resident. - He/she was told "to watch" CNA E by the previous DON. - He/she was unaware of how the resident obtained the bruises to his/her right forearm or left hand. During an interview on 04/12/11, at 1:15 P.M., LPN A said the following: - H/she believed the incident occurred on 04/03/11. - He/she noted the bruising to the resident's right forearm and left hand after breakfast. - No incidents were reported regarding the injury or CNA E to him/her. - He/she said the injuries may have occurred when CNA E dressed the resident before breakfast. - He/she said the resident was combative at times. - CNA E could be "firm" with residents at times. - He/she saw the resident's right forearm on 04/11/11. - On 04/11/11 the LPN observed the resident had a large knot that was painful to the touch on his/her right forearm. - The area caused the resident pain. - He/she should have completed a risk management/incident report, but did not. - The risk management/incident report would have been sent to the DON. - An investigation of the injury would have been conducted by the DON. - He/she would have completed a risk management/incident report if the resident had fallen or if the resident had an open wound. - Since the resident only had bruising, he/she did not feel a risk management/incident report needed to be completed. - He/she could tell the resident did not have any broken bones by looking at the injury. - The resident does not "work well" with CNA E. During an interview on 04/12/11, at 2:15 P.M., CNA E said the following: - He/she always had another CNA or staff member with him/her when he provided care to residents. - He/she usually worked in the dementia care unit or the heavy care hall. - CNA FF assisted him/her with dressing the resident on the morning of 04/05/11 or 04/06/11. - He/she was unaware of any incidents regarding the resident. - He/she noticed a bruise on the resident's right forearm when he/she entered the room to provide care on 04/05/11 or 04/06/11. - The bruise should be documented on the shower sheet. - He/she reported the bruise to the charge nurse but could not remember which one. - The resident was combative (yelling and kicking) on the morning of 04/05/11 or 04/06/11 when CNA E entered the room. - He/she never had to hold the resident's arm down during the combative behavior. - CNA FF remained in the room the entire time CNA E was present. - He/she worked with the resident today (04/12/11). - The resident did not have a knot or swelling to his/her right forearm today 04/12/11. - He/she would report any allegations of abuse or neglect to the DON or administrator immediately. During an observation and interview on 04/12/11, at 2:23 P.M., with LPN X and MDS Coordinator K in the resident's room revealed the following: - LPN X attempted to raise the resident's right sleeve to assess the forearm. - The resident cried out in pain. - The resident attempted to pull his/her arm away from the staff member. - The resident said "it hurts real bad". - The resident said "that is from where he grabbed me". - The resident said it was a male staff member. - The resident was unsure of the staff member's name. - The resident said the incident occurred "not too long ago". - The resident believed the incident occurred when the male staff member was assisting him/her out of bed in the morning. - The resident said he/she had reported the incident to an unknown nurse. - LPN X and MDS Coordinator K said they were not aware of the injury. - LPN X and MDS Coordinator K said an incident report had not been completed. During an interview on 04/12/11, at 2:35 P.M., the administrator said the following: - He was unaware of the injury of unknown origin on the resident. - A head to toe skin assessment would be conducted on the resident. - Staff would notify the resident's physician regarding the injury. - Staff would notify the resident's family regarding the injury. - He/she would immediately begin an investigation related to the injury of unknown origin. Record review of a nurses note, written on 04/12/11 at 9:01 P.M., showed facility staff contacted the resident's family regarding the incident that occurred on 04/03/11 to the resident's right forearm. (Staff notified the family nine days after the first documentation of the bruising and after Departmetn of Health and Senior Services (DHSS) surveyors alerted facility management staff of the bruising. Staff did not inform the resident's family the facility had initiated an abuse/neglect invetigation into the cause of the bruising.) Observation on 04/13/11, at 9:58 A.M., showed CNA E in the front hall of the facility in his/her scrubs. During interview on 04/13/11, at 10:00 A.M., the administrator said staff stayed late and investigated the allegations regarding the bruising the resident's arm. About 8:00 P.M. on 04/12/11, the staff discovered the staff member in question was CNA E. The administrator was unaware the CNA was scheduled to work on 04/13/11 and said he/she would be removed from the building. During interview on 04/13/11, at 10:10 A.M., the administrator said the resident's physician was out of the office so staff were going to call the on-call physician. Record review of facility's Employee Conference Report, dated 04/13/11, showed CNA E was to be sent home due to a pending investigation of alleged resident abuse. During observation and interview on 04/13/11, at 9:45 A.M., LPN AA assessed the resident's arm. The knot on the resident's arm was soft and measured 2 cm x 2 cm x 2 cm with dependent bruising from wrist to elbow. The resident said it hurt and it felt belt better when he/she laid it down. Observation on 04/13/11, at 11:23 A.M., showed the resident in his/her wheelchair in a group area, next to the nurse's station, in front of the television. The resident moaned and appeared to be in pain. During an interview on 04/13/11, at 12:02 P.M., CNA GG said the following: - He/she first identified the bruise on the resident's right forearm on 04/06/11 during a shower. - The resident had a large bruise and knot on his/her right forearm. - He/she documented the injury on the bath sheet. - He/she gave the bath sheet to the charge nurse for review. - He/she reported the injury to RN BB. - RN BB was aware of the injury. - He/she assumed the nursing staff "had it taken care of". Record review of the resident's progress note, dated 04/13/11 at 11:08 A.M., showed staff notified the on-call physician of a known bruise on the resident's right forearm with a soft knot the size of half of a ping pong ball in the middle. Staff informed the on-call physician the area had been present for several days and it was very painful to the resident with movement of the extremity. The on-call physician said an x-ray was not necessary and to have the resident's normal physician to look at the site. The on-call physician said to treat the resident pain and monitor the site. ( Staff did not notify the on-call physician how the bruise was obtained or of a alleged abuse investigation.) During interview on 04/19/11, at 10:05 A.M., the DON said it is her understanding the management was unaware of the allegations against CNA E. The DON expected once the bruising to the resident was identified, the staff should have completed an incident report, notified the physician and family and completed an investigation. The management was unaware of the injury prior to the state entering the building. A skin assessment should have been completed on the resident's arm. 4. During interview on 03/29/11, at 9:20 A.M., the administrator said there had been no recent investigations of resident to resident or staff to resident incidents. 5. Record review of the CNA E's personnel file showed the following information: - CNA's hire date was 01/24/07. - Employee Warning Notice, dated 07/21/08, showed CNA E had recent outbursts with staff and resident. - Signed written statement, dated 09/17/09, by Staff Member N showed he/she saw CNA E punch a resident in his/her right leg after telling the resident to stop moving while he/she was sitting on the shower chair. CNA E was trying to fasten a brief across the resident's lap. - Typed summary statement, undated, completed by RN P, acting Assistant Director of Nursing (ADON) at the time of statement, showed Staff Member N reported to the ADON he/she saw the CNA hit a resident on his/her right leg. The resident was checked for injury and a faint discoloration was possibly on his/her right leg, but it could have been normal for resident. The resident denied pain. CNA E denied the accusation and said the resident was jumping around and fighting while he/she was putting the brief on. The CNA's hands were probably going up and down trying to get the brief on. Other staff was questioned and the resident was on the dementia unit and not interviewable. Staff noted it came down to what the staff member thought he/she saw and could have been misinterpreted and CNA E's word. No injuries were found on the resident on 09/18/09 and the resident denied pain. The CNA asked to not dress the resident alone anymore. - Employee Warning Notice, dated 09/18/09, showed CNA E was accused of hitting a resident which was unsubstantiated. CNA E was told if another incident arose that involved a resident that was substantiated, the CNA would be terminated. 6. Record review of Resident #8's face sheet showed the resident's original admitted was 12/08/09 and his/her current admitted was 01/31/11. Record review of the resident's April 2011 physician's orders [REDACTED]. Record review of the resident's admission MDS, dated [DATE], showed the following information: - Not oriented to day, month or year; - Unusually decreased level of activity (such as sluggishness, staring into space, staying in one position or moving slowly) that fluctuates in severity; - Unclear speech with slurred and mumbled words; - Usually makes self understood; - Understands others; - No behaviors; - Requires limited assistance of one staff for bed mobility and transfer; - Requires extensive assistance of one staff for dressing; - Active [DIAGNOSES REDACTED]. Record review of the resident's current care plan, initiated on 02/08/11, showed the following information: - At risk for injury due to imbalance, cognitive impairment and prior fall; - Chronic confusion related to late effects of stroke; - Self care deficit related to weakness and cognitive impairment. During interview on 04/14/11, at 10:45 A.M., CNA DD said she had seen CNA E handling Resident #8 in a rough manner. The CNA said he/she turned in a report to LPN G a month ago. The CNA said a housekeeper reported the incident also. Record review of a written statement completed by Housekeeper D, undated, showed the housekeeper wrote he/she was in a room across the hall from Resident #8's room and could hear the resident saying he/she did not want to get up. The housekeeper could hear a man saying, "you have to get up" and the resident said, "no". The housekeeper walked over to the room and saw CNA E pulling on the resident to make him/her get up. On top of the paper in different writing "sometime in March" is written. During interview on 04/14/11, at 11:06 A.M., LPN G said he/she had never witnessed CNA E being inappropriate with a resident and has never had any allegation of abuse or rough handling reported to him/her. The CNA has a rough demeanor. During interview on 04/14/11, at 2:40 P.M., the housekeeping supervisor said she would go to the charge nurse if staff reported abuse/neglect to her. Housekeepr D did report to her that CNA E was rough with Resident #8. The housekeeping supervisor said she reported this to the charge nurse, but cannot remember which charge nurse it was. The resident did not want to get up and the CNA pulled on the resident's arm. She made this report about a month ago. During interview on 04/14/11, at 3:45 P.M., the DHSS surveyor made the administrator aware of the allegations of abuse involving Resident #8. The administrator said the allegation was just brought to her attention by the housekeeping supervisor. Record review of the resident's medical record and CNA E's personnel file showed staff did not document an investigation into this allegation of possible abuse. Staff did not document notifying the resident's family or physician of the allegation. 7. During interview on 03/29/11, at 10:05 A.M., CMT L said completed shower sheets are given to the charge nurse who forwards them to the MDS Coordinator. During interview on 03/29/11, at 10:45 A.M., CNA M said completed shower sheets are given to the charge nurse. If he/she has an immediate concern with a resident he/she gets the nurse immediately to look at a skin issue or concern. During interview on 04/12/11, at 2:40 P.M., the clinical manager said shower sheets are completed when showers are given, given to the charge nurse and then to LPN J. She had recently been taking old shower sheets and entered them into a log to track when showers are given. There had been no prior tracking system of showers given. During interview on 04/13/11, at 10:00 A.M., the administrator said bath sheets are completed on each resident and given to the charge nurse who should review them and follow up on any issues as needed. LPN J then gets the bath sheets for review. The first time a skin issue is noticed the bath aide needs to use the call light to have the charge nurse or LPN J look at the skin right then. CNAs are to turn in bath sheets after each shower instead of waiting until the end of the day. Staff should document a new skin issue in the nurse's notes and prepare a skin report. During interview on 04/13/11, at 10:15 A.M., Social Service Worker (SSW) F said if he/she was aware of any allegation of possible abuse he/she would immediately take action. The staff in question would be removed and full statements of any staff with information would be taken. He/she would report the allegation to the charge nurse, MDS Coordinator K and the administrator. During interview on 04/13/11, at 10:25 A.M., LPN S said if a resident had a new bruise or injury he/she would check out the situation and review the chart. He/she would look for a possible fall or incident charted that might explain the bruise or injury. If he/she did not find one he/she would document the bruise/injury in the chart, complete an incident report, notify the resident's physician and family and try to investigate the cause. He/she would pass the information on to the next shift. If the bruising or injury showed changes over time he/she would report the changes to the physician. The LPN said he/she reviews shower sheets and if there is a new skin issue the LPN is not aware of he/she will check the resident, document the concern and notify the physician. During interview on 04/13/11, at 2:02 P.M., CMT R said if he/she saw or heard anything questionable with a resident he/she would report it to a charge nurse and if it was not taken care of he/she would report up the change of command at the facility. He/she would do the same if he/she discovered a new bruise on a resident. During interview on 04/13/11, at 2:09 P.M., CMT T said if he/she sees or hears anything that might be abusive he/she will report it to the charge nurse. If not taken care of, he/she would report it up the facility's chain of command. He/she would do the same on a newly discovered bruise. During interview on 04/13/11, at 2:20 P.M., CNA U said shower sheets are given to the nurse after each shower and he/she puts everything on it. If he/she hears or sees anything that concerns him/her he/she reports it to the charge nurse and if it is not taken care of he/she would report it up the chain of command at the facility. If he/she discovered a new bruise she would document it on shower sheet and report it to the charge nurse. During interview on 04/13/11, at 2:26 P.M., LPN V said if staff reported possible abuse or neglect to him/her he/she would counsel the staff member, have the staff member go home and notify supervisors involved. If a resident had a new bruise he/she would assess the bruise, investigate the cause and review the chart. If there was no prior incident or documentation the LPN would complete a skin report. During interview on 04/14/11, at 9:50 A.M., CNA Z said if he/she suspects abuse or neglect by a staff member he/she will report it to the charge nurse and will pursue it up the chain of command if needed. If he/she noticed new bruising on a resident he/she would report that to the charge nurse. During interview on 04/14/11, at 10:10 A.M., LPN AA said shower sheets are reviewed and if there are any new skin issues he/she will take care of them and notify the physician of the skin issues. If there is any allegation of possible abuse or neglect the LPN would start an immediate investigation and ask for the staff member the allegation is against to leave the facility. If a new bruise or injury was found on a resident the LPN would assess it, measure it, complete a skin assessment and risk management paperwork. The paperwork would go to LPN X for further investigation of the bruise/injury. LPN AA would notify the resident's family and physician of the bruise/injury. He/she has not seen any CNA be rough recently with residents, but some resident have complained about CNA E before. During interview on 04/14/11, at 10:45 A.M., CNA DD said if he/she noticed a new bruise on a resident he/she should alert the charge nurse and have them look at it. If she felt it was not assessed or looked at close enough he/she would report the concern up the chain of command in the facility. During interview on 04/14/11, at 11:06 A.M., LPN G said if abuse or neglect was reported to him/her, he/she would talk with the alleged staff member and call the DON and ADON. He/she would send the staff person home if needed. During interview on 04/19/11, at 10:05 A.M., the DON said she expects to be notified immediately of any abuse/neglect allegations. She expects CNAs to follow through and if they see that something has not been followed up on then they are to contact her. Any staff being investigated should be suspended pending the investigation. She is still being trained on the facility's policies (this is day six on the job and the DON was out last week), so she is not positive what the policy is for injuries of unknown origin. The DON did say an injury of unknown origin has to be investigated and if the cause can not be determined it must be reported to the state agency. Charge nurses review the shower sheets and the clinical manager also reviews them to make sure nothing is missed and any concerns are documented in the system. It would not be acceptable to have a staff member with multiple allegations of rough or inappropriate handling of residents care for residents. MO # 735

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". A monitoring visit was completed on 5/05/11. Based on interviews, observations and record review completed during the onsite revisit, it was determined the facility had implemented corrective action to address and lower the violation at this time. The facility had provided in-service training on how to complete an incident report, resident rights, types of abuse and reporting any injury of unknown origin. The facility had interviewed 40 residents and/or families regarding abuse/neglect. The families and residents were provided written information on the types of abuse/neglect, signs to watch for and how to report an allegation. The facility had conducted four investigations related to possible allegations of abuse/neglect since the exit date of 4/19/10. The allegation named in the complaint had not been investigated or reported to the facility. The reporter in the complaint could not recall whom he/she reported the incident to. One resident had a large bruise approximately 15.5. by 17 cm on his/her calf. The facility failed to conduct an investigation of the cause of the injury. The facility did not notify the resident's family regarding the bruise. The DON said the resident bruises easily due to his/her medical condition. However, no documentation could be found to confirm a medical condition that would cause bruising. The DON and administrator continue to monitor and investigate allegations of abuse/neglect for compliance. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State Law (Section 198.026.1 RSMo) requiring that prompt remedial action to be taken to address Class I violation.

Based on observation, interviews, and record review the facility failed to assess, monitor, and treat three residents (Resident #1, #2 and #5) with pain in a timely manner. Staff failed to assess an acute injury of unknown origin and provide appropriate pain management of the injury for Resident #2. Staff failed to identify and treat pain prior to providing wound treatment for [REDACTED].#5) pain medication on a regular basis, failed to ensure the resident's medications were available and failed to notify the resident's family and physician when medication was not available for administration. The resident went to the emergency room and returned to the facility after being treated for [REDACTED]. The facility had a census of 99. 1. Record review of the facility's Pain Management policy, updated 03/29/07, showed the following information: - Screen each resident for pain on admission, readmission, significant change in condition, quarterly and any time pain is suspected using the pain assessment tool; - Provide a comprehensive pain assessment to identify underlying causes for each resident having pain; - Develop a care plan based on clinical rationale and the resident's and/or family's goals, considering both pharmacological and non-pharmacological interventions; - Implement and evaluate the resident's response to the interventions, including their effectiveness and adverse consequences; - Be aware that cognitively impaired residents may not present with the typical complaints of pain and instead may present with nonverbal cues; - If a resident's pain can not be controlled despite repeated attempts and various approaches, consider a referral to other resources such as a hospice program, pain management specialist or a pain center; - When a pain medication is given, the nurse will document location and score of the pain on the pain flow sheet and follow up to determine the effectiveness of the medication. 2. Record review of the Bruner and Suddarth's Textbook of Medical-Surgical Nursing, 9 th edition, copyright 2000, revealed the following information regarding Behavioral Responses to Pain: - Behavioral responses to pain may include verbal statements, vocal behaviors, facial expressions, body movement, physical contact with others, or altered responses to the environment. - A person in acute pain may cry, moan, frown, immobilize a body part, clench a fist or withdraw. - The person may become angry or irritable. Sounds from a radio or television may be very annoying to the person with pain. These behaviors vary greatly from one time to the next. - Although a patient's behavioral responses may be the first indication that something is wrong, behavioral responses should not be used as a substitute for pain management except in unusual situations in which pain measurement is not possible (e.g., the person is severely mentally retarded, cognitively impaired or unconscious). 3. Record review from the Journal of the American Geriatrics Society (AGS) Panel article, "The Management of Persistent Pain in Older Persons" (June 2002-Vol.,50, No. 6, Supplement) revealed, in part, the following information: - Pain management is most successful when the underlying cause of pain is identified and treated definitively. A thorough initial assessment and an appropriate work-up are necessary to determine whether disease-modifying interventions could address the cause of a patient's persistent pain. Assessment should include evaluation of acute pain that might indicate new concurrent illness rather than an exacerbation of persistent pain. - In the evaluation process, interdisciplinary assessment may help identify all the potentially treatable contributors to pain. - Even patients with mild to moderate cognitive impairment can be assessed with [REDACTED]. 4. Record review of Resident #1's 30-day Minimum Data Set (MDS- a federally mandated comprehensive assessment tool completed by facility staff), dated 03/25/11, showed the following information: - Severely impaired cognitive skills for daily decision making; - Required total dependence of one to two staff members for all activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); - Functional limitation in range of motion on both sides of the body to both upper and lower extremities; -Resident had not been on a scheduled pain medication regimen during the last 5 days; -Resident frequently experienced moderate pain; -[DIAGNOSES REDACTED]. Record review of the resident's plan of care, initiated on 04/26/10, showed the facility staff had identified the resident to be at risk for pain due to the [DIAGNOSES REDACTED]. The facility staff had initiated the following interventions to address the pain: -Provide diversionary activities; -Monitor for break-thru pain; -Notify the resident's physician for as needed (PRN) pain medication to treat break-thru pain; -Administer pain medications as ordered and note the effectiveness; -Acknowledge the presence of pain and discomfort; -Document/report complaints and non-verbal signs of pain. Record review of the resident's Pain Assessment in Advanced Dementia, dated 07/06/10, showed the facility identified the resident as being at mild risk for pain. Record review of the resident's care plan review sheet, dated 07/16/2010, showed the resident received [MEDICATION NAME] (narcotic pain medication) every four hours routinely for pain. Record review of the resident's Pain Assessment in Advanced Dementia, dated 09/20/10, showed the facility identified the resident as being at mild risk for pain. (Note: Based on record review the facility staff failed to document the completion of a pain assessment on the resident from 09/21/10 until the time of exit on 04/19/11. At the time of exit staff had not completed a current pain assessment.) Record review of the resident's physician's orders [REDACTED]. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's March 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - One dose on 03/07/11; - One dose on 03/09/11; - One dose on 03/28/11. Record review of the resident's April 2011 MAR indicated [REDACTED] - One dose on 04/14/11; - Two doses on 04/15/11; - One dose on 04/16/11; - One dose on 04/17/11; - One dose on 04/18/11. Record review of the resident's nurses' notes showed the following information: - On 04/03/11 staff documented the resident had no complaints of pain. - On 04/10/11 staff documented that repositioning was painful for the resident; - On 04/12/11 staff documented no pain was noted. (The facility staff could not provided further documentation, upon request, to show the facility staff had completed pain assessments on the resident.) During an observation and interview on 04/12/11, at 11:29 A.M., Licensed Practical Nurse (LPN) G provided wound care to the resident's right foot. The resident sat upright in his/her wheelchair during the treatment. The resident attempted to pull his/her foot away from the LPN during the treatment. The resident grimaced when staff treated the wound. The resident said to the LPN, "that hurts, that's enough". The LPN said to the surveyor, "the wounds hurt him/her a lot" and "we try to be very careful". The resident appeared to be comfortable after the treatment was completed by the LPN. During observation on 04/14/11, at 10:47 A.M., LPN J provided wound care to the resident's right foot, left index finger and buttocks. MDS Coordinator K assisted in positioning the resident during the treatment. The resident lay in his/her bed during the treatment. He/she appeared uncomfortable during the wound care. The resident grimaced and attempted to pull his/her right foot away each time the LPN manipulated the wounds. The staff attempted to calm the resident by offering verbal reassurance to the resident. The resident said, "I do not want this" and "why are you doing this to me". The resident had one stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) and one unstageable pressure sore (not stageable due to coverage of wound bed by slough and/or eschar) on his/her right foot. The resident also had an infected stage II-III (stage III -- full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure sore on his/her left index finger. Following the treatment of [REDACTED]. The resident immediately became upset. MDS coordinator attempted to console the resident. The resident continued to be upset and began to cry out. The resident's hands were very contracted, with his/her fingers pulled in toward the palm of the hand. The MDS coordinator attempted to extend the resident's finger away from the palm to position the index finger for treatment. The resident cried out in pain. The resident said to the MDS coordinator, "Just leave me alone for a little bit". The LPN quickly provided wound treatment to the area. Due to the location of the wound, the contracted fingers, and the resident resisting treatment, the wound was very difficult to assess. The LPN said the wound was a stage II pressure sore, possibly a stage III. During the treatment the resident said, "It is hurting more than you will ever know". Following the wound treatment, staff repositioned and made the resident comfortable. (Staff did not administer pain medication to the resident.) During an interview on 04/14/11, at 11:15 A.M., LPN J said the resident was "definitely in pain" during the treatment. The LPN said staff should have administered pain medication prior to the treatment and he/she should have made sure the resident received medication before he/she began the treatment. The LPN said, the resident "hurts like hell". During an interview on 04/14/11, at 12:20 P.M., Certified Medication Technician (CMT) I said the resident did not have a scheduled or PRN pain medication currently ordered. (The CMT did not state staff had notified the physician and were trying to obtain a pain medication for the resident.) During an interview on 04/14/11, at 12:25 P.M., MDS Coordinator KK said the resident was "absolutely in pain" during the wound treatment. He/she said anytime staff move or reposition the resident he/she is in pain. He/she said staff should administered pain medication to the resident prior to the wound treatment. Record review of the resident's physician's orders [REDACTED]. (Note: This order was obtained as part of the facility's immediate plan of correction related to an J level citation at F309 on 4/14/11.) Record review of the resident's physician's orders [REDACTED].) During an interview, on 04/19/11 at 10:05 A.M., the Director of Nursing (DON) said she believed the dressing change would be painful for the resident and staff should administer pain medication to the resident prior to separating and/or performing wound care on the resident's finger. 5. Record review of Resident #2's face sheet showed staff admitted the resident to the facility on [DATE] with the following Diagnosis: [REDACTED]. - [MEDICAL CONDITION]; - Generalized pain; - Anxiety; - Depression; - History of fracture to the forearm. Record review of the resident's Quarterly MDS, dated [DATE], showed the following information: -Short and long term memory problems; -Moderately impaired cognitive skills for daily decision making; -Required total dependence of one to two staff members for bed mobility, transfers, locomotion, toilet use and personal hygiene; -Functional limitation in range of motion on both sides of the body to lower extremities; -Resident had not been on a scheduled pain medication regimen during the last 5 days; -Resident had non-verbal sounds, vocal complaints of and facial expressions as indicators of pain; -Resident frequently experienced moderate pain; -No bruises; -[DIAGNOSES REDACTED]. Record review of the resident's plan of care, initiated on 12/09/08, showed the facility staff had identified the resident to be at risk for pain due to a history of chronic pain. Staff established a goal for the resident to be pain free. The facility staff had initiated the following interventions to address the pain: -Assess resident every shift for pain or discomfort; -Observe for non-verbal signs of pain, such as facial grimace, guarding, crying out and moaning; -Administer pain medications as ordered and note the effectiveness; -Look for sources of discomfort in addition to pain including new skin irritation, constipation, recent falls and environmental conditions (too hot, too cold, lighting and noise); -Behaviors that are likely to be signs of pain include guarding a body part, reluctance to move or be moved, restlessness, vocalizations, irritability, and decreased appetite. Record review of the resident's March 2011 POS showed the following orders: - [MEDICATION NAME] (narcotic pain medication) 500/5 mg, one tablet, as needed for generalized pain on 11/29/10. (Note: The order did not specify the frequency at which the resident could receive one tablet as needed for pain.) - [MEDICATION NAME] 75 micrograms (mcg) patch (narcotic pain medication) every three days for generalized pain on 03/01/11. Record review of the resident's Pain Assessment in Advanced Dementia, dated 07/08/10 and 03/20/11, showed the facility identified the resident as being at moderate risk for pain. (Note: Based on record review the facility staff failed to document the completion of a pain assessment on the resident from 03/20/11 until the time of exit on 04/19/11. At the time of exit staff had not completed a current pain assessment.) Record review of the resident's March 2011 MAR indicated [REDACTED] - One tablet on 03/03/11; - One tablet on 03/06/11; - One tablet on 03/11/11; - One tablet on 03/26/11; - One tablet on 03/28/11. (Note: Staff documented the reason for administration of the PRN pain medication and the effectiveness on 03/03/11. Staff failed to provide documentation related to the administration of the pain medications on 03/06/11, 03/11/11, 03/26/11 and 03/28/11.) Record review of the resident's April 2011 MAR indicated [REDACTED] - One tablet on 04/03/11; - One tablet on 04/07/11; - One tablet on 04/13/11. Record review of the resident's nurse's note written on 04/03/11, at 12:02 P.M., showed the following information: - The resident had a bruise on his/her left wrist. - The resident had a large hematoma (bruise) on his/her right forearm that was painful to touch. - The resident was able to move his/her arm, fingers and wrist without pain. (Staff did not document notifying the resident's physician or family of the bruising. No further assessments or monitoring of the injury was noted until 4/10/11.) Record review of the resident's skin assessment, dated 04/06/11, showed the resident had irritation under his/her right breast. The facility staff failed to document the hematoma on the resident's left hand or the large bruise on the resident's right wrist/forearm. Record review of the resident's skin monitoring shower sheet, dated 04/06/11, showed the resident had a large purple bruise and knot to his/her right forearm. The shower sheet was signed as reviewed by Registered Nurse (RN) BB on 04/06/11. Record review of the resident's nurse's note, dated 04/10/11 at 8:11 P.M., showed the following information: - The resident received a hematoma on his/her right arm. - The resident received the hematoma on 04/03/11. - The hematoma was painful to the touch. - The resident had complete range of motion in his/her right arm. - The resident has difficulty gripping with his/her right hand. - The hematoma was 2.5 centimeters (cm) by 2.0 cm in size. (Staff did not document administering pain medication to the resident.) Record review of the resident's physician/nurse communication sheet, dated 04/10/11, showed the staff notified the physician of the following information: - The resident received a hematoma on his/her right arm. - The resident received the hematoma on 04/03/11. - The hematoma was painful to the touch. - The resident had complete range of motion in his/her right arm. - The resident has difficulty gripping with his/her right hand. - The hematoma was 2.5 cm by 2.0 cm in size. (Note: The physician responded to the communication with an order to observe the area.) During general observations, on 04/12/11 at 10:30 A.M., showed the resident sat in his/her wheelchair near the nurse's station/television area. While talking with the resident, bruising was noted to the resident's left hand and right forearm. During observation and interview, on 04/12/11 at 10:35 A.M., the resident sat in his/her wheelchair in his/her room. CMT EE was present in the resident's room. The resident had a dark purple round bruise to the top of his/her left hand approximately 4 cm in diameter and a large bruise to his/her right forearm approximately 2.5 cm by 2.5 cm with a 2.0 cm raised knot in the center of the injury. The bruise on the forearm was light to dark purple in color. The area appeared to be very painful to the resident as the CMT raised the resident's sleeve for inspection. The resident cried out "ouch" and moaned. The resident guarded the injury and attempted to pull his/her arm away. The resident said, "someone was rough with me when helping me to bed" and "it was someone who works here". The resident could not remember if the staff member was male or female. The resident said his/her arm hurts. When asked how he/she received the bruise to the top of his/her left hand, the resident responded by saying, "that's where they grabbed me". The resident said he/she had not seen the physician regarding the injuries. The resident said his/her right forearm currently hurt. The resident denied pain to any other area of the body. During an interview on 04/12/11, at 10:38 A.M., CMT EE said the following: - He/she did not know how the resident received the injury. - He/she noted the bruising on the resident's left hand and right forearm on 04/08/11. - He/she reported the injury to LPN A immediately upon discovery. - The bruised areas appeared to cause the resident pain. During an interview, on 04/12/11 at 1:15 P.M., LPN A said the following: - He/she believed the incident occurred on 04/03/11; - He/she noted the bruising to the resident's right forearm and left hand after breakfast; - He/she saw the resident's right forearm on 04/11/11; - On 04/11/11 the resident had a large knot that was painful to the touch on his/her right forearm; - The area caused the resident pain. (LPN A did not administer pain medication to the resident on 04/12/11.) During an interview on 04/12/11 at 2:05 P.M., CNA FF said the following: - He/she heard the resident calling out from his/her bedroom; - He/she saw CNA E struggling with the resident; - CNA E had his/her hand wrapped around the resident's right forearm; - He/she asked CNA E to leave the room; - The resident had a red area where CNA E held the resident's right forearm; - The resident appeared to be in pain following the incident. During an observation, on 04/12/11 at 2:23 P.M., with LPN X and the MDS Coordinator K present showed the following: - The resident lay in bed. - LPN X attempted to raise the resident's right sleeve to assess the forearm. - The resident cried out in pain. - The resident attempted to pull his/her arm away from the staff member. - The resident said "it hurts real bad". - The resident said his/her right forearm hurt when the incident occurred. (Staff did not administer pain medication to the resident after the observation.) Record review of the resident's nurse's note, dated 04/12/11 at 9:01 P.M., showed facility staff contacted the resident's family regarding the incident that occurred on 04/03/11 to the resident's right forearm. Observation on 04/13/11, at 11:23 A.M., showed the resident in his/her wheelchair in a resident group area, next to the nurse's station, in front of the television. The resident moaned and appeared to be in pain. During observation and interview, on 04/13/11 at 9:45 A.M., LPN AA assessed the resident's arm. The knot on the resident's arm was soft and measured 2 cm x 2 cm x 2 cm with dependent bruising from wrist to elbow. The resident said it hurt and it felt better when he/she laid it down. Record review of the resident's progress note, dated 04/13/11 at 11:08 A.M., showed staff document they notified the on-call physician of the known bruise on resident's right forearm with a soft knot the size of half of a ping pong ball in the middle. Staff informed the physician the area had been present for several days and it was very painful to the resident with movement of the extremity. The physician said an x-ray was not necessary and to have the resident's normal physician to look at the site. The physician said to treat the resident's pain and monitor the site. During an interview, on 4/19/11 at 10:05 A.M., the DON said she believed the resident's right forearm was painful. 6. Record review of Resident #5's face sheet showed an admission date of [DATE]. Record review of the resident's April 2011 POS showed [DIAGNOSES REDACTED]. cord and nerves). Record review of the resident's current care plan, initiated 02/21/11, showed the following information: - ADL deficit related to pain and lack of energy. - Assist to keep pain controlled. - Resident has chronic pain related to history of numerous fractures. - Assess for complaint of pain when giving care and during conversations. - Administer routine pain medication as ordered, monitor results and if pain persists notify the physician. - Offer as needed pain medication for break thru pain. Record review of the resident's March 2011 POS showed the resident had orders for following medication: - [MEDICATION NAME] ([MEDICATION NAME]) 10 mg three times a day for adjustment disorder with anxiety. Order start date was 11/10/10. - MS Contin, 30 mg, four times a day for chronic pai[DIAGNOSES REDACTED]. Order start date was 12/16/10. - [MEDICATION NAME] 10 mg/5 milliliter (ml) as needed for chronic pai[DIAGNOSES REDACTED]. Order start date 11/10/10. Record review of the resident's pain assessment, dated 02/15/11, showed the following information:- The resident had pain in the last seven days and rated the pain a five. (A rating of four is moderate pain and a rating of six is severe pain.) - Pain is worse when the resident is awake. - Resident is in pain all the time. - Pain types include throbbing, dull ache and tingling. Record review of the resident's February 2011 MAR indicated [REDACTED].M. on 02/12/11, 02/13/11, 02/15/11, 02/23/11 and 02/27/11 and at 7:00 A.M. and 11:00 A.M. on 02/28/11. Staff noted on the MAR indicated [REDACTED]. Staff administered the resident's as needed [MEDICATION NAME] eight times in February 2011. (Staff did not document why the medication was not administered on the dates besides 02/12/11.) Record review of a written statement, dated 04/18/11, provided by facility RN H showed the RN said he/she worked the night of 03/12/11 when it was documented the resident did not request his/her pain medication. The RN said the resident said he/she would request the pain medication when he/she was ready for it and he/she did not request it that evening, however he/she has always requested it. (The facility provided the statement in regards to the 02/12/11 documentation even though the RN referred to 03/12/11.) Record review of resident's social service progress note, dated 02/25/11 at 3:10 P.M., showed behavior interventions were in place for the resident. He/she had a history of [REDACTED]. (The staff did not address the staff not administering the resident's pain medication as ordered.) Record review of the resident's nurse's notes for February 2011 showed staff did not document why the resident did not receive his/her pain medication as ordered and did not document contacting the resident's physician or family about staff not administering the medication as ordered. Record review of the resident's March 2011 MAR indicated [REDACTED].M. (noon) on 03/10/11 through 12:00 P.M. on 03/22/11 (37 doses). Staff did not administer the resident's [MEDICATION NAME] 7:00 A.M. on 03/21/11 through 7:00 A.M. on 03/22/11 (four doses). Staff administered the resident's as need [MEDICATION NAME] once from 03/01/11 through 03/09/11. Staff administered the resident's as needed [MEDICATION NAME] 17 times from 03/10/11 through 03/22/11. Staff noted on the MAR indicated [REDACTED]. (Staff did not document why the [MEDICATION NAME] not administered and did not document why all the doses of [MEDICATION NAME] were not administered.) Record review of the resident's progress note, dated 03/21/11 at 9:08 P.M., showed the resident was anxious and agitated. The resident was threatening to hurt someone. Staff noted condition necessitating discharge was physician order [REDACTED]. Staff did not document notifying the resident's family or physician about medications not administered.) Record review of resident's telephone physician's orders [REDACTED].M., showed the physician ordered the resident sent to the emergency room for evaluation. Record review of the resident's hospital discharge instruction, dated 03/21/11 at 10:01 P.M., showed the following: - Resident was treated for [REDACTED]. - Resident left the hospital with order for MS Contin, 30 mg every eight hours and [MEDICATION NAME], 5 mg, three times a day. Record review of resident's nurse's notes, dated 03/22/11 at 1:13 A.M., showed the resident returned from the emergency room and had new orders for [MEDICATION NAME], 5 mg three times a day and MS Contin, 30 mg, three times a day. Record review of resident's social service progress notes, dated 03/22/11 at 8:55 A.M., showed staff made repeated attempts to obtain medication from the VA (dates and times not provided). The physician's prescriptions were reviewed and it was noted they were missing several vital pieces of information. The physician was asked to provide this information on two separate times so that the medication could be obtained (dates and times not provided). After the facility received what was believed to be complete prescriptions, staff hand delivered the information to the VA pharmacy to attempt to obtain the medication same day. Repeated attempts were made to call and fax the physician when additional information was needed (dates and times not provided). The staff then called a VA physician to attempt to request emergency stop-gap measures while the problem was being resolved which the physician did comply with (date and time not provided). The staff are still obtaining the needed information for the prescriptions to be filled by the VA for continuing care. (The staff did not state which medication were needed, when the order for the stop-gap medications was received and when the medications needed were received. Staff did not document telling the resident's physician or family of the medications not administered to the resident.) During interview on 04/19/11, at 11:05 A.M., the resident said he/she went days without some medications and ended up in the hospital because he/she "could not take it". The resident says he/she stays up late so getting his/her night medication is not an issue. The resident hurts a lot because he/she has had 30 surgeries, 26 broken bones, an artifical knee replacement [MEDICAL CONDITION]. During interview on 04/13/11, at 2:45 P.M. and 3:14 P.M., LPN W said a resident should not have to ask for a routine medication to be administered. During interview on 04/13/11, at 3:21 P.M., CMT Y said a resident should not have to ask for a routine medication to be given. During interview on 04/13/11, at 3:37 P.M., MDS Coordinator K said if medication are not administered, staff should document the reason in the medication record or on the MAR. The resident should not have to request a routine medication Staff should call quickly to see the reason a medication is not available. Staff not administering the [MEDICATION NAME] and [MEDICATION NAME] have contributed to the resident being sent to the hospital. During interview on 04/14/11, at 9:43 A.M., LPN S said if a medication is scheduled to be administered routinely the resident should not have to ask for the medication. If staff does not administer a medication, staff should document the reason on the MAR. During interview on 04/14/11, at 9:45 A.M., CMT R said staff should not wait until a resident asks for a routine medication to administer that medication. If staff does not administer a medication, staff should document the reason on the MAR. During interview on 04/19/11, at 10:05 A.M., the DON said residents should not have to request routine pain medications be administered by staff. 7. During an interview, on 04/19/11 at 10:05 A.M., the DON said the following information: - If a resident says they are in pain, they are in pain. - Staff should assess the resident's pain and give a PRN pain medication. - She expected a pain assessment to be completed every shift on each resident. - All residents should have a PRN pain medication order. If a resident does not have a current PRN pain medication order the staff member should obtain an order. - Guarding, pulling away, moaning, and crying are signs of pain. - It was sometimes difficult to assess whether a resident was in pain; - She expected staff to treat it as pain if the resident stated he/she is in pain; 8. Department of Health and Senior Services surveyor placed a telephone call to the offices of Resident #1 and Resident #2's physicians on 04/12/11, at 11:00 A.M., and on 04/20/11, at 10:45 A.M. The physicians have not returned the calls. MO # 284

Based on observations, record review and interviews the facility failed to provide assessments, monitoring, and services necessary to prevent the development of pressure ulcers for three randomly selected residents out of 12 pressure sores (Resident #1, Resident #3 and Resident #4) with facility acquired pressure sores. Resident #1 developed two unstageable pressure sores to his/her right foot and one pressure sore on his/her left index finger that became infected and required antibiotics. Resident #3 developed one unstageable pressure sore requiring antibiotics for infection and wound vac therapy. Resident #4 developed an unstageable pressure sore requiring hospitalization to treat the infected wound. A sample of three residents was chosen for review in a facility with a census of 99. 1. Pressure ulcer staging according to State and Federal guidelines: - Stage I pressure ulcer (a persistent area of skin redness without a break in the skin that is nonblanchable) -Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. -Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. -Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. According to terminology defining unstageable pressure ulcers in the Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0: -Unstageable-Non-removable dressing - Known but not stageable due to non-removable dressing/device. -Unstageable-Slough and/or Eschar - Known but not stageable due to coverage of wound bed by slough and/or eschar. -Unstageable-Deep Tissue - Suspected deep tissue injury in evolution. Record review of the U.S. Department of Health and Senior Services, Agency for Health Care Policy and Research revealed "a bed-bound individual may form pressure ulcers in as little as one to two hours, whereas those who are confined to chairs may form pressure ulcers in even less time because of the greater relative force on their skin. When a resident is identified as being at risk for pressure ulcer development or presents with a pressure ulcer, then preventative interventions should be instituted that address pressure reduction (or management of tissue loads) and repositioning needs. Reducing or eliminating the risk factors can prevent pressure ulcer formation or deterioration of existing ulcers". According to Medical Surgical Nursing, Critical Thinking for Collaborative Care 4th edition, many residents require turning and repositioning every two hours. However, pressure ulcers can occur in less time, and the actual turning/repositioning schedule for each resident should be individualized based upon the resident's risk factors such as immobility and disease processes. Pillows and other positioning devices are to be used at all times to keep heels pressure free for high risk residents. Frequent assessment of heel positioning is needed to ensure that pressure is not redistributed to another high risk area, such as the sides of the feet. Assessment is needed even more frequently when devices that hide the feet, such as boots, are used, especially if the resident has a peripheral vascular problem. Individuals who are in bed should not be positioned on the pressure ulcer. If the ulcer is on a circumscribed area such as the heel, positioning devices should be used to raise the ulcer off the support surface. 2. Record review of the facility's Wound Care/Pressure Ulcers Policy and Procedure, undated, showed the following information: - Policy is preventative measures will be implemented to reduce the risk of development of pressure ulcers. Nurses will assess resident's risk at regular intervals. - Objectives include identify residents at risk for development of pressure ulcers by using the Braden Scale, development of an appropriate care plan, implement appropriate interventions as quickly as possible after identifying risk, routine assessments of pressure ulcers and wounds and prevent and reduce the development of pressure ulcers through education and supervision of staff. - Braden Scale will be completed upon admission and then once weekly for four more weeks, quarterly and with significant change. - A skin note will be done upon admission and every shift for the first 48 hours, then weekly for four weeks. - A skin note will be done monthly for those residents identified at risk with prompt notification of the MDS Coordinator. - Nursing staff will observe for and report skin issues and utilize the "bath sheets" during routine bathing. - Residents identified at risk for the development of pressure ulcers will have appropriate interventions implemented as quickly as possible after identifying risk. - All pressure ulcers will be assessed initially and then weekly using pressure ulcer assessment along with the PUSH tool. Assessment will include location, size, stage, tunneling or undermining, cause, color, drainage, odor, pain, wound bed and condition of surrounding tissue. Assessment should also include treatment and response to treatment. - All wounds will be assessed initially and then weekly. Assessment will include location, size, cause, color, drainage, odor, pain, wound bed and condition of surrounding tissue. The assessment should also include treatment and response to treatment. - Physicians and DPOA's will be notified of all pressure ulcers and wounds upon identification, when wound not progressing towards healing or when wound is worsening. - A pain assessment or pain screening will be done initially and then weekly with assessment of wound or pressure ulcer. - A weekly skin condition report will be done weekly by the LN assigned to do the assessments. Copies will be given to the administrator, DON, MDS Coordinator and the DM. The reports should be submitted monthly to the nurse consultant. - All pressure ulcers shall be documented upon finding of pressure ulcer and then weekly by LN. The documentation should include location, stage, size, undermining/tunneling, wound bed tissue and color, drainage, odor, peri wound condition, treatment and response to treatment. - Documentation of changes to plan of care is indicated at the time of assessment of the pressure ulcer and implementation of treatment plan. - Early intervention and prevention includes turning and repositioning, proper positioning, use of pressure relieving devices, good skin care, maintaining nutritional status, labs, vitamin and mineral supplements, educate of staff and specialized education of LN regarding wound assessment, staging and treatments. - The assessment and treatment of [REDACTED]. - Pain that interferes with movement or affects mood may contribute to immobility and contribute to the potential for developing a pressure ulcer or for delay healing or non-healing of an existing ulcer. - Consider pain medication before dressing changes/treatments. - Before performing any type of wound treatment, assemble all supplies outside the room before entering and if using stock supplies use medication cups to carry an appropriate amount of the needed item into the room, then dispose of the cup when the treatment is completed. These practices prevent cross contamination. - Wear gloves when performing any type of wound care. - Remove gloves after an old dressing has been removed, wash hands and apply new gloves to apply new dressing. - Dispose of wound care supplies in the proper waste receptacle. 3. Record review of the Resident #4's face sheet showed he/she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Record review the resident's Braden Scale (a measured assessment completed by facility staff to determine pressure sore risk based on predetermined criteria) admission assessment, dated 11/01/10, showed the facility staff identified the resident as being at low risk for the development of pressure sores. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 11/08/10, showed the following: - Resident required extensive assistance of one staff for bed mobility, transfers and dressing. - Resident required limited assistance of one staff for eating. - Resident required total dependence on one staff for toilet use. - Resident uses walker and wheelchair. - Formal assessment tool used and clinical assessment completed. - Resident at risk of developing pressure ulcers. - Resident has no unhealed pressure ulcers. - Skin treatments included pressure reducing device for chair and bed, turning/repositioning program, nutrition or hydration intervention to manage skin problems, application of nonsurgical dressings other than to feet and applications of ointments/medication other than to feet. Record review of the resident's physician/nurses communication sheet, dated 12/29/10 at 3:00 A.M., showed the following information: - The resident had an open area on his/her coccyx (tailbone). - The area was 1 centimeter (cm) by 1 cm in size. -The staff requested an order for [REDACTED]. -The physician agreed to the request. Record review the resident's skin condition assessment, dated 12/31/10, showed the following information: - Poor skin turgor. - Open area to the coccyx. - Stage II pressure sore present. - The wound was approximately 1 cm by 1 cm in size. - The wound bed was pink with pink surrounding tissue. - Small amount of clear drainage was present. - No odor was noted. Record review of the resident's skin condition assessment, dated 01/07/11, showed the following information: - Fair skin turgor. - Open area to the coccyx. - The wound was approximately 1 cm by 1 cm in size. - The wound bed was pink with pink surrounding tissue. - Small amount of clear drainage was present. - No odor was noted. Record review of the resident's skin condition assessment, dated on 01/15/11, showed the following information: - Good skin turgor. - Area to the coccyx was healed. Record review the resident's Braden Scale Assessment, dated 01/28/11, showed the facility staff identified the resident as being at moderate risk for the development of pressure sores. Record review of the resident's quarterly MDS, dated [DATE], showed the following: - Resident required extensive assistance of one staff for bed mobility, dressing and eating. - Resident required extensive assistance of two staff for transfers and toilet use. - Resident uses walker and wheelchair. - Formal assessment instrument/tool used and clinical assessment completed. - Resident is at risk for developing pressure ulcers. - Resident does not have one or more unhealed pressure ulcers. - Skin treatments included pressure reducing device for chair and bed and turning/repositioning program. Record review of resident's Braden Scale Assessment, dated 02/05/11, showed the facility staff identified the resident as being at low risk for the development of pressure sores. Record review of the resident's skin condition note, dated on 03/02/11 at 3:43 A.M., showed the following information: -The resident had poor skin turgor. -The resident had a small open area to his/her coccyx approximately 0.2 cm by 0.6 cm in size. -Staff will notify the resident's physician and responsible party during daytime hours. (Staff failed to document follow-up with the physican or a treatment order received.) Record review of the resident's March 2011 Treatment Administration Record (TAR) showed staff did not document treatments to the wound from 03/01/11 through 03/16/11. Record review of the resident's skin condition assessment, dated 03/15/11, showed the following information: - Poor skin turgor. - Open area to coccyx. - The wound to the resident's coccyx was approximately 1.2 cm by 1.5 cm. - Stage II pressure sore. - The wound bed was red with white surrounding tissue at the wound edges. - Small amount of red drainage present. - No odor present. Record review of the resident's physician/nurses communication sheet, written on 3/15/11 at 12:10 P.M., showed the following information: - The wound on the resident's coccyx was larger. - The staff requested to change the previous order of a thin [MEDICATION NAME] dressing to Collagen cream (a product used to remove dead tissue from a wound) covered with a foam dressing to be changed daily. - The physician agreed to the request. (Staff did not document physician notification between the 03/02/11 skin condition note and this communication sheet (13 days). Staff did not document notification of the resident's family of the wound. Staff did not document a prior treatment order received.) Record review of the resident's March 2011 physician's orders [REDACTED]. Record review of a nurse's note, written on 03/20/11 at 8:06 A.M., showed the resident had a superficial round wound approximately 1.5 cm in size to his/her right inner buttock. (Staff did not mention the state of the resident's wound on his/her coccyx or notifying the resident's family about the new wound.) Record review of the resident's physician/nurses communication sheet, dated 03/20/11 at 8:06 A.M., showed the following information: - The resident had a superficial area to his/her right inner buttock. - Staff cleansed the area with soap and water and applied a thin [MEDICATION NAME] dressing. - The staff requested an order to continue this treatment. - No response from the physician was noted. Record review of resident's physician/nurses communication sheet, written on 03/21/11 at 11:30 A.M., showed the following information: - The wound to the resident's coccyx had gotten worse. - The wound was approximately 3 cm by 2 cm in size. - The wound was unstageable due to light and dark tan eschar (dead tissue, usually dark in color, can be hard and dry or moist and is sometimes foul smelling). - Odor was noted from the wound. - Present treatment of [REDACTED]. - The staff requested changing the current order to Santyl cream (a debridement agent) with a foam dressing to be changed daily. - Staff requested a wound culture. - The resident had a new open area to his/her right buttock. - The wound to the right buttock was 2.5 cm by 2 cm in size. - The staff requested Santyl cream with a foam dressing for this area. - The staff requested an order for [REDACTED]. -The physician responded to the fax with "ok to above". Record review of a resident's nurse's note, dated 03/21/11 at 11:50 A.M., showed the resident had a new stage II pressure sore to his/her right buttock. Record review the resident's skin condition assessment, dated 03/21/11, showed the following information: - Poor skin turgor. - Open areas to coccyx and right inner buttock. - The wound to the resident's coccyx was approximately 2 cm by 3 cm with an unknown depth. - The area was unstageable due to a dark tan wound bed. - The surrounding tissue was hard. - The wound had a moderate amount of medium tan drainage and a strong odor present. - The wound to the resident's right inner buttock was 2.5 cm by 2.0 cm in size. - The wound bed was red with pink surrounding tissue. - A small amount of red tinged drainage with no odor was present. Record review of the resident's dietary progress note written on 3/21/11, showed the following information: - Stage II pressure sore on the resident's coccyx. - Superficial wound to the resident's right inner buttock. - Recommended adding daily multiple vitamin and [MEDICATION NAME] for wound healing. Record review of the resident's March 2011 physician's orders [REDACTED]. - An order, written on 03/22/11, [MEDICATION NAME], one package, twice daily. - An order, written on 3/22/11, to treat the wound to the resident's coccyx with [MEDICATION NAME] (moisture barrier) to the periwound, then apply Santyl to pressure sore and cover with a foam dressing once daily. Record review of a wound culture report collected from drainage of the wound on the resident's coccyx on 03/23/11 showed the following: - Moderate growth of Proteus Mirabilis (a species of anaerobic, motile, rod-shaped bacteria found in putrid meat, abscesses and fecal material). - Moderate growth of Escherichia Coli (bacteria commonly found in human or animal feces stool); - Heavy growth of [MEDICATION NAME] Faecalis (bacteria commonly found in human or animal feces (stool). Record review of the resident's nurse's note, dated 03/27/11 at 9:03 P.M., showed the wound to the resident's coccyx was very malodorous. Record review of the resident's nurse's note, dated 03/28/11 at 1:33 A.M., showed the following information: - The dressing to the coccyx wound was changed following an episode of bowel incontinence. - The wound had a foul odor. Record review of the resident's physician/nurses communication sheet, dated 03/28/11 at 12:16 P.M., showed the following information: - The results of the resident's wound culture were faxed to the physician over the weekend. - Staff will fax the results to the physician again. - The staff requested an order for [REDACTED]. - The physician responded with an order for [REDACTED]. Record review of the resident's physician/nurses communication sheet, dated 03/28/11 at 2:15 P.M., showed the following information: - The resident had an unstageable pressure sore on his/her coccyx. - The wound was approximately 3 cm by 3 cm in size. - The wound was greenish-tan in color with brownish-black eschar noted to the wound bed. - The skin surrounding the wound was hard. - The wound was deteriorating and had a foul odor. - The wound culture from 3/27/11 showed wound was infected with E Coli and [MEDICATION NAME]. - Staff requested treatment for [REDACTED]. - The physician responded with an order for [REDACTED]. Record review of the resident's March 2011 physician's orders [REDACTED]. Record review the resident's skin condition assessment, dated 03/28/11, showed the following information: - Poor skin turgor. - Open area to coccyx and right inner buttock. - The wound to the resident's coccyx was approximately 3 cm by 3 cm with an unknown depth. -The area was unstageable due to light green wound bed; -The surrounding tissue was hard; -The wound had a moderate amount of dark tan drainage and a strong odor present; -The wound to the resident's right inner buttock was 1.2 cm by 0.8 cm in size; -The wound had a red wound bed with pink surrounding tissue; -A small amount of red tinged drainage with no odor was present. Record review the resident's, dated 03/29/11 at 3:32 A.M., showed the following information: - The resident had begun antibiotic treatment to help promote wound healing. - The wound on the resident's coccyx was odorous upon entering the room. Record review of the resident's nurse's notes, dated 03/30/11, showed the following information: - The resident remained on antibiotic therapy for a wound infection. - The resident was repositioned from side to side to keep weight off his/her coccyx. Record review of the resident's physician/nurses communication sheet, dated 03/31/11 at 9:52 A.M., showed the following information: - Staff had been unable to schedule an appointment for the resident with a wound specialist nurse due to the wound care specialist benig ill. - The wound continued to deteriorate. - Staff requested the resident be seen by a wound care physician. - The physician responded to the request with an order for [REDACTED]. Record review of the resident's nurse's note, dated 03/31/11 at 9:52 A.M., showed the following information: -Staff had been unable to schedule an appointment for the resident with a wound specialist nurse. -The wound continued to deteriorate. -Staff requested the resident be seen by a wound care physician. -The physician responded to the request with an order for [REDACTED]. Record review of the resident's nurse's note, dated 03/31/11 at 11:13 A.M., showed the facility staff received an order for [REDACTED]. Record review of the resident's nurse's note, dated 03/31/11 at 3:42 P.M., showed the following information: - The resident continued to be on antibiotics for a wound infection. - Odor from the wound not as bad today. Record review of the resident's nurse's note, dated 04/01/11 at 10:50 A.M., showed the following information: - The wound to the resident's coccyx was bleeding. - The resident had an appointment to see wound care specialist on 04/04/11. - MDS Coordinator K will contact the resident's physician to see if the resident can be assessed sooner. Record review of the resident's physician/nurses communication sheet, dated 04/01/11 at 10:51 A.M., showed the following information: - The coccyx wound's slough wound base had perforated (opened). - The wound had tunneling measuring 1.3 to 1.5 c.m. in depth. - Odor from the wound was more prominent. - The wound continued to have induration (abnormal hardening of soft tissue) to the entire peri-wound (skin surrounding the wound) with slow bleeding. - Wound bed was dusky-gray. - The resident had an appointment scheduled with a wound care physician on 04/04/11. - Staff requested the resident be sent to a local hospital for immediate intervention. - The physician responded to the facility's request with an order to send the resident to the hospital for an evaluation. Record review of the resident's nurse's note, dated 04/01/11 at 11:18 A.M., showed staff contacted the resident's physician and requested the resident be sent to a local hospital for an evaluation and treatment of [REDACTED]. Record review of a physician's telephone order sheet, written on 4/01/11 at 11:18 A.M., showed an order to send the resident to a local hospital for treatment of [REDACTED]. Record review of the resident's nurse's note, dated 04/01/11 at 11:43 A.M., showed the resident left the facility in an ambulance. (At the time of exit, on 04/19/11, the resident had not returned to the facility from the hospital.) Record review of the resident's emergency department admission assessment, dated 04/01/11, showed the resident's chief complaint was a stage II pressure sore that developed into an unstageable wound "overnight". Record review of the resident's history and physical from the hospital, dated 4/01/11, showed the following: - Infected Stage III pressure sore on the resident's coccyx area; - Approximately 3- 4 cm in size; - The wound is deep; - Foul odor present; - Resident admitted for IV antibiotics and surgical debridement (The removal of dead or damaged tissue); - Will require a wound vac following debridement. (The [DEVICE] assisted closure (VAC) device is used to facilitate wound healing by converting an open wound to a closed wound. VAC consists of an evacuation tube embedded in a foam dressing. After the foam dressing is placed in the wound bed and sealed by an occlusive dressing, the tube is attached to a vacuum unit. The application of negative pressure causes the foam to collapse resulting in removal of excess fluids; increased blood flow and decreased bacterial colonization; granulation tissue formation; and wound closure.) Record review of hospital records showed the resident received surgical debridement to the wound on his/her coccyx on 4/07/11. The resident remained in the hospital with wound vac therapy in place at the time of review. The resident's condition was poor. During interview on 04/13/11, at 12:34 P.M., MDS Coordinator K said he/she would expect staff to update Resident #4's care plan to reflect the resident's wounds and wound treatments appropriately. The MDS Coordinator could not explain why the documentation in the chart on 03/15/11 asked for a new treatment when a prior treatment order could not be located in the chart. He/she would expect staff to be completing and documenting weekly skin assessments on the resident. During interview on 04/19/11, at 10:05 A.M., the DON said when a CNA identifies a new wound or skin area of concern, they should notify the charge nurse to look at it. The nurse will assess, get an order for [REDACTED]. They had a wound nurse that was not doing the job correctly and they are now implementing a new skin team that will track wounds weekly. The charge nurse will continue to complete wound treatments and should document what they see, but the same nurse will measure the wounds and complete the assessments weekly. The DON would expect to see interventions care planned for Resident #1 and efforts in place to prevent wounds on the resident's hands from the contractures. Therapy and the floor staff should work together to position the resident properly. Staff should care plan resident with potential for wound development. She is not sure of the system/scale used to assess for likely wound development. The residents should be assessed weekly for four weeks after admission and then at least quarterly after that. 4. Record review of Resident #3's face sheet showed he/she was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Record review of the resident's plan of care dated 11/10/10, showed the staff identified the resident at risk for skin breakdown related to decreased mobility and incontinence of bowel and bladder. The staff initiated the following interventions to decrease the risk of breakdown to the resident's skin: -Staff to assist the resident with toileting before and after meals, at bed time, and as needed. -Staff to perform all hygiene when the resident is incontinent of bowel or bladder. -Pressure relief mattress on the resident's bed and a cushion to the seat of his/her wheelchair. -Licensed staff to perform skin assessment monthly. -Shower aid will assess the resident's skin twice weekly and report any skin concerns to the charge nurse. (Staff failed to update the resident's plan of care following the development of a pressure sore. Staff failed to document new or changed interventions.) Record review of the resident's admission assessment, dated 11/11/10, showed the following information: - The resident had a shingles rash. - The resident's heels were soft but not open. - The resident had no skin breakdown to his/her coccyx or buttocks. Record review the resident's Braden Scale (a measured assessment completed by facility staff to determine pressure sore risk based on predetermined criteria) admission assessment, dated 11/11/10, showed the facility staff identified the resident as being at moderate risk for the development of pressure sores. Record review of the resident's admission MDS, dated [DATE], showed the following information: - Resident required limited assistance of one staff for bed mobility and dressing. - Resident required extensive assistance of one staff for transfer. - Resident required extensive assistance of two staff for toilet use. -Resident incontinent of bladder and bowel. - Resident used wheelchair for mobility. - Clinical skin assessment completed. - Resident identified as at risk of developing pressure ulcers. - Resident did not currently have any unhealed pressure ulcers. - Skin treatments included pressure reducing devices for chair and bed. Record review the resident's Braden Scale assessment, dated 12/04/10, showed the facility staff identified the resident as being at high risk for the development of pressure sores. (Staff last documented a Braden Scale assessment over three weeks prior on 11/11/10.) Record review of the resident's skin condition assessment, dated 12/17/10, showed the following information: - Poor skin turgor; - Pressure sore to the resident's coccyx approximately 6 cm by 5 cm in size; - The wound was unstageable; - Dark tan eschar was present in the wound bed approximately 2 cm by 2.2 cm in size; - The wound edges were white in color; - A slight odor was present. (This is the facility's first documentation of the wound. Staff did not document notification of the resident's family or physician of the wound. Staff did not document what treatments were in place and what, if any, treatments changes were put into place. Staff did not care plan the wound or any interventions and treatments in place.) Record review of the resident's skin condition assessment, dated 12/21/10, showed the following information: -Poor skin turgor; -Pressure sore to the resident's coccyx approximately 4.5 cm by 4.0 cm in size; -The wound was unstageable; -Dark tan eschar was present in the wound bed approximately 2 cm by 2.5 in size; -The wound edges were pink in color; -No odor was present. Record review of the resident's skin condition assessment, dated 12/28/10, showed the following information: - Poor skin turgor; - Pressure sore to the resident's coccyx approximately 4 cm by 2 cm in size; - The wound was unstageable; - Light tan eschar was present in the wound bed approximately 2 cm by 1.5 in size; - The wound edges were pink in color; - No odor was present. (Staff did not document notifying the resident's family or physician of the wound. Staff did not document what treatments and interventions were in place.) Record review of the resident's skin condition assessment, dated 12/31/10, showed the following information: - Poor skin turgor; - Two open areas to the coccyx; - Site A was approximately 1 cm by 1.5 cm in size. The wound was unstageable due to light tan wound bed. The wound had pink wound edges and a moderate amount of light tan drainage with odor was present. - Site B was approximately 1 cm by 0.7 cm in size. The wound was also unstageable due to a light tan wound bed. The wound had pink wound edges and a moderate amount of light tan drainage with odor was present. Record review of the resident's nurse's note, dated 12/31/10 at 3:23 P.M., showed the resident had an unstageable wound on his/her coccyx. The wound had light tan foul smelling drainage. The wound was currently treated with Santyl and a foam dressing. The staff requested an order for [REDACTED]. Staff did not document the physician's response.) Record review of the resident's physician/nurses communication sheet, dated 01/09/11 at 12:04 P.M., showed the following information: - The pressure sore on the resident's coccyx was tunneling; - The wound was 1.4 cm by 2.3 cm with a depth of 1.5 cm; - The resident currently had an order for [REDACTED]. - The physican responded with an order for [REDACTED]. (Staff did not address the second wound identified on 12/31/11.) Record review of the resident's plan of care, initiated by staff on 01/10/11, showed the resident had impaired skin integrity related to the presence of an unstageable pressure sore on his/her coccyx. The staff had the following interventions in plac