Every finding on record at Moore Few Care Center

Based on interview and record review, the facility failed to provide respiratory care consistent with standards of practice when staff failed to administer oxygen as ordered, failed to notify the physician of respiratory changes, and failed to create a timely comprehensive care plan that addressed oxygen usage for one residents (Resident #1). The resident went into respiratory distress and was sent to the emergency department. The facility census was 46. Review showed the facility did not provide a policy regarding change of condition procedures. Review showed the facility did not provide a policy regarding physician notification. 1. Review of the Resident #1's face sheet (brief look at resident information) showed the following information: -admission date of [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - a progressive lung disease that makes it difficult to breathe). Review of the resident's admission screening, dated [DATE], showed the following information: -Respiratory rate labored with lung sounds clear to auscultation (the act of listening to the sounds from the lungs, with a stethoscope) bilaterally (LCTAB), and no cough or shortness of breath with lying, sitting, or on exertion. Resident must wear oxygen at 3 liters (L) per minute continuously via nasal cannula. Review of the resident's [DATE] Physician Order Sheet (POS) showed the following: -An order, dated [DATE], for oxygen at 3L per nasal cannula (nc) every shift; -An order, dated [DATE], for opratropium-albuterol (a combination medication use to prevent wheezing, difficulty breathing, chest tightness, and coughing) inhale one vial via nebulizer three times a day related to COPD. Review of the resident's [DATE] Medication Administration Record (MAR) showed on [DATE], staff noted the resident's oxygen was administered at 3L with a night shift oxygen saturation of 88% (with a normal range of 95%- 100%). Review of the resident's record showed staff did not document physician notification of the reduced oxygen saturation level. Review of the resident's [DATE] MAR showed on [DATE], staff noted the resident's oxygen was administered at 3L with oxygen saturation levels of 90% on day shift and 92% on night shift. Review of the resident's progress note dated [DATE], at 8:59 P.M., showed the resident was on admission charting and was not experiencing any shortness of breath with a oxygen level at 95 % on 2L of oxygen (physician's order was for 3L of oxygen). LCTAB and respirations (rise and fall of the chest) at 22 per minute (with a normal range of 15-18 breaths per minute). Review of the resident's [DATE] MAR showed on [DATE], staff noted the resident's oxygen was administered at 3L with oxygen saturation levels of 95% on day shift and 93% on night shift. Review of the resident's progress note dated [DATE], at 10:25 P.M., showed the resident continued on admission charting and was not experiencing any shortness of breath with a oxygen level at 94% on 4L of oxygen (physician's order was for 3L of oxygen). Lung sounds were diminished (weakened or quieter breath sounds.) No respiration rate obtained. (Staff did not document physician notification of the resident's lung sound change.) Review of the resident's [DATE] MAR showed on [DATE], staff noted the resident's oxygen was administered at 3L with oxygen saturation levels of 91% on day shift and 94% on night shift. Review of the resident's progress note dated [DATE], at 10:24 A.M., showed the resident was adjusting well and gave no medically specific information. Review of the resident's [DATE] MAR showed on [DATE], staff noted the resident's oxygen was administered at 3L with oxygen saturation levels of 93% on day shift and 94% on night shift. Review of the resident's progress note dated [DATE], at 11:22 A.M., showed the resident was not experiencing any shortness of breath with a oxygen level at 93% on 4L of oxygen (physician's order was for 3L of oxygen). Lung sounds were diminished. Respirations at 18 breaths per minute with no edema present. (Staff did not document physician notification of the resident's diminished lung sounds.) Review of the resident's [DATE] MAR showed on [DATE], staff noted the resident's oxygen was administered at 3L with oxygen saturation levels of 93% on day shift and 94% on night shift. Review of the resident's progress note dated [DATE], at 11:00 P.M., showed the resident was experiencing shortness of breath while lying flat with an oxygen level at 94% on 3L of oxygen. Lung sounds were diminished. The resident had a cough with respirations at 20 breaths per minute. (Staff did not document physician notification of the resident's shortness of breath, cough, or diminished lung sounds.) Review of the resident's [DATE] MAR showed on [DATE], staff noted the resident's oxygen was administered at 3L with oxygen saturation levels of 92% on day shift and 93% on night shift. Review of the resident's [DATE] MAR showed on [DATE], staff noted the resident's oxygen was administered at 3L with oxygen saturation levels of 92% on day shift and 96% on night shift. Review of the physician's progress note, dated [DATE], showed the resident was seen by the physician for admission to the facility. The physician did not mention shortness of breath, cough, or diminished lung sounds in the note and no new orders related to shortness of breath, cough, or diminished lung sounds. Review of the resident's progress note dated [DATE], at 10:38 P.M., showed the resident was not experiencing shortness of breath with an oxygen level at 92% on 2L of oxygen (the physician's order was for 3L of oxygen). LCTAB with no cough and respirations at 18 breaths per minute. Review of the resident's progress note dated [DATE], at 7:38 A.M., showed the resident was not experiencing shortness of breath with an oxygen level at 93% on 3 L of oxygen. LCTAB and moist and loose cough present. Respirations at 20 breaths per minute. (Staff did not document physician notification of moist loose cough.) Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated [DATE], showed the following information: -Intact cognition; -Required substantial to maximum assistance from staff for mobility; -Required continuous oxygen. Review of the resident's progress note dated [DATE], at 12:02 A.M., showed the resident was not experiencing shortness of breath with an oxygen level at 91% on 3 L of oxygen. LCTAB with no cough. Respirations at 18 breaths per minute. Review of the resident's progress note dated [DATE], at 11:44 P.M., showed the resident was not experiencing shortness of breath with an oxygen level at 92% on 3 L of oxygen with lung sounds diminished and moist/loose cough. Respirations at 22 breaths per minute. (Staff did not document physician notification of the resident's diminished lung sounds and cough.) Review of the resident's progress note dated [DATE], at 9:40 A.M., showed the resident was not experiencing shortness of breath with an oxygen level at 93% on 3 L of oxygen. LCTAB with no cough and respirations at 19 breaths per minute. Review of the resident's progress note dated [DATE], at 1:24 P.M., showed the resident was not experiencing shortness of breath with an oxygen level at 94% on 3 L of oxygen. LCTAB with no cough and respirations at 20 breaths per minute. Review of the resident's progress note dated [DATE], at 12:31 A.M., showed the resident was not experiencing shortness of breath with an oxygen level at 90% on 3L of oxygen. LCTAB with dry non- productive cough present. Respirations at 20 breaths per minute. (Staff did not document physician notification of the resident's cough.) Review of the resident's progress notes, dated [DATE], showed the following: -At 7:41 A.M., the resident tested positive for Covid. Staff notified the physician notified; -At 3:50 P.M., the resident was not experiencing shortness of breath with an oxygen level at 90% on 3L of oxygen. LCTAB with dry non- productive cough present. Respirations at 20 breaths per minute. Review of the resident's progress note dated [DATE], at 11:49 P.M., showed the resident was not experiencing shortness of breath with an oxygen level at 93% on 3L of oxygen. LCTAB with dry non- productive cough present. Respirations at 20 breaths per minute. Review of the resident's progress note dated [DATE], at 8:38 A.M., showed the resident was not experiencing shortness of breath with an oxygen level at 91% on 3L of oxygen. LCTAB with no cough and respirations at 20 breaths per minute. Review of the resident's progress note dated [DATE], at 3:47 P.M., showed no concerns with the resident's oxygen level at 90% on 4L of oxygen (the physician's order was for 3L of oxygen). Review of the resident's progress note dated [DATE], at 12:35 A.M., showed the resident was experiencing shortness of breath with lying flat with an oxygen level at 91% on 3L of oxygen. LCTAB with dry non-productive cough and respirations at 18 breaths per minute. (Staff did not document physician notification of the resident's shortness of breath or cough.) Review of the resident's progress note dated [DATE], at 11:55 P.M., showed the resident was not experiencing shortness of breath with an oxygen level at 94% on 3L of oxygen. LCTAB with moist loose cough and respirations at 20 breaths per minute. (Staff did not document physician notification of the resident's moist loose cough.) Review of the resident's progress note dated [DATE], at 9:50 A.M., showed the resident was experiencing shortness of breath with lying flat and with activity with an oxygen level at 92% on 3L of oxygen. LCTAB with moist loose cough and respirations at 20 breaths per minute. (Staff did not document physician notification of the resident's shortness of breath and moist cough.) Review of the resident's care plan, dated of [DATE] (24 days after admission and 11 days after completion of the admission MDS), showed the following: -Required oxygen via nasal cannula at 3L per minute continuously for COPD; -Give aerosol or bronchodilators (medications to help relax the muscles around your breathing airways) as ordered. Monitor and document at side effects and effectiveness; -Monitor for difficulty breathing on exertion; -Monitor/document any signs and symptoms of respiratory infection, fever, chills, increase in sputum (thick mucus coughed up from the lungs), increase in difficulty breathing, increased coughing, and wheezing; -Monitor/document any complications to skin such as cyanosis (a bluish or purplish discoloration of the skin and mucous m a bluish or purplish discoloration of the skin and mucous membranes, primarily caused by a shortage of oxygen in the blood membranes, primarily caused by a shortage of oxygen in the blood) and pallor (pale color of skin). Review of the resident's progress note dated [DATE], at 8:57 P.M., showed the resident was experiencing shortness of breath with lying flat with an oxygen level at 94% on 3L of oxygen. Left lung sounds diminished with moist loose cough and respirations at 20 breaths per minute. (Staff did not document physician notification of the shortness of breath and moist cough.) Review of the resident's progress notes dated [DATE] showed the following: -At 11:38 A.M., staff noted the resident was not experiencing shortness of breath with lying flat with an oxygen level at 96% on 3L of oxygen. LCTAB with no cough noted and respirations at 18 breaths per minute; -At 3:55 P.M., the resident's oxygen dropped to 87% while talking. When the resident would stop talking, oxygen level went up to 93%. (Staff did not document physician notification of the resident's oxygen levels dropping with speaking.) Review of the resident's progress note dated [DATE], at 11:55 P.M.,showed the resident was not experiencing shortness of breath with an oxygen level at 91% on 3L of oxygen. Lung sounds diminished bilaterally with moist loose cough and respirations at 18 breaths per minute. (Staff did not document physician notification of the resident's diminished lung sounds and cough.) Review of the resident's progress notes, dated [DATE], showed the resident continued on Covid monitoring with no complaints of Covid related symptoms. The resident did have a cough that was present before Covid, lung sounds were diminished bilaterally, and oxygen level was 93%. (Staff did not document physician notification of the resident's diminished lung sounds.) Review of the resident's progress notes, dated [DATE] to [DATE], showed staff did not document regarding the resident's shortness of breath, oxygen status, lung sounds, cough, or respirations. Review of the resident's progress note dated [DATE], at 2:18 P.M., showed staff did not document regarding the resident's shortness of breath, oxygen status, lung sounds, cough, or respirations. Review of the resident's progress notes, dated [DATE] through [DATE] , showed staff did not document regarding the resident's shortness of breath, oxygen status, lung sounds, cough, or respirations. Review of the resident's progress note dated [DATE], at 12:20 A.M., showed staff did not document related the resident's shortness of breath, oxygen status, lung sounds, cough, or respirations. Review of the resident's late entry progress notes, dated [DATE], showed the following: -At 2:30 A.M., the nurse, Registered Nurse (RN) B left the resident's room and heard an aide yell out that the resident had passed out. The nurse ran to the resident's room and upon entering noticed the resident was being supported in and upright position on the side of the bed by two aides; -The resident was cyanotic, gasping for air, and his/her tongue was protruding; -The nurse turned the resident's concentrator up to 5L with no improvement in the resident; -The nurse turned up the residents oxygen concentrator up to 10L with no improvement in the resident; -The resident was placed onto a gurney with assist of four staff members; -Two aides ran the resident to the Emergency Department (ED). Review of the resident's ED documentation, dated [DATE], showed the following information: -The resident was brought into the ED from nursing staff at the facility on campus; -The resident was brought in due to concerns for cardiac and respiratory arrest; -Upon arrival to the ED the resident was gray in color and having difficulty breathing; -Shortly after arrival the resident went into cardiac arrest and cardiopulmonary resuscitation (CPR - cardiopulmonary resuscitation is an emergency procedure that combines chest compressions and rescue breathing to restart a persons breathing and heart beat) was performed; -The resident's family reported the resident had been having respiratory issues three days prior to the incident, with increasing shortness of breath; -The staff at the facility report they found the resident lying on the floor at 2:00 A.M., in the morning; -Assessment includes distress, rapid labored breathing, high heart rate, and gray in color. During an interview on [DATE], at 2:56 P.M., Resident # 2 said the following: -He/she remembered the resident. He/she was on continuous oxygen. Sometimes the resident would have to sit on the side of his/her bed and attempt to catch his/her breath; -Not long before the resident was sent to the ED, the resident had an awful cough. It sounded like water splattering on a tin pan. He/she even asked the staff if he/she should be around the resident because the cough sounded like something contagious; -The resident often complained about his breathing status. During an interview on [DATE], at 3:18 P.M., Certified Nursing Assistant (CNA) A said the following: -On Tuesday, [DATE], he/she was working with the resident on the evening shift. The resident put on his/her call light and asked him/her if the physician was coming. He/she responded and said the physician comes on Sundays. The resident insisted he/she needed to see the physician about his trouble breathing; -The aide reported this to the nurse as well as the resident was having a hard time getting his voice out. He/she was nearly whispering due to lack of air. The nurse wrote it down on a sticky note and put it up on the nurses' desk for when the doctor come in on Sunday; -On [DATE], he/she heard about one of the day shift nurses, Licensed Practical Nurse (LPN) B, tell the resident's family and other staff he/she did not want to send the resident to the ED per his/her request due to pain with breathing. The nurse insisted to the resident's family that the resident was just having anxiety and there was no need to go to the ED; -On the early morning hours of [DATE], he/she took care of the resident. The resident rolled out of bed trying to catch his/her breath. Shortly after that they were having to get him onto a gurney for loosing consciousness; -The resident struggled to breath often, he/she would always have to sit up on the edge of the bed to try to have appropriate positioning for breathing, even with continuous oxygen on; -Aides know how to care for residents by their plans of care. They can be found in the resident rooms. He/she could not recall if the resident had a plan of care. During an interview on [DATE], at 10:57 A.M., CNA C said the following: -The resident often had complaints of pain and inability to breathe; -On the afternoon of [DATE], approximately 2:30 P.M., the resident was gray in color and was complaining of shortness of breath and inability to breathe. He/she reported this to LPN E; -LPN E went and assessed the resident as the resident had family at the facility around 4:00 P.M., who also requested he/she come assess the resident due to his/her breathing and gray color; -While assessing the resident, LPN told the family it's simply anxiety and no reason to go to the ED. The family wanted the resident sent to the ED, but LPN kept insisting it was not needed and eventually the family left the facility; -Anytime a resident shows a change in condition, the physician should be contacted; -The resident was always on continuous oxygen at a rate of 4L; -All care aspects should be care planned. During an interview on [DATE], at 2:17 P.M., Restorative Aide (RA) D said the following: -The resident was often unable to participate in therapy due to his/her pain and or inability to breath. The resident reported the pain was in his/her chest from having trouble to breathe; -The last time he/she tried to work with the resident, he/she helped the resident propel in a wheelchair, and just from that the resident's oxygen level dropped to 72%. He/she did take the resident to the nurse immediately and reported the oxygen level and explained the resident would not be able to participate due to his/her inability to breathe; -All care aspects should be in the care plan, which can be found in resident rooms. During an interview on [DATE], at 3:20 P.M., LPN E said the following: -Symptoms of respiratory distress are elevated respiratory rate, low oxygen level, and change in color; -If a resident has a change of condition, the physian should be called. If a resident exhibited weight gain, shortness of breath, edema, moist cough, and diminished lung sounds the resident should be sent to the ED; -The above mentioned symptoms sound like fluid overload; -The resident exhibited no change of condition a week prior to going to the ED; -Around 4:00 P.M., on [DATE], one of the resident's family members said the resident was having increased shortness of breath. After listening to the residents lungs, he/she changed the residents oxygen tubing to a shorter tube as that could have caused his/her extra shortness of breath; -CNA C reported to him/her that the resident wanted to go to the ED, but the resident's lungs were clear when LPN E listened, so he/she chalked it up to be anxiety; -He/she offered to call the physician and or send the resident out to the ED, to which the resident refused; -The resident's voice was not raspy and he/she was not gray in color; -He/she did not report the resident's complaints to the physician as he/she did not believe it was a problem; -All aspects of care are care planned. During an interview on [DATE], at 9:25 A.M., Registered Nurse (RN) B said the following: -Changing an oxygen administration rate on a resident with COPD can eliminate their drive to breathe. If it is an emergency situation, nursing can turn an oxygen concentrator up to 15L. If staff administer too much oxygen to a resident with COPD it can cause respiratory distress; -If a resident had an acute change of condition, the physician needed to be called. A sticky note is not appropriate; -If he/she noticed a resident exhibited weight gain, shortness of breath, increased pain, a change in lung sounds lung sounds, and a wet cough, he/she would be sending them out to the ED, as that could be fluid overload which is life threatening left untreated; -The resident was an anxious person with usual respiration rate of 20 per minute. The resident would be up and down often trying to position better for breathing. He/she often complained of shortness of breath, always had a raspy voice due to having a hard time breathing while talking, he/she had a dry cough, and diminished lung sounds a week prior to him/her going to the ED; -He/she was the nurse on shift at the time of the incident. He/she received report from the day shift nurse, LPN E, around 6:00 P.M. LPN E told him/her that the resident was extremely anxious and he/she needed to call the physician for an anti-anxiety medication and that he/she had put the resident on the list to see the physician on [DATE]. The nurse did not report to him/her that the resident had any other symptoms; -Around 7:30 P.M., he/she went and assessed the resident. At that time the resident was tachypneic (having a rapid breathing rate), had a hard time speaking complete sentences, and there was no air movement in his/her lungs when he/she listened, The resident was very anxious and almost panting to breathe with an oxygen level at 86%; -He/she texted the physician for the anti-anxiety medication order, after receiving the order, he/she realized the medication was not stocked in the E-kit. He/she texted the physician again and got an order for Benadryl (antihistamine medication that has sedative properties); -He/she administered the Benadryl and told the resident it would help within an hour to an hour and a half. He/she then got busy with other residents and did not re-assess the resident until he/she was called into his/her room around 2:00 A.M., with a report that he/she had fallen; -Upon entering the room, the resident seemed fine and was assisted back to bed to get his/her breathing under control; -Around 2:30 A.M., not long after the nurse had exited the room, he/she heard staff call out he/she passed out The nurse re-entered the room and found the resident to have agonal breathing (abnormal gasping breaths) , purple in color, and had his/her tongue hanging out; -Two aides ran the resident over to the ED on a gurney and sternal rubbed the resident until they arrived at the ED; -When the ED nurse called and spoke with him/her. They reported that the resident was drowning in fluids; -If LPN E had been aware of all of those symptoms he/she should have called the physician right away and sent the resident to the ED; -The resident was short of breath often and because of that, he/she did not find the trouble breathing an issue that was too concerning. Most staff just assumed the resident was suffering from anxiety, per usual. During an interview on [DATE], at 1:25 P.M., the MDS Nurse said the following: -Oxygen orders should be followed and care planned; -If a resident experiences any change of condition, they physician should be contacted immediately; -Symptoms such as weight gain, increased shortness of breath, diminished lung sounds, wet cough, and edema could be respiratory failure and should probably be sent to the ED; -From what she understands is the resident had anxiety and that was what caused his breathing issues; -All aspects of care should be care planned. During an interview on [DATE], at 2:50 P.M., the resident's Physician said the following: -He did not recall if he was contacted regarding the resident's change of conditions; -He heard that LPN E wanted to send the resident to the ED and the resident and family refused; -Had he known about the resident's change of conditions, he would have ordered lab work; -If the resident had exhibited weight gain, poor lung sounds, edema, and shortness of breath, he would say that was fluid overload; -Fluid overload is very possible given the resident's symptoms; -Anytime a resident exhibits an acute change of condition, he should be notified; -Oxygen should be administered as ordered. During an interview on [DATE], at 10:52 A.M., the Director of Nursing (DON) said the following : -Symptoms of respiratory distress are shortness of breath, change in color, coughing, and air hunger (anxiety); -If a resident exhibits a change in condition she expected the staff to do a full assessment and notify the physician; -If a resident has weight gain, edema, cough, and shortness of breath, that could be fluid overload; -Upon admission the resident was anxious. The resident would always say he/she couldn't breathe; -A sticky note was not an acceptable way to contact the physician; -She was not aware the resident exhibited a change of condition a week prior to his death; -He/she expected all staff to accurately and timely assess resident's as well as document all findings and contact the physician with any changes; -All aspects of care should be documented. During an interview on [DATE], at 12:01 P.M., the Administrator said the following: -She expected staff to notify the DON as well as the physician for any change of condition; -She expected all aspects of care to be in the care plan and to be documented; -The physician should have been contacted. MO00253943

Based on observation, interview, and record review, the facility failed to implement and maintain and effective pain management regimen when the facility failed to accurately assess, monitor, address, care plan, and notify the physician of increased and unrelieved pain for one resident (Resident #1) resulting in increased pain. The facility census was 46. Review of the facility policy titled, Pain Management Program, reviewed on 11/17/16, showed the following information: -The facility will assess all resident's on admission, quarterly, and as needed; -Complete pain assessment for all residents. Monitor for persistent as needed (PRN) medication use; -Assess pain presence, frequency, effect on function, and intensity; -Ask resident to rate pain using the pain scale; -Determine if staff assessment for pain is needed; -If staff assessment is needed, review indicators of pain or possible pain; -Based on pain assessment, initiate routine and PRN pain medication regimen or non-medication interventions; -Complete physician notification and reassess PRN. 1. Review of the Resident #1's face sheet (brief look at resident information) showed the following information: -admission date of 03/24/25; -Diagnoses included chronic obstructive pulmonary disease (COPD- a progressive lung disease that makes it difficult to breathe) and peripheral vascular disease (PVD - a circulatory condition where blood vessels outside the heart and brain become narrowed, blocked, or have spasms, leading to reduced blood flow). Review of the resident's March 2025 Physician Order Sheet (POS) showed an order, dated 03/24/25, for pain monitoring. Staff to assess the resident for pain every shift. Review of the resident's admission screening, dated 03/25/25, showed the resident was not experiencing pain at the time of admission. Review of the resident's March 2025 POS showed an order, dated 03/26/25, for acetaminophen 325 milligram (mg), give two tablets by mouth every four hours as needed (PRN) for pain, not to exceed 3000 mg in a 24 hour period. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 04/06/25, showed the following information: -Intact cognition; -Received scheduled pain medication regimen; -Received PRN pain medications; -The resident rarely had pain, but described his/her pain level at a ten on a scale of one to ten scale, with 10 being the worst pain possible, at the time of the assessment. Review of the resident's pain monitoring assessment, dated 04/08/25, showed the resident had a pain level of 0 out of 10, for both day and night shifts. Review of the resident's April 2025 Medication Administration Record (MAR) showed on 04/08/25, at 8:17 P.M., staff administered two tablets of acetaminophen 325 mg for pain rated 7 out of 10. Staff noted the dose was effective in treating the pain. Review of the resident's progress note dated 04/08/25, at 9:42 P.M., showed staff administered two tablets of acetaminophen 325 mg for bottom pain. Staff noted the dose was effective with a follow-up pain scale of 0 out of 10. (Staff did not document physician notification of the increased pain.) Review of the resident's pain monitoring assessment, dated 04/10/25, showed the resident had a pain level of 6 out of 10 for the day shift and 0 out of 10 for the night shift. Review of the resident's April 2025 MAR showed on 04/10/25, at 11:19 P.M., staff administered two tablets of acetaminophen 325 mg for a pain rated a six out of 10. Staff noted the dose was effective in treating the pain. Review of the resident's progress note dated 04/11/25, at 12:42 A.M., showed staff administered two tablets of acetaminophen 325 mg. Staff did not indicate where the resident's pain was. Staff noted the dose was affective with a follow-up pain scale of 0 out of 10. (Staff did not document physician notification of the increased pain.) Review of the resident's pain monitoring assessment, dated 04/14/25, showed the resident had a pain level of 3 out of 10 for the day shift and 0 out of 10 for the night shift. Review of the resident's MAR and progress notes, dated 04/14/25, showed staff did not document pain interventions taken for the 3 out of 10 pain level. Review of the resident's April 2025 MAR showed on 04/14/25, at 1:22 A.M. and at 11:12 P.M., staff administered two tablets of acetaminophen 325 mg for a pain rated 7 out of 10. Staff noted the dose was effective in treating the pain. Review of the resident's progress notes dated 04/14/25, at 2:36 A.M. and 11:42 P.M., showed the staff administered two tablets of acetaminophen 325 mg for all over pain. Staff noted the doses were effective with a follow-up pain scales of 0 out of 10. (Staff did not document physician notification of the increased pain.) Review of the resident's pain monitoring assessment, dated 04/15/25, showed the resident had a pain level 3 out of 10 for the day shift and 0 out of 10 for the night shift. Review of the resident's MAR and progress notes, dated 04/15/25, showed staff did not document pain interventions implemented for the three out of 10 assessment of pain. Review of the resident's pain monitoring assessment, dated 04/16/25, showed the resident had a pain level of thee out of 10 for the day shift and 0 out of 10 for the night shift. Review of the resident's April 2025 MAR showed on 04/16/25, at 12:22 A.M., staff administered two tablets of acetaminophen 325 mg for a pain rated a 5 out of 10. Staff noted the dose was effective in treating the pain. Review of the resident's progress note dated 04/16/25, at 2:40 A.M., showed the resident was administered two tablets of Acetaminophen 32 5 mg for pain. Staff noted the dose was effective with a follow-up pain scale of one out of 10. Review of the resident's care plan, dated of 04/17/25, showed staff did not care plan related to the resident's pain. Review of the resident's pain monitoring assessment, dated 04/21/25, showed the resident had a pain level of 0 out of 10 for the day shift and 0 out of 10 for the night shift. Review of the resident's April 2025 MAR showed on 04/21/25, at 12:20 A.M., the staff administered two tablets of acetaminophen 325 mg for a pain rated a 0 out of 10. Staff noted the dose was effective in treating the pain. Review of the resident's progress note dated 04/21/25, at 2:41 A.M., showed staff administered two tablets of acetaminophen 325 mg. Staff noted the dose was effective with a follow-up pain scale of 0 out of 10. Review of the resident's pain monitoring assessment, dated 04/23/25, showed the resident had a pain level of 4 out of 10 for the day shift and 2 out of 10 for the night shift. Review of the resident's MAR and progress notes, dated 04/23/25, showed staff did not document pain intervention implement for the 4 or 2 out of 10 pain assessment. Review of the resident's pain monitoring assessment, dated 04/25/25, showed the resident had a pain level of 4 out of 10 for the day shift and 0 out of 10 for the night shift. Review of the resident's MAR and progress notes, dated 04/25/25, showed staff did not document pain intervention implemented for the 4 out of 10 pain assessment. Review of the resident's pain monitoring assessment, dated 04/26/25, showed the resident had a pain level of 0 out of 10 for the day shift and 3 out of 10 for the night shift. Review of the resident's progress notes, dated 04/26/25, showed the following: -At 2:18 P.M., showed the resident was requesting a pain medication other than acetaminophen that his/her levels of pain have been 10 out of 10 in the lower back and the acetaminophen had been ineffective. The nurse contacted the physician and there were no new orders sent. -At 3:24 P.M., the resident was administered 2 tablets of acetaminophen 325 mg. -At, 8:40 P.M., the dose was effective with a follow up pain scale of 3 out of 10. Review of the resident's April 2025 MAR, dated 04/26/25, showed the following: -At 3:24 P.M., staff administered two tablets of acetaminophen 325 mg for a pain rated a 10 out of 10. Staff noted the dose was effective in treating the pain. -At 10:43 P.M., staff administered an additional dose for back pain with a pain rated a 9 out of 10. Staff noted the dose was effective in treating the pain. Review of the resident's pain monitoring assessment, dated 04/27/25, showed the resident had a pain level of 0 out of 10 for the day shift and 0 out of 10 for the night shift. Review of the resident's April 2025 MAR showed on 04/27/25, at 9:49 P.M., staff administered two tablets of acetaminophen 325 mg for back pain with a pain scale of 0 out of 10. Staff noted the dose was effective in treating the pain. Review of the resident's progress notes dated 04/27/25 showed the following: -At 9:49 P.M., staff administered two tablets of acetaminophen 325 mg. -At 1:38 A.M., staff noted the dose was effective with a follow up pain scale of 2 out of 10. Review of the resident's pain monitoring assessment, dated 04/28/25, showed the resident had a pain level of 0 out of 10 for the day shift and 10 out of 10 for the night shift. Review of the resident's April 2025 MAR showed on 04/28/25, at 7:12 P.M., staff administered two tablets of acetaminophen 325 mg for a pain scale of 10 out of 10. Staff noted the dose was effective in treating the pain. Review of the resident's progress note dated 04/28/25, at 7:59 P.M., showed staff administered two tablets of acetaminophen 325 mg. Staff noted the dose was effective with a follow up pain scale of 6 out of 10. (Staff did not document physician notification of the increased pain or steps taken to address the unrelieved pain.) Review of the resident's pain monitoring assessment, dated 04/29/25, showed the resident had a pain level of 2 out of 10 for the day shift and 8 out of 10 for the night shift. Review of the resident's April 2025 MAR showed on 04/29/25, 3:04 P.M., staff administered two tablets of acetaminophen 325 mg for a pain scale of eight out of 10. Staff noted the dose was ineffective. Review of the resident's progress notes, dated 04/29/25, showed the following: -At 3:04 P.M., staff administered two tablets of acetaminophen 325 mg. -At 4:19 P.M., staff noted the dose was ineffective with a follow up pain scale of 6 out of 10. The resident said he/she was still in pain. (Staff did not document physician notification of the pain level or steps taken to address the unrelieved pain.) -At 6:17 P.M., a nurse documented that the resident has had complaints of pain and the PRN acetaminophen was not helping. The resident would like to see the physician when he comes in. (Staff did not document physician notification of the pain level or steps taken to address the unrelieved pain.) Review of the resident's pain monitoring assessment, dated 04/30/25, showed the resident had a pain level of 5 out of 10 for the day shift and 0 out of 10 for the night shift. Review of the resident's April 2025 MAR showed on 04/30/25, at 12:01 A.M., staff administered two tablets of acetaminophen 325 mg for a pain scale rated as 10 out of 10. Staff noted the dose was effective. Review of the resident's progress note dated 04/30/25, at 12:19 A.M., showed staff administered two tablets of acetaminophen 325 mg, The dose was effective with a follow up pain scale of 8 out of 10 (18 minutes after it's administration). Staff noted the resident was complaining of lower back and feet pain. Staff continue to monitor. (Staff did not document physician notification of the pain level or steps taken to address the unrelieved pain.) Review of the resident's pain monitoring assessment, dated 05/01/25, showed the resident had a pain level of 0 out of 10 for the day shift and 0 out of 10 for the night shift. Review of the resident's April 2025 MAR showed on 05/01/25, at 2:12 P.M., staff administered two tablets of acetaminophen 325 mg for a pain rated a five out of 10. Staff noted the dose was effective in treating the pain. Review of the resident's progress note dated 05/01/25, at 5:11 P.M., showed staff administered two tablets of acetaminophen 325 mg. The resident complained of bottom pain and had not been out of bed on this day. Staff noted the dose was effective with a follow-up pain scale of 0 out of 10. Review of the resident's April 2025 MAR showed on 05/01/25, at 8:47 P.M., staff administered two tablets of acetaminophen 325 mg for a pain scale of 10 out of 10. Staff noted the dose was effective. Review of the resident's progress note dated 05/01/25, at 10:29 P.M., showed staff administered two tablets of acetaminophen 325 mg. Staff noted the dose was effective with a follow up pain scale of four out of 10. (Staff did not document physician notification of the continued pain, or steps taken to address the unrelieved pain.) Review of the resident's pain monitoring assessment, dated 05/02/25, showed staff did not document a pain assessment completed. During an interview on 05/09/25, at 3:18 P.M., Certified Nursing Assistant (CNA) A said the following: -The resident did experience a lot of pain. He/she reported that the pain was in his/her chest; -Anytime the resident reported pain, he/she would tell his/her charge nurse immediately; -He/she assumed the pain was related to the resident's diagnosis of COPD and trouble breathing putting pressure on his/her chest; -Several of the nurses would tell him/her it was anxiety related; -Aides can find out about resident diagnoses and required care by viewing the care plan. During an interview on 05/12/25, at 10:57 A.M., CNA C said the following: -The resident did experience a lot of pain, causing him/her to stay in bed a lot. -He/she informed the nurse on duty of the resident's complaints often; -Aides can find out about resident diagnoses and required care by viewing the care plan. During an interview on 05/12/25, at 2:17 P.M., Restorative Aide (RA) D said the following: -The resident participated in therapy for a short while. He/she would refuse to participate related to his/her pain due to complications breathing; -Anytime the resident complained of pain or had care concerns, he/she would report it to the nurse; -All resident care aspects should be care planned. During an interview on 05/12/25, at 9:25 A.M., Registered Nurse (RN) B said the following: -If a resident complained of pain the nurse on duty should go and assess it. If the resident has a PRN medication, it should be given. If the PRN medication does not work, the physician should be notified for something stronger; -Writing a resident's complaints and/or concerns down on a sticky note is not acceptable, especially if a medication is ineffective at treating the resident. The physician should be called; -Pain and any required care should be care planned. During an interview on 05/13/25, at 3:20 P.M., Licensed Practical Nurse (LPN) E said the following: -If a resident complained of pain, he/she would assess the pain level and start with non-pharmacological interventions first. If those interventions were not effective, he/she would administer PRN pain medications; -If PRN pain medications were not effective and the level of pain was a 10 out of 10, he/she would call the physician; -The resident has chronic pain to his/her bottom. He/she was aware of complaints of pain to the chest but believed it was related to anxiety due to breathing complications; -Residents have pain scale documentation on them every shift and will be checked on throughout the day; -He/she never contacted the doctor regarding the resident's pain. It would be written down for the physician to see when he came in on Sundays; -All aspects of care are and should be care planned. During an interview on 05/15/25, at 2:25 P.M., the MDS Nurse said the following: -If a resident complained of pain, the nurse on duty should assess the resident, and administer PRN medications. If the PRN medications are not effective the physician should be called; -All resident care aspects should be care planned. During interviews on 05/12/25, at 11:52 A.M. and 2:50 P.M., the resident's Physician said the following: -He did not see any documentation related to the resident's pain being reported to him; -If any kind of acute change happens with any resident, he wished to and should be notified. During an interview on 05/13/25, at 10:52 A.M., the Director of Nursing (DON) said the following: -If a resident complained of pain, she expected staff to assess it, and use nursing judgement to determine if the pain can be treated without medical intervention. If it cannot be managed in that manner, staff should review the resident's care plan and provide the appropriate intervention; -If all non-pharmacological and pharmacological interventions have been unsuccessful, staff should call the resident's physician; -All aspects of care should be care planned. During an interview on 05/13/25, at 12:01 P.M., the Administrator said the following: -She expected staff to assess residents for pain. If interventions were not effective on reassessment, the physician should be notified for instruction; -She expected the nursing staff to treat pain subjectively and not make their own assumptions on resident complaints; -All aspects of care should be care planned. MO00253943

Based on observation, interview, and record review, the facility failed to ensure facility staff adhered to the facility policy and standards of care for wearing the appropriate Personal Protective Equipment (PPE) for residents that had tested positive for COVID for four of four residents (Resident #95, #22, #94, and #144) observed for transmission-based precautions. Review of the facility's policy titled COVID-19, effective 09/19/23, showed the following: -Residents who test positive will be in a private rooms unless another resident is positive. In this case, cohorting will be permissible. Cohorting is not permissible for a positive resident and a presumptive resident. Movement outside the room will be extremely limited during quarantine period. -Staff will be required to wear full PPE including goggles, gloves, and N95 (K95) (filtration) masks when providing care or entering the room. Review of the Centers for Disease Control and Prevention's (CDC) website titled, Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 (COVID) Infection or Exposure to SARS-CoV-2, dated 03/18/24, showed the following: -Healthcare personnel with mild to moderate illness can return to work once symptoms have improved if at least 24 hours have passed without fever and at least seven days have passed since symptoms first appeared with a negative test; or when 10 days have passed if a second test is not performed. -Healthcare personnel who are asymptomatic can return to work when at least seven days have passed since the first positive test when a negative test is obtained; or 10 days have passed if a second test is not performed. 1. Observations on 07/29/24, at 2:01 P.M., showed Certified Nursing Assistant (CNA) 1 and CNA 2 entered Resident #95's room, who had tested positive for COVID and was on transmission-based precautions (TBP) droplet precautions. Neither of the CNAs were wore goggles or a face shield while providing care to resident. During an interview on 07/29/24, at 2:06 P.M., both CNA1 and CNA2 confirmed they had not worn goggles or face shield while in the resident's room and that they were supposed to be wearing them. 2. Observations and interview on 07/29/24, at 2:05 P.M., showed CNA3 was observed entering Resident #22's room, which was identified as TBP-droplet precautions. CNA3 did not wear a face shield or goggles. Upon exiting the room at 2:10 PM, CNA3 was questioned about PPE requirements for droplet isolation and should he/she wear a face mask or goggles. The CNA said yes, I should wear a face shield, but I did not. I also tested positive this morning for COVID-19 and am only working with COVID positive residents. 3. Observation and interview on 07/29/24, at 2:09 P.M., showed Registered Nurse (RN) 2 in Resident #94's room, which was identified as TBP-droplet precautions, providing care to the resident. The RN was not wearing goggles or a face shield. RN2 confirmed he/she was not wearing either of them, but that was because they were not available for use. 4. Observation and interview on 07/30/24, at 9:15 A.M., showed the Housekeeping Supervisor (HSKS) was standing outside of door of Resident #144's room and said one of the residents was moved because this was now a COVID positive room. There were no TBP-droplet precautions signs on the door, and no PPE cart was located outside of the resident's room. During an interview on 07/30/24, RN2 said when he/she came in that morning, he/she was aware the resident tested positive for COVID, and had asked staff to put the sign and PPE at the door. The RN was unaware of why it was not there. Observation and interview on 07/30/24, at 9:20 A.M., showed a visitor was observed coming out of the resident's room only wearing a surgical mask and no other PPE. When asked, the visitor said he/she knew the resident was positive for COVID, but was not aware of what PPE to wear since he/she had not visited a positive resident for two years. During an interview on 07/30/24, at 9:30 A.M., the Director of Nursing (DON) said the resident had tested positive for COVID later on 07/29/24 and a sign and PPE cart should have been located outside the door. She was unaware of why it was not there. 5. During an interview on 07/29/24, at 2:22 P.M., the Administrator said she expected the staff to follow the TBP-droplet precautions while providing care to COVID positive residents. Additionally, she has asked COVID positive staff members, whether asymptomatic, or symptomatic, not work. 6. During an interview on 07/30/24, at 9:30 A.M., the DON said staff were expected to wear goggles or face shields while providing resident care to COVID positive residents. 40847

Based on observation, interview, and record review, the facility failed to ensure residents were assessed for safety and physician orders obtained prior to self-administration of medication when one resident (Resident #28) had medications for self-administration at his/her bedside. Review of the facility's policy titled Self-Administration of Medications, dated 02/2021, showed the following: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. -If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record, and the care plan. -The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision making status. -Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. 1. Review of Resident #28's Admission Record, undated, located in the EMR under the Profile tab, showed the following: -admitted [DATE]; -Readmitted [DATE]; -Diagnoses included myasthenia gravis (chronic autoimmune disorder resulting in weakness of skeletal muscles) with acute exacerbation of pulmonary hypertension (high blood pressure in the lungs), acute respiratory failure with hypoxia (low oxygen), chronic obstructive pulmonary disease (COPD) with acute exacerbation, symptoms and signs involving cognitive functions and awareness, and cognitive communication deficit. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an ARD of 05/28/24, located in the EMR under the MDS tab, showed the following: -Resident was cognitively intact. -Resident did not exhibit any behaviors during the assessment period; -Resident required substantial assistance with toileting hygiene, shower/bathe self, upper body dressing, and lower body dressing. Observations during the initial tour on 07/29/24, at 12:02 P.M., showed medications located on the resident's bedside table in a small open basket. The medications included an albuterol (medication used to treat breathing) inhaler 90 microgram (mcg), a 50 milliliters (ml) bottle of saline nasal mist, and a 1/2 ounce bottle of artificial tears. Observation on 07/30/24, at 9:18 A.M., showed the resident's medications were still on his/her bedside table. Observations and interview on 07/31/24, at 9:20 A.M., during the Medication Pass with Certified Medication Technician (CMT) 1 showed the same medications inside a basket on the resident's over the bed table in his/her room. The resident said that his/her family brought him/her eye drops and saline spray for his/her nose and he/she kept his/her inhaler near his/her in case the facility cannot get his/her medications for any reason. CMT1 removed the medications from the resident's room and said he/she thought the resident had an order to keep his/her inhaler at his/her bedside. CMT1 said he/she had not observed the medications in the resident's room before. After reviewing the resident's medication orders on his/her computer at the medication cart, an order for the resident to keep the three medications at the bedside for the resident to use as needed was not found. CMT1 said the resident had never told him/her he/she takes these medications so he/she can get an order and document the dosage. CMT1 showed he/she would let the charge nurse know about the medications. During an interview on 07/31/24, at 1:45 P.M., the Director of Nursing (DON) said he/she was made aware of the resident's unsecured medications this afternoon. The DON said her expectations were the resident would be assessed to self-administer his/her own medications and reassessed, as necessary. Additionally, this would be documented in the resident's medical record, to include a physician's order, and where the medications would be stored. The DON confirmed the resident had not been assessed for self-administration of medications.

Based on observation, interview, and record review, the facility failed to ensure residents were as free from accident hazards as possible when staff failed to have an effective process in place to reduce the likelihood of residents burning themselves with hot liquids resulting in one resident (Resident #13) suffering a burn on his/her foot from hot chocolate and when the facility staff left a mechanical lift stored in a resident's room resulting in one resident (Resident #1) falling. 1. Review of the facility's policy titled Safety of Hot Liquids, dated 10/2014, showed the following: -Residents will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission and on change of condition; -Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury; -The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions; -Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk from burns; -Interventions may include maintaining hot liquids serving temperature of not more than 140 degrees Fahrenheit; serving hot beverages in a cup with a lid; encouraging residents to sit at a table while drinking or eating hot liquids; providing protective lap covering or clothing to protect skin from accidental spills; and staff supervision or assistance with hot beverages. Review of Resident #13's Admission Record, undated, located in the electronic medical record (EMR), under the Profile tab, showed the following: -Initial admitted [DATE]; -Readmitted [DATE]; -Diagnoses included cerebral infarction (stroke), ankylosing spondylitis in spine (arthritis causing inflammation in the spine), cognitive communication deficit, and dementia. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) with an Assessment Reference Date (ARD) of 07/14/23, located in the EMR under the MDS tab, showed the following: -The resident was moderately cognitively impaired. -The resident was dependent with bed mobility, transfers, dressing, toilet use, and personal hygiene. -The resident was assessed as requiring supervision, oversight, encouragement, or cueing for eating. -The resident was wheelchair bound. Review of the resident's quarterly MDS, with an ARD of 05/21/24, located in the EMR under the MDS tab, showed the following: -The resident was cognitively intact. -The resident was dependent with bed mobility, transfers, dressing, toilet use, and personal hygiene. -The resident was assessed as requiring supervision of oversight, encouragement or cueing for eating. -The resident required supervision or touching assistance for eating. -The resident was wheelchair bound. Review of the resident's Skin/Wound Note, dated 05/22/24, located in the EMR, under the Progress Notes tab, showed the nurse was called to the dining room as the resident knocked his/her hot chocolate off the table and burned his/her left foot. Upon assessment, the top of his/her left foot was very red and blistering. Education given to staff about putting some ice in hot drinks before being served. Staff notified physician and an order was received to apply antibiotic ointment to a nonstick dressing pad, apply to the top of her foot, and use spandage to hold in place. Review of the resident's Incident Report dated 05/22/24, at 4:48 P.M., supplied by the facility, showed the incident occurred in the dining room and the resident said he/she dropped his/her cup and it spilled. Observation on 07/29/24, at 12:23 P.M., showed the resident in the dining room reclined at approximately 30 degrees in his/her tilt in space wheelchair. Observation on 07/30/24, at 11:35 A.M., with the Director of Nursing (DON) showed the temperature of the water brewed for the hot chocolate measured at 160 degrees Fahrenheit (F) as verified by two thermometers and the DON. During an interview on 07/29/24, at 12:41 P.M., the resident said he/she had burned the top of his/her foot recently. During an interview on 07/30/24, at 11:40 A.M., the DON said he/she was not sure if anyone monitored the water temperatures of the liquids served at meals. The staff had been educated after the incident to place ice cubes in the hot liquids. The DON expected staff to check the temperatures prior to giving residents hot liquids. 29728 2. Review of the facility's policy titled, ''Assessing Falls and Their Causes,'' dated 03/2018, showed the following; -'The purpose of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. -If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine and extremities. -Identifying causes of a fall or fall risk such as if any environmental risk factors were involved (such as slippery floor, poor lighting, furniture, or objects in the way). Review of Resident #1's ''Admission Record,'' located in the EMR under the ''Profile'' tab, showed the following: -admitted [DATE]; -Diagnoses included dementia, difficulty in walking, unspecified fall, and unsteadiness on feet. Review of the resident's quarterly MDS, located in the EMR under the ''MDS'' tab, with an ARD of 05/21/24, showed the following: -The resident was moderately cognitively impaired. -The resident required moderate assistance with most activities of daily living. -The resident used a wheelchair for mobility. -The resident had not experienced a fall within the last three months. Review of the resident's ''Progress Note, located in the EMR under the ''Progress Note tab and dated 07/20/24, showed 'the resident was found sitting on the floor in front of the sit-to-stand beside his/her roommate's bed. The resident denied hitting his/her head. Staff found no bumps, bruises, or skin tears. Resident denied pain. Order received to not leave lift equipment in resident's room. Staff notified the resident's family and medical doctor.' Review of the resident's ''Incident Report,'' provided by the DON, showed the resident was found sitting on the floor in front of a sit-to-stand lift beside his/her roommate's bed. The resident denied hitting his/her head, denied pain, and had no bumps, bruises, or skin tears noted. Per the report, an order was placed to not leave equipment in the resident's room. During an interview on 07/31/24, at 8:40 A.M., Registered Nurse (RN) 3 said he/she walked by the resident's room and saw the resident on the floor in front of the roommate's bed with his/her legs draped over the stand base. RN3 recalled the resident told him/her he/she was trying to go to bed. RN3 said he/she added an intervention to the care plan to never leave the lift in the resident's room. RN3 said Certified Nurse Aide (CNA) 4, who was working with the resident that evening, was new. RN3 thought this was the first time CNA4 had worked by him/herself. RN3 talked to CNA4 about not leaving the lift in the room after it was used, but place it in the shower room at the end of the hall. RN3 said CNA4 told him/her he/she left the lift in the room for convenience. CNA4 used it to get the resident up for dinner and left it in the room to use it again to put the resident back in bed. During an interview on 07/31/24, at 10:20 A.M., CNA4 said he/she was the one that left the lift in the resident's room. He/she had only worked in the facility for one month, but had been a CNA for seventeen years. He/she received training on the proper use and storage of the lifts, and he/she should have known better than to leave it in the room. The resident and his/her roommate were the only two residents that used the sit-to-stand lift, so he/she pushed it under the roommate's bed since he/she was going to use it to put the resident back to bed. He/she was instructed by the nurse to never leave the lift in the room again and he/she had not. CNA4 said this was the only time he/she had left it in the room and the lifts left in the shower room. During an interview on 07/31/24, at 1:40 P.M., the DON said it was her expectation the lift should not be left in the resident's room. It should always be stored in the shower room.

Based on observations, interviews, and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure proper storage of oxygen/nebulizer supplies for two residents (Resident #3 and #28) of two residents reviewed for oxygen management out of a total sample of 16 residents. Review of the facility's policy titled Oxygen Therapy, dated 07/2023, showed staff to store cannulas and masks in plastic bags when not in use. Staff to change cannula, mask, tubing, and storage bag every seven days or as indicated. 1. Review of Resident #3's Admission Record, undated, located under the ''Profile'' tab, showed the following; -admitted [DATE]; -Diagnoses included acute and chronic respiratory failure with hypoxia (oxygen is insufficient at the tissue level). Review of the resident's annual ''Minimum Data Set (MDS - a federally mandated assessment completed by facility staff),'' located in the resident's EMR under the ''MDS'' tab, with an Assessment Reference Date (ARD) of 06/04/24, showed the resident had moderately impaired cognition. Review of the resident's ''Physician Orders,'' located in the resident's EMR ''Orders'' tab, showed the following: -An order, dated 08/2024, for oxygen at two liters per minute by nasal cannula to keep oxygen saturations greater than 92% every shift; -An order, dated 08/2024, for albuterol sulfate inhalation aerosol solution (medication used to help with breathing), two puffs, inhale orally every four hours as needed for shortness of breath/wheezing; -An order, dated 08/2024, to change oxygen tubing on wheelchair and concentrator weekly and change humidifier/clean filter on oxygen concentrator every Wednesday on night shift. During an observation on 07/29/24, at 12:07 P.M., in the resident's room, showed the resident's nasal cannula was draped on the oxygen concentrator not labeled, dated, or stored in a bag to protect from debris. During an observation on 07/29/24, at 2:07 P.M., in the resident's room, showed the resident's nasal cannula was draped on the oxygen concentrator not labeled, dated, or stored in a bag. During an observation on 07/30/24, at 9:07 A.M., in the resident's room, showed the resident's nasal cannula was draped on the oxygen concentrator not labeled, dated, or stored in a bag. 29015 2. Review of Resident #28's Admission Record, undated, located in the EMR under the Profile tab showed the following: -admitted [DATE] and readmitted [DATE]; -Diagnoses included myasthenia gravis (chronic autoimmune disorder resulting in weakness of skeletal muscles) with acute exacerbation of pulmonary hypertension (high blood pressure in the lungs), acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD - prevents airflow to the lungs, causing breathing problems) with acute exacerbation, symptoms and signs involving cognitive functions and awareness, and cognitive communication deficit. Review of the resident's annual MDS, with an ARD of 05/28/24, located in the EMR under the MDS tab, showed the following: -Resident was cognitively intact. -Resident did not exhibit any behaviors during the assessment period. -Resident required substantial assistance with toileting hygiene, shower/bathe self, upper body dressing, and lower body dressing. Review of the resident's Physician Orders, dated 03/01/23, located in the EMR Orders tab, showed the following: -A current order to change oxygen bottle, tubing for concentrator, place in plastic bags, every Wednesday night on night shift; -A current order for albuterol sulfate 2.5 mg per 3 milliliters (ml), one vial inhaled orally every four hours as needed for shortness of air. Observations on 07/29/24, at 11:42 A.M., and on 07/30/24, at 9:09 AM, showed the resident's oxygen tubing was on the floor. There was no label indicating when the resident's oxygen tubing had been changed. The resident's nebulizer mouthpiece that was connected by an oxygen tubing to the nebulizer machine was observed sitting on a bedside table in a Styrofoam cup open to air. There was no label on the oxygen tubing. Observation on 07/30/24, at 9:18 A.M., in the resident's room, showed Licensed Practical Nurse (LPN) 2 confirmed that the resident's oxygen tubing was observed on the floor and was not labeled, and the nebulizer mouthpiece was not in plastic bag. 3. During an interview on 07/30/24, at 9:15 A.M., LPN 2 said the oxygen tubing was changed every Wednesday by night shift staff and it should be labeled when changed. The nebulizer was cleaned between uses and stored in a plastic bag. 4. During an interview on 07/30/24, at 10:17 A.M., the Director of Nursing (DON) said oxygen tubing should be changed weekly, and the equipment should be protected from contamination by placing it in plastic bags.

Based on interview and record review, the facility failed to ensure that all residents who wished to receive pneumococcal vaccines received them when staff failed to administer one pneumococcal vaccine to one resident (Resident #9) of five residents reviewed for immunizations. Review of the facility's policy titled Immunization Records, dated 07/2023, showed the following: -Adult pneumococcal recommendations if previous PPSV23 [pneumococcal polysaccharide vaccine - Pneumovax 23] only administer PCV20 or PCV15. 1. Review of the Resident #9's Admission Record, undated, located in the resident's electronic medical record (EMR), under the Profile tab, showed the resident was admitted on [DATE] with a readmission on 05/24/23. Review of the resident's Vaccine Consent Form, dated 09/22/23, showed the requested vaccines included Pneumovax23 and Prevnar13 (pneumococcal conjugate vaccine (PCV) 13). Review of the resident's complete EMR showed the resident received the Pneumovax23 on 11/30/18, but had not received either the PCV 13, 15, or 20 vaccinations. Additionally, there was no physician's order for the vaccination located in the EMR. During an interview on 07/30/24, at 10:22 A.M., the Director of Nursing (DON), who was the current Infection Control Preventionist, confirmed the resident's vaccination consent was signed, but the vaccination was not given, and it should have been given.

Based on record review and interviews, the facility failed to ensure all residents were kept free from possible accident hazards when the facility staff did not fully secure one resident (Resident #1) in a wheelchair during transport in the facility's van. The facility census was 53. On 03/05/24, at 3:00 P.M., the Interim Administrator and the Acting Director of Nursing (DON) were notified of the Past Non-Compliance that occurred on 01/10/24. On 01/10/24, DON E notified the Department of Health and Senior Services (DHSS) of the incident, began an investigation, educated the employees involved, and initiated a new competency checklist for all transportation drivers. The noncompliance was corrected on 01/12/24. Review showed the facility did not have a policy and procedure specific to transporting residents in the facility van. 1. Review of Resident #1's face sheet (general resident profile information) showed the following: -admitted [DATE]; -Diagnoses included end stage renal disease (kidney failure), dependence on renal dialysis (manual filtering of waste products and excess fluid from the blood), stroke, congestive heart failure (CHF - decreased heart function caused by abnormality of the heart chamber walls), muscle weakness, history of left femur (upper leg bone), left humerus (upper arm bone), and left tibia (lower leg/shin bone) fractures, history of vertebral compression fracture, legal blindness, carpal tunnel syndrome (impairs wrist function, causes pain), and depression. Review of the resident's Physician Order Sheet (POS) showed an order, dated 06/27/23, for dialysis on Monday, Wednesday, and Friday each week. Review of the resident's care plan, dated 08/21/23, showed the resident needed dialysis related to renal failure. Encourage the resident to go for the scheduled dialysis appointments on Monday, Wednesday, and Friday. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 11/21/23, showed the following information: -Mild cognitive impairment; -Functional limitation in range of motion in upper and lower extremity on one side; -Mobilization utilizing a wheelchair usually propelled by others; -Dependent on staff for transfers from bed to chair/wheelchair; -Chronic pain. Review of a facility's Incident/Accident Report (Witnessed Fall) for the resident dated 01/10/24, at 9:10 A.M., showed during transport to dialysis, the resident slid out of his/her wheelchair while in the transportation van. The resident was assisted back into the wheelchair and taken to dialysis. Review of an intake report received by the State Agency on 01/10/24, at 11:28 A.M., showed the following information: -The resident was being transported to dialysis in facility van. At approximately 8:40 A.M., there were two vehicles in front of the transport van that slammed on their brakes. The transport van also hit their breaks to avoid a collision. The resident slid out of his/her wheelchair, landing on the van floor. Per the statement by the driver all safety straps were in place prior to leaving the facility; -The facility was investigating what happened and educating staff/updating policies to ensure the residents' safety. Review of the facility's internal event investigation file showed the following: -A signed statement by Staff A, dated 01/10/24, showed Staff A said he/she strapped the resident in his/her seat using all four straps, loaded another resident, and left the facility to take the residents to dialysis appointments. -Two cars ahead of the facility transport van slammed on their brakes, causing Staff A to also slam on the brakes. The resident slid out of his/her wheelchair. -Staff A pulled into a parking lot, got out of the van, and went to the back door. Staff A said the wheelchair remained where he/she had secured it with the four straps. During an interview on 03/01/24, at 3:43 P.M., Staff A said he/she was hired to be a transportation driver. Training was done by another transportation driver, who instructed him/her to strap down a wheelchair using two front and two back straps. Staff A said the trainer said they only needed to use the seatbelts if they were going out of town. Staff A said on 01/10/24, he/she secured the resident's wheelchair in the back of the van, but did not put the seatbelt on the resident. Staff A said while they were enroute to the dialysis center, a vehicle in front of them slammed on their brakes. Staff A had to also slam on the brakes. The resident slid from her wheelchair, but the wheelchair remained strapped in place to the van floor. Review of the facility's internal event investigation file showed the following: -A signed statement by Staff B , dated 01/10/24, showed Staff A called him/her due to the resident sliding out of his/her chair and Staff A needed help getting the resident up. Staff B reported the incident to the Director of Nursing (DON), who was also the acting Administrator at the time. Review of the facility interview with Resident #2's after the incident showed the following: -Staff A had to slammed on the brakes due to someone braking ahead of them; -Resident #2 heard Resident #1 moan and looked over to see him/her lying on the floor. During an interview on 03/01/24, at 3:42 P.M., Resident #2 said Resident #1 slid out of her chair when Staff A had to slam on the brakes. Resident #2 said the driver did not put a seatbelt on Resident #1. Review of the facility's interview with Resident #1 after the incident showed the following: -Resident #1 reported Staff A had to hit the brakes hard to avoid a collision with the driver ahead of them who braked hard. Resident #1 remembered sliding out of her chair and onto the floor of the van. He/she was unable to recall if he/she had a seatbelt across his/her lap, but stated I must not have, because I slid out of the chair. Review of the facility's Follow-Up Investigation Report to DHSS, undated, showed the following information: -Resident #1 said he/she knew the van made a sudden stop and he/she was thrown forward landing on the floor. He/she did not know if he/she had a lap belt on; -Resident #2 said the van had to stop suddenly, throwing residents forward. He/she looked over an saw Resident #1 on the van floor; -Staff A said he/she had to make a sudden stop. Safety straps were in place on Resident #1's wheelchair, but the resident slid out of the chair onto the floor; -Conclusion: Resident was not appropriately restrained. Implemented mandatory safety videos and competencies for drivers. Written warning to Staff A for failing to comply with Missouri laws regarding seat belts. Observation made of the facility van on 03/01/24, at 1:40 P.M., showed the van would accommodate two wheelchairs. There were four-point straps and shoulder/lap belts for each wheelchair position. During an interview on 03/01/24, at 2:51 P.M., Staff C said he/she received van transportation training quite a few years ago which included to latch the door open while loading residents, lock the wheels on the wheelchair, anchor wheelchairs with four corner straps (he/she crosses the back straps diagonally for better tightness), and secure the resident with the seatbelt, testing the straps and belt for any excess slack to be tightened. Staff C said he/she always secured Resident #1 in the back position of the van, with the seatbelt across the abdomen. During an interview on 03/01/24, at 3:05 P.M., Staff D said he/she received van transportation training which included instructions to use all four anchor straps, criss-crossing the two back straps for added strength and tightening effect. The resident should be secured with the seat belt across their lap. Staff D checks all straps and the seatbelt to ensure they are tight enough. During an interview on 03/05/24, at 3:00 P.M., with the Interim Administrator and the Interim DON, the Administrator said he/she was not working there at the time of the van incident on 01/10/24, and wasn't involved in the in-service education. The facility had initiated a new competency checklist that was utilized for all van drivers. The drivers should secure all wheelchairs with the four straps provided in the van, and they should put the seatbelt on the resident. The driver should also wear a seatbelt and cannot use their cell phone during transit. The Administrator said the facility did not have a specific policy regarding van transportation. MO00230479

Based on interview and record review, the facility failed to notify one resident's (Resident #1's) responsible party in a timely manner after a change in health condition occurred. The facility census was 58. Review showed the facility did not provide a policy regarding responsible party or family notification related to a resident change in condition. 1. Review of Resident #1's face sheet (brief profile of resident) showed the following: -admitted [DATE]; -Resident had a responsible party and three emergency contacts listed; -Diagnoses included multiple sclerosis (progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problems), polyneuropathy (nerves become damaged causing problems with sensation, coordination, or other body functions), and chronic pain. Review of the resident's care plan, dated 01/20/23, showed the following; -The resident plans to remain in the facility long term; -The resident's family is supportive. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/27/23, showed the following: -Cognitively intact; -Required total dependence of one staff for bed mobility, dressing, toilet use, and personal hygiene; -Required total dependence of two staff for transfers; -Required set up assistance for eating and locomotion; -Resident used wheelchair for mobility. Review of the resident's progress notes showed staff documented the following: -On 08/01/23, at 2:18 P.M., the resident was outside on the patio and had refused to come in during lunch. The resident did take medication at 12:30 P.M. Then at 2:00 P.M., the aides brought the resident up the hall. The resident was unable to operate his/her electric wheelchair and was not responding to verbal questions. The resident would not open his/her eyes. The resident was transferred with the Hoyer lift (assistive device that allows patients to be transferred between a bed and a chair) to his/her bed. Staff undressed the resident and applied cold compresses. The resident's vital signs were temperature 102.3 degrees F (normal is 98.6 degrees), pulse (P) 106 (normal is 60 to 100 for an adult), blood pressure (BP) 90/47 (normal is 120/80 for an adult), respirations (R) 18 (normal is 12 to 18 breaths per minute), oxygen saturation (O2) 93% (normal is 92 to 100%) on room air. The resident was able to respond almost immediately once in bed with cold compresses. The resident was drinking from a straw and took two tablets of Tylenol 325 mg (used to reduce fever and relieve minor pain) without complication. His/her skin was sunburned slightly and the resident stated to the nurse he/she had to of fallen asleep out there. The nurse agreed and the resident smiled and stated I won't be doing that again. (Staff did not document contacting the resident's family or representative.); -On 08/03/23, at 8:46 A.M., spoke with resident's family about incident via phone the following day due to oncoming shift did not notify them as requested. During an interview on 08/22/23, 12:00 P.M., the resident said that staff did not contact his/her family about an incident earlier this month. He/she had spoken to his/her family the following day, 08/02/23, and his/her family was not happy to hear about it from the resident. During an interview on 08/22/23, at 12:20 P.M., Registered Nurse (RN) A said that staff should call the resident's responsible party with new orders, health changes, falls, transfers to hospital, or any other changes, as soon as possible. During an interview on 08/22/23, at 12:30 P.M., Licensed Practical Nurse (LPN) B said that the resident's family should also be notified as soon as possible. During an interview on 08/22/23, at 12:40 P.M., Certified Nurse Aide (CNA) C said that if he/she noticed a resident with a change of health condition that he/she would notify the nursing staff. He/she said that the nurses contact the family as soon as possible. During an interview on 08/22/23, at 1:20 P.M., the Interim Director of Nursing (DON) said that staff should contact any resident's responsible party or family of change in health condition the day of the event if possible. She said this would include health changes such as falls or new physician orders. She said that the day of the resident's change in condition she had asked the oncoming shift to notify the family and that did not get done until the following day. During an interview on 08/22/23, at 130 P.M., the Administrator said that staff should notify the resident's responsible party of health changes as soon as possible. It would not be appropriate to wait one to two days to contact the responsible party. MO00222733

Based on observation, record review, and interview, the facility failed to provide protective oversight for residents when the facility did not have a policy and system in place to monitor residents who entered the enclosed courtyard during periods of increased temperature and humidity resulting in one resident (Resident #1) suffering non-responsiveness and sunburn from being outside for an extended period of time. The facility census was 60. The Administrator was notified on 08/03/23, of the Past Non-Compliance Immediate Jeopardy which occurred on 08/01/23. On 08/02/23, the Director of Nursing (DON) and Administrator reviewed the resident's charts, began an investigation, educated employees involved, in-serviced all facility staff, and began monitoring the daily temperatures to ensure resident safety when outdoors. The noncompliance was corrected on 08/02/23. Review showed the facility did not have a policy related to residents being out in heat or on the enclosed patio prior to 08/03/23. 1. Review of Resident #1's face sheet (brief profile of resident) showed the following: -admitted [DATE]; -Re-admitted [DATE]; -Diagnoses included multiple sclerosis (progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problems), polyneuropathy (nerves become damaged causing problems with sensation, coordination, or other body functions), and chronic pain. Review of the resident's care plan, dated 01/20/23, showed the following; -The resident loves to spend time outdoors; -Staff should invite the resident to participate in activities daily. -Staff did not care plan monitoring or interventions to ensure the resident's safety while outside. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/27/23, showed the following: -Cognitively intact; -Required total dependence of one staff for bed mobility, dressing, toilet use, and personal hygiene; -Required total dependence of two staff for transfers; -Required set up assistance for locomotion on and off unit; -Resident used wheelchair for mobility. Review of the localconditions.com showed the following weather for 08/01/23 for the facility's town: -At 10:30 A.M., the temperature was 86 degrees Fahrenheit (F) with humidity of 63.35%; -At 11:00 A.M., the temperature was 87.8 degrees F with humidity of 58.89%; -At 11:30 A.M., the temperature was 89.6 degrees F with humidity of 55.65%; -At 12:00 P.M., the temperature was 89.6 degrees F with humidity of 55.65%; -At 12:30 P.M., the temperature was 91.4 degrees F with humidity of 52.61%; -At 1:00 P.M., the temperature was 93.2 degrees F with humidity of 49.75%; -At 1:30 P.M., the temperature was 93.2 degrees F with humidity of 52.86%; -At 1:50 P.M., the temperature was 95 degrees F with humidity of 50.01%. Review of the resident's progress note dated 08/01/23, at 2:18 P.M., showed staff documented the following: -The resident was outside on the patio and had refused to come in during lunch. The resident did take medication at 12:30 P.M. Then at 2:00 P.M., the aides brought the resident up the hall. The resident was unable to operate his/her electric wheelchair and was not responding to verbal questions. The resident would not open his/her eyes. The resident was transferred with the Hoyer lift (assistive device that allows patients to be transferred between a bed and a chair) to his/her bed. Staff undressed the resident and applied cold compresses; -The resident's vital signs were temperature 102.3 degrees F (normal is 98.6 degrees) , pulse (P) 106 (normal is 60 to 100 for an adult), blood pressure (BP) 90/47 (normal is 120/80 for an adult), respirations (R) 18 (normal is 12 to 18 breaths per minute), oxygen saturation (O2) 93% (normal is 92 to 100%) on room air -The resident was able to respond almost immediately once in bed with cold compresses. The resident was drinking from a straw and took two tablets of Tylenol 325 mg (used to reduce fever and relieve minor pain) without complication. His/her skin was sunburned slightly and the resident stated to the nurse he/she had to of fallen asleep out there. The nurse agreed and the resident smiled and stated I won't be doing that again. Review of the resident's medical record showed staff did not document regarding the resident being outside, any monitoring, any assessment, or any attempt to reapproach the resident about returning inside. Review of the resident's progress note showed the following: -On 08/02/23, at 10:22 A.M., the nurse spoke with resident several times and resident was alert and oriented at baseline. The resident did state that his/her face and arms were hurting a bit from the sunburn, but it would go away. The resident was in good spirits and laughing; -On 08/03/23, at 8:46 A.M., staff documented response from the physician with noted, no further orders; -On 08/03/23, at 9:37 P.M., the resident's family member called the nurse and said something was wrong with the resident. He/she had talked to the resident in the morning and they discussed another family member's birthday. The resident spoke with the other family member and did not tell them happy birthday. The family wanted the doctor notified and orders for labs because the resident seems off. A fax was sent to the doctor at this time; -On 08/03/23, at 11:40 P.M., the resident was on follow up for change of condition charting related to resident being outside for an extended period of time and sunburn; -On 08/04/23, at 10:24 A.M., resident remained on change of condition charting related to being outside for extended period of time and receiving a sunburn. The sunburn has greatly improved, only sunburn on shoulders and side of face by ears. Review showed the facility did not provide an investigation or written statements regarding the resident being outside in the heat. During an interview on 08/03/23, at 11:55 A.M., the resident said an aide helped him/her out through the patio doors and never told anyone he/she was out there and did not come back. The resident said that Nurse Aide (NA) B is the staff that opened the door for him/her. The resident cannot remember what time he/she went out and does not remember coming back in. The resident said his/her face and upper chest were a little red. Staff did not check on him/her. He/she said that he/she cannot open the door to get back in, it requires a code and assistance to get back in the building. The staff did not tell my children that I had been out there too long and did not offer to send to the hospital. The resident said he/she told his/her children on the telephone later that day. He/she has been out there before and staff know when he/she was out there and he/she was able to knock on the door to the dining room to come back inside. Observation of the outside patio on 08/03/23, at 12:15 P.M., showed the area approximately 50 feet in length by 10 feet in width. The area closest to the dining room was partially shaded. The area closer to the office windows was in direct sun. During an interview on 08/03/23, at 11:30 A.M., Registered Nurse (RN) A said the following: -The resident got up on 08/01/23, at about 10:15 A.M., and then went outside. The RN was unsure about what time he/she actually went outside; -At about 11:30 A.M., Dietary Aide (DA E) asked the resident if he/she wanted to come inside for lunch. The resident said no (over an hour after the resident went outside in the heat); -At about 12:30 P.M., Licensed Practical Nurse (LPN) F went to the resident and provided medications and the resident did not want to come in at that time (an hour after the last time the resident was checked on in the heat.); -At about 2:00 P.M., two aides were bringing the resident down the hall and motioning to the nurse. He/she met them about halfway and helped the aides get the resident into his/her room and transferred to the bed. The resident was not responding and not able to propel his/her power wheelchair. (one and one-half hours after the resident was last checked on in the heat.); -The resident received aloe to the sunburn and Tylenol for pain; -It is believed that NA B opened the door for the resident to go out to the courtyard, but the nurse aide denied helping the resident outside. During an interview on 08/03/23, at 1:52 P.M., DA E said about 11:30 A.M. he/she went outside to ask the resident to come in for lunch. The resident did not come in at that time. The resident was in the direct sun. The resident normally goes outside every day, but usually comes in for lunch. He/she was unsure if he/she reported to anyone that the resident declined lunch. During an interview on 08/03/23, at 3:10 P.M., LPN F said he/she took medications to the resident at about 12:30 P.M. on 08/01/23 on the outdoor patio. The resident was in his/her wheelchair in the direct sun and his/her eyes were closed. The resident opened his/her eyes when LPN F talked to him/her. The resident was a little pink, but did not want to come inside. He/she was alert and oriented. He/she gave the resident a cup with water, the resident only took enough water to get the medication down. There was not a policy about residents being outside on the patio before this incident. During an interview on 08/03/23, at 12:35 P.M., DA C said he/she went to the patio after lunch was over and found the resident to be red and unresponsive. When he/she tried to get the resident back inside his/her badge would not work and had to get other staff attention inside to get the doors opened. He/she said his/her shift started at 1:00 P.M., and thinks that it was at least 1:30 P.M. when he/she was outside to check on the resident. He/she did not think the resident had a drink outside. During an interview on 08/03/23, at 12:25 P.M., Certified Nurse Aide (CNA) D said the resident went outside at about 10:30 A.M. The resident usually goes out every day at that time. Before lunch a dietary aide went to check on the resident and the resident did not want to come inside. When the resident was checked on later, he/she was all red and not responding. Staff got him/her transferred, took off his/her clothes, and got wet towels and ice. The resident had a cup of water around noon because he/she received medication at that time. It took about 30 minutes for the resident to become alert. He/she was drowsy and could not talk, but would open his/her eyes. Staff gave him/her water when became alert. The nurse was going to send the resident to the emergency room , but then he/she became alert. There was not a previous policy related to residents being outside in the heat. During an interview on 08/03/23, at 3:20 P.M., CNA G said he/she was not aware of a facility policy regarding residents being outside in the heat before this incident. During an interview on 08/03/23, at 3:25 P.M., Certified Medication Tech (CMT) H said he/she was not aware of a facility policy regarding residents being outside in the heat before this incident. During an interview on 08/03/23, at 3:30 P.M., with Registered Nurse (RN) I and RN J, they said that were not aware of a facility policy regarding residents being outside in the heat before this incident. During an interview on 08/04/23, at 2:00 P.M., CNA K said that he/she was not aware of a facility policy regarding residents being outside in the heat before this incident. During an interview on 08/04/23, at 2:15 P.M., CNA L said he/she was not aware of a facility policy regarding residents being outside in the heat before this incident. During an interview on 08/03/23, at 12:15 P.M., the DON said the following: -The resident requested to go outside; -At lunch time an aide checked to see if the resident would come in for lunch and the resident declined; -A nurse provided medications about noon and the resident did not want to come in at that time; -The staff cleaning the dining room after lunch checked on the resident and brought him/her back in the building; -The patio door requires a code to leave the building and requires a staff badge access to return from the outside; -The resident usually has a drink with him/her when outside; -The facility had not had a previous policy about residents being outside in the heat; -The office staff could see the resident at about 11:58 A.M., seated in direct sunlight outside the windows. During interviews on 08/03/23, at 2:25 P.M., and on 08/04/23, at 1:15 P.M., the Administrator said the following: -There was not a policy related to residents being outside in the heat or on the patio prior to the new policy implemented; -There was not a policy before this incident, but all staff should always monitor all residents whether they were inside or outside the building. MO00222387

Based on record review and interview, the facility failed to complete and document a facility-wide assessment to determine what resources were necessary to care for facility residents competently during both day-to-day operations and emergencies as required. The facility had a census of 60. Review showed the facility did not provide a policy pertaining to a process to complete a facility assessment. 1. Review of the facility's Resident Census and Condition Form, updated 08/11/23, showed a census of 60 and the following resident characteristics: -Sixteen residents dependent on staff for transferring; -Fifteen residents dependent on staff for toilet use; -Eight residents with an indwelling catheter (tubing to drain the bladder); -Thirty-one residents with documented signs and symptoms of depression; -Twenty-nine residents with documented psychiatric diagnosis (excluding dementias and depression); -Two residents with behavioral healthcare needs; -Two resident receiving renal dialysis (mechanical filtering of the blood to remove waste); -Two residents requiring ostomy (allows bodily waste to pass through a surgically created opening on the abdomen) care; -One resident requiring tube feeding services; -Thirty-nine residents on psychoactive (affecting the mind) medication; -Forty-one residents on a pain management program. Review of documentation provided by the facility showed the facility did not provide a facility assessment that specifically addressed what resources were necessary to care for facility residents competently during both day-to-day operations and emergencies as required and included all the regulation required pieces. During an interview on 08/04/23, at 1:50 P.M., the Administrator said he/she was unfamiliar with the regulation and process to complete a facility assessment. The Administrator said since he/she was unable to locate one completed by previous administration, he/she had started the process to complete an assessment using a Facility Assessment Tool; it was not yet finished. 41787

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan, that includes measurable objectives to meet the resident's medical and nursing needs identified in the comprehensive assessment, for four residents (Residents #24,#25, #31, and #95). The facility census was 42. Record review of the facility's policy entitled MDS and Care Plan Policy, reviewed 2/20/2012, showed the following information: -The purpose of this policy is to initially and periodically conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity, to provide the facility with the information necessary to develop a care plan and to provide the appropriate care and services for each resident; -The facility will adhere to the guidelines for resident assessment consistent with the requirements for the Resident Assessment Instrument; -The Comprehensive Assessment: -Will describe both the resident's capability to perform daily life functions and significant impairments in functional capacity and address all the resident's needs and strengths, regardless of whether the issue is included in the MDS or Care Area Assessment and Analysis (CAA); -Will be conducted no later than 14 days after the date of admission and within 14 days after a significant change in the resident's physical or mental condition; -The Interdisciplinary Team (IDT) consists of the MDS Coordinator, nursing personnel, social services, dietary, activities, therapies, and hospice. Each of these persons will interview the resident and perform assessment appropriate to his/her professional responsibility; -Will be edited by each department with regard to their section of the MDS. All departments will provide the information in compliance with the designated assessment reference date for the assessment; -Care Plans: -The Care Plan consists of problem sheets, ADL's (activities of daily living), pressure ulcers, urinary incontinence, ROM (range of motion), feeding tubes, hydration, mental/psychosocial needs, and special needs; -The facility will develop a comprehensive Care Plan for each resident, including measurable objectives and timetables to meet a resident's medical nursing, mental and psychosocial needs as identified in the Comprehensive Assessment; -An Admission Care Plan will be created on the day of admission. Within three days of admission, each discipline will review the existing problem sheets and edit or add to a new problem to provide all essential services; -The list of triggered CAA's will be reviewed, and the IDT will record their decision of whether or not to proceed to care plan for each one. On or prior to the 21st day after admission, the IDT will meet to edit the Comprehensive Care Plan; -The Care Plan will be reviewed as often as changes occur in the resident's condition and will be revised to maintain accuracy. Each discipline recording the change in condition shall be responsible for making the appropriate changes to the printed Care Plan; -Each resident's Comprehensive Assessment and Care Plan will be reviewed at least every three (3) months by all members of the IDT including the resident and family, who will then meet to discuss any change in service required. 1. Record review of Resident #95's face sheet (gives basic profile information) showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Change catheter (tubing to drain the bladder) every 30 days; -May change catheter as needed. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 8/3/2022, showed the following information: -admitted to the facility from the hospital on 7/27/2022; -Cognition intact; -Indwelling catheter: (left blank); -Frequently incontinent of bowel and bladder; -Required extensive assistance of at least two persons for bed mobility, transfers, dressing, toileting, and personal hygiene. Observation on 8/9/2022, at 1:14 P.M., showed the resident had a catheter collection bag inside a dignity bag, hanging underneath the bedside commode. Observation on 8/12/2022; at 12:20 P.M., showed the resident's catheter collection bag inside a dignity bag hanging on the lower rail of the bed. Record review made on 8/09/2022, at 2:06 P.M., of the resident's Care Plan, last updated on 8/3/2022, showed the following: -admitted [DATE]; -Needs supervision for ADL's (activities of daily living) due to feeling weak and unsteady. At risk for incontinence, falls, and skin breakdown; -Increased needs for protein due to wounds and multiple fractures. (Staff did not care plan the resident's an indwelling catheter.) During an interview on 8/12/2022, at 9:45 A.M., the Social Services Director (SSD) confirmed that the resident's catheter was not on the care plan, but should be added. 2. Record review of Resident #24's face sheet (gives basic profile information) showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), major depressive disorder, anxiety disorder, [CONDITION(S)] (high cholesterol), [CONDITION(S)] (the wearing down of the protective tissue at the ends of bones (cartilage) occurring gradually and worsening with time) and retention of urine. Record review of the resident's admission MDS, dated [DATE]:, showed the following information: -Cognition intact; -Required extensive assistance of at least two persons for bed mobility, transfers, dressing, toileting, and personal hygiene; -The resident is receiving hospice services. Record review of the resident's current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Hospice Services ordered and provided. Record review on 8/10/22 of the resident's Care Plan, last updated on 8/3/2022, showed the following: -admitted [DATE]; -Staff did not care plan regarding the resident receiving hospice services. During an interview on 8/12/2022, at 12:15 P.M., the SSD said the following: -He/she is currently doing the care plans for the residents; -He/she knows hospice should be included in a resident's care plan. 3. Record review of Resident #26's face sheet showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's annual MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Wander/elopement alarm used daily; -Uses wheelchair for mobility; -Supervision required for transfers, locomotion on and off unit; -Assistance of one staff for personal hygiene and toileting. Record review of the resident's August 2022 POS showed the following: -Check wander guard (a bracelet type of electronic alarm worn on the ankle of residents which sounds an alarm when an exit door is opened) every shift; -Check expiration date on wander guard every Wednesday morning. Record review of the resident's progress notes showed staff documented the following information: -On 1/2/2022, at 12:08 P.M., the resident was exit seeking, went to the south side of the building and exited outside of the building. Administrator, doctor, family and hospice notified. Staff put 15-minutes checks in place. Wander guard in place and working properly. The staff will continue to monitor. -On 1/3/2022, at 3:55 P.M., the hospice staff documented they received a call from the facility staff that the resident left the building through the kitchen in his/her wheelchair and walked back in the other door when he/she found out it was cold and his/her car was not in the parking lot. The resident does have an alert bracelet on that did not alert on the back door that he/she left through. Record review on 8/10/2022 of the resident's Care Plan, last updated on 3/10/2022, showed the following: -Last reviewed 3/10/2022; -Staff did not care plan regarding the resident's use of a wander guard. 4. Record review of Resident #31's face sheet showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Wander/elopement alarm used daily; -Uses wheelchair for mobility; -Supervision required for transfers, locomotion on and off unit; -Assistance of one staff for personal hygiene and toileting. Record review of the resident's August 2022 POS showed the following: -Check wander guard every shift; -Check expiration date on wander guard every Wednesday morning. Record review on 8/10/2022 of the resident's Care Plan, last updated on 4/7/2022, showed the following: -Last reviewed 4/7/2022; -Staff did not care plan regarding the resident's use of a wander guard. 5. During an interview on 8/11/2022, at 8:50 A.M., Licensed Practical Nurse (LPN) G said that Resident #26 had a wander guard on his/her ankle and Resident #31 had a wander guard on his/her wheelchair. The nursing staff check to ensure the wander guards are intact for each resident once every shift. The nurses check the wander guard once per week to ensure that it functions with a hand held checker or take the resident near the exit doors that have the alarms, which included the interior building door to the hospital and the front door. He/she did not know if this information was on either resident's care plan. 6. During an interview on 8/11/2022, at 9:15 A.M., LPN E said that Resident #26 had a wander guard on his/her ankle and Resident #31 had a wander guard located on his/her wheelchair. The nurses are responsible for checking the wander guard expiration date every Wednesday and that it is intact once per shift. He/she did not know if this information was on the resident care plans. 7. During an interview on 8/12/2022, at 1:45 P.M., Administrator and the Director of Nursing (DON) said care plans should include all detailed information pertaining to a resident's needs and preferences for care. A care plan should include hospice involvement, indwelling catheter, and the use of a Wanderguard.

Based on interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases when the facility failed to follow their policy and infection control practices when staff did not ensure staff completed and read employee [CONDITION(S)] (TB - a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests timely on hire for four staff members. The facility census was 42. Record review of the facility's policy [CONDITION(S)], Employee Screening, dated July 2010, showed the following: -The oversight of the TB monitoring will be designated to one person; -All employees shall be screened for TB infection and disease using a two-step [MEDICATION(S)] skin test (TST) or blood assay for [CONDITION(S)] [CONDITION(S)] and symptom screening, prior to beginning employment; -Each newly hired employee will be screened for TB infection and disease after an employment offer has been made, but prior to the employee's duty assignment; -The initial TB testing will be a two-step TST performed by injecting 0.1 milliliter (ml) (5 [MEDICATION(S)] units) of purified protein derivative (PPD) intradermal; -If the reaction to the first skin test is negative, the facility will administer a second skin test 1 to 2 weeks after the first test; -The new employee may begin duty assignments after the first skin test, if negative, unless prohibited by state regulations. Record review of the facility's policy [CONDITION(S)] Screening, Administration, and Interpretation of [MEDICATION(S)] Skin Tests, dated February 2014, showed the following: -Only qualified healthcare practitioners will administer and interpret the TST for employees; -After obtaining a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Individuals with less than 10 millimeters (mm) of induration, unless otherwise indicated, will receive a booster of 0.1 ml of PPD one to two weeks after the initial TST; -A qualified nurse or healthcare practitioner will interpret the TST 48 to 72 hours after administration. 1. Record review of Certified Nurse Aide A's personnel file showed the following: -Hire date of 6/27/22; -First step of the TB test administered on 6/26/22; -Staff did not document the reading of the first step; -Staff did not document a second step given. 2. Record review of Certified Medication Technician B's personnel file showed the following: -Hire date of 1/24/22; -First step of the TB test administered on 1/19/22; -Staff did not document the reading of the first step; -Staff did not document a second step given. 3. Record review of Certified Feeding Assistant C's personnel file showed the following: -Hire date of 2/10/20; -Staff did not document administration of a TB test. 4. Record review of Housekeeper D's employee file showed the following: -Hire date of 2/21/21; -First step of the TB test administered on 3/3/21 and read on 3/5/21; -Staff did not document administration of the second step of the TB test. 5. During an interview on 8/12/22 at 10:11 A.M., Licensed Practical Nurse E said the following: -First and second steps of the TB screening are completed upon being hired; -He/she had also given one or two TB shots to new employees; -Everyone should have both steps completed; -If a new employee missed their second step, they would have to start all over. 6. During an interview on 8/12/22 at 10:22 A.M., Registered Nurse F said he/she would expect everyone to have both steps of the TB screening tests completed. 7. During an interview on 8/12/22 at 10:30 A.M., the Social Service Director said the following: -He/she had given the TB shots, both first and second steps, to new employees before; -The TB screenings should be done on the first day of hire or on the floor; -The second step should be within a couple weeks following the first step. 8. During an interview on 8/12/22 at 10:53 A.M., the Director of Nursing said the following: -A new employee should be getting the first step done on their day of hire; -The first step is done by the human resources (HR) department in the hospital; -The reading of the first step is also done by HR in the hospital; -The facility does the second step for staff. 9. During an interview on 8/12/22 at 11:12 A.M., the Administrator said the following: -He/she was already aware that the TB's are a problem; -The problem started when the prior nurse that was giving them left abruptly; -He/she feels the problem is caused by the way the process is being done.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for two residents (Residents #34 and #41). The facility census was 42. Record review of the facility's policy entitled Transfer or Discharge Documentation, revised December 2016, showed the following information: -When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: -The basis for the transfer or discharge; -If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include the specific resident needs that cannot be met, this facility's attempt to meet those needs, and the receiving facility's service(s) that are available to meet those needs; -That an appropriate notice was provided to the resident and/or legal representative. Record review of the facility's policy entitled Transfer or Discharge, Emergency, revised August 2018, showed the following information: -Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s); -Residents will not be transferred unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; -Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: -Notify the resident's Attending Physician; -Notify the receiving facility that the transfer is being made; -Prepare the resident for transfer; -Prepare a transfer form to send with the resident; -Notify the representative (sponsor) or other family member. Record review of the facility's two-part form entitled Nursing Home to Hospital Transfer Form, showed the following: -Staff should fill in information including the resident's full name, name of hospital, name of nursing home, resident's contact person, nursing home contact information, and key clinical information regarding the resident; -Indication for the two parts of the form were: white copy to hospital and canary copy to facility. 1. Record review of Resident #34's face sheet (gives brief information about the resident) showed the following information: -admitted [DATE], -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's progress notes showed the following information: -On 6/5/2022, resident was transferred to the hospital due to symptoms of increased pain, agitation, confusion, complaints of being overheated when room is cold, unable to follow instructions, and falls asleep during communication/assessment. Record review of the resident's medical record showed staff did not document notification to the resident or resident's responsible party in writing of the resident's transfer to the hospital on 6/5/2022. 2. Record review of Resident #41's face sheet showed the following information: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's progress notes showed the following: -On 4/18/2022, the resident transferred to the hospital due to symptoms of low oxygen saturation and lethargic. The doctor gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff left a message for the resident's family of the transfer. Record review of the resident's medical record showed staff did not document notification to the resident or resident's responsible party in writing of the resident's transfer to the hospital on 4/18/2022. 3. During an interview on 8/11/2022, at 8:51 A.M., Licensed Practical Nurse (LPN) G said that when a resident is transferred to the hospital the nurse sends a hospital transfer form, the resident's face sheet, and Medication and Treatment Administration Records. The nurse will notify the family by phone. He/she said the nurses do not send any written letter to the family or resident. 4. During an interview on 8/11/2022, at 11:30 A.M., the Social Service Director (SSD) said that when residents are sent to the hospital the nurse will notify the family by phone and document in a progress notes. He/she said that no written notification was sent to the resident's family. 5. During an interview on 8/11/2022, at 11:31 A.M., Medical Records said he/she was not aware of any written notice being sent to the family or resident regarding transfer from the facility. 6. During an interview on 8/11/2022, at 12:20 P.M., the Director of Nursing (DON) said that when a resident transfers to the hospital the staff call and talk to the resident's family about the transfer. There was not a written notice that was sent to the family. 7. During an interview on 8/12/2022, at 1:45 P.M., the facility administrator said staff should send a written notice of transfer to the resident and/or their representative whenever a resident is transferred out to the hospital.

Based on interview and record review, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for two residents (Residents #34 and #41) who were transferred out to the hospital. The facility census was 42. Record review of the facility's policy entitled Bed-Holds and Returns, revised March 2017, showed the following information: -Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy; -Residents may return to and resume residence in the facility after hospitalization as outlined in this policy; -Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail the rights and limitations of the resident regarding bed-holds; the reserve bed payment policy as indicated by the state plan (Medicaid residents); the facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and the details of the transfer (per the Notice of Transfer). 1. Record review of Resident #34's face sheet (gives brief information about the resident) showed the following information: -admitted [DATE], -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's progress notes showed the following information: -On 6/5/2022, resident was transferred to the hospital due to symptoms of increased pain, agitation, confusion, complaints of being overheated when room is cold, unable to follow instructions, and falls asleep during communication/assessment. Record review of the resident's medical record showed staff did not document notification to the resident or resident's responsible party of the facility's bed hold policy when the resident transferred to the hospital on 6/5/2022. 2. Record review of Resident #41's face sheet showed the following information: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's progress notes showed the following: -On 4/18/2022, the resident transferred to the hospital due to symptoms of low oxygen saturation and lethargic. The doctor gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff left a message for the resident's family of the transfer. Record review of the resident's medical record showed staff did not document notification to the resident or resident's responsible party of the facility's bed hold policy when the resident transferred to the hospital on 4/18/2022. 3. During an interview on 8/11/2022, at 8:51 A.M., Licensed Practical Nurse (LPN) G said that when a resident is transferred to the hospital the nurse sends a hospital transfer form, the resident's face sheet, Medication and Treatment Administration Records. The nurse will notify the family by phone of the resident's transfer. He/she said the nurses do not send any written information regarding bed hold to the family or resident. 4. During an interview on 8/11/2022, at 11:30 A.M., the Social Service Director (SSD) said that when residents are sent to the hospital the nurse will notify the family by phone and document in a progress notes. He/she said that no bed hold policy information was sent to the resident's family. 5. During an interview on 8/11/2022, at 11:31 A.M., Medical Records said he/she was not aware of any written notice being sent to the family or resident regarding transfer from the facility. He/she said that bed hold information is charted in the resident's chart and after three days the resident is discharged from the computer and started as a new admission on return. She was not aware of this information being sent to the resident or the resident's family. 6. During an interview on 8/11/2022, at 12:20 P.M., the Director of Nursing (DON) said that when a resident transfers to the hospital the staff call and talk to the resident's family about the transfer and the bed hold, but there was not a written notice that was sent to the family. 7. During an interview on 8/12/2022, at 1:45 P.M., the Administrator said staff should send a written notice of transfer, including the bed-hold policy, to the resident and/or their representative whenever a resident is transferred out to the hospital.

Based on record review and interview, facility staff failed to complete an annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument, completed by facility staff) assessment for one resident (Resident #1) within the required 14 days from the assessment reference date (ARD). The facility had a census of 42. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The Annual assessment is an OBRA (Omnibus Budget Reconciliation Act of 1987) comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA (Significant Change in Status Assessment) or an SCPA (Significant Correction to Previous Assessment) has been completed since staff completed the most recent comprehensive assessment; -The Annual assessment ARD is the ARD of previous OBRA comprehensive assessment plus 366 calendar days, and ARD of previous OBRA Quarterly assessment plus 92 days. Record review of the facility's policy entitled MDS and Care Plan Policy, reviewed 2/20/2012, showed the following information: -The purpose of this policy is to initially and periodically conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity, to provide the facility with the information necessary to develop a care plan and to provide the appropriate care and services for each resident; -The facility will adhere to the guidelines for resident assessment consistent with the requirements for the Resident Assessment Instrument. 1. Record review of Resident #1's MDS submitted reports showed the following information: -admitted to the facility 6/4/2019; -Annual assessment, ARD 5/31/2021; -Quarterly assessment, ARD 8/30/2021; -Quarterly assessment, ARD 11/29/2021; -Quarterly assessment, ARD 3/1/2022; -Staff did not submit a subsequent Comprehensive or Annual Assessment within 366 days of the most recent annual assessment. During an interview on 8/12/2022, at 10:48 A.M., the Director of Nursing (DON) said the following: -She was asked by administration to assist with the MDS assessments and submissions right after he/she starting working at the facility in March 2022. At that time, there was no MDS Coordinator, as the former MDS Coordinator had already left employment there; -She thought all required assessments had been caught up and submitted and was unaware that the assessments for the resident had not been submitted. During an interview on 8/12/2022, at 1:45 P.M., the Administrator said staff should complete and submit all MDS required assessments according to the regulatory time frames. He was not aware that any assessments were overdue or had not been completed.

Based on record review and interview, facility staff failed to complete a quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument, completed by facility staff) assessment for one resident (Resident #4) within 14 days from the assessment reference date (ARD). The facility had a census of 42. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type; -The quarterly assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored; and -The ARD must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. Record review of the facility's policy entitled MDS and Care Plan Policy, reviewed 2/20/2012, showed the following information: -The purpose of this policy is to initially and periodically conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity, to provide the facility with the information necessary to develop a care plan and to provide the appropriate care and services for each resident; -The facility will adhere to the guidelines for resident assessment consistent with the requirements for the Resident Assessment Instrument. 1. Record review of Resident #4's MDS submitted reports showed the following information: -admitted to the facility 2/7/2017; -Annual assessment ARD of 1/18/2022; -Significant Change assessment ARD of 3/29/2022; -Staff did not complete or submit a quarterly assessment within 92 days of the most recent comprehensive assessment. During an interview on 8/12/2022, at 10:48 A.M., the Director of Nursing (DON) said the following: -She was asked by administration to assist with the MDS assessments and submissions right after he/she starting working at the facility in March 2022. At that time, there was no MDS Coordinator, as the former MDS Coordinator had already left employment there; -She thought all required assessments had been caught up and submitted and was unaware that the assessment for the resident had not been submitted. During an interview on 8/12/2022, at 1:45 P.M., the Administrator said staff should complete and submit all MDS required assessments according to the regulatory time frames. He was not aware that any assessments were overdue or had not been completed.

Based on record review and interview, the facility failed to transmit a Discharge Assessment - Return Anticipated Minimum Data Set (MDS - a federally mandated assessment instrument, required to be completed by facility staff for care planning) record within 14 days of discharge for two residents (Resident #2 and #3). The facility had a census of 42. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The discharge assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed when the resident is discharged from the facility and the resident is expected to return to the facility within 30 days; -The discharge assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored; and -The ARD must be not more than 14 days after the discharge date . Record review of the facility's policy entitled MDS and Care Plan Policy, reviewed 2/20/2012, showed the following information: -The purpose of this policy is to initially and periodically conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity, to provide the facility with the information necessary to develop a care plan and to provide the appropriate care and services for each resident; -The facility will adhere to the guidelines for resident assessment consistent with the requirements for the Resident Assessment Instrument. 1. Record review of Resident #2's medical record showed the following information: -admitted to the facility on [DATE]; -discharged to the hospital on 5/6/2022 and did not return to the facility. Record review of the resident's MDS submitted reports showed the following information: -admitted to the facility 9/23/19; -Quarterly Assessment; ARD 3/1/2022; -Staff did not submit a discharge assessment within 14 days of the resident's discharge. 2. Record review of Resident #3's medical record showed the following information: -admitted to the facility on [DATE]; -discharged to the hospital on 5/8/2022 and did not return to the facility. Record review of the resident's MDS submitted reports showed the following information: -admitted to the facility 4/26/2017; -Significant Change Assessment ARD of 3/22/2022; -Entry Assessment ARD of 6/17/2022; -14-day Admission Assessment ARD of 6/24/2022; -Staff did not complete or submit a discharge assessment within 14 days of the resident's discharge. 3. During an interview on 8/12/2022, at 10:48 A.M., the Director of Nursing (DON) said the following: -She was asked by administration to assist with the MDS assessments and submissions right after he/she starting working at the facility in March 2022. At that time, there was no MDS Coordinator, as the former MDS Coordinator had already left employment there; -She thought all required assessments had been caught up and submitted and was unaware that the assessments for the residents had not been submitted. 4. During an interview on 8/12/2022, at 1:45 P.M., the Administrator said staff should complete and submit all MDS required assessments according to the regulatory time frames. He was not aware that any assessments were overdue or had not been completed.

Based on interview and record review, the facility failed to thoroughly screen and document staff results for COVID-19 prior to working and/or caring for residents in the facility. These facility staff cared for all residents of the facility, and provided services to all residents of the facility. The facility also failed to ensure that staff reporting possible signs or symptoms of COVID-19 were not allowed to work with non-positive residents. In total, the facility failed to thoroughly screen staff and document the results of the screening in at least 112 individual instances since late July. Additionally, the facility experienced an outbreak of COVID-19 identified on or around 10/20/20, when a staff person tested positive during routine testing. That same staff person reported possible signs or symptoms of COVID-19 during the screening process on 10/20/20 and in the days before they tested positive. The staff person was allowed to work their scheduled shifts. As of 10/28/20, 39 residents and 15 staff had tested positive for COVID-19. Furthermore, the facility also failed to ensure that visitors and staff were thoroughly screened when the facility failed to include questions regarding travel and exposure to someone with or under investigation for COVID-19 on the screening logs. A determination was made that the facility's noncompliance with one or more requirements of participation placed all 63 residents of the facility in immediate jeopardy, beginning on 7/27/20. On 10/28/20 at 2:53pm, the Administrator was notified of the immediate jeopardy at F880, Infection Prevention and Control. The immediate jeopardy was removed on 10/28/20 when surveyors verified implementation of a removal plan. The scope and severity was lowered to an F. Findings include: I. On 10/28/20 at 9:22am, the Administrator indicated that the facility experienced an outbreak of COVID-19 on or around 10/20/20, which was discovered when an employee, Medication Aide (MA1) tested positive for COVID-19. The Administrator indicated that MA1 did not display any symptoms of COVID-19 on the employee screening forms, when being screened at the beginning of their shift. The Administrator indicated that staff would screen themselves when arriving to the facility. The screening process consisted of taking their temperatures and oxygen saturation levels using a pulse oximeter (a device placed on the end of the finger that measures the oxygenation of blood). Staff would document the results and then answer the screening questions, which asked about the presence of sore throat, cough, or shortness of breath. The Administrator indicated that the screening process had no known issues. II. Review of the facility's employee and visitor screening logs, titled COVID-19 Screening, revealed that staff and visitors were to document their name, if they performed hand hygiene upon entering the facility, what their oxygen saturation was, and what their temperature was. They were then to answer three questions with a yes or no: presence of cough, shortness of breath, or sore throat. Further review of the screening logs revealed the following: 1.) On an undated form, Medication Aide (MA1), two unknown persons, Nurse Aide (NA1), NA2, NA3, Registered Nurse (RN1), MA3, and LPN4 failed to document their temperatures. In addition, one of the unknown persons reported the presence of a sore throat. Transportation Aide (TA1) failed to answer the screening questions. 2.) On 7/27/20, TA1 failed to document their temperature and indicated that they experienced a cough. Review of time clock records documented that TA1 worked their scheduled shift. The form lacked any documented follow-up. 3.) On 7/28/20, MA4 and RN2 indicated that they both experienced a cough. Both staff worked their scheduled shifts. Additionally, a visitor failed to document their temperature and indicated that they experienced a sore throat. The form lacked any documented follow-up. 4.) On 7/29/20, TA1 and MA4 indicated that they both experienced a cough. Both staff worked their scheduled shifts. Additionally, a visitor indicated that they experienced a sore throat. The form lacked any documented follow-up. 5.) On 8/4/20, Maintenance Staff (M1) failed to answer the screening questions. Review of time clock records documented that M1 worked their scheduled shift. 6.) On 8/12/20, two unknown persons failed to answer the screening questions. 7.) On a second undated form, RN3 indicated that they experienced a sore throat. The form lacked any documented follow-up. 8.) On a third undated form, two visitors failed to answer the screening questions. 9.) On 8/18/20, RN4 indicated that they experienced a sore throat. Review of time clock records documented that RN4 worked their scheduled shift. Additionally, a visitor failed to document their temperature. 10.) On a fourth undated form, NA5 failed to answer the screening questions. 11.) On a fifth undated form, NA4 failed to answer the screening questions. 12.) On 8/19/20, the Activities Assistant (AA) failed to answer the screening questions. Review of time clock records documented that the AA worked their scheduled shift. Additionally, two unknown persons failed to answer the screening questions. 13.) On a sixth undated form, M1 failed to answer the screening questions. 14.) On a seventh undated form, NA6 failed to answer the screening questions. 15.) On an eighth undated form, Feeding Assistant (FA1) failed to answer the screening questions. 16.) On 8/20/20, two unknown persons failed to answer the screening questions. 17.) On a ninth undated form, NA4 failed to document their temperature or answer the screening questions. 18.) On 8/25/20, NA6 and M2 failed to answer the screening questions. Review of time clock records documented that both staff worked their scheduled shifts that day. 19.) On 8/27/20, two unknown persons failed to answer the screening questions. 20.) On a tenth undated form, FA1 failed to document their temperature. 21.) On 9/2/20, NA4 failed to document their temperature or answer the screening questions. Review of time clock records documented that NA4 worked their scheduled shift that day. 22.) On 9/5/20, a visitor failed to document their temperature. 23.) On 9/6/20, three visitors failed to document their temperatures. 24.) On an 11th undated form, two visitors and NA7 failed to answer the screening questions. 25.) On 9/11/20, FA2 failed to answer the screening questions. Review of time clock records documented that FA2 worked their scheduled shift. 26.) On a 12th undated form, FA1, M3, a visitor, and an unknown person failed to document their temperatures. NA5 failed to answer the screening questions. 27.) On a 13th undated form, NA8 and two visitors failed to document their temperatures. 28.) On 9/19/20, a visitor failed to document their temperature or answer the screening questions. 29.) On 9/20/20, M2 failed to answer the screening questions. Review of time clock records documented that M2 worked their scheduled shift. 30.) On 9/22/20, NA6 failed to answer the screening questions. Review of time clock records documented that NA6 worked their scheduled shift. 31.) On 9/24/20, the Activity Director (AD) and FA1 failed to document their temperatures. Review of time clock records documented that both staff worked their scheduled shifts. 32.) On 9/29/20, the MDS Coordinator failed to document their temperature. Review of time clock records documented that the MDS Coordinator worked their scheduled shift. 33.) On 10/1/20, NA5 indicated that they experienced a sore throat, a cough, and shortness of breath. Review of time clock records documented that NA5 worked their scheduled shift. The form lacked any documented follow-up. 34.) On 10/3/20, MA1 indicated that they experienced a sore throat and a cough. Review of time clock records documented that MA1 worked their scheduled shift. Additionally, M1 failed to answer the screening questions. Review of time clock records documented that M1 worked their scheduled shift. 35.) On 10/4/20, a visitor failed to answer the screening questions. 36.) On 10/5/20, the MDS Coordinator failed to document their temperature and RN2 indicated that they experienced a cough. Review of time clock records documented that both staff worked their scheduled shifts. The form lacked any documented follow-up. 37.) On 10/6/20, MA1 indicated that they experienced a cough. Review of time clock records documented that MA1 worked their scheduled shift. 38.) On 10/8/20, MA1 indicated that they experienced a cough. Review of time clock records documented that MA1 worked their scheduled shift. 39.) On 10/10/20, MA1 indicated that they experienced a cough. Review of time clock records documented that MA1 worked their scheduled shift. 40.) On 10/11/20, NA10 indicated that they had a cough and a sore throat. Review of time clock records documented that NA10 worked their scheduled shift. The form lacked any documented follow-up. 41.) On 10/12/20 and 10/13/20, MA1 indicated that they experienced a cough. Review of time clock records documented that MA1 worked their scheduled shift each day. 42.) On 10/14/20, the AA failed to answer the screening questions. Review of time clock records documented that the AA worked their scheduled shift that day. 43.) On 10/18/20, MA1 indicated that they experienced a cough. Review of time clock records documented that MA1 worked their scheduled shift that day. 44.) On 10/19/20, the MDS Coordinator indicated that they experienced a sore throat, a cough, and shortness of breath. NA9 indicated that they experienced a sore throat and a cough. Review of time clock records documented that the MDS Coordinator and NA9 worked their scheduled shifts. Additionally, a visitor indicated that they had a sore throat, a cough, and shortness of breath. The form lacked any documented follow-up. 45.) On 10/20/20, MA1 indicated that they experienced a cough. Review of time clock records documented that MA1 worked for four hours before being sent home, after testing positive for COVID-19. III. Staff interviews On 10/28/20 at 11:27am, Licensed Practical Nurse (LPN1) indicated that when staff came into work, they screened themselves into the facility. Staff would perform hand hygiene, measure their temperatures using a thermometer, and measure their blood oxygen saturation using a pulse oximeter. The staff would then document the results on the screening log, and answer the screening questions. LPN1 indicated that the facility experienced an outbreak of COVID-19 recently, and that Medication Aide (MA1) was the first staff person to test positive. LPN1 indicated that MA1 had a bad cough, but had tested negative for COVID-19 one to two weeks prior to the outbreak occurring. LPN1 indicated that approximately 40 residents and 20 staff were positive for COVID-19. On 10/28/20 at 12:30pm, LPN2 indicated that staff screened themselves into the facility. LPN2 indicated that the screening process consisted of measuring their temperatures and oxygen saturation levels, and then answering the three questions on the form. LPN2 indicated that if staff didn't have a fever, even if they displayed other symptoms of COVID-19, they were expected to work their scheduled shift. On 10/28/20 at 1:45pm, LPN3 indicated that staff screened themselves into the facility. Staff would check their temperatures and answer the questions on the form. On 10/28/20 at 2:12pm, the Director of Nursing (DON) indicated that staff and visitors were expected to screen themselves upon arrival to the facility, and that if they had any possible symptoms of COVID-19, they were to inform administration. The DON indicated that the screening logs were reviewed by staff for completion, and that she was not aware of missing information or other issues with the screening process. On 10/28/20 at 2:25pm, the Administrator indicated that the expectation of staff was to thoroughly complete the screening process, document all required information, and inform administration of the presence of any possible COVID-19 symptoms. The Administrator indicated that she was unaware of the multiple instances of missing information on the screening logs. IV. The facility policy, undated, titled Employee Screening Guidelines, documented the following: C- Screening and Assessment: Each person will complete a questionnaire and be screened for temperature and symptoms indicative of 'influenza-like illness' as follows: 1. Fever- The Fever screen is considered positive at >99.7F. 2. Symptom Screen- Within the past 48 hours, have you experienced any of the following? a. Acute onset of respiratory illness b. Cough c. One or more of the following: 1) sore throat 2) new onset of shortness of air NOTE: Symptom screen is considered positive if individual answers yes to a, b, and c. D. Action: 1. Negative screen. If individual is negative for all screens, they may go to work. 2. Positive screen. If an individual is positive for any of the screens above, they should be deferred from work and referred for further evaluation. V. Review of CMS guidance, documented in QSO memo 20-14 NH, released 3/4/20, documented the following: How should facilities monitor or limit visitors? Facilities should screen visitors for the following: 1. International travel within the last 14 days to restricted countries. For updated information on restricted countries visit: https://www.cdc.gov/coronavirus/2019-ncov/[MEDICATION NAME]/index.html 2. Signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat. 3. Has had contact with someone with or under investigation for COVID-19. The guidance also documented: How should facilities monitor or restrict health care facility staff? The same screening performed for visitors should be performed for facility staff (numbers 1, 2, and 3 above). - Health care providers (HCP) who have signs and symptoms of a respiratory infection should not report to work. - Any staff that develop signs and symptoms of a respiratory infection while on-the-job, should: Immediately stop work, put on a facemask, and self-isolate at home; Inform the facility's infection preventionist, and include information on individuals, equipment, and locations the person came in contact with; and Contact and follow the local health department recommendations for next steps (e.g., testing, locations for treatment). VI. Review of the facility's employee and visitor screening logs, titled COVID-19 Screening, documented that upon arrival to the facility, staff and visitors were to document their name, if they performed hand hygiene upon entering the facility, what their oxygen saturation was, and what their temperature was. They were then to answer three questions with a yes or no: presence of cough, shortness of breath, or sore throat. The form failed to document questions regarding international travel and contact with an individual with or under investigation for COVID-19. VII. Staff interviews On 10/28/20 at 11:27am, LPN1 indicated that staff screened themselves into the facility by measuring their temperatures, oxygen saturation levels, and by answering three questions about presence of cough, sore throat, or shortness of breath. LPN1 indicated that the facility did not ask any further questions during the screening process. On 10/28/20 at 12:30pm, LPN2 indicated that facility staff screened themselves into the facility by measuring temperatures, oxygen saturation levels and by answering three questions about presence of cough, sore throat, or shortness of breath. On 10/28/20 at 2:12pm, the DON indicated that facility staff screened themselves into the building and answered the three screening questions about cough, shortness of breath, and sore throat. The DON indicated that the facility did not include any further questions on the screening log. VIII. The facility policy, undated, titled Employee Screening Guidelines, documented the following: C- Screening and Assessment: Each person will complete a questionnaire and be screened for temperature and symptoms indicative of 'influenza-like illness' as follows: 1. Fever- The Fever screen is considered positive at >99.7F. 2. Symptom Screen- Within the past 48 hours, have you experienced any of the following? a. Acute onset of respiratory illness b. Cough c. One or more of the following: 1) sore throat 2) new onset of shortness of air NOTE: Symptom screen is considered positive if individual answers yes to a, b, and c. D. Action: 1. Negative screen. If individual is negative for all screens, they may go to work. 2. Positive screen. If an individual is positive for any of the screens above, they should be deferred from work and referred for further evaluation. IX. Review of CMS guidance, documented in QSO memo 20-14 NH, released 3/4/20, documented the following: How should facilities monitor or limit visitors? Facilities should screen visitors for the following: 1. International travel within the last 14 days to restricted countries. For updated information on restricted countries visit: https://www.cdc.gov/coronavirus/2019-ncov/[MEDICATION NAME]/index.html 2. Signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat. 3. Has had contact with someone with or under investigation for COVID-19. The guidance also documented: How should facilities monitor or restrict health care facility staff? The same screening performed for visitors should be performed for facility staff (numbers 1, 2, and 3 above). - Health care providers (HCP) who have signs and symptoms of a respiratory infection should not report to work. - Any staff that develop signs and symptoms of a respiratory infection while on-the-job, should: Immediately stop work, put on a facemask, and self-isolate at home; Inform the facility's infection preventionist, and include information on individuals, equipment, and locations the person came in contact with; and Contact and follow the local health department recommendations for next steps (e.g., testing, locations for treatment).

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (SNFABN - form CMS- ) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents (Residents #86 and #89) out of three sampled residents who remained in the facility upon discharge from Medicare Part A services. The facility census was 74. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS- ) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of either the SNFABN (form CMS- ) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them his/herself or through other insurance they may have; -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination. 1. Record review of Resident #86's SNF Beneficiary Protection Notification Review, dated 8/30/19, showed the following: -On 8/13/19, Medicare Part A skilled services started; -On 8/23/19, last covered day of Medicare Part A services. The Medicare Part A Service was terminated/discharged voluntarily; -Facility staff did not provide the resident or his/her legal CMS- or representative the required SNFABN form an alternative denial letter. 2. Record review of Resident #89's SNF Beneficiary Protection Notification Review, dated 8/30/19, showed the following: -On 5/28/19, Medicare Part A skilled services started; -On 6/21/19, last covered day of Medicare Part A services; -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted; -Facility staff did not provide the resident or his/her legal representative the required SNFABN form CMS- or an alternative denial letter. 3. During an interview on 8/30/19, at 10:25 [NAME]M., the Administrator said the following: -The facility's pervious social services director left in (MONTH) (YEAR); -The facility failed to direct the current interim social services designee to complete the SNFABN form; -The facility staff have not completed SNFABN's for residents discontinuing skilled services since (MONTH) (YEAR). -The facility has been giving verbal notifications to the residents, but no written notifications at discharge from skilled services. 4. During an interview on 8/30/19, at 12:36 P.M., the social worker designee said the following: -He/she was not aware the SNFABN's needed to be provided to the residents that were discharging from Medicare part A services; -He/She has not been providing the SNFABN to residents upon discharge; -He/She was not sure if there was a facility policy about beneficiary notices.

Based on observation, interview, and record review, the facility failed to complete and document an accurate and comprehensive pressure ulcer assessment, at least weekly (according to the facility's policy), for four residents (Resident #1, #2, #4, and #6), failed to provide treatment as ordered by the physician for one resident (Resident #2), failed to follow infection control standards during pressure ulcer care for three residents (Resident #2, #4, and #6). Three residents (Resident #1, #2, and #6) developed facility-acquired pressure ulcer infections. The facility failed to change treatment when the pressure ulcer failed to show evidence of healing for two residents (Resident #1 and Resident #6). The facility failed to provide and implement pressure-relieving devices for two residents (Resident #1 and #6), identified by the facility staff as high-risk for pressure ulcer development, and one resident (Resident #4), identified by the facility staff as low-risk for pressure ulcer development. Resident #1, Resident #2, and Resident #4 developed facility-acquired pressure ulcers. Two residents (Resident #1 and #2) developed facility-acquired pressure ulcers which deteriorated to Stage IV pressure ulcers and impacted their overall health status. This deficient practice has the potential to affect all residents in the facility. The facility identified seven residents with pressure ulcers. The sample selection included four out of those seven residents with a total sample selection of 14 residents in a facility with a census of 84. Record review of the Pressure Ulcer Prevention and Treatment, 2009 edition, showed the following information: -Infection is not common in Stage I or Stage II pressure ulcers. Assessment of infection should focus on Stage III and Stage IV pressure ulcers. -Infection may spread beyond the pressure ulcer, resulting in serious systemic infections such [MEDICAL CONDITION]; -To avoid these serious consequences, the professional should focus on identification of high-risk individuals, prevention, early detection, and prompt effective treatment of [REDACTED]. Record review of the facility's At-Risk Skin Assessment Policy, reviewed 03/2008, showed the following information: -Staff will assess all resident's for "skin at risk" on admission and at least quarterly thereafter; -Resident's with a Braden scale score of 17 or below are considered "at risk" for skin breakdown; preventative measures shall be implemented and addressed on the care plan; -The "at risk" residents will have head to toe assessments completed by a licensed nurse weekly to assure skin breakdown does not occur; -The nurse will go to each resident and physically check their skin and equipment paying special attention to pressure relief interventions; -Document all areas included in the assessment on the weekly report; -If an "at risk" resident has no interventions (i.e. gel cushion to wheelchair, positioning pillow/wedges, air mattress) initiate them and document on the report. 1. Record review of Resident #2's admission nursing assessment, dated 6/16/11, showed the resident did not have any pressure ulcers. Staff provided the resident with a pressure relieving wheelchair cushion and initiated an every two hour turn schedule due to his/her bed mobility limitations. Record review of the Braden Scale (a tool used to predict pressure ulcer risk), dated 06/16/11, showed the resident's total score was 14 (a total score of 17 and below requires a weekly skin assessment and documentation in the medical record). Record review of the admission Minimum Data Set (MDS), a federally mandated comprehensive assessment tool, completed by facility staff, dated 06/23/11, showed the following information: -Severely impaired cognition; -Required extensive assistance with bed mobility, transfers, dressing and personal hygiene; -Always incontinent of bowel and bladder; -[MEDICAL CONDITION]; -At risk for developing pressure ulcers; -No unhealed pressure ulcers; -Pressure relieving device for the bed and chair. Record review of a physician's orders [REDACTED]. (tailbone) and change every three days until healed. Record review of the Wound and Skin Progress Report, dated 06/27/11, showed on 06/26/11 staff identified a 0.5 centimeters (cm) x 1.0 cm Stage I pressure ulcer (a persistent area of skin redness without a break in the skin, that is nonblanchable) on the resident's coccyx. The pressure ulcer had a depth of less than 0.1 cm with no drainage and no odor. Record review of the facility's form entitled Decubitus Ulcer (pressure ulcer) Procedure Checklist, initiated 06/26/11, showed the following Stage I interventions implemented by staff: -Begin pressure ulcer procedure (assess, measure, document); -Pressure reducing mattress (Maxi float (a specialized pressure-reduction mattress)); -Wheelchair cushion; -Positioning devices (pillows); -Turn every two hours and as needed; -High calorie/protein nutrition supplement (Prostat 101 (pure protein), 30 milliliters (ml) three times a day); -Vitamin C, Vitamin E and a Multivitamin. Record review of the care plan, initiated on 06/30/11, showed the following information: -Required extensive/total assist for Activities of Daily Living (ADL); -Observe skin for redness/open areas during cares and report to charge nurse; -Weekly skin assessments per quarterly Braden scale; -Impaired cognition related to [MEDICAL CONDITION]; -Wears briefs for incontinence. Record review of the July 2011 Physician order [REDACTED]. Record review of the resident's current medical record showed staff did not complete the weekly "At Risk" skin assessment for the week of 07/03/11-07/09/11 or the week of 07/10/11-07/16/11. Record review of the weekly wound documentation, completed by facility staff, dated 7/6/11, showed the resident had a 0.5 cm x 1.0 cm Stage I pressure ulcer to his/her coccyx which staff treated with [MEDICATION NAME] CGF. The pressure ulcer showed no change from the previous week. Preventative measures included a maxi-float mattress, wound care vitamins and staff to turn resident every two hours. On 10/06/11 the MDS coordinator provided a hand written statement showing staff provided a gel cushion for the resident's wheelchair on 07/07/11. Record review of the weekly wound documentation, completed by facility staff, dated 7/13/11 (17 days after staff first identified a pressure ulcer), showed the resident had a 1.6 cm x 1.4 cm x unknown unstageable pressure ulcer to his/her coccyx which staff treated with [MEDICATION NAME] CGF. The pressure ulcer was larger and covered with slough (moist, soft dead tissue). Preventative measures included a maxi-float mattress, wound care vitamins and turning every two hours. The nurse arranged a wound care clinic appointment for the resident. The nurse did not document any further description of the pressure ulcer. During an interview conducted on 10/04/11, at 11:00 A.M., the assistant director of nursing (ADON), who is also the wound nurse for the facility, said the resident was admitted to the facility due to a right [MEDICAL CONDITION]. On admission, staff assessed the resident as high risk for developing pressure ulcers. When the resident was admitted he/she was "somewhat stationary" and stayed in bed more because sitting up caused him/her more pain. When staff identified the Stage I (pressure ulcer) they initiated the wound care protocol which includes wound care vitamins, gel wheelchair cushion and sometimes an air mattress. The ADON also said because staff assessed the resident as high risk, he/she would have already received the gel wheelchair cushion. The ADON said she asked the physician for a referral to the wound clinic because the resident's pressure ulcer deteriorated significantly in one week's time. She also said sometimes wounds will have an odor because of the reaction between the [MEDICATION NAME] and wound drainage. Record review of the wound assessment report, completed by wound clinic staff, dated 7/14/11, showed the following information: -2.2 cm x 2.5 cm unstageable pressure ulcer; -Tissue type and color: 50% yellow slough, 50% brown eschar (hard, dry dead tissue); -Minimal amount of serous (clear pale yellow) drainage with a slight odor; -Periwound (area of skin surrounding the wound) condition: Cool, [DIAGNOSES REDACTED]tous (redness of the skin; often a sign of inflammation or infection); -Comments: Treatment changed from [MEDICATION NAME] CGF to Dakin's solution (typically a mixture of bleach, baking soda and water that kills germs and prevents germ growth in wounds) with the plan to debride (removal of dead or damaged tissue) the pressure ulcer next week. Record review of a physician's orders [REDACTED]. -Discontinue the [MEDICATION NAME] to the coccyx; -Apply Dakin's 25% solution, using wet-to-wet technique, every six hours; -Apply 3M No Sting Spray to the skin around the pressure ulcer where the tape will rest and Sensicare (a protective barrier ointment) to the periwound; cover with gauze and secure with tape; -Turn every two hours while in bed; -Low-flow air mattress (a specialized mattress that consists of air- filled sacs inflated at a constant pressure, through which air can pass). Record review of the resident's current medical record showed staff did not complete the weekly "At Risk" skin assessment for the week of 07/17/11-07/23/11. Record review of the weekly wound documentation, completed by facility staff, dated 7/19/11, showed the resident had a 2.0 cm x 2.2 cm x unknown, unstageable pressure ulcer to his/her coccyx which staff treated with Dakin's solution. The pressure ulcer was larger, covered 100% with slough and had a minimal amount of serosanguinous (blood tinged) drainage. Preventative measures included an air mattress, gel cushion in his/her wheelchair, wound care vitamins, turn every two hours and weekly wound clinic appointments. The nurse did not document any further description of the pressure ulcer. During an interview conducted on 10/04/11, at 11:00 A.M., the ADON said she probably did notice an odor to the pressure ulcer but did not document it on the weekly assessment. Normally she would document if she noticed an odor but the facility initiated new weekly wound forms and there was not enough room. The ADON said she does not document as much as she used to or as much as she should. Record review of the wound assessment report, completed by wound clinic staff, dated 7/21/11, showed the following information: -2.5 cm x 2.5 cm unstageable pressure ulcer; -Tissue type and color: 5% red granulation tissue (new tissue, usually pink to red in color), 5% yellow slough, 90% brown eschar; -Moderate amount of gray drainage with a very strong foul odor; -Periwound condition: Warm, [DIAGNOSES REDACTED]tous; -Wound assessment is consistent with signs and symptoms of infection; -Wound status: Wound decline; -Comments: Performed sharp debridement (removal of dead tissue by means of scalpel, scissors or other sharp object) of necrotic tissue. Upon physical examination, at the wound care clinic, the resident had a body temperature of 100.2 degrees Fahrenheit. Record review of a physician's orders [REDACTED]. -Continue Dakin's 25% solution, apply solution to ? inch plain packing strips and loosely pack in coccyx ulcer; -Continue Sensicare ointment and 3M No Sting Spray as previously ordered; -Bactrim DS (an antibiotic), one tablet two times a day for 10 days. Record review of the weekly wound documentation, completed by facility staff, dated 7/26/11, showed the resident had a 2.0 cm x 2.2 cm x 1.6 cm Stage IV pressure ulcer (full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures) with a 3.4 cm tunnel (open tunnels extending from the wound) at the 11 o'clock position to his/her coccyx which staff treated with Dakin's solution. The pressure ulcer was 75% granulation tissue and 25% slough and had a minimal amount of serosanguinous drainage. Preventative measures included an air mattress, gel cushion in his/her wheelchair, wound care vitamins, turn every two hours and weekly wound care clinic appointments. The nurse did not document any further description of the pressure ulcer. Record review of the nurses' notes, dated 07/25/11-07/26/11, showed the following information: -On 07/25/11, at 10:42 A.M., the nurse observed a foul odor when he/she changed the resident's dressing; -On 07/25/11, at 4:00 P.M., the resident's Stage III pressure ulcer (full thickness skin loss involving damage or death of subcutaneous tissue that may extend down to but not including the bone) had a scant amount of yellow/green purulent (thick yellow, green or brown fluid with a pungent, strong, foul, fecal or musty odor) drainage and was painful to touch; -On 07/26/11, at 1:30 P.M., the wound care nurse completed the treatment to the resident's Stage IV pressure ulcer. The pressure ulcer tunneled at 11 o'clock, had a moderate amount of serosanguinous drainage and no odor. The resident had no pain during the treatment; -On 07/26/11, at 5:05 P.M., the pressure ulcer had no redness to the periwound, minimal amount of drainage and a foul odor. Record review of the resident's current medical record showed no indication staff notified the physician of the persistent pressure ulcer odor. Record review of the wound assessment report, completed by wound clinic staff, dated 7/27/11, showed the following information: -2.3 cm x 2.0 cm unstageable pressure ulcer; -3.8 cm undermining (erosion or extension of the wound edge underneath the visible edge) from 9 o'clock to 2 o'clock; -Tissue type and color: 40% red granulation tissue, 60% yellow slough, exposed subcutaneous tissue (deepest layer of skin consisting of fat and connective tissue); -Moderate amount of serous drainage with a very strong foul odor; -Periwound condition: Warm, [DIAGNOSES REDACTED]tous; -Wound assessment is consistent with signs and symptoms of infection; -Comments: The deepest undermining is at 11 o'clock. Continue Dakin's solution, continue Bactrim DS and obtain Physical and Occupational Therapy evaluation for wheelchair cushion and positioning. Record review of the resident's current medical record showed staff did not complete the weekly "At Risk" skin assessment the week of 07/10/11-07/16/11through the week of 07/31/11-08/06/11. Record review of the weekly wound documentation, completed by facility staff, dated 8/02/11, showed the resident had a 1.9 cm x 1.9 cm x 1.4 cm Stage IV pressure ulcer with a 3.1 cm tunnel, from 11 o'clock to 1 o'clock, on his/her coccyx which staff treated with Dakin's solution. The pressure ulcer was 80% granulation tissue and 20% slough and had a minimal amount of serosanguinous drainage. Preventative measures included an air mattress, gel cushion in his/her wheelchair, wound care vitamins, turn every two hours and weekly wound care clinic appointments. The nurse did not document any further description of the pressure ulcer. Record review of a nurse's notes, dated 07/28/11, at 11:05 A.M., showed the wound care nurse and Certified Occupational Therapy Aide (COTA) '"feel" Physical and Occupational Therapy evaluation for wheelchair cushion and positioning was not indicated at this time because the resident had a gel cushion for his/her wheelchair and the staff lay the resident down right after meals; the resident is only up in hi/her wheelchair for a limited time. Record review of the wound assessment report, completed by wound clinic staff, dated 8/03/11, showed the following information: -1.8 cm x 1.4 x 1.0 cm unstageable pressure ulcer; -3.1 cm undermining from 10 o'clock to 11 o'clock; -Tissue type and color: 80% red granulation tissue, 20% yellow slough, exposed subcutaneous tissue; -Minimal amount of serous drainage, no odor; -Periwound condition: Warm, intact; -Comments: Measurements are positional; pressure ulcer measured by a different nurse. Change treatment to Silverlon (a silver antimicrobial dressing). Record review of a physician's orders [REDACTED]. Apply Silverlon to coccyx pressure ulcer, cover with gauze and secure with tape. Change the dressing daily and as needed when soiled. Record review of the resident's current medical record showed staff did not complete the weekly "At Risk" skin assessment for the week of 08/07/11-08/13/11 or the week of 08/14/11-08/20/11. Record review of the weekly wound documentation, completed by facility staff, dated 8/09/11, showed the resident had a 2.0 cm x 1.4 cm x 1.9 cm Stage IV pressure ulcer with a 3.5 cm tunnel, from 11 o'clock to 1 o'clock, on his/her coccyx which staff treated with Silverlon. The pressure ulcer was "cleaner" and "deeper," with 100% granulation tissue and had a minimal amount of serosanguinous drainage. Preventative measures included an air mattress, gel cushion, wound care vitamins, turn every two hours and weekly wound care clinic appointments. The nurse did not document any further description of the pressure ulcer. Record review of the wound assessment report, completed by wound clinic staff, dated 8/10/11, showed the following information: -1.7 cm x 1.6 x 1.2 cm Stage IV pressure ulcer; -3.5 cm undermining from 10 o'clock to 12 o'clock; -Tissue type and color: 80% red granulation tissue, 20% yellow slough; -Moderate amount of serous drainage with a very strong foul odor; -Periwound condition: cool, intact; -Comments: The deepest undermining is at 11 o'clock; measurements are positional. Change the treatment to Silverlon. The resident has a specialty mattress on his/her bed and a gel cushion in his/her wheelchair. Record review of a physician's orders [REDACTED]. Please be sure to loosely pack the tunnel at 11 o'clock with the long strip of Silverlon (two strips are provided). Record review of the weekly wound documentation, completed by facility staff, dated 8/16/11, showed the resident had a 2.0 cm x 1.4 cm x 1.5 cm Stage IV pressure ulcer with a 3.0 cm tunnel, from 11 o'clock to 1 o'clock, on his/her coccyx which staff treated with Silverlon. The pressure ulcer had "less depth" and was 100% granulation tissue with a minimal amount of serosanguinous drainage. Preventative measures included an air mattress, gel cushion, wound care vitamins, turn every two hours and weekly wound care clinic appointments. The nurse did not document any further description of the pressure ulcer. Record review of the wound assessment report, completed by wound clinic staff, dated 8/17/11, showed the following information: -1.2 cm x 1.2 x 1.2 cm Stage IV pressure ulcer; -3.4 cm undermining from 10 o'clock to 11 o'clock; -Tissue type and color: 80% red granulation tissue, 20% yellow slough; -Moderate amount of serous drainage, no odor; -Periwound condition: cool, intact; -Comments: Will change the treatment to [MEDICATION NAME] Blue (an antimicrobial dressing). The resident has a specialty mattress on his/her bed and a gel cushion in his/her wheelchair. Record review of a physician's orders [REDACTED]. Loosely pack the pressure ulcer and tunnel with saline moistened [MEDICATION NAME] Blue. Apply 3M Mo Sting spray to skin where tape rests, cover with gauze and secure with [MEDICATION NAME] (a transparent film dressing); change daily. Record review of the resident's current medical record showed staff did not complete the weekly "At Risk" skin assessment for the week of 08/21/11-08/27/11. Record review of the weekly wound documentation, completed by facility staff, dated 8/23/11, showed the resident had a 1.8 cm x 1.4 cm x 1.5 cm Stage IV pressure ulcer with a 2.9 cm tunnel, from 11 o'clock to 1 o'clock, on his/her coccyx which staff treated with [MEDICATION NAME] Blue. The pressure ulcer was "smaller in length," covered with 100% granulation tissue and had a minimal amount of serosanguinous drainage. Preventative measures included an air mattress, gel cushion, wound care vitamins, turn every two hours and weekly wound care clinic appointments. The nurse did not document any further description of the pressure ulcer. Record review of the wound assessment report, completed by wound clinic staff, dated 8/24/11, showed the following information: -1.6 cm x 1.5 x 1.1 cm Stage IV pressure ulcer; -3.2 cm undermining from 10 o'clock to 11 o'clock; -Tissue type and color: 90% red granulation tissue, 10% yellow slough; -Minimal amount of serous drainage, no odor; -Periwound condition: cool, intact; -No change in wound status; -Comments: Measurements are positional; will continue treatment using [MEDICATION NAME] Blue. Record review of the resident's current medical record showed staff did not complete the weekly "At Risk" skin assessment for the week of 08/28/11-09/03/11 or the week of 09/06/11-09/13/11.. Record review of the weekly wound documentation, completed by facility staff, dated 8/30/11, showed the resident had a 1.6 cm x 1.1 cm x 1.4 cm Stage IV pressure ulcer with a 3.0 cm tunnel, from 11 o'clock to 1 o'clock, on his/her coccyx which staff treated with [MEDICATION NAME] Blue. The pressure ulcer had a "smaller wound opening," with 100% granulation tissue and with a moderate amount of serosanguinous drainage. Preventative measures included an air mattress, gel cushion, wound care vitamins, turn every two hours and weekly wound care clinic appointments. The nurse did not document any further description of the pressure ulcer. Record review of the wound assessment report, completed by wound clinic staff, dated 8/31/11, showed the following information: -1.0 cm x 1.1 x 0.7 cm Stage IV pressure ulcer; -3.4 cm undermining from 10 o'clock to 11 o'clock; -Tissue type and color: 90% red granulation tissue, 10% yellow slough; -Minimal amount of serous drainage, no odor; -Periwound condition: cool, rash; -Comments: Measurements are positional; changed the treatment to Silverlon. The resident is incontinent of bowel and bladder. Stool observed on the dressing and in the pressure ulcer. [MEDICATION NAME] (antifungal medication) powder applied around the wound. Record review of the weekly wound documentation, completed by facility staff, dated 9/06/11, showed the resident had a 1.2 cm x 0.9 cm x 1.1 cm Stage IV pressure ulcer with a 3.0 cm tunnel, from 11 o'clock to 1 o'clock, on his/her coccyx which staff treated with Silverlon. The pressure ulcer was "smaller," had 100% granulation tissue and a moderate amount of serosanguinous drainage. Preventative measures included an air mattress, gel cushion, wound care vitamins, turn every two hours and weekly wound care clinic appointments. The nurse did not document any further description of the pressure ulcer. Record review of the "At Risk" Weekly Skin Condition Report, dated 09/07/11, showed the following information: -Airflow mattress for pressure relief; -Gel wheelchair cushion for personal pressure relief; -Staff did not mark any vitamins; -Every two hour turn schedule; -Positional devices/restraints: Bed and wheelchair alarm; -Protein shake (supplement) three times a day; -Incontinent of bowel and bladder; -Received pressure ulcer treatments; -Staff documented the resident had a new area of compromise-multiple old skin tears. Record review of the wound assessment report, completed by wound clinic staff, dated 9/07/11, showed the following information: -1.0 cm x 0.8 x 0.7 cm Stage IV pressure ulcer; -2.3 cm undermining from 10 o'clock to 11 o'clock; -Tissue type and color: 90% red granulation tissue, 10% yellow slough; -Minimal amount of serous drainage, no odor; -Periwound condition: cool, rash; -Comments: Measurements are positional; rash has improved to the skin around the ulcer. Continue Silverlon treatment to the pressure ulcer and [MEDICATION NAME] powder to periwound. Record review of the wound assessment report, completed by wound clinic staff, dated 9/13/11, showed the following information: -0.7 cm x 0.7 x 0.4 cm Stage IV pressure ulcer; -3.0 cm undermining from 10 o'clock to 11 o'clock; -Tissue type and color: 90% red granulation tissue, 10% yellow slough; -Minimal amount of serous drainage, no odor; -Periwound condition: cool, intact; -Comments: Measurements are positional; continue Silverlon. Record review of the Braden Scale, dated 09/20/11, showed the resident total score was 15 (a total score of 17 and below requires a weekly skin assessment and documentation in the medical record). Record review of the weekly wound documentation, completed by facility staff, dated 9/20/11, showed the resident had a 0.6 cm x 0.4 cm x 0.6 cm Stage IV pressure ulcer with a 1.7 cm tunnel, from 11 o'clock to 1 o'clock, on his/her coccyx which staff treated with Silverlon. The pressure ulcer was 'smaller', had 100% granulation tissue and a minimal amount of serosanguinous drainage. Preventative measures included an air mattress, gel cushion, wedge, wound care vitamins, turn every two hours and weekly wound care clinic appointments. The nurse did not document any further description of the pressure ulcer. Record review of a quarterly MDS, dated [DATE], showed the following information: -Short and long term memory problems; -Severely impaired daily decision making skills; -Required extensive assistance with bed mobility, transfers, dressing and personal hygiene; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -Weight loss of 5% or more in the last month or loss of 10% or more in the last six months; -Not on a physician-prescribed weight-loss regimen; -At risk for developing pressure ulcers; -One Stage IV pressure ulcer; -Pressure relieving device for the bed and chair; -Ulcer care; -Application of dressings other than to feet. Record review of the wound assessment report, completed by wound clinic staff, dated 9/21/11, showed the following information: -0.6 cm x 0.3 x 0.5 cm Stage IV pressure ulcer; -2.3 cm undermining from 10 o'clock to 11 o'clock; -Tissue type and color: 90% red granulation tissue, 10% yellow slough; -Minimal amount of serous drainage, no odor; -Periwound condition: cool, intact; -No significant change in wound status; -Comments: Measurements are positional; continue Silverlon. Record review of the "At Risk" Weekly Skin Condition Report, dated 09/07/11, showed the following information: -Airflow mattress for pressure relief; -Gel wheelchair cushion for personal pressure relief; -Staff did not mark any vitamins; -Every two hour turn schedule; -Positional devices/restraints: Bed and wheelchair alarm; -Protein shake (supplement) three times a day; -Incontinent of bowel and bladder; -Received pressure ulcer treatments; -Staff documented the resident had no change and a new area of compromise-left forearm skin tear. Record review of a physician's orders [REDACTED]. Change outer dressing when soiled. Record review of the care plan, updated on 09/22/11, showed staff added the following undated interventions: -Healing Stage IV pressure ulcer to the coccyx; -Air mattress; -Treatment to wound as ordered; -Wound clinic appointments as ordered; -Wound care vitamins. Record review of a physician's orders [REDACTED]. Discontinue [MEDICATION NAME] powder. An observation on 09/27/11, at 9:07 A.M., showed the ADON, the wound nurse, entered the north medication room to gather her wound care supplies. The ADON opened the treatment cart but did not find any 4 inch x 4 inch (4x4) gauze dressings. She opened the cabinet, removed and opened a large package of gauze dressings, and without washing her hands or applying gloves, removed several 4x4 gauze dressings and placed half of them in a Styrofoam cup and the other half in an empty dressing package. The ADON placed the rest of the opened package of 4x4 gauze into the bottom drawer of the treatment cart. The ADON moistened the gauze, in the cup, with wound wash and carried the Styrofoam cup, bottle of wound wash, opened package of gauze dressings, two long cotton-tipped applicators and tape into the resident's room. The ADON placed the supplies on a paper towel she laid on the resident's bed. The ADON and Licensed Practical Nurse (LPN) C turned the resident onto his/her left side and unfastened his/her incontinent brief. Dried stool was visible on the lower half of the resident's gauze dressing. The resident was incontinent of bowel. After the nurses provided perineal care (cleansing of the genitalia and surrounding area), they washed their hands and applied gloves. As the ADON removed the resident's coccyx dressing, a piece of Silverlon fell into the resident's incontinent brief; no Silverlon was packed into the wound. The LPN left the room to get a second piece of Silverlon. The deep, dime-sized, pressure ulcer's wound bed was red with a small amount of light yellow slough. After the ADON moistened the piece of Silverlon with tap water, the LPN returned with a second piece of Silverlon. The ADON inserted the moistened Silverlon into the resident's pressure ulcer using one of the cotton-tipped applicators, covered the pressure ulcer with the second piece of Silverlon and gauze. The ADON inserted the Silverlon dressing, that lay directly underneath the stool-soiled gauze, into the resident's pressure ulcer, possibly contaminating the pressure ulcer. As the LPN motioned towards the Styrofoam cup on the bed that contained the moistened 4x4 gauze dressings. LPN C asked the ADON what she was going to do with those 4x4 gauze dressings. The ADON removed the gauze covering the second piece of Silverlon, placed the moistened gauze over the Silverlon, then covered with a dry gauze and tape. The ADON did not clean the pressure ulcer prior to applying the new dressing and did not follow physician's orders [REDACTED]. During interviews conducted on 09/27/11, at 9:04 A.M. and 9:35 A.M., the ADON said the pieces of Silverlon dressing can be used for seven days. She measures and performs dressing changes usually on Tuesdays. If the resident goes to the wound care clinic she does not measure the wound that week and does not usually replace the Silverlon. The ADON said she did not measure the resident's wound or replace the Silverlon because the resident had a wound care clinic appointment tomorrow (09/28/11). During an interview conducted on 10/04/11, at approximately 12:45 P.M., the ADON said the resident did not have a strip of Silverlon packed inside the pressure ulcer when he/she performed the dressing change on Tuesday (09/27/11). Record review of the weekly wound documentation, completed by facility staff, dated 9/27/11, showed the resident had a 0.4 cm x 0.3 cm x 0.4 cm Stage IV pressure ulcer with a 3.0 cm tunnel, from 11 o'clock to 1 o'clock, on his/her coccyx which staff treated with Silverlon. The pressure ulcer was "smaller," had 100% granulation tissue and a minimal amount of serosanguinous drainage. Preventative measures included an air mattress, gel cushion, wedge, wound care vitamins; turn every two hours and weekly wound care clinic appointments. The nurse did not document any further description of the pressure ulcer. During an interview conducted on 09/28/11, at 9:40 A.M., Registered Nurse (RN) O said if the resident goes to the wound care clinic, they change the Silverlon, if not then the ADON changes it. The nurse said the resident did not have a wound care clinic appointment today. An observation on 09/28/11, at 9:40 A.M., RN O entered the north hall medication room to gather his/her wound care supplies. The

Based on observation, interview, and record review, the facility failed to consistently assess, monitor, and administer pain medication in a timely manner for one resident (Resident #3) who experienced severe pain in a sample selection of 14 residents in a facility with a census of 84. 1. Record review of Resident #3's outpatient medical clinic progress note, dated 2/15/11, showed the history of the present illness as complaints of leg pain. The resident's family member said the resident was having a horrible time at night and pain medication was not touching the pain during the night. The family member said the resident might be having leg spasms. Record review of the admission nursing assessment showed the resident was admitted on [DATE], at 1:00 P.M.. Record review of the resident's care plan, dated 3/18/11, showed the following information: -Problem: decline in ability to care for self at home, with increased depression and crying, history of stroke with right-sided weakness, chronic knee and leg pain related to severe [MEDICAL CONDITION]. The resident required limited to extensive assistance with activities of daily living (ADLs). Pain interferes with mobility. -Interventions included: Pain medications as ordered, monitor for effectiveness. Record review of the physician order [REDACTED]. Change the patch every 72 hours. Check placement of the patch every shift. Record review of the physician's progress note, dated 4/28/11, showed the following information: -The resident continues to have intermittent problems with his/her legs and complaint of leg pain. The physician increased the [MEDICATION NAME] to 75 mcg daily and the resident is also on [MEDICATION NAME] (pain medication) 10/325, two tablets three times a day. -The physician recently increased the resident's pain medications, but continues to complain of pain. The resident has had multiple studies in the past. The physician documented she was going to recheck the resident's chart and see the last time the resident had any sort of nerve conduction study. -The resident has known severe [MEDICAL CONDITION] of the knees bilaterally, but the physician would expect that the amount of pain medication he/she is on right now that the pain would be improving. Record Review of the POS [REDACTED] Record review of the monthly nursing summary, dated 6/6/11 and 6/20/11, showed the resident had mild pain less than daily. Record review of the physician's progress note, dated 6/28/11, showed the following information: -The resident admitted to the facility in March 2011 for pain control and nursing staff reports the resident's pain is well controlled. However, the resident's family is struggling with the resident's mental status. They are disappointed, but do understand that this is probably due to the medication to control the resident's pain. Record review of the resident's significant change Minimum Data Set (MDS), a federally mandated comprehensive assessment tool, completed by facility staff, dated 7/6/11, showed the following information: -Short and long term memory problem; -Severely impaired decision-making skills; -Total dependence on staff for bed mobility, transfers, toilet use, and personal hygiene; -Required extensive assistance for dressing; -Always incontinent of urine; -Frequently incontinent of bowel; -[DIAGNOSES REDACTED]. -In the previous 5 days, the resident had been on a scheduled pain medication regimen; -In the previous 5 days, the resident had not received any as needed pain medications; -In the previous 5 days, the resident had not received any non-medication interventions for pain; -Indicators of pain or possible pain exhibited by the resident in the last 5 days included: non-verbal sounds, such as crying, whining, gasping, moaning, or groaning; facial expressions, such as grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw; protective body movements, such as bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement; -The indicators of pain were observed in 3-4 days in the previous 5 days. Record review of the monthly nursing summary, dated 7/6/11, showed the resident had moderate daily pain. The resident had a routine pain medication of [MEDICATION NAME]. Record review of Care Area Assessment Documentation, showed on 7/7/11, the MDS coordinator documented the resident had a [DIAGNOSES REDACTED]. The resident continues to experience pain. The resident usually has facial grimacing, increased agitation, and restlessness when experiencing pain. Hospice services began on 7/6/11 due to dementia and need for adequate pain control. The resident experiences daily pain and has been picked up by hospice for pain management and cares. Record review of the resident's care plan showed staff added the following information: -On 7/6/11, staff added the intervention of hospice services; -On 7/7/11, staff made the following changes/additions to the care plan: -Total/extensive assistance with ADLs; -Required total assist of one staff for bed mobility, transfers, toilet use, and personal hygiene. -Staff did not include any other interventions, medication or non-medication to address the resident's pain; -Staff did not address the specific method of pain assessment or signs and symptoms to monitor for pain. Record review of the July 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -Staff administered [MEDICATION NAME] every morning at 8:00 A.M.; -Staff administered [MEDICATION NAME] every 72 hours. -From July 1 through July 7, 2011 at 1:00 P.M., staff administered [MEDICATION NAME] 10/325, two tablets three times a day routinely at 8:00 A.M., 1:00 P.M., and 8:00 P.M. Staff documented a number on the pain scale each time staff administered the routine [MEDICATION NAME] dose. The resident did not have any as needed medication for staff to administer for complaints of pain during that time period. Record review of the physician order [REDACTED]. -On 7/7/11, the physician ordered [MEDICATION NAME] (pain medication) 2.5 mg every 12 hours routinely. Check pain scale; -On 7/7/11, the physician ordered Roxinol (pain medication) 20 mg/ml. Give 0.25 ml or 5 mg by mouth or under the tongue every 1-2 hours as needed for pain or air hunger. Record review of the July 2011 MAR, showed the following information: -From 7/7/11 at 8:00 P.M. through 7/31/11, staff administered [MEDICATION NAME] 2.5 mg, at 8:00 A.M. and 8:00 P.M. routinely. Staff did not document a pain assessment when administering the [MEDICATION NAME] dose. -On 7/9/11, staff administered the as needed Roxinol 0.25 ml at 12:35 A.M. and 1:35 A.M. for complaints of leg pain. The nurse documented the resident was resting at 1:00 A.M. and 2:00 A.M. -On 7/11/11, at 12:30 P.M., the nurse administered Roxinol 0.25 ml for complaints of leg pain. The nurse documented the resident's level of pain as 8 out of 10. The nurse followed-up at 1:00 P.M. and documented the pain medication was effective. -On 7/19/11, the nurse administered Roxinol at unknown time and did not document any other information regarding the pain medication or follow-up. -On 7/24/11, the nurse administered Roxinol 0.25 ml at 3:10 P.M. for complaint of leg pain. The nurse documented the resident's pain level as 8 out of 10. The nurse followed-up and documented the pain medication was effective. At 8:45 P.M., the nurse administered Roxinol 0.25 ml for complaints of general discomfort. The nurse followed-up and documented the pain medication was effective. -On 7/30/11, at 11:20 P.M., the nurse administered Roxinol 0.25 ml for resident complaints of knee and leg pain. The nurse followed-up and documented the pain medication was effective. -On 7/31/11, at 1:30 P.M., the nurse administered Roxinol for complaints of leg pain. The nurse followed-up and documented the pain medication was effective. Record review of the August 2011 MAR, showed the following information: -Staff administered the [MEDICATION NAME] every morning at 8:00 A.M.; -Staff administered the [MEDICATION NAME] every 72 hours at 8:00 P.M. as ordered; -Staff administered the [MEDICATION NAME] 2.5 mg every 12 hours at 8:00 A.M. and 8:00 P.M. routinely as ordered. Staff documented a pain assessment with a number when administering the [MEDICATION NAME] dose of medicine. -On 8/3/11, at 4:45 P.M., the nurse administered Roxinol 0.25 ml for complaints of general pain at a pain level of 8. The nurse followed-up and documented the pain level decreased to 2. -On 8/4/11, at 7:00 A.M., the nurse administered Roxinol 0.25 ml for complaints of back pain. The resident's pain level was 7. The nurse followed-up and documented the medication was effective. -On 8/4/11, at 11:05 P.M., the nurse administered Roxinol 0.25 ml for complaints of leg pain at pain level of 8. The nurse followed-up and documented the medication was effective. -On 8/5/11, at 7:00 P.M., the nurse administered Roxinol 0.5 ml for general pain at a pain level of 8. The nurse followed-up and documented the pain level decreased to 2.; -On 8/11/11, at 1:15 A.M., the nurse administered Roxinol 0.25 ml for pain at a pain level of 10. The nurse followed-up and documented "no complaints". On 8/13/11, at 9:10 P.M., the nurse administered Roxinol 0.25 ml for general pain at a pain level of 9. The nurse did not follow-up and assess the effectiveness of the pain medication. -On 8/14/11, at 12:00 A.M., the nurse administered Roxinol 0.25 ml for general pain at a pain level of 10. The nurse followed-up and documented the medication was effective. -On 8/14/11, at 2:00 A.M., the nurse administered Roxinol 0.25 ml for complaints of leg pain and yelling, at a pain level of 10. The nurse followed-up and documented the medication was effective. -On 8/16/11, at 8:40 P.M., the nurse administered Roxinol 0.5 ml for crying and general pain, at a level of 10. The nurse followed-up and documented the pain medication was effective. -On 8/19/11, at 10:50 A.M., the nurse administered Roxinol 0.25 ml for complaints of back pain. The resident's pain level was 8. The nurse followed-up and documented the resident was smiling. -On 8/22/11, at 5:15 P.M., the nurse administered Roxinol 0.25 ml for complaints of left arm pain. The resident's pain level was 8. The nurse followed- up and documented the medication was semi-effective and the resident's pain level was 4. -On 8/22/11, at 7:50 P.M., the nurse administered Roxinol 0.25 ml for complaints of knee pain. The resident's pain level was 5. The nurse followed-up and documented the medication was not effective. -On 8/25/11, at 8:50 P.M., the nurse administered Roxinol 0.5 ml for crying with complaints of pain. The nurse followed-up and documented the medication was effective. Record Review of the POS [REDACTED]. Give 0.25 ml up to 1 ml (5-20 mg) by mouth or under the tongue every two hours as needed for pain. Record review of the August 2011 MAR indicated [REDACTED] -On 8/26/11, at 9:10 A.M., the nurse administered Roxinol 0.25 ml for complaints of pain and crying. The nurse followed-up and documented the medication was not effective. -On 8/26/11, at 11:00 A.M., the nurse administered Roxinol 0.75 ml for complaints of pain and crying. The nurse followed-up and documented the resident was "better". -On 8/27/11, at 12:05 A.M., the nurse administered Roxinol 1 ml for crying in leg pain, at a pain level of 10. The nurse followed-up and documented the medication was effective. -On 8/28/11, at 1:30 P.M., the nurse administered Roxinol 1 ml for crying with leg pain. The nurse did not follow up regarding the effectiveness of the pain medication. -On 8/29/11, at 8:30 P.M., the nurse administered Roxinol 0.5 ml for complaints of pain and crying. The nurse followed-up and documented the medication was effective. Record review of the monthly nursing summary, dated 8/6/11, showed the following information: -The resident had daily moderate pain. The resident had a routine pain medication of [MEDICATION NAME]. -On 7/6/11, the resident admitted to hospice services; -On 7/7/11, the physician changed the resident's antidepressant medication; -On 7/7/11, the physician discontinued the [MEDICATION NAME] medication and started the resident on [MEDICATION NAME] 2.5 mg, one tablet every twelve hours. The physician started the resident on Roxinol. Record review of the monthly nursing summary, dated 9/6/11, showed the resident had daily moderate pain. The resident had Roxinol and Methodone ordered for pain. On 8/26/11, the nurse documented the resident's Roxinol had been increased. Record review of the September 2011 MAR, showed the following information: -Staff administered the [MEDICATION NAME] 100 mg every morning routinely as ordered; -Staff administered the [MEDICATION NAME] 75 mcg every 72 hours routinely as ordered; -Staff administered the [MEDICATION NAME] 2.5 mg every 12 hours at 8:00 A.M. and 8:00 P.M. routinely as ordered. Staff assessed the resident's pain level when administering the [MEDICATION NAME] medication. -On 9/1/11, at 1:15 P.M., the hospice staff administered Roxinol 1 ml to the resident. Staff did not document any follow-up or additional information regarding the resident's pain. -On 9/6/11, at 1:25 P.M., the nurse administered Roxinol 1 ml for complaints of increased pain. The nurse followed-up and documented the resident was "resting". -On 9/8/11, at 1:00 P.M., the nurse administered Roxinol 1 ml for complaints of increased pain. The nurse followed-up and documented the medication was effective. -On 9/8/11, at 5:00 P.M., the nurse administered Roxinol 1 ml for crying and complaints of leg pain. The nurse followed-up and documented the medication was effective. -On 9/11/11, at 7:45 P.M., the nurse administered Roxinol 1 ml for crying with leg pain. The nurse followed-up and documented the resident was "sleeping". -On 9/16/11, at 11:45 P.M., the nurse administered Roxinol 1 ml for complaints of leg hurting and anxious. The nurse followed-up and documented the medication was effective. -On 9/18/11, at 11:15 P.M., the nurse administered Roxinol 1 ml for complaints of severe leg pain and crying. The nurse followed-up and documented the medication was effective. -On 9/19/11, at 9:55 A.M., the nurse administered Roxinol 1 ml for complaints of leg pain. The nurse followed-up and documented the medication was effective. -On 9/19/11, at 11:35 P.M., the nurse administered Roxinol 1 ml for complaints of right leg pain at a pain level of 10. The nurse followed-up and documented the medication was effective and the resident was sleeping. -On 9/21/11, at 1:20 P.M., the nurse administered Roxinol for complaints of pain. The nurse did not document the amount of medication given. The nurse followed-up and documented the resident "resting". -On 9/22/11, at 7:20 P.M., the nurse administered Roxinol 1 ml for complaints of right leg pain at a pain level of 10. The nurse followed-up and documented the medication was effective and the resident was sleeping. -On 9/25/11, at 7:00 P.M., the nurse administered Roxinol 1 ml for complaints of right leg pain at a pain level of 10. At 9:00 P.M., the nurse followed-up and documented the resident still hurt at a pain level of 7. -On 9/25/11, at 9:00 P.M., the nurse administered another dose of Roxinol 1 ml for complaints of right leg pain at a pain level of 8. The nurse followed-up and documented the medication was effective and the resident was sleeping. Observation on 9/27/11, at 1:00 P.M., showed the resident sat in the wheelchair in the dining room eating lunch. The resident complained to the certified feeding assistant (CFA) that he/she had pain in the left shoulder. The aide said he/she would tell the nurse when they went back down (to the resident's hall and nurses' station). At 1:04 P.M., the resident complained again that his/her left shoulder hurt. The resident pointed at it and continued to complain of pain. At 1:11 P.M., the CFA wheeled the resident out of the dining room and down the hall to the area by the nurses' station and the resident's room. The CFA left the resident there without telling nursing about the resident's complaints of shoulder pain. The resident moved his/her left arm and said "Ooh!" as if it hurt to move the arm. At 1:25 P.M., CNA P wheeled the resident into the room. CNA Q entered the room. CNA P said the resident probably would not lay down this afternoon because the resident laid down that morning. CNA P said the resident was kind of agitated and worked up about something. The two aides transferred the resident to bed and left the room. At 1:30 P.M., the resident yelled and cried out, spitting on the floor beside the bed. The resident sat up partway in the bed and talked out loud. At 1:35 P.M., the resident yelled, "I want to come home! I got to go to the bathroom!" CNA P talked to the nurse regarding the resident yelling. At 1:40 P.M., the resident yelled, "Hey, can you take me?" At 1:43 P.M., CNA P and CNA R entered the room and transferred the resident from the bed to the wheelchair. The aides wheeled the resident to the bathroom and transferred the resident to the toilet. The aides provided perineal care. The aides transferred the resident to the wheelchair. At 1:55 P.M., staff had not administered any pain medication to the resident. At 2:25 P.M., CFA S said he/she was the one who assisted the resident at lunch. The CFA said the resident had arthritis and sometimes it was hard for the resident to eat because of the pain. The CFA said he/she told someone as he/she walked down the hall with the resident earlier. The CFA did not know who he/she told about the resident's pain. The CFA said it might have been a CNA. The staff person said they would take care of it. At 2:28 P.M. staff wheeled the resident from the activity in the dining room to the nurses' station. Upon the surveyor request, at 2:53 P.M., licensed practical nurse (LPN) C asked the resident if his/her left shoulder still hurt. The resident immediately said, "Oh!" and grabbed his/her left shoulder. The resident said "Yes, it did hurt". The nurse asked the resident if he/she wanted pain medication and the resident said, "Yes". LPN T asked the resident if it was hurting pretty bad and the resident said, "Oh, yes!" LPN C said he/she had not been told about the resident hurting. At 2:55 P.M., (almost 2 hours after the resident first notified staff of pain) LPN T administered Roxinol for the resident's pain. Record review of the September 2011 MAR, showed the following information: -On 9/27/11, at 2:50 P.M., the nurse administered Roxinol 0.5 ml for complaints of right shoulder pain. The resident had facial grimacing. At 3:10 P.M., the nurse followed-up and documented the medication was effective. The resident did not have facial grimacing. Observation on 9/28/11, at 8:20 A.M., showed staff wheeled the resident out of the dining room. At 8:25 A.M., the resident sat in the wheelchair by the resident room. At 8:37 A.M., the resident said, "I need to pee! I need to poop!" The surveyor notified CNA H. The aide said he/she would take the resident in just a second. At 8:37 A.M., the aide took the resident to the bathroom. The aide provided perineal care for the resident. The resident stood while the aide cleaned the resident, but had difficulty standing. The aide sat the resident back down on the toilet to rest. The aide transferred the resident from the toilet to the wheelchair. The aide asked the resident if he/she wanted to lie down. The resident said, "Yes, I imagine". At 8:45 A.M., the aide wheeled the resident to bed and transferred the resident to bed. The resident began gasping. The surveyor questioned if the resident did that because of pain. The aide said the resident just did it sometimes. The aide asked the resident if he/she hurt. The resident said, "Yea, just all the time" and pointed to the left shoulder. The aide asked the resident if he/she wanted pain medication. The resident said yes, he/she would take it. At 8:50 A.M., the aide left the room and walked directly to another resident room. The aide did not tell anyone about the resident's pain. At 8:54 A.M., the resident's bed alarm sounded. At 8:55 A.M., CNA P entered the room. The aide said the sensor alarm pad was too low on the resident. CNA P and CNA U repositioned the sensor pad in the bed. No other staff entered the room. At 10:08 A.M., the resident continued to lie in bed. The resident sobbed and cried and grabbed his/her left shoulder and said the left shoulder hurt. At 10:10 A.M., the surveyor informed the LPN B regarding the resident's pain. The nurse said the resident had scheduled [MEDICATION NAME] for pain. The surveyor explained the resident was sobbing and crying in his/her bed. The nurse said no one had told him/her anything regarding the resident's pain. At 10:13 A.M., the nurse and surveyor entered the room. The resident continued to cry and sob. The resident grabbed his/her shoulder and rubbed it and held the left shoulder. The resident said, "Oh, my arm hurts". The nurse administered Roxinol 1 ml (1 ? hours after showing signs of pain and communicating to staff regarding the pain) to the resident. The resident said "Oh, my arm, shoulder, leg hurts so bad". Another staff entered the room and the two staff repositioned the resident off the left shoulder. At 10:17 A.M., the resident said, "I want to go home". LPN B said he/she was going to get a warm moist pack for the resident's left shoulder and arm. At 10:50 A.M., the resident lay in bed with the warm pack on the left shoulder and rested quietly. Record review of the September 2011 MAR, showed the following information: -On 9/28/11, at 10:10 A.M., the nurse administered Roxinol 1 ml for crying and pain in the right shoulder. The nurse followed up and documented the resident was asleep. During interview on 9/28/11, at 1:32 P.M., the hospice nurse said when the resident started on hospice the resident had a lot of uncontrolled pain. The resident was on routine [MEDICATION NAME] and had crying episodes with horrible pain. The resident did not eat and lost 40 pounds in the last six months. The resident started on [MEDICATION NAME] twice a day and the resident has done quite a bit better with that. The resident had one episode of uncontrolled pain when hospice was here. The resident was crying and could not sit up. The staff had to massage the resident until the pain medication took effect. That was the resident's normal prior to starting the Methodone. The resident has Roxinol as needed for pain. When that uncontrolled episode occurred, staff had already given [MEDICATION NAME]. The hospice staff increased the frequency after that episode. It seemed like the resident's right leg is where the most pain is usually. The resident also has general discomfort. The hospice nurse was not aware of the resident complaining of left shoulder pain. The resident had not complained of pain there to the hospice nurse. Record review of the September 2011 MAR, showed the following information: -On 9/28/11, at 1:55 P.M., the nurse administered Roxinol 1 ml for crying and pain. The nurse followed-up and documented the medication was effective. During an interview on 9/28/11, at 2:20 P.M., CNA H said the resident would occasionally tell the staff if he/she was hurting. If the resident is crying, then they know the resident is hurting. Usually, in the morning when the resident gets up, he/she is in pain. When they roll the resident in bed, he/she fights the staff and stiffens up. We don't want to touch him/her because of the pain. The aides tell the medication nurse about the resident's pain. He/she tells the nurse as soon as possible so the nurse can get pain medication to the resident as soon as possible. The aide said the resident had complained of left shoulder pain 1-2 times before. It has been awhile since the resident had the complaint of left shoulder pain. Usually, the resident complains of his/her right leg hurting. The aide said he/she did not know of any incident that would cause increased pain to the left shoulder. During an interview on 9/28/11, at 2:25 P.M., registered nurse (RN) O said staff assess the resident's pain every morning and every evening when the Methodone is administered. The evening shift administers and checks the [MEDICATION NAME] for the resident. Staff assess the resident's pain at that time. In between those times, the resident is assessed every two to three hours with bed checks. Staff assess the resident's pain if the resident complains of pain or has the scheduled pain medication. Staff can tell when the resident hurts. The resident gets "rowdy" and sometimes gets mean when staff asks the resident a question. The nurse said staff gave the resident two doses of Roxinol and [MEDICATION NAME] this afternoon to settle the resident down. Staff assesses non-verbal signs and symptoms of pain. The resident can tell sometimes also, but also look at the signs and symptoms. The signs staff look for is crying, agitation, "worked-up". Staff looks at behaviors. When the resident first entered the facility, the resident would grab and pull parts of his/her body. The resident occasionally complains of shoulder or back pain, usually complains of pain in the right leg. When the resident first came to the facility, the physician ordered an x-ray of the shoulder. The resident's complaint of left shoulder pain is periodic. The resident used to play softball and has arthritis in the shoulder. The resident also has arthritis in the knees. When the resident first entered the facility, the resident's pain was much uncontrolled. It was hard to get the physician to understand that [MEDICATION NAME] four times a day was not helping the resident's pain. When the resident started hospice services, they helped a lot with the pain control. Staff document pain assessments on the MAR under the [MEDICATION NAME] dose. It is a 0-10 scale. A facial scale coordinates with the numbers to give a number on the pain scale. Staff assesses the resident's pain prior to administering the [MEDICATION NAME] dose. If staff administers an as needed pain medication, staff assess the resident's pain before and after the medication. Staff should document it on the back of the MAR. For scheduled pain medications, staff just writes the number next to it. The aides should tell the medication nurse or the charge nurse within 15 minutes of a resident's complaint of pain. As soon as they are finished with the resident, they should tell the nurse. The medication nurse has 30 minutes to administer the pain medication after being notified of the resident's pain. Record review of the facility's policy, titled "Pain Management Program", reviewed on 10/10, showed the following information: -Purpose of policy: To provide system of monitoring resident's pain level and effectiveness of [MEDICATION NAME]/non-drug interventions in order to evaluate treatment approaches and provide for maximum pain relief. Procedure: -Staff will complete pain assessment for all resident's on admission, quarterly, and as needed for signs and symptoms of pain regardless of current level of pain; -Assess pain presence, frequency, effect on function, and intensity; -Ask resident to rate pain using the pain scale; -Determine if staff assessment for pain is needed; -If staff assessment is needed, review indicators of pain or possible pain; -Based on pain assessment, initiate routine or as needed pain medication regimen; -Reassess as needed. -The facility's policy on pain included a facial scale of smile/frown that associated with a number on the pain scale. A score of 10 indicated the worst possible pain. A score of 8 indicated very severe pain. A score of 6 indicated severe pain. A score of 4 indicated moderate pain. 0 indicated no pain.

Based on observation, interview and record review, the facility failed to appropriately assess the fall risk for two residents (Resident #3 and #4). Resident #4 fell at home and fractured his/her right arm. The resident continued to sustain falls in the facility. Some falls resulted in injuries including a fracture of the right arm above the previous fracture site. The facility failed to consistently implement interventions and/or failed to identify and implement different interventions in an attempt to prevent further falls for these residents in a sample selection of 14 residents in a facility with a census of 84. 1. Record review of Resident #4's admission nursing assessment, dated 1/27/11, showed the following information: -Alert and oriented; -No elopement risk; -Cast to right hand to below shoulder for fractured humerus; -Elevate right arm for swelling and keep right arm in sling. Keep cast dry. -Fall risk assessment score was 4. A score of 4 indicated the resident at minimal risk for falls. The nurse documented the resident had a [DIAGNOSES REDACTED]. -The nurse marked chair and bed alarm as fall interventions put into place at the time of admission. Record review of the physician order [REDACTED]. Staff checks the alarms weekly. Record review of the individual resident accident reports, showed the following information: -On 2/8/11, at 8:35 A.M., the resident had a fall. The resident did not sustain any injury related to the fall. The resident fell in the bathroom. The resident's family member had removed the alarm from the chair. -On 2/10/11, at 4:00 A.M., the resident had a fall. The resident's bed alarm sounded. Staff found the resident on the floor. The facility sent the resident to the emergency room for sutures to the forehead. The resident sustained [REDACTED]. During interview on 10/5/11, at 4:50 P.M., the Minimum Data Set (MDS) coordinator said after the resident's fall on 2/8/11, she was sure they would have re-educated the family about removing the alarm. That would have been the intervention after the fall. Regarding the fall on 2/10/11, the accident report mentions the lap buddy and low bed. The MDS coordinator said the assistant director of nursing (ADON) would have documentation regarding the lap buddy and when it started and stopped. The MDS coordinator thought the lap buddy and low bed might have been in place at the time of the fall on 2/10/11. At a later time, the MDS coordinator provided information that showed the lap buddy started on 2/10/11 and staff discontinued it on 3/8/11. The low bed started on 2/10/11 and staff discontinued it on 3/8/11. Record review of the resident's significant change MDS, a federally mandated comprehensive assessment tool, required to be completed by facility staff, dated 4/26/11, showed the following information: -Cognitively intact; -Staff did not document any behaviors of the resident in the previous seven days before the assessment; -Required limited assistance for bed mobility, transfers, dressing, and toilet use; -Required only supervision for personal hygiene; -When moving from a seated position to a standing position, the resident is not steady, but is able to stabilize without human assistance; -The resident did not walk; -When turning around, moving on and off the toilet, and transferring between bed and chair, the resident is not steady and is only able to stabilize with human assistance; -Although the resident sustained [REDACTED]. Record review of the care plan, dated 4/27/11, showed the following information: -Problems included: healing fractured distal right humerus (upper arm), at risk for recurrent falls, poor balance, refuses to let staff use gait belt; impaired vision, wears glasses; hopes to return home with family; -Required limited assistance with transfers, bed mobility, dressing and toilet use; -Sling on right arm at all times except for bathing; -Bed/chair alarms to alert staff of rising unassisted, check every week for proper functioning. Record review of the physician order [REDACTED]. -The order for the bed and chair alarm continued. -On 4/27/11, the physician ordered the resident to participate in the walk and dine program (walking to and from the dining room at meal times) with the gait belt, cane, and aide; -On 4/28/11, the physician ordered occupational therapy to treat five times a week for four weeks for therapy exercises and edema (swelling) control of the right hand; -On 5/3/11, the physician ordered to keep the brace on the right arm except for bathing. May apply sling as needed. Do not rest elbow on firm surfaces. -On 6/15/11, the physician ordered to continue with the brace on the right arm and remove it for bathing. Record review of the monthly nursing summary, dated 6/13/11, showed the resident as alert and oriented, confused at times. The nurse documented the resident as quiet and anxious. The resident is easily upset and interferes with cares at times. The resident uses a wheelchair. Staff did not document any safety devices or alarms currently used for the resident. The nurse did not document the date of the resident's last fall. Record review of the POS, dated 7/1/11 through 7/31/11, included the following information: -The order continued for the bed and chair alarm; -The order continued for the walk and dine program; -The order continued for the brace to the right arm. Record review of the resident's quarterly MDS assessment, dated 7/19/11, showed the following information: -Limited assistance for bed mobility, transfers, and toilet use; -Required extensive assistance for dressing; -Staff did not document any behaviors of the resident in the previous seven days before the assessment; -When moving from a seated to standing position, walking, turning around, moving on and off the toilet, and transferring between bed and chair; the resident is not steady and is only able to stabilize with human assistance; -The staff did not document any falls since admission or prior assessment, whichever is more recent; -Staff did not document providing any restorative or therapy services in the previous seven days prior to the assessment. Record review of the nurses' notes, dated 7/22/11, at 12:10 A.M., showed the nurse heard the aide yell and responded. The resident lay in the floor by the bathroom on his/her right side. The resident yelled with pain in his/her right arm. Staff checked the resident's vital signs. The resident had an elbow brace in place and the shoulder was swelling. The nurse called the physician and obtained orders to send the resident to the emergency room . Staff notified the family regarding the incident. Record review of the fall investigation, dated 7/22/11, showed the following information: -Staff found the resident in the bathroom on the right side. -The resident could not give a statement of what happened at the time of the fall. The resident had a chair alarm, but it did not go off. Staff documented there was not an alarm in the chair. -The investigation did not include the time of the fall or any interventions changed or added to attempt to prevent another fall. Record review of the POS, dated 7/22/11, from the hospital discharge progress notes, showed the following information: -Transfer the resident back to the nursing home; -New Diagnosis: [REDACTED]. -Notify the resident's primary physician in the morning of the new diagnosis; -Sling to the right arm; -Fall precautions; -Ultram (pain medication) 50 mg, one tablet every six hours routinely for two weeks. Give the first dose up on arrival to the nursing home. Record review of the nursing home POS, dated 7/21/11 through 7/31/11, showed the following information: -On 7/22/11, at 2:55 A.M., the nurse transcribed the orders from the hospital to include: -Ultram (tramadol, pain medication) 50 mg, one tablet every six hours routinely for two weeks with the first dose given upon arrival to the nursing home; -Sling to the right arm; -Notify the primary physician in the morning of the resident's new [DIAGNOSES REDACTED]. -On 7/22/11, the primary physician ordered to give tramadol (Ultram) 50 mg with Tylenol 325 mg. Staff may give an additional dose of both medications every four hours as needed for pain for a total of eight doses in 24 hours. The physician ordered Lorazepam (antianxiety medication) 0.5 mg by mouth or injection every six hours as needed for anxiety. -On 7/22/11, at 3:00 P.M., the nurse transcribed a telephone order to leave the sling on the right arm at all times to stabilize until further notice; -On 7/22/11, at 6:55 P.M., the nurse wrote a telephone order for intravenous fluids to be administered at 100 cc per hour for one liter; -On 7/22/11, the physician documented the resident is comfortable at this time, but would need attentive care regarding the right shoulder; -On 7/23/11, the nurse wrote a telephone order for oxygen at two liters per minute per nasal canula as needed to keep the resident's oxygen saturation level about 90%; -On 7/23/11, the physician documented the resident was more comfortable today and starting to take oral food and fluids. The medications seem to be doing an adequate job; -On 7/23/11, the nurse documented an order to hold the intravenous fluids until further notice. Record review of the resident's care plan, showed the following information: -On 7/21/11, staff reviewed the care plan. On unknown date, staff added the resident had a fall with a re-fracture of the right arm; -On an unknown date, staff documented the resident refused to wear the sling at times. -Staff did not add any additional interventions or change any interventions to attempt to prevent additional falls. During an interview on 10/5/11, at 4:50 P.M., the MDS coordinator said the 7/22/11 fall is when the resident re-fractured his/her arm. Staff did not change any interventions after the fall. Staff just continued the bed and chair alarm. The lap buddy and low bed were not in place at that time. (At a later time, the MDS coordinator provided information that showed staff discontinued the lap buddy and low bed on 3/8/11.) Record review of the POS showed on 7/25/11, the physician discontinued the order for the restorative nursing program that focused on hand strengthening and decreased hand edema. Record review of the nurses' notes, dated 7/28/11, at 7:30 P.M. showed the resident was yelling and combative. The resident resisted cares. The resident was confused and tried to eat a Band-Aid. The nurse documented the resident was picking at "things" in the air. The nurse administered Ativan (Lorazepam) to the resident. The resident hit the medications out of the LPN's hand. Staff called the family to come sit with the resident. Record review of the POS, dated 8/1/11 through 8/31/11, showed the following information: -The order continued for the bed and chair alarm; -The walk and dine program remained on hold; -The order to leave the sling on the right arm at all times to stabilize until further notice continued; -The physician documented the resident was doing better and seemed more comfortable. The positioning of the right shoulder is okay and the resident is able to be up in the chair. Record review of the monthly nursing summary, dated 8/20/11, showed the following information: -Alert, oriented, confused at times; -Emotional: quiet, easily upset at times, cooperative, interferes with cares at times; -Ambulation: wheelchair; staff did not document the use of any safety devices or alarms. The nurse did not document the date of the resident's last fall. -The nurse assessed the resident's fall risk as a score of 3. A score of 3 indicated minimal risk for falls. The nurse marked the resident for assistive devices, cognitive impairment, and fall in the last 31-180 days. The nurse did not mark the resident for a fall in the past 30 days. -Resident continues to wear sling for the right fractured shoulder. Record review of the POS, dated 9/1/11 through 9/30/11, showed the following information: -The order continued for the bed and chair alarm; -The walk and dine program continued to be held; -The order to leave the sling on the right arm at all times to stabilize until further notice continued. Record review of the nurses' notes, dated 9/8/11, at 12:05 P.M., the resident complained of dysuria (painful urination) with increased confusion noted. The nurse obtained a new order for urinalysis with culture and sensitivity if indicated. At 6:40 P.M., the nurse documented that the urinalysis results was unremarkable. The urinalysis did not indicate a culture or sensitivity needed. Record review of the POS showed on 9/13/11, the physician ordered the resident to sit at the restorative table for all meals. Record review of the nurses' notes, showed the following information: -On 9/16/11, at 3:05 P.M., the nurse documented the aide found the resident lying on the left side on the floor. The resident had a dime-sized raised area on the forehead, with bruising and light purplish color. The nurse assessed the resident. The resident informed the nurse he/she "was getting ready to join the wedding party". The nurse documented the resident's pupils were "fixed", normal for this resident. The resident's speech is clear. The nurse applied an ice pack to the resident's forehead. -On 9/16/11, at 3:20 P.M., the staff assisted the resident to the wheelchair, according to the aides the resident had been in the wheelchair minutes before the incident. The nurse notified the physician of the incident. The resident's had "fixed pupils". The resident had a large raised hematoma (collection of blood trapped in the tissues of the skin, resulting from trauma) on the forehead. -On 9/16/11, at 3:40 P.M., the nurse notified the resident's family of the incident. The raised hematoma on the forehead was now the size of a small apple. -On 9/16/11, at 5:20 P.M., the nurse assessed the resident as alert, speech clear. The resident's neurological checks were without incident, except for the "normally fixed" pupils. Record review of the fall investigation, dated 9/16/11, showed the following information: -The resident fell in the resident room and staff found the resident on the floor between the room door and the bed. The resident lay on the left side with face facing head of bed. The resident sat in the wheelchair prior to the fall. The resident had a chair alarm, but the alarm did not go off. Staff did not document why the alarm did not sound. -The investigation did not include the time of the fall or any interventions changed or added to attempt to prevent another fall of the resident. Record review of the individual resident accident report, showed on 9/16/11, at 3:05 P.M., the resident had a fall and sustained a bruise to the forehead. The resident's right upper extremity remained in sling and the resident's bed alarm was on. Record review of the POS showed on 9/16/11, the physician ordered to not send the resident to the emergency room unless the resident had signs and symptoms of concussion or other injuries in the next 72 hours. Record review of the nurses' notes, showed the following information: -On 9/17/11, at 9:25 A.M., the nurse documented the resident had bruising noted to the face and eyes. Resident complained of his/her left forehead being "sore" when touched. -On 9/19/11, at 1:50 A.M., the nurse documented the resident had bruising to both eyes. -On 9/19/11, the fall team minutes showed staff found the resident on the floor on 9/16/11 at 3:05 P.M. The resident had large bruise to the left forehead. The resident was alert and talkative. The resident's vital signs were within normal limits. The resident has a chair and bed alarm. The resident had increased confusion in the past two weeks. During an interview on 10/5/11, at 4:50 P.M., the MDS coordinator said regarding the 9/16/11 fall, the bed and chair alarm were still in place and staff did not change any interventions after the fall. Record review of the monthly nursing summary, dated 9/20/11, showed the following information: -Alert, staff did not assess the resident's orientation; -Emotional: friendly, anxious at times, cooperative interferes with cares at times. -Ambulation: wheelchair, bed or chair bound. The resident's last fall was on 9/16/11. -Staff did not document any safety devices or alarms in place. -The nurse documented on the narrative on the back of the summary, the resident continued to have problems with falls. The resident's last fall was on 9/16/11. The resident hit his/her head. No other injuries noted. Staff continues to assist the resident with ADLs with much encouragement. The resident can be uncooperative at times. -Staff assessed the resident's fall risk at a score of 2. A score of 2 indicated no fall interventions needed. Staff marked the resident used an assistive device and had fallen in the past 30 days. Staff did not mark the resident for cognitive impairment, depressed, or upset. The nurse did not mark the resident for arthritis. The nurse did not mark the resident for a fall in the past 31-180 days. Observation and interview on 9/27/11, at 7:50 A.M., showed the resident sat in the wheelchair in the doorway of the resident room. The resident's face had green/yellow, and purple bruising all over the front. The resident said he/she fell hard on his/her head. At 7:52 A.M., staff brought the resident's breakfast into the room. The aide said he/she guessed the resident sits at the restorative table so the staff can help the resident, but the resident refused to go to the dining room that morning. At 8:02 A.M., the resident seemed confused and did not eat. The resident moved the silverware around the plate and tray and took a bite of food. At 8:45 A.M., the resident had eaten 100% of the breakfast. At 9:12 A.M., the activity director invited the resident to the exercise activity. The resident said, "I can't hear". The director offered to sit the resident close where he/she could hear. At 9:20 A.M., certified nursing assistant (CNA) R entered the room and told the resident he/she needed to change the resident's pants. The resident sat in the wheelchair and talked about getting "stitches back". The aide wheeled the resident to the bathroom. The resident did not want to change the pants because they were okay. The resident said, "I brushed off most of it". The resident said, "My vision is so bad. I'm not going to change my pants; it is too tiring to change clothes all the time. I will change them in the morning". At 10:54 A.M., CNA P said the resident had been getting more confused lately, probably the last week or so. The resident was [AGE] years old. The resident had lived at home alone and had a garden. The resident fell at home and fractured his/her humerus and came to the facility. The resident has been here pretty much ever since. The resident was trying to go home, but with the confusion, he/she cannot. The family is very involved with the resident. They come every day and check on the resident. Right now, the staff can hardly get the resident to come out of the room. The resident can eat without staff assistance, but it is not good for the resident. It probably does not help with the confusion. Now, the resident is telling me that he/she does not have a good relationship with his/her family. Observation and interview on 9/27/11, at 11:43 A.M., showed the assistant director of nursing (ADON) and licensed practical nurse (LPN) C entered the room and told the resident they needed to take the resident to the bathroom. The resident said he/she needed to use the bathroom. The staff assisted the resident to the toilet. The resident asked, "How do I find my personal things?" The resident's wheelchair seat had a pressure pad alarm in it. Observation on 9/28/11, at 10:43 A.M., showed the resident lay in bed on his/her left side. The resident did not have a low bed. During an interview on 10/06/11, at 4:40 P.M., RN DD said Resident #4 has a regular bed in the lowest position, alarms, and the same wheel chair. The resident is confused, has dementia, and doesn't follow directions. During an interview on 10/4/11, at 10:03 A.M., the ADON said the resident did not have any decline or change in condition after 7/19/11. The resident had more cognitive issues at times. The resident transfers self back into bed from the wheelchair. During an interview on 10/4/11, at 4:44 P.M., the director of nursing (DON) said the resident admitted to the facility with decline in cognition. The resident's change in cognition is sporadic. When the resident first entered the facility, family hired a sitter because they did not want the resident left alone. The resident's agitation and confusion fluctuates a lot. The resident is going to do what he/she is going to do. If the resident wants to go, he/she will get up. Record review of the resident's care plan on 10/5/11 showed staff did not add or change any interventions on the care plan to attempt to prevent another fall. During an interview on 10/5/11, at 4:50 P.M., the MDS coordinator said sometimes, the physician writes an order for [REDACTED]. It makes it easier to track if there is an order. The MDS coordinator reviewed the current care plan. The MDS coordinator said the care plan was written in April 2011. The old care plan, which would contain information prior to April 2011, was kept by another staff member. The DON completes the accident report. At this time, the bed and chair alarm currently remain in place. The resident does not have a low bed in place. 2. During an interview on 10/5/11, at 4:50 P.M., the MDS coordinator said bed and chair alarms are pressure alarms that staff start on all residents at admission for the first 72 hours. If the resident is alert and oriented, then it is re-evaluated and discontinued if the resident is not at risk for falls. Staff assesses all new admissions for fall risk. Based on the assessment, staff follows the admission fall risk guidelines. The fall risk assessments are updated on a monthly basis. Staff would follow the guidelines of interventions on the fall risk assessment. 3. Record review of Resident #3's admission nursing assessment, dated 3/4/11, showed the following information: -Alert and oriented; -No elopement (attempt to leave the building) risk; -No wander guard (device to alert staff when resident attempts to leave building); -Staff assessed the resident's fall risk as a score of 4. A score of 4 indicated minimal risk for falls. Staff marked the resident used an assistive device, took diuretics, and hypotensive medication, had depressed and upset mental status, and fell in the past 30 days. -The nurse initiated the use of a bed and chair alarm as fall prevention interventions put into place based on the fall risk assessment score. Record review of the physician order [REDACTED]. Staff to check the functioning of the alarm every week. Record review of the resident's care plan, dated 3/18/11, showed the following information: -History of stroke with right-sided weakness; -Chronic knee and leg pain related to severe osteoarthritis; -Pain interferes with mobility; -Risk for falls due to low endurance and poor balance with transitions; -Requires extensive assistance for dressing and ambulation in the corridor; -Limited assistance for bed mobility, transfers, toilet use, and personal hygiene; -Wander guard to alert staff of elopement attempts. Staff checks the functioning every week; -Bed and chair alarm to alert staff of rising unassisted; -On 4/6/11, staff added restorative services as ordered. Record review of the POS showed the following information: -On 4/6/11, the physician ordered the restorative program for exercise for strengthening and range of motion as tolerated, standing activities for balance three times a week for 12 weeks; -On 4/7/11, the physician ordered the resident to attend the restorative group exercise class three times a week for 90 days. Staff marked "discontinued" on unknown date; -On 4/7/11, the physician ordered wander guard to alert staff of elopement attempts. Staff to check the functioning of the alarm every week; Record review of the individual resident accident report showed the following information: -On 4/19/11, at 10:30 A.M., staff found the resident on the floor. The resident did not have any injuries. The resident's bed alarm did not sound. Staff applied a new sensor pad; -On 4/22/11, at 12:00 A.M., staff found the resident on the floor. The resident said he/she sat down to put on shoes. The resident's bed alarm sounded. Staff did not document any interventions changed or put into place to attempt to prevent another fall. During an interview on 10/5/11, at 5:35 P.M., the MDS Coordinator said she did not know if any intervention was changed after the 4/22/11 fall. Record review of the September 2011 POS, showed on 5/19/11, the physician ordered restorative nursing program three times a week for 90 days, focus program is upper extremities of both sides. Record review of the individual resident accident report showed on 5/22/11, at 10:40 A.M., the resident fell from the wheelchair in the north hallway. Staff did not document any further information or any change in interventions to attempt to prevent another fall. Record review of the fall team minutes, dated 5/31/11, showed on 5/22/11, at 10:40 A.M., an unidentified person brought the resident to the nurses' station. The resident had fallen out of the wheelchair in the hallway. The resident's chair alarm did not sound. The resident did not sustain any injuries. Staff did not document any changes in interventions to attempt to prevent another fall. Record review of the nurses' notes, dated 6/3/11, at 6:40 P.M., showed a CNA found the resident on the floor by the medication room. The aide said the resident had been on the left side, and then sat up into sitting position without staff assistance. The resident "hollering help me repeatedly". The nurse noted the resident's head was bleeding. The resident had a 3 centimeter laceration to the right forehead. The resident's lap buddy lay on the floor. The nurse cleansed the laceration and applied a pressure dressing. The nurse notified the physician and obtained orders to send the resident to the emergency room . The nurse notified the family of the fall with injury. At 9:50 P.M., the nurse documented the hospital admitted the resident due to hematoma behind knee and increased INR (bleeding time). Record review of the individual resident accident report showed on 6/3/11, at 6:40 P.M., the resident fell in the north hall. Staff found the resident on the left side with head bleeding. The resident took the lap buddy off. The resident admitted to the hospital for one night. Staff documented "seatbelt and low bed now". Record review of the POS, showed on 6/6/11, the physician ordered a seat belt while up in the wheelchair due to increased falls. Record review of the resident's care plan showed the following additions or changes: -On 6/6/11, staff discontinued the chair alarm; -On 6/6/11, staff added the waist restraint, release every two hours and as needed. Staff to review the restraint quarterly for the least restrictive device. During an interview on 10/5/11, at 5:35 P.M., the MDS Coordinator said on 6/6/11, the staff discontinued the chair alarm. Record review of the monthly nursing summary, dated 6/6/11 and 6/20/11, showed the following information: -Mental status: Alert and confused, changes often, poor memory, and wanders; -Emotional: anxious, noisy, easily upset, and interferes with cares; -Ambulation: wheelchair and uses safety devices; chair and bed alarm; -Staff documented the resident's last fall occurred on 4/19/11 (two other falls on 5/22 and 6/3/11); -Restraints: lap belt in wheelchair; -The nurse assessed the resident's fall risk as a score of 5. A score of 5 indicated the resident at minimal risk of falls. The nurse documented the resident used assistive devices, took diuretic and hypotensive (blood pressure) medications, had cognitive impairment, depressed, upset mood, and fell in the past 30 days. The nurse did not mark the resident as having osteoarthritis or having a fall in the past 31-180 days. This would have increased the resident's score to 7, which placed the resident at high risk for falls. A score of 7 would cause the initiation of the Falling Leaf Program. -The nurse documented in the narrative the resident sundowns (becomes more active in the evening hours) often and becomes anxious, resisting cares, yelling, and wandering. The nurse placed the resident in a low bed due to falls; -On 6/3/11, at 6:40 P.M., staff found the resident on the fall (floor). The nurse started fall follow-up charting. The resident sustained [REDACTED]. The nurse admitted the resident to the hospital related to hematoma behind the knee. On 6/4/11, the resident readmitted back to the nursing home. Record review of the pre-restraining assessment, dated 6/6/11, showed the following information: -Alert to name, short attention span, and disoriented; -Balance when sitting: falls forward and slides down and slumps in chair. At times, recovers balance when leaning forward; -Ambulation: unsteady on feet, loses balance, history of falls, leans forward, and can propel self with feet in wheelchair. -The interdisciplinary team recommended waist restraint while in the wheelchair. The resident has had several falls. A lap buddy had been attempted and was not successful. The resident removes it and attempts to stand. -The resident was currently on restorative program. Record review of the individual resident accident report showed on 6/21/11, at 9:10 P.M., the resident crawled out of the low bed onto the landing mat. Record review of the fall team minutes, dated 6/27/11, showed on 6/21/11 at 9:10 P.M., the resident crawled out of the low bed. The resident did not have any injuries. The resident had increased agitation. The resident's vital signs were within normal limits. The team documented "bed alarm". The team did not document any change in interventions to attempt to prevent another fall. Record review of the individual resident accident report showed on 6/27/11, at 3:15 P.M., staff found the resident sitting on the floor mat by the low bed. Staff did not document any change in interventions to attempt to prevent another fall. Record review of the fall investigation, dated 6/27/11, showed the following information: -The resident fell in his/her room, facing the window on the floor mat. The resident sat with his/her back against the bed. -When the resident was asked what he/she tried to do at the time of the fall, the resident said, 'Trying to get jacket from the chair." Prior to the fall, the resident lay in bed. -Staff documented the resident had a chair alarm, but did not document any further information about the chair alarm; -Staff documented the resident had a bed alarm and the alarm did go off. -The resident had a low bed and a restraint ordered. -The investigation did not include the time of the fall or any interventions changed or added to attempt to prevent another fall. Record review of the fall team minutes, dated 7/5/11, showed on 6/27/11, at 3:15 P.M., staff found the resident on the floor by the bed (low bed). The resident's bed alarm sounded. The resident's vital signs were within normal limits. The resident did not have any injuries. The team did not document any interventions changed to attempt to prevent another fall. Record review of the individual resident accident report showed on 7/5/11, at 9:55 P.M., the reside

Based on observation, interview, and record review, the facility failed to effectively address the weight loss of three residents (Resident #2, #3, and #6). All three residents experienced a severe weight loss in a short period of time and staff did not implement interventions according to their weight loss protocol, acceptable nursing practices and resident preferences. The facility also failed to provide the needed feeding assistance to ensure residents ate as much as possible. Fourteen residents were sampled in the facility census of 84. Federal guidelines for suggested parameters for evaluating significance of unplanned & undesired weight loss are: Significant Loss: 1 month 5% 3 months 7.5% 6 months 10% Severe Loss: 1 month = greater than 5% 3 months = greater than 7.5% 6 months = greater than 10% Record review of the facility's weight loss protocol, dated 10/00, showed the following information: -Purpose of policy is to monitor and provide intervention to residents that are a weight loss, or at risk for weight loss, and to review them weekly in the team meeting; -The staff will weigh residents upon admission or readmission, within 24 hours of admission, weekly times four, and monthly thereafter. Weekly weights will continue as long as the resident meets any focus criteria. Weights over/under 5 pounds difference from prior weight will be re-weighed. -Focus criteria included: residents with significant weight loss as described by the RAI (Resident Assessment Instrument - federal assessment guidelines) guidelines; residents with trend of weight loss, such as decrease in weight 3 consecutive weights; residents under ideal body weight unless documentation reflects acceptable reason, such as history of low weight. -The weight loss team will visit with resident and/or family to determine possible reason for loss, if appropriate; review the medical record, initiate food acceptance record and monitor its completeness and accuracy; -The weight loss team will discuss and determine appropriate interventions based on need and resident preferences, if possible, to be obtained by the director of nursing (DON). -Examples of interventions included: high calorie snack, medication pass supplement, super cereal, supplement at meals, speech therapy referral, occupational therapy referral; -The physician is informed of the weight loss, interventions, and recommendations, and his suggestions and order; -Residents referred to the weight loss team will continue to be discussed until a weight gain is obtained for 3 consecutive weights. 1. Record review of Resident #3's admission nursing assessment, dated 3/4/11, showed the following information: -Admission weight 146 pounds; -Alert and oriented; -Regular diet with no supplement. Record review of the resident's nutritional assessment, completed by the registered dietitian (RD), dated 3/14/11, showed the following information: -The resident's food intake meets 75-100% of the resident's estimated needs. The resident's weekly food intake was 50-100%. The resident is a fussy eater. -The RD documented the resident as alert and oriented; -The resident received the diuretic [MEDICATION NAME] (rids the body of excess fluid); -The resident was medically stable before admission. The resident is at the facility for rehabilitation due to leg pain; -The resident has decreased functional abilities; -The resident eats independently with adequate chewing and swallowing abilities. -The resident is at moderate risk for nutritional problems. Record review of the resident's care plan, dated 3/18/11, showed the resident as independent with meals. Record review of the quarterly nutrition assessment, dated 5/18/11, showed the following information: -Gradual weight loss with no significant changes; -Regular diet; -Food intake less than needs level (calculated caloric intake to meet needs) though weight loss may benefit the resident due to [MEDICAL CONDITION] (OA) knee problem and continued pain; -The resident receives the diuretic [MEDICATION NAME]; -The resident's functional abilities declined due to knee and OA pain; -The resident self propels the wheelchair; -The resident is oriented with increased confusion, possibly medication induced; -The resident does not have any difficulty with the regular diet. -The resident feeds self with no adapt aids. -The resident remains unstable medically and some declined function with no significant weight loss. The resident is nutritionally unstable and is a moderate risk of nutritional problems. The resident refuses a mechanical soft diet. The RD documented to continue the current plan of care and routine monitoring. -The facility had a care plan conference with family in attendance, discussed weight issues with the gradual weight loss. The family agrees the resident is a picky eater and the facility's food is not like the resident's usual. The resident likes fried foods and country style. The resident had a nine pound weight loss since admission, which is non-significant. The family is satisfied with this. The family agreed to bring in favorite foods and treats. No other problems noted. Record review of the resident's significant change MDS assessment, dated 5/24/11, showed the following information: -Severe cognitive impairment; -Required extensive assistance for transfers, dressing, personal hygiene, and toilet use; -Required supervision with set-up help only for eating; -The resident weighed 137 pounds. The facility documented the resident did not have a weight loss of 5% or more in the last month or a loss of 10% in the last 6 months. Record review of the nurses' notes, showed the following information: -On 6/3/11, at 9:50 A.M., the nurse documented the resident choking on liquids at breakfast and pocketing food. The nurse obtained an order for [REDACTED]. -On 6/9/11, at 1:30 P.M., the nurse documented the resident's diet changed to mechanical soft per speech therapy recommendation. Record review of the nutrition orders, dated 6/9/11, showed staff wrote an order change to mechanical soft diet. Record review of the nurses' notes, showed the following information: -On 6/14/11, medicare team meeting documentation showed the resident received speech therapy four times a week due to moderate pocketing on the left side. -On 6/14/11, the nurse documented the resident's diet change to mechanical soft with nectar thick liquids. Record review of the monthly nursing summary dated 6/6/11 and 6/20/11, showed the following information: -Mental status: Alert and confused, changes often, poor memory, wanders; -Emotional: Staff documented the resident as anxious, noisy, easily upset, and interferes with cares; -Eating habits: The resident usually had a poor appetite and ate with assistance. The resident ate in the dining room. The resident did not have [MEDICAL CONDITION] (accumulation of excess fluid in dependent areas such as the feet and ankles). The nurse documented the resident had a 3 pound weight loss from April 2011. On 6/3/11, the resident choked on food and staff moved the resident to the assistive dining table. On 6/14/11, the physician changed the diet to mechanical soft and nectar thick liquids. Record review of the physician's progress note, dated 6/28/11, showed the following information: -Resident was admitted in March for pain control. Nursing staff reports pain is well controlled; -However, the resident's confusion has increased and the family is struggling with the resident's mental status. The family is disappointed, but understands this is probably due to the medication to control his/her pain. -The resident is not alert or oriented to person or place. The resident does not answer questions when asked. Record review of the monthly weight and vital sign sheet, dated 2011, showed the resident weighed 136 pounds in June 2011. The resident weighed 120 pounds in July 2011. Staff checked the weight twice. The resident lost 16 pounds in one month. The resident had an 11.7% weight loss in one month. Record review of the resident's significant change MDS assessment, dated 7/6/11, showed the following information: -Short and long term memory problem; -Severely impaired decision-making skills; -The resident did not exhibit behaviors of rejecting care; -Total dependence on staff for bed mobility, transfers, toilet use, and personal hygiene; -Required supervision with set-up help only for eating; -[DIAGNOSES REDACTED]. -Height of 64 inches; -The resident weighed 120 pounds. -The facility staff documented a weight loss of 5% or more in the last month or loss of 10% in the last 6 months and was not on a physician-prescribed weight-loss regimen. -The resident received a mechanically altered diet. Record review of the Altered Nutrition Status (ANS) committee notes, dated 7/6/11, showed the following information: -Significant weight loss within one month; -Change in cognition; -Family advised of weight changes; -The staff documented interventions as dependent dining and hospice consult. Record review of the monthly nursing summary, dated 7/6/11, showed the following information: -Mental status: alert and confused, changes often, poor memory, wanders; -Emotional: anxious, noisy, easily upset, hostile frequently, and interferes with cares; -Eating habits: Usually good appetite. The resident eats in the dining room and staff checkmark assistive feeding devices, but did not specify the type. The resident did not have [MEDICAL CONDITION]. The nurse documented in the narrative the resident was very confused and gets very active when in bed. Record review of the resident's care plan, showed the following interventions: -On 7/6/11, staff added hospice services for the resident; -On 7/7/11, staff added the following interventions of required supervision and set-up for meals. Record review of the ANS committee documentation, dated 7/12/11, showed the following information: -Significant weight loss within one month; -Change in cognition; -Family advised of weight changes; -Hospice care accepted; -Continue current plan of nutrition care. Record review of the resident's care plan, showed the following problem and interventions added on 7/13/11: -High risk for alteration in nutrition and hydration related to chewing and swallowing problems, decreased self feeding, and low hemoglobin (part of the red blood cell that carry oxygen); -See meal ticket for meal requirements; -Provide relaxed social environment for dining; -Offer substitutes when intake is less than 25%; -Provide assistance for total feeding; -Provide fresh water to bedside. -Provide medications and monitor tolerance; -Routine nutrition assessments. Record review of the nutritional assessment, completed by the RD, dated 7/13/11, showed the following information: -Greater than 5% weight change in one month; -Meets 26-75% of estimated nutritional needs. Oral intake not tracked; -Fluid intake not tracked; -The resident receives the diuretic [MEDICATION NAME]; -The resident had depression and dysphagia (difficulty swallowing); -The resident had increased confusion. The confusion may possibly be related to medication, though it is possibly related to mental status decline; -The resident has chewing and swallowing problems; -The resident is bedridden; -The resident is dependent with feeding and is an aspiration (choking - foreign substance such as food enters the airway) risk. -The resident's functional ability has declined; -The resident is at high risk for nutritional problems; -The RD documented a significant change assessment and that the resident admitted to hospice services. The resident is at high nutritional risk related to significant weight loss within one month. The resident has dysphagia, choking and pocketing food within one month. The resident is not able to follow commands for speech therapy treatment. The resident's pain medication may contribute to the confusion and decreased feeding abilities. The resident has functional declines noted. The plan of care included: mechanical soft diet with nectar thick liquids, dependent dining with assistance at meals, allow choices for meal options when possible. Also, medications changed per hospice. The RD documented follow-up quarterly or as needed. Record review of the monthly weight and vital sign sheet, dated 2011, showed the resident weighed 111 pounds August 2011. This was a nine pound loss from the previous month. This was a 7.5% severe weight loss in one month, or a 18.3% severe weight loss in the previous two months. Overall, the resident experienced a 23.9 % severe weight loss in the five months since admission. Record review of the monthly nursing summary, dated 8/6/11, showed the following information: -Mental status: Alert and confused. The resident wanders; -Emotional: The resident interferes with cares. The resident is anxious, noisy, easily upset, and hostile frequently. -Eating habits: The resident usually had a good appetite, eats in the dining room, and staff check marked assistive feeding devices, but did not specify what type of devices. The resident had a regular diet. The resident did not have [MEDICAL CONDITION]. On 8/6/11, the nurse documented the resident admitted to hospice services. The nurse documented the resident continued to require total assistance with ADLs. Record review of the ANS committee documentation, dated 8/9/11, showed the following information: -Monthly trigger of 8% in one month and 19% in 3 months; -Big declines recently, the resident currently in hospice care; -Interventions documented were mechanical soft diet and nectar thick liquids; -[MEDICATION NAME] and [MEDICATION NAME] (narcotics) for pain control for one month; -Declining intake; -Weight loss with [MEDICAL CONDITION]; snacks as needed; -Family brings in food; -Will not pick up. (The committee will not follow this resident with weekly weights and monitoring.) Record review of the monthly weight and vital sign sheet, dated 2011, showed the resident weighed 106 pounds in September 2011. This represented another five pound weight loss for the month. The resident had another 4.5% weight loss in one month or a 27.3% weight loss in six months. Record review of the monthly nursing summary, dated 9/6/11, showed staff documented the resident as alert and confused, and cooperative. Staff documented the resident usually had a good appetite and ate with assistance and fed self. The resident's diet was mechanical soft and the resident had nectar thick liquids. The resident did not have [MEDICAL CONDITION]. On 9/6/11, the nurse documented the resident has had no major change in condition. On 9/9/11, the nurse documented the resident had [MEDICATION NAME] treatment due to 2+ [MEDICAL CONDITION]. Record review of the ANS committee documentation, dated 9/8/11, showed the following information: -Significant weight loss in 3 and 6 months related to rapid declines in cognition and function leading to comfort care only. Weight loss expected; -Interventions documented were hospice, will not pick up. Record review of the occupational therapy (OT) screen, dated 9/20/11, showed the resident referred to OT due to need for adaptive equipment. The resident feeds self with fingers. The comments/summary section noted brown left handle, curved built-up handle fork. Staff needs to scoop food, and then put hand over handle, resident will put it in his/her mouth. Record review of the nutrition orders, dated 9/20/11, showed the therapy staff wrote an order for [REDACTED]. Observation on 9/26/11, at 12:25 P.M., showed the resident eating a roll. The resident held a fork. The resident did not have any drinks at the table. The resident picked up a bowl of pudding and started eating with a fork. Staff did not assist or cue the resident. At 12:43 P.M., the resident ate 100% of the pudding and half of the roll. Staff did not assist the resident with eating. The resident did not have any special adaptive silverware. Observation on 9/27/11, at 12:55 P.M., showed the resident in the dining room. The resident ate ice cream with a regular spoon. The resident did not have the adaptive fork or spoon. At 12:59 P.M., staff asked the resident if he/she wanted more ice cream. The resident said, yes. The resident picked up a glass of orange juice and drank some of it. At 1:03 P.M., the staff assisted the resident to eat ice cream. At 1:04 P.M., the resident picked up the orange juice and took a drink. The staff asked the resident if done. The resident said it was too cold on his/her throat. The staff began to assist another resident. At 1:06 P.M., the resident began to eat ice cream without staff assistance. The resident took one bite. The resident began to try to eat the ice cream with his/her fingers. Staff assisted the resident to find his/her regular spoon. The resident took one bite and sat the ice cream down. Observation on 9/28/11, at 7:52 A.M., showed the resident in the dining room. The resident ate a bowl of Malto meal. The resident had the special adaptive silverware. At 8:00 A.M., the resident had not eaten any food on the plate, which included biscuits and gravy. The resident drank all of the orange juice and most of the milk. At 8:07 A.M., the resident tried to drink more orange juice, but the glass was empty. Staff did not assist or cue to the resident to eat or drink, or obtain more orange juice for the resident. At 8:17 A.M., the resident sat in the dining room and did not eat or drink anymore food or drink. Staff did not assist the resident to eat or drink. At 8:20 A.M., staff wheeled the resident out of the dining room. Observation on 9/29/11, at 12:17 P.M., showed the resident sat in the Geri-chair in the dining room. The resident had chicken pot pie, roll, beets, and a bowl of tapioca pudding. The resident had red juice and apple juice. The resident had regular silverware, not the special adaptive silverware. At 12:19 P.M., the resident did not eat. Staff did not assist or cue the resident to eat. At 12:24 P.M., the resident continued without staff assisting or cueing the resident to eat. At 12:27 P.M., the resident picked up the fork and put it in his/her mouth. At 12:27 P.M., the resident scooped up a bite of beets and took a bite. At 12:31 P.M., the resident picked up the fork and took a bite of beets. At 12:35 P.M., the resident ate a bite of beets. At 12:35 P.M., the Certified Feeding Assistant (CFA) called out the resident's name. The CFA sat diagonally across the table from the resident. At 12:38 P.M., the resident picked up the roll and took a bite. At 12:42 P.M., the resident held the roll and took small bites of it. At 12:47 P.M., the resident sat the roll down. At that time (approximately 30 minutes after the resident received his/her lunch), the CFA went to the resident and asked how lunch was going and asked if the resident had tried the pudding. The resident placed his/her fingers in the pudding. The CFA handed the resident a regular spoon and the resident took a bite of pudding. The CFA asked the resident if he/she wanted a bite of chicken pot pie. The CFA offered a bite to the resident. The resident said, "Ah, don't want that!" The CFA left the table. The resident picked up the glass of apple juice and held it to his/her mouth. At 12:56 P.M., the CFA came to the resident and asked how lunch was going. The resident said he/she, "Did not want any of it, its cold!" The CFA did not heat the resident's food or obtain different food for the resident. The CFA offered the resident yogurt. The resident did not respond. The resident scooped up beets with the spoon. The CFA left the resident and went to assist another resident. At 12:58 P.M., the resident picked up the roll and sat the juice glass in the pudding. The resident took a bite of the roll. The CFA came to the resident and took the juice out of the pudding. At 1:00 P.M., the resident took a bite of the roll. The CFA came to the resident and the resident said he/she "liked the bread". The CFA sat by the resident. The resident held the roll and looked out the window. The CFA offered the resident a bite of beets. The CFA asked the resident if he/she wanted more beets. The resident nodded his/her head and said, yes. The CFA gave the resident two more bites of beets. The resident continued to hold the roll in the left hand. The CFA offered juice to the resident. The CFA assisted the resident to get more beets on the spoon. At 1:10 P.M., the resident said, "I got it," and took a bite of beets. At 1:11 P.M., the CFA asked the resident if he/she wanted more beets. The resident opened his/her mouth. At 1:12 P.M., the CFA assisted the resident with the final two bites of beets. At 1:14 P.M., the resident continued to hold the roll in his/her hand. The resident took a bite of the roll. The CFA offered a drink of juice. The CFA encouraged the resident to eat the roll. The CFA asked the resident, "Are you finishing up?" The CFA asked the resident if he/she wanted some of the pot pie now. The CFA asked the resident if it was cold. The resident said, yes. The CFA asked the resident if he/she was done and if he/she wanted to go back to his/her room. At 1:25 P.M., the resident ate the roll. The CFA asked if wanted the apple juice before he/she left the dining room. The CFA asked the resident if he/she was ready to leave. The resident said, "No!" The resident leaned forward in the Geri-chair. At 1:28 P.M., the CFA reclined the Geri-chair back and wheeled the resident out of the dining room. The resident sat in the dining room for over an hour and had only eaten the beets and the roll from his/her lunch. Record review of the quarterly nutrition assessment, dated 9/30/11, showed the following information: -Mechanical soft diet with nectar thick liquids; -The resident's oral intake is less than needs as evidenced by significant weight loss. Food and fluid intake not tracked. The resident did not receive a supplement; -The resident receives the diuretic [MEDICATION NAME]; -The resident had decline in his/her functional abilities through the quarter with increased falls and declined speech. The resident did not have problems with the mechanical altered diet and nectar-thick fluids. -The resident is dependent for feeding, but may feed self; -The resident has adaptive aids of Geri-chair and seat belt; -The resident is nutritionally unstable and is at high nutritional risk related to inadequate intake. The resident remains on palliative care; -Continue current plan of care; -The RD recommended a between meal supplement; -The resident has [MEDICAL CONDITION] related to prolonged pain, advancing dementia, and mental changes. The resident has declined speech and cognition. The resident has chewing and swallowing problems. The current interventions include mechanical soft diet with nectar thick liquids, dependent dining, assist and supervise as needed. Food and water is offered but allow the resident to refuse foods. Allow choice where possible. Family will bring in food, favorites and specials that the resident prefers. The RD recommended a house supplement between meals and will offer the recommendation to family at the care conference. The RD will follow-up quarterly or as needed. Record review of the resident's care plan, showed staff added the following problem and interventions on 9/30/11: -Significant weight loss due to inadequate intakes; -Offer food and fluids for meals and between as needed; -See meal ticket for mechanical soft diet and nectar liquids; -Family will bring in favorites and special foods; -Allow to refuse food and fluids; -Allow to self feed, though assist up to total feeding; -Goals included: maintain weight at 106 pounds plus/minus five pounds; fluid balance; allow control over oral intakes; weight loss anticipated. During an interview on 10/5/11, at 5:35 P.M., the Minimum Data Set (MDS) coordinator said the Registered Dietitian (RD) adds the weight loss interventions to the care plan. The MDS coordinator said he/she adds interventions like, no straws, thickened liquids, or adaptive equipment. The RD adds items to the care plan like supplements or changes in the diet. Record review of the physician order [REDACTED]. -On 6/15/11, the physician ordered mechanical soft diet with nectar thickened liquids with food, thin liquids permitted without food. -On 8/12/11, the physician ordered [MEDICATION NAME] 20 mg every day. Record review of the OT therapy screen, dated 9/20/11, showed staff noted at the bottom of the form the following information, "Discovered on 10/4/11 that this order was added to another resident's meal notes. Human error, corrected on discovery". During an interview on 10/3/11, at 5:59 P.M., the director of nursing (DON) and the administrator said they would expect a note to say the resident triggered for weight loss, but they discontinued the resident off weekly weight monitoring. The resident was removed from the weight list. If the facility had been monitoring the resident, interventions would be put in place. The facility placed the resident on hospice services so there was nothing else to do. The resident continued to lose weight. On 7/6/11, the weight loss team noted significant weight loss and moved the resident to dependent dining. When asked about changes in the resident's condition, the administrator said the resident had been to the emergency room for several transient ischemia attacks (TIA, small [MEDICAL CONDITION]) after admission to the facility. The resident had cognitive decline. The resident bounces around. The resident has declined in the last 30 days and sits at an assist table. When questioned how much assistance the resident requires for eating, the DON and administrator described the different tables that identified the amount of feeding assistance a resident needed. The administrator and the DON said the resident sat at the "feeder table" and is more total assistance. The weight team determines when weekly weights are stopped for a resident. The DON said, upon reviewing the medical record, she did not see any interventions or supplements attempted for the resident to address the weight loss. The DON said she would look further for interventions attempted to address the resident's weight loss. During an interview on 10/5/11, at 11:05 A.M., the RD said the resident just came up for quarterly review. The resident entered the facility as a different person, pretty vocal, pretty set. When the resident was admitted in March 2011, the resident was brand new to her. On 3/22/11, the resident was nutritionally stable. The resident was here temporarily, but got worse and worse. The resident always disliked the facility's food. The resident liked fried chicken. The facility offered different foods and the resident said he/she was not eating. The resident refused the mechanical soft diet at one point. When the resident was losing weight, the family was very involved. The RD said she had numerous contacts with the family and the family would offer the resident any foods that he/she might eat. Approximately in May 2011, the facility encouraged the family to bring in food. The facility had a care plan conference and that is when the resident started to lose weight. The resident had lots of changes, cognitive decline, not able to talk, garbled speech, losing thoughts. The resident became meaner verbally and was hateful. The family said the resident requested a food item and the family brought it in the next day and the resident would not eat it. The RD said she left it in the family's hands in May 2011. The RD said she just left it at that. The resident was "hands-off" to her. The facility tried different interventions, not food, but functional adaptations. The resident had pain in his/her legs. The facility changed the resident's dining locations. The facility wanted the resident to be as independent as possible. The facility let the resident control his/her intake and just dealt with the functional issues, such as different staff assisting the resident, and seating at different tables. The resident is cognitively dependent. The resident is not feeding self and needed cues. The resident might accept feeding assistance from some staff. In July 2011, the facility worked on pain control, but also to keep the resident awake and alert. The RD was not sure when the facility moved the resident to the dependent dining table. In July 2011, the facility offered hospice services for assistance with pain control. The resident had a lot of behaviors that may have been related to pain. The altered nutritional status committee did not pick up the resident because the resident was losing weight and was resistant for everything. Hospice got involved and the family was very active in the resident's care. The resident is dependent for meals. The facility offers options, keep it lighthearted and try to keep the resident happy. Last week, the resident came up for quarterly review. The RD talked to the family. The resident is a new person, less responsive. The resident is losing weight. The RD asked the family if they wanted to try snacks. The family said they did not mind, but did not want that to interfere with the other foods the resident does eat. The RD said, in the past, they had offered multiple snacks, including Ensure (supplement). The ANS team did not document snacks or supplements tried. The RD said, she wrote on 10/4/11 for the resident to have house supplement at bedtime. The RD told the staff to offer Ensure, pudding, coke, candy bars. The RD reviewed her nutritional assessments completed since admission. The RD said the interventions the facility had tried were not well noted. The RD said the facility might have documented meal intakes, but she doubted it. The RD reviewed her notes further and said, the meal intakes were not monitored. Facility staff monitors weekly weights on residents who are monitored by the ANS. When the ANS notes say "not picked up", it meant the ANS team did not complete weekly weights and the ANS team did not monitor the resident weekly. The RD reviewed her weight records and said the facility staff monitored the resident's weights weekly in March, when first admitted to the facility. The weekly weights stopped in May 2011. 2. Record review of Resident #2's physician's admission orders [REDACTED] -[DIAGNOSES REDACTED]. -Mechanical soft diet; -Ensure (supplement) two times a day; -Weigh weekly for four weeks. Record review of a physician's orders [REDACTED]. Record review of the 2011 monthly weight and vital sign sheet, showed on 06/21/11 staff documented the resident weighed 109 pounds. Record review of the ANS committee notes, dated 6/22/11, showed the following information: -Weekly weight was 109 pounds; -RD assessment pending; -Nutritionally stable at his/her previous facility; -Interventions: ANS monitors resident for two weeks. Record review of the admission nutrition assessment, completed by the RD, dated 06/22/11, showed the following information: -Usual weight was 102-108 pounds; -Moderate nutrition risk related to decreased intake of food and liquids, and multiple medications; -Ate 80% of facility diet meets the resident's estimated needs; -Ate 25%-50% of meals; -Drank 25% of supplement; -Mechanically altered diet due to problems with swallowing and chewing; -Poor intake of the supplement between meals; -Changed supplement to Prostat (liquid protein) to increase protein for wound healing; -Follow-up in 14 days or as needed; -Addendum: The resident required assisted dining; -ANS committee to monitor the resident for two weeks. Record review of a physician's orders [REDACTED]. -Administer [MEDICATION NAME] 20 milligrams (mg) every day for five days, then, [MEDICATION NAME] 20 mg every day as needed for swelling; -Mechanical soft diet; -Discontinue Ensure two times a day due to poor intake; -Prostat 101 30 milliliters (ml) three times a day. Record review of the resident's admission MDS ass