Every finding on record at Myers Nursing & Convalescent Center

Based on observation, interview and record review, the facility failed to prevent physical abuse for two sampled residents (Resident #1 and Resident #2) out of four sampled residents. On 5/25/26 Resident #1 hit Resident #2 on the head. Resident #2 struck Resident #1 with an aluminum cane, the cane broke and resulted in Resident #2 having an approximately 2-inch pink, unbroken area on his/her left upper thigh. The facility census was 84 residents.The Administrator was notified on 6/2/26 of the past noncompliance which began on 5/25/26. The facility immediately completed education for staff for Abuse and Neglect. Resident care plans were updated. Both residents had medical and psychological evaluations. Resident #2's anxiety medication was increased. Resident #1 moved to a new facility. The deficiency was corrected on 5/26/26. Review of the facility's undated Abuse and Neglect Policy showed:-Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish.-Physical abuse was the use of physical force that might result in bodily injury, physical pain or impairment.-Physical abuse included punishing, slapping, hitting, shoving, striking with or without an object, pinching, kicking or burning.-Emotional or psychological abuse included verbal or nonverbal infliction of anguish, pain or distress that resulted in mental or emotional suffering, including demeaning statements, harassment, threats, insults, humiliation and intimidation. 1. Review of Resident #1's admission Record face sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses:-Major depressive disorder (a serious mood disorder characterized by a persistent feeling of profound sadness, hopelessness and loss of interest in activities).-Generalized anxiety disorde(intense, excessive and persistent worry and fear about every day activities).-Schizophrenia (a serious mental health condition that affects how people think, feel and behave). Review of Resident #1's quarterly Minimum Data Set (MDS- a federally mandated assessment completed by facility staff), dated 4/11/26, showed the resident was assessed as cognitively intact. Review of Resident #1's Care Plan dated 4/9/26 showed:-He/She had limited mobility and was able to walk with a cane.-He/She had impaired thought processes and cognitive function.-He/She did not have any documentation of physical aggression or behaviors prior to this incident, or related interventions. Review of Resident #2's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Paranoid schizophrenia (a severe type of schizophrenia characterized by delusions of persecution and unwarranted suspicion).-Schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms and mood disorder symptoms).-Post-traumatic stress disorder (persistent mental and emotional stress occurring as a result of injury or severe psychological shock).-Depression.-Anxiety disorder. Review of Resident #2's quarterly MDS dated [DATE], showed the resident was assessed as cognitively intact. Review of Resident #2's Care Plan dated 4/2/26 showed he/she did not have any documentation of physical aggression or behaviors prior to this incident, or related interventions. Review of the facility's investigation dated 5/25/26 showed:-An altercation between Resident #1 and Resident #2 occurred on 5/25/26 at approximately 6:33 A.M.-The incident was witnessed by Resident #3 who reported the incident to the charge nurse.-Licensed Practical Nurse (LPN) A, the charge nurse, responded and observed Resident #1 being struck twice with an aluminum mobility cane by Resident #2. -The residents were immediately separated and 911 was contacted.-Law enforcement responded to the facility and interviewed Resident #1.-Resident #1 declined to press charges and reported he/she was physically ok.-Both the night shift nurse and the day shift nurse attempted to complete skin assessments on Resident #1; however, he/she refused both assessments at the time. -The Administrator met with Resident #1 alongside the day shift nurse. The resident then agreed to be transferred to the Veteran's Administration (VA) for further evaluation and treatment if deemed necessary.-The Administrator also met with Resident #2 to obtain his/her account of the incident.-Resident #2 reported he/she was in the smoking room, and asked Resident #1 for a cigarette.-According to Resident #2, Resident #1 became verbally aggressive, cursed at him/her and struck him/her in the face. -Resident #2 said he/she defended him/herself and struck Resident #1 twice.-Resident #2 further stated that Resident #1 had used the aluminum mobility cane during the altercation and the cane broke during the incident.-Resident #1 confirmed he/she had only been struck twice and reported pain/discomfort to the upper portion of his/her left thigh. Review of Resident #1's Progress Notes dated 5/25/26 at 6:54 A.M. showed:-He/She was in the smoke room smoking a cigarette when he/she was assaulted by another resident.-He/She was witnessed being beat with a cane by another resident.-The nurse was able to stop the resident from being assaulted and separated the two residents.-The resident was told 911/police would be called.-The resident was told a skin assessment needed to be performed.-The resident stated, I'm ok for now, I think. I don't feel any pain or anything except for my leg, but I have had leg problems for a long time.-The resident also stated, Just leave me alone for a second so I can calm down.-No apparent injury noted to head, arms, chest or back at that time.-Unable to assess the resident's legs, hips and buttocks as the resident declined. Review of Resident #1's hospital Progress Notes dated 5/25/26 showed the radiology report of his/her thigh showed no fracture or misalignment. Review of a photograph taken on 5/26/26 of the resident's upper thigh showed an approximately 2-inch pink oval shaped area with a small darker center. There was no break in the skin. Observation and interview on 6/2/26 at 10:45 A.M. showed the Resident #2's had no marks, bruises or injuries to his/her head. He/she said: -Resident #1 hit him/her on the head twice. -The two residents were inside the smoking room. -He/She was standing, and Resident #1 was sitting. -Resident #1 called him/her a motherfucker. -He/She doesn't know why Resident #1 hit him/her. -Resident #1 hit him/her first. -Then he/she kicked their ass. -He/She held Resident #1 down with his/her foot.-He/She told Resident #1 he/she did not want to fight him/her. -He/She then walked away from the situation. -Nobody separated them. -He/She was defending him/herself. During an interview on 6/2/26 at 11:40B A.M., LPN B said:-He/She was working when the two residents got into the altercation. -That morning, he/she was at the nurses station and he/she was informed by another resident that this person is getting assaulted in the smoking room. -He/She went over there, and she saw Resident #2 hitting Resident #1 with the cane. -The cane snapped. -Resident #2 did not have a cane and did not use an assistive device. -The cane was not heavy like a wooden cane; it was light weight. -He/ She was able to get Resident #2 to stop. -Resident #2 said, he/she hit me first. -He /She asked Resident #2 why he/she didn't come tell him/her that. - Resident #2 left out of the smoking room. -He/She saw Resident #2 hit Resident #1 on his/her leg. -He/ She got Resident #1 up. -Resident #1 said Resident #2 started hitting him/her for no reason. -He/She asked Resident #1 if it was about cigarettes.-He/She has never seen these two residents being aggressive. It was a total shock to him/her. -He/She had never known either resident to have behaviors-He/She did not remember who else was in the smoke area at the time. -Resident #3 was the resident who told him/her what was going on. -Resident #1 would not allow a skin assessment; he/she said he/she was ok. -He/She did not see anything on Resident #1s face or his/her head, arms or hands. -Resident #2 did not have any visible injuries. During a telephone interview on 6/2/26 at 1:00 P.M, the Psychiatric Nurse Practitioner said hitting was considered abuse, but he/she did not feel like it was abuse in this case. Review of Resident #3's admission Record face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's quarterly MDS dated [DATE], showed the resident was assessed as cognitively intact. During an interview on 6/2/26 at 1:30 P.M, Resident #3 said:-He/She did not see what happened before he/she arrived at the smoke room. -He/She went to smoke and saw Resident #2 standing over Resident #1 and the cane was broken. -He/She went right away to get the nurse. During an interview on 6/2/26 at 2:40 P.M., the Administrator said:-He/She did not feel this incident was preventable or predictable. -He did not feel that it was intention of either resident to harm the other as far as abuse. -He/She did not save the cane because it was broken. It was thrown out.-Resident #2 had no injuries or marks. -Resident #1 just had the red mark on his/her leg. The photograph of the mark was taken the day after the altercation, when the resident allowed staff to assess him/her. -Resident #1 transferred to a new facility on 5/28/26 per guardian's wish to have him/her out of the neighborhood. During a telephone interview on 6/5/26 at 1:30 P.M., the resident and LPN D said:- The resident did not have any marks on his body during his/her admission assessment, and he/she did not appear to have any injuries.-The resident said he/she did not want to get anyone in trouble. -The resident got agitated and did not want to discuss it further and said to hang up the phone. Incident 3022707

Based on observation and interview, the facility failed to maintain the cleanliness in the kitchen there was dust build up on the overhead piping systems and exit sign that were over the preparation serving area, dust built up on the two big blue and black fans, the floor and wall behind the gray grease trap box under the three compartment sink had dirt and debris, the stove knobs that turn the burners on had residue built up on them, and the walk-in cooler had dust on the fan and there was debris on the floors. The floors under the refrigerators, eye was station, and stove had missing tiles and needed to be repaired. The ice machine tray that collects the overflow of ice and water had brownish/reddish debris all over it potentially mold and where the ice and water come out there was black spots on the inside and out of it potentially mold and there were some black spots in the white plastic reservoir at the top of the machine. This practice potentially affected all 78 residents. The facility census was 78 residents.Observations and interview during the initial walk-through 10/7/25 9:55 A.M., showed:-Food debris and debris on the floor of the walk-in cooler under the shelves. -Dust on the fans of the walk-in cooler. -The Dietary Supervisor said the walk-in cooler was cleaned every Tuesday before the truck comes in on Wednesday. Observations and interview during the lunch meal preparation on 10/8/25 from 10:00 A.M. through 1:00 P.M., showed:-Dust on the pipes and exit sign above preparation serving area.-Dust on the two blue and black fans.-Dirt and debris on the floor and wall behind the gray grease trap box under the three-compartment sink.-The stove knobs that turn the burners on had residue built up on them. -The floors under the refrigerators, eye was station, stove, had missing tiles.-Dietary Supervisor said they are cleaned daily.Observation on 10/9/25 at 9:00 A.M. showed the ice machine in the South Hall ice machine tray that collects the overflow of ice and water had brownish/reddish debris on it. During an interview on 10/9/25 at 9:45 A.M. the Dietary Supervisor said housekeeping was responsible for the ice machines in the halls.During an observation and interview on 10/9/25 at 10:03 A.M., the Housekeeping Supervisor and Corporate Maintenance Person said:-Housekeeping oversees the outside of the ice machine and they would wipe it down daily.-Maintenance oversees the inside of the ice machine and it would be cleaned quarterly.-Maintenance opened the ice machine and the appearance of a black substance was on the plastic spout where the ice and water come out and in the white plastic reservoir above.

Based on observation and interview, the facility failed to do the following: maintain a fan in the activity area free from a heavy buildup of dust; failed to maintain one ceiling tile free of a black colored stain; failed to maintain the climate control unit in North resident room [ROOM NUMBER]-6 free from a dust buildup; failed to maintain the light fixture in North resident room free from a buildup of debris on the fixture; failed to maintain the handles of a shower chair in the North east Shower Room free from cracks which rendered those handles not easily cleanable; failed to maintain the ceiling vent in the restroom of resident room [ROOM NUMBER]-40, from a heavy buildup of dust; failed to maintain two sprinkler heads in the dining room free from a dust; failed to maintain a stand -up lift in the South [NAME] shower room free from a buildup of grime; failed to implement a system to monitor hot water temperatures to ensure that hot water in south resident rooms 11--12, 29-32, 15-16, and 19-20, would remain above 105 degrees F (degrees Fahrenheit) ; failed to maintain the floors in resident rooms South 29-32, South 19-20, and South 21-24, free of a grime buildup. This practice potentially affected at least 40 resident s who resided in or used those areas. The facility census was 76 residents.1. Observation on 10/7/25 at 11:51 A.M., with the Activity Director and the Corporate Maintenance Person, showed a heavy buildup of dust on the fan which blew air and dust across the main sitting area of the activity area in the basement.During an interview on 10/7/25 at 11:56 A.M., the Activity Director said he/she has been in the Activity Department since 6/24, and he/she has never seen the fan cleaned.2. Observation on 10/7/25 at 11:53 A.M., with the Corporate Maintenance Person and the Housekeeping Supervisor, showed the presence of a black substance on one ceiling tile in the room next to the pool table room.During an interview on 10/7/25 at 11:57 A.M., the Corporate Maintenance Person said the ceiling tile needed to be changed and there used be a leak at that location in the past.3. Observation on 10/7/25 at 12:13 P.M., with the Corporate Maintenance Person and the Administrator, showed a buildup of dust the climate control unit in North resident room [ROOM NUMBER]-6.During an interview on 10/7/25 at 12:13 P.M., the Administrator said the facility's plan was to replace the climate control units.4. Observation on10/7/25 at 1:08 P.M., with the Corporate Maintenance Person and the Housekeeping Supervisor, showed a buildup of dust and debris on the light fixture above one of the beds in resident room North 9-10.During an interview on 10/7/25 at 1:10 P.M., the Housekeeping Supervisor said the housekeeping staff was not cleaning on top of the light fixtures very well. 5. Observation on 10/7/25 at 1:20 P.M., with the Corporate Maintenance Person and the Housekeeping Supervisor showed the presence of cracked handles on the shower chair in the Northeast Shower room.6. Observation on 10/7/23 at 1:23 P.M., with the Housekeeping Supervisor showed a heavy buildup of dust inside of the ceiling vent in North resident room [ROOM NUMBER]-40.During an interview on 10/7/23 at 1:23 P.M., the Housekeeping Supervisor said he/she has only worked as a Housekeeping Supervisor for 3 months and the reason why the vents have not been cleaned, was related the absence of a regular maintenance person in 1 year and 3 months. 7. Observation on 10/7/25 at 2:59 P.M., with the Housekeeping Supervisor showed a buildup of dust on two sprinkler heads in the dining room.During an interview on 10/7/25 at 3:00 P.M., the Housekeeping Supervisor said the housekeepers have never cleaned the sprinkler heads.8. Observation on 10/7/25 at 3:22 P.M., with the Housekeeping Supervisor and the Administrator showed a buildup of grime on the base of the stand-up lift (a specialized medical devices designed to assist individuals with limited mobility in transitioning from a seated to a standing position) in the Southwest shower room.During an interview on 10/7/25 at 3:22 P.M., the Administrator said that the night shift staff members are mostly responsible for cleaning the lifts.9. Observations on 10/8/25 of the hot water temperatures showed the following: after the hot water was allowed to flow for 2 minutes or more:At 10:07 A.M., the hot water temperature in resident room South 11-12 was 91.9 FAt 10:15 A.M., the hot water temperature in resident room South 29-32. was 95.0 FAt 10:36 A.M., the hot water temperature in resident room South 15-16, was 82.4 FAt 10:46 A.M., the hot water temperature in resident room South 19--20, was 70.1 FAt 10:54 A.M., the hot water temperature in resident room South 19--20, was 98.8 FDuring an interview on 10/8/25 at 11:02 A.M. the Corporate Maintenance Person said there was a hot water pipe that was not turned off at a janitor's closet close to the smoke room and the constant flowing of the hot water caused less hot water to go to those rooms. During an interview on 10/9/25 at 11:19 A.M., the Housekeeping Supervisor said he/she had not heard of checking water temperatures until that survey.During an interview on 10/9/25 at 11:20 A.M., the Corporate Maintenance Person said he/she checked water temperatures about 3 months prior to the survey10. Observation on 10/8/25 At 10:15 A.M., with the Housekeeping Supervisor, showed the floor in south resident room [ROOM NUMBER]-32 had a buildup of grime and debris and the presence of a heavy buildup of dust on the blades of two fans in that room.During an interview on 10/9/25 at 2:07 P.M., the Housekeeping Supervisor said he/she had not thought about cleaning the fans before this survey. 11. Observation on 10/8/25 At 10:37 A.M., with the Housekeeping Supervisor, showed the presence of grime on the floor of South resident room [ROOM NUMBER]-28. 12. Observation on 10/8/25 At 10:46 A.M., with the Housekeeping Supervisor, showed the presence of grime and dust behind the beds in South resident room [ROOM NUMBER]-20. 13. Observation on 10/8/25 At 10:54 A.M., with the Housekeeping Supervisor, showed the presence of grime on the floor of South resident room [ROOM NUMBER]-24.

Based on observation, interview and record review, the facility failed to properly store respiratory continuous positive airway pressure (C-PAP is a machine that uses mild air pressure to keep breathing airways open while you sleep) mask when not in use for one sampled resident (Resident #13) and failed to ensure oxygen equipment, nasal cannulas nasal cannula (a device used to deliver supplemental oxygen through a plastic tube into the nose in a sanitary manner; a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) and tubing was kept covered when not in use for two sampled residents (Resident #45 and #72) out of 18 sampled residents. The facility census was 76 residents. Review of the facility Respiratory Care policy and procedure dated 2006, showed the purpose was to maintain the proper infection control technique when providing respiratory care to the residents. The policy showed:-All respiratory equipment shall be checked and cleaned daily/weekly and as needed.-There was documentation in the policy showing how respiratory equipment should be stored when not in use. 1.Review of Resident #45's Face Sheet showed the resident was admitted with diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung diseases that cause ongoing airflow obstruction and breathing problems). and emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 5/19/25, showed the resident:-Was alert and oriented but had cognitive loss.-Had shortness of breath when sitting, lying flat and any exacerbation.-Did not receive oxygen therapy during the lookback period. Review of the resident's Physician Order Sheet (POS) dated 10/2025 showed physician's orders for Oxygen 2 liters per nasal canula, as needed for shortness of breath. Observation on 10/7/25 at 10:38 A.M., showed the resident was laying on his/her bed. He/she was not wearing oxygen. There was an oxygen concentrator that was against the wall beside the resident's bed, and the nasal cannula and tubing was coiled around the concentrator, uncovered. Observation on 10/9/25 at 8:15 A.M., showed the resident was outside in his/her wheelchair without oxygen on. In his/her room was his/her oxygen concentrator with the nasal cannula coiled around the concentrator, uncovered. Observation and interview on 10/9/25 at 9:20 A.M., showed the resident was laying down on his/her bed reading a book. He/she was not wearing oxygen. His/her oxygen concentrator was against the wall beside his/her bed. The nasal canula and tubing were coiled around the concentrator, uncovered. The resident said:-He/She used his/her oxygen at night most of the time, but he/she sometimes used it during the day.-He/She had a plastic bag for his/her breathing treatment machine, but he/she did not have anything to put her oxygen tubing in. During an interview on 10/9/25 at 9:26 A.M., Certified Nursing Assistant (CNA) B said:-They are supposed to check for any resident who has a respiratory device to ensure the device was covered.-They have residents who have oxygen and use masks and nasal cannulas.-The masks and tubing are supposed to remain covered when it's not in use. During an interview on 10/10/25 at 10:46 A.M., Licensed Practical Nurse (LPN) A said:-Usually the resident used his/her oxygen at night, and he/she would remove the nasal cannula himself/herself and put it up.-There should be a plastic bag for the nasal cannula and tubing to go into.-The nasal cannula and tubing should be covered when it is not in use, and the nursing staff should be observing during the day to ensure it is in a bag and covered. 2.Review of Resident #72's Face Sheet showed the resident was admitted with diagnoses including COPD. Review of the resident's quarterly MDS dated [DATE], showed the resident:-Was alert, oriented and cognitively intact.-Needed moderate assistance with toileting and dressing and maximum assistance with bathing.-Had no oxygen therapy during the look back period. Review of the resident's POS dated 10/2025, showed physician's orders for Oxygen at 2 liters per minute as needed for shortness of breath (5/15/25). Review of the residents Medication Administration Record (MAR) showed: -9/2025 showed resident did not use oxygen during the month.-10/2025 showed the resident did not use oxygen during the month. Observation on 10/07/25 at 11:29 A.M., showed the resident was not in his/her room. There was an oxygen concentrator that was sitting across from his/her bed, against the wall. It was not on, and the nasal cannula and tubing were coiled around it, uncovered. The resident was in his/her wheelchair in the hallway and was not wearing oxygen. Observation on 10/8/25 at 8:32 A.M., showed the resident was sitting in his/her wheelchair in the hallway outside of his/her room. He/she was not wearing oxygen. His/her oxygen concentrator was sitting across from his/her bed with the nasal canula and tubing coiled around it, uncovered. The oxygen concentrator was not on. Observation on 10/9/25 at 8:18 A.M., showed the resident was in his/her room standing up adjusting his/her pants before transferring himself/herself to his/her wheelchair. He/she was not wearing oxygen. His Her oxygen concentrator was sitting across from his/her bed with the nasal cannula and tubing coiled around the concentrator, uncovered. LPN B went into the room to check the resident's blood sugar and then came out of the resident's room without covering the resident's oxygen tubing. Observation and interview on 10/9/25 at 9:32 A.M., showed the resident was in his/her bed with his/her eyes closed, resting comfortably without oxygen on. The oxygen concentrator was across from the resident's bed, and the nasal cannula and tubing were wrapped around the concentrator, uncovered. CNA B said:-He/She saw his/her oxygen concentrator, but the resident rarely used his oxygen, in fact he/she never had seen the resident use oxygen.-If the resident has oxygen in his/her room, the nasal cannula and tubing should be covered. During an interview on 10/9/25 at 9:58 A.M., LPN B said:-The resident has not had to use his/her oxygen that he/she is aware of.-If the resident does not use oxygen, the concentrator should not be in his/her room.-If the resident used oxygen at night, the tubing should be covered.-At this time LPN B instructed the nursing staff to remove the nasal cannula and tubing from the oxygen concentrator and discard it.-He/She said the resident's order was for oxygen as needed. During an interview on 10/10/25 at 1:57 P.M. the Director of Nursing (DON) said:-The oxygen nasal cannulas, tubing and face masks should be in a bag labeled and dated.-They should not be left uncovered.-He/She expected the staff to check daily as they go in/out of resident rooms.-If the resident had oxygen that was not being used, they should not have nasal cannula and tubing attached-it should be discarded until they need it. 3. Review of Resident #13's admission Record showed was admitted to the facility on [DATE] with diagnosis of COPD. Record review of the resident's Quarterly MDS dated [DATE], showed he/she:-Was cognitively intact.-He/She was able to understand others and make his/her needs known. Record review of the resident's Care plan updated on 8/12/25 showed:-Diagnosis of COPD.-Requires ongoing use of C-PAP (continuous positive airway pressure) is a machine that uses mild air pressure to keep breathing airways open while you sleep) use. Review of the resident's POS dated 10/1/25 to 10/31/25 showed:-C-PAP on at bedtime duet to sleep apnea -Change tubing to C-PAP and clean weekly on Mondays. During an observation of the resident's room and interview with the resident on 10/7/25 at 11:18 A.M. showed his/her C-PAP machine was on the bedside table with the C-PAP mask uncovered and hung over the side rail of the resident's bed, there was no storage bag for the mask. The resident said: -He/She has a C-PAP machine on the bedside table. -The facility cleans the C-PAP machine and mask as needed.-He/She was able to apply and remove C-PAP mask by himself/herself. Observation on 10/7/25 at 1:31 P.M., the resident room showed his/her C-PAP mask was hung uncovered on the siderail. Observation and interview on 10/9/25 at 10:04 A.M., of the resident in his/her room showed his/her C-PAP mask was not stored in plastic bag or covered; the c-pap mask was hanging over side rail. The resident did not have C-PAP storage bag in his/her room at that time. The resident said:-He/She normally has a plastic bag to store C-PAP mask in when not in use. -Nursing staff provide the storage bag as needed. During an interview on 10/9/25 10:45 A.M., CNA B said:-The resident's C-PAP mask should be stored in plastic bag when not in us. -The resident was able to place his/her C-PAP mask on and removed by himself/herself. -CNA would monitoring during rounds to ensure the C-PAP mask was stored when not in use. During an interview on 10/9/25 10:45 A.M., LPN B said:-The resident's C-PAP mask should be stored in a bag when not in use. -The facility night staff were responsible to ensure the resident would have new storage bag every week. -The resident was able to place C-PAP mask on and removed by himself/herself. During an interview on 10/10/25 at 1:57 P.M., the DON said:-He/She would expect nursing staff and care staff to ensure proper storage for the resident's C-PAP mask when not in use. -The resident's C-PAP mask should be stored in a plastic bag, labeled with resident name and dated when changed, -Night nursing staff were responsible for ensure the resident have plastic storage bag for C-PAP mask.

Based on observation, interview, and record review the facility failed to ensure Hospice (is a special kind of care that focuses on a person's quality of life and dignity as they near the end of their life) physician orders were obtained and documented on the physician's order sheet for four sampled residents (Resident #52, #13, #45, and #58) out of 18 sampled residents. The facility census was 76 residents. Review of the facility's policy for Physician Order dated 2013 showed:Purpose:-To ensure the accuracy of transcribing order.-To have physician orders transcribed from the Physician Order Sheet (POS) to the appropriate administration record. Policy:-All nursing staff must follow the policy for transcribing medication, medication management and receiving physician order. All nursing staff must be compliant with this policy. Procedure:-The licensed nurse documents the complete orders on the POS. Sign name, date and the nurse practitioners and/or physician's name.-The POS will be reviewed by a licensed nurse monthly during the changeover to capture all information for the next month. -The POS will be reviewed by the physician/assistant nurse practitioners monthly to ensure the appropriate treatment and orders. -Should be documented or transcribed exactly the order upon receipt on the POS, MAR, and Treatment book. Review of the Facility's policy for Collaborative Practice with Hospice Care and Services dated 2010 showed: Purpose:-To enhance the quality of care via collaborative services between hospice agencies and the facility.-To promote the communication between hospice and nursing staff.-To ensure the continuum of care provided to the residents. 1. Review of Resident #52's admission Record showed the resident had diagnoses:-Senile degeneration of the brain (is a decline or death of brain cells, it's a process deteriorates intellectual functions like memory, speech, and coordination, and while there is no cure, treatments can help manage symptoms). -Dementia (is used to describe the gradual deterioration of intellectual abilities and behavior that eventually interferes with customary daily living activities).-Moderate Intellectual disabilities (is a term used when there are limits to a person's ability to learn at an expected level and function in daily life).-admitted to Hospice Services. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/26/25, showed he/she:-Was cognitively impaired.-Received hospice services. Review of the resident's POS dated September 2025, and October 2025 showed he/she had no physician orders for hospice services and care, to include when the resident was admitted to hospice, name of hospice provider and supporting diagnosis. Review of the resident's Hospice Medical Record binder on 10/9/25 at 8:17 A.M. showed:-The resident's hospice physician order to recertify hospice services from 8/16/25 to 10/14/25 with admitting diagnosis of senile degeneration of the brain.-His/Her hospice care plan dated on 3/19/25 to include hospice aide visits on Monday and Wednesday.-He/She had a hospice bath aide sheet completed on 10/7/25 to include shower, peri care, nail care and oral care. 2. Review of Resident #13's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses of:-Chronic Obstructive Pulmonary Disease (which includes chronic bronchitis and emphysema, is a long-term lung disease that makes it hard to breathe).-admitted to Hospice Services. Review of the resident's Hospice Medical Record binder showed: -The resident was recertified for Hospice services on 7/10/25. -His/Her Hospice Plan of Care was dated 7/24/25 showed, he/she was scheduled for hospice aide visits on Tuesday and Thursday. Licensed Nurse visits on Tuesday. Review of the resident's Care Plan updated on 8/12/25 showed he/she admitted to hospice care 4/11/25 with diagnosis of COPD. Review of the resident's Quarterly MDS dated [DATE], showed he/she:-Was cognitively intact.-Was able to understand others and make his/her needs known.-Received hospice services. Review of the resident's POS dated 9/1/25 to 9/30/25 showed he/she had no physician orders for hospice services and care, to include when was admitted to hospice, name of hospice provider and supporting diagnosis. Review of the resident's Nursing Note dated 9/21/25 at 4:00 P.M. showed the resident continues to be on hospice services. Review of the resident's POS dated 10/1/25 to 10/31/25 showed he/she had no physician orders for hospice services and care, to include when was admitted to hospice, name of hospice provider and supporting diagnosis. During an interview on 10/07/25 at 1:31 P.M., the resident said he/she was on hospice services and hospice care staff provide showers, help with basic care needs, and medication. During an interview and review of the resident medical record on 10/09/25 at 11:15 A.M., showed review of the resident's POS with Licensed Practical Nurse (LPN) B:-The resident did not have physician orders transcribed to the facility POS for hospice services. -He/She would expect to have a physician order for a resident on hospice services to include the hospice provider name and supporting diagnosis. 3.Review of Resident #45's Face Sheet showed the resident was admitted with diagnoses including COPD, emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness), and high blood pressure. Review of the resident's quarterly MDS dated [DATE], showed the resident:-Was alert and oriented but had cognitive loss.-Did not show hospice services during the lookback period. Review of the resident's POS showed:-The POS dated 4/2025 showed a physician's order dated 4/11/25, for a hospice evaluation and treatment.-POS's dated 5/2025, 6/2025, 7/2025, 8/2025, 9/2025 and 10/2025 showed no physician's orders for hospice services was documented. Review of the resident's Hospice Record showed:-The resident was approved for and started on hospice services on 4/11/25, was re-certified on 7/9/25 and again 10/2025.-The hospice related diagnosis was COPD.-The hospice physician's orders showed 4/11/25 (the date the order was written).-Documentation showed hospice started on 4/11/25 and has continued since that date. During an interview on 10/9/25 at 9:20 A.M., the resident said he/she was still receiving hospice services and the nurse came to visit every week to see how he/she was doing and he/she was satisfied with his/her care. During an interview on 10/10/25 at 10:46 A.M., Licensed Practical Nurse (LPN) A said:-With resident's who receive hospice services, the orders are only on the hospice order sheet. -Regarding the resident, the hospice orders showed on the POS dated 4/2025, that the resident was to receive a hospice evaluation and treatment.-Hospice did pick the resident up for services and so there should be an order for hospice on the POS.-The resident started hospice services on 4/11/25.-The hospice order should have been documented on the resident's POS and carried over from month to month.-When they change an order on the POS, it is picked up by pharmacy and it's supposed to be changed on the POS for the following month.-The nurse was supposed to check the POS for accuracy from month to month.-If they notice that the order did not carry over, they were supposed to change it on the POS and they should notify the pharmacy that the order needs to be changed for the following month.-He/She would make sure that the residents who are on hospice that he/she cared for have hospice orders that are documented on their POS. 4. Review of Resident #58's admission Sheet dated 3/13/15 showed the following diagnoses:-Multiple Sclerosis (MS, a neurological disease that attacks the protective covering of the nerves, leading to impaired sensory and motor nerve function, and in most cases some degree of disability).-Essential (primary) hypertension (HTN- high blood pressure).-Anxiety disorder, unspecified (a psychiatric disorder causing feelings of persistent anxiety)-Other chronic pain.-Other muscle spasm.-Dysphagia, unspecified (inability or difficulty swallowing). Review of the resident's MDS dated [DATE] showed: -He/She was moderate cognitive impairment.-He/She was on hospice. Review of the resident's POS dated 10/8/25 showed the resident did not have orders for hospice. Review of hospice communication book on 10/9/25 showed that hospice had visited and communicated with staff on 9/18, 9/25, 10/1, 10/3 2025. 5.During an interview on 10/10/25 at 9:06 A.M., LPN A said he/she would expect to have a physician order for residents on hospice services to include the hospice provider name and supporting diagnosis. During an interview on 10/10/25 at 10:46 A.M., LPN A said:-With residents on hospice, the orders were only on the hospice order sheet. -They have a list of residents who were on hospice. -There should be an order for hospice on the POS During an interview on 10/10/25 at 1:57 P.M., the Director of Nursing (DON) said:-Residents on hospice should have hospice orders on their POS.-He/She would expect the resident's physician's order to include the hospice provider, date the order was written, associated diagnosis and physician who wrote the order. During an interview on 10/10/25 at 1:57 P.M., the Director of Nursing (DON) said:-Residents on hospice should have hospice orders on their POS.-Typically, the order should show the hospice provider, date the order was written, associated diagnosis and physician who wrote the order.

Based on observation and interview, the facility failed to maintain the drainage sink in the North Hall Janitor's closet free from being clogged; failed to ensure that there was not a heavy buildup of dust on the ventilation fan and blades in the laundry above the dryers; failed to maintain the hopper (sinks in soiled utility rooms which are used for the disposal of liquid clinical waste) in the South side soiled linen room close to the nurse's station free from being clogged; and failed to ensure that grime was removed from the hopper in the soiled utility room next to South rooms 13-14. This practice potentially affected at least 30 residents who resided close to or use the corridors adjacent to these areas. The facility census was 76 residents.1.Observation on 10/7/25 at 1:16 P.M., with the Housekeeping Supervisor and the Corporate Maintenance Person, showed a clogged sink in the North Hall soiled utility room. During an interview on 10/7/25 at 1:16 P.M., the Corporate Maintenance Person said he/she did not know about it because he/she has not been at the facility in a while. 2. Observation on 10/7/25 at 1:32 P.M., with the Corporate Maintenance Person and the Housekeeping Supervisor, showed the wall mounted fan in the laundry area, was encrusted with a layer of dust. During an interview on 10/7/25 at 1:33 P.M. the Housekeeping Supervisor said he/she did not know he/she needed to remove the dust from that vent fan. 3. Observation on 10/8/25 at 9:59 A.M., with the Corporate Maintenance Person, showed a clogged hopper in the South side Soiled utility room close to the nurse's station. During an interview on 10/8/25 at 10:00 A.M., the Corporate Maintenance Person said he/she did not know how long the hopper was clogged. 4. Observation on 10/8/25 at 10:24 A.M., with the Housekeeping Supervisor showed a heavy build of grime in the hopper within the South side soiled utility room located next to resident room [ROOM NUMBER]-14 and a very pungent odor emanating into the adjoining corridor from that room. During an interview on 10/8/25 at 10:25 A.M., the Housekeeping Supervisor said he/she did not know how long the grime had existed on the hopper and that hopper was not flushing properly as well.

Based on observation and interview, the facility failed to ensure there was adequate ventilation in the following areas: North resident rooms 21-24, 25-28, 15-16, 13-14, 29-32, 33-36, 9-10, South resident rooms 37-40, 1, 13-14, the soiled utility room close to South 13-14, and South 17-18. This practice potentially affected at least 20 residents who resided in those rooms or used corridors close to those areas. The facility census was 76 residents.**Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was drawn to the vent, then negative air flow was present; if the paper fell, then negative airflow was absent.1. Observations on 10/7/25 with the Corporate Maintenance Person and the Housekeeping Supervisor, showed:At 12:41 P.M., there was the absence of negative airflow in the ceiling vent of Resident room North 21-24.At 12:50 P.M., there was the absence of negative airflow in the ceiling vent of Resident room North 25-28.At 12:52 P.M., there was the absence of negative airflow in the ceiling vent of Resident room North 15-16.At 12:54 P.M., there was the absence of negative airflow in the ceiling vent of Resident room North 13-14.At 12:56 P.M., there was the absence of negative airflow in the ceiling vent of Resident room North 29-32.At 1:01 P.M., there was the absence of negative airflow in the ceiling vent of Resident room North 11-12.At 1:04 P.M., there was the absence of negative airflow in the ceiling vent of Resident room North 33-36.At 1:06 P.M., there was the absence of negative airflow in the ceiling vent of Resident room North 29-32.At 3:20 P.M., there was the absence of negative airflow in the ceiling vent of Resident room South 37-40.At 3:29 P.M., there was the absence of negative airflow in the ceiling vent of Resident room South 37-40.At 3:36 P.M., there was the absence of negative airflow in the ceiling vent of Resident room South 7-8.During an interview on 10/7/25 at 1:04 P.M., the Corporate Maintenance Person said a motor on the roof of the facility, which controlled the negative airflow may not have worked at that time. Observations on 10/8/25 with the Corporate Maintenance Person and the Housekeeping Supervisor, showed: -At 10:22 A.M., there was the absence of negative airflow in the ceiling vent of Resident room South 13-14.-At 10:23 A.M. there was the absence of negative airflow and the presence of a strong odor in the soiled utility room next to South 13-14.During an interview on 10/8/25 at 10:23 A.M., the Housekeeping Supervisor said he/she did not know how long that soiled utility room had been like that.-At 10:44A.M., there was the absence of negative airflow in the ceiling vent of Resident room South 17--18.-At 10:46A.M., there was the absence of negative airflow in the ceiling vent of Resident room South 21--24.During an interview on 10/9/25 at 11:11 A.M., the Housekeeping Supervisor said he/she did not know how to check for negative airflow, until that survey.During an interview on 10/9/25 at 11:12 A.M., the Corporate Maintenance Person said he/she was not always at that facility but did try to get to that facility 3-4 times per month, if there were not emergencies at the other facilities, that he/she served for the corporation.

Based on observation, interview, and record review, the facility failed to ensure to obtain and transcribe a physician order for self-administration of medication and failed to ensure nursing staff documented and completed a self-administration medication assessment for the resident's ability to store medication safely at bedside and to administer medication by himself/herself, for one sampled resident (Resident #13) out of 18 sampled residents. The facility resident census of 76 residents. Review of the facility's Self-Administration of medication dated 8/16/07 showed:-All bedside medication must be approved and ordered by the resident attending physician. -Each resident who desires to self-administer their own medication will be provided education about medication with return demonstration on proper administering or are adequately trained in the techniques of the medication. -Nursing staff are responsible to monitor and ensure the prescribed medication are properly administrated by the resident. -Nursing staff are responsible to ensure the safety on of bedside medication by checking storage regularly. 1.Review of Resident #13's admission Record showed was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (which includes chronic bronchitis and emphysema, is a long-term lung disease that makes it hard to breathe).Review of the resident's Care Plan updated on 8/12/25 showed:-He/She has diagnosis of COPD.NOTE: no care plan for self-medication administration of inhaler. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/9/25, showed he/she:-Was cognitively intact.-He/She was able to understand others and make his/her needs known.Review of the resident's Physician Order Sheet (POS) dated 10/1/25 to 10/31/25 showed:-Albuterol HFA 90 Micrograms (mcg) (inhaler used to treat shortness of breath) inhale one puff orally every six hours as needed for shortness of air.-NOTE: did not have physician order to keep medication at bedside or self-administer any medication. Review of the resident Medication Administration Record (MAR) dated 10/1/25 to 10/31/25 showed:-Albuterol solution HFA 90 MCG (Ventolin) inhale one puff orally every six hours for shortness of air.NOTE: There was no physician order to keep medication at bedside or self-administer any medication. During an and observation and interview with the resident on 10/07/25 at 1:31 P.M., showed: -Observed the resident had a red and white medication box with an albuterol inhaler laid at the foot of his/her bed. -He/She had been instructed on how to administer the inhaler medication by facility nursing staff and kept the inhaler at bedside due to his/her breathing issue. Observation on 10/9/25 at 10:04 A.M., of the resident in his/her room showed he/he had an Albuterol HFA inhaler in a red and white box at the foot of his/her bed. The prescription label was dated refilled on 7/29/25. Observation on 10/9/25 at 10:10 A.M., of the Certified Medication Technician (CMT) medication cart showed the resident had an Albuterol inhaler HFA in a box with a pharmacy label refilled in June 2025. During an interview on 10/9/25 at 10:10 A.M., CMT A said:-The resident should have a physician order for self-administration and a licensed nursing assessment for self-administration of inhaler be completed to keep any medication at bedside. -He/She was not aware the resident had the inhaler medication left at bedside. -The resident did not have physician order for self-administration of inhaler or any other medication. -He/She removed the inhaler medication from the resident room. During an interview on 10/9/25 10:45 A.M., Licensed Practical Nurse (LPN) B said: -Residents were not allowed to keep prescribed or over-the-counter medication at bedside.-He/She would expect the resident to have a physician order for self-administration of medication and nursing assessment for the ability to self-administration medication safely. During an interview on 10/10/25 at 1:57 P.M., Director of Nursing (DON) said:-He/she would expect to have physician orders for self-administration of medication and completed nursing assessment for the resident ability to keep and administer medication safely.-The facility did not have any residents with physician orders for self-administration of medication and able to keep medication at bedside. -The facility CMT and licensed nursing staff would be responsible for ensuring resident's medication were stored safely and no medication left in resident room.

Based on observation, interview and record review, the facility failed to ensure the correct code status (a medical designation that communicates a patient's wishes regarding resuscitation if their heart stops or they stop breathing) was documented on the resident physician's order sheet and was consistent throughout the resident's medical record for one sampled resident (Resident #43) out of 18 sampled residents. The facility census was 76 residents.Review of the Physician's Orders policy and procedure dated 2013, showed the purpose was to ensure the accuracy of the order and to have the physician's orders transcribed to the appropriate administration record. The procedure showed:-The physician dictated the order through phone or fax.-The nurse will document the exact order on the physician's order sheet (POS) and transcribe the order to the medication administration record (MAR)/treatment administration record (TAR).-The POS will be reviewed by the nurse monthly during the changeover to capture all of the information for the next month.-The POS will be reviewed by the physician monthly to ensure the appropriate treatment orders.-All necessary information related to code status, allergy, specialized diets, and care instructions must be transcribed to the medical record. 1.Review of Resident #43's Face Sheet showed the resident was admitted on e 2/10/22, with diagnoses including dementia, hypokalemia (low levels of potassium in the blood), schizophrenia (a chronic mental health condition characterized by significant disturbances in thought, perception, emotion, and behavior), insomnia (a sleeping disorder), (COPD-a group of lung diseases that cause ongoing airflow obstruction and breathing problems), diabetes, movement disorder, hypothyroidism, high blood pressure and history of breast cancer. Review of the resident's Hospice (end of life) records showed the resident was a do not resuscitate (DNR) and there was a DNR form in the record dated 4/24/25.Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 5/28/25, showed the resident:-Was alert with significant confusion.-Received Hospice services. Review of the resident's Physician's Order Sheets (POS) showed:-The POS dated 4/2025, showed on 4/22/25 the resident had an order for hospice to evaluate and treat the resident.-A physician's telephone order dated 4/24/25 showed the resident's code status showed DNR.-The POS dated 4/2025, 5/2025 and 6/2025 showed the resident's code status was DNR.-The POSs dated 7/2025, 8/2025, 9/2025, and 10/2025 showed the resident's code status was full code. Review of the resident's Physician's Note dated 8/12/25, showed:-The resident was on Hospice services and was declining.-Regarding his/her code status the physician documented do not resuscitate? Review of the resident's Care Plan dated 9/11/25, showed the resident chose to be DNR.Review of the resident's medical record showed there was no documentation showing the resident had changed his/her code status from DNR back to full code since 7/2025. During an interview on 10/9/25 at 9:20 A.M., the resident said:-He/She was on hospice services and was content with the services he/she received.-He/She did not want to be resuscitated if he/she was no longer breathing. During an interview on 10/10/25 at 10:46 A.M., Licensed Practical Nurse (LPN) A said:-If they have a resident who is on hospice and they were full code but are now DNR, then the order should be changed to show they are no longer full code on the POS.-The resident's code status changed when he/she started receiving hospice services.-(After looking at the resident's medical record) the resident determined he/she did not want to be a full code and started hospice on 4/24/25 the resident signed the DNR form.-The resident's POS showed the code status changed from full code to do not resuscitate in April and seemed to have dropped off of the POS in July.-The POS was incorrect and should have showed the code status as DNR.-When they put changed orders on the POS, the POS goes to the pharmacy and it should have been changed for the following month, but sometimes it's not.-This had been a continuous problem with the pharmacy. -They try to ensure the orders are current and correct on the POS from month to month, but they must have missed it. During an interview on 10/10/25 at 1:57 P.M., with the Director of Nursing (DON) and Administrator, the DON said:-The resident should have an advanced directive that is current.-They have had issues with the pharmacy not updating the POS and orders falling off of the POS, but the advance directive for the resident should be current and, on the POS.-The Administrator said the issues with the pharmacy dropping orders off the POS occurs monthly. They are in process of transferring their orders to the electronic record as of November and hopefully this issue will be resolved.

Based on observation, interview, and record review the facility failed to ensure the area next to the bed was clear of clutter including a siderail for one sampled resident (Resident #22) out of 18 sampled residents. The facility census was 76 residents. An Accident Hazards policy was requested but not provided by the exit date.1. Review of Resident 22's undated face sheet showed he/she admitted to the facility with diagnoses that included:-Left below knee amputation (left BKA a surgical procedure to remove the leg below the knee joint, keeping the knee intact).-Alcohol use, unspecified with intoxication.-Polyneuropathy (a disease affecting many peripheral nerves, causing symptoms like numbness, tingling, and weakness).Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 9/9/25 showed:-Activities of Daily Living (ADL dressing, grooming, bathing, eating, and toileting) assistance necessary for health and well-being had been rejected previously.-Had lower extremity impairment on one side.-Required substantial/maximal assistance transferring from a sit to stand position.-Required substantial/maximal assistance transferring from bed/chair-to-chair.Review of the resident's care plan dated 9/18/25 showed:-The resident was a high risk for falls related to recent fall, left leg amputation, refusal of care, altered mobility status and self-transferring to bed, wheels unlocked.-The resident had ADL, self-care performance deficits related to left below knee amputation, continually refusing to let staff assist with toileting and continuing to refuse to let staff assist with ADL'S.-The resident had limited physical mobility related to below knee left leg amputation, has ongoing use of wheelchair for mobility and continues to be non-compliant with assistance with transfers from wheelchair with staff.Observation on 10/7/25 at 9:49 A.M. showed:-The resident was sitting in the wheelchair in his/her room at bedside watching television.-The resident's bed was positioned on the left side of room, his/her BKA was on his/her left side.-The bed was positioned with a curtain separating the room on the right side of the bed with less than one foot between the edge of the bed and the curtain. -Left side bed rail was lying on the floor partially under bed between the resident and the left side of the bed.Observation on 10/7/25 at 1:14 P.M., 10/8/25 at 9:05 A.M., and 10/9/25 at 2:10 P.M. showed the left side bed rail was lying on the floor partially under bed between the resident and the left side of the bed.During an interview on 10/10/25 at 1:30 P.M., Certified Nursing Assistant (CNA) A said:-He/She knew what a resident's interventions, assistance requirements, and/or mobility needs were based on experience and working with the residents.-He/She was not aware if the resident had fallen in the past.-The resident required assistance but preferred to do everything for himself/herself and liked to be independent.-The resident's room should be free of clutter.-He/She did not know there was a side rail on the floor, the siderail was put back in place recently and thought it was still attached.-The bed side rail should not be on floor or under the resident's bed.-The right side would be the best side for the resident to get in and out of bed.During an interview on 10/10/25 at 1:52 P.M., Licensed Practical Nurse (LPN) B said:-He/She knew what the resident's interventions, assistance requirements and/or mobility needs were by looking at the resident's chart.-The resident had a fall in the past but not recently.-The resident did everything on his/her own but should be getting standby assistance from staff.-The resident frequently refused assistance from staff.-The resident should be reminded to ask for help with transfers and to use the call light for assistance.-The resident's room was free from clutter and was safe.-He/She was not aware that the resident's bed rail was on the floor.-The resident's room should be free of clutter.-The bed rail should not be on the floor.-The right side would be the best side for the resident to get in and out of bed.During an interview on 10/10/25 at 3:00 P.M., the Director of Nursing (DON) said:-He/She would expect the staff to encourage the resident to wait for assistance before transferring.-He/She would not expect for a bed's side rail to be on the floor or under bed.-He/She would expect staff to remove a non-working or broken piece of equipment when discovered.-He/She would expect the resident's room to be free of clutter.-If the resident was being non-compliant, he/she would expect staff to encourage the resident to ask for assistance, notify the nurse, tell him/her, notify physician, and do a care plan review and follow up.

Based on observation, interview and record review, the facility failed to ensure a physician ordered dietary supplement for weight loss was provided to one sampled resident (Resident #45) who had gradual weight loss out of 18 sampled residents. The facility census was 76 residents.1.Review of Resident #45's Face Sheet showed the resident was admitted with diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung diseases that cause ongoing airflow obstruction and breathing problems) emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 5/19/25, showed the resident:-Was alert and oriented but had cognitive loss.-Was independent with eating and needed moderate assistance with bathing, hygiene and supervision with transfers.-Had no chewing or swallowing problems.-Had no significant weight loss during the lookback period. Review of the resident's Weight Record showed:-On 5/14/25 the resident weighed 100.4 pounds.-On 6/20/25 the resident weighed 94.6 pounds (represented a significant weight loss within a month).-On 7/22/25 the resident weighed 95 pounds (there was no significant weight loss within 3 months).Review of the resident's Dietary Progress Notes dated 7/25/25, showed the Registered Dietician (RD) assessment noted the resident had a 6-pound weight loss in 30 days, the resident's weight was down significantly.-The resident was placed on hospice (end of life care).-The resident received a regular diet and was eating well at meals.-The resident was ordered health shakes three times daily or magic cup three times daily.-He/She suspected the resident's pain would have an effect on his/her weight loss.-The resident would benefit from Isosource (a nutritionally complete liquid formula, designed to meet the dietary needs of patients who are unable to meet their nutritional requirements through normal food intake) 8 ounces, twice daily. Review of the resident's Weight Record showed Weight Record showed the resident's weight on 9/3/25 was 94.2 pounds. Review of the resident's Care Plan updated on 9/4/25, showed the resident:-Was admitted with a history of malnutrition and weighed 94.2 pounds.-Was to receive a house supplement with all meals and weight monitoring.-Received hospice services.-Interventions included provide and serve the diet as ordered, offer house supplement with meals and snacks. Review of the resident's Weight Record showed Weight Record showed the resident's weight on 10/2/25=92.9 pounds. The resident's weight loss was gradual but was not a significant weight loss over a 6-month period. Review of the resident's Physician Order Sheet (POS) dated 10/2025 showed:-A Regular diet.-Give health shakes three times daily with meals, substitute for magic cup (a fortified frozen dessert that serves as a nutritious and calorie-dense snack, ideal for individuals with involuntary weight loss or those on special textured diets) as needed.-There was no response to the Registered Dietician's recommendation on 9/25/25 for Isosource twice daily. Observation on 10/7/25 at 8:15 A.M., showed the resident was served a regular diet of a boiled egg with toast and cold cereal with milk, juice and coffee. He/she was not served a magic cup or health shake. The resident was eating without assistance or an assistive device. When he/she finished eating, he/she self-propelled from the dining room to his/her room. The resident did not receive a house supplement or magic cup. Observation on 10/9/25 at 8:16 A.M., showed the resident was sitting in his/her wheelchair at the dining table eating an egg sandwich with cold cereal and there was a magic cup with juice, coffee and water at his/her place setting. He/she was eating without assistance and ate 100 percent of his/her meal. When he/she was done, he/she self-propelled out of the dining room back to his/her room. During an interview on 10/9/25 at 9:20 A.M., the resident said:-He/She had a good appetite and has been eating.-He/She received the ice cream like cup this morning, but he/she had not been receiving it before yesterday.-Yesterday he/she received one at lunch and then again, this morning.-He/She did not know how often he/she was supposed to receive the magic cup.-He/She thought the staff were trying to get him/her to gain weight. During an interview on 10/10/25 at 10:46 A.M., Licensed Practical Nurse (LPN) A said:-The resident was supposed to receive magic cup or a supplement with every meal for weight gain/maintenance.-The resident does eat well, but he/she was not sure about what his/her weight currently was.-Usually the dietary staff were responsible for providing the magic cup and/or supplements to the resident.-They have not been documenting whether the resident received the supplement/magic cup daily and they have not been documenting how much of the magic cup/supplement he/she eats.-The resident usually eats everything on his/her plate that is given to him/her so he/she knew that if the resident received the magic cup, he/she ate it.-He/She would start documenting the amount of magic cup the resident consumed in his/her medical record. During an interview on 10/10/25 at 11:22 A.M., the Dietary Manager said:-The dietary staff was responsible for providing the magic cup and supplements.-The supplement/magic cup was on the resident's meal ticket.-The dietary staff are aware of the residents who receive supplements and magic cups, and they have the supplements and magic cups available in the kitchen.-He/She did not know why the resident did not receive the magic cup, but he/she should have received it and should receive it with every meal.-Dietary staff should read the ticket and ensure the supplement is on the resident's tray when they serve it to the resident. During an interview on 10/10/25 at 1:57 P.M., the Director of Nursing (DON) said he/she expected residents who receive health shakes to be given them as ordered and they should probably monitor the resident's intake if the resident is at risk for weight loss.

Based on observation, interview and record review, the facility failed to obtain and transcribe physician orders for dialysis (is a treatment used to remove waste products and excess fluid from the blood when the kidneys are not functioning properly) services to include name of dialysis clinic, days of treatment, and failed to obtain physician orders for daily monitoring of the resident's dialysis shunt site (is a surgical connection between an artery and a vein that allows for the flow of blood during dialysis treatment) to assess the thrill (a vibration) and bruit (a whooshing sound) that indicates proper blood flow of the access site and to assess for bleeding at shunt site for one sampled resident (Resident #2) out 18 sampled resident. The facility resident census of 76 residents. A policy for dialysis was requested and not received at the time of exit. Review of the facility's Policy for Physician Order dated 2013 showed: -The licensed nurse documents the complete physician order onto the resident's Physician's Order Sheet (POS) administration record. -Transcribe physician orders to the POS, Medication Administration Record (MAR) and Treatment Administration Record (TAR). -The POS will be reviewed by licensed nursing staff monthly during the changeover to capture all information for the next month of physician orders. 1. Review of Resident #2's admission Record showed the resident admitted to the facility on [DATE] with diagnosis of:-Chronic Kidney Disease Stage 4 (Very poor kidney function; your kidneys are severely damaged and close to not working).-End Stage Renal Disease (ESRD, is when you have permanent kidney failure that requires a regular course of dialysis or a kidney transplant).-Received services at a dialysis center.Review of the resident's Dialysis Care Plan updated 9/11/25 showed: -Receives hemodialysis treatment for ESRD, three times a week on Monday, Wednesday and Friday. --Encourage resident to go for the scheduled dialysis appointments. Monitors vital signs and notify the resident's physician any changes. -NOTE: did not have intervention documented to monitoring and care the resident dialysis shunt daily, before and after dialysis treatments. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/24/25 showed he/she:-Was cognitively intact.-He/She was able to understand others and make his/her needs known.-Required dialysis treatment and services. Review of the Resident's Dialysis Catheter/Fistula/Shunt Care & Monitoring Sheet for September 2025 showed: -Nursing staff documented daily findings of the monitoring of the resident's shunt for bruit and thrill.-NOTE: Nursing staff were providing and documenting the resident's dialysis shunt assessment and care without physician orders. Review of the resident's POS dated 9/1/25 to 9/30/25 showed he/she did not have physician orders for dialysis services or daily monitoring and care of the resident's dialysis shunt. Review of the resident's MAR and TAR dated 9/1/25 to 9/30/25 showed no physician order for the dialysis services and monitoring of the resident dialysis shunt daily and before and after dialysis treatment.Review of the resident's POS dated 10/1/25 to 10/31/25 showed he/she did not have physician orders for dialysis services/treatment or daily monitoring and care of the resident's dialysis shunt. Review of the resident's MAR and TAR dated 10/1/25 to 10/31/25 showed no physician order for the dialysis services and monitoring of the resident dialysis shunt daily and before and after dialysis treatment. Review of the Resident's Dialysis Catheter/Fistula/Shunt Care & Monitoring Sheet for October 2025 showed: -Nursing staff documented daily findings of the monitoring of the resident shunt for bruit and thrill.-NOTE: Nursing staff were providing and documenting the resident's dialysis shunt daily assessment and care without physician orders. During an interview on 10/7/25 at 10:47 A.M. the resident said:-He/She does leave the facility for dialysis three days a week.-He/She goes to dialysis clinic on Monday, Wednesday and Friday.Review on 10/9/25 at 9:00 A.M., of the resident's Dialysis Communication binder showed:-Had documentation of the name of the dialysis clinic.-Was scheduled for dialysis on Monday, Wednesday and Friday.-He/She had a dialysis chair time of 12:15 P.M. -He/She did not have any completed dialysis communication sheet (completed before and after dialysis for assessment performed by facility nursing staff and the dialysis clinic staff) placed in the binder for past dialysis visits. During an interview on 10/9/25 at 9:05 A.M., Licensed Practical Nurse (LPN) B said:-The facility nursing staff would send the dialysis communication form with the resident.-The resident's dialysis communication form has not been completed or returned after dialysis. -The facility nursing staff would be responsible for contacting the resident's dialysis clinic to obtain a copy of the completed form. -He/She was not sure where the facility had filed any of the resident's completed dialysis communication form. Requested the resident's dialysis communication documentation and had not received as of 10/9/25 at 1:31 PM.Observation and interview on 10/10/25 at 8:44 A.M., of the resident's dialysis shunt by LPN B showed the resident dialysis shunt located on his/her right upper arm, with no redness noted. LPN B said:-Nursing staff were to check the resident's dialysis shunt every shift, before and after dialysis.-Nursing staff would assess for any bleeding, the bruit and thrill of the dialysis shunt. -The facility nursing staff would complete a special dialysis site monitoring form and placed it in a separate nursing TAR binder.During an interview and review of the resident's medical record on 10/10/25 at 8:46 A.M., LPN B said:-Review of the resident medical chart with LPN B, he/she did not find documentation of physician's orders for the resident's dialysis services and treatment. -The resident should have orders for dialysis to include the dialysis clinic name, days scheduled, and chair times. -Had no documentation of a physician order for the monitoring of the resident's dialysis shunt for bruit and thrill, check for bleeding from the site, report to dialysis and physician any concern with dialysis shunt or any changes in the resident condition. -Licensed nursing staff would be responsible for ensuring to have physician orders for the Resident #2 dialysis treatment and monitoring of the dialysis site daily, before and after dialysis treatment. -There should have been a communication form for the facility and the dialysis facility to fill out and add to the Dialysis Communication Binder, but it was not being done.During an interview on 10/10/25 at 9:06 A.M., LPN A said: -The resident should have dialysis order transcribed onto the resident's POS, to include dialysis provider name, chair time and days at dialysis. -He/She would expect to have a physician order for monitoring the resident dialysis shunt every shift, before and after dialysis. -Nursing staff should be monitoring the resident's dialysis shunt site for any bleeding after dialysis, to monitor the shunt for bruit and thrill every shift and after dialysis treatment. -Nursing staff would be responsible for documenting assessment of the resident dialysis shunt finding on the resident special dialysis flow sheet. -There should have been a communication form for the facility and the dialysis facility to fill out and add to the Dialysis Communication Binder, but it was not being done. During an interview on 10/10/25 at 1:57 P.M., Director of Nursing (DON) said:-He/She would expect to have physician's orders for the resident's dialysis services to include, name dialysis clinic, days schedule and chair times. -He/She would expect to have physician orders for the monitoring of the resident dialysis shunt daily and before and after dialysis treatment. -The facility has chart checks completed by night shift nursing staff. -The facility nursing staff would be responsible for check the resident vital signs and shunt for thrill and bruit before and after dialysis. -He/She would expect nursing staff to document assessment on the resident's dialysis communication sheet before and after dialysis treatment. -He/She would expect nursing staff to call the dialysis clinic to obtain the resident's dialysis communication sheet after dialysis treatment.

Based on interview and record review, the facility failed to ensure two sampled residents (Resident #3 and Resident #5) medications were documented as administered as ordered by the physician out of 10 sampled residents. The facility census was 71 residents. Review of the facility's Medication Administration and Monitoring Policy dated 2025 showed: -To ensure quality of care delivery by instructing nursing staff to administer medications safely and appropriately. -Responsibility of nursing professional to: --Be aware of action, correct dosage and route, frequency and other considerations (pulse, blood pressure, meal) is required for administration of medications. --Notify physicians of any acute change in resident condition or status to obtain an order for holding or administering medication. --Coordinate communication between the pharmacy and the physician. --Report to the Director of Nursing (DON) when the resident refuses the medication on two consecutive occasions. -If the medications are not available from pharmacy and the physician authorizes for immediate implementation, use the Emergency box (E-kit) to obtain the medication to provide it to the residents if needed. -Document properly in the E-kit and in nurse notes and notify the pharmacy for replacement. -Circle initials on the Medication Administration Record (MAR) if medications are not administered as ordered and record reason in the as needed (PRN)/omission medication section of the chart (usually on the back of the MAR). -When auditing (monthly, quarterly and/or PRN) by designated licensed nurse, any omission of medication shall be investigated by the asking nurse/CMT and recount the medication. -If there is an actual medication error rather than documentation error, the physician shall be notified. 1. Review of Resident #3's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis: -High Blood Pressure (HTN). -Type II Diabetes Mellitus (DMII - a long-term condition in which the body has trouble controlling blood sugar and using it for energy). -Hyperlipidemia (HLD - high levels of fat particles in the blood). -Neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of the resident's Care Plan dated 4/10/25 showed: -Give medications as ordered. -Allow the resident to make decisions about treatment regime, to provide sense of control. -Educate resident of the possible outcome(s) of not complying with treatment or care. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 4/25/25 showed the resident was cognitively intact. Review of the resident's Physician's Order (POS) and Medication Administration Record (MAR) dated 4/1/25 through 4/30/25 showed: -Blood Pressure, obtain blood pressure once daily for HTN. --Blood pressure was not taken 22 out of 30 opportunities. --Eighteen of the missed blood pressure were left blank, three were the resident refused, and one the resident was out of the facility. -Accuchecks, obtain four times daily with meals and at bedtime for DMII. --Accuchecks were not taken 12 out of 120 opportunities. --Five of the missed checks were left blank, four were refused by the resident, and three of the missed checks the resident was out of the facility. -Amlodipine BES 10 milligrams (mg) Tablet, take one tablet by mouth every day for HTN. --Amlodipine BES 10 mg was not given 13 out of 30 opportunities. --Eleven doses were left blank, one resident was out of the facility, and one the resident refused. -Atorvastatin 20 mg Tablet, take one tablet by mouth every day for HLD. --Atorvastatin 20 mg was not given 13 out of 30 opportunities. --Twelve doses were left blank and one the resident was out of the facility. -Furosemide 40 mg Tablet, take one tablet by mouth every day for HTN. --Furosemide 40 mg was not given 11 out of 30 opportunities. --Ten doses were left blank and one the resident was out of the facility. -Jardiance 25 mg Tablet, take one tablet by mouth every morning for DMII. --Jardiance 25 mg was not given 11 out of 30 opportunities. --Ten doses were left blank and one the resident was out of the facility. -Losartan Potassium 50 mg Tablet, take one tablet by mouth every day for HTN. --Losartan Potassium 50 mg was not given 11 out of 30 opportunities. --Ten doses were left blank and one the resident was out of the facility. -Gabapentin 100 mg Capsule, take two capsules by mouth two times a day for neuropathy. --Gabapentin 100 mg was not given 26 out of 60 opportunities. --All 26 doses were left blank. -Janumet 50 - 1,000 mg Tablet, take one tablet by mouth two times a day for DMII. --Janumet 50 - 1,000 mg was not given 25 out of 60 opportunities. --Twenty-four doses were left blank and one dose the resident was out of the facility. -Insulin Aspart 100 unit/milliliter (ml) (prime pen prior to dose with two units per manufacture), inject eight units subcutaneously (under the skin) three times a day for DMII. --Insulin Aspart was not given 31 out of 90 opportunities. --Eight missed doses were left blank, four the resident was out of the facility, and 19 missed doses were held due to blood sugar levels. ---NOTE: Out of the 19 times the insulin was held due to blood sugar levels, the resident refused accuchecks two times and one time the blood sugar was 65. All other blood sugars documented during those time frames were between 87 - 134 (normal blood sugar ranges from 70-100). --NOTE: The POS and MAR does not have parameters for holding Insulin Aspart when out of range. -Lantus Solostar 100 unit (prime pen prior to dose with two units per MFG), inject 15 units subcutaneously at bedtime for DMII. --Lantus Solostar was not given five out of 30 opportunities. --One dose was blank, two doses were refused by the resident, and two doses were held due to blood sugar levels. ---NOTE: Out of the two times the Lantus was held due to blood sugar levels, the resident's blood sugar was within normal range. --NOTE: The POS and MAR does not have parameters for holding Lantus Solostar when out of range. Review of the resident's Nurse's Notes for April 2025 showed: -No documentation as to why the resident did not receive his/her medications. -No documentation that the physician was notified of the missed medications. Review of the resident's POS and MAR dated 5/1/25 through 5/31/25 showed: -Blood Pressure, obtain blood pressure once daily for HTN. --Blood pressure was not taken 31 out of 31 opportunities. --All 31 of the missed blood pressures were left blank. -Accuchecks, obtain four times daily with meals and at bedtime for DMII. --Accuchecks were not taken 35 out of 124 opportunities. --One of the missed checks was left blank, two were refused by the resident, and 32 of the missed checks the resident was out of the facility. -Amlodipine BES 10 milligrams (mg) Tablet, take one tablet by mouth every day for HTN. --Amlodipine BES 10 mg was not given eight out of 31 opportunities. --Seven doses were left blank and one the resident refused. --NOTE: Six of the missed doses were consecutive days. -Atorvastatin 20 mg Tablet, take one tablet by mouth every day for HLD. --Atorvastatin 20 mg was not given eight out of 31 opportunities. --Seven doses were left blank and one the resident was out of the facility. --NOTE: Six of the missed doses were consecutive days. -Furosemide 40 mg Tablet, take one tablet by mouth every day for HTN. --Furosemide 40 mg was not given two out of 31 opportunities. --Both doses were refused by the resident. -Jardiance 25 mg Tablet, take one tablet by mouth every morning for DMII. --Jardiance 25 mg was not given two out of 31 opportunities. --Both doses were refused by the resident. -Losartan Potassium 50 mg Tablet, take one tablet by mouth every day for HTN. --Losartan Potassium 50 mg was not given two out of 31 opportunities. --Both doses were refused by the resident. -Gabapentin 100 mg Capsule, take two capsules by mouth two times a day for neuropathy. --Gabapentin 100 mg was not given 11 out of 62 opportunities. --Eight doses were left blank and three were refused by the resident. -Janumet 50 - 1,000 mg Tablet, take one tablet by mouth two times a day for DMII. --Janumet 50 - 1,000 mg was not given 9 out of 62 opportunities. --Six doses were left blank and three were refused by the resident. -Insulin Aspart 100 unit/milliliter (ml) (prime pen prior to dose with two units per manufacture), inject eight units subcutaneously (under the skin) three times a day for DMII. --Insulin Aspart was not given 37 out of 93 opportunities. --One missed dose was left blank, 20 missed doses the resident was out of the facility, five doses the resident refused, and nine missed doses were held due to blood sugar levels. --NOTE: The POS and MAR does not have parameters for holding Insulin Aspart when out of range. -Lantus Solostar 100 unit (prime pen prior to dose with two units per MFG), inject 15 units subcutaneously at bedtime for DMII. --Lantus Solostar was not given eight out of 31 opportunities. --Two doses were left blank, one dose was refused by the resident, four doses the resident was out of the facility, and one dose was held due to blood sugar levels. --NOTE: The POS and MAR does not have parameters for holding Lantus Solostar when out of range. Review of the resident's Nurse's Notes for May 2025 showed: -No documentation as to why the resident did not receive his/her medications. -No documentation that the physician was notified of the missed medications. During an interview on 6/3/25 at 1:12 P.M. the resident said: -He/She does not receive his/her medications as ordered by the physician. -If he/she should go out of the facility on a pass he/she does not get his/her medications after returning to the facility if medication pass is done. -He/She needs his/her medications due to serious medical conditions. 2. Review of Resident #5's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis: -High Blood Pressure. -Type II Diabetes Mellitus. -Hyperlipidemia. -Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Chronic Obstructive Pulmonary Disease (COPD - is a common lung disease causing restricted airflow and breathing problems). -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Insomnia (difficulty falling asleep, staying asleep. Or waking up too early). Review of the resident's undated Care Plan showed: -Give medications as ordered by the physician. -Monitor/document side effects and effectiveness. Review of the resident's quarterly MDS dated [DATE] showed the resident was cognitively intact. Review of the resident's POS and MAR dated 4/1/25 through 4/30/25 showed: -ANORO ELLIPTA 62.5 - 25 micrograms (mcg), inhale one puff every day for COPD. --ANORO ELLIPTA 62.5 - 25 mcg was not given five out of 30 opportunities. --All five doses were refused by the resident. -Aspirin EC 81 mg Tablet, take one tablet by mouth every day for HLD. --Aspirin EC 81 mg was not given five out of 30 opportunities. --Two doses were left blank and three were refused by the resident. -Atorvastatin 10 mg Tablet, take one tablet by mouth every day for HLD. --Atorvastatin 10 mg was not given five out of 30 opportunities. --Two doses were left blank and three were refused by the resident. -Escitalopram 20 mg Tablet, take one tablet by mouth every day for depression. --Escitalopram 20 mg was not given four out of 30 opportunities. --All four doses were refused by the resident. -Metformin HCL 500 mg Tablet, take one tablet by mouth every day with/after meals for DMII. --Metformin HCL 500 mg was not given four out of 30 opportunities. --All four does were refused by the resident. -Buspirone HCL 5 mg Tablet, take one tablet by mouth two times a day for anxiety. --Buspirone HCL 5 mg was not given 17 out of 60 opportunities. 11 of the missed doses were the 4:00 P.M. dose. --Thirteen doses were left blank, and four doses were refused by the resident. -Fluticasone PROP HFA 220 mcg, inhale one puff into lungs two times a day for COPD. --Fluticasone PROP HFA 220 mcg was not given 23 out of 60 opportunities. 10 of the missed doses were the 4:00 P.M. dose. --Thirteen doses were left blank, and 10 doses were refused by the resident. -Melatonin 3 mg Tablet, take two tablets (6 mg) by mouth at bedtime for insomnia. --Melatonin 3 mg Tablet was not given 15 out of 30 opportunities. --Thirteen doses were left blank, and two doses were refused by the resident. -Trazodone 100 mg Tablet, take two tablets (200 mg) by mouth at bedtime for insomnia. --Trazodone 100 mg Tablet was not given 20 out of 30 opportunities. --Thirteen doses were left blank, and seven doses were refused by the resident. Review of the resident's POS and MAR dated 5/1/25 through 5/31/25 showed: -Metformin HCL 500 mg Tablet, take one tablet by mouth every day with/after meals for DMII. --Metformin HCL 500 mg was not given two out of 31 opportunities. --Both does were on order and had not been delivered by the pharmacy. -Trazodone 100 mg Tablet, take two tablets (200 mg) by mouth at bedtime for insomnia. --Trazodone 100 mg Tablet was not given three out of four opportunities. --One dose was left blank, and two doses were refused by the resident. --NOTE: No documentation as to why the resident did not receive his/her medications or if the physician was notified of the missed doses. During an interview on 6/3/25 at 11:00 A.M. the resident said: -He/She was not concerned about missing medications. -The medications have been getting better. 3. During an interview on 6/3/25 at 1:29 P.M. the Administrator said: -He/She expects Certified Medication Technicians (CMT)s/nurses to pass medications as ordered by the physician. -The physician should be notified of any missed medications and documented in the resident's medical record the physician was notified. During an interview on 6/4/25 at 1:02 P.M. the Nurse Practitioner (NP) A said: -Would expect CMTs/nurses to give the residents their medications as ordered by him/her or the physician. -If a resident is refusing medications or out of the facility the missed medications should be documented why the medication was missed on the back of the MAR or resident's medical record. -He/She should be notified if a resident refuses his/her medications daily. -He/She had not been notified of medication refusals. -If a resident is out of the facility at the same time or refuses medications at a same time then he/she needs to find out why and change the time of the medication so the resident will take the medication. -He/She was not notified Resident #3 was gone at the same time each day and not getting his/her medications. During an interview on 6/4/25 at 1:29 P.M. CMT A said: -He/She will re-order medications when the resident has three days left of medication. -If the MAR was not signed then the resident did not get their medications. -He/She notifies the charge nurse if the resident refuses medications or if the resident was out of a medication. -The charge nurse is to notify the physician if the resident misses' medications due to refusal or out of the medication. -If the resident was out of the facility during medication pass, he/she would initial the medication and circle his/her initials that shows the resident did not get that medication. During an interview on 6/4/25 at 2:43 P.M. Licensed Practical Nurse (LPN) A said: -Resident #3 is out of the facility a lot during medication pass and comes back after the hour window. -He/She must call the physician to get an order to give the resident his/her medications when the resident get back to the facility. -He/She tried to give the resident his/her medications first when he/she first gets to work before the resident leaves for the day. -He/She notifies the NP/Physician if a resident refuses medications. -Staff should document physician and NP notification in the resident's nurse's notes. -The refusal should be charted on the back of the MAR because the medication was not given. During an interview on 6/4/25 at 3:10 P.M. the Director of Nursing (DON) said: -He/She had educated the CMTs and nurses in the past on making sure they are documenting the medication pass on the resident's MARs and to check the MARs after medication pass to make sure they have signed off on each medication given. -Medications should be given as ordered by the physician. -He/She expects to be notified if a resident keeps refusing medications or has a habit of being out of the facility during medication pass. -He/She expects staff to document on the residents' MARs when a medication had been administered. -He/She expected staff to document in the residents' notes when staff notify the resident's physician of refused medications, any missed doses, or if the resident was out of the facility during the medication administration times. -He/She would expect CMTs and nurses to reorder resident medications at least three days prior to the resident running out of the medication. MO00253692 MO00254572

Based on interview and record review, the facility failed to meet the required discharge requirements for one resident (Resident #1) out of three sampled residents. The facility census was 68 residents. Review of the facility's Protocol for Discharge Planned dated 2022 showed: -Residents who were admitted to the facility would be assessed for potentials upon admission, quarterly and whenever needed as wished or voice by the resident or facility professional staff. -The Quality Assurance (QA) committee discussed the potential discharge (immediate discharge, involuntary discharge) to investigate and analyze if the discharge was the best interest for the residents in the facility and/or for the resident who was discharged . -The QA committee would carefully monitor and discuss before making the decision and consult with the resident's primary physician, family or designated power of attorney (DPOA). When the committee agreed with the decision, the director of operations would be notified and discussed. -The director of operations would authorize the discharge notice. The facility would obtain the physician's order for discharge. -The administrator would issue the letter of notice to the resident and family. 1. Review of Resident #1's Admission Record face sheet showed he/he was admitted to the facility on [DATE] with the following diagnoses: -Anxiety disorder, (persistent and excessive worry about various aspects of life). -Depression, (a mental illness characterized by feelings of sadness, hopelessness and lack of interest or pleasure in activities once enjoyed). -Adjustment disorder, (a mental health condition characterized by emotional and behavioral symptoms in response to a stressor or group of stressors). -He/She was his/her own responsible party. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandate assessment tool required to be completed by staff), dated 2/6/24, showed he/she was cognitively intact. Review of the resident's Notice of Discharge (Immediate Notice) dated 4/29/24 effective at 2:15 P.M. showed: -The safety of individuals in the facility was endangered due to clinical or behavioral status of the resident. -The health of individual in the facility would otherwise be endangered. -The reason for the discharge was his/her physical attempt for suicide by taking a pair of scissors and trying to cut his/her left wrist and continued verbalization of suicide. -Due to the seriousness and/or violent nature of the discharge, filing the appeal would not allow him/her to remain in the facility until the hearing was held unless a hearing officer found otherwise. -There was no discharge location. During an interview on 5/10/24 at 9:46 A.M., Ombudsman A said: -The resident had filed an appeal effective 5/10/24. -The facility had been notified. -The facility would be recommended to take the resident back from the hospital. -There was no letter provided for discharge to the resident or the hospital. -There was a letter the resident signed in the ambulance and sent to the Ombudsman's office, however a copy was not given to the resident. -The resident was in crisis when he/she signed. Review of the resident's Order of Dismissal of discharge date d 5/15/24 showed: -The facility discharged the resident on 4/29/24. -The discharge notice failed to meet the requirements for the discharge notice. -The discharge notice failed to contact the required information prescribed in the provisions of 19 CSR 30-82.050, Specifically : --(4)(B)5. that filing an appeal will allow a resident to remain in the facility until the hearing is held unless a hearing official finds otherwise; --(4)(B)6. The location to which the resident is being transferred or discharged . -The facility did not meet the requirements for appropriate discharge to the resident. During an interview on 5/20/24, Ombudsman A said: -The letter provided to the resident was invalid, so the hearing unit sent a dismissal of the discharge notice. -The letter did not have the information that the resident was allowed to remain in the facility until the hearing decision and it did not have a location for new placement. -On 5/10/24, Ombudsman B reached out to the facility and spoke with the social worker and administrator on-site, advocating for the resident to come back, since the discharge letter was invalid and the resident was in mental health crisis when he/she signed it. -On 5/15/24, the hospital social worker reached out to the facility and the facility social worker said he/she could not return. During an interview on 5/30/31 at 3:00 P.M., Social Worker A said the resident got a copy of his/her discharge notice when he/she signed it. During an interview on 5/31/24 at 3:00 P.M., the Administrator said: -He/She made the decision to discharge the resident. -He/She got a letter stating the resident's discharge was inappropriate from [NAME] City. By that time the resident had already been placed at another facility. MO00235779

Based on interview and record review, the facility failed to permit one sampled resident (Resident #1) to return to the facility out of three sampled residents. The facility census was 68 residents. 1. Review of Resident #1's Admission Record face sheet showed he/he was admitted to the facility on [DATE] with the following diagnoses: -Anxiety disorder, (persistent and excessive worry about various aspects of life). -Depression, (a mental illness characterized by feelings of sadness, hopelessness and lack of interest or pleasure in activities once enjoyed). -Adjustment disorder, (a mental health condition characterized by emotional and behavioral symptoms in response to a stressor or group of stressors). -He/She was his/her own responsible party. Review of the resident's Care Plan dated 11/7/23 showed: -The resident had a diagnosis of depression and was being medicated and observed for it. -The resident did not have any care planning for behaviors. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning), dated 2/6/24, showed he/she was cognitively intact. Review of the resident's Nurse's Notes dated 4/29/24 at 2:00 P.M. showed he/she had a suicidal attempt and was transferred to the hospital. Review of the resident's Social Service Progress Notes dated 4/29/24 at 2:20 P.M. showed the resident was served an immediate discharge notification for suicidal attempt and ideation. Review of the hospital Progress Notes dated 5/2/24 showed: -The facility was contacted to inquire about discharge and return at 12:51 P.M. -Qualified Mental Health Professional/Social Worker A (QMHP) asked to speak with someone regarding discharge arrangements for the resident. He/she was transferred to the DON. -The DON asked for the resident's name and responded that he/she had been discharged . -The DON refused to state a date. He/She responded to each question that he/she didn't have the patient's information in front of him/her and refused or was unable to provide details to QMHP's questions. -The DON stated the resident was alert and oriented and able to share information to answer these questions. -QMHP said the resident had stated he/she had been discharged on [DATE]. -The DON continued to insist the resident was discharged and could not return, and that a social worker would be able to find other placement. -QMHP stated the resident was by law required to have a 30-day written notice for evictions. The DON continued to repeat the same statement that the resident had been discharged . -QMHP asked if there was anyone else he/she could speak with regarding this resident. -The DON asked for the name, call-back number and title and said this information would be passed along. -QMHP informed supervisor, who left a voice mail for legal representative to inquire about patient rights at 1:00 P.M. -QMHP received a call back from the facility at 1:11 P.M. from the DON, who stated he/she was the person QMHP previously spoke with and was informed the facility would work on placement of the resident, but he/she still could not return to the facility due to being discharged . -The DON reported that a local homeless shelter's administrator would work on the referral and asked for his referral to be faxed to his/her number. -QMHP faxed referral and informed treatment team and supervisor of interaction. During an interview on 5/10/24 at 9:46 A.M., Ombudsman A said: -The resident had filed an appeal to the discharge effective 5/10/24. -The facility had been notified. -The facility would be recommended to take the resident back. -The facility social worker said the resident was suicidal and continued to be suicidal after the police had come. -The resident was sent to the hospital for evaluation. -There was no letter provided for discharge to the resident or the hospital. -There was a letter the resident signed in the ambulance and sent to the Ombudsman's office, however a copy was not given to the resident. -The resident was in crisis when he/she signed. Review of the resident's Order of Dismissal of discharge date d 5/15/24 showed: -The facility discharged the resident on 4/29/24. -The discharge notice failed to meet the requirements for the discharge notice. -The resident was given inadequate notice. -The resident could remain at the facility. During an interview on 5/20/24, Ombudsman A said: -On 5/10/24, Ombudsman B reached out to the facility and spoke with the social worker and administrator on-site, advocating for the resident to come back, since the discharge letter was invalid and the resident was in mental health crisis when he/she signed it. -On 5/15/24, the hospital social worker reached out to the facility and the facility social worker said he/she could not return. During an interview on 5/30/24 at 12:55 P.M., Ombudsman B said: -The facility was set in their decision not to take the resident back because he/she had actively been trying to cut his/her wrists, even when the staff were trying to stop him/her. -If the resident had an emotional emergency, the facility did the right thing by sending him/her to the hospital for evaluation. -Once the resident was stable, he/she did not meet the criteria for discharge from the facility. -The resident said he/she had made his/her home at the facility and hoped they would forgive him/her and allow him/her to come back. He/She was willing to go back. He/She was calling Ombudsman's office regularly to see if he/she could go back. During an interview on 5/30/31 at 1:55 P.M., the DON said: -The hospital social worker had called and spoke to the DON after hours and immediately said, I'm going to hotline you if you don't take the resident back. -The hospital never tried to send the resident back, have a nurse call report or give them a pick-up time. -He/she was aware that the administrator said he could not come back. -He/She knew they could not discharge the resident to the hospital. During an interview on 5/30/31 at 3:00 P.M., Social Worker A said: -The resident was not given a bed hold because he/she had been discharged . -The administrator made the decision of not allowing the resident to come back. During an interview on 5/31/24 at 3:00 P.M., the Administrator said: -He/she had made the decision the resident could not return to the facility after the resident hospital stay. He/she had discharged the resident. -He/She did not talk to an ombudsman, but got a letter stating the resident's discharge was inappropriate from [NAME] City. By that time the resident had already been placed at another facility. During an interview on 6/5/24 at 2:00 P.M., Hospital Social Worker A said: -The facility did not provide any paperwork for the resident. -The hospital staff checked through the resident's clothing and found nothing. -The resident signed his/her discharge notice while being transported by the EMTs. MO00235779

Based on observation, interview, and record review, the facility failed to have a Registered Nurse (RN) for eight consecutive hours a day for seven days a week, and failed to ensure the Director of Nursing (DON) did not serve as the charge nurse, when the facility maintained a daily census of more than 60 residents. This deficiency had the ability affect all residents. The facility census was 68 residents. Review of the facility's undated policy, titled Policy for Staffing showed: -A RN was required eight hours a day, seven days a week. -The DON was not to provide cares of treatments for residents unless the facility had 60 or less residents. 1. Review of DON's time sheet from 1/1/23-11/31/23 showed he/she did not work eight consecutive hours for 184 days out of 334 days. 2. Review of the facility's daily census showed the facility had greater than 60 residents during the survey. During an interview on 12/6/23 at 11:00 A.M., the Administrator said: -When the facility is short-staffed due to an employee not showing up, the DON will occasionally come in and work in their place. -The DON provided treatments for residents when he/she covered a shift for another employee. Observation on 12/7/23 at 7:59 A.M. showed the DON was passing medications to residents. During an interview on 12/7/23 at 8:06 A.M., the DON said: -The facility had staffing issues since he/she had been employed so he/she generally worked extra hours. -He/she came in on the weekend to assist the Licensed Practical Nurses (LPNs) so they did not become overwhelmed. -He/she provided treatment and cares to resident during his/her hours worked. -He/she assisted with medications and orders when the facility was short-staffed. -He/she was not in his/her office much except for the weekends. Observation on 12/7/23 at 8:58 A.M. showed the DON was feeding a resident. During an interview on 12/8/23 at 9:19 A.M., Certified Nursing Assistant (CNA) A said: -The DON provided treatments and cares to the residents at least four times a week, as well as on the weekends and overnight. -He/she frequently saw the DON passing medications and providing nursing care. During an interview on 12/8/23 at 9:28 A.M., CNA B said the DON worked the floor all the time. During an interview on 12/8/23 at 10:05 A.M., LPN A said: -The DON worked as nursing staff whenever an employee did not show up. -He/she believed the DON provided nursing cares to residents an average of a week or more each month. During an interview on 12/8/23 at 10:26 A.M., LPN B said the DON provided nursing cares to resident every day. 3. During an interview on 12/7/23 at 10:26 A.M., the Administrator said the DON was the only RN that worked in the facility from 1/1/23-11/30/23. During an interview on 12/7/23 at 12:07 A.M., the Administrator said: -He/she was aware the DON was not to provide resident cares or treatments when the average daily census was more than 60 residents. -He/she was aware the DON helped out with resident cares and treatments. -He/she was aware there were days when the facility did not have a RN for eight consecutive hours, seven days a week. During an interview on 12/8/23 at 1:49 P.M., the DON said: -He/she provides resident treatment and cares when needed. -He/she performed a majority of his/her DON responsibilities while assisting staff with resident cares and treatments. -He/she assisted staff by entering orders, providing wound care to residents, and reviewing labs. -He/she was not aware that he/she was the only RN that worked in the facility from 1/1/23-11/30/23. -He/she expected federal and state regulations to be followed. -He/she was not aware the DON could not provide resident cares or treatment when the facility's average daily census was greater than 60 residents.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) received yearly evaluations and education based on the result of those findings. This had the potential to affect all residents. The facility census was 68 residents. A copy of the facility's CNA yearly evaluation policy was requested and not received at time of exit. 1. A request for the evaluations and education of CNAs was made to the Administrator and not received at time of exit. During an interview on 12/6/23 at 11:00 A.M., the Administrator said: -He/she did not perform staff evaluations yearly. -He/she performed evaluations only when there was a problem. During an interview on 12/8/23 at 9:28 A.M., CNA B said: -He/she had worked at the facility for two years. -He/she had never had an evaluation.

Based on observation, interview, and record review, the facility failed to ensure staffing was posted correctly at the beginning of each shift including facility name, date, census, and the total number and actual hours worked per shift which could have the potential to affect all residents in the facility. The facility census was 68 residents. The facility's undated policy, titled Policy for Staffing showed a staffing board was required to be displayed in a public area. 1. Observation on 12/4/23 at 8:52 A.M. showed no staffing sheets posted at the front desk or either nurse station. Observation on 12/5/23 at 9:04 A.M. showed: -Staffing sheets were taped under the counter of both nurse stations, facing the staff, unable to be seen by residents or visitors. -Staffing sheets did not include the resident census or number of hours for each discipline. During an interview on 12/5/23 at 9:06 A.M., the Director of Nursing (DON) said: -He/she was responsible for posting the staffing sheets. -He/she posted staffing sheets at both the north and south nurse stations. -He/she had not had time to posting the staffing sheets that day. Observation on 12/6/23 at 9:28 A.M. showed no staffing sheets posted at the front desk or either nurse station. Observation on 12/7/23 at 7:49 A.M. showed: -No staffing sheets posted at the front desk or either nurse station. -The DON was in the building. Observation on 12/8/23 at 9:53 A.M. showed: -No staffing sheet posted at the front desk or south side nurse station. -A staffing sheet was taped under the counter of the north nurse station, facing the staff, unable to be seen by residents or visitors. During an interview on 12/8/23 at 1:49 P.M., the DON said: -He/she posted the staffing sheets every day. -He/she posted the staffing sheets to face toward the nurse station so nursing staff could see it. -He/she did not know the staffing sheets were to be visible to visitors and residents, he/she thought it was for the staff only.

Based on observation, interview and record review, the facility failed to follow the menu for breakfast on 12/7/23, by not serving cinnamon rolls according the menu for that day. This practice potentially affected all residents who received food from the kitchen. The facility census was 68 residents. 1. Record review of the Week 2 Week-at-a-Glance Menu, dated 2023, showed the following items for breakfast: - Assorted juice. - Choice of hot or cold cereal. - Egg of choice. - Bacon. - Cinnamon Roll. - Margarine. - Milk/Beverage. Observation on 12/7/23 from 8:15 A.M. through 8:42 A.M., during the breakfast meal service showed no cinnamon rolls were served with breakfast to any resident and no substitution was served to the residents. During an interview on 12/7/23 at 8:44 A.M., Dietary Aide (DA) C said there were no cinnamon rolls to serve during the breakfast meal that morning. During an interview on 12/8/23 at 2:14 P.M., the Dietary Manager (DM) said the following: - The facility's supplier of baked goods does not have cinnamon rolls. - The facility food delivery service did not have cinnamon rolls for the facility to order. - In the future, he/she would request the Registered Dietitian (RD) to change cinnamon rolls to Danishes (a sweet pastry for one person, often filled with fruit or cheese) on the menu. During a phone interview on 12/12/23 at 1:32 P.M., the RD said: - He/she has been going to the facility on ce per month. - The facility has a substitution log that they should write down substitutions used. - He/she was not aware that the facility's grocery supplier did not have cinnamon rolls.

Based on interview and record review, the facility failed to submit accurate information to the Payroll Based Journal data (PBJ-a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for two of the last four quarters, which had the potential to affect all residents. The facility census was 68 residents. A copy of the Centers for Medicare and Medicaid (CMS) policy, dated August 2015, titled Electronic Staffing Data Submission Payroll-Based Journal showed: -Staff were required to submit accurate and timely information. -The nursing home was ultimately responsible for accuracy of each submission, even if the facility used a third party vendor to submit information on behalf of the nursing home. 1. Review of the facility's PBJ Quarter One (2023) from 10/1/22-12/31/22 showed no licensed nurse coverage 24 hours a day. Review of the facility's payroll, dated 10/1/22-12/31/22 showed a licensed nurse was on duty each shift. Review of the facility's PBJ Quarter Two (2023) from 1/1/23-3/31/23 showed no licensed nurse coverage 24 hours a day. Review of the facility's payroll, dated 1/1/23-3/31/23 showed a licensed nurse was on duty each shift. During an interview on 12/7/23 at 9:21 A.M., the Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) Coordinator said: -He/she was responsible for submitting information to the PBJ. -He/she received the information from the Administrator. -The facility used a third party vendor for payroll. -The vendor sent a file with hours worked for each department but they were coded and he/she did not know what the codes meant. -He/she normally submitted to the PBJ early so he/she could find problems and fix them before the deadline for submission. During an interview on 12/7/23 at 12:06 P.M., the MDS Coordinator said: -The PBJ submissions were not correct for Quarter One (2023) or Quarter Two (2023). -The facility had a licensed nurse on each shift for both quarters. During an interview on 12/8/23 at 1:49 P.M., the Director of Nursing (DON) said he/she expected the PBJ submissions to be submitted on time and accurately.

Based on observation, interview, and record review, the facility failed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure the cohorting of residents was not allowed after three residents (Residents #1, #2, and #3) out of 13 sampled residents tested positive for COVID-19 on 1/14/22 and were allowed to stay in their rooms with five residents (Residents #4,# 5, #6, #7 and #8) who had tested negative for COVID-19. The facility census was 61 residents. The Administrator was notified on 1/16/22 at 11:42 A.M. of an Immediate Jeopardy (IJ) which began on 1/14/22. The IJ was removed on 1/18/22 as confirmed by surveyor onsite verification. Record review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated September 10, 2021, showed: -Older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as [CONDITION(S)]-CoV-2 (the pathogen that causes COVID-19 infection). -Even as nursing homes resume normal practices, they must sustain core infection prevention and control (IPC) practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and health care personnel (HCP) in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death. -Identify Space in the Facility that could be dedicated to monitor and care for residents with confirmed [CONDITION(S)]-CoV-2 infection. -The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with [CONDITION(S)]-CoV-2 infection. -Residents should only be placed in a COVID-19 care unit if they have confirmed [CONDITION(S)]-CoV-2 infection. Record review of the facility COVID-19 Cohorting and Transitional Policy Updated, 8/2021, showed: -The purpose of the policy was to ensure the proper transitional procedures during COVID-19 outbreak. -Preventing the spreading of infection is critical to prevent entry and spread of COVID-19 in long-term care facilities. -Isolation separates residents with a contagious disease, like COVID-19 from people who are not sick. -Quarantine separates and restricts the movement of people who were exposed to, or may have been exposed to a contagious disease, like COVID-19 in case they become infectious. -Cohorting is an infection prevention and control strategy that includes physical and procedural controls to separate infectious residents and decrease risk of transmission to uninfected residents. -The facility designates three different zone areas to indicate the locations and transfer policy from zone to zone. -Full transmission-based precautions and all recommended COVID-19 personal protective equipment (PPE - medical equipment worn to protect from infection) should be used for all residents who are COVID-19 positive, symptomatic or suspected of having COVID-19, unvaccinated new and re-admissions, exposed to any COVID-19 positive person (staff, visitor, roommate). -Red Zone for COVID positive (confirmed) residents - full PPE - Gown, N95 Respirator, eye protection (goggles/face shield), gloves, room doors should be kept closed unless resident safety concerns require reopening, visitations should be restricted to compassionate/end of life visits only. -Yellow Zone for new admissions, exposed residents, symptomatic residents awaiting confirmation of test results - full PPE, room doors should be kept closed unless patient safety concerns require reopening, exposed residents are those with a positive COVID roommate or exposure to positive staff member. 1. Record review of Resident #1's Admission Record showed he/she had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning), dated 12/4/21, showed: -He/she was cognitively intact. -He/she had no behavioral symptoms. -He/she was independent with transfer (moving between surfaces including from bed/chair to a standing position). Record review of the resident's COVID-19 Testing Verification Form, dated 1/14/22, showed: -The resident was tested for COVID-19 on 1/14/22. -The resident's test result was positive for COVID-19. Observation on 1/15/22 at 1:03 P.M., showed the resident in his/her four bed room with residents #4, #5, and #6, all who had tested negative for COVID-19 on 1/14/22. Observation on 1/15/22 at 4:33 P.M., showed the resident had been moved to the COVID-19 isolation area of the facility in a room beyond the zippered plastic barrier in the South resident room hallway. 2. Record review of Resident #2's Admission Record showed he/she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed: -He/she was severely cognitively impaired. -He/she had no behavioral symptoms. -He/she received limited assistance form one staff person for transfer and used a wheelchair for mobility. Record review of the resident's COVID-19 Testing Verification Form, dated 1/14/22, showed: -The resident was tested for COVID-19 on 1/14/22. -The resident's test result was positive for COVID-19. Observation on 1/15/22 at 1:02 P.M. P.M. showed the resident in his/her four bed room with Residents #7 and #8 who tested negative for COVID-19 on 1/14/22. Observation on 1/15/22 at 4:33 P.M., showed the resident had been moved to the COVID-19 isolation area of the facility in a room beyond the zippered plastic barrier in the South resident room hallway. 3. Record review of Resident #3's Admission Record showed he/she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed: -He/she was moderately cognitively impaired. -He/she had behavioral symptoms toward others. -He/she received setup assistance with transfers and used a wheelchair for mobility. Record review of the resident's COVID-19 Testing Verification Form, dated 1/14/22, showed: -The resident was tested for COVID-19 on 1/14/22. -The resident's test result was positive for COVID-19. Observation on 1/15/22 at 1:02 P.M., showed the resident in his/her four bed room with Residents #7 and #8 who tested negative for COVID-19 on 1/14/22. Observation on 1/15/22 at 4:33 P.M., showed the resident had been moved to the COVID-19 isolation area of the facility in a room beyond the zippered plastic barrier in the South resident room hallway. 4. Record review of Resident #4's Admission Record showed he/she had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed: -He/she was cognitively intact. -He/she had no behavioral symptoms. -He/she was independent in transfer and walking. Record review of the resident's COVID-19 Testing Verification Form, dated 1/14/22, showed: -The resident was tested for COVID-19 on 1/14/22. -The resident's test result was negative for COVID-19. Observation on 1/15/22 at 12:53 P.M. showed the resident in his/her four bed room with Resident #1 who tested positive for COVID-19 on 1/14/22. 5. Record review of Resident #5's Admission Record showed he/she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed: -He/she was cognitively intact. -He/she had no behavioral symptoms. -He/she received extensive one staff person assistance for transfer and used a wheelchair for mobility. Record review of the resident's COVID-19 Testing Verification Form, dated 1/14/22, showed: -The resident was tested for COVID-19 on 1/14/22. -The resident's test result was negative for COVID-19. Observation on 1/15/22 at 12:53 P.M. showed the resident in his/her four bed room with Resident #1 who tested positive for COVID-19 on 1/14/22. 6. Record review of Resident #6's Admission Record showed he/she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed: -He/she was severely cognitively impaired. -He/she had no behavioral symptoms. -He/she received limited one staff person assistance for transfer and used a wheelchair for mobility. Record review of the resident's COVID-19 Testing Verification Form dated 1/14/22 showed: -The resident was tested for COVID-19 on 1/14/22. -The resident's test result was negative for COVID-19. Observation on 1/15/22 at 12:53 P.M. showed the resident in his/her four bed room with Resident #1 who tested positive for COVID-19 on 1/14/22. 7. Record review of Resident #7's Admission Record showed he/she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's quarterly MDS, dated [DATE], showed: -He/she was severely cognitively impaired. -He/she had no behavioral symptoms. -He/she received limited one staff person assistance for transfer and used a wheelchair for mobility. Record review of the resident's COVID-19 Testing Verification Form, dated 1/14/22, showed: -The resident was tested for COVID-19 on 1/14/22. -The resident's test result was negative for COVID-19. Observation on 1/15/22 at 1:02 P.M., showed the resident in his/her four bed room with Residents #2 and Resident #3 who tested positive for COVID-19 on 1/14/22. Record review of the resident's COVID-19 Testing Verification Form, dated 1/17/22, showed: -The resident was tested for COVID-19 on 1/17/22. -The resident's test result was positive for COVID-19. 8. Record review of Resident #8's Admission Record showed he/she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed: -He/she was severely cognitively impaired. -He/she had no behavioral symptoms. -He/she was independent for transfer and walking. Record review of the resident's COVID-19 Testing Verification Form, dated 1/14/22, showed: -The resident was tested for COVID-19 on 1/14/22. -The resident's test result was negative for COVID-19. Observation on 1/15/22 at 1:02 P.M., showed the resident in his/her four bed room with Residents #2 and Resident #3 who tested positive for COVID-19 on 1/14/22. 9. During an interview on 1/15/22 at 2:48 P.M., LPN C charge nurse on the South side of the building said: -Resident #1 tested positive for COVID-19 on 1/14/22. -Resident #2 tested positive for COVID-19 on 1/14/22. -Resident #3 tested positive for COVID-19 on 1/14/22. -He/she was told in the 7:00 A.M. nursing shift report on 1/15/22 that residents including Residents #1, #2 and #3 had tested positive for COVID-19 on 1/14/22; at that time the residents remained in the same rooms with the same roommates, including with their roommates who had tested negative for COVID-19 on 1/14/22. -He/she did not know why Residents #1, #2 and #3 had not been moved to the COVID-19 isolation area beyond the plastic barrier on the South hall, they should have been moved on 1/14/22. During an interview on 1/15/22 at 12:53 P.M., Licensed Practical Nurse (LPN B), charge nurse on the North side of the building said: -The Infection Preventionist completed COVID-19 tests for facility residents on 1/14/22, completing the tests by around lunch time. -Eleven residents tested positive for COVID-19 on 1/14/22. -Some, not all of the residents were moved to different rooms, he/she could not say what happened on the South Hall. During an interview on 1/15/22 at 4:12 P.M., the Administrator said: -A total of eleven residents tested positive for COVID-19 on 1/14/22, including Residents #1, #2, and #3. -Resident #1's three roommates, Residents #4, #5, and #6 tested negative for COVID-19 on 1/14/22. -Resident #2 and #3's two roommates, Resident's #7 and #8 tested negative for COVID-19. -Resident's #1, #2 and #3 should have been moved to the COVID Isolation Red Zone, behind the plastic barrier on the South hall as soon as the positive COVID-19 results were known on 1/14/22 so that they no longer shared a room with Residents #4, #5, #6, #7, and #8 who tested negative for COVID-19 on 1/14/22. -He/she could not say why Resident's #1, #2, and #3 were not moved to the COVID-19 Red Isolation area, except that 1/14/22 was a chaotic day. During a telephone interview on 1/20/22 at 11:52 A.M., the Infection Preventionist (IP) said: -He/she completed resident COVID-19 testing on 1/14/22 by about 2:30 P.M. -He/she told the charge nurses to move the residents who were positive to the COVID unit, behind the plastic curtain (the infection control barrier for the COVID unit), including Resident #1, #2 and #3. -He/she was at the facility until about 8:00 P.M., it was very chaotic moving residents. -He/she could not say why Resident's #1, #2 and #3 remained in their rooms with their roommates that were not positive for COVID. -The charge nurse called him/her on 1/15/22 regarding that Resident's #1, #2 and #3 were in rooms with their COVID negative roommates. -He/she told the charge nurse to move Residents #1, #2 and #3 to the COVID unit and to put their roommates on quarantine due to their exposure to COVID. -Resident's #1, #2 and #3 were not moved to the COVID unit on 1/14/22. He/she could not say why this was not done on 1/14/22 except that 1/14/22 was a very chaotic day at the facility. The residents were moved to the COVID unit in the afternoon on 1/15/22. During a telephone interview on 1/20/22 at 12:44 P.M., the facility Medical Director said: -When resident's test positive for COVID-19 the facility was to place those resident's in quarantine. -Those COVID positive resident's with roommates would need to move to another room or the COVID negative roommates would need to move to another room, depending on the facility policy and on available rooms for isolating COVID positive residents together and separated from COVID negative residents. -COVID positive residents needed to be in quarantine with other COVID positive residents for the recommended amount of time; the recommended amount of isolation time has changed over time. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 919

Based on observation, interview, and record review, the facility staff failed to protect residents from mental anguish and intimidation when staff forced two residents (Resident's #1 and #2) to bathe against their will. Resident #1 swung his/her arms at staff and repeatedly told staff to stop. Resident #1 said he/she felt like he/she was raped, molested, and violated. The facility census was 71 residents. Record review of the facility policy and procedure regarding Abuse and Neglect, revised 2016, showed in part: -The Code of Federal Regulation (CFR) provides the following regulatory definitions of abuse and neglect at 42 CFR 488.301: --Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.; --Emotional or psychological abuse: The verbal or non-verbal infliction of anguish, pain, or distress that results in mental or emotional suffering; Failure to offer a choice when the individual is capable of making choices. -Purpose: To ensure the residents' rights are respected. These rights provide protection from physical and mental abuse, corporal punishment, involuntary seclusion and any physical or chemical restraints imposed for the purpose of discipline or convenience of staff. All employees of the facility are considered to be staff. To ensure that each resident is treated with dignity and care, free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. -Policy: Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, volunteers, individual contractors or other staff agencies that provide services to residents or the facility and visitors including the individual, family members, or legal guardians, friends, or other individuals. All suspected incidents must be investigated immediately. Record review of the facility policy and procedure regarding personal care, tub and shower bath, showed the policy does not include any information regarding what to do if a resident refuses to bathe. 1. Record review of the Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment tool required to be completed by facility staff and used care planning), dated 1/15/16, showed: -Was admitted on [DATE]; -Cognitively intact; -Had verbal behaviors towards others four to six days per week, had other behaviors one to three days per week, and rejected care one to three days per week; -Required extensive assistance of one staff for bed mobility, dressing, toilet use, and bathing; -Was totally dependent on one staff for transfers from one surface to another; -Had [DIAGNOSES REDACTED]. Record review of the resident's care plan regarding his/her bathing deficit, updated on 1/20/16, showed staff were instructed to document his/her refusals of care and continue to encourage the resident to allow staff to help him/her. Record review of the resident's care plan, updated 10/1/15, regarding his/her impaired coping, history of manipulative and attention seeking behaviors, malingering and his/her repeated verbalizations of unhappiness related to placement at this facility, showed staff were instructed to: -Encourage the resident to talk and give realistic assurance; -Encourage him/her to discuss his/her fears and anxiety, allow to cry, report tears and crying; -Encourage him/her to discuss feelings about placement in a long term care facility, his/her physical condition, and loss of independence; -Use kind firmness to reinforce facility policies; -Validate his/her complaints; -Two staff members should be present at all times when providing care. Record review of the resident's nurse's note, dated 2/11/16 at 8:30 A.M., showed staff documented the resident continued to refuse showers. Record review of the resident's nurse's note, dated 2/20/16 at 9:00 P.M., showed staff documented the resident refused incontinent care, refused to go to bed, and his/her clothing was soiled. Record review of the resident's nurse's note, dated 3/22/16 at 10:00 P.M., showed staff documented they gave the resident a complete bed bath, he/she refused all cares, yelled and screamed the entire time. Scheduled doctor's appointment on 3/23/16, left in bed due to severe agitation. Staff gave the resident [MEDICATION NAME] 2 milligrams (mg) and [MEDICATION NAME]. Record review of the resident's Medication Administration Record [REDACTED] -One [MEDICATION NAME] at 3:00 P.M. for anxiety rated 10 out 10, Registered Nurse (RN) A documented it was effective; -One [MEDICATION NAME] at 11:00 P.M. for anxiety rated 10 out of 10, RN A documented it was effective. Record review of the resident's MAR for controlled substances showed an order for [REDACTED].M. for generalized pain rated 8 out of 10, it was effective and his/her pain decreased to a 2/10. Record review of the resident's MAR for controlled substances showed an order for [REDACTED]. Record review of the resident's Physician Order Sheet (POS), dated April 2016, showed physician's orders for: -[MEDICATION NAME] Dr (antidepressant) 20 mg one capsule twice daily for depression; -[MEDICATION NAME]/[MEDICATION NAME] (antianxiety) 2 mg every six hours as needed for increased anxiety; -[MEDICATION NAME] (pain medication) 50 mg 1-2 tablets by mouth every four to six hours as needed for pain. Record review of the resident's MAR for controlled substances for [MEDICATION NAME] 50 mg every 4-6 hours as needed for pain, showed staff gave the resident [MEDICATION NAME] on 4/6/16. Record review of the resident's physician's progress note, dated 4/7/16, showed: -Staff reports: agitation and refusing baths; -Patient reports: Patient upset about staff bothering him/her about baths; -Observation: Patient calm at this time; -[MEDICAL CONDITIONS]- patient does have history of [MEDICAL CONDITION] and had heightened anxiety during a recent bath; -The physician discussed the need for routine hygiene with the patient, but reinforced with him/her and staff that he/she does have the right to refuse; -The resident reported feeling safe at this time and understood he/she needed to cooperate in getting his/her needs met. During an interview on 4/7/16 at 10:05 A.M., Resident #1 said: -A few weeks ago, he/she was forced to take a bath one evening because he/she had a doctor's appointment the next day. He/she was not soiled, wet or in dirty clothes; -He/she was outside smoking and Certified Nurse Aide (CNA) A came up behind him/her and told him/her he/she had no choice and had to take a bath. The staff forced him/her to go to his/her room. Then the staff took his/her clothes off without his/her permission, and held his/her hands down because he/she started to fight with them; -It was done by CNA A and CNA B because RN A, the charge nurse, told them to do it. He/she felt like RN A did it because he/she had hotlined the facility previously; -He/she felt like he/she was raped, violated and molested, and begged them to stop. He/she told them don't touch me and started fighting them. He/she swung his/her gait belt at the male CNA but not the female CNA. He/she said he/she was hollering and screaming; -The CNA's refused to give him/her back his/her clothes, he/she did not want to be stuck in bed after that, but was forced to stay in his/her bed the rest of the night. RN A gave him/her two [MEDICATION NAME] and two [MEDICATION NAME] to try to calm him/her afterwards, he/she felt like the nurse was trying to knock me out; -He/she still has nightmares about what happened; -His/her muscles hurt the next day; -He/she was not physically hurt, but he/she was emotionally upset; -He/she did not want to be here after that night; -He/she is his/her own guardian and can make his/her own decisions; -He/she has [MEDICAL CONDITION]. The next day he/she felt nasty because of what happened and stayed in his/her room most of the day. He/she refused to go to his/her psychiatric appointment the next day because of what happened. During an interview on 4/7/16 at 12:48 P.M., CNA B said: -He/she has been a CNA for seven months, and has been employed at this facility for two months. He/she usually works in the evening; -If a resident refuses to bathe he/she will ask the resident again later in the evening. If the resident refuses again, he/she will tell his/her charge nurse. -Resident #1 usually refuses to bathe; -They have to push him/her to bathe, he/she fought, kicked and screamed, but they bathed him/her anyhow because he/she refuses a lot. They put him/her on the bed and gave him/her a bed bath; -The resident yelled and screamed they were raping and molesting him/her, the resident said to get him/her off the bed, and he/she was going to report them to the police; -This happened one time two to three weeks ago. CNA A and CNA B bathed the resident. The charge nurse said they had to bathe the resident because he/she had a doctors appointment the following morning. They went to get the resident while he/she was smoking; -In CNA training he/she was taught if the resident refuses, try again, if they refuse again they were not to give a bath and to tell the charge nurse; -He/she felt bad about it, but they did it because the charge nurse said to do whatever it took; -He/she felt like they were forcing the resident to do something he/she did not want to do; -The charge nurse was aware the resident did not want to bathe because the resident started screaming in the hall way before they got him/her to his/her room; -At the time he/she was not really thinking it was abusive, but just following what his/her charge said to do; -After he/she felt bad, and wondered if it was abusive; -He/she knows he/she has to report abuse, but he/she did not tell anyone because it was his/her charge nurse's directive. During interviews on 4/7/16 at 1:31 P.M. and 3:03 P.M., RN A said: -He/she has worked at the facility for nine months; -A lot of the residents refuse to bathe. When they refuse, he/she gives them a choice between a shower or a bed bath at bed time. If they still refuse he/she marks it as refused; -Incontinent residents get a partial bed bath when they give them care; -He/she was not aware of any resident being forced to bathe; -Maybe at the beginning of March, Resident #1 had diarrhea all over him/her and he/she was trying to go in the dining room. He/she heard about it from residents using a loud voice telling the resident to leave the dining room. RN A took the resident to his/her room and put him/her down for incontinence care. The resident was mad at the other resident, but not at staff for cleaning him/her up. After the incontinent care, they got him/her back up in his/her wheelchair; -Staff would not force a resident to bathe as it's against their rights. He/she has not ever heard the resident say he/she felt violated, raped or molested; -He/she knows Resident #1 refused his/her outside physician appointments; -RN A works on Tuesdays and would have been there on 3/22/16; -He/she never remembers forcing anyone to get a bed bath. If they refuse that's their right and they let the Administrator know. The aides aren't going to force anyone; -He/she does not remember documenting that Resident #1 had a complete bed bath on that night, yelling and screaming the entire time, but the resident does refuse care; -He/she would not force anyone to bathe even if Resident #1 had an appointment the next day. The resident has hotlined them before for not having him/her clean at one of his/her appointments. He/she refuses baths a lot. He/she would just let the night shift know the resident still needs a bath before the appointment the next morning; -The resident does not go to bed in the evenings and he/she stays up all night; -He/she knows not to force any resident to bathe. If they don't want it, they don't have to have it; -He/she would expect the CNA's to leave the resident alone if the resident was yelling, screaming feeling violated, raped and molested. - 95% of these residents take [MEDICAL CONDITION] medications and they want to avoid confrontation at all times because of their mental health issues. During an interview on 4/8/16 at 11:15 A.M., the Medical Director said: -He/she saw Resident #1 yesterday after the Director of Nursing (DON) informed him/her of what happened; -The resident told him/her he/she was forced to bathe; -The resident has a history of [MEDICAL CONDITION]; -He/she wants the resident to have the right to refuse. He/she did discuss with the resident the importance of good hygiene and also his/her right to refuse; -He/she believed the staff intentions were good but once the resident was saying no, feeling violated, molested the staff should have stopped; -Staff think they needed to get him/her clean for his/her appointment but they crossed a line that day; -His/her assessment on 4/7/16, showed the resident felt safe, he/she was calm, he/she was a good historian, he/she is his/her own responsible party and able to make his/her own decisions. The resident psyche was good, he/she did not feel he/she needed to be sent for immediate psychiatric care. During an interview on 4/8/16 at 3:12 P.M., CNA A said: -He/she has been a CNA for four years and has worked at the facility since May 2015; -He/she has had training on what to do if he/she witnesses abuse, he/she is to tell the Administrator, DON, and charge nurse; -Some residents refuse bathing; -Resident #1 refused bathing often; -About two to three weeks ago, the charge nurse, RN A, told them to give the resident a bath. The nurse said to do whatever you have to do to give him/her a bath because we were cited by the state for him/her smelling and having long nails. The resident had a physician's appointment the next day. -He/she got the resident from smoking and wheeled him/her to his/her room to give him/her a bed bath; -As they started to get the resident into the bed and remove his/her clothing the resident started yelling stop, stop, you're abusing me. He/she told the resident, we are just giving you a bath so you smell good for your appointment; -The resident was quiet for a second but then started to kick some and move his/her arms in the air, saying stop, stop, I'm being molested. He/she told the resident he/she was not being molested just getting a bath. -He/she said the bath took about 10-15 minutes. The resident was calmer/quieter at the end. He/she and the other CNA were washing the resident's top half and the other was washing the bottom half; -He/she denied holding the resident down; -He/she said it was an up and down situation, sometimes yelling and sometimes not; -He/she did not stop when the resident yelled that he/she was being abused, molested, violated because he/she had a witness to show he/she was not abusing the resident but bathing him/her; -In CNA training he/she was told to tell the charge nurse if the resident refused or told you to stop. He/she did not feel he/she could do that since it was the charge nurse that told them to do what they needed to do to give the resident a bath; -He/she did not think this was abusive because he/she was following the charge nurse's instruction; -The charge nurse was making sure the resident got a bath because he/she had an appointment the next day and they had been cited on it before. During an interview on 4/7/16 at 11:12 A.M., the Administrator said: -Staff are not to force residents to take a bath. We can encourage them but never make them. -The CNA's should have called him/her if they thought the charge nurse was telling them to do something they did not feel right about. His/Her number is posted all over the building to call him/her with concerns of abuse/neglect. During an interview on 4/7/16, at 12:20 P.M., the DON said: -He/she would not expect any staff to force a resident to bath. Residents can refuse. During an interview on 4/7/16 at 3:00 P.M. and 4/8/16 at 9:10 P.M., the Administrator said: -After speaking to the two CNA's it was noted they were listening to the charge nurse's instructions; -The nurse admitted to him/her that he/she wanted the resident bathed because they had been cited and he/she was going to an appointment the next day; -He/she has terminated the nurse because of this situation. -The resident always has a right to refuse care, and staff are supposed to document it. 2. Record review of Resident #2's quarterly MDS, dated [DATE], showed: -Had adequate hearing, usually understood but missed part of the intent of message; -Had moderately impaired cognition; -Rejected care one to three days per week; -Was independent with activities of daily living including bathing; -Used a wheelchair; -Had [DIAGNOSES REDACTED].) Record review of the resident's POS, dated 4/1/16 to 4/30/16, showed the following: -[DIAGNOSES REDACTED]. -medications: [REDACTED]. Record review of the resident's care plan, dated 2/4/16, showed he/she refused showers and staff were instructed to: -Document refusals of care and continue to encourage to allow staff to assist him/her; -Provide positive constructive feedback during task performance; -Compliment after bathing; -Use kind firmness to insist on bathing; -Explain expectations and demonstrate tasks. Record review of the resident's nurse's notes, dated 3/25/16, showed the resident refused nail care. Observation on 4/7/16 at 10:34 A.M., showed Resident #2 walking independently and appeared to be clean and well groomed. During an interview on 4/7/16 at 10:35 A.M., Resident #2 said: -He/she was forced to take a shower about two nights ago. Four of the staff surrounded him/her and grabbed his/her wrists and forced him/her in the shower. It was after 3:00 in the afternoon, maybe around 4:00 P.M., because he/she was getting ready for dinner. All of the staff were female; -The staff asked him/her first to shower, when he/she refused they drug him/her in the shower room. He/she did not have a chance to get his/her shampoo for his/her hair, they just used their soap on his/her body and hair; -I know how to bathe on my own, I'm old enough. -All the staff stayed in the shower room and watched him/her. They also washed him/her and I do that myself; -He/she could not remember which staff members were involved. -He/she felt intimidated. Record review of Resident #4's annual MDS, dated [DATE], showed he/she: -Was cognitively intact; -Did not exhibit behaviors. During an interview on 4/7/16 at 11:49 A.M., Resident #4 said: -He/she saw the evening staff last week surround Resident #2, grab his/her hands and take him/her to the shower room; -It was CNA A, RN A, and two other female staff, he/she does not remember who they were; -RN A said to Resident #2 as he/she was trying to pull away, You can pull as hard as you want, but I'm stronger than you; -Resident #2 does not weigh more than 100 pounds, seemed like a lot of staff to surround the resident; -Resident #2 was upset; -Resident #4 said he/she was shocked by what they did, he/she had not seen anything like that happen here before. During an interview on 4/7/16 at 12:48 P.M., CNA B said: -He/she has been a CNA for seven months, and has been employed at this facility for two months. He/she usually works in the evening. -If a resident refuses to bathe he/she will ask the resident again later in the evening. If the resident refuses again, he/she will tell his/her charge nurse. -In CNA training he/she was taught if the resident refuses, try again, if they refuse again they were not to give a bath and to tell the charge nurse. During an interview on 4/7/16 at 1:31 P.M. and 3:03 P.M., RN A said: -He/she has worked at the facility for nine months; -A lot of the residents refuse to bathe. When they refuse, he/she gives them a choice between a shower or a bed bath at bed time. If they still refuse he/she marks it as refused; -Incontinent residents get a partial bed bath when they give them care; -He/she was not aware of any resident being forced to bathe; -Resident #2 was not forced to bathe, he/she stayed in the shower after they got him/her in there; -Resident #2 did complain about not having clothes and he/she told the resident, I brought you clothes from home. -It was RN A and another CNA. They did not surround Resident #2 or grab him/her by the arms/wrists. The resident barely weighs 100 pounds. He/she did not tell him/her he/she was stronger than him/her. During an interview on 4/8/16 at 3:12 P.M., CNA A said: -In CNA training he/she was told to tell the charge nurse if the resident refused or told you to stop. -He/she denied he/she ever forced Resident #2 to shower. He/she was not ever told to do what it took to shower Resident #2. He/she has not surrounded Resident #2 to get him/her to shower. During an interview on 4/7/16 at 11:12 A.M., the Administrator said: -Staff are not to force residents to take a bath. We can encourage them but never make them. During an interview on 4/7/16, at 12:20 P.M., the DON said: -He/she would not expect any staff to force a resident to bath. Residents can refuse. Complaint # MO 088

Based on observation, interview and record review, the facility staff failed to provide 24 hour supervision and protective oversight for one severely cognitively impaired sampled resident (Resident #16) who was at high risk for elopement out of 18 sampled residents. Resident #16 left the facility unattended by staff, was found in the facility's South parking lot by visitors, and brought back into the building by visitors. The resident was dressed in teal pants and a light pink sweater. The temperature at the time of the elopement was 36 degrees. At the time of the elopement, the resident was wearing a wanderguard bracelet on his/her left ankle which did not alarm when the resident went out of the facility or upon return to the facility; failed to perform thorough investigations for one sampled resident's falls (Resident #2); and failed to accurately assess a resident for the use of side rails for two sampled residents (Resident #6 and #7), failed to complete a thorough fall investigation for one sampled resident with three unwitnessed falls (Resident #6) and failed to complete a Wander Risk assessment for a resident who was a high risk for elopement for one resident (Resident #17); and failed to assess a resident's request for a restrictive belt-like device to be attached to his/her wheelchair to prevent falls, as a potential accident hazard for one sampled resident (Resident #7); and failed to obtain a Physician's order for the use and failed to adequately monitor a resident's wanderguard device for proper functioning for one sampled resident (Resident #18), who was assessed to be a high wander/elopement risk; out of 18 sampled residents. The facility census was 74 residents. Record review of the facility's Elopement Risk Assessment Policy and Procedure dated [DATE] showed: -Elopement is defined as an unassisted, unsupervised, or unscheduled departure from the facility by a resident requiring the implementation of the resident response protocol. -Policy: --Residents deemed to be at risk for elopement will be monitored. The care plan will outline the methods of monitoring (secure care unit, observation, personal assistant). --Staff will be oriented to the Missing Resident Protocol (a protocol used if a resident is missing) regarding assessing and identifying the residents who are at risk for elopement to prevent and report such occurrences. -Procedure: --Documentation of each incident including attempt to elope and successful elopement. These shall be updated to the resident's responsible party and physician. Record review of the facility's undated policy titled Internal Report Fall Protocol showed: -Staff were directed to notify the Administrator on call, the resident's physician, and the resident's family. -Revise the resident's Fall Risk Assessment. -Complete an Incident Report. -Document the fall in the resident's chart. -Complete a Fall Investigation and turn the investigation in with the Incident Report to the Administrator. -Revise the resident's Care Plan. -Complete a Fall Follow-up Assessment 72 hours. Record review of the facility's undated Incident/Accident Report included in the facility's Fall Investigation Protocol showed: -Staff were directed to document the date and time of the incident, the type of incident, and if any equipment or property was involved in the incident. -Staff were directed to describe what happened, why it happened, and what caused the incident to happen. -Document any type of injury to the resident as well as the resident's vital signs. -Notify the resident's physician and responsible party. -Obtain the name, title, address, and phone number of any witnesses. Record review of the facility's undated Fall Interventions assessment form included in the Fall Investigation Protocol showed: -Staff were directed to check the appropriate interventions for the resident. -Staff were provided space for a narrative for the resident's 72 hour follow-up. 1. Record review of Resident #16's Face Sheet showed the resident had been admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Record review of the resident's Durable Power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) For Financial and General Matters dated [DATE] showed: -The resident had a DPOA for all medical treatment and personal care. Record review of the resident's annual Minimum Data Set (MDS-a federally mandated tool required to be completed by the facility staff for care planning purposes) dated [DATE] showed the resident: -Was severely cognitively impaired. -Was independent with ambulation, transfers, dressing, eating, toileting, and personal hygiene. -Did not wander. Record review of the resident's Nurses Notes dated [DATE] through [DATE] showed: -There was no staff documentation related to the resident wandering or elopement attempts. -There was no further staff documentation after the date of [DATE]. Record review of the resident's Care Plan dated [DATE] showed: -The resident had impaired thought processes. -The resident was at high risk for wandering through doors. --The resident would have no harm from his/her wanderguard use over the next three months. --Re-evaluate for need annually and as needed. --Check for the placement of his/her wanderguard daily. --Check the resident's wanderguard battery function monthly, check the resident's wanderguard expiration date and replace as needed. -The care plan did not instruct the staff how to monitor the resident for wandering. Record review of the resident's Wander Data Collection Tool dated [DATE] showed staff assessed: -Summary of findings: --The resident was a wander/elopement risk. --The residents wanderguard was replaced due to the expiration date. --The resident's care plan was updated. --The interventions that were utilized were a wanderguard and the staff were aware of the resident's wander risk. Record review of the resident's Social Services Progress Notes date [DATE] showed: -The Social Services Director (SSD) changed the resident's wanderguard on his/her left ankle due to the wanderguard's expiration date. -The Director of Nursing (DON) and nursing staff were aware. Record review of the resident's Social Services Progress Notes date [DATE] showed: -The resident's care plan meeting was completed that day. -There were no changes since the last care plan. -The resident had no behaviors. --The staff did not document any information regarding the resident wandering or potential for elopement. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Was independent with ambulation. -Needed the limited assistance of staff for transfers, dressing, toilet use, and personal hygiene. -Did not wander. Record review of the resident's Wander Data Collection Tool dated [DATE] showed staff assessed: -Summary of findings: --The resident was a wander/elopement risk. --Continue to keep wanderguard on as a precaution due to the resident's cognitive deficits. --The resident's care plan was updated. --The interventions that were utilized were a wanderguard and the staff were aware of the resident's wander risk. Record review of the resident's Physician's Orders Sheet dated [DATE] showed the resident had the following physician ordered medications: -Risperadone 1 milligram (mg) tablet for psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning). --There were no physician's orders for the resident's wanderguard I'm not acutally sure you need an order-nursing treatment?. Observation on [DATE] at 11:41 P.M., in the South facility parking lot showed: -The resident was standing near a van with two visitors. -The resident was dressed in teal pants and a light pink sweater. -The resident was walking away from the two visitors in a direction away from the facility. -The two visitors stopped the resident and said you don't have a coat on, let's get you back inside. -The two visitors escorted the resident through the south lobby door to the SSD who was sitting at the front lobby desk. -When the resident came in with the visitor at the south lobby door, the resident's wanderguard alarm did not sound at the door when the resident went through the door. -The visitors told the SSD they had found the resident in the parking lot and were bringing the resident back in the building. During an interview on [DATE] at 11:45 A.M., the SSD said: -The resident must have gone out the door with other people. -He/she had been sitting at the front desk and had not seen the resident go out the door. -Visitors had brought the resident back into the building. During an observation on [DATE] at 12:00 P.M., showed: -The resident was in the dining room seated at a table. -There were no staff sitting or directly by the resident. -There were no staff monitoring the resident. During an interview on [DATE] at 12:10 P.M., Licensed Practical Nurse (LPN) A said: -He/she was the resident's charge nurse. -The resident was not a flight risk. -The resident was alert and oriented and knew where he/she lived. -The resident could sometimes hold a conversation but at other times the resident was out in left field. -The resident had a wanderguard on his/her leg. -He/she showed the resident's wanderguard was placed on his/her left ankle. -The resident had a potential for elopement due to his/her dementia diagnosis. -The resident had never eloped from the facility. -He/she had not been told of the elopement that happened that day. -The resident had probably got into a crowd of church people after an event at the facility and went outside. -When a resident eloped from the facility the Administrator should be notified, an incident report needed to be completed, and the incident needed to be reported to the oncoming shift. -The resident normally did not try to go out of the building. During an interview and observation on [DATE] at 12:20 P.M., the Housekeeping Supervisor said: -He/she had tested wanderguard system at the lobby doors. -He/she had tested the wanderguard system with a spare wanderguard, not with the resident's wanderguard. -The wanderguard sensor was placed too high on the door. -It needed to be moved down on the door. -The wanderguard sensors on the lobby doors were higher than ankle level. During an interview on [DATE] at 1:20 P.M. the SSD said: -He/she was responsible for the resident's wanderguards. -He/she tested all the wanderguards for function every three months. -He/she did not keep a log of when the wanderguards were tested . -He/she only documented when he/she changed a resident's wanderguard. -The resident's wanderguard had expired so he/she had recently replaced it. -Prior to changing the resident's wanderguard, he/she had tested the wanderguard at the lobby doors. -He/she tested the wanderguard by holding it by the door before placing it on the resident. -The wanderguard was working when he/she had placed it on the resident. -He/she had just tested the resident's wanderguard at the lobby door and it did not work. -He/she was going to put a new one on the resident now. -The resident's wanderguard had not been changed yet. -When the resident had gone outside, he/she had reported this to the DON and the Administrator. -The resident had worn a wanderguard since admission. -The resident would walk around the facility and stand by the doors. -The resident had not gone out alone before. During an interview on [DATE] at 1:34 P.M., the Housekeeping Supervisor said: -The only two doors alarmed with a wanderguard system were the North and South Lobby doors. -All other doors were exit doors were coded and alarmed upon opening. During an interview on [DATE] at 1:40 P.M., Certified Medication Assistant (CMT) B said: -The resident had no exit seeking history. The resident would walk around the facility, sit at different benches, and have random conversations with others. -The resident did have a wanderguard on. -The monitoring of the wanderguards were completed by the SSD. During an interview on [DATE] at 2:00 P.M., the Administrator said: -He/she had the SSD check the resident's wanderguard after the resident had been brought back inside the building. -He/she had not told LPN A about the resident's incident. -He/she had not made LPN A aware the resident needed to be monitored. Observation on [DATE] at 2:01 P.M., showed: -The resident was walking down the hall from the South nurses station towards the South lobby doors and looked outside. -The resident went back down the hall and looked in a resident room. -The resident was unattended by staff. -The DON walked up to the resident and took the resident to the South lobby door to test his/her wanderguard. -The wanderguard did not alarm when the resident was near the door. During an interview on [DATE] at 2:05 P.M., Certified Nursing Assistant (CNA) A said: -The resident wandered a lot. -The resident would go to the South lobby door but he/she had not seen the resident try to go out the South lobby door recently. -The resident had pushed on the other exit doors at the facility down the halls. -The exit doors at the facility were alarmed. -When he/she first started working here a few months ago, a staff member had found the resident in the South parking lot at the facility in the evening hours. -This happened sometime in [DATE]. -He/she had been new at the time and could not remember the staff members involved. During an interview on [DATE] at 2:15 P.M., CMT A said: -The resident had a wanderguard on and would walk around. -Sometimes, he/she tried to walk behind someone who was going out the lobby door but not that often. -He/she was not aware of the resident going out prior to today's incident. -He/she would watch the resident closely. -The SSD monitored the resident's wanderguard. During an interview on [DATE] at 2:26 P.M., CNA B said: -The resident walked around a lot but he/she had not seen the resident try to go out the doors. -He/she had not seen the resident try to follow others out the lobby doors. -He/she had just started at the facility five days ago. -He/she was not trained on elopement upon hire. -He/she had not been told which residents were at risk of elopement upon hire. During an interview on [DATE] at 5:50 P.M., CNA C said: -The resident would walk around the building and was an elopement risk. -The resident had a wanderguard on. -The wanderguard was how the facility monitored the resident. -There was no other monitoring in place for the resident. -He/she had not been told the resident needed any different type of monitoring today. During an interview on [DATE] at 6:30 P.M., LPN D said: -The facility used the resident's wanderguard to monitor the resident. -There was no other monitoring in place. -The staff did complete general observations of the resident. -The resident did wander and would stand at the doors and look out. -He/she had not known of any elopement attempts for the resident until today's incident. During an interview on [DATE] at 9:45 A.M., the MDS Coordinator said: -The resident would walk up and down the halls at the facility, but did not wander. During an interview on [DATE] at 10:30 A.M., the DON and Administrator said: -The facility completed a wandering assessment upon admission. -The staff try to watch residents with a [DIAGNOSES REDACTED]. -The SSD checked the residents wanderguard for function monthly and change the residents wanderguard as needed. -The SSD did not document the wanderguard checks for the residents. -The CNA's would look at the residents wanderguards and if the wanderguard band was frayed, the CNA would notify the SSD. -There were only two residents with a wanderguard in the building. -The Administrator said: --The facility was not a locked facility. --He/she would try to tell the family/responsible party the facility was not a locked facility when they were admitting a resident to the facility. --wanderguards do not keep the residents in the building. --The resident would walk around and sit in alcoves in the facility. --Nurses do rounds to monitor the residents. --CNA's and housekeeping watch around the facility. --At this time, he/she declined any further interviews. During a telephone interview on [DATE] at 1:30 P.M., the Medical Director (also the resident's physician) said: -The resident was cognitively impaired and was a risk for elopement. -He/she expected the facility to have some type of monitoring regimen in place to monitor the resident. -He/she was unsure on how often wanderguards needed to be checked for function, this was the Administrator's decision. -The resident was at high risk for an occurrence by leaving the building unattended by staff, with the temperature being 36 degrees and only being dressed in a light sweater. 2. Record review of Resident #2's Face Sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). Record review of the resident POS dated [DATE] showed the resident had the following physician's ordered medications: -Baclofen 20 mg tablet: Give one tablet three times a day for muscle spasms. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated tool required to be completed by the facility staff for care planning purposes) dated [DATE] showed staff assessed the resident as: -Cognitively intact (no problems). -Non ambulatory (does not walk). -Used a wheelchair for mobility. Record review of the resident's Care Plan originally dated [DATE] showed the resident: -Had physical mobility impairment and other deficits including toileting, bathing and hygiene, and routine care needs. -The plan did not contain any information to address the resident's potential risk of falling and interventions to prevent falls due to impaired mobility. Record review of the resident's Nurses Notes dated [DATE] showed the resident: -Sat in his/her electric wheelchair on the outside deck area. -Tried to open the door and lost his/her hand grip and balance in his/her wheelchair. -fell and landed on his/her left side. -Denied hitting his/her head. -Had an abrasion on his/her left knee. -Had no pain at this time and his/her vital signs were checked. -Was told to ask for assistance when opening the door. Record review of the resident's Investigation dated [DATE] showed: -The resident had an unwitnessed fall when he/she was coming in the North lobby door. -A previous scab had come off the resident's knee and no other injuries were noted. -The resident was sitting and reaching while coming in the door. -The resident had impaired judgment. -The time of day was 3:00 A.M. when the incident occurred. -The conclusion/summary: The resident had a history of [REDACTED]. Record review of the resident's Nurses Notes dated [DATE] showed the resident('s): -fell out of his/her wheelchair while having a muscle spasm. -Was helped back to his/her wheelchair by nurses and staff. -Did not have a loss of consiousness, complained of head and back pain, and had a bruise on his/her left leg. -Vital signs were taken and the resident was given pain medication. Record review of the resident's Investigation dated [DATE] showed: -The resident had a witnessed fall and sustained a bruise to on his/her left leg. -The resident was sitting at the nurses station at the time of the fall. -Conclusion/summary: The resident was on medication for muscle spasms and had a history of [REDACTED]. -Further review of the resident's nurses notes showed the notes do not contain any information to show staff continued to assess the resident for injuries after the fall. Staff did not document that they had notified the resident's physician of the fall and had sustained a bruise from the fall. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was cognitively intact. -Required the extensive assistance of staff for bed mobility and transfers. -Was totally dependent on the staff for dressing, eating and toilet use. -Did not ambulate. -Used a wheelchair for mobility. -Had not fallen. During an interview on [DATE] at 10:26 P.M., LPN B said: -If a resident falls, staff are directed to assess the resident for injuries including range of motion, vital signs, and vision. -Staff should notify the resident's physician. -He/she would complete an incident report and give the incident report to the DON. During an interview on [DATE] at 12:30 P.M., the DON said: -When a resident falls, the nurses are responsible for completing a fall packet. -Depending on the severity of the fall, staff are expected to do neurochecks. -The resident's physician needed to be notified. -The nurses should list the interventions on the incident report then give the form to him/her. -He/she would file the incident report in the residents files. -He/she would bring up the falls during care plan meetings. 3. Record review of Resident #17's Admission Record Face Sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Hypertension (HTN - high blood pressure). -Schizophrenia (a psychotic disorder characterized by loss of contact with the environment, by noticeable deterioration in the level of functioning in everyday life). -Mild cognitive impairment. Record review of the resident's Comprehensive Care Plan dated [DATE] showed the resident: -Was an elopement risk. -Staff was directed to not allow the resident to pack his/her clothing or leave out the door. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Was not at risk for wandering. Record review of the resident's medical record showed the staff did not complete a wandering Risk Assessment for the resident. During an interview on [DATE] at 2:30 P.M., LPN A said: -The resident was alert and oriented. -He/she will sit by the door but has not attempted to leave or go out the door. Observation on [DATE] at 4:30 P.M. showed the resident was walking up and down the hallway. He/she would stop at the exit doors at the end of the hallway to look out the windows. During an interview on [DATE] at 10:45 A.M., the DON said: -The resident should have had a Wandering Risk Assessment completed in his/her medical record. 4. Record review of Resident #6's Admission Record Face Sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -[DIAGNOSES REDACTED] (paralysis/weakness affecting one side of the body). -HTN. Record review of the resident's Nurse's Notes dated [DATE] showed the resident: -Had an unwitnessed fall to the floor. -Staff did not document where this fall occurred, where the resident was found, and what the resident fell from. -He/she hit his/her head. -Required several staff to assist the resident off the floor. -Was sent to the emergency room for evaluation. Record review of the resident's medical record showed the facility did not complete a fall investigation after the resident's fall on [DATE]. Record review of the resident's admission MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Required staff supervision for bed mobility. -Required extensive staff assistance for locomotion. -Required total staff assistance for transfers, dressing, toileting, and bathing. -Had one non injury fall and one injury fall since admission. Record review of the resident's Care Plan dated [DATE] showed: -Impaired Physical Mobility care plan showed the resident required two staff to assist with transfers. -Trauma, Potential for Fall Risk with high risk of fractures and seizures and the care plan showed the following interventions: --Staff were directed to answer the resident's call light promptly. --Administer medications as ordered. --Provide quality listening time and encourage the resident to express feelings. --Divert the resident's attention through activities as tolerated. --Keep the resident's bed in a low position for safe transfers. --Use appropriate seating and/or device when out of bed to decrease the risk for falls. --Assess thoroughly if a fall occurs due to osteopenia (bone mineral density is lower than normal) and was a high risk for fractures. -The resident's care plan did not reflect the use of half side rails. -The resident's care plan was not updated following the resident's fall. --The resident had two half-side rails. Record review of the resident's Nurse's Notes dated [DATE] showed the resident: -Was found sitting on the floor in front of his/her wheelchair. -The resident's fall was unwitnessed. -Three staff assisted the resident from the floor to his/her wheelchair. -Reminded the resident to ask for assistance and wait for staff to assist him/her. -His/her retention level is not very good. Record review of the facility's Fall Investigation dated [DATE] showed: -The resident had an unwitnessed fall. -The resident fell from his/her wheelchair in the hall. -It was unknown how the resident fell . -The conclusion/summary showed the resident had a non-injury fall, the staff will monitor the resident for acute confusion, and hospice has been consulted for end-stage dementia. -No staff interviews we included in the investigation. Record review of the resident's Nurse's Notes dated [DATE] showed: -The resident's hospice provider was going to provide an electric bed with half side rails for positioning and assist with transfers and pads on the floor for safety. Record review of the resident's Evaluation of Side Rail Usage dated [DATE] showed: -The resident has a DPOA. -The resident's DPOA was notified of the side rail use and signed a consent for the side rail use. --A consent was not located in the resident's medical record and was not provided by the facility. -The resident had a history of [REDACTED]. -The resident did not have any falls from his/her bed. -The resident cannot get in and out of bed safely without any human assistance or assistive device. -The resident has decreased safety awareness. -The side rails are not a restraint as the resident is unable to get out of bed without assistance. Record review of the resident's Nurse's Notes dated [DATE] showed: -The resident was found on the floor during shift change rounds. -The resident's fall was unwitnessed by the facility staff. -The resident required three to four staff to assist the resident from the floor to the bed. Record review of the resident's medical record showed the facility did not complete a fall investigation after the resident's fall on [DATE]. Record review of the resident's hospice Nursing Biweekly Comprehensive Assessment Update Visit Report dated [DATE] showed the resident had floor mats, a low bed, and half side rails for increased fall risk. Observation and interview on [DATE] at 1:00 P.M., showed: -The resident was in his/her bed with two half-side rails up on either side of his/her bed. -A floor mat was on the floor on the right side of the bed. No mat was on the floor on the left side of the bed. -The resident was unable to pull himself/herself using the side rail. -He/she said the side rail was to keep him/her from falling out of bed. -The resident said he/she did not have the strength to pull himself/herself up with the side rail. Observation on [DATE] at 5:15 A.M., and 7:15 A.M., of the resident showed: -He/she was in his/her bed with two half-side rails up on either side of his/her bed. -A floor mat was on the floor on the right side of the bed. No mat was on the floor on the left side of the bed. Observation on [DATE] at 7:55 A.M., of the resident showed: -He/she was in his/her bed with two half-side rails up on either side of his/her bed. -A floor mat was on the floor on the right side of the bed. No mat was on the floor on the left side of the bed. -The resident draped his/her right arm over the top of the left side rail when staff requested the resident assist to pull himself/herself to the side for personal cares. The resident did not assist with repositioning. -The resident draped his/her left arm over the top of the right side rail when staff requested the resident assist to pull himself/herself to the side for personal cares. The resident did not assist with repositioning. -CNA D and CNA E assisted the resident to sit on the side of the bed, placed the gait belt around the resident's waist, then transferred the resident to his/her wheelchair. The resident did not use the side rail to assist with repositioning. During an interview on [DATE] at 8:15 A.M., CNA D and CNA E said: -The resident's side rail was for repositioning. -The resident did not use the side rail when repositioned in the bed or during the transfer to the wheelchair. During an interview on [DATE] at 10:50 A.M., the Administrator said: -The facility completed a fall investigation for any unwitnessed fall. -The facility does not complete a fall investigation for a witnessed fall since the staff knows what happened. -Resident #6 did not have a fall investigation for his/her falls dated [DATE] and [DATE]. 5. Record review of Resident #7's Admission Record Face Sheet showed the resident was: -admitted to the facility on [DATE]; -admitted with medical [DIAGNOSES REDACTED].>--[DIAGNOSES REDACTED] (a group of diseases that cause progressive weakening and wasting of the body's muscles) --Diabetes Mellitus Type 2 (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) --Hypertension already defined (HTN- High blood pressure); --Depressive Disorder; and --Anxiety Disorder. Record review of the resident's Fall Risk Assessment, dated [DATE], showed: -The resident was chair bound, required restraints, and assistance with bowel/bladder elimination; -The resident was not assessed for being at high risk for falls. Record review of the resident's Impaired Physical Mobility Care Plan, dated [DATE], showed: -Monitor the resident for complications of immobility: contractures, venous stasis, thrombus, pneumonia, urinary tract infection, and report; -Transfer the resident using a Hoyer lift (an electronic lifting device used to transfer a resident) with two staff member assi

Based on observation, interview and record review, the facility staff failed to identify non-pressure wounds for one sampled resident (Resident #9) out of 21 sampled residents, who had blackened, odorous areas on his/her toes with a thick sticky tan substance between the toes of his/her right foot and blackened areas between his/her toes of the left foot; failed to have a system in place to ensure staff complete on-going skin assessments; failed to notify the resident's physician of his/her skin abnormalities and obtain treatment orders; failed to provide needed interventions; failed to complete skin assessments; failed to monitor bath sheets; failed to ensure Certified Nursing Assistants (CNAs) reported changes/abnormalities in the resident's skin condition to licensed nursing staff; failed to update the resident's care plan; and failed to have an effective policy regarding non-pressure wounds. The facility census was 77 residents. Record review of the facility policy form titled, "Skin assessment and Wound Treatment Policy", dated 10/31/2001, showed the following instructions for facility staff: -All resident's are to have a "full body assessment" completed by a licensed nurse upon admission and readmission to the facility; -Resident's will receive a weekly skin bath assessment conducted by a "Bath Aide" (CNA) during bathing; -The weekly Bathe Aide skin assessments are provided to the "Charge Nurse" for review and follow-up; -The Charge Nurse will assess, describe, document the skin breakdown, and notify the resident's physician and treatment orders obtained; -A wound assessment record will be completed weekly to monitor the wound progression and these assessments will be part of the resident's medical record; -The resident's physician will be notified of any wound deterioration or needed changes in treatment; -The physician ordered wound treatment will be completed and documented as ordered in the residents medical record. -The licensed nurse will complete all wound care; and -Any concerns regarding treatment will be reported to the residents physician. Record review of the facility policy form titled "Non-Pressure Ulcer Assessment and Treatment" dated 2007, showed: -All non-pressure ulcers are assessed and documented weekly using the facility form. -All residents are assessed every thirty days for skin integrity and documentation on the facility form. -All non-pressure ulcers will be treated according to physician's order. -Complicated wounds will be referred to special clinic for treatment. -Ulcers/Wounds are assessed properly and accurately to determine type of ulcer. -Treatment, monitoring and preventative measures are implemented according to the type of ulcer. -The following instructions for staff on the procedure for treatment: --Skin assessment according to the bath schedule; --Assessment weekly/monthly or more frequent as instructed by the Director of Nursing (DON) or Registered Nurse (RN); --Focus assessment on leg, foot as directed above; --Communicate among shift of the progress healing; --Consult physician or other recommended healthcare providers for treatment; --Assess the resident for relieved/comfort devices to support; --Provide treatment per physician order, not limited to pain, infection; --Notify the Quality Assurance committee about progress, process, and changes. (Quality Assurance refers to the systematic activities performed in a system to evaluate quality of the service provided.) 1. Record review of Resident #9's Hospital Consultation Note dated 1/27/12 showed: -The resident denied any [DIAGNOSES REDACTED]. -The resident had four hip surgeries and debridement of his/her pressure sores. -There was a question whether he/she had some skin breakdown on his/her feet at one time. -The resident had no skin breakdown on his/her feet at this time. Record review of the resident's wound company Assessment reports from 2/3/12 through 9/7/12 showed: -The resident was being followed by the wound company for chronic pressure sores. -There was no documentation related to the resident having any wounds on his/her feet. Record review of the resident's undated Face Sheet showed the resident: -Was admitted to the facility on [DATE]. -Had the following Diagnoses: [REDACTED]. --[MEDICAL CONDITION] (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). --Spinal Stenosis: (Narrowing of the spinal column that causes pressure on the spinal cord). --Constipation: (bowel movements that were infrequent or hard to pass). --History of [MEDICATION NAME] (ETOH) abuse ([MEDICAL CONDITION]). --History of polysubstance (a type of substance dependence disorder in which an individual uses at least three different classes of substances indiscriminately and does not have a favorite drug that qualifies for dependence on its own) abuse. Record review of the undated facility South Side Resident Bath Schedule showed: -The resident was scheduled for baths on Tuesdays, Thursdays, and Saturdays on the 3:00 P.M. to 11:00 P.M. shift. Record review of the resident's Admission Nursing assessment dated [DATE] showed the resident: -Was alert and oriented, friendly, and cooperative. -His/her feet stay cold. -Had partial weight bearing on his/her left leg and no weight bearing on his/her right leg. Record review of the resident's Physician's Orders Sheet dated 2/1/12 showed: -The resident had the following physician orders: --Vitamin C 500 milligrams (mg): Give 500 mg by mouth twice a day. --Aspirin 81 mg: Give one tablet by mouth daily for [MEDICAL CONDITION] ([MEDICAL CONDITION],stroke)/[MEDICAL CONDITION] infarct ([MEDICAL CONDITION]). --[MEDICATION NAME] 20 mg: Give 20 mg for depression (the order did not say how often). --[MEDICATION NAME] 300 mg: Give one tablet daily for [MEDICAL CONDITION] (damage to the nerves resulting in sensory loss in the extremities). --Multivitamin with minerals: Give one tablet by mouth daily. --[MEDICATION NAME] 25 mg: Give one tablet by mouth daily. --[MEDICATION NAME]-S: Give one tablet by mouth twice a day for constipation. --Zinc sulfate 220 mg: Give one tablet daily as a supplement (This order was discontinued on 2/21/12). --Protein power: Give one scoop by mouth twice a day for 30 days. --Ambien 10 mg: Give one tablet at night for sleeplessness. --Fleet enema: Give one enema rectally every other day as needed for constipation. --Milk of magnesia 10 milliliters (ml): Give 10 ml by mouth as needed for constipation. --[MEDICATION NAME] rectal: Give one suppository rectally as needed for constipation. --[MEDICATION NAME] 325 mg: Give two tablets every four hours as needed for pain/elevated temperature. --[MEDICATION NAME] 40 mg inject daily for a [MEDICAL CONDITION] ([MEDICAL CONDITION]-a blood clot in lower extremities). (This order had been marked out discontinued but was not dated). --[MEDICATION NAME] 5/325 mg: Give one tablet by mouth every four hours as needed for pain. --[MEDICATION NAME] 0.5 mg: Give one tablet by mouth every four hours as needed for anxiety. --On 2/20/12, [MEDICATION NAME] 750 mg by mouth daily for pneumonia for 13 days (inflammation of one or both lungs with consolidation). -Had the following physician's treatment orders: --A low air loss mattress for pressure reduction. Record review of the resident's Nurses Notes completed by Licensed Practical Nurse (LPN) D dated 2/1/12 at 10:00 P.M. showed the resident: -Was alert and oriented times three (person, place and time). -Right outer foot was red. -Was encouraged to lie on his/her left side. -Right lower leg was painful to the touch. -Was encouraged to lie on his/her sides. -Agreed to lie on his/her sides. Record review of the resident's Nurses Notes dated 2/2/12 on the 11:00 P.M. to 7:00 A.M. shift, showed the resident('s): -Had aching pain in his/her lower right leg and was given pain medications. Record review of the resident's Nurses Notes dated February 2012 through 1/6/13 showed: -There was no licensed staff documentation that showed the resident had any wounds on his/her feet. -There was no licensed staff documentation to show the resident's skin had been assessed or if preventative measures, including waffle boots or a low air loss mattress, had been put into place. Record review of the resident's Nurses Notes dated 2/3/12 at 3:05 P.M., showed the resident: -Was up for meals in his/her wheelchair. -Appeared to be adjusting to the facility. --Note: The staff did not document anything regarding the skin condition of the resident. Record review of the resident's History and Physical dated 2/7/12 showed: -The resident had been admitted to the facility from a psychiatric facility. -The resident was being evicted from his/her home and had made suicidal statements. -The resident had the following diagnoses/conditions: --[MEDICAL CONDITION]. --Pressure sore Stage II to the coccyx (tailbone). --[MEDICAL CONDITION]. --Chronic hip pain. --Pelvic (lower abdomen area) pain. --Anorexia ([MEDICAL CONDITION]). --Spinal stenosis. --Immobility. --[MEDICAL CONDITION] (a disease or [MEDICAL CONDITION] state of the peripheral nerves in which motor, sensory, or vasomotor nerve fibers may be affected and which is marked by muscle weakness and atrophy, pain, and numbness). -Four surgeries to the right hip. -The diagnosis/plan: --The Stage II pressure ulcer was being managed by a wound care company. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated tool required to be completed by the facility staff) dated 2/13/12 showed the resident: -Had adequate vision, hearing and speech. -Had intact cognition and no memory loss. -Had no behaviors and had not rejected cares. -Was independent with bed mobility and eating. -Required the limited assistance of one staff member for transfers and dressing. -Required the extensive assistance of one staff member for toilet use, personal hygiene, toileting, and bathing. -Used a wheelchair for mobility. -Was always incontinent of bladder. -Was frequently incontinent of bowel. -Had frequent pain. -Did not have any wounds. Record review of the resident's Care Plan dated 2/14/12 showed: -Problem: Bathing and hygiene deficit. --The resident needed staff assistance including showering/bathing three times per week. --The resident's finger nails and toe nails needed to be checked and cleaned when bathed. --The resident would participate in bathing/hygiene from the waist up. -Note: The staff did not develop a care plan related to the resident having compromised skin, that he/she was unable to bear weight on his/her right leg, or include preventative measures that had been put into place for the resident. Record review of the resident's Dietary History and Initial Screening dated 2/14/12 showed: -The resident was alert and oriented, had a regular diet, and had protein powder added to his/her diet for 30 days. Record review of the resident's Nurses Notes dated 2/16/12 at 5:15 P.M., showed the resident('s): -Left foot had [MEDICAL CONDITION] (Fluid swelling of the lower extremities. Pitting [MEDICAL CONDITION] can be demonstrated by applying pressure to the swollen area by depressing the skin with a finger. If the pressing causes an indentation that persists for some time after the release of the pressure, the [MEDICAL CONDITION] is referred to as [MEDICAL CONDITION]) and right foot the right foot had [MEDICAL CONDITION]. -The resident's physician was called. Record review of the resident's Nurses Notes dated 2/16/12 at 6:10 P.M., showed the resident('s): -Physician sent the resident to the hospital due to the [MEDICAL CONDITION] in his/her legs. Record review of the resident's hospital History and Physical dated 2/16/12 showed: -The resident was sent to the emergency room related to lower extremity swelling and right foot pain. -The resident was admitted to the hospital. -A bilateral lower extremity doppler (an ultrasound to determine blocked or reduced blood flow through the major arteries of the legs) was completed on the resident's legs. -The resident had blood flow to his/her lower legs and the blood flow was within normal limits (WNL). -The resident was treated with [MEDICATION NAME] (a medication used to treat infections) for a possible [MEDICAL CONDITION] infection (infection of the lungs) and possible right foot and ankle [MEDICAL CONDITION] (an infection of the deep tissue of the skin). -The right foot and ankle [MEDICAL CONDITION] was more consistent with stasis [MEDICAL CONDITION] ([MEDICAL CONDITION] skin condition that develops secondary to fluid build-up). Record review of the hospital Wound Care Final Report dated 2/20/12 showed: -The resident was in bed resting on an envision mattress (a low air loss mattress). -The recommendations were to add waffle boots to the resident's feet while in bed and elevate the lower extremities. Record review of the resident's Nurses Notes dated 2/20/12 at 3:00 P.M., showed: -The resident returned to the facility with no new orders other than vitamins. Record review of the resident's Nurses Notes dated 2/21/12 at 2:45 P.M., showed the resident: -Was able to move around by use of his/her wheelchair. Record review of the resident's Nurses Notes dated 2/24/12 at 5:15 P.M., showed the resident: -Was refusing to get up for meals. -Has an excuse on why he/she would not get up for meals. Record review of the resident's Nurses Notes dated 2/29/12 at 9:15 P.M., showed the resident('s): -Toe nail was partially off of his/her right foot little toe. -Note: There was no staff documentation related to any interventions/treatments related to his/her toe nail. Record review of the resident's Nurses Notes dated 3/19/12 at 3:00 P.M., showed the resident: -Was refusing to get up for meals. -Had pain related to his/her right hip. -Was not keeping his/her agreement to get up for meals. Record review of the resident's Nurses Notes dated 3/20/12 at 2:45 P.M., showed the resident: -Was refusing to get up for meals. -Was not keeping his/her agreement to get up for meals. Record review of the Resident's Physician's Progress Note dated 3/20/12 showed: -The resident denied baths and was not getting out of bed. -The resident needed to be encouraged to get out of bed for meals. -There was no documentation to show the resident's skin had been assessed or if preventative measures, including waffle boots or a low air loss mattress, had been put into place. Record review of the resident's Nurses Notes dated 3/24/12 at 2:40 P.M., showed the resident: -Was refusing to get up for lunch. -Had refused to take a shower. -Had excuses on why he/she would not cooperate with the staff. Record review of the Resident's Physician's Progress Note dated 4/10/12 showed the resident: -Had no new concerns. -Was being followed by the wound company. -There was no documentation related to the resident having any wounds on his/her feet. Record review of the resident's Nurses Notes dated May 2012 showed: -There was no licensed staff documentation related that showed the resident had any wounds on his/her feet. -There was no licensed staff documentation to show the resident's skin had been assessed or if preventative measures, including waffle boots, had been put into place. Record review of the Resident's Physician's Progress Note dated 5/8/12 showed the resident: -There was no documentation related to the resident having any wounds on his/her feet. Record review of the resident's Nutritional Progress Notes dated 5/18/12 showed the resident: -Received Vitamin C and a multivitamin with minerals daily. -Had a diet order of as tolerated and it should be changed to regular. Record review of the Resident's Physician's Progress Note dated 6/5/12 showed the resident: -Needed to be encouraged to get up for meals and isolated himself/herself in his/her room. -There was no documentation related to the resident having any wounds on his/her feet. Record review of the Resident's Physician's Progress Note dated 7/10/12 showed the resident: -Had no new concerns. -Had been encouraged to get of bed but was non-compliant. Record review of the Resident's Physician's Progress Note dated 8/14/12 showed the resident('s): -There was no documentation related to the resident having any wounds on his/her feet. Record review of the resident's POS dated 9/1/12 showed: -The resident had the following physician orders: --Vitamin C 500 milligrams (mg): Give 500 mg by mouth twice a day. --Aspirin 81 mg: Give one tablet by mouth daily for [MEDICAL CONDITION] /[MEDICAL CONDITION]. --[MEDICATION NAME] 40 mg: Give one tablet by mouth daily for depression. --[MEDICATION NAME] 300 mg: Give one tablet four times daily for [MEDICAL CONDITION]. --Multivitamin with minerals: Give one tablet by mouth daily. --[MEDICATION NAME] 25 mg: Give one tablet four times by mouth daily. --[MEDICATION NAME]-S 50 mg: Give one tablet by mouth twice a day for constipation. --Fleet enema: Give one enema rectally every other day as needed for constipation. --Milk of magnesia 10 milliliters (ml): Give 10 ml by mouth as needed for constipation. --[MEDICATION NAME] rectal: Give one suppository rectally as needed for constipation. --[MEDICATION NAME] 325 mg: Give two tablets every four hours as needed for pain/elevated temperature. --[MEDICATION NAME] 5/325 mg: Give one tablet by mouth every four hours as needed for pain. --Calcium Carb 500 mg: Give one tablet by mouth twice daily for [MEDICAL CONDITION] (decrease in bone mass and density and enlargement of bone spaces producing fragility). --[MEDICATION NAME] 17 grams (gms): Mix 17 gms into eight ounces of fluid daily for constipation. --Vitamin D 1000IU tablet: Give two tablets daily by mouth for a vitamin D deficiency. -Note: There were no physician orders on the POS for the resident's waffle boots or the low air loss mattress. Record review of the Resident's Physician's Progress Note dated 9/11/12 showed: -The resident was noncompliant with care and refused to get out of bed. -There was no documentation related to the resident having any wounds on his/her feet. Record review of the resident's POS dated 10/1/12 showed: -Had the same physician orders as the 9/1/12 POS. Record review of the resident's Nurses Notes dated 10/9/12 at 9:00 P.M., showed the resident: -Refused to get up for a bath. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Had adequate vision, hearing and speech. -Had intact cognition and no memory loss. -Had no behaviors and had not rejected cares. -Was independent with bed mobility and eating. -Required the limited assistance of one staff member for transfers and dressing. -Required the extensive assistance of one staff member for toilet use, personal hygiene, toileting, and bathing. -Used a wheelchair for mobility. -Was always continent of bladder. -Was frequently incontinent of bowel. -Had frequent pain. The POS for 11/1/12 had been requested by the surveyor but had not been received by the facility by the end of the survey. Record review of the Resident's Physician's Progress Note dated 11/6/12 showed the resident('s): -Continued to stay in bed even after encouragement. -Was being followed by the wound company. -(Note: The wound company terminated services related to being told the resident was being discharged from the facility in September.) Record review of the resident's Skin Bath assessment dated [DATE] showed the resident: -Had an open area to the coccyx/buttocks area. -Had no other skin abnormalities. Record review of the resident's Skin Bath assessment dated [DATE] showed the resident: -Had a raw area to the coccyx area. -Had no other skin abnormalities. The POS for 12/1/12 had been requested by the surveyor but had not been received by the facility by the end of the survey. Record review of the resident's Skin Bath assessment dated [DATE], 12/13/12, and 12/27/12 showed the resident: -Had refused to have his/her bath. During an interview on 1/7/13 at 7:48 A.M., Licensed Practical Nurse (LPN) A (also the day shift charge nurse) said: -The wound company was seeing the resident and tracking his/her wounds. -The facility did not measure wounds or track wounds. -He/she had not completed any wound measurements for the resident. -The wound company records were not kept in the chart. -The resident did not have any treatment orders for wounds. During an interview on 1/7/13 at 7:55 A.M., the Director of Nursing (DON) said: -The resident was non-compliant and refused the wound company's treatment. -The wound company stopped seeing the resident due to the resident refusing treatment. -LPN A was responsible for measuring and tracking the wound. -He/she would obtain the facility's wound records. Observation and interview on 1/7/13 at 8:02 A.M. showed: -The resident was lying in bed on his/her regular mattress on his/her back. -The resident said his/her bed was the bed that had been brought to the facility from his/her home. -The resident's great (first), second and third toes on his/her right foot were black with an appearance of eschar (a dry scab) and had a light tan sticky odorous substance between his/her toes. -LPN A said she did not know about the resident's toes. During an interview on 1/7/13 at 9:48 A.M., the DON said: -The resident had his/her baths on the evening shift. -He/she expected the Certified Nursing Assistants (CNA's) to report any abnormalities to the charge nurses. -He/she expected the nurses to report any skin abnormalities to him/her. -The facility only kept bath sheets for 30 days. -The facility would look back on the 30 days of bath sheets if a skin abnormality was discovered. Observation and interview on 1/7/13 with the DON at 10:00 A.M., showed: -The resident's right first, second and third toes were blackened with an appearance of eschar, which extended down the toes. -The resident's left first, second, third, and fourth toes had darkened areas in between the toes. -The DON said: --The resident's right first, second and third toes were blackened which extended down the toes. --The resident's left first, second, third, and fourth toes had darkened areas in between the toes. --The resident's feet were dry and scaly. -No one had reported the condition of the resident's toes to him/her until LPN A informed him/her today. -The resident said his/her right big toe hurt badly. During an interview on 1/7/13 at 11:02 A.M., CNA E said: -He/she had worked with the resident until about one month ago. -About a month ago, the resident had black areas on his/her toes and the toes were very dry. -He/she did not tell anyone about the black areas on the resident's toes. -He/she had not been instructed on how to position the resident's legs, feet, or body. -The resident always wanted his/her feet propped up with pillows and the resident would instruct him/her on how to do this. -The facility did not use CNA care sheets to communicate how to care for the residents. During an interview on 1/7/13 at 11:07 A.M., the DON said: -He/she would look for the resident's bath sheets. -He/she did not know where the bath sheets were kept. -He/she did not review the resident's bath sheets. -The facility did not use CNA care sheets to communicate how to care for the residents. During an interview on 1/7/13 at 11:09 A.M., LPN A said: -The facility did not use CNA care sheets to communicate how to care for the residents. During an interview on 1/7/13 at 11:15 A.M., CNA F said: -He/she was one of the resident's main caregivers. -The resident was "no problem at all" and "never refuse cares" from him/her. -The resident preferred to have consistent care givers. -He/she used to bathe the resident on the day shift until September 2012 or October 2012. -The resident had not refused baths from him/her. -He/she always rubbed the lotion on the resident's feet. -The resident really liked to have lotion rubbed on his/her feet. -He/she had not noticed the resident had blackened toes. -He/she did not know where the bath sheets were kept or if the facility used them anymore. -The resident liked to have pillows placed under his/her legs because of leg pain. -The resident did not have baths on his/her day shift. -The resident would refuse to get out of bed related to leg pain. Record review of the facility's Bath Book located at the south nurses station on 1/7/13 at 11:25 A.M., showed: -There were no bath sheets in the bath book for the resident. During an interview on 1/7/13 at 11:40 A.M., LPN A said: -He/she was the charge nurse during the week for the resident. -The resident did not have a low air loss mattress and never had a low air loss mattress. -The staff were supposed to keep the resident dry and repositioned. -The resident used pillows to prop up his/her right leg due to hip pain. -The facility did not measure or track wounds. -He/she had never measured the resident's wounds. -He/she was unaware the resident had not been seen by the wound company. -He/she was unaware of the resident's toe wounds. -He/she was "very frustrated" the staff had not told him/her about the condition of the resident's toes. -He/she expected the CNA's to report any abnormal skin conditions to him/her. During an interview on 1/7/13 at 12:20 P.M., the resident said: -A representative from a wound specialty hospital had been there. -The representative showed up after "the state" had watched wound care. -He/she had been told he/she would be going to a wound specialty hospital due to his/her multiple wounds and to get my feet "healed". -He/she instructed the staff to put pillows under his/her right lower leg and foot because he/she had hip pain. -He/she did not like to get out of bed because it caused him/her hip pain. During an interview on 1/7/13 at 12:30 P.M., LPN A said: -He/she thought a representative from a wound specialty hospital had come into see the resident. -He/she thought the DON may have called the wound specialty hospital. -The representative had looked at the resident's wounds and said he/she would "work something up" and get back with the facility. -He/she was not sure what the wound specialty hospital was going to do. -He/she could not give any information related to the wound specialty hospital. A telephone call was made to the wound specialty hospital on [DATE] at 1:38 P.M. A message was left but the phone call was not returned to the surveyor. During a telephone interview on 1/7/13 at 1:40 P.M., Physician A (also the Medical Director) said: -The staff had not notified him/her of the condition of the resident's wounds. -He/she thought the wound company was monitoring, treating, and tracking the resident's wounds. -He/she had not been notified the wound company had not been seeing the resident since September 2012. -He/she had been told by staff the resident was non-complaint with getting out of bed and showering. -He/she was unaware of the condition of the resident's toes until today. -His/her nurse practitioner was involved with the resident also. -He/she expected the facility to be monitoring and tracking the resident's wounds if the wound company was not seeing the resident. -He/she had just been told by the facility staff the resident refused to see the wound company. -He/she expected the facility to document the refusal of cares. -The resident should have had his/her heels floated. -The licensed nursing staff should be completing skin assessments weekly and documenting the skin assessments. -He/she had not been notified by the facility staff of a consult with the wound specialty hospital. During an interview on 1/7/13 at 2:00 P.M., wound company Registered Nurse (RN) A said: -The resident was last seen by the wound company on 9/7/12. -The resident was discharged from the wound company because he/she was being discharged from the facility due to financial reasons. -The resident stated he/she was leaving to move to an apartment. -This was confirmed with the facility. -The resident was not discharged from wound services related to non-compliance. -The resident had not been refusing treatments. During a telephone interview on 1/7/13 at 2:50 P.M., Nurse Practitioner (NP) A said: -He/she was unaware if the wound company was seeing the resident. -The DON had the wound company records. -He/she did not have access to the wound records because the records were not kept on the chart. -The wound records should be kept on the chart. -He/she would not say the resident was non-compliant. -The resident did not like to get out of bed. -The resident did like to drink alcohol and get intoxicated which might make it difficult at times to provide care for the resident. -The resident like to have things done in his/her own time. -The staff had reported to him/her the resident like to take his/her time in doing things. -He/she liked to talk and would try to engage in longer conversations. -He/she had ordered a low air loss mattress many times. -He/she had spoken directly to the charge nurses about the low air loss mattress but the facility never provided one to the resident. -He/she had written another order for low air loss mattress and gave it directly to the DON. -He/she had talked with the DON directly multiple times about getting a low air loss mattress. -The facility should have provided the resident with a low air loss mattress. -He/she was unaware of the condition of the resident's toes until today. Record review of the resident's Nurses Notes dated 1/7/13 at 2:25 P.M., showed the resident: -Had been discharge to a wound specialty hospital related to multiple wounds. -The physician and DPOA were notified. Record review of the resident's Nurses Notes dated 1/7/13, showed: -The resident had black tissue on his/her right foot and in between toes. -A representative from the wound specialty hospital had seen the resident and accepted to take him/her for wound treatment. -In route to the wound specialty hospital the resident was denied admission due to insurance issues. -The resident was routed to a hospital emergency room . -(Note: There was no staff documentation that showed the resident's physician had been notified). During an interview on 1/7/13 at 3:25 P.M., the DON said: -He/she "thought" the resident had a low air loss mattress at one time. -He/she would find out if a low air loss mattress had ever been ordered for the resident. -He/she did not know about the wound specialty hospital. -Social services was handling the wound specialty hospital. During an interview on 1/7/13 at 3:28 P.M., Social Services Designee (SSD) A said: -He/she knew nothing about the wound specialty hospital. -The wound specialty hospital had called to verify the resident's insurance for admission purposes. -He/she did not know who called or the phone number for the contact person. During an interview on 1/7/13 at 3:45 P.M., LPN D said: -The resident would sometimes delay his/her cares. -The resident would say he/she was "tired". -He/she worked Monday through Friday as the evening charge nurse. -The resident received his/her baths on Tuesdays, Thursdays, and Saturdays. -He/she completed weekly skin assessments on the resident but did not write the assessments down. -He/she had not ever looked at the resident's feet but was suppose to be completing a full body assessment weekly. -"I messed up". -The CNA's had not reported the resident's foot conditions to him/her but should have. -The facility did not have a policy/protocol for turning and or floating the resident's heels. During an interview on 1/8/13 at 3:30 P.M., CNA B said: -He/she was a primary caregiver for the resident. -The resident did not like to shower or get up out of bed even for meals. -The resident always let him/her provide cares, including cleaning him/her up after a bowel movement. -The resident would turn on his/her call light when he/she needed cares. -He/she had given the resident a bath around Christmas time. -The resident had darkened areas in between his/her toes on both feet at that time. -He/she did not report this to the charge nurse because the areas did not cause the resident any pain and he/she thought the resident "just needed a pedicure". During an interview on 1/8/13 at 3:50 P.M., CNA C said: -He/she was a primary caregiver for the resident. -The resident could be hard to work with at times for certain CNA's. -The resident liked him/her and always let him/her provide cares. -The resident only refused baths. -The resident did not like to get up often. -The resident liked to have pillows placed under his/her knees. -He/she had not noticed any abnormalities on the res

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interviews, and record review completed during this revisit, it was determined the facility had implemented corrective action to address and lower the violation at this time. Facility staff had received inservices regarding wound care and and skin care. Facility staff had also completed all skin assessments. A wound care company is now employed by the facility, and the facility has also hired an Assistant Director of Nursing to assist the Director of Nursing, and free him/her for additional duties. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State law (Section 198.0261 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

Based on observation, interview and record review, the facility staff failed to keep one sampled resident (Resident #9) out of 21 sampled resident's free from an avoidable Stage III (full thickness with skin loss) pressure sore to the left buttock and avoidable suspected deep tissue injuries (localized area of discolored intact skin) on his/her right and his/her left foot. The facility failed to have a system in place to ensure staff completed on-going skin assessments, failed to identify the resident's pressure sores, failed to notify the resident's physician of his/her pressure sores and obtain treatment orders, failed to have an effective system to monitor and track the resident's pressure sores, failed to provide needed interventions to promote pressure sore healing and prevention, failed to monitor skin assessments and bath sheets, failed to complete full skin assessments, failed to ensure certified nursing assistants (CNA) reported changes/abnormalities in the residents skin condition to licensed nursing staff, failed to ensure licensed nursing staff were administering the physician ordered treatments to the resident's pressure sores, failed to update the resident's care plan with appropriate interventions, and failed to have an effective policy with the current standards of practice regarding pressure sores. In addition, the facility also failed to identify a new pressure ulcer on one resident's (Resident #12) right buttock and and failed to assess, monitor and implement interventions to treat and promote healing of a pressure ulcer on the resident's coccyx. The facility census was 77 residents. Record review of the facility policy form titled "Skin assessment and Wound Treatment Policy", dated 10/31/2001, showed the following instructions for facility staff: -All resident's are to have a "full body assessment" completed by a licensed nurse upon admission and readmission to the facility; -Resident's will receive a weekly skin bath assessment conducted by a "Bath Aide" (Certified Nursing assistant -CNA) during bathing; -The weekly Bath Aide skin assessments are provided to the "Charge Nurse" for review and follow-up; -The Charge Nurse will assess, describe, document the skin breakdown, and notify the resident's physician and treatment orders obtained; -Residents with skin breakdown will have weekly wound assessments completed by the charge nurse until healed; -A wound assessment record will be completed weekly to monitor the wound progression and this assessment will be part of the resident's medical record; -The resident's physician will be notified of any wound deterioration or needed changes in treatment; -The physician ordered wound treatment will be completed and documented as ordered in the resident's medical record. -The licensed nurse will complete all wound care; and -Any concerns regarding treatment will be reported to the resident's physician. Record review of the facility's undated policy Pressure Ulcer Treatment and Procedure showed staff were to: ---Assess the pressure sore by using the wound assessment form weekly. ---Assess the resident's nutritional status. ---Assess for other consults needed. ---Assess the resident's pain related to the pressure sores. ---Assess for diaper and absorbent pad use. ---Assess for a bladder/bowel retraining program. ---Reduce or eliminate causative factors such as pressure, shear, friction, moisture, circulatory impairment, ---Provide systemic support for wound healing by providing nutritional and fluid support and control of systemic condition affecting wound healing. ---Use appropriate topical therapy per physician order or recommendations from wound care specialist. --Interventions: ---Management of tissue loads, pressure relief, friction, shear, and moisture. ---Avoid positioning the resident on the pressure ulcer. ---Establish written repositioning/turning schedule including resident's on pressure reducing support surfaces. ---Use devices such as foam wedges to prevent direct contact between bony prominence's. ---Encourage the resident to shift his/her weight every 15 minutes in his/her wheelchair. 1. Record review of Resident #9's Hospital Consultation Note dated 1/27/12 showed: -Resident had chronic Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) pressure sores to his/her buttocks. -The resident denied any [DIAGNOSES REDACTED]. -The resident had four hip surgeries and debridement of his/her pressure sores. -The resident had no evidence of any other skin breakdown at that time. -There was a question whether he/she had some skin breakdown on his/her feet at one time. -The resident had no skin breakdown on his/her feet at this time. Record review of the resident's undated Face Sheet showed the resident was admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. --[MEDICAL CONDITION], --Spinal Stenosis (narrowing of the spinal column that causes pressure on the spinal cord), --Constipation, --History of [MEDICATION NAME] (alcohol) abuse, --History of polysubstance abuse, --History of suicidal ideation. Record review of the undated facility South Side Resident Bath Schedule showed the resident was scheduled for baths on Tuesday, Thursday, and Saturday on the 3:00 P.M. to 11:00 P.M. shift. Record review of the resident's Admission Nursing assessment dated [DATE] showed the resident: -Had a Stage II pressure sore to the left buttock. -Had a Stage II pressure sore to the right buttock. -Had a Stage I pressure sore (intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; it's color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue) to the right outer foot. -Was alert and oriented, friendly, and cooperative. -His/her feet stay cold. -Had partial weight bearing on his/her left leg and no weight bearing on his/her right leg. Record review of the resident's Physician's Orders Sheet (POS) dated 2/1/12 through 2/29/12 showed orders for: --Vitamin C 500 milligrams (mg): Give 500 mg by mouth twice a day. --Aspirin 81 mg: Give one tablet by mouth daily for [MEDICAL CONDITION] ([MEDICAL CONDITION], stroke)/[MEDICAL CONDITION] infarct ([MEDICAL CONDITION]). --[MEDICATION NAME] 300 mg: Give one tablet daily for [MEDICAL CONDITION] (damage to the nerves resulting in sensory loss in the extremities). --Multivitamin with minerals: Give one tablet by mouth daily. --Zinc sulfate 220 mg: Give one tablet daily as a supplement (this order was discontinued on 2/21/12). --Protein powder: Give one scoop by mouth twice a day for 30 days. --[MEDICATION NAME] 325 mg: Give two tablets every four hours as needed for pain/elevated temperature. --[MEDICATION NAME] 40 mg inject daily for a [MEDICAL CONDITION] ([MEDICAL CONDITION]-a blood clot in lower extremities). (This order had been marked out discontinued but was not dated). --[MEDICATION NAME] 5/325 mg: Give one tablet by mouth every four hours as needed for pain. --A low air loss mattress for pressure reduction. --Apply zinc oxide (a topical astringent and skin protectant) topical with Vaseline gauze then cover with a sterile dressing. (This order was not dated and did not state what area of the resident's body to apply this treatment). --No order for wound company to assess and/or treat resident's pressure sores. Record review of the resident's Braden Scale (for predicting pressure sore risk) dated 2/1/12 showed the resident('s): -Had some sensory impairment which limited his/her ability to feel pain or discomfort. -Skin was usually moist and required an extra linen change approximately once a day. -Ability to walk was severely limited or nonexistent and he/she could not bear weight and must be assisted into his/her chair or wheelchair. -Was very limited with mobility and could make occasional slight changes in body or extremity position but unable to make frequent or significant changes. -Had inadequate nutrition. -Moved feebly or required minimum assistance. During a move his/her skin probably slides to some extent against sheets, chair, or other devices. Maintains relatively good positioning in his/her chair or bed most of the time but occasionally can slide down. -Had a total score of 14 which meant the resident was not at high risk for pressure sores. (A total score of 12 or less represents a high risk of pressure sores). --Staff completed the resident's Braden scale upon admission. Staff did not complete any further Braden Scale assessments. Record review of the resident's Wound Assessment-Pressure Ulcer form completed by Licensed Practical Nurse (LPN) D dated 2/1/12 showed: -The resident had a Stage II coccyx pressure sore upon admission. -LPN D did not document the measurements and description of the wound. -Pressure relieving chair pads, a pressure relieving mattress, and heel pressure devices had been ordered. -The resident had a behavioral concern of refusing treatment. -Staff did not document any information that showed the resident had been refusing treatment upon admission prior to being admitted to the facility. -Had diabetic [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. -There was no information in the resident's hospital medical records or from the resident's physician related to the resident having these diagnoses. -The resident would be followed by the wound team. -LPN D didn't document any information about a pressure sore on the resident's right or left buttocks or on the right outer foot as described in the 2/1/12 Admission Nursing Assessment. Record review of the resident's Nurses Notes completed by LPN D dated 2/1/12 at 10:00 P.M. showed the resident('s): -Was alert and oriented times three (person, place and time). -Had a Stage II pressure sore to his/her bilateral buttocks. -Pressure sores to his/her buttocks were pink and had no odors. -Right outer foot was red. -Was encouraged to lie on his/her left side. -Right lower leg was painful to the touch. -Was encouraged to lie on his/her side. -Agreed to lie on his/her side. Record review of the resident's Nurses Notes dated 2/2/12 on the 11:00 P.M. to 7:00 A.M. shift, showed the resident('s) had a treatment completed to his/her buttocks. He/She had aching pain in his/her lower right leg and was given pain medications. Record review of the resident's wound company Wound Assessment report dated 2/3/12 by a wound nurse practitioner showed: -The resident had a chronic Stage II sacral (a triangular-shaped bone at the bottom of the spine) pressure sore which measured 3.5 centimeters (cm) in length by 2.1 cm in width by 0.1 cm in depth. The wound had 100% granulated tissue (any soft pink fleshy projections that form during the healing process in a wound that does not heal by first intention) attached to the wound base and the surrounding skin tissue was normal. -The resident's physician ordered staff to apply Santyl to the wound bed approximately nickel thick, cover with Vaseline gauze, cover or wrap loosely with gauze and change the dressing daily. -The resident's extremities were warm to the touch. -The resident was alert and oriented. -The resident was incontinent. Record review of the resident's Nurses Notes dated 2/3/12 at 3:05 P.M., showed the resident was up for meals in his/her wheelchair. Record review of the resident's Nurses Notes dated 2/3/12 on the 11:00 P.M. to 7:00 A.M. shift, showed the resident had a dry dressing applied to his/her buttocks, had pain and was given pain medications. Record review of the resident's POS dated 2/4/12 showed staff were to cleanse the wound (the order didn't specify where the wound was) with normal saline and apply nickel thick Santyl (active enzymatic therapy that continuously removes necrotic tissue from wounds) to the wound bed, cover with Vaseline gauze (a medical dressing covered in Vaseline), then cover with gauze. Record review of the resident's Treatment Administration Records (TAR's) dated 2/4/12 through 2/29/12: -Staff documented "Santyl" had only been applied 14 times out of 17 times from 2/3/12 through 2/23/12. --(Staff only wrote "Santyl". There were no directions to instruct the staff where the treatment was to be applied, how often to apply the treatment, or the type of wound dressing). -Apply zinc oxide topical with Vaseline gauze then cover with a sterile dressing. Staff did not document this treatment had been completed from 2/4/12 through 2/29/12. --The staff did not document the zinc oxide was discontinued after receiving new wound treatment orders on 2/4/12 from the wound company. Record review of the resident's History and Physical dated 2/7/12 showed the resident had been admitted to the facility from a psychiatric facility. The resident had the following [DIAGNOSES REDACTED]. --[MEDICAL CONDITION]. --Had a Stage II pressure sore to his/her coccyx (tailbone). --[MEDICAL CONDITION]. --Chronic hip pain. --Pelvic (lower abdomen area) pain. --Anorexia ([MEDICAL CONDITION]). --Spinal stenosis. --Immobility. --[MEDICAL CONDITION] (a disease or [MEDICAL CONDITION] state of the peripheral nerves in which motor, sensory, or vasomotor nerve fibers may be affected and which is marked by muscle weakness and atrophy, pain, and numbness). --Has had four surgeries to the right hip. --The diagnosis/plan: the Stage II pressure ulcer was being managed by a wound care company. Record review of the resident's wound company Wound Assessment report dated 2/10/12 completed by a Nurse Practioner showed: -The resident had a chronic Stage II sacral pressure sore which measured 3.0 cm in length by 1.5 cm in width by 0.1 cm in depth with 10% [MEDICATION NAME] and 90% pink granulated tissue, attached to the wound base and the surrounding skin tissue was normal. -The staff were to continue the current Santyl orders. -The resident was alert and oriented. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by the facility staff) dated 2/13/12 showed the resident: -Had adequate vision, hearing and speech. -Had intact cognition and no memory loss. -Had no behaviors and had not rejected cares. -Was independent with bed mobility and eating. -Required the limited assistance of one staff member for transfers and dressing. -Required the extensive assistance of one staff member for toilet use, personal hygiene, toileting, and bathing. -Used a wheelchair for mobility. -Was always incontinent of bladder. -Was frequently incontinent of bowel. -Had frequent pain. -Was at risk of developing pressure sores. -Had one Stage I pressure sore. -Had one Stage II pressure sore with granulated tissue upon admission. -Did not have pressure sore care. -Had a low air loss mattress. Record review of the resident's Care Plan dated 2/14/12 showed: -Problem: Bathing and hygiene deficit. --The resident needed staff assistance including showering/bathing three times per week. --The resident would participate in bathing/hygiene from the waist up. -Problem: Bowel incontinence. --The resident needed to receive incontinence care in the morning, evening, and after every bowel movement. -The staff did not develop a care plan or interventions for pressure sore care for the resident. Record review of the resident's Dietary History and Initial Screening dated 2/14/12 showed the resident was alert and oriented, had a regular diet, and had protein powder added to his/her diet for 30 days. Record review of the resident's Nurses Notes dated 2/16/12 at 5:15 P.M., showed the resident's left foot had [MEDICAL CONDITION] (fluid swelling of the lower extremities. Pitting [MEDICAL CONDITION] can be demonstrated by applying pressure to the swollen area by depressing the skin with a finger. If the pressing causes an indentation that persists for some time after the release of the pressure, the [MEDICAL CONDITION] is referred to as [MEDICAL CONDITION]) and the resident's right foot had [MEDICAL CONDITION]. The resident's physician had been notified. Record review of the Nurses Notes dated 2/16/12 at 6:10 P.M., showed the physician sent resident to the hospital due to the [MEDICAL CONDITION] in his/her legs. Record review of the resident's hospital History and Physical dated 2/16/12 showed: -The resident was sent to the emergency room related to lower extremity swelling and right foot pain. -The resident was admitted to the hospital. -A bilateral lower extremity doppler (an ultrasound to determine blocked or reduced blood flow through the major arteries of the legs) was completed on the resident's legs. -The resident had blood flow to his/her lower legs and the blood flow was within normal limits (WNL). -The resident was treated with [MEDICATION NAME] (an antibiotic) for a possible [MEDICAL CONDITION] infection (infection of the lungs) and possible right foot and ankle [MEDICAL CONDITION] (an infection of the deep tissue of the skin). -The resident's right foot and ankle [MEDICAL CONDITION] was more consistent with stasis [MEDICAL CONDITION] ([MEDICAL CONDITION] skin condition that develops secondary to fluid build-up). Record review of the hospital Wound Care Final Report dated 2/20/12 showed: -The resident was in bed resting on an envision mattress (a low air loss mattress). -The resident had a Stage II pressure sore to his/her right buttock that measured 1 cm in length by 1 cm in width. -The resident had a right lateral ankle open area that measured 1 cm in length by 1 cm in width. -The resident had a left lateral ankle scab that measured 1 cm by 1 cm. -The recommendations were to add waffle boots to the resident's feet while in bed and elevate the resident's lower extremities. Record review of the resident's Nurses Notes dated 2/20/12 at 3:00 P.M., showed the resident returned to the facility with no new orders other than vitamins. Record review of the resident's Nurses Notes dated 2/21/12 at 2:45 P.M., showed the resident was able to move around by the use of his/her wheelchair. He/she had a treatment administered to his/her buttocks. Record review of the resident's wound company Wound Assessment report dated 2/24/12 completed by a Nurse Practioner showed the sacral pressure sore was closed. The resident had [MEDICAL CONDITION] to his/her legs and his/her legs were warm to the touch. The resident was alert and oriented. Record Review of the resident's TAR showed on 2/24/12, next to the treatment order for Santyl, staff wrote "healed, put barrier cream on". Record review of the resident's Nurses Notes dated 2/24/12 at 2:20 P.M., showed the resident had been seen by the wound company. Treatment orders were discontinued to the resident's sacral area because the wound was healed. Record review of the resident's Nurses Notes dated 2/24/12 at 5:15 P.M., showed the resident had been refusing to get up for meals and had an excuse on why he/she would not get up for meals. Record review of the resident's Nurses Notes from 2/25/12 through 3/1/12 showed no staff documentation about any new pressure sores. Record review of the resident's POS dated 3/1/12 through 3/30/12 showed the following physician's ordered treatments: -Cleanse the wound with normal saline and apply nickel thick Santyl to the wound bed, cover with Vaseline gauze, then cover with gauze. This order was not discontinued until 3/9/12 but should of been discontinued on 2/24/12 when the wound was healed. -Apply zinc oxide topical with Vaseline gauze then cover with a sterile dressing. This order was discontinued on 3/9/12 but should have been discontinued on 2/24/12 when the wound company ordered the Santyl treatment. -On 2/1/12, the physician ordered a low air loss mattress but the order was not on this POS. Record review of the resident's TAR dated 3/1/12 through 3/31/12 showed: -Apply [MEDICATION NAME] cream, apply to the buttocks twice a day and as needed and alternate the treatment with a moisture barrier cream. --Staff documented these treatments were completed on the day shift a total of 12 times out of 14 times from 3/10/12 through 3/23/12. --Staff documented these treatments were completed a total of 0 times out of 14 times on the evening shift from 3/10/12 through 3/23/12. ---The staff did not show did not document which alternating treatment was applied on which day. Record review of the resident's Amended Comprehensive Care Plan dated 3/7/12 showed: -Problem: The resident was at high risk for further complications of current pressure sores related to lack of mobility as evidenced by refusing to be placed up in his/her wheelchair. --Goal: The resident will receive appropriate mobility daily to help increase his/her circulation. --Interventions: ---The staff will assist the resident in his/her wheelchair before meals and will assist the resident back to bed after meals immediately. ---The staff will serve the resident his/her meals right after the diabetic trays were served. ---The staff will keep the resident informed of his/her healing process. ---The nursing staff would continue to monitor the resident for increased discomfort and/or pain. -Staff did not add the intervention of the low air loss mattress as ordered by the physician on 2/1/12. Record review of the resident's wound company Wound Assessment report dated 3/9/12 completed by a Nurse Practioner showed: -The resident had a right buttock Stage II pressure sore which measured 0.9 cm in length by 0.5 cm in width by 0.1 cm in depth with 100% red granulated tissue, attached to the wound base, and the surrounding skin tissue was normal. -The physician ordered treatment was apply [MEDICATION NAME] cream to the affected area twice a day and as needed. Alternate with a moisture barrier cream. -The resident needed an offloading alternating pressure pad (APP) mattress overlay (used in the prevention and treatment of [REDACTED]. -The resident was alert and oriented. Record review of the resident's Nurses Notes dated 3/9/12 showed the resident had been seen by the wound company. Had new physician treatment orders. Record Review of the POS [REDACTED]. The antifungal works by killing sensitive fungi. The cream works by providing a protective barrier to prevent skin irritation) cream to the affected area on buttocks twice a day and as needed and alternate the treatment with a moisture barrier cream. Record review of the resident's wound company Wound Assessment report dated 3/10/12 completed by a Nurse Practioner showed: -The resident had a left buttock Stage II pressure sore which measured 0.5 cm in length by 0.5 cm in width by 0.1 cm in depth with 100% pink granulation, attached to the wound base, and the surrounding skin tissue was normal. -The physician ordered treatment was apply [MEDICATION NAME] cream to the affected area twice a day and as needed. Alternate with a moisture barrier cream. Record review of the resident's wound company Wound Assessment report dated 3/16/12 completed by a Nurse Practioner showed: -The resident had a right buttock Stage II pressure sore which measured 2.5 cm in length by 4.0 cm in width by 0.1 cm in depth with 60% [MEDICATION NAME], 40% pink granulation, attached to the wound base, and the surrounding skin tissue was normal. -The physician ordered treatment was apply [MEDICATION NAME] cream to the affected area twice a day and as needed. Alternate with a moisture barrier cream. Record review of the resident's Nurses Notes dated 3/19/12 at 3:00 P.M., showed the resident was refusing to get up for meals and was not keeping his/her agreement to get up for meals. He/she had pain related to his/her right hip. Record review of the Physician's Progress Note dated 3/20/12 showed the resident denied baths and was not getting out of bed. The resident needed to be encouraged to get out of bed for meals. Record review of the resident's POS dated 3/20/12 showed a physician's order for the resident to get out of bed for all meals and to schedule a bath twice a week. Record review of the resident's Nurses Notes dated 3/20/12 at 2:45 P.M., showed the resident was refusing to get up for meals was not keeping his/her agreement to get up for meals. Record review of the resident's comprehensive care plan showed staff did not update the plan with the physician orders dated 3/20/12. Record review of the resident's Nurses Notes dated 3/21/12 at 3:00 P.M., showed the resident was refusing to get up for meals and had an excuse on why he/she would not get up for meals. Record review of the resident's Nurses Notes dated 3/22/12 at 3:30 P.M., showed the resident was refusing to get up for meals and had an excuse on why he/she would not get up for meals. He/she had a treatment administered to his/her buttocks. Record review of the resident's wound company Wound Assessment report dated 3/23/12 completed by a Nurse Practioner showed the resident's left buttock was healed. Record review of the resident's TAR dated 3/23/12 showed staff documented the treatment order for [MEDICATION NAME] had been discontinued "healed per wound". Record review of the resident's Nurses Notes dated 3/24/12 at 2:40 P.M., showed the resident was refusing to get up for lunch and had refused to take a shower. He/she had excuses on why he/she would not cooperate with the staff. Record review of the Nurses Notes dated 3/25/12 through 4/1/12 showed no staff documentation about any new pressure sores. Record review of the resident's POS dated 4/1/12 through 4/31/12 showed the following physician ordered treatments: --Moisture barrier cream to affected areas on the buttocks twice a day and as needed, alternate with [MEDICATION NAME] cream. (This order was originally dated 3/10/12 but was not listed on the March POS). --[MEDICATION NAME] cream to the affected areas twice a day and as needed, alternate with a moisture barrier cream. (This order was originally dated 3/10/12 but was not listed on the March POS). --([MEDICATION NAME] cream is the generic name for [MEDICATION NAME] cream. This was written as two separate orders on the POS). -The physician ordered low air loss mattress originally ordered on the 2/1/12 was not on this POS. Record review of the resident's TAR dated 4/1/12 showed: -Apply moisture barrier cream to affected areas on the buttocks twice a day and as needed, alternate with [MEDICATION NAME] cream. This was crossed off and noted "healed discontinued treatment". On 4/16/12, "resume treatment". -Apply [MEDICATION NAME] cream to the affected areas twice a day and as needed, alternate with a moisture barrier cream. This was crossed off on the TAR "healed discontinued treatment". On 4/16/12, "resume treatment". -Staff did not document applying the [MEDICATION NAME] cream and alternating barrier cream to the resident 30 out of 30 times on the day shift from 4/1/12 through 4/30/12 and 30 out of 30 times on the night shift from 4/1/12 through 4/30/12. -The [MEDICATION NAME] cream and alternating barrier cream were not documented as being administered to the resident 30 out of 30 times on the day shift and 30 out of 30 times on the night shift from 4/1/12 through 4/30/12. Record review of the Resident's Physician's Progress Note dated 4/10/12 showed the resident: -Had no new concerns. -Had a chronic wound on his/her coccyx. -Declined to have the wounds assessed at that time. -Was being followed by the wound company. Record review of the resident's Nurses Notes dated 4/22/12 at 8:00 P.M., showed the resident: -Had open wounds to his/her buttocks with granulated wound beds. -Had a treatment of [REDACTED]. -The resident was instructed to lay on his/her side and not on his/her back. Record review of the resident's wound company Wound Assessment report dated 5/1/12 showed: -The resident had a bilateral buttocks Stage II pressure sore which measured 15.0 cm in length by 7.9 cm in width by 0.3 cm in depth with 60% [MEDICATION NAME], 40% pink granulation, attached to the wound base, and the surrounding skin tissue was normal. -The physician ordered treatment was to apply a thick layer of moisture barrier every shift and as needed. -The resident was to only be up out of bed for meals and kept off his/her buttocks. -The resident was alert and oriented, calm and cooperative. Record review of the resident's POS dated 5/1/12 through 5/31/12 showed: -The following physician ordered treatments: --Moisture barrier cream to affected areas on the buttocks twice a day and as needed, alternate with [MEDICATION NAME] cream. (This order was originally dated 3/10/12). --[MEDICATION NAME] cream to the affected areas twice a day and as needed, alternate with a moisture barrier cream. (This order was originally dated 3/10/12). --[MEDICATION NAME] cream is the generic name for [MEDICATION NAME] cream. This was written as two separate orders on the POS). -On 5/1/12, the wound company ordered for the staff to apply a thick layer of moisture barrier every shift and as needed to the resident's buttocks. This order was not added to the POS. The [MEDICATION NAME]/[MEDICATION NAME] order should have been discontinued on the POS when this order was written. -The physician ordered low air loss mattress originally ordered on [DATE] was not on this POS. Record review of the resident's TAR dated 5/1/12 through 5/31/12 showed: -The following physician ordered treatments: --[MEDICATION NAME] cream to the affected areas twice a day and as needed, alternate with a moisture barrier cream. Documented by nursing staff "Discontinued long time ago area healed". --Moisture barrier cream to affected areas on the buttocks twice a day and as needed, alternate with [MEDICATION NAME] cream. Documented by nursing staff "Discontinued long time ago area healed". --Apply moisture barrier cream daily. This had been documented as being administered 16 times on the day shift from 5/1/12 through 5/18/12. On 5/20/12, discontinued, see new TAR. Record review of the Resident's Physician's Progress Note dated 5/8/12 showed the resident: -Continued to have pressure sores. -Was bed bound and refused to get out of bed. -Gave excuses why he/she would not get out of bed. -Had a Stage I pressure sore on the left buttocks and a Stage II pressure sore on the right buttocks. --(The wound company requested the resident to only be up at meals, have a pressure reducing mattress and to stay off his/her buttocks). --There was no document to show that a low air loss mattress had been delivered to the resident. Record review of the resident's Nurses Notes dated 5/8/12 at 11:00 A.M., showed the resident: -Had been seen by the Physician A. -Had new pressure sore treatment orders. -The staff did not document that the resident had a low air loss mattress. Record Review of the POS [REDACTED] -Clean the bilateral buttocks with normal saline and apply a [MEDICATION NAME] dressing (Occlusive and adhesive wafer dressings which combine absorbent [MEDICATION NAME] materials with adhesive [MEDICATION NAME] to manage light to moderate amounts of wound exudate. Most [MEDICATION NAME] react with wound exudate to form a gel-like covering which protects the wound bed and maintains a moist wound environment - also called duoderm) every three days and as needed for pressure sores on the bilateral buttocks. The wound company needed to follow up on the residents pressure sores. The resident needed to be out of bed for all meals. Record review of the resident's TAR dated 5/8/12 showed: -Clean bilateral buttocks with normal saline and apply [MEDICATION NAME] dressing every three days and as needed. Staff documented this treatment had been provided on 5/8/12, 5/10/12, 5/13/12, 5/16/12, and 5/20/12. Documented by the nursing staff discontinued, see new TAR. Record review of the resident's Nurses Notes dated 5/10/12 at 11:00 P.M., showed the resident: -Had a treatment of [REDACTED]. -The staff did not document that the resident had a low air loss mattress. Record review of the resident's wound company Wound Assessment report dated 5/11/12 showed: -The resident had a Stage III bilateral buttocks pressure sore which measured 3.0 cm in length by 5.0 cm in width by 0.4 cm in depth with 10% slough, 80% [MEDICATION NAME], 10% pink granulation, and the surrounding skin was macerated (the process in which the skin is softened and broken down by extended exposure to wetness or moisture). --(

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interviews, and record review completed during this revisit, it was determined the facility had implemented corrective action to address and lower the violation at this time. Facility staff had received inservices regarding pressure sores and skin care. Facility staff had also completed all skin assessments. The worst pressure wound currently in the facility was a Stage II pressure sore. A wound care company is now employed by the facility, and the facility has also hired an Assistant Director of Nursing to assist the Director of Nursing, and free him/her for additional duties. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State law (Section 198.0261 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

Based on observation, interview and record review, the facility staff failed to provide protective oversight and supervision for one sampled resident (Resident #10) who was smoking a cigarette unattended in his/her room while wearing supplemental oxygen delivered by nasal cannula (a device for delivering oxygen by way of two small tubes that are inserted into the nostrils) and sustained a flame burn injury to his/her nose and lips requiring medical treatment on 11/12/12, with the resident having prior and continued noncompliance with the facility's smoking policy after the flame burn smoking incident, failed to assess and reassess the resident's safety with smoking, failed to develop and implement an individualized effective smoking plan for the resident, failed to communicate the resident's noncompliant unsafe smoking behaviors to the staff and failed to implement individualized supervision for the resident based on the resident's smoking behaviors; failed to care plan for one sampled resident's (Resident #17) risk for and actual falls, complete post falls assessments and falls investigations and provide interventions to keep resident safe; failed to implement interventions to prevent a shoulder injury and leg fracture from an unknown source and a fall for one sampled resident (Resident #12); failed to transfer a resident (Resident #18) in a safe manner using a gait belt out of 21 sampled residents. The facility census was 77 residents. Record review of "Fire Safety and Oxygen," a 2008 publication of the Emergency Care Research Institute (ECRI - a non-profit organization designated as an Evidence-Based Practice Center by the U.S Agency for Healthcare Research and Quality and listed by the U.S. Department of Health and Human Services as a federal Patient Safety Organization)showed: -Use of oxygen can put individuals and others at risk so it is important to know how to keep individuals and others safe. -Oxygen therapy is used to increase the supply of oxygen to the lungs, which in turn, makes more oxygen available to other body tissues. -Oxygen can be delivered from high-pressure cylinders or oxygen concentrating devices (oxygen concentrators). -The Oxygen flows from the supply through a long thin plastic tube that connects to a breathing device (such as a nasal cannula or face mask) worn by the individual. -One of the greatest risks of using oxygen is the potential for fire. -Smoking while breathing supplemental oxygen can cause the cigarette to burst into flame and ignite nearby clothing and furniture. -Smoking while oxygen is in use or nearby is the greatest cause of oxygen-user deaths. -The flame from a match or igniter can cause fire on or around a person using oxygen or on or around the oxygen supply. -Never smoke while using oxygen or near an oxygen supply. -The oxygen concentration in ordinary air is 21 percent and if that concentration is increased by only a little, the risk of fire grows dramatically. -In oxygen-enriched environments (defined as greater than 23 percent oxygen), fires can be easily started and spread by means that would not happen in ordinary air. -Many materials that do not burn in air will burn easily and vigorously in oxygen-enriched atmospheres (the air in any particular place. -Those fires burn hotter and faster than ordinary fires. -The higher the level of oxygen, the worse the fire. Record review of the undated facility Smoking Policy showed: -Prohibited smoking areas included resident rooms and restrooms. -Permitted smoking areas were the resident smoke room (a room located on an adjacent hall from Resident #10's room). -The activity room (located in the facility basement with access by elevator). -The outdoor courtyard located in the central area of the facility. Record review of the facility Smoking Assessment policy revised 5/9/08 showed: -Each resident who smoked would be assessed with [REDACTED]. Each resident who smoked would be reassessed annually. -If a resident began to exhibit unsafe smoking practices, that resident would be immediately reassessed. -When a resident was assessed and that resident was found to be unsafe to smoke unattended, then that resident would be provided with a staff member to attend them while they smoked. Record review of the facility Smoking Assessment Observation form revised 5/9/08 boxes in which to indicate yes/no responses to the following questions: -Does the resident hold the cigarettes too close to the fire or ashes? -Does the resident dump ashes in the ashtray as often as needed? -Does the resident fall asleep while smoking? -Does the resident express knowledge of the facility's smoking areas and rules? -Do the resident's clothes show cigarette burns? -Does the resident extinguish cigarettes in an ashtray? -Does the resident appear to be easily distracted while smoking? -Does the resident exhibit appropriate usage of a cigarette lighter? 1. Record review of Resident # 10's History and Physical report, completed by his/her physician on 3/6/12 showed: -The resident was oxygen dependent (required supplemental oxygen therapy due to inadequate lung function). -He/she had Chronic Obstructive Pulmonary Disease (COPD - an umbrella term used to describe chronic lung diseases that are characterized by progressive obstruction of the airflow into and out of the lungs and increased shortness of breath). Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff) dated 11/23/12 showed staff assessed the resident and found he/she: -Had adequate hearing. -Had clear speech. -Was understood by others. -Understood others. -Was cognitively intact. -Had a Mood symptom of feeling tired or having little energy every day for the past 12 to 14 days, -Was independent in activities of daily of bed mobility, transfer, walking, dressing, eating, toilet use and personal hygiene. -Received two staff person assistance in transfer when bathing. -Was continent of bladder and bowel. -Had shortness of breath with exertion, when sitting at rest and when lying flat, -Had no skin conditions. -Had oxygen therapy and hospice care. Record review of the resident's Nurse's Notes dated 4/18/12 at 9:00 A.M. showed: -The resident was smoking in his room and was observed by a Certified Medication Technician (CMT - a nursing assistant who has completed a course in medication administration approved by the Department of Health and Senior Services). -The resident's cigarettes and lighter were given to the facility social services designee where he/she could get access and smoke when he/she was out of his/her room. Record review of the resident's Physician's Orders sheet (POS) dated 6/1/12 showed on 6/15/12 the resident's physician ordered: -Oxygen (O2) saturation (sat.) each shift and as needed. -Notify physician if O2 sat. is lower than 88 percent. -No smoking, no cigarettes. -O2 concentrator at night - remove in morning. - Give 30 day discharge notice if smoking in room continues. Record review of the resident's Nurse's Notes dated 6/15/12 at 10:00 A.M. showed: -The charge nurse observed the resident smoking in his/her room with oxygen on. -The resident was educated to the dangers of smoking with oxygen on. -The Administrator was notified. -The resident's physician was notified and orders were received. -The nurse "warned" the resident that continued behaviors could lead to discharge. Record review of the resident's smoking care plan updated on 6/15/12 showed: -A problem dated 9/30/12 that he/she was noncompliant with the facility smoking policy. -A goal dated 9/30/12 that he/she would smoke only in designated areas. -An approach dated 4/28/04 that he/she would be escorted to the smoking area during designated smoking times to smoke under supervision. -An approach dated 4/28/04 that staff was to monitor his/her room for signs of smoking in his/her room and smoking materials, if found were to be turned into administration for use during smoking time. -An approach dated 4/28/04 that staff was to remind the resident of the policy when noncompliance was discovered. -An approach dated 6/15/12 that staff was to remind the resident that his/her physician had ordered that he/she have no cigarettes (dated 6/15/12). -An approach dated 6/15/12 that staff was to document noncompliance with the order for no cigarettes. Record review of the resident's Social Service Progress dated 6/20/12 showed: -The resident's care plan was completed on 6/20/12. -The resident had no complaint or concerns at that time. -He/she needed reminders regarding facility smoking policies. -He/she had no behaviors at that time. Record review of the resident's impaired breathing patterns care plan dated 6/15/12 showed: -A goal that he/she would resume effective breathing pattern as evidenced by a reduction of difficulty breathing. -An approach dated 6/15/12 that the resident uses oxygen and if not in use, place the cannula in a plastic bag. -An approach dated 8/1/11 that his/her oxygen would be at 2.5 L/minute by way of nasal cannula as ordered at night and remove his/her oxygen concentrator from his/her room every morning. -An approach dated 8/1/11 to assess his/her respiratory status and to notify his/her physician if the resident's oxygen saturation is less than 88 percent. -Staff was to encourage the resident not to smoke. -Staff was to offer hard candy and other items to assist him/her with smoking cessation. -Staff was to document noncompliance with the facility smoking policy especially smoking in his/her room. -Staff was to remind the resident's family and visitors to not bring cigarettes to him/her. Record review of the resident's Nurse's Notes dated 8/3/12 at 11:15 A.M. showed: -The resident was smoking in his/her room with his/her oxygen concentrator. -The resident's oxygen concentrator was removed from his/her room. -The Administrator "caught" the resident smoking in his/her room. -The resident had been "caught" smoking in his/her room before. Record review of the resident's Social Services Progress Notes dated 9/12/12 showed: -The resident's care plan was completed on 9/12/12. -He/she had no complaints or concerns. -He/she continued to need reminders regarding facility policies. Record review of the resident's Nurse's Notes dated 9/13/12 for the 3:00 P.M. to 11:00 P.M. shift showed: -The resident requested his/her oxygen concentrator back. -The safety concerns for him/her and his/her roommates regarding smoking in his/her room, "Refer back to physician's order about (his/her oxygen) concentrator and smoking." Record review of the resident's Nurse's Notes dated 9/22/12 at 12:35 P.M. showed: -The resident put on his/her call light and said he/she was short of breath and needed a room tray. -The CMT who answered the light said the resident's room smelled of smoke. -A lunch tray was taken to the resident in his/her room. -The resident was informed not to smoke in his/her room. -The resident was aware of the smoking rules and smoking areas. Record review of the resident's physician's progress note dated 10/2/12 showed: -The resident had poor concentration. -He/she had COPD and was oxygen dependent. -He/she occasionally smoked with oxygen on. -He/she was educated several times regarding smoking with oxygen on, but this did not help. Record review of the resident's Nurse's Notes dated 11/12/12 at 2:30 P.M. showed: -The resident put on his/her call light at 9:50 A.M. -The Licensed Practical Nurse (LPN) went to the resident's room. -The resident was on the toilet with his/her nasal cannula in his/her hands. -The resident's nasal cannula was burnt into two pieces. -The resident's mustache and nose were also burnt. -The LPN could smell the scent of burnt hair and plastic. -The resident was smoking while using his/her portable oxygen tank (a tank on wheels that delivers oxygen at prescribed flow levels). -The resident "would not admit what happened." -The resident was given a bath and shaved, and then cream was applied to his/her burnt nose and upper lip area. -The resident's physician was notified and gave an order for [REDACTED]. three times daily until healed and an order that the resident was to only be allowed to smoke in designated smoking areas, not in his/her room. -The Director of Nursing (DON) and Administrator were notified. Record review of the resident's Physician's Order Form (POS) dated 11/1/12 through 11/30/12 showed on 11/12/12 the resident's physician ordered: -Apply Silvadene Cream to burns on the resident's face three times daily until healed. -Resident was to be only allowed to smoke in designated smoking area, not in his/her room. Record review of the resident's care plan for the problem potential for trauma dated 11/12/12 showed: -Goals that the resident would safely smoke in designated area with staff supervision as evidenced by no incidents of smoking in non-designated areas and that the resident would be free from injury, harm to himself/herself or others as evidenced by no incidents of injury to himself/herself or others related to smoking habits. -Approaches included that staff was to: --Respond to the resident's call light promptly and keep the resident's call light within his/her reach. --Divert the resident's attention through activities as tolerated. --Provide quality listening time an encourage the resident to express his/her feelings. --Counsel him/her on the hazards of smoking in undesignated smoking areas. --Monitor the resident during smoking. --Counsel his/her visitors on the facility policy and request cooperation. --Reinforce with the resident the reasons for no smoking in his/her room. --Remove cigarettes and lighters and matches from his/her room. --Reinforce the reasons oxygen must be kept away from flames from lighters, matches and lit cigarettes. --Offer to escort the resident to the smoking room at smoking times. --Remind the resident's peers and visitors to not give him/her smoking materials. --Discuss with the resident the use of nicotine patch and provide if he/she was willing. --Check for smoking materials and for signs of smoking in his/her room, if present remove all smoking materials from his/her room. --Offer electronic cigarettes ("E" cigarette, also known as personal vaporizer or PV, is an electronic inhaler that that vaporizes a liquid solution into an aerosol mist) to the resident and provide to him/her if he/she was agreeable. --Be familiar with the location of the nearest fire extinguisher and nearest fire extinguisher and fire alarm pull station. --Remove all paper, Styrofoam and plastic cups from his/her room as they are used for ashtrays. --Educate all staff on how to turn oxygen tanks and concentrators off. --Keep the resident's room door open at all times. --Reinforce to the resident, roommates and visitors of the safety hazards related to the use of oxygen and flames, including cigarettes, matches and lighters. --Make sure no smoking sign is placed on the door of the resident's room. Record review of the resident's Nurse Practitioner's (NP - an RN who has completed an advanced training program in a medical specialty such as internal medicine, an NP may function as a primary direct provider of health care and prescribe medications), progress note dated 11/13/12 showed: -The NP saw the resident for follow-up for burns to his/her face. -The resident was oriented to himself/herself, others, where he/she was, and to time. -The resident had burns on the tip of his/her nose and his/her upper lip. -The resident had COPD and was oxygen dependent. -He/she smoked with his/her oxygen on. -The resident's NP discussed no smoking with oxygen on with the resident. Record review of the resident's Nurse's Notes dated 11/13/12 for the 11:00 P.M. to 7:00 A.M. shift showed: -He/she was awake, sitting at his/her bedside. -Ashes were in a cup in his/her room. -The treatment for [REDACTED]. -The resident refused his/her as needed medication. -A Maxi mist treatment was done. -He/she had no complaint of discomfort. Record review of the resident's Physician's Order Form (POS) dated 11/1/12 through 11/30/12 showed on 11/15/12, the resident's physician ordered the resident's oxygen be increased to 3 - 4 liters per minute (LPM) per nasal cannula. Record review of the resident's Physician's Order Form (POS) dated 1/1/13 through 1/31/13 showed his/her physician ordered the following: -[DIAGNOSES REDACTED]. -Resident is only to smoke in designated smoking areas - not in his/her room. -Oxygen at 3 to 4 liters per nasal cannula continuous, dated 11/19/12. During an interview on 1/8/13 at 3:28 P.M., the resident said: -Normally he/she smoked in his/her bathroom once or twice a day. -He/she did not have any way to get money, the facility staff took all his/her money, that was not right. -He/she had to beg, borrow or steal cigarettes. -Anything he/she said to the facility staff was "like talking to a wall." -The way he/she was treated by staff at the facility was "inhumane." -He/she could not get a candy bar or a pop, all he/she could get was what was on his/her meal tray. -The staff walked by his/her room not to check on him/her to see if he/she was "OK." -The staff brought him/her medication. -He/she had some cigarettes and the staff came and physically held him/her down and took them away from him/her. -He/she had a burn injury about a month ago on his/her nose and upper lip from smoking in his/her room with his/her oxygen on. -The staff did not do anything different after his/her burn. -The staff did put something on his/her burn; the staff did not do anything else. -He/she used the Styrofoam cup that was on his/her overbed table as an ashtray. -A Styrofoam cup was what he/she used as an ashtray when smoking in his/her room; he/she also used the Styrofoam cup as a container for spit. -He/she wished he/she had a lighter. -When asked if the staff checked on him/her, he/she said that staff come around at shift (change) and every once in a while during the night. -The staff had "cut (him/her) off" from having his/her "little $30.00 a month." -"How could they treat a dog like that, they know they got you over a rock and a hard place." -The staff did not try to be kind about it. -If he/she used his/her call light, staff would come but just to check on him/her, only if he/she requested something. -In the past, the Administrator had said he/she could smoke in his/her room and brought a large ashtray to his/her room and then the whole thing just stopped. -He/she had to have his/her oxygen off when he/she smoked in his/her room. -The Administrator brought a large ashtray from the smoking room to his/her room. -Then the Administrator said he/she could not smoke in his/her room. -If he/she could smoke in his/her room then why could he/she not smoke in his/her room now, it did not make sense. -He/she did smoke in his/her room with his/her oxygen on; yes he/she had sometimes done that. -He/she would be just fine with someone sitting with him/her in his/her room when he/she smoked in his/her room. -He/she did not go the resident smoke room with his/her oxygen, it was inconvenient. -He/she smoked in his/her room. -He/she was not trying to be rebellious, his/her legs hurt. -No matter what the staff say, they can make an "accommodation for me to smoke (in his/her room), they did it before." -"All I get is negative from them." During an interview on 1/8/12 at 6:44 P.M., LPN I said: -The resident was a smoker. -He/she had been known to smoke in his/her room. -As soon as staff smelled cigarette smoke, they confiscated the resident's cigarette. -Other residents gave the resident cigarettes, staff had tried telling other residents not to give him/her cigarettes. -Staff go into the resident's room (he/she did not say how frequently when asked). -He/she did not know anything about the resident's care plans. -He/she did not have time to read the resident's care plans. -When he/she worked, he/she fulfilled the roles of LPN, CMT and Certified Nursing Assistant (CNA). During an interview on 1/8/12 at 6:52 P.M., CNA J said: -He/she had occasionally seen the resident smoking in his/her room when checking on other residents in his/her room or when walking by his/her room. -He/she had last seen the resident smoking in his/her room about a week ago. -He/she did not tell the charge nurse. -He/she just asked the resident for his/her cigarette, the resident gave him/her the cigarette and he/she threw it in the trash. -He/she did not know if the resident had matches or a lighter and did not ask the resident how he/she had lit his/her cigarette. -He/she had never been asked to check on the resident intentionally for smoking. -Staff used to go into the resident's room and supervise him/her smoking, but that was stopped the end of November or beginning of December (2012). During an interview on 1/8/13 at 6:56 P.M., CNA K said: -The resident smoked in his/her room once, that was why staff took his/her cigarettes away from him/her. -When he/she worked on the 11:00 P.M. to 7:00 A.M. shift the previous week, the licensed charge nurse told him/her to check on the resident every two hours to see if he/she was smoking. -Observation in the resident's room on 1/8/12 at 7:01 P.M. showed: -A cigarette with a burned end on the resident's overbed table. -A cigarette butt in a Styrofoam cup on the resident's overbed table. During an interview on 1/8/12 at 7:20 P.M., the Administrator said: -The resident had smoked in his/her room for a long, long time; that was not the policy of the facility. -The resident could not be without his/her oxygen and could not smoke with his/her oxygen on. -He/she had tried to have the resident smoke in his/her room supervised by staff, but even after that he/she was "caught" smoking in his/her room, so he/she stopped the resident's supervised smoking in his/her room. -The Administrator agreed to put the resident on every 15 minute checks by staff. During an interview on 1/9/13 at 2:20 P.M., the Housekeeping Supervisor said: -He/she walked past the resident's room on 1/8/13 at about 7:00 A.M. and the resident was smoking. -He/she got the licensed charge nurse who told the resident to put the cigarette out and the resident put the cigarette out. -At that time the oxygen cannula was not on the resident. -A little later he/she told the Director of Nursing (DON) he/she had seen the resident smoking in his/her room. -He/she had "caught" the resident smoking on another occasion before the resident "blew (himself/herself) up" smoking in (his/her) room. During an interview on 1/9/13 at 2:49 P.M., the facility social services designee (SSD) said: -He/she had caught the resident smoking in his/her room again after he/she had the burn incident while smoking with oxygen on in his/her room. -Facility staff did not give the resident cigarettes. -Other residents may have been giving him/her cigarettes. During an interview on 1/9/13 at 1:43 P.M., housekeeping staff A said: -The resident had a past accident in his/her room with smoking. -He/she had not seen cigarettes in the resident's room. -He/she had not seen the resident smoking in his/her room before the resident was on oxygen, -He/she had seen the resident smoke in his/her room before he/she had oxygen. -He/she had gone into the resident's room and smelled cigarette smoke in the resident's bathroom. -He/she had not caught the resident smoking in his/her room. During an interview on 1/9/13 at 1:50 P.M., housekeeping staff B said: -He/she had smelled cigarette smoke in the resident's room. -He/she had not witnessed the resident smoking in his/her room. -He/she saw alot of ashes on the floor and thought it was ash, not cigarette butts. -He/she had not seen cigarette butts in the resident's trash. During an interview on 1/9/12 at 1:55 P.M., the DON said: -The resident could not tolerate being off oxygen. -Staff had caught him/her numerous times smoking with his/her oxygen on. -He/she was not getting that he/she could not smoke with his/her oxygen on. -In the past, staff supervised his/her smoking in his/her room but he/she still tried to smoke unsupervised. -The facility staff had been struggling with the resident's smoking in his/her room with oxygen on for over six months. -The facility staff did not want to "kick (the resident) out." -The facility staff was trying to "accommodate" him/her. -At the time of the resident's facial burn from smoking in his/her room with oxygen on, he/she refused to go to a hospital emergency room . -Staff "had him where we had the (resident's) door open." -Staff was in the resident's room about every half hour. -The resident was "crafty." -He/she also used to drink alcohol in his/her room also. -"We busted him yesterday" smoking in his/her room with oxygen on at about 8:00 A.M. -The resident had the cigarette gone by the time he/she got to the resident's room. -He/she could tell a cigarette had just been burning because the odor was different from a lingering cigarette odor. -The resident denied having smoked a cigarette in his/her room. -It took three staff including he/she and the Administrator to remove the resident's cigarettes from him; at that time he/she had a discussion with the resident that he/she could not have cigarettes and smoke unsupervised with his/her oxygen on in his/her room. -He/she believed they did find a lighter also at that time. During an interview on 1/9/12 at 3:12 P.M., CNA E said: -He/she did not know where the resident got his/her cigarettes -He/she and other staff had "caught" the resident smoking in his/her room; he/she had been "caught alot." -The resident had his/her oxygen on one time when he/she was seen smoking in his/her room. -He/she had not recently heard that the resident had smoked in his/her room with oxygen on since the burn incident. -The resident once had over 30 lighters in his/her dresser and alot of cigarette packs with one or two cigarettes in them, that was several months ago when he/she lived on the end of the middle hall adjacent to his/her room. -He/she did not think the resident was on oxygen at that time. -Staff had been just kind of checking the resident every 20 minutes or so. -Ever since the accident, he/she had not "caught" the resident smoking in his/her room. -Now (on 1/9/13) the resident was on every 15 minute checks and staff had been signing off the checks on a sheet." During an interview on 1/9/13 2:20 P.M., LPN G said there was no Smoking Assessment in the resident's medical record. Record review on 1/9/12 at 2:21 P.M. showed no Smoking Assessment(s) in the resident's medical record. During an interview on 1/9/12 at 2:32 P.M., the SSD said: -The resident was noncompliant and smoked in his/her room. -He/she had seen the resident smoking in his/her room about a month prior. -He/she did not have oxygen on at that time. -He/she "looked at me like I was crazy" when he/she spoke to the resident about smoking in his/her room. -He/she explained to the resident that he/she was not to smoke in his/her room. -The resident denied smoking in his/her room. -He/she took the Styrofoam cup with the ashes out of the resident's room. -He/she did not tell any of the other staff that he/she had seen the resident smoking in his/her room. -He/she did not search the resident's room for cigarettes, matches or lighters. -He/she did not do anything further regarding finding the resident smoking in his/her room. During an interview on 1/9/13 at 5:05 P.M., charge nurse LPN E said: -There was nothing new going on with the resident or with his/her care, nothing had gone on with the resident since yesterday. -The resident was not being monitored differently than other residents. -He/she had not been told anything in shift change report regarding the resident. During an interview on 1/9/13 at 5:07 P.M., CNA H said he/she only knew that the resident was on 15 minute checks. During an interview on 1/9/13 at 5:09 P.M., CNA I said: -He/she had been told to check on the resident every 15 minutes. -The reason he/she was to check on the resident every 15 minutes was to see if he/she needed ice. Record review of the resident's care plan dated 1/9/13 showed: -A problem of alterations in comfort related to end stage COPD , dependent on oxygen with strong desire to smoke and history of noncompliance with smoking regulations. -A goal that the resident's comfort level would be maintained and safety for himself/herself and others would not be compromised. -Approaches of: --Maintain one to one (1:1 - one staff person assigned to constantly observe for one resident's safety) observation of the resident at all times including trips to the bathroom until the time of discharge from the facility. --Continue oxygen as ordered. --Provide alternatives/help for smoking cessation and encourage use. --Escort him/her by wheelchair to the smoking room every two hours during facility smoking times on odd hours; allow him/her to smoke one half to one cigarette as tolerated. --Return him/her to his/her room after smoking the cigarette as tolerated and resume his/her oxygen. --Monitor him/her for increased breathing difficulties while smoking; return him/her to an area where he/she could have oxygen if he/she has breathing distress or when he/she finishes his/her cigarette. During an interview on 1/10/13 at 2:05 P.M., Supplemental Resident #107 (whose 11/30/12 quarterly MDS showed he/she had adequate hearing and vision, understood others and was understood others, was cognitively intact and had no mood or behavior symptoms) said: -The resident smoked in his/her room; he/she used oxygen and smoked in his/her room. -Smoking in your room at the facility "is a big deal. You can get kicked out of here for it. But for some reason (the resident) had been allowed to smoke in (his/her) room." -The resident did everything in his/her room, "eats, smokes, everything." -The resident's meal tray sits in his/her room for a couple of hours after he/she eats. -In his/her opinion, the resident needed to be moved to a private room because of eating and smoking in his/her room. -Smoking in resident rooms was dangerous, but for some reason the resident was allowed to smoke in his/her room. -The resident generally smoked after meals and sometimes a couple of other times when someone gave him/her a cigarette. During an interview on 1/25/12 at 1:20 P.M., the resident's facility physician said: -He/she expected the staff would have monitored the resident one on one for a period of time following his/her smoking facial burn injury and then transition the resident to less monitoring at the facility if the resident was compliant with the facility smoking policy, or discharge the resident from the facility if the resident continued to smoke in his/her room. -He/she expected the facility staff would have developed a specific plan for what to do regarding the resident. -He/she had ordered the resident was only to smoke in designated smoking areas, not in his/her room; if the resident continued to smoke in his/her room he/she would have to be transferred from the facility. -He/she had talked to the resident several times regarding the dangers of smoking with oxygen to himself/herself and to other residents but the resident's behaviors had not changed. -The resident was very non-compliant and unless the resident decided to change, there was very little that the facility staff could do; the resident could not be kept on one to one forever. -He/she expected the facilty staff to follow nursing practice, to keep the resident and other residents safe, document everything regarding the resident, and discharge the resident if he/she did not follow the facility smoking policy. Record review of the facility policy form titled "Fall Policy and Procedure", dated 2005, showed the following definitions and procedure: -A

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview, and record review, completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. Facility staff were inserviced regarding the smoking policy and the monitoring of residents who smoke. The facility also completed all of the resident smoking assessments. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State law (Section 198.0261 RSMo.) requiring that prompt remedial action be taken to address Class I violations.