Every finding on record at NHC Healthcare, Joplin

Based on observation, interview and record review, the facility failed to provide adequate assistance with toileting needs in a manner that promoted quality of life, dignity, respect, and individuality for three residents (Residents #77, #72, and #51) of 23 sampled residents. The facility census was 79. Review of the facility policy Quality of Life-Dignity, revised August 2009, showed the following: -Residents shall be treated with dignity and respect at all times; -Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth; -Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by promptly responding to the resident's request for toileting assistance; -Staff shall treat cognitively impaired residents with dignity and sensitivity by addressing the underlying motives or root causes for behavior and not challenging or contradicting the resident's beliefs or statements. Review of the facility policy Activities of Daily Living (ADL), revised March 2018, showed the following: -Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition demonstrate that diminishing ADLs are unavoidable; -The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs; -He/she has been offered alternative interventions to minimize further decline; -Appropriate care and services will be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking), elimination (toileting). 1. Review of Resident #77's face sheet (admission information at a glance) showed the following: -admission [DATE]; -Diagnoses that included Parkinson's disease (degenerative disorder of the central nervous system that cause tremors, slowness of movement, and difficulty in walking), dementia (progressive impairments in memory, thinking, and behavior), anxiety, prostate (gland in the male reproductive system) cancer. Review of the resident's physician's orders dated 07/04/26, showed an order for an indwelling catheter care every shift. Review of the resident's comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 07/09/26, showed the following: -Brief Interview for Mental Status (BIMS), showed severely impaired cognition; -Indwelling urinary catheter; -Always incontinent of bowel; -Dependent on staff for transfers and toileting. Review of the resident's care plan dated 07/11/26, showed the care plan did not address the catheter, toileting, or transfers. Observation made on 07/13/26 showed the following: -At 6:15 P.M., surveyor and staff at the nurse's station heard the resident hollering down the hall. -At 6:15 P.M., the resident lay on a low bed, with the head of the bed slightly raised, and a urinary catheter bag below the bed. The resident kept hollering from his/her room that he/she had to go. He/she loudly hollered, I already went. I need to go more. I need to go, please. -At 6:15 P.M. Certified Medication Technician (CMT) C was preparing medications to administer at the medication cart on the hall. During an interview, on 07/13/26 at 6:25 P.M, CMT C said the resident hollered all the time. Observation on 07/13/26 at 6:25 P.M., showed the resident urgently and continuously hollering, I have to go. I already went and need to go more. I need to go, please. During an interview, on 07/13/26 at 6:25 P.M, Certified Nursing Assistant (CNA) D said the resident had a catheter and had a slight bm (bowel movement), but he/she had to get help to do his/her care. Observation made on 07/13/26 showed the following: -At 6:30 P.M. CNA D went into his/her room and told the resident, Go ahead and go into your brief. I have to have a Hoyer (mechanical) lift to transfer you. The resident kept hollering loudly, I have to go poo. Help me, please over and over. I've already gone poo in my pants and have to go again. Help me. Oh, no, I did it again. CNA D was in his/her room for a minute and then walked out. CMT C kept preparing medications to administer to other residents at the medication cart on the hall. -At 6:35 P.M. the resident cried out, Oh no, I just did it again. In my pants. Help me! I have to go bad. I already pooed my pants and have to go again. Help me! Help me!; -At 6:37 P.M., CMT C and CNA D went into the resident's room where the resident's left leg was hanging off the low bed. They raised the bed and his/her one leg hung over the side of the bed. The catheter bag with dark urine hung from the side of the bed; -At 6:38 P.M., CMT C told the resident that since he/she no longer walked, they needed the Hoyer lift. CMT C said they would center him/her in bed to clean him/her; -At 6:40 P.M. CMT C and CNA D put on gowns and gloves while the resident kept hollering loudly about pooping his/her pants to them. They put the catheter bag with dark urine on the bed. They removed his/her pants. He/she wore an incontinence brief. The resident had a large runny bowel movement. CMT C wiped the bm off the resident's feet after removing his/her pants. The resident kept saying he/she pooped his/her pants. They tried to roll the resident toward CMT C and then he/she told CNA D to go get the nurse since the resident was hollering that he/she was afraid of falling since he/she was kicking his/her feet over the side of the bed. CNA D lowered the bed; -At 6:45 P.M. the resident said, I'm ashamed of myself. As CMT C talked quietly to him/her as they waited for CNA D and the nurse to come to the room. The resident said, I'm ashamed for wetting and pooping my pants; -Between 6:50 P.M -7:14 P.M., Licensed Practical Nurse (LPN) A came in to help CMT C and CNA D with perineal and catheter care for the resident. The resident kept asking them to help him/her as they provided care. When they moved him/her up in the bed and put pillow beneath his/her head, he/she thanked them. 2. Review of Resident #72's face sheet showed the following: -admission [DATE]; -Diagnoses that included fractured left leg with left artificial hip joint replacement, multiple fractures of pelvis, ribs, heart failure, high blood sugar, moderate dementia (progressive impairments in memory, thinking, and behavior, with mood disturbance). Review of the resident's quarterly MDS dated [DATE], showed the following: -BIMS indicate intact cognition; -Impairment of one lower extremity; -Dependent on staff for transfers and toileting; -Always incontinent of urine and bowel. Review of the resident's care plan dated 07/10/26, showed the following: -Cognition/communication strengths/deficits; -Approaches included: able to make needs known, able to use call light, alert/cognitively intact, and verbal; -Bowel and bladder occasionally incontinent; -Approaches included: incontinence care per needs, incontinence pads or briefs as needed; -Behaviors/mood; -Approaches included: give resident choice as much as possible regarding care times and preferences, can be manipulative in behaviors with staff and family and will insist staff get him/her up and then immediately want to be laid back down-if not immediately addressed, he/she will threaten to throw self on the floor; (The care plan did not address transfers and toileting for the resident) During observation and interview on 07/13/26 at 7:44 P.M., the resident who was in bed, said the following: -He/she wanted to get up out of bed; -Staff had to help him/her get up and down; - Staff tell him/her to go (pee or have bowel movement) in his/her incontinence brief. He/she wore an incontinence brief in bed; -The resident turned on his/her call light. CNA E came in to answer the call light. The resident said he/she wanted to get up. CNA E said as soon as other staff were done using the Hoyer (mechanical) lift to lay another resident down. (There was a mechanical lift sling in the resident's wheelchair). During an interview on 07/14/26 at 12:00 noon in the dining room, the resident said the following: -He/she had broken his/her left hip and his/her left foot slides when they transfer him/her; -He/she can stand with one staff helping him/her. The staff sometimes have used a gait (transfer) belt and lifted him/her; -The staff do use a Hoyer lift to transfer him/her. During an interview on 07/16/26 at 11:15 A.M. the resident said the following: -Staff will tell him/her to urinate in his/her incontinence brief. This was normal for nursing; - They can't get him/her up fast enough when he/she calls them to go to the bathroom. He/she can't wait now to hold his/her urine and bowels like when he/she was younger; -He/she waits 5 minutes or 30 minutes and it depends on how busy the staff are and what hall staff were on. Some of the residents want to get up at the same time; -It doesn't bother him/her too much to go in his/her incontinence brief. He/she just wants to be changed. He/she then added that it did bother him/her a little though. - A dry brief is more comfortable than a wet one. I can pee three times in a brief; 3. Review of Resident #51's face sheet showed the following: -admitted : 12/30/25; -Diagnoses: Connective tissue and disc stenosis of intervertebral foramina of lumbar region (the narrowing of the bony openings where nerve roots exit your lower spine), spinal stenosis (the space inside the backbone becomes narrow and puts pressure on the spinal cord and the nerves that pass through the spine), lumbar region without neurogenic claudication (the spinal canal is narrowed) and a history of falls. Review of the resident's care plan, dated 12/30/25, showed the following: -Problem: Bowel and Bladder -incontinence due to urgency, weakness and the ability to easily get to bathroom; -The resident's continence status will be maintained at current level (or improved); strengthen of lower extremities. -The resident will have his/her needs related to incontinence status addressed; to provide dignity and respect. Maintain and keep skin clean and dry and free from redness and skin breakdown. Review of the resident's quarterly MDS, dated [DATE], showed the following: -BIMS indicates intact cognition; -No pressure ulcers; -Always incontinent of bowel & bladder; -Substantial assistance needed for toileting with two assist for transfer to toilet. During the resident council meeting on 07/14/2026, at approximately 2:05 P.M., Resident #51 said the following: -There are never two people to help [me] go to the bathroom; -He/she does not require a lift but does require two aides to assist him/her with toileting; -He/she is capable of toileting on his/her own, but needs assistance to get to/from the toilet; -If he/she lets staff know he/she is needing to go, they will say they need to find someone to help but they never find anyone else; -He/she has been told numerous times to go ahead and just go in his/her brief, since they cannot find help; -Staff will say that since there is not another to assist, they can clean the person if they go ahead and just go in their briefs, therefore that is the easiest choice; -Makes me feel bad because I'm [AGE] years old and pooping in my diaper!; - I can go to the bathroom, so it is humiliating; -He/she states it is because he/she cannot wait for another person to help, so they say to go in his/her diaper; -It embarrasses him/her each time. 4. During interview on 07/16/26 at 9:10 A.M., the Director of Nursing (DON) said the following: -If a Hoyer mechanical lift was unavailable for a resident to transfer, staff were not to tell residents to go in their incontinence brief; -They were to find a bed pan or urinal for the resident to use. During interview on 07/16/26 at 9:25 A.M., the administrator said the following: -Staff were not to say to a resident to go to the bathroom in their incontinence brief; -They do have bedpans and/or urinals to use to toilet. During interview on 07/16/26 at 2:05 P.M., CMT G said the following: -Two staff were needed to use a Hoyer (mechanical) lift; -If a resident needed a Hoyer lift and had to use the toilet, he/she would go find another lift; -Staff were never to tell a resident to just go in their incontinence brief; that wasn't dignity and respect; -Staff were to get a bedpan or urinal for the resident to use to toilet; -They weren't able to get any resident into the bathroom when they required a mechanical lift transfer. During interview on 07/16/26 at 2:23 P.M., Licensed Practical Nurse (LPN) A said the following: -Staff were not to tell a resident to go in their incontinence brief. This would not be dignity and respect; -The resident had an option for a bedpan or urinal than to go in their incontinence brief; - Sometimes staff were using the Hoyer lifts, or the lift's battery was dead, but they did have four lifts. During an interview on 07/17/26, at approximately 11:45 A.M., CNA F said the following: -If someone requires a Hoyer, then it requires two staff; -Someone may require two assist without needing a Hoyer, they may just need two people to help get them up/down; -If unable to find anyone to assist, they would always offer a bedpan or urinal to use, so they do not go in their pants, which is embarrassing; -He/she would never tell anyone to just go ahead and go if I cannot find anyone to assist. During an interview on 07/17/26, at approximately 12:10 P.M., CMT G said the following: -He/she also works as a CNA, occasionally, she does assist with resident's personal cares; - If you are unable to find assistance to get a resident to the toilet, then you should offer a urinal or bedpan; -He/she would never attempt to get them up without assistance; -He/she would also never tell a resident to go to the bathroom in their pants, that is humiliating. During an interview on 07/17/26, at approximately 1:20 P.M., CMT C said the following: -He/she has overheard aides, very loudly, telling the resident to go ahead and go and then they will come back and assist; -Residents should be offered bedpans or urinals, instead; -This would be degrading to the resident. During an interview on 07/17/26, at approximately 4:45 P.M., the DON said the following: -An aide should always be able to find a CNA to assist with getting a resident up/down or to wherever they are needing to be; -If a resident requires two to transfer then they should never transfer by self; -If it were the case, then at the very least offer a bedpan or urinal to the resident; -It is never appropriate to tell someone to go ahead and go in their briefs; -There will be some education and if found out who, someone is possibly fired; -He/she encourages residents to speak up if there is an issue, so he/she is aware. During an interview on 07/17/26, at approximately 5:35 P.M., the Administrator said the following: -It is never appropriate to tell a resident to just go ahead and go in their briefs, instead of getting assistance; -There is always someone else (staff) in the building that can assist; -It is not okay for the residents to feel embarrassed about toileting needs. Complaint 3068945 Complaint 3068915 Complaint 3045131 Complaint 3051550

Based on observation, interview and record review, the facility failed to provide appropriate catheter care for two residents (Residents # 77 and #82) of four sampled residents with catheters when facility staff placed the catheter bag on the low bed and the urinary catheter bag lay on the fall mat on the floor increasing the residents' risk for infection. The facility census was 79. Review of the facility policy from the Infection Control Manual Volume 1, updated March 2026, showed for patients with urinary catheters, staff were to keep drainage bags off the floor, but below the level of the patient's bladder.1. Review of Resident #77's face sheet (admission information at a glance) showed the following:-admission [DATE];-Diagnoses that included Parkinson's disease (degenerative disorder of the central nervous system that cause tremors, slowness of movement, and difficulty in walking), dementia (progressive impairments in memory, thinking, and behavior), anxiety, prostate (gland in the male reproductive system) cancer. Review of the resident's physician's orders dated 07/04/26, showed an order for an indwelling catheter care every shift. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/09/26, showed the following:-Brief Interview for Mental Status (BIMS), showed severely impaired cognition;-Indwelling urinary catheter;-Always incontinent of bowel;-Dependent on staff for transfers and toileting. Review of the resident's care plan dated 07/11/26, showed the care plan did not address the catheter and any catheter care. Observation of the resident on 07/13/26 showed the following:-At 12:21 P.M., the resident lay on a low bed with the catheter bag with dark urine resting on the fall mat on the floor;-At 2:47 P.M. the resident was lying in a low bed with mat on floor with the urinary catheter bag with dark urine laying on the mat on the floor;-At 4:03 P.M., the resident was lying in a low bed with urinary catheter bag with dark urine, lying on the fall mat on the floor; -At 6:15 P.M., the resident lay on a low bed, with the head of the bed slightly raised, and a urinary catheter bag with dark urine resting on the fall mat on the floor.-At 7:31 P.M, after staff performed catheter care, staff lowered the bed, attached the catheter bag with dark urine to the side of the bed. The catheter bag rested on the fall mat on the floor. Observation of the resident on 07/15/26 showed the following:-At 6:15 A.M. the resident's catheter bag hung from the bedsheet on the low bed and touched the fall mat on the floor as the resident appeared to be sleeping. The room was dark;-At 6:51 A.M. the resident was in the low bed with the bottom of urinary catheter bag on the fall mat. There was dark urine in the catheter bag. 2. Review of Resident #82's face sheet showed the following: -admission [DATE];-Diagnoses that included: congestive heart failure, bacteremia ( presence of bacteria in the bloodstream or infection), muscle weakness, chronic kidney disease, anxiety, dysphagia (difficulty swallowing). Review of the resident's comprehensive MDS dated [DATE], showed the following:-BIMS showed severely impaired cognition;-Indwelling urinary catheter;-Always incontinent of bowel;-Required partial/moderate assistance of staff for transfers and toileting. Review of the resident's physician's orders dated 06/05/26-06/07/26, showed the following:-Do bladder training for 24 hours prior to catheter being removed. Special instructions; Clamp catheter for four hours, then empty for 15 minutes, then re-clamp for another four hours. Document output every four hours;-Discontinue (D/C) foley catheter early morning after completing bladder training one time;-Monitor urine output after foley removed. Special instructions: if urine output is less than 500 milliliters (ml) in 24 hours, insert new catheter and notify provider. Review of the resident's care plan dated 07/06/26, did not address the resident having a catheter, toileting, and personal cares. Observation on 07/13/26 at 2:40 P.M. showed the resident lying in low bed with the urinary catheter bag lying on the fall mat. No urine was observed in the catheter bag. Observation on 07/13/26 at 4:03 P.M. showed the resident sat up on low bed with the urinary catheter bag on the mat on the floor. Observation on 07/13/26 at 7:31 P.M. showed Certified Nurse Aide (CNA) D moved the resident in the Broda (reclining geriatric chair) to the low bed and the fall mat on the floor. CNA D raised the bed a little and pulled the Broda chair close to the bed. He/she took the urinary catheter bag and placed it on the side of the bed. He/she helped the resident stand as he/she took his/her hands and the resident walked to the side of the bed and he/she helped him/her lie down. He/she lowered the bed and the urinary catheter bag sat on the floor mat. Observation on 07/15/26 at 6:05 A.M., showed the resident was lying in bed with the urinary catheter bag on the fall mat on the floor. During interview on 07/16/26 at 1:50 P.M., CNA F said the following:-The urinary catheter bag was to hang on side of the resident's bed. While doing care, it can lay on the end or on the resident's lap but must be lower than the bladder;-He/she was not sure if the urinary catheter bag was to lay on the fall mat or touch the floor. -He/she only knew the urinary catheter bag was to hook to the side of the bed. 3. During interview on 07/16/26 at 2:05 P.M., Certified Medication Technician (CMT) G said the following:-They were to hook the urinary catheter bag to the side of the resident's bed and it should be kept at the level of the bladder;-When the resident was on a low bed with a fall mat on the floor, the catheter bag should not touch the floor and probably shouldn't touch the fall mat. During interview on 07/16/26 at 2:23 P.M., Licensed Practical Nurse (LPN) A said the following:-Staff were to place a urinary catheter bag on the side of the resident's bed and off the ground;-If a resident was in a low bed, they were to keep the urinary catheter bag off the ground as much as they could. The catheter bag should not lay on the fall mat. During interview on 07/17/26 at 9:10 A.M. the Director of Nursing (DON) said the following:-The catheter bag was to be below the bladder and not on the floor;-The staff can place the urinary catheter bag in a basin and have a dignity bag to cover them;-The urinary catheter bag was not to lay on or touch the floor or a fall mat. During interview on 07/17/26 at 9:25 A.M., the administrator said the following:-The urinary catheter bag was not to be below the bladder;-When the resident had a low bed, the urinary catheter bag was not to be on the floor or the fall mat;-Staff were to go get a basin and let the catheter bag lay in the basin. MO 2993589

Based on interview and record review, the facility staff failed to notify one resident's (Resident #19) durable power of attorney (DPOA) of any medication changes, refusals of repositioning, transfers, and medications. The facility census was 79.The facility did not provide a notification policy.1. Review of Resident #19's face sheet (brief resident profile sheet) showed the following:-readmitted to the facility on [DATE];-Diagnoses included paraplegia (paralysis of the lower portion of the body and of both legs), mild dementia with anxiety, chronic kidney disease (impaired kidney function); heart failure (impaired heart function); moderate protein-calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets.)Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) dated 06/25/26, showed the following:-Severe cognitive impairment;-Indwelling catheter (a sterile tube inserted into the bladder to drain urine);-Dependent on toileting hygiene, bathing, dressing, and transfers;-Always incontinent of bowel.Review of the resident's current care plan, dated 06/25/26, showed on 02/24/26, staff implemented the following:-Document all refusals and inform physician and representative;-Resident to be up out of bed daily for one hour.Review of the resident's physician order report showed the following orders, dated 03/04/25:-Ask/encourage resident to turn/reposition every two to three hours;-Resident to be up out of bed daily for one hour.Review of the Medication Administration Record (MAR) dated 04/15/26 - 05/14/26, showed the following:-Staff documented the physician order for staff to ask/encourage the resident to turn/reposition every two to three hours as not administered/refused on the following dates with no documentation of contact with the DPOA: 04/18/26, 9:00 A.M.; 04/18/26, 12:00 P.M.; 04/18/26, 3:00 P.M.; 04/18/26, 6:00 P.M.; 04/19/26, 9:00 A.M.; 04/19/26, 3:00 P.M.; 04/19/26, 6:00 P.M.; 04/22/26, 9:00 A.M.; 04/22/26, 12:00 P.M.; 04/22/26, 3:00 P.M.; 04/22/26, 6:00 P.M.Review of the MAR, dated 04/15/26 - 05/14/26, showed the following:-Staff documented the physician order for the resident to be up out of bed daily for one hour once a day as not administered/refused on the following dates with no documentation of contact with the DPOA: 04/17/26; 04/18/26; 04/19/26; 04/21/26; 04/22/26.Review of the resident's progress note, dated 04/23/26, at 2:37 P.M., showed the following:-New orders received from hospice: discontinue Colace (stool softener) and start senna (laxative used to treat constipation), take two tablets every night. Resident aware of plan. Staff did not document notification to DPOA of change in medication orders.Review of the MAR, dated 04/15/26 - 05/14/26, showed the following:Staff documented the physician order for staff to ask/encourage the resident to turn/reposition every two to three hours as not administered/refused on the following dates with no documentation of contact with the DPOA:-04/23/26, 9:00 A.M.; 04/23/26, 12:00 P.M.; 04/23/26, 3:00 P.M.; 04/23/26, 6:00 P.M.; 04/24/26, 9:00 A.M.; 04/24/26, 12:00 P.M.; 04/24/26, 3:00 P.M.; 04/24/26, 6:00 P.M.; 04/27/26, 9:00 A.M.; 04/27/26, 12:00 P.M.; 04/27/26, 3:00 P.M.; 04/27/26, 6:00 P.M.; 04/28/26, 9:00 A.M.; 04/28/26, 12:00 P.M.; 04/28/26, 3:00 P.M.; 04/28/26, 6:00 P.M.; 05/02/26, 6:00 A.M.; 05/02/26, 9:00 A.M.; 05/02/26, 12:00 P.M.; 05/02/26, 3:00 P.M.; 05/02/26, 6:00 P.M.; 05/03/26, 9:00 A.M.; 05/03/26, 12:00 P.M.; 05/03/26, 3:00 P.M.; 05/03/26, 6:00 P.M.; 05/06/26, 9:00 A.M.; 05/06/26, 12:00 P.M.; 05/06/26, 3:00 P.M.; 05/06/26, 6:00 P.M.; 05/07/26, 9:00 A.M. Review of the MAR, dated 04/15/26 - 05/14/26, showed the following:-Staff documented the physician order for the resident to be up out of bed daily for one hour once a day as not administered/refused on the following dates with no documentation of contact with the DPOA: 04/23/26; 04/24/26; 04/25/26; 04/27/26; 04/28/26; 05/02/26; 05/03/26; 05/04/26; 05/05/26; 05/06/26.Review of the resident's progress note, dated 05/07/26, at 10:43 A.M., showed the following:-New orders received to change fesoterodine extended release (medication to treat overactive bladder) 8 milligrams (mg) to Tolterodine (medication used to treat overactive bladder) 1 mg twice daily for bladder spasms. Resident aware of plan. Staff did not document notification to DPOA of change in medication orders.Review of the MAR, dated 04/15/26 - 05/14/26, showed the following:-Staff documented the physician order for staff to ask/encourage the resident to turn/reposition every two to three hours as not administered/refused on the following dates with no documentation of contact with the DPOA: 05/07/26, 12:00 P.M.; 05/07/26, 3:00 P.M.; 05/07/26, 6:00 P.M.; 05/08/26, 9:00 A.M.; 05/08/26, 12:00 P.M.Review of the MAR, dated 04/15/26 - 05/14/26, showed the following:-Staff documented the physician order for the resident to be up out of bed daily for one hour once a day as not administered/refused on the following dates with no documentation of contact with the DPOA: 05/07/26; 05/08/26.Review of the resident's progress note, dated 05/08/26, at 2:56 P.M., showed the following:-Change hydrocodone (strong opioid medication to treat severe pain) to as needed for pain. Change hydroxyzine (medication that can be used to treat allergic skin itching) to as needed for itching. Discontinue multivitamin. Changes brought to the attention of hospice. Resident wanted to stop taking medications that do not work. Resident aware of plan. Staff did not document notification to DPOA of change in medication orders.Review of the MAR, dated 04/15/26 - 05/14/26, showed the following:-Staff documented the physician order for staff to ask/encourage the resident to turn/reposition every two to three hours as not administered/refused on the following dates with no documentation of contact with the DPOA: 05/08/26, 3:00 P.M.; 05/08/26, 6:00 P.M.; 05/11/26, 9:00 A.M.; 05/11/26, 12:00 P.M.; 05/11/26, 3:00 P.M.; 05/11/26, 6:00 P.M.; 05/12/26 9:00 A.M.; 05/12/26, 12:00 P.M.; 05/12/26, 3:00 P.M.; 05/12/26, 6:00 P.M.Review of the MAR, dated 04/15/26 - 05/14/26, showed the following:-Staff documented the physician order for the resident to be up out of bed daily for one hour once a day as not administered/refused on the following dates with no documentation of contact with the DPOA: 05/10/26; 05/11/26; 05/12/26; 05/13/26;Review of the resident's progress note, dated 05/12/26, at 4:11 A.M., marked late entry showed the following:-Staff offered the resident routine nighttime medications and he/she refused. Staff informed the resident the need to take the medications and he/she refused again. Certified Medication Technician (CMT) marked them as refused in the MAR and disposed of the medications properly. Staff did not document notification to DPOA of refusal of the medications.Review of the MAR dated 05/15/26 - 06/14/26, showed the following:-Staff documented the order for the resident to be up out of bed daily for one hour once a day as not administered/refused on the following dates with no documentation of contact with the DPOA: 05/15/26; 05/16/26.Review of the resident's progress note, dated 05/18/26, at 10:25 A.M., showed the following:-New orders received from hospice for Bisacodyl 10 mg rectal suppository one time daily as needed for constipation. Hyoscyamine 0.125 mg disintegrating table every three hours as needed for secretions. Staff did not document notification to the DPOA of the new orders.Review of the resident's progress note, dated 05/19/26, at 9:27 P.M., showed the following:-Resident had small red circle spots on right foot near the toes. Skin prep ordered, apply twice daily until resolved. Staff did not document notification to DPOA of new skin issue or new order placed.Review of the MAR, dated 05/15/26 - 06/14/26, showed the following:-Staff documented the physician order for staff to ask/encourage the resident to turn/reposition every two to three hours as not administered/refused on the following dates with no documentation of contact with the DPOA: 05/20/26, 9:00 A.M.; 05/20/26, 12:00 P.M.; 05/20/26, 3:00 P.M.; 05/20/26, 6:00 P.M.; 05/20/26, 9:00 P.M.; 05/21/26, 9:00 A.M.; 05/21/26, 12:00 P.M.; 05/21/26, 3:00 P.M.; 05/21/26, 6:00 P.M.; 05/21/26, 9:00 P.M.; 05/22/26, 9:00 A.M.; 05/22/26, 12:00 P.M.; 05/22/26, 3:00 P.M.; 05/25/26, 9:00 A.M.; 05/25/26, 12:00 P.M.; 05/25/26, 3:00 P.M.; 05/25/26, 6:00 P.M.; 05/26/26, 9:00 A.M.; 05/26/26, 12:00 P.M.; 05/26/26, 3:00 P.M.; 05/30/26, 9:00 A.M.; 05/30/26, 12:00 P.M.; 05/30/26, 3:00 P.M.; 05/30/26, 6:00 P.M.; 05/31/26, 9:00 A.M.; 05/31/26, 12:00 P.M.; 05/31/26, 3:00 P.M.; 05/31/26, 6:00 P.M.; 06/03/26, 9:00 A.M.; 06/03/26, 3:00 P.M.; 06/04/26, 9:00 A.M.; 06/04/26, 12:00 P.M.; 06/04/26, 3:00 P.M.; 06/04/26, 6:00 P.M.; 06/05/26, 9:00 A.M.; 06/05/26, 12:00 P.M.; 06/05/26, 3:00 P.M.; 06/08/26, 9:00 A.M.; 06/08/26, 12:00 P.M.; 06/08/26, 3:00 P.M.; 06/08/26, 6:00 P.M.; 06/09/26, 9:00 A.M.; 06/09/26, 12:00 P.M.; 06/09/26, 3:00 P.M.; 06/13/26, 6:00 A.M.; 06/13/26, 9:00 A.M.; 06/13/26, 12:00 P.M.; 06/13/26, 3:00 P.M.; 06/13/26, 6:00 P.M.; 06/14/26, 9:00 A.M.; 06/14/26, 12:00 P.M.; 06/14/26, 3:00 P.M.; 06/14/26, 6:00 P.M.Review of the MAR dated 05/15/26 - 06/14/26, showed the following:-Staff documented the physician order for the resident to be up out of bed daily for one hour once a day as not administered/refused on the following dates with no documentation of contact with the DPOA: 05/20/26; 05/21/26; 05/22/26; 05/23/26; 05/24/26; 05/25/26; 05/26/26; 05/27/26; 05/28/26; 05/29/26; 05/30/26; 05/31/26; 06/01/26; 06/02/26; 06/03/26; 06/04/26; 06/05/26; 06/07/26; 06/08/26; 06/09/26; 06/10/26; 06/11/26; 06/12/26; 06/13/26; 06/14/26.Review of the MAR dated 06/15/26 - 07/15/26, showed the following:-Staff documented the physician order for staff to ask/encourage the resident to turn/reposition every two to three hours as not administered/refused on the following dates with no documentation of contact with the DPOA: 06/17/26, 9:00 A.M.; 06/17/26, 12:00 P.M.; 06/17/26, 3:00 P.M.; 06/17/26, 6:00 P.M.; 06/18/26, 6:00 A.M.; 06/18/26, 9:00 A.M.; 06/18/26, 12:00 P.M.; 06/18/26, 3:00 P.M.; 06/18/26, 6:00 P.M.; 06/19/26, 9:00 A.M.; 06/19/26, 12:00 P.M.; 06/19/26, 3:00 P.M.; 06/19/26, 6:00 P.M.; 06/22/26, 9:00 A.M.; 06/22/26, 12:00 P.M.; 06/22/26, 3:00 P.M.; 06/23/26, 9:00 A.M.; 06/23/26, 12:00 P.M.; 06/23/26, 3:00 P.M.; 06/23/26, 6:00 P.M.; 06/27/26, 6:00 A.M.; 06/27/26, 9:00 A.M.; 06/27/26, 12:00 P.M.; 06/27/26, 3:00 P.M.; 06/28/26, 9:00 A.M.; 06/28/26, 12:00 P.M.; 06/28/26, 3:00 P.M.; 06/28/26, 6:00 P.M.; 07/01/26, 9:00 A.M.; 07/01/26, 12:00 P.M.; 07/01/26, 3:00 P.M.; 07/02/26, 9:00 A.M.; 07/02/26, 12:00 P.M.; 07/02/26, 3:00 P.M.; 07/03/26, 9:00 A.M.; 07/03/26, 12:00 P.M.; 07/03/26, 3:00 P.M.; 07/03/26, 6:00 P.M.; 07/06/26, 9:00 A.M.; 07/06/26, 12:00 P.M.; 07/06/26, 3:00 P.M.; 07/06/26, 6:00 P.M.; 07/07/26, 9:00 A.M.; 07/07/26, 12:00 P.M.; 07/07/26, 3:00 P.M.; 07/07/26, 6:00 P.M.; 07/09/26, 9:00 P.M.; 07/10/26, 12:00 A.M.; 07/10/26, 3:00 A.M.; 07/11/26, 6:00 A.M.; 07/11/26, 9:00 A.M.; 07/11/26, 12:00 P.M.; 07/11/26, 3:00 P.M.; 07/11/26, 6:00 P.M.; 07/12/26, 9:00 A.M.; 07/12/26, 12:00 P.M.; 07/12/26, 3:00 P.M.; 07/12/26, 6:00 P.M.Review of the MAR dated 06/15/26 - 07/15/26, showed the following:-Staff documented the physician order for the resident to be up out of bed daily for one hour once a day as not administered/refused on the following dates with no documentation of contact with the DPOA: 06/15/26; 06/17/26; 06/18/26; 06/19/20; 06/20/26; 06/21/26; 06/22/26; 06/23/26.Review of the resident's progress note, dated 06/23/26, at 4:05 P.M., showed the following:-Resident had new skin issue of red, peeling skin on the inner right thigh. Denied pain or discomfort in area. Order placed for nystatin powder, apply twice daily. Staff did not document notification to DPOA of new skin issue or new order placed.Review of the MAR dated 06/15/26 - 07/15/26, showed the following:-Staff documented the physician order for the resident to be up out of bed daily for one hour once a day as not administered/refused on the following dates with no documentation of contact with the DPOA: 06/24/26; 06/25/26; 06/26/26; 06/27/26; 06/28/26, 1:00 P.M.; 06/29/26, 1:00 P.M.; 06/30/26; 07/01/26; 07/02/26; 07/03/26; 07/04/26; 07/05/26; 07/06/26; 07/07/26; 07/08/26; 07/09/26; 07/10/26; 07/11/26; 07/12/26.Review of the resident's progress note, dated 07/15/26, at 10:28 A.M., showed the following:-Resident had new skin issue of small red bumps on back. CeraVe (lotion) order placed, apply twice daily. Repositioning encouraged. Staff did not document notification to DPOA of new skin issue or new order placed.During an interview on 07/16/26, at 9:09 A.M., Resident #19's responsible party said the following:-He/she did not think staff assisted the resident as ordered with repositioning in his/her bed or transferring out of the bed into his/her chair;-Staff have not notified the responsible party of all resident order changes;-He/she expects staff to contact the responsible party with any change of condition, change of orders, or refusals of care. During an interview on 07/17/26, at 11:13 A.M., CMT I said the following:-When a resident refused medications, would mark refused on the MAR and destroy medications;-He/she would notify the nurse of any refused medications.During an interview on 07/17/26, at 11:20 A.M., Licensed Practical Nurse (LPN) O said the following:-If a resident refused medications, he/she would notify physician, follow orders, and document actions in progress notes;-Repositioning residents helps prevent pressure ulcers;-Residents should be repositioned at least every two to three hours;-Resident #19 refused to be repositioned and refused to be transferred out of bed frequently;-He/she did not know the care plan stated to document all refusals and to inform physician and representative;-LPN O documented resident refusals on the MAR, but did not contact his/her DPOA;-Staff should document all future contacts with the resident's DPOA after all refusals of cares in the progress notes.During an interview on 07/17/26, at 4:45 P.M., the Director of Nursing (DON) said the following:-She would expect staff to ask the nurse for assistance if the resident refused medications, repositioning or transferring;-She would expect the nurse to notify the resident's DPOA or family member of any medical changes;-She would expect all notifications to the DPOA to be documented in the progress notes;-She would expect staff to follow the resident's care plan. During an interview on 07/17/26, at 5:39 P.M., the administrator said the following:-She would expect staff to reposition residents every two hours;-She would expect staff to educate the resident if he/she refused repositioning or medications;-She would expect another staff member to attempt to reposition or administer medications to the resident;-Staff should document all attempts, education, refusals and notifications to supervisors, physicians and family in the progress notes;-She would expect staff to follow the resident's care plan. Complaint 3045131

Based on observation and interview, the facility failed to provide a sanitary and comfortable environment when staff failed to replace a soiled privacy curtain for one resident (Resident #55). A sample of 23 residents were reviewed; the facility census was 79.The facility did not present a policy specific to the cleaning of privacy curtains. 1. Review of Resident #55's face sheet (gives basic profile information) showed the following:-admitted to the facility on [DATE];-Received hospice services;-Diagnoses included breathing disorders with dependence on supplemental oxygen, chronic kidney disease, heart disease, congestive heart failure, irregular heart function, severe obesity, diabetes, pain, dementia, and anxiety. Review of the resident's quarterly Minimum Data Set (MDS; a federally mandated comprehensive assessment tool completed by facility staff), dated 06/18/26, showed the following:-Resident cognitively intact;-Dependent on assistance of others for positioning in bed. Review of the resident's care plan, last updated 06/17/26, showed the following:-Terminal diagnosis/hospice; goal: will maintain maximum quality of life as possible while needs continue to be met;-Limited bed mobility, assist with positioning for comfort; During an interview on 07/14/26, at 1:30 P.M., Resident #55 pointed at his/her privacy curtain, which was extended between his/her bed and the roommate's side of the room. He/she said he/she had experienced an episode of explosive diarrhea about four months ago, resulting in loose stool being splashed onto the privacy curtain during incontinent care. Staff did not clean the curtain at that time, nor had they cleaned or replaced the curtain after he/she had pointed it out to them more than once since then. The resident said that was really annoying to look at, especially since the room was all he/she had to look at in his/her life. Observation at that time showed the privacy curtain had four areas of dried, smeared brown substance at knee/calf level on the side facing the resident's bed. Observation on 07/16/26, at 12:32 P.M., showed the resident's privacy curtain was pulled between his/her bed and the roommate's side of the room. The curtain had four areas of dried, smeared brown substance at knee/calf level on the side facing the resident's bed. Observation on 07/17/26, at 12:20 P.M., showed the resident's privacy curtain was pulled between his/her bed and the roommate's side of the room. The curtain remained in soiled condition with four areas of dried, smeared brown substance at knee/calf level on the side facing the resident's bed. 2. During an interview on 07/17/26, at 1:20 P.M., the Director of Nursing (DON) said staff should take down a soiled privacy curtain; the curtain should not remain soiled with fecal matter. The curtains are washable, and there are clean curtains available to replace a soiled one. Any of the staff can take the curtain down or ask housekeeping or maintenance staff for assistance. During an interview on 07/17/26, at 1:32 P.M., the Administrator said a soiled privacy curtain should be taken down and sent to laundry. Nursing staff can ask housekeeping or maintenance staff for assistance to take the curtain down and replace it with a clean curtain. During an interview on 07/17/26, at 1:38 P.M., certified nursing assistant (CNA) R said a soiled privacy curtain should be cleaned or changed out. The CNA wasn't aware of Resident #55's soiled curtain. During an interview on 07/17/26, at 1:45 P.M., the Infection Preventionist Registered Nurse (IP RN) and Licensed Practical Nurse (LPN) O both said if a privacy curtain becomes soiled, staff should remove it and give it to housekeeping or laundry staff to clean. A replacement curtain was always available and could be retrieved and installed. If the staff was unable to remove the soiled curtain by themself, they should notify housekeeping or maintenance to have it changed out.2993589

Based on observation, interview, and record review, the facility failed to ensure food was stored in a manner to protect the food from possible contamination when staff failed to store food in sealed containers and failed to dispose of expired food items. The facility had a census of 85 residents. 1. Review of the facility's policy titled, Safety and Sanitation Best Practice Guidelines-Dry Storage, revised June 2025, showed the following:-All Time/Temperature Control for Safety (TCS) foods shall be stored in a clean and dry location; not exposed to splash, dust or other contamination;-Items will be stored at least six inches off the floor;-Foods will be stored in their original packages, if possible. If opened, packages should be closed securely to protect product. Review of the facility's policy titled, Safety and Sanitation Best Practice Guidelines-Refrigerator and Freezer Storage, revised June 2025, showed the following:-Each center will have a system for date marking. Foods will be stored in their original container, or a Food and Nutrition Services (FNS) approved container or wrapped tightly in moisture-proof film, foil, etc. Foods should be clearly labeled with the contents with the use by date and/or date opened;-Once food is cooked, perishable items must be labeled with the use by date before properly storing in the refrigerator. The use by date is determined by a 7-day period that includes the day the food was prepared plus the 6 days following. Review of the facility's policy titled, Safety and Sanitation Best Practice Guidelines-Nourishment Pantries, revised January 2025, showed the following: -Cleaning of the refrigerators and storage areas in the nourishment pantries will be the responsibility of the Nursing, FNS, or Housekeeping partners, and/or assigned by the Administrator'-Food and beverages brought into center from outside will be securely package, labeled, and stored appropriately. Each food/beverage item should be labeled with patient name and the date the items(s) were brought into the center. Nursing and FNS partners will monitor. Perishable foods will be discarded within 7 days unless expiration is before the 7 days per manufactures' Use by, best by, or expiration dates. Review of the facility's policy titled, Safety and Sanitation Best Practice Guidelines-Food Brought Into Center From Outside Sources, dated November 2017, showed the following:- Food and beverages brought into center from outside will be securely package, labeled, with the patient's name and date the item(s) were brought into the center;-Food or beverage items may be stored in center nourishment pantries, refrigerators, freezers, or patient's personal room refrigerators, if applicable;-Food or beverage items will be monitored and discarded by the center as follows: Perishable foods will be discarded within 3 days, or per manufactures' Use by, best by, or expiration dates.Review of the Missouri Food Code, published 2013, regarding refrigerator food storage, showed the following:-Refrigerated, ready-to-eat, potentially hazardous food, prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of forty-one degrees Fahrenheit (41 F) or less for a maximum of seven days or when held at a temperature of forty-five degrees Fahrenheit (45 F) or less for a maximum of four days.-Refrigerated, ready-to-eat, potentially hazardous food, prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified:-The day the original container is opened in the food establishment shall be counted as day 1;-The day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety;-Food shall be protected from cross contamination by storing the food in packages, covered containers, or wrappings. Observation on 07/28/25, at 1:45 P.M., of the dry storage area in the kitchen showed the following: -A partial package of rotini pasta taped up with no open date;-A brown cardboard box of lasagna noodles with a loose fitting lid;-Three loose unopened bags of white bread mix, one with a grease spot that permeated the packaging, with no expiration date;-Two loose unopened sleeves of saltine crackers with no expiration date, next to trash bags and a first aid kit.Observation on 07/28/25, at 2:00 P.M., of the walk-in refrigerator in the kitchen showed the following: -A tray holding water condensation directly above an open container of celery;-Open package of turkey lunchmeat, received on 06/26/25, with no open date;-Cheese slices in reusable container with no date;-Open container of pimento cheese, received date 07/10/25, with no open date. Observation on 07/31/25, at 10:32 A.M., of the back dry storage area behind the kitchen showed the following:-Three open containers of Hershey syrup on the hydration carts with packaging that read refrigerate after opening. The three containers were room temperature to the touch;- A box of potatoes, nine with visible eyes;-A mesh bag of onions hanging off of the bottom shelf;-One onion still in the bag, sitting on the floor;-One onion loose on the floor under the shelf;-Brown sugar in reusable container with lid partially off;-Flour in reusable container with lid partially off.Observation on 07/31/25, at 10:45 A.M., of the dry storage area in the kitchen showed the following: -A brown cardboard box of lasagna noodles with a loose fitting lid;-A partial package of rotini pasta taped up with no open date;-Four loose unopened bags of white bread mix, two with grease spots that permeated the packaging, with no expiration date;-Two loose unopened sleeves of saltine crackers with no expiration date, next to trash bags and a first aid kit.Observation on 07/31/25, at 10:55 A.M., of the walk-in refrigerator in the kitchen showed the following: -A tray holding water condensation directly above an open container of celery (4 to 5 stalks);-Open container of pimento cheese, received date 07/10/25, with no open date.-Boiled eggs in a reusable container, dated 07/21/25;-Cooked diced chicken in a Ziplock bag, dated 07/19/25.Observation on 07/31/25, at 11:30 A.M., of the hydration room refrigerator, showed the following:-On the outside of the refrigerator, signage indicating resident use only and staff must label all items with the resident's name and date;-Eight hot dogs in Ziplock bag in the door, resident name present with no date;-Two sausages in Ziplock bag in the door, resident name present with no date;-A jar of apple butter in the door, resident name present with no date;-Chili in reusable container with no resident name and no date;-Raw vegetables in liquid in a reusable container, resident name present with no date;-Leftover food, overflowing outside of the Styrofoam container with no resident name and no date;-A dish of baked beams covered with saran wrap, resident name present with no date;-A cinnamon roll in a plastic container, resident name present with no date;-Watermelon in an opened container, resident name present and best by date of 07/24/25;-A plastic bag filled with fruit (grapes, oranges, apples, plums, and nectarines), first name of resident present with no date;-An unopened bottle of peach iced tea, resident name present, with best by date of 06/25/25;-In the freezer, a bag of loose burritos, not sealed, resident name present with no date. Observation on 08/01/25, at 2:05 P.M., of the refrigerator in the B Hall showed the following:-On the outside of the refrigerator the facility policy regarding hydration rooms;-One cup of Jello covered with saran wrap with no resident name and no date;-One carafe of apple juice with no date;-A fast food bag from Burger King, rolled over, with no resident name and no date;-In the freezer, an ice cream container, resident name present with no date.Observation on 08/04/25, at 9:54 A.M., of the hydration room refrigerator, showed the following:-Eight hot dogs in Ziplock bag in the door, resident name present with no date;-Two sausages in Ziplock bag in the door, resident name present with no date;-One loose [NAME] in the door with no resident name and no date;-Seven individually package sausage biscuits in a plastic bag in the door, resident name present and dated 07/20/25;-Chili in reusable container with no resident name and no date;-A cinnamon roll in a plastic container, resident name present with no date;-Watermelon in an opened container, resident name present with best by date 07/24/25;-A salad covered with saran wrap, resident name present with no date;-A bag of grapes with no resident name and no date;-Marinated vegetables in a reusable container, resident name present with no date;-A bag of grapes, resident name present and dated 07/02/25;-An unopened bottle of peach iced tea, resident name presentand best by date of 06/25/25;-An open bottle of chocolate syrup, no resident name, received 04/08/24, opened 08/12/24.Observation on 08/04/25, at 10:05 A.M., of the refrigerator in the B Hall showed the following:-One cup of Jello covered with saran wrap, no resident name with no date;-One carafe of apple juice with no date;-A fast food bag from Burger King, rolled over, with no resident name and no date;-Beef and vegetables in a reusable container with no resident name and no date;-In the freezer, an ice cream container, resident name present with no date.Observation on 08/04/25, at 10:14 A.M., of the back dry storage area behind the kitchen, showed the following:-Three open containers of Hershey syrup on the hydration carts. Packaging read refrigerate after opening. All containere were room temperature to the touch; -Brown sugar in reusable container with lid partially off. During an interview on 08/04/25, at 10:08 A.M., Certified Nursing Assistant (CNA) E said the following:-Items placed in the hydration refrigerator are labeled and dated;-Dietary was responsible for discarding items and cleaning the refrigerator.During an interview on 08/04/25, at 10:10 A.M., Licensed Practical Nurse (LPN) F said the following:-Dietary oversaw cleaning out the refrigerator;-Items brought in are labeled and dated.During an interview on 08/04/25, at 10:16 A.M., Dietary Aide (DA) J said the following:-The dishwashing staff was responsible for cleaning out the hydration refrigerators;-In the walk-in refrigerator, all staff were responsible for ensuring all items are labeled and date;-Staff should look at labels and dates every time they enter the walk-in refrigerator;-Opened items should be throw out after three days;-No open items should be stored underneath the condensation tray;-All items that indicate refrigerate after opening should be placed back in the refrigerator when not in use;-Opened items need to be in a sealed container with a secured lid;-He/she would notify the Dietary Manager (DM) prior to throwing out a packaged soiled food item;-Eyes should be cut off potatoes before preparing;-No food items should be stored near non-food items;-Food items that fall on the floor in dry storage, like onions or potatoes, can be washed off and placed back on the shelf. During an interview on 08/04/25, at 10:35 A.M., DA K said the following:-Dietary was responsible for cleaning out the hydration refrigerators;-Open food items in all refrigerators should be disposed of after three days;-Items in the hydration refrigerators need to have the resident's name and be dated;-Items in the walk-in refrigerator need to be labeled and dated;-He/she was unsure if open food items can be stored under a condensation pan;-Condiments that indicate refrigerate after opening should be placed in the refrigerator after use;-All food items should be properly sealed and all lids should be secure;-He/she was unsure of what staff should do with potatoes with eyes;-He/she was unsure if food items could be stored next to non-food items.During an interview on 08/04/25, at 2:16 P.M., DA L said the following:-All staff were responsible for checking the walk-in refrigerator for proper storage and expiration dates;-Food items underneath the condensation tray need to be covered;-Open food items over 3 days old are thrown away;-All items should have a secure fitting lid;-Food packaging that is dirty and looks like it could contaminate the item should be thrown away;-Condiments should be replaced back into the refrigerator after use;-Potatoes with eyes should be thrown away;-Any food found on the floor should be thrown away;-Food should not be stored by non-food items;-Dishwashing staff was responsible for cleaning out the hydration refrigerators.During an interview on 08/04/25, at 2:23 P.M., DA M said the following:-He/she checked the hydration refrigerator daily;-he/she disposed of any items three days or older, or if the item did not have a name or date.During an interview on 08/04/25, at 2:39 P.M., the DM said the following:-All opened items should be dated and be secured shut;-Open items are disposed of after three days;-Exposed items, like fruit or vegetables should not be stored below the condensation tray;-Condiments should be in the refrigerator when not in use;-Food items should not be stored next to non-food items;-Any food item found on the floor should be thrown away;-Potatoes with eyes should be thrown away;-Dishwashing staff are responsible for cleaning out the hydration refrigerators, and ensuring all items have a resident name and date;-If no name or date is present, the item should be thrown out.

Based on record review and interview, the facility failed to ensure each resident's choice of code status (whether to receive cardiopulmonary resuscitation (CPR - an emergency lifesaving procedure performed when the heart stops beating) or do not resuscitate (DNR)) was clearly and consistently documented throughout residents' medical records and facility documentation when the facility staff documented contradictory information regarding the code status of three residents (Resident #76, #23, and #36). A sample of 11 residents was selected for review out of a facility census of 85. Review of the facility policy titled, Advanced Directives, revised [DATE], showed the following information:-Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record;-The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive;-The Interdisciplinary Team (IDT) will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care and medical record;-The IDT will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument.1. Review of Resident #76's electronic health record (EHR) showed the following information:-readmission date of [DATE];-Code status of full code (a patient's wishes to receive all possible life-saving measures in the event of a medical emergency, including CPR).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated [DATE], shows the resident to be cognitively intact.Review of resident's progress note, dated [DATE], showed the following:-Resident advised nursing the he/she would like to revoke his/her DNR and become a full code;-Social Services notified of resident revocation of DNR and banner (in electronic record on face sheet) changed to reflect resident wishes.Review of current Physician's Order Sheet (POS) showed an order, dated [DATE], for resident to be a full code. Review of resident's care plan, dated [DATE], showed the care plan did not address the resident's wishes to receive CPR. Review, on [DATE], of the facility's Advance Directive Notebook showed the resident signed a healthcare Durable Power of Attorney (DPOA), dated [DATE], which indicated if incapacitated, a designated DPOA can make all decisions regarding lifesaving measures and do not resuscitate. Review, on [DATE], of the resident's Face Sheet (resident information) and Sign Out (a document signed to indicate a resident leaving the facility) book on [DATE], located at the nurses' station, showed the resident's face sheet, dated [DATE], indicating DNR. During an interview on [DATE], at 11:32 A.M., the resident said he/she was no longer a DNR, and was now a full code.2. Review of Resident #23's EHR showed the following information:-readmission date of [DATE];-Code status of DNR.Review of the resident's quarterly MDS, dated [DATE], showed the resident was severely cognitively impaired.Record review of resident's progress notes, dated [DATE], showed the following:-Nursing notified Nurse Practitioner (NP) and Social Worker of resident's recent decline;-Social worker contacted family and received an out of hospital DNR;-Awaiting new order from NP.Review of the resident's current POS showed an order, dated [DATE], for resident to be a DNR. Review of resident's care plan, dated [DATE], showed the resident was a DNR. Review of resident's physician note, dated [DATE], showed the resident to be full code. Review, on [DATE], of the Advance Directive Notebook showed the resident had signed a DNR order. Review, on [DATE], of the Face Sheet and Sign Out Book, located at the nurses' station, showed the resident's face sheet, dated [DATE], indicating resident was full code.3. Review of Resident #36's electronic face sheet showed the following:-admission date of [DATE];-Code status was full code state. Review of the resident's progress notes dated [DATE], at 1:36 P.M., showed the following:-Quarterly care plan meeting with staff, resident, and spouse in attendance;-The resident's spouse signed a DNR order and nursing was notified.Review of the resident's quarterly MDS, dated [DATE], showed mild to moderate impaired cognition.Review of the resident's care plan, revised [DATE], showed the following:-The resident was a full code status;-Wish for resuscitation will be honored through 120 days from update/last review. Review of the binder with current code status for residents located in the Social Service Designee's (SSD) office, showed the purple form titled Outside the Hospital Do-Not-Resuscitate (OHDNR) Order, signed by the resident's power of attorney on [DATE], and signed by the attending physician on [DATE]. During an interview on [DATE], at 5:30 P.M., the Director of Nursing (DON) said if the resident electronic medical record's face sheet showed on the banner that he/she was a full code status and then had a DNR in the code status book, then this was contradictory and a problem.4. During an interview on [DATE], at 11:22 A.M., Certified Nursing Assistant (CNA) B said the following:-Code status was found on the computer under the resident's name;-A hard copy was located in a book at the nurses' station. During an interview on [DATE], at 11:19A.M., Certified Medication Technician (CMT) A, said the following:-Resident code status can be found on the computer;-Code status is on the report sheet that is distributed daily;-CMT A was only provided the report sheet for his/her assigned hall.During an interview on [DATE], at 8:50 A.M., Licensed Practical Nurse (LPN) G said the following:-The code status was found in the electronic chart;-There was not a hard copy available. During an interview on [DATE], at 8:24 A.M. and 8:48 A.M., LPN H said the following: -Code status could be found on a sheet located in a drawer at the nurses' station; -Code status of Full was in the residents' chart and they do have it on the daily roster at the nurses' station;-The Social Services Designee (SSD) updates the code status;-Most of the time, staff look in the residents' chart for code status;-They always review the resident's information in the computer since information can change frequently.During an interview on [DATE], at 10:11 A.M., LPN F said the following:-Code status was found in the resident's electronic chart;-There was no longer a code status book at the nurses' station;-LPN F would access the facility's policy and procedure manual to find out where to access a hard copy of code status. During an interview on [DATE], at 11:06 A.M., the Social Services Director (SSD) said the following:-Hard copies of code status (DNR) are located in a binder in his/her office;-The office is locked when he/she is out of the building;-Only housekeeping and upper management (ex. DON and Administrator), possess keys to his/her office.During interviews [DATE], at 10:20 A.M., and [DATE], at 5:40 P.M., the DON said the following:-Code status can be accessed through the resident's electronic chart;-A hard copy of resident code status can be located on the resident's face sheet, which is located in the Face Sheet and Sign Out book at the nurses' station; -Code status can be found in the EHR on the face sheet and POS;-The Face Sheet and Sign Out Book is only for inventory and for residents to sign out of the facility;-Code status was done when the resident was admitted ;-The code status forms were located in the medication room in binder and maintained by social services.During an interview on [DATE], at 6:17 P.M. the Administrator said the following:-The code status was located on the computer on the banner (face sheet) and on the POS;-The advance director binder was kept in the SSD's office.

Based on record review and interview, the facility failed to have processes in place to ensure each resident was offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized, when staff failed to follow-up regarding pneumococcal vaccines at admission for three residents (Residents #9, #49, and #91). A sample of five residents was selected for review out of a facility census of 85. Review of the facility's policy entitled Pneumococcal Vaccine, revised August 2016, showed the following:-All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections;-Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated;-Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission if not conducted prior to admission;-Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record;-Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per the facility's physician-approved pneumococcal vaccination protocol;-Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination;-For resident who receive the vaccines, the date of the vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record;-Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 1. Review of Resident #9's face sheet showed the following:-admission date of 07/07/25;-Diagnoses included Parkinson's disease, heart disease, chronic kidney disease, and Type 2 diabetes. Review of the resident's current Physician Order Sheet (POS), current as of 08/04/25, showed an order, dated 07/07/25, for resident may have pneumovax (vaccines) as directed by the provider. Review of the resident's electronic records showed the following:-Staff did not document the resident was offered or given vaccines on admission;-Staff did not document information pertaining to vaccines received outside the facility prior to admission. During an interview on 08/01/25, at 10:18 A.M., the Director of Nursing (DON) said no documentation was present in the admission records of the resident regarding immunizations being offered or administered. 2. Review of Resident #49's face sheet showed the following:-admission date of 07/14/25;-Diagnoses included severe dementia with psychotic disturbance – hallucinations, chronic kidney disease, congestive heart failure, dependence on supplemental oxygen, Type 2 diabetes, and obesity. Review of the resident's current POS, current as of 08/04/25, showed an order, dated 07/14/25, for resident may have pneumovax (vaccines) as directed by the provider. Review of the resident's electronic records showed the following:-Staff did not document the resident was offered or given vaccines on admission;-Staff did not document information pertaining to vaccines received outside the facility prior to admission. During an interview on 08/01/25, at 10:18 A.M., the DON said no documentation was present in the admission records of the resident regarding immunizations being offered or administered. 3. Record review of Resident #91's medical record showed the following information:-admission date of 07/23/25;-Diagnoses included acute cystitis without hematuria (inflammation of the bladder), klebsiella pneumoniae (a type of bacteria found in intestines), and muscle weakness;-No immunization information. Review of the resident's current POS showed an order, date 07/23/25, for resident may have pneumovax as directed by the provider. During an interview on 08/04/25, at 2:10 P.M., Resident #91 said he/she was not offered any vaccinations upon admission. During an interview on 08/01/25, at 10:18 A.M., the DON said no documentation was present in the admission records of the resident regarding immunizations being offered or administered. 4. During an interview on 08/04/25, at 11:16 A.M., Licensed Practical Nurse (LPN) D said the following:-The Social Service Director (SSD) offers vaccines during admission;-He/she does not administer vaccines. During an interview on 08/04/25, at 11:30 A.M., LPN F said the following:-The admitting charge nurse offers vaccines to new residents; -The admitting charge nurse or next nurse coming on duty, would administer the vaccines. During an interview on 08/04/25, at 5:40 P.M., the DON said the following:-Upon admission, a flu and pneumococcal vaccine should be offered to the resident by the admitting nurse;-Administration or refusal of the vaccines should be documented in the resident's chart. During an interview on 08/04/25, at 6:17 P.M., the Administrator said the following:-Upon admission, the facility should obtain the resident's vaccine record;-If the resident has not received their pneumococcal vaccine, it should be offered upon admission;-The admitting nurse should administer the vaccines, or notify the Assistant Director of Nursing.

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities when staff failed to provide preferred activities to one resident (Resident #70) who voice importance of routinely getting fresh air. The facility census was 85. Review of the facility's policy titled Recreation Policy and Procedure Manual-Philosophy, Goals and Objectives, Standards/Performance Standards, revised 09/01/14, showed the following:-Recreation/Activity/Wellness partners will gather data about each resident's leisure preferences and plan to meet individual needs based on resident's abilities and preferences;-Family members, friends and other partners can be extremely important to recreation. The recreation partners will utilize these resources, when appropriate, to enhance the resident's leisure time;-Residents will be encouraged to participate in the center's recreation program and/or in their own independent leisure interests, but never forced to do so;-Recreation will participate as a team member in the overall plan of care for each resident;-If a resident chooses to be involved in leisure skills on an independent basis, the recreation partners will be responsible for seeing that the resident has what he/she needs in order to engage in their interests;-A variety of organized group activities will be provided to meet the individual needs and interests of all resident. These will include recreational, social, diversional, intellectual, religious, physical, creative, service oriented, and civic (to include voting);-As residents' leisure interests and needs may occur any time during a 24-hour period, and as recreation is not staffed 24 hours a day, the recreation partners should act as resource staff to all other partners;-When an activity is scheduled, it is the responsibility of the Recreation Coordinator to see that it is carried out. No scheduled activity will be canceled unless absolutely necessary. 1. Review of Resident #70's Face Sheet (resident information) showed the following:-admission date of 07/09/25;-Diagnoses included subluxation of C1/C2 cervical vertebrae (a misalignment or partial dislocation between the first and second cervical vertebrae), cervicalgia (neck pain), spinal stenosis (a condition where the spaces within your spine narrow, putting pressure on the spinal cord and/or nerve roots), obstructive and reflux uropathy (conditions affecting the urinary tract where urine flow is either blocked (obstructive) or flows backward (reflux)), and malignant neoplasm of prostate (a cancerous tumor that develops in the prostate gland).- Review of resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/21/25, showed the following:-Cognitively intact;-Independently uses manual wheelchair;-Preference of going outside is very important. Review of resident's current Physician Order Sheets (POS) showed an order, dated 07/09/25 for resident may participate in planned activities as tolerated. Review of resident's activity progress notes, dated 07/09/25, showed the resident used to be an avid gardener. Record review of resident's care plan, dated 07/10/25, showed the following:-Resident will maintain desired level of activity and engagement;-Assist to and from activities as needed;-Provide calendar of events/encourage participation;-Provide in-room activities as desired. Review of the resident's Social History/Social Services admission Assessment, dated 07/10/25, showed activity preferences of gardening, fishing, and outdoors. Review of the facility's July 2025 Activity Calendar showed the following:-Outdoor walk and gardening every Tuesday at 4:00 P.M.;-Outdoor walk every Saturday at 3:00 P.M. Review of resident's progress notes, dated 07/15/25, showed the following:-Resident was working with restorative program;-Resident attended therapy and worked on the bike when therapy was present;-Resident was opinionated and made his/her needs and wants known. Review of the resident's Life Enrichment Assessment, dated 07/30/25, showed the following:-Favorite activity: Gardening-Time preference: Morning or Afternoon;-Very important to go outside and get fresh air. Review of the resident's Engagement Insights and Programs Attended, dated 07/11/25 through 08/02/25, showed the resident attended the following activities:-On 07/11/25, arts and crafts, 60 minutes, active;-On 07/13/25, manicures, 60 minutes, disengaged;-On 07/19/25, balloon toss, 30 minutes, active;-On 07/24/25, ice cream Social, 30 minutes, active;-On 07/25/25, July birthday cupcakes, 119 minutes, active;-On 07/29/25, ice cream social, 30 minutes, active;-On 08/02/25, ice cream Social, 30 minutes, active;-On 08/02/25, outdoor walk, 60 minutes, active. During interviews on 07/29/25, at 1:25 P.M., and on 08/01/25, at 12:01 P.M., the resident said the following:-The only activity he/she enjoyed was the garden club;-The facility had not had gardening club because it was too warm. He/she did not understand why the club cannot be held in the morning;-If he/she asked to go outside, staff tell him/her that he/she can go out with the smokers;-He/she does not smoke, and does not like to be around smoke;-He/she enjoyed tending to the tomato plants but they are kept in the smoking area;-He/she did not enjoy going to ice cream events, as he/she tried to watch what he/she ate;-Upon admission, staff advised him/her that he/she could go out anytime;-Last week, staff told him/her that he/she could only go out with staff, which is when the smokers go outside. During an interview on 08/04/25, at 10:54 A.M., the resident said the following:-He/she did not go outside this weekend;-This morning, he/she observed some resident's outside, but no one notified him/her they were going outside;-He/she said he/she needed to go outside to get some vitamin D as it is important. During an interview on 08/04/25, at 11:19 A.M., Certified Medication Technician (CMT) A said the following:-CMT A has only seen the resident outside once. -If a resident asked to go outside, CMT A will ask to nurse to see if he/she can take the resident out;-Staff has to be present when residents are outside;-Residents cannot go out any time they want;-Residents can go outside with smokers. During an interview on 08/04/25, at 11:22 A.M., Certified Nursing Assistant (CNA) B said the following:-Residents cannot go outside by themselves;- Activities have certain days they take residents out;-If a resident asks to go outside, CNA B will try to find a staff to take the resident out. During an interview on 08/04/25, at 11:30 A.M., Licensed Practical Nurse (LPN) F said the following:-Residents can go outside without staff if they are cognitively intact;-Residents are allowed in the courtyard and can ask any staff to assist them out;-Activities will occasionally take residents outside;-He/she does not recall seeing the resident outside;-The resident is capable of going outside independently. During an interview on 08/04/25, at 12:30 P.M., the Activities Director (AD), said the following:-He/she asked residents in resident council about their activity preferences;-Upon admission, an activities assessment is completed;-Activity preferences are indicated on the care plan, which the MDS Coordinator completes;-He/she attends care plan meetings;-He/she attempts to tailor activities to accommodate individual resident preferences;-Activity staff takes residents outside, but at no specific set time;-Gardening club is on Tuesdays and outdoor walk is on Saturdays;-Gardening club had been cancelled due to the heat with no alternative time provided;-Activities are listed on the calendar provided to residents;-Activity staff go around to residents that normally attend to remind them of upcoming activities;-Residents do not smoke during gardening club;-Plants are not located by the smoking area;-The resident enjoys gardening club;-The resident could be outside by himself. During an interview on 08/04/25, at 12:45 P.M., the MDS Coordinator said the following:-Activity preferences are included in the care plan;-The AD and Social Service Director (SSD) notified him/her of the activity preferences to add to the care plan. During an interview on 08/04/25, at 1:20 P.M., CNA O said he/she was unsure if residents can go outside by themselves. During an interview on 08/04/25, at 1:24 PM, LPN H said the following:-Residents can go outside independently;-Activities takes residents out occasionally;-If a resident required staff to be present when they outside, the resident will be taken out with the smokers;-He/sh was unsure if the resident could go outside independently. During an interview on 08/04/25, at 4:27 P.M., the resident said the following:-He/she had not attend a balloon toss or any arts and crafts activities;-If he/she was in the area when those activities were taking place, he/she would have declined as he/she had no interest;-He/she did not recall eating cupcakes as an activity as he/she is a puree diet. During an interview on 08/04/25, at 4:34 P.M., AD said the following:-The resident was not listed as attending the gardening club as he/she does not like to attend;-During garden club the resident ate some of the tomatoes which upset other residents;-He/she asked the resident if he/she would like to go out at an alternative time, but has not followed up with him/her. During an interview on 08/04/25, at 5:40 P.M., the Director of Nursing (DON) said the following:-Activity assessments are completed upon admission, and updated quarterly and annually;-Activity preference and attendance are documented in a new program;-Resident's activity preference should be honored and documented in the care plan; -Activity staff completes the activity section in the MDS and updates the care plan;-Residents can go outside whenever, within reason;-If a resident is cognitively intact, they can outside by themselves;-The resident is incapable of going out by self, as he/she cannot self-propel and could overheat. During an interview on 08/04/25, at 6:17 P.M., the Administrator said the following:-An activities assessment is complete upon admission;-Activity preferences should be documented in MDS and Care Plan;-Activities staff updates the activity section in the MDS and Care Plan;-Activity preference should be updated quarterly and annually;-Staff should make an effort to fulfill resident's preferred activity;-Residents can go outside whenever they want, based on temperature;-Alert and oriented residents can go out independently, but should notify staff;-The resident can go out independently as he/she is cognitively intact;-Residents that do not smoke should not have to go outside with the smokers.

Based on observation, interview, and record review, the facility failed to maintain an observed medication error rate below 5% when staff made two medication errors in 25 opportunities resulting in a medication error rate of 8% involving two residents (Resident #19 and Resident #3). The facility census was 85. Review of the facility policy, Specific Medication Administration Procedures: Insulin Administration, revised 2/25/25, showed the following:-Perform hand hygiene and don gloves;-Attach pen needle to pen. Prime pen by dialing up 2 units and hold the pen with the needle pointing upwards. Tap the pen gently to remove air bubbles and then push the injection button until a drop of insulin appears at the tip of the needle;-Turn the dose selector to the number of units needed;-Expose the area to be injected and clean the skin with an alcohol wipe;-Administer the injection by holding the pen at a 90 degree angle into the skin. Insert the needle fully into the skin. Press the injection button and hold it for a count of 10 to ensure the full dose is delivered. Withdraw the needle from the skin. 1. Review of Resident #19's face sheet (admission information at a glance) showed the following:-admission date of 06/25/20;-Diagnoses included Type 2 diabetes mellitus. Review of the resident's comprehensive Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), dated 06/19/25, showed the following:-Resident was a reliable interview;-Received insulin injections seven of seven days. Review of the physician's order, dated 04/20/25, showed the following:-An current order for Novolog (rapid actin insulin) U-100 insulin 100 units/milliliters (ml)(3 ml) insulin pen 5 units, subcutaneous (just below the skin) before meals. Add 5 units with meals along with sliding scale;-An order,dated 11/22/23, for Novolog FlexPen u-100 insulin 100 units/ml insulin pen per sliding scale, subcutaneous before meals and at bedtime as follows:-If blood sugar was 141 to 180 milligram/deciliter (mg/dL), administer two units;-If blood sugar was 181 to 220 mg/dL, administer four units;-If blood sugar was 221 to 260 mg/dL, administer six units;-If blood sugar was 261 to 300 mg/dL, administer eight units;-If blood sugar was 301 to 340 mg/dL, administer ten units;-If blood sugar was 341 to 380 mg/dL, administer 12 units;-If blood sugar was 381 to 400 mg/dL, administer 14 units;-If blood sugar was greater than 400 mg/dL, call the physician. Observation on 07/30/25, at 3:50 P.M., showed Licensed Practical Nurse (LPN) G sanitized his/her hands, donned gloves, and performed an AccuCheck (blood test to determine glucose/sugar level) for the resident. The test result was 196 mg/dl. The LPN reviewed the sliding scale for the ordered insulin Novolog U-100 and said the resident required 9 units total. LPN G put a new needle on the pen and without first priming the pen, the LPN set the pen dose meter to 9. LPN G cleansed the resident's arm with an alcohol swab and administered the insulin. 2. Review of Resident #3's face sheet showed the following:-admission date of 07/15/24;-Diagnoses included Type 2 diabetes mellitus. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severely impaired cognition;-Diagnoses included diabetes mellitus;-Received insulin seven of seven days a week. Review of the resident's POS, dated 03/9/25, showed the following:-A current order for insulin aspart (Novolog) U-100 unit/ml (3 ml) insulin pen per sliding scale subcutaneous before meals and at bedtime per sliding scale:-If blood sugar was 141 to 180 mg/dL, administer two units;-If blood sugar was 181 to 220 mg/dL, administer four units;-If blood sugar was 221 to 260 mg/dL, administer six units;-If blood sugar was 261 to 300 mg/dL, administer eight nits;-If blood sugar was 301 to 340 mg/dL, administer ten units;-If blood sugar was 341 to 380 mg/dL, administer 12 units;-If blood sugar was 381 to 400 mg/dL, administer 14 units;-If blood sugar was greater than 400, call the physician. Observation on 07/30/25, at 4:15 P.M., showed LPN G sanitized his/her hands, donned gloves, and performed an AccuCheck for the resident. The test result was 374 mg/dl. The LPN reviewed the sliding scale for the ordered insulin aspart U-100/ml (3 ml) and said the resident required 12 units. LPN G put a new needle on the pen. Without first priming the pen, the LPN set the pen dose meter to 12. LPN G cleansed the resident's abdomen with an alcohol swab, and administered the insulin. 3. During an interview on 07/30/25, at 4:23 P.M., LPN G said he/she did not prime the pen and thought maybe he/she was to waste like one unit of insulin to make sure the insulin came to the end of the needle to administer. During an interview on 08/04/25, at 10:22 A.M., LPN F said to administer insulin to a resident with an insulin pen, check the order on the electronic medical record, wash and or sanitize hands, put on gloves, place the needle on the pen, prime the pen with two units of insulin before dialing up the dosage, and then administer to the resident. During an interview on 08/04/25,at 5:30 P.M., the Director of Nursing (DON) said, to administer insulin to a resident with an insulin pen, they were to wash hands, put on gloves, put needle on pen, prime with two units before dialing proper amount of insulin, wipe area with alcohol , inject and hold 10 second. During an interview on 08/04/25, at 6:10 P.M., the Administrator said she expected staff to prime the insulin pen before administering insulin.

Based on observation and interview, the facility failed to ensure residents were free of significant medication errors when staff failed to prime the insulin pens prio to insulin administration for two resident (Residents #19 and #3). The facility census was 85.Review of the facility policy, Specific Medication Administration Procedures: Insulin Administration, revised 2/25/25, showed the following:-Perform hand hygiene and don gloves;-Attach pen needle to pen. Prime pen by dialing up 2 units and hold the pen with the needle pointing upwards. Tap the pen gently to remove air bubbles and then push the injection button until a drop of insulin appears at the tip of the needle;-Turn the dose selector to the number of units needed;-Expose the area to be injected and clean the skin with an alcohol wipe;-Administer the injection by holding the pen at a 90 degree angle into the skin. Insert the needle fully into the skin. Press the injection button and hold it for a count of 10 to ensure the full dose is delivered. Withdraw the needle from the skin. 1. Review of Resident #19's face sheet (admission information at a glance) showed the following:-admission date of 06/25/20;-Diagnoses included Type 2 diabetes mellitus. Review of the resident's comprehensive Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), dated 06/19/25, showed the following:-Resident was a reliable interview;-Received insulin injections seven of seven days. Review of the physician's order, dated 04/20/25, showed the following:-An current order for Novolog (rapid actin insulin) U-100 insulin 100 units/milliliters (ml)(3 ml) insulin pen 5 units, subcutaneous (just below the skin) before meals. Add 5 units with meals along with sliding scale;-An order,dated 11/22/23, for Novolog FlexPen u-100 insulin 100 units/ml insulin pen per sliding scale, subcutaneous before meals and at bedtime as follows:-If blood sugar was 141 to 180 milligram/deciliter (mg/dL), administer two units;-If blood sugar was 181 to 220 mg/dL, administer four units;-If blood sugar was 221 to 260 mg/dL, administer six units;-If blood sugar was 261 to 300 mg/dL, administer eight units;-If blood sugar was 301 to 340 mg/dL, administer ten units;-If blood sugar was 341 to 380 mg/dL, administer 12 units;-If blood sugar was 381 to 400 mg/dL, administer 14 units;-If blood sugar was greater than 400 mg/dL, call the physician. Observation on 07/30/25, at 3:50 P.M., showed Licensed Practical Nurse (LPN) G sanitized his/her hands, donned gloves, and performed an AccuCheck (blood test to determine glucose/sugar level) for the resident. The test result was 196 mg/dl. The LPN reviewed the sliding scale for the ordered insulin Novolog U-100 and said the resident required 9 units total. LPN G put a new needle on the pen and without first priming the pen, the LPN set the pen dose meter to 9. LPN G cleansed the resident's arm with an alcohol swab and administered the insulin. 2. Review of Resident #3's face sheet showed the following:-admission date of 07/15/24;-Diagnoses included Type 2 diabetes mellitus. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severely impaired cognition;-Diagnoses included diabetes mellitus;-Received insulin seven of seven days a week. Review of the resident's POS, dated 03/9/25, showed the following:-A current order for insulin aspart (Novolog) U-100 unit/ml (3 ml) insulin pen per sliding scale subcutaneous before meals and at bedtime per sliding scale:-If blood sugar was 141 to 180 mg/dL, administer two units;-If blood sugar was 181 to 220 mg/dL, administer four units;-If blood sugar was 221 to 260 mg/dL, administer six units;-If blood sugar was 261 to 300 mg/dL, administer eight nits;-If blood sugar was 301 to 340 mg/dL, administer ten units;-If blood sugar was 341 to 380 mg/dL, administer 12 units;-If blood sugar was 381 to 400 mg/dL, administer 14 units;-If blood sugar was greater than 400, call the physician. Observation on 07/30/25, at 4:15 P.M., showed LPN G sanitized his/her hands, donned gloves, and performed an AccuCheck for the resident. The test result was 374 mg/dl. The LPN reviewed the sliding scale for the ordered insulin aspart U-100/ml (3 ml) and said the resident required 12 units. LPN G put a new needle on the pen. Without first priming the pen, the LPN set the pen dose meter to 12. LPN G cleansed the resident's abdomen with an alcohol swab, and administered the insulin. 3. During an interview on 07/30/25, at 4:23 P.M., LPN G said he/she did not prime the pen and thought maybe he/she was to waste like one unit of insulin to make sure the insulin came to the end of the needle to administer. During an interview on 08/04/25, at 10:22 A.M., LPN F said to administer insulin to a resident with an insulin pen, check the order on the electronic medical record, wash and or sanitize hands, put on gloves, place the needle on the pen, prime the pen with two units of insulin before dialing up the dosage, and then administer to the resident. During an interview on 08/04/25,at 5:30 P.M., the Director of Nursing (DON) said, to administer insulin to a resident with an insulin pen, they were to wash hands, put on gloves, put needle on pen, prime with two units before dialing proper amount of insulin, wipe area with alcohol , inject and hold 10 second. During an interview on 08/04/25, at 6:10 P.M., the Administrator said she expected staff to prime the insulin pen before administering insulin.

Based on observation, record review, and interviews, the facility failed to implement an effective infection control program when staff did not complete appropriate hand hygiene when providing incontinent care to one resident (Resident #23). Staff also failed to follow Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multi-drug-resistant organisms (MDRO) that employs targeted gown and glove use during high-contact activities) during catheter care and personal hygiene for one resident (Resident #49) of eight residents with indwelling catheters. The facility had a census of 85.Review of a facility policy entitled Handwashing/Hand Hygiene, revised August 2015, showed the following:-The facility considered hand hygiene the primary means to prevent the spread of infections;-All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors;-Hand hygiene products and supplies shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies;-Use an alcohol-based hand rub, or alternatively soap and water to be used before and after direct contact with residents; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after handling used dressings, contaminated equipment, etc., after contact with objects in the immediate vicinity of the resident; and after removing gloves;-Hand hygiene is the final step after removing and disposing of personal protective equipment;-The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections;-Perform hand hygiene before applying non-sterile gloves; (after care) remove gloves and perform hand hygiene. 1. Review of Resident #23's face sheet (gives basic profile information at a glance) showed the following;-readmission date of 05/07/25;-Diagnoses included stroke with right/dominant side weakness. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 05/08/25, showed the resident was severely cognitively impaired. Review of the resident's care plan, updated 07/31/25, showed the following:-Incontinent of bowel and bladder;-Staff to provide incontinent care per needs. Observation on 07/31/25, at 9:42 A.M., showed Certified Nursing Assistant (CNA) B and Certified Medication Technician (CMT) A washed their hands and donned gloves, explaining care to the resident. The aides assisted the resident to turn to his/her right side. CMT A unfastened the resident's brief and a large amount of loose stool was present. CMT A said the resident had diarrhea for the past couple of days. CMT A cleaned the resident's coccyx (tail bone) and buttocks using pre-moistened wipes. CMT A rolled the soiled brief, bed pad, and soiled sheet to the center. CMT A changed gloves without performing hand hygiene. The CNA turned the resident onto his/her back. CMT A cleaned the front perineal area using wipes. Without changing gloves, the CMT applied protective barrier cream to the resident's groin area. The aides turned the resident back to his/her right side. Using the same contaminated gloves, CMT A applied the cream to the resident's coccyx and buttocks and removed the rolled linens. CMT A then washed his/her hands and donned new gloves, placed a clean sheet and bed pad and positioned a new brief, and turned the resident back onto his/her right side to complete placement of the clean linens. CMT A bagged the soiled linens and washed his/her hands in the bathroom sink. During an interview on 08/04/25, at 3:30 P.M., CMT A said staff should wash their hands prior to doing personal care for a resident and again when they are finished. The CMT said staff should change gloves in between soiled/clean steps to the care to avoid contamination. Staff should wash or use hand sanitizer with each glove change. During an interview on 08/04/25, at 3:34 P.M., CMT C said staff should wash their hands before and after any personal care for a resident, changing gloves after each step so they don't soil a clean place. Staff should sanitize their hands with glove changes. During an interview on 08/04/25, at 3:40 P.M., Licensed Practical Nurse (LPN) F said staff should wash their hands and don gloves before doing personal care for a resident. They should change their gloves after completing each soiled area and should change gloves and sanitize their hands in between soiled/clean steps. Staff should wash their hands before leaving the resident's room. During an interview on 08/04/25, at 5:30 P.M. the Director of Nursing (DON) said staff are expected to wash their hands before starting personal care for a resident, change gloves and sanitize their hands in between dirty and clean parts of the body/care, and wash their hands after finishing the care. Clean gloves should be used to apply any creams or lotions. During an interview on 08/04/25, at 6:09 P.M., the Administrator said staff should wash their hands and don gloves to perform a resident's personal care. The staff should change gloves after each dirty part of the care, washing or sanitizing their hands with each glove change. Staff should also wash or sanitize their hands before touching anything else in the room. 2. Review of the facility's policy entitled Enhanced Barrier Precautions, updated February 2025, showed the following:-EBP refers to an infection control intervention designed to reduce transmission of MDRO that employs targeted gown and glove use during high-contact activities. EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact patient care activities that provide opportunities for transfer of MDRO to staff hands and clothing;-EBP are indicated for patients with wounds and/or indwelling medical devices even if the patient is not known to be infected or colonized with a MDRO;-Providers and partners must wear gloves and a gown for high-contact patient care activities including dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; and device care or use including urinary catheter. Review of a policy entitled EBP Precautions, undated, showed staff to wear PPE when providing personal care and when accessing any catheter. Review of Resident #49's face sheet showed the following:-admission date of 07/14/25;-Diagnoses included neuromuscular dysfunction of bladder, Parkinson's disease, heart disease, peripheral vascular disease (blood circulatory disorder) with presence of coronary bypass graft, chronic kidney disease, PTSD (post-traumatic stress disorder), depression, and Type 2 diabetes. Review of the resident's Physician Order Sheet (POS), current as of 08/04/25, showed the following:-An order, dated 07/14/25, for needs related to catheter use will be addressed and risks of complications minimized;-An order, dated 07/14/25, for catheter and to change catheter as needed; irrigate catheter as needed for sluggish drainage or increased sediment; and provide catheter care daily and as needed. Review of the resident's care plan, updated 07/14/25, showed the following;-Resident had a catheter;-Needs related to catheter use will be addressed and risks of complication minimized;-Catheter to be changed as needed per order; irrigate catheter as needed for sluggish drainage or increased sediment per order; provide catheter care daily and as needed per order;and position and anchor catheter tubing and bag below level of bladder. Observation on 08/04/25, at 2:43 P.M., showed CNA D entered the resident's room, explained the care process to the resident, and placed a stack of washcloths on the bedside table. The resident's catheter collection bag hung on a lower bed rail. The CNA washed his/her hands at the sink, filled the tub with soapy water, dried his/her hands, and donned gloves. The CNA D did not don a gown. CNA D provided peri-care and catheter care without donning a gown. During an interview on 08/04/25, at 3:24 P.M., CNA E said staff should wear a gown and gloves to do personal care with a resident who has an infection or who has an indwelling catheter. CNA E said the orange dot on a resident's nameplate indicated the need for EBP. During an interview on 08/04/25, at 3:30 P.M., CMT A said an orange sticker on a resident's nameplate indicated staff should take extra precaution and wear a gown and gloves to do personal care for the resident, such as when the resident has a catheter or certain infections. During an interview on 08/04/25, at 3:34 P.M., CMT C said he/she was new at this facility and did not know the significance of the orange dot on a resident's nameplate. He/she had not done any catheter care at this facility and was unsure of the protocol. During an interview on 08/04/25, at 3:40 P.M., Licensed Practical Nurse LPN F said staff should wear a gown and gloves to do personal care for a resident who had a catheter, was on contact precautions, or who was known to have MRSA (methicillin-resistant staphylococcus aureus; bacterial infection resistant to many common antibiotics). The full PPE was to help prevent the spread of any infection. During an interview on 08/04/25, at 5:30 P.M., the DON said staff should wear a gown and gloves to do personal and/or catheter care for a resident with a catheter. There is an orange dot on the resident's nameplate if there is an indication for EBP PPE. During an interview on 08/04/25, at 6:09 P.M., the Administrator said staff should follow EBP protocol and wear both a gown and gloves for any care requiring close contact, such as catheters, wounds, and also if the resident has infections requiring contact precautions. An orange dot on a resident's nameplate indicates the need to follow EBP guidelines and wear a gown and gloves while doing cares.

Based on interview and record review, the facility failed to provide pressure ulcer care and monitoring per standards of practice when staff failed to follow physician orders for treatment of an unstageable pressure ulcer (occurs when the base of a full-thickness tissue loss wound is covered by a layer of dead tissue that prevents staging of the ulcer) to one resident's (Resident #1's) coccyx (tailbone area), failed to update the treatment after a visit to the wound clinic, and failed to complete a weekly wound assessment of the resident's pressure ulcer. The resident developed a subsequent infection of his/her pressure ulcer that required hospitalization . The facility census was 68. Review of the facility assessment guideline titled, Assessments, dated January 2024, showed the following:: -Braden Scale (skin risk assessment completed by facility staff) completed within 24 hours of admission and then weekly for four weeks; -Weekly wound assessment; -Daily pressure ulcer monitoring will include an evaluation of the ulcer if no dressing is present; an evaluation of the status of the dressing if present (intact, drainage, leaking); status of the area surrounding the ulcer that can be observed without removal of the dressing; presence of possible complications such as signs of increasing of are of ulceration or soft tissue infection; and presence of pain. Review of the facility's policy/procedure titled, Wound Care, revised October 2010, showed the following: -The purpose of the procedure was to provide guidelines for the care of wound to promote healing; -Verify that there is a physician's order for the procedure; -The following information should be documented in the resident's medical record: the type of wound care provided; the date and time the wound care was given; the name and title of the of the individual performing the wound care; any change in the resident's condition; all assessment data (wound bed color, size, drainage, etcetera) obtained when inspecting the wound; any problems or complaints by the resident related to the procedure; if the resident refused the treatment and the reason why; and the signature and title of the person recording the data. 1. Review of Resident #1's face sheet showed the following: -admitted [DATE]; -Diagnoses included post coronary artery bypass graft (CABG - a medical procedure to improve blood flow to the heart), muscle weakness, and difficulty in walking. Review of the resident's admission assessment (body diagram), dated 04/18/24, completed by the facility's wound nurse, showed the wound nurse drew a circle over the resident's coccyx area with a number one, indicating an unstageable pressure ulcer to the area. Review of the resident's Wound Management Detail Report, dated 04/28/24 at 5:39 P.M., completed by the facility's wound nurse, showed the following: -Date/time identified: 04/18/24 at 5:38 P.M.; -Wound Type: Pressure ulcer; -Wound Location: Coccyx; -Present on Admission: Yes -Length: 11.0 centimeters (cm) in length (head to toe direction); -Width: 2.0 cm in width (side to side direction); -Can depth be measured: No; -Exudate (drainage) amount: Light -Exudate type: Serous (clear, amber, thin, and watery); -Stage: Unstageable due to presence of slough (a yellow or white, soft, wet, or dry material that can appear in the wound bed during the inflammation phase of healing); -Tissue Type: Slough; -Skin surrounding the wound: Dark purple or rusty discoloration. Review of the resident's April 2024 Physician Order Sheet (POS) showed the following: -An order, dated 04/18/24, for staff to cleanse the affected area to the coccyx, pat dry, apply a Mepilex (silicone adhesive foam) sacrum (area of the low back directly above the coccyx) dressing. Staff to change every three days on the day shift; (6:00 A.M. to 6:00 P.M.) and daily, as needed, if missing or soiled; -An order, dated 04/18/24, for wound care company to evaluate and treat the resident as indicated. Review of the resident's April 2024 Treatment Administration Record (TAR) showed the following: -An order, dated 04/18/24, for staff to cleanse the affected area to the coccyx, pat dry, and apply a Mepilex sacrum dressing once a day (6:00 A.M. - 6:00 P.M.) every three days; -The nurses did not initial completion of the treatment on 04/18/24, the day of admission to the facility. Review of the resident's Braden Scale for Prediction of Pressure Sore Risk (Acuity), dated 04/19/24, showed staff assessed the resident as not at risk for the development of a pressure ulcer. Review of the resident's April 2024 TAR showed the nurses did not initial completion of the ordered treatment on 04/19/24 or 04/20/24. Review of the resident's April 2024 TAR showed the following: -On 04/21/24, Registered Nurse (RN) B initialed completion of the ordered treatment with a comment of Late Administration: Other, Comment: Done on night shift. (Three days after the initial treatment order was received.); -The nurses did not document completion of the treatment on 04/22/24 and 04/23/24; -On 04/24/24, RN B initialed completion of the treatment with a comment of Late Administration: Other, Comment: Done on night shift; -The nurse did not document completion of the treatment on 04/25/24. Review of the resident's wound care clinic office visit, dated 04/25/24, showed the following: -Wound Site: Sacrum; -Cause: Pressure; -Onset: 04/10/24; -Care started: 04/25/24; -Length 4.3 cm, width 2.5 cm, Depth 1.1 cm; -Stage: 4 (a full thickness skin loss that extends to muscle, bone, tendon, or ligament); -Depth: Full thickness; -Amount of Drainage: Moderate; -Drainage type: Yellow/Tan; -Slough: 26-50%; -Necrotic (black, brown, or dark dead tissue) : 26-50%; -Sacrum cleansed with soap; -Odor after cleansing: None/Absent; -Mechanical debridement (removal of dead tissue using physical force) performed with gauze and saline. -Exposure: Subcutaneous tissue (the innermost layer of skin/fat) exposed; -Peri wound skin: Denuded (loss of the skin's outer layer); -Sharp debridement (the removal of dead tissue using a sharp instrument, such as a scalpel) performed by a physician; -Patient instructions: Any wound can become infected. Signs of infection include: redness, red streaks, swelling, pus, drainage, warmth in the area of the wound, fever, or increased pain or tenderness. Call the wound center if you have any questions; -Clean the wound as directed. Apply medication to the wound as directed. Dress with supplies as directed by the nurse and physician. Change dressing as directed; -After debridement you may see some bleeding. If bleeding occurs, hold pressure on the wound and re-bandage wound. If bleeding does not stop, call the wound center or go to the nearest emergency room ; -Please schedule a follow-up appointment in one week; -Orders faxed or sent to the facility. Review of the resident's wound care clinic referral form, dated 04/25/24, showed the following: -Diagnosis of pressure ulcer of sacral region, stage 4; -Wound care orders signed by the wound care physician on 04/25/24 as follows: Nursing home to perform wound care every other day and as needed (PRN). Cleanse sacrum with soap and water. Irrigate with normal saline (NS). Apply skin prep to periwound. Apply Alginate Silver (a highly-absorbent, antibacterial dressing), then cover with Mepilex Border sacrum; -Call the clinic with any questions. Review of the resident's medical record showed staff did not document the weekly wound assessment due to be completed on 04/25/24 (one week after the resident's initial wound assessment). Review of the resident's New Patient History and Physical, completed by the facility physician, dated 04/25/24, showed the following: -Chief complaint included pressure ulcer of the coccyx; -Resident has a pressure ulcer on his/her coccyx and wound care is following him/her. Review of the resident's April 2024 POS showed an order, dated 04/25/2, for nurses to complete weekly skin observation assessments on Thursdays on 6:00 P.M. - 6:00 A.M. shift. Review of the resident's April 2024 TAR showed the following: -An order, dated 04/18/24, to cleanse affected area to the coccyx, pat dry, apply a Mepilex sacrum dressing once a day (6:00 A.M. - 6:00 P.M.) every three days; -Staff did not initial completion of the treatment on 04/25/24 and 04/26/24; -Staff did not update the resident's treatment order based on the wound care clinic's orders for treatment from 04/25/24. Review of the resident's Braden Scale for Prediction of Pressure Sore Risk (Acuity), dated 4/26/24, showed the following: -Staff assessed the resident as at risk for the development of a pressure ulcer; -Pressure reducing device for chair and bed. Review of the resident's weekly skin observation sheet, dated 04/26/24, showed the following: -Resident current pressure ulcer risk score 17 (at risk); -Pressure reducing device to bed. Review of the resident's April 2024 TAR showed the following: -An order, dated 04/18/24, to cleanse affected area to the coccyx, pat dry, apply a Mepilex sacrum dressing once a day (6:00 A.M. - 6:00 P.M.) every three days; -On 4/27/24, Licensed Practical Nurse (LPN) C documented: Not administered: Other, Comment: Order changed per wound clinic; -Staff did not update the resident's treatment order based on the wound care clinic's orders for treatment from 04/25/24. Review of the resident's progress note dated 04/28/24, at 10 :30 A.M., showed a nurse documented the following: -Resident was alert and oriented, pleasant, and cooperative. He/she able to voice needs. Skin was warm/dry. Temperature measured 101.6 degrees Fahrenheit (F) (average normal temperature is 98.6 degrees F). Staff administered Tylenol and temperature is now 99.6 degrees F. Resident asked how he/she felt, and resident replied, I feel alright. Medications as ordered. Review of the resident's April 2024 TAR showed the following: -An order, dated 04/18/24, to cleanse affected area to the coccyx, pat dry, apply a Mepilex sacrum dressing once a day (6:00 A.M. - 6:00 P.M.) every three days; -Staff did not document completion of the treatment on 04/28/24 and 04/29/24; -Staff did not update the resident's treatment order based on the wound care clinic's orders for treatment from 04/25/24. Review of the resident's progress note dated 04/29/24, at 11:37 P.M., showed a nurse documented the following: -Resident started on intramuscular (IM - into the muscle injections) antibiotic for patchy left lung opacities (hazy gray areas on an X-ray that may indicate a concern, such as pneumonia or other respiratory disorder). IM injection given to the resident's left upper arm. The resident shared that he/she does not have much appetite. No adverse reaction noted or reported. Review of the resident's April 2024 TAR showed the following: -An order, dated 04/18/24, to cleanse affected area to the coccyx, pat dry, apply a Mepilex sacrum dressing once a day (6:00 A.M. - 6:00 P.M.) every three days; -On 04/30/24, LPN A initialed completion of the treatment (six days after the last documented treatment); -Staff did not update the resident's treatment order based on the wound care clinic's orders for treatment from 04/25/24. Review of the resident's progress note dated 04/30/24, at 10:24 A.M., showed a nurse documented the following: -Resident's emergency contact called the facility to request an update on the resident's condition. This nurse informed the resident's emergency contact of the resident's hemoglobin (red blood cells that carry oxygen from the lungs to the rest of the body) levels as well as the chest X-ray and antibiotics. The emergency contact expressed thankfulness for the prompt reply. No complaints of pain or discomfort. The resident began oral antibiotics this shift. No signs/symptoms of adverse reaction. Lung sounds diminished. Resident remains on room air. oxygen saturation is 93 %. Vital signs are within normal limits. Fluids encouraged. Review of the resident's progress note dated 04/30/24, at 3:52 P.M., showed a nurse documented the following: -The physician returned call related to resident's hemoglobin blood test result of 7.1 grams/deciliter (g/dL) (normal range 13.8-17.2 g/dL); -Verbal orders for labs erythrocyte sedimentation rate (ESR - a non-specific indicator or inflammation or infection in the body) and a C-Reactive protein (CRP - an indication of inflammation in the body). Review of the resident's progress note dated 04/30/24, at 4:28 P.M., showed a nurse documented the following: -Resident having decreased blood pressure this shift; -Notified the resident's physician via phone call; -Verbal physician order to discontinue amlodipine (a medication used in the treatment of high blood pressure) and lisinopril (a medication used in the treatment of high blood pressure and heart failure); -Monitor blood pressure every shift for one week and then routinely; -Continue Coreg (a medication used in the treatment of high blood pressure and heart failure) 25 milligrams (mg) twice daily; -Add parameters to Coreg, do not give if blood pressure less than 110/60 millimeters of Mercury (mm/Hg) or if pulse less than 60 beats per minute. Review of the resident's progress note dated 04/30/24, at 8:58 P.M., showed an on-call physician documented the following: -Was called because the resident had been spiking a fever of 102.2 F; -The resident apparently has a decubitus (pressure ulcer) to his/her coccyx with foul smelling discharge and has been coughing and a recent chest x-ray showed a patchy infiltrate in the left lung; -The resident is indicating a cough and is already on ceftriaxone (an antibiotic); -On-site examination was by the nurse and the resident was evaluated by the physician via video with the assistance of the nurse; -Alert/awake, not in any significant distress; -Lungs per nurse good air entry bilaterally and no wheezing or crackles; -Heart sounds regular per nurse; -Able to move arms and legs; -Assessment: 1. pneumonia, 2. possible infected decubitus (pressure ulcer); -Plan: 1. pneumonia- resident is being sent to the hospital for further evaluation and advise; 2. possible infected decubitus pressure ulcer. Review of the resident's progress note dated 04/30/24, at 9:30 P.M., showed RN B documented the following: -Resident had a fever and puking. Vital signs were as follows: Temperature = 102.2 degrees F, pulse oximetry = 87 % on room air (normal range = 95-100 %), heart rate = 97 beats per minute (normal range = 60-100), and blood pressure 142/71 mm/Hg (normal = 120/80 mm/Hg). Nurse called the on-call physician and shared what was going on with the resident. The physician advised the resident to be sent out to the hospital for further evaluation and treatment, resident agreed. The nurse called the hospital emergency room to give report and called the ambulance for transport. Resident transferred from his/her bed to the stretcher with two staff assisting from the facility and two ambulance staff assisting. Review of the resident's hospital emergency department visit documentation, dated 05/01/24, showed the following: -Seen by provider on 04/30/24, at 10:48 P.M.; -Presents in the emergency department due to fever, increased weakness. According to emergency medical services (EMS) report the patient did have a recent CABG about three weeks ago, and was at the nursing home for rehabilitation. Patient does express increased weakness, mild cough, and occasional shortness of breath, but otherwise declines physical complaints. Patient is also found to have a stage IV sacral decubitus ulcer. This was discussed with general surgery who recommended admission to the hospital with surgical consultation; -Impression/Diagnosis: Sacral decubitus ulcer, stage IV, generalized weakness. Review of the resident's hospital brief provider note, dated 05/01/24, showed the following: -Examination of the resident's sacral decubitus ulcer revealed a large, deep, gangrenous (dead tissue caused by infection or lack of blood flow) sacral decubitus ulcer, at least 10 cm in diameter, with dark, gray, gangrenous tissue throughout and a foul odor; -Recommended surgical debridement of wound. During interviews on 06/20/24, at 11:00 A.M. and 2:18 P.M., the wound nurse said the following: -Upon arrival from the hospital, the resident had a Mepilex dressing on his/her coccyx. The nurse removed the dressing and discovered an unstageable pressure ulcer; -The pressure ulcer was covered with slough and therefore he/she could not determine the depth of the wound; -He/she contacted the physician and obtained treatment orders; -He/she assessed the resident's wound and changed the resident's dressing; -He/she did not document the dressing change; -The wound nurse assessed the resident's wound on admission, but he/she then took off work for the remainder of the resident's stay at the facility; -He/she typically completed wound assessments weekly on any resident pressure ulcers; -During the resident's stay, on 04/25/24, facility staff transported the resident to an out of the facility wound clinic for treatment; -In the past, the wound clinic frequently asked the facility to leave other residents' dressings in place until their return to the wound clinic. During an interview on 06/20/24, at 11:25 A.M., LPN A said the following: -He/she cared for the resident a few times and remembered the resident had a pressure ulcer to his/her coccyx; -The resident went to a wound clinic for treatment; -He/she was unsure if any nurses at the facility measured or assessed the resident's pressure ulcer while the wound nurse was off work. During an interview on 06/20/24, at 2:27 P.M., the Director of Nursing (DON) said the following: -On 04/25/24, LPN A received a verbal phone order from the wound clinic to leave the resident's treatment in place, but LPN A did not document the order. During an interview on 06/20/24, at 2:31 P.M., LPN A said the following: -After the resident's return, the wound clinic called and told LPN A not to remove the resident's coccyx dressing because the treatment would be done at the wound clinic on the next weekly visit; -LPN A passed the information on in verbal report to the night nurse, but did not document any change in the resident's treatment order. During an interview on 06/20/24, at 3:05 P.M., LPN C said the following: -He/she did not recall ever seeing the resident's pressure ulcer; -He/she recalled during a shift to shift report, the off going nurse informed him/her not to remove the resident's coccyx dressing during a change of shift report because the wound clinic would be completing the treatment; -LPN C was unsure which day he/she heard this information. During an interview on 06/20/24, at 3:11 P.M., Registered Nurse (RN) B said the following: -He/she changed the dressing on the resident's coccyx, but did not recall any odor from the wound until 04/30/24; -On 04/30/24, the resident developed a fever, despite staff administration of ordered antibiotics for a respiratory infection; -The nurse became concerned the resident's fever might be an indication of something serious; -He/she contacted the on-call physician, and the on-call physician conducted a virtual visit with the resident; The resident exhibited increased weakness, vomiting, and a the nurse assessed a foul odor coming from his/her coccyx pressure ulcer; -RN B did not recall the appearance of the resident's pressure ulcer. During an interview on 06/24/24, at 12:37 P.M., the Transportation Director said the following: -On 04/25/24, he/she accompanied the resident to the wound clinic; -After the appointment, the wound clinic staff tried to give orders verbally to the Transport Director to not change the resident's pressure ulcer dressing for 24 hours, but he/she informed the wound care clinic staff they would need to give any orders to the facility nurse, as he/she was not a nurse; -Upon return to the facility, the Transportation Director relayed this information to the facility nurse, LPN A. During an interview on 06/24/24, at 11:15 A.M., the Director of Nursing (DON) said the following: -Staff admitted the resident to the facility on [DATE] from the hospital, but the hospital did not inform the facility of the resident's coccyx pressure ulcer upon admission to the facility and the hospital discharge paperwork did not contain an order for treatment to the pressure ulcer; -On 04/18/24, the wound nurse observed the resident's coccyx pressure ulcer and obtained a physician's order for treatment; -The wound care nurse was then off work starting on 04/19/24 for several days; -If the wound nurse or any nurse was unable to initial a pressure ulcer treatment order as completed, he or she should document the wound care performed in a progress note in the resident's medical record; -If the resident went to the wound clinic and the wound clinic did not send any paperwork back with the resident, then the nurse on duty should call the wound clinic and request the wound clinic to send the information; -The nurse working on 04/25/24, LPN A, said the wound clinic called and informed LPN A not to change the resident's dressing, but LPN A failed to document the conversation or write an order to hold the treatment; -The nurse should have entered a physician's order into the computer to discontinue the wound care order and should have documented in a progress note about the conversation; -LPN C told the DON, another nurse passed on in report to LPN C to hold (not perform) the resident's wound care, but staff did not place an order to hold or discontinue the wound care order; -LPN C should have followed the current pressure ulcer treatment order for wound care or called the wound care clinic to clarify the order, rather than just hold the treatment without an order; -Facility nurses should complete weekly skin assessments and the wound nurse should complete weekly wound assessments; -The DON did not assign another nurse to complete the weekly wound assessment during the week the wound nurse was off work, but the wound clinic assessed the wound 04/25/24; -The facility did not request the wound clinic paperwork, which included the assessment of the resident's pressure ulcer or the treatment orders until 06/20/24, after the surveyor requested the information. During an interview on 06/24/24 at 1:05 P.M., the Administrator said nurses should follow physician's orders for treatment of pressure ulcers. MO00237757

Based on observations, interviews, and record review, the facility failed to have sufficient staff on duty to perform resident showers. This failure affected seven residents (Resident #6, #15, #17, #21, #25, #28, and #40) on one of four halls (B hall). The facility census was 70. Review of the facility's policy titled, Certified Nurse Assistant Job Descriptions, dated 11/03/21, showed the following: -Performs all tasks/procedures included on assignment or reports to charge nurse any tasks not completed. 1. During an interview on 10/24/23, at 10:48 A.M., Resident #28 said he/she had not had shower since a week ago Tuesday. The facility got rid of the shower aide and now residents are not getting showers. During the resident group interview on 10/25/23, at 1:00 P.M., Resident #25 said he/she only gets a shower every three weeks. If residents don't give their own, resident don't get one. The residents in the group interview said the shower aide hasn't been at the facility for weeks. During an interview on 10/26/23, at 1:30 P.M., Shower Aide (SA) 2 said she had not been at the facility for 2 1/2 weeks. During an an interview on 10/27/23, at 9:27 A.M., with the Director of Nurses (DON) and the Administrator, the DON said there are two bathing aides. Their work is divided up for who is to have a shower on the specific day. They are not assigned to a specific hall. The DON said they have had other staff fill in since SA 2 had been out. Review of the bathing records for the month of October 2023 for B Hall showed the following: -Resident #6 had a shower one day a week on Wednesdays with limited assistance of one. The resident had no showers documented as having been provided from 10/1/23 to 10/26/23 and four missed showers; -Resident #15 had a shower one day a week on Wednesdays with limited assistance of one. The resident had showers documented as having been provided from 10/01/23 to 10/26/23 with one refusal documented on 10/03/23; -Resident #17 did not have a specific shower day noted on the forms provided by the DON. The resident had one shower documented as having been provided on 10/12/23 during the timeframe of 10/08/23 to 10/19/23; -Resident #21 had a shower one day a week on Wednesdays and required a Hoyer lift (mechanical lift for non-weight bearing residents). The resident had no showers documented as having been provided from 10/01/23 to 10/23/23, three missed showers; -Resident #25 was not identified to have a specific shower day on the forms provided by the DON. The resident had no showers documented as having been provided from 10/01/23 to 10/25/23. -Resident #28 was not identified to have a specific shower day on the forms provided by the DON. The resident had no showers documented as having been provided from 10/1/23 to 10/26/23. -Resident #40 was identified to have a shower on Monday and Thursdays with limited assistance of one. The resident had no showers documented as having been provided from 10/9/23 to 10/16/23, four missed showers. Review of the daily staffing worksheet showed two shower aids (SA 1 and SA 2) listed on the daily staffing worksheet, except for 10/11/23, 10/18/23, 10/19/23, 10/20/23, 10/23/23, 10/24/23, and 10/25/23 when only one was listed. During an interview on 10/27/23, at 11:30 A.M., the DON confirmed showers had not been given. The DON said if it wasn't charted, it did not occur. The DON did not know why showers were not provided or reported as having been missed.

Based on interview and record review, the facility failed to ensure COVID-19 resident vaccinations were offered, administered, or refused by the resident and/or resident representative for four (Resident #36, #39, #42, and #49) of five sampled residents reviewed for immunizations. In addition, the facility failed to develop and implement a COVID-19 policy for resident vaccination against the COVID-19 virus. The facility census was 70. 1. Review of Resident #36's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) showed the following: -admitted [DATE]; -Diagnoses included multiple sclerosis (a long-lasting (chronic) disease of the central nervous system), diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), and chronic kidney disease. Review of the resident's Immunizations located in the Preventative Health tab of the EMR showed no documentation staff offered the COVID-19 vaccination upon or after admission or that the resident refused. 2. Review of Resident #39's Face Sheet located in the Face Sheet tab of the EMR showed the following: -admitted [DATE]; -Diagnoses included heart failure (the heart can't pump enough oxygen-rich blood to meet your body's needs), irregular heart rhythm, and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Review of the resident's Immunizations located in the Preventative Health tab of the EMR showed no documentation staff offered the COVID-19 vaccination upon or after admission or that the resident refused. 3. Review of Resident #42's Face Sheet located in the Face Sheet tab of the EMR showed the following: -admitted [DATE]; -Diagnoses that included Alzheimer's disease and dementia. Review of the resident's Immunizations located in the Preventative Health tab of the EMR showed no documentation staff offered the COVID-19 vaccination upon or after admission or that the resident refused. 4. Review of Resident #49's Face Sheet located in the Face Sheet tab of the EMR showed the following: -admitted [DATE]; -Diagnoses that included Parkinson's disease (a progressive neurological disease) and dementia. Review of the resident's Immunizations located in the Preventative Health tab of the EMR showed no documentation staff offered the COVID-19 vaccination upon or after admission or that the resident refused. 5. During an interview on 10/25/23, at 2:00 P.M., the Director of Nursing (DON) said, if staff did not document the vaccination on the Immunizations page, then it was not offered. 6. During an interview on 10/27/23, at 9:16 AM, the DON said the facility did not develop a policy regarding immunizations for COVID-19.

Based on observation, interview, and record review, the facility failed to ensure communication occurred with the dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to) center for one resident (Resident #1) of one sampled resident reviewed for dialysis. This failure placed the resident at risk of complications that might otherwise have gone unnoticed. The facility census was 70. Review of the facility's Dialysis Contract, dated 10/01/18, showed the following: -Collaboration of Care - Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Long-Term Care Facility and the ESRD (End-Stage Renal Disease - permanent kidney failure that requires a regular course of dialysis or a kidney transplant) Dialysis Unit; -To provide to the Long-Term Care Facility information on all aspects of the management of the ESRD resident's care related to the provision of Renal Dialysis Services. the Long-Term Care Facility shall ensure that ESRD residents are prepared to spend an extended length of time at the ESRD Dialysis Unit and have received proper nourishment and any medications prescribed for reasons other than the treatment of ESRD, as appropriate, before coming to the ESRD Dialysis Unit. 1. Review of Resident #1's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) showed the following: -admitted [DATE]; -Diagnoses that included ESRD, heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs), and was dependent on dialysis. Review of the the resident's Dialysis Care Plan, located in the RAI tab of the EMR, dated 04/09/21, showed the following: -Resident had stage 4 kidney disease and required dialysis; -Dialysis started in January 2020; -Resident is now getting hemodialysis (a machine filters wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work); -Resident had a shunt (aids the connection from a hemodialysis access point to a major artery) revision for dialysis in May 2020; -Check thrill and bruit (sounds that are made as blood passes through the dialysis fistula) every shift; -Notify the doctor as needed; -Make arrangements for resident to get to dialysis three times a week; -Monitor blood pressure, especially on dialysis days; -Notify the doctor if resident gains three pounds in a day or 5 pounds or more in two days. Review of the resident's Nutrition Care Plan, dated 04/09/21, located in the RAI tab of the EMR, showed the following: -The resident is at nutritional risk due to receiving dialysis and diagnoses of obesity & Alzheimer's; -Staff to provide foam silverware at meals (edited on 01/23/23), a regular diet (edited on 01/23/23), prefers meals in the dining room (edited on 05/04/23), one ounce extra protein at each meal; -The resident likes to choose double meat portions due to lactose intolerance (edited 08/16/21); -Lactose intolerant-requests almond milk at breakfast and lunch (edited 04/09/21); -Educate resident on the importance on protein-rich foods (edited on 04/09/21). Review of the resident's current Physician Orders located in the Orders tab of the EMR showed the following: -An order, dated 05/23/23, for dialysis on Monday, Wednesday, and Friday; -An order, dated 06/28/23, for fluid restriction of 1500 ml (milliliters) every 24 hours. Special Instructions included 120 ml with each meal; 100 ml with each medication pass, four times daily; and 400 ml each day; and 350 ml each night. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) located in the RAI tab of the EMR with an Assessment Reference Date (ARD) of 09/09/23 showed the following: -The resident had severely impaired in cognition; -The resident was independent in eating/drinking; -The resident was dialysis. Review of the resident's Nutrition Progress Note, an 07/18/23, located in the Progress Notes tab of the EMR by the Registered Dietician (RD) showed the following: -History of bilateral lower extremity edema (swelling), but none at this time; -Remains fluid restriction of 1500 ml/24 hours; -History of forgetting the fluid restriction; -Dialysis RD recommended encouraging the resident to refrain from excess salt and fluids; -Charge nurse re-educated today per progress notes; -It is noted that with education, the resident makes healthy choices initially, but within minutes, he/she is requesting snacks (salty, high fat, or bananas) and more beverages. Review of the resident's Nutrition Care Plan, located in the RAI tab of the EMR, showed staff did not update with the RD updates or revisions regarding the dialysis RD recommendations or to show the fluid restriction. Review of the resident's quarterly Nutrition Progress Note located in the Progress Notes tab of the EMR showed current and generalized edema. The resident remains on fluid restriction of 1500 ml/24 hours. Resident has a history of forgetting the fluid restriction. Review of the resident's Resident Documents and Progress Notes sections of the EMR showed staff did not document a Post-Dialysis Communication Worksheet or documentation in the Progress Notes by nursing regarding a follow-up call regarding the resident's dialysis session or if there were any complications from July 2023 to 10/26/23. During an interview on 10/27/23, at 8:14 A.M., the Director of Nursing (DON) staff do not always get back the communication forms. The DON was not aware if staff call and get a verbal report from the dialysis center. During an interview on 10/27/23, at 10:33 A.M., the RD said she reviews the resident one time a month. Staff should be documenting better on the resident. The resident is is very demanding, and the RD does explain about the fluid restriction. The resident is not defiant, but five minutes later he/she is thirsty and even though staff remind him/her about the restriction, he/she will get upset. The RD said she was responsible for the Nutrition Care Plan and it was her fault that it had not been updated/revised, it should have been. During an interview on 10/27/23, at 11:11 A.M., Registered Nurse (RN) 2 said, when the resident goes to dialysis, the night nurse prints out the communication form and staff send it with the resident. It does not always come back though. The RN was not aware that staff needed to follow up to ensure the have had the documentation needed.

Based on interview and record review, the facility failed to ensure medications were available for administration for one resident (Resident #39) of five sampled residents reviewed for unnecessary medications. The resident had the potential to experience adverse effects as the result of missing prescribed medications. The facility census was 70. 1. Review of Resident #39's electronic medical record (EMR) Face Sheet tab showed the following: -admitted [DATE]; -Diagnoses included hypertensive (high blood pressure) heart disease with heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs.), atherosclerotic heart disease (build-up of fats/cholesterol in the artery walls) of native coronary artery without angina pectoris (chest pain or discomfort that keeps coming back), hyperlipidemia (elevated blood lipids (cholesterol, triglycerides)), depression, and gastroesophageal reflux disease. Review of the resident's EMR Orders tab showed the following orders: -An order, dated 12/16/22, for atorvastatin (antilipidemic) 40 milligrams (mg), one tab to be given at bedtime for hyperlipidemia; -An order, dated 12/16/22, for Eliquis (blood thinner) 5 mg, one tablet to be given twice a day, clinical indication blood thinner; -An order, dated 12/16/22, for omeprazole capsule (used to treat acid reflux) delayed release 20 mg, one capsule to be given at bedtime for gastroesophageal reflux disease (GERD); -An order, dated 10/19/23, for Senna (a laxative medication) 8.6 mg one tablet to be given twice a day; -An order, dated 10/13/23, for Wellbutrin extend release 150 mg, one and a half tablet to be given twice daily from 07/31/23 through 10/13/23. -An order, dated 10/19/23, for Wellbutrin (an antidepressant) extend release 150 mg, one and a half tablet to be given for depression twice daily from 10/13/23 through 10/19/23; -An order, dated 10/19/23, for Wellbutrin sustained release 150 mg, one tablet to be given twice a day. Review of the resident's September 2023 and October 2023 Medication Administration Record (MAR) located under the EMR Reports tab showed the resident's prescribed medications were documented as not administered due to the medication not being available on the following occasions: -Atorvastatin was not available for administration on 09/30/23, 10/02/23, 10/04/23, 10/05/23, 10/07/23, and 10/09/23; -Eliquis was not available for administration on 10/14/23' -Omeprazole was not available for administration on 09/25/23, 10/05/23, 10/06/23, and 10/07/23; -Senna was not available for administration on 10/19/23 P.M. dose, 10/22/23 P.M. dose, 10/23/23 A.M. dose, 10/24/23 A.M. dose, 10/25/23 A.M. dose, and 10/26/23 A.M. dose; -Wellbutrin was not available for administration on 09/02/23 A.M. dose, 09/24/23 A.M. and P.M. dose, 09/25/23 A.M. dose, 09/26/23 A.M. and P.M. dose, 09/27/23 A.M. dose, 09/28/23 to 09/29/23 A.M. and P.M. doses, 09/30/23 P.M. dose, and 10/02/23 A.M. dose. During an interview on 10/26/23, at 11:22 AM, Certified Medication Technician (CMT) 1 said the resident's medications took a while to get him/her because they received his/her medications through the Veteran's Administration (VA) and the medications needed to be called in and were shipped to the facility. CMT stated the network pharmacy should be notified to send medications over when they were delayed from the VA. During an interview on 10/27/23, at 10:37 AM, the Director of Nursing (DON) confirmed the resident's medications were ordered from the VA, and the facility had a designated person who called in the next refill for VA medications once the medication was received by the facility. The network pharmacy can fill medications in the interim and provide new medications until the VA mail-in order was received. The network pharmacy delivered nightly, except on Sundays. The Senna was an over-the-counter medication and should have been available to administer to the resident. The network pharmacy will often respond that the resident's medications are filled by the VA and once nursing staff confirms with need for coverage they will send the medication over. There was no reason for the medications to be missed.

Based on interview and record review, the facility failed to ensure one resident (Resident #49) of five sampled residents reviewed for unnecessary medications, was not administered an antiseptic medication used to treat recurrent urinary tract infections while being administered an antibiotic for a urinary tract infection. This failure placed the resident at risk for complications related to the use of a medication that is not recommended to be used when being administered an antibiotic. The facility census was 70. Review of a facility policy titled, Adverse Consequences and Medication Errors, revised April 2014, showed the following: -Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported. 1. Review of Resident #49's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) showed the following: -admitted [DATE]; -Diagnoses included Parkinson's disease (a progress disease of the nervous system) and dementia. Review of the resident's current Physician Orders located in the Orders tab of the EMR showed the following: -An order, dated 05/04/23, the for methenamine hippurate (an antiseptic medication) 1 gram twice a day. Resident to stop taking if antibiotics ordered also. Resume order when antibiotic therapy completed. Review of the resident's Nursing Progress Notes, located in the Progress Notes tab of the EMR showed the following: -On 10/10/23, at 3:27 A.M., received C&S (culture and sensitivity) final report. A new order received from physician to start resident on cephalexin (an antibiotic) 500 mg (milligrams) three times daily for seven days. Review of a 10/10/23, at 9:22 A.M., the resident's Pharmacy Progress Note located in the Progress Notes tab of the EMR showed the following: -Antibiotic review: UTI (urinary tract infection), cephalexin (10/10/23 to 10/16/23), UTI- prophylaxis-methenamine (ongoing). Review of the resident's October 2023 Medication Administration Record (MAR) showed staff did not document that the methenamine was held while the resident was administered antibiotics. During an interview on 10/27/23, at 7:54 AM, the Director of Nursing (DON) said the methenamine should have been held and the pharmacist should have caught this.

20706 32513 Based on observation, interview, and record review, the facility failed to establish and monitor resident-specific behaviors for the use of an antipsychotic medication for two residents (Residents #49 and #39) out of ten sampled residents. These failures placed residents at risk for a diminished quality of life and potential unmet care needs. The facility census was 70. Review of a facility policy titled, Medication Monitoring and Management, revised 01/09/19, showed the following: -In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use; -When selecting medications and nonpharmacological interventions, members of the interdisciplinary team participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition. 1. Review of Resident #49's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) showed the following: -admitted [DATE]; -Diagnoses included Parkinson's disease (a progressive neurological disease) and dementia. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) located in the RAI (Resident Assessment Instrument) tab of the EMR, with an Assessment Reference Date (ARD) of 09/01/23, showed the resident was cognitively intact for decision-making and was administered an antipsychotic medication daily. Review of the resident's current Physician Orders located in the Orders tab of the EMR showed the following psychotropic medications: -An order, dated 09/22/22, for olanzapine (an antipsychotic medication) 5 milligrams (mg) at bedtime; -An order, dated 04/29/22, for escitalopram (an antidepressant medication) 20 mg each morning; -An order, dated 04/29/22, for temazepam (a hypnotic medication used to treat insomnia) 30 mg at bedtime. Review of the resident's Psychiatric Condition Care Plan, dated 05/18/22 and reviewed/revised on 09/20/23,located in the RAI tab of the EMR showed the following: -The resident has dementia, depression, and insomnia; -Observe for changes in mood and in behavior; monthly drug review by pharmacy; listen attentively to concerns, fears, explain changes in routine, procedures, etc.; and consult medical doctor as needed for changes in mood and behavior; -Behavior observation every shift for anxiolytic (antianxiety medications) and/or antipsychotic use; -Assess behaviors and try to determine cause, approach in calm manner and smile, administer donepezil (medication for dementia), escitalopram, olanzapine, temazepam as ordered and observed for adverse effects. (Staff did not document specific behaviors that were to be monitored for the use of the psychotropic medications.) During an interview on 10/25/23, at 2:07 P.M., the resident was asked what the reason was he/she was prescribed an antipsychotic medication. The resident stated he/she had hallucinations. They are visual and at times are very scary. The resident said the medication was helpful to him/her. During an interview on 10/27/23, at 7:59 A.M., the DON said the 'Care Plans' are an issue. She was aware that they are not resident-specific. The resident had entered the facility on the olanzapine and staff did not know the behaviors. The DON was not aware of the visual hallucinations as the reason for the use of the antipsychotic medication. This should have been care planned. 2. Review of the Highlights of Prescribing Information for Abilify (aripiprazole), retrieved from /www.accessdata.fda.gov/, showed the following: -Abilify is an atypical antipsychotic medication indicated in the treatment of schizophrenia (delusions (false beliefs), hallucinations (seeing or hearing things that don't exist), unusual physical behavior, and disorganized thinking and speech), bipolar I (manic episodes that last for at least 7 days (nearly every day for most of the day) or by manic symptoms that are so severe that the person needs immediate medical care), adjunctive treatment of major depressive disorder, irritability associated with autistic disorder (a developmental disability caused by differences in the brain), and treatment of Tourette's (a condition of the nervous system which causes people to have tics); -The warnings and precautions included an increased incidence of stroke in elderly people (cerebrovascular problems) that can lead to death and metabolic changes included increased blood sugars and undesirable alterations in lipid levels. Review of Resident #39's EMR Face Sheet tab showed the following: -admitted [DATE]; -Diagnoses which included hypertensive (high blood pressure) heart disease with heart failure (a condition where the heart cannot pump sufficient blood to the organs); atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of plaque in the arteries without chest pain); unspecified atrial fibrillation (irregular heartbeat that can contribute to blood clots); hyperlipidemia (elevated blood lipids); unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; depression, unspecified; and history of falling. Review of the resident's EMR Progress Notes tab located in the Resident section, on 08/23/23, showed the following: -Social Services Director (SSD) completed quarterly review with the resident. The resident is alert and able to make his needs known. Resident jokingly states that he/she will lie about all answers he/she gives and did state that he/she does not like to be asked questions because he/she does not believe anyone needs to know; -The resident refused to complete the Brief Interview for Mental Status; -The resident denied any signs/symptoms of mood at this time. Resident can easily become agitated, annoyed and can begin yelling toward others. The resident spends most time in his/her room and listens to music or watches TV; -SSD will monitor and assist as needed. Review of the resident's Active Orders in the EMR Orders tab of the resident section showed the following: -An order, dated 10/13/23, aripiprazole (Abilify) 5 mg, one tablet for clinical depression at bedtime. (The orders did not include monitoring of targeted behaviors for Abilify.) Review of the resident's Abilify Order located in the EMR Resident Documents tab in the Resident section showed the following revealed a copy of four nursing progress notes with the physician's order to add 5 milligrams of Abilify handwritten on the notes. The included notes showed: -On 09/26/23, at 6:01 A.M., the resident was noted having behaviors at the start of this shift. Resident was yelling at another resident for being in the center court and not having his dinner. Staff member offered to warm resident's food, but resident refused and proceeded to yell at staff member. Resident then went back to his room; -On 09/28/23, at 1:01 P.M., witnessed resident verbal outburst when shower aide went to his room and offered to give him/her a shower. Resident was yelling obscenities and crying, ordering shower aide out of his/her room. This nurse spoke with resident about his concerns. The resident was crying, verbally jumping from subject to subject, ranging from his/her care here, to his/her Army experiences, to his/her stay at another facility, to his/her PTSD (post-traumatic stress disorder) and other subjects. After approximately 10 minutes, he/she calmed down enough to agree to take a shower; -On 09/30/23, at 5:35 P.M., the resident refused to take all his/her medications through the shift. He/she placed his/her nightstand at the back of his door preventing staff to enter his/her room. Staff attempted to talk to the resident, but he/she just said 'No. Staff left the resident in his room while he's laying on his bed. Plan of care to continue; -On 10/09/23, at 4:00 AM, the resident refused majority of bed time medication this shift. Resident observed barricading door to room, resident stated he/she didn't want anyone in his/her room anymore, this nurse informed resident staff have to check on him/her occasionally to ensure his/her safety, but he/she has a right to not have anyone in his/her room he/she did not want unless there are concerns for safety. Resident yelled at staff twice this shift, but was able to redirect easily. Review of the resident's medical record showed it lacked evidence evidence of behavioral monitoring. During an interview on 10/26/23, at 11:13 A.M., Certified Nursing Assistant (CNA) 1 said the resident was mostly alert and oriented without confusion. CNA1 stated there was one resident who wandered that the resident did not like. The resident would yell and shut his/her door and stay in his/her room when that resident was around. The resident was loud, but generally happy and in a good mood. During an interview on 10/26/23, at 11:22 A.M. with Registered Nurse (RN) 2 and Certified Medication Technician (CMT) 1, RN 2 said the resident had post-traumatic stress disorder and would become irritated at times with some of the residents so nursing staff tried to prevent those interactions. RN2 said the resident usually calmed himself down. CMT 1 said the resident was moody and yelled at times. CMT 1 said the resident was easily calmed down. CMT 1 said the resident who wandered was no longer a resident at the facility. During an interview on 10/27/23, at 10:37 A.M., the DON said the resident cycled hard with his/her depression and had times when he/she was great and times when he/she yells and says he/she should not have come back from war. The resident had been referred for psychiatric services, but had refused previously. In a follow-up interview at 1:13 PM, the DON stated there was no behavior monitoring for the resident's Abilify. The resident did calm down eventually when upset, but how long depended on how mad he/she had gotten. 36375

Based on observation, interviews, and record review, the facility failed to ensure all residents were free from significant medication errors when staff failed to ensure one resident's (Resident # 1) insulin was administered per manufacturer's recommendation. The facility census was 70. , Review of the facility policy titled, Adverse Consequences and Medication Error, revised April 2014, showed the following: -A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services; -Examples of medication error include wrong time. Review of the Manufacturer's Drug Insert for Novolog aspart insulin (fast acting insulin) provided by the Director of Nursing (DON) showed the following: -Inject subcutaneously (below the skin) within 5 to 10 minutes before a meal into the abdominal area, thigh, buttocks, or upper arm; -Warnings and precautions hypoglycemia (low blood sugar) may be life-threatening; -Increase frequency of glucose monitoring with changes to meal pattern and in patient with renal disease. 1. Review Resident #1's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) showed the following: -admitted [DATE]; -Diagnoses included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and end-stage renal disease (a condition characterized by a gradual loss of kidney function over time. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) located in the RAI (Resident Assessment Instrument) tab of the EMR with an Assessment Reference Date (ARD) of 09/08/23 showed the following: -The resident was severely impaired in cognition; -The resident was administered insulin six out of seven days during the observation period. Review of the residents's Physician Order located in the Orders tab of the EMR showed an order, dated 05/28/23, of the following: -Sliding scale insulin to be administered before meals and at bedtime order; -Novolog U-100 insulin aspart solution 100 units/ml per sliding scale; -If blood sugar is 141 milligram(mg)/deciliter (dl) to 180 mg/dl, administer 2 units of insulin; -If blood sugar is 181 mg/dl to 220 mg/dl, administer 4 units of insulin; -If blood sugar is 221 mg/dl to 260 mg/dl, administer 6 units of insulin; -If blood sugar is 261 mg/dl to 300 mg/dl, administer 8 units of insulin; -If blood sugar is 301 mg/dl to 340 mg/dl, administer 10 units of insulin; -If blood sugar is 341 mg/dl to 380 mg/dl, administer 12 units of insulin; -If blood sugar is 381 mg/dl to 400 mg/dl, administer 14 units of insulin; -If blood sugar is greater than 400 mg/dl, notify the physician. Observation on 10/25/23, at 10:32 A.M., showed Certified Medication Technician (CMT) 1 performed a Fasting Blood Sugar (FBS) test on resident. The results of the FBS test were 143 mg/dl. CMT 1 said the resident would received two units of insulin. Observation on 10/25/23, at 10:37 A.M., showed CMT 1 administered two units of the Novolog insulin into the resident's abdomen. The CMT 1 said the resident would go down to the dining room by 11:00 AM and have an appetizer. Observation on 10/25/23, at 11:09 A.M., showed the resident in bed, asleep. CMT 1 entered the resident's room to wake him/her up and to tell him/her to go to the dining room for the appetizers. The resident got up out of bed and independently self-propelled his/her wheelchair towards the dining room. Observation on 10/25/23, at 11:22 A.M., showed the resident was not provided an appetizer, but a diet coke. CMT 1 spoke with dining staff and a graham cracker packet was provided to the resident. During an interview on 10/25/23, at 11: 27 A.M., showed the Dietary Manager (DM) said the resident did not receive an appetizer on this date due to the appetizer being passed out was mozzarella sticks and since the resident was lactose intolerant. The DM said there was no alternate for the resident for the appetizer. Observation on 10/25/23, at 12:05 P.M., the resident was served lunch (one hour and 17 minutes after the sliding scale insulin was administered). During an interview on 10/16/23, at 5:45 AM, the Director of Nursing (DON) said waiting over one hour to receive a meal after insulin administration means it was too early to have been given insulin to the resident.

Based on interview and record review, the facility failed to offer or provide documentation of consent refusal of pneumonia vaccinations for two residents (Resident #1 and #42) of five sampled residents The facility census was 70. Review of Centers for Disease Control and Prevention (CDC) website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, showed the following: -CDC recommends pneumococcal vaccination for all adults [AGE] years or older; -For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends one dose of PCV15 or PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later; -If PCV20 is used, a dose of PPSV23 is not indicated; -For adults [AGE] years or older who have only received a PPSV23, CDC recommends to give one dose of PCV15 or PCV20; -The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination;. -For adults [AGE] years or older who have only received PCV13, CDC recommends to give PPSV23 as previously recommended; -For adults who have received PCV13, but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete. 1. Review of Resident #1's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) showed the following: -admitted [DATE]; -Diagnoses included end-stage renal disease, heart failure (the heart can't pump enough oxygen-rich blood to meet your body's needs.), and was dependent on dialysis (a treatment for people whose kidneys are failing); -Resident was over age 65. Review of the resident's Immunizations located in the Preventative Health tab of the EMR showed the residents's last dose of PPSV 23 was dated 10/30/15 and the next scheduled dose was noted for 10/30/20. Staff did not document administration or refusal of the 10/30/20 dose. 2. Review of Resident #42's Face Sheet located in the Face Sheet tab of the EMR showed the following: -admitted [DATE]; -Diagnoses included Alzheimer's disease, dementia, and chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems); -Resident was over age 65. Review of the resident's Immunizations showed the resident was last administered the PPSV 23 pneumonia vaccine on 01/09/09. Staff did not document to show that PPSV 20 was offered or refused, upon admission to the facility, in 2022. 3. During an interview on 10/25/23, at 2:00 PM, the Director of Nursing (DON) said if staff did not document the information on the Immunization page then it was not asked of the resident.

Based on observation, interview, and record review, the facility failed to provide complete wound tracking and monitoring for six residents (Residents #1, #2, #3, #4, #5, and #6), failed to obtain wound orders in a timely manner for two residents (Resident #1 and #2), and failed to complete and document wound care as ordered for one resident (Resident #5). The facility census was 83. Record review of the U.S. Department of Health and Human Services Clinical Practice Guidelines, Number 15, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Assess the pressure ulcer initially for location, stage, size, tracts, exudate (any fluid that has been forced out of the tissues or its capillaries because of the inflammation or injury), necrotic tissue (death of tissue in response to disease or injury), and presence or absence of granulation tissue (formation of new tissue, usually pink to red in color) and epithelialization (healing by the growth of epithelium over a denuded surface); -To monitor progress or deterioration, the examiner must accurately measure the length, width, and depth of the ulcer; -Reassess pressure ulcers at least weekly; -Indicators of a deteriorating pressure ulcer include increases in exudate and wound [CONDITION(S)] (swelling or puffiness from fluid), loss of granulation tissue, and a purulent (containing pus) discharge; -A clean pressure ulcer should show evidence of some healing within 2 to 4 weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary. Record review of the facility's policy, titled Nursing Services Policy and Procedure Manual for Long-Term Care, dated April 2018 showed the following: -The nursing staff will assess and document an individual's significant risk factors for developing pressure ulcers (for example, immobility, recent weight loss, and a history of pressure ulcers); -In addition, the nurse should describe and document/report a full assessment of pressure sore, including location, stage, length, width, and depth, presence of exudates, or necrotic tissues; -The staff will examine the skin of newly admitted residents (within 8 hours) for existing pressure ulcer/injury risk factors; -Repeat the risk assessment weekly and upon any changes in condition. 1. Record review of Resident #5's face sheet shows the following information: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's annual MDS, dated [DATE], showed the following: -Severely cognitively impaired; -Required extensive assistance of two staff for bed mobility, -Required total dependence on two staff for transfers, dressing, and personal hygiene; -Range of motion impairment of lower extremity on both sides; -Resident at risk for developing pressure ulcers; -No unhealed pressure ulcers; -No venous or arterial ulcers; -Pressure reducing device for bed; -Application of ointments/medications other than to feet. Record review of the resident's Skin Integrity Condition (A) form, observation date of 11/29/19 and completion date of 12/01/19, showed the following: -Bottom of left foot next to the fifth toe has a dark purple area measuring 3 x 2.1; -Possible vascular; -No exuduate or odor; -Pressure relieving device for chair and bed; -Turning/positioning program; -Application of dressings; -Dietary referral; -Provider notified; -Interventions somewhat effective (no further details documented); -Plan of care updated (no further details documented). (Staff did not document the units of measure for the area wound.) Record review of the resident's care plan showed the following: -On 11/30/29, staff updated the care plan with resident has a dark area on bottom of left foot next to fifth toe; -On 11/30/19, staff updated the care plan with skin treatment to bottom of left foot as ordered and notify physician if area does not improve. Record review of the resident's Skin Integrity Condition (A) form, dated 12/2/19, showed the following: -An area on plantar/bottom of left foot just under fifth toe with measurements of 3.4 x 2.0 x .2; -Vascular/diabetic ulcer? -Wound bed had necrotic slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture); -Scant serosanguineous (containing serum and blood) exudate; -No odor; -No [CONDITION(S)] (increased fluid volume tissues between the body's cells); -Turning/repositioning program; -Application of dressings; -Application of ointments/medications; -Elevate edematous/affected area; -Podus boots (protective boots); -Interventions effective; -No referrals necessary; -Continue current plan of care. (Staff did not document the unit of measure for the wound.) Record review of the resident's Skin Integrity Condition (A) form, dated 12/11/2019, showed staff documented the following: -A 3 x 2 skin condition on the left foot, under the fifth toe, with an open area in the center that was 1.2 x 1 with a dark center; -Possible vascular; -Scant bloody exudate; -No odor; -Pressure relieving device for chair and bed; -Nutrition or hydration intervention to manage skin problems; -Application of dressings; -Interventions somewhat effective (no further details documented); -Dietary referral; -Provider notified; -Plan of care updated (no further details documented). (Staff completed the assessment nine days after the last documented wound assessment. Staff did not document the units of measure for the wound, if the wound had depth, or if wound was improving or declining.) Record review of the resident's care plan showed the following: -On 12/11/19, staff updated the care plan with an area on the resident's left foot under the fifth toe; -On 12/11/29, staff updated the care plan with provide skin treatment as ordered until area is healed and notify physician as needed. Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 12/14/2019, to clean to bottom of the left foot with normal saline, and apply a [MEDICATION(S)] (a bordered foam dressing) dressing every three days and as needed. The order was discontinued on 12/21/2019. Record review of the resident's Skin Integrity Condition (A) form, dated 12/19/2019, showed the following: -A 6 x 6.3 blister surrounding the wound to the left foot under the second toe; -Possible vascular; -The wound bed had necrotic slough and had scant serosanguineous drainage; -No odor; -Pressure relieving device for chair and bed; -Turning/repositioning program; -Nutrition or hydration intervention to manage skin problems; -Application of dressings; -Application of ointments/medications; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . They develop on areas of skin that often flex - such as the lower abdomen, upper thighs or armpits); -Interventions somewhat effective (no further details documented); -Provider notified; -Plan of care updated (no further details documented). (Staff completed the assessment eight days after the prior assessment. Staff did not document a depth of the wound or the unit of measure for the length or width of the wound.) Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 12/21/2019, to clean the bottom of the left foot with normal saline and pat dry. Apply calcium alginate (a highly absorbent dressing that is used mainly on wounds with a high amount of drainage) to the wound bed only, cover with a dry dressing or foam dressing and change every three days and as needed for excessive soiling. Staff to monitor for changes and report to the Director of Nursing (DON) and/or treatment nurse or physician. The order was discontinued on 1/4/2020. Record review of the resident's Skin Integrity Condition (A) form, dated 12/25/2019, showed the following: -Wound on the left foot on the bottom under the second toe area spread to the ball of the foot, with a measurement of 3.6 x 7.0.; -Possible bulbous pemphoid; -Wound bed as dark and moist, and documented the area started as a dark purple area then a blister covered the original area and then spread to the ball of the foot; -Scant serosanguineous exudate; -No odor; -[CONDITION(S)] (redness of the skin caused by congestion of the capillaries in the lower layers of the skin. It occurs with skin injury, infection, or inflammation); -Pressure relieving device for chair and bed; -Turning/repositioning program; -Nutrition or hydration intervention to manage skin problems, -Application of dressings; -Application of ointments/medications; -Provider notified; -Interventions somewhat effected (no further details documented); -No referrals necessary; -Continue current place of care. (Staff did not document a depth of the wound or the unit of measure for the length or width of the wound.) Record review of the resident's nursing notes showed the following: -On 12/30/2019, at 4:30 P.M., recorded as a late entry on 1/3/2020, at 8:25 A.M., called and spoke with resident's responsible party. Staff suggested sending him/her to the wound clinic to receive treatment. Responsible party stated, I'm all for whatever will help him/her. Received order from physician and an appointment scheduled. During an interview on 2/21/2020, at 11:15 A.M., the resident's responsible party said he/she was never made aware of the wound on the resident's foot until the resident was being sent to the hospital for another issue. Record review of resident's nursing notes showed the following: -On 1/1/2020, at 10:31 A.M., staff documented treatments done per order to left foot. Cleansed with normal saline and calcium alginate with a foam dressing and Kerlix (a woven rolled gauze). Record review of the resident's care plan showed the following: -On 1/3/2020, staff updated the care plan for open area on left foot under fifth toe. Resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has developed a fluid filled area located on the bottom of his/her left foot. Physician has ordered an appointment at wound clinic; -On 1/3/2020, staff updated the care plan with provide treatment as ordered, notify physician and family as needed, and ensure resident goes to wound clinic as ordered. Record review of the resident's treatment administration records (TARs), dated 11/16/2019 to 2/20/2020, showed staff did not perform the ordered treatments to the resident's left plantar foot between the order date of 12/21/2019 and the discontinued date of 1/4/2020 (five treatments). Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 1/6/2020, for weekly Braden (a scale/assessment completed by facility staff that predicts the risk of developing a pressure ulcer/injury) and skin assessments to be done; -An order, dated 1/8/2020, to clean the left plantar foot with normal saline and apply [MEDICATION(S)] (an antiseptic used for skin disinfection), and cover with a dry gauze daily and as needed. The order was discontinued on 2/11/2020. Record review of the resident's Skin Integrity Conditions (A) form, dated 1/11/2020, showed the following: -Wound to the ball of the left foot measured 6.3 x 4.0; -Possible deep tissue injury (DTI - intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.); -Wound bed exhibited necrotic eschar (dead tissue) and a foul odor; -Scant dark serosanguineous exudate; -[CONDITION(S)]; -[CONDITION(S)]; -Pressure relieving device to chair and bed; -Turning/repositioning program; -Nutrition or hydration intervention to manager skin problems; -Application of dressings; -Application of ointment/medications; -Elevate edematous/affected area; -Heel protectors; -Other treatment as ordered; -Interventions somewhat effective (no further details documented); -Wound clinic referral; -Continue current plan of care. (Staff complete the assessment 17 days after prior assessment. Staff did not document a depth of the wound or a unit of measure for the length or width of the wound.) Record review of the resident's Skin Integrity Conditions (A) form, dated 1/20/2020, showed the following: -Wound to the ball of the left foot measured 6 centimeter (cm) x 3 cm; -Possible DTI with bulbous pemphigoid; -Wound bed exhibited necrotic eschar, a foul odor, and [CONDITION(S)] to the surrounding tissue; -Scant dark serosanguineous exudate; -[CONDITION(S)]; -Pressure relieving device for bed; -Turning/repositioning program; -Application of dressings; -Application of ointments/medications; -Wound clinic; -Interventions effective; -Continue current plan of care. (Staff completed the assessment nine days after the prior assessment. Staff did not document a depth of the wound.) Record review of the resident's Skin Integrity Conditions (A) form, dated 1/31/2020, showed the following: -Left foot plantar area wound measured 3 x 5.7; -Possible DTI with bulbous pemiphigold; -Wound bed exhibited necrotic eschar with scant yellowish exudate, and had a foul odor; -The surrounding tissue showed [CONDITION(S)]; -Trace [CONDITION(S)]; -Pressure relieving device for chair and bed; -Application of dressings; -Application of ointments/medications -Treatment as ordered; -Interventions somewhat effective (no further information documented); -No referrals necessary; -Continue current plan of care. (Staff completed the assessment 11 days after the prior assessment. Staff did not document a depth of the wound or unit of measure for the length or width of the wound.) Record review of the resident's Skin Integrity Conditions (A) form, dated 2/4/2020, showed the following: -Left plantar wound area measured 2.0 x 5.2 x 0.4; -Suspected DTI with [CONDITION(S)]; -Wound bed exhibited necrotic slough and eschar, had scant serosanguineous drainage, and a foul odor; -Surrounding skin was erythematous; -Pressure relieving device for chair; -Application of dressings; -Other preventative or protective skin care; -Provider contacted; -Interventions somewhat effective (no further documentation); -Wound clinic; -Continued plan of care. (Staff did not use a unit of measure for the wound measurements.) Record review of the resident's Skin Integrity Conditions (A) form, dated 2/10/2020, showed the following: -Left plantar wound measured 2.0 x 5.0 x 0.5; -Suspected DTI with [CONDITION(S)]; -Wound bed exhibited necrotic slough and eschar with granulation tissue; -Moderate amount of serosanguineous drainage with no odor and the surrounding tissue was erythematous; -Application of dressings; -Application of ointments/medications; -Provider notified; -Interventions somewhat effective (no further documentation) -Continue current plan of care. (Staff did not use a unit of measure for the wound measurements.) Record review of the resident's Physician's Progress Note from wound care, dated 2/11/2020, showed the following: -Wound #1 - left plantar; -Cause - pressure; -Length of 2 cm by width of 5 cm by depth 1.0 cm; -Resident has a necrotic wound with gangrenous (the death of body tissue due to either a lack of blood flow or a serious bacterial infection) changes of the plantar surface of the left foot across the metatarsal (a group of five long bones in the foot) heads; -Onset unknown. Resident's responsible party was unaware of wound until resident was referred by physician; -Debridement (the removal of lacerated, devitalized, or contaminated tissue) performed; -Post debridement measurements of 2 cm by 5 cm x 1.2 cm; -Assessment of Stage IV pressure ulcer of the plantar surface of left foot. Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 2/12/2020, to cleanse the left plantar foot with soap and water, and pat dry. Apply a thin layer of [MEDICATION(S)] (an antibiotic ointment) to the wound bed and cover with a clean, dry dressing daily and as needed. Record review of the resident's care plan showed the following: -On 2/12/2020, staff updated the care plan with with venous doppler study was done with; results were negative for DVT (deep vein [CONDITION(S)] - occurs when a blood clot forms in one or more of the deep veins in the body, usually in the legs). Resident did go to wound clinic. Record review of the resident's Wound Management form, dated 2/17/2020 showed the following: -Wound on bottom of left foot; -Measured 1.7 cm x 4.7 cm x .3 cm; -No exudate or odor; -Granulation tissue present. Observation on 2/21/2020, at 9:15 A.M., showed Licensed Practical Nurse (LPN) D provided wound care as ordered to the wound on the resident's left foot. Record review of the resident's quarterly MDS, date 2/25/2020, showed the following: -Severely cognitively impaired; -Required extensive assistance of two staff for bed mobility, -Required total dependence on two staff for transfers, dressing, and personal hygiene; -Range of motion impairment of lower extremity on both sides; -Resident at risk for developing pressure ulcers; -One unhealed Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer; -No venous or arterial ulcers; -Pressure reducing device for bed; -Pressure ulcer care; -Application of nonsurgical dressings other than to feet; -Application of ointments/medications other than to feet. 2. Record review of Resident #1's face sheet showed the following information: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission skin assessment, dated 2/11/2020, showed staff drew circles on a body map indicating the resident's genital area and upper right buttock. Staff labeled the circles as sore/wound/opened on the buttock and redness on the genital area. (Staff did not document measurements, exudate, or further description of the wounds.) Record review of the resident's physicians' orders showed the following: -An order, dated 2/11/2020, for weekly Braden scales and weekly skin assessments. Record review of the resident's baseline care plan, dated 2/13/2020, showed staff care planned the resident needed wound care and needed to be monitored for skin issues. Record review of the resident's physicians' orders showed the following: -An order, dated 2/15/2020, for Pressure Ulcer Prevention Protocol; -An order, dated 2/15/2020, for Wound Care Nurse to See; -An order, dated 2/17/2020, to cleanse coccyx (tailbone) with normal saline, apply calcium alginate and cover with [MEDICATION(S)] daily and as needed (six days after the resident admitted to the facility and staff identified a wound); -An order, dated 2/17/2020, to cleanse right buttock with normal saline, apply calcium alginate, and cover with [MEDICATION(S)] daily and as needed. (Order was received six days after the resident admitted to the facility and staff identified a wound). Record review of resident's TAR showed staff did not perform wound treatments on the resident's wounds between admission on 2/11/2020 and 2/17/2020. Record review of the resident's progress note dated 2/17/2020, at 3:29 P.M., showed the following: -Resident noted to have pressure ulcer to coccyx and right buttock; -Surrounding skin warm and dry and intact to both areas; -Granulation tissue noted to coccyx wound; -Epithelial (thin tissues that cover all exposed surfaces of the body) tissue noted to right buttock; -Treatment orders in place; -Resident tolerated treatment well. Record review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance of two staff for bed mobility, transfers, and personal hygiene; -Resident at risk for pressure ulcers; -One unhealed Stage II pressure ulcer; -One unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer; -Pressure ulcer care. 3. Record review of Resident #2's face sheet showed the following information: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's physicians' orders showed the following: -An order, dated 2/14/2020, for a weekly Braden and skin assessment to be done. Record review of the resident's admission Skin Assessment, dated 2/15/2020 (the day after admission), showed staff drew multiple circles on a body map including the following: -Buttock and coccyx circle - softball shaped breakdown, butterfly shape, Stage I (intact skin with a localized area of non-blanchable [CONDITION(S)] (redness)) or Stage II. (Staff did not document an assessment, measurements, or further description of the wound.) Record review of the resident's physicians' orders showed the following: -An order, dated 2/15/2020, for Pressure Ulcer Prevention Protocol; -An order, dated 2/17/2020, to cleanse coccyx with normal saline, apply Santyl to the upper portion of the wound bed, and cover with [MEDICATION(S)] daily and as needed. (Order received three days after admission and two days after the wound was identified by facility staff.) Record review of the resident's TAR showed staff did not perform wound treatments to resident's wounds between 2/14/2020 and 2/17/2020. Record review of the resident's progress notes, dated 2/17/2020, showed the following: -Resident noted to have pressure wound to coccyx with slough to the upper portion of the wound bed with beefy red tissue present; -The surrounding skin warm, dry, and intact; -Treatment in place and the resident tolerated well. Record review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Required extensive assistance of two staff for bed mobility and transfers; -Required extensive assistance of one staff for personal hygiene; -At risk to develop pressure ulcers; -One unhealed Stage II pressure ulcer; -Pressure ulcer care. Record review of the resident's care plan, dated 2/26/2020, showed the resident was a nutritional risk due to a coccyx wound. 4. Record review of Resident #3's face sheet showed the following information: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Weekly Skin Assessments showed staff completed assessments on 11/23/2019 and 11/26/2019. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely cognitively impaired; -Required extensive assistance of two staff for bed mobility; -Transfer did not occur in the look-back period; -Total dependence of one staff for personal hygiene; -Range of motion impairment of both lower extremities; -At risk for pressure ulcer development; -One Stage II unhealed pressure ulcer; -One unstageable unhealed pressure ulcer; -Pressure ulcer care. Record review of the resident's Weekly Skin Assessments showed staff completed an assessment on 12/13/2019. Record review of the resident's care plan, updated 12/13/2019, showed staff care planned an area to lateral (side) of left foot. Record review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 12/13/2019, to clean left foot wound with normal saline, apply Santyl (a prescription medication ointment that removes dead tissue from wounds) to wound bed (the very bottom of the wound) and cover with [MEDICATION(S)] daily and as needed; -An order, dated 12/15/2019, to cleanse the left foot between 5th and 3rd toe with normal saline, apply triple antibiotic ointment, and cover with gauze daily until healed. Record review of the resident's Weekly Skin Assessments showed staff completed an assessment on 12/16/2019. Record review of the resident's Weekly Skin Assessment, dated 1/18/2020, showed the following: -A check mark on the yes box under wound/open/red area with the phrase left outer ankle red. (Staff completed the assessment four weeks after staff had last documented a skin assessment. Staff did not document any additional information regarding the wound, including size, exudate, or if wounds were improving or declining.) Record review of the resident's Weekly Skin Assessment, dated 1/18/2020, showed the following: -A check mark on the yes box under wound/open/red area and a check mark by foot-left. (Staff completed the assessment four weeks after staff had last documented a skin assessment. Staff did not document any additional information regarding the wound, including size, exudate, or if wounds were improving or declining.) Record review of the resident's Weekly Skin Assessment, dated 1/25/2020, showed the following: -A check mark on the yes box under wound/open/red area and under the description the phrase Left foot has open wound and left 2nd and 3rd toe closed wound with redness around wounds noted, red area noted sacrum (a large triangular bone at the base of the spine)/coccyx area. (Staff did not document any additional information regarding the wounds, including size, exudate, or if wounds were improving or declining.) Record review of the resident's Weekly Skin Assessment, dated 1/26/2020, showed the following: -A check mark on the yes box under wound/open/red area with the phrase, reddened area left outer ankle. (Staff did not document any additional information regarding the wounds, including size, exudate, or if wounds were improving or declining.) Record review of the resident's Weekly Skin Assessment, dated 2/1/2020, showed the following: -A check mark on the yes box under wound/open/red area, with the phrase, left outer ankle. (Staff did not document any additional information regarding the wounds, including size, exudate, or if wounds were improving or declining.) Record review of the resident's Weekly Skin Assessment, dated 2/9/2020, showed the following: -A check mark on the yes box under wound/open/red area with the phrase coccyx, groin area, buttocks, and heels, see treatment orders. (Staff did not document any additional information regarding the wounds, including size, exudate, or if wounds were improving or declining.) Record review of the resident's Weekly Skin Assessment, dated 2/16/2020, showed the following: -A check mark on the yes box under wound/open/red area with the phrase see treatment orders for left foot. (Staff did not document any additional information regarding the wounds, including size, exudate, or if wounds were improving or declining.) Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance of two staff for bed mobility; -Transfer did not occur in the look-back period; -Total dependence of one staff for personal hygiene; -Range of motion impairment for both upper and lower extremities; -At risk for pressure ulcer development; -One unstageable unhealed pressure ulcer; -Three unhealed unstageable pressure ulcers with suspected deep tissue injury; -Pressure ulcer care. 5. Record review of Resident #4's face sheet showed the following information: -admitted on [DATE]; -Latest return on 12/16/2019; -admitted to the hospital on 2/10/2020; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Extensive assistance for bed mobility, transfer, and personal hygiene; -One unhealed unstageable wound. Record review of the resident's physicians' orders showed the following: -An order, dated 11/16/2019, for pressure ulcer prevention protocol; -An order, dated 1/18/2020, for weekly Braden and skin assessments. Record review of the resident's care plan showed the following: -On 11/25/2019, staff updated the care plan with risk for pressure ulcer due to decreased weakness and decreased mobility with recent butterfly shaped area on the sacral/coccyx area with redness and some slough in the middle; -On 11/25/2019, staff updated the care plan with cushion in wheelchair to relieve pressure and maximfloat mattress in bed; -On 11/25/2019, staff updated the care plan with staff will complete a skin assessment weekly and inspect my skin each shift. Record review of the resident's Weekly Skin Assessments showed staff did not document skin assessments between admission on 11/13/2019 and 1/20/2020. Record review of the resident's Skin Integrity Conditions (A) form, dated 1/20/2020, showed the following: -Moisture associated skin damage (MASD) on the coccyx, with a measurement of 5 centimeter (cm) x 4.5 cm. (Staff did not include depth on the measurement.) Record review of the resident's Weekly Skin Assessment, dated 1/20/2020, showed the following: -A check mark on the yes box under wound/open/red area with the phrase open area- MASD to coccyx area. (Staff did not document any additional information regarding the wounds, including size, exudate, or if wounds were improving or declining.) Record review of the resident's physicians' orders showed the following: -An order, dated 1/21/2020, for Triad to moisture associated skin damage around coccyx area every shift and as needed until resolved. The order was discontinued on 1/30/2020. Record review of the resident's Weekly Skin Assessment, dated 1/27/2020, showed the following: -A check mark on the yes box under wound/open/red area with the phrase coccyx/ bilateral buttocks - see treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] (Staff did not document any additional information regarding the wounds, including size, exudate, or if wounds were improving or declining.) Record review of the resident's physicians' orders showed the following: -An order, dated 1/30/2020, to clean coccyx with normal saline, apply Santyl to wound bed and Triad to surrounding areas, and cover with [MEDICATION(S)]. Change daily and as needed; -An order, dated 2/2/2020, to have the wound nurse look at a butterfly area. Record review of the resident's Weekly Skin Assessment, dated 2/3/2020,

Based on interview and record review, the facility staff failed to call emergency medical services and begin cardiopulmonary resuscitation (CPR- an emergency procedure that is performed when a person's heartbeat or breathing has stopped) for two residents (Resident #1 and #2) when the residents were found not breathing and without a pulse. The residents did not have physician's orders [REDACTED]. Facility census was 89. Record review of the facility's policy titled NHC Social Work Services Manual; Section: Clinical Social Work Services; Subject: Advance Directives, dated ,[DATE], showed the following information: -Upon admission the admissions coordinator/social worker will inquire whether the resident has made provisions for advance directives, either in the form of Living Will, Durable Power of Attorney for Health Care or other written instructions; -If the resident's agent does wish to present his/her already prepared advance directive, the social worker will document the patient's wishes in the medical record, and obtain a copy of the patient's document for the medical record and a copy for the financial file; -If the resident expresses interest in advance planning, but has not executed a formal document, the social worker will provide basic written information, note on the social services assessment the patient's need for further clarification, and will follow up with specific assistance an support in carrying out planning to meet the patient's objective; -Do not resuscitate (DNR - CPR is not started if the resident is found not breathing or without a heartbeat) orders on transfer - The admitting nurse will discuss the order with the physician who will determine the advisability of renewing the order. When the order is renewed, the patient/family will verify knowledge of the order and the conversations will be recorded in the progress notes. There may be state-specific DNR forms. Follow state regulations regarding the DNR order process. The DNR order status is reviewed quarterly with the patient and/or legal representative, and if there has been a significant change of status; -Discussion of various treatment options will be held between the physician and the resident or resident's agent whenever the resident's physical condition merits such a discussion. The physician will document in the physician progress notes [REDACTED]. -Any conversations with the resident, persons speaking on behalf of the patient or the physician regarding the communication of decision making processes, including the acceptance or refusal of medical or surgical treatment, shall be documented by the appropriate partner in the medical record as they occur; -Consent for CPR is assumed unless there is a current valid physician's orders [REDACTED]. Record review of the facility's policy titled NHC Policy on the Patient's Right to Self-Determination Including the Right to Formulate Directives in Advance, undated, showed the following information: -In the absence of advance directives, appropriate standards of practice and decision-making protocols will be followed; -A Living Will or other written directive from the patient is not required in order to forego or withhold treatment, including cardiopulmonary resuscitation; -Consent for Cardio [MEDICAL CONDITION] Resuscitation is assumed unless there is a currently valid physician's orders [REDACTED]. 1. Record review of Resident #1's hospital discharge instructions, printed [DATE], showed the following information: -Resident hospitalized from [DATE] to [DATE]; -[DIAGNOSES REDACTED]. -Level of care: Rehabilitation; -Code status: Full code. Record review of the resident's diagnostic problem list, located in the resident's closed medical record, included the [DIAGNOSES REDACTED]. Record review of the resident's living will located in the resident's medical chart, dated [DATE] showed, in part the following: -If the situation should arise in which there is no reasonable expectation of my recovery from physical or mental disability, the resident requested that he/she be allowed to die and not be kept alive by life sustaining procedures, such as, but not limited to, mechanical ventilator (respirator) and tube feedings (food and water delivered through a tube in the vein, nose or stomach). (The living will did not state CPR to be withheld). Record review of the resident's physician order [REDACTED]. Record review of the resident's baseline care plan, dated [DATE], showed staff did not complete the section containing check boxes for CPR, DNR, or advanced directive. Record review of the resident's social service note, dated [DATE], showed the admission's coordinator documented the following: -admitted resident to the facility from the hospital for short-term stay after TIA; -Goal is to return home within 20 days; -Admission completed with resident's family member, who said he/she was the resident's power of attorney (POA). The admissions coordinator requested copies of the POA paperwork; -Resident did not have an advanced directive (legal documents that allow you to spell out your decisions about end-of-life care ahead of time). Record review of the resident's social service note, dated [DATE], showed the care plan coordinator documented the following: -Resident did not know what his/her code status was; -Gave resident a copy of his/her physician order [REDACTED]. Record review of the resident's 5-day Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated [DATE], showed the following: -Moderately impaired cognition; -Resident expected to discharge to the community. Record review of the resident's nurses' notes from [DATE] through [DATE], showed the following information: -On [DATE] at 12:20 P.M., a nurse documented the resident was alert and oriented with confusion. He/She yelled out throughout the shift. The resident transferred himself/herself and walked this shift without calling for assistance. Staff reminded the resident frequently to use his/her call light. The resident participated in ordered therapies and tolerated it well. The resident was able to voice his/her needs and had no complaints; -On [DATE] at 7:30 P.M., Registered Nurse (RN) F documented the resident was confused, restless, cried out, and tried to get out of the wheelchair. Staff administered anti-anxiety medication to the resident with no change in behavior; -On [DATE] at 11:00 P.M., RN F documented the resident continued to moan and yell, and was restless and confused. His/Her vital signs were stable. He/She sat at the nurses' station. Staff administered anti-anxiety medication to the resident. -On [DATE] at 1:00 A.M., RN F documented the resident was slightly calmer. Staff assisted him/her to bed. He/She had oxygen on. The nurse would continue to monitor. -On [DATE] at 2:00 A.M., RN F documented a Certified Nurse Aide (CNA) checked on the resident and called this nurse to the room. The resident had no respirations and no heart tones. The RN asked Licensed Practical Nurse (LPN) J for a second opinion and he/she also heard no heart tones. Staff notified the physician, family and funeral home. (Staff did not document starting CPR.) During an interview on [DATE] at 10:30 A.M., the Social Service Director (SSD) said when staff admitted a resident to the facility, the admission coordinator determined the resident's code status, communicated the information to nursing and documented the conversation in the social service notes. During an interview on [DATE] at 10:43 A.M., Care Plan Coordinator I said the following: -On [DATE], he/she met with the resident and conducted an orientation meeting; -During the meeting, the resident said he/she did not know his/her code status; -The care plan coordinator did not remember if he/she told anyone about the resident's code status, but he/she may have verbally communicated the information to one of the nurses; -The admitting nurse was responsible for establishing the resident's code status on admission. During an interview on [DATE] at 11:10 A.M., RN F said the following: -He/She worked from 6:00 P.M. to 6:00 A.M. on the night of [DATE] to [DATE]; -During report, the day nurse said the resident had been agitated and more confused. He/She called the physician and obtained orders for labs and an anti-anxiety medication twice daily for agitation; -The resident continued to be agitated and restless on the evening of [DATE], so he/she kept the resident in a wheelchair at the nurse's desk; -Around 11:00 P.M., he/she administered the anti-anxiety medication to the resident and eventually the resident calmed down and became sleepy; -He/She and Certified Medication Technician (CMT) K assisted the resident to bed; -The CMT checked on the resident shortly after that and called RN F to the room. The resident had passed away; -RN F said the resident's body was still warm to touch, but the resident appeared blue around his/her mouth and fingertips. The resident was a no code. The RN asked the nurse supervisor LPN J to verify the resident's death approximately five minutes later; -RN F determined the resident's code status by reviewing white papers clipped together in the resident's chart. The papers indicated the resident did not want certain measures taken, including CPR; -RN F said in that type of facility, he/she just kind of assumed all residents have do not resuscitate orders. During an interview on [DATE] at 1:00 P.M., LPN L said the following: -He/She admitted the resident to the facility on [DATE]; -A resident's code status is usually in the paperwork from the hospital; -A nurse must obtain a DNR order from the resident's physician; -The nurse should document the code status of the resident on his/her physician's orders [REDACTED].>-The resident did not have code status orders on admission; -If a resident did not have a DNR order, then the resident is considered a full code; -The facility was working on placing stickers in the front of the chart to indicate the resident's code status, but not all resident charts have the stickers. During an interview on [DATE] at 2:25 P.M., the Admission Coordinator said the following: -She was responsible for asking if residents have a durable power of attorney (DPOA) or advance directive on admission; -The admitting nurse or SSD were typically responsible for establishing the resident's code status; -After reviewing the resident's admission paperwork, the Admission Coordinator said the resident had a full code order from the hospital. During an interview on [DATE] at 4:05 P.M., the Director of Nursing (DON) said the following: -Depending on when the facility admitted a resident, either the admitting nurse or the care plan coordinator was responsible for establishing a resident's code status; -During the week (Monday-Friday), the care plan coordinator was responsible for asking the resident his/her code status. Once the code status is established, facility nurses obtain a physician's orders [REDACTED]. -On the weekend, the admitting nurse was responsible for establishing the resident's code status; -Additionally, Care Plan Coordinator I worked Saturday and Sunday and completed a base line care plan on all newly admitted residents. He/She discussed code status with the resident at that time; -If a resident does not have a DNR order, the nurse should assume the resident is a full code. During an interview on [DATE] at 6:00 P.M., RN F reviewed the resident's medical record in an attempt to find the documentation he/she viewed on the night the resident passed away that led him/her to the decision not to perform CPR on the resident. RN F said the night the resident passed away, he/she initially checked the physician order [REDACTED]. The RN then reviewed the rest of the resident's record and could not find a DNR order. The nurse reviewed the resident's living will with the surveyor and said the living will did not look like the document he/she saw the night the resident passed away, but he/she saw no other documents in the record pertaining to the resident's end of life wishes. RN F said he/she asked the nurse supervisor LPN J to check the resident and LPN J listened for heart tones. During an interview on [DATE] at 1:40 P.M., the resident's physician said the following: -The admitting nurse should use the hospital discharge instructions for facility admission orders [REDACTED] -The nurses generally documented the code status in the medical record; -The facility nurses should verify the resident code status with the physician, but they have not been doing so; -The facility nurses should administer CPR to the resident if the resident did not have a DNR order; -The facility nurses should perform CPR on a resident when the resident's body is still warm to touch; -The physician did not think the nurses informed him/her of the resident's death until the following day; -If a resident was a full code, nurses should start CPR immediately and call Emergency Medical Services (E[CONDITION]); -Nurses should continue CPR until E[CONDITION] takes over, and notify the resident's physician and family of the situation. During an interview on [DATE], at 4:35 P.M., CMT K said the following: -He/She worked the night the resident passed away ([DATE] to [DATE]); -CMT K asked RN F to send the resident out to the hospital for evaluation, but RN F informed the CMT there was nothing the hospital could do for the resident; -CMT K and RN F kept the resident up in a chair at the nurse's desk and talked with the resident. Later they assisted the resident to bed; -At approximately 2:00 A.M., the CMT checked on the resident and found the resident deceased . The resident's body was still warm to touch and showed no signs of mottling (blotchy, red-purplish marbling of the skin); -The CMT immediately got the nurse; -RN F asked the CMT if the resident was a full code, the CMT replied that he/she did not know; -RN F checked the resident's chart and said the resident was not a full code; -CMT K asked RN F if he/she was sure of the resident's code status and he/she replied yes. 2. Record review Resident #2's diagnostic problem list, located in his/her closed medical record, showed [DIAGNOSES REDACTED]. Record review of the resident's SSD quarterly note, dated [DATE] and signed [DATE], showed the following: -Resident was a long-term resident and had a guardian due to his/her inability to live independently; -He/She was a full code; -He/She was cognitively intact. Record review of the resident's monthly nursing summary report, dated [DATE], showed the following: -Alert and oriented; -Walked ad lib (as much and as often as desired); -Independent with activities of daily living (ADLs); -Able to voice needs. Record review of the resident's physician order [REDACTED]. Record review of the resident's physician progress notes [REDACTED]. -No complaints; -No chest pain or shortness of breath. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Cognitively intact; -Required staff supervision with bathing; -Independent with all other activities of daily living. Record review of the resident's nurses' notes, dated [DATE], showed LPN D documented the following: -At 1:10 A.M., the resident expired. He/She was walking and talking to this nurse, went to his/her room, and a few minutes later said he/she could not breathe. Staff checked the resident's pulse oximetry (pulse ox - an electronic device that measures the saturation of oxygen carried in your red blood cells (normal pulse ox level was ,[DATE]%)) which was [AGE]%. While staff obtained an oxygen concentrator for the resident, the resident went to his/her room, sat on the bed and expired; -At 1:30 A.M., the nurse notified the DON and resident's family, and called the resident's physician for an order to release the body to a funeral home; -At 2:00 A.M., the resident's family member called and told the nurse to contact the guardian in the morning and to notify the family member with what the guardian said. (The nurse did not document an assessment of the resident for presence or absence of respirations or pulse. Staff did not document beginning CPR.) Record review of the document titled, [LOCATION] Coroner Death Information Form, undated, showed the following: -Decedent name = Resident #2; -Person discovering death = LPN D; -Pronouncement of death on [DATE] at 1:10 A.M. by LPN D; -Circumstances = Resident discovered with no pulse and no respirations; -Condition of body = No trauma. During an interview on [DATE] at 11:10 A.M., RN F said the following: -On the night of [DATE] to [DATE], LPN D walked down the hall where RN F was working and asked if RN F would listen to the resident's heart tones. When RN F entered the resident's room, the resident was lying on his/her back in bed. RN F assessed the resident with a stethoscope and heard no heart tones and no respirations. RN F asked LPN D what the resident's code status was. LPN D did not know and left the room to look for the resident's code status in the his/her chart; -LPN D reviewed the resident's chart and said the resident was a full code. RN F said Well, what are we going to do? LPN D was unsure of what to do. RN F suggested asking a third nurse (RN E), what to do. The two nurses asked RN E to assess the resident. -After RN E assessed the resident, he/she said, since the facility did not have a defibrillator (a device that restores a normal heartbeat by sending an electric pulse or shock to the heart), it would not do any good to start CPR. The three nurses decided not to provide CPR to the resident. -RN F said he/she did not notice any discoloration to the resident's normal skin tone and did not observe any rigor mortis (stiffening of the joints and muscles of a body that occurs a few hours after death.) RN F did not contact the DON, administrator, or resident's physician during this time. During an interview on [DATE] at 12:33 P.M., LPN D said the following: -The resident was normally pleasant and walked everywhere. He/She was also independent with ADLs; -On the night of [DATE] to [DATE], LPN D worked as the resident's nurse; -The resident came out of his/her room sometime late in the night on [DATE] to [DATE] and said he/she could not breathe. The nurse obtained the resident's pulse ox and the result was in the [AGE]'s; -The nurse told the resident he/she would be right back with oxygen. The LPN found an oxygen concentrator in a nearby vacant resident room; -CNA G offered to assist the nurse. He/She entered the resident's room with the oxygen concentrator and found the resident had expired. CNA G yelled for the nurse to come to the resident's room. LPN D entered the resident's room, listened for the resident's heart tones and respirations, but there were none. The resident's body was warm. -Two to three minutes prior to finding the resident dead, the resident was walking around; -LPN D asked two more nurses (RN E and RN F) to assess the resident. RN F arrived in the resident's room approximately 2 minutes later and RN E arrived approximately two minutes after that. Both RNs confirmed the resident had no signs of life. The LPN D asked the other two nurses to assess the resident because they were RNs and the LPN wanted the correct opinion; -At some point, LPN D checked the resident's code status and determined the resident was a full code; -LPN D and the other two nurses decided not to perform CPR. They (LPN D, RN E, and RN F) checked the resident and decided the resident was expired. LPN D said there was no point in doing CPR because the resident had no signs of life. -LPN D contacted the resident's family and called the physician for orders to release the body to the funeral home; -LPN D said the following day (LPN did not remember exact date-[DATE] or [DATE]) the DON and administrator asked him/her to describe what happened. The DON told the LPN to always call the paramedics. During an interview on [DATE] at 12:38 P.M., CNA G said the following: -On the night of [DATE] to [DATE], LPN D informed him/her the resident was having a hard time breathing. The nurse told the resident to sit on his/her bed and went to get an oxygen concentrator for the resident; -After answering a resident's call light, the CNA saw LPN D sitting at the nurse's desk attempting to put oxygen tubing together. The LPN said he/she forgot the bubbler (a water bottle used to humidify the oxygen); -The CNA offered to take the oxygen concentrator to the resident, after he/she brought another resident a pitcher of ice water. When the CNA walked past the resident's room, heading towards the other resident's room, Resident #2 was sitting on the side of the bed. Approximately one to two minutes later, the CNA entered the resident's room with the oxygen concentrator and found the resident lying slightly crossways on the bed with his/her lower legs and feet hanging off the side of the bed. Upon entering the room, the CNA heard the resident exhale loudly. The CNA yelled for the nurse and attempted to straighten the resident up in bed. LPN D came immediately into the resident's room; -LPN D looked at the resident and listened to his/her chest with a stethoscope, then told the CNA the resident had expired. LPN D asked the CNA to get help to verify the resident's death; -The CNA went to another hall and asked RN F to assess the resident. RN F also checked the resident with a stethoscope; -The CNA then left the resident's room to answer call lights; -The CNA said a few minutes later, a third nurse, RN E, also came to check the resident; The CNA said the nurses did not mention the resident's code status while he/she was present in the room. During an interview on [DATE], at 4:05 P.M., the DON said the following: -It was his/her understanding the resident was a full code, but LPN D did not start CPR on the resident. LPN D called two additional nurses, RN F and RN E, for assistance; -The DON said on the morning of [DATE], a day shift nurse working at the facility notified her, via telephone, of the situation, because he/she (the DON) was out of the facility the day ([DATE]) the resident passed away; -After the nurse reported the situation to the DON, the DON subsequently started interviewing the three nurses involved. LPN D said the resident came out of his/her room and complained of shortness of breath. The LPN told the resident to sit down and retrieved an oxygen concentrator, not in use, from a nearby resident room. When LPN D returned to the room, approximately three minutes later, the resident had no heart tones or respirations. LPN D asked RN F to confirm the resident's death. RN F agreed the resident had passed away. LPN D then called over RN E to check the resident. RN E examined the resident's pupils and said they were blown (a term that usually means the pupil of one eye is larger than the other). LPN D asked RN E and RN F if he/she should call the physician and they both answered yes; -LPN D said he/she knew the resident was a full code; -RN E and RN F told the DON they knew the resident's code status when they checked the resident; -The DON asked why the nurses did not initiate CPR. LPN D said RN E and RN F told him/her the resident was already gone. RN F said he/she did not think it (CPR) was a decision he/she could make, because he/she did not know the resident well enough. RN E said he/she did not think CPR would do any good because the facility did not have an AED (automated external defibrillator) and the resident's pupils were blown; -RN E said he/she did not know if a resident had passed away that he/she should still initiate CPR. During an interview on [DATE] at 1:40 P.M., the resident's physician/facility medical director said he did not think the facility notified him the night the resident passed away. He/She was surprised of the resident's death, because the resident had no signs or symptoms of any problems. During an interview on [DATE] at 1:40 P.M., the resident's physician/facility medical director said the following: -Some of his/her responsibilities included overseeing facility protocols, including DNR status; -If an emergency occurred at the facility, the nurses were supposed to call the physician or call the hospital and the hospital will get in touch with the physician; -Facility staff should call Emergency Medical Staff (E[CONDITION]), start CPR, and continue CPR until E[CONDITION] arrived and they should call the family and the physician; -Facility nurses should start CPR on any resident who did not have a DNR order; -Facility nurses should start CPR on a resident who was a full code, when the resident's body was still warm. During an interview on [DATE] at 3:05 P.M., RN E said the following: -On [DATE], at approximately 12:30 A.M., he/she observed LPN D and RN F walking through the center of the building. The two nurses asked RN E to follow them to the resident's room. RN E assessed the resident and found no carotid pulse, no chest rising, no movement, no breathing and his/her pupils were dilated to ,[DATE] millimeters; -After looking at the resident and verifying he/she had passed away, LPN D mentioned the resident was a full code. LPN D asked if he/she should call the physician. RN E told the LPN D yes. LPN D went to the nurse's desk to call the physician; -RN E said the nurses did not discuss whether CPR should be initiated or not. He/She thought the other nurses just wanted him/her to verify the resident's death; -RN E did not think it was worth breaking the resident's breast bone at that point to perform CPR, especially since the facility did not have a defibrillator (AED); -At the time RN E assessed the resident, his/her body was warm to touch, his/her joints were still pliable and he/she was not in rigor mortis; -After this situation happened, the DON printed out papers regarding when to initiate CPR. The DON also informed the RN that residents have the right to be a full code. During an interview on [DATE] at 2:30 P.M., Certified Medication Technician (CMT) A said staff can locate the code status of a resident on a sticker under the front cover of the resident's chart which should indicate whether the resident is a full code or DNR. Staff can also look at the physician's orders [REDACTED]. If the staff do not find a DNR order or form in the resident's chart or the physician has not signed the DNR form, staff should treat the resident as a full code status and begin resuscitation efforts. CMT A said if a resident has no pulse and is not breathing then staff should verbally call for help, page code blue, and check the resident's code status. If the resident is a full code then a CPR certified staff should start chest compressions. Staff should continue CPR until E[CONDITION] arrives and takes over the code. CMT A said Resident #1 and Resident #2's deaths were unexpected and Resident #1 was admitted to the facility for rehabilitation and was planning to return home after therapy. During an interview on [DATE], at 3:00 P.M., CNA B said staff can locate the code status of a resident in the Medication Administration Record [REDACTED]. CNA B said he/she has a paper that he/she keeps on his/her person that lists the code status of every resident on his/her assigned hall and there is a list that is located on the back of the 24 hour report binder that is updated weekly. CNA B said the nurse will alert the CNAs when a resident's code status changes. CNA B said if a resident is not breathing and has no pulse the CNA would notify the nurse by paging the nurse to the hall. If staff were not sure of the resident's code status then they would check first. If the resident is a full code the staff should call E[CONDITION], start chest compressions, and continue CPR until E[CONDITION] arrives and takes over. CNA B said if a resident was clearly deceased staff should still start chest compressions. CNA B said he/she worked with Resident #2 and his/her death was unexpected. CNA B said he/she did not receive an inservice on code status, but thinks there were a couple. During an interview on [DATE] at 3:30 P.M., LPN C said staff can locate the code status of a resident on a sticker under the front cover of the resident's chart which should indicate whether the resident is a full code or DNR. Staff can also look at the physician's orders [REDACTED]. LPN C said when they receive a signed DNR form from a resident the nurse should immediately fax it to the physician for his/her signature and he/she should fax it right back to the facility. LPN C said when the nurse admits a resident from the hospital they are expected to call the physician to verify the orders including medications and code status. LPN C said even if the resident admits from the hospital with a DNR the code status must be verified with the physician. If a resident does not have orders for a DNR status from the physician then the resident is considered to have a full code status. LPN C said if he/she assesses a resident and the resident is not breathing and has no pulse, then the nurse should stay with the resident and the CMT should look in the resident's chart to check code status. LPN C said the CMT could also look on the back of the book labeled Nursing Documentation and it has the code status of all the resident's on that hall. The night nurses update the code status every night on the Nursing Documentation book and check charts for new orders and make sure the code status' match. LPN C said if the resident was a full code then the nurse should delegate staff to call E[CONDITION] and keep record of time. He/She would start chest compressions and continue until E[CONDITION] arrives and takes over. Staff should not stop CPR once a full code is started. LPN C said the facility had a code status/CPR inservice the week prior. NOTE: At the time of the abbreviated 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. During the onsite visit, the facility started a medical record audit, implemented a new process to identify residents' code status, and started inservices of staff on the new process and CPR policy. A final revisit will be conducted to determi

Based on interview and record review, the facility failed to ensure that one resident (Resident #1) remained free of significant medication errors when staff administered three doses of [MEDICATION NAME] (an antianxiety medication), ordered to be administered twice daily, to the resident in an approximately five hour period of time. A sample of five residents was selected for review. The facility census was 89. Record review of the facility's policy titled Medication Orders, revised November 2014, showed the following: -The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders; -When recording orders for medication, specify the type, route, dosage, frequency, and strength of the medication ordered; -When recording as needed (PRN) medication orders, specify the type, route, dosage, frequency, strength, and the reason for administration. Record review of the facility's policy titled Adverse Consequences and Medication Errors, revised April 2014, showed the following: -The staff and practitioner shall strive to minimize adverse consequences by: Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; -A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders [REDACTED]. Record review of the facility's policy titled Administering Medications, revised December 2012, showed the following: -Medications shall be administered in a safe and timely manner, and as prescribed; -Medications must be administered in accordance with the orders, including any required time frame; -The individual administering the medication must initial the resident's medication administration record (MAR) on the appropriate line after giving each medication and before administering the next ones; -As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: The date and time the medication was administered; the dosage; the route of administration; any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed; and the signature and title of the person administering the medication. 1. Review of Resident #1's hospital discharge instructions, printed on 2/01/19, showed, in part, the following: -Resident hospitalized from [DATE] to 2/01/19; -[DIAGNOSES REDACTED]. -Level of care: Rehab. Record review of the resident's diagnostic problem list showed [DIAGNOSES REDACTED]. Record review of the resident's 5-day Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 2/08/19, showed the following: -Moderately impaired cognition; -No behaviors; -Resident expects to discharge to the community. Record review of the resident's nurse note, dated 2/09/19, at 12:20 P.M., showed the following: -Alert and oriented with confusion noted; -Yells out throughout the shift; -Has been transferring self and ambulating this shift without calling for assistance; -Reminded frequently to use call light; -No complaints noted; -Will continue to monitor. Record review of the resident's physician order [REDACTED]. Record review of the facility's narcotic E-kit (emergency medications) administration/transfer record showed the following: -On 2/09/19 at 5:45 P.M., Licensed Practical Nurse (LPN) M signed out one [MEDICATION NAME], 0.5 mg, tablet for the resident; -On 2/09/19 at 9:30 P.M., Registered Nurse (RN) F signed out one [MEDICATION NAME], 0.5 mg, tablet for the resident. Record review of the resident's medication administration record (MAR) showed the following: -An order dated 2/9/19 for [MEDICATION NAME] 0.5 mg, one tablet twice daily as needed; -Administration of [MEDICATION NAME] initialed twice on 2/09/19 by RN F; -The nurse did not document specific times of administration or effectiveness on the MAR. Record review of the resident's nurse note dated 2/09/19, at 7:30 P.M., showed RN F documented the following: -Resident confused, restless, crying out, and trying to get out of the wheelchair; -High fall risk; -[MEDICATION NAME] 0.5 milligram (mg) given per physician orders; -No change in behavior; -Will continue to monitor. Record review of the resident's nurse note dated 2/09/19, at 11:00 P.M., showed RN F documented the following: -Resident continues to be restless, moaning out, yelling, confused; -Incontinent of bowel and bladder, taken into the bathroom and cleaned; -Vital signs stable; -Sitting at nurse's station; -[MEDICATION NAME] 0.5 mg given. Record review of the resident's nurse note dated 2/10/19, at 1:00 A.M., showed RN F documented the following: -Slightly calmer; -Assisted to bed with oxygen on; -Will continue to monitor. During an interview on 3/06/19, at 11:10 A.M., RN F said the following: -He/She worked from 6:00 P.M. to 6:00 A.M. shift on the night of 2/09/19 to 2/10/19; -During report, the day nurse, LPN L, said the resident had been agitated and more confused; -LPN L reported calling the physician and obtaining orders for labs and [MEDICATION NAME], 0.5 mg. twice daily for agitation; -The resident continued to be agitated and restless on the evening of 2/09/19, so RN F kept the resident in a wheelchair at the nurses' desk; -He/She gave the resident two separate doses of [MEDICATION NAME], the last dose at around 11:00 P.M., and eventually the resident calmed down and became sleepy; -He/She and Certified Medication Technician (CMT) K assisted the resident to bed. During an interview on 3/06/19, at 1:00 P.M., LPN L said the following: -LPN L worked 6:00 A.M. to 6:00 P.M. shift on 2/09/19; -During the day on 2/09/19, the resident was alert and oriented part of the day and confused part of the time; -The resident frequently tried to transfer him/herself out of the wheelchair and was yelling out; -Sometime during the day, the nurse said LPN M spoke to the resident's physician and obtained an order for [REDACTED].>-LPN L said he/she then documented the order on the physician order [REDACTED].>-LPN L gave the resident an [MEDICATION NAME] 0.5 mg tablet right before leaving for the day around 6:00 P.M.; -LPN L said she did not transcribe the order onto the MAR and did not initial or document the administration of the [MEDICATION NAME] to the resident; -After reviewing the narcotic E-kit administration/transfer record, LPN L said he/she did not sign out the dose, but instead had LPN M sign for and obtain the [MEDICATION NAME] at 5:45 P.M. from the E-kit; -LPN L said LPN M handed him/her the [MEDICATION NAME] pill in a medication cup and LPN L administered the medication to the resident. During an interview on 3/07/19, at 2:30 P.M., LPN M said the following: -On the evening of 2/09/19, he/she took the resident out of the dining room sometime between 4:30 P.M. and 5:30 P.M. to the resident's hall, because the resident was trying to get out of his/her chair and was not safe; -LPN M told LPN L the resident was having anxiety; -LPN M said he/she and LPN L assisted the resident to bed, because the resident complained of not feeling well; -LPN M said he/she then spoke to the resident's physician on the phone and obtained orders for [MEDICATION NAME] and labs and wrote the orders on a piece of paper and handed the paper to LPN L; -LPN M said he/she then pulled an [MEDICATION NAME] tablet from the E-kit and handed the medication to LPN L to administer to the resident; -LPN M did not believe he/she documented administration of the resident's [MEDICATION NAME]. During an interview on 3/07/19, at 4:05 P.M., the Director of Nursing (DON) said the following: -If a physician orders [REDACTED]. -If the resident's symptoms were not relieved by the first [MEDICATION NAME] dose, the nurse should have called and notified the physician. During an interview on 3/07/19, at 6:00 P.M., RN F said he/she administered two doses of [MEDICATION NAME], 0.5 mg, to the resident, one near the beginning of his/her shift at around 7:30 P.M. and another dose at around 11:00 P.M. RN F said the day nurse called and obtained the order for the resident's [MEDICATION NAME], but did not inform RN F that he/she administered a dose of [MEDICATION NAME]. During an interview on 3/08/19, at 1:40 P.M., the resident's physician said the following: -The physician saw the resident on the night of admission, 2/01/19; -The physician said nurses should not administer [MEDICATION NAME], 0.5 mg, twice daily as needed for anxiety two or three times in one evening; -The physician said he expected nurses to give the medication once in the morning and once in the evening at the most, when ordered twice daily; -The physician said nurses administering two to three doses of the [MEDICATION NAME] in a five hour period of time could have a sedative effect on the resident. During an interview on 3/08/19, at 4:35 P.M., CMT K said the following: -He/She worked the night the resident passed away (2/09/19 to 2/10/19); -The resident exhibited increased confusion; -CMT K said he/she and RN F kept the resident up in a chair at the nurse's desk and talked with the resident; -CMT K said they later assisted the resident to bed when the resident became drowsy. MO 587

Based on interview and record review, the facility failed to assess, monitor, and notify the physician to obtain emergency medical treatment orders, and provide medical treatment in a timely manner for one resident (Resident #1) who facility staff found in an unresponsive state for unknown length of time who did not respond to the medical treatment provided by facility staff for an extended period of time. The resident had critically low blood glucose levels that did not respond to medication resulting in admission to the critical care unit of the hospital. A sample of five residents was selected for review in a facility with a census of 94. Record review of the facility policy, revised (MONTH) 2011, titled Nursing Care of the Resident with Diabetes Mellitus, showed the following information: -Signs and symptoms of [DIAGNOSES REDACTED] (blood glucose below reference ranges) included the more severe symptoms of stupor, unconsciousness and/or convulsions and coma. -If these or other abnormal conditions exist, notify the physician; -Normal blood glucose ranges are approximately 70-130 milligrams per deciliter (mg/dl) before meals; -Approximate blood glucose reference ranges for [DIAGNOSES REDACTED] are mild ranging from 55-70 mg/dl, moderate ranging from 40-55, and severe less than 40 mg/dl.; -Management of [DIAGNOSES REDACTED] for symptomatic and unresponsive residents with [DIAGNOSES REDACTED] (less than 70 mg/dl or less than the physician-ordered parameter), immediately administer oral glucose paste ([MEDICATION NAME]) to the [MEDICATION NAME] mucosa (mouth), intramuscular [MEDICATION NAME], or IV 50% [MEDICATION NAME], per facility protocol and notify the physician for further orders. If the resident remains unresponsive, call 911, remain with the resident, monitor vital signs, and hold all diabetic medications. -Documentation should reflect the carefully assessed diabetic resident and include vital signs as ordered, level of consciousness, assessment of the skin, including color, moisture, and temperature. Record review of the facility policy titled, Regarding Change in Patient Status showed the following information: -The charge nurse on duty is notified immediately of any change in a patient's condition. The charge nurse will then assess the patient's condition and notify the physician or physician extender and the patient's family/legal representative. -The patient may not be transferred to the hospital without first notifying the family unless to delay would be harmful to the patient. If unable to contact the family, the patient will be transferred per doctor's orders and efforts to reach the family will be continued and documented. -In emergency situation, the charge nurse will: 1. Render appropriate care to the patient, pending communication with the physician or physician extender. 2. Notify the physician or physician extender. 3. Notify the family or legal representative. 4. Transfer the patient if and as appropriate. 5. In the event of an acute change in medical condition and the attending and/or alternate physician are unavailable, the nursing partners will take the steps necessary to assure appropriate medical intervention. -Care of critically ill patient/significant change in medical condition. -When a significant change in medical condition has occurred or the patient is assessed to be critically ill, the attending physician will be notified immediately. Should the attending physician or physician extender not be available, the alternate physician will be notified. 1. Record review of Resident #1's admission summary sheet, showed the resident admitted to the facility on [DATE] at 4:45 P.M., with the following Diagnoses: [REDACTED]. -Chronic [MEDICAL CONDITION]; -[MEDICAL CONDITIONS]; -Long term use (Current) use of inhaled steroids; -Type 2 diabetes mellitus (DM) with diabetic [MEDICAL CONDITION]. Record review of the resident's nurse's notes, showed the resident admitted to the facility on [DATE] at 4:45 P.M. Staff did not document any additional nurses' notes on 8/8/17. Record review of the physician's history and physical, dated 8/8/17, showed the following information: -Resident alert and oriented, no cognitive deficit; -Full code status. Record review of the physician order sheet (POS), dated 8/8/17 through 8/14/17, included the following orders: -Full code status; -Regular diet; -Accucheck(blood sugar check) before meals and at bedtime; -Sliding scale insulin humalog (dose B); -Continue BPAP (Bilevel Positive Airway Pressure, a non-invasive form of therapy for patients suffering from sleep apnea) from 9:00 P.M. until 6:00 A.M. -The POS did not contain any orders to follow any protocol for [MEDICATION NAME] (medication used to treat severe [DIAGNOSES REDACTED]) administration in case of emergency or any parameters of when to notify the physician. Record review of an (undated) generic POS, located in the resident's chart, showed the following information regarding insulin sliding scale and accucheck protocols: -If staff complete a fingerstick glucose and the level is less than 60, staff should call the physician. If the resident is unable to swallow, is to have nothing by mouth (NPO), or is not alert, administer 12.5 grams [MEDICATION NAME] 50% water intravenously or 1 milliliter (ml) [MEDICATION NAME] intramuscularly (IM) or intravenous push (IVP); -If the glucose level is less than 40, treat as above. Draw STAT (immediate) laboratory blood glucose and call the physician; -If the level is less than 60, and resident is alert and able to swallow, Step 1: give four ounces of orange juice or soda, or one cup of skim milk. Wait 15 minutes and recheck blood glucose. If blood glucose is still less than 60, repeat step 1 and recheck in 15 minutes. If it is greater than 60, and it is time for a meal, feed the resident. If it will be greater than 30 minutes before the meal, proceed with Step 2. Step 2: If the blood glucose is greater than 60, treat with 6 saltine crackers and one tablespoon of peanut butter or 6 saltine crackers and a slice of cheese. -Insulin sliding scales for amounts of insulin to administer for elevated blood glucose levels. Record review of the resident's admission care plan, dated 8/8/17, showed the following information: -Staff to assist resident with transfers by pivot and gait belt; -Resident will accept toileting help every 1-2 hours; -Potential for weight loss; -Diet as ordered; -Weight every week for four weeks; -Observe eating patterns; -The care plan did not address interventions or a problem regarding blood glucose monitoring and treatment for [REDACTED]. Record review of the resident's current medication/treatment administration record, for admitted [DATE], showed the following information: -Staff did document any treatment order for completing accuchecks before meals and at bedtime. -Staff did not document completing any accuchecks on 8/8/17 or 8/9/17; -The record did not include orders for administration of [MEDICATION NAME]; -Staff did not document administration of [MEDICATION NAME] on 8/8/17 or 8/9/17. Record review of the (undated) multi-resident BM/VOID monitoring sheet that includes a resident's blood glucose level showed the following information: -Unknown staff documented undated/untimed entries of the following numbers: 23, 27, 47, 49, 43, 50, 37 for this resident (normal level would be 70-100 milligrams per deciliter (mg/dl); -At 8:30 A.M., unknown staff documented administration of Gluc ([MEDICATION NAME]) #2 for this resident; -At 8:43 A.M., staff documented 35; -At 8:50 A.M., staff documented 55; -At 9:04 (A.M.), staff documented 43; -At 9:20 A.M., staff documented 47; -At 9:40 A.M., staff documented 35; -At 9:50 A.M., staff documented Gluc ([MEDICATION NAME]); -At 10:10 A.M., staff documented 44. During an interview on 8/11/17, at 12:30 P.M. Licensed Practical Nurse (LPN) E said he/she found Resident #1 unresponsive around 7:30 A.M. and took the resident's blood glucose. The initial reading showed a level of 23, so LPN E gave the resident an IM (intramuscular, placing the medication into the muscle tissue) injection of [MEDICATION NAME] 1.0 mg. He/she rechecked the resident's blood glucose six more times (no times noted on record) with readings of 27, 47, 49, 50, 37 before 8:30 A.M. when at that time he/she administered a second dose of [MEDICATION NAME]. LPN E checked the resident's blood glucose five more times with readings of 35, 55, 43, 47 and 35. LPN E administered a third dose of [MEDICATION NAME] at 9:50 A.M. LPN E said the resident's family member arrived in the facility around 10:00 A.M. Record review of the resident's nurses' notes, showed the following information: -On 8/9/17 at 10:10 A.M., the nurse documented the resident's family member at the facility. The nurse informed the family member of the resident's low blood glucose levels that morning. Blood glucose checked multiple times. It would increase and then go back down. The resident's original blood glucose this morning was 23. [MEDICATION NAME] administered intramuscularly (IM) three times with little to no improvement. Nurse informed family member the resident should be sent to the emergency room due to the inability to stabilize the resident's blood glucose. Family member agreed. -On 8/9/17 at 10:20 A.M., the nurse called the ambulance for emergency transport to the emergency room . -On 8/9/17 at 10:30 A.M., ambulance here. Resident's blood glucose level reads as 30. -On 8/9/17 at 10:35 A.M., resident left facility via ambulance for transport to emergency room ; -From 8/8/17 at 4:45 P.M., through the time the resident left the faciity on [DATE] at 10:35 A.M., staff did not document notification of the physician regarding clarification of orders, notification of the resident's change in condition, or the resident's transfer to the hospital. During an interview on 8/11/17, at 1:15 P.M., LPN E said Resident #1's only response to him/her involved pulling his/her arm away when touched. Resident #1 never became responsive between the time of the first blood glucose check and [MEDICATION NAME] administration at 7:30 A.M. and the arrival of the EMS at 10:30 A.M. Record review of the emergency department provider notes, dated 8/9/17, showed the following information: -Resident presented to the emergency department via EMS due to complaints of [DIAGNOSES REDACTED]; -Physical exam showed the resident oriented to person, place, and time. Resident poorly responsive, moaning. Pupil reaction sluggish bilaterally. -Clinical impression final Diagnoses: [REDACTED]. During an interview on 8/11/17 at 11:25 A.M., LPN A said if he/she had a resident with a low blood glucose, he/she would make sure the resident would have [MEDICATION NAME] (a medication that is injected to reverse low blood glucose). LPN A would contact the physician. If the resident was able to drink the nurse would give the resident juice to drink. During an interview on 8/11/17 at 11:35 A.M., LPN B said if he/she had a resident with a low blood glucose, he/she would recheck the blood glucose and check for physicians orders, give juice and recheck blood glucose and call the physician. If the blood glucose continued to be low, LPN B would call the physician and send the resident to the hospital. If a resident was unresponsive, he/she would call the physician and send the resident to the emergency room . During an interview on 8/11/17 at 12:10 P.M., LPN C said if he/she had a resident with a low blood glucose and was unresponsive LPN C would check for a [MEDICATION NAME] order and call the physician or call 911 if he/she had to. During an interview on 8/11/17, at 12:20 P.M., Certified Medication Technician (CMT) D said if he/she had a resident with a low blood glucose, CMT D would get the nurse and they would try juice or jelly if possible. If the resident was not able to take juice or jelly, the nurse would give the resident a shot of [MEDICATION NAME]. CMT D said it would be up to the charge nurse to notify the physician. During an interview on 8/11/17 at 12:55 P.M., the Director of Nursing (DON) said the facility policy and guideline is that physician notification is the standard. The DON would expect staff to stabilize the resident first before calling the physician. She believes LPN E should have called the physician sooner. The DON could not provide a copy of the policy for treating [DIAGNOSES REDACTED] until a phone call was placed to the corporate consultant nurse who e-mailed a copy of the guidelines to the facility. During a telephone interview on 8/11/17 at 1:50 P.M., the resident's physician and the facility medical director said if he had been contacted by the facility he would have advised them to start an IV (intravenous line that allows medications and fluids to be administered directly into the bloodstream) and run [MEDICATION NAME] (concentrated sugar medication used to reverse low blood sugar). If the blood glucose remained low after the [MEDICATION NAME] he would have advised them to call EMS for transport to the emergency room . The resident's physician said the facility should not have waited so long to call EMS and the facility did not contact him at any time. The resident's physician said he always has his cellular phone with him and he should have been called. The physician said he was shocked when he found out the resident was not in the building. He visited with the resident upon admission and the resident was comfortable and doing fine. During an interview on 8/11/17 at 3:30 P.M., the ADON (Assistant Director of Nursing) said with any blood glucose levels below 50 the body starts losing brain cells. The ADON said LPN E should have called 911 with a blood glucose level of 23. She said the nurse should not have waited so long to call. The ADON said LPN E should definitely have called the physician. The ADON worked 7:00 P.M. to 10:00 P.M. on the night the resident was admitted to the facility and she did not check the resident's blood glucose. During an interview on 8/11/17 at 3:40 P.M., the DON said she called the admitting nurse who took care of the resident when he/she first admitted to the facility and the nurse did not check the resident's blood glucose. She said the facility could not find any documentation showing staff had checked vital signs for the resident. Complaint number MO 667

Based on interview and record review the facility staff failed to appropriately assess, monitor and document when one resident (Resident #1), who had a history of [REDACTED]. The staff failed to notify the physician in a timely manner when the resident had a decline in mental and physical functioning, increased pain and requested to go to the hospital. The resident was later diagnosed with [REDACTED]. Sixteen residents were sampled in a facility with a census of 93. Record review of the facility's policy/procedure titled Change in Patient Status, revised 3/4/15, showed the following information: -Staff should encourage the resident to be involved in all decision-making regarding changes in the plan of care; -Staff should notify the charge nurse on duty immediately of any change in a resident's condition. The nurse should assess the resident's condition and notify physician and family; -Staff should notify the physician immediately when a significant change in medical condition has occurred; -The facility uses the Stop and Watch Early Warning Tool to identify changes in a residents condition; -The staff should notify the nurse if the resident seems different than usual, talks or communicates less, overall needs more help, new or worsening pain, eats less, weight change, agitated or nervous more than usual, tired, weak, confused, needs help with walking, transferring, toileting more than usual. 1. Record review of Resident #1's admission summary showed the following: -Staff admitted the resident on 7/23/12 with [DIAGNOSES REDACTED]. organs), long term use of anticoagulants, unsteadiness on feet and muscle weakness. -The resident was his/her own responsible party and there was no durable power (DPOA) of attorney listed in the medical record. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 08/01/16, showed the following information: -Brief Interview for Mental Status (BIMS - a facility completed assessment to determine cognitive level of a resident) assessment showed a score of 13 which showed cognition was intact; -Staff did not identify any behavioral concerns; -The resident was independent with transfers, bed mobility, ambulation, toileting and hygiene; -Required staff supervision for dressing and staff to set-up meals; -Independent with eating; -Required the assistance of one staff for bathing; -Used a walker and wheelchair for mobility; -No recent falls; -No issues with pain. Record review of the resident's care plan, dated 8/04/16, showed the following information prior to the fall: -Dresses and grooms self; -Needs assistance with bathing and showers; -Transferred self; -Used a walker and wheelchair for mobility; -had a history of [REDACTED]. Record review of the resident's nurse's note dated 9/11/16, at 10:30 P.M., showed Licensed Practical Nurse (LPN) H noted the following information: -Certified Nurse Aide (CNA) I was in the resident's room passing ice when the resident who was ambulating with his/her walker turned and tripped over his/her own feet and fell landing on the floor on right side with his/her head striking the night stand. -Nurse assessment revealed an abrasion to the right side of head with discoloration; -No further injuries noted; -Staff assisted the resident to bed with ice pack applied and antibiotic ointment to the abrasion; -Staff notified family and physician with no new orders; -Neurochecks initiated and vital signs were within normal limits; -Staff to monitor for any changes. Record review of a form titled Post Fall, dated 9/11/16, showed the following: -At 10:30 P.M., the resident fell while ambulating from dresser to his/her bed, turned with walker and tripped over his/her own feet; -CNA I witnessed the resident's fall; -The resident was ambulating in his/her room unattended; -The resident fell landing on his/her right side; -Resident complained of pain to the right side of his/her head; -Abrasion to the right side of head with minimal bleeding and discoloration; -First aide administered and neurological checks initiated; -The resident was alert and all vital signs were within normal limits; -Staff notified family; -Staff notified physician and orders were to monitor per protocol. Record review of the resident's Medication Administration Record [REDACTED].M. with a notation of fairly effective results. Record review of the resident's nurse's note dated 9/12/16, no time documented, showed LPN O noted the following information: -Continued on fall follow-up; -The resident has an abrasion to the right side of head, no other injury noted; -The resident requested to go to the hospital; -LPN O completed neurochecks and noted he/she explained to the resident his/her vital signs were stable and the staff will continue to monitor him/her and the resident was ok with this; -Staff gave as needed pain medication with relief; -The resident has stayed in his/her room all shift; -Staff will continue to monitor; (LPN O did not document notifying family or physician regarding the resident's request to go to the hospital.) Record review of the resident's MAR, dated 9/12/16, showed no documentation of a pain medication dispersed from the day shift. Record review of the nurse's notes dated 9/12/16, at 8:00 P.M., showed LPN J noted the following information: -CNA's came to this nurse telling of inappropriate remarks the resident was making to them; -He/she stated his/her private area was too big for the assistive toileting device and that was why he/she urinated in the trash can. -The resident wanted the CNA to assist him/her with all dressing and toileting; -The resident wanted the staff to stay with while he/she did his/her business; -The resident had been using his/her call light continuously throughout the evening wanting small things done; -The resident told LPN J that he/she had a recent fall and did not understand what was going on with him/herself; -The resident said when he/she fell he/she bumped the right side of his/her head; -The resident said the left side of his/her head was dumb and he/she clarified dumb not numb; -LPN J assured the resident he/she was ok to ambulate to the bathroom by him/herself and to dress self; -The resident had also refused all meals today; -LPN J noted the resident's blood sugar was 211 milligrams/deciliter (mg/dl); -The resident continued to make remarks so LPN J asked the residents family member to come in and talk with the resident; -The family member came into the facility and it was decided between the two of them if the resident still felt bad tomorrow and continued to complain of neck and head issues that the day shift staff could send the resident to the hospital to be evaluated; -The family member did not want the resident to miss another night's sleep; -The family member asked staff to notify him/her if behaviors continued or if the staff sent the resident to the hospital; -Clarification for staff to send the resident between breakfast and lunch and wanted a CT scan of the head; -The resident was on an anticoagulant medication and had very little bleeding from head wound. Record review of the resident's MAR, dated 9/12/16, showed the nurse dispersed a pain medication of [MEDICATION NAME] 5/325 to the resident at 3:30 P.M. with a notation of fairly effective results at 4:40 P.M. Record review of the resident's meal intake record, dated 9/12/16, showed the resident refused his/her breakfast and dinner meals. Record review of the resident's nurses' notes dated 9/12/16, 10:00 P.M. to 6:00 A.M., shift showed LPN H noted the following: -Continued on fall follow-up; -All neurochecks within normal limits; -Vital signs remain stable; -Area to the right side of head (abrasion) clear with no drainage; -Denies pain at this time; -No behaviors noted; -Staff noted the family member requested to send the resident to the hospital by ambulance on 9/13/16 if complaints of neck and head pain continued; -LPN H will pass on information to the day shift and continue to monitor for any changes. Record review of the neurological checks, dated 9/11/16 through 9/13/16, showed the following information: -Vital signs completed with blood pressure ranging from 126/64 millimeters of mercury (mm/Hg) to 171/81 mm/Hg (normal blood pressure range is at or below 120/80 mm/Hg); -Pupil and extremities: Staff noted the resident's pupil size and reaction fixed with a strong hand grasp; -Consciousness: Staff noted the resident was fully conscious; -Speech: clear. Record review of the resident's MAR, dated 9/13/16, showed the nurse dispersed a pain medication of [MEDICATION NAME] 5/325 mg to the resident. The nurse did not document time completed or results. Record review of the resident's nurse's notes, dated 9/13/16, showed LPN O noted the following information: -At 8:05 A.M., LPN O called and left a message for the physician to send the resident to the hospital; -At 9:20 A.M., LPN O called again to the physician's office to get an order to send the resident to the hospital; -At 9:40 A.M., the physician called back and gave the order to send the resident to the hospital; -At 10:00 A.M., LPN O called for a non-emergent transport to the hospital; -At 10:15 A.M., the emergency staff transported the resident by ambulance to the hospital; -At 10:20 A.M., LPN O notified the family member of the transport to the hospital; -At 12:00 P.M., LPN O noted staff from the hospital called and informed the facility the resident was admitted with a C spine fracture. Record review of the resident's hospital discharge record, dated 9/17/16, showed the following information: -The resident was admitted on [DATE] for a fall and head pain; -The resident was diagnosed with [REDACTED]. -A halo device (a device used to manage cervical spine injuries to minimize neurological damage, requiring long-term immobilization; in the halo device, pins are inserted on the outer skull for skeletal traction, using a 2-3 kilogram (kg) weight for upper cervical injuries and 10-15 kg for lower cervical injuries) was put in place and the resident was discharged back to the facility. Record review of Resident #1's significant change MDS, dated [DATE], showed the following information: -BIMS assessment score of 14 which shows cognition was intact; -Staff did not identify any behavioral concerns; -Required extensive assistance from staff with transfers, bed mobility, dressing and toileting; -Required staff to set-up meals, but independent with eating; -Required limited assistance from staff for hygiene; -Required the extensive assistance from staff for bathing; -Used a wheelchair for mobility; -One fall with major injury; -Resident was requesting pain medication occasionally; -Had an eight pound weight loss. Record review of the resident's care plan, updated 10/06/16, showed the following information: -Staff should place personal items and water within reach; -The resident was walking with walker in his/her room and tripped over his/her own feet and fell and hit his/her head on the nightstand; -After admission to the hospital resident was diagnosed to have fractures to his/her cervical spine; -Resident will wear a non-invasive halo at all times; (The halo was removed on 11-2-16 and was replaced with a neck collar that should be worn at all times) -Staff will provide assistance with all activities of daily living during the resident's recovery. During a telephone interview on 11/08/16, at 6:00 P.M., CNA I said: -He/she was passing ice in the resident's room when he/she fell ; -The resident was ambulating with a walker and tripped over his/her own feet fell and hit right side of head on the night stand; -The resident's head was cut and bleeding; -CNA I yelled for LPN H; -LPN H assessed the resident; -CNA I and LPN H assisted the resident up off the floor and onto his/her bed and cleaned and applied ice to the wound; -The resident complained of pain and LPN H gave the resident pain medication; -The resident asked to go to the hospital a few times; -The resident said he/she had a sharp pain in his/her head; -CNA I said he/she checked on the resident every 15 minutes and the first check the resident asked again to go to the hospital because the pain medication had not kicked in yet; -The resident eventually went to sleep; -The resident eventually went to the hospital; -Prior to the fall the resident was independent with ADL's (activities of daily living -- dressing, grooming, bathing, eating, and toileting) and was able to voice needs; -It was not normal for the resident to complain of pain; -After the fall the resident required more help from staff with cares; -CNA I said he/she was not sure what happened, but the resident returned from the hospital with a brace on. During a telephone interview on 11/08/16, at 11:40 A.M., LPN H said: -The resident was alert and oriented; -Prior to the fall the resident was very independent with toileting self, the resident required very little care from staff; -No history of behaviors, overall a very sweet person; -The resident very rarely requested pain medication; -The night the resident fell he/she was ambulating with his/her walker and tripped over his/her own feet fell and struck head on the night stand; -CNA I witnessed the fall; -The resident had very little bleeding from his/her head; -LPN H assessed the resident and staff assisted the resident to the bathroom; -The resident pointed to his/her head and requested pain medication for a headache; -Staff gave pain medication to the resident; -Staff initiated neurochecks; -Staff notified family and physician; -No order to send the resident to the hospital; -Staff monitored the resident throughout the night; -Staff did watch the resident's head due to the resident being on an anticoagulant medication; -Staff looked for any increased bleeding or bruising under the skin; -Staff should have contacted the physician if there was any change in condition from the resident's baseline; -Any change in condition would have been a trigger to notify the physician to include increased confusion, increased pain or abnormal behaviors; -If the resident requested to go to the hospital, LPN H said he/she would have notified the family and physician and sent the resident to the hospital; -Since the fall the resident returned from the hospital with a halo device to wear at all times and now wears a neck brace due to the neck/spine fracture from the fall; -The resident requested and required more assistance from staff with ADL's and care after the fall. During an interview on 11/4/16, at 12:25 P.M., LPN O said prior to Resident #1's fall, the resident ambulated independently using a walker and was able to care for him/her self. The resident fell on [DATE]. The nurse worked the following two days, 9/12/16 and 9/13/16, from 6:00 A.M. to 2:00 P.M. On 9/12/16, the resident refused to get out of bed for breakfast. The resident informed the nurse, he/she felt, dumb. The resident said something about wanting to go to the hospital. The resident later got up out of bed, went to the bath room, and was up walking around. The nurse suggested the resident should wait to go the hospital and the resident agreed to wait. The nurse said something happened later that night and the resident's family member came in to the facility. The resident was acting weird. The resident talked about his/her private parts being too large. The family member said if the resident wanted to go to the hospital, staff should send the resident the next day on 9/13/16. On the morning of 9/13/16, the resident was up and dressed and wanting to go to the hospital. LPN O called the resident's physician and received orders to send the resident to the hospital via ambulance (two days after the fall). The hospital later called and said the resident had a fracture of his/her cervical spine. During an interview on 11/8/16, at 11:40 P.M., LPN O said Resident #1 did not exhibit any behaviors and had never asked to go to the hospital prior to his/her 9/11/16 fall. On 9/12/16, the resident complained of a headache and the LPN gave the resident a pain pill. The LPN said when the resident asked to go to the hospital on [DATE]; he/she did not contact the physician. The LPN instead asked the other nurses in the building what they would do and was advised if the resident's neuro checks and vital signs all check out, just watch the resident. The LPN said she did not know if the resident's blood pressure was above baseline for him/her. During an interview on 11/8/16, at 2:00 P.M., LPN J said: -Prior to the fall the resident was alert and oriented with confusion at times; -The resident toileted and ate without assistance; -No behaviors until after the fall; -The resident got his/her feet tangled up while ambulating with walker and fell hitting right side of head causing an abrasion; -Staff did not send the resident out to the hospital; -Staff were to monitor the resident for any changes in condition; -Neuro-checks were all within normal limits; -The resident was a little more confused; -The resident told LPN J his/her private area was too big for the assistive toileting device; -The resident told LPN J his/her head felt dumb; -LPN J called the resident's family member to come into the facility and talk with the resident; -LPN J wanted the family member to see if the resident was more confused and if the resident needed to be sent to the hospital; -The resident told the previous shift that he/she wanted to be sent to the hospital; -The family member told LPN J if the resident felt that he/she still needed to go to the hospital not to send the resident until the next day between breakfast and lunch; -LPN J said he/she thought the family member was the resident's DPOA and was supposed to make decisions for the resident; -LPN J reviewed the nurses' notes and said he/she would not have notified the physician with all the concerns noted; (LPN J failed to notify the physician for direction when the resident showed changes in his/her condition.) During an interview on 11/02/16, at 2:35 P.M., Resident #1 said he/she had a fall a few months ago. While ambulating with his/her walker the privacy curtain hung down in his/her path when he/she attempted to push the curtain out of the way it threw him/her off balance and he/she fell to the floor hitting his/her head on the night stand. The resident said the staff sent him/her to the hospital immediately. The resident said he/she hasn't been the same since the fall. The resident said after the fall he/she ambulates with his/her wheelchair a lot more than the walker. The resident said he/she has needed more assistance from staff with cares. The resident was very upset about having to wear the halo and then the neck brace. During an interview on 11/08/16, at 10:45 A.M., LPN L said: -When a resident has a fall nursing staff should assess the resident immediately and notify family and physician for direction; -Staff should report any change in condition to the physician immediately; -If a resident requests to go to the hospital the staff should notify the physician for direction; -If a resident who was alert and oriented and is their own responsible party requests to go to the hospital the staff should notify the physician for an order and LPN L said he/she would send that resident to the hospital; -Resident #1 was alert and oriented and he/she was not aware of any history of behaviors. During an interview on 11/08/16, at 10:30 A.M., CNA K said: -The resident was alert and oriented; -Independent with most ADL's prior to the fall; -The resident had no behaviors; -After the resident fell he/she was very scared and afraid to use the bathroom alone in fear of falling again; -After the fall the resident was required to wear a halo device at all times due to the fractures on his/her vertebrae; -The resident now wears a neck brace at all times; -After the fall the resident required assistance from staff for most ADL's. -Staff should report any change in condition to the charge nurse to include confusion, crying, a resident not getting up for meals, anything different from their normal behavior. During a telephone interview on 11/09/16, at 12:25 P.M., CNA M said: -Prior to the resident's fall he/she was able to do most ADL's; -The resident was alert and oriented; -CNA M was on shift the day shift after the fall; -The resident complained of a headache; -The resident requested to go to the hospital, but did agree to try pain medication first; -When CNA M assisted the resident in the bathroom he/she kept saying his/her head hurt; -CNA M said he/she reported the resident's complaints of pain to the nurse; -The resident did not eat breakfast that day due to a massive headache; -The resident asked for more help with toileting that day; -The resident kept grabbing his/her forehead and complained of headache pain throughout the day; -The neuro-checks were all within normal limits. During an interview on 11/08/16, at 7:25 P.M., the Director of Nursing (DON) said: -Resident #1 had a history of [REDACTED].>-No history of behaviors or sexual misconduct; -The resident was alert and oriented; -The resident was pretty independent used a walker and wheelchair to ambulate, toileted and fed self; -The resident had no issues with pain; -The resident had a recent fall, a non-injury event; -Staff notified the DON of the residents fall and reported to her a non-injury fall; -The resident was his own responsible party and family member was only an emergency contact; -The resident fell in his/her bathroom and hit his/her head; -A couple of days later there was increased pain; -DON said the staff should have notified the physician and family of any changes in the resident's condition; -She said the staff should have notified the physician when the resident requested to go to the hospital; -After reviewing the nurse's notes the DON said the staff should have contacted the physician at least on one of the shifts on 9/12/16. During a telephone interview on 11/10/16, at 10:00 A.M., the physician said he would expect the staff to report any change in a resident's condition. Staff told him the fall was a non-injury fall. He said if the resident requested to go to the hospital he would have wanted the staff to notify him and he would have given an order to do so.

Based on record review, observation and interview the facility failed to notify the physician of a deteriorating Stage IV pressure ulcer (full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures); failed to change treatment when the pressure ulcer showed no signs of healing and declined; and failed to provide wound care using acceptable infection control standards for one resident (Resident #2) in a selected sample 16 residents. The facility's census was 93. Record review of the facility's Skin Integrity Prevention and Management Policy, dated 1-1-03, showed the following: -Notify the physician timely (1-14 days) of lack of progress in wound healing; -Notify physician of wounds that increase in size of depth in the absence of debridement,or of signs and symptoms of infection; -Notify physician timely for new orders as wound heals; -If a physician fails to respond to changes in a resident's medical condition, or when orders obtained are inconsistent with wound care standards, the nurse will promptly notify the Director of Nursing (DON) for assistance in finding resolution; -Notify nursing staff and ancillary departments when a change condition results in the development of a pressure ulcer; -Notify nursing staff and ancillary departments of changes to the patient plan of care and treatment changes. 1. Record review of Resident #2's admission summary showed staff admitted the resident to the facility on [DATE]; his/her [DIAGNOSES REDACTED]. Record review of the resident's physician's orders [REDACTED]., apply Baza Antifungal (AF) cream (an antifungal moisture barrier cream) around the wound, pack the wound with 0.25% acetic acid (a synthetic acid with antibacterial and antifungal properties) moistened gauze, cover with and ABD pad (a highly absorbent dressing that provides padding and protection) and secure with [MEDICATION NAME] tape (cloth adhesive tape); and change dressing every day and as needed. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 08/09/16, showed the following information: -Cognitively intact; -Required extensive assistance from staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene and bathing; -Had an indwelling catheter (sterile tube inserted into the bladder to drain urine); -Always incontinent of bowel; -Hospice; -One Stage IV pressure ulcer present upon admit; -Tissue type for ulcer at most advanced stage: Eschar (black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin); -Measured 6.8 centimeter (cm) x 4.7 cm x 1.2 cm; -Pressure relieving devices for bed and chair; -Nutrition or hydration intervention to manage skin problems; -Pressure ulcer care; -Application of nonsurgical dressings other than to feet; -Application of ointments/medications other than to feet. Record review of the resident's care plan, dated 08/11/16, showed the following information: -Right hip pressure ulcer; -[DIAGNOSES REDACTED]; -Turn every two hours; -Provide skin treatment as ordered; -Low air loss mattress to bed; -Monitor skin with routine cares during bathing and at weekly skin assessment, report any concerns to licensed staff to follow-up on. Record review of the resident's weekly wound assessment record and weekly wound assessment progress notes showed a nurse documented the following information regarding the Stage IV pressure ulcer on the resident's right buttock : -On 08/15/16, the wound nurse documented staff reported the resident's wound had increased drainage that was purulent (containing pus) with a green-tinge. Staff notified the physician and hospice and received a new order to culture the wound and a new treatment order for acetic acid to address the possibility of pseudomonas (an infectious organism) in the wound. -On 08/18/16, the wound nurse documented the pressure ulcer measured 8.4 cm x 4.8 cm x 0.8 cm. The wound nurse documented 100% pink granulation tissue (the formation of new tissue, usually pink to red in color) in the wound bed with a moderate amount of purulent green-tinged drainage. The wound had slightly improved with the new treatment orders. -On 08/25/16, the wound nurse documented the pressure ulcer measured 7.7 cm x 4.6 cm x 0.8 cm. The wound nurse documented the resident's wound had red granulation tissue and a moderate amount of serosanguinous (yellowish with small amounts of blood) drainage. The physician ordered antibiotics for wound infection. -On 09/01/16, the wound nurse documented the pressure ulcer measured 7.5 cm x 5.4 cm x 1 cm. The wound nurse documented the resolving Stage IV pressure ulcer had moderate amount of serosanguinous drainage, the wound had 50% pink granulation tissue and 50% adherent yellow slough (yellow devitalized tissue, that can be stringy or thick and adherent on the wound bed). The nurse did not document notifying the physician of the wound's decline (increase in size and presence of slough in the wound bed). -On 09/08/16, the wound nurse documented the pressure ulcer measured 8.3 cm x 4.8 cm x 1.5 cm. The wound nurse documented same as above without many changes. Continue treatment and plan of care. The nurse did not document notifying the physician of the wound's decline (increase in size). -On 09/15/16, the wound nurse documented the pressure ulcer measured 8.4 cm x 5.3 cm x 1.3 cm. The wound nurse documented the resolving Stage IV pressure ulcer had a moderate amount of serosanguinous drainage, the wound bed had 50% pink granulation tissue and 50% adherent yellow slough. The nurse did not document notifying the physician of the wound's decline (increase in size and continued presence of slough in the wound bed). -On 09/22/16, the wound nurse documented the pressure ulcer measured 8.4 cm x 4.8 cm x 1.4 cm. The nurse check marked boxes on the form indicating the pressure ulcer had not improved in 3-14 days; he/she notified the physician, DON, dietary, rehabilitation coordinator, he/she implemented new orders/treatment implemented and he/she updated the care plan. (The medical record showed no new treatment orders or care plan updated for this date.). The wound nurse documented the resolving Stage IV pressure ulcer had a moderate amount of serosanguinous drainage, the wound bed had 60% pink granulation tissue and 40% adherent slough. Continue current treatment and plan of care. -On 09/29/16, the wound nurse documented the pressure ulcer measured 8.9 cm x 4.9 cm x 1.4 cm, undermining (deep tissue (subcutaneous fat and muscle) damage around the wound margin) from 11 o'clock to 1 o'clock measured 1.3 cm. The wound nurse documented the resolving Stage IV pressure ulcer had a moderate amount of serosanguinous drainage, the wound bed had 50% adherent yellow slough and 50% pink granulation tissue. Continue current treatment and plan of care. The nurse did not document notifying the physician of the wound's decline (increased size, continued yellow slough and undermining). -On 10/06/16, the wound nurse documented the pressure ulcer measured 9.2 cm x 5.3 cm x 1.9 cm, undermining from 11o'clock to 1 o'clock measured 1.3 cm. The wound nurse documented the resolving Stage IV pressure ulcer had a moderate amount to serosanguinous drainage, the wound bed had 30% adherent yellow slough and 70% pink granulation tissue. Continue current treatment and plan of care. The nurse did not document notifying the physician of the wound's decline (increased size). -A nurse did not document a wound assessment for the week of 10/09/16-10/15/16. -On 10/19/16, the DON documented the pressure ulcer measured 9.5 cm x 5 cm x 2 cm. The DON documented the impairment was tear/rain drop shaped with the widest part at 6 o'clock. The wound bed had 50% red beefy granulation tissue and 50% adherent slough with scant bleeding while cleansing. No foul odor. Sinus tract (narrow tract that are away from the wound margins and go downward into the wound) observed at the top of the wound at the point of the tear drop. Treatment per current order. Provided education, at bedside, to reposition often and use pillows to avoid pressure to current skin issue and prevent further decline. The nurse did not document notifying the physician of the wound's decline (increased size, continued yellow slough and sinus tract). Record review of the resident's care plan showed on 10/19/16 staff added the following interventions: -Utilize body pillow, bed pillows and gel cushions to off-load pressure/weight from bony prominences; -The resident often prefers to sit up for long periods of time related to wanting to smoke. Staff to encourage increased time in bed as able. Record review of the Quality Improvement Work Product weekly pressure ulcer log, dated 10/28/16, showed the following: -The resident had a Stage IV pressure ulcer to his/her right buttock that measured 9.5 cm x 5 cm x 2 cm. The wound had a pink, glossy, granulated wound bed, serosanguinous drainage, and macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) skin observed around the wound. -Treatment: Vashe, acetic acid moistened gauze. Record review of the physician's orders [REDACTED]. Record review of the resident's care plan showed on 10/31/16 staff added the following intervention: -The resident has wounds to his/her right buttock and sacrum (triangular-shaped bone at the base of the spine). Follow current treatment orders and notify the physician and DON on change of condition. An observation on 11/02/16, at 2:15 P.M., showed the following: -Licensed Practical Nurse (LPN) D gathered wound care supplies and entered the resident's room. LPN D and LPN G assisted the resident onto his/her left side. LPN D placed his/her wound care supplies (three opened packages of ABD pads (an absorbent dressing), a small medication cup of Baza cream, a small cup of 4 x 4 gauze soaking in Vashe solution, a small cup of antibacterial soap and normal saline (a sterile sodium chloride solution), a small cup of 4 x 4 gauze soaking in acetic acid, dry 4 x 4 gauze, a box of gloves and a roll of tape) on a towel, located on the bed next to the resident. -LPN D removed the large dressing covering the resident's buttocks and showed an orange-sized unstageable pressure ulcer on the resident's sacrum (triangular shaped bone at the base of the spine) and a plum-sized tear-shaped Stage IV pressure ulcer on the resident's right buttock. The Stage IV pressure ulcer's wound bed was pink with and yellow slough with a small tunnel (a narrow tract that extends from a wound into and through subcutaneous tissue or muscle) located at the top of the wound. -LPN D cleaned the Stage IV pressure ulcer with normal saline and 4 x 4 gauze, cleaning the center of the wound outward, then cleaned the skin around the wound. -LPN D packed the right buttocks pressure ulcer with Vashe moistened gauze and changed gloves. -LPN D cleaned the sacral wound, from the outside of the wound inward, with antibacterial soap and gauze, then, using the same gauze, cleaned the skin surrounding the pressure ulcer on the right buttock. After cleaning the sacral wound the LPN applied a foam dressing to the wound bed and covered it with an ABD pad. -The LPN D changed gloves and removed the Vashe moistened gauze from the resident's buttock wound. He/she changed gloves and cleaned the wound with normal saline and gauze. The LPN cleaned the outer edges of the wound working towards the center of the wound, then using the same gauze, rubbed the wound, vigorously, from top to bottom, in a back and forth motion (possibly introducing bacteria into the wound and potentially damaging wound tissue). The LPN packed the wound with acetic acid moistened gauze, changed gloves, applied Baza cream on the skin surrounding the wound, changed gloves and left the room. The LPN reentered the room, applied more Baza cream to the skin surrounding the wound and changed gloves. The LPN covered the wound with gauze and an ABD pad and secured the dressing with tape and changed gloves. The LPN made the resident comfortable, removed his/her gloves and washed his/her hands. The LPN did not wash his/her hands when he/she entered the room and did not wash his/her hands after changing gloves when performing both wound treatments (potentially cross-contaminating the wounds). During an interview conducted on 11/03/16, at 10:30 A.M., the DON said until recently (10/14/16) the Assistant Director Nursing (ADON) completed the weekly wound assessments and would discuss wounds with staff during the weekly Patients at Risk (PAR) meeting. The DON attended PAR meetings approximately 50% of the time. The MDS coordinator also attended the PAR and would report any problems the DON missed to the DON. The ADON was not assessing and documenting acquired pressure ulcers correctly and was subsequently terminated. When the DON became aware of the inaccurate assessments, the DON assessed the wounds and documented her findings on the weekly wound assessment record and weekly wound assessment progress notes. Record review of the resident's weekly wound assessment record and weekly wound assessment progress notes, dated 11/04/16, showed the DON documented the pressure ulcer measured 9.0 cm x 4 cm x 2 cm. Undermining observed from 11-12 o'clock and measured 2 cm x 1 cm. The DON documented continue current treatment to the resident's right buttock. Area smaller with healthy appearing tissue; moist, red wound bed with glossy pink wound edges, no sinus tract located, undermining at top edge of wound. Record review of a physician's orders [REDACTED]. New order to cleanse the right buttock wound with Vashe and allow to soak for five minutes. Pack wound loosely with 0.125% Dakin's solution (a diluted bleach solution used to prevent and treat skin and tissue infections) moistened gauze, apply moisture barrier cream and [MEDICATION NAME] (a protective barrier wipe) around the wound, cover with an ABD pad and secure with tape. Change the dressing every day and as needed. During an interview conducted on 11/08/16, at 4:45 P.M., the physician said when a resident has a wound, staff either fax him the wound care orders or the wound care nurse would call him about wound orders. The physician observed residents' wounds once in a while, but usually the wound nurse just described the wound appearance to him once a week, while he was at the facility. The wound nurse would also let the physician know if she was changing the treatment. If a wound is not getting better after two to three weeks, the treatment should be changed. The physician relied on the ADON (wound nurse) for wound assessments and treatment suggestions. The physician did not know the ADON was terminated due to inconsistencies with wound assessments and the facility did not notify him of his residents who were affected by the ADON's inconsistencies. During an interview conducted on 11/08/16, beginning at 7:25 P.M., the DON and administrator said the following: -The DON said staff should wash their hands when entering or leaving a resident's room. Nurses should wash or sanitize their hands when they change their gloves and then going from dirty to clean. Staff should clean wounds from the middle out, and they should not clean the skin and then clean the wound bed with the same gauze. -The DON said if a wound does not improve or the wound declines, the treatment should be changed. There was no timeframe for when treatment orders should be changed. -The resident's treatment changed in August 2016. The resident had an infection in the wound and took oral antibiotics. The acetic acid treatment helped keep the extra bacteria out of the wound. Staff had to change the treatment to the resident's right buttock recently (11/08/16) because the facility could no longer get the acetic acid from the pharmacy, so staff changed the order to Dakin's solution. -The DON said she did not know why the treatment was not changed when the wound declined or when the wound did not show signs of healing. She could only talk about what has happened with the wounds since she has been involved in the assessments. -The DON said the ADON would change or adjust a wound treatment then let the physician's know of the change. The physicians assess wounds as needed but there is not a set timeframe for when they do assess wounds. -The administrator said the ADON would give her a weekly skin report, but it did not include a lot of detail about the wounds. -The DON said no one really monitored the ADON/wound nurse's reports; she monitored her own reports. -The DON said during the recent QA meeting she let the physicians know they were having difficulty with the wound nurse/ADON, but she did not specifically tell the physicians which residents were affected. -The DON said former ADON did not want other nurses documenting anything about residents' wounds. The DON has scheduled in-services for the nurses regarding pressure ulcers.

Based on observation, interview, and record review, the facility staff failed to ensure staff recognized, documented and thoroughly addressed the mental or psychosocial needs of three sampled residents (Resident #7, #13 and #15). Staff failed to develop a care plan with goals and approaches that were consistent with one resident's (Resident #7) specific conditions and behaviors. Staff failed to ensure one resident (Resident #15) did not develop chronic or recurrent fear/anxiety that manifested as avoidance of the fear-inducing situation(s) or person and verbal expressions of fear. Staff failed to appropriately assess, document, monitor, and intervene in a timely manner when one resident (Resident #7) exhibited verbally abusive behaviors towards one resident (Resident #13) and exhibited verbally abusive, threatening and taunting of another resident (Resident #15). Resident #15 expressed fear and of being "afraid" of Resident #7 to facility staff. Twenty (20) residents were sampled in a facility with a census of 113. Record review of the Alzheimer's Association www.alz.org regarding dementia and sundowning showed, in part, the following information:-Aggressive behaviors may be verbal or physical. They can occur suddenly, with no apparent reason, or result from a frustrating situation. While aggression can be hard to cope with, understanding that the person with Alzheimer's or dementia is not acting this way on purpose can help. -Aggression can be caused by many factors including physical discomfort, environmental factors and poor communication. If the person with Alzheimer's is aggressive, consider what might be contributing to the change in behavior.-Anxiety and agitation may be caused by a number of different medical conditions, medication interactions or by any circumstances that worsen the person's ability to think. Ultimately, the person with dementia is biologically experiencing a profound loss of their ability to negotiate new information and stimulus. It is a direct result of the disease.-Situations that may lead to agitation include:-Moving to a new residence or nursing home; -Changes in environment, such as travel, hospitalization or the presence of houseguests; -Changes in caregiver arrangements; -Misperceived threats; -Fear and fatigue resulting from trying to make sense out of a confusing world;-Residents with Alzheimer's and dementia may have problems sleeping or increases in behavioral problems that begin at dusk and last into the night (known as sundowning).-If the person is awake and upset:-Approach him or her in a calm manner. -Find out if there is something he or she needs. -Gently remind him or her of the time. -Avoid arguing. -Offer reassurance that everything is all right. 1. Record review of Resident #7's, outside of facility office visit, dated 10/10/13, showed, in part, the following information:-Resident had an established [DIAGNOSES REDACTED]. His/her mental status appeared to be gradually deteriorating over the last 1-2 months. At his/her current level of functioning, he/she could not bathe, dress self, feed self, converse in a meaningful manner, recognize familiar faces, find his/her way home, remember his/her way home, where he/she lives or the date. In regard to grooming, his/her overall appearance was disheveled. Behavior was described as agitated. Associated symptoms included confusion, [MEDICAL CONDITION], and disturbed sleep with sun downing. Record review of the October 2013 physician's orders [REDACTED]. Record review of the facility history and physical dated 10/16/13, showed the resident's past history included dementia and sun downing. Record review of Resident #7's nurse's notes and social service notes showed the following information: -On 10/17/13 at 12:45 A.M., staff documented they obtained a urine specimen for urinalysis via catheter. Resident was in a very "foul" mood, cussing at staff. Resident was very pleasant earlier, very agitated at this time;-On 10/17/13 at 1:40 A.M., the resident was very "hateful". The resident continued cussing at staff, very upset that he/she was awakened to obtain a urine specimen. The nurse offered the resident a snack, but, the resident refused. The resident got up in his/her wheelchair, then got out of the wheelchair and walked back to his/her room. The nurse followed the resident. The resident said, "I don't need no help. I've been in the hospital for the past [AGE] years every three years and this is the damnedest hospital I've ever been in". Resident did finally lay down;-On 10/17/13, at 10:00 A.M., the resident became "angry" this morning and was not happy about being in "a place like this again".-On 10/17/13 at 9:00 P.M., Resident #7 argued with roommate Resident #13. Resident #7 cussed at Resident #13 and the staff. The nurse talked to Resident #7 and informed him/her, "We will not tolerate this behavior". Resident #7 started to argue but after redirection started to calm down. Resident #7 said he/she "feels cornered in". The nurse opened the curtain some and the resident said that was better. Resident #7 said he/she would speak to his/her family about going home;-Between 10/17/13 at 9:00 P.M. to 10/22/13, staff did not document the resident had any behaviors and/or sun downing. Staff did not document further regarding monitoring or assessment of the resident's behaviors Record review of the psychosocial assessment dated [DATE], showed, in part, the social service director (SSD) documented the following information:-Moderately impaired cognitive decision-making;-Had [DIAGNOSES REDACTED]. He/she was appropriate during the interview. Nurses' notes indicated his/her mood could change, and the resident had a [DIAGNOSES REDACTED]. The physician office visit showed the same information. The SSD did not have information regarding medication for mood. The resident had an order for [REDACTED]. The resident seemed to be adjusting well per his/her report. The resident had some behaviors with yelling and cursing with a [DIAGNOSES REDACTED]. Record review of Resident #7's admission Minimum data set (MDS) a federally mandated assessment completed by facility staff dated 10/22/13, showed the following information:-Able to make self understood;-Able to understand others;-Moderately impaired cognitive decision-making;-Feeling down, depressed or hopeless: Yes, never or 1 day;-Behavioral symptoms present:-Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others): staff marked "Behaviors not exhibited". (nurse's notes showed behaviors occurred on 10/17/13).-Overall presence of behavioral symptoms: Were any behavioral symptoms present: staff marked "No". If staff had marked "Yes" the MDS prompted staff to determine the behavioral symptoms impact on the resident and the impact on others.-Change in behavior or other symptoms (how does resident's current behavior status compare to prior assessment): Staff marked N/A because no prior MDS assessment (Record showed resident had a prior admission to facility from 3/6/13 to 4/12/13, with 3 prior assessments completed). Record review of the nurse's notes and social services notes showed the following information: -From 10/23/13 to 10/28/13, staff did not document the resident had any behaviors and/or sundowning. Staff did not document further monitoring or assessment of the resident's behaviors. Record review of the cognitive loss assessment dated [DATE], showed, in part, the SSD documented the following information:-The resident's family reported per record notes, the resident had sundowners and behaviors in the evening. The resident was more than they could handle;-Nurse's notes indicated disorientation, yelling, and cursing;-SSD documented he/she would address cognition. Staff to provide supervision of care, safety with ambulation, and approaches for sundown behaviors. Record review of the nurse's notes and social service notes showed the following information: -From 10/28/13 to 10/31/13, staff did not document any resident behaviors and/or sundowning. Staff did not document any further monitoring or assessment of the resident's behaviors Record review of the care plan dated 10/31/13, showed, in part, the following information:-Problem: Resident has middle stages of dementia. Resident has sundowners in the evening sometimes and yelled and argued with others;-Goals: Staff did not implement any goal related the resident's sundowners or behaviors;-Approaches: Staff did not implement any approaches related to the resident's sundowners or behaviors.Record review of the nurse's notes showed the following information: -From 11/1/13 to 11/19/13, staff did not document the resident had any behaviors and/or sun downing. Staff did not document any further monitoring or assessment of the resident's behaviors; -On 11/19/13, staff documented the resident moved from A-hall to D-hall into the room with Resident #15. Staff did not document what prompted the room move. Staff moved Resident #7 to the bed by the door and Resident #15 to the bed by the window, where he/she had resided since 3/15/11. Record review of Resident #13's (Resident #7's roommate from 10/19 to 11/19/13) quarterly MDS assessment dated [DATE], showed the following information:-No long or short-term memory problems;-No cognitive impairment;-No behaviors noted;-Extensive assistance with mobility and transfers. Record review of Resident #13's nurse's notes and SSD notes showed staff did not document regarding any behaviors that occurred between Resident #13 and Resident #7. Record review of Resident #7's social services notes showed the SSD did not document any notes after 10/30/13. The SSD did not document regarding behaviors that occurred between Resident #13 and Resident #7. The SSD did not document what prompted the room move. Record review of Resident #15's medical record, showed the following information:-Staff admitted the resident on 3/15/11;-The resident was [AGE] years old;-[DIAGNOSES REDACTED].-On 5/30/13, SSD documented the resident told him/her about an upcoming physician's appointment and the resident was worried about it because he/she has claustrophobia (Claustrophobia is an anxiety disorder in which the sufferer has an irrational fear of having no escape or being closed-in. It frequently results in a panic attack and can be triggered by certain stimuli or situations) referring to the bus and the physician's office he/she had to be in. Record review of Resident #15's significant change MDS assessment dated [DATE], showed, in part, the following information:-Moderately impaired cognitive decision-making;-Feeling or appearing down, depressed or hopeless: Yes, never or 1 day;-Indicating that he/she felt bad about self, was a failure or had let self or family down: Yes, 2-6 days.-Staff did not document any behaviors;-Extensive staff assistance for mobility, transfers, toileting, and hygiene. Record review of Resident #7's nurse's notes showed the following information:-On 11/19/13 at 9:00 A.M., the resident was unhappy about being moved. Resident said, "I don't know why I am down here with all these old people". Reassurances offered; -On 11/19/13 at 10:00 P.M., licensed practical nurse (LPN) R documented Resident #7 could be heard telling roommate Resident #15 to "shut up, shut up". Other residents complained this resident was yelling at Resident #15 and waking up other residents. LPN R documented he/she explained to Resident #7 how he/she, along with other residents have the right to their area of living, their televisions and stress free of others yelling. Before this nurse could complete the sentence, Resident #7 stated, "You're not very [***] ing smart, neither of you" referring to the nurse and the aide. Resident #15 began talking. Resident #7 said to Resident #15, "Shut up or I will come over and shut you up". Staff were unable to redirect Resident #7. The nurse documented staff would monitor. LPN R did not document he/she notified SSD, the physician, or the Director of nurses (DON). -Between 11/19/13 at 10:00 P.M., to 11/20/13 at 1:00 A.M., staff did not document further monitoring or assessment of the resident's behaviors;-On 11/20/13 at 1:00 A.M., LPN R documented Resident #7 continued to "threaten" Resident #15. The call light came on and when the nurse answered the call light, Resident #7 said, "Are you in charge of getting things done?" LPN R said, "What can I do for you?". Resident #7 said, "Shut off that [***] ing light, it's in my eyes". The nurse explained the light was on all the time, even when the other lights were off. Resident #7 began ranting and said, "I will find out who runs this place and find out why it's ran this way and why they haven't the balls to run it correctly". The nurse could not redirect the resident. Resident #7 continued to cuss at Resident #15 and the staff. Resident #7 said, "I call for you to shut off the hall light and you go to his/her bed." He/she (Resident #15) is a "yakking old [***] . I called, not him/her". LPN R did not document he/she notified the physician, SSD and/or DON;-On 11/20/13 at 3:00 A.M., Resident #7 no longer yelled at Resident #15 or the staff. Record review of Resident #7's progress notes dated 11/26/13 at 6:30 P.M., showed the following information: -Complaint of: physician left the area blank-Assessment: dementia.-See orders;-The physician did not document regarding Resident #7's behaviors toward Resident #13, Resident #15 or the staff. Record review of the PO on 11/26/13, showed the physician ordered four lab tests. During a phone interview on 1/22/14, SSD said on 11/27/13, staff moved Resident #7 and Resident #15's beds. Staff moved Resident #7 to the bed by the window and Resident #15 to the bed by the door. Record review of Resident #7's nurse's notes showed the following information: -Between 11/20/13 to 12/3/13, staff did not document further monitoring or assessment of the resident's behaviors. On 11/27/13, staff did not document about moving the resident's bed.-On 12/3/13 at 3:00 A.M., LPN R documented Resident #7 was overheard talking to Resident #15. Resident #7 said, "You stay out of my things over there, I don't get in yours". LPN R checked on Resident #15 and the resident was asleep;-On 12/3/13 at 4:15 A.M., LPN R documented Resident #7 called the nurse into the room to bring attention to Resident #15 moving things on Resident #7's side of the room. Resident #7 began moving all the items on his/her bedside table. Resident #7 said, "Now, the light's in my eyes". Staff pulled the privacy curtain between the residents' bed around to the foot of Resident #15's bed.-On 12/3/13 at 11:50 P.M., LPN R documented Resident #7's call light was on. The nurse answered the light and the resident said, "What's wrong with you damn people? Don't you know your job?. Get that damn light out of my eyes". Resident #7 continued cussing at the nurse. LPN R said to the resident, "There are some lights that stay on, I can't alter the system, I can pull the curtain". Resident #7 said, "The bunch around here are stupid". LPN R pulled the privacy curtain and exited the room. The aide reported Resident #7 said the nurse hurt his/her feelings; -On 12/4/13 at 1:20 P.M., Resident #7 called the aide to the room and requested the mirror be removed. The resident said, "He/she (Resident #15) keeps watching me when he/she's not over here moving my stuff around". Resident #15 was sound asleep with no attempts to get out of the bed. The aide told Resident #7 he/she was unable to move the mirror. -Between 12/4/13 to 1/5/14, staff did not document further monitoring or assessment of the resident's behaviors. Record review of Resident #15's nurse's notes showed the following information:-On 11/19/13 to 1/5/14, showed staff did not document regarding Resident #7's cursing, yelling, and threatening of Resident #15. -On 11/27/13, staff did not document about moving the residents' bed location. Staff did not document interventions put in place to protect Resident #15. Record review of the Resident #15's social service notes, showed the following information:-On 11/21/13, the SSD had a care plan meeting with the resident's family. The SSD said the resident was no longer on hospice. The SSD did not document about Resident #7's cursing, yelling, and threatening of Resident #15 on 11/19/13 and 11/20/13. -On 11/27/13, SSD did not document about moving the residents' bed location. -The SSD did not document any further information in the record. Record review of Resident #15's progress note dated 11/22/13, showed the following information:-Complaint of: physician left the area blank-Assessment: continues on hospice care (On 11/21/13, SSD documented the resident was no longer on hospice services); -See orders;-The physician did not document regarding Resident #15 being cussed at, yelled at, or threatened by Resident #7. Record review of Resident #15's progress note dated 12/27/13, showed the following information:-Complaint of: no new complaints;-Assessment: continues on hospice care;-See orders;-The physician did not document regarding Resident #15 being cussed at, yelled at, or threatened by Resident #7. Record review of Resident #15's nurse's notes showed the following information:-On 1/5/14 at 12:50 A.M., LPN R documented Resident #15 was upset with Resident #7. Resident #15's blood pressure elevated to 215/99 (in the previous four months, the resident's blood pressure levels ranged from 121/58 to 184/84) and diminished lung sounds. The nurse sent a fax to the physician requesting a chest x-ray and antibiotic. Resident #7 and Resident #15 have not gotten along for some time. Since Resident #7's move to his/her room, Resident #15 has been upset with the verbal cursing received by Resident #7. Resident #15 said, "I am afraid of Resident #7". LPN R did not document he/she notified the physician, SSD and/or DON of Resident #15 being afraid and upset. LPN R did not document any interventions put in place to protect Resident #15. -Between 1/5/14 at 12:50 A.M. to 1/6/14 at 12:35 P.M., staff did not document any further monitoring or assessment of Resident #15 being afraid and upset with Resident #7. Staff did not document any interventions put in place to protect Resident #15. Record review of Resident #15's progress note dated 1/6/13 at 3:10 P.M., showed the following information:-Complaint of: cough;-Blood pressure: 215/99;-Assessment: continues on hospice care. High blood pressure uncontrolled;-See orders;-The physician did not document regarding Resident #15 being cussed at, yelled at, afraid of, or threatened by Resident #7. Record review of Resident #7's nurse's notes showed the following information:-On 1/6/14 at 12:50 A.M., LPN R documented Resident #7 had been "taunting" Resident #15, leaning over the foot of the bed cussing at Resident #15 and saying, "Oh boo, keep your light on, something's going to get you. I'll shut the door, that will get you". Resident #7 shut the door. LPN R opened the door and Resident #7 pushed his/her body up against the door. The resident pushed the nurse up against the door frame. Resident #7 said, "All of you take Resident #15's side and she's a lying long nosed [***] ". LPN R said, "Resident #15 has rights too, you did not like the bed by the door, so the beds were switched. Now you argue, cuss and yell at Resident #15. Other residents are being woken up. This needs to stop. Closing the door when Resident #15 has a "phobia" about closed-in places is a mistake". Resident #7 said, "Now, this is a mistake". Resident #7 placed his/her fist close to the nurse's face and shook it. Resident #7 returned to his/her bed. When Resident #15 began speaking, Resident #7 began "taunting", "boo hoo, poor old [***] " over and over. Resident #7 told Resident #15, "I'll wait till they leave and I will shut the door again". LPN R did not document he/she notified the physician, SSD and/or DON;-On 1/6/14 at 1:00 A.M., Resident #7 requested for LPN R to lay down in his/her bed. The nurse told Resident #7, staff do not lay down in resident beds. Resident #7 grabbed the nurse by the jacket and sleeve trying to force the nurse to comply. Resident #7 was "serious", yelling at staff and Resident #15. Resident #7 said, "I will have my attorney on you" and threatened staff with his/her fist in their face. Resident #7 said to Resident #15 "He/she is [AGE] years old. You're old and you[***]your pants and you're a [***] ". Resident #15 said, "I'm afraid of Resident #7, I need protection". LPN R reassured Resident #15 and said, "all will be taken care of in the morning light, get some sleep". Resident #7 said, "Oh boo hoo, poor thing" over and over. The nurse documented staff would monitor. LPN R did not document he/she notified the physician, SSD and/or DON.-On 1/6/14 at 2:00 P.M., Resident #7 watched television with his/her overhead light on and talking loudly to Resident #15. Resident #7 said, "I have won [MEDICAL CONDITION] twice, I will win over you, you old [***] !" LPN R reported behaviors to SSD and sent a fax to the physician about behavior. (This is the first note since 11/19/13, where staff documented they notified SSD and the physician of behaviors).-On 1/6/14 at 8:40 A.M., the nurse received new orders from the physician. Record review of the fax communication sheet dated 1/6/14 (no time given), showed the following information:-LPN R documented FYI: All events have been charted. Resident #7 had been having issues with behaviors. Resident #7 had been moved from A-hall to D-hall. Resident #7 is "verbally abusive" to Resident #15. Last night, Resident #7 became "physical" with pushing staff and "threatening" Resident #15. Resident #7 is "very out of control of his/her temper". All has been charted and SSD has been notified. Resident #15 is another of your residents and Resident #15 said, "He/she is afraid". -Physician response: Verbal order given to day nurse. Will see resident today. Record review of Resident #7's PO dated 1/6/14 at 8:40 A.M., showed an order for [REDACTED]. Record review of Resident #15's nurse's notes showed the following information:-On 1/6/14 at 12:35 P.M., Resident #15 "upset" and "very anxious" about Resident #7 coming back from lunch. Resident #15 said, "I am scared of Resident #7. Resident #7 makes it dark in here and yells at me." Resident #15 does not want to be left alone with Resident #7. Resident #15 said, "I need a body guard". The nurse documented he/she would continue to monitor the resident's actions. The nurse did not document he/she notified the SSD, the physician and/or the DON of Resident #15 being scared to be left alone with Resident #7. Record review of Resident #7's progress notes dated 1/6/14 at 3:07 P.M., the physician documented the following information:-Complaint of: The nurse reported the resident has increased agitation in the P.M.;-Assessment: increased agitation. Record review of Resident #15's nurse's notes showed the following information:-On 1/6/14 at 11:20 P.M., LPN R documented Resident #15 said, "Can you stay with me tonight? I am afraid of Resident #7". The nurse reassured Resident #15 and said he/she would do his/her best to keep Resident #15 safe. LPN R did not document he/she notified the SSD and/or DON of Resident #15 being afraid. LPN R did not document any interventions put in place to protect Resident #15. Record review of Resident #7's nurse's notes showed the following information: -Between 1/6/14 at 2:00 A.M. to 1/7/14 at 11:00 A.M., staff did not document any further monitoring or assessment of the resident's behaviors;-On 1/7/14 at 11:00 A.M., registered nurse (RN) A documented Resident #7 was alert and pleasant today. No aggressive behaviors today. Resident #7 and Resident #15 are getting along fine during the daytime hours. Record review of the fax communication sheet dated 1/7/14, showed the following information:-RN A documented the physician ordered [MEDICATION NAME]. Per the DON, [MEDICATION NAME] is on the black list (not to be used in facilities). Resident #7 becomes agitated and "abusive" in the evening with escalation at night. Could we have an order for [REDACTED]. The nurse requested either a routine order or something as needed;-Physician response: Discontinue [MEDICATION NAME]. [MEDICATION NAME] 0.5 mg every night as needed. Record review of Resident #7's nurse's notes showed the following information: -On 1/7/14 at 4:15 P.M., discontinue [MEDICATION NAME] and start [MEDICATION NAME] (antianxiety) 0.5 mg at bedtime as needed.-Between 1/7/14 at 11:00 A.M., to 1/12/14 at 12:11 A.M., staff did not document any further monitoring or assessment of the resident's behaviors;-On 1/12/14 at 12:11 A.M., LPN R documented Resident #7 was speaking loudly and complaining about Resident #15. Resident #7 called out and the aide answered the call light. Resident #7 said, "I want that curtain pulled all the way, I don't care if Resident #15 is cold". The aide said, "The nurse wants the curtain out of your eyes, yet where Resident #15 can feel the heat". Resident #7 said, "You're an[***] ". The aide left the room and Resident #7 continued to complain. The nurse documented he/she would observe and monitor for behaviors.-Between 1/12/14 at 12:11 A.M. and 1/14/14, staff did not document further monitoring or assessment of the resident's behaviors. Record review of Resident #7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of Resident #15's nurse's notes showed the following information: -Between 1/6/14 at 11:20 P.M. to 1/14/14 at 11:20 P.M., staff did not document any further monitoring or assessment of Resident #15 being afraid and upset with Resident #7. Staff did not document any interventions put in place to protect Resident #15. During the initial tour of the facility on 1/13/14 at 9:50 A.M., RN A said Resident #15 was alert with confusion but interviewable. The resident was [AGE] years old. The resident has claustrophobia. Resident #7 does not like the light from the hall and it starts a World War III between Resident #7 and Resident #15, but after 5:00 A.M., there is some improvement. Resident #15 stays in bed most of the time and eats most meals in his/her room. Observation and interview showed Resident #15 was small-framed and short in stature. The resident appeared his/her stated age. The resident laid in the bed with the head of the bed elevated. He/she smiled, was pleasant and answered questions appropriately. During the initial tour of the facility on 1/13/13 at 9:55 A.M., RN A said Resident #7 was alert with confusion but interviewable. The resident stays in his/her room most of the time, does puzzles and reads. The resident had been recently moved from another hall. RN A was not sure if the resident had issues on the other hall. The resident had a [DIAGNOSES REDACTED].#15, staff got an order for [REDACTED]. (Record review of the MAR indicated [REDACTED]. Observation showed the resident laid in bed on his/her back. During observation and interview on 1/13/14 at 4:12 P.M., Resident #7 sat on the side of his/her bed. The resident was alert with confusion. He/she wanted to know what time dinner was. The resident was not very hungry, just feeling anxious about it, but not sure why. The resident said staff treat him/her "good", if they didn't I'd give them a what for". Observation between 1/13/14 and 1/14/14, showed Resident #7 and Resident #15 remained in their room majority of the time together. The residents left the room for lunch and dinner meal and for bathing. Resident #7 and #15 rarely participated in activities outside of the room. Record review of Resident #7's care plan on 1/14/14, showed staff documented the following information:-Problem: -Between 11/19 to 1/14/14, staff did not address the resident's escalated agitation, verbally and physically abusive behaviors and threatening/taunting of resident's and staff;-On 1/13/14, the physician recently put the resident on some medications to help him/her stay calm;-Goals: Staff still did not implement any goals related the resident's sundowners or behaviors. Staff did not implement any goals for the new medication to calm the resident;-Approaches: -On 1/13/14, monitor the resident for symptoms of anxiety/agitation and administer my [MEDICATION NAME] as needed per order and monitor for side effects and effectiveness.- Staff still did not implement any approaches related the resident's sundowners or behaviors. -Between 11/19 to 1/14/14, staff did not implement any approaches related to the resident's escalated agitation, verbally and physically abusive behaviors and threatening/taunting of resident's and staff. During an interview on 1/15/14 at 8:46 A.M., Resident #15 said:-Resident #7 pulls the curtain closed and it made Resident #15 "go crazy" (when it happened);-When Resident #15 was five years old, his/her two brothers locked him/her in a refrigerator (the resident was tearful). He/she always made sure things were opened. -When his/her family member takes the resident to the physician, the resident made sure the family member knew to tell the physician to keep the door open during the examination. -The resident said he/she lived in the bed by the window for three years (at the facility). -He/she kept the shades open and the (privacy) curtain pulled back to see the opened door to the hallway. -When Resident #7 moved in (to the first bed), he/she would close the (privacy) curtain and close the shades. -Staff switched the roommates where Resident #15 lived by the door and Resident #7 lived by the window now. -Resident #15 said when he/she lived by the window, he/she was happy because the shades were open. -Resident #15 said, one time Resident #7 walked in the front door, by Resident #15's bed, cussing and kept saying, "Goddamn" and yelled at Resident #15.-Resident #15 did not think Resident #7 was normal. Resident #7 undressed at night. Resident #15 thought, "God, I hoped (Resident #7) doesn't pull that curtain." -Resident #15 said it was an "awful feeling". -Resident #15 was always nice to Resident #7 and never said a cruel word to Resident #7. -Resident #15 never knew when Resident #7 would "act out". -Resident #7 made jokes but then would be "mean". -Resident #15 never forgot the incident that happened. -Resident #7 could not stand the light (shining) in the hallway. Resident #7 pulled the curtain closed and get so mad (if the curtain was open). -Resident #15 asked staff to check on him/her because he/she was afraid. -Resident #15 would "pray to Jesus to protect" him/her. -Resident #15 said he/she felt like his/her stomach shook when he/she was in the room with Resident #7. -Resident #7 wanted to close the door but Resident #15 had to keep the door open. -Resident #15 asked, "What am I, chopped liver?" -Resident #15 wanted a different roommate. He/she said, "Oh God, if (Resident #7) could go away." -Resident #15 just never knew when Resident #7 was "going to snap." -Resident #15 was nervous Resident #7 would find out about this interview. Resident #15 begged the surveyors, "Please, don't say anything to Resident #7). -I don't know what I'd do if (Resident #7) knew. I just don't know what (Resident #7)'d do to me." -When surveyors told Resident #15, they would talk to social service about getting a different roommate, Resident #15 had tears in his/her eyes and said, "Can you really do that? Oh thank you, Jesus". During an interview and record review on 1/15/14 at 9:30 A.M., SSD and the admission coordinator said the following: -SSD completes the psych

Based on observations, interviews, and record review, the facility failed to put interventions in place for one resident (Resident #1) who the facility identified as at risk for [MEDICAL CONDITION]. Staff did not implement weight loss interventions in a timely manner to address the resident's weight loss and as a result the resident lost additional weight. Resident #1 had 26 pounds or 17.3% severe loss in five months. 12.2 pounds or 8.9% severe loss in three weeks. Twenty residents were sampled out of a facility census of 113. Federal Guidelines define suggested parameters for evaluating significance of unplanned & undesired weight loss as: -1 month loss of 5% indicates significant weight loss and greater than 5% indicates severe loss; -3 months loss of 7.5% indicates significant weight loss and greater than 7.5% indicates severe loss; -6 months loss of 10% indicates significant weight loss and greater than 10% indicates severe loss. Record review of "The Diet Manual", a comprehensive resource and guide for facilities (available on the Department's website), Becky Dorner and Associates, Inc, Akron, Ohio, 2006 showed the following information: -The goal of medical nutrition therapy is to stabilize the weight, identify underlying causes or factors contributing to the significant unplanned weight loss, and intervene as appropriate to resolve the problem. -Significant weight loss (which also included a 1-2% weight loss in one week in addition to the federal guidelines); -Review the food intake records; -Assess the risk of [MEDICAL CONDITION], identify potential causes, and document findings in the medical record; -Review the plan of care; -Interview the individual to identify possible causes and to determine appropriate interventions; -Request/implement nutrition interventions; -For residents that have 1% to 2% weight loss in a week, staff should provide individualized aggressive calorie augmentation. This may include, but is not limited to: high calorie/high protein supplement, whole milk or cream, extra mayonnaise or gravy on foods, pudding/ice cream/milk shakes/sherbet; enhanced foods (high calorie/protein), and cater to individual preferences as much as possible; -Confer with appropriate family, staff and physicians regarding intervention to be taken. Record review of the facility interdisciplinary weight loss/gain risk team protocols dated 9/17/12, showed in part the following information:-Purpose: monthly weight meetings and weekly Patient At Risk (PAR) meetings will provide an avenue to monitor weight loss, determine reason for weight loss, identify appropriate interventions for corrective plan of actions and determine follow up to monitor resident progress;-Weight loss discussed at each weekly PAR meeting:-PAR team discussion to determine interventions to correct and possibly prevent further weight loss;-Physician will be faxed with the following situations: -Significant weight loss (5% in one month, 7.5% in 3 months or 10% loss in 6 months); -Interventions may include, but not limited to: snacks, extra portions, and supplements. Record review of Resident #1's medical record showed the following information: -Staff admitted the resident on 8/20/13; -Admission weight 150 pounds; -Regular diet; -[DIAGNOSES REDACTED]. Record review of the weight record (part of the resident's medical record) showed the following information: -8/24/13: 146 pounds; -9/1/13: 146 pounds; -9/7/13: 137.6 pounds; -9/15/13: 141 pounds. Record review of the dietary progress notes, dated 9/24/13, showed the dietary manager (DM) documented the resident weighed 141 pounds, was down 6% in the last month, due to dentures not fitting right, and resident had sores on mouth so would monitor. The DM did not document any further interventions. Record review of the weight record showed on 9/29/13, the resident weighed 140.8 pounds (which was a 9.2 pound loss since admission, 6.2% severe loss in 30 days). Record review of the nutritional assessment report showed the following information: -Data entry date: 8/27/13: -Current body weight, 146 pounds; -Has tremors; -At risk for [MEDICAL CONDITION]; -No supplements; -Resident is alert and able to voice needs. Resident has Parkinson with new tremors but does not want any adaptive devices at this time. -Has been maintaining weight but appetite is only fair. Will have Registered Dietitian (RD) follow-up; -On 9/29/13, the RD came to the facility and documented the resident weighed 140.8 pounds. (9.2 pounds loss since admission. 6.2% severe loss in 30 days). Record review of the dietary progress notes on 9/29/13, showed the RD documented the resident weighed 140.8 pounds. Weight is stable for 3 weeks. (the weight record showed the resident's weight fluctuated during the three weeks) but had a 3.4% loss from 8/24/13 to 9/29/13. (Since admission on 8/20/13, the resident had a loss of 9.2 pounds or 6.2% loss). Intakes averaged 55% which is fairly normal for the resident. [MEDICAL CONDITION] does not seem to be an issue. No recommendations at this time. Record review of the physician's orders [REDACTED]. Record review of the October and November 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] times a day to the resident. Record review of the weight record showed the following information: -10/5/13: 136 (14 pounds loss or 9.2% since 8/20/13); -10/9/13: 137.8 pounds; -10/19/13: 138 pounds; -11/3/13: 138.8 pounds; -Record showed the resident's weight stabilized while receiving the house supplement. Record review of the quarterly Minimum data set (MDS), a federally mandated assessment instrument completed by facility staff dated 11/20/13, showed the following information:-Moderately impaired cognitive decision-making skills -Extensive staff assistance for transfers, toileting and personal hygiene;-Supervision and set-up assistance for eating;-Weight 138 pounds. Record review of the care plan dated 11/21/13, showed the following information: -[DIAGNOSES REDACTED]. Record review of the dietary progress notes showed the following information: -Between 9/29/13 to 11/20/13, showed staff did not document regarding the new order for the house supplements. -On 11/20/13, the resident's current weight was 138.8 pounds, up 1% in the last month and up 8% in the last three months (the weight record showed a 11.2 pound loss in 3 months, still down 7.2%). Still doing well, no changes. -On 12/2/13, the resident having trouble swallowing meat, resident placed on mechanical soft diet. Record review of the weight record showed on 12/8/13, the resident weighed 137.8 pounds. Record review of the nurse's notes showed the following information: -12/4/13, change in condition, more confused and lethargic. Required feeding assist and increased activities of daily living (ADL) help; -Between 12/4/13 to 12/14/13, the resident had episodes of low blood sugar, low blood pressure and increased agitation; -admitted to the hospital from 12/15/13 to 12/19/13. Record review of the weight record showed on 12/12/13, the resident weighed 133 pounds. Record review of the medical record showed the following information: -Staff readmitted the resident on 12/19/13; -Regular diet; -133 pounds; -Staff did not document any orders for house supplements. Record review of the nurse's notes on 12/20/13, showed the resident had a fair appetite. Record review of the weight record showed on 12/23/13, the resident weighed 135.6 pounds. Record review of the nurse's notes showed on 12/23/13, staff sent the resident to the emergency room for low blood pressure. The resident returned the same day. Record review of the nutritional progress note showed the following information: -Data entry date: 12/26/13: -Current body weight 135 pounds; -Has tremors; -At risk for [MEDICAL CONDITION]; -No supplements; -Resident had a hospital stay with a little weight loss, but he/she is up 2 pounds this week but down 15 pounds from admission on 8/21/13. RD did not interview the resident because of confusion. Intakes have varied since readmission. Resident did not eat well yesterday, but ate 100% of breakfast today. Current weight is 135.6 with a 2 month range of 133 to 138. Record review of the weekly weight record (used by staff to record all residents on weekly weights. Staff were to transfer the weekly weights to the resident's medical record) showed on 12/28/13, staff documented the resident weighed 136.2 pounds. Record review of the fax communication to the physician dated 12/31/13, showed the following information: -Resident has trouble swallowing, was on mechanical soft diet but returned from the hospital with an order for [REDACTED]. May we change back to mechanical soft diet; -Physician order: okay with above. Record review of the dietary progress notes dated 1/2/14, showed the DM noted the resident's current weight 135.6 pounds, is down two pounds from the last month, still having chewing and swallowing problems per staff and needs encouragement to eat. The DM did not document any further interventions. Record review of the 14 day MDS assessment dated [DATE], showed the following information: -Weight 135 pounds;-Signs and symptoms of swallowing problems: staff marked none of the above;-Nutritional approaches: staff marked none of the above. Staff did not check the resident received a mechanically altered diet. -Weight loss: 5% or 10% loss in 6 months: staff marked "no"(resident had been at facility for 5 months. Admit weight on 8/21/13, 150 pounds. 15 pound loss in 5 months equals a 10% weight loss). Record review of the nurse's notes on 1/4/14, staff documented the resident's appetite was poor. Record review of the weekly weight record showed the following information: -1/5/14, 127 pounds; -1/6/14, 124.8 pounds; -1/7/14, 125.6 pounds. -Staff did not document the 1/6/14 and 1/7/14 weight in the resident's medical record. Record review of the dietary progress notes on 1/7/14, showed the DM documented the resident's current weight 127 pounds was down 7% in the last month (weekly weight record on 1/7/14, showed the resident weighed 125.6, 11.2 pounds since 12/28/13 or 8.2% severe loss, 23 pound loss or 15.3% since 8/21/13). The DM spoke to the nurse. The resident is on a mechanical soft diet, [MEDICATION NAME] for depression, multivitamin and [MEDICATION NAME] (diuretic) 20 milligrams. The DM did not document any further interventions. The DM did not document she notified the physician of the resident's severe weight loss. Record review of the care plan revised on 1/7/14, showed the DM documented the resident had weight loss last month. The DM did not include any goals and/or interventions for the resident's weight loss. During an interview on 1/16/14 at 10:00 A.M., with the administrator, DM, RD and Director of nursing (DON), the DM said during the 1/8/14, patient at risk (PAR) meeting, staff calculated the resident's weight loss but did not implement any new interventions. The DM did add the resident to the RD list of residents to see on her next visit. The DON said the resident was on a diuretic. During an interview on 1/16/14 at 10:10 A.M., the RD said the resident was on a diuretic, but it was a maintenance dose. Record review of the nurse's notes showed the following information: -On 1/8/14, three day eating average done. Results of 15%. Resident appetite poor. -On 1/10/14, resident appetite poor; -On 1/11/14, poor appetite, encouraged to eat; -On 1/12/14, poor appetite, encouraged fluids and food; -Between 1/8/14 to 1/12/14, staff did not document they notified the resident's physician of the resident's severe weight loss and poor appetite. Staff did not document any new interventions started. Record review of the weekly weight record on 1/11/14, showed staff documented the resident weighed 124 pounds. (26 pounds or 17.3% since 8/21/13, 12.2 pounds or 8.9% since 12/28/13). Record review of the meal intake record showed staff documented the resident's intake for the following days: -On 1/7/14: Breakfast: 5% Lunch: bites Dinner: 20%; -On 1/8/14: Breakfast: 5% Lunch: 5% Dinner: 25%; -On 1/9/14: Breakfast: 5% Lunch: 40% Dinner: 30%; -On 1/10/14: Breakfast: bites Lunch: bites Dinner: 15%; -On 1/11/14: Breakfast: 20% Lunch: 30% Dinner: 30%; -On 1/12/14: Breakfast: refused Lunch: 30% Dinner: 50%; -On 1/13/14: Breakfast: 10% Lunch: 5% Dinner: 50%. During the initial tour of facility on 1/13/14 at 9:36 A.M., registered nurse (RN) A said the resident was alert and interviewable. The resident had [MEDICAL CONDITION] and diabetes. The resident had had a decline in function, cognition and increased tremors. The resident had weight loss and a poor appetite. Observation showed the resident laid in the bed. Resident alert and appropriate with responses. The resident said he/she did not have much of an appetite lately. Record review of the dietary progress notes on 1/13/14 at 5:30 P.M., showed the RD documented the resident weighed 127 pounds which represents an undesirable loss of 6.3% over three weeks (most current weight was 124 pounds on 1/11/14, 11.6 pounds or 8.5% loss in three weeks. This was the first documented intervention by staff. The DM documented regarding the resident's severe weight loss on 1/7/14. The staff documented the resident lost 3 more pounds between 1/7/14 to 1/11/14). Record review of the fax communication to the physician dated 1/13/14, showed the following information: -6.3% weight loss in three weeks. Received house supplements before but not at this time; -Recommend house supplements 90 ml three times a day with medication pass; -Physician order: house supplement 120 ml three times a day; -Noted by staff at 8:20 P.M. Observation and interview on 1/14/14, showed the following information: -At 7:28 A.M., the resident sat in the wheelchair in the dining room;-At 7:35 A.M., staff served the resident breakfast;-At 8:05 A.M., the resident sat at the table with his/her food in front of him/her. The resident had a bowl of cereal, mechanical texture meat with gravy, eggs, mandarin oranges and a whole glazed donut. The cereal bowl sat in the middle of the plate surrounded by the other food items. RNA E encouraged the resident to eat his/her cereal. The resident said "I will". The resident took a small bite of cereal. The resident had not eaten any of the other food. -At 8:10 A.M., and 8:12 A.M., the resident had not taken any further bites of food. Staff were not present at the table;-At 8:18 A.M., RNA E reentered the dining room and told the resident he/she had not eaten much and this was his/her favorite cereal. RNA E gave the resident a few bites of cereal. The resident said he/she was full. The resident had eaten less than 50% of the cereal and 0% of the eggs, meat and doughnut;-At 8:20 A.M., RNA E documented the resident ate 20% of his/her breakfast. RNA E did not offer the resident any other food or drink and wheeled the resident out of the dining room. -At 12:20 P.M., the resident sat in the wheelchair in the dining room. The resident said he/she did not have much of an appetite, just did not "feel" hungry. He/she was trying to eat more. The resident said his/her mom fixed three big meals and "you ate what was in front of you". The surveyor asked the resident if he/she fixed big meals for his/her family. The resident said yes. The resident looked at the food in front of him/her and said, "that's a lot of food, I know I need to eat". -At 12:50 P.M., staff served the resident Alfredo noodles, bread, salad, and dessert. -At 12:55 P.M., staff checked with the resident. The resident said it was good.-At 1:00 P.M., the resident continued to pick at his/her food and ate small bites. Record review of the meal intake record showed on 1/14/14, staff documented the resident ate 10% of his/her lunch. Record review of the MAR indicated [REDACTED].M., showed from 1/14/14 to 1/15/14, staff initialed they administered the house supplement to the resident as ordered four times. On 1/15/14, at approximately 9:30 A.M., upon request of the state surveyor, certified nurse assistant (CNA) B weighed the resident. The aide said the resident weighed 124.4 pounds. During an interview on 1/15/14 at 4:00 P.M., the DM said the following: -Staff weighed the residents weekly for four weeks when admitted . If there was loss or gain of 5 pounds, the staff weighed the resident for three days in a row. -Staff had the PAR meeting weekly;-The RD comes to the facility 2-3 times a week;-The computer system triggers a resident's weight loss but staff still had to check the chart for current information to verify the resident's weights;-Resident #1 had some change in status and a decrease in appetite;-The resident had received house supplements prior to his/her hospital stay on 12/19/13;-The DM said he/she was not aware the resident was not receiving house supplements prior to the new order on 1/13/14. The house supplement intervention was not addressed in the 1/8/14 PAR meeting;-A NIP (nutritional intervention program) was a high calorie diet and was an option. Resident #1 was not put on the NIP, but the resident would benefit from it;-On 1/7/14 the resident weighed 127 pounds. The DM said she did not add any interventions, but did add the resident to the RD list. The RD saw the resident on 1/13/14. During an interview on 1/16/14 at 9:05 A.M., the administrator, DM, RD and DON were present. -The RD said the DM tracked the weights and notified her of any concerns. -The DM said on 1/7/14, she did not implement any interventions. She just added Resident #1 to the RD list; -The DM said the NIP program was for all residents in the facility, only a few residents were not on it. The dietary staff added butter to potatoes, gave residents high calorie supercereal or oatmeal for breakfast. Staff gave Resident #1 supercereal for breakfast. Surveyor reported the resident did not receive supercereal or oatmeal for breakfast. The DM said, "Oh, he/she didn't?" The DM then recalled the resident ate cinnamon cereal brought in by his/her family;-The RD said the DM or nursing staff can get an order for [REDACTED]. The RD said she goes by the weights recorded in the chart when completing her assessments; -The RD said the weekly weights should have been charted in the resident's medical record for her to review. During an interview on 1/16/14 at 10:10 A.M., the RD said the staff was going to add the resident's weekly weights to his/her record. During observation and interview on 1/16/14, at 12:45 P.M., Restorative nurse assistant (RNA) D said the resident was in the main dining room and then was moved to the assisted dining room. The resident had a poor appetite. He/she attended the weekly PAR meeting and reported if a resident had any eating concerns. Observation showed the resident sat in the wheelchair in the dining room. The resident was alert with slow appropriate responses. The resident said he/she feels good today. His/her appetite was the same. Surveyor asked the resident if he/she liked the shakes the staff had given him/her the past few days. The resident said, "Oh yes, I really do". Told the resident the shakes had a lot of calories. The resident said, "Oh good". CNA C asked the resident what he/she wanted to drink, then asked the resident if he/she wanted some chocolate milk. The resident said he/she did not like chocolate milk. CNA C served the resident water and juice. Staff served the resident meatloaf, vegetables and desert. Surveyor asked the resident if the food looked good and if he/she liked meatloaf. The resident said, "oh it's alright, I guess". Staff laid the resident's diet card on the table. The card showed the resident disliked chocolate milk.