Every finding on record at Oak Knoll Skilled Nursing & Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure staff provided adequate supervision and assistance to prevent accidents for two out of three residents sampled for falls. Staff failed to put leg rest on one resident's wheelchair, who put his/her feet down while staff propelled the chair, resulting in the resident falling from the wheelchair. The resident obtained a laceration on his/her forehead (Resident #76). In addition, staff failed to follow acceptable standards of practice when staff transferred the resident without using a gait belt (a transfer belt secured around the resident's waist, over clothing, used to steady and guide a resident who bears some weight) (Resident #53). The census was 69. Review of the facility's Fall Management Policy and Procedures policy, dated 10/11/23, showed:-The facility assesses each resident for fall risk, designs an individualized care plan, and implements interventions to minimize falls and/or injury while striving to promote resident safety and protect resident rights and dignity;-Collection of circumstances at time of fall:-Interventions implemented to minimize future falls. 1. Review of the facility's undated Wheelchair Seating and Positioning policy, showed:-It is the policy of the facility that every resident who uses a wheelchair is assessed for proper chair fit and seating needs, and is positioned according to the individualized care plan;-Positioning device -footrest, used to maintain safe and functional alignment;-Footrests are swung away or removed before transfers and are in place before the chair is moved. Review of Resident #76's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 05/05/26, showed:-Cognitively intact;-Impairment in functional range of motion: upper extremity on one side;-Mobility devices normally used: wheelchair;-Diagnoses included: non-Alzheimer's dementia, depression, and schizophrenia (serious mental disorder in which people interpret reality abnormally). Review of the resident's care plan in use at the time of survey, showed:-Focus: Resident had a history of falls with injury including nose fracture related to unsteady gait, poor safety awareness, sensory impairment, high risk medications, cognitive impairment, urinary incontinence, and age. When utilizing wheelchair refuses to use wheelchair legs so he/she can self-propel. He/She will self-report falls and ask if staff will be coming to his/her room or taking vital signs etc. 7/15/26 fell out of wheelchair;-Goal: will remain free from serious injury through next review date;-Interventions: The care plan failed to show a new intervention after fall on 7/15/26 and failed to direct staff when to use the wheelchair and if any positioning devices or foot pedals were needed. Review of the resident's Physical Therapy Discharge Summary, date of service: 1/28/26 through 5/21/26, showed:-Medical history: history of multiple recent hospitalizations due to decreased levels of functioning in all areas (mobility, activities of daily living (ADL), eating, etc.);-Prior equipment: wheelchair;-Transfers and ambulation required supervision or touching assistance;-Wheelchair mobility: no;-Discharge reason: highest practical level achieved;-Discharge recommendations: continue with staff at current level. During an interview on 7/20/26 at 2:20 P.M., the resident said he/she fell last week when staff were propelling him/her in the wheelchair. Review of the progress notes dated 7/15/26, showed:-At 8:35 A.M., student was propelling resident to the dining room, resident does not utilize wheelchair legs, elected to hold both feet up while being propelled, resident put both feet down without saying anything to the student, causing the resident to catapult out of the wheelchair landing on his/her face. When the nurse arrived to assess situation, resident had rolled onto his/her left side, bleeding from laceration to left side of forehead;-At 8:25 A.M. Resident observed laying on left side in dining room with a laceration to left side of forehead, bright red blood noted on floor, actively bleeding from laceration, resident breathing on his/her own, able to answer questions, did not lose consciousness, nurse applied pressure, 911 called for transport to emergency room, when assisted to stretcher via Emergency Medical Service (EMS) x two resident complained of pain to upper and lower back, transported to hospital;-At 9:12 P.M. Resident returned from hospital at 03:00 P.M., glue noted on forehead laceration. Observation on 7/21/26 at 9:15 A.M., showed Staff M and Staff N walked with the resident down the hall towards the dining room, just after they crossed the intersection in the hall, they stopped walking. Staff M instructed Staff N to stand behind the resident and then he/she walked down the hall. A few minutes later Staff M returned with a wheelchair. The resident sat down in the chair. There was no leg rest on the chair. Staff instructed the resident to hold his/her feet up and propelled the resident to the dining room. Observation on 7/22/26 at 8:45 A.M., showed the resident in the dining room and sat in a wheelchair. No leg rests on the wheelchair. During an interview on 7/22/26 at 10:25 A.M., the Director of Rehab said during the morning meeting, they discussed resident who has fallen and try to determine why the resident fell and if a new intervention needs to be put into place. New interventions are communicated to the staff by the Director of Nursing (DON)/Assistant DON. The resident ambulates on his/her good days and other days he/she cannot walk. On those days staff use a wheelchair and sometimes when the resident is in a wheelchair, he/she will get up and walk. The resident can hold his/her legs up or staff can use the leg rest as needed. The resident's ability varied shift to shift. During an interview on 7/22/26 at 10:40 A.M., Certified Nursing Assistant (CNA) O said some days the resident was able to walk and other days he/she used a wheelchair. The day the resident fell, a student propelled the resident to the dining room. The resident put his/her feet down and fell. CNA O did not know if the resident had leg rests on his/her wheelchair or not. The student did not know the resident used leg rests. The leg rests are usually kept in the resident's room. If there were no leg rest in the room, he/she would assume the resident did not use them. Observation on 7/22/26 at 1:10 P.M., showed the resident at the dining room table in a wheelchair with leg rest on. At 1:45 P.M. the resident said he/she liked the leg rests on the wheelchair. During an interview on 7/23/26 at 12:40 P.M., Licensed Practical Nurse (LPN) G said most of the time the residents walked, other times the resident cannot do anything. When the resident was unable to do anything, staff used a wheelchair. It depended on the resident's mood on whether he/she would allow staff to put the leg rest or not. Sometimes when the leg rest is on the wheelchair, the resident will get up and walk. During an interview on 7/23/26 at 3:06 P.M., LPN I said post-fall the facility tried to figure out the cause of the fall and look to see if a new intervention needed to be implemented. New interventions are added to the care plan. Prior to the resident's fall, staff were encouraging the resident to use the leg rest, but he/she refused. The resident could hold his/her feet up. The day of the fall, LPN I was called to the dining room where he/she saw the resident lying on the floor with a laceration to the forehead that was actively bleeding. The nurse applied pressure while LPN I made the phone calls. A student was propelling the resident, and the resident put his/her feet down and was catapulted to the floor. LPN I did not get a chance to talk to the student to find out if the student was propelling the resident too fast or if the resident could not hold his/her feet up. There is no policy showing the residents must use leg rest on their wheelchairs. The intervention the facility put in place post fall was for staff to encourage the resident to use leg rest on the wheelchair. During an interview on 7/23/26 at 5:06 P.M., the DON said LPN I told her that a student was propelling the resident in wheelchair while the resident was holding his/her feet up. The resident planted his/her feet on the floor and fell out of the wheelchair. The DON said she talked with the resident, and she denied it. They talked about using leg rest and the resident did not want to use them because he/she could not propel him/herself in the wheelchair. During an interview on 7/23/26 at 1:26 P.M. the Administrator said residents who staff propel in wheelchairs should have leg rest on the wheelchair. 2. Review of the facility's undated Resident Transfers, Mechanical Lifts, and Gait Belts policy showed:-It is the policy of the facility that every resident is transferred and ambulated only by themethod, equipment, and number of staff identified in the resident's current assessment and care plan. A gait belt is used for all assisted transfers and ambulation unless contraindicated and documented;-Transfer status is assessed on admission, quarterly, upon significant change in condition, following any fall, and upon return from hospitalization. Assessment is completed by nursing in coordination with therapy and reflected in the care plan;-The resident's transfer method, equipment, and required number of staff are posted or communicated through the care plan, the CNA assignment sheet or Kardex (patient care summary), and shift report. Staff verify transfer status before every transfer;-A gait belt is applied snugly over clothing at the waist, with the buckle in front and two fingers able to fit under the belt. Staff grasp the belt with an underhand grip, keep the back straight, and never pull on a resident's arms, shoulders, or clothing. Review of Resident #53's annual MDS, dated [DATE], showed the following:-Severely impaired cognition; -Substantial/maximal assistance from staff for chair/bed-to-chair transfer;-Physical impairment of one upper and one lower extremity;-Mobility device: Wheelchair;-Diagnoses included Paraplegia (impairment in motor or sensory function of the lower extremities), depression, and stroke. Review of the resident's care plan, dated 6/19/26, and in use during the survey, showed the following:-Problem: Falls: Resident is at risk for falls related to impaired balance due to right side weakness. He/She also can become impatient and try to place him/herself in bed at times;-Goal: He/She will be free from serious injury through next review date;-Approach: Placed in fall prevention program. Place in supervised area when out of bed. Keep call light within reach. Provide assistance for transferring. Remind the Resident not to transfer without assistance;-The care plan did not identify the type of transfer required. Review of the Resident's physician order sheet (ePOS) did not show an order for means of transfer for the Resident. Observation on 7/22/26 at 12:22 P.M., showed a staff person in the resident's room assisted the resident. He/She sat the resident up in the bed and swung both the resident's legs to the side of the bed. He/She placed shoes on the resident. He/She then grabbed the resident by the back of his/her pants and placed the Resident in his/her chair. No gait belt used. After placing the resident in his/her wheelchair, the staff person grabbed the resident by the back of his/her pants, yanked on the pants, and adjusted him/her in his/her wheelchair. During an interview on 7/24/26 at 2:45 P.M., with the Administrator and the DON, the DON said the resident self-transfers on his/her own although staff encourage him/her to let staff transfer him/her. Staff transfer him/her via a gait belt. She would have expected staff to use a gate belt when providing transfer assistance to the resident. She had extra gait belts in her office if staff needed them. 3044550

Based on observation, interview and record review, the facility failed to investigate an injury of unknown origin for one of three sampled residents (Resident #1). The census 67. Review of the facility's policy on Injuries of Unknown Origin, updated 4/30/20, showed the following: -Investigation should include Who, What, When, Why and How. Enable the investigator to record the information and establish a reasonable cause known source of the incident or injury within 24 hours of the incident or injury. If the investigator is unable to establish a reasonable cause or known source, further investigation is required. -Extended Investigation: Further investigation is required if there is Injury of Unknown Origin or Suspected Abuse within 24 hours and 1 hour for Abuse. The following will be needed: Statements from all involved witnesses and reporters. Expand the time frame surrounding the incident for collecting data and begin timeline. Follow-up on new information. Obtain related professional expertise. If the suspected perpetrator is staff, interview the other residents the staff person was assigned to. Gather assignment sheets and begin conducting interviews. Additional information obtained in the investigation should allow the investigator to answer the Who, What, When, Where, Why and How and lead the establishment of a reasonable cause. If the reasonable cause cannot be established in either investigative phase, the cause should be reported as unknown; -Corrective Action Required Following: After the investigative phase is completed, the nursing home is required to take action based upon the findings to correct the known and reasonable causes as well as the prevent further reoccurrence of the alleged incident. -Evidence of Investigation: The resident's record must include enough information about the incident to enable staff to identify, plan for and meet the resident's needs. Evidence of the investigation must be readily available to state licensing and certification staff and others according to their authority. Review of Resident #1's 5 Day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/9/25, showed the following: -Diagnoses of Alzheimer's disease, high blood pressure and pneumonia; -Short/Long term memory loss; -Required maximum assistance of staff for bathing, dressing, grooming and toilet use; -Required moderate to maximum staff assistance for transfers; -No open areas or bruises. Review of the resident's progress note, dated 5/26/25 at 8:22 A.M., showed the following: -Sent to the hospital related to swelling and pain of the left hip; -Resident has shortness of breath and congestion; -Family and physician aware; -No documentation regarding the resident's skin. During an interview on 5/29/25 on 1:30 P.M., hospital staff said the resident has a second degree burn with blistering on the dorsal side (back side) of his/her right hand overlying first and second metacarpal (bones in your hand that connect your wrist to your thumb and finger bones) that is of superficial partial thickness. He/She also had a couple of little spots of blistered skin on his/her fingers on the inside of his/her hand, as well as burns on his/her left hand and thigh. The Director of Nursing (DON) told the hospital staff she had no idea how the resident could have gotten burned, because he/she does not have access to anything hot like a coffee pot or curling iron. His/Her spouse visited him/her at the facility on May 26, 2025 and said he/she did not have the burns then. Observation on 6/5/25 at 10:15 A.M., showed the resident lay in a low bed next to the wall with a fall mat on the right side. The resident's left hand showed a healing wound approximately 4 centimeters (cm) in size. During an interview on 6/5/25 at 10:10 A.M., Certified Nurse Aide (CNA) B said he/she has taken care of the resident on the day shift. He/She recently saw the wound on his/her left hand. The resident didn't have the wound prior to him/her going on vacation a week ago. CNA B doesn't know how he/she developed the wound. During an interview on 6/6/25 at 10:22 A.M., Registered Nurse (RN) A said he/she was the charge nurse on 5/26/25. Staff reported the resident complained of left leg pain. During the assessment, the resident's leg appeared swollen and he/she complained of pain. An order was received to send the resident to the hospital. CNA D reported a blister to the resident's left hand when the resident was on his/her way to the hospital. RN A did not assess the resident's skin and did not notice the blister to the left hand. He/She was more focused on the resident's leg. RN A failed to document the blister or report it to the DON. During an interview on 6/5/25 at 2:50 P.M., Licensed Practical Nurse (LPN) C said he/she was made aware of the blister to the resident's left hand when the resident was on his/her way to the hospital. The blister was fluid filled and intact at the time of transfer. LPN C failed to document the blister in the medical record. During an interview on 6/5/25 at 3:10 P.M., the DON said the hospital called about the wound to the resident's left hand and asked whether the resident sustained a burn. The resident had no access to hot liquids. She interviewed the charge nurses but failed to talk to nurse aides. The staff failed to report the change in the resident's skin. She expected staff to report it to the nurse who should assess, notify the physician and document in the medical record. During an interview on 6/6/25 at 11:17 A.M., the Administrator said staff failed to report the blister prior to the resident going to the hospital. If staff had reported the blister, an investigation would have been done to determine the cause of the blister. He expected staff to report any changes to the resident's skin to the charge nurse. The charge nurse should assess, call the physician for orders and document in the medical record. MO00254960 MO00255257

Based on observation, interview and record review, the facility failed to ensure one resident was free from physical abuse from a staff member (Resident #1). The sample was six. The census was 68. The Administrator was notified on 5/27/25 at 1:22 P.M., of the past non-compliance, which occurred on 5/18/25. The facility provided in-servicing for all staff regarding the facility's abuse and neglect policy with emphasis on reporting in a timely manner. The deficiency was corrected on 5/20/25. Review of the facility's Abuse and Neglect Policy, dated 5/14/24, showed the following: -Purpose: The facility has a ZERO TOLERANCE policy on any form of abuse or neglect against residents. Each resident has the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, and neglect. All facility residents will not be subjected to abuse by anyone, including but not limited to; facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, visitors, friends, or any individual that is in the facility. -Definition: -Physical Abuse- includes pushing, hitting, slapping, punching, pinching and kicking. It also includes controlling behavior through corporal punishment and unwanted physical movement. -Identification and Investigation: -An investigation will ensue following a report of abuse, injury of unknown origin, or suspicion of abuse. -1. Staff, residents, family members & visitors are to report any suspected abuse to any of the following persons: -a. Administrator; -b. Director of Nursing (DON); -c. Charge Nurse; -d. Social Worker (Grievance Officer); -c. Administration Department Heads; -2. Incident/Accident Reporting Policy: The facility must begin the investigation immediately in order to collect accurate data related to the incident/accident. The facility will begin a timeline of events (before, during, after event occurred) to include resident and staff statements, security camera review and nurses' assessments. Federal law requires the facility to do a thorough investigation of the incident. In order for the facility to provide evidence of the thoroughness of the investigation, the information must be recorded in a facility self-report form. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/11/25, showed the following: -Severe cognitive impairment; -Physical and verbal behaviors; -Diagnoses of dementia, schizophrenia (a chronic brain disorder characterized by a range of symptoms that can include hallucinations, delusions, disorganized thinking, and negative symptoms), anxiety and depression. Review of the resident's care plan, dated 1/14/25, showed the following: -Problem: The resident has verbal and physical behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others, hitting/pushing others). He/She also has physical behaviors directed at him/her self such as throwing him/herself to the floor and into walls; -Resolution: Maintain a calm environment and approach the resident. Review of the resident's nurse's note, dated 5/18/25 at 6:53 P.M., showed it was reported to this writer that earlier today this resident was in an altercation with a staff member. It was told to this writer that this resident was laying on the couch and the housekeeper forcefully removed him/her off the couch. This resident does not remember the event and after evaluating his/her body there are no bruising or red marks found. The resident said he/she is not in any pain or discomfort at this time. Nursing will continue to monitor and assess. During an interview on 5/27/25 at 9:20 A.M., the resident said he/she was downstairs in the common area of the old building and Housekeeper (Hsk) A was cleaning. Hsk A asked him/her to move to the other room. The resident said he/she moved and Hsk A hit him/her in the face near his/her left eye. The resident said he/she feels safe. Observation at that time showed the resident did not have any bruising to his/her left eye. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -No cognitive impairment; -No moods or behaviors; -Diagnoses of high blood pressure, depression and schizophrenia. During an interview on 5/27/25 at 11:00 A.M., the resident said he/she was sitting in the common area in the old building across from Resident #1. Resident #1 lay on the small couch. Hsk A said to Resident #1, he/she needed to move. Resident #1 stood up in front of Hsk A and they started pushing each other. The resident said he/she saw Hsk A hit Resident #1 in the eye. The resident was not sure which eye. Resident #1 just walked away. The resident said he/she was not sure he/she should report the incident. The resident said later that day he/she told the receptionist. The resident said he/she feels safe. During an interview on 5/28/25 at 9:07 A.M., Certified Nurse Aide (CNA) B said he/she was in the breakroom in the old building and he/she heard Hsk A tell Resident #1 is was not time to smoke yet and go back upstairs. CNA B said he/she came out of the breakroom and told Resident #1 to go back upstairs until smoke time. CNA B said he/she went back into the breakroom. CNA B said Hsk A talks loudly. CNA B did not hear any type of argument. CNA B said he/she has heard Hsk A speak to residents inappropriately, but he/she has never reported the concern to the DON or the Administrator because other staff were around and he/she thought they would report it. CNA B said he/she was inserviced on the facility's abuse and neglect policy with an emphasis on reporting concerns immediately. During an interview on 5/28/25 at 9:20 A.M., Hsk C said he/she was mopping by the vending machine in the old building when he/she heard Hsk A and Resident #1 talking. Hsk A asked the resident to move over. Hsk C said he/she heard the resident get up and when he/she looked over he/she saw the resident make a fist and saw Hsk A holding the resident's wrist and telling the resident to calm down and the resident pulled away. Hsk C said he/she did not see anyone get hit. Hsk C said he/she did not report the incident because he/she thought it was resolved with the resident walking away. Hsk C said he/she should have reported the incident. He/She was recently inserviced on the facility's abuse and neglect policy regarding reporting immediately. During an interview on 5/28/25 at 9:53 A.M., Receptionist (Rec) D said on 5/18/25, he/she was sitting at the front desk talking with Resident #2. Resident #2 said did you hear what happened with Resident #1 and Hsk A? Rec D said no, what happened? Resident #2 said they were pushing each other and Resident #1 got hit. Rec D said we need to report this immediately. Rec D said he/she reported the incident to the charge nurse. Rec D said she was inserviced on the facility's abuse and neglect policy regarding reporting immediately. Review of Hsk A's employee file, showed documentation he/she was terminated on 5/19/25 for failing to report the altercation. During an interview on 5/28/25 at 1:22 P.M., the Administrator and DON said they expected all employees to follow the facility's abuse and neglect policy which includes reporting allegations or altercations immediately. The Administrator said he completed the inservices of all staff members on 5/20/25. MO00254467

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents was free from abuse. Certified Nurse Aide (CNA) A pulled on Resident #1's hair while taking the resident back to his/her room for hygiene care. The census was 62. The Administrator was notified on 4/3/25, of the past non-compliance. On 3/26/25, the management was notified of an abuse allegation that occurred the evening of 3/25/25. Upon notification of an abuse allegation on 3/26/25, the facility immediately suspended staff, investigated and implemented abuse/neglect in-servicing to all facility staff. During the onsite investigation, interviewed staff verified recent in-servicing and verbalized education. The deficiency was corrected on 3/26/25. Review of the abuse/neglect policy, revised 5/24/23, showed: -Purpose: the facility has a zero tolerance policy on any form of abuse or neglect against residents. Each resident has the right to be free from verbal, sexual, physical, mental abuse and neglect. Residents will not be subjected to abuse by anyone, including staff, other residents or any individual in the facility. The prime directive is to develop and operationalize policies and procedures for screening and training for all staff for protection of residents and the prevention, identification, investigation and reporting of abuse, neglect, mistreatment and misappropriation of property in an effort to prevent any occurrence of the abuse; -Definitions: -Abuse: a willful infliction of injury, unreasonable confinement, intimidation, pain, mental anguish or punishment with resulting physical/mental harm; -Physical abuse: includes hitting, slapping, pinching and kicking. It also includes controlling behaviors through corporal punishment; -Training: All staff will be trained upon orientation and continued facility in-service training that focus on facility policies and procedures related to abuse prohibition practices which include but not limited to: -What constitutes abuse, neglect and misappropriation of resident property; -Appropriate interventions to implement with aggressive behavior of staff, residents and visitors; -How staff, residents, and visitors should report their knowledge relating to any allegations without fear of retaliation; -How to recognize signs of burnout, frustrations and stress that may lead to abuse; -Prevention: Resident, families. Volunteers and staff are provided with information on how and to whom to report concerns, incidents, accidents, complaint, grievances and provide feedback without the fear of retribution. Concerns can be made directly or anonymously by filling out a complaint/grievance form and placing it under the administrator's and/or social worker designee's office door. Administration will identify, correct and intervene on all risk situations in which abuse, neglect and/or misappropriation of the resident property are likely to occur. The following is an analysis of intervention approach: -Sufficient deployment of staff on each shift to meet the needs of residents and assure that staff assigned have knowledge of the resident care needs; -Features of the physical environment where abuse and/or neglect incident/accidents are more likely to occur, such as secluded areas of the facility; -The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, and/or ignoring residents while giving care; -The assessment, care planning, and monitoring of all residents with needs and behaviors with may lead to conflict, abuse or neglect including residents with a history of aggressive behaviors, residents who have behaviors such as residents with communication disorders and those dependent on staff for assistance; -Identification and investigation: an investigation will ensue following a report of abuse or suspicion of abuse: -Staff, residents, family members and visitors are to report any suspected abuse to any of the following persons: Administrator, Director of Nursing (DON), nurse, social worker and administration department heads; -Reporting: the facility must begin the investigation immediately to collect accurate data related to the incident/accident. Investigation will include statements from staff and residents, security camera review and nurses' assessments. Review of Resident #1's medical record, showed: -admitted : 7/16/17; -Diagnoses included dementia without behavior disturbances, mood disturbance, anxiety, stroke, diabetes, aphasia (difficulty speaking), and contracture of the right hand. Review of the care plan, in use during the abbreviated survey, showed: -Problem: the resident is limited in ability to perform daily self care tasks due to right sided weakness; -Goal: the resident will have care needs met; -Approach: staff provide assistance with transfers, toileting, bathing and other care needs; -Problem: Cognitive loss/Dementia; -Goal: the resident will have positive experiences in daily routine; -Approach: calm the resident if signs of distress develop during the decision making process. Respect the resident's right to make decisions. Staff provide cues and supervision for daily care. Observation of the facility's video footage, dated 3/25/25, showed Resident #1 in his/her wheelchair in the dining room. Three staff were noted in the nursing station counter area. Certified Medication Technician (CMT) B, CNA A and CNA C. CNA A stood at the edge of the counter, speaking to the resident. The resident propelled away from the desk and CNA A approached the resident and spoke into the resident's ear. The resident used his/her left arm, swung behind himself/herself and stuck CNA A in the face as he/she propelled away. CNA A followed the resident and grabbed the resident's hair. The resident used his/her left hand and grabbed CNA A's left wrist. CNA A released the resident's hair and looked at his/her wrist and pushed the resident toward the hallway. CNA A grabbed the resident's hair again, released the hair and grabbed and held onto the hair a third time, as he/she pushed the resident down the hallway. CNA C and CMT B did not intervene during the incident. Review of CNA A's time sheet, dated 3/25/25, showed: -In: 3:36 P.M.; -Out: 10:55 P.M.; -No additional days worked after 3/25/25. During an interview on 4/3/25 at 8:22 A.M., the DON said on the morning on 3/26/25, she was notified by Resident #4 that Resident #3 had observed the interaction between CNA A and Resident #1 the evening of 3/25/24. Resident #4 recommended the DON view the camera. The DON said she and the Administrator viewed the footage and verified the allegation. Resident #1 received a skin assessment with no abnormal findings and due to his/her cognitive status, was not able to recall the incident. CNA A worked the evening shift and was not scheduled to return for duty for several days. The management team started an investigation, obtained statements, and suspended all of the staff in the footage pending investigation. CNA A was terminated. In-servicing on all facility staff was conducted for abuse/neglect policy and reporting. During an interview on 4/3/25 at 11:13 A.M., CNA C said he/she worked the evening shift of 3/25/25 with CNA A and CMT B. The shift was short staffed, and staff were very busy. He/She did not witness any abuse or an incident between CNA A and Resident #1. He/She received abuse/neglect in-servicing yearly and on 3/26/25. If he/she witnessed or if any allegation of abuse were reported, he/she would protect the resident, tell the charge nurse and notify the DON. During an interview on 4/3/35 at 11:30 A.M., CMT B said he/she worked the evening shift on 3/25/25 with CNAs A and C. The shift had been busy. He/She did not observe an altercation between Resident #1 and CNA A. Later in the shift, CNA approached him/her for topical ointment for scratches to his/her left wrist. CNA A said Resident #1 scratched him/her earlier in the shift while taking the resident to his/her room for care. Any witnessed or reported abuse/neglect is immediately reported to the DON and Administrator. The resident is protected, and the charge nurse notified. CMT B was in-serviced on the abuse/neglect policy prior to his/her shift on 3/26/25. During an interview on 4/3/25 at 11:46 A.M., CNA A said he/she worked the evening shift on 3/25/25 and worked with Resident #1. Resident #1 had soiled himself/herself and CNA A whispered in the resident's ear he/she needed to be changed. Resident #1 reached back and scratched his/her face. In a reaction, CNA A grabbed the resident's hair, the resident then grabbed and dug his/her fingers into CNA A's left wrist. CNA A released the resident's hair and grabbed it again to prevent the resident from scratching him/her. He/She had been terminated on 3/26/25. He/She felt very badly about what happened and cried during the interview. He/She said it was wrong to grab the resident's hair and he/she did not mean to hurt or frighten the resident. His/Her left wrist bled from the resident's nails and he/she reacted without thinking. He/She was in-serviced on abuse/neglect prevention around seven months ago. During an interview on 4/3/25 at 11:58 A.M., CNA E said the facility provided frequent in-services. He/She was in-serviced on abuse/neglect on 3/26/25. Staff report all abuse/neglect issues to the nurse and the DON immediately. Staff should intervene and protect the resident and get help if needed. During an interview on 4/3/25 at 12:05 P.M., Licensed Practical Nurse (LPN) D said he/she was in-serviced on 3/26/25 regarding abuse/neglect. Staff should protect the resident first and intervene. The nurse provides a skin assessment, reports to the DON and Administrator and suspends the staff. Staff are responsible for resident safety. During an interview on 4/3/35 at 1:16 P.M., the Administrator said all departments had been in-serviced on the abuse/neglect policy on 3/26/25. MO00251777

37681 Based on interview and record review, the facility failed to ensure complete, accurate and individualized care plans to address the specific needs of residents for five of 18 sampled residents (Resident #2, #36, #34,#26 and #13). The census was 66. Review of the facility Care Plan Policy, dated 2001, revised [DATE], showed: -An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident; -Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff); -Each resident's comprehensive care plan is designed to: -Incorporate identified problem areas; -Incorporate risk factors associated with identified problems; -Build on the resident's strengths; -Reflect the resident's expressed wishes regarding care and treatment goals; -Reflect treatment goals, timetables and objectives in measurable outcomes; -Identify the professional services that are responsible for each element of care; -Aid in preventing or reducing declines in the resident's functional status and/or functional levels; -Enhance the optimal functioning of the resident by focusing on a rehabilitative program, and reflect currently recognized standards of practice for problem areas and conditions; -Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan; -Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident; -Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process; -Reflect currently recognized standards of practice for problem areas and conditions; -Reflect areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan; -Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change; -The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: -When there has been a significant change in the resident's condition; -When the desired outcome is not met; -When the resident has been readmitted to the facility from a hospital stay; and at least quarterly; -The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies; - Policy Interpretation and Implementation: The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: -The resident's Attending Physician; -The Registered Nurse who has responsibility for the resident; -The Dietary Manager/Dietitian; -The Social Services Worker responsible for the resident; -The Activity Director/Coordinator; -Therapists (speech, occupational, recreational, etc.), as applicable; -Consultants (as appropriate); -The Director of Nursing (as applicable); -The Charge Nurse responsible for resident care; -Nursing Assistants responsible for the resident's care; and -Others as appropriate or necessary to meet the needs of the resident; -The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan; -Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family; -When a resident has no family, the ombudsman will be invited to attend the care plan meeting if desired by the resident; -The mechanics of how the Interdisciplinary Team meets its responsibilities in the development of the interdisciplinary care plan (e.g., face-to-face, teleconference, written communication, etc.) is at the discretion of the Care Planning Committee. 1. Review of Resident #2's annual MDS, dated [DATE], showed: -Cognitively impaired; -Dependent on staff assistance for all activities of daily living (ADLs); -Bed rail not used; -Diagnoses included high blood pressure, dementia, diabetes, chronic lung disease and depression. Review of the resident's medical record, showed no physician's order or assessment for the bed rail. Review of the resident's care plan, dated [DATE], showed: -Problem: Resident has a memory/recall problem due to vascular dementia; -Goal: Will not sustain serious injury due to memory/recall deficit; -Approach: Redirect resident when entering unsafe areas. Ensure resident's areas are free of hazards. Resident's bed has at least two lockable wheels. Ensure assistive devices available and in good condition (walkers, canes, wheelchairs); -Problem: Needs moderate ADL care assistance. Staff to assist with hygiene needs, mouth care, peri care (washing the genitals and anal area), dressing, etc. by setting resident up for care needs or staff performing hygiene needs; -Goal: Resident will be groomed properly. Assisted if needed or can't perform for themselves; -Approach: Staff will make sure resident hygiene needs are met daily; -No use of bed rails noted and/or direction for staff regarding the use of bed rails. Observation on [DATE] at 1:45 P.M. and on [DATE] at 9:06 A.M., showed the resident lay in bed, with one quarter length bed rail raised, located on the left side of the resident's bed, adjacent to the window. During an interview on [DATE] at 9:21 A.M., Licensed Practical Nurse (LPN) J said the side rails just come with the bed, he/she was not sure if the resident used the rail or not. He/She said he/she would ask one of the Certified Nursing Assistants (CNAs) and find out if the resident used the rail. During an interview on [DATE] at 9:22 A.M., CNA I said the only time the resident used the rail was when staff provided care, the resident will hold onto the rail when turned onto his/her side. 2. Review of Resident #36's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -No behaviors; -Diagnoses included high blood pressure, anxiety and dementia; -Bed rails not used. Review of the resident's care plan, last reviewed [DATE], showed no information regarding the use of bed rails. Review of the resident's medical record, showed no physician's order or assessment for the use of bed rails. Observation on [DATE] at 3:14 P.M. and [DATE] at 1:17 P.M., showed the resident lay in bed on his/her back. Quarter length side rails were raised on both sides of the bed. 3. Review of Resident #34's annual MDS dated [DATE], showed: -admitted on [DATE]; -Severe cognitive impairment; -Diagnoses included cancer, atrial fibrillation (a-fib, irregular heart rhythm), high blood pressure, diabetes, and dementia. Review of the emergency medical procedures, provided by the facility, showed: - In the event of an observed medical emergency, basic cardiac resuscitation (CPR, full life saving measures) is to be initiated and 911 called; -The form was signed on the line for signature of resident and/or legal representative. The signature was illegible and dated [DATE]. Review of the resident's care plan, in use at the time of survey showed, no information regarding code status. During an interview on [DATE] at 2:05 P.M., LPN C said the Social Worker (SW) reviewed the code status with the resident. During an interview on [DATE] at 2:30 P.M., the SW said the code status was reviewed on admission and quarterly with the care plan meeting. Code status should be on the care plan. The code status on the care plan should be updated quarterly with the care plan meetings. 4. Review of Resident #26's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included: high blood pressure and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). Observation on [DATE] at 8:50 A.M., [DATE] at 9:05 A.M., [DATE] at 7:12 A.M. and on [DATE] at 9:30 A.M., showed the resident lay in bed with the top two quarter side rails up. Review of the side rail use and risk assessment, dated [DATE], showed: -Purpose of side rail use evaluation: other-no side rail. Review of the care plan, in use at the time of survey, showed side rails not addressed. 5. Review of Resident #13's annual MDS, dated [DATE], showed: -Cognitively intact; -Bowel and bladder appliances: indwelling (inside the body) catheter (a flexible tube inserted into the bladder); -Diagnoses included: anemia (low red blood count), high blood pressure, renal disease, and dementia. Observation on [DATE] at 8:55 A.M., [DATE] at 9:03 A.M., and 2:22 P.M., [DATE] at 7:15 A.M. and on [DATE] at 9:35 A.M., showed the resident was lying in bed with the top quarter side rails up on both sides of the bed and the catheter was draining urine to gravity. The resident said he/she used the side rails to help him/her turn and reposition and he/she had the catheter because he/she had a wound on his/her back side. Review of the care plan, in use at the time of survey, showed, side rails and the catheter not addressed. Review of the electronic medical record, observation history dated [DATE] through [DATE], showed no side rail assessment. 7. During an interview on [DATE] at 8:18 A.M., the Director of Nursing (DON) said the MDS Coordinator was responsible for updating care plans. They had not had a consistent MDS Coordinator after the last one quit. Care plans should reflect the resident's current needs. Hospice, side rails and other needs specific to the resident should be included on the care plan. 8. During an interview on [DATE] at 1:58 P.M., the DON, the Owner and the Administrator said care plans should be an accurate assessment of the care needs of the resident. They would expect for side rails and catheters to be on the care plan. 42247

Based on interview and record review, the facility failed to establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation for one of one controlled substance binders reviewed. This had the potential to affect all residents with controlled substance orders. The census was 66. Review of the facility's Controlled Substance Policy, dated December 2011, showed: -Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II (drugs with a high abuse risk) and other controlled substances (a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction); -The Director of Nursing (DON) services will identify staff members who are authorized to handle controlled drugs; -Controlled substances must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together. Both individuals must sign the designated narcotic record. Review of the facility's Controlled Substance Inventory Record, showed: -Dated: March 2024: -7 A.M. through 3 P.M., Nurse 7-3 in: eight out of 31 opportunities were blank; -3 P.M. through 11 P.M., Nurse 7-3 out: seven out of 31 opportunities were blank; -3 P.M. through 11 P.M., Nurse 3-11 in: two out of 31 opportunities were blank; -11 P.M. through 7 A.M., Nurse 3-11 out: one out of 31 opportunities were blank; -Dated: April 2024: -7 A.M. through 3 P.M., Nurse 11-7 out: three out of 30 opportunities were blank; -3 P.M. through 11 P.M., Nurse 7-3 out: one out of 30 opportunities were blank; -Nurse 3-11 in: six out of 30 opportunities were blank; -11 P.M. through 7 A.M., Nurse 3-11 out: eight out of 30 opportunities were blank; -Nurse 11-7 in: four out of 30 opportunities were blank; -Dated: May 2024: -7 A.M. through 3 P.M., Nurse 11-7 out: one out of 22 opportunities were blank; -3 P.M. through 11 P.M., Nurse 7-3 out: one out of 22 opportunities were blank; -Nurse 3-11 in: five out of 22 opportunities were blank; -11 P.M. through 7 A.M., Nurse 3-11 out: nine out of 22 opportunities were blank; -Nurse 11-7 in: one out of 22 opportunities were blank. During an interview on 5/24/24 at 8:12 A.M. and at 11:05 A.M., the DON said the nurse coming on to a shift and the nurse going off shift should count the controlled substances together and document it on the controlled substance inventory record. If there was a blank on the form, that meant someone forgot to sign the page. The DON said she reviewed the inventory log and the blanks on the form are from agency staff. The DON expected all staff to sign the form when the count was completed.

Based on observation, interview and record review, the facility failed to ensure medications were stored in accordance with acceptable professional principles when staff walked away from the medication cart, leaving it unlocked. In addition, staff left the medication room unlocked. The census was 66. Review of the facility's Storage of Medications Policy, dated April 2007, showed: -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 1. Observation on 5/21/24 at 7:50 A.M., showed Licensed Practical Nurse (LPN) C passing medications on the 100 hall. The medication cart (med cart) was in front of the bird cage. LPN C prepared a resident's medication and walked away from the med cart to administer the medication. The med cart was left unlocked. At approximately 7:52 A.M., LPN C returned to the med cart and prepared another resident's medication and walked into the dining room, leaving the med cart unlocked. One resident walked past the unlocked med cart. LPN C walked past the unlocked med cart into the sitting room and administered the resident's medication. LPN C returned to the medication cart and prepared another resident's medication and walked away from the med cart, leaving the med cart unlocked. Observation on 5/21/24 at 8:45 A.M., showed the nurse's med cart was parked by the bar area on the 200 halls. The med cart was unlocked. LPN C was in the second-floor dining room approximately 100 feet from the med cart. At 8:46 A.M., the nurse returned to the med cart and prepared medication and walked away from the medication cart, leaving the med cart unlocked. 2. Observation on 5/21/24 at 8:33 A.M., showed the 200-hall medication room was halfway open and there was no staff at the nurse's station. At 9:00 A.M., the medication room door on the 200 hall was open approximately three to four inches. There were no staff at the nurse's station. At 9:04 A.M. Registered Nurse (RN) B came to the nurse station, with his/her med cart. He/She parked the med cart against the wall. The med cart was unlocked. At 9:20 A.M., RN B walked away from the nurse's station, leaving the med room door open and the med cart unlocked. At approximately 9:21 A.M., the physical therapist walked into the med room unsupervised, after approximately one minute, he/she left the med room without closing the door. At 9:23 A.M., RN B returned to the nurse's station. During an interview on 5/21/24 at 9:27 A.M., RN B said nurses had the key to the med room and only direct patient care staff can go into the med room. Certified Medication Technicians (CMT) and Certified Nurse Aides (CNAs) can go into the med room, they just need to go through the nurse first. Physical therapists, residents and visitors are not allowed in the med room. The med room door must be locked if there were no staff at the nurse's station. 3. During an interview on 5/23/24 at 11:25 A.M., CMT F said the medication cart should be locked if you walk away from it and the med room on the second floor should be locked. 4. During an interview on 5/23/24 at 11:45 A.M. CMT M said if you leave the med cart, it should be locked, and the med room should be locked. 5. During an interview on 5/23/24 at 1:20 P.M., the Director of Nursing (DON) said staff should lock the med cart when they walk away from it. The med room door should be always locked and only nursing staff should enter the med room unless staff were right there. 6. During an interview on 5/24/24 at 2:00 P.M. the DON, the Owner and the Administrator said they expected the med carts and med rooms to be lock.

Based on observation and interview, the facility failed to maintain food under sanitary conditions by not ensuring food was labeled and dated after opened. This had the potential to affect all residents who consumed food from the facility kitchen. The census was 66. Review of the Dietary Infection Control/Sanitation Policy, undated, showed: -Food is stored in a safe and sanitary manner; -Food stored in freezers and refrigerators are covered, labeled and dated, especially foods taken out of their original containers and leftovers. Observation of the kitchen on 5/20/24 at 12:12 P.M., 5/23/24 at 1:41 P.M., and on 5/24/24 at 9:00 A.M., showed: -A plastic bag of frozen hamburger, opened and undated; -A plastic bag of frozen pork chops, opened and undated; -A plastic bag of frozen hash browns, opened and undated; -A plastic bag of frozen taco meat, opened and undated; -A plastic bag of frozen buns, opened and undated; -Bowls of mixed fruit, covered with plastic wrap, undated; During an interview on 5/24/24 at 9:13 A.M., the Dietary Manager said she expected staff to label and date food once the package has been opened. During an interview on 5/24/24 2:05 P.M., the Director of Nursing said opened/stored food should be labeled and dated.

42247 Based on interview and record review, the facility failed to ensure that in accordance with acceptable professional standards and practices, medical records were complete and accurately documented including the administration of medications and treatments for six residents (Resident #13, #30, #26, #2, #51 and #24). The sample was 18. The census was 66. Review of the facility's Administering Medication Policy, dated April 2010, showed: -Policy statement: medications shall be administered in a safe and timely manner, and as prescribed; -Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so; -The Director of Nursing (DON) Services will supervise and direct all nursing personnel who administer medications and/or have related functions; -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; -Topical medications used in treatments must be recorded on the resident's treatment record (TAR); -If a dug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose; -As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: the signature and title of the person administering the drug. 1. Review of Resident #13's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 3/14/24, showed: -Cognitively intact; -Diagnoses included: anemia (low red blood count), high blood pressure, renal disease, and dementia. Review of the care plan, in use at the time of survey, showed: -Focus: Resident has multiple open areas to right upper extremity (RUE) and being treated for infection to wounds. He/She refuses dressing changes frequently; -Intervention: Treat per Medical Doctor (MD) order; -Focus: Resident complains of the taste of many foods. He/She is used to family members bringing him/her food but has been unable to related to Covid restrictions. He/She likes to add hot sauce to many items and keeps a bottle/packets in his/her room. Current diet is regular; -Intervention: Provide 2 Cal supplements (nutritional supplement), 90 milliliters (mL) three times a day (TID); Review of the physician order sheet (POS) dated 5/21/24, showed: -An order for: 2 cal (supplement) 120 mL four times a day (QID); -An order for: iron tablet 325 milligrams (mg) give one tablet once daily (q day); -An order for: Keppra (anticonvulsant) 500 mg twice daily (BID); -An order for liquid protein fortifier (supplement), administer 30 mL q day; -Probiotics administer 1 capsule BID for 20 days, diagnoses (DX) protein calorie malnutrition; -An order for: Sertraline (used to treat depression) 100 mg q day; -An order for: Calmoseptine ointment (barrier cream), apply to excoriation (chafing) to coccyx (tailbone) area and genital every shift; -An order for: clean area at top of coccyx with wound cleanser, apply foam dressing daily and as needed (PRN). Review of the resident's MAR/TAR, dated 5/1/24 through 5/22/24, showed: -An order for: 2 cal 120 mL QID; -Documentation showed: At 8:00 A.M., 11 out of 21 opportunities were blank; -At 12:00 P.M., two out of 21 opportunities were blank; -At 4:00 P.M., nine out of 21 opportunities were blank; -At 8:00 P.M., one out of 21 opportunities were blank; -An order for: iron tablet 325 mg give one tablet q day: -Documentation showed: 10 out of 21 opportunities were blank; -An order for: Keppra 500 mg BID; -Documentation showed: At 7:00 A.M. through 10:45 A.M., two out of 21 opportunities were blank; -At 3:00 P.M. through 7:45 P.M., four out of 21 opportunities were blank; -An order for: liquid protein fortifier, administer 30 mL q day; -Documentation showed: three out of 21 opportunities were blank; -An order for: Probiotic administers 1 capsule BID for 20 days; -Documentation showed: At 3:00 P.M. through 7:45 P.M., four out of 20 opportunities were blank; -An order for: Sertraline 100 mg q day; -Documentation showed: two out of 21 opportunities were blank; -An order for: Calmoseptine ointment, apply to excoriation to coccyx area and genital every shift; -Documentation showed: On Days: three out of 21 opportunities were blank; -An order for: clean area at top of coccyx with wound cleanser, apply foam dressing daily and PRN; -Documentation showed: three out of 21 opportunities were blank; -An order for: Dakin's Solution (strong topical antiseptic used to clean infected wounds, ulcers and burns) clean area to coccyx with Dakin's solution, pack with Dakin's-soaked gauze, cover with foam border dressing daily and PRN; -Documentation showed: 11 out of 21 opportunities were blank. Review of the progress notes dated 5/1/24 through 5/24/24, showed no explanation for the blanks on the MAR/TAR's. 2. Review of Resident #30's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included: coronary artery disease (CAD, plaque buildup in the wall of the arteries that supply blood to the heart), high blood pressure, diabetes, and seizure disorder. Review of the care plan in use at the time of survey, showed: -Focus: Resident has history of left leg infection. He/She is receiving long usage of antibiotic therapy. He/She is at risk for side effects, infection getting worse, decrease fluid/food intake or medication not being effective. He/She is also dependent for most activities of daily living (ADL's, grooming, dressing, bathing); -Interventions: Nursing staff to give medication as ordered; -Focus: Resident is at risk for pressure ulcers (Injury to skin and underlying tissue resulting from prolonged pressure on the skin) related to incontinence, impaired mobility and spends majority of day in bed or wheelchair. Pressure ulcer to left lateral (outer) ankle; -Intervention: provide wound care as ordered. Review of the POS, dated 5/1/24 through 5/24/24, showed: -An order for: 2 cal 90 mL TID; -An order for: Advair HFA (inhaler, used to prevent and control symptoms caused by asthma)115-21 microgram (mcg), administer 1 puff BID; -An order for: Dilantin 125 mg/5 mL (used to treat and prevent seizures), administer 4 mL TID; -An order for Eliquis (blood thinner) 5 mg BID; -An order for: famotidine (acid reducer) 20 mg, administer 1 tablet BID; An order for: Lopressor (used to treat blood pressure) 100 mg, administer 1 tablet TID, hold if blood pressure is less than 110/70 or heart rate less than 55; -An order for probiotic, administer 1 capsule BID; -An order for: Risperdal 1 mg BID, DX bipolar (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)); -An order for: valproic acid solution (anticonvulsant) 250 mg/5 mL, administer 15 mL TID; -An order for: apply skin prep (skin protectant) to bilateral ankles and heels daily; -An order for: clean area to buttocks, apply alginate foam dressing (absorbs exudate (fluid that leaks out of blood vessels into near by tissues) away from the wound) daily and PRN; -An order for: mupirocin 2% (used to treat skin infections), apply a small amount to left bunion area, cover with ABD (absorbent dressing) and dressing once daily. Review of the MAR/TAR, dated 5/1/24 through 5/24/24, showed: -An order for: 2 cal 90 mL TID; -Documentation showed: At 6:00 A.M., seven out of 23 opportunities were blank; -At 2:00 P.M., three out of 23 opportunities were blank; -At 10:00 P.M., two out of 23 opportunities were blank; -An order for: Advair HFA 115-21 mcg, administer 1 puff BID; -Documentation showed: At 7:00 A.M. through 10:45 A.M., four out of 23 opportunities were blank; -At 7:00 P.M. through 10:45 P.M., two out of 23 opportunities were blank; -An order for: Dilantin 125 mg/5 mL, administer 4 mL TID; -Documentation showed: At 6:00 A.M., seven out of 23 opportunities were blank; -At 2:00 P.M., three out of 23 opportunities were blank; -At 10:00 P.M., two out of 23 opportunities were blank; -An order for Eliquis 5 mg BID; -Documentation showed: At 7:00 A.M. through 10:45 A.M., four out of 23 opportunities were blank; -At 3:00 P.M. through 7:45 P.M., nine out of 23 opportunities were blank; -An order for: famotidine 20 mg, administer 1 tablet BID; -Documentation showed: 7:00 A.M. through 10:45 A.M., five out of 23 opportunities were blank; -At 3:00 P.M. to 7:45 P.M., nine out of 23 opportunities were blank; -An order for: Lopressor 100 mg, administer 1 tablet TID, hold if blood pressure is less than 110/70 or heart rate less than 55; -Documentation showed: At 6:00 A.M., seven out of 23 opportunities were blank; -At 2:00 P.M., four out of 23 opportunities were blank; -At 10:00 P.M., two out of 23 opportunities were blank; -An order for probiotic, administer 1 capsule BID; -Documentation showed: At 7:00 A.M. through 10:45 A.M., four out of 23 opportunities were blank; -At 3:00 P.M. through 7:45 P.M., nine out of 23 opportunities were blank; -An order for: Risperdal 1 mg BID; -Documentation showed: At 8:00 A.M. through 10:45 A.M., four out of 23 opportunities were blank; -An order for: valproic acid solution 250 mg/5 mL, administer 15 mL TID; -Documentation showed: At 6:00 A.M., six out of 23 opportunities were blank; -At 2:00 P.M., three out of 23 opportunities were blank; -At 10:00 P.M., two out of 23 opportunities were blank; -An order for: apply skin prep to bilateral ankles and heels daily; -Documentation showed: two out of 21 opportunities were blank; -An order for: clean area to buttocks, apply alginate foam dressing daily and PRN; -Documentation showed: three out of 21 opportunities were blank; -An order for: mupirocin 2% apply a small amount to left bunion area, cover with ABD and dressing once daily; -Documentation showed: two out of 21 opportunities were blank. Review of the progress notes dated 5/1/24 through 5/24/24, showed: -On 5/7/24 at 10:38 A.M., Resident up in chair in dining room, treatment deferred until returns to bed; -On 5/11/24 at 8:43 A.M., treatment deferred as is up in chair in dining areas; -There were no other explanations for possible blanks on the MAR/TAR. Review of the MAR/TAR dated 5/7/24 and 5/11/24, showed: -Apply skin prep to bilaterally ankles daily was documented on 5/7/24 and 5/11/24; -Clean area to buttocks, apply alginate foam dressing daily and PRN was documented on 5/7/24 and 5/11/24; -Mupirocin 2%, apply small amount to left bunion area, cover with ABD and dressing daily was documented on 5/7/24 and 5/11/24. 4. Review of Resident #26's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included: high blood pressure and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). Review of the POS, dated 5/1/24 through 5/24/24, showed: -An order for: Amoxicillin-pot clavulanate (antibiotic) 875-125 mg tablet, administer 1 tablet every 12 hours; -An order for: Buspirone (antianxiety) 5 mg TID; -An order for: doxycycline monohydrate 100 mg (antibiotic) administer 1 capsule every 12 hours. Patient is on long term antibiotic regimen; -An order for: Flonase allergy relief 50 mcg, administer 1 spray in each nostril BID; -An order for gabapentin (anticonvulsant) 300 mg, administer 1-tab TID; -An order for: melatonin (helps with sleep) 3 mg, administer 3 tabs at bedtime; -An order for: tizanidine (muscle relaxant) 4 mg BID; -An order for: clean area to abdomen, remove any stool that may be sitting on the skin, cover abdomen with stoma powder (helps with irritation), cover area with ABD pads, disposable pad and secure with brief, check every 2 hours. Review of the MAR, dated 5/1/24 through 5/24/24, showed: -An order for: Amoxicillin-pot clavulanate 875-125 mg tablet, administer 1 tablet every 12 hours; -Documentation showed: At 8:00 A.M., four out of 9 opportunities were blank; -At 8:00 P.M., two out of eight opportunities were blank; -An order for: Buspirone 5 mg TID; -Documentation showed: At 6:00 A.M. six out of 23 opportunities were blank; -At 2:00 P.M., four out of 23 opportunities were blank; -At 10:00 P.M., four out of 23 opportunities were blank; -An order for: doxycycline monohydrate 100 mg administers 1 capsule every 12 hours; -Documentation showed: At 8:00 A.M., 11 out of 23 opportunities were blank; -At 8:00 P.M., three out of 23 opportunities were blank; -An order for: Flonase allergy relief 50 mcg, administer 1 spray in each nostril BID; -Documentation showed: eight out of 23 opportunities were blank; -An order for gabapentin 300 mg, administer 1 tab TID; -Documentation showed: At 7:00 A.M., 12 out of 23 opportunities were blank; -At 2:00 P.M., four out of 23 opportunities were blank; -At 10:00 P.M., four out of 23 opportunities were blank; -An order for: melatonin 3 mg, administer 3 tabs at bedtime; -Documentation showed: three out of 23 opportunities were blank; -An order for: tizanidine 4 mg BID; -Documentation showed: At 3:00 P.M. through 7:45 P.M., eight out of 23 opportunities were blank; -An order for: clean area to abdomen, remove any stool that may be sitting on the skin, cover abdomen with stoma powder, cover area with ABD pads, disposable pad and secure with brief, check every 2 hours; -Documentation showed: At 12:00 A.M., five out of 23 opportunities were blank; -At 2:00 A.M., three out of 23 opportunities were blank; -At 6:00 A.M., two out of 23 opportunities were blank; -At 8:00 A.M., five out of 23 opportunities were blank; -At 10:00 A.M., three out of 23 opportunities were blank; -At 12:00 P.M., three out of 23 opportunities were blank; -At 2:00 P.M., five out of 23 opportunities were blank; -At 4:00 P.M., three out of 23 opportunities were blank; -At 6:00 P.M., three out of 23 opportunities were blank. Review of the progress notes dated 5/1/24 through 5/24/24 showed: -On 5/4/24 at 9:35 P.M., antibiotic/urinary tract infection (UTI) on going. Resident very difficult to arouse for medications. Narcotics held, no dinner eaten, unable to offer fluids. Respirations even and unlabored. Will try to re-offer before 11:00 P.M.; -No other documentation to explain the blanks on the MAR/TAR. Review of the MAR/TAR dated 5/4/24 showed: -Amoxicillin-pot clavulanate 875-125 mg tablet, administer 1 tablet every 12 hours, the 8:00 P.M. dose was blank; -Bursar 5 mg TID, the 10:00 P.M. dose was blank; -Doxycycline monohydrate 100 mg administers 1 capsule every 12 hours, the 8:00 P.M. dose was blank; -Gabapentin 300 mg, administer 1-tab TID, the 10 P.M. was blank; -Melatonin 3 mg, administer 3 tabs at bedtime, the 8:00 P.M. dose was blank; -Clean area to abdomen, remove any stool that may be sitting on the skin, cover abdomen with stoma powder, cover area with ABD pads, disposable pad and secure with brief, check every 2 hours, the 6:00 P.M. time slot was blank. 5. Review of Resident #2's annual MDS, dated [DATE], showed; -Cognitively impaired; -Diagnoses included dementia, diabetes, chronic lung disease and depression. Review of the resident's Electronic Physician Orders Sheet (ePOS), in use at the time of the survey, showed: -An order dated 3/16/24, for Cardizem (used to treat high blood pressure), 30 mg, 1 tablet QID; -An order dated 3/16/24, for Metoprolol Tartrate (used to treat high blood pressure), 25 mg, 1 tablet orally BID; -An order dated 3/16/24, for Eliquis (used to treat and prevent blood clots and to prevent stroke), 5 mg tablet, orally, BID; -An order dated 3/16/24, for Pepcid (used to treat a condition which the stomach contents move up into the esophagus), 40 mg, 1 tablet orally once an evening; -An order dated 10/10/23, for Latuda (used to treat mood disorders), 80 mg, 1 tablet orally, once an evening; Review of the resident's May 2024 MAR, showed; -22 out of 80 scheduled Cardizem medication doses with blank entries; -10 out of 40 scheduled Metoprolol Tartrate medication doses with blank entries; -Four out of 40 scheduled Eliquis medication doses with blank entries; -Four out of 20 scheduled Latuda medication doses with blank entries; -Four out of 20 scheduled Pepcid medication doses with blank entries. Review of the resident's nurse's progress notes, showed no documentation to explain the blanks on the MAR/TAR. 6. Review of Resident #51's quarterly MDS, dated [DATE], showed; -Cognitively intact; -Diagnoses included heart failure and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Review of the resident's ePOS, in use at the time of the survey, showed: -An order dated 11/2/21 for Carbidopa-Levodopa (used to treat Parkinson's disease), 25-100 mg, 1 tablet orally TID; Review of the resident's May 2024 MAR, showed; -10 out of 60 scheduled Carbidopa-Levodopa medication doses with blank entries. Review of the resident's nurse's progress notes, showed no documentation to explain the blanks on the MAR/TAR. 7. Review of Resident #24's annual MDS, dated [DATE], showed; -Cognitively impaired; -Nutritional Approach: Tube feeding (A feeding tube is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation); -Average fluid intake per day by tube feeding, 501 cubic centimeter (cc)/day or more; -Diagnoses included high blood pressure and stroke. Review of the resident's ePOS, in use at the time of the survey, showed: -An order dated 8/21/2019 to record resident's tube feeding input/output (The process involves recording all the fluid that goes into the patient and the fluid that leaves the body) every shift (three times a day). Review of the resident's May 2024 MAR, showed; -6 out of 60 scheduled recorded input/output amounts with blank entries. Review of the resident's progress notes, dated 5/1/24 through 5/24/24 showed: -5/10/24 at 8:29 A.M., resident's feeding tube broke off when trying to flush tube (flushing the tube with warm water helps release any formula stuck to the inside of the tube). Physician notified, sent resident to the hospital to have the feeding tube replaced; -5/10/24 at 11:57 A.M., resident back to the facility, feeding tube intact. Tube feeding infusing at 70 ml per hour; -No other documentation regarding blank entries in the resident's MAR. 8. During an interview on 5/24/24 at 9:23 A.M., Nurse J said if the MAR was not initialed, it could be the medication was missed, regardless, if something was not documented, it didn't happen. 9. During an interview on 5/24/24 at 9:20 A.M., the Certified Medication Technician (CMT) M said if a resident refused his/her supplement or medication he/she would document it on the MAR. 10. During an interview on 5/24/24 at 1:58 P.M., the DON, Owner and Administrator said they would expect for staff to document medication and treatments as they were administered. If medications/treatments were not administered, the reason why should be documented. They would expect for the medical record to be complete and accurate.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program when staff failed to wear appropriate personal protective equipment (PPE), in accordance with the facility's policy, during high-contact activities with residents on enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for three residents (Residents #30, #46 and #24). In addition, the facility failed to follow accepted infection control and prevention to implement their water management program to prevent the spread of waterborne pathogens, such as legionella (a bacteria that causes legionnaire's disease which is a severe form of pneumonia or lung inflammation). This failure had the potential to affect all residents in the facility. The sample was 18. The census was 66. Review of the facility's Enhanced Barrier Precautions Policy, dated August 2022, showed: -EBPs are used as an infection prevention and control intervention to reduce the spread of MDRO to residents; -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply; -Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room); -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: - Dressing; - Transferring; - Providing hygiene; - Device care or use (feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation.)) - Wound care (any skin opening requiring a dressing); -EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization; -EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk; -Staff are trained on EBPs prior to caring for residents on EBP; -Signs are posted on the door or the wall outside the resident room indicating the type of precautions and PPE required. Review of the facility's EBP signage, undated, showed: - Everyone must: clean their hands, including before entering and when leaving the room; -Providers and staff must also: wear gloves and gown for the following high contact resident care activities: -Dressing; -Bathing/showering; -Transferring; -Changing linens; -Personal hygiene; -Changing briefs or assisting with toileting; -Device care or use: -Central line (a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided into a large vein above the right side of the heart), urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag), feeding tube, tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing); -Wound care: any skin opening requiring a dressing; -Do not wear the same the same gown and gloves for the care of more than one person. Review of the facility's undated Legionella Water Management Program, showed: -Policy: Facility is to maintain and follow local and state water standards and should follow manufacturer's instructions regarding cleaning, disinfecting, and maintenance of any water systems in facility. Facility is to have a water management program to prioritize water safety for residents who are at increased risk for Legionnaires' disease; -Facility is to contact Missouri division of American Water Company every 6 months for a water report of water coming into the facility; -Refer to Emergency Preparedness Plan if it is determined to be an emergency water issue; -Refer to Housekeeping and infection control policy for cleanliness and disinfecting of any water systems including medical equipment, ice machines, eyewash stations, showerheads; -Refer to infection control policy if there is an outbreak of Legionnaires' disease; -The facility did not have a water management team nor did the facility have a water flow diagram or a text version of the water flow. Review of the facility's Infection Preventionist binder, showed it contained directions in developing a Legionella water management program. This included establishing a water management program team and describing the facility's water systems using text or flow diagram. 1. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 2/9/24, showed: -Moderately impaired cognition; -Diagnoses included: coronary artery disease (CAD, plaque buildup in the wall of the arteries that supply blood to the heart), high blood pressure, diabetes, and seizure disorder. Review of the care plan, in use at the time of survey, showed: -Focus: Resident is at risk for pressure ulcers (Injury to skin and underlying tissue resulting from prolonged pressure on the skin) related to incontinence, impaired mobility and spends majority of day in bed or wheelchair. Pressure ulcer to left lateral (outer) ankle 12/17/2020; -Goal: will be monitored for skin impairment and will have adequate wound care through next Assessment; -Interventions: Staff must use EBP (wear gown and gloves) related to resident having chronic wounds. During all the following activities urinary catheter, feeding tube, wound care: any skin opening requiring addressing dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting. Observation on 5/21/24 at 8:20 A.M., showed an EBP sign on the residents door. The resident lay in bed, dressed, with a mechanical lift cloth under him/her. Certified Nurse Aide (CNA) L and CNA G wore gloves and a face mask, while they connected the lift cloth to the mechanical lift. They raised the resident up and guided the resident into his/her chair and unfastened the lift cloth from the lift. Both CNAs removed their gloves and performed hand hygiene. Staff failed to wear a gown while transferring the resident from the bed to the chair. Observation on 5/23/24 at 7:50 A.M., showed an EBP sign on the resident's door. The resident lay in bed. CNA H and CNA G entered the resident's room, performed hand hygiene, and put on a gown and gloves. Staff provided A.M. care (personal hygiene and dressing) to the resident. CNA H removed his/her gown and gloves and left the room. A few minutes later CNA H entered the room with the mechanical lift. CNA H performed hand hygiene and put gloves on. He/She failed to put a gown on. Both CNA's attached the lift cloth to the mechanical lift and transferred the resident to the chair. During an interview on 5/23/24 at 12:00 P.M., CNA H said staff should wear gown and gloves with residents who have wounds and catheters, so the residents are safe, and staff are safe. During an interview on 5/23/24 at 12:05 P.M. CNA G said residents who had feeding tubes, wounds, and catheters, should have a sign on their door to wear PPE. PPE should be worn whenever a resident was physically touched, such as dressing, grooming, bathing and transferring the resident. He/She would not need to wear PPE if they just went into the room to drop off a meal tray. 2. Review of Resident #46's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included: heart failure, high blood pressure and dementia. Review of the medical record, showed the resident was not on EBP. Observation on 5/21/24 at 8:20 A.M., showed, Resident #30 and Resident #46 shared a room. There was an EBP sign on the door of the residents' room. The signage did not indicate which resident or if both residents were on EBP. Staff used the mechanical lift to transfer Resident #30 from the bed to the chair. Staff then used the same lift to transfer Resident #46 from the bed to the chair without sanitizing the lift between residents. 3. Review of the Resident #24's quarterly MDS, dated [DATE], showed: -Should a brief interview for mental status be conducted? No; -Diagnoses included: stroke, high blood pressure and diabetes; -Gastrostomy tube (g-tube). Review of the care plan, in use at the time of survey, showed: -Focus: Impaired swallowing related to dysphasia (difficulty swallowing). Family has signed an informed consent dining meaning that they wish for the resident to have regular foods fed to him/her by them when they are with him/her for pleasure, dated 12/2023; -Goal: Resident will not exhibit malnutrition or dehydration; -Intervention: Staff must use EBP (wear gown and gloves) related to resident having a feeding tube. During all the following activities urinary catheter, feeding tube, wound care, any skin opening requiring addressing dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting. Observation on 5/23/24 at 8:20 A.M., showed an EBP sign on the resident's door. Licensed Practical Nurse (LPN) D entered the resident's room, performed hand hygiene, and put gloves on. LPN D prepared the resident's medications and administered the medications via g-tube without wearing a gown. During an interview on 5/23/24 at 11:45 A.M., Certified Medication Technician (CMT) M said if a resident had a sign on their door to wear PPE, he/she would wear whatever the sign said to wear. During an interview on 5/23/24 at 12:10 P.M. Registered Nurse (RN) B said EBPs were used for residents who had an infection or had the potential for infection. The PPE was used to protect yourself in case there was any secretions and to avoid possible cross contamination. PPE was worn at the bedside while providing care. All staff who entered the room should wear PPE even if they were delivering a meal tray because they may need to do something else while in the room. During an interview on 5/23/24 at 1:20 P.M., the Infection Preventionist/Director of Nursing (IP/DON) said residents who had indwelling devices such as catheters, g-tubes and if the resident was colonized or had a MDRO or if the resident had a wound, they should be on EBP. A sign was posted on their door with instructions on what PPE the staff should wear. PPE should be worn when staff were in close contact with the resident such as grooming, dressing, bathing, and transferring the resident. The mechanical lift should be cleaned and sanitized between all residents regardless if a resident was on EBP or not. If the lift was not sanitized between residents, there was a chance the infection could spread to the next resident. Staff should wear a gown and gloves when administering g-tube medications. 4. During an interview on 5/24/24 at 9:51 A.M., the IP/DON said she was not aware of the facility's water systems. During an interview on 5/24/24 at 10:00 A.M., the Administrator said the facility had no water systems in place. During an interview 5/24/24 at 10:23 A.M., the Maintenance Director (MD) said he did not have information on the facility's water systems and had not seen a water flow system of the facility in his [AGE] years of employment. The MD said he was aware Legionella could be present in water fountains but was not aware that it might cause respiratory infections. The facility had no water management team. The MD checked the water temperature once a month and it was adjusted when out of the 105-120 degrees Fahrenheit range. He did not say where. The maintenance staff repaired any water issues as reported. They communicated with the water company for the facility's water system. During an interview on 5/24/24 at 1:58 P.M., the IP/DON, Owner and Administrator said they would expect staff to follow the facility's policy and procedures for infection control. They also agreed to have a water system in place using text or flow diagram specific to the facility. 45083

37681 Based on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed/side rails as part of a regular maintenance program to identify areas of possible entrapment for five of 18 sampled residents (Resident #62, #36, #26, #2 and #13). The census was 66. Review of the facility's Proper Use of Side Rails policy, revised October 2010, showed: -The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids to and prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; -General Guidelines: -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; -An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: -Bed mobility; -Ability to change positions, transfer to and from bed or chair, and to stand and toilet; -The use of side rails as an assistive device will be addressed in the resident's care plan; -Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol; -The risk and benefits of side rails will be considered for each resident; -The resident will be checked periodically for safety relative to side rail use; -When side rails usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used). 1. Review of Resident #62's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/24, showed: -admitted on [DATE]; -Severe cognitive impairment; -No behaviors; -Diagnoses included cancer, high blood pressure, kidney disease, diabetes, high cholesterol, dementia, anxiety and depression; -Bed rails not used. Review of the resident's medical record, showed no maintenance assessment for the use of bed rails. Observation on 5/20/24 at 1:56 P.M., and 5/21/24 at 3:16 P.M., showed the resident lay in bed. A u-shaped side rail was raised on the left side of the resident. Observation on 5/24/24 at 9:04 A.M., showed the resident was not in the room and the side rail was gone or removed. During an interview on 5/24/24 at 9:07 A.M., Licensed Practical Nurse (LPN) C said he/she did not recall if the resident had a side rail on the bed. He/She said side rails typically came with the bed and were used for residents' positioning. They usually called them grab rails. There were no assessment sheets for nurses to fill out. During an interview on 5/24/24 at 9:11 A.M., Certified Nursing Assistant (CNA) K said the resident used the left side rail for repositioning and mobility. He/She was not aware the side rail had been removed. 2. Review of Resident #36's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -No behaviors; -Diagnoses included high blood pressure, anxiety and dementia; -Bed rails not used. Review of the resident's medical record, showed no maintenance assessment for the use of bed rails. Observation on 5/21/24 at 3:14 P.M. and 5/23/24 at 1:17 P.M., showed the resident lay in bed on his/her back. Quarter length side rails were raised on both sides of the bed. During an interview on 5/24/24 at 9:11 A.M., CNA K said the resident used the side rails for repositioning and mobility. 3. Review of Resident #26's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included: high blood pressure and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). Observation on 5/21/24 at 8:50 A.M., 5/22/24 at 9:05 A.M., 5/23/24 at 7:12 A.M. and 5/24/24 at 9:30 A.M., showed the resident lay in bed with the top two quarter side rails up. Review of the medical record, showed no maintenance assessment for the use of side rails. 4. Review of Resident #2's annual MDS, dated [DATE], showed: -Cognitively impaired; -Dependent on staff assistance for all activities of daily living (ADLs); -Bed rail not used; -Diagnoses included high blood pressure, dementia, diabetes, chronic lung disease and depression. Review of the resident's medical record, showed no physician order or maintenance assessment for the bed rail. Review of the resident's care plan, dated 4/24/24, showed no direction for staff regarding the use of bed rails. Observation on 5/23/24 at 1:45 P.M. and on 5/24/24 at 9:06 A.M., showed the resident lay in bed, with one quarter length bed rail raised located on the left side of the resident's bed, adjacent to the window. During an interview on 5/24/24 at 9:21 A.M., LPN J said the side rails just came with bed. He/She was not sure if the resident used the rail or not. He/She would ask one of the CNAs and find out if the resident uses the rail. During an interview on 5/24/24 at 9:22 A.M., CNA I said the only time the resident used the rail was when staff provided care. The resident held onto the rail when turned onto his/her side. 5. Review of Resident #13's annual MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included: anemia (low red blood count), high blood pressure, renal disease, and dementia. Observation on 5/21/24 at 8:55 A.M., 5/22/24 at 9:03 A.M., and 2:22 P.M., 5/23/24 at 7:15 A.M. and 5/24/24 at 9:35 A.M., showed the resident lay in bed with the top quarter side rails up on both sides of the bed. The resident said he/she used the side rails to help him/her turn and reposition. Review of the medical record, showed no maintenance assessment for the use of side rails. 6. During an interview on 5/24/24 at 8:12 A.M., the Director of Nursing (DON) said Maintenance staff should do the maintenance checks on the side rails. 7. During an interview on 5/24/24 at 10:23 A.M., the Maintenance Director said if there was an order for bed rails, he would install them. He measured the rails once they were placed on the bed. The holes were already pre-drilled on the bed and a kit came with the bed. He had not measured the bed, mattress and rail while a resident was in bed. The weight of the resident would not affect the gap between the mattress and the rail. He only measured when the rails were first placed onto the bed. He was not aware of a routine maintenance program to assess for the risk of entrapment of bed rails. 8. During an interview on 5/24/24 at 2:00 P.M., the Administrator and DON said there was supposed to be a maintenance assessment for the use of side rails done on a quarterly basis and as needed. 42247 45083

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. The facility maintained a census of greater than 60 residents, and this deficiency had the potential to affect all residents. The census was 66. Review of the facility's daily assignment sheets, dated 4/20/24 through 5/20/24, showed no RN was scheduled on 4/22, 4/24, 4/26, 4/29, 5/1, 5/3, 5/6, 5/8, 5/9, 5/15, 5/17, and 5/20. During an interview on 5/21/24 at 9:04 A.M., RN B said he/she worked part-time, every Tuesday, Thursday and some weekends. During an interview on 5/22/24 at 11:45 A.M., the Director of Nursing (DON) said there were three RNs in the facility, including herself. She said RN B worked Tuesdays, Thursdays and every other weekend. The other RN worked every other weekend only. The DON said the facility had an RN daily because she worked whenever the other two RNs were not working. She worked Monday to Friday and weekends if needed. She understood that due to their census, the DON could not be considered as a staff RN. During an interview on 5/24/24 at 2:00 P.M., the Administrator and DON agreed that the facility had to have RN coverage eight hours a day, seven days a week.

37681 Based on observation, interview and record review, the facility failed to ensure bed rails were accurately assessed as a necessary device prior to installation and use for five of 18 sampled residents (Resident #62, #36, #26, #2 and #13). The facility also failed to document usage in the resident's care plan. The census was 66. Review of the facility's Proper Use of Side Rails policy, revised October 2010, showed: -The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids to and prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; -General Guidelines; -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; -An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's; -Bed mobility; -Ability to change positions, transfer to and from bed or chair, and to stand and toilet; -The use of side rails as an assistive device will be addressed in the resident's care plan; -Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol; -The risk and benefits of side rails will be considered for each resident; -The resident will be checked periodically for safety relative to side rail use; -When side rails usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used). 1. Review of Resident #62's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/24, showed: -admitted on [DATE]; -Severe cognitive impairment; -No behaviors; -Diagnoses included cancer, high blood pressure, kidney disease, diabetes, high cholesterol, dementia, anxiety and depression; -Bed rails not used. Review of the resident's care plan, last reviewed 3/15/24, showed no information regarding the use of bed rails. Review of the resident's medical record, showed no maintenance assessment for the use of bed rails. Observation on 5/20/24 at 1:56 P.M., and 5/21/24 at 3:16 P.M., showed the resident lay in bed. U-shaped side rail was raised on the left side of the resident. Observation on 5/24/24 at 9:04 A.M., showed the resident was not in the room and the side rail was gone or removed. During an interview on 5/24/24 at 9:07 A.M., Licensed Practical Nurse (LPN) C said he/she did not recall the resident had a side rail in the bed. He/She said side rails typically came with the bed and are used for residents' positioning. They usually call them grab rails. There were no assessment sheets that nurses fill out. During an interview on 5/24/24 at 9:11 A.M., Certified Nursing Assistant (CNA) K said the resident used the left side rail for repositioning and mobility. He/She was not aware the side rail has been removed. 2. Review of Resident #36's Significant Change MDS, dated [DATE], showed: -Severe cognitive impairment; -No behaviors; -Diagnoses included high blood pressure, anxiety and dementia; -Bed rails not used. Review of the resident's care plan, last reviewed 3/15/24, showed no information regarding the use of bed rails. Review of the resident's medical record, showed no physician's order or assessment for the use of bed rails. Observation on 5/21/24 at 3:14 P.M. and 5/23/24 at 1:17 P.M., showed the resident lay in bed on his/her back. Quarter length side rails were raised on both sides of the bed. During an interview on 5/24/24 at 9:11 A.M., Certified Nursing Assistant (CNA) K said the resident used the side rails for repositioning and mobility. 3. Review of Resident #26's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included: high blood pressure and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). Observation on 5/21/24 at 8:50 A.M., 5/22/24 at 9:05 A.M., 5/23/24 at 7:12 A.M. and on 5/24/24 at 9:30 A.M., showed the resident lay in bed with the top two quarter side rail up. Review of the side rail use and risk assessment, dated 4/4/24, showed: -Purpose of side rail use evaluation: other-no side rail. During an interview on 5/24/24 at 9:45 A.M. CNA L said Resident #26 used side rails to keep him/her from falling out of bed. He/She gets his/her arms moving and he/she might fall out of bed, so they keep the side rails up. 4. Review of Resident #2's annual MDS, dated [DATE], showed: -Cognitively impaired; -Dependent on staff assistance for all activities of daily living (ADLs); -Bed rail not used; -Diagnoses included high blood pressure, dementia, diabetes, chronic lung disease and depression. Review of the resident's medical record, showed no physician's order or assessment for the bed rail. Review of the resident's care plan, dated 4/24/2024, showed: -Problem: Cognitive Loss/Dementia. Resident has a memory/recall problem due to vascular dementia; -Goal: Will not sustain serious injury due to memory/recall deficit; -Approach: Redirect resident when entering unsafe areas. Ensure resident's areas are free of hazards. Resident's bed has at least two lockable wheels. Ensure assistive devices available and in good condition (walkers, canes, wheelchairs); -Problem: ADLs Functional, needs moderate ADL care assistance. Staff to assist with hygiene needs, mouth care, peri care, dressing, etc. by setting resident up for care needs or staff performing hygiene needs. Make sure if resident have on brief if needed; -Goal: Resident will be groomed properly. Assisted if needed or can't perform for themselves; -Approach: Staff will make sure resident hygiene needs are met daily; -No direction for staff regarding the use of bed rails. Observation on 5/23/24 at 1:45 P.M. and on 5/24/24 at 9:06 A.M., showed the resident lay in bed, with one quarter length bed rail raised, located on the left side of the resident's bed, adjacent to the window. During an interview on 5/24/24 at 9:21 A.M., LPN J said the side rails just comes with the bed, he/she was not sure if the resident used the rail or not. He/She said he/she would ask one of the CNAs and find out if the resident uses the rail. During an interview on 5/24/24 at 9:22 A.M., CNA I said the only time the resident used the rail is when staff provide care, the resident will hold onto the rail when turned onto his/her side. 5. Review of Resident #13's annual MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included: anemia (low red blood count), high blood pressure, renal disease, and dementia. Observation on 5/21/24 at 8:55 A.M., 5/22/24 at 9:03 A.M., and 2:22 P.M., 5/23/24 at 7:15 A.M. and on 5/24/24 at 9:35 A.M., showed the resident lay in bed with the top quarter side rails up on both sides of the bed. The resident said he/she used the side rails to help him/her turn and reposition. Review of the electronic medical record, observation history, dated 5/3/23 through 5/24/24, showed no side rail assessment. During an interview on 5/24/24 at 9:45 A.M. CNA L said Resident #13 used side rails for turning and positioning 6. During an interview on 5/22/24 at 1:40 P.M., Certified Medication Technician (CMT) F said the facility did not use side rails because it was considered a restraint. 7. During an interview on 5/22/24 at 2:00 P.M. CNA H said some residents used side rails because they like to hold on to something to help them turn and reposition when in bed. 8. During an interview on 5/24/24 at 9:07 A.M., Licensed Practical Nurse (LPN) C said residents used side rails for positioning and turning. Side rails were included with resident beds and nursing was not responsible for assessing for the use of side rails. 9. During an interview on 5/24/24 at 2:00 P.M., the Administrator and Director of Nursing (DON) said the use of side rails should be assessed by nursing before installation and should be assessed annually and during a significant change. The use of side rails should also be included in the care plan. 42247 45083

Based on observation, interview and record review, the facility failed to ensure residents' needs were met by failing to ensure 10 residents who needed assistance with meal setup and eating were served and assisted for meals at the same time as the other residents in the dining room that did not require assistance. The ten residents sat and watched others at their table eat while they waited for food. Three of the ten residents were sampled residents (Resident #4, #2, and #3). Resident #4 was the last to be provided a meal and assistance with eating and waited over 30 minutes. The sample size was 4. The census was 70. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/22/23, showed: -Severe cognitive impairment; -Eating: Setup or clean-up assistance. Helper sets up or cleans up. Resident completes activity; -Upper body dressing: Supervision or touching assistance; -Lower body dressing: Supervision or touching assistance; -Personal hygiene: Blank; -Diagnoses include dementia, seizures, anxiety, depression, schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). -Review of the resident's electronic physician order sheet (EPOS), showed: -An order, dated, 3/19/20, diet thin liquids; -An order, dated 5/18/23, diet regular. Review of the resident's care plan, last edited 10/2/23, showed: -Problem: Resident is at risk for impaired nutrition related to no natural teeth or dentures. Resident wears upper and lower dentures, which currently cannot be located. Resident had previously been placed on a mechanical soft diet (type of texture-modified diet for people who have difficulty chewing and swallowing) after loss of previous dentures. Family is aware and reported that the resident used to hide them at home prior to coming to the nursing center. He/She continues to be reviewed by the dietician. He/She will at times try to wrap his/her food up in napkins instead of eating it and not want to give it to the staff. The resident does require assistance with cutting up his/her food and reminders to eat; -Goal: Nutrition needs will be met and weight maintained within acceptable parameters through next review date; -Approach: Encourage resident to eat slowly. Avoid foods that are difficult to chew. Offer available substitutes if resident has problems with the food being served. Provide resident with setup help, cueing, physical help, and assistance for meals. Monitor for weight loss. Report decreased food intake to appropriate clinician. Consult with dietician and follow recommendations; -Problem: Resident limited in ability to maintain grooming/personal hygiene related to cognitive impairment. Staff assists resident in choosing clothes and dressing. Staff also toilets resident, provides oral care, bathing needs, etc; -Goal: Resident will be groomed and all personal hygiene needs will be met through the next review date; -Approach: Provide assistance/full staff performance for oral care, washing/drying face and hands, perineum, bathing, dressing, etc; -The care plan did not include the physician ordered diet for the resident. Review of the facility's Special Diet List, provided by the facility on 11/15/23, showed the resident did not receive a special diet. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Functional Abilities: -Eating: Supervision or touching assistance. Helper provides verbal cues or touching assistance- Helper provides verbal cues or touching/steadying assistance as resident completes activity; -Upper body dressing: Substantial/maximal assistance. Helper does more than half the effort; -Lower body dressing: Substantial/maximal assistance. Helper does more than half the effort; -Personal hygiene: Substantial/maximal assistance. Helper does more than half the effort; -Diagnoses include dementia, seizures, anxiety, depression, schizophrenia. Review of the resident's care plan, last revised 7/26/23, showed: -Problem: Resident has a history of experiencing weight loss related to Covid-19 positive; -Goal: Resident will not lose 7.5% through next review; -Approach: Encourage oral intake of food and fluids. Monitor/record weights monthly. Notify physician and family of significant weight change; -Problem: Resident choking episode, where he/she grabbed a sandwich and stuffed in his/her mouth then got choked up; -Goal: Resident will not have any further choking episodes; -Approach: Staff to make sure food is cut up and resident is being monitored with all foods; -Problem: Resident is at risk for malnutrition related to no natural teeth or dentures. Resident is a feeder related to resident will pick up food and stuff in his/her mouth; -Goal: Weight will be maintained within acceptable parameters; -Approach: Report decrease in food intake to appropriate clinician. Monitor weight loss. Keep physician and significant other/designated family member informed of any weight loss. Review of the resident's EPOS showed an order, dated, 10/18/22, diet pureed (texture modified foods that do not require chewing), thin liquids. Review of the facility's Special Diet List provided by the facility on 11/15/23, showed the resident received a pureed diet. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Required moderate assistance from staff to eat; -Diagnoses include dementia and anxiety. Review of the resident's care plan, edited 9/27/23 showed the care plan did not address the resident's need for staff assistance with eating. Review of the resident's electronic physician's order sheet, showed an order, dated 9/22/23, diet regular, mechanical soft texture. Review of the facility's Special Diet List provided by the facility on 11/15/23, showed the resident received a mechanical soft diet. 4. Observations of the dining room on 11/15/23, showed: -At 12:40 P.M. Certified Nurse Assistants (CNAs) began bringing out meal trays to residents. There were 9 tables in the dining room, where residents who needed assistance sat at tables next to residents who did not need assistance; -At 12:50 P.M. Resident #3 sat at a table across from two other residents. The resident had not been provided a drink or a meal. He/She watched the other residents at the table eat. A fourth person at the table had already left the dining room and his/her plate of food remained on the table. He/She continued to look at the other residents at the table as they ate; -At 12:52 P.M., Resident #4 sat at a table behind Resident #3. Resident #4 and another resident at that table who required assistance, had not been served a meal or offered a drink. Two other residents who did not require staff assistance had been served their meals and provided drinks. Resident #4 sat at the table and waited for his/her food; -At 1:00 P.M., At a table in the corner by the elevator, three residents sat at the table. Two waited for food while the third resident ate. Both residents that waited had drinks; -At 1:02 P.M., On the other side of the dining room, at a table of four, three residents ate while one waited for his/her food; -At 1:03 P.M., A total of ten residents had not been served lunch and watched others at their tables eat while they waited for their meal and staff assistance; -At 1:04 P.M., Resident #2 sat at a table with another resident who also needed assistance and waited for their food; -At 1:05 P.M., Resident #4 and a resident who needed assistance, who sat next to him/her, were provided sippy cups (adaptive drinking cup). The drinks were placed in front and slightly out of reach of the residents. Other residents at the table, who did not require staff assistance with eating, ate their lunch; -At 1:07 P.M., CNA F walked towards the hallway with a cart of meal trays. Another CNA shouted across the dining room and asked if those were the hall trays. CNA F yelled back, Yes, doing the feeders' now, and walked past the nurses' station and down the hall; -At 1:08 P.M., CNA G sat next to the other resident, who needed assistance, at Resident #4's table and requested other staff to bring that resident's tray; -At 1:09 P.M., CNA D brought out two trays. One for Resident #2 and one for the resident next to Resident #2. CNA D started to assist both residents with eating. Nurse A brought out a tray for the resident at Resident #4's table. Staff also started to bring out food for other residents who needed assistance. Six residents had still not been served food, including Resident #3 and #4; -At 1:10 P.M., A resident, who did not require assistance with eating, was finished and requested dessert; -Four residents remained without their meal. Resident #3 had not been offered a drink or served food. Resident #4 watched staff assist the resident next to him/her with his/her meal. Resident #4 had a drink in a sippy cup in front of him/her but staff had not offered assistance to drink; -At 1:14 P.M., Staff brought out two trays. One tray was served to the resident at the table to the left of Resident #4. The other tray was served to Resident #3. Staff sat both trays down in front of the residents and walked away. CNA C brought a clothing protector to Resident #3 and placed it on him/her. CNA C went to the resident to the left of Resident #4 and began to feed that resident while he/she stood over the resident; -At 1:15 P.M., CNA H brought a chair next to Resident #3 and began assisting him/her; -At 1:16 P.M., Resident #4 was the last resident who had not been served; -At 1:18 P.M., CNA B brought a tray to Resident #4, sat it in front of him/her and walked away. CNA B then returned with a chair; and sat the tray in front of the resident. He/she walked away and came back with chair; -Resident #4 had waited over 30 minutes to be served his/her meal and watched other residents eat at his/her table while he/she waited; -1:20 P.M., A resident requested staff assistance back to his/her room. The Director of Nursing (DON) said the resident needed to wait until staff were finished assisting residents to eat. Most of the residents in the dining room had finished and left the dining room; -At 1:25 P.M., Resident #3 appeared to be asleep in his/her chair. CNA H encouraged the resident to wake up and eat. 5. During an interview on 11/15/23 at 2:15 P.M., CNA B said the observation at lunch was the way things were normally done. Sometimes staff could ask for the tray from kitchen early, but today was a normal day. There was a routine. Sometimes everyone could eat at the same time. They tried to get to everyone. Resident #4 needed extra time and ate slowly. 6. During an interview on 11/15/23 at 2:20 P.M., Nurse A said residents who needed assistance were given their food last. Staff waited to bring it out. He/She would not want to wait. The staffing for that day was pretty normal. They could use more hands when it came to assisting residents to eat. If staff asked the kitchen, they could get the trays earlier. 7. During an interview on 11/15/23 at 2:25 P.M., CNA F said they could change how residents were assisted. Staff tried to change it up sometimes. They began assisting residents to eat after all trays had been passed. CNA F said if he/she was with it and alert, then it would bother him/her to have to wait. However, if he/she was not alert and did not know what was going on, he/she would not care to wait. 8. During an interview on 11/15/23 at 2:30 P.M., The DON said she was now aware of the problem. She noticed a problem the dining room today. She did not consider it dignified to have residents watch others eat. She did not think it was ok for Resident #4 to wait over 30 minutes for food while he/she watched those around him/her eat. Staff should have offered assistance with the drink in front of the resident. It was not ok for Resident #3 to wait close to 30 minutes without a drink. Some residents who required assistance had a history of weight loss. She started to address the issue and would continue to address the problem. MO00225969

Based on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed and submitted for processing for four of 17 residents (Resident (R)13, R35, R36 and R137) in the sample. This failure has the potential to adversely affect the care planning and care provision for any resident that may not have received a comprehensive assessment. Findings include: 1. Review of R13's Face Sheet from the electronic medical record (EMR) Resident tab showed an admitted [DATE], readmission of 05/13/22, with medical diagnoses that included schizophrenia, major depressive disorder, mood (affective) disorder, neuropathy, asthma, cataracts, and atrial fibrillation. Review of R13's EMR MDS tab showed quarterly MDS assessment reference date (ARD) 02/15/22 and 05/18/22 with a status of Production Accepted. No quarterly MDS for August was found. In an interview on 11/10/22 at 1:10 PM, the MDS Coordinator (MDSC) confirmed there was a missing assessment, stating, No August quarterly assessment was completed. 2. Review of R35's Face Sheet from the EMR Resident tab showed an admitted [DATE] with medical diagnoses that included schizophrenia, chronic obstructive pulmonary disease, chronic kidney disease, and hyperlipidemia. Review of R35's EMR MDS tab on 11/08/22 at 2:01 PM showed two quarterly MDS, ARDs of 07/11/22 and 10/22/22 as In Process status. During an interview on 11/10/22 at 1:17 PM the MDSC stated the last MDS processed was 04/10/22 and those (two quarterlies) should have been sent. 3. Review of R36's Face Sheet from the EMR Resident tab showed an admitted [DATE], a readmitted [DATE], with medical diagnoses that included mild cognitive impairment, non-traumatic intra-cerebral hemorrhage, hypertension, type II diabetes, major depressive disorder, seizures, pseudobulbar affect, and atrial fibrillation. Review of R36's EMR MDS tab on 11/08/22 at 1:22 PM showed two quarterly MDS, ARDs of 07/14/22 and 10/14/22 with In Process status. During an interview on 11/10/22 at 1:14 PM, the MDS Coordinator (MDSC) reviewed the EMR and stated, I just did those today. Review of R36's EMR MDS tab on 11/20/22 at 1:15 PM showed the two quarterly MDS assessments no longer had a status of In Process. 4. Review of R137's Face Sheet from the EMR Resident tab showed an admitted [DATE], readmitted [DATE], with medical diagnoses that included paranoid schizophrenia, type II diabetes, glaucoma, hypertension, and major depressive disorder. Review of R137's EMR MDS tab on 11/08/22 at 1:57 PM showed two quarterly MDS, ARDs of 12/26/21 and 09/26/22 with In Process status. During an interview on 11/10/22 at 1:18 PM, the MDSC reviewed the EMR and stated, the last one [MDS] processed was 03/28/22, missing quarterly assessments . Review of R137's EMR MDS tab on 11/10/22 showed the 12/26/21 quarterly MDS had been finalized but had not yet been transmitted. During an interview on 11/10/22 at 2:35 PM, the Director of Nursing (DON) stated the facility did not have policies regarding MDS assessment. The DON stated, .use the RAI [Resident Assessment Instrument] Manual for MDS completion. I expect that everything [all assessments] would be up to date. Review of the October 2019 RAI Manual, page 2-33, showed: 05. Quarterly Assessment. The Quarterly assessment is an . non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous . assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD . must be not more than 92 days after the ARD of the most recent . assessment of any type.

Based on interview and record review, the facility failed to ensure one of three residents (Resident (R) 28) received quarterly personal fund statements. Specifically, R28 was cognitively impaired and R28's Resident Representative (RR) did not receive quarterly personal fund statements for January through September 2022. Findings include: Review of R28's undated Face Sheet located in the electronic medical record (EMR) under the resident tab revealed R28 was admitted [DATE] with diagnosis of dementia. Review of R28's annual Minimal Data Set (MDS), located in the EMR under the RAI tab, revealed R28 had a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated the resident was severely cognitively impaired. During an interview on 11/08/22 at 4:04 PM, R28's RR stated the facility managed R28's personal funds account. R28's RR stated that he/she did not receive quarterly statements for R28's personal funds account. Review of R28's Personal Funds Ledger Card dated January through September 2022 revealed the signature space titled Quarterly Review was blank. During an interview on 11/09/22 at 3:12 PM, the Administrator stated he managed the residents' personal funds accounts. He stated he provided quarterly personal fund statements to residents who could personally sign but did not provide them to the RR of residents who were cognitively impaired. He confirmed that he had not provided R28's RR with quarterly personal fund statements. The Administrator stated the facility used the information contained in the Resident Handbook as the policy for the resident personal fund. The Resident Personal Fund section located on page 15 of the Resident Handbook read, . A Quarterly Statement will be made available for review detailing deposits and withdrawals made during the previous their [sic] month period . During an interview on 11/11/22 at 04:04 PM, the Administrator stated 48 residents had trust funds. The Administrator stated five residents were cognitively impaired and would not be able to understand their own quarterly statement, so quarterly statements would need to be sent to their RR.

Based on interview, record review, and facility policy review, the facility failed to notify the power of attorney (POA) or Hospice when a resident had a fall and was transferred to the hospital for one of one resident (Resident (R) 21) reviewed in a total sample of 17 residents. Findings include: Review of R21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/03/22 found in the Electronic Medical Record (EMR) under the Resident assessment tab revealed that R21 had a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated resident was cognitively intact during the time of the accident. Review of R21's Progress note under the Progress notes tab showed that R21 was placed on hospice care on 09/21/22 by sister who was the POA. Review of the Advance Directive document confirmed the sister was the POA. Review of progress notes dated 10/03/22 found in the EMR under the Progress notes tab showed that no follow-up was made to the POA after R21 had fallen and hit her head. Review of the Progress note dated 10/03/22 at 04:39AM revealed, .due to the extent of her injury, 911 was called for transport and F/u [follow up] calls will be made to RP [responsible party] and hospice by Licensed Practical Nurse (LPN) 1. Review of progress notes found in the EMR under the Progress notes tab revealed a note dated 10/03/22 at 06:57AM., Sister called facility asking why she wasn't contacted about resident going to the hospital, this nurse apologized for not contacting sooner and let her know what was going on, sister stated she was calling hospice, hospice called not long after and asked that next time they are to be notified first before she's sent to the hospital. Nursing LPN 1. Interview on 11/09/22 at 12:23 PM the POA stated that she had never received a phone call from the facility about R21 being taken to the hospital for an injury. The POA stated that she had been contacted by the hospital to get an approval to treat R21 for the injuries. Interview on 11/09/22 at 3:30PM, the Director of Nursing (DON) stated she was contacted by the nurse about having to send out R21 to the hospital. DON stated, the POA had never requested a time for the facility to not call her. POA wanted to be notified when anything was to ever be done or if anything was to ever happen. Interview on 11/11/22 at 4:48PM, the Social Worker (SW) stated there was no actual policy for the notification of transfer or notification of change in status just that they had a bed hold policy. Review of the facility's policy titled, Bed Hold Policy dated ---- revealed, When a community member is transferred to an acute hospital or is on a therapeutic leave the community member's responsible party or legal representative will be contacted by telephone regarding the transfer or leave

Based on interview and record review, the facility failed to ensure three of three residents (Resident (R)32, R37, R38) or Resident Representative (RR) were issued a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) related to the end of Medicare A Skilled Services. This failure left the Residents and/or Resident Representatives uninformed of the possibility of continuing services and the expense that might be incurred. Findings include: 1. Review of R32's Face Sheet from the electronic medical record (EMR) Resident tab showed an admitted [DATE], readmitted [DATE] with medical diagnoses of congestive heart failure, hypertension, permanent atrial fibrillation, lymphedema, and cognitive communication deficit. Review of the Medicare A Notice of Medicare Provider Non-Coverage [NOMNC] document showed R38 started PT/OT/ST [physical/occupational/speech therapies] on 02/28/22 and was discontinued on 03/30/22. No SNFABN notice was provided to R32 or his/her Resident Representative. 2. Review of R37's Face Sheet from the EMR Resident tab showed an admitted [DATE], readmission on 07/15/20, with medical diagnoses that included pneumonitis due to inhalation of food or vomit, dysphagia, anxiety, major depressive disorder, type II diabetes, hypertension, repeated falls, and schizophrenia. Review of the Medicare A discontinuance document showed R37 started Medicare A services on 07/15/20 and would be discontinued on 08/07/20. No SNFABN notice was provided to R37 or his/her Resident Representative. 3. Review of R38's Face Sheet from the EMR Resident tab showed an admitted [DATE], readmission on 04/17/20, with medical diagnoses that included acute respiratory disease, encephalopathy, chronic kidney disease, dysphagia following cerebrovascular disease, epilepsy, pulmonary embolism, syncope with collapse, and embolism/thrombosis. Review of the Medicare A discontinuance document showed R38 started Medicare A services on 04/17/20 and would be discontinued on 05/30/20. No SNFABN notice was provided to R38 or his Resident representative. In an interview on 11/10/22 at 5:12 PM, the Administrator stated there was no policy, just the information that was in the Admission Packet. When asked about the SNFABN forms, the Administrator stated that the Therapy Director was in charge of those forms. During an interview on 11/11/22 at 9:05 AM, the Therapy Director (TD) stated, The State told us we needed to use the NOMNC maybe three or four years ago. I came in a year ago [here] and instituted the NOMNC. When asked about the SNFABN form, TD stated, I've been managing [therapy departments] for [AGE] years and was never asked about an ABN. The TD sorted a few papers in hand and pulled out a SNFABN form, stating, I called my boss, and she didn't know about the form either. In an interview on 11/11/22 at 10:00 AM the Director of Nursing (DON) stated nobody at the facility was aware of the beneficiary notices. Review of the Centers for Medicare and Medicaid Services website (https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-SNF-ABN-) showed: FFS SNF ABN Skilled Nursing Facilities (SNFs) must issue a notice to Original Medicare (fee for service - FFS) beneficiaries in order to transfer potential financial liability before the SNF provides: an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or custodial care. For Part A items and services: SNFs use the SNF ABN as the liability notice

28154 Based on interview, record review, and admission packet review, the facility failed to ensure two of three residents (Resident (R)34, and R135) and/or their representatives reviewed for an emergent discharge to the hospital, out of a total sample of 17, were provided with a written notice of transfer that included all required information. The facility 's transfer notice forms did not include information on how to contact the Ombudsman or how to file an appeal, if desired. In addition, although transfer forms prepared by the facility may have been faxed to the hospital where the resident was being transferred, the facility failed to assure that both the resident and their representative received the forms. This failure has the potential to affect the resident and/or their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: 1. Review of R135's Face Sheet from the electronic medical record (EMR) Resident tab showed a facility admitted [DATE], a readmitted [DATE] During an interview on 11/09/22 at 10:54 AM, R135 stated he/she had gone to the hospital last month after a fall because nobody could pick him/her up, so they called the ambulance. Review of R135's Progress Notes from the EMR Resident tab revealed: 10/06/22 7:43 AM Nursing Resident was observed laying on floor 2 [at] bedside, movements slowed, speech slowed, vs [vital signs] . , resident unable to state how he/she became on the floor. Subsequent call to Dr. [name] re this observation and change in condition, to transport to [hospital name] for evaluation in ER [emergency room ]. In response to a request for a written notice of transfer / discharge regarding the 10/06/22 emergent transfer, the facility provided a form that at the top stated discharge date : 10/6/22 Return Date: 10/8/22. The form had two different styles of handwriting and two different types of ink. In a different form from the discharge / return date, the reason for transfer was listed as Altered Mental Status and signed by the Director of Nursing (DON) with the same handwriting noted on the Resident Signature line Unable to sign. While the written notice did state R135 was being transferred to a specific named hospital with a reason for the transfer, the notice did not include: -A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; -The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; or -For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. During a telephone interview on 11/10/22 at 1:55 PM, R135's resident representative (RR135) was contacted regarding receipt of the written notice of transfer and written bed hold for the 10/06/22 hospital transfer. RR135 responded to the query stating, I was contacted by phone by the hospital. When specifically asked if she had received a written notice of discharge or transfer, RR135 stated, No. During an interview on 11/10/22 at 4:50 PM, the NHA confirmed everything provided was from the Admission Packet, We don't have policies. 11/11/22 05:00 PM during an interview with the DON regarding the transfer notices and the difference in the ink/handwriting, she stated, They brought it to her yesterday and asked her to sign because nobody wants to put their signature on anything. Clarified, that R135's written notice of transfer had just been signed on 11/10/22 Yes. 2. Review the Face Sheet, located in the EMR under the Resident tab revealed R34 was admitted [DATE]. Review of the admission MDS with an ARD of 08/08/22, located in the EMR under the RAI tab, revealed R34 had a BIMS score of 8 out of 15 indicating resident had moderate cognitive impairment. Review of Progress Notes dated 09/02/22, located under the Resident tab in the EMR indicate R34 was transferred to the hospital. During an interview on 11/11/22 at 10:40 AM, the SW presented a Discharge/Transfer/LOA [Leave of Absence] Bed Hold Notice form for a discharge date of [DATE]. The document was signed by the resident but there was no date on the document. The SW stated a discharge notice was not sent to R34's representative. During an interview on 11/11/22 at 10:48 AM, R34 stated he/she received and signed the Discharge/Transfer/LOA Bed Hold Notice form on 11/11/22. During an interview on 11/11/22 at 11:24 AM, the DON stated R34 was given and signed Discharge/Transfer/LOA Bed Hold Notice on 11/10/22. She stated he/she had not received it prior to yesterday and a discharge notice was not sent to R34's representative. 46584

28154 Based on interview, record review, and review of facility policy, the facility failed to ensure three of three (Resident (R) 135, 21, and R34) reviewed for hospitalization , the resident and/or their Resident Representative (RR) received a written bed hold notice upon emergent transfer to the hospital. This failure had the potential to contribute to possible denial of re-admission following a hospitalization for residents transferred emergently to the hospital. Findings include: 1 Review of R135's Face Sheet from the electronic medical record (EMR) Resident tab showed a facility admitted [DATE], a readmitted [DATE] During an interview on 11/09/22 at 10:54 AM, R135 stated he/she had gone to the hospital last month after a fall because nobody could pick her up, so they called the ambulance. Review of R135's Progress Notes from the EMR Resident tab revealed: 10/06/22 7:43 AM Nursing Resident was observed laying on floor 2 [at] bedside, movements slowed, speech slowed, vs [vital signs] .resident unable to state how he/she became on the floor. Subsequent call to Dr. [name] re this observation and change in condition, to transport to [hospital name] for evaluation in ER [emergency room ]. In response to a request for the written bed hold notice provided to the resident or resident representative on 10/06/22, the document provided was undated and signed by the resident and witnessed by the facility Social Worker. During a telephone interview on 11/10/22 at 1:55 PM, R135's resident representative (RR135) was contacted regarding receipt of the written bed hold notice for the 10/06 /22 hospital transfer. RR135 responded to the query stating, I was contacted by phone by the hospital. When specifically asked if she had received a written bed hold notice provided at the time of transfer or as soon as possible, RR135 replied, No. During an interview on 11/10/22 at 4:50 PM, the Administrator confirmed everything provided was from the Admission Packet, We don't have policies. 2. Review of R 21's EMR revealed an admission on 10/03/22. The Minimum Data Set (MDS) located on the MDS tab with an Assessment Reference Date (ARD) of 10/28/22 showed a Brief Interview of Mental Status (BIMS) score of a 15 of 15 which indicated the resident was cognitively intact. Review of R21's EMR under the Resident tab revealed Progress notes which indicated that R21was discharged to the hospital on 10/03/22. During an interview with the Power of Attorney (POA) on 11/10/22 at 01:30 PM. the POA stated that she had not received any notice of a bed hold policy when R21 was transferred to the hospital. During an interview with the Director of Nursing (DON) on 11/11/22 at 01:30 PM about R21 going to the hospital, the DON stated that it is the Social Worker (SW) that handles sending the bed hold policy to the resident and representative. During an interview with the SW on 11/11/22 at 02:45PM, the SW stated that they called and faxed the paperwork to the hospital and noting was given to R21 3.Review the Face Sheet, located in the EMR under the Resident tab revealed R34 was admitted [DATE]. Review of the admission MDS with an ARD of 08/08/22, located in the EMR under the RAI tab, revealed R34 had a BIMS of 8 out of 15 which indicated the resident had moderate cognitive impairment. Review of Progress Notes dated 09/02/22, located under the Resident tab in the EMR indicate R34 was transferred to the hospital. During an interview on 11/11/22 at 10:40 AM, the SW presented a Discharge/Transfer/LOA (Leave of Absence)/Bed Hold Notice form for a discharge date of [DATE]. There was no date for the resident signature. The SW stated that the bed hold policy was not sent to R34's resident representative (RR). During an interview on 11/11/22 at 10:48 AM, R34 stated he/she received and signed the Discharge/Transfer/LOA Bed Hold Notice form on11/11/22. During an interview on 11/11/22 at 11:24 AM, the DON stated R34 was given and signed the Discharge/Transfer/LOA/Bed Hold Notice on 11/10/22. She stated he/she had not received it prior to yesterday and a bed hold policy was not sent to R34's RR. During an interview with the Administrator on 11/11/22 at 06:46PM, the Administrator stated that they had not mailed any bed hold policy out. The Administrator was not aware of having to send the bed hold policy to the resident or the representative. Review of the facility Bed Hold Policy from the facility admission packet revealed: Policy: This facility offers a bed hold when a resident is transferred to an acute hospital or is on a therapeutic leave. Procedure: 1. Upon admission to the facility and again when the resident is transferred to an acute hospital or is on therapeutic leave, the resident, family member, or legal representative will be informed of the bed hold policy. 2. When a resident is transferred to an acute hospital or is on a therapeutic leave the resident's responsible party or legal representative will be contracted [sic] by telephone regarding the transfer or leave. The resident will be given the bed hold policy prior to leaving this facility to be carried with them to their designated location. 3. All responsible residents, family, or legal representatives will also have the policy mailed to them . 46584

Based on observation, interview and record review, the facility failed to ensure skin assessments were completed and documented for two of two sampled residents, with a [DIAGNOSES REDACTED]. The medical records of these two sampled residents with discolored and/or open areas did not contain documentation to show staff were monitoring, notifying the physician and providing appropriate care and services to treat and heal the affected areas. One of the residents required hospitalization for treatment of [REDACTED]. (Residents #1, #3, #11 and #15) The census was 36. 1. Review of Resident #1's current face sheet, no date, showed an admission date of [DATE], and [DIAGNOSES REDACTED]. Review of the resident's admission nursing assessment, dated 3/15/11 at 3:40 P.M., showed a diagram used to indicate all body parts, with two lines drawn across, indicating no open areas. Review of the resident's admission nurse's note, dated 3/15/11, identified the resident as homeless and failed to show documentation of a skin assessment. Review of the resident's admission physical exam, dated 3/24/11, showed the following: -Past medical history of [REDACTED]. -Review of systems: Skin: no rash or wound; -Functional status: Skin: no [MEDICAL CONDITION], no rashes, no ulcers; -Assessment and plan: diabetes, high blood pressure, spinal stenosis and arthritis. Review of the resident's medical record, showed the facility failed to complete an admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff. Review of the resident's computerized care plan, dated 4/2011, showed a handwritten note, no date, identified a risk of infection related to gangrene and amputation of an unidentified site. Review of the resident's monthly summaries, showed the following: -3/2011 and 4/2011, skin: fair, nails: toes, podiatrist written in by staff, no open areas. Review of the resident's nurse's notes, dated 3/15/11 through 5/21/11, failed to show documentation of any open areas to the resident's left foot. Review of the resident's physician's nursing home follow up visits, dated 4/13/11 and 5/11/11, showed no documentation of ulcers to the resident's left foot. During an interview on 7/26/11 at 7:08 A.M., Certified Nurse Aide (CNA) I said the first time he/she worked with the resident was after his/her readmission from the hospital and he/she didn't know whether the resident an ulcer on the left foot before going to the hospital. During interviews on 7/26/11 at 7:21 A.M., CNA D said the resident had an ulcer on his/her left foot when he/she came to the facility, but the facility didn't put anything on it. CNA E said he/she couldn't remember whether the resident had an ulcer on his/her left foot. During an interview on 7/28/11 at 8:55 A.M., Nurse C said he/she did a monthly summary on 5/13/11. Review of the resident's monthly summary at this time, showed 5/2011, no specific date documented, skin: left great toe black, pain: yes, nails: podiatrist written in. The nurse said he/she recalled doing the monthly summary, but didn't know why he/she didn't document the complete date. The resident's great toe was black and he/she told the Director of Nurses (DON). The nurse did not assess, measure, document or call and inform the resident's physician at that time. Review of the resident's medical record, including treatment records, showed no further documentation regarding the wound to the left great toe. During an interview on 7/26/11 at 11:15 A.M., the DON said she notified the resident's physician about the development of the ulcer on the resident's left great toe but failed to document it in the resident's medical record. During an interview on 7/27/11 at 11:50 A.M., the resident's physician said she would expect staff to notify her of any breakdown in the resident's skin and to assess and document in the medical record. She said the resident did not have any open areas when he/she was admitted to the facility. The physician said she was aware of the left great toe wound, but could not say why the medical record contained no documentation regarding the left great toe. During an interview on 7/28/11 at 8:30 A.M., the facility podiatrist said the facility provides a list of residents for him to see. The facility hadn't put the resident on the list for him too see and he had never trimmed the resident's toe nails. Review of the resident's nurse's note, dated 5/21/11, showed the following: -1:05 P.M., lost his/her balance and fell , vital signs were; temperature: 101.9 Fahrenheit (F) (normal 98.6), pulse 100 (normal 68-72), respirations 22 (normal 16-20) and blood pressure 160/90 (normal 120/70); -1:15 P.M.: vomited a moderate amount of undigested food; -1:25 P.M.: vomited a large amount of undigested food; -1:50 P.M.: physician notified, order received to send to the emergency room for evaluation of emesis; -2:30 P.M.: temperature: 102.9 F, Tylenol 650 milligrams (mg) given, awaiting ambulance arrival. Review of the resident's hospital emergency department notes, dated 5/21/11 at 4:43 P.M., showed the following: -Chief complaint: fever, fall, nausea and vomiting for two days; -[DIAGNOSES REDACTED]. -Unable to palpate pulses in feet; -White blood count: (indication of infection) 11.5 high, (normal 4.5 through 11); -Physical exam of skin revealed a 2 centimeter (cm) ulcer with necrotic tissue on top of left great toe, a smaller necrotic (dead tissue) ulceration next to the 2 cm ulcer, the left great toe is purple and mottled to the joint; -Diagnosis: [REDACTED]. -IV antibiotics: [MEDICATION NAME] (antibiotic used to treat serious infections); -Admit to hospital; -Assessment and plan: cyanotic (bluish color), [MEDICAL CONDITIONS] (infection of the blood) present on admission. Review of the resident's hospital podiatry consult, dated 5/23/11 at 1:38 P.M., showed the left foot was cool to the touch with swelling, redness and a 1.5 cm ulceration with necrotic tissue. Review of the resident's hospital discharge summary, dated 5/26/11 at 2:10 P.M., showed the following: -Necrosis and [MEDICAL CONDITION] of the left foot [MEDICAL CONDITION]; -Severe [MEDICAL CONDITION] ([MEDICAL CONDITION], disease that causes poor blood flow to the legs); -Resident refused vascular surgery at this time. Will result in possible amputation. Review of the resident's readmission physical exam, dated 5/27/11, showed the following: -Current medical problem: left great toe ulcer, pain; -Skin: left great toe gangrene, pedal pulse not present; -Assessment and plan: severe [MEDICAL CONDITION], resident refused amputation. Review of the residents physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Order dated 5/27/11: surgical shoe for left foot; -Order dated 6/1/11: Specialized Wound Management (SWM) to consult and treat wounds as indicated. Review of the resident's SWM consultation, dated 6/7/11, showed the following: -Left great toe/foot gangrene; -Resident agreed to amputation of left great toe at this time; -Consult with vascular surgeon for amputation of left great toe. Review of the resident's physician's progress record, showed the following: -Admit to hospital: 6/8/11; -Amputation of left great toe and second toe. Review of the resident's POS, dated 6/14/11, showed the following: -readmitted to facility on 6/14/11; -[DIAGNOSES REDACTED]. Review of the resident's nurses note, dated 7/12/11, showed the following: -5:30 P.M.: Shaky and disoriented, temperature: 102.2 F; -5:45 P.M.: 911 called; -5:55 P.M.: Sent to hospital for evaluation. Review of the resident's POS, dated 7/21/11, showed a [DIAGNOSES REDACTED]. Observation on 7/26/11 at 7:21 A.M., showed the resident lay in bed with a dressing to the left [MEDICAL CONDITION] and a 1 cm dark scabbed area to the top of the right great toe. Review of the resident's medical record showed no mention of the scabbed area to the top of the right great toe. Observation on 7/27/11 at 12:30 P.M., showed the resident sat in his/her wheelchair. The resident's physician and the DON assessed the resident's right foot and noted the 1 cm scabbed area to the resident's right great toe. The DON said staff had not reported the scabbed area to the resident's right great toe to her. The resident's physician said she would order something for the wound. Review of the POS [REDACTED] -Watch right great toe wound, apply triple antibiotic ointment; -Surgical boot for right foot. During an interview on 7/26/11 at 11:15 A.M., the DON was asked for the facility's policy on how staff should assess and document skin breakdown. She said the facility had a policy on Pressure Ulcer prevention which would include any break in the resident's skin. Staff should have documented any break in a resident's skin on the shower sheet after giving a shower and given the shower sheet to the nurse who should have assessed the area, documented his/her findings and notified the resident's physician. Review of the facility's Pressure Ulcer Prevention Policy and Procedures, no date, showed the following: -Upon admission, change in physical status, and periodically as needed, residents will be assessed for actual and/or potential risk of developing pressure ulcers or skin breakdown. -The criteria to be assessed will be overall physical condition, mental state, activity level, mobility, continence and nutritional status; -Any resident with actual skin problems or at risk will immediately have preventative measures initiated as follows; -#8: CNAs will check skin every shift for signs of redness or skin breakdown and report it to the charge nurse immediately; -#9: Charge nurse will initiate treatment protocol for any pressure ulcer or skin integrity problem; -Charge nurse will notify the Director of Nurses and Administrator of any actual breakdown or pressure ulcers as soon as possible and weekly skin assessments will be completed and given to Director of Nursing; -Resident's primary physician and responsible party will be kept informed of progression of any actual wounds and healing process. During an interview on 7/28/11 at 1:48 A.M., the DON said staff should fill out shower sheets and document any open or discolored areas. She could not find any shower sheets or skin assessments for the resident. Staff should have documented in the nurse's notes any change in the resident's skin and notify the physician. 2. Review of Resident #3's admission nursing assessment, dated 3/1/11 at 12:45 P.M., showed the right great toenail was brittle and broken, and both feet were cold to the touch. Both of the resident's legs had dark scaly skin patches, and the left leg was sore to the touch. Review of the resident's initial POS, dated 3/1/11, showed [DIAGNOSES REDACTED]. Review of the resident's admission physical exam, dated 3/2/11, showed the following: -Review of Skin: no rashes or wounds; -Skin: no [MEDICAL CONDITION], no rashes, no ulcers; -Psych: oriented to person, place, and time - mood and affect appropriate; -Assessment and plan: high blood pressure use blood pressure medication, past stroke use aspirin therapy and diabetes. Review of the resident's initial MDS, dated [DATE] showed the following: -No memory or recall problems; -No behavior problems; -No rejection of care; -Independent in all areas of daily living except required limited assistance of one staff member for personal hygiene, and supervision and set up required for bathing; -Not steady, but able to stabilize without human assistance for rising, walking, turning while walking, moving on and off the toilet and surface to surface transfers; -Impaired range of motion of the lower extremities on one side; -Continent of bladder, frequently incontinent of bowel; -No foot problems; -Height 75 inches, weight 217; -No venous or arterial ulcers; -No foot problems. Review of the resident's comprehensive plan of care, dated 3/20/11, showed the following problems and interventions: -Potential for falls as a result of a [MEDICAL CONDITION] disorder and a history of a stroke. Interventions included: room and hallways well lit and free of clutter, monitor for [MEDICAL CONDITION], gait and balance, encourage to walk with walker at all times, proper fitting shoes, and monitor laboratory tests and medications as ordered; -Nutritional status related to diabetes. Interventions included: assess for hyper/[DIAGNOSES REDACTED], assist with choice of healthy snacks, provide bedtime snack, diet as ordered, dietician consult as needed, monitor labs and medications as ordered. Review of the resident's monthly nursing summaries, in his/her medical record, showed the following: -3/16/11, skin assessment section was not filled out, toenails cut by staff; -4/15/11, skin turgor: good, free of any open areas, toenails cut by staff, podiatrist as needed written in by staff; -5/11/11, skin turgor good, toenails cut by staff, podiatrist as needed written in by staff; -6/15/11, skin turgor good, toenails cut by staff ; -7/11/11, skin turgor good, toenails cut by staff. Review of the resident's podiatrist's note, dated 4/26/11, showed the following; -The resident reported pain on ambulation. Right great toe - dry, pain, ulcer (marked on the end of the right great toe on a detailed diagram of the right foot). Both feet: cool to the touch, skin texture thin, elasticity decreased, and hair growth absent. Pain in limb. Difficulty walking. Fungal infection of toenails. The podiatry note showed the resident developed an ulcer on the right foot and directed staff to monitor the foot and decrease any pressure. Review of the resident's nurse's notes, showed the following: -Admission on 3/1/11; -From 3/1/11 through 5/4/11, the resident ambulated throughout the facility with use of either a cane or a walker. The notes showed nothing concerning pain with ambulation, nothing indicating any skin assessments had been completed, and no skin problems; -5/4/11, fell while attempting to arise from a chair. Lost balance and fell in the courtyard. Arose with the assist of a staff member. Sustained no apparent injury; -From 5/4/11 through 6/23/11, the resident ambulated throughout the facility with the use of either cane or walker. The notes showed nothing concerning pain with ambulation, nothing indicating any skin assessments had been completed and no skin problems; -6/23/11, fell in the shower room. No injuries noted upon body assessment; -6/23/11, small puss filled bumps with a foul odor in the resident's hair. Resident's left great toe and tip of the toe were black, as well as the tip of the second toe. The resident's left foot was fluid filled. The nurse contacted the resident's physician who ordered antibiotic, Keflex (antibiotic) 500 milligrams, to be administered for seven days; -6/24/11, the nurse offered the resident the use of a wheel chair; -6/30/11, the resident's left great toe and second toe remained black; -From 7/1/11 through 7/25/11, the resident ambulated or wheeled throughout the facility. The notes showed nothing concerning pain with ambulation, and nothing indicating any skin assessments had been completed. The only mention of the resident's feet after 6/30/11, was noted on 7/3/11. The nurse documented the resident's great toe and second toe on the left foot remained black, and all the resident's toe nails were dry and brittle. Review of an update to the resident's comprehensive plan of care, dated 6/15/11, showed the following: -Problem: Dark areas noted on both feet. Goal: will not develop pressure area. Interventions: weekly skin assessments and encourage use of good fitting shoes with socks. Review of the monthly treatment record sheets, in the resident's medical record, showed no documentation of a weekly skin assessment for March 2011, April 2011, May 2011, or June 2011. Review of the monthly treatment record, dated July 1-31, 2011, showed an order, dated 6/2/11, for a weekly skin assessment. When reviewed on 7/25/11 and again on 7/28/11, only one weekly skin assessment was documented, dated 7/14/11. The entry concerning it on the reverse side of the sheets read "no open areas". In the comment section the documentation showed: -Right lower extremity dark discoloration of skin; -Left lower extremity dry skin; -Right foot, big toe black including second toe; -Left foot, big toenail broken needs to be seen by podiatrist. During an interview on 7/26/11 at 11:15 A.M., the DON said nurses document skin assessments weekly on treatment records. The CNAs were supposed to document the condition of each resident's skin, on a shower sheet, each time they assist a resident with a shower. During an interview on 7/26/11 at 1:40 P.M., the DON said no routine weekly skin assessments were completed by a facility nurse before 7/14/11. She found four shower sheets completed by CNAs concerning skin assessments completed in conjunction with the resident's showers. The shower sheets were dated: 4/5/11, 5/28/11, 6/12/11 and 6/28/11. None of the four shower sheets showed any problems with the resident's skin. The DON said the update to the resident's plan of care, on 6/15/11, was written in response to contact from the resident's family member. The family member had called her in mid-June 2011, to report the resident had "necrotic areas" on his/her feet. The DON said she looked at the resident's feet and did not believe the dark areas were necrotic, she thought they areas looked like darkened calluses. She did not call the resident's physician concerning the darkened areas on the resident's feet, however she wrote the update to the care plan. When asked why the care plan update was not in the care plan book with the rest of the resident's care plan, the DON said she found it on her desk after the surveyor asked about the resident's skin assessments. When asked if the antibiotic ordered by the resident's physician on 6/23/11, was to treat the scalp infection or the blackened areas on the resident's feet, the DON said she believed it was ordered for the scalp infection. During observation on 7/25/11 at 12:00 P.M., the resident sat in a wheelchair at a dining room table. The resident had no complaints of foot pain and said he/she used the wheelchair when he/she had trouble walking or felt particularly tired. Review of the resident's podiatrist's notes, dated 7/25/11, showed the following; -The resident reported pain on ambulation. Area still noted on the end of the right great toe. Debrided an area on the left great toe; a 4 millimeter ulcer with purulent drainage. Dark area noted on the first knuckle of the left second toe. Both feet: cool to the touch, skin texture thin, elasticity decreased, hair growth absent. Pain in limb. Difficulty walking. Fungal infection of toenails. Review of the resident's POS, showed an order, dated 7/25/11, to rinse the resident's left great toe with normal saline, dry it, apply triple antibiotic ointment, and cover the area with a bandage twice daily. The order also directed staff to insure the area received no shoe pressure until it was healed. During an interview on 7/27/11 at 11:45 A.M., the resident's physician said she was not aware of any problem with the resident's feet until she received a call from the staff concerning the resident's infected bumps on his/her head and blackened areas on his/her toes in late June. When asked if she ordered the antibiotic, on 6/23/11, for the scalp infection or the blackened areas on the resident's feet the physician said she believed it was to treat both conditions. She did not know the resident's family member had complained to the DON of "necrotic areas" on the resident's feet in June. She said if the DON saw darkened areas on the resident's feet in June, she failed to notify her of the areas. She said the DON should have told her about the family member's concerns and reported her assessment of the darkened areas on the resident's toes. The physician said she had not been told the podiatrist had debrided areas on the resident's toes on 7/25/11. During an interview on 7/28/11 at 9:0 0 A.M., the facility podiatrist said the facility provides a list of residents for him to see. He had seen the resident twice, once in April and on 7/25/11. He routinely sees the resident's on the facility list every three months, but is able to be reimbursed for seeing the diabetic residents every two months (if the resident's primary physician provides an order for [REDACTED]. The resident's feet had been rubbing against the inside of his/her shoes caused the blackened areas. When he debrided the area on the left great toe purulent drainage came out. The black, thickened skin developed to protect the toes as they rubbed against the inside of the shoe. The skin layers moved against each other and caused breakdown, which then became infected. The purulent drainage was evidence of the infection. The podiatrist said the infection might have been avoided if staff had been doing their routine skin assessments and addressed the problem earlier. If staff had gotten the order for a podiatry consult for June, the resident's toe might not have progressed to its current state. Review of the facility's undated policy on Resident's Condition Change Reporting showed the following: -Physicians are kept current on resident conditions through the daily report from the Assistant DON or a designee; -If after nursing assessment the change in condition is determined to be significant it will be reported before the scheduled report; -If a nurse is unable to reach the out-of -house physician, the long-term care medical director is notified; -If there is a question by nursing about the appropriateness of a physician follow-up, the medical director is notified; -Family must be notified of any change in condition as soon as possible; -Document in the clinical notes the resident's condition and that the supervisor, family, and physician were notified; -Update the resident's care plan to reflect the resident's change in condition. 3. Review of Resident #11's quarterly MDS, dated [DATE], showed the following: -Admission 10/30/09; -Sometimes understands: responds adequately to simple, direct communication only; -Independent for bed mobility, transfers, walking in room/corridor, locomotion on/off the unit and toilet use; -Not steady, but able to stabilize without human assistance: moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on/off the toilet and surface to surface transfers (transfers between bed and chair or wheelchair); -Mobility device: cane/crutch; -[DIAGNOSES REDACTED]. Review of the resident's most recent care plan, dated 3/2011, showed the following: -Difficulty with both long and short term memory related to [MEDICAL CONDITION]; -Potential for communication difficulties related to decreased cognition; -Risk for falls related to a history of falls, unsteady gait balance. Review of a nurse's note, dated 4/11/11 at 7:30 P.M., showed the resident attempted to get into the wheelchair and fell to the floor, hitting the right side of his/her head and sustaining a hematoma (blood bruise) on the left eye. Review of the resident's medical record showed staff completed one neurological assessment (to check for level of conscience changes which could indicate swelling on the brain), on 4/11/11, on the 11:00 P.M. - 7:00 A.M. shift. Review of a nurse's note, dated 6/22/11 at 3:30 P.M., showed the resident attempted to get out of the wheelchair at the nurse's station and fell hitting his/her head into the wall. Review of the resident's record showed staff failed to initiate neurological assessments. During an interview on 7/28/11 at 1:30 P.M., the DON said the facility did not have a neurological assessment policy. If the nurses did not document neurological assessments in the nurse's notes, then they were not done. 4. Review of Resident #15's face sheet, showed the following: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Rarely, never understood others; -Required total dependence of one person for transfers. Review of a nurse's note, dated 6/3/11 at 5:00 P.M., showed the locks on the resident's wheelchair were not working properly and CNA B lost his/her balance during a transfer. The resident had three lacerations on his/her top lip. Review of a statement written by CNA B, regarding the incident on 6/3/11, showed he/she transferred the resident from bed into a wheelchair. CNA B locked the wheelchair, but it moved and he/she lost his/her balance and lowered the resident to the floor. The resident hit his/her face on the round metal part of the wheelchair. CNA B picked the resident up and put him/her in the wheelchair which is when CNA B noticed the skin tear on the resident's left arm and the cuts on his/her lip. During an interview on 7/29/11 at 7:25 A.M., CNA B said the wheelchair brakes did not hold and CNA B lowered the resident to the floor. The resident hit his/her face on the armrest. CNA B picked up the resident because he/she did not think it was that bad. During an interview on 6/23/11 at 8:07 A.M., Nurse O said the resident maintained consciousness and had two small lacerations on his/her top lip and a skin tear on his/her elbow. Nurse O applied pressure to the resident's lip and cleaned his/her arm. The resident's lip stopped bleeding but was swollen. Review of the hospital records, dated 6/4/11 at 10:23 A.M., showed the resident had swelling and bruising to the right side upper and lower lips, multiple lacerations to the inside upper lip and mild bruising to mid facial areas. During an interview on 7/05/11 at 9:25 A.M., the DON said she talked to CNA B about picking the resident up off the floor instead of having the nurse assess the resident. MO 775