Every finding on record at Oak Park Care Center

Based on observation, interview and record review, the facility failed to ensure necessary services were provided to maintain personal care and oral hygiene for two of 18 sampled residents (Residents #4 and #1). The census was 79. Review of the facility's Activities of Daily Living (ADL) policy, dated 04/09/2026, showed:-Policy: Nursing staff will assist in bathing residents to promote cleanliness and dignity. The charge nurse will be made aware of residents who refuse bathing;-Procedure: Assist with dressing/grooming as needed. If resident refuses, notify charge nurse and document refusal in medical record. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/20/2026, showed:-Diagnoses included paraplegia (loss of movement and feeling in the lower half of the body), dementia, contracture of the left hand, diabetes and multiple sclerosis (MS, autoimmune disease);-Moderately impaired cognition;-No rejection of care. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: Resident has an ADL self-care performance deficit;-Goal: Resident will maintain current level of function with ADLs through the review date;-Interventions: Oral care: resident has his/her own teeth, broken teeth, carious teeth, sore gums. Requires oral inspection with care, report changes to the Nurse;-Personal hygiene/oral care: dependent on staff;-Bathing: Check nail length and trim and clean on bath day and as necessary. Review on 08/06/2026 at 12:22 P.M., of the resident's Electronic Medical Record (EMR), showed:-In the task section for oral hygiene, one documentation of refusal of oral hygiene on 07/29/2026. Observation and interview on 08/04/2026 at 1:32 P.M., showed the resident in bed awake wearing a hospital gown. He/She said nursing staff did not always assist him/her with brushing his/her teeth. He/She said he/she was bedbound and unable to get to the sink to brush his/her teeth. He/She said he/she would like his/her teeth brushed twice a day. The resident's teeth were observed to have white/yellow matter on them. The resident said staff had not trimmed his/her nails in a while. He/She would like his/her nails trimmed. The fingernails on the resident's left hand were yellow, jagged, and were approximately half an inch long. Observation on 08/06/2026 at 11:46 A.M., showed the resident in bed awake watching the television. The fingernails on the resident's left hand were yellow, jagged, and were approximately half an inch long. The resident's teeth were observed to have white/yellow matter on them. The resident said no one brushed his/her teeth today. During an interview on 08/06/2026 at 12:11 P.M., Certified Nursing Assistant (CNA) F said the resident was dependent on staff for ADL care. He/She said the resident refused ADL care a lot but if staff approached him/her in a calm manner, the resident would let staff provide ADL care. He/She said CNAs were to document ADL care and refusals in the task section in the EMR. He/She said the resident was diabetic, so the nurse was responsible for trimming the resident's nails. During an interview on 08/06/2026 at 12:58 P.M., Licensed Practical Nurse (LPN) A said the resident was dependent on staff for all ADL care. He/She said the resident refused nail care but had never refused oral care. He/She would expect refusals of ADL care to be documented and included in the resident's care plan. He/She would expect the resident's nails to be trimmed and teeth to be brushed twice a day. 2. Review of Resident #1's quarterly MDS, dated [DATE], showed:-Diagnoses included quadriplegia (total loss of use in all four limbs and torso);-Cognitively intact;-No rejection of care. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: Resident has an ADL self-care performance deficit;-Goal: Resident will maintain current level of function with ADLs through the review date;-Interventions: Personal hygiene/oral care: dependent on staff. Review on 08/06/2026 at 12:54 P.M., of the resident's EMR, showed:-In the task section for oral hygiene, no documentation of refusal of oral hygiene from 07/08/2026 to 08/06/2026. Observation and interview on 08/03/2026 at 11:30 A.M., showed the resident's teeth were yellow and had white matter on them. The resident said no one assisted him/her with his/her teeth that morning. Observation and interview on 08/05/2026 at 7:21 A.M., showed the resident in bed awake. The resident's teeth were yellow and had white matter on them. The resident said staff did not brush his/her teeth every day. He/She said every blue moon staff brushed his/her teeth. He/She would like his/her teeth brushed every day. During an interview on 08/06/2026 at 12:11 P.M., CNA F said the resident was dependent on staff for ADL care. He/She said the resident was not resistive to care. He/She would expect the resident's teeth to be brushed twice a day. During an interview on 08/06/2026 at 12:58 P.M., LPN A said the resident was dependent on staff for all ADL care. He/She said the resident had never refused oral care. He/She would expect the resident's teeth to be brushed twice a day. 3. During an interview on 08/06/2026 at 2:03 P.M., the Director of Nursing (DON) said both Resident #1 and Resident #4 were totally dependent on staff for ADL care. She had never heard of either resident refusing oral care. She would expect any refusal of ADL care to be documented by the CNAs, in the task tab of the EMR and in the resident's care plan. She would expect documentation to be accurate. During an interview on 08/06/2026 at 3:41 P.M., the Administrator said she would expect residents to be clean and groomed. She would expect residents' nails to be trimmed and teeth to be brushed. 311103129943201564242

Based on observation and interview, the facility failed to ensure reports with respect to surveys, certifications, and complaint investigations conducted during the preceding three years were accessible for review by residents, family members, and legal representatives of residents. The census was 79.Observations on 08/03/26, 08/04/26, 08/05/26, and 08/06/26, showed no visible survey results maintained at the entrance of the building, in the lobby of the building, or visible at the desk with the receptionist. No visible signs were posted for the location of the survey results and/or availability of the last survey or complaint investigations. During a group interview on 08/04/26 at 9:53 A.M., six residents, whom the facility identified as alert and oriented, attended the group meeting. All six residents said they did not know where the survey binder was and had never viewed it. They did not know they had access to the survey binder. During an observation and interview on 08/06/26 at 9:54 A.M., Receptionist I said there was usually a sign on the desk indicating the survey binder was available. She had not seen it lately. When asked where the survey binder was, the receptionist pointed to a binder located behind the receptionist's desk. Approximately four other binders were stacked in front of the survey binder. The receptionist said the binder was not accessible to residents and visitors. During an interview on 08/06/26 at 3:35 P.M., the Administrator said she thought the binder was accessible if residents and visitors looked over the desk and next to where the receptionist sat. There was also a sign posted in the lobby, but it fell about a week ago.

Based on observation, interview and record review, the facility failed to store food in a safe and sanitary manner to prevent potential cross-contamination and failed to label and date food items. This had the potential to affect all residents who consumed food from the facility kitchen, The facility had a census of 85. Review of the facility Food Storage Policy, dated [DATE], revised on [DATE], showed: -Policy: Ensure food storage and safety practices are maintained and monitored and comply with Federal and State regulations governing food storage and safety; -Responsibility: Dietary Aide, Dietary Cook, & Dietary Manager; -Dating of leftovers shall be as follows: -Multiple ingredients shall be used the same day of preparation then discarded; -Other potentially hazardous leftovers shall be labeled with an expiration date of three (3) days; -Leftovers which are not expired but change appearance or lose quality shall be discarded immediately; -Foods shall be stored in an organized manner and shall be maintained in their original containers unless they are considered a leftover. All leftovers shall be labeled and dated with an expiration date of no more than three days. 1. Observation of the kitchen on [DATE] at 10:22 A.M., showed: -Inside the dry storage area, two bags of cheesecake mix inside Ziplocked bags, with partial contents spilled inside the bottom of the Ziplocked bag, opened, and undated; -A bag of yellow corn bread in Ziplocked bag, opened, and undated; -A 25 pound bag of fish breading, rolled shut/partially opened, and undated; -A large bag of white rice inside a plastic tub, opened, uncovered and undated; -A large bag of all-purpose flour inside a plastic tub, opened, uncovered and undated. Observation of the kitchen on [DATE] at 12:00 P.M., showed: -Inside the dry storage area: -Two bags of cheesecake mix inside ziplocked bags, with partial contents spilled inside the bottom of the Ziplocked bag, opened, and undated; -A bag of yellow corn bread in Ziplocked bag, opened and undated; -A 25 pound bag of fish breading, rolled shut/partially opened, and undated; -A large bag of white rice inside a plastic tub, opened, uncovered and undated; -A large bag of all-purpose flour inside a plastic tub, opened, uncovered and undated; -Inside the walk in refrigerator; -Three small Ziplocked bags of orange slices, undated; -One small Ziplocked bag of apple slices, undated; -Five paper bagged sack lunches, undated; -One large plastic bag of lettuce, opened/partially uncovered, undated. 2. Observation and interview on [DATE] at 11:00 A.M., showed the inside the walk-in refrigerator, 8 paper sack lunches on a tray, undated. The dietary manager said the lunches are for people who go to dialysis, the bags contain a deli sandwich, juice, chips, and fruit. Observation of the kitchen on [DATE] at 5:00 P.M., showed; -Seven paper sack lunches on a tray, undated; -Six Ziplocked bags of orange slices, undated; -One Ziplocked bag of apple slices, undated. 3. During an interview on [DATE] at 10:00 A.M., the Dietary Manager said she expected staff to date and label opened food prior to placing the food in the refrigerator, and to cover and/or wrap opened packaging and ensure the package is dated after opening. 4. During an interview on [DATE] at 11:10 A.M., the administrator said she expected staff to ensure opened food is covered, labeled, and dated.

45083 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) for three residents (Residents #57, #29 and #82). Furthermore, the facility failed to follow their incontinent care policy when staff provided perineal area care (cleansing between the legs and buttocks area) to Resident #82. 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 85. Review of the facility's Enhanced Barrier Precautions (EBP) Policy, dated 5/15/24, showed: -Procedure: -Examples of high-contact resident care activities requiring gown and glove use for EBP: -Transferring; -Providing Hygiene; -Changing Briefs or Toileting; -Device Care; Enteral Tube (pertaining to the gastrointestinal tract); -Steps: -Post signage in the resident room with information on use of EBP and required PPE (e.g., gown and gloves). EBP signage should include information on high contact resident care activities that require the use of gown and gloves. Review of the facility's Incontinent Care Policy, dated 7/21/22, showed: -Policy: -The facility will provide incontinent care as directed in the plan of care. incontinent care will include a skin evaluation of the resident; promoting hygiene and skin prevention with infection/irritation; -Responsibility: -Nursing Assistant, Licensed Nurses, Nursing Administration, ICP and Director of Nursing; -Procedure: -Gather supplies; -Identify resident and explain procedure; -Provide privacy; close door/blinds, pull privacy curtain; -if resident refuses incontinent care; inform charge nurse/supervisor; -Place equipment on clean surface within reach; -Perform hand hygiene and apply gloves; -Assist with positioning resident in a safe/comfortable position, avoid overexposing the body; -Remove soiled brief/underpad by rolling the brief/underpad; -Cleanse perineal area with a perineal cleanser; -Females: separate labia, cleanse one side and then the other, cleanse center of the labia wiping towards the rectal area; -Cleanse perineal area from front to back, cleanse thighs, rectal area and buttocks; -Males: retract foreskin if uncircumcised, cleanse the penile tip using a circular motion starting with the urethra working outward; -Cleanse penile shaft, scrotum, rectal area, thighs & buttocks; -Use a clean surface area of the cloth for each wipe; -Use multiple cloths, if necessary, to maintain infection control; -Remove soiled gloves, perform hand hygiene and apply clean gloves; -If necessary, apply protective ointment; -Remove gloves, perform hand hygiene and apply clean gloves, apply clean brief and clothing; -Discard contaminated items in a plastic liner; -Remove gloves and perform hand hygiene; -Reposition resident in a safe/comfortable position (bed in low position unless contraindicated); -Place call light within reach of the resident; -Residents with indwelling catheters; refer to catheter care policy; -Report abnormal findings to the charge nurse/supervisor of discharge, bleeding, odor or skin changes. Review of the facility's Legionella Water Management Program Policy, dated 11/23, showed: -The Facility is committed to the prevention, detection and control of water-borne contaminants including Legionella; -The water management program includes the following elements: -Detailed description and diagram of the water system in the facility, including the following: -Receiving; -Cold water distribution; -Heating; -Hot water distribution; -Waste. 1. Review of Resident #57's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 5/20/24, showed: -Short and long-term memory problem; -Diagnoses included atrial fibrillation (a-fib, irregular heart rhythm), heart failure and dementia; -Feeding tube (gastrostomy tube (g-tube), a tube placed through the abdomen into the stomach to provide nutrition, hydration and medication). Observation on 8/12/24 at 12:01 P.M., showed a sign on the door that the resident was on EBP. The resident was lying in bed. Licensed Practical Nurse (LPN) N administered medication to the resident via feeding tube. LPN N failed to apply a gown during the process. 2. Review of Resident #29's medical record, showed: -Moderately impaired cognition; -Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) wound to the sacrum (triangular bone located above the coccyx). Observation on 8/12/24 at 10:00 A.M., showed a sign on the door that the resident was on EBP. The resident was lying in bed. Certified Nurse Aide (CNA) C and CNA E put gloves on, unfastened the resident's brief and provided perineal care and rolled the resident side to side to place a clean brief on the resident. Staff failed to wear a gown while providing personal care. 3. Review of Resident #82's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -Dependent to staff on toileting hygiene, shower or bath, upper and lower body dressing; -Frequently incontinent of both bladder and bowel; -Diagnoses included stroke, anemia, high blood pressure, kidney failure, diabetes, aphasia (a language disorder that affects a person's ability to communicate), hemiplegia (muscle weakness or partial paralysis on one side of the body); -Feeding tube. Observation on 8/13/24 at 10:22 A.M., showed a sign on the door that the resident was on EBP. CNA L provided perineal care to the resident. The resident was lying in bed. CNA L applied gloves and failed to apply a gown. He/She obtained a bath towel, placed one end on the sink with running water while the other end was hanging out of the sink. He/She then applied soap and squeezed some liquid out. He/She removed the resident's brief, wiped the perineal area up and down and side to side with the wet end of the towel. He/She then dried the area with the other end of the towel. He/She placed the dirty towel in the plastic bag which he/she laid on the floor. He/She turned the resident on his/her back and picked up the dirty towel from the plastic bag and started wiping the resident's buttocks and anal area, then dried with the same dirty towel. He/She applied a clean brief and put on the resident's pants. CNA L failed to replace gloves and performed hand hygiene in between handling clean and dirty. 4. During an interview on 8/13/24 at 12:04 P.M., Registered Nurse (RN) I said staff should wear gowns and gloves while providing care to residents in EBP rooms. Staff may use wash cloths or disposable wipes in providing perineal care to residents. He/She expected staff to use clean wash cloths or wipes for each area to and never to re-use dirty wash cloths or towels. He/She expected staff to properly follow the perineal area care procedures found in the facility's policy. 5. During an interview on 8/14/24 at 8:30 A.M., CNA F said he/she knew which residents were on EBP because the resident would have a red pillow on their bed, and they would have a caddy on the door with PPE in it. Staff should wear PPE if a resident has a wound. 6. During an interview on 8/14/24 at 8:40 A.M., Licensed Practical Nurse (LPN) G said staff know which residents require PPE because the facility has a list of residents who are on EBP, and the residents have a caddy on their door. PPE is worn while providing dressing changes, personal care and transfers. Staff do not need to wear PPE for residents with a g-tubes. 7. During an interview on 8/14/24 at 9:10 A.M., the Assistant Director of Nursing (ADON) said all staff have been in-serviced on EBP and if they do not know, they should ask the nurse. Staff should wear PPE when they provide direct patient care. 8. During an interview on 8/14/24 at 9:20 A.M., RN I, who was also the Infection Control Preventionist (ICP), said residents who have g-tubes, and wounds require EBP, and staff should wear PPE while providing direct care. The ICP expected staff to follow the facility's policy. 9. During an interview on 8/14/24 at 10:52 A.M., the Administrator and the Director of Nursing (DON) said they expected staff to wear PPE per the facility's policy. They said staff are expected to follow the facility's proper procedures in providing perineal care to prevent the spread of infection. In addition, the Administrator said she did not have a detailed description or a diagram of the facility's water system. She expected the facility to have all the components of their policy.

Based on observation, interview and record review, the facility failed to ensure all residents were treated in a manner to maintain dignity when one resident's (Resident #90's) catheter bag (urine drainage bag) was visible to the hallway from the resident's room. In addition, staff fed one resident (Resident #43) while standing over the resident during a meal. The sample size was 18. The census was 85. Review of the facility's Resident Rights policy, reviewed 4/26/23, showed: -Policy: The facility shall treat residents with kindness, respect and dignity and ensure resident right are being followed. The resident/resident representative will be informed on their rights upon admission; -Procedure: Employees will receive education and training on resident rights upon hire and annually; -Resident Rights included: -Exercise Rights; -Respect and Dignity; -Privacy and confidentiality. 1. Review of Resident #90's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/22/24, showed: -Mild cognitive impairment; -No behaviors; -Dependent on staff for toileting and hygiene; -Uses an indwelling urinary catheter; -Diagnoses included traumatic brain injury, seizures, urinary tract infection (UTI), and anxiety. Review of the resident's care plan, initiated 7/24/24, showed: -Focus: Requires catheterization indwelling catheter related to urinary retention; -Goal: The resident will be/remain free from catheter-related trauma through review date; -Interventions: The resident has an indwelling urinary catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Observation on 8/8/24 at 10:48 A.M., showed the resident lay in bed on his/her back. The resident's catheter bag was halfway filled with urine and visible from the doorway upon entering the resident's room. Observation on 8/9/24 at 5:47 A.M., showed the resident lay in bed on his/her back with his/her eyes opened. The resident's catheter bag hung on the right side of the bed, visible to the hallway. When asked if the exposed catheter bag bothered the resident, he/she nodded his/her head to indicate yes. During an interview on 8/13/24 at 8:18 A.M., Certified Nursing Assistant (CNA) O said catheter bags should not be visible from the hallway. Catheter bags should have a privacy slip covering the bag to maintain a resident's dignity. During an interview on 8/13/24 at 11:41 A.M., Licensed Practical Nurse (LPN) N said catheter bags should be covered and not visible from the entrance of the doorway to maintain the resident's dignity. During an interview on 8/13/24 at 12:17 P.M., the Administrator said catheter bags should be covered and not visible from the hallway. 2. Review of Resident #43's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -No behaviors; -Substantial or maximal assistance with eating; -Diagnoses included kidney disease, dementia, malnutrition, anxiety, depression, Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and asthma. Observation on 8/8/24 at 12:18 P.M., showed the resident sat in the secured unit dining room at the table. His/Her plate of food was untouched, and the resident lay his/her head on his/her hand at the table. CNA P stood over the resident and said, try to take a bite of your food and scooped up the food on a spoon and placed it at the resident's mouth. The resident would not eat the food. CNA P sat the spoon down and assisted another resident with feeding while standing. He/She then returned to Resident #43 and attempted to spoon feed the resident a second time while standing. The resident refused to eat the food offered to him/her. During an interview on 8/13/24 at 11:44 A.M., CNA Q said he/she should pull up a chair next to the resident to assist them in eating. During an interview on 8/13/24 at 12:04 P.M., Registered Nurse (RN) I said staff are expected to be at eye-level when assisting residents with eating. Standing up while feeding the residents is not acceptable. During an interview on 8/14/24 at 10:52 A.M., the Administrator and Director of Nursing (DON) said staff should be seated when feeding residents to maintain dignity. 45083

Based on observation, interview and record review, the facility failed to follow facility policy when one resident (Resident #29) fell on the facility's transport van while returning from a doctor's appointment and staff moved the resident without a nurse physically assessing the resident or calling 911. The census was 85. Review of the facility's Fall Management Policy, dated 2/28/23, showed: -Definition: fall is a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object; -Prevention/treatment: Prior to moving the resident, the charge nurse will evaluate for injury. Review of Resident #29's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 8/14/24, showed: -Moderately impaired cognition; -Dependent on staff for rolling left to right; -Dependent on staff for chair/bed to chair transfer; -Used manual wheelchair; -Diagnoses included: diabetes and hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) or hemiparesis (slight weakness in a leg, arm, or face, it can also be paralysis on one side of the body). Review of the resident's care plan, in use at the time of survey, showed: -Focus: at risk for falls related to amputation, dependent on staff for transfers. On 7/4/22, found lying on left side. Complained of right hip pain; -Goal: will not have injuries related to falls through next review; -Interventions: Anticipate and meet my needs. During an observation and interview on 8/12/24 at 4:30 P.M., the resident lay in bed. The resident said he/she had a fall on the van today. He/She went out for a doctor's appointment, and on the way back to the facility the pad he/she was sitting on slipped and he/she slipped out of the chair. The driver and one of the aides picked up the resident and put him/her back in the chair. The resident returned to the facility. His/Her right fourth fingernail was bleeding and they put a bandage on it. During an interview on 8/12/24 at 6:00 P.M., the Administrator said while the resident was out today at a doctor's appointment. The driver stopped at the stop sign and the resident's cushion in his/her wheelchair scooted and the resident slipped out of the wheelchair. The wheelchair did not scoot, it was secured. The resident was buckled in. Staff did not follow facility policy. They should have called a nurse to assess, or they should have called 911. During an interview on 8/13/24 at 10:47 A.M., Transportation Specialist B said transportation Specialist A put the resident into the van and secured him/her. He/She sat in the front passenger seat. Certified Nurse Aide (CNA) K sat behind him/her and behind CNA K was the resident. On the way back to the facility, they stopped at a stop sign and he/she heard the resident say he/she was on the floor. Transportation Specialist A pulled over and he/she and CNA K tried to assist the resident back into his/her chair, but they were unable. Transportation Specialist B got out of the van to help assist the other two staff members position the resident on the mechanical lift pad and lift the resident back into the chair. The resident complained of pain in his/her right finger. The van had a first aid kit, the finger was cleaned, and a bandage was put on. The resident had no other injuries. He/She did not call the facility to notify them the resident had slipped out of his/her chair, nor did he/she call 911. He/She could not recall if anyone else called the facility. During an interview on 8/13/24 at 12:27 P.M., Transportation Specialist A said normally the CNAs bring the residents up to the front desk and he/she will load the resident onto the van and secure the resident. The residents' wheelchairs are secured and then the residents are secured with a seat belt. The van had a shoulder strap and a waist strap. Resident #29 only used a waist strap because of his/her size. On the way back from the appointment, the van came to a stop sign and the resident slipped out of the wheelchair onto the floor. The resident slipped under the seat belt. Transportation specialist A called the Director of Nursing (DON). CNA K checked the resident. The DON asked if the resident hit his/her head. The resident would be able to tell us if he/she had hit his/her head. The resident complained of pain in his/her butt. After the DON said it was ok, all three staff used the mechanical lift pad to lift the resident up and into the wheelchair. The only injury the resident had was a chipped nail. The resident was brought back to the facility. During an interview on 8/13/24 at 12:53 P.M., CNA K said on the way back to the facility, the resident was saying he/she felt like he/she was sliding out of his/her wheelchair. The transportation specialist pulled over and staff checked the resident and he/she was ok. The resident again said he/she was sliding and CNA K told the resident that he/she would pull the resident up when they got back to the facility. The resident did not look like he/she was sliding. When the van stopped at the stop sign, the resident slipped out of the wheelchair. CNA K said he/she tried to break the fall, but it happened so fast. The resident broke his/her fingernail. Staff cleaned it off and put a bandage on it. He/she asked the resident to raise his/her arms and wiggle his/her toes. The resident said he/she was ok. The staff put the mechanical lift pad back under the resident and all three staff members lifted the residents back into the chair. On the way back to the facility, CNA K stood in front of the resident to hold him/her because he/she was still sliding. CNA K asked transportation specialist A to drive slowly. The incident occurred about three minutes from the facility. CNA K did not know someone had to call the facility and have the nurse come to the scene to assess the resident. During an interview on 8/13/24 at 1:43 P.M. the DON said Transportation Specialist A called her on her cell phone and reported the incident. She could hear the resident saying his/her butt hurt and the CNA was asking the resident to move his/her arms. The DON asked the transportation specialist if the resident hit his/her head. The resident's finger was bleeding, a bandage was put on. The DON told the transportation specialist if the resident did not hit his/her head, to get him/her up in the chair and she would assess them when they got back to the facility. The DON would expect staff to follow the same fall policy if a resident fell off site as on-site. If the resident was off site, staff should call the DON/Assistant DON and if they were within close proximity the nurse could go to the scene and assess the resident, or they could call 911 to have them come assess the resident. She would consider close proximity as within six to seven minutes of the facility. The resident quit complaining of pain. So, the DON told the transportation specialist she would assess the resident when they got to the facility. When the resident got to the facility the resident was complaining of pain in his/her right hip and started to complain of pain in his/her left hip. CNAs cannot assess residents. The CNA was not doing an assessment. The CNA was doing a wellness check, and they are allowed to do range of motion. During an interview on 8/14/24 at 10:52 A.M., the Administrator said ideally it is best to have the resident assessed before they are moved. The resident slid down, and someone was with him/her. The potential for injury was less. The Administrator would expect for staff to follow the facility's policies and procedures.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice. The facility identified four medication carts, two nurse's carts, one treatment cart, and one medication room. Of those medication storage areas, three medication carts, one nurse's cart, and one medication room was reviewed. Issues were found in one medication cart and one nurse cart. A carton of Ensure Plus nutrition shake was opened and undated. A tube of Venelex ointment (used on the skin to cover wounds) and a tube of Betamethasone cream (used to help relieve redness, itching, swelling, or other discomforts caused by certain skin conditions) were opened, undated and unlabeled. The census was 85. Review of the facility's Medication Storage Policy, dated 11/2018, showed: -Policy: Medications and biologicals are stored safely, securely, and properly following the manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -All medications dispensed by the pharmacy are stored in the container with the pharmacy label; -Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from the inventory, disposed according to procedures of medication disposal; -Drugs dispensed in the manufacture's original container will be labeled with the manufacture's expiration date; -Certain medications, including some multi-dose preparations, may require different dating once opened per regulations/guidelines; -The nurse will check the expiration date of each medication before administering it; -All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner; -Disposal of any medications prior to the expiration dating will be required if contamination or decomposition is apparent; -Nursing staff should consult with the dispensing pharmacist for any questions related to medication expiration dates. 1. Observation of the nurse cart for Halls 100 and 200, on 8/9/24 at 11:10 A.M., showed ; -Venelex ointment, opened, undated and unlabeled with resident's name; -Betamethasone cream, opened, undated and unlabeled with resident's name. During an interview on 8/9/24 at approximately 10:00 A.M., Certified Medication Technician (CMT) J said the opened containers of medications should be dated once opened. Undated medications should be discarded. 2. Review of Ensure Plus nutrition shake manufacturer's instruction, showed once a bottle of Ensure and drinks have been opened, it should be used or refrigerated within four hours. The remaining product should be used or discarded after 48 hours. Observation and interview on 8/12/24 at 10:24 A.M., showed the CMT medication cart for Hall 200, had a carton of Ensure Plus shake 8 ounce, opened, undated and unlabeled. The carton was half full, not refrigerated or iced and was placed in the medication cart drawer. CMT J said he/she was not aware when the shake was opened. 3. During an interview on 8/14/24 at 10:52 A.M., the Administrator and Director of Nursing (DON) said they expected the staff to follow the facility's Medication Storage Policy. The staff should always date and label the medications after opening. The Ensure Plus nutrition shake 8 oz was supposed to be for one resident and one-time use only. If a resident was unable to finish the one carton, it should be discarded.

Based on interview and record review, the facility failed to provide appropriate administration of water flushes and enteral nutrition for one resident who was dependent upon a gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach) for nutrition and hydration for one residents (Resident #1). Resident #1 was admitted to the facility on [DATE]. Admission orders showed Nepro (balanced, high-calorie nutrition) 50 milliliters (ml)/hour via g-tube continuously and water flushes 180 ml every four hours. On 3/5/24, the order was changed to Glucerna (calorically dense formula) due to the unavailability of Nepro. The resident was hospitalized on [DATE] and diagnosed with metabolic encephalopathy (a neurological disorder not caused by primary structural abnormality and caused by chemical imbalance in the blood, by illness or organs not working like they should), uremia (a buildup of waste products in the blood that occurs as a result of untreated kidney failure) and hypernatremia (net water loss or excess sodium intake). The census was 79. Review of the facility's Medication Administration-Preparation and General Guidelines Policy, undated, showed: -Medications are administered in accordance with written orders of the presciber; -If a dose seems excessive considering the resident's age and condition or a medication order seems unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary, contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate; -Documentation (including electronic): The individual who administers the medication dose records the administration on the resident's Medication Administration Record (MAR) directly after the medication is given. At the end of each medication pass, the person administering the medication review the MAR to ensure necessary doses were administrated and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. Review of the facility's Tube Feeding Management Protocol, provided on 4/29/24, at 8:35 P.M., showed: -Enteral/Parental (nutrition given through the vein) feeding will be documented on the MAR, and/or Treatment Administration Record (TAR) which will be completed each shift by Nursing; -Nursing will monitor and document for feeding complications and tolerances/intolerances to Tube Feeding (TF)/Parental Document in nursing notes as well any negative outcomes in nurses' notes. Weekly weight monitoring will continue until stable; -If resident receives an oral diet in addition to nutrition support, Nursing personnel will monitor and document the resident's eating performance and abilities. (Document % of supplement if taken and oral diet on meal intake form, Certified Nursing Assistant (CNA) sheet or Nursing notes); -Nursing administers, monitors and documents the type, rate and volume of nutritional support as ordered or documents reason for variance. -Nursing Service will send a consultation order to Nutrition Services requesting resident nutritional assessment by the Consultant Dietitian within 24 hours of admission or Monday for Weekend Admissions. Recommendations for changes to the original tube feeding and/or water flushes should be provided to the Director of Nursing (DON)/designee immediately upon completion of the consultation; -DON and/or designee are responsible for training and monitoring of nursing personnel on nutrition support procedures, documentation, and orders. Review of Resident #1's hospital discharge documents, dated 2/27/24 at 1:16 P.M., showed: -Physician's orders included: water flushes 180 ml, per the feeding tube, every four hours; Nepro 50 ml/hr, per the feeding tube, continuous; Furosemide (Lasix, a diuretic, treats fluid retention) 40 milligrams (mg), per feeding tube, once a day. Review of the resident's progress notes, showed: -On 2/27/24 at 5:00 P.M., the resident was transferred from the hospital to the facility. The resident was flaccid (soft or weak) on his/her right side and has aphasia. The resident could not communicate and was alert and oriented to self and place. The resident was nothing by mouth (NPO) with a g-tube order for Nephro 1.8 50 ml/hr continuous with 100 ml water every four hours. The resident's orders were verified by the Nurse Practitioner (NP). Review of the resident's MAR, dated 3/1/24 through 3/31/24, showed: -An order, dated 2/27/24, for Lasix, give 40 mg per feeding tube every day for heart failure. Documentation showed the facility administered the medication according to the physician order; -An order, dated 2/27/24, to flush tube with 100 mls of water every 4 hours, every shift, for supplement, showed the facility left the documentation blank for 7A-7P shift on 3/1, 3/2, 3/3, 3/6, 3/8, 3/9 and 3/10. The facility left the documentation blank for 7P-7A shift on 3/4; -An order, dated 2/27/24, for Nephro 50 ml/hr, continuous, every shift for supplement, showed the facility left the documentation blank for 7A-7P shift on 3/1, 3/2, and 3/3. The facility also left documentation blank for 7P-7A shift on 3/4/24. Review of the resident's progress notes, dated 3/5/24 at 1:57 P.M., showed the resident's tube feeding was changed to Glucerna 1.2 related to increased blood sugar levels. Review of the resident's MAR, dated 3/1/24 through 3/31/24, showed an order, dated 3/5/24, for Glucerna 1.2 at 50 ml/hr continuous for every shift for supplement. The facility left documentation blank for 7A-7P shift on 3/6, 3/7, 3/8, 3/9, 3/10, 3/12 and 3/13. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/5/24, showed: -admitted on [DATE]; -Rarely/never understood by others; -Rarely/never understands others; -Short and long term memory problems; -Severely impaired cognition skills for daily decision making; -Inattention present; -Impairment to upper and lower body on one side; -Dependent on one or two staff members for all activities of daily living (ADLs); -Diagnoses included: heart failure, kidney disease, diabetes mellitus, aphasia (language disorder affecting ability to communicate), stroke, hemiparesis (muscle weakness or partial paralysis on one side of the body), and malnutrition; -Feeding tube present; -Received 51% or more of total calories received through parenteral (nutrition given through the vein) or tube feeding; -Received an average of 501 mls of fluid intake per day intravenously (IV, through the vein) or tube feeding. Review of the resident's care plan, undated, showed: -Focus: Alternative nutritional intake via tube feeding. Interventions included: Resident was dependent with tube feeding and water flushes, see physician orders for current feeding orders; Assist with tube feeding and water flushes; -Focus: Resident has renal (kidney) insufficiency; Interventions included: Dietary consult to regulate protein, Na and potassium (K) intake. Review of the resident's progress notes, showed: -On 3/8/24 at 3:08 P.M., a nurse's skilled evaluation showed the resident was lethargic, oriented to person and was on tube feeding; -On 3/11/24 at 3:57 P.M., a nurse's skilled evaluation showed the resident was confused, disoriented, inattentive, stuporous and oriented to person. Last bowel movement on 3/11/24 had blood streaks/melena (dark tarry stool); -On 3/12/24 at 9:59 P.M., new orders were obtained from NP, related to dark colored stools and bloody drainage to penis as reported per staff. Review of the resident's nutritional evaluation, dated 3/13/24 at 10:10 A.M., showed: -The resident was NPO; -The resident appeared to be tolerating tube feeding per nursing; -The resident had a diagnosis of moderate protein-caloric malnutrition, at risk for dehydration and weight loss; -Recommended to increase water flushes to 150 to 200 ml every fours hours, obtain weekly weights and follow up on labs. Review of the resident's progress notes, showed: -On 3/13/24 at 5:21 P.M., the NP progress note: resident was seen for DM management, with recent reports from staff of elevated blood glucose (BG, amount of sugar in blood) trends and dark tarry stools. The resident's mouth had dry thick build up which was difficult to visualize as the resident refused to open his/her mouth open. New orders to get labs to assess for a possible gastro-intestinal (GI, digestive tract) as well as nutritional status and to get weekly weights; -On 3/14/24 at 11:24 P.M., showed the resident change of condition. The lab called to report the resident had a critical BUN level of 157. The nurse called the Primary Care Physician (PCP) and was waiting for a call back; -Record review showed no progress note showing when the resident left the facility or why. Review of the resident's lab results, reported on 3/14/24 at 12:07 P.M., showed: -Sodium (Na) high at 158 (normal range 136-145); -Chloride (Cl) high at 119 (normal range 98-110); -BUN critically high at 157 (normal range 7-25); -Creatine high at 2.2 (normal range 0.7 - 1.3). Review of the resident's hospital admission documents, showed: -A physician's note, dated 3/14/24 at 12:41 P.M., the resident was admitted to the emergency room from the facility due to abnormal BUN, NA, and white blood count (WBC). The resident appeared dehydrated especially related to his/her oral mucosa (mouth and throat); -A critical care physician note, dated 3/14/24, the physician was present while the resident was critically ill and provided critical care services. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of dehydration, uremia and altered mental status; -On 3/15/24, a physician's progress note: the resident was treated for metabolic encephalopathy, uremia, hypernatremia of uncertain etiology- possibly hypovolemic hypernatremia as evidenced by NA of 158 and BUN greater than 100 and a change in mental status; Assessment and Plan showed, hypernatremia, likely due to decreased PO intake; -A discharge summary of hospital stay, dated 4/5/24, the resident had several episodes of melena for which GI was consulted. An esophagogastroduodenoscopy (EDG, examination of upper GI tract), colonoscopy (examination of rectum and colon) and a video capsule endoscopy (procedure to examine GI tract, areas not visualized by EDG or colonoscopy) were performed and the results showed no source of an internal bleed. During an interview on 4/10/24 at 4:17 P.M., the Administrator said: -She expected nurses to read the orders and follow them as written by the PCP; -She expected the nurse to call the PCP and clarify orders if they had any questions; -The DON and ADON were responsible for reading the RD notes and verify any orders with the PCP, then write the orders in residents' POS; -If the MAR had a check mark documented, that meant the task was completed; -If the MAR had an X documented, that meant the order was put in without requiring any nursing staff to document; -If the MAR or TAR had a blank documented, that meant the nurse failed to document on that order; -The risk for dehydration for residents who were NPO, and dependent on tube feedings and water flushes was high; -If residents were receiving tube feedings and water flushes, she expected nursing staff to give water flushes as ordered. During an interview on 4/25/24 at 10:04 A.M., Licensed Practical Nurse (LPN) B said: -He/She was assigned to the resident whenever he/she worked the day shift (7:00 A.M. through 7:00 P.M.) and was the resident's main day nurse; -Nurses were expected to document intake and output totals every 24 hours in a resident's MAR; -Nurses were expected to read all orders before administering TF and/or water flushes; -The resident had an order for a continuous tube feed with water flushes every four hours. He/She set up the resident's TF and water flushes to run on one pump when he/she had the resident on his/her assignment; -Nurses were expected to document accurately in residents' MAR/TAR while on shift; -If there was a blank in the MAR/TAR, it meant the nurse did not document; -He/She did not know why the resident's MAR/TAR showed blanks in the documentation for the TF and water flush orders; -LPN B expected the DON to notify him/her if he/she was not documenting in the resident's MAR/TAR so LPN B could correct it; -He/She was not notified by the DON of any missed documentation, and he/she did not receive any education from the DON regarding missed documentation in the resident's medical record; -The resident was sent out to the hospital due to the family's request after they were notified of the resident's elevated BUN lab result; -He/She did not notice the resident had any signs or symptoms of dehydration such as dry skin, dry oral mucosa (mouth and tongue), sunken features in his/her face or poor skin tugor (elasticity of skin); -The resident's family visited every day and were there all hours of the day, into the evening. They were very involved in the resident's care. During an interview on 4/25/24 at 11: 9 A.M., two of the resident's family members said: -Family visited the resident every day, at different times, during his/her stay at the facility; -One of the family members was there almost every day from 12:00 P.M. until 7:00 P.M. The other family member was there almost every day from around 8:00 A.M. until late afternoon or after the dinner hour; -During their visits, they saw the resident was receiving TF continuously through a pump. There was never a water flush bag hung with the TF to give water flushes through the pump; -The only day they saw the resident receiving the TF with the water flush set up through the pump was on 3/14/24, the day the resident was sent out to the hospital due to the results of his/her lab report; -They did not witness nurses give the resident water flushes manually during their visits; -The family was knowledgeable about how a TF with water flushes would be set up on a pump as the resident had the same order in the hospitals he/she was at prior to admission to the facility. During an interview on 4/26/24 at 10:48 A.M., the Registered Dietician (RD) said: -She was supposed to do nutritional evaluations on all new admissions/re-admissions; -She didn't know about the resident until she came in on her regularly scheduled visit on 3/13/24; -The facility did not notify her when the resident was admitted on [DATE]; -She completed a nutritional evaluation on the resident as he/she was listed on the new admissions report. She did not know the resident received tube feeds until she looked at his/her chart; -The facility needed to do a better job of informing her when residents received TF, as they were very fragile. Her company policy stated the RD needed to complete nutritional evaluations on all residents on TF upon admit; -She did not have access to residents' MAR/TAR to see if the facility was administering tube feeds and water flushes as ordered. She needed access to that information to see if residents were getting their TF and flushes as ordered; -She expected the nurses to accurately document in the MAR/TAR as it affected the plan of care; -If residents were not getting TF or water as ordered, they were at extreme risk for dehydration. There was no other way for them to get fluids if they were nothing by mouth (NPO); -The failure to provide the resident's TF and water flushes as ordered would cause significant dehydration; -The RD said nothing else would have caused the resident's significant dehydration as found in his/her elevated BUN, Creatine, Na and Cl labs which resulted on 3/14/24. During an interview on 4/29/24 at 10:05 A.M., the Administrator and DON said: -They expected nursing staff to document accurately and truthfully as it affected the plan of care; -They expected the order for a water flush every four hours to be written on the MAR/TAR with specific times to administer; -They were unable to determine if a resident received a water flush every four hours if the MAR only showed documentation for the day shift and night shift; -The DON audited the orders on residents' admission and/or re-admission for accuracy; -The DON audited medicine/treatment administration every day. If there was missing documentation or if a medication/treatment was not given as ordered, the DON would ask the nurse or CMT what happened and have them make corrections as needed; -They expected nursing staff to have knowledge of, and to follow, facility policies. During an interview on 4/29/24 at 11:22 A.M., the facility Nurse Practitioner (NP) said: -He visited the facility three times a week to care for residents; -He would see residents who had acute conditions as indicated by a review of the facility report and the residents who the nurses requested him to assess/evaluate; -The resident came in from an acute long term hospital with an order to give Nepro continuously, with water flushes; -He was not aware the nurses were not giving the resident's TF or water flushes as ordered; -He expected nurses to follow orders as given by himself or the Primary Care Physician (PCP); -He expected nurses to document accurately as he looks at residents' medical record when assessing residents. Inaccurate documentation could affect residents' plan of care. During an interview on 4/29/24 at 1:48 P.M., the Primary Care Physician (PCP) said: -He expected nurses to follow the discharge orders as given from residents' hospital stay; -He expected nurses to follow physician orders as written; -He expected nurses to document accurately, as it affects the plan of care; -He expected the RD to assess and evaluate residents who were NPO and received all their nutrition and water via a g-tube upon admission; -The nurse who put in the order for a water flush 100 ml/hr, four times a day made a mistake. The order should have followed the discharge order from the resident's hospital stay. The order should have been water flushes, 180 mls/hr, four times a day; -He was not aware the resident was not receiving TF or water flushes as ordered; -The resident's high BUN level could have been caused by dehydration or due to the resident passing melena (bloody) stool. During an interview on 4/29/24 at 7:34 P.M., the Regional Nurse Consultant (RNC) said: -They currently did not have a Tube Feeding Policy; -She educated nursing staff on the professional standards of care for tube feeding, using the Tube Feeding Management Protocol. During an interview on 5/1/24 at 8:43 A.M., the DON said: -She completed admission and re-admission audits on the day of resident's arrival to the facility, the next day, or on Monday if they were a weekend admit; -She verified residents' tube feed and water flush orders from the hospital were correct; -If there was a discrepancy between the facility admission orders and the discharge orders from the hospital, she would call the PCP and verify orders; -She would notify the RD of residents with tube feed orders within 24 hours of admission/re-admission or on Monday if the resident was a weekend admission; -Both she and the ADON were responsible for pulling a daily medication administration report to review for missing documentation and/or residents not receiving medications; -They would notify the nurse or Certified Medication Technician (CMT) if they had any questions regarding their documentation in residents' MAR or TAR; -She expected nurses to follow physician orders as they were written; -She did not regularly check the daily medication administration reports in March as the facility was short-staffed and she was often pulled to work as a nurse. There was no ADON on staff at that time. MO00233756

Based on observation, interview and record review, the facility failed to make an appointment with a surgeon for one resident with wounds on his/her fingers on both of his/her hands. The wound care company's physician requested a consult with a surgeon on 11/30/23, due to exposed bone on some of the resident's fingers. Facility staff failed to make the surgeon's appointment for the resident until 1/10/24 (Resident #5). The census was 86. Review of the facility's Wound Management policy, dated 11/15/22, included: -Policy: To promote wound healing of various types of wounds, the facility will provide evidenced based treatments in accordance with current standards of practice and physician orders; -Procedure: -Wound Management: -Wound treatment will be provided in accordance with physician order: cleansing method, type of dressing, frequency of dressing change; -Pressure injuries will be differentiated from non-pressure wounds: arterial (caused by poor circulation), venous (caused by abmornal vein function), diabetic, surgical, moisture associated skin damage. Review of the facility's Essential Functions of Wound Care Nurse policy, undated, included the following: -Assesses, treats, and cares for patients with wounds such as pressure ulcers, skin breakdowns or other wounds. Treatment tasks include cleaning, bandaging, and working with the care team to determine if other treatments are necessary; -Assess residents on admission and document appropriately as condition changes; -Contribute knowledge of residents' conditions and document observations as required; -Notify physician of changes in resident's condition and follow through until appropriate action is taken; -Accurately and promptly implement physician orders; -Implement plan of care for the resident based on assessments and goals as established by the interdisciplinary care team; -Perform other task and duties as assigned. Review of Resident #5's nursing admission screening/history, dated 8/22/23, showed: Right hand: Necrotic (dead tissue) fingertips. Left hand: Amputated fingers. Right toes: Amputated. Left toes: Amputated. Review of the resident's physician's progress note, dated 8/24/23, showed resident was seen as a new admission. Resident was taken to the hospital on 6/4/23, and found to have pneumonia and respiratory failure. He/She went into septic shock (the last and most severe stage of sepsis (infection) that can cause dangerously low blood pressure) requiring vassopressors (constricts/tightens blood vessels, raising the blood pressure). Developed gangrene (tissue death) and underwent amputations on the right hand 2, 3, 4, 5 digits. Left hand 3rd and 4th digits still black. Review of the resident's care plan, located in the electronic health record (EHR), showed: -Date Initiated: 9/9/23: Focus: At risk for impairment of skin integrity related to limited bed mobility and diabetes mellitus (insufficient production of insulin characterized by increased blood sugar levels). Resident also has post surgical wounds status post amputation secondary to gangrene and arterial wounds. 8/29/23: Right hand, third finger arterial; left hand, third finger arterial; left hand, fourth finger arterial; left foot and right foot, surgical; -Goal: Will remain without complications through next review; -Interventions: 12/7/23, Being followed by the wound care company services. Wound doctor to follow wounds. Observe for signs of infection. Provide treatment per current order; -Date Initiated: 9/9/23: Focus Activities of daily living deficit related to limited mobility and weakness. Ambulatory (walking) with limited assistance. Uses a wheelchair for long distances; -Goal: Will maintain current level of functioning; -Interventions: Assist of one for bed mobility, personal hygiene, toilet use, transfer and dressing. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/21/23, showed: -admitted [DATE]; -Adequate hearing; -Speech Clarity: Clear speech, distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands, clear comprehension; -Cognitively intact; -Rejection of Care: Behavior not exhibited; -Functional Limitation in Range of Motion: Upper extremity, no impairments; lower extremity, impairment on both sides; -Diagnoses of anemia (low red blood cell count), high blood pressure, septicemia (systemic infection of the blood), diabetes mellitus, anxiety and depression; -Number of Venous and Arterial Ulcers: 2; -Other Ulcers, Wounds and Skin Problems: Infection of the foot (e.g., cellulitis (inflammation of subcutaneous or connective tissue)); -Other Problems: Surgical wounds; -Skin and Ulcer Treatments: Surgical wound care and applications of dressings to feet. Review of the resident's wound care company notes, dated 11/30/23, showed: -Site #2: Arterial wound of the right third finger: -Wound Size: (Length x Width x Depth) 0.4 centimeters (cm) x 0.7 cm x 0.2 cm. Exudate (drainage): Light serous (thin, watery, clear drainage). Granulation tissue (healing tissue); 25%. Other viable tissues: 75% (bone, dermis (skin)). Wound Progress: Exacerbated (to make worse) due to resident dug at wound and removed part of the nail; -Dressing Treatment Plan: Collagen (a protein used to treat wounds) sheet/powder, apply three times a week for 30 days. Xeroform gauze (an absorbent gauze) apply once weekly for 30 days. Secondary dressing: Gauze roll apply three times a week; -Recommendations: Surgery consult for exposed bone with non-healing wound; -Site #3: Post-surgical wound of the left third finger: -Wound Size: 1.1 cm x 1.0 cm x not measurable. Exudate: None. Other viable tissues: 100% bone. Wound progress: Not a goal; -Dressing Treatment Plan: Xeroform apply three times a week for 30 days; -Secondary Dressing: Adhere compression wrap (Coban) apply three times a week for 30 days; -Site #4: Post-surgical wound of the left fourth finger: -Wound Size: 0.9 cm x 0.4 cm x 0.1 cm. Exudate: Light Serous. Slough: 25%. Skin: 75%. Wound Progress: Not a goal; -Dressing Treatment Plan: Collagen sheet/powder apply three times a week for 30 days. Xeroform gauze apply three times a week for 30 days. Secondary dressing: Dry dressing, self adhere compression wrap apply three times a week for 30 days; -Recommendations: Surgery consult for exposed bone with non-healing wound. Review of the resident's medical record, physician's order sheet, and progress notes, showed no documentation regarding a surgeon consult per the wound care company request on 11/30/23. Observation on 1/9/24 at 7:50 A.M., showed the resident lay in bed with Coban wrap on his/her fingers and dressings on both of his/her feet. The resident said he/she went to a specialist for his/her feet and the wound care company came to the facility to treat his/her hands/fingers. Observation on 1/10/24 at 1:30 P.M., showed the resident lay in bed. The wound care company physician and the facility Wound Nurse (WN) stood at the bedside and the physician assessed the resident's hands/fingers. The physician said this was the first time she saw the resident as she was taking over for the previous wound care company physician. The physician informed the resident and WN the resident should be seen by a surgeon due to bone exposure on the fingers. Review of the resident's wound care company notes, dated 1/10/24, showed: -Site #2: Arterial wound of the right third finger: -Wound Size: 0.5 cm x 0.9 cm x 0.2 cm. Exudate: Light serosanguinous (thin drainage that contains blood). Granulation tissue: 25%. Other viable tissue: 75% dermis. Wound progress: At goal; -Dressing Treatment Plan: Xeroform gauze apply once daily for 30 days. Secondary dressing: Gauze sponge sterile apply once daily for 30 days. Self adhere compression wrap apply once daily for 30 days; -Recommendations: Surgery consult for exposed bone with non-healing wound; -Site #3: Post-surgical wound of the left third finger: -Wound Size: 1.2 cm x 1.4 cm x 0.1 cm. Exudate: None. Other viable tissue: 100% bone. Wound Progress: Exacerbated due to resident with exposed bone; -Dressing Treatment Plan: Xeroform gauze apply three times per week for 30 days. Secondary dressing: Self adhere compression wrap apply three times per week for 30 days; -Recommendations: Surgery consult for exposed bone with non-healing wound; -Site # 4: Post-surgical wound of the left fourth finger: -Wound Size: 0.2 cm x 0.5 cm x not measurable. Exudate: None. Skin: 75%. Wound progress: Improved; -Dressing Treatment Plan: Skin Prep apply once daily for 30 days; -Recommendations: Surgical consult for exposed bone with non-healing wound. Review of the resident's progress note, dated 1/10/24 at 5:36 P.M., showed staff made an appointment with an orthopedic surgeon to see the resident's fingers on both hands. During an interview on 1/11/24 at 10:34 A.M., the facility WN said she started at the facility on 11/22/23. She made rounds with the previous physician, but had not followed up on making the consult with the surgeon. She should have gotten the consult at the time the previous physician ordered it. The surgeon appointment was made yesterday. During an interview on 1/11/24 at 1:45 P.M., the Director of Nurses said she expected staff to promptly follow-up with physician's orders. The resident's surgeon consult should have been made when the wound care company physician first recommended it on 11/30/23. During a telephone interview on 1/24/24 at 11:54 A.M., the wound care company physician said she expected facility staff to follow the wound care orders, and follow them promptly. Another physician from her company wrote the order on 11/30/23, for the resident to see the surgeon for the exposed bones on the fingers. When she saw the resident on 1/10/24, one of her concerns about the exposed bone was risk for infection. The surgeon would be able to decide what else could be done such as removing some of the bone and a skin flap to cover it.

Based on observation, interview and record review, the facility failed to ensure staff followed their Wound Management Policy, failed to follow and/or promptly follow new and/or altered treatments and discontinued treatments as ordered by the wound care company physician for one resident with pressure ulcers/injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin) on the left heel, right heel, sacrum (the bony area between the lower back and upper buttocks) and right lateral ankle. (Resident #10). The facility also failed to ensure one resident with a care plan intervention to wear a heel protector while in bed, and an order from the wound care company to wear off-loading boots, wore those pressure relieving devices. Staff also failed to notify the wound care company with a new order upon readmission on 1/3/24 to assess the resident resulting in the resident to not be seen on 1/10/24 during wound care company rounds (Resident #3). In addition, the facility failed to ensure the facility's Wound Nurse (WN) was not frequently removed from his/her duties as the WN to work the units as a Charge Nurse. The facility identified eight residents with pressure ulcers/injuries. Two of those residents and one resident sampled as a closed record were reviewed and problems were found with two. The census was 86. Review of the facility's Wound Management policy, dated 11/15/22, included: -Policy: To promote wound healing of various types of wounds, the facility will provide evidenced based treatments in accordance with current standards of practice and physician orders; -Wound Management Procedures: -Wound treatment will be provided in accordance with physician order: cleansing method, type of dressing, frequency of dressing change; -Charge Nurse will notify physician in the absence of treatment orders; -Wound dressings will be applied in accordance with manufacturer's recommendations; -Treatment selection will be based on the etiology of the wound; -Pressure injuries will be differentiated from non-pressure wounds: arterial (due to poor blood circulation), venous (caused by abnormal or damaged veins), diabetic, surgical, moisture associated skin damage; -Wound characteristics/documentation: Location of the wound, pressure injury and stage, non-pressure-level of tissue destruction, size (shape, depth, tunneling and/or undermining), volume and exudate (drainage) characteristics, pain evaluation, presence of infection, condition of the wound bed and wound edges, condition of the peri-wound (skin surrounding the pressure injury or wound), and resident/resident representative preferences/goals; -Guidelines for Dressing Selection: obtain physician's order, review wound care formulary to assist in treatment decision process, wound care formulary may not be appropriate for use in all circumstances; -Treatments will be documented on the Treatment Administration Record (TAR); -The effectiveness of treatments will be monitored through ongoing evaluation of the wound(s); -Considerations Modifications: lack of progression towards healing, changes in wound characteristics, changes in the resident/resident representative's preference/goals. Review of the facility's Essential Functions of Wound Care Nurse policy, undated, included the following: -Assesses, treat, and care for patients with wounds such as pressure ulcers, skin breakdowns or other wounds. Treatment tasks include cleaning, bandaging, and working with the care team to determine if other treatments are necessary; -Assess residents on admission and document appropriately as condition changes; -Contribute knowledge of residents' conditions and document observations as required; -Notify physician of changes in resident's condition and follow through until appropriate action is taken; -Accurately and promptly implement physician orders; -Implement plan of care for the resident based on assessments and goals as established by the interdisciplinary care team; -Perform other task and duties as assigned. 1. Review of Resident #10's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/22/23, showed: -admitted [DATE]; -Cognitively intact; -Rejection of Care: Behavior not exhibited; -Substantial/maximal assistance - helper does more than half the effort: personal hygiene; -Independent: roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand; -Frequently incontinent of bowel and bladder; -Diagnoses of high blood pressure, renal (kidney) insufficiency, diabetes mellitus (insufficient production of insulin resulting in high blood sugar levels), and malnutrition; -Risk of Pressure Ulcers: Yes; -Unhealed Pressure Ulcers: No. Review of the resident's care plan, dated 12/6/23 and located in the electronic health care records (EHR), showed: -Focus: 11/28/23 Unstageable due to necrosis (known but not stageable due coverage of wound bed by slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) and/or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin), left heel. 11/28/23 Unstageable deep tissue injury (DTI, suspected deep tissue injury in evolution) right heel. 11/28/23 Stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) sacrum. 11/28/23 Unstageable DTI right lateral ankle; -Goal: Pressure ulcers will show signs of healing and remain free of infection; -Interventions: Administer treatments as ordered and monitor effectiveness. Assess/record/monitor wound healing weekly. The care plan did not identify a problem with the resident being non-compliant with treatment care or rejecting treatments; -Focus: Alteration in Mobility. Requires the following assistance for: Transfers - Dependent, bed mobility - partial assist of 1-2 staff, toileting - substantial assist of 1-2 staff (1/9/24); -Focus: Bladder Incontinence; -Interventions: Check and change for incontinence (1/9/24); -Focus: Bowel Incontinence; -Interventions: Check resident as required and assist with toileting as needed. Provide care after each incontinence episode (1/9/24). Review of the resident's physician's order sheet (POS), located in the EHR, showed the following orders: -Left buttock, Skin Prep (a liquid that forms a protective film), apply foam dressing daily. Order Date: 11/29/23. Start Date: 12/1/23. Order Status: Discontinued (DC); -Left buttock. Apply Skin Prep to peri wound (the skin surrounding the pressure injury/wound), apply Medihoney/leptospermum honey (a natural antibacterial product used to treat burns, pressure injuries, and wounds), apply foam dressing and change daily. Order Date: 12/4/23. Start Date: 12/5/23. Order Status: Active; -Sacrum, Apply Santyl/collagenase ointment (used to treat burns and skin ulcers and helps to remove dead skin tissue). Order Date: 1/10/24. Start Date: 1/11/24. Order Status: Active; -Right heel, Skin Prep daily; Order Date: 11/29/23. Start Date: 11/29/23; -Right heel, Betadine (used to treat or prevent skin infection in wounds) soaked gauze, wrap with kling (gauze wrap) and change every Monday-Wednesday-Friday. Order Date: 12/13/23. Start Date: 12/15/23; -Right heel, Betadine soaked gauze pad wrap, apply calcium alginate (highly absorbent dressing for drainage control) with silver (antimicrobial wound dressings) then kerlix wrap and change daily. Order Date: 1/11/24. Start Date: 1/11/24; -Left Heel, Apply collagen pad wrap with kling wrap and change daily. Order Date: 12/20/23. Start Date: 12/21/23; -Left heel, Betadine soaked gauze pad wrap, apply calcium alginate with silver then kerlix wrap and change daily. Order Date: 1/11/24. Start Date: 1/12/24; -Left Lateral Ankle (the site should be identified as right lateral ankle): Left lateral ankle (identified incorrectly, should be right lateral ankle). Apply Santyl and cover with calcium (alginate calcium). Change daily. Order Date: 1/11/24. Start Date: 1/11/24. Review of the resident's TAR, dated 11/1/23 through 11/30/23, showed: -Right heel, apply Skin Prep daily. Staff failed to initial that the treatment had been completed on 11/29/23 and 11/30/23. Start Date: 11/29/23, DC Date: 12/20/23; -Left heel, apply Skin Prep daily. Staff failed to initial the treatment had been completed on 11/29/23 and 11/30/23. Start Date: 11/29/23, DC Date: 12/20/23: Review of the resident's wound care company progress notes/treatment orders for 12/2023, showed: -Date: 12/7/23: The resident's visit was rescheduled. Resident refused this afternoon, requesting morning visits; -Date: 12/14/23: No progress note/treatment orders found for this date; -Date: 12/20/23: -Site #1: Unstageable DTI of the left heel: Etiology (cause/origin): Pressure. Wound Size (Length x Width x Depth): 2.4 centimeters (cm) x 11.1 cm x not measurable. Exudate: None. Skin: Intact with purple/maroon discoloration. Dressing Treatment Plan: Betadine apply once daily for 30 days. Debridement History: This wound had previously undergone autolytic debridement (the removal of necrotic/devitalized tissues through a moist environment that utilizes the body's own enzymes); -Site #2: Unstageable DTI of the right heel: Etiology: Pressure. Wound Size: 5.5 cm x 6.8 cm x not measurable. Exudate: None. Skin: Intact with purple/maroon discoloration. Dressing Treatment Plan: Betadine apply once daily for 30 days. Debridement History: This wound had previously undergone autolytic debridement; -Site #3: Pressure wound sacrum: Etiology: Pressure. Wound Size: 8.6 cm x 4.5 cm x 0.1 cm. Exudate: Light serous (thin, watery, clear drainage). Slough: 30%. Granulation Tissue (healing tissue): 40%. Skin: 30%. Dressing Treatment Plan: Leptospermum honey apply once daily for 30 days. Peri Wound Treatment: Zinc ointment (a mineral used to treat skin irritations) apply once daily for 30 days. Debridement History: Surgical excisional debridement (the removal of necrotic/devitalized tissues using surgical instruments such as a scalpel, curette (a surgical instrument used to scrape or debride tissue), scissors, etc.) was performed today on this wound; -Date: 12/27/23: -Site #1: Left heel: Wound Size: 2.7 cm x 9.5 cm x not measurable. Exudate: None. Skin: Intact with purple/maroon discoloration. Wound Progress: Improved. Dressing Treatment Plan: Betadine apply once daily for 23 days. Debridement History: This wound has previously undergone autolytic debridement; -Site #2: Right heel: Wound Size: 6.3 cm x 9.5 cm x not measurable. Exudate: None. Skin: Intact with purple/maroon discoloration. Wound Progress: Improved. Dressing Treatment Plan: Betadine apply once daily for 23 days. Debridement History: This wound has previously undergone autolytic debridement; -Site #3: Sacrum: Wound Size: 9.1 cm x 3.4 cm x 0.1 cm. Exudate: Light serous. Slough: 30%. Granulation Tissue: 40%. Skin: 30%. Wound Progress: Improved. Dressing Treatment Plan: Leptospermum honey apply once daily for 23 days. Peri Wound Treatment: Zinc ointment apply once daily for 23 days. Debridement History: Surgical excisional debridement was performed today on this wound; -Site #4 (new): Unstageable DTI of the left lateral ankle (this should be right lateral ankle). Etiology: Pressure. Wound Size: 9.7 cm x 2.6 cm x not measurable. Exudate: None. Blister: Dry. Dressing Treatment Plan: Off-load wound. Initial Evaluation Note: Discontinue Skin Prep and off-load wound. This wound has previously undergone autolytic debridement. Review of the resident's TAR, dated 12/1/23 through 12/31/23, showed: -Left Heel (identified as Site #1 on the wound care company progress notes/treatment orders): -Start Date: 11/29/23, discontinue (DC) Date: 12/20/23 Left heel, Skin Prep daily. Staff initialed the treatment had been completed from 12/2/23 through 12/19/23, except on 12/12/23 when staff documented RE (refused); -Start Date: 12/21/23, DC Date: 12/21/23 Left heel, apply collagen pad wrap with kling wrap and change daily. Staff initialed the treatment had been completed on 12/21/23; -Start Date: 12/22/23, DC Date 1/11/24: Left heel, apply Betadine soaked gauze wrap with kling wrap and change daily. Staff initialed the treatment had been completed from 12/22/23 through 12/31/23; -Right Heel (identified as Site #2 on the wound care company progress notes/treatment orders): -Start Date: 11/29/23, DC Date: 12/20/23. Right heel, apply Skin Prep daily. Staff initialed the treatment had been completed from 12/2/23 through 12/19/23, except on 12/12/23 when staff documented RE; -Start Date: 12/15/23, no DC date: Right heel, apply Betadine soaked gauze wrap with kling wrap and change on Monday-Wednesday-Friday. Staff initialed the treatment had been completed on 12/15, 12/18, 12/20, 12/22, 12/25, 12/27 and 12/29; -No order to DC the Betadine treatment on Monday-Wednesday-Friday, and start the treatment daily per the wound care company orders on 12/20/23 and 12/27/23; -Left Buttock/Buttock/Sacrum (identified as Site #3 on the wound care company progress notes/treatment orders): -Start Date: 12/1/23, DC Date: 12/20/23: DTI to left buttock. Apply Skin Prep and foam dressing daily. Staff initialed the treatment had been completed from 12/4/23 through 12/19/23, except on 12/12/23 when staff documented RE; -Start Date: 12/4/23, no DC date: Buttock, apply Medihoney and cover with dry dressing daily. Staff initialed the treatment had been completed 12/4/23 through 12/31/23; -Start Date: 12/5/23, no DC date: Left buttock, apply Skin Prep to peri wound apply Medihoney and foam dressing daily. Staff initialed the treatment had been completed 12/5/23 through 12/31/23; -No order to DC the Skin Prep and start zinc ointment to the peri wound per the wound care company orders on 12/20/23 and 12/27/23; -Left Lateral Ankle (right lateral ankle, and identified as Site #4 on the wound care company progress notes/treatment orders): -Start Date: 12/27/23, DC Date: 1/11/24: Left lateral ankle, Skin Prep daily. Staff initialed the treatment had been completed from 12/27/23 through 12/31/23; -No order to DC the Skin Prep per the wound care company order on 12/27/23; -Heel protectors on at all times, may remove for activity, hygiene and skin checks: Start Date 12/7/23: Staff initialed the resident was compliant wearing the heel protectors except on 12/12/23, when staff documented RE. Review of the resident's January 2024 wound care company progress notes/treatment orders, showed: -Date 1/3/24: -Site #1: Left heel: Wound Size: 4.7 cm x 10.5 cm x not measurable. Depth is unmeasurable due to presence of nonviable (necrotic or devitalized) tissue and necrosis. Exudate: Light serosanguinous (thin drainage that contains blood). Thick adherent black necrotic tissue (eschar): 90%. Slough: 10%. Wound Progress: Exacerbated (made worse) due to generalized decline of resident. Dressing Treatment Plan: Betadine apply once daily for 16 days. Alginate calcium with silver apply once daily for 30 days. Debridement History: Surgical debridement was performed today on this wound; -Site #2: Right heel: Wound Size: 6.8 cm x 8.2 cm x not measurable. Exudate: None. Skin: Intact with purple/maroon discoloration. Wound Progress: Improved. Dressing Treatment Plan: Betadine apply once daily for 16 days. Debridement History: This wound has previously undergone autolytic debridement; -Site #3: Sacrum: Wound Size: 9.1 cm x 2.0 cm x 0.1 cm. Exudate: Moderate serosanguinous. Slough: 30%. Granulation Tissue: 40%. Skin: 30%. Wound Progress: Improved. Dressing Treatment Plan: Alginate calcium with silver apply once daily for 30 days. Peri Wound Treatment: Zinc ointment apply once daily for 16 days. Skin Prep apply once daily for 30 days. Debridement History: Surgical excisional debridement was performed today on this wound; -Site #4: Right lateral ankle: Wound Size: 10.8 cm x 2.4 cm x not measurable. Exudate: None. Blister: Fluid filled. Wound Progress: At goal. Dressing Treatment Plan: Collagen sheet apply once daily for 30 days. Debridement History: This wound has previously undergone autolytic debridement; -Date: 1/10/24: -Site #1: Left heel: Wound Size: 4.2 cm x 10.0 cm x 0.1 cm. Exudate: Light serosanguinous. Thick adherent black necrotic tissue: 90%. Granulation Tissue: 10%. Wound Progress: Improved. Dressing Treatment Plan: Betadine once daily for 9 days. Alginate calcium with silver apply once daily for 23 days. Debridement History: The most recent debridement of this wound was an excisional debridement performed on 1/3/24; -Site #2: Right heel: Wound Size: 6.7 cm x 7.6 cm x not measurable. Exudate: Light serosanguinous. Skin: Intact with purple/maroon discoloration. Wound Progress: Improved. Debridement History: This wound has previously undergone autolytic debridement; -Site #3: Sacrum: Wound Size: 9.1 cm x 2.0 cm x 0.2 cm. Exudate: Moderate serosanguinous. Slough: 30%. Granulation Tissue: 40%. Skin: 30%. Wound Progress: At goal. Dressing Treatment Plan: Santyl once daily for 30 days. Alginate calcium once daily for 30 days. Peri Wound Treatment: Zinc ointment apply once daily for 9 days. Skin Prep apply once daily for 23 days. Debridement History: Surgical excisional debridement was performed today on this wound; -Site #4: Right lateral ankle: Wound Size: 9.9 cm x 2.4 cm x 0.1 cm. Exudate: Moderate serosanguinous. Slough: 80%. Granulation Tissue: 20%. Wound Progress: Improved. Dressing Treatment Plan: Santyl once daily for 30 days. Alginate calcium apply once daily for 30 days. Debridement History: Surgical excisional debridement was performed today on this wound. Review of the resident's TAR dated 1/1/24 through 1/31/24, showed: -Left Heel Site #1: Start Date: 12/22/23, DC Date: 1/11/24: Left heel, apply Betadine soaked gauze pad wrap with kerlix wrap and change daily. Staff initialed the treatment had been completed from 1/1/24 through 1/10/24; -No order to add alginate calcium with silver daily per the wound company orders on 1/3/24, and 1/10/24; -Right Heel Site #2: Start Date: 12/15/23, no DC date: right heel, apply Betadine soak gauze wrap with kling wrap every Monday-Wednesday-Friday. Staff initialed the treatment had been completed on 1/1, 1/3, 1/5, 1/8 and 1/10/24; -No order to DC the Betadine treatment on Monday-Wednesday-Friday and start the treatment daily per the wound care company orders on 12/20/23, 12/27/23 and 1/3/24; -Start Date: 1/12/24, no DC date: Right heel, Betadine soaked gauze pad wrap then apply calcium alginate with silver then kerlix wrap and change daily; -Left Buttock/Buttock/Sacrum Site #3: Start Date: 12/4/23, no DC date: Buttock, apply Medihoney and cover with dry dressing daily. Staff initialed the treatment had been completed from 1/1/24 through 1/10/24; -Start Date: 12/5/23, no DC date: Left buttock, apply Skin Prep to peri wound, apply Medihoney and foam dressing daily. Staff initialed the treatment had been completed from 1/1/24 through 1/10/24; -Start Date: 1/11/24, no DC date: Sacrum, Santyl ointment every day; -No order for zinc ointment to the peri wound per the wound care company orders on 12/20/23, 12/27/23, 1/3/24 and 1/10/24; -No order for alginate calcium with silver, zinc ointment and Skin Prep to the peri wound per the wound care company orders on 1/3/24 and 1/10/24; -Left Lateral Ankle (right lateral ankle) Site #4: Start Date: 12/27/23, DC Date: 1/11/24: Skin Prep to left (right) lateral ankle every day shift. Staff initialed the treatment had been completed from 1/1/24 through 1/10/24; -No order to DC the Skin Prep per the wound care company orders on 12/27/23, prior to 1/11/24; -No order for collagen sheet apply once daily for 30 days per the wound care company orders on 1/3/24; -Start Date: 1/11/24, no DC date: Right lateral ankle, apply Santyl cover with calcium change daily; -Heel protectors on at all times, may remove for activity, hygiene and skin checks: Start Date 12/7/23; -Review of the TAR showed staff did not document RE for any treatment or intervention. Observation on 1/11/24 at 9:54 A.M., showed the resident lay in bed. The facility WN and Nurse I completed the resident's treatments per the wound care company orders received on 1/10/24. Both of the resident's heels were black in appearance, the right lateral ankle was covered with white/yellow slough, and the sacrum had a small amount of yellow slough and red beefy tissue. The resident did not complain or reject the treatment. During an interview on 1/11/24 at 12:56 P.M., the WN said the reference to the resident's buttock, left buttock, and sacrum are all the same area. The wound care company had designated it as the sacrum and he/she did not change the buttock or left buttock to the sacrum. She should have changed it all to sacrum. 2. Review of Resident #3's care plan, located in the EHR showed: -12/5/22: Focus: Potential for impaired skin integrity and/or development of pressure-related ulcer(s) and/or breakdown related to reduced bed mobility, thin fragile skin; -Goal: Skin integrity will improve without injury-related deficits; -Interventions: Follow new wound care instructions. 3/7/23: Heel protectors while in bed. Refer to weekly skin check sheet/TAR for treatment plan for actual impaired skin integrity problems. Review of the resident's wound care company progress notes/treatment orders, dated 12/20/23, showed: -Unstageable DTI of the left distal lateral foot. Etiology: Pressure. Wound Size: 3.0 cm x 2.7 cm x not measurable. Recommendations Included: Pressure off-loading boots; -Unstageable DTI left proximal lateral foot. Etiology: Pressure. Wound Size: 2.0 cm x 1.4 cm x not measurable. Recommendations not listed; -Unstageable (due to necrosis) left lateral ankle. Etiology: Pressure. Wound Size: 2.5 cm x 1.9 cm x 0.1 cm. Recommendations Included: Pressure off-loading boots. Review of the resident's progress notes, showed: -12/26/23 at 5:03 P.M.: Resident's oxygen level would not stabilize with oxygen and nebulizer treatment (medication to expand the lungs and delivered by an aerosol mist). Physician gave order to send resident to the emergency room ; -1/3/24 at 4:45 A.M.: Resident transported via emergency medical services (EMS) to unit on stretcher accompanied by two EMS drivers. Resident reoriented to room. Medications reviewed with no changes/new orders; -1/3/24 at 6:24 P.M.: Braden Scale (an assessment used to determine a residents risk of developing pressure ulcers/injuries) score of 13 (moderate risk); -1/4/24 at 11:23 A.M.: Skin assessment completed. No documentation regarding the resident's left foot pressure ulcers/wounds; -1/5/24 at 12:57 A.M.: Skin: Pressure ulcer/injury. Location: left foot. Wound odor: No. Tunneling: No. Undermining: No. Painful: No; -1/5/24 at 12:16 P.M. (physician progress note): Necrotic tissue present to left foot and ankle in multiple areas. Pressure ulcer of left heel unstageable. Frail skin with multiple pressure ulcers and wounds. Daily cleaning and wound care per order set. Consult wound care company for resumption of rounds; -Review of the resident's medical record and progress notes showed no readmission assessments that included the measurements of the pressure ulcers/injuries of the left foot. Review of the resident's POS and TAR dated 1/1/24 through 1/31/24, showed: -Revision Date 12/21/23. Start Date 12/22/23: Clean the left lateral (side), and left lateral foot, apply Medihoney, daily and PRN; -Revision Date 12/21/23. Start Date 12/22/23: Clean left foot proximal (nearer to the point of reference) paint with Betadine (used to prevent/treat skin infection), cover with dressing and wrap with gauze daily and PRN; -1/4/24 (POS only): Wound care company to evaluate and treat; -No order for heel protectors/pressure off-loading boots while in bed on the POS or TAR. Review of the facility weekly pressure ulcer report, dated 1/5/24, showed: -Start Date 12/5/23, acquired in facility: Medial/middle left lateral (side) L foot (identified on the wound care company report as the left distal lateral foot), unstageable pressure ulcer measuring 3.0 cm x 2.7 cm; -Start Date 12/5/23, acquired in facility: Left proximal (near/closest to) lateral foot:, unstageable pressure ulcer measuring 2.0 cm x 1.4 cm. Unstageable pressure ulcer; -Start Date 12/5/23, acquired in facility: Left lateral ankle: Unstageable pressure ulcer measuring 2.5 cm x 1.9 cm x 0.1 cm. Review of the resident's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Short-Long Term Memory Problem; -Rejection of care: Behavior not exhibited; -Dependent - Helper does all of the effort: Lower body dressing; -Diagnoses of renal insufficiency, neurogenic bladder, and dementia; -Risk of Pressure Ulcers: Yes; -Unhealed Pressure Ulcer(s): Yes; -Unstageable Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar: Number of unstageable pressure ulcers,1; -Unstageable Deep tissue: Number of suspected deep tissue injury in evolution: 2; -Skin and Ulcer Treatments: Applications of dressings to feet. Observations of the resident, showed: -On 1/9/24 at 12:35 P.M., the resident was transferred to bed from the wheelchair by Nurse B and Certified Nursing Assistant (CNA) G. During a skin assessment, the resident was observed with a dressing on his/her left foot. After the skin assessment was completed, the Nurse and CNA left the room without placing heel protectors/pressure off-loading boots on the resident; -On 1/10/24 at 6:15 A.M., the resident lay in bed with a dressing on the left foot. The resident did not have on heel protectors/pressure off-loading boots; -On 1/11/24 at 6:30 A.M., the resident lay in bed with no heel protectors/pressure off-loading boots on. During an interview on 1/11/24 at 6:30 A.M., CNA D said he/she was not aware the resident's care plan showed the resident should wear heel protectors/pressure off-loading boots in bed. He/She said there was a form on the inside of the resident's closet that showed the type of care the resident should have. Review of the form at that time showed: MDS Kardex Report, dated 7/26/23, showed no guidance to staff for the resident to wear heel protectors/pressure off-loading boots while in bed. Observation of the resident's closet showed two green boots. The CNA said he/she had taken care of the resident several times and had never put the boots on the resident. During an interview on 1/10/24 at 7:30 A.M., the facility WN said the resident returned from the hospital on 1/3/24. She worked on the unit as a floor nurse 1/4, 1/5, 1/6, 1/7 and 1/8/24, and has not seen the resident since his/her readmission. She was usually pulled to the floor to work the unit two or three times a week. When that happened the nurses on duty were supposed to do the readmission assessments. The wound care company was supposed to see the resident today and they will do the readmission pressure ulcer assessment. During observation and interview on 1/11/24 at 8:26 A.M., the resident lay in bed. The facility WN said the wound care company physician did not see the resident yesterday, 1/10/24. She thought the wound care company would automatically see the resident after returning on 1/3/24. She was supposed to notify the wound care company with the new order for them to see the resident, but he/she had not. The wound care company would see the resident next week. She measured the resident's pressure ulcers. The medial left lateral foot measured 4.1 cm by 2.9 cm, 90% slough, 5% necrotic, and 5% granulation tissue. The left lateral ankle measured 3.8 cm by 3.4 cm, 95% slough and 5% granulation tissue. The left proximal lateral foot measured 2.5 by 2.8 cm, 90% necrotic and 10% slough. The WN said this was the first time she measured the resident's pressure ulcers since he/she returned on 1/3/24. The measurements on the facility weekly pressure ulcer report were the same measurements the wound care company documented on 12/20/23. She had not had time to measure the resident's pressure ulcers because he/she kept getting pulled to work the units. She was aware the resident should have heel protectors/pressure off-loading boots on while in bed. The nurses should have given staff instructions for the resident to wear the heel protectors/pressure off-loading boots. She was not sure why the heel protectors were documented on the care plan and the pressure off-loading boots were on the wound care company orders, but not documented on the POS. During an interview on 1/11/24 at 6:40 A.M., Nurse H said he/she was aware the resident should wear heel protectors/pressure off-loading boots while in bed. The nurses were responsible to inform the CNAs the resident should wear them. He/She had never told CNA D to put heel protectors/pressure off-loading boots on the resident and had not noticed the resident was not wearing them. Review of the wound care company progress notes/treatment orders, dated 1/12/24, showed: -Unstageable DTI of the left distal lateral foot: Etiology: Pressure. Size: 1.6 cm x 1.9 cm x not measurable. Exudate: Light serosanguinous. Skin: Intact purple/maroon discoloration. Wound Progress: Improved. Recommendation(s): Pressure off-loading boot; -Unstageable DTI of the left proximal foot: Etiology: Pressure. Size 3.4 cm x 2.2 cm x not measurable. Exudate: Light serosanguinous. Thick adherent black necrotic tissue (eschar) 70%. Slough: 20%. Granulation Tissue: 10%. Debridement History: Surgical excisional debridement was performed today on this wound. Recommendation(s): Pressure off-loading boot; -Unstageable (due to necrosis) of the left lateral ankle. Etiology: Pressure. Wound Size 2.8 cm x 2.4 cm x 0.1 cm. Exudate: Light serosanguinous. Thick adherent devitalized tissue: 45%. Slough: 40%. Granulation Tissue: 15%. Wound Progress: Exacerbated due to generalized decline of resident. Debridement History: Surgical excisional debridement was performed today on this wound. Recommendation(s): Pressure off-loading boot. During an interview on 1/11/24 at 7:20 A.M., the Director of Nurses (DON) said if the heel protectors are on the care plan, she expected the resident to wear them, and there should be an order on the POS. She was not aware the wound company ordered pressure off-loading boots on their weekly progress notes. She would assume the heel protectors/pressure off-loading boots should be worn in bed and while up in the wheelchair. 3. During an interview on 1/11/24 at 6:40 A.M., Nurse H said when he/she did treatments, he/she looked at the TAR in the computer system. If there was a new or changed order and it was not on the TAR in the computer, he/she would not know to complete the new or changed order. 4. During an interview on 1/11/24 at 6:52 A.M., Nurse E said when he/she did treatments, he/she looked at the TAR in the computer. If a new treatment order hadn't been added or an existing order had been changed but not on the TAR, he/she would not know to complete the order. 5. During an interview on 1/11/24 at 12:56 P.M., the WN said she started at facility on 11/22/23. Since starting, she was usually pulled from the WN position to the unit two or three times a week. She was not able to keep up with all of the assessments and documentation like she wanted to. She usually received the wound care company notes no later than the next day after they left. She had not been able to review all of the wound care company notes promptly to ensure all the new or changed orders had been added to the POS and TAR. The wound care company orders should be transcribed correctly. 6. During an interview on 1/11/24 at 1:45 P.M., the Administrator and DON said the facility did not have an official WN for

Based on observation, interview and record review, the facility failed to ensure one resident with an order for an indwelling urinary catheter (thin tube inserted through the urethra and into the bladder to drain the bladder of urine) had the size of catheter as ordered on the physician's order sheet (POS). In addition, the facility failed to ensure the resident's catheter bag (used to collect the urine and is attached to the catheter by catheter tubing) remained below the resident's bladder during a Hoyer lift (a machine used to transfer a resident that is unable to bear weight) transfer, and the catheter bag remained off the floor. The facility identified two residents with catheters, one was sampled (Resident #3) and problems were identified. The census was 86. Review of the facility's Catheter Care policy, dated 7/13/22, showed: -Policy: The facility will maintain consistent and adequate hygiene standards for residents with an indwelling catheter to maintain function and prevention or complications; -Responsibility: Nursing Staff, Licensed Nurses, Nursing Administration, and Director of Nurses (DON); -The policy did not identify positioning of catheter bags. Review of Resident #3's quarterly Minimum Date Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/10/24, showed: -Short-Long term memory problem; -Rejection of care: Behavior not exhibited; -Diagnoses of renal insufficiency, neurogenic bladder (neuromuscular dysfunction), and dementia; -Indwelling catheter; -Urinary Continence: Not rated, resident had a catheter. Review of the resident's POS, showed an order dated 12/5/23, with a revision date of 1/4/24, for the resident to have a 14 french (fr., the size of the catheter) indwelling urinary catheter. The size of the catheter bulb (the bulb is inflated once inside the bladder and used to anchor the catheter) was not documented. Review of the resident's treatment administration record (TAR) dated 1/1/24 through 1/31/24, showed -Order date 11/6/23: Maintain 14 fr. (with no bulb size noted) catheter. Change every month and PRN (as necessary) on the 5th of each month; -The TAR showed staff initialed the 14 fr. catheter had been changed on 1/5/24. Review of the resident's care plan, located in the electronic health care record, in use during the survey, showed: -Focus (no start date): Indwelling catheter related to a diagnosis of neuromuscular dysfunction of bladder; -Goal(s): Will remain free from catheter related trauma through next review date. Will show no signs or symptoms of urinary infection through next review date; -Intervention(s): 18 fr 10 milliliters ((ml) size of the bulb) catheter. Position catheter bag and tubing below the level of the bladder. Observation on 1/9/24 at 12:35 P.M., showed the resident sat in a wheelchair as Nurse B and Certified Nursing Assistant (CNA) G transferred the resident from the wheelchair to the bed using a Hoyer lift. Prior to transferring the resident, CNA G attached the resident's catheter bag to the bars on the Hoyer lift, which were above the resident's bladder. The catheter bag had urine in both the catheter tubing and the catheter bag. The Nurse and CNA completed the Hoyer transfer with the catheter remaining above the resident's bladder. After the resident was in bed, the Nurse looked at the resident's catheter and said the catheter size was 18 fr./10 ml. Observation on 1/10/24 at 6:15 A.M. showed the resident lay in bed. His/Her catheter bag lay on the floor underneath one of the bed's wheels. CNA D entered the room at that time. He/She said he/she had recently emptied the resident's catheter bag. He/She thought he/she hung the catheter bag on the bed frame, off the floor after emptying the catheter bag. He/She did not know how the catheter bag ended up on the floor underneath a bed wheel. He/She said the catheter bag should never be on the floor. During an interview on 1/11/24 at 7:20 A.M., with Nurse H and Nurse B, Nurse H said the resident's catheter order on the POS was not current. He/She thought the resident had a 16 fr./10 ml catheter. Nurse H did not know why the POS showed a 14 fr. catheter or that the resident had an 18 fr./10 ml catheter inserted. Facility staff were not supposed to change the catheter. The resident was supposed to be sent to the urologist for catheter changes. Nurse B said he/she must not have been paying attention to the catheter bag during the Hoyer transfer on 1/9/24. The catheter bag should always be below the bladder to prevent urine from backflowing into the bladder. During an interview on 1/11/24 at 1:45 P.M., the DON said the resident's catheter could be changed by nursing staff in the facility. She expected the resident to have the size of catheter that was on the POS, which was a 14 fr. She did not know why the resident had an 18 fr./10 ml catheter in place or why it was not the resident's care plan. If the nurses wee not sure, they should have contacted the resident's physician or urologist to clarify the order. The catheter bag should remain below the bladder at all times and the catheter bag should not be on the floor. MO00229357

Based on interview and record review, the facility failed to provide services to promote the highest practicable physical well-being for two residents. The facility failed to adequately assess, monitor and implement interventions to resolve ongoing dehydration and elevated blood sugar levels experienced by one resident, and also failed to ensure the resident was treated by the Infectious Disease Clinic as ordered (Resident #1). The facility also failed to adequately assess, monitor and intervene for one resident (Resident #5) when staff documented the resident was not having bowel movements but failed to report to his/her physician or registered dietitian (RD). The resident incurred a fecal impaction (a mass of dry, hard stool that cannot pass out of the colon or rectum). The sample size was eight. The census was 78. Review of the facility policy titled Notification of a Change in Condition, revised 4/26/23, showed direction for staff to notify a resident's attending physician/physician extender (nurse practitioner, physician assistant, or clinical nurse specialist) and the resident representative of a change in the resident's condition, per standards of practice and Federal and/or State regulations. It was the responsibility of all licensed nursing personnel, nursing administration and the Director of Nursing (DON). The guideline for notification of physician/resident representative (not all inclusive) listed the following: significant change or unstable vital signs, emesis (vomiting)/diarrhea, onset of pressure injuries, accident/incident, signs/symptoms of infection, abnormal laboratory results, 5% weight gain/loss in 30 days, repeated refusal take prescribed medications, change in level of consciousness, abnormal complaints of pain, ineffective relief of pain from current regimen, unusual behavior, missing resident, glucometer reading below 70 or above 200 (unless specific parameters were given by physician for reporting). Staff was to document in interdisciplinary team (IDT) notes: resident change in condition, physician/physician extender notification and notification of resident representative. Review of the facility policy titled, Transportation-Social Services Policy, dated 2/1/26, showed the facility was to help arrange transportation for residents as needed. Except in emergencies, the resident or his or her representative (sponsor) shall be expected to arrange for transportation (e.g. to outside physician or clinic appointments for a planned transfer or discharge from the facility). Social services was to help the resident as needed (PRN) to obtain transportation. The resident shall assume full responsibility for paying for any transportation to or from the facility. The facility will not act as a billing agent for transportation charges. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/7/23, showed the following: -Entry date 3/31/23; -Long and short-term memory problem; -Signs and symptoms of delirium: continuous inattention; -Diagnoses including diabetes mellitis (DM), discitis (bacterial, viral or fungal infection of the discs between the small bones which form the spine) lumbar (lower back) region, malnutrition, heart failure, high blood pressure, chronic kidney disease (CKD, the kidneys are damaged and cannot filter the blood the way they should), seizure disorder, candiadiasis (fungal infection caused by a yeast called candida), encephalopathy (disease, damage, or malfunction of the brain) and low back pain; -Nutrition approach: feeding tube; -Proportion of total calories the resident received via tube feeding: 51% or more; -Average fluid intake per day by IV (intravenous) or tube feeding: 501 cubic centimeters (cc)/day or more; -Always incontinent of bowel and bladder; -Total dependence on full performance by one staff person for personal hygiene and bathing; -Total dependence on full performance by two+ staff for bed mobility, transfers, dressing and toilet use. Review of the resident's undated care plan, showed the following: -The resident has bladder incontinence related to disease process, history of urinary tract infection (UTI) and physical limitations; -Check the resident on rounds for incontinence. Wash, rinse and dry perineum (area including and between the genitals and anus). Change clothing PRN after incontinence episodes; -Administer diabetes medication as ordered by the physician. Monitor/document for side effects and effectiveness; -The resident requires gastrostomy tube (g-tube, a surgically placed device which provides direct access to the stomach for supplemental feeding, hydration or medicine) feeding related to resisting eating and swallowing problem; -He/She is dependent with tube feeding and water flushes. See the physician's orders for current feeding orders; -Flush the g-tube before and after feeding per current order; -The resident is on diuretic therapy (use of medication which promotes the increased production of urine, in order to treat high blood pressure); -Monitor diuretic dose. May require modification in order to achieve desired effects while minimizing adverse consequences. Review of the resident's physician's orders, showed the following: -3/31/23, Keppra oral solution 100 milligrams (mg)/milliliter (ml), give 7.5 ml via g-tube 2 times a day for seizures; -3/31/23, Intake and output every shift; -3/31/23, Flush tube with 30 cubic centimeters (cc) of water (H2O) before and after medications every shift; -4/1/23, Nothing by mouth (NPO) diet. Review of the resident's physician's orders, did not show an order for bolus feedings. Review of the resident's after visit (Infectious Disease Clinic) summary, dated 4/21/23, showed the following: -The following issues were addressed: bacteremia (the presence of bacteria in the blood), acute hematogenous osteomyelitis of other site (an infection which occurs when bacteria spreads into bones) and epidural abscess (an infection that forms in the spine due to an accumulation of pus-fluid filled with bacteria as well as with dead white blood cells which were sent to fight the infection); -Continue ceftriaxone (antibiotic) 2 grams (gm) via IV every (Q) 24 hours; -Continue weekly safety labs: complete blood count (CBC, shows the numbers of white and red blood cells, and platelets-blood fragments) and comprehensive metabolic panel (CMP, checks the body's fluid balance, electrolyte balance and how well the kidneys and liver are working); -Repeat erythrocyte sedimentation rate (ESR, a blood test which may indicate and/or helps monitor an increase in inflammatory activity within the body) in two weeks; -Labs ordered today, to be completed by 4/21/23: CBC with auto differential, c-reactive protein (CRP, test which checks for this protein. A higher amount in the bloodstream indicates inflammation in the body), CBC and ESR. Review of the resident's medical records, did not show any lab results dated between 4/21/23 and 4/27/23. Review of the resident's physician's orders, showed the following: -4/25/23, CBC and CMP weekly every Thursday and call results to the Infectious Disease Clinic every day shift every Thursday; -4/25/23, ESR and CRP labs to be drawn every two weeks. Call results to the Infectious Disease Clinic; -4/25/23, Ceftriaxone Sodium Intravenous Solution Reconstituted (a solution containing approximately 83 mg of sodium per gram which used to treat certain infections caused by bacteria) 2 gm, use 1 application intravenously one time a day for infection related to discitis unspecified lumbar region and candida stomatitis (fungal infection, caused by the overgrowth of the candida yeast, of the mucous membranes of the mouth). Flush with normal saline before and after. Review of the resident's lab results, dated 4/27/23, showed the following results: -CRP 30.1 H (high; normal range: 10.0 mg/L (liters); -CMP: Glucose 320 H, sodium 159 H (normal range 136-145 mEq (milliequivalent); -BUN 59 H (blood urea nitrogen, normal range: 6 to 20 mg/dL); -ESR 130 H (normal range: 0-20 mm (millimeters)/hr (hour); -GFR 38 L (normal range, .60 mL/min/1.73 m2 (square meter)); -ESR 130 H, (normal range: 0-20 mm/hr). Review of the resident's progress note, dated 4/28/23 at 9:54 A.M., showed a note from the Nurse Practitioner (NP): he/she saw the resident for follow up on BP and recent abnormal lab values. Assessment: hypernatremia (rise in serum sodium concentration exceeding 145 mmol/L(millimoles per liter)), anemia. Plan: lab values abnormal, but improved from hospital stay. Increase free water flush from 180 Q 4 hours to 220 Q 4 hours. Lab values to be faxed to Infectious Disease prior to appointment later today. Review of the resident's physician's orders, showed an order dated 4/28/23, for staff to flush tube with 220 cc of H20 every four hours for flush. Review of the resident's progress note, dated 4/29/23 at 8:45 A.M., showed call placed to the exchange for a return call from the NP. At 11:25 A.M., the resident's Family Member A spoke with Family Member B, who called the facility and spoke with the Charge Nurse as the resident had a small episode of seizure activity. The Charge Nurse explained the resident had already received his/her seizure medications, it needed time to work, the provider had been contacted and the resident could have treatment provided at the facility via lab work and an order to increase his/her seizure medications. The family still wanted the resident sent out to the hospital. The Charge Nurse also contacted the on call Assistant Director of Nursing (ADON) to report it. At 11:41 A.M., the Charge Nurse called for an ambulance, checked the resident afterwards and unhooked the g-tube. The resident displayed no episodes of shaking or seizure activity. Review of the resident's physician's orders, showed an order dated 4/29/23, for staff to send to hospital to evaluate and treat for seizure activity. Review of the resident's physician's orders, dated 5/1/23 through 5/31/23, did not show the order end dates for the CBC & CMP every Thursday and monitoring of intake and output. Review of the resident's MAR, dated 5/1/23 through 5/31/23, showed discontinuation on 5/2/23, of the order dated 4/25/23, for a CBC and CMP every Thursday and discontinuation of the order dated 3/31/23, for intake and output every shift. Review of the resident's hospital after visit summary, dated 5/5/23, showed the following: -Hospital problems: hypernatremia and severe malnutrition; -You were hospitalized for high sodium and changes in your mental status; -Instructions: Please follow up with the Infectious Diseases Clinic for your spine infection; -Stop taking the ceftriaxone for the infection in your spine; -New medication: Amoxicillin (penicillin antibiotic used to treat infections caused by bacteria) 875 mg three times a day. Review of the resident's NP visit note, dated 5/10/23, showed staff sent the resident to the hospital (on 4/29/23) for possible seizure activity, as he/she had constant tremors. In the emergency department (ED), the resident was found to have a sodium (Na) level of 163, received IV fluids and his/her sodium trended down. The shaking/tremors resolved. The resident's altered mental status due to hypernatremia also resolved with IV fluids. The resident was taken off ceftriaxone for discitis and started on Amoxicillin per the ID. He/She returned to the facility on [DATE]. Review of the resident's labs, dated 5/11/23, included the following results: glucose 384 H, sodium 149 H and BUN 50 H. Review of the resident's progress notes, dated 5/12/23 at 9:17 A.M., showed the Registered Dietitian (RD) noted the resident had gone from weighing 180 lbs. on 4/5/23 to 170 lbs. on 5/11/23. Significant weight loss of 5.5% noted, possibly due to increased calorie and protein needs due to infection. Uncontrolled glucose levels. Noted accuchecks 184-442, poor DM control. May be able to switch to Glucerna tube feeding formula, if BUN and potassium (K) have decreased. Plan: 1. Recommend changing tube feeding formula to Glucerna pending, 2. Increase water flushes to 240 cc q four hours, 3. Recommend increase insulin per physician and start sliding scale insulin. Review of the resident's weights and vitals summary, showed on 5/13/23 at 11:33 A.M., the resident's blood sugar level was 594 mg/dL (deciliter). Review of the resident's hospital after visit summary, dated 5/17/23, showed staff sent the resident to the hospital on 5/13/23, because he/she had pulled out his/her feeding tube. This might have happened, because you had a seizure. You were dehydrated. After receiving tube feeding formula and water flushes, the resident's dehydration improved. On exam in the ED, the resident began to have what appeared to be full body seizures which stopped with 2 mg of IV Ativan (treats seizure disorders). An abdominal binder was placed to help prevent re-occurrence of g-tube removal. Free water flushes and tube feeds were titrated for his/her hypernatremia and acute kidney injury (AKI). The resident was alert and oriented times zero. He/She did not meaningfully answer questions or follow commands. Discharge instructions: the resident should stop taking Amlodipine (relaxes the blood vessels and lowers blood pressure) and Torsemide (helps treat fluid retention). It was important to take both the Keppra and Lacosamide (used with other medications to treat primary generalized tonic-colonic seizures-lasts longer than five minutes) seizure medications. Review of the resident's labs, dated 5/18/23, included the following results: glucose 143 H, sodium 142 and BUN 45 H. Review of the resident's progress notes, showed the following: -5/18/23 at 4:13 P.M., the resident was seen by the NP. New order to increase tube feeding to 50 cc/hour. New order for Humalog insulin to be administered at meals per sliding scale; -5/22/23 at 6:37 P.M., NP notes: the NP saw the resident for elevated BP and BG. Assessment: DM2, HTN. Plan: increase Insulin Glargine (Lantus Subcutaneous Solution) to 20 U every day (QD), Losartan 50 mg, 1 tablet QD. Review of the resident's labs, dated 5/25/23, included the following results: glucose 300 mg/dL, sodium 140 mEq/L and BUN 57 mg/dL. Review of the resident's progress notes, showed the following: -5/26/23 6:33 P.M., Resident seen by NP, increase H2O flush 240 cc Q 4 hours. Increase glargine to 25 units (U) daily; -5/26/23 at 8:00 P.M., Levetiracetam Oral Solution (used to treat seizures) 100 mg/ml, give 7.5 ml via g-tube two times a day for seizures. Review of the resident's progress notes, showed the following: -6/2/23 at 9:43 A.M., the resident had an appointment at the Infectious Disease Clinic. The Night Nurse attempted to set up transportation with the ambulance company and was advised that a payment was needed, in order for transportation to be provided. The Charge Nurse left a message for Family Member B to call the facility. At 4:49 P.M., the resident's NP increased the resident's glargine insulin to 28 units QD; -6/6/23 at 3:03 P.M., NP at facility. New order to increase glargine to 33 units QD and start Hydralazine (used to treat HTN to rapidly reduce BP in hypertensive urgency or emergency) 25 mg QD; -6/9/23 at 6:08 A.M., Nurse A was called to the resident's room by Certified Nurse Aide (CNA) B. Nurse A noted that the resident had expectorated a large amount of brown vomitus. The g-tube feeding was stopped. The resident's skin was cool and clammy to the touch. He/She had his/her eyes open but was not responding to verbal stimuli. The resident's respirations were slow. Nurse A noted the resident's vital signs as follows: Pulse (P) 70 (normal range: 60 - 100 beats per minute), Respirations (R) 16 (normal range: 12 - 18 breaths per minute), BP 142/70 (normal range: 90/60 mm/Hg (millimeters of mercury) to 120/80 mm/Hg). Nurse A placed a call to the exchange, left a message for the on call NP and awaited a return call. At 6:32 A.M., the NP had not returned the call. Nurse A called the exchange again and waited for a return call. At 7:10 A.M., the NP had not returned the call. Nurse A called the exchange again. At 8:51 A.M., oncoming Nurse B was alerted to the resident's room in reference to a change of condition in the resident. Upon assessing the resident, Nurse B observed the resident had his/her eyes rolled back with mouth open. The resident's was cold and clammy to the touch, lethargic and unresponsive to stimuli or commands. Nurse B noted the resident's vital signs as BP 146/86, P 89, R 16, T 97.9 and oxygen saturation 93% (sp O2, normal range: 95%-99%). The resident's blood sugar accucheck machine reading was HI. Nurse B administered 10 units of Humalog, left a message for the physician and notified the resident's family. At 9:14 A.M., Nurse B documented having called 911 and the resident leaving the building at 7:30 A.M. Review of the resident's hospital records, dated 6/9/23, showed the following: -Presented to the hospital from the facility with altered mental status, mute and only responding to painful stimuli without tracking or regarding, after experiencing a seizure enroute. The resident arrived hypotensive (abnormally low blood pressure) with tachycardia (heart rate faster than the normal rate of 100 beats per minute) and active seizures, likely from hyperglycemia which required aggressive treatment. In the ED, the resident had a myoclonus seizure (brief shock-like jerking of a group of muscles) with right gaze deviation (abnormal upward drifting of the eyes due to electrical stimulation from the brain); -Hospital staff collected samples from the resident at 9:27 A.M. and obtained the following lab results: glucose 1,093 (critical), BUN 174 H, sodium 142, Cr (creatinine) 2.55 H, urine clarity- turbid A (abnormal; indicates the presence of pus and a UTI); -The resident was admitted to the hospital MICU (medical intensive care unit) for treatment of hyperglycemia, likely hyperosmolar hyperglycemic syndrome (HHS, a condition of extremely high blood glucose, dehydration and decreased alertness/consciousness); -Diagnoses included: acute on chronic (occurs when someone with a chronic condition also develops an acute condition) encephalopathy (global functional alteration of mental status due to decreased blood flow or oxygen to the brain), seizure disorder, AKI on CKD, UTI, L3-L4 (spinal segments in the middle of the lumbar spine which help support the torso and protect the nerves descending from inside the spinal cord) discitis, type II DM and HTN. During an interview on 7/13/23 at 3:05 P.M., Family Member C said on 4/29/23, Family Member C and others arrived to find the resident shaking nonstop, despite the fact that the Charge Nurse said he/she had administered his/her seizure medication. The Charge Nurse did not want to call the physician or send the resident out. Family Member C had to request three times that staff send the resident to the hospital. The hospital physician said that the resident's sodium level was so elevated that there was no way that staff had been administering the water flushes as prescribed. The family had quality of care concerns throughout the resident's stay and attempted without success to discuss them with management, which was never available and did not respond to Family Member C's requests for contact. Staff never informed the family that they were responsible for arranging the resident's transportation to and from medical appointments. There was never any mention of a care plan meeting. During an interview on 7/12/23 at 2:19 P.M., Family Member B said staff never contacted him/her regarding the resident's medical appointments. Family Member B only found out about missed infectious disease clinic appointments, when the clinic sent emails to Family Member B. Staff never said anything about transportation needing to be paid out of pocket. Family Member B was not able to reach anyone at the facility by phone and when he/she visited the facility on weekends, there was only agency staff on duty. Family Member B had to just show up early on a weekday, in order to catch management, which was unresponsive to his/her concerns. The resident was hospitalized three times, due to elevated BS and sodium levels. When Family Member B visited, the tube feeding machine was not always hooked up or working properly. The resident did not consistently receive his/her water flushes as ordered. The staff was always apologetic, explaining they were waiting for the tube feeding machine to be checked or a part for the machine to be delivered. During an interview on 7/13/23 at 3:05 P.M., Family Member A said he/she visited and bathed the resident on Saturdays and Sundays. Towards the end of the resident's stay at the facility, there were times when staff informed Family Member A the resident's tube feeding machine was unplugged because it was not working. During an interview on 7/13/23 at 7:58 A.M., Nurse A said the resident was nonverbal. The resident's family came in and cleaned the resident, who was incontinent and eliminated large volumes of urine. On 6/9/23, Nurse A saw the resident, before the CNA reported a change in condition. At that point, the shift was ending. Nurse A worked from 7:00 P.M. to 7:00 A.M. There was vomit on the floor in front of the resident. It did not look like tube feeding formula or blood. It was the resident's stomach contents. The resident was not struggling to breathe. His/Her respirations were just a little slow. Nurse A checked the resident's vital signs, but did not think to check the resident's blood sugar. The oncoming nurse later got the resident's blood sugar, when the oncoming nurse arrived. Nurse A left the CNA with the resident and went to call the physician's exchange, since he/she did not think it was a 911 situation. Nurse A thought the resident was stable enough to wait for the NP to call back with an order. During an interview on 7/13/23 at 8:20 A.M., CNA B said on 6/9/23, he/she arrived at the facility right at change of shift, sometime between 6:15 A.M. and 6:30 A.M. The outgoing CNA told CNA B to keep an eye on the resident, because the resident had been throwing up. CNA B waited to go in and see the resident, until after the other CNA cleaned the resident up. That took approximately 15-20 minutes, then CNA B went in to see the resident who appeared to still be asleep. The resident was still lying in bed without moving. CNA B greeted the resident, who normally yelled out for his/her family members. The resident was silent and did not respond to CNA B's greeting. At around 7:00 A.M. or 7:15 A.M., the resident began throwing up again. During an interview on 7/12/23 at 12:34 P.M., the DON said on 6/9/23, in a medical emergency, depending on what it is, staff should attempt to contact the resident's physician, let the DON know and call 911. Staff does not need to wait on the physician or NP to call them back. When staff noted the resident was unresponsive, the nurse should have sent the resident out. Noting unresponsiveness at 6:08 A.M. and sending him/her out at 7:30 A.M. took too long. If a resident was septic with very high temperatures, then that could trigger a seizure. High blood sugars could result in a coma. The resident's blood sugars were all over the place throughout the resident's stay at the facility. Staff could never get a stable blood sugar reading on the resident; one minute the resident had a good number then the next, it was elevated. Nursing staff interventions were to monitor the resident via blood sugar checks and treat elevated blood sugar with insulin. A resident's MAR and physician's orders should both reflect discontinuation of any orders. The DON was aware of reported issues with the resident's tube feeding machine. Staff would say the machine was malfunctioning, but some staff members just did not understand how to work the machine which would be checked and found to either be unplugged or have a low battery. The resident did not miss any water flushes or tube feedings, because staff called and got an order for bolus feeding whenever they thought the tube feeding machine was malfunctioning. The resident was getting hydrated via water flushes. He/She had ongoing issues with dehydration, because he/she had kidney issues. The resident's labs remained pretty much the same as when he/she was first admitted from the hospital. He/She had the same jerking and seizures while in the hospital and did not improve in the hospital. During an interview on 6/21/23 at 10:50 A.M., the Infectious Disease Clinic NP E said the labs requested by the clinic were necessary to check inflammatory markers, in order to determine how the discitis was progressing and adjust the medications if the resident's osteomyelitis infection was not improving. The last labs were received on 5/2/23, from the hospital. The facility never faxed or called in any lab results. Unmanaged blood sugar and dehydration impaired the body's ability to heal. Under stress, the resident's infection could drive his/her blood sugar level up. The resident's blood sugar would worsen the infection, if it stayed high. NP E expected to be kept apprised of ongoing issues of dehydration and elevated blood sugar. Staff never notified the clinic of those issues. The resident had not been to the infectious diseases clinic since 4/21/23. On 5/8/23, the clinic attempted to contact the facility, but could not reach anyone. On 6/2/23, the resident was a no show at the clinic and his/her appointment was never rescheduled. During an interview on 6/15/23 at 2:45 P.M., NP F said the resident was very dehydrated and malnourished on admission and NP F had been attempting to increase the resident's Lantus dosage. NP F was increasing the tube feedings and free water flushes based on lab results. The resident's tube feeding formula was making the resident's blood sugar significantly elevated. NP F kept the resident's blood sugar in the 100-200 range by increasing the dosage of long acting insulin. A blood sugar level of 500 was extremely abnormal for the resident. On 6/9/23, NP F had entered the facility as the resident was going out on a stretcher. NP F was not sure what happened, since the resident's blood sugar had been 201 during the previous night. The CBC and CMP labs, requested by the infectious diseases clinic, which were not obtained for the weeks of 6/4/23-6/20/23, might have revealed an impending issue causing something to be out of whack which might have caused the resident's blood sugar to become markedly elevated. The resident's infection could have played a role in the resident's condition on 6/9/23. However, there was very little communication between the facility and the infectious diseases clinic. Without a catheter, it would have been difficult to monitor the resident's output. However, if staff had documented any changes in urinary output and bowel movements then that information would have helped NP F more effectively adjust tube feeding and water flushes to meet the resident's needs. During an interview on 7/14/23 at 2:18 P.M., the Administrator said an hour and a half was not a long time in a medical emergency, when staff was working together to assess the resident. The Charge Nurse was expected to use nursing judgement and communicate with a resident's physician. Making transportation arrangements for medical appointments was an interdisciplinary team process between the clinical and social services team. The nurse was expected to let the Social Worker know when arrangements needed to be made. 2. Review of Resident #5's undated face sheet, showed and admitted [DATE] and a family member serving as DPOA (durable power of attorney). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Fluctuating inattention; -Diagnoses including Type II diabetes mellitus with hyperglycemia, right upper arm muscle wasting and atrophy (thinning of muscle mass); -Weight 109 lbs.; -Loss of 5% or more in the last month or loss of 10% or more in the last six months; -Required limited assistance of one with eating. Review of the resident's undated care plan, showed the following: -The resident has a potential nutritional problem AEB (as evidenced by) low body mass index (BMI, weight to height ratio) 17.3%; -3/29/23, 5% weight loss in approximately two months; -The resident needs a calm, quiet setting at meal times with adequate eating time; -Provide the resident with fluids with meal trays. Maintain drinking water at bedside. Encourage fluid intake. Provide and assist as needed to drink fluids; -The resident requires extensive assist times one to two staff with toileting needs; -Related to incontinence, the resident is at risk for UTI; -The resident has DM. Monitor/document/report to physician PRN signs/symptoms of hypoglycemia (lower than healthy blood sugar level): sweating, tremor, tachycardia (increased heart rate), pallor (unusual or extreme paleness), nervousness, confusion, slurred speech, lack of coordination, staggering gait. Review of the resident's physician's orders, showed the following: -3/29/23, Resident up in wheelchair in dining room for all meals three times a day; -3/30/23, Remeron (appetite stimulant) 15 mg, give 0.5 tablet at bedtime related to unspecified severe protein-calorie malnutrition. Review of the resident's progress notes, showed on 4/11/23 at 11:53 A.M., NP in the building to consult with the resident. The resident was clammy and had low BP. His/her blood sugar (BS) was 145. Vital signs 95/55, 18, 97.5, 70, 95%. New order given to send the resident to the emergency room for further evaluation. Review of the resident's physician patient visit note, dated 4/11/23, showed the resident was barely responsive, when the NP visited. The resident's eyes attempted to open, when the NP touched and called out the resident's name. The resident had an undigested pill on the right shoulder, his/her mouth was agape, he/she was slightly pale and his/her tongue was dry. The resident's breakfast tray was untouched. The NP pulled back the covers and discovered the resident was drenched in sweat. His/her SpO2 was 90% and his/her pulse was 80. The facility aide said when he/she gave the resident his/her breakfast tray, the resident was at baseline. Will send the resident out for evaluation, in order to rule out sepsis (a severe blood infection, in which the bloodstream is overwhelmed by bacteria, which can lead to organ failure and death). Review of the hospital transfer orders, dated 4/11/23, showed the resident presented at the hospital with lethargy (state of deep and prolonged unconsciousness resembling slumber from which one can be aroused but into which one immediately relapses) due to hypoglycemia. At the ED, he/she was hypertensive (having higher than normal blood pressure) at 151/79. His/her glucose was 39 from the nursing home. The resident was diagnosed with toxic metabolic encephalopathy due to hypoglycemia (damage or malfunction of the brain due to severe and prolonged hypoglycemia). Review of the resident's progress notes, showed the following: -4/19/23 at 3:25 P.M., NP note: the resident was being seen for follow up on weakness. The NP observed the resident with an aide assisting him/her to eat. The resident ate everything and said he/she even wanted more. Plan: discussed with staff assisting the resident with every meal to promote intake and ordering double portions to help the resident regain some weight and strength; -4/20/23 at 10:17 P.M., daily skilled charting: eating: supervision/cueing. Always incontinent of urine. Color: yellowish to amber. Clarity: clear. Odor: ammonia (occurs when chemicals in urine are concentrated due to a lack of water); -4/22/23 at 1:06 P.M., daily skilled charting: eating: independent with set up assist. Urine color: yellowish to amber. Clarity: clear. Odor: Musty. Review of the resident's physician's orders, showed a diet orde [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure staff provided care to one of three sampled residents in a manner which maintained his/her dignity by refraining from engaging in the demeaning act of pulling the resident's hand off of a meal tray and taking it away, rather than abiding by the resident's request to keep his/her breakfast tray until he/she finished drinking his/her coffee (Resident #1). The census was 78. Review of the facility policy titled, Quality of Life Dignity Policy, revised 3/2017, showed that each resident was to be cared for in a manner which promoted and enhanced quality of life, dignity, respect and individuality. Being treated with dignity meant that the resident was to be assisted in maintaining and enhancing his/her self-esteem and self-worth. Staff shall speak respectfully to residents, including addressing the resident by his/her name of choice. Demeaning practices and standards of care which compromised dignity were prohibited. Staff shall treat cognitively impaired residents with dignity and sensitivity, for example: addressing the underlying motives or root causes for behavior and not challenging or contradicting the resident's beliefs or statements. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/31/23, showed the following: -Severe cognitive impairment; -Signs and symptoms of delirium: fluctuating inattention; -Required supervision of eating; -Required limited assistance of one with bed mobility, transfers, ambulation in room, dressing, toilet use, personal hygiene and bathing; -Diagnoses included Alzheimer's disease, muscle weakness (generalized), adult failure to thrive, generalized abdominal pain, other fracture and unsteadiness on feet. Review of the resident's progress note, dated 4/19/23 at 10:06 A.M., showed the resident approached the nurse saying he/she did not eat any breakfast and asked what was for breakfast which was eggs, biscuit with gravy and oatmeal but he/she did not want it. The dietary attendant came for room trays. The resident then asked for a fried egg. The dietary attendant informed him/her that it would be an hour before the resident could get one, as the dietary aide was picking up all the trays and doing lunch. So the resident then got an attitude and rolled back to his/her room. Review of the resident's care plan, updated 4/24/23, showed the following: -The resident has impaired cognitive function/possible dementia and impaired thought process as evidenced by impaired decision making; -Provide him/her with a homelike environment; -The resident has a potential nutritional problem related to being a picky eater per his/her daughter. Ensure the resident and family has the always available menu. Provide the resident and daughter with monthly diet menus; -He/She has a mood problem related to admission. The resident needs encouragement/assistance/support to maintain as much independence and control as possible; -Provide the resident with necessary cues, stop and return if agitated; -The resident has a history of verbally aggressive behavior. Review of the resident's progress note, dated 4/27/23 at 9:31 A.M., showed the Director of Nursing (DON) was summoned to the secured unit, due to a commotion going on with the resident. The resident was standing at the exit door yelling, accusing staff of hurting and mistreating him/her. The resident refused to move away from the door. The alarm was going off. The resident requested police presence and 911 and emergency medical services (EMS) was called. The resident agreed to go to his/her room and only wanted to speak to the Administrator. Police and EMS arrived on the scene and advised the resident that he/she would be taken to the hospital. The resident refused. The DON left a voicemail message for the resident's daughter, called and spoke to the resident's son. Review of the facility's undated self-report, submitted to Department of Health and Senior Services (DHSS) on 4/27/23, showed the resident told the Administrator that he/she asked the nurse for coffee, but the nurse was on the phone so another staff person got him/her a cup of coffee. The resident refused to speak with the Administrator further until law enforcement arrived. At approximately 8:45 A.M., a police officer arrived. Another officer arrived ten minutes later. EMS arrived at approximately 9:00 A.M. While speaking with his/her son on the phone, the resident said that he/she hurt his/her hand, shoulder and hip. EMS, the DON, Administrator and son all spoke with the resident about going to the hospital to get checked. The resident refused and hung up on his/her son. The Administrator moved Certified Nurse Aide (CNA) A off of the hall to another part of the building and requested video surveillance from the hall. The video showed that at 8:28 A.M., CNA A took the resident's tray off of the table, the resident grabbed the tray and attempted to yank it back. At 8:33 A.M., the resident left the dining hall and went to the doors, opened them and CNA A came to her to attempt to diffuse. Another staff person was shown approaching and then going out the door to get assistance. Review of CNA A's written statement, dated 4/27/23, showed the incident started when he/she was cleaning up after breakfast. CNA A went to collect the resident's food tray which was trashed; the resident had placed all of his/her trash on the plate and was only drinking his/her coffee. The resident proceeded to ram his/her coffee towards CNA A's hands and arms. CNA A continued to work and saw the resident move towards the door. He/She was already at the door, when CNA A calmly approached and said that CNA A needed the resident to come off of the door, because the alarm was sounding and it needed to be reset. The resident started to yell and scream. CNA A told him/her that CNA A could get the nurse for him/her but first, he/she needed to step away from the door. CNA A sat his/her hand on top of the resident's hand, just to see if that would prompt him/her to move it. The resident started swinging and hitting CNA A. The housekeeper tried to calm the resident down and asked if CNA A wanted the housekeeper to get the nurse. The housekeeper got the nurse. CNA A pulled out a phone to call the nurse's station. The resident thought CNA A was calling the police. CNA A told the resident that CNA A was trying to call the nurse, not the police. After all of that, CNA A walked off. By that time, the DON, Assistant Director of Nursing (ADON) and Administrator were there to handle it. CNA A proceeded to care for other residents. Review of the undated written statement of Housekeeper B showed, he/she was cleaning rooms on the secured unit, heard the resident yelling at CNA A and walked out of a resident's room to see what was going on. CNA A was collecting breakfast trays. The resident propelled his/her wheelchair to the door and made the alarm go off. CNA A was trying to calm the resident down. The resident started hitting CNA A and yelling. Housekeeper B went and got the ADON. Review of the written statement of Certified Medication Technician (CMT) C, dated 4/27/23, showed he/she witnessed staff knocking at the door, because the resident was hitting a staff member. CMT C opened the door and asked the resident to have a seat in his/her wheelchair. CMT C did not see any staff mistreating the resident. Observation of the security camera footage, dated 4/27/23, showed CNA A approach the resident who was sitting in the secured unit dining room, drinking coffee. After a brief exchange, which is not audible, CNA A reached for the tray with his/her right arm (his/her left arm and the resident's right arm were obscured by CNA A's body, due to the camera angle). The resident put his/her coffee cup on the meal tray in front of him/her and grabbed the tray with his/her left hand. CNA A held the back of the tray (on the side opposite from the resident), attempted unsuccessfully take the tray away because the resident also held onto the tray. CNA A then pulled the resident's hand off of the tray. CNA A still held the tray as it abruptly jerked forward, away from the resident. CNA A lifted the tray from the table. The resident's cup of coffee spilled onto the table. The resident was visibly upset and propelled his/her wheelchair to the doors leading off of the unit. The angle of the camera over the doors partially obscured the right side of CNA A's body and the left side of the resident's body. The resident stood and appeared to be knocking on the doors leading off of the unit. CNA A appeared to be attempting to redirect the resident, who was agitated and gesturing emphatically. At one point, CNA A used his/her left hand to swat away one of the resident's hands. Housekeeper B approached, briefly interacted with them and then departed. During an interview on 4/28/23 at 1:39 P.M., Housekeeper B said on the morning of 4/27/23, the resident was a little agitated about not getting what he/she wanted for breakfast. As Housekeeper B cleaned resident rooms, he/she heard CNA A asking the resident if he/she was going to eat his/her breakfast. The resident said, no, I don't want none of this. CNA A said, Ok, you not hurting anybody but yourself. The resident said, I'm not hurting anybody. Housekeeper B did not witness the exchange between them over the breakfast tray. Housekeeper B heard the resident yelling and stepped out into the hallway in time to see the resident propel his/her wheelchair up to the doors leading off of the unit, stand up and start knocking on the doors. CNA A told the resident that he/she was going to fall, but did not grab the resident's arm. CNA A asked the resident to come back here and sit down. The resident started swinging on CNA A. Housekeeper B did not witness CNA A point in any direction or touch the resident, other than placing a hand at the resident's back in an attempt to keep him/her from falling. Housekeeper B asked CNA A, do you want me to get help? CNA A said yes. The resident was standing in the way and refused to move aside, so Housekeeper B had to squeeze through the small opening created after the resident pushed the bar on the door and it opened slightly. During an interview on 4/28/23 at 1:15 P.M., CMT C said he/she was on unit 100 passing medications (the hall opposite from the secured unit entrance), when the secured unit door alarm began sounding on the morning of 4/27/23. CNA A was banging on the door, saying the resident was hitting him/her. CNA A was trying to get someone's attention outside of the unit. The resident said CNA A was rude to him/her and said something about CNA A smashing his/her finger. At that point, CNA A was not touching the resident, who was agitated and refusing to sit back down in his/her wheelchair. By that time, the DON and ADON had arrived. The resident held the push bar on the secured unit door. Once the door to the unit opened, the resident stopped hitting CNA A. During an interview on 4/28/23 at 1:00 P.M., Nurse D said on the morning of 4/27/23, the resident was standing up by the double doors leading off of the unit, holding the bar on the right door leading off of the secured unit. His/Her wheelchair was next to the left door. The resident was swinging at staff and cursing at them, saying he/she needed to talk to the police because, this place isn't right. Ya'll know you not supposed to be pulling on a resident. I want to talk to my daughter. Nurse D called 911. During an interview on 4/28/23 at 9:00 A.M., the resident said it made him/her very ill when staff tried to take his/her tray, while he/she was still drinking his/her coffee and juice. The resident did not consider his/her meal completed, until he/she had consumed his/her beverages. Staff never allowed him/her to finish meals. Right after breakfast on 4/27/23, CNA A tried to take the resident's tray, while the resident was still drinking his/her coffee. The resident said no. CNA A said, well, I got to take the tray. The resident replied, you can have it when I'm through and picked up his/her coffee. He/She quickly put it back down, when CNA A reached for the tray. In a nasty tone CNA A said, I want this tray. They're taking up the trays now. The resident held onto the tray with his/her good right arm because his/her left arm was weak due to a stroke. CNA A pushed down on the tray, smashing the resident's thumb, which was on the underside of the tray, then pried the resident's thumb back. The resident said, stop hurting my hand. CNA A said, I'm not hurting your hand and yanked the tray out from under the resident. The resident's coffee went everywhere and some splashed on one of the other residents at the table. Resident #1 demanded to speak with a policeman or someone in authority. CNA A said, I am the authority. So, the resident wheeled him/herself over to the doors leading off of the unit and began knocking on the doors, until the alarm went off. CNA A pointed his/her finger in the resident's face and said, don't go out that door. You can't go out that door. The resident said, don't point your finger in my face. CNA A said, I don't have my finger in your face and then snatched the resident's hand off of the door. The resident said, don't do that. My arm is sore. CNA A pulled the resident's arm harder. The resident was afraid, because CNA A had the upper hand, since the resident was in a wheelchair and weak on one side of his/her body. Other staff came running, in response to the alarm. They got the resident's son on the phone. He told the resident just to go along with staff, because he was ashamed. That angered the resident, who said no, I'm not. We'll settle it today. The Administrator told the resident to go to the emergency room . The resident declined, preferring to be assessed at the facility. CNA A was regularly rude to the resident, whose prior complaints regarding CNA A's rudeness had not been addressed. On 4/27/23, when CNA A spoke to the resident in a nasty tone, yanked his/her tray away and put his/her hands on the resident, it caused the resident's anger to boil over. During an interview on 5/2/23 at 3:10 P.M., CNA A said he/she had worked on the secured unit for almost three years with only one day a week and every other weekend off. So, he/she was very familiar with the resident and had never been rude to or had any problems with him/her. The resident performed activities of daily living independently, so the only time CNA A interacted with the resident was at mealtime. Although the resident did not like the breakfast served on 4/27/23, the problem between them did not stem from the resident being upset about it. CNA A was working on the unit alone that day and was trying to keep up with his/her time. So, he/she had asked the resident multiple times if the resident was done. The resident would not respond. He/She wanted more coffee. The maintenance guy went and got the resident more coffee and he/she was holding onto it. CNA A explained he/she didn't need the coffee, just the tray. The resident rammed the cup down on the tray. CNA A believed the resident was attempting to throw coffee on his/her arms. CNA A retrieved the tray and thanked the resident. He/She did not recall touching the resident or yanking the tray. CNA A continued collecting meal trays, as the resident propelled his/her wheelchair out of the dining room. By the time CNA A realized the resident was at the doors leading off of the unit, the resident had set off the door alarm by pressing on the bar on one of the doors. CNA A could not allow the resident to walk out, so he/she attempted to redirect the resident. The resident told CNA A to get out of his/her face. CNA A said, I'm not in your face. I can get the nurse. Please let go of the door. When the resident refused to let go of the door, CNA A sat his/her hand on top of the resident's hand, hoping that it would get him/her to release the door. CNA A never pulled on the resident's hand or arm. The resident became more agitated saying, don't put your hands on me and started hitting CNA A. CNA A had worked with residents with dementia and Alzheimer's for several years. Normally, he/she would have diffused the confrontation in the dining room by walking away and coming back later. However on 4/27/23, CNA A was the only nursing staff working on the secured unit and was concerned with staying on schedule. He/She did not treat the resident any differently than he/she treated the other residents. An additional staff person on the unit would have been helpful. That way, the other staff person could have stepped in and dealt with the resident so that CNA A could walk away and finish his/her task. During interviews on 4/28/23 at 3:20 P.M. and 4:00 P.M., the DON said when a resident was agitated, the staff person should walk away in order to give the resident time to calm down. On 4/27/23, CNA A should have left the resident's tray. Every meal with the resident was an issue, because the resident wanted something other than what was served. CNA A resigned his/her position. The DON was unaware of any prior issues between CNA A and the resident. During an interview on 4/28/23 at 3:30 P.M., the MDS Coordinator said the facility had daily clinic meetings and weekly risk meetings during which staff discussed resident behavioral issues for which she developed care plan interventions when warranted. Any staff member could add an intervention to the care plan, but the MDS Coordinator preferred to update the care plans. Consequently, staff usually informed her of behaviors/issues which needed to be addressed on resident care plans. No one had informed the MDS Coordinator of the resident's behaviors during meals stemming from not receiving what he/she wanted to eat and not being allowed to completely finish meals before staff took away his/her meal tray. The MDS Coordinator planned to add care plan interventions directing staff to give the resident time to eat and ask the resident for permission to remove his/her tray from the table after meal service. She could also add an intervention for staff to explain what they were about to do. There was nothing on the resident's care plan to address the resident's tendency to become agitated, but an intervention could be added to address that issue. During interviews on 4/28/23 at 10:15 A.M. and 3:55 P.M., the Administrator said CNA A could have handled the incident with the resident on 4/27/23 differently. CNA A should have walked away when the resident refused to allow CNA A to take his/her tray. She was unaware of any prior issues between CNA A and the resident. MO00217687

Based on observation, interview and record review, the facility failed to provide residents with a clean, comfortable and homelike environment by not ensuring two resident rooms, bathroom and the dining room were clean and in good repair (Residents #67 and #27). The census was 82 1. Observation on 1/22/23 at 12:04 P.M., of the main dining room, showed approximately 3 feet of plastic baseboard, loosened from the wall under the dining room windows. Parts of the baseboard lay on the floor. The wall behind the baseboard appeared torn, dirty and in disrepair. 2. Review of Resident #67's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/27/22, showed: -Responds adequately to simple, direct communication; -Requires one person physical assistance in toilet use, dressing and personal hygiene; -Always incontinent of bowel and bladder; -Diagnoses included high blood pressure and Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Observation of the resident's room on 1/23/23 at 5:32 P.M., showed five square tiles were broken, with some pieces scattered over the resident's floor at bedside. The baseboards under the sink were missing, exposing dirty gaps between the floor and wall. There was a loosened piece of the corner baseboard from under the sink to behind the dresser drawer. The piece of baseboard material hung down, exposing the dirty wall. During an interview on 1/23/23 at 5:35 P.M., the resident's roommate said there has been water leakage on his/her roommate's side of the floor for a while and the facility could not determine the source of the leakage. Observation and interview on 1/24/23 at 1:14 P.M., showed the resident in his/her room, in the wheelchair at bedside. The broken floor tiles were replaced and water seeped out in between gaps where broken tiles were used to be. The resident said the facility just fixed the floor but water is still coming out. He/She said the problem had been going on for a long time. He/She had to step on and run over the wet floor when he/she propels him/herself around the area. The baseboards under the sink remained missing. A box fan was placed by the sink, facing towards the wet floor. The fan was turned off. Observation and interview on 1/26/23 at 8:52 A.M., showed the water leakage on the floor had worsened, with more water coming out from the tile gaps. Housekeeper S said he/she was responsible for cleaning all residents' rooms and hallways. He/She had just mopped the floor in the resident's room. He/She said there were issues with the tiles and was recently repaired. Observation was made with the housekeeper and he/she agreed water was coming out from under the floor. He/She stepped on the tiles and water continued to come out. He/She said when there are environment or maintenance issues as observed, he/she verbally reports to his/her supervisor or maintenance staff. During an interview on 1/27/22 at 8:35 A.M., the Maintenance Supervisor said the maintenance log books were placed at each nurses' station for the staff to list any maintenance-related issues. He/She then checks the book twice daily, every morning and after lunch time. He/She said the staff also reports maintenance issues verbally. He/She did not recall when the water leakage issue started, but had contacted a contractor about a week ago. They could not determine the source of the water leakage. He/She said the contractor will do an x-ray on the area to determine the problem and implement a permanent solution. The baseboards under the sink were also caused by water damage. They will be replaced once the water leakage gets repaired. The broken baseboards in the dining room were also caused by water leakage from the windows and will be repaired appropriately. During an interview on 1/27/23 at 8:49 A.M., the Administrator said he/she was made aware of the water leakage issue in the resident's room, one week ago, through verbal report of one of the staff. He/She said the maintenance department had addressed the issue. He/She was not aware of the broken and missing baseboards in the resident's room and in the main dining room. He expected all staff to report any maintenance issues immediately. He/She also expected the maintenance staff to address any issues appropriately. 3. Review of Resident #27's care plan, in use at the time of the survey, showed: -Problem: Resident had a stroke; -Outcome: Resident will communicate care needs daily; -Interventions: Monitor/document bladder and bowel function. If incontinent monitor/document for appropriate bowel and bladder training program and implement. Review of November 2022 Resident Council Meeting showed the broken/missing toilet paper holder was discussed as a concern for the resident. Observation on 01/22/23 at 12:07 P.M., showed ketchup splattered across the lower part of the resident's bathroom wall, a ketchup packet on the floor, the toilet not flushed and a broken toilet paper holder. Observation on 01/24/23 at 8:17 A.M., showed the resident's bathroom had ketchup splattered on the floor and wall. The toilet paper holder was broken. During the same observation, the Resident said he/she brought up the broken toilet paper holder in the November 2022 Resident Council Meeting and (he/she) has brought up the broken toilet paper holder more than one time. Observation on 01/25/23 at 2:19 P.M., showed a dried up dark red substance on the door frame in the bathroom, sticky floor, and the toilet unflushed. During an interview on 01/27/23 at 1:46 P.M., the Administrator said he did not know the toilet paper holder was broken and said he would take a look right now. 46970

Based on observation, interview and record review, the facility failed to ensure residents receive the necessary services to maintain good personal hygiene for two residents observed during perineal care (cleansing of the area between the legs to include the buttocks and genitals) who were left soiled for an extended period of time and then not completely cleaned (Residents #83 and #46). The facility also failed to ensure weekly showers were provided and hair cleansed for two residents (Resident #5 and Resident #67). The sample was 18. The census was 82. Review of the incontinent care policy, dated 7/21/22, showed: -Policy: The facility will provide incontinent care as directed in the plan of care; -Procedure: Explain procedure to the resident. Perform hand hygiene and apply gloves. Removed soiled brief. Cleanse the peri-area. -For females: separate the skin and cleanse one side and then the other. Cleanse down the center in a front to back manner. Cleanse the thighs, buttocks and in between the buttocks; -For males: Gently pull back on the foreskin and cleanse the penis tip using a circular motion. Cleanse down the shaft, the scrotum, thighs and buttocks; -Use a clean surface area for the cloth for each wipe. 1. Review of Resident #83's medical record, showed: -admitted : 1/18/23; -Diagnoses included multiple sclerosis (degenerative nerve disease), diabetes, drug abuse, weakness, stroke and heart failure; -Bowel and bladder incontinence. Review of the baseline care plan, dated 1/19/23, showed: -Check the resident for bowel and bladder incontinence episodes and assist with perineal care every two hours. During observation and interview on 1/24/23 at 6:10 A.M., Certified Nurse Aide (CNA) G and H entered the resident's room and greeted the resident. The resident lay in bed and wore a urine saturated brief. The bed pad and fitted sheet were urine saturated. CNA G removed the urine saturated brief and the bed linens. He/She used a soapy washcloth and cleaned the groin and thighs in a back and forth motion and disposed of the washcloth. He/She did not change sections of the washcloth during care. CNA G used a wet washcloth and wiped off the soap. CNAs G and H assisted in turning the resident and exposed the buttocks. CNA G obtained a soapy washcloth and cleaned in between the resident's buttocks in a back and forth motion. CNA G obtained a washcloth and rinsed the area between his/her buttocks. CNAs G and H applied a clean brief. CNA G did not cleanse the peri-area in an appropriate manner or dry the skin. During an interview, CNA G and H said perineal care should be completed in a front to back manner. All areas of the skin should be cleansed, including the hips and thighs. 2. Review of Resident #46's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/6/23, showed: -Severe cognitive impairment; -Total assistance needed for hygiene, bathing and toileting; -Always incontinent of bowel and bladder; -Diagnoses included: dementia, kidney disease and heart disease. Review of the resident's care plan, showed: -Focus: The resident is dependent on staff to provide toileting and hygiene; -Goal: The resident will remain at his/her current level of functioning; -Interventions: Staff provide assistance with hygiene and toileting. Observation and interview on 1/24/23 at 5:40 A.M., showed the resident asleep in bed. CNA F approached the resident and explained care. The resident wore a urine saturated brief and lay on a urine saturated bed sheet and pad. CNA F applied gloves and removed the brief. He/She obtained a wet washcloth and cleaned the resident's groin in a front to back motion. CNA F removed the urine saturated linens and positioned the resident to lay on the wet mattress. CNA F applied a clean brief under the resident and secured it into place. CNA F dressed the resident and transferred him/her into the wheelchair. CNA F said the resident wore a urine saturated brief and lay in a wet bed prior to care. CNA F had forgotten to provide cleansing with soap or cleanser. All areas of the groin should be cleaned completely, rinsed and dried before completing care. During an interview on 1/26/23 at 12:00 P.M., the Assistant Director of Nursing (ADON) said women should be cleansed in a front to back manner, using a new section of the washcloth or a wet wipe. Men should be cleaned from the penis tip down the shaft. If a resident lay in a urine saturated brief or bed, the entire thighs and buttock should be cleaned. 3. Review of Resident #5's annual MDS, dated [DATE], showed: -Cognitively intact; -Required extensive staff assistance with toileting and hygiene; -Total staff assistance needed with bathing; -Diagnoses included heart and kidney failure, diabetes and schizophrenia (a serious mental disorder in which people interpret reality abnormally). Review of the care plan, updated 1/2023, showed: -Focus: The resident is incontinent of bladder and at risk for skin breakdown; -Goal: The skin will be kept clean, dry and odor free; -Interventions: Monitor the resident for incontinent episodes and provide care. During an interview on 1/22/23 at 9:23 A.M., the resident said he/she does not receive showers on a routine basis. At times, he/she had not received a shower in over a week. Staff occasionally would use a wet wipe and wipe him/her off in bed. He/She preferred a shower twice a week. A shower would feel really good at least weekly. Review of the January 2023 care tasks, showed out of 27 days, the resident received a documented shower on 1/2/23, 1/16/23 and 1/23/23. During an interview on 1/26/23 at 12:00 P.M., the ADON said all residents should receive a minimum weekly shower and should be offered showers twice weekly. CNAs document showers in the electronic medical record under the task section for each resident. Wiping a resident off does not substitute for a shower. 4. Review of Resident #67's quarterly MDS, dated [DATE], showed: -Responds adequately to simple, direct communication; -Requires one person physical assistance in toilet use, dressing and personal hygiene; -Always incontinent of bowel and bladder; -Diagnoses included high blood pressure, Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Review of resident's medical record, showed: -readmitted on [DATE]; -Diagnoses included aphasia, lack of coordination, and need for assistance with personal care. Review of the resident's care plan, in use during the time of the survey, showed: -Focus: ADL (activities of daily living) self-care performance deficit; -Goal: ADL Function: Resident requires assistance with ADL care and mobility; -Interventions: Bathing/showering: 1 assist - twice weekly and as necessary. Check nail length and trim and clean on bath days and as necessary. Report any changes to the nurse. 1-assist with personal hygiene. Observation and interview on 1/22/23 at 9:51 A.M., showed the resident up in wheelchair by the nurses' station, hair combed in a pony tail, using a piece from a glove as a hair elastic tie. The resident's hair was very greasy and flaky. Some flakes were observed on his/her clothes' sleeves and back. The resident said he/she had a shower about a week ago. Observation on 1/24/23 at 12:45 P.M., showed the resident's hair remained very greasy and flaky. His/Her hair was again tied with a piece of a glove. During an observation and interview on 1/26/23 at 6:33 A.M., the resident sat in his/her wheelchair in his/her room. The resident's hair appeared greasy and in a pony tail, held by a plastic piece of rubber. The resident said he/she received a shower on 1/25/23, but staff did not wash his/her hair. He/She did not know why his/her hair was not washed. He/She would like his/her hair washed and combed. His/Her head is itchy and hair felt knotted. During an interview on 1/27/23 at 9:27 A.M., the ADON said the residents are to be provided with showers two times a week and as needed. Residents' hair should be washed as necessary. The ADON expected staff to provide the residents with proper hair tools or accessories and not to use a piece of a glove as hair ties. At 9:42 A.M., the ADON observed the resident's greasy and flaky hair, and had a piece of a glove tied to his/her pony tail. The ADON said he/she will correct the issues appropriately. MO00179168 MO00176265 MO00189077 MO00192427 45083

Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 82. Review of the facility's Facility Assessment Tool, updated 1/5/23, showed: -Average daily census: 80; -Staffing type/plan: Administrator, RN, licensed practical nurses (LPNs), and certified nurse aides (CNAs); -Position: Licensed nurses providing direct care (RN or LPN): 7; -CNAs: 20; -Other nursing personnel: 3; -How did the facility assess the resident population: Point Click Care (PCC, electronic medical record), Minimum Data Set (MDS), and Quality Assurance and Performance Improvement Plan (QAPI); -Does this reflect the population observed: yes; -How did the facility determine the staffing level: Census vs acuity. Review of the staffing sheets, provided by the Assistant Director of Nursing (ADON) for staffing 12/1/22 through 12/27/22, showed: -Wednesday, 12/1/22: No RN worked any shift; -Thursday, 12/2/22: No RN worked any shift; -Friday, 12/3/22: No RN worked any shift; -Saturday, 12/5/22: No RN worked any shift; -Sunday, 12/12/22: No RN worked any shift; -Monday, 12/13/22: No RN worked any shift; -Thursday, 12/16/22: No RN worked any shift; -Saturday, 12/25/22: No RN worked any shift; -Sunday, 12/26/22: No RN worked any shift; -Monday, 12/27/22: No RN worked any shift. During an interview on 1/27/23 at 9:14 A.M., the Administrator said he had been at the facility since the end of December 2022, but there was RN coverage. The corporate RN came to the facility and they also have a new DON as well. He expected the facility to have the required number of nurse hours. It should be accurate and reported. He expected the staffing sheets to be accurate to reflect RN coverage. 46970

Based on observation, interview, and record review, the facility failed to complete the controlled substance inventory sheets appropriately to maintain accurate accountability of the inventory of all controlled substances administered at all times. The facility had incomplete controlled substance sheets for three of six narcotic count sheets sampled. The sample size was 18. The census was 82. Review of the Controlled Substance Storage policy, dated 2/2020, showed: -Policy: Controlled substances are subject to special handling, storage, disposal and record keeping in the facility; -Procedures: -The Director of Nursing (DON), in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances; -Schedule II-V medications subject to abuse of diversion are stored in a permanently affixed, double locked compartment separate from all other medications; -At each shift change, or when keys are transferred, a physical inventory of all controlled substances including refrigerated items is conducted by two licensed nurses, or facility policy and is documented on the shift verification of controlled substance count. The emergency supply may be verified by assuring that the seal on the supply has not been broken. If the seal is broken, then a physical count of the contents must be conducted by two nurses or facility policy and paperwork must be present to account for any medications removed from the supply; -Any discrepancy in the controlled substance count is reported to the DON immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The DON documents irreconcilable discrepancies in a report to the Administrator: -If a major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, the DON notifies the Administrator and consultant pharmacist immediately; -The Administrator, consultant pharmacist, and/or DON determines whether other actions are needed; -The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medication ordered and the goal of therapy is met; -Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and Controlled Substance Accountability Sheet; -Current controlled substance accountability records are kept in the MAR, or designated book. Completed accountability records are submitted to the DON and kept on file for 5 years at the facility. During an observation and interview on 1/22/23 on 12:20 P.M., showed the 300/400 nurse medication cart unlocked. No nurse or Certified Medication Technician (CMT) was present in the hallway or at the nurse's desk. The Assistant Director of Nursing's (ADON) office door was slightly opened to the hallway. The office window blinds were completely closed. The medication cart was unable to be viewed from the office. At various times 5 to 10 residents walked past the unsecured medication cart. At 12:33 P.M., Licensed Practical Nurse (LPN) J walked past the medication cart and locked the cart. He/She said all medication carts should be locked when not in use. During an observation and interview on 1/24/23 at 9:43 A.M., of the 300/400 nurse medication cart, showed 1 vial of Haldol (Class II controlled substance, used to treat psychotic behaviors)100 milligram (mg)/milliliter (ml) loose in the second drawer. The Haldol vial was not secured behind two locked areas. LPN J said Haldol should be secured in the cart's narcotic box, and double locked. He/She had not participated in the narcotic count and did not know why the Haldol was loose in the medication cart. Observation and interview on 1/24/23 at 9:58 A.M., of the 300/400 CMT cart, showed no narcotic substance log sheets as of September 2022. During an interview, CMT O said he/she had worked at the facility for several months. Since his/her employment, he/she had not completed an off-going/on-coming narcotic count. Occasionally, he/she worked a split shift and the charge nurse would not be available to complete the narcotic count. During an observation and interview on 1/24/23 at 10:03 A.M., of the 100/200 nurse cart controlled substance log sheet, showed no signatures or controlled substance sheet as of 12/4/22. During an interview, LPN K said he/she had not completed the narcotic count sheet. He/She was asked to work unexpectedly. LPN K verified no narcotic counts had been completed since 12/4/22. During an interview on 1/27/23 at 12:03 P.M., the ADON said he/she expected the nurses and CMTs to conduct the on-coming/off-going narcotic counts. All Class II through Class V medications need to be secured behind a double locking system. If narcotic count sheets are not complete or inaccurate, staff should report the error to the nursing management immediately. No one has been monitoring and she expected staff to do it as part of standards of practice. She was unaware the narcotic counts were not being completed. 45083

Based on interview and record review, the facility failed to ensure monthly medication reviews (MMR) were completed timely (Residents #6, #17, #31, #44 and #47). The facility also failed to complete the physician's order to consult psychotherapy services following a gradual dose reduction (GDR) recommendation in December 2022 (Resident #47). The sample was 18. The census was 82. Review of the facility's Medication Regimen Review (MRR) policy, dated 12/2017, showed: -Policy: The AlixaRx clinical pharmacist (ACP) performs a comprehensive review of each resident's medical record at least monthly. Irregularities, findings, and recommendations are reported at a minimum to the Director of Nursing (DON), attending physician, and the Medical Director; -Recommendations and/or MMR reports are provided to attending physicians and Medical Director within 72 hours of receipt or within three business days. 1. Review of Resident #6's electronic medical record (EMR), showed: -Diagnoses included stroke, anemia (the blood doesn't have enough healthy red blood cells), hypertension (HTN, high blood pressure), diabetes, high cholesterol, aphasia (loss of ability to understand or express speech), seizure disorder and depression; -No documentation of completed MMRs from August 2022 through December 2022. 2. Review of Resident #31's EMR, showed: -Diagnoses of hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness) affecting right dominant side, right hand contracture and Type 2 Diabetes Mellitus; -No documentation of completed MRRs from August 2022 through December 2022. Review of Resident #31's electronic physician order sheet, showed: -An order for Lexapro (used to treat depression/mood) 20 milligrams, one pill, once daily. 3. Review of Resident #17's annual Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 12/2/22, showed: -Severe cognitive impairment; -Diagnoses of major depressive disorder, dementia with behavior disturbance, and Type 2 Diabetes Mellitus; -No documentation of completed MRRs from September 2022 through December 2022. Review of Resident #17's electronic physician order sheet, showed: - An order for Haldol (used to treat psychosis) inject intramuscularly 100 mg/ml every 30 days during the day. 4. Review of Resident #44's EMR, showed: -Diagnoses included Alzheimer's, hypertension (HTN, high blood pressure), orthostatic hypotension (low blood pressure that happens when standing after sitting or lying down), diabetes, aphasia, dementia and seizure disorder; -No documentation of completed MMRs from August 2022 through December 2022. 5. Review of Resident #47's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included: viral hepatitis (liver disease), depression, heart and kidney disease; -Takes an antidepressant daily; -Has a GDR been attempted: blank; -Physician documented the GDR as clinically contraindicated: blank; -Drug Regimen Review: blank; -Medication follow up: not assessed/no information. Review of pharmacy recommendation form, dated 11/24/22, showed: -The resident is taking multiple psychotropic medications and all orders are in need of a GDR or documentation stating that a dose reduction is contraindicated. If the resident is able to tolerate a dose reduction of psychotropic therapy, would you please indicate which area is best to target: The drug, dose, duration and indications of all psychotropic orders are clinically appropriate, further reductions are contraindicated. See rationale below; -A handwritten note, showed: GDR not indicated at this time as would cause psychotic instability by exacerbating underlying psychological disorder. Review of a nurse progress note, dated 12/7/22 at 9:03 A.M., showed pharmacy recommendations reviewed by the physician and referred to psychiatric services. The psychiatric physician denied a dose reduction at this time. Attempted to call the next of kin, no answer. Review of the progress notes and medical record, dated 11/1/22 through 1/24/23, showed no psychiatric assessment, consult or visit notes. Review of the care plan, updated 1/2023, showed: -Focus: The resident uses antidepressant medication; -Goal: The resident will remain free of medication side effects; -Interventions: administer medications, monitor for side effects, discuss with physician and the family the need for medication. Review of the electronic physician order sheet, showed: -An order for Trazadone (used to treat depression) 50 milligram (mg) take once daily, dated 6/29/20; -An order for Celexa (used to treat depression), 40 mg take one tablet once daily, dated 5/28/20; -An order for Divalproex delayed release (used to treat behaviors), take 125 mg, take one three times a day, dated 5/2020. 6. During an interview on 1/24/23 Corporate Nurse A said the prior Director of Nursing (DON) did not do MRRs for the residents per the facility's policy, so the MRRs that she was able to find were the only ones completed. 7. During an interview on 1/26/23 at 11:45 A.M., the Administrator and Corporate Nurse A said it was identified during the facility's January performance improvement plan (PIP) meeting, the facility identified MMR, GDR and pharmacy recommendations as system failures. 8. During an interview on 1/26/23 at 11:50 A.M., the Assistant Director of Nursing (ADON) said all residents should have a monthly pharmacy review. The pharmacist should document the visit in the EMR and send all recommendations to nursing management. If a GDR is recommended, the physician should be contacted and orders followed. If a GDR is not followed, psychiatry should document clear reasons why and supporting documentation should be noted in the medical record. 46888 46967

37672 Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident exposed during personal hygiene after staff left the resident's room door open to the hallway and the bedroom curtains open to the parking lot (Resident #46). Staff left a resident exposed in his/her brief in the wheelchair and also spoke to him/her in a disrespectful manner when the resident notified the staff of a high blood sugar level (Resident #37) The sample size was 18. The census was 82. Review of the incontinence care policy, dated 7/21/22, showed to provide privacy, close the door and the curtains and or the blinds. 1. Review of Resident #46's quarterly Minimum Data Set (MDS) a federally required assessment instrument completed by facility staff, dated 10/6/22, showed: -Severe cognitive impairment; -Total staff assistance needed with dressing, hygiene and toileting; -Always incontinent of bowel and bladder; -Diagnoses included dementia, depression and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). Review of the undated care plan, showed: -Focus: The resident is dependent on staff and requires staff assistance for eating, hygiene, toileting, showering and dressing; -Goal: The resident will maintain the current level of function; -Interventions: Dressing and personal hygiene use one staff assistance; -Focus: The resident has bowel and bladder incontinence; -Goal: The resident will remain free from skin breakdown and odors; -Interventions: Staff provide peri-care (cleaning from the front of the hips, between the legs and the back of the hips). Observation and interview on 1/24/23 at 5:40 A.M., showed the resident asleep in the bed. Certified Nurse Aide (CNA) F entered the room. CNA F left the door opened to the hallway. CNA F gathered hygiene care supplies and placed them next to the sink. CNA F woke the resident and explained care. CNA F did not close the fully open window curtains and the front parking lot was observed from the resident's bedroom window. CNA F removed the brief and hospital gown from the resident and provided care. At 5:55 A.M., a staff member walked out to his/her car, directly across from the resident's open window. At 6:05 A.M., CNA F said he/she had forgotten to close the bedroom door and the resident's window curtains. The curtains and the door should have been closed to give the resident privacy. During an interview on 1/26/23 at 11:57 A.M., the Assistant Director of Nursing (ADON) said doors and window curtains should be completely closed prior to any care. Doors and curtains should be closed to ensure privacy. During an interview on 1/27/23 at 2:00 P.M., the Administrator said he expected all residents to be treated with dignity and respect. The doors and privacy curtains should be closed when residents are undressed. 2. Review of Resident #37's medical record, showed: -admitted [DATE]; -Diagnoses included acquired absence of right leg above the knee, acquired absence of left leg above knee, altered mental status, lack of coordination and need for assistance with personal care. Observation on 1/23/23 at 10:44 A.M., showed the resident in his/her room. He/She sat in the electric wheelchair. He/She wore a soiled brief and a shirt. His/Her door was open and the resident was visible from the hallway. Staff took his/her pants to the laundry, but he/she did not have pants to wear. The resident said he/she did not want to miss therapy due to not having pants because it happened before. The resident received therapy to use his/her orthotics, so he/she was more anxious about missing therapy. The resident was not offered a blanket or other clothing to cover him/herself. Observation and interview on 1/27/23 at 1:40 P.M., showed the resident and a CNA were at the nurse's station to report the resident's Dexcom (a glucose monitoring device) to Nurse L. The resident showed his/her phone to the CNA and said, I need a shot before I go to therapy. The CNA reported to Nurse L the resident's phone showed a blood sugar of 400 and he/she needed his/her shot. Nurse L said the resident needs to go to their own unit and tell one of the nurses there. The CNA walked away and said, I'll take you over there. I do not know why (Nurse L) would not get up. At 1:50 P.M., the resident said he/she was frustrated because no one would help him/her. He/She said hi/hers phone was showing a high blood sugar, probably higher than 400 because it does not read above 400. The resident said therapy will not begin if his/her blood sugar was too high because he/she could fall using his/her orthotics. During an interview on 1/27/23 at 2:00 P.M., the Administrator said he expected all residents to be treated with dignity and respect. It was not appropriate for Nurse L to not assist the resident. If he/she was busy, he expected Nurse L to find someone who could assist the resident. 45083

Based on interview and record review, the facility failed to refund resident funds within 30 days of discharge for one resident (Resident #133). The sample was 18. The census was 82. 1. Review of Resident #133's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/22, showed: -Entry date: 8/16/21; -Unplanned discharge; -Discharge assessment: return anticipated; -Discharge status: acute hospital. Review of the resident's admission/discharge/death to social security form, dated 9/20/22, showed the resident discharged on [DATE]. Review of the resident's progress notes, showed on 8/22/22 at 5:54 P.M., call placed to hospital to get update on resident's condition. Spoke to nurse who states the resident remains in Intensive Care Unit (ICU) on ventilator and meeting has been scheduled for possible trachea placement. Review of the resident's trust account, showed: -On 8/3/22, the facility deposited the resident's August 2022 social security money in the amount of $1,346.00; -No care cost debited for August 2022; -On 8/3/22, the resident's trust showed a balance of $7,466.39; -On 9/2/22, the facility deposited the resident's September 2022 social security money in the amount of $1,346.00; -On 9/6/222, the facility deposited the resident's August 2022 pension in the amount of $213.06; -No care cost debited for September 2022; -On 9/6/22, the resident trust showed a balance of $9,032.03; -On 10/3/22, the facility rejected the resident's October 2022 social security money in the amount of $1,346.00; -The resident trust showed the facility deposited the resident's pension in the amount of $213.06 in October and November 2022; -Resident trust status: Frozen as of 12/8/22; -As of 1/27/23, resident has a balance of $9,719.29. During an interview on 1/24/23 at 10:56 A.M., the Business Office Manager (BOM) said the resident went to the hospital several months ago. He/She was supposed to return to the facility, but ended up in another facility in a different state. They tried to find out where he/she was to send the money. He/She did not have a guardian or responsible party. The facility froze his/her account so he/she no longer had deposits. The BOM did not send the money to social security because they believed the resident was supposed to return to the facility. The facility did not have a resident trust policy. During an interview on 1/27/22 at 2:00 P.M., the Administrator said he expected staff to complete the necessary documentation and notify social security within 30 days if a resident was discharged from the facility and then return the money.

Based on interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for one resident (Resident #5) with a history of choking episodes. The resident was seen by speech therapy on [DATE] for a choking episode at breakfast. The resident was care planned for aspiration risk for chewing food too quickly. The resident had a choking episode on [DATE] and was sent to the emergency room . The care plan was updated to include the resident taking food from other residents and aspirating it. The resident resided on the locked unit. On [DATE], facility staff left the locked unit unsupervised. After hearing a loud noise, a different resident on the locked unit started banging on the locked doors to get the staff attention, staff entered the locked unit and found the resident face down on the locked unit dining room floor, expired. He/she had food debris in his/her mouth. Life saving measures were attempted and unsuccessful at that time. Staff assigned to care for the resident at the time he/she expired were not aware of the resident's history of aspiration. The sample was 12. The census was 78. The administrator was notified on [DATE] at 2:18 P.M. of an Immediate Jeopardy (IJ) past-noncompliance which began on [DATE]. The facility conducted an investigation and immediately in-serviced staff on protective oversight and the requirement to ensure a staff person remained on the unit at all times. Staff not present were contacted via phone. This in-service was added to the new employee in-service training requirements. Management began random audit checks on the unit to ensure compliance. The IJ was corrected on [DATE]. Review of Resident #5's Annual Minimum Data Set (MDS,) a federally mandated assessment instrument completed by facility staff dated [DATE], showed: -Severe cognitive impairment; -Supervision required for walking in the room and in the corridor; -Supervision required for locomotion on the unit; -Independent with eating; -Diagnoses included pneumonia and aphasia (difficulty communicating). Review of the resident's physician order sheet, showed: -An order dated [DATE], for full code (all life saving measures); -An order dated [DATE], for a regular mechanical soft texture diet; -An order dated [DATE], for Speech Therapy (ST) evaluate and treat related to choking. Review of the resident's diagnoses list, showed: -Acute respiratory failure with hypoxia (not enough oxygen in the body tissues), initiated [DATE]; -Pneumonitis (inflammation of the lungs) due to inhalation of food and vomit, initiated [DATE]; -Aphasia, initiated [DATE]. Review of the resident's speech therapy evaluation and treatment plan, dated [DATE], showed: -Diagnoses included disorientation, attention and concentration deficit, and aphasia; -Reason for referral/current illness: Patient referred to ST due to exacerbation of aphasia, cognitive-communicative deficits, cognitive impairment, and safety awareness; -Patient was previous a resident of this facility where he/she consumed mechanical soft diet/thin liquids and required occasional supervision for swallowing; -Precautions/contraindications: communication, aspirations, fall risk, high blood pressure and mechanical soft diet; -Cognitive/communicative skills impaired; -Motor speech skills impaired; -Patient demonstrates deficits in alert and orientation, memory, thought organization, word finding, and functional problem solving skills. Review of the resident's ST note, dated [DATE], showed patient seen one on one today. Per occupational therapy, patient had choking episode at breakfast on mechanical soft diet. Response to session, actively participates with skilled interventions. Review of the resident's progress notes, dated [DATE], showed: -At 5:13 P.M., resident was found in a chair not responsive, blue with his/her head fallen forward. Resident was moved to the floor with the assistance of an aide and nurse. The resident then began to cough. The resident was sat up and began coughing food remnants up; -At 5:45 P.M., upon arrival to the unit, patient was surrounded by staff sitting on the floor. Patient was bluish but talking, stating he/she still had something stuck in his/her throat. Staff began to suction patient and make him/her gag and the remaining food came up. Patient color started to come back and he/she stated he/she started feeling a little better. The fire department and ambulance arrived and assessed the resident. Patient was sent to the hospital; -At 8:52 P.M., received a call from the hospital to inform that the resident was stable and would be returning to the facility. X-rays were negative and the resident was no longer coughing after having received a breathing treatment. Awaiting return to the facility. Review of the resident's care plan, showed: -At risk for aspiration related to chewing food too quickly; -Updated [DATE], choking episode from removing food from another resident's tray and aspirating. Sent to the emergency room (ER); -Goal: Risk for injury from aspiration will be minimized; -Interventions included: Assist with intake as needed, assess for signs and symptoms of aspiration. Monitor for and report abnormal findings to physician (i.e., coughing, active choking, dyspnea (difficulty breathing), cyanosis (bluish discoloration cause by poor oxygenation of the tissues), increased sputum production, and change in sputum characteristics). ST to screen/evaluate/treat, monitor progress. Review of the resident's progress note, dated [DATE] at 5:23 P.M., showed resident remains on observation for a choking episode. No signs or symptoms of distress noted at this time. Resident was found eating another resident's dinner against his/her diet order. Patient was redirected. Review of the resident's ST note, dated [DATE], showed patient seen one on one in activity room. Therapist received orders to evaluate patients swallowing following choking episode. Patient states that staff had given him/her an apple, but that's too hard, I can't eat that. Patient instructed that when given crunchy/hard foods, he/she does not have to eat them and can request and alternative. Patient verbalized understanding and acceptance. Review of the resident's ST discharge summary, dated [DATE], showed: -discharge date [DATE]; -Discharge recommendations: To facilitate optimal cognitive-communication performance, the following strategies are recommended. Visual aides to increase orientation/promote recall, forced choice to facilitate patient's involvement in decision making and procedural tasks to facilitate patient independence; -Discharge reason: Highest practical level achieved. Review of the resident's progress notes, dated [DATE], showed: -At 3:45 A.M., this nurse heard a loud thud from the hall. Went right away to the unit and found the resident on the floor, face down without a pulse or respirations. CPR was started immediately and 911 was called. Resident was observed to have a white substance coming out of his/her mouth. Finger sweep was done and a moderate amount of food was removed from his/her mouth; -At 5:30 A.M., resident's family notified of the resident's death. Review of the census report dated [DATE], showed 13 residents resided on the locked unit at the time of the incident. Review of the list of staff at the facility at the time of the incident, showed four staff listed. Licensed Practical Nurse (LPN) C, LPN D, Certified Nursing Assistant (CNA) E, and CNA F. During an interview on [DATE] at 11:49 A.M., Resident #12 said he/she heard a chair turn over and the resident was on the floor. No staff were on the unit at that time. That is normal for this place. He/she saw the resident on the floor and went to the door to try to get staff. It took a good couple of minutes for staff to respond to him/her knocking. Review of LPN D's written statement, undated, showed observed resident lying on his/her stomach on the floor in the dining room of the 200 hall. He/she had a white substance coming out of his/her mouth. 911 was called immediately and CPR was started. Resident had no pulse or respirations. During an interview on [DATE] at 8:17 A.M., LPN D said he/she was the nurse assigned to the 100 and 200 hall. There was also one CNA assigned on both of those halls as well. He/she was not aware of the resident's history of choking until after he/she expired and he/she was reading his/her chart. He/she was not sure if any extra precautions were required as a result of this because he/she was not working when he/she choked in the past. On that night, he/she was sitting at the nurse's station near the 100 hall and he/she heard a thud. Everything happened so fast and he/she does not recall all the details. There was a resident who came to the locked unit doors banging on it. This was Resident #12. He/she and the CNA ran back to the unit dining room and the resident was on the floor with a white substance coming out of his/her mouth. He/she was pulseless and was not breathing. He/she did a finger sweep and got as much out as possible. He/she later found out it was a cupcake. When the other nurse got back the unit, he/she was already doing CPR. Someone else did help with CPR and he/she sent the other nurse to call 911. Both the CNA and he/she were on the 100 hall, just outside of the locked unit when it happened. The facility had never provided staff with any guidance or expectations regarding the need for someone to always be on the locked unit. Review of CNA E's written statement, dated [DATE], showed he/she worked on the 3rd shift from 11:00 P.M. to 7:00 A.M. This was his/her first time at the facility. Upon arrival, the nurse gave him/her report and did round on both the 100 hall and the locked unit. On the locked unit, all residents were in bed, on the 100 hall there were a few residents still up and moving. At around 3:40 A.M., he/she heard a loud sound as if someone had fallen. Thinking it was a resident on the 100 hall, he/she checked them first. Then he/she proceed to the locked unit. A resident was pushing on the door which made the alarm go off. The resident said that a resident was on the floor. The nurse and he/she went to check and found the resident on the floor, face down in the dining area. The nurse checked the resident, then CPR was done and 911 was called. During a telephone interview on [DATE] at 1:52 P.M., CNA E said he/she works for a staffing agency and this was his/her first time working at this facility. When he/she first arrived, he/she and the nurse did rounds together so he/she could get to know the residents. He/she was assigned both the 100 hall and 200 hall locked unit. Most of the residents on the locked unit were quiet that night. He/she did have some high fall risk residents on the 100 hall that were up and about that night, so they required monitoring and frequent observations. He/she checked the unit at about 1:40 A.M., and they were fine. At about 3:40 A.M., he/she and the nurse were at the nurse's station and heard a loud noise. It sounded like someone fell . He/she thought it was someone on the 100 hall because there were fall risk residents up and about. The nurse got up too, but he/she told the nurse he/she got this and he/she went to check the residents on the 100 hall. When coming back to the nurse's stations, a resident started banging on the door inside the locked unit and the door alarm went off because the resident had pushed on the door. He/she and the nurse went to the locked unit and the resident was on the floor in the dining room face down with food in his/her mouth. Both the nurse and he/she did CPR until EMS arrived. It was a cupcake he/she had choked on. Apparently, earlier that day, they had cupcakes and sparkling soda and he/she must have kept a cupcake for later. At 3:57 P.M., CNA E said when he/she got report from and did rounds with the nurse, no one informed him/her that the resident had a choking episode in the past and/or that he/she required any additional observation. Review of LPN C's written statement, dated [DATE], showed called to 200 unit by the other nurse. Resident lying on floor in the dining room. CPR started, 911 called and they took over upon arrival. During an interview on [DATE] at 12:20 P.M., with the administrator and ADON, they said the facility will staff at least two CNAs and a nurse on that side, the 100 and 200 halls. We assign so that someone is on the unit the whole time. There should always be someone on the unit. If the CNA had to go somewhere, the nurse should go into the locked unit. It should never be left unattended. MO00211538

Based on observation, interview and record review, the facility failed to immediately initiate basic life support, including cardiopulmonary resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to restore spontaneous blood circulation and breathing) and failed to immediately notify Emergency Medical Services (EMS) for one resident, who was found unresponsive and was a full code (full support which includes CPR, if the patient has no heartbeat and is not breathing) (Resident #1). Facility staff found the resident unresponsive at 7:54 A.M. Staff notified the physician at 8:00 A.M., that the resident had expired, however at 8:20 A.M., staff obtained the crash cart and rushed to the resident's room. At 8:30 A.M., staff called emergency medical services (EMS). The census was 77. Of those 77 residents, 70 had physician orders for a full code. The administrator was notified on [DATE] at 12:54 P.M., of an Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Cardio-Pulmonary Resuscitation policy dated [DATE], showed: -The facility will provide basic life support, prior to the arrival of EMS (emergency medical services) including initiation of CPR to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with the resident advanced directives, or a signed DNR order; -Charge nurse will initiate CPR unless a valid DNR is in place; -Clinical evaluation reveals obvious signs of clinical death (rigor mortis (stiffening of the joints and muscles of a body a few hours after death), dependent lividity (a reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the blood vessels evident in the lower lying parts of the body in the position of death), decapitation (removal of the head), transection or decomposition (aortic transection or disruption, is a condition in which the aorta, the largest artery in the body, is torn or ruptured)); -Initiating CPR could cause serious injury/immediate danger to the rescuer; -Upon resident assessment with absent vital signs charge nurse will initiate a code blue (code that alerts staff there is a medical emergency); -Resident who is a full code will have CPR initiated immediately. CPR will continue until EMS arrives to take over CPR; -Another employee will dispatch EMS by placing [DATE] call. Employee will direct EMS to the resident location in need of life saving efforts; -Physician will be notified of resident condition, lack of vital signs and CPR initiation; -Charge nurse will document a timeline of events in the interdisciplinary team (IDT) notes in point click care (PCC, an electronic medical record (EMR)) in the resident medical record. Review of Resident #1's face sheet, showed the following: -admitted [DATE]; -Code Status: No documentation regarding the resident's code status; -Primary diagnosis of acute kidney failure. Other diagnoses included atrial fibrillation (A-Fib, irregular heart rhythm), hypertension (high blood pressure), heart failure and chronic obstructive pulmonary disease (COPD, lung disease). Review of the resident's baseline care plan, dated [DATE], showed the following, under the advanced directives/code status section with a check mark in the box next to the following items: -Cardiopulmonary Resuscitation; -Life Support; -Resuscitation; -The following items listed in section E with area for documentation to be typed in; -Identify other advanced directives not listed above: Limited (typed in); -Code Status box was blank. Review of the resident's physician order sheet, showed no physician order for code status. Review of the resident's miscellaneous tab in the EMR, showed code status procedures uploaded: -When a resident is found to be without a heartbeat or respirations, the nurse on duty identifies the code status; -If the resident is Full Code status CPR is started and emergency 911 services are activated; -If the resident is Do Not Resuscitate (DNR) status, the following procedures are followed; -The nurse on duty contacts the attending physician/nurse practitioner (NP)/physician assistant (PA) and communicates the clinical information; -In order to determine the resident and families wishes and to eliminate confusion, this form needs to be completed and maintained in the resident's medical chart; -The line next to #1 had a check mark that read: In the event of the observed absence of vital signs, basic cardiopulmonary resuscitation CPR is to be initiated and [DATE] called; -Signed by resident and Social Worker and dated [DATE]. Review of the resident's progress notes, showed the following: -[DATE] at 10:20 P.M., resident alert and oriented x 3 (resident knows name, present location and the date). Able to make needs known. No complaints of pain or discomfort voiced at this time. Resident lying in bed watching TV at this time. Call light within reach; -[DATE] at 9:30 A.M., This nurse called to resident room by staff at approximately 8:10 A.M. Resident found lying in bed with eyes closed. Resident unresponsive. CPR started. Call placed to 911. Emergency response here and took over CPR methods. Emergency Medical Technicians (EMT's) arrived and resident pronounced at 8:46 A.M. Call placed and spoke with Physician D. Spoke with coroner. Resident's daughter here and informed nurse that funeral home will be picking up resident. -Staff failed to document the resident's vital signs. Review of video footage dated [DATE] for the camera facing up 300 hall towards ,d+[DATE] nurse's station, showed the following: -7:54 A.M., Licensed Practical Nurse (LPN) A went into the resident's room; -7:59 A.M., LPN A went up the 300 hall towards the ,d+[DATE] nurse's station; -8:04 A.M., The ADON ran into the resident's room; -8:09 A.M., The ADON and LPN A were in the resident's room; -8:09 A.M., LPN A exited the resident's room and went up 300 hall towards the ,d+[DATE] nurse's station; -8:20 A.M., The crash cart was brought to the room by the ADON. Review of the facility's video footage dated [DATE] for the camera facing the ,d+[DATE] nurse's station, showed the following: -8:06 A.M., the Assistant Director of Nursing (ADON) ran past the ,d+[DATE] nurse's station and down the 300 hall; -8:08 A.M., the ADON was on his/her cell phone walking back up 300 hall past the ,d+[DATE] nurse's station; -8:09 A.M., LPN B walked down the 300 hall and LPN A sat at the ,d+[DATE] nurse's station looking at a chart; -8:11 A.M., LPN B walked back up the 300 hall past the nurse's station with LPN A. LPN B sat at the nurse's station with LPN A and both nurses looked at a chart; -8:13 A.M., the ADON carried towels down the 300 hall; -8:17 A.M., the ADON remained down the 300 hall. LPN A and LPN B sat at the ,d+[DATE] nurses station reviewing at a chart; -8:19 A.M., the ADON walked up to the ,d+[DATE] nurse's station and began to look at a chart with LPN A and LPN B; -8:20 A.M., the ADON grabbed the crash cart and ran down the 300 hall. LPN A and LPN B both followed the ADON down the 300 hall; -8:23 A.M., LPN A returned to nurses station. Review of the EMS patient care record for [DATE], showed: -Call received at 8:29:24 A.M.; -Dispatch notified at 8:31:14 A.M.; -In route at 8:31:53 A.M.; -On scene at 8:35:00 A.M.; -With resident at 8:38:00 A.M.; -Resident was pronounced deceased at 8:46:00 A.M. During an interview on [DATE] at 6:09 A.M., LPN A said to locate the code status for a resident, he/she could look in the resident's hard chart, or in the computer in PCC. The code status was also located on the report sheet. During an interview on [DATE] at 9:02 A.M. Certified Nurse's Aide (CNA) C said he/she found the resident dead. The resident was not responding, had no pulse and was not breathing. He/she notified LPN A immediately. During an interview on [DATE] at 6:30 A.M., LPN A said normally the code status is in the front of the hard charts. If the resident is new the first 24 hours signed code status is in the front of the hard chart. Full code has a green sheet in front of the hard chart and the facility only has a couple of residents that are DNR. LPN A said he/she was there on [DATE] and started CPR. A nursing assistant found the resident after 7:00 A.M. and came and got LPN A. LPN A said he/she knew the resident was a full code and LPN B assisted with CPR. 911 was called and they came and took over. During an interview on [DATE] at 6:11 A.M., LPN B said LPN A asked for help on [DATE] in determining the resident's code status. LPN B said he/she went to the ,d+[DATE] nurses station desk and the resident's chart was already open and LPN B began looking for the resident's code status. LPN B said the ADON came to the nurse's station, began looking at the resident's chart and found the resident was a full code. That's when CPR was started. LPN B said the resident was blue and cold. LPN B said to determine a resident's code status, the hard charts have green for full code and red for DNR. During an interview on [DATE] at 9:42 A.M., the ADON said LPN A came to the ,d+[DATE] hall nurses station on [DATE] and asked the ADON to assist with the resident. LPN A said the resident was unresponsive. The ADON said the resident appeared to be lying in bed like he/she was sleeping and was warm to the touch. The resident was unresponsive with no pulse and no rise and fall in his/her chest. She went to the ,d+[DATE] nurse's station and checked the code status, then started CPR on the resident. The ADON said LPN B was in the room and took over CPR for her. During second interview with ADON on [DATE] at 1:44 P.M., she said LPN A called on [DATE] and asked her to come and assist with the resident because the resident had a change in condition. When the ADON went into the resident's room, the resident was found to have a faint pulse and very shallow respirations. She said while looking for the resident's code status, Maintenance Assistant E was in the room with the resident. She was unsure if Maintenance Assistant E was CPR certified. The ADON said she left the room and obtained towels for the resident's roommate because the resident's roommate requested them. LPN B was assisting LPN A in looking for the resident's code status. She said she went up to the ,d+[DATE] nurses station and looked for the resident's code status. The resident's code status was found and it was a full code. The ADON said she then grabbed the crash cart and ran down to the resident's room with LPN A and LPN B and initiated CPR. She was unsure who called 911 and when. When EMS arrived, they took over CPR and they stopped the code and pronounced the resident deceased . If a resident is found unresponsive, the expectation is to call the code blue, not to leave the resident alone, and send someone to check the chart for the resident's code status. If the resident is a full code, then start CPR. It should not take up to 20 minutes to determine a resident's code status. Staff can look in PCC or the front of the hard chart. She was unsure if a code blue was announced. Once the change in condition was noticed, Maintenance Assistant E was in the room with the resident the entire time. Instructions were given to Maintenance Assistant E to watch the resident's breathing and to notify her if the resident's breathing changed. During an interview on [DATE] at 2:03 P.M., Maintenance Assistant E said he/she has been at this facility for about a year. He/she said on [DATE], he/she assisted the ADON with the resident. Maintenance Assistant E said he/she walked down the 300 hall and saw the ADON standing over the resident in the resident's room, looking at the resident. The ADON was the only staff in the resident's room. The ADON asked him/her to watch the resident and let the her know if there was anything different with the resident's breathing. He/she was unsure if a code blue was called or if the ADON took the resident's vitals. He/she was also unsure if the resident wore oxygen while he/she was in the room. He/she said the resident appeared to be breathing normally which meant the resident was alive. When the ADON and another nurse returned, he/she left the room. He/she did not observe any nurse perform chest compressions on the resident before he/she left. He/she was in the room alone with the resident for approximately ,d+[DATE] minutes. Maintenance Assistant E did not have current CPR certification. During an interview on [DATE] at 1:24 P.M., the Regional Nurse Consultant said she would expect the physician to be notified of a change of condition with a resident. She reviews investigations that are completed on CPR that is performed in facilities. She had not reviewed this investigation because the Director of Nursing (DON) was working on it now. The Regional Nurse Consultant said reviewing the investigation verifies that everything is processed correctly and she can see if the staff need any further education on the policy. During an interview on [DATE] at 10:11 A.M., the Medical Director's Social Worker said Physician D did not recall speaking with a nurse on [DATE] regarding the resident. The exchange shows LPN B called the exchange on [DATE] at 8:00 A.M., to notify the physician that the resident had expired. The exchange shows the call went out to Physician D on [DATE] at 8:02 A.M. The physician took the call as being notified. Physicians do not always call the facility back if they receive a notification call. During a third interview on [DATE] at 2:48 P.M. the ADON said if she had known the resident's codes status the first time she went to assess the resident, she would have initiated CPR. That is the proper procedure. She believed vital signs were taken by LPN A because LPN A had a piece of paper with vital signs written on it. She would expect the vital signs obtained to be documented accurately in the resident's chart. Oxygen was not started because she was not familiar with the resident. CPR was initiated at 8:20 A.M. when she took the crash cart to the resident's room. She started chest compressions and LPN A started the ambu bag (a self-refilling bag-valve-mask unit, used for artificial respiration) on the resident when they arrived to the resident's room. Delaying CPR to a full code resident could have potential harm by complicating the situation which could result in possible death. The resident's advanced directive was in the chart with the green sign. It did not take her long to find it. A CPR in-service was done not long ago but she was unsure why. During an interview on [DATE] at 12:01 P.M., the Regional Nurse Consultant said the timeline and investigation was now complete. She spoke with LPN A on [DATE] and LPN A said there was a discrepancy with the code status. LPN A said he/she saw a DNR in the hospital paperwork and called for assistance. At that time the resident had a faint pulse. During a fourth interview on [DATE] at 12:24 P.M., the ADON said there was a discrepancy with the resident's code status. At 8:00 A.M. the change of condition was noticed. The ADON was unsure if oxygen was administered, or if the head of the bed was elevated at that time. During an interview on [DATE] at 11:42 A.M., the Medical Director's Social worker said the facility placed a call to the physician's exchange at 8:00 A.M. on [DATE] that the resident had expired. The Social worker said the Medical Director saw the resident on [DATE] and no calls were made to the exchange on any change of condition until the call from [DATE] at 8:00 A.M. saying the resident had expired. During an interview on [DATE] at 1:45 P.M., the Fire Chief verified a 911 call came in for the facility on [DATE] at 8:30 A.M., for a cardiac arrest (cessation of respirations and/or pulse). During a fifth interview on [DATE] at 1:54 P.M. the ADON said she initiated CPR and LPN B assisted her. She said she sent LPN A to the nurse's station to make phone calls. She clarified that LPN B was the nurse that assisted with CPR. When she took the crash cart down to the resident's room, she did a quick assessment and the resident had no pulse and no rise and fall in the chest. She and LPN B moved the resident to the floor and then she started chest compressions and LPN B had the ambu bag. She is unsure how long they were performing CPR before EMS arrived but it wasn't long. Maintenance Assistant E was in the room when she arrived with the crash cart and did not say anything about if the resident's breathing had changed. When she entered the room, Maintenance Assistant E left the room and was not in the room when they started CPR. During an interview on [DATE] at 10:30 A.M., LPN B said he/she called the physician's exchange and told the exchange the resident was dead because the resident was dead. The resident's color was ashen he/she was cold and had no pulse. LPN B said LPN A did not put oxygen on the resident when he/she found him/her because the resident was dead. LPN B said LPN A asked for his/her help that morning. LPN A was upset and crying and told LPN B there wasn't a code status in the resident's chart. He/she looked through the chart and found the resident's recent hospital admission paperwork. This showed the resident's code status as no code (DNR). LPN B said when the ADON looked through the chart, she found the resident's advance directive and said, Oh no!, he/she's a full code, let's go! and they grabbed the crash cart and ran to the room. He/she started the chest compressions. During an interview on [DATE] at 7:04 A.M., the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Coordinator said to determine a resident's code status, staff can look on the face sheet in the hard chart or in PCC. She said if staff found a resident unresponsive and the staff member was unsure of the resident's status, her expectation would be for the nurse to yell for help and start CPR. That is nursing practice, if the nurse found out the resident was a DNR, the nurse would stop performing CPR. During an interview on [DATE] at 3:16 P.M., the DON said the procedure for a new admission is for the nurse to enter all medication orders. Social services obtains the code status if the admission comes Monday through Friday between the hours of 8:00 A.M. to 5:00 P.M. If the new admission comes outside the times of the social services' hours, the nurse is responsible for obtaining the resident's code status. The nurse is also responsible for entering the code status order into PCC. She would expect a physician's order for code status to be entered into PCC. She would expect the correct code status to be in the hard chart. She would expect the facility to have a process to direct staff to the correct code status in the hard chart and not the hospital code status. CPR should be started immediately if a resident who is a full code is found without signs of life. CPR should be initiated as soon as the resident is noted without signs of life, unless there are obvious signs of clinical death such as rigor mortis. She would expect basic life support measures would be taken such as taking vital signs, administering oxygen if needed, calling 911 immediately, and calling the physician if a resident with a full code status is found with a faint pulse and very shallow breathing. The DON would expect staff to follow the facility's policies and procedures. Staff that are CPR certified should stay with a resident with a faint pulse and shallow respirations. After interviewing the nursing staff that cared for the resident, she would consider the resident's condition to have been critical. She said she would have picked a nurse over the maintenance assistant if nurses were available. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). 46104

Based on interview and record review, the facility failed to ensure that residents received appropriate treatment and care when the facility failed to provide ongoing clinical assessments, identify a change in condition after a resident's fall and suffered a subdural hematoma, notify the physician of a new [DIAGNOSES REDACTED]. These practices negatively impacted one of three sampled residents (Resident #1). The census was 86. 1. Review of Resident #1's physician order [REDACTED]. -Order dated [DATE], for aspirin tablet, give 81 milligrams (mg) once a day for blood thinner; -Oder dated [DATE], for [MEDICATION NAME] ([MEDICATION NAME], anti-platelet medication used to prevent blood clot formation), give 75 mg once a day. Review of the resident's care plan, dated [DATE], showed the following: -Focus: Resident is at risk for abnormal bleeding, hemorrhage (bleeding; blood loss inside or outside of body) and/or increased/easy bruising related to anticoagulant/antiplatelet medication use; -Goal: Resident will be free from signs and symptoms of abnormal bleeding; -Interventions included: Monitor for and report to the nurse and physician any signs or symptoms of bleeding; -Focus: Resident at risk for falls due to weakness; -Goal: Fall related injuries will be minimized through review date; -Interventions included: Anticipate and meet needs. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Brief Interview for Mental Status (BIMS, screening tool used to assess cognition) score of 8 (moderate cognitive ability); -Required extensive assistance of one person for bed mobility, transfer, dressing, toilet use and personal hygiene; -Required assistance of one person with eating; -Used a wheelchair for ambulation; -Incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident's physician visit notes, dated [DATE], showed the following: -The resident was admitted to facility on [DATE]; -Per facility staff, the resident now had end of life Medicare and family was only going to proceed with hospice if the resident was unable to receive Medicare services; -The resident was making progress in physical therapy sessions, and would benefit from additional skilled therapy services. Review of the resident's progress notes, dated [DATE], showed the following: -At 4:15 A.M., Nurse E was called to the resident's room by certified nurse assistant (CNA) F. The resident was found next to his/her bed, lying face down on the floor. A full body assessment was performed and a large raised area on the resident's left forehead was noted. The resident's nose was also bleeding. The resident was alert and oriented to self and place (A&O x 2) and was able to move all his/her limbs. The nurse obtained orders from the Nurse Practitioner (NP) to obtain a series of x-rays on the resident's skull. A phone call was placed to the facility's contracted mobile x-ray company who told Nurse E the resident's insurance would not cover the skull series. Nurse E called the NP back and received new orders to send the resident out to the hospital for the skull series. The resident's family was called to notify them of the resident's fall and new orders to go out the hospital. Review of the resident's electronic medical record assessments, dated [DATE], showed the following: -At 4:15 A.M., Nurse E completed a neurological check list (assessment to monitor and record temperature (T), pulse (P), respirations (R, breathing rate), blood pressure (BP), pupil size and reactivity, and equality of hand grips), with the following information: -Vital signs were T of 97.7 degrees Fahrenheit (F) (normal temperature for elderly: 97.8 to 99 degrees F), 86 P (normal pulse rate for elderly: 60 to 100 beats per minute), 18 R (normal respiratory rate for elderly: 12 to 18 breaths per minute) and ,[DATE] BP (normal BP for elderly: ,[DATE] or below). Oriented to person and situation; alert; pupils equal and reactive to light, cannot follow finger with eyes. Responded to simple commands and verbalized appropriately. Resident asked to be picked up off the floor. No verbal expression of pain. Showed non-verbal signs of pain. Resident never complained of pain. Movement and sensation intact on all four limbs. Review of the resident's paper neurological checklist, dated [DATE], showed the following: -Checklist should be completed at the following intervals (initial assessment followed by every 15 minutes times four times, every 30 minutes times two, every hour times two, once per shift for 72 hours) for follow up for all unwitnessed falls or falls in which head is struck. Any change in the resident's condition requires a phone call to the primary care physician; -At 4:15 A.M., Nurse E wrote the following vital signs: ,[DATE] BP, 86 P and 18 R; Oriented to person, opened eyes spontaneously and purposely. Pupils reactive and of normal size. Hands, arms and legs all showed mild weakness. Physician and family notified if change in status. During an interview on [DATE] at 2:19 P.M., CNA F said the following: -He/she worked the night shift on [DATE]. On the morning of [DATE], he/she found the resident had fallen from his/her bed. CNA F called for Nurse E to come into the room to assess the resident before they moved the resident; -CNA F did not take the resident's vitals. During an interview on [DATE] at 1:53 P.M., Nurse E said the following: -He/she worked the night shift on [DATE]. On the morning of [DATE], he/she was notified by CNA F that the resident had fallen out of his/her bed; -He/she did not start a paper neuro checklist flow sheet on [DATE] at 4:15 A.M. when he/she found the resident on the floor. Nurse E only obtained one set of vitals and conducted the first neuro check which he/she documented in the resident's electronic medical record. Nurse E was busy calling the Nurse Practitioner (NP) on call to get new orders for the resident, and then sending the resident out to the hospital to get x-rays of his/her skull; -Nurse E asked CNA F to stay with the resident while he/she was outside of the unit at the nurse's station preparing to send the resident out to the hospital; -Nurse E did not instruct CNA F to take vital signs on the resident. Further review of the resident's progress notes, dated [DATE], showed the following: -At 4:25 A.M., Nurse E placed a call to the local ambulance service for transportation to the hospital. Further review of the resident's paper neurological checklist, dated [DATE], showed the following: -At 4:37 A.M., Nurse E wrote the following: ,[DATE] BP, 87 P and 18 R; Oriented to person, opened eyes spontaneously and purposely. Pupils reactive and of normal size. Hands, arms and legs all showed mild weakness; Physician and family notified if change in status; -At 4:45 A.M., Nurse E wrote the following: ,[DATE] BP, 83 P and 18 R; Oriented to person, opened eyes spontaneously and purposely. Pupils reactive and of normal size. Hands, arms and legs all showed mild weakness. Physician and family notified if change in status; -At 5:00 A.M., Nurse E wrote the following: ,[DATE] BP, 88 P and 18 R. Oriented to person, opened eyes spontaneously and purposely. Pupils reactive and of normal size. Hands, arms and legs all showed mild weakness; Physician and family notified if change in status. Further review of the resident's progress notes, dated [DATE], showed the following: -At 5:07 A.M., the resident left the faciity on a stretcher with the ambulance attendants. Review of the facility's 24 hours shift report sheet for the 100 hall, dated [DATE], showed the following: -No documentation that the resident fell during the night shift, neuro checks were started, new orders received to send the resident out to the hospital, nor documentation the resident was sent out to the hospital and the family was notified. Review of the resident's hospital discharge paper work, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. Usually caused by a head injury strong enough to burst blood vessels. Age, blood thinning drugs, and [MEDICAL CONDITION] increase risk); -Imaging results: Computed tomography (CT, series of detailed x-ray images) scan of the head, spine and neck showed [MEDICAL CONDITION] (bleeding between the brain tissue and skull or within the brain tissue itself, can cause brain damage and be life threatening); -At 5:15 A.M., vitals were 81 P, 11 R, and ,[DATE] BP; -Discharge instructions included: -Changes to medication list; Ask physician about current medication list included aspirin 81 mg, take once daily and [MEDICATION NAME] 75 mg, take once daily; -Intracranial hematoma: A collection of blood inside the skull. The blood leaks from a tear or rupture in a vein or artery. The collected blood puts pressure on the brain. Serious medical problems can develop, such as [MEDICAL CONDITION] or a coma. An intracranial hematoma is a life-threatening emergency that needs immediate medical care; -Call the local emergency number there are any signs of a stroke, a [MEDICAL CONDITION], or new problems with balance or movement; -Return to the emergency department if sleepier or are harder to wake than usual, have problems thinking, behavior or personality changes, repeated or forceful vomiting; -Call the physician if there is nausea or vomiting, symptoms worsen; -Manage or prevent another intracranial hematoma; -Manage health conditions: Diabetes can increase the risk of a stroke; -Check blood pressure as directed: High blood pressure can increase the risk for stroke; -Take blood thinners exactly as directed: Blood thinners increase the risk for an [MEDICATION NAME] hematoma. The physician may make changes regarding the blood thinner if it caused the hematoma. Always follow directions so too much of the medication is not taken. Further review of the resident's progress notes, dated [DATE], showed the following: -At 10:48 A.M., Nurse C documented the resident returned to the facility by ambulance. The resident responded to his/her name, and shook his/her head No when asked if in pain. The resident had a laceration (a deep cut or tear in skin) to his/her left eye and his/her jaw was swollen with bruising. Vitals signs were ,[DATE] BP, 87 P and 18 R. -There was no documentation of the new [DIAGNOSES REDACTED]. During an interview on [DATE] at 12:24 P.M., Nurse C said the following: -He/she worked on [DATE] when the resident returned from the hospital; -He/she reviewed the resident's discharge paperwork and noted the discharge paperwork said the resident had a laceration on his/her head and the hospital did not take any x-rays that showed the resident had head trauma; -When the resident returned from the hospital, Nurse C took the resident's vital signs, which were stable, asked the resident if he/she was in pain, which the resident denied, and noted the resident was alert and oriented to self only; -When asked if he/she knew the definition of a subdural hematoma, Nurse C replied he/she knew the resident had a hematoma because there was a bruise on the resident's face when he/she returned from the hospital. The nurse could not provide the definition of a subdural hematoma when questioned further; -He/she was not told by the CNA or the CMT that anything was wrong with the resident during his/her shift on [DATE]. Review of the resident's Medication Administration Record [REDACTED] -On [DATE], time unknown in the A.M., [MEDICATION NAME] 75 mg; -On [DATE], time unknown in the A.M., aspirin 81 mg. During an interview on [DATE] at 12:38 P.M., CMT D said the following: -He/she worked on [DATE] when the resident returned from the hospital; -The resident did not take his/her medications when CMT D tried to administer them to him/her after the resident returned from the hospital. When CMT went into the resident's room, the resident was sitting up in his/her bed, was really still and was staring off into space. The resident did not respond to his/her name; -It was unusual for the resident to refuse his/her medications; -The CMT reported the unusual behavior and the resident's refusal to take his/her medications to Nurse C; -CMT D entered the resident's room again on [DATE], at approximately 1:30 P.M., and saw the resident was sitting up in his/her bed, was very still and was staring off into space, just as he/she was earlier that day; -CMT D did not report the resident's unusual behavior to the nurse a second time; -CMT D did not administer any morning medications to the resident and did not know if the resident ever received his/her morning medications from Nurse C; -Nurse C did not inform CMT D why the resident went out to the hospital earlier that morning, nor did Nurse C tell the CMT the resident had any new diagnoses. During an interview on [DATE] at 10:23 A.M., CMT D said the following: -He/she signed off on the MAR before administering the medication to the resident; -The resident refused the medication; -CMT D informed Nurse C the resident refused his/her medication and was acting strangely; -Nurse C told CMT D that he/she would try to administer the medication to the resident and to not worry about it; -Nurse C told CMT D not make any changes to the MAR indicated [REDACTED] -CMT D gave the keys to the medication cart to Nurse D and did not make a correction to the MAR indicated [REDACTED] -CMT D did not know if Nurse C gave the resident the medication. During an interview on [DATE] at 10:41 A.M., Nurse C said the following: -He/she did not administer any medication to the resident on [DATE]; -Nurse C could not remember if CMT D reported to him/her the resident refused his/her medication after the resident returned from the facility; -He/she could not remember if CMT D reported the resident was behaving strangely and staring off in to space. Further review of the resident's paper neurological checklist, dated [DATE], showed the following: -At 10:48 A.M., Nurse C documented the following: ,[DATE] BP, 87 P and 18 R; Oriented to person, opened eyes spontaneously and purposely. Pupils reactive and of normal size. Hands, arms and legs all showed mild weakness. Physician and family notified if change in status; -There was no further documentation of neurological checks. Further review of the resident's progress notes, dated [DATE], showed the following: -At 11:09 A.M., Nurse C documented the resident was on incident follow up for a fall. Neurological check was done on resident, the resident responded to his/her name and was able to verbalize if he/she was in pain. The resident had a laceration to his/her left eye, and his/her jaw was swollen with bruising. Vital signs were ,[DATE] BP, 87 P and 18 R. Further review of the resident's electronic medical record assessments, dated [DATE], showed the following: -At 11:10 A.M., Nurse C completed a neurological checklist with the following vital signs: T of 97.7 degrees F, 86 P, 18 R and ,[DATE] BP; Oriented to person; Alert. Pupils equal and reactive to light, can follow finger with eyes. Responded to simple commands and verbalized appropriately. Verbalized pain and showed non-verbal expressions of pain. Movement and sensation intact on all four limbs; -At 1:24 P.M., Nurse C completed a Daily Skilled Summary with the following vital signs: T of 97.7 degrees F, 86 P, 18 R. Decisions poor, cues/supervision required. Able to recall current season, location of own room, staff names/faces, that he/she was in facility/home. Short term memory impaired. Did not state pain or shows signs of pain. No open areas, cuts, lacerations, skin tears abrasions or bruises present on skin. Had a fall within the last three months with injury of laceration to his/her left forehead; -At 1:31 P.M., Nurse C completed a COVID-19 Coronavirus Risk Assessment with the following vital signs: T of 97.7 degrees F, 86 P, 18 R; No issues noted with screening questions. Further review of the facility's 24 hour shift report sheet for the 100 hall, dated [DATE], showed the following: -Vital signs for the day shift were 97.7 T, 87 P, 18 R and ,[DATE] BP; -No documentation showing the resident returned from the hospital with a new [DIAGNOSES REDACTED]. During an interview on [DATE] at 5:13 P.M., CNA G said the following: -He/she worked during the second shift (from roughly 3:30 P.M. until 11:00 P.M.) on [DATE]; -Nurse C gave CNA G report when he/she came on shift and asked the CNA to check on the resident to make sure he/she was ok because the resident fell earlier that day; -Nurse C did not inform CNA G the resident had a new [DIAGNOSES REDACTED]. -The resident was asleep the whole day during his/her shift; -The resident opened his/her eyes and said yes when CNA G asked the resident if he/she was ok. This occurred when CNA G was giving care to the resident. The CNA could not remember when it occurred; -The resident ate a little amount for dinner; -The last time CNA G saw the resident was at approximately 10:30 P.M., when the CNA rolled the resident to his/her side to check if the resident needed incontinence care. The resident opened his/her eyes and then went back to sleep; -CNA G left before the on-coming CNA came onto the floor to relieve him/her; -CNA G could not remember if Nurse C was there when he/she left the hall. Further review of the resident's electronic medical record assessments, dated [DATE], showed the following: -At 9:01 P.M., Nurse E completed a COVID-19 Coronavirus Risk Assessment with the following vital signs: T of 97.7 degrees F, 86 P, 18 R; No issues noted with screening questions; -At 9:02 P.M., Nurse E completed Daily Skilled Summary with the following vital signs: T of 97.7 degrees F, 86 P, 18 R; Decisions poor, cues/supervision required. Able to recall current season, staff names/faces, that he/she was in facility/home. Short term memory impaired. Did not state pain or shows signs of pain. No open areas, cuts, lacerations, skin tears, abrasions or bruises present on skin. No falls in the last 3 months, no injury from falls. Further review of the resident's progress notes, dated [DATE], showed the following: -At 11:40 P.M., Nurse E wrote the resident was observed in his/her bed, lying down on his/her back, unresponsive with blood coming from his/her nose. A sternum rub (a painful stimulus used to rouse an unresponsive patient by rubbing the knuckles of a closed fist firmly and vigorously to the center of the chest) performed with no response from the resident. 911 called. Will continue to monitor until paramedics arrive. Vital signs ,[DATE] BP and 22 R; -At 11:57 P.M., the resident left the faciity on a stretcher with the ambulance attendants. During an interview on [DATE] at 1:53 P.M., Nurse E said the following: -Nurse E worked on [DATE], arriving shortly after 11:00 P.M. When he/she started his/her shift on the 100 hall, Nurse C was not present to do rounds with Nurse E or give report; -There was nothing on the 24 hour report sheet saying the resident came back from the hospital with a new [DIAGNOSES REDACTED]. There was not a paper neurological check list flow chart for the resident either. During an interview on [DATE] at 2:19 P.M., CNA F said the following: -He/she worked the night shift on [DATE], arriving shortly after 11:00 P.M., and received report from the off-going CNA (he/she could not remember who gave him/her report); -CNA F found the resident unresponsive in his/her bed when CNA F did his/her rounds shortly after coming on shift and called out for Nurse G to come to the resident's room; -The off-going CNA did not tell CNA F the resident had a new [DIAGNOSES REDACTED]. The off-going CNA reported all the residents were fine, with no issues and asleep. During an interview on [DATE] at 9:21 A.M., Nurse C said the following: -If a resident had a head injury, he/she would start neurological checks, complete them as directed for 72 hours, update the 24 hour shift report showing head injury and neurological checks started while on his/her shift; -Neurological checks were documented in the residents' electronic medical record under Assessments; -When he/she started his/her shift, Nurse C would hold a short meeting with the CNAs and the CMT working on the unit with him/her, to update them on any new signs and symptoms to look for in residents in their care; -He/she expected CNAs and CMTs to report anything unusual to him/her immediately so he/she could assess the resident. During an interview on [DATE] at 10:11 A.M., Nurse C said the following: -24 hour shift reports were kept at the nurse's station and were used to update oncoming staff of any changes in the residents, doctor appointments, allergies [REDACTED]. During an interview on [DATE] at 1:11 P.M., the Director of Nursing (DON) said the following: -Nurses were expected to review discharge paperwork to see if there were any changes to medications, review laboratory and radiology reports and note if there were any new [DIAGNOSES REDACTED]. -Nurses were expected to notify the physician when residents return from the hospital, report any new diagnoses, verify hospital orders and get new orders, if any; -Nurses were expected to notify residents' family members when residents return from the hospital reporting new [DIAGNOSES REDACTED]. -Nurses should document all communication with physicians and family member in residents' progress notes; -Nurses are expected to write a progress note detailing residents' return from the hospital noting any new diagnoses, new orders and any pertinent details from the hospital discharge paper work; -Nurses were expected to initiate neurological checks, notify the physician and obtain orders for a skull series x-ray if a resident had a head injury from a fall. If insurance did not cover x-rays by the facility's mobile x-ray company, the nurse was expected to send the resident out to the hospital because the resident may have sustained a brain bleed. Brain bleeds could be fatal and it was important to get a diagnosis; -Nurses were expected to resume neurological checks when a resident returned from the hospital. Nurses would include the hours when the resident was in the hospital and count them as part of the 72 hour neurological checks. For example, if the resident fell at 12:00 P.M. and was in the hospital for five hours, the nurse was expected to resume neurological checks beginning at 6:00 P.M., the sixth hour from time of fall; -Nurses were expected to resume neurological checks as described above and check on the resident hourly for unresponsiveness if a resident returned from the hospital with a new [DIAGNOSES REDACTED]. -Nurses were expected to complete a paper neurological check flow sheet, update the 24 hour shift report with new diagnosis, fall follow up, any new orders and if a resident went out or returned from the hospital; -Nurses used the 24 hour shift reports to help update oncoming staff; -The unit manager was ultimately responsible for checking over any discharge orders from a hospital. There was not a unit manager working during the day shift on [DATE]. During an interview on [DATE] at 3:53 P.M., the DON said the facility did not have a fall policy or a policy which included when staff were expected to initiate neurological checks, how long to do them or how to document neurological checks. The facility had an incident/accident policy and a change of condition policy, neither of which addressed the above issues. During an interview on [DATE] at 4:25 P.M., the DON and Administrator said they expected nursing staff to document accurate information in residents' medical records. Review of the detailed hour overview for staff, dated [DATE], showed the following: -Nurse C clocked in at 6:30 A.M. and clocked out at 11:00 P.M.; -CNA G clocked in at 3:40 P.M. and clocked out at 11:09 P.M.; -CNA F clocked in at 11:09 P.M. and clocked out on [DATE] at 7:19 A.M. During an interview on [DATE] at 11:40 A.M., Nurse G said the following: -The DON had a meeting with Nurse G on [DATE] to discuss the resident; -The DON said she/he filled out a paper neurological check list based on Nurse G's initial neurological assessment in the resident's electronic medical record; -Nurse G explained to the DON that he/she was only able to do the initial neurological check because the nurse was busy getting discharge paperwork together and making calls to the physician, the x-ray service, then the physician again, and then the ambulance service. During an interview on [DATE] at 11:03 A.M., the DON said the following: -The effective date on the electronic assessments indicates what date and time the information on the assessment reflects, and the signature shows the date and time the nursing staff actually completed and signed the document; -Only the nurses have access to their own log in passwords for the facility's electronic medical record system; -Nurse E signed and locked the COVID-19 risk assessment on [DATE] at 9:02 P.M.; -The DON was not sure why the COVID-19 risk assessment showed Nurse E signed the document on [DATE] at 9:02 P.M. because Nurse E did not come into work until 11:09 P.M. on [DATE]; -The time card showed Nurse D clocked in on[DATE] at 7:01 P.M. through [DATE] at 7:40 A.M. He/she clocked in again on [DATE] at 10:23 A.M. through 10:59 A.M.; -The DON asked Nurse E to come back into work on [DATE] to complete COVID-19 assessments on residents; -The time cards were wrong for every staff member on [DATE], due to the system malfunctioning; -She could not verify if the sign off date and time on the COVID-19 assessment on [DATE] at 9:02 P.M. was correct in the electronic medical record, nor could she verify if any of the information in the electronic medical was correct or incorrect. During an interview on [DATE] at 9:39 A.M., the NP for the facility's medical director said the following: -The NP was on call on [DATE] and gave the order to send the resident out after the fall; -There was no order for hospice. Hospice was brought up as an option for the family to look into when the resident was at the hospital; -Nurses were expected to call the physician or him/herself when a resident returned from the hospital to report any new diagnoses, go over medications and any medication changes, report changes of condition and what happened at the hospital, such as lab and radiology reports; -He/she was not aware the staff gave aspirin and [MEDICATION NAME] to the resident after he/she returned from the hospital; -He/she expected the nursing staff at the facility to watch the resident when he/she returned from the hospital and provide basic medical management. He/she expected them to monitor the resident closely and call with any changes; -He/she expected the staff to take vital signs and perform neurological checks at least hourly for at least a day to make sure the resident was stable or accepted into hospice care; -He/she expected staff to notify him/her if there was a change in the resident's condition so the NP, along with the resident's family, could make a decision on how to treat; -The cause of the resident's death on [DATE] was the subdural hematoma secondary to the fall. 2. Review of the facility's accident and incident documentation and investigation policy, last reviewed on [DATE], showed the following: -The nurse assigned at the time of the incident is responsible for conducting an investigation of the circumstance surrounding the accident/incident, and for notifying the Supervisor, Director, and/or the Administrator as appropriate; -Nurse's notes should contain the following documentation: -Clear objective facts of what occurred; -An evaluation of the resident's condition at the time of the accident/incident may include a description of the resident, vital signs, and any other physical characteristic apparent as a result of the accident/incident; -Any treatment provided; -Any contacts made or attempted with the resident's physician, family, legal representative, or any other health care professional or person involved with the resident's care; -The resident's outcome, and any information concerning the incident; -The Nurse's signature, date, and time of charting; -There is no documentation in the policy stating when neurological checks should be obtained after an accident/incident. 3. Review of the facility's notification of a change in a resident's condition policy, last reviewed [DATE], showed the following: -Policy: The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations. MO 654

Based on interview and record review, the facility failed to provide protective oversight to prevent or minimize the elopement potential for a confused resident with a history of wandering and elopement. The facility did not update the comprehensive care plan to identify the resident as an elopement risk or include interventions to address the potential for elopement for one of three residents (Resident #1). The census was 85. Review of Resident #1's physician's orders [REDACTED]. Review of the resident's POS, from the current facility showed he/she was admitted on [DATE], with no documented diagnoses. Review of the resident's brief interview for mental status (BIMS, a brief screener for cognition), dated [DATE], showed a total score of 13.0 (cognitively intact). Review of the resident's elopement-wandering risk scale, dated [DATE], showed the following: -Ability to communicate; -History of wandering; -No [DIAGNOSES REDACTED]. -Score of 4.0 (,[DATE] indicates low risk). Review of the resident's progress notes, dated [DATE] at 6:48 P.M., showed the resident arrived at the facility alert and oriented to his/her name only. He/she independently propelled his/her wheelchair. The resident ambulated with an unsteady gait. He/she had a wanderguard (electronic monitoring device) on his/her right ankle. During an interview on [DATE] at 11:03 A.M., the Director of Nursing (DON) said staff removed the wanderguard from the resident's leg and sent it back to his/her previous facility. Review of the resident's interim care plan, dated [DATE], showed the following: -No cognitive impairment; -The resident could not communicate easily with or understand staff; -Required assistance with bed mobility, transferring, and ambulation. Further review of the resident's interim care plan, showed no documentation of the resident's history of wandering. During interviews on [DATE] at 11:50 A.M. and on [DATE] at 11:41 A.M., Nurse A said he/she documented that the resident was alert and oriented to name only because the resident knew his/her name but not where he/she was, what town he/she was in, or anything pertinent like identifying the current president. The resident's speech was clear and he/she appeared to understand what staff said. Nurse A was informed the resident received a wanderguard at his/her previous facility just as a precaution. Nurse A based the resident's admission elopement-wandering risk scale assessment on observations, mobility, the ability to maneuver a wheelchair, and where the resident propelled the wheelchair in the facility. There was no indication of an elopement risk or tendency to wander. During an interview on [DATE] at 12:41 P.M., hospice Nurse D said upon admission to the facility, the resident was able to express his/her needs and hold a conversation. The resident was very agitated, because he/she was upset about being moved to the facility. He/she said, I want to go home. Review of the resident's elopement-wandering risk scale, dated [DATE], showed the following: -Inability to communicate; -History of wandering; -Medical [DIAGNOSES REDACTED]. -Score of 14.0 (above 11 indicates high risk to wander). Further review of the resident's interim care plan, showed no documentation of the resident's high risk to wander and no interventions to address that risk. During an interview on [DATE] at 9:36 A.M., the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Coordinator said the resident only had an interim care plan. She created resident care plans based upon an interview with the resident, assessment, and hospital records. When staff reported, during morning staff meetings, that a resident was at risk for wandering or elopement, the MDS Coordinator updated their care plans with that information and interventions to address the issue. However, if a nurse reassessed a resident and found that he/she had become a wandering or elopement risk, then that nurse should update the resident's care plan. Nurses could access resident interim care plans via the facility's database. During an interview on [DATE] at 11:53 A.M., the DON said the facility did not care plan the resident's elopement risk. Upon review of the resident and his/her records at his/her previous facility, the resident was not on a locked unit. The resident's previous facility reported that he/she had not attempted to elope while in their care and the wanderguard was placed on him/her as a precaution, because he/she was mobile. During an interview on [DATE] at 2:38 P.M., hospice Social Worker B said he/she was involved in the resident's care, since the resident began receiving hospice services on [DATE]. At that time, the resident was discharged from the hospital to a nursing and rehabilitation center which subsequently discharged him/her, because he/she kept eloping and the facility did not have a locked unit. He/she got onto the facility parking lot a couple of times. The resident was moved to the locked unit of another skilled nursing facility, where he/she did well. In (MONTH) (YEAR), the facility closed its locked unit and moved the resident into general population with a wanderguard on his/her leg. On [DATE], the facility transferred the resident to the current facility. Social Worker B contacted Social Worker C at that facility, informed him/her of the resident's history of elopement, and urged him/her to have the resident placed on the locked unit. Social Worker C conferred with the DON and informed Social Worker B that it was not a good idea to place the resident on the locked unit, because it was very intense due to a lot of behaviors (of other residents). The facility saw no need to place the resident on the locked unit, saying that he/she had not approached the front door. They were unconcerned by the possibility that he/she would do so, because it was necessary to enter a code into a keypad in order to exit via the front door. During an interview on [DATE] at 12:31 P.M., Social Worker C denied having a conversation with Social Worker B about the resident having a history of elopement or needing to be placed in a locked unit. Social Worker B did express concerns about the resident not receiving more protective oversight, due to his/her move from one facility to another. In order for a resident to be placed on the facility's locked unit, there had to be a diagnosis (e.g. dementia) or behavior necessitating that placement. The resident did not have a [DIAGNOSES REDACTED]. During an interview on [DATE] at 1:00 P.M., the DON said no one told her about the resident having a history of elopement. She was not informed that his/her hospice provider wanted him/her on the locked unit, due to the elopement history. Review of the resident's hospice clinical notes, dated [DATE], showed Social Worker C said staff were aware of the resident's history and were watching him/her closely. Further review of the resident's progress notes, dated [DATE] at 12:19 A.M., showed the resident remained with hospice care and continued to have time confusion. During an interview on [DATE] at 11:50 A.M., Nurse A said on [DATE], he/she documented the resident had time confusion, because when the resident slept hard, he/she awoke confused and thinking it was a different time of day. Staff had to reorient him/her to the correct time of day. Review of the resident's hospice clinical notes, showed the following: -[DATE] at 9:15 A.M., Nurse A informed Social Worker B that the resident was independently getting in and out of bed whenever he/she desired. Social Worker B informed Nurse A of the resident's history of exiting the building at a previous long term care facility; -[DATE] at 9:47 A.M., On [DATE], hospice Nurse D informed Social Worker B facility staff reported that the resident might have had a [MEDICAL CONDITION] (an episode of poor circulation to the brain), as staff reported some droopiness in his/her face. Social Worker B visited the resident and saw some slight drooping to the left side of his/her mouth and slight drooling. The resident was weak and seemed more disoriented than usual. Social Worker B could not understand much of what he/she said. The only words Social Worker B could understand was that he/she wanted to go. The Assistant Director of Nursing (ADON) informed Social Worker B the resident was very agitated earlier, talked about needing to get to his/her car outside, but calmed down after they medicated him/her. During an interview on [DATE] at 2:38 P.M., Social Worker B said on [DATE], Nurse A had no concerns about the resident's condition. He/she said each time the resident had a bad day, it was worse than the last bad day. Social Worker B discussed the resident's change in condition, which was a suspected TIA, with the ADON who informed him/her the resident did not need to go to the hospital. The ADON said she just wanted to inform the resident's hospice staff of his/her change in condition. Social Worker B told her about the resident's elopement history. The ADON had no concerns about the resident eloping due to the keypad at the front door requiring a code for exit and no attempts made by the resident to exit via the front door. During an interview on [DATE] at 12:51 P.M., the ADON said no one informed her about the resident's elopement history. She did not recall the resident experiencing any change in condition, getting agitated, or talking about leaving the facility on or around [DATE]. During an interview on [DATE] at 12:41 P.M., hospice Nurse D said he/she saw the resident at the facility on [DATE]. The resident was not very talkative, appeared to be tired, and did not want to get out of bed. Facility staff thought perhaps he/she had a TIA. Nurse D informed Nurse A there was no assessment Nurse D could do and the only option would be to send the resident to the hospital. Further review of the resident's progress notes, dated [DATE] at 11:39 A.M., showed the resident was out of bed after the morning meal requesting to eat lunch. Nurse A explained that lunch was still a couple of hours away, but he/she could have a snack. The resident continued to move towards the dining room. The resident ambulated without assistance. His/her gait was weak and slow. Nurse A got the resident's wheelchair, asked him/her to have a seat, and assisted him/her into the wheelchair after he/she stopped ambulating. The resident was pale in the face and wide-eyed. Nurse A instructed staff to assist him/her back to his/her room and notified the resident's hospice staff of the need for an evaluation. At 2:27 P.M., Nurse A informed the hospice nurse (Nurse D) regarding the resident's mental status and noted increased confusion and agreed to continue to monitor him/her. Review of the resident's medical record did not show any documented vital signs on [DATE]. There was no reassessment of the resident's elopement-wandering risk. During interviews on [DATE] at 11:50 A.M. and [DATE] at 11:41 A.M., Nurse A said on [DATE], the resident did not talk. He/she just looked at whomever spoke to him/her. He/she usually verbalized something. The resident held onto the railings along the walls, as he/she ambulated. Nurse A had to go and get the resident's wheelchair and remind him/her to sit down. The resident appeared to want to see something down the hall, so he/she wheeled him/her down the hall before returning to his/her room. Nurse A notified hospice Nurse C of the resident's change in condition: not knowing the time, having to use a wheelchair, staff having to verbally redirect him/her back to his/her room, and him/her wanting to get out of bed. Staff had to anticipate the resident's needs that day, in order to see if there was a reason for him/her getting up unassisted. Nurse A did not notify the resident's physician of his/her mental status change and increase in confusion, because Nurse A contacted the hospice nurse and assumed the hospice nurse would notify the resident's physician. During an interview on [DATE] at 12:41 P.M., hospice Nurse D said on [DATE], Nurse A called and informed him/her the resident had experienced increased confusion. Nurse D informed Nurse A that if the family wanted the resident to get checked out at the hospital, they could do so. The hospice physician was not monitoring or providing any medical care to the resident. Nurse D did not contact the resident's facility physician. During an interview on [DATE] at 10:36 A.M., the resident's physician said he expected facility or hospice staff to notify him of the resident's change in mental status and increased confusion on [DATE]. An increase in confusion would have made the resident more at risk for wandering and elopement. Staff should have increased his/her level of supervision. The resident's physician would have ordered one-on-one supervision, after learning of the resident's change in mental status and increased confusion. Hospice could have gotten a sitter for the resident. Review of the resident's admission MDS, dated [DATE], showed the following: -Facility entry date of [DATE]; -Moderate cognitive impairment; -No diagnoses, listed on the assessment, within the last seven days; -Wandering not exhibited; -No mobility devices. Further review of the resident's progress notes, dated [DATE] at 6:44 P.M., showed when the charge nurse arrived back from break at approximately 4:25 P.M., a certified nurse aide (CNA) said the resident was missing and the alarm on the exit door was going off. The CNA said he/she just checked on the resident, who was in bed sleeping. The CNA had gone into another room doing rounds. When he/she emerged, the alarm was going off and the resident was missing. Nurse C ran back down the hall and outside of the building to search the perimeter, but did not see the resident. Nurse D went back into the facility to check rooms and bathrooms. He/she did not see the resident and told the CNA to stay on the hall, while he/she drove around the neighborhood to search for the resident. When Nurse D pulled back up to the facility, a CNA was pushing a wheelchair to the apartment complex across the street from the facility. The resident was inside the building with a blanket wrapped around him/her. The fire department arrived and took the resident to the hospital. During an interview on [DATE] at 12:35 P.M., CNA F said the resident was on 100 hall for several days, prior to [DATE]. Consequently, staff had to have been aware of his/her confusion and risk for wandering and elopement. No one informed CNA F. The other residents on 100 hall were not confused. They could all express their needs and only required physical assistance. The resident had recently transferred, with several other residents, to the facility. As a result, there were 18 residents, rather than the usual 11 residents on 100 hall. CNA F was the only aide working on that hall and felt very overwhelmed. On [DATE], he/she began his/her shift at 3:00 P.M. by conducting rounds. At 4:00 P.M., CNA F saw the resident in bed asleep and continued on his/her rounds. At approximately 4:15 P.M., CNA F was across the hall in another resident's room with the door closed. He/she heard the alarm for the door at the end of 100 hall sounding. Because CNA F was not working on a locked unit that day, he/she did not consider the possibility that a resident had eloped. CNA F continued assisting the other resident for approximately three minutes, before emerging from the room. By then, the resident was no longer on facility property. CNA F went out, got into his/her vehicle and drove around the neighborhood. Approximately ten minutes later, he/she returned to the facility. CNA F remained there, in order to keep other residents from eloping while staff searched for the missing resident. If someone informed him/her the resident was confused and an elopement risk, then he/she would not have closed the door while across the hall in the other resident's room. That way, he/she could have heard what was going on in the hall and peeked around the pulled privacy curtain. During an interview on [DATE] at 2:35 P.M., Nurse E was the charge nurse for 100 hall on [DATE], when the resident eloped. His/her level of alertness and orientation fluctuated. No one informed Nurse E of the resident's high risk for wandering and eloping. The resident was up and down out of bed and into his/her wheelchair, propelling it with his/her feet. Nurse E was on a break when the resident eloped. Upon Nurse E's return from break, CNA F said the resident was missing. Nurse E checked the resident's room and noticed his/her wheelchair was still in the room. Nurse E proceeded to check the perimeter of the building. He/she went inside and another resident informed him/her the resident had eloped approximately five minutes earlier. Nurse E notified staff on the other side of the building the resident was missing. He/she instructed CNA F to watch the hall. Nurse E got into his/her car and drove around. He/she returned to the facility and saw a CNA pushing the resident's wheelchair across the street. When staff brought him/her back to the building, the resident was confused but not agitated. He/she had no visible bruising or scratches. Nurse E did not get a chance to assess the resident. During an interview on [DATE] at 2:25 P.M., Nurse G said he/she was working on 300 and 400 halls on [DATE] at 4:25 P.M., when Nurse E informed him/her the resident was missing. Nurse G got up and checked his/her halls. He/she relayed the information to a nurse who lived in an apartment building across the street. Sometime between 4:35 P.M. and 4:36 P.M., Nurse G learned the resident was in an apartment building across the street. Nurse G went across the street. The resident was sitting down, covered with a jacket and blanket someone had given him/her. The resident was calm and showed some confusion. He/she knew his/her name and could answer questions. The resident denied any pain. Nurse G asked if he/she could stand up and the resident said no. Nurse G called the facility and had someone bring them a wheelchair. When the other staff arrived with the wheelchair, they performed a two-man transfer of the resident into the wheelchair. He/she had no visible bruises or scratches. Review of the resident's hospital records, dated [DATE], showed the resident arrived in the emergency room wearing short socks, an adult brief, and a stranger's jacket. Stool was present around the adult brief. The resident was unshaven and his/her hair was disheveled. The chief complaint was cold exposure. The resident had wandered from facility and was outside for approximately 20 minutes in a soiled brief. Strangers found the resident wearing just an adult brief and socks. They gave him/her a jacket and called emergency medical services. The resident was oriented times one and had mottled skin (lace-like purplish discoloration caused by reduced blood circulation). Due to dementia, the resident could not provide a history. His/her vital signs were blood pressure ,[DATE] (normal range, less than 120 over less than 80), pulse 57 (normal range, 60 - 100 beats per minute), temperature 97.7 degrees Fahrenheit (normal range, 97.8 - 99.1 degrees F), respirations 14 (normal range, 12 - 18 breaths per minute), blood oxygen saturation 94% (normal range, 94% to 99%). At 5:11 P.M., the resident's blood pressure was ,[DATE]. At 5:15 P.M., the resident's blood pressure was ,[DATE]. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of cardiac failure. A comprehensive metabolic panel (blood tests) showed high blood urea nitrogen level (reveals how well the kidneys and liver are working) of 34 (normal range: ,[DATE] milligrams (mg)/deciliters (dL)) and creatinine level (a high serum creatinine level means the kidneys are not working well) of 1.60 (normal range: 0XXX,[DATE].30 mg/dL), which led to a [DIAGNOSES REDACTED]. The resident was admitted to the cardiac telemetry unit. The final diagnoses were cold exposure, dementia with behavioral disturbance, elevated blood pressure reading, pneumonia due to organism, adult neglect, QT (cardiac output) prolongation (electrical heart rhythm disturbance), [MEDICAL CONDITION] (slow heart action), and [MEDICAL CONDITION] with unknown LVEF (left ventricle ejection fraction; how well the left ventricle pumps blood with each heart beat). During an interview on [DATE] at 9:22 A.M., the resident's physician said he was not informed of the resident's elopement history. If staff had notified him of the resident having multiple elopements, then he would have instructed staff to place the resident on the facility's locked dementia unit, until an appropriate placement could be found. The resident did not have a medical [DIAGNOSES REDACTED]. A wanderguard would have also been an appropriate intervention. The resident's physician said he was not notified of the resident potentially having had a TIA on [DATE]. A TIA was a significant change in condition that warranted facility or hospice staff notifying him. A TIA would exacerbate the resident's level of confusion. The resident's physician was unaware of the resident's [DIAGNOSES REDACTED]. The resident's physician said the resident's elevated blood pressure upon admission was likely due to the stress of being cold/anxious/agitated, or the contraction of blood vessels brought on by the cold, or breathing issues related to his/her pneumonia and surging [MEDICATION NAME]. The mottled skin suggested poor circulation; the blood vessels contracted into the body, in an attempt to keep the resident warm. Elopement placed the resident at moderate risk for harm, given his/her pre-existing health condition, cold exposure, and confused wandering outside without staff supervision. During an interview on [DATE] at 11:03 A.M., the DON said staff were informed of a resident's care needs during report, at the beginning of their shifts, and via resident care plans in binders at the nurses' stations. When a door alarm sounded, direct care staff were expected to secure the resident to whom they were attending and then immediately go to the door where the alarm was sounding, look out and see if they spotted a resident attempting to elope. If they did not see anyone, then they were to go back inside and do a head count of residents, in order to determine whether or not anyone was missing. If a resident did elope, then staff were to do a perimeter search and continue expanding the search area outward, until they found the resident. During an interview on [DATE] at 9:51 A.M., the Administrator said there was no keypad for the door at the end of 100 hall. The bar across the door had to be pressed for 15 seconds, in order to exit via that door. The door would then open and a delayed egress alarm, which was not very loud, would sound. A louder backup alarm would also be triggered. Outside that door was a gate with no lock, atop a hill with no steps, which led to an alley. Staff were trained as needed on what to do when door alarms sounded; they received in-service training following related incidents. The only exception to the required immediate response by staff to a triggered door alarm was if someone had expired and the funeral director needed entrance to the building. Review of the facility's policy titled Prevention of Elopement dated [DATE], showed direction for staff to provide a safe environment by assessing residents' risk factors and implementing a plan of care to prevent accidents related to wandering behavior or elopement. Elopement was defined as leaving the facility or supervised environment without accompaniment or knowledge of the staff prior to their scheduled discharge. Staff was to prevent elopements by appropriately assessing resident risk factors, observing resident patterns, communication with family/responsible party, identifying the significance of risk factors and implementing prevention interventions. Each resident who was independently mobile, either by ambulation or wheelchair, should be evaluated upon admission and with a change in condition using the wandering/elopement risk assessment. The care plan was to include, but not be limited to, off ground privileges and supervision required to leave the facility grounds. Residents identified with significant risk factors beyond the facility's environmental capabilities (unsecured facilities) should be evaluated for transfer to a more secure facility. Review of the facility's emergency preparedness plan titled, missing resident showed direction for staff to record the time that a resident was discovered missing, as well as when and where he/she was last seen. They were to verify that the resident had not signed out and was not discharged . Staff was to perform census verification and resident roll call to determine if there were any other missing residents. They were to activate the facility's emergency operations plan. Announcing Dr. Wander three times on the overhead paging system would alert staff. Staff was to search the facility grounds for the resident. If necessary, they were to distribute copies of the resident's photograph. Staff was to keep a record of the areas searched. If staff did not find the missing resident, following an expedient search, then they should call 911. Staff was to notify the resident's responsible party or next of kin, local authorities, and the Department of Health and Senior Services that the resident was missing and a search was underway. Staff was to coordinate with public safety agencies in searching for the missing resident. Review of the facility's policy titled Change in Condition dated [DATE], showed direction for staff to make every effort to inform the resident, consult with the resident's physician and notify, consistent with his/her authority, the resident's representative when there was the following: an accident involving the resident which resulted in injury and had the potential for requiring physician intervention, a significant change in the physical, mental or psychosocial status, that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complications, a need to alter treatment due to adverse consequences/commence a new form of treatment, or a decision to transfer/discharge the resident from the facility. MO 7031

Based on observation, interview and record review, the facility failed to appropriately assess and provide timely treatment for [REDACTED].#10, #1, #2 and #3). The census was 57. 1. Review of Resident #10's medical record, showed the following: -An April 2012 face sheet included [DIAGNOSES REDACTED]. -Review of a significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed the following: -sometimes understands/sometimes understood; -memory and decision making impairments; -extensive assistance of staff for bed mobility, transfers, toilet use, personal hygiene and bathing; -incontinent of bowel and bladder; -Review of nurse's notes dated 6/25/12, showed the following: -at 12:32 A.M., Nurse F wrote the resident's temperature elevated, at 103.5 degrees Fahrenheit (F) (normal 98.6 degrees F). Feverall (medication used to treat pain and temperature) suppository 650 milligrams (mg) given; -no further assessment of the resident's status documented between 12:32 A.M. and 6:30 A.M.; -at 6:30 A.M., resident re-checked for elevated temperature. Temperature at 104.1 degrees F. Tylenol (medication used to treat pain and temperature), 650 mg given; -at 6:32 A.M., called Physician D's exchange. Physician E on-call for Physician D. Awaiting a call back; -at 6:50 A.M., Physician E returned call and gave orders to send the resident to the hospital for evaluation; -at 9:00 A.M., call placed to power of attorney (POA) to inform him/her of resident's change in condition and order to send to the hospital. No answer, will call later; -at 9:54 A.M., call to ambulance for transportation, no estimated time of arrival, will be here as soon as possible and call back if resident's condition changes; -at 10:00 A.M., ambulance arrived to transport resident to the hospital. -no further assessment of the resident status documented between 6:30 A.M. and when the resident left via ambulance at 10:00 A.M. Review of the resident's hospital admission record dated 6/25/12, showed the following: -Presented to the emergency room for fever and [MEDICAL CONDITION] with blood pressures in the 70s/40s (normal 110/70); -Given 4 liters of normal saline and blood pressure responded appropriately; -After [MEDICATION NAME], blood pressure decreased again, but was able to maintain with further administrations of fluids; -Started on [MEDICATION NAME] (an antiinfective), [MEDICATION NAME] (an antiinfective) Meropenem (antiinfective) and [MEDICATION NAME] (antiinfective) via left internal jugular catheter (a catheter inserted into a major vein in the neck); -Transfer to the intensive care unit; -Diagnosis: [REDACTED]. During an interview on 7/25/12 at 10:05 A.M., the Director of Nursing (DON) said she would expect Nurse F to check on the resident within 30 minutes after giving the 12:32 A.M., dose of Feverall (on 6/25/12) to see if the medication was effective in reducing the 103.5 degrees F. temperature. To not check on the resident for another six hours, is unacceptable. At 6:30 A.M., when the resident had 104.1 degree F. temperature, whether he/she got hold of a physician or not, he/she should send the resident out. She could not explain the delay of three hours between when the physician gave the order to send the resident to the hospital and when Nurse F called the ambulance. The DON said there would be no documentation, other than nurse's notes, where Nurse F would record temperature or vital signs. During an interview on 7/27/12 at 11:25 A.M., Nurse F said on 6/25/12 at 12:32 A.M., after he/she gave the Feverall, he/she did attempt to call the physician, but was put on hold. He/she was on hold when something else at the facility took his/her attention and he/she hung up on the exchange. He/she was the only nurse at the facility that night. He/she recalled giving the resident Tylenol around 1:30 A.M., and his/her fever went down to around 100.4 degree F. The resident was sweating, but the room was warm and Nurse F adjusted the A/C unit to cool the room. Nurse F said he/she took the resident's temperature and vital signs three times that night and it should be documented in the nurse's notes. It is facility practice to call the physician before sending the resident to the hospital. When Nurse F did receive the order to send the resident to the hospital, he/she delayed calling the ambulance as he/she wanted to speak with the power of attorney to see if it was okay to send the resident to the hospital. During an interview on 7/27/12 at 2:00 P.M., the DON said no documentation had been found to show what/if any medication Nurse F gave the resident the night of 6/25/12 to lower his/her temperature. During an interview on 8/7/12 at 2:00 P.M., the resident's physician said if the resident had a fever between 103 degrees F and 104 degrees F, he would expect staff to notify him and he would have facility staff transfer the resident to the hospital emergency room for evaluation, a fever that high may mean the resident is septic. He would expect when a physician ordered the resident be sent to the hospital, staff would contact the ambulance and send the resident to the hospital right away. Review of the facility's policy on "Change in a Resident's Condition of Status" dated 4/11, showed the following: -The facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status; -The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been a significant change in the resident's physical/emotional/mental condition; -Unless otherwise instructed by the resident, the nurse supervisor/charge nurse will notify the resident's family or representative when there is a significant change in the resident's physical, mental or psychosocial status or if it is necessary to transfer the resident to a hospital/treatment center; -The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 2. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Moderately cognitively impaired; -Long and short term memory problems; -Always incontinent of bladder; -Extensive assistance required for toileting, bathing, personal hygiene and transfers; -Nonambulatory; -One Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.); -No pain. Review of the resident's pain evaluations, showed the following: -6/6/12: The resident denied all pain, total score for the pain scale (a scale used for measurement of pain in people with dementia who cannot verbalize) was zero. While observing the resident, score questions one to six using the following scores: absent = 0, mild = 1, moderate = 2, severe = 3. The following vocalization (groaning or crying), facial expressions (frowning or grimacing), change in body language (fidgeting, rocking or guarding part of the body), behavioral changes (increased confusion, refusing to eat or alteration in usual patterns), physiological change (temperature, pulse or blood pressure), physical changes (skin tears or pressure areas.) Total pain score 0-2 = no pain was selected. Past pain question was marked not applicable (N/A), past pain interventions of prescribed medications, over the counter medications and non-medication interventions were all marked N/A. Current pain (using the following scale, rate how in the past 24 hours pain has interfered with): ability to communicate, mood, ability to ambulate, relation with people, toileting, eating (mouth pain/weight loss), sleeping, enjoyment and other all were marked zero's on the pain assessment. No documentation was on the back of the pain assessment; -7/13/12: The resident denies all pain, total score for the pain scale Total pain score 0-2 = no pain selected. Past pain question was marked not applicable (N/A), past pain interventions of prescribed medications, over the counter medications and non-medication interventions were all marked N/A. Current pain all were marked zero's on the pain assessment. No documentation on the back of the pain assessment. Review of the resident's care plan dated 10/5/11 and in use during the survey, showed no pain interventions documented. Review of the physician order [REDACTED]. -[DIAGNOSES REDACTED]. -6/12/12: Tylenol 650 mg (for mild to moderate pain) every four hours whenever needed (PRN) for pain; -7/13/12: [MEDICATION NAME] (narcotic pain medication) 5/325 mg every six hours PRN pain. Observation on 7/19/12 at 3:00 P.M., showed the resident lay in bed. The wound nurse administered Tylenol to the resident. At 3:30 P.M., the resident lay in bed. The wound nurse entered the room to change the dressings on the resident's pressure and arterial wounds. During the dressing change, the resident kicked his/her feet and yelled out "ouch that hurts!" He/she moaned, groaned and had facial grimacing during the entire dressing change. Review of the follow up visit wound progress/procedure note dated 7/17/12, showed the following: -Date acquired 1/30/12, pressure and arterial wound, Unstageable (slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) and/or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding tissue): Known but not stageable due to coverage of wound bed by slough and/or eschar at the time of admission) on the resident's left heel, measured 2.0 cm by 3.0 cm, slough covered 60% of the wound bed, moderate serosanguinous (semi-thick reddish fluid) exudate (drainage), peri wound tissue (area around the wound) dry and intact, odor present, eschar covered 40%, 60% granulation (healing tissue); -Date acquired 1/30/12, pressure and arterial wound, Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) on the resident's right heel, measured 4.5 cm by 4.5 cm by 0.4 cm, small amount of serosanguinous exudate, peri wound tissue dry and intact, no odor present, yellow slough covered 30% of the wound bed, no eschar present, 70% granulation present, fascia (fibrous connective tissue) exposed; -Date acquired 1/30/12, pressure and arterial wound, Stage IV on the resident's right posterior leg, measured 11.5 cm by 2.0 cm by 0.5 cm, large amount of serosanguinous exudate, peri wound tissue dry and intact, strong odor present, yellow slough covered 30% of the wound bed, no eschar present, 70% granulation present, muscle exposed. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -Tylenol 650 mg administered on 7/14 at 1:00 P.M., on the back of the MAR indicated [REDACTED].M., documentation showed the result was effective; -Tylenol 650 mg administered on 7/19/12 at 3:00 P.M., on the back of the MAR indicated [REDACTED].M. -[MEDICATION NAME] 5/325 mg one tablet every six hours PRN, no documentation of medication administered. No documentation on the back of the MAR indicated [REDACTED] During an interview on 7/19/12 at 3:10 P.M., the wound nurse said the resident usually kicks, hits and curses during dressing changes. During an interview on 7/25/12 at 8:00 A.M., the wound nurse said the CMT is to administer pain medication to the resident 30 minutes prior to dressing changes. [MEDICATION NAME] is not available because the pharmacy said the POS has to be signed by the resident's physician because the medication is a narcotic. She has not followed up on getting the order clarified, she thought the ADON was going to follow up on that. The CMT is responsible to administer pain medication prior to treatment and the wound nurse does not have access to the medication cart. She said Tylenol is not an appropriate pain medication for a resident with two Stage IV pressure ulcers and one Unstageable pressure ulcer, but that is all that was available for the resident at the time. She has suggested to the resident's physician [MEDICATION NAME] liquid (narcotic pain medication to treat severe pain) but his/her physician said that medication was not appropriate for the resident at that time. 3. Review of Resident #2's admission MDS dated [DATE], showed the following: -admitted on [DATE]; -Understood/understands; -Total assistance required for transfers; -Occasionally incontinent of bowel; -Always incontinent of bladder; -Extensive assistance required for toileting, bathing, personal hygiene and range of motion; -On admission one Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) located on the resident's buttock that measured 1.0 cm by 0.1 cm by 0.2 cm. Review of the admission nursing assessment form dated 5/25/12, showed an open areas on the resident's buttock, a recent [MEDICAL CONDITION] of the right leg and a recent left foot toe amputation. The assessment did not show the size, measurements, description of or any further assessment of the areas. Review of the pain scale evaluation, showed the following: -5/25/12: In the section, is the resident in pain, there are two check marks, currently in pain, at risk for pain, experienced pain the in past, no pain reported. It is unable to be determined what the two check marks refer to. "No" to the question is the resident reluctant to verbalize or express pain, all zeros were documented for the section of does the resident demonstrates sign of cognitive and sensory impairment and communication difficulties. No total pain score documented. Past pain interventions: prescribed medication effective, over the counter medications N/A, non-medical interventions effective. Current pain all marked zero's on the pain assessment. No documentation on the back of the pain assessment; -6/25/12: In the section, is the resident in pain there was one check mark, currently in pain, at risk for pain, experienced pain the in past, no pain reported. It could not be determined what the one check mark meant. "No" to the question is the resident reluctant to verbalize or express pain, all zeros documented for the section does the resident demonstrate sign of cognitive and sensory impairment and communication difficulties. No total pain score documented. Past pain interventions: prescribed medication N/A, over the counter medications N/A, non-med interventions N/A. Current pain all were marked zero's on the pain assessment. No documentation was on the back of the pain assessment. Review of the resident's record, showed no further documentation of the resident's skin upon admission. Review of the Braden Scale assessments, showed the following: -On 5/25/12, score of 13 (total score of 12 or less represented high risk for skin breakdown); -On 6/25/12,score of 13. Review of the admission nursing assessment form dated 6/25/12, showed a right leg [MEDICAL CONDITION] and toes on the left foot amputated, no documentation regarding any skin breakdown or open areas. Review of the POS [REDACTED] -Diagnoses: [REDACTED]. -6/26/12: [MEDICATION NAME] soaked gauze with Kling wrap to the left foot daily; -An order dated 5/25/12, Citric Aid Clear (barrier cream) apply to buttocks twice a day (BID) and whenever necessary (PRN.) Review of the treatment administration record (TAR), dated 7/7/12 through 8/6/12, showed the Citric Aid Clear barrier cream was not initialed as applied on the following dates and times: -7:00 A.M. through 3:00 P.M., 7/20, 7/21, 7/22/12; -3:00 P.M. through 11:00 P.M., 7/20, 7/21, 7/23/12; -The barrier cream discontinued on 7/24/12; -No documentation of the cream administered PRN; -Review of the back of the TAR, showed no documentation of why the cream was not administered. Review of the wound management sheet, dated 7/18/12, showed the resident was not listed as having wounds. During an interview on 7/19/12 at 1:35 P.M., the wound nurse said she usually works Tuesday, Wednesday and Friday, she does all the wound dressings in the facility and when she is not there the treatments should be completed by Nurse C. Observation on 7/19/12 at 1:45 P.M., showed the resident sat in his/her wheelchair in his/her room. The wound nurse entered the room to do a dressing change on the resident's left foot surgical wound. The wound nurse assisted the resident to lift his/her foot onto the chair beside him/her. When the nurse lifted the resident's foot onto the chair, the resident groaned and grimaced and said "that hurts." Observation of the surgical wound, showed an open area at the left great toe amputation site that measured approximately 2 cm by 2 cm, slough covered approximately 50% of the wound bed, a small amount of serosanguinous exudate, peri wound tissue dry and intact and no odor present. Observation on 7/19/12 at 3:30 P.M., showed Nurse C and Nurse N entered the resident's room and transferred the resident from his/her wheelchair to the bed with a Hoyer lift (mechanical lift). Nurse C removed the resident's incontinence brief, turned the resident onto his/her left side, exposed a superficial open area on his/her left ischium (inferior dorsal portion of the hip bone) that measured approximately 1.2 cm x 1.2 cm with pink tissue covering the wound bed. The resident's right and left buttock were red and excoriated. No other open areas were noted. Review of the care plan dated 7/20/12, showed the following: -Problem: One Stage III pressure ulcer to the buttock upon admission related to incontinence and immobility; -Documented healed, no date. Noted: remains at risk for skin breakdown. -Interventions: keep the skin clean and dry, change incontinence pad as soon as possible after voiding (urinating) or bowel movement, apply protective or barrier ointment after each incontinent episode, avoid hot water and irritating soaps, provide treatment and dressing changes as ordered, use a draw sheet or lifting device to move the resident, maintain adequate nutrition and hydration. Review of the undated CNA care card, showed no documentation of skin breakdown. Observation on 7/20/12 at 2:30 P.M., showed the resident lay in bed. CNA B assisted to resident to roll to his/her left side. The resident had an open area on the resident's left ischium. The area measured approximately 1.0 cm by 1.0 cm . The resident's right and left buttock remained red and excoriated. No other open areas noted. Review of the facility's licensed nurse weekly skin assessment, dated 7/20/12 showed the resident had a red buttock. Review of the resident's medical record, showed no assessment, physician notification or documentation of the pressure ulcer on the resident's left ischium between 7/20 and 7/24/12. Observation and interview on 7/24/12 at 8:00 A.M., showed the resident lay in bed. CNA A and CNA B enter the room to provide care for the resident. During a skin assessment, the resident had five open areas on his/her buttock and posterior inner thigh and a red raised rash on his/her right upper inner thigh area. Dried feces was between the resident's right thigh and perineal fold area. The resident said his/her buttocks had been raw for days and has been very uncomfortable. Observation and interview on 7/24/12 at 8:25 A.M., showed the Director of Nurses (DON) assessed the resident's buttock and abdominal fold. She had not been conducting wound rounds with the wound nurse because she was working on MDS's and care plans. She was unaware of the open areas on the resident's buttock and posterior inner thigh. The DON said the resident was admitted with a pressure ulcer to his/her coccyx (tailbone) but that had healed. The DON measured the open areas: -Right buttock open area was red, no drainage, slough or odor assessed, measured 2.0 cm by 1.0 cm; -Right buttock open area red, no drainage, slough or odor assessed, measured 0.5 cm by 1.0 cm; -Left buttock open area, red, no drainage , slough or odor assessed, measured 1.5 cm by 1.0 cm; -Left buttock open area, red, no drainage, slough or odor assessed, measured 1.0 cm by 1.0 cm; -Left buttock open area, red, no drainage, slough or odor assessed, measured 0.5 cm by 0.5 cm. During an interview on 7/24/12 at 8:40 A.M., the DON said the five areas open. She was unaware the resident had the open areas until just then. She would have the wound physician see the resident. Review of the wound physician assessment dated [DATE], showed type of wound-other, multiple excoriations including both buttocks measured 0.5 cm to 1.5 cm. Plan of care; skin prep on any open wound on perineum. During an interview on 7/25/12 at 8:00 A.M., the wound nurse said the open area on the resident's left foot has been open and slough covered since he/she started working at the facility, approximately three months ago. She has not notified the resident's physician to get a new treatment order for the open area. When she cleanses the surgical wound, she sprays wound cleanser directly on the open area and scrubs it with a 4 by 4 gauze pad in an attempt to debride (process of removing dead tissue) from the wound. 4. Review of Resident #3's admission MDS dated [DATE], showed the following: -admitted on [DATE]; -[DIAGNOSES REDACTED]. -Alert and oriented; -Set up assistance from staff for activities of daily living (ADL's); -Continent of bowel and bladder; -No wounds or skin problems. Review of the admission POS dated 6/29/12, showed the following: -An order dated 6/29/12, for staff to cleanse the open area on the left heel with normal saline (sterile cleansing solution used for wounds), apply Santyl (ointment used to treat and promote healing of wounds) and a dry dressing daily; -An order dated 6/29/12, for Meda boot (specialized boot used for protection) to be applied to the left foot; -An order dated 7/11/12, for staff to apply heel protectors (extra padded foam used to protect heels) while supine (positioned on the back) in bed to prevent shearing (exertion of pressure on the skin or tissue). Review of the admission nursing assessment dated [DATE], showed the following: -Stage III area to left heel; -treatment for [REDACTED]. -No description of the open area, no documentation regarding what type of wound and no measurement of the open area on the resident's left heel. Review of the initial care plan completed by the nursing staff dated 6/29/12, showed no problem identified for the open area on the left heel and intervention for pressure relief mattress. No other interventions addressed on the care plan. Review of the comprehensive care plan dated 7/25/12, showed no problem identified for the open area on the left heel and no interventions addressed on the comprehensive care plan. Review of the facility's wound management sheet, showed the following: -On 6/27/12, no documentation on the wound report regarding the resident's open area on his/her left heel; -On 7/11/12, trauma, left heel wound measured 0.3 cm. by 0.3 cm by 0.2 cm; -On 7/18/12, trauma, left heel wound measured 0.3 cm by 0.2 cm by 0.1 cm. Review of the weekly skin assessment, showed the following: -On 7/6/12, open area to the left heel measured 0.3 cm x 0.1 cm x 0.1 cm; -On 7/20/12, open area to the left heel measured 0.3 cm x 0.2 cm x 0.1 cm; -No description of the wound; -No documentation regarding the type of wound. Observation on 7/19/12, showed the following: -At 1:00 P.M., the resident sat in his/her wheelchair in the therapy department without the Meda boot on his/her left foot. -At 2:00 P.M., the resident sat on the edge of his/her bed without the Meda boot on his/her left foot. -At 3:00 P.M., the resident lay on his/her back in bed without heel protectors applied to his/her heels and no Meda boot on his/her left foot. The heel protectors lay on the end of the bed. Observation on 7/20/12, showed the following: -At 6:40 A.M., the resident ambulated in the room without a Meda boot on his/her left foot. He/she ambulated to the bathroom in his/her bare feet with a soiled dressing on his/her left heel. -At 10:00 A.M., 11:45 A.M. and at 3:00 P.M., the resident without a Meda Boot on his/her left foot. Observation on 7/23/12 at 10:00 A.M., showed the resident sat in his/her wheelchair in the activity room without a dressing on his/her left heel and no Meda boot on his/her left foot. The resident's left heel pressed directly on his/her shoe. The open area on the resident's left heel measured approximately 0.5 cm x 0.5 cm with pink tissue that covered the wound bed. Observation and interview on 7/23/12 at 11:50 A.M., showed Nurse X entered the resident's room and provided treatment and dressing application to the resident's left heel. Nurse X cleansed the open area on the left heel with normal saline, measured the open area as 0.5 cm x 0.5 cm with yellow slough (dead tissue) that covered the wound bed, applied Santyl ointment with cotton tip applicator and dry dressing. The nurse said the resident was admitted to the facility with the open area on his/her left heel and it was not a pressure ulcer, but an open wound. Nurse X said he/she did not remove a dressing from the resident's left heel prior to providing the treatment and the open area should have a dressing to promote healing of the wound and due to infection control. The nurse expected nursing staff to notify the charge nurse when the dressing was not intact and the charge nurse should reapply a dressing to the left heel. At that time, the resident said the dressing fell off during the night and he/she notified nursing staff during the night regarding the dressing. The night shift nursing staff informed him/her, they did not apply treatments and dressing application. Observation on 7/23/12 at 5:00 P.M., showed the resident sat in his/her wheelchair in the dining room without a Meda boot on his/her left foot. Observation on 7/24/12, showed the following: -At 6:50 A.M., the resident lay on his/her back in bed without heel protectors on his/her heels and his/her heels pressed directly against the mattress. The heel protectors lay on the end of the bed. -At 8:15 A.M. and 12:30 P.M., the resident sat in his/her wheelchair without a Meda boot on his/her left foot. During an interview on 7/25/12 at 10:05 A.M., the DON said the resident was admitted to the facility with the open wound on his/her left heel and it was not a pressure ulcer. Nursing staff should notify the charge nurse when a dressing fell off and staff should reapply a dressing to any open wound. She expected all charge nurse's to provide a treatment and application of a dressing when the wound nurse was not at the facility. The resident's open wound should have a dressing intact to promote healing and infection control.

Based on observation, interview and record review, the facility failed to identify, assess and provide appropriate care for residents at risk for pressure ulcers. The facility identified two residents with pressure ulcers. Both residents were included in the sample of 13. One of the two residents did not receive appropriate care and staff did not implement prevention protocols to prevent pressure ulcers on one resident. (Residents #1 and #9). The census was 57. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/9/12, showed the following: -Moderately cognitively impaired; -Long and short term memory problems; -Always incontinent of bladder; -[MEDICAL CONDITION] (a surgical opening through the abdomen to excrete feces) for bowel; -Extensive assistance required for toileting, bathing, personal hygiene and transfers; -Nonambulatory; -One Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) pressure ulcer. Review of the care plan last updated 10/5/11 and in use during the survey, showed the following: -Problem: at risk for skin breakdown related to incontinence and decreased mobility; -Interventions: pressure reduction mattress, educate the resident to reposition frequently, staff will inspect skin while providing incontinence care, bathing and weekly, report to physician accordingly, encourage fluid intake for adequate hydration. Review of the undated certified nurses aide (CNA) care plan, showed the resident should be assisted by one staff or a sit to stand lift. The CNA care plan did not show the resident had pressure ulcers. Review of the Braden Scale assessment (assessment for predicting risk of pressure ulcer development), dated 6/6/12, showed the following: -Score of 13 (total score of 12 or less represented high risk for skin breakdown); -No further Braden Scale assessment since 6/6/12. Review of the physician order [REDACTED]. -[DIAGNOSES REDACTED]. -6/27/12, Hoyer lift (full body lift) due to non weight bearing status; -6/15/12, Off loading boots both heels every day; -7/10/12, Bactrim DS 800 milligrams (mg)/160 mg (broad spectrum antibiotic); -7/17/12, cleanse left heel with wound cleanser (WC), apply Santyl ([MEDICATION NAME] ointment) and Silver Alginate (antimicrobial gauze) every day; -7/17/12, cleanse left lower leg with WC, apply Santyl and Silver Alginate every day; -7/17/12, cleanse right heel with WC, apply Santyl and Silver Alginate every day. Review of the follow up visit by the wound specialist, wound progress/procedure note dated 7/17/12, showed the following: -Date acquired 1/30/12, pressure and arterial wound, Unstageable (slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) and/or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin): Known but not stageable due to coverage of wound bed by slough and/or eschar at the time of admission) on the resident's left heel, measured 2.0 cm by 3.0 cm, slough covered 60% of the wound bed, moderate serosanguinous (semi-thick reddish fluid) exudate (drainage), peri wound tissue (area around the wound) dry and intact, odor present, eschar covered 40%, 60% granulation (healing tissue); -Date acquired 1/30/12, pressure and arterial wound, Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) on the resident's right heel, measured 4.5 cm by 4.5 cm by 0.4 cm, small amount of serosanguinous exudate, peri wound tissue dry and intact, no odor present, yellow slough covered 30% of the wound bed, no eschar present, 70% granulation present, fascia (fibrous connective tissue) exposed; -Date acquired 1/30/12, pressure and arterial wound, Stage IV on the resident's right posterior leg, measured 11.5 cm by 2.0 cm by 0.5 cm, large amount of serosanguinous exudate, peri wound tissue dry and intact, strong odor present, yellow slough covered 30% of the wound bed, no eschar present, 70% granulation present, muscle exposed. Observation and interview on 7/19/12 at 3:30 P.M., showed the resident lay in bed. The wound nurse entered the room to provide wound care. He/she washed his/her hands and applied gloves. The wound nurse applied a paper barrier under the resident's lower legs and feet, then removed the off loading foam boots from the resident's lower legs. The wound nurse removed his/her gloves then went in and out of the resident's room several times getting additional supplies from the treatment cart. She applied gloves, failed to wash his/her hands then opened the Calcium Alginate dressing and set them on the treatment cart with no barrier, cut them with a scissors to fit the wound areas, then placed them on the top of the treatment cart. He/she applied Santyl to the Calcium Alginate gauze dressing and used the same scissors to cut the dressing off the resident's right posterior leg. A large amount of purulent (containing or forming pus) exudate was visible on the dressing/wound. The wound nurse put the soiled dressing dated 7/18/12 in a trash bag, sprayed WC on several 4 by 4 gauze pads to cleansed the wound. The wound nurse then got the dressing from the top of the treatment cart and applied it over the wound bed, applied two ABD (absorbant dressing) dressing over the wound and wrapped the area with Kling (rolled gauze.) With the same soiled gloves, the wound nurse removed the dressing from the resident's right foot using the same scissors. A moderate amount of serosanguinous exudate visible on the soiled dressing. He/she put the soiled dressing dated 7/18/12 in trash bag, sprayed WC on several 4 by 4 gauze pads to cleansed the wound. The wound nurse then got the dressing from the top of the treatment cart and applied it over the wound bed, he/she lined the area with 4 by 4 gauze then applied an ABD dressing over the wound and wrapped the area with Kling. She removed his/her gloves and without washing his/her hands, he/she went back to the treatment cart to get additional supplies. After he/she re-entered the resident's room, he/she washed his/her hands and applied gloves. The wound nurse removed the dressing from the resident's left foot using the same scissors, from the top of the treatment cart. A large amount of purulent exudate visible on the soiled dressing. He/She put the soiled dressing dated 7/18/12 in trash bag,sprayed WC on several 4 by 4 gauze pads and cleansed the wound. The wound nurse then got the dressing from the top of the treatment cart and applied it over the wound bed, she lined the area with 4 by 4 gauze, applied an ABD dressings over the wound and wrapped the area with Kling. The wound nurse removed his/her gloves and applied a new pair of gloves, applied the resident's off loading boots, removed his/her gloves and washed his/her hands. The wound nurse said the resident has had multiple doses of antibiotics for his/her infected wounds. During an interview on 7/25/12 at 10:05 A.M., the Director of Nurses (DON) said she would expect the nurses to wash their hands upon entering the resident room, after removing the soiled dressing and after completing wound care, and she would expect the nurse to sanitize the scissors with alcohol or some type of sanitizer between each dressing change for infection control reasons. Observation on 7/20/12, showed the resident reclined in his/her Geri-chair by the nurses station. The off loading boot on his/her left lower leg was up by his/her left knee and his/her left heel lay directly on the Geri-chair foot rest from 6:40 A.M. through 8:30 A.M. Observation on 7/20/12 at 8:30 A.M., showed the resident reclined in his/her Geri-chair by the main entrance of the facility ready to go to a doctors appointment. Transportation arrived to pick the resident up and told facility staff the resident must be transferred into a wheelchair. Nurse C wheeled the resident down to another resident's room to transfer him/her to a wheelchair. Nurse C put a gait belt around the resident's waist and Certified Medication Technician (CMT) G assisted Nurse C to transfer the resident to the wheelchair, using a two person transfer. When they stood the resident up, the resident put direct pressure on his/her heels, he/she grimaced and yelled out "ouch!" Nurse C removed the gait belt from the resident's waist and wheeled the resident to the main entrance of the facility. The resident's feet, covered only with Kling wrap dressings, dragged on the floor from the resident room to the main entrance of the facility, which was approximately 300 feet. During an interview on 7/25/12 at 7:45 A.M., CNA H said there is a CNA care plan book at the nurse's station, so if staff have questions about how to care for a resident, they can look in there. The book has how to transfer the resident and if they are incontinent and other important information on how to care for the resident. CNA H said the resident is a two person sit to stand transfer at this time. During an interview on 7/25/12 at 8:45 A.M., Nurse C said he/she knows how to care for a resident by checking the CNA care plan book. That book includes how to transfer a resident and other activities of daily living information. Nurse C said the resident was a Hoyer lift because he/she has pressure ulcers on his/her heels and non weight bearing for that reason. He/she transferred the resident from the Geri-chair to the wheelchair with a two person transfer on 7/20/12, because it was urgent he/she went to the doctors appointment. During an interview on 7/25/12 at 10:05 A.M., the DON said there is a therapy book at the nurses station and a CNA care plan book that tells staff how to care for a resident, including how a resident transfers. She is responsible for updating the CNA care plan book when changes occur with the residents. The resident should have been transferred using a Hoyer lift due to the non weight bearing status on the POS. She said applying pressure to his/her heels while transferring him/her with a two person transfer would cause more pressure to the resident's heels and could possibly make the pressure ulcers worse. The DON also said dragging his/her feet from the other resident's room could cause more pressure to the resident's heels and could possibly make the pressure ulcers worse as well. 2. Review of Resident #2's admission nursing assessment dated [DATE], showed an open areas on the resident's buttock, a recent [MEDICAL CONDITION] of the right leg,and a recent toe amputation on the left foot. The assessment did not show the size, measurements, description or any further assessment of the areas. Review of the resident's record, showed no further documentation of the resident's skin upon admission. Review of the Braden Scale assessments, showed the following: -On 5/25/12, score of 13 (total score of 12 or less represented high risk for skin breakdown); -On 6/25/12,score of 13. Review of the admission nursing assessment form dated 6/25/12, showed a right leg [MEDICAL CONDITION] and toes on the left foot amputated, no documentation regarding any skin breakdown or open areas. Review of the resident's admission MDS, dated [DATE], showed the following: -admitted on [DATE]; -Understood/understands; -Total assistance required for transfers; -Occasionally incontinent of bowel; -Always incontinent of bladder; -Extensive assistance required for toileting, bathing, personal hygiene and range of motion; -Present on admission one Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) on the resident's buttock that measured 1.0 centimeters (cm) by 0.1 cm by 0.2 cm. Review of the care plan dated 7/20/12, showed the following: -Problem: One Stage III pressure ulcer to the buttock upon admission related to incontinence and immobility; -Documented healed, no date. Noted: remains at risk for skin breakdown. -Interventions: keep the skin clean and dry, change incontinence pad as soon as possible after voiding (urinating) or bowel movement, apply protective or barrier ointment after each incontinent episode, avoid hot water and irritating soaps, provide treatment and dressing changes as ordered, use a draw sheet or lifting device to move the resident, maintain adequate nutrition and hydration. Review of the undated CNA care card, showed no documentation of skin breakdown. Review of the POS [REDACTED] -[DIAGNOSES REDACTED]. -An order dated 5/25/12, Citric Aid Clear (barrier cream) apply to buttocks twice a day (BID) and whenever necessary (PRN.) Review of the treatment administration record (TAR), dated 7/7/12 through 8/6/12, showed the Citric Aid Clear barrier cream was not initialed as applied on the following dates and times: -7:00 A.M. through 3:00 P.M., 7/20, 7/21, 7/22/12; -3:00 P.M. through 11:00 P.M., 7/20, 7/21, 7/23/12; -The barrier cream discontinued on 7/24/12; -No documentation of the cream administered PRN; -Review of the back of the TAR, showed no documentation of why the cream was not administered. Review of the wound management sheet, dated 7/18/12, showed the resident was not listed as having pressure ulcers. During an interview on 7/19/12 at 1:35 P.M., the wound nurse said she usually works Tuesday, Wednesday and Friday, she does all the wound dressings in the facility and when she is not there the treatments should be completed by Nurse C. Observation on 7/19/12 at 3:30 P.M., showed Nurse C and Nurse N entered the resident's room and transferred the resident from his/her wheelchair to the bed with a Hoyer lift (mechanical lift). Nurse C removed the resident's incontinence brief, turned the resident onto his/her left side, exposed a superficial open area on his/her left ischium (inferior dorsal portion of the hip bone) that measured approximately 1.2 cm x 1.2 cm with pink tissue covering the wound bed. The resident's right and left buttock were red and excoriated. No other open areas were noted. Observation on 7/20/12 at 2:30 P.M., showed the resident lay in bed. CNA B assisted to resident to roll to his/her left side. A Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) open area observed on the resident's left ischium. The area measured approximately 1.0 cm by 1.0 cm . The resident's right and left buttock remained red and excoriated. No other open areas noted. Review of the facility's licensed nurse weekly skin assessment, dated 7/20/12 showed the resident had a red buttock. Review of the resident's medical record, showed no assessment, physician notification or documentation of the pressure ulcer on the resident's left ischium between 7/20 and 7/24/12. Observation and interview on 7/24/12 at 8:00 A.M., showed the resident lay in bed. CNA A and CNA B enter the room to provide care for the resident. During a skin assessment, the resident had five Stage II areas on his/her buttock and posterior inner thigh and a red raised rash on his/her right upper inner thigh area. Dried feces was between the resident's right thigh and perineal fold area. The resident said his/her buttocks had been raw for days and has been very uncomfortable. Observation and interview on 7/24/12 at 8:25 A.M., showed the Director of Nurses (DON) assessed the resident's buttock and abdominal fold. She had not been conducting wound rounds with the wound nurse because she was working on MDS's and care plans. She was unaware of the open areas on the resident's buttock and posterior inner thigh. The DON said the resident was admitted with a pressure ulcer to his/her coccyx (tailbone) but that had healed. The DON measured the open areas: -Right buttock open area was red, no drainage, slough or odor assessed, measured 2.0 cm by 1.0 cm; -Right buttock open area red, no drainage, slough or odor assessed, measured 0.5 cm by 1.0 cm; -Left buttock open area, red, no drainage , slough or odor assessed, measured 1.5 cm by 1.0 cm; -Left buttock open area, red, no drainage, slough or odor assessed, measured 1.0 cm by 1.0 cm; -Left buttock open area, red, no drainage, slough or odor assessed, measured 0.5 cm by 0.5 cm. During an interview on 7/24/12 at 8:40 A.M., the DON said the five areas are Stage II pressure ulcers. She was unaware the resident had the open areas until just then. 2. Review of Resident #9's medical record, showed the following: -A quarterly MDS, dated [DATE], showed the following: -memory and decision making impairments; -extensive assistance of staff for bed mobility; -total assistance of staff for transfers, dressing, eating, toileting, hygiene and bathing; -incontinent of bowel and bladder; -weight 118 pounds with recent weight loss; -mechanically altered diet; -at risk for pressure ulcers; -A care plan dated 10/24/11 and in use during the survey, did not show the resident at risk for pressure ulcers and did not direct staff with interventions to prevent pressure ulcers; -An April 2012 face sheet, showed [DIAGNOSES REDACTED]. -A weekly skin assessment completed by the facility's wound nurse dated 4/20/12, showed the resident with a reddened area to the right buttock; -A quarterly MDS dated [DATE], showed the following: -memory and decision making impairments; -extensive assistance of staff for bed mobility; -total assistance of staff for transfers, dressing, eating, toileting, hygiene and bathing; -incontinent of bowel and bladder; -weight 108 pounds with recent weight loss; -mechanically altered diet; -at risk of developing pressure ulcers; -A physician's orders [REDACTED]. -A weekly skin assessment completed by the facility's wound nurse dated 5/4/12, showed a pressure area to the resident's right buttock that measured 2.5 centimeters (cm) by 2.0 cm by 0.1 cm; -A Braden scale dated 6/28/12, showed the resident scored 14 (13-14 = moderate risk of developing pressure ulcers). Review of the facility's Prevention of Pressure Ulcer protocol dated 10/2010, showed the following: -The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors; -The protocol identified the following risk factors: -moisture; -friction and shear; -bed or chair fast; -immobility; -bowel/bladder incontinence; -poor nutrition; -lowered mental awareness; -Tools for assessing skin and pressure ulcer risk included the following: -pressure ulcer risk assessment form; -resident's medical record, including admission assessment and MDS; -skin assessment form. Review of the resident's record, showed the facility did not follow their prevention of pressure ulcer protocol to attempt to prevent Resident #9 from developing the pressure ulcer. During an interview on 7/25/12 at 10:05 A.M., the administrator said the weekly skin assessment is an identifier, the first step to providing treatment. With the resident's dementia, compromised nutritional status, incontinence and decreased mobility, the wound nurse could have ordered a skin barrier that would have protected the resident's reddened buttock area more than the skin protectant that the CNAs would normally use during routine pericare. The facility could not provide a Braden scale assessment prior to 6/28/12. 4. Review of the pressure ulcers/skin breakdown policy dated 10/10, showed the following: -Purpose: to provide for the care of existing pressure ulcers and the prevention of additional pressure ulcers; -Assessment and recognition: nursing staff and attending physician will assess and document a resident's significant risk factors for developing pressure ulcers, for example: immobility, recent weight loss and a history of pressure ulcers. In addition, facility staff shall assess and document/report a full assessment of the pressure ulcer including location, stage, length, width, depth, the presence of exudates or necrotic tissue. The physician and facility staff will examine the skin of a new admission for pressure ulcers or indications of a Stage I pressure area (intact skin with non-blanchable redness of a localized area usually over a bony prominence) that has not yet ulcerated at the surface. 5. During an interview on 7/25/12 at 10:05 A.M., the administrator said the wound nurse comes in once a week and does a head to toe skin assessment on all the resident's in the facility. She documents her findings on the licensed nurse weekly skin assessment. The administrator expects when a CNA is providing incontinence care and assisting the residents with activities of daily living to report to the charge nurse reddened and/or open areas on the resident's skin. She expects the charge nurse to assess the resident's skin and to notify the physician to obtain a treatment order. A head to toe skin assessment should be completed on every admission and readmission to the facility, which is the admitting nurses responsibility to complete. The administrator said she knows the nurses are not doing the admission skin assessments, they wait for the wound nurse to complete the skin assessment. The nurse should complete the skin assessment on admission and/or readmission and document the location of the open area, measure and describe the open area.

Based on observation, interview and record review, the facility failed to adequately assess, identify, document and monitor pain for three of six sampled residents (Resident #2, #1 and #3). The facility failed to assess and monitor significant changes in the resident's condition and failed to notify the physician of these changes for two sampled residents (Resident #1 and #3). The facility census was 55. 1. Review of Resident #2's face sheet, dated 3/10/11, showed the following: -admitted on [DATE] at 1:20 P.M. -[DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/10/11, showed the following: -No short or long term memory problems; -No impairment in cognitive skills of decision making; -Required limited assistance in transfers and dressing; -Independent with bed mobility, eating, toilet use and personal hygiene; -Continent of bowel and bladder. Further review of the resident's MDS, dated [DATE], under "Section J Health Condition", showed the following: -Has the resident had pain at any time in the first five days of admission? Yes; -How much of the time has the resident experienced pain or hurting? Frequently; -Over the first five days of the admission, had the pain made it hard for the resident to sleep at night? Yes; -Over the first five days of the admission, had the day-to-day activities been limited because of the pain? Yes; -Rate the resident's worst pain over the first five days of the admission, ten as the worst pain the resident can imagine, zero being no pain? Eight (8). Review of the resident's admission nursing evaluation, dated 3/10/11, showed the following: -Staples to the right upper hip with a traction device (a set of rods and screws for straightening broken bones) attached and going through to the left thigh, knee and calf on the left leg and a cast on the left hand. -No documentation on admission of a pain assessment for the resident. Review of the resident's care plan, dated 3/10/11, showed the following: -Mobility: wheelchair transfer of one; -Bed Mobility: turn with assist of one; -Pain was not addressed on the resident's care plan. Review of the resident's nurses notes, dated 3/10/11, show the following: -2:00 P.M., the resident had a cast on his/her left hand, traction device on the left lower extremity, a surgical wound on the right upper hip laterally, bruising and healed scabbed skin over the right side of the head and left lower extremity. -5:30 P.M., medications were verified with the resident's physician. Review of the resident's physician order [REDACTED]. -[MEDICATION NAME], (narcotic pain reliever) controlled release 10 milligrams (mg) one tablet by mouth every 12 hours; -[MEDICATION NAME] 5/325 mg one to two tablets by mouth every four hours as needed for pain. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [MEDICATION NAME] controlled release 10 mg by mouth every 12 hours was not documented as administered for the times of 9:00 P.M., on 3/10/11 and 9:00 A.M., on 3/11/11. -[MEDICATION NAME] 5/325 mg one to two tablets by mouth every four hours as needed for pain was not documented as administrated on 3/10/11 for all three shifts. -There was no documentation on the MAR indicated [REDACTED]. Further review of the nurses' notes, dated 3/10/11 and 3/11/11, showed the following: -The vital sign section for all three shifts, showed no documentation of any pain assessments performed by staff. During an interview on 3/11/11 at 2:55 P.M., Family Member (FM) O said the resident came to the facility on [DATE] around 2:00 P.M., for rehabilitation after having several surgeries on his/her legs and hip. The resident had a lot of pain and the staff told FM O they ordered the resident's pain medications, but the pain medications had not been delivered. Around 11:00 P.M., on 3/10/11, FM O came into the facility after the resident called, crying about his/her pain. Observation on 3/16/11 at 7:50 A.M., showed the following: -The resident lay in bed with the head of the bed elevated. -The resident's left leg showed three rods, one through the resident's thigh, the next rod through the knee, and the third rod through the calf. The resident's leg was bent at a 45 degree angle and elevated on a pillow. The area where the rods went through the resident's leg was dark with dry crusty drainage at each opening. -Bruising was visible on the resident's left forehead and a cast was covered with an ace wrap on the resident's left hand. During an interview on 3/16/11 at 7:50 A.M., the resident said the following: -He/she came into the facility on [DATE] after 2:00 P.M., after a motor vehicle accident. -The pain was excruciating, he/she could not lay still in bed and cried. The resident's family came in and the staff had no pain medication for him/her. They were waiting for the pain medication to come in. -He/she hurt all night. During an interview on 3/16/11 at 10:50 A.M., Nurse K said the facility did not have the resident's pain medication in the stat box (box on the nursing unit that houses narcotics and antibiotics for emergency use). No one called the physician to get something else for the resident's pain. Observation of the stat box at that time, showed Tylenol #3 as the only pain medication. During an interview on 4/16/11 at 11:00 A.M., the MDS Coordinator said each resident should have a separate pain assessment done upon admission. He/she was not aware Resident #2 did not have a pain assessment done on admission. During an interview on 4/25/11 at 12:22 P.M., the Administrator said she expected the nurse to call the resident's physician when they did not have pain medication for the resident. Staff could have called the pharmacy to find out the status of the pain medication. During an interview on 4/26/11 at 3:29 P.M., the Medical Director said the following: -The resident was involved in a motor vehicle accident and sustained a [MEDICAL CONDITION] patella. -The facility should have called the physician when they were unable to get the pain medication on the day of admission and the physician could have prescribed another type of pain medication. -The resident should not have waited 17 hours before receiving pain medications. -The injuries the resident sustained [REDACTED]. 2. Review of Resident #1's face sheet, showed the following: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's MDS, dated [DATE], showed the following: -No short or long term memory problems; -Required total care from the staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene; -The resident has a gastrostomy tube, [MEDICAL CONDITION] tube and a catheter (tube inserted into the bladder to drain urine). Further review of the resident's MDS, dated [DATE], under "Section J Health Condition", showed the following: -The resident had a condition/disease that results in a life expectancy of less than six months. Review of the resident's admission nursing evaluation, dated 2/14/11, showed the following:-Readmitted on [DATE]; -Bruises noted to upper bilateral extremities and a skin tear mid-back. -There was no documentation on admission of a pain assessment for this resident. Review of the resident's care plan, dated 2/14/11, showed the following: -Mobility: wheelchair transfer of one; -Bed Mobility: turn with assist of one; -Pain was not addressed on the resident's care plan. Review of the resident's POS, dated 3/1/11, showed the following: -An order, no date, for Tylenol 325 mg, two tablets by mouth every six hours as needed for pain. -[MEDICATION NAME] 1.5 (nutritional supplement that contains 1.5 calories per 1 cubic centimeter(cc) of solution) tube feeding per GT at 80 ml/hour, on at 5:00 P.M. and at 8:00 A.M. -On 3/9/11, an order for [REDACTED]. Review of the resident's MAR, dated 3/1/11 through 4/6/11, showed no documentation of any Tylenol administered to the resident for pain as ordered. Observation of the resident on 3/16/11 at 8:06 A.M., showed the following: -He/she lay on his/her back, hands gripping both side rails and the head of the bed up. -His/her mouth opened, staring up at the ceiling and face grimaced. -The resident's name was called with no response or change in the resident's posture in bed. Observation of the resident on 3/16/11 at 9:30 A.M., showed the following: -Remained on his/her back, pulling the gown up exposing his/her stomach. -Had facial grimacing and his/her forehead was wrinkled. -Respiratory rate was 24 (normal range,16 to 20) and the resident showed labored respiration using all accessory muscles to breathe. During an interview on 3/16/11 at 11:23 A.M., the Assistant Director of Nurses said nursing staff should assess the resident for pain and if the resident was distressed, staff should get vital signs and called the physician. During an interview on 3/16/11 at 11:40 A.M., Nurse D said the resident [MEDICAL CONDITION] and looked like he/she was in pain. He/she had pain and the only thing the resident had ordered was Tylenol. Nurse D did not give the resident Tylenol for pain, assess the resident for pain or a change in the respiratory status, or call the physician. Observation on 3/16/11 at 2:30 P.M., showed the following: -The resident faced the door and his/her body was up against one of the siderails. -His/her breathing was 40 times per minute, moaning, groaning, appeared anxious and pale. -Nurse A entered the room and with the assistance of Nurse D, turned the resident to face the window. -Nurse A and Nurse D left the room. During an interview on 3/16/11 at 2:30 P.M., Nurse D said Nurse A should call the physician for pain medications and to report the resident's condition. Further observation on 3/16/11 at 2:30 P.M., showed the following: -Nurse A walked to the nurses' station to give report to the oncoming nurse, Nurse Q. -Nurse A did not assess the resident's change in condition, obtain any vital signs, or call the physician regarding the resident's condition. During an interview on 3/16/11 at 4:00 P.M., Hospice Nurse R said the following: -The resident looked bad with a pulse of 136 (normal range, 60 to 100 beats per minute) and blood pressure 72/32 (normal range, 90 to 140 over 60 to 90) and his/her toes were dark and had tremors of both lower extremities -The resident had no pain or anxiety medications ordered. -Hospice Nurse R called the physician and obtained an order for [REDACTED]. During an interview on 3/16/11 at 4:10 P.M., Nurse Q said Nurse A should have called the physician when the resident started having problems at 9:30 A.M. During an interview on 4/16/11 at 11:00 A.M., the MDS Coordinator said each resident should have a separate pain assessment done upon admission. He/she was not aware the resident did not have a pain assessment done on admission. During an interview on 4/16/11 at 4:00 P.M., the Director of Nurses said all changes in a resident's condition should be reported to the physician to get orders. During an interview on 4/25/11 at 12:22 P.M., the Administrator said the following: -She expected the nursing staff to call the physician when the resident did not have pain medication ordered. -She expected the nurses to call the physician when there is a change in a resident's condition and document those changes in the nurses's notes. During an interview on 4/26/11 at 9:24 A.M., the Assistant Director of Nurses said the following: -The nurses are the overseer; they should be continuously on the floor addressing concerns for the residents. -When the resident was observed to have a change in his/her condition around 9:30 A.M. on 3/16/11, nursing should have called the physician and hospice about the resident's condition at that time. -The nurse should not wait until a change of shift to notify the physician, hospice and the oncoming evening nurse. During an interview on 4/26/11 at 3:29 P.M., the physician said the following: -The resident was a hospice patient. When the resident showed signs of pain at 8:00 A.M. on the morning of 3/16/11, the nurse should have called the physician. The physician could have given the facility orders for pain medication, additional oxygen or to send the resident to the emergency room . -Hospice could have been called also. -If the nurse could not get in touch with hospice or the resident's physician, 911 could be called. 3. Review of Resident #3's MDS, dated [DATE], showed the following: -admitted [DATE]; -No short or long term memory problems; -[DIAGNOSES REDACTED]. -Independent in cognitive skills of decision making and no mood or behavior problems; -Required extensive assistance in bed mobility, transfer, toilet use and personal hygiene; -Daily moderate pain; -Occasionally incontinent of bowel and bladder. Review of the resident's care plan, dated 9/6/10, showed pain was not addressed on the care plan. There was no updated care plan past 9/16/10. Review of the resident's admission pain assessment, dated 11/24/09, showed the following: -Abbey pain scale (for measurement of pain in people with dementia who cannot verbalize): Vocalization (whimpering, groaning, crying), the score was two, moderate; Facial expressions (frowning, grimacing, looking frightened), the score was two, moderate; Change in body language (fidgeting, rocking, guarding), the score was three, severe. -There was no documentation on the Wong-Baker Faces pain rating scale (for non-communicative residents using facial expressions) performed by the staff. Review of the resident's POS, dated 2/11 through 3/11, showed the following: -11/23/10, [MEDICATION NAME] ([MEDICATION NAME] used for moderate and severe pain) 50 mg one by mouth three times a day; -12/7/10, [MEDICATION NAME] (used for [MEDICAL CONDITION] arthritis) 2.5 mg by mouth once a week. -12/26/10, [MEDICATION NAME], (narcotic pain reliever) 5/325 mg one tablet by mouth twice a day; -12/26/10, [MEDICATION NAME] 5/325 mg one tablet by mouth every four hours as needed for pain; Review of the resident's MAR, dated 1/7/11 through 2/6/11, showed no documentation of the administration of [MEDICATION NAME] 2.5 mg by mouth once a week. Review of the resident's nurses' notes, showed the following: -1/10/11, no time documented, the resident was having uncontrolled pain; -1/21/11 at 3:30 P.M., the resident complained of general physical pain all over the body not being controlled. The resident said he/she wanted to go to the hospital. Review of the resident's MAR, dated 2/7/11 through 3/6/11, showed the following:-No documentation of the administration of [MEDICATION NAME] 2.5 mg by mouth once a week as ordered. -No documentation of the administration of [MEDICATION NAME] 5/325 mg one tablet by mouth twice a day and [MEDICATION NAME] 5/325 mg one tablets by mouth every four hours as needed for pain as ordered. Further review of the resident's nurses' notes, showed the following: -2/11/11 at 6:00 A.M., noted open area on coccyx (no stage documented). -3/3/11, no time documented, the resident complained of earache. The physician paged. There was no documentation of an assessment of the resident's pain by the nurse. -3/4/11, there was no documentation of the resident's condition for all three shifts. During an interview on 3/5/11 at 6:00 P.M., FM S said the following: -The resident was in extreme pain all over with an open area on his/her foot and heel and was not sure but thought the resident had an open area on his/her bottom. -The resident stayed in pain all the time and must receive pain medications. -The resident was sent to the emergency roiagnom on [DATE] because he/she was in so much pain. Additional review of the nurse' notes, dated 3/5/11, showed the following: -7:00 P.M., the physician was called by Nurse E because FM S requested the resident go to the emergency room . -8:07 P.M., Nurse E waiting on physician's return call. There was no documentation of an assessment of the resident's condition. -8:35 P.M., 911 operator called facility and stated FM S called and requested an ambulance sent to the facility. -8:57 P.M., the ambulance at the facility and the resident was transported to the hospital -No documentation of the resident's condition or pain medications given to the resident. During an interview on 4/16/11 at 4:00 P.M., the Director of Nurses said all changes in a resident's condition should be reported to the physician. During an interview on 4/25/11 at 12:22 P.M., the Administrator said the following: -She expected the nursing staff to call the physician when the resident did not have pain medication ordered from 2/7/11 through 3/6/11. -She was not aware the resident has no pain medications from 2/7/11 through 3/6/11. -She expected the nurses to call the physician when there is a change in a resident's condition and document that change in the nurses's notes. During an interview on 4/26/11 at 9:24 A.M., the Assistant Director of Nurses said the following: -The nurses are the overseer, they should be continuously on the floor addressing concerns for the residents. During an interview on 4/26/11 at 3:29 P.M., the physician said the following: -The resident had multiple problems, including diabetes, [MEDICAL CONDITION] arthritis and stroke. He/she complained of pain in his/her body and required pain medication constantly. The facility could have called the physician to obtain orders for pain medications or sent the resident to the emergency room . -If the nurse could not get in touch with the resident's physician, 911 could be called. 4. Review of the facility's policy titled, "Routine Resident Checks", revised December 2007, showed the following: -Policy Statement: staff shall make routine resident checks to maintain resident safety and well-being. -Policy Interpretation: routine resident checks to determine if the resident's needs are being met, identify any change in the resident's condition. 5. Review of the facility's policy titled "Change in a Resident's Condition or Status", revised March 2004, showed the following: -Policy Statement: our staff shall promptly notify the resident's physician of changes in the resident's condition or status. -Policy Interpretation: the charge nurse will notify the resident's physician when there has been a significant change in the resident's physical condition regardless of the resident's current physical condition. MO 059 MO 893