Every finding on record at Ozark Riverview Manor

Based on interview and record review, the facility failed to ensure an effective pain management program was in place for all residents when staff failed to document complete assessments of pain and failed to document administration of pain medication after complaints of pain for one resident (Resident #1) who suffered a broken hip. The facility census was 74. Review of the facility's policy Pain Assessment and Management, dated March 2020, showed the following:-The purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs that address the underlying caused of pain;-Pain management program is based on a facility wide commitment to appropriately assess and treat pain;-Pain management is defined as the process of alleviating the resident's pain based on his/her clinical condition;-Pain management is a multidisciplinary care process that includes the following: assessing the potential pain, recognizing the presence of pain, identifying the characteristics of pain, addressing underlying causes of pain, developing and implementing pain management, monitoring for the effectiveness of interventions, and modify as needed;-Acute pain or significant and worsening pain, should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained;-Possible behavioral signs of pain include, groaning, crying, screaming, grimacing, frowning, resisting care or participation in activities, guarding or rubbing a part of the body;-Possible physiological signs include increased blood pressure, increased respirations. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following:-admission date of 06/10/26;-Diagnoses included stroke, depression, anxiety, aphasia (disorder that impairs the ability to speak), vascular dementia (decline in thinking and memory skills), sciatica on right side lower back pain (nerve pain), and cognitive communication deficit. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/10/26, showed the following:-Severe cognitive impairment;-Usually understood by others, difficulty communicating some words, but usually understands others but missed some or part of the message. Review of the resident's care plan, dated 06/11/26, showed the following:-Resident had a communication problem related to a stroke, resulting in neurocognitive communication deficit;-Resident had impaired thought process related to left parietal ischemic stroke with petechial hemorrhages (blockage of blood flow in the parietal lobe of the brain leading to tissue damage). Ask yes or no questions to determine needs;-Resident had acute/chronic pain related to stroke;-Monitor/record/report to nurse any signs or symptoms of non-verbal pain;-Monitor and report to the nurse resident complaints of pain or request for pain treatment. Observe and report changes in usual routine, or decreased functional abilities;-Pain management as needed, provide alternative comfort measures as needed. Review of the resident's progress note dated 06/13/26, at 5:54 P.M., showed the following:-The resident was found in the floor beside the wheelchair next to the bed in his/her room;-Resident said he/she fell and hurt his/her right leg and landed on his/her butt. His/her butt hurt as well;-Border gauze placed on scrape of lower right leg below shin;-Upon assessment, there was weakness with no obvious sign of broken bone, bruising or bleeding;-Resident had right sided weakness from previous stroke and will have to be closely monitored for activity level;-Resident did not respond to questions well and had obvious deficits processing information and answering questions;-Initial vitals indicate continued elevated blood pressure with no fever. Review of the resident's June 2026 Physician Order Sheet (POS) showed an order, dated 06/13/26, for Tylenol tablet (pain reliever) 325 milligrams (mg), two tablets by mouth, every four hours, as needed for pain. Review of the resident's June 2026 Medication Administration Record (MAR) showed the following:-On 06/13/26, at 6:42 P.M. Certified Medication Technician (CMT) B administered Tylenol 325 mg, two tablets for pain rated 4 out of 10 and medication. The CMT noted the pain medication was effective. (Staff did not document where the pain was located.); -On 06/14/26, at 3:54 A.M., staff administered Tylenol 325 mg, two tablets for pain rated 5 out of 10 and medication. Staff noted the pain medication was effective. (Staff did not document where the pain was located.) Review of the resident's progress note dated 06/14/26, at 10:10 A.M., showed a certified nurse aide (CNA) reported resident's foot fell off of the wheelchair foot rest when attempting to push wheelchair, causing second digit of right foot to have toenail torn almost completely off from nail bed. Review of the resident's June 2026 MAR showed on 06/14/26, at 4:52 P.M.,CMT B administered Tylenol 325 mg, two tablets for pain. The CMT noted the pain medication was effective. (The CMT did not document a pain level or the location of the pain.) Review of resident's occupational therapy notes, dated 06/15/26, showed the following:-Resident grimaced with pain with right knee and leg when being touched;-Nursing confirmed resident had fallen this weekend;-While in therapy, resident participated in dynamic and strengthening exercises of the upper extremities to improve self-care;-Resident refused to stand;-Wheeled resident to the nurses' station to decrease risk of repeat falls. Review of resident's physical therapy notes, dated 06/15/26, showed the following:-Resident had a fall over the weekend;-Significant, increased right knee pain with range of motion (ROM) and weight bearing with minimal redness around the right knee;-Resident had difficulty with transfers and weight bearing and range of motion with increased knee pain, nursing aware. Review of the resident's medical record, dated 06/15/26, showed staff did not document follow-up assessment or treatment of pain noted in therapy notes. Review of the resident's June 2026 MAR showed on 06/16/26, at 1:43 A.M., Registered Nurse (RN) G administered Tylenol 325 mg, two tablets for pain rated 6 out of 10. The RN noted the pain medication was effective. (The RN did not document where the pain was located.) Review of resident's occupational therapy notes, dated 06/16/26, showed the resident unable to stand at this time due to pain in the right knee and big toe. Resident demonstrating level of confusion and inability to solve simple instructions. Review of resident's physical therapy notes, dated 06/16/26,showed the following:-Resident provided with skilled instruction for performing sit-to-stand transfers;-Resident provided with max verbal and tactile cues for hand and feet placement for set up, verbal cues for improved positioning including scooting forward and increased forward weight shift;-Resident provided with substantial assist of two and was unsuccessful in achieving standing this date due to decreased processing and increased pain in right lower extremity. Review of the resident's progress note dated 06/16/26, at 3:58 P.M., showed the following:-Resident had vocal complaints of pain of new location;-Right anterior elbow and right knee with pain level of 7 out of 10;-Non-medication interventions did not provide relief;-Physician notified of need for stronger as needed pain medication, currently only has Tylenol. Review of the resident's pain assessment and evaluation dated 06/16/26, at 4:06 P.M., showed the following:-Resident able to communicate appropriately;-Resident had frequent pain in the last five days;-The resident rated his/her pain intensity of 6 out of 10;-Frequency of which resident complained or showed evidence of pain or possible pain, showed indicators of pain the last three to four days;-Received as needed pain medication;-Received non-medication intervention for pain and it was somewhat helpful. Review of the resident's June 2026 POS showed the following:-An order dated 06/16/26, at 5:45 P.M., for right hip and right upper extremity x-ray related to pain and recent fall;-An order, dated 06/17/26, for tramadol (narcotic used to treat moderate to severe pain) 50 mg, give one syringe by mouth every six hours, as needed for pain. Review showed of the resident's medical record, dated 06/16/26, showed staff did not document administration of pain medication to address the residents reported pain. Review of resident's physical therapy notes, dated 06/17/26, showed the following:-Sit to stand transfers with mod assist of two with front wheeled walker, pain to the right lower extremity;-Static (maintain stable, motionless upright posture against gravity) standing with minimal weight bearing on right lower extremity;-Resident continued to have significant pain with right knee and lower extremities with range of motion and standing. Nursing was notified. Review of the resident's progress notes, dated 06/17/26, showed the following: -At 5:34 P.M., order received for tramadol, 50mg, one syringe by mouth every six hours as needed for pain;-At 7:11 P.M., resident vocalizes pain in right upper arm and right thigh with pain level 4 out of 10. Review of the resident's record, dated 06/17/26, showed staff did not document an assessment of the resident's pain or pain medication administered. Review of the resident's progress notes, dated 06/18/26, showed the following:-At 12:13 A.M., x-ray called and informed staff that resident had a fractured right hip. Staff called on-call physician and who directed staff to send resident out to the emergency room for evaluation;-At 7:30 A.M., hospital communicated update on resident. Resident had right hip fracture and was scheduled for surgery. Review of the resident's hospital records, admission date of 06/18/26, showed the following:-Resident had a fall at the nursing home about six days ago;-The resident presented to the hospital in a delayed fashion at about four days out from the fall;-Resident found to have right displaced femoral neck fracture (broke hip on the right side);-Surgical management in the form of a hip hemiarthroplasty (replaces only the ball portion of the hip joint) in order to restore stability to the hip and allow for early mobilization and improve pain control. During an interview on 06/25/26, at 2:24 P.M., the Director of Rehabilitation said the following:-Therapy began working with the resident on 06/11/26;-When the resident began with therapy he/she didn't show any signs of pain, he/she had some upper hemiplegic (paralysis on one side) and some stiffness. The resident couldn't tell staff exactly where he/she hurt, if staff touched various body parts he/she wouldn't be able to tell staff what hurts;-On Friday, 06/12/26, the resident needed little assistance with walking and transfers. On 06/15/26, after the fall over the weekend, the resident needed two of the staff to transfer him/her and it took more strength from the staff. The resident would not put weight on the right leg;-On 06/15/26, the resident gave non-verbal signs of pain like grimacing and he/she said ow. When moving the resident's right leg, he/she showed pain and grimaced. Staff tried to figure out exactly where the pain stemmed because the resident couldn't tell them;-When doing range of motion at first itpainful for the resident then he/she seemed to relax and it was some better. The therapy staff completed assistive range of motion;-He/she let a nurse know on 06/15/26, the concerns regarding the residents changes;-Therapy continued to work with the resident on 06/16/26 and 06/17/26 and the resident continued to show pain so they did not work with the right side. He/she discussed obtaining an x-ray with the nurse on 06/16/26. During an interview on 06/25/26, at 2:30 P.M., CNA A said the following:-When staff assisted the resident with personal cares before the fall the resident didn't display any pain, after the fall the resident would curse when moving him/her;-When he/she assisted the resident the following Monday, after the fall, the resident needed more help. The resident didn't say he/she was in pain, but when he/she transferred the resident, he/she would curse and yell and one time patted his/her right hip;-He/she informed the nurse and the Assistant Director of Nursing (ADON). During an interview on 06/25/26, at 2:52 P.M., CNA C said the following:-The resident could verbalize when he/she had pain;-On 06/15/26, the resident was a two-person max assist, sometimes three. When rolling the resident, he/she would scream and curse in pain. He/she alerted the nurses;-The resident showed pain each time he/she assisted him/her after the fall. During an interview on 06/25/26, at 2:45 P.M., CMT B said the following:-The resident was quiet, but he/she would moan if he/she was in pain and could tell staff yes or no;-If a resident had pain, he/she would look to see if they have an order for pain medication, and administer the medication;-He/she did not remember if the resident had pain, or if he/she administered pain medication to the resident. During an interview on 06/25/26, at 3:07 P.M., RN D said the following:-He/she did not recall any aides or therapy telling him/her the resident was having pain. If they had told him/her about pain, he/she would have told the CMT to administer pain medication;-If the resident needed a narcotic, he/she would have gotten that and administered him/herself;-He/she doesn't recall the resident telling him/her the resident had pain. During an interview on 06/25/26, at 3:19 P.M., RN E, said if a resident complained of pain, he/she would give the resident pain medication. If the medication doesn't help, he/she would notify the doctor. During an interview on 06/26/26, at 8:52 A.M., RN F said the following:-He/she didn't witness the resident in pain. The resident was non-verbal and never spoke of pain and he/she never showed signs of pain like grimacing or guarding. He/she would -The Director of Therapy told him/her one day the resident was having pain and he/she assessed and did not find that to be the case;-If staff tell him/her the resident is in pain, he/she would assess and administer pain meds as needed. During an interview on 06/29/26, at 2:40 P.M., RN G said the following:-Nonverbal signs of pain would be grimacing, or other things on the pain sheet;-The resident never told him/her that the resident had pain. The resident would nod his/her head and staff could tell by the look on his/her face if he/she had pain, he/she would scrunch his/her head;-One night the resident told an aide he/she was hurting, and by the time he/she got to the resident's room, the resident was asleep, so he/she never administered any pain medication;-The night he/she sent the resident to the hospital was the first night he/she saw the resident in pain. The resident was grimacing and looked scared;-No other aides told him/her the resident was in pain;-If a resident has pain staff administer pain meds, if the pain meds aren't working, would call the doctor to get something stronger. During an interview on 06/25/26, at 4:45 P.M., the RN Supervisor said the following:-Staff could tell if the resident had pain by observing and the resident could tell staff if he/she had pain;-When he/she asked about pain, the resident would deny having any pain. One day the aides said when they touch the resident's right leg or arm, he/she would display pain. He/she notified the doctor and the doctor ordered an x-ray and tramadol;-If a resident showed signs of pain, grimacing, frowning, blood pressure elevated, the staff should provide pain medication to the residents;-He/she was not aware the staff did not administer the tramadol to the resident. During an interview on 06/25/26, at 3:00 P.M., the Assistant Director of Nursing (ADON) said the following:--If a resident had pain, the staff were to notify the charge nurse and the nurse would assess the resident and should be able to tell by the baseline if the resident had changes;-On 06/16/26, therapy let nursing know the resident was not doing much. The resident never told him/her that the resident was having pain, and never showed any pain such as grimacing;-None of the aides told him/her the resident was having pain. During an interview on 06/25/26, at 3:50 P.M., Director of Nursing (DON), said the following:-The resident told therapy his/her other leg, shin was sore;-The resident did have an x-ray and it was found he/she had a fracture;-If a resident showed signs of pain, the aides need to tell the nurse and the nurse should be documenting and administering pain medication. During an interview on 06/26/26, at 10:20 A.M., the physician said the following:-If staff find a resident in pain, they typically call him/her;-He/she would expect staff to administer pain medications if a resident is having pain and if it's not effective, they should be notifying him/her to obtain an order for something else;-He/she remembered the resident, and said the resident was tricky, was aphasic (communication disorder), and would nod his/her head at times but sometimes would need to ask questions in different ways;-The resident would shake his/her head up and down to questions;-If the resident has a tremendous amount of pain, tramadol will not take care of it. During an interview on 06/25/26, at 4:13 P.M., the Administrator said when an aide finds a resident in pain, he/she needs to tell the charge nurse. The charge nurse needs to do a pain assessment and pain scale, notify the doctor and administer pain medication. Complaint 3047734

Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for four residents (Resident #61, #74, and #6) . The facility census was 77.Review showed the facility did not provide a shower policy. 1. During interviews on 09/22/25, at 9:58 A.M., during the resident council group meeting, the residents said there were issues with receiving showers. Some residents receive two showers per week, but most only receive one. 2. Review of Resident #61's face sheet (a general information sheet) showed the following:-admission date of 11/16/23;-Diagnoses included congestive heart failure, morbid obesity, and depression. Review of the resident's quarterly Minimum Data Set (MDS - federally mandated assessment instrument completed by facility staff), dated 08/15/25, showed the following:-No cognitive impairment;-Partial/moderate assistance with shower/bathing;-Staff supervision with personal hygiene. Review of the resident's care plan, last reviewed on 09/24/25, showed the following:-Resident had an activities of daily living (ADL – shower, grooming, toileting, etc.) self-care performance deficiency due to limited mobility, congestive heart failure and reduced mobility;-If agrees, he/she preferred to shower on Wednesdays. Review of the resident's August 2025 shower sheets showed the following:-On 08/06/25, resident received a shower;-On 08/13/25, the resident refused a shower (seven days after the last offered shower);-On 08/20/25, the resident received a shower (14 days after the previous shower and seven days after the last offered shower);-On 08/27/25, the resident refused a shower (seven days after the last offered shower). Review of the resident's August 2025 nursing notes showed staff did not document any additional showers, addition shower attempts, or additional refusals by the resident. Review of the resident's September 2025 shower sheets showed the following:-On 09/02/25, the resident received a shower;-On 09/05/25, the resident refused a shower;-On 09/10/25, the resident received a shower (eight days after the last shower and five days after the last offered shower);-On 09/12/25, the resident received a shower;-On 09/18/25, the resident received a shower (six days after the last shower);-On 09/26/25, the resident received a shower (eight days after the last shower). Review of the resident's September 2025 nursing notes showed staff did not document any additional showers, addition shower attempts, or additional refusals by the resident. Observation and interview on 09/23/25, at 10:00 A.M., showed the following;-The resident's hair appeared oily;-He/she said she/she would like to have a shower two times per week but only receives one shower per week. During an interview on 09/26/25, at 12:39 P.M., the Assistant Director of Nursing (ADON) said the resident sometimes refused showers depending on what he/she was doing when staff asked. During an interview on 09/26/25, at 2:28 P.M., the Director of Nursing (DON) said the resident used to like to shower on Wednesdays and lately has taken more showers. 3. Review of Resident #74's face sheet showed the following:-admission date of 04/30/25;-Diagnoses included chronic obstructive pulmonary disease (COPD- a group of lung diseases that cause ongoing inflammation and narrowing of the airways, making it difficult to breathe), chronic kidney disease, morbid obesity, Type 2 Diabetes, and end stage renal disease. Review of the resident's care plan, last reviewed on 02/18/25, showed the following:-Resident had an ADL self-care performance deficit;-Staff to check nail length and trim and clean on bath day and as necessary. Review of the resident's quarterly MDS, dated [DATE], showed the following:-No cognitive impairment;-Substantial/maximum assistance for showers/bathing;- Partial/moderate assistance with personal hygiene. Review of the resident's August 2025 shower sheets showed the following:-On 08/06/25, the resident received a shower;-On 08/13/25, the resident received a shower (seven days after the prior shower);-On 08/19/25, the resident received a shower (six days after the prior shower);-On 08/26/25, the resident refused a shower (seven days after the last shower);-On 08/29/25, the resident received a shower (ten days after the last shower and three days after the last offered shower). Review of the resident's August 2025 nursing notes showed staff did not document any additional showers, addition shower attempts, or additional refusals by the resident. Review of the resident's September 2025 shower sheets for showed the following:-On 09/01/25, the resident received a shower;-On 09/08/25, the resident received a shower (seven days after the prior shower);-On 09/15/25, the resident received a shower (seven days after the prior shower);-On 09/22/25, the resident received a shower (seven days after the prior shower);-On 09/25/25, the resident received a shower. Review of the resident's September 2025 nursing notes showed staff did not document any additional showers, addition shower attempts, or additional refusals by the resident. Observation and interview on 09/24/25, at 2:49 P.M., showed the following: -The resident's hair appeared oily;-He/she said he/she would like showers the night before dialysis;-He/she said it is important for him/her to be clean before leaving for dialysis, as the clinic is a sterile environment, and he/she does not want to risk bringing in germs. During an interview on 09/26/25, at 12:39 P.M., the ADON said he/she was not aware of the resident refusing showers. During an interview on 09/26/25, at 2:28 P.M., the DON said the resident's shower schedule depends on his/her dialysis schedule. He/she leaves early and comes back late. He/she could possibly receive two showers, but probably not three. During an interview on 09/25/25, at 4:38 P.M., Certified Medication Technician (CMT)/Shower Aide (CMT/SA) O said the resident occasionally refused showers if one falls on his/her dialysis day. He/she has requested to receive showers before dialysis. His/her shower days are Monday and Thursday. He/she attends dialysis on Tues, Thursday and Saturday. He/she could receive his/her two showers on Monday and Wednesday, but it would be too long to go from Wednesday to Monday. There is not staff available to provide showers on Saturday. 4. Review of Resident #6's face sheet (a brief information sheet about the resident) showed the following:-admission date of 10/13/23;-Diagnoses included COPD, chronic respiratory failure with hypoxia (condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen levels or chronically high carbon dioxide levels), type 2 diabetes mellitus, chronic pain syndrome, and overactive bladder. Review of the resident's care plan, last updated 02/20/25, showed the following:-Resident needed partial to maximum assist with transfers, toileting, bed mobility and dressing;-Staff provide supportive care, assistance with mobility as needed and document assistance as needed.(Staff did not care plan related to the resident's resident shower preferences.) Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Used of wheelchair for mobility;-Required partial to moderate assistance of staff for oral hygiene, toileting hygiene, showering, dressing, personal hygiene, transfers. Review of the facility CNA Shower Forms, showed the following:-On 09/01/25 (Monday), received shower. Staff marked no new skin issues;-On 09/03/25 (Wednesday), received shower. Staff marked no new skin issues;-On 09/09/25 (Tuesday), received shower. Staff marked no new skin issues. (Six days since last shower);-On 09/12/25 (Friday), received shower. Staff marked red areas noted;-On 09/17/25 (Wednesday), received shower (one shower this week);-As of 09/26/25 resident had not had a shower for the week. Review of the resident's medical record showed staff did not document in nursing progress notes information related to showers. During an interview on 09/21/25, at 4:15 P.M., the resident said that staff had been a little lax with showers. He/she had not received two showers per week and would prefer at least two times per week. He/she said it feels good to have a shower. During an interview on 09/24/25, at 8:50 A.M., the resident said he/she had not had a shower for over one week, he/she would prefer to receive two per week and thought he/she was scheduled for Tuesday and Fridays. He/she said he/she did not feel good when had not received a shower. 5. During an interview on 09/25/25, at 2:30 P.M., Certified Nurse Aide (CAN) F said the facility had two shower aides. The shower aides were pulled to work on the floor as an aide when staff call in. Residents should receive two showers per week. Some residents only receive one shower per week and CNA F believes this coincided with when the aides were being pulled to the floor to work. During an interview on 09/25/25, at 3:18 P.M., CNA H said the facility had a shower aide. The facility would pull the shower aide to the floor to assist with resident care. Residents should receive two showers per week. The facility would sometimes ask staff to stay late to complete showers. During an interview on 09/25/25, at 4:38 P.M., CMT/SA O said the following: -Residents get at least one shower per week. He/she tried to ensure residents receive two, but it was difficult because there were a lot of residents, and he/she was sometimes pulled to the floor to work as a CMT;-Residents or nurses will inform him/her of a resident's shower preference. He/she can also refer to the care plan;-Shower days are Monday/Thursdays or Tuesday/Fridays. He/she used Wednesday as a make-up day to ensure all residents get a least one shower per week;-Approximately two weeks ago, several residents complained about not getting showers, as CMT/SA O was off work for approximately two weeks. During an interview on 09/26/25, at 9:45 A.M., Licensed Practical Nurse (LPN) I said the facility had shower aides. He/she believed residents received two showers per week. Occasionally, shower aides will be pulled to the floor to work as an aide. During an interview on 09/26/25, at 10:02 A.M., LPN J said the facility has shower aides. Residents should receive two per week, but he/she was unsure if residents receive two. The shower aides were sometimes pulled to the floor to work as aides. During an interview on 09/26/25, at 12:39 P.M., the ADON said the goal was for residents to have two showers per week, however some receive more and some less. Shower aides were pulled to the floor occasionally to work as aides. Some residents have voiced concerns about not receiving showers. Residents can receive showers on Saturday. During an interview on 09/26/25, at 2:28 P.M., the DON said the residents should be receiving at least one shower per week, hopefully two. A few residents ask for three, but that doesn't always work out. There was one shower aide per side of the facility. The facility tried to get a third person a day or two a week. The shower aide was pulled to the floor to work as an aide, but normally the restorative aide was pulled before shower aide. Periodically, residents will voice concerns about not getting two showers. During an interview on 09/26/25, at 4:03 P.M., the Administrator said he/she was unsure of the shower schedule, but residents should be receiving two showers per week. The shower aide is occasionally pulled to the floor to work as an aide. Residents can receive three showers a week. If a resident would like to receive a shower on the weekend, they would need to let staff know in advance.

Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not correctly reconciling each month. The facility managed funds for 25 residents. The census was 77.Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not correctly reconciling each month. The facility managed funds for 25 residents. The census was 77.Review showed the facility did not provide a policy related to the resident funds. 1. Review of the corporate maintained bank statements for account ending in #7994, dated September 2024, showed the last check number to clear was #2481. Review of the corporate maintained reconciliation form for account ending in #7994, dated 09/30/24, showed the following:-An outstanding check #2482 for $97.30;-An outstanding check #2483 for $155.05. Review of the corporate maintained bank statements for account ending in #7994, dated October 2024, showed the following:-On 10/11/24, check #2482 for $97.20 was deducted from the account;-On 10/17/25, check #2483 for $395.00 was deducted from the account. Review of the corporate maintained reconciliation form for account ending in #7994, dated 10/31/24, showed the following:-An outstanding check #2482 for $97.30;-An outstanding check #2483 for $155.05;-Check number #2483 for $395 deducted from the account. Review of the corporate maintained reconciliation form for account ending in #7994, dated 11/30/24, showed the following:-An outstanding check #2482 for $97.30;-An outstanding check #2483 for $155.05. Review of the corporate maintained reconciliation form for account ending in #7994, dated 12/31/24, showed the following:-An outstanding check #2482 for $97.30;-An outstanding check #2483 for $155.05. Review of the corporate maintained reconciliation form for account ending in #7994, dated 01/31/25, showed the following:-An outstanding check #2482 for $97.30;-An outstanding check #2483 for $155.05. Review of the corporate maintained reconciliation form for account ending in #7994, dated 02/28/25, showed the following:-An outstanding check #2482 for $97.30;-An outstanding check #2483 for $155.05. Review of the corporate maintained reconciliation form for account ending in #7994, dated 03/31/25, showed the following:-An outstanding check #2482 for $97.30;-An outstanding check #2483 for $155.05. Review of the corporate maintained reconciliation form for account ending in #7994, dated 04/30/25, showed the following:-An outstanding check #2482 for $97.30;-An outstanding check #2483 for $155.05. Review of the corporate maintained reconciliation form for account ending in #7994, dated 05/31/25, showed the following:-An outstanding check #2482 for $97.30;-An outstanding check #2483 for $155.05. Review of the corporate maintained reconciliation form for account ending in #7994, dated 06/30/25, showed the following:-An outstanding check #2482 for $97.30;-An outstanding check #2483 for $155.05. Review of the corporate maintained reconciliation form for account ending in #7994, dated 07/31/25, showed the following:-An outstanding check #2482 for $97.30;-An outstanding check #2483 for $155.05. Review of the corporate maintained reconciliation form for account ending in #7994, dated 08/31/25, showed the following:-An outstanding check #2482 for $97.30;-An outstanding check #2483 for $155.05. During an interview on 09/26/25, at 11:48 A.M., the Financial Specialist (FS) said the following:-The data entry error was made by his/her predecessor;-The Chief Financial Officer (CFO) reviewed the reconciliation;-The company has an outside entity conduct a yearly audit. During an interview on 09/26/25, at 1:18 P.M., the CFO said the following:-The FS conducted the reconciliation of the resident trust;-The employee who made the data entry error is no longer with the company.

Based on observation, interview, and record review, the facility failed to ensure proper assessment and documentation was completed before side rail use, failed to document risk versus benefit review, failed to obtain informed consent, and failed to care plan use of side rails for two residents (Residents #8 and #75), and failed to complete gap measurements to reduce risk of entrapment for three residents (Resident #8, #12, and #75). The facility census was 77. Review of the facility policy titled Proper Use of Side Rails, dated December 2016, showed the following:-The purpose of these guidelines is to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms;-Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents;-An assessment will be made to determine the resident's symptoms, risk of entrapment, and reason for using side rails;-When used for mobility or transfer, an assessment will include a review of the resident's bed mobility, ability to change positions, transfer to and from bed or chair, and to stand and toilet, risk of entrapment from the use of side rails, and that the beds dimensions are appropriate for the resident's size and weight;-The use of side rails as an assistive device will be addressed in the resident's care plan;-Consent for restrictive devices will be obtained from the resident or legal representative per facility protocol;-The risks and benefits of side rails will be considered for each resident;-Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks;-Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails;-The resident will be checked periodically for safety relative to side rail use;-When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment. 1. Review of Resident #12's face sheet showed the following information:-admission date of 10/01/15;-Diagnoses included right-sided weakness and paralysis following a stroke, history of transient ischemic attack (TIA; mini-stroke), unable to speak, gastrostomy (tube inserted through the abdominal wall into the stomach to provide nourishment and/or medications), muscle wasting, epilepsy/convulsions/seizures, low blood pressure, major depressive disorder, anxiety, osteoporosis (weakening of bones, contracture, difficulty sleeping, and chronic pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 07/25/25, showed the following information:-Severely impaired cognition;-Range of motion impaired to upper and lower extremities, one sided. Review of the resident's physician order sheet (POS) showed an order, dated 01/04/24, for side rails x 2 while resident was in bed due to diagnosis of convulsions, epilepsy, and seizure disorder for resident's safety. Review of the resident's care plan, last updated 07/25/25, showed resident had full side rails x 2 per family's request for safety and a sense of security. The rails do not limit resident's access to his/her body or prevent him/her from doing what he/she wants as he/she was total care. Side rails do not restrict mobility and are not a restraint. Durable Power of Attorney (DPOA) does not want padding on side rails due to it scares resident. Observation on 09/21/25, at 5:10 P.M., showed the resident in bed watching television. Bilateral side rails were in the raised position. A photo blanket was draped over the resident's right (wall side) rail. Observation on 09/22/25, at 12:15 P.M., showed the resident in bed. Bilateral side rails were in the raised position. A photo blanket was draped over the resident's right (wall side) rail. A family member said the side rails were requested for the resident's safety due to a long history of seizures. Observation on 09/25/2025, at 10:30 A.M., showed the resident in bed watching television. Bilateral side rails were in the raised position. A photo blanket was draped over the resident's right (wall side) rail. By signing yes, the resident said he/she wanted the side rails in place. Review of the resident's electronic record showed a copy of an informed consent form for the use of bilateral side rails, dated 01/04/24. Review of maintenance logs pertaining to safety/gap measurements of residents' side rails showed no documentation for Resident #12's bilateral side rails. 2. Review of Resident #8's face sheet showed the following:-admission date of 03/26/19;-Diagnoses included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), post-traumatic stress disorder (PTSD – disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), generalized anxiety disorder, history of falling, and weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Use of wheelchair;-Supervision or touching assistance with transfers;-Setup or clean-up assistance for toilet transfers;-Partial to moderate assistance with personal hygiene, dressing, showering, toileting hygiene. Observation and interview on 09/21/25, at 4:48 P.M., showed the resident in bed with a grab bar (side rail) on left side of the bed. The resident said he/she used the bar for mobility and transfer assistance. Review of the resident's Care Plan, last updated 03/05/25 , showed staff did not care plan related to the use of the grab bar. Review of the resident's POS, current as of 09/26/25, showed staff did not document an order for grab bars or side rails. Review of the resident's electronic medical record showed the following:-A bed rail assessment, dated 08/20/24, for side rails used to assist and serve as an enabler to promote independence;-No risk and benefits consent;-No side rail measurements or routine monitoring noted in chart. 3. Review of the face sheet for Resident #75, showed the following:-admission date of 04/24/25;-Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), fibromyalgia (chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), and chronic pain syndrome. Observation and interview on 09/22/25, at 3:41 P.M., showed the resident had grab bars on both sides of his/her bed. The resident said he/she used the grab bars to move around in bed and to help roll for staff when providing personal cares. Review of the resident's care plan, last updated 04/24/25, showed the following:-Resident had an activities of daily living self-care performance deficit related to fibromyalgia;-Resident used grab bars x 2 to maximize independence with transferring and repositioning. Review of the resident's significant change in condition MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Use of wheelchair;-Dependent of staff for toileting hygiene, showering;-Required substantial to moderate assistance for dressing, personal hygiene. Review of the resident's POS, current as of 09/26/25, showed staff did not document orders related to grab bar usage. Review of the resident's electronic medical record showed the following:-No bed rail assessment;-No risk and benefits consent;-No side rail measurements or routine monitoring noted in chart 4. During an interview on 09/24/25, at 12:30 P.M., the Corporate Nurse said the positioning only bars were not felt to be a risk and therefore do not have measurements or consent completed. There were no gap measurements for Resident #8's grab bar. During an interview on 09/26/25, at 10:00 AM., the Maintenance Supervisor said he/she was told by staff when a resident needed bed rails and when he/she was told that the therapy evaluation indicated they could have the rails. He/she installed the bed rails. He/she did not have measurements or routine safety checks. During an interview on 09/26/25, at 2:27 P.M., the Director of Nursing (DON) said therapy should evaluate a resident to determine if eligible for a side rail or grab bar. The staff notify maintenance, and he/she installed the bars. The DON did not know if there was routine assessments or measurements. During an interview on 09/26/25, at 3:32 P.M., Administrator said residents should have an assessment for use of side rail or grab bar. The therapy staff will evaluate and determine if beneficial for the resident. The maintenance staff will do gap measurements and install the rails. And there should be a review done quarterly. The staff are good to let us know something needs looked at. Not sure there is an informed risk and benefit consent. Grab bars should be evaluated and measured.

Based on observation, interview, and record review, the facility failed to nurse aides were not employed and used for resident care longer than four months without proper certification when four nurse aides (Nurse Aide (NA R, NA S, NA T, and NA U), of fifteen sampled NAs, failed to complete a certified nurse aide (CNA) training program within four months of employment in the facility as a nurse aide. The facility census was 84. Review showed the facility did not provide a policy regarding nurse aide certification or training. 1. Review of NA R's personnel information showed the following:-Date of hire of 01/24/25 (eight months and two days since date of hire);-Staff did not have documentation NA R had completed the nurse aide training program.Review of the state agency CNA registry, on 09/26/25, showed the NA R did not have an active CNA certification.Review of the nursing staff schedule, dated 09/21/25 through 09/26/25, showed the following:-On 09/21/25, NA R worked on the evening shift;-On 09/22/25, NA R worked on the evening shift;-On 09/25/25, NA R worked on the day shift;-On 09/25/25, NA R scheduled to work on the evening shift;-On 09/26/25, NA R scheduled to work on the evening shift.Observations on 09/21/25, at 3:45 P.M., showed NA R working, providing direct care to residents in the facility.Observation on 09/22/25, at 3:20 P.M., showed NA R working, providing direct care to residents in the facility. 2. Review of NA S's personnel information showed the following:-Date of hire of 04/15/25 (five months and nine days since date of hire);-Staff did not have documentation NA S had completed the nurse aide training program. Review of the state agency CNA registry, on 09/26/25, showed the NA S did not have an active CNA certification.Review of the nursing staff schedule, dated 09/21/25 through 09/26/25, showed on 09/25/25, NA S scheduled to work on the evening shift.3. Review of NA T's personnel information showed the following:-Date of hire of 04/29/25 (four months and twenty-seven days since date of hire);-Staff did not have documentation NA T had completed the nurse aide training program.Review of the state agency CNA registry, on 09/26/25, showed the NA T did not have an active CNA certification.Review of the nursing staff schedule, dated 09/21/25 through 09/26/25, showed on 09/22/25, NA T worked on the day shift.Observation on 09/22/25, at 10:30 A.M., showed NA T working, providing direct care to residents in the facility. 4. Review of NA U's personnel information showed the following:-Date of hire of 05/13/25 (four months and thirteen days since date of hire);-Staff did not have documentation NA U had completed the nurse aide training program.Review of the state agency CNA registry, on 09/26/25, showed the NA U did not have an active CNA certification.Review of the nursing staff schedule, dated 09/21/25 through 09/26/25, showed the following:-On 09/24/25, NA U worked on the evening shift;-On 09/25/25, NA U scheduled to work on the evening shift;-On 09/26/25, NA U scheduled to work on the evening shift.Observation on 09/24/25, at 3:15 P.M., showed NA U working, providing direct care to residents in the facility.Review of the state agency CNA registry (a state-maintained list that confirms a Certified Nursing Assistant's (CNA) eligibility to work by verifying they have completed state-approved training and passed the required competency exam), on 09/26/25, showed the Nurse Aides were not listed with an active certificate. 5. During an interview on 09/25/25, at 12:45 P.M., the Director of Nursing (DON) said the CNA instructor should be monitoring the students to ensure they complete their course work and test within 120 days. NA R and NA U were close to done. She was not aware that they were over 120 days. During an interview on 09/25/25, at 3:00 P.M., Administrator said NA staff should be certified within four months of hire.

Based on observation, interview, and record review, the facility failed to provide restorative nursing services to maintain or improve residents' functional status as directed by therapy for three residents (Residents #55, #72, and #75). The facility census was 77.Review of the facility's policy, Restorative Nursing Services, revised July 2017, showed the following information:-Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies);-Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care;-Restorative goals and objectives are individualized and resident-centered and outlined in the resident's plan of care;-Restorative goals may include, but are not limited to supporting and assisting the resident in adjusting or adapting to changing abilities, developing, maintaining or strengthening his/her physiological and psychological resources, maintaining his/her dignity, independence and self-esteem, and participating in the development and implantation of his/her plan of care. 1. Review of Resident #55's face sheet (gives basic profile information) showed the following information: -admission date of 01/23/25;-Diagnoses included hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke) and chronic pain. Review of resident's Restorative Hand-off Form, dated 03/05/25, showed the following:-Tentative date for Physical and Occupational Therapy discharge of 02/27/25;-Therapy delivered range of motion (ROM), strength, balance, transfers, and activities for daily living (ADL);-Goals of ROM, strengthening, and transfers. Review of Restorative Therapy (RT) log, dated August 2025, showed the following:-Resident received RT on 08/05/25 and 08/06/25;-Resident refused RT on 08/07/25;-No RT received the week of 08/11/25;-Resident received RT on 08/19/25, 08/20/25, and 08/21/25;-No RT received the week of 08/25/25. Review of resident's care plan meeting summary, dated 08/19/25, showed not applicable (N/A) for therapy concerns. Review of resident's comprehensive Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 08/29/25, showed the following:-Upper and lower extremity impairment on one side;-Wheelchair use;-Substantial/maximal assistance with personal hygiene;-Dependent on staff for transfers;-Restorative therapy range of motion occurred once in seven-day period. Review of resident's Restorative Therapy log, dated September 2025, showed the following:-No RT received the week of 09/01/25;-Resident received RT on 09/08/25;-No RT received the week of 09/14/25;-Resident received RT on 09/21/25. Review of resident's care plan, last updated 09/22/25, showed the following:-Resident has an activity of daily living (ADL - self-care performance deficit due to intercranial hemorrhage with hemiplegia (stroke with paralysis);-Resident is dependent on staff for all ADL's;-Physical Therapy and Occupational Therapy evaluation and treatment as per physician orders;-Resident is a risk for falls sure to left side hemiplegia;-Physical therapy evaluate and treat as ordered or as needed (PRN). Review of the resident's Physician Order Sheet (POS), current as of 09/26/25, showed staff did not document orders related to restorative therapy. Observation and interview on 09/22/25, at 2:06 P.M., showed the resident was observed to have weakness on his/her left side. The resident said he/she should receive restorative therapy but does not receive it regularly. During an interview on 09/25/25, at 2:21 P.M., the resident said when he/she does not receive restorative therapy, he/she starts to tighten up which can be painful. During an interview on 09/25/25, at 3:18 P.M., Restorative Aide (RA) H said the resident sometimes refuses. During an interview on 09/26/25, at 2:28 P.M., the Director of Nursing (DON) said he/she does not believe the resident has refused RT. 2. Review of Resident #72's Face Sheet showed the following:-admission date of 11/08/24;-Diagnoses included complete amputation at knee level. Review of resident's care plan dated 06/11/25, showed the following:-Resident had an ADL self-care performance deficit due to recent below the knee amputation;-Resident required assistance for ADL's, transfers, and mobility using Hoyer lift (mechanical lift for non0weightbearing residents) and wheelchair;-Resident will improve current level of function in all ADL's through the next review date. Review of resident's care plan meeting summary, dated 06/12/25, showed not applicable (N/A) for therapy concerns. Review of resident's care plan meeting summary, dated 09/09/25, showed no information next to therapy concerns. Review of resident's Restorative Nursing screener, section GG of the MDS, dated [DATE], showed the following:-Self-Care: Unknown;-Indoor Mobility (Ambulation): Unknown;-Stairs: Unknown;-Functional Cognition: Unknown;-Manual wheelchair;-Mechanical lift;-Resident was able to effectively communicate using their current method(s);-Resident was currently not receiving rehabilitation therapy;-No comments noted. Review of resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Resident was dependent on staff for bathing, personal hygiene, and mobility;-No restorative therapy indicated. Review of the resident's Physician Order Sheet (POS), current as of 09/26/25, showed staff did not note orders for restorative therapy. During an interview on 09/22/25, at 3:02 P.M., the resident said the following:-He/she was supposed to received RT;-He/she has a contracture and has pain;-He/she and her family have requested RT in the last two care plan meetings. During an interview on 09/25/25, at 2:14 P.M., the resident's next of kin (NOK) said at the resident's care plan meeting in June 2025, they requested restorative therapy. At the care plan meeting in September 2025, they asked again about restorative therapy and were told the resident would be put on the list. Last week, they asked the restorative aide and were informed the resident was not on the list. The resident's ankle is declining and becoming contracted. During an interview on 09/25/25, at 3:18 P.M., RA H said the resident did not receive RT. During an interview on 09/26/25, at 12:39 P.M., the Assistant Director of Nursing (ADON), said the following:-The resident's next of kin asked yesterday about him/her receiving RT;-The ADON spoke to the RA and he/she advised the resident was not on the list;-The ADON does not know if RT was addressed in the resident's care plan meetings as he/she does not attend. During an interview on 09/26/25, at 1:30 P.M, the MDS Coordinator said he/she did not recall the resident or his/her family requesting RT during their care plan meeting. During an interview on 09/26/25, at 2:28 P.M., the DON said he/she was unsure if the resident had requested RT. 3. Review of Resident #75's face sheet showed the following:-admission date of 04/24/25;-Diagnoses included chronic pain syndrome. Review of the resident's form titled Restorative Hand-Off Form, dated 06/17/25, showed the following:-Tentative therapy discharge on [DATE];-Diagnosis of weakness;-Interventions included active ROM and transfer training/ balance;-Specific tasks included bilateral upper and lower extremity, strength exercises with 0 to 1 pound and sitting balance on edge of bed. Review of the resident's POS, current as of 09/26/25, showed an order, dated 09/10/25, for activity as tolerated. Review of the resident's baseline care plan, dated 09/10/25, showed the following:-Resident required two-person physical assist for transfers;-Resident used a wheelchair for mobility;-Physical therapy goal was to improve functional status through restorative nursing. Review of the resident's significant change in condition MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Use of wheelchair;-Dependent of staff for toileting hygiene, showering;-Required substantial to moderate assistance for dressing, personal hygiene. Review of the restorative aide notebook, undated, showed the following:-Sheet dated 08/18/25 to 08/23/25, with 08/19/25 note of resident sat on edge of bed for 5 minutes;-Sheet dated 08/25/25 to 08/30/25, with 08/27/25 notes of ROM upper extremity active, ROM lower extremity active, upper extremity exercise with no weight, lower extremity with no weights;-Sheet dated 09/01/25 to 09/06/25 marked as at the hospital;-Sheet dated 09/07/25 to 09/12/25 no marks as completed or not completed;-Sheet dated 09/21/25 to 09/23/25 showed transfers to be done three times per week with no marks of completed or not completed;-Sheet dated 09/14/25 to 09/20/25, no marks of completed or not completed; During an interview on 09/24/25, at 1:30 P.M., the resident said that he/she would like to go and exercise. Staff used to do that with him/her. He/she could not make his/her leg work, but would really like to exercise. 4. During an interview on 09/25/25, at 2:30 PM Certified Nurse Aide (CAN) F said the following:-The RA was sometimes pulled to the floor to complete aide duties;-RT should be in the care plan. During an interview on 09/25/25, at 3:18 P.M., RA H said the following:-Residents receive RT three times per week;-Therapy notifies him/her who receives RT and he/she was provided with an updated list every 30 days;-Residents do not always receive RT three times per week;-He/she gets pulled to the floor to work as an aide;-He/she had started documenting refusals;-RT should be in a resident's care plan. During an interview on 09/26/25, at 9:45 A.M., Licensed Practical Nurse (LPN) I said he/she was unfamiliar with restorative therapy and believed therapy provides all services. During an interview on 09/26/25, at 10:02 A.M., LPN J said the following:-The facility utilized a RA;-He/she was unsure how often residents receive RT;-The RA gets pulled to the floor to perform aide duties;-RA should be documented in the care plan. During an interview on 09/26/25, at 12:39 P.M., the Assistant Director of Nursing (ADON) said the following:-He/she was unsure how often residents receive RT;-Residents can request RT or they can be referred by therapy; -The RA is sometimes pulled to the floor as an aide;-Some residents have voiced concerns due to not receiving RT;-RT should be documented in the care plan. During an interview on 09/26/25, at 1:30 P.M, the MDS Coordinator said RT should be documented in the care plan. During an interview on 09/26/25, at 2:28 P.M., the DON said the following:-Residents receive RT close to three days per week;-There is only one RA. If he/she was pulled to the floor to perform aide duties, residents do not receive RT;-The RA was pulled to work on the floor before the shower aide;-Residents can request RT, and will be assessed by therapy;-RT should be documented in the care plan. During an interview on 09/26/25, at 4:03 P.M., the Administrator said the following:-Residents should receive RT three times per week;-The RT gets pulled to the floor to work as an aide;-Residents can request RT, or they are recommended for RT after completing therapy;-RT should be documented in the care plan.

Based on observation, record review, and interview, the facility failed to establish and maintain a complete infection control program when staff failed to use Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs - microorganism that has developed resistance to one or more classes of antibiotics, making infections caused by it more difficult to treat) in nursing homes) per nursing standards of infection control during wound care for one resident (Resident #5), during urinary catheter (thin tube that remains in the bladder for continuous urine drainage, often held in place by a small balloon and connected to a collection bag) care for one resident (Resident #67), and during medication administration via peg tube for one resident (Resident #12). The facility census was 77. Based on observation, record review, and interview, the facility failed to establish and maintain a complete infection control program when staff failed to use Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs – microorganism that has developed resistance to one or more classes of antibiotics, making infections caused by it more difficult to treat) in nursing homes) per nursing standards of infection control during wound care for one resident (Resident #5), during urinary catheter (thin tube that remains in the bladder for continuous urine drainage, often held in place by a small balloon and connected to a collection bag) care for one resident (Resident #67), and during medication administration via peg tube for one resident (Resident #12). The facility census was 77. Review of the facility provided policy titled Enhanced Barrier Precautions, dated May 2024, showed the following:-EBPs employ target gown and glove use during high contact resident care activities when contact precautions do not otherwise apply;-Glove and gown are applied prior to performing the high contact resident care activity;-Personal protective equipment (PPE - equipment worn to minimize exposure to hazards include gown, gloves, face mask) is changed before caring for another resident;-Examples of high-contact resident care activities requiring use of gown and gloves for EBPs include dressing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (urinary catheter, feeding tube, tracheostomy/ventilator) and wound care (any skin opening requiring a dressing);-EBPs are indicated of resident infected or colonized with methicillin-resistant staphylococcus aureus (MRSA - type of staph germ that has become resistant to many common antibiotics, making infections harder to treat);-EBPs are indicated for residents with wounds and/or indwelling devices regardless of MDRO colonization;-EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk;-The use of EBPs does not impose limitation on group activities or room restrictions for residents;-Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status;-Staff are trained prior to caring for residents on EBP;-Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required;-PPE is available outside of the resident rooms;-Residents, families and visitors are notified of the implementation of EBPs throughout the facility. 1. Review of Resident #5's face sheet showed the following:-admission date of 08/13/24;-Diagnosis included stage 3 pressure ulcer (full-thickness skin loss that extends into the subcutaneous tissue but does not involve muscle, tendon, or bone) of sacral region (area at the lower back, above the buttocks). Review of the resident's Physician Orders Sheet (POS), current as of 09/26/25, showed an order, dated 09/12/25, for sacral wound care. The orders did not address use of EBP. Review of the resident's annual assessment Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 07/25/25, showed the following:-Cognitively intact;-Resident had one or more unhealed pressure ulcer;-Resident had one stage 3 pressure ulcer that was not present on admission. Review of the resident's care plan, last updated 01/23/25, showed the following:-Resident had a stage 3 pressure wound to coccyx (tailbone);-Staff should provide treatment to coccyx as ordered daily;-Staff should document weekly treatment to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations(Staff did not care plan related to EBP.) Oservation on 09/24/25, at 8:35 A.M., showed the Assistant Director of Nursing (DON) and Certified Nurse Aide (CNA) B entered the resident's room. ADON and CNA provided incontinent care and wound care to the resident. Both wore gloves, but neither of them wore a gown. There was an EBP sign on the resident room door that advised staff to wear PPE, including gown and gloves, while working with the resident. During an interview on 09/25/25, at 2:40 P.M., Licensed Practical Nurse (LPN) A said EBP should be used with residents that have wounds. During an interview on 09/25/25, at 3:10 P.M., LPN E said EBP required staff to wear gown and gloves when providing care to residents that have any wound. During an interview on 09/25/25, at 3:20 P.M., the ADON said residents with wounds should be on EBPs. He/she should have worn a gown when completing wound care for Resident #5. During an interview on 09/26/25, at 2:27 P.M., the Director of Nursing (DON) said staff should follow the EBP policy for residents that have wounds. During an interview on 09/26/25, at 3:32 P.M., the Administrator said staff should wear gown, gloves, and mask if needed when providing cares for residents with wounds. 2. Review of the facility policy titled Urinary Catheter Care, September 20214, showed the following:-The purpose of this procedure is to prevent catheter-associated urinary tract infections;-Use standard precautions when handling or manipulating the drainage system;-Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. Review of Resident #67's face sheet showed the following:-admission date of 08/07/25;-Diagnoses included flaccid neuropathic bladder (nerve damage causes the bladder muscle to lose its ability to contract properly) and chronic kidney disease stage 3 (CKD – kidneys are damaged and can't filter blood the way they should, mild to moderate damage). Review of the resident's physician orders, current as of 09/26/25, showed the following:-An order, dated 09/05/25, to change foley (catheter) every shift starting on the first and ending on the fifth of every month and as needed for occlusion or leakage;-An order, dated 09/05/25, for urinary catheter care every shift.(Staff did not care plan related to EBP.) Review of the resident's admission MDS, dated [DATE], showed the following:-Cognitively intact;-Resident had an indwelling catheter. Review of the resident's care plan, last updated 09/11/25, showed the following:-The resident had an indwelling catheter for neurogenic bladder;-Staff should monitor and document for pain or discomfort due to catheter;(Staff did not care plan related to EBP.) Observation on 09/25/25, at 2:00 P.M., showed CNA B and CNA C entered the resident's room. The resident was seated in his/her wheelchair with a catheter bag under the wheelchair. There was an EBP sign on the resident's door advising staff to wear gown and gloves with resident cares. The staff washed hands at the sink and applied gloves. The staff did not apply gowns. The aides transferred the resident, emptied the resident's catheter bag and provided catheter care, and removed the resident's shoes and resident pants. During an interview on 09/25/25, at 2:20 P.M., Nurse Aide (NA) D said catheter care does not require a gown to be worn, only gloves. During an interview on 09/25/25, at 2:40 P.M., LPN A said EBP should be used with residents that catheters to protect the resident. During an interview on 09/25/25, at 3:10 P.M., LPN E said EBP required for staff to wear gown and gloves when providing care to residents that have any catheter. During an interview on 09/25/25, at 3:20 P.M., the Assistant Director of Nursing (ADON) said with catheters should be on EBPs. During an interview on 09/26/25, at 2:27 P.M., the DON said staff should follow the EBP policy for residents that have catheters. Staff should wear gown and gloves when providing care to a resident with a catheter. During an interview on 09/26/25, at 3:32 P.M., Administrator said staff should wear gown, gloves, and mask if needed when providing cares for residents with catheters. 3. Review of Resident #12's face sheet showed the following information:-admission date of 10/01/15;-Diagnoses included gastrostomy (tube inserted through the abdominal wall into the stomach to provide nourishment and/or medications. Review of the resident's quarterly MDS, dated [DATE], showed feeding tube present while a resident. Review of the resident's POS showed current orders for feeding tube care and administration of medication in feeding tube. Staff did not note any orders related to EBP. Review of the resident's care plan, last updated 07/25/25, showed resident required EBP due to PEG tube (feeding tube), post signage on the door or wall of the room indicating precautions for PPE, utilize PPE as indicated during cares, ensure standard precautions are used when handling PEG tube per facility protocol and provide treatment care to tube site as ordered and observe for signs/symptoms of infection at tube site. Observation on 09/25/25, at 11:45 A.M., showed LPN J used sanitizer and donned gloves, but did not don a gown. LPN J adjusted the resident's bed covers and clothing to expose the feeding tube site. He/she administered medication through the tube retrieved the administration tubing and syringe from a drawer, primed the tubing, During an interview on 09/26/25, at 11:35 A.M., LPN J said staff should wear both gown and gloves while performing any care or medication administration involving the resident2's G-tube. He/she had forgotten to don a gown prior to the antibiotic administration during the observation on 09/25/25. During an interview on 09/25/25, at 2:40 P.M., LPN A said EBP should be used with residents that have wounds tube feedings. Staff should wear a gown when completing medications by peg tube. During an interview on 09/25/25, at 3:10 P.M., LPN E said EBP is required for staff to wear gown and gloves when providing care to residents that have any tube feeding. During an interview on 09/26/25, at 3:32 P.M., Administrator said staff should wear gown, gloves, and mask if needed when providing cares for residents feeding or peg tube. 4. During an interview on 09/25/25, at 2:20 P.M., NA D said EBP signs mean the resident has a transmittable illness and staff should wear gown, gloves, and mask. During an interview on 09/25/25, at 2:30 P.M., CNA B said he/she would have to check with the nurse about the EBP signs. At previous facilities he/she had worked, they required staff to wear gown and gloves with catheter care and direct resident care for residents when there was an EBP sign. During an interview on 09/26/25, at 3:32 P.M., Administrator said staff should follow the EBP policy.

Based on interview and record review, the facility failed to ensure each residents' representatives were notified timely of changes in condition when staff failed to notify one resident's (Residents #72) representatives regarding a change in condition and new orders. A sample of 26 residents was reviewed for notification of changes; the facility census was 77. Review showed the facility did not provide a policy regarding notification of resident representatives. 1. Review of Resident #72's Face Sheet (resident information) showed the following:-admission date of 11/08/24;-Diagnoses included complete amputation at knee level, anorexia, depression, anxiety, and heart failure;-Contact Emergency Contact (EC) #1 if any new orders are received or if a change in condition. Review of resident's care plan, dated 06/11/25, showed the following:-Resident has an ADL self-care performance deficit due to recent below the knee amputation;-Resident requires assistance for ADL's, transfers, and mobility using Hoyer lift and wheelchair;-Resident will improve current level of function in all ADL's through the next review date. Review of resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 09/12/25, showed the resident to be cognitively intact. Review of resident's progress note, dated 08/08/25, showed the following:-Physician group rounded this afternoon;-New order received for Midodrine (treats low blood pressure);-Order processed;-Resident informed;-Staff did not document EC notification. Review of resident's progress note dated 08/18/25, at 2:30 P.M., showed the following:-Resident with no further emesis (vomiting), but had some diarrhea;-PRN (as needed) Zofran (used to treat nausea) administered for continued nausea;-Resident refused all oral medication due to nausea;-Physician notified;-Staff did not document EC notification. Review of resident's progress note dated 08/18/25, at 6:57 P.M., showed the following:-Staff observed a small amount of pink urine present between the resident's legs during incontinent care;-Earlier physician contacted and requested a stool sample for C-Diff (a bacterium that can cause inflammation of the colon (colitis));-Staff did not document EC notification. Review of resident's progress note, dated 08/19/25, showed the following:-An order for ondansetron oral tablet disintegrating (used to treat nausea) 4 milligrams (mg);-Give one tablet by mouth three times a day for nausea for three days;-Staff did not document EC notification. Review of resident's progress note, dated 08/21/25, showed the following:-Optometry rounded on 08/20/25;-New orders received for Ocuvite (medication to support eye health);-Order processed;-Staff did not document EC notification. Review of resident's progress notes, dated 08/25/25, showed the following:-Physician group rounded this evening;-Received orders for urology referral and potassium daily;-Orders processed and resident aware;-Received order to resume apixaban (blood thinner), order resumed;--Staff did not document EC notification. Review of resident's progress note, dated 09/01/25, showed the following:-Resident with new order for Miralax (medication for constipation);-No gastrointestinal distress voiced;-Staff did not document EC notification. Review of resident's progress note, dated 09/05/25, showed the following:-Resident with small-moderate amount of bloody urine in brief;-Staff will continue to monitor;-Staff did not document EC notification. Review of resident's progress note, dated 09/11/25, showed the following:-Resident had gastric tube that was not being utilized for feedings/medication at this time;-Dressing change to site with a large amount of bloody discharge and gas escaping from the stoma (a surgically created opening on the abdomen);-Granulation tissue (wound healing tissue) appeared to be irritated causing slight bleeding;-No signs or symptoms of infection noted;-Staff will continue to monitor and report changes as needed;-Staff did not document EC notification. Review of resident's progress note, dated 09/14/25, showed the following:-Resident's feeding tube is leaking a large amount of brownish contents;-Dressing changed;-Area is slightly red and sore to the touch;-Staff did not document EC notification. Review of resident's progress note, dated 09/16/25, showed the following:-Urine screen collected via catheter (tube used to drain urine from the bladder);-Staff did not document EC notification. Review of resident's progress note, dated 09/19/25, showed the following:-Physician rounded this afternoon;-Received orders for fortified and milk between meals;-Orders processed;-Resident aware;-Staff did not document EC notification. Review of resident's progress note, dated 09/24/25, showed the following:-Order for ciprofloxacin oral tablet (used to treat infection) 500mg;-Give one tablet by mouth two times a day for urinary tract infection for seven days;-Order for Imodium oral tablet 2mg;-Give one tablet by mouth three times a day for diarrhea for three days;-Staff did not document EC notification. During an interview on 09/22/25, at 2:35 P.M., with the resident and his/her next of kin (NOK) they said the following:-The NOK had requested the facility contact him/her regarding all medication changes and changes in the resident's condition;-The facility does not regularly contact the NOK concerning new orders or when a resident had a change in condition;-The facility will sometimes notify the NOK when he/she is in the facility, but that is often several days after the medication was ordered;-The NOK has voiced her concerns facility staff. During an interview on 09/26/25, at 2:28 P.M., the Director of Nursing (DON) said the resident's NOK had voiced concerns over not being notified. Most of the correspondence with the resident's NOK was through email, but it should be documented in the resident's record. During an interview on 09/26/25, at 4:03 P.M., the Administrator said he/she was not aware of any concerns regarding NOK notification concerning the resident. During an interview on 09/25/25, at 2:30 P.M., Certified Nursing Assistant (CNA) F said nurses notify the resident's NOK if the resident has a change in condition. This should be documented in the resident's progress notes. During an interview on 09/25/25, at 3:00 P.M., CNA G said nurses and possibly Certified Medication Technicians (CMT) notify the resident's NOK if there is a change. This information should be documented in the resident's notes. During an interview on 09/25/25, at 3:18 P.M., CNA H said NOK notifications are made by the nurses. During an interview on 09/25/25, at 4:38 P.M., CMT O said nurses notify families regarding resident concerns. Any contact with the family should be documented. During an interview on 09/26/25, at 9:45 A.M., Licensed Practical Nurse (LPN) I said nurses notify a resident's family anytime there are new orders or a change in condition. The contact is documented in the resident's progress notes. During an interview on 09/26/25, at 10:02 A.M., LPN J said nurses notify a resident's family when there is a change in condition or a medication change. This notification is documented in the progress notes. During an interview on 09/26/25, at 12:39 P.M., the Assistant Director of Nursing (ADON) said normally the Registered Nurse (RN) Supervisor would notify the family, but any nurse can made the contact. The NOK should be notified of medication changes or change in condition. The contact should be documented in progress notes. During an interview on 09/26/25, at 2:28 P.M., the DON said the resident's NOK should be notified of new medications or if there has been a change in condition. The floor nurse, or the nurse entering the order should contact the family. The contact should be documented in the resident's record. During an interview on 09/26/25, at 4:03 P.M., the Administrator said the resident's NOK should be notified of changes in condition or medication changes. The charge nurse normally contacts the NOK, but it could be the DON, whomever receives the new order. All notifications should be documented in the resident's progress notes.

Based on observation, interview, and record review, the facility failed to provide appropriate oral care for one resident (Resident #12) who was dependent on staff for all activities of daily living. The facility census was 77.Review showed the facility did not provide a policy specific to assisting residents with oral care. 1. Review of Resident #12's face sheet showed the following information:-admission date of 10/01/15;-Diagnoses included right-sided weakness and paralysis following a stroke, history of transient ischemic attack (TIA - mini-stroke), unable to speak, gastrostomy (tube inserted through the abdominal wall into the stomach to provide nourishment and/or medications), muscle wasting, epilepsy/convulsions/seizures, low blood pressure, major depressive disorder, anxiety, difficulty swallowing, osteoporosis (weakening of bones), history of urinary tract infections (UTI), contracture, history of COVID-19, difficulty sleeping, and chronic pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 07/25/25, showed the following information:-Severely impaired cognition;-Range of motion impaired to upper and lower extremities, one sided;-Dependent on others for oral hygiene;-Feeding tube present while a resident. Review of the resident's care plan, last updated 07/25/25, showed the resident needed total assist with all activities of daily living (ADLs) related to right sided hemiplegia. Staff to do oral care every shift and after meals and as needed. Staff to provide appropriate oral care for moisture and hygiene throughout the day and night between brushings. During an interview on 09/22/25, at 12:15 P.M., the resident's family member said staff did not do daily oral care every shift, and sometimes not even daily. He/she said the resident often had horrible breath when he/she arrived to visit. The resident had his/her own supplies on hand, including an electric toothbrush and toothpaste. Observation on 09/25/25, at 10:00 A.M., showed the resident's breath was very malodorous. When the surveyor asked if the staff had cleaned his/her mouth that morning, the resident signed no. Observation on 09/26/25, at 10:30 A.M., showed the resident's breath was malodorous. When the surveyor asked if the staff had cleaned his/her mouth and teeth that morning, the resident signed no. When asked if he/she wanted that done, the resident signed yes. During an interview on 09/26/25, at 12:10 P.M., Licensed Practical Nurse (LPN) J said the staff should really be doing more oral care for the resident. The aides should do the care every day. During an interview on 09/26/25, at 12:14 P.M., Certified Mediation Technician (CMT) V said the resident usually cooperates with him/her regarding care. The floor aides don't usually do the oral care; it is done by the shower aide on Mondays, Wednesday, and Fridays. During an interview on 09/26/25, at 1:45 P.M., Certified Nurse Aide (CNA) F said the resident had an electric toothbrush provided by the resident's family. The shower aide does the oral care on shower days, or the resident's family does the care. The other aides should probably do oral care, too. The resident will allow the aides to do oral care if his/her family isn't present. During an interview on 09/26/25, at 1:54 P.M. LPN I said for residents who need assist, oral care should be done after mealtime. During an interview on 09/26/25, at 2:28 P.M., the Director of Nursing (DON) said the aides or nurses should do oral care for residents at least every shift. The DON said the resident bites down on the toothbrush and doesn't always like the care, but the CNA's should try to do it anyway. During an interview on 09/26/25, at 3:52 P.M., the Administrator said staff should assist residents as needed with oral care at least every morning and every evening, including the resident. Oral care should be done by the CNAs unless the care is specified to be done by the nurse.

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities when staff failed to provide preferred activities to one resident (Resident #72) who voice importance of attending activities. The facility census was 77. Review showed the facility did not provide a policy related to activities. 1. Review of Resident #72's face sheet (resident information) showed the following:-admission date of 11/08/24;-Diagnoses included complete amputation at knee level, anorexia, depression, anxiety, and heart failure. Review of resident's Activities-Initial Review Assessment, dated 11/11/24, showed the following:-Resident liked to read, watch TV, and do puzzles;-Resident attended church services in the community, and it was unknown if he/she would like clergy visits in the facility;-Resident did not wish to participate in activities in the facility. Review of resident's care plan, dated 02/17/25, showed the following:-Resident had little or no activity involvement;-Resident came to activities per his/her choice;-Resident liked to attend church services or stay in his/her room and watch TV;-Modify daily schedule and treatment plan as needed (PRN) to accommodate activity participation as requested by the resident. Review of resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 03/20/25, showed the following:-Cognitively intact;-Resident was dependent on staff for bathing, personal hygiene, and mobility;-Preference of listening to music was very important;-Preference of being around animals was important;-Preference in participating in favorite activities was very important;-Preference in going outside to get fresh air was important;-Preference in participating in religious services or practices was important. Review of the facility's August 2025 Activity Calendar showed the following:-Bingo every Monday, Wednesday, and Friday at 2:00 P.M.;-Bible study every Tuesday at 10:00 A.M.;-On 08/08/25, zoo program;-On 08/14/25, gospel music;-On 08/21/25, a music program. Review of resident's Activity Notes dated August 2025, showed the following:-The Daily Chronicle (facility newsletter) was delivered to the resident every Monday-Friday;-The Activity Director (AD) conducted room visits once per week (varied days);-On 08/12/25, resident had his/her nails done;-On 08/19/25, resident declined to have her nails done.(Staff did not document offering the resident the opportunity to attend bible study, zoo program, or music programs.) Review of resident's Activities-Quarterly/Annual Participation Review, dated 09/09/25, showed the following:-Resident preferred to stay in bed, but did agree to try to come to more activities, maybe bingo or music;-Activity related focus remained appropriate/current as per current care plan;-Activity goals were met;-Activity interventions/approaches had been effective in reaching goals;-Unknown if assistance should be provided to get the resident to the activity. Review of the facility's September 2025 Activity Calendar showed the following:-Bingo every Monday, Wednesday, and Friday at 2:00 P.M.;-Church every Tuesday and Wednesday at 10:00 A.M.;-On 09/05/25 and 09/18/25, a music program was held. Review of resident's Activity Notes dated September 2025, showed the following:-The Daily Chronicle was delivered to the resident every Monday-Friday;-On 09/02/25, the AD conducted a room visit;-On 09/16/25, resident had his/her nails done.(Staff did not document offering the resident the opportunity to attend church or music programs.) During an interview on 09/22/25, at 2:13 P.M., the resident said staff never ask or notify him/her of activities. He/she would at least like to go to bingo. During an interview on 09/24/25, at 1:15 P.M., the resident said staff had not asked if he/she would like to go to bingo today (2:00 P.M. start time). During an interview on 09/24/25, at 2:47 P.M., the resident said staff did not offer to take him/her to bingo. During an interview on 09/25/25, at 2:14 P.M., the resident said staff had not come by his/her room to notify him/her of any activities for the day. During an interview on 09/25/25, at 2:30 P.M., Certified Nurse Aide (CAN) F said the following:-He/she believed the resident was asked by staff if they would like to attend activities, however, he/she does not attend;-He/she did not know if the resident's activity participation or refusals was documented. During an interview on 09/25/25, at 3:00 P.M., CNA G said he/she was not aware if the resident attended activities. During an interview on 09/25/25, at 3:18 P.M., CNA H said he/she believed the resident was invited to activities. During an interview on 09/25/25, at 4:38 P.M., Certified Medication Technician (CMT) O said the resident had started getting up more, but was unsure if he/she was attending activities. During an interview on 09/26/25, at 11:15 A.M., the Activities Director (AD) said the following: -The resident enjoyed watching tv and reading;-The resident would participate in pet therapy;-He/she believed the resident was invited to attend the music program last week, but refused;-The resident was often tired after lunch;-He/she was unsure if staff had asked the resident if he/she would like to attend bingo. During an interview on 09/25/25, at 2:30 P.M., CNA F said staff remind residents in the morning of the daily activities. The activities calendar was posted in the hallways. During an interview on 09/25/25, at 3:00 P.M., CNA G said the following:-Activity sheets were passed out to all residents;-Staff invited resident to activities;-Activity preferences should be listed in the care plan. During an interview on 09/25/25, at 3:18 P.M., CNA H said the following:-Residents should have an activity calendar posted in their room;-CNAs notified residents of activities and offered assistance;-Activity preferences should be documented in the care plan. During an interview on 09/25/25, at 4:38 P.M., CMT O said the following:-Residents were notified of activities through calendars placed on their doors and around the facility;-Staff reminded residents of activities, especially of the popular ones;-Activities preferences should be in the care plan. During an interview on 09/26/25, at 9:45 A.M., Licensed Practical Nurse (LPN) I said the following:-Activities were posted on the bulletin board;-Aides ask residents if they would like to attend activities;-Activity preferences should be in the care plan. During an interview on 09/26/25, at 10:02 A.M., LPN J said the following:-Activities were posted in hallway and a printout is provided to residents;-Activities staff come by resident rooms in the morning and check if there were any activities the resident wanted to attend that day;-CNAs also ask residents if they would like to attend activities. During an interview on 09/26/25, 11:15 A.M., AD said the following:-He/she would discuss with residents their activity preferences and complete the activity assessment;-Preferences are placed in the care plan, and he/she also kept information about preferences; -He/she distributed a monthly calendar to residents and also wrote it on the window in the activities area;-He/she passed out the Daily Chronicle and would advise residents of the upcoming activities for the day;-If a resident showed interest in that day's activities, prior to the activity, he/she would remind the resident and would ask if they need assistance to the activity. If assistance was needed, he/she would inform the aides;-If an aide knew a resident liked to attend a certain activity, they invited them to the activity;-He/she checked in with residents and encouraged residents to attend;-If the resident did not want to attend group activities, he/she would offer a one-on-one activity with the resident; -He/she only documented if a resident refuses a one-on-one meeting. During an interview on 09/26/25, at 2:28 P.M., the Director of Nursing (DON) said the following: -Activity preference was obtained by conducting an activity assessment;-The AD should be discussing activity preferences with the residents;-Activity calendars are posted in resident rooms and at the nurses' station;-The AD will walk around the building and ask residents if they would like to attend;-CNAs can ask residents if they would like to attend activities;-If staff are aware of a resident's activity preference, they should ensure the resident is invited to that activity;-Refusals to attend activities should be documented. During an interview on 09/26/25, at 4:03 P.M., the Administrator said the following:-Activity preferences should be discussed at the resident's care plan meeting;-Residents should be encouraged to attend activities;-If a resident's activity preference change, it should be documented;-Activity calendars are provided to each resident;-Staff remind residents of upcoming activities;-The AD reminds residents of the daily activities when passing out the Daily Chronicle;-The AD highlights on a calendar what each resident attended;-He/she is unsure if the AD documents refusals.

Based on observation and interview, the facility failed to ensure access to survey results to family, visitors, and residents when the prior survey results were not kept in a readily accessible, public location. The facility census was 77.Review showed the facility did not provide a policy regarding survey results accessibility. 1. Observation on 09/24/25, at 2:00 P.M. showed the following:-A white binder located behind the front desk, lying flat in a wire bin;-Two sets of public bathroom keys lying on top of the binder;-The height of the desk counter was approximately four feet tall;-The binder was not visible behind desk if seated in a wheelchair;-No signage was present notifying of the location of the survey results. During interviews on 09/22/25, at 9:58 A.M., during the resident council group meeting, the residents said they were unaware that they previous year's survey results were available for residents to review. None of the resident were aware of the location of the survey results in the facility. During an interview on 09/24/25, at 11:00 A.M., the Administrator said the facility does not currently have a receptionist at the front desk. During an interview on 09/25/25, at 2:30 P.M., Certified Nursing Assistant (CNA) F said he/she was unsure of the location of the survey results and would have to ask a nurse. During an interview on 09/25/25, at 3:00 P.M., CNA G said he/she does not know where survey results were kept. If a resident asked to see the results, he/she would ask the charge nurse. During an interview on 09/25/25, at 3:18 P.M., CNA H said if a resident asked to see the survey results, he/she would ask the Administrator where the results were located. During an interview on 09/26/25, at 9:45 A.M., Licensed Practical Nurse (LPN) I said he/she was unsure where the survey results were kept. He/she would ask the Assistant Director of Nursing (ADON) or the Director of Nursing (DON) for the location of the results. During an interview on 9/26/25, at 10:02 A.M., LPN J said he/she was unsure of the location of the survey results. He/she would ask the DON. During an interview on 09/26/25, at 2:28 P.M., the DON said survey results were kept in a binder behind the front desk. There was no signage indicating the location. During an interview on 09/26/25, at 4:03 P.M., the Administrator said the following:-The survey results were located behind the front desk;-The survey results used to be on top of the counter at the front desk, but the binder would disappear;-No residents have asked to view the survey results;-Residents often used the front restrooms, and could see the survey results under the bathroom keys;-No signage was present indicating the location of the survey results.

Based on interview and record review, the facility failed to maintain an effective system of records and disposition of controlled medications when staff could not locate two cards of a controlled medications and failed to destroy the discontinued controlled medication in a timely fashion for one resident (Resident #1). The facility census was 56. On 04/02/24, the Assistant Director of Nursing (ADON) was notified of the Past Non-Compliance that occurred on 04/01/24. The ADON notified the physician, the Director of Nursing (DON), and the Administrator. The Administrator notified the Ozark Police Department. The DON and ADON completed an narcotic count audit. Administration interviewed staff and residents and reviewed the camera surveillance. The Administrator suspended the employee pending completion of the investigation. Administration completed in-service education with all licensed nurses and certified medication technicians (CMT) regarding controlled substances. The noncompliance was corrected on 04/10/24. Review of the facility's policy titled Controlled Substances, dated 04/2007, showed the following: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances; -Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises; -Controlled substances must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together. Both individuals must sign the designated narcotic record; -If the count is correct, a control sheet must be made for each substance. Do not enter more than one prescription per page. This record must contain: name of resident, name and strength of the drug, quantity received, number on hand, name of physician, prescription number, name of issuing pharmacy, dated and time received, time of administration, method of administration, signature of person receiving medication and signature of nurse administering medication; -Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services (DON) or Designee; -The Director of Nursing Services or Designee shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings; -When a resident or patient is transferred or discharged from the facility, Schedule II drugs may not be given to the resident to take with them and may not be returned to the pharmacy, but must be destroyed in accordance with established policies. Review showed the facility did not provide a policy related to destruction of controlled medications. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE] and discharge date of [DATE]; -Diagnoses included arthritis of the left knee and dementia. Review of the resident's care plan, revised 08/02/23, showed the following: -The resident had a potential for pain related to knee replacement with a wound infection; -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; -Monitor, record, and report to the nurse any signs or symptoms of non-verbal pain; -Monitor, record, and report to the nurse resident complaints of pain or requests for pain treatment; -Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain; -Report to the nurse any change in usual activity attendance patterns or refusal to attend activities related to signs, symptoms or complaints of pain or discomfort. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 03/06/24, showed the following: -Cognitively intact; -The resident had occasional pain and was on a scheduled pain medication regimen. Review of the resident's April 2024 Physician's Order Sheet (POS) showed the following: -An order, dated 07/21/23 and discontinued 07/25/23, for oxycodone HCL (a drug to treat moderate to severe pain) 5 milligram (mg) tablet, give 5 mg by mouth (PO) every four hours as needed for severe pain with maximum daily amount of 30 mg. Review of the resident's July 2023 Medication Administration Record (MAR) showed staff did not administer oxycodone to the resident from 07/21/23 through 07/25/23. Review showed the facility did not provide a narcotic control sheet for the oxycodone. Review of the facility's investigation, dated 04/02/24, showed the following: -On 04/02/24, at approximately 8:30 A.M., it was reported to the ADON there was a potential discrepancy in the narcotic count; -An audit was completed and it was noted narcotics for the discharged resident had been removed from the cart. The resident had discharged the afternoon of 04/01/24; -The resident's narcotics had not been destroyed by nurse leadership as the resident was just discharged ; -An investigation was initiated by the facility; -Upon completion of the investigation, the facility acknowledged there was sufficient evidence to support employee Licensed Practical Nurse (LPN) E had diverted what is believed to be unknown medication from the facility. During an interview on 04/18/24, at 1:18 P.M., CMT D said the following: -When he/she arrived at work, he/she counted medications with the night nurse; -They first counted the number of medication cards and bottles of narcotics and then the total amount of pills and ensured both counts matched the narcotic sheets; -If he/she noticed a discrepancy, he/she checked the computer to see if a dose was given and not documented on the narcotic sheet. If a discrepancy remained, he/she notified the ADON and did not accept the cart until the discrepancy was resolved; -On 04/02/24, he/she pulled a medication card out of the cart and the number did not correspond with the narcotic sheet. He/she immediately took this to the ADON and the ADON found them signed as given in the computer and not marked on the narcotic sheet; -Later the same day, he/she emptied a card of narcotics and went to mark it off on the narcotic record and notices the narcotic record had two cards of Norco marked off with his/her signature forged on the narcotic sheet. He/she immediately stopped what he/she was doing and took this to the ADON and that prompted a search of both the CMT and the nurses' carts; -He/she counted with LPN E that morning. During an interview of 04/18/24, at 4:18 P.M., LPN B said the following: -When he/she and LPN E counted the medication, the resident's oxycodone was in the cart; -He/she knew this because he/she counted this medication since 07/2023. -On 04/01/24, he/she and LPN E counted the medications in the nurses' cart together; -When he/she counted with the oncoming nurse, the oncoming nurse had the cart and he/she gave the numbers from the narcotic book. During an interview on 04/18/24, at 1:55 P.M., LPN C said the following: -When he/she arrived at work, he/she counted medications with the night nurse on the nurses' cart and the CMT counted medications with the same nurse on the CMT cart; -They counted the number of narcotic cards and then the number of pills to ensure they were the same as the narcotic record; -If he/she noticed a discrepancy, he/she did not accept the cart and notified the ADON immediately. At times, the ADON oversaw the counts; -When he/she gave a narcotic medication, he/she documented this in the computer and in the narcotic log that showed the amount of pills and cards. During an interview on 04/18/24, at 11:45 A.M., Registered Nurse (RN) A said the following: -CMTs count medications with the next shift; -When nursing or CMTs gave a narcotic, they documented this in the narcotic book with the time, their initials, date given and how many pills left; -If he/she noticed a discrepancy, he/she would first recount the medication, not take control of the medication cart until the count was correct, and notified the DON; -The facility required two RNs to destroy medications. Until the medications were destroyed, the medications remained in the cart and nursing staff or CMTs counted them daily. During an interview on 04/18/24, at 2:11 P.M., the ADON said the following: -She found the narcotic log for adding or removing cards of medication showed LPN E removed four cards of oxycodone, but the ADON realized the resident only had two cards of this medication; -She looked for the narcotic log that showed the amount of pills for the oxycodone and could not find it and never did find it; -The resident's oxycodone was not in the cart. The resident had one card of 30 pills and one card of 12 pills and he/she never used that medication. During an interview on 04/18/24, at 3:23 P.M., the DON said the following: -Nursing staff should have destroyed the resident's oxycodone a long time ago if it was discontinued on 07/25/23; -Nursing staff should have pulled the oxycodone off the cart the day it was discharged . During an interview on 04/18/24, at 3:52 P.M., the Administrator said the following: -The DON and ADON destroyed medications and she had a discussion with the DON and ADON about how long the resident's oxycodone stayed in the cart; -The DON and ADON should have destroyed the oxycodone; -She was unable to account for 42 pills of oxycodone and all indicators pointed to LPN E took the medication. MO00234123

Based on observation, interview, and record review, the facility staff failed ensure medication error rates below 5% when staff failed to to prime (removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.) the insulin pens before administering insulin to three residents (Residents #6, #3, and #20). The facility had three medication errors out of 34 opportunities for error resulting in a facility medication error rate of 8.82%. The facility census was 56. Review of the facility policy regarding insulin administration, revised September 2014, showed the following: -Purpose to provide guidelines for the safe administration of insulin to residents with diabetes; -The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use; -Insulin delivery: pens-containing insulin cartridges deliver insulin subcutaneously through a needle. Review of How to Use FlexPen, dated September 2021, showed before administering insulin with a FlexPen the pen should be primed by the following steps: -Turn dose selector to two units; -Hold FlexPen with the needle pointing up and gently tap the cartridge a few times to make any air bubbles collect at the top; -Keep needle upwards and press the push-button all the way in. A drop of insulin should appear on the needled tip; -Repeat the process, no more than six times, until a drop of insulin is present. If a drop is not present, a different pen must be used. Review of the Instructions for use Humalog (fast acting insulin) KwikPen, dated 07/2023, showed the pen needs to primed before each use. The pen should be primed by the following steps: -Turn dose knob to two units; -Hold pen with needle pointing up; -Tap the cartridge holder gently to collect air bubbles at the top; -Continue holding the pen with needle pointing up and push dose knob until it stops. Insulin should be at the tip of the needle; -Repeat, no more than four times, until insulin is visible. 1. Review of Resident #6's face sheet (admission information at a glance) showed the following: -Admission 02/09/2023; -Diagnoses that included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose). Review of the resident's physician's order, dated 02/08/24, showed an order for Novolog (rapid acting insulin) FlexPen subcutaneous (administered under the skin) solution pen-injector 100 unit/milliliter (ml) administered before meals per following sliding scale: -If blood sugar level is 70 mg/deciliter (dL) to 130 mg/dL, administer no insulin; -If blood sugar level is 131 mg/dL to 180 mg/dL, administer two units of insulin; -If blood sugar level is 181 mg/dL to 240 mg/dL, administer four units of insulin; -If blood sugar level is 241 mg/dL to 300 mg/dL, administer six units of insulin; -If blood sugar level is 301 mg/dL to 350 mg/dL, administer eight units of insulin; -If blood sugar level is 351 mg/dL to 400 mg/dL, administer ten units of insulin; -If blood sugar level is 401 mg/dL to 450 mg/dL, administer 15 units of insulin; -If blood sugar level is 451 mg/dL to 500 mg/dL, administer 18 units of insulin. Observation on 02/21/24, at 10:59 A.M., showed Licensed Practical Nurse (LPN) P took the glucometer (device use to measure blood sugar levels) into the resident's room, completed an accucheck (blood sugar level check), and got the blood glucose (sugar) reading of 301 mg/dL. LPN P took the glucometer back to the cart and retrieved the resident's Novolog FlexPen from the cart. LPN P used hand sanitizer on his/her hands, dialed up the eight units of Novolog insulin, returned to the resident's room and administered the insulin to the resident. The LPN did not prime the pen prior to the insulin administration. 2. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus with mild diabetic retinopathy (retina eye disease) and with diabetic mononeuropathy (nerve damage that often damages nerves in the legs and feet). Review of the resident's physician order, dated 04/24/23, showed Humalog KwikPen subcutaneous solution pen injector 100 units/ml, administer before meals per sliding scale: -If blood sugar level is 70 mg/dL to 130 mg/dL, do not administer insulin; -If blood sugar level is 131 mg/dL to 180 mg/dL, administer two units of insulin; -If blood sugar level is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If blood sugar level is 241 mg/dL to 300 mg/dL, administer ten units of insulin; -If blood sugar leave is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If blood sugar level is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If blood sugar level is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If blood sugar level is 451 mg/dL to 500 mg/dL, administer 30 units of insulin. Observation on 02/21/24, at 11:15 A.M., showed LPN P took the glucometer into the resident's room, completed an accucheck, and got a blood glucose reading of 193 mg/dl. LPN P took the glucometer back to the cart and retrieved the resident's Humalog Kwikpen from the cart. LPN P used hand sanitizer on his/her hands, dialed up the 8 units of Humalog insulin, went into the room, and administered the insulin to the resident. The LPN did not prime the insulin prior to administration of the insulin. 3. Review of Resident #20's face sheet showed the following: -admitted [DATE]; -Diagnoses that included type 2 diabetes mellitus. Review of the resident's physician's order, dated 06/01/22, showed an order for Novolog Flexpen, inject at meal times per following sliding scale: -If blood sugar level is 70 mg/dL to 130 mg/dL, do not administer insulin; -If blood sugar level is 131 mg/dL to 180 mg/dL, administer four units of insulin; -If blood sugar level is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If blood sugar level is 241 mg/dL to 300 mg/dL, administer ten units of insulin; -If blood sugar level is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If blood sugar level is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If blood sugar level is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If blood sugar level is 451 mg/dL to 500 mg/dL, administer 30 units of insulin. Observation on 02/21/24, at 11:26 A.M., showed LPN P took the glucometer into the resident's room, completed an accucheck and got the blood glucose reading of 274 mg/dL. LPN P took the glucometer back to the cart and retrieved the resident's Novolog Flexpen from the cart. LPN P used hand sanitizer on his/her hands, dialed up the 10 units of Novolog insulin, went into the resident's room, and administered the insulin to the resident. The LPN did not prime the insulin pen prior to administering the insulin. 4. During an interview on 02/22/24, at 12:12 P.M., LPN P said he/she will do the accucheck on the resident's blood sugar and then will look at the resident's orders for insulin and the sliding scale for the amount of insulin he/she was to administer to the resident. He/she will dial up the units on the insulin pen and will administer this to the resident and hold the pen for ten seconds. He/she knew to prime an insulin pen like one to two milliliters (ml), but thought this was completed once a day. He/she did not know to prime a resident's insulin pen with each administration to the resident. He/she did not prime the three residents' insulin pens during the medication pass yesterday on 02/21/2024. 5. During interview on 02/26/24, at 11:03 A.M., the Director of Nursing (DON) said he/she would expect staff to administer insulin to residents with the insulin pens by priming the pen with at least two units insulin before administering to the resident. 6. During interview on 02/26/24, at 6:40 P.M., the Administrator said staff were to administer insulin to the residents with insulin pens by priming the insulin pen according to policy and manufacturer's instructions.

Based on observation, interview, and record review, the facility staff failed ensure all residents were free from significant medication errors when staff failed to to prime (removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.) the insulin pens before administering insulin to three residents (Residents #6, #3, and #20). The facility census was 56. Review of the facility policy regarding insulin administration, revised September 2014, showed the following: -Purpose to provide guidelines for the safe administration of insulin to residents with diabetes; -The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use; -Insulin delivery: pens-containing insulin cartridges deliver insulin subcutaneously through a needle. Review of How to Use FlexPen, dated September 2021, showed before administering insulin with a FlexPen the pen should be primed by the following steps: -Turn dose selector to two units; -Hold FlexPen with the needle pointing up and gently tap the cartridge a few times to make any air bubbles collect at the top; -Keep needle upwards and press the push-button all the way in. A drop of insulin should appear on the needled tip; -Repeat the process, no more than six times, until a drop of insulin is present. If a drop is not present, a different pen must be used. Review of the Instructions for use Humalog (fast acting insulin) KwikPen, dated 07/2023, showed the pen needs to primed before each use. The pen should be primed by the following steps: -Turn dose knob to two units; -Hold pen with needle pointing up; -Tap the cartridge holder gently to collect air bubbles at the top; -Continue holding the pen with needle pointing up and push dose knob until it stops. Insulin should be at the tip of the needle; -Repeat, no more than four times, until insulin is visible. 1. Review of Resident #6's face sheet (admission information at a glance) showed the following: -Admission 02/09/2023; -Diagnoses that included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose). Review of the resident's physician's order, dated 02/08/24, showed an order for Novolog (rapid acting insulin) FlexPen subcutaneous (administered under the skin) solution pen-injector 100 unit/milliliter (ml) administered before meals per following sliding scale: -If blood sugar level is 70 mg/deciliter (dL) to 130 mg/dL, administer no insulin; -If blood sugar level is 131 mg/dL to 180 mg/dL, administer two units of insulin; -If blood sugar level is 181 mg/dL to 240 mg/dL, administer four units of insulin; -If blood sugar level is 241 mg/dL to 300 mg/dL, administer six units of insulin; -If blood sugar level is 301 mg/dL to 350 mg/dL, administer eight units of insulin; -If blood sugar level is 351 mg/dL to 400 mg/dL, administer ten units of insulin; -If blood sugar level is 401 mg/dL to 450 mg/dL, administer 15 units of insulin; -If blood sugar level is 451 mg/dL to 500 mg/dL, administer 18 units of insulin. Observation on 02/21/24, at 10:59 A.M., showed Licensed Practical Nurse (LPN) P took the glucometer (device use to measure blood sugar levels) into the resident's room, completed an accucheck (blood sugar level check), and got the blood glucose (sugar) reading of 301 mg/dL. LPN P took the glucometer back to the cart and retrieved the resident's Novolog FlexPen from the cart. LPN P used hand sanitizer on his/her hands, dialed up the eight units of Novolog insulin, returned to the resident's room and administered the insulin to the resident. The LPN did not prime the pen prior to the insulin administration. 2. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus with mild diabetic retinopathy (retina eye disease) and with diabetic mononeuropathy (nerve damage that often damages nerves in the legs and feet). Review of the resident's physician order, dated 04/24/23, showed Humalog KwikPen subcutaneous solution pen injector 100 units/ml, administer before meals per sliding scale: -If blood sugar level is 70 mg/dL to 130 mg/dL, do not administer insulin; -If blood sugar level is 131 mg/dL to 180 mg/dL, administer two units of insulin; -If blood sugar level is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If blood sugar level is 241 mg/dL to 300 mg/dL, administer ten units of insulin; -If blood sugar leave is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If blood sugar level is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If blood sugar level is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If blood sugar level is 451 mg/dL to 500 mg/dL, administer 30 units of insulin. Observation on 02/21/24, at 11:15 A.M., showed LPN P took the glucometer into the resident's room, completed an accucheck, and got a blood glucose reading of 193 mg/dl. LPN P took the glucometer back to the cart and retrieved the resident's Humalog Kwikpen from the cart. LPN P used hand sanitizer on his/her hands, dialed up the 8 units of Humalog insulin, went into the room, and administered the insulin to the resident. The LPN did not prime the insulin prior to administration of the insulin. 3. Review of Resident #20's face sheet showed the following: -admitted [DATE]; -Diagnoses that included type 2 diabetes mellitus. Review of the resident's physician's order, dated 06/01/22, showed an order for Novolog Flexpen, inject at meal times per following sliding scale: -If blood sugar level is 70 mg/dL to 130 mg/dL, do not administer insulin; -If blood sugar level is 131 mg/dL to 180 mg/dL, administer four units of insulin; -If blood sugar level is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If blood sugar level is 241 mg/dL to 300 mg/dL, administer ten units of insulin; -If blood sugar level is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If blood sugar level is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If blood sugar level is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If blood sugar level is 451 mg/dL to 500 mg/dL, administer 30 units of insulin. Observation on 02/21/24, at 11:26 A.M., showed LPN P took the glucometer into the resident's room, completed an accucheck and got the blood glucose reading of 274 mg/dL. LPN P took the glucometer back to the cart and retrieved the resident's Novolog Flexpen from the cart. LPN P used hand sanitizer on his/her hands, dialed up the 10 units of Novolog insulin, went into the resident's room, and administered the insulin to the resident. The LPN did not prime the insulin pen prior to administering the insulin. 4. During an interview on 02/22/24, at 12:12 P.M., LPN P said he/she will do the accucheck on the resident's blood sugar and then will look at the resident's orders for insulin and the sliding scale for the amount of insulin he/she was to administer to the resident. He/she will dial up the units on the insulin pen and will administer this to the resident and hold the pen for ten seconds. He/she knew to prime an insulin pen like one to two milliliters (ml), but thought this was completed once a day. He/she did not know to prime a resident's insulin pen with each administration to the resident. He/she did not prime the three residents' insulin pens during the medication pass yesterday on 02/21/2024. 5. During interview on 02/26/24, at 11:03 A.M., the Director of Nursing (DON) said he/she would expect staff to administer insulin to residents with the insulin pens by priming the pen with at least two units insulin before administering to the resident. 6. During interview on 02/26/24, at 6:40 P.M., the Administrator said staff were to administer insulin to the residents with insulin pens by priming the insulin pen according to policy and manufacturer's instructions.

Based on observation, interview, and record review, facility staff failed to maintain an effective infection control program when when staff failed to sanitize the glucometer (used to check blood sugar levels) after performing accuchecks and failed to have a clean, sanitary barrier to place the glucometer on while performing the accuchecks for four of four residents (Residents #6, #3, #20 and #5) during the medication pass and when staff failed to wash and/or sanitize hands properly during and after a dressing change for one resident (Resident #1). The facility census was 56. 1. Review of the facility policy Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2018, showed the following: -Non-critical items are those that come in contact with intact skin, but not mucous membranes. Most non-critical reusable items can be decontaminated where they are used; -Reusable items are cleaned and disinfected or sterilized between residents; -Intermediate and low-level disinfectants for non-critical items included ethyl or isopropyl alcohol. 2. Review of the [NAME] Quintet AC Blood Glucose Meter Owner's Manual showed the following: -Indirect transmission of Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV) during the delivery of healthcare services has been increasingly reported; -The cleaning procedure is to remove dust, blood, and body fluid from the surface and should be performed whenever the meter is visibly dirty. The disinfecting procedure is necessary to kill pathogens such as HIV, HBV, and HCV on the device; -The meter must be cleaned and disinfected after use on each patient; -Thoroughly wipe the entire surface of the meter with disinfecting wipes listed to clean any possible dirt dust blood and other body fluids; -Take another disinfecting wipe and wipe the meter thoroughly (all blood and body fluids should be cleaned from surface before using the disinfecting wipe to wipe the meter thoroughly); -Allow the surface to remain wet for two minutes; -Allow to air dry; -Clean and disinfect the outside of the device only. 3. Review of the facility policy Obtaining a Fingerstick Glucose Level, revised October 2011, showed the following: -Place the equipment on the bedside stand or over bed table and arrange the supplies so that they can be easily reached; -Always ensure that blood glucose meter intended for reuse are cleaned and disinfected between resident uses. 4. Review of Resident #6's face sheet (admission information at a glance) showed the following: -Admission 02/09/23; -Diagnoses that included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose). Observation on 02/21/24, at 10:59 A.M., showed Licensed Practical Nurse (LPN) P took the [NAME] Quintet AC glucometer out of the top of the treatment cart. He/she sanitized his/her hands with hand sanitizer from on top of the cart and took the glucometer into the resident's room and laid it on the resident's dresser top without sanitizing the dresser top or using a barrier to lay the glucometer on. The LPN got the droplet of blood on the test strip and placed it into the glucometer, got the reading, took the glucometer out to the cart, removed his/her gloves, and disposed of the strip and gloves. LPN P used hand sanitizer on his/her hands, prepared the insulin pen with the number of units and then went into the room and administered the insulin to the resident. He/she returned to the cart and did not clean and sanitize the glucometer. The LPN laid the glucometer on top of the cart. 5. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses that included type 2 diabetes mellitus with mild diabetic retinopathy (retina eye disease) and with diabetic mononeuropathy (nerve damage that often damages nerves in the legs and feet). Observation on 02/21/24, at 11:15 A.M., showed LPN P used hand sanitizer, put on gloves, and took the [NAME] Quintet AC glucometer into the resident's room, laid the glucometer on the resident's bedside table without sanitizing the top of the bedside table or putting a barrier down to lay the glucometer on, got the droplet of blood on the test strip, and placed into the glucometer. LPN P took the glucometer and placed it on top of the cart, without cleaning and sanitizing the glucometer, removed his/her gloves, and disposed of the test strip and gloves. LPN P sanitized his/her hands, prepared the resident's pen with the number of insulin units, and went into the resident's room and administered the insulin to the resident. He/she returned to the cart, did not clean and sanitize the glucometer. He/she moved on to the next resident's room to do an accucheck. 6. Review of Resident #20's face sheet showed the following: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus. Observation on 02/21/24, at 11:26 A.M., showed LPN P used hand sanitizer, put on gloves, and took the [NAME] Quintet AC glucometer without first cleaning and sanitizing the glucometer, into the resident's room, laid the glucometer on the resident's bedside table without sanitizing the top of the bedside table or putting a barrier down to lay the glucometer on, got the droplet of blood on the test strip, and placed into the glucometer. LPN P took the glucometer and placed it on top of the cart, removed his/her gloves, sanitized his/her hands, prepared the resident's pen with the number of insulin units and then went into the resident's room and administered the insulin to the resident. When he/she returned to the cart, he/she took an alcohol swab and cleaned the glucometer, but did not sanitize the glucometer, before laying it on top of the cart. During interview on 02/21/24, at 11:35 A.M., LPN P said he/she tried to clean the glucometer with an alcohol swab every time between residents. It was his/her goal. 7. Review of Resident #5's face sheet showed the following: -admitted [DATE]; -Diagnoses that included type 2 diabetes mellitus with diabetic chronic kidney disease (kidneys are less likely to filter waste and fluid out of your body) and polyneuropathy (multiple peripheral nerves become damaged and problems with sensation, coordination and other body functions). Observation on 02/21/24, at 11:37 A.M., showed LPN P used hand sanitizer, put on gloves, and took the [NAME] Quintet AC glucometer without first sanitizing the glucometer, into the dining room at the resident's table, laid the glucometer on the resident's table without sanitizing the top of the table or putting a barrier down to lay the glucometer on, got the droplet of blood on the test strip, and placed into the glucometer. LPN P took the glucometer and placed it on top of the cart, removed his/her gloves, got an alcohol swab and cleaned the glucometer, but did not sanitize the glucometer, before placing it back in the top drawer of the cart. 8. Observation on 02/22/24, at 12:12 P.M. showed no disinfecting wipes on the nurses' cart for the 100-200 hall. 9. During an interview on 02/22/24, at 12:12 P.M., Licensed Practical Nurse (LPN) P said the procedure to do an accucheck was to look at the resident's chart, get supplies, use hand sanitizer and put on gloves, go into room and ask permission to check the resident's blood sugar. Then, he/she will use an alcohol wipe on the resident's finger, get a drop of blood and put it on the strip and then put into the monitor. It took five seconds to get a reading. Then go back to the cart, take off gloves, hand sanitize, and record blood sugar in the computer. Before putting the glucometer in the drawer, use an alcohol swab to wipe the glucometer. He/she only used an alcohol swab to clean the glucometer. There were no disinfecting wipes on the cart. During an interview on 02/22/24, at 12:40 P.M., the Corporate Nurse said they used the [NAME] Disposable Germicidal surface wipes to clean and disinfect the glucometers. During an interview on 02/26/24, at 11:03 A.M., the Director of Nursing (DON) said the following: -Staff were to wash and/or sanitize hands in between residents when doing accuchecks on residents; -Staff were to disinfect the glucometer in between residents and they were to wait approximately one to three minutes after disinfecting the glucometer before using it on the next resident; -Staff were to use a barrier on the dresser and/or bedside table when they go into the resident's room to do an accucheck for the glucometer and supplies. During an interview on 02/26/24, at 6:40 P.M., the Administrator said the staff were to clean and disinfect the glucometers between residents. 10. Review of the facility policy Handwashing/Hand Hygiene, revised August 2019, showed the following: -Hand hygiene is the primary means to prevent the spread of infection; -Wash hands with soap and water for when hands were visibly soiled and after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. difficile; -Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively soap and water, before and after coming on duty; before and after direct contact with residents; before preparing or handling medications, handling an invasive device, donning sterile gloves, handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after contact with resident's skin; after contact with blood or bodily fluids; after contact with objects such as medical equipment in the immediate vicinity of the resident; and after removing gloves; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of Resident #1's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Diagnoses include elevated white blood cell count, unspecified intestinal obstruction (a blockage that keeps food or liquid from passing through your small intestine or large intestine (colon)), personal history of transient ischemic attack (TIA-stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness following a stroke), and aphasia (a language disorder that affects a person's ability to communicate). Review of the resident's care plan, last revised 06/26/2023, showed the following: -Resident requires a tube feeding related to diagnosis of dysphagia (difficulty swallowing) status post stroke. Resident has a history of gastronomy infection; -Resident's insertion site will be free of signs and symptoms of infection through the review date; -Provide treatment care to G-tube (gastrostomy tube is a tube inserted through the belly that brings nutrition directly to the stomach) site as ordered and observe for signs and symptoms of infection. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/02/24, showed the following: -Resident significantly cognitively impaired; -Completely dependent on staff for activities of daily living; -Receives tube feeding. Review of the resident's physician order, dated 02/19/24, showed the following: -J-tube site (tube feeding site), cleanse with wound cleanser pat dry, apply skin prep in two-three inch radius around tube insertion site and place Drawtex (used to control excessive wound exudate (drainage) and draws bacteria from the wound bed into the dressing) or equivalent cut to fit around tube, as needed for skin integrity. Observation on 02/26/24, at 8:20 A.M., showed Registered Nurse (RN) I went into the resident's room. The resident was lying in bed. He/she opened the resident's bedside dresser, removed a Drawtex dressing from the package and picked up the scissors from the drawer. The RN did not clean the scissors. The RN cut the dressing approximately two to three inches in the middle, and then laid the dressing on top of the dresser without cleaning the top of the dressing and/or putting a barrier down to lay the dressing. A shower aide came to the doorway and said they were going to give the resident a shower. RN left the dressing on the bedside dresser. Observation on 02/26/24, at 9:37 A.M., showed the resident was back in bed after the shower. The same Drawtex dressing lay on top of the resident's dresser top beside the bed. RN I came into the room, put on gloves, without washing hands, cleansed the wound and surrounding skin around the gastrostomy site with wound cleanser, then sprayed skin prep around the reddened wound and surrounding skin at the gastrostomy site, picked up the approximately Drawtex pre-cut dressing from the top of the dresser (left earlier) , and placed around the resident's gastrostomy tube opening. RN I, wearing the same gloves, took the water graduate container and pulled up water flushes with 55 milliliters (ml) of water with the syringe and flushed the water through the resident's gastrostomy tube, and then removed his/her gloves. Without washing and/or sanitizing hands, RN I went over to the resident's shelf and got a DVD and put this into the DVD player, and picked up the remote and turned this on for the resident. RN I picked up the water graduate container and rinsed the graduate at the sink. RN I picked up the packaged feeding and opened the package. Without washing and/or sanitizing hands, RN I put on a pair of gloves, and touched the IV pole to set the water flush on at 67 ml/hour (hr), and then poured the Jevity (nutrition formula for use with tube feeding) 1.5 feeding into the bag and set the rate to 45 ml/hr and then attached the tubing to the resident's gastrostomy tube. RN I removed his/her gloves, did not wash and/or sanitize hands, put the trash into the trash bag and removed this bag, the empty gallon water jug , and other supplies, went out of the room, down the hall to the soiled utility room to throw these away. During an interview on 02/26/24, at 10:00 A.M., RN I said he/she would have sanitized his/her hands before he/she left the resident's room, but he/she threw trash into the soiled utility room. He/she usually saw a paper towel laid on the bedside dresser for the dressing to lay on, but today it was not there. During an interview on 02/26/24, at 1:20 P.M., RN I said they were to wash hands or sanitize hands anytime before entering a resident's room. Sometimes he/she uses the and sanitizer that's on his/her cart. Most of the time, he/she would use the hand sanitizer unless it was a nasty wound, then he/she would probably wash his/her hands. He/she had taken off his/her gloves before leaving the resident's room and did not wash hands at the resident's sink since he/she was headed out of the resident's room anyway. During an interview on 02/26/24, at 3:10 P.M., Certified Nurse Assistant (CNA) A said staff should wash hands between gloving when providing care and wash hands again prior to leaving the room. During an interview on 02/26/24, at 3:39 P.M., CNA B said staff should use hand sanitizer or wash hands between providing care on residents and changing gloves, wash hands following the care. During an interview on 02/26/24, at 3:44 P.M., Licensed Practical Nurse (LPN) P said the following: -Staff should never place dressing for G-tubes on an unsterile surface without a barrier; -Staff should wash hands in between glove use, and wash hands again following care. During an interview on 02/26/24, at 6:28 P.M., the Director of Nursing (DON) and Administrator said the following: -Staff should wash hands prior to donning gloves, in between changing gloves to provide care and after removing gloves upon completion of providing care to a resident; -Staff should never place dressing for G-tubes on an unsterile surface without a barrier. During an interview on 02/26/24 at 11:03 A.M., the DON said the following: -Staff were to wash and/or sanitize hands when they go in and out of a resident's room, for any type of wound care such as applying or removing a dressing, when they remove their gloves and wash hands before applying gloves; -Staff were to use a barrier on the dresser and/or bedside table when they go into the resident's room to do a dressing change for any dressings. During interview on 02/26/24, at 6:40 P.M., the Administrator said the following: -Staff were to wash and/or sanitize hands when taking care of residents, before applying gloves and after removing gloves; -Staff were to apply a barrier on bedside tables or other places to do treatments and dressing changes. 45190

Based on observation, interview, and record review, the facility failed to provide care per professional standards related to pressure ulcers when staff failed to document physician notification of wound development/changes, failed to obtain orders for all treatments provided, failed to document complete and routine assessments of wounds, failed to consistently implements identified interventions, and failed to update the care plan timely regarding actual skin breakdown and intervention changes for one resident (Resident #24) of seven sampled residents. The facility census was 56. Review of the facility's policy Prevention of Pressure Injuries, revised April 2020, showed the following: -Assess the resident on admission for existing pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) risk factors. Repeat the risk assessment weekly and upon any changes in condition; -Inspect the skin on a daily basis when performing or assisting with personal care or ADLs (activities of daily living - bathing or showering, dressing, getting in and out of bed or a chair, using the toilet, and eating); -Identify any signs of developing pressure injuries such as non-blanchable erythema (discoloration of the skin that does not turn white when pressed); -Inspect pressure points (sacrum (the large triangle bone in the lower spine that forms part of the pelvis), heels (back part of the foot), buttocks (the two fleshy parts that form the lower rear area of a human), coccyx (small bone or tailbone), elbows, and ischium (a paired bone of the pelvis that forms the lower and back part of the hip bone)); -Wash the skin after any episodes of incontinence; -Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team; -Use a barrier product to protect skin from moisture; -Use incontinence products with high absorbency; -Evaluate, report, and document potential changes in the skin. Review of the facility policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018, showed the following: -The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers to include immobility, recent weight loss, and a history of pressure ulcer(s) (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device); -The nurse may describe and document/report the following: -Assessment of pressure sore including location, stage, length, width and depth, present of exudates or necrotic tissue, pain assessment, mobility status, and current treatments; -The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers; -The physician will assist the staff to identify the type and characteristics of an ulcer; -The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing, dressings and application of topical agents; -During resident visits, the physician will evaluate and document the progress of wound healing, especially for those with poorly-healing wounds; -The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions; -Current approaches should be reviewed for whether they remain pertinent to the resident's medical conditions, and affected by factors influencing wound development or healing. Review of the facility's Wound Care Policy, revised October 2010, showed the following: -Staff were to document type of wound care; date and time the wound care was provided; name and title of staff performing the wound care; any change in the resident's condition; all assessment data (such as wound bed color, size, drainage, etc) when inspecting the wound, and any problems or complaints made by the resident related to the procedure, in the resident's medical record. 1. Review of Resident #24's face sheet (document that gives admission information at a glance) showed the following: -admitted [DATE]; -Diagnoses included spinal stenosis (spaces inside the bones of the spine get too small and affects mainly the neck and lower back); Type 2 diabetes mellitus (high blood sugar) with other diabetic kidney complication; moderate protein-calorie malnutrition (poor dietary intake to cause muscle wasting and loss of body fat); chronic atrial fibrillation ( abnormal heart rhythm); peripheral neuropathy (damage that affects any part of the peripheral nervous system that transmits vital information from brain and spine to the body); chronic kidney disease (kidney damage where they are less likely to filter waste and fluid out of the blood); and anemia (a lack of red blood cells that leads to reduced oxygen flow to the body's organs). Review of the resident's care plan, revised on 12/20/22, showed the following: -Staff to perform skin audits per facility protocol and report all abnormalities noted to the physician; -Staff to check all of body for breaks in skin and treat promptly as ordered by the physician. Review of the resident's progress notes, dated 12/11/23, showed the staff assessed the resident as a high risk for development pressure ulcers. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/12/24, showed the following: -Resident's cognition was intact and resident was interviewable; -Always incontinent of bowel and bladder; -At risk for pressure ulcers; -No unhealed pressure ulcers; -Has pressure reducing device for chair and bed; -Applications of ointments/medical other than to feet. Review of the resident's care plan, revised 12/15/23, showed the following: -Potential for impairment to skin integrity related to incontinence of bowel and bladder and weakness and decreased mobility and use of wheelchair for locomotion; -Apply a moisture barrier cream as needed; -Pressure relieving/reducing mattress on bed when in bed and pressure relieving/reducing cushion in wheelchair when in the wheelchair; -Staff to perform Braden scale (tool used to predict pressure ulcer risk for developing pressure ulcers) quarterly and as needed (PRN) per facility protocol; -Perform skin audits per facility protocol and report all abnormalities noted to physician; -Staff to perform treatments per prescription and ensure effectiveness. If area worsens, notify the physician. -Staff to ensure resident was repositioned and buttocks (the two round fleshy parts that form the lower rear area of the trunk) was offloaded (minimize or remove weight to help prevent and heal pressure ulcers) at least every two hours and as needed. Review of the resident's Treatment Administration Record (TAR), dated December 2023, showed the following: -Staff to monitor for coccyx/perineal area for breakdown and/or bleeding one time a day; -Skin assessment weekly every day shift on Thursday; -Offload coccyx as tolerated related to pain every day and evening shift for pain; -Barrier cream to perineal area three times a day and as needed for excoriation; -Staff documented they completed these interventions and treatments. Review of the resident's shower sheet, dated 12/21/23, showed the following: -Shower aide circled the lower sacrum on the diagram of the stick figure person's back on the shower sheet and wrote two open breakdown at the top area of the resident's bottom; -The nurse commented at the bottom of the sheet chronic open area to coccyx (the triangular bone at the very bottom of the spine or tailbone), stage II (partial thickness loss of dermis (top layer of skin) presenting as a shallow open ulcer with red or pink wound bed, without slough (shedding skin) or bruising. May also present as an intact or open/ruptured blister); superficial, with treatment in place. Review of the resident's skin evaluation only note, dated 12/21/23, showed the following: -Staff documented the resident had current skin excoriation (skin is scraped, red or abraded or coming off) on the resident's coccyx that measured one centimeter width and one centimeter length; -Staff documented the resident had ongoing chronic area to the coccyx that was being treated daily and PRN. Staff was to apply a cushion to the wheelchair for further pressure relief prevention. (Staff did not document notifying the resident's physician of the area.) Review of the resident's care plan showed staff did not update the care plan with the area to the coccyx or any new interventions. Review of the resident's skin/wound progress note, dated 12/24/23, showed there was an open area to the coccyx surrounded by discoloration. Staff educated to reposition the resident every two hours and apply barrier cream every shift and as needed with incontinence episodes. (Staff did not document notifying the resident's physician of the area.) Review of the resident's care plan showed staff did not update the care plan with the area to the coccyx or new interventions related to the area. Review of the resident's skin/wound progress note, dated 12/25/23, showed the resident had a small open area on the coccyx. A small mepilex (multilayer foam dressing designed for use on the sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis) to prevent pressure ulcers) was put on the area. Staff were to lay the resident down first and get the resident up last. (Staff did not document notifying the resident's physician of the area.) Record review of the resident's Physician's Order Sheet, dated December 2023, showed no orders for use of mepilex on the wound. Review of the resident's care plan showed staff did not update the care plan with the area to the coccyx or new interventions related to the area. Review of the resident's skin evaluation only note, dated 12/28/23, showed the resident had a pressure area on the coccyx with no odor, tunneling (skin loss and depth), or undermining (the damage under the tissue was larger than what appears at the surface). Staff noted this was a new skin issue to the coccyx and applied barrier cream to the pressure ulcer. (Staff did not document a full assessment including measurements of length, width, depth, or further description of the pressure ulcer. Staff did not documentation notifying the physician of the area.) Review of the resident's care plan showed staff did not update the care plan with the area to the coccyx or new interventions related to the area. Review of the resident's shower sheet, dated 12/29/23, showed the shower aide circled the diagram of the stick figure's sacrum and said open. There were no nurse comments at the bottom of the form. Review of the resident's nurse's progress note, dated 01/02/24, showed the physician saw the resident's skin and gave a new order for a treatment of medihoney (for removal of necrotic (death of cells and tissue which eventually becomes black, hard, and leathery) tissue and aids in wound healing) for use on pressure ulcers) to the buttocks topically twice a day with foam dressing. (Staff did not document a full assessment including measurements of length, width, depth, or further description of the pressure ulcer.) Review of the resident's POS, dated 01/02/24, showed an order for medihoney wound and burn dressing external paste to apply to buttocks abrasion two times a day in the morning and in the evening and to apply a foam dressing. Review of the resident's care plan showed staff did not update the care plan with the area to the coccyx or new interventions related to the area. Review of the resident's shower sheet, dated 01/04/24, showed the shower aide circled the diagram of the stick figure's small area at the top of the resident's buttocks and wrote open sore. Review of the resident's shower sheet, dated 01/11/24, showed the shower aide circled the diagram of the stick figure's area from the top of the lower spine coccyx to the bottom of the buttocks and wrote big open spot on bottom. The staff documented they applied a treatment. Review of the resident's skin only evaluation note, dated 01/11/2024, showed the resident had excoriation on the coccyx. There was no new skin issues noted and staff did treatment on the present skin wound. (Staff did not document a full assessment including measurements of length, width, depth, or further description of the pressure ulcer.) Review of the resident's shower sheet, dated 01/19/24, showed the shower aide circled the diagram of the stick figure's area from the upper buttock to the sacrum and circled in the middle and wrote open. Review of the resident's skin only evaluation note, dated 01/19/24, showed the resident had a pressure ulcer/injury on the coccyx that was a Stage II and unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.) (Staff did not document a full assessment including measurements of length, width, depth, or further description of the pressure ulcer.) Review of the resident's shower sheet, dated 01/25/24, showed the shower aide circled the diagram of the stick figure's sacrum area and wrote open. The nurse did not make any comments about the open skin at the bottom of the form. Review of the resident's physician's examination form, dated 01/30/24, showed the nurse practitioner saw the resident for coccyx pain-MASD (moisture-associated skin damage) and UTI (urinary tract infection), and documented to continue current treatment and offload as tolerated. Review of the resident's progress notes, dated 01/31/24, showed staff documented an entire area of abraded skin from center of anus (opening which solid waste matter leaves the body) to lower back with no open skin areas noted. (Staff did not document a full assessment including measurements of length, width, depth, or further description of the pressure ulcer.) Review of the resident's skin only evaluation note, dated 02/01/24, showed the resident's skin had excoriation on the coccyx. The skin tissue was warm. There was a treatment in place. (Staff did not document a full assessment including measurements of length, width, depth, or further description of the pressure ulcer.) Review of the resident's shower sheet, dated 02/05/24, showed the shower aide circled the diagram of the stick figure's resident's buttocks and wrote open and deep. The charge nurse signed it. Review of the resident's shower sheet, dated 02/08/24, showed the shower aide on the diagram of the stick figure circled the sacrum and wrote open. Review of the resident's shower sheet, dated 02/12/24, showed the shower aide on the diagram of the stick figure, circled the entire buttocks and wrote open. Observation and interview on 02/21/24, at 12:49 P.M., showed the resident sat in a wheelchair in the resident's room. The resident said he/she was waiting on staff to assist him/her back into bed after lunch. The resident said he/she had a sore that developed while a resident at the facility. He/she said staff would leave him/her in a wheelchair for extended periods, instead of assisting him/her back to bed. Staff appeared to be doing something to treat the redness. Observations on 02/21/24, at 1:58 P.M., showed the resident in bed on his/her left side. Certified Nurse Aide (CNA) Q put on gloves, and removed the resident's incontinence brief and opened up the resident's buttocks to check the skin. CNA Q said, Oh, it's a pressure ulcer. There was a red excoriated area approximately seven to eight centimeters in length by three to four centimeters in width with an approximately three centimeter slit, open area (Stage II pressure ulcer) in the center of the coccyx with yellowish slough and moisture. There was no dressing covering the pressure ulcer and the incontinence brief was wet with urine. CNA Q went to get the nurse to assess this area. During an interview on 02/21/24, at 1:58 P.M., the resident said he/she had sores for quite some time and the nurse puts ointment on them. During interview on 02/21/24, at 2:09 P.M., Licensed Practical Nurse (LPN) O said the resident had a treatment order for medihoney and it was done daily. He/she was not sure when the treatment was usually, done but it had not been done yet that day. He/she does not stage any wounds. The wound nurse did this. He/she thought the Associate Director of Nursing (ADON) was the wound nurse and did the treatment. He/she usually worked evenings, but would go ahead and do the treatment. Observation on 02/21/24, at 2:16 P.M., showed LPN O brought in wound care supplies to do the wound treatment. CNA R and CNA Q assisted the nurse. LPN O measured the outer reddened excoriated skin as 8.5 cm by 4.5 cm width, but did not measure the Stage II pressure ulcer in the middle of the coccyx. The nurse cleaned the area with wound cleanser, then patted it dry, applied skin prep around the edges of the reddened abrasion skin, applied medihoney, and the border gauze foam dressing. During interview on 02/21/24, at 2:16 P.M., CNA R said he/she would have expected the border foam dressing on the resident. He/she said the dressing came off due to the resident's urine and bowel incontinence. If they told the nurse when the dressing came off, the nurse would come and put a dressing on it. Review of the resident's progress note, dated 02/21/24, showed there was a wound on the resident's coccyx. (Staff did not document the length, size, depth, characteristics of the pressure ulcer). Observation on 02/23/24, at 9:49 A.M., showed the resident was in bed on his/her right side. The resident said he/she needed to be changed and said he/she hadn't had a treatment on his/her bottom done since yesterday. During observation and interview on 02/23/24, at 9:58 A.M., CNA G answered the resident's call light who said he/she was a little wet (with urine). CNA G prepared to do perineal care. The resident's dressing was on the resident's buttocks, but was not dated and the urine had seeped underneath the dressing. While the resident lay on his/her side, he/she was urinating more. When CNA S came into the room and turned the resident to his/his left side, he/she said it looked like the resident had a pressure sore and it had changed. It had gotten bigger and irritated since they began the honey treatment. CNA G said the area looked a lot worse. They performed incontinence care and put a clean incontinence brief on the resident and said the nurse will come in to do the dressing. Observation and interview on 02/23/24, at 10:15 A.M., showed the following: -The resident said he/she had a sore on his/her bottom; -The staff were doing a treatment on his/her bottom; -The resident said back in December 2023, he/she was left sitting in his/her wheelchair for over five hours which was too long. That was when his/her bottom started hurting; -The resident's wheel chair had no cushion, -The resident said his/her wheel chair did not have a cushion in it, and he/she will place a pillow in the wheelchair. Observation on 02/23/24, at 10:16 A.M., the ADON went into the resident's room to observe the resident's skin on his/her bottom. The resident was lying on his/her left side, and the ADON loosened the side of the incontinence brief enough to look down the side of the resident's buttock without opening the right buttock to exam the inner buttock and coccyx, then re-attached the incontinence brief. While assessing the resident's wound, he/she said this wound was not on his/her tracking system since it was not bad enough. During an interview on 02/23/24, at 10:16 A.M., the ADON said the physician looked at the resident's pressure ulcer and ordered the medihoney and dressing which the physician reviewed weekly. The ADON said he/she was not a wound nurse and did not stage wounds since it was not in his/her scope of practice. There was a weekly tracker for wounds and this resident was not on this weekly tracker or the weekly wound report. If staff do not tell him/her, he/she does not know if it the skin continued to get worse. The ADON said, in his/her opinion the resident's skin had not gotten worse, but it was not healing. It was an open pressure ulcer. He/she would probably stage the resident's skin as a Stage 1 for the peri-wound (the area around the Stage 2 pressure ulcer) and a Stage 2 in the center. He/she would recommend the wound care company to see the resident since it was not healing quick enough. Observation on 02/23/24, at 10:16 A.M., showed no cushion in the resident's wheelchair in the room. During interview on 02/23/24, at 2:40 P.M., CNA F said if skin was starting to break down, or anything, they he/she would report this to the nurse so they would come and assess the resident's skin and put barrier cream on it. Review of the resident's Nurse Practitioner's (NP) pressure wound evaluation, dated 02/23/24, showed the following: -Pressure ulcer determined to be Stage III (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 and tunneling after debridement (removal of dead or unhealthy tissue from wound)); -Sacral chronic Stage 3 pressure injury measuring 1.9 centimeters (cm) by 3.6 cm width by 0.1 cm depth, width area of 6.84 square cm. No tunneling and undermining noted and tunneling; a moderate amount of serous (yellow fluid draining out of the wound) drainage noted with no odor. Wound bed had no granulation (the development of new tissue and blood vessels in a wound during healing process). 76-100% slough (yellow/white dead skin cells accumulate in the wound bed) , no eschar (collection of dead tissue present within the wound) and no epithelialization (process of covering the surface skin lost) present. The periwound (the surrounding area of the wound edge) skin was moist. The secondary diagnosis for this wound is MASD; -Recommended to apply calcium alginate dressing to wound base and to change dressing daily and as needed for soiling, saturation, or unscheduled removal. During interview on 02/26/24, at 1:32 P.M., the Director of Nursing (DON) said she would expect staff to do a full body skin assessment weekly on all residents. The charge nurse assigned to the residents would do the skin assessments and if anything changes from the previous assessment, they were to do another skin assessment. If there was a new admission, they were to do a full body skin assessment. She would expect staff to follow the treatment order. The nurses can assess the wounds, but it was subjective. She would trust the wound care company and their knowledge. If a dressing was ordered twice a day, she would expect this completed as ordered. She would expect to change a dressing treatment order if the pressure ulcer had gotten worse or had not or was not getting better, they would call and get an order to change the dressing. She would expect staff to let the nurse know to change the dressing if it became wet or soiled. The ADON was responsible for the wound tracking report. When she looked at the resident's skin a while back, it was not flagged as an issue. His/her skin looked macerated. If a pressure ulcer was open, it was a Stage II. The cushions in the wheelchair stay in the wheelchairs and the covers typically were changed. The resident had an order for a protective cushion to bilateral feet and to offload the coccyx, but not order for a protective cushion in his/her wheelchair. The cushions for the wheelchairs were stored at therapy and not that you had to go through therapy to get a cushion though. During an interview on 02/26/24, at 6:40 P.M., the Administrator said staff were expected to assess residents' skin upon admission, when there was a change in the resident's condition even with their skin, and any pressure area. Staff were to do a weekly skin assessment on residents. She would expect staff to provide pain control with any skin treatment. The DON was to assess the resident's skin if it got worse and would involve the wound care company to evaluate the resident for wound care. 28865

Based on interview and record review, the facility failed to ensure any resident weight loss was unavoidable when staff failed to identify weight loss, failed to notify the physician and register dietician of weight loss, failed to care plan weight loss, and failed to implement new interventions to prevent future weight loss for one resident (Resident # 22). The facility census was 56. Review of the facility policy titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, dated September 2017, showed the following: -The nursing staff will monitor and document the weight and dietary intake of residents; -The staff and physician will define residents with weight loss and significant risk for impaired nutrition; -The staff will report to the physician any significant weight loss; -The staff and physician will identify pertinent interventions based on identified causes; -The staff and physician will monitor nutritional status in response to interventions. 1. Review of Resident #22's face sheet (brief resident profile sheet) showed the following information: -admitted [DATE]; -Diagnoses included dementia, diabetes, chronic obstructive pulmonary disease (COPD - a group of lung diseases making it difficult to breathe), and hypothyroidism (deficient amount of thyroid hormone). Review of the resident's physician order sheet, dated 08/04/22, showed the following information: -Regular diet; -Obtain weight once per month. Review of the resident's care plan, revised 08/17/22, showed the following information: -Resident is dependent on staff for meeting emotional, intellectual, physical, and social needs; -Dietary consult for nutritional regimen as needed; -Offer substitutes for foods not eaten; -Encourage to drink extra fluids with meals and in between meals; -Observe for adverse reactions to antidepressant therapy: change in appetite, appetite loss and weight loss; -Maintain adequate nutritional status by maintaining weight within 5% of baseline and consuming at least 50% of at least two meals daily; -Observe for significant weight loss: three pounds in one week, greater than 5% in one month, greater than 7.5% in three months, or greater than 10% in six months; -Registered dietician to evaluate and make diet change recommendations. Review of the resident's vital signs showed on 08/03/23, the resident weighed 141 pounds. Review of the resident's dietary services progress note, dated 08/17/23, showed the following information: -Current weight 141 pounds; -Regular diet order; -Annual evaluation shows weight is stable at 141 pounds; -Labs reviewed and stable; -Able to make needs known; -Recommended to continue current care plan. Review of the resident's vital signs showed the following information: -On 09/04/23, the resident weighed 139 pounds (a loss of 4 pounds); -On 10/02/23, the resident weighed 137 pounds (a loss of 2 pounds in a month and 6 pounds total); -On 11/01/23, the resident weighed 132 pounds (a loss of 5 pounds in a month and 11 pounds total); Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/07/23, showed the following information: -Severe cognitive impairment; -Able to feed self; -Did not indicate any weight loss. Review of the resident's care plan showed staff did not update the care plan with the weight loss and any new interventions. Review of the resident's dietary notes showed regarding the resident's weight loss of a referral to a registered dietician (RD). Review of the resident's vital signs showed the following information: -On 12/01/23, the resident weighed 134 pounds (a gain of 2 pounds); -On 01/01/24, the resident weighed 129 pounds (a loss of 5 pounds in a month and 12 pounds total); -On 02/05/24, the resident weighed 124 pounds (a loss of 5 pounds in a month and 17 pounds total); -On 02/23/24, the resident weighed 122 pounds (a loss of 2 pounds in two weeks and 19 pounds total). Review of the resident's care plan showed staff did not update the care plan with the weight loss and any new interventions. Review of the resident's dietary notes showed regarding the resident's weight loss of a referral to a RD. Review of the resident's progress notes, dated 09/2023 to 02/2024, showed staff did not document regarding the resident's weight loss or physician notification of weight loss. During an interview on 02/23/24, at 11:45 A.M., Certified Nurse Aide (CNA) E said getting the resident to eat can be hard at times. The resident always comes to the dining room, but sometimes leaves before meals are served and staff must go get him/her and remind him/her that he/she hasn't eaten. During an interview on 02/23/24, at 12:16 P.M., Dietary Aide (DA) M said staff document the percentage of food eaten of all residents. The resident is hit or miss. Sometimes he/she eats good and sometimes he/she does not. Dietary does not weigh the residents, the CNA's weigh them. The Dietary Manager (DM) will add fortified shakes if he/she is concerned about a resident losing weight. The resident is not currently on any fortified shakes. During an interview on 02/23/24, at 1:01 P.M., CNA G said the CNA's weigh the residents. Some residents they weigh weekly and some they weigh monthly. It depends on the physician orders. The nurse will tell them who needs to be weighed. They will write down the weight and give to the nurse to review and document. During an interview on 02/26/24, at 9:00 A.M., CNA F said all residents are weighed weekly. The CNA will give the weights to the nurse or the restorative aide to review, document, and follow up on. There is currently no one with weight loss. If he/she is aware that a resident is losing weight, he/she will give them chocolate milk in the morning and any supplement shakes they have ordered. He/she is updated on the plan of care from either the nurse or report from the previous shift. During an interview on 02/26/24, at 9:09 A.M., Nursing Aide (NA) H said there are currently no residents with weight loss. The nurse will inform the CNAs of any resident with weight loss. The nurse will leave a list of residents that need to be weighed. The CNA's weigh the residents and let the nurse know their weight. The nurse will document the weights and follow up as needed. During an interview on 02/26/24, at 09:15 A.M., Registered Nurse (RN) I said he/she does not have any residents he/she is currently monitoring for weight loss. The CNA's weigh the residents. Either the nurse or the restorative aide will document the weights. If a resident is losing weight, the RN will have the CNA document the percentage of food eaten at every meal. The data is reviewed at the care plan meetings with the Assistant Director or Nursing (ADON), Director of Nursing (DON), and the Administrator. During an interview on 02/26/24, at 10:45 A.M., DM J said he/she has not been reviewing resident weights for months due to being short staffed. If weight loss is identified, nursing and the RD are notified. Supplements and shakes would then be ordered. The resident eats better at breakfast. If the resident has to wait too long, he/she leaves the dining room and nursing must go get him/her and remind him/her that he/she has not eaten. During an interview on 02/26/24, at 11:25 A.M., RD K said that the Dietary Manager fills out a referral form so that the following residents would be seen by the RD and includes all new admissions, readmissions, annuals, tube feeds, and weight loss residents. The RD will also check with the DON and the charge nurse if they have any residents they have concerns with while he/she is at the facility. There is a RD at the facility once per month. The RD was not notified of the resident's weight loss. During an interview on 02/26/24, at 1:15 P.M., Registered Dietician (RD) L said that a RD comes to the facility every month. RD L said the last time he/she was at the facility was 02/13/24. He/she will observe the residents that the Dietary Manager has listed for him/her to observe. RD L does not remember seeing the resident on the list to be seen. RD L said that any weight loss over 10 % is considered significant weight loss and those are the residents he/she typically sees. RD L said he/she usually will first visit with the resident to determine whether the weight loss was planned or unplanned. He/she will also make sure the resident is not on hospice. RD L said he/she normally will first add food and extra calories to meals, as well as add in-between meal snacks to the resident with significant weight loss before adding supplements. RD L said that he/she would have expected to be notified of the resident's weight loss. During an interview on 02/26/24, at 1:35 P.M., Restorative Aide (RA) N said that every resident gets weighed either weekly or monthly depending on the physician orders. The DON will print off a list of all residents that have had weight loss or a decline in general. The DON will discuss this information with the DM and up-date the residents care plans. The resident has not had a real drastic weight loss that he/she is aware of. During an interview on 02/26/24, at 6:40 P.M., the Director of Nursing (DON) and the Administrator said that the RA N will notify the DON if a resident has a 5% weight loss in a week. DON said he/she can also run a report and then he/she would notify the Dietary Manager. The resident does flag on significant weight loss. He/she has had a decline in his/her cognition. He/she eats good sometimes then refuses to eat other times. The resident was started on TwoCal HN 2.0 (nutritional supplement) three times a day on 02/23/24 . It should have been started earlier. The physician was notified on 02/23/24.

Based on observation, interview, and record review, the facility failed to provide care for all residents on oxygen per professional standards of practice when staff failed to ensure oxygen equipment was cared for in a manner to prevent possible contamination or bacteria growth, when staff failed to administer oxygen per physician orders, and when staff failed to care plan regarding oxygen use and the care of oxygen equipment for one resident (Resident #42). The facility census was 56. Review of the facility's policy titled Oxygen Administration, revised October 2010, showed the following: -Verify that there is a physician's order for this procedure; -Review the physician's orders or facility protocol for oxygen administration; -Review the resident's care plan to assess for any special needs of the resident; -After completing the oxygen set up or readjustment, document the date and time performed, the name and title of individual performing, the rate of oxygen flow, route and rationale and the frequency and duration of the treatment in the resident's medical record. Review showed the facility did not provide a specific policy for changing oxygen tubing, nasal cannula, and dehumidifier. 1. Review of Resident #42's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Diagnoses include acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues of your body), chronic obstructive pulmonary disease with (acute) exacerbation (COPD - a group of lung diseases that block airflow and make it difficult to breathe with a sudden worsening in airway function), atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease), and chronic kidney disease. Review of the resident's Physician Order Sheet (POS), dated 10/26/23, showed an order for oxygen saturation level of less than 90%, apply oxygen at two liters per nasal cannula. Staff to call physician if oxygen saturation drop has occurred and oxygen has been applied. Staff can apply as needed for oxygen saturation level less than 90%. Review of the resident's care plan, last reviewed 12/07/23, showed the facility did not care plan for the resident's oxygen use or care of the oxygen concentrator, humidifier, tubing, or nasal cannula. Review of resident's significant change Minimum Data Set (MDS - federally mandated assessment tool completed by staff) dated 01/17/24, showed the following: -Resident cognitively intact; -Dependent on staff for transfers; -Uses wheelchair; -Walking did not occur. -Resident receives oxygen therapy. Review of the resident's February 2024 Medication Administration Record (MAR) showed the following: -An order, dated 10/26/23, for if oxygen saturation level less than 90%, apply oxygen at two liters per nasal cannula. Call physician if oxygen saturation drop has occurred and oxygen has been applied as needed for oxygen saturation less than 90%. Observation and interview on 02/20/24, at 1:39 P.M., showed the following: -Resident laid in bed receiving oxygen per nasal cannula; -The resident said he/she is on continuous oxygen at three liters of oxygen per minute; -The concentrator was set at five liters of oxygen per minute; -There was no label on the tubing to show when the tubing was last changed; -The resident was appeared to be short of breath. Observation and interview on 02/21/24, at 8:50 A.M., showed the following: -The resident sat in his/her wheelchair watching television in his/her room; -The resident said he/she just finished a breathing treatment; -He/she was receiving oxygen per nasal cannula at the rate of five liters per minute; -The resident said he/she is supposed to be receiving oxygen at three liters per minute; -No label on the tubing showing when it was last changed. Observation and interview on 02/23/24, at 12:45 P.M., with the resident showed the following: -The resident was sat in his/her wheelchair with staff preparing a breathing treatment; -Resident received oxygen per nasal cannula at five liters per minute; -The resident said he/she is on continuous oxygen and never touches the oxygen concentrator to turn up or down; -The resident said the liters per minute should be set to three; -No label on the tubing showing when it was last changed. Observation on 02/26/24, at 7:09 A.M., showed the resident in the dining room eating breakfast. His/her portable oxygen tank was set at three liters per minute. Observation and interview on 02/26/24, at 9:56 A.M., showed the following: -Resident sat in room sitting in his/her wheelchair receiving oxygen per nasal cannula at three liters per minute; -No label on the tubing showing when it was last changed; -The resident said he/she has not observed staff changing the tubing or nasal cannula since she/she admitted to the facility. During an interview on 02/26/24, at 3:10 P.M., Certified Nurse Assistant (CNA) A said the following: -He/she does not change oxygen tubing or cannulas and does not think CNAs perform the task at the facility; -He/she would only increase or decrease a resident's oxygen liters if requested by the nurse; -He/she believes the resident's oxygen is set at three liters, but cannot recall the physician orders; -He/she is not aware if staff increased the oxygen to five liters. During an interview on 02/26/24, at 3:39 P.M., CNA B said the following: -Nurses change oxygen tubing, nasal cannulas, and dehumidifiers at the facility; -He/she never increases or decreases the liters on oxygen concentrators: -He/she does not remember what the resident's oxygen liters are supposed to be set, but physician orders determine the number of liters. During an interview on 02/26/24, at 3:44 P.M., Licensed Practical Nurse (LPN) C said the following: -Nurses change oxygen tubing, nasal cannulas, and dehumidifiers once per week per the treatment administration record (TAR), usually specified to day and time; -He/she has changed tubing and nasal cannulas at the facility; -Staff use physician orders to determine when to change the oxygen equipment and visual indicators such as a hole in the tubing; -Staff should place tape with date, time and initials on or near tubing after changing; -Staff use physician orders to determine the amount of oxygen liters per minute to set oxygen concentrators; -Nurses only should increase or decrease oxygen liters in the event of an emergency and follow up with a physician's; -He/she has never changed the resident's oxygen equipment; -He/she looked at the resident's medical record and said the physician order is for the oxygen liters to be set at two. During an interview on 02/26/24, at 4:00 P.M., Registered Nurse (RN) D said the following: -Staff should check physician orders or the medication administration record (MAR) to determine the number of liters of oxygen for a resident; -Staff rely on the TAR for prompting to change the oxygen equipment such as tubing; -Staff should put a date and time on tape of after changing oxygen equipment; -Nurses change the oxygen equipment at the facility, but she does not know if there is a specific date or time for all oxygen equipment changes; -Staff should not increase or decrease oxygen liters for extended periods of time without an order, only for emergency situations; -He/she has changed the resident's oxygen equipment, but it has been over a month. During an interview on 02/26/24, at 6:28 P.M., the Director of Nursing (DON) and the Administrator said the following: -Staff should change oxygen equipment weekly; -There should be a physician's order to change oxygen equipment weekly and the information should be on the TAR; -Staff should document date and time of oxygen equipment change on tape and place on the equipment; -Staff should have residents' oxygen liters set at amount in physician orders; -Staff should notify the physician if a resident's needs for oxygen increase; -The resident's physician orders are for the oxygen liters to be set at two liters; -Staff increasing oxygen liters without an order can be dangerous for residents who retain carbon monoxide.

Based on interview and record review, the facility failed to protect residents from misappropriation of property when four residents (Resident #1, Resident #2, Resident #3, and Resident #4) had medications go missing while in possession of the facility staff. The facility census was 54. Review of the facility's policy titled, Discarding and Destroying Medications, dated April 2019, showed the following: -All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of; -For unused, non-hazardous controlled substances that are not disposed of by an authorized collection, the Environmental Protection Agency (EPA) recommends destruction and disposal of the substance with other solid waste following the steps of taking the medication out of original containers, mix medication, either liquid solid, RX Destroyer, or with an undesirable substance, like sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage; -Dispose with the solid waste in the presence of two witnesses; -Document the disposal on the medication disposition record; -Include the signature(s) of at least two witnesses; -Destruction of a controlled substance must render it non-retrievable, meaning that the process permanently alters the physical or chemical properties of the substance so that it is no longer available or usable, and cannot be illegally diverted; -The medication disposition record will contain the following: the resident's name, date medication disposed, the name and strength of the medication, the name of the dispensing pharmacy, the quantity disposed, method of disposition, reason for disposition and signature of witnesses. Review of the facility's policy titled, Controlled Substances, dated April 2007, showed the following: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Scheduled II and other controlled substances; -Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must made the count together. They must document and report any discrepancies to the Director of Nursing Services (DON) or Designee; -The DON or Designee shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings. 1. Review of the facility's investigation, dated 08/23/23, showed the following: -On 8/23/23, at approximately 5:38 A.M., Registered Nurse (RN) A reported to the Assistant Director of Nursing (ADON) that RN B appeared to be lethargic and nodding off as he/she was leaning against the medication cart; -The ADON observed RN B leaning against the medication cart with a trash bag in his/her hand; -The ADON aroused RN B by touching his/her shoulder and RN B said he/she was tired; -RN B's purse was searched per his/her consent and facility medications were found; -Upon completion of the investigation, the facility was able to substantiate that RN B was attempting to divert narcotics from the facility. 2. Review of the Police Department Incident Report form, dated 8/23/23, showed the following: -On 8/23/23, at 7:31 A.M., an officer was dispatched to the facility in reference to a theft incident. The reporting party, the ADON, stated morphine (liquid pain medication) and Ativan (oral anxiety medication) were missing from the facility and believed to be in the possession of RN B; -Upon arrival, the officer contacted the ADON and RN A. The ADON said he/she was contacted by RN A due to RN B's unusual behavior last night and early this morning. RN B told RN A that he/she was tired. RN B went on break and went to his/her vehicle for a lengthy amount of time. When RN B came back inside the building, he/she was carrying a white hoodie that had a pink substance on it. RN B said it was vomit and went into the medication room to wash it out. RN A said RN B was in the medication room for a long amount of time. RN A checked on RN B and observed him/her dozing off at the sink. RN A advised RN B that it was time to pass medications; -After RN A and RN B completed their medication pass, RN B started wandering around the desk and medication carts while dozing off intermittently; -RN A contacted the ADON about RN B's unusual behavior. The ADON said when he/she arrived at the facility he/she observed RN B slumped over a medication cart with a trash bag in his/her hand; -While waiting to be picked up, RN B consented a search of her person and purse. The ADON located two 25 milligram (mg) promethazine (anti-nausea medication) pill packets, one empty 25 mg promethazine pill packet, and two 25 mg diphenhydramine (allergy medication) pill packets. The ADON said the medications located inside RN B's purse belonged to the facility and were prescribed for the facility residents. The ADON said RN B told him/her that he/she had taken one of the promethazine medication pills because he/she felt sick. The ADON said they searched the medication cart and found Ativan and morphine were missing. The ADON said RN B had possession of all four medicine carts, the keys to access the medicine carts and was he/she was the only one with access to the medicine carts during the shift. The ADON believed the missing Ativan and morphine were in RN B's vehicle and wanted the vehicle searched; -The officer contacted RN A, who said RN B had keys to access the medicine carts. RN A said RN B appeared lethargic, and was slumped over the medicine carts and took a very long amount of time on break. While RN B was on break, he/she went into his/her vehicle and was there for an extensive amount of time. RN A stated during their shift, RN B and RN A accessed morphine and other medications that needed to be destroyed per the facility policy and procedures; -The officer spoke with RN B and asked for consent to search his/her vehicle, in which he/she consented; -The officer searched RN B's purse and duffle bag. The officer located a syringe containing a purple liquid substance inside the syringe. RN B told the officer that he/she had taken it from the facility and that it was codeine cough medication. The officer also located an empty syringe labeled lidocaine hydrochloride jelly. RN B said the syringe had contained lidocaine in which he/she had taken for pain and had taken from the facility. The officer contacted the ADON and advised of findings. The ADON confirmed they were taken from the facility; -An officer searched the vehicle and located a syringe containing a purple gel like substance inside the center console of RN B's vehicle; -The officer showed the syringe to RN A, who advised the syringe was similar and consistent to the facility's prescribed morphine. The officer found a purse in the trunk portion of RN B's vehicle and located an empty vial labeled morphine inside the purse; -RN B was arrested for felony possession of controlled substance and stealing prescription medication. 3. Review of RN A's witness statement, dated 8/23/23, showed the following: -RN B counted the narcotic carts with the evening nurse's on 8/22/23, at 10:30 P.M.; -RN B seemed ok, however halfway through the shift he/she started to act tired and then lethargic; -Both RN A and RN B were out back vaping. RN A started to come back inside and RN B advised he/she was going to go to their car; -RN B was at his/her car for a good length of time and RN A looked and saw him/her moving around in his/her car; -When RN B came back inside, he/she had a white hoodie in his/her hands with a pink substance on it which RN B said was vomit; -RN B asked where he/she could wash his/her hoodie and RN A advised he/she could was in the medication room; -RN B went into the medication room and was in there for an extended amount of time. RN A observed RN B to be dozing off while standing up. RN A knocked on the door and advised RN B that it was time to pass synthroid medications; -RN B came out and kept stating how tired he/she was. RN B was wandering around the desk and carts dozing off intermittently; -RN A contacted the ADON about RN B's behavior. The ADON advised he/she was right outside the building and came in immediately; -The ADON told RN B that he/she needed to go home after RN B said he/she was just tired; -The ADON got the keys from RN B and gave them to RN A; -RN B took several minutes to gather his/her things and stated he/she had just a few things left to sign out of the narcotic book. RN B signed whatever he/she signed, grabbed his/her stuff, and headed toward the front entrance; -RN A advised the ADON that RN B's vehicle was in the back. The ADON got RN B and took him/her to the DON's office; -The ADON had RN A come in to witness RN B's bag search. The ADON found multiple packets of pills that belonged in the medication cart and a syringe with a pink water-like substance in it. The ADON called the Police. 4. Review of the ADON's Witness Statement, dated 8/23/23, showed the following: -On 8/23/23, at 5:38 A.M., the ADON arrived at the facility after receiving a call from RN A stating that RN B was acting lethargic and nodding off, leaning over against the medication cart and on walls; -Upon entering the facility, the ADON observed RN B slumped over the medication cart with a trash bag in his/her hand; -The ADON aroused RN B by touching his/her shoulder. RN B said he/she was just tired. The ADON requested/directed RN B to exit his/her shift due to safety issues; -RN B collected his/her belongings and started to ruffle though the medication books. The ADON again told RN B that he/she was relieved of their duties; -RN B headed to the front door, at which time RN A advised the ADON that RN B was parked out back; -The ADON directed RN B to an office and advised him/her to call someone to come pick him/her up; -RN B emptied her pockets, purse, and bag, and two promethazine HCL tablets 25 mg with another empty packet were located. RN B reported he/she took one of them because he/she felt sick; -Two diphenhydramine HCL tablets, 25 mg each were located, belonging to a resident; -At 6:12 A.M., the Administrator was notified and at 6:13 A.M., the Director of Nursing (DON) was notified; -The police were called to conduct a search due to missing Ativan and morphine from the facility nursing carts; -RN B had possession of all four sets of medication cart keys. RN B willingly turned over all keys to the ADON; -Only RN A and RN B had access to the two medication carts and two nursing carts during shift hours beginning on 8/22/23 at 10:30 P.M. 5. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admitted [DATE]; -Diagnoses included dementia and malignant neoplasm (cancer) of unspecified part of bronchus or lung. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/05/23, showed the resident to have a significant cognitive deficit. Review of the resident's physician order sheet, dated August 2023, showed the following; -An order, dated 08/10/23, for Lorazepam Intensol Oral Concentrate (oral anxiety medication), 2 mg/ml (milligrams/milliliters), give .25 ml by mouth every 4 hours as needed for anxiety; -An order, dated 08/10/23, for Morphine Sulfate (Concentrate) Solution 20 mg/ml, give .25 ml by mouth every four hours as needed for pain/air hunger. Review of the electronic Medication Administration Record (MAR), dated August 2023, showed the following: -On 8/13/23, at 2:40 P.M., Morphine Sulfate (Concentrate) Solution, .25 ml was administered; -Staff did not document administration of Lorazepam Intensol Oral Concentrate. Review of the controlled Drug Receipt/Record/Disposition Form for Lorazepam Intensol Oral Concentrate, dated 8/11/23, showed the following: -On 08/12/23, at 3:15 P.M., .25 ml was administered leaving with 29.50 ml remaining in the bottle; -On 08/23/23, at 4:46 P.M., 29.25 ml was destroyed by the ADON and an RN. (Staff did not document the administration of the .25 ml of Lorazepam on 08/12/23 on the MAR. Between 8/12/23 and 08/23/23 .25 ml of Lorazepam was unaccounted for.) Review of the controlled Drug Receipt/Record/Disposition form for morphine sulfate (concentrate) solution, dated 8/11/23, showed the following: -On 08/12/23, at 3:15 P.M., morphine sulfate (concentrate) solution, .25 ml was administered; -On 08/13/23, at 3:00 P.M., morphine sulfate (concentrate) solution, .25 ml was administered. (Staff did not document the administration of the .25 ml of morphine on 08/12/23 on the MAR.) Review of the resident's nurses' notes, dated 08/15/23, showed the resident's passed away. During an interview on 08/25/23, at 2:05 P.M., RN A said the resident passed a week earlier and is unsure why his/her narcotics were not destroyed earlier. RN A said possibly there were not two RN's available. During an interview on 08/25/23, at 12:30 P.M., the ADON said he/she did not know why the resident's medications (morphine and Lorazepam) were not destroyed after he/she passed. 6. Review of Resident #2's face sheet showed the following information: -admitted [DATE]; -Diagnoses included Alzheimer's disease, type II diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), and kidney disease. Review of the resident's significant change MDS, dated [DATE], showed the resident to have a significant cognitive deficit. Review of the resident's physician order sheet, dated August 2023, showed the following; -An order, dated 09/29/22, for Benadryl Allergy Tablet 25 mg, give 25 mg by mouth every eight hours as needed for pruritus (itchiness). Review of the resident's MAR, dated August 2023, showed staff did not document administration of Benadryl to the resident. During an interview on 08/25/23, at 12:30 P.M., the ADON said he/she located a non-narcotic medication (Benadryl) belonging to the resident in RN B's purse. 7. Review of Resident #3's face sheet showed the following information: -admitted [DATE]; -Diagnoses included encephalopathy (a broad term for any brain disease that alters brain function or structure), type II diabetes, and heart disease. Review of the resident's admission MDS, dated [DATE], showed the resident to be cognitively intact. Review of the resident's physician order sheet, dated August 2023, showed the following; -An order, dated 07/18/23, for promethazine tablet 25 mg, give 1 tablet by mouth every 8 hours as needed for nausea and vomiting. During an interview on 08/25/23, at 12:30 P.M., the ADON said he/she located a non-narcotic medication (promethazine) belonging to the resident in RN B's purse. 8. Review of Resident #4's face sheet showed the following information: -admitted [DATE]; -Diagnoses included heart failure, chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), type II diabetes, atrial fibrillation (irregular heartbeat), and kidney disease. Review of the resident's significant change MDS, dated [DATE], showed the resident to be cognitively intact. Review of the resident's physician order sheet, dated August 2023, showed the following; -An order, dated 04/20/23, for oxycodone oral tablet, give 1 tablet by mouth every 6 hours as needed for pain. Record review of the MAR, dated August 2023, showed the following: -On 8/11/23, at 11:46 A.M., oxycodone 5 mg was administered; -On 8/19/23, at 4:59 P.M., oxycodone 5 mg was administered; -On 8/22/23, at 10:10 A.M., oxycodone 5 mg was administered. Review of the resident's Controlled Drug Receipt/Record/Disposition form for oxycodone 5 mg, dated 06/08/22, showed the following: -On 08/11/23, at 11:47 A.M., 5 mg was administered, with 14 pills remaining; -On 08/19/23, at 5:00 P.M., 5 mg was administered, with 13 pills remaining; -On 08/22/23, at 10:10 A.M., 5 mg was administered, with 12 pills remaining; -On 8/23/23, no time noted and no pills administered. The form showed a balance of 11 pills remaining, with two nurse's signatures. During an interview on 08/25/23, at 12:30 P.M., the ADON said he/she was not aware the resident was missing an oxycodone until today. During an interview on 08/25/23, at 1:15 P.M., Licensed Practical Nurse (LPN) D said he/she does not know why the resident's oxycodone narcotic sheet is marked out with a new number. During an interview on 08/25/23, at 1:50 P.M., RN E said he/she notified the ADON of the discrepancy with the resident's oxycodone. He/she does not know the circumstances surround the count being off. 9. During an interview on 08/25/23, at 2:05 P.M., RN A said the following: -RN A and RN B were working the overnight shift and RN A was helping with RN B's orientation; -When it was time to count, RN B asked to count because he/she wanted more training and wanted to do it by him/herself; -At 3:30 A.M., RN A noticed RN B was overly tired. RN A asked RN B if he/she was ok, and he/she said they were not used to nights; -Around this time, RN B said he/she was going to their car. After about 15 to 20 minutes, RN A went to check on RN B and observed him/her in his/her car. RN B did not return back inside for another 15 to 20 minutes; -When RN B returned inside, he/she was holding a white hooded sweatshirt. RN B said he/she had been sick and threw up on the shirt. RN A noticed there was pink on the hoodie. RN B asked where he/she could wash the shirt out at, and RN A said the medication room; -RN A said RN B was in the medication room for about 30 minutes, and was falling asleep standing up. RN A started tapping on the window, and RN B just nodded. RN B finally came out, to start to pass medications; -The ADON arrived and took RN B's keys. The ADON had RN conducted count on the medication carts; -RN A discovered the count was off, as there was Ativan and morphine missing; -RN A said earlier in the evening, he/she and RN B destroyed Resident #1's medications as he/she had passed; -RN A saw RN B hold up Resident #1's medications while he/she was standing at the nurse's desk before they went into the medication room, but RN A did not check the name on narcotic sheet, or check the bottles him/herself before destroying. After destroying the medications RN B told RN A to sign the narcotic sheets, which he/she did, but did not verify the resident's name on the sheet; -After the narcotic count was complete, RN A found out it was Resident #5's medications that had been destroyed; -Discontinued narcotic medications are continued to be counted as long as they are in the cart; -Narcotic medications are destroyed by two RN's, which need to be upper management. Once destroyed, the narcotic sheet is signed by both staff and removed from the narcotic book; -RN A said he/she thought it was ok that RN B was pulling discontinued narcotic medications as he/she was a staff at the facility, as RN A was an agency staff. ; -Administration of narcotic medications are documented in the MAR and on the narcotic sheet. 10. During an interview on 08/25/23, at 12:30 P.M., the ADON said the following: -On 08/23/23, at 5:38 A.M., as the ADON was pulling in the parking lot, he/she received a call from RN A; -RN A said RN B was having odd behavior; -The ADON entered the building and observed RN B leaning over the medication cart, holding an empty trash bag, and nodding off. The ADON had to tap RN B on the shoulder three times to arouse him/her; -RN B said he/she was tired as they were not used to working nights; -The ADON advised RN B that he/she could go. RN B started ruffling items on the medication cart and said he/she needed to sign the narcotic book. RN B came over to the nurses' station and dropped the book. The ADON told RN B that he/she did not need to count medications; -RN B started to walk toward the front door, but he/she was parked out back. The ADON suggested RN B call for a ride; -RN A notified the ADON that he/she conducted a narcotic count with the oncoming shift and narcotics were missing; -The ADON then asked to search RN B's property (a purse and bag); -The ADON located non-narcotic medications belonging to Resident #2 and Resident #3 in RN B's purse; -The ADON called the police, and they reported to the facility; -RN B gave consent to have his/her car searched. The police located a full syringe of a pink liquid; -When administering narcotic medications, staff should document in the MAR and on the narcotic sheet; -Narcotic medication counts are conducted at shift change. The oncoming shift is counting cards and medications, and the off going is documenting in the narcotic book; -If the count is off, staff should try to resolve, but if cannot be resolved, the staff cannot leave and the ADON and DON will be notified and a count will be conducted of all narcotic medications; -An investigation will be initiated, and the State will be notified within 24 hours; -Staff are not allowed to take resident medications because it is considered theft of property; -If a narcotic medication is discontinued, staff should notified the ADON or DON because the facility requires two RN's to destroy medications; -Staff should leave the discontinued narcotic in the cart and the medication will continued to be counted until removed from the cart and destroyed; -Discontinued narcotics should be pulled from the cart and destroyed on the same day, unless there are not two RN's available (like overnight shift); -When destroying medications, the two RN's should ensure the medications and the narcotic sheets match; -The RN's will both sign the narcotic sheet, and then sign the destruction log sheet. The narcotic sheet is then placed in the medical records bin. 11. During an interview on 08/25/23, at 11:30 A.M., Certified Medication Technician (CMT) C said the following: -The narcotic count is conducted at shift change by oncoming and off going staff; -The ongoing staff counts the cards and the individual pills in the cards, and the off going staff documents in the narcotic book; -If there is an issue with the narcotic count, staff report the issue to the ADON, DON, and/or charge nurse. The facility will start and investigation and report it to the state within 24 hours; -Staff cannot take resident medications as is misappropriation of property/abuse; -Discontinued narcotics are continued to be counted until they are removed from the cart; -If a medication is discontinued, CMT C will place a note on the medication that it needs to be destroyed. Staff can also notified the ADON or DON; -Mediations are destroyed by two RN's, and one has to be the ADON or DON; -There is not a set schedule when medications are destroyed. Narcotics are normally destroyed every week or two; -When administering narcotics, they are documented as given in the electronic MAR and on the narcotic sheet. 12. During an interview on 08/25/23, at 1:15 P.M., Licensed Practical Nurse (LPN) D said the following: -Narcotic counts are conducted at shift change. The oncoming staff counts the cards and pills and the off going staff documents in the narcotic book; -If the narcotic count is not right, the supervisor/DON is notified and no one leaves; -Staff cannot take resident medications because it is illegal as it is misappropriation; -Discontinued narcotic medications should not sit in the cart. Staff should notify the DON if a medication has been discontinued. If a discontinued medication is still in the cart, it should continue to be counted. Two RN's have to be present to destroy medications. LPN D believes carts are checked daily by the ADON or DON; -Staff administering narcotics should document in the MAR and in the narcotic book. 13. During an interview on 08/25/23, at 1:50 P.M., RN E said the following: -On 8/23/23, RN E worked the day shift. When he/she arrived at work, he/she was directed by the VP to count all narcotics and report any issues to him/her or the ADON; -At shift change, the oncoming and off going shift conduct the narcotic count. The oncoming shift counts the cards, pills, bottles, and patches, and the off going staff documents in the narcotic book; -Discontinued medications will be included in the count until they are removed from the cart; -If a count is off, staff will not sign the narcotic book, or accept the cart. The ADON and DON will be notified and an investigation will be initiated. The State will be notified; -Staff cannot take resident medications as it is misappropriation of property; -RN E will remove discontinued narcotic medications from the medication cart and destroy the medications with the ADON, as two RN's have to destroy narcotic medications. There is no set destruction schedule; -When destroying medications, staff verify the name on the narcotic, the narcotic medication, and the narcotic sheet to ensure they all match. Both staff will sign and date on the narcotic sheet after it is destroyed and place in the medical records basket. 14. During an interview on 08/25/23, at 2:39 P.M., the [NAME] President said the following: -Narcotic medication counts are conducted at shift change. Both nurses should be looking at cards and pills; -If a narcotic count is off, staff need to recount and then call the DON or on call staff. Staff need to remain in the building until management arrives. The facility will start an investigation and notify the State within 24 hours; -Staff cannot take resident medications as it is against the law and considered misappropriation of property; -Discontinued narcotics are continued to be counted as long as they are in the medication cart; -Narcotics should remain in the cart until they are destroyed; -Staff can notify the DON if there are narcotics in the cart that need to be destroyed; -Medications are destroyed by two RNs, which one has to be the DON or an RN designated by the DON. The RN's should pull the medication and the narcotic sheet. The RN's should verify the count, verify the narcotic medication against the resident name, and the narcotic sheet. Each RN signs the narcotic sheet and the destruction sheet; -When administering narcotic medications, staff should document in the MAR and on the narcotic sheet. MO00223430

Based on observation, interview, and record review, the facility failed to provide protective oversight for residents when the facility did not have a policy and system in place to monitor residents who entered the enclosed courtyard during periods of high temperature and increased humidity resulting in one resident (Resident #1) becoming unresponsive and being sent to the hospital. The facility census was 59. The Chief Executive Officer (CEO) and Director of Education were notified on 07/28/23, at 5:30 P.M., of an Immediate Jeopardy (IJ) which began on 07/27/2023. The IJ was removed on 08/01/2023, as confirmed by surveyor onsite verification. 1. Review of Resident #1's face sheet (brief profile of resident) showed the following: -admitted [DATE]; -Diagnoses included cerebral infarction (disrupted blood flow to the brain), dementia, Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), hyperlipidemia (high levels of fat particles in the blood), and hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). Review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 07/06/23, showed the following: -Moderately cognitively impaired; -Required limited assistance for bed mobility, transfers, walking in room, locomotion on and off unit, dressing, and toileting. Review of the resident's care plan, last reviewed 07/11/23, showed the following; -Limited physical mobility related to stroke requiring therapy for strengthening; -Impaired cognitive function related to stroke and dementia with noted cognitive impairment; -At risk for falls related to history of falls and recent stroke with weakness and impaired thought process; -Resident is on anticoagulant (blood thinners that help prevent blood clots) therapy related to recent stroke. Review of the resident's progress notes, dated 07/27/23, showed the following: -At 3:52 P.M., resident was found unresponsive by staff. Staff notified physician and power of attorney (POA, legal document that allows someone else to act on your behalf) notified. -Staff did not document prior to 3:52 P.M. regarding the resident being in the courtyard, checks of the resident, assessment of the resident while outside, or attempts to reapproach the resident regarding leaving the courtyard; -At 4:50 P.M., in report, staff reported the resident was in the courtyard and refused on multiple attempts to come back inside the facility; -At 9:49 P.M., in report staff reported the resident was found in the courtyard and refused on multiple attempts to come back inside the facility. Nurse and Certified Nurse Aide (CNA) went to courtyard and found the resident sitting on the bench with emesis (vomit) on his/her chest. Staff assisted resident to wheelchair and brought resident into facility. The resident's blood oxygen level (SPO2) was 66% (normal SPO2 level in adults is 92 to 100%); -Staff called emergency medical services (EMS) and applied oxygen. Review of the National Weather Service Heat Advisory, dated 07/27/23, showed the following: -Heat advisory in effect from 07/27/23 at 4:31 A.M. eastern daylight time (EDT) until 07/28/2023 at 10:00 P.M. EDT; -Heat index values of 100 to 109 degrees Fahrenheit (F) expected; -Hot temperatures and high humidity may cause heat illness to occur. Review of localconditions.com showed the following observations on 07/27/23 for the town the facility is located: -At 12:30 P.M., temperature of 95 degrees F and humidity of 39.13%; -At 12:45 P.M., temperature of 95 degrees F and humidity of 41.64%; -At 1:00 P.M., temperature of 96.8 degrees F and humidity of 37.04%; -At 1:15 P.M., temperature of 96.8 degrees F and humidity of 39.41%; -At 1:30 P.M., temperature of 95 degrees F and humidity of 41.64%; -At 1:45 P.M., temperature of 96.8 degrees F and humidity of 37.04%; -At 2:00 P.M., temperature of 96.8 degrees F and humidity of 39.41%; -At 2:15 P.M., temperature of 96.8 degrees F and humidity of 37.04%; -At 2:30 P.M., temperature of 96.8 degrees F and humidity of 37.04%; -At 2:45 P.M., temperature of 96.8 degrees F and humidity of 37.04%; -At 3:00 P.M., temperature of 96.8 degrees F and humidity of 37.04%; -At 3:15 P.M., temperature of 98.6 degrees F and humidity of 32.94%; -At 3:30 P.M., temperature of 96.8 degrees F and humidity of 32.67%. During an interview on 08/03/23, at 9:22 A.M., a social worker from the hospital said the following: -The resident presented in the emergency room (on 07/27/23) covered in vomit, not responding, opening eyes spontaneously, with rhythmic movement of right arm; -The resident was intubated (a tube inserted into a body part for ventilation) for airway protection; -The resident was admitted to the ICU (intensive care unit); -The resident remains in critical condition. Observations on 07/28/23, at 1:15 P.M., showed the bench in the courtyard did not have shade at 1:15 P.M. During an interview on 07/28/23, at 1:20 P.M., the Dietary Manager (DM) said the following: -She observed the resident go out to the courtyard on 07/27/23, somewhere between 12:30 P.M. to 1:00 P.M.; -She immediately went to the nurses' station for 100/200 hall and informed an unknown staff member the resident was in the courtyard due to the extreme heat; -She called the nurses' station before she left for the day, around 2:00 P.M., to ensure staff knew the resident was still outside; -After making the call, she left the dining room and observed two staff members at the door going out to the courtyard, but did not know the names of the staff. During interviews on 07/28/23, at 12:55 P.M. and 2:34 P.M., CNA A said the following: -There is one door, without an alarm, going into the courtyard, which is across from the dining room; -Staff should check on residents more often when outside in extreme weather; -Staff should attempt to redirect residents in the courtyard during extreme weather back inside the facility; -Staff should offer water to residents outside in extreme weather, but there is no protocol for how often; -Staff do not always know if a resident was outside; -Staff perform regular checks of residents every two hours; -He/she last interacted with the resident at about 12:30 P.M., when picking up his/her lunch tray. The resident appeared to be at baseline at that time; -He/she was informed the resident was in the courtyard about 2:00 P.M., after the Dietary Manager (DM) called the nurses' station to inform staff; -CNA E went outside about 2:00 P.M., (one and one half hours after the resident first went outside) to encourage the resident to come inside, but the resident refused; -The resident asked the staff member (CNA E) to assist him/her with taking off his/her shirt and the staff member assisted; -Staff should document when a resident refuses to come inside during extreme weather; -He/she advised the evening shift during report, around 2:30 P.M., of the resident being outside in the courtyard, and the team observed him/her from behind, sitting on the bench in the courtyard from the resident's room window. The resident was not wearing a shirt. During interviews on 08/01/23, at 1:41 P.M. and 2:06 P.M., CNA E said the following: -On 07/27/23, between 1:30 P.M. and 2:00 P.M., he/she checked on the resident who refused to come inside and asked for assistance to take his/her shirt off. He/she helped the resident take the shirt off and went back inside; -At approximately 2:30 P.M., he/she informed staff during report the resident was outside, and they observed the resident from behind, still shirtless, through the window in the resident's room; -He/she stopped CNA D between 2:30 to 3:00 P.M., and advised the resident was outside and would need to be checked. During an interview on 07/28/23, at approximately 4:07 P.M., CNA D said the following: -The courtyard door is always unlocked; -The facility has no rules regarding time frames for when residents can be in the courtyard; -Staff advised him/her on 07/27/23, at about 2:45 P.M., the resident was in the courtyard and had refused to come inside; -Staff advised him/her between 3:15 P.M. to 3:30 P.M., (over one hour since staff last checked on the resident) the resident was in the courtyard unresponsive and had vomited; -He/she and other staff went to the courtyard, assisted the resident into his/her wheelchair, brought him/her inside, began taking vitals, and called emergency medical services; -The resident has been out to the courtyard before and came back inside with no issues. During an interview on 07/28/23, at 3:52 P.M., CNA C said the following: -The courtyard door is never locked; -He/she is not aware of a facility policy regarding checking on residents in extreme weather, but he/she knows to check on residents, especially when it is hot or cold; -On 07/27/23, between 2:30 and 3:00 P.M., he/she received report regarding the resident being outside in the courtyard and refusing to come inside; -He/she did not go outside to assess the resident following report; -He/she next observed the resident around 3:30 P.M., inside the dining room hall area as they were going to check on him/her. During an interview on 07/28/23, at 2:22 P.M., License Practical Nurse (LPN) B said the following: -The resident refused both morning and noon accuchecks (blood sugar checks) and insulin on 07/27/23; -He/she documented the resident's refusals in the doctor communication book; -The resident goes out to the courtyard often; -He/she was notified by kitchen staff the resident was in the courtyard on 07/27/23, at about 2:15 P.M., -He/she was informed staff checked on the resident about 2:00 P.M. and the resident did not want to come inside; -He/she relayed this information to the evening shift nurse at report. During an interview on 07/28/23, at 3:46 P.M., the Activity Director said the following: -The courtyard door is typically unlocked 24 hours; -She is not aware of a facility policy regarding checking on residents in the courtyard; -She observed the resident in the courtyard on 07/27/23 at about 2:30 P.M., and the resident looked like he/she was taking a nap. During an interview on 07/28/28, at 4:24 P.M., the Assistant Director of Nursing (ADON) said the following: -The facility has a general policy to lay eyes on residents every hour; -She is not aware of a facility policy to check on residents in the courtyard during extreme heat or cold, but residents should be checked on every 15 minutes; -She said staff would know if a resident went outside by doing their rounds or observing a resident go outside; -She said the resident was in the courtyard often and liked being in the sun while not wearing a shirt; -The resident refused to come inside; -She does not know who checked on the resident while he/she was in the courtyard; -She was told the resident was checked on before and after shift change; -She does not know when the resident went outside to the courtyard; -The resident was more susceptible to medical issues after refusing insulin. During an interview on 07/28/23, at 4:42 P.M., the Director of Education and the CEO said the following: -There is an alarm that goes off when the door to the courtyard is opened to alert staff when a resident is goes out there; -The facility does not have a policy regarding how long residents can be outside in the courtyard or the hours residents can be in the courtyard; -The facility does not have a policy or procedure regarding checking on residents while outside in the courtyard during extreme weather; -The resident is known to go outside into the courtyard and has the ability to go in and out on his/her own; -An investigation was completed showing the resident was checked on two times, the first time around 2:00 P.M., and the last time when he/she was found unresponsive sometime between 3:15 P.M. to 3:30 P.M. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00222135

Based on observation, interview, and record review, the facility failed to routinely assess for pain, notify the physician of pain and provide adequate pain control for one resident (Resident #4), with dementia and an infected pressure ulcer, who displayed multiple physical signs of significant pain. Thirteen residents were selected for review in a facility with a census of 78 residents. Record review of the facility's (undated) pain assessment and treatment policy showed the following information: -Pain must be initially assessed and managed in a timely fashion. Initial assessment and treatment rests with nursing staff. Nurses must ask residents about pain (intensity, frequency, characteristics and location) using the resident's self-report as the primary source of information, using a pain scale; -To adequately manage pain, a complete physical examination must be made and assessment made of how the pain affects emotional status and preferences. Nursing staff must act as a team with the other nursing staff and disciplines as well as the physician in monitoring pain and it's effects on the resident; -Systematic continuing evaluations must be ongoing on a regular basis. Teach residents, families and direct care providers to report any new pain so appropriate reassessment and treatment can be initiated; -Assess characteristics of pain: Intensity, location, onset and pattern, frequency and duration, description, change, what makes pain better or worse, effects of [MEDICATION NAME]; -Nursing observations: Pain behavior/body movements, change in facial expression, vocal expression, change in routine, change in mental status, impact of pain on quality of life; -Physical examination: Examine site of pain, are there outside factors, such as type of chair, position of limb, mobility and function; -Educate the direct care staff on the cause of pain (diagnosis) pain assessment, prognosis, treatment options and side effects, goals of treatment and multidisciplinary plan of care; -The interdisciplinary team (nurses, practitioner, pharmacists, etc.) is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain, such as during a treatment. The regimen considers factors such as the causes, location, and severity of the pain; -Care plan must include a section on pain control and documentation made at least quarterly. Record review of the facility's (undated) policy on pain terminology and types of pain (addendum #1) showed the following: -Location, document on pain map, anatomical drawing or description tool; -Intensity or severity, document by numerical, verbal descriptor of faces scale; -Frequency, how long the pain lasts; -Quality, description of type of pain; -Pain behaviors, facial (wrinkled forehead, tightly closed eyes, grimacing, frowning), nonverbal behavior (bracing, rubbing, guarding), vocalizations (crying, yelling, groaning, moaning) -Nonverbal indicators of discomfort, aggressive, crying , fearful, noisy respirations, pacing repetitive, restless, rocking, confusion, irritability, increased activity, withdrawal, tense, calling out, grunting, knees pulled up, other change in usual activities or behavior patterns/routine; -Duration, how long the pain has been present; -Pattern, how the pain starts, what was being done when it started, what makes it better or worse. 1. Record review of Resident #4's current March 2017 physician orders [REDACTED]. -Displaced intertrochanteric fracture of right femur (upper leg bone) with repair; -Generalized muscle weakness; -[MEDICAL CONDITION]; -Anxiety disorder; -Major [MEDICAL CONDITION], recurrent; -Other chronic pain; -Stage 3 pressure ulcer (full thickness skin loss involving damage or death of subcutaneous tissue that may extend down to but not including the bone) of left hip and unstageable pressure ulcer of right gluteal fold (area below the buttock and above the posterior thigh). Review of the resident's 24 hour clinical notes dated 12/7/16, at 1:40 P.M., showed the admitting nurse did not document a pain assessment. Record review of the resident's care plan, dated 12/8/16, showed the following; -Resident was sometimes understood in ability to express ideas and wants, if restless, assess for pain/discomfort or other physical needs; -Observe resident for changes in mood/behavior (sleep patterns, fatigue, appetite, ability to concentrate, participation in activities, crying). Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/14/16, showed the following information: -admitted on [DATE]; -Cognition severely impaired; -Limited assistance of one staff needed for bed mobility, transfers, dressing, and toileting; -Extensive assistance of staff needed for personal hygiene and bathing; -No pain per pain assessment interview. Review of the resident's 24 hour clinical notes, dated 1/24/17, showed a nurse documented the resident had a red area to the right gluteal fold. Staff notified the physician and obtained a treatment order. Record review of the resident's care plan, updated on 01/24/17, showed reddened area in right gluteal; see treatment orders. Record review of the resident's daily wound monitoring form, dated 2/14/17, showed the resident had a left hip pressure ulcer and a right gluteal fold pressure ulcer. The ulcer had a change in appearance since last assessment with pain at site. (The nurse did not document notification of the physician about the the pain.) Record review of the resident's 24 hour clinical notes, dated 2/8/17, showed a nurse documented the resident was restless and crying off and on most of the shift, staff administered as needed [MEDICATION NAME] (anti-anxiety medication), repositioned the resident and offered water. Record review of the resident's 24 hour clinical notes, dated 2/16/17, showed a nurse documented the resident was combative, swinging his/her arms and resistant during cares. Record review of the resident's 24 hour clinical notes dated 2/17/17, at 2:36 P.M., showed a nurse documented the resident's physician looked at the resident's wounds and gave no new orders. Record review of the resident's weekly wound assessment, dated 3/01/17, showed the resident had a stage 3 right gluteal fold pressure ulcer and pain with treatment. (Staff did not document addressing the resident's pain.) Record review of the resident's 24 hour clinical notes, dated 3/1/17, at 3:05 P.M., showed a nurse documented the resident's physician examined the resident's wounds with no new orders. Record review of the resident's care plan, updated 3/12/17, showed a wound culture to right gluteal fold wound with positive growth. Record review of the resident's care plan, updated 3/17/17, showed the resident began receiving [MEDICATION NAME] (an antibiotic). Record review of resident's significant change MDS, dated [DATE], showed changes that included: -Extensive assistance of two or more staff needed for bed mobility, transfers, dressing, and toileting; -Extensive assistance needed for personal hygiene and dependent on staff for bathing; -Presence of two pressure ulcers, one stage 3 pressure ulcer and one unstageable pressure ulcer; -No pain per interview of the resident. Record review of the resident's March 2017 Medication Administration Record [REDACTED]. Staff to notify nurse if pain present. Record review of the resident's March 2017 non-PRN medication notes showed the following: -On 3/20/17 staff assessed the resident's pain on the 7-3 and 3-11 shift as 0; -On 3/21/17 staff assessed the resident's pain on the 7-3 shift as 3. Observation and interview on 3/21/17 at 8:45 A.M., showed CNA J assisted the resident out of a wheelchair and into bed. The CNA said the resident was having a really bad morning. The CNA placed the resident onto his/her side in bed and the resident cried out in pain and grabbed at his/her right hip/buttock area. The CNA said the resident did not have much pain, except for his/her pressure ulcers. The CNA said he/she could tell the pressure ulcers were very painful to the resident because if the CNA accidentally bumped or touched them during cares or pulled the resident's clothes over the pressure ulcer areas, the resident cried out and tried to put his/her hand over the areas. The CNA said when the resident showed signs of pain, he/she asked the Certified Medication Technician (CMT) to give the resident Tylenol. The CNA said the Tylenol worked to control the resident's pain. Record review of the resident's medication administration records and physician orders [REDACTED]. Observation on 3/21/17, at 12:20 P.M., showed CNA J assisted the resident with dressing. The CNA pulled the resident's pants up over the resident's right buttock and the resident, attempted to put his/her right hand over his/her riguteal fold pressure ulcer. The CNA said to the resident, I know that hurts, I will tell the nurse. The CNA assisted the resident to sit up on the side of the bed and the resident grimaced and became tearful. Observation on 3/21/17, at 12:40 P.M., showed CMT N ask the Assistant Director of Nursing (ADON) to contact the physician to get a Tylenol or pain medication order for the resident because the resident did not have an order for [REDACTED].>Record review of the resident's March 2017 MAR indicated [REDACTED]. Staff began administering the medication at 4:00 P.M. on 3/21/17. Record review of the resident's March 2017 non-PRN medication notes, dated 3/21/17, showed staff assessed the resident's pain on the 3-11 shift as 0. Observation on 3/22/17, at 9:55 A.M., showed the ADON and Licensed Practical Nurse (LPN) A entered the resident's room to provide wound care to the resident's left hip and right gluteal fold pressure ulcer. The resident cried out when the nurses turned and repositioned the resident. The nurse sprayed wound cleanser into the wound and wiped the pressure ulcer with dry gauze; the resident cried out and showed facial grimacing. The ADON said, the resident Reacts like this to everything. The ADON asked the resident if the wound hurt, the resident responded, Uh huh. The resident continued to cry. The ADON said, We are going to have to get the resident something stronger for pain when we do dressing changes. (The ADON and LPN A did not stop treatment when the resident showed signs of pain including crying.) During an interview on 3/22/17, at 10:35 A.M., LPN A said the resident showed increased signs of pain over the last one to two weeks. The nurse said he/she started packing the right gluteal fold pressure ulcer approximately two weeks. The nurse said the wound packing was painful for the resident, because the resident cried and grimaced during the treatments. Review of the resident's 24 hour clinical notes, dated 3/22/17, showed a nurse documented the resident was tearful, moaning and grimacing with the pressure ulcer dressing change, staff notified the physician and obtained an order for [REDACTED]. Record review of the resident's March 2017 MAR indicated [REDACTED]. Staff began administering the medication at 4:00 P.M. on 3/22/17. Record review of the resident's March 2017 non-PRN medication notes, dated 3/22/17, showed staff assessed the resident's pain on the 7-3 and 3-11 shift as 0. Observation and interview on 3/22/17 at 3:20 P.M., showed CNA H in the resident's room and the resident sat in a wheelchair. CNA H said the resident was getting a little restless, so staff assisted the resident out of bed. The resident placed a hand under his/her right buttock, grimaced and said, Oh boy. The CNA said the resident was very anxious making it difficult to tell if the resident was in pain. The resident usually cried out when staff moved his/her knees apart to perform incontinent care. The CNA said he/she was unaware the resident had hip surgery in the past. During an interview on 3/22/17 at 3:35 P.M., CMT N said yesterday (3/21/17) was the first time staff told him/her the resident was in pain. The CMT said he/she previously worked the night shift until two weeks ago and the resident usually slept. The CMT said the facility started doing pain assessments on the resident on 3/20/17, before that CMTs were not doing pain assessments on the resident. The CMT said if a resident was confused, he/she looked for signs of pain, such as fidgeting, groaning or facial expressions. During an interview on 3/22/17 at 6:00 P.M., the resident's family member said the resident started showing signs and symptoms of pain approximately 10 to 14 days ago. The family member noticed the resident tried to position him/her self off of his/her right buttock while in the wheelchair, by tilting to the side. Record review of the resident's March 2017 non-PRN medication notes, dated 3/23/17, showed staff assessed the resident's pain on the 7-3 and 3-11 shift as 0. Observation and interview on 3/23/17 at 9:15 A.M., showed the ADON performed a treatment change to the resident's right ischium (hip) pressure ulcer and measured the ulcer. The ADON said the resident was a lot calmer today, because staff administered [MEDICATION NAME] (pain medication) and PRN [MEDICATION NAME] (as needed antianxiety medication) prior to the treatment. The ADON said the resident was fearful on 3/22/17 during the treatment, It's hard to tell if (the resident is) in pain or scared. After the treatment, the ADON said the resident had, a totally different demeanor today. During an interview on 3/23/17 at 12:30 P.M., CMT I said the resident showed signs of moderate to severe pain during cares for approximately the past two weeks. The CMT said a couple of CNAs approached him/her to notify the CMT the resident was in pain, but the resident did not have any pain medication except for maybe Tylenol PRN. The CMT said he/she could see the pain in the resident's face. The CMT said he/she reported the resident's pain to a nurse, but did not remember which nurse. The CMT said he/she assisted the nurses during pressure ulcer treatments. During the treatments, the resident tried to grab and scratch at the ulcers, so the CMT tried to hold the resident's hands during the treatment. During interviews on 3/21/17 at 12:20 P.M. and on 3/23/17 at 2:30 P.M., the DON said dementia residents are hard to assess for pain, but staff should look for facial grimacing, review the resident's medical history and talk to the resident's family. The DON said the resident cried and his/her emotions were all over the place. The DON said if the resident cried out during the treatment, the nurse should have stopped the treatment and called the physician for pain medication. The DON said nurses should chart daily on the resident's pain and chart an assessment if the resident showed signs of pain during the pressure ulcer treatment. The nurse said CMTs and CNAs should report any signs or symptoms of pain to the nurse immediately. The DON said she was unaware the resident was not on pain medications prior to 3/21/17.

Based on observation, interview, and record review, the facility failed to assess and monitor a pressure ulcer, for 22 days, after initially identifying the wound and failed to timely notify the physician when a pressure ulcer worsened for one resident (Resident #4) out of 13 sampled residents. The facility had a census of 78 residents. Review of the facility's (undated) pressure ulcer treatment policy showed guidelines for documentation as follows: -Upon admission or at the first sign of a pressure ulcer, documentation is to be made on the Skin assessment Sheet and Nurses Notes with updates weekly by the person doing the treatment; -Include appearance of skin, site, staging, undermining and description of exudate (drainage) and condition of surrounding skin -Include documentation of pressure relieving protocols and preventative measures, nutrition status and compliance by the resident. -Physician is notified immediately upon discovery of a pressure ulcer. Specific orders are followed and notification is made as progress is made or if a change in orders is needed. 1. Record review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/14/16, showed the following information: -admitted on [DATE]; -Cognition severely impaired; -Limited assistance of one staff needed for bed mobility, transfers, dressing, and toileting; -Extensive assistance needed for personal hygiene and bathing; -Wheelchair for mobility; -Frequently incontinent of bowel; -Urinary catheter; -Fracture related to a fall in the last six months; -At risk for development of pressure ulcers. -No pressure ulcers. Review of the resident's current March 2017 physician orders [REDACTED]. -Generalized muscle weakness; -[MEDICAL CONDITION]. Review of the resident's current care plan, effective 12/8/16 to present, showed the following; -Resident at risk for the development of pressure ulcers; -Check skin for redness, skin tears, swelling, or pressure ulcers; -Report any signs of skin breakdown; -Use pillows, pads, or wedges to reduce the risk of skin breakdown; Review of the resident's clinical notes showed the following: -On 12/7/16 at 1:40 P.M., the admitting nurse documented the resident had no skin issues except for three spots on right hip from surgery on leg. -On 12/14/16 at 12:56 P.M., a nurse documented no pressure ulcers or wounds at this time. Review of the resident's current care plan, update on 12/16/16, showed the following: -Staff to perform a complete assessment of skin one time weekly; -Staff to note areas of redness. Record review of the resident's current medical record showed from 12/16/16-01/24/17, the nurses did not document a weekly skin assessment. Review of the resident's clinical note, dated 1/24/17 at 2:22 P.M., showed a nurse documented the resident had a red area on his/her right gluteal fold that measured 1.7 centimeter (cm) x 1.5 cm. Staff notified the physician and obtained an order to apply [MEDICATION NAME] (antimicrobial wound gel) to the area, every shift. Review of the resident's care plan showed on 01/24/17 staff documented reddened area on the resident's right gluteal fold that measured 1.7 cm x 1.5 cm; see treatment orders. Record review of the resident's January 2017 treatment administration record (TAR) showed staff completed the wound treatment to the resident's right gluteal fold as ordered. Review of the resident's history and physical, dated 2/8/17, showed the physician documented the resident had one Stage III (full thickness skin loss involving damage or death of subcutaneous tissue that may extend down to but not including the bone) pressure ulcer on his/her left hip. The physician did not mention the area on the resident's right gluteal fold. Review of the resident's daily wound monitoring form, dated 2/14/17, showed the following: -Right gluteal fold pressure ulcer measured 2.5 cm, appeared red and swollen with slight drainage (staff did not document a description of the drainage) and pain at the site. The ulcer had a change in appearance since the last assessment (01/24/17); -The nurse did not document notification of the physician about the deterioration of the right gluteal fold pressure ulcer; -Staff did not document an assessment of the right gluteal fold ulcer, including size, Stage, wound bed appearance, drainage, appearance of the surrounding skin (periwound) and pain from 1/24/17 until 2/14/17 (22 days). Review of the resident's clinical note, dated 2/17/17 at 2:36 P.M., showed a nurse documented the physician looked at the resident's wounds and wrote no new orders. Review of the resident's weekly wound assessment, dated 2/21/17, the resident had a stage III pressure ulcer on his/her right gluteal fold, that measured 1.5 cm x 2.5 cm x 0.5 cm. The wound bed had yellow slough (yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed) and 30 % granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) with a small amount of drainage (staff did not document a description of the drainage). Staff did not document the appearance of the periwound. Record review of a physician's orders [REDACTED]. Record review of the resident's February 2017 TAR showed staff completed the wound treatment to the resident's right gluteal fold as ordered by the physician. Review of the resident's weekly wound assessment dated [DATE], showed the resident had a Stage III pressure ulcer on his/her right gluteal fold that measured 2.0 cm x 2.2 cm x 1.0 cm with white slough and granulation tissue to 90% of the wound bed, no drainage and pain with treatment. Staff did not document the appearance of the periwound or pain intervention. Review of the resident's clinical notes, dated 3/1/17 at 3:05 P.M., showed a nurse documented the resident's physician examined the resident's wounds with no new orders. Review of the resident's weekly wound assessment dated [DATE], showed the resident had a stage III pressure ulcer on his/her right gluteal fold that measured 2.0 cm x 2.5 cm x 0.5 cm with white slough and granulation tissue to 75% of the wound bed. The wound had a small amount of drainage (staff did not describe the type of drainage). Staff did not document the appearance of the periwound. Review of the resident's care plan, update on 3/12/17, showed a wound culture to right gluteal fold pressure ulcer. Review of the resident's clinical notes showed the following: -On 3/13/17 at 11:31 A.M., a nurse documented, since admission two pressure ulcers have developed with one on the left hip and one on the right gluteal fold. The wound on the right gluteal fold was unstageable (unable to determine the depth of a wound) with eschar (dead tissue) and slough covering the wound bed and undermining (extension of the wound edge underneath the visible edge) on the lower edge. Both wounds have daily dressing changes with changes made and physicians notified. -On 3/13/17 at 3:53 P.M., a nurse documented to discontinue [MEDICATION NAME] and start new treatment. Record review of a physician's orders [REDACTED]. Review of the resident's weekly wound assessment, dated 3/13/17, showed staff the Stage III pressure ulcer on the resident's right gluteal fold measured 3.0 x 3.0 x 2.0 cm with black eschar on wound bed and tan/brown colored slough on the edges. Undermining from 3 o'clock to 8 o'clock with the start of a tunnel around 8 o'clock. Moderate amount of greenish brown drainage with a strong odor. Periwound was reddish pink. Record review of Resident #4's significant change Minimum Data Set (MDS), dated [DATE], showed, in part, the following changes: -Extensive assistance of two or more staff needed for bed mobility, transfers, dressing, and toileting; -Extensive assistance needed for personal hygiene and dependent on staff for bathing; -One Stage III pressure ulcer (left hip); -One unstageable pressure ulcer (Right gluteal fold). Review of the resident's care plan, update on 3/17/17, showed the following: -Wound culture to right gluteal fold wound showed positive bacterial growth; -Resident started on [MEDICATION NAME] (an antibiotic) on 3/17/17. Review of the resident's weekly wound assessment dated [DATE], showed a nurse documented the resident had a Stage IV (full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures) pressure ulcer on his/her right gluteal fold. Staff measured the wound as 2.0 cm x 2.2 cm x 0.5 cm deep with yellow slough and 25% granulation tissue to the wound bed. Staff did not document tunneling, the appearance of the periwound, or if any drainage. Observation on 3/22/17 at 9:00 A.M., showed the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) A entered the resident's room to provide wound care to the resident's right gluteal fold pressure ulcer. As LPN A pulled the resident's pants and incontinent brief down, a golf ball sized area of light brown drainage was visible on the brief and pants in the area over the existing dressing. The LPN removed the current dressing and said the foam was saturated with drainage. The nurse sprayed wound cleanser into the wound and wiped the pressure ulcer with dry gauze; the resident cried out and showed facial grimacing. The ADON said, (the resident) Reacts like this to everything. The ADON asked the resident if the wound hurt, the resident responded, Uh huh. The ADON said, We are going to have to get her something stronger for pain when we do pressure ulcer dressing changes. The ADON described the appearance of the wound as follows: The wound bed had approximately 25% granulation tissue, 25% soft white tissue/slough and 50% grayish black eschar, and a visible depth of approximately 1 cm. The periwound was firm to touch in an area approximately 1 cm out from the wound around the circumference the surrounding intact skin was reddened skin to approximately 0.5 cm out from the wound edge with slight maceration to the wound edge (these measurements were estimated, staff did not measure the wound). LPN A said the pressure ulcer on the resident's right gluteal fold pressure ulcer had eschar in the wound bed for the past two weeks approximately. During an interview on 3/22/17 at 11:20 A.M., the ADON said he/she called the resident's physician and obtained an order for [REDACTED]. Observation on 3/23/17 at 9:15 A.M., the ADON performed a dressing change to the resident's right gluteal fold pressure ulcer and measured the ulcer. The ADON measured the ulcer as follows: 2.0 cm x 2.3 cm x 2.0 cm, with a tunnel in the wound bed at approximately 9 o'clock measured 0.5 cm deep, the wound had a small amount of tan colored drainage with an odor, the ADON estimated the wound bed tissue as 25% necrotic, 50% gray slough and 25% pink tissue. The ADON said the resident was a lot calmer today and said she had the staff give the resident a PRN [MEDICATION NAME] (as needed antianxiety medication) prior to the treatment. The ADON said the resident was fearful the day before during the treatment, It's hard to tell if (the resident is) in pain or scared. After the treatment the ADON said the resident had, a totally different demeanor today. During an interview on 3/23/17 at 3:10 P.M., Registered Nurse (RN) B said she previously held the position of DON in the facility, but changed positions to an RN supervisor sometime in February 2017. RN B said during the time she worked as the DON, the RN supervisors were responsible for completing the weekly pressure ulcer assessments on the resident's on their assigned hall. The RN said she did not check to see if the RNs were doing the weekly pressure ulcer assessments, but they told her they completed the weekly assessments. RN B said if a resident's wound worsened, she expected the nurse to notify the resident's physician. During an interview on 3/21/17 at 12:20 P.M., the DON said she had been working in the facility as the DON for approximately the past two months. The DON said when she started staff were not doing proper weekly pressure ulcer assessments. The DON said over the past two weeks, she had re-vamped the weekly pressure ulcer measurements and the ADON now performed the weekly measurements of all pressure ulcers and took pictures of the ulcers. The DON said she expected nurses to notify the physician if the ulcer deteriorated, showed signs of pain or infection.