Every finding on record at Pacific Care Center

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 53.1. Review of the facility's policies showed staff did not provide a policy for RN coverage. Review of the facility Payroll Based Journal (PBJ), a method to collect auditable and verifiable staffing data from nursing facilities, report for Fiscal Year 2025, Quarter 4 (July 1 through September 30) showed the facility triggered for no RN hours for Saturdays and Sundays on the following: July 05, 06, 12, 13, 19, 20, 26, and 27th. August 02, 03, 09, 10, 16, 17, 23, 24, 30 and 31st . September 06, 07, and 13th.Review of the facility's RN staff schedule, dated July 2025, showed the facility did not have an RN in the building, for eight consecutive hours on Saturday 07/05, Sunday 7/06, Saturday 07/12, Sunday 07/13, Saturday 07/19, Sunday 07/20, Saturday 07/26 and Sunday 07/27/25. Review of the facility's RN staff schedule, dated August 2025, showed the facility did not have an RN in the building for eight consecutive hours, on Saturday 08/02, Sunday 08/03, Saturday 08/09, Sunday 08/10, Saturday 08/16, Sunday 08/17, Saturday 08/23, Sunday 08/24, Saturday 08/30, and Sunday 08/3/25. Review of the facility's RN staff schedule, dated September 2025, showed the facility did not have an RN in the building for eight consecutive hours on Saturday 09/06, Sunday 09/07, and Saturday 09/13/25. Review of the facility's RN staff schedule, dated October 2025, showed the facility did not have an RN in the building for eight consecutive hours on Saturday 10/04, Sunday 10/05, Saturday 10/11, and Sunday 10/12/25. Review of the facility's RN staff schedule, dated December 2025, showed the facility did not have an RN in the building for eight consecutive hours on Saturday 12/13, Saturday 12/20, Sunday 12/21, Saturday 12/27, and Sunday 12/28/25. Review of the facility's RN staff schedule, dated January 2026, showed the facility did not have an RN in the building for eight consecutive hours on Sunday 01/04, Sunday 01/11, Sunday 01/18/26. Review of the facility's RN staff schedule, dated February 01 thru February 12, 2026, showed the facility did not have an RN in the building for eight consecutive hours on Sunday 02/01, Saturday 02/07/26. During an interview on 02/11/26 at 4:40 P.M., the Human Resource (HR) director said he/she is responsible for schedules and does help with PBJ reporting. The HR said he/she did realize after he/she pulled the schedule information for survey the extent of the days without RN coverage. HR said he/she knew there were some days not covered, they are trying, and it is getting better. The HR said he/she had not thought of the 12hr shift the nurses work being split between two days, which would cause the eight-hour requirement to not be fulfilled. During an interview on 02/12/26 at 1:25 P.M., the Director of Nursing (DON) said HR and the administrator handle staffing. The facility has had some issues with RN coverage. The weekend lacks coverage, but they are actively hiring RN's for the weekend. There are two as needed RN's to utilize. The DON said the importance of having an RN in the building to oversee the nurse duties in the building. During an interview on 02/12/2026 at 1:55 P.M., the Administrator said she is aware of the non-coverage of RN hours. She said there has been some staffing difficulties.

Based on observation, interview, and record review, the facility staff failed to document the stage (classifying a pressure ulcer based on the depth and severity of tissue damage) for one (Resident #52) of three sampled residents with wounds. Staff failed to document the administration of one residents (Resident #23) medication out of three sampled residents. The facility census was 53.1. Review of the facility's Wounds policy, undated, showed all wounds must be measured and documented on weekly (skin tears, surgical, ulcers, blisters, etc ). The policy did not contain guidance on the staging of wounds.2. Review of Resident #52's Annual Minimum Date Set (MDS), a federally mandated assessment, dated 02/06/26, showed staff assessed the resident a cognitively impaired and has one or more unhealed pressure ulcer.Review of the resident's care plan, dated 01/22/26, showed the resident is on enhanced barrier precautions (EBP) related to a nephrostomy tube, a feeding tube, and a wound. The resident is at risk for pressure ulcer due to nutrition, moisture, and bedfast/mobility. Review of the resident's physician order sheet (POS), dated February 2026, showed an order to cleanse open area to coccyx with vasine (wound cleansing solution), skin prep to wound, apply santyl (prescription debriding agent to remove dead tissue), and cover with calcium alginate (wound dressing) every night and as needed. Review of the resident's nursing progress notes, dated 01/20/26, showed the resident re-admitted from acute care setting with a small pea sized area just above coccyx. Review of the resident's wound assessments showed the following: - 01/20/26: Sacral wound measurement of 0.7 centimeters (cm) x 0.3 cm x 0.1 cm. The assessment did not contain a stage of the wound;- 01/27/26: The assessment did not contain measurements for the sacral wound or stage of the wound;- 02/03/26: Sacral wound measurement of 3.5 cm x 2.5 cm x 0.2 cm. The assessment did not contain a stage of the wound;- 02/06/26: Sacral wound measurement of 3.6 cm x 3.0 cm and unstageable. During an interview on 02/12/26 at 9:30 A.M., Licensed Practical Nurse (LPN) A said if a resident is not being seen by the wound care clinic, the nursing staff are responsible to measure wounds, and the Director of Nursing (DON) is responsible for staging wounds. LPN A said he/she was not aware the residents wound was not measured on 01/27/26 and the wound was not staged until 02/06/26. During an interview on 02/12/26 at 9:56 A.M., the DON said if a resident is not seeing the wound care clinic, nursing staff are responsible to measure the wound and he/she is responsible to stage the wound. The DON said he/she missed staging the resident's coccyx wound from 01/20/26 to 02/06/26 and the wound should be in staged during that time.During an interview on 02/12/26 at 1:31 P.M., the Administrator said if a resident is not seeing the wound care clinic, the nursing staff are expected to complete wound assessments and said nursing staff and the DON are responsible for staging wounds. The Administrator said he/she was not aware the resident's coccyx wound was not staged from 01/20/26 to 02/06/26. 3.Review of the facility's policy for Medication Administration, undated, showed it is the facility's responsibility to ensure the residents receive their medications timely and as ordered by the resident's physician orders.4. Review of Resident #23's Comprehensive MDS, dated [DATE], showed staff assessed the resident as cognitively impaired and on isolation/quarantine for active infectious disease. The resident admitted on [DATE]. Review of the resident's care plan, dated 01/19/26, showed the resident is on antibiotic for Clostridioides difficile (c-diff, a bacterium that causes severe diarrhea, fever, nausea, and abdominal pain by inflaming the colon). Review of the resident's POS, dated January 2026, showed an order for Vancomycin (antibiotic medication to treat severe infections) 125 milligrams (mg) capsule four times a day. Review of the resident's medication administration record (MAR) showed staff did not document they administered the residents Vancomycin as directed on 01/09/26-01/11/26, 01/15/26, 01/19/26, 01/20/26, and 01/22/26. Review of the resident's nurse notes showed the staff did not notify the nurse or the doctor the resident's medications were not administered. During an interview on 02/12/26 at 9:31 A.M., certified medication technician (CMT) C said he/she marks on the MAR the medication is not available due to the drug not available. He/She said he/she noticed the resident's medication is in the cart, but the staff will not give the medication to the resident. CMT said he/she does not know why, he/she marked the resident's medication not available because the resident has the medication. He/She said if the medication is not in the medication cart, we report it to the nurse. He/She said usually the nurse can get the medication that day, if he/she reports it. During an interview on 02/12/26 at 9:54 A.M., LPN A, said if the staff document the medication is not administered, he/she would assume the medication is not in the medication cart. The LPN said most antiobiotics are available. LPN said the CMT should communicate with the nurse if a medication is not available. He/She was not aware the resident did not get is antibiotic. The LPN said the nurse would complete the documentation once the CMT informed the nurse a medication was not available. He/She said if we do not know the medication is not available, we cannot call. He/She said all the nurses should know if a resident's medication is not available and or given timely. During an interview on 02/12/26 at 10:08 A.M., the Director of Nursing (DON) said if the medication is not available, they should contact the nurse, and the nurse will call the pharmacy. The DON said he/she was not aware the resident's medications were unavailable/ not given/ missed. He/She said the CMT will have a book they keep with the medications not available and communicate this with the nurse. He/She said if the resident does not get his antibiotic for C diff, then it will not get rid of the resident's C diff. During an interview on 02/12/26 at 1:29 P.M., the Administrator said he/she expects staff to check the e stat kit, then inform the nurse or the doctor regarding the missed meds. He/she said if the antibiotic is not given then it is not going to do what it is supposed to do. He/She said if the resident's medication is not received for several days, he/she expects the CMT to notify the nurse. He/She said the DON would monitor the MARS at least monthly. He/She said in our morning meetings, we should track the antibiotic daily. The Administrator said he/she was not aware they were not completed, nor the resident's medication was not available or given.

Based on observation, interview and record review, facility staff failed to ensure a medication error rate of less than five percent (%). Out of 35 opportunities observed, three errors occurred, resulting in a 8.57% error rate, which affected two residents (Resident #11 and #31) of six sampled residents. The facility census was 53. 1.Review of the facility's Medication Errors and Drug Reactions policy, undated, showed staff are directed to report all medication errors immediately to the physician, Director of Nursing (DON) and administrator. The policy did not contain a definition of a medication error. Review of the facility's Medication Administration Guidelines policy, undated, showed it is important that the residents receive their medication on a timely basis. The policy did not contain a definition of a medication error. Review of the facility's Medication Administration policy, undated, showed the policy did not contain a definition of a medication error. 2. Review of Resident #11's physician order sheet (POS), showed an order dated 02/10/26, for Cephalexin (an antibiotic) 500 milligrams (mg) four times a day at 7:00 A.M. to 8:00 A.M., 12:00 P.M. to 1:00 P.M., 5:00 P.M. to 6:00 P.M., and 10:00 P.M. to 11:00 P.M. Observation on 02/11/26 at 7:23 A.M., showed Certified Medication Technician (CMT) B documented Cephalexin as not administered, waiting for the nurse. During an interview on 02/11/26 at 7:23 A.M., CMT B said the medication was not available in the emergency kit and had to tell the nurse. Observation on 02/11/26 at 2:08 P.M., showed the DON verified one tablet of Cephalexin in the emergency supply kit. During an interview on 02/11/26 at 2:08 P.M., the DON said there was not a medication delivery yet and will not be a delivery until after 5:00 P.M. The emergency kit is automatically refilled after a medication is pulled from the supply. He/She does not know why the CMT did not pull the medication for use but should have. He/She said this is considered a medication error since the medication was not given as ordered. 3. Review of Resident #31's POS, dated February 2026, showed the physician ordered Midodrine (medication used to treat low blood pressure when standing) 5 mg daily early morning before breakfast between 5:00 A.M. and 7:00 A.M. and Pantoprazole (reduces stomach acid) 40 mg three times a day between 5:00 A.M. - 7:00 A.M., 11:00 A.M. to 1:00 P.M., and 3:00 P.M. to 5:00 P.M. Observation on 02/11/26 at 7:41 A.M., showed CMT B administered midodrine 5 mg and pantoprazole 40 mg to the resident. During an interview on 02/11/26 at 10:42 A.M., CMT B said he/she frequently has to administer these medications on his/her shift due to the night shift not having enough staff to get it done on time. During an interview on 02/11/26 at 2:08 P.M., the DON said failing to give medication during the ordered time is a medication error. 4. During an interview on 02/11/26 at 2:08 P.M., the DON said staff are expected to follow the seven rights of medication administration (right resident, medication, route, dose, time, reason and documentation). He/She said failing to follow these rights could result in a medication error. The physician should be notified for all medication errors. The DON said he/she is aware there are some medication issues with the night shift pushing off medications the dayshift and is reworking the times to be administering the medications. The CMT's are responsible to ensure medications are ordered timely and to notify the DON and/or the charge nurse if unavailable so a follow up can occur. Staff are expected to report all medication errors to the DON. He/She was not aware of any medication errors.

Based on observation, interview, and record review, staff failed to ensure medications were stored in a safe and effective manner, when staff failed to ensure medications were properly labeled and contained in their original package until time of administration for three medication carts of five sampled carts. The facility census was 53.1.Review of the facility's policy, Storage of Medications, undated, showed medications must be store in the container in which they were received and no discontinued, outdated, or deteriorate drugs or biologicals may be retained for use. 2. Observation on 02/09/26 at 10:45 A.M., showed the D medication cart on the B hall contained the following: -19 and a half unidentified loose pills;-Nine unidentified loose capsules;-30 ounces (oz) of active liquid protein (nutritional medical-grade protein supplement) opened and undated;-One medication cup with three unidentified pills; -One small pudding cup opened and undated. 3. Observation on 02/09/26 at 11:35 A.M., showed the C medication cart on the B hall contained 15 and a half unidentified loose pills and one unidentified capsule. Observation on 02/09/2026 at 11:35 A.M., showed the A medication cart on the B hall contained 22 and a half unidentified loose pills and two unidentified capsules. During an interview on 02/09/26 at 11:24 A.M., the Director of Nursing (DON) said Certified Medication Technicians (CMT) who are passing medications on that shift are responsible for maintaining their cart. He/She said it is his/her expectation that carts are monitored and cleaned daily as needed. He/she said he/she was not aware there were so many loose pills in the carts. He/She said he/she is not sure why carts were not clean. During an interview on 02/09/2026 at 11:55 A.M., CMT C said there is not a schedule to clean the medication carts. CMT C said he/she started a couple of months ago and never cleaned the carts. CMT C said when we do a shift change, we count the medications, but we have not cleaned the carts. During an interview on 02/12/2026 at 1:29 P.M., the Administrator said it is the responsibility of the CMT's to maintain medication carts and it is his/her expectation that the CMT's are cleaning the carts at least weekly and that they are following the facility's policy on medication storage. He/She said the concern of having too many loose pills is that medication errors may occur.

Based on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections, when staff failed to develop and review the (IPCP), policies and procedures annually. Facility staff failed to post Enhanced Barrier Precautions (EBP) signs for one resident (Resident #26) out of six sampled residents and failed to wear Personal Protective Equipment (PPE) for one resident (Resident #52) out of three sampled residents with wounds. Facility staff failed to use transmission-based precautions (TBP) (extra infection-control measures used alongside standard precautions for patients with suspected or confirmed highly contagious diseases, that requires staff to wear PPE for one resident (Resident #23) of one sampled resident. Staff failed to perform appropriate hand hygiene during a medication pass for five of five sampled residents (Resident #27, #11, #24, #31, and #2). The facility census was 53.1.Review of the facility policies showed staff did not provide a written IPCP policy.Review of the facility's IPCP Procedure Manual showed the policies were not dated and had not been reviewed annually. Review of the facility's Antibiotic Stewardship binder, showed staff did not document infection surveillance or antibiotic tracking January through May 2025, and January through February 11, 2026.During an interview on 2/11/26 at 3:20 P.M., the Director of Nursing (DON) said he/she is the facility Infection Preventionist (IP) and he/she is responsible for maintaining the IPCP. He/She said he/she just started at the end of august and has not had time to get the policies and procedures updated. He/She said he/she knows they should be done annually. He/She is not sure why they were not updated previously before he/she started.During an interview on 2/12/26 at 1:29 P.M., the Administrator said the DON is their IP and is responsible for maintaining the IPCP. He/She said the IPCP policies and procedures should be reviewed annually. He/She said he/she does not have the IPCP policies and procedures updated for last year because they just started the process.2. Review of Resident #26's Quarterly Minimum Data Set Assessment (MDS), a federally mandated assessment tool, dated 01/23/26, showed staff assessed the resident as:-Cognitively intact:-Stage one pressure injury not on admission;-Application of treatment/dressing to foot. Review of the resident's care plan, dated 01/22/26, showed the resident was on EBP for wounds and signage will be on door to notify staff of EBP.Review of the resident's Physician Order Sheet (POS), dated 02/08/26, showed an order for left heel open area, cleanse area, skin prep peri-wound, apply calcium alginate (a natural, highly absorbent wound dressing derived from brown seaweed, designed for managing moderate to heavily draining, chronic, or acute wounds), cover once every night shift and as needed for soiling.Observation on 02/09/26 at 12:30 P.M., showed the resident's door did not contain a EBP sign or PPE outside his/her room. Observation showed the resident sat on the bedside with left foot wrapped with a dressing.Observation on 02/10/26 at 9:04 A.M., showed the resident's door did not contain a EBP sign or PPE outside his/her room.Observation 02/10/26 at 2:08 P.M., showed the resident's door did not contain a EBP sign or PPE outside his/her room. Observation on 02/11/26 at 8:14 A.M., showed the resident's door did not contain a EBP sign or PPE outside his/her room.Observation on 2/12/26 at 8:32 A.M., showed the resident's door did not contain a EBP sign or PPE outside his/her room. During an interview on 2/12/26 at 10:08 A.M., the DON said he/she along with housekeeping are responsible for putting up EBP signs. He/She said changes are discussed in morning meeting, housekeeping is made aware and places signs and then it is his/her responsibility to ensure it is completed. He/She said staff should wear PPE before providing care for the resident. He/She said staff should wear gowns and gloves for EBP. He/She said he/she a sign should be placed on this resident's door because he/she has a wound. He/She said he/she is not sure why the sign was not placed on the resident's door and said it might have been overlooked.During an interview on 2/12/26 at 1:29 P.M., the Administrator said the DON is the IP and responsible for ensuring EBP signs are placed on the doors of residents on EBP. He/She said the resident has a wound and should have a sign placed on his/her door. He/her expectation that signs are placed on the doors of residents who have wounds. He/She said he/she is not sure why the resident did not have a sign on his/her door.3. Review of Resident #52's Annual MDS, dated [DATE], showed the staff assessed the resident as cognitively impaired and has one or more unhealed pressure ulcer. Review of the resident's care plan, dated 01/22/26, showed the resident is on EBP related to a nephrostomy tube, a feeding tube, and a wound. Signage will be on door to notify staff of EBP, and staff will wear appropriate PPE while caring for the resident according to EBP. Review of the resident's POS, dated February 2026, showed an order to cleanse with vasine (wound cleansing solution), skin prep to wound, apply santyl (prescription debriding agent to remove dead tissue), and cover with calcium alginate (wound dressing) every night and as needed for the resident's open area to coccyx (the small bone at the bottom of the spine). Observation on 02/09/26 at 3:14 P.M., showed an EBP sign on the resident's door which instructed staff to put on a gown and gloves prior to providing care or treatments for the resident. Observation on 02/11/26 at 1:52 P.M., showed Licensed Practical Nurse (LPN) A did not wear a gown or gloves when he/she removed the residents wound dressing. During an interview on 02/12/26 at 9:30 A.M., LPA A said he/she should have put on a gown and gloves before touching the resident's wound dressing. LPN A said because he/she was only removing the wound dressing to observe the wound, he/she forgot to put the gown and gloves on and said because he/she touched the wound dressing, he/she should have had a gown and gloves on before doing so.During an interview on 02/12/26 at 1:00 P.M., the DON said he/she expects for staff to follow the EBP guidance and to put on gowns and gloves prior to touching a residents wound dressing.During an interview on 02/12/26 at 1:31 P.M., the Administrator said he/she would expect for staff to follow the EBP guidance before entering a resident's room with a wound and prior to touching the wound dressing. The Administrator said that is important to help prevent infections. 4. Review of the facility's policy for Transmission Based Precautions (TBP), undated, showed:-Contact precautions, staff will implement contact precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment;-Clostridioides difficile (c-diff, a bacterium that causes severe diarrhea, fever, nausea, and abdominal pain by inflaming the colon), and requires contact precautions in place;-Staff will wash their hands after direct or indirect contact with the resident;-Staff will wear gloves (clean, non-sterile) when you enter the room;-Staff will change gloves after an infected contact task (contact with resident);-Staff will remove gloves before you leave the room and perform hand hygiene (handwash with soap and water);-Staff will wear a gown when you perform a task;-Staff will remove the gown and perform hand hygiene before you leave the resident's room;-Staff will clean and disinfect resident care equipment (stethoscope-device use to measure blood pressure reading) after and before use. 5. Review of Resident #23's Comprehensive MDS, dated [DATE], showed staff assessed the resident as cognitively impaired and on isolation/quarantine for active infectious disease. Review of the resident's care plan, dated 01/22/26, showed staff did not document the need for TBP. Review of the resident's nurse's notes showed the following: -On 02/01/06, the resident continues treatment for c-diff, isolation precautions in place for c-diff, isolation precautions in place, staff are to don (put on)/doff (take off) PPE to prevent contamination or injury) with cares;-On 02/07/26, the resident continues treatment for c-diff, PPE is enforced;-On 02/11/26, the resident receives antibiotic treatment for c-diff with isolation precautions in place. The staff documented to don/doff PPE with cares/therapy. 6. Observation on 02/11/26 at 9:50 AM showed the resident's door stood open with TBP sign on the door. CNA H entered the resident's room, touched the bedrail, touched the resident's call light and placed on the resident's bed. The staff left the resident's room, knocked on a separate resident's door. The staff member went to the bottle of sanitizer and applied to his/her hands. The staff entered two more resident's rooms. The staff did not apply PPE before he/she entered the resident's room. CNA H did not wash his/her hands after contact with the resident or upon leaving the resident's room. 7. Observation on 02/11/26 at 10:49 A.M., during morning medication pass, the DON pushed the medication cart to the resident's room. The resident's door stood open with the TBP sign on door. The DON walked in the resident's room. The DON took the resident's blood pressure and gave the resident his/her medications. The DON walked out of the resident's room, placed the blood pressure cuff directly on the medication cart and pushed the medication cart to another resident's room. The DON did not apply PPE prior to entering the resident's room. The DON did not wash his/her hands after he/she provided direct hands-on care to the resident. The DON did not disinfect the medical equipment after he/she used it on the resident. During an interview on 02/12/26 at 1:11 P.M., the DON said during the morning medication pass yesterday, he/she did not apply the gown and gloves. He/She said he/she did not hand wash between the med passes. The DON said he/she did not disinfect the equipment after he/she completed the process with the resident. The DON said we have proper cleaning supplies for C- diff. The DON said he/she could potentially spread C-diff because of the spores. The DON said he/she is responsible to ensure TBP is followed, and he/she monitors TBP practices. 8. During an interview on 02/12/26 at 9:31 A.M., CMT C said regarding c diff, we have precautionary bins, we have the gowns and the masks. CMT said he/she doesn't think we have anyone on C-diff right now. He/She said the resident's been off C-diff precautions for two to three weeks. CMT said he/she did enter the resident's room yesterday without PPE and TBP precautions because she wasn't aware he was still on C-diff precautions. He/She said we had an in-service recently regarding precautions, she said the DON provides the in-services. During an interview on 02/12/26 at 9:54 A.M., LPN A said the DON will place the EBP and TBP signs. LPN said with contact barriers, staff will apply precautions, such as, hand washing, place gown, apply gloves. The LPN said isolation requires the resident's door closed, especially airborne (spores) to prevent the spread. The LPN said he/she expects the staff to apply PPE. The LPN said residents who are on TBP precautions is communicated daily with the staff. He/She said the resident is currently on precautions for C- diff. He/She was part of the infection control tracking until December. LPN said he/she was not aware TBP was not being followed for the resident. During an interview on 02/12/26 at 10:08 A.M., the DON said the resident originally came to the facility with C-diff. He/She said as far as he/she is aware, the resident remains on TBP precautions. The DON said his/her staff should be aware the resident is on precautions. The DON said with contact precautions, you apply gloves and gown. The DON believes the door can stay open. During an interview on 02/12/26 at 10:35 A.M., the DON we would use the contact precaution and take down the EBP. The DON said he/she is responsible to place the EBP and TBP signs outside the resident's rooms. During an interview on 02/12/26 at 1:29 P.M., the Administrator said the DON oversees the infection control program. He/She said the DON is in charge to place the TBP signs, complete the education, verbally, related to infection control with our staff. He/She said staff is expected to wear proper gown, gloves, wash hands ect. He/She said items out of the resident's room, staff should bag the items. Staff is expected to take off their PPE before they come out of the resident's room, so they do not spread the infection to additional rooms. Staff should disinfect equipment used during resident care. He/She is overall responsible to ensure his/her staff follow safe infection control procedures. 9. Review of the facility's Handwashing policy, undated, showed the policy did not contain direction or guidance on when to wash hands.Review of the facility's Hand Cleanser (antiseptic) policy, undated, showed:-Staff are to clean the hands between resident contacts during care and prevent the spread of infection;-Staff are to place a container of antiseptic solution on his/her medication cart or out of resident reach;-Wash his/her hands;-Administer medications or provide care to the resident; -Apply recommended amount of antiseptic cleanser to the palm and rub briskly until the cleaner has evaporated.Review of the Medication Administration policy, undated, showed staff are directed to wash his/her hands before administering medication. 10. Observation on 02/11/26 at 7:15 A.M., showed Certified Medication Technician (CMT) B administered medication to Resident #27, grabbed a soiled gown off the residents' nightstand, took the gown to the soiled linen cart and returned to the medication cart and prepped Resident #11's medication. He/She did not wash his/her hands or use an antiseptic cleanser before administering medication to Resident #27 or #11.Observation on 02/11/26 at 7:23 A.M., showed CMT B administered medication to Resident #11, returned to the medication cart and prepped Resident #24's medication. He/she did not was his/her hands or use an antiseptic cleanser before administering medication to Resident #11 or #24.Observation on 02/11/26 at 7:30 A.M., showed CMT B administered medication to Resident #24, returned to the medication cart and prepped Resident #31's medication. He/She did not wash his/her hands or use an antiseptic cleanser before administering medication to Resident #24 or #31.Observation on 02/11/26 at 7:41 A.M., showed CMT B administered medication to Resident #31 and obtained Resident #2's blood pressure, and return to the medication cart. He/She did not perform hand hygiene before administering Resident #31's medication or before or after taking Resident #2's blood pressure. During an interview on 02/11/26 at 10:42 A.M., CMT B said he/she is supposed to wash or sanitize his/her hands between residents when passing medications to keep from spreading germs. He/She is usually much better at washing or sanitizing but was nervous and forgot. During an interview on 02/11/26 at 2:08 P.M., the DON said he/she expects staff to wash or sanitize between residents during a medication pass. The CMT observed is a part time staff member and should have known to wash or sanitize between residents.

Based on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 53.1.Review of the facility's policy titled, Antibiotic Stewardship Program (ASP), undated, showed it directed staff as follows:-Infection Preventionist (IP): This person will be the hub of the ASP. They will have the knowledge and expertise to effectively develop, implement, and monitor the ASP;-The IP/designee will be responsible to audit the clinical assessment documentation at the time of the antibiotic prescription'-The IP/designee will be responsible for auditing of the completeness of antibiotic prescribing documentation to include dose, route, state date, end date, days of therapy, and indication;-The IP/designee will track C. difficile (a bacterium that causes severe, often painful, watery diarrhea and intestinal inflammation, usually following antibiotic treatment that disrupts healthy gut flora) and antibiotic-resistant infections. The facility will work with the consultant laboratory personnel to develop a quarterly report of any instances of C. difficile or antibiotic-resistant infections, such as methicillin-resistant Staphylococcus aureus ((MRDA) is a type of staph bacteria that causes infections resistant to many common antibiotics) or E. coli (a bacterium commonly found in the intestines of humans and other animals, some strains of which can cause severe food poisoning).Review of the facility's antibiotic stewardship program showed the following: -Staff did not have a process in place to track and trend antibiotic usage;-Did not contain documentation of an infection/antibiotic control logs for January through May of 2025;-Did not contain documentation of an infection/antibiotic control logs for January through February of 2026.Review of the facility's Infection/Antibiotic control log, dated September 2025, showed 24 antibiotics used, four of the antibiotics did not have documentation of signs and symptoms, five did not have documentation of the site of infection, one did not have documentation of onset of symptoms, three did not have documentation if a culture was done, and three did not have documentation if the pathogen identified. Review of the facility's Infection/Antibiotic control log, dated October 2025, showed 24 antibiotics used, 14 of the antibiotics did not have documentation of signs and symptoms, four did not have documentation of the site of infection, six did not have documentation of onset of symptoms, one did not have documentation if a culture was done, and one did not have documentation if the pathogen identified.Review of the facility's Infection/Antibiotic control log, dated November 2025, showed 12 antibiotics used, eight of the antibiotics did not have documentation of signs and symptoms, three did not have documentation of the site of infection, three did not have documentation if a culture was done, and three did not have if the pathogen was identified. Review of the facility's Infection/Antibiotic control log, dated December 2025, showed seven antibiotics used, seven of the antibiotics did not have documentation of signs and symptoms, one did not have documentation of the site of infection, one did not have documentation if a culture was done, two did not have documentation of if the infection was resolved. During an interview on 02/11/26 at 3:20 P.M., the Director of Nursing (DON) said he/she is the infection preventionist and is responsible for maintaining the antibiotic stewardship program. He/She said he/she started in September and is unsure why it was not completed prior to him/her starting. He/She said he/she was having another nurse come in on Wednesdays to fill out the infection/antibiotics logs but he/she has not done that recently. He/She said he/she looks at antibiotics daily during morning meeting, but he/she does not log/document them or do any trending with them. He/She said he/she knows he/she should be trending the antibiotics because it is important to indicate if any issues need further education or if intervention is needed. He/She said he/she knows the infection/antibiotic logs were not filled out for the last two months. He/she said he/she is trying to catch up.During an interview on 02/12/26 at 1:29 P.M., the administrator said the DON is their IP and is responsible for maintaining the antibiotic stewardship program. He/She said they go over antibiotics in their morning meeting and he/she would expect that the infection/antibiotic logs would be updated at that time. He/She was not aware that the logs and trending were not being done. He/She said he/she is not sure of what the risks are to not having the antibiotic stewardship program maintained and infection trending.

Based on interview and record review, facility staff failed to obtain a contract between the facility and dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) clinic, failed to obtain physician orders to receive dialysis, and failed to obtain physician orders to check the Artery Vein (AV) graft for one (Resident #5) out of one sampled resident who received dialysis services at a dialysis clinic. The facility census was 53.1. Review of the facility's policy titled, Dialysis, Care of a Resident Receiving, undated, showed staff were directed to: -Care for the Artery Vein shunt/fistula/graft (a surgical connection between the artery and vein):-Keep the area clean and dry;-Feel for the thrill sensation daily and document in the resident record, if no thrill notify the physician;-Inspect access for redness, swelling, or warmth;-Avoid excessive pressure on the puncture site after dialysis;-Watch for bleeding after dialysis and monitor for signs of infection. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/09/26, showed staff assessed the resident as: -Cognition intact;-Received dialysis;-Diagnosis of End Stage Renal Disease (ESRD) (the final stages of chronic kidney disease). Review of the resident's medical record showed the record did not contain a contract between the facility and dialysis clinic. Review of the resident's care plan, revised 04/15/25, showed dialysis is every Monday, Wednesday, and Friday. Review of the resident's physician order sheet (POS), dated February 2026, did not contain an order for the resident to receive dialysis and did not contain an order to check the residents Artery Vein graft. Review of the resident's Medication Administration Record (MAR), dated February 2026, showed the MAR did not contain direction for staff to check the residents Artery Vein graft. During an interview on 02/12/26 at 11:14 A.M., the resident said the Artery Vein graft is in his/her left arm and the dialysis clinic covers the sight with band aids after the treatment is completed. The resident said facility staff will sometimes check his/her Artery Vein graft but not all the time. During an interview on 02/12/26 at 10:58 A.M., Licensed Practical Nurse (LPN) A said he/she does not know if the facility has a contract with the resident's dialysis clinic. He/She said the resident should have a physician order to receive dialysis and should have an order to check the residents Artery Vein graft and how often. The LPN said he/she does not recall ever seeing physician orders for the resident's dialysis and believes it's been overlooked. LPN A said the nursing staff are responsible to obtain these orders and he/she did not realize the orders were missing. The LPN said he/she is not sure if staff are checking the residents AV graft daily and not sure if it's been documented in the residents' medical record.During an interview on 02/12/26 at 1:00 P.M., the Director of Nursing (DON) said he/she believes the facility has a contract with the resident's dialysis clinic, but the facility does not have a copy of the contract. The DON said the resident should have a physician order for dialysis and thought there were orders in place that included the name of the dialysis clinic, what days the resident goes to dialysis, directions on checking the residents Artery Vein graft, assessing for thrill, how often to check, and when to contact the physician. The DON said he/she does not know if nursing staff are checking the residents Artery Vein sight daily and documenting those checks because there is no order in place directing them to check. The DON said not having physician orders in place for the resident's dialysis was overlooked and he/she was not aware of it until today. During an interview on 02/12/26 at 1:31 P.M., the administrator said the facility has been trying for a few weeks to obtain a contract from the resident's dialysis clinic, but has not received one. The administrator said he/she would expect for the resident to have physician orders related to the dialysis treatment.

Based on observation, interview and record review, facility staff did not maintain a comfortable and homelike environment, when staff failed to ensure a comfortable sound level for residents when they failed to ensure the keypad for hallway C's entrance and exit door was in working order to prevent a continuous beep sound every time staff enter or exit the hall. The facility census was 53.1.Review of the facility's policies showed the facility did not provide a policy for environment.2. During an interview on 02/09/26 at 3:13 P.M., Resident #44 said the beeping noise is the broken back door that leads to the laundry room. He/She said staff start arriving at 4:00-5:00 A.M He/She said he/she is often woken up by the sound of the beeping door. He/She said staff use that door all day long until 2:30-3:00 P.M He/She said he/she does not like the consistent beeping noise because it wakes him/her and makes him/her feel crazy.Observation on 2/10/26 at 9:06 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when maintenance personnel held down the metal bar for 15 seconds, before he/she exited the hall. Resident #8 began to yell out from his/her room, while the door beeped.Observation on 2/10/26 at 9:20 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when the Certified nurse assistant (CNA) held down the metal bar for 15 seconds, before he/she exited the hall. Resident #8 began to yell out from his/her room, while the door beeped.Observation on 2/10/26 at 9:43 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when laundry aide held down the metal bar for 15 seconds, before he/she exited the hall. Resident #8 began to yell out from his/her room, while the door beeped.During an interview on 02/10/26 at 9:57 A.M., Resident #3 said the loud beeping coming from the door down the hall sounds like a fire alarm at times. He/She believes it is broken. He/She said it wakes him/her up in the mornings and sounds periodically all day long and sometimes at night. He/She said he/she is not sure how long it has been going on like this, but said it bothers everyone.Observation on 2/10/26 at 10:10 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when laundry personnel held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/10/26 at 10:27 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when maintenance personnel held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/10/26 at 10:29 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when CNA personnel held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/10/26 at 10:38 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when laundry personnel held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/10/26 at 10:40 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when housekeeping personnel held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/10/26 at 10:42 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when housekeeping personnel held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/10/26 at 1:26 P.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when housekeeping personnel held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/11/26 at 9:46 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when a staff personnel member held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/11/26 at 10:03 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when a staff personnel member held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/11/26 at 10:05 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when a staff personnel member held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/11/26 at 10:12 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when a staff personnel member held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/11/26 at 10:16 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when a staff personnel member held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/11/26 at 10:18 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when a staff personnel member held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/11/26 at 10:24 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when a staff personnel member held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/11/26 at 10:32 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when a staff personnel member held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/11/26 at 10:33 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when a staff personnel member held down the metal bar for 15 seconds, before he/she exited the hall.Observation on 2/11/26 at 10:35 A.M., showed the secure metal door that led to an outside exit, in C hall, beeped loudly when a staff personnel member held down the metal bar for 15 seconds, before he/she exited the hall. During an interview on 02/12/26 at 11:29 A.M., laundry aide G said metal door down C hall leads to the laundry room and the keypad is broken. He/She said maintenance is aware it has been broken for a couple of weeks. He/She said it beeps for the 15 seconds while staff hold the bar down to open it, then until they put the code in on other side. He/She said the laundry aides arrive by 6:00 A.M. to start their day and leave around 2:30 P.M. He/She said that door is used frequently because it is the only way in or out from the laundry room. During an interview on 02/12/26 at 12:58 P.M., the Director of Nursing (DON) said he/she was not made aware of the broken keypad and the beeping situation down C hall until we arrived. He/She said he/she has been told that the keypad is broken, and they are waiting for a part to come in to fix it. He/She said he/she is unsure how long it has been broken for. He/She said maintenance is in charge of fixing it the door and the administrator is in charge of ensuring it is fixed.During an interview on 02/12/2026 at 1:29 P.M., the administrator said he/she was not aware the keypad to the metal door down C hall was broken, until this week. He/She said it is maintenance responsibility to fix the door. He/She said he/she has a call out to the door company to get the door fixed.During an interview on 02/27/2026 at 8:54 A.M., the maintenance director said he/she was aware the door keypad was broken. He/She said he/she was waiting on invoices to be paid in order for the part to be ordered to fix the door. He/She said when there is an issue, staff fill out and submit a work order on paper to him/her. He/She said he/she doesn't do any work until he/she has the work order. He/She said he/she gets a monthly budget for fixing/maintaining the building. He/She as long as the budget is good, he/she does not need administrative approval to fix items.

Based on observation, interviews and record review the facility failed to post the required Department of Health and Senior Services (DHSS) hotline information (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SA) in a form and manner accessible to residents and visitors. The facility census was 53.1.Review of the facility's policies did not contain a policy for the required postings.Observation on 2/12/26 at 8:15 A.M., showed staff posted the Elder Abuse Hotline number and contact information in a manner not accessible for all residents and resident representatives. During an interview on 2/12/26 at 8:44 A.M., Resident #44 said he/she was not aware of the number being posted in the building, but he/she found it. During an interview on 2/12/26 at 8:53 A.M., Resident #1 said he/she was not aware of the hotline number or its posted location in the building. During an interview on 2/12/26 at 9:02 A.M., Certified Nurse Aide (CNA) E said he/she was not aware of the hotline number or its posted location in the building.During an interview on 2/12/26 at 9:02 A.M., CNA F said he/she was not aware of the hotline number or its posted location in the building.During an interview on 2/12/26 at 9:06 A.M., Licensed Practical Nurse (LPN) A said he/she was not aware of the hotline number or its posted location in the building. During an interview on 2/12/26 at 1:05 P.M., the Director of Nurse (DON) said the hotline number is in the hall by the main entry. He/She said if a resident asked him/her for the number to the hotline he/she would support them and write it down for them. He/She said he/she knows the hotline is available but said it maybe too high and the font size might be too small for residents to use it discreetly if needed. During an interview on 2/12/26 at 1:57 P.M., the administrator said the hotline number is in the hall of the front office. He/She said he/she knows the sign is available to all residents, staff and family but he/she is not sure if it visible from its location and thinks it should be lowered and the font made larger.

Based on observation, interview and record review, facility staff failed to help prevent the development and transmission of infections when staff failed to perform hand hygiene in a manner to reduce the spread of infection for for three residents (Resident #14, #24, and #35) out of 14 sampled residents. The facility census was 54. Review of the Centers for Disease control and Prevention CDC Hand Hygiene in Healthcare Settings guidelines, last reviewed 01/10/20, showed the guidance directs healthcare personnel to follow the following recommendations: -Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indication: -Immediately before touching a patient; -Before performing an aseptic task (e.g. placing an indwelling device) or handling medical devices; -Before moving from work on a soiled body site to a clean body site on the same patient; -After touching a patient or the patient's immediate environment; -After contact with blood, body fluids, or contaminated surfaces; -Immediately after glove removal. 1. Review of the facility's policy titled Handwashing, not dated, did not address the use of alcohol based hand sanitizer or direct staff when to wash their hands. Review of the facility's policies showed the facility did not provide a policy for incontinence care. 2. Review of facility's education logs, dated 05/14/24 to 06/09/2024 showed an annual staff education completion log for hand hygiene. 3. Review of Resident # 14's Annual Minimum Date Set (MDS), a federally mandated assessment tool dated 05/22/2024, showed: -Cognitively Intact; -Frequently incontinent of bladder and always incontinent of bowel; -Diagnosis of Parkinson's Disease (a brain disorder that caused unintended or uncontrollable movements). Observation on 07/24/24 at 11:00 A.M., showed Nurse Aide (NA) K and Certified Nurse Aide (CNA) H entered the resident's room and provided bowel incontinence care. NA K removed his/her soiled gloves and applied clean gloves without performing hand hygiene. The NA dressed the resident. Observation showed CNA H removed his/her gloves and left the room without performing hand hygiene. 4. Review of Resident #24's Annual MDS, dated [DATE], showed: -Mild to moderate cognitive impairment; -Required partial/moderate assistance from staff with toileting; -Always incontinent of bowel and bladder; -Diagnoses of stroke (a loss of blood flow to part of the brain, which damages brain tissue) and hemiplegia (paralysis that affects only one side of the body) or hemiparesis (partial paralysis or weakness on one side of the body). Observation on 07/25/24 at 9:00 A.M., showed CNA H and CNA G entered the resident's room to provide incontinence care. CNA H provided perineal care, and with the same soiled gloves on applied barrier cream to the resident's bottom. CNA H removed his/her gloves and applied clean gloves without performing hand hygiene and put a clean brief on the resident. During an interview on 07/25/2024 at 2:00 P.M., CNA H said staff should wash their hands when entering the room and then put gloves on. The CNA said hands should be washed again after care is provided. The CNA said hand sanitizer it not available in the resident rooms and gloves are kept in the bathrooms which makes it hard to do it right. 5. Review of Resident #35's Quarterly MDS, dated [DATE], showed: -Mild cognitive impairment; -Required substantial/maximal assistance for toileting; -Indwelling urinary catheter (plastic tube placed placed directly in the bladder to drain urine); -Occasionally incontinent of bowel. Review of the care plan revised 06/24/24 included staff direction for care of indwelling catheter and frequent bowel incontinence. Observation on 07/25/24 at 1:27 P.M., showed CNA I applied gloves, provided incontinence care, and changed his/her gloves without performing hand hygiene between gloves changes. CNA I then wiped the resident's catheter tubing. CNA I changed his/her gloves again, without performing hand hygiene between glove changes, and put a clean brief on the resident. During an interview on 7/25/2024 at 4:00 P.M., the Director of Nursing (DON)/Infection Preventionist (IP) said he/she expects staff to perform hand hygiene during catheter care and perineal care by removing gloves, washing hands or using hand sanitizer, and putting on clean gloves on. The DON/IP said staff should change gloves and perform hand hygiene prior to moving from a dirty to clean task. The DON/IP said staff have access to pocket sized hand sanitizers. The DON said staff have received education and been audited in regard to hand hygiene. He/She said the outcome of poor hand hygiene could be increased infections. During an interview on 7/26/2024 at 2:21 P.M., the Administrator said he/she does not believe pocket hand sanitizers are available to staff.

Based on interview and record review, facility staff failed to notify the State Long-Term Care Ombudsman in writing of a resident transfer to the hospital, including the reason for transfer for four residents (Resident #9, #13, #21, and #49) out of 14 sampled residents. The facility's census was 54. 1. Review of the facility's policies showed they did not contain a policy for notifying the ombudsman for transfers and discharges. 2. Review of Resident #9's medical record showed the resident transferred to the emergency room (ER) on 07/01/24 and readmitted to the facility on [DATE]. The record did not contain documentation staff notified the ombudsman of the resident's transfer. 3. Review of Resident #13's medical record showed the resident transferred to acute care on 07/23/24. The record did not contain documentaion staff notified the ombudsman of the resident's transfer. 4. Review of Resident #21's medical record showed the resident transferred to acute care on 05/14/24 and readmitted to the facility on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer. 5. Review of Resident #49's medical record showed the resident transferred to the emergency room (ER) on 07/13/24 and readmitted on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer. 6. During an interview on 07/25/24 at 2:22 P.M., the Social Service Director (SSD) said he/she notifies the ombudsman when nursing staff completes the bed hold information. The SSD said he/she does not think the nursing staff is completing the bed holds so he/she not getting notified of resident transfers. He/She said if he/she is not notified of the transfer then he/she does not know he/she needs to notify the ombudsman. The SSD said he/she typically notifies the ombudsman with every transfer/discharge notification he/she receives. During an interview on 07/25/24 at 2:22 P.M., the Administrator said the charge nurses are responsible to complete a bed hold when a resident is transferred and give it to the SSD. The Administrator said the SSD is responsible to notify the Ombudsman of the transfer. The Administrator said a ombudsman notification must be completed with each resident transfer, including aER on ly visit. The Administrator said the Ombudsman notifications are not being completed and he/she is aware of that. During an interview on 07/26/24 at 9:36 A.M., Licensed Practical Nurse (LPN) C said he/she is not sure who notifies the Ombudsman when a resident is transferred. During an interview on 07/26/24 at 1:45 P.M., the ADON said the charge nurse is responsible to complete a bed hold when a resident is transferred. The ADON said the bed hold is sent to the SSD and the SSD is responsible for notifying the Ombudsman. The ADON said he/she did not know the ombudsman notifications were not being completed. During an interview on 07/26/24 at 1:45 P.M., the Nurse Consultant said the charge nurse is responsible to complete a bed hold when a resident is transferred. The Nurse Consultant said once the bed hold is completed it should be given to the SSD to follow up and notify the Ombudsman. The Nurse Consultant said he/she did not know the Ombudsman notifications were not being completed. 48982 50432

Based on interview and record review, facility staff failed to inform the resident and/or resident's representative, in writing, of the facility's bed hold policy at the time of transfer for four residents (Resident #9, #13, #21, and #49) out of 14 sampled residents. The facility's census was 54. 1. Review of the facility's Bed Hold Policy Guidelines, undated, showed the facility will notify all residents, and/or their representative of the bed hold policy guidelines. This notification shall be given: upon admission to the facility, at the time of the transfer to the hospital or leave, and at the time of non-covered therapeutic leave. 2. Review of Resident #9's medical record showed the resident transferred to the emergency room (ER) on 07/01/24 and readmitted to the facility on [DATE]. Review of the medical record did not contain documentation staff notified the resident or resident representative in writing of the bed hold policy prior to transfer/discharge. 3. Review of Resident # 13's medical record showed the resident transferred to acute care on 07/23/24. Review of the medical record did not contain documentation staff notified the resident or resident representative in writing of the bed hold policy prior to transfer/discharge. 4. Review of Resident #21's medical record showed the resident transferred to acute care on 05/14/24 and readmitted to the facility on [DATE]. Review of the medical record did not contain documentation staff notified the resident or resident representative in writing of the bed hold policy prior to transfer/discharge. 5. Review of Resident #49's medical record showed the resident transferred to acute care on 07/13/24 and readmitted to the facility on ,d+[DATE]. Review of the medical record did not contain documentation staff notified the resident or resident representative in writing of the bed hold policy prior to transfer/discharge. 6. During an interview on 07/25/24 at 2:22 P.M., the Social Service Director (SSD) said the charge nurse is responsible to complete a bed hold when a resident is transferred and turn them into him/her. The SSD said he/she has not gotten a bed hold form from the charge nurse is quite a while. During an interview on 07/25/24 at 2:22 P.M., the administrator said the charge nurses are responsible to complete a bed hold when a resident is transferred and give them to the SSD. The administrator said if a resident is sent out emergently the charge nurse is responsible to follow up and ensure the bed hold is completed. The administrator said a bed hold must be completed with each resident transfer, including anER on ly visit. The administrator said the bed holds are not being completed and he/she is aware of that. During an interview on 07/26/24 at 9:36 A.M., Licensed Practical Nurse (LPN) C said the charge nurse is responsible to complete the bed holds when a resident is transferred then he/she thinks they are given to the Assistant Director of Nursing (ADON). LPN C said he/she has worked in the facility six weeks, and he/she has not had to transfer a resident, so he/she has not completed a bed hold. LPN C said the bed hold form is kept at the nurse's station. During an interview on 07/26/24 at 9:36 A.M., LPN E said the charge nurse is responsible to complete the bed hold when a resident is transferred and turn them in to the ADON. LPN E said he/she has worked at the facility three weeks, and he/she has sent one resident to the emergency room (ER) during that time. LPN E said he/she did not complete the bed hold due to it being an emergency situation LPN E said he/she did not attempt to complete the bed hold after the resident had been transferred with the family either. During an interview on 07/26/24 at 1:45 P.M., the ADON said the charge nurse is responsible to complete a bed hold when a resident is transferred. The ADON said the bed hold is sent to the SSD. The ADON said he/she did not know the bed holds were not being completed. The ADON said no one monitored to ensure the bed holds were completed. During an interview on 07/26/24 at 1:45 P.M., the Nurse Consultant said the charge nurse is responsible to complete a bed hold when a resident is transferred. The Nurse Consultant said once the bed hold is completed it should be given to the SSD. The Nurse Consultant said a bed hold should have the date of transfer, resident name, and a signature of the resident or responsible party. He/She said if the form is unable to be signed then it can be verbally signed with two staff members. The Nurse Consultant was not aware the bed holds were not being completed. 48982 50432

Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for seven residents (Resident #16, #21, #25, #32, #33, #49, #50) out of 14 samples residents. The facility census was 54. 1. Review of the facility's policy titled MDS and Care Planning Guidelines dated [DATE] shows it is the policy of this facility is to use the most current Centers for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Manual, any published interim RAI manual errata documents, and applicable federal guidelines as the authoritative guide for completion of MDS, CAAs and resident care planning. 2. Review of Resident # 16's Quarterly MDS, a federally mandated assessment tool, dated [DATE], showed staff assessed resident as: -Significantly cognitively impaired; -Received hospice. Review of the resident's hospice documentation, dated [DATE], that showed the resident discharged from hospice services. Review of the care plan, revised [DATE], showed staff documented the resident received hospice services. Review of Physician Order Sheet (POS), dated ,d+[DATE], did not contain an order for hospice care. 3. Review of Resident # 21's Admission MDS, dated [DATE], showed staff assessed the resident as: -Did not receive anticoagulant (a medication to thin the blood) medication; -Did not assess cognitive status. Review of the resident's care plan, dated [DATE], showed: -Regular diet; -Did not contain direction for Nectar thickened liquids; -Did not contain direction for anticoagulant medication. Review of the resident's Physician Orders Sheet (POS), dated [DATE], showed: -Xarelto (an anti-coagulant medication) 15 milligrams (mg) daily; -Mechanical soft diet; -Nectar thickened liquids. 4. Review of Resident # 25's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Moderate cognitive impairment; -Had functional impairment on one side of both upper and lower extremities; -Required moderate assistance from staff for toileting, hygiene, dressing, and bathing; -Did not receive anticoagulant medications. Review of the resident's care plan, dated [DATE], showed staff docuemented: -At risk for bleeding due to anticoagulant medication; -Full code status (wanting to have Cardiopulmonary Resucitation (CPR) performed); -Do Not Resuscitate (DNR) (not wanting to have CPR performed) code status; -Did not contain direction for toileting, hygiene, dressing, or bathing; -Did not contain direction for the right arm tray on his/her wheelchair. Review of the resident's POS, dated [DATE], showed: -Aspirin (an anti-platelet medication) 81 mg daily; -DNR code status. Observation on [DATE] at 2:32 P.M., showed the resident in his/her wheelchair and had a padded arm tray on the right arm of his/her wheelchair with his/her arm in it. Observation on [DATE] at 11:26 A.M., showed the resident in his/her wheelchair and had a padded arm tray on the right arm of his/her wheelchair with his/her arm in it. Observation on [DATE] at 8:35 A.M., showed the resident in his/her wheelchair and had a padded arm tray on the right arm of his/her wheelchair with his/her arm in it. Observation on [DATE] at 8:35 A.M., showed the resident in his/her wheelchair and had a padded arm tray on the right arm of his/her wheelchair with his/her arm in it. 5. Review of Resident # 32's Quarterly Minimum Date Set (MDS), a federally mandated assessment tool dated [DATE], showed staff assessed resident as: -Significantly cognitively impaired; -Diagnoses of Alzheimer's Disease, stroke, high blood pressure, anxiety and depression; -Received hospice. Review of the resident medical record showed a signed contract and consent for hospice care dated [DATE]. Review of the care plan, revised [DATE], showed it did not contain a plan for hospice care. 6. Review of Resident #33's Admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and did not use bed rails. Review of the resident's care plan, date [DATE], showed it did not contain direction for bed rail use. Review of the resident's POS, dated [DATE], showed it did not contain orders for bed rail use. Observation on [DATE] at 2:15 P.M., showed the resident in bed with both half bed rails up. Observation on [DATE] at 5:15 A.M., showed the resident sat on his/her bed with both half bed rails up. Observation on [DATE] at 10:57 A.M., showed the resident in bed with both half bed rails up. Observation on [DATE] at 8:30 A.M., showed the resident in bed with both half bed rails up. Observation on [DATE] at 8:27 A.M., showed the resident sat on his/her bed with half both bed rails up. 7. Review of Resident # 49's Admission MDS, dated [DATE], showed staff assessed the resident had severe cognitive impairment and did not use bed rails. Review of the resident's care plan, dated [DATE], showed it did not contain direction for the resident's code status or bed rail use. Review of the resident's POS, showed an ordered dated [DATE] for full code status. Observation on [DATE] at 11:04 A.M., showed the resident transferred himself/herself from bed with both bed rails up. Observation on [DATE] at 2:17 P.M. showed the resided laid in bed and both half both bed rails up. Observation on [DATE] at 5:17 A.M. showed the resided laid in bed and both half both bed rails up. Observation on [DATE] at 1:28 P.M. showed the resided sat in bed and both half both bed rails up. Observation on [DATE] at 8:22 A.M. showed the resided sat in bed and both half both bed rails up. Review showed staff failed to update the care plan with the resident's code status and bed rail use. 8. Review of Resident # 50's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Did not assess the resident as a smoker. Review of the resident's smoking assessment, dated ,d+[DATE], showed staff documented the resident smoked. Review of the resident's care plan, revised [DATE], showed it did not contain direction for staff in regard to the resident smoking. During an interview on [DATE] at 8:35 A.M., the resident said he/she smokes. 9. During an interview on [DATE] at 8:33 A.M., Certified Nurse Assistant (CNA) I said the MDS Coordinator is responsible to update the care plans for each resident. CNA I said the purpose of the care plan is to show the type of care and how much assistance a resident needs. CNA I said he/she would expect the care plan to be individualized and contain things such as special equipment, code status, if a resident smokes, the amount of care a resident needs, and bed rails. During an interview on [DATE] at 9:36 A.M., Licensed Practical Nurse (LPN) C said the purpose of the care plan is to drive the residents care and let staff know what to do for each resident. LPN C said care plans should match the POS and be individualized for each resident. LPN C said he/she would expect the care plan to contain things such as special assistive devices, diets, how much care a resident needs, code status, bed rails, special mattresses, and if a resident smokes. During an interview on [DATE] at 9:36 A.M., LPN E said the MDS Coordinator is responsible for updating the care plans. LPN E said care plans should be individualized and match the resident's POS. LPN E said he/she would expect a care plan to show if a resident smokes, code status, bed rails, any special assistive devices, how much care a resident needs, and certain medications such as anticoagulants. During an interview on [DATE] at 11:00 A.M., the Assistant Director of Nursing (ADON) said he/she is the MDS Coordinator/ADON and is responsible for the MDS's and care plans. The ADON said the care plan should be updated quarterly, annually, and as needed with changes or interventions. The ADON said the purpose of the care plan is to direct staff on how to care for a resident and their needs. The ADON said a care plan should be individualized and match the resident's POS. The ADON said the care plan should contain code status, how much care or assistance a resident needs, certain medications such as anticoagulants, any special assistive devices used, if the resident receives hospice, and bed rails. The ADON said the care plans were not updated because he/she compelted staffing, MDS assessments, care plans and helped with other duties. During an interview on [DATE] at 1:45 P.M., the Nurse Consultant said the purpose of the care plan is to direct the staff on what care to provide for a resident. The Nurse Consultant said the MDS Coordinator or nursing management are responsible for updating the care plans. The Nurse Consultant said the care plan should be updated at least quarterly and as needed with changes. The Nurse Consultant said he/she would expect the care plan to contain code status, any special adaptive equipment a resident uses, how much care the resident needs, if they receive hospice care, certain medications such as anticoagulants, and bed rails. The Nurse Consultant said the care plan should match the POS and be individualized for each resident. The Nurse Consultant said the cooperate reimbursement specialist is available for any training needs and questions to the facility staff. The Nurse consultant did not say why the care plans had not been updated. During an interview on [DATE] at 2:21 P.M., the Administrator said the MDS Coordinator, and Director of Nursing (DON) are responsible for updating the care plans. The Administrator said the charge nurses have been trained to update the care plan as needed. The Administrator said care plans are updated quarterly, annually, and as needed with changes. The Administrator said the purpose of the care plan is to make sure the needs of the residents are being met. The administrator said he/she would expect the care plan to be individualized and match the POS. The Administrator said the care plan should have things on it such as diet, special equipment, how much care a resident needs, bed rails, if the resident is a smoker, certain medications, code status, and any behaviors.

Based on observation, interview, and record review, facility staff failed to provide activities of daily living (ADLs) for eight residents (Resident #9 #21, #23, #26, #27, #33, #40 and #210) out of fourteen sampled residents when staff did not provide showers. The facility's census was 54. 1. Review of the facility's policy titled, Daily Care Needs, undated, showed before beginning care, check the resident's care plan. 2. Review of Resident # 9's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/20/24, showed staff assessed the resident as severely cognitively impaired, and dependent on staff for hygiene and bathing. Review of the resident's care plan, dated 06/22/24, showed: -Cognitive loss and memory issues; -Received Hospice care; -Dependent on staff for bed mobility, transfers, dressing, toileting, and hygiene; -Dependent on staff for bathing/showers. Review of the master shower list showed the resident not on the list. 3. Review of Resident # 21's Admission MDS, dated [DATE], showed staff assessed the resident as: -Required maximum assistance from staff for transfers, toileting, and dressing; -Dependent on staff for hygiene, and bathing; -Did not assess cognitive status. Review of the resident's care plan, dated 07/26/24, showed: -Cognitive loss and memory issues; -Recieved Hospice care; -Required assistance from staff for bed mobility, transfers, dressing, toileting, and hygiene; -Dependent on staff for bathing/showers. Review of the master shower list showed the resident listed to receive a shower on Monday and Thursday during the day shift. Review of the resident's shower documentation showed it did not contain documentation staff showered the resident. 4. Review of Resident # 23's Admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and required supervision or touch assistance from staff for dressing, hygiene, toileting and bathing. Review of the resident's care plan, dated 06/17/24, showed staff documented the resident required assistance for transfers, dressing, toileting, hygiene and bathing. Review of the master shower list showed the resident not listed. Review of the resident's shower documentation showed staff documented showers on 04/12/24, 04/30/24, 05/10/24, 06/18/24 and 07/21/24. During an interview on 07/26/24 at 08:11 A.M., the resident said he/she does not get his/her showers two times a week like staff said. Sometimes it is one week or even week and a half between showers. The resident said if he/she does not get his/her showers it makes his/her head itch really bad. 5. Review of Resident #26's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Dependent on staff for toileting and personal hygiene; -Required setup or cleanup assistance from staff with eating, oral hygiene; -Required substantial/maximal assistance from staff with bathing. Review of the resident's care plan, dated 07/22/24, showed the resident requires assistance with bed mobility, transfers, dressing toileting, hygiene and bathing. Review of the master shower list showed the resident listed on the schedule for Tuesday day shift. Review of the resident's shower documentation showed staff documented showers on 05/01/24, 05/15/24, 05/17/24, 06/28/24 and 07/09/24. 6. Review of Resident #27's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required partial/moderate assistance from staff with personal hygiene; -Required setup or cleanup assistance from staff with oral hygiene; -Required substantial/maximal assistance from staff with toileting and bathing. Review of the resident's care plan, dated 05/17/23, showed the resident requires assistance for bed mobility, transfers, dressing, toileting, hygiene, and bathing. Review of the master shower list showed the resident listed on the schedule for Monday and Thursday day shift. Review of the resident's shower documentation showed staff documented showers on 04/11/24, 04/25/24, 04/30/24, 05/10/24, 05/14/24, 05/27/24, 06/03/24 and 07/22/24. During an interview on 07/26/24 08:03 A.M., the resident said if he/she does not get his/her showers when he/she is supposed to it makes him/her feel horrible and rundown. The resident said it makes him/her not feel good about himself/herself. 7. Review of Resident # 33's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required set up assistance from staff with dressing, hygiene, and bathing; -Received hospice care. Review of the resident's care plan, dated 06/17/24, showed: -Cognitive loss and memory issues; -Received hospice care; -Required assistance for bed mobility, transfers, dressing, toileting, hygiene, and bathing. Review of the master shower list showed the resident listed as hospice and not on the facility shower schedule. During an interview on 07/23/24 at 11:37 A.M., the resident said hospice provides all his/her showers. The resident said he/she had asked the facility staff about getting showers and he/she was told they would be offered to him/her. The resident said the facility staff does not offer him/her a shower. The resident said he/she wished the facility staff did offer him/her showers. 8. Review of Resident #40's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Independent with eating, toileting, and hygiene; -Required supervision from staff with dressing, and bathing; -Received hospice care. Review of the resident's care plan, dated 06/17/24, showed: -Received hospice care; -Required assistance from staff for bed mobility, transfers, dressing, toileting, hygiene, and bathing. Review of the master shower list showed the resident listed as hospice and not on the facility shower schedule. Observation on 07/23/24 at 12:15 P. M., showed the resident in the dining room and with a green shirt and black shorts on. Observation on 07/24/24 at 6:28 A.M. and 10:55 A.M., showed the resident wore the same green shirt and black shorts. The resident had long facial hair. During an interview on 07/24/24 at 11: 05 A.M., Licensed Practical Nurse (LPN) B said the resident is showered by hospice. Observation on 07/25/24 at 8:22 A.M., showed the resident sat in the dining room and wore a blue shirt and gray shorts. The resident had long facial hair. Observation on 07/26/24 at 7:15 A.M., showed the resident in the dining room and wore a blue shirt and gray shorts. 9. Review of Resident # 210's medical record showed it did not contain a MDS assessment. Review of the resident's care plan, dated 07/03/24, showed: -Cognitive loss and memory issues; -Required assistance from staff for bed mobility, transfers, dressing, toileting, hygiene, and bathing. Review of the master shower list showed the resident not listed on the schedule. Review of the resident's shower documentation showed it did not contain documentation staff provided a shower to the resident. 10. During an interview on 07/26/24 at 8:33 A.M., Certified Medication Technician (CMT) F said he/she is the shower aide. CMT F said he/she had been responsible for updating the master shower sheet and giving all the showers until recently. CMT F said the Assistant Director of Nursing (ADON) is now responsible for updating it. CMT F said all residents should be on the shower schedule twice a week. CMT F said he/she did not know that some of the residents were not on the master shower schedule. CMT F said if a resident is not on the shower schedule, then staff don't know when to give the resident a shower. During an interview on 07/26/24 at 8:33 A.M. Certified Nurse Assistant (CNA) I said the ADON is responsible to update the master shower schedule, but he/she is not sure how often it is updated. CNA I said prior to the ADON updating it CMT F was responsible for keeping it updated, and documenting and providing all the showers. CNA I said if a resident is not on the shower schedule, then staff don't know when to give them a shower. CNA I said all residents are to be on the shower schedule twice a week. CNA I said the aide assigned to the hall is responsible for the showers on their hall. CNA I said whoever completes the shower is responsible to document the shower on a shower sheet. CNA I said the facility staff does not provide showers for residents who receive hospice care unless hospice staff are not available. CNA I said the facility staff is responsible for the care of a resident. During an interview on 07/26/24 at 9:36 A.M., LPN C said the ADON is responsible to make and update the master shower schedule. LPN C said he/she is not sure how often the shower schedule is updated. LPN C said all facility residents should be on the shower schedule twice a week. LPN C said if a resident is not on the shower schedule staff may not know to give a resident a shower and the resident could potentially go without one. LPN C said all hospice residents should be offered facility showers on opposite days from the hospice shower schedule as hospice is supplemental care. LPN C said the facility staff is responsible to make sure all residents are cared for. LPN C said the aide working on the hall is responsible to provide the showers on the hall assigned that day, then they are expected to document the shower on a paper shower sheet and turn into the charge nurse. During an interview on 07/26/24 at 11:00 A.M., the ADON said CMT F had been responsible for updating the master shower schedule until about a week ago. The ADON said he/she is now responsible for making a master shower schedule and ensuring it is updated. The ADON said he/she realized that not all residents were on the shower schedule this week. The ADON said not all residents were receiving showers due to not being on the list. The ADON said he/she was not sure how CMT F updated the master shower schedule, or if she had at all. The ADON said all residents in the facility should be on the shower schedule twice a week, including hospice residents. The ADON said the hospice residents should be offered facility showers on opposite days of the hospice scheduled shower days. The ADON said facility staff is responsible for the care of the residents and hospice is an added care. The ADON said the aide assigned to the hall is responsible to complete any scheduled showers on their hall. The ADON said when the aide completes the shower, or if a resident refuses, they are responsible to document this on the shower sheet and turn into the charge nurse. The ADON said the DON and ADON are responsible to oversee and ensure all the residents get showers. During an interview on 07/26/24 at 1:45 P.M., the Nurse Consultant said the DON or ADON are responsible to make the master shower schedule and to update it at least weekly. The Nurse Consultant said all residents, including hospice residents, in the facility should be on the shower schedule twice a week. The Nurse Consultant said hospice residents should be on opposite days of the hospice shower as hospice is an extra care to the resident. The Nurse Consultant said the facility is responsible to ensure each resident is taken care of. The Nurse Consultant said he/she did not know all residents were not on the master shower schedule. The Nurse Consultant said if the resident is not on the shower schedule staff would not know to give them a shower. The Nurse Consultant said when the aide gives the resident a shower, or if the resident refuses as shower, the aide is responsible to document on the shower sheet and turn it in to the charge nurse. The Nurse Consultant said nursing management is responsible to oversee and ensure all residents receive showers. During an interview on 07/26/24 at 2:21 P.M., the administrator said nursing management is responsible to make and update the master shower schedule. The administrator said the shower schedule should be updated with each resident admission and discharge. The administrator said all residents should be on the shower schedule twice a week. The administrator said he/she did not know all residents were not on the master shower schedule. The administrator said hospice residents must be offered showers on opposite days of their hospice shower schedule because hospice is a supplemental care, and the facility staff are still responsible for the residents' care. The administrator said staff must document showers on the shower sheets and he/she expects the charge nurse to sign them and turn them into the DON or ADON. The administrator said the DON and ADON are responsible to oversee and ensure all residents get showers. 48982

Based on observation, interview, and record review, facility staff failed to reconcile narcotics at the change of shift when the medication cart changed from one staff member to another. The facility census was 54. 1. Review of the facility's policy titled Narcotic Count, undated, showed one Registered Nurse (RN), Licensed Practical Nurse (LPN), or Certified Medication Technician (CMT) going off duty and one RN, LPN, CMT coming on duty must count and justify accuracy of narcotics supply for each resident at the change of shift. Narcotic records are to be retained for at least one year. After the supply is counted and justified, the nurse/CMT records the date and his/her signature verifying the count is correct. 2. Review of the facility's staffing report showed: -Day shift charge nurse worked 7:00 A.M. to 7:00 P.M.; -Night shift charge nurse worked 7:00 P.M. to 7:00 A.M.; -Day shift CMT worked 6:00 A.M. to 2:00 P.M.; -Evening shift CMT worked 2:00 P.M. to 10:00 P.M.; -Did not contain a night shift CMT from 10:00 P.M. to 6:00 A.M. 3. Review of the facility's unlabeled on-coming an off-going narcotic count sheets, dated 04/01/24 through 04/30/24, showed -On 04/02/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 04/04/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 04/05/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 04/07/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 04/08/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 04/10/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 04/11/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 04/12/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 04/19/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 04/24/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 04/28/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures. Review showed the narcotic count sheets did not contain documentation staff completed narcotic counts at all shift changes. Review of the facility's unlabeled on-coming and off-going narcotic count sheets, dated 05/01/24 through 05/31/24, showed -On 05/05/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 05/20/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 05/28/24 at 6:00 A.M., and 2 P.M., did not contain two licensed staff signatures. Review showed the narcotic count sheets did not contain documentation staff completed narcotic counts at all shift changes. Review of the facility's unlabeled on-coming and off-going narcotic count sheets, dated 06/01/24 through 06/30/24, showed -On 06/04/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 06/06/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 06/12/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 06/26/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures. Review showed the narcotic count sheets did not contain documentation staff completed narcotic counts at all shift changes. Review of the facility's on-coming an off-going narcotic count sheets, dated 07/01/24 through 07/24/24, showed: -Hall A: -On 07/06/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/11/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/14/24 at 2:00 P.M., did not contain two licensed staff signatures; -Hall B: -On 07/06/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 07/08/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 07/09/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 07/11/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/14/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 07/16/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 07/17/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/18/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/19/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/20/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/21/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/22/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/23/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/24/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -Hall C: -On 07/06/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/11/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/14/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 07/24/24 at 2:00 P.M., did not contain two licensed staff signatures; -Hall D: -On 07/06/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 07/11/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/23/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 07/24/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; Review showed the narcotic count sheets did not contain documentation staff completed narcotic counts at all shift changes. 4. Observation on 07/24/24 at 6:05 A.M., showed LPN C worked the day shift as the medication nurse for Hall A, B, C and D. Observation showed LPN C got a medication cart from the medication room and began to administer medications. LPN C did not complete a shift change narcotic count with the night nurse LPN D. During an interview on 07/26/24 at 7:15 A.M., LPN C said narcotics should be counted by two licensed staff members at each shift change or if a new staff member takes over the medication cart. LPN C said both licensed staff who count the narcotics must sign the narcotic count log. LPN C said narcotic counts should not be completed alone. LPN C said he/she did not complete a narcotic count on 07/24/24 with LPN D and he/she should have but got busy. 5. During an interview on 07/26/24 at 7:15 A.M., LPN E said narcotics must be counted by two licensed staff members at each shift change or if a new staff member takes over the medication cart. LPN E said both licensed staff who count the narcotics must sign the narcotic count log. LPN E said narcotic counts should not be completed alone. LPN E said some staff members don't count narcotics at shift change, but they should. The LPN said most of the staff say I trust you and leave without counting. During an interview on 07/26/24 at 8:33 A.M., CMT F said narcotics are to be counted by two licensed staff anytime someone different takes over the cart, and at each shift change. CMT F said staff should not count narcotics alone. CMT F said the person accepting the keys to the medication cart is responsible to ensure the narcotic count is completed. CMT F said both licensed staff who count must sign the narcotic count log. CMT F said he/she has been signing the narcotic log alone and he/she should not have been. During an interview on 07/26/24 at 1:45 P.M., the Assistant Director of Nursing (ADON) said narcotics are to be counted by two licensed staff at each shift change. The ADON said both licensed staff must sign the narcotic log when they count. The ADON said the Director of Nursing (DON) is responsible to oversee and ensure the narcotic counts are being completed. During an interview on 07/26/24 at 1:45 P.M., the Nurse Consultant said narcotics are to be counted by two licensed staff at each shift change. The Nurse Consultant said both licensed staff must sign the narcotic log when they count, and staff should not sign alone. The Nurse Consultant said the DON is responsible to oversee and ensure the narcotic counts are being completed. The Nurse Consultant said he/she was not aware the narcotic counts were not being completed each shift by two staff members. During an interview on 07/26/24 at 2:21 P.M., the Administrator said he/she was not aware the narcotic counts were not being completed. The Administrator said he/she expected two licensed staff members to complete narcotic counts with each shift change and anytime a different staff member accepts the keys to the medication cart. The Administrator said both licensed staff must sign the narcotic count log when they complete the count. The Administrator said staff should not count the narcotics alone or sign the narcotic log alone. The Administrator said the DON and ADON are responsible to oversee and ensure the narcotic counts are being completed.

Based on observation, interview, and record review facility staff failed to conduct regular inspections of bed rails as a part of regular maintenance program for four residents (Resident #21, #25, #33, and #49) of 14 residents' sampled to identify areas of possible entrapment. The facility census was 54. 1. Review of the facility's policy titled Bed Rails, undated, showed staff will conduct regular inspections of all bedframes, mattresses, and bed rails to identify areas of possible entrapment. Review of the United States Food and Drug Administration (FDA) document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review showed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013 identifies seven different potential, zones of entrapment. This guidance characterizes the head, neck, and chest as key body parts that are at risk of entrapment. Review of the FDA document entitled, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts shows the potential risk of bed rails may include: -Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; -More serious injuries from falls when patient climb over rails; -Skin bruising, cuts and scrapes; -Inducing agitated behavior when bed rails are used as a restraint; -Feeling isolated or unnecessarily restricted; -And preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom, or retrieving something from a closet; -When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. 2. Review of Resident #21's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as: -Required maximum assistance from staff for bed mobility, toileting, and dressing; -Dependent on staff for transfers, hygiene, and bathing; -Did not use bed rails; -Did not assess cognition. Review of the resident's care plan, revised [DATE], showed: -Required assistance from staff for bed mobility, transfers, dressing, hygiene, and toileting; -Dependent on staff for bathing; -Bed rails for mobility and positioning; -Did not contain cognition level. Review of the resident's Physician Orders Sheet (POS), showed an order dated [DATE] for quarter bed rails bilaterally for positioning. Review of the resident's medical record showed it did not contain an entrapment assessment or measurements. Observation on [DATE] at 11:00 A.M., showed the resident laid in bed with both half bed rails up. Observation on [DATE] at 11:04 A.M., showed the resident laid in bed with both half bed rails up. Observation on [DATE] at 8:44 A.M., showed the resident laid in bed with both half bed rails up. Observation on [DATE] at 8:24 A.M., showed the resident laid in bed with both half bed rails up. 3. Review of Resident # 25's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required moderate assistance from staff for bed mobility, toileting, hygiene, dressing, and bathing; -Dependent on staff for transfers; -Did not use bed rails. Review of the residents care plan, dated [DATE], showed bed rails for mobility and positioning. Review of the Bed Rail Assessment and entrapment measurements, dated [DATE], showed: -Zone one: -Bed rail assessment entrapment zone one, showed less than 4 ,d+[DATE] inches () is pass and greater than 4 ,d+[DATE] is fail; -Staff documented side one measurement as 5 and marked passed; -Staff documented side two measurement as 7.5 and marked passed; -Zone two: -Bed rail assessment entrapment zone two, showed less than 4 ,d+[DATE] is pass and greater than 4 ,d+[DATE] is fail; -Staff documented side one measurement as 10 and marked passed; -Staff documented side two measurement as 5 and marked passed; -Zone three: -Bed rail assessment entrapment zone three, showed less than 4 ,d+[DATE] is pass and greater than 4 ,d+[DATE] is fail; -Staff documented side one measurement as 8.5 and marked passed; -Staff documented side two measurement as 5 and marked passed; Zone four: -Bed rail assessment entrapment zone four, side one showed less than 2 ,d+[DATE] is pass and greater than 2 ,d+[DATE] is fail; -Staff documented side one measurement as 3 and marked passed; -Bed rail assessment entrapment zone four, side two showed less than 4 ,d+[DATE] is pass, and greater than 4 ,d+[DATE] is fail; -Staff documented side two measurement as 5 and marked passed; -Staff documented zone five as low risk of entrapment; -Staff documented zone six as low risk of entrapment; -Staff documented zone seven as low risk of entrapment. -Did not contain any other measurements for entrapment. Review showed staff documented the resident's bed rails passed and entrapment assessment when the measurements did not pass. Observation on [DATE] at 2:32 P.M., showed the resident sat next to his/her bed with both half bed rails up. Observation on [DATE] at 5:16 A.M., showed the resident laid in bed with both half bed rails up. Observation on [DATE] at 8:35 A.M., showed the resident sat next to his/her bed with both half bed rails up. 4. Review of Resident #33's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Independent for bed mobility, and toileting; -Required supervision from staff for transfers, dressing, hygiene, and bathing; -Did not use bed rails. Review of the resident's care plan, dated [DATE], showed: -Required assistance for bed mobility, transfers, dressing, hygiene, toileting, and bathing; -Did not contain direction for bed rails. Review of the resident's medical record showed the record did not contain any measurements for entrapment. Observation on [DATE] at 2:15 P.M., showed the resident laid in bed with both half bed rails up. Observation on [DATE] at 5:15 A.M., showed the resident sat on his/her bed with both half bed rails up. Observation on [DATE] at 8:30 A.M., showed the resident laid in bed with both half bed rails up. Observation on [DATE] at 8:27 A.M., showed the resident sat on his/her bed with both half bed rails up. 5. Review of Resident #49's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required supervision from staff for transfers; -Required moderate assistance from staff for toileting, and hygiene; -Required maximum assistance from staff for dressing; -Dependent on staff for bathing; -Did not use bed rails. Review of the resident's care plan, dated [DATE], showed: -Required assistance for bed mobility, transfers, dressing, hygiene, toileting, and bathing; -Did not contain direction for bed rails. Review of the resident's medical record showed the record did not contain an entrapment assessment with measurements. Observation on [DATE] at 11:04 A.M., showed the resident transferred himself/herself from his/her bed and both half bed rails up. Observation on [DATE] at 5:17 A.M. showed the resided laid in bed and both half bed rails up. Observation on [DATE] at 1:28 P.M. showed the resided sat in bed and both half bed rails up. Observation on [DATE] at 8:22 A.M. showed the resided sat in bed and both half bed rails up. 6. During an interview on [DATE] at 9:36 A.M., Licensed Practical Nurse (LPN) C said the charge nurse notifies the maintenance person who is responsible to install the bed rails on the bed. LPN C said he/she was not sure who was responsible to complete the entrapment measurements. LPN C said he/she does not do entrapment measurements and was not aware it was on the bed rail assessment form used by the facility. LPN C said bed rail assessments, consents, and entrapment measurements should be completed quarterly and anytime something is changed on the bed. LPN C said if a bed rail is placed improperly a resident could potentially be cause harm and get stuck in one. During an interview on [DATE] at 10:46 A.M., the maintenance person said he/she thinks the charge nurse is responsible to complete the bed rail assessment and he/she is responsible to install the bed rails on the bed. The maintenance person said he/she does not complete entrapment measurements for each zone and is not sure what that is. The maintenance person said he/she is not sure who is responsible to complete the entrapment measurement. During an interview on [DATE] at 1:45 P.M., the Nurse Consultant said the bed rail assessment and entrapment measurements should be completed upon admission and quarterly after. The Nurse Consultant said housekeeping is responsible to complete the entrapment assessments. The Nurse Consultant said if the bed rails are placed improperly the resident could potentially end up stuck in the bed rail and be harmed. During an interview on [DATE] at 2:21 P.M., the administrator said maintenance is responsible to install the bed rails on the bed and to measure entrapment zones. The Administrator said he/she is not sure how often the entrapment measurements should be completed after installation. The Administrator said residents could have potential harmful outcomes if the bed rails are not placed and measured properly. During an interview on [DATE] at 10:00 A.M., the bed product support company said staff should follow the FDA recommendations and Centers for Medicare and Medicaid Services (CMS) guidelines regarding bed rail assessments, consent, and entrapment measurements. 50432

Based on interview and record review, facility staff failed to ensure four nurse aides ((NA) NA R, NA K, NA Q, and NA S) out of six sampled NA's, completed the nurse aid training program within four months of their employment in the facility. The facility census was 54. 1. Review of the facility's policy's showed the facility did not provide a policy for the completion of the nurse aide training program. Review of the Facility Assessment Tool, dated July 2024, showed staff documented all NA's must be certified within 120 days. 2. Review of NA R's personnel file showed a hire date of 10/10/23. The file did not contain documentation NA R completed the nurse aide training program. Review of NA K's personnel file showed a hire date of 10/24/23. The file did not contain documentation NA R completed the nurse aide training program. Review of NA Q's personnel file showed a hire date of 12/12/23. The file did not contain documentation NA R completed the nurse aide training program. Review of NA S's personnel file showed a hire date of 01/02/04. The file did not contain documentation NA R completed the nurse aide training program. 3. Observation on 07/24/24 at 11:10 A.M., showed NA K performed incontinence care on Resident #14. Observation showed NA K removed fecal soiled gloves, put on clean gloves, and assisted the resident to put on clothing. Observation showed NA K did not perform hand hygiene between glove changes. 4. During an interview on 07/24/24 at 3:17 P.M., the Business Office Manager (BOM) said he/she is not sure who is responsible for monitoring the NA's to ensure they complete the Certified Nurse Aide (CNA) training within 120 days of their hire date. The BOM said he/she was not aware there were four NA's who had not completed training in the required time frame. During an interview on 07/24/24 at 3:17 P.M., the administrator said he/she is not sure who is responsible for monitoring the NA's to ensure they complete the CNA training within 120 days of their hire date. The administrator said the CNA classes are completed online. The administrator said he/she was aware the facility had four NA's past their 120 days to complete the CNA training. The administrator said the NA's had missed classes, the tests, and not tested . The Administrator said he/she told the NA's to go to class. During an interview on 07/24/24 at 3:51 P.M., the Director of Nursing (DON) said he/she was not aware there were four NA's out of compliance with CNA class completion. The DON said the Assisted Living Facility (ALF) Coordinator was responsible for monitoring the NA's to ensure they completed CNA class within 120 days of their date of hire. During an interview on 07/25/24 at 10:00 A.M., the ALF Coordinator said he/she is responsible for completing new hire orientation, CNA class enrollment, and monitoring the CNA class completion. The ALF Coordinator said he/she is responsible for tracking the NA's to ensure they complete the CNA class within 120 days from their hire date. The ALF Coordinator said he/she was aware the facility had four NA's past their 120 days to complete the CNA training. The ALF Coordinator said the CNA classes are completed online. The ALF Coordinator said if a NA misses a class the course instructor will send him/her an email to let him/her know. The ALF Coordinator said he/she emails the Administrator, DON, Assistant Director of Nursing (ADON), and the BOM to let them know of the missed class. The ALF Coordinator said the NA's had missed classes or not taken their exam. During an interview on 07/26/24 at 1:45 P.M., the ADON said the ALF Coordinator is responsible for monitoring the NA's to ensure they complete CNA classes within 120 days of their hire date. The ADON said he/she was not aware there were four NA's out of compliance and over their 120-day mark. The ADON said if a NA misses a class the course instructor will send an email to the ALF Coordinator to notify the facility of the missed class. He/She said the ALF Coordinator then sends an email to him/her, the Administrator, and the DON to notify them of the missed class. The ADON said if a NA misses a class, it is the NA's responsibility to schedule a makeup class with the course instructor. The ADON did not know why the four NA's were still being allowed to work the floor at this time. During an interview on 07/26/24 at 1:45 P.M., the Nurse Consultant said the ALF Coordinator is responsible for monitoring the NA's to ensure they complete the CNA classes within 120 days of their hire date. The Nurse Consultant said he/she was not aware there were four NA's out of compliance and over their 120-day mark as he/she is not at the facility each day. During an interview on 07/26/24 at 2:21 P.M., the administrator said the ALF Coordinator is responsible to oversee the CNA classes. The administrator said he/she is not sure what happens if a NA misses a class, but he/she assumed they make the class up. The administrator said if a NA misses a class the course instructor sends the ALF Coordinator an email to notify the facility of the missed class. He/She said the ALF Coordinator then sends an email to him/her and the DON to notify them of the missed class. The administrator said he/she has no excuse or explanation for why four of the NA's are out of compliance and continue to work as NA's on the floor.

Based on observation, interview, and record review facility staff failed to complete bed rail assessments and obtain consent for the use of bed rails for three (Resident #21, #33, and #49) of 14 sampled residents. The facility census was 54. 1. Review of the facility's policy titled Bed Rails, undated showed staff were directed to: -Complete bed rail observation; -Obtain consent for the bed rails; -Provide education to the resident/legal representative on the benefits and risk of bed rail use; -Develop a care plan for bed rail use; -Staff will conduct regular inspections of all bedframes, mattresses, and bed rails to identify areas of possible entrapment. Review of the United States Food and Drug Administration (FDA) document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review showed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013, identifies seven different potential, zones of entrapment. This guidance characterizes the head, neck, and chest as key body parts that are at risk of entrapment. Review of the FDA document entitled, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts shows the potential risk of bed rails may include: -Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; -More serious injuries from falls when patient climb over rails; -Skin bruising, cuts and scrapes; -Inducing agitated behavior when bed rails are used as a restraint; -Feeling isolated or unnecessarily restricted; -And preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom, or retrieving something from a closet; -When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. 2. Review of Resident #21's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as: -Required maximum assistance from staff for bed mobility, toileting, and dressing; -Dependent on staff for transfers, hygiene, and bathing; -Did not use bed rails; -Did not assess cognition. Review of the resident's care plan, revised [DATE], showed: -Required assistance for bed mobility, transfers, dressing, hygiene, and toileting; -Dependent on staff for bathing; -Bed rails for mobility and positioning; -Did not contain cognition level. Review of the resident's Physician Orders Sheet (POS), showed an order, dated [DATE], for quarter bed rails bilaterally for mobility and positioning. Review of the resident's medical record showed a bed rail assessment and consent, dated [DATE]. Review showed it did not contain any further bed rail assessments or signed consents. Observation on [DATE] at 11:00 A.M., showed the resident laid in bed with both half bed rails up. Observation on [DATE] at 5:18 A.M., showed the resident laid in bed with both half bed rails up. Observation on [DATE] at 8:44 A.M., showed the resident laid in bed with both half bed rails up. Observation on [DATE] at 8:24 A.M., showed the resident laid in bed with both half bed rails up. 3. Review of Resident #33's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Independent for bed mobility, and toileting; -Required supervision for transfers, dressing, hygiene, and bathing; -Did not use bed rails. Review of the resident's care plan, dated [DATE], showed: -Required assistance for bed mobility, transfers, dressing, hygiene, toileting, and bathing; -Did not contain direction for bed rails. Review of the resident's medical record showed it did not contain a bed rail assessment, or a signed consent for the use of bed rails. Observation on [DATE] at 2:15 P.M., showed the resident laid in bed with both half bed rails up. Observation on [DATE] at 5:15 A.M., showed the resident sat on his/her bed with both half bed rails up. Observation on [DATE] at 8:30 A.M., showed the resident laid in bed with both half bed rails up. Observation on [DATE] at 8:27 A.M., showed the resident sat on his/her bed with both half bed rails up. 4. Review of Resident #49's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required supervision for transfers; -Required moderate assistance for toileting, and hygiene; -Required maximum assistance for dressing; -Dependent on staff for bathing; -Did not use bed rails. Review of the resident's care plan, dated [DATE], showed: -Required assistance for bed mobility, transfers, dressing, hygiene, toileting, and bathing; -Did not contain direction for bed rails. Review of the resident's medical record showed the record did not contain a bed rail assessment, or a signed consent for the use of bed rails. Observation on [DATE] at 11:04 A.M., showed the resident transferred himself/herself from his/her bed with both half bed rails up. Observation on [DATE] at 5:17 A.M. showed the resided laid in bed and both half bed rails up. Observation on [DATE] at 1:28 P.M. showed the resided sat in bed and both half bed rails up. Observation on [DATE] at 8:22 A.M. showed the resided sat in bed and both half bed rails up. 5. During an interview on [DATE] at 9:36 A.M., Licensed Practical Nurse (LPN) C said the charge nurse is responsible for completing the bed rail assessments on every resident when admitted and obtain consent from the resident or responsible party if bed rails are needed. LPN C said it also the charge nurse's responsibility to educate the resident and responsible party about the bed rail risks, and potential for harm. LPN C said the charge nurse then notifies the maintenance person who is responsible for installing the bed rails on the bed. LPN C said bed rail assessments should be completed quarterly and as needed. LPN C said if a bed rail is placed improperly a resident could potentially be harmed and get stuck in one. During an interview on [DATE] at 10:46 A.M., the maintenance person said he/she thinks the charge nurse is responsible to complete the bed rail assessment and he/she is responsible to install the bed rails on the bed. The maintenance person said he/she does not complete entrapment measurements for each zone and is not sure what that is. The maintenance person said he/she is not sure who is responsible to complete the entrapment measurements. During an interview on [DATE] at 1:45 P.M., the Nurse Consultant said the Director of Nursing (DON) is responsible to complete the bed rail assessments and obtain signed consents from a resident or responsible party if bed rails are used. The Nurse Consultant said the bed rail assessment should be completed upon admission and quarterly after. The Nurse Consultant said the bed rail consent should be signed upon admission and then annually. The Nurse Consultant said if the bed rails are placed improperly the resident could potentially end up stuck in the bed rail and be harmed. During an interview on [DATE] at 2:21 P.M., the Administrator said the DON or Assistant Director of Nursing (ADON) is responsible to complete the bed rail assessments and obtain signed consent. The Administrator said the bed rail assessment and signed consent must be completed when bed rails are placed on a resident's bed, but he/she was not sure how often it should be updated. The Administrator said maintenance is responsible to install the bed rails on the bed and to measure entrapment zones at that time. The Administrator said he/she was not sure how often the entrapment measurements should be completed after installation. The Administrator said residents could have potential harmful outcomes if the bed rails are not placed and measured properly. During an interview on [DATE] at 10:00 A.M., the bed product support company said staff should follow the FDA recommendations and Centers for Medicare and Medicaid Services (CMS) guidelines regarding bed rail assessments, consent, and entrapment measurements.

Based on observation, interview and record review, the facility staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure outdoor waste containers remained covered when not in actual use. The facility census was 54. 1. Review of 2022 United States Food and Drug Administration Food Code, subsection 5-501.113 (Covering Receptacles), showed receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered with tight-fitting lids or doors if kept outside the food establishment. Observation on 07/23/24 at 12:45 P.M., showed the outside dumpster, which contained waste, uncovered and it did not contain lids or doors to cover the waste. Observation also showed paper and food waste scattered on the ground around the dumpster and a plastic bag of waste on the ground near the right facing side of the dumpster. Observation on 07/24/24 at 8:17 A.M., showed the outside dumpster, which contained waste, uncovered and it did not contain lids or doors to cover the waste. Observation also showed paper and food waste scattered on the ground around the dumpster and a plastic bag of waste on the ground near the right facing side of the dumpster. Observation showed two cats rummaged through the plastic bag of waste. During an interview on 07/24/24 at 8:56 A.M., the administrator said the facility did not have a written policy for waste disposal or the maintenance of waste disposal areas, but the dietary staff have been trained to pick up trash if they see any on the ground around the dumpster when they take out trash. The administrator said the dumpster should be kept covered and he/she did know the dumpster did not have a lid. During an interview on 07/24/24 at 9:09 A.M., the Dietary Manager said waste container should be kept covered and he/she did not know that the dumpster did not have a lid. 48982

Based on record review and interview, facility staff failed to prevent the misappropriation of funds for one resident (Resident #1) out of four sampled residents, when Housekeeper A stole the Resident #1's wallet and used his/her debit card without the resident's consent consent. The facility census was 54. 1. Review of the facility's Abuse, Neglect, Exploitation or Mistreatment Policy and Procedure, undated, showed it is the right of residents to be free from abuse, neglect, exploitation or mistreatment, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility is committed to protecting residents from mistreatment, neglect, abuse and exploitation by anyone including but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. Misappropriation is defined as the deliberate misplacement, exploitation or wrongful, temporary or permanent, use of a resident ' s belongings or money without the resident ' s consent. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/25/24, showed staff assessed the resident as cognitively intact and without inattention, disorganized thinking, or altered level of consciousness. Review of the facility's investigation, dated 5/6/24, showed the resident reported his/her wallet which contained his/her debit card missing. Review showed the facility contacted the Department of Health and Senior Services and the local police department to report the incident. Review showed staff reviewed the resident's bank records and confirmed the debit card recently used. Review showed staff documented the local police obtained a photo of Housekeeper A at a location at a gas station with the resident's debit card and he/she had used it as the payment method. Review of the local police department's investigation report, dated 5/22/24, showed on 5/6/24 the investigator reviewed a printout of the resident's unauthorized bank account transactions from three different local businesses. Review showed the investigator contacted one of the local businesses who confirmed the resident's debit card was used for multiple transactions and identified the user as Housekeeper A. Review showed the investigator returned to the facility and confirmed Housekeeper A was an employee from the facility who had access to the resident's room. Review showed the investigator interviewed Housekeeper A and he/she admitted he/she took the residents wallet without permission. Review showed the Housekeeper informed the investigator he/she used the resident's debit card without permission. Review of the resident's bank account transactions, from 5/3/24 through 5/6/24, showed seven unauthorized transactions which totaled $308.96. During an interview on 5/6/24 at 12:45 P.M., Resident #1 said this morning he/she noticed his/her wallet missing from his/her purse which was stored in the second drawer of his//her bedside table. The resident said he/she did not recognize any of the recent charges reported to him/her by the bank from a debit card that was in his/her wallet. The resident said he/she gave no one permission to use his/her debit card. During an interview on 5/6/24 at 12:40 P.M., the administrator said the resident reported his/her wallet missing and the social worker and the resident contacted the bank and found out someone had used the resident's debit card recently at a gas station. During an interview on 5/14/24 at 9:22 A.M., the administrator said police found Housekeeper A had used Resident #1's debit card on a gas station's surveillance camera and used the debit card to purchase lottery tickets. MO00235742

Based on interview and record review the facility staff failed to record daily urine output per the facility's policy for four (Residents #1, #2, #3, #4) residents with urinary catheters (tube inserted into the bladder to drain urine) and one (Resident #5) with a [MEDICATION NAME] (a surgical procedure that creates a stoma (artificial opening) for the urinary system) of five residents sampled for review. The facility staff also failed to notify the nurse of Resident #1 having little to no urine output over a 24 hour period. Resident #1 was transferred to the hospital when the facility nurse found him/her in bed lethargic, unable to answer questions appropriately and no urine output in his/her urinary catheter bag. The facility census was 90. 1. Review of the facility's urine output, measuring and recording policy (no date) showed it directed staff to accurately determine the amount of urine that a resident excreted in a 24-hour period. Further review showed the policy directed staff to record the amount in the facility's Matrix system(computer) and on the intake/output record. 2. Review of the facility's Guidelines for Reporting for nurse assistants (no date) showed it directed nurse assistants to immediately report to the charge nurse the following: - If a resident's urine output was less than 120 cubic centimeters (cc) in 4 hours or 240 cc in 8 hours or if the resident had not voided on their shift. 3. Review of Resident #1's plan of care dated 10/02/15 showed the care plan directed staff to monitor his/her urinary catheter for output and Foley urinary catheter care every shift. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/09/15 showed staff assessed the resident as follows: - Alert and oriented; - Required extensive assistance from staff for his/her Activities of Daily Living (ADLs); - Indwelling urinary catheter. Review of the resident's urinary output record for October showed staff recorded seven urinary output amounts out of a possible 93 entries. Review of the aides assignment sheets dated 10/25/15-10/27/15 showed the aides did not document the resident's urinary output. Review of the resident's nurses notes dated 10/28/15 at 9:19 A.M., showed staff recorded the resident was sent to the hospital due to no urine output over last 24 hours. Staff recorded the resident was very lethargic, unable to answer questions appropriately and ashy gray skin color. Staff recorded when the Foley catheter tubing was repositioned, a large amount of frank red bloody urine was discharged from around the catheter site. Staff recorded the resident's abdomen was slightly distended and firm. Staff recorded the resident was unable to answer if he/she was in any pain. Staff recorded the resident's temperature was 100.2 degrees Fahrenheit (normal is 98.6). During an interview on 10/29/15 at 10:00 A.M., hospital Registered Nurse (RN) A said there was so much blood in the resident's urine you couldn't even tell it was urine. RN A said when he/she changed the Foley urinary catheter, a large blood clot came out which probably caused the blockage of urine. He/she said the urine just came gushing out. He/she said the residents abdomen was swollen from all the urine. RN A said after he/she changed the Foley, there were several smaller blood clots in the urine. During an interview on 10/29/15 at 1:10 P.M., the Interim Director of Nursing (DON) said RN B reported to her on that Wednesday, 10/28/15, the resident had had no good measurable urinary output for 24 hours. She said she instructed RN B to try flushing the catheter to see if it was just clogged. The DON said she also instructed RN B to reposition the catheter tubing. She said when RN B repositioned the catheter tubing, urine came out around the catheter site and not into the catheter tubing. She said the resident did not look good and they called 9-1-1. During an interview on 10/29/15 at 1:20 P.M., RN B said he/she was the day shift charge nurse on Tuesday, 10/27/15 and Wednesday, 10/28/15. RN B said during report on 10/28/15, the day shift aides reported to him/her that on 10/27/15, the resident only had urine in his/her catheter tubing with none in the catheter bag and they forgot to tell him/her. RN B said he/she assessed the resident on 10/27/15 and he/she did see urine in the catheter tubing which was clear yellow but a little dark. He/she said the resident's abdomen was soft. RN B said the resident was his/her usual self with no changes to his/her mental status. RN B said that on 10/28/15, the aides went into the resident's room and informed him/her the resident's catheter bag and tubing looked the same as it had the day before with little urine in the tubing and none in the catheter bag. RN B said he/she went into the resident's room and the resident was lethargic, grayish and not able to answer questions appropriately which was a change in his/her normal mental status. He/she said there was no urine in the resident's catheter bag. RN B said he/she told the DON about the situation. The DON instructed him/her to flush the urinary catheter and maybe try to reposition the catheter tubing. He/she said when he/she repositioned the catheter tubing, dark bloody urine came out around the catheter site and not into the tubing. RN B said they immediately notified 9-1-1. He/she said Certified Nurse Assistant (CNA) C told him/her that on Monday, 10/26/15, he/she had emptied the resident's catheter bag but did not have time to record the output. RN B said when he/she assessed the resident on 10/27/15 and only saw urine in the catheter tubing, he/she was not concerned because the catheter bag was emptied every morning. RN B said if the resident had a urinary catheter, it was the facility's policy to document the urine output each shift. He/she said the aides are to record the urinary output amounts in the computer system and on the aides assign sheets which are then given back to the charge nurse to review. During an interview on 10/29/15 at 1:40 P.M., CNA D said that on 10/27/15 around 2:00 P.M. he/she saw yellow urine with no blood in the resident's catheter tubing but none in the catheter bag. CNA D said he/she asked CNA C if he/she had emptied the resident's catheter bag and he/she said, no. CNA D said he/she meant to go back to see if there was any urine in the catheter bag, but did not. CNA D said he/she should have told RN B, but did not. He/she said the resident was his/her normal self on 10/27/15. CNA D said the aides record urinary output amounts in the computer, on their assignment sheets and then return the sheets back to the charge nurse at the end of the shift. During an interview on 10/29/15 at 1:45 P.M., CNA C said he/she did not recall if the resident's urinary catheter bag was emptied on 10/27/15. He/she said CNA D asked him/her if he/she had emptied it and he/she said, no. CNA C said he/she saw yellow urine in the catheter tubing but none in the bag. CNA C said he/she should have told the nurse, but forgot until they received report from the nurse on 10/28/15. CNA C said that on 10/28/15, he/she and CNA D went into the resident's room and the catheter bag looked the same with urine just in the tubing and none in the catheter bag. During an interview on 10/29/15 at 1:55 P.M., LPN E said he/she was the evening charge nurse on 10/27/15. LPN E said if the resident did not have any urine output, the aides did not notify him/her of it. LPN E said he/she assessed the resident on 10/27/15 and found no irregularities. He/she said the resident did not complain about anything other than having diarrhea. LPN E said the resident's abdomen was soft and not distended. He/she said there was amber colored urine in the resident's catheter tubing but none in his/her catheter bag. LPN E said he/she was not concerned, at the time, because the catheter bag would have been emptied on the previous shift. LPN E said the aides are to record the urine output in the computer and on their assignment sheets which are then returned to the nurse at the end of the shift. During an interview on 10/29/15 at 3:05 P.M., CNA F said he/she worked the evening shift on 10/27/15. CNA F said there was maybe 200 cubic centimeters (cc) of dark yellow urine in the resident's catheter bag, but he/she forgot to record it in the computer. CNA F said he/she did not typically work that hall so he/she did not know if that was a normal amount for the resident. He/she said the resident did not complain of anything. CNA F said he/she did not notify the nurse of the amount of urine in the resident's catheter bag. During an interview on 10/29/15 at 7:30 P.M., CNA G said he/she worked the evening shift on 10/27/15. CNA G said at the beginning of the shift, the catheter bag was empty, but he/she did not check on it again after that. CNA G said he/she thought he/she was giving the residents their showers and did not work the hall again. CNA G said the urine output of residents with urinary catheters was to be recorded on the aides assignment sheets and in the computer. During an interview on 10/29/15 at 7:50 P.M., LPN H said he/she was the night nurse on 10/27/15. LPN H said no one reported to him/her if the resident had no urine output that night. LPN H said he/she was in and out of the resident's room multiple times to give him/her medication. LPN H said the resident appeared to be himself/herself. During an interview on 10/29/15 at 8:45 P.M., CNA I said he/she worked the evening-night shift on 10/27/15. CNA I said he/she assisted the wound nurse at 10:00 P.M. CNA I said he/she saw approximately 50 cc of urine in the catheter bag with some in the catheter tubing. CNA I said he/she asked CNA G if he/she had emptied the resident's catheter bag and he/she said, no. CNA I said he/she did not notify the nurse. CNA I said the next morning there was maybe 100 cc in the bag, but he/she did not empty it or inform the nurse. CNA I said the resident appeared okay and just his/her usual self. CNA I said the urine was a golden color with no blood. During an interview on 10/29/15 at 9:10 P.M., CNA J said he/she worked the nightshift on 10/26/15. CNA J said on the morning of 10/27/15 he/she emptied the resident's catheter bag of 1100 cc. CNA J said he/she was newly hired and could not get into the computer system to record the urine output, but he/she told his/her hall partner so he/she could enter it. 4. Review of Resident #2's plan of care dated 07/12/15 showed the care plan directed staff to monitor and record his/her urine output at the end of each shift. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/09/15 showed staff assessed the resident as follows: - Confused; - Required extensive to total assistance from staff for his/her ADLs; - Required an indwelling urinary catheter. Review of the resident's urinary output record for October showed staff recorded eight urinary output amounts out of a possible 93 entries. 5. Review of Resident #3's plan of care dated 09/24/15 showed the care plan directed staff to monitor and record his/her urine output. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/08/15 showed staff assessed the resident as follows: - Oriented; - Required extensive to total assistance from staff for his/her ADLs'; - Required an indwelling urinary catheter. Review of the resident's urinary output record for October showed staff recorded 32 urinary output amounts out of a possible 93 entries. 6. Review of Resident #4's plan of care dated 07/17/15 showed the care plan directed staff to monitor and record his/her urine output every shift. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 08/17/15 showed staff assessed the resident as follows: - Oriented; - Required extensive assistance from staff for his/her ADLs; - Required the use of an indwelling urinary catheter. Review of the resident's urinary output record for October showed staff recorded 14 urinary output amounts out of a possible 93 entries. 7. Review of Resident #5's plan of care dated 03/05/15 showed the care plan directed staff to monitor and record his/her urine output on a daily basis. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 08/26/15 showed staff assessed the resident as follows: - Oriented; - Required extensive assistance from staff for his/her ADLs; - Required a [MEDICATION NAME]. Review of the resident's urinary output record for October showed staff recorded eight urinary output amounts out of a possible 93 entries. 8. During an interview on 10/29/15 at 3:00 P.M., the DON said he/she expected the charge nurse to write the resident's name on the aides assignment sheets of who needed their urine output recorded. The DON said the charge nurse was to review the assignment sheets at the end of the day to ensure the tasks were completed. The DON said it also was to be recorded in the computer. The DON said she expected staff to alert the charge nurse to any changes in the residents' conditions. MO 762

Based on interview and record review, facility staff failed to provide foot support during wheelchair transport to prevent an avoidable accident for one dependent resident (Residents # 9), out of 18 sampled residents. Facility staff failed to apply wheelchair foot rests while they wheeled the resident towards his/her room, which caused the resident to fall forward, hit his/her head on the floor, and received a hematoma (a collection of blood under the skin that fell s spongy, rubbery, or lumpy) on his/her forehead. Additionally the resident sustained [REDACTED]. The facility census was 88. 1. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 5/8/13, showed staff assessed the resident as follows: - Severely cognitively impaired; - Did not walk; - Required extensive assistance from two staff persons for transfers and toilet use; - Required extensive assistance from one staff person for locomotion, dressing, eating, and personal hygiene; - Used a wheelchair; - diagnosed with [REDACTED]. Review of the resident's care plan, dated 8/16/12, showed staff identified the resident was at risk for falls, non ambulatory, and the resident's primary mode of locomotion was a wheelchair propelled by staff both long and short distance due to tremors and weakness. Review of the resident's care plan showed the following updates: - 5/9/13 - Aide pushing the resident down hall to room, the resident placed feet on floor and propelled self out of wheelchair onto the floor; - Undated - Foot rest in wheelchair. Review of the resident's nurses' notes showed the following: - 5/9/13 6:55 - "Nurses aide was pushing the resident down hall towards room due to resident repeating "I want to go to bed". This resident after a few steps put feet firmly onto floor and landed onto forehead on floor. Noted a large knot hematoma on forehead. Resident stated "I hit my head" and "I have a knot on my forehead"". Staff called the resident's family member who requested the resident go to the hospital. An ambulance transported the resident to a hospital; - 5/9/13 11:45 P.M. - Staff from the emergency room called and said the resident would be returning to the facility. X-rays of the resident's shoulder and hip showed there were no fractures and a CT of the resident's neck and head showed no acute abnormalities. Hospital staff suspected a "re-torn left rotator cuff tear" and applied a sling. Review of the emergency room Physician's note, dated 5/9/13, showed the physician documented the final [DIAGNOSES REDACTED]. During an interview on 6/6/13 at 1:10 P.M., Certified Nurse Aide (CNA) G said the resident never propelled his/herself in a wheelchair. CNA G said staff are supposed to put foot pedals on wheelchairs of residents that do not propel themselves to prevent injury. During an interview on 6/6/13 at 1:15 P.M., Licensed Practical Nurse (LPN) K said staff are supposed to put foot pedals on wheelchairs of residents that do not propel themselves to prevent injury. During an interview on 6/6/13 at 1:25 P.M., the Director of Nurses (DON) said when the resident first came to the facility he/she was in a wheelchair. The resident did not propel his/her self so staff put foot pedals on his/her wheelchair to prevent accidents/injury. Staff switched the resident from a wheelchair to a "tilt" chair (a chair that can be reclined to tilt and/or lay the resident back to prevent falls). Something broke on the tilt chair and staff had to send it to be fixed. Staff put the resident in a regular wheelchair after his/her chair broke. Staff propelled the resident in a wheelchair and the resident put his/her feet down on the floor and fell forward out of the wheelchair. The DON said staff should not have put the resident in a wheelchair, they should have found a comparable chair to his/her "tilt" chair or left the resident in bed until his/her "tilt" chair was fixed. The DON said staff are supposed to put foot pedals on wheelchairs of residents that do not propel themselves to prevent injury. During an interview on 6/6/13 at 1:40 P.M., the Assistant Director of Nurses (ADON) said staff failed to place foot pedals on the wheelchair they put the resident in on 5/9/13. The ADON said when the resident placed his/her feet on the floor as staff propelled the resident's wheelchair, it caused the resident to fall forward out of the wheelchair. During an interview on 6/20/13 at 8:33 A.M., the DON said the facility does not have a policy directing staff to put foot pedals on the wheelchairs of residents that do not propel themselves. During an interview on 6/20/13 at 8:40 A.M., CNA N said the following: - On 5/9/13 on the evening shift, he/she and another CNA got the resident up from bed to a wheelchair but did not put foot pedals on the residnet's wheelchair. The resident sat by the nurses' station in his/her wheelchair without foot pedals and requested to go to bed so he/she turned the resident's wheelchair around to propel it down the hallway and after only a few steps the resident "planted his/her feet, fell out of the wheelchair, and landed straight on top of his/her head"; - Staff are not expected to put foot pedals on the wheelchairs of all the resident's that can not propel themselves. Staff only put foot pedals on the wheelchairs of resident's that Physical Therapy has evaluated to need foot pedals.

Based on observation, interview and record review, the facility failed to treat and prevent the development of a stage II facility acquired pressure ulcer for one dependent resident (Resident #1). The facility failed to treat and prevent the development of facility acquired stage III pressure ulcers for three dependent residents (Residents #4, #5, and #3). The facility failed to treat and prevent the development of an unstageable facility acquired pressure ulcer for one dependent resident (Resident #13). The facility failed to thoroughly and accurately assess pressure ulcers for one dependent resident (Resident #1). The facility failed to document weekly wound assessments for one dependent resident (Resident #4). The facility failed to follow the resident's plan of care to promote healing of pressure ulcers and prevent the development of new pressure ulcers for two dependent residents (Residents #1 and #5). The facility failed to replace a dressing in a timely manner for a stage III pressure ulcer for one dependent resident (Resident #5). The facility census was 88. Review of the facility's "Wound Management Protocol", undated, showed staff are directed to do the following for pressure ulcers: - Stage I (an observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues): relieve pressure; apply a pressure reducing mattress; turn the resident every one to two hours; avoid friction; keep the perineal area clean and dry; cleanse the area with soap and water and apply [MEDICATION NAME] spray with gentle massage every shift and as needed; - Stage II (a partial thickness loss of the dermis presenting as a shallow open ulcer with a red-pink wound bed without slough; may also present as an intact or open/ruptured blister) "clean": measure the wound and document; cleanse the wound with normal saline or soap and water; apply antibiotic ointment; cover the wound with 2 x 2 gauze and a clear dressing after applying skin prep; check the dressing every shift; change the dressing every other day and as needed; relieve pressure by applying a pressure reducing mattress, turning the resident every one to two hours, avoiding friction, and keeping the perineal area clean and dry; - Stage II "dirty (yellow to black)": measure the wound and document; cleanse the wound with normal saline or soap and water; apply santyl ointment (a topical medication used to help heal pressure ulcers by breaking up and removing dead tissue and skin) and [MEDICATION NAME] powder (an antibiotic powder that helps prevent infection in wounds); apply a gauze 2 x 2 or 4 x 4 and cover with a clear dressing after applying skin prep; check the dressing every shift and change every day and as needed; relieve pressure by applying a pressure reducing mattress, turning the resident every one to two hours, avoiding friction, and keeping the perineal area clean and dry; - Stage III (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed; slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy at times) may be present but does not obscure the depth of tissue loss; may include undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface) and tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound)) "clean": measure the wound and document; cleanse the wound with normal saline; apply hydrogel (a dressing that aids in the healing of wounds by keeping them moist to rehydrate and remove dead tissue) and pack lightly; cover the wound with a gauze 4 x 4 and a clear dressing after applying skin prep; check the dressing every shift and change daily and as needed; relieve pressure by applying a pressure reducing mattress, turning the resident every one to two hours, avoiding friction, and keeping the perineal area clean and dry; - Stage III "dirty (yellow or necrotic (dead tissue))": measure the wound and document; cleanse the wound with normal saline; apply santyl ointment and [MEDICATION NAME] powder and pack lightly; cover the wound with a gauze 4 x 4 and a clear dressing after applying skin prep; check the dressing every shift and change daily and as needed; relieve pressure by applying a pressure reducing mattress, turning the resident every one to two hours, avoiding friction, and keeping the perineal area clean and dry; - Stage IV (full thickness tissue loss with exposed bone, tendon or muscle; slough or eschar may be present on some parts of the wound bed; often includes undermining and tunneling) "clean": measure the wound and document; cleanse the wound with normal saline; apply hydrogel and pack lightly; cover with 2 x 2 or 4 x 4 gauze and a clear dressing after applying skin prep; relieve pressure by applying a pressure reducing mattress, turning the resident every one to two hours, avoiding friction, and keeping the perineal area clean and dry; - Stage IV "dirty (yellow to black)": measure the wound and document; cleanse the wound with normal saline; apply santyl ointment and [MEDICATION NAME] powder; cover with 2 x 2 or 4 x 4 gauze and a clear dressing after applying skin prep; relieve pressure by applying a pressure reducing mattress, turning the resident every one to two hours, avoiding friction, and keeping the perineal area clean and dry. - Measuring of wounds will be done weekly on Tuesdays on the weekly wound report. This form is kept in the treatment book behind the treatment sheet; - "Sign out treatment (Remember if not signed out not done)". 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 5/29/12, showed staff assessed the resident as follows: - Severe cognitive impairment; - Required extensive assistance from two staff members for bed mobility, transfers, dressing, and toilet use; - Required extensive assistance from one staff member for locomotion and personal hygiene; - Lower extremity impairment on both sides; - Indwelling catheter; - Frequently incontinent of bowel; - Had listed [DIAGNOSES REDACTED]. - Received tube feeding; - At risk for pressure ulcers; - Did not have pressure ulcers; - Had a surgical wound. Review of the resident's comprehensive care plan, dated 5/29/12, showed staff identified the resident was at risk for skin breakdown and planned the following interventions: - Assist with bed mobility and positioning with one to two staff persons; - Encourage frequent turning and repositioning while in bed; - May be up in wheelchair for up to two hours twice a day; - Transfer with a mechanical lift; - Anticipate all of the resident's needs as he/she is unable to consistently verbalize to staff; - Continue low air loss mattress; - Assess skin during care and notify the charge nurse if any areas are reddened or open areas. Review of the resident's physician's orders [REDACTED]. - Apply [MEDICATION NAME] (a topical medication that provides a barrier to prevent irritation from moisture and to promote healing) to the resident's buttock three times a day (TID) and as needed until healed (order dated 5/24/12); - Apply [MEDICATION NAME] ointment (ointment that helps prevent infection of a wound) to all open areas every day (order dated 2/29/12). Review of the resident's Treatment Administration Record (TAR), dated 5/15/12 through 6/14/12, showed the following: - an order for [REDACTED]. Review showed the resident's TAR did not include any information to show staff administered the resident's [MEDICATION NAME] as directed by the physician on seven of nine days between 5/22 and 5/30/12 to promote healing and prevent further decline in the resident's skin condition. Further review showed the resident's TAR did not include the physician's orders [REDACTED]. Staff did not transcribe the physician's orders [REDACTED]. Review of the resident's Wound Condition Reports showed facility staff circled areas on a diagram of a human body, numbered them, and documented below the diagram the wound description according to number. Review showed staff documented the following wound assessments for the resident's pressure ulcers: - On 5/22/12 a superficial open area measuring 5.0 cm by 5.0 centimeter (cm) to the right lower buttock surrounded by a 17 cm by 8 cm dark purple nonblanchable circular area. Staff did not document the stage of the pressure ulcer or the description of the wound bed to aid in the ongoing evaluation of the pressure ulcer. - On 5/29/12 a 4.7 cm by 5.0 cm open superficial beefy red wound that "appears sheared" to the right lower buttock surrounded by a 15 cm by 15 cm discolored area. - On 6/5/12 a 4.1 cm by 1.6 cm open superficial wound surrounded by a 12 cm by 8 cm discolored dark red/purple area. Staff did not number or document the site of the open wound. Staff did not document the stage of the pressure ulcer or description of the wound bed to aid in the ongoing evaluation of the pressure ulcer. - On 6/12/12 a 3.5 cm by 0.5 cm "superficial red granulated tissue with serous drainage - light purple" to the resident's right lower buttock. Staff also documented the resident had a 0.5 cm by 0.5 cm red granulated wound bed and labeled this skin site as #4. Staff did not document the location of the facility acquired pressure ulcer and did not label the diagram of a human body to indicate the location to aid in the ongoing evaluation of the pressure ulcer. Observation on 6/11/12 at 1:00 P.M., showed the resident lay in bed on his/her back with the head of the bed elevated 30 degrees. Observation on 6/11/12 at 4:45 P.M., showed the resident continued to lay in bed on his/her back with the head of the bed elevated 30 degrees. During this time staff did not reposition the resident off his/her back to relieve pressure from the resident's buttocks, to assist with healing his/her skin. Observation on 6/11/12 at 6:00 P.M., showed the resident continued to lay in bed on his/her back with the head of the bed elevated at 30 degrees. Observation showed staff did not assist or encourage the resident to reposition in bed to promote healing of the resident's skin and as directed by the care plan. Observation on 6/12/12 at 6:00 A.M., showed the resident lay in bed on his/her back with the head of the bed elevated at 30 degrees. Observation on 6/12/12 at 8:00 A.M., showed the resident continued to lay in bed flat on his/her back with the head of the bed elevated at 30 degrees. Observation on 6/12/12 at 9:40 A.M., showed the resident continued to lay in bed flat on his/her back with the head of the bed elevated at 30 degrees. Observation on 6/12/12 at 11:20 A.M., showed the resident continued to lay in bed on his/her back with the head of the bed elevated at 30 degrees. Staff did not change the resident's position between at least as early as 6:00 A.M. until at least as late as 12:00 P.M.. Observation on 6/12/12 at 12:00 P.M., showed the following: - The resident lay in bed on his/her back with the head of the bed elevated at 30 degrees; - Certified Nurse Aids (CNA)s L and M turned the resident to his/her side to provide cleansing; - The resident had two stage II pressure ulcers on his/her buttock; - The pressure ulcer on the left side of the resident's buttock was a shallow ulceration that had red granulation tissue and measured 3.5 cm long by 0.5 cm wide; - The pressure ulcer on the right side of the the resident's buttock was a shallow ulceration that had red granulation tissue and measured 0.5 cm long by 0.5 cm wide; - CNAs L and M transferred the resident with the assistance of a mechanical lift to a wheelchair. Observation on 6/12/12 at 1:15 P.M., showed the resident sat in a wheelchair which he/she propelled up and down the hallway. Observation on 6/12/12 at 1:45 P.M., showed the resident sat in a wheelchair which he/she propelled up and down the hallway. Observation on 6/12/12 at 2:30 P.M., showed the resident lay in bed on his/her back with the head of the bed elevated at 30 degrees. Observation on 6/13/11 at 8:00 A.M., showed the resident lay in bed on his/her back with the head of the bed elevated at 30 degrees. Observation on 6/13/11 at 9:30 A.M., showed the resident continued to lay in bed on his/her back with the head of the bed elevated at 30 degrees. Observation showed staff did not assist or encourage the resident to reposition in bed as the care plan directed to promote healing of his/her pressure ulcer. Observation on 6/13/11 at 10:15 A.M., showed the resident continued to lay in bed on his/her back with the head of the bed elevated at 30 degrees. Observation showed staff did not assist or encourage the resident to reposition in bed as the care plan directed to promote healing of his/her pressure ulcer. Observation on 6/13/11 at 12:00 P.M., showed the resident continued to lay in bed on his/her back with the head of the bed elevated at 30 degrees. Observation showed staff did not assist or encourage the resident to reposition in bed as the care plan directed to promote healing of his/her pressure ulcer. Observation on 6/13/12 at 3:00 P.M., showed the resident sat in a wheelchair in the dining room. Observation on 6/13/12 at 3:40 P.M., showed the resident sat in a wheelchair in the dining room. Observation on 6/13/12 at 4:15 P.M., showed the following: - The resident lay in bed on his/her back with the head of the bed elevated at 30 degrees; - Licensed Practical Nurse (LPN) G and an unidentified aid turned the resident on his/her left side; - The resident had bloody gauze on the right and left pressure ulcers; - LPN G removed the bloody gauze; - LPN G cleansed the wound with wound cleanser spray and applied [MEDICATION NAME] ointment to the right and left pressure ulcers and then applied 2 x 2 gauze and an OpSite (a clear dressing that promotes wound healing by maintaining a moist wound environment and providing a barrier to water and bacteria) over each pressure ulcer. During an interview on 6/13/12 at 4:15 P.M., LPN G said staff are expected to turn the resident every two hours. During an interview on 6/14/12 at 9:15 A.M., the Director of Nurses (DON) said the following: - She was not able to tell where the resident's pressure ulcers were by reviewing the resident's Wound Condition Reports; - The resident currently has a pressure ulcer on his/her right buttock which was acquired at the hospital; - She has not seen the resident's right buttock pressure ulcer; - The resident is on a low air loss mattress so he/she does not need to be turned; - The "floor nurses" are not allowed to stage pressure ulcers; - Pressure ulcers are only staged by a MDS coordinator during a MDS assessment. During on interview on 6/14/12 at 9:30 A.M., LPN H said the following: - The resident did not have any open areas on his/her buttocks when he/she went to the hospital on [DATE]; - He/she was the nurse that readmitted the resident to the facility from the hospital on [DATE] and the resident had a hospital acquired pressure ulcer on his/her right buttock at that time; - Staff found a unidentified facility acquired pressure ulcer on 6/12/12 on the resident's left buttock and he/she was unsure if anybody had staged it yet; - The "floor nurses" are not allowed to stage pressure ulcers. Observation on 6/14/12 at 9:45 A.M., showed the resident lay in bed flat on his/her back with the head of the bed elevated at 30 degrees. Observation on 6/14/12 at 10:30 A.M., showed the resident continued to lay in bed flat on his/her back with the head of the bed elevated at 30 degrees. Observation showed staff did not assist or encourage the resident to reposition in bed as the care plan directed to promote healing of his/her pressure ulcer. Observation on 6/14/12 at 11:35 A.M., showed the resident continued to lay in bed on his/her back with the head of the bed elevated at 30 degrees. Observation showed staff did not assist or encourage the resident to reposition in bed as the care plan directed to promote healing of his/her pressure ulcer. Review of the resident's nurses notes, dated 6/12/12 through 6/14/12, showed staff did not document they notified the resident's physician of the facility acquired pressure ulcer found on 6/12/12. Further, review showed staff did not document the location of the facility acquired pressure ulcer. 2. Review of Resident #4's MDS, dated [DATE], showed staff assessed the resident as follows: - Cognitively intact; - Required extensive assistance from two staff members for bed mobility, transfers, and dressing. - Required extensive assistance from one staff member for personal hygiene; - Totally dependent on staff for toileting; - Lower extremity impairment on both sides; - Indwelling catheter; - Ostomy (a surgical made opening in the body for the discharge of body wastes); - Had listed [DIAGNOSES REDACTED]. - At risk for pressure ulcers; - Had one stage III pressure ulcer measuring 4.5 cm long by 2.5 cm wide and 0.3 cm deep. Review of the resident's comprehensive care plan, dated 6/29/11, showed staff identified the resident was at risk for skin breakdown due to a history of pressure ulcers and impaired physical mobility. Review showed staff are directed to do the following interventions for the resident: - Reposition frequently while in a wheelchair or in bed to reduce risk of skin impairment; - Use Roho pressure relieving cushion to wheelchair to reduce pressure; - Nurse to administer topical medications as ordered to protect fragile skin surfaces; - Assess body during all clothing/linen changes, perineal care, showers, and daily dressing to check for any indication of pressure or skin injuries and notify the nurse, physician, and family of any findings. Review of the resident's POS, dated 4/15/12 through 5/14/12, showed on 5/9/12 a physician directed staff to cleanse "area" to buttocks and apply [MEDICATION NAME] TID until healed. Review of the resident's TAR, dated 4/15/12 through 5/15/12, showed staff did not transcribe the order to apply [MEDICATION NAME] TID to the "area" on the resident's buttocks to ensure administration to promote healing and prevent further decline in the resident's skin condition. Review of the resident's POS, dated 5/15/12 through 6/14/12, showed the following: - Staff did not carry over the order to cleanse "area" on buttock and apply [MEDICATION NAME] TID until healed from the 4/15/12 through 5/14/12 POS; - O 5/31/12, the resident's physician ordered staff to cleanse the "area" under the genitalia and apply Santyl and a dry dressing until healed; - On 6/5/12 Specialized Wound Management (SWM) consult to consult and treat. Review of the resident's TAR, dated 5/15/12 through 6/14/12, showed staff documented the order to cleanse the "area" to buttock and apply [MEDICATION NAME] TID until healed. Review showed the resident's TAR did not include any information to show staff administered the resident's [MEDICATION NAME] as directed by the physician on 12 of 16 days between 5/24 and 6/8 to promote healing and prevent further decline in the resident's skin condition. Further, review showed the resident's TAR did not include the physician's orders [REDACTED]. Staff did not transcribe the physician's orders [REDACTED]. Review of the nurses note, dated 5/8/12, showed staff documented they readmitted the resident from the hospital. Review of the resident's Wound Condition Reports for the month of May, showed staff documented the following wound assessments for the resident's pressure ulcers: - On 5/8/12 an open area on the resident's scapula that measured 1 cm by 0.5 cm which was pink. An open area on the resident's mid back that measured 0.5 cm by 0.5 cm which was pink. An open area on the resident's sacrum that measured 7.0 cm by 7.5 cm and the "wound bed beefy red". - On 5/15/12 staff failed to document any weekly wound assessments as directed by the facilities Wound Management Protocol to aid in the ongoing evaluation of a pressure ulcer; - On 5/22/12 an open area on the resident's scapula that measured 0.8 cm by 0.5 cm which was "red". An open area on the resident's med back that measured 0.5 cm by 0.5 cm which was "pink granulated tissue". An open area on the resident's sacrum that measured 6.0 cm by 5.0 cm which was "pink granulated tissue". - On 5/29/12 staff failed to document any weekly wound assessments as directed by the facilities Wound Management Protocol; - On 5/31/12 a 4.0 cm by 2.0 cm facility acquired open area on the resident's lower buttocks that was 0.3 cm deep. The wound had macerated edges and white slough to the center. Further, review showed staff failed to document any assessment of the three previously documented open areas from 5/22/12. Observation on 6/12/12 at 10:00 A.M., showed the following: - SWM NP (nurse practitioner) completed the resident's dressing change; - The resident had a stage III pressure ulcer to his/her left lower buttock that measured 1.5 cm by 2.8 cm and was 0.2 cm deep and showed 100 % pink granulation tissue. During an interview on 6/14/12 at 9:30 A.M., LPN H said the resident's pressure ulcer was facility acquired. 3. Review of Resident #5's MDS, dated [DATE], showed staff assessed the resident as follows: - Moderate cognitive impairment; - Required extensive assistance from two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene; - Totally dependent on staff for locomotion; - Lower extremity impairment on both sides; - Always incontinent of bladder; - Frequently incontinent of bowel; - Severely impaired vision; - At risk for pressure ulcers; - Had no pressure ulcers. Review of the resident's admission nurses note, dated 3/10/12, showed staff documented the resident had no open areas upon admission. Review of the resident's comprehensive care plan, dated 3/20/12, showed staff identified the resident as the following: - Dependent on staff for all toileting and perineal care due to cognitive and physical mobility impairment; - At risk for skin breakdown, pressure ulcers, and infections due to cognitive impairment, physical impairment, and incontinence; - Free from evidence of infection or skin breakdown. Further, review showed the resident's comprehensive care plan directed staff to provide the following interventions for the resident: - Assess body during all clothing/linen changes, perineal care, showers, and daily dressing to check for any indication of pressure or skin injury; - Notify the resident's nurse, physician, and family of any abnormal findings; - Check often for incontinence; - Provide perineal care and clean, dry clothing as needed; - Assist with repositioning at frequent intervals. Review of the resident's most recent plan of care, updated 4/18/12, showed staff identified the resident had a "wound to coccyx" and planned the following interventions: - Turn and reposition frequently side to side; - Avoid positioning on back; - Up to geri chair (a chair that can tilt and recline to help keep the resident properly positioned in the chair, without needing to use physical restraints) for meals but lay down in bed between meals; - Place pressure reducing mattress on bed and cushions in chair; - Nurse to provide wound care as ordered and document per protocol; - CNA to report to nurse if dressing to coccyx becomes wet, soiled, loose, or is missing from coccyx so nurse can provide care. Review of the resident's POS dated 4/2012 showed staff were directed to provide: -Cleanse coccyx wound and apply Santyl dry dressing every day and as needed. Review of the resident's POS dated 5/1/12 showed the physician changed the resident's treatment to: -Cleanse coccyx wound with normal saline and apply Santyl and cover with a saline moistened gauze dressing every day and as needed. Review of the resident's TAR dated 5/2012 showed staff did not transcribe the resident's new treatment order dated 5/1/12 to promote healing and prevent further decline in the resident's wound condition. Review showed the resident's TAR dated 5/2012 still directed staff to provide: -Cleanse coccyx wound and apply Santyl dry dressing every day and as needed. Review of the resident's TAR, dated 5/15/12 through 6/14/12, showed staff transcribed a physician order [REDACTED]. treatment as directed by the physician on eight of 17 days between 5/23 and 6/8/12 to promote healing and prevent further decline in the resident's wound condition. Review of the culture and sensitivity report, resulted on 5/4/12, showed the culture from the resident's coccyx wound grew the bacteria proteus mirabilis. Further, review of the sensitivity showed the bacteria was resistant to (unable to be treated by) several antibiotics. Review of the resident's Wound Condition Reports showed staff documented the following: - On 4/18/12 a 5.0 cm by 2.0 cm facility acquired open area on the resident's coccyx that had no depth. The wound had a 2.5 cm by 1.5 cm necrotic area and a "small patch of yellow slough". - On 4/24/12 a 3.7 cm by 2.5 cm open area on the resident's coccyx that was 0.3 cm deep. The wound was 50 % slough tissue and 50% necrotic tissue. The wound had tan drainage and a foul odor. Review of the resident's SWM notes showed the NP documented the following: - On 5/1/12 a stage III pressure ulcer on the resident's coccyx that developed on 4/18/12 and measured 4.5 cm by 3.0 cm. The pressure ulcer's depth was unable to be determined because the wound bed was 90 % "yellow thick necrotic tissue" and 10% pink tissue. The wound had a foul odor. The NP scored (a procedure used to open necrotic tissue to let medication penetrate the wound) the wound to allow Santyl to penetrate the necrotic tissue. The NP recommended a culture and sensitivity (lab test to determine what bacteria are present in a specimen) on the pressure ulcer and that the treatment be changed to clean the pressure ulcer with with normal saline, apply Santyl, cover with saline moistened gauze, and cover with a dry dressing once daily and as needed. - On 5/8/12 a stage III pressure ulcer on the resident's coccyx that measured 4.5 cm by 3.0 cm and that the depth was unable to be determined. The pressure ulcer had tunneling 3.0 cm to the upper right portion and the wound bed was 70% yellow thick necrotic tissue. The pressure ulcer was worse than the previous week. - On 5/22/12 a stage III pressure ulcer on the resident's coccyx that measured 3.0 cm by 2.0 cm and was 2.8 cm deep. It had undermining 5.0 cm to the right side of the wound and the wound bed was 20% yellow thick necrotic tissue and 80% pink granulation tissue. - On 5/29/12 a stage III pressure ulcer on the resident's coccyx that measured 3.0 cm by 2.0 cm and was 2.0 cm deep. It had undermining 5.0 cm to the right side of the wound and the wound bed was 25% yellow slough and 75% pink granulation tissue. - On 6/5/12 a stage III pressure ulcer on the resident's coccyx that measured 2.5 cm by 2.0 cm and was 1.8 cm deep. It had undermining 5.0 cm to the right side of the wound and the wound bed was 30% yellow slough and 70% pink granulation tissue. Observation on 6/12/12 at 6:35 A.M., showed the resident sat in a geri chair in the dining room with his/her eyes closed. During this time the resident did not eat and staff in the dining room did not assist the resident to eat. Staff did not have the resident in bed between meals and off his/her back as the care plan directed to promote healing of his/her pressure ulcer. Observation on 6/12/12 at 7:55 A.M., showed the resident sat in a geri chair in the dining room with his/her eyes closed. During this time the resident did not eat and staff in the dining room did not assist the resident to eat. Staff did not have the resident in bed between meals and off his/her back as the care plan directed to promote healing of his/her pressure ulcer. Observation on 6/12/12 at 8:00 A.M., showed the resident in a geri chair in the dining room. Observation showed staff assisted the resident with eating. Observation on 6/12/12 at 8:30 A.M., showed the resident in a geri chair in the dining room. Observation showed staff assisted the resident with eating. Observation on 6/12/12 at 9:30 A.M. showed the resident lay in bed. The Wound Nurse and LPN H entered the room to provide a treatment to the resident's coccyx. The Wound Nurse removed the soiled dressing and cleansed the wound with normal saline. The wound was circular and measured 2.5 cm x 2.5 cm x 1.0 cm depth. During this time, the Wound Nurse said the resident's pressure ulcer measured as a Stage III and had improved since the antibiotics were started to treat the resident's infection. Observation on 6/12/12 at 1:15 P.M., showed the resident in a geri chair by the nurses station. The resident called out "help me" repeatedly. Staff did not have the resident in bed between meals and off his/her back as the care plan directed to promote healing of his/her pressure ulcer. Observation on 6/13/12 at 10:00 A.M., showed the resident in the shower room. CNAs R and S repositioned the resident in a shower chair. CNA S told CNA R to remove the resident's dressing on his/her coccyx. CNA S left the shower room. Observation on 6/13/12 at 2:30 P.M., showed LPN G provided a treatment to the resident's coccyx. Observation showed the resident's coccyx contained an open stage III pressure ulcer which did not contain a dressing. During this time the resident lay in bed incontinent of urine. The pads beneath the resident's buttocks were soaked with urine. The resident's buttocks was soiled with urine including the resident's open pressure ulcer. Staff did not ensure the resident's pressure ulcer had a dressing as directed by the physician to promote healing and prevent further decline. During an interview on 6/13/12 at 2:40 P.M., LPN G said the following: - A CNA came to tell him/her after lunch that the residents dressing came off; - He/she assumed the dressing came off during incontinence care the aids provided after they laid the resident in bed after lunch; - Aids should remove dressings or have a nurse remove dressings before giving a resident a shower; - Aids should notify the charge nurse or treatment nurse as soon as they finish the resident's shower so a nurse can reapply the resident's dressing. During an interview on 6/13/12 at 3:05 P.M., CNA R said he/she took the resident's coccyx dressing off while he/she gave the resident a shower. CNA R said he/she did not notify a nurse that the resident's dressing was off until after aids laid the resident down after lunch. Observation on 6/13/12 at 3:40 P.M., showed unidentified aids assisted the resident from bed and to a geri chair and took the resident into the dining room. Staff did not have the resident in bed between meals and off his/her back as the care plan directed to promote healing of his/her pressure ulcer. Observation on 6/13/12 at 4:45 P.M., showed the resident sat in a geri chair in the dining room with his/her eyes closed. During this time the resident did not eat and staff in the dining room did not assist the resident to eat. Staff did not have the resident in bed between meals and off his/her back as the care plan directed to promote healing of his/her pressure ulcer. During an interview on 6/14/12 at 11:00 A.M., CNA T said if a resident's dressing is off

Based on observation, interview and record review, facility staff failed to provide care and services to prevent avoidable accidents including falls. Staff did not implement interventions as directed by the Minimum Data Set (MDS), a federally mandated assessment instrument and plan of care for three residents ( #8, #11 and #10). Additionally the facility failed to provide oral care to prevent pocketing of food for one resident who is a choke risk (Resident #2). The facility census was 83. Review of the facility's Fall Prevention Program (undated) showed; Fall response: 1) Evaluate and monitor resident for 72 hours after the fall(vital signs and assessment every shift) 2) Investigate fall circumstances: date, day of week, time, location type of fall/injury, likely cause, activity at the time of fall, staff present, type of footwear, aids in use (walker, foot buddy, etc), restraint use, side rail use, alarm use 3) Record circumstances, resident outcome and staff response, and notify the physician and family 5) Implement immediate interventions within the first 24 hours. Add fall Prevention Intervention Care Plan sheet to the care plan book 6) Complete falls assessment (with fall committee) 7) Develop plan of care 8) Monitor staff compliance and resident response. The fall committee meets weekly, committee consist of representatives from: Therapy, Restorative, Housekeeping, dietary, activities, and nursing(incudes nurses and CDNAs). Meetings will consist of reviewing all falls of the week and work through CCAs or Fall assessment or one of the Primaris forms. 1. Review of Resident #8's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/16/11, showed staff assessed the resident as follows: - Memory problems; - Required extensive assistance for bed mobility, transfers, dressing, personal hygiene and toilet use; - Two or more person assist for transfers; - Unsteady during transfers and walking; - Loss of functional range of motion of upper extremity on one side; - Incontinent of bowel and bladder; - Fall since last assessment; - Takes antipsychotic, antidepressant and hypnotic medication (all increase fall risk). Review of the resident's last fall risk assessment dated [DATE] showed staff assessed the resident at a 17, with numbers 16 or greater identified as at risk for falls. Review of the resident's care plan last reviewed on 3/16/11 showed staff staff planned the following care; - Resident requires moderate to extensive assistance to ensure all activity of daily living needs are completed, that all transfers including to the toilet, shower chair, and wheelchair to be completed with the assist of two staff and a gait belt; - Resident is at high risk for falls related to her lack of self-safety awareness, use of psychotropic medications, and history of falls. Review of a resident's monthly Resident Summary completed by facility staff showed staff are directed to complete all transfers using a gait belt and two staff. Review of the resident's nurses notes showed; - On 4/26/11 at 8:00 P.M. LPN H documented the resident continues on antibiotics for a urinary tract infection without adverse signs or symptoms noted. - (next entry) On 4/27/11 at 9:00 A.M. an LPN documented an aide reported that the resident complained of a 10 out of 10 score on the pain scale (highest level). Upon assessment the resident complained of right ankle and shin pain with swelling observed. When the resident's sock was removed he/she complained "it hurts, it hurts". The resident said he/she had fallen, "but would not elaborate and wanted to go out on a smoke break." -On 4/27/11 at 9:10 A.M. LPN documented he/she notified the doctor and x-rays were ordered. - On 4/27/11 at 9:30 A.M. the LPN documented the aides reported the resident complained of pain during the entire transfer (two person with a mechanical lift assist) back into bed after smoking. - On 4/27/11 at 10:45 A.M. staff documented x-ray results showed the resident has a fracture of the distal fibula and medial malleolus with minimal displacement (lower portion of the leg bone ). The resident's physician directed staff to send the resident to the hospital. - On 4/27/11 at 10:55 A.M. the resident's responsible party was notified. - On 4/27/11 at 12:15 P.M. the resident left the facility for the hospital. - ON 4/27/11 (no time) a late entry for 4/26/11 at 9:45 P.M. showed LPN H documented the resident had fell the previous night. The LPN documented that he/she found the resident laying on his/her back in the bathroom located in front of the toilet. The resident had street shoes on and that transfer assist had been provided by only one CNA using a gait belt. The aide told the LPN he/she transferred the resident from the toilet to the wheelchair by using the grab bar on the wall beside the toilet. The resident told the aide "my leg hurts and are getting weak". The aide lowered the resident to the floor. The LPN documented an assessment was completed (not documented) and the resident denied pain and that the resident's range of motion and vital signs had been within normal limits at the time of the incident. - On 5/2/11 at 2:00 P.M. staff documented the resident returned from the hospital by ambulance with a [DIAGNOSES REDACTED]. Observation on 5/12/11 at 7:10 A.M. showed the resident lay in bed wearing knee and foot stabilizer. LPN K provided a dressing change to the incisions on the resident's right foot. The observation showed the resident had a incision approximately two inches in length on the inner side of the ankle and a 4 inch incision on the outer side of the right ankle. The resident reported to the LPN that his/her pain level was a 8 on a 0 to 10 pain scale. During an interview on 5/13/11 at 12:45 P.M. the Director of Nursing said staff should not have transferred the resident with only one staff member and expected staff to to use a minimum of a two person with a gait belt transfer as the resident's care plan directs. The DON said that she would have expected the nurse on duty that night to follow the facility fall policy; document the fall, document assessment of the resident, notify the physician and responsible party, and communicate the fall to ongoing shifts so the resident's condition would be monitored. 2. Review of Resident #11's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 4/6/11, showed staff assessed the resident as follows: - No memory problems; - Required extensive assistance for bed mobility, transfers, and dressing; - Total assist with toilet use; - Non-ambulatory; - Loss of functional range of motion of both lower extremities; - Catheter/Ostomy (opening which connects a portion of the body cavity to the outside environment); - No falls indicated. Review of the resident's care plan last updated on 4/6/11 showed staff assessed the resident as follows; - Care plan for activity of daily living needs due to a [DIAGNOSES REDACTED]. - Care plan for falls showed staff are directed to keep call light near resident and answer promptly. Review of the resident's nurses notes showed; - On 5/9/11 staff document at 9:00 P.M. the resident complained that he/she had "leaking around his/her urostomy (artificial opening in the urinary system due to obstruction), and that his/her clothes are soaking wet." After observation the resident's bag was found to be leaking and attempts to flush the catheter could not be completed due to resistance. The LPN documented a new catheter was placed and urostomy bag applied. The LPN documented clear yellow urine draining, no leaking noted and that the resident tolerated the procedure well. - On 5/10/11 at 12:40 A.M. the nurse documented that staff called her/him to the resident's room. The observation showed the resident lay on the floor face down next to the bed. The resident was alert and neurological checks were within normal limits. The resident denied nausea but complained of pain all over. The resident was assisted back to bed. The resident said that he could not reach the call light to get assistance. - On 5/10/11 1:40 A.M. the resident is in bed, awakens easily and denies pain. the resident had been given oxycodone 30 milligrams (mg) for pain which appeared effective. - On 5/10/11 at 4:00 A.M. the resident awakens easily, observe no bruising or skin tears. Frequent room checks this shift, call light in reach of the resident. Will notify family in morning and the physician has been notified by fax. - On 5/10/11 at 8:00 A.M. staff document the resident complained of 10 out of 10 (highest level of pain) on the pain scale. MS Contin (pain medication) given. The resident said the pain is "just so bad". - On 5/10/11 at 8:30 A.M. staff document the resident's physician directed staff to send the resident to the emergency room for evaluation and treatment. - On 5/10/11 at 9:45 A.M. staff document resident was sent to the emergency room by ambulance. - On 5/10/11 at 8:00 A.M. staff document the resident returned from the emergency room with no no acute disease or fractures. The resident complained of "all over pain." - On 5/11/11 at 2:45 P.M. staff document complained of pain in back and wants pain medication reviewed. During an interview on 5/12/11 at 11:00 A.M. the resident said that on the evening of 5/9/11 he/she complained about his/her catheter bag leaking. The resident said LPN H changed the catheter and drain bag while he/she laid in the bed. The resident said that the LPN left the resident laying at the edge of the bed when he/she completed care and pressed the call light to "get a aide to come and clean him/her up" at about 9:30 P.M. The resident said that the LPN did not leave the call light within reach when he/she left the room. The resident said a CNA came to the room and said he/she would be right back to clean him/her up, and turned off the call light. The resident said the CNA left him/her positioned at the edge of the bed, did not leave the call light within his/her reach, and left the room, closing the door behind them. The resident said the staff member never returned, the resident could not reach the call light and laid on the wet linens and mattress. The resident said he/she attempted to call out several times, but staff were stripping floors and with the door closed and he/she could not be heard. The resident said that he/she laid there until after 12:00 A.M. when he fell out of the bed, landing on the tiled floor below. The resident said he/she laid on the floor until staff made rounds and found him/her at about 12:30 P.M.. The resident said he/she "landed face down on the floor when he/she fell and must of pulled muscles in my back because I still have pain." During an interview on 5/13/11 at 12:45 P.M. the DON said that she would expect both the LPN and the CNA to ensure that the resident was positioned safely in the center of the bed and had access to his/her call light before leaving the resident alone in the room. The DON said that she would expect that the CNA return promptly to address the resident's needs or arrange for another staff to care for the resident. 3. Review of Resident #10's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 5/6/11, showed staff assessed the resident as follows: - Memory problems; - Required extensive assistance for bed mobility, transfers, eating, personal hygiene, and toilet use; - Total dependance for dressing and bathing; - Unsteady during transfers and walking; - Incontinent of bowel and bladder. Review of the resident last fall risk assessment dated [DATE] showed staff assessed the resident at a score of 18. Scores of 16 or greater indicate the resident is at risk for falls. Review of the resident's care plan for falls, last updated on 5/6/11, showed staff are directed to use a personal alarm at all times in bed to decrease the chance of an unassisted transfer. Review of the resident's nurses notes dated 1/24/11 at 10:45 A.M. showed staff found the resident on the floor when responding to the resident's personal alarm. The resident had slid out of his/her chair. Observation on 5/11/11 at 9:35 A.M. showed the resident lay in bed with no personal alarm. Observation on 5/11/11 at 2:30 P.M. showed staff did not have a personal alarm on the resident as he/she lay in bed. Observation on 5/12/11 at 2:30 P.M. showed staff did not have a personal alarm on the resident as he/she lay in bed. Observation on 5/13/11 at 11:00 A.M. showed staff did not have a personal alarm on the resident as he/she lay in bed. During an interview on 5/13/11 at at 1:00 P.M. the DON said that she expects staff to use a personal alarm on the resident if directed by the resident's care plan. 4. Review of Resident #2's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/15/11, showed staff assessed the resident as: - Modified independence with cognitive skills for daily decision making; - Needs assistance with dressing, grooming, and hygiene; - Needs supervision and encouragement with meals; - Problems with depression; - Problems with swallowing. Review of the resident's care plan dated 8/23/2010, showed the resident is at risk of aspiration while eating and staff are directed to provide the following care for the resident: - Ensure resident is in comfortable and proper position during mealtime to reduce the chance of pain, loss of appetite or aspiration; - Monitor resident closely for pocketing of food; - Provide verbal cueing to resident during meals. During an interview on 5/12/2011 at 10:00 A.M., the facility Administrator said he/she expects staff to remain in the dining room and assist the resident until the resident is finished eating. The Administrator said he/she also expects staff to provide oral care after meals to prevent the resident from aspirating on pocketed food. Observation on 5/10/201 at 3:00 P.M., showed the resident in a wheelchair in his/her room. Observation showed saliva and partially eaten food dripped from the resident's mouth. Observation failed to show staff present in the resident's room to assist the resident if he/she aspirated. Observation on 5/10/2010 at 6:15 PM showed the resident sat in the dining room eating the supper meal. During this time there were not any other residents in the dining room. Observation failed to show staff present in the dining room to assist the resident if he/she aspirated. Observation on 5/11/2011 at 2:00 P.M., showed the resident in a wheelchair in his/her room. Observation showed saliva and partially eaten food dripped from the resident's mouth. Observation failed to show staff present in the resident's room to assist the resident if he/she aspirated. During an interview on 5/11/2011 at 3:00 P.M., Registered Nurse (R.N.) N said staff are directed to be with the resident while he is dining and food should be removed from the resident's mouth prior to he/she returning to his/her room after a meal.