Every finding on record at Parkside Manor

Based on observation, interview and record review, facility staff failed to document they completed physician ordered skin assessments for three residents (Resident #1, #2 and #3) of three sampled residents. The facility census was 73.The administrator was notified on 08/26/26 of past Non-Compliance which occurred 07/03/26 to 8/21/26, when staff were in-serviced on the facility's policies on completing physician ordered weekly skin assessments and timely documentation of those assessments. 1. Review of the facility's policy, Resident Examination and Assessment, dated 03/12, showed the purpose of the procedure is to examine and assess the resident for any abnormalities in health status. Staff are directed to examine and note skin intactness, moisture, color, texture and presence of bruises, pressure sores, redness, edema, and rashes. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as moderately cognitive impairment and was at risk of developing pressure ulcers/injuries.Review of the resident's Physician Order Summary (POS), dated 04/17/26, showed an order for staff to assess the resident's skin every Friday and document in the resident's medical record.Review of the residents' weekly skin assessment, dated 06/26/26 through 08/21/26, showed staff did not document they completed skin assessments:-On 07/03/26;-On 07/10/26;-On 07/17/26;-On 07/24/26;-On 08/07/26;-On 08/14/26;-On 08/21/26. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed it did not contain a Brief Interview of Mental Status and the resident and not at risk of developing pressure ulcers/injuries.Review of the resident's POS, dated 09/18/25, showed an order for staff to assess the resident's skin every Friday and document in the resident's medical record.Review of the residents' weekly skin assessment, dated 06/26/26 through 08/07/26, showed staff did not document they completed skin assessments:-On 07/03/26;-On 07/10/26;-On 07/17/26;-On 07/24/26;-On 07/31/26;-On 08/07/26. 4. Review of Resident #3's MDS, dated [DATE], showed staff assessed the resident as cognitively intact and not at risk of developing pressure ulcers/injuries.Review of the resident's POS, dated 04/02/26, showed an order for staff to assess the resident's skin every Thursday and document in the resident's medical record.Review of the residents' weekly skin assessment showed staff did not document skin assessments were completed on 06/25/26 and 08/06/26. 5. During an interview on 08/26/26 at 11:12 A.M., Licensed Practical Nurse (LPN) A said nurses were directed to assess the resident's skin weekly and document in the resident medical record.During an interview on 08/26/26 at 12:19 P.M., the administrator said nurses were expected to assess the resident's skin on a weekly basis and document in the resident's medical records. They discovered staff were not completing the weekly skin checks and in-service over skin assessment, expectations and implemented measures to ensure staff are completing skin assessments.During an interview on 08/26/26 at 12:20 P.M., the Director of Nursing (DON) said staff are educated to conduct skin assessments each week and to document in the resident's medical records. She said they did know staff were not completing the weekly skin assessments and have conducted an in-service with staff over skin assessment requirements. She said they have implemented an audit system to ensure staff are following procedure. 3169635

Based on observation, interview and record review, facility staff failed to maintain resident dignity, when staff entered resident rooms without knocking and/or failed to identify themselves prior to entering the room affecting two sampled residents (Resident #53 and #12), failed to answer a call light in a timely manner which resulted in one of three sampled residents (Resident #12) being incontinent and discussed the bowel habits of one resident (Resident #43) while they provided care for another resident (Resident #12). The facility census was 79.1. Review of the facility's Resident Rights policy, undated, showed each resident shall be treated with consideration, respectfully, and a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. 2. Review of Resident #53's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/09/26, showed staff assessed the resident as cognitively intact. Observation on 06/15/26 at 10:31 A.M., an unknown housekeeper and unknown Certified Nurse Aide (CNA) did not knock or announce themselves before they entered the resident's room. During an interview on 06/15/26 at 10:31 A.M., the resident said staff barge in the room all the time to take care of his/her roommate and do not know. He/She said he/she does not like to complain and most of the time it does not bother him/her.3. Review of Resident #12's Annual MDS, 03/18/26, showed staff assessed the resident as:-Cognitively intact;-Dependent on staff for toileting;-Frequently incontinent;-Diagnosed with Multiple sclerosis (disease of the central nervous system).Observation on 06/16/26 at 8:50 A.M., showed the resident's call light on. At 9:09 A.M., Nurse Aide (NA) N did not knock or announce himself/herself before he/she entered the resident's room. The aide left the room at 9:12 A.M., he/she informed the resident he/she had to obtain a mechanical lift. The aide returned at 9:23 A.M., with CNA E and the mechanical lift. As CNA E entered the room, he/she informed NA N he/she planned to help with Resident #43 because the resident had a bowel movement. NA N used the lift and lifted the resident from his/her wheelchair and as the resident rose a stream of urine flowed from the resident's bottom to the wheelchair cushion, to the floor, and to the bed where the resident had been lowered. During an interview on 06/16/26 at 9:32 A.M., the resident said staff often just come into the room and do not announce themselves. He/She said it's frustrating but you just get used to it. He/She said it when urine falls to the floor it he/she is embarrassed and angry, but it happens all the time. The resident said that's nothing new that staff talk about other residents in front of residents. He/She said he/she knew about a lot of resident's personal stuff. He/She said he/she doesn't care about hearing other residents' toileting problems. The resident said, often staff will come in and complain about the smell of his/her bowel during care. He/She said those comments are hurtful and he/she often feels like a burden.During an interview on 06/16/26 at 9:29 A.M., NA N said he/she is new and is still training but he/she should have knocked and announced himself/herself before going into the room. He/She said he/she just got busy and seen the call light on. The NA said he/she thought when the light was on that was an invitation to come into the room. The NA said he/she would be embarrassed if he/she had been incontinent of urine and it flowed to the floor. During an interview on 06/18/26 at 10:42 A.M., CNA E said he/she should not have talked about Resident #43 in front of Resident #12. That information should have been kept quiet and not said in front of other residents to maintain the residents' dignity. He/She said if he/she had to sit in urine for a long period of time to the point it leaked to the floor, he/she would be embarrassed and ashamed. He/She said if staff go into a resident's room, they should knock and announce themselves because that is how he/she would want it at my house, otherwise I'd feel they were invading my space. 4. During a group interview on 06/16/26 at 11:04 A.M. the residents said the staff make comments when a resident needs help like, It's not my hall. Staff barge into the rooms without knocking and don't introduce themselves. The staff talk about other residents all the time where it can be heard by everyone. This causes anxiety and should be addressed. During an interview on 06/18/26 at 2:05 P.M., the Director of Nursing (DON) said staff are expected to treat residents with dignity and respect by knocking and announcing themselves before going into residents' rooms, not talking about residents in earshot of other residents, and responding to call lights and toileting needs timely. He/She said failing to do so would cause humiliation and embarrassment. During an interview on 06/18/26 at 2:35 P.M., the Interim Administrator said staff are expected to provide privacy and dignity to all residents which would include knocking on the doors, announcing who they are before entering the rooms, toileting residents timely and only discussing resident needs privately and not in front of others. He/She said it is embarrassing to be left wet and talked about in front of others.

Based on observation, interview and record review, facility staff failed to maintain a comfortable and homelike environment. The facility census was 79.1. Review of the facility's policy titled, Environmental, undated, showed floors and tabletops will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Observation on 06/15/26 at 10:20 A.M. and 1:32 P.M., showed the hallway outside the conference room with a strong foul odor. The carpet had an irregularly shaped dark stain. Observation on 06/16/26 at 7:45 A.M. and 4:00 P.M., showed the hallway outside the conference room with a strong foul odor. The carpet had an irregularly shaped dark stain. Observation on 06/17/26 at 8:52 A.M., showed the hallway outside the conference room with a strong foul odor. The carpet had an irregularly shaped dark stain. 3. Observation on 06/15/26 at 10:56 A.M., showed the carpet outside resident occupied room [ROOM NUMBER] with two bleached areas. 4. Observation on 06/15/26 at 12:08 P.M., showed the carpet outside resident occupied room [ROOM NUMBER]'s door with a large orange stain. 5. Observation on 06/15/26 at 2:19 P.M., showed Resident #46's carpet in his/her room with a large brown circular stain beside the bed, two stains by the dresser. The ceiling popcorn spackle bubbled and hung from the ceiling with exposed unpainted drywall. During an interview on 06/15/26 at 2:19 P.M., the resident said he/she does not feel like the stained carpet in his/her room is homelike. 6. During an interview on 06/15/26 at 12:23 P.M., Resident #54 said the carpet needs shampooed but staff said the shampooer is broken and the staff will get to the carpets when they get a new shampooer. During an interview on 06/16/26 at 11:11 A.M., Resident #22 said sometimes when staff open the door to his/her room, he/she gets whiffs of bad odors that come into his/her room from the hallway. The resident said he/she noticed the stains on the carpets. During an interview on 06/18/26 at 10:39 A.M., Certified Nurse Aide (CNA) E said some of the circular stains on the carpets are from spilt drinks, from residents who have accidents. He/She said maintenance cleans the carpets when they can. The CNA said he/she smells urine when walking up and down the halls. The CNA said he/she would feel disgusted if his/her home smelled like the halls in the facility and he/she would not want to live like that. During an interview on 06/18/26 at 11:32 A.M., Certified Medication Technician (CMT) B said he/she would describe the carpet as old and nasty. The CMT said he/she is so used to the smells but sometimes can smell urine when walking in the halls. The CMT said he/she doesn't feel like the carpet is homelike. During an interview on 06/18/26 at 12:03 P.M., Floor Tech C said the stains have been on the carpet for a while because the shampooer and the stain machine do not work. He/She said he/she told the front office, and they said they are waiting for a brush to come in. The machine used on the stains has not worked for at least two months. He/She said he/she notices the odors in the hallway and when the shampooer was working the smell was not so bad. He/She said it's not homelike. During an interview on 06/18/26 at 12:17 P.M., the Activity Director said he/she hates the carpet, it's always stained and keeps the smell in the halls. He/She said the halls smell like urine and even the carpet cleaner doesn't help. The Activity Director said the carpet is not homelike. During an interview on 06/18/26 at 12:50 P.M., Licensed Practical Nurse (LPN) D said the carpet in the halls is stained and the facility smells of urine. The LPN said he/she becomes used to the smell after a while. The LPN said he/she worked last weekend, and the stains were on the carpets, and they have gotten worse. The LPN said the carpet machine does not have proper suction to clean the stains from the carpet. During an interview on 06/18/26 at 1:15 P.M., the Maintenance Director said he/she noticed the stains and odors with the carpet. He/She said the carpet cleaner is broken and he/she has been waiting for parts to fix it. 7. Review of the policies provided by the facility showed the facility did not provide a policy for building maintenance. Review of the facility's two Maintenance Books showed the books did not contain any maintenance requests for the observations below. Review showed the Maintenance Books contained requests dated up to a year ago that were not completed or signed.8. Observation on 06/15/26 at 11:01 A.M., showed the 200 hall air vent above nurse's station the ceiling with screws coming out of the drywall. 9. Observation on 06/15/26 at 11:02 A.M., showed the therapy room's door frame skid guard broken and hung off the doorframe. 10. Observation on 06/15/26 at 11:05 A.M., showed the 200 hall lounge chairs by the nurse's station had torn and cracked vinyl the length of the arm rests. 11. Observation on 06/15/26 at 11:26 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom door with large chunks of wood and paint missing. 12. Observation on 06/15/26 at 11:27 A.M., showed resident occupied room [ROOM NUMBER]'s door frame unscrewed from the door with a screw off the frame and the bottom of the door drug the ground. Observation showed the bathroom door with a baseball sized hole. 13. Observation on 06/15/26 at 11:28 A.M., showed the ceiling in resident occupied room [ROOM NUMBER] with removed spackle and exposed unpainted drywall and the wall behind bed A with approximately two feet of exposed unpainted drywall. 14. Observation on 06/15/26 at 11:39 A.M., showed the community sitting area with broken and jagged plastic skid guards along the base of the door frame. 15. Observation on 06/15/26 at 11:42 A.M., showed the armchair rail by resident occupied room [ROOM NUMBER] and between resident occupied rooms [ROOM NUMBERS] loose and hung off the wall. 16. Observation on 06/15/26 at 11:53 A.M., showed the main dining room light frame, spackle and drywall hanging from the ceiling. 17. Observation on 06/15/26 at 11:57 A.M., showed the smaller dining room ceiling with a water stain. 18. Observation on 06/15/26 at 3:10 P.M., showed resident occupied room [ROOM NUMBER]'s call light with light above the door and light on the wall did not work when the call light is pushed. During an interview on 06/18/26 at 12:50 P.M., LPN D said he/she works on the resident's hall and is not aware of his/her call light having issues or not working. The LPN said he/she would expect staff to tell him/her. During an interview on 06/18/26 at 1:15 P.M., the Maintenance Director said staff have not notified him/her the resident's call light is not working. 19. Observation on 06/16/26 at 9:19 A.M., showed a light fixture above the 100 hall nurse's station without a cover and the fixture with only one of four light bulbs. 20. Observation on 06/15/26 at 2:39 P.M., showed the left vinyl armrest of Resident #7's wheelchair cracked and torn. Observation showed a scratch on the resident's left forearm. The vinyl is peeled back with sharp edges. During an interview on 06/15/26 at 2:39 P.M., the resident said his/her left arm got scratched by the wheelchair armrest. The resident said it would be nice to have it fixed. 21. Observation on 06/15/26 at 2:19 P.M., showed around the can light on the ceiling of resident #46's room, the popcorn spackle has bubbled and hung from the ceiling with exposed unpainted drywall. During an interview on 06/15/26 at 2:19 P.M., the resident said he/she does not feel like the condition of his/her room is homelike. 22. During an interview on 06/18/26 at 10:39 A.M., CNA E said there is a book at the nurse's station to put maintenance requests in. Staff leave the maintenance requests in the book, and maintenance checks the requests and documents when the requests are completed. The CNA said when the maintenance request is completed it stays in the book. The CNA said he/she has seen spackling missing off the ceiling and has not reported it, and assumed maintenance knew about the issues. The CNA said the facility is not homelike. The CNA said he/she has noticed some damage to walls and doors or doorframes, and the issues were reported. The CNA said he/she has noticed bulbs not working in the dining room and dayroom but has not personally reported them. During an interview on 06/18/26 at 11:32 A.M., CMT B said he/she has noticed damaged doors, walls and doorframes in residents' rooms and staff are supposed to report these types of concerns to maintenance. The CMT said the previous Maintenance Director, who left a week or two ago, was not responsive to maintenance requests. The CMT said there are issues with spackling missing on the ceilings and he/she did not report it to the old Maintenance Director. The CMT said the maintenance request book is at the nurse's station and the Maintenance Director is supposed to look at the book daily. During an interview on 06/18/26 at 12:50 P.M., LPN D said staff are supposed to put maintenance requests in the maintenance log, but that has been a waste of time because the previous Maintenance Director did not follow up on the requests. The LPN said he/she has noticed the rips in the wheelchair armrests and several other chairs need repaired. The LPN said the facility really hasn't had a maintenance person for a long time. During an interview on 06/18/26 at 1:15 P.M., the Maintenance Director said there is a maintenance request book at each of the two nurse's stations that staff are expected to write maintenance requests in. The Maintenance Director said the book is checked daily and there has not been any requests made this week. The Maintenance Director said he/she has not gotten any maintenance requests about the carpet, ceilings, light fixtures, door frames or walls. The Maintenance Director just took over in the last week or two and that is why there is maintenance requests up to a year old in the maintenance books that have not been completed. #3025947#3028948#3046404#3034727

Based on observation, interview and record review, facility staff failed to develop and implement a person-centered comprehensive care plan for three (Resident #1, #9 and #58) of five sampled residents. The facility census was 79.1. Review of the facility's policy titled Care Plan Comprehensive, undated, showed an individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being. The care plan will be based on a thorough assessment that includes but is not limited to the Minimum Data Set (MDS), a federally mandated assessment tool.Review of the facility's MDS and Care Planning Guidelines, dated October 2015, showed it is the policy of the facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, any published interim RAI manual errata documents, and applicable federal guidelines as the authoritative guide for completion of the MDS, Care Area Assessments (CAA)'s and resident care planning. 2. Review of Resident #1's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and felt it is somewhat important to keep up with the news, do activities with groups of people, do favorite activities and get fresh air when the weather is good. Review of the resident's care plan dated 03/17/26, showed the care plan did not contain the resident's activity preferences. 3. Review of Resident #9's admission MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-Felt it was very important to have books/magazines, listen to music he/she enjoys, do activities with pets, keep up with the news, do things with groups of people, do favorite activities, go outside when the weather is good, and participate in religious activities;-Used oxygen;-Used a wheelchair for locomotion;-Smoked;-Used an antidepressant and anticoagulant (blood thinner).Review of the resident's care plan dated 06/01/26, showed the care plan did not contain direction or preferences for activities, wheelchair use, smoking, antidepressant and anticoagulant use, and oxygen use. Observation on 06/15/26 at 2:20 P.M., showed the resident in bed with a wheelchair within proximity of the bed. He/She wore oxygen via nasal cannula. 4. Review of Resident #58's admission MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-Felt it was very important to have books/magazines, listen to music he/she enjoys, do activities with pets, keep up with the news, do things with groups of people, do favorite activities, go outside when the weather is good, and participate in religious activities;-Used a diuretic (pill to pull water from the body).Review of the resident's care plan dated 06/16/26, showed the care plan did not contain activity preferences or direction and guidance for diuretic use. 5. During an interview on 06/18/26 at 10:42 A.M., Certified Nurse Aide (CNA) E said resident preferences are in the care plans, but he/she isn't sure if he/she has access to care plans. He/She said staff can always ask the nurses about resident care needs. During an interview on 06/18/26 at 11:58 A.M., the MDS/Care plan Coordinator said he/she is responsible for creating the care plans. He/She said care plans should be completed upon admission, reviewed quarterly, and should include resident preferences. He/She said he/she uses the Resident Assessment Instrument (RAI) manual to help him/her complete the care plans and his/her work is overseen by the corporate nurse. The facility went for a long period of time without an MDS Coordinator, and he/she is trying to get caught up, but he/she is pulled to the floor to fill in as charge nurse and had to complete all the quarterly assessments and observations in addition to the MDS assessments. He/She said he/she did not think the CNA's had access to the care plans. During an interview on 06/18/25 at 2:05 P.M., the Director of Nursing (DON) said the MDS Coordinator is responsible for updating and completing care plans and a corporate nurse looks oversees the completion. Care plans are discussed in the Quality Assurance and Performance Improvement (QAPI) meeting and weekly care plan meetings and should include resident preferences and care needs.

Based on interview and record review, facility staff failed to provide transportation to outside activities for one resident (Resident #51) out of one sampled resident whose wheelchair would not fit in transport van. The facility census was 79.1. Review of the facility policy titled Residents Rights, undated, showed each resident shall be permitted to participate, as well as not participate, in activities of social, religious or community groups at his/her discretion, both within the facility, as well as outside the facility, unless contraindicated for reasons documented by the physician in the resident's medical record. 2. Review of Resident #51's Five-Day PPS (Prospective Payment System), Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/27/26, showed staff assessed the resident as cognitively intact, used a motorized wheelchair, had lower extremity impairments on both sides, and was dependent on staff for chair/bed to chair transfers.During an interview on 06/15/26 at 10:36 A.M., the resident said his/her electric wheelchair does not fit in the facility transport van. The resident said he/she does not get to go shopping or go to outside activities like other residents because he/she is unable to get on the facility van. He/She said if he/she was put in a manual wheelchair, the chair still would not fit on the van.During an interview on 06/18/26 at 11:45 A.M., the resident said when he/she does not get to participate in outside activities he/she feels, sad, left out, and segregated. He/She said about a month ago the other residents got to go fishing as an activity, but he/she could not attend because his/her chair does not fit on the transport van. He/She said when the activities director (AD) announced the activity he/she was sad that he/she could not go and the AD said, I know, I'm sorry, I know you love to fish. He/She said the facility should be able to accommodate all residents who live in the facility. During an interview on 06/18/26 at 12:21 P.M., the AD said, We don't have the proper van for some of the residents, I feel bad that they can't go and I know it would help their mental health. He/She said he/she has mentioned it to management, but nothing has been done. During an interview on 06/18/26 at 2:01 P.M., the Director of Nursing (DON) said he/she was not aware of the transportation van issue. He/She said they had borrowed another facility van before for transportation. During an interview on 06/18/26 at 2:41 P.M., the administrator said he/she was not aware until today the facility van did not accommodate the resident for activities. He/She said the facility should be able to figure out a way for every resident to attend activities even if they must borrow a van or use an alternative method of transportation. Complaint #3028502

Based on record review and interview, facility staff failed to have systems in place to prevent misappropriation for one resident (Resident #15) of three sampled residents', when the resident's $360.00 cash was not located in the facility safe. The facility census was 79 residents.1. Review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/17, showed each resident of the facility would be free from misappropriation of property.2. Review of the facility's policy titled, Protection of Residents Funds, undated, showed the facility shall furnish the Resident with a written receipt for all expenditures and deposits regarding any of the Resident's funds deposited with the Facility. A record of all transactions regarding the Resident's funds shall be maintained by the Facility in accordance with the generally accepted accounting principles. The resident shall have reasonable access, upon request, to the above record and shall receive an itemized quarterly statement of his or her account. 3. Review of the facility's investigation, dated 06/18/26, showed staff documented Resident #1 $360.00 could not be located in the facility safe. Review showed the facility conducted and investigation and determined the resident's $360.00 had been misappropriated by staff.During an interview on 06/16/26 at 1:43 P.M., the Business Office Manager (BOM) said the former administrator, him/her and any past BOMS would have the code to the facility's safe. He/She said the resident's money had been put in the safe because he/she had waved the money around and staff were trying to keep him/her from getting it stolen, so he/she put it in the safe before he/she could get the resident's account set up. During an interview on 06/16/26 at 1:49 P.M., the Corporate Financial Consultant said the only staff with keys to the business office are the BOM, Former Administrator and Social Services Designee (SSD). He/She said the corporate office would like the BOM to take the money to the bank, but he/she wasn't listed on the accounts yet. He/She said the residents' $360.00 went missing between 05/07/26 and 05/22/26. He/She said Certified Medication Technician (CMT) G had been a BOM here as well and the safe code had not been changed after the CMT left the BOM position. He/She said the safe code was only supposed to be shared between the BOM and the administrator. He/She said CMT A had also been a BOM for a short time before he/she returned to work on the floor. He/She said both CMTs would have still had the code to access the safe. He/She said corporate has proof the resident had $360.00 cash in the safe, so the corporate office will refund the money. The BOM is supposed to give the money in the safe to the receptionist and the receptionist deposits in the bank.During an interview on 06/16/26 at 2:22 P.M., the SSD said he/she had been a BOM at the facility. He/She said he/she still has a key to the business office, and he/she knows the code to the safe. The SSD said there are only three staff who have keys to the Business office, the BOM, himself/herself and the administrator. He/She said the Activity Director told him/her on May 22nd, the resident's $360.00 was missing, after the Activity Director had went to the Business Office to get some of the resident's money for cigarettes, so he/she directed the resident and Activity Director to the former administrator and that was the last he/she heard of it. The SSD said he/she did not take the money. During an interview on 06/16/26 at 3:30 P.M., the Corporate Nurse said he/she worked with the Director of Operations (DO) on the investigation. He/She said he/she thinks the SSD, the administrator and the BOM had the code to the safe and he/she thinks the BOM and administrator have a key to the safe. He/She said he/she told the former administrator about the missing money, and he/she put her hands in the air and would not talk about it. The Corporate Nurse said he/she interviewed the Activity Director on 06/04/26 and the Activity Director told him/her staff found out about the resident's missing money on 05/21/26, when the Activity Director went to get some of the resident's money for the resident to use and the money was gone. During an interview on 06/17/26 at 7:46 A.M., CMT A said he/she was the BOM for a short time and the safe was in the business office at that time. The CMT said he/she had the code to the safe and he/she kept it on a piece of tape under the keyboard because he/she could never remember the numbers. The CMT said he/she had a key to the business office. The CMT said the former administrator was the only other person with the code to the safe and maybe previous BOMs that had been in there, like the current SSD.During an interview on 06/17/26 at 8:44 A.M., the Activity Director said he/she is aware of the residents' missing money. The Activity Director said when he/she went to get some of the resident's money for cigarettes, the BOM said the resident's money went missing a month or so ago. The Activity Director said the BOM never gave him/her a receipt for the resident's $360.00 when the BOM put it in the facility safe. The Activity Director knew nothing about how the money was kept or monitored.During an interview on 06/17/26 at 9:52 A.M., the former administrator said the current SSD used to be in the Business Office. The safe has always had the same code through all the BOM changes. He/She said he/she did not know why he/she didn't change the code to the safe. The former administrator said there is a key to the business office on the BOM's keys, administrator's keys, SSD's Keys and Maintenance Director's keys. The former administrator said the money was found to be missing on 05/22/26 and no one was in the office 05/21/26 but the BOM. The former administrator said he/she has not stolen money from any resident. The former administrator said he/she did not know the $360.00 was even in the safe until it was missing. He/She said when he/she was a BOM, he/she would sign money out of trust for the residents. He/She said the SSD has a key to the business office and knows the code to the safe. He/She said he/she doesn't know why the SSD would have a key to the business office, it doesn't make sense, and he/she was a previous BOM and he/she had a code to the safe. He/She said money was constantly missing when SSD was the BOM, the SSD would leave money on the table with the safe open and say the money came up missing. The former administrator said the code to the safe is in the drawer of the business office desk, on a post it note, so if staff can get in the office, they could find it. During an interview on 06/17/26 at 2:01 P.M., the BOM said on 05/22/26 when he/she first noticed the $360.00 missing, he/she did not know he/she was supposed to report missing money. The BOM said he/she guesses he/she should have said something about it then. The BOM said he/she told the Corporate Financial Consultant about the missing $360.00 on 06/04/26.During an interview on 06/17/26 at 2:55 P.M., the SSD said he/she learned about the $360.00 missing the day the Activity Director was supposed to go to the store for the resident, because he/she came and told him/her about it. The SSD said he/she told the Activity Director to go to the former administrator and notify him/her of the missing money. #3034106

Based on interview and record review, facility staff failed to report an allegation of misappropriation of $360 for one resident (Residents #15) of 39 sampled residents to the State Agency. The facility census was 79.1. Review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/17, showed the nursing home administrator or designee will report to the State Agency per state and federal requirements. The facility shall report misappropriation to the State Agency no later than 24 hours after the allegation is made. The facility will comply with the seven-step approach to abuse and neglect, which include: Reporting and Response; Screening; Training; Prevention; Identification; Investigation and Protection. 2. Review of the facility's investigation, dated 06/08/26 through 06/11/26, showed Resident #15's $360.00 had been reported to facility staff as missing the 3rd week of May and had been reported to the State Agency on 06/04/26, by the former administrator. During an interview on 06/16/26 at 1:43 P.M., the Business Office Manager (BOM) said the residents' $360.00 in cash had been in the facility's safe and had been taken. The BOM said he/she first noticed the cash missing on 05/22/26. During an interview on 06/16/26 at 1:49 P.M., the Corporate Financial Consultant said he/she thought the resident's missing $360.00 had been reported to the state agency since it had been reported missing on 05/22/26. During an interview on 06/16/26 at 2:22 P.M., the Social Service Designee (SSD) said he/she did not report the resident's missing money to the State Agency. He/She said he/she assumed the administrator reported the missing money. The SSD said he/she did not have an answer, as to why he/she did not follow up to see if the missing money had been reported. The SSD said he/she knew the money was missing on 5/22 because the Activity Director went to the BOM and asked for some money to get the resident cigarettes. During an interview on 06/16/26 at 3:30 P.M., the Corporate Nurse said the missing $360.00 should have been reported to the State Agency. During an interview on 06/17/26 at 3:19 P.M., the Director of Operations said when residents' money is missing, he/she expects staff to report the missing money to the State Agency within 24 hours, then staff have time to follow up with an investigation. The Director of Operations said he/she found out on 06/04/26 about the missing, $360.00, and he/she was told by the former administrator the missing money had been reported to the State Agency.

Based on observation, interview and record review, facility staff failed to ensure a medication error rate of less than five percent (%) out of 30 opportunities observed, five errors occurred, resulting in a 16.67% error rate, which affected four residents (Resident #32, # 34, #43, and #71) of seven sampled residents. The facility census was 79. 1.Review of the facility's policy titled Medication Errors and Drug Reactions, 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 medication error definition. Review of the facility's policy titled Medication Administration Guidelines, undated, showed it is important that the residents receive their medication on a timely basis. If there is doubt concerning the administering of medications, the physician's order must be verified before the medication is administered. The policy did not contain a medication error definition.Review of the facility's Medication Administration policy, undated, showed the policy did not contain a medication error definition.Review of the policies provided by the facility showed the facility did not provide a policy for insulin administration via an insulin pen.Review of the Autoshield Safety Duo Pen Needle brochure at Embecta.com, dated 2016, showed dial two units for priming the pen and dispense the two units. It is important to prime the needle successfully before administering the injection. 2. Review of Resident #32's Physician's Order Sheet (POS), dated June 2026, showed an order for a stool softener8.6-50 milligrams (mg), three tablets daily for constipation and an order for sertraline (an antidepressant) 100 mg daily for depression.Observation on 06/17/26 at 7:25 A.M., showed Certified Medication Technician (CMT) H administer one stool softner 8.6-50 mg tablet. He/She documented the medication given as ordered. The CMT omitted the resident's sertraline medication and documented it as unavailable. During an interview on 06/17/26 at 11:32 A.M., CMT H said the medication was not available in the emergency kit and he/she had to tell the nurse. He/She said the resident often will only take one of the Senna Plus tablets so that is all he/she gave. He/She said he/she should have told the nurse he/she did not administer the correct dose. Medication errors would include wrong dose, wrong resident, wrong time and wrong form. He/She said not giving medication would be considered a medication error.During an interview on 06/18/26 at 12:55 A.M., Licensed Practical Nurse (LPN) D said he/she was not informed of any errors with Resident #32. 3. Review of Resident #34's POS, dated June 2026, showed an order for lidocaine (pain reducing) adhesive patch 5 %, topical, place on the resident in the morning and off at bedtime for diagnosis of pain in left shoulder.Observation on 06/17/26 at 7:25 A.M., showed CMT H applied a lidocaine 5% patch to the resident's lower back. During an interview on 06/17/26 at 11:36 A.M., CMT H said staff let the resident tell them where to put the patch on his/her body. He/She said the order probably should say where to put it since the diagnosis is for shoulder pain. 4. Review of Resident #43's POS, dated June 2026, showed an order for Humalog U100 insulin per sliding scale, give two Units (U) for blood sugar between 150 and 250.Observation on 06/17/26 at 11:12 A.M., showed CMT H obtained the resident's blood sugar with a result of 161. The CMT attached a new Autoshield Duo needle pen needle to a Humalog insulin pen, dialed the pen to 2 U of Humalog insulin and administered the medication. He/She did not prime the needle. 5. Review of Resident #71's POS, dated June 2026, showed and order for Novolin R Flexpen100 units/milliliter (ml) per sliding scale, give 6 U for blood sugar 300 to 349. Novolin R U100 insulin, give 7 U between 11:00 A.M. and 12:00 P.M.Observation on 06/17/26 at 11:02 A.M., showed CMT H obtained the resident's blood sugar with a result of 314. The CMT attached a new Autoshield Duo needle pen needle to a Novolin insulin pen, dialed 13 U of Novolin insulin and administered the medication. He/She did not prime the needle. During an interview on 06/17/26 at 11:36 A.M., CMT H said staff do not have to prime the Autoshield Duo pen needles. 6. During an interview on 06/18/26 at 12:55 A.M., LPN D said he/she would expect the CMT's to report medication errors. He/She was not informed of any errors with Resident #32. LPN D said medication errors consist of wrong medication, dose, and time and would need to be reported to the physician. He/She would expect the CMT's to prime all insulin needles, so the residents get the correct dose and remove air from the needle.During an interview on 06/18/26 at 2:05 P.M., the DON said he/she expects staff to report all medication errors to the DON and the physician. There should be medications in the emergency kit if the resident is out of medication. CMT's should alert the nurse if the resident is out of a medication and/or refuses medication. He/She expects the CMT's to follow the physician orders, so the residents get the correct medication. He/She said he/she is not sure about priming the insulin pens since it has been a while since he/she has administered insulin. During an interview on 06/18/26 at 2:39 P.M., the Interim Administrator said topical patch orders should indicate a location, and insulin pens should be primed before administering the insulin to prevent medication errors. #3028948

Based on interview and record review, the facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse when Housekeeper B witnessed Certified Nurse Aide (CNA) A hug and kiss the resident on the mouth. The facility census was 76. The administrator was notified on 03/31/26 of Past Non-Compliance which occurred on 03/30/26. On 03/30/26, the administrator suspended CNA A, investigated the allegation, notified the required parties and agencies, in-serviced staff on the facility's abuse and neglect policy, and terminated CNA A on 03/31/26. 1. Review of the facility's Abuse and Neglect Policy, dated 11/2017, showed the purpose is to ensure each resident will be free from abuse. Abuse is defined as verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion, and to ensure immediate reporting of all abuse allegation to the Nursing Home Administrator. Review showed sexual abuse defined as a non-consensual sexual contact of any type with a resident.2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally required assessment, dated 12/24/25, showed staff assessed the resident as cognitively intact.Review of the resident's plan of care, updated 11/12/25, showed staff assessed the resident as independent for activities of daily living (ADL's). Review of the facility's investigation, dated 03/30/26, showed the administrator documented Housekeeper B reported witnessing CNA A kissing the resident. The Housekeeper B documented he/she was walking down back hall to start cleaning resident rooms. He/She documented he/she saw CNA A walk to the resident's room. He/She said he/she was on his/her way to clean the resident's room, the door was cracked open, he/she looked in the doorway and saw CNA A and the resident kissing. He/She documented he/she did not knock on the door because he/she saw CNA A enter the resident's room before he/she reached the room.Review of CNA A written statement, dated 03/30/26, showed he/she went to the resident's room to tell the resident, the resident's roommate left the facility for an appointment. He/She documented the resident told him/her the resident was nervous so he/she, gave him/her a hug to comfort him/her. He/She documented he/she returned to another hallway of the facility until, being requested to the administrator's office.Review of the resident's statement, dated 03/30/26 at 11:05 A.M., showed he/she documented he/she has found himself/herself in a situation with a staff member that is inappropriate. He/She documented often when he/she is alone or perceived to be alone, he/she is approached and hugged and kissed. He/She said these are not actions initiated by him/her or encouraged by him/her. The resident documented CNA A was greatly appreciated by our entire friend group, and when these incidents occurred, he/she hesitated to do what he/she should have done to maintain homeostasis. He/She documented he/she did not ask to be woken up by CNA A while his/her roommate was in the bathroom, nor did he/she request he/she come into his/her room later in the morning for a hug.During an interview on 03/31/26, at 10:32 A.M., CNA A said, at approximately 9:00 A.M. on 03/30/26, he/she hugged the resident because the resident was upset regarding his/her roommate having a medical procedure. He/She said he/she did not kiss the resident. He/She said staff trained him/her regarding abuse and neglect of residents, including sexual abuse, but he/she said hugging residents is not considered inappropriate. During an interview on 03/31/26, at 10:37 A.M., the administrator said the resident has not made prior allegations regarding any staff or residents being physically inappropriate. During an interview on 03/31/26, at 10:52 A.M., Housekeeper B said between 8:00 A.M. and 9:00 A.M. on 03/30/26, he/she was walking down the hallway with his/her cleaning cart, and observed CNA A walk to the nurses' station from the direction of the resident's room, look around the area, and then quickly went back to the resident's room. He/She said he/she went to the resident's room to clean the room, quietly knocked on the door, and looked into the room. He/She said he/she saw CNA A and the resident in a full hug, and CNA A was kissing the resident on the mouth. He/She said he/she reported the incident to Housekeeper C, who reported the incident to the Administrator. During an interview on 03/31/26, at 11:48 A.M., Housekeeper C said Housekeeper B notified him/her he/she witnessed CNA A hugging and kissing the resident on the mouth. Housekeeper C said he/she immediately reported the incident to the Administrator. During an interview on 04/01/26, at 11:00 A.M., the resident said CNA A would come into his/her room when his/her roommate was not in the room, or the roommate was asleep, and hug and kiss him/her. He/She said on 03/30/26, in the morning, CNA A came into his/her room, hugged him/her, and kissed him/her on the mouth. He/She said he/she did not want to kiss CNA A, and he/she felt uncomfortable. He/She said he/she heard someone come into the room, but he/she did not know who. He/She said he/she did not tell anyone about the incidents because he/she did not want CNA A to treat him/her or his/her friends any differently. Complaint #2963341

Based on observation, interview and record review, facility staff failed to use appropriate hand hygiene infection control practices during perineal care for one residents (Resident's #1) out of two sampled residents; staff failed to follow Enhanced Barrier Precautions (EBP), (the wearing of gown and gloves during high contact patient care activities to prevent the spread of multi-resistant organisms), for two residents (Resident #1 and #2) out of two sampled residents; and staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when facility staff failed change and/or store oxygen in a manner to prevent the spread of bacteria for three residents (Resident #1, #3 and #4) out of three sampled residents. The facility census was 80.1. Review of the facility's Cleaning Guideline-Oxygen Equipment policy, dated 03/12, showed tubing, masks, and cannulas used with oxygen therapy should be replaced monthly and pro re nata (PRN), and marked with date and initials.Review of the facility's Handwashing policy, dated 03/12, showed the purpose is to reduce transmission of organisms from resident to resident, nursing staff to resident and resident to nursing staff. The policy did not provide direction to staff regarding how often to wash hands.Review of the facility's Hand Cleanser (Antiseptic) policy, dated 03/12, showed staff are directed to cleanse the hands between resident contacts during care and to prevent spread of infection.Review of the facility's Perineal Care policy, undated, showed staff are directed to provide perineal care, turn resident away from staff and use a new washcloth and wash around the anus. Staff are directed to help resident reposition to his/her back then remove gloves and wash hands. The policy did not provide direction to staff regarding performing hand hygiene and glove change between a dirty and clean task.Review of the facility's Enhanced Barrier Precautions to Infection Control Guidance policy, dated 03/24, showed to prevent broader transmission of MDRO (multidrug-resistance organisms) and to help protect patients with chronic wounds and indwelling device. EBP (Enhanced barrier precautions) should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed, who requires EBP are residents known to be infected or colonized with a MRDO and residents with a wound, regardless of their MRDO status, EBP should be used when changing briefs or assisting with toileting and transferring residents from one position to another, gloves and donning and doffing of gown are required when conducting high-contact resident care activities that are listed above. 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/30/25, showed staff assessed the resident as:-Severe cognitive impairment;-Required assistance from two or more staff members for toileting assistance;-Did not use oxygen therapy;-Did not have pressure ulcers.Review of the resident's care plan, dated 12/07/25, showed staff assessed the resident as at risk for developing a MRDO and to take extra precautions with high contact resident care activities including dressing, bathing, transferring, hygiene, changing linen and briefs, assisting with catheters by utilizing a disposable gown and gloves. Resident is at risk for respiratory complications due to Morbid Obesity related to hypoventilation, aspiration risk and swelling of ankle with exertion and while lying flat without oxygen. The care plan did provide direction for staff in regard to the use of oxygen as needed. The plan showed the resident was incontinent of urine and needed assistance from staff with perineal care and required extensive to total assistance from staff with transfers. Review of the resident's Physician Order Sheet (POS), dated 12/15/25 through 12/31/25, showed an order to change oxygen tubing monthly on Sunday, cleanse left thigh posterior areas with wound cleaner and apply triad paste once a day or as needed.Review of the resident's Treatment Administration Record, dated 12/01/25 through 12/31/25, showed it did not contain documentation staff changed the oxygen tubing on 12/14/25. Review of the resident's POS, dated 01/01/26 through 1/16/26, showed an order to change oxygen tubing monthly on a Sunday. The POS showed an order to cleanse areas with wound cleaner to the left thigh posterior and apply triad paste once a day or as needed.Review of the resident's TAR, dated 01/01/26 through 01/16/26, showed it did not contain documentation staff changed the oxygen tubing on 01/14/26. Observation on 01/15/26 at 9:25 A.M., showed the resident's nasal canula and oxygen tubing on the floor. The oxygen concentrator did not have a storage bag attached to the machine to contain the tubing when not in use.Observation on 01/15/26 at 9:44 A.M., showed resident's door contained a sign resident on EBP and staff should be wearing a gown and gloves.Observation on 01/15/26 at 9:45 A.M., showed staffed entered the resident's room to provide perineal care. Nurse Aide (NA) A, NA B and Certified Nurse Aide (CNA) C did not wear a gown. NA B picked up the resident's oxygen tubing off the floor and put it on the concentrator. NA A touched the bottom of the resident's shoes and with the same soiled gloves, put the resident's oxygen in his/her nose. NA B, provide perineal care, and without performing hand hygiene or changing gloves, placed a clean brief under the resident. NA B applied powder to the resident, touched the resident's drawer, fastened clean brief and touched the resident's mechanical lift sling with the same soiled gloves. NA B touched oxygen tubing with same gloves, removed his/her gloves and gave the resident his/her call light without performing hand hygiene. NA A placed the bag with the soiled brief on the floor, touched the resident's crayons and placed on the bedside table, then left the room without performing hand hygiene. NA B adjusted the resident's bed, placed the bedside table in front of the resident, touched the resident's personal items without performing hand hygiene. NA B did not leave the room without performing hand hygiene.During an interview on 01/15/26 at 10:09 A.M., CNA C said he/she did not know the resident was on EBP. He/She said the resident did not have any wounds. He/She said he/she did not see the signage on the door directing staff to use gown and gloves when providing care. He/She said staff are directed to change the oxygen tubing if it was on the floor. He/She said staff are directed to use hand hygiene upon entering the resident room and perform hand hygiene and glove changes during care and after touching bodily fluids. He/She said the nighttime nurse was responsible to ensure there was a storage bag for the oxygen tubing attached to the oxygen concentrator. During an interview on 01/15/26 at 10:10 A.M., NA A, said he/she did not know the resident was on Enhanced Barrier Precautions. He/She said the resident did not have any wounds. He/She said he/she did not see the signage on the door directing staff to use gown and gloves when providing care. He/She said staff are directed to change the oxygen tubing if it was on the floor. He/She said he/she did not realize the tubing was on the floor before picking it up and placing the oxygen on the resident. He/She said staff are directed to use hand hygiene upon entering the resident room and perform hand hygiene and glove changes during care and after touching bodily fluids. He/She said he realized he/she missed a hand hygiene and glove change opportunity when providing care. He/She said he/she missed the opportunity because he/she did not think about it.During an interview on 01/15/26 at 10:11 A.M., NA B said he/she did not know the residents was on EBP or if the resident had a wound. He/She said he/she did not see the signage on the door directing staff to use gown and gloves when providing care. He/She said staff are directed to change the oxygen tubing if it was on the floor. He/She said staff are directed to use hand hygiene upon entering the resident room and perform hand hygiene and glove changes during care and after touching bodily fluids. He/She said he realized he/she missed a hand hygiene and glove change opportunity when providing care. He/She said he/she missed the opportunity because he/she was in the moment.During an interview on 01/15/26 at 1:13 P.M., the administrator said staff are educated to label the oxygen tubing with the date the tubing was changed and document in the TAR. He/She said staff if staff did not label the oxygen tubing with the date it was changed and/or document in the TAR, staff would not know the tubing was changed. He/She said there was no current system in place to ensure the oxygen tubing was replaced and documented in the TAR, but the Assistant Director of Nursing (ADON) would be responsible to ensure the task have been completed. He/She said staff are educated to replace oxygen tubing if it laid on the floor to prevent an infection control concern. He/She said staff are educated to perform hand hygiene upon entering and exiting a resident's room and should change gloves and perform hand hygiene when moving from a dirty to a clean task to prevent cross contamination and infection control issues. He/She said signage was hung a resident's door if the resident was placed on any type of precautions. He/She said the signage would include what type of personal protective equipment should be worn when providing care. He/She said if a resident was on EBP, staff are educated to use a gown, gloves and a mask to prevent cross contamination and infection control issues. During an interview on 01/15/26 at 1:14 P.M., the ADON said staff are directed to label the oxygen tubing with the date the tubing was changed and document in the TAR. He/She said staff would not know the oxygen tubing was replaced if it was not documented in the TAR and/or if the tubing was not labeled with the date the tubing was replaced. He/She said there was no current system in place to ensure the oxygen tubing was replaced and documented in the TAR, but he/she will not be responsible to ensure the task have been completed. He/She said staff are directed to replace oxygen tubing if it was on the floor to prevent an infection control concern. He/She said staff are directed to perform hand hygiene upon entering and exiting a resident's room and should change gloves and perform hand hygiene when moving from a dirty to a clean task to prevent cross contamination and infection control issues. He/She said if a resident was on any type of precautions, there was a sign on the resident's door stating the type of precaution and what personal protective equipment should be worn. He/She said if a resident was on EBP, staff are directed to use a gown, gloves and a mask to prevent cross contamination and infection control issues. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed staff assessed the resident as:-Moderately cognitively impairment;-Required assistance from two or more staff members for toileting assistance;-Did not have pressure ulcers.Review of the resident's care plan, dated 12/07/25, showed the resident is at risk for skin breakdown and required assistance from staff for incontinence. Review showed the resident at risk of developing a MRDO due to having a wound and staff will take extra precautions when providing high contact resident activities including dressing, bathing, transferring, hygiene, changing linen, briefs or assisting with catheters, by utilizing a disposable gown and gloves. The plan showed the resident required one to two person assistance with bed mobility, transfers, toileting, perineal car, personal hygiene and bathing.Review of the resident's POS, dated 01/01/26 through 01/16/26, showed an order to cleanse area to back left thigh with wound cleanser, apply skin prep once daily and as needed and apply dry dressing placed on lateral thigh every shift and as needed.Observation on 01/15/26 at 11:05 A.M., showed the resident door with a sign for EBP precautions and staff should be wear a gown and gloves.Observation on 01/15/26 at 11:06 A.M., showed CNA C entered the resident's room to provide perineal care. The CNA C did not wear a gown while he/she provided direct care. During an interview on 01/15/26 at 11:06 A.M., the resident said he/she had wounds on his/her buttocks. During an interview on 01/15/26 at 12:05 P.M., CNA C said he/she did not know the resident had a wound and did not notice the signage to wear a gown until after he/she left the resident's room. During an interview on 01/15/26 at 1:13 P.M., the administrator said signage was hung a resident's door if the resident was placed on any type of precautions. He/She said the signage would include what type of personal protective equipment should be worn when providing care. He/She said if a resident was on EBP, staff are educated to use a gown, gloves and a mask to prevent cross contamination and infection control issues. During an interview on 01/15/26 at 1:14 P.M., ADON said if a resident was on any type of precautions, there was a sign on the resident's door stating the type of precaution and what personal protective equipment should be worn. He/She said if a resident was on EBP, staff are directed to use a gown, gloves and a mask to prevent cross contamination and infection control issues. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident as does not require a Brief Interview for Mental Status and does not use oxygen.Review of the resident's POS, dated 12/01/25 through 01/15/26, showed it did not contain an order for oxygen or when the oxygen tubing should be changed.During an observation on 01/15/26 at 9:38 A.M., resident laid in his/her bed with his/her nasal canula inserted into his/her nose. The oxygen tubing was undated, and the oxygen concentrator did not have a storage bag attached to the machine to contain the tubing when not in use. 5. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/26/25, showed staff assessed the resident as cognitively intact and did not use oxygen. Review of the resident's care plan, dated 01/20/26, showed staff assessed the resident as does not use oxygen.Review of the resident's POS, undated, showed an order to administer oxygen at two liters as needed for shortness of breath. The POS did not contain an order to replace oxygen tubing.Observation on 01/15/26 at 9:30 A.M., showed the resident wearing an undated oxygen nasal cannula. The oxygen concentrator did not have a storage bag attached to the machine to contain the tubing when not in use.Review of the resident's TAR, dated 01/01/26 through 01/15/26, showed it did not contain documentation staff changed the oxygen tubing.6. During an interview on 01/15/26 at 12:50 P.M., LPN D said the oxygen tubing was changed weekly by the night shift nurse. He/She said the oxygen tubing should be labeled with the date the tubing was changed and a storage bag attached to the concentrator for storage when not in use. He/She said the tubing should be stored in a bag when not in use. He/She said if staff noticed tubing not labeled or a storage bag available, then they are responsible to complete the tasks. He/She said he/she has noticed resident's tubing not labeled and no storage bag for the tubing, but he/she was the only nurse during the day and did not have time to complete the task. He/She said if the oxygen tubing was not labeled, staff would not know it was changed. He/She said the concern with the oxygen tubing used after it laid on the floor, was the potential to cause the resident to be sick. During an interview on 01/15/26 at 1:13 P.M., the administrator said staff are educated to label the oxygen tubing with the date the tubing was changed and document in the Treatment Administration Record (TAR). He/She said staff if staff did not label the oxygen tubing with the date it was changed and/or document in the TAR, staff would not know the tubing was changed. He/She said there was no current system in place to ensure the oxygen tubing was replaced and documented in the TAR, but the Assistant Director of Nursing (ADON) would be responsible to ensure the task have been completed. He/She said staff are educated to replace oxygen tubing if it laid on the floor to prevent an infection control concern. During an interview on 01/15/26 at 1:14 P.M., the ADON said staff are directed to label the oxygen tubing with the date the tubing was changed and document in the TAR. He/She said staff would not know the oxygen tubing was replaced if it was not documented in the TAR and/or if the tubing was not labeled with the date the tubing was replaced. He/She said there was no current system in place to ensure the oxygen tubing was replaced and documented in the TAR, but he/she will not be responsible to ensure the task have been completed. He/She said staff are directed to replace oxygen tubing if it was on the floor to prevent an infection control concern. #2706858

Based on observation, interview and record review, facility staff failed to provide a clean, comfortable and homelike environment for residents, staff, and visitors. Staff failed to ensure carpet in shared hallways maintained a pleasant odor, and air vents remained free from excessive build-up of a black unknown substance. The facility's census was 71.1. Review of the facility's Housekeeping Department-Seven Step Cleaning Procedure policy, undated, showed the resident room cleaning procedure should be used for all resident rooms to maintain cleanliness and to promote infection control. Staff are directed as follows:-High dust surfaces above shoulder height;-Wipe down all surfaces, lower ledges and pipes of the sink;-Wipe the tub and shower with approved disinfectant cleaner ready-to-use solution with a clean cloth;-Note any maintenance work that needs to be done, notify your supervisor of any maintenance work.2. Observation on 08/07/25 at 9:50 A.M., showed Resident #1's bathroom door with gouges and a hole to the lower left corner, the air vent contained a build-up of a dark grey substance, the faucet contained a build-up of debris, and the toilet tank lid on the floor in the corner under the sink.During an interview on 08/07/25 at 11:54 A.M., the resident said staff have been taking him/her to use the bathroom in the residents' shower room. During an interview on 08/07/25 at 2:04 P.M., the Maintenance Director said he/she was not aware of the hole in the resident's bathroom door, but he/she turned the water supply off to the resident's toilet to prevent a leak at the base of the toilet, and had a new toilet ordered to replace it. He/She said he/she notified staff to assist the resident to use the bathroom in the spa room until he/she installs the new toilet. He/She said housekeeping is responsible to clean the faucets daily, and if they notice any build-up areas, they should report to him/her to address. 3. Observation on 08/07/25 at 10:00 A.M., showed Resident #3's room ceiling with areas of missing paint. Observation showed the bathroom shower stall with clothing, suitcase, a walking cane, plastic storage containers, and the toilet's arm rest with cracks and sharp edges.During an interview on 08/07/2025 at 2:18 P.M., the Director of Nursing (DON) said the residents who reside inside the room do not normally use the bathroom inside the room. He/She said he/she was not aware of the items stored inside the residents' shower stall and would expect staff to place the items on a raised surface for cleanliness if the shower stall was being used as storage.4. Observation on 08/07/25 at 11:28 A.M., showed Resident #2's ceiling missing paint, the air vent contained pieces of white debris under the window air conditioning unit, the bathroom air vent with build-up of a dark grey substance, and areas of patched/unpainted drywall next to the toilet paper holder.During an interview on 08/07/25 at 11:30 A.M., Resident #2 said housekeeping staff does not always sweep or vacuum the carpet in his/her room, and the debris under the window unit has been there for at least two days. The resident said he/she was recently moved to his/her current room due to concerns of a toilet overflow from the adjacent room, and potential mold on the carpet inside his/her old room. 5. Observation on 08/07/25 at 11:41 A.M., showed occupied resident room [ROOM NUMBER] Resident #5's room carpet with dark stains and multiple areas of missing/unpainted ceiling texture.6. During an interview on 08/07/2025 at 11:35 A.M., Housekeeper C said maintenance staff are responsible to clean the air vents, and housekeeping staff is responsible to clean the resident rooms, bathrooms, blinds, and to sweep and vacuum the floors daily.During an interview on 08/07/2025 at 1:15 P.M., Certified Medical Technician (CMT) A said a couple residents expressed their concerns to staff of potential mold inside their rooms and were moved to different rooms. He/she said staff are expected to document maintenance issues in the maintenance book at the nurses' station or tell the maintenance director/administrator. The CMT said he/she did not recall the exact residents. During an interview on 08/07/2025 at 1:28 P.M., CMT B said staff are expected to document concerns with broken stuff and room maintenance issues in the maintenance logbook kept at each nurses' station.During an interview on 08/07/2025 at 1:40 P.M., the Housekeeping Supervisor said housekeeping staff are responsible to clean the resident rooms daily and maintenance is responsible to clean the air vents.During an interview on 08/07/2025 at 2:04 P.M., the Maintenance Director said he/she was responsible to maintain the building with drywall repairs, painting, etc. He/She said staff are expected to use the maintenance book on each hall to report any broken items or maintenance concerns for him/her to address.During an interview on 08/07/2025 at 2:18 P.M., the DON said staff are expected to report any maintenance issues by documenting in the maintenance logbook at the nurses' stations. During an interview on 08/07/2025 at 2:30 P.M., the administrator said he/she expects staff to document maintenance issues/concerns in the maintenance logbook at the nurses' stations rather than verbally telling the maintenance director, the maintenance director to check the books daily, and sign/acknowledge each concern once they have been addressed.7. Review of the facility's policies showed staff did not provide a policy regarding the maintenance of hallway carpets and building air vents.Review of the administrator's electronic communication with the Corporate Maintenance staff, dated 08/07/25, showed an email with subject line Carpet odor and possible mold. The Corporate Maintenance staff documented the Maintenance Supervisor contacted him/her a week prior to discuss carpet concerns, and he/she ordered and shipped a chemical carpet cleaner to the facility to be used, and if the Maintenance Supervisor had any issues or questions to contact him/her to come up with another solution. 8. Observation on 08/07/25 at 9:15 A.M., showed the hallway carpet on the [NAME] Hall with scattered dark-colored stains marks, a musty smell, and an unpleasant pungent odor.Observation on 08/07/25 at 1:48 P.M., showed the hallway carpet on the [NAME] Hall with scattered dark-colored stains marks, a musty smell, and an unpleasant pungent odor.During an interview on 08/07/2025 at 1:40 P.M., the Housekeeping Supervisor said the floor technicians are responsible to clean the floors and carpets in the hallways daily, and he/she oversees that it gets done. 9. Observation on 08/07/25 at 10:04 A.M., showed four square ceiling air vents surrounding the nurses' station on the [NAME] Hall with a scattered build-up of a black unknown substance.During an interview on 08/07/2025 at 2:04 P.M., the Maintenance Director said he/she had not had the chance to clean the vents by the [NAME] Hall nurses' station.10. Observation on 08/07/2025 at 10:46 A.M., showed two large square air vents on the wall in the dining room with an accumulation of a dark grey substance and dirt.11. Observation on 08/07/2025 at 10:48 A.M., showed the air vents in the kitchen and the dietary managers office contained build-up of a black unknown substance:12. Observation on 08/07/2025 at 10:55 A.M., showed two large vents in the facility kitchen above the two-sink compartment with an accumulation of a dark grey substance and dirt.13. Observation on 08/07/2025 at 11:01 A.M., showed two ceiling air vents surrounding the nurse's station on the Colonial Hall with a scattered build-up of a black unknown substance.During an interview on 08/07/2025 at 11:35 A.M., Housekeeper C said maintenance staff are responsible to clean the air vents. Housekeeper C said he/she reported to maintenance about a week prior that the air vents near the nurses' station were covered with a black substance. He/She said maintenance did clean some of the air vents, but the black substance is still there.During an interview on 08/07/2025 at 1:15 P.M., CMT A said he/she noticed black stuff inside the vents by the nurses' stations about a week and had verbally reported it to maintenance. During an interview on 08/07/2025 at 1:28 P.M., CMT B said a little over a week ago he/she reported to the housekeeping supervisor, maintenance, and the Administrator that there was a black substance on the air vents surrounding the Colonial Hall nurses' station and inside the clean utility room. He/She said they did clean some of the vents, but you can see it building back up inside the vents by the nurses' station. The CMT said he/she is not sure if anyone has a schedule to clean the air vents. 14. During an interview on 08/07/2025 at 1:40 P.M., the Housekeeping Supervisor said the floor techs are responsible to clean the floors and carpets in the hallways, and maintenance is responsible to clean the air vents. The Housekeeping Supervisor said he/she has seen what looks like mold on carpets in some of the empty rooms and he/she sprayed the areas earlier in the morning with a chemical that usually works well. He/She said the floor techs are expected to clean the floors and carpets in the hallways daily, and he/she oversees that it gets done. During an interview on 08/07/2025 at 2:04 P.M., the Maintenance Director said he/she is responsible for cleaning the air vents. The Maintenance Director said he/she recently cleaned the air vents on the Colonial Hall, but still needs to clean the other air vents. The Maintenance Director said he/she does not have a routine schedule to clean the air vents, but he/she will clean them as needed. He/She said they have had issues with condensation on the air vents which has been making them dirty and has talked with the facility's corporate maintenance staff about getting rid of extra condensation because it could lead to mold. The Maintenance Director said he/she does not currently have concerns of mold being on the vents but understands the air vents are dirty and has had staff members report that the air vents are dirty. The Maintenance Director said he/she received a chemical to use to clean the carpets in the rooms that smell like mildew, and the chemical will kill the mold if there is mold.During an interview on 08/07/2025 at 2:18 P.M., the DON said about a week prior, one staff member reported there was a black substance on the air vents by the Colonial Hall nurses' station. The DON said he/she reported it to maintenance and the Administrator. The DON said room [ROOM NUMBER] and room [ROOM NUMBER] were two rooms that residents were moved out of because of concerns with suspected mold.During an interview on 08/07/2025 at 2:30 P.M., the Administrator said the DON sent him/her a picture of the air vents on the Colonial Hall that showed the air vents covered in a black substance, he/she reported it to maintenance who went and cleaned the air vents. The Administrator said the facility does not currently have a set schedule to clean the air vents, but he/she would expect maintenance to clean the vents every two weeks and as needed. He/She said that about a week prior, two residents noticed signs of a wet dark sport on the carpet in their rooms, and had a musty smell, and both residents have been removed from those rooms and moved into different rooms. The Administrator said he/she and maintenance have started to clean the carpets with a chemical.Complaint # 2575243, 2574982, 2576588, 2578982

Based on observation, interview, and record review, facility staff failed to take appropriate action when one resident (Resident #1) threatened suicide. The facility census was 77. 1. Review of the facility's Suicide Threats policy, undated, showed: -Resident suicide threats shall be taken seriously and addressed appropriately; -Staff shall report any resident threats immediately to the charge nurse; -The charge nurse shall immediately assess the situation and shall notify the director of nursing of such threats; -A staff member shall remain with the resident until the charge nurse arrives to evaluate the resident; -After assessing the resident in more detail, the charge nurse shall notify the resident's attending physician and responsible party, and shall seek further direction from the physician; -All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately; -As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated; -If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present; -Staff shall document details of the situation objectively in the resident's medical record. 2. Review of the resident's face sheet showed Resident #1 was admitted to the facility on [DATE]. Review showed admitting diagnoses included generalized anxiety disorder and suicidal ideations. Review of the resident's electronic health record showed it did not contain a care plan. Review of the resident's nurse's note, dated 04/05/2025 at 6:45 P.M., showed Licensed Practical Nurse (LPN) A documented resident frequently cries, was overheard one time from a staff member in the hall, she was in her room on the phone, saying something in regard to, he/she did not know if he/she wanted to live anymore. Staff member reported this to this nurse, this nurse went and spoke to resident about what was overheard, told him/her that if he/she was having these feelings, it would be a good idea to go to the hospital where they would be able to help him/her better with his/her emotional state. The nurse documented he/she asked the resident if he/she had a plan to hurt him/herself, resident denied he/she had any kind of plan, and he/she had made an appointment with his/her usual doctor over video conference and would be okay to wait until this date. This nurse checked on resident at least every 15 minutes, sometimes more frequently to see how he/she was feeling. After speaking with him/her several times, resident was quite pleasant and said he/she felt a lot better and thanked me for listening. Will continue to monitor resident closely for emotional status and behavior. Review showed the documentation did not contain the date and time of the incident. Review of the resident's Electronic Health Record (EHR) showed the record did not contain: -The date the resident stated he/she did not want to live anymore; -Documentation of Director of Nursing (DON) notification; -Documentation of physician notification. During an interview on 04/05/25 at 6:20 P.M., the LPN A overheard the resident telling someone on the phone he/she did not want to live. The LPN said he/she thought the incident was a couple of weeks ago and he/she did not remember which staff member overheard the resident. LPN A said he/she spoke with the resident. The LPN said he/she did not notify the DON or resident's doctor because he/she thought the resident was okay after he/she spoke with the resident. The LPN said he/she did not document the incident at the time because he/she thought the resident was okay. During an interview on 04/05/25 at 8:00 P.M., the DON said he/she was never notified of any issues with the resident. During an interview on 04/07/25 at 10:20 A.M., the DON said he/she would expect to be notified if a resident said they did not want to live anymore. The DON said he/she would expect the resident's doctor to be notified. The DON said the nurse should document the resident's emotional distress and any actions taken to reduce the distress. The DON said he/she was aware the resident had a psychiatric history but was not aware of the resident's diagnosis of suicidal ideations. During an interview on 04/07/25 at 11:52 A.M., the administrator said he/she would expect the charge nurse to notify the DON and doctor if a resident talked about suicide. The administrator said the charge nurse is responsible for ensuring the resident is closely monitored and all actions are documented and shared with other staff caring for the resident. The administrator said nursing staff should develop a written plan to address any resident's emotional distress. The administrator said he/she was unaware of any issues with the resident. The administrator said he/she was not aware of the resident's diagnosis of suicidal ideations. During an interview on 04/14/25 at 1:05 P.M., the physicians nurse said there was no record of the facility contacting the physician's office between 03/26/25 and 04/04/25 related to suicidal comments or emotional distress. MO00252319

Based on observation, interview, and record review, facility staff failed to notify one resident's (Resident #1) physician when the resident said he/she did not want to live anymore. The facility census was 77. 1. Review of the facility's Suicide Threats policy, undated, showed: -Resident suicide threats shall be taken seriously and addressed appropriately; -Staff shall report any resident threats immediately to the charge nurse; -The charge nurse shall immediately assess the situation and shall notify the director of nursing of such threats; -After assessing the resident in more detail, the charge nurse shall notify the resident's attending physician and responsible party, and shall seek further direction from the physician; -Staff shall document details of the situation objectively in the resident's medical record. 2. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of generalized anxiety disorder and suicidal ideations. Review of the resident's Electronic Health Record (EHR) showed the health record did not contain a care plan. Review of the resident's nurse's note, dated 04/05/2025 at 6:45 P.M., showed staff documented resident frequently cries. Review showed staff documented they overheard the resident on the phone a few weeks ago, say he/she did not know if he/she wanted to live anymore. Staff member reported this to this nurse, this nurse went and spoke to resident about what was overheard, told him/her if he/she was having these feelings, it would be a good idea to go to the hospital where they would be able to help him/her better with his/her emotional state. Review of the resident's EHR showed the record did not contain documentation staff notified the residents physician of the resident saying he/she did not know if he/she wanted to live anymore. During an interview on 04/05/25 at 6:20 P.M., Licensed Practical Nurse (LPN) said the resident cries all the time. The LPN said a staff member overheard the resident telling someone on the phone he/she did not want to live. The charge nurse said he/she thought the incident was a couple of weeks ago and he/she did not remember which staff member overheard the resident. The LPN said he/she spoke with the resident. LPN A said he/she did not notify the DON or resident's doctor because he/she thought the resident was okay after he/she spoke with the resident. The LPN said he/she did not document the incident at the time because he/she thought the resident was okay. The LPN said he/she was not aware of the resident talking about suicide today. During an interview on 04/07/25 at 10:20 A.M., the DON said he/she would expect to be notified if a resident said they did not want to live anymore. The DON said he/she would expect the resident's doctor to be notified. The DON said the nurse should document the resident's emotional distress and any actions taken to reduce the distress. The DON said he/she was aware the resident had a psychiatric history but was not aware of the resident's diagnosis of suicidal ideations. During an interview on 04/07/25 at 11:52 A.M., the administrator said he/she would expect the charge nurse to notify the residents doctor if a resident talked about suicide. The administrator said the charge nurse is responsible for ensuring the resident is closely monitored and all actions are documented and shared with other staff caring for the resident. MO00252319

Based on interview and record review, facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required time frame for one (Resident #1) of one sampled resident. The facility's census was 77. 1. Review of the RAI manual version 3.0 RAI Omnibus Budget Reconciliation Act (OBRA)-required Assessment Summary showed an admission (Comprehensive) MDS completion date no later than 14th calendar day of the resident's admission. 2. Review of Resident #1's Entry Tracking Record MDS, showed the resident admitted to the facility on [DATE]. Review of the resident's electronic health record did not contain a completed MDS or submitted admission assessment within the required time frame. Review showed the admission assessment included a due date of 04/02/25. During an interview on 04/07/25 at 10:20 A.M., the Director of Nursing (DON) said the MDS coordiantor was responsible for ensuring the admission assessment was completed within 14 days of admission. During an interview on 04/07/25 at 10:45 A.M., the MDS Coordinator said he/she had 14 days to complete the admission assessment. The MDS coordinator said the corporate registered nurse (RN) then had three days to sign the completed MDS. The MDS coordinator said the MDS assessment was not complete until an RN signed it. During an interview on 04/07/25 at 9:18 A.M., the administrator said the MDS Coordinator is responsible to complete the residents' MDS within the required time frames. He/She said the residents' admission MDS should be completed within 14 days after admission. The administrator said he/she was not aware of an additional three day period for an RN to sign the MDS assessment. The administrator said he/she was not aware the resident's MDS assessment was not completed. MO00252319

Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered baseline care plan to meet the resident's medical, nursing, mental and psychosocial needs for one resident (Resident #1). The facility's census was 77. 1. Review a baseline care plan showed staff are directed to complete the baseline care plan within 48 hours of admission. After completion, print and file following community protocols 2. Review of Resident #1's medical record showed staff documented the resident was admitted to the facility on [DATE]. Review showed the record did not contain a baseline care plan. During an interview on 04/05/25 at 7:42 P.M., the Assistant Director of Nursing (ADON) said he/she loaded the baseline care plan template into the Electronic Health Record when the resident was admitted . The ADON said the admitting nurse was responsible for completing the baseline care plan upon admission. The ADON said the DON was responsible for ensuring the baseline care plan was completed as required. During an interview on 04/07/25 at 10:20A.M., the DON said the admitting nurse was responsible for completing a comprehensive assessment, which served as the baseline care plan, by the end of the shift on the day of admission. The DON said he/she or the ADON were responsible for ensuring baseline care plans were completed. The DON said he/she was on vacation the week the resident was admitted and the baseline care plan was missed. The DON said he/she was aware the resident had a psychiatric history but was not aware of a recent diagnosis of suicidal ideations. During an interview on 04/07/25 at 11:52 A.M., the administrator said baseline care plans are to be completed upon admission by the admitting nurse. The administrator said he/she would expect the ADON or DON to follow up on missing care plans. MO00252319

Please see Event ID 8CNK12 exit date 02/13/2025 Based on observation, interview and record review, facility staff failed to notify one resident's (Resident #24) representative when the resident's toilet came unsecured from the floor and tipped and required a room change. Facility staff failed to notify two resident's (Resident #24 and #32) physician in a timely manner when the resident had a skin injury. The facility census was 73.

Based on interview and record review, facility staff failed to provide adequate nursing staff on night shift, in accordance with their Facility Assessment based on the care needs of the residents. The facility's census was 66. 1. Review of the facility's Facility Assessment, dated 07/02/24, showed facility staff documented for an average daily census of 65-70 residents, the staffing requirements needed on the night shift to meet the care needs of their residents are as follows: -Two Licensed Nurses (one on each nurses' station); -Five to eight Certified Nursing Assistants (CNAs). 2. Review of the facility's Nursing Staff schedule, dated 12/12/24 through 12/17/24 showed: -12/12/24: One-Licensed Nurse and Four-CNAs scheduled to work the shift; -12/13/24: One-Licensed Nurse and Four-CNAs scheduled to work the shift; -12/14/24: One-Licensed Nurse and Three-Nursing Assistants (NAs) scheduled to work the shift; -12/15/24: One-Licensed Nurse and Three-NAs scheduled to work the shift; -12/16/24: One-Licensed Nurse and Four-CNAs scheduled to work the shift; -12/17/24: One-Licensed Nurse and Four-CNAs scheduled to work the shift; Review showed facility staff did not schedule at least two licensed nurses and five CNAs to work each night shift as directed by their facility assessment. 3. Review of the facility's daily Nurse Staff posting, dated 12/12/24 through 12/17/24, showed staff documented a daily census of 66 residents, and one licensed nurse and four CNAs worked each night shift. 4. Review of the facility's time-keeping records for the nursing staff showed: -12/12/24: One-Licensed Nurse, Two-CNAs, and One-NA worked the shift; -12/13/24: One-Licensed Nurse, One-CNA, and Two-NAs worked the shift; -12/14/24: One-Licensed Nurse, and Three-NAs worked the shift; -12/15/24: One-Licensed Nurse, and Three-NAs worked the shift; -12/16/24: One-Licensed Nurse, Two-CNAs, and One-NA worked the shift; -12/17/24: One-Licensed Nurse, Two-CNAs, One-NA worked the full shift, One-CNA at 4:14 A.M. During an interview on 12/18/24 at 6:52 A.M., the administrator said the Assistant Director of Nursing (ADON) was responsible for scheduling the nursing staff. He/She said for a daily census of 66 residents, he/she expects the ADON to schedule at least four CNAs and one licensed nurse to work the night shift to ensure the residents' safety and their care needs are being met. The administrator said he/she was not aware there were less than four CNAs working the night shift because the facility has a system in place to ensure the minimum nurse staff requirements are being met. During an interview on 12/18/24 at 7:22 A.M., the administrator said he/she was not aware the ADON had only scheduled three NAs to work the night shift on 12/14/24 and 12/15/24, which was unacceptable since the NAs are not certified, and staff should have scheduled at least one CNA to work with the NAs. During an interview on 12/18/24 at 7:36 A.M., the ADON said he/she was responsible to schedule sufficient nursing staff for each shift, and for a census of 66 residents, he/she is expected to schedule at least four CNAs and one licensed nurse to work each night shift. The ADON said it was unacceptable to only have NAs work the shift as they lacked full competency to meet the residents' care needs. During an interview on 12/18/24 at 4:44 A.M., CNA K said he/she was the only staff assigned to the side of the building with Colonial Hall and the secured Memory Care Unit (MCU) for 12/17/24 night shift, and he/she was only responsible for the residents on the MCU. During an interview on 12/18/24 at 5:16 A.M., CNA K said there is not always a CNA assigned to work on Colonial Hall on the night shift. The CNA said he/she had been at work since beginning of shift on 12/17/24 at 6:00 P.M., and there was not a CNA assigned to Colonial Hall for the shift. During an interview on 12/18/24 at 6:52 A.M., the administrator said when there is only one licensed nurse working the night shift, he/she works from the [NAME] nurses' station located on the opposite side of the building from Colonial Hall, and if a CNA/NA was not assigned to Colonial Hall and a resident on Colonial Hall pushed his/her call light, the staff on [NAME] would not receive the call light notification unless someone physically walked over to Colonial Hall to check. He/She said it was unacceptable to not have any staff assigned to the Colonial Hall on night shift to ensure the residents' safety and their care needs are being met. During an interview on 12/19/24 at 1:12 P.M., the ADON said he/she is expected to schedule nursing staff based on the current facility assessment and for a census of 66 residents, he/she thought a minimum of one licensed nurse and four CNAs met the staffing requirement for the night shift. He/She said one CNA is assigned to the MCU each night and if four CNAs are scheduled, one is assigned to Colonial Hall, and two to [NAME] Hall. He/She said if three CNAs are scheduled, two are assigned to [NAME] due to the care needs of the residents, and likely no one assigned on Colonial. During an interview on 12/19/24 at 3:50 P.M., the administrator said the nursing staff requirements documented in the current facility assessment is accurate based on the census of 66 residents, but the facility is just not able to consistently provide two licensed nurses and five to eight CNAs to work the night shift due to a current staffing challenge.

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 66. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. 2. Review of the facility's RN staff schedule, dated October 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates of: -Tuesday 10/01/24; -Saturday 10/05/24; -Sunday 10/06/24; -Thursday 10/10/24; -Friday 10/11/24; -Saturday 10/12/24; -Sunday 10/13/24; -Monday 10/14/24; -Tuesday 10/15/24; -Friday 10/18/24; -Saturday 10/19/24; -Sunday 10/20/24; -Tuesday 10/22/24; -Thursday 10/24/24; -Friday 10/25/24; -Saturday 10/26/24; -Sunday 10/27/24; -Tuesday 10/29/24; -Wednesday 10/30/24. 3. Review of the facility's RN staff schedule, dated November 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates on: -Friday 11/01/24; -Saturday 11/02/24; -Sunday 11/03/24; -Monday 11/04/24; -Tuesday 11/05/24; -Wednesday 11/06/24; -Friday 11/08/24; -Saturday 11/09/24; -Sunday 11/10/24; -Tuesday 11/12/24; -Friday 11/15/24; -Saturday 11/16/24; -Sunday 11/17/24; -Monday 11/18/24; -Tuesday 11/19/24; -Friday 11/22/24; -Saturday 11/23/24; -Sunday 11/24/24; -Monday 11/25/24; -Tuesday 11/26/24; -Thursday 11/28/24; -Friday 11/29/24; -Saturday 11/30/24. 4. Review of the facility's RN staff schedule, dated December 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates of: -Sunday 12/01/24; -Saturday 12/07/24; -Monday 12/09/24; -Tuesday 12/10/24; -Friday 12/13/24; -Saturday 12/14/24; -Sunday 12/15/24. During an interview on 12/17/24 at 2:00 P.M., the Director of Nursing (DON) said he/she is currently the only RN on the schedule. He/She said its his/her expectation an RN needs to be in the facility eight consecutive hours daily. The DON said he/she was aware there was not an RN for several days because if he/she was not there, then there was no other RN to be in facility. He/She said the reason there were days that weren't full eight hours was because he/she is salaried and he/she was only in the building to take care of the facility needs and not really the RN coverage hours. He/She said the risk of not having an RN in the building eight consecutive hours daily is not having the RN knowledge in case something was to happen. During an interview on 12/17/24 at 2:10 P.M., the administrator said it is expected to have an RN on schedule eight consecutive hours daily. He/She said he/she was aware there hasn't been an RN eight consecutive hours daily because they currently only have one RN on schedule. He/She said the risk of not having an RN daily is not having the RN experience and knowledge in case something is needed.

Based on interview and record review, facility staff failed to ensure three Nurse Aide's ((NA) NA A, NA C, and NA E) of five sampled staff completed the nurse aide training program within four months of his/her employment in the facility. The census was 66. 1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications. 2. Review of the facility's employee file, undated, showed NA A's hire date as 12/07/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 3. Review of the facility's employee file, undated, showed NA C's hire date as 07/25/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. During an interview on 12/18/24 at 4:45 A.M., NA C said he/she was told he/she needed to be certified within 90 days of hire. He/She said he/she has not taken any classes. He/She said they used to be able to take classes at another facility, but they are not able to take classes there anymore. He/She said the facility staff has not reached out to him/her about taking classes to become certified. NA C said he/she had not left his/her employment with the facility since January 2024. NA C said he/she had been employed as an NA in 2023 but then was rehired in January 2024. 4. Review of the facility's employee file, undated, showed NA E's hire date as 08/08/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 5. During an interview on 12/19/24 at 10:35 A.M., the Assistant Director of Nursing (ADON) said NA's need to be certified within 120 days from hire. He/She said he/she is aware they have NA's outside of 120 days. He/She said staff are outside the 120 days because they did not have a place for them to take the classes. He/She said staff were able to take classes at another facility previously and they are no longer able to take classes there. He/She said he/she has been looking for another place for the NA's to take classes. The ADON said he/she could not provide documentation to show attempts had been made to take classes elsewhere. During an interview on 12/19/24 at 10:38 A.M., the administrator said they do not offer NA classes at their facility. He/She said he/she knows the regulation says NA's should be certified 120 days from date of hire. He/She said he/she is aware they have three NA's outside of the 120 days. He/She said they were using another facility to take the classes, but they are no longer able to use that facility. He/She said his/her ADON is working on finding a facility that they can get their NA's into. The administrator said he/she did not have any documentation to show the NA's had been in any CNA training classes at other facilities. During an interview on 12/19/24 at 2:40 P.M., the Director of Nursing (DON) said NA's should be certified within 120 days of hire. He/She said they do not currently have any of their NA's taking classes. He/She said finding a place for the NA classes has been a struggle because the other facility used was bought out three weeks ago. He/She said the ADON has been responsible for looking for an alternative location for classes.

Based on observation, interview, and record review, facility staff failed to maintain professional standards of care, when staff failed to follow physician's orders regarding water flushes during medication administration for one resident (Resident #12) with a Percutaneous endoscopic gastrostomy (PEG) tube and one resident (Resident #38) with a Gastrostomy Tube (G-Tube), (tube inserted through the stomach used for administration of food, fluids, and medications). The facility census was 66. 1. Review of the facility's policy for Medication, Administration by Naso-Gastric or Gastrostomy Tube, undated, showed staff are directed as follows: -Wash hands; -Verify the recipient with physician orders and medication administration record; -Check residual, if less then 100 milliliters (ml) return to stomach and flush with amount of water as ordered; -Give medication only by gravity; -At completion of medication administration, flush tube with water as ordered. 2. Review of the facility's policy on Physician Orders, undated, showed staff are directed as follows regarding Tube Feeding: -Specify the type of feeding, amount, frequency of feeding, frequency for tube change, and rationale if as needed; -Should always be followed by water. 3. Review of Resident #38's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/04/24, showed staff assessed the resident with a feeding tube. Review of the resident's plan of care, last updated 09/13/24, showed staff assessed the resident as a nutritional risk, and risk of alteration in fluids related to feeding tube. Review of the resident's Physician's Order Sheet (POS), dated December 2024, directed staff to flush G-tube with 30 milliliters (ml) of water before and after meds. Observation on 12/18/24 at 7:00 A.M., showed LPN G entered the resident's room with prepared medications, in total 4 medication cups. The LPN filled a graduated container with 500 ml of tap water. Observation showed LPN G attached a syringe to the resident's G-tube, and flushed with the 60 ml of water, LPN G administered each medication and flushed 30ml of water after each medication. He/She then flushed the remaining 320 ml of water and closed the tube. Staff did not flush the G-tube as ordered by the physician when they gave to much water during the mediction administration. 4. Review of Resident #12's Quarterly MDS, dated [DATE], showed staff assessed the resident with a feeding tube Review of the resident's plan of care, last updated 12/16/24, showed staff assessed the residents nutritional status as a Percutaneous Endoscopic Gastrostomy (PEG) tube with continuous feedings at night. Review of the resident's Physician's Order Sheet (POS), dated December 2024, directed staff to flush tube with 60 ml of water before and after meds. Observation on 12/18/24 at 7:20 A.M., showed LPN G entered the resident's room with prepared medications in four medication cups. The LPN filled a graduated container with 500 ml of tap water. Observation showed LPN G attached a syringe to the resident's PEG tube, and flushed with the 60 ml of water, LPN G administered each medication and flushed 30ml of water after each medication. He/She flushed 150 ml of water, leaving 200ml in the container and closed the tube. Staff did not flush the Peg tube as ordered by the physician when they gave to much water during the mediction administration. 5. During an interview on 12/19/24 at 2:35 P.M., LPN G said he/she was not sure on the amount of water for the flush for the resident with a G-Tube or Peg tube, Just went of the top of my head but said he/she should have looked at the order and followed it. During an interview on 12/19/24 at 3:10 P.M., the Director of Nursing (DON) said before the nurse gives the medications a flush is done, then another flush after all medications is given. The DON said he/she would expect the nurse to follow the physician's orders for the administration of medication, and if they are not sure then check the order. During an interview on 12/19/24 at 4:05 P.M., the administrator said she would expect the nurse to always follow the physician's orders when they administrator medication.

Based on interview and record review, facility staff failed to provide a proper mechanical lift transfer for one resident (Resident #1) in a manner to prevent accidents when staff failed to remove his/her arm from under him/her and the resident sustained an injury to his/her arm. The facility census was 72. 1. Review of the Electric Portable Patient Lift owner's operator and maintenance manual, undated, showed the guide recommends operators of the mechanical lift use two staff to perform the transfer. The use of one assistant is based on the evaluation of the health of the resident by the health care professional for each individual case. Review of the facility's Hydraulic Lift policy, undated, showed the policy is to enable one individual to lift and move a resident safely. The use of one assistant is based on the evaluation of the health of the resident by the health care professional for each individual case. 2. Review of Resident #1's Annual minimum data set (MDS), a federally mandated assessment tool, dated 12/13/223, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Totally dependent for transfers with two plus staff to assist; -Hemiplegia (muscle weakness or paralysis on one side of the body); -Utilized wheelchair for mobility. Review of the residents plan of care, dated 6/22/23, showed staff assessed the resident required the use of the mechanical lift for all transfers with two person assistance. Review of the resident's nurse notes, dated 1/20/24 at 9:00 A,M,. showed staff documented the resident's left arm/bicep had a bruise and inflammation from his/her arm stuck underneath him/her while being transferred. Review of the resident's nurse notes, dated 1/20/24 at 5:02 P.M., showed staff documented the resident's arm swollen and he/she was unable to move it. Physician orders were given for X-ray to humerus on left side. Reviewed showed staff documented the facility's portable X-ray performed and it appears broken. Reviewed showed staff called 911 and resident sent to hospital. Review of the resident's X-ray report, dated 1/20/24, showed an acute left proximal humeral fracture (a fracture that is broken up near the shoulder joint). During an interview on 1/21/24 at 2:42 P.M., Certified Nursing Assistant (CNA) A said he/she does not know if the resident's arm was behind him/her in the sling when he/she lifted the resident into the bed but noticed it behind him/her when he/she was readjusting the resident. He/She said he/she reached over the resident in bed, grabbed the resident's wrist and above his/her elbow and pulled the residents arm out from underneath him/her. He/She denied the resident was in any pain. During an interview on 1/21/24 at 3:23 P.M., CNA B said facility staff are directed to always have two staff with a hoyer lift to make sure it is safe and it reassures the resident. During an interview on 1/21/24 at 3:33 P.M., Licensed Practical Nurse (LPN) C said it is not standard for staff at the facility to perform a hoyer lift with one person. He/She said CNA A has been with the facility a long time and probably always does hoyers often by himself/herself. He/She said hoyers need two staff for safety. During an interview on 1/21/24 at 4:17 P.M., the Director of Nursing (DON) said staff are trained to use two people assist on hoyer lift and he/she personally knows it should always be two, regardless of policy. He/She said the residents care plan is assessed for a two person assist with hoyers. During an interview on 1/21/24 at 4:18 P.M., the Assistant Director of Nursing (ADON) said he/she does not know why CNA A performed a hoyer lift by himself/herself because staff are instructed to utilize two assist. During an interview on 1/23/24 at 12:14 P.M., the administrator said staff are expected to utilize two staff members when a mechanical lift is performed. He/She said staff know this and a lift should not have been completed with only one staff member because it is not safe. MO000230591

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse when Dishwasher A came into the resident's room and kissed him/her and touched him/her inappropriately. The facility census was 62. The administrator was notified on 3/23/22 at 2:02 P.M. of an Immediate Jeopardy (IJ) which began on 2/5/22. The IJ was removed on 2/10/22 as confirmed by surveyor on-site verification. 1. Review of the facility's policy, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated July 2020, showed the facility is committed to protecting residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual. Review showed the policy of this facility every resident has the right to be free from any physical, or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Review showed every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. Additional review showed: -Mistreatment, neglect, or abuse of residents is prohibited by the facility; -Class I neglect, failure of an employee to provide reasonable and necessary services to maintain the physical and mental health of any consumer when that failure presents imminent danger to the health, safety, or welfare of a consumer, or a substantial probability that death or physical injury would result; -Class II neglect, failure of an employee to provide reasonable or necessary services to a consumer according to the individualized treatment/rehabilitation plan, if feasible, or according to acceptable standards of care. This includes action or behavior, which may cause psychological harm to a consumer due to intimidating, causing fear or otherwise causing undue anxiety. Review of Resident #1's Minimum Data Set (MDS), a federally mandated tool used to assess residents, dated 2/2/22, showed staff assessed the resident as cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Dishwasher A's timesheet, dated 2/5/22, showed he/she did not clock in when he/she arrived for work. Observation of the facility's surveillance camera, dated 2/5/22, showed at 5:09 A.M., Dishwasher A entered the hall where Resident #1 resides. At 5:19 A.M., Dishwasher A exited the hall back out the door where he/she entered. Additional review showed Dishwasher A had on a red stocking hat. During an interview on 2/5/22 at 1:15 P.M., the resident said he/she used to hang out with the employee. He/She said the staff member had always been nice to him/her in the past and reported when he/she told Dishwasher A to stop touching him/her, he/she did and left. The resident said he/she remembered Dishwasher A had on a red stocking hat at the time of incident. During an interview on 3/8/22 at 1:00 P.M., the resident said on the morning of 2/5/22 he/she was in his/her recliner next to the bed with his/her legs and feet across the bed. He/She said Dishwasher A from the kitchen came into his/her room and said, What are you doing? When he/she said, Nothing, What are you doing? The resident said Dishwasher A then said, I just wanted to get with you a little bit and he/she said, Ok. The resident said then Dishwasher A pulled him/her across the bed toward the edge and began to kiss him/her, touch his/her chest under the shirt, had him/her touch his/her genitals, and then began to lick him/her down there in my privates. The resident said at that point it felt uncomfortable, so he/she said, Stop, you need to leave my room now. He/She said then Dishwasher A left his/her room. During an interview on 2/5/22 at 1:30 P.M., Certified Med Tech (CMT) C said the resident came to him/her shortly after the shift started and requested to talk to him/her. CMT C said he/she would say it was somewhere around 6:15 A.M. The resident then began to report a kitchen staff member came into his/her room that morning. CMT C said at that point he/she stopped the resident and took him/her to the conference room and had the charge nurse come in. At that point the resident then said the kitchen staff member had come into his/her room that morning at approximately 5:15 A.M. and started to kiss him/her, touch his/her chest under the shirt, had him/her touch the employee's genitalia, and then performed oral sex on him/her. During an interview on 2/5/22 at 2:00 P.M., Licensed Practical Nurse (LPN) B said CMT C brought the resident to the skilled hall conference room at approximately 6:45 A.M. and said he/she had to report sexual abuse from a staff member. LPN B said the resident told him/her it was an employee who worked in the kitchen who had come into his/her room that morning and that he/she was in his/her recliner with his/her legs across the bed. The employee knelt beside the resident's bed and pulled him/her to the edge of the bed began to kiss him/her, touch his/her chest, had his/her touch the employee's genitals, and then began to lick the resident's genitals. LPN B said at that time he/she called the Administrator to report the incident. He/She then put staff one on one with the resident for safety. LPN B said when he/she went to the kitchen to inform staff they were not allowed down the hall until the Administrator arrived, Dishwasher A was wearing a red stocking hat which the resident had reported the employee was wearing. LPN B said Dishwasher A got very agitated and defensive with him/her to the point of anger which concerned him/her. During an interview on 2/5/22 at 1:00 P.M., the administrator said staff phoned him/her with the resident's report of alleged sexual abuse. He/She immediately came in to start the investigation. The administrator said when he/she went to interview Dishwasher A, he/she had left the building already. He/She reported the incident to the police and also questioned staff and residents. The facility suspended Dishwasher A pending investigation and all door codes were changed to ensure he/she could not enter the facility. Staff terminated the dishwasher on 2/7/22. During an interview on 2/5/22 at 4:30 P.M., the Police Officer called to the facility said when he/she arrived to the facility, Dishwasher A had already left the facility and was not able to be reached by phone. The officer said he/she collected Dishwasher A's information and the investigation is ongoing. He/She said the resident refused to have a sexual assault exam or to press charges. Review of the facility investigation, dated 2/5/22, showed staff documented a staff member reported to LPN B that a resident informed him/her an employee from the kitchen had come into his/her room and started to kiss and touch him/her inappropriately, then licked his/her genitals. The Administrator was notified of the incident. Staff documented the resident was upset, tearful, and feared the staff member would return to his/her room if he/she did not report it. Review showed the resident was interviewed. The accused staff member had left the building before he/she could be interviewed for the investigation. The police were notified and Resident #1 refused to have a sexual assault exam. The facility changed all the door codes to the building immediately and kept staff with the resident until he/she felt safe. Alleged Perpetrator was terminated for no response to phone calls, not cooperating with the investigation, and walking out for his/her shift. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 860

Based on interview and record review, facility staff failed to ensure one resident (Resident #16), out of 18 sampled residents, remained free of significant medication errors. Facility staff failed to administer an antibiotic according to physician's orders [REDACTED]. Facility staff administered the antibiotic every day for three days, exacerbating the resident's condition. The facility census was 90. 1. Review of the facility's Medication Pass Policy, dated 03/2015, showed the completion of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container) verifying it with the physician's orders [REDACTED]. 2. Review of Resident #16's discharge Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff for care planning, dated 11/22/15, showed staff documented the resident received an antibiotic four of the last seven days. Review of the resident's Physician order [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. Further review showed staff documented the resident admitted to the hospital on [DATE]. Review of the resident's Physician's Nursing Home Note, dated 11/18/15, showed the physician documented the resident with [DIAGNOSES REDACTED]. Review showed the physician documented, suspect pneumonia. Will get stat (urgent) chest x-ray; if that confirms pneumonia will plan to start [MEDICATION NAME]. Given renal function will need to dose that every 48 hours. Review of a facsimile from facility staff to the physician, dated 11/18/15, showed staff documented, Received orders for [MEDICATION NAME] 750 mg by mouth every 48 hours times seven days. Do you want only three doses or seven doses. Pharmacy has only sent three doses. Further review showed the physician documented, Only three doses for seven days. He/She has decreased renal function. Review of the physician's Final Report, dated 11/18/15, showed the physician's staff documented, Informed nursing staff at (the facility), they called and clarified that (the physician) wanted every 48 hours not every 24 hours, confirmed with them every 48 hours NOT every 24 hours. Faxed to (facility). Review of a facsimile from the facility to the physician, dated 11/21/15, showed staff documented, Resident has order for [MEDICATION NAME] 750 mg by mouth every 48 hours. Noted medication error. Resident received medications every day instead. All four doses administered in four days. No adverse affects noted. Further review showed the physician documented, This is unacceptable. We confirmed twice with your facility the dose. Please provide staff education and let family know. Review of a handwritten note provided by facility staff to the resident's family, undated, showed staff documented, Resident was ordered to take [MEDICATION NAME] 750 mg one tablet every 48 hours times seven days for pneumonia. Discovered on 11/21/18 that medication error was made. The [MEDICATION NAME] has been given every day instead of every other day. He/She has decreased renal function. Review shows the physician clarified the order for [MEDICATION NAME] 750 mg every 48 hours on 11/18/15. Review of the physician's Final Report, dated 11/22/15, showed the physician documented, Call from nursing home this morning. Reported they were unable to reach on call provider. (Resident) was diagnosed on Wednesday with pneumonia, started on [MEDICATION NAME] which was ordered to be dosed 750 mg every 48 hours due to his/her renal function. Apparently despite clarifying these orders on two occasions the staff have been giving it daily. Nursing reports today his/her oxygen saturation got down into the upper 70's but rebounded when they put oxygen on. However, he/she seems very confused; more shaky than usual and is not talking to nursing. Apparently following some commands. They feel he/she is worsening. I advised emergency room evaluation this morning. Review of the resident's hospital History and Physical, dated 11/22/15, showed hospital staff documented the resident, was diagnosed with [REDACTED]. He/She does have a history of [MEDICAL CONDITION]. Review of the resident's hospital Progress Note Report, dated 11/23/15, showed hospital staff documented, He/She was diagnosed with [REDACTED]. However, he/she got it every day and developed [MEDICAL CONDITION]. Review of the resident's hospital Progress Note Report, dated 11/24/15, showed hospital staff documented, Nursing reported no acute events overnight. Will plan to repeat a renal function panel at 3:00 P.M. His/Her [MEDICAL CONDITION] did exacerbate after the patient was continued on [MEDICATION NAME] on a daily basis instead of every other day previously to being admitted . Review of the resident's Discharge Summary Report Death Summary, dated 11/26/15, showed the reason for admission as altered mental status and acute [MEDICAL CONDITION]. Further review shows hospital staff documented the resident, currently diagnosed with [REDACTED]. Does have a history of [MEDICAL CONDITION]. During an interview on 12/8/15 at 4:10 P.M., the Assistant Director of Nursing (ADON) said staff discovered the medication error on 11/22/15 and staff sent the resident to the hospital. The ADON said the nurses transcribe the orders. The ADON said she expects staff to check the physician's orders [REDACTED]. During an interview on 12/09/15 at 9:28 A.M., Certified Medication Technician (CMT) F said staff inform the nurse if they notice a resident has a change in condition. During an interview on 12/09/15 at 9:31 A.M., Licensed Practical Nurse (LPN) E said the nurses transcribe physician's orders [REDACTED]. MO 9657

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain the highest practicable well-being for four residents (Residents #7, #9, #16, and #17), in a review of 17 sampled residents (including three discharged residents) and two additional residents (Residents #20 and #21 ). Facility staff failed to document pain assessments prior to and after administration of pain medication to determine the effectiveness of the medications for Residents #7, #9, #16, #17, #20, and #21. Staff failed to assess and timely administer PRN pain medications to Resident #16 who was under hospice care and presented with verbal and non-verbal complaints of pain, including uncontrolled movements, moaning, and crying during the dying process. Staff failed to assess for pain and administer pain medication to Resident #7, who made verbal complaints of pain and whose family member requested pain medication be given. Staff failed to administer the proper dose (less than ordered by the resident's physician), of PRN pain medication upon Resident #20's request for pain medication and failed to ensure narcotic pain medication (which the resident stated kept his/her pain to tolerable level), was available upon the resident's request. Staff failed to assess and administer narcotic pain medications as requested by Resident #17 to ensure his/her pain remained under control. Staff failed to assess Resident #9's pain related to injuries he/she sustained and failed to document interventions provided (if any) for pain when the resident expressed discomfort related to his/her catheter. The facility census was 81. 1. Review of the facility's policy for pain management guidelines showed the following: -Objective: To manage pain symptoms so residents will be as free of pain and discomfort as possible. The goal of pain management will be to control pain so it will not interfere with the ability to have restful sleep patterns, perform activities of daily living (ADLs), participate in usual activities, or cause problems with mood or behaviors; -Definition: An unpleasant sensory and emotional experience associated with actual or potential tissue damage; -Because pain is subjective and lacks objective markers, self-report of pain by residents is generally held to the standard of pain assessment; -Guidelines: At a minimum, screening for chronic pain will be conducted upon admission and at each quarterly review during the resident assessment instrument/minimum data set, (RAI/MDS, a federally mandated assessment instrument required to be completed by the facility) the assessment scale (1-10) will be conducted whenever pain is suspected resulting in the administration of pain medication, i.e. verbal complaints of pain, behavioral changes due to pain, and depression symptoms; -A licensed nurse or certified nurse aide may assess and communicate degrees of pain to the person administering the pain medication to the residents; -Pain medications are to be administered according to the physician's orders [REDACTED]. -All pain medications will be recorded on the medication administration record (MAR) when administered; -Additional documentation of pain may also be recorded in the DART (data, action, response, and teaching) charting program, in the nurse's notes, under behavior documentation, and on pain documentation records (facility choice); -Hospice residents will be provided pain medications according to the hospice program and physician orders; -Hospice orders will be documented in the resident's record, with administration of the medications recorded on the resident's MAR; -If a resident reports pain for a period of 14 days or more, it requires a significant change adjustment of the comprehensive assessment with further evaluation of pain intensity, location, quality, and associated symptoms by the licensed nurse with interventions and treatments documented in the permanent care plan using the RAI process; -An assessment of the cause of pain that cannot be relieved by nursing interventions is to be determined by the licensed nurse/medication pass person and action taken according to the physician's orders [REDACTED]. -The resident's description of his/her pain will be documented in the nurses progress notes/DART charting and/or on the MAR of the resident's medical record; -Actions/interventions will be determined by the charge nurse and/or pain management team with documentation on the MAR or the nurse's progress notes; -All medication orders will be recorded on the physician's orders [REDACTED]. resident's record; -Treatment and intervention guidelines: chronic pain is to be treated with regularly scheduled pain medications, as needed (PRN) dosing is only appropriate for chronic pain as an adjunct to routine medications and/or to determine the need for regularly scheduled medications; -If a resident is assessed to have chronic pain and there are no orders for regularly scheduled pain medications, the physician is to be contacted for consideration of a change in or new orders; -Non-pharmacological interventions for managing pain will be considered when a resident is complaining of pain, the intervention may include, but not limited to comfort measures of; reassuring words and touch, being kept clean, dry, well positioned, padding applied, comfortable temperature, light and noise level, toileting, hydration and/or nourishment, and necessary support for mobility, transfer or ambulation; -Hospice nurse/doctor will be notified of resident's unresponsiveness, deep sleep with difficulty to arouse (respirations under 12-14/minute) for additional instructions regarding administration or holding of medications due to the assessment of the resident at the end states of life; -A resident that cannot be easily aroused may have the oral medications held until the resident wakes, due to risk of choking on the medication; -The care plan team will monitor the use of pain medications with updating of the RAI process, to include the care plan , and interventions will be communicated to all staff caring for the resident; -The hospice program will address pain medication and pain assessment, with communication to the nursing staff as to the need for medications; -The facility staff may contact the hospice nurse/doctor when additional pain medication is required; -The quality assurance (QA) team will review the use of antipsychotic pain medications quarterly during the QA meetings and will monitor quality indicators (QI) and quality measures (QM) for pain quarterly. 2. Review of Resident #16's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/18/13, showed the following: -He/she was sometimes understood by others (ability is limited to making concrete requests) -He/she sometimes understands others (responds adequately to simple, direct communication only); -He/she was severely cognitively impaired; -He/she received scheduled pain medication in the past five days; -He/she did not receive PRN pain medications during the past five days; -He/she did not exhibit any indicators of pain or possible pain in the last five days; -He/she experienced shortness of breath with exertion; -He/she had a condition or chronic disease that may result in a life expectancy of less than six months. Review of the resident's care plan, reviewed by facility staff on 12/18/13, showed the following: -Category: Pain, I am risk for pain due to [MEDICAL CONDITIONS], and Tietze's Disease (an [MEDICAL CONDITION] disorder characterized by chest pain and swelling of the cartilage of one or more of the upper ribs); -Short term goal target dated 2/3/14: I will continue to report a pain level which does not interfere with my daily activities; -Approach: I receive a [MEDICATION NAME] (narcotic pain [MEDICATION NAME] medication) 25 micrograms (mcg) to be changed every 72 hours, I also have PRN (as needed) medications (see MAR), I am able to express pain, staff to observe my non-verbals as I do not always express my pain, staff to assess pain on scale of 0-10 and document interventions, notify physician of changes in pain level or location, and use activities like social gatherings to redirect my attention. -Handwritten note (written under the approach category with no date): [MEDICATION NAME] (narcotic pain medication used to treat moderate to severe pain) scheduled. Review of the resident's physician orders [REDACTED]. -[DIAGNOSES REDACTED]. -Hospice; -[MEDICATION NAME]es 25 mcg/hour, apply one patch topically and change every 72 hours (start date 12/13/13); -[MEDICATION NAME] (Tylenol) 500 mg caplet, administer one caplet by mouth (PO) every six hours as needed for pain (start date 1/22/13); -[MEDICATION NAME] 100 mg/5 milliliters (ml), administer 0.25 ml by mouth or sublingually every four hours as needed for pain (give with [MEDICATION NAME] and aspirin for chest pain) (start date 1/22/13); -[MEDICATION NAME] (medication used to treat or prevent attacks of chest pain) 0.4 mg tablet, administer one tablet under the tongue every five minutes times three as needed for chest pain (administer with aspirin and [MEDICATION NAME]) (start date 1/22/13). Review of the resident's Medication Administration Record (MAR), dated 1/1/14 through 1/31/14, showed the following: -[MEDICATION NAME]es 25 mcg/hour, apply one patch topically and change every 72 hours; -[MEDICATION NAME] 500 mg caplet, administer one caplet PO every six hours as needed for pain; -No documentation [MEDICATION NAME] was administered; -[MEDICATION NAME] 0.4 mg tablet, dissolve one tablet under the tongue every five minutes times three as needed for chest pain (give with aspirin and [MEDICATION NAME]); -No documentation that [MEDICATION NAME] was administered; -[MEDICATION NAME] sulfate 100 mg/ml, administer 0.25 ml by mouth or sublingually every four hours as needed for pain (give with nitro and aspirin for chest pain); -No documentation [MEDICATION NAME] 100 mg/ml 0.25 mg dose was administered; -Assess pain using 0-10 numeric pain scale as needed (no documentation of assessment noted). Review of the resident's nursing report sheet, dated January 2014, showed the following: -On 1/1/14 on the 11:00 P.M. to 7:00 A.M. shift, the resident was combative and yelled at the top of his/her lungs; -On 1/1/14 on the 7:00 A.M. to 3:00 P.M. shift, staff documented the resident's last [MEDICATION NAME] was at approximately 1:00 P.M. Review of the nurses notes showed no documentation of a pain assessment or the [MEDICATION NAME] sulfate administered at 1:00 P.M. Review of the Controlled Substances Record showed the resident received [MEDICATION NAME] 0.25 ml dose on 1/1/14 at 1:00 P.M. (Review of the resident's MAR showed no documentation the medication was given, no documentation of a pain assessment prior to administration of the medication, and no documentation of an assessment completed after the resident received the medication.) Review of the resident's nurses notes, dated 1/1/14 at 9:00 P.M., showed staff documented the resident was very restless, mildly combative, then became very lethargic. [MEDICATION NAME] solution 0.25 ml received. Resident refused meal. Mottling noted to toes, mid-calf, knees, and bilateral finger tips. Call to hospice and made aware of the resident's status. Review of the Controlled Substances Record showed the resident received [MEDICATION NAME] sulfate 0.25 ml dose on 1/1/14 at 9:00 P.M. (Review of the resident's MAR showed no documentation the medication was given, no documentation of a pain assessment prior to administration of the medication, and no documentation of an assessment completed after the resident received the medication.) Review of the nursing report sheet dated January 2014, showed the following: -On 1/2/14 on the 7:00 A.M. to 3:00 P.M. shift, staff changed the [MEDICATION NAME], the resident was apneic (periods of not breathing), and sitter at bedside; -On 1/2/14 on the 3:00 P.M. to 11:00 P.M. shift, staff administered [MEDICATION NAME] at 8:20 P.M., voided one time, and periods of apnea. Review of the Controlled Substances Record showed the resident received [MEDICATION NAME] sulfate 0.25 ml dose on 1/2/14 at 8:30 P.M. (Review of the resident's MAR showed no documentation the medication was given, no documentation of a pain assessment prior to administration of the medication, and no documentation of an assessment completed after the resident received the medication. There was also no documentation in the resident's nurses notes for 1/2/14.) Review of the resident's controlled substances record showed the resident received [MEDICATION NAME] 0.25 ml dose on 1/3/14 at 12:47 A.M. (Review of the resident's MAR showed no documentation the medication was given at 12:47 A.M., no documentation of a pain assessment prior to administration of the medication, and no documentation of an assessment completed after the resident received the medication. There was also no documentation in the resident's nurses notes.) Review of the nurses notes, dated 1/3/14 at 2:52 A.M., showed an order was received from the hospice nurse to increase [MEDICATION NAME] sulfate to 0.5 ml every hour PRN for pain. (There was no documentation in the nurses notes regarding why the dose and frequency of the medication was increased, from 0.25 ml every four hours to 0.5 ml every hour.) Review of the resident's POS showed a verbal order received on 1/3/14 to increase [MEDICATION NAME] sulfate 100 mg/5 ml to 0.5 ml every hour as needed for pain. Review of the resident's controlled substances record showed the resident received [MEDICATION NAME] 0.5 ml dose on 1/3/14 at 3:00 A.M., 4:05 A.M., and 6:09 A.M. (Review of the resident's MAR showed no documentation of a pain assessment prior to administration of the medication, and no documentation of an assessment completed after the resident received the medication. There was no documentation in the resident's nurses notes.) Review of the nursing report sheet, dated January 2014, showed on 1/3/14 on the 11:00 P.M. to 7:00 A.M. shift, staff medicated the resident three or four times. (There was no documentation on the report sheet to show the resident's [MEDICATION NAME] dose was increased and was also now ordered for every hour PRN.) Review of the resident's MAR showed staff administered the [MEDICATION NAME] 0.5 ml dose at 7:35 A.M. on 1/3/14. There was no documentation of a pain assessment completed prior to administration of the medication and no documentation of an assessment completed after the resident received the medication. Review of the resident's nurses notes, dated 1/3/14 at 7:45 A.M., showed [MEDICATION NAME] 0.5 ml was given for intermittent periods of restlessness/agitation. The sitter was at the resident's bedside. The resident had frequent periods of apnea. Review of the resident's nurses notes, dated 1/3/14 at 4:00 P.M., showed the resident lay quietly in bed, was nonverbal, and was physically responsive to tactile stimuli. Staff documented the resident's respirations were unlabored with periods of apnea approximately 30 to 45 seconds in length. Staff noted mottling (discoloration in irregular patches) in the resident's fingertips. The sitter requested the resident have [MEDICATION NAME]. Staff documented no medication was needed at this time. Review of the resident's nurses notes, dated 1/3/14 at 5:45 P.M., showed Licensed Practical Nurse (LPN) O documented the following: -Resident had intermittent jerking/movement of bilateral upper extremities; -Resident appeared comfortable and in no acute distress; -Call from hospice nurse and reported resident's status; -Hospice sitter at bedside. Review of the resident's MAR showed [MEDICATION NAME] 0.5 ml was administered on 1/3/14 at 7:06 P.M. (There was no documentation in the resident's nurses notes.) (The resident did not receive the [MEDICATION NAME] 0.5 ml (ordered every hour as needed for pain) from 7:35 A.M. until 7:06 P.M.) Review of the resident's hospice progress notes, dated 1/3/14 at 8:30 P.M., showed hospice Registered Nurse (RN) Q documented the following: -He/she received a call from hospice sitter P with reports that the resident was experiencing pain and needed pain medication; -Hospice sitter P reported LPN O refused to administer pain medication; -Hospice RN Q determined the resident was in pain after he/she physically assessed the resident at the facility; -RN Q administered [MEDICATION NAME] ([MEDICATION NAME]) with some pain relief noted; -Followed up with hospice sitter P after the pain medication was administered and he/she said the resident appeared more comfortable. During a telephone interview on 2/27/14 at 2:48 P.M., hospice RN Q said the following: -Hospice sitter P contacted him/her on 1/3/14 at 5:45 P.M. in regard to a concern he/she had with the facility nurse (LPN O); -Hospice sitter P reported the resident was in pain and LPN O refused to medicate because he/she did not think the resident was in pain; -Hospice RN Q arrived to the facility and found the resident with signs and symptoms of pain; -The resident was moaning, reaching out, and thrashing in the bed; -Resident had been declining in the prior few days; -He/she was behaving differently than his/her normal; -RN Q medicated the resident with pain medication as ordered at 7:06 P.M. (0.5 ml of [MEDICATION NAME] 100 mg/5 ml was documented as signed out by RN Q on the controlled substance record). During an interview on 2/27/14 at 3:55 P.M., LPN O said the following: -On the evening of 1/3/14, the hospice sitter complained the resident was restless and attempting to get out of bed; -He/she had assessed the resident a couple of times for pain and found him/her to be resting peacefully with no signs of restlessness noted; -He/She called the hospice nurse after the second complaint of pain was voiced by the hospice sitter; -The hospice RN came to assess the resident and he/she administered [MEDICATION NAME] (anti-anxiety medication) or the pain medication that was ordered for that resident ([MEDICATION NAME] 0.5 ml was signed out on the controlled substance record for by hospice RN Q at 7:06 P.M.). Review of the resident's MAR showed the staff administered [MEDICATION NAME] 0.5 ml on 1/4/14 at 6:45 A.M. The resident did not receive the medication (ordered every hour as needed for pain) from 7:06 P.M. on 1/3/14 until 6:45 A.M. on 1/14/14. Review of the hospice documentation, dated 1/3/14 (11:00 P.M. to 7:00 P.M. shift) showed LPN B documented sitter at bedside. The resident received pain medications at 6:45 A.M. (There was no documentation of a pain assessment for the 11:00 P.M. to 7:00 A.M. shift.) Review of the resident's controlled substance record for [MEDICATION NAME] sulfate, dated 1/4/14, showed 0.50 ml was signed out on 1/4/14 at 9:15 A.M. Review of nurses notes, dated 1/4/14 at 10:00 A.M., showed the resident exhibited no visible signs of life, was without respirations, pulse and blood pressure. Review of the nurses notes showed no documentation, including a staff assessment of the resident, between 5:45 P.M. on 1/3/14 and 10:00 A.M. on 1/4/14, when the resident exhibited no visible signs of life. Review of the statement of violation letter provided to LPN B by the Director of Nursing (DON) on 1/10/14 showed the following: -DON received a grievance on 1/6/14 regarding circumstances that had occurred with the resident on the morning of his/her passing; -At 1:30 A.M., LPN B was asked to medicate the resident as he/she exhibited signs of pain (crying and hitting the wall); -Pain medication for Resident #16 was requested by the hospice sitter; -LPN B responded to the CNA by stating that the resident has nothing ordered for crying; -LPN B did not assess the resident for pain; -LPN B did not go to the unit until 6:30 A.M.; -Residents are placed on hospice to provide them with comfort and a pain free death, medication should never be withheld or the resident not assessed; -This incident with regards to pain medication was neglect and is unacceptable and cannot be tolerated; -It is LPN B's responsibility to assess all residents when a problem is brought to your attention by a CNA; -The residents deserve to be treated with [MEDICATION NAME]; -LPN B violated policy #26.2 as per the facility's employee hand book: 1) failure to maintain acceptable standards of respect for residents, visitor, or co-worker; and 2) failure to readily carry out general or specific instructions with pain medication as written by M.D. (physician) -LPN B violated policy #26.4 as per the facility's employee hand book: resident abuse or neglect by not providing him/her pain medication as it was ordered. Review of CNA A's written statement, dated 2/16/14, showed the following: -He/she was working one night shift and had a resident (Resident #16) on hospice that was passing away with hospice sitter at bedside (hospice sitter R); -At approximately 1:15 A.M., the hospice sitter requested he/she notify the nurse the resident needed pain medication; -The resident was crying and beating on the wall; -He/she reported to the nurse (LPN B) that the resident was crying and that the hospice sitter requested pain medication; -The nurse's (LPN B) response to his/her request was that he/she did not have medication for crying; -Nurse (LPN B) did not assess or administer pain medication until between approximately 6:00 A.M. and 6:30 A.M.; -He/she said the resident passed later that morning, still crying; -He/she asked the nurse (LPN B) for pain medication once; -He/she attempted to keep the resident comfortable until the nurse (LPN B) came to assess and administer the medication. During an interview on 2/27/14 at 6:15 A.M., CNA A said the following: -He/she completed his/her rounds of the special care unit (SCU) at 1:00 A.M. on 1/4/14; -At approximately 1:15 A.M., the resident was very restless, banging his/her fist against the wall, and crying (not like crying in the past) with tears flowing down his/her face; -He/she left the SCU at that time to report findings to LPN B; -He/she reported the resident was crying, restless, and banging his/her fist on the wall; -LPN B told CNA A he/she did not have anything for crying; -He/she asked LPN B if he/she would come to the SCU and assess why the resident was crying and experiencing these behaviors; -LPN B did not come to the SCU to assess the resident or administer pain medication; -Later in the night, he/she spoke with the hospice sitter who reported to him/her that he/she left the SCU to request pain medication from LPN B because the resident had not received any; -He/she noted the resident was very weak through the night and would fall over as he attempted to get out of bed; -The resident was very restless in bed and was asking to lay on the floor; -Resident cried all night; -At approximately 6:00 A.M., LPN B came to the unit to assess the resident; -LPN B had not been on the unit between the time he/she reported the resident's condition at 1:15 A.M. and 6:00 A.M.; -It was reported to her/him the resident's pain medication was increased the day before; -He/she had worked with this resident for over a year and the resident had never acted like this before. During an interview on 2/26/14 at 2:45 P.M., LPN B said the following: -If a CNA reported a resident was in pain, he/she would first ask which resident, then would finish his/her current task (such as passing medications), and then would assess the resident; -He/She did not believe waiting five hours to assess a resident after complaints of pain was acceptable nursing practice, however, he/she did not wait five hours to assess the resident on 11:00 P.M. to 7:00 A.M. shift (1/3/14 and 1/4/14); -He/She responded when CNA A told him/her the resident was in pain; -The resident was crying and he/she gave the resident his/her pain medication. It was normal for the resident to cry; -He/She did not tell CNA A the resident did not have any medications for crying; -He/She has never met or seen the hospice sitter who was with the resident. During an interview on 2/27/14 at 5:00 P.M., LPN B said the following: -He/she didn't really remember what happened on the 11:00 P.M.-7:00 A.M. shift (1/3/14-1/4/14); -He/She knew there was a hospice sitter with the resident, however, he/she did not know him/her and has never seen the sitter; -He/she remembered CNA A came out of the SCU and reported the resident needed pain medication; -He/she was unable to recall the time that staff reported the resident's pain to him/her and how much time elapsed before administering the pain medication; -He/she was also unable to recall what he/she did during the time between when CNA A reported the resident's pain and when pain medication was administered; -LPN B said it could have been one to one and one-half hours between when CNA A reported the pain and the time pain medication was administered. Review of a written statement provided by LPN B on 2/27/14 at 5:30 P.M., showed the following: -He/she received report from the 3:00 P.M. to 11:00 P.M. shift at 11:00 P.M.; -He/she was informed the resident had a sitter and his/her condition had worsened; -He/she completed a walk through of the Special Care Unit (SCU) at the beginning of the shift; -The resident's door to his/her room was closed, he/she knocked and opened the door, and the resident was in bed; -At approximately 5:00 A.M., he/she was getting prepared for administration of morning medications when CNA A reported the resident needed pain medication; -He/she acknowledged to CNA A that he/she had heard him/her; -He/she then started to obtain blood sugars and pass morning medications; -He/she administered pain medication to the resident as soon as he/she obtained it from the medication room (review of the controlled substance record showed the resident's [MEDICATION NAME] was signed out at 6:50 A.M.). During an interview on 2/27/14 at 10:10 A.M., hospice sitter R said the following: -On 1/4/14, the resident was extremely agitated and unstable; -He/she was disoriented and kicked him/her approximately ten times; -The resident constantly tried to get out of bed and made complaints of pain; -The nurse reported to him/her that he/she was not going to administer any pain medication because he/she did not exhibit enough signs of pain; -The resident stated he/she hurt; -He/she reported the resident's complaint of pain to CNA A; -CNA A reported the resident's complaint of pain to the nurse; -He/she was aggravated the resident was extremely agitated and complained of pain for almost six hours while he/she was fighting him/her; -The resident finally settled down after the pain medication was administered; -He/she did not recall the nurse coming to the room during the night. Review of written statement provided by hospice sitter R, dated 2/28/14 at 1:30 P.M., showed the following: -He/she arrived at the facility on 1/4/14 at 12:00 A.M.; -At approximately 1:00 A.M., the resident started to move his/her leg slightly and make sounds; -He/she asked the nurse (LPN B) to check on the resident and administer him/her pain medication; -The nurse (LPN B) assessed the resident (unknown time) and said that it was not time for pain medication ([MEDICATION NAME] was last administered on 1/3/14 at 7:06 P.M. per MAR and [MEDICATION NAME] 100 mg/5 ml 0.5 ml is to administered every hour PRN pain per POS); -The CNA (CNA A) came to the room several times to assess the resident for incontinence and to reposition him/her; -The CNA (CNA A) also requested the nurse (LPN B) assess the resident and administer pain medication; -At approximately 6:00 A.M., he/she stepped off of the SCU and requested pain medication for the resident to the nurse (LPN B); -The CNA (CNA A) reported the nurse (LPN B) assessed the resident and administered his/her pain medication during the sitter's absence from the room; -There was no documentation of the time that the resident was assessed, or when pain medication was administered ( [MEDICATION NAME] 0.5 ml was signed out on 1/4/14 at 6:50 A.M. by LPN B); -The resident moved slightly but appeared to be sleeping until he/she left him/her at 8:30 A.M. During a telephone interview on 2/28/14 at 3:00 P.M., hospice sitter R said the following: -He/she clarified the difference between his/her initial interview on 2/27/14 and his/her written statement; -He/she was confused on the dates when he/she was first interviewed; -On 1/4/14, the resident did not get up out of bed at all; -The resident moaned when he/she was repositioned; -At approximately 1:00 A.M., he/she asked the nurse (LPN B) if the resident could have some pain medication, but was told it was not time ([MEDICATION NAME] 0.5 ml was last signed out on 1/3/14 at 7:06 P.M. and the resident could have had medication); -At approximately 2:00 A.M., the nurse (LPN B) came to the resident's room, observed and attempted to communicate with the resident, and said it was not time for pain medication to be administered ([MEDICATION NAME] 0.5 ml was last signed out on 1/3/14 at 7:06 P.M. and is ordered every hour PRN pain per POS); -The CNA (CNA A) reported to the nurse (LPN B) after each time the resident was repositioned that he/she was in a lot of pain and moaned and had "Water running from his/her eyes when he/she was moved;" -He/She believed the resident was in pain (based on the resident's breathing, moaning, and eyes watering), when he/she was repositioned and could have taken pain medication, however, he/she did not receive any medications; -The resident was turned and repositioned every two hours; -On 1/1/14, 1/2/14, and 1/3/14, the resident was getting up out of bed, undressing, and attempting to use the toilet; -The resident stated he/she was tired and just wanted to go "in the ground;" -At approximately 5:30 A.M. on 1/2/14, the resident stated he/she hurt and would point to his/her stomach. He/she reported the resident's complaints of pain and his/her need to use the bathroom. The nurse assessed the resident, but he/she did not recall any medications administered at that time ([MEDICATION NAME] 0.25 ml was signed out on 1/1/14 at 9:00 P.M.). Also on the morning of 1/2/14, the resident was a "handful." The resident said he/she hurt, was kicking, was more agitated and combative. During an interview on 2/26/14 at 10:15 A.M., the administrator said the following: -The complaint regarding the resident's pain was immediately addressed; -LPN B was suspended for three days; -LPN B was told he/she was not the physician and to administer pain medications as ordered; -He/she thought more education for the nursing staff with regards to pain and pain medication administration was needed; -LPN B was provided education that crying was a sign of pain and to give pain medication as ordered; -He/she did not consider the complaints as neglect; -He/she thought hospice had in-serviced nursing staff on pain management for the hospice residents. During an interview on 2/26/14 at 3:40 P.M., the DON said the following: -He/she decided not to pursue the incident related to LPN B not providing pain medications to Resident #16 as neglect because he/she could not prove LPN B did not go onto the unit to assess the resident between 1:30 A.M. and 6:30 A.M. on 1/4/14. However, LPN B did not deny not going on to the unit until 6:30 A.M. on 1/4/14; -LPN B reported the resident was crying on 1/4/14 but did not assess for why he/she was crying. He/She told the CNA he/she did not have anything for crying; -Resident #16 was combative and agitated at times During an interview on 2/27/14 at 3:15 P.M., the administrator said the following: -He/she was told CNA A reported LPN B did not respond when he/she was notified of the resident's pain; -LPN B said the resident had no medications ordered for agitation; -He/she would have expected LPN B to administer the [MEDICATION NAME] ([MEDICATION NAME]) as ordered; -The DON investigated CNA A's grievance with LPN B; -LPN B had already had a verbal consultation with the DON in regard to pain medication administration for another resident (Resident #17); -The decision was made that LPN B needed to learn from this and was suspended for three days; -LPN B was educated on the importance of pain management; -He/she spoke with hospice administrator to address the pain situation with LPN O on the evening of 1/3/14, and determined that more education was needed; -All nursing staff was in-serviced on pain management. During an i

Based on observation, interview, and record review, facility staff failed to ensure residents assessed at risk for pressure ulcers who entered the facility without pressure ulcers did not develop pressure ulcers in the facility. Staff failed to provide necessary treatment and services to promote healing, prevent infection, and the development of new pressure ulcers for seven of 15 sampled residents with pressure ulcers out of a total sample of 20 residents (Residents #18, #14, #2, #4, #6, #1, and #5). Staff failed to provide pressure relieving devices, failed to seek treatment in a timely manner, and failed to keep Resident #18's skin clean and dry. Staff failed to provide pressure relieving devices and did not consistently document they provided treatments for Resident #14. Staff failed to provide pressure relieving devices, failed to document they provided treatments as ordered, and failed to implement dietary recommendations in a timely manner for resident #2. Staff failed to provide pressure relieving devices and failed to document they provided treatments as orders for Resident #4. Staff failed to obtain treatment orders for Resident #6 in a timely manner. Staff failed to document they provided treatments as ordered, failed to accurately assess pressure ulcers to monitor for improvement or decline, and failed to update the plan of care for Resident # 1. Staff failed to document the provided treatments as ordered for Resident # 5. The facility census was 100. 1. Review of Resident #18's closed record showed hospital Post Discharge Orders, dated [DATE], where hospital staff documented the resident had a pressure ulcer that required general skin care and protection. Review of the resident's admission nurse's notes, dated [DATE] at 10:22 P.M., showed the resident arrived to the facility at 1:00 P.M. Staff documented the resident had two "red areas" on his/her buttocks measuring 0.2 cm by 0.3 cm on the left inner buttock fold and 0.1 cm by 1.5 cm on the right inner buttock fold. Additionally, staff documented the resident had a suprapubic catheter (an indwelling catheter that is placed directly into the bladder through the abdomen) that is "leaking." Staff documented they notified the physician and received an order for [REDACTED]. Review of the resident's physician's orders [REDACTED]. - [MEDICATION NAME] ointment (barrier paste) to red areas on buttocks every shift and as needed until healed, then on an as needed basis (ordered [DATE]). Review of the resident's Pressure Ulcer Assessment, dated [DATE], showed staff assessed the resident at risk for pressure ulcers; however review of the resident's Braden Scale for predicting pressure ulcer risk, dated [DATE], showed staff did not assess the resident at high risk for pressure ulcers. Review of the resident's Initial Care Plan, dated [DATE], showed facility staff did not document any information regarding the reddened areas to the resident's buttocks assessed on admission, nor did they document they assessed the resident as being at risk for pressure ulcers. Review of the resident's corresponding plan of care, dated [DATE], showed staff documented the resident is at risk for skin breakdown due to reduced mobility and paraplegic status. Staff documented the resident was admitted to the facility with "two areas to his/her coccyx." Review showed the plan of care directed staff to: - Assist and teach the resident to reposition; - Body/skin audit at least weekly; - Keep linens dry and wrinkle free; - Examine skin during showers to detect any new skin conditions; - Notify physician of any new open or red areas so he/she can be treated without delay; - [MEDICATION NAME] ointment to red areas on buttocks every shift until healed, then as needed; - Assist resident with positioning every two hours; - Encourage to lay down for rest periods during the day; - Whirlpool on shower days; - [MEDICATION NAME] powder (topical antifungal antibiotic) to perineal area for redness; - Half siderails on bed to promote bed mobility. Review of the resident's plan of care, dated [DATE], showed staff did not plan care for any pressure reducing devices to the resident's wheelchair for the reddened areas on his/her buttocks. Review of the resident's shower sheet, dated [DATE], showed staff documented the resident had reddened areas to his/her buttocks. Review of the resident's Nursing Report Sheet, dated [DATE] on the 7:00 A.M. to 3:00 P.M. shift, showed staff documented the resident's "bottom is redder" and staff encouraged him/her to lay down. Review of the resident's nurse's notes, dated [DATE] at 2:18 P.M., showed staff documented the resident has increased redness to his/her coccyx (tailbone) and perineal area and an open area to the coccyx. Staff documented they faxed the physician with the information regarding the buttocks. Staff also documented that if the resident's buttocks do not improve with the [MEDICATION NAME] treatment, staff will fax the physician again for a new treatment order. Staff documented they encouraged the resident to lay down throughout the day and to "give his/her buttocks some air," and the resident agreed to this. Review of the resident's Nursing Report Sheet, dated [DATE] on the 7:00 A.M. to 3:00 P.M. shift, showed staff documented the resident's perineal area is red and his/her coccyx is red and bleeding. Staff documented they turned the resident onto his/her side. Review of a faxed request sent to the resident's physician, dated [DATE] (no time), showed staff documented the following: - The resident has a new open area to his/her coccyx and redness to the perineal area. - The current treatment order is [MEDICATION NAME] ointment. - Staff would like to continue the current treatment for [REDACTED]." - Staff will encourage the resident to be turned every two hours and encourage the resident to lay down throughout the day. Review of the faxed request to the resident's physician, dated [DATE], showed the physician did not respond to the faxed request until [DATE]. Review showed the physician documented he/she agreed with the facility's request. Review of the resident's admission MDS, dated [DATE], showed staff assessed the resident as: - Cognitively intact; - Requires extensive assistance of two or more staff with bed mobility and transfers; - Requires extensive assistance of one staff member with locomotion off unit (moving and returning from areas such as dining, activities or treatments), dressing, toileting, and personal hygiene; - Totally dependent on one staff member with two or more staff members with bathing; - Has bilateral lower extremity functional limitation in range of motion; - Uses a wheelchair; - Has an indwelling catheter, including suprapubic catheter; - Has an ostomy (an opening in the body for the discharge of body wastes); - Occasionally incontinent of urine; - Paraplegic; - Weighs 134 pounds; - At risk for pressure ulcers; - Has three Stage I pressure ulcers (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); - Has one Stage II pressure ulcer (partial thickness skin loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough; may also present as an intact or open/ruptured blister) acquired in the facility and identified on [DATE] with the most severe tissue type being granulation tissue (pink or red tissue with shiny, moist, granular appearance); - Has a pressure reducing device for the bed; - On a turning/repositioning program; - Receives ulcer care; - Receives application of ointments/medications other than to feet. Review of the resident's MDS, dated [DATE], showed staff did not document that the resident had any pressure reducing device for his/her wheelchair. Review of the resident's nurse's notes, dated [DATE] at 11:35 A.M., showed staff documented the resident's incontinence "pad was wet when the resident was repositioned" and "urine appears to be draining from the perineal area" rather than the catheter area. Review of a faxed request sent to the resident's physician, dated [DATE] (no time), showed staff documented the resident's coccyx area "is not better." Staff requested [MEDICATION NAME] cream to be used as needed and to start [MEDICATION NAME] (a highly absorbent adhesive dressing) with Hydrogel (wound dressing used to maintain a moist wound-healing environment) twice daily and as needed until healed. Review showed the resident's physician did not respond to the faxed request until [DATE]. Review of the resident's medical record showed no documentation that facility staff contacted the physician for a timely response to the faxed request between [DATE] and [DATE]. Review of the resident's Wound Report, dated [DATE], showed facility staff documented the following wounds: - A Stage II pressure ulcer to his/her left buttock cheek crease that measured 3.5 cm by 1.0 cm with a date of onset as [DATE]; - Two Stage II pressure ulcers to his/her left buttock that measured 1.2 cm by 0.5 cm and 0.4 cm by 0.8 cm, with a date of onset as [DATE]; - Two Stage II pressure ulcers to his/her right buttock that measured 2.1 cm by 0.5 cm and 3.0 cm by 0.5 cm. - The current treatment is Hydrogel with [MEDICATION NAME] tape (adherent foam dressing), change twice daily and as needed. Review of the physician's response to the faxed request that staff sent on [DATE], showed the physician documented he/she agreed with the request on [DATE] for Hydrogel with [MEDICATION NAME]. Review of the resident's POS, dated [DATE], showed the following order: - Change [MEDICATION NAME] cream to use as needed (ordered [DATE]); - Apply [MEDICATION NAME] with Hydrogel; cleanse with wound cleanser to coccyx twice daily and as needed (ordered [DATE]). Review of the resident's TAR, dated [DATE], showed staff documented they administered the [MEDICATION NAME] ointment to the resident's reddened buttocks through the 7:00 A.M. to 3:00 P.M. shift on [DATE]. Additionally, review of the resident's TAR showed staff documented they obtained an order from the physician for [MEDICATION NAME] with Hydrogel for the open areas on the resident's buttocks on [DATE] and began this treatment on the 3:00 P.M. to 11:00 P.M. shift. Review of the resident's Nursing Report Sheet showed the following entries: - On [DATE] on the 11:00 P.M. to 7:00 A.M. shift, the resident had "leaking from the front and back." - On [DATE] at 6:00 A.M. the resident had leaking from his/her stoma and backside; - On [DATE] at 6:30 A.M., the resident's catheter continued to leak and the resident's perineal area is "red and burns." - On [DATE] at 6:30 A.M., the resident's catheter continued to leak and they applied [MEDICATION NAME] powder to the resident's perineal area. Review of the resident's Nursing Report Sheet, dated [DATE] on the 3:00 P.M. to 11:00 P.M. shift, showed staff documented the resident's bottom "looks horrible" and they called the resident's physician to obtain an order for [REDACTED]." Review of the resident's POS, dated [DATE], showed the following order: - Schedule appointment with the wound clinic as soon as possible (ordered [DATE]). Review of the resident's nurse's notes, dated [DATE] at 10:49 P.M., showed staff documented the resident has several open areas on his/her buttocks that are "not improving." Staff documented the following open areas: - Left upper leg measured 0.5 cm by 1.0 cm; - Above the left upper leg measured 0.5 cm by 0.5 cm; - Left crease on buttocks measured 1.2 cm by 1.2 cm; - Right upper back of leg measured 0.5 cm by 2.0 cm; - Right buttock crease measured 0.5 cm by 2.0 cm by 0.7 cm depth. Additionally, review of the nurse's notes, dated [DATE] at 10:49 P.M., showed staff documented they administered the current treatment of [REDACTED]. Staff documented they called the resident's physician and obtained an order to send the resident to the wound clinic "as soon as possible." Staff documented the resident's perineal area as "necrotic." Staff documented the resident's suprapubic catheter continues to leak around the stoma and from his/her perineal area. Staff documented they notified the physician of this information. Review of the resident's Registered Dietician (RD) recommendations, dated [DATE], showed the dietician made the following recommendations for wound healing: - Multivitamin with minerals; - Zinc (helps repair damaged tissue and heal wounds) 50 mg per day for 30 days; - [MEDICATION NAME] ([MEDICATION NAME]-intensive powder formulated for patients recovering from burns, surgery, or chronic wounds) with eight ounces clear soda twice daily for 30 days. Review of the resident's RD recommendations made on [DATE], showed the physician did not respond to the recommendations until [DATE], when the physician responded that he/she agreed to the recommendations. Review of the resident's medical record showed staff did not document any information to show they contacted the physician to obtain a timely response regarding the Dietician's recommendations for wound healing. Review of the resident's Wound Report, dated [DATE], showed facility staff documented: - The resident's Stage II pressure ulcer to his/her right buttocks measured 5.0 cm by 3.0 cm by 11.5 cm depth with tunneling, and has deteriorated. - The resident goes to the wound clinic, where his/her wound was debrided. - The current treatment is Kerlix (gauze) dampened with Dakin's (antiseptic solution to treat infected wounds), then [MEDICATION NAME] tape. - The wound clinic physician feels this wound is worse due to the resident's urine leakage, for which the resident has seen the urologist. Review of the resident's Treatment Administration Record (TAR), dated [DATE], showed staff documented they administered the treatment of [REDACTED]. Review of the resident's Nursing Report Sheet, dated [DATE] and [DATE] on the 3:00 P.M. to 11:00 P.M. shift, showed staff documented they administered the resident's treatment and it "looks horrible." Review of the resident's medical record, showed an appointment for the resident with the wound clinic on [DATE]. Review of the resident's Burn Surgery Clinic Note (Wound Clinic), dated [DATE], showed the wound clinic physician documented he/she saw the resident on this date for the first time from the nursing facility. The wound clinic physician documented: - The resident was admitted to the hospital on [DATE] from home. - The Skin Care Team was consulted during the hospitalization and the resident had an ulcer at the gluteal crease of the ischium (one of the three sections of the hip bone) that measured 1.5 cm by 3.0 cm, and was "thought to be partial thickness." - The resident has a right below-the-knee amputation. - The resident was admitted to the facility on [DATE] and "there are significant problems." - The resident now has a severe "level 4" right ischial ulcer that measures 11.5 cm by 5 cm, and a moderate left ischial ulcer near the crease of the groin posteriorly that is a "level 3" ulcer and measures 3.0 cm by 2.0 cm. - The resident has a suprapubic catheter but urine continues to leak through the urethra, which is associated with the rapid spread of the ischial ulcers. - The resident has had skin flaps (mass of tissue from one part of the body moved to a different part of the body) previously on at least three occasions for treatment of [REDACTED]. - The wound clinic physician debrided the ulcers of large amounts of necrotic tissue. - The ulcerations are very devastating and getting healing in the presence of the previous flaps that have been done makes flap closure futile in the current condition. - Paramount will be positioning the resident in the provision of a satisfactory mattress such as a Clinitron bed (air fluidized therapy and low air loss therapy on an articulating frame to provide pressure ulcer prevention and treatment). - He/she will return to the wound clinic in one week. Review of the Doctor's Progress Notes, dated [DATE], from the Wound Clinic showed the wound clinic ordered: - Needs to see a urologist to obstruct the outlet due to suprapubic catheter leaks and the leak is the cause of the ulcers and must be controlled to make headway. - Pack each ulcer with Kerlix and ,[DATE]% Dakin's moistened three times daily for now. - "Consider a Clinitron bed!" Review of the resident's POS, dated [DATE], showed the following order: - Pack left and right sided coccyx wounds with Kerlix and ,[DATE] % Dakin's moistened three times daily (ordered [DATE]). Review of the resident's medical record showed no documentation to indicate they obtained a Clinitron or other mattress with air loss therapy as directed by the wound clinic physician. Additionally, review of the resident's medical record showed no documentation to indicate the resident returned to the wound clinic one week after the appointment on [DATE]. Review showed staff documented the resident's next appointment with the wound clinic was [DATE]. Review of the resident's Nursing Report Sheet, dated [DATE] on the 11:00 P.M. to 7:00 A.M. shift, showed staff documented the resident's Dakin's treatment was not done because they did not have any Dakin's. Review of the resident's TAR, dated [DATE], showed staff initialed and circled the Dakin's treatment on the 11:00 P.M. to 7:00 A.M. shift. Review of the resident's Urology Clinic Note, dated [DATE], showed the urologist documented the following: - The resident has a [MEDICAL CONDITION] bladder resulting in urethral and perisuprapubic tube urinary incontinence, which is exacerbating his/her sacral pressure ulcers. - Suspicion that the resident would be a high-risk surgical candidate. Review of the resident's Wound Report, dated [DATE], showed facility staff documented the following information: - The resident's right buttocks Stage II pressure ulcer measured 5.0 cm by 3.0 cm by 11.5 cm depth with tunneling. - The resident's wound was debrided at the wound clinic. - The current treatment is ,[DATE]% Dakin's, then [MEDICATION NAME] tape. - The wound clinic feels this wound is worse because of the urine leakage, for which the resident has seen the urologist. Review of the resident's POS, dated [DATE], showed the physician ordered the following based on the results of the RD's recommendations made on [DATE]: - Multivitamin with minerals (ordered [DATE]); - Zinc 50 mg daily for 30 days (ordered [DATE]); - [MEDICATION NAME] with eight ounces of clear soda twice daily for 30 days (ordered [DATE]). Review of the resident's Wound Report, dated [DATE], showed facility staff documented the following: - The resident's Stage II pressure ulcer on his/her right buttock measured 4.0 cm by 5.0 cm by 8.0 cm depth with tunneling, and is healing. - The resident's Stage II pressure ulcer on his/her left buttock measured 5.5 cm by 8.0 cm with tunneling and was acquired on [DATE]. - The resident goes to the wound clinic, where the right buttock wound was debrided. - The current treatment for [REDACTED]. - The wound clinic physician feels both wounds are worse due to the urine leakage, for which the resident has seen the urologist. Review of the resident's Wound Report, dated [DATE], showed facility staff documented the following: - The resident's Stage II pressure ulcer to the right buttock measures 7.0 cm by 5.0 cm by 3.0 cm depth with tunneling, and is healing. - The resident's Stage II pressure ulcer to the left buttock measures 6.0 cm by 5.0 cm by 2.0 cm depth with tunneling, and is healing. - The resident goes to the wound clinic, where they debrided the right buttock ulcer. - The current treatment to both wounds is Kerlix dampened with ,[DATE]% Dakin's, then [MEDICATION NAME] tape. - The wound clinic physician feels the wounds are worse because of the urine leakage, for which he/she has seen the urologist. Review of the resident's Burn Surgery Clinic Note (Wound Clinic), dated [DATE], showed the wound clinic physician documented: - The resident presents today for follow up of bilateral ischial wounds. - The resident said he/she has recently had significant drainage from urinary incontinence with constant wetting of her posterior buttock area, which he/she thinks caused the wounds. - The resident said he/she sits up in his/her wheelchair for approximately four to eight hours per day and has to change his/her dressings due to saturation every four hours. - The resident has a urinary catheter and continues to leak around it, for which he/she saw a urologist. - The left ischial wound measured 5.5 cm by 5 cm by 2 cm depth. - The right ischial wound measured 4.0 cm by 6.0 cm by 3.5 cm depth extending into the perineal area. - The wound beds extend down to scar and there is no palpable bone. Review of the resident's Doctors Progress Note, dated [DATE], showed the following orders: - Continue Dakin's moistened gauze packing to ischial wounds twice daily and as needed; - Minimize sitting no more than one to two hours at a time and do not exceed more than four hours total sitting in 24 hours. Review of the resident's Wound Report, dated [DATE], showed facility staff documented the following: - The resident's Stage III pressure ulcer (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss and may include undermining or tunneling) on the right buttock measured 8.0 cm by 6.0 cm by 3.5 cm depth with tunneling, and has deteriorated. - The resident's Stage II pressure ulcer on the left buttock measured 5.5 cm by 5.0 cm by 2.0 cm depth with tunneling, and is healing. - The resident goes to the wound clinic, where they debrided the right ischial ulcer. - The resident's wounds are being treated with Kerlix dampened with ,[DATE]% Dakin's, then [MEDICATION NAME] tape. - The wound clinic physician feels the wounds are worse because of the urine leakage, for which he/she has seen the urologist. Review of the resident's TAR, dated [DATE], showed staff did not document information to show they administered the resident's treatment of [REDACTED].M. to 11:00 P.M. shift on [DATE]. Review of the resident's Wound Report, dated [DATE], showed facility staff documented the following: - The resident's Stage III right buttock pressure ulcer measured 9.5 cm by 7.0 cm by 1.0 cm depth with tunneling, and is healing. - The resident's Stage II left buttock pressure ulcer measured 4.0 cm by 3.0 cm by 1.0 cm depth with tunneling, and is healing. - The resident goes to the wound clinic, where they debrided the right ischial ulcer. - The resident's wounds are being treated with Kerlix dampened with ,[DATE]% Dakin's, then [MEDICATION NAME] tape. - The wound clinic physician feels the wounds are worse because of the urine leakage, for which he/she has seen the urologist. Review of the resident's Burn Surgery Clinic Note (Wound Clinic), dated [DATE], showed the wound clinic physician documented: - The resident has two areas approximately four square centimeters in total of necrotic tissue, which he/she debrided. - Both ischei are exposed with large ulcerations measuring 5 cm by 10 cm each. - The ulcerations crowd against perineal area, where the resident leaks some urine. - The treatment can be changed to a honey saturated gauze. - The resident needs padding to collect any urine that leaks. Review of the resident's wound care instructions from the wound clinic, dated [DATE], showed the physician ordered: - Change dressing routine; begin pure honey-saturated Kerlix, pack into each side ulcer twice daily; - Place a padding or Kerlix in the perineal area to contain urine, hold in place with an incontinence pad. Review of the resident's Wound Report, dated [DATE], showed facility staff documented the following: - The resident's Stage III right buttock pressure ulcer measured 9.5 cm by 7.0 cm by 1.0 cm depth with tunneling, and is healing. - The resident's Stage II left buttock pressure ulcer measured 4.0 cm by 3.0 cm by 1.0 cm depth with tunneling, and is healing. - The resident's Stage II pressure ulcer on the coccyx measured 4.0 cm by 3.4 cm by 3.0 cm depth with tunneling, and is a new area identified on [DATE]. - The resident goes to the wound clinic, where they debrided the right buttock ulcer. - The treatment to all of the resident's open areas is Kerlix dampened with ,[DATE]% Dakin's, then [MEDICATION NAME] tape. - The wound clinic feels the wounds are worse because of urine leakage, for which the resident has seen the urologist. Review of the Wound Report, dated [DATE], showed the report did not contain the current treatment ordered on [DATE] for pure honey-saturated Kerlix packed into each ulcer twice daily. Review of the resident's nurse's notes, dated [DATE] at 9:15 P.M., showed staff documented they noted a "foul smell" from the resident's buttocks wounds. Review of the resident's medical record, showed the record did not contain any information to show staff notified the resident's physician of the "foul smell" from his/her buttocks wounds. During an interview on [DATE] at 1:45 P.M., the Assistant Director of Nursing (ADON) said the resident's physician is "bad" about responding timely to faxed information, such as dietary recommendations. The ADON said the Administrator talked to the physician about not responding to orders timely, and the physician said facility staff would have to wait for a response until he/she made a visit to the facility. The ADON said the physician comes to the facility approximately once per month. During an interview on [DATE] at 2:00 P.M., the Administrator said facility staff did not stage the resident's wound correctly on the Wound Report dated [DATE]. Additionally, the Administrator said the resident did not go to the wound clinic until [DATE] and did not see the urologist until days after the wound clinic appointment, even though the Wound Report documentation, dated [DATE], showed the resident had already been to the wound clinic, started a new treatment, and had seen the urologist. During an interview on [DATE] at 3:08 P.M., the resident's family member said the resident had urinary leakage when he/she lived at home and he/she saw the urologist about a year prior to admission to the facility. The family member said the resident had some urinary leakage that would "go down through the creases and around to his/her bottom." The family member said he/she did not know if the resident had urinary leakage from his/her perineal area while at home. The family member said the resident did not have any severe pressure ulcer areas when he/she lived at home, but had "a couple of small areas" on his/her bottom "every once in a while." During an interview on [DATE] at 1:35 P.M., the Wound Clinic Nurse (WCN) said the resident was seen at the clinic a few times. The WCN said the resident's wounds "were pretty bad" and he/she "thought the facility would have gotten the resident an appointment at the clinic sooner" than they did. The WCN said the resident had urinary leakage from the suprapubic catheter, and his/her wounds were "down to the bone." The WCN said the facility's Wound Report, dated [DATE], that assessed the depth of the resident's wound as 11.5 cm did not sound accurate for the resident. During an interview on [DATE] at 2:20 P.M., CNA E said the resident did not have a cushion in his/her wheelchair when he/she was first admitted , but he/she got one later. CNA E said the resident stayed up in his/her wheelchair a lot when he/she was first admitted , but approximately a month or two before the resident died they limited him/her to four hours per day in the wheelchair. During an interview on [DATE] at 3:25 P.M., the Administrator said the resident had a pressure relieving mattress. During an interview on [DATE] at 3:30 P.M., the ADON said the resident did not have a specialty air mattress while in the facility. During an interview on [DATE] at 3:35 P.M., the Quality Assurance Nurse (QAN) said the facility does not have any of the Clinitron beds that the wound clinic physician recommended for the resident. The resident did not have a Clinitron bed. During an interview on [DATE] at 5:20 P.M., CNA P said the resident had "some kind of cushion" in his/her wheelchair that was "a couple of inches thick." CNA P said the resident did not have a special mattress, but had a soft mattress that the resident's family member brought from home. During an interview on [DATE] at 10:30 A.M., LPN Q said he/she is also a family member of the resident. LPN Q said: - He/she wrote the admission nursing assessment on the resident on [DATE], and the resident did not have any open areas on admission, but had reddened areas on his/her buttocks. - The resident developed open areas to his/her buttocks at the facility possibly because he/she sat up in his/her wheelchair a lot and had urine leakage from the suprapubic catheter. - The resident's suprapubic catheter leaked from the stoma and perineal area off and on for years, but the resident usually stayed in bed when he/she lived at home. - The resident saw a urologist when he/she lived at home, and the urologist had always said the resident was not a good candidate for surgical intervention. - The resident sometimes refused to lay down, but also "did okay" with staying up for only four hours out of a 24 hour period. - The resident's family member brought in a pressure relieving mattress for the resident a couple of weeks after admission to the facility. - The resident had a black cushion in his/her wheelchair that was brought from home, but not sure what kind of cushion. - The flaps on the resident's buttocks were from approximately [AGE] years ago. - The resident did not have any open areas on his/her bottom over the last three to four years prior to admission to the facility, but it became red at times. - The resident's perineal area had necrotic tissue on it for approximately one to two weeks prior to the resident's first appointment with the wound clinic. - The resident's physician wouldn't respond to the Dietician's recommendations because the physician said "they are not an emergency" and are "only recommendations." During an interview by phone on [DATE] at 2:15 P.M., the Administrator said the resident had an air flow mattress that the resident's family brought from home. 2. Review of Resident #14's medical record, showed the resident was admitted to the facility from the hospital on [DATE]. Review showed the resident was admitted to the facility with an unstageable pressure ulcer (suspected deep tissue injury in evolution) on his/her left heel. Review of the resident's Braden Scale for predicting pressure ulcer risk, dated [DATE], showed staff did not assess the resident as being at high risk for pressure ulcers. Review of the resident's corresponding plan of care, dated [DATE], showed staff documented the resident is at risk for skin breakdown due to reduced mobility and had a stroke. Staff documented the resident was admitted to the facility with an unstageable pressure ulcer on his/her left heel. Review showed the plan of care directed staff to: - Perform a body/skin audit at least weekly; - Keep linens dry and wrinkle free; - Examine the resident's skin during showers to detect any new skin conditions; - Notify the physician of any new open or red areas to obtain treatment without delay; - Apply [MEDICATION NAME] spray twice daily to the left heel; - Assist with changing positions a

Based on observation and interview, the facility staff failed to promote care for residents in a manner and an environment that maintained, enhanced, and/or respected each resident's dignity. The facility staff failed to promote resident dignity by failing to assist one resident (Resident #22) with toileting in a timely manner. Staff failed to engage in conversation or interaction with two residents (Resident #16 and #23) during meal times when being assisted by staff to eat. Staff failed to speak to 12 residents in a respectful manner and staff failed to speak to each other in a respectful manner in front of the residents (Residents #24, #27, Anonymous residents A, B, C, D, E, F, G, H, and I, Anonymous family member L, and one unknown resident). Staff failed to make accommodations for appropriate cell phone ring tones and volume in the presence of residents for nine residents (Anonymous residents A, B, C, D, E, F, G, H, and I). Staff failed to allow 16 residents (Residents #2, #25, Anonymous residents A, B, C, D, E, F, G, H, and I, and five unknown residents) choices such as natural wake up times or going to their rooms when the resident chooses. Staff failed to transport one resident (Resident #9) in a dignified manner by pulling the resident backwards in a geri chair. Staff failed to promote dignity by lining seven residents (Residents #12, 14, 34, 35, and three unknown residents) in the hallway in a front to back manner for extended periods of time and without any visual or auditory stimulation. The facility census was 93. 1. Review of Resident #22's Minimum Data Set (MDS), a federally mandated comprehensive assessment required to be completed by staff and used for planning care, dated 7/21/11, showed staff assessed the following: -requires extensive assistance for all activities of daily living including personal hygiene, transfers, and toileting. Observation on 8/11/11 at 8:00 A.M., showed the resident sat in the dining room in his/her wheelchair. Registered Nurse (RN) A wheeled the resident out of the dining room. The resident said to RN A, "I have to go to the bathroom really bad right now." RN A took the resident to the side of the dining room hallway and said, "Let's take your blood sugar real fast, the closest bathroom is back at the nurses' station." The resident again said he/she "need to go to the bathroom". At this time the resident placed his/her hand across his/her lower stomach area and moaned and said "I have to pee." RN A did not respond and instead proceeded to test the resident's blood sugar. At 8:05 A.M. the resident said to RN A, "It's too late, I went." RN A shook his/her head and said "Oh." The resident then wheeled himself/herself back to the table to eat breakfast. During an interview at this time the resident said, "it's too late, I peed on myself." The resident said he/she asked staff for assistance but they "didn't take me." Observation at this time showed the resident sat at the breakfast table eating. RN A did not assist the resident to the toilet after repeated requests for assistance. RN A did not provide or assist the dependent resident with cleansing after incontinence to maintain the resident's dignity during dining. 2. Observation on 8/10/11 at 6:15 P.M., showed several residents sat at or near the nurses' station on the Essex wing. At 6:15 P.M. an unknown Certified Nurse Assistant (CNA) walked in the hallway of the Essex wing and near the residents at the nurses' station. During this time, the CNA's personal cell phone rang playing an inappropriate ring tone. The ring tone contained curse words including "Ass." The ring tone continued loudly until the CNA entered a resident shower room with the cell phone still ringing. During the group interview on 8/11/11 at 10:30 A.M., Anonymous residents B, C, D, E, F, H, and I said staff carry their cell phones with them while working in the facility. All seven residents said some of the staff have "very inappropriate" ring tones on their phones that play loudly when they ring. 3. Observation on 8/11/11 at 6:30 A.M., showed residents #12, #14, #34, and two other unknown residents sat in their wheelchairs positioned along the wall on the back area of the Essex wing. During this time the residents sat lined in a front to back position. Further, observation showed resident #35 and one unknown resident, along the Essex right hallway, lined in the same front to back position waiting for staff to assist them to breakfast. Observation showed residents remained in the same position until 7:15 A.M. when staff wheeled them to the dining room for breakfast. Staff did not position the residents in a manner that promoted interaction with other residents or maintained their dignity. Observation on 8/15/11 at 4:45 P.M., showed Resident #12, #14, and #34 positioned along the wall on the back area of the Essex wing. During this time the residents sat lined in a front to back position. During an interview at 4:45 P.M. CNA T said the prior nursing shift (7:00 A.M. to 3:00 P.M.) lined the residents along the wall. CNA T said the residents were already positioned there when he/she came to work. CNA T said the residents will remain there until "I take them to the dining room for supper." CNA T said the supper meal is scheduled for 5:15 P.M.. 4. During a group interview on 8/11/11 at 10:30 A.M., nine out of 11 residents in attendance (Anonymous residents A, B, C, D, E, F, G, H, and I) said staff use foul and vulgar language when speaking to residents "and each other." Each listed resident said staff do not treat them in a respectful manner and they believe that the language is inappropriate. Anonymous resident C said staff use inappropriate racial slurs toward each other, but while providing care to residents. Anonymous residents B and C said staff use the phrase "[***] you" towards each other, but in the presence of the residents. The residents said facility staff "act like you're your imposing on them" when using your call light to request assistance. The same residents said when staff answer call lights they make inappropriate comments like "what do you want?". The same residents said this is "intimidating" to them. Anonymous residents B, C, D, E, F, H, and I said facility staff do not toilet or provide incontinence care for any dependent residents during meals. The residents said staff will not help residents with toileting until after the meal is over. The residents each/all said they have sat in the dining room or lay in their bed incontinent of urine or bowel for an extended period of time waiting for facility staff to assist them. During this interview anonymous residents (B, C, D, H, I) cried while describing how they "feel" staff members treat the residents. The same residents said they were not only "saddened" by the way staff treat them but also the way staff treat other residents "who can't speak up or defend themselves." Additionally, the same residents said they do not have a choice about what time they get up in the morning. The listed residents said staff "begin at one end of the hall at 5:00 A.M., and wake each resident up as they go down the hall." 5. During an interview on 8/12/11 at 12:05 P.M., an anonymous family member (Family member L) said he/she was concerned with facility staff attitudes towards the residents. He/she said facility staff "act like they are doing you a favor or you are imposing on them" when making a request. 6. During an interview on 8/12/11 at 4:10 P.M., anonymous resident C said staff display a "hurtful and disrespectful" attitude when providing his/her care. The resident said staff use foul language to each other during evening and weekend meals in the dining room. The resident said staff talk to each other while assisting residents, and speak inappropriately including foul and vulgar language. Anonymous resident C also said staff personal cell phones ring "offensive and foul language" loudly during resident care. The resident said his/her roommate is confused and dependent on staff for assistance. Anonymous resident C said staff get his/her roommate out of bed at 5:30 A.M. in the morning and the resident's roommate "has to sit in the hall waiting for breakfast." 7. Review of Resident #24's MDS, dated [DATE], showed the staff assessed the resident as follows: -Moderate cognitive impairment; -No behaviors; -Limited assistance with transfers; -Supervision and set up with mobility; -Extensive assistance with dressing and personal hygiene; -Utilized a walker for mobility. Observation on 8/11/11 at 7:15 A.M., showed the resident lay in bed asleep and fully dressed. At 7:15 A.M. DHSS surveyor staff stood in the hallway outside the resident's room. At this time, CNA M entered the resident's room and instructed, "get up", "come on, get up it's breakfast time." CNA M did not approach the sleeping resident calmly to wake him/her for the day before beginning instructions. CNA M did not interact with the resident in a manner that maintains his/her dignity. 8. Review of Resident #27's MDS, dated [DATE], showed the staff assessed the resident as follows: -Moderate cognitive impairment; -Minimal depression; -Extensive assistance with transfers, dressing and personal hygiene; -Utilized a wheelchair for mobility; -Impairment on both sides lower extremity. Observation on 8/12/11 at 11:30 A.M., showed the resident ate lunch in the dining room on the Special Care Unit. The resident rolled the wheelchair away from the table and toward the door leading to the hallway. CNA N asked the resident loudly and from across the dining room "where are you going?" The resident replied "to my room." CNA N walked up behind the resident while in his/her wheelchair and said loudly "Go to your room then." The resident wheeled from the dining room to the hallway and stopped. While standing behind the resident's wheelchair, CNA N loudly instructed the resident to, "hurry up". The resident again wheeled him/herself toward his/her room and said "I'm going, see". CNA N did not offer to assist the resident. CNA N did not interact with the resident in a manner that maintains his/her dignity. 9. During an interview on 8/11/11 at 3:30 P.M., an anonymous resident I said staff use "curse words" when talking with residents. The resident said staff use inappropriate language to each other but "in front of us." The resident said hearing staff use "curse words" "upsets me" and "I have cried about it." The resident said he/she has reported this to an unknown nurse aide but staff continue to use the same language in the same manner. 10. Observation on 8/15/11 at 11:25 A.M., showed an unknown resident sat in a wheelchair in the 100 hallway. The resident sat with his/her feet on the floor. An unknown CNA approached the resident from behind the wheelchair and instructed "Feet Up, were going to the dining room." The CNA wheeled the resident toward the dining room. CNA staff did not offer to assist the resident to the dining room. CNA staff did not inform the resident of the transport before wheeling the resident in the hall, to prevent the resident from startling and to maintain the resident's dignity during care. 11. Review of the facility provided list of interviewable (able to participate in a discussion about the daily aspects of their life) resident included anonymous resident B. During an interview on 8/11/11 at 11:30 A.M., anonymous resident B said he/she is "not able to decide when to go to bed." Anonymous resident B said CNA staff "tell you when you have to go to bed." The resident said staff tell him/her "You need to get to bed." Anonymous resident B also said staff are disrespectful when they speak with residents and are disrespectful when resident use their call lights for assistance. Anonymous resident B said an unknown CNA responded and said, "you keep calling me and I get tired of coming back every ten minutes" when answering an anonymous resident's call light recently. Anonymous resident B said he/she did not report this to anybody, "I'm just trying to keep an even keel." Additionally, anonymous resident B said, " I hate it here, and how they treat me." 12. During an interview on 8/15/11 at 12:35 P.M., the Director of Nursing (DON) said "staff need to communicate better with the residents." The DON said staff are expected to approach any resident and explain what they are going to do before "just doing it." The DON said if you just tell residents what you are going to do then that "sounds like demanding" instead of an offer of assistance. 13. Observation in room [ROOM NUMBER] on 8/11/11 at 6:30 A.M., showed one unknown resident lay in his/her bed atop the linens and fully dressed in day clothes. Observation in room [ROOM NUMBER] on 8/11/11 at 6:30 A.M., showed two resident lay in their beds atop the linens and fully dressed in day clothes. Observation in room [ROOM NUMBER] on 8/11/11 at 6:30 A.M., showed two resident lay in their beds atop the linens and fully dressed in day clothes During the Group interview on 8/11/11 at 10:30 A.M., anonymous residents (A, B, C, D, E, F, G, H and I) said staff wake them up early in the morning. The residents said staff "start at one end of the hall at 5:00 A.M. and work their way toward the nurses station, getting the residents up in each room as they go." During an interview on 8/11/11 at 7:15 A.M., CNA M said night shift staff get the residents dressed before they leave then put them back to bed in their clothes. CNA M said when day shift staff get here, we "just have to get them up for breakfast because they're already dressed." 16. During the initial tour on 8/10/11 at 11:15 A.M., Licensed staff identified Resident #23 as: -cognitively impaired -totally dependent on staff for eating Observation on 8/15/11 at 12:02 P.M., showed the resident sat in the dining room at a table designated for residents that are dependent on staff for eating. Resident #23 sat upright and awake. During this time, LPN D approached the resident and positioned him/herself standing next to the resident's side and facing away from the resident. LPN D picked up the resident's fork, obtained food items from the resident's plate, then held the fork to the resident's mouth while continuing to stand with his/her back facing the resident. The resident ate the bite of food then LPN D left the area. LPN D did not speak with the resident and did not position him/herself facing the resident. LPN D did not interact with the resident in a manner that maintained his/her dignity. 17. Review of Resident #16's MDS, dated [DATE], showed staff assessed the resident as follows: -Requires extensive assistance with bed mobility, transfers, locomotion on unit, dressing, eating toilet use and personal hygiene; -Wheelchair used for mobility; -Dementia; -Depression. Review of the resident's comprehensive care plan, dated 2/23/11, directed staff on the following interventions; -The resident eats in the main dining room and is assisted by staff; -Develop communication system with the resident; -Encourage to participate in a conversation with the resident; -Establish an environment of mutual trust and respect; -Give praise and rewards for accomplishments. Observation on 8/16/11 at 12:45 P.M., showed the resident sat at a table in the main dining room during lunch. During this time, an unknown staff member sat beside the resident and assisted her/him with eating and drinking. During this time the unknown staff member instructed the resident; "time to eat, and take a bite" repeatedly, but did not engage the resident in any conversation. Staff did not interact with the resident as directed by the plan of care and in a manner that maintains a dignified dining environment. 18. Review of Resident #9's MDS, dated [DATE], showed the staff assessed the resident as follows: -Dependent with the assistance of two staff members for transfers; -Dependent with assistance of one staff member for dressing, eating, locomotion and personal hygiene; -Utilized a wheelchair for mobility; -[DIAGNOSES REDACTED]. Observation on 8/10/11 at 4:10 P.M., showed the resident sat in his/her geri chair near the nurses' station. During this time, CNA D approached the resident and used the handle on the back of the geri chair to pull the resident in the hallway toward his/her room backwards. During an interview on 8/16/11 at 2:30 P.M., CNA E said staff are instructed, "never pull a resident's wheelchair or gerichair backwards." During an interview on 8/16/11 at 4:30 P.M., the Assistant Director of Nursing (ADON) said staff are expected to "never pull a resident backwards when transporting them." 21. Review of Resident #2's MDS, dated [DATE], showed the staff assessed the resident as follows: -Does not refuse care; -Favorite activities are important; -Going outside for fresh air is very important; -Keeping up with news is important; -Using the telephone in private is very important; -Requires extensive assistance by two staff members in bed mobility, transfers and dressing; -Dependent with locomotion and toilet use; -Upper and lower extremity impairment on both sides; -Uses wheelchair for mobility; -Anxiety disorder. Review showed the facilities list of interviewable residents included Resident #2. Review of the resident's comprehensive care plan, dated 2/4/11 showed staff are directed to provide the following interventions for activities; -The resident likes to watch television privately in his/her room; Observation on 8/11/11 at 2:00 P.M., showed the resident sat at the nurses station in his/her wheelchair. At 2:00 P.M. CNA E assisted the resident to his/her room then left the area. Observation showed a television in the resident's room. During an interview at this time the resident said he/she enjoys watching TV but residents "are not allowed to be in their rooms alone while sitting in a wheelchair." As surveyor staff left the resident's room, CNA E approached the resident's room and said, "he/she cannot be left alone in the room when she/he is in the wheelchair." CNA E wheeled the resident back out to the nursing station and positioned the resident between two unidentified residents, then left the area. During an interview on 8/11/11 at 2:15 P.M., CNA E said the resident is "not allowed" to sit in a wheelchair in his/her room alone because of the possibility the resident "may fall." 23. Review of Resident #25's MDS, dated [DATE], showed the staff assessed the resident as follows: -Very important for the resident to have magazines, books or newspapers to read; -Very important for the resident to listen to music; -Very important for the resident to do favorite activities; -Very important for the resident to get fresh air outside when the weather is nice; -Uses wheelchair for mobility; -Did not have a fall two-six months prior to admission into facility; -Requires extensive assistance with transfers by two staff members; Review of the resident's comprehensive care plan, dated 6/24/11, showed staff are directed to provide the following interventions: -Keep call light within reach; -(8/17 update) Encourage resident to stay out of her/his room to visit with others or his/her spouse unless going to bed; -Talk to resident during care and explain procedures; -Provide verbal reminders and give directions; - Staff should allow resident to ventilate feelings; -Resident has "indicated that it is important for me to choose my bedtime, have reading material available, listen to music, go outside when the weather is nice, remind me of upcoming activities." Observation on 8/10/11 at 5:55 P.M., showed the resident sat in his/her wheelchair positioned next to the wall, in the hallway. The resident stopped the surveyor and asked for assistance to his/her room. The surveyor informed the ADON and DON who were at the nurses' station. 24. During an interview at this time, both the DON and Assistant Director of Nursing (ADON) said the resident "is not allowed in his/her room alone because of the risk of falling."

Based on resident, Physician, and staff interview, and record review the facility failed to provide care to prevent the development of pressure ulcers and as directed by the Physician for one dependent resident (#5) with a high risk for skin impairments. The resident developed a facility acquired stage III (full thickness loss of skin). Staff also failed to assess one resident's skin condition at the time of admission (Resident #17), and failed to identify pressure ulcers upon admission, to obtain treatment orders and prevent further decline, of 19 sampled residents. The facility census was 93. 1. Review of Resident #5's Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/15/10, showed the staff assessed the resident as follows: -At risk for the development of a pressure ulcer; -No skin impairments. Review of the resident's comprehensive care plan, dated 12/16/10, directed staff on the following interventions: -Staff should examine my skin during showers to detect any new skin conditions; -Staff should notify my physician of any new open or red areas so that I can be treated without delay; -Apply cream to my skin for hydration; Review of the resident's Admission Nursing Assessment, dated 12/3/10, showed staff documented the resident did not have any skin breakdown. During an interview on 8/16/11 at 4:30 P.M., the Assistant Director of Nursing (ADON) said Certified Nurse Assistant (CNA) staff assist all residents with a bath or shower twice per week. The ADON said CNA staff are directed to document any identified skin impairments on a "shower sheet form" and notify the charge nurse. Review of the resident's shower sheet skin assessment, dated 5/03/11, showed staff recorded the resident had a red coccyx and groin area. Review of the resident's nurses' notes, dated 5/3/11, showed the notes do not contain any information to show licensed staff assessed the resident's coccyx or notified the physician to obtain treatment orders to prevent further decline and promote healing of the resident's identified skin impairment. Review of the resident's shower sheet skin assessment, dated 5/10/11, showed staff did not assess any reddened areas or other impairments. Review showed staff did not complete another shower sheet for the resident until 5/26/11(15 days). Staff did not assess the resident's skin during weekly showers as directed. Review of the resident's shower sheet skin assessment, dated 5/26/11, showed staff did not assess any reddened areas or other impairments. Review of the resident's shower sheet skin assessment, dated 5/27/11, showed CNA staff did not assess any reddened areas or other impairments. CNA staff did not record an assessment of the resident's right heel pressure ulcer identified in the resident's nurses' notes on 5/27/11 (same day). Review of the resident's shower sheet skin assessment, dated 5/31/11, showed CNA staff did not assess any reddened areas or other impairments. CNA staff did not record an assessment of the resident's right heel pressure ulcer identified in the resident's nurses' notes on 5/27/11 (four days prior). Review of the physician's orders [REDACTED]. Review of the POS [REDACTED]. Review of the resident's MDS, dated [DATE], showed the staff assessed the resident as follows: -Cognitively intact; -Limited assistance by one staff member with bed mobility and locomotion; -Extensive assistance by one staff member with transfers, dressing, toilet use and personal hygiene; -Requires physical help in part of bathing activity; -Lower extremity impairment with range of motion; -Uses a wheelchair for mobility; -Diabetes Mellitis; -Frequent complaints of pain; -Therapeutic diet; -At risk for the development of a pressure ulcer; -One unstageable (not stageable due to the presence of eschar or slough tissue covering the wound bed) pressure ulcer measuring measured 4.0 cm (centimeters) x 3.0 cm x 0.5 cm depth; -Necrotic tissue (dead tissue that needs to be removed); -Pressure ulcers were not present on the prior assessment; -Nutrition/hydration interventions to manage skin problems. Review of the resident's corresponding plan of care showed staff updated the care plan on 7/18/11 to include: -provide pressure relieving boots for the resident's heels to "off load pressure" at all times Review of the resident's weekly wound report showed staff documented the following: - 5/27/11 at 1:00 A.M., staff documented a "2.0 centimeter (cm) area of brown hard eschar" on the resident's right heel. -6/6/11-right heel pressure ulcer measured 6.0 cm x 4.5 cm, unable to determine depth. Physician B ordered santyl, nickel thick, cover with dressing daily on 6/1/11. Further review showed the physician ordered Bactrim (antibiotic) twice daily for seven days for a "red and swollen" right foot; -6/8/11-right heel pressure ulcer measurements are unchanged, Physician F ordered una boots (dressings that provides compression to prevent swelling) to be changed by wound clinic staff at next appointment; -7/13/11-right heel pressure ulcer measured 3.2 cm x 2.5 cm with 0.7 cm depth. Physician F directed staff to provide honey-soaked gauze, discontinued the una boot and provided compression stocking (assists to prevent swelling) and pressure relieving boot to "protect from pressure" to the resident's right heel daily; -7/18/11-right heel pressure ulcer measured 5.0 cm x 3.5 cm with 0.7 cm depth, pressure ulcer deteriorating, Physician F directed staff to apply pressure relieving boots at all times to both legs, discontinue honey-soaked dressings to right heel, apply compression hose to left lower extremity 23 hours a day, and leave una boot to right lower extremity until next wound clinic visit; -7/25/11-right heel pressure ulcer declined and measured 5.0 cm x 2.8 cm with 1.0 cm depth, Physician F continued the una boot to the right heel changed by the wound clinic weekly. Physician F discontinued the the compression hose to the left lower leg and ordered an una boot to be maintained by the wound clinic weekly. Review of the resident's venous doppler study (test used to determine circulation and blood flow to lower legs) dated 6/1/11, showed "normal. (without decreased blood flow)." Review of the resident's Treatment Administration Record (TAR), dated August 2011, showed staff did not record any information to show staff provide the resident's pressure relieving boots for his/her heels to; promote healing of his/her pressure ulcer, prevent the development of new pressure ulcers, prevent further decline in the resident's skin condition, and as directed by the resident's Physician, on evening shifts of 8/1/11, 8/2/11, 8/3/11, 8/5/11, and day shifts of 8/2/11, 8/3/11, 8/6/11, and 8/7/11. Review of Physician F's progress note, dated 7/25/11, showed the Physician documented the resident is at "risk for pressure on heels, right heel increased in size and left heel is vulnerable." Physician F documented he directed staff to provide the resident an una boot to both legs because "the compression stockings were not applied by facility staff 23 hours out of the day." Further, review showed Physician F documented, "stocking management lags." During an interview on 8/11/11 at 11:20 A.M., the resident said staff "never put any heel protectors on me before I got the sore on my heel." The resident said his/her feet were "always just bare" when he/she lay in bed. The resident said he/she had not "wore any shoes since I been here." During an interview on 8/16/11 at 4:30 P.M., the Assistant Director of Nursing (ADON) said she was not sure how the resident obtained the right heel pressure ulcer. The ADON said she "can not be sure" if any preventative measures were implemented prior to the development of the pressure ulcer. During an interview on 8/19/11 at 9:15 A.M., Physician F said the resident is "very vulnerable" to the risk of developing pressure ulcers due to his/her right knee contracture and history of [MEDICAL CONDITION] (condition that causes fluid retention in the extremities). The Physician said the resident sits in the wheelchair for approximately 15 hours a day with his/her heel either on the wheelchair pedal or on the floor. Physician F said the pressure ulcer "certainly started out as a reddened area or a blister" before resulting in a hard, necrotic eschar. The physician said the resident's right heel pressure ulcer was a full thickness necrotic wound when he first saw it on 6/8/11. Physician F said he ordered compression stocking to control the [MEDICAL CONDITION] (swelling) and prevent skin decline, "but the staff at the nursing home did not keep the stockings on" as instructed resulting in more pressure from the [MEDICAL CONDITION]. Therefore, physician F discontinued the compression stockings and started compression wraps (una boots) for the resident's right heel pressure ulcer. Physician F said the resident has sufficient arterial flow so healing should be successful if staff provide the treatments as ordered. Physician F said currently the resident's right heel pressure ulcer is a stage III (full thickness loss of skin). 2. Closed review of Resident #17's nurses' notes showed facility staff admitted the resident from another long term care facility on 7/1/11. Review of the resident's transfer and discharge summary sheet (completed by staff at another facility), dated 7/1/11, showed the resident assessed with [REDACTED]. Review of the resident's admission nurses' notes, dated 7/1/11, showed licensed staff assessed the resident's skin as warm, moist, and intact. Review showed staff did not document any information regarding the resident's skin condition on his/her coccyx or legs. Review showed the resident's Physician order [REDACTED]. Review of the resident's intermittent plan of care, dated 7/8/11, showed staff identified the resident at risk of skin breakdown and planned the following interventions to prevent the development of pressure ulcers: -assist to reposition every two hours -assess the resident's skin weekly Review of the resident's intermittent plan of care showed staff did not plan any interventions to promote healing of the resident's pressure sores at the time of his/her admission to the facility. Review of the resident's nurses' notes, dated 7/9/11, showed unidentified CNA staff notified licensed staff of an "open area on the resident's buttocks measuring 2.0 cm round." Licensed staff did not assess and plan interventions to prevent decline in the resident skin condition until at least eight days after admission. During an interview on 8/16/11 at 3:45 P.M., the Assistant Director of Nursing (ADON) said licensed staff are expected to assess each resident skin at the time of admission and follow up with any identified areas. The ADON said licensed staff did not identify Resident #17's "open areas" at the time of his/her admission.

Based on observation, interview and record review facility staff failed to treat facility acquired pressure ulcers in a timely manner. In addition, staff failed to notify the physician of facility acquired pressure ulcers in a timely manner for one resident (Resident #4) out of three residents sampled. The facility census was 91. 1. Review of the resident's admission nurses notes dated 01/31/11 at 3:50 P.M., showed licensed staff recorded, "Resident's perianal area red, but no excoriation or open areas." Review of the resident's admission skin assessment dated [DATE] showed licensed staff recorded the resident's peri-anal area was "red." Staff did not record the resident had any pressure ulcers. Review of the resident's Pressure Ulcer assessment dated [DATE] showed licensed staff assessed him/her as being at risk for pressure ulcers. Review of the resident's Braden Scale assessment (a form used to determine the resident's risk of developing a pressure ulcer) dated 02/01/11 showed licensed staff assessed the resident with a score of 16 (a score 15-18 showed him/her at mild risk for pressure ulcers). Review of the resident's treatment record dated 02/01/11 through 02/10/11 showed licensed staff did not document they completed any pressure ulcers treatments. Review of the resident's nurses notes dated 02/06/11 at 10:40 P.M., showed licensed staff recorded the following information: - "Charge nurse was called in to resident's room when resident was turned to his/her side. Charge nurse noted open areas on his/her sacrum (area between the left and right buttocks) and the gluteal fold (crease between the thigh and the buttocks). Area cleansed with soap and water and covered with [MEDICATION NAME] dressings (foam wound covering to protect the open area) and will get an order from the doctor for dressings initiated. Night shift nurse was notified of what was observed." The licensed staff did not record wound measurements, wound descriptions of the pressure ulcers to show on-going monitoring for healing or decline or that they notified the resident's physician of his/her facility acquired pressure ulcers. Review of the resident's weekly skin assessment dated [DATE] showed licensed staff recorded the following information: - "Open bleeding area at crease of right buttock. Dressing to left buttock. Faint odor noted." The licensed staff did not record measurements or other description of the pressure ulcers to show on-going monitoring for healing or decline. Staff did not record they notified the resident's physician of the pressure ulcers with signs of infection to obtain a treatment to promote healing of the facility acquired pressure ulcers. Review of the resident's nurses notes dated 02/11/11 at 11:15 A.M., showed licensed staff first recorded measurements of the resident's facility acquired pressure ulcers identified on 02/06/11. Staff recorded they noted during perineal cleansing an "open area" on the resident's right buttocks surrounded by "old scar tissue." The area measured 4 centimeters (cm) x 2cm x 2.4 cm in size with "green colored discharge" and "painful to touch." Licensed staff recorded they applied a "temporary" dressing to the area. In addition, staff recorded an assessment of a "second area" on the resident's left buttocks "appearing to be new" with no drainage. Staff recorded it measured 4cm x 2cm x 0.05cm in size. Staff recorded they notified the resident's physician who ordered a wound consultation. Review of the resident's wound clinic report dated 02/11/11 showed the wound clinic physician recorded the following information: - "Ulcer number 1 of the right ischium tuberosity (a rounded protuberance of the lower part of the ischium. It forms a bony area on which the human body rests when in a sitting position) is 7cm x 6.8cm x 1.7cm. It is at least a stage III (full thickness tissue loss), but it is really hard to say due to the slough (dead tissue separated from living tissue). There is a moderate amount of serosanguineous (mixture of watery fluid and blood) drainage. Small amount of granulation (rich blood supply to the healing surface) tissue and a large amount of yellow and black necrotic (death of a portion of tissue) tissue." - "Ulcer number 2 of the left buttocks is 1.6cm x 2.4cm x 0.1cm. This is a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed). Small amount of serosanguineous drainage. Large amount of pink granulation. Small amount of yellow necrotic tissue. Review of the resident's physician's orders [REDACTED]. - Dakin's 1/4 strength solution (chlorine solution to kill germs and to prevent growth of germs) soaked gauze to right buttock wound three times daily and as needed; - [MEDICATION NAME] (barrier cream) to left buttock three times daily and as needed. Record review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/11/11 showed staff assessed the resident with the following: -Required limited to extensive assistance of staff for his/her Activities of Daily Living; - Indwelling urinary catheter (tube inserted into the bladder to drain urine); - Frequently incontinent of fecal material; - Bilateral above the knee amputations; - At risk of developing pressuer ulcers; - (0) stage one pressure ulcers (intact skin with non-blanchable redness) on admission; - (1) stage two pressure ulcer; - (0) stage two pressure ulcers on admission; - (1) stage three pressure ulcer; - (0) stage three pressure ulcers on admission. Review of the resident's plan of care dated 02/12/11 showed the care plan directed staff to provide the following interventions for the resident: - Notify the physician of any new open or red areas for treatment "without delay"; - Pack wound with gauze soaked with Dakins 1/4 strength to right buttocks. Change three times daily and as needed; - Apply [MEDICATION NAME] to left buttocks three times daily and as needed; - Transfer back to bed after breakfast and lunch; - Assess pressure ulcer size, depth, and color weekly; - Therapy to re-evaluate cushion in the resident's electric chair; -Apply a low air loss (pressure relieving) mattress. Review of the resident's wound report dated 02/11/11 showed staff recorded the following information: - Right gluteal fold, stage III, 4.0cm x 2.0cm x 2.4cm, date of onset 02/06/11, "In house acquired"; - Left buttocks, stage II, 4.0cm x 2.0cm x 0.1cm, date of onset 02/06/11, "In house acquired." Review of the facility's Wound Care and Treatment policy dated April, 2006 showed licensed staff are directed to do on-going skin assessments with weekly documentation of status. Review of the resident's "weekly skin assessment" dated 02/14/11 showed licensed staff recorded the following information: - Continue treatment of [REDACTED]." Licensed staff did not record descriptions; measurements; or size, depth, and color as directed in the plan of care of the pressure ulcers on the "weekly skin assessment" to show on-going monitoring for healing or decline. Review of the resident's wound clinic report dated 02/17/11 showed the wound clinic physician recorded the following information: - "Ulcer number 1 is on the right ischium tuberosity. Today, it is decreased in size to 5.5cm x 4cm x 2.4cm. It is stage 3 with slough removed. There is a moderate amount of serosanguineous tissue, granulation tissue, as well as yellow debris present, but decreased in amount from the wound." - "There is also a stage 2 pressure ulcer on the left buttock that also is decreased in size to 1.4cm x 1.3cm x 0.1cm. It also has exudate (fluid) and serosanguineous tissue." During an interview on 02/17/11 at 1:45 P.M., the Director of Nursing (DON) said she expected staff to notify the physician immediately with any change in condition. The DON said she expected staff to document wound measurements and descriptions of pressure ulcers. Observation on 02/17/11 at 3:25 P.M., showed the resident lay in bed. Additional observation showed the following: - One Stage II pressure ulcer to his/her left buttocks which measured approximately 1.5cm x 1.5cm with a beefy red wound bed and serosanguineous drainage present; - One Stage III pressure ulcer to his/her right gluteal fold which measured approximately 5.0cm x 5.0cm x 2.5cm with a beefy red wound bed and serosanguineous drainage present. During an interview on 02/18/11 at 1:00 P.M., Physician A said he/she expected staff to notify him/her immediately any time a resident experienced a change in condition. MO 420