Every finding on record at Parkwood Skilled Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to obtain a resident's admission physician orders, including current gastrostomy tube (g-tube, a tube surgically inserted into the stomach to provide hydration, nutrition, and medications) feeding orders and a complete medication list, for one resident admitted to the facility for a respite stay (Resident #2). During the resident's stay, the facility failed to transcribe a new physician's order for added g-tube water flushes and a change to g-tube feedings from bolus (single/specified dose given all at once) to continuous. These deficient practices resulted in the resident not receiving all prescribed medications, water flushes, or continuous g-tube feedings throughout the day. The sample was 3. The census was 83.Review of the facility's Admissions policy and procedure, last reviewed 10/30/24, showed:-Purpose: The purpose of this policy and procedure is to facilitate a fluid transition of a resident into the skilled nursing facility;-Procedure:--Medical information will be requested to be reviewed by the interdisciplinary team to ensure the facility will be able to meet the needs of the potential resident;--Prior to or upon admission, Social Services (SS) will go over admission paperwork with the resident or resident representative;--A face sheet will be filled out;-Upon admission: --Nursing staff will perform admission assessment;--Nursing staff to complete the admission Checklist (a tool/form used to verify all physician admission orders, a complete list of current medications, assessments, steps, and other requirements were completed upon admission to the facility). Review of the facility's admission Checklist and Audit sheet, undated, showed:-Medication list with diagnosis;-Orders verified (clinical process where facility nurse meticulously confirms the resident's physician's admission orders/instructions are accurately transcribed into the facility's medical records and are then reviewed and verified with the facility physician at the time of admission);-Nurse signature and date. Review of the facility's Transcribe and Follow Physician Orders Accurately policy and procedure, last reviewed 04/24/25, showed:-Procedure:--There shall be a written order on a physician's order sheet for all medications, treatments, therapy, and special and modified diets, dated and signed by the physician and placed in the resident's chart;--Orders received orally or by telephone shall be taken, signed, and dated by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) acting within the scope of practice as defined by state law and is under the supervision of the physician;--Each set of orders is to be dated, and time noted when received;--All verbal and/or telephone orders are to be signed with physician's name and name of nurse receiving orders;-When taking orders for medications, include the following information:--Name;--Dosage;--Frequency;--Special instructions;-When transcribing physician's orders:--Read carefully and check with another nurse if you are unsure;--Check with physician if there are any questions;--Medication orders are placed in the electronic health record (EHR);--Dietary orders are placed in the EHR;-Orders received by physicians are to be followed as prescribed. Review of the facility's Respite admission policy, undated, showed:-The Admissions Coordinator will get the effective dates resident will be staying for the respite care stay, and coordinate with Director of Nursing (DON) any needs for care of the resident;-Purpose: The company recognizes the need for temporary caregiver relief and offers private pay respite care services when appropriate and establishes the requirements, expectations, and conditions governing private pay respite admissions within the facility;-Policy Statement:--Private pay respite care is a short-term stay provided to individuals who require temporary nursing, personal care, supervision, or supportive services while their primary caregiver is unavailable or in need of relief;-Eligibility and admission Requirements:--Completion of all required admission documentation, physician orders, medication information, and emergency contact information must be provided before admission;-The facility reserves the right to:--Require additional assessments, documentation, or physician information at any time;--The community will collaborate with the Medical Director regarding any orders needed for care of the resident;-The community Medical Director will give any orders needed to care for the resident during their respite stay. Review of Resident #2's pre-admission physician orders and medication information, received 06/05/26 at 2:19 P.M. from the resident's family, Family Member C, showed:-The physician's office fax transmittal confirmation sheet result details documented as successfully sent to facility on 04/08/26 at 4:42 P.M. and completed on 04/08/26 at 4:58 P.M;-History of present illness: The resident was seen on 04/08/26 for chronic conditions, with diagnoses of dementia, stroke, difficulty swallowing (using feeding tube), neurogenic bladder (nerve damage disrupts the communication between the brain and bladder), heart attack, atrial fibrillation (irregular heart rhythm), chronic obstructive pulmonary disease (COPD, lung disease), and diabetes;-Outpatient medications, listed as e-prescribe (current, active medications), as of 04/08/26:--Fluoxetine (antidepressant) 40 milligrams (mg) by g-tube daily;--Eliquis (blood thinner) 5 mg by g-tube twice daily;--Amiodarone (used to treat heart rhythm disorders) 200 mg tablet once daily by g-tube;--Metoprolol tartrate (treats high blood pressure) 50 mg tablet, take one tablet by mouth twice daily;--Atorvastatin (lowers bad cholesterol) 80 mg tablet, take one tablet by g-tube once daily at bedtime;--Aspirin (inhibits blood clotting to help prevent heart attacks and strokes) 81 mg tablet, once daily by g-tube;--Blood glucose meter kit (measures the amount of sugar in the blood) and test strips to check blood sugars with lancets (small, sterile, disposable needles), three times daily before tube feeding;--Lantus SoloStar U-100 insulin (a pre-filled, disposable insulin pen containing a long-acting insulin), 100 unit/ml pen, syringe. Give 32 units every morning;--Novolog FlexPen U-100 Insulin (a rapid-acting insulin pen), 100 unit/ml, pen syringe (must give before tube feeding):---Give 2 units for blood sugar between 151-200;---Give 4 units for blood sugar between 201-250;---Give 6 units for blood sugar over 250;--Budesonide (potent steroid to reduce lung/respiratory inflammation) 0.5 mg/2 ml suspension for nebulization (medication is put into the nebulizer medical device that converts the liquid medication into a fine mist that is easily inhaled into the lungs). Take 4 ml (1 mg) by inhalation daily;--Xopenex (a bronchodilator/rescue inhaler) 0.63 mg/3 ml solution for nebulization. Take 3 ml by inhalation every four hours, as needed, for shortness of breath or wheezing;--[NAME] Farms Glucose Support (plant-based nutrition shake) 1.2 calories per 1 ml of fluid (250 ml per bottle). Give 320 ml (one and 1/4 cartons) bolus, via a percutaneous endoscopic gastrostomy (PEG, a medical device inserted directly through the abdominal wall into the stomach to provide a direct channel for liquid nutrition, hydration, and medications) tube, four times daily;--Tube feeding recommendations from dietitian August 2025, for [NAME] Farms Glucose Support 1.2 cartons (250 ml each), give one and 1/4 cartons, four feedings daily. Flush with 70 ml of water before and after each feeding. Review of the resident's nurse's note, dated 05/07/26 at 3:06 P.M., showed RN B documented the resident was admitted for 5-day respite care stay. The DON and charge nurse were made aware of resident's arrival. The note did not include documentation of verification of the resident's admission orders with the facility physician. Review of the resident's physician order sheet (POS) and medication administration record (MAR), dated 05/07/26 through 05/11/26, showed:-admission date 05/07/26;-An order, dated 05/07/26, for Lantus SoloStar U-100 insulin 100 unit/ml (3 ml) subcutaneous pen 22 units subcutaneous every morning;--The order for Lantus SoloStar U-100 insulin 100 unit/ml (3 ml) for 10 units less than indicated on the resident's pre-admission physician orders and medication information;-An order, dated 05/07/26, for [NAME] Farms Glucose Support 1.2 0.06 gram-1.2 kilocalorie (kcal)/ml oral liquid, 1 Misc PEG tube every six hours. [NAME] Farms Glucose Support 1.2 0.06 gram-1.2 kcal/ml oral liquid, Misc 1 1/4 box PEG tube every six hours; --The order for [NAME] Farms Glucose Support 1.2 did not define Misc and did not include specify the medication to be administered as bolus feeding, as indicated the resident's pre-admission physician orders and medication information;-No physician orders or documented medication administration for fluoxetine 40 mg, atorvastatin 80 mg, aspirin 81 mg, Budesonide 0.5 mg/2 ml suspension, or Xopenex 0.63 mg/3 ml solution for nebulization;-No physician order for Novolog FlexPen U-100 insulin or sliding scale insulin;-No physician orders for blood glucose meter kit and test strips or documentation of obtaining the resident's blood glucose;-No physician order for PEG tube water flushes 70 ml before and after each tube feeding, as indicated on the resident's pre-admission physician orders and medication information. Review of the resident's medical record, showed a physician's handwritten order, dated 05/08/26 (no time), for the tube feeding to be changed to 55 ml per hour, with every four-hour 100 ml water flushes. The order was signed off as transcribed by the DON, who wrote below the order to continue stock from home, and dated 05/09/26 (no time). Review of the resident's electronic POS and MAR from 05/08/26 to 05/11/26, showed no new order for the resident to have continuous gastrostomy tube feeding at 55 ml per hour, with every four-hour, 100 ml, water hydration flushes. During an interview on 06/02/26 at 1:30 P.M., LPN Unit Manager (UM) A, said they used the resident's prescription bottles, which the family brought in, and the family member's verbal instructions to write the resident's admission orders. During an interview on 06/03/26 at 12:20 P.M., RN B said he/she admitted the resident in the afternoon on 05/07/26, and he/she was not sure if there were admission orders. He/She did not recall seeing a hard chart, but there could have been one. There had to be physician orders, but he/she could not recall. Family Member C provided staff with all the resident's medications in a bag and all had pharmacy labels. RN B did not recall using the resident's prescription bottles/labels to input the medication orders into the electronic chart. His/Her practice is to compare the prescription bottles to the paper orders. Family Member C also brought in the resident's tube feeding cartons and set everything up for the tube feedings in the resident's room. RN B understood the tube feedings were bolus feedings and he/she did not see any gravity feeding bags brought in by the family member. When asked if he/she called the resident's facility physician to verify the admission orders, RN B could not recall. During an interview on 06/02/26 at 2:15 P.M., the Admissions Marketer said the resident had admission orders and they would have been written within 60 days or so of the resident's facility admission date. She would not have accepted the resident for an admission/respite stay without physician's orders. She gave the orders to the admission nurse, via placement in the resident's paper chart/hard chart. Hard charts were still used, in addition to the EHR, for new admission packet placements and for some physicians to write orders in. During an interview on 06/03/26 at 1:17 P.M., the DON said admission orders were to be verified and clarified upon admission. She audited the resident's admission orders on 05/09/26. The DON gave no details of the audit. During an interview on 06/12/26 at 12:25 P.M., the Administrator said he was out of town when the resident was admitted . Normally, their respite admissions are in hospice care, so they come to the facility with clear orders for care and medications from the hospice company. Resident #2 was not in hospice care. All the resident's physician orders should have been followed. 3012241

Based on observation, interview, and record review the facility failed to ensure orders for weight monitoring were completed as ordered. Concerns were noted in four of five residents identified by the facility as receiving dialysis services (Resident's #6, #9, #10 and #12). The resident sample was 11. The census was 85.Review of the facility's Physician's Orders policy, revised 4/16/2024, showed:-The purpose of the policy is to transcribe and follow physician orders accurately;-Orders received by the physician are to be followed as prescribed. In the event that a resident refuses, documentation must be completed and the physician must be notified. Review of the facility's Dialysis policy, revised 4/16/2024, showed:-Ongoing communication, coordination, and collaboration between the nursing home and the dialysis staff is imperative in providing optimal care for the resident;-For a resident receiving dialysis, the charge nurse will communicate with the attending physician/practitioner, resident/resident representative, and dialysis staff regarding any significant changes in a resident's status that may impact the dialysis portion of the care plan;-A dialysis communication form may be utilized to assist with communication between facilities. 1. Review of Resident #6's quarterly Minimum Data Set (MDS, a federally-mandated resident assessment instrument completed by facility staff), dated 1/6/26, showed:-The resident was cognitively intact;-Medical diagnoses including congestive heart failure (a chronic cardiac condition in which the lower chambers of the heart fail to adequately pump blood to the arteries), history of thrombotic pulmonary emboli (blockages in the arteries of the lungs), and iron deficiency anemia (a chronic condition in which the body fails to adequately metabolize iron into the blood, reducing red blood cell count). Review of the resident's physician order sheet, showed:-An order for weekly weights to be recorded every Sunday on day shift, for 4 weeks entered on 10/24/25 with a stop date of 1/15/26;-An order for weekly weights to be recorded every Monday on day shift, one time only, entered on 11/21/25 with a stop date of 1/15/26;-An order for weekly weights to be recorded every Monday for 4 weeks entered on 1/24/26 with a stop date of 2/4/26;-An order for weekly weights to be recorded on day shift for 4 weeks entered on 1/15/26 with a stop date of 1/24/26. Review of the resident's recorded weights, documented under the Weights tab in the electronic medical record (EMR), showed:-No recorded weight in October of 2025;-A recorded weight of 141.4 pounds (lbs) on 11/3/25;-A recorded weight of 140 lbs on 12/10/25;-No recorded weight in January 2026;-No recorded weight in February 2026. Review of the resident's scanned documentation, showed the most recent recorded dialysis communication sheet was received on 12/16/25 with a post-dialysis weight of 140.2 lbs. 2. Review of Resident #9's comprehensive MDS, dated [DATE], showed:-The resident was cognitively intact;-Medical diagnoses including End Stage Renal Disease (ESRD, a chronic condition in which the kidneys fail to adequately filter toxins from the blood), history of transient ischemic attack (TIA, an occlusion of one of the blood vessels in the brain), history of acute myocardial infarction (MI, a heart attack). Review of the resident's active physician order sheet showed:-An order for weekly weights to be recorded every Sunday on day shift entered on 11/3/25 with a stop date of 2/16/26. Review of the resident's recorded weights, documented under the Weights tab in the EMR showed:-No recorded weight in November of 2025;-A recorded weight of 180 lbs on 12/10/25;-No recorded weight in January of 2026;-A recorded weight of 195.3 lbs on 2/24/26;-A recorded weight of 193.6 lbs on 3/3/26. 3. Review of Resident #10's quarterly MDS, dated [DATE], showed:-The resident is cognitively intact;-Medical diagnoses including ESRD, personal history of TIA, unspecified heart failure, and coronary artery disease (a chronic buildup of plaque in the arteries of the heart, eventually leading to a vessel occlusion). Review of the resident's active physician orders, showed:-An order for weekly weights to be recorded weekly on day shift entered on 11/14/24 with no stop date that had been placed on hold;-An active order for weekly weights to be recorded on Monday day shift entered on 2/25/25. Review of the resident's recorded weights, documented under the Weights tab in the EMR, showed:-No recorded weight in December of 2025;-No recorded weight in January of 2026;-A recorded weight of 214.5 lbs on 2/10/26;-A recorded weight of 214.7 lbs on 3/9/26. 4. Review of Resident #12's quarterly MDS, dated [DATE], showed:-The resident is cognitively intact;-Medical diagnoses including ESRD, essential hypertension (chronic high blood pressure), iron deficiency anemia, and insomnia. Review of the resident's active physician orders showed:-An active order for weekly weights to be recorded on day shift entered on 1/23/25. Review of the resident's recorded weights in the EMR showed:-A recorded weight of 205 lbs on 1/22/26;-A recorded weight of 198.4 lbs on 2/2/26;-A recorded weight of 206.2 on 3/5/26. 5. During interview on 3/12/26 at 2:05 P.M. Licensed Practical Nurse (LPN) B said residents on dialysis are typically placed on weekly weights, and weights are also recorded at each dialysis session. Weights taken by facility staff should be placed in the EMR for tracking purposes, and dialysis communications sheets with recorded post-dialysis weights are gathered by the nurse managers to be transcribed into the electronic record. Staff are expected to follow physician orders as written. 6. During interview on 3/12/26 at 2:15 P.M. Certified Medication Technician (CMT) C said residents on dialysis have individualized weight orders but often have monthly or weekly orders to record a weight. Any nursing staff member can obtain a resident's weight and should record it in the EMR. Nursing managers will gather any dialysis communication forms brought from dialysis by residents returning to the facility so post-dialysis weights can be recorded in the electronic record. Staff are expected to follow physician orders as written. 7. During interview on 3/12/26 at 2:56 P.M. the facility Director of Nursing (DON), Assistant Director of Nursing (ADON) and LPN A said residents on dialysis should have orders placed for weekly recorded weights unless directed otherwise by the physician. Any nursing staff member can record a resident's weight, and all obtained weights should be placed in the EMR under the Weights tab. The DON, who recently took the position, said weight tracking was an issue that was identified recently, and during the most recent Quality Assurance and Performance Improvement (QAPI) meeting the team began to set new expectations and systems to track resident weights. The previous DON was receiving all dialysis communication forms in her office and failed to upload or transcribe the majority of post-dialysis weights provided on the dialysis communication forms.

Based on observation, interview and record review, the facility failed to follow acceptable nursing practice when staff left one resident's topical gel and inhaler in the resident's room (Resident #6). The resident had not been assessed as safe to self-administer medications and did not have an order to self-administer medications. The sample was 7. The census was 86. Review of the facility's Self-Administration of Medication policy, dated 6/1/2018, showed:-Policy: in order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer;- If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process;-For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or when there is a significant change in condition;-The resident is instructed in the use of the package, purpose of the medication, reading of the label, and scheduling of medication doses;-The resident is then requested to read the label on each package and indicate at what time the medication should be taken and any other special instructions for use;-The resident is asked to demonstrate the removal of the medication from the package and, in the case of nonsolid dosage forms such as an inhaler, to verbalize the steps involved in administration;-The resident is asked to complete a bedside record indicating the administration of the medication (if bedside storage is to be used);-The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each medication authorized for self-administration, the label contains a notation that it may be self-administered;-If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. 1. Review of Resident #6 medical record, showed:-Alert and oriented times four (person, place, time and situation);-Diagnoses included: legally blind, diabetes and end stage renal disease (ESRD, irreversible damage to the kidneys) requiring hemodialysis (treatment to filter wastes and water from the blood);-A care plan in use at the time of survey, did not show the resident could keep medications at bedside and self-administer;-No assessment completed to show the resident was assessed as able to self-administer medications. Review of the resident's physician orders sheet dated 10/1/25 through 11/25/25, showed: -A physician order for: Breztri Aerosphere inhaler (medication used to treat chronic lung disease) 160 microgram (mcg)-9mcg-4.8mcg, two puffs by mouth two times per day. Diagnoses: high blood pressure;-A discontinued order for: Voltaren arthritis pain 1 % topical gel (diclofenac sodium) apply two Grams (gm) topically three times per day. Apply to bilateral (both) knees. Diagnosis: post-traumatic osteoarthritis of right knee (inflammation in a joint that develops after a traumatic injury);-No physician order to keep medications at bedside and self-administer. Observation on 11/25/25, showed at 7:55 A.M., a tube of diclofenac sodium 1% on an over bed table. There was a second over bed table closer to the bed with a Breztri inhaler on it. At 9:41 A.M., the medications remained in the same spot. During an interview on 11/25/25 at 11:45 A.M., the resident said he/she used the inhaler as needed and he/she applied the diclofenac topical gel to his/her knees as needed. During an interview on 11/25/25 at 12:58 P.M., Licensed Practical Nurse (LPN) B said if a resident wanted to keep their medications at bedside and self-administer, they would assess the resident by having the resident do a return demonstration and they would need to obtain a physician order. During an interview on 11/25/25 at 12:19 P.M. and 1:46 P.M. LPN A said if a resident wanted to self-administer their medications, they would need to assess the resident for alertness. To keep medications at bedside and self-administer them required a physician order. Currently there were no residents who had medications at their bedside or who could self-administer their own medications. LPN A went into the resident's room and the medications were in the same place. LPN A said he/she would need to check to see if the resident could have the medications at his/her bedside. During an interview on 11/25/25 at 1:46 P.M., LPN C said the resident did not have an order for self-administration because of his/her vision. LPN C had staff remove the medications from the resident's room. During an interview on 11/25/25 at 2:26 P.M., the Administrator said he would expect medications to be stored on the medication cart and he would expect staff to follow the facility's policies and procedures. 2676769

Based on observation, interview and record review, the facility failed to meet professional standards when staff failed to follow physician orders when staff provided wound care for one resident (Resident #5). The sample was 7. The census was 86. Review of the facility's Physician Orders policy, dated revised October 2023, showed when a Physician gives orders on any resident, nursing staff will have the orders written in the Medication Administration Record (MAR) and/or Treatment Administration Record (TAR) of the medical record of the resident. Nursing staff will follow through with any order(s) that were provided by the physician in the time frame given by the physician. 1. Review of Resident #5's medical record, showed:-Diagnoses included: high blood pressure, diabetes and heart failure;-A physician order summary dated 11/15/25 through 11/25/25, showed a physician order to cleanse one time per day, bilateral (both) lower extremities with Vashe (wound cleanser), soak 3-5 minutes; apply silver wound gel (antimicrobial wound gel designed to provide a moist healing environment) to wound bed. Apply mepitel (a soft, flexible silicone dressing) cover with abdominal (ABD, gauze dressing that absorbs fluid from large or heavily draining wound) pad and wrap with kerlix (gauze) and ace wrap daily. Observation and interview on 11/24/25 at 9:55 A.M., showed the resident lay in bed, he/she had gauze dressing on his/her lower legs. The resident said his/her dressings are not changed daily, last week they were changed three-four times. No ace wrap was in place. Observation on 11/24/25 at 10:35 A.M., showed the resident lay in bed. Licensed Practical Nurse (LPN) D put gloves on and removed the dressing from both lower legs. The right lower leg had two small open areas and one closed area. The left lower leg had several small open areas. LPN D changed his/her gloves, cleaned the wounds with Vashe, applied silver 1% sulfadiazine cream (used to prevent and treat wound infections), applied an ABD pad and wrapped both legs with gauze. No soak was done, no silver wound gel or mepitel was applied to the wounds. The ace wraps were not applied. Observation on 11/25/25 at 1:40 P.M., showed the resident lay in bed, he/she had slipper socks on over the dressings. No ace wraps were in place. The resident said he/she only had ace wraps applied once when he/she was in the hospital. During an interview on 11/25/25 at 12:19 A.M. and 1:46 P.M., Licensed Practical Nurse (LPN) A said silver wound gel and sulfadiazine cream are not the same. LPN A checked the treatment cart, and he/she did not see silver wound gel on the cart. During an interview on 11/25/25 at 2:26 P.M., the Administrator said he would expect for staff to follow physician orders and the facility's policies and procedures. 26720742675750

Based on interview and record review, the facility failed to notify one resident's responsible party regarding the resident's pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) and when the resident's pressure wound condition deteriorated. The facility also failed to notify the resident's responsible party regarding new medications ordered for the resident's behaviors (Resident # 2). The sample was five. The census was 89. Review of the facility's Change in Condition Policy, revised 8/13/25, showed:-The facility provides medical care to all the residents in this community with all their varied diagnosis and medical conditions. If a resident has a change in condition at any time during their stay at the facility, the nurse will be made aware immediately and call the physician. The nurse will provide any services that the doctor orders from the result of the change in condition. The nurse will contact the family and/or responsible party after the physician has given the orders for care of the change in condition. The nurse will document that the family and/or responsible party were contacted about the change in condition. If the family or responsible party do not answer or reply, the nurse will document that they left a message for the family or responsible party in regard to the change in condition. The facility managers have stand up meetings Monday through Friday at 9:00 A.M. to discuss al residents in the community and any change in condition along with any new services that may need to be provided in the care due to the change in condition. Review of the facility's Psychotropic (medication to treat mental disorders) Medication Policy and Procedure, undated, showed:-Responsible party actions required: -Physician and Psychiatrist: Document discussion with the resident and/or responsible party regarding the risk versus benefit of the use of the medication. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/26/25, showed:-Cognitively intact;-At risk for developing pressure wounds;-One unhealed Stage One pressure wound (skin that is not broken but is red, inflamed or dark in color). Review of the resident's care plan, in use while the resident was admitted to the facility, showed:-Problem: The resident takes antidepressant medications as evidence by yelling out frequently, has concerns that people are in his/her room lying on the floor, and wanting to go home because the resident had to go to work.-Problem: The resident has a wound, abrasion, scar, or other form of breakdown present; The resident was admitted with dermatitis (inflammation of the skin) to his/her buttocks, open area to right inner thigh, and a pressure ulcer to right heel;-Interventions: Inspect the skin daily with care and bathing; Inspect skin completely head to toe every week and document results; Weekly treatment documentation to include measurement of each area of skin breakdown width, length, type tissue and drainage. Review of the resident's face sheet, undated, showed:-Primary contacts listed three family members names before the resident's name. -Diagnoses included mild protein malnutrition (inadequate nutrition), mood disorder, dementia depression, and pulmonary embolism (blood clot in the lungs). Review of the resident's progress notes, showed:-On 9/17/25 at 10:40 P.M., the resident has a dark, soft area to resident's right heel; The area was assessed and is not open at this time.-On 10/11/25 at 3:49 A.M., the dark soft area to the resident' s right heel has opened. Slough (yellowish, soft, and often stringy material that forms in wounds as a result of dead or dying tissue) noted to wound bed and eschar (dark colored dead tissue) noted. The area is measuring 3 centimeters (cm) length by 7 cm wide;-No documentation the resident's responsible party was notified regarding the resident's right heel pressure wound. Review of the resident's Physician Order Sheets, dated 9/15 through 10/24/25, showed:-An order, dated 9/24/25, doxepin (medication used to treat depression) 25 milligrams (mgs) one capsule at bedtime for depression;-An order, dated, 10/6/25 stop date 10/13/25, Depakote Sprinkles (mood stabilizer)125 mg delayed release, two capsule, three times a day for mood disorder due to unknown physiological condition with depressive features;-An order, dated 10/13/25, hydroxyzine (medication used to treat anxiety) 25 mg, one tablet twice a day, for restlessness and agitation. Review of the resident's Psychiatry Nurse Practitioner (NP) notes, dated 10/4/25, showed: The resident is at the facility for a psychiatric evaluation. The resident does not know where he/she lived. As far as historical information the resident has dementia and cannot provide information. The resident has been very irritable in the evenings, unable to sleep and hard to re-direct. The resident is confused and usually is not congruent (agreement) about what the conversation is about. Medications orders attached to encounter: Depakote Sprinkles125 mg delayed release, two capsules, three times a day; doxepin 25 mgs one capsule at bedtime; hydroxyzine 25 mg, one tablet twice a day. No documentation that the Psychiatry NP notified the resident's responsible party regarding the addition of Depakote Sprinkles, doxepin, and hydroxyzine medications was noted. Review of the resident's progress notes, showed no documentation of staff notifying the resident's responsible party regarding the addition of Depakote Sprinkles, doxepin and hydroxyzine medications. During an interview on 11/5/25 at approximately 12:00 P.M., Licensed Practical Nurse (LPN) C said the resident was confused since the day he/she arrived at the facility. The resident would yell out a lot, disrupt other residents in the common area, and he/she was paranoid. The responsible party, which is usually the family, should be notified of any new wounds, treatments and medications by the Charge Nurse, Nurse Manager or Wound Nurse. Communication with the resident's responsible party is documented in the progress notes. During an interview on 11/6/25 at 8:00 A.M., LPN B said the responsible party should be notified with any medication changes, the development of a pressure wound and if the condition of the wound changes. LPN B wasn't sure if the Charge Nurse or the Psychiatry NP notifies the resident's responsible party when new medication is ordered. The Charge Nurse or the Wound Nurse notifies the resident's responsible party regarding skin conditions. During an interview on 11/6/25 at 9:32 A.M., Nurse Manger A said the Psychiatry NP will add his/her own orders into the computer without notifying nursing staff that the new medication is added. The Psychiatry NP notes, dated 10/4/25, were the only notes that were e-mailed to Nurse Manager A. The resident was confused, and the responsible party should have been notified regarding the condition of the pressure wound and the new medications. During an interview on 11/6/25 at 12:30 P.M., the facility's Wound Nurse said the Charge Nurse or the Wound Nurse are responsible for notifying the resident's responsible party when a wound is identified or there are changes in the wound. During an interview on 11/6/25 at 10:45 A.M., the Director of Nursing said the resident's responsible party is expected to be notified by the nursing staff of any changes in condition, changes in a wound, and new medication or treatment orders. She expected the notification to be documented in the progress notes. 2655121

Based on interview and record review, the facility failed to ensure one resident with a pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) was assessed and monitored by performing accurate skin assessments on admission and weekly (Resident #2). The sample size was five. The census was 89. Review of the facility's Pressure Ulcer: Prevention and Findings Reporting policy, undated, showed:-Purpose: To prevent Pressure ulcers by identifying residents at risk; To treat an identified pressure ulcer as soon as possible and initiate treatment.-Policy and Procedure: The Braden scale is used as an instrument to identify skin at risk for breakdown. The Braden scale is done upon admission and quarterly. The Charge Nurse is to complete a skin assessment at least weekly, and at any time a care provider reports a change in the appearance of the skin. The Charge Nurse will complete an initial approximate measure and description of the wound in the nurse's notes. The Wound Nurse will assess the skin area of concerns and will review the physician orders for any details that might need to be described further, or need to be followed by a wound care nurse practitioner. The Wound Nurse will confirm and document wound and document wound care in a nurse's note. The Wound Nurse will document any noted additional skin changes, if any along with a detailed note outlining current condition of wound and level of progress each week. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/26/25, showed:-Cognitively intact;-At risk for developing pressure wounds;-One unhealed Stage One pressure wound (skin that is not broken but is red, inflamed or dark in color). Review of the resident's care plan, in use while the resident was admitted to the facility, showed:-Problem: The resident has a wound, abrasion, scar, or other form of breakdown present; The resident was admitted with dermatitis (inflammation of the skin) to his/her buttocks, open area to right inner thigh, and a pressure ulcer to right heel;-Interventions: Inspect the skin daily with care and bathing; Inspect skin completely head to toe every week and document results; Weekly treatment documentation to include measurement of each area of skin breakdown width, length, type tissue and drainage. Review of the resident's face sheet, undated, showed his/her diagnoses included mild protein malnutrition (inadequate nutrition), mood disorder and pulmonary embolism (blood clot in the lungs). Review of the resident's Physician Order Sheets, dated September 2025, showed an order dated, 9/15/25, weekly skin assessment by Registered Nurse (RN) or Licensed Practical Nurse (LPN) every Monday night. Review of the resident's Treatment Administration Record (TAR), dated 9/15 through 10/24/25, showed:-An order dated. 9/15/25, weekly skin assessment by RN or LPN every Monday night;-On 9/15, 9/23, 9/29, 10/6, 10/13, and 10/20/25, the resident's skin assessment documented as completed. Review of the resident's progress notes, showed:-On 9/15/25, no note related to the resident's admission or skin assessment;-On 9/17/25 at 10:40 P.M., the resident has a dark, soft area to resident's right heel. The area was assessed and is not open at this time; The area was cleaned with wound cleaner and patted dry; Betadine (a type of liquid treatment to prevent infection) was applied and covered with foam dressing. The area was secured with Kerlix (a specialized dressing). Treatment to be completed every day and as needed. Heel protectors applied to both feet. Review of the resident's skin assessment data form, dated 10/6/25, showed;-Wounds: Yes;-Location of wound: Inner thigh;-Heel discoloration: No. Review of the resident's progress notes, dated 10/11/25 at 3:49 A.M., showed the dark soft area to the resident' s right heel has opened. Slough (yellowish, soft, and often stringy material that forms in wounds as a result of dead or dying tissue) noted to wound bed and eschar (a layer of dead tissue) noted. The area is measuring 3 centimeters (cm) length by 7 cm wide; The area was cleaned with Vashe (wound cleaner) and patted dry; A nickel thick layer of Santyl (an ointment that removes dead tissue) applied to wound bed and covered with silver alginate (a specialized dressing) and secured with a foam dressing. The treatment is to be completed daily and as needed. Review of the medical record, showed no further completed skin assessment data forms and no further documentation of the condition of the resident's right heel pressure wound was noted. During an interview on 11/6/25 at 8:00 A.M., LPN B said on admission, a head-to-toe assessment should be completed. The weekly skin assessments are signed off on the TAR and a skin assessment data form should be completed even if there are no skin issues to report. If the resident has wounds or a skin condition, a description and the condition of the wound should be addressed on the weekly skin data assessment and in the progress notes. If a change in condition occurs related to the wound, the facility Wound Nurse is called. The Wound Nurse completes some of the treatments but not all of them. During an interview on 11/6/25 at 9:32 A.M., Nurse Manger A said the admission for the resident was not completed. The resident did not have a Braden Score completed or a skin assessment on admission. A head-to-toe assessment is expected to be completed on admission and weekly. The Charge Nurse is expected to sign off the TAR, complete a skin data form, and write a note related to wound's condition if applicable every week. During an interview on 11/6/25 at 12:30 P.M., the Wound Nurse said the Charge Nurse is responsible for documenting the weekly wound assessments and completing treatments. A head-to-toe assessment is to be completed and documented on admission by the admitting nurse. The Wound Nurse said she was not sure if the resident came into the facility with the right heel pressure wound because a skin assessment was not performed on admission. She was not aware of the dark, soft area to the resident's right heel until 9/17/25 when a staff member notified her. The Wound Nurse said the soft dark area to the resident's right heel was a deep tissue injury (damage to the skin underneath and appears like a dark bruise) when she initially assessed the wound. She was notified on 10/11/25 by a staff member that the resident's right heel had opened and at that time, she consulted the Wound Nurse Practitioner. The Wound Nurse is not responsible to document the condition of the wound weekly unless the resident is seen by the Wound Nurse Practitioner. The resident was not seen by the Wound Nurse Practitioner until 10/16/25. The Wound Nurse said she does not complete all the treatments, and if the wound is not looking better, she expected staff to inform her. The resident's skin assessment completed on 10/6/25 is inaccurate. She expected staff to accurately describe the resident's skin condition and where the skin condition is located. She expected staff to sign the treatment off on the TAR and complete a skin data assessment form each week. The Wound Nurse said she also has Nurse Manager duties, and it would be impossible for her to complete every skin assessment on every resident every week. During an interview on 11/6/25 at 10:45 A.M., the Director of Nursing said she expected weekly skin assessments to be completed timely and accurately. If a resident has a wound, she expected staff to add a progress note about the progression or decline of the wound each week. 2655121

Based on interview and record review, the facility failed to follow its policy by not reporting an allegation of abuse for one of four sampled residents (Resident #1). Resident #1 reported an abuse allegation to staff, and the facility failed to notify the regulatory authority as required by their policy and state/federal regulations. The facility census was 84. Review of the facility's undated Abuse Policy and Procedures/Investigation Protocols showed the following:-The facility is committed to protecting residents from mistreatment, neglect, abuse and misappropriation of resident property. -This facility has adopted the guidelines of the Department of Health and Senior Services, as well as Centers for Medicare and Medicaid Services (CMS), for defining abuse, reporting, investigating and responding to appropriate parties. -The facility will ensure al alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation do not result in serious bodily injury, to the administrator of the facility and to the other officials (including to the state Survey Agency) in accordance with State Law through established procedures. Review of Resident #1's electronic medical record, showed:-An admission date of 10/15/25;-Diagnoses included morbid obesity due to excessive calories, generalized anxiety disorder and unspecified, and benign neoplasm (non-cancerous growth) of unspecified adrenal gland (produces hormones);- An initial care plan, dated 10/15/25, showed the resident is dependent on staff for mobility, requires assistance with toileting, and requires assistance with nutrition. During an interview on 10/20/25 at 8:40 A.M., the resident said on 10/18/25 around 3:00 P.M., Certified Nurse's Aide (CNA) A entered his/her room without knocking, without identifying himself/herself, and without asking to turn on the over bed lights. The lights hurt the resident's eyes, and she/he was confused and didn't understand what was happening. The resident made the comment to CNA A, you have to warn me when you're going to turn lights on, and this set (him/her) off as the CNA began yelling, You're refusing to get your ass cleaned, you don't refuse around here and used profanities. CNA A was at the resident's bedside leaning directly over him/her and continued his/her rhetoric about the resident refusing to be changed and added if I don't clean your fat ass, no one else is going to. The resident then reached for her/his bed remote to raise the head of the bed and engage in the conversation better, but CNA A snatched the bed remote out of her/his hands. The resident asked the CNA to leave for the second time. The CNA threw the remote at the resident, hitting her/him in the arm, and left the room saying he/she will smack the shit out of the resident. The resident could hear staff in the hallway asking CNA A what's going on. About 30 minutes later, Licensed Practical Nurse (LPN) C and another nursing staff entered his/her room, and LPN C said the resident will not have to work with this nurse aide again and took the resident's statement. During an interview on 10/20/25 at 11:40 A.M., assigned charge nurse LPN C said he/she received a phone call (on 10/18/25) from CNA A saying CNA B and CNA A just had an incident with the resident while trying to provide incontinence care. CNA A reported the resident refused care, called them bitches, and is saying CNA A threw the bed remote at the resident. CNA A said they left the room and called LPN C. LPN C called and reported the incident to the Administrator immediately. The resident was generally confrontational with all staff. The resident is young, dependent on staff to meet all activities of daily living and seems to be alert and oriented. During an interview on 10/20/25 at 2:00 P.M., CNA A said he/she and CNA B entered the resident's room (on 10/18/25), and CNA B waited at the door. CNA A said she/he announced their arrival and reason they were there and turned the light on. CNA A approached the resident and while reaching to pull the curtain, he/she accidently brushed up against resident's leg. CNA A said the resident responded to this with You better get out of my room bitch and then said it again in a loud voice. CNA A and CNA B left the resident's room. CNA A immediately called and reported this to the charge nurse. During an interview on 10/20/25 at 2:30 P.M., CNA B said he/she was present during the incident on Saturday (10/18/25) with the new resident (Resident #1). CNA B said the resident had been yelling at different staff all day on Saturday, saying get the f*** out of my room and things like that. CNA B said CNA A did not physically or verbally abuse or neglect the resident during the interaction on 10/18/25. The resident yelled at CNA A, saying Get out my room bitch, get out of my room bitch. CNA A did not throw a bed remote at the resident and both CNA A and CNA B left the room when told to. During an interview on 10/20/25 at 3:00 P.M., the Administrator said the facility did not report this allegation because he/she thought since they did the investigation and determined abuse did not happen, they did not need to report the allegations. The Administrator learned of the allegations from the charge nurse, who contacted him that day,10/18/25. 2646480

Based on observation, interview and record review, the facility failed to transcribe one resident's treatment orders in the medical record when the resident was readmitted to the hospital (Resident #1) and failed to accurately document completed wound treatments or treatment refusals by the resident on the Treatment Administration Record (TAR) for three residents (Residents #1, #4 and #2). The sample was 4. The census was 82.Review of the facility's Documenting/Implementing Doctors Orders policy, dated revised February 2025, showed:-Documentation: record all orders in the residents' chart. Review of the facility's Documentation policy, dated revised February 2025, showed:-Purpose: ensure resident clinical records are accurate, complete, secure, and compliant with facility requirements and professional standards;-Maintain clinical records complete, accurate, readily accessible, and systematically organized on each nursing unit;-Include essential documentation: admission assessments, diagnoses, care plans, progress notes, treatment, medications, vital signs, consents, and discharge summaries. Review of the facility's Pressure Ulcer: Prevention and Findings Reporting policy, undated, showed:-Purpose: to treat an identified pressure ulcer as soon as possible (ASAP) and initiate treatment;-If there is a need for a treatment, the charge nurse and or wound nurse, will phone the physician and implement the order as described;-The treatment will be placed on the TAR at the time the physician order is executed;-The wound nurse will confirm, and document wound and document wound care in a nurse's note;-Wound nurse will document all treatments on the TAR, just as the charge nurse would be expected to perform;-The charge nurse and wound nurse will review the resident for a change in condition and implement the appropriate skin care interventions as ordered by the physician or wound nurse practitioner. 1. Review of Resident #1's medical record, showed:-Alert and oriented times four (person, place, time and situation);-Dependent on staff for all activities of daily living (ADLs, grooming, dressing and bathing);-Diagnoses included bilateral lower extremity amputation, bilateral hand amputations and end stage renal disease (ESRD, the kidneys no longer work as they should to meet the body's needs). Review of the care plan, in use at the time of survey, showed:-Problem: resident is frequently incontinent of bowel and bladder (B & B) and is dependent with toileting hygiene. He/She requires minimal (min)/moderate (mod) assist with transfers. He/She had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) to coccyx (tailbone) at a previous admission, 6/6/25: onset;-Goal: utilize interventions to help limit risk of skin breakdown;-Interventions included: monitor for skin breakdown and report to nurse/physician/family;-Problem: resident requires min/mod assist with bed mobility and transfers. He/She is dependent with toileting hygiene related to bilateral hand amputations. He/She is frequently incontinent of B & B. He/She had a prior Stage II pressure ulcer to his/her coccyx. He/She has a surgical wound to his/her chest per nurse's notes, 6/6/25: onset;-Goal: utilize interventions to help limit risk of skin breakdown;-Interventions included:-Apply protective or barrier lotion after incontinence;-Inspect skin complete body head to toe every week and document results;-Inspect skin daily with and care and bathing, and report any changes to charge nurse;-Treatments and dressings as ordered per physician. Review of the progress notes, dated 5/26/25 through 5/31/25, showed:-On 5/26/25 at 9:21 P.M., noted open area to resident's chest area measuring 2.5 centimeters (cm) X 2 cm. No odor noted but drainage present. Hyper granulation (an overgrowth of granulation tissue that extends beyond the wound's surface, forming a raised, red, and friable mass) noted. Area cleansed with Vashe wound cleanser (used for cleansing, irrigating, moistening and debriding acute and chronic wounds) and pat dry, a small amount of mupirocin ointment (topical antibiotic) placed to a small piece of collagen and applied to wound bed. Area covered with foam dressing. Treatment to be done every other day (QOD) and as needed (PRN) for saturation;-On 5/28/25, electronically signed on 6/5/25 at 12:05 A.M., resident was referred to wound practitioner, wound blister to the chest that opened. Initial assessment was scheduled for this day. Resident was unable to be seen by wound practitioner due to outside facility appointment which conflicted with the time in which wound practitioner made rounds at the facility. Review of the TAR, dated 5/26/25 through 5/31/25, showed:-A physician order for cleanse open area to chest with Vashe wound cleanser and pat dry. Apply a small amount of mupirocin ointment to a 2 x 2 cut piece of Puracol collagen (wound dressing). Apply to wound bed and cover with foam dressing. Treatment to be done QOD and PRN for saturation. Diagnosis: unspecified open wound of unspecified front wall of thorax (chest) without penetration into thoracic cavity, start date:5/28/2025. -Documentation showed on 5/28, 5/29 and 5/30 at 9:00 P.M., an X (medication not administered) was documented. On 5/31/25 at 9:00 A.M. and 9:00 P.M., an H (hold) was documented. Review of the progress notes, dated 5/26/25 through 5/31/25, showed no documentation why the treatment was not administrated or why the treatment was held. Review of the resident's hospital record, Post Care Hand Off, dated 6/5/25, showed:-Wounds:-Site: sternal (chest), first time assessed 6/1/25;-Site: coccyx (tail bone), first time assessed 6/1/25;-Discharge Review of Systems (ROS): chest: wound vacuum (Negative Pressure Wound Therapy (NPWT, wound vacuum (vac), is a treatment that pulls fluid and bacteria out of a wound to help it heal better) in place-sternum; -Discharge orders:-Wound Care Instructions: Location of wound(s} which need treatment(s}: -Sternum: continue NPWT with dressing changes every Monday, Wednesday and Friday. Next vac dressing change was 6/6/2025; -Sacrum (triangular bone at the base of the spine /bilateral gluteal (both sides of the buttocks), bedside nursing, please apply Critic-Aid Clear ointment (petrolatum-based, barrier ointment) twice a day (BID) and PRN. Review of the TAR, dated 6/1/25 through 6/30/25, showed:-A physician order for: cleanse open area to chest with Vashe wound cleanser and pat dry. Apply a small amount of mupirocin ointment to a 2 x 2 cut piece of Puracol collagen. Apply to wound bed and cover with foam dressing. Treatment to be done every QOD and PRN for saturation. Diagnoses: unspecified open wound of unspecified front wall of thorax without penetration into thoracic cavity, start date:5/28/2025 end date: 08/27/2025: -Documentation showed: 60 out of 60 opportunities an H (hold) was documented;-There was no physician order for the NPWT or for critic-acid ointment. Review of the progress notes, dated 6/1/25 through 6/30/25, showed:-On 6/4/25, electronically signed 6/5/25 at 12:05 A.M., Resident was unable to be seen by wound practitioner for initial assessment of blister to chest that has opened, due to resident being admitted to the hospital at this time;-On 6/5/25, electronically signed 6/6/25 at 12:20 A.M., readmitted from the hospital, dressing intact to sternum at this time. Skin warm and dry to touch. Skin turgor good. Skin color within normal limits;-No documentation when the resident went to the hospital;-No documentation the treatment was changed or why the treatment was not administrated or placed on hold. During an interview on 9/9/25 at 9:25 A.M., the Unit Manager said the resident had redness on his/her buttocks, but it never opened. The facility put barrier on it and it resolved in about a week. The resident went to the hospital on 5/30/25 and returned 6/6/25. When he/she returned to the facility, he/she had a wound vac. The facility ordered the wound vac and it probably arrived around 6/11/25. When the wound vac was not in place, the facility used wet to dry dressings. The resident often dislodged the wound vac because he/she said it itched. The admitting nurse was responsible for entering the treatment orders into the computer and placing the order on the TAR. Holding the treatment for mupirocin ointment was an oversight. It should have been discontinued when the resident returned from the hospital. 2. Review of Resident #4's medical record, showed:-Disoriented to time and place;-Dependent on staff for all ADLs-Diagnoses included atrial fibrillation (a-fib, irregular heart rhythm), dementia, anxiety and Parkinson's disease(a disorder of the central nervous system that affects movement, often including tremors). Review of the care plan, in use at the time of survey, showed:-Problem: resident is dependent with bed mobility, transfers via Hoyer lift, and toileting hygiene. He/She is incontinent of B&B. He/She had noted redness to coccyx upon admission. He/She also has a wound to left great toe with treatment in place as evidence by wound (pressure/diabetic/stasis) yes;-Goal: measures will be taken to prevent skin breakdown; utilize interventions to help limit risk of further skin breakdown; and measures will be taken to prevent further skin breakdown;-Interventions included: treatments and dressings as ordered per physician; notify physician of any worsening of skin breakdown;-Problem: Non-compliance with facility recommended interventions or physician orders as evidenced by refusing to take showers or get out of bed;-Goal: Resident will show signs of improved compliance or will have no new non-compliance related episodes;-Interventions: Accept resident's right to refuse and show respect for their decision; Educate resident on facility concerns associated with non compliance. Review of the physician order sheet, dated 9/5/25, showed:-A physician order for air mattress to bed. Check for proper functioning every shift;-A physician order to cleanse left buttocks with wound cleanser and pat dry. Apply triple antibiotic ointment (TAO) to a 2 x 2 dressing and apply to wound bed. Cover with foam dressing. Treatment to be done every day and PRN for dressing displacement. Diagnosis: pressure ulcer (any lesion caused by unrelieved pressure that results in damage to the underlying tissue) of left buttock, unspecified stage;-A physician order to cleanse sacrum wound with wound cleanser and pat dry. Apply Santyl to 2 x 2 gauze and apply to wound bed. Cover with foam dressing. Treatment to be done every day and prn for soiling. Diagnosis: pressure ulcer of sacral region, stage 3 (full thickness tissue loss, subcutaneous fat may be visible, but the bone, tendon or muscle is not exposed) Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) Review of the TAR, dated 8/11/25 through 9/9/25, showed:-A physician order for air mattress to bed. Check for proper functioning every shift; -Documentation showed: 8/11 through 9/9 a H was documented; -A physician order to cleanse left buttocks with wound cleanser and pat dry. Apply TAO to a 2 x 2 dressing and apply to wound bed. Cover with foam dressing. Treatment to be done every day and as needed for dressing displacement; -Documentation showed: on 8/16 through 8/18, 8/20, 8/22 through 8/24 and 9/8 were blank; On 8/25 through 9/2 and 9/5 and 9/6 an X was documented;-A physician order to cleanse sacrum wound with wound cleanser and pat dry. Apply Santyl to 2 x 2 gauze and apply to wound bed. Cover with foam dressing. Treatment to be done every day and as needed for soiling; -Documentation showed: on 8/16 through 8/18, 8/20, 8/22 through 8/24 and 9/8 were blank; On 8/25 through 9/2 and 9/5 an X was documented. Review of the progress notes, dated 8/11 through 9/9/25, showed:-No documentation the resident refused his/her treatments and no documentation showing why the treatment was not administered. During an interview on 9/9/25 at 9:25 A.M., the Unit Manager said if there was a blank on the TAR, she would not know if the treatment was administered or not. When an X was documented, the resident may have been in the hospital. It was difficult to tell when residents were out of the facility. The Unit Manager expected staff to document when a resident left the facility and when the resident returned. The resident had an air mattress on his/her bed. When the resident returned from the hospital, the nurse should have clicked on the air mattress to reactivate the order. 3. Review of Resident #2's medical record, showed:-admitted on [DATE];-Had a wound on sacrum on admission;-Diagnosis included dementia. Review of the care plan, in use at the time of survey, showed:-Problem: Skin breakdown-at risk for/actual breakdown present evidence by occasional incontinence, onset 8/8/25;-Goal: measures will be taken to prevent skin breakdown;-Interventions included: apply protective barrier after incontinence; inspect skin complete body head to toe every week and document results. Observation on 9/5/25 at 3:45 P.M. showed the resident's right buttocks had a quarter size patch of dry skin with three tiny, scabbed areas in the center of it and two tiny, scabbed areas on the outer side of the dry patch. The skin had a reddish-maroon discoloration at the coccyx and down the right side of the gluteal fold. Review of the physician order sheet, dated 9/5/25, showed:-A physician order to cleanse right glute (buttocks) open area with wound cleanser and pat dry. Apply Medi-honey (used for removing necrotic tissue and aides in healing) to 2 x 2 gauze and apply to wound bed. Cover with foam dressing. Change every day and prn for soiling or dressing displacement. Diagnoses: unspecified open wound of right buttock, dated 8/15/2025;-A physician order to cleanse with Vashe and pat dry, apply calmoseptine ointment (barrier) to cover area, leave open to air (OTA), to be done three times a day (TID) and PRN, dated 8/8/2025. Review of the TAR, dated 8/8/25 through 8/31/25, showed:-A physician order to cleanse with Vashe and pat dry, apply calmoseptine ointment to cover area, leave OTA, to be done TID and PRN; -Documentation showed: On 8/10, 8/11, 8/13 through 8/15, 8/17, 8/18 and 8/20 were blank; On 8/22 through 8/26 and 8/28 through 8/31 an X (not administered) was documented;-A physician order to cleanse right glute open area with wound cleanser and pat dry. Apply Medi-honey to 2 x 2 gauze and apply to wound bed. Cover with foam dressing. Change every day and PRN for soiling or dressing displacement; -Documentation showed: On 8/15 through 8/18 and 8/20 was blank; On 8/22 through 8/31 a X was documented. Review of the progress notes, dated 8/8/25 through 8/31/25, showed no documentation why the treatment was not administered or if the physician was made aware the treatment was not administered. Review of the TAR, dated 9/1/25 through 9/5/25, showed:-A physician order to cleanse with Vashe and pat dry, apply calmoseptine ointment to cover area, leave OTA, to be done TID and PRN; -Documentation showed: On 9/1 and 9/2, an X was documented;-A physician order to cleanse right glute open area with wound cleanser and pat dry. Apply Medi-honey to 2 x 2 gauze and apply to wound bed. Cover with foam dressing. Change every day and PRN for soiling or dressing displacement; -Documentation showed: On 9/1 and 9/2, an X was documented. Review of the progress notes, dated 9/1/25 through 9/5/25, showed no documentation why the treatment was not administered or if the physician was made aware the treatment was not administrated.4. During an interview on 9/5/25 at 3:53 P.M., Licensed Practical Nurse (LPN) A said the facility had a wound nurse who completed treatments sometimes. The nurse on the floor completed them when the wound nurse did not. If the nurse found a wound, he/she would notify the doctor and obtain treatment orders. The nurse who obtained the order was responsible for entering the orders into the computer.5. During an interview on 9/9/25 at 9:25 A.M., the Unit Manager said the nurse on the floor was responsible for completing the treatments. When the wound practitioner visited the facility, nurse management completed the treatments. On the weekends, the facility sometimes scheduled a third nurse who will do treatments, but overall, the floor nurse was responsible for completing the treatments. When a wound was found the nurse should assess the area, notify the physician to obtain treatment orders and document it. Documentation should include the location and a description of the wound along with approximate measurements. The wound practitioner measured and staged the wound. Treatments are documented on the TAR when they are completed. If a treatment was not completed, it should be documented on the TAR along with an explanation of why the treatment was not administered in the nurse notes. A blank on the TAR meant it was not done, or it was not marked off. The Unit Manager did not understand why there would be a blank on the TAR because when the audits are completed, if something was not completed it would show up red, and she has not seen a treatment that was red. If an H was documented, that meant the resident was in the hospital and the medication was held. She expected staff to accurately document when a resident left and returned to the facility.6. During an interview on 9/10/25 at 8:55 A.M., the Administrator said when a resident is admitted /readmitted to the facility, the admitting nurse was responsible for entering the treatment orders into the computer. Treatments should be documented when the treatments are completed. If a treatment was not competed, staff should document why it was not completed and notify the physician. A blank on the TAR meant it was not signed out. Treatments are being completed. When residents leave the facility and return to the facility, it should be documented in the progress notes. The Administrator expected staff to follow physician orders and the facility policies and procedures and for the medical record to be complete and accurate. 2598153

40290 Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity when staff spoke to one resident in a disrespectful manner regarding the resident's hygiene and failed to provide care to promote his/her dignity (Resident #9), staff failed to provide one resident with grooming and feeding assistance (Resident #168) and staff entered one resident's room without knocking (Resident #34). In addition, staff failed to wear name badges to identify themselves to residents. The sample was 17. The census was 67. Review of the facility's Resident's Rights, provided to residents upon admission, showed the right to be treated with respect and dignity. Review of the facility's undated Resident Privacy/Dignity/Customer Service policy, showed: -Staff will always aim to communicate with residents in a manner which respects their individuality and needs, taking their view and needs into account; -Staff will protect the dignity, particularly modesty, of very ill or confused patients who may act inappropriately and present challenging behavior while the root cause of the problem is ascertained and treated. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/9/24, showed: -Diagnoses included Alzheimer's disease; -Moderately impaired cognition; -Substantial/maximal assistance required for toileting hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for problems with elimination. Frequently incontinent of bowel and bladder and requires extensive assistance with toileting and perineal care (care to the surface area between the thighs, extending from the pubic bone to tail bone); -Interventions included: Assist with toileting before and after meals, at hour of sleep, and as needed. Monitor bowel movements daily. Provide perineal care after each incontinent episode. Observation on 8/26/24 at 2:06 P.M., showed the resident in his/her room in bed, on his/her back. He/She brought his/her hands out from under his/her blanket. The resident had a brown substance on his/her hands and under his/her nails. A strong odor of bowel movement was present in the room. At 2:20 P.M., Certified Nursing Assistant (CNA) A entered the resident's room and asked the resident why you doing that. The resident said he/she cannot help it. CNA A said give me your hands. He/She wiped the resident's hands with a paper towel, told the resident he/she was going to tell his/her CNA, and then exited the room and walked down the hall. No perineal care was provided. At 2:55 P.M., the resident remained in bed on his/her back. The smell of bowel movement permeated the room. At 3:09 P.M., the resident self-propelled in a wheelchair out of his/her room and down the hall. The room continued to have a strong smell of bowel movement. The resident propelled him/herself into the television area near the nurse's station. The resident had brown matter on his/her hands and under his/her nails. A smell of bowel movement was noted when standing close to the resident. At 4:04 P.M., CNA A told the resident to head to the elevator for dinner. The resident propelled away towards the elevator. No personal care was provided. The resident's hands appear soiled. During an interview on 8/26/24 at 4:07 P.M., the Administrator said if a resident is observed to put his/her hands in stool, he expected staff to address this immediately. The resident's hands should be cleaned and care provided. He would deal with this right now. The Administrator went and talked with CNA A. Observation on 8/26/24 at 4:09 P.M., showed CNA A got on the elevator to head down to the dining room. He/She said CNA B was the resident's CNA today. Shift change is at 3:00 P.M., so he/she was not sure who the resident's CNA was now. CNA A went to the main dining room and told the resident I have to wash your hands cause you was being nasty. The resident looked down and said oh. The resident had two other residents at his/her side when this was said. The CNA took the resident to the shower room on the first floor and assisted the resident to wash his/her hands at the sink. 2. Review of Resident #168's medical record, showed: -admitted [DATE]; -Diagnoses included injury of neck, pain in hand and vertigo (dizziness). Observation on 8/26/24 at 10:59 A.M., showed the resident sat in a wheelchair in his/her room. The resident's hair was in a disheveled ponytail, with sections of hair loose and outside of the ponytail. During an interview, the resident said he/she was admitted to the facility three days ago for therapy. He/She just had surgery on the discs in his/her neck and does not have full use of his/her arms. Staff has not helped him/her brush his/her hair since he/she was admitted . Staff dropped of his/her breakfast tray this morning and left it there without helping him/her. Observation on 8/27/24 at 8:45 A.M., showed the resident in a wheelchair in his/her room. CNA K delivered a tray of breakfast to the resident's room, said he/she would come back to feed the resident, and left the room. During an interview, the resident said staff do not offer to help him/her. He/She is doing the best he/she can to fend for him/herself. The staff lack compassion. The resident became tearful during the interview. At 9:13 A.M., the resident remained seated in his/her room with the breakfast tray untouched. During an interview, the resident said the facility staff lack compassion and care. It makes him/her sad and he/she does not want to ask them for help. He/She is sitting in his/her wheelchair with his/her pants not fully pulled up, leaving his/her bottom uncovered on the wheelchair, because he/she cannot lift his/her pants up all the way. At 12:13 P.M., the resident remained seated in his/her wheelchair with pants not pulled up all the way. During an interview on 8/28/24 at 9:11 A.M., the resident said staff come into his/her room without knocking on the door or telling him/her who they are. Sometimes they are not wearing name badges and they don't tell him/her their names. 3. Review of Resident #34's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnosis of depression. Observation on 8/26/24 at 11:42 A.M., showed the resident in bed in his/her room. During an interview, CNA A entered the resident's room without knocking or announcing him/herself. He/She was not wearing a name badge. CNA A asked the resident if his/her call light was on and the resident said no. CNA A left the room. The resident said staff do this all the time. Staff just walk right on in his/her room without knocking first. 4. Observation on 8/29/24 at 10:01 A.M., showed Licensed Practical Nurse (LPN) E with no name badge while working at the nurse's station. During an interview, LPN E said staff should wear name badges while working. He/She never got around to getting a badge. Staff should knock and announce themselves when entering resident rooms because this is their home. 5. During an interview on 8/28/24 at 10:58 A.M., CNA A said staff should knock and announce themselves when entering a resident's room so the resident knows who is coming into their room. Staff are required to wear name badges while working. 6. During an interview on 8/29/24 at 12:50 P.M., with the Director of Nursing (DON) and LPN L/Unit Manager, they said residents should be treated with dignity and respect. Staff should not scold the residents. Staff are expected to knock and announce themselves before entering a resident's room for dignity and respect. Staff are expected to wear name badges while they are working. The DON did not wear a name badge during the interview. 7. During an interview on 8/29/24 at 2:55 P.M., the Administrator said he expected staff to knock upon entering a resident's room. This is a privacy and resident rights issue. He expected staff to wear name badges in the facility during their shift. He expected residents to be treated with dignity and respect. MO00239684 MO00240891 MO00240930

Based on observation, interview and record review, the facility failed to ensure resident requests for less than $100.00 ($50.00 for Medicaid residents) are honored within the same day, and the facility failed to ensure resident funds in excess of $100.00 (or $50.00 for Medicaid residents), were held in an interest-bearing account. This affected 40 residents whose funds were handled by the facility. The census was 76. 1. During a group interview on 8/29/24 at 10:04 A.M., seven residents, whom the facility identified as cognitively intact, said requests for personal funds are limited to $20.00. If a resident wants more than $20.00, they have to wait. During an interview on 8/29/24 at 11:03 A.M., the Business Office Manager (BOM) said she handles requests for cash made by residents who have funds held by the facility. She usually only does $20.00 for cash withdrawals. She prefers to do smaller amounts like $20.00, in case the resident misplaces their money. Years ago, she was told residents could only get $20.00 per day, unless they go out of the facility, at which point they can request more money. The BOM was not aware requests for up to $49.00 should be honored by the facility within 24 hours for Medicaid residents. 2. Observation on 8/29/24 at 11:03 A.M., showed the BOM counted the petty cash amount on hand, totaling $4,938.17. She was not aware that cash on hand had to be limited to $50.00 for Medicaid residents, and $100.00 for Medicare residents, and that any overage must be in an interest-bearing account. Review of the facility's balance report and census, showed: -The facility holds funds for 36 Medicaid residents. The total amount of cash on hand for the residents should be $1800.00; -The facility holds funds for four non-Medicaid residents. The total amount of cash on hand for the residents should be $400.00. 3. During an interview on 8/29/24 at 2:55 P.M., the Administrator said it has always been the facility's policy to provide up to $20.00 when residents request personal funds. If a resident wants more than $20.00, the facility will ask the resident what they are purchasing and might contact their loved one to run the request by them. They don't want to chance the resident losing their money. He expected funds held in excess of $50.00 for Medicaid residents, or $100.00 for non-Medicaid residents, to be held in an interest bearing account.

40290 42795 46888 Based on observation, interview, and record review, the facility failed to ensure residents' rooms and medical equipment and resident common areas were clean and homelike, affecting 13 of 17 sampled (Residents #9, #24, #43, #69, #32, #55, #27, #2, #50, #4, #269, #47 and #45). The facility also failed to ensure the 200 veranda hallway had clean floors. The census was 67. Review of the facility's housekeeping disinfecting cleaning schedule, revised 2/24/23, showed: -Housekeeping staff is responsible for the cleaning and disinfection of resident's room. Staff have responsibilities that are scheduled on a daily, weekly, and monthly basis. Housekeepers are responsible for every resident room on their halls which includes suites, gardens and terrace; -Disinfects bathrooms toilet and rails. Wipe sink and clean mirrors with Spic and Span. If nursing staff has to change sheets make sure the bed is disinfected with chemicals depending if the room is a deep clean or vacant room make sure bed is made. Sweep rooms starting from the top of the rooms to the outside room. Check privacy curtains to see if it needs to be laundered and put back up in the room before the end of the day. Clean Air Conditioning(AC) units and wall are cleaned. Make sure all furniture nightstands bed side tables are wiped off and cleaned. Make sure toilet tissue paper towels and soap is stocked in the room before mopping from top to bottom. After mopping room make sure wet floor sign is outside the door. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/9/24, showed: -Diagnosis of Alzheimer's disease; -Moderately impaired cognition; -Required substantial/maximal assistance for toileting hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for problems with elimination. Frequently incontinent of bowel and bladder and requires extensive assistance with toileting and perineal care (care to the surface area between the thighs, extending from the pubic bone to tail bone); -Interventions included: Assist with toileting before and after meals, at hour of sleep, and as needed. Monitor bowel movements daily. Provide perineal care after each incontinent episode. Observation on 8/26/24 at 2:06 P.M., showed the resident in his/her room in bed, on his/her back. He/She brought his/her hands out from under his/her blanket. The resident had a brown substance on his/her hands and under his/her nails. A strong odor of bowel movement in the room. At 2:20 P.M., Certified Nursing Assistant (CNA) A entered the resident's room, wiped the resident's hands with a paper towel, and then exited the room and walked down the hall. On 8/26/24 at 2:55 P.M., the resident remained in bed on his/her back. The smell of bowel movement permeated the room. Observation on 8/26/24 at 5:59 P.M., showed CNA A entered the resident's room and assisted the resident to be cleaned. A strong odor of bowel movement permeated the room. Observation showed brown matter smeared on the sheets, blankets, pillow, and on the wall. CNA A changed the resident's linen. The wall was not cleaned. Observation of the floor under the bed, showed several small balls of brown matter along the wall on the right side of the bed and near the head of the bed. A plastic cup, used gloves, and paper towels were also under the bed. Observation on 8/27/24 at 6:46 A.M., showed a strong odor of bowel movement in the room. The trash that had been on the floor under the bed was no longer present. The balls of brown matter remained on the floor under the bed. At 12:13 P.M., the balls of brown matter had been cleaned up, but smears of brown matter were still visible under the bed. On 8/28/24 at 6:21 A.M. and 8/29/24 at 9:22 A.M., the resident lay in bed, asleep. The smears of brown matter remained under the bed. During an interview on 8/28/24 at 10:58 A.M., CNA A said housekeeping cleans rooms once a day, but they do not mop under furniture. The resident throws his/her poop. The CNAs pick it up, they can clean up the big messes and do the best they can. They need housekeeping to clean up the rest but housekeeping does not clean. 2. Review of Resident #24's significant change MDS, dated [DATE], showed: -Diagnoses included manic depression and schizophrenia(mental illness that affects how people think, feel, and behave); -Cognitively intact. Observation and interview on 8/26/24 at 10:24 A.M., showed the resident lay in bed. The floor in the resident's room appeared dirty with debris, dirt, and dried spills throughout. Behind the resident's head of bed, were large gashes in the wall, vertically up and down the wall. The resident said it bothers him/her to have the wall so scratched up. 3. Review of Resident #43's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Dependent on assistance with toileting; -Diagnoses included hemiplegia (paralysis on one side of the body) or hemiparesis (weakness on one side of the body), depression, and anxiety. Review of Resident #69's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required substantial/maximum assistance with toileting; -Diagnoses included hemiplegia or hemiparesis and anxiety. During an interview on 8/27/24 at 1:11 P.M., Residents #43 and #69 said the toilet in the bathroom they share runs all the time and it is annoying. Resident #43 said the bathroom door has to stay shut at night or it will keep him/her awake. Both residents said the water in their bathroom sink does not get hot. The residents require staff assistance when they become soiled and staff clean them up with cold water. Resident #69 said the water has not been getting hot for a long time. When he/she tells staff, they say there is nothing that can be done. Observation on 8/27/24 at 1:50 P.M., showed the residents' toilet ran intermittently while not in use. The hot water faucet turned on and ran continuously for two minutes. The hot water measured 86.6 degrees Fahrenheit (F). During an interview on 8/28/24 at 1:54 P.M., Licensed Practical Nurse (LPN) C said the sink's water has been like this for a long time and he/she has told management. Observation on 8/28/24 at 6:57 A.M., showed the residents' toilet ran intermittently while not in use. The hot water faucet turned on and ran continuously for two minutes. The hot water measured 82.4 degrees F. During an interview on 8/28/24 at 10:58 A.M., CNA A said the residents' toilet runs and Resident #43 prefers the bathroom door to be shut because of this. The water in the residents' sink does not get hot. The toilet and sink have been this way for two years. All resident rooms should have hot water. During an interview on 8/29/24 at 2:20 P.M., the Maintenance Director said he has been working with the facility for 10 days. He was not aware of any concerns with the toilet running or the water temperature in the residents' room. He expected water temperatures to be within range. He does not routinely check water temperatures in resident rooms. He expected staff to fill out a work order for these issues. During an interview on 8/29/24 at 2:55 P.M., the Administrator said he expected staff to report issues with the environment, such as running toilets and sinks without hot water, to himself or the Maintenance Director. He expected water temperatures to be within the appropriate range. He expected residents to be provided with a comfortable environment. 4. Review of Resident #32's admission MDS, dated [DATE], showed: -Resident rarely/never understood; -Dependent for assistance with mobility; -Diagnoses included dementia and depression. Review of Resident #55's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Dependent for assistance with all activities of daily living; -Diagnosis included stroke. Observations on 8/26/24 at 11:54 A.M 12:34 P.M., 1:28 P.M., and 4:29 P.M., and on 8/27/24 at 7:13 A.M. and 12:16 P.M., showed splatters of a dried beige substance on top of Resident #55's oxygen concentrator, fall mat, and floor underneath the resident's tube feeding pole. Dirt and debris were on the floor with three tube caps on the floor underneath the head of Resident #32's bed. Observations on 8/28/24 at 6:39 A.M. and 8:15 A.M., and on 8/29/24 at 7:11 A.M., showed splatters of a dried beige substance on top of Resident #55's oxygen concentrator, fall mat, and floor underneath the resident's tube feeding pole. 5. Review of Resident #27's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses include high blood pressure and depression. Observation and interview on 8/26/24 at 10:40 A.M., and on 8/27/24 at 9:15 A.M., showed the resident lay in bed. The resident's bedside table was cluttered with old food wrappers, medication cups and an empty soda bottle. Behind the resident's bed were multiple food wrappers, a white and blue pill, food crumbs and dead roaches. The resident's bathroom had brown roaches crawling on the door and wall of the bathroom. The resident said he/she thought someone cleaned his/her room daily but wasn't sure. During an interview on 8/27/24 at 9:15 A.M., a family member said he/she has not seen anyone deep clean the resident's room in several months. The family member he/she normally cleans the resident's room. 6. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart failure, renal (kidney) failure, dementia and depression. Observation on 8/26/24 at 10:30 A.M. and 3:30 P.M., and on 8/28/24 at 6:45 A.M., showed the resident in his/her wheelchair in his/her room. The resident's bed was positioned against the wall. Behind the resident's bed and dresser were an empty water cup, crumbs, a white dried liquid and dead roaches. The resident's overhead bedside table was covered with a sticky substance. The resident's bathroom had brown roaches crawling on the walls of the bathroom. During an interview on 8/29/24 at 8:15 A.M., Housekeeper V said housekeepers move the furniture and beds out to deep clean with sweeping and mopping about once or twice a month. Housekeeping can clean the resident's bedside tables off when needed. 7. Review of Resident #50's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnoses of acute kidney failure and major depressive disorder. Observations on 8/26/24 at 1:03 P.M., 8/27/24 at 12:13 P.M., and 8/28/24 at 10:18 A.M., showed the resident's room to have sticky floors with debris, the AC unit had dust accumulation and debris on the inside and out, and a dirty privacy curtain with various brown stains. 8. Review of Resident #4's quarterly MDS, dated [DATE], showed the following: -Cognitively intact. -Diagnoses of anxiety disorder and major depressive disorder. Observations on 8/26/24 at 10:54 A.M., and 8/28/24 at 10:25 A.M., showed the resident's AC unit had dust accumulation and debris on the inside and out. 9. Review of Resident #269's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition. -Diagnosis of acute respiratory failure. Observations on 8/26/24 at 10:34 A.M., 8/27/24 at 6:57 A.M., and 8/28/24 at 10:18 A.M., showed the resident's room with sticky floors with dark splattered matter on the resident's fall mat and surrounding floor. Dust build up was on the inside and outside of the AC unit. 10. Review of Resident #47's quarterly MDS, dated [DATE], showed the following: -Cognitively intact. -Diagnosis of end stage renal disease. Observations on 8/26/24 at 11:24 A.M., 8/27/24 at 7:38 A.M., and 8/28/24 at 10:18 A.M., showed brown smears on the wall by the resident's bed. The AC unit had dust and debris accumulation on the inside and outside. 11. Review of Resident #45's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included major depressive disorder, anxiety disorder and Alzheimer's disease. Observations on 8/26/24 at 11:12 A.M., 8/27/24 at 10:45 A.M., and 8/28/24 at 10:17 A.M., showed the resident's floor was sticky with various debris and liquid spills. The resident's closet had dead bugs on the ground, along with cobwebs. The wall behind the resident's bed had dust build up and cobwebs. The AC had dark speckled matter that covered the top of the unit and on the windowsill. 12. Observation of the 200 hall TV area, showed: -On 8/26/24 at 4:04 P.M., crumbs and debris on the floor throughout the area. An area of light brown substance smeared near the entrance to the B200 hall. Dried spills with dirt and debris stuck to the spill scattered throughout the area; -On 8/27/24 at 6:51 A.M., some of the loose debris had been swept up. The smeared brown substance and dried spills with stuck on debris remained; -On 8/28/24 at 8:13 A.M., crumbs and debris on the floor throughout the area. An area of light brown substance smeared near the entrance to the B200 hall. Dried spills with dirt and debris stuck to the spills, scattered throughout the area; -On 8/29/24 at 9:22 A.M., crumbs and debris on the floor throughout the area. An area of light brown substance smeared near the entrance to the B200 hall. Dried spills with dirt and debris stuck to the spill scattered throughout the area. 13. Observation of the B200 and C200 halls, on 8/26/24 at 4:04 P.M., 8/27/24 at 6:51 A.M., 8/28/24 at 8:13 A.M., and 8/29/24 at 9:22 A.M., showed several dried spills and debris throughout the floor. Dust and debris stuck to the various spills. Crumbs and debris gathered near the edges of the halls. 14. Observation of the front entrance walkway, sitting area and down the A200 hall, showed: -On 8/26/24 at 10:00 A.M. and 8/27/24 at 7:48 A.M., several areas with speckled dried spills, with dust and debris stuck to the spills, throughout the front entrance and extended through the A200 hall. The sitting area near the entrance had several pinkish reds dried spots/spills scattered around on the floor, the drips were approximately the size of dime to penny sized. Blue debris was stuck to the floor that appeared to be small pieces, smaller than dime size, of painter's tape, stuck on various areas of the floor; -On 8/28/24 at 8:13 A.M., the front entrance appeared to be mopped. The blue bits of what appeared to be painter's tape remained stuck to the floor; -On 8/29/24 at 9:22 A.M., the blue bits of what appeared to be painter's tape remained stuck to the floor. 15. During an interview on 8/28/24 at 10:58 A.M., CNA A said housekeeping staff is shorthanded. CNAs pitch in to help clean. Housekeeping staff clean resident rooms once a day, but they don't mop under furniture. Resident #9 throws his/her feces and CNAs pick it up, clean up the big messes and do the best they can, but they need housekeeping staff to help too, but housekeeping staff don't clean. There is no housekeeping staff working in the evenings. When housekeeping leaves around 3:00 P.M., they lock up their cleaning supplies and nursing staff do not have access to the cleaning supplies if they need them. Housekeeping staff come in at 7:00 A.M. A lot of messes can be made between 3:00 P.M. and 7:00 A.M. The facility needs housekeeping staff to work later to help keep things clean. 16. During an interview on 8/29/24 at 8:28 A.M., Housekeeper R said housekeeping staff work 7:00 A.M. to 3:00 P.M. He/She wishes there was housekeeping staff in the evenings because it would help keep the facility cleaner. A lot happens between 3:00 P.M. and 7:00 A.M., and the rooms are a mess when day shift comes in. If housekeeping worked in the evening, the rooms would not be so horrible. Some rooms require more attention and time because some of the residents are [NAME]. Resident rooms are cleaned daily. The daily routine is to empty trash cans, clean toilets, wipe counters and tables, stock toilet paper and paper towels, sweep, and mop. Housekeeping staff should mop underneath furniture. There is no deep cleaning schedule. If staff notice a room requires deep cleaning, they mark it on a board in the basement and the Housekeeping Supervisor addresses it. If rooms are cleaned properly, they won't need to be deep cleaned. 17. During an interview on 8/29/24 at 12:36 P.M. with the Director of Nurses (DON) and Licensed Practical Nurse (LPN) L/Unit Manager, they said staff should clean up spills, such as tube feeding formula. Housekeeping staff should clean resident rooms daily. Housekeeping staff work day shift and do not work in the evenings. 18. During an interview on 8/29/24 at 2:20 P.M., the Maintenance Director/Housekeeping Supervisor said the prior Housekeeping Supervisor left on the 19th of this month, so he was assigned the position. There are five housekeeping staff employed at the facility. They work day shift, 7a-3p. Then, no one from housekeeping is at the facility until the next morning. Housekeeping staff do not leave any cleaning supplies out when they leave for the day. They will take care of spills before the end of the shift. If there is a spill that happens overnight, it might have to wait until the next day, unless nursing staff decide to help out. There are typically three housekeeping staff working per day. One on the 100 halls, one on the 200 halls, and a floor tech. The floor tech is responsible for all halls, common areas, shower rooms, dining room, etc. The other staff are responsible for resident rooms on their halls. The floor tech should clean the floors throughout the common areas, daily. The housekeeping staff assigned to a floor should clean each room daily. Cleaning the rooms includes cleaning the floors, sweeping and mopping. This includes mopping under the furniture and beds and moving the furniture if needed, wiping down tables, sinks, vents, AC units, and cleaning the bathroom and toilets. Privacy curtains should be observed for stains. Maintenance concerns are reported via a work slip. These are given to him and he handles them from there. If needed, he will consult the administrator to develop a plan. Staff should fill out a work order for gouges in the walls. The turn around time depends on how bad the issue is. MO00238869 MO00239680 MO00240930

Based on interview and record review, the facility to develop a policy for and complete background checks for all newly hired employees, to include the Nurse Aide (NA) Registry (checks for Federal Indicators (FI) given to individuals found guilty of abuse, neglect, and misappropriation of resident property) for thee of five newly hired employees sampled. The census was 67. Review of the facility's Policy on Background Checks, revised 8/29/24, showed: -The facility will conduct background checks on all employees before they start working at the facility; -Upon hire background checks will be completed two days prior to the employee start date; -Human Resources (HR) will conduct an annual Family Care Safety screening and quarterly Employee Disqualification List (EDL) screening; -The policy failed to identify which background checks will be completed prior to hire; -The policy failed to require the NA Registry check for all staff to ensure the staff has no Federal Indicators. Review of Dietary Aide P's employee file, showed: -Date of hire 6/6/24; -No NA registry check. Review of Licensed Practical Nurse (LPN) O's employee file, showed: -Date of hire 7/5/24; -No NA registry check. Review of Housekeeping Aide N's employee file, showed: -Date of hire 2/23/24; -No NA registry check. During an interview on 8/27/24 at 1:04 P.M., the Human Resources/Staffing Coordinator said employee background checks include the Family Care Safety Registry (FCSR) and Employee Disqualification List (EDL) check. The NA registry is only checked for the Certified Nursing Assistants, Nursing Assistants, Certified Medication Technicians, and nurses. She was not aware that the NA registry needed to be checked on all staff to check for federal indicators.

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal hygiene. Resident #9 was not provided care after having a bowel movement and getting that bowel movement on his/her hands. In addition, the resident was not checked for incontinence or cleaned, resulting in the resident's brief being saturated through his/her pants (Resident #9). One resident was not provided showers or hair washing for an extended period of time and the hair care that was provided was not sufficient to cleanse the hair, resulting in the resident's hair becoming matted in a hard thick clump (Resident #32). In addition, staff failed to provide basic activities of daily living to include brushing residents' hair, providing feeding assistance, providing baths and/or showers, and providing nail care for four residents (Residents #168, #269, #29, and #16). The sample was 17. The census was 67. Review of the facility's Activity of Daily Living (ADL) policy, dated 8/17/20, showed: -It is the standard of the facility to promote the highest level of health and hygiene for the residents residing at the facility, while promoting the utmost independence. In order to adhere to this standard, it is the policy that any resident that is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal oral hygiene; -Assistance with the bathroom: Refers to the residents ability to use the toilet room, transfer on/off the toilet, clean themselves, change absorbent pads or briefs, and adjust clothes; -Assistance with ADLs will be performed if the ADLs cannot be performed independently by the resident. The level of assistance with ADLs provided by staff are based on the residents ability to maintain highest level of health and hygiene. Review of the facility's Peri Care (perineal care, care to the surface area between the thighs, extending from the pubic bone to tail bone) policy, dated 1/5/20, showed: -Purpose: To clean the perineum and to prevent infection and odor; -Wash hands, put on cloves, drape the resident for privacy; -Wipe the resident from front to back thoroughly cleaning the genitals. Repeat process until disposable wipe is free of soiling and discard; -Remove gloves, wash hands, apply gloves; -Wipe the peri rectal area from front to back. Repeat until disposable wipe is free of soiling and discard. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/9/24, showed: -Diagnoses included Alzheimer's disease; -Moderately impaired cognition; -Substantial/maximal assistance required for toileting hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for problems with elimination. Frequently incontinent of bowel and bladder and requires extensive assistance with toileting and perineal care; -Interventions included: Assist with toileting before and after meals, at hour of sleep, and as needed. Monitor bowel movements daily. Provide perineal care after each incontinent episode. Observation on 8/26/24 at 2:06 P.M., showed the resident in his/her room in bed, on his/her back. He/She brought his/her hands out from under his/her blanket. The resident had a brown substance on his/her hands and under his/her nails. A strong odor of bowel movement in the room. At 2:20 P.M., Certified Nursing Assistant (CNA) A entered the resident's room and asked the resident why you doing that. The resident said he/she cannot help it. CNA A said give me your hands. He/She wiped the resident's hands with a paper towel, told the resident he/she was going to tell his/her CNA, and then exited the room and walked down the hall. No perineal care provided. At 2:55 P.M., the resident remained in bed on his/her back. The smell of bowel movement permeated the room. At 3:09 P.M., the resident self-propelled in a wheelchair out of his/her room and down the hall. The room continued to have a strong smell of bowel movement. The resident propelled him/herself into the television area near the nurse's station. The resident had a brown substance on his/her hands and under his/her nails. A smell of bowel movement was noted when standing close to the resident. At 4:04 P.M., CNA A told the resident to head to the elevator for dinner. The resident propelled away towards the elevator. No personal care was provided. The resident's hands appear soiled. During an interview on 8/26/24 at 4:07 P.M., the Administrator said if a resident is observed to put his/her hands in stool, he expected staff to address this immediately. The resident's hands should be cleaned, and care provided. He will deal with this right now. The Administrator went and talked with CNA A. Observation on 8/26/24 at 4:09 P.M., showed CNA A got on the elevator to head down to the dining room. He/She said CNA B was the resident's CNA earlier today. Shift change is at 3:00 P.M., so he/she was not sure who the resident's CNA is now. CNA A went to the main dining room and took the resident to the shower room on the 1st floor. He/She assisted the resident to wash his/her hands at sink. There was a large amount of brown debris under the resident's nails and on his/her hands and fingers. CNA A assisted to wash the resident's hands using three different scrubs in order to get all of the dried debris off of the resident's hands. CNA A brought the resident to the table in in the main dining room. No perineal care was provided. CNA A said when he/she went into the resident's room earlier, he/she was playing in his/her stool. He/She cleaned his/her hands at that time, but he/she did not provide perineal care. He/She told the resident's CNA the resident needed care. This behavior of playing in stool is a normal for the resident and is why he/she does not have a roommate. Observation on 8/26/24 at 4:22 P.M., showed the resident remained in the dining room and waited for dinner. Observation on 8/26/24 at 5:49 P.M., showed the resident returned to the second floor from the main dining room. He/She self-propelled around at the nurse's station. CNA A then told the resident to go in to his/her room and he/she was going to clean him/her. The resident propelled to his/her room and transferred him/herself to bed. At 5:59 P.M., CNA A entered the resident's room with supplies. He/She asked the resident to stand up and sit back in his/her wheelchair so he/she could change the bed. As the resident stood and pivoted, the back of the resident's pants appeared very wet near the buttocks area and between the legs. A strong odor of bowel movement permeated in the room. Observation showed stool smeared on the sheets, blankets, pillow, and on the wall. CNA A placed gloves on and made the resident's bed, changing his/her gloves and sanitized his/her hands after touching the soiled linen and before placing the clean linen on the bed. CNA A assisted the resident to stand, removed his/her pants, and lowered his/her brief. The brief was saturated with dark colored urine and stool. As the resident started to stand, the resident began to have another bowel movement. CNA A assisted the resident into the bathroom and onto the toilet. During an interview on 8/29/24 at 12:50 P.M., with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) L/Unit Manager, they said the aide or any nursing staff can clean a resident's hands if they appear soiled. Residents should be cleaned if they are known to have a bowel movement. Residents who are incontinent should be checked every two hours and cleaned up before meals. 2. Review of Resident #32's admission MDS, dated [DATE], showed: -admitted [DATE]; -Resident is rarely/never understood; -Rejection of care behavior not exhibited; -Upper extremity impairment on both sides, lower extremity impairment on one side; -Dependent for assistance with personal hygiene; -Diagnoses included dementia, Parkinson's disease (brain disorder causing unintended or uncontrolled movements), depression, and generalized muscle weakness. Review of the resident's care plan, in use at the time of survey, showed: -Care area/problem: Resident has a self-care deficit; -Goals: Resident will maintain or improve self-care area of dressing, grooming, hygiene, and bathing. Resident will accept assistance with area of dressing, grooming, hygiene, and bathing; -Interventions included provide assistance with self-care as needed; -The care plan failed to identify the resident's individual needs and preferences related to bathing, including the resident's dependence on staff for assistance with personal hygiene and grooming. Review of the facility's shower schedule, undated, located in the shower binder at the nurse's station, showed the resident scheduled to receive showers during day shift on Wednesdays and Saturdays. Review of the resident's shower sheets for July and August 2024, showed: -On 7/10/24 and 7/24/24, shower sheets completed and signed by a CNA and a nurse. No notes regarding the resident's hair; -On 8/1/24, shower sheet completed and signed by a CNA. Not signed by a nurse. No notes regarding resident's hair; -No other shower sheets completed. Observations on 8/26/24 at 11:12 A.M., 12:34 P.M., 1:28 P.M., 4:29 P.M., and 6:19 P.M., showed the resident on his/her back in bed. His/Her hair was disheveled and in a ponytail at the top of his/her head. Large chunks of white flakes were throughout the resident's hair, from the crown of his/her head to the end of his/her ponytail. Observations on 8/27/24 at 7:13 A.M. and 8:49 A.M., showed the resident on his/her back in bed with his/her hair in a disheveled ponytail. Large chunks of white flakes were throughout the resident's hair, from the crown of his/her head to the end of his/her ponytail. Observation on 8/27/24 at 11:00 A.M., showed the resident on his/her back in bed with his/her hair in a disheveled ponytail. The back of his/her head was bald with clumps of hair on his/her pillow. His/Her hair was matted into a large clump on the side of his/her head. During an interview, the resident shook his/her head no when asked if his/her hair had been washed recently. Observation on 8/28/24 at 6:54 A.M., showed CNA D entered the resident's room. The resident lay on his/her back. CNA D uncovered the resident and unsecured his/her brief. CNA D assisted the resident to his/her left side. The resident's hair was matted and stuck straight out from the left side of his/her head in a large clump. Large chunks of white flakes stuck in the matted hair. During an interview on 8/28/24 at 10:58 A.M., CNA A said staff follow a shower schedule at the nurse's station. When a shower or bed bath is completed, staff fill out a shower sheet and put it in the binder at the nurse's station. Staff should mark any observed issues on the shower sheet and report it to the nurse, including flakes in a resident's hair. The resident requires total assistance from staff with his/her care needs. He/She does not get out of bed and screams when touched. CNA A is not sure why the resident screams or if it is due to pain. The resident gets bed baths. Staff use a wet washcloth to wash the resident's hair. They have tried using regular shampoo in the past. CNA A does not know how the resident's hair got the way it has. His/Her hair has been this way for about a month. Observation on 8/29/24 at 8:48 A.M., showed the DON entered the resident's room. The resident lay on his/her back in bed. The DON lifted the resident's head and observed the resident's hair matted into a large clump. Large chunks of white flakes were throughout the resident's hair. The DON explained to the resident that his/her hair was matted and needed to be cut. The resident said he/she wanted staff to try brushing his/her hair first. The DON asked CNA K to look at the resident's hair and CNA K entered the resident's room and observed the resident's hair. CNA K said he/she has tried to get the resident to wash his/her hair, but the resident says no. CNA K said while giving bed baths, he/she has been wetting a washcloth and rubbing it on top of the resident's head. During an interview on 8/29/24 at 8:52 A.M., CNA K said the resident was admitted to the facility a couple of months ago with his/her hair in a ponytail. CNA K tried to wash the resident's hair, but the elastic band holding the ponytail wouldn't come out and the resident's hair started pulling away from his/her scalp. CNA K left the elastic band in the resident's hair and thought someone else would try to get it out. CNA K has given the resident several bed baths and uses a wet washcloth to push the resident's hair back and wipe the flakes out of his/her hair. CNA K told one of the nurses about the flakes in the resident's hair. The resident does not have a medicated shampoo. During an interview on 8/29/24 at 10:01 A.M., LPN E said the resident is total care, receives bed baths, and does not like to get up. He/She is in pain all the time and does not like to be touched. Yesterday, LPN E heard the resident's hair was matted. The resident lays toward one side all day, so LPN E can see how his/her scalp would get like this. He/She would have expected staff to notify the nurse if they observed flakes in the resident's hair. The nurse could notify the physician to get a medicated shampoo. If staff observe the resident's hair is matted so severely it cannot be brushed, they should report it to the nurse. The nurse would notify the family about the resident's hair to see if there is anything they can do or get consent to cut the resident's hair. Because of the resident's pain, staff could make sure the resident gets a Tylenol or pain medication before getting a shower to stay ahead of the pain. During an interview on 8/29/24 at 9:03 A.M., the DON said the resident's hair did not get like this overnight. She expected staff to have reported the resident's matted hair, flakes, and refusals to have his/her hair washed. She expected staff to get the resident's family involved if the resident has been refusing. She expected the nurse to notify the resident's physician about the flakes in the resident's hair so an order could be obtained for a medicated shampoo or topical treatment. 3. Review of Resident #168's medical record, showed: -admitted [DATE]; -Diagnoses included unspecified injury of the neck, pain in unspecified hand, and vertigo (dizziness). Review of the resident's care plan, in use at the time of survey, reviewed 8/26/24, showed: -Care area/problem: Resident has a self-care deficit; -Goals included: Resident will maintain or improve self-care area of dressing, grooming, hygiene, and bathing. -Interventions included provide assistance with self-care as needed. Observation on 8/26/24 at 10:59 A.M., showed the resident sat in a wheelchair in his/her room. The resident's hair was in a disheveled ponytail, with chunks of hair loose and outside of the ponytail. During an interview, the resident said he/she was admitted to the facility three days ago for therapy. He/She just had surgery on the discs in his/her neck and does not have full use of his/her arms. Staff has not helped him/her brush his/her hair since he/she was admitted . Staff dropped off his/her breakfast tray this morning and left it there without helping him/her. Observations on 8/26/24 at 12:21 P.M. and 1:14 P.M., showed the resident sat in a wheelchair in his/her room. His/Her hair was in a disheveled ponytail, which had chunks of hair loose and outside of the ponytail. During an interview at 1:14 P.M., the resident said his/her hair is a mess and he/she does not like it that way. Being disheveled makes him/her very uncomfortable. Review of the resident's Occupational Therapy (OT) evaluation, dated 8/26/24, showed: -Goal: Patient will complete all activities of daily living (ADL)/self-care tasks with independence. Baseline, as of 8/26/24: Dependent; -Functional skills assessment: Substantial/maximal assistance with eating. Dependent with personal hygiene and dressing. Observation on 8/27/24 at 8:45 A.M., showed the resident in a wheelchair in his/her room. CNA K delivered a tray of breakfast to the resident's room, said he/she would come back to feed the resident, and left the room. During an interview, the resident said staff do not offer to help him/her. He/She is doing the best he/she can to fend for him/herself. The staff lack compassion. The resident became tearful during the interview. At 9:13 A.M., the resident remained seated in his/her room with breakfast tray untouched. During an interview, the resident said the facility staff lack compassion and care. It makes him/her sad and he/she does not want to ask them for help. He/She was sitting in his/her wheelchair with his/her pants not fully pulled up, leaving his/her bottom uncovered on the wheelchair, because he/she cannot lift his/her pants up all the way. At 12:13 P.M., the resident remained seated in his/her wheelchair with his/her pants not pulled up all the way. Observation on 8/28/24 at 9:11 A.M., showed the resident sat in wheelchair. His/Her hair was in a disheveled bun and said his/her friend put his/her hair in a bun yesterday. Staff have not offered to help him/her brush his/her hair or to assist him/her in taking a bath or shower since he/she was admitted to the facility. During an interview on 8/28/24 at 10:58 A.M., CNA A said the resident is a new admission. Staff should get report from the nurse about what type of assistance is needed. The resident needs some assistance from staff with eating and brushing his/her hair. Staff should offer and provide this assistance as needed. During an interview on 8/29/24 at 10:01 A.M., LPN E said the resident is a new admission to the facility. When he/she first arrived at the facility, his/her arms were not really mobile at all. Now, he/she can use his/her lower arms. Staff still need to help him/her with some things and should provide assistance, like brushing the resident's hair. During an interview on 8/29/24 at 12:36 P.M. with the DON and LPN L/Unit Manager, they said they expected staff to provide assistance to the resident as needed. 4. Review of Resident #269's quarterly MDS, dated [DATE], showed the following: -Diagnosis of acute respiratory failure; -Moderately impaired cognition. Review of the resident's care plan, dated 6/24/24 and in use at the time of the survey, showed: -Focus: Resident has a self-care deficit. He/She requires extensive assist with most of his/her ADL care. He/She is not ambulatory at this time; -Goal: Utilize interventions to help resident become as independent as possible while making sure his/her needs are met; -Interventions: Encourage resident to participate in ADLs and praise accomplishments and give resident as many choices as possible about care. Observation on 8/26/24 at 10:32 A.M., 8/27/24 at 6:50 A.M., and 8/28/24 at 12:40 P.M., showed the resident's finger nails to be at various lengths with dark matter underneath the nails. During an interview on 8/29/24 at 7:51 A.M., CNA S said CNAs are responsible for trimming residents' nails during showers or as needed. He/She expected residents' nails to be trimmed and clean. During an interview on 8/29/24 at 12:50 P.M., the DON said all nursing staff are able to trim residents' nails. She said nurses are responsible for trimming the nails of residents with diabetes. She expected residents to have clean, trimmed nails. 5. Review of Resident #29's quarterly MDS, dated [DATE], showed: -Mild cognitive impairment; -Requires maximum assistance from staff with personal hygiene and bathing; -Diagnoses include heart disease and stroke. Review of the resident's care plan, in use at the time of survey, showed: -Care area: Self-care deficient; -Interventions: Give the resident as many choices as possible. Encourage the resident to complete as much self-care as possible independently or as possible. Provide assistance with self-care as needed. Observation and interview on 8/26/24 at 10:50 A.M., showed the resident lay in bed with fingernails on both hands that were approximately one-fourth inch long, with jagged edges and with brown matter underneath. The resident said he/she did not like his/her nails that long and thought they looked dirty. During observation and interview on 8/29/24 at 9:30 A.M., the resident said he/she received a shower the evening before, but the staff did not trim his/her nails. He/She could not trim his/her nails by him/herself. The resident's fingernails on both hands were approximately one-fourth inch long, with jagged edges, and with brown matter underneath. During an interview on 8/27/24 at 9:15 A.M., CNA S said nail care is part of the residents' routine showers and bathing care. 6. Review of Resident #16's, admission MDS, dated [DATE], showed: -Cognitively intact; -No rejection in care; -Requires maximum assist from staff for bathing, upper body dressing and personal hygiene; -Dependent on staff for lower body dressing; -Diagnosis included: diabetes, peripheral vascular disease (PVD, constricts the blood flow to lower extremities) and lung disease. Review of the resident's care plan, in use at the time of survey, showed: -Care Area: Self- care deficient related to the resident has an above the knee amputation (AKA) and requires maximum assistance with transfers, turning, grooming, positioning, and dressing. -Interventions: Occupational therapy (OT) and physical therapy (PT) evaluation as needed. Provide self-care as needed. During observation and interview on 8/26/24 at 10:25 A.M. and 4:07 P.M., 8/27/24 at 1:15 P.M., 8/28/24 at 8:40 A.M., and 8/29/24 at approximately 9:00 A.M., the resident lay in bed with a yellow facility gown and a blue cardigan sweater. The resident's hair was frizzy and had small knots of hair at the back of his/her head. The resident said he/she would like to get out of bed, look in the mirror, and be able to fix his/her own hair because he/she used to be a beautician. He/she gets a bed bath from staff but is normally just cleaned after he/she is incontinent. His/Her clothing does not get changed. He/She would like to get his/her clothing changed. During an interview at 8/27/24 at 1:15 P.M., the resident's family member said he/she visits the resident about once a week and has never seen the resident out of bed. The resident always wears a hospital gown and never wears any of his/her own personal clothing. The resident also has his/her own wheelchair with chair cushion. During an interview 8/28/24 at 8:40 A.M., Wound Clinic Nurse F said it is important for the resident to get out of bed to promote circulation and off load pressure. During an interview on 8/29/24 at 7:50 A.M., CNA S said the resident should be getting his/her clothing changed daily but the resident will refuse at times to get out of bed. During an interview on 8/29/24 at 9:45 A.M., LPN C said the resident would benefit from at least two hours a day getting out of bed and should be getting his/her clothing changed daily. During an interview on 8/29/24 at 12:40 P.M., the DON said she expected the resident to have his/her clothing changed daily and to get out of his/her of bed if the resident will allow staff to do so. 7. During an interview on 8/28/24 at 10:58 A.M., CNA A said some residents have their own hairbrushes, but the facility only supplies combs for the rest of the residents. There is a shared hairbrush used for residents who do not have their own individual hairbrush. CNA pointed at a hairbrush in the common area by the nurse's station, and said it was used this morning on several residents seated in the common area. 8. During an interview on 8/29/24 at 10:01 A.M., LPN E said residents should be provided with showers or bed baths in accordance with the facility's shower schedule and the resident's needs and preferences. When staff assist in completion of a shower or bed bath, they should document it on a shower sheet. The shower sheet should be given to the nurse for them to review and sign. Once reviewed by the nurse, the shower sheet goes in the binder at the nurse's station, which is reviewed by the DON. Staff should document any observed issues on the shower sheet and immediately report the issues to the nurse. 9. During an interview on 8/29/24 at 12:36 P.M. with the DON and LPN L/Unit Manager, they said the facility does have a sufficient supply of hairbrushes. Each resident should be provided with their own individual hairbrush. It would not be acceptable to use a shared hairbrush on all residents. CNAs are responsible for trimming residents' nails and cleaning residents' hands. Staff should document all bed baths and showers on shower sheets. Any area of concerns should be indicated on the shower sheet. If a resident refuses a shower or bed bath, staff should document this on the shower sheet and notify the nurse. The nurse should notify the family and physician. Ongoing refusals should be documented on the residents' care plan. MO00234383 MO00239684 MO00238437 MO00238869 MO00239680 MO00240891 MO00240930 40290 42795 46888

40290 Based on observation, interview and record review, the facility failed to provide individual activities designed to meet the interests of and to support the psychosocial well-being of each resident, in accordance with needs and preferences for three residents (Residents #32, #9, and #55). The census was 67. 1. Review of Resident #32's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/24, showed: -Resident rarely/never understood; -Dependent on assistance for mobility; -Somewhat important to resident to have books, newspapers, and magazines to read; -Somewhat important to resident to go outside to get fresh air when the weather is good; -Somewhat important to resident to participate in religious services or practices; -Very important to resident to listen to music he/she likes; -Very important to resident to do things with groups of people; -Very important to resident to do his/her favorite activities; -Diagnoses included dementia, Parkinson's disease (brain disorder causing unintended or uncontrolled movements), and depression. Review of the resident's care plan, in use at the time of survey, showed no documentation regarding the resident's needs and preferences related to activities. Review of the resident's medical record, showed no activity assessments. Review of the Activity Director's activity documentation from July and August 2024, showed: -On 8/1/24, staff documented the resident participated in Resident Photo List activity; -No other documentation of other activities offered to the resident in July or August 2024. Observations on all days of the survey, from 8/26/24 through 8/29/24, showed the resident in bed in his/her room. No observations of 1:1 activities offered or provided to the resident. No observations of the resident out of his/her room and participating in group activities. During an interview on 8/27/24 at 12:16 P.M., the resident nodded and shook his/her head to respond to questions and nodded his/her head yes when asked if he/she was bored. 2. Review of Resident #9's annual MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included Alzheimer's disease; -Interview for activity preferences: -How important is it to you to listen to music you like: Somewhat important; -How important is it to you to be around animals such as pets: Somewhat important; -How important is it to you to keep up with the news: Somewhat important; -How important is it to you to do things with groups of people: Somewhat important; -How important is it to you to do your favorite activities: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Very important. Review of the resident's care plan, in use at the time of the survey, showed: -Prefers to participate in individual activities/self-directed activities; -No goals for activities specified; -Interventions: Encourage participation and positive feedback and praise. Explore and obtain past interest and potential re-motivation. Offer activity cart/wellness on wheels supplies: Games, reading materials, audio books, music supplies, health/wellness, education, cognitive games, spiritual materials. Provide a schedule of events to post in his/her room. Provide materials, equipment or supplies for preferred activity pursuits. Provide one-on-one interventions, to include music therapy, maintenance program, health education, and sensory stimulation. Review of the resident's Activity Interest and Initial Assessment, dated 3/6/22, showed: -Activity interests and initial assessment: Bingo, books, listening to music, sitting outside for fresh air, movies, news, other TV/Internet activity interests; -Activity environment preferences: Day room/activity room; -Activity preferences that are very important to the resident: Listening to music. Participating in favorite activities. Reading books, newspapers, or magazines. Spending time outdoors; -Cognitive adaptions and interventions: Needs reminders of activities. One-on-one activities. Review of the resident's medical record, showed only one, one-on-one activity documented since admission. No further activity participation documented. Review of the resident's one-on-one visit, dated 4/2/24, showed: -Sensory stimulation, snack/hydration, nail care; -Duration: 20 minutes; -Location: In room; -Response: Resident enjoys nail care and decorations added to his/her room. Resident likes to explore with activity direction, but easily loses track of activity/attention. Activity director paints resident's nails and helps decorate the room with his/her instruction of how they want it set up. Review of the resident's Activities Quarterly/Annually Assessment, dated 7/17/24, showed: -Preferred activity setting: In-room, dining room, other. Resident roams building when not stationed in his/her room or in the dining hall; -Cognitive status: Disorganized thinking; -Behavior: Wanders intrudes on others; -Resident will roam if not supervised or informed on where to go. Resident likes being stationed at a table or by a window to enjoy nature scene; -Participates in individual leisure activities: No; -Resident likes to be near television, but does not focus on what is on/easily distracted; -Other: Listening to music, socializing with others, visiting the beauty shop, crafts; -Staff to provide: one-on-one interventions: Encouragement, provide schedule of programs; -Staff to provide activity cart visits, verbal reminders, assistance to and from groups. Observation on 8/26/24 at 2:06 P.M., showed the resident in his/her room in bed, on his/her back. The resident had a brown substance on his/her hands and under his/her nails. A strong odor of bowel movement was in the room. No activity calendar was posted in the resident's room. At 2:20 P.M., Certified Nursing Assistant (CNA) A entered the resident's room and asked the resident why you doing that. The resident said he/she cannot help it. CNA A said give me your hands. He/She wiped the resident's hands with a wipe, told the resident he/she was going to tell his/her CNA, and then exited the room and walked down the hall. At 2:55 P.M., the resident remained in bed on his/her back. At 3:09 P.M., the resident self-propelled in a wheelchair out of his/her room and into the television area near the nurse's station. At 4:04 P.M., CNA A told the resident to head to the elevator for dinner. The resident propelled away towards the elevator. At 4:22 P.M., the resident remained in the dining room and waited for dinner. At 5:49 P.M., the resident returned to the second floor from the main dining room. He/She self-propelled around at the nurse's station. CNA A then told the resident to go in to his/her room and he/she is going to clean him/her. The resident propelled to his/her room and transferred him/herself to bed. Observation on 8/27/24 at 6:46 A.M., showed the resident in a wheelchair near the 200-hall nurse's station. Observation on 8/28/24 at 6:21 A.M., showed the resident in bed, asleep. No observations of staff interacting with the resident or providing mental stimulation outside of routine resident care. 3. Review of Resident #55's medical record, showed diagnoses included stroke and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following stroke. Review of the resident's activity assessment, dated 3/18/24, showed: -Interest in games: Bingo; -Interest in arts and crafts: Coloring, drawing, painting; -Specify any types of reading/writing that patient prefers: Resident expressed interest in simple reads, such as magazines; -Interest in music: Listening to music; -Interest in socializing with others: Phone calls, social visits; -Interest in outdoor activities: Sitting outside; -Interest in TV/Internet: Game shows, movies; -Interest in other areas: Resident does not mind trying out simple activities, but prefers to be offered options to pick through; -Activity environment preferences: Day room/activity room, self-directed, resident prefers to be offered options and picks through what he/she wants; -Chooses not to participate in group activities; -Types of activities patient participates in: Activity Director brings activity cart to resident's room to pick through; -Participation level in activities: Behaviors in activities is appropriate, responsive to one to one visits; -Activity schedule preference: Afternoon, evening; -Activity preferences that are very important to resident: Listening to music, participating in favorite activities, reading books, newspapers, or magazines; -Physical adaptations and interventions: Activity Director does room visits with this resident; -Cognitive adaptions and interventions included one to one activities. Review of the resident's significant change MDS, dated [DATE], showed: -Moderate cognitive impairment; -Dependent on assistance for mobility; -Somewhat important to resident to do his/her favorite activities; -Somewhat important to resident to get outside to get fresh air when the weather is good; -Very important to resident to have books, newspapers, and magazines to read; -Very important to resident to listen to music he/she likes. Review of the resident's care plan, in use at the time of survey, showed: -Care area/problem: Resident has a need for/prefers socialization activities; -Goal and interventions: Blank; -The care plan failed to identify the resident's specific needs and preferences related to activities. Review of the Activity Director's activity documentation from July and August 2024, showed: -On 8/2/24, staff documented the resident participated with assistance in Nail Care activity; -On 8/6/24, staff documented the resident taken already, for Room Visit activity; -On 8/8/24, staff documented the resident's name on the list of Room Visits. Participation level was not indicated; -No other documentation of other activities offered to the resident in July or August 2024. Observations on all days of the survey, from 8/26/24 through 8/29/24, showed the resident in bed in his/her room. No observations of 1:1 activities offered or provided to the resident. No observations of the resident out of his/her room and participating in group activities. 4. During an interview on 8/29/24 at 12:11 P.M., the Activity Director said she has been working with the facility since February 2024. She does not have a specific list of residents who receive 1:1 activities. There is no set schedule for residents to receive 1:1 activities. Residents #32 and #55 are bed bound. She sees them in their rooms, but not on a specific schedule. When residents do not come to the group activities, she tries to see them later in that day. She does not have any additional documentation of activities provided to Residents #32 and #55. She needs to work on her documentation and getting more structure for the residents at the facility. She does not do formal activity assessments. She does do some activity assessments in the electronic medical record (EMR) when residents are newly admitted . She checked the EMR and verified there is no activity assessment for Resident #32. Residents need activities for their quality of life. 5. During an interview on 8/29/24 at 12:36 P.M. with the Director of Nurses (DON) and Licensed Practical Nurse (LPN) L/Unit Manager, they said it is hard to keep Resident #9's attention, but he/she enjoyed watching others do puzzles and interactions with staff. Activity staff should learn about the residents to see what activities they would benefit from. Residents #32 and #55 are total care and they are in bed most of the time. It is very painful for resident #32 to move. It is expected that Residents #32 and #55 receive 1:1 activities. 1:1 activities should be offered to residents who cannot or do not want to attend group activities. It is expected that all residents be offered activities in line with their needs and preferences. Activities can help improve the quality of a resident's life. Activities can help decrease behaviors. It is expected for residents at risk of social isolation to be offered activities. 6. During an interview on 8/29/24 at 2:55 P.M., the Administrator said he expects residents who are unable or unwilling to attend group activities to be offered/provided 1:1 activities. He expects the Activity Director to have a schedule/routine for providing activities to residents who are risk of social isolation.

Based on interview and record review, the facility failed to ensure the activity program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional. The census was 67. Review of the facility's Facility Assessment Tool, updated 11/2/23, showed: -Facility resources needed to provide competent support and care for the resident population every day and during emergencies included: -Therapy services (e.g., activities professionals); -In addition to nursing staff, other staff needed for behavioral healthcare and services included Activity Director; -Staff training/education and competencies: Upon hire, all staff go through formal orientation for education and competency testing; -No documentation regarding the training requirement for a qualified Activity Director. During an interview on 8/29/24 at 12:11 P.M., the Activity Director said she began working in her position with the facility in February 2024. During an interview on 8/29/24 at 2:13 P.M., the Activity Director said she had no training in activities when she began working with the facility. The Director of Nurses (DON) helped train her a little bit. She is not licensed, registered, or certified as an Occupational Therapist or in activities. This is her first job as an Activity Director. She has expressed interest in taking Activity Manager classes and this has been discussed with the facility's owner, but she has not been signed up for classes or received a certification, yet. During an interview on 8/29/24 at 2:55 P.M., the Administrator said he expects the facility to employ a qualified Activity Director. The Activity Director had some training with the previous Activity Director. There are plans for the Activity Director to get certified, but she has not signed up for classes, yet.

Based on observation, interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for three out of three medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 67. Review of the facility's Narcotic Count Change of Shift Policy, dated 1/4/23, showed: -Narcotics must be counted with the nurse or Certified Medication Technician (CMT) at the change of shift; The nurse and CMT must count the total number or cards and packages and note total on count sheet; Each care and package must be counted to ensure that the total number of narcotics is accurate and matches that total number of narcotics in the card or package; The nurse or CMT arriving for their shift and leaving their shift must initial the change of shift count sheet; If any discrepancies are noted at the change of shift the nurse or CMT are to notify the Director of Nursing (DON) or nursing management immediately. 1. Observation on 8/26/24 at 11:35 A.M., showed the Garden Unit nurses cart did not have a narcotic count sheet dated August, 2024. 2. Observation and interview on 8/26/24 at 11:40 A.M., showed the Garden Unit CMT cart did not have a narcotic count sheet dated August, 2024. CMT M said someone must have taken it because it was in the book earlier. During an interview on 8/29/24 at 11:50 A.M., the DON said the Garden Unit narcotic sheets dated August, 2024 could not be located. 3. Review of the Terrace Unit, Controlled Substance Shift Change Count Check Sheet, dated August, 2024, showed: -26 out of 50 shifts did not have a total number of packages noted; -Eight out of 50 shifts with no staff initials for the shift change count; -16 out of 50 shifts had only one staff initial for the shift change count. During an interview on 8/28/24 at 6:58 A.M., CMT U said the narcotic count is to be completed with one on-coming staff member and one off-going staff member every shift, every day. During an interview on 8/29/24 at 9:45 A.M., Licensed Practical Nurse (LPN) C said the narcotic sheets are to be available on each cart that has narcotics. The sheets should indicate the number of packages and initials of the staff counting. The narcotic count is to be completed with one on-coming staff member and one off-going staff member every shift, every day. The nurses and CMTs work twelve hour shifts. 4. During an interview on 8/29/24 at 11:50 A.M., the DON said it is expected for CMTs and nurses to count the narcotics every day on every shift. The count should be completed with one on-coming staff member and one off-going staff member. The number of packages counted is expected to be written on the shift count sheet.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals stored in a medication room refrigerator had a temperature log in one of two medication rooms observed. In addition, staff failed to keep a medication cart locked when left unattended. The census was 67. Review of the facility's Medication Storage policy dated, 6/1/18, showed: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier; -Procedures: All medications are maintained within the temperature ranges noted in the United States Pharmacopoeia (USP, an organization that sets standard for health care products) and the Centers for Disease Control (CDC); Medications and biologicals are stored at their appropriated temperatures and humidity according to the USP guidelines for temperature ranges; The facility should maintain a temperature log in the storage area to record temperatures at least one a day; Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 1. Observation and interview on 8/27/24 at 8:25 A.M., showed the Garden Unit medication room with a small black refrigerator. The refrigerator had multiple insulin pens and insulin vials. A thermometer hung on the inside of the refrigerator door. The refrigerator temperature logs were not available for review. Certified Medication Technician (CMT) M searched in the medication room and the nurses station but could not locate any temperature logs. CMT M said the Unit Manager checks the temperatures. During an interview on 8/29/24 at 12:40 P.M., the Director of Nurses (DON) and Licensed Practical Nurse (LPN) L/Unit Manager said temperatures are expected to be checked by nursing staff on the night shift every day. The temperature logs for the Garden Unit medication room refrigerator could not be located. 2. Observation on 8/28/24 at 9:12 A.M., showed the nurses' medication cart on Garden Unit was unlocked. There were multiple residents returning from breakfast, ambulating with walkers and self-propelling in wheelchairs past the unlocked medication cart. The nurse was not near the medication cart. At 9:25 A.M., LPN Y returned to the medication cart and then locked the medication cart. During an interview on 8/28/24 at 11:46 A.M., CMT T said the medication cart should be locked every time the staff member walks away from the cart. It is to ensure residents don't get into the medications cart and remove something they shouldn't. There are many confused residents on the Garden Unit and locking the medication cart ensures resident safety. During an interview on 8/29/24 at 9:45 A.M., LPN C said the medication cart is to be locked every time the staff member walks away. Locking the medication cart ensures resident safety. During an interview on 8/29/24 at 12:40 P.M., the DON said all medication carts are expected to be locked when the staff leave the cart. The DON expected all medication carts to always be locked when not in use.

46888 Based on observation, interview and record review, the facility failed to provide residents food that is palatable and at a safe and appetizing temperature for two residents (Residents #24 and #45) and residents on the Veranda hall. The sample was 17. The census was 67. Review of the facility's meal service temperatures policy, revised January 2019, showed: -Purpose: to ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service; -Policy: meals temperatures shall be monitored by the dietary manager and the cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees. Cold food shall be chilled to a temperature below 40 degrees. 1. Review of Resident #24's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/21/24, showed: -Cognitively intact; -Diagnoses included manic depression and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 8/26/24 at 10:24 A.M., the resident said he/she eats meals in his/her room. He/She said the food is not good and the temperature is usually too cold. 2. Review of Resident #45's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included major depressive disorder, anxiety disorder and Alzheimer's disease. During an interview on 8/26/24 at 11:14 A.M., the resident says the food is not good and is sometimes cold. 3. Observation on 8/28/24 at 9:10 A.M., of breakfast trays served on the Veranda hallway, showed the following: -Pancakes measured at 105.2 degrees Fahrenheit (F); -Sausage measured at 99.5 degrees F. 4. Observation on 8/28/24 at 1:02 P.M., of lunch trays served on the Veranda hallway, showed the following: -Mashed potatoes measured at 100.4 degrees F; -Chicken fried steak measured at 107.4 degrees F; -Cooked carrots measured at 95.7 degrees F. 5. During an interview on 8/29/24 at 7:25 A.M., Dietary Aide G said food should be served to residents at a safe and palatable temperature. He/She said this is important to keep residents from getting sick. 6. During an interview on 8/29/24 at 7:29 A.M., the Food Service Manager said she expected food to be delivered to residents at a safe and palatable temperature. She said this is important so residents get their food while it is still hot. 7. During an interview on 8/29/24 at 1:00 P.M., the Director of Nursing (DON) said she expected food to be delivered at the correct and palatable temperature. 8. During an interview on 8/29/24 at 3:01 P.M., the Administrator said he expected food to be delivered at a safe and palatable temperature. MO00240930

Based on observation, interview and record review, the facility failed to follow hair restraint policies while preparing food, keep the kitchen equipment clean and floors free of trash and grime. This had the potential to affect all residents who eat from the facility kitchen. The census was 67. Review of the facility's food service policy, undated, showed: -The facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes; -Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. Review of the facility's dietary cleaning schedule, undated, showed: -Items to be cleaned: walk in refrigerator are to be swept and mopped, the fryer is to be cleaned inside and out. 1. Observation on 8/26/24 at 10:10 A.M., 8/27/24 at 8:38 A.M., and 8/29/24 at 6:38 A.M. of the kitchen, showed: -The deep fryer had sticky liquid streaks on the sides of the fryer; -The dry storage room had food debris and various trash wrappers on the ground; -The walk-in refrigerator had food debris and trash wrappers on the ground under the racks. 2. Observation on 8/27/24 at 8:31 A.M., showed: -The Administrator and Maintenance Aide W walked into the kitchen during breakfast preparations. Maintenance Aide W did not wear a hairnet or beard net and walked up to the oven where eggs were being cooked. His/Her beard was approximately 1 inch long; -Dietary Aide G walked up to the steam table where the cook was dishing out breakfast plates with a hair net on that did not cover all his/her hair. His/Her hair hung out of the hairnet in the back and was approximately 10 inches long. Observation on 8/28/24 at 7:56 A.M., showed Food Service Assistant J stood over the steam table with uncovered food. His/Her hair net was pulled back and exposed approximately 1 inch of uncovered hair. 3. During an interview on 8/29/24 at 7:25 A.M., Dietary Aide G said hairnets should be worn in the kitchen and anytime staff are around food. This is important for sanitation. All kitchen staff are responsible for cleaning the floors in the kitchen, dry storage room, and walk in refrigerator. 4. During an interview on 8/29/24 at 7:29 A.M., the Food Service Manager said she would expect any staff member who comes in the kitchen during meal prep times to wear hair restraints. This includes hair nets and beard nets. Hair restraints should be worn correctly. All kitchen staff are responsible for sweeping the floors in the kitchen. The cook is responsible for cleaning the fryer. 5. During an interview on 8/29/24 at 3:01 P.M., the Administrator said he would expect the kitchen and appliances to be clean. He would expect for staff to be wearing hair restraints properly when in the kitchen.

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with central lines to include dialysis access sites and centrally inserted intravenous (IV) lines, urinary catheters, wounds requiring treatment, and tube feedings administered via a feeding tube surgically inserted into the stomach through the abdomen, for nine of nine residents sampled for EBP (Residents #68, #32, #269, #55, #16, #29, #62, #69, and #5). The facility also failed to follow proper infection control practices during medication administration when staff touched the residents' medications and stuck their fingers into stock medication bottles to dig out medication, for two residents (Residents #269 and #45). In addition, the facility failed to ensure newly hired employees had their first step purified protein derivative (PPD, used to determine the presence of tuberculosis) read prior to starting at the facility and that the PPD results were read within 24 to 48 hours after administered, for four of five newly hired employees sampled. The sample was 17. The census was 67. Review of the facility's Matrix for Providers CMS form 802, provided during the annual survey, showed: -The facility identified seven residents as receiving tube feedings: -Of those seven, five were investigated for EBP (Residents #68, #32, #269, #55, and #29) -The facility identified one resident as having a urinary catheter: -Of the one, the resident was investigated for EBP (Resident #62); -The facility identified three residents as receiving dialysis: -Of the three, two were investigated for EBP (Residents #69 and #5); -The facility identified one resident as having intravenous access: -Of the one, the resident was investigated for EBP (Resident #68). Review of the most recent pressure ulcer/wound report, dated 8/21/24, showed six residents identified as having wounds. Of those six, two were included in the sample (Residents #32 and #16). Review of CMS memo QSO-24-08-NH, dated March 20, 2024, showed: -Subject: Enhanced Barrier Precautions in Nursing Homes; -CMS is issuing new guidance for State Survey Agencies and long-term care (LTC) facilities on the use of EBP to align with nationally accepted standards; -EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status (MDROs); -The new guidance related to EBP is being incorporated into F880 Infection Prevention and Control; -EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing; -Examples of chronic wounds include, but are not limited to, pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction), diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers; -Indwelling medical device examples include central lines, urinary catheters, and feeding tubes; -EBP should be used for any residents who meet the above criteria, wherever they reside in the facility; -For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: -Dressing; -Bathing/showering; -Transferring; -Providing hygiene; -Changing linens; Changing briefs or assisting with toileting; -Device care or use: central line, urinary catheter, feeding tube; -Wound care: any skin opening requiring a dressing; -Effective Date: April 1, 2024. Observation during all days of survey, from 8/26/24 through 8/29/24, showed no EBP signs posted on any resident doors and no PPE besides gloves available to staff for any resident room in the facility. 1. Review of Resident #68's medical record, showed: -An order dated 8/3/24, custom order night shift cleanse gastrostomy tube (g-tube, feeding tube) incision site with wound cleanser and pat dry. Apply 4x4 split gauze to site and secure with tape; -An order dated 8/16/24, for vancomycin (antibiotic) 1.25 gram IV solution 275 milliliter (ml) IV every 12 hours. Observation on 8/27/24 at 9:18 A.M., showed the resident in his/her room, in bed, and covered with a blanket. At 9:26 A.M., Licensed Practical Nurse (LPN) C entered the room, put on gloves, and exposed a single lumen peripherally inserted central catheter (PICC, intravenous access line inserted into a central vein) line and said this was the IV access site used for the resident. No EBP sign was posted on the door and no gown available to staff or worn. Observation on 8/28/24 at 6:25 A.M., showed the resident lay in bed. A phlebotomist with the lab company stood at the resident's side and drew blood from the resident's left-hand. The phlebotomist wore gloves. No EBP sign was posted on the door and no gown available to the phlebotomist or worn. 2. Review of Resident #32's medical record, showed: -An order dated 6/25/24, for Peg-tube (a type of feeding tube) dressing one time per day. Cleanse PEG site with warm water, pat dry and apply split gauze. Secure with tape. Document any signs and symptoms of infection; -An order dated 8/14/24, custom order, day shift cleanse left great toe wound with wound cleanser and pat dry. Apply Mupirocin (antibiotic) ointment to open area. Cover with 2x2 gauze and wrap with small piece of Coband (wrap). Wrap with just enough to wrap around wound one time. Treatment to be done every day. Observation on 8/28/24 at 6:54 A.M., showed Certified Nursing Assistant (CNA) D entered the resident's room. The resident lay on his/her back with his/her tube feeding connected to the g-tube, but turned off. CNA D uncovered the resident and unsecured his/her brief. CNA D assisted the resident to his/her left side. Observation of the resident's buttocks showed an open area to the coccyx (tailbone area). The opened area appeared reddened and had no dressing in place. CNA D pointed to the open area. The resident had stool in the buttocks crack. CNA D cleansed the resident, removed his/her gloves, and washed his/her hands. He/She wore no gown. CNA D then assisted the resident to be repositioned to his/her back and covered. No EBP sign was located on the resident's door or gowns available to staff for use. Observation on 8/28/24 at 9:22 A.M., showed Wound Clinic Nurse F and the facility Wound Nurse entered the resident's room. The Wound Nurse cleaned the resident's bedside table with a bleach wipe and placed a clean barrier down. Both staff sanitized their hands and the Wound Nurse applied gloves. Wound Clinic Nurse F said the area to be treated is to the toe and is a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed) and is healing well. The Wound Nurse set out the supplies to provide care to the left toe. No gown was worn. Wound Clinic Nurse F uncovered the resident. The resident's tube feeding was connected to the g-tube but turned off. Wound Clinic Nurse F placed a towel under the resident's foot. He/She wore no gloves. No other PPE was worn. Wound Clinic Nurse F said he/she was not aware of any other open areas on the resident. The Wound Nurse said no one had told her of any new open areas on the resident. The Wound Nurse cleaned the resident's toe and applied the ordered treatment. As the area was treated, both staff leaned over the resident and their lab coats hung on the resident and the resident's bed. The Wound Nurse then wrapped the residents' foot with the wrap and said this helps keep the dressing on. The Wound Nurse removed her gloves and washed her hands with soap and water. The wound nurse assisted the resident to his/her right side. Wound Clinic Nurse F observed the area to the resident's coccyx and said the area is opened and presents as a stage II. He/She instructed the Wound Nurse to clean the area, apply betadine, and apply a Mepalex dressing (foam dressing with adherent edges). Wound Clinic Nurse F said the opened area was caused by the resident laying on his/her back too much. The Wound Nurse cleaned the area, applied betadine, and covered with a Mepalex dressing. The Wound Nurse removed her gloves and washed her hands. The Wound Nurse applied gloves and both staff assisted to position the resident onto on his/her right side with pillows. No EBP sign was located on the resident's door or gowns available to staff for use. 3. Review of Resident #269's medical record, showed an order dated 8/3/24, custom order, night shift cleanse g-tube site with wound cleanser and pat dry. Apply 4x4 split gauze to site and secure with tape. Observation on 8/27/24 at 7:39 A.M., showed Certified Medication Technician (CMT M) entered the resident's room and covered him/her with a blanket. He/She then grabbed the resident's arm to put a blood pressure cuff on the resident's right wrist. The resident's blood pressure was measured and the CMT F removed the blood pressure cuff. CMT M then assisted the resident to reposition in bed by grabbing his/her hands and assisting to move his/her legs. He/she wore no gown. No EBP sign was located on the resident's door or gowns available to staff for use. 4. Review of Resident #55's medical record, showed an order dated 5/1/24, for Jevity 1.5 Cal (liquid meal replacement) 70 ml per hour. At 6am start continuous feeding, at 6am to 10pm. 200 water flush every 4 hours. Observation on 8/26/24 at 1:04 P.M., showed CNA K entered the resident's room and assisted to feed the resident pureed food. No gown or gloves were worn. No EBP sign was located on the resident's door or gowns available to staff for use. On 8/27/24 at 9:18 A.M., CNA K entered the resident's room and assisted to feed the resident pureed food. No gown or gloves were worn. No EBP sign located on the resident's door or gowns available to staff for use. At 12:14 P.M., the resident lay in bed. Tube feeding Jevity 1.5 infused at 70 ml per hour. No EBP sign located on the resident's door or gowns available to staff for use. 5. Review of Resident #16's medical record, showed a wound clinic note, dated 8/21/24: -Evaluate and treat multiple pressure wounds to the right foot, right lateral (outer) foot, and sacrum (tailbone area), below the knee amputation to the left leg; -Goal: Resolve open pressure wounds with weekly visits until closure. Observation and interview on 8/28/24 at 8:40 A.M., showed the resident lay in his/her bed on his/her right side and the Wound Nurse and the Wound Clinic Nurse F stood on each side of the resident's bed with gloved hands. The Wound Clinic Nurse F said they had just completed the resident's coccyx dressing. The resident was repositioned on his/her left side by the Wound Nurse and the Wound Clinic Nurse F. The Wound Nurse removed the resident's right heel protector, and the resident's right foot and heel dressing. Wound Clinic Nurse F cleaned the resident's right foot and heel wound with a dry gauze and measured the resident's wounds. The Wound Nurse leaned over the resident's bed and cleaned the resident's right foot and heel wound with wound cleanser and redressed the resident's wounds. The Wound Nurse's name badge and uniform top touched the resident's leg and bedding while cleaning and redressing the resident's wound. The resident's heel protector was reapplied by Wound Clinic Nurse F. The Wound Nurse and the Wound Clinic Nurse covered the resident with a bed sheet and blanket. The Wound Nurse and the Wound Clinic Nurse F did not wear a gown during the resident's treatment. No EBP sign located on the resident's door or gowns available to staff for use. 6. Review of Resident #29's medical record, showed an order dated 2/6/24, for peg-tube dressing, night shift change dressing to peg tube insertion site daily, monitor for signs and symptoms of infection, notify physician of any changes. Observation on 8/27/24 at 9:15 A.M., showed the resident lay in his/her bed. CNA S applied gloves and assisted the resident to turn to his/her left side. CNA S removed the resident's brief, and the resident was checked for incontinence. The resident was dry and was repositioned by CNA S to his/her back. The resident's bed sheets were adjusted and pulled up over the resident. No gown was worn during the resident's care. No EBP sign located on the resident's door or gowns available to staff for use. 7. Review of Resident #62's medical record, showed an order dated 6/20/24, for Foley (brand of urinary catheter) and suprapubic catheter (a urinary catheter surgically inserted through the abdomen and into the bladder) every 2 shift, cleanse peri-area and catheter tubing with warm soap and water. Observation on 8/28/24 at 7:47 A.M., showed the resident in his/her room and sat in a chair. He/She wore long pants and said he/she does have a urine bag attached to his/her leg. The urine drains from a tube inserted into his/her abdomen. No EBP sign located on the resident's door or gowns available to staff for use. 8. Review of Resident #69's medical record, showed an order dated 12/18/20, for every 2 shift, monitor shunt/graft/fistula (different types of dialysis access sites) for signs and symptoms of infection and adequate circulation. Observation on 8/27/24 at 1:15 P.M., showed LPN C donned gloves and pulled the resident's gown down at the neck of and said the resident used to have a dialysis access site in his/her arm, then he/she had a blockage and now his/her dialysis site is in her upper right chest. He/She now has a double lumen central main line access site. LPN C wore gloves but no gown worn. No EBP sign located on the resident's door or gowns available to staff for use. 9. Review of Resident #5's medical record, showed an order dated 11/16/22, custom order every 2 shift, check bruit and thrill (the sound made and vibration felt as blood passes through the shunt) left forearm atrial venous (AV). Observation and interview on 8/26/24 at 11:01 A.M., showed the resident in his/her room in a wheelchair. A dressing was intact to his/her left arm, just above the elbow near the bicep area. The resident said this was his/her dialysis access site. Staff monitor it when he/she returns from dialysis. The dialysis company applies the dressing while at dialysis. It is a shunt. He/She just got back from dialysis. He/She has no concerns with care and is very happy. No EBP sign was located on the resident's door or gowns available to staff for use. 10. During an interview on 8/29/24 at 9:50 A.M., CNA K said he/she did not know what EBP is. 11. During an interview on 8/29/24 at 9:12 A.M., the Wound Nurse and unit manager said she did not know what EBPs are. She has not received any training on it. 12. During an interview on 8/29/24 at 7:51 A.M., CNA S said he/she did not know what EBP was and has received no training on it, but there is personal protective equipment (PPE) in central supply. 13. During an interview on 8/29/24 at 9:45 A.M., LPN C said he/she had no idea what EBP was, and he/she had not received any education or in-servicing on EBP. 14. During an interview on 8/29/24 at 12:50 P.M., with the DON and LPN L/Unit Manager, they said the administrator had approached them a while back about a new requirement for gowns and other PPE during routine care. They did not believe it applied to them, so it was not implemented. 15. During an interview on 8/29/24 at 2:55 P.M., the administrator said regarding the requirement for enhanced barrier precautions, he did bring it to the DONs attention, and she said she did not feel it was relevant to them. Nothing has been implemented. 16. Review of the facility's Medication Administration policy, dated 6/1/18, showed; -Oral medication administration; -For solid medications: Pour or push the correct number of tablets or capsules into the souffle' (medication) cup, taking care to avoid touching the tablet or capsule, unless wearing gloves. 17. Review of Resident #269's face sheet, undated, showed diagnoses that included: respiratory failure, gastro-esophageal reflux disease (heartburn, GERD), anxiety disorder, high blood pressure and kidney disease. Observation on 8/27/24 at 7:45 A.M., showed CMT M prepared to pass medications for residents on the Garden Unit CMT cart. CMT M removed one acid reducer 20 milligram (mg) tablet and one renal (kidney) vitamin 0.8 mg tablet out of the facility stock bottle by placing his/her ungloved fingers into the bottle to retrieve the medications and then placed the medication into a clear medication cup. CMT M removed one amlodipine (used to treat high blood pressure) 10 mg tablet; one apixaban (blood thinner) 5 mg tablet; one benztropine (used to treat muscle tremors) 0.5 mg tablet; one buspirone (used to treat anxiety) 15 mg tablet; one clonidine (used to treat high blood pressure) 0.1 mg tablet; and one escitalopram (used to treat depression and anxiety)10 mg tablet by popping the medication out of the medication bubble card into his/her ungloved hand and then placing it into the clear medication cup. CMT M then placed the medication in a clear sleeve and crushed medications. CMT T then mixed the crushed medication in pudding and administered the medications to the resident. 18. Review of Resident #45's face sheet, undated, showed diagnosis that included: Alzheimer's disease, depression, and anxiety. Observation on 8/27/24 at 7:54 A.M., showed CMT M removed one loratadine (medication used to treat allergy symptoms) 10 mg tablet out of the facility floor stock bottle with ungloved fingers, placed it in a clear medication cup and administered the medication to the resident. 19. During an interview on 8/28/24 at 11:46 A.M., CMT T said medications that are in the facility stock bottles are to be dispensed by shaking the medication into the lid of the bottle and then place it in the medication cup. The medications should not be dispensed by placing fingers in the medication bottle. The bubble pack medications are to be popped directly into the medication cup. The medications should not be placed in the staff's hand first. The resident's medication should never be touched prior to administration. It is poor infection control practices. 20. During an interview on 8/29/24 at 9:45 A.M., LPN C said the medication should be directly placed into the medication cups. Staff should not be touching the medication prior to giving it to the resident. If they do have to touch the medications, then they should be wearing gloves. 21. During an interview on 8/28/24 at 12:50 P.M., the DON said that staff are expected to use proper infection control practices and not directly touch the resident's medication prior to administration. 22. Review of the facility's undated PPD Tuberculosis Testing and Screening policy for employees, showed: -A two step PPD skin test is to be administered on all new employees prior to employment with the first step being completed prior to start date, unless the test was performed within the past month; -If the initial test is negative after 48 to 72 hours, the second PPD test is to be given. Review of Staff AAA's employee file, showed: -Date of hire 10/2/23; -First step PPD administered on 10/2/23; -First step PPD read late on 10/6/23. Staff BBB's employee file, showed: -Date of hire 6/6/24; -First step PPD administered on 6/5/24; -First step PPD read negative on 6/8/24. Staff CCC's employee file, showed: -Date of hire 7/5/24; -First step PPD administered on 7/5/24; -First step PPD read negative on 7/8/24. Staff DDD's employee file, showed: -Date of hire 11/30/23; -First step PPD administered on 11/30/23; -First step PPD read late on 12/4/24. During an interview on 8/27/24 at 1:04 P.M., the HR/Staffing Coordinator said the first date working in the facility does not necessary correspond to the date of hire. She will provide the first date worked for the sampled staff. Nursing staff is responsible for new employee PPDs. Review of the list of staff first date worked, showed Staff AAA, Staff BBB, Staff CCC, and Staff DDD's date of hire was the same as their first date worked. During an interview on 8/29/24 at 12:50 P.M., with the DON and LPN L/Unit Manager, they said they way they have done it, is make sure the first step is given by date of hire, but they are not reading it before the staff start. They were not aware of the requirement that the first step be read prior to starting. PPDs should be read within 2-3 days. 40290 42795

42247 Based on interview and record review, the facility failed to ensure staff provided cardiopulmonary resuscitation (CPR, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased) for one resident (Resident #80) per the resident's wishes. Resident #80 was found to be unresponsive and without signs of life. Staff began CPR, then stopped. When Emergency Medical Services (EMS, 911, first responders, paramedics, police officers and/or fire fighters) arrived, staff were not performing CPR. The sample was 19. The census was 92. The Administrator was notified on [DATE] at 1:44 P.M. of an Immediate Jeopardy (IJ) of past non-compliance which occurred on [DATE]. On [DATE], the Administrator became aware of the deficient practice to not administer CPR to a resident who wished to receive it. On [DATE] through [DATE], the facility in-serviced staff on the code status policy. The IJ was corrected on [DATE]. Review of the facility's Advance Directives Policy, undated, showed: -Definitions: -Code Status, refers to the level of medical intervention a person wishes to have started if their heart or breathing stops; -Do Not Resuscitate (DNR) order, refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest. Existence of an advance directive does not imply that a resident has a DNR order. The medical record should show evidence of documented discussions leading to a DNR order; -Advance Directives: -An Advanced Directive allows an individual to communicate health care preferences in the event he/she is no longer able to make those decisions. Many view advanced care planning as a way to help ensure that wishes about end of life care are honored; -Advanced Directives can be as simple as determining code status upon admittance into the facility; -The term code status essentially describes what type of intervention (if any) a health team will conduct should their resident's heart stop beating or lungs stop moving air in the event of a medical emergency; -Upon admission, every resident or resident representative is asked to determine code status-Full Code (CPR is performed when the resident experiences a catastrophic event such as cardiac/respiratory arrest) or DNR; -In the event a code status is under discussion or a determination is pending, the resident is considered a Full Code. Review of the facility's Adjustment and Addition to Code Status Policy, dated revised [DATE], showed: -When the desired code status is established by the resident if able, or family/responsible party if the resident is unable, a copy of the code status will be made for the medical records to scan into the computer. The nurse on the wing of the resident will be informed of the code status to be put in the computer. A green name tag will be placed outside the door of the resident indicating a full code and a red name tag will be outside the door indicating a no code status; -Nursing will follow the code status established by the resident and or family/responsible party. If a resident is full code and the resident codes (term used for cardiopulmonary arrest is happening to a patient) during their stay at the facility, the nursing staff will initiate the code (begin CPR, if the resident was a full code) and call 911. When 911 arrives and takes over the code process of full code, the full code process will not stop until EMS has determined that the resident expired or the resident has recovered and is no longer needed; -If a resident that was on hospice services while at the facility, needs an updated code status due to the change in condition and/or resident and or family/responsible party preference, the Hospice Company may initiate a new code status sheet that will be accepted as the official code status once completed. If the Hospice Company faxes the new code status sheet to the facility, a copy will be made and sent to medical records to be scanned into the computer and original placed in the hard chart. The nurse on the wing will put orders into the computer and nursing will follow the desired updated code status of the resident and or responsible party. The facility will communicate with the Hospice Agency to get the desired code status into the hard chart and computer once hospice has theirs completed. However, until hospice completes their code status, the facility will follow the desired code status established by the resident and/or family/responsible party; -The resident can change the code status at any time during their stay at the facility and if the resident is unable to sign the family/responsible party can update or change the code status at any time during the stay at the facility. If the code status is changed during the stay at the facility the orders will be changed in the computer by the nurse and the new name tag with the desired code status will be put outside the resident's door. Review of the Policy and Procedure binder, revised on [DATE] and located at the suites nurses' station, reviewed on [DATE] at 9:03 A.M., showed: -Purpose: Assure all residents at the facility have an updated code status that reflects the wishes of the resident and/or responsible party and also reflects the physician orders; -Procedure: upon admission and on the annual anniversary of the resident, social services will have completed a code status sheet, in purple color, with the wishes of the resident and/or responsibility party. The social worker will give the completed code status to the nurse on the division of the resident. The nurse will get orders form the physician to reflect the desires of the resident and/or the responsible party on the code status sheet. The physician will then sign the code status sheet; -Any resident that does not have a code status sheet in their chart will be considered a full code until the code status sheet has been added to the chart. Review of Resident #80's medical record, showed: -Resident's Code Status policy, dated [DATE], showed Level 1: Full Code: -(A) begin CPR, every measure would be taken to resuscitate the individual, was circled; -(B) 911 will be called, was circled; -The form was signed by the resident and dated [DATE]; -The form was signed by the medical doctor; -An order, dated [DATE], for Full Code; -No physician order for hospice services. Review of the care plan, dated [DATE], showed: -Problem: Advance Directive/code status evidence by social services discussed advanced directives and code status with resident and/or resident representative; -Goal: Facility will discuss advanced directives with the resident and/or responsible party upon admission. The facility will follow the resident's advanced directive; -Interventions: Assure advanced directives are discussed and appropriate paperwork is obtained and a copy of the advanced directive is scanned into the electronic medical record or placed in a code status binder located at the nurses station. Review of the Resident/Patient Transfer Form, dated [DATE], showed the resident was a full code. Review of the Social Services note, dated [DATE] at 9:56 P.M. showed, the resident passed away here at the facility this evening. He/She coded and the nurse called the code and started CPR. Licensed Practical Nurse (LPN) J called 911 while in the room and started CPR. LPN I, said there was discussion about hospice with Resident Representative B, especially over the multiple hospitalization s. LPN I asked staff to stop CPR while he/she called the family about hospice. Resident Representative B, said, no the resident was not on hospice and he/she was a full code. LPN J and staff were going to restart CPR again and that is when 911 arrived and they began CPR again. Resident Representative B told the Administrator, he/she knew that they had talked about hospice and DNR in the past but he/she never committed to hospice or DNR. Review of the resident's progress notes, showed on [DATE] at 2:36 A.M., resident was observed absent of life at shift change at 7:28 P.M., 911 was immediately contacted and CPR initiated. Prior nurse informed that there was a change to the resident status and that the resident was hospice. Hospice was contacted for verification at 7:35 P.M., stating discussion was had but resident was not on file. Family was contacted at this time by prior nurse to confirm hospice status and family informed the nurse that resident was in fact not on hospice. Staff re-entering room to restart CPR as EMS arrived at 7:32 P.M. EMS arrived on scene at 7:32 P.M. and CPR was re-initiated under their call. Family was at facility at that time. Paramedics called time of death at 5:56 P.M. from hospital Medical Doctor. Review of the police report, dated [DATE] at 7:28 P.M., showed: -On [DATE] at approximately 7:28 P.M., the Police Officer was dispatched to the facility in reference to an unresponsive resident. Communications advised staff was in the room starting CPR; -Upon the Police Officer's arrival, he/she made contact with Paramedics. It should be noted all doors to the facility were locked and were not opened for approximately one minute after all units arrived on the scene; -Once inside the facility, all units proceeded to the provided room. Upon entry to the room, the Police Officer noticed the room empty and no staff members were providing aid to the resident; -The resident was lying in a supine position (face pointing upward) on the bed; -Paramedics began to provide aid and advised the resident did not have a pulse. The delay between communications receiving the call and the aid being provided was approximately 10 minutes; -The Police Officer asked nearby staff members where a nurse was and none of the staff knew. The Police Officer eventually contacted a nurse, identified as LPN I. LPN I advised he/she had just arrived at work moments prior and he/she was not informed of this incident; -The Police Officer made contact with the charge nurse, LPN J. The Police Officer asked LPN J why none of the staff had provided aid to the resident. LPN J advised it was due to the belief the resident had been on hospice. It was determined after reading the paperwork that the resident was not on hospice nor did the resident have a DNR. Review of Ambulance Run Report 1, dated [DATE], showed: -At 7:30 P.M., an alarm was received; -At 7:34 P.M., the unit arrived at the facility; -Remarks: Upon arrival crew met a Police Officer in parking lot and attempted to enter main lobby but doors were locked. About 90 seconds later a staff member gave crew access along with two other units. We were led to a room and found an unattended resident in bed lying supine in cardiac arrest (a sudden, sometimes temporary, cessation of function of the heart). No staff members were present with patient. Advanced Cardiac Life Support (ACLS, clinical guidelines for the urgent and emergent treatment of life threatening cardiovascular conditions) protocol initiated immediately. Two other units assisted with care. The staff member who let crews in the building was told to find the nurse for the patient, and advised patient was in cardiac arrest. Crews worked code for approximately 20 minutes until the hospital Medical Doctor was contacted by one of the units who advised to stop life saving measures per MD. Staff admitted after the code that they thought the patient had a DNR but later found out that he/she didn't have one on file. They admitted to not performing CPR or any care for the patient. Review of Ambulance Run Report 2, dated [DATE], showed: -Dispatch was notified at 7:29 P.M.; -The unit was on scene at 7:36 P.M. and was at the resident at 7:38 P.M.; -Narrative: -Three units responded to the facility for a cardiac arrest. In route dispatch updated out call notes to inform us that this patient was just placed on hospice and compressions were withheld by the staff waiting for our arrival; -Upon arrival to the scene, one unit was already on scene and entering the building, they indicated they were slightly delayed to the patient due to no nursing staff being present and they were not able to open the door. Once we entered the facility the first crew member from Unit One had entered the patient's room and they indicated no nurse was in the room and the rest of the responders yelled out attempting to locate the patient's nurse to meet us at the room and verify if this was a full code or if the patient was a DNR but were unable to find anyone. After 30 seconds or so the nurse returned and stated the patient was a full code and he/she was trying to find paperwork to see if the resident was recently placed on hospice. Compressions (CPR) were immediately started; -The patient's nurse returned to inform us that the patient was not on hospice and was in fact a full code so they were unsure where they heard that from; -A crew member from Unit One who talked to the nurse who called, said they found the patient down and last known well was 6:30 P.M., over one hour prior. He/She immediately began compressions, yelling for help and was told the patient was just recently placed on hospice and compressions were discontinued until we had arrived; -The patient was pronounced deceased at 7:56 P.M. Review of the facility's investigation, dated [DATE], showed: -On [DATE] at 7:28 P.M., the resident was found without a pulse. 911 was immediately contacted. CPR initiated immediately. The Day Nurse informed the Night Nurse to hold on. The Day Nurse thought there was a possible change in the code status from full code to a DNR. CPR was stopped. Hospice and family were contacted immediately for verification. Family reassured staff the resident was still a full code and that hospice care had not been decided. At 7:32 P.M. EMS had arrived and reinitiated CPR. Time of death was called at 7:56 P.M. with cause of death myocardial infarct (heart attack). During an interview on [DATE] at approximately 9:00 A.M., Nurse Aide (NA) M said he/she would know a resident's code status by looking in the book by the nurses' station and/or by the color of the name tag outside the resident's room. Green meant the resident was full code and red meant the resident was DNR. If he/she did not know a resident's code status he/she would do CPR. During an interview on [DATE] at 8:24 A.M., Certified Medication Technician (CMT) N said the resident's code status could be found in the resident's chart and on their door. If a resident was found unresponsive, he/she would tell the nurse. During an interview on [DATE] at 10:25 P.M., LPN J, said on [DATE], he/she went into the resident's room at approximately 7:28 P.M. or 7:29 P.M. Nurse J found the resident, unresponsive and without signs of life. LPN J went to the doorway and yelled out, then started CPR, along with Certified Nurse Aide (CNA) K. LPN J called 911 from the resident's room, while LPN J was on the phone with 911, LPN I said the resident was on hospice. LPN J relayed this information to 911. 911 said they were already in route and they were coming. LPN J left the resident's room to overhead page the code and to verify the resident was receiving hospice services. The Hospice Company said they had information on the resident but the resident was not on hospice. LPN I called the family and the family verified the resident was not on hospice and the resident was a full code. After learning this information, LPN J grabbed the crash cart and was heading towards the resident's room when EMS was coming into the building. LPN J asked if he/she could step outside for a few minutes and they said yes. LPN J said CPR was stopped for approximately three to five minutes. The resident's name tag on his/her door was green. During an interview on [DATE] at 10:14 A.M., Resident Representative A said on [DATE], an employee said, CPR was stopped while staff checked to see if the resident was on hospice and/or DNR and to call the paramedics. When the paramedics arrived at the facility they could not find anyone. The police said they found the resident alone and curled up in a ball and they found the nurse on the patio outside. During an interview on [DATE] at 11:20 A.M., the Director of Nursing (DON) said on [DATE], LPN I worked the day shift and LPN J was working the night shift. LPN J found the resident without signs of life and yelled out, immediately started CPR and called 911. LPN J said LPN I said to stop CPR because he/she thought the resident may have changed their code status due to recent hospitalization s. CPR was stopped. The family and hospice were called to verify the resident's code status, and the DON was called. About the same time the code status was verified, EMS was coming into the building. EMS restarted CPR. The DON said staff should have continued CPR until EMS arrived. She would expect for staff to follow the facility's policies and procedures. The resident's name tag was green and the resident's code status in the computer and on the resident's code status sheet all showed the resident was a full code. The staff were educated on code status, door name tag colors, checking the chart for a code status form and checking the Medication Administration Record (MAR) for the code status. In-services were completed on [DATE] and [DATE]. During an interview on [DATE] at approximately 11:30 A.M., the Administrator said he was at the facility the evening of [DATE] and heard LPN J call a Code Blue (Cardiac or respiratory arrest or medical emergency). LPN J was doing CPR. Prior to this incident, LPN I said he/she overheard the family say something about hospice. He/She told this to LPN J and told LPN J to hold off on CPR, while he/she checked the resident's code status. During an interview on [DATE] at 12:24 P.M., CNA K said if a resident had a green sign on their door, that meant the resident was a full code. On [DATE], he/she was coming out of another resident's room when he/she heard LPN J yell Code Blue. Both LPN J and CNA K went into the resident's room. CNA K said he/she began CPR and LPN J left the room to get a phone. CNA K did CPR for approximately one minute, until LPN J came back into the room and took over. CNA K left the room. He/She did not know if anyone else came into the room to assist with CPR after he/she left the room. He/She did not know if anyone was doing CPR when EMS arrived. He/She did hear someone talking about whether or not they should continue CPR. During an interview on [DATE] at 12:02 P.M., the Nurse Practitioner (NP) said all residents should have a code status. If a resident was found unresponsive and there were no signs of life, he would expect for staff to start CPR. If staff were concerned there was a change in the resident's code status, he would expect for one staff member to verify the code status while the other staff member continued CPR. He would expect for staff to continue CPR until they were 100% certain of the resident's code status. MO00216404 MO00216401

Based on observation, interview, and record review, the facility failed to provide appropriate care and treatment to prevent the development of pressure ulcers and/or aide in healing and prevent the deterioration of existing pressure ulcers. The facility identified eight residents with pressure ulcers, five were sampled, four originally sampled and one from an expanded sample, and problems were found with all five. The facility failed to ensure staff completed routine assessments, notified the physician timely, monitor, document and track pressure ulcers. One resident was admitted to the facility without pressure ulcers, staff identified a pressure ulcer to his/her right buttock, but failed to monitor, assess, and notify the physician. The resident continued to develop new unstageable pressure ulcers and the existing pressure ulcers worsened. The unstageable pressure ulcers to the resident's buttocks were large and had a foul odor (Residents #16, #9, #32, #10, and #14). The census was 100. Review of the facility Pressure Ulcer: Prevention and Findings Reporting policy, dated 2/25/14, showed the following: -Purpose: To prevent pressure ulcers by identifying residents at risk, and to treat an identified pressure ulcer as soon as possible and initiate treatment; -The Braden Scale is used as an instrument to identify skin at risk for breakdown. The Braden Scale is done upon admission and quarterly; -The Braden Scale should be done when there is a change in condition (examples: Weight loss, ADL decline, change in mobility); -The CNA is to observe and report any areas of change in appearance on the skin during routine daily care and during resident showers; -The CNA must document on the shower record, sign, and have the charge nurse sign and review. Report to charge nurse for further assessment and follow-up; -The charge nurse is to do a skin assessment at least weekly, and at any time a care provider reports a change in the appearance of the skin (e.g. during routine care, showers); -The charge nurse will complete an initial approximate measure and description of the wound in the nurse's notes; -If there is a need for a treatment, the charge nurse and or wound nurse will phone the physician and implement the order as described; -The treatment will be placed on the TAR at the time the physician order [REDACTED].>-The wound nurse will assess the skin area of concern, and will review the physician order [REDACTED].>-The wound nurse will confirm and document wound and document in the wound care section of the medical record; -The wound nurse will document all treatments on the TAR, just as the charge nurse would be expected to perform; -The charge nurse and wound nurse will review the patient for a change in condition and implement the appropriate skin care interventions (associated with the Braden Scale) and or ordered by the physician; -CNAs will be educated on skin care observations during routine care and shower care and associated reporting to the charge nurse; -The CNAs will be educated on the prevention of pressure ulcers (e.g. incontinent care, repositioning, mobility, weight loss, skin inspections); -The charge nurse will be educated on: Skin assessments (use of existing form/tool/instrument), writing the physician order, executing the physician orders [REDACTED].), putting an immediate plan of care in place (low air loss mattress, turn schedule, skin barrier, and the proper selection of skin care protocol based on the wound observation), identification of residents at risk, use of the Braden Scale on admission, readmission, and change of condition. 1. Review of Resident #16's hospital History and Physical, dated 12/27/16 at 8:50 P.M., showed the following: -History of present illness: Reports he/she fell at home three times, after the last fall was unable to get up and spent the night on the floor; -Assessment/Plan: Urinary tract Infection [MEDICAL CONDITION], rhabdomyolysis (a breakdown of muscle tissue, due to a direct or indirect muscle injury, that causes the release of a damaging protein into the blood) likely due to prolonged immobility, frequent falls: physical therapy (PT) and occupational therapy (OT); -Weight 116 pounds (lbs). Review of the resident's hospital discharge summary, dated 12/30/16, showed the following: -Discharge Diagnosis: [REDACTED].>-Assessment and Plan: rhabdomyolysis likely due to prolonged immobility. OT and PT to evaluate and treat. Review of the resident's admission nurse's note, dated 12/30/16 at 2:40 P.M., showed the following: -[DIAGNOSES REDACTED]. -Skin assessment: Right elbow scab 5.8 centimeters (cm) by 2.5 cm, left elbow abrasion 1.3 cm by 2.4 cm, left elbow skin tear 2.0 cm by 3.0 cm, three back abrasions 11.0 cm by 4.0 cm, 9.5 cm by 4.0 cm and 15.5 cm by 5.0 cm, left shoulder abrasion 2.2 cm by 1.0 cm, two right shin abrasions 5.0 cm by 3.0 cm and 1.0 cm by by 5.0 cm, left knee scab 1.5 cm by by 1.0 cm and large abrasion to coccyx and buttocks 10 cm by 7 cm; -Order received for triple antibiotic ointment (TAO) with dry dressings to scabs and abrasions. Review of the resident's admission physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -PT and OT to evaluate and treat; -Nutritional supplement three times per day (line drawn through order with the word clarified 12/31/16), written in; -Daily weights. Review of the resident's undated Interim Admission Care Plan, addressed falls and nutrition/or hydration risk. It did not address any skin integrity issues or the multiple skin abrasions and skin tears. Review of the resident's treatment administration record (TAR), dated 12/30/16, showed no documentation regarding the abrasions or skin tears. A 12/31/16 weight of 117.4 lbs. Review of the facility's Weekly Pressure/Wound Tracking Report, dated 12/30/16, showed no entries for the resident at all. Review of the resident's undated POS, showed the following orders dated 12/31/16: -Clarification nutrition supplement: Med pass (a concentrated nutritional supplement) 90 milliliters (ml) by mouth three time per day; -Cleanse areas to right elbow, left elbow, left shoulder, right knee, right shin, and left knee, apply TAO and cover with bordered dressing (a self adhesive all-in-one dressing proven to minimize patient pain and trauma to the wound and surrounding skin); -Cleanse large abrasion to buttock, apply TAO, and cover with large foam dressing; -No treatment for [REDACTED]. Review of the resident's History and Physical, dated 12/31/16, showed the following: -Chief complaint: [AGE] year old with a recent hospitalization secondary to falls, three times in a day, and apparently spent the night on the floor. Presents with urinary tract infection and rhabdomyolysis secondary to falls; -Skin: No open areas; -Rehab potential: Fair, used a cane at home, occasionally used a walker; -Full code. Review of the resident's Weight and Vital Sign Tracking Tool, showed a 1/1/17 weight of 104 lbs. Review of the resident's Braden Scale (used for predicting pressure sore risk), dated 1/1/17, showed a score of 21, (mild risk: 15-18, moderate risk: 13-14, high risk: 10-12, severe risk: less than nine). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/5/17, showed the following: -No short/long term memory problems; -BIMS (Brief Interview for Mental Status, used to determine cognitive status) score of 15 (13-15 indicates intact cognition); -Required limited staff assistance for bed mobility; -Required extensive staff assistance for transfers, dressing, personal hygiene, and bathing; -Incontinent of bowel and bladder; -Skin: No pressure ulcers; -Occupational therapy; -Physical therapy; -Active discharge planning in place for return to the community. Review of the resident's skilled daily nurse's note, dated 1/6/17, 7:00 P.M. to 7:00 A.M. shift, showed a red area on buttocks, treatment in place. Review of the facility's Weekly Pressure/Wound Tracking Report, dated 1/7/17, showed no entry for the resident at all. Review of the first page of the resident's TAR, dated 1/2017, showed the following: -Front of TAR: Cleanse scabbed areas to the right elbow, left elbow, left shoulder, left knee, and right knee, apply TAO, cover with bordered dressing. Staff initialed as complete 1/1, 1/3, 1/5-9/17; -No documentation regarding the three back abrasions; -Back of TAR: Blank. Review of the second page of the resident's TAR, dated 1/2017, showed the following: -Front of TAR: Cleanse large abrasion to buttock, apply TAO, cover with bordered dressing. Staff initialed as complete 1/1, 1/3, 1/5-9/17. Blank 1/2 and 1/4/17; -Back of TAR: Week one: 1/5/17: Skin warm and dry to touch with no new open areas. Current treatment remains in place and effective. Review of the resident's certified nurse aide (CNA) bathing record, dated 1/9/17, showed the following: -Instructions: Staff must sign and complete this document for quality assurance purposes. Staff must review with their nurse to ensure communication of issues that are found; -Front of diagram: blank; -Back of diagram: Circle on back with a line drawn to the word redness, circle drawn in the middle of the buttocks with a line drawn to the word open area, the word old circled. Written in scabs all over extremities, healing abrasions; -Signed by the CNA; -No signature by the nurse. Review of the first page of the resident's TAR, dated 1/2017, showed the following: -Cleanse scabbed areas to the right elbow, left elbow, left shoulder, left knee, and right knee, apply TAO, cover with bordered dressing; -1/10/17, open to air, healed written in by staff after right elbow, left shoulder, left and right knee, right shin; -Back of TAR: Blank. Review of the second page of the resident's TAR, dated 1/2017, showed the following: -Front of TAR: Cleanse large abrasion to buttock, apply TAO, cover with bordered dressing. Staff initialed as complete 1/10-1/24/17, Blank: 1/25/17. Written in under initials for dates of 1/19-1/24/17 and 1/26-1/31/17, leave open to air; -Back of TAR: Second week: 1/12/17: Skin warm and dry to touch with no new open areas. Area to buttock remains, current treatment in place, healing; -Documentation for Week three and four: Blank. Review of the resident's Weight and Vital Sign Tracking Tool, showed a 1/10/17 weight of 105 lbs. Review of the resident's Nutritional Assessment, dated 1/11/17, showed the following: -Supplements: Med Pass 90 ml three times per day; -Weight 118 lbs, height 63 inches; -Recommended weight range: 112-136 lbs; -Assessment: Resident is within recommended weight range. No decubitus (pressure ulcers); -Plan: Change diet order to no added salt (NAS). Will monitor weights and labs; -This was the only nutritional assessment or note in the medical record. Review of the facility weekly pressure/wound tracking reports, showed no report for the week of 1/14/17. Review of the resident's physician's progress note, dated 1/16/17, showed the following: -Resident reports doing better with therapy, able to stand up with assistance and walk in therapy; -Resident reports he/she needs assisted living and is working with social services; -Plan: Falls: Will need assistive devices such as a walker, continue PT and OT, possible assisted living facility. UTI: Asymptomatic, no fevers. Diabetes: Continue accuchecks, low dose of [MEDICATION NAME] (medication used to treat diabetes). [MEDICAL CONDITION]: Continue [MEDICATION NAME] (medication used to treat enlarged prostate). Review of the resident's skilled daily nurse's note, dated 1/17/17, 7:00 P.M. to 7:00 A.M. shift, showed the following: -Incontinent of urine; -Coccyx reddened, dressing dry and intact to coccyx area. Review of the facility weekly pressure/wound tracking reports, showed no report for the week of 1/21/17. Review of the resident's CNA Bathing Record, dated 1/23/17, showed the following: -Front of diagram: Circle drawn on left arm; -Back of diagram: Circle drawn on middle of back; -Note: The words rash, redness, and skin tear checked; -Signed by the CNA and nurse. Review of the resident's Weight and Vital Sign Tracking Tool, showed a 1/23/17 weight of 105.8 lbs. Review of the resident's care plan, dated 1/24/17, showed it did not address any skin integrity issues or the resident's reddened areas, rash or skin tears. Review of the resident's physician's progress note, dated 1/26/17, showed the following: -Recent fall from wheelchair, denies acute pain, weight 105.8 lbs; -Assessment/plan: Falls, no acute fracture, resident reports doing better with walker in therapy, discharge planning continues, resident looking at assisted living facilities. Review of the facility weekly pressure/wound tracking reports, showed no report for the week of 1/28/17. Review of the resident's nurse's note, dated 1/29/17, 7:00 A.M. to 7:00 P.M. shift, showed the following: -Pressure ulcer to right buttock; -Measured: 1.0 cm by 0.4 cm; -Area cleaned and dry dressing applied; -Call placed to physician to make aware, new order received to cleanse area to right buttock, cover with dry dressing daily until healed. Review of the resident's undated POS, showed an order dated 1/29/17, to cleanse area to right buttock and cover with a dry dressing daily until healed. Review of the resident's TAR, dated 1/2017, showed the following: -Front of TAR: Order dated 1/29/17. Cleanse area to right buttock, cover with dry dressing; -Staff initialed as complete on 1/29 and 1/30/17. Blank on 1/31/17; -Back of TAR: No documentation/description regarding the right buttock area. Review of the resident's Weight and Vital Sign Tracking Tool, showed a 1/30/17 weight of 104 lbs. Review of the resident's TAR, dated 2/17/17 through 2/28/17, showed the following: -Front of TAR: Cleanse large abrasion to buttocks and apply TAO and cover with large foam dressing. Line drawn through with the word healed written in; -Cleanse area to right buttock with dermal wound cleaner and apply dressing every day. Staff initialed as complete: 2/1, 2/2, 2/4, 2/6 through 2/14, 2/16 through 2/22, 2/24 through 2/27/17. Blank: 2/3, 2/5, 2/15, 2/23 and 2/28/17; -Undated handwritten order for skin assessment weekly, with boxes marked to be done on 2/4, 2/11, 2/18 and 2/25/17: All of the boxes were blank; -Back of TAR: Blank. Review of the resident's CNA Bathing Record, dated 2/2/17, showed the following: -Front of diagram: Multiple circles drawn on front of body with the word rash written in. -Back of diagram: Circle drawn on middle of back with the word rash written in. Circle colored in on the entire buttocks with a line to the word red; -Note: The words rash and redness checked, the word old circled; -Signed by the CNA and nurse. Review of the resident's nurse's notes, dated 2/3/17 at 9:00 A.M., showed the following: -Small open area noted above the rectal area; -No documentation of a description or measurement of the open area. Review of the facility weekly pressure/wound tracking reports, showed no report for the week of 2/6/17. Review of the resident's Weight and Vital Sign Tracking Tool, showed a 2/6/17 weight of 104 lbs. Review of the resident's skilled nurse's notes, dated 2/10/17, no time, showed the following: -Foam dressing to buttocks changed, no drainage noted on dressing; -No documentation of a description or measurement; -No further documentation regarding the resident's skin until 2/24/17. Review of the resident's Weight and Vital Sign Tracking Tool, showed a 2/13/17 weight of 107 lbs. Review of the facility weekly pressure/wound tracking reports, dated 2/13/17, showed no entries for the resident. Review of the resident's Weight and Vital Sign Tracking Tool, showed the following: -2/14 through 2/18/17: 108 lbs, 2/19/17: blank; -2/20/17: 103 lbs. Review of the facility weekly pressure/wound tracking reports, dated 2/20/17, showed no entries for the resident. Review of the resident's Weight and Vital Sign Tracking Tool, showed the following: -2/21/17: 104.4 lbs; -2/22/17: 103 lbs. Review of the resident's physician's progress note, dated 2/23/17, showed the following: -Recent increase in anxiety; -Weight 104.4 lbs, now at the feeder table, appetite fair; -Recently treated for [REDACTED]. -Plan: Right upper extremity [MEDICAL CONDITION], improved with [MEDICATION NAME] (antibiotic). Protein calorie malnutrition, now at the feeder table, appears to have declined; -No documentation regarding open areas above rectal area. Review of the resident's undated POS, showed following orders, dated 2/23/17: -Revisit the code status, resident did not want to go to the hospital recently; -HIV (human immunodeficiency virus) test, [DIAGNOSES REDACTED]. -Recheck weight, [DIAGNOSES REDACTED]. Review of the resident's Weight and Vital Sign Tracking Tool, showed the following: -2/23/17: blank; -2/24/17: 100 lbs. Review of the resident's skilled nurse's notes, dated 2/24/17, no time, showed the following: -Seen by the physician on 2/23/17; -[DIAGNOSES REDACTED]. -Redness noted to coccyx, buttocks, and bilateral gluteal folds; -No documentation whether staff notified the physician of the redness to the coccyx, buttocks, or bilateral gluteal folds; -No documentation of measurements or description of the redness to the coccyx, buttocks, or bilateral gluteal folds; -No further documentation regarding the resident's skin until 3/5/17. Review of the resident's Weight and Vital Sign Tracking Tool, showed 2/25 though 2/27/17, blank. Review of the facility weekly pressure/wound tracking reports, dated 2/27/17, showed no entries for the resident. Review of the resident's Weight and Vital Sign Tracking Tool, showed a 2/28/17 weight of 102.3 lbs. Review of the resident's nurse's notes, dated 2/28/17, showed no documentation regarding the resident's weight. Review of the resident's Weight and Vital Sign Tracking Tool, showed a 3/5/17 weight of 101 lbs. Review of the resident's nurse's notes, dated 3/5/17, no time, showed the following: -Three pressure ulcers noted to the resident's coccyx and buttocks, new order obtained for dressing change; -No documentation, description, or measurement of three pressure ulcers; -No documentation whether staff notified the physician of the resident's weight. Review of the resident's POS, dated 3/5/17, showed the following; -3/5/17: Insert Foley catheter (a thin, sterile tube inserted into the bladder to drain urine); -Cleanse pressure ulcer to coccyx with dermal wound cleanser (DWC), apply Santyl (an enzymatic [MEDICATION NAME] ointment to help break down and remove dead tissue from wounds) and calcium alginate (specialized dressing used to help remove excess wound drainage), cover with foam dressing daily and as needed (PRN) when soiled; -Cleanse pressure ulcer to left gluteal fold with DWC, apply Santyl and calcium alginate and cover with foam dressing daily and PRN when soiled; -Cleanse pressure ulcer to right gluteal fold with DWC, apply Santyl and calcium alginate and cover with foam dressing daily and PRN when soiled; -Mobile Wound Solution (MWS) to evaluate and treat. Review of the resident's undated TAR, showed the following: -Front of TAR: 3/5/17: Cleanse pressure ulcers to coccyx, left gluteal fold, and right gluteal fold with DWC, apply Santyl and calcium alginate, cover with foam dressing daily and PRN when soiled. Staff documented as complete from 3/5 through 23/17; -Undated order: Barrier cream to bilateral buttocks every shift and PRN (First time documented on TAR, not documented on the POS). Staff documented as complete 7:00 A.M. to 7:00 P.M.: 3/1 through 3/31/17 and 7:00 P.M. to 7:00 A.M.: 3/1 through 3/29/17; -Undated order: Skin assessment weekly: Blank; -Back of TAR: Blank. Review of the resident's Weight and Vital Sign Tracking Tool, showed a 3/6/17 weight of 101 lbs. Further review of the resident's nurses notes showed: -On 3/6/17 at 11:00 A.M., resident and durable power of attorney (DPOA) notified of MWS, awaiting decision; -On 3/7/17 at 1:00 P.M., declined MWS services. Wants wound treatment in house by doctor. Review of the resident's POS, dated 3/5/17 through 3/31/17, showed an order, dated 3/7/17, to discontinue order for MWS to evaluate and treat as resident declined services. Review of the resident's Weight and Vital Sign Tracking Tool, showed the following: -3/7/17: 105 lbs; -3/8/17: 108 lbs. Review of the facility weekly pressure/wound tracking reports, dated 3/8/17, showed the following: -Resident name; -Type of wound: pressure; -Location: coccyx and gluteal folds; -Measurement: blank; -Description: blank; -Treatment: blank; -Written at the top of the wound report the word incomplete. Review of the resident's Weight and Vital Sign Tracking Tool, showed the following: -3/9/17: 113 lbs; -3/10, 11/17: blank; -3/12, 13/17: 102 lbs; -3/14/17: 105 lbs. Review of the resident's POS, dated 3/5/17 through 3/31/17, showed the following: -Order dated 3/14/17; -Low air loss mattress (LAL, provides alternating pressure and is designed to be used in the prevention, treatment and management of pressure ulcers); -Turn and position every two hours; -Roho cushion (pressure relief cushion); -Float bilateral heels while in bed, apply skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film); -Multivitamins with mineral daily; -Active liquid protein (nutritional supplement with multiple nutrients, vitamins and minerals needed to aid in the healing of pressure ulcers) 30 ml by mouth once daily. Review of the resident's undated TAR, showed the following: -Front of TAR: Low air loss mattress with 1/4 side rails times two per manufacturer's recommendation, turn and position every two hours, Roho cushion to wheelchair, apply skin prep to bilateral heels daily, float bilateral heels while in bed. Staff documented as completed 3/14 through 3/23/17; -Back of TAR: Blank. Review of the facility weekly pressure/wound tracking reports, showed no report for the week of 3/15/17. Review of the resident's Weight and Vital Sign Tracking Tool, showed a 3/15/17 weight of 100 lbs. Review of the resident's nurse's notes, dated 3/15/17 (first note since 3/7/17), showed the following: -New order for resident to see the registered dietician and hospice/palliative care consult; -No further documentation until 3/20/17. Review of the resident's POS, dated 3/14/17 through 3/31/17, showed an order dated 3/15/17, for registered dietician consult and hospice and palliative care consult. Review of the resident's Weight and Vital Sign Tracking Tool, showed a 3/16/17 weight of 92 lbs. Review of the resident's significant change MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -No short/long term memory problems; -BIMS score of 15; -Required extensive staff assistance for bed mobility; -Required total staff assistance for transfers, dressing, eating, personal hygiene, toilet use, and bathing; -Indwelling urinary catheter; -Incontinent of bowel and bladder; -Weight: 92 lbs; -Pressure ulcer: Three unstageable (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar at the time of admission), not present upon admission; -Other skin problems: moisture associated skin damage. Review of the resident's Weight and Vital Sign Tracking Tool, dated 3/17 though 3/19/17, showed no weights documented. Review of the resident's nursing notes, dated 3/20/17, no time, first note since 3/15/17, showed the following: -Staff updated the physician regarding reddened areas to mid back, feet, and a pressure ulcer to left inner ankle, orders noted; -No documentation whether staff contacted the registered dietician regarding the resident's weights or pressure ulcers; -No documentation to show staff updated the doctor on the pressure sores to the ischiums or coccyx. Review of the resident's undated POS, showed the following orders dated 3/20/17: -Apply foam dressing to left mid back/spine, change every three days and PRN; -Cleanse left inner ankle pressure ulcer with DWC, pat dry and apply foam dressing, change every three days and PRN; -Skin prep to bilateral feet twice a day. Review of the facility's Weekly Pressure Ulcer/Wound Report, dated 3/20/17, showed the following for the resident: -Type of Wound: Unstageable wound bed, Location: right ischium, measurement: 5.6 cm by 2.7 cm by unable to determine (utd), description: 90% eschar (thick, dry black dead tissue) 10% slough (yellow thick dead tissue) purulent (containing pus) drainage with odor; -Type of Wound: Unstageable, Location: left ischium, measurement 10 cm by 5.5 cm by utd, description 6 cm by 2.5 cm eschar, wound edges with slough; -Type of Wound: Unstageable, Location: sacrum, measurement 9 cm by 6.6 cm by utd with 7.6 cm by 3.4 cm eschar, description: slough with pink outer wound edges; -Type of Wound: Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound, without slough. May also present as an intact or open/ ruptured blister), Location: scrotum, measurement 2.0 cm by 2.2 cm, wound bed pink, scant sanguineous drainage. Review of the resident's Weight and Vital Sign Tracking Tool, showed a 3/20/17 weight of 92 lbs. Review of the resident's nurse's notes, dated 3/21/17, no time, showed the following: -Pressure ulcer to the resident's genitalia; -Small amount of sanguineous (clear bloody) drainage; -Physician notified, new orders received. Review of the resident's undated POS, showed the following orders, dated 3/21/17: -Cleanse open area to genitalia, pat dry, apply skin protectant paste twice a day, apply skin protectant paste twice a day and PRN; -Admit to hospice. Review of the resident's medical record, showed he/she enrolled in hospice care, on 3/21/17, with a primary [DIAGNOSES REDACTED]. Review of the resident's Weight and Vital Sign Tracking Tool, showed a 3/21 and 3/22/17 weight of 95 lbs. Further review of the resident's record, showed no registered dietician consult was completed as ordered on [DATE]. Observation of the resident on 3/24/17, showed the following: -5:30 A.M.: he/she sat in his/her wheelchair on a pressure relieving cushion in front of the nurse's station watching television; -7:00 A.M.: remained in his/her wheelchair at the nurse's station, dozing; -7:45 A.M.: he/she sat at a table in the dining room with a straw in his/her hand, with juice, milk, and water in front of him/her on the table. He/she was unable to place the straw in the glass; -8:00 A.M.: a CNA fed the resident 100% of dry cereal and milk; -8:10 A.M.: he/she consumed few bites of omelet, hash brown potatoes, and toast. No supplement was offered during the meal; -9:35 A.M.: he/she lay in bed. CNA G said he/she just helped the resident to bed. During an observation and interview on 3/26/17 at 9:35 A.M., showed the resident lay in bed on a low air loss mattress. The room had a strong putrid odor. As the resident spoke of his/her life at the facility, his/her voice was raspy, his/her mouth and tongue were very dry, and he/she complained of being thirsty. He/she said the staff rarely offered him/her water and he/she was unable to reach the water pitcher on his/her bedside table. He/she asked for a drink of water, and this surveyor asked staff to give the resident something to drink. The resident said he/she was admitted to the facility without pressure ulcers and now he/she had some pretty severe ones. Staff had left him/her wet in his/her wheelchair for long periods of times without changing his/her position. His/her appetite fluctuated at times, even when he/she lived at home, but he/she always drank a protein shake and wondered why he/she hadn't received them while at the facility. When asked if an assessment of his/her pressure ulcers could be observed, he/she said it was fine with him/her, but this surveyor would need a mask because the odor in the room was from his/her pressure ulcers. Observation on 3/27/17 at 5:35 A.M., during personal care, showed the resident lay in bed on a low air loss mattress. CNA L removed the bed covers which showed the resident's socked feet lay on the mattress. CNA L removed the brief revealing three large foam dressings which almost covered the resident's buttocks and ischiums dated 3/26/17. The resident had a pressure ulcer with slough on the under side of his/her genitalia, an approximately 2 cm long pressure ulcer with slough on his/her right lower inner leg, 1/2 cm pressure ulcers above and on the right ankle, and a 1/2 cm pressure ulcer on the right lateral foot. There were no dressings on these areas. The left inner ankle had a dressing dated 3/26/17. During an interview on 3/27/17 at 9:21 A.M., Nurse I said he/she was the nurse who assessed the resident's pressure ulcers on 3/5/17. He/she didn't know why he/she didn't measure and describe the pressure ulcers in the nurse's notes, but he/she should have. He/she noted three pressure ulcers, one on the coccyx and one on each ischium. He/she described the coccyx pressure ulcer as black eschar with yellow slough surrounding it and the right and left ischiums had yellow slough covering the wound beds. The resident's skin assessments were to be done weekly by the nurse on Saturdays. He/she was unable to complete it on Saturday 3/4/17 and completed it on 3/5/17. He/she found the pressure ulcers when the CNA reported the resident complained of difficulty urinating and he/she assessed his/her abdomen. He/she didn't know the last time the resident's skin was assessed. The resident's shower days were Wednesday and Saturday. He/she didn't know if the resident received a shower on Saturday 3/4/17. He/she didn't recall staff reporting the pressure ulcers. No one reported any changes with the resident's skin that day, 3/27/17. Observation and interview during a skin assessment on 3/27/17 at 9:36 A.M., the wound nurse said the left ischium was unstageable and measured 6.5 cm by 3.9 cm by utd with 90% eschar and slough. The right ischium was unstageable and measured 5.9 cm by 3.5 cm with 100% eschar. The coccyx was unstageable and measured 11.5 cm by 5.6 cm by utd with 100% eschar and slough. The under side of the genitalia was unstageable and measured 0.7 cm by 0.7 cm by utd with slough covering the wound bed. The left inner ankle was unstageable and measured 1.6 cm by 0.8 cm by utd with 100% eschar. The right upper thigh/lower buttock was a Stage II and measured 0.8 cm by 0.7 cm. In addition she said no one informed her of the resident's new unstageable pressure ulcers, below the right inner knee, which measured 2.5 cm by 1.2 cm with slough, the two pressure ulcers, one above the right ankle which measured 0.2 cm by 0.3 cm and the right ankle which measured 0.6 cm by 0.5 cm and the right lateral foot which measured 0.7 cm by 0.3 cm. During an interview on 3/27/17 at 11:05 A.M., the wound nurse said she would have expected staff to report any

Based on observation, interview, and record review, the facility failed to ensure staff were aware of and provided adequate monitoring for one of 17 sampled residents with a Judgement and Order for Conditional Release for discharge from a psychiatric center, that specified the resident was not allowed to leave the facility unaccompanied and without prior approval of the guardian and court appointed Forensic Case Monitor. On 3/12/17, the resident told a staff member he/she was leaving to get cigarettes, walked a half a mile from the facility to a church, knocked on the door, and complained of being tired. Church members called the facility to inform them of the resident's whereabouts. In addition the facility failed to investigate a bruise of unknown origin for one sampled resident, in order to find and address the cause to prevent future injury. (Residents #8 and #11). The census was 100. 1. Review of Resident #8's medical record, showed a Judgement and Order for Conditional Release, dated 1/6/16, directly behind the face sheet in the front of the chart, showed the following: -1. The resident may be discharged to a skilled nursing facility. He/she may be moved to another appropriate, Department of Mental Health (DMH) approved, nursing facility, or rehabilitation center as needed to accommodate his/her medical needs with the prior approval of his/her guardian and Forensic Case Monitor. He/she shall follow all rules and regulations of the facility. He/she shall not change his/her place of residence without the prior approval of his/her guardian and Forensic Case Monitor. He/she shall not move to a residence with less supervision without the prior approval of the court. The Forensic Case Monitor shall notify the court of any change of address; -3. At the discretion of his/her Forensic Case Monitor, the resident may have a day pass away from his/her residence with his/her family, with the prior approval of his/her guardian and Forensic Case Monitor. Passes will be issued at the discretion of his/her Forensic Case Monitor and based on his/her compliance with his/her conditional release; -4. He/she shall meet with the Forensic Case Monitor at least once per month for the purpose of monitoring his/her compliance with these conditions of release. He/she shall comply with the directives of his/her Forensic Case Monitor; -6. All activities must be approved by his/her Forensic Case Monitor and he/she will be supervised at all times on any activities that take place outside the facility -7. He/she will be supervised at all times on any appointments that take place outside the facility. Review of the resident's Psychiatric Rehabilitation Center's discharge summary, dated 5/25/16, and provided by the facility's admissions director, showed the following: -[DIAGNOSES REDACTED]. -Release Plan: A full Conditional release was granted by the Courts, the plan is to discharge the resident to the facility, where his/her physical and psychiatric needs could be meet. He/she will be supervised 24 hours per day for treatment compliance as well as safety toward him/her self and others. He/she will have no access to alcohol/drugs. Staff will be able to intervene quickly should he/she start to get agitated or try to strike out. The resident's legal guardian, Forensic Case Monitor and facility staff will provide an adequate social support system. Review of the resident's facility face sheet, showed an admission date of [DATE]. Review of the resident's care plan, updated 7/15/16, showed the following: -Problem: Cognitive loss/dementia: Resident has impaired decision making related to suffering a closed head injury that resulted in a left hemiparesis (weakness on one side of the body) and a personality change after being hit by a car in 1979. He/she has organic personality disorder (an impairment of the central nervous system causing a change in behaviors and characterized by depression, emotional instability, irritability and impulsive behaviors) and a history of alcohol and narcotic abuse. He/she has had multiple psychiatric admissions; -Approach: Set clear expectations in accordance with his/her conditional release to the facility. Keep resident in view of staff for supervision. Continue to follow up with mental health agency social worker, case manager, and family for coping mechanisms. -The care plan did not address the resident expressing a desire to leave the facility and get cigarettes; -Problem: Behavioral symptoms: Resident is a threat to self and or others related to closed head injury resulting in organic personality disorder, history of excessive alcohol abuse with aggressive, anger outburst, easily agitated with noises, increasingly confused, compulsive with stealing and lying. Experiences paranoia and mood swings related to memory problems; -Approach: Set clear expectations with the resident in accordance with his/her conditional release to this facility.(See the front of the chart). Keep resident in view of staff for supervision. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/2/16, showed the following: -[DIAGNOSES REDACTED]. -Short/Long term memory loss; -Brief Interview for Mental Status (BIMS) score of 6 (a score of 0-7 indicates severe impairment); -Behavior: Verbal behavioral symptoms directed toward others: Occurred daily. Other behavioral symptoms not directed at others such as screaming: Occurred four to six days a week but not daily. Rejects care: Occurred four to six days but not daily; -No wandering behaviors exhibited; -Required supervision with set up only of staff for bed mobility, transfers, walking in room, walking in corridor, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene; -Required extensive assistance of staff for bathing; -Range of motion: Upper and lower extremity impairment on one side; -Walker and wheelchair for ambulation; -Unsteady when walking, but able to stabilize without assistance; -Antipsychotic used daily; -Antianxiety used daily; -Antidepressant used daily. Review of the resident's psychiatric progress note, dated 12/13/16, showed the following: -History of present illness: dementia; -Hit by a car and in a coma for three weeks, a long time ago; -Per staff, resident is forgetful, yells a few times per week and becomes irritable, usually pertaining to cigarettes, punches at the wall at times; -Doesn't have many interests and staff feels the resident was depressed; -Was in the state hospital in the past; -Not happy about being at the facility. Wants to go home, says he/she has a house and that he/she is here because he/she doesn't have any money; -Angry at other residents for crying, started yelling and cursing at him/her; -Feels down at times and angry at all of the people at the facility; -Memory is poor, doesn't know why he/she is at the facility or where he/she was before; -This visit: Resident said he/she was okay, denies feeling depressed or anxious lately; -Wants to go back to prior facility; -Physical exam: General appearance: poor eye contact. Flow of thought: logical. His/her memory is observed to be alert, disoriented to time, poor recent memory and poor remote memory. Insight/Judgement: Poor insight and poor judgement. Review of the resident's hospital transfer orders, showed the following: -Admission to hospital on [DATE]; -Discharge back to facility on 1/3/17; -Discharge Diagnosis: [REDACTED]. Review of the resident's hospital Medical Necessity for Non Emergent Ambulance Transportation, dated 1/3/17, showed the following: -[DIAGNOSES REDACTED]. -Cognitive: Flight or elopement risk, cognitive impairment and requires supervision during trip; -Medical: Seizure precautions. Review of the resident's Elopement/Wandering Review form, dated 1/3/17, showed the following: -Instructions: Complete upon admission, thirty days after admission, quarterly and at significant change or per facility policy. Review Potential Risk Factors and Resident Status and check yes or no under the appropriate review date. On side two, complete the corresponding Summary of Review; -Side one: Potential Risk Factors/Resident Status: -Is the resident cognitively impaired with poor decision making skills (intermittent confusion, cognitive deficits or disoriented? Yes, (if yes comment on Side Two); -Does the resident have a pertinent [DIAGNOSES REDACTED].? Yes, (if yes comment on Side Two); -Does the resident ambulate independently, with or without the use of an assistive device (including a wheelchair)? Yes, (if yes comment on Side Two); -Is this a new behavior, has there been any changes in the resident's status or routine? (medication, illness, pain, infection,frustration, personal tragedy? Yes, (if yes comment on Side Two); -Unsigned; -Side Two: Blank. Review of the resident's fall risk assessment form dated 1/3/17, showed the resident scored a 12 (a total score above 10 represents a high risk) and showed the following: -Disoriented times one; -One to two falls in the last three months; -Balance problem while standing/walking; -Change in gait pattern when walking (i.e.-shuffling). Review of the resident's psychiatric progress note, dated 2/15/17, showed the following: -History of illness: dementia; -This visit: Resident at baseline lately per staff. Visiting with his/her caseworker earlier. Appears calm and having no issues; -Physical exam: General appearance: poor eye contact. Flow of thought: logical. His/her memory is observed to be alert, disoriented to time, poor recent memory and poor remote memory. Insight/Judgement: Poor insight and poor judgement. Review of the facility's Incident Investigation - Charge Nurse written statement, undated, showed the following: -Upon return the resident was assessed and found to have no injuries; -The resident was educated on the facility's sign in and out process and was agreeable to communicating with facility staff prior to leaving the facility in the future; -Responsible party made aware; -Facility on call person, Director of Nurses, and Administrator made aware; -Signed by charge nurse (unable to identify). Review of the employee written statement, dated 3/12/17, completed by Certified Nurse Aid (CNA) AA, showed the following: -He/she was in the dining room feeding residents when the resident left the facility; -He/she was unaware the resident left the facility; -He/she came out of the dining room, the charge nurse said the resident was gone. Review of the Event Witness Statement, dated 3/12/17, completed by Nurse BB, showed the following: -When was the last time the resident was seen: In the dining room at 6:00 P.M.; -Resident's description of what occurred: He/she got outside fever and needed a long walk. He/she wanted to get out of the facility for cigarettes and walked to the store; -Describe the resident's mood and demeanor before and after the alleged incident: Calm before and verbally agitated afterwards; -Signed by the charge nurse. Review of the employee written statement, dated 3/12/17, completed by CNA CC, who was assigned to the resident, showed the following: -He/she wasn't aware the resident was missing until he/she left the dining room and another CNA said the resident was missing; -The facility received a call from the church, the resident had walked 10 minutes to; -When he/she found out the resident was missing he/she walked to try and find him/her; -The resident went all the way to a church; -When he/she arrived, the church members were sitting with the resident; -The church members gave them a ride back to the facility; -The resident was very excited and hyper; -He/she took the resident's vital signs; -The staff are trying to watch the resident to make sure he/she was okay. Review of the employee written statement, dated 3/12/17, completed by CNA Y, showed the following: -Before the resident got out he/she asked the resident where he/she was going; -The resident said he/she was going to see his/her sister; -Approximately 15 minutes later, the facility received a call from the church, who said the resident was at the church. Review of the nurse's notes, showed no documentation, on 3/12/17 at 7:00 A.M. to 7:00 P.M., regarding the resident's elopement from the facility. Review of the resident's nurse's notes, dated 3/12/17 at 7:00 P.M. to 7:00 A.M., showed the following: -Resident up ad lib in wheelchair throughout the shift; -Cooperative and compliant with medications; -Monitored frequently, every 15 minutes checks; -No attempts to leave facility; -Independent with transfers; -Voiced no concerns. Review of the safety observations for 15 minute checks, provided for the resident, showed the form completely blank. During an interview on 3/21/17 at 9:00 A.M., after the initial tour, Nurse GG said the resident was alert and oriented times two to three with periods of confusion. He/she able to stand and ambulate short distances. During an interview on 3/27/17 at 8:27 A.M., Nurse Z said he/she worked the 7:00 P.M. to 7:00 A.M. shift on 3/12/17. On 3/12/17, the agency nurse who worked the 7:00 A.M. to 7:00 P.M. shift, reported the resident had left the faciity on the day shift. Staff were told to do every 15 minute checks, but he/she didn't know where staff were to document the checks. He/she believed a incident report was made, but didn't know were to find it. He/she was unaware the resident had a Court Order for Conditional Release, nor was he/she aware the resident could not leave the facility without supervision and prior authorization from his/her guardian and Forensic Case Monitor. During an interview on 3/24/17 at 5:47 A.M., Nurse EE said he/she had taken care of the resident, but wasn't at the facility on the day the resident eloped. The resident has some psych issues and often talked to himself/herself like he/she was speaking to someone else. He/she was confused, difficult to redirect, delusional, and paranoid. He/she also refuses his/her medications at times. At times on the day shift, the resident has said he/she was going to leave and go to the store to get cigarettes. He/she becomes angry when the time to smoke is late. He/she found out on 3/18 or 3/19/17, the resident had eloped from the facility to a church down the street. He/she was unaware the resident had a Court Order for Conditional Release, nor was he/she aware the resident could not leave the facility without supervision and prior authorization from his/her guardian and Forensic Case Monitor. During an interview on 3/27/17 at 3:02 P.M., Nurse GG said he/she found out the resident eloped when he/she returned two days after the incident. In report the nurse said to provide more oversight. Staff were supposed to do every 15 minute checks, but he/she didn't know where they were documenting them. He/she was unaware the resident had a Court Order for Conditional Release, nor was he/she aware the resident could not leave the facility without supervision and prior authorization from his/her guardian and Forensic Case Monitor. During an interview on 3/24/17 at 6:25 A.M., CNA D said the resident has a bad temper, is confused and wanted to smoke all the time. He/she didn't have an alarm or wanderguard and was able to get out of his/her wheelchair without assistance. He/she will stand up and walk at times especially when he/she becomes angry. He/she does go upstairs on the elevator when he/she wants to smoke. He/she was unaware the resident had a Court Order for Conditional Release and must be supervised whenever he/she left the facility. During an interview on 3/24/17 at 6:30 A.M., CNA HH said the resident often said he/she could leave the facility whenever he/she wanted to. When the resident gets upset, he/she gets loud and argues with other residents. He/she can stand up and walk, but his/her gait is unsteady. This was the first time that he/she knew of the resident leaving the facility. The nurse said to keep an eye on him/her. He/she was unaware the resident had a Court Order for Conditional Release and must be supervised whenever he/she left the facility. During an interview on 3/23/17 at 7:25 A.M., CNA W said he/she wasn't working the day the resident eloped from the facility. The resident has a bad temper and becomes angry when he/she can't smoke. He/she is able to stand and walk, but uses a wheelchair most of the time. The facility hadn't given any instruction on what to do since he/she eloped. He/she was unaware the resident had a Court Order for Conditional Release and must be supervised whenever he/she left the facility. During an interview on 3/21/17 at 3:20 P.M., CMT FF said the resident likes to smoke and often said he/she was going to leave the building because staff won't let him/her smoke. He/she also talks about going to got to the store to get cigarettes. The resident is able to stand and walk short distances and self propels in a wheelchair in the facility. He/she was unaware the resident had a Court Order for Conditional Release and must be supervised whenever he/she left the facility. During an interview on 3/21/17 at 2:40 P.M., CNA Y said he/she had worked at the facility since August of last year. The resident is confused, mostly uses a wheelchair, but is able to stand and walk short distances. The resident recently eloped from the facility. The facility hadn't told them to do anything different since the elopement. He/she was unaware the resident had a Court Order for Conditional Release and must be supervised whenever he/she left the facility. During an interview on 3/21/17 at 3:03 P.M., CNA DD said he/she had worked at the facility for approximately eight months. He/she didn't recall if he/she worked the evening the resident left the facility. The resident is confused and often said he/she wanted to leave the building to get cigarettes. He/she was able to stand, but his/her gait was unsteady and self propelled in a wheelchair. Since the incident the nurse has said to keep an eye on the resident. He/she wasn't told to document the resident's whereabouts. He/she was unaware the resident had a Court Order for Conditional Release and must be supervised whenever he/she left the facility. Review of the resident's nurse's notes, dated 3/13/17, at 11:00 P.M. to 7:00 A.M., showed the following: -Slept most of the night; -Up in wheelchair once during the night; -Able to make needs known; -No complaints or discomfort voiced; -No attempts to leave the facility. Review of the resident's nurse's notes, dated 3/14/17 at 11:00 A.M., showed the following: -Resident up in his/her wheelchair; -Alert and oriented times three to four; -Resident verbalized an increase in anxiety; -Call placed to the resident's physician to request need for a as needed (PRN) medication; -New order received to refer the resident to psychiatrist; -Face sheet sent to the psychiatrist to notify of the referral. Review of the resident's nurse's note, dated 3/14/17, no time, showed the following; -Resident was assessed by mental health counselor on 3/13/17; -The resident said he/she wanted to go for a walk before his/her family member came to visit; -He/she walked out of the facility by himself/herself without notifying staff who saw him/her 15 minutes earlier; -Local church member contacted the facility via telephone to notify staff the resident knocked on their door and stated he/she was tired and wanted to return home; -Resident verbalized he/she understands he/she should not leave the facility alone and without notifying staff; -A full assessment was completed by staff upon the resident's return, no injury was noted; -Power of attorney and physician was notified by the charge nurse; -15 minute checks implemented; -The resident has made no additional attempts to leave the facility. Observation and interview on 3/21/17 at 12:44 P.M., showed the resident propelled himself/herself to his/her room. The resident talked about his/her room and which bed he/she preferred to sleep in. He/she stood, walked to his/her closet, removed a clean shirt and put it on. His/her gait was fairly steady. He/she complained of knee pain, pointing to his/her right knee. Observation and interview on 3/22/17, showed the following: -9:30 A.M.: The resident sat in his/her wheelchair in the smoking room. He/she self propelled from the smoking room into the hallway asking where was his/her room. A unknown staff member took the resident to his/her room; -12:48 P.M.: Resident was in his/her room and Nurse GG entered the room to check on him/her and said the resident was an escape artist; -3:00 P.M.: This surveyor spoke to the resident about his/her life at the facility. The resident said he/she left the facility to get a pack of cigarettes before his/her family came. Observation of the resident showed he/she did not have a wanderguard on. During a telephone interview on 3/23/17 at 9:06 A.M., the Forensic Case Monitor said, the facility had not made her aware the resident had left the facility. He/she is not supposed to leave the facility unsupervised. The facility is supposed to notify her of any problems or concerns regarding the resident. She visited the facility on 3/22/17, and no one reported the resident had left the faciity on [DATE]. Observation on 3/23/17 at 12:45 P.M., showed the resident came out of his/her room and closed the door. He/she asked for ice, held his/her arm up showing a wanderguard and said they put this on that morning. He/she rolled away quickly saying he/she didn't like it. Observation on 3/23/17 at 1:00 P.M., from the facility to the church, showed the following: -From the facility to the church was 1/2 mile; -The sidewalk from the facility to church was all downhill; -The quickest way to reach the church entrance is by walking from the sidewalk through the grass and across the church parking lot to the entrance or it can be reached by continuing down the sidewalk to the church driveway and then through the parking lot and back up to the entrance. During an interview at the facility on 3/23/17 at 1:53 P.M., the Forensic Case Monitor said the resident received extensive in house psychiatric treatment related to psychosis. She visits the facility monthly as part of the resident's conditional release. The facility hadn't notified her of the resident leaving the facility. She was unaware the resident had made statements of wanting to leave the facility to get cigarettes. Staff should have made her aware of the resident's statements so she could intervene. She had spoken to the administrator on several occasions but was unaware whether he knows she is the resident's Forensic Case Monitor. She will have to notify the Court of the resident's elopement from the facility. After speaking with this surveyor earlier that day, she called the facility to ask what measures the facility was going to put in place to prevent this from occurring again. The facility then placed a wanderguard bracelet on the resident to alert them if he/she goes towards the doors. During an interview on 3/27/17 at 5:10 P.M., the social service director said no one notified her the resident eloped from the facility. Staff should have notified her so she could follow up with the resident and document the follow up in the medical record. She was also unaware the resident had a Judgement and Order for Conditional Release, Forensic Case Monitor or that the resident must be supervised whenever he/she left the facility. During an interview on 3/23/17 at 7:35 A.M., the acting Director of Nurses (DON) said the resident was alert and oriented times two to three with periods of confusion. He/she wanted to take a walk to get a cigarette. The resident didn't notify anyone he/she was going to leave the facility. She was unaware the resident had a Judgement and Order for Conditional Release. She was also not aware the resident made statements about leaving the facility for cigarettes. She was unaware the resident had a court ordered Forensic Case Manager. Nor did she know staff were to notify the Forensic Case Monitor for any changes with the resident. Neither the resident's Elopement Wandering Review nor Care Plan had been updated. Both should have been updated after the resident eloped. In addition staff should have documented the every 15 minute checks on the Safety Observations sheet. The nurse should have documented the elopement in the nurse's notes. She didn't know why staff failed to complete the sheet or document in the nurse's notes. During interviews on 3/23/17 at 6:47 A.M. and 8:23 A.M. and 3/27/17 at 2:35 P.M., the administrator said the resident was not an elopement risk. On 3/12/17, the resident left the facility, made a right and went a couple of blocks down to a church. He/she wanted to go and get cigarettes before his/her family member came. He was not aware of any stipulations or the Judgement and Order for Conditional Release. He was aware the resident has a guardian, but was unaware of the Forensic Case Monitor. After reviewing the resident's chart the administrator said he was not aware of the Judgement and Order for Conditional Release located in the front of the resident's medical record. He was told by the admissions director the resident could leave the building. He was unaware the resident had made statements about leaving the facility to staff. The resident didn't tell anyone he/she was going to leave facility when he/she left on 3/12/17. He was under the impression he didn't have to report the occurrence to the state agency unless it was a true elopement, because the resident was alert and oriented. He would expect staff to document the resident's leaving the facility in the medical record and update the care plan. Staff should have notified the nurse of the resident's statements of wanting to leave the facility for cigarettes. During an interview on 3/27/17 at 7:48 A.M., the admissions director said he/she was not the admissions director at the time of the resident's admission from a psychiatric hospital. The former administrator and former DON approved the resident's admission after reviewing the paperwork. During an interview on 3/30/17 at 2:45 P.M., the physician's nurse practitioner said he would have expected the facility staff to document the resident's elopement from the facility. He also would have expected the facility to put measures into place after the elopement and update his/her care plan. He was aware of the resident's Judgement and Order for Conditional Release. During an interview on 3/31/17 at 11:44 A.M., the resident's psychiatrist said the facility did not notify him when the resident eloped from the facility. After speaking with facility staff, they seemed unaware he was the resident's psychiatrist. Staff had not made him/her aware of the resident's statement of wanting to leave the facility for cigarettes. The resident should not leave the facility unsupervised. He was aware the resident had a Judgement and Order for Conditional Release. During a telephone interview on 4/3/17 at 3:00 P.M., the medical director said he would have expected the facility to notify him of the resident's elopement from the facility. In addition staff should document in the medical record, put interventions in place and update the resident's care plan. He was not aware of the resident's Judgement and Order for Conditional Release, but the facility staff should have been. Review of the facility's policy on Elopement, undated, showed the following: -Purpose: Elopement of a resident is defined as leaving a facility by a resident who has impaired decision making ability, is oblivious to his/her own safety and is at risk for injury outside the confines of the facility without the knowledge of the staff. The facility wants to assure the safety of the residents who are at risk of possible elopement; -Goal: The facility has a responsibility to maintain an environment which will keep the residents safe, protect them from harm, while allowing them as much freedom within the facility as possible. The goal of the elopement policy is to ensure the residents safety while allowing them independence within the facility; -Plan: #1. If a alarm sounds, staff members are to respond immediately and go outside the doors and check for residents and call for assistance if necessary. The staff will also look internally for the resident. #4. If the resident is still not found, the staff will notify the doctor and family. The staff will document and refer information to the care plan coordinator for care planning. #5. If the resident remains unseen, a Code Green is called. Follow Code Green protocol and policy at all time. All wings will then be checked for the resident's locations. #6. The next procedure is to notify the police, family, physician, Department of Health and Senior Services, Administrator, and Director of Nurses, while continuing to search the grounds, building and assigning staff to drive in the area to look for the resident. A picture will be made available for the police if requested and needed. #7. Finally continue to update the family, physician and Department of Health and Senior Services until the resident is either found or the situation is resolved. 2. Review of Resident #11's quarterly MDS, dated [DATE], showed the following: -Understood/understands; -Brief interview for mental status (BIMS) score of 11 (a score of 8-12 indicates moderate cognitive impairment); -No delirium/behaviors; -Did not reject care; -Extensive assistance of one person required for bed mobility, transfers, locomotion off the unit, dressing, toilet use, and personal hygiene; -One person physical assistance required for bathing; -Mobility device: Wheelchair; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -No falls since admission or prior assessment; -Hospice care. Observation on 3/23/17 at 5:25 A.M., showed the resident lay in bed as CNA M provided personal care. The CNA turned the resident, revealing a large purple and yellow bruise on the resident's left breast/chest area. There was a hard raised knot in the center of the bruise. The CNA said he/she did not know what caused the bruise and had not been told anything about the bruise. The resident said he/she did not know how the bruise occurred or how long it had been there. He/she said it may have happened in the shower. Review of the resident's medical record, showed no information regarding a bruise on the resident's left upper breast/chest area. Review of the facility's Accident/Incident Report Log, from 3/1/17 through 3/23/17, showed no information regarding the resident's bruise. During an interview on 3/23/17 at 5:50 A.M., CNA P said he/she had not worked with the resident, but in report no one said anything about the resident having a bruise on the left breast/chest area. During an interview on 3/23/17 at 7:05 A.M., Nurse R, 7:00 P.M. to 7:00 A.M. shift, said he/she was not aware the resident had a bruise on his/her left breast/chest area. He/she checked the report log at the nurse's station and said there was no information about a bruise. During an interview on 3/23/17 at 7:10 A.M., Nurse S, 7:00 A.M. to 7:00 P.M. shift, said he/she did not know anything about a bruise on the resident's left breast/chest area. During an interview on 3/23/17 at 9:50 A.M., CNA Q said he/she had been taking c

Based on observation, interview, and record review, the facility failed to identify newly acquired pressure ulcers in a timely manner and provide appropriate care, treatment, and documentation to promote the healing of pressure ulcers. The facility identified six residents with pressure ulcers. Of those six, three were selected for the sample of 19 and problems were found with all three regarding care and treatment. (Residents #43, #13, and #5) The census was 97. 1. Review of the facility's policy on Pressure Sore Treatment/Documentation, dated 5/2015, showed the following: -Policy: It will be the policy of the facility to monitor residents with or without wounds. In the event a resident obtains a wound no matter the reason the wound nurse and his/her designee will measure the wound, evaluate the possible cause, communicate with the family, physician and obtain orders and other devices needed to treat and assist in prevention of further damage. As always the goal is to prevent damage, infection and to promote healing process; -Staff responsible: all licensed nurses. 2. Review of Resident #43's Nursing Evaluation/Data Collection form, completed by a nurse, dated 3/10/16, showed the following: -Admission 3/10/16 at 4:45 P.M.; -Skin condition: Comments: Written in: Right inner thigh blister. No other information documented about the blister; -Front of body diagram: Circle on right side of thigh; -Functional status: Dependent on the assistance of two staff for bed mobility and transfers. Unable to walk or propel own wheelchair; -Signed by a nurse. Review of the resident's Braden Scale-For Predicting Pressure Ulcer Risk, dated 3/10/16, showed staff documented a score of 15 (total score of 12 or less represents high risk). Further review of the assessment, showed the numbers actually added up to 13. Review of the resident's 14 day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/23/16, showed the following: -Brief Interview for Mental Status (BIMS): scored 3 of 15 (a score of 0 to 7 indicates severe cognitive impairment); -Limited assistance of one staff for bed mobility; -Total dependence of two staff for transfers and bathing; -Extensive assistance of one staff for locomotion on and off the unit, dressing, eating, personal hygiene, and toilet use; -Non ambulatory, used wheelchair; -[DIAGNOSES REDACTED]. -At risk for developing pressure ulcers; -No pressure ulcers present on admission; -No venous or arterial ulcers (caused by decreased blood circulation) present on admission; -No foot/feet problems. Review of the resident's care plan, dated 3/23/16, showed the following: -3/23/16, Problem: Risk for developing pressure ulcers related to not being independent in mobility/repositioning and incontinence; -Goal: Skin will remain intact; -Approaches included: Conduct a systematic skin inspection, nurse to perform weekly. Report any signs of skin breakdown (sore, red, tender, or broken areas) to the charge nurse. Review of the resident's Bath/Shower: CNA Skin Assessment sheets, for April 2016, showed the following: -Must sign as completed and submit to your charge nurse for review and signature; -The charge nurse must observe any new finding visually at the time of the bath/shower; -If the resident refuses, document in the areas provided below and notify the charge nurse, who will notify the Director of Nurses (DON), Assistant Director of Nurses (ADON) and the administrator; -4/13/16: -Skin condition: The boxes with the words Dry and Redness were checked; -Front of body diagram: Blank; -Back of body diagram: Circle around the buttocks; -Right foot: Blank; -Left foot: Blank; -Signed by a CNA, a nurse and the treatment nurse; -4/16/16: -Skin condition: Blank; -Front of body diagram: Blank; -Back of body diagram: Circle around the buttocks with a hand written description: Open area on buttocks; -Right foot: Blank; -Left foot: Blank; -Signed by a CNA, a nurse and the treatment nurse; -4/27/16: -Skin condition: The boxes with the words Dry, Redness, New, and Open were checked; -Front of body diagram: Circle around the pubic area with the word Redness written; -Back of body diagram: Circle around the buttocks with a hand written description: Two open areas; -Right foot: Circled with the words, Extremely dry, written; -Left foot: Circled with the words, Extremely dry, written; -Signed by a CNA, a nurse and the treatment nurse; -4/30/16: -Skin condition: The box with the words, Open area, was checked; -Front of body diagram: Left ankle circled with the words, Ankle wrap, written. No further description; -Back of body diagram: Circle around the buttocks with a hand written description: Open area and Redness; -Right foot: Blank; -Left foot: Blank; -Signed by a CNA, a nurse, and the treatment nurse. -No other shower sheets, for April, provided by the facility. Review of the resident's physician's orders [REDACTED]. Review of the resident's nurse's notes, showed no documentation from 4/4/16 until 4/30/16. During an interview on 5/26/16 at 10:30 A.M., the DON said there were no additional April nurse's notes for the resident. Review of the resident's treatment administration record (TAR), dated 4/1/16 through 4/30/16, showed the following: -Weekly skin assessment: -Initialed as completed on 4/4/16 and 4/18/16; -Blank for 4/11/16 and 4/25/16; -No treatment orders or documentation regarding the resident's feet; -No documentation on the back of the TAR about the feet. Review of the facility's Weekly Wound Tracking Worksheet, dated 5/9/16 and 5/16/16, showed the resident was not listed on the report. Review of the resident's nurse's notes, showed the following: -5/17/16, 10:00 A.M., blackened area to left heel, measured 3.0 centimeters (cm) by 5.0 cm with suspected deep tissue injury (SDTI, purple or maroon discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear); -New order obtained from physician; -Treatment provided; -No documentation the resident's family notified of new wound. Review of the resident's care plan, updated 5/17/16, showed the following: -5/17/16, Left heel, SDTI; -Approaches included: Report changes in skin status (i.e.: signs or symptoms of infection, nonhealing or new areas) to physician. Complete weekly skin assessments. Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. Float heels (keep heels suspended off the mattress) when in bed. Wound care as ordered by physician-see current Wound Treatment and Progress Record; -The care plan did not address the use of a low air loss mattress (mattress to reduce pressure), bilateral pressure relief boots or to keep family informed of progression of the wound. Review of the resident's Bath/Shower: CNA Skin Assessment sheets for May 2016, showed the following; -5/18/16: -Skin condition: The box with the words, skin intact, was checked. In the space designated as other, the hand written words, Patched/wrapped, with no further information; -Front of body diagram: Blank; -Back of body diagram: Blank; -Right foot: Blank; -Left foot: Blank; -Signed by a CNA; -Not signed by a nurse or the treatment nurse; 5/21/16: -Skin condition: The boxes with the words, open area, and old, were checked; -Front of body diagram: Blank; -Back of body diagram: Circle around the buttocks; -Right foot: Blank; -Left foot: Blank; -Right heel Blank; -Left foot: marked with a black dot and written above the picture, the words, open areas; -Signed by a CNA and a nurse; -Not signed by the treatment nurse; -No other shower sheets for May, were provided by the facility. Review of the resident's nurse's notes, showed the following: -5/21/16 at 12:40 P.M., resident's family member at facility, reported they were unaware of new wound. Nurse on duty called the wound nurse; -5/21/16 at 2:00 P.M., wound care nurse called the facility, told the nurse on duty, he/she would call the resident's family on 5/23/16; -5/22/16 at 4:00 P.M., family back at facility, upset resident has a wound and they were not notified. Family demanded staff send resident to the hospital. Orders obtained to send resident to hospital; -5/22/16 at 5:25 P.M., resident transported to hospital; -5/22/16 at 11:50 P.M., resident returned to the facility with new orders for laboratory tests, medication, and treatment orders. No documentation or assessment of the resident's skin or left heel; -5/23/16 at 11:00 A.M., nurse noted a blackened area to right heel, measuring 2.5 cm by 3.0 cm., physician notified, new orders obtained. No further documentation or assessment of area on left heel. Further review of the resident's care plan, updated 5/23/16, showed the following: -Problem: Right heel, SDTI; -Approach: No new approaches added to the care plan; -The care plan did not address the use of a low air loss mattress, bilateral pressure relief boots or to keep family informed of progression of the wound. Review of the resident's TAR, dated 5/1/16 through 5/24/16, showed the following: -Weekly skin assessment: -Blank on 5/4/16 and 5/11/16; -Initialed as completed on 5/18/16; -5/17/16, New order: Left heel, cleanse with wound cleaner (WC), pat dry, apply [MEDICATION NAME] (antibacterial drying agent), cover with a gauze pad and wrap with supra form (gauze wrap), secure with tape daily; -Initiated as completed on 5/17/16, 5/19/16, 5/21/16 and 5/22/16; -Blank on 5/18/16 and 5/20/16; -5/23/16, New order: Right heel, cleanse with WC, pat dry, apply [MEDICATION NAME] to wound and cover with gauze, wrap with gauze wrap and secure with tape daily; -Initialed as completed on 5/23/16 and 5/24/16; -No documentation pressure relief boots were utilized; -No documentation of use of a pressure relief mattress; -The back of the TAR, showed no documentation of any assessment of wounds on the resident's bilateral heels. Review of the resident's wound tracking worksheets, dated 5/23/16, showed the facility identified a SDTI to the resident's left heel that measured 3.0 cm by 5.0 cm and a SDTI to the right heel that measured 2.5 cm by 3.0 cm. -No documentation the facility supplied support surfaces (pressure relief boots) or a specialty mattress. Observation and interview on 5/24/16 at 10:06 A.M., showed the resident sat in a wheelchair wearing bilateral pressure relief boots. A low air loss mattress laid on the floor beside the bed, plugged in and inflating. Both of the resident's feet were wrapped with a gauze dressing. The resident said his/her feet hurt. During an interview on 5/24/16, at 11:10 A.M., the treatment nurse said he/she was responsible for the weekly wound rounds and filled out the weekly wound reports. Residents were supposed to get a shower two times per week. Skin assessments were done on a resident's shower/bath days. The shower aides filled out a bath sheet every time a resident received a shower. The aides assess the resident's skin and document it on a bath sheet. If a skin issue was identified, the charge nurse working should assess the area, call the physician, and notify the wound nurse. The shower/bath sheet should then be signed by the aide, the charge nurse, and the wound care nurse. The wound nurse discovered the black area on the resident's left heel on 5/17/16, while doing other residents' treatments. The resident's left foot was wrapped with a gauze dressing. The resident did not have orders for a treatment for [REDACTED]. The nurse did not know who applied the dressing or how long the dressing had been on the resident's foot. After the nurse identified the blackened area on the resident's left heel, he/she called the physician to obtain a treatment order. He/she did not notify the resident's responsible party of the new pressure ulcer or update the care plan. In addition to the treatment order, the nurse said he/she applied a pressure relief boot to the resident's left foot. The facility did not have a system in place to document the use of durable medical equipment. The nurse that readmitted the resident to the facility on [DATE], should have done a skin assessment, but no skin assessment was completed until the treatment nurse came to work the next day. While the treatment nurse assessed the resident's left foot, she noted a blackened area on the resident's right foot. She notified the resident's physician and obtained treatment orders and an order for [REDACTED]. She did not document in the resident's medical record about applying a pressure relief boot or the use of a low air loss mattress. The facility had been short of staff and she had been pulled from the position of treatment nurse to charge nurse more often than not, causing things to get missed or overlooked. During an interview on 5/24/16 at 1:10 P.M., CNA X said he/she was assigned to do showers. At the end of April, he/she recorded on the resident's bath/shower sheet, the resident had a dressing around his/her left foot. The nurse he/she gave the shower report to no longer worked at the facility. Sometimes the dressing would be on the resident's foot and sometimes there was no dressing. Observation and interview on 5/24/16 at 11:42 A.M., showed the facility wound physician removed the dressings from the resident's feet, measured the areas on both heels and performed a bedside Doppler study (measures blood flow) to both feet. He/she said the Doppler showed no impairment with the blood flow to the resident's feet. The resident had bounding (strong), palpable (easily felt) pedal (foot) pulses. The areas on the resident's bilateral heels were definitely pressure injuries. The physician would expect staff to document all interventions put in place to prevent or decrease the size of pressure ulcers including the use of pressure relief devices. During an interview at on 5/24/16 at 2:30 P.M., the administrator and DON said the facility did not have a policy regarding pressure relief devices. They did not get physician's orders [REDACTED]. Pressure relief devices were used per nursing judgement. The facility did not document the application or use of pressure relief boots or low air loss mattresses. The administrator said, the nursing staff should probably be documenting somewhere about pressure relief devices. The administrator did know about the resident's first pressure ulcer, but he just found out the resident had developed a second pressure ulcer. A low air loss mattress was put on the resident's bed while the surveyor was in the facility. He did not know when the pressure relief boots were put on the resident. During an interview on 5/26/16 at 1:45 P.M., the DON said she did not know why the treatment nurse signed the bath/shower sheet on 4/30/16, showing the resident had a dressing to his/her left foot and then did not follow up on it. 3. Review of Resident #13's Nursing Evaluation/Data Collection form, completed by the nurse, dated 4/27/16, showed the following: -admitted [DATE] at 2:30 P.M.; -Skin condition: Comments: Written in: Three open areas, other areas are skin breakdown that could potentially lead to open areas; -Left side view of body diagram: Circle on left outer ankle; -Front of body diagram: Circle on left side of forehead; -Back of body diagram: Circle on right upper back, coccyx, left lower arm and right outer leg; -Signed by a nurse. Review of the resident's POS, dated 4/27/16 through 4/30/16, showed the following: -Order dated 4/28/16: Cleanse left temporal (side of head) with normal saline, pat dry, apply therahoney (helps to promote autolytic debridement of necrotic tissue) to wound bed, cover with dry dressing daily until healed; -Order dated 4/28/16: Cleanse left lateral ankle with wound cleaner, apply therahoney to wound bed, cover with foam dressing daily until healed; -Order dated 4/28/16: Cleanse right lateral ankle with wound cleanser, pat dry, apply skin prep, cover with foam dressing daily until healed; -No orders/documentation regarding the resident's coccyx. Review of the resident's TAR, dated 4/27/16 through 4/30/16, showed the following: -Weekly skin assessment: -Initialed as completed on 4/4/16 and 4/18/16; -Blank on 4/11/16 and 4/25/16; -Left temporal region wound: Initialed as completed on 4/28/16 through 4/30/16; -Left lateral ankle: Initialed as completed on 4/28/16 through 4/30/16. -Right lateral ankle: Initialed as completed on 4/28/16 through 4/30/16; -No documentation regarding the resident's coccyx. Review of the resident's nurse's note, showed the following: -4/27/16 at 3:30 P.M.: readmitted to the facility. Open areas to right calf, left ankle, right lower shoulder blade, backside slight breakdown, left wrist, and left temporal region; -4/28/16 at 6:30 A.M.: Treatment nurse skin assessment: Left temporal region 2.5 cm by 4.0 cm with 0.5 cm by 0.5 cm granulation (new tissue growth formed on the surface of a wound during the healing process). Left lateral ankle 1.5 cm by 1.5 cm granulation. Right lateral ankle, suspected deep tissue injury, black area 1.5 cm by 1.5 cm, old scarring to coccyx area [MEDICATION NAME] (multipurpose, moisture barrier ointment, that does not require a prescription and is sold over the counter) applied. New orders obtained; -No documentation regarding the resident's coccyx. Review of the resident's TAR, dated 5/1/16 through 5/31/16, showed the following: -Front of TAR: -Weekly skin assessment: Blank for 5/2/16. Initialed as completed on 5/9/16 and 5/16/16; -Cleanse left lateral ankle: Blank for 5/1/16, 5/12/16 and 5/18/16. Initialed as completed for 5/2/16 through 5/11/16, 5/13/16 through 5/17/16 and 5/19/16; -Left temporal region wound healed 5/6/16; -Back of TAR: -First week: Blank; -Second week: Right ankle wound no description or measurement. Left ankle wound no description or measurement; -Third week: Right ankle wound no description or measurement. Left ankle wound, no description or measurement; -No documentation regarding the coccyx. Review of the resident's May 2016 Bath/Shower: CNA Skin Assessment sheets, showed the following: -5/4/16: -Skin condition: The box with the words, skin intact, open area, and old were checked; -Front of body diagram: Circle drawn on forehead; -Back of body diagram: Circle drawn on head; -Signed by a CNA, a nurse and the treatment nurse; -5/7/16: -Skin condition: The box with the words, Skin intact was checked; -Front of body diagram: Blank; -Back of body diagram: Blank; -Signed by a CNA, a nurse and the treatment nurse. Review of the facility's Weekly Wound Tracking Worksheet, dated 5/9/16, showed the following for the resident: -Left temporal: Wound type: Abrasion (an area damaged by scraping or wearing away). Date of onset: On admit. Size 0.3 cm by 0.3 cm; -Left outer ankle: Wound type: Pressure ulcer. Date of onset: On admit. Size 1.2 cm by 1.3 cm; -Right outer ankle: Wound type: Pressure. Date of onset: On admit. Size 0.5 cm by 0.5 cm; -No documentation regarding the resident's coccyx. Review of the resident's quarterly MDS, dated [DATE], showed the following: -BIMS score 13 of 15 (a score of 13 to 15 indicates cognitively intact); -No short/long term memory loss; -[DIAGNOSES REDACTED].>-Required total staff assistance for all activities of daily living; -Incontinent of stool; -Urinary catheter (a sterile tube placed through the urethra into the bladder, used to drain urine); -Pressure ulcer: One Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) and one Unstageable (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and or/eschar). Review of the resident's Care Plan Conference Summary sheet, dated 5/10/16, showed readmission with skin breakdown was discussed. Review of the resident's care plan updated 5/20/16, showed an onset date of 2/20/16 regarding the resident being at risk for pressure ulcers. The care plan was not updated to reflect the resident as having any pressure ulcers. Review of the resident's Bath/Shower: CNA Skin Assessment sheet, dated 5/18/16, showed the following: -Skin condition: The boxes with the words, Skin intact, bruises, Redness, Open area, and Old were checked; -Front of body diagram: Colored in circle on forehead with word, bruise, written in; -Back of body diagram: Colored in circle on buttocks; -Signed by a CNA; -No nurse or treatment nurse signature. During a skin assessment and interview on 5/20/16 at 8:15 A.M., the resident lay in bed. The treatment nurse assessed the resident's forehead and noted a small open area which measured 0.5 cm by 0.3 cm from pressure on his/her new wheelchair head rest. She said the resident was receiving treatments to his/her left and right lateral ankles. CNA A turned the resident to his/her right side revealing a large uncovered pink pressure ulcer, with areas of slough on his/her coccyx. The treatment nurse said the coccyx area measured 5.0 cm by 5.5 cm, was unstageable with suspect deep tissue injury and 95% granulation and 5% slough. She said she would notify the physician for a treatment order and the wound physician to follow. The treatment nurse said she was not aware of the pressure ulcer on the resident's coccyx. She would have expected staff to notify her of the pressure ulcer. During an interview on 5/20/16 at 8:30 A.M., CNA A said said the resident's buttocks had been sore for about a month. He/she didn't report it to anyone because he/she thought everyone knew about it. During an interview on 5/20/16 at 8:40 A.M., the resident said he/she knew he/she had a sore on his/her buttocks, but was unable to feel it because he/she was paralyzed. Review of the resident's POS, dated 5/1/16 through 5/31/16, showed the following: -5/20/16: Cleanse left temporal region with wound cleanser, pat dry, apply therahoney to wound bed cover with gauze and dry dressing daily and as needed; -5/20/16: Cleanse coccyx with normal saline, pat dry, apply Santyl (enzyme used break up and remove dead skin and tissue) to the wound bed, cover with foam dressing daily and as needed until resolved. During an interview on 5/20/16 at 11:47 A.M., the DON said the resident was readmitted with a pressure ulcer to his/her buttocks and the treatment nurse was aware. She expected staff to notify the nurse of any changes in a resident's skin. 4. Review of Resident #5's annual MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Short/long term memory loss; -BIMS assessment unable to be conducted as resident is rarely/never understood; -Required total staff assistance with all activities of daily living; -Urinary catheter; -Incontinent of bowel; -Pressure ulcer: One Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). Review of the resident's care plan, dated 4/20/16, showed the following: -Problem: Risk for developing pressure ulcers related to limited mobility and bowel incontinence; -Approach: See physician's orders [REDACTED]. Report any signs of skin breakdown (sore, red, tender or broken areas) to the charge nurse. Review of the resident's Braden Scale assessment, dated 5/10/16, showed staff documented a score of 10 (total score of 12 or less represents high risk). Review of the resident's POS, dated 5/1/16 through 5/31/16, showed the following: -Skin Prep (liquid film-forming dressing that, upon application to intact skin, forms a protective barrier) apply to both heels every day, effective 11/20/15; -Cleanse right buttock with wound cleanser, pat dry, apply Puracol AG (specialized dressing with antibacterial silver) cover with foam dressing every day, effective 2/3/16. Review of the resident's TAR, dated 5/1/16 through 5/31/16, showed the following: -Front of TAR: -Weekly skin assessment: Blank for 5/1/16, 5/8/16 and 5/15/16; -Skin Prep to both heels every day: Initialed as completed on 5/5/16, 5/7/16 through 5/12/16, 5/14/16, 5/15/16 and 5/17/16. Blank on 5/1/16 through 5/4/16, 5/6/16, 5/13/16 and 5/18/16; -Cleanse right buttocks with wound cleanser, pat dry, apply Puracol AG, cover with foam dressing daily until healed. Initialed as completed on 5/1/16 through 5/17/16. Blank on 5/18/16; -No treatment order for right foot; -Back of TAR: Blank. Review of the resident's Bath/Shower CNA Skin Assessment sheet, dated 5/4/16, showed the following: -Skin condition: The box with the words Skin intact was checked; -Front of body diagram: Blank; -Back of body diagram: Blank; -Right foot: Blank; -Left foot: Blank; -Signed by a CNA, a nurse and the treatment nurse. Review of the facility's Weekly Wound Tracking Worksheet, dated 5/9/16, showed the following for the resident: -Right Hip: Wound type: In house acquired, Pressure, Stage IV, 3.1 cm by 1.7 cm; -Left foot: Wound type: In house acquired, Pressure, unstageable, 2.3 cm by 2.1 cm; -No documentation regarding right foot. Review of the resident's nurse's notes, dated 5/1/16 through 5/17/16, showed no documentation regarding the resident's right buttocks or either foot. Review of the resident's Bath/Shower: CNA Skin Assessment sheet, dated 5/18/16, showed the following: -Skin condition: The box with the word, Skin intact, was checked; -Front of body diagram: Blank; -Back of body diagram: Colored in circle on buttocks; -Right foot: Colored in circle on right heel; -Left foot: Colored in circle on left heel; -Signed by a CNA; -No nurse or treatment nurse signature. Observation on 5/19/16, showed the following: -5/19/16 at 6:45 A.M., the resident sat in his/her recliner in the sitting area in front of the nurse's station; -5/19/16 at 9:50 A.M., CNA A and CNA I transferred the resident to bed using a total body mechanical lift. CNA A removed the resident's brief, turned the resident onto his/her left side, revealing the right buttock pressure ulcer without a dressing. CNA A said the resident was up when he/she got to work that morning; -5/19/16 at 10:00 A.M., during a skin assessment, the surveyor noted a darkened area to the resident's right outer foot. The treatment nurse said the wound was from pressure, unstageable, and measured 1.0 cm by 0.5 cm. Also she would have expected staff to notify the charge nurse whenever a dressing becomes soiled. The dressing to the left foot had a date of 5/17/16. The treatment nurse said she did not work on 5/18/16, and didn't know why the treatment wasn't done; -5/19/16 at 10:15 A.M., the administrator assessed the resident's right outer foot and said he expected staff to do weekly skin assessments and treatments as ordered. Staff should have assessed the resident's feet while applying the Skin Prep and should have seen any changes in the resident's skin. 5. During an interview on 5/20/16 at 11:47 A.M., the DON said she expected staff to notify the charge nurse when a dressing became soiled and had to be removed. She expected staff to do the treatments as ordered by the physician. Staff should have assessed the resident's feet while applying the Skin Prep and notify the physician of any changes in the resident's skin. 6. During an interview at on 5/24/16 at 2:30 P.M., the administrator and DON said it was facility policy for bath/shower sheets to be filled out every time a resident received a shower, and the CNA, charge nurse, and treatment nurse should all sign the sheets before they were turned into the DON. Skin assessments should be done on admission, readmission, and two times per week there after. Nurses should notify a resident's responsible party any time there was a change in condition and the development of a new pressure ulcer would be considered a change in condition. Care plans should be individualized to each resident and updated to reflect a change in condition. MO 018

Based on observation, interview and record review, the facility failed to provide appropriate care and services, for one of 19 sampled residents, by not ensuring the resident had transportation to a cardiologist appointment, had a cardiac medication as ordered, the cardiologist was notified when it was discovered the medication would not be available for up to three days and the resident had an elevated pulse. The resident was admitted to the hospital with a rapid pulse rate after missing three does of the medication. (Resident #20) The census was 106. Review of Resident #20's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/13/13, showed the following: -Adequate hearing and vision; -Clear speech; -Understood/Understands; -No behavioral issues; -Did not reject care; -Limited assistance of one person required for bed mobility, transfers, walking in room and corridor, locomotion on/off the unit, dressing, toilet use and personal hygiene; -[DIAGNOSES REDACTED]. -Other health conditions: Shortness of breath or trouble breathing with exertion, and shortness of breath or trouble breathing when lying flat. Review of the resident's care plan, dated 12/27/13, showed the following: -No memory or cognitive deficits; -No problems or interventions related to the resident's [DIAGNOSES REDACTED]. Review of the resident's medical record, showed the following: -admitted on [DATE]; -readmitted from a hospital on [DATE], with a [DIAGNOSES REDACTED]. -Full code (all measures of resuscitation to be taken). Review of the resident's physician's orders [REDACTED]. -Oxygen at 3 liters a minute continuously; -[MEDICATION NAME] (heart rhythm medication) 250 micrograms (mcg) at 8:00 A.M. and 8:00 P.M.; -[MEDICATION NAME] (diuretic, removes excessive fluid from the body) 20 milligrams (mg) daily; -[MEDICATION NAME] (corticosteroid, used to treat inflammation) 30 mg for three days, 20 mg for three days, 10 mg for three days, 5 mg for three days then discontinue; -[MEDICATION NAME] CD (used to treat high blood pressure and prevent [MEDICAL CONDITION] (chest pain)) 120 mg daily; -[MEDICATION NAME] (used to treat high blood pressure) 100 mg at 8:00 A.M. and 8:00 P.M.; -Daliresp (used to treat [MEDICAL CONDITION]) 500 mcg daily; -[MEDICATION NAME] (used to treat high blood pressure) 50 mg daily; -Xarelto (used to reduce the risk of blood clots and [MEDICAL CONDITION] in people with A-fib) 15 mg daily; -Bi-pap (respiratory ventilation machine used to treat sleep apnea (pauses in breathing during sleep)) on at night and for all naps; -[MEDICATION NAME] (aerosol medication used to treat [MEDICAL CONDITION]) two inhalations at 8:00 A.M. and 8:00 P.M.; -[MEDICATION NAME] (aerosol medication used to treat [MEDICAL CONDITION]) nebulizer treatment at 6:00 A.M., 12:00 P.M., 6:00 P.M. and 12:00 A.M.; -[MEDICATION NAME] (aerosol medication used to treat [MEDICAL CONDITION]) at 8:00 A.M.; -[MEDICATION NAME] Diskus (aerosol medication used to treat [MEDICAL CONDITION]) at 8:00 A.M. and 4:00 P.M.; -Imdur (used to treat chest pain related to CAD) 30 mg at 6:00 A.M. and 6:00 P.M. daily. Review of the resident's "Skilled Nursing Assessment Flow Sheets", dated 2/2/14 through 2/20/14, showed the following: -2/2: 7:00 A.M. - 7:00 P.M., Pulse 84; -2/3: 7:00 P.M. - 7:00 A.M., Pulse 70; -2/4: 7:00 A.M. - 7:00 P.M., Pulse 88; 7:00 P.M. - 7:00 A.M., Pulse 82; -2/5: 7:00 A.M. - 7:00 P.M., Pulse 78; 7:00 P.M. - 7:00 A.M., Pulse 80; -2/6: 7:00 A.M. - 7:00 P.M., Pulse 76; 7:00 P.M. - 7:00 A.M., Pulse 72; -2/7: 7:00 P.M. - 7:00 A.M., Pulse 76; -2/8: 7:00 P.M. - 7:00 A.M., Pulse 72; -2/9: 7:00 P.M. - 7:00 A.M., Pulse 84; -2/10: 7:00 P.M. - 7:00 A.M., Pulse 90; -2/11: 7:00 P.M. - 7:00 A.M., Pulse 76; -2/12: 7:00 A.M. - 7:00 P.M., Pulse 82; 7:00 P.M. - 7:00 A.M., Pulse 78; -2/13: 7:00 A.M. - 7:00 P.M., Pulse 68; 7:00 P.M. - 7:00 A.M., Pulse 76; -2/14: 7:00 A.M. - 7:00 P.M., Pulse 82; 7:00 P.M. - 7:00 A.M., Pulse 76; -2/15: 7:00 A.M. - 7:00 P.M., Pulse 94; 7:00 P.M. - 7:00 A.M., Pulse 76; -2/16: No notes available; -2/17: 7:00 A.M. - 7:00 P.M., Pulse 88; -2/18: 7:00 A.M. - 7:00 P.M., Pulse 74; -2/19: 7:00 A.M. - 7:00 P.M., Pulse 88; -2/20: 7:00 A.M. - 7:00 P.M., Pulse 88; 7:00 P.M. - 7:00 A.M., Pulse 80; -No "Skilled Nursing Assessment Flow Sheet", dated 2/21/14, at the time of the review. Observation on 2/21/14 at 8:10 A.M., showed the resident sat on his/her bed. Certified Medication Technician (CMT) A used the facility automatic blood pressure/pulse machine to obtain the resident's pulse of 161. The CMT began to prepare the resident's morning medications and after a couple of minutes, rechecked the resident's pulse with the automatic machine. The resident's pulse was 163. The CMT continued to prepare the resident's morning medications and said he/she could not give the resident his/her [MEDICATION NAME], because it was out of stock. Review of the Medication Administration Record [REDACTED]. At 8:20 A.M., Nurse B walked by and the CMT informed the nurse about the resident's rapid pulse rate. Nurse B manually checked the resident's pulse and said it was 150. Nurse B informed Nurse C, the floor charge nurse about the rapid pulse rate. At 8:25 A.M., the CMT handed the resident a cup filled with 15 different medications. The resident looked in the cup and said one of the medications was missing. The CMT said the [MEDICATION NAME] was out of stock and a nurse would call the doctor to have it reordered. The resident took the medications at that time. At 8:35 A.M., Nurse C entered the resident's room and assessed the resident. During an interview on 2/21/14 at 8:40 A.M., the Director of Nurses (DON), said the facility would have to contact the resident's cardiologist to obtain an order for [REDACTED]. The appointment was missed and will have to be rescheduled. During an interview on 2/25/14 at 10:00 A.M., Nurse C said the resident was alert, oriented and aware of the medications he/she takes. The resident may not know them all by name but he/she knows what they are for. The resident knows [MEDICATION NAME] is a heart medication. A couple of weeks ago, he/she could not recall the day, the CMT told him/her the resident's [MEDICATION NAME] was running out. Nurse C knows [MEDICATION NAME] is a cardiac medication and should not be stopped abruptly. He/She contacted the cardiologist's office and scheduled an appointment for 2/18/14, so the resident could get the [MEDICATION NAME] prescription refilled. He/She completed a "Transportation Request Form" and left it on the transportation aide's desk, because the transportation aide was not in the room at the time. He/She did not realize the appointment had been missed until 2/21/14, when the resident ran out of the [MEDICATION NAME]. Nurse B told him/her the resident's pulse was 150 and the CMT had obtained a pulse of 161 and 163 on that same day. When he/she took the resident's pulse that morning, it was 112 with the machine and 84 when he/she took it manually. He/She documented the pulse of 84 on the "Skilled Nursing Assessment Flow Sheet", but he/she did not document the pulses of 161, 163, 150 or 112. Nurse C contacted the cardiologist's office and rescheduled the appointment for 2/25/14. He/She could not recall if he/she told them about the resident's pulses of 161, 163, 150 or 112, or who he/she spoke to at the cardiologist's office. He/She did not document anything in the resident's medical record. Someone from the cardiologist's office faxed the facility a prescription and he/she faxed it to the pharmacy. The pharmacy informed him/her they could not deliver the medication until 2/24/14, because they did not keep it in stock and it would have to be ordered. He/She did not document that, or inform the cardiologist, but he/she should have. Nurse C informed the DON and was told to check the resident's pulse every three hours, but he/she did not get any more pulses on the resident that day. He/She did not document anything that occurred that day on shift report log and did not verbally tell the on-coming nurse in report, on 2/21/14 at 7:00 P.M. Nurse C did not know why he/she did not document any of this information but said there really was no excuse other than it just slipped his/her mind. During an interview on 2/24/14 at 8:10 A.M., the DON said he personally checked the resident's pulse, on 2/21/14, after being notified about the rapid pulse and it registered 118. He took it again before he went home that evening, and it was 107. He did not document either of the pulse rates but he should have. He contacted the cardiologist's nurse practitioner that day, about the resident's [MEDICATION NAME] being out of stock. He told the nurse practitioner the resident had pulses in the 150s and 160s earlier in the day and she did not seemed concerned since the resident had no other symptoms like chest pain. He did not ask and she did not say, if staff should monitor the resident's pulse more frequently. The nurse practitioner faxed a prescription for the [MEDICATION NAME] to the facility and they faxed the prescription to the pharmacy. The pharmacy said they did not keep [MEDICATION NAME] in stock, would have to order it and it wound not be delivered until 2/25/14. He told Nurse C to monitor the resident's pulse every four hours. He did not document that or anything about the conversation he had with the nurse practitioner but he should have. He did not recall the name of the nurse practitioner. The facility missed the resident's appointment with the cardiologist on 2/18/14. The appointment was necessary to get the [MEDICATION NAME] reordered. The cardiologist did not want to refill the prescription without seeing the resident first. Had the appointment not been missed, the resident would not have ran out of the [MEDICATION NAME]. Nurse C told him an appointment had been made on 2/18/14. The DON checked the transportation calendar and the appointment was not scheduled. He thinks Nurse C forgot to schedule the appointment with the transportation aide. He reviewed the resident's medical record and did not know why Nurse C failed to document anything from 2/21/14. During an interview on 2/25/14 at 8:00 A.M., Nurse G said he/she relieved Nurse C, on 2/21/14 at 7:00 P.M. Nurse C did not inform him/her about the resident having a rapid pulse that day or that he/she did not have the [MEDICATION NAME]. He/She did not receive any orders or direction to monitor the resident's pulse every three hours. During an interview on 2/24/14 at 9:40 A.M., the facility transportation aide said he had checked his transportation calendar and he did not have an appointment for the resident with the cardiologist scheduled for 2/18/14. The nurses were supposed to give him a "Transportation Request Form". He did not have one for the resident on 2/18/14, and none of the nurses told him verbally about the resident having an appointment for that date. Review of the resident's February 2014, MAR, on 2/24/14 at 7:00 A.M., showed the following: -On the front of the MAR, staff had initialed, then circled their initials (an indication a medication was not administered as ordered) for the [MEDICATION NAME] on 2/21 at 8:00 A.M. and 8:00 P.M. and 2/22/14 at 8:00 A.M.; -On the back of the MAR, staff documented the [MEDICATION NAME] had not been administered on the following dates and times: -2/21 at 9:00 A.M.: Not given, "on order"; -2/21 at 8:00 P.M.: Waiting on pharmacy to release medication per physician's approval. Gave last dose on 2/20/14. Had pre-ordered. Phoned pharmacy. Need physician's approval. Review of the resident's medical record, on 2/24/14 at 7:20 A.M., showed the following: -2/21: "Skilled Nursing Assessment Flow Sheet", 7:00 A.M. - 7:00 P.M., Pulse 84, strong and regular; -No documentation regarding the resident's pulse of 161, 163 or 150 obtained on 2/21/14; -No documentation of staff notifying the resident's cardiologist regarding the resident's pulses; -No documentation by Nurse C regarding his/her assessment of the resident on 2/21/14; -No documentation regarding follow-up pulses after the 2/21/14 "Skilled Nursing Assessment Flow Sheet" 7:00 A.M. - 7:00 P.M., showing a pulse of 84, until 2/22/14, when Nurse D recorded a pulse of 112 on the "Skilled Nursing Assessment Flow Sheet" for the 7:00 A.M. - 7:00 P.M. shift; -A faxed copy of a prescription for [MEDICATION NAME], dated 2/21/14, with the following hand written note: "pharmacy has a copy of this information", but no documentation who obtained the prescription or when; -A "Long Term Care Hand Off Communication" form, dated 2/22/14 at 3:55 P.M., showed staff sent the resident to a local hospital for pain in his/her leg and an irregular heart rate of 114. The resident is alert and oriented. During an interview on 2/24/14 at 7:30 A.M., Nurse D said he/she was the charge nurse, on 2/22/14 from 7:00 A.M. until 7:00 P.M., and he/she sent the resident to the hospital at around 4:00 P.M. The resident said he/she felt different and the nurse checked the resident's vitals for the first time that day and found the resident's pulse was around 112. He/She called the resident's primary physician's (not the cardiologist's) nurse practitioner and did not get a response. The resident said he/she wanted to go to the hospital so he/she called the DON, who gave permission to send the resident out. The resident was admitted to the hospital for the rapid pulse. Nurse D had not been told during the change of shift report, on 2/22/14, about the resident's pulses of 161, 163 and 150 on 2/21/14. He/She had not been instructed to monitor the resident's pulse rate more frequently. The nurse had worked at the facility for about eight months and had not known the resident's pulse to be in the 150s or 160s before. Had Nurse D known, he/she would have checked the resident's pulse before the afternoon on 2/22/14. He/She got busy and failed to document the resident's change in condition or that he/she had to send the resident to the hospital that day, but he/she would document those events now. Review of the resident's nurse's notes, showed an entry dated 2/15/14, and then no other note until Nurse D's the entry, dated 2/24/14 at 7:35 A.M., which showed the following: -Additional information: resident sent to hospital on [DATE], at approximately 4:00 P.M. Resident had irregular pulse and complained of not feeling the same as usual. Vitals: blood pressure: 126/75 (normal 90/60 to 120/80), pulse: 113 - 120 (normal 60 to 100), respirations: 24 (normal 12 to 18), oxygen saturation of 96% (normal 95 to 100%). Contacted the DON due to not being able to speak with the on call nurse practitioner right away. Informed the DON of resident's status and desire to go to the hospital. Resident sent to hospital via ambulance. During an interview on 2/24/14 at 8:10 A.M., the DON said he did not know why Nurse D failed to document anything from 2/22/14. The Assistant Director of Nurses said she was at the facility, on 2/22/14, and Nurse D told her the resident's pulse was too fast to count. She told Nurse D to call the resident's physician's on-call number. The DON did not know why staff failed to monitor the resident's pulse more closely after knowing the resident had no [MEDICATION NAME] left. All of this should have been documented including what he had done. During a telephone interview on 2/24/14 at 11:15 A.M., the resident's cardiologist said he had no idea why the resident missed his/her appointment with him, on 2/18/14, and he did not know the resident's pulse had been in the 150s or 160s on 2/21/14. There are several nurse practitioners that work for his office and he did not get an update about the resident being out of the [MEDICATION NAME] or the resident's rapid heart rate on 2/21/14. It is not unusual for a patient with A-fib to have a heart rate that rapid at times and if the resident was not having other symptoms he probably would not have sent the resident to the hospital. He would have expected staff to monitor the resident's pulse at least every four to six hours though. He did not know the resident was out of [MEDICATION NAME] and that he/she might have been out of the medication for three days. The facility should have informed him. The resident's admitting [DIAGNOSES REDACTED]. Being out of the medication is what likely led to the resident having a rapid heart rate and the hospitalization . Further review of the resident's medical record, showed he/she returned from the hospital, on 2/24/14 at 5:10 P.M., with an order to resume [MEDICATION NAME] 250 mcg two times a day. Review of the hospital records, dated 2/24/14, showed the following: -2/22/14: Pulse at 4:08 P.M. - 120, 4:23 P.M. - 143, 4:26 P.M. - 141, 4:35 P.M. - 108, 4:36 P.M. - 128, 5:00 P.M. - 129, 6:00 P.M. - 97, 7:00 P.M. - 94, 10:00 P.M. - 127, 11:00 P.M. - 118; -Resident came to emergency department with a rapid ventricular rate of 110 - 120. Patient states he had not taken [MEDICATION NAME] for two days. Patient also admitted for [MEDICAL CONDITION], bleeding colon ulcer and [MEDICAL CONDITION]. During an interview on 2/25/14 at 8:15 A.M., the resident said he/she did not know he/she had an appointment or that he/she missed the appointment on 2/18/14. No one had told him/her. [MEDICATION NAME] is a medication for his/her heart and he/she knows it is important because the cardiologist told him/her in the past about it. His/Her elevated heart rate, on 2/21/14, did not concern him/her too much. It had been that high before, but he/she had learned to deal with it. After the morning of 2/21/14, no one took his/her pulse again until right before they sent him/her to the hospital on [DATE]. On 2/22/14, he/she was in his/her room and did not feel well: he/she felt dizzy. He/she told Nurse D, who took his/her vitals. That was the first time since Friday morning, 2/21/14, anyone had checked his/her pulse and the resident told Nurse D he/she wanted to go to the hospital at that time.

Based on observation, interview and record review, the facility failed to provide appropriate care and services to prevent the development of a pressure ulcer for one sampled resident. The facility identified thirteen residents with pressure ulcers. Four were sampled and problems were found with one. The sample was 13. (Resident #14) The census was 106. 1. Review of Resident #14's admission Clinical Health Status, dated 7/23/13, and completed on admission, showed the following: -Hard of hearing, deaf; -Legally blind; -Skin conditions: Body diagram: Buttocks circled with "reddened" written in. Left foot circled with "pressure ulcer and 1.8 centimeter (cm) by 1.5 cm by 0.1 cm" written in. Right foot circled with "surgical and 0.4 cm by 0.4 cm" written in; -Braden scale (a tool used to assess pressure ulcer risk): Total score:10, high risk. Review of the resident's Interim Admission Care Plan, dated 7/23/13, showed the following: -Problem: Impaired Skin Integrity and At Risk for Impaired Skin: marked with an "x" . Location/Stage: "unable to get up" written in; -Goal: Will remain free from new areas of skin breakdown over next 30 days. Resident's wounds will show evidence of healing and be free from infection over next 30 days. No documentation of where wounds were located. -Approach: See current physician's orders [REDACTED]. Review of the resident's history and physical examination [REDACTED]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/30/13, showed the following: -[DIAGNOSES REDACTED]. -Severe cognitive impairment; -Required total assistance of staff for all activities of daily living; -Incontinent of bowel; -Indwelling catheter (a sterile tube inserted through the urethra into the bladder, used to drain urine); -Pressure ulcers: none. Review of the resident's Certified Nurse Assistant (CNA) Bath Record, showed the following: -Instructions: Staff must sign as completed and submit to the charge nurse for review and signature. The charge nurse must observe any new findings visually at the time of bath/shower. -11/4/13 at 6:30 P.M.: Skin condition: Redness marked. Body diagram: Front: Perineal area colored in. Right foot: circled with the word "bandage" written in. Back of body diagram: Center of buttocks colored in. Signed by the CNA and a nurse. Review of the resident's nurse's notes, showed no documentation regarding perineal or buttocks redness noted on 11/4/13. Review of the resident's physician's orders [REDACTED]. Review of the resident's TAR, dated 11/1/13 through 11/30/13, showed the following: -Nutrashield: May utilize PRN; -Front of TAR: blank; -Back of TAR: blank, no documentation regarding redness. Review of the resident's CNA Bath Record, dated 11/21/14, showed the following: -No time noted. Skin Condition: Skin intact marked. Body Diagram: Blank. Signed by CNA, no nurse signature. Review of the facility Weekly Wound Report, dated 11/25/13, showed the following for the resident: -Site: right ischial tuberosity (lower buttocks, where the thigh and buttocks meet); -Size: 1.4 cm by 2.4 cm by 0.1 cm; -Stage: III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling); -Treatment: Cleanse, apply skin prep (a drying agent) to periwound, apply Santyl (a sterile enzymatic [MEDICATION NAME] ointment used to remove dead tissue) to wound bed, [MEDICATION NAME] (specialized dressing, ideal for most draining wounds. Coated with a [MEDICATION NAME] to prevent dressing adherence while allowing exudate (drainage) to easily pass through) and dry dressing daily; -Acquired in house on 11/25/13; -Appearance/Detail: Periwound intact, erythemic (red). Wound bed 70% yellow, loosely adhered moist slough (dead, dying tissue); -Status: New. Review of the resident's POS, dated 11/1/13 through 11/30/13, showed an order, dated 11/25/13, to cleanse buttocks with wound cleanser, apply Santyl daily, cover with Adaptive and dry dressing. Review of the resident's TAR, dated 11/1/13 through 11/30/13, showed the following: -Front of TAR: No order to cleanse buttocks with wound cleaner, apply Santyl ointment, [MEDICATION NAME] and dry dressing daily; -Back of TAR: Blank. No description of pressure ulcer. Review of the resident's nurse's notes, for the month of November 2013, showed two entries, one dated 11/7/13 and one dated 11/15/13. Neither entry was related to the resident's skin/pressure ulcer or treatment orders. During an interview on 2/26/14 at 8:30 A.M., the Director of Nurses (DON) said he was unable to find any further documentation of skin assessments for November 2013. Review of the physician's progress note, dated 12/6/13, showed no documentation regarding a pressure ulcer on the resident's buttocks. Review of the resident's weekly skin integrity review, dated 12/9/13, showed the following: -Skin condition: The word "other" checked, "treatment in place", written in; -Open area checked, old checked; -Diagram of body: Front: unmarked, Back: "x" marked on buttocks. No documentation of size or description of the pressure ulcer. Review of the resident's Wound Management assessment, dated 12/9/13, showed the following: -Wound: Pressure ulcer/unstageable; -Body part: Right ischium; -Status: New; -Description: Eschar (dead tissue): fully covered; Wound base color: 90 % yellow, black 10%; Necrotic (dead) tissue: Extensive, Drainage amount: scant; -Measurement: 2.7 cm by 3.3 cm by 0.3 cm; -Obtain X-ray of the right ischial tuberosity to rule out osteo[DIAGNOSES REDACTED] (infection of the bone). This was the first Wound Management visit related to the resident's right ischial/buttocks pressure ulcer and the first documented assessment in the resident's medical record. Review of the resident's POS, dated 12/1/13 through 12/31/13, showed an order, dated 12/11/13, for an X-ray of the right ischial tuberosity to rule out osteo[DIAGNOSES REDACTED]. Review of the resident's nurse's notes, showed the following: -12/11/13 at 9:20 P.M., received an order for [REDACTED]. -12/12/13 9:40 A.M., call placed to order the X-ray of the right ischial tuberosity; -No further documentation regarding the right ischium/buttocks pressure ulcer in the December 2013, nurse's notes. Review of the resident's right hip X-ray results, dated 12/12/13, showed no acute abnormalities. Review of the resident's skin integrity review, dated 12/16/13, showed the following: -12/16/13: Other: checked: "treatment in progress" written in. Open area: The word "old" checked. Body diagram: Front: Blank. Back: "x" marked on lower buttocks. No documentation of measurements or description of the pressure ulcer. Review of the Wound Management assessments, showed the following: -12/16/13 -Pressure Ulcer: Unstageable; -Body part: Right ischium; -Predebridement length: 3.5 cm, width: 2.8 cm, depth: 0.5 cm; -Description: Eschar: fully covered, Wound base: 100% yellow, Necrotic tissue: moderate; -Procedure: Excisional debridment (forcible removal of dead tissue); -Response to treatment: Did not tolerate the procedure well. Notes: Debrided tissue was surgically excised with a rim of viable tissue. Unable to fully debride Eschar due to pain; -12/23/13 -Pressure ulcer: Unstageable; -Body part: Right ischium; -Status: not healed; -Quality of tissue: deteriorated; -Wound status: deteriorated; -Pre debridment: Length: 3.7 cm, width: 3.7 cm, depth: 0.7 cm; -Description: Eschar: fully covered, wound base: 90% yellow, 10% black; -Off-loading/immobilization: Keep weight off right hip at all times; -Procedure: Excisional debridment. Review of the resident's skin integrity review, dated 12/30/13, showed the following: -Skin condition: The words "dry", "rash" and "open area" checked; -Front of body diagram: The word "rash" written in, arrows pointing to abdomen and perineal area. Back of body diagram: "x" marked on lower buttocks. No documentation of measurements or description of the pressure ulcer. Review of the resident's facility's Wound Assessment, dated 12/30/13, showed the following: -Measurement: right ischial tuberosity: 5.7 cm by 3.9 cm by 0.7 cm; -Type: Pressure; -Pressure ulcer is deteriorating. Wound bed 100% covered by yellow, brown, slightly moist, thick firmly adhered slough. Review of the resident's TAR, dated 12/1/13 through 12/31/13, showed the following: -Front of the TAR: a handwritten order to cleanse buttock with wound cleanser, apply Santyl, [MEDICATION NAME] and dry dressing, that staff had initialed as completed as ordered, except on on 12/6 and 12/23; -Back of TAR: No pressure ulcer measurement or description. Just an entry, dated 12/23/14, 7 P.M. to 7 A.M., buttock wound: up in chair, unable to do. Review of the resident's physician's progress notes, dated 1/2/14, showed the following: -Patient seen for a follow up; -Right buttock ulcer: Stage IV (Full thickness skin loss with extensive destruction, tissue necrosis, damage to muscle, bone or supporting structures (tendon or joint). Some necrotic tissue on base; -Plan: Possible wound clinic consult. Review of the resident's facility Wound Assessment, dated 1/7/14, showed the following: -Right ischial tuberosity measurements: 5.7 cm by 3.9 cm by 0.7 cm; -Wound type: pressure. Review of the resident's POS, dated 1/1/14 through 1/31/14, showed a order dated 1/7/14, to insert an indwelling urinary catheter (a tube inserted through the urethra to drain the urine from the bladder), related to wound care and schedule consult with hospital wound clinic. Review of the resident's POS, dated 1/1/14 through 1/31/14, showed the following: -Order, undated: X-ray right hip and gluteal area to rule out osteo[DIAGNOSES REDACTED] and evaluation of soft tissue to rule out abscess; -Order undated: Right buttock wound: Cleanse with wound cleaner, apply [MEDICATION NAME] (antibiotic ointment) and Santyl cover with Silver alginate (specialized wound dressing used to provide antimicrobial action to prevent infection, absorb exudates and maintain a moist environment) and dry dressing Review of the resident's right hip X-ray results, dated 1/24/14, showed four views compared to 12/12/13, X-ray and nothing acute. Review of the resident's POS, dated 1/1/14 through 1/31/14, showed the following: -1/27/14: Discontinue Wound Management; -1/27/14: Right ischial wound: apply saline moist gauze to ischial wound base, cover with ABD (large gauze dressing) and secure with tape. Review of the resident's nurse's notes, showed the following: -1/28/14 at 5:00 P.M., a right ischial skin assessment: 8.1 cm by 4.7 cm by 2.2 cm; -1/31/14 at 2:00 P.M.: Discharge to the hospital. 4:45 P.M.: admitted to hospital. Review of a physician's progress note, dated 2/2/14, showed the resident went to the hospital to have the right buttock Stage IV pressure ulcer surgically debrided. Review of the resident's hospital discharge plan, dated 2/7/14, showed the following: -Diagnosis: [REDACTED]. -Infection: [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). Review of the resident's readmission nurse's notes, dated 2/7/14 at 9:00 P.M., showed the following: -Right ischial tuberosity pressure ulcer with a wound vac (promotes healing through negative pressure); -PICC line (peripherally inserted central catheter; a form of intravenous access for prolonged usage). Review of the resident's POS, dated 2/1/14 through 2/28/14, showed an order for [REDACTED]. During an interview on 2/24/14 at 5:35 P.M., Nurse H said he/she had worked at the facility for one month. When a resident developed a pressure ulcer staff were to notify the charge nurse, who should get a treatment order and notify the treatment nurse. During an interview on 2/25/14 at 7:40 A.M., CNA I said the resident used to sit in a gerichair during the day prior to having the surgery to his/her buttocks. The pressure ulcer developed one to two months ago. It started small and progressively got worse. Observation on 2/26/14 at 1:45 P.M., showed the resident lay in bed on a low air loss mattress. Nurse H removed the wound vac dressing revealing a large pressure ulcer with yellow slough to the right ischial. He/She said the pressure ulcer was unstageable and measured 5.1 cm by 7.8 cm by 2.1 cm, and the area of slough measured 3.7 cm by 3.8 cm. Review of the facility's Pressure Ulcer: Prevention and Findings Reporting, updated 2/25/14 (date verified), showed the following: -Purpose: To prevent Pressure Ulcers by identifying resident's "At Risk"; -Policy and Procedure: 1. The Braden Scale is used as an instrument to identify "skin at risk for breakdown". The Braden Scale is done upon admission and quarterly. 2. The Braden Scale should be done when there is a change of condition. 3. The CNA is to observe and report any areas of change in the appearance on the skin during routine care and during resident showers (CNA must document on the shower record, sign and have the Charge Nurse sign and review). Report to the charge nurse for further assessment and follow up. 4. The charge nurse is to do a skin assessment at least weekly, and at any time a care provider reports a change in the appearance of the skin (during routine care, showers). 5. The charge nurse will complete an initial approximate measure and description of the wound in the nurse's notes. 6. If there is a need for a treatment, the Charge Nurse and or Wound Nurse, will phone the physician and implement the order as described. 7. The treatment will be placed on the TAR at the time the physician order [REDACTED]. The Wound Nurse will assess the Skin Area of Concern and will review the physician's orders [REDACTED]. 9. The Wound Nurse will confirm and document wound and document in the Wound Care Section of the medical record. 10. The Wound Nurse will document all treatments on the TAR, just as the charge nurse would be expected to perform. 11. The charge nurse and the wound nurse will review the patient for a change in condition and implement the appropriate Skin Care Interventions (associated with the Braden Scale) and or as ordered by the physician. Review of the facility's Care Alert, dated 2/25/14, showed the following: -CNAs: Report any skin redness or areas that appear to have a change in the appearance of the resident's skin. (example: A resident discovered with a pressure ulcer already at a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) or III with yellow appearing tissue within the ulcer is an indication that we missed the opportunity earlier to prevent and treat; -You must give all showers as assigned; -Sign your shower records. Assure your nurses sign your shower records. If they refuse, notify administration (DON, ADON, Wound Nurse and/or Administrator); -Nurses: When a CNA reports they see a change in skin condition, it is your obligation and responsibility to take immediate action to assess, and follow-up and treat; -Example: same as above; -Assure your CNAs are doing their showers; -Sign the shower records. Review them for any skin findings; -If finding, assess areas immediately; -You must sign all shower records; -The Wound Care Nurse has the authority to assure all the above is done to completion. During an interview on 2/26/14 at 8:30 A.M., the DON said he would expect staff to notify the physician, obtain an order and document in the nurse's notes or on the back of the TAR. He didn't know why staff failed to put the 11/25/13, treatment order on the TAR or why they didn't document in the nurse's notes a measurement and description of the pressure ulcer. During an interview on 2/28/14 at 12:25 P.M., the resident's physician said when an order was given for a treatment he expected the treatment to be done and documented in the medical record. He was unaware the treatment ordered on [DATE], wasn't done until 12/1/13. It was possible for the pressure ulcer to deteriorate if the treatment wasn't done as ordered. It would be difficult to determine if the treatment was working if the staff weren't doing it. MO 962

This deficiency is uncorrected. For previous examples refer to the statement of deficiencies dated 2/26/14. Based on observation, interview and record review, the facility failed to provide care to a pressure ulcer in a manner to prevent infection and promote healing for one resident (Resident #14). The census was 103. 1. Review of Resident #14's physician's orders [REDACTED]. -[MEDICATION NAME] (intravenous (IV) antibiotic used to treat severe infections)1250 milligrams (mg) per IV every 24 hours; -Wound vac to right hip, change every Monday, Wednesday and Friday and as needed. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/24/14, showed the following: -Short/long term memory problem; -Severe cognitive impairment; -Required total assistance of staff for all activities of daily living; -Incontinent of bowel; -Pressure ulcer: Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling); -Special treatments: IV medication. Review of the weekly wound tracking worksheet dated 4/11/14, showed the resident had a Stage IV pressure sore on his/her right ischium (lower back part of the hip bone) which measured 3.8 centimeters (cm) by 4.8 cm and 2.2 cms deep. Observation on 4/17/14 at 12:20 P.M., showed the resident lay in bed, incontinent of a large amount of liquid feces. The liquid feces covered the resident's pressure ulcer dressing, wound vac tubing and urinary (sterile tubing inserted through the urethra into the bladder) catheter. Nurse D washed his/her hands, applied gloves, began to wipe the resident's buttocks with several disposable wash cloths. After wiping off the wound vac dressing and without changing his/her gloves, Nurse D began to wipe the feces off of the wound vac tubing, reaching under the edge of the dressing. Feces were was still visible under the edges of dressing. Without changing his/her gloves, Nurse D continued to wipe the resident's perineal area, at times wiping toward the perineal area, while cleaning the urinary catheter tubing. Without removing his/her gloves, Nurse D touched a rash on the resident's right thigh and assisted Certified Medication Technician (CMT) N with positioning, touching the resident's face in the process. Nurse D said the treatment nurse would change the resident's wound vac dressing as soon as he/she finished in the dining room. Without providing any more care to the resident, Nurse D and CMT N left the room. At 1:12 P.M., the resident lay in bed and the wound vac was beeping. Nurse Q said it was due to the dressing being loose. Prior to changing the resident's dressing, Nurse Q said the resident's wound vac dressing was soiled with feces and should have been changed immediately. During an interview on 4/18/14 at 2:00 P.M., the Director of Nurses said she expected the nurse to change the wound vac dressing immediately if soiled. The resident recently completed intravenous antibiotic therapy for a wound infection, so it would be important to keep feces off the wound as much as possible.

Based on observation, staff interview and record review, the facility failed to adequately identify, assess, monitor and provide treatment to pressure ulcers. The facility identified ten residents with pressure ulcers. Of those ten, five were chosen for the sample. Of those five, one did not have pressure ulcers assessed or treated (Resident #7). The total sample was 17. The census was 98. 1. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/20/10, showed the following: -[DIAGNOSES REDACTED]. -Short/long term memory problems; -Severe cognitive impairment; -Speech unclear, slurred or mumbled speech; -Required extensive to total assistance for activities of daily living; -Incontinent of bowel and bladder; -Gastrostomy tube ([DEVICE], tube surgical inserted into the stomach to provide nutrition, medications and hydration); -Pressure ulcer (localized injury to the skin and/or underlying tissue usually over bony prominence)-none; -Risk of developing pressure ulcers. Review of the hospital record dated 1/8/11, showed the following: -Right hip pressure ulcer; -Right lateral (outer aspect) ankle pressure ulcer; -Right lateral foot pressure ulcer; -Left medial (inner aspect) foot pressure ulcer; -No documentation of the stage of the pressure ulcers, no description and size of the pressure ulcers. Review of the admission face sheet and physician order [REDACTED]. -Originally admitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the nursing admission assessment dated [DATE], showed the following: -Blood blister to the right hip; -Reddened buttocks; -Abrasion (scraping of the skin) to the left hallux (great toe); -Abrasion to the right lateral malleolus (outer aspect of the ankle) and right lateral foot. Review of the resident's weekly skin assessment dated [DATE], showed bruises to both upper and lower arms and scab to the right lower leg. No documentation of any open areas or pressure ulcers. Review of the wound assessment dated [DATE], showed the following: -Right ischium (lower portion of the hip bone) pressure ulcer, measured 3.5 centimeters (cm) in length by 5.6 cm in width, unstageable (slough and/or eschar (dead and dying tissue) coverage to wound bed) pressure ulcer, eschar/slough black in color; -Left ischium pressure ulcer, measured 3.0 cm by 3.2 cm, Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) pressure ulcer; -treatment for [REDACTED]. -treatment for [REDACTED]. Review of the certified nurse's assistant (CNA) bath sheets, showed the following: -On 1/15/11, skin intact, no open areas or pressure ulcers identified; Review of the physician's progress note dated 1/17/11, showed no documentation of any abrasions, open areas or pressure ulcers identified by the physician. Review of the wound assessment dated [DATE], showed the following: -Right ischium measure 5.8 cm by 4.0 cm, unstageable pressure ulcer; -Left ischium measured 3.4 cm by 3.0, unstageable pressure ulcer with yellow slough/eschar; -treatment for [REDACTED]. Further review physician order [REDACTED]. -An order dated 1/18/11, to cleanse the left ischium, apply Santyl and apply a dry dressing daily until healed. -An order dated 1/18/11, to cleanse the right ischium with wound cleanser, apply Santyl and dry dressing until healed; -No treatment order for the abrasion on the left hallux, right lateral malleolus and right lateral foot. Review of the CNA bath sheet dated 1/19/11, showed skin intact. No open areas or pressure ulcers identified; Review of the resident's weekly skin assessment dated [DATE], showed open areas to the right and left ischium. Review of the CNA bath sheets dated 1/22/11, showed skin intact. No open areas or pressure ulcers identified. Review of the nurse's notes dated 1/12/11 through 1/25/11, showed no documentation of any open areas or pressure ulcer identified on the resident's feet and right ankle. During observations on 1/24/11 at 12:05 P.M., 1:35 P.M. and 3:00 P.M., on 1/25/11 at 7:15 A.M., 9:10 A.M., 12:20 P.M. and 2:00 P.M., showed staff positioned the resident onto his/her right side in the bed with a low air loss (alternating pressure relief) mattress on the bed. Review of the physician's orders [REDACTED]. -Multi podus boots to both feet; -Cleanse right ankle with normal saline (sterile solution used to cleanse wounds), apply [MEDICATION NAME] (medication used to debride necrotic tissue and heal pressure ulcers) and dry dressing daily; -Apply skin prep to left lateral great toe daily; -Apply skin prep to left lateral foot daily; -Apply skin prep to right medial foot daily; -Specialized wound management (SWM) consult; -Zinc (mineral for wound healing) 220 milligrams (mg) twice daily for 14 days; -Vitamin C 500 mg daily; -Multivitamin daily; -Protein powder 1 scoop daily; -Pre-[MEDICATION NAME] (laboratory test) level on 2/9/11. During observation on 1/26/11 at 10:50 A.M., the resident lay on his/her right side in the bed. Licensed Practical Nurse (LPN) T removed the dressing from the resident's left ischium, measured the pressure ulcer at 5.0 cm by 4.5 cm and provided the treatment to the left ischium as ordered. Staff positioned the resident onto his/her left side, the nurse removed the dressing from the right ischium, measured the pressure ulcer as 7.8 cm by 5.4 cm and provided the treatment to the right ischium as ordered. The nurse removed the resident's socks and identified new pressure ulcers on the resident's feet and right ankle. LPN T staged the open area on the resident's right outer ankle a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) that measured 2.2 cm by 2.0 cm, center of the pressure ulcer with yellow necrotic tissue that covered the wound bed. The nurse identified two areas on the right lateral foot as Unstageable (eschar and/or necrotic tissue covering the wound bed) pressure ulcers, one measured 1.2 cm by 1.3 cm and the other pressure ulcer measured 2.2 cm by 2.0 cm with purple, brown eschar that covered the wound bed. LPN T identified the area on the resident's left great toe as an Unstageable pressure ulcer that measured 4.8 cm by 4.0 cm with black and yellow necrotic tissue that covered the wound bed. The nurse identified the area on the resident's left medial foot as a Stage II pressure ulcer that measured 2.5 cm by 3.0 cm with a pink wound bed. During observation and interview on 1/26/11 at 10:50 A.M., the Director of Nurse's (DON) assessed the areas on the resident's feet and right ankle. The DON said the areas were pressure ulcers and she did not know about the pressure ulcers on the resident's feet and right ankle until 1/26/11. She expected night shift nursing staff to complete weekly skin assessments on all residents, document the findings on the weekly skin assessment, notify the resident's physician for treatment orders and notify the wound care nurse. During an interview on 1/26/11 at 10:50 A.M., the wound care nurse said he/she did not know about the pressure ulcers on the resident's feet and right ankle until 1/26/11. He/she said the charge nurse does the weekly skin assessments and should notify him/her regarding any skin breakdown or pressure ulcers. The wound nurse said he/she usually measured the wounds and pressure ulcers identified on the weekly skin assessments. He/she does not conduct a complete skin assessment when he/she completes the weekly wound and pressure ulcer measurements. During an interview on 1/26/11 at 11:50 A.M., CNA U said he/she had given the resident his/her shower over the last two weeks and reported the open areas on the resident's hips, feet and right ankle to several charge nurses. During an interview on 1/27/11 at 2:00 P.M., CNA V said he/she had given the resident a bath or shower on 1/19/11 and 1/22/11. The CNA said he/she did not document the open areas on the resident's feet and right ankle because he/she reported the areas to the charge nurse on 1/13/11. The CNA said he/she only documented new areas of skin breakdown on the bath sheet. During observation on 1/28/11 at 7:30 A.M. and at 8:20 A.M., the resident lay on his/her right side in the bed. The resident wore no multi podus boots on his/her feet as ordered by the physician. During an interview on 1/28/11 at 7:55 A.M., CNA W said he/she did not notice any multi podus boots on the resident when he/she started the night shift on 1/27/11. The CNA said the multi podus boots were not on the resident during his/her shift and did not know why. During an interview on 1/28/11 at 9:45 A.M., the DON said she expected nursing staff to turn and reposition residents with a low air loss mattress at least every two hours. The DON said the multi podus boots should be worn at all times. Review of the SWM consult dated 1/28/11, showed the following: -Right ischium, unstageable pressure ulcer that measured 9.0 cm by 5.5 cm with black/yellow necrosis with pink edges; -Left ischium, Stage II pressure ulcer that measured 1.5 cm by 2.2 cm; -Right ankle unstageable pressure ulcer that measured 0.7 cm by 0.9 cm with yellow necrotic tissue; -Right lateral foot Stage II pressure ulcer that measured 1.0 cm by 1.4 cm; -Left medial foot suspected deep tissue injury (damage of underlying soft tissue from pressure) that measured 2.0 cm by 2.5 cm; -Left great toe, unstageable pressure ulcer that measured 5.0 cm by 4.5 cm with black/yellow necrotic tissue. Review of the facility's undated policy for prevention of pressure ulcers, showed the following: -Purpose: To reduce and minimize the risk of pressure areas and skin breakdown by maintaining proper body alignment and pressure redistribution; -Turn and reposition at least every two hours and may require positioning more frequently; -The policy did not address physician notification of new, non-healing or changes in pressure ulcers, the initial and frequency of nursing skin assessments and information to be included in the assessment, information to be included on CNA bath sheets, nursing response to changes in a resident's skin condition when made aware of changes by a CNA and applying pressure reducing devices as ordered by a physician.