Every finding on record at Pillars of North County Health & Rehab Center, The

Based on interview and record review, the facility failed to follow appropriate discharge procedures for one resident (Resident #6) when staff failed to re-admit the resident from the hospital following an immediate discharge order dismissal. The sample size was six. The census was 58. Review of the facility's Immediate Discharge Policy & Procedure Manual, revised November 2017, showed:-Residents would not be transferred or discharged unless permitted by federal and Missouri regulations. An immediate discharge occurred when the safety or health of the resident or others was endangered, when the facility could not meet the resident's needs, or when the resident's behavior presented an immediate threat;-Purpose: To ensure immediate discharges were conducted safely, consistently, and in compliance with survey requirements;-Criteria:-Immediate danger to self or others;-Violent, aggressive, or threatening behavior;-Repeated unmanageable behaviors;-Facility unable to meet the resident needs;-Medical or psychiatric emergency required another level of care;-Procedure: -Assessed resident condition; -Notified Administrator and Director of Nursing (DON); -Obtained physician notification/order when appropriate; -Notified resident and responsible party; -Arranged safe discharge destination; -Provided discharge instructions and medications as applicable; -Completed all required documentation;-Required documentation: -Immediate Discharge Notice; -Progress Notes; -Nursing Assessment; -Physician Notification; -Responsible Party Notification; -Transfer Documentation; -Agency Notifications (if applicable);-Discharge appeal rights: Residents would be informed of applicable rights and provided information regarding state agencies when required by regulation. Review of Resident #6's hospital referral assessment plan, dated 04/15/26, showed:-admitted on [DATE];-Active problems: Adjustment disorder with mixed disturbance of emotions and conduct, depression (a serious mood disorder that caused persistent feelings of sadness, emptiness, and a loss of interest in activities), anxiety (chronic, exaggerated worry and tension about everyday events, often with no obvious cause), history of substance use disorder, chronic lower extremity wounds and colostomy (surgical procedure that creates an opening, called a stoma, in the abdominal wall); -Psychiatry evaluated the resident on 04/05/26 and prescribed Remeron (antidepressant primarily used to treat major depressive disorder.) and Zoloft (antidepressant medication). The resident refused to take the medications. The medications were discontinued;-Case management assisted with discharge planning due to the resident's reported abuse at the nursing home. Nursing home staff reported threats from the resident and refused to take him/her back;-The resident was deemed incompetent in May 2024 and had a legal guardian;-Disposition: Pending placement. Review of the resident's progress notes, showed:-On 04/21/26 at 1:13 P.M., the resident arrived at the facility in a wheelchair. His/Her diagnoses included stasis ulcers (a shallow, slow-healing open wound that develops on the lower legs or ankles) and adjustment disorder with disturbance of emotions and conduct. At 2:30 P.M., the resident refused wound care. The physician was notified. Review of the resident's care plan, in use during survey, showed:-Problem: The resident was at risk for alteration in mood and/or psychosocial well-being due to being in a new facility and adjustment disorder with mixed disturbance of emotions and conduct (start date: 04/22/26);-Approach: Staff conducted one-to-one visits and/or bedside socialization/activities as needed, consulted with practitioner for changes in mood or psychosocial status, encouraged the resident to socialize with other residents and attend activities, observed changes in mood and sleep patterns, changes in behavior, weight loss, crying episodes, nervousness, and provided opportunities for expression of feelings;-Problem: The resident could not be discharged to the community. He/She required 24-hour care (start date: 04/22/26);-Approach: Staff provided one-to-one visits as needed, call light within reach while in room, assisted the resident's family and friends as needed. Review of the resident's progress notes, showed:-On 04/24/26 at 9:22 P.M., the resident was outside a female resident's room. He/She yelled I got something I can put in you that feels really good. Staff educated the resident on inappropriate behaviors and tried to redirect him/her. The resident continued to call female staff bitches. Staff left a message for the physician. The resident did not display violent behaviors or threatening gestures;-On 04/25/26 at 5:57 P.M., the resident was belligerent towards staff. He/She made demeaning statements and used profanity. Staff redirected the resident;-On 04/30/36 at 2:46 P.M., staff attempted to provide wound care to resident. The resident said, I'm getting the fuck out of here and propelled down the hall in his/her wheelchair. The physician was notified. No new orders given. Review of the resident's care plan, in use during survey, showed:-Problem: The resident was verbally abusive, socially inappropriate, disruptive and resisted care. He/She made inappropriate drawings of his/her penis and told staff he/she was going to fuck them in the butt. He/She made inappropriate sexual advances towards staff and residents. He/She was non-compliant with wound and dressing changes. He/She ejaculated in the dining room in front of other residents (start date: 05/01/26);-Approach: Staff encouraged family support and/or involvement, encouraged the resident to vent his/her feelings, fears, and frustrations as needed, encouraged him/her to participate in activities of choice, notified the physician as needed, observed involvement in activities, provided medications as ordered and monitored effectiveness, and consulted the psychiatrist as needed. Review of the resident's progress notes, showed on 05/02/26 at 10:45 A.M., the resident displayed erratic behaviors. He/She refused medications. He/She made inappropriate statements to female residents in the dining room. He/She argued with staff and other residents. Staff tried to redirect him/her and use one to one, with no effectiveness. The resident refused PRN (as needed) behavior medications. The physician gave an order to send the resident to the hospital for a psychiatric evaluation. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/03/26, showed:-The resident could not complete the cognitive assessment;-Displayed disorganized thinking;-Physical behaviors towards others;-Diagnoses: Pain and chronic venous insufficiency (occurred when the veins in the legs did not efficiently return blood to the heart);-No therapy services. Review of the resident's progress notes, showed:-On 05/03/26 at 5:59 P.M., the resident told staff and other residents Somebody is going to die in this bitch today. He/She removed his/her clothes in the dining room and swung his/her colostomy bag. He/She threatened to throw feces on staff and other residents. Staff redirected the resident with limited effectiveness. Staff modified the environment to reduce stimulation. No physical contact or injuries noted to others. Staff notified the supervisor, physician and guardian. The guardian did not answer. The physician gave an order to send to the hospital for psychiatric evaluation;-On 05/11/26 at 2:45 P.M., the resident returned to the facility. He/She was upset his/her room was changed;-On 05/12/26 at 12:10 P.M., the physician assessed the resident. The resident wanted to do his/her own wound treatments for his/he bilateral, lower leg wounds. The nurse educated the resident on how to complete wound treatments. The physician gave approval for the resident to do his/her own wound treatments;-On 05/17/26 at 12:24 A.M., the resident masturbated in the dining room. Staff asked him/her to go to his/her room. The resident was angry and yelled. The resident was provocative (to cause a strong emotional, mental, or physical reaction) and inappropriate with staff during the night shift. Staff were unable to redirect the resident. At 2:22 A.M., the resident yelled and threatened staff. He/She wrote explicit letters to staff. He/She went into other residents' rooms while they slept. Staff were unable to redirect the resident. Staff notified the physician at 2:20 A.M. The resident was sent to the hospital for a psychiatric evaluation. Staff left a message for the resident's guardian. At 1:52 P.M., the resident returned to the facility with new medication orders. At 6:34 P.M., the resident propelled around the facility and yelled provocative and inappropriate things at staff and residents. Staff attempts to redirect the resident were unsuccessful. At 9:07 P.M., the resident was aggressive and verbally abusive towards staff. Staff attempts to redirect the resident were unsuccessful. The physician gave an order to send the resident to the hospital. The resident was transferred to the hospital for a psychiatric evaluation and treatment at 9:00 P.M.;-No documentation regarding the resident's discharge. Review of the Immediate Notice of Discharge, dated 05/17/26, showed:- The facility determined the resident's behaviors created concerns regarding the health, safety, and welfare of the resident and/or others. The facility was unable to meet the resident's needs safely at this level of care. Transfer to the hospital was necessary for further evaluation, treatment, and stabilization. The resident was transferred with available medical information and personal belongings as appropriate. Review of the Department of Health & Senior Services (DHSS) Appeals Unit Order of Dismissal, dated 05/22/26, showed:-The immediate discharge notice failed to contain: -The resident's right to appeal the transfer or discharge notice to the director of the DHSS or his/her designated hearing official within 30 days of the receipt of the notice; -That a request for hearing should be sent to the DHSS Appeals Unit, the Appeals Unit address, phone/fax number and email address; -The location to which the resident was being transferred or discharged ; -The name, address and telephone number of the designated regional long-term care ombudsman (an impartial, designated official or representative who investigated and helped resolve complaints between individuals and large institutions) office; -For Medicare and Medicaid certified facility residents with developmental disabilities, the mailing address and telephone number of the Missouri Protection and Advocacy Agency, or the current address and telephone number of the protection advocacy agency if it has changed; -The facility's discharge of the resident was dismissed due to inadequate notice. The resident could remain at the facility. If the resident was discharged , based upon the defective notice, the facility was directed to allow the resident to return to the facility; -A copy of the notice was sent to the resident, Administrator, ombudsman and hospital social worker. During an interview on 06/02/26 at 2:20 P.M., the hospital social worker said the resident was transferred to the hospital from another hospital. The resident's guardian filed an appeal of the discharge. The Appeals Unit dismissed the discharge. The facility refused to allow the resident to return. The facility said they would take the fine. The resident remained at the hospital. He/She was not aggressive but yelled racial slurs at staff. During an interview on 06/04/26 at 1:54 P.M., the Administrator, DON and Social Worker said they were not aware of the resident's behaviors prior to admission. The resident's medication was adjusted. The psychiatrist said the medication would not help the resident. They did not send any referrals prior to discharge. They did not contact the ombudsman for assistance. The Administrator typed the immediate discharge notice. Staff called him/her at home, and she quickly typed the letter. She was aware of the immediate discharge notice requirements. She received the order of dismissal. She did not take the resident back due to safety concerns for staff and residents. 3021042

Based on interview and record review, the facility failed to follow their policy and procedure for the Abuse Prevention Program to ensure one resident's safety when staff failed to report an abuse allegation immediately to administration for one of four sampled residents (Resident #2). The census was 64.Review of facility policy and procedure for Abuse Prevention Program dated 9/29/22, showed: -Internal reporting requirements and identification of allegations;-Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator. Review of Resident #2's medical record, showed:-Diagnoses included dementia, heart failure, mood disturbance, anxiety and psychotic disturbance;-Admitting nursing assessment dated [DATE], resident is alert and oriented to person, place, and time. Review of facility's investigation of sexual abuse allegation for the resident, dated 9/4/25 at 9:00 P.M., showed the resident's family called police for allegations against Certified Nurse Assistant (CNA) G for sexual abuse. When police arrived the family member said she had called about a wellness check and was not aware of the sexual abuse allegation until CNA H brought it up after he/she called the police. The investigation showed the allegation happened on 9/3/25 and CNA G, CNA H, CNA I said they did not report it because they did not believe it happened. The resident was interviewed and denied the sexual abuse allegation. During an interview on 9/8/25 at 8:43 A.M., the Director of Nursing (DON) said they were not informed of the sexual abuse allegation until staff told the resident's family member, who is not the resident's Power of Attorney (POA), then family had called police. CNA H said the family member came up to the nursing desk and said he/she was calling the police about the resident. CNA H assumed it was in reference to the resident's allegation of sexual abuse from 9/4/25, but in fact the family member called police for a wellness check because he/she could not get staff to change him/her. The family member went outside to call the police and upon him/her reentering the facility, accompanied by the police, CNA H told the family member about the allegation from the day prior, and this was the first time the family heard anything about the allegation. Staff notified the Assistant Director of Nursing (ADON) who called the DON about the allegation. This was the first time administrative staff heard about the allegation. The DON said as soon as she was notified, she came to the facility. Upon arrival, the police, the resident, and the resident's family were present. The investigation started immediately, and the resident denied the allegation happened and said no one has ever touched him/her inappropriately. The resident's POA was notified, and he/she refused to have the resident sent to the hospital for evaluation. The investigation showed CNA G was assisting the resident to bed and the resident accused him/her of sexual assault. CNA G said as soon as the resident accused him/her, he/she walked out of the room and told CNA H and CNA I what the resident said, and they went into the resident's room and assisted him/her back to bed. When they asked the resident why he/she said CNA G sexually assaulted him/her, he/she said he/she did not like staff of the opposite sex taking care of him/her, so he/she made the allegation. The DON said she interviewed CNA G, CNA H, and CNA I separately and they all responded that they felt like the situation had been resolved and they knew nothing had happened. CNA G said, I just left the room and walked out, and they walked in, and I felt like it was over. The DON started the investigation immediately, reported the incident to the state and started education with staff on abuse reporting. She expected staff to have reported this incident immediately and not have waited over 24 hours to report the incident. During an interview on 9/8/25 at 10:01 A.M., the resident's family member said while he/she was visiting the resident, he/she called the police on 9/4/25 around 8:00 P.M. for a wellness check because the resident was soiled, and he/she had asked the staff several times to come and change the resident. When police arrived, CNA H told the resident's family member about the resident accusing CNA G of sexual abuse and it was not true. 2608912

Based on interview and record review, the facility failed to provide services that meet professional standards when the facility failed to follow physician orders for one of four sampled residents (Resident #1). The facility did not provide adequate enteral gastrostomy tube (g-tube, a feeding tube inserted into the stomach for resident nutrition, fluids and medications) management, which led to resident weight loss. The census was 64Review of the facility's Enteral Nutrition Policy and Procedure, dated 3/28/25, showed: Adequate nutritional support through enteral feeding will be provided to residents as ordered;-If a resident has an enteral feeding tube placed prior to admission or returning to the facility, the Physician and interdisciplinary team (a team that consists of at least a physician, nursing and dietary), will review the rational for the placement of the enteral feeding tube, the resident's current clinical and nutritional status, and the treatment goals and wishes of the resident;-The nursing staff and physician will monitor the resident for signs and symptoms of inadequate nutrition, altered hydration, hypo- or hyperglycemia (low or high blood sugars), altered electrolytes. The nursing staff and physician will also monitor the resident for worsening of condition that place the resident at risk;-Staff caring for the residents with enteral feeding tubes will report complications associated with the insertion and/or use of the feeding tube such as: -Aspiration (inhalation of food or liquid into the airway and lungs); -Leaking and skin breakdown around insertion site; -Perforation of the stomach or small intestine leading to peritonitis (inflammation or infection of the peritoneum, the tissue lining the abdominal cavity); -Esophageal (throat) swelling, strictures (abnormal narrowing or constriction of a bodily passage or opening), fistulas (abnormal tunnel or connection that forms between two body parts); -Clogging of enteral feeding tube;-Staff caring for residents with enteral feeding tubes will recognize and report complications relating to the administration of enteral nutrition products, such as: -Nausea, vomiting, diarrhea and abdominal cramping; -Inadequate nutrition; -Metabolic abnormalities (condition when the body's chemical process, that creates and uses energy, is disrupted, leading to the accumulation or lack of the bodies essential substances that can cause harm to the body); -Interactions between feeding formula and medications; -Aspiration;-Risk of aspiration will be assessed by the nurse and physician and addressed in the individual care plan. Risk of aspiration may be affected by: -Diminished level of consciousness; -Moderate to severe swallowing difficulties; -Improper positioning of the resident during feeding; -Failure to confirm placement of enteral feeding tube prior to initiating the feeding;-No policy and procedures to check residual of enteral feeding, height of resident position during enteral tube feeding, how to confirm enteral feeding tube placement, and how often residual should be checked. Review of Resident #1's medical records, showed:-admitted to facility on 7/31/25 at 7:54 P.M.;-Medical history: cerebral infarction (stroke), hemiplegia of non-dominant left side (paralysis), aphasia (difficulty speaking), myocardial infarction (heart attack), severe protein-calorie malnutrition, gastrostomy status (g-tube);-Resident is alert and oriented to name, place and time;-Resident weight at hospital, prior to admitting to facility, 81 pounds (lbs). Review of the resident's progress notes, showed:-7/31/25 at 8:58 P.M., resident is alert and oriented to person, place, time, and event (A&O x 4), able to verbalize needs. Resident is nothing by mouth (NPO) currently, has a history of strokes and falls. Resident stated he/she was walking before a recent fall. Some discomfort noted during care this shift. Left hand edema noted, extremity elevated. Resident has a Foley catheter (drains and collect urine from the bladder when a person cannot urinate on their own), urine is draining to gravity. Incontinent of bowel and bladder. Last bowel movement 7/31/25. Bony prominence noted. Small pressure sore noted to sacrum/coccyx (lower back/bottom). Treatment is dry and intact. G-tube noted, no bleeding/redness. Other skin is dry and intact. Heels are soft and clear currently. Boots are being worn. Vitals taken and recorded. Medications sent to Medical Director for verification. Resident is in bed, head of bed (HOB) elevated, bed in low position, resident educated on use of call light, call light is within reach.-8/1/25 at 2:17 A.M., resident is a new admit. Resident is alert to self and location. Resident is NPO, g-tube patent and intact. No facial grimacing. No signs or symptoms of pain. Foley intact and draining with gravity. Assisted activities of daily living (ADLs), temperature (T) 97.4.-8/2/25 at 12:18 A.M., resident is alert and oriented and voices no complaints of pain or discomfort. He/She receives and tolerates continuous tube-feeding with no noted distress. Resident is resting well and tolerates being turned and reportioned every two hours with HOB up at 45 degrees. Review of the resident's physician orders, showed:-Order dated 8/5/25, resident diet, NPO;-Order dated 8/13/25, weekly weights to monitor resident weight due to g-tube feedings, scheduled for Wednesdays between 7:30 A.M. and 3:00 P.M.;-Order dated 8/13/25, g-tube, flush g-tube with 60 cubic centimeter (cc) water, every four hours at 2:00 A.M., 6:00 A.M., 10:00 A.M., 2:00 P.M., 6:00 P.M., 10:00 P.M.;-Order dated 8/21/25, Fibersource (nutritionally complete tube feeding formula) with high nitrogen (HN) per g-tube (PGT) at 42 milliliters per hour (ml/hr) continuous;-No orders for Fibersource entered prior to 8/5/25;-No orders for g-tube residual check, placement check, administering medications through g-tube, care of g-tube insertion site, monitor hypo/hyperglycemia checks, and monitoring intake. Review of the resident's care plan, updated 8/7/25, showed:-Problem: Resident is at risk for complications related to g-tube and at risk for weight alteration; -Goal: Resident will remain free of complications and maintain a stable weight through to next care plan review; -Approach and discipline: -Dietary consult as needed, nursing responsibility; -Keep head of bed always elevated, all staff responsibility; -Monitor for signs and symptoms of aspiration. Monitor coughing, choking and discomfort, all staff responsibility; -Observe g-tube site for signs and symptoms of infection (pain, redness, and drainage) and report to Medical Director as needed, nursing responsibility; -Observe tolerance, nursing responsibility; -Provide enteral feeding as ordered, see Physician Order Sheet (POS)/Medication Administration Record (MAR), nursing responsibility; -Record intake; nursing responsibility; -Staff will monitor weight, monitor labs as available, diet as orders see POS, Certified Nurse Assistant (CNA) and nursing. Review of the resident's MAR and Treatment Administration Record (TAR), dated 7/31/25 through 8/8/25, showed:-Fibersouce HN PGT at 40 ml/hr, continuous, not completed 7/31/25, 8/1/25, 8/2/25, 8/3/25, 8/4/25, 8/5/25;-Weekly Weights to monitor resident's weight showed: 8/6/25 no weight recorded, 8/13/25 weight 83.2 pounds (lbs.), 8/20/25 weight 84 lbs., 8/27/25 weight 84 lbs., 9/3/25 weight 83.8 lbs.;-Flush g-tube with 60 cc water every four hours (2:00 A.M., 6:00 A.M., 10:00 A.M., 2:00 P.M., 6:00 P.M. and 10:00 P.M.), not completed 8/1/25 through 8/12/25, 8/13/25 at 2:00 A.M., 8/13/25 at 6:00 A.M., 8/28/25 at 2:00 P.M. Review of facility grievance/complaint log, dated 8/25/25, showed: -The resident's family member reported 8/25/25 the resident was left up all day on 8/23/25 in his/her wheelchair until the family member arrived around 6:30 P.M. The feeding tube had no fluid on it and resident was complaining of pain in his/her butt, head and was soiled;-Director of Nursing (DON) investigated and wrote report description: On 8/23/25 resident up all day, in A.M. and was left in chair until 6:30 P.M. Feeding tube no bags on the pole and so no fluid all day. Complaining of butt and head hurting and resident soiled;-Investigation summary/findings showed: After investigation it was found that Assistant Director of Nursing (ADON) worked the day of the incident, and the resident was not in the wheelchair for 12 hours. Resident was in a Broda chair (specialized wheelchair and positioning device used for individuals with mobility challenges and long-term sitting needs) and was able to recline;-Action taken: Spoke with resident;-Signature: DON dated 8/25/25;-Resolution notification and reviewed: Administrator dated 8/25/25;-No investigation into g-tube feeding missing from enteral feeding pump pole. During an interview on 9/8/25 at 9:35 A.M., the resident's roommate said his/her roommate's tube feeding machine goes off and beeps all the time and keeps him/her awake at night. He/She was told they fixed it, but it still beeps. Observation and interview on 9/8/25 at 9:39 A.M., upon entering the resident's room, showed the resident asleep and lying flat on his/her back. The HOB was not elevated and the enteral tube feeding pump administering Fibersource HN at 42 ml/hr., along with water (H2O) bag was programmed at 60 ml every four hours. No date, time, or initials on were documented on the H2O bag and no time was documented on the Fibersource HN bag. The resident said the staff do not get him/her out of bed. He/She has to lay in bed all day. He/She said the feeding pump keeps beeping, and the staff will not fix it. During an interview on 9/10/25 at 6:55 A.M. Registered Nurse (RN) D said the resident takes all medications through his/her g-tube and nothing by mouth. He/She was aware of issues with the resident's enteral feeding pump beeping. It is because staff do not zero out the record of total feeding and H2O when they change out the bags or the line is kinked. RN D does not record the total amount of Fibersource HN the resident received because he/she receives the whole bag. RN D said last night about 300 ml was left in the bag. RN D did not record the amount left and he/she did not let the physician know. Last night the pump was having issues, so RN D changed it out with a new pump. RN D dates, times, and initials the nutritional bag and H2O. RN D does not check for placement or residual for a resident with continuous feeding unless the resident is showing signs and symptoms of not handling the nutritional feeding, such as coughing, choking, vomiting, pain, ect. If this happens, he/she stops the feeding, checks residual and calls the physician for orders. RN D said the resident's HOB should always be elevated at 45 degrees for continuous feeding, but this resident does not like to have the HOB up that high. Staff educate him/her often on complications of lying flat or less than 45 degrees. During an interview on 9/10/25 at 2:13 P.M., Family Member (FM) C said he/she has asked along with other family members if the resident has been screened to eat a puree diet and nothing has been done. This has been going on since the resident arrived at the facility. The resident is starving, and the pole keeps beeping and not working. FM C took the resident to the cardiologist on 8/26/25, and they weighed the resident around 77 lbs., yet facility staff keep telling FM C the resident weighs 84 lbs. The resident is losing weight and getting weaker. During an interview on 9/10/25 at approximately 2:30 P.M., the Administrator said she was not aware of the issues that concerned the family member, including not caring for him/her, leaving him/her up for 12 hours soiled, lack of nutrition, and in pain. The Administrator said she signed the complaint/grievance dated 8/25/25 and the investigation into issues with resident's feeding tube and lack of nutrition were not investigated. She said she missed it when she reviewed it and signed it. Observation on 9/10/25 at around 2:45 P.M. showed CNA E weighed the resident on the scale in the wheelchair with pressure relief cushion in place. The resident wore a hospital gown and heel proactive boots. Weight observed 130.2 lbs. CNA E said the weight on the wheelchair is on the bottom of the seat and observation showed 50.2 lbs. This surveyor had resident #1's wheelchair along with pressure relief cushion weighed by the DON. The weight of the wheelchair and cushion was 53.4 lbs. (chair 50.2 lbs. plus pressure relief cushion 3.2 lbs.). Total weight of wheelchair, cushion, and resident 130.2 lbs. subtract weight of wheelchair with cushion 53.4 lbs. equals 76.8 lbs., the current weight of resident. CNA E said he/she was not aware of any weight variances charted. The DON was not aware staff did not consider the weight of the cushion into the total weight of the chair when weighing residents. During an interview on 9/10/25 at approximately 3:00 P.M., the Medical Director said he was not aware of the resident's enteral tube feeding issues, loss of weight, and the facility not following standard practices and procedures for residents requiring nutritional support through a g-tube. Standard practices and procedures should be part of the facility's policy and procedures or standing orders. Standard practices and procedures for residents on continuous tube feedings include checking for g-tube placement, injecting air into the tube and listening for a growl sound in the stomach. This should happen when the nutritional feeding is changed once a day along with twice a day residual checks (check remaining contents of stomach by using a syringe) during the 24-hour feeding. If the entire feeding did not get completed, this amount should be documented along with the reason why it was not completed, and the Medical Director should be informed. If the resident has a bolus feeding, tube placement should be checked prior to feeding along with residual before and after feeding. The Medical Director should always be informed of difficulties with feeding. The Medical Director was not aware the resident's g-tube feedings have not been managed per policy and procedures of standard practice of care, and that the resident has not been receiving all his/her nutrition due to difficulty with the feeding pump. The Medical Director was also not aware the facility does not have standing orders on how to manage tube feedings. The Medical Director did not write out the standard practice orders when writing an order for tube feedings. This should be part of the facility policy and procedures or standing orders to follow standard of practice for residents requiring tube feeding. The facility should always follow standard of practice. During an interview on 9/11/25 at 10:21 A.M., the Administrator and DON said they were not aware of issues with the resident's enteral feeding pump with Fibersource HN not infusing completely, the resident's weight loss, and the physician orders were not entered for care of enteral feeding. They were also not aware the physician assumed the facility policy and procedure for standing orders for enteral feeding were automatically entered. They said the facility does not record total amount of enteral feeding a resident receives but expected staff to let the physician know if the resident had not received or tolerated the total feeding and this should be documented in progress notes. They expected nursing staff to know how to care for enteral tube feedings and to report issues when they arise.

Based on observations, record review, interviews, and policy review, the facility failed to maintain clean and bug-free bathroom vents, store urinals and plungers in a sanitary manner, and maintain fixtures/equipment in a safe and functional manner for 11 of 26 residents (Resident (R) 27, R24, R43, R111, R14, R9, R112, R56, R11, R26, and R30) observed for the environment. These failures had the potential cause avoidable allergies or spread of infection and injury from broken fixtures/ equipment. Findings include: Review of the facility's policy titled, Routine Maintenance, dated 08/06/22, revealed Maintenance staff is responsible to ensure that preventative, routine maintenance is completed in compliance with applicable life safety standards and needs of the facility. A housekeeping policy was requested but was not received prior to the survey exit. 1. Review of R56's entry Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/26/25 and located in the MDS 3.0 tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE]. Review of R11's quarterly MDS with an ARD of 11/15/24 and located in the MDS 3.0 tab of the EMR, revealed she was admitted to the facility on [DATE]. During an observation on 03/18/25 at 10:09 AM in the shared bathroom of R56 and R11, the vent had a thick coating of grey dust and white stringy matter that appeared like cobwebs all across the openings. A spider was hanging from a cobweb approximately two feet below the vent near the toilet. During an observation along with the Maintenance Director (MD) on 03/21/25 at 3:32 PM in the shared bathroom of R56 and R11, the dusty, stringy vent and spider hanging down were again observed. The MD confirmed the vent needed to be cleaned and the cobwebs dusted. The MD stated the housekeeping staff was expected to dust the bathroom vents during regular cleaning. 2. Review of R26's entry MDS with an ARD of 02/10/25 and located in the MDS 3.0 tab of the EMR, revealed he was admitted to the facility on [DATE]. Review of R30's annual MDS with an ARD of 12/19/24 and located in the MDS 3.0 tab of the EMR, revealed he was admitted to the facility on [DATE]. During an observation on 03/18/25 at 10:42 AM in the shared bathroom of R26 and R30, a plunger was in direct contact with the floor and numerous dead bugs were in the light fixture cover. During an observation along with the MD on 03/21/25 at 3:36 PM, the plunger was again in direct contact with the floor and the bugs were still in the light fixture. The MD stated the plunger should have been kept in a plastic tub to keep it from contact with the floor or other surfaces and the bugs in the light needed to be cleaned. 3. Review of R14's entry MDS with an ARD of 01/04/25 and located under the MDS 3.0 tab of the EMR, revealed he was admitted to the facility on [DATE]. Review of R9's quarterly MDS with an ARD of 02/07/25 and located under the MDS 3.0 tab of the EMR, revealed he was admitted to the facility on [DATE]. During an observation in the shared bathroom of R14 and R9 on 03/18/25 at 10:45 AM, a plunger was observed directly in contact with the bathroom floor and the bathroom vent fan had a coating of grey dust and white stringy matter that appeared like cobwebs across the openings. During an observation along with the MD on 03/21/25 at 3:38 PM in the shared bathroom of R14 and R9, the plunger was in contact with the floor and the dusty, stringy bathroom vent were confirmed by the MD. He stated the plunger should not be directly on the floor and the vent needed to be cleaned. 4. Review of R24's quarterly MDS with an ARD of 01/16/25 and located in the MDS 3.0 tab of the EMR, revealed she was admitted to the facility on [DATE]. During an observation in R24's room on 03/18/25 at 11:56 AM, the bathroom vent fan had a thick coating of grey dust and white stringy matter that appeared like cobwebs across the openings. During an observation along with the MD on 03/21/25 at 3:41 PM in R24's room, the bathroom vent was again observed coated in dust and stringy white matter. The MD stated this needed to be cleaned and it looked like it was covered in cobwebs. 5. Review of R112's admission MDS with an ARD of 03/03/25 and located in the MDS 3.0 tab of the EMR, revealed she was admitted to the facility on [DATE]. During an observation on 03/18/25 at 11:59 AM in R112's room, the top piece of her bed's footboard, with four sharp nails and screws sticking out of it, was on top of the resident's dresser. There were sharp, broken edges of wood on the footboard around where the nails and screws had been torn out. During an observation along with the MD on 03/21/25 at 3:38 PM, the broken piece of the footboard with the sharp nails and screws was again on top of the dresser and the footboard had jagged edges of wood around the holes. The MD stated this could cause an accident because it was sharp and needed to be fixed immediately. 6. Review of R27's admission MDS with an ARD of 01/09/25 and located in the MDS 3.0 tab of the EMR, revealed she was admitted to the facility on [DATE]. During an observation in R27's room on 03/18/25 at 2:58 PM, a plunger was observed directly in contact with the bathroom floor and the bathroom ceiling light was missing its cover, exposing the bulbs and mechanism. During an observation along with the MD in R27's room on 03/21/25 at 3:31 PM, the plunger was again observed in contact with the bathroom floor and the light without a cover. The MD stated the plunger should be stored in a plastic tub to keep it from coming in contact with the floor and he was unaware the light was missing its cover. 7. Review of R43's admission MDS with an ARD of 02/03/25 and located in the MDS 3.0 tab of the EMR, revealed he was admitted to the facility on [DATE]. Review of R111's entry MDS with an ARD of 02/19/25, revealed he was admitted to the facility on [DATE]. During observations in the shared bathroom of R43 and R111 on 03/18/25 at 3:07 PM and 03/21/25 at 2:58 PM, two dirty urinals, without labels, were hanging on the handrail and were in direct contact with the rail. During an observation along with the MD on 03/21/25 at 3:35 PM in the shared bathroom for R43 and R111, a staff member was in the bathroom placing the urinals in plastic bags. The MD stated urinals should be stored in bags for sanitation purposes. During an interview on 03/21/25 at 3:30 PM, the MD stated the facility had a process to receive work requests from staff via a mailbox and paperwork request slips. He stated he received requests infrequently and had not received work requests for any of the above issues. The Director of Housekeeping was not available for interview.

Based on observation, record review, interviews, and facility recipe review, the facility Dietary [NAME] (DC) failed to ensure the puree chicken lunch entree was proper texture for four of four residents (Resident (R) 6, R13, R39, and R262) reviewed for pureed diet of 22 sample residents. This failure had the potential to make the entree unpalatable and difficult to swallow for the residents who required a puree meal. Findings include: Review of the Chicken Maple Glazed Puree Thick recipe found in the dietary department recipe folder for week five lunch, dated 10/15/24, revealed .Maple Glazed Chicken 10 serving 1 breast. Chicken Base 1 1/8 teaspoon. Water 1 cup 2 tablespoons. Food Thickener 2 2/3 cup. WASH HANDS. 1. Place prepared Maple Glazed Chicken into food processor. 2. Add broth and process until smooth in texture. 3. Add food thickener and process 4. briefly until mixed. scrape down sides with spatula and reprocess. Pour into the steam table pan coated with cooking spray. Cover tightly and heat in conventional oven at 350 Fahrenheit until temperature reaches .145 Fahrenheit: Final Internal cooking F. Temperature Must Reach a minimum of 145 degrees F, Held for minimum of 15 seconds. Let set 5-10 minutes before serving .Portion one #8 scoop of pureed Maple Glazed Chicken per serving . 1. Review of R6's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/24, revealed R6 was admitted to the facility on [DATE] with diagnoses which included quadriplegia and traumatic brain injury. R6 required a mechanically altered diet. Review of the Order Report located in the electronic medical record (EMR) under Orders tab, dated 12/27/23, revealed R6 was ordered a .thin/puree (Reg) regular as tolerated . 2. Review of R13's annual MDS with an ARD of 01/03/25, revealed R13 was admitted to the facility on [DATE] with a diagnosis which included cerebral palsy. R13 required a mechanical altered diet. Review of the Order Report located in the EMR under Orders tab, dated 12/13/24, revealed R13 required a .thin/Puree (reg) as tolerated . 3. Review of R39's quarterly MDS with an ARD of 01/25/24, revealed R39 was admitted to the facility on [DATE] with a diagnosis of Malnutrition. R39 required a mechanical altered diet. Review of the Order Report located under the Orders tab of the EMR under Orders tab, dated 03/20/25, revealed R39 required a regular puree diet with thin liquids. 4. Review of R262's Face sheet located under the Face Sheet tab of the EMR revealed R262 was admitted to the facility on [DATE] with a diagnosis of dysphagia. Review of the Order Report dated 03/01/25 and located under the Orders tab of the EMR, revealed R262 required a regular, puree, diet with nectar thick liquids. 5. Observation in the kitchen at the steam table on 03/20/24 at 12:39 PM, revealed a tray of puree chicken that contained water surrounding the chicken. During an interview on 03/20/25 at 1:46 PM, the DC confirmed she did not use thickener for the puree chicken. The Dietary Aide (DA) stated honestly I forgot. There was a lot going on just I forgot. During an interview on 03/20/25 at 1:50 PM, the Dietary Manager (DM) stated I noticed it (puree chicken). We have the thickener gel we could have just mixed it up. It should have been made right. During an interview on 03/21/25 at 4:10 PM, the Administrator stated she expected the DC to follow the recipe to make puree chicken.

Based on observations, interviews, and facility policy review, the facility failed to maintain the walk-in refrigerator at 41 degrees Fahrenheit (F) or below during two of two observations in one of one kitchen of 55 of 71 census residents which could have caused food spoilage and failed to distribute and maintain clean water pitchers for three of three residents (Resident (R) 47, R61, and R38) observed for cleanliness. This failure had the potential to affect resident safety. Findings include: Review of the facility's policy titled, Safe Food Preparation and Safe Handling, dated January 2012, revealed . Food will be prepared to conserve maximum nutritive value in a safe and sanitary environment . Review of the 2022 Food and Drug Administration Food Code, dated 01/18/23, and located at https://www.fda.gov/media/164194/download?attachment, page 3-28, revealed Time/ temperature control for safety food shall be maintained .at 41 degrees F or less. Review of the facility's policy titled, Bedside Water Containers, dated February 2012, revealed Bedside water containers will be cleaned and sanitized daily. 1. The food service department will maintain a minimum supply of two (2) complete water container sets for each resident. 2. The nursing staff is responsible for replacing the dirty complete water container set with a clean set and placing the set outside the kitchen door. 3. Food service will collect the dirty sets . wash, rinse and sanitize them. Food service will also return a complete sanitized water container set .outside the kitchen on a covered rack for access by nursing staff. 1. Observation in the kitchen on 03/18/25 at 9:34 AM, revealed no walk-in refrigerator temperatures were recorded on temp log since 03/16/25. During an interview, the Dietary Manager (DM) stated the Dietary [NAME] (DC) would put in the temperatures each shift. I normally come and check it. We have to catch up two days. Observation in the kitchen on 03/18/25 at 9:42 AM, revealed the walk-in refrigerator thermometer read 46 degrees F. Observation and interview in the kitchen with the DM on 03/18/25 at 5:09 PM revealed the walk-in refrigerator thermometer read 42 degrees F. The DM stated the walk-in refrigerator temperatures were supposed to be checked and recorded during the weekend. If the thermometer was not up to temperature, they should have called me to call someone to check and service the refrigerator. During an interview on 03/21/25 at 4:02 PM, the Administrator stated she expected the refrigerator to be at the desired temp and the staff monitor the temps daily. 2. Observation on 03/18/25 at 11:24 AM revealed R47's water container was on his bedside table with unknown brown substance on the side of the container. Observation on 03/18/25 at 12:28 PM revealed R61 drinking out of his water container with unknown brown substance on the handle. Observation on 03/18/25 at 11:17 AM revealed R38's water container was in the bathroom on the back of the toilet tank noted with brown unknown substance on handle and side of container. During an interview on 03/21/25 at 3:58 PM, the Dietary Manager (DM) stated the water pitchers are to be cleaned every morning and to my knowledge the pitchers are washed every day. I am not always in the kitchen as I have a lot of responsibilities, and I am not completely up to date with all the policies. DM also stated, We do not have two complete water container sets for each resident and do not have space for them. During an interview on 03/21/25 at 3:57 PM, the Activities Director (AD) stated it was the responsibility of the nursing and dietary staff to make sure the water containers were cleaned.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure the call light was within reach for two of 22 sample residents (Resident (R) 163 and R34) reviewed for accommodation of needs and preferences. This failure had the potential to cause R163 and R34 to have unmet care needs. Findings include: 1. Review of R163's Face Sheet located under the Profile tab of the electronic medical record (EMR), revealed R163 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease and chronic obstructive pulmonary disease. Review of R163's entry Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25 and located under the RAI (Resident Assessment Instrument) tab, showed there had been no assessment of R163's cognition prior to her passing on 03/18/25. Review of R163's Progress notes, dated 03/07/25 through 03/18/25 and located under the Assessments tab of the EMR, revealed documentation the resident had multiple falls during her stay. Review of R163's Care Plan located in the EMR under the Care Plan tab and last revised 03/14/25, revealed R163 was at risk for falling, due to history of falls, cognitive impairments, decreased safety awareness, required assistance of daily living (ADL) assistance with transfers and mobility, incontinence. - 03/11-Had an unwitnessed fall, found by staff, no injuries. 03/12- Had an unwitnessed fall, bruise to face. During an observation and interview on 03/18/25 at 10:10 AM, R163 was observed lying in her bed. Her call light was clipped to the privacy curtain approximately three feet out of reach. R163 did not know where her call light was. Her daughter was present and retrieved the call light, her daughter revealed the call light was usually clipped to the curtain when she came in each morning. During an observation on 03/18/25 at 2:30 PM, the call light was observed clipped to the privacy curtain, out of sight, and out of reach of the resident. 2. Review of R34's Face Sheet located under the Profile tab of the EMR, revealed R34 was admitted to the facility on [DATE] with diagnoses which included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, and epilepsy. Review of R34's significant change MDS with an ARD of 01/29/25 and located under the RAI (Resident Assessment Instrument) tab, revealed R34 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R34 was moderately cognitively impaired. Review of R34's Progress notes, dated 03/07/25 through 03/18/25 and located under the Assessments tab of the EMR, revealed documentation the resident had several recent falls. Review of R34's Care Plan located in the EMR under the Care Plan tab and last revised 02/18/25, revealed R34 was at risk for injuries due to history of falls with injuries, had a displaced intertrochanteric fracture of right femur, and subsequent encounter for closed fracture with routine healing. During an observation on 03/18/25 at 10:35 AM, R34 was observed lying in his bed watching television. His call light was draped over the light affixed to the wall over the bed, out of reach of R34. During an observation on 03/18/25 at 2:45 PM, the call light remained draped over the light affixed to the wall, over R34's bed out of sight, and out of reach of the resident. During an observation on 03/19/25 at 9:30 AM, the call light remained draped over the light affixed to the wall, over R34's bed out of sight, and out of reach of the resident. During an observation and interview on 03/19/25 at 10:10 AM, Licensed Practical Nurse (LPN) 1 stated that residents' call lights should be within reach. Upon observation of R34's call light hanging over the light fixture, she confirmed that it was improperly placed and out of reach of the resident. LPN1 said she would place it back within reach of R34. LPN1 stated that all staff were responsible for ensuring call lights were accessible. During an interview on 03/19/25 at 11:00 AM, Registered Nurse (RN) 1 confirmed that all staff were responsible for ensuring call lights were in reach of the residents.

Based on record review and interviews, the facility failed to obtain a level two pre-admission screening and resident review (PASARR) assessment for one of one residents (Resident (R) 19) reviewed for PASARR of 22 sample residents. This failure could affect R19 from receiving services to assist in the treatment of psychiatric diagnoses. Findings include: Review of the Admission Referral Paperwork located in the Document tab of the EMR, dated 03/18/24, revealed R19 had diagnosis which included anxiety disorder 02/03/17, schizoaffective disorder 11/24/23, and major depressive disorder 03/29/22. Review of the Face Sheet located in the Profile tab of the EMR revealed R19 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder, anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/24, revealed R19 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R19 was moderately cognitively impaired. Review of the PASARR Level One located in the Document tab of the electronic medical record EMR, dated 02/10/17, revealed R19 had a level one PASARR which did not reflect new psychiatric diagnoses of schizoaffective disorder, major depressive disorder, and anxiety disorder. Review of the Progress Note, dated 05/19/24 and located in the Progress Note tab of the EMR, revealed R19 was transferred to the psychiatric hospital for evaluation due to combativeness with staff and exit seeking in the facility. Review of the Care Plan problem located in the Care Plan tab, dated 01/22/25, revealed . [named R19] experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). [named R19] has episodes of paranoia r/t [related to] past life events. [named R19] thinks that someone is coming in the facility to cause him harm and he periodically attempts to exit seek. [named R19] uses inappropriate language and threatens staff at times. [named R19] pulls his clothing off the hangers and out of the closets and puts them on the floor . During an interview on 03/19/25 at 2:24 PM, the Social Service Director (SSD) confirmed R19 did not have a level two PASARR assessment. The SSD expected to be notified to redo a PASARR for R19. Further interview revealed the SSD suspected the psychiatric diagnoses were present before admittance to the facility. During an interview on 03/21/25 at 4:28 PM, the Administrator stated she did not know R19 had admitted with the diagnoses which would qualify the resident to be reevaluated for level two PASARR.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure one of ten residents (Resident (R) 55) reviewed for bathing had his preference of bathing type of 22 sample residents. The failure affected R55's right to make choices and honor preferences. Findings include: Review of facility policy titled, Resident Rights, dated 08/31/23, indicated The resident has the right to accommodations of residents need and preferences . The resident has the right to make choices that are significant to the resident . Review of R55's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed he admitted on [DATE] with diagnoses including, quadriplegia, C5-C7 incomplete, depression, and hypertension. Review of R55's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/24, located under the MDS 3.0 Resident Assessments tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated he was cognitively intact. The importance of bath choice was marked, indicating the bath of his choice was very important to R55. Review of R55's care plan, dated 10/22/24 and located under the Care Plan tab of the EMR did not address R55's bath type or shower preferences. Review of daily shower sheets for January 2025, February 2025, and March 2025, provided by the facility, revealed R55 had received a bed bath on regular scheduled days. During an observation and interview on 03/20/25 at 4:20 PM R55 was sitting up in wheelchair at bedside with bed prepared with pads and towels for a bed bath. R55 stated he told his Certified Nurse Assistant (CNA) he wanted a shower, and she replied, the shower bed was broken. During an interview 03/20/25 at 4:25 PM, CNA9 revealed she was going to give R55 a bed bath. When asked if she knew he preferred a shower she stated she did, but the shower bed was broken, and he would not use the shower chair. During an interview on 03/21/25 at 4:41 PM CNA8 revealed she was told by R55 that he had gotten a bed bath when he wanted a shower. She stated she knew R55 preferred a shower and not a bed bath, but the shower bed was broken. She stated R55 did not feel comfortable using the shower chair because it did not have any leg rests, and his legs drag because he did not have any control of them. During an interview on 03/21/25 at 3:54 PM, the Maintenance Director (MD) stated he did not know of any concerns with the shower bed until the evening of 03/09/25 when he was notified by a staff member by phone that all four of the wheels on the shower bed were missing. He stated he notified the Administrator on the morning of 03/10/25 and she ordered the wheels the same morning. He stated the wheels came in on 03/11/25 and he put them on the shower bed. The Administrator provided the invoice, and the MD provided the facilities maintenance logs with weekly checks of the Hoyer lifts and shower chair and bed, and no concerns were noted. MO00250981

Based on interviews, record review, and policy review, the facility failed to implement policies and procedures for ensuring the reporting of an allegation of abuse to the Administrator and to the State Survey Agency (SSA) for one of three residents (Resident (R) 24) reviewed for abuse of 22 sample residents. These failures placed residents at risk of continued verbal abuse, which could cause depression, fear, or mental anguish. Findings include: Review of the facility's undated policy titled, Staff Obligations to Prevent & Report Abuse, Neglect, and Theft, dated 12/26/16, revealed The facility will report to the State agency .any incident of alleged abused [sic], neglect, exploitation, or mistreatment .The alleged violations are to be reported immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Staff are obligated to report to the administrator of the facility and to other officials . Review of R24's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed she admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, vascular dementia, fibromyalgia, depression, and anxiety. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/25, located under the MDS 3.0 Resident Assessments tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she was cognitively intact. The assessment revealed R24 did not exhibit mood symptoms but exhibited verbal behavioral symptoms directed toward others several times a week but less than daily. Review of R24's Care Plan, dated 06/01/24 and located under the Care Plan tab of the EMR, revealed [R24] exhibiting problems as seen by: Verbally Abusive, Socially Inappropriate and Disruptive. The approaches included: Provide meds [medications] as ordered and monitor effectiveness .Encourage family support and/or involvement .[and] Psychiatric consult as needed .Encourage [R24] to keep involvement in activities of choice .[and] Encourage [resident] to vent feelings, fears, frustrations PRN [as needed]. During an interview on 03/18/25 at 3:24 PM, R24 stated a female Certified Nurse Aide (CNA) on the night shift cussed me out. She stated the CNA cursed at her and was mean and nasty. R24 stated this happened about two or three weeks ago and she had reported the situation to the Activity Director (AD). The resident added she did not recall the CNA's name, but stated the CNA still worked with her most nights and she would know the CNA when she saw her. R24 stated this situation made her angry. During an interview on 03/18/25 at 3:42 PM, the Administrator stated no incidents of abuse had been reported to the SSA in 2025. During an interview on 03/18/25 at 3:49 PM, the AD stated R24 had mentioned to her on 03/13/25, during the Resident Council meeting that she and a night shift CNA had words and the CNA was cussing. The AD added R24 could not tell her when the incident occurred or the name of the CNA. The AD stated she had not done anything further to investigate the allegation and she shared this allegation with the Social Services Director (SSD) for follow-up. During an interview on 03/18/25 at 4:24 PM, the SSD stated the AD mentioned to me this morning that R24 made an allegation of being cussed out by a CNA. The SSD stated she did not hear of the allegation until 03/18/25 and she passed the information on to the Administrator to begin the reporting and investigation process. The SSD added that R24 had a history of making false accusations and was unable to recall any details, dates, or names associated with the allegation. The SSD stated this allegation should have been reported to the Administrator immediately for follow-up when it was made on 03/13/25. During an interview on 03/18/25 at 4:33 PM, the Administrator stated she did not know the allegation was made on 03/13/25 and stated her expectation was that the allegation be reported to her immediately when it was made for appropriate follow-up, including notification to the SSA. The Administrator stated she had interviewed R24, and the resident was able to identify the alleged CNA by description, and CNA6 was suspended pending investigation. MO00251300

Based on interview, record review, and policy review, the facility failed to ensure a comprehensive Care Plan was developed for two of 25 sampled residents (Resident (R) 111 and R27) to address R111's pain and R27's dependence on staff for activities of daily living (ADLs). These failures had the potential to contribute to inadequate or inappropriate pain intervention for R111 and lack of provision of ADL care for R27. Findings include: Review of the facility policy titled, Resident Assessment Instrument, dated November 2017, revealed, Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning .Within seven (7) days of the completion of the resident assessment, a comprehensive care plan will be developed. 1. Review of R111's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed he admitted to the facility on [DATE] with diagnoses including arthritis, pain in the left hip and right hand, muscle weakness, and general pain. Review of R111's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/28/25 and located under the MDS 3.0 tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. He received pain medication and non-pharmacological pain approaches and did not have pain upon assessment. During an interview on 03/18/25 at 3:07 PM, R111 stated his pain had increased over the last few days in his hip, and he was receiving morphine and Tylenol to control the pain. Review of R111's Orders tab of the EMR revealed a physician's order, dated 02/19/25, for acetaminophen, 1,000 milligrams (mg) three times a day as needed for pain and a physician's order, dated 02/20/25, for morphine, 15mg twice a day for pain. Review of the Care Plan tab of R111's EMR revealed there was no Care Plan addressing pain, non-pharmacological pain interventions, and pain medication use. During an interview on 03/21/25 at 2:25 PM, the MDS Coordinator (MDSC) stated the resident had diagnosis of pain, used scheduled morphine, and should have had a pain Care Plan in place to ensure individualized and appropriate pain intervention. The MDSC stated the pain Care Plan should have been there but was forgotten. 2. Review of R27's Face Sheet located under the Face Sheet tab of the EMR, revealed she admitted on [DATE] with diagnoses including congestive heart failure, anxiety, glaucoma, and adult failure to thrive. Review of R27's admission MDS with an ARD of 01/09/25 and located under the MDS 3.0 tab of the EMR, revealed a BIMS score of seven out of 15 indicating severely impaired cognition. R27 was dependent on staff for oral hygiene, toileting hygiene, showering, dressing, and personal hygiene. She required substantial/maximal assistance with eating. R27 required substantial/maximal assistance with bed mobility and was dependent on staff for transfers and mobility. Review of the Care Plan tab of R27's EMR revealed there was no Care Plan addressing her need for assistance with ADLs. During an interview on 03/21/25 at 2:31 PM, the MDSC stated R27 was totally dependent on staff for ADLs, and this should have been included in the Care Plan. She stated an ADL Care Plan would be added.

Based on observations and interviews, the facility failed to ensure nail care was provided for one of 22 sample residents (Resident (R) 34) reviewed for activities of daily living (ADL). This failure had the potential to cause R34 to have unmet care needs. Findings include: Review of R34's Face Sheet located under the Profile tab of the electronic medical record (EMR), revealed R34 was admitted to the facility on [DATE] with diagnoses which included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, chronic obstructive pulmonary disease, and epilepsy. Review of R34's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/25 and located under the RAI (Resident Assessment Instrument) tab, reveal R34 has a Brief Interview for Mental Status (BIMS) of 12 out of 15 which indicated R34 was moderately cognitively impaired. Review of R34's Care Plan located in the EMR under the Care Plan tab and last revised 02/27/25, revealed Resident is totally dependent on nursing for all aspects of care .Resident will be kept well groomed, free of odors and clean and dry through to next care plan review. During an observation and interview on 03/18/25 at 10:35 AM, R34 was observed lying in his bed watching television. R34's fingernails were noted to be greater than half an inch over his fingertips. When asked if he preferred long nails, R34 stated no I want them trimmed. During an observation on 03/19/25 at 9:30 AM, R34's nails remained greater than half an inch over his fingertips. During an observation and interview on 03/19/25 at 10:10 AM, Licensed Practical Nurse (LPN) 1 was asked to enter R34's room and look at R34's fingernails. LPN1 stated that R34 was on hospice so the hospice aide should have trimmed R34's nails. LPN1 was asked who was responsible for trimming a resident's nails if the hospice didn't, LPN1 stated they were, and stated she would get R34's nails trimmed. During an interview on 03/20/25 at 2:00 PM, Certified Nurse's Assistant (CNA) 4, was asked who was responsible for trimming a resident's nails if hospice didn't, CNA4 stated we are, unless the resident is diabetic then the nurse will trim the resident's nails. During an interview on 03/20/25 at 2:15 PM, CNA3 was asked who was responsible for trimming a resident's nails if hospice didn't, CNA3 stated we are, unless the resident is diabetic then the nurse will trim the resident's nails. During an interview on 03/20/25 at 2:30 PM, LPN3 was asked who was responsible for trimming a resident's nails if hospice didn't, LPN3 stated we are, unless the resident is diabetic then the nurse will trim the resident's nails.

Based on observations, interviews, and record review, the facility failed to ensure one of 22 sample residents (Resident (R) 55) reviewed for appointments had scheduled physician's appointments. The failure increased R55's risk of delayed medical care. Findings include: Review of R55's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed he admitted on [DATE] with diagnoses including, quadriplegia, C5-C7 incomplete, depression, and hypertension. Review of R55's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/24, located under the MDS 3.0 Resident Assessments tab of the EMR, revealed a Brief Interview for Mental Status (BIMS)' score of 14 out of 15 which indicated he was cognitively intact. During an observation and interview on 03/20/25 at 4:00 PM, R55 stated he had an appointment that he was unaware he had and at the last minute he was notified so needed to get ready. R55 pointed to white board on wall that had his appointments written on it and his phone that he verbally commanded appointment reminder. R55 indicated he told Registered Nurse (RN) 1 he did not have time to get ready and was not prepared. During a phone interview on 03/20/25 at 4:15 PM, Spinal Orthopedic Scheduler (SOS) indicated that the appointment was originally scheduled as a follow up appointment for 03/18/25 and on 02/27/25 the appointment was rescheduled for 03/20/25 at 2:00 PM due to a scheduling conflict with the Spinal Orthopedic office. During an interview on 03/20/25 at 4:30 PM, RN1 indicated she was assigned to R55 and stated she was aware of R55 having an appointment on 03/20/25 at 2:00 PM and had forgotten about the appointment. RN1 indicated the night nurse routinely pulled the appointment sheets from the appointment binder located on the Nurses Station desk and gave it to the oncoming nurse in report and due to having a contract nurse the night of 03/19/25 she was unaware of the process for appointments. I attempted to reach contract nurse but was not successful. RN1 indicated she was reminded of R55 appointment at 1:30 PM and went to R55 room to inform him of the appointment and due to R55 being total care and not knowing previously of the appointment R55 refused as he did not have time to get ready and was not prepared. The appointment sheet was verified as in the appointment binder. During an interview on 03/21/25 at 10:00 AM Reception (REC) indicated she took the call on 02/27/25 to reschedule appointment for R55, wrote it on the appointment sheet and placed a copy in the master notebook she kept at her desk and put a copy in the appointment book at the Nurses Station for the 300-hall. When asked who notified R55 of his appointments she replied, no specific person. MO251413

Based on interview, record review, and policy review, the facility failed to ensure one of three residents (Resident (R) 32) reviewed for dialysis received as-needed medication as ordered and her physician was notified when a dialysis appointment was missed of 22 sample residents. These failures had the potential to cause significant risks, including increased mortality, hospitalization , and cardiovascular complications, due to the buildup of toxins and fluids in the body. Findings include: Review of the facility policy titled, Care of a Resident with End-Stage Renal Disease, dated November 2017, revealed Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care .Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. The policy did not address procedures for missed dialysis appointments. Review of R32's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed she admitted to the facility on [DATE] with diagnoses including end-stage renal disease, anemia, and malnutrition. Review of R32's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/25 and located under the MDS 3.0 tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. R32 received dialysis. During an interview on 03/19/25 at 4:24 PM, R32 could not recall if she missed any dialysis appointments. Review of R32's Care Plan, dated 04/18/22 and located under the Care Plan tab of the EMR, revealed, [R32] is at risk for complications due to End Stage Renal Disease & Hemodialysis therapy. [R32] attends .on Tuesdays, Thursdays, and Saturdays for dialysis. Transportation arrives at 0930. The approaches included providing a therapeutic diet, monitoring labs, observing for infections or complications, and If transportation has not arrived by scheduled time; (not after dialysis appointment) Please inform sister. Review of the Orders tab of R32's EMR revealed a physician's order, which originated on 12/24/22, for one packet of Lokelma (for treatment for high levels of potassium in the blood) powder as needed for missed dialysis days. Review of R32's Progress Notes tab of the EMR revealed there was no documentation on 03/01/25 to indicate a missed dialysis appointment. During an interview on 03/18/25 at 2:29 PM, the Administrator stated the facility van was broken and R32 had to rely on Medicaid transportation to dialysis appointments. The Administrator stated on 03/01/25, R32 missed a dialysis appointment because transportation did not show up. She added R32 did not have any health concerns related to the missed dialysis appointment. Review of R32's March 2025 Medication Administration Record (MAR), located under the Reports tab of the EMR, revealed the Lokelma was not administered on 03/01/25. During a telephone interview on 03/21/25 at 1:20 PM, the Dialysis Center Social Worker (DSW) stated R32 missed her dialysis appointment on 03/01/25. She stated the corresponding note was Cancelled - patient related. During an interview on 03/21/25 at 4:04 PM, the Director of Nursing (DON) stated if a resident missed a dialysis appointment, she would expect a note to be documented in the EMR, the physician to be notified, and for R32, Lokelma to be administered as ordered. The DON stated she was not aware of R32's missed appointment on 03/01/25. During an interview on 03/21/25 at 4:30 PM, Licensed Practical Nurse (LPN) 3, who worked with R32 on 03/01/25, stated R32 missed dialysis on 03/01/25 because her transportation did not show up. LPN3 stated she did not document the missed appointment and did not notify the physician of the missed appointment. LPN3 stated she did not administer Lokelma to R32 on 03/01/25 because she did not know about the order. LPN3 stated since the order was not scheduled, and she typically did not look at all the as-needed medications for each resident, she did not know it needed to be administered. LPN3 stated the Lokelma should have been given on 03/01/25.

Based on observation, interview, record review, and policy review, the facility failed to ensure one of one resident (Resident (R) 14) reviewed for dental was provided with a visit to the dentist as ordered by the physician to address a mouth infection of 22 sample residents. This failure had the potential to lead to spread of infection, increased pain, and difficulty eating for R14. Findings include: Review of the facility's policy titled, Dental Examination/Assessment, dated July 2014, revealed 1. Prior to, or within ninety (90) days after admission, the resident shall undergo a dental examination. 2. Dental examinations will be made by the resident's personal dentist or by the facility's Consultant Dentist. 3. Records of dental care provided shall be made a part of the resident's medical record. 4. Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. Review of R14's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed he admitted on [DATE] with diagnoses including ulcerative oral mucositis and cirrhosis. Review of R14's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/25 and located under the MDS 3.0 tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. He did not have any oral problems. During an interview on 03/18/25 at 10:45 AM, R14 stated he needed to see a dentist because he had rotten teeth, missing teeth, and a broken tooth in front. R14 stated he had an oral abscess which was painful. He stated the physician prescribed antibiotics and said he should see a dentist, but he had not heard anything further about seeing the dentist. R14 added he was chewing his food on one side of his mouth and really needed to get his teeth taken care of. R14's mouth was observed with several missing teeth on one side and a broken tooth on the top front. Review of R14's Nurse's Note, dated 01/23/25 and located under the Progress Notes tab, revealed, [Physician] visited today, new orders received for Dentist appointment ASAP [as soon as possible] r/t [related to] tooth/gum infection, Orajel [pain ointment] to gums QID [four times a day] prn [as needed] for soreness et [and] Augmentin [antibiotic] 500 mg PO [orally] BID [twice daily] x 7 days. Review of a Physician's Orders sheet in R14's hard chart at the nurses' station revealed a handwritten physician's order, dated 01/23/25, for dentist appointment ASAP. Review of R14's hard chart at the nurses' station and Resident Documents tab of the EMR revealed there was no record of a dental visit. During an interview on 03/21/25 at 2:11 PM, the Social Services Director (SSD) stated she was not aware of the physician's order to see a dentist on 01/23/25. The SSD stated the nursing staff typically communicated a need to see a dentist either to her for in-house services or to the receptionist if an outside appointment needed to be made. The SSD stated R14 had not seen a dentist. During an interview on 03/21/25 at 3:20 PM, the receptionist stated she never received information requesting a dental appointment for R14. During an interview on 03/21/25 at 4:05 PM, the Director of Nursing (DON) stated the nurse who reviewed and signed off on the physician's order for a dental appointment should have communicated the information to the SSD or receptionist for follow up. She stated R14 had not seen the dentist.

Based on interview, record review, and policy review, the facility failed to ensure three of 22 sample residents (Resident (R) 2, R32, and R7) had accurate physician's orders. These failures had the potential to affect provision of hospice services for R2, provision of dialysis and communication with the dialysis center for R32, and provision of restorative services for R7. Findings include: Review of the facility's policy titled, Obtaining and Following Physician Orders, dated July 2014, revealed Physician orders will be obtained by licensed personnel and followed. If the licensed professional does not in his/her best judgment think that the order is not in the best interest of the resident, he/she has the obligation to further investigate prior to fulfilling the order. If those orders are not followed for any reason, the Physician and Director of Nursing will be promptly notified. Procedure: 1. Physician orders may be obtained by: a. The physician visiting and writing the order. b. The physician visiting and giving a verbal order. c. The facility contacting the physician via phone. d. The facility contacting the physician via fax. 2. Obtain the order. 3. Completed a telephone order slip for verbal or telephone orders. Follow the Telephone Order. 1. Review of R2's Face Sheet located under the Face Sheet tab of the EMR revealed R2 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. Review of the significant change MDS with an ARD of dated 12/18/24, revealed R2 had a BIMS score 11 out of 15 which indicated R2 was moderately cognitively impaired. Review of the physician orders, dated 06/07/23 and located in the Order tab of the EMR, revealed .Hospice Evaluation and Treat . During an interview on 03/21/25 at 6:36 PM, the Administrator confirmed R2 continued to have hospice orders and were just discontinued yesterday. I expect the nursing staff to go through and discontinue the order so the medical record could be accurate. 2. Review of R32's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR), revealed she admitted to the facility on [DATE] with diagnoses including end-stage renal disease, anemia, and malnutrition. Review of R32's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/25 and located under the MDS 3.0 tab of the EMR, revealed R32 received dialysis. Review of R32's Orders tab of the EMR revealed an active physician's order, dated 04/26/22, for Dialysis T-Th-Sat [Tuesday, Thursday, and Saturday] at Chromally American Kidney Center . During an interview on 03/21/25 at 10:19 AM, the Administrator stated the Chromally dialysis clinic closed down, and R32 was now receiving dialysis at the Forest Park dialysis center. The Administrator stated the physician's order in the EMR was incorrect and needed to be fixed. The administrator stated she was aware of a problem with inaccuracy of physician's orders in the EMR and they need to get cleaned up. The Administrator stated she expected orders to be accurate and up to date. During a telephone interview on 03/21/25 at 1:20 PM, the Forest Park Dialysis Center Social Worker (DSW) stated the Chromally dialysis center had closed and R32 was receiving dialysis at Forest Park since November 2024. 3. Review of R7's Face Sheet located under the Face Sheet tab of the EMR revealed she admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia, unspecified affecting left nondominant side, and chronic kidney disease. Review of R7's quarterly MDS with an ARD of 01/07/25 and located under the MDS 3.0 tab of the EMR, revealed that R7 required substantial to max assistance for self-care with a BIMS score of 11 out of 15 which indicated R7 was moderately cognitively impaired. Review of orders, dated 11/10/23 with no end date (open ended) and located under the Orders tab of the EMR, indicated R7 was to receive Restorative Dining x2 meals/day x5 days/ week to provide support as needed due to low vision. Once A Day, Restorative Program x3 days/ week for Right hand splint up to 4 hours for contracture management. Once A Day Restorative Program x3 days/ week for Right UE [upper extremity] PROM [Passive Range OF Motion] x10 all joints, all directions. During an interview on 03/19/25 at 1:59 PM, the Administrator stated the physician's order in the EMR was incorrect and needed to be fixed, R7 did not have splints any longer and they did not have a Restorative therapy program, but the Certified Nurse Assistant (CNAs) were trained to do the range of motion (ROM). When asked if the ROM was done as ordered the Administrator stated No, that is an old order and should not still be there. The Administrator stated she was aware of a problem with inaccuracy of physician's orders in the EMR and they need to get cleaned up. The Administrator stated she expected orders to be accurate and up to date. 40415 52322

Based on observations, interviews, record review, and policy review, the facility failed to ensure staff donned (put on) appropriate personal protective equipment (PPE) for three of five residents (Resident (R) 43, R61, and R262) reviewed for use of Enhanced Barrier Precautions of 22 sample residents. These failures had the potential to cause the spread of infection from staff to other residents. Findings include: Review of the facility's policy titled, Isolation Precautions/Enhanced Barrier Precaution (EBP), dated 04/01/24, revealed Enhanced Barrier Precautions is [sic] used in combination with Standard Precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs [multi-drug resistant organisms] to staff hands and clothing .EBP will be used for any resident who meets the following criteria: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; Chronic wounds, such as, pressure ulcer, venous stasis ulcers, diabetic ulcers, unhealed surgical wounds; Indwelling medical devices, such as, central lines, urinary catheters, feeding tubes, and tracheostomies 2. Residents who meet the above criteria, EBP are recommended when performing the following high-contact resident care activities: Dressing, Providing hygiene, Bathing/showering, Transferring, Changing linens, Changing briefs or assisting with toileting, Indwelling medical devices care, Chronic wound care. 3. Place EBP sign at entrance to the room for the resident [sic] who meet the criteria. Staff will clean their hands before entering and when leaving the room. Staff will wear gloves and a gown for High-Contact Resident Care Activities. 1. Review of R43's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed he admitted to the facility on [DATE] with diagnoses including stage three pressure ulcers of the sacrum and right buttock and stage two pressure ulcer of the left buttock. Review of R43's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/25 and located under the MDS 3.0 tab of the EMR, revealed he had a current stage three pressure ulcer. Review of the Wound Observation History tab of the EMR revealed on 03/13/25, a wound to R43's coccyx was present and measured six centimeters (cm) long, 6cm wide, and 0.3cm deep. Review of R43's Orders tab of the EMR revealed an active order, dated 02/21/25, to Cleanse coccyx with wound cleanser/NS [normal saline], apply Medihoney [Wound & Burn Dressings, containing Active Leptospermum (Manuka) Honey (ALH)] with dry dressing daily. During an observation on 03/20/25 beginning at 10:39 AM, a sign was posted outside R32's room indicating EBP was required. The Wound Physician (WP) and his accompanying Wound Licensed Practical Nurse (WLPN) both entered the room and donned gloves but did not wear a gown. They cleaned R32's bottom, cleaned the pressure ulcer with normal saline, assessed the wound, and applied the dressings, all while not wearing gowns. During an interview with the WP and WLPN on 03/20/25 at 10:50 AM, the WP stated he did not wear a gown during the wound treatment for R43. The WLPN confirmed she did not wear a gown during the wound treatment. The WP stated regulation called for gowns to be worn while providing care for residents with wounds; however, he did not have any gowns available at the moment and was taking care of the wound real quick. During an interview on 03/21/25 at 3:57 PM, the Infection Preventionist (IP) stated she had done training with all the staff on using EBP but had not conducted training with the WP or WLPN. The IP stated she expected any staff member providing direct care to a resident on EBP to wear a gown as well as gloves. The IP stated residents requiring EBP included those with open wounds, catheters, feeding tubes, or other indwelling devices. 2. Review of R61's Face Sheet located under the Face Sheet tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including a left heel pressure ulcer. Review of R61's EMR under the Wound Observation History tab revealed on 03/13/25, he had a pressure ulcer to the sacrum measuring 1cm long, 0.3cm wide, and 0.1cm deep. Review of R61's Orders tab of the EMR revealed an active physician's order to, apply barrier cream to coccyx q [every] shift et prn [and as needed]. During an observation in R61's room on 03/20/25 at 12:28 PM, Certified Nurse Assistant (CNA) 7 was in the room assisting R61 with incontinence care and changing his bed linens while he was in bed. CNA7 was wearing gloves but no gown. CNA7 exited the room at 12:34 PM. During an interview on 03/20/25 at 12:41 PM, CNA7 stated she was from a staffing agency, and this was her first day at the facility. CNA7 stated she had assisted R61 with incontinence care and a total bed linen change. She confirmed she did not wear a gown while providing care and stated she did not have any available in R61's room. CNA7 stated R61 was on EBP, and gowns and gloves should be worn while providing care. During an interview on 03/21/25 at 4:02 PM, the IP stated R61 had a current open pressure ulcer and required EBP. The IP stated the CNA should have worn a gown while providing care to R61. The IP stated she had provided education to facility staff on EBP but had not provided education to agency staff. 3. Review of R262's Face Sheet located under the Face Sheet tab of the EMR revealed R262 was admitted to the facility on [DATE] with a diagnosis of nontraumatic intracerebral hemorrhage intraventricular. Observation on 03/20/25 at 10:56 AM revealed R262 door had EBP signage on the door and on top of the PPE supplies in the room. Observation and interview on 03/20/25 at 10:59 AM revealed CNA2 entered the room and observed R262 was exposed from the top of her upper body. CNA2 confirmed she did not put on PPE before attempting to dress R262. 52322

Based on record review, interview, and policy review, the facility failed to ensure two of five residents (Resident (R) 164 and R61) reviewed for vaccinations, who consented to receive vaccinations, were administered the vaccines of 22 sample residents. These failures had the potential to cause avoidable spread of pneumonia or influenza. Findings include: Review of the facility's policy titled, Infection Control, dated July 2017, revealed Residents and employees are offered the influenza vaccine annually between October and March. The pneumococcal vaccine is offered to all residents at the time of admission and throughout their stay as per current standards of practice. 1. Review of R164's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed she admitted to the facility on [DATE] with diagnoses including dementia and right lower leg fracture. Review of R164's Pneumococcal Vaccine Consent and Release, dated 02/03/25 and provided by the facility, revealed she consented to receive the pneumococcal vaccine. Review of R164's EMR under the Preventative Healthcare and Resident Documents tabs revealed no record the pneumococcal vaccine was administered. During an interview on 03/21/25 at 6:28 PM, the Infection Preventionist (IP) stated R164 had consented to receive the pneumococcal vaccine, and it should have been administered. The IP stated it should not take this long to administer the vaccination and stated it had been missed. 2. Review of R61's Face Sheet located under the Face Sheet tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including a left heel pressure ulcer. Review of R61's Influenza Vaccine Consent and Release, dated 02/27/25 and provided by the facility, revealed R61 consented to receive the influenza vaccination. Review of R61's EMR under the Preventative Healthcare and Resident Documents tabs revealed no record the influenza vaccine was administered. During an interview on 03/21/25 at 6:28 PM, the IP stated R61 consented to receive the influenza vaccination but had not yet received it. The IP stated it should not have taken so long after consent was obtained and the vaccine should have been administered; however, R61 was missed.

Based on observation, interview and record review, the facility failed to follow their pressure ulcer and wound care policies/procedures by failing to ensure Resident #3's wound care Physician's orders were initiated when ordered, and Registered Dietician's (RD) recommendations were promptly followed. The facility also failed to promptly identify, assess, document and notify the resident's Physician regarding the resident's pressure ulcers located on both feet/heels. In addition, the facility failed to ensure Resident #2, who was admitted on [DATE], with a pressure ulcer on the coccyx (the tailbone), had a treatment order in place until 7/1/24, failed to ensure a nurse contacted the physician for a treatment order prior to administering a treatment to the coccyx, failed to ensure the wound care Physician's orders were initiated and the RD's recommendations were promptly followed. The facility identified two residents with pressure ulcers and problems were found with both. The census was 57. Review of the facility Wound Management Program policy dated November 2022, showed: -Policy: It is the policy of this facility to manage resident skin integrity through prevention, assessment, and implementation and evaluation of interventions; -Procedure: 1. The facility is provided with wound care protocols. These are to be utilized to assist in the care and treatment of wounds. Physician orders should be obtained and followed for each resident; 2. The Braden Scale (an assessment used to determine a resident's risk of developing a pressure ulcer (an injury that breaks down the skin and underlying tissue)) will be completed on admission weekly for four weeks post admission and quarterly thereafter to assess skin breakdown risk; 3. Residents identified at risk on the Braden Scale will have this addressed on their care plan and will have interventions put in place for preventative measure. Interventions: pressure reducing mattress and/or cushion, be reviewed by a Dietician and lab values as needed. Resident's identified with wounds will have a care plan initiated regarding impaired skin integrity; 4. The facility will assess residents weekly for current skin conditions; a. The charge nurse for each hall will do skin assessments; b. The skin assessment will be documented on the Weekly Skin Assessment, which is completed as follows: i. Observe the skin for the following: 1. Open areas; 2. Redness; 3. Rashes; 4. Discolored areas; ii. Indicate the location of any identified areas on the body figure; iii. Describe the area(s); c. If any new areas are identified, write a nurse's note describing the area found and the protocol followed to treat it. The new area should also be noted on the 24 Hour Report; d. The nurse will measure the area, call the physician to obtain appropriate treatment order, call the guardian/family member, document the area on the POS (physician's order sheet), and initiate the treatment; 5. The Skin Assessment should be also completed whenever a new skin condition is noted; 6. All wounds will be reported weekly on the Wound Report; 7. It is important that wounds are assessed correctly to differentiate between pressure and non pressure wounds; 8. It is the responsibility of the Administrator to review the Wound Report weekly; 9. Interdisciplinary team meetings will be held weekly. The committee should include at a minimum the nurse responsible for treatments, representative from therapy, Director of Nursing (DON), and representative from dietary; 10. During the meeting, the Wound Report will be reviewed to assess the progress of the residents. Any wounds designated as not improving should be discussed further in the meeting. Review of the facility Dressings, Dry/Clean policy, dated January 2018, included: -Verify that there is a physician's order for this procedure; -Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs; -Check the treatment record; -Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the dressing was changed; 2. Wound appearance, including wound bed, edges, presence of drainage; 3. The name and title of the individual changing the dressing; 4. The type of dressing used and wound care given; 5. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; 9. The signature and title of the person recording the data; -Report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #3's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/17/24, showed: -Severe cognitive impairment; -No functional limitations of the upper/lower extremities; -Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity for: Toileting, shower/bathe, lower body dressing, putting on/taking off footwear, and personal hygiene; -Substantial/maximal assistance - Helper does more than half the effort required to: Roll left and right, sit to lying, lying to sitting on side of bed, chair/bed to chair transfer, and toilet transfer; -Always incontinent of urine and bowel; -Diagnoses of anemia (the capacity of the blood to carry oxygen is reduced), and diabetes mellitus (high blood sugar); -Risk of Pressure Ulcers: Yes; -Unhealed Pressure Ulcers: No; -Hospice care. Review of the resident's Braden Scale dated 5/19/24, showed the resident was at moderate risk to develop pressure ulcers. Review of the resident's progress notes, located in the electronic healthcare record (EHR), showed: -5/19/24 at 10:19 A.M., Stage 2 pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous). May also present as an intact or open/ruptured blister) on coccyx. 4.0 centimeters (cm) (height) x 4.5 cm (width) x 1.0 cm (depth) reported to on-call Physician. Received new order to cleanse with wound cleanser, apply Medihoney (a medical grade honey used for wound care), optifoam every three days and PRN (as necessary); -5/22/24 at 1:02 P.M. and documented by the RD, quarterly note. New onset pressure ulcer on coccyx. Appropriate to consider addition of vitamin/protein supplementation. Currently on no added sodium/salt (NAS), low concentrated sweets (LCS) diet. Appropriate to consider liberalizing diet due to wishes for comfort. Recommend: 1) Discontinue NAS/LCS diet. 2) Add multivitamin with minerals daily. 3) Add liquid protein (for wound healing) 30 milliliter (ml) two times a day; -6/1/24 at 2:21 P.M., Resident seen by the wound care Physician. No new orders. Review of the resident's medication administration record (MAR), dated 5/1/24 through 5/31/24, showed no order for a multivitamin with minerals daily or liquid protein 30 ml daily. Review of the resident's care plan, located in the EHR and last edited on 6/4/24, showed: -7/1/20: Problem: Activities of daily living functional status. Goal: Resident will be able to maintain present level of functioning through next review. Approach: Staff assist 1-2 with transfers, bed mobility and personal care. Resident is non-ambulatory and can self propel in his/her wheelchair. Observe skin condition with daily care; -7/1/20: Problem: Pressure Ulcer/Injury. Goal: Resident will have skin remain intact by next review date. Approach: Provide treatments and medication as ordered. Assist with mobility and transfers. Ensure proper body alignment in bed or chair. Observe skin condition with daily care. Report changes to the physician and obtain treatment as ordered. Weekly body audit; -The resident's care plan had not been updated to include any known pressure ulcers or that the skin was no longer intact. Review of the resident's Skin Observation assessments, showed: -6/21/24: Pressure Injury/Blister/Open Areas - Yes, coccyx. Describe any additional body marks or sores: Blank; -6/26/24 and completed by Licensed Practical Nurse (LPN) E: Pressure Injury/Blister/Open Areas - Yes. Wound to bottom and lle (left lower extremity). Describe any additional body marks or sores: Blank; -Review of the resident's progress notes, POS and MAR, showed no assessment, physician notification or treatment order for the resident's left lower extremity. Review of the wound care Physician's progress note, dated 6/28/24, showed: -Wound Location: Coccyx; -Wound Type: Pressure Ulcer - Unstageable (Slough and/or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin); -Wound Status: Improving; -Pre-debridement Measurement: 4.5 cm x 4.6 cm x 1.5 cm; -Tunneling (passageways underneath the skin): Absent; -Undermining (a pocket of dead space under the skin originating from the edges and spreading outwards): Absent; -Odor: Absent; -Eschar (dead tissue that forms over healthy skin and then, over time, falls off (sheds)): Absent; -Exposure: Tendon/Muscle/Ligament; -Tissue Type: Slough, Granulating (new tissue/healing); -Exudate (is fluid that leaks out of blood vessels into nearby tissues) Amount: Moderate; -Exudate Color: Serosanguineous (thin, clear pink drainage); -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement (removal of tissue): Indication for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Nonexcisional (a scalpel is not used to remove devitalized tissue); -Description of Tissue Removed: Slough. Blood Loss: None. Instrument Used: 4x4's (gauze); -Dressing Order: Cleanse wound with wound cleanser, slightly moistened collagen (protein based) pad, 4x4's gauze lightly packed, Zetuvit (an absorbent dressing for moderate to heavy exudate) plus silicone border dressing, ok to substitute with generic border gauze if unavailable; -Change Dressing: Every 24 hours; -No documentation about the resident's left lower extremity. Review of the resident's physician's orders sheet (POS) on 7/1/24 at 12:43 P.M., located in the EHR, showed: -6/5/24: Liquid protein 30 ml twice a day; -6/5/24: One multi-vitamin with mineral daily; -6/5/24: Regular diet; -The liquid protein, multivitamin with mineral and regular diet were not ordered until 14 days after the RD's recommendations on 5/22/24; -6/9/24: Cleanse coccyx wound with full strength Dakins solution (a diluted bleach solution), pat dry, apply Medihoney in and around wound bed, gently pack with calcium alginate (absorbs exudate (wound drainage)), apply foam dressing daily and PRN; -No order dated 6/28/24 (from the wound care Physician) to cleanse the coccyx with wound cleanser, slightly moistened collagen (protein based) pad, 4x4's gauze lightly packed, Zetuvit (an absorbent dressing for moderate to heavy exudate) plus silicone border dressing, ok to substitute with generic border gauze if unavailable. Review of the resident's MAR, dated 6/1/24 through 6/30/24, showed: -6/5/24: Multivitamin with minerals daily; -6/5/24: Liquid protein 30 ml daily; -5/28/24 - 6/4/24: Cleanse coccyx with wound cleanser, apply Medihoney with bordered gauze daily; -6/4/24 - 6/9/24: Cleanse coccyx with wound cleanser, apply Medihoney with bordered gauze daily; -6/9/24 - 7/1/24: Cleanse coccyx wound with full strength Dakins solution, pat dry, apply Medihoney in and around wound bed, gently pack with calcium alginate, apply foam dressing daily and PRN; -No order dated 6/28/24 (from the wound care Physician progress notes) to cleanse the coccyx with wound cleanser, slightly moistened collagen pad, 4x4's gauze lightly packed, Zetuvit plus silicone border dressing, ok to substitute with generic border gauze if unavailable; -The resident did not have a treatment administration record (TAR). All physician orders were on the MAR. Review of the resident's MAR dated 7/1/24 through 7/31/24, showed: -7/1/24: Cleanse wound with wound cleanser, apply collagen pad and pack 4x4 in wound bed, cover with foam dressing daily. During a telephone interview on 7/10/24 at 8:10 A.M., LPN E said he/she reviewed the skin observation he/she completed on 6/26/24. He/She documented the information wrong. He/She did not mean to document the resident had a wound on the left lower extremity, only the coccyx. There was a piece of Duoderm (a cushioned/absorbent adhesive dressing) on the left lower extremity, but there was no pressure ulcer or wound underneath it. There was no order for the Duoderm. He/She thought it was there as a preventative measure. Observation on 7/1/24 at 9:07 A.M., showed the resident lay in bed for a skin assessment. Certified Nursing Assistant (CNA) C and CNA D assisted the resident onto his/her left side, showing an undressed pressure ulcer with a small amount of yellow slough on the resident's coccyx. CNA D said he/she had to remove the dressing earlier that morning when he/she cleaned the resident because it was soiled. The resident's left foot was wrapped with clean kling gauze (rolled gauze used for wrapping a dressing to a pressure ulcer/wound). There was no date on the left foot dressing. The right foot showed two dark/red circular areas on the right heel. Observation on 7/2/24 at 10:39 A.M., showed the resident lay in bed. CNA G and LPN F prepared the resident for his/her coccyx treatment. LPN F applied collagen to the pressure ulcer and covered it with a dressing. LPN F said he/she was not aware of the dark/red areas on the resident's right and left feet/heels. He/She thought the areas were caused from pressure. He/She worked yesterday and no one told him/her about the areas on the resident's feet/heels. Had he/she been made aware, he/she would have assessed the areas and called the physician. He/She did not know how long the areas had been there. There were no current treatment orders for those areas. At 10:45 A.M., the DON entered the room to assess the resident's heels/ankle. She identified the areas as pressure related. She was not aware of the areas. The CNAs should have reported any new areas to the charge nurse when they were first noted and the charge nurse should have assessed, contacted the physician and documented any new orders. LPN G measured the areas and noted the following: right outer heel 3.6 cm x 4.4 cm, right inner heel 3.4 cm x 2.7 cm, left inner ankle 3.2 cm x 0.9 cm and left heel 4.7 cm x 6.7 cm. During an interview on 7/2/24 at 11:22 A.M., LPN F said he/she worked 6/29/24 (Saturday) and did the resident's treatment. He/She did not use the treatment ordered by the wound care Physician on 6/28/24, because it had not been entered on the MAR. He/She did the previous treatment for Dakins and Medihoney that began on 6/9/24. During an interview on 7/2/24 at 11:50 A.M., CNA D said he/she worked at the facility for about a month and had taken care of the resident several times. The areas on the resident's right/left feet/heels had been there since he/she had been taking care of the resident. He/She told the nurses about the areas, but could not recall who he/she had told. During an interview on 7/2/24 at 12:00 P.M., Registered Nurse (RN) A said he/she did not usually work on the resident's hall. No one reported any pressure ulcers on the resident's feet to him/her. Had that been reported to him/her, RN A would have assessed the areas, called the physician and documented it in EHR. During an interview on 7/2/24 at 12:37 P.M., the DON said she had no idea who put the dressing on the resident's left foot that was observed on 7/1/24. She reviewed the resident's EHR and there was no documentation about the resident's heels/ankle. She was not aware the wound care Physician wrote a new order for the coccyx on 6/28/24. That treatment should have been implemented before 7/1/24. Review of the wound care Physician's progress note, dated 7/5/24, showed: -Wound Location: Coccyx; -Wound Type: Pressure Ulcer Stage 4; -Wound Status: Improving; -Pre-debridement Measurement: 5.0 cm x 5.0 cm x 1.1 cm; -Tunneling: Absent; -Undermining: Absent; -Odor: Absent; -Eschar: Absent; -Exposure: Tendon/Muscle/Ligament; -Tissue Type: Granulating; -Exudate Amount: Moderate; -Exudate Color: Serosanguineous; -Surrounding Skin: Intact; -Signs of Infection: Absent; -Debridement: In for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Nonexcisional; -Description of Tissue Removed: Slough. Blood Loss: None. Instrument Used: 4x4's; -Dressing Order: Cleanse wound with wound cleanser, slightly moistened collagen pad, 4x4's gauze lightly packed, Zetuvit plus silicone border dressing, ok to substitute with generic border gauze if unavailable; -Change Dressing: Every 24 hours; -Wound Location: Right lateral (toward the outside) heel; -Wound Type: Pressure Unstageable; -Wound Status: First Visit; -Pre-debridement Measurement: 4.0 cm x 4.0 cm x 0.0; -Exudate Amount: None; -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement: Debridement not indicated; -Dressing Order: Apply Skin Prep (a liquid that when applied to the skin forms a protective film or barrier) daily. Offloading boots (designed to alleviate pressure) at all times; -Wound Location: Right medial (toward the middle) heel; -Wound Type: Pressure Ulcer Unstageable; -Wound Status: First Visit; -Pre-debridement Measurement: 1.5 cm x 0.3 cm x 0.0; -Exudate Amount: None; -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement: Debridement not indicated; -Dressing Order: Apply Skin Prep daily. Off loading boots at all times; -Wound Location: Left medial heel; -Wound Type: Pressure Ulcer Unstageable; -Wound Status: First Visit; -Pre-debridement Measurement: 4.0 cm x 4.0 cm x 0.0; -Exudate Amount: None; -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement: Debridement not indicated; -Dressing Order: Apply Skin Prep daily. Off loading boots at all times; -Wound Location: Left medial ankle; -Wound Type: Pressure Ulcer Unstageable; -Wound Status: First Visit; -Pre-debridement Measurement: 4.0 cm x 5.0 cm x 0.0; -Exudate Amount: None; -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement: Debridement not indicated; -Dressing Order: Skin Prep daily. Off loading boots. During a telephone interview on 7/10/24 at 10:51 A.M., the Medical Director said he expected CNAs to promptly report any new pressure ulcers or areas of concerns to the charge nurse immediately. The nurse should assess the areas and contact the physician for any new orders. This should be documented on the POS, MAR and in the EHR. During a telephone interview on 7/10/24 at 11:30 A.M., the wound care Physician said he did not do a total skin assessment on the residents he saw. He only looked at what the facility had identified. If a staff member noticed a new pressure ulcer it should be communicated to the nurse and DON and they could call him for new orders. He was not aware of the pressure ulcers on the resident's feet until 7/5/24. The pressure ulcers on the resident's feet could occur anywhere from a few hours to several days. 2. Review of Resident #2's admission face sheet, located in the EHR, showed: -admitted [DATE]; -Diagnoses of Alzheimer's disease, dementia, anemia, and pressure ulcer of sacral region (the area between the lower back and the upper buttocks). Review of the resident's Baseline Care Plan, undated, showed: -Respite (short term stay); -Disease/Illness Management: Pain, weight loss, weakness and wound; -Other Special Care Instructions: Follow protocol to care for wound care: Blank. Review of the resident's Braden Scale dated 6/25/24, showed the resident had a very high risk to develop pressure ulcers. Review of the resident's progress notes, located in the EHR, showed: -6/25/24 at 3:10 P.M.: Returned by ambulance, transferred from stretcher to bed by two emergency medical staff. Alert and oriented to self. On hospice and here for respite care for 5 days. All orders verified by physician. Skin issues noted. Area on coccyx 9.0 cm x 9.0 cm with tunneling area 5.0 cm x 4.0 cm x 1.5 cm. Treatment to coccyx changed; -6/26/24 at 7:33 P.M. and documented by the RD: Admission on hospice services. Skin with pressure ulcer coccyx. Recommend 1) add liquid protein 30 ml twice a day. 2) Add Boost (nutritional drink) twice daily. Review of a hospice order dated 7/1/24 at 5:39 P.M., and received by the facility on 7/1/24 at 6:56 P.M. from hospice, showed: Late entry 6/26/24. Cleanse stage 4 pressure ulcer to coccyx with wound cleanser, rinse with normal saline, gently pat dry, cover with dry dressing. HSN (hospice skilled nurse) two times a week and FSN (facility skilled nurse) daily and PRN if soiled. May discontinue when wound is healed. Review of the resident's MAR dated 6/25/24 through 6/30/24, showed: -No treatment order for the coccyx, liquid protein or Boost; -The resident did not have a TAR. All physician orders were on the MAR. Review of the wound care Physician's progress note, dated 6/28/24, showed: -Wound Location: Coccyx; -Wound Type: Pressure Ulcer Stage 4; -Wound Status: First Visit; -Pre-debridement Measurement: 13.0 cm x 9.0 cm x 3.0 cm; -Tunneling: Absent; -Undermining: Absent; -Odor: Absent; -Eschar: Absent; -Exposure: Tendon/Muscle/Ligament; -Exudate Amount: Moderate; -Exudate Color: Serosanguineous; -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement: Indication for debridement: Reduce devitalized tissue, decrease risk of infection. and promote wound healing; -Type of Debridement: Nonexcisional; -Description of Tissue Removed: Slough. Blood Loss: None. Instrument Used: 4x4s; -Dressing Order: Cleanse wound with wound cleanser. Flagyl (antibiotic) powder. Medihoney gel. Zetuvit plus silicone border dressing, ok to substitute with generic border gauze if unavailable; -Change Dressing: Every 24 hours and as needed. Review of the resident's POS located in the EHR on 7/1/24 at 1:44 P.M., showed: -7/1/24: Cleanse wound with wound cleanser, apply Flagyl powder and Medihoney to wound bed, then cover with border gauze daily; -No order for liquid protein or Boost. Observation of the resident on 7/1/24, showed: -8:21 A.M.: The resident lay in bed sleeping on a low air loss (pressure reducing) mattress; -8:56 A.M.: The resident lay in bed. The Assistant Director of Nursing (ADON), RN A and Certified Medication Technician B turned the resident onto his/her left side. A strong foul odor was immediately noted. The resident's dressing was dated 6/29/24, and heavily saturated with drainage. The ADON said the dressing should be changed daily. She did not know why it was not changed the day before on 6/30/24. RN A packed the pressure ulcer with wet to dry 4x4s (saturated with normal saline) and covered it with a foam dressing; -2:20 P.M.: The DON said the resident did not have an treatment order in the EHR for the resident's coccyx until today. She did not know why. Review of the resident's POS located in the EHR on 7/2/24 at 9:15 A.M., showed: -An order, dated 7/1/24, five days after the RD recommendation on 6/26/24, for: Liquid protein 30 ml two times a day; -An order, dated 7/1/24, five days after the RD recommendation on 6/26/24, for: Boost two times a day with meals. During an interview on 7/2/24 at 9:38 A.M., the ADON said she spoke to hospice. Hospice said they verbally told the charge nurse on 6/26/24 about the order for the coccyx, but did not leave the order in writing. She contacted hospice and received the late entry order yesterday evening. If hospice told the admitting nurse about the treatment order for the coccyx, the admitting nurse should have entered the treatment order on the POS and MAR at that time. She was not sure what staff had been treating the pressure ulcer with or how often prior to 7/1/24. The resident was no longer at the facility on respite. He/She would be staying long term. During an interview on 7/2/24 at 11:22 A.M., LPN F said he/she worked on 6/29/24 and completed the resident's coccyx treatment. He/She could not find a treatment order on the POS or MAR. He/She was not aware the resident was being seen by the wound care Physician and was not aware he wrote new orders on 6/28/24. He/She used a Dakins wet to dry dressing on 6/29/24. He/She did not have a physician's order to do that. He/She had experience as a wound nurse and thought the Dakins wet to dry dressing would be best since there was no order. He/She should not have done that. He/She should have contacted the physician or hospice and gotten a treatment order. During an interview on 7/2/24 at 12:00 P.M., RN A said he/she could not find an order on the POS or MAR yesterday. RN A used a wet to dry dressing on the resident's coccyx because he/she had previously heard the hospice Nurse say that was the order. He/She should have contacted hospice or the Physician to confirm the order. He/She was not aware the wound care Physician had written a new order on 6/28/24, or he/she would have used that order. The wound care Physician sent his orders to the DON. When he/she admitted a new resident he/she assessed any pressure ulcers/wounds and contacted the physician for an order. He/She documented all of that at the time of admission and entered it on the POS and MAR. Review of the wound care Physician's progress note, dated 7/5/24, showed: -Wound Location: Coccyx; -Wound Type: Pressure Ulcer Stage 4; -Wound Status: Deteriorating; -Pre-debridement Measurement: 14.0 cm x 12.0 cm x 3.0 cm; -Tunneling: Absent; -Undermining: Absent; -Odor: Absent; -Eschar: Absent; -Exposure: Tendon/Muscle/Ligament; -Exudate Amount: Moderate; -Exudate Color: Serosanguineous; -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement: Indication for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Nonexcisional; -Description of Tissue Removed: Slough. Blood Loss: None. Instrument Used: 4x4s; -Dressing Order: Cleanse wound with wound cleanser. Flagyl powder (antibiotic). Dakins moistened gauze dressing; -Change Dressing: Every 72 hours. During a telephone interview on 7/10/24 at 10:51 A.M., the Medical Director said it was the facility's responsibility to ensure a newly admitted resident with a pressure ulcer had an order in place upon admission. Someone between the resident's admitted and 7/1/24 should have noticed there was not a treatment order and contacted him, the wound care Physician or hospice for an order. Nurses should not administer any treatment without a physician's order. During a telephone interview on 7/10/24 at 11:30 A.M., the wound care Physician said he did not feel the resident's pressure ulcer would ever heal due to the resident's declining condition. He ordered the Flagyl to help with the odor. 3. During an interview on 7/2/24 at 12:37 P.M., the DON said the facility wound care policies were current and should be followed. The wound care Physician typically made rounds on Fridays. A facility nurse made rounds with the wound care Physician but not always. The wound care Physician would normally tell the nurses if there were any new orders. He sent copies of any order changes via e-mail to her, the ADON and Administrator by Monday the following week. She realized his treatment orders needed to be implemented the same day he wrote the orders. They would start making sure a nurse made rounds with the wound care Physician going forward to ensure any new treatment orders were implemented the day he made rounds. The RD sent her recommendations to her, the ADON and the Dietary Manager the day she was in the building or no later than the next day after she left. They should have any new recommendations followed up on within 72 hours after the RD's recommendations. She was not sure why that had not been done consistently. 4. During a telephone interview on 7/10/24 at 10:51 A.M., the facility Medical Director said the facility should follow their pressure ulcer and wound policies. The RD recommendations should be called to him within a day after she wrote the recommendations. 72 hours was too long to wait. The wound care Physician's orders should be implemented at the time he wrote the orders. It should not take three days to implement the orders. 5. During a telephone interview on 7/10 24 at 11:30 A.M., the wound care Physician said he typically made rounds on Fridays and sometimes on the weekend if he was behind. After he rounded he always told the nurse on duty if there were any new treatment orders. He expected the orders to be changed at that time. He also followed up by e-mailing any orders to the Administrator, DON and ADON. MO00238085

Based on interview and record review, the facility failed to monitor a full code resident who was diagnosed with COVID-19 (an infectious disease caused by the SARS-CoV-2 virus), in accordance with their policy (Resident #1). The facility did not document assessments of symptoms, vital signs, oxygen saturation levels and respiratory symptoms. The sample was four. The census was 57. Review of the facility's Change in Condition Policy, dated February 2012, showed the following: -Policy: It is the policy of the facility that resident change in condition will be assessed promptly and follow up activity will occur as appropriate and in a timely manner; -Definition: -Change in condition is defined as an improvement or decline in the resident's physical, mental or psychosocial status that affects less than two areas of activities of daily living; -Significant change is defined as an improvement or decline in the resident's physical, mental or psychosocial status that affects two or more areas of activities of daily living; -Procedure: 1. The staff person who first notices the change reports resident change in condition immediately to the licensed nurse. 2. The licensed nurse assesses the resident including vital signs and notes signs and symptoms, regarding physical and mental changes in condition. 3. The results of the assessment, including the vital signs, signs and symptoms and any physical and/or mental changes in condition are documented in the resident's medical record. 4. The resident's primary physician or designated alternate will be notified immediately of any change in resident's physical or medical condition, this includes: a. Need to alter treatment (i.e. need to discontinue an existing form of treatment due to adverse consequences or to commence new form of treatment); b. A decision to transfer or discharge from the facility. Review of the facility's Management of Residents with Confirmed & Suspected COVID-19 Infection and Duration of Transmission Based Precautions, dated [DATE], showed the following: -Policy: The facility will manage resident placement and duration of Transmission Based Precautions to aid in the prevention of the transmission of COVID-19: -Residents with Confirmed and Suspected COVID-19: -Increase clinical monitoring to every shift: Assessment of symptoms, vital signs, oxygen saturation levels, and respiratory exam. Residents that are suspected but not yet confirmed shall be clinically monitored daily and increased to every shift if they develop a fever or COVID-19 symptoms. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Moderate cognitive impairment; -No moods or behaviors; -Dependent with activities of daily living (ADLs); -Diagnoses of congestive heart failure, high blood pressure and Alzheimer's Disease. Review of the resident's nurse's notes, dated [DATE] at 6:55 P.M., showed the resident tested positive for COVID-19. The resident's physician was notified. New orders were received for paxlovid (treatment for COVID-19) ,d+[DATE] milligram (mg) tablet, (150 mg x 2)-100 mg; Amount to Administer: two tablets by mouth. The resident was in bed resting at this time. The resident had a appetite poor. Fluids were encouraged and vital signs charted within normal limits. During an interview on [DATE] at 10:06 A.M., Certified Nurse Aide (CNA) D said the resident did not seem like him/herself on [DATE]. The resident was more down and depressed than usual. He/She reported this to Registered Nurse (RN) G. CNA D said he/she was not taking vital signs, the Charge Nurse should take vital signs. He/She was aware the resident had COVID-19. During an interview on [DATE] at 12:08 P.M., RN G said a CNA reported to him/her the resident did not eat breakfast and this was not like the resident. RN G said he/she decided to give the resident a COVID test on [DATE] and it came back positive. He/She passed the information on in report to the evening shift and called the resident's family. RN G said he/she took the resident's vital signs and they were within normal limits. The vital signs should have been documented in the resident's medical record. RN G said the Charge Nurse should take the resident's vital signs every shift and record them in the resident's medical record. RN G was not aware the resident's vital signs were not documented. RN G said he/she did not remember working the next day. Review of the resident's medical record, showed no documentation of the resident's vital signs. Review of the resident's care plan, showed no documentation of the resident's diagnoses of COVID-19. During an interview on [DATE] at 10:34 A.M., CNA B said he/she was assigned to the resident on [DATE] on the evening shift. The resident was lethargic and this was normal for the resident. He/She gave care to the resident with no concerns. CNA B said he/she was new to the facility. He/She did not report anything because he/she did not think there was anything to report. He/She did not get vital signs. The Charge Nurse should get the vital signs. Review of the next nurse's note, dated [DATE] at 7:52 A.M., showed the CNA notified the nurse and said during perineal care, the resident became unresponsive. The Charge Nurse entered resident's room at 4:20 A.M. The resident had no rise or fall of his/her chest, he/she was pulseless and unable to obtain vital signs. Cardiopulmonary Resuscitation (CPR, a medical emergency first aid procedure to help someone whose heartbeat and/or breathing has stopped by performing chest compressions, intubation, and/or defibrillation) was initiated. A call placed to 911 at 4:21 A.M. and 911 arrived 4:29 A.M. and took over CPR administration which was unsuccessful. The time of death was called 4:51 A.M. The resident's physician was notified of above and named the cause of death as COVID-19. A call was placed to the resident's family. Review of the resident's medical record, showed no documentation on ,d+[DATE] through [DATE] of monitoring, assessment or vital signs to the resident's change of condition During an interview on [DATE] at 10:14 A.M., Licensed Practical Nurse (LPN) A said a CNA came and got him/her and said the resident had expired during perineal care. He/She went to assess the resident and found the resident unresponsive. He/She started CPR with CNA C. Another nurse called 911 and they arrived and took over. The resident had expired. The resident did not eat much at lunch but did not have any complaints. At 12:28 P.M., LPN A said he/she saw the resident around 3:00 P.M. to 4:00 P.M. on [DATE]. The resident was breathing fine. LPN A said knew the resident had COVID-19 and was not at his/her baseline. The resident was usually very talkative. The Charge Nurse should have obtained vital signs from the resident each shift. LPN A said he/she left for the evening and came back later on [DATE] to work the night shift 11:00 P.M. to 7:00 A.M The resident was sleeping at that time and did not show any signs of concern. LPN A said he/she usually takes vital signs at the end of the shift which would be about 4:00 A.M. to 6:00 A.M. He/She saw the resident sleeping and did not want to wake the resident so the vital signs were not obtained. He/She did not see any concerns with the resident. He/She did not know what the facility's policy was on the timeframe of taking vital signs. During an interview on [DATE] at 2:12 P.M., CNA C said he/she came on shift at 11:00 P.M. on [DATE]. He/She did rounds at that time and the resident was breathing properly. CNA C went to do rounds at approximately 4:00 A.M. and went to give the resident perineal care and found the resident was not breathing. He/She went to get LPN A and they initiated CPR. CNA C said he/she did not get vital signs on his/her shift. LPN A should get vital signs. CNA C said he/she did not remember anything being wrong with the resident. During an interview on [DATE] at 3:07 P.M., Physician F said he/she may have gotten a call from the facility regarding the resident having COVID-19, he/she did not remember. The facility was good about keeping him/her updated. He/She expected the facility to follow their COVID policy with the resident being a full code and call if there was a change of condition for further instruction and orders. The resident was elderly and any major illness such as COVID could have taken the resident. During an interview on [DATE] at 12:10 P.M., the Director of Nursing (DON) said she expected the facility's COVID Policy and Change of Condition Policy to be followed as written. The DON expected the Charge Nurse to use nursing judgment to obtain the vital signs each shift. The purpose of obtaining vital signs would be to help monitor the resident for any change of condition. If there was a change of condition, the resident's physician should have been notified for further instructions. MO00233024

Based on observation, interview and record review, the facility failed to follow their policy by not communicating the significant weight loss of four sampled residents (Residents #38, #50, #42 and #210) to the physician and registered dietician (RD). Furthermore, the facility failed to follow physician orders [REDACTED].#38 and #50). The sample was 14 and the census was 55. Review of the facility weight management policy, dated July 2014, showed the following: Policy: -It is the policy of the facility to manage resident weight through prevention, assessment, and implementation and evaluation of interventions; Procedure: -Upon admission/re-admission, quarterly and with a significant change; -On the first through the fifth days of the month, the Certified Nursing Assistant (CNA) will take the weights for all monthly weights. Weekly weights will be obtained for any resident determined by the weekly weight committee: -Re-weigh required - compare the previous weight to the current weight to determine if there is a various of five or more pounds. If the weight variance is greater than five pounds mark a check in the column; -Re-weight - record the new weight that was just obtained; -Date re-weight - record the date the new weight was obtained; -In the event a different scale is used or the regular scale has been repaired or re-calibrated, this information will be documented on the weight log in the top right hand corner. Information should include the date and what was done, such as scale calibrated or repaired; -Weight committee meetings will be held weekly; -The weight committee will include the Director of Nursing (DON), the Minimum Data Set (MDS) coordinator, dietary manager and other departments as needed; -The weight loss tracking is to be used during the meeting to aide in the discussion/assessment of residents who have had a five pound or more weight loss. Residents who have not had weight loss will not be reviewed; -The weight loss tracking is completed by reading the list of interventions, selecting the appropriate ones, writing the date the intervention was used, the initials of who a completing the form, and any follow up needed or comments; -The interventions used will be documented on the weight committee meeting minutes; -The weight review committee meeting minutes is completed as follows: -Date -write the date the meeting is being held; -Resident - write the name of the resident who is being discussed; -Interventions - write the new interventions determined to be appropriate from the discussion/assessment; -Follow up - write any actions or activities that need to be completed as a result of these new interventions; -Committee member sign in - all members present at the meeting should sign the committee minutes form; -The DON or his/her designee will list all residents who have had a weight loss or gain greater than five pounds, poor intake, pressure ulcers, chewing or swallowing problems, receive tube feedings, all new admissions, all readmissions, or abnormal lab results will be given to the registered dietician for assessment and recommendations; -The DON will then distribute the registered dietician recommendations per wing to the charge nurse; -The charge nurse will notify the attending physician of the current resident's condition and of the registered dietician's recommendations, and document the physician's orders [REDACTED]. -The charge nurse will then initiate a diet order and communication form to the dietary manager who will chart the change in the dietary progress note and to the MDS coordinator to update the care plan. 1. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/20, showed the following: -admitted to the facility on [DATE] and last re-entry 7/22/20; -Severe cognitive impairment; -Extensive assistance required for transfers, bed mobility, dressing and personal hygiene; -Unable to ambulate; -Weight 114 pounds (lbs) and height 59 inches; -Swallowing disorder: No; -Weight loss of 5% or more in the last month or 10% or more in the last six months? No -[DIAGNOSES REDACTED]. Review of the care plan, dated 4/22/20 and last updated 7/22/20, showed the following: -Problem: Resident at risk for weight loss; -Goal: Resident weight will remain stable with no loss or gain of 3% or more per month per quarter; -Interventions: Assess medications effects to appetite, assess resident's food preferences often to update likes and dislikes, pureed diet, dietary consult at least quarterly and as needed, during periods of decreased appetite monitor for constipation/intestinal obstruction/pain/mood/behavior problems, encourage oral intake of food and fluids, monitor and record intake of food, monitor and record weight, notify physician of any weight changes, offer available substitutes if resident has a problem with the food being served, provide set-up help/cueing/physical help, etc., assistance for meals as needed, speech therapy consult if noted changes in swallowing, when resident leaves 25% or more of food, determine why and assist if needed to complete meal; -Problem: Nutritional status, risk for weight loss; -Goal: Will maintain current weight; -Interventions: Eats in room, provide appropriate diet, monitor intake, provide food likes. Review of the current physician's orders [REDACTED]. -An order, dated 1/17/20, to administer [MEDICATION NAME] (antidepressant and can cause increase in appetite) 15 milligrams (mg) one tablet every bedtime for a [DIAGNOSES REDACTED]. -An order, dated 5/4/20, to administer Ensure clear (nutritional supplement) three times a day with meals; -An order, dated 5/7/20, for a mechanical soft (ground meat and easy to chew soft foods) diet; -An order, dated 5/19/20, for a dietician consult; -An order, dated 5/19/20, to obtain weekly weights every Wednesday. Review of RD C's progress note, dated 6/4/20, showed consult as ordered by physician. Poor intake since original admission due to stomach issues. Resident is able to feed self and make needs known. Often orders broth and mashed potatoes and calls daughter when unhappy with meal. [MEDICATION NAME] may affect intake/weights. Cater to resident's preferences as much as possible and offer snacks between meals. Has order for Ensure clear and does not like health shake. Review of RD D's progress note, dated 6/23/20, showed resident readmitted from the hospital and receiving mechanical soft diet with Ensure clear. Noted decreased intakes. Daughter encouraged to bring in food and daughter stated resident is not eating the food so will try fruit smoothies. Continues to order bland foods. Order for [MEDICATION NAME] daily has the potential for appetite stimulation. Continue current interventions. Review of RD D's progress note, dated 7/28/20, showed resident readmitted from the hospital. Twelve teeth extracted on 7/27/20. Remains on mechanical soft diet with Ensure clear three times a day. Noted decreased intakes. Daughter encouraged to bring in food. [MEDICATION NAME] has the potential for appetite stimulation. Continue current interventions. Review of the RD E's progress note, dated 8/13/20, showed weight history of 117.8 pounds on 5/8/20, 113.6 pounds on 5/27 and 114 pounds on 7/28/20. No updated weight for August. Antibiotic for tooth extraction noted. Continues mechanical soft diet with ensure clear. Refused breakfast and had soup for lunch on 8/11 and 8/12. [MEDICATION NAME] 15 mg daily which may cause increased appetite. Stage II pressure ulcer (PU -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 sacrum. Continue to monitor weights and intakes. Offer snacks between meals. Recommend: 1. Trial fortified mashed potatoes with lunch and supper for calorie support and 2. update weight. Review of the RD D's progress note, dated 9/3/20, showed weight of 107.2 pounds on 8/12/20 which shows a significant weight loss of 8.9% for three months. Receiving mechanical soft diet with Ensure clear three times a day. [MEDICATION NAME] 15 mg which can help with appetite stimulation. Noted declining condition and frequently refusing meals. Has snacks in room. Recommend: Increased supervision/assistance with meals and Med Pass (nutritional supplement) 90 milliliters (ml) three times a day for calorie support with poor intakes. Further Review of the POS [REDACTED]. Review of weights, showed the following: -Weight not obtained weekly as ordered; -A total of five weights obtained from 5/8/20 through 9/7/20; -Weight recorded as 102.4 pounds on 9/7/20, which indicated another 4.4% loss in three weeks. Review of the progress notes from 5/1 through 9/10/20, showed the following: -Multiple entries recorded that resident refused meal or intake inadequate; -Family member encouraged to provide pleasure foods and resident did not eat them; -No documentation the physician had been notified of poor intake and weight loss. Review of the intake section of the chart for 5/1 through 5/31, 6/1 through 6/30, 7/1 through 7/31, 8/1 through 8/31 and 9/1 through 9/10/20, showed no documentation regarding food or fluid intake and no documentation regarding consumption of Ensure clear. Review of the activities of daily living (ADL) section of the chart for 5/1 through 5/31, 6/1 through 6/30, 7/1 through 7/31, 8/1 through 8/31 and 9/1 through 9/10, showed no documentation regarding food or fluid intake and no documentation regarding amount of Ensure clear consumed. During an interview on 10/5/20 at 11:10 A.M., the DON said the resident's family member requested that all of resident's teeth be removed and resident fitted for dentures. She said she does not know the reasoning for that, but the resident's intake decreased even more after his/her teeth were removed even though they gave him/her soft food. She said since the weights were ordered to be completed weekly, she would expect them to have been done and recorded. The physician also should have been informed of the weight loss and resident's poor intake and refusal of food. She did speak with the family member the day before the resident went to the hospital this last time, that they may have to start talking about a [DEVICE] (small rubber tube surgically inserted into the stomach to provide nutrition and fluids) versus hospice, but then he/she declined very rapidly. She said she wrote a note in the chart, however, no note was found. During an interview on 10/5/20 at 12:15 A.M., the social worker said she had never spoken with the daughter about a [DEVICE] or any other options regarding the lack of intake and weight loss. During an interview on 10/9/2020 at 11:00 A.M., RD D said she receives consults from the dietary manager. She is presently working off site and obtains most of her information on the computer. She looks for weight loss and any other issues that may arise. If she has a recommendation, she e-mails it to the dietary manager, the DON and anyone else who needs it and would expect those individuals to follow up with the physician regarding those recommendations. For Resident #38, she was not sure why the recommendations were not passed along to the physician. During an interview on 10/15/20 at 10:50 A.M., the medical director and resident's physician said that he was not contacted regarding the recommendation for fortified foods and Med Pass supplement. He said if he had, he would have ordered them and believes it could have possibly helped with the resident's weight loss and wound care. He went on to say that he believed the resident had little fight left in him/her and at that time was not a good candidate for a feeding tube. 2. Review of Resident #50's medical record, showed the following: -On 3/2/20, a weight of 142.2 lbs; -[DIAGNOSES REDACTED]. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Sever cognitive impairment; -Required extensive assistance with transfers, dressing, personal hygiene and limited assistance with eating; -One or more pressure ulcers (Pressure injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) Stage 1 or higher: Yes. Review of the resident's medical record, showed the following: -An order, dated 5/1/20, for staff to monitor and record the percentage of food and fluid intake for dinner; -An order, dated 5/2/20, for weekly weights on Wednesdays. Review of the resident's intakes, showed the following: -Staff documented the resident's dinner and fluid percentage 7 out of 31 opportunities in May 2020; -Staff documented the resident's dinner and fluid percentage 2 out of 30 opportunities in June 2020. Review of the resident's weekly weights, showed the following: -On 5/13/20, a weight of 133.6 lbs; -On 5/19/20, a weight of 133.8 lbs; -On 5/27/20, a weight of 126.4 lbs (a significant loss of 5.53% in one week); -On 6/9/20, a weight of 122.6 lbs (a weight loss of 3% in two weeks); -Staff failed to document the resident's weight weekly as ordered. Further review of the resident's medical record, showed the following: -An order, dated 6/17/20, for [MEDICATION NAME] ([MEDICATION NAME]) 7.5 mg, give one tablet at bedtime for depression; -An order, dated 6/17/20, for weekly weights; -An order, dated 6/17/20, for Ensure with all meals; -An order, dated 6/17/20, for dietary consult; -A dietary consult completed on 6/24/20. Further review of the resident's daily dinner and fluid intake percentages, showed staff documented the following: -Four out of 31 opportunities in July 2020. -Five out of 31 opportunities in August 2020. Further review of the resident's weekly weights, showed the following: -On 6/24/20, a weight of 129.8 lbs (a significant weight increase of 5.87% in two weeks); -On 7/2/20, a weight of 131 lbs; -On 7/8/20, a weight of 133.2 lbs; -Staff failed to document the resident's weekly weights as ordered. Review of the RD note, dated 7/10/20, showed weight on 7/8/20 was 133.2 lbs. Weight has shown an increase of 10.6 lbs in one month (8.6%) and a decrease of 10.4 lbs in 6 months (7.2%). Receiving mechanical soft diet with health shakes at meals and consuming per dietary manager (DM). Resident's appetite still has been fair/poor. Resident usually chooses an alternative at meals, but DM first offers facility meal and encourages to consume. [MEDICATION NAME] 7.5 mg in place which can help aid in appetite stimulation. On weekly weights to monitor. Due to weight trend up, continue current interventions. If weight starts to decline, consider providing Ensure clear between meals as resident used to receive this and did consume. Monitor. RD following. Further review of the resident's July weekly weights, showed the following; -On 7/22/20, a weight of 129.8 lbs; -No other weights documented. Further review of a nurse's note, dated 8/1/20, showed the resident has change in appetite. Resident has been declining meals. All vitals are within normal range. No mental status change. Resident's physician notified and gave order for UA and [MEDICATION NAME] 7. 5 mg at bedtime. Review of the RD note, dated 8/13/20, showed the resident's most recent weight available (7/22/20) as 129.8 lbs. No updated weight for August available at this time. Mechanical soft diet with health shakes with meals continues. Also receives Ensure with meals. Change in appetite with resident declining meals per nursing note on 8/1/20. Encourage intakes and offer alternatives and snacks as accepted. Monitor [MEDICATION NAME] 7.5 mg daily which may cause increase appetite. Decline in wound with notes of area bigger in size and foul odor on 8/3/20. Continue to monitor weight and intakes. Recommend: -Update weight; -Juven (nutritional supplement used to promote wound healing) twice a day to promote skin integrity; -Trial fortified mashed potatoes with lunch and supper for calorie support. Review of the resident's medical record, showed the following: -An order, dated 8/13/20, for Juven powder in packet. Give one packet twice a day; -An order, dated 8/13/20, for mechanical soft diet, health shake with meals, mashed potato with lunch and dinner; -Staff documented the resident's dinner and fluid intakes five out of 31 opportunities in August; -On 8/13/20, a weight of 126.8 lbs (significant weight loss of 10.8%in 6 months); -Staff failed to document any other weights for the month of August; -The resident was hospitalized from [DATE] through 8/27/20 for wound treatment; -Staff failed to document notifying the resident's physician or representative regarding the significant weight loss. Review of the resident's care plan, last revised on 8/31/20, and in use during the survey, showed the following: -Problem Start Date: 4/17/20 Category: Nutritional Status. Resident is at risk for weight loss due to prior history of weight loss. Resident feeds self and consumes a mechanical soft diet. He/she likes soul food, honey buns, hamburgers and payday candy bars. Has snacks in his/her room. Has Ensure clear, power potatoes and shakes ordered. November 2019 weight 142 lbs; April 2020 weight 141 lbs; May 2020 weight 133 lbs; May weight triggers significant weight loss. June 2020 weight 122.6 lbs; July 2020 weight 131 lbs; August 2020 weight 129.8 lbs; -Goal: Resident will have weight remain within 4% of current body weight in a 30 day period by next review; -Interventions included diet as ordered, encourage fluid with meals and between meals, honor food preference as needed, monitor weight. Review of the RD note, dated 9/2/20, showed the resident readmitted from the hospital with an open wound to the right foot and is on antibiotics. Weight on 8/13/20 was 126.8 lbs. Significant weight loss triggering 16.8 lbs loss in 6 months (11.7%). Weight fluctuating between 122.6 lbs and 133.2 lbs since 5/27/20. Currently receiving mechanical soft diet with multiple nutritional interventions in place: Ensure with meals, health shake with meals, mashed potatoes with lunch and dinner, Juven twice a day. Noted declining condition per DM. Resident was feeding self but now needing more assistance. [MEDICATION NAME] 7.5 mg in place which can help with appetite stimulation. Weekly weights to monitor nutritional status. Continue current interventions. Encourage intakes and provide alternatives at meals as desired. RD to follow. Review of the resident's September 2020 intakes, showed staff documented the resident's dinner and fluid percentage four out of 30 opportunities. Review of the resident's September 2020 weekly weights and intakes, showed on 9/7/20, a weight of 120 lbs (significant loss of 15.7% in 6 months and 5.36% loss in one month). Further review of the resident's progress notes, showed the following: -Staff failed to document notifying the resident's physician or representative of the severe weight loss; -An RD note, dated 9/10/20, showed weight on 9/7/20 was 120 lbs. Significant weight loss triggering loss of 6.8 lbs (5.4%) in one month and loss of 22.4 lbs 6 months (15.7%). Currently receiving mechanical soft diet with multiple nutrition interventions in place: Ensure with meals, mighty shake with meals, mashed potatoes with lunch and dinner, Juven twice a day. Noted was feeding self but now needing more assistance. Sending grilled cheese sandwich along with regular meal per preference. [MEDICATION NAME] 7.5 mg in place which can help with appetite stimulation. Weekly weights to monitor nutritional status. Continue current interventions. Encourage intakes and provide alternatives at meals as desired. Recommend: -Start multivitamin with minerals daily for skin integrity; -Trial nutritional treat twice a day to help aid in weight maintenance and monitor acceptance. Review of the resident's September 2020 physician order [REDACTED]. -No order for a daily multivitamin with minerals; -No order for nutritional treat twice a day. Further review of the resident's medical record, showed the following: -A weight, dated 9/30/20 of 113 lbs (a significant weight loss of 20.64% in 6 months and 10.88% loss in one month); -No documentation staff completed a re-weight; -No documentation staff notified the resident's physician or representative. Observations of the resident on 9/29/20 at 8:32 A.M., showed the resident lay in bed with the head of bed up and an over the bed table to the left of the resident's bed. A plate with mechanical soft food sat on the over the bed table. The resident was not eating. He/she had eaten approximately 25% of the meal. No Ensure or health shake was observed on the table. No staff present to assist the resident. Further observations of the resident on 9/30/20 at 12:38 P.M., 10/2/20 at 9:20 A.M., and 10/5/20 at 8:50 A.M., showed, the resident was served a mechanical soft meal. No Ensure was served to the resident. No staff observed assisting the resident with eating. Further observation of the resident between meals on 10/1/20 at 9:10 A.M., 10/2/20 at 5:20 A.M., 10/5/20 at 11:50 A.M., and 10/6/20 at 10:00 A.M., showed no nutritional treats served to the resident by staff. No snacks were available to the resident in his/her room. During an interview on 10/5/20, the facility's social worker said she has not noticed any change with the resident's mood. The resident does not seem depressed. The resident is spending more time in bed due to his/her wound. During an interview on 10/6/20 at 7:47 A.M., Nurse A said he/she thought the weight from last week was inaccurate. If the weight was accurate and the weight loss significant, he/she would call the doctor and suggest hospice. The resident has had a poor appetite since he/she has been sick. He/she used to eat 50-75% of breakfast. He/she has been downgraded to mechanical soft but still isn't eating. He/she won't accept assistance. He/she tried giving soup and he/she usually really likes grilled cheese, but has not been eating them. He/she did consume supplements and liquids okay. Nurse A will obtain a re-weight this morning. During an interview on 10/6/20 at 10:05 A.M., the DM said the resident has had a decline in appetite. She has been taking snacks into him/her between meals sometimes. The resident will usually only eat a couple of bites. Before the pandemic, the resident always liked grilled cheese and would eat them. Now he/she only ate a few bites. She was unaware of how much of the supplements were consumed by the resident. Dietary staff put the health shakes on the tray. The resident received health shakes with all meals and fortified potatoes for lunch and dinner. The resident would benefit from assistance, but since on isolation, he/she no longer ate in the dining room. If he/she ate in the dining room, he/she would receive assistance with eating. During an interview on 10/6/20 at 11:28 A.M., Certified Nurses Aide (CNA) B said he/she reweighed the resident and his/her weight was 113.4 lbs. The resident has had a decrease in appetite. He/she was given a pureed meal this morning and refused it. After being weighed, CNA B got the resident a new plate of pureed food and tried to get the resident to eat, but he/she refused. Review of the resident's dietary card, showed the following: -Dietician consult, ordered 6/17/20; -Ensure with meals ordered 6/17/20; -Mechanical soft, health shakes with meals, mashed potatoes with lunch and supper, ordered 8/13/20; -Staff failed to include the RD's recommendation for nutritional treats between meals. During an interview on 10/6/20 at 12:00 P.M., the administrator and DON said the nurse should have obtained a re-weight and then notified the doctor if there was a significant weight loss. If there was no documentation, then it most likely was not done. The resident was receiving cues from staff when he/she ate in the dining room. The resident now eats in his/her room due to being on contact precautions for going out of the facility for treatment of [REDACTED]. During an interview on 10/9/20 at 11:00 A.M., the facility's RD said she would expect staff to implement her recommendations. She forwards her recommendations to the DM, DON and administrator and then they are entered as orders. The DM provided resident weights, and the RD also tracked resident weights. During a telephone interview on 10/13/20 at 11:00 A.M. the facility Medical Director and resident's physician said he was unable to access the resident's record at the time of the interview. He is in the facility about once a week. He was aware the resident was having weight loss but he was not sure if he had been notified the resident had a significant weight loss of 5.83% on 9/30/20. He would have ordered an RD consult. He was aware the resident was on isolation and was being confined to his/her room. If the resident required assistance to eat in the dining room, he would expect staff to assist the resident with meals in his/her room as well. He was not aware the resident was refusing to eat. Had he been notified, he would have explored possible tube feeding or hospice or palliative care for the resident. He would expect the facility to document any discussion or orders in the resident's medical record. 3. Review of Resident #42's MDS, dated [DATE], showed the following: -An admission date of [DATE]; -Cognitively intact; -Required supervision with eating, extensive assistance with dressing, personal hygiene and transfers; -[DIAGNOSES REDACTED]. -Height 58 inches, weight 84 lbs; -Weight loss of 5% or more in the last month or 10% or more in the last 6 months? Yes, not physician prescribed weight loss regimen; -Oral/dental status: blank. Review of the resident's medical record, showed an order, dated 1/31/20, for mechanical soft diet with thin liquids. Review of the resident's monthly weights, showed the following: -Admission weight, dated 2/4/20, 84 lbs; -3/2/20, 83.2 lbs; -3/25/20, 82.4 lbs; -4/4/20, 84.6 lbs; -5/19/20, 77.4 lbs (significant weight loss of 8.5% in six weeks). Review of the resident's medical record, showed staff failed to notify the resident's physician and representative of the significant weight loss on 5/19/20. Review of the resident's therapy screenings, showed the following: -A therapy screening on 5/6/20, no reason given. Comments: Resident requires increased time at meals due to slow mastication (chewing); -No interventions ordered; -A speech therapy screening on 6/9/20 due to weight loss. Comments: Physical therapy referred to speech therapy due to weight loss. Resident observed during meal. Resident reports no change in appetite, mouth pain, difficulty swallowing. No increase or signs or symptoms of dysphagia (difficulty swallowing) observed. Continue to monitor, resident is a poor historian; -No interventions ordered; -No other assessments available. Review of the resident's RD notes, dated 5/29/20, showed the resident was assessed per significant weight loss. Weight at 77 lbs, 9% loss in one month. Ordered mechanical soft diet. Per nursing, fair intake at meals, though does take a while to eat. Will ask to leave the trays way past mealtime so he/she can finish. Has been on Ensure clear in the past, but did not consistently drink. Isolation precautions have not affected resident as he/she preferred to eat in room alone prior to COVID. Tolerating diet. Noted that resident refuses medications often. Recommend to trial health shakes between meals or nutritional treat for additional calories or protein. RD following. Further review of the resident's medical record, showed the following: -An order, dated 7/8/20, for a dietary consult; -An order, dated 7/8/20, for Ensure (nutritional supplement) with each meal; -An order, dated 7/8/20, for weekly weights on Wednesdays. Review of the resident's medical record, showed the following: -No documentation from the RD regarding the dietary consult ordered on [DATE]; -A nurse's note, dated 7/27/20, showed resident was refusing to eat, stating he/she was doing a liquid diet. Staff reported resident's urine appeared very cloudy, almost milky-like. Collection of urine in progress at this time, with resident's cooperation; -A nurse's note, dated 7/28/20, showed resident's urine collected for urinalysis (UA) and culture and sensitivity (C & S). Resident's physician and representative made aware; -A nurse's note, dated 8/3/20, showed UA results received and faxed to resident's physician. Awaiting response; -A nurse's note, dated 8/6/20, showed follow up with resident's representative during care plan meeting. Explained resident does have a urinary tract infection [MEDICAL CONDITION] and is taking an antibiotic (ABT) to treat it; -A nurse's note, dated 8/9/20, showed resident continues on ABT for UTI and is alert and oriented to time and place with confusion present. Non-compliant with medication. Refused breakfast and lunch. Encouraged alternative choices, but resident declined. Verbalized to be left alone. Review of the resident's care plan, last revised on 8/16/20 and in use during the survey, showed the following: -Problem Start Date: 6/13/2020. Category: Nutritional Status. Resident has had a significant weight loss and noted fluctuation in weights since admission. He/she is edentulous and consumes a mechanical soft diet with thin liquids. He/she feeds self and will sometimes use his/her fingers. Prefers to remain in his/her room for meals. Requires staff supervision related to poor consumption and right wrist contracture. Does not like to talk to anyone while he/she is eating. Has health shake ordered with meals. February 2020 weight, 85 lbs; March 2020 weight, 83 lbs; April 2020 weight 84 lbs; May 2020 weight 77.4 lbs. Significant trigger; June 2020 weight 86.8 lbs; July weight 90 lbs; August 2020 weight 84 lbs; -Goal: Resident will have weight remain within 4% of current body weight in a 30 day period by next review; -Interventions included: Diet as ordered, encourage fluids between meals, honor food preferences, monitor tolerance, monitor weight; -Staff failed to include the interventions for Ensure with each meal and weekly weights. Further review of the resident's weights, showed the following: -7/13/20, 90 lbs; -8/5/20, 84 lbs; -8/13/20, 84 lbs (6.6% loss in one month); -9/2/20, 83.6 lbs (7.1% loss in six weeks); -9/7/20, 83.6 lbs; -Staff failed to obtain weekly weights as ordered. Further review of the medical record, showed the following: -Staff failed to notify the resident's physician or representative of the resident's significant weight loss from 7/13/20 to 8/13/20; -An RD note, dated 9/10/20, showed resident's weight on 9/7/20 was 83.6 lbs. Weight overall stable compared to admission weight. Mechanical soft diet with ensure with meals. Fair intakes per DM. Does choose to fast at times per own preference. Continue to monitor this. Stability guarded with overall disease progression. Continue current intervention. Encourage intakes and provide alternative if consumes less than 50% at meal. RD to follow as needed. Further review of the resident's monthly weights, showed a weight on 9/30/20 of 75.8 lbs (12XXX