Every finding on record at Rehabilitation Center of Independence, The

Based on interview and record review, the facility failed to prevent misappropriation for one sampled resident (Resident #4) when Social Services Director (SSD) used the resident's debit card to pay his/her personal cell phone bill in the amount of $350.00 out of seven sampled residents. The facility census was 121 residents.On 1/28/26 the Administrator and Director of Nursing were notified of past non-compliance which occurred on 1/21/26. On 1/21/26 the facility Administrator was notified of the incident and the investigation was started. No employees were allowed to work prior to reeducation completed 1/21/26. SSD was terminated on 1/22/26. The deficiency was corrected on 1/22/26. Review of the facility's Abuse Prevention and Prohibition Program dated 10/24/22 showed: -Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property.-The facility is committed to protect residents from abuse by anyone, including but not limited residents, family members, legal guardians, surrogates, sponsors, friends, and visitors.-The facility does not knowingly employ anyone who has had disciplinary action against his/her professional license, or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment or misappropriation or has been convicted of abusing, neglecting, or mistreating other people. 1. Review of Resident #4's admission Record showed he/she was admitted to the facility with the following diagnosis:-Chronic Obstructive Pulmonary disease (a progressive lung disease that causes difficulty breathing, chronic cough, and mucus).-Chronic Systolic (Congestive) Heart Failure (a chronic progressive condition where the heart cannot pump blood efficiently to meet the body's needs, causing fluid to collect in the lungs, legs, and other tissue).-Chronic Kidney disease Stage 3 (means the kidneys are not cleaning waste from the blood as well as they should).-Major Depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), recurrent, moderate.-Anxiety (persistent, excessive fear or worry that interferes with daily life). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/12/26 showed the resident:-Was moderately cognitively impaired.-Understands others and was understood by others. Review of the resident's undated Care Plan showed:-He/she had a psychosocial well-being problem actual related to Major depressive disorder, recurrent, generalized anxiety, cognitive communication deficit, chronic pain, respiratory insufficiency/Shortness of Breath.-Causing him/her to frequently feel short of breath causing him/her to feel upset/emotional.-To allow the resident time to answer questions and to verbalize feelings perceptions and fears as needed.-Consult with pastoral care, social services, psychiatric services, or other.-Will be able to communicate basic needs daily.-Administer medications as ordered.-On 1/21/26 he/she discovered that he/she was missing money prompting a facility investigation that later involved speaking to the police. Because of this he/she has displayed increased tearfulness.-Allow the resident time to answer questions and to verbalize feelings perceptions, and fears as needed. Review of the facility Investigation dated 1/21/26 showed:-On 1/21/26 the Administrator was informed by Therapist A that the resident had money missing from his/her account.-The resident's online banking showed a transaction dated 12/31/25 in the amount of $350.00 to a wireless cell phone carrier in the name of SSD.-This reminded the Therapist A of a text message he/she received from the SSD on 12/29/25 asking if he/she could borrow $350.00 to pay his/her cell phone bill.-An investigation was started, and SSD was suspended pending investigation.-Completion of the investigation showed SSD did used the resident's debit card to pay his/her cell phone bill in the amount of $350.00.-SSD's employment was terminated on 1/22/26. Review of Therapist A's text messages from SSD dated 12/29/25 showed:-From SSD I have a question to ask but I have no one else to turn to right now. I need $350 to pay my phone bill or its going to get shut off. Could I borrow it and pay you back. If not it's okay.-From the therapist Things have been really tight for me too around the holidays, I'M really sorry but I'M not able to help.-From SSD That's okay, I understand. Review of the resident's checking account dated 12/31/25 showed a Web Pay to the cell phone carrier in the amount of $350.00. Review of convenient store receipt dated 1/21/26 showed Money Order for $350.00 and Money Order Fee of $3.00 for a total of $353.00. Review of the police report dated 1/21/26 showed the Police Officer was dispatched to the facility for financial exploitation of elderly/disabled. During an interview on 1/27/26 at 11:36 A.M. the resident said:-He/She never told SSD to use his/her debit card to pay for their cell phone bill.-His/Her debit card has been shut off and he/she has a new card. During an interview on 1/27/26 at 4:16 P.M. the Director of Nursing (DON) said:-He/She did not help with Resident #4's investigation.-He/She expected staff to follow Abuse Policy and not exploit residents for money, gifts, etc.-Employees suspected of misappropriation would be suspended pending the outcome of the investigations and possibly terminated from the facility. During an interview on 1/27/26 at 4:16 P.M. the Administrator said:-He/She was notified the resident was missing money and that SSD had paid his/her cell phone bill using the resident's debit card.-The investigation was started, and SSD was suspended pending outcome of the investigation.-Local law enforcement was called. A total of $8000 was missing with quite a few ATM withdrawals. Due to the amount the case was turned over to detectives for investigation.-The resident's bank was filing a fraud report and was investigating the missing money.-It was verified that SSD took $350.00 to pay a cell phone bill.-It was unknown who had done the ATM withdrawals. Review of Social Worker (SW) A's written statement dated 1/21/26 showed:-The resident and Therapist A came to his/her office.-The resident was upset saying someone took all of his/her money.-The resident signed onto his/her account and showed him/her and Therapist A what was on the bank statement.-The charges and SSD's name came up to a cell phone carrier.-He/She helped the resident call the bank and shut off the resident's debit card.-He/she called the police after the debit card was shut off to make a report. During an interview on 2/2/26 at 1:27 P.M. SW A said:-The resident came to him/her saying all of his/her money was gone.-The resident had received a lump sum payment from Social Security for back pay.-The resident paid the facility the balance due on his/her account that left him/her with about $9,000.00 in his/her account.-There was a thousand left in the residents account when the resident came to his/her office.-He/She and the resident were going over the account with the therapist to see where the money was going.-That was when it was noticed the SSD had paid a cell phone bill that was in his/her name.-He/She helped the resident put a stop on the debit card and notified the bank of the fraud charges.-The resident had also given the debit card to a friend, and he/she advised the resident to not give the debit card out to anyone. Review of SSD written statement dated 1/21/26 showed:-He/She had only assisted the resident with logging into his/her bank account on his/her new cell phone.-He/She had not received/ loaned money from the resident and had not used the resident's debit card in any manner.-He/she had not received any gifts from the resident at all either. Review of the facility interview with SSD on 1/21/26 at 12:30 P.M. showed he/she said:-The resident received a lump sum from Social Security.-Denied using the resident's debit for personal purchases.-SW A helped the resident get a replacement card.-The SSD said, All I've done is help his/her log into her account.-SSD denied ever receiving money or gifts from the resident. During an interview on 2/3/29 at 9:18 A.M. SSD said:-He/She had helped the resident with getting his/her Social Security straighten out with the right bank account information so the resident could start getting his/her checks.-He/She helped the resident download the bank app to his/her phone and how to log into the account.-He/she witnessed SW A tell the resident not to not give the debit card out to people.-At the time he/she was dealing with a lot and his/her phone was about to get shut off.-He/She had his/her user's name and password to his/her phone bill on his/her desk and it came up missing.-The resident was in his/her office a lot getting help and could have taken the user's name and password and paid his/her phone bill because the resident knew he/she was having problems.-He/she never asked the resident to pay his/her phone bill and would not take any money from the resident. Review of the written statement from Therapist A dated 1/21/26 showed:-On 12/29/25 at 11:17 A.M. he/she got a text message from SSD asking if SSD could borrow $350.00 to pay his/her cell phone bill.-He/She told SSD he/she did not have the money and thought nothing more of it until 1/21/26 when the resident reported that another resident took his/her debit card and was spending his/her money.-The resident showed the therapist his/her online banking account with a charge for $350.00 on 12/31/25 with SSD's name on it to a wireless cell phone carrier.-He/she reported the incident to the Administrator. During an interview on 2/3/26 at 11:31 A.M. Therapist A said:-He/She was helping the resident and SW A go through the resident's bank account on the resident's phone.-That was when he/she seen the amount of $350.00 with SSD's name under it.-Back on 12/29/25 SSD had texted him/her asking to borrow $350.00 to pay his/her phone bill.-Told SSD that he/she did not have the money to loan.-He/she took a picture of the transaction on the resident's phone.-Went to the Administrator and informed him/her of SSD asking him/her for $350.00 and then that exact amount was taken out of the resident's account on the same day SSD asked him/her for the loan.-On 2/2/26 the resident said SSD did ask him/her for money to pay a cell phone bill. 2722465

Based on observation, interview, and record review, the facility failed to ensure the resident's physician was notified of all injuries sustained after a fall for one sampled resident (Resident #1) out of eight sampled residents. The facility census was 118 residents. Review of the facility Fall Evaluation and Prevention Policy dated 8/2020 showed: -Following a fall, the following steps should be undertaken: --Evaluate the resident promptly in order to identify and treat injuries. --Monitor closely for indications of pain or discomfort in any areas, reddened or discolored areas or other signs of injury. Review of the facility Change of Condition Notification Policy dated 6/2020 showed: -To ensure residents, family, legal representatives, and physicians are informed of changes in the residents condition in a timely manner. -Acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. -Clinically important means a deviation that, without intervention, may result in complications or death. -Members if the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent ACOC. -The facility will promptly inform the resident, consult with the resident's attending physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to an injury or accident. -The licensed nurse will notify the resident's attending physician when there is an: --Incident/accident involving the resident. --An accident involving the resident which results injury and has the potential for requiring physician intervention. --A decision to transfer or discharge the resident from the facility. -The attending physician will be notified timely with a resident's change in condition. -Notification to the attending physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or sign and symptoms for which the notification is required. -Emergency situations such as intense pain and unexpected bleeding, the nurse will immediately call the attending physician. -The licensed nurse will document the following: --Date, time, and pertinent details of the incident and the subsequent assessment in the nursing notes. --The time the attending physician was contacted, the method by which he/she was contacted, the response time, and whether or not orders were received. --The time the family/responsible party was contacted. --The incident and brief details in the 24-hour report. -Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the 24-hour report. 1. Review of Resident #1's admission Record showed the resident was admitted on [DATE] with diagnoses including muscle weakness, repeated falls and traumatic subdural hemorrhage with loss of consciousness (most dangerous type of head injury, a collection of blood within the skull pressing on the brain, is potentially life-threatening, usually requires immediate treatment, might include surgery to remove the blood). Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 1/25/25 showed the resident was cognitively intact. Review of the resident's Fall Investigation dated 3/6/25 showed: -Certified Nursing Assistant (CNA) A reported to Licensed Practical Nurse (LPN) A the resident had fallen. -LPN A assisted the resident off the floor and back to the resident's room. -Injuries documented was a bruise to his/her right front knee and unable to determine injury to face. -Family, Director of Nursing (DON) and physician notified. --The investigation did not include the resident had a history of falls, any past interventions that should have been in place at the time of this fall, and did not include documentation related to the resident's broken teeth as a result of the fall. Review of the resident's Progress Note dated 3/6/25 at 8:27 P.M. showed: -CNA A reported resident had fallen. -Assessed the resident for injuries, broken teeth from an implanted partial was found on the floor and he/she has a bruise to his/her right knee. -Physician called and notified. -Order received for x-ray of his/her right knee. Review of the resident's Order Summary report showed: -X-ray of right knee two views, 3/6/25. -Hydrocodone-Acetaminophen (a narcotic pain medication) 5/325 milligram (mg), given one tablet by mouth every six hours as needed for pain, 8/15/24. Review of the resident's Medication Administration Record (MAR) dated 3/1/25 through 3/31/25 showed one dose of Hydrocodone-Acetaminophen given on 3/5/25 at 5:00 A.M. No documentation of the location of the resident's pain. Review of the residents Controlled Drug Administration Record dated 3/3/25 through 3/12/25 showed: -Hydrocodone-Acetaminophen 5-325 mg, one tablet orally every six hours as needed for pain. -3/2/25 at 11:30 P.M. -3/3/25 at 6:00 P.M. -3/4/25 at 12:00 A.M., 8:00 A.M., and 5:00 P.M. -3/5/25 at 12:00 A.M., 9:00 A.M., and 12:00 P.M. -3/6/25 at 8:00 A.M., and 5:00 P.M. -3/7/25 at 8:00 A.M., 12:00 P.M., and 5:00 P.M. -3/8/25 at 8:00 A.M., 12:00 P.M., 5:00 P.M. and 11:00 P.M. -3/9/25 at 8:00 A.M., 12:00 P.M., 4:00 P.M., 8:00 P.M. -3/10/25 at 8:00 A.M., 12:00 P.M., and 5:00 P.M. -3/11/25 at 8:00 A.M., 12:00 P.M., and 5:00 P.M. -3/12/25 at 8:00 A.M. --No documentation of the location of the resident's pain. Review of the resident's Progress Note dated 3/7/25 at 4:47 P.M. showed: -He/she denied pain or discomfort at that time. -X-ray was completed on that shift, waiting results. -Pain management with PRN hydrocodone. -Nurse to continue to monitor. -Resident laying in bed. --No documentation related to the resident's broken implanted teeth. Review of the resident's Progress Note dated 3/8/25 at 1:06 P.M. showed: -Denied pain or discomfort at that time. -No findings on x-ray results. -Pain management with PRN hydrocodone. -Nurse to continue to monitor. -Resident laying in bed. --No documentation related to the resident's broken implanted teeth. During an observation and interview on 3/9/25 at 9:25 A.M., the resident said: -He/She was in the room next door when he/she fell. -His/Her right knee was hurting although the x-ray did not show a break. -His/Her front bottom teeth fell out from the fall and needs to be taken care of. -His/Her right hand was sore and complained of pain to his/her chin and where his/her teeth broke in his/her mouth. -Resident's knees were bruised. -Noted bruising to the resident's face under both eyes, both sides of nose extending to top lip, from the left corner of mouth extending downward and under the chin. -There was swelling from between the eyebrows and across the bridge of the nose. -He/She was retrieving his/her cup from the other resident's room at the time of the fall. -He/She was laying in a pool of blood and knew it was bad at that time. -He/She screamed and yelled for help. -He/She has not seen a doctor. -He/She did not go to the Emergency Room. -He/She was not asked if he/she wanted to go to the Emergency Room. -His/Her bottom teeth have not been addressed. -He/She does not know if his/her nose is broken, but it was painful and swollen. During an interview on 3/9/25 at 12:47 P.M. the Director of Nursing (DON) said: -He/She was aware of the resident falling with bruising to his/her right knee and a little bruising to his/her face. -He/She was not aware of any other injuries. -He/She felt the broken partial implanted teeth was reported to the doctor who did not want anything done except neurological checks. -He/She felt the resident's medical needs were met. -According to the nurses the resident had no complaints of pain. -He/She was unaware of the complaints of pain by the resident about his/her right knee, right hand, nose, and mouth. During an interview on 3/10/25 at 7:26 P.M. LPN A said: -CNA A came to get him/her because the resident had fallen. -He/She applied pressure to the laceration on the resident's top lip and got an order to x-ray the right knee. -The right knee was bruised with an abrasion and the resident was complaining of pain. -The resident had blood in his/her mouth and there were teeth on the floor. -He/She did not recall informing the provider of the laceration and broken teeth, his/her primary concern was the resident's knee due to the complaint of pain. -He/She did not administer any pain medication as he/she did not have keys to the cart containing the resident's PRN medication. During an interview on 3/10/25 at 7:44 P.M. the Physician said: -He/She was in the facility on 3/10/25 and did not see the resident. -He/She was not aware of the resident's fall or other injuries. -He/She was concerned if the resident had been sent to the emergency room or not on the day of the fall. -He/She expects the nurses to call and report all injuries when a resident falls. -He/She was not the provider on call at the time of the resident's fall. During an interview on 3/10/25 at 8:00 P.M. LPN B said: -He/She was informed the resident had a fall when he/she arrived on 3/7/25. -He/She was told there was an x-ray for the resident's knee pain. -Although the resident complained about his/her knee the x-ray was okay. -He/She noticed the resident's face was bruised up, but the resident did not complain of pain. -The resident told him/her they lost a couple of teeth on the bottom when he/she fell. -He/She asked the resident about pain frequently. -He/She offered PRN hydrocodone and administered in the morning and in the afternoon. -He/She did not contact the physician or Nurse Practitioner about the resident's facial injuries or increased use of PRN hydrocodone since the fall. -The resident continued to have bruising and swelling to his/her face. -The resident did not complain of knee pain, only a sore face and wanted to rest. -He/She did not notice any injuries in the mouth but did notice broken teeth. -He/she was aware of the laceration to the top lip just under the right nare. -There was a steri-strip to the laceration, although he/she did not recall when it was removed. -If he/she was to find a resident that had fallen, he/she would assess the resident, do neuros and vitals, contact the physician and management. -When notifying the physician, be sure to inform of the fall as well as any and all injuries. -Just looking at the resident he/she could tell the resident was sore from the injuries. -He/She felt social services would contact dental for the resident. During an interview on 3/10/25 at 8:37 P.M. LPN C said: -He/She was not in the building at the time the resident fell. -When he/she came in for his/her shift, LPN A advised of the resident's fall. -He/She assumed all contacts had been made, therefore he/she did not feel he/she needed to contact the physician. -He/She documented on the Neurological Assessment Flow Sheet the injuries he/she observed, but not in the progress or nursing notes. -He/She applied steri-strips to the laceration to the resident's top lip. -The resident kept wiping the steri-strip off and had another nurse help with application to ensure the wound edges were approximated and the bleeding stopped. -The resident's nose was swollen from the face plant (falling face first to the ground). -He/She put ice on the resident's nose every 20 minutes and reduced the swelling, but did not document in the progress or nursing notes and did not notify the physician. -He/She was aware the resident's front teeth were cemented in prior to the fall, but did not assess the oral cavity. -He/She was not aware of any orders for the resident's facial injuries. -He/She would not have done anything different than what was already done before he/she arrived. During an interview on 3/10/25 at 8:50 P.M. CNA A said: -He/She heard the resident yelling out. -He/She turned on the light and observed the resident was bleeding from his/her nose and mouth. -The resident told him/her the resident's teeth were missing. -He/She found the resident's teeth on the floor and placed them in a cup. -He/She went to get LPN A to assess the resident and gave LPN A the resident's teeth. -He/She could not see any injuries in the resident's mouth. -The resident complained about the bridge of his/her nose being painful from the impact of the fall. -He/She applied pressure and ice pack to the resident's face and put the head of the bed up. -The resident's nose was pretty swollen, but felt the ice did help with the swelling. During an interview on 3/11/25 at 7:24 A.M. LPN A said: -The resident was in the room next door when he/she fell. -He/She assisted the resident off the floor and to his/her room. -The resident complained of pain to the right knee when it was touched. -The provider he/she spoke with was the Nurse Practitioner. During an interview on 3/12/25 at 1:58 P.M. the Administrator said: -He/She was aware the resident had fallen and sustained injuries. -When a resident has a fall he/she expects the resident to not be moved until assessed by a nurse. -He/She prefers neuros be done on all residents with a fall. -He/She expects the physician and responsible parties to be notified. -When contacting the physician, he/she expects the physician to be informed of all relevant facts, if the resident hit their head, and any other relevant information specific to the resident. -Nurses are to follow orders if any are given. -Documentation should be done in the risk management and some in the progress notes. -He/She expects all nurses to follow facility policy on charting. -The resident should have been charted on every shift for the first 72 hours in the progress or nursing notes. -Administration of PRN narcotics should be documented on the resident's MAR. -All first aid administered to the resident, including the steri-strips and ice packs should have been documented in the progress or nursing notes. -He/She expects the physician or Nurse Practitioner to see a resident after a fall within a week or sooner if needed. During an interview on 3/12/25 at 2:32 P.M. the DON said: -When a resident has a fall he/she expects the nurses to assess the resident, obtain vital signs, start neuro checks, check the resident's baseline, and if there are injuries significant enough to send the resident to the Emergency Room. -He/She expects the physician and the family to be notified of the resident's fall and if they were sent to the hospital. -He/She expects the physician to be told how the resident fell, if they hit their head, any suspected injuries, range of motion and complaints of pain. -The on call provider should have been informed of the resident's partial facial injuries. -He/She expects the physician or Nurse Practitioner to see the resident within 3 to 4 days after a fall. -Due to the resident's history of falls and subdural hematoma, he/she should have had facial injuries checked sooner than 5 days after his/her fall. -There should have been more documentation related to the resident's fall and follow up including treatments, interventions and wound measurements. -He/She did not feel there was a negative impact on the resident due to his/her missing teeth and social services was setting up a dental appointment. -PRN narcotics should be documented in the resident's MAR as it triggers for follow up in the electronic system. -There should have been follow up and possible interventions for the resident's wounds to his/her nose and chin as well as other injuries. During an interview on 3/12/25 at 3:31 P.M. the Nurse Practitioner said: -He/She was the provider on call when the resident fell. -He/She did not recall being informed of the resident having any injuries to his/her face or broken teeth. -He/She recalled being informed the resident was having knee pain after the fall and ordering an x-ray to the right knee. -He/She expected to get accurate information and be informed of all injuries post fall. MO00250752

Based on interviews and a review of medical records, the facility failed to identify and implement the necessary care and services to address the needs of diabetic residents. Specifically, facility staff failed to: 1. Recognize and appropriately respond to signs and symptoms of hyperglycemia, such as changes in mental status, feelings of anger, excessive hunger, excessive thirst, and frequent urination. 2. Implement blood glucose monitoring as ordered by the medical provider. Failed to transcribe and/or verify insulin orders and blood glucose monitoring with the physician upon admission. 3. Administer insulin as ordered by the medical provider resulting in the resident becoming physically and verbally combative, excessively hungry, resulting in hypoglycemia and a blood sugar of 541. This deficient practice contributed to the subsequent hospitalization of one (1) of two (2) residents reviewed for hospitalization from a total of 36 residents sampled (Resident #101). The findings include: According to Mayo Clinic (accessed 1/9/25 https://www.mayoclinic.org/diseases-conditions/hyperglycemia/symptoms-causes/syc-20373631), High blood sugar, also called hyperglycemia, affects people who have diabetes. Several factors can play a role in hyperglycemia in people with diabetes. They include food and physical activity, illness, and medications not related to diabetes. Skipping doses or not taking enough insulin or other medication to lower blood sugar also can lead to hyperglycemia. It's important to treat hyperglycemia. If it's not treated, hyperglycemia can become severe and cause serious health problems that require emergency care, including a diabetic coma. Hyperglycemia that lasts, even if it's not severe, can lead to health problems that affect the eyes, kidneys, nerves and heart.' Hyperglycemia usually doesn't cause symptoms until blood sugar (glucose) levels are high - above 180 to 200 milligrams per deciliter (mg/dL), or 10 to 11.1 millimoles per liter (mmol/L). 1. A comprehensive review of Resident #101's medical record revealed an initial admitted [DATE]. The resident's medical history included metabolic encephalopathy and diabetes. A comprehensive minimum data set (MDS) was not completed, as Resident #101 was admitted on [DATE], and discharged to acute care on 10/29/24. Resident #101's discharge medication list from the hospital dated 10/28/24, was reviewed. The medication list contained a note indicating Resident #101 as having a recurrent trend of low Accu-Checks [blood sugars]. A review of the discharge medications revealed an order for insulin lispro 1-6 units to be injected subcutaneously four (4) times daily with meals and nightly. A second order was noted for insulin aspart sliding scale 0-14 units to be injected subcutaneously three times daily before meals. A third order was noted for insulin glargine 10 units to be injected subcutaneously nightly. Additional instructions on the medication list directed nursing staff to monitor Resident #101's blood glucose every two (2) hours for two (2) episodes and then every four (4) hours for two (2) episodes. A review of the medications transcribed to Resident #101's medical record revealed that as of 1/10/25,-date fixed neither the order for insulin lispro nor the order for insulin aspart were transcribed. An order was noted for insulin glargine 10 units to be injected subcutaneously at bedtime. A review of Resident #101's administration record for October 2024 revealed the insulin glargine injection was not administered the night Resident #101 was admitted to the facility. An indication on the administration record directed the reader to refer to progress notes. A subsequent review of the nursing progress notes revealed no documentation that indicated why the insulin glargine was not administered. Continued review of Resident #101's medical record revealed one (1) blood sugar assessment dated [DATE] at 5:42 p.m. The result was 290 milligrams per deciliter (mg/dL). There was no evidence that additional blood sugar monitoring was conducted at two (2) and four (4) hour intervals as directed by the hospital discharge instructions. A nursing progress note dated 10/28/24 at 5:30 p.m. indicated Resident #101 arrived at the facility in a wheelchair. The note described Resident #101 as being nonverbal at the time of admission but responded to yes or no questions appropriately. Additionally, the note identified Resident #101 as being a diabetic. A narrative in the progress note read, Doctor will look at insulin orders tomorrow when come as the orders from the Hospital are not clear. BS [blood sugar] 290 . The note did not indicate how facility staff planned to monitor and treat Resident #101's abnormal blood sugars until the insulin orders were reviewed by the medical provider. A nursing progress note dated 10/29/24, at 10:02 a.m. noted that at 8:30 a.m., Resident #101 was observed lying on the floor adjacent to their bed. The resident was assisted with dressing and then transferred to their wheelchair, being subsequently taken to the dining room. The progress note did not specify whether Resident #101's blood sugar levels were assessed or whether Resident #101 was evaluated for signs or symptoms of hypoglycemia or hyperglycemia. A progress note dated 10/29/24, at 10:09 a.m. documented Resident #101's disruptive behaviors in the dining room. Resident #101 engaged in combative actions, threw a bowl of oatmeal onto the table, and knocked orange juice out of the Certified Nurse Aide (CNA)'s hand when the CNA offered it to Resident #101. The note further described Resident #101's behavior as sitting near the nurse's station, where he/she began hollering and sliding out of the wheelchair. Resident #101 was subsequently provided with a peanut butter sandwich and orange juice, which appeared to have a calming effect on the resident temporarily. The progress note did not indicate whether Resident #101's blood sugar levels were assessed or whether Resident #101 exhibited any signs or symptoms of hypoglycemia or hyperglycemia at that time. A progress note dated 10/29/24 at 1:09 p.m. indicated that the nurse practitioner was in the building and ordered depakote sprinkles 125 milligrams (mg) to be given by mouth every 12 hours for restlessness and agitation. The progress note failed to indicate whether Resident #101's insulin orders were reviewed by the nurse practitioner at the time of their visit. A progress note dated 10/29/24 at 3:58 p.m. by Licensed Practical Nurse LPN FF documented that the resident ate a total of two peanut butter and jelly sandwiches and a meat sandwich. Afterward, the resident was assisted to his/her room where the resident became combative. The note further described the resident's persistent hunger. The note indicated the resident's blood sugar at 12:00 p.m. was 389. The resident was assisted to the dining room where he/she ate a full meal and still wanted more. Resident #101 became upset when he/she was taken out of the dining room and started sliding himself/herself out of the wheelchair. The resident calmed down when given a piece of bread but continued to get upset after eating. The resident was then allowed to sit on the floor. Additional behaviors were described as kicking and hitting. The Administrator responded to the room and directed staff to send the resident to a psychiatric hospital. The note indicated the resident's blood sugar was 541 at 2:55 p.m. The NP was informed and an order was given for 20 units of insulin. However, the medical record did not contain evidence that the 20 units of insulin were administered. A Recapitulation of Stay Resident Discharge Summary dated 10/30/24 at 4:13 p.m. was reviewed. The summary was signed by the Director of Nursing and indicated Resident #101 was transferred to the hospital on 10/29/24 at 4:00 p.m. due to noncompliance with care along with verbal and physical aggression toward staff. The summary did not contain vital signs (to include blood glucose). On 1/10/25 at 5:01 p.m. an interview was conducted with the Administrator and the Director of Nursing (DON). Both the Administrator and DON recalled Resident #101 and the circumstances of his/her transfer to the hospital. The Administrator explained that the resident became verbally and physically aggressive with staff due to psych issues and thus was transferred to the hospital for that reason. When asked about whether facility staff were aware that the resident's blood glucose levels had gone unmonitored since shortly after admission, the DON stated, No, we sent [him/her] to the hospital for the behaviors. The DON explained he/she was not aware that Resident #101 was admitted to the facility with insulin and blood glucose monitoring orders that had not been carried out as ordered and subsequently discharged from the facility with a blood glucose level of 541 at last check. The DON acknowledged that the resident's symptoms of anger, excessive hunger, excessive thirst, and frequent urination were indicative of uncontrolled hyperglycemia but that this was not recognized or considered at the time of his/her hospital transfer. When asked how facility staff ensured physician's orders were accurately transcribed from the hospital discharge reconciliation, the DON explained that a checklist had been developed to facilitate the review of new admissions. However, when asked to produce the checklist for Resident #101's admission, the DON was unable to provide it. When asked what the expectation of a nurse would be in the event that a resident's blood glucose was continuously trending upward with orders for insulin, the DON stated the nurse would be expected to notify the medical provider immediately and acknowledged the notification had not occurred for Resident #101.

Based on interviews, and record review, facility leadership failed to maintain adequate nursing staffing, as established by the facility's leadership, to provide appropriate nursing care and services to meet the needs of residents. This deficient practice had the potential to affect all residents living in the facility. The findings included: 1. Due to the scope and severity deficient practice found during the survey, facility leadership was asked to produce daily staffing hours for the month of December 2024. A review of the facility's daily staffing hours revealed: - On 12/8/24, the facility's census was 95. Actual nursing staff hours worked was 2.68 PPD. - On 12/9/24, the facility's census was 95. Actual nursing staff hours worked was 2.57 PPD. - On 12/10/24, the facility's census was 95. Actual nursing staff hours worked was 2.54 PPD. - On 12/11/24, the facility's census was 96. Actual nursing staff hours worked was 2.72 PPD. - On 12/12/24, the facility's census was 96. Actual nursing staff hours worked was 2.70 PPD. - On 12/13/24, the facility's census was 92. Actual nursing staff hours worked was 2.56 PPD. - On 12/14/24, the facility's census was 95. Actual nursing staff hours worked was 2.42 PPD. - On 12/15/24, the facility's census was 95. Actual nursing staff hours worked was 2.30 PPD. - On 12/16/24, the facility's census was 95. Actual nursing staff hours worked was 2.59 PPD. - On 12/17/24, the facility's census was 96. Actual nursing staff hours worked was 2.48 PPD. - On 12/18/24, the facility's census was 95. Actual nursing staff hours worked was 2.61 PPD. - On 12/19/24, the facility's census was 97. Actual nursing staff hours worked was 2.34 PPD. - On 12/21/24, the facility's census was 99. Actual nursing staff hours worked was 2.03 PPD. - On 12/22/24, the facility's census was 99. Actual nursing staff hours worked was 2.23 PPD. - On 12/23/24, the facility's census was 99. Actual nursing staff hours worked was 2.22 PPD. - On 12/24/24, the facility's census was 97. Actual nursing staff hours worked was 2.25 PPD. - On 12/25/24, the facility's census was 98. Actual nursing staff hours worked was 2.34 PPD. - On 12/26/24, the facility's census was 100. Actual nursing staff hours worked was 2.19 PPD. - On 12/27/24, the facility's census was 101. Actual nursing staff hours worked was 2.40 PPD. - On 12/28/24, the facility's census was 101. Actual nursing staff hours worked was 2.23 PPD. - On 12/29/24, the facility's census was 101. Actual nursing staff hours worked was 2.24 PPD. - On 12/30/24, the facility's census was 101. Actual nursing staff hours worked was 2.13 PPD. - On 12/31/24, the facility's census was 99. Actual nursing staff hours worked was 2.38 PPD. During an interview with the Administrator and Director of Nursing (DON) on 1/10/25 at 5:10 p.m. the Administrator was asked whether the facility had established a minimum nursing staffing level to ensure residents received necessary care and services. The Administrator explained that the minimum nurse staffing expectation to meet the needs of residents was 2.8 nursing staff hours per patient per day (PPD) and acknowledged that the facility was routinely failing to meet that established benchmark. 45108

Based on interviews and record review, the facility was unable to provide documentation of regular Quality Assurance Performance Improvement Plan (QAPI) meetings and evidence of participation by the required parties. This affected all facility residents. The findings include: During an interview on 1/10/25 at 12:20 p.m., the Administrator reported the committee's plan was to meet monthly, but he/she could not locate all the verification of attendance for the QAPI meetings held since the last survey in June of 2023. The Administrator provided QAPI verification of attendance records, and a documentation review was completed for meetings held June 2024, August 2024, September 2024, and October 2024. There was no additional evidence of required meetings, and no additional documentation regarding those in attendance at the required meetings.

Based on resident interviews, a resident council meeting, observations, and an observation of a test tray meal evaluation, the facility failed to provide palatable foods per resident preferences for taste and temperature as evidenced by improper temperatures. This deficient practice had the potential to affect residents residing on four (4) out of five (5) units eating meals from the kitchen. The findings include: 1. During the initial tour of the facility on 1/7/25 at approximately 10:00 a.m., through 1:00 p.m., the following residents verbalized a concern with the quality of the food and food temperatures: Resident #12 was admitted to the facility on [DATE] with diagnoses including anemia, hemiplegia and heart failure. The most recent Minimum Data Set (MDS), dated [DATE], Revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #12 stated at 10:30 a.m., that the food was usually cold. She /he didn't think it was dietary's fault. The resident said that the trays sat in the hallway for too long due to the facility being short staffed. Resident #58 was admitted to the facility on [DATE] with a diagnosis that included diabetes. The most recent MDS, dated [DATE] coded the resident as having a BIMS score of 15, indicating the resident's cognition was intact. 2. Resident #58 stated at 10:50 a.m., that the food was usually cold to lukewarm, and the meals came out later than the posted times. The resident usually skipped breakfast and ate lunch and dinner in the dining room. Often times, he /she stated they ordered out due to not liking the food. 3. Resident #78 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, hypertension, and hyperlipidemia. The most recent MDS, dated [DATE], coded the resident as having a BIMS score of 15, indicating intact cognition. Resident #78 stated at 11:10 a.m., that oftentimes the food was cold, and the trays were late. The resident said that any day of the week the dinner was served at 7:00 p.m. He/she stated that sometimes when the kitchen was short staffed, they used plastic, and the food was usually cold. 4. Resident #82 was admitted to the facility on [DATE] with diagnoses including ventricular tachycardia, unspecified severe protein calorie malnutrition, major depressive disorder, recurrent, chronic pain syndrome, hypotension, and gastro esophageal reflux. The most recent MDS, dated [DATE], coded the resident as having a BIMS score of 14, indicating intact cognition. On 1/7/25 at 12:49 pm, Resident #82 stated. Food is horrible, it is nasty, served cold. They don't know how to cook here. 5. Residents made the following comments regarding the food on 1/8/25: Resident #37 was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis. The most recent MDS, dated [DATE], coded the resident as having a BIMS score of 14, indicating the resident's cognition was intact. Resident #37 stated at 1:15 p.m., that he didn't care for the food. It's often late and cold. 6. A review of Resident #63's medical record revealed an initial admitted [DATE]. Resident #63's medical history included chronic obstructive pulmonary disease and chronic kidney disease. A quarterly MDS assessment with an assessment reference date (ARD) of 10/10/24 revealed a BIMS score of 14 out of 15 possible points, which indicated that Resident #63's cognition was not impaired. On 1/8/25 at 11:33 a.m. an initial interview was conducted with Resident #63 regarding the care and services he received in the facility. When asked about nutrition and food, Resident #63 described most meals as just not good. When asked to expand on his food concerns, Resident #63 explained that food temperatures were always cold and that the food tastes like slop. When asked whether he voiced his food concerns to facility staff, Resident #63 stated, I think we all have. It don't get any better. 7. Resident #88 was admitted to the facility on [DATE] with diagnoses including renal failure, diabetes, and hypertension. The most recent MDS, dated [DATE], coded the resident as having a BIMS score of 14, indicating intact cognition. Resident #88 stated at 10:00 a.m. that the food was always late and cold. The resident said that facility staff want the residents to go to the dining room for breakfast at 7:00 a.m., and they don't serve the food until 8:30 a.m. Resident #88 stated at 12:49 p.m., Food is usually late and cold. Residents made the following comments regarding the food on 1/9/25: Resident #58 stated at 11:00 a.m., that the coffee was cold again, but the breakfast was better than normal. On 1/10/25, Resident #88 was observed in the dining room at 8:00 a.m., he /she stated the posted time for breakfast was 7:30 a.m. and that the trays had not come out yet. 8. Review of the Resident Council Meeting Minutes revealed the following: 8/8/24- Dietary: Hamburgers were very dry being cooked for too long. Ran out of milk several times this month. Staff served tacos without salsa, no sour cream. Staff served brown gravy with biscuits and the gravy was horrible. Resident would like dietary to order chicken noodle soup. Residents would like to have salt and pepper shakers at the table. 9/4/24- New Business- CNAs are not asking the residents what they want to eat, the CNA's are just filling out the meal tickets. Dietary: Still running out of milk and yogurt. Still no sour cream. Still no salt and pepper. Dietary Response: Yogurt is going by fast because everyone eats it and nursing comes and asks for it for meds. Can only order so much due to budget. Salt and pepper shakers waiting for them to get added to my order guide. 10/2/2024- New Business: Meals are late daily. 11/6/2024-New Business- Meals are late daily. 12/4/2024- New Business: Lunch and dinner are still always late. Dietary: Too much fruit cocktail, meals always late. Dietary keeps running out of sugar, ketchup, cream, sweetener. French fries always cold. Resident do not like the turkey bacon. Residents' plates come and have no silverware. Dietary Response: Explained a few condiments weren't ordered due to the budget, explained that fries are difficult to keep hot once they leave the kitchen but will try harder. Ordered regular and turkey bacon, when we run out of regular bacon, we utilize turkey bacon. On 1/10/2025 at 2:00 p.m., during a Resident Council meeting, the residents stated they were still getting late meals, and the dietary department was still running out of condiments. The always available menu that included daily substitutes, wasn't always available. They don't always get silverware with their meals. They stated that they don't always get juice with their breakfast, and their food preferences don't always get honored. They used to get chocolate milk all the time and now they don't. The food temperatures were still a concern for them. There were five months of food complaints in the Resident Council Meeting Minutes and the residents were still complaining about the food on 1/10/25. 9. An observation of the breakfast meal dining service occurred on 1/10/25 at 7:00 a.m. A test tray was requested to be sent out on the last food cart for the 500 hall. The test tray left the kitchen at approximately 9:28 a.m. The food trays were served on open carts with plastic covering. The test tray temperatures were as follows: Eggs - 93 degrees ( ) Fahrenheit (F); meat - 93 F; hot cereal 129 F; and milk - 44.7 F. The Food Service Supervisor was present, and she stated the food was too cold and that it sat in the hallway for too long. On 1/10/25 at 6:00 p.m., in an interview with the Administrator, he /she acknowledged that the food complaints were a concern. 42070

Based on observations, interviews, and record review, the facility failed to ensure a resident's right to a dignified existence, including being treated with respect during all care interactions for three (3) of three (3) residents observed for dignity (Resident #66, Resident #82 and Resident #39). The findings included: Review of the facility's policy titled Adaptive Equipment-Feeding Devices with a revision date of 12/2020 noted: Adaptive feeding equipment is used by residents who need to improve their ability to feed themselves and in order to enable residents with physically disabling conditions to improve their eating functions. 1. Resident #39 was admitted to the facility on [DATE] with diagnoses which included Diffuse Traumatic Brain Injury with Loss of Consciousness, Cerebral Infarction due to Occlusion of Stenosis of Small Artery, Morbid Obesity, Muscle Weakness and Repeated Falls. Record review of Resident #39's Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) summary score of 13 which indicated the resident's cognition was intact. Resident #39 was coded as requiring setup or clean-up assistance for eating. Record review of Resident #39's Physician's Orders with no initiation date and a revision date for 12/30/24, revealed an Occupational Therapy order: Pt to trial built-up utensil daily for meals as he tolerates. [sic] In an observation on 1/8/25 at 12:43 p.m. Resident #39 was seated at a table in the large dining room, with three (3) other residents. Resident #39 requested assistance with his/her meal and staff moved the resident to the area for residents who required assistance with meals. An unknown staff member sat down with the resident and provided aid. In an observation on 1/9/25 at 1:30 p.m. Resident #39, was in bed with his/her meal tray and not eating. In an interview on 1/9/25 at 1:30 p.m. with Resident #39, the resident reported being frustrated that staff were not available to assist him with his meals. Resident #39 stated he could not grasp the utensils to eat his meal independently. Resident #39 reported he/she did not like the way staff treated him/her when it came to providing assistance with eating his/her meal. In an interview on 1/9/25 at 1:33 p.m. Restorative Nursing Aide (RNA) AA, stated that Resident #39, .for the most part he feeds himself. [sic] 2. Resident #66 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Other Fracture of T11-T12 Vertebra, Chronic Systolic (Congestive) Heart Failure, Thoracic Aortic Aneurysm without Rupture, Obstructive Sleep Apnea, Non-Pressure Chronic Ulcer of Unspecified Part of Right Lower Leg with unspecified severity and Acquired Absence of Left Leg Below Knee. Record review of Resident #66's Annual MDS dated [DATE], revealed a BIMS summary score of 15 which indicated the resident's cognition was intact. Resident #66 was coded as having occasional incontinence of bladder and frequent incontinence of bowel. Record review of Resident #66's Care Plan with an initiation date of 1/21/24 and a revision date of 1/2/25 revealed interventions that documented the resident preferred to sleep in a recliner and, . typically independent with toileting but at times may require additional assistance. Monitor for increased need . Resident #66's Care Plan did not address whether the resident needed assistance with transferring from the rocking recliner. An observation on 1/9/25 at 11:22 a.m. of Resident #66's room, revealed the resident did not have a bed in his/her room, and other than the manual wheelchair the resident was sitting in, the resident only had a rocking recliner. An interview on 1/9/25 at 11:22 a.m. with Resident #66, revealed that Resident #66 was sleeping in his/her manual wheelchair. The resident reported that he/she had difficulty getting in and out of bed in his/her current room, due to the side that the bed controls were located. The resident stated that the facility suggested the recliner. Resident #66 also reported that due to the fact that the recliner was also a rocking chair, he/she was unable to get up from the chair without assistance. The resident said he/she felt that it was easier for him/her to sleep in the manual wheelchair. Resident #66 further reported that he/she could only sleep for two (2) hours at a time in the wheelchair, and that he/she did not like the rocking recliner and wanted a bed to sleep in. Resident #66 said when he/she told the facility about his/her issue with the rocking recliner that it was suggested to have his/her family member purchase a different recliner. In an interview on 1/9/25 at 11:50 a.m. with Certified Medication Aide (CMA) CC reported that the resident had been without a bed, .a week or two (2). In an interview on 1/9/25 at 11:55 a.m. with Licensed Vocational Nurse (LVN) Treatment Nurse DD confirmed that the resident was sleeping in the manual wheelchair, that the resident reported difficulty with the rocking recliner, and it was suggested to the resident to have a family member purchase a different recliner for the resident. 3. Resident # 82 was admitted to the facility on [DATE] with diagnoses which included Ventricular Tachycardia, Overactive Bladder, Major Depressive Disorder and Chronic Pain Syndrome. Review of Resident #82's Admission MDS dated [DATE] revealed the resident had a BIMS summary score of 14 which indicated the resident was cognitively intact. The MDS further revealed Resident #82's functional abilities were coded as dependent on staff for toileting hygiene; and coded the resident as frequently incontinent of bladder and always incontinent of bowel. An observation on 1/9/25 at 3:33 p.m. of Resident #82's perineal care revealed RNA AA, engaged in inappropriate behavior by using profane language directed at Certified Nursing Aide (CNA) BB in the presence of Resident # 82. This behavior occurred at the bedside while performing intimate perineal care, compromising the resident's right to a dignified and respectful environment. In an interview on 1/9/25 at 4:12 p.m. with the Administrator, Director of Nursing, Regional Director and Regional Nurse it was reported that RNA AA would be suspended pending an investigation and a safe survey with trauma assessments would be provided for Resident #82. In an interview on 1/10/25 at 3:07 p.m. with Resident #82, when asked about the incident with RNA AA, he stated .I don't like it at all. That was rude and disrespectful.

42070 Based on observations, interviews and record review, the facility failed to ensure residents received the necessary nursing care and services for activities of daily living by failing to 1) Provide residents with showers in accordance with bathing schedules for two residents (Resident #2 and Resident #58) and 2) Provide residents requiring assistance with toileting the necessary care and services to transfer on and off the toilet for one (1) of six (6) residents reviewed (Resident #70), and 3) Ensure that two (2) of 36 residents sampled (Resident #39 and Resident #82) were provided with personal hygiene care and/or adaptive eating equipment in accordance with their preference and Care Plans. The findings included: Cross-Reference to F725 Sufficient Nursing Staff Review of the facility policy, Showering a Resident, undated, documented Purpose: A shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors. Policy: Residents are offered a shower at a minimum of once weekly and given per resident request. 1. Resident #2 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, depression, anxiety, non-weight bearing, spastic diplegic, and obesity. The most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was conducted and the resident was coded as 15 indicating the resident had intact cognition. The MDS also coded the resident as having upper and lower impairment in range of motion and coded the resident as being dependent on staff for showers, transfers, and hygiene. The resident 's care plan, initiated 7/5/17, documented under Focus that the resident required assistance with activities of daily living (ADL) due to weakness and cerebral palsy. The goal listed the resident was to maintain their current level of functioning through the next review date. The intervention was for the resident to receive substantial/maximal assistance by staff for showering, bed mobility and transfers. The care plan documented the resident was to receive a shower two (2) times weekly and as needed. An intervention was a Hoyer lift for transfers with the assistance of two staff. On 1/7/25 at approximately 11:00 a.m., in an interview with Resident #2, she /he stated that the staff was short, and they (the staff) asked them to stay in bed and take a shower another day. She/he said that when they were short staffed, they often asked her/him to do that. She /he didn ' t know what happened, but the facility seemed to be short staffed a lot recently. Resident #2 said they used to get showers two times per week but now they was lucky if she /he got a shower one (1) time per week. She /he stated they thought some of the staff were scared to move her/him due to being a two-person assist. On 1/10/25 at 10:30 a.m., in an interview with CNA EE, she/he stated that when they were short staffed, they (the staff) asked Resident #2 to change their shower day and sometimes asked the resident to stay in bed. CNA EE stated that Resident #2 had a diagnosis of obesity along with cerebral palsy and this made her difficult to transfer. Review of the Skin Monitoring: Comprehensive CNA shower Review sheets from October 2024 through December 2024 revealed the following: October - the resident received 5 showers, November - the resident received 4 showers, December - the resident received 5 showers. On 1/10/25 at approximately 2:30 p.m., in an interview with the LVN DD, who monitored the skin on bath days, she/he stated that if the residents refused a shower, they were supposed to sign the form. She /he also stated that she/he wasn ' t familiar with Resident #2 refusing showers recently. There was no record of Resident #2 refusing showers. 2. Resident #58 was admitted to the facility on [DATE] with the following diagnoses: seizure, atrial fibrillation and chronic obstructive pulmonary disease. The most recent MDS, dated [DATE], revealed a BIMS was completed and coded the resident as a 15, indicating intact cognitive status. The MDS also coded the resident as needing partial assistance with bathing. The resident ' s care plan, updated 10/24, documented under Focus that the resident had a Activity of Daily Care deficit due to generalized muscle weakness, heart failure, alcohol dependence, lymphedema, muscle wasting and atrophy. The resident had a need for assistance with personal care. The interventions listed included: The resident required supervision/ set up assistance with bathing/showering two (2) times weekly and as needed or desired and that the resident was dependent on staff for personal hygiene and oral care. On 1/8/25 at approximately 10:00 a.m., Resident #58 complained about not getting showers two (2) times weekly like he used to. He stated the facility was usually understaffed and often times the staff would ask him to take a shower on a different day because of this. Resident #58 stated they needed more help, especially on the weekends. He /she stated he usually got a shower one (1) time per week. He /she stated he usually asked staff when he could take a shower. He /she stated he tried to get on the [showering] list. Review of the Skin Monitoring: Comprehensive CNA Shower Review sheets from October 2024 through December 2024 revealed the following: October - the resident received four showers, November - the resident received four showers. December - the resident received five showers. On 1/10/25 at approximately 2:30 p.m., in an interview with the LVN DD, who monitored the skin on bath days, he/she stated that if residents refused a shower, they were supposed to sign a form. She/he also stated that she wasn ' t familiar with Resident #58 refusing showers lately. There was no record of Resident #58 refusing showers. On 1/10/25 at approximately 5:15 p.m., in an interview with the Director of Nursing, she /he acknowledged that the residents should have at least two (2) showers per week. The facility's policy governing call light responses was reviewed. The policy was titled Answering the Call Light, and had a revision date of March 2021. The policy's purpose was to ensure timely responses to residents' requests and needs. Step 2 of the procedure instructed staff to identify themselves and politely respond to the resident by name. Subsection B of Step 2 required staff to notify another staff member if the resident's request necessitated assistance. Subsection C instructed staff to complete the task within five minutes if possible. 3. A review of Resident #70's medical record revealed an initial admitted [DATE]. The resident's medical history included hemiparesis affecting the right dominant side, morbid obesity, chronic obstructive pulmonary disease, and fatigue. A quarterly minimum data set (MDS) assessment conducted on 11/12/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points. This suggested that the resident's cognition was not impaired. The assessment also noted that Resident #70 used a wheelchair for mobility and was completely dependent on staff for toileting assistance. A review of Resident #70's plan of care revealed a focus area for ADL self-care performance deficit. An intervention dated 10/7/24, directed staff to provide Resident #70 with substantial/maximal assistance with toileting. On 1/9/25 at 11:05 a.m., the flashing call light in room [ROOM NUMBER]-B indicated a call for assistance from the restroom. An audible alert from the nurse's station was heard. From 11:05 a.m. to 11:18 a.m., the call light continued to flash, and the beep from the call light panel at the nurse's station persisted. During this time, Licensed Practical Nurse (LPN) GG was observed at the nurse's station, using a computer to document in the electronic medical record system. Continued observation on 1/9/25 revealed: At 11:18 a.m., Resident #70 was seen sitting on the toilet in their restroom with the door open. When asked if they needed assistance transferring back to their wheelchair, the resident responded, Yes, please! I've been sitting here forever! At 11:20 a.m., two maintenance employees passed by Resident #70's room but failed to acknowledge the call light or respond to the call for assistance. At 11:22 a.m., a Certified Occupational Therapy Assistant (COTA) approached the door of room [ROOM NUMBER], looked up at the flashing call light, turned around, and walked back down the hallway. The COTA did not return to assist Resident #70. At 11:23 a.m., the Administrator walked past the 300 hallway, glanced down the hallway, and proceeded to the Director of Nursing's office. At 11:24 a.m., a maintenance employee entered the room across from 303. The employee did not acknowledge the call light or respond to Resident #70's call for assistance. At 11:26 a.m., a surveyor informed Certified Medication Technician (CMT) HH that Resident #70 needed assistance. CMT HH responded to Resident #70's room and helped him/her back to their wheelchair. On 1/9/25 at 12:42 p.m., an interview was conducted with Resident #70. Resident #70 confirmed that they required physical assistance from staff for transfers to and from the toilet due to weakness in both lower extremities. Resident #70 mentioned that Restorative Nursing Assistant (RNA) AA had assisted them to the toilet around 11:00 a.m. and instructed them to pull the cord when you're done. However, Resident #70 expressed frustration that RNA AA had not responded to the call request. Resident #70 stated that this was typical of most of the people that work here. When asked if they had brought this concern to facility leadership, Resident #70 responded, What's the use? On 1/9/25 at 1:13 p.m., an interview was conducted with CMT HH to discuss Resident #70's care requirements. CMT HH confirmed that Resident #70 needed physical assistance for transfers to and from the toilet. CMT HH also mentioned that while assisting Resident #70 off the toilet at 11:26 a.m., Resident #70 had expressed concern about the time it took to receive toileting assistance. An interview with RNA AA was not possible because they were suspended from employment by facility leadership on 1/9/25 at approximately 4:00 p.m., for an unrelated allegation. On 1/9/24 at 5:01 p.m., an interview was conducted with the Administrator and the Director of Nursing (DON). During the interview, the Administrator and DON were asked about their expectations regarding the facility staff's response to call lights. The DON clarified that every employee should respond to a call light or a resident's request for assistance. If an employee was unable to provide the necessary assistance, they were expected to report the resident's request to an appropriate staff member and follow up to ensure proper care was provided. The Administrator also emphasized the importance of a reasonable response time to call lights, stating that waiting over 20 minutes for assistance with transferring off the toilet was excessive. Review of the facility's policy titled, Showering a Resident, undated, revealed that residents should be offered a minimum of one (1) shower per week and given if requested by the resident. A shower schedule was reviewed and based on the resident's room number he/she is provided a shower on both Mondays and Thursdays or Tuesdays and Fridays. Review of the facility's policy titled, Adaptive Equipment-Feeding Devices, revised 12/2020, revealed, Adaptive feeding equipment is used by residents who need to improve their ability to feed themselves and in order to enable residents with physically disabling conditions to improve their eating functions. 4. A review of Resident #39's electronic health record revealed an admitted [DATE], with diagnoses that included Diffuse Traumatic Brain Injury with Loss of Consciousness, Cerebral Infarction due to Occlusion of Stenosis of Small Artery, Morbid Obesity, Muscle Weakness and Repeated Falls. Review of Resident #39's Admission Minimum Data Set (MDS) dated [DATE], noted a Brief Interview for Mental Status (BIMS) summary score of 13, indicating the resident was cognitively intact. According to the assessment, the resident was dependent on staff for assistance with shower/bathe self. Resident #39 was coded as requiring setup or clean-up assistance for eating. Review of Resident #39's Care Plan with an intervention initiation date of 12/26/24 documented that the resident was dependent on staff for bathing and personal hygiene care. Record review of Resident #39's Physician's Orders with no initiation date and a revision date for 12/30/24, revealed an Occupational Therapy order: Pt to trial built-up utensil daily for meals as he tolerates. [sic] Review of Shower documentation revealed Resident #39 was documented to have received a shower on 12/29/24, 12/31/24 and on 1/10/25. In an observation on 1/8/25 at 12:43 p.m. Resident #39 was seated at a table in the large dining room, with three (3) other residents. Resident #39 requested assistance with his/her meal and staff moved the resident to the area for residents who required assistance with meals. An unknown staff member sat down with the resident and provided aid. In an observation on 1/9/25 at 1:30 p.m. Resident #39, was in bed with his/her meal tray and not eating. In an interview with Resident #39 on 1/8/25 at 1:29 p.m., the resident reported that he had received one (1) bed bath and no showers since being admitted on [DATE]. He stated that staff would keep him clean by changing his bedding and clothes. In an interview on 1/9/25 at 1:30 p.m. with Resident #39, the resident reported being frustrated that staff were not available to assist him with his meals. Resident #39 stated he could not grasp the utensils to eat his meal independently. Resident #39 reported he/she did not like the way staff treated him/her when it came to providing assistance with eating his/her meal. In an interview on 1/9/25 at 1:33 p.m. Restorative Nursing Aide (RNA) AA, stated that Resident #39, .for the most part he feeds himself. [sic] 5. Resident # 82 was admitted to the facility on [DATE] with diagnoses that included Ventricular Tachycardia, Overactive Bladder, Major Depressive Disorder and Chronic Pain Syndrome. Review of Resident #82's Admission MDS dated [DATE] revealed the resident had a BIMS summary score of 14, indicating intact cognition. The MDS further revealed Resident #82's functional abilities indicated the resident was dependent on staff for assistance with toileting hygiene and shower/bathe self. Review of Shower documentation for Resident #82 revealed, was the resident was documented to have received a shower 12/26/24, 1/2/25, and 1/9/25. In an interview with Resident #82 on 1/8/25 at 1:09 p.m., Resident #82 reported that he was not receiving showers. Resident #82 stated, .it's embarrassing, because I smell bad. In an interview with the Administrator and the Director of Nursing (DON) on 1/10/25 at 5:30 p.m., DON stated that residents were supposed to get two (2) showers a week. The DON also said, . staff, or bath aides, or anyone can give a bath. Some prefer the bath aides. [sic] 45108

Based on interviews, credential review and review of facility policy, the facility failed to employ a qualified social worker as mandated for facilities with greater than 120 beds. This failure affected 96 of 96 residents at the facility. The findings include: 1. Review of the provided Job Description for position 7001 Social Worker, Revised December 2023, revealed License Qualification: LSW, LCSW or LMSW [Licensed Social Worker, Licensed Clinical Social Worker or Licensed Master of Social Work]: Qualifications * Certified, licensed, or registered in the state of practice, required. * Bachelor's Degree in Social Work or a bachelor's degree in Human Services field including but not limited to Sociology, Special Education, Rehabilitation Counseling and Psychology from an accredited school of social work, required. * One year of supervised social work experience in a healthcare setting working directly with geriatric individuals. Review of credentials for the Social Worker (SW) revealed that he/she held a Bachelor of Arts in Human Services. The SW was not a licensed by state as required in the Qualifications listed on the job description provided by the facility. In an interview on 1/10/25 at 7:50 a.m. the SW confirmed they did not have a license and also confirmed not having the required year of supervision.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure that residents received wound care in a manner to prevent infections for two (2) of two (2) residents observed for wound care (Resident #26 and Resident #82), and 2) Failed to implement Enhanced Barrier Precautions as indicated by the resident's plan of care for one (1) of three (3) residents reviewed from a total of 36 residents sampled. The findings included: 1. Review of the facility's policy titled, Hand Hygiene revised 6/2020, revealed the purpose of the policy was to ensure that all individuals used the appropriate hand hygiene while in the facility. The hand hygiene policy did not address when to wash hands or don gloves prior to providing care. Review of the facility's policy titled, Dressing-Application and Technique revised 6/2020, revealed, .C. Wash hands before and after each procedure, and put on gloves. Resident # 82 was admitted to the facility on [DATE] with diagnoses that included Ventricular Tachycardia, Overactive Bladder, Major Depressive Disorder and Chronic Pain Syndrome. Review of Resident #82's Admission MDS dated [DATE] revealed the resident had a BIMS summary score of 14, indicating intact cognition. The MDS further revealed Resident #82's was coded for having a stage three (3) pressure injury. During the observation on 1/9/25 at 11:09 a.m. the Licensed Vocational Nurse Treatment Nurse (LVN) AA did not perform hand hygiene before donning gloves and subsequently touched the curtain and Resident #82's bedside table prior to starting the wound care for the resident. 2. Resident #26 was admitted to the facility on [DATE] with diagnoses that included Acute Transverse Myelitis in Demyelinating Disease of Central Nervous System, Complete Traumatic Amputation at level between left hip and knee, Paraplegia. Review of Resident #26's Significant Change Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) summary score of 10, indicating the resident was moderately cognitively impaired. The MDS further revealed Resident #26's was coded to have a stage four (4) pressure injury. During the observation on 1/9/25 at 12:06 p.m., the Licensed Vocational Nurse Treatment Nurse (LVN) AA did not perform hand hygiene before donning gloves and subsequently touched the curtain and Resident #26's bedside table prior to starting the wound care for the resident. 3. Review of the facility policy, Standard and Enhanced Precautions, implemented 4/1/24, documented under Purpose: To ensure the use of appropriate personal protective equipment to improve infection control as required in the care of residents . V. Enhanced Barrier Precautions [EBP] - A. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. B. For residents of whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities: 1. Dressing; 2. Bathing/showering; 3. Transferring; 4. Providing hygiene; 5. Changing linens; 6. Changing briefs or assisting with toileting; 7. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; [and] 8. Wound care: any skin opening requiring a dressing. C. EBP are intended to be in place for the duration of a residents stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at high risk. Resident #37 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis and chronic kidney disease. The resident had a pressure injury on their sacral area and had a suprapubic catheter in place. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that there was a Brief Interview for Mental Status (BIMS) which coded the resident as a 14, indicating the resident ' s cognition was intact. Review of the Care Plan, initiated 11/7/24, documented as a focus area that the resident was on Enhanced Barrier Precautions due to wounds and catheter care. The goal listed was to reduce the transmission of pathogens. The intervention listed was for staff members to wear a clean gown and gloves while performing high contact resident care activities to include Dressing, Bathing/Showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices like central lines, catheters, feeding tubes, tracheostomy/ventilator. Observations of Resident #37 revealed the following: 1/7/25 at 11:30 a.m. - Observed resident in room: there was no signage outside the door that indicated precautions were in place and there was no PPE [personal protection equipment] inside or outside the room. There was a hazardous waste container inside the room. 1/8/25 at 10:15 a.m. - Observed resident inside their room, no signage posted for enhanced barrier precautions. PPE was not available. 1/9/25 at 9:30 a.m. - no signage posted outside or inside the room for enhanced barrier precautions. Observations on 1/8/25 at 10:15 a.m. of Resident #37 ' s room revealed that there was no signage outside the resident ' s room indicating the resident was on enhance barrier precautions. There was no PPE outside or inside the resident ' s room for staff to use. There was a box in the room marked hazardous waste, but no PPE could be found. This was observed on all days of the survey. On 1/10 /25 at approximately 5:15 p.m., in an interview with the Director of Nursing (DON), she /he acknowledged that the resident should be on enhanced barrier precautions, and acknowledged a sign should have been posted to let the staff know. The DON stated they would service the staff on the correct precautions for Resident #37. 45108

Based on observation, interviews and record review, the facility failed to appropriately address and resolve grievances raised during previous resident council meetings. Residents voiced specific concerns regarding food, missing laundry items, and not receiving showers over numerous monthly meetings. This deficient practice had the potential to affect all residents who resided in the facility. The census on the first day of survey entrance was 96 residents. The findings included: 1. Record review of Resident Council Meeting Minutes dated 7/3/24, revealed that residents reported they were not receiving showers. Record review of Resident Council Meeting Minutes dated 9/4/24, revealed that residents reported they were not receiving showers and reported that the Dietary department ran out of milk and yogurt. Record review of Resident Council Meeting Minutes dated 10/2/24, revealed that residents reported that they were not getting their clothes back from the laundry department in a timely fashion and residents were running out of clothing. Record review of Resident Council Meeting Minutes dated 11/6/24, revealed that residents reported that not all resident rooms were cleaned daily, and residents were not getting their clothes back from the laundry department. Record review of Resident Council Meeting Minutes dated 12/4/24 revealed that residents reported that resident rooms were not being cleaned daily, residents were not getting their clothing back from the laundry department, and the Dietary department was running out of condiments. There was no evidence in the meeting minutes that the residents' reported concerns had been addressed by facility leadership. An observation during the Resident Council meeting on 1/10/25 at 2:00 p.m., revealed residents reported having lost and/or damaged laundry; the facility ran out of paper towels and hand soap; resident rooms were not being cleaned daily; and meal trays were not matching the dining tickets due to the dietary department running out of food items. An interview with the Administrator and the Director of Nursing (DON) on 1/10/25 at 5:30 p.m., revealed that facility leadership met with the Activity Director who conveyed the residents' concerns in a leadership meeting. The Administrator also mentioned that Resident Council meetings were discussed in Interdisciplinary Team meetings. Per the DON, each department gave a response to the issues brought up in resident council. Neither the Administrator nor the DON provided a response as to why the concerns had not been addressed by the facility.

Based on interviews and facility policy, the facility staff failed to protect the rights of a resident whose room was changed without notice prior to the change for one (1) of one (1) resident reviewed for room changes. Resident #65 left the facility for an appointment and returned to learn his/her belongings had been moved to another room. The findings include: Review of facility policy titled Room or Roommate Change Version 1.0, Revised 8/2020 revealed the policy's Purpose -To ensure that a resident is able to exercise their right to change rooms or roommates .Procedure -III. Prior to changing a room assignment, the resident, the resident's representative (if available), the resident's new roommate, will be given timely advance notice of such change according to state and federal regulations. A. When the resident is being moved at the request of the Facility, the notice of a change in room assignment will be in writing and will include the reason(s) for the change. B. Social Services Staff will assist in orienting the resident to his or her new room and/or roommate. 1. Resident #65 was admitted to the facility 10/2/24 with diagnoses including diabetes, kidney failure, repeated falls, hypokalemia, hypomagnesemia, hypertensive heart without heart failure, hyperlipidemia, atrial fibrillation, anxiety disorder, muscle weakness and arthritis. In an interview on 1/7/25 at 12:15 p.m., Resident #65 stated that the facility moved his belongings to a new room when he/she was out for an appointment without notifying the resident before the move. Resident #65 stated that it caused a misunderstanding between him/her and his/her former roommate as each thought the other had asked for the move. In an interview on 1/10/25 at 7:50 a.m., the Social Worker (SW) reported that it was a clinical decision to move Resident #65. SW also acknowledged that Resident #65 had only left the building for an appointment. SW also confirmed that the move was not discussed with the resident. In an interview on 1/10/25 at 5:00 p.m., the Administrator stated that staff were expected to implement policy correctly.

Based on observation, interviews and record review, the facility failed to ensure appropriate notification following a fall during a transfer for one (1) of 36 residents sampled (Resident #39). Resident # 39 reported falling while being transferred from a wheelchair to the bed by Restorative Nursing Aide (RNA) AA and Maintenance Supervisor. The staff involved did not notify the nurse or physician of the incident, as required. This deficient practice compromised the resident's right to prompt assessment and care and potentially placed the resident at risk for unrecognized or untreated injuries. The findings included: 1. Record review of Resident #39's Admission Minimum Data Set (MDS) dated [DATE], revealed an admitted [DATE], and a Brief Interview for Mental Status (BIMS) summary score of 13 which indicated the resident was cognitively intact. Resident #39 was coded as dependent for a chair/bed to chair transfer. Continued review revealed diagnoses which included Diffuse Traumatic Brain Injury with Loss of Consciousness, Cerebral Infarction due to Occlusion of Stenosis of Small Artery, Morbid Obesity, Muscle Weakness and Repeated Falls. Record review of an undated Visual Bedside Kardex Report revealed that Resident #39 required the mechanical aid of a Hoyer lift with two (2) staff members assisting for transfers. Review of Resident's #39's Care Plan revealed there was an intervention with an initiated date of 12/26/24 that the resident required mechanical aid Hoyer lift with two (2) staff assisting for transfers. There was no evidence in the Progress Notes that a fall with Resident #39 had been reported. In an observation on 1/9/25 at 1:00 p.m. of a skin assessment on Resident # 39 with Licensed Vocational Nurse Treatment Nurse (LVN) DD revealed that Resident # 39 had two (2) closed abrasions, that were red and scabbed over below the resident's left knee. LVN DD cleaned the abrasions and applied skin prep, without a written order for the treatment. In an interview with Resident # 39 on 1/8/25 at 1:29 p.m., the resident reported that on the date of admission 12/24/24, he/she fell during a staff assisted transfer from the wheelchair to the bed. Resident # 39 was only able to recall one of the staff members who assisted during the transfer. The resident stated that had he/she sustained an injury to his/her left leg. The first day here, they dropped me trying to transfer. A couple guys dropped me when my legs gave out. Took a gash out of my left leg. [sic] In an interview on 1/9/25 at 11:00 a.m. with LVN DD, he/she stated that no staff member notified her of the two (2) red scabbed over abrasions to the resident's left leg, and was not aware that a fall had occurred with the resident In an interview on 1/9/25 at 5:00 p.m. with the Maintenance Supervisor, revealed that he/she and the RNA AA were the staff members who assisted the resident with the transfer. The Maintenance Supervisor stated that the resident's admission paperwork did not list that the resident was to be transferred via a mechanical Hoyer lift. The Maintenance Supervisor reported that Resident # 39 during transfer started to slip out of their wheelchair but did not fall. RNA AA was unavailable to be interviewed due to being recently suspended earlier in the day.

Based on interview and record review, the facility failed to provide documentation of appropriate notification of pending benefit changes to Medicare services for one (1) of three (3) residents sampled for beneficiary notices (Resident #90). The findings include: 1. The 1/10/25 review of the notices given to three (3) residents selected from the form entitled Beneficiary Notice - Residents discharged Within the Last Six Months (provided to the facility during the Entrance Conference) revealed none was available for 1 of 3 sampled residents, Resident #90. In an interview, the Social Worker (SW) on 1/10/25 at 2:28 p.m. reported not being in the position until August 2024 and the SW was unable to provide proof of notification letters sent to Resident #90.

Based on interviews and record review, the facility failed to notify the resident and the resident's representative of a facility-initiated emergency transfer to an acute care hospital. This deficient practice affected one (1) of two (2) residents reviewed for hospitalization s from a total of 36 residents sampled (Resident #101). The findings include: The facility's policy governing resident transfer and discharge processes was reviewed. The policy, titled Transfer and Discharge was dated 10/24/22. The policy directed staff from Social Services (or a designee) to prepare a written transfer notice to send with the resident in the event of an emergency transfer. 1. A review of Resident #101's medical record revealed an admitted [DATE]. His/her medical history included metabolic encephalopathy, hemiparesis affecting his/her left side, and history of CVA. A comprehensive minimum data set (MDS) was not completed as the resident was admitted on [DATE] and discharged on [DATE]. Resident #101 did not return to the facility after hospitalization . A Recapitulation of Stay Resident Discharge Summary dated 10/30/24 revealed that Resident #101 was transferred to the hospital on 10/29/24 at 4:00 p.m. due to a change in medical condition. The electronic form was signed by the Director of Nursing (DON). Continued review of Resident #101's medical record revealed no evidence of a written notice of transfer having been sent to the resident or the resident's representative. On 1/9/25 at 12:10 p.m., an interview was conducted with Licensed Practical Nurse (LPN) FF regarding the facility's practices for transferring residents to acute care settings. According to LPN FF, the nurse that transferred the resident to the hospital would be expected to complete the notice of transfer and send it with the resident at the time of transfer, as part of the transfer paperwork. LPN FF added that a copy of the notice should be kept in the resident's medical record. On 1/10/25 at 5:01 p.m., an interview was conducted with the facility's Administrator and the DON. During the interview, the DON confirmed that a written notice of transfer was not sent with Resident #101 at the time of his/her transfer nor was it sent to the resident's representative. The DON added that the nurse transferring the resident to the hospital should have completed the notice of transfer. When reminded that he/she signed Resident #101's discharge summary, the DON stated he/she was unable to recall whether a notice of transfer was sent.

Based on interviews and record review, the facility failed to provide the resident and the resident's representative with a written notice of the facility's bed-hold policy upon transferring a resident to an acute care hospital. This deficient practice affected one (1) of two (2) residents reviewed for hospitalization s from a total of 36 residents sampled (Resident #101). The findings included: The facility's policy governing resident transfer and discharge processes was reviewed. The policy, titled Transfer and Discharge was dated 10/24/22. The policy directed staff to provide a resident and a resident representative with a written notice which specified the duration of the resident's bed-hold at the time of transfer. 1. A review of Resident #101's medical record revealed an admitted [DATE]. His/her medical history included metabolic encephalopathy, hemiparesis affecting his/her left side, and history of CVA. A comprehensive minimum data set (MDS) was not completed as the resident was admitted on [DATE] and discharged on [DATE]. Resident #101 did not return to the facility after hospitalization . A Recapitulation of Stay Resident Discharge Summary dated 10/30/24 revealed that Resident #101 was transferred to the hospital on 10/29/24 at 4:00 p.m. due to a change in medical condition. The electronic form was signed by the Director of Nursing (DON). Continued review of Resident #101's medical record revealed no evidence of a written notice of the facility's bed-hold policy having been sent to the resident or the resident's representative. On 1/9/25 at 12:10 p.m an interview was conducted with Licensed Practical Nurse (LPN) FF regarding the facility's practices for transferring residents to acute care. According to LPN FF, the nurse that transferred the resident to the hospital was expected to complete the notice of bed-hold and send it with the resident at the time of transfer as part of the transfer paperwork. LPN FF added that a copy of the notice should be kept in the resident's medical record. On 1/10/25 at 5:01 p.m. an interview was conducted with the Administrator and the DON. During the interview, the DON confirmed that a written notice of bed-hold policy was not sent with Resident #101 at the time of his/her transfer nor was it sent to the resident's representative. The DON added that the nurse transferring the resident to the hospital should have completed the notice of bed-hold.

Based on observation, interviews and record review, the facility failed to ensure the accuracy of a skin assessment when the corresponding assessment did not reflect the actual condition of the skin for one (1) of 36 residents sampled (Resident #39). Inaccurate documentation compromised the facility's ability to provide appropriate and timely care, potentially putting the resident at risk for further complications. The findings included: 1. A review of Resident #39's electronic health record revealed an admitted [DATE], with diagnoses that included Diffuse Traumatic Brain Injury with Loss of Consciousness, Cerebral Infarction due to Occlusion of Stenosis of Small Artery, Morbid Obesity, Muscle Weakness and Repeated Falls. A further review of Resident #39's Admission Minimum Data Set (MDS) dated [DATE], noted a Brief Interview for Mental Status (BIMS) summary score of 13, which indicated the resident's cognition was intact. Section M of the MDS noted Moisture Associated Skin Damage (MASD), and no other skin problems were present. A review of a Skin/Wound note dated 12/25/24 at 9:25 p.m. created by Licensed Vocational Nurse Treatment Nurse (LVN) DD, documented that LVN DD assessed Resident #39, and the resident had no skin issues noted. There was no evidence of any other documentation that noted Resident #39's skin issues. In an observation on 1/9/25 at 11:00 a.m. of a skin check/assessment on Resident # 39 conducted by LVN DD revealed that Resident # 39 had two (2) closed abrasions that were red and scabbed over located below the resident's left knee. LVN DD cleaned the abrasions and applied skin prep. In an interview with Resident #39 on 1/8/25 at 1:29 p.m. the resident reported that on his/her date of admission 12/24/24, Resident #39 fell during a transfer from the wheelchair to the bed and sustained an injury to his left leg. Resident #39 said, The first day here, they dropped me trying to transfer. A couple guys dropped me when my legs gave out. Took a gash out of my left leg. [sic] In an interview on 1/9/25 at 11:00 a.m. with LVN DD, the nurse stated that no staff member notified him/her of the two (2) red scabbed over abrasions to the residents left leg of Resident #39, he/she was not aware of an injury or a fall and had not documented them. In an interview on 1/9/25 at 5:00 p.m. with MS, revealed that he/she and the RNA AA were the staff members who assisted the resident with the transfer. MS stated that the resident's admission paperwork did not list that the resident was to be transferred via a mechanical Hoyer lift. MS reported that Resident # 39 during transfer started to slip out of their wheelchair but did not fall. RNA AA was unavailable to be interviewed due to being recently suspended earlier in the day.

Based on interviews and record review, the facility failed to obtain a physician ordered urinalysis (UA) sample in a timely manner for Resident #5, one (1) of one (1) resident reviewed for laboratory results from a total of 36 residents sampled. The findings include: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses including but not limited to cellulitis, heart disease, anemia, morbid obesity, infection of unspecified joint, pain and diabetes with diabetic neuropathy. Review of the clinical health record for Resident #5 revealed a physician's order dated 1/3/24 for a UA. On 1/9/25 the laboratory results were requested from the Director of Nursing Services (DON) with reminders provided as other requests were completed. In an interview on 1/10/25 at 5:10 p.m., the DON reported that the 1/3/25 physician's order was executed on 1/10/25 and the sample was earlier that day. There was no reason provided for the delay in obtaining the sample.

Based on observation, interview and policy review, the facility did not provide meaningful activities on the weekends for two (2) residents (Resident #58 and Resident #78), and did not get one (1) resident out of bed for activities that they wanted to attend (Resident #39) out of 36 residents sampled. The findings include: The facility's policy Activities Program, revised 6/2020, documented under Purpose: To encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. Listed under Policy: The facility provides an Activity Program designed to meet the needs, interests, and preferences of residents. The activities are varied and work to address the needs and interests identified through the assessment process. The Activity Program may address areas including but not limited: A. Social Activities: B. Indoor ad Outdoor activities: C. Activities away from the facility: D. Religious programs: E. Opportunity for resident involvement for planning activities: F. Creative activities: G. Educational activities: and H. Exercise activities. II. A Variety of activities should be offered on a daily basis, which includes weekends and evenings. 1. Resident #39 was admitted to the facility on [DATE], with diagnoses including diffuse traumatic brain injury with loss of consciousness, status unknown other cerebral infarction, due to occlusion or stenosis of small artery, muscle weakness, mild cognitive impairment of uncertain or unknown etiology other idiopathic peripheral, autonomic neuropathy, chronic obstructive pulmonary disease, chronic kidney disease, and Bipolar 1. The most recent Minimum Date Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) and the resident was coded as 15, which indicated the resident's cognition was intact. The MDS also documented under section F (Preferences for Customary Routine and activities) the resident preferred group activities, animals (pet therapy) and doing their favorite activities was very important to them. Further review of Resident #39's medical record revealed a Care Plan, dated 12/24/24, documented under activities as a Focus area that the resident was dependent on staff for cognitive stimulation and social interaction. The goal was for the resident to participate/attend activities of choice two (2) to three (3) times per week by next review. The interventions listed were for the resident to be invited to activities, groups, music groups, and special events. Also, the facility was to provide a program that was of interest and empowered the resident by encouraging /allowing choice, self-expression, and responsibility. On 1/8 /25 at 1:29 p.m., Resident #39 stated that since he/she couldn't get out of bed by himself, that staff were not getting him up for activities. I would like to go to bingo, but nobody comes to get me. I'm a smoker, but they say because I can't function, they don't take me. 2. Resident #58 was admitted to the facility on [DATE] with the following diagnoses: seizure, atrial fibrillation and chronic obstructive pulmonary disease. The most recent MDS dated [DATE], revealed a BIMS was completed and coded the resident as a 15, indicating intact cognitive status. The F section of the MDS (Preferences for customary routine and activities) documented music, books, news, outside activities, and religious activities were very important to him. Further review of the medical record revealed a Care Plan, updated on 10/30/24, documented under activities that the resident didn't care for group activities due to physical mobility/limitation issues and listed under Goals: the resident would express satisfaction with the type of activities and level of activity involvement through the next review date. The interventions were to invite the residents to activities, thank the residents for attendance at bingo, music, and social events. The resident liked to socialize with peers and watching programs on T.V. In an interview with Resident #58 on 1/7/25 at 3:45 p.m., the resident complained of having no activities to participate in for the weekends. He /she stated he was here for two years, and they have never had activities on the weekends. He /she stated they liked Bingo, but it was rarely offered on weekends, and he /she gets bored. Reviews of the activity attendance records for the months of October 2024 through December 2024 revealed Resident #58 attended two bingo activities on Saturday in the past three months. 3. Resident #78 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, obesity, and cerebral infarction. The most recent MDS dated [DATE] revealed a BIMS was conducted, and the resident was coded as 13, indicating intact cognitive status. The most recent annual MDS dated [DATE] documented under section F (Preferences for customary routine and activities) that it was very important for him to participate with groups of people, religious activities, listen to music, and participate in his favorite activities. Review of the Care Plan, updated on 12/9/24, documented as a concern that Resident #78 had little or no activity involvement due to eating in the dining room. Resident #78 preferred to eat in his /her room/bed especially in the morning. Listed under goals was that resident would express satisfaction with type of activities and level of activity involvement when asked through the next review date. Interventions included that the resident enjoyed playing Bingo, Farkle, and attending special events in the lobby. On 1/9/25 at 9:40 a.m, in an interview with Resident #78, the resident stated the facility really didn't have weekend activities. The resident stated that he/she got bored on the weekends. He stated he /she liked Bingo but it was not always offered on the weekends. He /she stated they would also like their church to come to the facility on Sundays. Review of the activity attendance records for the months of October 2024 through December 2024, revealed that Resident #78 attended two (2) activities on the weekend within the three months: Farkle and Wellness Walk was attended on 10/5/24. On 1/10/22 at 10:02 a.m., in an interview with the Activity Director (AD), she stated that the residents would start card games with other residents on the weekend; however, the [activity] staff weren't there to observe what was done on the weekends, except for Bingo. When questioned about the church services, the AD stated they weren't aware of the churches not coming. However, they weren't in the facility to observe. On 1/10/25 at 10:02 a.m., in a follow-up interview with the AD with the Assistant AD present, they explained that they don't staff the Sunday weekend activities. The AD said that they leave out materials, such as board games and cards, so the residents can do things independently. On Saturdays they come in and staff Bingo, but that's the only weekend activity that was staffed by the Activity department. Bingo for the past three months had been done every other Saturday, due to the holidays and having other activities going on. However, the only available activities listed on Saturdays and Sundays were coloring sheets, card games, table games, fell owship church, chat with coffee, and South Christian Church. They only supervise the activities during the week. The Activity Director stated that starting in the month of January 2025 they will be offering Bingo every Saturday. On 1/10/25 at 5:00 p.m. in an interview with the facility's Administrator, he /she acknowledged that the activities were a concern, and stated he /she knew how to correct the situation. 45108

Based on observations, interviews, and record review, the facility failed to ensure the environment was as free from accident hazards by failing to 1) Ensure residents smoked only in the areas designated by the facility's safety committee in accordance with the facility's policy; and 2) Supervise residents while they smoked in accordance with the facility's policy. This deficient practice affected two (2) of four (4) residents reviewed for accident hazards related to smoking from a total of 36 residents sampled (Resident #13 and Resident #20). The findings include: The facility's policy governing practices for residents who smoke was reviewed. The policy, titled Smoking by Residents contained a revision date of November 2023. The policy's purpose read, To respect resident choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers. Section II of the policy read, The facility permits smoking only in the area(s) designated by the Facility's Safety Committee. Line X of the procedure read, All smoking sessions will be supervised by Facility Staff members. 1. A review of Resident #13's medical record revealed an initial admitted [DATE]. The resident's medical history included chronic obstructive pulmonary disease and hemiparesis affecting the resident's left side. A quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/20/24 revealed a brief interview for mental status (BIMS) score of 14 out of 15 possible points indicating the resident's cognition was not impaired. Resident #13 required supervision or touching assistance to walk distances greater than ten (10) feet. On 1/7/25 at 10:00 a.m., Resident #13 was observed smoking near the facility's front door. There were no staff supervising Resident #13 as he/she was smoking. Signs were observed on the columns of the facility's front awning which directed staff to smoke only in designated areas. On 1/7/25 at 3:25 p.m., Resident #13 was observed smoking immediately to the right of the facility's front door. There were no staff supervising Resident #13 as he/she smoked. On 1/8/25 at 1:30 p.m., Resident #13 was observed smoking near the facility's front door. There were no staff supervising Resident #13 as he/she smoked. On 1/8/25 at 1:50 p.m., an interview was conducted with Resident #13. When asked whether he/she had received directions about the facility's smoking procedures, Resident #13 explained that he/she had but that they don't ever take us on time, so I just go myself. Resident #13 went on to explain that, at some point in the past, he/she voiced concerns about facility staff not adhering to the established smoking times and that he/she was told just sign out and go out to the street. 2. A review of Resident #20's medical record revealed an initial admitted [DATE]. Resident #20's medical history included hemiparesis affecting the left side and tobacco use. An annual MDS assessment with an ARD of 10/16/24 revealed a BIMS score of 15 out of 15 possible points indicating the resident's cognition was not impaired. The assessment identified Resident #20 as currently using tobacco. On 1/7/25 at 9:55 a.m., Resident #20 was observed attempting to exit the facility through the front door. The receptionist stated, [Resident #20], you have to sign out before you go out there to smoke. Resident #20 proceeded to sign out using a binder that was in the facility's lobby before exiting onto the front walkway near the facility's entrance. At 10:00 a.m., Resident #20 was observed lighting and smoking a cigarette with Resident #13. There were no staff supervising Resident #13 or Resident #20 as they smoked. On 1/7/25 at 1:33 p.m., an interview was conducted with Resident #20 regarding the facility's practices for smoking. Resident #20 explained that facility staff were always late assisting residents to the designated smoking area. Resident #20 went on to explain that facility maintenance staff had not cleared the designated smoking area from a recent snowstorm and that residents were not able to use that area. On 1/7/25 at 1:45 p.m., an observation of the designated smoking area confirmed the patio area was covered with snow. A letter signed by the Administrator, dated 10/24/24, was posted near the patio door. The letter indicated that the only designated smoking area for residents was the rear outside patio. The letter added that no other area on this property may be used for resident smoking. In addition, resident smoking may only occur in this designated area under staff supervision. On 1/7/24 at 2:55 p.m., an interview was conducted with Licensed Practical Nurse (LPN) FF regarding the facility's practices for monitoring residents who smoked. LPN FF confirmed he/she was familiar with the care needs of both Resident #13 and Resident #20. LPN FF added that Resident #20 had some functional range of motion limitations in his/her upper extremities and would likely have difficulty extinguishing a cigarette if it fell into his/her lap. LPN FF also confirmed that both Resident #13 and Resident #20 should have staff supervision when smoking and that the designated smoking area was the facility's rear patio. When asked how he/she monitored residents' whereabouts to ensure smoking safety, LPN FF stated, You know, we try hard but there's only so many of us. On 1/10/25 at 5:01 p.m., an interview was conducted with the Administrator and the Director of Nursing (DON). During the interview, the Administrator and the DON were asked about the facility's practices for monitoring residents who smoked. The Administrator confirmed that the only designated smoking area was the facility's rear patio. Additionally, the Administrator confirmed that all residents required staff supervision while smoking. When asked how facility leadership ensured residents smoked only in the designated smoking areas, and received supervision in accordance with the facility's established policy, the Administrator shook his/her head No and did not elaborate.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #18) was free from resident to resident abuse. On 5/31/23 around 2:00 A.M., Resident #78 struck Resident #18 with a wooden back scratcher resulting in multiple bruises to his/her face, arms, legs, and lower rib cage; a broken left pinky finger; and laceration to his/her head that required 5 staples. The facility census was 91 residents. Review of the undated Facility Abuse and Prohibition Program policy showed: -The purpose of the policy included ensuring a standardized methodology for the prevention of abuse. -Each resident had the right to be free from abuse. -The facility was committed to protecting the residents from abuse by anyone. 1. Review of Resident #78's Level One Nursing Facility Pre-Admission Screening for Mental Illness/Mental Retardation or Related Condition, dated 8/13/21, showed the resident did not show any signs or symptoms of mental illness. Review of Resident #78's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Hemiplegia (paralysis or weakness on one side of the body), and hemiparesis, (weakness or partial paralysis) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting the right, dominant side. -Aphasia (a communication disorder that affects the ability to understand and express language). -Alcohol abuse. -Cocaine abuse. -Major depressive disorder, single episode. Review of Resident #78's Care Plan, dated 2/24/23, showed: -The problem identified: --He/she resided in the memory care unit for his/her safety. --He/she had a behavior issue of taking and using other residents' belongings and being verbally abusive. -Undated interventions included: --Reporting agitation to the charge nurse. --Report to social services. --If agitated and unable to settle down, provide a safe space for him/her to pace off some energy. --Attempt to understand the cause for agitation. --Anticipate and meet the resident's needs, use calm voice. Review of Resident #78's Admission Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning), dated 2/27/23, showed: -The resident did not exhibit behaviors or wandering. -He/she had a Brief Interview for Mental Status (BIMS) score of 99 indicating he/she was not able to answer the questions and was cognitively impaired. -No behaviors were indicated. Record review of Resident #78's Progress Notes, dated 5/31/23 at 1:55 A.M., showed: -He/she was discovered in his/her room sitting in a wheelchair with a backscratcher in his/her hand hitting another resident, while the other resident was sitting on the floor. -The residents were immediately separated and assessed. -911 was called. Record review of Resident #78's Investigation, dated 5/31/23, showed:. -At approximately 2:00 A.M. CNA A heard a noise coming from another room. -He/she alerted the nurse and they responded immediately. -Upon entering the room they observed Resident #78 sitting in his/her wheelchair with a back scratcher in his/her hand, hitting Resident #18, who had wandered into his/her room. -Resident #18 was sitting on the floor. -The staff immediately separated both residents. -The charge nurse assessed both residents for injury and administered first-aid as necessary. -An investigation was initiated immediately. -Both residents were placed on 1:1 observation. -Upon completion of the investigation, the facility substantiated that the altercation did occur, however it did not substantiate abuse, as prior to, during and post occurrence, Resident #78's severe cognitive deficits restricted his/her ability to willfully or deliberately cause pain, mental anguish or injury to Resident #18. -Based on findings from the investigation and observation, Resident #78 was startled in a dark room and reacted to being startled and scared, not to willfully or deliberately cause pain, mental anguish or injury to another resident. -Resident #78 had no known history of physical aggression toward other residents. 2. Review of Resident #18's Level One Pre-Admission Screening for Mental Illness, Intellectual Disability or Related Condition, dated 12/29/22, showed: -He/she was able to transfer from bed to walking with minimal help and walk to the dining room with no assistance. -He/she was able to roll over in bed and get up by his/herself. -He/she did not exhibit behaviors. Review of Resident #18's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Repeated falls. -Cognitive communication deficit. -Personal history of Transient Ischemic Attack (TIA a temporary interruption of blood flow to the brain) and cerebral infarction, (a blockage of blood flow to the brain leading to cellular damage or death). -Age related osteoporosis, (decreased bone density and increased bone fragility). -Hemiplegia following cerebral infarction affecting the right, non-dominant side. -Unspecified mood disorder. Review of Resident #18's Care Plan, dated 4/24/23, showed: -He/she resided in the memory care unit due to his/her responsible party's request. --Interventions included monitoring the resident per protocol to ensure safety. -He/she had impaired cognitive function/dementia or impaired thought processes. --Interventions included cueing, reorienting and supervision as needed, monitoring and reporting any changes in cognitive function and keeping his/her routine and caregivers as consistent as possible. -He/she was at risk for falls and had a fall with injury prior to admission while at a prior facility. --Interventions included ensuring the resident's call light was in reach and the resident was encouraged to use it; the resident was to be encouraged to participate in activities that promoted physical exercise and activity for strengthening and improved mobility. -He/she had a mood problem. --Interventions included: administration of medications as ordered and monitoring for side effects. Review of Resident #18's quarterly MDS dated [DATE] showed: -He/she had a BIMS score of 0 indicating he/she was cognitively impaired. -He/she did not exhibit wandering or other behaviors. Review of Resident #18's Progress Notes, dated 5/31/23 at 1:33 A.M., showed: -Certified Nursing Assistant (CNA) A responded to a noise coming from a resident's room. -Upon entering the room, he/she observed Resident #18 sitting on the floor in Resident #78's room. Resident #78 was hitting him/her with a wooden back scratcher. -The residents were immediately separated and assessed. -Received order to transport Resident #18 to the hospital. -Resident #18 was noted to have approximately 3 hematomas to right side of his/her skull and a laceration (a tear or cut in the skin or soft tissue) was noted on his/her skull. -The origin of the laceration was not able to be located due to bloody drainage. -Abrasions noted to both lower extremities, redness noted to the right knee. -A skin tear was noted to the left head. -Bruising noted on face from the eyebrow to the nose. -The abuse coordinator and hospice were notified. Review of Resident #18's hospital Emergency Department Provider Report, dated 6/1/23 at 8:30 A.M., showed the resident had the following injuries after an assault: -Multiple old bruises to the right side of his/her the face. -Hematoma (localized collection of blood outside the vessels) and lacerations to multiple areas of his/her scalp. -There were three lacerations in total: two 2 centimeter (cm) lacerations and one 1 cm laceration. -Bruising over extremities on both sides. -Cuts to his/her right and left fingers. -Bruising on his/her left fifth finger. -No head or neck injuries. -Fracture of his/her fifth finger with soft tissue swelling. -Staples were used to close the lacerations. -He/she also had a urinary tract infection. Review of Resident #18's Re-Admission Evaluation skin assessment, dated 6/1/23, showed: -He/she had a laceration to the top of the scalp measuring 1.9 cm with 5 staples in place. There was redness to the surrounding tissue, with a moderate amount of swelling. -His/her right hand had purple/red bruising. -His/her left hand had purple/red bruising. -There was a 1 cm laceration and bruising on the left shin, bruising on the left ankle, and redness and bruising on the right ankle and shin. -There was redness to the left side area, under the ribs. -There was scattered bruising to both arms. -The left fifth finger was in a splint and wrapped with a bandage due to a fracture. Record review of Resident #78's Incident Report, dated 5/31/23 at 1:10 A.M., showed: -CNA A was in another room giving care to a resident when he/she heard a noise coming from another room. -He/she alerted the charge nurse and they responded immediately to where the noise was coming from. -Upon entering the room, they observed Resident #78 sitting in his/her wheelchair with a back scratcher in his/her hand and he/she was hitting Resident #18 who had wandered in his/her room. -Resident #18 was sitting on the floor. -The two residents were immediately separated. -Resident #78 was taken to another area of the unit with a staff member while assessment of Resident #18 was conducted. -Staff members were assigned to stay with each resident. -Assessments of both residents were conducted. -Resident #78 had no noted injuries. -Resident #18 noted some bleeding, several abrasions, small laceration to the scalp, redness to the knee and shin. -Resident #18 was alert and able to respond to stimuli. -First aid was provided. -The abuse coordinator was contacted and informed of the incident, the doctor was contacted and an order was obtained to send both residents out for evaluation. -911 was called and the ambulance arrived with the police. -Durable Power of Attorneys (DPOA a legal document that gives one person (such as a relative, lawyer, or friend) the authority to make legal, medical, or financial decisions for another person ) and family members were contacted. -There were no witnesses. During an interview on 6/1/23 at 8:30 P.M., Licensed Practical Nurse (LPN) A said: -Resident #18 could not initially walk and used a wheelchair. -He/she had been able to walk for about a month. -Resident #18's family said he/she was a little impulsive. -Resident #18 was easy to redirect and never gave staff any problems. -He/she was not aware that Resident #78 had a back scratcher. -He/she was not surprised that Resident #78 did this becuase resident #78 would become irritable if someone walked close to him/her and wanted to be by himself/herself most of the time. -Resident #78's niece told him/her the resident had a history of verbal aggression and had made threats of physical agression before he/she came to the facility. -Resident #78 had an attitude and could convey what was on his/her mind. -He/she was surprised Resident #18 was in Resident #78's room. -If a staff person were back there alone, he/she could open the double door and shout for help or page overhead. -LPN B was actually assigned to that hallway, but he/she was closer, so he/she responded to the call for help. -When he/she came in to Resident #78's room, Resident #78 was in his/her wheelchair and Resident #18 was sitting on the floor. -Resident #78 was kicking his/her left foot out towards Resident #18, but was not making contact. -Resident #18 and was complaining that Resident #18 was in his/her room. -Resident #18 did not say anything and was not able to answer questions. -The police came to the facility, but did not do anything. During an interview on 6/2/23 at 10:30 A.M., the Assistant Director of Nursing (ADON) said: -There were 14 residents in the memory care unit. -CNA A was the only staff member on the unit at the time of the incident. -LPN B was the nurse for that hall. -CNA A found the residents and called LPN A because he/she was the closest. -There was always at least one staff person back there. -LPN B called the police. -He/she didn't think the two residents had previously interacted, at least in a negative manner. -Resident #78 was a little territorial, but not aggressively territorial. He/she preferred to stay in his/her room and have his/her things when he/she wanted them. -He/she did not think this incident was predictable on a dementia unit. During an interview on 6/2/23 at 11:40 A.M., LPN B said: -He/she was assigned to the dementia unit on the night of the incident. -He/she was getting a medication for another resident at the time. -CNA A alerted them that there was an altercation. He/she had been previously assisting another resident. -He/she started the paperwork since LPN A responded to the incident. -LPN A did the assessments of the residents, so when he/she saw Resident #18, he/she was already on the stretcher. -He/she did rounding every two hours to look in on the residents. -This was the first time something like this had happened since he/she worked at the facility. -Resident #18 usually slept through the night, and as far as he/she knew, Resident #18 did not wander around at night. -If Resident #18 did walk around, it was up and down the hallways, not in other residents' rooms. -He/she had not interacted with Resident #78 very much. -The resident had always been pleasant to him/her. -He/she did not think this could have been prevented, but the main thing was that everyone was kept safe. -He/she did not know where Resident #78 got the back scratcher. During an interview on 6/2/23 at 1:10 P.M., CNA A said: -He/she found the two residents. -When he/she heard the commotion, he/she was assisting another resident. -He/she heard a resident calling for help and when he/she got to the room, Resident #78 was over Resident #18 with a back scratcher. -He/she did not see Resident #78 actually hit Resident #18 with the back scratcher. -Resident #78 was shouting, Get out! Get out! -He/she just saw the blood all over Resident #18 and told Resident #78 to back off. -He/she took the blood covered back scratchier away from Resident #78 and put it on the bed. -He/she left the room and called the nurse and the nurse told him/her to take Resident #78 out of the room and stay with him/her, so he/she took the resident to the dining room. During an interview on 6/5/23 at 1:45 P.M., CNA A said: -The last time he/she saw Resident #78, he/she was asleep. All of the residents were asleep. -He/she checked the residents every 1-2 hours. -He/she didn't remember what time she saw the residents before that. -He/she was assisting a resident in another room when he/she heard a cry for help, and went out in the hallway to locate where it came from. -The light was off when he/she went in Resident #78's room, but he/she could see in the room because of the light from the hallway. -He/she turned the light on and saw Resident #18 sitting on the floor, screaming for help. -Resident #78 was in his/her wheelchair, leaning over Resident #18 with a back scratcher in his/her hand and was yelling get out. -Resident #78's hand was raised, but he/she did not see the resident strike out with it. -He/she was the only staff person on the dementia unit. -He/she had to leave the room to call the nurse. -When he/she opened the double door, he/she could see the nurse. -He/she was only gone possibly 5-10 seconds, maybe less. -The two residents were separated, but both remained in the same room. -He/she was not able to see the residents the whole time he/she was out of the room. -The only other alternative he/she had for calling for help would have been to run to the dining room to call an overhead page for help. -It would have taken longer than the 5-10 seconds he/she was out of the room to run to the dining room to call for help. -He/she did what he/she was supposed to do, which was call for help. -Maybe it would have helped to have another staff person on the unit. During an interview on 6/5/23 at 2:00 P.M., LPN A said: -When he/she walked in the room, the light was on and Resident #18 was sitting on the floor to the left of the doorway. -He/she did not know what the residents were doing prior to that. -The last time he/she saw Resident #18, was around 11:00 P.M. when his/her call light was going off. -Resident #78 had his/her door closed. He/she usually kept it closed. -Resident #18 was usually in bed all night. -He/she had never really seen Resident #18 get up and walk around at night. -Resident #18 was capable of opening a room door. -He/she had no real reason to go back there at that time. -The staff did face checks every 1-2 hours. -Resident #78 could have been sleeping and Resident #18 surprised him/her. -Resident #78 would not have reacted well to this. -He/she was the closest nurse to the unit. -CNA A physically came out to get help -The two residents were left alone together during that time. -5-10 seconds was about right, the double door did not even have time to close before he/she got to Resident #78's room. -When he/she entered the room, Resident #78 was hitting Resident #18. -Residents were supposed to be immediately separated in a situation like this. -He/she had been told the overhead pager was not working, so CNA A had no alternative but to come and get him/her. -It would have been better if CNA A had placed Resident #78 in the hallway before getting help. -Resident #78 could move pretty fast in his/her wheelchair. -Prior to this, neither of the residents were showing any unusual behavior patterns. 3. During an interview on 6/1/23 at 10:20 A.M., Resident #18's family member A said: -He/she was the resident's DPOA. -Resident #78 hit Resident #18 with a back scratcher. -Resident #78 was seated in his/her wheelchair and possibly knocked Resident #18 down. -He/she had been told Resident #78 was very territorial. -Resident #18 wandered into Resident #78's room. Observation of Resident #18 on 6/1/23 at 10:40 A.M., showed: -The forehead open gash was still freshly bleeding and blood was streaming down the resident's face. -He/she had reddish-purple areas all over the back of his/her head that appeared fresh. -His/her hair was full of blood. -He/she had a laceration in his/her scalp closed with five staples. -The resident had what appeared to be a bruise partially visible under a heart monitor patch that was approximately 3 cm. -He/she also had some small purple areas below his/her shoulder blade and on his/her back. -There was a darkened purple area on his/her right cheek. -There were large yellow-green areas on both sides of his/her face. -His/her left small finger was splinted and wrapped with a bandage. -He/she had several small superficial reddened areas on his/her arms and legs. -The gash on the forehead was closed with ten sutures. During an interview on 6/1/23 at 11:05 A.M., Resident #18 said: -He/she felt pretty good. -He/she did not remember what happened to him/her the day before or how he/she got hurt. During an interview on 6/1/23 at 2:00 P.M., Resident #78 said: -He/she did not remember hitting anyone. -He/she did not remember why he/she was angry. -He/she knew Resident #18, but did not remember fighting with him/her. 4. During an interview on 6/1/23 at 3:25 P.M., Psychiatric Nurse Practitioner A said: -He/she had not met either resident yet. -Dementia residents are highly unpredictable and it was hard to know what their triggers were. -Not remembering an event was pretty typical of a person with dementia. -The facility could call day and night when there were resident behaviors. -He/she did not feel the facility could have predicted this incident. During an interview on 6/2/23 at 10:00 A.M., Resident #78's family member said: -The resident came to stay with him/her for a while after he/she was at his/her previous facility. -The resident had a history of drinking and living on the streets for years. He/she was homeless for several years. -He/she knew his/her family member had assaulted a resident at a previous facility. -He/she was getting overwhelmed with caring for the resident. -The resident threatened to hit him/her, but never actually did it. -He/she did not know where the resident got the back scratcher. None of the family purchased it for him/her. -The resident was getting kicked out of places due to his/her behaviors. He/she was verbally aggressive. -The resident was only able to use one hand and did not have control of the other side of his/her body. -He/she had not talked with the administrator about the resident's past behavior when he/she was admitted to the facility. During an interview on 6/2/23 at 10:15 A.M., Physician B said: -He/she knew both residents. -Nobody was aware that Resident #78 could be aggressive. -The facility had a history of taking complex residents. -Resident #18 came to the facility and was in a wheelchair with a fractured wrist. He/she had a history of severe falls. -Resident #18 came to the facility for therapy. -Being on aspirin would have contributed to Resident #18 bleeding from his/her injuries. -If they knew a resident was aggressive, they would do labs to rule out issues, and keep him/her on 1:1 observation until another solution could be determined. -This sort of incident was tough to predict, and could not always be avoided in a memory care unit. No one had an answer to predicting behaviors with dementia residents. -The staff handled the situation appropriately. -They should try to keep potentially aggressive residents apart. -Residents should not be hitting other residents. -Abuse was never acceptable. During an interview on 6/5/23 at 11:05 A.M., the Resident #18's family member said: -The facility tried to call him her on 5/31/23 at 2:05 A.M. to notify about the incident between the two residents, but his/her phone was off and he/she did not receive it. -He/she called the facility back on 5/31/23 at 5:16 A.M. and spoke to the DON, who said the resident had been involved in an altercation with another resident had had been sent out to the hospital. -He/she saw the resident at the hospital. -The hospital had a report that the resident was attacked by another resident with a back scratcher. -The family was notified by the facility there was going to be a meeting with the Administrator and staff regarding the incident, and they and the hospice nurse were welcome to come. -He/she was told CNA A was assisting another resident when Resident #18 called for help. -The DON told him/her the facility had a moral and legal responsibility to make sure that residents were safe and they did not do that for Resident #18. -Since Resident #18 came home, he/she had an emotional response when the home health nurse held a thermometer up, Resident #18 would put his/her hands up in a defensive posture and duck his/her head, even though he/she had no memory of the incident at the facility. MO00219209 MO00219246

Based on interview and record review, the facility failed to follow discharge orders including daily weights, failed to follow subsequent physician's orders for weekly weights, failed to get clarification on conflicting orders for obtaining weights, and failed to notify the physician of excessive weight gain which resulted in one closed record sampled resident (Resident #501) who gained a total of 112.5 pounds (lbs.) from 1/7/21 to 2/1/21 and failed to follow physician orders including daily weights and notifying the physician of weight changes for one sampled resident (Resident #84) out of 22 sampled residents and 16 closed record sampled residents. The facility census was 95 residents. The Administrator was notified on 5/27/21 at 12:46 P.M. of an Immediate Jeopardy (IJ) which began on 4/5/21. The IJ was removed on 4/14/21 as confirmed by surveyor onsite verification. Record review of the facility Assessment and Management of Resident Weights policy revised June 2020 showed: -Staff were to ensure that each resident maintains acceptable parameters of weight and nutrition. -Weights were obtained upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. -Additional weights may be obtained at the discretion of the licensed nurse or the interdisciplinary team (IDT). -A licensed nurse or designee will weigh residents. -If the weight is less than or greater than five lbs. from the previous weight, immediately re-weigh and have a licensed nurse verify the accuracy of the weight. -Weights will be entered into the clinical record on that shift. -Significant weight change management: --Will be reviewed by a licensed nurse. --Significant weight changes are less than or more than 5% in one month, 7.5% in three months or 10% in six months. -Report weight change in the medical record and on the 24-hour report. -Notify the physician and dietitian of significant weight changes and document notification in the nurse's notes. -Residents with significant weight changes will be weighed at least weekly and discussed at the Resident at Risk or other clinical meeting to determine possible causes of weight gain or loss including goals for care. -The care plan will be updated to reflect individualized goals and approaches for managing the weight change. Record review of the facility Physician Order Policy revised on June 2020 showed: -This will ensure that all physician orders are complete and accurate. -The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary. -A licensed nurse will transcribe orders with date, time and signature of the person receiving the order. -Licensed nurse receiving the order will be responsible for documenting and implementing the orders. -Documentation pertaining to physician orders will be maintained in the resident's medical record. 1. Record review of Resident #501's New Admission paperwork dated 12/24/20 showed: -Weight on 12/9/20 was 276 pounds (lbs.). -CHF: [MEDICATION(S)] (diuretic - increase the amount of water and salt expelled from the body as urine) appears euvolemic (appears to have a normal circulatory or blood fluid volume within the body). Record review of the resident's Discharge Order Summary from the sister facility dated 12/24/20 showed weekly weight times 4 weeks, every day shift, every seven days for weight monitoring for four weeks, start on 12/11/20. Record review of the resident's Order Summary Report dated 12/24/20 showed: -Daily weights for three days every shift for three days' start 12/24/20 and end 12/27/20. -Weekly weight times four weeks, every day shift every seven days start on 12/25/20. Record review of the resident's Weight Monitoring dated 12/24/20 showed the resident weighed 276 lbs. Record review of the resident's Weight Monitoring dated 12/25/20 showed: -Weekly weight times four weeks, every day shift, every seven days start on 12/25/20 and end on 1/22/21. -The resident weighed 274 lbs. -The absence of any requested clarification related to the change in the order or an order to discontinue the previous order for daily weights for three days. Record review of the resident's Weight Monitoring dated 12/27/20 showed the resident weighed 276 lbs. Record review of the resident's Admission Minimum Data Set (MDS, is a federally mandated assessment instrument to be completed by facility staff for care planning) dated 12/30/20 showed: -The resident was admitted on [DATE]. -Was cognitively intact, able to make his/her needs known and able to understand others. -CHF was not marked/noted as a diagnosis. Record review of the resident's Weight Monitoring dated 1/7/21 showed: -Weekly weight times four weeks, every day shift every seven days start on 12/25/20 and end on 1/22/21. -The resident weighted 273.6 lbs. Record review of the resident's Nutrition assessment dated [DATE] showed: -Resident's weight was 273.6 lbs., dated 1/7/21. -Resident's weight fluctuates some, suspected in part due to fluid shift. -Right arm was currently edematous (swelling with an excessive accumulation of fluid), monitoring. Record review of the resident's Weight Monitoring dated 1/21/21 showed: -Weekly weight times four weeks, every day shift, every seven days, start on 12/25/20 and end on 1/22/21. -The resident weighed 366.4 lbs. -The resident had a 92.8 lb. (25%) weight gain in 14 days. -Record review of the nurse's notes showed no documentation the nurses had assessed the resident for the rapid weight gain or notified the resident's physician. Record review of the resident's complete weight monitoring showed the absence of: -The daily weight to be completed on 12/26/20. -The first weekly weight to be completed on 1/3/21. -The daily weight that would have been due on 1/14/21. -The daily weight for 1/28/21. Record review of the resident's Nursing Note dated 2/1/21 showed: -The resident complained of chest pain and left arm pain, abdominal breathing, pulse was irregular, difficulty breathing with speaking. -Call placed to the physician, received new order to send the resident to the hospital. -Daughter was notified of the transfer. Record review of the resident's Hospital Discharge Summary dated 2/8/21 showed: -Admission Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] --Acute on chronic [CONDITION(S)] with [CONDITION(S)] and hypercapnia (acute [CONDITION(S)] occurs when fluid builds up in the air sacs in your lungs. Chronic [CONDITION(S)] the airways that carry air to your lungs become narrow and damaged. [CONDITION(S)] is not enough oxygen in the blood. Hypercapnia is too much [MEDICATION(S)] in the blood). --Acute or chronic CHF. --Acute Kidney injury (the kidney suddenly cannot filter waste from the blood develops rapidly over a few hours or days, it can be fatal). --Anasarca (the whole body is swollen from head to their feet). -Admission weight on 2/1/21 was 386.1 lbs. (a 112.5 lb., 29% weight gain in one month). -Discharge weight on 2/8/21 was 366.9 lbs. (a 19.2 lb, 5% weight loss while in the hospital for seven days). -Resident was discharged on [MEDICATION(S)] (([MEDICATION(S)]) a diuretic - increase the amount of water and salt expelled from the body as urine) 40 milligrams (mg) twice a day. Record review of the resident's Order Summary Report dated 2/8/21 showed [MEDICATION(S)] ([MEDICATION(S)]) 80 mg, give one tablet twice a day for [CONDITION(S)], start 2/8/21. Record review of the resident's Care Plan related to his/her CHF diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Resident was on diuretic therapy ([MEDICATION(S)]) related to [CONDITION(S)]. -Monitor and document intake and output as per facility policy. -Administer medication as ordered by the physician. -Encourage compliance with fluid restriction as ordered. -May require modification in order to achieve desired effects while minimizing adverse consequences. Record review of the resident's Nutrition assessment dated [DATE] showed: -Current weight was 370 lbs. (a 3.1 lbs., 1% weight gain in one day) -Weight continues to fluctuate significantly at times, suspect in part due to fluid shift with a history of CHF and [CONDITION(S)]. -Order for diuretic medication and weight monitoring. -Weight increase of 96.4 lbs., 26% in one month. Record review of the resident's Order Summary Report dated 2/10/21 showed: -Daily weights every day shift, start 2/10/21. -Daily weights for three days every day shift for three days, start 2/10/21. -Weekly weight for four weeks every day shift every seven days, start 2/11/21. Record review of the resident's Daily Weight Monitoring dated February 2021 showed: -The last time the resident was weighed was on 2/9/21 at 370 lbs. -The absence of a daily weight being completed on 2/11/21, 2/12/21, and 2/13/21. Record review of the resident's Nursing Note dated 2/14/21 showed: -Resident complained of difficulty breathing. -Repositioned and pulled up in bed to sit up better. -Resident took a nap for about an hour before calling 911 himself/herself. -Resident was transferred to the hospital, and did not return to the facility. 2. Record review of Resident #84's Admission Record showed he/she admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Essential primary hypertension (high blood pressure). -Acute kidney failure, unspecified. -Cardiac arrhythmia (irregular or abnormal heart beat) unspecified. -Rheumatic multiple valve disease (a condition in which there is permanent damage to heart valves), unspecified. -Unspecified [CONDITION(S)] (abnormally low activity of the [CONDITION(S)], a gland that regulates growth and development). -[CONDITION(S)] (extreme amount of excess body weight), due to excess calories. -Acute and chronic [CONDITION(S)] (a condition in which the blood doesn't have enough oxygen or has too much [MEDICATION(S)]), with [CONDITION(S)], (absence of enough oxygen to sustain bodily functions). Record review of the resident's Care Plan completed 5/15/20 and reviewed 3/22/21 showed: -He/she had high blood pressure and received medications to treat high blood pressure. -He/she had a goal to remain free of complications related to high blood pressure. -He/she was to be monitored for [CONDITION(S)], which was to be documented. The physician was to be notified of any [CONDITION(S)]. -He/she had a potential for fluid deficit due to taking diuretic medication. -He/she was to be weighed and weight recorded as ordered. -The physician was to be notified of weight loss greater than five pounds. -He/she was to be monitored for weight loss due to [CONDITION(S)] due to medication. -He/she was on [MEDICATION(S)] related to [CONDITION(S)] and would exhibit fluctuations in weight. -He/she had a potential nutrition problem related to obesity. -He/she had a goal to maintain weight within five pounds of current weight. -He/she had unplanned/unexpected weight gain related to hypertension and [CONDITION(S)]. -He/she was to be weighed at the same time of day, in the morning, on the south side scale. -Reasons for weight gain or significant weight changes were to be monitored, recorded and reported to the physician. Record review of the resident's current Physician's Order Summary Report dated 4/6/21 showed he/she had the following orders: -Daily weight, if weight gain of greater than two pounds in 24 hours or greater than five pounds in one week, call doctor. Every day shift for CHF. -[MEDICATION(S)], tablet 80 mg by mouth, two times a day for fluid retention. -[MEDICATION(S)] HCL (a medication used to treat high blood pressure), ER Capsule Extended Release 24 hour, 120 mg, one capsule by mouth, one time a day for hypertension. -[MEDICATION(S)], (a medication that treats underactive [CONDITION(S)] function), tablet 150 micrograms (mcg), one tablet by mouth, one time a day for [CONDITION(S)]. Record review of the resident's Weights and Vitals Summary dated 4/14/21 showed: -From 8/1/20 to 8/31/20, his/her weights were not documented 7 times. -Documented weights from 8/30/20 to 8/31/20, showed he/she had a weight loss of 29.2 pounds. -From 9/1/20 to 9/30/20, his/her weight were not documented 22 times. -From 10/1/20 to 10/31/20, his/her weights were not documented 28 times. -From 11/1/20 to 11/30/20, his/her weights were not documented 18 times. -Documented weights from 11/18/20 to 11/25/20, showed he/she had a weight loss of 6.52 pounds. -From 12/1/20 to 12/31/20, his/her weights were not documented 27 times. -From 1/1/21 to 1/31/21, his/her weights were not documented 25 times. -From 2/1/21 to 2/28/21 his/her weights were not documented 20 times. -Documented weights from 2/20/21 to 2/22/21, showed he/she had a weight gain of 26.8 pounds. -From 3/1/21 to 3/31/21 his/her weights were not documented 17 times. -From 4/1/21 to 4/14/21 his/her weights were not documented 5 times. Record review of the resident's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -There was no documentation the physician was notified, as ordered, of weight changes of greater than two pounds in 24 hours or greater than five pounds in one week. -There were no changes made in ordered medications since 5/15/20. 3. During an interview on 4/13/21 at 9:55 A.M., LPN A said: -The charge nurse transcribes all orders for new admits and re-admits. -He/she put the orders into the computer. -ADON goes in and does order audit the next day after he/she puts the orders in the computer. -He/she does not know who audits the MARS and TARS. -He/she would notify the physician if a resident had too much weight gain, especially if they have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 4/8/21 at 12:11 P.M., the resident's Physician and Nurse Practitioner (NP) said: -He/she would expect the nursing staff to follow the physician's orders. -Nurses should be documenting and assessing the residents. During an interview on 4/13/21 at 9:40 A.M., the Assistant Director of Nursing (ADON) said: -Nurses were responsible to make sure orders were transcribed and entered into the computer. -The ADONs monitor the orders. -He/she and other staff review MAR and Treatments Administration Record (TAR) in morning meeting. -He/she notified the Director of Nursing (DON), physician and Nurse Practitioner. -He/she would notify the physician if a resident had a weight change of two pounds in one day, five pounds in five days if there was an order. -He/she would look at the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Weight change of 3% in thirty days and 5% in 60 days. -For daily weights the residents weight was recorded on the TAR. -The nurse was to make sure the resident was weighed daily. -The TAR would flag the residents that needed daily weights. -When a resident was admitted , the nurse would familiarize himself/herself with the resident. -If a resident had a large weight gain, the resident should be reweighed and the physician should be contacted. -The physician should be notified if a resident had a weight change over 2 pounds in a day or over 5 pounds in a month. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 026

Based on observation, interview, and record review, the facility failed to ensure an unwitnessed injury, to the second finger of a resident who was severely cognitively impaired was thoroughly investigated and to immediately put interventions in place to prevent further injury. Within less than 30 days the resident sustained a similar injury to his/her third finger. The facility failed to thoroughly investigate the second injury and failed to immediately put interventions in place to prevent further injury. This affected one sampled resident (Resident #97) out of 22 sampled residents. The facility census was 95 residents. The Administrator was notified on 5/27/21 at 12:46 P.M. of an Immediate Jeopardy (IJ) which began on 4//5/21. The IJ was removed on 4/14/21 as confirmed by surveyor onsite verification. Record review of the facility's Care Planning policy, dated 6/2020 showed: -A comprehensive, person-centered Care Plan will be developed for each resident to meet the resident's needs. -Changes will be made to the plan on an ongoing basis for the duration of the resident's stay. Record review of the facility's Incident Investigation policy, dated 8/2020 showed: -The licensed nurse will fill out the Incident/Accident Report as soon as possible after an injury. -Interviews with staff members and other witnesses will be documented. Record review of the facility's Abuse Prevention and Prohibition Program, dated 8/2020 showed: -The facility will promptly and thoroughly investigate injuries of unknown origin. -The investigation might include some of the following: --Relevant documentation. --The resident's medical records. --Interviews with residents, the physician, facility staff, witnesses, and persons making the allegation. --Reviews of events leading up to the alleged incident. -The Administrator will provide written report of the investigation and retain documentation. -Unexplained injuries are promptly and thoroughly investigated by the Director of Nursing/or designee. -The charge nurse on duty will complete an Incident and Accident Report and record the information in the resident's medical record, including documentation of relevant risk factors that predisposes the resident to the incident or injury. The nurse will discuss the situation with the physician. 1. Record review of the Resident #97's quarterly Minimum Data Set (MDS - an assessment tool used for care planning), dated 2/4/21, showed the resident: -Was moderately cognitively impaired. -Required supervision for locomotion (oversight, encouragement and/or cueing). -Used a wheelchair (WC) for mobility. Record review of the resident's 3/8/21 Progress Notes showed: -A nursing note written at 12:12 A.M., showing at the start of the shift the off-going nurse found the resident had a wound to the index finger of his/her left hand. The wound was covered and a call was placed to the on-call Nurse Practitioner (NP) and the resident's family member. Orders were obtained to send the resident to the ER for evaluation and treatment. The resident returned with a fractured finger and orders for Antibiotic Therapy (ABT) for an open wound. -A nursing note written at 3:48 A.M., showed the resident was found after the evening meal on 3/7/21 in his/her room. The resident appeared to have gotten his/her finger caught in the wheelchair while propelling to his/her room after supper. The wheelchair was inspected with no findings of anything out of order. Record review of the resident's medical records for his/her emergency room (ER) visit on 3/7/21 showed: -The resident's hospital face sheet showed he/she was admitted for evaluation and treatment on 3/7/21. -The Patient Visit Information, dated 3/7/21 at 9:41 P.M. showed: --The resident was seen for a closed fracture of the tuft (small fragments chipped off the bone edge) of the distal (situated away from the center of the body) phalanx, avulsion (separation of part or all) of nail plate, and avulsion (wound with pulled off or torn away tissue) of soft tissue. Record review of the resident's Incident Investigation, dated 3/8/21 showed: -An injury incident report showing: --The resident was found on 3/8/21 (the hospital medical report showed the resident went to theER on [DATE]) after the evening meal in his/her wheelchair in his/her room. The resident's left index finger had a skin tear to the tip and the nail was coming off. Blood was on his/her wheelchair around the wheel. The resident said he/she got caught. The resident appeared to have gotten his/her finger caught in the wheelchair while propelling himself/herself after the dinner meal. The wheelchair was inspected with no findings of anything out of order. --The resident was oriented to self and had impaired memory. There were no predisposing environmental or situational factors contributing to the incident. -The resident was described as follows: --Severely cognitively impaired with restlessness and agitation, cognitive communication deficit, dementia, and anxiety. --Had behaviors of clenching up and grabbing the wheels of his/her wheelchair tightly. --The resident was unable to be interviewed due to cognition related to dementia. -CNA B's interview showed on 3/8/21 after dinner he/she was getting ready to assist the resident into bed when CNA B noticed blood on the resident's bed rail, wheelchair wheel and on the resident's left hand. CNA B reported the resident propelled himself/herself the evening of 3/8/21. The resident had a behavior when other residents walk past the resident of clenching up in reaction and grabbing the wheels of his/her wheelchair tightly while propelling, causing the wheelchair to stop and jerk. -There were no interventions related to preventing further injury mentioned in the investigation. -The investigation did not indicate if the resident's environment had been assessed for other possible causes of the injury. Record review of the resident's Comprehensive Care Plan, dated 2/12/21 showed: -A Skin Integrity Impairment Care Plan, showed an intervention, dated 3/8/21, Maintenance was to inspect the wheelchair to ensure no repairs were needed. -There were no interventions added to the resident's Physical Therapy and Restorative Aide (Certified Nursing Assistants (CNAs) with specialized training to help residents maintain physical, mental, and emotional well-being) care plan, dated 3/8/21; his/her Activities of Daily Living (ADL - feeding, grooming, transfers) Care Plan, initiated 5/24/17; or on any of the resident's other care plans related to the resident's supervision needs while sitting in or propelling himself/herself in his/her wheelchair. Record review of the facility's incident investigation for the resident's second finger injury, undated, showed: -An incident note showing four points: --The resident was noted on 3/26/21 to have a laceration to the third digit of the left hand. --The root cause was the resident was seen by staff chewing on his/her finger. --There was no documentation on the incident note of who wrote the four points (such as a signature or typed name). -There was no documentation included in the incident investigation that the resident's environment was investigated for other possible causes of the injury or documentation of who witnessed the resident chewing on his/her finger and there were no witness statements. -There was no documentation of the situational details related to the injury such as where the resident was when the injury was found, who else was in the environment at the time, whether or not the finger chewing was a new behavior, and whether or not the environment had been checked for other possible causes of the injury. --The left third digit was initially assessed and described on 4/2/21 as follows: The wound location was the third finger, caused by trauma, and measured 3.2 centimeters (cm) in length by 1.6 cm in width by 0.1 cm in depth. -None of the resident's existing care plans had interventions for immediate measures to prevent further injury or indicated the resident's level of supervision needs while using his/her wheelchair. Record review of the resident's nursing notes, dated 3/26/21 through 4/8/21 showed: -There was no documentation of the third digit injury on 3/26/21. -A note written on 3/29/21 at 2:36 P.M., showed the resident's third digit looked much like the second prior to the amputation. The note did not indicate the circumstances in which they discovered the injury. Observation in the dining room on 4/5/21 at 11:03 A.M., showed: -The resident was sitting at the dining room table with the second and third digits of his/her left hand bandaged. The second digit was short as if amputated. Certified Medication Technician (CMT) A was nearby and said one finger was caught in the resident's wheelchair. -Observation showed the resident's wheels had many thin metal spokes. The spokes of the resident's WC were not covered. Record review of the resident's PT treatment encounter notes dated 4/6/21 and 4/8/21 showed: -The resident was given visual cues for correct hand placement to promote WC mobility with the resident unable to follow, requiring maximum assistance for WC mobility. Record review of the resident's OT note, dated 4/8/21 showed spoke guards were placed bilaterally (both sides) on the WC wheels due to previous incidents of catching left fingers in the WC spokes. Observation and interview in the resident's room on 4/8/21 at 9:55 A.M., showed: -The resident was sitting in his/her room in his/her wheelchair facing away from the bedroom door leaning over the front and right side of the WC with his/her right hand about two or three inches from the WC spokes. -A few minutes later CMT A pivoted the resident's WC to face the bedroom door while the resident was still leaning over the front and right side of his/her chair with his/her right hand, within two or three inches of the spokes. After pivoting the chair to face the door, CMT A lifted the resident's right arm away from the spokes and placed it to where the WC arm would provide support while rolling the resident out of the room. -The resident was placed at the dining room table and was observed to repeatedly place his/her right hand on the right side WC spokes and to also touch the right side of the WC with his/her right hand between the front wheel and the right WC brake handle. Observation on 4/12/21 at 1:19 P.M., showed the resident resting quietly in bed with his/her eyes closed. The wheels were covered with a round piece of clear plastic exposing approximately ½ to 3/4 inch of WC spokes near the wheel rim and approximately 1 ½ inches of the hub of the wheel spokes. The plastic was attached to the WC wheel spokes in three places on each side to the WC. During a telephone interview on 4/7/21 at 12:01 P.M., the resident's legal representative said: -He/She was contacted by the facility a month ago and was told the resident had an accident in which the resident's index finger had been torn. The accident also tore up the resident's index finger nail. -He/She received a second call that there was damage to another finger. -He/She was told the facility thought the resident got his/her hand stuck in his/her wheelchair both times. During an interview on 4/7/21 at 12:32 P.M., LPN D said: It was his/her understanding that Maintenance and Occupational Therapy inspected the resident's wheelchair after the injuries and therapy evaluated his/her ability to safely use the wheelchair. During an interview on 4/7/21 at 12:45 P.M., CMT C said the resident tended to put his/her hands into the WC spokes. When being pushed in the wheelchair, the resident would put his/her hands down towards the wheels. From what was reported to him/her, nobody witnessed the injuries. During an interview on 4/7/21 at 2:15 P.M., CNA B said: -He/She discovered the resident's left index finger the day it was injured. -He/She had seen other residents push the resident in his/her WC. Staff would tell the resident to stop when they saw a resident push another resident's wheelchair. -He/She had not noticed anything sharp or hazardous in the resident's room. -The resident's chair was custom made and had thin metal spokes. Most of the residents' wheelchairs have thicker and fewer plastic spokes. During an interview on 4/7/21 at 2:18 P.M., CMT A said: -Someone in therapy brought the resident's third finger injury to his/her attention. -He/She had never noticed anything sharp or hazardous in the resident's room. -He/She had seen other residents push the resident while he/she was in his/her wheelchair. When that happened, the resident might have had his/her hands down around the spokes or would hold onto the spokes of his/her wheelchair. -Staff were to redirect the residents if they catch a resident pushing someone. During an interview on 4/8/21 at 10:20 A.M., the Maintenance Assistant said: -The wheelchair was examined to make sure there were no sharp areas and it functioned properly and safety after the second finger injury. During a telephone interview on 4/8/21 at 12:11 P.M., the resident's physician said: -Management should document and investigate the accident leading to the injury of the resident's finger. -The investigation of injuries of unknown origin should be thorough so that a cause of the accident could be determined and measures could be put in place to prevent further injury. -Management should follow all Centers for Medicare and Medicaid Services guidelines for investigating injuries. During an interview on 4/12/21 at 2:15 P.M., CMT A said: -The charge nurse asked him/her what happened to the resident's third finger. He/She was not asked to write a statement. -Staff were not told what they should do to prevent another injury. -He/She was not aware of any measures immediately put into place to prevent future injuries following either of the two accidents. The facility staff did recently put plastic disks over the resident's WC spokes. During an interview on 4/13/21 at 1:36 P.M., the Therapy Director said: -Staff talked about the index finger injury in the morning meeting on 3/8/21 and discussed it in the Risk meeting on 3/11/21. The therapy department staff were told by the nursing staff they thought the resident's finger got caught in the WC. -Therapy communicated with a wheelchair company to get the resident new wheels because staff didn't know if the resident was injured on the spokes of the wheels. The plastic spoke cover was installed on 4/8/21. He/She communicated back and forth with the wheelchair company and ordered the new wheels over the phone. -He/She learned about the injury to the resident's third finger in the first morning meeting following the accident. Communication with the wheelchair company occurred before the injury to the resident's second finger. Therapy checked out the resident's WC for safety after the injury to the second finger. It was discussed in the morning meetings that Maintenance would also check out the resident's WC after the pointer finger injury. -There had been no adjustments or additions to the resident's wheelchair prior to the arm rest bolster being added and the wheelchair spoke covers being installed on 4/8/21. The only adaptation to resident's wheelchair had been the bolster and spoke covers. -On 4/9/21 the resident's status changed to hospice services (care given at the end of life). The resident had been on Skilled services when the WC wheels were ordered. Medicaid would not cover the new wheels because the resident was now receiving hospice services and Medicaid services ended on 4/8/21. He/She needed to talk with hospice to see if they would pay for the new wheels or if they could provide other options. -The resident had a custom fit chair. During an interview on 4/14/21 at 11:05 A.M., MDS Coordinator B said: -When there were injuries, the charge nurse was responsible for putting in an immediate intervention. -The injury would be discussed in clinical Interdisciplinary (IDT) meetings for a more permanent intervention. -The IDT Meetings included the Administrator, the Director of Nursing (DON), both ADONs, both MDS Coordinators, Social Services, and the Therapy Director or designee. During an interview on 4/14/21 at 12:37 P.M., LPN B said: -He/She was the resident's nurse both times his/her finger was injured. -The CNA reported the index finger injury. It appeared the resident could have gotten his/her index finger caught in his/her wheelchair. The resident kept putting his/her hand near the spokes before the accident to the index finger. -He/She was not aware of any interventions put in place to prevent further injury. -There were no interventions put in place immediately following the third digit injury to prevent future injury. During an interview on 4/14/21 at 1:35 P.M., the DON, ADON B, and the Corporate Nurse Consultant were interviewed and said the following: -If there was a significant injury such as one resulting in a broken bone, the injury should be charted by the charge nurse electronically under Risk Management. -The charge nurse or ADON should put an intervention in place immediately. The injury should be discussed in the next morning meeting to ensure a more permanent intervention was put in place. Management would review and discuss the injury in their weekly Clients at Risk (CAR) clinical meeting. -An investigation should be started after an unwitnessed injury and used to develop interventions. During an interview on 4/29/21 at 7:16 P.M., the Medical Director said: -He/She would have expected staff to thoroughly investigate any injury, especially one that required a hospital visit. -He/She would have expected the facility to interview staff and identify any possible witnesses to the injury. -He/She would have expected the facility staff to develop and put into place appropriate interventions to prevent additional injuries immediately. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on observation, interview, and record review, the facility failed to ensure a resident who was severely cognitively impaired received Antibiotic Therapy (ABT) as prescribed for an injury to his/her index (second) finger. The resident's index finger became infected with two infections resulting in the need to partially amputate the resident's index finger. Following the amputation, the resident was placed on two antibiotic medications and the facility failed to ensure the resident received the ABT as prescribed or to contact the physician when the resident refused the medication. This affected one resident (Resident #97) out of 22 sampled residents. In addition, the facility failed to ensure two sampled closed record residents (Resident #502 & Resident #512) out of 16 sampled closed record residents, were free from significant medication errors by failing to administer medications as prescribed by the residents' physician. The facility census was 95 residents. The Administrator was notified on 5/27/21 at 12:46 P.M. of an Immediate Jeopardy (IJ) which began on 4/5/21. The IJ was removed on 4/14/21 as confirmed by surveyor onsite verification. Record review of the facility's Administration Procedures for All Medications policy, undated, showed: -Administer medications in a safe and effective manner. -Prior to removing the medication package or container from the medication cart, check the Medication Administration Record (MAR) for the order. -Check the label against the order on the MAR. -If the resident refuses the medication, document the refusal on the MAR and research the reason for the refusal. -Notify the physician for persistent refusals. -Check for vital signs, other tests to be done during/prior to medication administration. -Obtain and record any vital signs or other monitoring parameters orders or deemed necessary prior to medication administration. -Notify the physician if medication was held for pulse, blood pressure, low or high blood sugar, or other abnormal test results, vital signs, resulting in medication being held. Record review of the facility Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -This will ensure that all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -The Medical Records Department will verify that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -A licensed nurse will transcribe orders with date, time and signature of the person receiving the order. -Licensed nurse receiving the order will be responsible for documenting and implementing the orders. -Medication/treatment orders will be transcribed onto the appropriate resident administration record. -Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline. -Documentation pertaining to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Current month's administration records will be maintained in the Medication Administration Record (MAR)/Treatment Administration Record (TAR). 1. Record review of Resident #97's Face Sheet showed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Unspecified Dementia (a condition in which a person has an impaired ability to remember, think, or make decisions that is severe enough to interfere with everyday activities) without Behavioral Disturbance. -Fracture of Unspecified Phalanx (bone) of Left Index Finger, Subsequent Encounter with Routine Healing. -Cognitive Communication Deficit (difficulty communicating related to cognitive issues). -Partial Traumatic Metacarpophalangeal (joint closest to the hand rather than the nail) Amputation of Left Index Finger. -[CONDITION(S)] (a potentially serious bacterial skin infection which can spread rapidly) of Left Finger . -Unspecified Open Wound of Unspecified Finger with Damage to Nail. Record review of the resident's 3/8/21 Progress Notes showed at the start of the shift the off-going nurse found the resident had a wound to the index finger of his/her left hand. The wound was covered and a call was placed to the on-call Nurse Practitioner (NP) and the resident's family member. Orders were obtained to send the resident to the emergency room (ER) for evaluation and treatment. The resident returned with a fractured finger and orders for (ABT) for an open wound. The resident was to get [MEDICATION(S)] (generic for [MEDICATION(S)], an antibiotic) 500 milligrams (mg) twice daily for 14 days. Record review of the resident's medical records for his/her ER visit on 3/7/21 showed: -The resident's hospital face sheet showed he/she was admitted for evaluation and treatment on 3/7/21. -The Patient Visit Information, dated 3/7/21 at 9:41 P.M. showed: --The resident was seen for a closed fracture of the tuft (small fragments chipped off the bone edge) of the distal (situated away from the center of the body) phalanx, avulsion (separation of part or all) of nail plate, and avulsion (wound with pulled off or torn away tissue) of soft tissue. --The resident was to take the prescribed antibiotic [MEDICATION(S)], 500 mg capsule orally twice daily for 14 days. Record review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)], 500 mg tablet two times daily for broken finger, left index finger starting 3/8/21. Record review of the resident's Treatment Administration Record (TAR) for March, 2021 showed orders for: -[MEDICATION(S)], 500 mg tablet two times daily for broken left index finger starting 3/8/21. Documentation for this medication showed: --On 3/8/21 for the 8:00 A.M. administration a 7 was indicated on the TAR. The chart key code showed code showed 7 meant the resident was sleeping. --Spaces for documenting the 3/10/21 morning and afternoon doses of [MEDICATION(S)] and for documenting the morning dose of [MEDICATION(S)] on 3/11/21 were left blank. --Documentation showed the resident received this medication five out of nine opportunities. --Staff documented they gave the 4:00 P.M. dose of [MEDICATION(S)] on 3/13/21 even though a 6 was documented the morning of 3/13/21. The key code for 6 indicated the resident was in the hospital. ---NOTE: Further record review showed the resident was hospitalized on [DATE] and returned to the facility on [DATE]. Record review of the resident's nursing notes for 3/8/21 through 3/13/21 showed: -No documentation by the facility staff why the resident's [MEDICATION(S)] doses on 3/8/21, 3/10/21, and 3/11/21 were left blank or why staff had indicated on the TAR the afternoon of 3/13/21 that the resident was administered [MEDICATION(S)] when record review showed the resident was in the hospital. Record review of the resident's hospital records, dated 3/12/21 through 3/17/21 showed: -The hospital admission History and Physical showed the resident presented to the ER because of a red inflamed left index finger with an avulsion of the left index nail plate and soft tissue avulsion of the pad of the finger. The pad of the finger was blackish brown, concerning of necrosis (dead tissue). The resident was discharged from another hospital on 3/7/21 with orders for [MEDICATION(S)], 500 mg twice daily, but the antibiotic was not given. The left second finger gradually became more erythematous (reddened), painful and swollen. The resident was sent to be seen by the hand surgeon. -The resident was given a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Magnetic Resonance Imaging (MRI - device that uses strong magnetic fields and radio waves to scan the body or body parts and produce images) was being considered to rule out [CONDITION(S)] (a bacterial or fungal infection that requires antimicrobial (kills micro-organisms) treatment and often surgery). -The resident, who is severely demented, presented to the ER due to worsening finger infection after fracturing it in his/her wheelchair (WC) a few days ago. After the initial injury he/she presented to another hospital ER where he/she was diagnosed with a fracture and prescribed [MEDICATION(S)]. Per report the nursing home did not receive this medication and was not giving the resident his/her antibiotic. A large portion of overlying skin around the nail bed was lifted and dangling. The pulp of the finger was hyper-pigmented and had an open wound surrounding the entire nail bed that had purulent (thick yellow, green or brown colored pus) and sanguineous (thin, pale red or pink) drainage. -An operative report, dated 3/14/21 showed: --The resident's injury involved a partial amputation of the tip of the finger. He/She subsequently had increasing redness and drainage from the finger. The patient (resident) presented with a significantly erythematous finger with quite a bit of swelling. He/She seeks revision of the amputation and drainage of any abscess. --The soft tissue of the second digit was amputated and a significant amount of purulence was noted, including the area of the bone. The tissues and bone were consistent with [CONDITION(S)]. Cultures were obtained. Increasing amounts of purulence from the dorsal aspect (back portion) of the finger was noted. As much purulence (a milky or thick green, brown, yellow or white colored drainage with a distinct odor, indicative of infection) material was expressed as possible which extended to about the Proximal Interphalangeal (PIP - second joint from the nail) joint. The bone was quite nauseous. The wound was debrided (a procedure in which damaged tissue or foreign objects are removed from a wound) back to healthy-looking bone, taking the amputation site into the mid area of the middle phalanx. Then the wound was thoroughly irrigated (a process where a steady flow of solution is used across an open wound surface to hydrate and remove debris). The wound was sutured and dressed. -A Discharge Summary, dated 3/17/21 showed: -The resident was admitted for inpatient service for management of finger [CONDITION(S)] and [CONDITION(S)]. -He/She was treated with intravenous antibiotic therapy and was ordered six more days of oral antibiotics and follow up with the physician in plastic surgery in two weeks. -Discharge orders included [MEDICATION(S)], 250 mg every eight hours for six days and [MEDICATION(S)] (an antibiotic used to treat bacterial infection), 100 mg, twice daily for six days. Record review of the resident's nurses' notes, dated 3/17/21 through 3/19/21 showed: -There was no nursing note on 3/17/21 showing the resident had returned to the facility on [DATE]. -On 3/19/21 there was a late entry skin wound note showing the nurse had assessed the resident's left index finger and confirmed the resident had a partial amputation to the left index finger. The area had three stitches and had light serosanguineous drainage (clear, pale red or pink colored drainage). The area was closed and intact with no signs of infection such as odorous drainage, redness or swelling. Record review of the resident's March, 2021 POS showed orders for: -[MEDICATION(S)] tablet, 250 mg. Give one tablet by mouth four times a day for infection of left hand for six days starting 3/17/21. -[MEDICATION(S)], 100 mg. Give one tablet by mouth two times a day for infection for six days starting 3/17/21. Record review of the resident's MAR for 3/2021 showed: -Orders for [MEDICATION(S)], 250 mg. Give one tablet by mouth four times a day for infection of left hand for six days starting 3/17/21. Documentation on the MAR showed: --Blank spaces on 3/17/21 for medication administration times at 4:00 P.M. and 10:00 P.M. --The resident refused the medication on 3/20/21 at 8:00 A.M. --The spaces to document medication administration were left blank on 3/20/21 at 10:00 P.M. and on 3/21/21 at 4:00 P.M. and 10:00 P.M. --On 3/22/21 MAR documentation showed the resident refused the medication at 4:00 P.M. and 10:00 P.M. --The MAR was left blank for the 3/23/21 12:00 P.M. medication administration. --The resident did not receive nine out of 24 opportunities for the ABT, [MEDICATION(S)] 250 mg. -Orders for [MEDICATION(S)], 100 mg. Give one tablet by mouth two times a day for infection for six days. Documentation on the MAR showed: --A blank space on 3/17/21 for the 5:00 P.M. medication administration time. --The resident refused the medication on 3/20/21 at 8:00 A.M. --The MAR space was left blank on 3/21/21 for the 5:00 P.M. administration time. --On 3/22/21 the resident refused the medication at the 5:00 P.M. medication time. --The resident received eight out of 12 doses of [MEDICATION(S)] 100 mg, and missed four out of 12 opportunities for the ABT. Record review of the resident's nursing notes for 3/17/21 through 3/23/21 showed there was no documentation explaining the MAR blanks for the two ABT medications or that the physician had been notified when the resident refused the medications. Observation of wound care in the resident's room on 4/7/21 at 12:32 P.M. showed: -The resident's bandage was off his/her second finger. The finger appeared to have been amputated between the distal (joint closest the nail) and proximal (joint closets the distal joint) joints of the left index finger. During an interview on 4/7/21 at 12:01 P.M., the resident's legal representative said: -He/She was contacted by the facility a month ago and was told the resident's had an accident in which the resident's index finger had been torn. The accident also tore up the resident's index finger nail. -The resident went to the ER and was put on an antibiotic. -Approximately three to four days later he/she received a call from a doctor at the hospital who was following up on the injury. He/She was told there were problems with the resident's finger because the facility forgot to give the resident his/her antibiotic. -While at the facility the index finger became infected and was amputated three weeks ago. During a telephone interview on 4/8/21 at 12:11 P.M., the resident's physician and Nurse Practitioner (NP) said: -He/She expected the resident's antibiotic to be given as ordered. If medications were not given as ordered there was an increased risk of infection. -He/She expected the nurses to monitor for signs and symptoms of infection. -All staff should be following Centers for Medicare and Medicaid Services guidelines related to medication administration and monitoring wounds. --The hospitals had recommended ABT treatment. The resident had orders for ABT and the nurses were responsible for ensuring physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] --They expected physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If there were any problems related to the ABT medications, they expected nurses to notify them. During an interview on 4/8/21 at 10:34 A.M., Assistant Director of Nursing (ADON) B said: -The resident was on [MEDICATION(S)] after returning from the ER following the injury to the second finger and was also on ABT after his/her finger amputation. -Nurses are expected to follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/13/21 at 1:01 P.M., Certified Medication Technician (CMT) A said: -The nurse was responsible for giving antibiotic medications and for ensuring the resident received it. -Antibiotics are kept on the nurses' medication cart. -If the nurse was too busy to give the antibiotic, he/she might ask the CMT to give it. -Antibiotic medication administration should be documented on the MAR like any other medication. -He/She didn't know if the resident missed any of his/her antibiotic medications. -The CMT is supposed to report to the nurse if a resident's medication had not been delivered to the facility, if his/her scheduled medication was missing, or if he/she refused the medication, -He/She didn't know who the nurse reported to regarding any missed antibiotics or other medications. During an interview on 4/14/21 at 12:37 P.M., LPN B said: -The charge nurse is responsible for ensuring the resident received their antibiotic medications. If the medication is not available from the pharmacy it should be taken out of the Emergency kit (E-kit - contains small quantities of medications which can be dispensed when pharmacy services are not available). -Most types of antibiotics were available in the E-kit, including [MEDICATION(S)]. -If a resident refused his/her antibiotic the nurse should report it to the physician. During an interview on 4/14/21 at 1:35 P.M. the Director of Nursing (DON), Assistant Director of Nursing (ADON) B, and the Corporate Nurse Consultant were interviewed and said the following: -If there were holes in the MARs, the ADON should talk to the charge nurse to verify whether or not the resident received his/her medication. There should not be any blank spaces in the MAR. If the medication was refused the refusal can be documented on the MAR. The electronic dashboard should show which scheduled medications were not given and flag it. The charge nurse, ADON and DON could see that it is flagged and the ADON and DON were responsible for monitoring medication administration issues. -The charge nurse was responsible for ensuring antibiotic medications are given as ordered. The nurse should call the physician if an antibiotic was not available or was refused. If an antibiotic was only given half the time it was prescribed and the resident wasn't refusing the medication, it is considered a medication error. -The risk of not giving an antibiotic was that it could result in a potentially worsened infection. It would require the physician to be contacted. The charge nurse should follow up by notifying the physician at the time if a resident's ABT was not available at the facility or was refused. -The ADON and DON were responsible for auditing to ensure medications are administered as ordered. -The physician does rounds at the facility weekly and the Nurse Practitioner is at the facility at least two to three days per week. Physicians can be notified when there are concerns about the residents' medications by telephone or when the physician or Nurse Practitioner are at the facility. 2. Record review of Resident #502's Admission Record dated 4/7/21 showed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Admission MDS, dated [DATE] showed: -The resident was admitted on [DATE]. -Had moderately impaired cognition. -Had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Order Summary Report dated January 2021 showed: -[MEDICATION(S)] Tablet 50 mg, give one tablet in the morning for [CONDITION(S)], start 12/1/20. --Parameters: Hold for Systolic Blood Pressure (SBP-measures the pressure in your arteries when the heart beats) less than 110, Diastolic Blood Pressure (DBP-measure the pressure in your arteries when your heart rests between beats) less than 60 (normal blood pressure is SBP 120 over DBP 80) or Pulse (heart rate (HR) heart beats per minute normal heart rate at rest is between 60-100) less than 60 start 12/1/20. -[MEDICATION(S)] Tablet 50 mg, give one tablet two times a day for [CONDITION(S)], start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. Record review of the resident's MAR dated January 2021 showed: -[MEDICATION(S)] Tablet 50 mg, give one tablet in the morning for [CONDITION(S)], start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. ---The resident's Blood Pressure (BP) and HR were not documented and medication administered 18 out of 31 opportunities. ---The resident received the medication on 1/31/21 when his/her BP of 96/75 was outside of the parameters and the medication was administered one opportunity out of 31 opportunities. -[MEDICATION(S)] Tablet 50 mg, give one tablet two times a day for [CONDITION(S)], start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. ---The resident's BP and HR were not documented and medication administered 17 out of 62 opportunities. ---The resident received medication when BP was outside of the parameters three out of 62 opportunities. Record review of the resident's Administration Note dated 1/14/2, showed the resident did not receive his/her 8:00 A.M. [MEDICATION(S)] Tablet 50 mg due to the medication was unavailable and was on order from the pharmacy. Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Was admitted on [DATE]. -Had moderately impaired cognition, sometimes understood others and made self-understood. -Had Debility Cardio-respiratory Conditions (involves multiple systems and disease). -Had [CONDITION(S)]. Record review of the resident's Order Summary Report dated February 2021 showed: -[MEDICATION(S)] Tablet 50 mg, give one tablet in the morning for [CONDITION(S)], start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60 start 12/1/20. -[MEDICATION(S)] Tablet 50 mg, give one tablet two times a day for [CONDITION(S)], start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. Record review of the resident's MAR dated February 2021 showed: -[MEDICATION(S)] Tablet 50 mg, give one tablet in the morning for [CONDITION(S)], start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. ---The resident's BP and HR were not documented and medication administered 15 out of 28 opportunities. ---The resident received medication on 2/13/21 when BP of 97/58 was outside of the parameters one out of 28 opportunities. -[MEDICATION(S)] Tablet 50 mg, give one tablet two times a day for [CONDITION(S)], start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. ---The resident's BP and HR were not documented and medication administered 21 out of 56 opportunities. ---The resident received medication when BP was outside of the parameters two out of 56 opportunities. Record review of the resident's Care Plan dated 2/8/21 showed: -Avoid taking the blood pressure reading after physical activity or emotional distress. -Give anti-hypertensive medications as ordered. -Monitor for side effects such as [CONDITION(S)] (a systolic blood pressure decrease of at least 20 millimeters of Mercury (mm Hg) or a diastolic blood pressure decrease of at least 10 mm Hg within three minutes of standing) and increased heart rate and effectiveness. -Monitor for and document any [CONDITION(S)] (swelling), notify the physician. -Monitor/document/report as needed (PRN) any signs/symptoms of malignant hypertension (extremely high blood pressure that develops rapidly and causes some type of organ damage), headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, [CONDITION(S)] activity, or difficulty breathing. Record review of the resident's Order Summary Report dated March 2021 showed: -[MEDICATION(S)] Tablet 50 mg, give one tablet in the morning for [CONDITION(S)], start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60 start 12/1/20. -[MEDICATION(S)] Tablet 50 mg, give one tablet two times a day for [CONDITION(S)], start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. Record review of the resident's MAR dated March 2021 showed: -[MEDICATION(S)] Tablet 50 mg, give one tablet in the morning for [CONDITION(S)], start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. ---The resident's BP and HR were not documented and medication administered 1 out of 1 opportunities. -[MEDICATION(S)] Tablet 50 mg, give one tablet two times a day for [CONDITION(S)], start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. ---The resident's BP and HR were not documented and medication administered 1 out of 1 opportunities. During an interview on 4/7/21 at 12:13 P.M., the Nurse Practitioner said: -He/she expected the nurses and CMT to take the resident's blood pressure and pulse before giving the medications. -The nurse or CMT would not know it was safe to give the medication if he/she didn't take the resident's blood pressure and pulse. -Medication should be reordered when the resident had 10 pills left. -No resident should run out of any medication because they were not reordered in time. -He/she should be notified if a medication was not given/held. During an interview on 4/8/21 at 1:30 P.M., ADON B said: -The ADON and DON were responsible to audit to ensure medications were administered per physician orders. -The charge nurse would check the orders for parameters such as blood pressure and pulse, and would contact the physician to verily the parameters. -The charge nurse was responsible to ensure parameters were followed and the resident's physician was notified of any instance the parameters were outside of range. -He/she takes the blood pressure and pulse before administering the medication and documents the blood pressure and pulse on the MAR. -If the blood pressure or pulse was below the parameters, the CMT was to hold the medication and notify the charge nurse. -He/she would not give blood pressure medication if the blood pressure was out of parameters. -He/she was not aware of bad Internet connections on the locked unit. -If the CMT was not entering the blood pressure and pulse into the MAR, the CMT needed training. During an interview on 4/8/21 at 1:45 P.M., CMT A said: -He/she would check the blood pressure first then administer the medication. -He/she would check the MAR to see what the blood pressure parameters were. -He/she would let the nurse know if the blood pressure medication was held due to being out of parameters. -He/she would write the blood pressure down in a note book because the Internet sometimes did not work on the locked unit. -He/She would later enter the information into the resident's electronic medical record or have the nurse enter the information into the resident's electronic medical record. -He/She did not tell anyone of the problem with not being able to document blood pressures in the electronic medical records due to having Internet issues, because he/she thought the DON and administrator already knew about it. -He/She could not explain how he/she was able to document the resident's medication administration in the resident's electronic medical record, but not be able to document the resident's blood pressure in the resident's electronic medical record. -If medication was back ordered he/she would call the pharmacy to check and see where the medication was located and then let the charge nurse know. During an interview on 4/8/21 at 2:00 P.M., LPN C said: -He/she checked the resident's blood pressure and pulse and if out of range he/she would hold the blood pressure medication. -He/she documented on the MAR if the medication was held. -If a resident was low or ran out of a medication he/she would call the pharmacy to make sure they have the order to fill. -He/she would check the E-kit and pull the medication from the E-kit to administer. During an interview on 4/8/21 at 2:50 P.M., CMT B said: -He/she always took the resident's blood pressure and pulse before he/she administered blood pressure medications. -He/she would hold the medication if to low and chart why the medication was held in a progress note. -He/she would notify the charge nurse of the low blood pressure or pulse. -The blood pressure and pulse were documented on the MAR. -He/she looked in the medication cart and medication room to see if the resident's medication has been delivered from the pharmacy. -He/she re-ordered the medications when there was five to seven days left. 3. Record review of Resident #512's Admission Record showed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident Order Summary Report dated November 2020 showed: -Sinement ([MEDICATION(S)]-[MEDICATION(S)]) (a prescription medicine used to treat the symptoms of [CONDITION(S)] ) tablet 25-100 mg, give one tablet three times a day for [CONDITION(S)], start 11/28/20. -[MEDICATION(S)] HCl (a medication used to treat [CONDITION(S)] ) tablet 3 mg, give one tablet three times a day for [CONDITION(S)], start 11/28/20. Record review of the resident's Order Summary Report dated December 2020 showed: -Sinement ([MEDICATION(S)]-[MEDICATION(S)]) tablet 25-100 mg, give one tablet three times a day for [CONDITION(S)], start 11/28/20. -[MEDICATION(S)] HCl tablet 3 mg, give one tablet three times a day for [CONDITION(S)], start 11/28/20. -No new orders for [MEDICATION(S)]-[MEDICATION(S)] Tablet 25-250 mg four times a day for 30 days per the resident's neurologist on 12/30/20. -No new order for [MEDICATION(S)] HCl Tablet 3 mg four times a day per the resident's neurologist on 12/30/20. Record review of the resident's Neurology visit dated 12/30/20 showed: -[CONDITION(S)] still significantly under treated. -Stop [MEDICATION(S)]-[MEDICATION(S)] tablet 25-100 mg three times a day (tripled since mid-December). -Start [MEDICATION(S)]-[MEDICATION(S)] tablet 25-250 mg four times a day for 30 days. -A physicians order to increase [MEDICATION(S)] HCl tablet 3 mg to four times a day. Record review of the resident's Medication Administration Record (MAR) dated December 2020 showed: -[MEDICATION(S)]-[MEDICATION(S)] Tablet 25-100 mg, give one tablet three times a day for [CONDITION(S)], start 11/28/20, missed five doses out of 90 opportunities. --NOTE: the resident's neurologist increased the resident's [MEDICATION(S)]-[MEDICATION(S)] to 25/250 mg four times daily on 12/30/20. No documentation the facility staff transcribed or administered the correct dose on 12/30/20 or 12/31/20. The resident did not get the correct dose eight out of eight opportunities. -[MEDICATION(S)] HCl Tablet 3 mg, give one tablet three times a day for [CONDITION(S)], start 11/28/20, missed four doses out of 90 opportunities. --NOTE: The resident's neurologist increased the resident's [MEDICATION(S)] to 3 mg four times daily on 12/30/20. No documentation the facility staff transcribed or administered the correct dose on 12/30/20 or 12/31/20. The resident did not get the correct dose two out of two opportunities. Record review of the resident's Care Plan last reviewed 12/15/20 showed: -Resident was readmitted to the facility on [DATE]. -At risk for altered comfort related to [CONDITION(S)]. -Administer medications as ordered. -Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in range of motion, withdrawal or resistance to care. Record review of the resident's Neurology visit dated 1/25/21 showed: -Current medications: [MEDICAL RECORD OR PHYSICIAN ORDER] --[MEDICATION(S)]-[MEDICATION(S)] 25/250 mg four times a day. ---Note: Facility MAR reflected he/she was only getting [MEDICATION(S)]-[MEDICATION(S)] 25-1

Based on observation, interview, and record review, the facility failed to provide supervision to prevent elopement for a resident who was identified as a high risk for elopement by the facility for one sampled resident (Resident #1) out of four sampled residents. The resident eloped from the locked dementia unit and went outside the facility on 7/8/20 at 7:40 P.M. and remained outside the facility until 5:00 A.M. on 7/9/20, without the facility staff aware of the resident's whereabouts for nine hours. The resident was found to have swollen legs and bruising on his/her right shoulder, chest, on the back of his/her knees, and the back of his/her right hand and redness to his/her buttocks after being found outside the facility the following morning. The facility census was 105 residents. The Administrator was notified on 7/13/20 at 5:23 P.M. of an Immediate Jeopardy (IJ) which began on 7/8/20. The IJ was removed on 7/13/20, as confirmed by surveyor onsite verification. Record review of the facility's undated Wandering and Elopement Policy showed: -The facility would identify residents at risk for elopement and minimize any possible injury as a result of an elopement. -Nursing and the interdisciplinary team would assess residents upon admission, readmission, quarterly and upon identification of a significant change in condition to determine the resident's risk of wandering and/or elopement. -When a resident was found missing, the charge nurse would call a Code Pink and organize a search. -Facility staff would search areas of the facility, including common areas, bathrooms, showers, and outside areas. -The licensed nurse most familiar with the incident would document in the resident's medical record how the elopement occurred. -The facility would make necessary reports to state agencies. Record review of the facility's undated Elopement Risk Reduction Approaches Policy showed: -Staff were to ensure that residents are able to move about freely while being monitored and remain safe. -Staff were to have a missing resident procedure that included accounting for each resident on a regular basis. -Staff were to accompany wandering residents on their journeys when supervision was required to ensure safety or to encourage a meaningful, alternate activity. Record review of the facility's undated Certified Nursing Assistant (CNA) and Certified Medication Technician (CMT) job descriptions showed the responsibility of checking on residents in their assigned section regularly when working. 1. Record review of Resident #1's hospital Physician's Progress Note, dated 6/5/20, showed: -Had a [DIAGNOSES REDACTED]. -had a history of [REDACTED]. -Had left his/her house and was found wandering around in his/her neighborhood. -Was brought to the hospital by the police. -The family requested the resident to be placed at a long-term care facility as they are unable to care for him/her at home. Record review of the resident's Face Sheet, showed he/she admitted to the facility on [DATE] with the following Diagnosis: [REDACTED].>-[MEDICAL CONDITION] (damage or disease to the brain which can cause an altered mental state, leaving the individual confused and not acting like he/she usually does). -[MEDICAL CONDITION], malnutrition, low potassium, high blood pressure. -Difficulty in walking. -Need for assistance with personal care. -Cognitive communication deficit. -[MEDICAL CONDITION] disorder (a mental condition that causes loss of contact with reality and mood problems). -Dementia. -Major [MEDICAL CONDITION] (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable). -Anxiety disorder. -Low back pain. Record review of the resident's Admission, History and Physical, dated 6/10/20, showed: -Was admitted to the facility due to wandering, altered mental status, and increased memory loss. -Had a [DIAGNOSES REDACTED]. -Was anxious and agitated about being in a medical facility and wanted to go home. Record review of the resident's Wandering Risk Scale, dated 6/10/20, showed: -Was at high risk for wandering with a score of 14 (11 or higher was high risk). -Was ambulatory. -had a history of [REDACTED]. -Had a medical [DIAGNOSES REDACTED]. -Had wandered within the home without leaving the property grounds. -Had wandered in the past month. Record review of the resident's Behavior Note, dated 6/11/20, showed: -Was combative. -Had blocked the door that goes in and out of the locked dementia unit. -Had slammed another resident's wheelchair into the back exit door and pushed the door to try to get out. -Had told healthcare team to shut up, and that it was their fault, he/she was 'going to sue them for keeping him/her in the memory care unit.' -Was able to be redirected. Record review of the resident's Admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff for care planning), dated 6/16/20, showed: -Was admitted to the facility on [DATE]. -Was severely cognitively impaired. -Displayed verbal behaviors one to three days out of the past seven days. -Displayed no physical or other behaviors. -Displayed behaviors that put the resident and others at risk for physical injury. -Displayed behaviors that significantly interfered with the resident's care and participation in activities and socialization. -Displayed behaviors that significantly intruded on others and disrupted care or the living environment. -Did not wander. -Displayed mood symptoms that indicated moderate depression. -Required supervision for most self-cares. -Was occasionally incontinent of bowel and bladder. -Some of his/her [DIAGNOSES REDACTED]. -Did not use tobacco. Record review of the resident's undated exit seeking care plan with the admitted showed: -He/she admitted [DATE]. -The resident was at risk for exit seeking and wandering related to being disoriented to place and had impaired safety awareness with a history of attempts to leave the facility. -Interventions included: --Assess the resident's fall risk. --Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or books. --Identify the resident's pattern of wandering and intervene as appropriate. Record review of the resident's undated memory care unit care plan showed: -admitted [DATE]. -Resided on the memory care unit related to a [DIAGNOSES REDACTED]. -Had the following interventions: --Address the resident by name when giving care and involve the resident as much as possible. --Explain all procedures using terms that the resident can understand. --Monitor the resident per protocol to ensure safety. Record review of the resident's Nurse's Note, dated 6/17/20, showed: -Was exit seeking by trying to go out the back door of the locked dementia unit. -Tried to scratch the staff member who was standing by the back door. -Believed he/she was at the facility because of the police. -Had said Jesus wanted him/her to leave now and that was why he/she was trying to exit out the door. Record review of the resident's Behavior Note, dated 6/27/20, showed: -Displayed increased anxiety and agitation towards staff. -Entered other residents' rooms without permission causing other residents to become upset. -Tried to exit both doors on the locked dementia unit and was redirected by staff. Record review of the resident's facility Skin Check, dated 7/3/20, showed he/she did not have any skin abnormalities (no bruising, rashes, wounds, etc.). Record review of the resident's monthly Physician's Progress Note, dated 7/8/20, showed: -Was oriented to self only. -Was anxious and agitated. -Had poor judgment and insight. -Had [MEDICAL CONDITION] (swelling) in his/her extremities. Record review of the resident's July 2020 Medication Administration Record [REDACTED] -On 7/8/20, the last medication the resident received was at 4:00 P.M. -On 7/8/20, the resident refused [MEDICATION NAME] (dementia medication) 20 milligrams (mg) which was scheduled for 8:00 P.M. Observation of the facility's video footage, dated 7/8/20, showed: -At 7:40 P.M., the resident was seen outside the locked dementia unit at the entrance to the 400 hallway, walked past the nursing station and turned left toward the 500 hall. -At 8:13 P.M., the resident walked by the building from the outside by the end of the 800 hall which is on the opposite end of the building from the locked dementia unit. Record review of Wunderground.com showed the weather on 7/8/20 was: -7:53 P.M. 86 degrees Fahrenheit (F) and 65% humidity. -8:53 P.M. 82 degrees F and 69% humidity. -9:53 P.M. 82 degrees F and 67% humidity. -10:53 P.M. 81 degrees F and 69% humidity. -11:53 P.M. 80 degrees F and 71 % humidity. -There was no precipitation noted. Record review of the facility Midnight Census, dated 7/9/20 1:52 A.M., showed the resident was checked in as present and Registered Nurse (RN) A signed the midnight census for the 300 and 400 locked dementia units. Record review of the facility's Self-Report to the State Agency, dated 7/9/20 at 9:38 P.M., showed the facility reported: -The resident, who resided on the 400 locked dementia unit, was found outside around 5:00 A.M. on 7/9/20. -At the time, it was unknown how the resident got out of the facility. -At the time, it was unknown how long the resident had been outside. Record review of Wunderground.com showed the weather on 7/9/20 was: -12:53 A.M. 79 degrees F and 77% humidity. -1:53 A.M. 76 degrees F and 82% humidity. -2:53 A.M. 77 degrees F and 82% humidity. -3:53 A.M. 78 degrees F and 79% humidity. -4:06 A.M. 77 degrees F and 66% humidity. -4:10 A.M. 76 degrees F and 67% humidity. -4:37 A.M. 70 degrees F and 81% humidity. -4:53 A.M. 70 degrees F and 78% humidity. -There was no precipitation noted. Further review of the resident's undated exit seeking care plan showed: -He/She wandered from the facility on 7/8/20. -There were no new interventions. Record review of the resident's Incident Audit Report, dated 7/10/20, showed: -On 7/9/20 at approximately 5:00 A.M., CNA A asked Assistant Director of Nursing (ADON) A to go with him/her to see if a person sitting outside was one of the facility's residents. -The resident was sitting between the trees. -ADON A notified the Director of Nursing (DON) immediately. -Staff brought a wheelchair out to the resident and returned him/her to the inside of the facility. -Vitals were obtained. -A head to toe assessment was completed. -The family member and nurse practitioner were notified. -The resident reported his/her pain level to be a 4 out of 10 with 10 being the worst pain ever. -The resident had bruises on his/her right shoulder, chest and back of knees and redness to his/her buttocks. -The resident had [MEDICAL CONDITION] 2+ (leaves a slight indentation when a finger is pressed into the skin) his/her left foot and 3+ (5-6 millimeter indentation that takes 10-30 seconds to return to normal after a finger is pressed into the skin) in his/her right foot. During an interview on 7/10/20 at 10:20 A.M., the Administrator said: -The DON called him/her around 5:30 A.M. on 7/9/20 and said the resident was sitting outside. -His/Her understanding was that the resident was smoking. -It wasn't until later in the afternoon of 7/9/20 that he/she realized the resident had been out all night. -The people that lived next door sit in the area where the resident was seen. During an interview on 7/10/20 at 10:20 A.M., the DON said: -They watched the video footage and could see the resident walking at the front of 400 hall, outside the locked area and he/she turned left and headed toward the 500 unit. -There was an alarm sounding on the 400 unit. -An alarm went off in the main dining room at 8:00 P.M. -Staff were looking at the alarm panel. -Staff said they checked out the main dining room door and called maintenance, because they couldn't re-set the main dining room door alarm. -Staff said they checked all residents on the 300, 400 and 500 units and they were all there. -CNA A saw a person outside sitting under a tree near the 900 unit at 11:00 P.M. on 7/8/20 when he/she took his/her lunch break, but it was not uncommon to see people over there. -CNA A then saw the same person sitting outside under a tree near the 900 unit when he/she took out the trash around 5:00 A.M. -CNA A went and got ADON A and they brought the resident in, did an assessment and made sure he/she was alright. -It was 75 degree F outside at the time the resident was found. -Someone had been in earlier on 7/8/20 working on the door alarms. -Staff thought the alarms were not functioning. -He/She notified the Administrator at 5:30 A.M. During an interview on 7/10/20 at 11:15 A.M., the Regional Director of Clinical Services said: -The resident was found with burrs (a seed or dry fruit that has hooks or teeth) on his/her socks. -The resident said he/she was looking for a table near the garage. -The facility staff had found the resident's shoes outside by the 900 hall. -The facility staff found one of the resident's socks to the left of the 900 unit outside the entrance near some bushes. -The facility staff found the resident seated under a tree, far back enough from the front of the building that staff would not be able to see him/her from the front entrance. Observation and interview on 7/10/20 at 11:30 A.M., showed the resident: -Was sitting in the lounge area of the locked dementia unit and a staff member was sitting nearby watching him/her. -Did not remember going outside or anything about the incident. -Had visible bruises of a circular purple bruise on the top of his/her right hand on the 5th finger side and a purple bruise and a lighter purple bruise about 2.5 inches long that wrapped from top side to bottom side of the resident's arm just below his/her wrist. During an interview on 7/10/20 at 3:44 P.M., CMT A said: -He/She worked 7:00 A.M. to 8:00 P.M. on the 400 locked dementia unit on 7/8/20. -He/She left before the resident eloped. -The resident was always trying to get out and would say he/she wanted to see his/her family. -He/She tried to distract him/her when the resident was anxious. -When he/she left on 7/8/20, the resident was sitting near another CNA and the resident was saying he/she was going to get out of here. -Sometimes the doors on the 400 hall got stuck and maintenance would fix them. Record review of CMT A's time sheet showed he/she clocked out at 7:38 P.M. on 7/8/20. During an interview on 7/10/20 at 3:50 P.M., the Maintenance Director said: -To enter the 400 locked dementia unit, one needed to push the button on the wall to the right of the door to deactivate the alarm and unlock the door. -To exit the unit, one entered the numeric code on the keypad panel to the right of the door inside the unit to deactivate the alarm and release the door. -The secured door (magnetically locked) onto the 400 hall could be opened if the push bar on the door was depressed for 15 seconds or more. -The door could be opened, but the door alarm would be activated. -Someone would need to silence the door alarm for it to stop sounding. -If the door was opened and held in place with the door magnets attached to the walls (such as when someone was taking in large objects into the unit like dietary and/or laundry carts, etc.), the alarm would sound the entire time the door was held open. -There were no records of activation of any door alarms as those alarms were not connected to the computer system/alarm company. -If a door alarm sounded, staff would get on the overhead intercom system and ask staff to address the alarm that was sounding. -Staff were to go to the area involved and assess the situation, and were to try to determine why the alarm was sounding. -If unable to determine why the alarm had sounded, staff would be expected to verify the presence of each resident within the building to ensure no resident had eloped (left the facility without letting staff know). -Two staff were expected to walk the perimeter of the building (one going right, the other going left) to determine if any residents had exited the building. -Staff would come back inside, findings were to be documented and the facility management notified. -If a resident was missing from the facility and hadn't been found, staff were supposed to notify the police. During an interview on 7/10/20 at 4:08 P.M., CNA E said he/she: -Worked 2:00 P.M. to 10:00 P.M. on 7/8/20 on the 300 unit. -Heard a door alarm sounding. -Found it was the alarm on the main dining room door that was going off. -Called the Maintenance Director at 8:05 P.M. to see if he/she could shut the door alarm off and he/she told him/her how to re-set it. -Was told a perimeter search was done but doesn't know who did it. -Waited further instructions from the charge nurse but was not given any. -The 400 doors to the facility locked unit had been malfunctioning. -On 7/8/20, when he/she pushed the 400 door, the alarm sounded but opened without a 15 second delay, he/she had reported this to the charge nurse. Record review of the resident's Incident Note, dated 7/10/20 at 4:55 P.M., showed: -DON, Administrator, family member/responsible party notified. -The incident was not described. -A head to toe assessment was completed on the resident and the resident was assessed for any injury. -Injuries were not identified on assessment. -A skin check was completed. -The results of the skin check were not identified. -The resident returned to the unit under constant observation or one-on-one. -The investigation continued. -The resident's family member was kept up to date on the investigation. -The resident's spouse was also in a skilled facility, the family chose to move the resident to the facility where the spouse was located. During an interview on 7/10/20 at 5:03 P.M., CMT B said: -The door alarms kept going off on 7/3/20 and it was getting annoying. -He/She reported the door problem to the Maintenance Manager then. -The door alarm was messing up on 7/7/20. -The 400 door wouldn't stick on 7/7/20 and wasn't closing. -He/She was passing medications on the 300 hall around 8:00 P.M. on 7/8/20. -At 8:17 P.M., CNA D from 500 hall said the door in the dining room was going off, so he/she did a head count on 300 hall and they were all there. -He/She asked CNA I to count the residents on the 400 unit. -He/She was not instructed to do a perimeter sweep. -He/She went on the 400 unit at some time after the alarm was sounding and no staff were on the 400 unit. -He/She asked RN B where CNA I was and RN B said he/she was on a break. -400 unit cannot be left unattended by staff. -CNA I was in and out of 400 unit and no one else was on the unit. During an interview on 7/10/20 at 5:25 P.M., RN B said: -Worked the day and evening shift on the 300 unit and half of the 400 unit on 7/8/20. -There was an electrical issue that resulted in the fire doors remaining shut. -Had passed medications on the 300 unit behind the closed fire doors when he/she heard some type of alarm. -Sent CNA E to find out what the alarm was. -CNA E found the dining room alarm was going off. -CNA E called the Maintenance Director to find out how to turn the alarm off. -CNA D did a head count on the 500 unit and all of the residents were there. -Had thought CMT B did the head count on the 400 locked dementia unit, because CMT B walked back onto the 400 unit. -Asked CNA D if a perimeter sweep was done and CNA D said it was, but did not say who did it. -Did not know who did the perimeter sweep. -CNA I came off of the 400 unit after the alarm went off and went for his/her break. -Assumed the 400 unit staff did their rounds on the unit. -He/She would expect the staff to do their rounds and physically see the residents. -The resident was aggressive, combative and is constantly trying to push the 400 unit doors open. -The resident tried to go out a window once. -Did not know how the resident got out off of the 400 locked dementia unit and out of the building. During an interview on 7/10/20 at 5:50 P.M., the DON said he/she was told that CNA D, CNA E and CMT B did a perimeter sweep. During an interview on 7/10/20 at 6:00 P.M., CNA A said he/she: -Worked on the rehab side of the facility on the night shift of 7/8/20 into the morning of 7/9/20. -Left for his/her lunch break around 11:00 P.M. -Saw a person wearing a mask who was sitting between a tree and a bush on the ground between the facility and the housing next door. -There were always people from the housing area next door outside on the lawn or outside smoking. -The person seemed fine and he/she had not seen the person before. -Had left the property. -Had turned in a different entrance when he/she returned to the facility. -At about 5:00 A.M., he/she was taking the trash out and he/she saw the same person in the same clothes, sitting in the same place and sitting in the same position. -The person had one sock on his/her left foot and none on his/her right foot and no shoes. -Asked the person his/her name and he/she responded that he/she was taking a break. -Asked the person his/her name again and he/she said it was none of his/her business. -Went inside the facility and asked ADON A to come with him/her to see if the person was one of their residents. -ADON A identified the person as Resident #1 who resided on the 400 locked dementia unit. -Reached his/her hand out and the resident was able to pull himself/herself up, the resident was able to stand fairly well with swollen legs. -ADON A had brought a wheelchair to the resident and took him/her inside. -Took the resident's vitals, wrote them down and gave them to ADON A, while the nurses assessed the resident. -Had not heard any door alarms sounding during his/her shift. During an interview on 7/12/20 at 11:27 A.M., CNA G said: -He/She worked the evening shift on 7/8/20 on the 500 unit with CNA D. -He/She usually worked on the other side of the building on the rehab unit. -The fire doors wouldn't attach to the magnets to keep them open. -He/She didn't hear any alarms go off on that evening. -He/She heard one of the 400 unit CNAs tell RN B about something after dinner, but he/she didn't hear what it was. -Then RN B asked him/her and CNA C and one other staff member (didn't know their name) to look around outside for any residents. -They walked around the whole building after dinner and no residents were found outside. -He/She was not familiar with the resident. -He/She rounds on the residents who are incontinent and need to be checked. -The other residents use their call lights if they need something. During an interview on 7/12/20 at 11:48 A.M. Licensed Practical Nurse (LPN) A said: -He/She worked the evening shift on the 500 hall on 7/8/20. -CNA D said the main dining room alarm went off that evening. -CNA D said he/she checked his/her hall, which was the 500 hall to see if all the residents were there and they were. -He/She was new there and didn't know how often rounds were usually done. During an interview on 7/13/20 at 1:00 P.M., the DON said he/she could not provide orientation paperwork on LPN A as he/she had not turned it in yet. During an interview on 7/12/20 at 11:57 A.M., CNA J said: -He/She worked on the 400 locked dementia unit from around 2:00 P.M. and left around 7:00 P.M. on 7/8/20. -The doors were fine and were not alarming when he/she left. -The resident was asking if he/she could go home. -He/She explained to the resident why he/she could not go home. -He/She re-directed the resident when he/she says he/she wants to go home. -He/She gave the resident some gloves and towels before he/she left, so the resident could wipe off the tables to keep the resident busy and distract him/her. -He/She told CNA I the resident would mess with the doors and told him/her to re-direct the resident and keep him/her busy with things like folding clothes. Record review of the facility timeclock, dated 7/28, showed CNA J left at 6:56 P.M. During an interview on 7/12/20 at 12:38 P.M., CNA I said: -He/She worked 2:00 P.M. to 10:05 P.M. on 7/8/20. -He/She did not initially have an assigned hall. -He/She floated between halls for about the first hour and then ended up staying on the 400 locked dementia unit for the rest of his/her shift. -He/She doesn't usually work on the 400 locked dementia unit. -He/She heard a bath aide say to CMT A that the 400 door was messing up again. -The last time the 400 door was messing up, the door wouldn't latch so the alarm would sound even if it was shut and the door alarm would just keep going off. -He/She heard something about the main dining room door going off that night, but the nurse took care of it so he/she didn't really know anything about it. -CNA J and CMT A were on the 400 locked dementia unit with him/her earlier in the shift. -CNA J left around 7:30 P.M. -They are supposed to do rounds every two hours. -He/She did rounds. -He/She talked to the DON and knows the resident was seen on video off of the 400 locked dementia unit around 8:00 P.M. -He/She remembers he/she had just put another resident to bed before leaving and the resident was trying to walk with him/her. -He/She thought he/she saw the resident sitting at the table in front of the fan on the 400 unit messing with plastic wrap on a cookie when he/she left the facility. -He/She could not explain why the facility video showed the resident outside at 8 :00 P.M. -The resident does wander. -The resident tried to go into other resident's rooms. -The resident thinks he/she was going to California. -The resident asked how to get out and tried to push on the door and they would have to try to distract him/her. -He/She gets most of the residents in bed on the 400 unit before leaving for the evening. -CMT A left around 9:00 P.M. Record review of the facility time clock, dated 7/8/20, showed CNA I clocked out at 10:00 P.M. During an interview on 7/12/20 at 12:59 P.M., RN A said: -He/She worked at the facility two shifts per week and had only worked at the facility for two weeks. -He/She was trained on the rehab unit and on the 500 unit. -He/She was not trained on the 300 or 400 unit. -He/She didn't know the residents on the 300 or 400 unit. -He/She worked the night shift and was responsible for the 300 unit and the even rooms on 400 unit, which was about 40 residents (this included Resident #1). -He/She came in at 10:00 P.M. -He/She was told the fire alarm went off that morning, so all the magnets were not working resulting in all of the fire doors remaining closed. -He/She didn't hear any alarms go off that night. -He/She spent most of the night on 300 unit and went on 400 unit once to give a resident a pill. -He/She didn't look to see what staff were on the 400 unit. -There was a CMT scheduled on the 400 unit, so he/she stayed on the 300 unit. -He/She relied on the 400 unit being a locked unit with two scheduled staff working on the unit. -He/She expected the staff to round every two hours and check on all residents. -LPN B gave him/her the resident roster and told him/her to do census on his/her side. -He/She had not seen other staff go room to room looking to see if the residents were there when marking midnight census. -He/She thought checking the midnight census was a billing thing and that it meant checking to see if there were any residents on the list that went out to the hospital or were discharged . -He/She did not think doing the midnight census was an actual head count. -He/She completed the midnight census that night, but not by doing an actual head count. -No one on the night shift that night said anything about a door alarming. -There was a resident on the 300 unit who was trying to get out the door at the end of the hall that he/she had to keep re-directing. During an interview on 7/12/20 at 1:49 P.M., LPN B said: -He/She worked from 10:00 P.M. on 7/8/20 to 6:00 A.M. on 7/9/20 and was assigned to the 500 unit and to the odd number rooms on 400. -The main dining door alarm happened before he/she got there. -The facility tested the alarms and they were working. -The fire doors were closed. -CNA K and CNA L were the CNAs on night shift on the 500 unit. -CNA C and someone else (he/she didn't know who) were the CNAs on the 400 locked dementia unit. -The resident who left the building was not on his/her side of the 400 hall. -The CNAs were supposed to do rounds every two hours. -He/She did his/her side of the midnight census (500 and 400 odd numbered rooms) and RN A did his/her side (300 and 400 even numbered rooms). -For the midnight census, he/she went back and checked to see if everyone was there and looked for anything different from what was on the census sheet, like if a resident changed rooms or was in the hospital. -All the residents in his/her area were present that night. -RN A was on the 300 unit most of the shift. -He saw RN A go on the 400 locked dementia unit once, possibly to give a resident medication. -No alarms went off while he/she was there that night. -There's a panel at the nurses' station and it did not indicate any doors were open. -It was a quiet night. -The resident had followed people off of the locked unit before. -The resident would say he/she wanted to go home and staff re-directed him/her. During an interview on 7/12/20 at 2:18 P.M., Dietary Aide A said: -He/She heard an alarm going off in the dining room around 7:00 P.M. -He/She didn't know why the alarm was sounding. -The alarm was still going off around 8:00 P.M. -Dietary staff closed the kitchen doors around 8:00 P.M. and he/she could no longer hear the alarm after the doors were closed. -No one announced any type of code to indicate the reason the alarm went off. During an interview on 7/12/20 2:24 P.M., the Cook said: -He/She heard alarms while he/she was in the kitchen when cleaning up after dinner. -He/She looked at the door in the dining room and the door in the hall by the dining room and they were closed. -A code was not announced overhead to indicate any type of alert they needed to respond to and no one asked them any questions about the alarm. -The alarm was going off for a long time. During an interview on 7/12/20 at 6:23 P.M., ADON A (ADON of the Express Recovery Unit (rehab) ERU) said: -He/She worked as the charge nurse on the rehab side of the facility from 6:00 P.M. on 7/8/20 to 6:00 A.M. on 7/9/20. -He/She didn't hear any alarms all night. -He/She was at the front of the building when CNA A came and asked him/her to see if the person he/she saw outside on the curb was one of their residents. -CNA A said he/she saw this person earlier when he/she left for his/her break around 11:00 P.M. and this person was in the same place as he/she was earlier. -He/She saw the person outside and knew it was one of their residents. -He/She asked the resident his/her name and the resident did not want to tell him/her

Based on observations, interviews, and record reviews, the facility failed to provide effective interventions to prevent the development of pressure ulcers (PU) (localized areas of tissue damage or necrosis (death) that develop because of pressure over a bony prominence), for a newly admitted resident when Resident #69 developed an unstageable (Injuries that include full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue that is yellow, tan, gray, green or brown) and/or eschar (dead tissue tan, brown or black in the wound bed ), PU to his/her left ankle and a Stage II (an area of partial thickness, loss of tissue presenting as a shallow open ulcer with a red pink wound bed, without slough), PU to his/her right buttock when facility staff failed to ensure treatment was provided for the Stage II PU's resulting in the resident being admitted to the hospital with [REDACTED]. Additionally, staff failed to communicate, document, asses, and obtain treatment orders for both newly identified PU's when the new PU's were first identified. The facility census was 107. 1. Review of the facility's policy titled PU/Prevention revised February 2019, showed: -Purpose: To identify residents at risk for skin breakdown, implement measures to prevent and/or manage PU and minimize complications; -The facility will identify residents at risk for PU and provide care and services to promote the prevention of PU development; -The Licensed Nurse will complete a Braden (a tool to identify risk of developing PU) Assessment upon admission and quarterly to identify residents at risk for skin breakdown; -If a resident is identified as having a wound upon admission, findings will be documented on the admission assessment and a Wound Monitoring Record ( tool used by the facility) will be implemented; -If a resident is identified as having a wound at any time other than admission, the Wound Monitoring Record will be implemented; -A Wound Monitoring Record will be implemented for each identified wound; -The Licensed Nurse will develop a care plan specific to the resident's risk factors; -Certified Nurse Aides (CNA) will inspect the resident's skin during activities of daily living (ADL)'s care and report unusual findings to the Licensed Nurse; -CNA's will complete body checks on resident's shower days and report unusual findings to the Licensed Nurse; -The Licensed Nurse will document effectiveness of PU prevention techniques in the resident's medical record on a weekly basis. Review of Resident #69's admission progress note dated 1/30/20, showed: -admitted for [DIAGNOSES REDACTED]. -Scab to left calcaneus (heel) scab to both lower extremities and bruising to upper extremities. Review of resident's Resident Data Set (RDS) (an assessment tool used by the facility) dated 1/30/20, showed: -admitted [DATE]; -Reason for admission compression fracture; -Skin conditions/wounds: scab to back of right hand and upper extremity, left heel: scab to left ankle and lower extremity; -No PU; -At risk skin care plan left blank. Review of the resident's admission Braden skin assessment dated [DATE], showed: -Score of 14 which indicated the resident was a moderate risk of developing a PU. Review of resident's physician admission progress note dated 1/31/20, at 9:47 A.M., showed: -Face to face encounter; -Recent hospitalization for a fall with compression fracture; -Skin intact no sores [MEDICAL CONDITION] or rash noted. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 2/5/20, showed: - Severe cognitive impairment; - Extensive assist of two staff for bed mobility, transfers, dressing and hygiene needs; - Indwelling catheter (a tube going into the bladder to drain urine); - Frequently incontinent of bowel; - At risk for PU; -No unhealed PU - [DIAGNOSES REDACTED]. Review of the resident's Braden dated 2/20/20, showed: -Score of 13 which indicated the resident was a moderate risk of developing a PU. Review of the resident's shower sheets for February 2020, showed: -2/1/20, staff documented random bruising all over; -2/9/20, staff documented redness to groin; -2/15/20, staff documented no skin concerns identified; 2/23/20, staff documented no new skin issues and the charge nurse signed the shower sheet which indicated the resident had no new skin issues; -2/26/20 staff documented very confused refused shower. Review of the resident's care plan, revised on 3/9/20, showed: - Extensive staff assistance with activities of daily living (ADL)s; -Skin inspection daily with cares and on bath days; -On [MEDICATION NAME] (antibiotic) related to wound infection; -The care plan did not include interventions for wound care or indicate the resident was at risk for PU development. Review of the resident's medical record from 1/30/20, thru 3/8/20, showed:-No documentation of a PU to the resident's left ankle or right buttock. Review of the resident's physicians' order sheet (POS) for March 2020, showed: -Start date 3/9/20, Cleanse wound to left outer ankle with normal saline or wound cleanser pat dry calcium alginate ( a highly absorbent, biodegradable dressing derived from seaweed) to wound bed cover with dry dressing every day shift and as needed. -Start date 3/9/20, [MEDICATION NAME] tablet 650 milligrams ( mg ) give one tablet orally two times daily for wound infection; -Start date 3/10/20, Heel raiser (foam protector) to both lower extremities to promote wound healing; -Start date 3/10/20, Barrier cream to buttock every shift and as needed to promote skin integrity. Review of the resident's shower sheets for March 2020, showed: - Staff documented no showers provided. Review of the resident's skilled nurses' notes dated 3/8/20, at 1:27 A.M., showed: -The charge nurse documented no changes in skin integrity. Review of the resident's skilled nurses' notes dated 3/8/20, at 4:15 P.M., showed: -LPN B charted no changes in skin integrity. Review of the resident's skilled nurses' notes dated 3/9/20, at 12:09 A.M., showed: -The charge nurse documented no changes in skin integrity. Review of the resident's skilled nurses' notes dated 3/9/20, at 11:15 A.M., showed: -The charge nurse documented no changes in skin integrity. Review of the resident's nurses' notes dated 3/8/20 and 3/9/20, showed: -No documentation that facility staff notified the responsible party of the newly identified PU's. Review of the resident's skilled nurses' notes dated 3/10/20, at 4:12 P.M., showed: -Registered Nurse (RN) A documented no changes in skin integrity Review of the resident's skilled nurses' notes dated 3/10/20, at 11:39 P.M., showed: -The charge nurse documented no changes in skin integrity. Observation and interview on 3/11/20, at 10:44 A.M., CNA A and CNA C entered the resident's room to provide incontinent care and they did and said the following: -Removed the resident's brief, provided perineal care, then rolled the resident onto his/her side; -The resident's right buttock showed an open area with a dark brown and crusty material indicative of eschar that was approximately 0.4 centimeters (cm) by 0.4 cm; -Both staff said they first discovered the area on the resident's right buttock on 3/8/20; -They also identified a PU to the resident's left ankle on 3/8/20; -Both of these skin changes were identified when they assisted the resident with a shower; -On 3/8/20, they verbally reported these new findings to LPN B; -After providing a shower staff should complete a shower sheet which should include newly identified skin concerns; -A shower sheet was not completed on 3/8/20. Observation on 3/11/20, at 11:00 A.M., the resident lay in his/her bed and Licensed Practical Nurse (LPN) C did the following: -Entered the resident's room and informed the resident that he/she planned to change the dressing to his/her left ankle; -There was a foul odor in the room; -He/she attempted to remove a [MEDICATION NAME] (elasticized tubular bandage) from the resident's left ankle; -The resident yelled out in pain; -LPN C informed the resident that he/she would inform LPN B that he/she required pain medication and he/she would return after the medication had been administered. Observation on 3/11/20, at 11:08 A.M., LPN B entered the resident's room and administered an [MEDICATION NAME] (medicines that are used to relieve pain) medication as the resident lay in his/her bed. During an interview on 3/11/20, at 11:15 A.M., the Assistant Director of Nursing (ADON) said: -He/she was not aware that the resident had an unstageable PU to his/her left ankle; -He/she was not aware that the resident had an open area to his/her right buttock; -The last skin report he/she had for Resident # 69 was related to his/her left heel; -When staff identify a new skin issue the charge nurse should assess the area, measure, inform the physician to obtain treatment orders, inform him/her, start a wound monitoring record and document his/her interventions and findings; -He/she reviewed the resident's electronic medical record and LPN B did not complete the required documentation. Review of the resident's medical record on 3/11/20, at 11:25 A.M showed: -No assessment to include measurements or new treatment orders on 3/8/20, for the unstageable PU to the resident's left ankle; -No assessment to include measurements or new treatment orders on 3/8/20, for the open area to the resident's right buttock; -No measurements on 3/9/20 or 3/10/20, for the unstageable PU to the resident's left ankle; - No measurements on 3/9/20 or 3/10/20, for the open area to the resident's right buttock. -No documentation staff did a new Braden skin assessment on 3/8/20 when the new skin issues were identified. Observation and interview on 3/11/20, at 11:40 A.M., LPN C did and said the following as the resident lay in his/her bed: -Said he/she is the wound nurse; -He/she entered the resident's room and informed the resident that he/she planned to change the dressing to his/her left ankle; -There was a foul odor in the room; -The linen under the resident left ankle was soiled with a large amount of serosanguineous (term used to describe discharge that contains both blood and a clear yellow liquid known as blood serum) drainage; -LPN C removed the saturated [MEDICATION NAME] stocking and gauze dressing dated 3/10/20, from the resident's ankle and the foul odor significantly increased; -The unstageable PU to the resident's left ankle was approximately the size of a tangerine and 80 % of the wound bed was covered with slough with eschar present with redness noted around the wound; -LPN C cleaned the wound with wound cleanser and applied calcium alginate to the wound bed and secured a clean gauze dressing; -Said the unstageable PU to the ankle was identified on 3/8/20, and he/she provided wound care on 3/9/20; -Said he/she notified the physician on 3/9/20, and obtained treatment orders and the resident was started on [MEDICATION NAME]; -On 3/9/20, he/she did not document measurements of the wound because he/she did not measure either PU on 3/9/20; -He/she should have measured the unstageable PU on 3/9/20; -Said he/she was not aware the resident had an open area on his/her right buttock; -Said he/she will asses the area now and LPN C and CNA A removed the resident's brief and rolled the resident onto his/her side; -Said the resident had an open area that contained eschar; -Said any wound with eschar is considered an unstageable wound. Review of the resident's Skin Check dated 3/11/20, at 12:39 A.M., showed: -LPN C documented new skin injury/wounds identified; -Wound type pressure; -PU noted to left ankle, PU to right buttock; -Scab noted to right buttock redness noted on left hip blanches no open area noted. Review of the resident's nurses' notes dated 3/11/20, at 12:43 P.M., showed: -Nurse Practitioner notified orders implemented to promote healing verbal consent obtained for the resident to followed by outside wound care team. Review of the resident's nurses' notes dated 3/11/20, at 4:40 P.M., showed: -Resident has increased pain to wound on left ankle requested pain medication for the resident prior to the treatment being done. Dressing saturated from drainage foul odor present. Area on buttock small scab noted origin unknown unable to determine depth due to scab. Stage II PU noted to right buttock approximately 0.8 cm by 0.5 cm. Review of the resident's temperature recorded on 3/12/2020, at 8:16 A.M., showed: -Temperature of 101.3 degrees Fahrenheit (F ) (normal range 97.7 to 99.5 F). Review of the resident's Skin and Wound Evaluation dated 3/12/20, at 9:18 A.M., showed: -Facility acquired Stage II PU to right buttock; -Area less than 0.1 cm length 0.4 cm, width 0.3 cm, wound bed [MEDICATION NAME] (outer layer of tissue) 80% wound covered, slough 20 % wound filled, no evidence of infection, light exudate (fluid) . Review of the resident's Skin and Wound Evaluation dated 3/12/20, at 9:24 A.M., showed: -Facility acquired Unstageable PU to left ankle with slough/eschar area 36.7 cm, length 11.7 cm, width 6.2 cm, slough to 70 % of wound bed eschar 30% of wound filled; -Evidence of infection increased drainage, pain, redness and inflammation, moderate exudate [MEDICAL CONDITION] (drainage that is a combination of serous (clear)drainage and pus indicative of infection), strong odor; -Painful facial grimacing, tense, and troubled; During an interview on 3/12/20, at 10:20 A.M., the resident lay in his/her bed and said the following: -He/she feels very ill and feels like he/she may die; -The resident then began to curse. Observation and interview on 3/12/20, at 12:25 A.M., LPN C did and said the following as the resident lay in his/her bed: -Entered the resident's room and attempted to inform the resident that he/she planned to change the dressing to his/her left ankle; -The resident was slow to arouse and appeared to be lethargic ( a state of tiredness, weariness, fatigue, or sluggish); -Additional staff were called to the room to arouse the resident and obtain vitals signs; -LPN C Removed the [MEDICATION NAME] stocking and gauze dressing from the resident's ankle and the foul odor significantly increased; -Redness was noted from the resident's toes half way up the resident's leg; -The unstageable PU to his/her left ankle was approximately the size of a tangerine and 90 % of the wound bed was covered with slough with a moderate amount of [MEDICAL CONDITION] drainage noted; -LPN C reapplied a clean dressing and said the resident's condition has deteriorated and they plan to send the resident to the hospital. During an interview on 3/12/20, at 12:37 P.M., LPN B said: -On 3/8/20, CNA A and CNA C informed him/her that the resident had a reddened area to his/her left ankle; -He/she does not recall CNA A and CNA C informing him/her that the resident also had an open area to his/her right buttock; -He/she did not provide a treatment to the resident's buttock on 3/8/20; -On 3/8/20, he/she obtained a verbal treatment order for the resident's left ankle but failed to write the verbal order in the resident's medical record; -When a new skin issue is identified staff are expected to complete the necessary documentation and report their findings to LPN C and the ADON; -He/she should have measured the PU to the resident's left ankle on 3/8/20, and documented the findings; -He/she should have completed a new Braden skin assessment on 3/8/20; -He/she left notes for the ADON and the wound nurse. During an interview on 3/12/20, at 4:30 P.M., LPN C said: -Initially he/she staged the PU on the resident's right buttock as an unstageable PU because of the eschar but the resident's nurse practitioner assessed the PU and staged it as a stage II PU. During an interview on 3/12/20, at 5:35P.M., LPN B said: -The resident was admitted with osteomylitis (an infection of the bone, a rare but serious condition). During an interview on 3/12/20 at 3:25 P.M. RN A said: -He/she was the charge nurse on 3/10/20; -He/she was unaware that the resident had an unstageable PU to his/her left ankle; -He/she was unaware that the resident had PU to his/her right buttock. During an interview on 3/12/20, at 2:15 P.M., the Director of Nursing (DON) said: -The goal is to implement measures before a resident's skin breaks down or developes a PU; -When a resident has a change in skin condition or when there is a sign of skin breakdown there are several things that need to be done to provide treatment and promote healing; -Nursing should do a thorough skin assessment, obtain treatment orders, document the information, and she expects the charge nurse to report these changes to the ADON and wound nurse; -A foul odor from a wound can be indicative of infection; -A Braden skin assessment should be done on admission and when there is a change in the resident's skin; -When a nurse receives a treatment order she expects the nurse to enter the new order into the electronic system.

Based on observation, interview, and record review, the facility failed to ensure staff provided indwelling urinary catheter (a sterile tube inserted into the urinary bladder to drain urine) care in a manner to prevent infection or the possibility of infection when they did not clean all areas soiled with fecal material, did not cleanse the catheter or the perineal area, did not change gloves and wash their hands after performing dirty tasks and before performing clean tasks, did not use a clean field to empty the urinary drainage bag, did not cleanse the urinary drainage bag port with alcohol after emptying the bag, failed to secure the urinary catheter to prevent tension and possible dislodgement of the catheter and did not assure catheter tubing did not come in contact with the floor for two of of 21 sampled residents (Resident #75 and #76) who had a urinary tract infection [MEDICAL CONDITION] and a history of urinary tract infections. Staff also failed to begin administration of an antibiotic ordered on [DATE], to treat a UTI which resulted in a worsening condition of the resident who was sent to the hospital with [MEDICAL CONDITION] (a systemic infection caused by an infection being left untreated.) The facility census was 100. Review of the facility's Indwelling Urinary Catheter policy, dated 1/2/14, showed: - Cleanse hands and put on gloves. - Wash the perineal area. - Wash area around catheter insertion site and then wash from urethra downward to the body; include all perineal skin folds; manipulate and cleanse all perineal skin folds. - Cleanse the proximal 1/3 of the catheter wash and rinse away from the insertion site. - Empty the catheter drainage bag at least every eight hours. - Remove gloves and cleanse hands. Review of the facility's Hand Hygiene policy, dated 2/15/18, showed: - Handwashing includes washing with soap and water when hands are visibly soiled and use alcohol based hand rub for routine decontaminations by all staff. - Purpose: To improve hand hygiene and reduce the transmission of pathogenic microorganisms. - Perform hand hygiene before resident care, before an aseptic (clean) procedure, after contact with blood or other body fluids, after resident care, and after contact with a resident's environment. 2. Review of Resident #75's care plan, dated 5/3/18, showed: - Bowel incontinence which required extensive assist with toileting; - Provide perineal care after each incontinent episode; - Urinary catheter for [MEDICAL CONDITION]; - Catheter care every shift and as needed; - Monitor for signs and symptoms of a UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. Review of the significant change in condition Minimum Data Set (MDS), a federally mandated assessment completed by the facility, dated 5/16/18, showed: - A brief interview of mental status (BIMS) score of 11 which indicated poor decision making, supervision needed in making decisions; - Extensive assist of two or more staff for toileting; - Indwelling catheter; - [DIAGNOSES REDACTED]. Review of the CAAS (Care Area Assessment, used to direct areas that need a plan of care), dated 5/17/18, showed: - Frequent bowel incontinence; - Assistance needed with toileting; - Indwelling urinary catheter; - Frequently incontinent of bowel. Review of a urine culture and sensitivity (C & S, a test to determine the organism that causes a UTI and the antibiotic to treat the UTI) dated 5/19/18 showed: - Colony count greater than 100,000 colony forming units (CFU)/ milliliter (ml) of urine which indicated a UTI; - Sensitive to [MEDICATION NAME] (an antibiotic). - There was no order found in the medical record for [MEDICATION NAME] that NP A said he/she ordered. Observation and interview on 5/23/18, at 11:49 A.M., Certified Nurse Aide (CNA) G and CNA H did and said: - CNA G washed his/her hands and put on gloves, sat a measuring cylinder on the floor without a clean field, emptied urine from the urinary drainage bag port, did not clean the port with an alcohol pad, and placed the port back into the holding chamber. - Rinsed the measuring cylinder in the resident's sink. - CNA G did not wash his/her hands after emptying the urine and put on clean gloves to provide perineal care. - Wiped the rectal area of fecal material; - Did not wash his/her hands or change his/her gloves and applied barrier cream; - Removed gloves, but did not wash hands and placed a clean brief beneath the resident; - Applied clean gloves; - Wiped the front of the perineal skin folds two times with two wipes; - Did not cleanse the catheter from insertion site down three to four inches or the perineal skin folds. - Did not cleanse all the perineal skin folds; - Changed his/her gloves and did not wash his/her hands and washed the odorous, reddened groin areas that were encrusted with dried white material, and applied barrier cream. - CNA H said the white material was dried barrier cream applied after a bath yesterday. - CNA G changed his/her gloves and covered the resident - CNA G said he/she did not change his/her gloves or wash his/her hands after cleaning fecal material from the resident. - Said he/she should have washed his/her hands and changed his/her gloves after performing dirty tasks and before performing clean tasks. - Said he/she should use a clean field to place the measuring cylinder on during the emptying of the urinary drainage bag. - Said he/she did not cleanse the urinary drainage port with alcohol after emptying the bag but he/she should have. - Said he/she should not rinse the measuring cylinder in the resident's sink. - Said he/she should have cleaned the catheter and all areas of the perineal area during care, but he/she did not. During an interview on 5/23/18, at 12:20 P.M., Licensed Practical Nurse (LPN) D said: - He/she collected the urine that was ordered on [DATE], and sent the urine for a urinalysis and C&S on 5/16/18. - The completed report was received in the facility on 5/19/18, but there is no indication in the medical record that staff notified the physician or received orders to treat the UTI. - The physician should have been notified before now. - The report should be on the dashboard of the computer for the physician to assess but the report is not listed there today. - The Nurse Practitioner (NP) is here now and may have looked at it today; the physician or NP are the only ones that can delete from the dashboard which means it was seen by one of them, but LPN D did not know when the physician or NP saw the results. - LPN D needed to follow up with the NP for orders. - The urine was collected because of the resident's worsening confusion and lethargy. - There was no order found in the medical record for any antibiotic order. During an interview on 5/23/18, at 1:00 P.M. NP A said: - He/she saw the urine and C&S report on 5/19/18, and gave an order to a nurse that day for [MEDICATION NAME] 750 milligrams (mg) daily for five days. - NP A showed his/her progress note, dated 5/19/18, to the surveyor and the order was noted in NP A's progress note for 5/19/18. - He/she looked today and the order was never transposed to the order sheet or Medication Administration Record [REDACTED] - He/she did not know why the [MEDICATION NAME] was not administered by staff. - He/she was going to reorder the [MEDICATION NAME] today, but upon examination of the resident, the resident's condition had worsened and he/she sent the resident to the hospital for admission and treatment. - The resident's pulse rate was increase and his/her blood pressure was low. - He/she thought the resident could be septic (a blood infection). During an interview on 5/24/18, at 4:40 P.M., the Director of Nursing (DON) said: - Hands should be washed and gloves changed between dirty and clean tasks. - Hands should be washed between residents; before care started and after care completed. - If hands soiled with fecal material, hands should be sanitized and gloves changed. - All areas of the skin should be washed/cleansed when soiled with fecal material or urine, the catheter should be cleansed from insertion site down to the area of attachment to the urinary drainage tubing, a clean field should be used when emptying the urinary drainage bag and the drainage port should be cleansed with alcohol. - Orders should be written and followed when received. 2. Review of Resident #76's readmission MDS, dated [DATE], showed: - A BIMS score of three, which indicates severe cognitive impairment; - Total dependence of two staff for activities of daily living (ADLs); - Indwelling catheter; - [DIAGNOSES REDACTED]. Review of the care plan, revised 4/3/18, showed: - Focus: Foley catheter; - Goal: No signs or symptoms of UTI through review date; - Interventions: Catheter care every shift and per current physician order; monitor for pain and discomfort due to catheter; monitor for signs and symptoms of a UTI. Review of a urine C & S, dated 5/11/18, showed: - Colony count for P stuartii (found in complicated urinary tract infections in residents with chronic indwelling catheters) greater than 100,000 /ml of urine which indicated a UTI. - Colony count for E. coli ESBL (resistant organisms among community-onset UTI's) greater than 90,000/ml of urine which indicated a UTI. - Sensitive to Ertapenem (an antibiotic). Review of the May, (YEAR), physician order [REDACTED]. - Ertapenem sodium solution 1 gram (gm) intravenously (IV, medications given in the vein) daily for 14 days. Observation on 5/21/18, at 11:29 A.M., showed: - The resident in bed with the catheter bag and tubing on the floor. Observation on 5/22/18, at 1:54 P.M., showed: - The resident in bed with the catheter bag and tubing on the floor. Observation and interview on 5/22/18, at 4:09 P.M., CNA A and CNA I did and said: - CNA A washed his/her hands, applied gloves and performed pericare and catheter care; - CNA A and CNA I rolled the resident to perform rectal care with no leg strap observed; catheter was pulled taunt as they rolled the resident; - With the same soiled gloves, CNA A wiped moderate amounts of fecal material (FM), applied barrier cream, and a clean brief. - CNA A said he/she should have removed the gloves and washed his/her hands after performing the catheter care and after cleaning FM prior to applying barrier cream and the brief. - CNA A said the resident should have a leg strap on to secure the catheter and should not be pulled tight. Observation on 5/23/18, at 4:22 A.M., showed: - The resident in bed with the catheter bag and tubing on the floor. During an interview on 5/24/18, at 4:30 P.M., the Director of Nursing (DON) said: - Staff should wash their hands and reapply clean gloves when going from dirty to clean tasks. - Staff should apply leg straps to secure catheters to prevent them from being pulled taunt. - Staff should secure catheter bags and tubing in a dignity bag off the floor attached to the bed frame or wheelchair at all times.

Based on observation, interview and record review, facility staff failed to put measures in place to prevent the development of a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) on the resident's right ankle; failed to document the wound consistently and failed to follow the facility's Pressure Ulcer Prevention & Management policy to also document the resident's risk factors and any attempted interventions; left the wound uncovered for an extended period of time after the resident's bath; failed to complete skin risk assessments and weekly skin assessments; and failed to follow facility policy regarding wound order time-limits for re-evaluation for one sampled resident (Resident #11) who had right-sided weakness from a stroke and swelling in his/her right lower extremity; the facility staff failed to follow the facility's pressure ulcer policy and adequately monitor and document deterioration or improvement of skin impairment for one sampled resident (Resident #18); and the facility staff failed to document wound characteristics consistently and failed to complete weekly skin assessments for two residents (Resident #1 and #15) out of 18 sampled residents. Four sampled residents had pressure ulcers and the facility identified four residents in the facility as having pressure ulcers. The facility census was 105 residents. Record review of the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel "treatment of [REDACTED].npuap.org), showed: -Wound dressings are a central component of pressure ulcer care; - The selection of the dressing should be based on the tissue in the ulcer bed, the condition of the skin around the ulcer bed; - Generally, maintaining a moist ulcer bed is the ideal when the ulcer bed is clean and granulating to promote healing or closure; - A Category/Stage II wound is Partial thickness loss of dermis (the layer of skin beneath the top epidermis layer) presenting as a shallow open ulcer with a red pink wound bed, without slough (tissue that has been shed; nonviable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed.). May also present as an intact or open/ruptured serum-filled blister;- A Category/Stage III wound is a full thickness skin tissue loss; - Subcutaneous fat may be visible but bone, tendon or muscle are not exposed; - Slough may be present but does not obscure the depth of tissue loss; - The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, the back of the head and malleolus (the bony area on the side of the outer ankle) do not have fatty tissue and Category/Stage III ulcers can be shallow. In contrast, areas with significant fatty tissue can develop extremely deep Category/Stage III pressure ulcers; - A Category/Stage IV wound is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface) and tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); - Wounds that are Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) are generally graded as Stage IV with depth unknown; - Positioning devices such as foam or pillows, are recommended, as necessary, to prevent direct contact of bony prominences with surfaces to avoid having the individual lie directly on the pressure ulcer. - If the ulcer does not respond within two weeks, other reasons for the ulcer's failure to respond need to be explored. Recommendations for the assessment of the individual with a pressure ulcer include: - Complete an initial assessment of the individual with a pressure ulcer, to include: -- A focused physical examination that includes; -- Factors that may affect healing (e.g., impaired perfusion (blood flow), impaired sensation (numbness), systemic infection); -- Vascular (blood flow) assessment in the case of extremity ulcers (e.g., physical examination, history of claudication (cramping in the lower leg while walking or exercising caused by blocked arteries in the leg) , and ankle-brachial index or toe pressure (a calculation used to assess the vascular status (blood flow) in patients with suspected arterial disease); 1. Record review of Resident #11's face sheet showed the resident was admitted to the Express Recover Unit (ERU) of the facility on 11/29/11. Record review of the resident's monthly record of weights showed in November 2011, the resident weighed 187 pounds. Record review of the resident's Admission Resident Data Set (RDS) dated 11/29/11 showed: - The resident was alert. - The resident was independent with decision-making (which was revised to have modified independence for decision-making after input from the resident's family). - The resident was usually understood by others and understood others (which was revised to sometimes understand and sometimes understood after input from the resident's family). - The resident scored a 13 for risk for pressure ulcers (16 or below was at risk). -- The resident had very limited sensory perception. -- The resident was chair-fast. -- The resident had very limited mobility. -- The resident probably had inadequate nutrition. -- The resident had potential problems with friction and sheer. - The resident had weakness in his/her right upper extremity (RUE) and his/her right lower extremity (RLE). - The resident had limited upper and lower extremities range of motion. - The resident had a deformity of his/her right foot (prior to stroke). - The section for "[MEDICAL CONDITION]" (swelling) was left blank. - There was no documentation regarding positioning his/her right RLE or any resident non-compliance. (Note: The next skin risk assessments were completed on 12/17/11 upon readmission and 1/12/12. The skin risk assessments should have been completed upon admission and weekly for four weeks). Record review of the resident's initial care plan dated 11/29/11 showed: - The resident would demonstrate acceptance to a limb restraint (it did not specify what) by cooperating with restraint usage and would not have any functional decline with restraint use. - The resident was at risk for skin breakdown. - Received anti-anxiety and anti-depressant medications. - Had [MEDICAL CONDITION] (total paralysis of the arm, leg and trunk on one side of the body, usually congenital or caused by a stroke) with the only directions to staff being to keep the resident and family informed. - Was "bedfast" most of the time and gave direction for staff to place a cushion to the resident's wheelchair. - Had impaired tactile sense to pain or pressure and gave direction for staff to teach the resident good skin care techniques. - It did not address the resident's RLE positioning. Record review of the resident's skilled nursing notes dated 11/29/11 showed: - The resident was admitted to the facility from a rehabilitation center for therapy related to right-sided weakness. - There was no documentation regarding his/her RLE positioning or any resident non-compliance (resists care was left blank). Record review showed there were no skilled nursing notes dated 11/30/11 for the resident. Record review of the resident's December 2011 Physician's Order Sheet (POS) showed: - Physician's orders dated 11/29/11 for: -- A regular diet. -- Vitamin D 2000 units twice a day for a supplement. -- Vitamin C 500 mg, twice a day for a supplement. -- Mag OX 400 mg daily (a magnesium supplement). -- Multi-vitamin for a supplement. -- [MEDICATION NAME] 10 mg three times a day for muscle spasms. -- [MEDICATION NAME] 800 mg for [MEDICAL CONDITION] (nerve damage). -- [MEDICATION NAME] Patch 50 micrograms (mcg), change every 72 hours. -- [MEDICATION NAME] 50/325 mg, one to two every four hours as needed for pain. -- Tylenol 650 mg every four hours as needed for pain. -- [MEDICATION NAME] HCL ([MEDICATION NAME]) 4 mg every eight hours as needed (pain medication). -- [MEDICATION NAME] (a protective skin ointment) to his/her coccyx daily. -- PT to treat five times a week for 30 days. -- OT to treat five times a week for 30 days. - There was no documentation or orders regarding the positioning/protecting of the resident's right lower extremity. - Physician's orders dated 12/17/11 for [MEDICATION NAME] to excoriations every shift and as needed. - Physician's orders dated 12/6/11 for [MEDICATION NAME] 20 mg daily as needed, not to exceed four doses for one week. - Physician's orders dated 12/10/11 for [MEDICATION NAME] 20 mg daily and KCL 10 meq daily. Record review of the resident's weight flow sheet showed in December 2011, the resident weighed 188.8 pounds. Record review of the resident's skilled nursing notes dated 12/1/11-12/4/11 showed: - The resident's skin was intact. - No documentation regarding the positioning of the resident's RLE. - No documentation regarding any resident non-compliance. - "Resists care" was left blank. - The resident was in an electric wheelchair. - "[MEDICAL CONDITION]" was left blank. Record review of the resident's lab results dated 12/3/11 showed the resident's: - Total protein was low at 6.0 (normal range = 6.4-8.9). - [MEDICATION NAME] was within normal range at 3.9 (normal range=3.5-5.7). Record review of the resident's history and physical report completed by the resident's physician dated 12/4/11 showed the resident: - Had a stroke in May 2011 and had been in a rehabilitation hospital. - Had right lower extremity weakness. - had a history of [REDACTED].), depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living), chronic pai[DIAGNOSES REDACTED], migraine headaches, and [MEDICAL CONDITION] (low hemoglobin). - Had a [MEDICATION NAME] (used to treat tight, stiff muscles) pump implantation. - His/her right lower extremity with 2+ ankle [MEDICAL CONDITION]. - His/her left lower extremity with 1+ ankle [MEDICAL CONDITION]. - Has flaccidity (lack of muscle tone) involving the right upper extremity and right lower extremity. - The physician's plan included TED ([MEDICAL CONDITION] disorder) hose (used to control [MEDICAL CONDITION]) for the right lower extremity [MEDICAL CONDITION]. Record review of the website, web.missouri.edu (The University of Missouri Sinclair School of Nursing) described the different stages of [MEDICAL CONDITION] as follows: -1+ [MEDICAL CONDITION] produces a barely detectable depression (when a finger is pressed into the skin) and there is immediate rebound; -2+ [MEDICAL CONDITION] produces a slight indentation and takes 15 seconds to rebound; -3+ [MEDICAL CONDITION] produces a deeper indentation and takes 30 seconds to rebound; and -4+ [MEDICAL CONDITION] takes more than 30 seconds to rebound). Record review of the resident's physician's orders dated 12/4/11 showed physician's orders for RLE TED hose (above the knees), change on bath days and as needed. Record review of the resident's skilled nursing notes dated 12/5/11 showed: - The resident's skin was intact. - No documentation regarding TED hose or any resident non-compliance. - "Resists care" was left blank. - The resident had blisters located on the dorsal (back) side of the lower right leg proximal to calf. The wound was open and draining serous sanguineous drainage. A dry dressing was applied. The family was notified. (Note: There was no further documentation regarding the blisters.). - Both of the resident's legs were elevated in bed. Record review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool required to be completed by facility staff used in the care planning process) dated 12/6/11 showed the following staff assessment of the resident: - Had adequate hearing. - Had clear speech. - Was usually understood by others. - Understands others. - Had short and long-term memory impairment. - Had moderately impaired cognitive skills for daily decision-making. - Said he/she had felt down, depressed or hopeless several days over the last two weeks. - Said he/she had trouble falling or staging asleep, or sleeping too much over the last two weeks. - Did not reject evaluation or care that was necessary to achieve the resident's goals for health and well-being. - Did not have any behavior symptoms. - Required extensive assistance with bed mobility, transferring from one surface to another, locomotion on and off the unit, dressing, using the toilet, bathing and personal hygiene. - Did not walk. - Required supervision only with eating. - Had impairment on one side of his/her upper and lower extremities. - Used a wheelchair. - Had a catheter. - Some of his/her [DIAGNOSES REDACTED]. - Received scheduled and as needed pain medications. - Said he/she had frequent pain. - Said his/her pain was at a level of 10 out of 10 (10 being the worst). - Said his/her pain did not affect his/her day-to-day activities. - Had fallen during the last month prior to admission. - Had fallen during the last two to six months prior to admission. - Was 5'3" and weighed 187 pounds. - Had not had any significant weight changes over the past six month (or it was unknown). - Was at risk for pressure ulcers. - Did not have any unhealed pressure ulcers. - Did not have any venous or arterial wounds (caused by poor circulation). - Did not have any other open wounds. - Had pressure reducing devices for his/her chair and bed. - Was not on a turning or repositioning program. - Did not receive any nutrition or hydration interventions to manage skin problems. - Received ointments or medications other than to his/her feet. - Received antianxiety, antidepressant and hypnotic medications over the past seven days. - Did not receive a diuretic (a drug used to treat [MEDICAL CONDITION] by increasing urination). - Received speech, occupational and physical therapy over the past seven days. - Did not have any restraints. Record review of the resident's Care Area Assessments (CAAs- a process to guide the Interdisciplinary Team (IDT) through a comprehensive assessment of a resident's functional status) dated 12/6/11 showed: - The resident had a history of [REDACTED]. - The resident was admitted to the facility for rehabilitation to be discharged home if possible. - The resident was incontinent of bladder and had a Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine). - The resident used a wheelchair for mobility. - The facility staff was to provide ointment to the resident's skin and skin monitoring with cares, showers twice a week and weekly by a nurse. - The facility staff were to provide pain monitoring every shift and as needed. - The resident had scheduled and as needed pain medications. - The resident fed himself/herself a regular diet with set up assistance. - The resident required assistance of two staff for all cares. - The wound nurse was to follow and treat (it did not specify what for). - The Registered Dietitian (RD) was to monitor the resident. - The facility staff was to weigh the resident weekly for four weeks and then monthly. - Psych was to follow the resident as needed. - There was no documentation regarding RLE positioning, TED hose or any resident non-compliance. Record review of the resident's skilled nursing notes dated 12/6/11-12/12/11 showed: - The resident's skin was intact seven out of seven days. - There was no documentation regarding the positioning of the resident's RLE six out of seven days. - There was no documentation regarding TED hose six out of seven days. - There was no documentation regarding any resident non-compliance seven out of seven days. - "Resists care" was left blank seven out of seven days. - "[MEDICAL CONDITION]" was left blank two out of seven days. - The resident had [MEDICAL CONDITION] five out of seven days. - The resident had TED hose on one day. - The resident complained of BLE pain at a 10 out of 10 level on 12/10/11. - The resident was educated on elevation of BLE (it did not state if the resident's BLE were elevated or not or if the resident agreed to or declined to have his/her feet elevated) on 12/12/11. Record review of the resident's lower extremity venous evaluation for BLE [MEDICAL CONDITION] and pain dated 12/12/11 showed all vessels were normal and it was negative for [MEDICAL CONDITION] ([MEDICAL CONDITION] - a blood clot in a deep vein in the leg). Record review of the resident's skilled nursing notes dated 12/13/11 showed: - The resident's skin was intact. - No documentation regarding the positioning of the resident's RLE, TED hose or any resident non-compliance. - "Resists care" was left blank. - "[MEDICAL CONDITION]" was left blank. Record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - There was a physician's order for right lower extremity TED hose (above the knee), change on bath days and as needed dated 12/4/11. - It was documented the resident had RLE TED hose (above the knee) on in the A.M. and off in the P.M. 12/5/11-12/12/11 (P.M. was left blank on 12/9/11 and 12/12/11). - The physician's order changed on 12/12/11 to knee high TED hose BLE on in A.M. and off in P.M.. - It was documented the resident had knee high TED hose BLE on in A.M. and off in P.M. on 12/12/11. Record review of the resident's nutritional history/assessment dated [DATE] showed: - The resident's current weight was 187 pounds. - The resident was obese. - The resident had recurring blisters on his/her right calf (Note: There was no documentation of the blisters in the resident's medical record other than the nurse's note on 12/5/11. There were no bath sheets available and there were no weekly skin assessments from December 2011. There were no wound reports for the resident for December 2011.). - The resident's [MEDICATION NAME] was within normal limits. - The resident was started on [MEDICATION NAME] for [MEDICAL CONDITION]. Record review of the resident's physician's orders dated 12/13/11 showed physician's orders to send the resident to the emergency room . Record review of the resident's face sheet showed the resident was readmitted to the facility on the Long-Term Care (LTC) unit on 12/17/11. Record review of the resident's admission orders [REDACTED] - A No Added Salt (NAS) diet. - Thera-M daily for a supplement. - Tylenol 650 mg every four hours as needed for arthritis. - Vitamin C 500 mg, twice a day for a supplement. - [MEDICATION NAME] to excoriated area daily. - Vitamin D 2000 U twice a day for a supplement. - [MEDICATION NAME] 50/325, one to two three times a day as needed for pain. - [MEDICATION NAME] 800 mg twice a day for pain with food. - Mag OX 400 mg daily for dietary supplement. - [MEDICATION NAME] 5/500 every four to six hours as needed for pain (cannot take [MEDICATION NAME] with [MEDICATION NAME]). - [MEDICATION NAME] 100 micrograms (mcg) to be changed every 72 hours for pain. - (Note: There were no orders for TED hose or RLE positioning interventions). Record review of the resident's daily and every shift charting dated 12/17/11 at 6:15 P.M. showed the resident was readmitted to the facility on the LTC side, the resident's skin was pink, the resident was able to move his/her right leg, and his/her right hand was in a splint. There was no documentation regarding the positioning of the resident's RLE. Record review of the resident's (Re-)Admission RDS dated 12/17/11 showed the resident: - Was alert. - Had modified independence for decision-making. - Had adequate hearing and vision. - Was usually understood by others and understood others. - The resident scored a 15 for risk for pressure ulcers (16 or below was at risk). -- The resident did not have any sensory perception impairment (Note: The 11/29/11 RDS showed the resident had very limited sensory perception). -- The resident was bedfast. -- The resident had very limited mobility. -- The resident probably had inadequate nutrition. -- Friction and sheer were potential problems. - Had BLE 1+ [MEDICAL CONDITION] in his/her lower extremities. - Had weakness in his/her right upper extremity. - Had a splint on his/her right hand. - Had limited upper extremities range of motion. - There was no documentation regarding TED hose, RLE positioning, or any resident non-compliance. Record review of the resident's nurse's progress notes dated 12/18/11-12/19/11 showed there was no documentation regarding the positioning of the resident's RLE, TED hose or of any resident non-compliance. Record review of the resident's skilled nursing notes dated 12/18/11-12/19/11 showed: - The resident's skin was intact two out of two days. - There was no documentation regarding the positioning of the resident's RLE on 12/18/11. - The resident's BLE were elevated on the day shift on 12/19/11. - There was no documentation regarding TED hose two out of two days. - The resident had on TED hose two days. - There was no documentation regarding any resident non-compliance two out of two days. - "Resists care" was left blank two out of two days. - "[MEDICAL CONDITION]" was left blank on 12/18/11. - The resident had [MEDICAL CONDITION] on 12/19/11. Record review of the resident's physician's orders dated 12/20/11 showed physician's orders for Physical Therapy (PT) and Occupational Therapy (OT) five times a week for 30 days. Record review of the resident's nurse's progress notes dated 12/20/11-12/31/11 showed there was no documentation regarding the positioning of the resident's RLE, TED hose or of any resident non-compliance. Record review of the resident's skilled nursing notes dated 12/20/11-12/23/11 showed: - The resident's skin was intact. - Had [MEDICAL CONDITION]. - It was documented twice that the resident had on TED hose. - It was documented once that the resident's legs were elevated. - There was no documentation of any resident non-compliance (and resists care was left blank) other than choosing not to go to the dining room for meals or to attend group activities. - There was no documentation regarding RLE positioning in the wheelchair. Record review of the resident's lab results dated 12/22/11 showed the resident's: - Total protein was low at 5.0 (normal range = 6.4-8.9). - [MEDICATION NAME] was low at 3.4 (normal range=3.5-5.7). Record review of the resident's care plan dated 12/23/11 showed: - The resident experienced discomfort due to pain. - The resident was a risk for cardiac distress related to high blood pressure, [MEDICAL CONDITION] (CAD - narrowing of the arteries to the heart) and stroke. - The resident required staff assistance for all activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) and cares related to a history of stroke and showed direction for staff to do the following interventions: -- Skin checks with cares, showers twice a week and weekly by nursing. -- Prompt the resident with verbal cues. -- Assist the resident with transfers as necessary. -- Provide occupational therapy as indicated. - The resident required staff assistance with mobility related to a stroke. - The resident was at risk for pressure ulcers and showed direction for staff to do the following interventions: -- Wound nurse to follow as needed (It did not indicate if this was for anything specific). -- Reposition the resident every two hours and as needed for comfort or request. -- Teach the resident and/or family risk factors for development of pressure ulcers. -- Assist resident with repositioning to avoid skin friction/shearing. -- RD to evaluate nutritional status as needed. -- Encourage resident's good nutritional intake. -- Teach resident/family consequences of non-compliance with therapeutic regime. -- Skin checks with cares, showers twice a week and weekly by nursing. -- Notify the physician and responsible party regarding presence of pressure ulcers. - The resident had a history of [REDACTED]. - The resident was at risk for side-effects from antidepressant medication use: -- Anti-depressant common side-effects: sedation, drowsiness, dry mouth, blurred vision, [MEDICAL CONDITIONS] muscle tremor, agitation, headache, skin rash, photosensitivity (skin), and excess weight gain. -- Anti-depressant special attention for: [MEDICAL CONDITIONS], chronic constipation, [MEDICAL CONDITION] disorder, and [MEDICAL CONDITION]. - The resident was at risk for side effects from hypnotic medication use to include dry mouth, constipation, blurred vision, retention of urine, headache, [MEDICAL CONDITION], nausea, fall in blood pressure, rapid heartbeat, weakness, sedation, lethargy, confusion, memory loss, allergic reactions and dependence. - The resident was at risk for side-effects from anti-anxiety medications of sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, and skin rash. - The care plan did not include the use of diuretics, the use or refusal of TED hose, did not include any positioning instructions for his/her right lower extremity, and did not indicate any non-compliance with any interventions. Record review of the resident's physician's progress note dated 12/24/11 showed the resident had BLE [MEDICAL CONDITION], right-sided weakness, a stroke with [MEDICAL CONDITION] and the physician was going to change the resident's diuretic from [MEDICATION NAME] to [MEDICATION NAME]. Record review of the resident's skilled nursing notes dated 12/24/11 -12/31/11 showed: - The resident's skin was intact. - Had [MEDICAL CONDITION]. - There was no documentation regarding the positioning of the resident's RLE or any resident non-compliance (resists care was left blank) other than choosing not to go to the dining room for meals or to attend group activities. - There was no documentation regarding TED hose or wheelchair positioning. Record review of the resident's MARs and TARs dated 12/17/11-12/31/11 showed there was no documentation regarding TED hose. Record review of the resident's January 2012 POS showed: - Dated 12/17/11 for a NAS diet. - Dated 12/17/11 for Vitamin D 2000 U twice a day. - Dated 12/17/11 for Thera M for a supplement. - Dated 12/17/11 Mag OX 400 mg daily (discontinued 1/3/12) - Dated 12/17/11 for Vitamin C 500 mg, twice a day for a supplement. - Dated 12/17/11 for [MEDICATION NAME] 100 mcg TR change every 72 hours for pain. - Dated 12/17/11 for [MEDICATION NAME] to excoriations every shift and as needed (discontinued 1/12/12). - Dated 12/17/11 for [MEDICATION NAME] 50/325 mg four times a day as needed for pain. - Dated 12/17/11 for [MEDICATION NAME] 5/500 mg every four hours as needed for pain. - Dated 12/17/11 for [MEDICATION NAME] 4-8 mg every four hours as needed for pain. - Dated 12/19/11 for [MEDICATION NAME] 10 mg three times a day as needed (changed to scheduled 1/12/12). - Dated 12/24/11 for [MEDICATION NAME] (diuretic) 1 mg every morning for high blood pressure (Note: The physician's progress note dated 12/24/11 showed it was being used as a diuretic for [MEDICAL CONDITION]). - Dated 1/3/12 start Mag OX 400 mg three times a day for a supplement. - There were no physician's orders for TED hose. - There were no physician-ordered interventions regarding the positioning of the resident's right lower extremity. Record review of the resident's weight flow sheet showed in January 2012, the resident weighed 200.8 pounds (up 13.8 pounds since November 2011). Record review of the resident's skilled nursing notes dated 1/1/12-1/12/12 showed: - The front of the sheet on 1/7/12 had notes for 1/8/12 written on it (so one day was missing for the front of the notes 1/8/12) and one day was missing for the back of the notes (1/7/12) resulting in 11 skilled nursing note sheets instead of 12 for the 12 days). - The resident was up in a motorized wheelchair on 1/1/12. - The resident drank two to three pots of coffee on 1/1/12. - The resident was wearing TED hose on 1/2/12, 1/3/12, 1/10/12, and 1/11/12. - The resident's RLE was elevated on 1/2/12. - The resident's RUE and RLE were elevated on 1/3/12, 1/10/12 and 1/11/12. - Elevation of the resident's RUE and RLE were encouraged on 1/5/12 (but it did not indicate whether the resident elevated them or not). - The resident drank four pots of coffee on 1/8/12. - The resident's skin was intact 11 out of 11 days. - There was no documentation regarding the positioning of the resident's RLE six out of 11 days. - There was no documentation regarding TED hose seven out of 11 days. - There was no documentation regarding any resident non-compliance 11 out of 11 days. - "Resists care" was left blank 11 out of 11 days. - "[MEDICAL CONDITION]" was left blank five out of 11 days. - The resident had [MEDICAL CONDITION] six out of 11 days. - The resident had TED hose on three out of 11 days. - The resident chose not to dine in the MDR or attend group activities. Record review of the resident's nurse's progress notes dated 1/1/12-1/31/12 showed there was no documentation regarding the positioning of the resident's RLE, TED hose or of any resident non-compliance. Record review of the resident's telephone orders dated 1/12/12 showed physician's orders to discontinue physical therapy. Record review of the resident's January 2012 nursing monthly summary dated 1/12/12 showed the resident: - Was alert. - Had no short or long-term memory impairment. - Had modified independence for decision-making. - Had adequate hearing and vision. - Was usually understood by others and understood others. - Had BLE 1+ [MEDICAL CONDITION]. - Did not have any wounds. - The resident scored a 15 for risk for pressure ulcers (16 or below was at risk). -- The resident did not have any sensory perception impairment (Note: The 11/29/11 RDS showed the resident had very limited sensory perception.). -- The resident was bedfast (Note: The resident actually used an electric wheelchair.). -- The resident had very limited mobility. -- The resident probably had inadequate nutrition. -- Friction and sheer were potential problems. - Had limited lower extremities range of motion. - Had a splint on his/her right hand. - There was no documentation regarding TED hose, RLE positioning, or any resident non-compliance. Record review of the resident's physical therapy and occupational therapy notes dated 11/29/11-1/12/12 showed: - There were no specific goals related to the positioning/protection of the his/her RLE. - Some of the resident's therapy goals included decreasing pain in his/her right shoulder and right upper extremity, decreasing pain in the resident's right hand and wrist and left elbow, completing sitting to standing transfers, increasing left shoulder flexion strength, increasing his/her left lower and upper extremity strength, increasing sitting balance, performing toileting tasks, performing upper body dressing, and tolerating passive range of motion to his/her right digits. - There was no documentation regarding the positioning of the resident's RLE. - There was no documentation regarding any resident non-adherence to any of his/her treatment plan. Record review of the resident's skilled nursing notes showed there were no notes dated 1/13/12, 1/14/12 day shift or 1/14/12 evening shift. Record review of the resident's skilled nursing notes dated the night shift of 1/14/12 showed there was no documentation regarding the positioning of the resident's RLE, TED hose or any resident non-compliance. This was the last skilled nurses' note. Record review of the resident's medication care plan dated 1/20/11 showed the resident was at risk for medication side effects due to the use of nine or more medications, but it did not mention any specific side effects. Record review of the resident's physician's progress note dated 1/30/12 showed the resident used a motorized wheelchair, had right-sided weakness, had right lower extremity [MEDICAL CONDITION] and had right lower extremity pain. Record review of the resident's telephone orders dated 1/30/12 showed physician's orders- For a RLE