Every finding on record at Ridge Crest Nursing Center

Based on interview and record review, the facility failed to ensure appropriate identification and timely treatment of a resident's broken femur and severe pain for one sampled resident (Resident #1) out of four sampled residents. On 05/30/26 at 11:12 P.M., the resident fell and had severe pain. The facility failed to perform pain assessments, did not provide any non-pharmacological pain relief, and the resident's pharmacological pain relief treatment was delayed until 05/31/26 around 7:00 A.M. X-Ray was not completed until 05/31/26 around 11:14 A.M. Facility staff did not notify the physician the resident's ordered pain medication was not sufficient for the resident's pain and the x-ray was delayed. The resident was transferred to the hospital on [DATE] at 12:34 P.M. The resident sustained an acute nondisplaced right femoral intertrochanteric fracture (anatomic site of this type of hip fracture is the proximal or upper part of the femur or thigh bone) and experienced severe pain. The facility census was 57 residents.The Administrator was notified on 07/22/26 at 11:30 A.M. of the Immediate Jeopardy (IJ) which began on 05/30/26. The IJ was removed on 07/03/26, as confirmed by surveyor onsite verification. Review of an evidence-based article, Attum B, [NAME] H. Intertrochanteric Femur Fracture,. Updated 08/08/23, In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493161/, showed:-Evaluation of a range of motion is typically not possible due to extreme pain. Review of an evidence-based article, undated,: [NAME], A. n.d. Intertrochanteric fractures. [NAME], MD: https://www.andrewbanosmd.com/intertrochanteric-fractures-orthopedic-surgeon-sports-medicine-specialist-newburyport-ma/ showed:-The signs and symptoms of intertrochanteric fractures included:--Severe pain in the hip or groin.--Swelling and bruising around the hip.--Inability to bear weight on the injured leg.--Unable to stand up or move after a fall.--Pain and stiffness in the injured leg.--Affected leg was externally rotated and shortened.-Most intertrochanteric fractures required surgical treatment within a couple of days of injury. Review of the facility policy titled Change in Resident's Condition or Status, revised February 2021, showed:-The nurse would notify the resident's attending physician or physician on call when there had been:--Accident or incident involving the resident.--Discovery of injuries of an unknown source.--Significant change in the resident's physical/emotional/mental condition.--Need to alter the residents' medical treatment significantly.--Need to transfer the resident to a hospital/treatment center.-A significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing interventions.-The nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility's undated policy titled Calling the Physician, showed staff were to:-Inform the physician of a change of condition and request orders in response to the condition change. -Act appropriately for the circumstances, especially in the event of an emergency, when expected orders were not received or when the physician could not be reached.-Take vital signs and assess neurological signs if necessary.-Implement body/system check on the resident.-Call the physician to report all data and request orders.-Contact the resident's family or legal representative to relay the change in condition. Relay that the physician has been notified, that orders were received and that nursing interventions have been implemented. -Implement physician's orders and provide additional nursing assistance as needed.-Monitor interventions for effectiveness.-Note all assessments taken and results and specify observations regarding the resident's change of condition.-Document actions taken and effectiveness.-Place another call to the Physician, if the actions taken were not effective.-The nurse's obligation to care for a resident's change of condition did not end with notification of the physician or attempts to reach the physician.-If the situation was critical, the resident should be sent to the hospital emergency room (ER) for evaluation.-If the nurse expected that new orders or interventions were necessary for resident care, but none were given when speaking with the Physician, those concerns should be addressed through the chain of command. 1. Review of Resident #1's admission Record showed he/she was admitted to the facility on [DATE], with the following diagnoses:-Alzheimer's Disease (a loss of cognitive functioning, thinking, remembering, and reasoning, and behavioral abilities to such an extent that it interferes with a person's daily life and activities).-Spondylosis, Lumbar Region (a progressive degenerative condition that affects the intervertebral discs, vertebral bodies, and associated joints of the lumbar spine).-Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).-Unspecified Lack of Coordination (the inability to move smoothly and harmoniously. It often manifests as clumsiness, jerky movements, or difficulty with daily tasks).-Muscle Weakness (a reduction in the strength of muscle contractions, which can manifest as difficulties in performing daily activities, such as climbing stairs or self-care tasks). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 05/25/26, showed he/she had severe cognitive impairment. Review of the resident's Clinical admission Assessment, dated 05/25/26, showed the resident had no indications of pain upon admission to the facility. Review of the resident's Physician Order Sheet (POS), dated 05/25/26, showed:-An active order that the resident could be transferred to the ER in the event of an emergency.-The resident was admitted to the facility for a 5-day respite (a brief interval of rest or relief from something difficult, tiring, or unpleasant) stay.-An active order for pain monitoring every shift. Document on a 1-10 scale, every shift for pain monitoring.-An active order for Tylenol Oral Tablet 325 MG (Acetaminophen- an over-the-counter medication classified as a pain reliever and fever reducer). Give 2 tablets by mouth every six hours as needed (PRN) for pain. Review of the residents' Care Plan, dated 05/29/26, showed: -Staff were to provide a line of sight to the resident while he/she was awake and up, dated 05/29/26.-Staff were to monitor, document, and report as needed to the physician for pain, bruises, changes in mental status, new onset confusion, sleepiness, inability to maintain posture, or agitation, dated 05/29/26.-The resident had an unwitnessed fall on 05/30/26.-No Care plan or interventions for pain. Review of the resident's incident note, dated 05/30/26 at 11:12 P.M., showed:-The nurse was notified by another resident that he/she walked by and the resident on the floor.-When the nurse entered the resident's room, the resident was lying on his/her right side on the floor. -The resident was not wearing shoes and only had regular socks on.-The resident was unable to state what happened and was unable to follow directions.-The resident showed signs of pain to his/her lower back and right hip area.-The resident was able to move all extremities.-No bruising or redness was noted.-The resident was assisted up off the floor and into his/her bed.-Nonskid socks were applied after the resident was placed back in bed.-A message was left with the on-call physician. -The fall was about 11:00 P.M. Review of the resident's EMR from 05/30/26 at 10:30 P.M. to 05/31/26 at 12:34 P.M., showed:-No pain assessment follow-up was documented after the resident's fall.-No nonpharmacological pain relief was documented as completed after the resident's fall.-No pain medication administration was documented. Review of the resident's nursing note, dated 05/31/26 at 1:04 A.M., showed:-Licensed Practical Nurse (LPN) B received a call back from the physician on call.-A new order was given for a 2 view x-ray of the right hip due to increased pain.-LPN B called and placed the order with the radiology company.-All appropriate parties were made aware of new order. Review of the resident's POS, dated 05/25/26, showed an order for a 2-view x-ray of the resident's right hip due to a fall with increased pain. Portable exam needed due to physical limitations, dated 05/31/26. Record review of the resident's medical record showed x-ray was ordered on 05/31/26 at 12:56 A.M., but was not performed on the night shift and no documentation a physician was updated on the delay in x-ray. During an interview on 07/02/26 at 3:05 P.M., Certified Medication Technician (CMT) A said:-He/She was working when the resident fell on [DATE].-When he/she entered the resident's room to assist after the fall, the resident was on the floor and in severe pain.-He/She helped get the resident back into the bed after the resident fell.-The entire time that staff transferred the resident back into the bed, the resident was screaming out in pain.-He/She checked on the resident periodically throughout the night.-The resident showed signs of being in continuous pain throughout most of the night.-LPN B was aware the resident had pain through the night.-The resident also showed signs of being anxious through the night shift.-Tylenol was the only pain medication available to give to the resident at the facility.-He/She did not administer Tylenol or any other pain medication to the resident. LPN B told him/her the pain was being managed by Tylenol that LPN B was administering it. -Nurses administer PRN medication, CMTs administer scheduled medication.-He/She never witnessed the resident being administered Tylenol or any other pain medication throughout the night.-The resident was up most of the night in pain, but did finally get some sleep toward the end of the night shift. -He/She believed the resident slept for a couple hours during his/her shift.-He/She was unsure of the exact time the resident finally fell asleep, but believed it was around 1:00 A.M. to 3:00 A.M. During an interview on 07/02/26 at 1:50 P.M., LPN B said:-He/She was the charge nurse on duty the night that the resident fell on [DATE].-He/She was at the nurse's station and was alerted by another resident the resident was on the floor.-Upon entering the resident's room, the resident was found on the floor.-He/She completed an assessment on the resident and the resident was in pain.-The resident was placed back in bed and he/she went and called the physician.-Physician A did not answer his/her call, so he/she called the physician's answering service.-He/She could not recall the name of the physician that he/she spoke to through the answering service.-The on-call physician that he/she spoke to gave orders to obtain an x-ray with no further orders at that time.-He/She reported to the on-call physician the resident had severe pain.-He/She did not report any leg deformity to the physician.-He/She did not notice a leg deformity after the resident fell.-He/She called the on-call physician shortly after the resident fell, but was unsure of the exact time of the call.-He/She contacted the radiology company and ordered the x-ray, but the x-ray had not been completed by the time his/her shift ended at 7:00 A.M. on 05/31/26.-He/She ordered the x-ray as routine and was told by the radiology company they would be out at the facility sometime in the morning of 05/31/26.-He/She did not contact the on-call physician and let them know of the time delay of the resident's x-ray.-He/She observed the resident having pain throughout the night and observed the resident moaning and grimacing off and on through his/her shift.-The resident stated I hurt, I hurt to him/her when neurological assessments and vitals were being performed through the night.-He/She completed range of motion assessments on the resident after the resident fell.-During the range of motion assessments, the resident had increased pain.-The resident complained of pain in his/her back and right hip area.-He/She administered Tylenol to the resident one time approximately one hour after the resident fell.-He/She did not administer any additional pain medications to the resident.-He/She did not request stronger pain medication from the physician. -He/She could not remember if he/she signed off in the resident's EMR that the Tylenol was administered to the resident.-The resident was restless throughout the entire night, but ended up going to sleep at approximately 3:00 A.M. to 4:00 A.M.-He/She was told by Certified Nurse Aide (CNA) staff later in the morning the resident was awake and crying out in pain again at approximately 7:00 A.M.-He/She did not contact the on-call physician again or attempt to contact the primary care physician to notify them the resident had continual pain off and on through the night before his/her shift ended. Review of the resident's Treatment Administration Record (TAR), dated May 2026, showed:-A physician order to monitor pain every shift. Document on a 1-10 scale every shift for pain monitoring. Start date 05/25/26 7:00 P.M.--On 05/31/26 at 7:00 A.M., during the day shift the resident's pain was documented as a pain level of 0.-A physician's order to document nonpharmacological pain interventions every shift using the following codes:--1.Reposition--2.Food/drink--3.Massage--4.Diversion techniques--5. Calm, quiet environment--6.Music therapy every shift for nonpharmacy interventions. Start date 5/25/26 7:00 P.M.--On 05/31/26 at 7:00 A.M., there was a 5 to indicate calm, quiet environment was used documented for the day shift Review of the resident's nursing note, dated 05/31/26 at 10:43 A.M., documented by LPN A showed:-The resident continued fall follow-up due to recent unwitnessed fall on 05/28/26 and 05/30/26.-The resident complained of severe pain in his/her right hip.-No new redness, bruising, or obvious deviations in bone and joint formations, but the resident did complain of severe hip pain.-The resident's range of motion was within the normal limits. Review of the resident's radiology patient report, dated 05/31/26 at 11:14 A.M., showed:-The resident had a critical (having the potential to decide an outcome, expressing careful analysis, or being absolutely essential) radiology finding.-The finding was an acute nondisplaced right femoral intertrochanteric fracture. Review of the resident's nursing note, dated 05/31/26 at 12:34 P.M., showed:-X-ray results indicated the resident had a right femur fracture.-Physician A was notified and an order was placed to send the resident to the ER for evaluation and treatment immediately.-The nurse contacted the resident's children who were the resident's Durable Power of Attorneys (DPOAs) and explained what occurred.-Physician A contacted the resident's DPOAs and explained the importance of the resident going to the ER for evaluation and treatment immediately.-The DPOAs agreed to Physician A's plan to send the resident to the ER right away.-Emergency personnel (911) was contacted for transport to the hospital. Review of the resident's POS, dated 05/25/26, showed an order to send to the ER due to a right hip fracture on 05/31/26 at 12:20 P.M. During an interview on 07/02/26 at 1:30 P.M., CNA A said:-He/She was a CNA on duty who worked with the resident the morning after the resident fell.-He/She worked the day shift and saw the resident for the first time on 05/31/26 at approximately 7:45 A.M.-The resident had already been returned to bed before his/her shift began on 05/31/26.-When he/she attempted to assist the resident to sit up for breakfast between approximately 7:45 A.M. and 8:00 A.M., the resident cried out in pain.-Due to the resident's severe pain and injury, the resident was unable to sit upright in bed and eat breakfast on the morning of 05/31/26.-He/She reported the noticeable pain and the inability to sit upright in bed and eat breakfast to LPN A.-The nurse said he/she was already aware of the resident's condition and was waiting on x-ray's to be done. -He/She monitored the resident closely on 05/31/26 and was going in to check on the resident often, but staff tried not to move the resident because they knew the resident was in pain and moving the resident made the pain worse.-He/She was in the room and present when the x-ray company performed the bedside x-ray on the resident.-The resident screamed during the entire process of obtaining the x-ray-He/She did not notice any deformity of the resident's leg or hip.-He/She was unable to get a good view of the injured leg and hip and was not sure if deformity or bruising was present at the time of the x-rays. During an interview on 07/02/26 at 12:30 P.M., LPN A said:-He/She was the day nurse that came on duty at 7:00 A.M., on 05/31/26.-During report with the night shift nurse, LPN B, told him/her the resident fell during the night.-He/She was unsure of the exact time of the resident's fall.-He/She was told by LPN B in report the resident had pain through the night and LPN B administered Tylenol to the resident.-He/She was not told by LPN B how many times the resident was administered Tylenol throughout the night.-He/She was unsure of the last time the resident was administered Tylenol prior to his/her shift starting at 7:00 A.M., on 05/31/26.-He/She checked on the resident in person, after report on 05/31/26, sometime between 7:00 A.M. and 8:00 A.M.-Upon his/her initial assessment of the resident, the resident had obvious injury to his/her right leg and was in pain.-He/She could tell the resident had a fracture by the way the resident's leg was turned inward and by the resident's increased pain.-The resident was in pain during his/her assessment as evidence by the resident moaning and grimacing during the assessment.-He/She administered Tylenol to the resident in the morning time on 05/31/26, after it was realized the resident was in pain.-He/She was unsure if the Tylenol that he/she administered was documented in the resident's EMR.-He/She continued to assess the resident throughout the rest of the morning for pain, and the resident was not showing signs of pain.-He/She did not document the follow-up pain assessments in the resident's EMR.-He/She ordered an x-ray for the resident after receiving report from the night shift nurse.-The x-ray results were received by the facility around 10:30 A.M. and confirmed the resident had a fracture.-The x-ray findings were reported by the radiology company over the phone and through fax due to being a critical finding.-Right after he/she got the results, he/she called Physician A at 11:02 A.M. and 11:16 A.M., to get further instruction.-Physician A instructed him/her to call EMS and send the resident to the ER.-He/She notified the resident's DPOA once the fracture was confirmed. He/She had not notified the DPOA prior to this call regarding the resident's fall.-He/She was unsure if the previous night shift nurse notified the DPOA when the resident first fell in the middle of the night.-When EMS arrived at the facility for transport, he/she observed the resident in severe pain with movement by the EMS staff.-EMS staff gave the resident pain medication prior to transferring the resident to the gurney for transport in the ambulance.-He/She observed during the cares being completed by the EMS staff for transport there was an obvious deformity.-His/Her observations through the morning hours confused him/her, because he/she was told by LPN B in the morning report the resident did have pain throughout the night, but did not have obvious deformity or injury. During an interview on 07/02/26 at 10:00 A.M., Paramedic A said:-He/She was one of the three first responders on scene to transport the resident from the facility to the hospital in the afternoon on 05/31/26, around noon time.-The facility contacted Emergency Medical Services (EMS) for transport to the hospital for evaluation and treatment approximately 15 hours after the resident fell at the facility.-The facility nurse reported to the EMS staff the resident fell the night prior, approximately 15 hours before EMS was contacted.-It was concerning to him/her the amount of time that lapsed between the resident falling at the facility and the time the facility called EMS.-It was apparent upon arrival at the facility the resident was in excruciating pain.-The resident was crying out in pain and could be heard down the hall upon EMS arrival to the facility.-The resident kept saying it hurts repeatedly.-The facility staff reported to the EMS staff they were unsure when the resident last had any pain medication.-The resident could not be moved without causing increased and unbearable pain.-He/She had to administer pain medication to the resident in the facility before the resident was able to be transferred to the EMS gurney for transport. -It was apparent upon arrival at the facility the resident had an obvious injury to the right leg and hip as evidence by the noticeable rotation of the resident's right leg and hip. During an interview on 07/02/26 at 11:40 A.M., Paramedic B said:-He/She responded with EMS after receiving a call from the facility that a resident fell and had injuries in the afternoon of 05/31/26.-Upon entering the resident's room, the resident was crying out in pain.-The resident had an obvious deformity of the leg consistent with a textbook pelvic or hip fracture.-The resident was pale and without normal skin color when EMS arrived.-Facility staff reported the resident fell the previous day.-The facility nurse reported to EMS the facility was waiting on results from x-rays but when the EMS staff arrived at the hospital, hospital staff informed EMS the resident's x-rays were already reported, and the resident had a femur/hip fracture.-The resident's obvious injuries and intense pain warranted immediate intervention and transfer to the hospital for evaluation and pain control.-The resident had to be administered pain medication at the facility by EMS staff to even handle being transferred to the hospital. During an interview on 07/07/26 at 8:30 A.M. Emergency Medical Technician (EMT) A said:-EMS received a call around 12:00 P.M., on 05/31/26 to transport the resident to the emergency room.-When EMS arrived at the facility, the resident was screaming out in pain.-He/She and the other two EMS personnel could hear the resident screaming out in pain from down the hall before reaching the resident's room.-It was observed by EMS staff immediately upon entering the resident's room the resident was ashen (a pale, grayish, or bluish-gray skin discoloration) in color. -Upon arrival into the resident's room, the resident was in bed.-The resident's right leg was visibly and noticeably shortened and fully turned inward.-The medics had to administer the resident pain medication on scene when they arrived due to the resident's extreme pain level.-The resident screamed in pain the entire time that they had to transfer the resident to the gurney.-The resident's leg was in an abnormal position and had obvious deformity.-The resident's leg was not splinted or supported in any way by the facility staff prior to EMS arrival at the facility.-He/She and the medics on the scene had to stabilize the resident's leg while on scene, prior to transferring the resident onto the gurney for transport.-The facility nurse reported to EMS staff the resident fell the night before around 11:00 P.M. the day before, which was about 13 hours prior to EMS being called to the facility for intervention and transport to the hospital.-The facility nurse reported the resident had x-rays, and they were waiting for the results.-The injury was very traumatic and very painful for the resident. -The facility nurse denied any recent pain medication administration to the resident prior to EMS arrival to the facility.-The facility nurse reported to the EMS staff that he/she was not sure when the resident last received any pain medication.-There was no physical way the facility staff were able to perform any range of motion assessments on the resident.-Any attempt to perform any range of motion assessments on the resident by EMS staff would make the resident scream louder in pain.-The resident had zero range of motion upon assessment by EMS staff.-The resident had uncontrolled, level 10 and beyond pain, upon assessment by the EMS staff.-The resident had an obvious fracture as evidence by noticeable deformity and abnormal rotation of the resident's right leg and hip.-The resident was classified as a medical emergency and EMS should have been contacted right after the resident fell, 13 hours prior. Review of the resident's nursing note, dated 05/31/26 at 4:01 P.M., showed:-The hospital ER nurse informed facility staff the resident had confirmed right hip fracture.-The resident was being admitted to the hospital on the medical-surgical unit. During an interview on 07/02/26 at 11:00 A.M., the Administrator said:-He/She completed rounds in the facility on the evening of 05/30/26 around 6:00 P.M., before leaving the facility.-The resident had not yet fallen prior to him/her leaving the facility at 6:00 P.M.-He/She was not in the facility when the resident fell later in the evening/night.-He/She was told the resident fell from bed and was found on the floor by another resident.-He/She was unsure when the resident fell exactly, but thought it was sometime between 11:00 P.M., on 05/30/26 and 12:00 A.M. on 05/31/26.-The fall occurred during the night shift.-He/She was told the resident complained of pain after the fall.-An ambulance was eventually called and the resident was transferred to the ER for evaluation and treatment on 05/31/26 around noon.-The resident was at the facility for a short respite care stay.-The resident never returned to the facility after being transported to the hospital on [DATE]. -His/Her expectation of the facility nursing staff would be to manage the resident pain and if the pain was not managed the facility physician would be contacted for further instruction. During an interview on 07/02/26 at 1:00 P.M., Physician A said:-He/She was the resident's primary care physician and very involved in the resident's care.-The resident was placed in the nursing facility for temporary respite care.-He/She was not notified about the resident falling until the daytime on 05/31/26 after the x-ray results were back.-He/She could not find a report or documentation at the time of the interview to support an on-call physician being notified in the middle of night after the fall on 05/30/26.-He/She was unsure of what physician the nurse would have spoken to the night of 05/30/26. -The results of the resident's x-ray confirmed the resident had a fracture that he/she considered a serious injury.-He/She would expect a nurse who was calling a fall report to a physician to provide details of the resident such as uncontrolled pain, decreased range of motion, and obvious deformity or evidence of a fracture.-He/She was unsure if those findings were reported to the on-call physician at the time of the resident's fall.-The type of fracture and injury the resident had would have shown signs such as shortened leg, rotation of leg/hip, and intense pain from the moment that the injury occurred.-He/She would have expected the nursing staff to be able to properly assess a resident after a fall and determine if the incident warranted emergent care.-There was an active physician's order in the resident's medical record for nursing staff to be able to send the resident to the ER in emergent situations.-A resident who had an unwitnessed fall followed by intense pain and/or any signs of fracture, warranted an immediate transfer to ER and should not have remained at the facility awaiting x-ray's. During an interview on 07/07/26 at 10:30 A.M., the Administrator said he/she:-Had not been able to determine who the physician was that the nurse allegedly spoke to and reported the resident's fall right after the fall occurred.-He/She called the hospital's on call service and the on-call service was unable to provide any details or evidence to support the phone call from the facility nurse to the on call physician after the fall.-Had not heard back from Physician A with any additional details.-Did not have an updated change in condition policy since the February 2021 dated one.-Expected all staff to follow the facility policies.-Expected his/her staff to manage a resident's pain after a fall.-Expected staff to document pain assessments and medication administration when completed on residents.-Expected notification of changes in condition of residents to physicians and family to be documented with complete details which included the name of the physician the nurse spoke with at the time of the call, as well as all interventions ordered. During an interview on 07/07/26 at 4:20 P.M., the Director of Nursing (DON) said:-He/She was familiar with the fall that occurred on 05/30/36 with the resident, but was not present in the facility at the time of the fall.-He/She was first notified of the fall over text message.-He/She was not called by the nursing staff when the fall occurred on 05/30/26.-He/She worked on Sunday, 05/31/26, the day after the fall occurred.-He/She was told the resident was in bed when he/she asked about the resident on 05/31/26, but was not given any additional details about uncontrolled pain or possible fractures by nursing staff.-He/She did not assess the resident himself/herself on 05/31/26 due to not being told the resident was having any issues.-If a resident had a fall and had pain, nursing staff was expected to control the resident's pain with administration of pain medication.-If Tylenol was ordered for a patient and the Tylenol was not controlling a resident's pain, it was expected that nursing staff would call the physician and receive an order for stronger pain medication.-The facility had an emergency kit that had stronger pain medication available to administer to the residents for situations like this, where the pain medication was warranted.-If a resident fell and had uncontrolled pain, it was expected the nursing staff would call him/her and not just send a text message that was lacking important details.-If a resident had uncontrolled pain, nurses were expected to call the physician back after 15 minutes to get an order for something stronger and pull the stronger medication out of the emergency supply kit.-He/She expected nursing staff to document all pain assessments in the resident's EMR.-He/She expected nursing staff to document uncontrolled pain in the resident's EMR.-He/She expected nursing staff to document all administration of pain medication to residents in the EMR.-Pain assessments should have been completed and documented each time the nurses checked on the resident or performed any other assessments, such as vitals.-It was expected after a non-witnessed fall that nurses completed and documented thorough assessments and notified the physician of all of the resident's assessment findings.-It would be expected after a non-witnessed fall that if a resident had any sign of fracture and/or any uncontrolled pain, that clinical information would be documented and the physician would be re-contacted for additional orders.-When nurses speak to physicians to notify them of falls or changes in a resident's condition, the nurse should document the physician's name and exactly what the physician stated to do during the call. 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 be taken to address Class I violation(s). 30289473028947

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility; failed to ensure handwashing to prevent cross contamination was performed during wound care for one sampled resident (Resident #22) and with transfers for one supplemental resident (Resident #40) out of 16 sampled residents. The facility census was 46 residents with a licensed capacity for 120 residents at the time of the survey. 1. Observation on 9/2/25 between 10:38 A.M. and 10:51 A.M. during the initial facility Life Safety Code (LSC) kitchen inspection with the Director of Maintenance (DOM) showed there was a three-sink area, a chemical dish-washing machine, a hand-washing sink, an ice machine, and a steam table (also referred to as a hot food table, is specifically designed to hold food at steady, safe serving temperatures, and not designed to cook or warm foods from a raw state). Review of the facility's untitled, undated white binder provided by the DOM showed the following:-There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188.-No Centers for Disease Control (CDC) toolkit assessment including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens was included.-A completed CDC Legionella Environmental Assessment Form was missing.-No schematic, flowchart, or diagram of the facility's water system with a written explanation of the water flow throughout the facility that identified and indicated specific potential risk areas of growth within the building with assessments of each individual area's potential risk level was included. Observation on 9/3/25 between 10:25 A.M. and 11:49 A.M. during the facility LSC walk-through inspection with the DOM and his/her assistant showed:-The municipal water main supply entered the building in the fire sprinkler system riser room (in a nutshell, a fire sprinkler riser room is a dedicated space for fire protection equipment situated on an outside wall at grade with direct exterior access) at the east end of 300 Hall with a sign on the double doors to the hall that read, Main Water Shut Off For Building.-The building was equipped with both a wet and a dry fire sprinkler system with sprinkler heads located throughout the facility. -There were housekeeping closets with floor mop sinks or ceramic service sinks (mop/service sinks are used in janitorial and maintenance areas to fill and empty mop buckets, clean mops, and dispose of dirty water), water heaters, water softeners, and hot/cold water piping throughout the five resident room hallways.-There were at least 50 resident rooms with private and/or shared bathrooms and sinks.-There were commercial clothes washers in the laundry area.-There were four used and unused bathhouses on the facility's middle hall. -There was a Beauty Shop with a sink.-Public restrooms were located on the front administrative office hall. During an interview on 9/3/25 at 10:31 A.M. at the sprinkler riser room the DOM said that was where the facility's water supply came in. Review of the facility's document entitled, Water Management Plan, last dated 4/1/25 and provided by the Administrator, showed the following:-No Centers for Disease Control (CDC) toolkit assessment including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens was included.-A completed CDC Legionella Environmental Assessment Form was missing.-Most pages had a footer that read, This Water Management Plan Expires on 4/1/2026. Review of the facility's Emergency Preparedness (EP) manual entitled, Emergency Procedure – Disaster Plan, last reviewed 4/11/25 and provided by the Administrator, showed the following:-Under Tab 11, named, Water Outage, Water Main Break, Utility Outages, there was a generic three-page policy, Legionella Water Management Program, without a:--Facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188.--Centers for Disease Control (CDC) toolkit assessment including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.--Completed CDC Legionella Environmental Assessment Form.-The last page was an arrowed diagram showing the distribution of the water flow after entering from the front of the building, but there was no accompanying written explanation of that flow throughout the facility that identified and indicated specific potential risk areas of growth within the building with assessments of each individual area's potential risk level. During an interview on 9/4/25 at 12:21 P.M. the DOM said that his/her responsibilities with their Legionella program included going around weekly to flush systems not being used, checking the water's pH (aka, Potential for Hydrogen = a solution's acidity or alkalinity on a scale of 0 to 14, with 7 being neutral) and chloramine levels with test strips, and documenting water temperatures. During an interview on 9/4/25 at 12:58 P.M. the Administrator said the following:-His/Her responsibility regarding the Legionella program was to oversee it.-He/She was educated on its requirements when the issue first came out years ago and with its updates since then; it had kind of evolved. 2. Review of Resident #22's Face Sheet showed the resident was admitted on [DATE] with diagnoses including heart failure, lack of coordination, abnormal gait and mobility, and cognitive communication deficit. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/28/25 showed the resident:-Was alert and oriented with minimal confusion.-Had limitations on one side of his/her lower extremity.-Needed set up to supervision for activities of daily living (bathing, dressing, eating) and used both walker and wheelchair for mobility.-Had two venous stasis ulcers that were treated with ointments and non-surgical dressings. Review of the resident's Physician's Order Sheet (POS) dated [DATE], showed physician's order for:-Cleanse the resident's left lower extremity with normal saline (salt water), apply moistened hydrofera blue (a foam wound dressing containing properties the promote a moist wound healing environment) dressing to the back of the achilles (the fibrous tendon found in the back of the lower leg), cover with an abdominal pad (ABD pad-a large thick highly absorbent dressing designed for wounds with heavy drainage or for providing padding and protection), wrap with a cotton dressing and ace wrap three times weekly on day shift on Tuesday, Thursday and Saturday (4/23/25). Observation and interview on 9/2/25 at 11:11 A.M., showed there was an enhanced barrier precautions (EBP-an infection control strategy that involves using gowns and gloves during high-contact resident care activities to reduce the spread of multidrug-resistant organisms (MDROs) and other pathogens in healthcare settings, particularly nursing homes) sign on the resident's door with personal protective equipment (PPE-clothing, gear, or equipment worn by an individual to protect against serious injuries, illnesses, or the spread of infection by minimizing exposure to various workplace or environmental hazards) in a container outside of the resident's door. The resident was sitting on his/her bed and was alert and oriented. He/She said:-He/She currently has a wound on his/her left lower leg that came about when he/she was taking medications that caused a skin reaction.-He/She initially had wounds on both legs, but the nursing staff was able to heal the wound on his/her right leg and the wound on his/her left leg had shrunk significantly. -The nurse changed the dressings every week and he/she would be here today to look at it and treat it. Observation and interview on 9/4/25 at 1:53 P.M., showed the resident was sitting up on the side of his/her bed. Licensed Practical Nurse (LPN) and Wound Care Nurse knocked on the resident's door and informed him/her that he/she was coming to provide wound care. The resident said he/she was ready and the Wound Care Nurse put on a gown and brought his/her wound supplies into the resident's room, placing them on a paper towel barrier on the resident's tray table. The resident said his/her dressing was already off of his/her leg. The Wound Care Nurse did the following:-The Wound Care Nurse then washed his/her hands and gloved then laid a barrier across the resident's bed.-The resident laid down placing his/her leg on the barrier. There was an open area on his/her achilles that was an elongated wound about pencil width, approximately one inch in length.-The Wound Care Nurse wiped the area with a cotton swab and wound cleanser.-Without discarding his/her gloves and washing or sanitizing his/her hands, he/she applied pre- moistened hydrothera blue to the wound, then applied the ABD pad and wrapped the resident's leg with a cotton dressing.-The Wound Care Nurse then opened an ace bandage and wrapped the resident's leg from his/her foot to his/her calf.-The Wound Care Nurse then discarded his/her gloves and washed his/her hands, drying them with a paper towel and turning off the water with a paper towel.-He/She bagged the trash, put a new liner in the trash can, then washed his/her hands, removed his/her gown, put it in the trash then left the resident's room. During an interview on 9/4/25 at 2:12 P.M., the Wound Care Nurse said after cleaning the resident's wound he/she should have washed or sanitized his/her hands before applying the new treatment to prevent cross contamination. 3. Review of Resident #40's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a progressive neurodegenerative disorder that affects movement, balance, and coordination), dementia, pain, muscle contracture (a fixed, abnormal shortening of muscle or other soft tissues (like skin, tendons, or ligaments) that restricts normal movement of a joint, often due to scarring, prolonged disuse, or neuromuscular conditions) of upper and lower extremity and history of falling. Review of the resident's quarterly MDS dated [DATE] showed the resident:-Was alert and oriented without cognitive deficits.-Had upper and lower extremity impairment on one side.-Was dependent with all transfers and used a wheelchair for mobility. Observation and interview son 9/4/25 at 9:16 A.M., showed Certified Nurse's Aide (CNA) B brought the sit to stand lift (a mechanical hydraulic device that helps a person move from a seated to a standing position and vice versa) into the resident's room. The resident was sitting up in his/her wheelchair. CNA B said he/she was going to transfer the resident into his/her recliner. He/she put a glove on one hand placed the lift in front of the resident, attached the sling around the resident and hooked it to the lift. He/she noticed the lift did not work and he/she left to go get a battery for the lift. He/she came back into the resident's room and put the battery on the lift. CNA B did the following:-Without removing the glove off of his/her right hand, washing or sanitizing his/her hands, he/she lifted the resident into a semi-standing position where the resident's legs were bent, but he/she was still holding onto the lift handles.-CNA B used his/her gloved hand to pull the resident's pants down, pulled his/her brief aside and used a urinal for the resident to use the bathroom while still semi-standing in the lift.-When the resident was done, CNA B pulled his/her brief back in place, pulled his/her pants up and then without sanitizing or washing his/her hands, lowered the resident down into his/her recliner.-CNA B then removed the glove, discarded it, washed his/her hands, re-gloved his/her right hand, poured the contents of the urinal into the toilet and flushed it.-CNA B then, without removing his/her glove and washing or sanitizing his/her hands, removed the lift from the resident's room.-CNA B said that he/she assisted the resident to use the urinal while he/she was up in the lift because it was easier for the resident to use the urinal while standing.-He/she did not think there was any concern with only gloving one hand and he/she did not realize he/she needed to wash his/her hands again when he/she re-entered the resident's room.-He/she did not notice that he/she had not washed or sanitized his/her hands after he/she assisted the resident with the urinal.-He/She thought he/she did wash his/her hands before leaving the resident's room. During an Interview on 9/5/25 at 2:17 PM with the DON and Administrator, both said:-Nursing staff should wash their hands upon entering the resident's room, after removing gloves, between dirty to clean tasks and before leaving the resident's room.-The Administrator said the Wound care Nurse said he/she had completed Resident #15's entire treatment without removing his/her gloves or washing his/her hands and he/she knew better than to do that.-CNA B had not followed several protocols for resident cares though he/she had been trained on said protocols.

Based on observation and interview, the facility failed to maintain a safe, functional, and sanitary environment by allowing floor tiles to separate creating possible tripping hazards with not easily cleanable cracks and ceilings to crack allowing possible contamination of food and/or drinks underneath. This deficient practice had the potential to affect residents, visitors, volunteers, and staff residing, visiting, using, or working in those locations. Additionally, the facility failed to ensure resident safety by failing to adequately monitor two sampled residents who had wandering and exit seeking behaviors (Resident #33, and #3) and failed to ensure safety during a transfer for one supplemental resident who required staff to use a mechanical lift to transfer (Resident #40) out of 16 sampled residents. The facility had a census of 46 residents with a licensed capacity of 120 residents at the time of the survey.1. Observation on 9/3/25 between 10:57 A.M. and 12:01 P.M. during the facility Life Safety Code (LSC) walk-through inspection with the Director of Maintenance (DOM) and his/her assistant showed:-Inside the double smoke doors at the south entrance of the Main Dining Room (MDR) were approximately (app.) 17 miscolored tiles laid the width of the doorway that did not fit tight in the floor creating cracks between themselves and other pre-existing tiles.-Inside the double smoke doors at the north entrance of the MDR were app. 21 miscolored tiles laid the width of that doorway that did not fit tight in the floor creating cracks between themselves and other pre-existing tiles.-The MDR vaulted popcorn ceiling (a type of ceiling finish that looks like tiny kernels of popcorn on the surface, created with a spray-on or paint-on texture that adds sound-deadening qualities and can hide imperfections) had three patches, each app. 5-inches () x 20, on the east slope where the popcorn was missing and either showed bare ceiling above or had patches of an unknown cracked substance.-At the west end of 200 Hall by an Electrical Closet there were app. 40 miscolored tiles inside the width of the exit door hallway that did not fit tight in the floor creating cracks between themselves and other pre-existing tiles.-The ceiling in the Employee Training Room was cracked and bulging at both sides of a light fixture.-App. 14 mis-colored tiles outside the north Clean Utility door did not fit tight in the floor creating cracks between themselves.-There was an app. 1/4 to 3/8 crack running the length of the ceiling in the Employee Breakroom.-The ceiling by a sprinkler head in the resident room [ROOM NUMBER] bathroom was cracked.-The pavement at the west resident enclosed smoking courtyard had multiple cracks running 9 feet (') or more with a cement patch toward the middle app. 3.5' x 5' that had broken apart edges that created gravel-like pieces. During an interview on 9/3/25 at 11:09 A.M. in the Employee Training Room the DOM said that all the ceiling cracks and patches were from roof leaks that occurred about four years ago. During an interview on 9/4/25 at 12:21 P.M. the DOM said that he/she would expect the facility to be free of any possible contamination of food and have no tripping hazards. During an interview on 9/4/25 at 12:58 P.M. the Administrator said they would expect the facility to have no tripping hazards and be free of any possible contamination of food or drinks. Review of the facility Safe Lifting and Movements policy and procedure dated July 2017, showed:-Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices.-Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary.-Mechanical lifts shall be made readily available and accessible to staff 24 hours daily. Back up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged.-All equipment design and use will meet or exceed the guidelines and regulations concerning residents' safety and the use of restraints.-The policy did not address how to use the mechanical lifts. 2. Review of Resident #40's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a progressive neurodegenerative disorder that affects movement, balance, and coordination), dementia, pain, muscle contracture (a fixed, abnormal shortening of muscle or other soft tissues (like skin, tendons, or ligaments) that restricts normal movement of a joint, often due to scarring, prolonged disuse, or neuromuscular conditions) of upper and lower extremity and history of falling. Review of the resident's quarterly MDS dated [DATE] showed the resident:-Was alert and oriented without cognitive deficits.-Had upper and lower extremity impairment on one side.-Was dependent with all transfers and used a wheelchair for mobility. Observation and interview on 9/4/25 at 9:16 A.M., showed CNA B brought the sit to stand lift (a mechanical hydraulic device that helps a person move from a seated to a standing position and vice versa) into the resident's room. The resident was sitting up in his/her wheelchair. CNA B said he/she was going to transfer the resident into his/her recliner. He/she placed the lift in front of the resident, attached the sling around the resident and hooked it to the lift. He/she noticed the lift did not work and he/she left to get a battery for the lift. He/she came back into the resident's room and put the battery on the lift. CNA B did the following:-He/She lifted the resident into a semi-standing position where the resident's legs were bent, but he/she was still holding onto the lift handles.-CNA B used a gloved hand to pull the resident's pants down, pulled his/her brief aside and used a urinal for the resident to use the bathroom while still semi-standing in the lift.-When the resident was done, CNA B pulled his/her brief back in place, pulled his/her pants up and then lowered the resident down into his/her recliner.-The resident did not show signs of fear or anguish, nor did he/she say he/she was afraid.-CNA B said that he/she assisted the resident to use the urinal while he/she was up in the lift because it was easier for the resident to use the urinal while standing. During an interview on 09/05/2025 2:17 PM with the DON and Administrator both said:-No one should be hanging on to the sit to stand lift while the staff are performing resident cares.-CNA B should have transferred the resident then provided the urinal, not while the resident was still in the sit to stand lift. Review of the facility Wandering and Elopement policy and procedure dated March 2019, showed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. It showed:-If identified at risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.-If an employee observed a resident leaving the facility, he/she should attempt to prevent the resident from leaving in a courteous manner, get help from other staff members in the immediate vicinity if necessary and instruct another staff member to inform the charge nurse or Director of Nursing that a resident is attempting to leave the premises.-The policy did not show any interventions regarding supervision to prevent the possibility of elopement. 3 Review of Resident #33's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including dementia, lack of coordination, stroke with paralysis on the left side. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/24/25, showed the resident:-Was alert with some confusion.-Did not have any behaviors delusions or wandering.-Had disorganized thoughts, trouble sleeping, trouble concentrating and sleeping.-Was independently mobile. Review of the resident's Care Plan dated 7/25/25, showed the resident had impaired cognitive function and impaired thought processes due to dementia, was an elopement risk and wandered, had impaired safety awareness and had a history of attempts to leave the facility unattended. Intervention showed staff would:-Attempt to redirect the resident away from exits when he/she wants to open doors.-Provide conversation to the topic the resident is showing interest in.-Ensure the safety of the resident and others.-Establish boundaries and limits with the resident.-Reorient the resident to person, place time and situation.-Utilize diversion techniques as needed.-Distract the resident from wandering by offering structured activities, food conversation, television, books.-Identify the resident's pattern of wandering and intervene as appropriate. Observation during the facility tour on 9/2/25 at 10:42 A.M., showed the resident was sitting in his/her wheelchair in the middle of the hallway. The resident said he/she did not know where his/her room was or where he/she was going. Nursing staff who was in the hallway told the resident where his/her room was and assisted the resident to his/her room. Observation on 9/3/25 at 9:38 A.M., showed the resident was standing in the hallway by the exit door. The resident opened the exit door and the alarm sounded. Facility staff came running immediately toward the resident and brought a wheelchair for the resident. Nursing staff encouraged the resident to sit down and asked the resident cognitive orientation questions (name, place) and the resident said he/she was not feeling good and that his/her head hurt. Nursing staff took the resident back to his/her room. During an interview on 9/3/25 at 10:00 A.M., Certified Nursing Assistant (CNA) A said:-The resident has dementia and needed partial assistance with cares.-The reside was able to ambulate and also used a wheelchair to mobilize in the facility.-When the resident was out in the facility, he/she did wander and was sometimes exit seeking.-The resident usually does not actively seek exits unless he/she is anxious or agitated.-The nursing staff will try to distract/redirect him/her by taking the resident to the nursing station and they will also take the resident to his/her room when he gets this way.-The resident set the alarm off this morning and was trying to exit, but staff immediately redirected him/her and took him/her to his/her room.-They received in report this morning that the resident had a difficult time sleeping last night and that may be why he/she was exit seeking this morning.-They were supposed to monitor the resident more frequently when he/she is this way.-They try to take the resident to or provide activities, but the resident will leave the activity. after a few minutes.-He/She did not know if the resident received one to one activities. During an interview on 9/3/25 at 10:19 AM the resident was sitting in his room, he/she said:-He/She did set the alarm off on the door, but it was an accident.-He/She was trying to get some different clothes to wear.-His/Her clothes were in another building. -He/She attended activities and had attended an activity yesterday where he/she played games and it was fun. Observation on 9/4/25 at 1:24 P.M., showed the Director of Nursing (DON) was sitting at the nursing station. The resident ambulated from his/her room, down the hall, to the exit door and opened it, setting off the door alarm. Several staff rushed to the door and asked the resident where he/she was going. The resident was dressed for the weather but was not wearing socks or shoes. The resident said he/she was going home. Nursing staff got his/her wheelchair and asked the resident to sit down and he/she complied. Nursing staff took the resident off of the hall to the nursing station where they provided the resident with a beverage and snack. During an interview on 9/4/25 at 1:30 P.M., Certified Nurse's Aide (CNA) B said:-He/She was the staff working on the hall with the resident today but was in another resident's room at the time the resident tried to get outside. -They try to prevent the resident from exit seeking and exiting by keeping him/her at the nursing station or involving him/her in an activity.-The resident liked to go outside and sometimes they take him/her outside.-Sometimes the interventions work and sometimes they do not.-They had to watch the resident more frequently to keep the resident from getting out of the door.-They do what they can. Observation on 9/4/25 at 1:43 P.M., Certified Medication Technician (CMT) A said:-The resident usually does not go out of the exit door but does wander and exit seek.-They had a routine for the resident during the day to try to keep the resident from wandering/exit seek.-During the during the day, the resident was usually either in the activity room, they will give him/her snacks or they will take him/her outside.-They try anything to keep the resident busy.-Whenever the resident is more agitated, the resident will exit seek and try to go outside.-Today the resident laid down after breakfast and didn't get up until lunch.-He/She did not know why he/she was taken back to his/her room after lunch today.-When the resident is anxious or agitated, they are more attentive to him/her and try to keep him/her occupied.-He/She was more likely to exit seek when he/she was alone or was not being engaged.-They typically have to keep an eye on the resident when he/she was up and mobile. During an interview on 9/5/25 at 2:17 P.M., with the Director of Nursing (DON) and Administrator, the DON said:-They have had in-services on behavior and dementia what it means and what it represents during their employee onboarding education.-They complete more frequent checks on residents that wander and exit seek.-If they see the resident is having increased anxiety or agitation, he/she expected nursing staff to notify the physician for any possible medications/medication changes.-If the resident is in his/her room, then he/she is in a safe place.-If the resident does come out of his/her room, then they will keep him/her in line of sight at all times and provide him/her with coffee or snacks.-He/She saw the resident when he/she was trying to leave on 9/4/25 and ran toward the resident when he/she was headed toward the door but did not get to him/her in time.-The staff was supposed to inform the nurse if they see any behavior in the resident that will trigger him/her to exit seek.-They have tried to take the resident to activities, but he/she usually just leaves.-They try to give him/her snacks and provide other types of activities, he/she likes to tinker.-Regarding residents who wander or are exit seeking, the Administrator said he/she expected staff to keep the resident in their line of sight especially when the resident is exhibiting behaviors. 4. Review of Resident #3 admission Sheet dated 3/11/16 showed diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbances (dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Review of the resident's annual comprehensive MDS dated [DATE], showed: -He/she was severely cognitively impaired. -He/she had behaviors (physical behavioral symptoms directed towards others), occurred 1 to 3 days-He/she had uncleared speech-slurred or mumbled words.-He/she rarely or never understood for being able to express themselves. Review of the resident's Care Plan, initiated 2/25/25, showed:-The resident was at risk of harm from others as evidenced by wandering, approaching peers without permission, decreased cognitive function and history of placing his hands on others. -The resident would be in line of sight, if cooperative with staff while up in a wheelchair and active. -Monitor the residents where abouts while up.-Redirect the resident when in an area that he/she should not be in. -Provide resident with handheld snacks or suckers to avoid negative interactions with other peers or staff.-Ensure/provide a safe environment.-Resident had a potential to be verbally aggressive.-The resident was an elopement risk/wanderer.-Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Review of Resident #20's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an observation and interview on 9/2/25 at 11:07 A.M. showed: -Resident #20 was yelling get help and help to get Resident #3 out of his/her room. -Resident #20 said the incident upset him/her because every time Resident #3 comes into his/her room and takes his/her stuff and candy. -Resident #20 said Resident #3 would try to touch him/her and Resident #20 would not let his/her. -Certified Nursing Assistant (CNA) D and therapy assistant from next door came in to redirect Resident #3 out of Resident #20's room. During an interview at 9/2/25 at 11:11 A.M. CNA D said the resident wanders the hallway, and staff were to be monitoring and redirecting the resident continually to keep him/her from entering other residents' room. During an observation on 9/2/25 at 2:51 P.M. showed: -The resident wandered into Resident #32's room in his/her wheelchair. -The resident was sitting in his/her wheelchair in Resident #32's room.-The resident had cornered him/herself in between two dressers and the bed. -The resident turned him/herself and opened a drawer on one of the dressers and was going through it.-Resident #32 was standing in his/her room and walked over to Resident #3 and was trying to talk to him/her. -Resident #3 started touching a stuffed animal on top of the smaller dresser and Resident #32 said that was my stuff. -Resident #32 closed the drawer and stood by the bed watching Resident #3.-Resident #3 started moving around in his/her chair again and just kicked the bed and hollered out in pain and knocked something off of the taller dresser.-Resident #32 told Resident #3 to hold still while he/she bent over and picked up the trinket off the floor under Resident #3 wheelchair. -Resident #32 was trying to tell Resident #3 to get out of his/her room and trying to turn him/her around.-Resident #3 tried to open another drawer and Resident #32 said no to Resident #3.-Resident #32 said you need to go over there not here. -Resident #32 was now trapped in the same corner trying to direct Resident #3 out of the room. -Resident #32 was now blocking Resident #3 so he/she would not open anymore dresser drawers.-Resident #32 trying to guide Resident #3 out of the room.-Resident #3 finally got out of the corner and out of the room the resident's room at 3:03 P.M.-Facility staff were not observed in the resident's room or in the hall. Review of Resident #32's comprehensive MDS, dated [DATE], showed facility staff assessed the resident was moderately cognitively impaired. During an interview on 9/2/25 at 3:03 P.M. Resident #32 said:-He/She was okay.-Resident #3 would come into his/her room a lot. During an observation on 9/2/25 at 2:51 P.M. through 3:03 P.M. showed:-There was no nursing staff on the 200 hall.- Two dietary staff walked by but and did not remove Resident #3 from Resident #32's room. Observation on 9/3/25 at 9:55 A.M. showed the resident rolling down the 100 hall in his/her wheelchair and pushed on the side emergency exit door next to the nursing station in between 100 and 200 halls. The door did not open. During an observation on 9/4/25 at 2:17 P.M. showed:-The resident was in common dining room by his/herself and was eating cooked carrots off of Resident #37s tray that was sitting out next to the table that holds dietary supplies and additional food condiments. -The resident stopped eating carrots and rolled over to condiment bin and started putting his/her hands on individual packaged condiments. -Dietary Aide A came out and grabbed the condiment bin from the resident and told the resident that he/she was going to get the resident a snack.-Dietary Aide A came back with a banana and gave it to the resident. -The resident started rolling toward 300 and 400 halls and a nursing staff turned him/her around and pushed him/her back toward the 200 hall. During an interview on 9/4/25 at 2:22 P.M., Dietary Aide A said: -The resident likes to come back to the dining room when lunch was over, and the room was empty and try to steal food off the trays.-The resident was head strong and he/she was afraid he/she was going to get hit when he/she grabbed the condiment bin away from the resident. During an interview on 9/4/25 at 2:23 P.M., the Dietary Manager said:-The resident would come back into the dining room to eat off of other resident's trays.-If the doors were open to the kitchen area the resident would come into the kitchen.-If the resident does come into the kitchen, then he/she would grab the resident a banana and redirect him/her back into the dining room. During an interview on 9/4/25 at 2:30 P.M. Certified Medication Technician (CMT) A said: -If the resident was in the hallway staff would move him/her into another location or sometimes take him/her outside.-He/She would redirect the resident if they would go into another resident's room. -When you approach the resident, you must explain in detail everything that you were going to do.-The resident would go into the dining room and eat off of other residents' trays.-He/She would take the tray away from the resident and get him/her a snack. During an observation on 9/5/25 at 9:31 A.M. showed:-The resident wheeling him/herself from the dining room by his/herself into the 200 hallway and kept trying to open a closet door.-The resident gave up and turned him/herself around and went back into the dining room and towards the 300 and 400 halls. During an interview on 9/5/25 at 9:55 A.M. Licensed Practical Nurse (LPN) A said:-The resident gets caught in the dining room eating off a tray at least once a week. -He/she would grab the resident a snack and redirect him/her back to his/her room. During an interview on 09/05/2025 2:17 PM with the Director of Nursing (DON) and Administrator both said:-Staff would redirect the resident out of other resident rooms.-Staff would use snacks, ball, or games to redirect the resident.-Staff would keep the resident in line of sight so they would always see him/her.-There were snacks at the nurse's desk to provide to the resident.-Staff should be redirecting the resident before he/she gets a chance to eat off other residents' plates.

Based on observation, interview, and record review, the facility failed to follow pre-prepared menus to ensure they met the nutritional needs of residents in accordance with established national guidelines and failed to have a basic ingredient in stock that was called for many of the recipes. These deficient practices potentially affected all residents who ate food from the kitchen. The facility's census was 46 residents with a licensed capacity for 120 residents.Review of the undated Week at a Glance menus for weeks 1 through 4, provided by the Dietary Manager, showed a variety of meals that met the nutritional needs of residents in accordance with established national guidelines. The lunch meal for week 3 that was supposed to be served:-Tuesday was as herb roast beef, brown gravy, roasted carrots, potatoes and onions, and pudding parfait. -Thursday was ham steak, garlic potatoes, buttered carrots, and fruit crumble.-Friday was oven fried fish, cheesy rice, seasoned spinach, and lemon cookie bar.Review of the Resource: Menu Substitution Form showed:-Tuesday the pot roast was substituted with beef stroganoff, and the pudding was substituted with a brownie. -Thursday the ham was substituted with pork.-Friday the fish was substituted with turkey, the spinach was substituted with broccoli, the lemon cookie bar was substituted with chocolate chip cake. During an interview on 9/2/25 at 10:43 A.M. Resident #42 said:-The food budget is too small and limits them on what and how much they can buy. -Dietary never serves what on the menu.-The resident had spoken with the Dietary Manager (DM), and he/she stated he/she can only feed what he/she had.-The resident had spoken with the Administrator, and he/she had stated that the budget was the reason for the food options. Observations on 9/2/25 at 12:20 P.M. showed the resident eating Beef Stroganoff, cooked carrots and a brownie. During interview on 9/4/25 between 9:50 A.M. and 12:00 P.M. the DM said:-The menus were on a 4-week schedule, and they are currently on week 3.-The menus go by seasons and currently on the spring and summer seasons that starts in April and ends in September. -Truck delivery every Tuesday. -The reason for all the substitutions was because the food items were too expensive, out of stock, and the residents were get tired of having the same beef, pork, and chicken all the time. -The dietary vendor was in charge of creating the menu and the representative said he/she would give access to the DM so he/she would be able to change the menu so the residents would have an idea of what would be served, but this hadn't happened yet. -Some foods like, cookies, cakes, and soups were being made in house to save on costs, plus the resident's seemed to like them better.Observations on 9/4/25 at 11:32 A.M. the lunch meal being prepped was for pork chops, buttered carrots, mashed potatoes, and peach cobbler.During an interview on 9/5/25 at 12:43 P.M., the Administrator said:-Corporate was responsible for the dietary budget.-The dietary vendor was responsible for coming up with the menu.-Menu substitution was due to the repetitiveness the resident's get tired of eating the same beef, pork, and chicken. -DM sometimes forgets to order the food.-There was a shopping list on the dietary vendor site, and the DM was educated on how to use. -Price of food had not really been a problem.-The only thing he/she was aware that was changed due to price was the size of the egg they used to get large eggs and now medium.

Based on observation, interview, and record review, the facility failed to maintain the cleanliness inside of the ice machine. This practice potentially affected all 46 residents who had ice in their drinks. The facility census was 46 residents. Review of the facility policy Ice Handling and Cleaning dated 2016 showed:-The ice machine would be wiped down daily with sanitizer.-Ice machine would be emptied quarterly and thoroughly cleaned with an approved sanitizer to remove any settlement or mineral build up in the ice discharge area and floor of the machine.-Ice storage bins shall be drained through an air gap. 1. Observations during the initial walk-through 9/2/25 9:46 A.M., showed the ice machine in the kitchen had a blackish and brownish substance growing inside on the ceiling where the ice comes out. During an interview on 9/4/25 at 9:50 A.M. the Dietary Manager (DM) said:-Maintenance was responsible for maintaining the ice machine. -It was cleaned every 3 to 6 months.During an interview on 9/4/25 at 2:09 P.M. the Maintenance Director (MD) said:-The ice machine company comes out and cleans it every 3 to 4 months.-The Dietary Manager was responsible to call the company. During an interview on 9/5/25 at 10:45 A.M. the DM said the MD may have a schedule of the ice machine being cleaned but he/she did not have it. During an interview on 9/5/25 at 11:29 A.M. the Maintenance Assistant said:-He/She did not know about an ice machine cleaning schedule.-The ice machine was a rental and either the kitchen or Maintenance would call the company to have them come out periodically and clean it. During an interview on 9/5/25 at 11:45 A.M. the MD said there was no schedule that he/she knew of the ice machine being cleaned unless Dietary kept track of it.

Based on interview and record review, the facility failed to ensure five sampled residents (Residents #4, #5, #7, #22 and #48) a were offered or had documentation of previous COVID-19 (a new disease caused by a novel (new) coronavirus) vaccinations or documentation of refusal of COVID-19 vaccine education provided out of 5 out 5 resident sampled for immunization review. The facility census was 46 residents. Review of the facility's Coronavirus (COVID-19) Vaccine policy dated 11/7/23 showed:-Each resident will have the opportunity to affirm or deny consent to receive the COVID-19 vaccine doses.-The facility will obtain consent for vaccination from each resident or representative.-Document screening and administration of the vaccine in the resident's medical records. 1. Review of Resident #4's admission Record showed he/she was readmitted to the facility on [DATE].Review of the resident's medical record showed no documentation of the resident's COVID-19 vaccine status or that the resident received education for the risks or benefits of the vaccine since admission to the facility. 2. Review of Resident #5's admission Record showed he/she was admitted to the facility on [DATE] and readmitted on [DATE].Review of the resident's medical record showed no documentation of the resident's COVID-19 vaccine status or that the resident received education for the risks or benefits of the vaccine since admission to the facility.3. Review of Resident #7's admission Record showed he/she was admitted to the facility on [DATE].Review of the resident's medical record showed no documentation of the resident's COVID-19 vaccine status or that the resident received education for the risks or benefits of the vaccine since admission to the facility.4. Review of Resident #22's admission Record showed he/she was admitted to the facility on [DATE].Review of the resident's medical record showed no documentation of the resident's COVID-19 vaccine status or that the resident received education for the risks or benefits of the vaccine since admission to the facility.5. Review of Resident #48's admission Record showed he/she was admitted to the facility on [DATE].Review of the resident's medical record showed no documentation of the resident's COVID-19 vaccine status or that the resident received education for the risks or benefits of the vaccine since admission to the facility.6. During an interview on 9/5/25 at 11:41 A.M., Licensed Practical Nurse (LPN) A said:-Resident's Immunization should be documented in electronic record under immunization tab. -Wound Nurse and charge nurse would be responsible for ensuring COVID-19 vaccine status or that the resident received education for the risks or benefits of the COVID vaccine documented upon admission and annually. During the Infection Control Surveillance interview on 9/5/25 at 11:54 A.M., the Infection Control Preventionist (ICP)/Administrator said: -Wound Nurse was responsible for tracking and documented vaccines when given or offered, and to document educated provided related to benefits and risk of the specific vaccine. -The facility was not able to locate request documentation of the sampled residents COVID-19 vaccine status, education provided and documentation of refusal of the vaccine. -He/She would expect the nursing staff and/or assigned staff member to document immunization into the resident electronic medical record as needed. During an interview on 9/5/25 at 11:45 A.M., Director of Nursing (DON) said:-Wound Nurse and ICP would be responsible for tracking and documentation of the resident's COVID-19 vaccine status or refusal.-Wound Nurse and ICP would be responsible to ensure the resident or representative had received education for the risks or benefits of the vaccine at time of admission and annually.

Based on observation, interview and record review, the facility failed to provide activities that were based on resident preferences and that were meaningful and failed to develop goal directed activity care plans and interventions for two sampled residents (Resident #33 and Resident #21) who were not able to self-direct activities out of 16 sampled residents. The facility census was 46 residents.Review of an undated Activity policy showed the activity department will work with the nursing department to coordinate resident care and needs with scheduled activities. Activity staff should be aware of the resident's safety concerns and transfer needs. The Activity Director is responsible for filling out the activities section of the Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) form, assisting with the activity care plan and attending care plan meeting. Activities should be meaningful and individualized to meet the needs of all residents. 1. Review of Resident #33's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including dementia, and stroke with paralysis on the left side. Review of the resident's admission MDS dated [DATE], showed the resident:-Was alert with some confusion.-Did not have any behaviors delusions or wandering.-Activities that were very important to the resident included reading books/magazines/news, animals/pets, going outside, activities with groups, music and favorite activities. Review of the resident's Care Plan dated 7/25/25, showed the resident had impaired cognitive function and impaired thought processes due to dementia, was an elopement risk and wandered, had impaired safety awareness and had a history of attempts to leave the facility unattended. Intervention showed staff would:-Distract the resident from wandering by offering structured activities, food conversation, television, books.-There was no goal directed activity plan or interventions documented in the resident's Care Plan. Review of the resident's Activity Participation Record dated August 2025 showed:-A list of activities during the month included Bingo, Bible study, Games, Crafts, Exercise, Baking, Movie, Talking, Coloring, Resident Counsel, Painting, Nail Care, News, Cards, Laundry, Badminton, Science, Bowling, Hospice, Tie-dye, Shuffleboard, and Racing.-The Participation record showed daily activities the resident was offered or participated in.-The resident's participation record showed staff offered the resident three activities daily from the list.-The resident participated in games on 8/28/25, science on 8/29/25, and bingo on 8/30/25 (a total of 3 activities out of 93 opportunities during the month). All of the other entries showed the resident either refused or was sleeping during the activity.-The participation record did not show the resident received any one to one activities. Observation during the facility tour on 9/2/25 at 10:42 A.M., showed the resident was sitting in his/her wheelchair in the middle of the hallway. The resident said he/she did not know where his/her room was or where he/she was going. Nursing staff who was in the hallway told the resident where his/her room was and assisted the resident to his/her room. At this time there was an activity in the activity room which started at 10:30 A.M. The resident was not encouraged to go to the activity room nor did staff take the resident to the activity. Observation on 9/3/25 at 9:38 A.M., showed the resident was standing in the hallway by the exit door. The resident opened the exit door and the alarm sounded. Facility staff came running immediately toward the resident and brought a wheelchair for the resident. Nursing staff encouraged the resident to sit down and asked the resident cognitive orientation questions (name, place) and the resident said he/she was not feeling good and that his/her head hurt. Nursing staff took the resident back to his/her room. The resident was not provided with an activity. During an interview on 9/3/25 at 10:00 A.M., Certified Nursing Assistant (CNA) A said:-The resident has dementia.-The reside was able to ambulate and also used a wheelchair to mobilize in the facility.-When the resident was out in the facility, he/she did wander and was sometimes exit seeking.-They try to take the resident to or provide activities, but the resident will leave the activity after a few minutes.-He/She did not know if the resident received one to one activity. During an interview on 9/3/25 at 10:19 AM the resident said:-He/She attended activities and had attended an activity yesterday where he/she played games and it was fun.-He/She was not aware of an activity that was going on at 10:30 A.M. in the activity room.-There was no activity calendar in the resident's room. Observation on 9/4/25 at 9:37 A.M., showed the resident was in his/her bed with covers drawn. The resident's eyes were closed and he/she was resting comfortably. The resident remained in bed during the scheduled activity at 10:30 A.M. Observation on 9/4/25 at 12:35 P.M., showed the resident was sitting in his/her wheelchair, in the dining room eating lunch. The resident did not have wandering behavior during the meal. When he/she was finished eating, staff took the resident back to his/her room. There were no scheduled activities until 3:30 P.M. During an interview on 9/4/25 at 1:30 P.M., CNA B said:-They try to prevent the resident from exit seeking and exiting by keeping him/her at the nursing station or involving him/her in an activity.-The resident liked to go outside and sometimes they take him/her outside.-Sometimes the interventions work and sometimes they do not. Observation on 9/4/25 at 1:43 P.M., Certified Medication Technician (CMT) A said:-During the during the day, the resident was usually either in the activity room, they will give him/her snacks or they will take him/her outside.-They try anything to keep the resident busy. 2.Review of Resident #21's Face Sheet showed the resident was admitted on [DATE] with diagnoses including dementia, lack of coordination, cognitive communication deficit, and muscle weakness. Review of the resident's admission MDS assessment dated [DATE], showed the resident:-Was alert with significant confusion.-Needed total care and did not ambulate and used a wheelchair for mobility.-Activities that were somewhat important included going outside, participating in religious services, snacks, animals/pets, group activities and music. Review of the resident's Activity Participation Record dated August 2025 showed:-A list of activities during the month included Bingo, Bible study, Games, Crafts, Exercise, Baking, Movie, Talking, Coloring, Resident Counsel, Painting, Nail Care, News, Cards, Laundry, Badminton, Science, Bowling, Hospice, Tie-dye, Shuffleboard, and Racing.-The Participation record showed daily activities the resident was offered or participated in.-The resident's participation record showed staff offered the resident at least three activities daily from the list.-The resident participated in 20 out of 97 activity opportunities provided during the month. The resident participated in bible study , games, crafts, a movie, talking, nail care, news, science and racing during the month. All of the other entries showed the resident either refused or was sleeping during the activity.-The participation record did not show the resident received one to one activity (nails). Review of the resident's Care Plan updated 9/2/25, showed the resident had impaired cognition, impaired communication and impaired mobility. Interventions for cognition showed staff should:-Incorporate alternative means of communication, such as music, song or visual demonstration.-Incorporate visual prompting and cues and provide reality orientation to focus the resident's attention.-There was no activity goal or interventions in the resident's care plan. Review of the resident's quarterly Activity assessment dated [DATE], showed:-The resident enjoyed coming to activities if he/she was up to it.-One to one activities seemed to work well since he/she enjoyed having conversations.-The resident enjoyed talking to staff and other residents, going outside, reading and puzzle books. The resident was not interested in bible study at this time.-The resident's activity related focuses remained appropriate and current as per the resident's care plan.-The resident's activity goals were met and the interventions had been effective in reaching his/her goals.-The resident participated in activities when at home, wanted to participate in group activities, wanted one to one activities with staff, and liked independent activities.-Activities should be modified due to the resident's cognitive deficit.-Assistance should be provided to get the resident to the activity. Observation on 9/2/25 at 11:41 A.M., showed the resident was in his/her room laying down in a low bed to the floor. He/she was resting with his/her eyes closed without signs or symptoms of discomfort. There were no books, television or music in his/her room and there were minimal belongings in his/her room. There was no activity calendar in resident's the room. Observation on 9/2/25 at 3:04 P.M., showed the resident was laying down in his/her bed that was low to the floor. The resident had his/her eyes closed, resting without signs or symptoms of discomfort. There were no books, music or television in his/her room. Observation on 9/3/25 at 11:20 A.M., showed the resident was in his/ room laying on his/er bed which was low to the floor. The resident was awake but was quiet. The resident had confusion and seemed to have no signs or symptoms of distress. There were no books, music or television in his/her room. Observation on 9/4/25 at 8:30 A.M., showed the resident was up in his/her wheelchair finishing breakfast in the dining room. Nursing staff took the resident to sit in front of the nursing station once he/she was done eating. The resident was not provided with any activity while sitting in front of the nursing station. At this time there were resident's in the activity room in a self-directed activity. Observation on 9/4/25 from 12:40 P.M. to 1:40 P.M. showed the resident was sitting up in his/her wheelchair in front of the nursing station. Observation on 9/4/25 at 2:44 P.M., showed the resident was laying down in his/her bed that was low to the floor. The resident was awake and singing to himself/herself. There was no books, music or television in the resident's room and no indication there was any additional activity provided to the resident while in his/her room. During an interview on 9/4/25 at 2:46 P.M., CNA A said:-The resident sometimes participated in activities like building blocks.-He/She played with blocks with the resident last week.-The resident was recently moved to his/her current room and did not have much in there but he/she thought the resident had a radio.-The resident slept a lot during the day.-He/She was not sure what activities the resident currently participated in.-He/She did not know if the resident had one to one activities. 3. During an interview on 9/5/25 at 11:22 A.M., the Activity Director said:-He/She recently went to the activity training in August. -He/She completed the initial and quarterly activity assessments on the residents.-The MDS Coordinator completed the activity care plan, goals and interventions and he/she followed the resident's activity plan of care.-He/She documented the activity that each resident participated in daily on the activity participation form. -They have three activities per day at 10:00 A.M., 2:00 P.M., and 4:30 P.M.,-Depending on the activity, like bingo, if the activity goes longer the residents don't want to do another activity until later in the evening.-They usually do not have activities after dinner.-Residents who were able to self-direct activities always have accessibility to the activity room and there are coloring sheets, puzzles.-Staff has keys to the activity closet to access board games and other items that are kept locked.-In the activity room they usually have music playing.-He/She said that he/she really has not been completing one to one activity with anyone, but he/she tried to either chat with residents or do nails with residents daily.-He/She did not have a list of residents or schedule for residents who needed more assistance participating in activities, who could not come to activities or who were more appropriate for one to one activities.-Regarding Resident #33, he/she did not do as much as he/she should regarding developing activities for the resident.-Usually, Resident #33 just roams and walks the facility.-He/She could walk with the resident or take him/her outside.-He/She and nursing staff try to get Resident #33 to come to the activity room to participate in activities, but the resident will come in for a few minutes then leave.-Resident #33 liked to sit at the nursing station and he/she liked snacks.-Resident #33 was a farmer but he/she had not gotten him/her any farming related books magazines or things he/she may be interested in-he/she said they have two other residents that were also farmers, and he/she could see if he/she could get the resident to engage with those two residents.-They try to get Resident #21 out more to participate in activities actively or passively.-They don't have any music playing in Resident #21's room, but he/she thought that before the resident moved to his/her current room, he/she did have a radio.-He/She could try to get the resident something to play music in his/her room.-He/She would explore other activities the resident may enjoy to participate in.-He/She would work on improving the activity program for the residents and providing activities for those residents who were not able to come to activities, who were more cognitively impaired or who needed more one to one activity plans.

Based on observation, interview, and record review, the facility failed to ensure physician's orders were accurately transcribe to include the Intravenous (IV, a way of giving a drug or other fluids through a needle or tube inserted into a vein) infusion rate (flow rate) for IV Vancomycin (antibiotic, used to treat severe bacterial infection) for one sampled resident (Resident #5) out of 16 sampled residents. The facility census was 46 residents.Review of the facility's Medication Order Policy dated 11/2014 showed: -Intravenous orders need to be specify the type of solution, rate of flow and volume to be infused. 1. Review of Resident's #5 admission Record showed the resident readmitted with diagnosis to include Clostridium difficile, (C-Diff is bacterial infection which causes watery or bloody diarrhea). Record review of the quarterly Annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 8/15/25 showed he/she:-Was cognitively intact.-He/She was able to understand others and make his/her needs known. Review of the resident's admission Note dated 8/29/25 at 5:06 P.M., showed: -The resident arrived at the facility around 4:30 P.M. from hospital. -He/She was admitted with diagnosis of C-Diff.-He/She returned with a single lumen Peripherally Inserted Central Catheter (PICC, is a thin, flexible tube that is inserted into a vein in the upper arm for IV therapy) line to his/her upper left arm. -He/She was admitted with order for IV vancomycin (antibiotic).-NOTE: No documentation related to the infusion flow rate. Review of the resident's Physician Order Sheet from 8/29/25 to 9/5/25 showed.-Vancomycin HCl Intravenous Solution 750 milligrams/150mililiter (Vancomycin HCl) Use 750 mg intravenously one time a day related to Enterocolitis due to C-Diff for 14 Days (ordered on 8/30/25 at 11:00 A.M. and stop medication on 9/13/25) -NOTE: The order did not have a detail physician order to include the IV infusion rate and how long to run. Review of the resident's Licensed Nurse Medication Record dated 9/1/25 to 9/30/25 showed:-Vancomycin HCl Intravenous Solution 750 mg/150ml (Vancomycin HCl) Use 750 mg intravenously one time a day related to Enterocolitis due to C-Diff be given for 14 Days. To be administered at 12:00 P.M.-NOTE: Did not have a detail physician order to include the IV infusion rate and how long to run. Review of the resident's Nursing Progress Note dated 9/2/25 at 2:12 A.M. showed:-The resident continues IV Vancomycin to treat C- Diff. -NOTE: No documentation related to the IV infusion flow rate. Observation of the resident's on 9/3/25 at 3:03 P.M. showed:-Licensed Practical Nurse (LPN) A entered the resident's room to disconnect the IV therapy and flushed the resident's PICC line. -The resident's antibiotic was still running with 1/4 of bag left. Observation of the resident's IV therapy on 9/4/25 at 2:28 P.M., showed: -The Director of Nursing (DON) obtained the resident bag of IV antibiotic solution.-He/She set the IV pump machine to infuse rate of 120 ml/hour for 75 minutes. -The IV bag had a pharmacy label with the resident name and to administer the medication over 75 minutes. Observation and interview on 9/5/25 at 9:40 A.M., with LPN A showed: -Review of the resident's physician orders did not have a details order to include the IV antibiotic infusion flow rate. -He/She had been administering per the pharmacy label which noted the IV antibiotic bag to infusion rate to run for 75 minutes. (did not have infusion rate on the bag label)-LPN A said he/she would expect the resident physician order to be detail to include IV infusion rate for IV Vancomycin. -He/She had reviewed the resident's hospital discharge order and instruction which did not have detail orders related to infusion rate. During an interview on 9/5/25 at 11:54 A.M., Infection Control Preventionist (ICP) said: -He/She had only audited the resident's physician order one time.-He/She would expect the resident to have comprehensive physician order for IV therapy to include the infusion rate per hour. During an interview on 9/5/25 at 2:18 P.M., DON said:-He/She would expect physician order to be detail and comprehensive. -He/She would expect the resident's physician order for IV antibiotic to include the infusion rate of 120 ml/hr over 75 minutes. -Nursing staff were to document in the resident licensed MAR and in the resident nursing note care task when completed. -The nursing staff and the DON would be responsible for ensure complete physician orders.-The Administrator and DON would complete any audits of the resident medical record to include accurately transcribe physician orders

Based on observation, interview and record review, the facility failed to ensure obtain physician orders for the monitoring and daily care of indwelling Foley catheter (a urinary bladder catheter inserted through urethra) and failed to have documentation monitoring and care of the foley catheter for one sampled resident (Resident #13) out 16 sampled residents, was at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system). The facility resident census of 46 resident. Review of the facility's Treatment Order Policy dated 7/2016 showed when ordering treatments need to specify the treatment, frequency and duration of the treatment. Received copy of facility Catheter Care, Urinary policy dated 8/2022 showed:-Indwelling foley catheter (is a tube retaining a balloon passed through the urethra into the bladder to drain urine). -Position the catheter drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. -Document in the resident medical record to include date and time catheter care was given and name and tile of persons provided the care, character of the urine such as color, clarity and odor noted; assess the skin around the catheter insertion site. 1. Review of Resident #13 admission Record showed the resident admitted with diagnosis of a Flaccid Neuropathic Bladder (is a condition where the bladder muscles are weakened or paralyzed, leading to difficulty or inability to urinate) Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) form, dated 7/16/25 showed:-The resident moderately cognitive impaired. -He/She able to make his/her known and understand others most of time. -Requires use of an indwelling foley catheter. -Had diagnosis of neurogenic bladder and instructed uropathy Review of the resident's infection note dated 7/24/25 at 2:22 A.M., showed:The resident continued to be on antibiotic for Urinary tract Infection (UTI, is an infection of one or more structures in the urinary system)-The resident denies any signs or symptoms of adverse reaction. -He/She denies pain at this time and is resting in bed comfortably. Review of the resident's Catheter Care Plan updated on 9/1/25 showed:-The resident has an indwelling catheter related to neurogenic bladder.--Licensed Nurses and Certified Nurse Assistant were to monitor foley catheter and document per facility policy.--The resident prefers dependent drainage bag to be placed onto bed when receiving personal care in bed, due to urethral sensitivity, was updated on 9/3/25. -NOTE: no care plan related how and when to provide perineal and catheter care for the resident. Review of the resident's Physican Order Sheet (POS) dated 9/2025 showed: -The resident Foley Catheter type was a 16 French (FR, size of the catheter) with a 30-milliliter (ml) Balloon. Change foley catheter as needed for clinical indications such as infection, obstruction, or when system is compromised related to diagnosis of Flaccid Neurogenic Bladder.-NOTE: Did not have comprehensive physician order for the ongoing monitoring and daily care for the resident foley catheter. Review of the resident's Treatment Administration Record (TAR) dated 9/1/25 to 9/30/25 showed: -Foley Catheter was a 16 FR/30cc Balloon, change as needed for clinical indications such as infection, obstruction, or when system is compromised related to diagnosis of Flaccid Neurogenic Bladder.-Did not have detail physician order for the care staff to provide ongoing monitoring and daily care for the resident foley catheter. -Did not find documentation of licensed nursing staff provided daily monitoring and assessment and provided daily catheter care. Observation of the resident's on 9/2/25 at 3:00 P.M., showed:-His/Her foley catheter drainage bag was in privacy bag hung on side bed rail. -Resident denied any concern with catheter care and had no current urinary infection at that time. Observation of the resident's catheter care on 9/3/25 at 10:22 A.M. showed:-Certified Medication Technician (CMT) A and Certified Nurse Assistant (CNA) C enter the resident room after they had washed hand, then applied gown and gloves. -When uncovered the resident for care, his/her catheter drainage bag laid on top of bed by the resident's feet. -The CNAs did not lower the bag to kept below the resident bladder during catheter care. -Catheter/perineal care (is the surface area between the thighs extending from the pubic bone to the tail bone) performed by CMT A.-CNA C and CMT A had completed catheter care/peri care with no concern noted. During interview on 9/3/25 at10:45 A.M., CMT A and CNA C said.-The resident's catheter bag should be laid on the bed during care, so does not pull the resident catheter tube when turning the resident. -The catheter drainage bag should be below the bladder in privacy bag after catheter care was completed. -He/She was unsure of the facility policy related to catheter care and placement of the catheter bag during personal cares. During an interview on 9/3/25 at 2:17 P.M., the resident said he/she recently had requested the catheter drainage bag be placed on bed during peri care due to pulling and sensitive of catheter site. Review of the resident's electronic medical record on 9/5/25 at 9:23 A.M., showed CNA's Task section did not have a catheter task to document catheter care was provided for the resident. Review of the resident's POS and TAR on 9/5/25 at 9:40 A.M., with Licensed Practical Nurse (LPN) A showed:-The resident did not have physician order for ongoing monitoring, assessment and care for the resident foley catheter. -LPN A said the resident should have PO to include type catheter care to provide and monitoring required. -Would expect to have documentation by nursing staff in the resident TAR, monitoring and catheter care provided for the resident. -Administrative staff were responsible for auditing the physician order to ensure have a complete comprehensive physician order. During an interview on 9/5/25 at 11:39 A.M., CNA A said he/she would document resident care including catheter care in the resident's Electonic Medical Record. During an interview on 9/5/25 at 11:54 A.M., with Infection Control Preventionist (ICP) said: -He/She had audited the resident's physician order one time after resident readmitted to the facility.-He/She would expect for the resident to have complete comprehensive physician order for nursing staff to provide catheter care and monitoring for infections. -Nursing should ensure to have documentation catheter care and assessment in the resident TAR and nursing notes. During an interview on 9/5/25 at 2:18 P.M., DON and Administrator said:-Best standard of practice he/she would expect the resident's catheter drainage bag remain below the bladder at all times.-The resident requested the foley drainage bag placed on the bed while CNA provide peri care. -The facility had just care planned the resident's request. -He/She would expect physician order to be detail and comprehensive. -He/She would expect the resident's physician order for the foley catheter to include the type of monitoring, catheter care to provide and when.-Nursing staff were to document catheter care and assessment in the resident's TAR and in the resident's nursing notes as completed. -CNA's who provide resident's catheter/peri care would document cares under the CNAs care task section in the resident's electronic medical records. -The nursing staff and the Director of Nursing (DON) would be responsible for ensure complete physician orders.-The Administrator and DON would complete any audits of the resident medical record to include accurately transcription of physician orders.

Based on observation, interview and record review, the facility failed to follow one sampled resident's nutritional plan for maintaining weight by failing to obtain and provide a physician ordered appetite stimulant in a timely manner and failing to provide a supplemental health shake at breakfast for one sampled resident (Resident #15) who was at risk for weight loss and needed substantial assistance to eat and drink out of 16 residents. The facility census was 46 residents.Review of the facility Nutrition (Impaired)/Unplanned Weight Loss policy and procedure dated September 2012, showed:-The staff and physician will define the resident's nutritional status and identify individuals with weight loss or gain and significant risk for impaired nutrition.-The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss or impaired nutrition.-The staff and physician will identify any pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes.-The physician will authorize appropriate interventions as indicated.-The physician will limit prescribing of appetite stimulants to situations in which underlying causes cannot be identified or treated, other pertinent interventions have not worked or are not feasible, these medications have a valid indication, and improving appetite and weight is consistent with the individual's condition, prognosis and wishes.-When medical conditions or medication related adverse consequences are causing or contributing to altered nutritional status, the physician and staff will collaborate in adjusting interventions, taking into account the status of those causes and the resident/patient's responses, goals, wishes, prognosis and complications.-The policy did not address following of physician's nutritional orders or Dietician recommendations. 1.Review of Resident #15's Face Sheet showed the resident was admitted on [DATE] with diagnoses including dementia, high blood pressure, cognitive communication deficit, aphasia (a language disorder that affects a person's ability to communicate through speaking, understanding, writing and reading) and insomnia (sleep difficulty). Review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/1/25 showed the entry tracking record but the assessment was not completed. Review of the resident's Physician's Order Sheet (POS) dated [DATE], showed physician's order for:-Regular diet, Regular texture, Regular/Thin consistency.-Health Shake with meals for nutrition (7/31/25).-House Supplement two times a day 60 milliliters (ml), twice daily with medication pass for nutrition maintenance (7/31/25).-Dronabinol 2.5 milligrams (mg) three times daily for appetite stimulant (9/1/25). -Weekly weights every Friday on the day shift (8/1/25). Review of the resident's Nursing Notes dated 7/1/25 showed:-Nursing staff discussed resident medications with both daughters in the resident's room and discussed the resident's likes and dislikes related to foods.-The resident's daughters stated that on a normal day at the resident's home, he/she ate a good breakfast, big lunch, and a light dinner.-The resident sat in the dining room tonight for evening meal with his/her daughter at his/her side. The resident had difficulty staying on task to eat due to being overstimulated and looking at everyone in the room. The resident's daughters asked that resident may do better if seated toward the windows until he/she gets adjusted to facility. Review of the resident's Care Plan dated 7/1/25 showed the resident had dementia with a self-care performance deficit due to impaired cognitive function and thought process and was at nutritional risk. Interventions showed staff would:-Determine the resident's ability to chew and swallow.-Modify the resident's diet as appropriate according to the resident's food tolerances and preferences.-An update on 8/6/25 showed the resident was at risk foe weight loss and was admitted to Hospice on 7/4/25 due to a diagnosis of senile degeneration of the brain.-There were no updates showing interventions that were implemented to maintain the resident's nutritional status. Review of Dietary Notes showed:-7/31/25 the Registered Dietician (RD) recommended weekly weights, house supplement 60ml twice daily, a health shake with meals, and to assist the resident with meals as needed.-8/29/25 the RD recommended changing the resident's diet to any items or preferences acceptable. staff currently offers substitutes, and family brings in take-out food daily. The resident is on hospice and weight loss with appetite changes are to be expected as natural progression of his/her disease occurs. Review of the resident's Medication Administration Record (MAR) dated August 2025, showed physician's orders for a house supplement 60 ml, twice daily with medication pass (7/31/25). The MAR showed:-House supplement (protein shake) was given twice daily as ordered.-There was no documentation showing health shakes were given with meals (documentation was not on the MAR). Review of the resident's RD assessment dated [DATE] showed:-The RD completed a Significant Change Assessment, reviewed the resident's medications and labs. He/she noted the resident was now on Hospice (end of life care).-The resident's current diet was regular with poor intake of meals and supplements at this time.-The resident did not attend lunch today.-The resident's August weight was 190.6 pounds.-The resident's weight may fluctuate due to diuretic therapy.-Recommend continuing to offer any items/preferences the resident is able to accept/tolerate, encourage intake. The RD will continue to follow as appropriate/requested. Review of the resident's MAR dated [DATE] showed physician's orders for Dronabinol 2.5 mg, give 1 capsule by mouth three times a day for appetite stimulant (Start date 9/1/25), house supplement 60 ml, twice daily with medication pass (7/31/25). The MAR showed:-House supplement was given as ordered-The physician's orders for Dronabinol were not followed on 9/1/25, 9/2/25, or 9/3/25. The attached note showed 'see notes'.-Notes showed on 9/1/25 the medication was not in yet, on 9/2/25 the medication was not in, the charge nurse was notified, they were waiting on pharmacy to deliver the medication, and the charge nurse advised. On 9/3/25 the medication was not in and the charge nurse was notified.-There was no documentation showing health shakes were given at every meal (documentation was not on the MAR). Observation and interview on 9/3/25 at 10:36 A.M., showed the resident was sitting up in his/her recliner and was alert with significant confusion. He/she was in constant movement (sitting up, leaning back, trying to rise from the chair). His/her adult child was giving him/her a protein shake with a straw and the resident was drinking it. He/she said:-The resident stopped eating on his/her own several weeks ago and now needs substantial assistance to eat and drink.-The resident had been losing weight and they were concerned about his/her nutritional status.-The resident was supposed to receive a health shake at meals, but he/she had not seen the facility nursing staff give it to the resident.-When he/she asked the DM about the shake, he/she said that the facility made their own health shakes to give to the residents who have orders for them.-The family has decided to bring in their own protein shakes so they can ensure the resident receives the protein.-They visit the resident almost daily and bring in shakes and meals and also feed the resident at least one meal daily.-He/She did not know if the resident was also supposed to receive an appetite stimulant or other nutritional interventions implemented to maintain his/her weight.-Today he/she did not eat much breakfast so he/she will be here to feed him/her lunch.-It sometimes took a long time to feed the resident, sometimes up to an hour, due to his constant movement and sometimes he/she will not open his/her mouth. Sometimes he/she will eat well and sometimes he/she will not.-The resident was on Hospice services now, but they still want to try to help him/her to maintain his/her weight. During an interview on 9/4/25 at 8:30 A.M., the DM said:-The resident was supposed to receive health shakes at every meal.-They made their own health shakes that were provided with the resident's meals.-The resident was usually fed in his/her room by nursing staff.-He/She was not sure about the resident's current weight, but the resident's family also came in regularly to feed the resident, they brought meals in for the resident and they also brought in their own protein shakes. Observation on 9/4/25 from 8:33 A.M. to 8:40 A.M., showed:-The resident was sitting in his/her recliner. There was a breakfast tray sitting beside the resident's recliner with a regular diet of cold cereal, a breakfast sandwich (egg, cheese) with two slices of bacon and a health shake supplement with a glass of juice and milk that was within reach of the resident. There were no straws on the tray or table. The resident was not eating, but was squirming in his/her recliner.-At 8:40 A.M. Certified Nursing Assistant (CNA) B, went into the resident's room, sat down and began feeding the resident cereal. The resident was eating while he/she was being fed and did not attempt to feed himself/herself to try to eat his/her bacon himself/herself.-The resident continued to move around while being fed but did not resist eating. CNA B did not attempt to give the resident any of his/her health shake.-At 8:54 A.M., CNA B finished feeding the resident his/her cereal then he/she took the resident's tray away leaving the milk and juice on the resident's tray table, but not the health shake.-CNA B did not come back to the resident's room but began collecting meal trays from other resident rooms. The resident did not attempt to take a drink from any of the beverages on his/her tray table. Observation on 9/4/25 at 12:49 P.M., showed:-The resident was laying down in his/her bed with the covers pulled up. CNA B was also in the resident's room with his/her meal tray that included the health shake. He/she said he/she was getting ready to try to feed him/her.-CNA B put the head of the resident's bed up and began trying to arouse the resident to get him/her to take a bite of food. The resident kept his/her eyes closed and did not respond to trying to get him/her to eat.-CNAN B took his/her health shake with a straw inside, put it to the resident's mouth and the resident immediately began to drink it. He/she drank all of the shake.-CNA B then again began trying to get the resident to take bites of food. CNA B said:-This was the resident's typical behavior at meals.-They try to get him/her to drink his/her shake if he/she won't eat.-This morning, he/she was able to get the resident to eat his/her cereal, and he/she did not give the resident his/her health shake since he/she ate the cereal.-He/She said, he did not act like he would drink it.-The resident usually drinks with the straw, but the straw probably was not on his/her tray this morning.-He/She did not know where the straws were kept (his/her family puts them away) but the resident drank better with the straws the family provides that the ones they have in the facility.-The resident was supposed to receive a health shake at every meal and his/her family also brought shakes in for the resident that they give to him/her when they visit.-Nursing staff were supposed to try to give the resident the health shakes whether he/she ate his/her meal or not.-It could take anywhere from 10 minutes to 45 minutes to feed the resident and lunch was the meal the resident would eat the most.-At breakfast the resident will not eat much or will not stay awake long enough to eat. During an interview on 9/5/25 at 9:59 A.M., Hospice Licensed Practical Nurse (LPN) said:-They started Hospice services due to the resident's brain degeneration and the resident has had subsequent weight loss due to not eating and has a wound they are trying to heal.-He/She initially lost weight because he/she used to walk and would walk all over the building constantly, but now he/she has forgotten how to walk and is not eating.-The resident's weight is currently 191 pounds and they have ordered 60 ml house shake supplement and he/she was also was supposed to receive health shakes with all meals. They recently implemented an appetite stimulant for the resident.-The resident's family also brought in food and protein shakes and fed the resident when they visit.-He/She usually came in the morning and has observed the meal time-He/she said the resident does not eat well but does drink better than he/she eats. -The facility staff was supposed to follow the orders for nutritional maintenance to try to maintain the resident's weight and help with wound healing. During an interview on 9/5/25 at 10:52 A.M., Physician A said:-He/She was the resident's Primary Care Physician and the resident has had some weight loss and they started him on health shake supplements to keep his/her weight up as much as possible.-He/She tried to start an appetite stimulant and initially the family did not want it but they were eventually agreeable.-Nursing staff informed him/her today that the appetite stimulant was ordered but had not come in yet from the pharmacy.-They should have gotten the medication within 24 hours from the pharmacy, but there may have been some issues with the pharmacy.-The charge nurse was going to check on it and get back with him/her today. During an interview on 9/5/25 at 12:45 PM the Director of Nursing (DON) said:-They had an order for an appetite stimulant for the resident but it had not come in from the pharmacy yet.-They still had not received the medication because the medication is a narcotic and it took longer to receive.-In the electronic medical record, if the physician ordered a narcotic medication, sometimes the electronic record did not flag the order which required an extra step to ensure the order goes in.-The physician had to sign to ensure the narcotic was ordered then the pharmacy will send it.-He/She had not checked to ensure the order went through to the physician so he/she could sign off on it and the script then can be routed to the pharmacy to send the medication.-They spoke with the physician today and will have the pharmacy send the medication today. During an interview on 9/5/25 at 2:17 P.M., with the DON and Administrator the DON said:-He/She expected nursing staff to follow the physician's nutritional orders.-Nursing staff should make the attempt to give the resident his/her supplement whether the resident eats his/her meal or not.-The Administrator said the nurse should document in the nursing notes if there is an order for medication that has not been obtained from the pharmacy.-The nurse should document that they notified the physician and the physician should respond within 15 minutes so that a resolution can be made regarding the medication.-They have corrected the issue with the electronic record to ensure physician's narcotic orders were sent and received from the pharmacy timely.

Based on interview and record review, the facility failed to ensure two sampled residents (Residents #4, and #22) were educated on, offered, and/or had the opportunity to decline Influenza vaccinations, failed to document educated on, offered, and/or had the opportunity to decline Pneumococcal vaccinations for two sampled Resident (Resident#4 and #22) out of 16 sampled residents and five supplemental residents. The facility census was 46 residents. Review of the facility's Influenza prevention and control Policy revised 10/2019 showed:-All resident is offered the vaccine unless there is a medical contraindication. Review of the facility's Influenza Vaccine Policy revised 3/2022 showed:-Residents will be offered the Influenza vaccine each year between October 1 and March 31, unless contraindicated or received the vaccine elsewhere during that time. -Prior to the vaccination, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's medical records.-Those residents that received vaccine, the date of the vaccination, lot number, expiration date, person administering and the site of vaccine will be documented in the resident medical record. -Refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record. Review of the facility's Pneumococcal Vaccine policy revised 10/2019 showed:-All residents will be offered pneumococcal vaccines to aid in preventing pneumococcal infections.-Assessment of pneumococcal vaccine status will be conducted with in five working days of the resident's admission if not conducted prior to admission.-Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. -If refuse the vaccine, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the vaccine. -For person who receives the vaccine, the date of vaccination. Lot number, expiration date person administering, and the site of vac [NAME] will be documented in the resident medical record.1. Review of Resident #4's admission Record showed he/she was readmitted to the facility on [DATE].Review of the resident's medical record showed no documentation of the resident's influenza and pneumococcal vaccine status or that the resident received education for the risks or benefits of the vaccine since admission to the facility and annually.2. Review of Resident #22's admission Record showed he/she was admitted to the facility on [DATE].Review of the resident's medical record showed no documentation of the resident's influenza and pneumococcal vaccine status or that the resident received education for the risks or benefits of the vaccine since admission to the facility and annually.3. During an interview on 9/5/25 at 11:41 A.M., Licensed Practical Nurse (LPN) A said:-Resident's Immunization should be documented in electronic record under immunization tab. -Wound Nurse and charge nurse would be responsible for ensuring influenza and pneumococcal vaccine status or that the resident received education for the risks and benefits of the vaccines.During Infection Control Surveillance interview on 9/5/25 at 11:54 A.M., the Infection Control Preventionist (ICP)/Administrator said: -Wound Nurse was responsible for tracking and documented vaccines when given or offered, and to document educated provided related to benefits and risk of the specific vaccine. -The facility was not able to locate request documentation of the sampled resident's vaccine status, education provided and documentation of refusal of the vaccines. -He/She would expect the nursing staff and/or assigned staff member to document immunization into the resident electronic medical record as needed. -The facility has not begun offer flu vaccine for 2025 yet. During an interview on 9/5/25 at 11:45 A.M., Director of Nursing (DON) said:-Wound Nurse and ICP would be responsible for tracking and documentation of the resident's vaccine status or refusal.-Wound Nurse and ICP would be responsible to ensure the resident or representative had received education for the risks or benefits of the vaccine at time of administration, as needed.

Based on observation, interview, and record review, the facility failed to ensure residents who required staff assistance with bathing received baths and/or showers to meet the needs of four sampled residents (Resident #1, Resident #3, Resident #4, and Resident #6) out of six sampled residents. The facility census was 50 residents. The facility was asked for the Bathing/Shower Policy and was provided with a copy of Code of State Regulations 19 CSR 30-85 (67 - 95). -The Administrator said the facility goes by the standard of care, generally two baths per week minimum, unless refused or care plan requests for one bath per week. 1. Review of Resident #1's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Glaucoma (a group of eye conditions that can cause blindness). -Legal blindness (a significant level of vision impairment). Review of the resident's Care Plan dated 2/1/25 showed the resident did not have a Care Plan for Activities of Daily Living (ADLs) for the resident's cares. Review of the resident's entry Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/22/25 showed only the resident's identification information. Review of the resident's paper bath sheets from 1/22/25 to 2/9/25 showed no paper bath sheets were available for review on 2/10/25. Review of the resident's Electronic Medical Record (EMR) on 2/10/25 showed: -Baths for the previous 30 days were provided to the resident on 1/27/25. -Staff documented Not Applicable on 1/31/25 and 2/7/25. Observation and interview on 2/10/25 at 1:16 P.M., showed: -The resident said he/she had only one shower since he/she was admitted to the facility on [DATE]. -He/She had asked the staff for showers, but staff said they did not have the time and were shorthanded. -He/She wants a shower at least twice a week. -He/She had body odor and his/her hair was greasy and uncombed. 2. Review of Resident #3's admission Record showed he/she was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses: -Hemiplegia (paralysis on one side of the body) and Hemiparesis (muscle weakness on one side of the body) following cerebral infraction (stroke) affecting right dominant side. -Legal blindness. Review of the resident's undated Care Plan showed the resident required moderate assistance from staff for bathing. Review of the resident quarterly MDS dated [DATE] showed the resident: -Was moderately cognitively impaired. -Required substantial/maximum assistance by staff for bathing. Review of the resident's EMR on 2/10/25 showed baths for the previous 30 days were provided to the resident twice on 1/28/25, 1/29/25, 2/1/25, and 2/8/25. Review of the resident's paper bath sheets for the previous 30 days showed baths were offered and/or received: -The resident received two baths from 1/10/25 - 1/28/25. -The resident received one bath from 1/29/25 - 2/9/25. During an interview on 2/10/25 at 1:31 P.M., showed: -The resident had requested showers at least once a week but was not getting them. -He/She went about a month without a shower before finally getting one at the end of January. -He/She requires staff to help him/her with the bath/shower. -He/She does not care what day or time he/she just wants a bath/shower. -He/She feels dirty, and it upsets him/her when no showers are given. -He/She was given a shower on 2/8/25. 3. Review of Resident #4's admission Record showed he/she was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of Hemiplegia (a medical condition that causes paralysis or weakness on one side of the body) and Hemiparesis following a cerebral infraction affecting his/her left non-dominant side. Review of the resident's undated Care Plan showed the resident required max assistance of two staff with showering twice weekly and as necessary. Review of the resident's quarterly MDS dated [DATE] showed the resident: -Was moderately cognitively impaired. -Was totally dependent on staff for bathing. Review of the resident's EMR on 2/10/25 showed baths for the previous 30 days were provided to the resident on 1/17/25 and 1/30/25. Staff documented not applicable on 1/14/25, 1/21/25, and 2/4/25. Review of the resident's paper bath sheets from 1/10/25 to 2/9/25 showed no paper bath sheets were provided on 2/10/25. Observation and interview on 2/10/25 at 2:01 P.M., showed: -The resident did not answer any questions. -He/She just sat in his/her wheelchair and looked down at the floor. -He/She had body odor and his/her hair was greasy. 4. Review of Resident #6's admission Record showed he/she was admitted to the facility on [DATE] with a diagnosis of unspecified dementia (the loss of cognitive functioning, thinking, remembering, and reasoning that interferes with daily life and activities). Review of the resident's undated Care Plan showed the resident: -Provide sponge bath when a full bath or shower cannot be tolerated. -The resident requires partial/moderate assistance by one staff with showering twice a week in the afternoon and as necessary. Review of the resident's quarterly MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Required substantial/maximal assistance by staff for bathing. Review of the resident's EMR on 2/10/25 showed baths for the previous 30 days were provided to the resident on 1/15/25, 1/19/25, and 1/26/25. Staff documented not applicable on 1/12/25. Review of the resident's paper bath sheets from 1/10/25 to 2/9/25 showed no paper bath sheets were provided on 2/10/25. Observation and interview on 2/10/25 at 2:15 P.M., showed: -The resident was not interview able due to being severely cognitively impaired. -His/her hair was greasy. 5. During an interview on 2/10/25 at 2:29 P.M., Certified Nursing Assistant (CNA) A said: -They have a bath aide to give the residents their baths/showers when he/she had the time. -No baths/showers are given on the days the bath aide was off because there was not enough staff to give them. -Resident should get two baths/showers a week and as needed. -Each bath/shower should be documented in the resident's chart. During an interview on 2/10/25 at 2:46 P.M., Licensed Practical Nurse (LPN) A said: -Residents are to be offered two baths/showers a week. -They do not have enough staff to give two baths/showers a week. -They do have a bath aide that works 12-hour days for three days then off two days. -The bath aide gets pulled to work the floor as a CNA and is not able to give all of the residents scheduled that day a bath/shower. -No baths/showers are given on the bath aides days off. -The CNAs were expected to give the residents on the hall that they were working on a shower if due, but they do not have enough help to do that. -A shower sheet was to be filled out anytime a resident was given a bath/shower or refuses a bath/shower. During an interview on 2/10/25 at 3:41 P.M., the Administrator said: -The bath/shower aide was pulled to work the floor on some days when a CNA was needed. -When that happens, all CNAs are responsible for giving their assigned residents a bath/shower if it was the residents assigned day. -The residents were not receiving showers on the bath aide's days off. -He/she had been working on making sure the residents get their baths/showers on the bath aide's days off by educating the staff that all CNAs are responsible for bath/showers. -He/she had hired a new bath aide for evenings and they start work on 2/11/25. -The shower days are to be scheduled days and not moved around to when every they have time to give the bath/shower. -Some CNAs chart bath/showers in EMR and other CNAs fill out shower sheets and give then to the nurses. -They go by the standard of care generally two baths/showers per week minimum, unless refused or care plan requests for one bath/shower per week. MO00249049 MO00249262

Based on interview, and record review, the facility failed to provide oversight and put appropriate interventions in place for one sampled resident (Resident #1) who fell twice on 12/27/24 and sustained head lacerations and then fell again on 1/3/25; failed to ensure fall investigations were completed to include root-cause analysis (RCA-a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems) and interventions that were put in place for three sampled residents (Resident #1, Resident #6, and Resident #7); failed to complete neurological checks for one sampled resident (Resident #6) after an un-witnessed fall, and failed to update the care plans for three sampled residents (Resident #1, Resident #6, and Resident #7) to include the interventions that were put in to place after the falls occurred out of seven sampled residents. The facility census was 47 residents. Review of the facility's policy titled Falls and Fall Risk, Managing dated March 2018 showed: -A fall was defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. -An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught himself/herself. -A fall without injury was still a fall. -Unless there was evidence suggesting otherwise, when a resident was found on the floor, a fall would be considered to have occurred. -The staff, with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. -If a systematic evaluation of a resident's fall risk identified several possible interventions, the staff may choose to prioritize interventions. -In conjunction with the consultant pharmacist and nursing staff, the attending physician would identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped, even if for a trial period. -If falls were to continue to occur despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remains relevant. -If underlying causes could not be readily identified or corrected, staff would try various interventions, based on assessment of the nature or category of falling, until was reduced or stopped, or until the reason for continuation of the falling was identified as unavoidable. -In conjunction with the attending physician, staff would identify and implement relevant interventions to try to minimize serious consequences of falling. -The staff would monitor and document each resident's response to interventions intended to reduce falling of the risks of falling. -If interventions were successful in preventing falling, staff would continue the interventions or reconsider whether the measures were still needed if a problem that required the intervention had resolved. -If the resident continued to fall, the staff would re-evaluate the situation and whether it was appropriate to continue or change current interventions. -The staff and/or physician would document the basis for conclusions that specific risk factors existed that would continue to present a risk for falling or injury due to falls. Review of the facility's policy titled Neurological Assessment dated October 2023 showed routine neurological assessments were conducted to evaluate the resident for small changes over time that may be indicative of a neurological injury. 1. Review of Resident #1's admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses: - Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, mostly affecting middle-aged and elderly people) with Dyskinesia (abnormality or impairment of voluntary movement). -Unspecified Convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders). -Traumatic Brain Hemorrhage (an escape of blood from a ruptured blood vessel) of Left Cerebrum (the largest part of the brain that is divided into two hemispheres) with Loss of Consciousness of Unspecified Duration. -Muscle Wasting and Atrophy (thinning of muscle mass). -Old Myocardial Infarction (heart attack- a blockage of blood flow to the heart muscle). -Difficulty in Walking. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 11/13/24 showed: -The resident was cognitively intact. -The resident had no Range-of-Motion (ROM) impairment. -The resident had not used any mobility devices. -The resident was independent with all care. -The resident had not had any falls since admission. Review of the resident's Fall Risk Evaluation completed on 12/23/24 at 6:07 P.M. showed: -The resident had one to two falls in the past three months. -The resident was ambulatory and continent. -The resident had predisposing diseases including Parkinson's Disease and seizures, which increased his/her fall risk. -The resident did not take any predisposing medications that would increase his/her risk for falls. -There were no clinical suggestions noted. Review of the resident's care plan dated 12/25/24 showed: -The resident had an Activities of Daily Living (ADLs) self-care performance deficit related to multiple health diagnoses with the resident being able to transfer independently. -The resident had Parkinson's Disease affecting mobility and staff were to monitor for risk of falls. -The resident had an actual fall with no injury on 8/31/24 with the following interventions: --Continue interventions on the at-risk plan. --Ensure all medications were ordered from pharmacy in a timely manner. --For no apparent acute injury, staff were to determine and address causative factors of the fall. --Monitor/document/report Pro re Nata (PRN- as needed) for 72 hours to medical director for signs and symptoms of pain, bruises, change in mental status, and new onset of confusion, sleepiness, inability to maintain posture, or agitation. --Neurological Checks per facility policy. --Pharmacy consult to evaluate medications. --Provide activities that promote exercise and strength building where possible. -All interventions for falls were placed in the resident's care plan after this initial fall only. -The resident's fall care plan was not updated upon re-admission or after each fall to include any new interventions that were put in place. Review of the resident's incident note dated 12/27/24 at 5:00 A.M. that Licensed Practical Nurse (LPN) B completed showed: -The nurse had been called into the resident's room and found the resident lying to the side of his/her fall mat. -Blood was coming from the back of the resident's head due to a laceration. -The nurse applied a pressure dressing. -Emergency services were called. -The resident stated that he/she was attempting to get his/her walker so he/she could go downstairs. -The resident was transferred to a gurney and was awake and alert upon leaving the facility to go to the local hospital. Review of the resident's Incident Audit Report dated 12/27/24 at 5:00 A.M. showed: -The resident had an un-witnessed fall. -The resident had been found on the floor next to his/her fall mat. -The resident was laying on his/her left side with his/her head propped up by his/her left arm. -The resident was awake and was apologizing for falling. -The resident was bleeding from laceration to the occipital region of skull. -The depth of the laceration was unable to be determined. -A pressure dressing had been applied. -The resident stated I was trying to get to my walker to go downstairs. I'm sorry. -The action that was taken at the time was applying the pressure bandage. -The resident was normally wheelchair bound. -The predisposing physiological factors included: --Confusion. --Gait imbalance. --Impaired memory. --Incontinence. --Recent change in condition. --Weakness/fainting. -No RCA was determined for this fall. -No interventions post-fall were documented. Review of the resident's emergency room (ER) Documentation dated 12/27/24 at 7:07 A.M. showed: -The resident was sent to the ER after a fall. -The resident was trying to test his/her ambulation. -The resident complained of right hip pain. -The resident had a two-inch laceration to the left back side of his/her head. -The resident had a laceration repair that required two staples. Review of the resident's Fall Risk Evaluation dated 12/27/24 at 1:05 P.M. showed: -The resident had three or more falls in the last three months. -The resident had intermittent confusion. -The resident was ambulatory and continent. -The resident did not have any predisposing diseases. -The resident had a recent change in condition. -The resident had a balance problem while standing. -The resident had a balance problem while walking. -The resident had decreased muscular coordination. -The resident required the use of assistive devices. -The resident took one to two predisposing medications including anti-seizure medication that would increase the resident's risk for falls. -There were no clinical suggestions noted. Review of the resident's incident note dated 12/27/24 at 4:13 P.M. completed by LPN A showed: -The nurse was called into the resident's room by the speech therapist. -The resident was on the floor behind his/her door. -The resident was on his/her stomach with blood on the floor from the resident's head. -The resident was awake and alert. -There was no reported further injury aside from the previous laceration from the fall that morning. -The resident was assessed and assisted up with two staff members and was placed in his/her wheelchair. -The nurse applied a pressure dressing to the resident's head to get the bleeding to stop. -Once the bleeding had stopped, the nurse had attempted to clean the resident's head and hair. -No new laceration noted. -The dressing had been placed on laceration along with rolled gauze. NOTE: There was no investigation or Incident Audit Report completed for this fall. Review of the resident's Transfer to Hospital Summary dated 12/27/24 at 7:30 P.M. completed by LPN B showed: -The nurse had approached the resident's room to greet the resident. -The resident was noted to be laying in bed with his/her pillow saturated in blood. -The resident had an abdominal (ABD) pad (a specialized medical dressing designed to manage and protect moderate to heavily exuding wounds) wrapped with Kerlix (a white gauze dressing/bandage) as a pressure dressing to his/her head. -The pressure dressing was completely saturated with blood. -The nurse alerted the day shift nurse of the finding and alerted the medical director. -New orders were given to send the resident to the emergency department (ED) for evaluation and treatment due to excessive bleeding. -The nurse assisted the resident into a sitting position and removed the saturated dressing. -The nurse assessed the resident's head and found a new laceration. -The nurse cleansed the wound. Applied a new ABD pad and secured the pad with Kerlix and Coban (a self-adhering bandage). -The resident was then transported to the local hospital by Emergency Medical Services (EMS). Review of the resident's ED-Physician Note dated 12/28/24 at 12:10 A.M. showed: -The resident had been seen in the ED for a fall and that the resident had hit the back of his/her head. -The resident had a four centimeter (cm) curved scalp laceration in his/her superior (top) occipital region with a small amount of oozing blood. -The resident received four staples to this area. -The resident's staples from the previous fall were still intact. Review of the resident's Health Status Note dated 12/28/24 at 1:00 A.M. completed by LPN B showed: -He/She had been notified by the local hospital's ED at 12:18 A.M. that the resident was discharging back to the facility. -The resident had another set of staples placed in order to close the new laceration to the resident's skull. -The resident arrived back to the facility at 1:00 A.M. -The resident was transferred to bed from the EMS gurney. -The nurse educated the resident on the importance of using the call light when in need of assistance. -The resident stated, I think I learned my lesson. -The nurse acknowledged the new orders. Review of a note in the resident's electronic medical record (EMR) dated 12/30/24 at 9:48 A.M. showed: -A bike helmet was brought in for the resident to wear when out of bed. -The resident was able to put on and take off the helmet independently. Review of the resident's admission MDS dated [DATE] showed: -The resident had moderately impaired cognition. -The resident had a fall in the last 2-6 months prior to admission. -The resident had two falls since admission. -The resident had one fall with no injury. -The resident had one fall with injury (except major) which included skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains, or any fall-related injury that causes the resident to complain of pain. -The resident used a wheelchair as a mobility device. -The resident was able to sit to stand (the ability to safely come to a standing position from sitting in a chair or on the side of the bed) with partial/moderate assistance (helper does less than half the effort). Review of the resident's Transfer to Hospital Summary dated 1/3/25 at 8:15 P.M. showed: -The resident was noted to be on the floor to the right side of his/her bed. -The resident's body was on the fall mat, but the resident's head was pressed up against the wall. -Blood was noted on the resident's right side of head and forehead. -A pressure bandage was applied, and the resident was sent to the local ED for evaluation and treatment. -The resident returned to the facility with no new orders around 2:30 A.M. -The resident was started on fall follow-up monitoring. -No specific injury was noted. NOTE: There was no investigation or Incident Report Audit completed for this fall. Review of the resident's hospital records dated 1/4/25 at 2:42 A.M. showed: -The resident had received a Computerized Tomography (CT) Scan of the head and spine with no acute findings. -The resident had an abrasion to his/her left posterior (back) scalp. -The abrasion had stopped bleeding. -The resident showed no signs of distress and was discharged back to the facility. 2. Review of Resident #6's admission Record showed he/she admitted to the facility with the following diagnoses: -Vascular Dementia (a general term describing problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage from impaired blood flow to the brain). -Epilepsy (a disorder in which nerve cell activity in the brain is disrupted, causing seizures). -Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow to the brain). -Muscle Weakness. -Unspecified Lack of Coordination. -Difficulty in Walking. Review of the resident's quarterly MDS dated [DATE] showed: -The resident was cognitively intact. -The resident used a walker. -The resident was able to move independently. -The resident had not had any falls since admission. Review of the resident's Incident Audit Report dated 12/30/24 at 2:30 P.M. showed: -The resident had an un-witnessed fall. -The nurse had been alerted by a Certified Nurses Aide (CNA) that the resident was found on the floor. -The CNA had recently assisted the resident into bed. -The resident was found sitting on the floor between the legs of the chair with his/her arms above his/her head. -The resident stated that he/she had pain in his/her left arm, but there were no visible injuries. -Resident was assisted up by the nurse and two CNAs and into his/her wheelchair. -The resident had stated that he/she wanted to get up and then fell. -The immediate actions that were taken: --Resident was assisted to his/her recliner. --The resident's bed was adjusted for better clearance of the resident's wheelchair. --The resident was educated to use his/her call light when feeling weak. -The report did not include the RCA of the fall. -NOTE: No neurochecks were completed for a resident who was moderately cognitively impaired. Review of the resident's undated care plan showed: -The resident was at risk for falls with a goal for the resident to be free from falls with the following interventions: --Assist resident with ambulation and transfers. --Determine the resident's ability to transfer. --Evaluate fall risk upon admission and PRN. --If fall occurs, notify provider. --If fall occurs, initiate frequent neurological assessments and bleeding evaluation per facility protocol. --If resident was a fall risk, initiate fall risk precautions. NOTE: The resident did not have an updated care plan related to any actual falls or any fall interventions that were put into place. A copy of the resident's Neurological Assessments for this fall were requested and not received at the time of exit. 3. Review of Resident #7's admission Record showed he/she admitted to the facility with the following diagnoses: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses. -Muscle Weakness. -Difficulty in Walking. -Unspecified Lack of Coordination. Review of the resident's undated care plan showed: -The resident had an ADL self-performance deficit related to a recent hospitalization and the resident was able to independently transfer using his/her walker. -The resident was at moderate risk for falls related to a history of falls prior to admission with a goal that the resident would be free from falls with the following interventions: -Anticipate and meet the resident's needs. --Ensure call light was within reach. --Educate resident/family/caregivers about safety reminders and what to do if a fall were to occur. --Follow facility fall protocol. --Review information on past falls and attempt to determine cause of falls. NOTE: The resident did not have an updated care plan related to any actual falls or interventions that were put into place after falls occurred. Review of the resident's admission MDS dated [DATE] showed: -The resident had moderately impaired cognition. -The resident used a walker and a wheelchair. - The resident was able to go from sitting to standing with partial/moderate assistance. -The resident needed partial/moderate assistance to walk ten feet. -The resident was dependent (helper does all of the effort and the resident does none of the effort to complete the activity) when wheeling more than 150 feet in his/her wheelchair. -The resident had a fall two to six months prior to admission to the facility. Review of the resident's Incident Audit Report dated 1/8/25 at 4:05 P.M. showed: -The resident had a witnessed fall. -The resident was witnessed by a Certified Medication Technician (CMT) standing at his/her closet hanging up a coat. -The resident lost his/her balance and landed on his/her buttock. -The CMT assisted the resident to a lying position with a pillow underneath his/her head. -The resident was assessed by the charge nurse and no injuries were noted. -The resident denied any pain. -The resident was assisted by two staff members onto his/her feet. -The staff assisted the resident into a chair. -The resident had not used his/her wheelchair and walker that were in her room and had not called for assistance. -There were no documented fall interventions that the facility put in place after the fall occurred. Review of the resident's Incident Audit Report dated 1/17/25 at 9:39 P.M. showed: -The resident had an un-witnessed fall. -A nursing aide (NA) had found the resident on the floor in his/her bathroom. -The resident stated that he/she had tried to take himself/herself to the bathroom and fell. -The resident had stated that he/she hit his/her head on the door frame. -The resident had scrapes to his/her knees, but they were not bleeding. -There was no noticeable injury to the resident's head. -The resident was assisted up and onto the toilet without difficulty. -The resident had pain to his/her head. -The resident became emotional and was upset about not being able to do his/her own things. -He/She did not want to have to ask the nurses for assistance. -The resident was educated on the importance of using his/her call light. -The report did not include the RCA of the fall. 4. During an interview on 1/24/25 at 11:15 A.M. the Director of Nursing (DON) said: -There was only one incident report for all of Resident #1's falls. -The nurses had only been doing progress notes for his/her other falls. -He/She was unaware the fall investigations were not completed. During an interview on 1/24/25 at 2:24 P.M. CNA A said: -CNAs were responsible for getting the nurse if they witnessed a fall or if they found a resident on the ground. -The CNAs could assist in getting the vital signs of the resident and helping the resident up if indicated. -All care staff could help perform the Neurological Assessments, but the nurses were the ones that completed the assessment and placed the findings in the resident's chart. -Resident #1 refused to use his/her call light and would get up without staff assistance, causing the falls. -Resident #1 had fall mats on both sides of his/her bed, but that was the only fall intervention that was put in place that he/she could think of. -Resident #6's falls normally occurred during the night. -Resident #6 had difficulty in asking for help but seemed to be getting better. -He/She remembered that Resident #7 had fallen in the bathroom, and that the resident did not like using his/her call light. -The fall intervention for Resident #6 and Resident #7 was education related to call light use. -He/She thought if a resident fell, then neurological assessments were mandated to be completed. -The neurological assessments were done for 48 hours in total. -Nurses were responsible for completing the fall investigations and updating the care plan. -The Administrator was responsible for ensuring the completion of the fall investigations. During an interview on 1/24/25 at 2:32 P.M. LPN A said: -He/She had been in the building during one of Resident #1's falls, his/her second fall on 12/27/24. -Resident #1 had told LPN A that he/she was trying to get up to go to the bathroom. -Resident #1 would also acknowledge that he/she had not used the call light. -When he/she assessed Resident #1, he/she could not tell where the resident was bleeding from, so he/she had applied a pressure dressing to the resident's head. -He/she was unaware the resident had a second injury to the head. -He/she did not put any interventions in place after the second fall. -He/She thought neurological assessments were completed for un-witnessed falls. -The CNAs could get the vital signs for the neurological assessments, but the nurses were responsible for all other parts of the assessment and would document the results in the resident's medical record. -The facility was not responsible for completing the neurological assessments if the resident was sent to the ER and had a CT scan done with negative findings. -He/She had only worked at the facility for a month. -He/She was unsure of the facility's policy related neurological assessments. -There should have been neurological assessments completed for Resident #6's fall. -He/She was unsure who completed the fall investigations. -He/She thought there was a form that the nurses could fill out after a fall occurred, but she was unsure of the facility's policy related to fall investigations. -He/She expected the CNAs or other floor staff to report all falls to the charge nurse. -He/She was unsure of the fall interventions that were in place for Resident #1, Resident #6, and Resident #7. -He/She confirmed the issues with the fall investigations for Resident #1, Resident #6, and Resident #7 as they did not show RCA or specific interventions that were put in place. -The nurses were not responsible for any part of the care planning process. -Care plans needed to be updated after every fall that occurred. -He/She was unsure why Resident #1, Resident #6 and Resident #7 did not have updated care plans. -Usually care plans would show the date of each fall and the intervention(s) that were put in place. During an interview on 1/24/25 at 3:05 P.M. the DON said: -He/She was not present for any of Resident #1's falls. -The DON was responsible for completing all fall investigations. -The fall investigations were usually completed in the risk management meetings. -He/She had been informed that there was no place to put the RCA on the fall investigations and that there needed to be a progress note that included RCA and the intervention that was put into place after each fall. -He/She confirmed that an RCA was not completed for Resident #1's fall investigation. -Resident #1 had a bike helmet that was brought in to protect his/her head when out of bed. -Resident #1 also had the following interventions in place: --Fall mats. --His/her bed was moved. --Frequent checks, meaning the resident was checked on every 15-20 minutes. --This was not documented anywhere but remembers this being in place for the resident as standard fall precautions. -Resident #6's intervention was education related to call light usage. -Resident #7's intervention was for him/her to use his/her wheelchair for mobility. -The description of action part of the Incident Audit Report could count as the intervention that was put in place after the fall. -He/She expected the floor nurses to complete the RCA and put interventions in place for each resident fall. -Social Services was responsible for all aspects of the care plan but had been informed since becoming the DON that he/she could also help with care plans. -The care plan did not need to be updated after each fall. -The care plan only needed to be updated if a new intervention was put into place after a fall occurred. -The nurses were responsible for completing the neurological assessments. -Neurological assessments were completed after un-witnessed falls. -The staff did not have to complete neurological assessments when residents came back from the hospital post-fall unless there was a noted head injury. -The DON ensures completion of the neurological assessments. -Neurological assessments should have been completed after Resident #6's fall. During a phone interview on 1/27/24 at 5:44 P.M. Physician A said: -He/She had been notified after each resident's falls. -Resident #1 could ambulate on his/her own and had no mobility restrictions. -He/She thought that Resident #'1 falls were unavoidable, however he/she was unaware that the facility had not been completing thorough fall investigations and were not putting interventions in place after each fall. -Neurological assessments did not need to be completed for residents who were sent out post-fall. -He/She expected staff to complete neurological assessments every hour after a fall and he/she would come in the next day to review them. -He/She was really involved in the resident post-fall care. -He/She was unsure of specific interventions that were put into place for residents post-fall. -He/She was unaware that Resident #1 had a bike helmet as part of the resident's fall interventions. -Anytime a new fall intervention was put into place the staff needed to inform him/her, to be able to approve of the intervention. -The facility needed to complete thorough investigations of each fall including the root cause of the fall. -He/She would review medications and do anything needed to mitigate fall occurrences. -Falls and fall intervention needed to be care planned and updated as needed. MO00248468

Based on observation, interview and record review, the facility failed to ensure residents were adequately groomed by not offering showers or baths for four sampled residents (Resident #1, #2, #3, and #4) out of seven sampled residents. The facility census was 49 residents. Review of the facility' s undated Policy, Professional Standards of Care, showed: -Providing personal care for clients was the primary responsibility of the nursing assistant. -Often referred to as Activities of Daily Living (ADLs), personal care includes anything that a client needs to maintain hygiene, well-being, self-esteem, and dignity. -ADLs were the foundation of health and wellness and a part of providing holistic care. -Standard of two showers a week. -Residents had the right to refuse. -(Staff) would have revisited any refusals. -(Staff) would have care planned residents preference of showers. 1. Review of Resident #1's face sheet showed he/she had been admitted to the facility on [DATE] with the following diagnoses: -Unspecified fall. -Dementia (a group of thinking and social symptoms that interferes with daily functioning. -Epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) -Transient cerebral ischemic attack (TIA - a brief stroke-like attach that, despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke). -Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Muscle weakness. -Difficulty in walking. -Unspecified lack of coordination. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 7/18/24 showed: -He/She was cognitively intact. -He/She used a walker and wheelchair. -He/She need substantial assistance for a shower or bath. Review of the resident's Care Plan dated 5/10/24 showed: -He/She required assistance to shower safely. -He/She would like to shower twice weekly, dated 12/28/24. Review of the residents' shower schedule showed the resident was scheduled to receive a shower on Wednesdays and Saturdays. Review of the resident's shower sheets dated July 2024 showed he/she received a shower on 7/1/24, 7/24/24 and 7/26/24. Review of the resident's records showed there were no showers completed 8/1/24 through 8/6/24. Observation and interview on 8/6/24 at 10:10 A.M. showed: -The resident was still in bed and declined an interview. -He/She looked unkept and his/her hair was oily in appearance. 2. Review of Resident #2's face sheet showed he/she had been admitted to the facility on [DATE] with the following diagnoses: -Dementia. -Unspecified fall. -Chronic pain. -Presence of an artificial hip joint. Review of the resident's Care Plan dated 5/24/24 showed: -He/She had the potential for falls as evidenced by history of incidents and occasional unsteady gait. -Staff was to provide assistance required for bathing weekly and as needed. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was moderately cognitively impaired. -He/She used a walker. -He/She needed moderate assistance to bathe. Review of the resident's shower schedule showed the resident was scheduled to receive a shower on Wednesdays and Saturdays. Review of the resident's shower sheets dated July 2024 showed he/she received a shower on 7/30/24. Review of the resident's records showed there were no showers completed 8/1/24 through 8/6/24. During an interview on 8/6/24 at 10:45 A.M. the resident said: -He/She does not often get a shower. -He/She had to clean himself/herself up at the sink. -His/Her hair felt dirty. -He/She had refused showers in the past but not for a long time. -There was not enough staff to give the residents even one shower a week. 3. Review of Resident #3's face sheet showed he/she had been admitted to the facility on [DATE] with the following diagnoses: -Paranoid schizophrenia (when a person experiences paranoia (fear) that feed into delusions(false belief) and hallucinations (a false perception of objects or events involving your senses; sight, sound, smell, touch or taste). -Mixed anxiety disorders. -Osteoarthritis of knee (when the flexible tissue at the end of the bone wears down). -Edema (water retention). -Extrapyramidal and movement disorder (a variety of movement disorders as a result of taking antipsychotic drugs usually used to control psychosis (a mental disconnect with reality). Review of the resident's Care Plan dated 5/24/24 showed: -He/She had impaired vision. -He/She required assistance to compete daily activities of care safely related to current conditions. -Staff was to bathe him/her as per schedule. Review of the resident's quarterly MDS dated [DATE] showed: -He/She had debility. -He/She had a history of TIA. -He/She had Chronic Obstructive Pulmonary Disease (a group of lung diseases that blocks air flowing making it hard to breathe). -He/She needed partial assistance to bathe. Review of the resident's shower schedule showed the resident was scheduled to receive a shower on Wednesdays and Saturdays. Review of the resident's shower sheets dated July 2024 showed he/she received a shower on 7/1/24 and 7/30/24. Review of the resident's records showed there were no showers completed 8/1/24 through 8/6/24. During an interview on 8/6/24 at 10:30 A.M. the resident said: -He/She would like to have had a shower at least weekly, but there was not enough staff. -He/She would take a sponge bath at the sink but would have liked to have had a shower. -He/She did not feel as clean when only taking a sponge bath. -His/Her skin was dry and flaky. 4. Review of Resident #4's face sheet showed he/she had been admitted to the facility on [DATE] with the following diagnoses: -Osteoarthritis, left hip. -Heart failure (when the heart does not pump blood as effectively as it should). -Cardiac arrhythmia (an irregular heart rhythm). -Pain in left hip. Review of the resident's annual MDS dated [DATE] showed: -He/She used a walker and wheelchair. -He/She needed substantial help to shower or bathe. -He/She had a debility. -He/She had cancer. -He/She had heart failure. -He/She had Peripheral vascular disease (PVD - a narrowed blood vessel). -He/She had End Stage Renal Disease (ERSD - the last stage of kidney failure). Review of the resident's shower schedule showed the resident was scheduled to receive a shower on Wednesdays and Saturdays. Review of the resident's shower sheets dated July 2024 showed he/she received a shower on 7/17/24. Review of the resident's records showed there were no showers completed 8/1/24 through 8/6/24. During an interview on 8/6/24 the resident said: -He/She does not get regular showers. -He/She had to wash up at the sink. -There was not enough staff to get two showers a week like he/she was supposed to have had. -He/She did not like it. -His/Her hair was stringy. 5. During an interview on 8/6/24 at 11:45 A.M. Certified Nursing Assistant (CNA) A said: -He/She did not know how often residents should have been offered a shower. -There was not enough staff to give the residents a weekly shower. -The residents were getting a shower once every two weeks. -There was a shower list which showed which residents were to have received a shower on which day. -There was a shower sheet and they would document on by writing a S for shower done or R for refused. -He/She had offered to work extra by coming in an extra day to just give showers and the corporation refused to pay the overtime. -There was no Shower Aide at this time. During an interview Graduate Licensed Nurse (GLN) A said: -The residents should have been offered a shower or bath twice a week. -At this time the residents were not getting even one shower a week. -There used to be a Shower Aide but he/she was pulled to work as a CNA on the floor. -Currently there was no Shower Aide, the CNAs were to give a shower or bath to the residents on their assigned hallway. -They do not have enough staff to give the residents two showers a week. -The CNAs know to chart on the shower sheet which then goes to the Director of Nursing (DON). During an interview on 8/9/24 at 10:53 A.M. Licensed Practical Nurse (LPN) A said: -The residents should be offered two baths or showers a week. -They do not have enough staff to give two showers a week. -They have hired CNAs and Bath Aides and they would not show up for work. -They did not have a Shower Aide at this time. -The CNAs were expected to give the residents on the hall that they were working on a shower but they don't have enough help to do that. -When a resident received a shower the staff should have filled out the shower sheet form and the form was sent to the DON. During an interview on 8/9/24 at 11:10 A.M. the Administrator said: -They did not have a Shower Aide currently. -They start and then do not show up. -They were currently advertising for a Shower Aide. -The DON was responsible for ensuring the residents were bathed. During an interview on 8/9/24 at 12:10 P.M. the DON said: -The residents should have been offered two showers a week. -They did not have enough staff to offer two showers a week to the residents. -Staff should have documented on the shower sheet when a shower or bath was given to the residents. -If a resident refused then the staff should have documented on the shower sheet and offered a shower at a different time. -He/She received the list of who was given a shower every month and then it was given to the Administrator. -Both him/her and the Administrator were responsible for ensuring the residents had the two showers a week and it has not been done as they don't have enough help although they have advertised for a Shower Aide. -At this time there was not a designated Shower Aide. -As of today 8/9/24 only one shower had been given to a resident in the month of August. MO 00239434 and MO 00239041

Based on interview, and record review, the facility failed to have a certified Infection Preventionalist employed at the facility. The facility census was 49 residents. The facility did not have a policy for Infection Preventionalist. Record review of the Administrator's Certificate of Training dated 1/11/24 showed: -The Administrator had completed the first module of the Infection Prevention and Control Program on 1/11/24. -No other training was done. -He/She had not completed the Infection Prevention course. 1. During an interview on 8/6/24 at 12:45 P.M. Graduate Practical Nurse (GPN) A said: -They have had COVID (a contagious disease caused by the coronavirus SARS-CoV-2) in the building since he/she had started. -He/She did not know where the Personal Protective Equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was stored. -He/She had not received any education about COVID or what was expected of him/her when a resident became positive. -He/She did not know if the facility had an Infection Preventionalist. During an interview on 8/6/24 at 1:45 P.M. the Director of Nursing (DON) said: -He/She has been doing the Infection Preventionalist's work such as the Antibiotic Stewardship and tracking infections and COVID. -He/She has not taken the Infection Preventionalist course nor was he/she certified. -The facility had an Infection Preventionalist but they quit six months ago. -The facility has been trying to hire an Assistant Director of Nursing (ADON) who would step into that roll, but at present there was no Infection Preventionalist employed at the facility and have not had one for the last six months. During a interview on 8/9/24 at 10:00 A.M. Licensed Practical Nurse (LPN) A said: -He/She was the Charge Nurse on the weekends. -The facility had provided some education on what to do with residents if they became positive with COVID. -He/She did not think the facility had anyone designated as the Infection Preventionalist. During an interview on 8/9/24 at 10:30 A.M. the Administrator said: -Both he/she and the DON were enrolled in the Infection Preventionalist on line class. -(Documentation showed he/she had completed one module in January 2024). -They have not had an Infection Preventionalist employed at the facility since February 2024. -They were trying to hire an ADON who would step into the Infection Preventionalist roll.

Based on observation and interview, the facility failed to ensure staffing was posted daily and accurately at the beginning of each shift including the total number and actual hours worked by licensed care staff which could have the potential to affect some residents and visitors in the facility. The facility census was 41 residents. 1. Review of the facility's policy titled Posting Direct Care Daily Staffing Numbers dated August 2022 showed: -The facility would post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. -Within two hours of the beginning of each shift, the number of licensed nurses Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) and the number of unlicensed nursing personnel Certified Nursing Assistants (CNAs) and Nurse Aides (NAs) directly responsible for the care is posted in a prominent locations and is in a clear and readable format. -Shift staffing information is recorded on a form and includes the following: --The name of the facility. --The current date (the date for which the information is posted). --The resident census at the beginning of the shift. --Twenty-four hour shift schedule operated by the facility. --Type (RN, LPN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contracted staff). --The actual time worked during that shift for each category and type of nursing staff. --The total number of licensed and non-licensed nursing staff working for the posted shift. --Within two hours of the beginning of each shift, the charge nurse or designee completes the form and posts the staffing information in the locations designated by the Administrator. Observation on 11/13/23 at 9:59 A.M. showed: -The posted staffing was dated 11/12/23. NOTE: An updated staffing sheet was not posted anytime throughout the day while on site. Observation on 11/15/23 at 10:47 A.M. showed no RN coverage in the building even though there was RN coverage for eight hours for that day. Observation on 11/16/23 at 8:59 A.M. showed: -The staffing sheet from 11/15/23 was still posted. NOTE: An updated staffing sheet was not posted anytime throughout the day while on site. During an interview on 11/16/23 at 1:52 A.M. CNA B said: -The facility posts staffing in a book, on a white board, and at the front of the building near the entrance. -He/she was unsure of who was responsible for posting the staffing sheets. -The staffing sheet should include the amount of care staff that are scheduled in the building. -The staffing sheet should be accurate and be posted daily. During an interview on 11/16/23 at 3:57 P.M. RN A said: -The charge nurse was responsible for posting the daily staffing sheets. -The staffing sheet should include the date, census, and the amount of care staff scheduled in the building. -The staffing sheet should be posted daily and be accurate. Observation on 11/17/23 at 9:15 A.M. showed a staffing sheet had been posted, but was dated for 11/16/23. During an interview on 11/17/23 at 9:35 A.M. the Administrator said: -The night nurse was responsible for posting the staffing sheet. -He/she expected this to be done daily and for the sheet to be accurate. -He/she would expect the on-coming day nurse and/or Director of Nursing (DON) to ensure that the daily staffing sheet had been posted.

Based on observation, interview and record review, the dietary department failed to have recipes available to process the following foods into a pureed (to make food into a paste or thick liquid suspension usually made from cooked food that was ground finely) form (peach crisp, chicken [NAME] pasta, and Italian Blend vegetables) potentially affecting three residents with pureed diets; and to provide a menu with a wider variety of choices for entrees, other than chicken, for the week 1 menu. This practice potentially affected all residents. The facility census was 41 residents. 1. Observation on 11/13/23 from 9:45 A.M. through 11:31 A.M., during the lunch meal preparation showed: - At 9:47 A.M., Dietary Cook (DC) A made pureed peach crisp with no recipe book open. - At 10:59 A.M., DC A made pureed vegetables with no recipe book open. - At 11:08 A.M., DC A made the pureed chicken [NAME] dish, with no recipe book open. During an interview on 11/13/23 at 1:38 P.M., the Dietary Manager (DM) said they have been using the fall menus for almost a month now but there were no recipes for pureed items so far and he/she would have to contact with the Administrator to obtain the recipes. During an interview on 11/16/23 at 11:09 A.M., the Administrator said: - The DM did not have access to the menus because he/she did not have a computer in his office. - He/she could access the recipes by asking the Administrator to print the recipes off or by going to someone else in the facility with a computer. During a phone interview on 11/17/23 at 2:05 P.M., the Consultant Registered Dietitian (RD) said: - The dietary staff would have to go to a website entitled Dining RD and print off the menus. - The DM did not have a computer in his/her office. - The facility would have to contact Dining RD to send the menus through the mail. 2. Review of the Menu for week 1 of the Cycle, showed the following for the week (11/13/23 through 11/17/23) the survey took place: - Chicken was the entree for lunch on 11/12/23 - Chicken was the entree for lunch on 11/12/23 - Chicken was the entree for dinner on 11/15/23. During an interview on 11/13/23, DC A said he/she had to make a change in the lunch menu for 11/13/23, from spaghetti with meat sauce to Chicken [NAME] pasta, because the dietary department ran out of sauce and meat for the menu for that day. Record review of Resident #34's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 4/10/23, showed he/she was cognitively intact with a Brief Interview for Mental Status (BIMS) of 14 out of 15. During an interview on 11/16/23 at 9:06 A.M., Resident #34, a resident said the facility has too much chicken on the menu. Record review of Resident #10's quarterly MDS dated [DATE], showed he/she was cognitively intact with a BIMS of 14 out of 15. During an interview on 11/16/23 at 9:15 A.M., Resident #10 said chicken was served too much. Record review of Resident #30's quarterly MDS dated [DATE], showed he/she was cognitively intact with a BIMS of 15 out of 15. During an interview on 11/16/23 at 9:31 A.M., Resident #30 said there was too much chicken on the menu and he/she wanted beef a little more often. During an interview on 11/16/23 at 10:31 A.M., the Administrator said: - He/she heard from the residents that there was too much chicken on the menu. - The company allowed the facility to make changes within the menu as long as those changes have been approved by the RD. - At that time (the time of the survey) the facility did not have always available substitutions. Record review of Resident #12's quarterly MDS dated [DATE], showed he/she had moderate cognitive impairment with a BIMS of 11 out of 15. During an interview on 11/16/23 at 11:23 A.M., Resident #12 said the facility did not seem to have a good variety of meals and there were too many chicken choices on the menu.

Based on observation and interview, the facility failed to discard a head of lettuce which turned brown; to label containers with a white powdery substance with what was in that container; to remove grime from the floor under the two compartment sink close to the walk-in refrigerator; to remove dirt and debris from behind the six-burner stove; to maintain 3 cutting boards without numerous nicks and in an easily cleanable condition; to maintain one mitten without a damaged area; to date containers of leftovers in the reach-in refrigerator with the date they were placed in the refrigerator; to label containers in the reach-in refrigerator with what the item was; and to maintain the faucet of the two compartment sink in good repair. This practice potentially affected all 41 residents. The facility census was 41 residents. 1. Observations on 11/13/23 from 9:14 A.M. through 12:35 P.M., showed: - One head of lettuce that was brown colored. - One unlabeled container with a green cover on the food preparation table with a white powdery substance in it. - One container of soup in the walk-in refrigerator, which was not labeled. - Other containers in the reach-in refrigerator which included refried beans with no label of the date or the item, a container of burgers with no date or name of item, a container of vegetable soup with a date of 10/25/23 which was 19 days prior to the date (11/13/23) of the observation, a container of bar-b-cue sauce without a date or a label of what was in that container and a container of ham and beans with no date that that container was placed in the refrigerator. - A buildup of dust and grime on the floor beneath the two compartment sink and behind the six-burner stove and convection oven. - Three cutting boards with numerous nicks and grooves which were not easily cleanable. - One mitten with a one-inch (in.) tear between the area where the thumb and the fingers were located. -A continuous leak from the faucet at the two compartment sink. - A light fixture over the food preparation table which illuminated intermittently. During interviews on 11/13/23, the Dietary Manager (DM) said the following: - At 10:06 A.M., the faucet has had a drip since July 2023, but the drip has gotten worse over the last few weeks. - At 10:08 A.M., he/she expected dietary employees to label the containers with what was in them. - At 10:10 A.M., He/she expected dietary employees to label the soup with the date the soup was placed in there. - At 10:13 The vegetable soup should have been discarded, - At 1:31 P.M., the dietary staff should get behind the stove and the two compartment sink at least once per week, but they have not been doing that consistently. - At 1:33 P.M., Anyone who used the cutting boards was responsible for notifying him/her that new ones needed to be ordered. - At 1:35 P.M., the dietary staff should notify him/her when the mittens were torn like that. During an interview on 11/14/23 at 10:42 A.M., the DM said he/she was not sure how long the light fixture over the food preparation table has not been working. During an interview on 11/14/23 at 10:43 A.M., the Maintenance Director said he/she did not know about the light fixture over the food preparation table not working. 2. Observation on 11/16/23 at 1:24 P.M., showed the same head of lettuce which was brown from the previous observation on 11/13/23. During an interview on 11/16/23 at 1:26 P.M., Dietary Cook (DC) A said he/she did not check the lettuce for that week.

Based interview and record review, the facility failed to establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 41 residents. Review of the facility's policy, dated December 2016, titled Antibiotic Stewardship-Orders for Antibiotics showed: -Appropriate indications for antibiotic use included a culture and sensitivity (C&S-a culture is a test to find germs (such as bacteria or a fungus) that can cause an infection; a sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) and having met the clinical definition of an active infection. Review of the facility's policy, dated December 2016, titled Antibiotic Stewardship-Staff and Clinician Training and Roles showed the Director of Nursing (DON) was to review all clinical documentation supporting antibiotic orders. 1. Review of the facility's Infection Control Log, dated August 2023, showed: -Staff listed the residents that had been given antibiotics. -Staff listed the antibiotics used by each resident but did not list the amount or duration of the medication. -No C&S testing had been performed for any of the residents. -A spreadsheet titled Antibiotic Usage Surveillance Tool was blank. Review of the facility's Infection Control Log, dated September 2023, showed: -Staff listed the residents that had been given antibiotics. -Staff listed the antibiotics used by each resident but did not list the amount or duration of the medication. -No C&S testing had been performed for any of the residents. -A spreadsheet titled Antibiotic Usage Surveillance Tool was blank. Review of the facility's Infection Control Log, dated October 2023, showed: -Staff listed the residents that had been given antibiotics. -Staff listed the antibiotics used by each resident but did not list the amount or duration of the medication. -No C&S testing had been performed for any of the residents. -A spreadsheet titled Antibiotic Usage Surveillance Tool was blank. During an interview on 11/15/23 at 11:10 A.M., the Regional Registered Nurse (RN) said: -He/she was the facility's Infection Control Preventionist (ICP). -He/she monitored antibiotics as much as he/she could but he/she had other work to do. -He/she looked at the facility's antibiotic log sometimes, and sometimes he/she did not. -The ICP was to log the antibiotic usage on the Antibiotic Usage Surveillance Tool. -The physicians frequently did not order a c&s or any testing to verify the appropriate antibiotic was in use. -The facility could not produce documentation of antibiotics used from May 2022 to November 2023. -He/she expected the antibiotic use in the facility to be monitored. -He/she was aware antibiotic use was not being monitored in the facility. During an interview on 11/16/23 at 2:23 P.M., the Administrator said: -He/she expected the ICP to monitor antibiotic use. -He/she expected the ICP to follow the criteria for infections listed in the facility's policy. During an interview on 11/17/23 at 12:06 P.M., the DON said: -He/she expected the ICP to monitor antibiotic use for the facility. -He/she expected the ICP to fill out the tracking forms for antibiotic use completely and accurately. -He/she expected the facility's policies to be followed. -He/she was not involved in the monitoring or tracking of the facility's antibiotic use; the ICP was responsible for that.

Based on interview and record review, the facility failed to ensure an Infection Preventionist (IP) was designated and certified in infection prevention and control. The facility census was 41 residents. Review of the facility's undated policy titled Components of Infection Control showed the IP was to complete the required Center for Disease Control's (CDC) course on Infection Preventionist training. 1. During an interview on 11/13/23 at 8:59 A.M., the Administrator said: -He/she had not completed the IP course. -The facility did not have an IP as of 10/27/23. -He/she had been tracking infections in the building until a new IP could be found. -He/she had hired a new Director of Nursing (DON) as of 11/13/23. During an interview on 11/15/23 at 10:07 A.M., the Administrator said: -The DON had completed the CDC Infection Preventionist training. -The Regional Registered Nurse (RN) oversaw the program but hadn't been running it. -The Regional RN usually came in once a week but would come more often if needed. Review of the Regional RN's IP training records, received 11/15/23 at 11:08 A.M., showed no certificate of completion. During an interview on 11/15/23 at 11:10 A.M., the Regional RN said: -He/she was in the facility at least once a week but sometimes twice. -He/she was typically in the building for eight hours per visit. -He/she took over the IP role 10/27/23. -The DON had not been filling the role of IP for the facility. -He/she tried to monitor infections and antibiotics as much as he/she could but he/she had other buildings to oversee. -He/she may or may not look at the infection and antibiotic log when he/she was at the facility. During an interview on 11/15/23 at 11:43 A.M., the Regional RN said he/she was aware antibiotic use was not being monitored. During an interview on 11/15/23 at 2:18 P.M., the Regional RN said he/she could not find the certificate of completion for the IP course. During an interview on 11/16/23 at 11:16 A.M., Licensed Practical Nurse (LPN) B said: -He/she expected federal regulation for the IP to be followed. -He/she expected someone in the building to monitor antibiotic use and infections. During an interview on 11/16/23 at 2:23 P.M., the Administrator said: -The DON was the IP. -The DON had not been able to find his/her certificate of completion for the IP course but had reached out to the CDC for assistance. -The Regional RN was the backup IP. -The DON had started October 2023. -The DON worked three to five days a week providing resident care. -The DON did not spend part time working on infection control. -He/she expected the IP to monitor antibiotic use and follow the facility's policy. During an interview on 11/17/23 at 12:06, the DON said: -He/she was unsure who the IP was for the facility. -He/she expected the IP to monitor infection and antibiotic use in the facility. -He/she expected the facility's policy and federal regulations to be followed. At time of exit, no staff member had submitted a certification of completion for the CDC's Infection Preventionist course.

Based on observation, interview and record review the facility failed to ensure fall interventions were implemented by staff resulting in a resident, who was at risk for falls and had a history of [REDACTED]. Additionally, staff failed to implement further fall interventions after the resident returned from the hospital. The resident continued to be left unattended in his/her room in his/her wheelchair and continued to transfer himself/herself independently, and the facility failed to educate the staff on the safest methods for removing the cervical collar for showers and baths to prevent further injury to the resident's neck for one sampled resident (Resident #27) out of 12 sampled residents. The facility census was 41 residents. The administrator was notified on 6/27/19 at 5:10 P.M. of an Immediate Jeopardy (IJ) which began on 6/15/19. The IJ was removed, as confirmed by surveyor onsite verification on 6/27/19. Record review of the facility's Accidents and Incidents - Investigating and Reporting Policy, dated (MONTH) (YEAR), showed: -The Nurse/Charge Nurse and/or Nursing Director or Supervisor shall promptly initiate and document investigation of the accident or incident; -The Report of Incident/Accident shall include any corrective action taken; -The Report of Incident/Accident must be submitted to the Director of Nursing (DON) within 24 hours of the incident or accident; -The DON shall ensure the Administrator receives a copy of the Report of Incident/Accident for each occurrence; -Incident/Accident reports will be reviewed by the safety Committee for trends or safety hazards and individual resident vulnerabilities will be analyzed. 1. Record review of Resident #27's Face Sheet showed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE] with the following Diagnoses: [REDACTED]. -Muscle weakness; -Lack of coordination; -Difficulty in walking; -Urinary incontinence; -Dementia (impairment of at least two brain functions such as memory loss and judgement) without behavioral disturbance; -Repeated falls. Record review of the resident's Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) Care Plan, dated 2/18/19, showed: -One to two staff were needed to transfer the resident; -When the resident was unable to assist with transfers, staff may use a mechanical lift as needed with the assistance of two staff members. Record review of the resident's Impaired Vision Care Plan, dated 2/18/19 showed: -The resident has glasses and regularly chooses not to wear them; -The resident should be placed away from glare; -A night light should be left on during the night; -Furniture in the resident's environment should not be rearranged without the resident requesting this or knowing about it; -Large print reading material should be offered as the resident desires; -Staff are to clean the resident's glasses when the resident is willing to wear them. Record review of the resident's Potential for Falls Care Plan, dated 2/26/18, showed the following interventions: -Refer for Therapy evaluations as needed; -Keep area free of clutter; -Ensure the resident is wearing non-skid socks or shoes during transfers; -Assist with toileting and mobility as needed; -Keep call light within reach; -Educate the resident to ask for staff assistance; -Staff to transfer the resident to recliner as desired; -Monitor the resident as needed while in room; -On 3/29/18 an intervention was added to educate staff on safe transfers; -On 4/5/18 staff were educated not to leave the resident sitting alone on the side of the bed; -On 5/29/18 staff were educated to toilet the resident prior to assisting him/her in his/her recliner; -On 9/15/18 staff were educated not to leave the resident in their wheelchair in his/her room; -On 9/26/18 the resident was educated to call for help; -On 10/8/18 staff were to start toileting the resident at night during staff rounds. Record review of the resident's quarterly Fall Risk Assessment, dated 11/14/18, showed: -The resident had one to two falls within the previous 90 day period, the latest fall on 9/26/18; -The resident could only stabilize with physical assistance, had behaviors (such as restlessness or disorganization) and limited vision, had difficulty ambulating, and had health conditions and took medications that increased his/her fall risks; -The resident was at high risk for falls. Record review of the resident's Potential for Falls Care Plan, dated 2/26/18, showed an intervention was added on 11/15/18 to bring the resident back to his/her room after meals and transfer (the plan didn't show to what surface the resident was to be transferred). Record review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment instrument to be completed by facility staff for care planning purposes), dated 2/11/19, showed the resident: -Was visually impaired. He/She could see large print, but not regular newspaper or book print; -Was severely cognitively impaired; -Had disorganized thinking (rambling or incoherent conversation or illogical flow of ideas); -Needed one-person extensive assistance with walking, toileting and transfers (movement from one surface to another); -Was only able to stabilize when rising from a seated to a standing position, moving on and off the toilet, transferring and walking with staff assistance; -Had lower extremity (hips, legs and feet) impairments in range of motion (ROM) on both sides of his/her body; -Used a walker and a wheelchair for mobility; -Was frequently incontinent of urine and occasionally incontinent of bowel; -Had one fall with a non-major injury and one fall with no injuries since the previous quarterly MDS assessment; -Was taking a diuretic (medication that promotes the formation of urine by the kidneys, often resulting in urinary urgency (a sudden, compelling urge to urinate); -Received Restorative Aide (RA - A Certified Nurse Assistant (CNA) with specialized training in increasing a resident's strength and mobility) services for ROM three times. Record review of the resident's Incident Report, dated 1/27/19, showed: -The incident time was 4:00 P.M.; -The resident had been assisted into his/her wheelchair and left in his/her room by the Licensed Practical Nurse (LPN) while waiting for supper; -The resident fell while self-transferring from his/her wheelchair, sustaining a 4 inch by 4 inch hematoma (localized bleeding outside of blood vessels due to disease or trauma) to the right forehead; -After the fall the call light was placed within reach and the resident was educated to call for help; -72 hour neurological checks (assessments to include the resident's vital signs (temperature, pulse, respiration and blood pressure); pupil size and reactivity to light; equality of hand grip strength; facial symmetry; level of consciousness and pain) were started at 4:00 P.M. Record review of the resident's Nurses' Note, dated 1/27/19 at 4:00 P.M., showed: -The resident was found lying on his/her back on the floor in his/her room; -Five minutes prior to the fall the resident was asked if he/she would like to be pushed into the Dining Room. The resident replied he/she would like to sit in his/her room for a while. The resident was left in his/her room and attempted to self-transfer, sustaining a hematoma to the right forehead as a result of the fall; -The resident's physician and responsible party were notified and the resident was placed on 72 hour monitoring; -The resident attempted to transfer twice following the fall before the shift ended on 1/27/18 and was educated on calling for help. Record review of the resident's Potential for Falls Care Plan, dated 2/28/18, showed the nurse was educated on 1/27/19 not to leave the resident alone in his/her room as an intervention to prevent further falls. Record review of the resident's quarterly Fall Risk Assessment, dated 2/11/19, showed: -The resident's latest fall was on 1/27/19; -The resident could only stabilize with physical assistance, had behaviors and limited vision, had difficulty ambulating, and had health conditions and took medications that increased his/her fall risks; -The resident was a high risk for falls. Record review of the resident's Potential for Falls Care Plan, updated on 2/18/19 when the resident's comprehensive annual Care Plan was updated, showed the fall interventions put into place on 1/27/19 were reflected on the 2/18/19 Fall Care Plan. No new interventions had been added to the 2/18/19 Fall Care Plan. Record review of the resident's Nurses' Note, dated 4/27/19 at 5:00 P.M., showed: -The resident was found in his/her room on the floor facing the doorway with his/her head close to the chest of drawers after the nurse and a Certified Nurse Aide (CNA) heard a noise from the hallway; -The resident said his/her head felt warm, but did not complain of dizziness or pain; -The resident had tried to stand up by him/herself from his/her wheelchair; -The resident required one-person assistance due to unsteady gait and balance; -Neurological checks were started and the resident's Primary Care Physician (PCP) was notified; -The resident was assisted up off the floor and into his/her wheelchair and brought to the nurses' station for further assessment. Record review of the resident's Incident Report, dated 4/27/19, showed: -The fall happened at 5:00 P.M. in the resident's room; -The CNA dressed and assisted the resident into his/her wheelchair and left the resident in his/her room; -The CNA and the Nurse found the resident on the floor; -The fall was unwitnessed by staff working at the time of the fall; -The resident was in his/her wheelchair trying to transfer him/herself and had been walking with his/her walker; -The resident's condition at the time of the fall was listed as: --Had a fall history; --Had Arthritis (disorder that affects the joints, causing pain, swelling and stiffness) and/or [MEDICAL CONDITION] (a bone disease causing weakened and porous bones which are more susceptible to breaks); --Was confused or disoriented; --Had incontinence and bowel and bladder urgency; --Had sensory limitations (disabilities related to sight, hearing, touch, taste or smell, which can affect how an individual gathers information from the environment); -The Root Cause Analysis (a process used to identity reasons for a problem and possible solutions) summary showed: --The possible causal factor for the fall was listed as the resident likes to lay in bed when not in the Dining Room; --The reason for the fall was listed as the resident was in his/her wheelchair and tried to transfer him/herself; --The solutions implemented at the time were: --Encourage resident to wait for assistance before starting to transfer; --After toileting, transfer the resident back into his/her recliner or bed. Record review of the resident's Potential for Falls Care Plan, dated 2/18/19, showed the intervention to encourage the resident to wait for assistance before standing or transferring himself/herself was added to the care plan on 4/27/19. This intervention was similar to two interventions already in place. These included: --Educate resident to ask for staff assistance; --The resident was educated to call for help. Record review of the resident's Fall Risk Assessment, dated 5/9/19, showed: -The resident's last fall was on 4/27/19; -The resident could only stabilize himself/herself with assistance, had behaviors and limited vision, had difficulty ambulating and had health conditions and took medications that increased his/her fall risks; -The resident was a high risk for falls. Record review of the resident's quarterly MDS, dated [DATE], showed: -Information about the resident was the same as at the time of the 2/11/19 MDS except as follows: -The resident was moderately cognitively impaired; -The resident had one non-injury fall since 2/11/19; -The resident received RA services twice. Record review of the resident's Quarterly Care Plan Review, dated 5/13/19, showed the resident: -Was up daily in his/her wheelchair for locomotion; -Was assisted by one staff members for transfers and toileting; -RA was working on ambulation, upper and lower extremity (arms and legs) ROM, and wheelchair positioning and mobility. The resident sometimes refused RA services. Record review of the resident's Incident Report, dated 6/15/19, showed: -Between 8:15 P.M. and 8:30 P.M. a CNA and a LPN heard yelling from down the hall; -The resident was found lying on the floor on his/her left side under his/her walker in front of his/her mini fridge; -The resident said he/she was trying to transfer from his/her wheelchair to his/her bed; -After the fall the resident had a hematoma on the left side of his/her head and swelling on the fourth and fifth fingers of the left hand; -The resident Neurological Assessment Flow Sheet showed the resident's neurological check was completed at 8:30 P.M.; -The resident was assisted back into his/her wheelchair and monitored at the Nurse's station while the resident's physician was being contacted and orders were obtained to transfer the resident to the hospital; -The legal representative was notified and the resident was transferred to the hospital at 8:45 P.M.; -The Root Cause Analysis showed: --The causal factor was listed as the resident likes being in his/her bed or recliner; --The reason for the problem was listed as the resident was in his/her wheelchair and transferred himself/herself; --The solution implemented was listed as the resident was sent to the hospital. Record review of the resident's Nurses' Notes, dated (MONTH) 2019, showed staff did not document on 6/15/19 about the incident, injuries or transfer to the hospital. Record review of the resident's acute medical hospital's discharge information, submitted 6/18/19, showed: -On 6/16/19 the resident had a Computed [NAME]ography [MEDICATION NAME] (CTA (Cat Scan) a high technology X-ray scanner using computer analysis that takes images from different angles and uses intravenous (through the vein) dye injection to provide 3-dimensional images of blood vessels (tubular structures carrying blood through tissues and organs) of the neck. Impressions showed a Type II dens fracture (break at the peg-like process on the second cervical (neck) vertebrae (spinal bone) on which C1 (first cervical vertebrae) rotates. There were no findings of displacement or vertebral artery dissection or occlusion (tear in the artery); -On 6/18/19 Cervical Spine views were obtained to compare with the CTA completed on 6/16/19. Impressions were Non-displaced Type II Dens Fracture; -Discharge Physician Orders, Instructions and Primary Diagnosis, dated 6/18/19 showed: --Primary [DIAGNOSES REDACTED]. --C-Collar (cervical brace to support the neck of persons who have had traumatic neck injures) in place at all times. Phili Collar (Philadelphia Collar - a neck brace used to prevent head and neck movement after a spinal injury) when showering; --Follow up with Neuro surgery in eight weeks. Schedule AP/Lateral X-Ray of cervical spine with C-Collar in place prior to follow-up appointment; --The hospital's discharge information did not contain specific instructions on how to change out the neck collar and replace it with the shower neck collar, how to hold the resident's neck during the replacement to prevent further injury to the resident. Record review of the resident's Nurses' Note, dated 6/18/19, showed: -The resident's return to the facility following a hospital stay; -The resident was to receive Physical Therapy (PT - treatment of [REDACTED]. -Nursing was to follow up with scheduling the resident's Neurosurgery appointment. Record review of the resident's Physician order [REDACTED]. -Orders beginning 6/18/19 for OT, PT and ST, all five times per week for four weeks; -Orders beginning 6/18/19 for C-Collar on at all times for eight weeks and Phili Collar for showers for Odontoid (tooth-like projection from the second cervical vertebra on which the first vertebra pivots), Type II Dens Fracture). There were no specific instructions for changing out the neck collars. Record review of the resident's PT Initial Treatment Plan for Rehabilitation, dated 6/18/19, showed: -Long Term Outcome Goals were for the resident to increase: --Bed mobility; --Lower extremity strength; --Transfers to moderately independent; --Gait to 150 foot with four-wheel walker and stand-by assistance; and --Standing balance. Record review of the resident's OT Initial Plan for Rehabilitation, dated 6/18/19, showed: -Long Term Outcome Goals were to: --Complete toileting tasks with good standing tolerance and balance with moderate assistance; --Completing transfers from multiple surfaces with moderate assistance; and --Increasing upper extremity strength and tolerance to propel self to 150 feet. Record review of Nursing Notes, dated 1/28/19 through 6/25/19, showed the facility was not documenting on the resident's attempts to transfer without assistance on the dates when there were no falls. Observation on 6/24/19 at 10:05 A.M., showed: -The resident was alone in his/her room sitting in his/her recliner wearing the C-Collar; -During a five minute interaction with the resident he/she did not attempt to get out of the recliner or state he/she didn't want to be in the recliner. Observation on 6/24/19 between 12:25 P.M. and 12:55 P.M., showed: -The resident was eating lunch in the dining room and wearing his/her C-Collar; -During the observation the resident was focused on the meal and was not attempting to leave the area to go to his/her room. Observation on 6/24/19 at 1:56 A.M., showed: -The resident was alone in his/her room sitting in his/her recliner wearing the C-Collar; -During a fifteen minute interaction with the resident he/she did not attempt to get out of the recliner or state he/she didn't want to be in the recliner. During an interview on 6/24/19 at 1:56 P.M., the resident said: -He/She recently cracked his/her neck and hit his/her head and had to go to the hospital; -He/She slipped and fell in his/her room and the staff heard the fall and came to assist; -Prior to the fall he/she was walking with his/her walker, which he/she still does with PT and OT. Observation on 6/25/19 at 1:47 P.M., showed: -The resident was alone in his/her room and calmly sat in his/her recliner with no attempts to get out of the recliner. During an interview on 6/27/19 at 7:50 P.M., LPN B said: -On 4/27/19 the resident was found on the floor facing the doorway with his/her head close to the dresser; -The resident said that he/she was trying to get up to walk and tried to stand up from his/her wheelchair and fell ; -He/She had CNAs bring the resident up to the Nurses' Station to complete Neuro checks and to prevent the resident from being alone in his/her room; -Nurses can put small interventions in place such as making sure lighting is good, shoes and/or non-skid socks are worn and the call light is within reach; -If falls are recurring the charge nurse, DON and MDS Coordinator work collaboratively to put interventions in place; -The charge nurse assesses the resident following a fall, fills out the Incident Report based on information from the resident and/or CNA and has staff fill out witness or non-witness statements; -The DON completed Investigations and tried to determine the cause of falls and interventions to address the reason for the falls, often with input from Nursing. During a telephone interview on 6/28/19 at 10:50 A.M., LPN F said: -On the evening of 6/15/19 he/she heard yelling from the resident's room and found the resident lying on the floor in his/her room. The resident said he/she was trying to transfer from his/her wheelchair into his/her bed. He/She checked the resident for injuries and contacted the Emergency Medical System (EMS), the resident's physician and family after determining the resident had sustained injuries. -After a fall nurses check the resident for signs of injury. If the fall was unwitnessed and the resident can't explain what happened or if the resident hit his/her head nurses do Neuro checks and then contact the doctor immediately after assessing the resident. We contact the DON and, as soon as possible, contact the family; -He/She usually worked weekends beginning at 3:00 P.M. or 4:00 P.M. and observed the supper meals. The meal usually ended around 6:30 P.M.; -The resident was impatient and wants to be in bed immediately following supper. As soon as the supper meal ends he/she tries to make sure the resident receives his/her evening hygiene care and is safely transferred into bed. Otherwise the resident tries to transfer himself/herself into his/her bed without help which was not safe for him/her. During an interview on 6/25/19 at 1:53 P.M., Licensed Practical Nurse (LPN) D said: -The resident has a history of falling every two to three months; -The resident fell at one point when he/she was working and sustained a hematoma on the forehead; -He/She was not here when the resident had his/her most recent fall. He/She was told the resident was attempting to transfer from his/her wheelchair to bed and fell backwards; -The resident required frequent staff reminders and encouragement to allow staff to help with transfers; -After lunch the resident is ready for bed and staff have to catch him/her immediately following the meal so the resident doesn't try to self-transfer. During an interview on 6/26/19 at 6:32 A.M., Certified Medication Technician (CMT) A said: -In late (MONTH) the resident fell and hit his/her head while attempting to self-transfer; -The resident needed at least one person to help him/her transfer. He/she shouldn't be transferring himself/herself. During an interview on 6/26/19 at 6:53 A.M., LPN [NAME] said: -The resident required one-person assistance for transfers; -After dinner the resident wants to go to bed very early. The staff know that is what the resident wants to do, although the resident might sit for a short while in his/her recliner; -The resident is the first person assisted to bed after everyone is finished with supper and the resident's bed is lowered to the floor; -Staff are to put the call light within the resident's reach. The resident rarely puts his/her call light on and, if awake, staff needs to ask him/her if he/she needs anything or needs to toilet and take him/her promptly, checking on the resident at least every two hours. Observation on 6/26/19 at 7:00 A.M., showed the resident was lying still in bed with eyes closed wearing the C-Collar. During an interview on 6/26/19 at 9:10 A.M., Certified Nurse Aide (CNA) G said: -The resident required one-person transfer assistance using a gait belt (safety device worn around the waist, providing support to help prevent falls); -He/She didn't know why the resident had a collar on and was not told any special instructions related to the C-Collar. During an interview on 6/26/19 at 11:06 A.M., LPN C said: -When a resident falls the charge nurse completes the incident report for falls, assesses the resident following falls, and has staff write witness statements; -He/She puts the report in a box for the Director of Nursing (DON) to review; and -Charge nurses complete admission assessments after admissions and re-admissions and were responsible for standard fall interventions following re-admissions. During an interview on 6/26/19 at 11:37 A.M., CNA C said: -The resident's transfer status was one-person stand by assist with a gait belt before the last fall; -The Therapy book showed the resident's current transfer status. (At this point CNA C looked in the Therapy book and was unable to find the resident's transfer status); -The CNA Book should show the resident's transfer status. (CNA C got out the CNA Book and was unable to find the resident's transfer status); -When the resident returned from the hospital he/she asked the nurse the resident's transfer status and was told the resident transferred with one-person assistance using a gait belt; -He/She didn't know if any new interventions were added to the resident's Fall Care Plan following his/her most recent fall of 6/15/19, although the resident started therapy after returning to the facility following his/her last fall. During an interview on 6/26/19 at 4:10 P.M., the DON and the Regional Nurse A said: -The charge nurse was responsible for obtaining witness and non-witness statements for completing Incident Reports; -There should have been new interventions in place after the resident returned from the hospital with a neck fracture; -He/She was responsible for putting new interventions in place; -No instructions were received on how to care for the resident with the neck brace; -He/She was responsible for putting the intervention in place upon return from the hospital; -Staff should be following all fall interventions put in place for the resident. During an interview on 6/26/19 at 4:50 P.M., LPN A said: -Therapy provided instruction on transferring the resident using one staff person and a gait belt; -He/She had not received instruction from PT or any other source on removing the resident's C-Collar for putting on the Phili Collar and didn't know if any nurses had received such training; -He/She didn't feel comfortable removing the collar without first receiving instruction. During an interview on 6/26/19 at 5:43 P.M., the DON said: -The resident's C-Collar should only be removed for showers and the Phili Collar should be worn during showers; -The DON was responsible for ensuring instruction related to the resident's collars. During an interview on 6/27/19 at 9:50 A.M., LPN A said: -He/She spoke with the DON the day before for clarification on the resident's neck collars; -He/She was instructed for the nurse take the C Collar off. The Phili Collar was to be worn during showers; -He/She wasn't sure if a nurse had to apply the Phili Collar or if a nurse had to ensure the resident's head did not move or if a CNA could do that, but thought probably two nurses should be involved with changing out the neck collars. During an interview on 6/26/19 at 1:57 P.M., LPN A said: -The resident had a long history of self-transfers; -He/She has had to provide the resident frequent reminders to use the call light for help with transfers and had educated the resident on the dangers of self-transferring; -The resident always wanted to go to the rest room or be in his/her bed; -He/She would use the toilet and then go to bed from his/her wheelchair; -He/She would usually try to self-transfer after meals; -CNAs were supposed to take the resident to the toilet after meals and then to bed; -Staff were to transfer the resident to a regular chair in the dining room so he/she didn't wander off without staff knowledge; -Since the resident's neck fracture he/she has observed the resident sitting on the side of his/her bed. It appeared as if the resident had transferred him/herself to bed; -When asked, the resident stated he/she transferred himself/herself without staff assistance. During an interview on 6/27/19 at 2:00 P.M., CNA C said -The resident was frequently caught trying to transfer himself/herself from his/her wheelchair into bed; -The resident had been self-transferring for almost five years; -The resident will go to his/her room after meals to go to bed and was usually was caught trying to self-transfer; -He/She had been told by the nurses to not remove the C Collar, that nurses had to remove it; -If the resident showers the nurses have to readjust the collar; -He/She didn't know what a Phili Collar was and was not educated beyond being told not to touch the resident's collar; -The resident preferred his/her door to be closed, but for safety reasons the door was kept open and the CNA would walk by the resident's room about every 15 minutes to check on him/her. During an interview on 6/27/19 at 2:02 P.M., CNA G said: -The resident transferred himself/herself from his/her wheelchair into bed or to the toilet and back to his/her wheelchair; -The resident did not transfer himself/herself out of bed as far as the CNA knew; -He/She had also heard other staff mention how the resident unsafely self-transferred; -Since the last fall of 6/15/19 he/she had seen the resident attempting to transfer himself/herself and assisted the resident when he/she observed the resident self-transferring. The resident was not supposed to self-transfer; -After meals the resident doesn't want to wait for someone to help him/her and will put himself/herself to bed; -Whenever he/she observed the resident self-transferring, the resident was trying to get either to the bathroom or into bed. During an interview on 6/27/19 at 2:15 P.M. with Physical Therapist (PT) A and Occupational Therapist (OT) A: -PT A said: --After the fall of 6/15/19 the resident required more cueing,instruction and encouragement such as instruction on hand placement during transfers; --The Physical Therapy Assistant normally worked with the resident. He/She didn't know what type of education, if any, the PTA would have provided staff related to the resident's transfer needs; --The Therapy Department didn't train Nursing staff on how to change out the resident's C-Collar at shower time. The nurses should be qualified to know what to do regarding the neck collars and provide training to the CNAs; --Therapy staff posted each resident's transfer status on the back of the resident's room doors so that CNAs knew how to transfer each resident; -OT A said: --The resident was a one-person assist with gait belt for transfers before the resident's fall on 6/15/19 and the resident continued to need one-person assistance with a gait belt for transfers; --The resident was working on toileting, transfers, dressing, standing, wheelchair mobility, fine motor control and chair positioning; and --The resident was moving a little slower after his/her most recent fall and needed staff to allow him/her more time for each transfer. Observation on 6/27/19 at 2:30 P.M., showed the resident was lying still in bed with eyes closed wearing the C-Collar. Observation on 6/28/19 at 8:55 A.M., showed the resident was in the Dining Room sitting in a dining room chair and wearing the C-Collar while eating breakfast. During an interview on 6/27/19 at 2:56 P.M., the DON said: -Charge nurses were responsible for filling out Incident Reports at the time of the incident, including having staff complete witness statements, contacting the PCP, family and DON; -He/She contacted the Administrator, did the investigation and initiated an intervention on the second sheet of the incident report; -He/She lets the charge nurse know what the initial intervention is and the nurses inform the CNAs; -He/She hadn't investigated the resident's 6/15/19 fall so no intervention had been put in place. Typically, the investigations are completed the same day as the fall; -He/She meets with the Interdisciplinary Team (IDT - Nursing, S

Based on observation, interview and record review, the facility failed to re-notify the resident's physician for wound care treatment when the resident's physician did not respond to the fax request for three days, which delayed the correct wound care treatment to the resident's buttocks wound; failed to consistently complete skin care assessments and to complete the resident's wound care to the resident's buttocks wounds that were a Stage 2 (partial thickness loss of skin with exposed dermis (thick layer of living tissue below the epidermis (skin surface) and deteriorated to Stage 3 (full thickness skin loss in which subcutaneous (below the skin) fat may be visible. Slough (soft, moist dead tissue) and/or eschar (black or brown dead tissue) may be visible, but does not obscure the depth of tissue loss) pressure ulcers/pressure injuries (PU/PI) and then deteriorated to unstageable pressure ulcers (If slough or eschar obscures the wound bed it is classified as an Unstageable PU/PI); and failed to put in place preventive measures for pressure relieving surfaces to the resident's bed and wheelchair to prevent further deterioration of the resident's pressure ulcers and the prevention of new pressure ulcers from occurring for a one sampled resident who was a high risk for developing pressure ulcers (Resident #38) out of 12 sampled residents. The facility census was 41 residents. Record review of the National Pressure Ulcer Advisory Panel (NPUAP - an independent not-for-profit professional organization dedicated to the prevention and management of PU/PI) Prevention and treatment of [REDACTED]. -Mattress and Bed Support Surfaces for Individuals with Existing Pressure Ulcers/Injuries: --Individuals with an existing PU/PI are at higher risk for development of additional PU/PI; --Whenever possible do not position an individual on an existing pressure ulcer; --Consider replacing the mattress with a support surface that provides more effective pressure redistribution, shear reduction and microclimate control for the individual who cannot be repositioned off an existing PU/PI, is at high risk for additional PU/PI, fails to heal or demonstrates ulcer deterioration despite appropriate comprehensive care and/or bottoms out on the existing support surface; --Select a support surface that provides enhanced pressure redistribution, shear reduction and microclimate control for individuals with Category/Stage 3 and Category/Stage 4 (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in ulcer) PU/PI. --Beds with air fluidized features (mattresses and other surfaces comprised of tiny beads, suspended by pressurized, temperature-controlled air with a polyester sheet covering the beads) produced better healing outcomes for Category/Stage 3 and Stage 4 pressure ulcers than standard beds; --Beds with low-air-loss features (mattresses and surfaces composed of inflatable air cushions used to relieve pressure on body parts) resulted in better healing outcomes for Category/Stage 3 and 4 pressure ulcers than foam mattresses; -Recommendations for Seating Support Surfaces showed: --Prolonged sitting resulted in a strong predisposition to pressure ulcer development, particularly in the ischial area (the ischium - the sit bones, marking the lateral (sides) boundary of the pelvic outlet); --Use a pressure redistributing seat cushion for individuals sitting in a chair whose mobility is reduced; --Select a cushion that effectively redistributes pressure away from the pressure ulcer; --Use alternating pressure seating devices judiciously for individuals with existing pressure ulcers, weighing the benefits of off-loading against the potential for instability and shear based on the construction and operation of the cushion; -Provide complete and accurate training on use and maintenance of support surfaces; -Nutritional guidelines in PU/PI Prevention and Treatment guidelines showed: --Screen nutritional status for each individual at risk of or with a pressure ulcer; --Provide individuals at risk of pressure ulcers vitamin and mineral supplementation when dietary intake is poor or deficiencies are confirmed or suspected; and --Monitor for signs and symptoms of dehydration; -Repositioning and Mobilization guidelines for Individuals with Existing PU/PI showed: --If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum (triangular shaped bone between the hips)/coccyx (the tail bone, located just below the sacrum) or ischium, to minimize pressure, limit sitting to three times a day in periods of 60 minutes or less; --Avoid seating an individual with an ischial ulcer in a fully erect posture. Record review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol Policy, revised (MONTH) (YEAR), showed: -The nurse shall describe and document the following: --Full assessment of pressure sore including location, length, width and depth, presence of exudates (drainage produced by the body in response to tissue damage) or necrotic (dead or devitalized tissue that cannot be salvaged and must be removed for wound healing) tissue; --Pain assessment; --The resident's mobility status; --Current treatments, including support surfaces; --All active diagnoses; -The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement (the removal of damaged tissue from a wound) approaches, dressings and application of topical agents and will help identify medical interventions related to wound management. 1. Record review of Resident #38's Face Sheet showed the resident was most recently admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] (CKD - longstanding disease of the kidneys where the kidneys eventually become unable to filter waste and excess fluids from the blood leading to renal (kidney) failure); -Type II Diabetes Mellitus (DM - a chronic condition in which the body either doesn't produce enough insulin or it resists insulin, a hormone produced by the pancreas which regulates the amount of glucose (sugar) in the blood); -Dementia (a group of thinking and social symptoms that interferes with daily functioning, characterized by impairments in at least two brain functions such as memory and judgment) without Behavioral Disturbance; -[MEDICAL CONDITION]'s Disease (chronic inflammation of the bowels, affecting the lining of the digestive tract); -[MEDICAL CONDITION] Status (a surgical opening in the abdominal wall that allows the ileum (end of the small intestines) to release stool); -Stage 4 left ankle pressure ulcer; -Acute Osteomyolitis (bone infection, often associated with DM and vascular impairments) of the left ankle and foot. Record review of the resident's Braden Scale for Predicting Pressure Sore Risk in Home Care (a tool used by health professionals, especially nurses, to assess the resident's risk of developing a Pressure Ulcer), dated 4/26/19, showed the resident: -Had no sensory limitations in his/her ability to feel and his/her skin was usually dry; -Was chair-fast; -Was slightly limited in his/her mobility and was able to make frequent slight changes in his/her body positioning; -Had excellent nutrition, eating four or more meat and dairy servings a day; -Had potential problems with friction (rubbing against another object or surface, causing damage to superficial tissue (skin) or shear (damage below the skin). The resident moved feebly or required minimum assistance and his/her skin is likely to slide against sheets or a chair and/or occasionally the resident slides in his/her chair or bed and -The resident's total Braden score was 19 out of a possible 23. The resident is considered most at risk when the Braden scale is 15 to 18 or lower; -Body marks such as bruises, skin tears and scars identified on the form were: --Foley catheter (a tube inserted into the bladder to drain urine into a urinary drainage bag); --[MEDICAL CONDITION] to mid-abdominal incision with approximately 14 staples; --Left ankle wound: 6 centimeters (cm) by 2 cm, pink to red wound bed with 1.5 cm by 0.5 cm area of yellow slough; and --There was no description of any skin damage to the buttocks and no skin damage drawn or indicated on the human body diagram of any skin issues other than those that were described narrative. Record review of the resident's Physician order [REDACTED].>-Zinc Ointment (treats yeast/fungal infections and minor skin irritations) starting 4/26/19. Apply to sacrum and buttocks twice a day until clear. The order did not indicate a reason for the medication; -Weekly skin assessment to be completed by the licensed nurses every Tuesdays. Record review of the resident's Treatment Administration Record (TAR), dated (MONTH) 2019, showed no documentation of skin assessment completed for the month of (MONTH) or explanation on the back of the TAR why the assessments were not completed. Record review of the resident's History and Physical, dated 5/3/19, showed: -The resident had a physical examination on 4/30/19; -No documentation of skin breakdown on the buttocks. Record review of the resident's Potential for Skin Injury related to Diabetes Mellitus and [MEDICAL CONDITION]'s Disease Care Plan, dated 5/6/19, showed: -The resident was admitted with a Stage 4 left ankle wound and a surgical wound to the abdomen. A line was drawn through these two admission [DIAGNOSES REDACTED]. -Also hand-written onto the care plan with no effective date indicated, the resident had a left ankle arterial wound (an open wound caused by poor delivery of oxygen to the affected tissue. The reduced blood flow leads to tissue necrosis (death of cells within the skin) and ulceration (inflammation and often [MEDICAL CONDITION] - an abnormal area of tissue outside the body that may or may not [MEDICAL CONDITION]); -Staff were directed to use the following interventions: -A pressure reduction mattress for the resident's bed; -Physician orders [REDACTED]. -Dietician referral to evaluate nutritional status as needed; -Linens and clothing to be kept as wrinkle free as possible; -Skin audits according to schedule and as needed (prn); -Wound consultant to evaluate and treat as needed. Record review of the resident's Comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument to be completed by facility staff for care planning purposes), dated 5/10/19, showed the resident: -Moderately cognitively impaired; -Required extensive two-person assistance with bed mobility and transfers (movement from one surface such as a chair to another surface such as a bed) and limited assistance with dressing and personal hygiene; -Was at risk for developing Pressure Ulcers; -Had one unhealed Stage 4 PU/PI present at the time of admission; -Had a surgical wound; -Had a pressure reducing device for his/her chair and bed; -Received PU/PI care and dressings to his/her feet. Record review of the resident's TAR, dated (MONTH) 2019, showed no skin assessment completed on 5/7/19 or 5/14/19 and did not contain an explanation on the back of the TAR why the assessment was not completed. Record review of the resident's TAR, dated (MONTH) 2019, showed: -A new physician's orders [REDACTED]. Apply [MEDICATION NAME] Cream (an anti-fungal medication) mixed with Collagen Powder (stimulates healing and dissolves to form a protective gel) twice a day (BID) until healed starting on 5/13/19; -The TAR showed the area was treated twice daily beginning on 5/13/19 except for the evening of 5/16/19 which was left blank; -No documentation on the back of the TAR to explain why the resident did not receive treatment the evening of 5/16/19; -A line was drawn beginning on 5/20/19 with the letters DC for discharged . Record review of the resident's Nurses' Notes, dated 5/20/19 showed the resident was sent to the emergency room for a possible Urinary Tract Infection [MEDICAL CONDITION]. There was no documentation of a PU/PI or any other skin issue on his/her buttocks at the time of transfer. Record review of the resident's Discharge Medical Information packet from the acute care hospital, dated 5/24/19, showed: -The following note on the resident's Final Report, dated 5/23/19: --Resident is continuing to complain of some buttock pain related to his/her superficial skin breakdown in that region; -The resident's Referral and Transfer Plan, dated 5/24/19, showed under the section Special Needs; --Sores on the resident's buttocks; -Comments on the resident's Patient Education Information form, dated 5/24/19, showed: --Nursing, please pay careful attention to the skin breakdown to the resident's buttocks; --Resume wound care to the resident's left ankle. Record review of the Nurses' Notes, dated 5/24/19, showed the resident was readmitted to the facility on [DATE]. There was no documentation of a PU/PI or any other skin issues on the resident's buttocks. Record review of the resident's Braden Scale for Predicting Pressure Sore Risk in Home Care, dated 5/24/19, showed the resident: -Had no sensory limitations in his/her ability to feel and his/her skin was usually dry; -Was chair-fast; -Was slightly limited in his/her mobility; -Had excellent nutrition; -Had potential problems with friction and shear; -The resident's total Braden score was 19 out of a possible 23; -Body marks were not described in the narrative section of the report; -On the human body diagram: --A surgical scar was drawn with the words [MEDICAL CONDITION] abdominal incision written next to it; --The words Foley catheter were written and a circle was drawn on the body to indicate the location of placement; --A circle was drawn on the left foot with the words left ankle wound written next to it; --There was no description of any skin damage to the resident's buttocks or marks indicated on the human body diagram of skin problems in that area; -Current needs were listed as: --Occupational Therapy (OT-treatment to develop, recover or maintain meaningful activities such as dressing, hygiene and toileting); --Physical Therapy (PT-treatment to improve physical functioning through exercise, activities and other non-pharmacological means); --Wound care; --Catheter care. Record review of the resident's Daily Skilled Nursing Notes, dated 5/25/19 through 5/27/19, showed: -All sections of the form were left blank except for the resident's vital signs (temperature, pulse, respiration, and blood pressure), oxygen needs and presence of a cough; -No documentation under the Skin category of any PU/PI, Arterial ulcer or any other skin condition; -No documentation on the back of the form except to get a daily pain level assessment on 5/25/19 and 5/26/19 on the Day Shift. Record review of the resident's Nursing Progress Notes, dated 5/25/19 through 5/27/19, showed no documentation of a PU/PI or any other skin issues to the resident's buttocks area. Record review of the resident's Physician Note, dated 5/27/19, showed: -The resident was seen by the physician on 5/27/19; -The resident continues to deal with some Stage 1 (Intact skin with localized area of non-blanchable (when pressed gently the skin does not turn a lighter color) [DIAGNOSES REDACTED] (redness) to Stage 2 skin breakdown on the resident's buttocks. Record review of the resident's Wound Evaluation, dated 5/28/19 at 1:55 P.M., completed by the wound care company showed: -The resident's right buttock wound was classified as a Stage 3 PU/PI; -The wound measured 4.12 cm in length, 2.74 cm in width and 0.10 cm in depth; --There was a small amount of serous drainage (pale yellow and transparent fluid) and no signs of infection; --The wound bed was described as 40 percent (%) granulation tissue (new vascular tissue in granular form on an ulcer or healing wound surface) and 60% slough; --Wound edges were described as distinct, with clearly visible outline and normal healthy skin surrounding the wound; --The wound had no odor, the status was Not healed and an enzyme debridement (removal of damaged tissue) was completed; --Comments were Yeast rash pretty well resolved. Now has a lot of slough. Changing orders; --Orders by the wound care physician were to Clean with Saline, Apply Santyl (debridement ointment) nickel thick layer to the wound bed. Apply Vaseline Gauze (gauze impregnated with petroleum jelly) cut to size. Cover with Bordered Gauze (an absorptive dressing that protects the wound and holds the dressing below it in place to maintain a moist wound environment). Change dressing daily to right buttock and as needed for soiling. Record review of the resident's facility Wound Assessment Reports, dated 5/28/19; showed: -Identification on 5/28/19 of a Stage 3 PU/PI; --The PU/PI identified on 5/28/19 was not present upon admission; --The location of the PU/PI was the right buttock and was referred to as Wound #2; --The Medical Director and Durable Power of Attorney (DPOA-a person chosen to legally act on one's behalf in the event the person becomes incapacitated) were notified on 5/28/19; -Treatment orders were pending. Record review of the resident's Daily Skilled Nursing Notes, dated 5/28/19 through 5/30/19, showed no documentation of a PU/PI on the checklist under the heading of Skin or on the back of the form in the Comments/Concerns section. Record review of the resident's TAR, dated (MONTH) 2019, showed the resident had orders to be treated with Zinc Oxide to bilateral buttocks, starting 5/24/19. The TAR did not give a reason for the order. These orders continued through 5/30/19. Record review of the resident's (MONTH) 2019, Physician order [REDACTED]. Apply nickel-thick size layer to wound bed. Apply Vaseline Gauze and border dressing daily and PRN. Record review of the resident's TAR, dated (MONTH) 2019, showed: -An order began on 5/30/19 to cleanse with NS. Apply Santyl, nickel thick to the wound bed. Cover with Vaseline Gauze cut to fit the wound and with a border gauze to the resident's right buttock; -The resident was first treated with Santyl on 5/31/19. Record review of the Daily Skilled Nurses' Notes for 5/31/19, 6/1/19 and 6/2/19, showed no documentation under the heading Skin of a PU/PI or of an Arterial wound. Documentation on the back of the form on 6/1/19 showed a note indicating that treatment orders to the buttocks had changed and that the resident should be encouraged to lay down after meals. Record review of the resident's Wound Evaluation, dated 6/3/19, from the wound care company showed: -The resident had an Unstageable PU/PI identified on 6/3/19 of the resident's left buttock. This was given a Wound ID number of two (Wound ID #2). The right buttock PU/PI was reassigned Wound ID #3; --Wound #2 (left buttock) was measured at 3.81 cm by 2.22 cm by 0.10 cm, had moderate amount of slough, small amount of serous (blood tinge) drainage, and had no odors. The PU/PI had 30% granulation tissue and 70% slough; --The wound status was Not healed and an enzyme debridement was done; --Wound care orders were: clean the wound with saline, apply Santyl, nickel thick layer to the wound bed. apply Vaseline Gauze cut to size; cover with a border gauze dressing and change dressing daily; -Wound #3 (right buttock): --Measurements were 3.38 cm by 1.31 cm by 0.10 cm and had changed from Stage 3 PU/PI to Unstageable with red granulation tissue, moderate amount of slough, a small amount of Serous drainage, no odors, and the slough was mechanically derided. The wound bed had 20% granulation tissue and 80% slough; --The wound status was Not healed and the wound was described as having increased slough; and -Treatment orders remained the same. The facility Wound Assessment Report, dated 6/3/19, showed: -Information about the wounds was consistent with the wound care company's assessment; -The right buttock PU/PI was reassigned Wound #3 and the left buttock PU/PI was referred to as Wound #2; -Both wounds were Unstageable due to slough; -The resident's Primary Care Physician (PCP) was notified on 6/3/19 of the new PU/PI. Record review of the resident's TAR, dated (MONTH) 2019, showed no documentation of a weekly skin assessment completed, due 6/4/19, and no explanation as to why on the back of the TAR. Record review of the resident's Potential for Skin Injury Care Plan, dated 5/6/19, showed the staff wrote and did not date that the resident had unstageable pressure ulcers to his/her right and left buttocks. No new interventions had been added to the plan. Record review of the resident's POS, dated (MONTH) 2019, showed a physician's orders [REDACTED]. Apply Santyl, nickel thick to the wound bed, cover with Vaseline Gauze dressing and cover with a dry dressing beginning 6/5/19. Record review of the resident's Daily Skilled Nurses Notes for 6/5/19, 6/6/19 and 6/7/19, showed no documentation of PU/PI or of an Arterial wound under the category Skin. Documentation on the back of the form for 6/5/19 showed treatments were completed to the resident's buttocks. Encourage the resident to self-propel and lay down between meals to promote wound healing. Record review of the resident's 14-Day MDS, dated [DATE], showed the resident's status was the same as at the time of the 5/10/19 MDS, except as follows: -The resident had disorganized thinking (incoherent, unclear or illogical); -Had two Unstageable PU/PIs. Record review of the resident's TAR for (MONTH) 2019, showed: -The resident did not receive his/her right and left buttock daily treatments on 6/7/19; -No documentation on the back of the TAR to show why the resident did not receive his/her treatment. Record review of the resident's Wound Evaluation, dated 6/10/19, from the wound care company showed: -Wound #2 (left buttock) was described as: --Unstageable, measured 3.48 cm by 4.14 cm by 0.10 cm, had 30% granulation tissue and 70% slough. There was a small amount of serous drainage and had no odors; --The wound status was Not healed; --An enzymic debridement was done and orders remained unchanged from the previous week; and --Comments were Larger area. Needs to offload more; -Wound #3 (right buttock) was described as: --Unstageable, measured 5.02 cm by 1.52 cm by 0.10 cm; had 40% granulation tissue and 50% slough with 10% [MEDICATION NAME] (process of scab formation covering the denuded (loss of surface layers) skin surface as part of the healing process) and small amount of serous drainage; --The wound status was Deteriorated and a mechanical debridement was done; --Comments were Needs to be out of wheelchair more; --Treatment orders remained unchanged from the previous week. Record review of the resident's facility-completed Wound Assessment Report, dated 6/10/19, showed: -Information was consistent with the wound care company's evaluation; -Wound edges were distinct with normal healthy skin; -The resident ate approximately 75% of most meals and the resident's weight was stable. Record review of the resident's Daily Skilled Nurses' Note, dated 6/10/19, 6/11/19 and 6/12/19, showed no documentation under the Skin section of an Arterial wound or of a PU/PI. Documentation for 6/11/19 on the back of the form showed staff were to encourage the resident to lay down after meals and the resident occasionally refuses. Record review of the resident's TAR, dated (MONTH) 2019, showed the resident did not receive his/her right and left Buttock treatment on 6/12/19 and 6/15/19. Review showed no documentation on the back of the TAR explaining why the resident did not receive the treatments. Record review of the resident's Wound Evaluation, dated 6/18/19, from the wound care company showed: -Wound #2 (left buttock): --Was classified as Stage 3 PU/PI, had 70% granulation tissue and 30% slough with a small amount of serous drainage and had no odor. Measurements were 3.57 cm by 3.46 cm by 0.10 cm; --The wound status was Improved and an enzymic debridement was done; --Comments were 90% better today; and --Treatment orders remained the same as the previous week; -Wound #3 (right buttock) showed: --The wound was Unstageable, with 100% granulation tissue, had a small amount of serous drainage and no odor. Wound measurements were 0.30 cm by 0.24 cm by 0.10 cm; --A mechanical debridement was done and comments were 40% better; --The wound status was Improved and orders remained unchanged from the previous week. Record review of the facility's Wound Assessment Report, dated 6/18/19, showed: -Information was consistent with the wound care company; -Wound edges were distinct with normal healthy skin; and -The resident ate approximately 75% at each meal and his/her weight was stable. Record review of the resident's Daily Skilled Nurses' Notes, dated 6/19/19, showed the Skin section was not filled out to document the resident's PU/PI and Arterial Ulcer. Daily Skilled notes for 6/20/19 on the back of the form showed staff were to encourage the resident to stay in bed and the resident was non-compliant at times. Record review of the resident's Fax Transmittal, sent by the Dietician to the resident's PCP, dated 6/20/19 showed: -Recommendations for a multivitamin with minerals due to Unstageable wounds to resident's right and left buttocks; -There was no response to the fax request indicating the physician's approval or denial and explanation if denied. Record review of the resident's POS, dated (MONTH) 2019, showed the resident was on a regular diet with mechanical soft texture (ground or flaky meats and cooked vegetables). Review showed no orders for a daily multivitamin with minerals. Record review of the resident's Daily Skilled Nurses' Notes, dated 6/21/19, showed no documentation under the Skin section of a PU/PI Record review of the resident's TAR, dated (MONTH) 2019, showed: -The resident did not receive treatment for [REDACTED]. -No explanation on the back of the TAR as to why the resident did not receive these treatments. Record review of the resident's Daily Skilled Nurses', dated 6/22/19 and 6/23/19, showed on 6/22/19 and 6/23/19 the staff were unable to do treatments to the residents buttocks due to the resident refused to lay down. Record review of the resident's Wound Evaluation, dated 6/24/19, completed by the wound care company physician showed: -Wound #2 (left buttock): --Was a Stage 3 PU/PI with 80% granulation and 20% slough and had a small amount of serosanguious fluid (clear, yellowish, milky or pale pink fluid composed of blood cells mixed with plasma (the liquid part of blood). Wound measurements were 3.24 cm by 3.64 cm by 0.10 cm; --The wound status was Improved and an enzymic debridement was done. Comments were Better looking; and --Treatment orders remained unchanged from the previous week; -Wound #3 (right buttock) documentation showed: --The PU/PI was Unstageable with 50% granulation tissue and 50% slough. Wound measurements were 4.92 cm by 2.12 cm by 0.10 cm. A small amount of serous drainage was present with no odors; --The Wound Status was Deteriorated and a mechanical debridement was done; --Comments were Continue Santyl. (MONTH) be able to change to collagen (encourages debridement and stimulates tissue growth) soon; and --Treatment orders remained unchanged from the previous week. Record review of the resident's facility-completed Wound Assessment Report, dated 6/24/19, showed: -Information was consistent with the wound physician's evaluation; -Wound edges were distinct with normal healthy skin; and -The resident was continuing to eat 75% of most meals and his/her weight was stable. Record review of the resident's Daily Skilled Nurses' Notes, dated 5/24/19, showed under the Skin category PU/PI was not indicated and this information was not on the back of the form. Record review of the resident's Nurses' Progress Notes, on 6/24/19 and 6/25/19, showed no documentation of any new skin issues on the resident's buttocks. Observation on 6/24/19 at 10:40 A.M., showed the resident, sat upright in his/her wheelchair. During an interview on 6/24/19 at 11:39 A.M., the resident said: -He/She had sores on his/her left and right buttock; -He/She got the sores when he/she was at the facility, but wasn't sure exactly how long he/she had the sores; -He/she received treatment on the sores. Observation in the resident's room on 6/24/19 at 11:40 A.M., showed: -The resident had a mattress which looked like the standard facility mattress; -It was not a specialized mattress such as a Low Air Loss mattress; -The resident was sitting up in his/her wheelchair on what looked like a foam seat cushion; -The seat cushion was smashed down where the resident sat on it and about a one to two inch amount of cushion was visible on the edges. Record review of the resident's TAR, dated (MONTH) 2019, showed no documentation of a weekly skin assessment, due on 6/25/19, and no explanation as to why on the back of the TAR. During an interview on 6/25/19 at 5:47 P.M., the Medical Director said: -He/She expected a full assessment upon a resident's admission, including a skin assessment; -If a resident has a PU/PI the resident's wound care team can makes recommendations for specialized needs or the facility nurse should contact the resident's PCP related to PU/PI needs such as a Low Air Loss mattress; -If the PCP is unavailable, as the Medical Director, he/she could be contacted regarding the resident's orders and needs. During an interview on 6/26/19 at 8:09 A.M., Licensed Practical Nurse (LPN) A said: -The resident's Arterial wound was found by the shower aide during a shower; -The resident started wound care with an outside wound care company the following Monday. The outside wound care company does the wound assessments and decides on treatments. The Day shift facility staff does treatments on all the resident's wounds; -The resident started to decline after the ankle wound; -The resident likes to be up all day in his/her wheelchair; -He/She had educated the resident that staying in his/her chair all day doesn't help with healing the wounds, but it is difficult for staff to get him to lay down during the day. During an interview on 6/26/19 at 8:46 A.M., Certified Nurse Assistant (CNA) G said: -The resident recently changed from a two-person transfer with a gait belt to a Sit-to-Stand (equipment designed to help residents who lack the strength or muscle control to rise to a standing position) lift with two staff assisting; -Staff turn residents who are unable to reposition themselves. The resident repositions himself/herself while in bed because he/she sees that the resident has scooted himself/herself around during the night; -The resident had a recliner, but he/she likes to stay in his/her wheelchair all day long so he/she can move about the building; -Sometimes the resident will lay down between lunch and dinner. During an interview on 6/26/19 at 9:30 A.M., LPN A said: -He/She just gave the resident a pain pill for ankle pain and he/she would start the resident's daily wound care in 15 to 30 minutes; -On 6/25/19 his/her transfer status had changed from one to two-person assistance using a gait belt to a Sit to Stand lift with two-person assistance; -The resident had been more independent and did things for himself/herself before his/her arterial ankle wound. His/Her mental status had declined over the past f