Every finding on record at River Oaks Care Center

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 67. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as a clean, sanitary and orderly environment. Observations on 08/05/25 at 3:03 P.M., and 08/06/25 at 8:00 P.M., of the 300 Hall showed: - A ceiling vent with a buildup of dust and rust in the hallway outside room [ROOM NUMBER]; - A ceiling vent with a buildup of dust and rust in the hallway outside room [ROOM NUMBER]; - A two-plug electrical outlet with a protective plate cover moved with minimal effort over the bed near the window in room [ROOM NUMBER]. During an interview on 08/05/25 at 3:07 P.M., the resident in room [ROOM NUMBER] said he/she had been shocked at different times when plugging and unplugging devices from the electrical outlet. He/She wasn't harmed from being shocked and had told the last Maintenance Supervisor about it. Observations on 8/05/25 at 3:32 P.M., 08/06/2025 at 10:32 A.M., and 08/07/2025 at 9:34 A.M., of the 400 Hall showed: - An exit door with both bottom sides of the frame deteriorated with exposed jagged edges near the classroom; - Two ceiling vents with a buildup of dust and rust in the hallway outside room [ROOM NUMBER]; - Two ceiling vents with a buildup of dust and rust in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. Observations on 08/05/25 at 3:43 P.M., 08/06/2025 at 11:55 A.M., and 08/07/2025 at 1:36 A.M., of the 500 Hall showed; - Two ceiling vents with a buildup of dust and rust in the hallway outside room [ROOM NUMBER]; - Two ceiling vents with a buildup of dust and rust in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER]; - A large window mini blind hung down on the top and lower left side with several broken slabs held together with clear tape by the bed next to the window in room [ROOM NUMBER]. Observations on 08/07/25 at 1:44 P.M., and 08/08/25 at 1:44 P.M., of the laundry room showed: - Three feet (ft) of cracked, worn, and loose linoleum flooring in the dirty linen room; - Three broken floor tiles in front of the doorway near the laundry sink; - 12 broken floor tiles in front of the chemical storage platform and both side-by-side washers; - Five broken floor tiles in front of the doorway leading to the clean linen room. Review of the Maintenance Requisition form, dated May 2025 - [DATE], showed: - No documentation of the area of concerns addressed. During an interview on 08/08/25 at 9:16 A.M., Laundry Aide A said any repairs or environmental concerns were reported to the Maintenance Supervisor or written down on a maintenance requisition form. If a resident reported an electrical issue, he/she would report it immediately to the maintenance department. He/She tripped and almost fell in the dirty linen room on the cracked linoleum floor because it moved and didn't stay down. He/She reported the concern in the past to his/her supervisor. During an interview on 08/08/25 at 9:21 A.M., Housekeeper B said any repairs or environmental concerns were reported to the Maintenance Supervisor or written down on a maintenance requisition form. If a resident reported an electrical issue, he/she would report it immediately to the maintenance department. During an interview 08/08/25 at 9:37 A.M., Housekeeper C said any repairs or environmental concerns were reported to the Maintenance Supervisor or written down on a maintenance requisition form. If a resident reported an electrical issue, he/she would report it immediately to the maintenance department. He/She tripped on the floors in the laundry area due to the cracked floor tiles and loose flooring. During an interview on 08/08/2025 at 10:24 A.M., the Maintenance Supervisor said staff should write down any repairs or environmental concerns on the requisition form. Staff told him/her in passing but he/she would rather have the concern be written down so it can be documented, addressed, and/or repaired. During an interview on 08/08/25 at 3:03 P.M., the Administrator said he would expect staff to write down any repairs or environmental concerns on the maintenance requisition form. If staff verbally told maintenance about a needed repair, he/she still needed to write the concern down for documentation purposes and to be addressed in a timely manner. He was not aware of the outlet issue in room [ROOM NUMBER] and would have maintenance to look at it. He would expect maintenance to repair any electrical issue with an outlet in a timely manner.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for one resident (Resident #70) out of three sampled closed resident records that included the instructions needed to provide effective and person-centered care to meet professional standards of quality care. The facility census was 67. Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, showed:- A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission;- The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meets professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to initial goals based on admission orders, discussion with the resident/representative, and physician orders;- The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed;- Provision of the summary to the resident and/or resident representative is documented in the medical record. 1. Review of Resident #70's closed medical record showed:- admitted on [DATE];- discharged on 06/02/25;- No baseline care plan completed within 48 hours after admission to the facility. During an interview on 08/07/25 at 2:47 P.M., Registered Nurse (RN) A said nursing should initiate the baseline care plan within two hours of a resident's admission to ensure it had been completed in a timely manner. During an interview on 08/07/25 at 2:49 P.M., the Director of Nursing (DON) said there should be a baseline care plan completed within 48 hours when a new resident was admitted to the facility. During an interview on 08/07/25 at 3:09 P.M., the Administrator said there should be a baseline care plan completed within 48 hours when a new resident was admitted to the facility.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than 5 percent (%). There were 26 opportunities with 10 errors made, resulting in an error rate of 38.46% for one resident (Resident #40) in the sample and one resident (Resident #10) outside the sample of six sampled residents. The facility's census was 67.Review of the facility's policy titled, Administering Medications, revised April 2019, showed:- Medications are administered in accordance with prescribers' orders, including any required time frame;- Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. - The individual administering the medication checks he label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication;- The individual administering the medication initials the resident's MAR (medication administration record) on the appropriate line after giving each medication and before administering the next ones;1. Review of Resident #10's Physician Order Sheet (POS), dated August 2025, showed:- admission date of 05/08/12;- Diagnoses of kyphosis (excessive curvature of the upper back), major depressive disorder (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), anxiety (excessive and persistent worry, fear, and nervousness), hyperlipidemia (high cholesterol), hemiplegia and hemiparesis following cerebrovascular disease (paralysis of one side of the body following a stroke), cerebral infarction (stroke), dysphagia (difficulty swallowing), aphasia (difficulty speaking), dementia (cognitive decline affecting memory, thinking, and language), hypertension (high blood pressure)- An order for metoprolol (treats high blood pressure) 50 milligrams (mg), give one tablet by mouth two times daily. Hold is systolic blood pressure (top number of blood pressure) is less than 110 or diastolic blood pressure (bottom number of blood pressure) is less than 70, dated 11/06/24.Review of the resident MAR, dated August 2025, showed:- The resident's blood pressure was 148/70;- Licensed Practical Nurse (LPN) E documented the metoprolol oral tablet administered on 08/06/25 at 8:00 A.M., LPN E did not administer the medication to the resident.Observation on 08/06/25 at 8:38 A.M., of the resident's medication pass showed:- LPN E did not administer the metoprolol tablet and charted that he/she administered the medication.2. Review of Resident #40's POS, dated August 2025, showed:- admission date of 02/21/22;- Diagnoses of chronic diastolic (congestive) heart failure (the heart can't pump enough blood), vascular dementia (cognitive impairment caused by a disruption of blood flow), cerebral infarction (stroke), neuropathy (nerve pain), hypertension (high blood pressure), benign neoplasm of colon, hyperlipidemia (high cholesterol), anemia (condition where the blood doesn't have enough healthy red blood cells or enough hemoglobin, a protein that carries oxygen), glaucoma (damage to the optic nerve), type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood), respiratory failure, fluid overload, dependence of renal dialysis, gastro-esophageal reflux disease (GERD-), - An order for aspirin (prevents blood clots) 81milligram (mg), give one tablet by mouth one time a day, dated 02/02/25;- An order for Dialyvite/Zinc oral tablet (B-complex w/C-zinc and folic acid)(supplement for people on dialysis), give one tablet by mouth one time a day, dated 12/24/24;- An order for ferrous sulfate (iron supplement) 325 mg, give one tablet by mouth one time a day, dated 03/21/24;- An order for Megestrol Acetate (appetite stimulant) tablet 20 mg, give two tablets by mouth one time a day, dated 12/24/24;- An order for torsemide (treats fluid retention) tablet 20 mg, give one tablet by mouth one time a day, dated 04/11/25;- An order for Trajenta (decreases blood sugar) tablet 5 mg, give one tablet by mouth one time a day, dated 06/17/24;- An order for gabapentin (treats nerve pain) capsule 100 mg, give one capsule by mouth two times a day, dated 02/01/25;- An order for pantoprazole sodium (treats heartburn) tablet delayed release 40 mg, give one tablet every morning and at bedtime, dated, 03/20/25;- An order for Prilosec (treats heartburn) tablet delayed release 20 mg, give one tablet two times a day, dated, 06/17/24;- An order to crush all medications and mix with pudding or applesauce every shift for difficulty swallowing, dated 01/07/25Review of the resident's MAR, dated August 2025, showed:- LPN E documented Dialyvite/Zinc oral tablet administered on 08/06/25 at 8:00 A.M., LPN E did not administer the medication to the resident;- LPN E documented the medications administered on 08/06/25 A.M. medication pass were crushed and LPN E did not crush the medications.Observation of Resident #40's medication pass on 08/06/25 at 8:48 A.M., showed:- LPN E did not administer Dialyvite/Zinc oral tablet (B-complex w/C-zinc and folic acid) and charted he/she administered the medication;- LPN E charted he/she crushed the resident's medications and mixed with pudding or applesauce and the LPN did not crush or mix the medications.During an interview on 08/07/25 at 11:45 A.M., LPN E said that Resident #40 doesn't typically require his/her medications to be crushed. LPN E said sometimes when the resident comes back from dialysis the resident is groggy or tired, so there is an order for his/her medications to be crushed if needed, but the resident always takes them whole for LPN E. LPN E did not know that Resident #10's metoprolol had not been given. During an interview on 08/08/25 at 1:50 P.M., the Director of Nursing (DON) said staff passing medications should follow physicians' orders as to what route the medications are given. If there is an order for medications to be crushed and mixed with pudding or applesauce every shift, the DON said he/she would expect staff to administer the resident's medications crushed in applesauce or pudding. The DON said staff should not chart medications have been given when they have not. During an interview on 08/08/25 at 2:15 P.M. the Administrator said if there is an order to crush resident's medications, he would expect staff to crush the resident's medications. He said staff should follow physician orders and administer medications as ordered.

Based on interview and record review, the facility failed to provide and document that residents received or declined Influenza (a viral infection of the respiratory system) immunizations and failed to provide and document pertinent education to the resident or resident representative regarding the benefits, side effects, or warnings of those immunizations for five residents (Residents #1, #9, #40, #41, and #49) out of five sampled residents. The facility's census was 67.Review of the facility's policy titled, Influenza Vaccine, revised August 2016, showed:- All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza;- The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or resident's legal representatives); for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy;- Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized;- Employees hired or residents admitted between October 1st and March 31st shall be offered the vaccine within five (5) working days of the employee's job assignment or the resident's admission to the facility;- Prior to the vaccination, the resident (or resident's legal representative) or employee 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/employee's medical record;- For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the resident/employee's medical record;- A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenzas Vaccine and placed in the resident's medical record.1. Review of Resident #1s medical record showed:- admission date of 03/03/25;- No documentation the facility provided information and education for the influenza vaccination to the resident and/or the resident representative for this year's influenza season;- No documentation of the consent or refusal for the influenza vaccination for this year's influenza season;- No documentation the influenza vaccination was administered or declined for this year's influenza season.2. Review of Resident #9's medical record showed:- admission date of 08/26/20;- No documentation the facility provided information and education for the influenza vaccination to the resident and/or the resident representative for this year's influenza season;- No documentation of the consent or refusal for the influenza vaccination for this year's influenza season.3. Review of Resident #40's medical record showed:- admission date of 02/21/22;- No documentation the facility provided information and education for the influenza vaccination to the resident and/or the resident representative for this year's influenza season;- No documentation of the consent or refusal for the influenza vaccination for this year's influenza season.4. Review of Resident #41's medical record showed:- admission date of 02/10/09;- No documentation the facility provided information and education for the influenza vaccination to the resident and/or the resident representative for this year's influenza season;- No documentation of the consent or refusal for the influenza vaccination for this year's influenza season;- No documentation the influenza vaccination was administered or declined for this year's influenza season.5. Review of Resident #49's medical record showed:- admission date of 01/19/23;- No documentation the facility provided information and education for the influenza vaccination to the resident and/or the resident representative for this year's influenza season;- No documentation of the consent or refusal for the influenza vaccination for this year's influenza season.During an interview on 08/08/25 at 1:50 P.M., the Director of Nursing (DON), said consents should be obtained prior to administration of immunizations. Refusals should also be signed by the resident or the resident representative.During an interview on 08/08/25 at 2:10 P.M., the Administrator said the admitting nurse obtains consent during the admission. The admitting nurse is responsible for administering any immunizations, but the Infection Preventionist and Director of Nursing should be conducting audits of those new admissions.

Based on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for two residents (Residents #7 and #17) out of four sampled residents with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). The facility's census was 67. Review of the facility's policy titled, Trauma Informed Care and Culturally Competent Care, revised August 2022, showed: - To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice; - To address the needs of trauma survivors by minimizing triggers and/or re-traumatization; - Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being; - All staff are provided in-service training about trauma and trauma-informed care in the context of the healthcare setting; - Nursing staff are trained on trauma screening and assessment tools; - All staff are guided in evidence-based organizational and interpersonal strategies that support trauma-informed and culturally competent care; - All staff receive orientation and in-service training regarding cultural competency as an aspect of resident-centered care; - Develop individualized care plans that address past trauma in collaboration with the resident and family as appropriate; - Identify and decrease exposure to triggers that may re-traumatize the resident. 1. Review of Resident #7's medical record showed: - admission date of 10/28/18; - Diagnoses of PTSD, anxiety (persistent worry and fear about everyday situations), schizoaffective disorder (a mental health condition characterized by symptoms of both schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life)), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and insomnia (persistent problems falling and staying asleep). Review of the resident's Trauma Care Informed Assessments, dated 06/18/24, 09/03/24, 03/04/25, and 06/24/25, showed: - No triggers. Review of the resident's August 2025 Physician Order Sheet (POS) showed: - An order for depakote (an anti-convulsant medication) delayed release 125 milligram (mg) by mouth two times a day for mood disorder, dated 04/16/25; - An order for citalopram (an anti-depressant medication) 20 mg daily for depression, dated 04/10/25; - An order for valium (an anti-anxiety medication)10 mg by mouth every 8 hours as needed (PRN) for anxiety, dated 10/02/24; - An order for mirtazapine (an anti-depressant medication) 7.5 mg by mouth at bedtime for anxiety, dated 06/16/25. Review of the resident's Care Plan, dated 08/06/25, showed: - Takes a psychotropic (medications that affect mental function, behavior, and experience) medication related to PTSD; - Did not address the resident's past trauma or any triggers that would cause resident to have behaviors. 2. Review of Resident #17's medical record showed:- admission date of 12/21/15;- Diagnoses of PTSD, bipolar disorder, schizoaffective disorder bipolar type, insomnia, alcohol abuse, major depressive disorder, and unspecified dementia (cognitive decline affecting memory, language, thinking and logic). Review of the resident's Trauma Care Informed Assessments, dated 08/12/24, 11/12/24, 02/14/25, and 05/15/25, showed: - No triggers . Review of the resident's August 2025 POS showed:- An order for Celexa (an anti-depressant) 10 mg by mouth daily for major depressive disorder, dated 06/05/25. Review of the resident's Care Plan, dated 08/05/25, showed:- Takes psychotropic medications related to PTSD;- Did not address past trauma or any triggers that would cause resident to have behaviors. During an interview on 08/07/25 at 2:56 P.M., the Director of Nursing (DON) said she would expect triggers to be addressed on the care plan for a resident diagnosed with PTSD. During an interview on 08/08/25 at 3:30 P.M., the Administrator said he would expect a resident with a diagnosis of PTSD to have triggers and interventions in place.

Based on interview and record review, the facility failed to ensure two residents (Residents #1 and #2) were free from physical and verbal abuse by staff. On 11/07/24, Certified Nurse Aide (CNA) A hit Resident #2 on the hand with a mug. The resident reported this to the administrator, in front of a witness. CNA A continued to work and measures were not taken after this incident to protect residents from further abuse. On 11/11/24, CNA A cursed at, shook and roughly threw Resident #1 into bed. This was witnessed by another staff member who reported up the command chain and the administrator was informed. The facility census was 73. The administrator was notified on 11/14/24 at 4:15 P.M., of an Immediate Jeopardy (IJ) which began on 11/07/24. The IJ was removed on 11/14/24, as confirmed by surveyor onsite verification. Review of the facility's policy titled, Abuse Prevention Program, dated September 2019, showed: - This facility will not tolerate verbal, sexual, physical or mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property; - All allegations will be investigated; - The Administrator and the Director of Nursing Services have an open door policy for reports of abuse, neglect, mistreatment, or misappropriation of resident property and confidential reports can be made at any time. 1. Review of Resident #2's medical record showed: - admitted on [DATE]; - Diagnoses of depression, hemiplegia (partial or total paralysis on one side of the body), Chronic Kidney Disease (kidneys fail to function leading to renal failure), stroke, and cognitive communication deficit (difficulty communicating due to cognition). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/24/24, showed the resident was moderately cognitively impaired and required moderate to partial assistance with all activities of daily living (ADLs). During an interview on 11/14/2024 at 11:15 A.M., Resident #2 said around 11/07/24, CNA A provided care to him/her. CNA A emptied the ice out of the resident's insulated pitcher, then hit him/her hard on the back of his/her right hand while saying I ain't got time to fucking mess with you to the resident. Resident #2 said he/she is afraid of CNA A. Resident #2 said he/she reported the incident to the Social Service Worker (SSW) and the Administrator (ADM). Observation on 11/14/2024 at 11:15 A.M., of Resident #2 showed a reddish-purple mark on the back of his/her right hand measuring 5 centimeters (cm) by 2 1/2 cm. The facility did not provide an investigation or facility reported incident (FRI) for the source of Resident #2's bruising. Review of the resident's medical record showed no documentation of the source of the resident's bruising or notes regarding the abuse allegation. During an interview on 11/14/24 at 11:35 A.M., the SSW said on 11/07/24, the ADM was sitting in his/her office, when Resident #2 came in. The resident reported CNA A had hit his/her hand and cussed at him/her. The ADM was sitting in the chair across from his/her desk, heard the resident and responded by saying this is the first I have heard of this and walked out of his/her office. The SSW said, he/she assumed the ADM was going to start an investigation. During an interview on 11/14/24 at 2:45 P.M., the ADM said he had never been informed of any incident with Resident #2 or any prior reports against CNA A. He denied the resident had informed him. The ADM said CNA A was not removed from the schedule. During an interview on 11/21/24, by phone CNA A denied hitting Resident #2 on the hand. He/she said he had no information on this matter. 2. Review of Resident #1's medical record showed: - The resident was admitted on [DATE]; - No documented history of behaviors; - Diagnoses of anxiety, depression, dementia (a group of conditions that interfere with daily living) without behaviors, borderline personality disorder (a mental disease characterized by unstable moods), Bi-Polar Disorder (a mental disease characterized by episodes of mood swings), and an amputation of the left leg above the knee. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively impaired and required maximum assistance with all ADLs. Review of the facility reported incident, received on 11/12/24 showed: - Resident #1 told staff that CNA A had used inappropriate language during care; - The resident denied any physical abuse; - No written statements provided from staff. Review of a written statement provided on 11/14/24 at 2:45 P.M. by the ADM, showed CNA B witnessed CNA A yelling and then shaking Resident #1 on 11/11/24. During an interview on 11/14/24 at 11:30 A.M., CNA B said on 11/11/24 he/she was taking dirty laundry down the hallway to the dirty laundry barrel which was parked beside Resident #1's room. CNA B said there was yelling coming from Resident #1's room. CNA B looked in the room of the resident and heard CNA A yelling and cursing the resident. CNA A was shaking the wheelchair with the resident in the chair, and then shook the resident by the shoulders and lifted the resident up and threw him/her into the bed. CNA B said he/she immediately went to find a charge nurse, but was unsuccessful. CNA B saw staff members Human Resources (HR) and Licensed Practical Nurse (LPN) C and reported the incident to them. LPN C went directly to the hallway to find the charge nurse to remove CNA A. HR told CNA B to write a statement. CNA B said he/she wrote a statement. During an interview on 11/14/24 at 11:40 A.M., HR said CNA B told her and LPN C that he/she had just witnessed CNA A cursing and shaking Resident #1. HR said she had CNA B confirm that CNA A had been physical, shaking Resident #1 and CNA B said 100%. HR and LPN C then informed the charge nurse, LPN D. They all addressed this with CNA A who did not write a statement and did not deny the allegation. CNA A cursed, left the room and building. HR notified the DON of the physical abuse by phone. During an interview on 11/14/24 at 12:00 P.M., LPN C said CNA B told him/her and HR that he/she had just witnessed CNA A cursing and shaking Resident #1. HR continued talking with CNA B while LPN C left to go find the charge nurse and report the incident. CNA A came to the conference room where LPN C, CNA A, HR and LPN D had gathered. CNA A did not deny the allegation and was asked to leave. The DON was contacted and informed of physical abuse. The charge nurse, LPN D, assessed the resident. LPN C said he/she asked the resident if he/she had been shaken and Resident #1 said yes. During an interview on 11/14/24 at 2:10 P.M., LPN D said he/she received a report of abuse from LPN C and asked CNA A into the conference room. CNA A denied knowing anything, cursed, and walked away. LPN D said the DON was informed of physical abuse by phone and came back to the facility. Resident #1 told LPN D that CNA A had been rough and had shaken his/her wheelchair and his/her body by the shoulders while cursing. During an interview on 11/14/24, at 2:00 P.M., the DON said on 11/11/24 after he had left the building for the evening, LPN D called to report CNA B had reported to have witnessed CNA A shake Resident #1's wheelchair as well as by the shoulders. The DON went back to the facility and CNA A had been sent home. The DON said he started a Resident Questionnaire and had CNA B write a statement. The DON was aware of the allegation of verbal and physical abuse and called and informed the ADM which is their protocol. During an interview on 11/14/2024 at 2:45 P.M., the ADM said, on 11/11/24, the DON contacted him and reported CNA A had used inappropriate language with Resident #1. The ADM denied being told of an allegation of physical abuse. On 11/12/24, the ADM interviewed the resident, who said there had been no physical abuse. At that time, the ADM concluded the investigation. The ADM said he had just now found a written statement from CNA B on his desk alleging physical abuse from CNA A to Resident #1, but felt the allegation was unclear. During an interview on 11/14/24 at 5:15 P.M., CNA A denied yelling at or shaking Resident #1. He/she said that no one could have seen in the room, because the door was closed. He/she said CNA B may have heard him/her grunting while doing care, but he/she was not yelling. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A 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). Complaint #MO245031

Based on interview and record review, the facility failed to thoroughly investigate reports of abuse for two residents (Residents #1 and #2), out of seven sampled residents. While providing care, on 11/07/24, Certified Nurse Aide (CNA) A hit Resident #2 on the hand with a mug. This was reported to the Administrator (ADM) by the resident. The allegation was not investigated and CNA A continued to work. On 11/11/24, Resident #1 was shaken and thrown on the bed by CNA A. The ADM did not investigate the allegations as per the facility policy and procedure. The facility census was 73. The administrator was notified on 11/14/24 at 4:15 P.M., of an Immediate Jeopardy (IJ) which began on 11/07/24. The IJ was removed on 11/14/24, as confirmed by surveyor onsite verification. Review of the facility's policy titled, Abuse Prevention Program, dated September 2019, showed: - This facility will not tolerate verbal, sexual, physical or mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property; - All allegations will be investigated; - The Administrator and the Director of Nursing Services have an open door policy for reports of abuse, neglect, mistreatment, or misappropriation of resident property and confidential reports can be made at any time. Review of the facility's policy titled Abuse Investigation and Reporting, dated July 2017 showed: - All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulation) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported. 1. Review of Resident #2's medical record showed: - admitted on [DATE]; - Diagnoses of depression, hemiplegia (partial or total paralysis on one side of the body), Chronic Kidney Disease (kidneys fail to function leading to renal failure), stroke, and cognitive communication deficit (difficulty communicating due to cognition). Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/24/24, showed the resident was moderately cognitively impaired and required moderate to partial assistance with all activities of daily living (ADLs). During an interview on 11/14/2024 at 11:15 A.M., Resident #2 said around 11/07/24, CNA A provided care to him/her. CNA A emptied the ice out of the resident's insulated pitcher, then hit him/her hard on the back of his/her right hand while saying I ain't got time to fucking mess with you to the resident. Resident #2 said he/she is afraid of CNA A. Resident #2 said he/she reported the incident to the Social Service Worker (SSW) and the ADM. Observation on 11/14/2024 at 11:15 A.M. of Resident #2 showed a reddish-purple mark on the back of his/her right hand measuring 5 centimeters (cm) by 2 1/2 cm. During an interview on 11/14/24 at 11:35 A.M., the SSW said on 11/07/24, the ADM was sitting in his/her office, when Resident #2 came in. The resident reported CNA A had hit his/her hand and cussed at him/her. The ADM was sitting in the chair across from his/her desk, heard the resident and responded by saying this is the first I have heard of this and walked out of his/her office. The SSW said he/she assumed the ADM was going to start an investigation. The SSW said he/she failed to document the allegations and did not follow up, but the facility policy would direct staff to initiate an investigation. During an interview on 11/14/24 at 2:45 P.M., the ADM said he had never been informed of any incident with Resident #2. He denied the resident had informed him. The ADM said CNA A was not removed from the schedule. The facility did not provide an investigation or facility reported incident (FRI) for the source of Resident #2's bruising. Review of the resident's medical record showed no documentation of the source of the resident's bruising or notes regarding abuse allegation. 2. Review of Resident #1's medical record showed: - The resident was admitted on [DATE]; - No documented history of behaviors; - Diagnoses of anxiety, depression, dementia (a group of conditions that interfere with daily living) without behaviors, borderline personality disorder (a mental disease characterized by unstable moods), Bi-Polar Disorder (a mental disease characterized by episodes of mood swings), and an amputation of the left leg above the knee. Review of Resident #1's quarterly MDS), dated [DATE], showed the resident was cognitively impaired and required maximum assistance with all ADLs. Review of the facility reported incident, received on 11/12/24 showed: - Resident #1 told staff that CNA A had used inappropriate language during care; - The resident denied any physical abuse; - No written statements provided from staff. Review of a written statement provided on 11/14/2024 at 2:45 P.M. by the ADM, showed CNA B witnessed CNA A yelling and then shaking Resident #1 on 11/11/24. During an interview on 11/14/24 at 11:30 A.M., CNA B said on 11/11/24 he/she was taking dirty laundry down the hallway to the dirty laundry barrel which was parked beside Resident #1's room. CNA B said there was yelling coming from the resident's room. CNA B looked in the room of Resident #1 and heard CNA A yelling and cursing the resident. CNA A was shaking the wheelchair with the resident in the chair, and then shook the resident by the shoulders and lifted the resident up and threw him/her into the bed. CNA B said he/she immediately went to find a charge nurse but was unsuccessful. CNA B saw staff members Human Resources (HR) and Licensed Practical Nurse (LPN) C and reported the incident to them. LPN C went directly to the hallway to find the charge nurse to remove CNA A. HR told CNA B to write a statement. CNA B said he/she wrote a statement. During an interview on 11/14/24 at 11:40 A.M., HR said CNA B told him/her and LPN C that he/she had just witnessed CNA A cursing and shaking Resident #1. HR said she had CNA B confirm that CNA A had been physical, shaking Resident #1 and CNA B said 100%. HR and LPN C then informed the charge nurse, LPN D. They all addressed this with CNA A who did not write a statement and did not deny the allegation. CNA A cursed said and left the room and building. HR notified the DON of the physical abuse by phone. During an interview on 11/14/24 at 12:00 P.M., LPN C said CNA B told him/her and HR the he/she had just witnessed CNA A cursing and shaking Resident #1. HR continued talking with CNA B while LPN C left to go find the charge nurse and report the incident. CNA A came to the conference room where LPN C, CNA A, HR and LPN D had gathered. CNA A did not deny the allegation and was asked to leave. The DON was contacted and informed of physical abuse. LPN C said he/she asked the resident if he/she had been shaken and Resident #1 said yes. During an interview on 11/14/2024 at 2:10 P.M., LPN D said he/she received a report of abuse from LPN C and asked CNA A into the conference room. CNA A denied knowing anything, cursed, and walked away. LPN D said the DON was informed of physical abuse by phone and came back to the facility. Resident #1 told LPN D that CNA A had been rough and had shaken his/her wheelchair and his/her body by the shoulders while cursing. During an interview on 11/14/24, at 2:00 P.M., the DON said on 11/11/2024 after he had left the building for the evening, LPN D called to report that CNA B had reported to have witnessed CNA A shake Resident #1's wheelchair, as well as by the shoulders. The DON went back to the facility and CNA A had been sent home. The DON said he started a Resident Questionnaire and had CNA B write a statement. The DON was aware of the allegation of verbal and physical abuse and called and informed the ADM, which is their protocol. During an interview on 11/14/2024 at 2:45 P.M., the ADM said, on 11/11/24, the DON contacted him and reported CNA A had used inappropriate language with Resident #1. The ADM denied being told of an allegation of physical abuse. On 11/12/24, the ADM interviewed the resident, who said there had been no physical abuse. At that time, the ADM concluded the investigation. The ADM said he had just now found a written statement from CNA B on his desk alleging physical abuse from CNA A to Resident #1, but felt the allegation was unclear. The ADM said he did not further investigate or question CNA B for clarity. The ADM said it is the facility policy and procedure to thoroughly investigate all allegations of abuse. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A 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). Complaint #MO245031

Based on observation, interview, and record review, the facility failed to use proper infection control techniques for glove use during wound care for two residents (Resident #24 and #56) and during incontinent care for two residents (Resident #62 and #67) out of four sampled residents. The facility census was 74. Review of the facility's policy, Infection Control, revised October 2018, showed: - This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections; - The objectives of our infection control policies and practices are to: - Prevent, detect, investigate, and control infections in the facility; - Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. Review of the facility's policy titled, Standard Precautions, revised September 2022, showed: - Gloves are worn when in direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material; - Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care; - Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another; - Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces; - After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environments. 1. Review of Resident #56's Physician's Order Sheet (POS), dated August 2024, showed: - An order, dated 08/04/24, to cleanse unstageable pressure ulcer (a type of wound that occurs when prolonged pressure on the skin prevents blood and oxygen from reaching the tissue and can be covered by a layer of dead tissue) to right heel with wound cleanser, pat dry, apply calcium alginate with silver (topical wound dressing to help reduce infections and are used to treat wounds with moderate to heavy drainage), cover with an abdominal pad (ABD, a dressing used to treat large wounds that require high absorbency), wrap with kerlix (conforming gauze) and secure with tape two times daily. Observation on 08/15/24 at 2:15 P.M., of wound care for Resident #56 showed: - Licensed Practical Nurse (LPN) C put on protective gown at the resident's door before entering the room, washed hands and put on gloves; - LPN C removed the old dressing from the resident's right heel; - LPN C removed his/her gloves, put on a clean pair of gloves and did not sanitize his/her hands; - LPN C cleansed the open area with wound cleanser (an antiseptic that helps reduce the risk of infection and prevent bacterial contamination) and gauze; - With the same soiled gloves, LPN C dried the area with gauze, applied calcium alginate with silver dressing placed over the open area, ABD dressing applied, wrapped with kling, secured with tape and removed the soiled gloves; - LPN C did not sanitize hands or change gloves between dirty and clean tasks. 2. Review of Resident #24's POS, dated August 2024, showed: - An order, dated 08/09/24, to apply barrier cream (a cream to provide protection from irritants) to bottom with incontinent episodes, every shift for stage II pressure injury (an open sore that occurs when the dermis, or deeper layer of skin, is partially lost). Observation on 08/15/24 at 4:35 P.M. of wound care for Resident #24 showed: - The resident stood on the side of his/her room near the bed, he/she removed pants and brief; - LPN C put on protective gown before entering the room, put on gloves and cleansed the resident's buttocks with wound cleanser and gauze; - LPN C dried the open area on the buttocks with gauze; - With the same soiled gloves, LPN C applied the barrier cream to the resident's buttocks; - LPN C removed the dirty gloves and did not sanitize hands or change gloves between dirty and clean tasks. 3. Observation on 08/15/24 at 1:29 P.M. of incontinent care for Resident #67 showed: - Certified Nurse Aide (CNA) J and K washed hands, and applied gloves; - CNA J and K assisted the resident into bed, removed pants and brief; - CNA J used a washcloth to clean the resident while CNA K assisted in positioning; - With the same soiled gloves, CNA J and K applied a clean brief to the resident and assisted with dressing the resident. 4. Observation on 08/16/24 at 12:52 P.M. of incontinent care for Resident #62 showed: - CNA L applied a gown at the doorway before entering the room; - CNA L left the room to get a privacy sheet from the hallway cart and did not remove or change gown; - CNA L left the room to get more washcloths from the hallway cart and did not remove or change gown. During an interview on 08/15/24 at 1:38 P.M., CNA J said that they do not normally change their gloves during incontinent care between dirty and clean. CNA K agreed that he/she does not change gloves between dirty and clean. During an interview on 08/15/24 at 4:40 P.M., LPN C said staff should have washed his/her hands and changed gloves between dirty and clean. LPN C said his/her hands should have been sanitized and gloves changed before the barrier cream was applied. During an interview on 08/16/24 at 2:18 P.M., the Director of Nursing (DON) said he/she would expect staff to remove gowns before leaving a room, and apply a new gown before entering. She also said staff should change gloves between dirty and clean, and should have also changed gloves before applying the barrier cream. 50260

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 74. Record review of the facility's Homelike Environment policy, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - Staff provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences; - The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which include clean, sanitary and orderly environment. 1. Observations made on 08/13/24 at 10:38 AM and 08/14/24 at 12:38 P.M., showed a long piece of decorative trim with several areas of chipped and peeled paint on the left side of the kitchen door entrance. 2. Observation made on 08/13/24 at 11:04 A.M., of the wardrobe cabinet in room [ROOM NUMBER], showed: - Soiled rolled towels placed around the front outside edge; - The right side of the inside bottom flooring rotted out with an exposed hole. During an interview on 08/13/24 at 11:08 A.M., the resident in room [ROOM NUMBER] said his/her wardrobe cabinet had been like that since he/she was admitted in July. 3. Observations made on 08/13/24 at 11:29 P.M. and 08/14/24 at 3:32 P.M., showed several areas of chipped and peeled paint on the outside surface walls of the nurse's station. 4. Observations made on 08/13/24 at 1:39 P.M. and 08/14/24 at 1:32 P.M., of the 500 Hall, showed: - A buildup of dust and debris visible on the inside of a light fixture cover in hallway located between rooms [ROOM NUMBERS]; - A buildup of dust and debris visible on the inside of a light fixture cover in hallway located between rooms [ROOM NUMBERS]; - A buildup of dust and debris visible on the inside of a light fixture cover in hallway located between rooms [ROOM NUMBERS]; - A buildup of dust and debris visible on the inside of a light fixture cover in hallway located between rooms [ROOM NUMBERS]; - Several dark stained areas on the ceiling tiles throughout the therapy/exercise room. 5. Observation on 08/15/24 at 8:40 A.M. showed: - Two ceiling tiles with brown circles in room [ROOM NUMBER]; - One ceiling tile with brown circle around the air vent in room [ROOM NUMBER]; - One ceiling tile with a brown circle in room [ROOM NUMBER]; - Two ceiling tiles with brown circles near the air vent in room [ROOM NUMBER]; - Ceiling tile with dark stained area around the air vent in room [ROOM NUMBER]; - Four ceiling tiles with dark brown and black areas in room [ROOM NUMBER]. 6. Observation on 08/16/24 at 2:33 P.M., of the 500-hall shower room, showed five 12-inch (in.) x12 in. floor tiles cracked and/or missing located in front of the shower stall. Review of the repair requisition log, dated 07/14/24 through 08/15/24, showed no documentation of areas of concerns addressed. During an interview on 08/16/24 at 9:20 A.M., Housekeeper A said there is a maintenance log that staff writes down things that need to be repaired. He/She also verbally tells maintenance if there are any environmental concerns that need addressed. He/she has told maintenance about some ceiling tiles that needed replaced recently. During an interview on 08/16/24 at 9:24 A.M., Housekeeper B said any environmental concerns are written down on the maintenance log to be addressed. He/She will also take pictures and show the maintenance supervisor. During an interview on 08/16/24 at 09:35 A.M., the Maintenance Supervisor (MS) said he/she would expect staff to write down any environmental concerns to be addressed. There is a clip board posted by the employee breakroom that staff can write down anything that needs fixed or replaced. During an interview on 08/16/24 at 2:20 P.M., the previous Administrator said the ceiling tiles have been ordered. The MS has a few extra tiles and will replace the ones in room [ROOM NUMBER] immediately. During an interview on 08/16/24 at 3:03 P.M., the Administrator said all staff is responsible for seeing issues and filling out the requisition forms for maintenance. The Administrator said he makes rounds throughout the facility daily. MO239543 50260

Based on observation, interview and record review, the facility failed to provide a safe transfer for two residents (Residents #62 and #67) out of 18 sampled residents, when staff did not utilize a gait belt (a thick fabric or vinyl belt that is placed around a patient's waist to help with mobility and prevent falls) as directed by therapy recommendations and the resident's care plan. The facility census was 74. Review of the facility's policy titled, Safe Lifting and Movement of Residents, revised July 2017, showed: - Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. - Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 1. Review of Resident #62's medical record showed: - An admitted [DATE]; - Diagnoses of Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by nerves), Multiple system atrophy (a neurological disorder that causes progressive damage to nerve cells in the brain and spinal cord), Acute Respiratory Failure with hypoxia (a condition that occurs when the lungs have trouble exchanging oxygen and carbon dioxide with the blood); Review of the resident's admission Minimum Data Set (MDS) (a federally mandated assessment completed by facility staff), dated 06/20/24, showed: - Dependent on staff for activities of daily living (ADL's); - Required substantial to maximal assist for transfers; - Impairment to both sides of upper and lower extremities (arms and legs); - Sit to stand and all transfers to be substantial/maximal assist (where helper does more than half the work). Review of the resident's care plan, revised on 07/15/24, showed the resident required substantial-maximal assistance with ADLs, transfers, and toileting. Observation on 08/15/24 at 8:42 A.M., showed: - Registered Nurse (RN) C and Nurse Aide (NA) I in Resident #62's room to transfer from wheelchair to bed; - RN C and NA I grabbed the resident by the waist band of pants and stood resident up by placing staff arms underneath the residents' arms, pulled the resident up to standing position; - Resident unable to pivot, RN C pulled residents pant leg to move the residents' foot and leg; - NA I wore gait belt around shoulder. During an interview on 08/16/24 at 8:51 A.M., Physical Therapy Assistant (PTA) said Resident #62 requires maximal assistance with two staff using a gait belt and a stand-pivot transfer. 2. Review of Resident #67's medical record showed: - An admitted [DATE]; - Diagnoses of Cerebrovascular disease (condition affecting blood flow to your brain), Displaced fracture of the base of the neck of right femur (broken bone), and Dementia (a disease affecting memory, language and problem solving). Review of the resident's quarterly MDS, dated [DATE], showed chair/bed to chair transfers require substantial/max assist where helper does more than half of effort. Review of the resident's care plan, dated 05/06/24, showed the resident required substantial/max assist with transfers. Observation on 08/15/24 at 1:29 P.M., showed: - Certified Nurse Aide (CNA) J and CNA K in Resident #67's room to transfer from wheelchair to bed; - CNA K bent down and put both arms underneath resident's arms and lifted resident to standing position; - Resident unable to pivot, CNA K turned resident and sat resident on bed and assisted into a lying position. - After care, CNA K again reached around the resident underneath his/her arms and lifted the resident into a sitting position and then back into the wheelchair; - CNA J wore a gait belt around waist, no gait belt used for transfer. During an interview on 08/15/24 at 1:38 P.M., CNA J said he/she thinks Resident #67 is just a one person transfer because the resident can bear weight and assist. CNA K said he/she would normally use a gait belt for transfers. During an interview on 08/15/24 at 2:18 P.M., the Director of Nursing (DON) said that he/she would expect CNAs to use a gait belt for transfers, not lifting by using under resident's arms. 50260

Based on observation, interview and record review, the facility failed to ensure gastric residual volume (the amount of liquid that drains from the stomach after enteral feeding is administered) was measured prior to administering tube feeding for two residents (Residents #62 and #15) out of two sampled residents. The facility also failed to follow standards of practice by using a plunger (used to force liquid into feeding tube catheter) during tube feeding on one resident (Resident #15) out of two sampled residents. The facility census was 74. Record review of the facility's policy, Enteral Nutrition, last revised November 2018, showed: - The provider will consider the need for supplemental orders, including: -Checks for gastric residual volume (GRV) before feeding and medication - The facility did not provide a policy on plunger use during a tube feed. 1. Review of Resident #62's Physician's Order Sheet (POS), dated August 2024, showed: - An order for Isosource 1.5 calorie ((cal) a calorically dense complete nutrition formula with fiber for increased calorie needs to support bowel function), 250 millimeter (ml) four times daily; - An order for 120 cubic centimeters (cc) water flush four times daily; - An order to check placement; - An order to hold feeding if residual is more than 60 cc. Observation on 08/15/24 at 8:33 A.M., showed: - The resident sat in bed with a gastrostomy tube (G-tube, a tube surgically inserted into the stomach to provide nutrition and medication); - Registered Nurse (RN) C uncapped the resident's G-tube and attached the barrel of a syringe into the G-tube; - RN C did not check residual of the stomach contents per physicians' orders prior to feeding administration; - RN C flushed the resident's G-tube with 30 cc of water; - RN C administered Isosource 1.5 cal and flushed with 60 cc of water. Observation on 08/15/24 at 1:53 P.M., showed: - The resident sat in bed with G-tube; - RN C uncapped the resident's G-tube and attached the barrel of a syringe into the G-tube; - RN C did not check residual per physicians' orders prior to feeding administration; - RN C flushed the resident's G-tube with 30 cc of water; - RN C administered Isosource 1.5 cal and flushed with 180 cc of water. Observation on 08/16/24 at 9:33 A.M., showed: - The resident sat in bed with G-tube; - Licensed Practical Nurse (LPN) D uncapped the resident's G-tube and attached the barrel of a syringe into the G-tube; - LPN D checked for placement: with auscultation (listening for air movement in the stomach with a stethoscope) - LPN D did not check residual of the stomach contents per physicians' orders prior to feeding administration; - LPN D flushed the resident's G-tube with 60 cc of water; - LPN D administered Isosource 1.5 cal and flushed with 60 cc of water. 2. Review of Resident #15's POS dated, August 2024 showed: - An order for Isosource 1.5 calorie at 250 ml four times daily; - An order for 180 ml water flush six times daily; - An order flush feeding tube with 30 cc of water before and after medication administration. Observation on 08/14/24 at 9:45 A.M., showed: - The resident laying in bed with G-tube; - LPN D uncapped the resident's G-tube and attached the barrel of syringe in residents G-tube; - LPN D did not check for placement by auscultation, or check residual; - LPN D flushed resident's G-tube with 30 cc of water; - LPN D administered 40 cc of Isosource 1.5 cal; - LPN D added approximately 20 cc of water to syringe while Isosource remained in syringe; - LPN D took a plastic straw laying on bedside table and used it to stir together Isosource and water inside the syringe; - LPN D added 50 cc more Isosource to syringe; - At 15 cc, LPN D added approximately 20 cc water to syringe and stirred with straw from bedside table. Observation on 08/14/24 at 10:15 A.M., showed: - LPN D uncapped residents G-tube and attached barrel of syringe in resident's G-tube; - LPN D flushed resident's G-tube with 30 cc of water; - LPN D added 120 cc of crushed medication mixed with water; - LPN D used plastic straw from bedside table to stir medication mixture in syringe; - LPN D added 60 cc of remaining medication mixture; - LPN D used plunger from syringe to force medication mixture into resident's G-tube; - LPN D added 30 cc of medication mixture to syringe, and used plunger to force medication into resident's G-tube. During an interview on 08/16/24 at 02:18 P.M., the Director of Nursing (DON) said he/ she would not expect staff to use a plastic straw to stir contents inside the syringe during a tube feed. The DON said he/she would not expect staff to add water to tube feedings or use the plunger to force feedings and/or medication into G-tube. During an interview on 08/14/24 at 3:36 P.M., LPN D said he/she checks for residual on residents sometimes. LPN D said he/she usually does not use the plunger to force feedings and medication through G-tube but does when it becomes thick or clogged. During an interview on 08/16/24 at 3:45 P.M., the DON said he/she expected staff to check for residual of a G-tube prior to medication administration or feeding.

Based on observation, interview, and record review, the facility failed to implement procedures to ensure medications were accurately administered, documented, disposed of and reconciled for one resident (Resident #100) outside of the 18 sampled residents. The facility census was 74. Review of the facility's policy titled, Pharmacy and Medication Administration, undated, showed: - Narcotics must be counted at the beginning and end of each shift and signed on the narcotic log by the oncoming and off going nurse or medication technician; - Monitoring the log weekly can help identify any missed counts or lax in counting by particular staff. Observation on 08/16/24 at 12:30 P.M., of the locked refrigerator in the main mediation room showed one bottle of opened liquid lorazepam (a controlled medication used to treat anxiety) 2 milligram (mg) per milliliter (ml) with 29.5 ml left in the 30 ml bottle for Resident #100. Observation on 08/16/24 at 12:40 P.M., of Medication Cart One showed one bottle of opened liquid morphine (a controlled medication used to treat pain and shortness of breath) 100 mg per five milliliters with 29.5 ml left in the 30 ml bottle for Resident #100. Review Resident #100's medical record showed: - An admitted [DATE]; - An order for morphine 0.25 ml every 2 hours for pain, dated 08/07/24; - An order for lorazepam 0.25ml every 2 hours for anxiety, dated 08/07/24; - A discharge date of [DATE] for the resident. Review of the controlled substance record book showed no individual controlled substance records for Resident #100's morphine 0.25 ml every 2 hours for pain or lorazepam 0.25ml every 2 hours for anxiety. During an interview on 08/16/24 at 12:33 P.M., Licensed Practical Nurse (LPN) D said there should have been a paper in the book for Resident #100's controlled medication of morphine and lorazepam. When residents were discharged , the unused controlled medications were given to the Director of Nursing (DON). During an interview on 08/16/24 at 12:35 P.M., Certified Medication Technician F said he/she did count with the off going nurse this morning, but just skipped over this resident's medications because the resident had passed away. During an interview on 08/16/24 at 3:30 P.M., the Director of Nursing (DON) said he/she was unable to locate a controlled substance sheet for the morphine or lorazepam, and there should have been one for each medication. The DON did not know why the morphine of lorazepam had not been brought to him/her for destruction.

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 68. Record review of the facility's Homelike Environment policy, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which include a clean, sanitary and orderly environment. 1. Observations on 5/1/23 at 10:35 A.M., 5/2/23 at 9:27 A.M. and 5/3/23 at 11:39 A.M., of the 300 Hall showed: - A five inch (in.) strip of baseboard coming apart from the wall located by the bathroom door in room [ROOM NUMBER]; - A six in. x three in. dark circle on a ceiling tile above the head of the bed located by the window in room [ROOM NUMBER]; - A six in. x 18 in. dark circle on a ceiling tile above the light fixture beside the bed located by the window in room [ROOM NUMBER]; - A four in. x 12 in. dark circle on a ceiling tile over the bed located by the window in room [ROOM NUMBER]; - A two in. x four in. dark circle on a ceiling tile near the air vent in room [ROOM NUMBER]; - A four in. x six in. dark circle on a ceiling tile located above the clothes closet in room [ROOM NUMBER]; - The air vent with a black buildup and a dark black circle located on a ceiling tile in room [ROOM NUMBER]; - Several areas of exposed sheetrock and peeled paint near the right-side area of the bed located by the door in room [ROOM NUMBER]; - A four foot (ft.) baseboard strip coming apart from the wall in front of the toilet in the bathroom shared between room [ROOM NUMBER] and 310. During an interview on 5/1/23 at 10:35 A.M., the resident in room [ROOM NUMBER] said he/she wanted the water spot stains on the ceiling tiles addressed. Observation on 5/1/23 at 10:44 A.M., 5/2/23 at 9:44 A.M., and 5/3/23 at 11:44 A.M., showed: - Missing baseboards and/or trim with a visible hardened white substance around the bottom circumference of the nurse's station located at the central part of the facility. Observations on 5/3/23 at 2:00 P.M., of 100 hall showed: - A two ft. x four ft. ceiling tile with a three in. x five in. brown circle near the window in room [ROOM NUMBER]; - A two ft. x two ft. ceiling tile with three in. x three in. brown circle in room [ROOM NUMBER]; - A five in. x five in. and a two in. x two in. dark circle near the privacy curtain tract in room [ROOM NUMBER]; - A two ft. x two ft. discolored tile near the sprinkler in room [ROOM NUMBER]; - A two ft. x two ft. ceiling tile with a black substance near the sprinkler in room [ROOM NUMBER]; - A two ft. x four ft. ceiling tile with three brown circles in room [ROOM NUMBER]; - Two - two ft. x four ft. ceiling tile with brown circles in the corner of room [ROOM NUMBER]; - A two ft. x four ft. sagging ceiling tile with an air vent located in the south end of the tile with a black substance build up and the perimeter of the air vent dark color in room [ROOM NUMBER]; - A one ft. x two ft. ceiling tile with a small hole near the privacy curtain tract near the entrance door in room [ROOM NUMBER]. Observation on 5/3/23 at 2:15 P.M., of the 200 Hall showed: - An eight ft. x one ft. ceiling tile with a large brown circle and an eight ft. x four ft. ceiling tile with a large brown circle over the resident's sink area in room [ROOM NUMBER]; - A two ft. x two ft. ceiling tile with a large brown circle in the corner of room [ROOM NUMBER]; - A two ft. x two ft. ceiling tile with a large brown area along the north side and a ceiling tile frame covered in a dark brown substance near the bed next to the window in room [ROOM NUMBER]; - An area above the resident's sink showed five holes in the wall in room [ROOM NUMBER]. Observation on 5/3/23 at 2:20 P.M., of the east end of the nurses' station showed: - A two ft. x four ft. ceiling tile with a two inch linear hole near the 100 hall double doors. Observation on 5/4/23 at 2:40 P.M., of room [ROOM NUMBER] showed: - Multiple dark brown colored circles of various sizes on the ceiling; - The white colored air vent in the ceiling with moderate amount of a black colored fuzzy substance; - The white colored air vent in the bathroom ceiling with a moderate amount of a dark brown substance. Observation on 5/4/23 at 2:45 P.M., of room [ROOM NUMBER] showed: - The wood painted chair rail trim on three sides of the room with numerous areas of missing paint; - The chair rail trim on the wall to the left of the door pulled away from the sheetrock with an exposed metal staple. During an interview on 5/4/23 at 2:45 P.M., the resident in room [ROOM NUMBER] said the trim was like that when he/she moved in the room and he/she wanted it to be fixed and repainted. Observation on 5/4/23 at 3:02 P.M., of 400 hall showed: - All of the while tiles on the ceiling past rooms [ROOM NUMBERS] with shades of yellow and brown; - One large brown circle on the ceiling tile in the middle of the hall between rooms [ROOM NUMBERS]; - One brown circle on the sagging ceiling tile surrounding the vent over the bed next to the window in room [ROOM NUMBER]. During an interview on 5/4/23 at 3:15 P.M., the resident in room [ROOM NUMBER] said he/she believed the ceiling was yellow due to prior smoking in the smoking room at the end of the hall. It looked dirty. Record review of the maintenance requisition log, dated 4/28/23 through 5/2/23, showed no current requests for areas of concern documented. During an interview on 5/3/23 at 2:09 P.M., Certified Nursing Assistant (CNA) A said that he/she verbally told maintenance if there were repairs needed such as baseboard issues, peeled paint, exposed sheetrock or stained ceiling tiles. He/she had not reported any recent repair requests. During an interview on 5/3/23 at 2:13 P.M., CNA B said that he/she verbally told maintenance if there were repairs needed such as baseboard issues, peeled paint, exposed sheetrock or stained ceiling tiles. He/she would sometimes write repairs on a clipboard if there was time during his/her shift. He/she had not reported any recent repair requests. During an interview on 5/3/23 at 2:18 P.M., Licensed Practical Nurse (LPN) C said that he/she verbally told the Director of Nursing (DON) and maintenance if there were repairs needed such as baseboard issues, peeled paint, exposed sheetrock or stained ceiling tiles. He/she had not reported any recent repair requests. During an interview on 5/3/23 at 2:24 P.M., the Maintenance Supervisor (MS) said the staff verbally informed him/her of any needed repairs. He/she would prefer the staff write down the needed repairs on the maintenance requisition log so it could be marked when completed. The MS said he/she just started in the maintenance supervisor role recently. During an interview on 5/3/23 at 2:34 P.M., the Administrator said staff should be writing down needed repairs or areas of concern needing addressed. He would expect baseboard issues, peeled paint, exposed sheetrock or stained ceiling tiles to be reported on the maintenance requisition log in a timely manner including other areas of concern. He did not keep a copy of the maintenance repair requisition once the repair was completed.

Based on interview and record review, the facility failed to implement a baseline care plan upon admission with specific interventions for one resident (Resident #2) out of two sampled residents. The facility census was 68. Record review of the facility's Care Plans - Baseline policy, revised March 2022, showed: - A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission; - The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident, but not limited to: initial goals based on admission orders and discussion with the resident/representative, physician goals, dietary orders, therapy services, and social services; - The baseline care plan is used until staff can conduct the comprehensive assessment and develop an interdisciplinary (a group of healthcare professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) person-centered comprehensive care plan (no later than 21 days after admission); - The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. 1. Record review of Resident #2's medical record showed: - An admitted [DATE]; - No documentation of a baseline care plan with specified interventions. During an interview on 5/4/23 9:43 A.M., Licensed Practical Nurse (LPN) D said every new admit should have a baseline care plan completed upon admission with specific interventions and it should be part of the admission process. During an interview on 5/4/23 9:43 A.M., the Assistant Director of Nursing (ADON) said every new admit should have a baseline care plan completed upon admission with specific interventions within 48 hours of admission to the facility. During an interview on 5/4/23 9:43 A.M., the Director of Nursing (DON) said she would expect every new admit to have a baseline care plan completed with specific interventions within 48 hours upon admission. During an interview on 5/4/23 9:43 A.M., the Administrator said he would expect a baseline plan with specific interventions to be completed within 48 hours for each new admission to the facility.

Based on observation, interview, and record review, the facility failed to store medications in a safe, secure, and orderly manner by allowing medications to sit at the bedside of one resident (Resident #68) out of 17 sampled residents. This had the potential to affect all residents. The facility census was 68. Review of the facility's Storage of Medications policy, undated, showed: - Drugs and biologicals are stored in locked compartments; - Only persons authorized to prepare and administer medication have access. 1. Review of Resident #68's medical record showed: - admitted [DATE]; - No order for magnesium (a dietary supplement); - No order for Tums (medication used to treat symptoms caused by too much stomach acid). Observations on 05/01/23 at 11:40 A.M., and 05/03/23 at 03:00 P.M., showed: - An opened bottle of magnesium, one third full, sat on the refrigerator at the bedside of the resident; - An opened bottle of Tums, with one inch of tablets remaining, sat on the refrigerator at the bedside of the resident. During an interview on 05/03/23 at 03:33 P.M., Resident #68 said the bottle of magnesium and Tums were purchased at a store prior to his/her admission to the facility and were brought in on admission. He/she self-administered the magnesium every day during the last meal of the day, but rarely took the Tums. Observation on 05/04/23 at 08:07 A.M., showed: - Certified Medication Technician (CMT) E administered medications to Resident #68 in the resident's room while the bottles of magnesium and Tums sat on the refrigerator at the resident's bedside. During an interview on 05/04/23 at 08:10 A.M., CMT E said if he/she saw a medication at the bedside of a resident, then he/she would take it to the Director of Nursing (DON) or the Assistant Director of Nursing (ADON). During an interview on 05/04/23 at 08:13 A.M., Licensed Practical Nurse (LPN) D said residents who wish to self-administer medications must have an order, be educated on how to take the medication, and the medication must be stored securely. During an interview on 05/04/23 at 12:08 P.M., the DON said she expected residents who self-administer medications to have an order for the medication, for it to be care planned, and for the medications to be stored safe and securely.

Based on interview and record review, the facility failed to report an allegation of abuse involving two residents (Residents #1 and #2) of three sampled residents, to the state licensing agency (Department of Health and Senior Services, DHSS) within two hours as required. The facility census was 61. Review of the facility's Reporting Requirement, taken from the facility's Abuse Prevention Program, updated 2017, showed the following: - If the events that cause the allegation involving abuse or results in serious bodily injury to a resident, a report must be made immediately and not later than 2 hours after forming suspicion. If the events that cause the allegation do not involve abuse or do not result in severe bodily injury, a report must be made within 24 hours of forming suspicion. The facility must report the suspicion and not wait until confirmed with an investigative process. Review of the Resident to Resident Altercations Policy Statement, updated 12/2016 showed: - Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. 1. Record review of Resident #1 admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/1/21, showed: - Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, indicating the resident was moderately cognitively impaired; - Supervision and set up for Activities of Daily Living (ADLS); - Ambulatory with no devices; - No behavior issues. Record review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan did not trigger for behaviors, but did trigger dementia and instructed staff to redirect and reorient as needed. Review of the resident's Nurse's Notes dated 8/1/21 at 1:20 PM, showed another resident alerted staff that Resident #1 had thrown Resident #2 from his/her wheelchair. Resident #1 had also kicked Resident #2 several times. Resident #1 was placed on one on one in the breakroom while staff assessed Resident #2. Both Residents were sent to the ER for treatment and evaluation. Review of Resident #1's medical record showed no documentation that facility staff notified the department regarding potential resident to resident abuse. 2. Record review of Resident #2's Significant Change MDS, dated [DATE], showed: - A BIMS of 01, with inattention, disorganized thinking, wandered, but was not intrusive; - Extensive to total ADL care, except for eating; - Wheel chair bound, but self propelled; - Receives Hospice services. Record review of Resident #2's POS, dated 7/16/21 to 8/15/21, showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Gastro-Intestinal cancer, metastatic liver and stomach disease, diabetes, post-traumatic stress disorder ([CONDITION(S)]), and unspecified [CONDITION(S)]. Review of Resident #2's care plan, updated 4/23/21, showed a history of delusions, anxiety and often displayed intense moods, racing thoughts, and exaggerated behaviors. Interventions included to provide a calm, pleasant environment. Present reality concisely and do not challenge any illogical thinking and are to avoid vague remarks. Review of the resident's Nurse's notes, dated 8/1/21 at 1:20 PM, showed Resident #2 found face down in another resident's room with his/her wheelchair outside the door. Another resident gave information that Resident #1 tossed Resident #2 out of the wheelchair and kicked him/her multiple times. Resident #1 and #2 were separated and assessed. Both residents were sent to emergency room s for assessment. Resident #2 returned the same night, with a non-displaced right femur fracture. The resident was not a surgical repair candidate. Review of DHSS facility reporting records showed no record of the altercation between Resident's #1 and #2, or Resident #2's injuries. During an interview on 8/6/21 at 11:31 AM, the Administrator said failure to report to DHSS was on him/her. It was not an on-going concern and did not feel it met criteria to report. MO 0

Based on interview and record review the facility failed to obtain an order for [REDACTED]. 1. Record review of Resident #12's Physician order [REDACTED]. - The resident admitted to the facility on [DATE]; - No order for [MEDICAL TREATMENT] services; - [DIAGNOSES REDACTED]. Record review of the resident's care plan, updated 1/22/20 showed: - The resident will tolerate [MEDICAL TREATMENT] without issue; - Labs as ordered; - Monitor [MEDICAL TREATMENT] catheter site and report changes in condition every shift. During and interview on 10/28/20 at 9:25 A.M., the resident said he goes to [MEDICAL TREATMENT] on Monday, Wednesday and Friday. 2. Record review of Resident #39's POS, dated October 2020 showed: - The resident admitted to the facility on [DATE]; - No order for [MEDICAL TREATMENT] services. During an interview on 10/27/20 at 11:30 A.M. Certified Nurse Aide (CNA) E said the resident goes to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. Record review of the resident's care plan, updated 9/8/20 showed: - The resident receives [MEDICAL TREATMENT] three times weekly; - Labs as ordered; - Monitor [MEDICAL TREATMENT] catheter site and report changes in condition every shift. During an interview on 11/4/20 at 10:44 A.M., the Administrator said he didn't know why the residents didn't have an order on the chart for [MEDICAL TREATMENT], they were both admitted on [MEDICAL TREATMENT], maybe the admitting nurse just didn't realize there had to be an order on the chart. Record review of the facility's Outpatient [MEDICAL TREATMENT] Services Coordination Agreement, dated 8/27/2019 showed, the Long Term Care Facility shall ensure a prescription for treatment by any other prescribing physician.

Based on interview and record review, the facility failed to complete a significant change assessment within 14 days of discontinuation of hospice services for one resident (Resident #55) out of 2 sampled residents. The facility census was 66 . 1. Record review of Resident #55's medical record, showed the following: - admitted to hospice services on 2/15/18; - Discontinued hospice services on 9/11/20. Record review of the resident's Minimum Data Set (MDS) (a federally mandated assessment instrument required to be completed by facility staff) showed no significant change assessment completed within 14 days of the admission or discontinuation of the resident's hospice services. During an interview on 11/3/20 at 1:37 P.M., the Administrator said he would expect a significant change to be completed when a resident goes on/off hospice or has a decline in status. The facility did not provide a policy regarding the completion of significant change assessments.

Based on interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, for two residents (Resident #43 and #67) out of 17 sampled residents. The facility census was 66. 1. Record review of Resident #43's annual MDS, dated [DATE] showed: - The A1500 preadmission screening and resident review (PASARR) area marked no. Record review of the resident's medical chart showed the resident's PASARR completed on 12/4/18. During an interview on 10/28/20 at 3:00 P.M. the Administrator said the MDS coordinator is a newer employee and just marked the MDS incorrectly. 2. Record review of Resident #67's annual MDS, dated [DATE] showed: - The A1500 PASARR area marked no. Record review of the resident's medical chart showed the resident's PASARR completed on 6/2/10. During an interview on 11/3/20 at 1:37 P.M., the Administrator said he would expect the MDS to be marked correctly showing a Level II PASARR had been completed and the facility follows the RAI (Resident Assessment Instrument) manual. The facility did not provide a policy.

Based on interview and record review, the facility failed to ensure resident's with a mental disorder and individuals with intellectual disability had a DA-124 level I screen (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASARR) level II screen is required) as required, for one resident (Resident #40) of eight sampled residents for PASARR. The census was 66. 1. Review of Resident #40's medical record, showed: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. activities); - No documentation of a DA-124 level I screen; - No documentation of a PASARR level II screen. During an interview on 10/30/20 at 1:54 P.M., the Administrator said he expects staff to complete DA-124 and PASARR for every resident. The facility did not provide a policy.

Based on observation, interview and record review, the facility failed to provide interventions to promote wound healing, provide medication for the control of diabetes mellitus, and monitor blood glucose levels for one resident (Resident #1). The facility census was 44. 1. Record review of Resident #1's Physician's Order Sheet (POS), dated January 2011, showed: - [DIAGNOSES REDACTED]. - [MEDICATION NAME] (antidiabetic medication to inhibit hepatic glucose production and increases sensitivity of peripheral tissue to insulin) 500 milligrams tablet, one every day, ordered on [DATE]; - Fasting blood sugar weekly; - Laboratory orders for Hemoglobin A1C (HGA1C) (a test to determine how well your diabetes is being controlled) every three months. Record review of the Nurses Notes, dated 2/08/11, (no time given) showed "Raised papule 3.5 centimeter (cm) in diameter. Raised area on right calf inside 12 cm x 12 cm fluid filled, yellow to green in color". Record review of the Office Visit Report, dated 2/08/11, showed: - Cold right foot; - New lesion to right leg; - Acute cellulites (a spreading bacterial infection of the skin) of the right leg; - Fascitis (inflammation of any fascia) (a fibrous membrane covering, supporting, and separating muscles). Record review of the Wound Evaluation Flow sheet, dated 2/08/11, showed: - New wound to right lower leg; - Acquired in house; - Length (L) 12.0 cm x Width (W) 12.0 cm; - [MEDICAL CONDITION]; - Yellow/green filled blister; - Wound margins intact; - Surrounding tissue red and swollen. Record review of the Wound Evaluation Flow sheet, dated 2/09/11, showed: - Blister open and draining to right leg; - L 12.0 cm x W 12.0 cm x Depth (D) 1.0 cm; - Surrounding tissue red and swollen; - Sent to the emergency room . Record review of the Nurses Notes showed the facility failed to document the resident's condition or that he/she was transferred to the hospital on [DATE]. Record review of the Hospital Records from 2/09/11 through 2/11/11, showed: - admitted on [DATE] at 6:00 P.M.; - admitting [DIAGNOSES REDACTED]. - He/she running a low-grade fever; - Laboratory glucose (sugar) level results on 2/09/11 showed 438 (Normal 70 -105); - Discharge back to the facility on [DATE] at 1:50 P.M. Record review of the Nurses Notes, dated 2/11/11 though 2/14/11, showed: - On 2/11/11 at 4:00 P.M., dressing to right leg with minimum drainage; - On 2/14/11 at 7:30 P.M., "resident unable to walk to shower room transfer by wheel chair bath given. New dressing to right leg will continue to monitor". Record review showed no documentation of the resident condition in the Nurses Notes from 2/15/11 until 3/04/11 which documents the resident out to the wound clinic. Record review showed the facility failed to monitor the resident's wound measurement or condition of the right leg from the time when the resident returned from the hospital on [DATE] until 2/16/11. Record review of the Wound Evaluation Flow sheet, dated 2/16/11, showed: - Right leg wound bed yellow, red, and black in color; - Odor; - L 13.0 cm x W 12.0 cm x D 1.0 cm; - Moderate amount of drainage; - Surrounding tissue red and swollen; - Wound Status worsening. Record review of the Physician Subsequent Visit report, dated 2/18/11, showed: - Well developed well nourished in no acute distress; - Skin intact, no rashes, [MEDICAL CONDITION], masses or ulcerations; - [MEDICAL CONDITION] right leg. Record review of the Wound Evaluation Flow sheet, dated 2/23/11, showed: - Right leg wound bed yellow, red, and black in color; - Odor; - L 15.0 cm x W 13.0 cm x D 1.2 cm; - Moderate amount of drainage; - Surrounding tissue red and swollen; - Wound Status larger. Record review of the Wound Center initial assessment, dated 3/04/11, showed, - Right lower leg; - L 18.1 cm x W 13.7 cm x D 1.6 cm; - Undermining 7.5 cm; - Eschar (dead matter that is cast off from the surface of the skin) partial coverage; - Necrotic tissue (death of portion of tissue) extensive; - Wound base color is red, yellow, black, and pale pink; - Large amount of yellow drainage. Record review of the Wound Evaluation Flow sheet, dated 3/04/11, showed: - Right leg wound bed yellow, red, black, and pink; - Odor; - L 18.1 cm x W 13.7 cm x D 1.6 cm; - Large amount of drainage; - Wound status undermining 7.5 cm. During an observation on 3/08/11 at 1:20 P.M., the resident lay in his/her bed. Licensed Practical Nurse (LPN) A and LPN C raised the resident's right leg up from the mattress showing a large yellow, wet area on the sheet where the resident's right leg had been laying. A large bandage covered the right leg with a large amount of yellow and red drainage on the bandage. The LPNs removed the bandage to show a large irregular shape wound starting below the knee from mid front of the leg to mid back of the calf and down to the ankle. The wound bed had a large black area in the middle of the wound, a deep sunken down area surrounding it with yellow drainage at the sunken area. The wound had a foul odor. Record review of the hospital record for Resident #1, dated 3/09/11, showed: - admitted to hospital at 8:30 A.M.; - Debridement (removal of foreign material and dead or damaged tissue) completed; - An open wound to the right leg, 30 cm x 15 cm; - Diabetic Ulcer right lower leg; - Laboratory HGA1C 10.7 (normal 4.8 - 5.9) and average glucose 304. Record review of Medication Administration Record, [REDACTED] - The facility discontinued the resident's [MEDICATION NAME] on 2/11/11, the date of his/her return from the hospital. - Only one fasting blood sugar record on 2/04/11 for the month. Record review of the History and Physical (H & P) from the hospital, dated 2/10/11, showed the physician "recommend placing the patient on [MEDICATION NAME] (insulin) and consider [MEDICATION NAME] as well. Right now his/her blood sugar is over 400 and according to the nursing staff the patient has frequent admissions and also has very high [MEDICAL CONDITION] (increased blood sugar) on these admissions. Will increase his/her [MEDICATION NAME], monitor electrolytes, put him/her on low dose [MEDICATION NAME] with sliding scale insulin." Record Review of the POS [REDACTED] - Fasting blood sugar weekly; - The medication [MEDICATION NAME] with a line though the order. Record review of the laboratory record, dated 3/03/11, showed HGA1C at 10.6 High. Record review of a POS, dated 2/11/11, showed 17 MEDICATION ORDERS FOR [REDACTED]. The orders were not signed or dated that the physician had been notified. No diabetes medication had been ordered. Record review showed the facility failed to verify the new orders with the physician. Record review of the facility policy on Physician medication orders, revised April 2010, showed: - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. - All drug and biological order shall be written, dated, and signed by the person lawfully authorized to give such an order. - Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include the date and time of the order. - Verbal orders must be signed by the prescriber at his or her next visit. During an interview on 3/15/11 at 9:50 P.M., the Director of Nursing (DON) said when a resident returns to the facility from the hospital, the Registered Nurse (RN) supervisor or nurse in charge is to call to verify the orders with the physician, then sign and date the orders. During an interview on 2/08/11 at 1:08 P.M., the DON said she had not seen the H & P, dated 2/10/11, and she would call the physician about the [MEDICATION NAME]. During an interview on 3/8/11 at 1:10 P.M., the DON said she is responsible to look through all the papers that come back from the hospital. She was on vacation when Resident #1 returned from the hospital. She would have expected the RN in charge to look at the papers. During an interview on 3/15/11 at 8:00 P.M., RN E said he/she measured Resident #1's wound on his/her right leg every week. The week the DON was on vacation, an LPN asked him/her to look at the resident's wound. The wound had a huge fluid filled blister. RN E said the LPN (who no longer works there) talked to the residents family. They decided he/she needed to go to the hospital. The wound measured 12 cm x 12 cm x 1 cm deep. The wound was not open yet. The wound was not open when the resident returned from the hospital. The wound was huge and should have been measured. He/she reported to the DON that the wound was getting worse. He/she was concerned with the blister popping and seeping. On 2/16/11, the wound measured 13 cm x 12 cm x 1 cm deep. On 2/23/11, the wound measured 15 cm x 13 cm. The DON looked at the wound. During an interview on 3/11/11 at 9:45 A.M., Doctor AA, who worked at the wound clinic, said he looked at the resident's wound. It looked nasty. Under the wound, there was an old blood clot. It was probably caused by some trauma to that leg and it got a hematoma (blood clot). The resident's leg was huge and was debrided two days ago. The resident spiked a temperature and remained in the hospital. The wound debrided well down to muscle and fascia. The resident was alert and demented. The resident came to the wound clinic on 3/4/11. He assumes the clinic did not get called for an appointment any sooner. He could not say with certainty that the wound would not be as bad if he/she would have been seen before three weeks went by. He was told that the resident was having whirlpool baths and ointment to the wound. The wound has been like that for quite a while. The resident needed to go to the hospital for the wound to be debrided. The wound culture showed gram negative rods (proteus mirabilis). He/she received intravenous (IV) [MEDICATION NAME] (antibiotic) in the hospital. The facility said the resident had diabetes mellitus. They did an HGA1C. The resident's blood glucose level could be a contributing factor to his/ her wound, if the diabetes was uncontrolled. During an interview on 3/11/11 at 12:45 P.M., Doctor BB said while the resident was in the hospital, he/she was on [MEDICATION NAME] and insulin. He understood the resident was on the [MEDICATION NAME] and the sliding scale insulin. He did not know what they did when he/she went back to the nursing home. If there was no treatment for [REDACTED]. He recommended the Insulin and [MEDICATION NAME]. The sliding scale insulin should have been continued. They should have continued the sliding scale insulin. It is extremely important to keep blood sugars under control. At the very least, the sliding scale insulin should have been continued. During an interview on 3/14/11 at 9:15 A.M., Doctor CC said he has a Physician's Assistant (PA), PA DD, who sees the patients at the office. He knew about Resident #1's leg after the fact. The facility did notify his PA about the resident's leg. He understood that he/she was on a sliding scale for insulin when returning to the nursing home on 2/11/11. He was not aware that the resident's diabetes mellitus was not being treated from 2/11/11 to 3/4/11. He did not know that his/her HG A1C was 10.6. He agrees that the facility did not provide the care the resident needed for his/her diabetes mellitus. The facility should have called him to verify the medications when he/she returned from the hospital. If they did not document it, it probably did not happen. The facility should have verified the resident's medications with him. During an interview on 3/14/11 at 9:20 A.M., PA. DD said, "Resident #1's right leg was looking OK, but then it got worse." He/she was not on any diabetic medications from 2/11/11 to 3/4/11. When he/she went back to the facility on [DATE], it was like the resident was a new resident. They simply missed the fact that he/she did not get his/her diabetic medication. The facility should have read the doctor's notes on the History and Physical and Progress Notes regarding the doctor's plan for diabetic treatment. However, there was a seventy-two hour delay in when the resident came back to the facility and when the H & P and the Progress Notes got to the facility. He would assume the hospital should have written orders for his/her diabetic treatment. He did not read the H & P and Progress Notes. In a perfect world, he should have caught that there was no order for his/her diabetes. The facility should also have caught the fact that there was no order for diabetic treatment. He did not know the facility was not doing regular weekly finger stick blood sugar checks. He was aware that the blood sugar was high. Record review of the facility policy on wound care, revised October 2010, showed: - Verify that there is a physician's order; - Document the type of wound care given; - The date and time the wound care was given; - The position in which the resident was placed; - The name and title of the individual performing the wound care; - Any change in the resident's condition; - All assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound; - How the resident tolerated the procedure; - Any problems or complaints made by the resident related to the procedure; - If the resident refused any treatment and the reason(s) why; - The signature and title of the person recording the data; - Notify the supervisor if the resident refuses the wound care. Complaint #MO NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review, completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility identified the following: inserviced all licensed staff on wound assessment and documentation, inserviced all licensed staff that blood sugars will be completed according to the physicians' orders, assure admission/readmission orders [REDACTED]' care. 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. The facility needs to ensure all staff receive inservice training regarding monitoring and assessment of the residents at risk for skin breakdown and utilize the new policies and procedures. 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 the Class I violation.