Every finding on record at South Hampton Rehabilitation & Health Care Center

Based on observation, interview and record review, facility staff failed to perform hand hygiene to prevent the spread of infection during wound care, failed to place wound care supplies on a protective barrier, failed to wear appropriate personal protective equipment (PPE) during care for one resident (Resident #2) who required Enhanced Barrier Precautions (EBP) (an infection control intervention) for wounds. Facility staff failed to wear PPE during care for one resident (Resident #1) who required EBP for a feeding tube (medical device used to safely deliver liquid nutrition, hydration, and mediations directly into the stomach or small intestine) out of two sampled residents. The facility's census was 67. 1. Review of the facility's Infection Prevention and Control Manual-Enhanced Barrier Precautions policy, undated, showed staff are directed as follows:-Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multi-drug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (such as residents that have wounds or indwelling medical devices);-Enhanced Barrier Precautions re recommended for resident with a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical devices include central venous catheters, urinary catheters, feeding tubes and tracheostomies/ventilators;-High-contact resident care activities where a gown and gloves should be used when performing wound care and caring for or using an indwelling medical device.Review of the facility's Infection Prevention and Control Manual policy, dated 2019, showed staff must perform hand hygiene even if gloves are utilized. The policy did not provide direction for staff on when to perform hand hygiene.Review of facility provided policies did not contain a policy to direct staff on when to apply a barrier prior to wound care supply placement. 2. Review of Resident #2's comprehensive Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, dated 06/08/26, showed staff assessed the resident with one stage two pressure ulcer and an indwelling catheter (flexible tube inserted into the bladder to continuously drain urine into an external collection bag).Observation on 05/27/26 at 2:04 P.M., showed EBP signage on the door directed staff to wear a gown when care is provided.Observation on 05/27/26 at 2:05 P.M., showed Licensed Practical Nurse (LPN) B provided wound care without a gown. LPN B left the resident's room without performing hand hygiene. He/She returned with wound care supplies and placed the supplies directly on the bed without a protective barrier. He/She did not wash his/her hand before he/she applied gloves and did not put on a gown before he/she provided wound care. LPN B cleansed the wound, and applied the clean bandage, he/she did not change his/her gloves or perform hand hygiene between tasks. Observation showed the resident had a catheter bag and the bag and tubing touched the floor.During an interview on 05/27/26 at 2:08 P.M., LPN B said he/she did not know where the gown and gloves were located. He/She said he/she did not notice the sign on the door reminding staff they were required to wear gown and gloves when in contact with the resident. He/She said the purpose of using a gown or gloves was to prevent any of the resident's bodily fluids from getting on staff. He/She said staff are directed to perform hand hygiene, before and after resident contact. He/She said he/she did not have a reason he/she missed a hand hygiene opportunity. He/She said staff are educated to place wound care supplies on the bedside table with a protective barrier under the supplies. He/She said he/she placed the wound care supplies directly on the bed, without a protective barrier, since the bedside table was not right next to the resident. He/She said there was a potential for an infection control issue when placing wound care items directly on the bed without a protective barrier. He/She said he/she did not have a reason he/she did not use a protective barrier. 3. Review of Resident #1's quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired, had a feeding tube and an indwelling catheter.Observation on 05/27/26 at 1:11 P.M., showed the entrance to the resident's room did not contain EBP signage.Observation on 05/27/26 at 1:12 P.M., showed LPN A provided tube feeding assistance without a gown on.During an interview on 05/27/26 at 1:15 P.M., LPN A said he/she did not know the resident was on EBP. He/She said he/she was not trained to use a gown when providing tube feeding assistance to the resident. 4. During an interview on 05/27/26 at 3:45 P.M., the administrator said staff are directed to wear a gown and gloves when providing care for residents placed on EBP. He/She said if staff did not wear a gown and gloves while providing care, there was a potential for infection control concerns.During an interview on 06/10/26 at 3:43 PM, the administrator said wound care supplies should be placed on a protective barrier to avoid potential infection control issues. He/She said staff should perform hand hygiene prior to putting on gloves, anytime gloves are changed, and before exiting the room. He/She said staff are directed to change gloves and perform hand hygiene after cleansing the wound and before touching the clean bandage to avoid introducing infection into the wound.During an interview on 05/27/26 at 3:45 P.M., the Director of Nursing (DON) said staff received education to wear a gown and gloves while providing care for residents placed on EBP. He/She said there is potential for infection control concerns if staff did not wear a gown or gloves while providing care to a resident placed on EBP.During an interview on 06/10/26 at 3:44 PM, the DON said wound care supplies should be placed on a protective barrier to avoid potential infection control issues. He/She said staff should perform hand hygiene prior to putting on gloves, anytime gloves are changed, and before exiting the room. He/She said staff are directed to change gloves and perform hand hygiene after cleansing the wound and before touching the clean bandage to avoid introducing infection into the wound. 3016076 and 3006504

Based on observation, interview and record review, facility staff failed to provide necessary treatment and services consistent with professional standards of practice, when staff failed to assess one resident (Resident #1's) skin upon readmission, failed to identify a left lower leg wound, and failed to obtain a physician's order for wound care treatment. The facility census was 67.1. Review of the facility's Skin Identification, Evaluation, and Monitoring policy, dated 02/26/26, showed staff are directed as follows:-A licensed nurse will evaluate skin integrity through a physical skin evaluation upon admission, weekly, and when a significant change is identified;-Licensed nurse upon admission with complete a physical skin evaluation and document findings. If a skin condition is present on admission or re-admission, the nurse will initiate protective dressing, notify health care provider of findings and for further treatment orders, notification/education of resident and resident representative of finds and physician orders and document evaluation in the medical record;-The Certified Nursing Assistant (CNA) will observe skin for changes with assisting with activities of daily living and report skin integrity changes to nurse. 2. Review of Resident #2's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/08/26, showed resident readmitted from the hospital on [DATE].Review of the resident's medical record did not contain documentation staff completed a re-admission skin assessment as directed in the facility policy.Observation on 05/27/26 at 2:05 P.M., showed the resident had an unlabeled bandage on the back of his/her left leg. Observation showed the nurse removed the bandage and exposed a large open area on the back of his/her left leg.During an interview on 05/27/26 at 2:08 P.M., Licensed Practical Nurse (LPN) B said staff are directed to assess a resident's skin based on the physician order and checked weekly. He/She said if staff noticed a skin concern, the nurse should assess, document in the resident's progress notes and report to the Director of Nursing (DON) and physician. He/She said he/she did not know the resident had a wound on the back of his/her leg and could not find an order for wound care treatment.During an interview on 05/27/26 at 2:27 P.M., the DON said staff should have completed a skin assessment upon re-admission from the hospital. He/She said he/she did not know the resident had any wounds. He/She said the resident's medical record did not contain documentation the resident had a wound on his/her left leg.During an interview on 05/27/26 at 3:45 P.M., the administrator said staff are directed to conduct a skin assessment on a resident upon admission, discharge, weekly and as needed. He/She said the charge nurse should perform skin assessment upon readmission. He/She said if an aide noticed a skin concern, they should report to a nurse for assessment. He/She said the nurse would contact the physician to obtain wound care orders.3006504

Based on interview and record review the facility failed to provide training for abuse, neglect, exploitation, and misappropriation of resident property and the reporting and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property for two employees (Certified Nurse Assistant (CNA) B and Nurse Aide (NA) C ) out of three employee. The facility census was 69.1. Review of the facility's policy, Abuse, Prevention and Prohibition Policy, dated 03/2025, showed facility staff shall be trained on the Abuse Prohibition Program during orientation, annually and ongoing during education sessions, and per state regulations. The facility's abuse prohibition program includes the following seven components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response. 2. Review of CNA B's employee file showed a hire date of 03/27/26. The file did not contain documentation of abuse and neglect training containing the seven components listed in the facility policy, during his/her orientation.During an interview on 04/21/26 at 12:56 P.M., CNA B said he/she did not receive orientation upon hire. He/She said he/she did not receive abuse and neglect training. 3. Review of NA C's employee file showed a hire date of 04/02/26. The file did not contain documentation of abuse and neglect training containing the seven components listed in the facility policy, during his/her orientation.During an interview on 04/21/26 at 1:00 P.M., NA C said he/she did not receive abuse and neglect training. 4. During an interview on 04/21/26 at 2:05 P.M., the staffing coordinator said he/ she educated staff to report abuse and neglect during orientation, but did not discuss the screening, training, prevention, identification, investigation, protection, and response to abuse and neglect. He/She said if a staff member did not know what qualifies as abuse and neglect, they may not know what is reportable. He/She said he/she was filling in on providing the training during orientation and did not know he/she was responsible for educating staff on screening, training, prevention, identification, investigation, protection, and reporting/response for abuse and neglect.During an interview on04/21/26 at 2:27 P.M., the administrator said new staff should receive screening, training, prevention, identification, investigation, protection, and response to abuse and neglect. He/She said he/she did not know the staffing coordinator was not providing in-depth training about abuse and neglect. He/She said he/she did not attend orientation with new staff members.During an interview on04/21/26 at 2:28 P.M., the Director of Nursing (DON) said new staff received abuse and neglect training, including, screening, training, prevention, identification, investigation, protection, and response. He/She said he/she did not know the staffing coordinator was not providing in-depth training about abuse and neglect. He/She said he/she did not attend orientation with new staff members. 2979350 and 2984790

Based on interview and record review, facility staff failed to ensure the admission policy did not require the resident and/or responsible party to waive facility liability for loss or damage to personal belongings and failed to complete a Resident Inventory Listing for two residents (Resident #1 and #2) out of three residents. The census was 69.1. Review of the facility's, Cash and Valuables Policy Update, undated, showed the facility will not be responsible for any money or personal items exceeding $40.00 limit.Review of the facility's admission agreement, dated 02/2018, showed the facility shall not be liable for any of the residents' items that are lost or stolen, except for those items noted for replacement under state guidelines that the facility might reside.Review of the facility's policy, Personal Property, dated 12/2024, showed the resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. 2. Review of Resident #1's medical record showed the admission agreement, signed and dated 04/16/26, by the resident/responsible party and facility representative. The medical record did not contain documentation staff completed a Resident Inventory Listing form. 3. Review of Resident's #2's medical record showed the admission agreement, signed and dated 04/14/26, by the resident/responsible party and facility representative. The medical record did not contain documentation staff completed a Resident Inventory Listing form. 4. During an interview on 04/21/26 at 11:48 A.M., administrator said the person who was responsible for completing the inventory list quit and the facility had not found a replacement yet, so he/she could not locate an inventory sheet for Resident #1 and Resident #2. He/She said the corporate legal department said in Missouri the facility was not required to replace stolen or missing items. He/She said the policy did state the facility was not responsible for replacing missing or stolen items, except on a case by case basis. 2979350 and 2984790

Based on interview and record review, facility staff failed to report an allegation of misappropriation of one resident (Resident #1's) credit card to the State Survey Agency (SSA) within the 24-hour time frame. The facility census was 82.1. Review of the facility's, Abuse, Prevention and Prohibition Policy, dated 03/2025, showed staff are directed that all alleged violations involving misappropriation of resident property will be reported immediately to the administrator or his/her designee. The person made aware of allegations will report the allegations to the mandated state agency and law enforcement. Review of the facility's investigation, dated 02/23/26, showed the resident reported his/her debit card was missing to an agency nurse sometime between 02/20/26 through 02/21/26. The resident reported there were fraudulent charges on the account. The administrator was informed of the allegation on 02/23/26. The administrator was shown a picture of Nurse Aide (NA) A at the computer repair store where the resident's debit card was used and terminated NA A. The investigation did not contain documentation staff notified SSA with the 24-hour time frame. Review of the Department of Health and Senior Services (DHSS) complaint/facility self-report database did not contain documentation the facility reported the allegation of misappropriation of property. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/25/26, showed staff assessed the resident as cognitively intact with an admission date of 09/15/22. Review of the resident's progress note, dated 2/21/2026, showed staff documented the resident reported his/her credit card stolen out of his/her wallet. Review showed staff documented the resident did find unauthorized transactions from his/her bank account. staff left a message for the administrator to call. During an interview on 02/23/26 at 2:34 P.M., the resident said he/she reported to staff his/her credit card missing and unauthorized charges on 02/21/26. During an interview on 02/24/26 at 3:47 P.M., the Administrator said if staff was aware of misappropriation of a resident's property, the incident should be immediately reported up the chain of command. He/She said he/she was responsible to report to the state agency, but did not know about the allegation until 02/23/26. He/She said he/she received a message from a nurse on 02/21/26, he/she tried to call her back and the nurse did not answer. He/She said the nurse did not leave a message to why he/she was calling and he/she forgot to call the nurse again. During an interview on 02/24/26 at 3:48 P.M., the Director of Nursing (DON) said staff are directed to immediately report allegations of misappropriation of a resident's property to the administrator or charge nurse, so DHSS can be called to file a report. Complaint #2785828

Based on interview and record review, facility staff failed to provide necessary treatment and services consistent with professional standards of practice, to promote the healing of existing pressure ulcers for two residents (Resident #2 and #3) out of two sampled residents who admitted to the facility with pressure ulcers, when staff failed to document a full wound assessment, complete weekly skin assessments, and follow up on the Registered Dietician's recommendations for Resident #2, and failed to document the administration of wound treatments as ordered by the physician for Resident #2 and #3. The facility census was 74.1. Review of the facility's Wound Care policy, dated 01/2025, showed the following documentation should be recorded in the resident's medical record: -Type of wound and location: stage the wound in pressure, use anatomical location in description;-Partial thickness or full thickness;-Wound measurements: Head to toe (Length), Left to right (width), depth;-Undermining, tunneling, or sinus tract: using the clock method;-Exudate/drainage: type, color, amount, odor (absence or presence and describe smell);-Wound bed: types of tissue visualized, amount of visible tissue;-Describe wound edges and surrounding tissue;-Pain: factors, duration, intensity, interventions for pain relief and effectiveness;-Interventions for healing. Review of the facility's policy on Charting and Documentation, dated 2018, showed the purpose is to have a complete account of the resident's care, treatment and response to the care, documentation should be completed chronologically as issues occur. Review of the facility's policies showed it did not contain a policy to address recommendations from the Registered Dietician (RD), or the frequency for which staff should complete a skin assessment. 2. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment, dated 02/10/26, showed staff assessed the resident as: -Moderate cognitive impairment;-At risk of developing pressure ulcers;-One stage two pressure ulcer (partial-thickness skin injury with exposed dermis) present on admission; -Used pressure reducing device for bed and chair; -Received pressure ulcer care; -Received application of nonsurgical dressings (with or without topical medications) other than to feet; -Received application of ointments/medications other than to feet. Review of the resident's hospital progress note dated 02/03/26, showed one skin care team dressing recommendation dated 02/02/26, for Sure Prep no-sting skin barrier, hydrophilic wound dressing paste (used to absorb moderate levels of wound drainage and softens/loosen necrotic tissue), every 24 hours to bilateral sacrum, gluteal buttocks, and ischium (sitting bones). The note did not contain measurements or description of the wounds to be treated. Review of the resident's admission skin assessment, dated 02/04/26, showed staff documented left inner thigh scrape, and one stage two pressure injury to the sacrum with partial thickness skin loss, measurements of 2 centimeters (cm) length x 1.5 cm width x 0 cm depth, no pain, and interventions to perform treatment of skin issues, and turn resident every two hours. The record did not contain documentation of a full assessment of the wound to the resident's sacrum to include drainage, tissue type, wound edges or surrounding tissue. Review of the resident's care plan, dated 02/04/26, showed the resident admitted with a sacral stage 2pressure ulcer and abrasion to left thigh. Staff were directed to evaluate skin integrity, provide and document wound care as ordered, RD to evaluate and make diet change recommendations as needed. Review of the resident's Electronic Medical Record (EMR), dated 02/04/26 through 02/24/26, showed the record did not contain documentation staff completed a skin assessment from 02/05/26 to 02/24/26. Review of the resident's progress note, dated 02/10/26, showed the RD documented he/she recommended to offer Juven (a nutritional supplement used to support wound healing), Arginaid (nutritional wound support), or similar wound healing protein supplement twice daily to support healing. Review of the resident's Physician's Order Sheet (POS), dated 02/04/26 through 02/24/26, showed: -02/04/26: Sacral area: Cleanse daily with wound cleanser, apply Triad (a hydrophilic wound dressing), cover with bordered gauze dressing every shift for wound care, discontinued 02/12/26;-02/05/26: Left Upper Inner Thigh: Cleanse abrasion with cleanser, apply Triad and cover with bordered gauze dressing every dayshift for wound care, discontinued 02/12/26;-02/05/26: Indwelling catheter care, three times a day for wound on sacrum;-02/12/26: Sacral area: Cleanse daily with wound cleanser, apply calcium alginate (to absorb moisture and minimize infection) and cover with border gauze every shift for wound care, discontinued 02/19/26.-02/20/26: Right buttock: Cleanse area and apply duoderm (waterproof hydrocolloid dressing to promote wound healing) every shift for wound care;-02/20/26: Sacral area: Vashe (wound cleanser used to clean, irrigate and debride wounds) wet to dry with Kerlix (sterile gauze), cover with border gauze every shift for Wound Care.-The POS did not contain an order for a nutritional supplement as recommended by the RD. Review of the resident's Treatment Administration Record (TAR), dated 02/04/26 through 02/24/26, showed the record did not contain documentation staff provided wound treatments as directed to the resident's sacral area on 02/05/26, 02/08/26, 02/10/26 and 02/13/26, or to the resident's left inner thigh on 02/05/26, 02/08/26 and 02/10/26. Review of the resident's progress notes, dated 02/04/26 through 02/24/26, showed the record did not contain documentation regarding the missed treatments or that the resident refused the treatments. During an interview on 03/03/26 at 2:17 P.M., the Director of Nursing (DON) said the resident's wounds were assessed by the wound physician weekly on 02/12/26 and 02/19/26, but the nurses are still expected to complete a weekly skin assessment as triggered in the EMR, document wound treatments on the TAR, and wound assessments should include a description of the wound, drainage, tissue type, wound edges or surrounding tissue. The DON said he/she receives the RD's report with recommendations and was in the process of ensuring someone was responsible to follow-up on the RD recommendations. During an interview on 03/03/26 at 3:30 P.M., the administrator said the nurses are expected to complete a skin assessment on each resident on admission and at least weekly as prompted by the facility's EMR system and document a full assessment of any skin concern/wound per the facility's wound care policy. The Administrator said the DON is responsible to review the RD's recommendations and ensure the orders are obtained and implemented by the nursing staff. During an interview on 03/12/26 at 10:25 A.M., the wound physician said he/she would consider the resident's buttock/sacral wounds to be mostly unavoidable due to reported refusals and reluctance from the resident to reposition/off-load pressure from the wounds, and positional challenges during the two wound assessments and evaluation he/she conducted. 2. Review of Resident #3's admission MDS, dated [DATE], showed staff assessed the resident as: -re-admitted to facility on 02/02/26;-Severe cognitive impairment;-Incontinent of bowel and bladder;-At risk of developing pressure ulcers;-One stage three pressure ulcer (full-thickness skin injury with visible fat in the ulcer) present on admission; -Used pressure reducing device for bed and chair; -Received pressure ulcer care; -Received nutrition or hydration intervention to manage skin problems;-Received application of ointments/medications other than to feet. Review of the resident's care plan, dated 01/12/26, showed staff were directed to administer treatments as ordered and monitor for effectiveness. Review of the resident's POS, dated 02/02/26 through 02/12/26, showed orders to apply border gauze to left heel every dayshift, start 01/05/26, and Triad Hydrophilic Wound Dressing External Paste, apply to buttocks/right sacral area topically every shift for skin integrity, start 1/12/26. Review of the resident's TAR, dated 02/02/26 through 02/12/26, showed the record did not contain documentation staff provided wound treatments as directed to the resident's left heel on 02/07/26 and 02/08/26, or to the resident's buttock/right sacral area on 02/03/26, 02/07/26 and 02/08/26. Review of the resident's progress notes, dated 02/02/26 through 02/12/26, showed the record did not contain documentation regarding the missed treatments or that the resident refused the treatments. During an interview on 03/03/26 at 2:17 P.M., the DON said the nurses are responsible to complete wound treatments as ordered and document on the TAR once completed. The DON said he/she did not know why the nurses did not document the treatments were completed as ordered. Complaint# 2789181 and 2789901

Based on observation, interview, and record review, facility staff failed to prevent the misappropriation of money from one resident's (Resident #1's) credit card when Nurse Aide (NA) A used the resident's credit card without permission for his/her personal use. The facility census was 82.1.Review of the facility's, Abuse, Prevention and Prohibition Policy, dated 03/2025, showed the owner, licensee, administrator, employee, or agent of the facility prohibit the misappropriation of resident property. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/25/26, showed staff assessed the resident as cognitively intact with an admission date of 09/15/22. Review of the resident's online bank statement, dated 02/21/26, showed an unauthorized transaction of $145.76 at a Computer Repair store. Review of a photo from the computer shop, undated at 10:44 A.M., showed Nurse Aide (NA)A at the store. Review of the computer repair shop receipt, dated 02/21/26 at 10:51 A.M., showed a charge of $145.76 paid with the resident's credit card. During an interview on 02/23/26 at 2:34 P.M., the resident said he/she kept his/her credit card in the top drawer of the dresser and found it odd it was on the floor. He/She said he/she decided to check his/her wallet and found another credit card missing. He/She said he/she checked his/her bank statements and noticed unauthorized charges on the credit card. During an interview on 02/23/26 at 3:12 P.M., the repair shop owner said NA A entered the shop around 10:50 A.M. on 02/21/26 and used the resident's credit card to purchase a laptop. During an interview on 02/23/26 3:49 P.M., Nurse Aide (NA) A said he/she did know the resident's credit card was stolen and there were fraudulent charges on his/her credit card. He/She said he/she was in the repair shop and confirmed the picture from the repair shop was him/her but he/she denied he/she used the resident's credit card. During an interview on 02/24/26 at 3:47 P.M., the administrator said staff should not take resident belongings. He/She said NA A was immediately terminated. Complaint #2785828

Based on observation, interview, and record review, facility staff failed to prevent a fall with major injury by not ensuring staff provided protective oversight for one resident (Resident #1) out of one sampled resident during a shower and failed to use a gait belt (a canvas belt placed around the resident's waist to assist with ambulation and transfers) during a transfer for one resident (Resident #4) out of one sampled resident. The facility census was 69.The administrator was notified on 09/22/25 of past Non-Compliance which occurred on 09/20/25 when the administrator implemented a new intervention to monitor the resident while showering. Staff were in-serviced on 09/20/25 and 09/21/25 regarding the new intervention.1. Review of the facility's Skilled Fall Policy, dated 05/2005, showed the purpose of the Fall Program is to develop, implement, observe and evaluate an interdisciplinary approach and mange strategies and interventions that foster resident independent and quality of life. The community shall ensure that the Fall Program is maintained to reduce the occurrence of falls, reduce risk of injury, and promote independence and safety. Each resident residing at this facility will be provided services and care that ensures that the resident's environment remains as free from accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. [NAME] resident will be assessed for the casual risk factors for falling at the time of admission/readmission, change of condition, quarterly and after every fall in the community.2. Review of Resident #1's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool, dated 07/19/25, showed staff assessed the resident as moderate cognitive impairment, lower extremity impairment on one side, required supervision or touching assistance from staff for showers and ambulating with a wheeled walker, and did not contain documentation of a fall since admission.Review of the resident's diagnoses record, undated, showed the resident had a diagnosis of Parkinson's Disease, history of falling, requires assistance with personal care, and other abnormalities of gait and mobility.Review of the resident's care plan, revised 09/20/25, showed staff documented the resident had a self-care deficiency with Activities of Daily (ADL)'s, resident chooses not to have assistance with showers which increases his/her risk for falls, ambulated with a wheeled walker with staff supervision, required staff participation to reposition and turn in bed, and required staff participation with personal hygiene and oral care.Review of the resident's progress notes, dated 09/20/25, showed staff documented the resident on the shower room floor. Staff documented resident was unable to move his/her arm and complained of pain, so staff sent him/her to the emergency room.Review of the resident's hospital paperwork, dated 09/20/25, showed the resident diagnosed with a fracture of his/her left pelvis and a fracture of his/her left shoulder.During an interview on 09/22/25 at 12:06 P.M., the resident said staff allowed him/her to shower by himself/herself. He/She said staff told him/her staff will now be in the shower room with him/her. He/She said he/she did not have a preference on whether a female or male staff member was in the shower room with him/her when he/she showered. He/She said he/she did not recall if he/she cared if a staff member was in the shower room with him/her prior to the fall in the shower room.During an interview on 09/22/25 at 12:08 P.M., Certified Nurse Aide (CNA) G said the resident refused to allow anyone in the shower with him/her, so staff did not stay in the shower room or monitor the resident while the resident showered. He/She said he/she was in-serviced after the resident fell to remain in the shower room while the resident showered. During an interview on 09/22/25 at 12:20 PM, Registered Nurse (RN) D said the resident was not independent with showers and should have been supervised during showers. He/She said he/she did not know staff left the resident unattended during showers. During an interview on 09/22/25 at 1:08 P.M., the administrator said the resident was a private and independent person, so there was not a staff member constantly present in the shower room with him/her. He/She said staff were following his/her request to have privacy while in the shower room. He/She said staff did periodically check on the resident while he/she was in the shower room. He/She said staff thought standing outside the door was protective oversight. The administrator said the resident will now be supervised while in the shower.During an interview on 09/22/25 at 1:09 P.M., the Director of Nursing (DON) said the resident preferred to have privacy while in the shower, so staff left him/her unattended while in the shower room. The DON said the resident told him/her, he/she did not want staff in the shower room with him/her. He/She said staff did check on the resident while in the shower room and they stood outside the closed door while he/she showered, so he/she believed staff were providing protective oversight. He/She said the resident will now be supervised during showers. 3. Review of Resident #4's admission Sheet, dated 09/17/25, showed the resident admitted to the facility on [DATE].Review of the resident's care plan, dated 09/22/25, showed the resident required assistance from two staff members for toileting. Review showed the care plan did not contain direction for staff to use a gait belt during transfers.Observation on 09/22/25 at 11:18 A.M., Certified Nurse Aide (CNA) E and Nurse Aide (NA) F entered the resident's room to provide toileting assistance. Observation showed the resident wanted the bathroom door closed, when CNA E and NA F opened the door, the resident sat on the toilet without a gait belt around his/her waist.During an interview on 11:21 A.M., CNA E said the resident required two staff members to transfer the resident to the toilet. He/She said he/she did not use a gait belt when he/she transferred the resident and staff were not required to use a gait belt to transfer him/her. During an interview on 09/22/25 at 1:08 P.M., the administrator said the resident required assistance from two staff members during transfers and staff should have used a gait belt. He/She said the concern with not using a gait belt was the potential for injury. He/She said he/she did not know the staff did not use a gait belt while transferring the resident.During an interview on 09/22/25 at 1:09 P.M., the DON said staff are required to use two members to transfer the resident and to utilize a gait belt during the transfer to prevent potential injury. He/She said he/she did not know staff did not use a gait belt when transferring the resident.Complaint #2622664

Based on interview and record review, facility staff failed to ensure two Nurse Aides (NA)'s (NA B and NA C) out of three sampled NAs completed the required nurse aide training program within four months of employment in the facility. The facility census was 69.1. Review showed the facility did not provide a policy in regard to requirements for NA's training program completion within four months of employment. 2. Review of NA B's personnel file showed a hire date of 04/08/25. The file did not contain documentation the NA completed the required nurse aide training program. 3. Review of NA B's personnel file showed a hire date of 04/14/25. The file did not contain documentation the NA completed the required nurse aide training program.During an interview on 09/22/25 at 10:56 A.M., Registered Nurse A said he/she was responsible to conduct the nurse aide training courses. He/She said nurse aides are required to be certified within three months. He/She said there was a period when the facility was not permitted to provide nurse aide training classes, since the facility lost their license from April until August. RN A said he/she did not know if the administration reached out to find other available classes. He/She said he/she met with the Director of Nursing (DON) weekly to discuss the status of each nurse aide in the program, but did not meet during the timeframe when the facility did not offer classes. He/She said the DON was responsible to ensure nurse aides were certified within the three months.During an interview on 09/22/25 at 12:20 P.M., RN D said NA's are required to be certified within three months of working at the facility. He/She the NA's are not allowed to work the floor after the three months if he/she was not certified.During an interview on 09/22/25 at 1:08 P.M. the administrator said NA's are required to be certified within one hundred and twenty days from the first date of employment. He/She said RN A conducts the classes and training and then discuss the status of the NA's with the DON. He/She said the facility did not provide classes from April to June, but he/she did not know what the facility was doing for the NA's during that time since he/she did not work at the facility. He/She said NA B and NA C were not certified, but still providing direct care after the one-hundred-and-twenty-day period. He/She said he/she did not know the staff were not certified but should not have been providing care until they were certified.During an interview on 09/22/25 at 1:09 P.M. the DON said NA's are required to be certified within one hundred and twenty days from the first day of employment. The DON said he/she met with RN A to go over the start dates and classes. The DON said he/she and RN A are responsible to ensure staff are certified, but there have been issues with classes. He/She said the facility was not able to conduct classes for about three weeks. He/She said the corporate office was supposed to get the NA's signed into courses at a different location. He/She said NA B and NA C were not certified but were providing direct care after the one hundred and twenty days of employment. He/She said he/she should not have been providing care for the residents when they were not certified after one hundred and twenty days. He/She said he/she was looking at terminating the NA's for not attending classes.Complaint #2615926

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to maintain an air gap in two ice machine drains. These failures have the potential to affect all residents. The facility census was 57. 1. Review of the facility's Food Storage policy, undated showed: -All food items will be labeled and the label must include the name of the food and the date by which it should be sold, consumed or discarded; -Discard food that has passed the expiration date; -Wrap food properly. Never leave any food item uncovered and not labeled; -Set refrigerators to the proper temperature to ensure the internal temperature of the food is 41 degrees Fahrenheit (F) or lower. Place hanging thermometer in the warmest part of the refrigerator. Observation on 04/01/25 at 10:30 A.M., showed the kitchen contained a stand-up mixer which was uncovered and contained an accumulation of dried white material in the area above the blade connection. Observation showed a walk-in freezer contained zippered bags of chicken patties and brown cubed meat, unlabeled and undated and a partially eaten chocolate creme pie which was unlabeled and undated. Observation of the walk-in cooler showed an opened container of chicken salad unlabeled and undated, opened packages of cheese and luncheon meat unlabeled and undated, and an opened ten pound container of hard cooked, peeled eggs with a use by date of 03/06/25. Observation on 04/02/25 at 11:55 A.M., showed the activity room contained a large bag of popcorn seeds which were open to the air. Observation showed the activity room cabinet contained three containers of seasonings. Observation showed all three containers were opened and undated and two containers were open to the air. Observation showed the activity room contained a white residential type refrigerator freezer which had a temperature log taped to the door. Observation showed the log included the months of March and April 2025. Observation showed one temperature of 38 recorded for 04/25/25. Observation showed the log did not contain any additional information or temperatures. Observation showed the refrigerator did not contain a thermometer. Observation showed the freezer contained a box of corn dogs which were undated and open to the air. Observation showed the refrigerator contained a package of cookies which were open to the air and an opened an undated container of meat sauce. During an interview on 04/02/25 at 12:00 P.M., the activity director said he/she was responsible for all food items in the activities area. The activity director said the corn dogs were opened about two weeks ago. The activity director said the refrigerator was used for his/her food as well as resident food. The activity director said all food should be sealed or covered. The activity director said he/she did not follow any specific labeling and dating policy since he/she had never received any food handling related training at the facility. The activity director said the refrigerator should have a thermometer. During an interview on 04/02/25 at 3:40 P.M., the dietary manager (DM) said staff all kitchen staff were responsible for dating and labeling opened and prepared food items. The DM said staff should discard food items past their use-by dates. The DM said he/she and the cook were responsible for monitoring food labeling and dating in the kitchen. The DM said food labels and dates were monitored as staff worked and did not follow a schedule. The DM said staff just overlooked some items. The DM said the activity director was responsible for food in the activities area and kitchen staff did not monitor the activities area. During an interview on 04/03/25 at 12:35 P.M., the administrator said food storage requirements applied to any areas that stored or prepared food for the residents, and this would include the activities area. The administrator said he/she did not know the activity director had not received food safety training. The administrator said he/she did not know the activity room refrigerator did not contain a thermometer. 2. Observation on 04/02/25, during the Life Safety Code tour showed the facility equipped with two ice machines which were for resident use. Observation showed a countertop ice machine, which sat in the dining room, contained a drain which was routed through the kitchen wall and connected to a sink drain. Observation showed the drain was directly connected to a floor drain with white plastic pipe and did not contain an air gap. Observation showed a room adjacent to the resident dining room contained an ice machine which contained a drain which ran to a floor drain. Observation showed the floor drain was open and the ice machine drain sat below the level of the floor. Observation showed the drain contained an accumulation of beige and brown foreign material where the drain terminated. Observation showed the room smelled of sewage. During an interview on 04/02/25 at 1:35 P.M., the maintenance director said he/she did not know the ice machine drains required an air gap. The maintenance director said he/she contacted a plumber about the sewage odor and was instructed to pour water in the drain to reduce the odor. The maintenance director said he/she could not remember when he/she spoke with the plumber and did not say how frequently he/she added water to the drain. The maintenance director said he/she followed the plumbers instructions and did not know what else to do to reduce the odor. The maintenance director said he/she had not tried anything else to remove the odor. During an interview on 04/03/25 at 12:35 P.M., the administrator said the maintenance director and the facility vendor were responsible for maintaining the ice machines. The administrator said he/she was not aware the ice machine drains did not contain an air gap.

Based on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to follow infection control practices when staff did not disinfect the blood glucose monitor between uses for three residents (Resident #37, #33, and #48) out of four sampled residents. The facility failed to provide current infection prevention policies that were updated and reviewed annually. The facility census was 57. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed: The bacterium Legionella can cause a serious type of pneumonia called Legionnaire's Disease in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit; -Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Water Management Program to Reduce Legionella Growth, undated, showed the facility will develop and implement a Water Management Program to inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water. Review of the program showed it did not contain: -Facility specific policies related to water management; -A description of the facility's water system; -Corrective actions to take if control measures are out of range. Review of the facility water management program showed a description of the facility water system which identified water entry at the east end of building next to the front parking lot. Review showed the program identified the resident halls as the Colonial, Aspen and [NAME] wings. Observation on 04/02/25, during the Life Safety Code tour showed the front parking lot located on the west end of the building. Observation showed resident halls were not identified as Colonial, Aspen and [NAME]. During an interview on 04/02/25 at 4:00 P.M., the Assistant Director of Nursing (ADON) said he/she was the facility's Infection Preventionist. The ADON said he/she was not familiar with the Water Management Program and he/she was not familiar with Legionella. During an interview on 04/03/25 at 10:30 A.M., the maintenance director said he/she was responsible for implementing the water management plan. The maintenance director said he/she had never reviewed the entire program and he/she just followed inspection checklists provided by corporate staff. The maintenance director said the resident halls were referred to as 100, 200 and 300 halls. The maintenance director said he/she was not aware of any specific corrective actions related to the water management program. During an interview on 04/03/25 at 12:35 P.M., the administrator said he/she, maintenance and corporate staff were responsible for writing the water management program. The administrator said he/she, the maintenance director, the housekeeping supervisor and the infection preventionist were responsible for implementing the program. The administrator said he/she reviewed the program annually in January or February but did not document the review. The administrator said the resident halls were referred to as 100, 200 and 300. The administrator said the resident halls were not identified as Colonial, Aspen or [NAME]. The administrator said he/she did not realize the program did not include facility specific policies or corrective actions. 2. Review of the facility's policy titled Cleaning and Disinfecting Blood Glucose Meters, dated 2019, showed thoroughly clean all visible soil and organic material (e.g. blood) from glucometer before disinfection. Follow manufacturer's guidelines for cleaning and disinfecting of glucose meters. Specific guidelines for glucose meters may vary with the manufacturer. When selecting a disinfecting cleaning product, review the required contact time. Nursing is to understand and demonstrate the necessary length of time the disinfectant must be in contact with the glucometer. Each disinfectant has specific instructions. Review of the manufacturer's instructions for The EvenCare G3 Meter, revised April, 2024, showed the meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. Inspect for blood, debris, dust or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both the front and back surfaces until visibly clean. Avoid wetting the meter test strip port. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe all external areas of the meter including both the front and back surface until visibly wet. Avoid wetting the meter test strip port. Wipe meter dry or allow to air dry. 3. Observation on 04/2/25 at 12:15 P.M., showed Registered Nurse (RN) I checked Resident #37's blood sugar. Observation showed RN I did not clean or disinfect the glucometer and placed it in the medication cart. Observation at 12:25 P.M., showed RN I used the same glucometer and checked Resident #33's blood sugar without cleaning or disinfecting the glucometer. Observation at 12:30 P.M., showed the RN used the same glucometer to check Resident #48's blood sugar. The RN did not cleanse or disinfect the glucometer before he/she checked Resident #48's blood sugar. 4. During an interview on 04/2/25 at 12:54 P.M., RN I said he/she did not know what the policy said in regard to cleansing and disinfecting the glucometers. RN I said if the glucometer is not cleaned blood borne pathogens could be passed from resident to resident. RN I said he/she did not know of any residents in the facility with hepatitis or Human Immunodeficiency Virus (HIV), a blood borne pathogen. RN I said he/she did not know why he/she did not clean the glucometer between uses. During an interview on 04/2/25 at 1:14 P.M., the Director of Nursing (DON) said she/she did not know if there was a policy in regard to cleaning the blood glucose meters. The DON said the staff are expected to clean the meters between each resident. The DON said if the glucometer is not cleaned between residents, pathogens can be transferred from resident to resident. The DON said there are not any current residents with hepatitis or HIV. During an interview on 04/2/25 at 1:23 P.M., the administrator said the policy for cleaning glucose meters is typically to have two meters, one in use and one wrapped in a disinfecting wipe. He/She said staff should use the clean meter for the next resident while the first one is disinfecting. The risk of not cleaning the meters is blood borne pathogens being spread from resident to resident. That is why the glucometers should be cleaned and he/she would expect staff to follow the cleaning policy. The administrator said he/she is not aware of any current residents with HIV or hepatitis. 5. Review of the facility's Infection Prevention policies showed the Antibiotic Stewardship and MDRO (Multiresistant Organisms), dated 2019, had not been reviewed annually. The policy included recommendations for establishing an antibiotic stewardship program, but did not include site-specific directions for conducting surveillance activities such as the Monthly Nosocomial Infection Report or Nosocomial Infection Worksheet currently in use; the process for antibiotic usage tracking, or resident reassessment to determine effectiveness and outcome analysis: -Long Term Care-Urinary Tract Infections, dated 2012, not reviewed annually. -Cleaning and Disinfecting Blood Glucose Meters, dated 2019, and not reviewed annually; -Standard Precautions: Hand Hygiene, dated 2019, and not reviewed annually; -Resident Immunizations and Vaccinations: Influenza Vaccine Program, updated 09/2/22, had not been reviewed annually and included specific vaccination available for the 2022-2023 influenza season; -Immunization Recommendations for Residents of Long Term Facilities, dated April 2016, had not been reviewed annually, and did not reflect current Centers for Disease Control and Prevention (CDC) guidelines for pneumococcal immunizations; -SARS CoV-2 (Coronavirus) Infection policy included the informational sheet Benefits of Getting a (Coronavirus 2019) COVID-19 Vaccine informational sheet, updated 01/5/21. The information sheet did not reflect current guidance found in the CDC's Staying Up to Date with Covid-19 Vaccines, dated January 27, 2025. During an interview on 04/8/25 at 5:35 P.M., the Infection Preventionist (IP) said staff use the Infection Prevention and Antibiotic Stewardship policies that have been given to them by corporate. The IP said he/she did not know the policies should be reviewed annually and assumed that would be done at the corporate level. During an interview on 04/8/25 at 6:04 P.M., the administrator said he/she did not know the Infection Prevention and Antibiotic Stewardship policies needed to be reviewed annually, but does know the CDC has not come out with updates since 2022. 50432

Based on interview and record review, facility staff failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS), complete and accurate direct care staffing information to the Payroll-Based Journal (PBJ) from October 1, 2024, through December 31, 2024. The facility census was 57. 1. The facility did not provide a policy for Payroll-Based Journal submission. 2. Review of the CMS Electronic Staffing Data Submission PBJ Policy Manual for submission guidelines showed submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. Timeframes for each reporting period are as follows: Fiscal Quarter 1 - Date Range October 1-December 31 - submission deadline February 14; Fiscal Quarter 2 - Date Range January 1-March 31 - submission deadline May 15; Fiscal Quarter 3 - Date Range April 1-June 30 - submission deadline February 14; Fiscal Quarter 4 - Date Range July 1-September 30 - submission deadline November 14. 3. Review of the fiscal years CMS PBJ Staffing Data Report, dated October 1 - December 1 showed: -The facility triggered for, Excessively Low Weekend Staffing, No Registered Nurse (RN) Hours, and Failed to have Licensed Nursing Coverage 24 Hours/Day. -Infraction dates for No RN Hours every day October 1 to November 30. -Infraction dates for Failed to have Licensed Nursing Coverage 24 Hours/Day every day October 1 to November 30. Review of the facility's nursing schedule, dated October 1 to November 30, showed the facility had eight or more RN hours per day and licensed nursing coverage 24 hours per day. During an interview on 04/03/25 at 11:02 A.M., the administrator said he/she did not know of a policy for the PBJ. The administrator said the corporate office is responsible to report the fiscal quarter staffing information for October 1 to December 31 by the deadline. During an interview on 04/08/25 at 6:04 PM, the administrator said he/she did not know why the PBJ information had not been submitted. The administrator said during training, the PBJ process was reviewed, and information is supposed to flow over and link up with the reporting. During an interview on 04/18/25 at 11:40 A.M., the Corporate Human Resource (HR) Officer for PBJ said the PBJ data for October 1 to November 30 was entered by their corporation on 12/11/24. The HR Officer said the new corporation had the responsibility to submit the information for December 1 to 31. The HR Officer said he/she did not know why the information submitted by their office was not included in the full quarter report.

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus to residents who received regular and pureed diets. The facility census was 57. 1. Review of the facility's Standardized Recipes policy, undated, showed standardized recipes will be used for all menu items, including pureed and therapeutic diets. Review showed each standardized recipe will include measurement and/or weight of ingredients and serving sizes. Review of the facility menu for Week 4, Day 17 showed the menu directed staff to serve: -Two, three ounce tuna patties, four ounces of yellow rice, four ounces of spinach and one slice of bread to residents who received regular diets; -A #6 scoop (five and one-third ounces) tuna patty, a #8 scoop (four ounces) yellow rice, a #12 scoop (two and two-thirds ounces) frozen spinach, and a #16 scoop (two ounces) of bread to residents who received pureed diets. Review of the facility's recipes showed they did not contain a recipe for tuna noodle casserole. Observation on 04/01/25 at 12:35 P.M., showed the dietary manager served four ounces of tuna noodle casserole to residents who received a regular diet instead of two, three ounce tuna patties as directed by the menu. Observation showed the dietary manager served one #8 scoop of pureed tuna noodle casserole, instead of a #6 scoop of tuna patty as directed by the menu, and one #8 scoop of pureed spinach (1 1/3 ounces more than directed) to three residents who received pureed meals. Observation showed the residents did not receive pureed bread. During an interview on 04/01/25 at 1:05 P.M., the dietary manager (DM) said he/she did not follow a recipe when he/she prepared the tuna noodle casserole. The DM said the food delivery was delayed so he/she prepared what he/she had on hand. During an interview on 04/03/25 at 12:35 P.M., the administrator said the cook was responsible for preparing and serving food in accordance with the recipes and menus. The administrator said he/she was unaware staff were not following the recipes and menus.

Based on observation, interview, and record review, facility staff failed to obtain consent for the use of bed rails for five residents (Resident #3, #6, #7, #19 and #26) out of six sampled residents, failed to assess residents for the use of bed rails and perform an entrapment assessment for two residents (Resident #7 and #26) of six sampled residents. The facility census was 57. 1. Review of the facility's policy titled Bed Rails, dated December 2024, showed prior to the installation of bed rails, attempts to provide the resident with alternative measures to meet their need for positioning, mobility, or transfer ability while in bed will be made. When alternatives are deemed ineffective or not adequate to meet the resident's needs, the resident will be assessed for the use of bed rails, including the risk of entrapment, and informed consent is obtained from the resident or resident's representative. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/06/25, showed staff assessed the resident as: -Severely cognitively impaired; -Diagnoses of cancer, multiple sclerosis, Parkinson's Disease, anxiety disorder and depression. -Restraints not used. Review of the resident's medical record showed the medical record did not contain an informed consent for bed rail use. Observation on 03/31/25 at 1:54 P.M., showed the resident in bed with one bed rail raised. During an interview on 03/31/25 at 1:54 P.M., the resident said he/she used the bed rail to assist in position changes. During an interview on 04/08/25 at 12:20 P.M., the Assistant Director of Nursing (ADON) said the resident gave verbal consent, but the facility did not obtain documentation of the entrapment assessment, the consent, or the resident's bed rail assessment. 3. Review of Resident #6's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderately cognitively impaired; -Diagnoses of coronary artery disease, peripheral vascular disease, diabetes, and lung disease. -Restraints not used. Review of the resident's medical record showed the medical record did not contain an informed consent for bed rail use. Observation on 03/31/25 at 2:18 P.M., showed the resident in bed with one bed rail raised. Observation on 04/01/25 at 9:35 A.M., showed the resident in bed with one bed rail raised. During an interview on 04/08/25 at 12:20 P.M., the ADON said the resident did not have a consent for the use of bed rails. 4. Review of Resident #7's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of coronary artery disease, heart failure, hypertension, hip fracture, dementia and asthma. -Bed rails not used. Review of the resident's medical record showed the medical record did not contain an informed consent for bed rail use, an entrapment assessment, or bed rail assessment. Observation on 03/31/25 at 1:45 P.M. showed the resident's bed with grab bars up on both sides. 5. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Cancer, atrial fibrillation, coronary artery disease, heart failure, diabetes, arthritis, anxiety disorder, and depression. -Bed rails not used. Review of the resident's medical record did not contain an informed consent for bed rail use. Observation on 04/01/25 at 9:07 A.M., showed the resident in bed with a bed rail raised. During an interview on 04/08/25 12:20 P.M., the ADON said the resident did have consent for the use of bed rails. 6. Review of Resident #26's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of hypertension, hyperlipidemia, thyroid disorder, hip fracture, and dementia. -Bed rails not used. Review of the resident's medical record did not contain an informed consent for bed rail use, an entrapment assessment, or bed rail assessment. Observation on 03/31/25 at 2:14 P.M., showed the resident in his/her bed with grab bars up on both sides. During an interview on 03/31/25 at 2:15 A.M., the resident said he/she did not use the grab bars. During an interview 04/08/25 at 12:20 P.M., the ADON said the resident did not have an entrapment assessment, consent, or resident assessment for bed rail use. 7. During an interview 04/08/25 at 12:20 P.M., the ADON said residents #3 and #26 had new beds, and no entrapment assessments, consents, or resident assessments had been completed. During an interview on 04/08/25 at 5:50 P.M., the Director of Nursing (DON) said the Registered Nurses (RN)'s complete the bed rail assessments and entrapment assessments. The DON said the assessments are checked for completion quarterly. The DON said they do have new beds and all the rails have not been removed. The DON said the bed rails will stay on the beds of the residents who request them. The DON said the new beds recently arrived and the staff had not had time to complete the paperwork. During an interview on 04/08/25 at 06:12 P.M., the Administrator said the bed rails assessments were done by the previous DON before he/she quit and now the current DON will be responsible for completing the required assessments. During an interview on 04/16/25 at 3:31 P.M., the administrator said consents are a part of the bed rail paperwork process. The administrator said the new beds arrived at the facility on the Thursday and Friday before the survey team arrived and there had not been enough time to complete the paperwork. 42484

Based on interview and record review, facility staff failed to ensure three Nurse Aides (NA)s (NA B, NA C, and NA D) of five sampled NA's completed the required nurse aide training program within four months of employment in the facility. The facility census was 57. 1. Review of the policies provided by the facility did not contain a policy for NA qualifications. 2. Review of the Facility Assessment Tool, dated August 18, 2017, showed the Facility Assessment did not address Nurse Aide Qualifications and Training Requirements. 3. Review of NA B's personnel file showed a hire date of 11/05/24. The file did not contain documentation the NA completed the required nurse aide training program. 4. Review of NA C's personnel file showed a hire date of 11/05/24. The file did not contain documentation the NA completed the required nurse aide training program. 5. Review of NA D's personnel file showed a hire date of 07/06/24. The file did not contain documentation the NA completed the required nurse aide training program. During an interview on 04/03/25 at 11:30 A.M., NA D said he/she had not passed the CNA exam. NA D said the facility is assisting him/her to reschedule the test. 6. During an interview on 04/03/25 at 04:45 P.M., the Clinical Coordinator said once the NA completes the course work requirements, the individual NA is responsible for scheduling and taking the Certified Nursing Assistant exam. The Clinical Coordinator said he/she does not track when or if the NA's pass their exam and receive their certification. During an interview on 04/08/25 at 05:35 P.M., the Director of Nursing (DON) said NA's should have their certification within 120 days of employment. The Clinical Coordinator tracks the NAs' progress and helps the NA's schedule and set up their exams. The DON said the Clinical Coordinator reports to him/her and should report NA's that have not received their license within 120 days. The DON said he/she did not know there were NA's that had not completed their training. During an interview on 04/08/25 at 6:04 P.M., the administrator said NA's should be certified within 120 days of employment. The administrator said a couple of the CNAs' had failed their tests. The administrator said the facility would not have NA's past the given 120 days, and the NA's would be taken off of the schedule.

Based on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 57. 1. Review of the facility's policy titled Antibiotic Stewardship & MDROs (Multiresistant Organisms), dated 2019, showed the Infection Preventionist (IP) will be responsible for surveillance, infection definition based on standards of practice, education, tracking, data management, analysis of data, communication with the DON (Director of Nursing), Medical and Consultant Pharmacist and ongoing system review. Ongoing review and updates will be completed based on standards of practice, and collaboration with Medical Director and Pharmacy Consultant. Tracking and reporting of antibiotic use and outcomes will be completed in the facility to identify adherence to facility policy and procedures, use and outcomes. Tracking will allow the facility to identify patterns, prevalence of antibiotic use as well as specific ordering data. Outcomes (i.e. adverse drug events,, antibiotic resistant organisms, Clostridium difficile infections, etc) will be tracked by the Infection Preventionist and discussed with the Quality Assurance Committee for action planning. 2. Review of the facility's Nosocomial Infections Worksheet Sites and Pathogens dated January, February and March 2025, showed staff documented the number of pathogens (infections caused by specific bacteria including Acinetobactor, Klebsiella, Clostridium difficile and Escherichia Coli by source. (i.e. Urinary Tract Infection (UTI), Cutaneous (relating to the skin), Upper Respiratory, Gastrointestinal (stomach), Intravenous site, etc). The documentation did not include antibiotics ordered for the infections or the outcome of antibiotic use. 3. Review of the facility's Monthly Nosocomial Infection Report for All Nursing Units dated January, February and March 2025 showed staff documented the total number of infections from specific sources (i.e. number of UTI's, Cutaneous, Upper Respiratory, etc). for the facility. The documentation did not identify the infections by unit or indicate antibiotic usage to determine patterns, trends and outcomes. During an interview on 04/08/25 at 2:35 P.M., the IP said he/she does not have an antibiotic tracker. He/She said the antibiotic orders are reviewed and that is how the information for the infection reports are gathered for the Quality Assurance and Improvement Committee. He/She said mapping infections is not done to determine patterns, trends and outcomes of antibiotic usage. The IP said the policies followed were given to facility staff by the corporate office. During an interview on 04/08/25 at 6:05 P.M., the administrator said he/she expects the IP to follow the facility policy for Antibiotic Stewardship and ensure it is up to date and locally relevant. 50432

Based on interview and record review, facility staff failed to prevent the commingling of 17 resident's (Resident #13, #19, #21, #46, #63, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, and #77) personal funds with the facility operating funds out of 55 sampled residents. The facility census was 55. 1. Review of the facility's policy titled Facility Resident Trust Fund Policy, revised 05/12, showed the facility will maintain a full and complete separate accounting ledger for each resident. The facility will maintain current written individual ledgers of all financial transactions. If a check is received for the resident's Accounts Receivable balance along with money for their resident trust account, the entire check should be deposited to the resident trust fund. A check then must be written from the resident trust fund to the accounts receivable account for the portion relating to the resident's accounts receivable balance. The facility will refund the balance of the resident's personal funds when a resident is discharged . The amount will be refunded by the end of the month following the month of discharge or by Federal/State specific guidelines if such policies are more stringent. Each quarter an audit will be performed by the Regional Financial Analyst, Administrator or designee. 2. Review of the facility-maintained Accounts Receivable Aging report, dated 03/31/25, showed the following residents with personal funds held in the facility operating account: Resident Amount Held in Operating Account #13 $630.00 #19 $1626.00 #21 $312.00 #46 $6306.68 #63 $5950.50 #66 $8195.50 #67 $3462.51 #68 $3616.00 #69 $240.00 #70 $1440.00 #71 $3695.83 #72 $25.00 #73 $192.95 #74 $924.00 #75 $3798.10 #76 $5718.07 #77 $300.00 Total $46,433.14 During an interview on 04/02/25 at 9:55 A.M., the Business Office Manager (BOM) said he/she started working at the facility on 03/03/25 and has not been completely trained. The BOM said he/she is supposed to attend training for this position in the next two weeks. The BOM said he/she has worked with the Regional BOM to learn his/her job, and the Regional BOM is available by phone or email when he/she needs assistance. During an interview on 04/02/25 at 10:03 A.M., the Regional BOM said he/she is responsible to oversee the BOM's within his/her region of the company. The Regional BOM said he/she is responsible to ensure the facility BOM is trained. The Regional BOM said he/she has been responsible for the facility funds while the facility did not have a BOM and will continue to oversee it after the new BOM is trained. The Regional BOM said the prior company changed hands to the present company on 12/01/24 and used a different computer system. The Regional BOM said the facility did not get the new computer system until 02/01/25. The Regional BOM said from 12/01/24 through 02/01/25 he/she did not have access to the facilities accounts, and the facility did not have a BOM at the time, therefore he/she did not address any credits or balances until the end of February once he/she had access to the old companies balances forward. The Regional BOM said refunds should be sent within 30 days of a resident discharge, but he/she knows the refunds have not been sent. The Regional BOM said the facility does not have written authorization to hold resident money in the facility operating account. During an interview on 04/02/24 at 11:30 A.M., the administrator said the BOM is responsible for the Accounts Receivable Aging report and resident billing, but the facility did not have a BOM and just recently hired the current BOM. The administrator said the Regional BOM has been responsible since the new company took over. The administrator said he/she did not know there were outstanding credits, and he/she did not think there should be. The administrator said all credits should be refunded within 30 days. The administrator said the facility does not have written authorization to hold resident funds in the facility operating account.

Based on interview and record review, facility staff failed to maintain professional standards of care, when staff failed to document neurological assessments for one resident (Resident #1) out of one sampled resident who had a fall with head injury. The facility census was 57. 1. Review of the facility's Fall Prevention policy, undated, showed it did not address a neurological post fall assessment for residents who incurred a head injury. Review of the facility's paper Neurological Evaluation flowsheet, revised November 2023, showed staff are directed to document neurological assessments for unwitnessed falls and head injuries every 15 minutes for one hour; every 30 minutes for two hours; every hour for four hours; and every shift for 72 hours. Review showed the neurological assessment should include: -Level of consciousness (Awake and Alert); -Orientation (Time/Place/Person); -Pupil reaction (pupils reaction to light); -Motor strength (extremity movement); -Sensation (numbness or tingling); -Gait and Balance (steps and pace); -Vital Signs (Blood pressure, pulse, respirations, and temperature). Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/16/25, showed staff assessed the resident as moderately cognitively impaired and at risk for falls. Review of the resident's care plan, dated 04/14/25, showed it did not contain documentation for risk of fall and interventions for falls. Review of the resident's Fall Data Assessment Template, dated 05/09/25, showed staff documented the resident was oriented to person and situation. Review of the progress notes, dated 05/09/25 at 11:54 P.M., showed staff documented a nurse witnessed the resident fall to the floor while reaching for a light switch. Staff documented a laceration that measured one centimeter by two centimeters to the left eyebrow, cleansed and steri-strips (adhesive bandage used to keep two sides of skin stay tightly closed) applied. The physician was in-house and notified. Review the resident's progress notes, dated 05/09/25 at 10:07 A.M., showed staff documented the resident experienced a change in condition including the inability to make needs known, and an oxygen saturation (percentage of cells in the blood carrying oxygen) below 90%. Resident emergently transferred to the hospital. Review of the progress notes, dated 05/10/25 at 3:34 A.M., showed staff documented the resident's pupils as equal, round, and reactive to light. The documentation did not include any further neurological assessment. Review of the medical record, dated 05/27/25, showed staff did not complete a Neurological Evaluation flowsheet for the resident. During an interview on 05/27/25 at 12:00 P.M., Licensed Practical Nurse A said if he/she saw a resident fall and they had to apply steri-strips to a head laceration, two hour neurological checks should be completed. During an interview on 05/27/25 at 3:30 P.M., Registered Nurse J said staff are expected to follow facility policy related to assessing injury after falls. He/She said fall assessments are completed after all falls. During an interview on 05/27/25 at 02:50 P.M., the Assistant Director of Nursing said the fall policy does not require staff to perform additional neurological checks when a fall is witnessed. During an interview on 06/17/25 at 08:45 A.M., the Director of Nursing (DON) said neurological assessments are performed after unwitnessed falls and falls with head injuries. During the facility's current electronic medical record transition, neurological assessments are documented on a paper form that is scanned in the EMR. The DON said the assessment includes vital signs, pupil reaction and size, speech, level of consciousness, and grip strength. MO#00354062

Based on interview and record review, facility staff failed to maintain professional standards of care, when staff failed to document neurological assessments for one resident (Resident #1) out of one sampled resident who had a fall with head injury. The facility census was 57. 1. Review of the facility's Fall Prevention policy, undated, showed it did not address a neurological post fall assessment for residents who incurred a head injury. Review of the facility's paper Neurological Evaluation flowsheet, revised November 2023, showed staff are directed to document neurological assessments for unwitnessed falls and head injuries every 15 minutes for one hour; every 30 minutes for two hours; every hour for four hours; and every shift for 72 hours. Review showed the neurological assessment should include: -Level of consciousness (Awake and Alert); -Orientation (Time/Place/Person); -Pupil reaction (pupils reaction to light); -Motor strength (extremity movement); -Sensation (numbness or tingling); -Gait and Balance (steps and pace); -Vital Signs (Blood pressure, pulse, respirations, and temperature). Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/16/25, showed staff assessed the resident as moderately cognitively impaired and at risk for falls. Review of the resident's care plan, dated 04/14/25, showed it did not contain documentation for risk of fall and interventions for falls. Review of the resident's Fall Data Assessment Template, dated 05/09/25, showed staff documented the resident was oriented to person and situation. Review of the progress notes, dated 05/09/25 at 11:54 P.M., showed staff documented a nurse witnessed the resident fall to the floor while reaching for a light switch. Staff documented a laceration that measured one centimeter by two centimeters to the left eyebrow, cleansed and steri-strips (adhesive bandage used to keep two sides of skin stay tightly closed) applied. The physician was in-house and notified. Review the resident's progress notes, dated 05/09/25 at 10:07 A.M., showed staff documented the resident experienced a change in condition including the inability to make needs known, and an oxygen saturation (percentage of cells in the blood carrying oxygen) below 90%. Resident emergently transferred to the hospital. Review of the progress notes, dated 05/10/25 at 3:34 A.M., showed staff documented the resident's pupils as equal, round, and reactive to light. The documentation did not include any further neurological assessment. Review of the medical record, dated 05/27/25, showed staff did not complete a Neurological Evaluation flowsheet for the resident. During an interview on 05/27/25 at 12:00 P.M., Licensed Practical Nurse A said if he/she saw a resident fall and they had to apply steri-strips to a head laceration, two hour neurological checks should be completed. During an interview on 05/27/25 at 3:30 P.M., Registered Nurse J said staff are expected to follow facility policy related to assessing injury after falls. He/She said fall assessments are completed after all falls. During an interview on 05/27/25 at 02:50 P.M., the Assistant Director of Nursing said the fall policy does not require staff to perform additional neurological checks when a fall is witnessed. During an interview on 06/17/25 at 08:45 A.M., the Director of Nursing (DON) said neurological assessments are performed after unwitnessed falls and falls with head injuries. During the facility's current electronic medical record transition, neurological assessments are documented on a paper form that is scanned in the EMR. The DON said the assessment includes vital signs, pupil reaction and size, speech, level of consciousness, and grip strength. MO#00354062

Based on interview and record review, facility staff failed to have a system in place to ensure Certified Nurse Aides (CNA)s received the required 12 hours in-service education based on performance reviews annually for three CNAs (CNA E, F, & G) out of three sampled CNAs. The facility census was 57. 1. Review of the policies provided by the facility did not show a policy for staff training, CNA training, or staff/CNA evaluations. Review of the Facility Assessment, dated August 18, 2017, showed the required in-services for nurse aides must: -Be sufficient to ensure the continuing competency of nurse aides (NA)s, but must be no less than 12 hours per year; -Address areas of weakness as determined in the NAs' performance training; -The Facility Assessment did not contain requirements of annual in-service education for nursing personnel by a registered nurse (RN) or qualified therapist to include turning and positioning for the bed-ridden resident, range of motion (ROM) exercises, ambulation assistance, transfer procedures, bowel and bladder retraining, or self-care activities of daily living. 2. Review of CNA E's employee record showed: -A hire date 06/08/10: -The record did not contain documentation of individual hours attended in the monthly in-service training and online training; -The record did not contain a performance review on which to base in-service education. 3. Review of CNA F's employee record showed: -A hire date of 09/20/18: -The record did not contain documentation of individual hours attended in the monthly in-service training and online training; -The record did not contain a performance review on which to base in-service education. 4. Review of CNA G's employee record showed: -A hire date of 07/03/12: -The record did not contain a performance review on which to base in-service education. 5. During an interview on 04/03/25 at 01:44 P.M., the administrator said the facility did not complete annual evaluations on employees. During an interview on 04/03/25 at 3:51 P.M., the receptionist said the employee on-line continuing education report does not document the number of education hours for the courses completed. During an interview on 04/08/25 at 05:35 P.M., the Director of Nursing (DON) said the Clinical Coordinator completes competency reviews for the new hires, but no competency or performance reviews are completed after hire. During an interview on 04/08/25 at 6:04 P.M., the administrator said CNA performance reviews will be started soon. The administrator said 12 hours of continuing education is online and the DON tracks the CNAs progress. CNA's are encouraged to complete one hour a month to achieve the 12 hours and the DON is responsible to track the hours.

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse when staff found Resident #2 with his/her hand between Resident #1's legs. The facility census was 55. 1. Review of the facility's Abuse Prohibition Protocol Manual, dated July 2020, showed it is the policy of the facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. Review showed residents will be protected from abuse, neglect, and harm while they are residing at the facility and no abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. Review showed the facility leadership will assess the needs of the residents in the facility to be able to identify concerns in order to prevent potential abuse. Review showed staff are to establish a safe environment that supports, to the extent possible, a residents consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the residents right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. Review showed the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing; wandering into other's rooms/space; and residents that require extensive nursing care and/or are totally dependent on staff for the provision of care. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 2/18/22, showed staff assessed the resident as follows: -Short and long term memory problems; -Severely impaired cognitive skills for daily decision making; -Dependent on two or more staff for transfers; -Diagnoses of dementia, anxiety, depression, and senile degeneration of the brain. Review the resident's plan of care, dated 2/23/22, showed the resident self-propels his/her wheelchair around the facility, opens drawers, and goes into other residents' rooms, and attempts to open doors. Review of Resident #2's Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follow: -Mild cognitive impairment; -Required limited assistance and one person assistance for transfers and locomotion, no limitations in functional range of motion; -Diagnosis of schizophrenia. Review of Resident #2's plan of care, reviewed and revised 3/1/22, showed the resident has inappropriate sexual behaviors and comments with staff of the opposite sex. The plan directed staff to remind the resident that making sexual remarks and gestures toward staff of the opposite sex was inappropriate. The plan did not list concern regarding behaviors towards residents of the opposite sex. Review of the facility investigation, dated 3/29/22, showed Certified Nursing Aide (CNA) A walked into Resident #1's room and witnessed Resident #2's hand between the legs of Resident #1. Review showed CNA A called for assistance and CNA B assisted in separating the residents. Review showed the administrator interviewed Resident #2 who said Resident #1 kept coming at me. Further review showed staff documented Resident #1 and #2 had been flirtatious with each other along with hand holding and playing with each other's hands. Review of both residents' most recent plans of care showed staff did not update the plans to give direction for staff to address the residents' increased interactions with each other. During an interview on 3/31/22 at 9:15 A.M., the administrator said she was informed about the incident that occurred on 3/29/22 at 8:00 P.M., between Resident #1 and Resident #2 and immediately came to the facility. She said Resident #1 and Resident #2 had been increasingly flirtatious over the past 3 weeks, playing with each other's hands. She said Resident #1 focuses on babies, wants a boyfriend/girlfriend, always asking others if they are married and goes in and out of other resident rooms. She said Resident #1 denied anything happened and had no injuries during the skin assessment. She said during her investigation, CNA A informed her that Resident #1 did not appear upset or tell Resident #2 to stop. She said Resident #2 can stand and put self on the floor but barely able to propel self in wheelchair. The administrator said during the investigation Resident #2 told her that Resident #1 wants me to fuck him/her. During a telephone interview on 3/31/22 at 2:00 P.M., Resident #1's family member said the resident was very religious, never married, never had children and had high moral standards before he/she became sick and would not have consented to this. MO00199154

Based on observation, interview, and record review, facility staff failed to accurately assess pressure ulcers on two (Resident #1 and Resident #2) out of three sampled residents with pressure ulcers. In addition, staff failed to notify one resident's physician (Resident #1) of the extent of the resident's pressure ulcers including assessment of slough (necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy) and other necrotic (dead) tissue, failed to provide the resident's pressure ulcer treatment as ordered, and failed to provide the resident's pressure relieving air mattress and heel boots during a temporary move to a different room. The facility census was 78. 1. Review of the facility Wound Care Policy, dated 2001, showed direction for staff to assess pressure ulcers as follows: - thoroughly document all wound information such as type, location, stage (if applicable), length, width, depth, drainage, notation of tunneling (channeling that extends from a wound into and through soft tissue or muscle) or undermining (tissue destruction underlying intact skin along wound edges), description of tissue, state of periwound (area surrounding wound) area, treatment of [REDACTED]. - notify appropriate personnel of all new pressure ulcers; - reevaluate dressing and skin integrity every shift. Reevaluate the wounds response to the prescribed treatment on a regular basis. 2. According to the Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0., pressure ulcer staging is defined as follows: -Stage I - An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: - Skin temperature (warmth or coolness); - Tissue consistency (firm or boggy); - Sensation (pain, itching); and/or - A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. - Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough (necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy (at times)). May also present as an intact or open/ruptured blister. - Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. - Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties & biological activity. Eschar may be loose or firmly adhered to the wound) may be present on some parts of the wound bed. Often includes undermining and tunneling. According to the National Pressure Ulcer Advisory Panel (NPUAP) a deep tissue injury is " A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. " (NPUAP, 2002). 3. Review of Resident #1's readmission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/14/13, showed staff assessed the resident as follows: - Moderately impaired cognitive skills for daily decision making; - Required extensive assistance for bed mobility, transfer, dressing, eating, toilet use, and hygiene; - Occasionally incontinent of urine; - Not at risk for pressure ulcers; - No pressure ulcers or wounds. Record review of the resident's Wound Report, dated 4/3/13, showed staff first documented assessments of the resident's pressure ulcers as follows: - "Stage II" pressure ulcer on the coccyx measured 2.5 centimeters (cm) by 1.0 cm; white/yellow proximal (closest to the center) wound bed with purplish skin flap distal (farthest from the center) wound bed, reddened periwound (area surrounding the wound); - Stage II pressure ulcer on the left heel measured 1.5 cm by 3.0 cm; dry intact purple blister purple discoloration extending to plantar (bottom) surface; - Stage II right heel measured 2.5 cm by 3.0 cm dry intact purple blister. Review of a fax to the Physician, dated 4/3/13, showed staff documented the following: -Skin breakdown to coccyx; dry intact purple blisters to bilateral heels. -Staff did not document notification of the physician in the fax communication the of the "white/yellow wound bed" (slough). Review showed staff updated the resident's plan of care on 4/3/13 to show the resident now had skin breakdown noted to coccyx (tailbone) and heels. Staff planned the following interventions: - Report any signs of skin breakdown; - Use pillows to relieve pressure on heels; - Conduct skin inspection weekly; - Turn and reposition every two hours; - Keep bony prominences from direct contact with one another. Review of the Physician order [REDACTED]. -On 4/5/13- Monitor bilateral heels every day until healed; Zinc (protective coating) ointment to coccyx every shift until healed. Review of the resident's Treatment Administration Record (TAR), dated 4/2013, showed staff did not document they applied Zinc cream to the resident's coccyx every shift as directed by the Physician, 4/6/13 through 4/10/13 (5 days). Staff documented the following: -On 4/6/13 staff documented they only applied the Zinc on two shifts; -On 4/7/13 staff documented they only applied the Zinc on one shift; -On 4/8/13 staff documented they only applied the Zinc on two shifts. Review of a fax to the Physician, dated 4/8/13, showed staff documented the following: -Transcription error with new order of Zinc Cream to coccyx every shift; written on the Treatment Administration Record (TAR) as every day; -Decline to coccyx area, new purple blister to right inner buttock. Review of the resident's nurses' notes and wound reports, dated 4/8/13, showed staff did not document an assessment of the newly identified coccyx pressure ulcer to show on-going monitoring for improvement or decline. Review of the resident's TAR, dated 4/2013, showed the following: -On 4/10/13 staff documented they only applied the Zinc treatment on one shift, instead of every shift as ordered. Observation on 4/10/13 at 11:00 A.M., showed the resident lay on a regular mattress, not an air mattress as instructed, with no heel protectors and without his/her heels elevated with a pillow for heel pressure relief. Observation on 4/10/13 at 12:40 P.M. showed the resident lay in bed on a regular mattress. The resident's legs rested directly on the mattress, without pillows to provide pressure relief. Observation with the nurse showed a quarter sized pressure ulcer on the resident's coccyx ,with yellow slough (dead tissue). Observation showed an unstageable, large egg-sized left heel pressure ulcer with a black necrotic center, purple colored surrounding tissue, and red edges. Observation showed a walnut sized dark purple unstageable right heel pressure ulcer. Observation also showed an approximately 3 cm by 2 cm black, crusty, unstageable wound on the resident's right calf. The resident's right buttock contained a small, red but blanchable area of intact skin. Review on 04/10/13, of the resident's nurses notes and wound reports, showed staff did not document an assessment, measurement, notification of the Physician for treatment orders, or notification of the family about the wound on the resident's right calf. During an interview on 4/10/13 at 12:40 P.M., the Director of Nursing (DON) said the resident's pressure ulcers had worsened since she assessed them on 4/8/13. She said she did not notice the wound on the resident's right calf on 4/8/13, and had not seen it before. The DON said the resident's skin was breaking down very quickly due to the disease process. The DON said they assessed heel blisters as Stage II at the facility. She said the resident should have an air mattress, and heel protectors on while in bed. Review of the resident's Wound Reports and nurses' notes showed the DON did not document an assessment of the resident's skin on 4/8/13. During an interview on 4/10/13 at 12:40 P.M., Licensed Practical Nurse (LPN) A said the resident did not have a treatment ordered for his/her heels, but the physician directed staff to monitor them. She said there was no treatment ordered for the resident's wound on the right calf, and said she did not know that the wound existed. During an interview on 4/10/13 at 1:00 P.M. Certified Nurse Assistant (CNA) B, assigned to care for the resident this shift, said the resident did not have heel boots. During an interview on 4/10/13 at 2:00 P.M. the Administrator said staff were instructed to assess pressure ulcer blisters as Stage II per the facility policy. She said the resident had an air mattress and heel protectors to prevent pressure ulcers. However, staff placed the resident in a different room for the day so they could deep clean the resident's room. The administrator said the staff did not apply the resident's heel protectors because they were left in the other room. 4. Review of Resident #2's Braden Scale (used to predict pressure ulcer risk), dated 1/7/13, showed staff assessed the resident at 18 (12 or less represents high risk for pressure ulcers). Review of the resident's plan of care, updated 2/2013, showed staff documented the resident was resistive to repositioning side to side while in bed. Staff were instructed to position the resident in a comfortable position while side-lying, and instruct the resident on pressure relief positioning. Review of the resident's Wound Report showed staff documented the following: -On 2/3/13-- Date of onset- Two Stage II coccyx pressure ulcers measured 6.0 cm by 2.5 cm and 3.0 cm by 2.5 cm. Review of the resident's plan of care, dated 2/2013, showed staff documented the resident had skin breakdown on his/her coccyx, with a history of a chronic coccyx ulcer. Staff were instructed to offload pressure areas as much as resident would allow; use air mattress to relieve pressure; and educate patient about the need for pressure relief. Review of the resident's wound report, showed staff documented the following: -On 3/6/13-- Three "Stage II" areas 3.0 cm by 3.0 cm, 2.0 cm by 1.0 cm, 2.0 cm by 3.0 cm. White wound bed proximal, and red wound beds on the other two open areas distal; -On 3/13/13-- Date of onset- Stage II right heel wound measured 2.5 cm by 2.5 cm; -On 3/25/13-- "Stage II" coccyx areas: 4.0 cm by 4.0 cm, 2.0 cm by 1.0 cm, 2.0 cm by 3.0 cm. Noted decline with yellow slough wound cover to proximal wound. Request to change treatment. Stage II right heel 2.0 cm by 3.0 cm red moist wound bed with even edges. Review of the resident's plan of care, dated 3/2013 showed staff documented the resident had right heel skin breakdown and planned the following interventions: - assess the pressure ulcer for location, stage, size; - report any signs of further skin breakdown; - offload pressure areas as resident allows. Review of the Physician order [REDACTED]. - Apply Xeroform gauze (antiseptic non-adhering dressing) and Kling (bandage roll) to the right heel every day; - 3/27/13 Santyl ointment ([MEDICATION NAME] ointment to remove dead tissue) and foam to coccyx daily. Review of the resident's nurses' notes showed staff documented the following: -On 4/1/13 6:47 P.M.- Two coccyx wounds with red periwound. Upon last assessment noted three areas, at present two areas with proximal and middle wound now one area. Proximal wound with gray slough with dark wound edges measuring 7.0 cm by 4.0 cm by 1.0 cm depth. Distal wound with red/pink wound bed and even edges; -On 4/2/13 3:55 P.M.-- coccyx wound with loosening slough and foul odor, continues with dark wound edges. Distal coccyx wound with red/yellow wound bed 2.0 cm by 2.5 cm. Resident requires maximum encouragement to offload buttocks. Right heel with dry peeling edge and dry pink wound bed 2.0 cm by 2.5 cm. Review of the resident's discharge Minimum Data Set, a federally mandated assessment instrument, dated 4/2/13, showed staff assessed the resident as follows: - No memory problems; - Required extensive assistance for bed mobility, transfer, dressing, toilet use, and hygiene; - Had one Stage II pressure ulcer; - Had no Stage I, III, IV, and unstageable (unknown stage due to coverage of wound bed by slough and/or eschar) pressure ulcers. Review of the nurses note, dated 4/2/13 at 9:50 P.M., showed staff documented the family observed the residents coccyx wound, and wanted the resident transferred to the hospital for evaluation and treatment. Review of the hospital Admission History and Physical, dated 4/2/13, showed on admission the resident presented with: - 5 cm by 5 cm round unstageable bed ulcer covered with thick dark (slough), and surrounded with redness; - two smaller inferior (inner) ulcers 2 cm by 3 cm, Stage II-III; - Stage II right heel ulcer (not measured). Review of the hospital discharge summary record, dated 4/12/13, showed the resident was admitted to the hospital with [REDACTED]. The resident's hospital physician surgically debrided (removal of dead or damaged tissue) the pressure ulcers, and applied a wound vac (instrument used to remove drainage/dead tissue). During an interview on 4/10/13 at 12:30 P.M., the Director of Nursing said, on 4/2/13, the resident's coccyx wound appeared to be debrided as expected from the use of the new medication. The DON said she staged the residents coccyx wounds as Stage II based on her assessment. MO 349

Based on interview, and record review, the facility failed to follow the facility's bowel protocol two times leading to rectal bleeding on one instance and a visit to the emergency room with a complaint of constipation three days after the second instance, for one resident (Resident #11) out of 16 sampled residents. The facility census was 80. 1. Review of Resident #11's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 8/11/11, showed staff assessed the resident as: - Able to repeat/recall three words; - Able to state correct year, month, and day of the week; - Requires extensive assistance of one person physically assist for personal hygiene; - Requires extensive assistance of two plus persons physically assist with toilet use; - Always continent of bowel. Review of the resident's plan of care, dated 8/11/11, showed staff were directed to: - Encourage fluids to 1500 cc(cubic centimeters) per day; - Ensure adequate bowel elimination; - Administer medications as ordered. Evaluate/record/report effectiveness and any adverse side effects. Review of the facility's Laxative Flow Sheet Guidelines, undated, showed staff were directed to: - Night shift: Certified Medicine Technician (CMT)/nurse is responsible for reviewing the Bowel Movement (BM) record daily. If no BM has been recorded for two days, it will be marked on laxative flow sheet for the morning of the third day without a BM; - Day shift: CMT/nurse will administer a laxative with the A.M. medicine pass. Record on laxative flow sheet the laxative and time it was given and if it was effective during your shift (small, medium, large, or 0); - Evening shift: CMT/nurse will review the laxative list. Any resident who still have not had a BM may receive another laxative. Record the effectiveness of laxatives of your shift (small, medium, large, or 0); - Night shift: CMT/nurse will review the laxative list. Any resident who still have not had a BM may receive another laxative. Record the effectiveness of laxatives of your shift (small, medium, large, or 0); - Day shift of fourth day: If the resident still has had no results on the morning of the fourth day, the nurse is to notify the attending physician for further orders and record on the laxative flow sheet the time of notification. Review of the resident's Physician order [REDACTED]. - [MEDICATION NAME] Suppository (a laxative): insert one suppository rectally once daily as needed; - [MEDICATION NAME] Sodium (a stool softener): take one capsule by mouth every 12 hours as needed; - Milk of Magnesia (an antacid and laxative): take 30 milliliters (ml) by mouth every 12 hours as needed. Review of the facility's ADL (activities of daily living) record, dated 7/22/11 through 8/21/11, showed staff did not record the resident had a bowel movement on the following dates: - August 14, 15, 16, 17, and 18, a total of five days; - August 22, 23, 24, and 25, a total of four days. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - 7/22/11 through 8/21/11, staff did not administer a [MEDICATION NAME] Suppository, [MEDICATION NAME] Sodium, or Milk of Magnesia as ordered by the resident's physician, and did not follow the Laxative Flow Sheet Guidelines; - 8/22/11 through 9/21/11, staff did not administer a laxative as directed by the Laxative Flow Sheet Guidelines from 8/22/11 through 8/25/11. Review of the resident's nurses' notes showed staff documented the following: - 8/18/11 9:00 A.M. Patient finally had BM after five days and had bright red rectal bleeding that stopped after a few minutes; - 8/28/11 10:00 P.M. Returned from emergency room (ER) after complaint of cannot pass stool, Doctor ordered to ER, return orders Magnesium [MEDICATION NAME] half bottle and if no result, enema and start Mirilax daily. During an interview on 9/16/11 at 2:00 P.M., the Director of Nursing (DON) said: - Aides are responsible for recording bowel movements, and for notifying the charge nurse if the resident has gone for two days with no bowel movement; - The charge nurse is responsible for checking the resident's chart, and a CMT or charge nurse will administer a laxative, if the resident has an order for [REDACTED]. - Most residents have orders for laxatives as needed, to use after two days with no bowel movement; - No one is responsible for overseeing residents' bowel movement records; - The facility had to send the resident to the hospital once for and "issue" with constipation; - He/she does not know why the resident went several days without a bowel movement and no laxative given; - After four days without a bowel movement, he/she expects staff to notify the resident's physician. During an interview on 9/16/11 at 3:15 P.M., the administrator said Certified Nurse Aides are responsible for documenting resident's bowel movements. She said staff should notify the charge nurse if a resident has not had a bowel movement per the facility's bowel protocol. She said nurses are expected to monitor resident's bowel movements daily.

Based on interview and record review, licensed facility staff failed to report the results of a urinalysis (UA-to check for infection) with culture and sensitivity (C and S-identifies the bacteria present and various antibiotics the bacteria is sensitive to) to the resident's physician for one resident (Resident #4) of five residents reviewed. The resident was hospitalized for [REDACTED]. The facility census was 82. 1. Record review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/16/10 showed staff assessed the resident with the following: - [DIAGNOSES REDACTED]. - Short and long term memory problems; - Modified independence in daily decision making; - No change in behavior symptoms; - [MEDICAL CONDITION]; - No urinary tract infection. Review of the resident's nurses shift-to-shift report for September 2010 showed staff documented the following: - On 09/26/10, "Getting more confused. Calling staff names." - On 09/27/10, "Acting funny. Confused." During an interview on 12/20/10 at 1:15 P.M., Licensed Practical Nurse (LPN) B said on 09/27/10 he/she faxed a request to the resident's physician for a UA with C&S because of the resident's "sudden mental status changes." LPN B said when a resident exhibited sudden mental status changes, especially in the elderly, one of the first things checked for was a possible UTI. Review of the resident's Physician order [REDACTED]. Review of the resident's UA report dated 09/29/10 showed the following abnormalities: - Appearance, turbid (normal is clear); - Blood/Hemoglobin, 2+ (normal is negative); - Leukocyte Esterase, 3+ (normal is negative); - White Blood Count, (WBC) >150 (normal is none seen); - Bacteria, 3+ (normal is none seen). Review of the resident's physicians orders dated 09/29/10, showed the resident's physician directed staff to [MEDICATION NAME](antibiotic) 500 milligrams (mg) twice daily for 14 days to treat the resident's UTI. Review of the resident's final urine C & S report dated 09/30/10 showed the bacteria identified was not sensitive to treatment with Cipro. According to Mosby's Manual of Diagnostic and Laboratory Tests, Third Edition, Copyright 2006: Urine cultures and sensitivity tests are performed to determine the presence of pathogenic bacteria in patients with suspected UTIs. An important part of any routine culture is assessment of the sensitivity to various antibiotics of any bacteria that are growing in the urine. The physician can then prescribe the safest, least expensive, and most effective antibiotic therapy for the specific bacteria. Review of the resident's nurses' notes and laboratory reports showed staff did not document they notified the resident's physician of the final urine culture and sensitivity report dated 09/30/10 showing the resident's infection was resistant to treatment with the antibiotic the physician prescribed. During an interview on 12/20/10 at 1:00 P.M., the administrator said she could not find documentation to show staff notified the resident's physician of the final urine culture and sensitivity report dated 09/30/10. During an interview on 12/20/10 at 10:30 A.M., LPN I said he/she did not recall having reviewed the resident's C&S report dated 09/30/10. LPN I said when he/she received a C&S report, he/she did not review the results, but just faxed the results to the resident's physician and waited for further orders. LPN I said when he/she received the C&S report back with documented physician's orders [REDACTED]. Review of the facility's September and October 2010 "Infection Control List" (residents currently treated for [REDACTED]. During an interview on 12/21/10 at 11:30 A.M., the Director of Nursing (DON) said she was responsible for monitoring the infection control program. The DON said she did not know why they did not include the resident on the Infection Control List. Review of the resident's nurses shift-to-shift report sheet for October 2010 showed staff documented the following: - On 10/03/10, "Antibiotic for UTI. Combative. Order for psych consult." - On 10/04/10, "Waiting for open bed" at the geriatric psychiatric hospital. - On 10/05/10, "Crawling on floor. Combative. ER." Review of the resident's Resident Transfer Form dated 10/05/10 showed staff transferred the resident to the hospital for "mental status changes." During an interview on 12/21/10 at 7:50 A.M., LPN C said on 10/05/10 they transferred the resident to the hospital because his/her behavior did not improve after starting treatment for [REDACTED]." to treat his/her UTI. Review of the resident's hospital admission notes dated 10/05/10 showed the hospital physician listed the resident's [DIAGNOSES REDACTED]. Review of the resident's hospital discharge summary dated 10/07/10 showed the hospital physician recorded the following: - Primary Discharge Diagnosis: [REDACTED]. - Secondary Discharge Diagnosis: [REDACTED]. - Secondary Discharge Diagnosis: [REDACTED]. - Secondary Discharge Diagnosis: [REDACTED]. - "With his/her history of UTI and antibiotics use a UA was ordered which shows 15 WBC (white blood count) in clumps [MEDICATION NAME] continued as this was started on 09/29/10 for suspicious UTI." Review of the resident's hospital discharge summary dated 10/07/10 showed the resident was discharged back to the facility with the following medication: -[MEDICATION NAME] mg, one tablet every 12 hours. Review of the resident's nurses shift-to-shift report sheet for October 2010 showed staff documented the following: - On 10/09/10, "Came back with order for Cipro/I thought the infection was resistant to Cipro..." - On 10/12/10, "Combative. See new orders, has prn (as needed) Loxitane (for agitation). Sent to ER at 11:45 P.M., returned at 3:30 A.M. No new orders. Paged on call physician. New orders for [MEDICATION NAME] (antipsychotic) one time only." During an interview on 12/21/10 at 7:50 A.M., LPN C said he/she wondered why the resident returned [MEDICATION NAME] ER staff reported to him/her [MEDICATION NAME] not the "appropriate" treatment for [REDACTED]. LPN C said he/she notified the Assistant Director of Nursing (ADON) of the C&S report showing the organism was not sensitive to Cipro. Review of the resident's nurses note dated 10/17/10 showed staff documented the resident's family member transported the resident to the "Geri-Psych unit" at a local hospital. During an interview on 12/21/10 at 11:30 A.M., DON said she expected the licensed staff to inform the physician of the resident's final C&S report. During an interview on 12/21/10 at 11:00 a.m., Physician F said he/she was the resident's attending physician while he/she was in the hospital from 10/05/10 to 10/07/10. Physician F said facility licensed staff did not notify him/her of the C&S report dated 09/30/10 which showed the organism was resistant to Cipro. Physician F said a UA collected in the hospital showed the WBC in clumps, which meant the count was "very high," so he continued [MEDICATION NAME] the resident had been on it in the nursing home. During an interview on 12/20/10 at 8:15 A.M., Physician H said facility staff did not notify him/her of the resident's urine culture and sensitivity report dated 09/30/10. Physician H said he/she would expect the nurses to notify him/her of the results in order to enable him/her to accurately prescribe the most effective medication to treat the infecting organism. MO 238

Based on observation, interviews and medical record review facility staff failed to contact one resident's (Resident #1) physician regarding the resident's frequent refusal of treatments for a pressure ulcer and failed to provide care to prevent the development of pressure ulcers for one resident (Resident #3) of three sampled residents. The facility census was 83. 1. Review of Resident #1's most recent plan of care dated 02/02/09, showed staff planned the following intervention to assist the resident: -Staff are to apply [MEDICATION NAME] (barrier cream) cream to the 2nd/3rd digits daily, may keep at bedside (documentation does not specify if this is for the resident's fingers or toes). Review of the facility's correspondence with the resident's physician dated 08/19/10 show staff documented they notified the resident's physician by fax of an open area with drainage on the resident's second toe. The physician wrote an order for [REDACTED]. Further review showed the wound clinic did not evaluate the resident's open area until 08/27/10. Review of the resident's physician order [REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/31/10, showed the facility assessed the resident as follows: -Short and long term memory ok; -Alert and oriented; -Dependent on one staff person for assistance with activities of daily living (ADLs) including transfers, dressing, toilet use and personal hygiene; -Repetitive health concerns; -Unpleasant mood in the morning; -Diabetes Mellitus; -Two Stage I (persistent area of redness on intact skin) pressure ulcers; -Mild pain less than daily. Review of the resident's care plan (undated) showed staff recorded "the resident has a Stage II (a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater) on his/her right second toe. [MEDICATION NAME] collagen wound dressing (treatment used to promote healing of open wounds) applied in wound every day." Review of the resident's Braden scale for predicting pressure ulcer risk dated 08/31/10 showed staff assessed the resident with a score of 21. A score of 12 or less represented high risk for pressure ulcer development. Review of the resident's physician order [REDACTED]. Review of the resident's physician order [REDACTED]. Review of the resident's physician order [REDACTED]. Review of the resident's Wound Healing Center physician's orders [REDACTED]. Further review of the resident's TAR dated 11/22/10 through 12/21/10 showed it did not contain the [MEDICATION NAME] treatment ordered on [DATE]. Review of the resident's treatment administration record (TAR) showed staff recorded the following: - Resident refused [MEDICATION NAME] treatment from 8/28/10 to 9/7/10; - Resident refused hydrogel treatment on 9/12/10, 9/15/10, 9/16/10; - Resident refused [MEDICATION NAME] treatment on 9/27/10, 10/19/10 to 10/21/10; - Resident refused [MEDICATION NAME] collagen treatment from 11/5/10 to 11/22/10, 11/26/10 to 11/30/10, 12/4/10 to 12/6/10 for a total of 44 treatments refused. During an interview on 11/23/10 at 11:30 A.M., Licensed Practical Nurse (LPN) A said he/she faxed the resident's physician on 08/16/10 about the "open area" and received an order for [REDACTED]. LPN A also said it was "the responsibility of the evening shift nurse" to provide resident treatments and notify physicians of any refusals for treatments. During an interview on 11/23/10 at 1:30 P.M., the resident said he/she let only "a couple staff" change the dressing on his/her foot. He/She said his/her foot felt "sore" and hurt. Observation on 12/7/10 at 10:30 A.M. showed the resident wheeled himself/herself in the hallway with regular Velcro tennis shoes on his/her feet even though the physician ordered a Prevalon boot. During an interview on 12/7/10 at 11:30 A.M. LPN A stated he/she faxed the resident's physician about the resident's refusals of treatment, however, could not find any information to show he/she faxed the resident's physician nor information showing the physician responded to the fax. Review of the resident's medical record showed it did not contain the fax sent to the physician regarding the resident refusing treatments or a response from the physician. During an interview on 12/7/10 at 3:25 P.M. LPN B said staff should have transcribed the resident's wound clinic physician orders [REDACTED]. LPN B said neither contained a physician's orders [REDACTED]. Observation on 12/7/10 at 3:30 P.M. showed LPN B attempted to remove the resident's old dressing, however, it remained stuck to the wound. LPN B administered the new dressing over the old one. LPN B did not assess the wound. The resident remained pleasant and cooperative during the treatment. The resident asked for his/her "blue boot" (Prevalon boot) following the treatment. During an interview on 12/7/10 at 3:30 P.M. LPN B said he/she thought the pressure ulcer resulted from the resident's toe "rubbing on his/her shoe." LPN B also said he/she preformed the dressing change a couple of week ago but it "looked better then." During an interview on 12/07/10 at 4:00 P.M., the director of nurses (DON) said the order for the Prevalon boot should be on the resident's TAR. She said she did not know why staff did not write the order on the TAR or why staff did not place the boot on the resident. Record review of the resident's nursing notes or social services notes dated 07/01/10 and 11/20/10 did not show any documentation regarding teaching to the resident or consequences of continuous refusal of treatments to the open area. Further review of nurses notes dated 08/19/10 (when staff assessed the open area) through current nurses notes did not show staff documented providing any information to the resident regarding consequences of refusing treatments. Review of the resident's Wound Healing Center physician's orders [REDACTED]." During an interview on 12/14/10 at 9:45 A.M., the resident's Physician said the resident's second toe ulcer was caused by a combination of pressure and and the way in which the second toe lay over the first toe. The Physician also said, early laboratory reports showed osteo[DIAGNOSES REDACTED] (infection of bone). The Physician said the resident was scheduled for surgical amputation of the second toe on his/her right foot. 2. Review of Resident #3's Braden scale assessment for predicting pressure ulcer risk dated 08/24/10, showed staff assessed the resident with a score of 14. A score of 12 or less represented high risk for pressure ulcer development. Review of the resident's most recent plan of care dated 08/28/10, showed staff planned interventions to assist the resident as follows: -Assist the resident to turn and reposition every two hours and as needed; -Utilize the Braden scale to determine pressure ulcer risk on admission, then quarterly; -Certified Nurse Aide (CNA) to monitor skin with showers, document skin issues on shower sheet, and give to charge nurse; -Keep skin clean and dry; -Night nurse to do weekly skin assessments; -Report new red or open areas to physician and the charge/skin nurse; -Skin nurse to monitor wounds weekly; -Teach staff to observe for skin changes. Review of the resident's 30 day Medicare MDS, a federally mandated assessment tool, dated 09/22/10, showed staff assessed the resident as follows: -Short and long term memory problem; -Moderately impaired cognitive skills for daily decision making; -Required extensive assistance of one staff person for activities of daily living (ADLs) including bed mobility, transfers, dressing, toileting and personal hygiene; -No pressure ulcers. -Regularly napped during the day. Review of the resident's nurse's notes dated 11/25/10 showed LPN C recorded he/she assessed a Stage I (persistent area of redness on intact skin) pressure area on the resident's right and left buttock and applied [MEDICATION NAME] cream (moisture barrier ointment). The nurse's notes do not show staff notified the physician of the areas. Review of the facility Wound Book (used to record on-going assessment of residents' skin condition including measurements and treatments) dated 12/02/10, showed Registered Nurse (RN) K documented the resident's pressure ulcer as a Stage I (intact skin) with an on-set date of 12/02/10. Review of the resident's nurse's notes dated 12/02/10 showed staff documented the resident's physician directed staff to apply [MEDICATION NAME] ([MEDICATION NAME] dressing) to the resident's "open areas"on the right and left buttocks until healed. Observation on 12/07/10 at 12:10 P.M., showed staff assisted the resident to lay in his/her back in bed. Further observation at 1:45 P.M. showed the resident continued to lay on his/her back with a wet incontinent pad under him/her. The resident lay on his/her back on the wet incontinence pad until at least 4:00 P.M. Review of the Wound Book showed on 12/09/10, staff assessed the resident's pressure ulcer as a Stage I on the left buttock. However, staff documented the physician's orders [REDACTED]. Staff did not document a description or measurements of the pressure ulcer in the middle of the resident's buttocks to show on-going monitoring for improvement or decline of the pressure ulcer. During an interview on 12/07/10 at 3:00 P.M., LPN C and LPN D said it was the wound care nurse's responsibility to notify the physician of open areas and to update the care plan. During an interview on 12/07/10 at 3:10 P.M. Certified Nurse Aide (CNA) E and CNA J said they knew of the resident's pressure ulcers, but did not know how they developed. CNA J said the resident liked to lay on his/her back and was incontinent. Both CNAs said the resident should be turned and repositioned at least every two hours and checked for incontinence with their rounds. Observation on 12/15/10 at 10:25 A.M., showed a 1 cm x 0.4 Stage II (a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater) pressure ulcer on the resident's middle buttocks with a beefy red wound bed. During an interview on 01/04/11 at 11:00 A.M., RN K said he/she followed residents who already had "open areas." He/She said it was his/her responsibility to treat wounds and it was the charge nurse's responsibility to prevent the pressure ulcers. He/She said it was the charge nurse and his/her responsibility to notify the physician of open areas as he/she saw the residents approximately three times a month. RN K said the resident's pressure areas on his/her right and left buttocks were never opened. He/She said the order indicated "open areas" because he/she transcribed the order "exactly as the physician wrote it". He/She said the pressure area in the middle of the resident's buttocks was open. MO 730